PSYCH Flashcards
Psych History
Intro HPC Past psych history Personal history Family history Drug history Forensic history MSE Physical examination Risk assessment Conclusion
What is included in the MSE?
Appearance + Behaviour Speech Mood Thought Perception Cognition Insight
MSE: Appearance + Behaviour
Eye contact Rapport Clothing Agitation Co-operation Hygiene
MSE: Speech
The production of speech not what is being said Speed - Slow, fast, hesitant, pressured Volume - loud, soft, muttered, shouting Language - accented, Dysphasia Neologisms, Punning
MSE: Mood
Mood
Affects
MSE: Thoughts
Content - Obsession, Preoccupied, Clang association, Delusions
Stream - Poverty, Racing, Withdrawal, Disinhibition
Form - Flight of idea, Looseness of association
MSE: Types of delusions
Persecutory Reference - things have significance Grandiose Worthlessness Control Possession of though Over-valued ideas Obsessive Self-harm/ Suicide
MSE: What are delusions?
False unshakable beliefs ideas or beliefs firmly held despite evidence to the contrary and that are not consistent with the persons education, culture or social background
MSE: Mood?
Mood and Affects
Does what the patient is saying match how they are saying it
Euthymic, Elated, Depressed, Irritable, Anxious, Reactive, Flat
MSE: Perceptions + Hallucinations
5 sense - Auditory, Visual, Tactile, Gustatory, Olfactory
Dissociative - Derealisation (world not real) + Depresonalisation (Detached from the world)
Illusion (misinterpretation of stimuli)
Hallucinations (perceptions without external stimuli)
MSE: Cognition
Cognitively intact
or
MMSE - Orientation, Registration, Attention and Calculation, Recall, Language (3 stage command), Copy Shapes
MSE: Insight
Understanding they have an illness
Willing to take treatment
Understand the consequence of not taking treatment
willing to seek help
5Ps of formulation?
Presenting problem Predisposing factors (factors that already exist) Precipitating factors (factors that just made things worse) Perpetuating factors (factors maintaining the illness, impending factors that could make things worse) Protective factors (what is saving them)
What is phenomenology?
No theories
Not unconscious
What is visible and Observable in terms of the patient experience
Objective description of abnormal states of mind avoiding preconceived ideas and theories. limited to the description of conscious experiences and observable behaviour
Disorders of perception?
Sensory distortions
Sensory depictions
Sensory distortions?
Change in intensity
Change in quality
changes in spatial form
Distortion of experience of time -Physical time + personal time (time flying or time stopping)
Sensory depictions?
Illusions
Hallucinations
What is an illusion?
Misinterpretation of stimuli
What are hallucinations?
Perceptions without object/ external stimuli
Auditory
Difference between 2nd + 3rd person auditory hallucinations?
2nd person - you will die, you are a bad person
3rd - running commentary, voices discussing or commenting
What are visual hallucinations?
Commonly seen in organic conditions e.g. brain pathology
Elementary (flashes of light) or fully organised (people, animals)
Functional hallucination
Auditory stimulus causes hallucination
Reflex hallucination?
Stimulus in 1 sensory modality produces a sensory experience in another
Extracampine hallucination?
Hallucination that is outside the limits of the sensory field e.g. voices in Paris when you are in london
Hypnagogic?
Hallucinations when the patient is fallling asleep
Hypnopompic?
Hallucination when the patient is waking up
4 main groups of thought disorders?
Stream
Possession
content
form
Disorders of stream of thought?
Tempo - Flight of ideas, Inhibition/ slowness, Circumstantiality
Continuity if thought - Perseveration, Thought block
Flight of ideas?
Example of stream of thought disorder
Jumping from thought to thought with a common link
Circumstantiality?
Example of stream of thought disorder
Talking around the point but not actually about the point. Giving all the peripheral information
Disorders of possession of thought?
Obsession + compulsion - Still have own thoughts but intrusive thoughts enter and are only relieved by actions. Thoughts become worse the more you try to stop
Thought Alienation - Insertion, withdrawal or broadcast
What is a delusion?
