Pseudoscience Flashcards
Give the DSM5 definition of major depressive disorder
Presence of >5 defining symptoms, during the same two-week period, where >1 of the symptoms is depressed mood or loss of interest or pleasure.
Plus four or more of the following:
* Disturbed sleep (decreased / increased compared to usual)
* Decreased / increased appetite / weight
* Fatigue / loss of energy
* Agitation / slowing down of movements and thoughts.
* Poor concentration / indecisiveness.
* Feelings of worthlessness or excessive / inappropriate guilt.
* Recurrent thoughts of death, recurrent suicidal ideas, or a suicide attempt or specific plan.
Give the NICE classification of depression severity according to the PHQ9
Less severe depression (subthreshold / mild): less than 16 on the PHQ-9 scale.
More severe depression (moderate / severe): 16 or more on the PHQ-9 scale.
List the items in PHQ9 scale
Nearly every day 3 points
More than half the days 2 points
Several days 1 point
Not at all 0 point
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
- Trouble falling or staying asleep, or sleeping too much
- Feeling tired or have little energy
- Poor appetite or overeating
- Feeling bad about yourself or that you are a failure or have let yourself or your family down
- Trouble concentrating on things, such as reading the newspaper or watching television
- Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
- Thoughts that you would be better off dead, or of hurting yourself
List the criteria for chronic depressive symptoms
Symptoms which continually meet the criteria for the diagnosis of a major depressive episode for >2 years
Have persistent subthreshold symptoms for >2 years
Have persistent low mood with or without concurrent episodes of major depression for >2 years
Give the first line treatment for depression
SSRI
When may electroconvulsive therapy be used in depression?
Depression with psychotic symptoms, suicidality, or catatonia
Later in treatment for people with refractory depression or intolerance to antidepressants
When should hospitalisation be considered in severe depression?
Significant suicidal ideation/intent + inadequate safeguards in family environment
Intent to hurt others
Unable to care for themselves/adhere to treatment
Psychotic symptoms
Uncontrolled agitation + impulsive behaviour
List the differences between mood disorders with psychotic features vs primary psychotic disorders
Mood disorder with psychotic features - Psychotic symptoms occur exclusively during mood episodes.
Schizophrenia - Mood symptoms, if present, are brief and not prominent.
List the features of Schizoaffective disorder
Mood episodes occur concurrent with symptoms of schizophrenia.
Lifetime history of delusions/hallucinations for 2 weeks outside of a mood episode.
Mood episodes are prominent and recur throughout illness.
List the SSRIs
Sertraline
Fluvoxamine
Fluoxetine
Paroxetine
Citalopram
Escitalopram
List contraindications for SSRI
Maniac phase of bipolar disorder
Poorly controlled epilepsy
Long QT syndrome
Concurrent with other drugs that cause QT prolongation
Severe hepatic impairment (sertraline)
List the adverse effects of SSRI
Sexual dysfunction
Headache
QT prolongation
List the SNRIs
Venlafaxine
Desvenlafaxine
Duloxetine
Milnacipran
Levomilnacipran
List the SNRI contraindications
Uncontrolled hypertension.
Hepatic impairment (duloxetine).
Severe renal impairment - creatinine clearance < 30 mL/min (duloxetine)
List the SNRI adverse effects
Hypertension
Headache
Diaphoresis
Bone resorption
List the TCA contraindications
Acute porphyria (lofepramine)
Arrhythmias, Heart block
During the immediate recovery period after MI
Severe hepatic/renal impairment (lofepramine)
During the manic phase of bipolar disorder
Taking a MAOi
List the TCA adverse effects
drowsiness (antagonism of histamine receptors)
antagonism of muscarinic receptors:
* dry mouth
* blurred vision
* constipation
* urinary retention
postural hypotension (antagonism of adrenergic receptors)
lengthening of QT interval
List the TCAs
Ami/Nor/Protriptyline
Doxepin
Clomi/Imi/Trimi/Desipramine
Maprotiline
Amoxapine
List the atypical antidepressants
Bupropion
Mirtazapine
Agomelatine
List the atypical antidepressant adverse effects
Bupropion- Seizures
Mirtazapine - Sedation, Weight gain
Agomelatine - hepatotoxicity
List the serotonin modulators
Nefazodone
Trazodone
Vilazodone
Vortioxetine
List the Serotonin Modulators adverse effects
Nefazodone - Hepatotoxicity (acute hepatitis with cholestasis and variable degrees of centrilobular necrosis)
Trazodone - Sedation, Priapism
Vilazodone - Diarrhoea
Vortioxetine - Nausea
List the Monoamine Oxidase Inhibitors (MAOIs)
Selegiline
Moclobemide
Tranylcypromine
Isocarboxazid
Phenelzine
List the MAOIs adverse effects
Potential for serotonin syndrome
Sexual dysfunction
List the TCA overdose effects
Fatal cardiovascular effects
* Tachycardia
* Postural hypotension
* Slowed cardiac conduction
Sedation
Coma
Seizures
List the Moclobemide (MAOI) overdose effects
Long QT syndrome
Hypertensive crisis
Serotonin and noradrenaline toxicity
Agitation, aggressiveness, and behavioural changes
List the Venlafaxine overdose effects
Vomiting
Sedation
Tachycardia
Hypertension
Seizures
List the Duloxetine overdose effects
Somnolence
Coma
Serotonin syndrome
Seizures
Vomiting
Tachycardia
List the triad in serotonin syndrome
Neuromuscular excitation
Autonomic effects
Altered mental status
List the clinical features in persistent depressive disorder (dysthymia)
Chronic depressed mood >2 years (1 year if children/adolescents)
No symptom-free period for >2 months
Presence of >2 of the following:
* Poor appetite / overeating
* Insomnia / hypersomnia
* Low energy / fatigue
* Low self-esteem
* Poor concentration / difficulty making decisions
* Feelings of hopelessness
List the drugs associated with serotonin toxicity
SSRI/SNRI/MAOI
Serotonin-releasing agents
* Fenfluramine
* Amphetamines
L-tryptophan - increase serotonin synthesis
Serotonin receptor agonists
Lysergic acid diethylamide (LSD)
Lithium
List the Hunter serotonin toxicity criteria
Serotonergic agent - increased dose, overdose, interaction
1. Spontaneous clonus
2. Inducible / Ocular clonus + Agitation OR Diaphoresis OR Hypertonia AND Hyperthermia
3. Tremor AND Hyperreflexia
If all null, not significant serotonin toxicity
List the serotonin syndrome severity grading
Mild toxicity
* Hyperreflexia
* Inducible clonus
* Tremor
* Myoclonic jerks
* Diaphoresis
* Headache
* Do not meet the HSTC
Moderate toxicity
* Anxiety and agitation
* Tachycardia
* Meets the HSTC, but no hyperthermia or hypertonia
Severe toxicity - Meet the HSTC and have hyperthermia and hypertonia
Give the characteristic for bipolar disorder
episodic depressed and elated moods and increased activity (hypomania / mania)
Define manic episode
Abnormally and persistently elevated, expansive, irritable mood lasting >7 days, with >3 additional symptoms:
* Abnormally elevated mood, extreme irritability, sometimes aggression.
