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Mental Health Flashcards

1
Q

What are the 3 Cardinal symptoms of depression?

A

Low mood
Loss of interest/enjoyment
Reduced energy

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2
Q

What are the additional symptoms of depression?

A 
Reduced concentration
Low self-esteem/confidence
Ideas or acts of self harm
Early morning wakening
Reduced appetite
Ideas of guilt and unworthiness
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3
Q

What specific things do you need to ask about in history of presenting complaint?

A

Depression
Anxiety
Psychosis
Deliberate self-harm

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4
Q

What are the categories of anxiety symptoms?

A

Biological
Psychological
Avoidance

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5
Q

What are the components of a mental state examination?

A 
Appearance and Behaviour
Speech
Mood/Affect
Thought
Perception
Cognition
Insight
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6
Q

What aspects of appearance and behaviour should you comment on?

A

Description
Psychomotor activity
Rapport
Other abnormal behaviours

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7
Q

What should you comment on regarding speech?

A 
Rate
Rhythm
Content
Tone
Formal thought disorder
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8
Q

What are the aspects of mood?

A

Subjective
Objective

Affect

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9
Q

How does affect relate to mood?

A

Mood is the season, affect is the weather

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10
Q

What parts of thought should you comment on?

A

Form
Content
Suicidal ideation

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11
Q

What aspects of perception should you comment on?

A

Hallucinatory experience
Modalities
Illusions
Pseudo hallucinations

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12
Q

How do you assess insight?

A

Do they think they’re ill?
Do they think they need treatment?
Do they think treatment is useful?

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13
Q

What is the mnemonic for cognitive assessment?

A

GOAL-CRAMP

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14
Q

What are the components of cognitive assessment?

A 
General
Orientation
Attention and concentration
Language
Calculation
Right hemisphere function
Abstraction
Memory
Praxia
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15
Q

Define psychosis

A

Any condition where reality judgement is significantly disturbed. The individual is unable to distinguish between their own subjective experience and external reality

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16
Q

What are the psychotic symptoms?

A

Hallucinations
Delusions
Thought disorder

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17
Q

Define a hallucination

A

A perception occurring in the absence of an external stimulus

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18
Q

What is the most common type of hallucination?

A

Auditory

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19
Q

Define an illusion

A

A misperception of an external stimulus

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20
Q

What is a pseudo hallucination?

A

A perception in the absence of an external stimulus (as for hallucination), but the perception is located in the internal (subjective) space
E.g. The patient is aware that the voice is in their own head

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21
Q

Define a delusion

A

A false, unshakable belief which is out of keeping with the person’s cultural and religious background

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22
Q

What is the most common type of delusion?

A

Paranoid (persecutory) - patient feels they are being persecuted and the persecutor is trying to cause harm

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23
Q

What are delusions of reference?

A

Things happening in the external environment are targeted at them

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24
Q

What types of delusions are commonly seen in schizophrenia?