Example of disorder of thought content
False unshakable belief that is out of character of the individual personal, cultural or social context
Difference between a primary and secondary delusion?
Primary - new meaning arises in connection with some other psychological event
Secondary - Arising from some other morbid experience
Nihilistic delusion?
Patient believes they are already dead
Patient denies the existence of their body, their mind, their loved ones and the world around them
Delusions of poverty?
Convinced that they are impoverished and believe destitution is facing them and their family
loosening of association?
There is lack of logical association between succeeding thoughts
Examples of disorders of memory?
Dissociative amnesia
Confabulations
Dissociative amnesia?
Sudden amnesia that occurs during the periods of extreme trauma and can last hours or days
Confabulations?
Falsifications of memory occurring in clear consciousness associated with organic pathology
Filling in gaps in memory with imagines or untrue experiences that have no basis in fact
Anhedonia?
Inability to experience pleasure of things that were usually enjoyable
Apathy?
Emotional indifference - lack of emotions
Incongruity of affect?
Emotional state and thought process are opposite
Blunting of affect?
Absence of emotional response
Conversion and Belle indifference?
Conversion - psychological conflict manifests into somatic symptoms (motor or sensory nature) that can’t be identified on neuro examination
Belle indifference - conversion disorder but remains emotionally indifferent
Depersonalisation?
Sense of detachment of one’s own body. A spectator of own activities
Derealisation?
Feeling the world isn’t real. the world is dull and grey
Passivity phenomena?
Actions/ Feelings/ drives are controlled by others
Somatic passivity?
Delusional belief that one is a passive recipient of bodily sensations from an external agency
Catatonia?
State of excited or inhibited motor activity in the absence of mood disorder or neurological disease
Waxy flexibility?
Patient’s limbs when moved feel like wax and remain in the position in which they are left
Echolalia (parrot)?
Automatic repetition of words heard
Echopraxia?
An automatic repetition by the patient of movements made by the examiner
Logoclonia?
Repetition of the last syllable of a word
Negativism?
Motiveless resistance to movement
Palilalia?
Repetition of a word over and over again with increasing frequency
Verbigeration (Brick)?
Repetition of one or several sentences or strings of fragmented word in a monotonous tone
Presentation order for psych?
History MSE Formulation (Presetting complaint, Predisposing, precipitating, Perpetuating (maintaining), Protective) Risk assessment Management plan
Positive symptoms
Hallucination
Delusions
Negative symptoms?
flat
Cognitive difficulty
Poor motivation
Social withdrawal
Examples of disorders of form of thought?
Derailment/ Knight’s moving
Tangientality
Circumstantiality
Difference between Knight’s move thinking and Tangientality?
Knight’s move thinking - Jumping from topic to topic and each sentence is unrelated
Tangientality is when the patient diverts from one topic to another but it is a gradual shift from topic rather than a sudden jump
Examples of disorders of stream of thought?
Pressured
Poverty
Thought block
Capgrass syndrome?
Irrational belief that a familiar person has been replaced with a duplicate
Fregoli?
Delusional misidentification - Thinking a total stranger is someone they are familiar with even if they look different
Delusional perception?
Real percept with delusional interpretation
Passivity phenomena/ Delusion of control?
Someone or something is controlling their body, mind and behaviour. They don’t want to do something but they are being forced to
Ekbom Syndrome?
Delusional Parasitosis - believing they have skin infestations that can result in serious harm
De Clérambault’s Syndrome?
Erotomania - Delusions that someone is in love with them
Examples of delusions of thought interference?
Insertion, Withdrawal, Broadcast
Folie à deux?
Shared delusions between 2 people
Grandiose?
When a patient believes they have special powers, abilities or possessions
Cotard’s syndrome?
Delusion of immortality, the patient believes they are already dead
Nihilistic delusions?
Belief of being dead or decomposed or having lost ones internal organs
What is personality?
Collection of characteristics/ traits that develop as we grow and it influences how we think, feel and behave
ICD 10 personality disorder definition?