* Increased energy/activity, restlessness, decreased need for sleep
* Pressure of speech/incomprehensible speech.
* Flight of ideas/racing thoughts.
* Distractibility, poor concentration.
* Increased libido, disinhibition, sexual indiscretions.
* Extravagant/impractical plans
* Psychotic symptoms: delusions (grandiose), hallucinations (voices).
And which:
* Is severe enough to cause marked impairment in social/occupational functioning/hospitalisation
* Includes psychotic features: delusions/hallucinations.
Define Hypomanic episode
Symptoms of mania that are:
* have lasted for at least 4 days
* not severe enough to cause marked impairment in social/occupational functioning/necessitate hospitalisation
* no psychotic features
Presentation
* Mild elevation of mood, irritability.
* Increased energy and activity, may lead to increased performance at work/socially.
* Feelings of well-being, physical mental efficiency.
* Increased sociability, talkativeness, over-familiarity.
Define Depressive episode
A period of at least 2 weeks during which there is either
* Depressed mood or
* Loss of interest or pleasure in nearly all activities (irritability in children and adolescents)
Accompanied by at least four additional symptoms:
* Disturbed sleep (decreased / increased compared to usual)
* Decreased / increased appetite / weight
* Fatigue / loss of energy
* Agitation / slowing down of movements and thoughts.
* Poor concentration / indecisiveness.
* Feelings of worthlessness or excessive / inappropriate guilt.
* Recurrent thoughts of death, recurrent suicidal ideas, or a suicide attempt or specific plan.
List the symptoms and signs that may help distinguish bipolar disorder from unipolar depression
Hypersomnia, lability, weight instability
Earlier age of onset (peak age 15-19 years), abrupt onset (possibly triggered by stressor).
More frequent episodes of shorter duration.
Comorbid substance misuse.
Higher postpartum risk.
Psychosis, psychomotor retardation, catatonia.
Lower likelihood of somatic symptoms.
Family history of bipolar disorder
State the diagnostic criteria for bipolar disorder in children and young people
Mania must be present.
Euphoria must be present on most days and for most of the time, for at least 7 days.
Irritability is not a core diagnostic criterion.
Define rapid-cycling bipolar disorder
At least four depressive, manic, hypomanic, or mixed episodes within a 12-month period.
Define Bipolar I disorder
> 1 manic episode with/without history of major depressive episodes.
Define Bipolar II disorder
One or more major depressive episodes and by at least one hypomanic episode, but no evidence of mania.
List the risk factors for bipolar disorder
Genetics - first-degree relatives
Environmental
* Early life stress, maternal death before a child reaches five years of age, childhood trauma, childhood abuse, emotional neglect/abuse.
* Toxoplasma gondii exposure.
* Cannabis use, cocaine exposure.
List the complications for bipolar disorder
Suicide / self-harm
Consequences of disinhibition and impaired social functioning
Associated psychological and physical illness
* Anxiety disorder, alcohol and other substance misuse disorders, personality disorders, ADHD
* Cardiovascular disease, hypertension
* Type 2 diabetes, dyslipidaemia, metabolic syndrome, obesity
* Chronic kidney disease
* COPD
Give the management for acute episode of mania and mixed episodes
First line: haloperidol, olanzapine, quetiapine, risperidone
If not effective: add lithium/sodium valproate
Give the management for acute episode of depressive episodes
Quetiapine
Fluoxetine + olanzapine
Olanzapine
Lamotrigine
Give the long term management plan for bipolar disorder
4 weeks after the acute episode has resolved:
Continue current treatment for mania
Start long-term treatment with lithium to prevent relapses
If lithium is not effective, add sodium valproate
If lithium poorly tolerated, use sodium valproate or olanzapine
Define Cyclothymia
Chronic disturbance of mood, consisting of periods of depression and hypomania, where the depressive symptoms do not meet the criteria for a depressive episode.
How is antipsychotic use monitored?
BMI - weekly for the first 6 weeks, then at 3 months, thereafter annually
FBC, U&E, eGFR, LFT, CK - annually
Blood lipids, HbA1c - 3 months after starting treatment, then every 12 months
Prolactin - 6 months after starting treatment, then every 12 months
ECG, blood pressure - during dose titration and change
List the adverse reactions related to clozapine
Neutropenia / agranulocytosis
Impairment of intestinal peristalsis (constipation, paralytic ileus)
List the contraindications for IM olanzapine
Unstable angina, Acute myocardial infarction.
Bradycardia.
Severe hypotension.
Sick sinus syndrome.
Recent heart surgery.