A

Paranoid
Delusions of reference
Passivity

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25
What are passivity delusions?
Belief that another agency is controlling the patient's mind
26
What are grandiose delusions?
Special beliefs/powers | Belief that other people are below them
27
What are nihilistic delusions?
Everything's going downhill | World's going to end
28
What's a common nihilistic delusion in elderly patients?
That their bowels aren't working
29
What is an important differential for delusions?
Overvalued ideas
30
What are overvalued ideas?
Ideas which tend to occupy the person and may affect their actions. They are shakable, and may be understandable culturally
31
What is form of thought?
The way someone orders their thoughts
32
What are the 3 components of consent?
Informed Competent Voluntary
33
Define capacity
The ability to make a specific decision
34
What are the 4 components of testing capacity?
1. Can they understand the information? 2. Retain the information 3. Use/weight it up 4. Communicate the decision
35
What are DOLS?
Deprivation of Liberty Safeguards
36
When can DOLS be used?
In hospital or care homes when the patient lacks capacity
37
Define mental disorder
Any disorder or disability of the mind
38
Who can use section 5(4)?
Registered Mental health Nurses, to detain patients for up to 6 hours for assessment by a doctor
39
Who can use section 5(2)?
RMO/junior on call | Detain patient for up to 72 hours
40
Who does a section 2 need to be completed?
2 doctors - at least one section 12(2) approved | 1 AMHP
41
What does a section 2 allow?
Max 28 days detainment for assessment and treatment of a mental disorder Can appeal within 1st 14 days
42
Who does a section 3 require to be completed?
2 doctors - at least one section 12(2) approved | 1 AMHP
43
What does a section 3 allow?
Detainment for max 6 months for treatment of mental disorder Treatment can only be forced for 3 months, then capacity must be assessed
44
What is a section 137?
Police power to remove to a place of safety from a public place, for an assessment by an AMHP and a doctor Can be held for up to 72 hours
45
What is a section 17?
While detained in hospital under S2 or 3, a patient may leave under S17
46
What is a CTO?
Community Treatment Order
47
Give some examples of static risk factors that increase a person's risk
Male Age Comorbid diagnosis eg MS History of recurrent major depressive disorder
48
Give some examples of dynamic risk factors for risk
Currently depressed Use of alcohol or drugs as coping strategy Recently unemployed
49
What are the 5 dimensions of risk that need to be assessed?
``` What is the risk? Severity of risk Frequency of risk Imminence of risk Who is at risk? ```
50
Define suicide
Verdict or category recorded by a coroner where death was unnatural and a result of the victim's own actions, with the intent to kill themselves
51
Define para-suicide
For whatever reason the victim survived the suicide attempt
52
In what group are suicide rates highest?
Men aged 40-44
53
What risk factors make an inpatient more likely to commit suicide?
``` Forensic history Previous suicidal behaviour Violence to property Recent bereavement Presence of delusions ```
54
What are post-discharge risk factors for suicide?
Unplanned discharge Lack of continuity of care Suicidal prior to admission
55
What are the general risk factors for suicide?
``` Male Living alone Unemployment Drug/alcohol misuse Mental illness ```
56
What is the lifetime suicide risk for depression?
15% higher than general population
57
What is the lifetime risk of suicide in alcohol abuse?
2-4 % increase on general population
58
What increases risk of suicide in schizophrenia?
``` Positive psychotic symptoms Post-psychotic depression Young and male 1st decade of illness Relapsing pattern of illness Recent hospital discharge Social isolation Good insight into illness ```
59
What type of personality disorder leads to highest suicide risk?
Borderline (emotionally unstable) | Due to accidental death after self harm
60
What are the 2 main types of deliberate self harm?
Self-poisoning | Self-injury
61
Why is alcohol use at the time of deliberate self harm dangerous?
Alcohol increases toxicity of psychotropic drugs | Unconsciousness can delay time to treatment
62
How do mood disorders affect risk to others?
No increase
63
In psychotic disorders, what increases risk of harm to others?
Specific persecutory delusions or hallucinations | Command auditory hallucinations
64
Name 3 specific toxic syndromes relating to psychiatric drugs
Prolonged QTc Serotonin syndrome Neuroleptic malignant syndrome
65
What is the mono amine hypothesis of depression?
Reduced levels of serotonin and noradrenaline lead to depression
66
How do TCAs work?
Non-specific reuptake inhibitors for both serotonin and noradrenaline
67
How do SNRIs work?
Serotonin and noradrenaline reuptake inhibitors
68
How does trazodone work?
Similar to TCA, complex serotonin action | Sedative effect
69
When is prophylaxis indicated for depression?
2 or more depressive episodes in 5 years Continue antidepressants for 2 years
70
In which antidepressants is discontinuation syndrome more common?
Shorter-acting antidepressants | Paroxetine and venlafaxine
71
Give two examples of TCAs
Amitriptyline | Imipramine
72
What is the safest and least cardio toxic TCA?
Lofepramine
73
What are the anticholinergic side effects of TCAs?
``` Dry mouth Blurred vision Urinary retention Constipation Worsening of glaucoma ```
74
What are the other side effects of TCAs?
``` Drowsiness and weight gain CVS - tachycardia, hypotension, prolonged QT Fine tremor, poor coordination, headache Lowered seizure threshold Allergic skin rashes ```
75
What SSRI has a longer half-life?
Fluoxetine
76
What SSRIs can cause prolonged QTc?
Citalopram | Escitalopram
77
How do SSRIs affect other drugs?
CYP enzyme inhibitors, so reduce metabolism and increase plasma drug levels
78
What are the side effects of SSRIs?
``` GI: nausea, loss of appetite, dyspepsia, bloating, diarrhoea, constipation Headache Sweating Sexual dysfunction Increased risk of bleeding ```
79
Give 2 examples of SNRIs
Venlafaxine | Duloxetine
80
What are the side effects of SNRIs?
``` Nausea Dry mouth Headache Dizziness Sexual dysfunction Hypo or hypertension ```
81
How do monoamine oxidase inhibitors work?
Block intracellular breakdown of dopamine, serotonin, noradrenaline and tayra mine
82
Why are there diet restrictions with MAOIs?
'Cheese reaction' can cause hypertensive crisis | These drugs block breakdown of dietary tyramine, found in foods such as cheese
