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Mental Health Flashcards

1
Q

What are the 4 different anxiety disorders?

A

Phobia
Obsessive Compulsive Disorder
Panic disorder
Generalised anxiety

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2
Q

Symptoms of anxiety (Somatic)

A
  • Palpitations
  • Tremor
  • Sweating
  • Dry mouth

Fatigue, Dizziness, Chest pain, breathlessness, headache, lack of libido, sleep disturbance, difficulty swallowing

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3
Q

Symptoms of anxiety (psychological)

A 
apprehension
irritability
worry
fear of impending disaster
poor concentration
catastrophizing
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4
Q

Define generalised anxiety disorder

A

At least 6 months of excessive worry about everyday issues that are disproportionate to any inherent risk causing distress or impairment

ICD10 - more than 6 months with 4 symptoms - one of which must be palpitations, tremor, sweating or dry mount

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5
Q

Risk factors for generalised anxiety disorder

A

Family history (4x increased if 1st degree family member)
Aged 33-54
Female
Being divorced, separated, living alone or lone parent
Childhood adversity
Stressors
Social isolation

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6
Q

What investigations should be done if anxiety is suspected?

A 
TFTs
Urine drug screen
24 hour urine
Pulmonary function tests
ECG
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7
Q

What screening tool can be used for generalised anxiety disorder?

A

GAD2 or GAD7

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8
Q

Management of generalised anxiety

A
  1. Identification, assessment and education. Treat any alcohol or substance abuse
  2. Low intensity psychological interventions
  3. CBT OR drug treatment
    - sertraline
    - alternative SSRI or venlafaxine
    - pregabalin
    - benzodiazepine (short term only)
  4. Specialist care
    Comprehensive care and drug combinations

Consider propranolol for symptomatic control

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9
Q

Define phobia

A

Intense fears of specific objects or situations that are triggered upon actual or anticipated exposure to phobic stimuli

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10
Q

Incidence of phobias

A

8% of population
Average of onset 7-10 years
2-3 times more common in women
increased in Caucasian

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11
Q

Risk factors for phobia

A

Female
Anxiety or mood disorders
Substance misuse disorders
Stress and negative life events

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12
Q

Treatment for phobia

A
  1. Recognition and diagnosis

2. Graded exposure

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13
Q

Describe graded exposure

A

Systematic desensitisation - deliberate confrontation of fear until anxiety reduces

Needs to be

  • Repeated frequently
  • Graded in steps
  • Wait in situation until the anxiety reduced (otherwise reinforces)
  • Clearly specified and planned
  • Prolonged
  • No artificial anxiolytic
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14
Q

Define panic disorder

A

ICD10
Recurrent panic attacks not consistently associated with a specific situation or object. Occur spontaneously.

Moderate = 4 or more attacks in 4 weeks
Severe = 4 or more attacks in 1 week for 4 weeks
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15
Q

Define panic attack

A

Discrete episode of intense fear or discomfort
Starts abruptly
Reaches a crescendo after a few minutes

4 or more of the following symptoms;
Palpitations, difficulty breathing, dizzy, hot flushes, sweating, derealisation, cold chills, trembling, chest pain, fear of losing control, numbness, dry mouth, tingling

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16
Q

Risk factors for panic disorder

A 
Female 
20-30 
First degree relative
Caucasian
Smoking
Major life disorders
Asthma
Caffeine
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17
Q

Treatment for panic disorder

A
  1. Recognition and diagnosis
  2. CBT or medication
    - SSRI (citalopram or paroxetine)
  3. Specialist care
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18
Q

Define obsessions

A

Unwanted intrusive thoughts, doubts, images or urges that repeatedly enter the mind

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19
Q

Define compulsions

A

Repetitive behaviours or mental acts that a person feels compelled to perform in response to an obsession. Involuntary.

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20
Q

Define rumination

A

Mental acts repeated endlessly in response to intrusive ideas and doubts

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21
Q

Incidence of OCD

A

1.6% of the population
Equal in gender
Age in men = late adolescent
Age in women = early 20s

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22
Q

Definition of OCD

A

Obsessional symptoms and compulsive acts
Most days for at least 2 weeks
Source of distress or interferes with activities

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23
Q

Treatment for OCD

A

Mild - low intensity psychological therapy or CBT. If no response SSRI

Moderate - choice between CBT and ERP (exposure and response prevention) OR SSRI

Severe - CBT and ERP and SSRI
Then can trial clomipramine alone
Then can add clomipramine to SSRI