List the typical antipsychotics
(Dopamine receptor antagonists)
Phenothiazines
* trifluoperazine, prochlorperazine, perphenazine, acetophenazine, triflupromazine, mesoridazine
Haloperidol
Thioxanthenes
Loxapine
Molidone
Pimozide
List the atypical antipsychotics
(Serotonin-dopamine antagonists)
Risperidone
olanzapine
quetiapine
clozapine
List the adverse effects of antipsychotics
Extrapyramidal symptoms (typical antipsychotics)
* Dystonia and pseudoparkinsonism - alleviated by procyclidine (antimuscarinic)
* Akathisa (motor restlessness) - relieved by reducing the dose
* Tardive dyskinesia
* Oculogyric crisis
Weight gain (atypical antipsychotics)
* Greatest potential: clozapine, olanzapine
* Followed by: quetiapine, risperidone
Hyperprolactinaemia
* Galactorrhoea
* Amenorrhoea
* Gynaecomastia
* Hypogonadism
* Sexual dysfunction
* Increased risk of osteoporosis
Dyslipidemia
Impaired glucose tolerance
Sedation
Anticholinergic effects
* Dry mouth
* Blurred vision
* Urinary retention/Constipation
* Cutaneous flushing
Reduced seizure threshold
Diplopia
Cardiovascular
* Postural hypotension
* Hypertension
* Cardiomyopathy, myocarditis, cutaneous vasculitis
* QT interval prolongation
* Stroke risk
* Venous thromboembolism
Neuroleptic malignant syndrome
Pneumonia
Neutropenia
Abnormal LFT
* Hepatitis (transaminase 3x normal)
* Abnormal prothrombin time / albumin
Photosensitivity (chlorpromazine)
Drug Reaction with Eosinophilia and Systemic Symptoms (olanzapine)
* High fever
* Morbilliform skin rash eruption
* Haematological abnormalities
* Lymphadenopathy
* Inflammation of one or more internal organs.
List the symptoms for neuroleptic malignant syndrome
Within 72 hours of dopamine antagonist / agonist withdrawal:
Hyperthermia
Muscle rigidity (cardinal feature)
Altered mental status
Sympathetic nervous system lability
* BP elevation/fluctuation
* Sweating
* Urinary incontinence
Hypermetabolism
* 25% increase heart rate
* 50% increase respiratory rate
Give the key investigation in neuroleptic malignant syndrome
Serum creatine kinase (CK) levels
Give the management of neuroleptic malignant syndrome
Remove causative drug
Rehydration - IV fluids
Cooling
Sedation - oral/IV benzodiazepine
List two DPA agonists
bromocriptine
amantadine
Give the definition for generalised anxiety disorder
Chronic, excessive worry for > 6 months that causes distress/impairment, and is hard to control.
Give the DSM-5-TR criteria for generalised anxiety disorder
> 3 out of 6 in adults, 1 in children:
Muscle tension
Sleep disturbance
Fatigue
Restlessness/sense of feeling ‘on edge’
Irritability
Poor concentration
Other symptoms:
Muscle aches
Sweating, Dizziness
Shortness of breath, Chest pain
Nausea, diarrhoea
Gastrointestinal complaints
Give the childhood risk factors in generalised anxiety disorder
Maltreatment
Parental mental health problems / substance use
Family disruption (e.g., divorce)
Overly harsh/protective parenting style
Bullying
Give the management options for generalised anxiety disorder
First line options:
* Psychological therapy - cognitive behavioural therapy
* SSRI - sertraline
* Alternative - Mirtazapine (atypical antidepressant)
Second line: SNRIs (duloxetine, venlafaxine)
Third line:
* Pregabalin (anticonvulsant)
* Buspirone (non-benzodiazepine anxiolytic)
Give the DSM5-TR criteria for panic disorders
Recurrent, unexpected panic attacks
>1 of the attacks followed by a period of >1 month of one or both of:
* persistent concern/worry about additional panic attacks/consequences (heart attack)
* a significant maladaptive change in behaviour related to the attacks (avoidance)
Panic symptoms must not be attributable to substance-related effects, other medical conditions, or other psychiatric disorders
Give the symptoms for panic attacks
Sudden onset intense physical + cognitive symptoms of anxiety
Peak within minutes
The need to do something urgently (e.g. escape to a safe place)
List other symptoms in panic attacks
Nocturnal panic attack
Heightened sympathetic nervous system activity
* Palpitations
* Increased SBP
* Hyperventilation
* Sweating
* Flushing
Chest pain and discomfort
Dizziness
Tingling or numbing sensations in the hands, feet, and facial areas
Nausea and vomiting
List the symptoms for phobias
Intense anxiety/panic during exposure to specific objects/situations
Sleep disruption
Depression
Extreme anticipatory anxiety may co-occur
Coping behaviours
* Avoidance
* Safety seeking
* Substance misuse
Give the classification for PTSD
Dissociative subtype - symptoms of depersonalisation (experience of being an outside observer) or derealisation (experience of unreality, distance, distortion) are present.
Delayed expression - full diagnostic criteria are not met until at least 6 months after the stressor.
Give the DSM-5-TR criteria for PTSD
Symptoms should
* Cause significant distress/functional impairment
* Not be caused by medication, substance use, or other illness.
* Be persistent for >1 month.
The person must have:
Been exposed to actual/threatened death/serious injury/sexual violence in >1 of the following ways:
* Directly experiencing
* Witnessing
* Learning that the traumatic event occurred to a close family member/friend.
* Experiencing repeated/extreme exposure to aversive details of the traumatic event
Persistently re-experience >1 of the following intrusive symptoms:
* Recurrent, involuntary, intrusive memories.
* Recurrent traumatic nightmares
* Dissociative reactions (e.g. flashbacks) in which the person feels or acts as if the traumatic event is recurring.
* Intense or prolonged distress after exposure to traumatic reminders.
* Marked physiologic reactivity after exposure to trauma-related stimuli.
Persistently avoid stimuli associated with the traumatic event
Experience >2 negative changes in mood or thoughts that began or worsened after the traumatic event:
* Unable to recall key features of the traumatic event.
* Persistent (usually distorted) negative beliefs and expectations about themselves or the world.
* Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
* Persistent negative emotional state (e.g. fear, horror, anger, guilt or shame).
* Markedly diminished interest in (pre-traumatic) significant activities.
* Feelings of detachment or estrangement from others.
* Persistent inability to experience positive emotions (happiness, satisfaction, love).