83
What is serotonin syndrome?
Too much serotonin, causing... | Restlessness, excess sweating, tremor, shivering, myoclonus, confusion, convulsions, death
84
What drugs can cause serotonin syndrome?
Antidepressants Tramadol Amitryptiline
85
What are the indications for antipsychotics?
Psychotic symptoms (delusions and hallucinations) Mania Acute behavioural disturbance Antidepressant augmentation
86
How do antipsychotics work?
Dopamine antagonists at D2 receptors
87
Name 3 dopamine pathways in the brain
Mesolimbic Nigrostriatal Pituitary temporofundibular
88
On which dopamine pathway do antipsychotics have their therapeutic effect?
Mesolimbic
89
What side effects are caused by antipsychotics taking effect on the nigrostriatal pathway?
Extra-pyramidal
90
What side effect is caused by antipsychotics taking effect on the pituitary temporofundibular pathway?
Hyperprolactinaemia
91
Name 3 typical antipsychotics
Haloperidol Chlorpromazine Sulpiride
92
What are the 4 types of extra pyramidal side effects?
Parkinsonism Akathasia Dystonia Tardive dyskinesia
93
What are the signs of Parkinsonism?
Tremor Cogwheel rigidity Bradykinesia
94
How is Parkinsonism treated?
Anticholinergics
95
What is akathisia?
Subjective restlessness | Doesn't respond to anticholinergic
96
What is dystonia?
Serious muscle spasm
97
What is tardive dyskinesia?
Serious long-term involuntary choreo-athetoid orofacial movements
98
Give 5 examples of atypical antipsychotics
``` Olanzapine Quetiapine Risperidone Aripiprazole Clozapine ```
99
What are the side effects of atypical antipsychotics?
Hyperprolactinaemia Anti-adrenergic eg sedation and postural hypotension Anticholinergic Cardiac arrhythmias
100
What monitoring is required for clozapine?
FBC initially weekly then monthly | Due to 0.5% risk of agranulocytosis
101
Give an example of a Depot antipsychotic injection
Haldol - haloperidol decanoate
102
What is neuroleptic malignant syndrome?
Rare response to antipsychotics Extra pyramidal side effects Autonomic dysfunction Creatine kinase increased
103
What are the indications for mood stabilisers?
Bipolar affective disorder Hypomania, mania, depression or mixed Treatment and prophylaxis of mood episodes
104
What classes of drugs can be used as mood stabilisers?
Antipsychotics Lithium Anticonvulsants
105
What are the indications for lithium?
Mania Prevention of manic and depressive episodes Treatment-resistant depression
106
What are the main causes of lithium toxicity?
Overdose Dehydration Drug interactions: NSAIDs, diuretics, ACEi
107
What are the side effects of lithium?
``` Polydipsia and polyuria Nausea, GI disturbance, weight gain, oedema Fine tremor Mild renal impairment Metallic taste in mouth Teratogenic ```
108
What are the signs of lithium toxicity?
``` Coarse tremor Ataxia Dysarthria Reduced consciousness Convulsions Coma Death ```
109
How may lithium effect the ECG?
T wave flattening | Widened QRS
110
What are the side effects of sodium valproate?
``` Tremor Sedation Headache GI disturbance Hyperammonaemia, thrombocytopenia, hair loss Teratogenic ```
111
What are the potential drug interactions of sodium valproate?
CYP inhibitors and inducers
112
What is the mechanism of action of carbamazepine?
Sodium channel blocker | Affects glutamate, dopamine and NA
113
What are the side effects of carbamazepine?
``` Dizziness, drowsiness, ataxia, headache, visual disturbance Hyponatraemia and oedema GI: anorexia, nausea, constipation Leukopenia (rare) Teratogenic ```
114
How does carbamazepine affect other drugs?
CYP inducer - decreases drug levels in plasma eg OCP
115
What class of drug is lamotrigine?
Anticonvulsant Used in bipolar depression
116
What are the side effects of lamotrigine?
GI: nausea, vomiting, diarrhoea Dizziness, tremor, ataxia Serious skin reactions eg Stevens Johnson syndrome Bone marrow failure
117
When are anxiolytics used?
2nd line for anxiety disorders eg GAD, panic disorder, OCD, PTSD, phobias
118
Give 4 examples of anxiolytics
Benzodiazepines Antidepressants Buspirone Pregabalin
119
How do benzodiazepines work?
Act on GABA-A receptors
120
Name a fast-acting benzodiazepine
Lorazepam
121
Name a long acting benzodiazepine
Diazepam
122
What is the effect of acute withdrawal of benzodiazepines?
Anxiety Insomnia Seizures Potential death
123
What are the side effects of benzodiazepines?
``` Drowsiness Light-headedness Ataxia Confusion Amnesia Paradoxical agitation Disinhibition ```
124
What are the effects of benzodiazepine overdose?
``` Ataxia Dysarthria Nystagmus Coma Respiratory depression ```
125
Name 5 hypnotic drugs
Benzodiazepines eg temazepam and diazepam Zopiclone Zolpidem Zalepon
126
When are hypnotics used?
As 2nd line to sleep hygiene measures
127
How does alcohol withdrawal syndrome present?
Anxiety Insomnia Agitation Risk of convulsions and death
128
What is the pharmacological management of alcohol detox?
Chlordiazepoxide - long-acting BZD | Multivitamins and pabrinex
129
What drugs are used to maintain abstinence from alcohol?
Acamposate/naltrexone to reduce craving | Disulfiram
130
How does disulfiram work?
Disrupts alcohol metabolism by inhibiting acetaldehyde dehydrogenase Causes acetaldehyde to build up causing an unpleasant reaction
131
Name 2 drugs used to treat opioid dependence
Methadone | Buprenorphine
132
Name 3 acetylcholinesterase inhibitors
Donepezil Rivastigmine Galantamine
133
What are the side effects of acetylcholinesterase inhibitors?
``` Nausea and vomiting Anorexia Diarrhoea Fatigue Insomnia Headaches Muscle cramps Bradycardia and syncope ```
134
What is the mechanism of action of memantine?
Partial glutamate agonist
135
What is the indication for memantine?
Behavioural disturbance in dementia
136
What are the side effects of memantine?
``` Constipation Dyspnoea Headache Dizziness Drowsiness ```
137
What type of drug is used for ADHD?
Central nervous system stimulants
138
Give 2 examples of drugs used in ADHD
Methylphenidate | Dexamphetamine
139
What is ECT?
Passage of small electrical current through the brain | View to inducing a generalised fit which is therapeutic
140
What are the indications for ECT?
Severe depressive illness Uncontrolled mania Catatonia
141
What are the side effects of ECT?
``` Risks of anaesthesia Confusion Headache Status epilepticus Stroke Arrhythmias Bleeding ulcers PE Broken teeth Memory - depends on total energy and site ```
142
What are the absolute contraindications to ECT?
Raised intracranial pressure Cerebral aneurysm History of cerebral haemorrhage