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24
Q

Symptoms of depression

A 
Depressed mod
Energy Loss
Pleasure loss (anhedonia)
Retardation/Agitation
Eating changes
Sleep disturbance
Suicidal thoughts
I'm a failure (loss of self-esteem/confidence)
Only me to blame (guilt)
No concentration
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25
Screening for depression
PHQ9 Patient health questionnaire | HAD - hospital anxiety and depression scale
26
Epidemiology of depression
``` 25% women, 10% men Female PMHx of depression Significant physical illness causing disability or pain Other mental health problems African-Caribbean, Asian Refugees, asylum seekers Family history ```
27
Definition of depression
1 core symptom: low mood or anhedonia plus some of other symptoms Mild - 4 symptoms Moderate - 5 to 6 symptoms Severe - 7+ symptoms or any psychotic symptoms
28
Causes of depression
``` Drugs = steroids, contraceptive pill, digoxin, beta blockers Hypothyroid Heart disease Stroke Cancer MS Dementia Alcohol abuse Illicit drug use Child birth (post-natal depression) Life events - unemployment, divorce, bereavement ```
29
Investigations in depression
``` U&Es LFTs TFTs Calcium FBC glucose inflammatory markers Magnesium Syphilis Drug screen ```
30
Treatment for depression
MILD - low intensity psychological therapies MODERATE Antidepressant or CBT SEVERE Antidepressant and CBT Antidepressant choice - SSRIs- fluoxetine, sertraline, citalopram - SNRI - venlafaxine - TCAs (high risk in OD) Note - increased risk of suicide in first 2 weeks
31
Define Bipolar disorder
Chronic illness associated with episodes of mania and depression At least 2 episodes in which a persons mood are significantly disturbed (1 of which MUST be mania or hypomania)
32
What are the 2 types of bipolar disorder
Type 1 - manic episodes. they are severe and result in impaired functioning and frequent hospital admission Type 2 - not full mania - hypomanic episodes. No psychotic symptoms
33
Define mania
``` At least 3 of the following symptoms: grandiosity decreased need for sleep pressured speech flight of ideas distractibility psychomotor agitation excess pleasurable activity with no thought for consequences ```
34
Epidemiology of bipolar disorder
2% Type 1 higher in males, type 2 in females Onset between 13 and 30 Strong family history relation ``` Drug or alcohol use Major life changes Abuse in childhood Early onset depression Periods of high stress ```
35
Symptoms of mania
``` Grandiose ideas pressure of speech excessive energy racing thoughts flight of ideas over activity less sleep easily distracted unkempt increased appetite sexual disinhibition recklessness financially ``` SEVERE auditory hallucinations delusions of persecution lack of insight
36
What is rapid cycling
4+ cycles of depression and mania in 1 year with no asymptomatic episodes Associated with longer course of illness, earlier age of onset, increase suicide, increased drug and alcohol abuse TEST THYROID FUNCTION
37
Management of acute manic episode
Increase antipsychotic dose to maximum if already taking 1. Haloperidol, olanzapine,quetiapine, risperidone 2. If one is not effective swap to another 3. If the second doesn't work - add lithium STOP all antidepressants
38
Management of depressive episodes in bipolar disorder
Use antidepressants carefully as can tip into mania - only used with anti-mania medication Don't treat if mild Moderate to severe 1. fluoxetine and olanzapine or quetiapine alone 2. Lamotrigine alone
39
Management of rapid cycling
Stop all antidepressnats Anti-mania therapy maximises Lithium + valproate
40
Long term treatment of bipolar disorder
1. Lithium 2. Add valproate Continue for 2 years but may need for 5 years. ECT can provide rapid improvement in severe mania but is short lived
41
Prognosis of bipolar
``` average 10 episodes in a lifetime High risk of recurrence Symptom free episodes get shorter with increased time 25-55% have at least 1 suicide attempt Highest rate of suicides ```
42
Define psychosis
Seeing or hearing things others do not Having unusual thoughts or beliefs Feeling confused or suspicious
43
Stages of psychosis
1. Prodromal phase Unclear, drop in functioning, sleep or mood disturbance 2. Psychosis and threshold Frank symptoms of psychosis - can occur at any age but most likely to occur in late teens, women tend to be older 3. remission 4. relapse
44
What is the early intervention rationale
Reduce the impact of psychosis by offering interventions at the earliest stage of condition as the longer the duration of the untreated psychosis = worse prognosis Early intervention work with 14-35 year olds for first occurrence for up to 3 years Reduce the impact
45
What risks should be assessed under mental health
``` suicide self-harm aggressive behaviour neglect exploitation by others self-neglect ```
46
Risk factors for suicide
``` Male Older age or teen Previous attempt Mental illness in 90% divorced, single or widowed bereavement social isolation physical ill health unemployed ```
47
What are the 3 categories of suicide/self harm
Failed suicide attempt - high risk of re-attempting. Likely to have mental health problems Impulsive self harm with ambivalence to death = overdose taken after stressful event. No real suicidal intent. Tend to be young and female Repeated self-harm without suicidal intent
48
If a person presents with suicide - what questions need to be asked?
``` Events preceding the event Details of the act themselves Intentions Current thoughts about suicide Was it planned? What happened after? Any previous attempts? ```
49
What are the 5 stages of grief (Kubler-Ross)
``` Denial (and isolation) Anger Bargaining Depression Acceptance ```
50
What is complicated grief?
Pathological reaction to loss associated with long term physical and psychological dysfunction Longer than 6 months and stuck in maladaptive state significant deviation from cultural norm or increase intensity of impairment
51
Risk factors for complicated grief
``` parental abuse Parental death controlling parents Close relationship with deceased Insecure attachment styles Emotional dependency Sudden death Death in hospital ```
52
Define adjustment disorder
Transient states of distress and emotional disturbance which arises in the course of adapting to a significant life change, serious physical illness or possibility of serious illness. Stressor is not of unusual or catastrophic type. - Must start within 3 months of stressful life event (usually within 1 month) - Course does not exceed 6 months - Depressive or anxiety symptoms that cause functional impairments
53
Aetiology of adjustment disorders
``` Relationship break up Unemployment Occupational dispute Bereavement Illness ```
54
Presentation of adjustment disorder
Depressed mood Anxiety Worrying Feeling or irritability to cope, plan ahead or continue Difficulty in daily living Liable to dramatic behaviour or violence Palpitations, rapid breathing, diarrhoea, tremor Aggression, deliberate self-harm, alcohol abuse, drug misuse, social difficulties
55
ICD10 subtypes of adjustment disorders
Brief depressive reaction Prolonged depressive reaction Mixed anxiety and depressive reaction Adjustment disorder - emotion/conduct/mixed
56
Prognosis of adjustment disorders
Usually resolve within a few months
57
Definition of schizophrenia
At least one must be present most of the time for 1 month - Thought echo, insertion, withdrawal or broadcast - Delusions of control referred to body parts, actions or sensations - Delusional perception - Hallucinatory voices giving running commentary, discussing the patient or coming from a part of the patient's body - Persistent bizarre or culturally inappropriate delusions OR 2 of the following for most of the time for 1 month: - Persistent daily hallucinations accompanied by delusions - Incoherent or irrelevant speech - Catatonic behaviours - stooping and posturing - Negative symptoms such as marked apathy, blunted or incongruous mood
58
Epidemiology of schizophrenia
``` 15 per 100,000 incidence 7 per 1000 prevalence Starts in adolescence and early 20s Peak age of onset is later in women More common in men More common in Blacks and ethnic minorities FHx association ```
59
Subtypes of schizophrenia
Paranoid - delusions or hallucinations prominent Hebephrenic - sustained, flattened or incongruous affect, lack of goal directed behaviour, prominent thought disorder Catatonic - sustained evidence over at least 2 weeks of catatonic behaviour including: stupor, excitement, posturing, rigidity. Simple - considerable loss of personal drive, progressive deepening of negative symptoms
60
First rank symptoms of schizophrenia