> 2 trauma-related alterations in arousal and reactivity that began/worsened after the traumatic event:
* Irritable/aggressive behaviour (with little or no provocation).
* Self-destructive or reckless behaviour.
* Hypervigilance.
* Exaggerated startle response.
* Problems in concentration.
* Sleep disturbance.
Give the severity grading in PTSD
Mild
Distress caused by the symptoms is manageable
Social and occupational functioning are not significantly impaired.
Moderate
Distress and impact on functioning lie somewhere between mild and severe
Not considered to be a significant risk of suicide, harm to self, or harm to others.
Severe
Distress caused by the symptoms is felt to be unmanageable
Significant impairment in social and/or occupational functioning
Considered to be a significant risk of suicide, harm to self, or harm to others.
Give the managements in PTSD
Psychological therapies
First line: Trauma-focused cognitive behavioural therapy
* Exposure therapy - the person confronts traumatic memories and is repeatedly exposed to situations which they have been avoiding that elicit fear.
* Trauma-focused cognitive therapy - identifies and modifies misrepresentations of the trauma and its aftermath that lead the person to overestimate the threat.
Eye movement desensitisation and reprocessing
Antidepressants:
* Venlafaxine (SNRI)
* SSRI
List the symptoms of PTSD in adults
Re-experiencing the event
Avoidance of external reminders/thoughts/memories of the event.
Hyperarousal (hypervigilance, anger, irritability).
Negative alterations in mood and thinking.
Negative self-perception
Emotional numbing.
Emotional dysregulation.
Dissociation.
Interpersonal difficulties/problems in relationships
List the symptoms of PTSD in children
Dreams of the trauma, nightmares.
Re-living the trauma in their play.
Losing interest in things that they previously enjoyed.
Expressing the belief not live long enough to grow up.
Stomach aches and headaches.
List the mental health complications for PTSD
Depression
Anxiety disorders
Substance use disorders
Somatic symptom disorder
Psychoses
Suicidal ideation
In children
* ADHD
* Oppositional defiant disorder
* Conduct disorder
List the 5 stages of grief
Denial
Depression
Bargaining
Aggression
Acceptance
List the positive and negative symptoms in psychosis
Positive symptoms:
* Hallucinations (perceptions in the absence of stimulus)
* Delusions (fixed or falsely-held beliefs)
* Disorganised behaviour, speech, thought disturbance
Negative symptoms:
* Emotional blunting.
* Reduced speech.
* Loss of motivation.
* Self-neglect.
* Social withdrawal
List the medical causes of psychosis
Central nervous system
* Trauma
* Space-occupying lesions
* Infection
* Stroke
* Epilepsy
* Cerebral hypoxia
Metabolic disturbances
* Urea cycle disorders
* Acute intermittent porphyria
* Wilson disease
* Renal / liver failure
* Hypoglycemia
* Na+/Ca2+/Mg2+ disturbances
Systemic
* SLE
* Thyroiditis
Give the ICD10 criteria for schizophrenia
Symptoms present most of the time for >1 month
One or more of the following features:
Hallucinatory voices
Thought echo, thought insertion/withdrawal, thought broadcasting.
Delusions
Persistent delusions of other kinds that are culturally inappropriate and completely impossible
Or any two of the following criteria:
Persistent hallucinations in any form accompanied by
* fleeting or half-formed delusions without clear affective content
* persistent overvalued ideas (similar to preoccupations)
* when occurring every day for weeks or months on end
Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms (invented words).
Catatonic behaviour
* Excitement, posturing, or waxy flexibility
* Negativism
* Mutism
* Stupor
Negative symptoms
A significant and consistent change in the overall quality of some aspects of personal behaviour
List the features of prodromal period for psychosis
Transient, low-intensity psychotic symptoms - intermittent, self-limiting episodes, typically lasting less than a week
* hallucinations/unusual perceptual experiences
* unusual thoughts
* unusual or uncharacteristic behaviour
Reduced interest in daily activities
* poor personal hygiene
* reduced performance at school or work
Problems with mood, sleep, memory, concentration, communication, affect, and motivation.
Anxiety, irritability, or depressive features.
Incoherent or illogical speech - thought disturbance.
List the risk factors for schizophrenia
Stressful life events (bereavement, job loss, eviction, relationship breakdown)
Childhood adversity (abuse, bullying, parental loss / separation)
Family heritage
Migration
Urban living
Cannabis
Substance use
* amphetamines, cocaine, ketamine, LSD
* inhaled substances eg. toluene and certain types of glue
High-dose corticosteroid
Early life factors
* exposures in utero to medication
* maternal stress
* nutritional deficiency
* Infection
* intrauterine growth restriction
* birth and postnatal trauma
Paternal age > 40 years and parental age < 20 years
Exposure to Toxoplasma gondii
List the complications for schizophrenia
Increased risks of
* Suicide
* Cardiovascular disease
* T2DM
* Smoking-related illness
* Cancer eg. breast
Social exclusion
Substance misuse
Give the management for acute psychosis
First line = de-escalation
Sedation
* IM lorazepam
* IM haloperidol + promethazine
List the antipsychotic treatment options
Aripiprazole, amisulpride, haloperidol, lurasidone, olanzapine, risperidone
Give the DSM5-TR criteria for schizoaffective disorder
An uninterrupted period of illness, during which there is a major mood episode (major depressive or manic) concurrent with a schizophrenia episode characterised by two or more of the following symptoms present for a considerable part of a 1-month period (at least one of these must be delusions, hallucinations, or disorganised speech):
* Delusions
* Hallucinations
* Disorganised speech (e.g., frequent derailment or incoherence)
* Grossly disorganised or catatonic behaviour
* Negative symptoms (i.e., diminished emotional expression or avolition).
During this time, there should be a period of at least 2 weeks with delusions and hallucinations, in the absence of a major mood episode (depressive or manic) during the lifetime duration of illness.
Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual period of illness.
Other possible etiologies or general medical conditions have been ruled out.