143
Define psychosis
Any condition where reality judgement is significantly disturbed
144
What are the psychotic symptoms?
Hallucinations Delusions Thought disorder
145
Define hallucination
A perception occurring in the absence of an external stimulus
146
Define an illusion
A misperception of an external stimulus
147
Define a delusion
A false, unshakable belief which is out of keeping with the person's cultural and religious background
148
Name 2 conditions in which there may be a formal thought disorder
Schizophrenia | Mania
149
What are the different types of formal thought disorder?
Flight of ideas Loosening of associations Neologisms
150
What is flight of ideas?
Ideas follow each other rapidly | Connection between ideas appears to be due to chance, usually understood by cues in the patient's language
151
What is loosening of associations?
Complete loss of normal structure of thinking | Transition from one topic to another either between sentences or mid-sentence
152
What are neologisms?
Words or phrases constructed (not consciously) by the patient and used with meaning in their conversation
153
What are the aspects of insight?
Understand they are unwell Understand they need treatment Accept treatment or make rational decisions about their treatment
154
What are the positive symptoms of schizophrenia?
Thought disorder Hallucinations Delusions
155
What are the negative symptoms of schizophrenia?
``` Loss of/not doing the activities they would normally have engaged with Apathy Social withdrawal Loss of motivation Neglect ```
156
What is the most common type of schizophrenia?
Paranoid
157
What are the likely symptoms of paranoid schizophrenia?
Delusions Hallucinations Loss of insight Possible formal thought disorder
158
What are schneider's first rank symptoms? Name the categories
``` Group of symptoms rarely thought to be found in disorders other than schizophrenia 3 hallucinations 3 thought possession delusions 3 'made' phenomena/delusions Delusional perception ```
159
What 3 hallucinations are commonly seen in paranoid schizophrenia?
Running commentary 3rd person hallucinations Thought echo
160
What 3 thought possession delusions are commonly seen in paranoid schizophrenia?
Thought withdrawal Thought insertion Thought broadcast
161
What is the prevalence of schizophrenia?
1 in 100
162
When is the peak incidence of schizophrenia?
Late teens/early 20s in males Late 20s in females
163
How does the environment influence development of schizophrenia?
Obstetric complications Migration Drug use - cannabis
164
What is the neurotransmitter abnormality in schizophrenia?
Excess dopamine causes positive symptoms
165
What are the differential diagnoses for schizophrenia?
``` Drug-induced psychosis Mania/depression with psychosis Delusional disorder Organic disorders eg delirium or SOL Personality disorder ```
166
How is schizophrenia managed?
Bio: antipsychotics Psycho: CBT, family therapy Social: OT, POC with CPN, employment/financial support
167
What is delusional disorder?
Single or set of related delusions present for 3 months Other schizophrenic symptoms not present Usually presents in older patients
168
How can you distinguish between schizophrenia and psychosis in mood disorders?
In mood disorders, symptoms are congruent with mood
169
What is psychosis typically like in mania?
Grandiose delusions Formal thought disorder - flight of ideas Auditory hallucinations
170
What is psychosis typically like in depression?
``` Delusions of guilt, nihilism or poverty Auditory hallucinations (often saying negative things in 2nd person) ```
171
How may psychosis present in the non-psychiatric environment?
``` Delirium Drug-induced psychosis Steroid-induced Neurosyphilis Epilepsy Mental illness ```
172
Define delirium
Clouding of consciousness with reduced levels of alertness, attention and perception of the environment
173
What are the core symptoms of depression?
Continuous low mood for 2 weeks or more Lack of energy Anhedonia
174
What are the somatic symptoms of depression?
``` Early morning wakening Reduced appetite Weight loss Psychomotor agitation or retardation Loss of libido ```
175
What are depressive cognitions?
``` Low self-esteem Guilt and self-blame Hopelessness Hypochondriacal thoughts Poor concentration and attention Suicidal thoughts ```
176
Define mild depression
2 core symptoms + 2 others
177
Define moderate depression
2 core symptoms + 3-4 others
178
Define severe depression
3 core symptoms + at least 4 others
179
What is the lifetime prevalence of depression?
10-20%
180
What are the features of atypical depression?
``` Variably depressed mood Overeating Oversleeping Extreme fatigue and heaviness in the limbs Pronounced anxiety ```
181
What type of delusions are commonly seen in depression?
Hypochondriacal Guilt Nihilistic Poverty
182
What are the risk factors for postnatal depression?
``` Personal or family history Older age Single mother Unwanted pregnancy Poor social support ```
183
How do you diagnose a manic episode?
Elevated, expansive or irritable mood + 3 more symptoms
184
What are the additional symptoms of mania?
``` Increased energy or activity Grandiosity or increased self-esteem Pressure of speech Flight of ideas Distractible Reduced need for sleep Increased libido Social inhibitions lost ```
185
What is hypo mania?
3 or more characteristic symptoms of mania for at least 4 days, but not severe enough to interfere with social or occupational functioning
186
Define bipolar I
1 or more manic/mixed episodes | And/or 1 or mor depressive episodes
187
Define bipolar II
1 or more depressive episodes with at least 1 hypomanic episode
188
What does ICD10 diagnosis of bipolar require?
At least 2 episodes, one of which must be hypomanic, manic or mixed
189
What is the prevalence of bipolar disorder?
0.3-1.5%
190
What is the median age of onset of bipolar disorder?
25
191
How is the suicide rate affected in bipolar disorder?
20x increased
192
What are the differential diagnoses of mood disorders?
``` Normal fluctuations in mood Adjustment disorder/bereavement Dementia or other brain disorders Underlying physical illness Personality disorders Anxiety disorders ```
193
Give examples of predisposing factors for mood disorders
Genetic factors | Childhood experiences
194
Give some examples of precipitating factors for mood disorders
Life events Substance use Change in routine Iatrogenic
195
Why should antidepressants be avoided in bipolar disorder?
Risk of manic switch
196
What are the possible psychological interventions for mood disorders?