Rare in other psychotic illness and only 1 present is strongly predictive of schizophrenia - Lack of insight - Auditory hallucinations - echoing of thoughts, 3rd person commentary - Thought insertion, removal or interruption - Thought broadcasting - Delusional perceptions (abnormal significance for normal event) - External control of emotions - Somative passivity - thoughts, sensations and actions are under external control
61
Negative symptoms of schizophrenia
``` Underactivity Low motivation Social withdrawal Emotional flattening Self-neglect ```
62
Signs of schizophrenia
Appearance - Withdrawal, suspicion, repetitive purposeless movements Speech - Interruptions to the flow of thought (thought blocking), loosing of associations, knight's move thinking Mood/affect - Flattening, incongruous or odd Beliefs - Delusion perceptions, delusions regarding thought control or broadcasting, passivity of experiences Hallucinations Cognition - attention, concentration, orientation and memory should be assessed and is often impaired
63
Risk factors for schizophrenia
``` FHx Premature birth or low birth weight Perinatal hypoxia Intrauterine infection - influenza in 2nd trimester Abnormal early cognitive neuromuscular development Social isolation Urban lifestyle Illicit drug use Migrants Abnormal family interactions Blacks and ethnic minority ```
64
Aetiology and pathophysiology of schizophrenia
Multifactorial: genetic, environmental and social Greatest risk factors in FHx - 40% in monozygotic twins NRG1 has some part Dopamine in mesolimbic system plays a key role Excessive dopamine adds salience to mundane and insignificant thoughts or perceptions Amphetamine misuse increases synaptic dopamine and can cause delusions and hallucinations
65
Investigations in schizophrenia
``` FBCs and LFTs Check for alcohol abuse Urine screening for drug misuse Serological tests for syphilis Check for intoxication or drug overdose ```
66
Management of schizophrenia
- Early intervention services - MDT - Health promotion - Increased compliance with medication DRUGS - Usually risperidone or olanzapine 1. Agree choice of antipsychotic 2. Titrate as necessary to minimum effective dose 3. Assess over 6-8 weeks 4. If not suitable, change drug and repeat steps 1-3 5. If not suitable - CLOZAPINE
67
Prognosis for schizophrenia
More than 80% of patients with their first episode will recover 20% will never have another episode Worse prognosis with: poor premorbid adjustment, slow insidious onset, long duration of untreated psychosis, prominent negative symptoms
68
Differentials for schizophrenia
ORGANIC - Drug induced psychosis - amphetamine, LSD, cannabis - Temporal lobe epilepsy - Encephalitis - Alcoholic hallucinosis - Dementia - Delirium - Cerebral syphilis PSYCHIATRIC - mania - psychotic depression - personality disorder - panic disorders - dissociative identity disorder
69
Define psychosis
Severe mental disorder in which there is extreme impairment of ability to think clearly, respond with appropriate motion, communicate effectively, understand reality and behave appropriately.
70
Define delusions
False, fixed strange or irrational belief with is firmly held
71
Define hallucinations
Sensory perception without an appropriate stimulus
72
Delusional themes
Delusion of control - someone else controlling feelings, behaviours and thoughts Delusional jealousy Delusion of guilt Thought insertion Delusion of reference Erotomania - belief that someone is in love with them Grandiose Grandiose religious - person is god or chosen to act as god Persecutory - followed/harassed/cheated or conspired against
73
Cotard delusion
Thought or belief that they don't exist or that they have died
74
Delusion of reference
Insignificant remarks or events have personal significance to patient
75
Types of hallucinations
Visual - more common in organic illness e.g. TLE, epilepsy, Parkinson's Auditory - more common in functional psychiatric illness. Tactile - cocaine bugs, simple partial seizures, somatic passivity experiences Olfactory - epileptic aura, tumours, schizophrenia Gustatory - epileptic aura and attack. Functional illness
76
Lilliputian Hallucinations
Seen in TLE (temporal lobe epilepsy) Size distortion Alice in Wonderland syndrome Also seen in migraines, brain tumours and EBV
77
Types of disordered thoughts
``` Paucity of thought Thought block Rapid uncontrollable thoughts Formal thought disorders - Derailment - Loosening of association - Knight's move thinking - Word salad ```
78
Organic causes of psychosis
Delirium - infections, electrolyte disturbance Epilepsy Medications - steroids, antibiotics, antivirals, dopamine agonists, stimulants Cancer MS SLE Neurodegenerative disorders e.g. Parkinson's Drug or alcohol withdrawal
79
Psychaitric causes of psychosis
``` Schizophrenia Schizoaffective disorder Bipolar disorder Major depression Acute psychosis Dementia Personality disorders ```
80
Risks in schziphrenia
Suicide rate is 10-15% High in early stages of disease Self-neglect Risk to others - mild increased in minor aggressive acts.
81
Extrapyramidal side effects
``` Dystonia Pseudoparkinsonism Akathisia Tardive dyskinesia Sedation Hyperprolactinaemia Decreased seizure threshold Postural hypotension ```
82
Dystonia
Dystonia is a movement disorder in which a person's muscles contract uncontrollably. The contraction causes the affected body part to twist involuntarily, resulting in repetitive movements or abnormal postures
83
Akathisia
Akathisia is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting.
84
Tardive dyskinesia
a disorder resulting in involuntary, repetitive body movements. In this form of dyskinesia, the involuntary movements are tardive, meaning they have a slow or belated onset
85
Somatisation
psychological distress manifested as physical symptoms e.g. pain
86
Dissociation.conversion
Psychological distress manifests as physical and mental signs e.g. paralysis and amnesia
87
Relationship between physical and psychiatric illness
- Psychiatric symptoms can be a consequence of physical illness e.g. organic - Physical symptoms are manifestations of psychiatric disorder e.g. MUS and somatisation - Psychiatric symptoms that are manifestations of underlying physical illness e. g. hypothyroid - Psychiatric symptoms precipitating physical illness Anxiety, depression can precipitated seizures, MS relapses, pain
88
Define medically unexplained symptoms
Physical symptoms not explained by organic disease and there is positive evidence or assumption that the symptoms are linked to psychological factors - Not a diagnosis of exclusion - requires positive psycholigcal factors - Most are transient and not deliberately produced
89
Define illness denial
Behaviours to avoid the stigma | Inability to accept the physical or mental illness
90
Define illness affirmation
Behaviours that inappropriately affirm the illness | Disproportionate disability in relation to signs and symptoms
91
Define somatisation
Manifestation of psychological stress as physical complaints with medical consultation. Can be acute or chronic often associated with psychiatric diagnosis Not a conscious process
92
ICD10 definition of medically unexplained symptoms
2 years of multiple and various physical symptoms Persistent refusal to accept advice and reassurance that there is no physical aetiology Some degree of impaired functioning Temporal relationship to stresses
93
Features of chronic somatisation
``` Many unexplained symptoms (often pain) Multiple investigations Frequent consultations Excessively disabled Polypharmacy Thick case notes Dissatisfied with care odd beliefs Unrealistic expectations of care Denial or minimise life problems ```
94
Define dissociative disorder
acute and dramatic onset Psychological distress manifests as physical mental signs Mental symptoms e.g. amnesia, fatigue states Caused by stressful life events, child hood neglect or abuse.
95
Define conversion disorders
acute and dramatic onset Psychological distress manifests as physical signs PHYSICAL symptoms e.g. paralysis, blindness Caused by stressful life events, child hood neglect or abuse.
96
Prevalence and outcome of medically unexplained symptoms
20% of general population 10-33% of GP presenting complaints Secondary care 30-50% 50% recede in 12 months 2.5% persist and lead to repeated consultation Conversion and dissociation disorders recover quickly
97
Clinical identification of MUS
Symptoms do not fit with existing disease models Patient is unable to give clear and precise description of symptoms Symptom or disability seems excessive in comparison to pathology Temporal relationship to stressful life events Patient attends frequently with different symptoms patient over anxious about the meaning of symptoms patient complains of pain in various sites
98
Management of MUS