List the management options for schizoaffective disorder
Atypical antipsychotics
* Paliperidone
* Olanzapine
* Ziprasidone
Give the DMS5 TR criteria for brief psychotic disorder
> 1 psychotic symptoms, where >1 must be delusions, hallucinations, or disorganised speech
Episodes lasts for >1 day, but <1 month, return to premorbid level of functioning.
No better accounted for by other conditions.
Give the first line management in brief psychotic disorder
Atypical antipsychotics
* Olanzapine
* Risperidone
* Quetiapine
* Ziprasidone
* Aripiprazole
* Paliperidone
Give the definition for anorexia nervosa
Restriction of food intake/persistent behaviour which interferes with weight gain and leads to low body weight.
Associated with body image disturbance and intense fear of gaining weight.
Give the definition for bullimia nervosa
Recurrent (>1/week for 3 months) episodes of binge eating followed by compensatory behaviour eg. self-induced vomiting, laxative abuse, excessive exercise.
Give the definition for binge eating disorder
Recurrent episodes of binge eating in the absence of compensatory behaviours.
Episodes are marked by feelings of lack of control.
Give the definition for atypical eating disorders (‘eating disorder not otherwise specified’)
Symptoms of an eating disorder such as anorexia nervosa, or bulimia nervosa, which do not meet the precise diagnostic criteria.
List the clinical features of anorexia nervosa
Restriction of energy intake resulting in low body weight (BMI < 18.5)
Intense fear of gaining weight
Behaviour that interferes with weight gain
* Self-induced purging
* Excessive exercise
* Appetite suppressant medication / diuretics
Psychological disturbances
* Distortion of body image, with a dread of being overweight.
* Low self-esteem and a drive for perfection.
* Over-evaluation of self-worth in terms of body weight and shape.
Denial of seriousness of malnutrition and its impact on physical health
Hormonal disturbance
* Females: amenorrhoea, menstrual irregularities
* Males: loss of libido or potency
* Affects onset of puberty, growth, and physical development in children
List the physical signs of anorexia nervosa
Dry skin, Hair loss
Bradycardia, Orthostatic hypotension
Hypothermia
Loss of muscle strength
Oedema
Constipation
Fainting, Dizziness
Fatigue
List the clinical features of bulimia nervosa
Recurrent episodes of binge eating occurring on average at least once a week for 3 months
Recurrent inappropriate compensatory behaviours to prevent weight gain
* Vomiting, Purging
* Fasting
* Excessive exercise
* Laxative, diuretic use
Weight is often within normal limits or above weight range for age.
Psychological features
* Over-evaluation of self-worth in terms of body weight and shape.
* Fear of gaining weight, with a sharply defined weight threshold set by the person.
* Mood disturbance and symptoms of anxiety and tension.
* Persistent preoccupation and craving for food and feelings of guilt and shame about binge eating.
* Self-harm
List the physical signs of bullimia nervosa
Bloating, fullness
Lethargy
Gastro-oesophageal reflux
Abdominal pain
Sore throat (vomiting)
Russell’s sign (knuckle calluses from inducing vomiting)
Dental enamel erosion
Salivary gland enlargement
List the differential diagnoses of weight loss
Malabsorption
* Coeliac disease
* Inflammatory bowel disease
* Peptic ulcer
Malignancy
Drug or alcohol misuse
Infection
* Tuberculosis
* HIV
* Infectious mononucleosis
Autoimmune diseases
Endocrine disorders
* Hyperthyroidism
* Diabetes mellitus
* Hypercortisolism
* Adrenal insufficiency
List the clinical features for refeeding syndrome
Wernicke-Korsakoff encephalopathy
Fluid imbalances
Metabolic
* Hypo K+, Mg2+, PO₄³⁻
* Hyperglycaemia
Cardiac arrhythmias, Cardiac failure
Pulmonary oedema
Give the definition for personality disorders
Manifest as problems in at least two of the:
* Cognitive-perceptual
* Affect regulation
* Interpersonal functioning
* Impulse control
List the cluster A personality disorders
(odd/eccentric)
Schizoid
* detachment in social relationships
* restricted emotional expression in interpersonal interactions
Schizotypal
* acute discomfort/reduced capacity for close relationships
* cognitive/perceptual distortions
* eccentric behaviour
Paranoid
* Distrust and suspiciousness of others, whose motives are viewed as malevolent
* Suspicious and bears grudges
List the cluster B personality disorders
(dramatic)
Borderline
* Instability of interpersonal relationships
* Intense anger and affective instability
Histrionic
* Excessive emotionality and attention-seeking
Antisocial
* Disregard/violation of rights of others occurring since age 15
* Impulsivity, deceitfulness, lack of remorse
Narcissistic
* Grandiosity
* Need for admiration
* Lack of empathy
List the cluster C personality disorders
Avoidant
* Social inhibition
* Feelings of inadequacy
* Hypersensitivity to negative evaluation
Dependent
* Excessive need to be taken care of, submissive and clinging behaviour
Obsessive-compulsive
* Preoccupation with orderliness, perfectionism, and mental/interpersonal control
* Lack of flexibility, openness, efficiency
Give the DSM5 TR criteria for catatonia
> 3 symptoms present:
Decreased Behaviours
* Stupor
* Negativism
* Mutism
* Posturing
* Catalepsy
Abnormal Behaviours
* Stereotypy
* Mannerism
* Waxy flexibility
* Echolalia
* Echopraxia
Increased Behaviours
* Agitation
* Grimacing
What psychiatric disorders is catatonia often secondary to
Bipolar disorder
Depression
Schizophrenia
Give the management for catatonia
IV 2mg lorazepam challenge
List the key elements in opioid dependence
Strong desire/compulsion to take opioids
Difficulty in controlling use
Physiological withdrawal state when opioid ceased/reduced.
Tolerance.
Neglect of alternative pleasures/interests.
Persistence despite overtly harmful consequences.
List the clinical features of opioid intoxication
Pupil constriction
Itching, scratching
Sedation, somnolence
Lower blood pressure
Slower pulse
Hypoventilation
List the presentations of acute opioid withdrawal syndrome
Watering eyes, rhinorrhoea, yawning, sneezing, cool and clammy skin, dilated pupils, cough.