Psychoeducation about illness, relapse signs, medication CBT IPT
197
How long should antidepressants be used for following a 1st depressive episode?
At least 6 months
198
What percentage of people suffering a depressive episode will experience another?
80%
199
How long should antidepressants be continued for if a patient suffers multiple episodes?
2 years
200
What are the poor prognostic factors for bipolar disorder?
Severe episodes Early onset Cognitive deficits
201
What is dysthymia?
Neurotic/chronic depression | Same cognitive and physical symptoms as depression, but less severe and longer lasting
202
Define neurosis
Persistent, inappropriate anxiety and worries | Not due to an organic brain disease, psychosis or personality disorder
203
Name the different types of neurotic disorder
Anxiety disorders: phobic anxiety, panic disorder, GAD OCD Dissociative disorders Neurasthenia - chronic fatigue syndrome Depersonalisation-de realisation syndrome
204
What are somatoform disorders?
Somatic symptoms unexplained by a medical or other psychiatric disease Eg hypochondriasis, dysmorphophobia
205
What are stress-related disorders?
A major external stressor appears to explain the symptoms of neurosis Eg acute stress reaction, adjustment disorders, PTSD
206
What are the features of normal (physiological) anxiety?
Adaptive Signals and alerts to real threat Causes cognitive and somatic symptoms
207
What is pathological anxiety?
Excessive Impairs functioning Persists in absence of a real threat
208
What are the cognitive symptoms of pathological anxiety?
Worry Recurrent morbid or fear-inducing thoughts/impending doom Inability to concentrate Over-arousal (hyper-vigilance and sleep disturbance) Irritability
209
What are the physical symptoms of anxiety?
Muscle tension | Autonomic arousal: sweating, headache, stomach disturbance, racing heart, hyperventilation
210
What may anxiety disorder be secondary to?
Substance use or disorder Medical condition or medication Other psychiatric disorder Psychosocial stressors eg adjustment disorder
211
What are the different types of primary anxiety disorders?
``` Panic disorder Agoraphobia Generalised anxiety disorder Social phobia Specific phobia OCD PTSD ```
212
Describe panic attacks
Recurrent unexpected urges of severe anxiety Discreet episodes of intense fear/discomfort Accompanied by at least 4 physical/psychological symptoms of anxiety Usually lasts between 30 mins and 2 hours
213
What proportion of people with panic disorder develop agoraphobia?
2/3
214
When do panic attacks become panic disorder?
At least 1 of the attacks are followed by at least 1 month of... Persistent concern about further attacks Worry about the consequences of a further attack Significant change in behaviour related to the attack
215
What is agoraphobia?
Fear in places or situations from which escape might be difficult, or in which help might not be available
216
What situations do people with agoraphobia commonly avoid?
Crowds Going outside the home Using public transport
217
What is required for ICD 10 diagnosis of agoraphobia?
2 situations causing distress + avoidance at some stage
218
What is the treatment for agoraphobia?
Pharmacological + CBT | May involve gradual exposure therapy
219
What is generalised anxiety disorder?
Persistent, excessive, inappropriate worry lasting at least 6 months Not related to any specific situation Person finds it difficult to control
220
What are the main features of generalised anxiety disorder?
``` WATCHERS: Worry Anxiety Tension in muscles Concentration difficulty Hyper-arousal Energy loss Restlessness Sleep disturbance ```
221
What is the treatment for generalised anxiety disorder?
Some SSRIs eg Escitalopram, paroextine, sertraline Diazepam short-term CBT
222
What is social phobia?
Marked, persistent and unreasonable fear of being observed or evaluated negatively by other people in social or performance situations
223
Define a specific phobia
Excessive or unreasonable fear of specific people, animals, objects of situations This is then avoided, or endured with significant personal distress
224
What is the 1st line treatment for specific phobias?
Exposure techniques
225
What are obsessions?
Recurrent, persistent thoughts, impulses or images
226
What are compulsions?
Repetitive behaviours or mental acts (eg counting, praying etc) They feel driven to perform these in response to an obsession or according to rules they must follow rigidly
227
Name some common obsessions in OCD
Contamination Accidents Religious or sexual matters
228
Name some common rituals in OCD
``` Washing Checking Cleaning Counting Touching ```
229
What is the treatment for OCD?
SSRIs Clomipramine (TCA) Exposure therapy and CBT
230
What are the stages of PTSD?
Exposure to trauma Re-experiencing Avoidance Hype-arousal
231
What does the PTSD mnemonic TRAUMA stand for?
``` Traumatic event Recurrent recollections Avoidance Unable to function Month long symptoms Arousal increased: insomnia, irritable ```
232
What psychological interventions are used for PTSD?
Trauma-focussed CBT to prevent chronic PTSD | EMDR - eye movement desensitisation and reprocessing
233
What is adjustment disorder?
Psychological reactions arising in relation to adapting to new circumstances
234
What are the symptoms of adjustment disorder?
``` Anxiety Worry Poor concentration Depression Irritability Physical symptoms caused by autonomic arousal eg palpitations, tremor ```
235
What are the time scales related to adjustment disorder?
Disorder must start within 3 months (usually within 1 month) Reaction is understandably related and in proportion to the stressful experience Most last several months, a few persist for years
236
Define bereavement
Loss through death of a loved one
237
Define grief
Involuntary emotional and behavioural response to bereavement
238
Define mourning
Voluntary expression of behaviours and rituals that are socially sanctioned responses to bereavement
239
What are the 5 stages of grief?
``` Denial Anger Bargaining Depression Acceptance ```
240
When is grief considered to be abnormal?
``` Unusually intense Unusually prolonged Delayed Inhibited Distorted ```
241
When is abnormal grief more likely?
Sudden, unexpected death Very close/dependent relationship with the deceased Previous psychiatric disorder Having to care for dependent children
242
What is an abnormal duration for a grief reaction?
Longer than 6 months
243
What weight is considered anorexic?
Refusal to maintain/achieve normal body weight 85% of normal BMI