Acknowledge that symptoms are genuine Provide clear explanation of investigations, results and conditions excluded Avoid extra investigations of referrals unless clinically indicated Address the patients concerns - Set up brief regular meetings every 6-8 weeks (they need to feel they are being taken seriously) - Symptom management e.g. analgesics, laxatives, antispasmodics, weight loss and exercise - Treat any anxiety or depression if present +/- IAPT - Counsellor if required Aim for patient coping and decreased impact on life rather than symptom cure.
99
Ways of parents managing child stress
Provide safe, secure, familiar, consistent environment Encourage the child to ask questions Listen to child without being critical Use encouragement and affection Use positive encouragement not punishment Allow child to make choices and have some control Recognise signs of unresolved stress
100
Methods of screening for dementia
``` Mini mental state exam (MMSE) MOCHA ACE-III DEMTECT AMTS ```
101
Describe MMSE
Out of 30 Cut off 24 Most commonly used for complaints of problems of memory Used for diagnosis and assesses progression and severity Tests memory, attention and language Not good for mild impairment X doesn't test frontal function X not designed to measure change
102
Describe MOCHA
Out of 30 Cut off 26 Aimed at detection of mild cognitive impairment Relatively comprehensive but brief Not biased towards a particular cognitive domain Not suitable for patients in advanced stages
103
Describe ACE-III
``` Out of 100 Cut off 82-88 Robust validation in various neurodegenerative conditions Appropriate for longitudinal studies Sensitive to subtle impairments Not sensitive to behavioural impairments ```
104
Describe AMTS
``` Out of 10 Cut off 6-8 Widely used in hospital settings 10 questions Easy to use Insufficient for more detailed assessment of cognition ```
105
Define dementia
Syndrome that is chronic and progressive in nature where there is a deterioration of cognitive function beyond what might be expected in normal aging. Affects: memory, thinking, orientation, comprehension, calculation, learning capacity. Impairment in cognitive function is commonly accompanied and occasionally preceded by deterioration in emotional, social control or motivation
106
Diagnostic criteria for dementia
- Affects ability to function in normal activities - Represents a decline from a previous level of function - Cannot be explained by delirium or other psychiatric disorder - Has been established from history and cognitive assessment - Involve impairment of at least 2 cognitive domains
107
Epidemiology of dementia
1.5% of 65-69 22% of over 85s ``` Increases with age Similar prevalence in males and females Alzheimer's more common in women. Vascular and mixed more common in men More common in Caucasians ```
108
Aetiology of dementia
``` Alzheimer's (50%) Vascular dementia (25%) Dementia with Lewy bodies (15%) Frontotemporal dementia (5%) Mixed dementia Parkinson's disease ``` Potentially treatable disease: - Substance abuse - Hypothyroidism - Space occupying lesions - Normal pressure hydrocephalus - Syphilis - Vitamin B12 deficiency
109
Investigations for dementia
- Ensure no treatable cause has been missed - FBC, ESR or CRP, U&Es, LFTs, glucose, calcium, TFTs, B12 and folate - MSU - VDRL/TPHA (syphilis) - Consider blood cultures, CXR, MRI and psychometric testing - Specialised assessment required to determine subtype - Can use HMPAO-SPECT to distinguish Alzheimer's from other types - CSF if ?CJD - Imaging: MRI preferred
110
Management of dementia (general)
- Person centred care - Discuss options - Valid consent where possible - Cognitive stimulation programmes - Music/Art/Dance therapy - Structured exercise program
111
Pathophysiology of Alzheimer's disease
Formation of senile plaques and neurofibrillary triangles Excess amyloid beta peptides due to over production or decreased clearance Formation of dense amyloid plaques Plaques cause inflammatory process - cytokines, complement cascade Synaptic and neuronal injury and cell death ``` Decreased brain weight Cortical atrophy - temporal, frontal and parietal areas Beta amyloid plaques Neurofibrillary triangles Neurotransmitter deficiencies ```
112
Risk factors for Alzheimer's disease
``` Increase in women Increases with age FHx (x3.5 if 1st degree family member) Apolipoportein E4 Head injury Hypercholesterolaemia Hypertension Diabetes Down's syndrome ```
113
Diagnostic criteria for Alzheimer's
- Dementia established by examination and testing - Deficits in 2 areas of cognition - Insidious onset (months-years) - Progressive worsening - No change in consciousness - Onset between 40 and 90 with no other cause
114
Presentation of Alzheimer's
Early stages - Memory lapses - Nominal dysphasia - Difficulty finding the right words - Inability to remember recent events - Forgetting appointments Progresses to: - Language difficulties - Apraxia - Difficulty planning - Confusion Late Stage: - Wandering, disorientation - Apathy - Psychiatric depression, hallucination delusions - Incontinence - Altered eating habits - Behavioural changes - disinhibition, aggression, agitation
115
Management of Alzheimer's
1. Acetylcholinesterase (AChE) inhibitors - Donepezil, galantamine, rivastigmine - For mild-moderate as long as benefit 2. NDMA antagonist - Memantine - for moderate-severe No cure.
116
Define vascular dementia
Group of syndromes of cognitive impairment caused by ischaemia or haemorrhage secondary to cerebrovascular disease
117
Aetiology of vascular dementia
Stroke related - single infarct or multi-infarct Subcortical - small vessel disease or Binswanger's disease Mixed - Alzheimer's and vascular Leukoraisosis - subcortical leukoencephalopathy Haemorrhage SPORADIC - most are sporadic, some familial traits CADASIL - most common inherited
118
Pathophysiology of vascular dementia
Once infarct or bleed reaches a certain volume, it will exhaust brains compensation Small infarcts are due to arteriosclerosis secondary to hypertension
119
Risk factors for vascular dementia
``` Hx of stroke or TIA AF Hypertension Diabetes Hyperlipidaemia Smoking Obesity CHD Fhx of stroke or CHD ```
120
Diagnostic criteria for vascular dementia
- Diagnosed dementia - Deficits interfere with ADLs - Cerebrovascular disease - signs or imaging - A relationship between disorders - Onset of dementia within 3 months of stroke - Abrupt deterioration in cognitive functions - Fluctuating stepwise progression of cognitive defects
121
Presenting features of vascular dementia
Focal neurological abnormalities - visual disturbances, sensory or motor symptoms EPS - extrapyramidal symptoms Difficulty with attention and concentration Seizures Depression and/or anxiety Early presence of disturbance in gait, unsteadiness, increased falls Bladder symptoms without urological dysfunction Emotional liability, psychomotor retardation, depression
122
Treatment for vascular dementia
No specific pharmacological treatment | Modify vascular risk factors
123
Complications of vascular dementia
``` Behavioural problems - wandering, delusions, hallucinations, poor judgement Depression Falls and gait abnormalities Decubitus ulcers Aspiration pneumonia ``` Prognosis worse than Alzheimer's - 3-5 years
124
Define Lewy Body dementia
Characterised by eosinophilic intracytoplasmic neuronal inclusion bodies (LEWY BODIES) in brainstem and neocortex. There is a spectrum which may overlap Parkinson's
125
Presentation of Lewy Body Dementia
Dementia - memory loss, decline in problem solving and spatial awareness Fluctuating levels of awareness and attention Signs of mild Parkinsonism - tremor, rigidity, poverty of facial expression, festinating gait Visual hallucinations Sleep disorders
126
Diagnostic criteria of Lewy body dementia
Presence of dementia 2 of 3 core features: - Fluctuating attention and concentration - Recurrent well formed visual hallucinations - Spontaneous Parkinsonism
127
Pathophysiology of Lewy body dementia
Pathology mimics Parkinson's | Lewy body inclusions are composed of a protein called alpha-synuclein
128
Treatment of Lewy body dementia
Avoid neuroleptic drugs Cholinesterase inhibitors (Rivastigmine) can help treat cognitive decline Average survival 5-8 years
129
Define fronto-temporal dementia
Also known as Picks disease Affects frontal and/or temporal lobes It is one of the more common causes of dementia before the age of 65
130
Epidemiology of FT dementia
More common in men Mean presentation 53-58 years No difference in ethnicity 15 per 100,000
131
Pathophysiology of FT dementia
Atrophy of frontal and temporal lobes Focused No increased plaques Protein inclusions in neurons and glial cells - TAU - TDP - FUS
132
Presentation of FT dementia