Abdominal cramps, nausea, vomiting, diarrhoea.
Tremor, sleep disorder, restlessness, anxiety, irritability, hypertension.
List the complications of opioid dependency
Death
Overdose
Infection
* S. aureus, Group A streptococci
* HIV
* Hepatitis B, C
* Clostridium infections
* Bacillus anthracis (anthrax)
* Tuberculosis
DVT, PE, Superficial thrombophlebitis
Poor nutrition and dental disease
Psychosocial problems
Give the management for opioid dependence
Opioid substitution therapy
* Methadone
* Buprenorphine - combined sublingual tablet (buprenorphine:naloxone 4:1)
Detoxification
Follows induction and stabilisation on opioid substitution therapy
Dose reduction for
* Methadone - 5mg every 1/2 weeks
* Buprenorphine - 2mg around every 2 weeks, with final reductions of 400micrograms
List the strong and weak opioids
Strong opioids
Morphine
Buprenorphine
Dipipanone hydrochloride
Diamorphine hydrochloride (heroin)
Alfentanil, fentanyl, remifentanil (intraoperative analgesia)
Methadone hydrochloride
Oxycodone hydrochloride
Pentazocine
Pethidine hydrochloride
Tapentadol
Tramadol hydrochloride
Weak opioids
Codeine phosphate
Dihydrocodeine tartrate
Meptazinol
List the drugs that cause anticholinergic poisoning
Antihistamines
TCA
Carbamazepine
Phenothiazine
List the symptoms of anticholinergic poisoning
Tachycardia
Warm and dry skin
Hyperthermia
Loss of sweating
Mydriasis
Urinary retention
Agitation/delirium
Seizures
List the drugs that cause cholinergic poisoning
Carbamates and organophosphate insecticides
Mushrooms
List the symptoms of cholinergic poisoning
Miosis
Salivation, Lacrimation
Urination, Diarrhoea, Vomiting
Bronchorrhoea, Bronchospasm
Bradycardia, Hypotension
Muscle weakness
List the causes for hallucinogenic poisoning
Amphetamines
Cocaine
MDMA
List the symptoms of hallucinogenic poisoning
Hallucinations
Panic
Seizures
Hypertension
Tachycardia, Tachypnoea
List the causes of opioid poisoning
Morphine
Heroin
Codeine
Methadone
List the symptoms of opioid poisoning
Miosis
Sedation
Bradycardia
Hypoventilation
Hypotension
List the causes of sedative/hypnotic poisoning
Anticonvulsants
Benzodiazepines
Ethanol
List the causes of sympathomimetic poisoning
Amphetamines
Cocaine
MDMA
List the symptoms of sympathomimetic poisoning
Tachycardia, Tachypnoea, Hypertension
Hyperthermia
Sweating
Mydriasis
Agitation
Tremor
Seizures
List the symptoms of antimalarials (quinine, chloroquine, hydroxychloroquine) toxicity
Rapid onset of life-threatening arrhythmias
Intractable convulsions
List the neurochemicals involved in sleep
Acetylcholine
Dopamine
Norepinephrine (locus coeruleus)
Serotonin (dorsal raphe nucleus)
Histamine (tuberomammillary nucleus of the posterior thalamus)
Hypocretin peptides (dorsolateral hypothalamus)
List the five sleep stages
Wake
NREM (75%)
* N1
* N2
* N3
REM
List the causes of short term insomnia
Stressful events
Changes in sleeping patterns
List the causes of chronic insomnia
Mental health conditions
* Anxiety
* Depression
* Bipolar disorder
Substance misuse
COPD
Obstructive sleep apnoea syndrome
Cardiovascular disease
Neurological conditions
* Stroke
* Parkinson’s disease
* Epilepsy
* Migraine
* Traumatic brain injury
Restless legs syndrome
Malignancy
Diabetes mellitus
Musculoskeletal conditions
Chronic pain
Give the management for short term insomnia
Short course (3-7 days) non-benzodiazepine hypnotic (z-drug)
* Zopiclone 7.5mg once daily at bedtime
* Zolpidem 10mg once daily at bedtime
Give the management for long term insomnia
First line: cognitive behavioural therapy
Give the classic tetrad in narcolepsy
Excessive daytime sleepiness
Cataplexy (generalised muscle weakness leading to partial/complete collapse)
Hypnagogic/hypnopompic hallucinations (visual/auditory perceptions on falling asleep or on awakening)
Sleep paralysis
Give the secondary causes of narcolepsy
CNS disorders
* Head trauma
* Encephalomyelitis
* CNS tumours
* Multiple sclerosis
Myotonic dystrophy
Prader-Willi syndrome
Niemann-Pick type C
Norrie’s disease
Germ cell testicular tumours (paraneoplastic anti-Ma antibodies)
Give the pathophysiology for narcolepsy
Hypocretin (orexin) deficiency is a clinical marker of narcolepsy type 1
Caused by the loss of hypocretin-producing neurons in the hypothalamus.
List the investigations in narcolepsy
Polysomnography and multiple sleep latency test
HLA typing - HLA-DQB1*0602 positive
Low CSF hypocretin-1 levels
List the management options for excessive daytime sleepiness in narcolepsy
Sodium oxybate
Pitolisant
Modafinil
Solriamfetol
List the effects of long-term benzodiazepines
Cognitive effects
Anxiety
Depression
Agoraphobia
Emotional blunting
Reduced coping skills
Amnesia
List the Benzodiazepine withdrawal symptoms
(mimic anxiety disorder)
Sweating
Insomnia
Headache
Tremor
Nausea
Palpitations
Anxiety
Depression
Panic attacks
Psychosis/seizures (rare)
List the Z-drug withdrawal symptoms
Insomnia, sleep disturbance
Anxiety, depression
Impaired concentration
Abdominal cramps
Palpitations
Hypersensitivity to physical, visual, auditory stimuli
Define functional neurological disorder (conversion disorder)
Medically unexplained neurological symptoms that do not fit any clinical syndrome, and have arisen most likely in response to a traumatic experience.