244
What are the 2 types of bulimia nervosa?
Purging type | Non-purging type
245
What is the main feature of bulimia nervosa?
Recurrent binge episodes + inappropriate compensatory behaviour
246
What is a binge?
Eating much more than someone around you would think is normal, in a short amount of time Loss of control of eating
247
Why may people with bulimia nervosa not be so obvious?
They may be normal weight and able to carry on working etc
248
What compensatory mechanisms do people with bulimia use?
Self-induced vomiting Drugs eg laxatives, diuretics, thyroxine Excessive exercise Omission/reduction in insulin dose
249
What is EDNOS?
Eating disorder not otherwise specified | Full criteria of AN or BN not met, mainly due to frequency of symptoms
250
What is binge eating disorder?
Binge eat, but don't engage in compensatory behaviours
251
What proportion of patients with anorexia die?
10% of total 50% from consequences of illness 50% from suicide
252
What are the physical complications of anorexia?
``` CVS GI, especially IBS Electrolyte disturbances Nutritional deficiencies Endocrine and reproductive Blood and bone marrow MSK ```
253
What is the most important complication of bulimia nervosa?
Hypokalaemia
254
What are the other potential complications of bulimia nervosa?
``` Other electrolyte disturbances Malory-Weiss tear Dental erosion Parotid enlargement Calluses on back of hand ```
255
What treatments are recommended for anorexia?
CBT IPT Focal psychodynamic therapy Family intervention for adolescents
256
What are the indications for admission in anorexia?
``` Patient wants to change Not progressing with outpatient treatment Home life not conducive to OP treatment Patient in immediate danger Complex cases eg comorbidities ```
257
What percentage of dementias are Alzheimer's disease?
60%
258
What are the reversible types of dementia?
``` Chronic alcohol abuse Vitamin deficiencies Normal pressure hydrocephalus Infection Metabolic and endocrine Neoplastic eg frontal lobe tumours ```
259
What are the risk factors for dementia?
Genetic - apoE4 allele | Vascular risk factors for vascular dementia
260
What are the protective factors for developing dementia?
Diet rich in antioxidants, vit C&E, fish, veg, fruits Physical activity Mental activity More complex work
261
What are the executive functions?
``` Problem solving Abstraction Reasoning Decision making Judgement Planning Organisation Processing ```
262
What are the signs someone's visuospatial abilities are diminished?
Getting lost Impaired driving Copying figures
263
What is apraxia?
Inability to carry out previously learned purposeful movements despite normal coordination and strength
264
What is agnosia?
Impaired recognition of sensory stimuli not attributed to sensory loss or language disturbance
265
What are the non-cognitive symptoms of dementia?
Disturbed perceptions - hallucinations Disturbed Thought content - delusions Disturbed emotion - depression and apathy Disturbed behaviour - wandering, aggression, restlessness
266
What are the pathological features of Alzheimer's?
Shrunken brain Wide Sulci Large ventricles
267
What are the pathological hallmarks of Alzheimer's?
Beta amyloid deposition - plaques Neurofibrillary (Tau) tangles Neuronal loss
268
What are the Parieto-temporal symptoms of dementia?
Aphasia Agnosia Apraxia Apathy
269
What are the frontal lobe symptoms of dementia?
Irritability | Disinhibition
270
What are the symptoms of advanced dementia?
Parkinsonian symptoms Logoclonia Seizures
271
What is the average duration of Alzheimer's disease from diagnosis to death?
Less than 10 years
272
What are the features of mild Alzheimer's disease?
Forgetfulness and recent memory deficit | Normal activities of daily living
273
What are the features of moderate Alzheimer's disease?
Significant memory loss with personality and behavioural changes Difficulties in orientation and language start Impairment in activities of daily living
274
What are the features of advanced Alzheimer's disease?
``` Dysphasia with disordered and fragmented speech Aggression, restlessness and wandering Hallucinations and delusions Incontinence Immobility, rigidity and falls ```
275
What percentage of people suffering a single stroke develop dementia?
10%
276
What are the features of vascular dementia?
Memory and cognitive impairment Emotional and behavioural disturbances Uneven distribution of deficits
277
What are the common features of Lewy body dementia?
Fluctuating memory and cognitive impairment Visual hallucinations Parkinsonism
278
What is required for ICD 10 classification of dementia?
6 months or more of Decline in memory Decline in other cognitive abilities Preserved awareness of the environment (no clouding of consciousness) Decline in emotional control, motivation, changes in social behaviour
279
What is pseudodementia?
Symptoms of poor concentration and impaired memory due to depression
280
How do you distinguish between dementia and depression in an elderly person?
Did low mood or poor memory come first? | Is the failure to answer questions due to lack of ability or lack of motivation?
281
What extra symptoms may depression present with in an older patient?
Apathy Anxiety Irritability Forgetfulness
282
What are the other differentials for dementia?
``` Depression Delirium Deafness Other psychiatric disorders Transient global ischaemia Epilepsy Drug-effects ```
283
What is mild cognitive impairment?
Isolated memory loss with preserved activities of daily living Don't meet the criteria for dementia but do have evidence of decline in cognitive function
284
What proportion of mild cognitive impairment cases progress to dementia?
30%
285
What is the purpose of tertiary prevention in dementia?
Reduce functional disability and improve quality of life
286
What is the purpose of secondary prevention in dementia?
Try to identify the pre-clinical stage of Alzheimer's disease, for early diagnosis and intervention
287
What aspects of tertiary prevention are used in dementia?
``` Cognitive training Psychosocial support for patient and carer Acetylcholinesterase inhibitors NMDA receptor antagonists Antidepressants ```
288
Give 3 examples of acetylcholinesterase inhibitors
Donepezil Rivastigmine Galantamine
289
Give an example of an NMDA antagonist
Memantine
290
What factors may exacerbate dementia symptoms?
Constipation Pain Infection Dehydration
291
What are the potential complications of dementia?
Depression Disturbed sleep Aggression
292
What are the prominent signs/symptoms of vascular dementia?