3 main clinical syndromes defined by predominant symptom at presentation - BEHAVIOURAL variant FT dementia (50%) Loss of inhibition, inappropriate social behaviour, decrease motivation, loss of empathy and sympathy, change in preferences, repetitive compulsive behaviour, decreased memory, echolalia, mutism - Progressive non-fluent APHASIA Slow, hesitant, difficult speech, grammatical errors in speech, loss of literary skills, impaired understanding of complex sentences, impairment of swallowing and coughing on demand - Semantic dementia Loss of vocab with fluency or maintained speech, difficulty finding right word, loss of recognition, preserved memory and visuospatial skills, asking meaning of familiar words
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Treatment of FT dementia
Stop cholinergics or CNS drugs SSRIs may help with behavioural symptoms Can use atypical antipsychotics if psychosis and agitation Levodopa/carbidopa if Parkinson's symptoms Average survival 8-10 years
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Define delirium
Aetiologically non-specific organic cerebral syndrome characterised by concurrent disturbances of consciousness and attention, perception, memory, behaviour, emotion and sleep wake cycle Duration is variable, as is severity
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Types of delirium
Prevalent - condition present on admission Incident - occurs during admission Hypoactive - apathy and quiet confusion. Can be confused with depression Hyperactive - agitation, delusions, disorientation
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Epidemiology of delirium
0.4% Increases with age More common in males 30% of ED patients Only 20-50% detected by medical professionals Most common complication of hospital stay in elderly Risk factors - Elderly - Malignancy - HIV/AIDS - Pre-existing cognitive issue - Past delirious episode - Burns - Emergency surgery - Orthopaedic surgery (hip) - Drug/substance abuse - Social isolation - Poor mobility - Terminally ill - Change of environment
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Aetiology of delirium
Acute infections Prescribed medications: benzos, analgesia, anticholinergics, anticonvulsants, steroids Post-op Toxic substances - alcohol, CO, barbituates, drug or alcohol withdrawal Vascular - Stroke, cardiac failure, ischaemia, subdural, subarachnoid, vasculitis, migraine Metabolic - hypoxia, electrolyte disturbance, hypo/hyperglycaemia Vitamin deficiencies - B12, thiamine, nicotine Endocrine - hypo/hyperthyroid, hypopituitarism, Cushing's Head injury Epilepsy Cancer
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Symptoms of delirium
``` Clouded consciousness Impaired cognition/ disorientation Poor concentration Memory deficits Abnormalities in sleep wake cycle Abnormalities of perception (hallucinations and illusions) Agitation Emotional lability Psychotic ideas Neurological signs (tremor and unsteady gait) ```
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Confusion Assessment Method
Patient must have - Acute onset and fluctuating course AND - Inattention AND EITHER - Disorganised thinking OR - Changed level of consciousness
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Investigations for delirium
``` Full examination FBC U&Es Glucose LFTs TFTs Troponin Vitamin B12 Syphilis PSA Urine dipstick and microscopy Blood cultures and serology ECG Pulse ox (and ABG if indicated) CXR and AXR ``` Other - head CT, LP, EEG
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Management of delirium
Treat underlying cause If cannot provide consent then treat in best interests - Supportive management: clear communication, reminder of day/time/place, clocks, familiar staff and objects from home - Environmental measures: single room control noise, lights and temperature, maintain abilities, attention to incontinence - Medical management: antipsychotics if aggressive and not responding to de-escalation Haloperidol and olanzipine
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Prognosis of delirium
Short term has no effect on mortality Long term - 2-3x mortality Some do not return to baseline Complications - hospital acquired infections, pressure sores, fractures, residual impairment, stupor, coma, death
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Indications for ECT
- Severe depression where fluid intake is so poor that it is lifethreatening - Depressive stupor - Psychomotor retardation - Psychotic depression - Depression with strong suicidal features - Treatment resistant
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Contraindications to ECT
``` Recent MI Arrhythmias Heart failure Stroke Respiratory problems GORD ```
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Side effects for ECT
``` Mortality 1 in 10,000 Prolonged seizures Headache, nausea, muscular aches Post ictal - confusion, impaired attention Some memory issues ```
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Social and emotional development milestones | 0-3 months
``` Interest in people Start to learn and recognise their primary caregivers Can be comforted by familiar adults Respond positively to touch Smiles ```
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Social and emotional development milestones | 3-6 months
Plays peek a boo Pays attention to own name Smiles spontaneously Laughs outloud
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Social and emotional development milestones | 6-9 months
Wider emotional range, strong preferences for familiar people Expresses several emotions Distinguishes friends from strangers Shows displeasure at loss of toys
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Social and emotional development milestones | 9-12 months
Able to feed themselves with fingers Can hold a cup with 2 hands and drink with assistance Hold out arms and legs when dressed Anxious when separated from primary care giver
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Social and emotional development milestones | 1-2 years
``` Intense feelings for parents Play by themselves, initiate own play Express negative feelings Begins to be helpful e.g. put things away Assertive ```
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Social and emotional development milestones | 2-3 years
Assertive about preferences Awareness of emotions and feelings or others Rapid mood shifts Displays aggression Enjoys parallel play, solitary actions near other children Begins to play house Defends positions
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Social and emotional development milestones | 3-4 years
``` Becomes more independent Completes simple tasks Wash hands unassisted More interested in other children More likely to share ```
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Define autism
Range of conditions with varying degrees of severity. Includes Asperger's and Rhett's It is a developmental disorder which affects 4 domains and starts before the age of 3. Domains: - Repetitive behaviours - Imagination - Language/communication - Social 6 abnormalities, 2 from B1
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Symptoms of autism (categories)
B1 - SOCIAL - Eye contact, gesture, body language - Failure to develop peer relationships - Empathy and social responses - Lack of seeking to share interest and pleasure B2 - COMMUNICATION - delay in language development (without gesture compensation) - conversational reciprocity - repetitive or unusual language - imagination B3 - BEHAVIOUR - preoccupation with abnormal intensity/content - Compulsions, rituals, sameness - Mannerisms or stereotypes - Sensory preoccupations or fears
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Asperger's
Same as autism BUT - No delay in language - No significant delay in cognitive development - Other associations: - Motor clumsiness - Some have isolated special skills
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Epidemiology of autism
``` Prevalence 6 in 1000 Age - under 3 More common in males No racial associations Positive family history ``` Increasing prevalence over the last few years due to increasing diagnosis
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Signs and symptoms of autism
``` Language delay or regression Verbal and non-verbal communication impairment Social impairment Repetitive, rigid or stereotyped interests, behaviours and activities Placcid or irritable as baby Unusual posturing Motor stereotypies Sensory interests ```
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Aetiology of autism
``` Genetic factors Maternal rubella Meningitis/encephalitis Fragile X syndrome Tuberous sclerosis Down's syndrome ``` NOT parental or environmental
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Pathophysiology of autism