Define somatic symptom disorder
Repeated presentation with medically unexplained symptoms, and the associated distress and anxiety associated with these.
List the typical comorbid diagnoses in functional neurological disorder
Mood disorders
Panic disorder
Generalised anxiety disorder
Post-traumatic stress disorder
Dissociative disorders
Social or specific phobias
Obsessive-compulsive disorders
Personality disorders
List the features in functional neurological disorder
Comorbid pain and fatigue
Psychiatric comorbidities
Active psychosocial stressors
Unhelpful behavioural responses
Unhelpful illness beliefs
List the features in somatic symptom disorder
Vague/inconsistent history of illness
Worries are not alleviated in spite of medical care/reassuring investigation results
Patient describes frequently checking their own body
Patients attribute normal sensations to medical illness.
List the physical features of functional limb weakness
Hoover’s sign - weakness of hip extension returns temporarily to normal during contralateral hip flexion against resistance.
Hip abductor sign - weakness of unilateral hip abduction returns to normal with attempt at bilateral hip abduction.
List the physical features of functional tremor
‘Entrainment test’
Watch the other (patient’s left) hand while the patient copies the examiner’s rhythmic pincer movements with their right hand
The functional tremor in the left hand stops during the task
List the physical features of functional dystonia
Usually presented as a fixed position, usually a clenched fist or inverted ankle (in contrast to other types of dystonia, which are usually mobile).
Functional facial dystonia usually presents with episodic contraction of the platysma or orbicularis.
List the physical features of functional visual loss
Tubular (as opposed to conical) vision - the visual field at 150cm distance is the same width as at 50cm (expected to increase conically with distance)
‘Spiralling’ on Goldmann perimetry - the longer the test goes on, the more constricted the visual field becomes
Define classical conditioning
Learning in which a natural response (salivation) is elicited by a conditioned, or learned, stimulus (bell) that previously was presented in conjunction with an unconditioned stimulus (food).
Usually elicits involuntary responses
Define operant conditioning
Learning in which a particular action is elicited because it produces a punishment or reward. Usually elicits voluntary responses.
Define reinforcement
Target behavior (response) is followed by desired reward (positive reinforcement) or removal of aversive stimulus (negative reinforcement).
Define punishment
Repeated application of aversive stimulus (positive punishment) or removal of desired reward (negative punishment) to extinguish unwanted behavior.
Define extinction
Discontinuation of reinforcement (positive or negative) eventually eliminates behavior. Can occur in operant or classical conditioning.
Define transference
Patient projects feelings about formative or other important persons onto physician (eg, psychiatrist is seen as parent).
List the mature defences
Sublimation - Replacing an unacceptable wish with a course of action that is similar to the wish but socially acceptable (vs reaction formation).
Altruism - Alleviating negative feelings via unsolicited generosity, which provides gratification (vs reaction formation).
Suppression - Intentionally withholding an idea or feeling from conscious awareness (vs repression); temporary.
Humour - Lightheartedly expressing uncomfortable feelings to shift the internal focus away from the distress.
List the immature defences
Acting out
Denial
Displacement
Dissociation
Fixation
Idealisation
Identification
Intellectualisation
Isolation of affect
Passive aggression
Projection
Rationalisation
Reaction formation
Regression
Repression
Splitting
What is the most common form of child maltreatment
Neglect
List the signs of child neglect
Poor hygiene
Malnutrition
Withdrawn affect
Impaired social/emotional development
Failure to thrive
List the signs of child physical abuse
Non-accidental trauma
Injuries often in different stages of healing or in patterns resembling possible implements of injury.
Caregivers may delay seeking medical attention for the child or provide explanations inconsistent with the child’s developmental stage or pattern of injury.
List the signs of sexual abuse in children
STIs, UTIs, genital, anal, oral trauma
Children often exhibit sexual knowledge/behavior incongruent with their age
List the signs of emotional abuse in children
Young:
* lack bond with the caregiver
* overly affectionate with less familiar adults.
* aggressive towards children, animals/unusually anxious.
Older
* emotionally labile, prone to angry outbursts.
* distance from caregivers/other children.
* Vague somatic symptoms for which a medical cause cannot be found.
Define adjustment disorder
Emotional/behavioral symptoms (anxiety, outbursts) that occur <3 months of an identifiable psychosocial stressor (eg, divorce, illness) lasting <6 months once the stressor has ended.
Define malingering
Symptoms are intentional, motivation is intentional.
Patient consciously fakes, profoundly exaggerates, or claims to have a disorder in order to attain a specific 2° (external) gain (eg, avoiding work, obtaining compensation).
Poor compliance with treatment or follow-up of diagnostic tests.
Complaints cease after gain (vs factitious disorder).
Define factitious disorders
Symptoms are intentional, motivation is unconscious.
Consciously creates physical/psychological symptoms to assume “sick role”/get medical attention and sympathy (1° [internal] gain).
Define factitious disorder imposed on self (Munchausen syndrome)
Chronic factitious disorder with predominantly physical signs and symptoms.
History of multiple hospital admissions and willingness to undergo invasive procedures.
What population is Münchausen syndrome most common in
Females and healthcare workers
Define factitious disorder imposed on another (Münchausen syndrome by proxy)
Illness in an individual being cared for (most often a child, also seen in disabled or older adults) is directly caused (eg, physically harming a child) or fabricated (eg, lying about a child’s symptoms) by the caregiver.
Form of child/elder abuse.
Define sleep terror disorder
Periods of inconsolable terror with screaming in the middle of the night.
Occurs during slow-wave/deep (stage N3) non-REM sleep with no memory of the arousal episode, as opposed to nightmares that occur during REM sleep (remembering a scary dream).
List the triggers for sleep terror disorder
emotional stress
fever
lack of sleep
List the stages in the transtheoretical model of change
Precontemplation - Denies problem and its consequences.
Contemplation - Acknowledges problem but is ambivalent or unwilling to change.
Preparation/determination - Committed to and planning for behavior change.
Action/willpower - Executes a plan and demonstrates a change in behavior.