Early gait disturbance Personality change, labile mood Early urinary symptoms Preserved insight
293
How does vascular dementia progress?
Stepwise
294
How do antipsychotics affect Lewy body dementia?
Worsen condition
295
What are the prominent signs/symptoms of huntington's disease?
Schizophrenia-like psychosis Choreiform movements Depression and irritability Dementia occurs later
296
What is delirium also known as?
Acute confusional state Acute brain syndrome Encephalopathy
297
What proportion of elderly patients in hospital experience an episode of delirium?
A third
298
What are the features of delirium?
Global impairment of cognition Disturbances of attention and conscious level Abnormal psychomotor behaviour and affect Disturbed sleep-wake cycle
299
What psychotic symptoms may be present in delirium?
Hallucinations - usually visual | Delusions
300
What is clouding of consciousness?
Drowsiness Decreased awareness of surroundings Disorientation in time and place Distractability
301
What are the differential diagnoses of delirium?
Dementia Psychosis Depression
302
How do you distinguish between dementia and delirium?
Delirium acute onset, with fluctuating course Attention poor in delirium Delusions are common in delirium
303
What drugs commonly cause delirium?
``` Antidepressants Antipsychotics Benzodiazepines Antiparkinsonians Anticholinergics Opiates Diuretics ```
304
What are the common medical causes of delirium?
``` Hypoxia Infection Organ failure Hypoglycaemia Dehydration Constipation ```
305
What neurological conditions cause delirium?
Epilepsy Head injury Space occupying lesion Encephalitis
306
What proportion of cases of delirium are caused by medication?
A third
307
What are the risk factors for delirium?
``` Elderly Male Dementia or cognitive impairment Current hip fracture Previous episode of delirium Sensory impairment ```
308
What are the environmental components of management of delirium?
Quiet surroundings with low lighting, clock, calendar etc. Regular routine, prevent transfer Clear simple communications with limited staff Involve family Avoid unnecessary procedures
309
What are the medical components of management of delirium?
Monitor vital signs Investigate and treat underlying cause Consider use of meds if agitation and behaviour places patient or others at risk Lorazepam OR haloperidol 1st line
310
What is the prognosis for delirium?
Depends on cause, but most recover in days or weeks. Can persist for several months Increases mortality - only 45% patients still alive 2-4 years after the episode
311
What is the link between delirium and dementia?
No evidence that delirium progresses to dementia | But pre-existing dementia is a risk factor for delirium
312
What is psychoeducation?
Giving people information to help them understand and cope with the illness
313
What is counselling?
Loosely-defined activity where people are helped to understand and cope with life's problems
314
What is supportive psychotherapy?
Formalised version of what a good friend might provide
315
What is problem-solving therapy?
Structured mix of counselling and CBT | Specify problem, select an option to tackle it and try out solutions/review effect
316
What is the focus of psychodynamic psychotherapy?
Unconscious phenomena from the past
317
What are the main indications for psychodynamic psychotherapy?
Difficulties with relationships | Some personality disorders
318
What is the aim of CBT?
Direct, practice-driven change in behaviour and/or cognitions
319
What are the main indications for CBT?
Depressive disorders Neuroses and somatoform disorders Eating disorders
320
What is transference?
The patient's pattern of previous relationships is evidenced most directly by the way they interact with the therapist
321
In whom should psychodynamic psychotherapy be avoided?
People with paranoid or antisocial personality disorder | Psychosis
322
How is exposure used in behavioural therapy?
Patient is re-exposed to a situation or behaviour that they have come to avoid, and learn to stop an inappropriate, excessive response Usually graded
323
What is flooding?
Sudden and prolonged exposure to a feared or avoided situation
324
How does graded exposure work?
Patient finds that each extra exposure increases anxiety, but it then subsides and hence they are desensitised to the stimulus
325
What are the aims of CBT?
Correct inaccurate/unhelpful ways of thinking | Aim is to improve mood, reduce anxiety and allow return to normal behaviour
326
What are cluster A personality disorders?
'Mad' Paranoid Schizoid
327
What are cluster B personality disorders?
'Bad' Dissocial Emotionally unstable (borderline) Histrionic
328
What are cluster C personality disorders?
'Sad' Anankastic Anxious Dependent
329
Define personality disorder
Enduring maladaptive patterns of behaviour, cognition and inner experience Exhibited across many contexts Deviates markedly from those accepted in individual's culture
330
What are the key aspects of emotionally unstable personality disorder?
Impulsivity and emotional instability High self-harm rates Association with childhood sexual abuse, PTSD and bulimia nervosa
331
In what group is EUPD most common in?
Young females
332
What is the management for medically unexplained symptoms (MUS)?
Normalise Minimise investigations and treatment Treat possible underlying condition eg antidepressants Consider referral to CBT/psych services
333
Where is Broca's area?
Frontal lobe
334
Where is wernicke's area?
Parietal lobe
335
What is the function of the precentral gyrus?
Motor cortex
336
What is the function of the postcentral gyrus?
Somatosensory
337
What is the pyramidal system?
Upper motoneurones originating in the motor cerebral cortex Lateral and ventral corticospinal tracts
338
Name 4 extra pyramidal tracts
Rubrospinal Tectospinal Vestibulospinal Reticulospinal
339
What is the function of the extra pyramidal system?
Responsible for constant descending inhibition of lower motoneurones Don't originate in cortex (mainly from brainstem)
340
What are the extra pyramidal signs?
``` Spastic paralysis Pill rolling Shuffling gait Choreoforms Tics ```
341
What amino acid neurotransmitters are found in the CNS?
Glutamate GABA Glycine
342
What biogenic amine neurotransmitters are found in the CNS?
``` Acetylcholine Noradrenaline Dopamine Serotonin Histamine ```
343
What is the function of glutamate synapses?
Excitatory
344
What type of receptors are NMDA receptors?
Ionotropic glutamate receptors
345
What is the main inhibitory transmitter in the brain?
GABA