UNKNOWN 3 Neurocognitive theories of autism - THEORY OF MIND Difficulties in considering how others may think and react in certain situations. Cannot put themselves into the minds of others - WEAK CENTRAL COHERENCE Failure to intergrate information into meaningful whole. Can't make meaning of things, can't get the gist - EXECUTIVE FUNCTION Difficulties with problem solving and forward planning in order to achieve a goal
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Management of autism
MDT approach - Multiple assessments - play based, school observations - Exclude other causes: deafness, abuse, attachment disorder, OCD, LD etc. - Develop social communication and learning and problem solving - Teach idiom and metaphor - Support routines of learning - Provide support and respite care and sibling support
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Investigations of autism
``` Childhood autism rating scale Diagnostic Questionnaires Observational assessment - multiple Fragile X and chromosome microarray testing EEG/MRI ```
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Differentials for autism
ADHD Social communication disorder Schizoid personality disorder
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Define ADHD
Attention Deficit Hyperactivity Disorder Begins in childhood with functional impairment, most often in home and school - Can limit academic and interpersonal and occupational success Patients with ADHD more likely to have co-existing psychiatric disorder
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Epidemiology of ADHD
5% One of the most common childhood disorders More common in males Higher in Blacks Occurs in children. Inattentive type presents later FHx - yes ``` RFs Family history Low birth weight Maternal smoking in pregnancy Poverty Lead exposure Iron deficiency ```
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Pathophysiology of ADHD
? dysfunction of NA and dopamine 85% respond to stimulants ?dysfunction in frontal subcoritical circuits due to executive dysfunction Decreased activation in basal ganglia and anterior frontal lobe
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Types of ADHD
``` Hyperactive impulse type (15%) Inattentive type 20-30% Combined type (50-75%) ```
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Hyperactive impulse type ADHD
15% of ADHD Need 6/9 criteria - fidgets with hands or feet/squirms in seat - leaves classroom when remaining seated is expected - Runs or climbs excessively when inappropriate - Difficulty playing or engaging in activities quietly - On the go - Talks excessively - Blurts out answers before questions fished - Difficulty waiting turn - Interrupts or intrudes on others
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Inattentive type ADHD
20-30% of ADHD Need 6/9 criteria - Fails to given attention to detail/careless mistakes - Difficulty sustaining attention in tasks or play - Doesn't listen when spoken to directly - Doesn't follow through on instruction e.g. homework - Difficulty organising tasks and activities - Avoids/dislikes tasks requiring sustained mental effort - Loses things necessary for tasks - Easily distracted - Forgetful in daily activities
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Investigations in ADHD
ADHD rating scale or attention deficits disorders evaluation scale Consider neuropsychological testing
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Management of ADHD
Pre-school - no drug treatment School with moderate impairment - group based parent education programmes. CBT and social skills training. School with severe impairment 1. Methylphenidate + psychoeducation + adjunct behavioural therapy 2. Atomoxetine 3. Guanfacine or clonidine 4. Antidepressant Parent training in communication, positive feedback, effective time outs and co-ordination of school behavioural plan
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Epidemiology of depression in children
1% in children 3% post-puberty Twice as common in girls Prevalence increasing ``` Risk factors: Family discord Bullying History of parental depression Physical, sexual or emotional abuse Homelessness Ethnic and cultural factors Refugee Living in institutional setting ```
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Presentation of depression in children
``` As adults with: Running away from home Separation anxiety School refusal Complaints of boredom Poor school performance Antisocial behaviour Insomnia or hypersomnia ``` * Somatic complaints * Irritability * Social withdrawal
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Management of depression in children
Midl psychological therapy used 1st line Moderate - refer to CAMHS Medication only alongside psychological therapies FLUOXETINE is the only drug where benefits>risks ECT only if very severe with life threatening symptoms (aged over 12)
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Prognosis of childhood depression
10% recover spontaneously in 3 months 50% depressed at 12 months, 30% at 2 years 30% will have recurrence within 5 years Worse prognosis with females, previous episodes of depression 1-3% attempt suicide with 5-15% recurrence
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Define conduct disorder
Psychological disorder diagnosed during childhood or adolescence that presents itself through a repetitive and persistent pattern of behaviour in which age appropriate norms are violated. Aggressive behaviour/deceitfulness/destruction of property/violation of rules
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Types of conduct disorders
Socialised conduct disorder Unsocialised conduct disorder Conduct disorders confined to family context Oppositional defiant disorder
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Epidemiology of conduct disorders
More common in males 8% of boys, 5% girls Appears in early to middle childhood Oppositional defiant disorder is more common in the under 10s RFs - Second hand smoking - Male - Non contact or mobile family - Coercive/ineffective parenting - Hyperactivity/ inattention - Smoking in pregnancy - Low birth weight
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Symptoms and criteria for conduct disorder
Must be under 18 At least 3 out of 15 criteria in past 12 months, at least 1 in last 6 months Aggression to people/animals - bullies, threatens, intimidates - initiates physical fights - use of a weapon - physically cruel to people or animals - stolen something while confronting victim - forced someone into sexual activity Destruction of property - deliberately fire setting, aiming to cause damage - Deliberately destroyed property Deceitfulness or left - Broken into house or car - Often lies to obtains goods, favours or void obligations - Stolen items without confronting victim Serious violation of rules - stays out at night desperate parental prohibitions - run away from home overnight (2+) - truant from school aged under 13
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Oppositional defiant disorder
``` Usually frequent or severe tantrums Often argues with adults Actively refuses adult request or defied rules Deliberately does things to annoy others Blames others for their mistakes Touchy or easily annoyed by others Angry or resentful Spiteful ```
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Management of oppositional defiant disorder
Multi-axial approach Deal with psychological illness, cognitive functioning, development, physical illness and psychosocial issues - May have developmental delay - Discrepancy between age and development - May have physical problems - Hunter's Comprehensive assessment Parent training programs Child group social and cognitive problem solving programmes If oppositional defiant disorder 0 given methyphenidate or atomoxetine - Clear rules or commands - Promoting play and positive relationships
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Classification of learning disabilities
Mild IQ 50-70 Language fair. little sensory or motor deficits. reasonable level of independence Moderate IQ 35-49 Better receptive than expressive language Severe IQ 20-34 Increasing sensory and motor deficits. 50% will have epilepsy. Profound IQ<20 Increase need. Vulnerable. Developmental level at about 12 months
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Define learning disability
IQ < 70 Loss of adaptive social functioning Onset before age 18
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Epidemiology of LD
More common in males Prevalence 2% Decrease life expectancy
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Aetiology of learning disability