Maintenance - New behaviors become sustained, integrate into personal identity and lifestyle.
Relapse - Regression to prior behavior (does not always occur).
Give the presentation of acute dystonia
Sudden onset of:
* muscle spasms
* stiffness
* oculogyric crisis occurring hours~days after medication use
* can lead to laryngospasm requiring intubation
List the causes for acute dystonia
Typical antipsychotics
Anticonvulsants
Give the treatments for acute dystonia
Benztropine
Diphenhydramine
List the presentation for lithium toxicity
Nausea, vomiting
Slurred speech
Hyperreflexia
Seizures
Ataxia
Nephrogenic diabetes insipidus
Give the treatments for lithium toxicity
Discontinue lithium
hydrate aggressively with isotonic sodium chloride
consider hemodialysis
Give the psychoactive mechanisms of alcohol
GABA-A receptor positive allosteric modulator.
Inhibits glutamate-induced excitation of NMDA.
Give the symptom timeline of alcohol withdrawal
3-36 hours: tremor, insomnia, diaphoresis, agitation, GI upset
6-48 hours: withdrawal seizures
12-48 hours: alcoholic hallucinations (usually visual)
>48 hours: delirium tremens
Give the mechanisms of alcohol withdrawal symptoms
Adaptation causes increased glutamate receptors
Symptoms results from unregulated excess excitation
Give the mechanisms for barbiturates and benzodiazepines
GABA-A receptor positive allosteric modulator
Give the symptom for barbiturate toxicity
Respiratory depression
Give the symptoms for barbiturate withdrawal
Delirium
Life threatening cardiovascular collapse
Give the symptoms for benzodiazepine withdrawal
ataxia
minor respiratory depression
Give the treatment for benzodiazepine toxicity
Flumazenil
Give the symptoms for benzodiazepine withdrawal
Seizures
Sleep disturbance
Depression
Give the treatment for opioid overdose
Naloxone
Give the mechanisms for cocaine
Blocks dopamine, serotonin, norepinephrine reuptake
Give the symptoms for cocaine overdose
Mydriasis, diaphoresis
Impaired judgment
Hallucinations, paranoia
Angina, sudden cardiac death
Perforated nasal septum
List the cocaine withdrawal symptoms
Restlessness
Hunger
Severe depression
Sleep disturbance
Give the mechanism of nicotine
Stimulates central nicotinic acetylcholine receptors.
Give the nicotine withdrawal symptoms
Irritability
Anxiety
Restlessness
Reduced concentration
Increased appetite / weight
List the treatment for nicotine withdrawal
Nicotine replacement therapy (patch, gum, lozenge)
Bupropion / varenicline
Give the mechanism of Lysergic acid diethylamide (LSD)
5HT-2A receptor agonist
Give the symptoms for LSD toxicity
Perceptual distortion (visual, auditory)
depersonalization
anxiety
paranoia
psychosis
flashbacks
mydriasis
Give the symptoms for cannabis toxicity
Euphoria
anxiety
paranoid delusions
perception of slowed time
impaired judgment
social withdrawal
increased appetite
dry mouth
conjunctival injection
hallucinations
Give the symptoms for cannabis withdrawal
Irritability
anxiety
depression
insomnia
restlessness
decreased appetite
Give the symptoms of MDMA intoxication
Euphoria
hallucinations
disinhibition
hyperactivity
thirst
bruxism
distorted perceptions
mydriasis
life threatening - serotonin syndrome.
Give the symptoms for MDMA withdrawal
Depression
Anxiety
Fatigue
Change in appetite
Difficulty concentrating
List the symptoms for phencyclidine (angel dust) intoxication
Violence
nystagmus
impulsivity
psychomotor agitation
tachycardia, hypertension
analgesia
psychosis
delirium
seizures
Which antipsychotic are the hyperprolactinemia side effects particularly common in
Risperidone
List the first line and second line management for alcohol misuse disorder
Naltrexone and acamprosate (acamprosate preferred in liver disease / opioid use)
2nd line: disulfiram
Thiamine
List the first line and second line management for Alcohol withdrawal syndrome
First line: long-acting benzodiazepines
* Chlordiazepoxide
* Diazepam
Lorazepam (preferred in hepatic failure)
Carbamazepine
List the 5P formulation of biopsychosocial interventions
(1) Presenting problem
(2) Predisposing factors
(3) Precipitating factors
(4) Perpetuating factors
(5) Protective factors
Give the triad in PTSD
Hypervigilance
Avoidance
Re-experiencing
List the symptoms of sedative/hypnotic toxicity
Ataxia
sedation
hallucinations
blurred vision
slurred speech
hypotonia
hyporeflexia
hypotension
nystagmus
Define tangentiality
The act of wandering from a topic without returning to it
Define Circumstantiality
Individual includes excessive and unnecessary detail when answering a question, although there are discernible links between topics.
Define Clang association
Ideas are connected through rhyme or similar sounds
Define flight of ideas
answering a question relatively immediately but then digressing from this answer.
What is flight of ideas associated with
Mania
Define delusional parasitosis
Fixed, false belief that they are infected by bugs
Define Capgras syndrome
belief that someone significant in their life, such as a spouse or a friend, has been replaced by an identical imposter.
Define Fregoli syndrome
belief that multiple people are in fact all the same person, who is constantly changing their appearance.
What should be given for patients with poor oral compliance to antipsychotics
Once monthly IM antipsychotic depot injections
Define:
De Clerambault’s
Cotard syndrome
Othello syndrome
Capgras delusion
Charles Bonnet syndrome
De Clerambault’s = erotomania (excessive horniness)
Cotard syndrome = believing you’re dead
Othello syndrome = delusional jealousy (usually of a partner)
Capgras delusion = believing a (close) acquaintance has been replaced by an imposter
Charles Bonnet syndrome = recurring hallucinations in those with impaired vision
What is the SSRI of choice in children and adolescents
Fluoxetine
Define Illness anxiety disorder (hypochondriasis)
Persistent belief in the presence of an underlying serious disease, e.g. cancer