346
How do GABA receptors work?
Receptors have integral chloride channels | Opening of these channels leads to hyperpolarisation, and decreased action potential firing
347
What drugs target GABA receptors?
Barbiturates | Benzodiazepines
348
What are the functions of cholinergic pathways in the CNS?
Arousal Learning and memory Motor control
349
What are the functions of dopamine receptors in the brain?
Motor control Mood Arousal Reward
350
What is the neurotransmitter abnormality in schizophrenia?
Too much dopamine
351
How do amphetamines affect the brain?
Release dopamine and noradrenaline, producing schizophrenia-like behaviour
352
Why is vomiting a common side effect of SSRIs?
Serotonin receptors also found in vomiting centre of brain
353
What are the signs of cerebellar dysfunction?
``` Ataxia Dysmetria Dysarthria Disequilibrium Hypotonia Nystagmus Dydiadochokinesia ```
354
What is the function of the basal ganglia?
Regulate amplitude and velocity of planned movement | Especially in relation to use of proprioceptive information
355
What is the triad of findings in Parkinson's disease?
Tremor at rest Increased tone Bradykinesia
356
What are the psychiatric manifestations of Parkinson's and why?
Depression and apathy | Degeneration of dopaminergic neurones also elsewhere in brain
357
Name one drug that can induce Parkinsonism
Haloperidol
358
What is wernicke's aphasia?
Fluent but unintelligible speech | Receptive/sensory aphasia
359
What is Broca's aphasia?
Poorly constructed sentences and disjointed speech | Comprehension is fine
360
What is the role of senile plaques in Alzheimer's disease?
Amyloid deposition in the centre of the plaque | Genetic link - mutations of genes on chr. 21
361
How do voltage-gated sodium channel blockers work in epilepsy?
Bind to internal surface of inactivated Na+ channel Act preferentially on neurones causing high-frequency discharge that occurs in a fit - depolarisation increases proportion of sodium channels in inactivated state
362
How does carbamazepine work?
Voltage-gated sodium channel blocker, prolonging inactivated state
363
How is the half-life of carbamazepine affected by long-term use?
T1/2 decreases because carbamazepine is a strong CYP inducer and increases its own metabolism
364
What are the side effects of carbamazepine?
``` CNS: dizziness, drowsiness, ataxia, numbness, tingling GI: vomiting CVS: BP variation Rashes Hyponatraemia ```
365
What drugs does carbamazepine interact with?
Any metabolised by CYP (enzyme inducer) | E.g. Phenytoin, warfarin, steroids, OCP
366
What is the mechanism of action of phenytoin?
Voltage-gated Sodium channel blocker
367
How does lamotrigine work?
Voltage-gated sodium channel blocker | ? Also calcium channel blocker
368
What are the potential drug interactions of lamotrigine?
OCP reduces plasma levels of lamotrigine | Valproate increases lamotrigine levels by competitive binding
369
What are the side effects of lamotrigine?
Less marked CNS dizziness, ataxia, somnolence, nausea than other AEDs
370
Name 2 agonists at GABA receptors
Benzodiazepine | Barbiturate
371
How do GABA agonists act as anti epileptics?
``` Bind to GABA Increase chloride current into neurone Hyper polarises neurone Increases threshold for activation Reduced likelihood of epileptic neuronal hyper-activity ```
372
How does Sodium Valproate work?
Inhibition of GABA inactivation enzymes Stimulates GABA synthesising enzymes Voltage-gated sodium channel blocker Calcium channel blocker
373
What are the side effects of sodium valproate?
CNS: sedation, ataxia, tremor, weight gain | Increases transaminases
374
What are the potential drug interactions of valproate?
Antidepressants inhibit valproate action Antipsychotics antagonise valproate by lowering seizure threshold Aspirin: competitive binding increases valproate levels in plasma
375
What are the side effects of benzodiazepines?
``` Sedation Tolerance with chronic use Confusion Impaired coordination Aggression Abrupt withdrawal seizure trigger Respiratory and CNS depression ```
376
What is the antidote to benzodiazepine overdose?
IV flumazenil
377
What enzymes are involved in dopamine degradation?
Monoamine oxidase | COMT enzyme
378
Why can't you give dopamine to treat deficiency in the brain?
Can't cross BBB | Causes peripheral effects
379
What are the antimuscarinic side effects?
``` Miosis + SSLUDGE Salivation Sweating Lacrimation Urinary incontinence Diarrhoea GI upset and hypermotility Emesis ```
380
Give 4 examples of SSRIs
Fluoxetine Citalopram Paroxetine Sertraline
381
Give 3 side effects of SSRIs
Anorexia Nausea Diarrhoea
382
How do TCAs work?
Block reuptake of serotonin and noradrenaline at pre synaptic membrane
383
What is the effect of TCA overdose?
Lethal | Cardio toxic can cause sudden cardiac death
384
Name 2 SNRIs
Venlafaxine | Duloxetine
385
How are SNRIs dose dependent?
Lower doses - serotonin action | Higher doses - noradrenaline action
386
What are the actions of antipsychotics?
Sedation within hours Tranquilisation within hours Antipsychotic within several days/weeks
387
Name 2 typical antipsychotics
Haloperidol | Chlorpromazine
388
What is the mechanism of action of antipsychotics?
D2 receptor antagonists
389
Which antipsychotic causes weight gain?
Olanzipine
390
Name 5 mood stabilisers
``` Lithium Sodium valproate Carbamazepine Lamotrigine Antipsychotics ```
391
What are the side effects of lithium?
``` Memory problems Thirst Polyuria Tremor Drowsiness Weight gain ```
392
How do you treat lithium toxicity?
Supportive Anticonvulsant Increase fluid intake/IV fluids Harmonica lysis
393
How do you differentiate between schizophrenia and amphetamine effects?
Amphetamines only cause positive symptoms, not the negative symptoms of schizophrenia
394
Give 3 examples of acetylcholinesterase inhibitors
Donepezil Rivastigmine Galantamine
395
How do acetylcholinesterase inhibitors affect prognosis of Alzheimer's?
Slows progression - extra year of independent living
396
What are the side effects of acetylcholinesterase inhibitors?
``` N & V, anorexia, diarrhoea Fatigue, insomnia, headache Bradycardia Worsening of COPD Gastric/duodenal ulcers ```
397
What is memantine?
NMDA receptor antagonist
398
What are the differential diagnoses for depression?
Normal sadness Anxiety disorders Schizophrenia Organic brain syndromes
399
What are the differential diagnoses for mania?
Schizophrenia Organic brain disease involving frontal lobes Amphetamines or other illicit drugs

Phase 2 (21 decks)

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