Genetics: Down's, Fragile X, Turner;s, Klinefelter's Metabolic: phenylketonuria, galactosaemia, Tay-Sachs disease, Hurler's syndrome Strucutural disorders: tuberous sclerosis, hydrocephalus, neurofibromatosis Intrauterine: iodine deficiency, infection (CMV, rubella, toxoplasmosis) Drugs - phenytoin, alcohol Cerebral malformations Pre-eclampsia, premature labour, APH Prologned labour, trauma, asphyxia Neonatal - hypoglycaemia, severe neonatal jaundice, meningitis, encephalitis anoxia, hypothyroid, malnutrition
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Presentation of learning disability
``` PHYSICAL PROBLEMS Motor and mobility problems abnormalities in movement speech, vision and hearing problems epilepsy urinary and faecal incontinence increase risk of obesity, fractures, GORD, constipation ``` ``` PSYCHOLOGICAL - all increased in LD Schizophrenia Anxiety and depression Personality disorder Early onset dementia ADHD Autism ``` BEHAVIOUR threatening own and others safety violent but harmless behaviour temper tantrums Sleep disorders Communication difficulties
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Investigations for LD
No lab investigations Diagnosis made by history, observations and assessment If developmental delay then chromosome and fragile X testing TFTs If severe delay, head MRI and CK
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management of LD
MDt support - social worker, psychologist, SALT, physio, nurses, psychiatry, OT Annual check with GP Direct support and coaching Psychotropic drugs rarely used Behaviour support plan - identify reactive and preventative strategies Anger management programmes
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Prognosis of learning difficulties
Death 25 years earlier than expected
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symptoms of depression in a patient with LD
``` Agitation Weight changes Appetite changes Poor sleep Psychomotor retardation Tearfulness ``` Biological problems more relevant when expression of feelings is difficult
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Ways of assessing for drug and alcohol dependence
CAGE questionnaire AUDIT SADQ
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Cage Questionnaire
Cut Down? Annoyed by people criticising your drinking? Guilty about drinking? Eye-opener 2 or more points suggests a problem, but it is not very specific
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AUDIT for alcohol
Alcohol Use Disorders Identification Test 10 items, 4 levels of risk 0-7 - alcohol education 8-15 = simple advice on cutting down 16-19 = simple advice + brief counselling and continued monitoring 20-40 = referral to specialist for diagnostic evaluation and treatment
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SADQ for alcohol
Assesses severity and degree of dependence once a problem is identified Covers - physical withdrawal symptoms - affective withdrawal symptoms - relief drinking - frequency of alcohol consumption - speed of onset <16 = mild dependence 16-30 = moderate >30 severe dependence
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ICD10 definition of dependence syndrome
Physiological and behavioural and cognitive phenomena in which use of a substance takes a higher priority than other behaviours. 3 or more in past year: - A strong desire to take a substance - Difficulties in controlling substance taking behaviour - Physiological withdrawal - Evidence of tolerance - Neglect of other interests - Persisting with substance use despite clear evidence its harmful - Narrowing of drinking repertoire (alcohol only)
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Symptoms of alcohol withdrawals
Clear evidence or recent cessation or reduction plus 3 of: - tremor - sweating - nausea, wretching, vomiting - tachycardia - hypertension - headache - psychomotor agitation - malaise, weakness - insomnia - transient hallucinations or illusions - Grand mal convulsions
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Epidemiology of alcohol dependence
9% men and 4% women show signs More common in males RFs - higher income - older people
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Epidemiology of drug dependence
``` More likely in younger population 16-19 More common in men Increased in urban living Increased in those visiting night clubs Increased in homosexuals Increased in mixed ethnic backgrounds ``` Most commonly cannabis, then opiates then cocaine
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Aetiology of drug and alcohol dependence
- Behavioural and learning theories: drug acts as positive reinforce - Psychodynamic theory: needs more satisfied by drug. reliable outcome. Influence of child abuse - Social: increased if FHx. Peer pressure from friends - Occupation: stressful job - Life events: separation, bereavement
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Long term physical complications of alcohol misuse
GI - oesophagitis, varices, peptic ulcers, pancreatitis, hepatitis, cirrhosis, cancer (stomach, liver, oesophagus) CV - HTN, arrhythmia, cardiomyopathy, IHD, stroke Neuro - amnesia, seizures, peripheral neuropathy, cerebellar degeneration, optic atrophy, central pontine myelinosis Other - episodic hypoglycaemia, vitamin deficiencies, anaemia, accidents, aspiration pneumonia, increased infection risk, impotence
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Social complications of alcohol misuse
``` Family and marital difficulties Employment difficulties Accidents Financial problems Vagrancy Homelessness Crime ```
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Psychiatric complications of alcohol misuse
``` Mood and anxiety disorders Suicide Deliberate self-harm Alcoholic hallucinosis Othello syndrome (pathological jealousy) Cognitive impairment ```
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Delirium Tremens
Medical emergency ``` Clouding of consciousness Disorientation in time and space Impaired short term memory Fear, agitation, restlessness Vivid visual hallucinations Paranoid delusions Insomnia Autonomic disturbances Coarse tremor nausea and vomiting Seizures Dehydration and electrolyte imbalance ```
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Wernicke-Korsakov's syndrome
** Confusion & ataxia & ocular palsy ** ``` Impaired consciousness and confusion Nystagmus Abducens and conjugate palsies Pupillary abnormalities Peripheral neuropathy ``` Results from thiamine B1 deficiency secondary to alcohol dependence 20% recover 10% diet 70% Korsakov's
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Korsakov's syndrome
Irreversible syndrome of prominent impairment of recent memory resulting from neuronal loss, gliosis and haemorrhage in mammillary bodies and damage to dorsomedial nucleus of thalamus
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Opiates & their effects
Heroin, morphine, codeine, buprenorphine, tramadol, fentanyl - dreamy/detached/euphoria - Respiratory depression - Sedation - Anorexia - Constipation - Loss of libido - Pruritus
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Stimulants & their effects
Cocaine, crack cocaine, amphetamines, ice, coaince, methyphenidate, MDMA - Euphoria - Decrease need for sleep and food - increased energy and activity
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MOA of cocaine
Blocks reuptake of serotonin and catecholamines Especially dopamine Euphoria Increased confidence and energy High disease can cause visual and auditory hallucinations
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Depressants & their effects
Benzodiazepines, alcohol, barbituates ``` Impair consciousness Impair co-ordination Disinhibition Analgesia Amnesia ```
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Hallucinogens & their effects
LSD, cannabis, MDMA visual hallucinations time distortion euphoria emotional lability
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MOA of LSD
Partial agonism of 5HT receptors
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Define plasticity
Extent to which drug effects are shaped by internal and external cues High = LSD, cannabis, solvents Low = heroin, amphetamines
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Define tolerance
Decrease effect for the same drug dose on repeated exposure
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Risk factors for illicit drug use
``` Younger age Living in council or inner city area Male Living in London Single, divorced or co-habiting Unemployed Earning over £30,000 per year Renting accommodation Visiting night clubs ```
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Psychological management of substance misuse
Motivational interviewing - Follows cycles of change - Based on cognitive dissonance theory - Decisional balance, non-confrontational CBT Contingency management - incentives to encourage staying off drugs - rewards 12 step AA Social support: occupation, finance, groups, housing, education
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Medications involved in managing alcohol misuse
Chlordiazepoxide - prevents DTs, fits and rescue drinking Pabrinex - B vitamins used to treat Wernicke-Korsakoff syndrome Acamprosate -used in abstinence and prevention of relapse. Blocks GABA and NDMA receptors to decrease cravings Naltrexone - competitive antagonist of opioid receptor. Decreases pleasure from drinking alcohol Disulfram - inhibits acetyl dehydrogenase, causes build up of acetaldehyde causing unpleasant effects
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Drugs used in managing opiate misuse
Methadone/Buprenorphine - Removes hazards of illicit drug use - removes criminal activity to fund habit - removes risk of injecting street drugs (VTE, sepsis) - Can be used as maintenance and detox with gradual drop in dose Can withdraw cold turkey - Lofexidine (alpha 2 antagonist) can decrease sweats and cramps
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Drug used in managing benzodiazepine withdrawal
Flumazenil - benzodiazepine receptor antagonist
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Management of smoking cessation
- Advice, self-help materials, referral - individual behavioural counselling - Group therapy - Self-help materials - nicotine replacement therapy - Medications: varencicline, buproprion - Referral to NHS stop smoking services
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Advice for those trying to stop smoking
``` Prepare mentally to stop - set a date, expect it to be hard, list reasons why to stop Involve family and friends Avoid situations associated with smoking Replace smoking with another activity Set targets and rewards for completion Try again if relapse Use medication! ```
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Risk factors for NON FATAL deliberate self harm
``` Young Female Financial/housing/employment/education Personality disorder Alcohol/substance misuse Social isolated Single ```
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Common methods for non-fatal deliberate self harm
Medication OD | Self-cutting
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Risk factors for suicide
``` Male 25-44 Single/widowed/divorced/separated Unemployed/retired Elderly Immigrants and refugees Prisoners Bereaved Vets, pharmacists, doctors, farmers Recent life crisis Victim of abuse Access to means Hx of self-harm Mental illness Physical illness - cancer/aids/epilepsy/MS/stroke ```
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Assessing risk after self-harm or suicide
- Precipitant - Planned - Method - Alone - Any alcohol - Any precautions against discovery - Help seeking - How did they feel when they were found - RFs for suicide - Examine mental state - Outlook for the future - Current suicidal intent - Homicidal intent - Any protective factors
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Physical complications for eating disorders
``` Hypokalaemia Peripheral oedema Hypotension Sudden death Arrhythmia Anaemia and thrombocytopaenia Hypoglycaemia Osteoporosis Constipation Infections Lack of growth or secondary sexual characteristics Infertility AKI or CKD Renal calculi Anxiety and mood disorders Alcoholism Social difficulties ```
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Psychological complications of eating disorders
``` Mood swings Low self-esteem Suicide Clinical depression Guilt and shame Anxiety Fear of discovery Hypervigilance Obsessional thoughts and pre-occupation Withdrawal from relationships in favour of social isolation Loneliness ```
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Define anorexia nervosa
Eating disorder characterised by low body weight, intense fear of gaining weight and body image disturbance - Weight loss, BMI <17.5 - Weight loss is self-induced by avoidance of fattening food - Self-perception of being fat with intrusive dread of fatness which leads to low self-imposed weight threshold - Endocrine disorder involving hypothalamic-pituitary-gonadal axis
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Epidemiology of anorexia nervosa
Increase in female Increased in 15-19 years Caucasians 0.3% prevalence 25% get concomitant OCD 50-70% develop dysthymia RFs - Obsessive and perfectionist traits - exposure to western media - middle and upper socioeconomic class - family dysfunction
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Aetiology and pathophysiology of anorexia nervosa
- Genetic links - Other psychiatric illness, perfectionism, low self-esteem - a susceptible person will diet - weight loss gives positive reinforcement to continue behaviours - low weight and starvation leads to nutritional imbalances and physiological change - Obsessive behaviours facilitate maintenance of anorexic cycle - Fear of food - Corticotrophin-releasing hormone released during starvation promotes appetite suppression
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Signs and symptoms of anorexia nervosa
``` Weight loss Amenorrhoea Orthostatic hypotension Fear of gaining weight Decreased subcut fat Bradycardia Disturbed body image Fatigue Dehydration Calorie restriction Poor concentration Arrhythmia Fainting Hair loss Constipation ```
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Investigations in anorexia nervosa
FBC - normocytic normochromic anaemia mild leukopaenia, thrombocytopaenia U&Es - low K, Na, Mg, phosphate, Ca, glucose. Raised urea TFTs - low T3 LFTs - raised AST and ALT, low ALP Dipstick - ketonuria ECG Bone densitometry = osteoporosis or osteopaenia
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Management of anorexia nervosa
Psycholigcal interventions (at least 6 months) - CBT - interpersonal therapy - family interventions - medication is not the sole or primary treatment - inpatient care if high risk - measure weight gain - aim for 0.5-1kg per week - may require multi-vitamin supplementation . Feeding against will is the last resort and only under Mental Health Act or Children's Act
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Prognosis of anorexia
``` Highest mortality of all psychiatric conditions 50% full recovery 33% improve 20% chronic Mortality rate 4% ```
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ICD10 definition for bulimia nervosa
Eating disorder characterised by recurrent episodes of binge eating, followed by behaviours aimed at compensating for the binge - Recurrent episodes of over eating (2x/week over a 3 month period) - Persistent preoccupation with eating and irresistible food craving - Patients attempt to counteract fattening effects of food by: self-induced vomiting, purging, alternating periods of starvation or use of drugs: diuretics, laxatives, appetite suppressants, thyroid preparations
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Epidemiology of bulimia nervosa
``` 0.5-1% More common in females (x10) Caucasian 20-35 years High heritability ``` ``` RFs Severe life stresses Personality disorder Physical/sexual abuse Substance misuse Fhx of depression Early menarche Parental/childhood obesity Family dieting Fhx of eating disorder Premorbid psychiatric disorder Disruptive events in childhood = parental death, alcoholism Perceived pressure to be thin ```
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History features of bulimia nervosa
``` Regular binge eating attempts to counteract binges preoccupation with weight/imaging Preoccupation with food/diet Mood disturbance/anxiety low self esteem self-harm irregular periods GI symptoms Hx of dieting ```
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Examination findings in bulimia nervosa
``` Usually normal if no complications Weight, height, BP Swollen parotid gland Russell's sign - callus on back of hand from teeth and vomiting Dental erosions oedema if laxative or diuretic misuse ```
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Management of bulimia nervosa
CBT adapted for bulimia Nutritional and meal support Medication - fluoxetine Manage physical aspects
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Neuroleptic malignant syndrome
MEDICAL EMERGENCY Life threatening neurological disorder most often caused by adverse reaction to neuroleptic or antipsychotics. Thought to be due to decreased levels of dopamine activity due to dopamine receptor blockage - Muscle cramps - Tremor - fever - Unstable BP - Diaphoresis - Rigidity - Sudden changes in mental status - agitation, delirium, coma Causes - Haloperidol - Promethiazine - Chlorpromazine - Levodopa To a lesser extent: clozapine, olanzapine, risperidone, quetiapine Stop antipsychotics Aggressive treatment of hyperthermia Supportive intensive care

Year 3 (6 decks)

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