Severe disturbance in characterological condition and behavioural tendencies of the individual in several areas of personality affecting their personal and social life considerably
DSM cluster A?
Odd/ Eccentric
- Schizoid, Paranoid, Schizotypical
DSM cluster B?
Dramatic/ Erratic/ Emotional
- EUPD, Narcissistic, Dissocial
DSM cluster C?
Anxious/ Fearful
- OC, Dependant, Avoidant
Clinical features of EUPD?
Emotional Dysregulation Impulsivity - sustenance, eating, exploitation, overspending Self-harm Interpersonal difficulty Lack of sense of self Abandonment issues Stress-induced paranoia Co-morbid mental health conditions
Ddx of EUPD?
Bipolar Affective Disorder
ADHD
Schizophrenia
Complex PTSD
Why would a patient with EUPD self-harm?
Not always suicidal but used to relieve psychic pain or feel something when feeling empty
Management of EUPD?
Acute - Crisis admission or HT
Medium - CMHT, CPN, Support worker, Care coordinator
Long term - DBT, OT
What is DBT?
Dialectical Behavioural Therapy - coping strategies as alternatives to self-harm
Review the situation from different perspectives and come to a conclusion
Develop coping skills to improve affective stability and impulse control
GPD: Dependant?
- Allowing others to make decisions for them
- Putting the needs of others before their own
- When alone, feel helpless and uncomfortable
- Fears of abandonment
- Requires excessive amount of advice
GPD: Dissocial?
- Callous unconcern for the feelings of others
- Disregard for social norms, rules and obligations
- Low threshold for discharge of aggression + violence
- Incapacity to experience guilt
- Prone to blame others
GPD: Anankastic?
- Obsessive behaviour associated with perfectionism and lack of flexibility
- Excessive adherence of social conventions
- Very conscientious
- Rigid + Stubborn
- Intrusive/ Unwelcomed thoughts
GPD: Histrionic?
- Dramatic + Theatrical AF, exaggerated expression of emotions
- Easily Influences
- Shallow + Labile
- Aims to be the centre of attention for excitement
- Inappropriate seductiveness in appearance and behaviour
- Only concerned with physical attractiveness
GPD: Anxious/ Avoidant?
- Persistent + Pervasive feelings of apprehension
- Feeling inferior to others
- Excessive preoccupation with being criticised
- Unwilling to get involved with people unless they are certain they will be liked or fear of being criticized
- Restricted lifestyle so require phsyical security
GPD: Schizoid?
- Few activities provide pleasure
- Emotionally cold
- Limited capacity to express warm feelings towards others
- Indifference to either praise or criticism
- Excessive preoccupation with fantasy
- Lack of close friend/ confiding relationships
GPD: Emotional unstable?
- Impulsive
- Difficulty controlling emotions
- Self-harm to relieve pain
- Feel empty
- Quick to make relationships but easily lose them
- Severe experience auditory hallucinations
GPD: Paranoid?
- Suspicious of everything
- Tendency to bear grudges
- Combative and Tenacious sense of personal rights
- Tendency to express excessive self-importance
3 examples of assessments for personality disorders?
- Minnesota Multiphasic Personality Inventory
- Eysenck Personality Inventory/ Personality Diagnostic Questionnaire
- Structured Psychometric Assessment
Alzheimers dementia cause?
Build up of amyloid plaques and neruofibrillary tangles + decreased acetylcholine production = tau build up and enlarged ventricles
Lewy body dementia?
Abnormal build up of alpha-synuclein
Signs of Lewy body dementia?
Parkinsonian features Hallucinations Shift in personality Syncope + falls Memory loss towards the end
Vascular dementia?
History of cerebral infarcts or arteriopathies or leukoencephalopathy
Signs of vascular dementia?
Stepwise increase in severity of symptoms Visual field defects Impaired gait Attention problems Personality changes
Frontal Temporal dementia?
Progressive degeneration of frontal/temporal lobe
Personality/ Behavioural changes
Progressive supraocular palsy?
Affects part of the brain just above the nerve cells that control eye movement
Problems with balance + coordination + dementia symptoms
Risk factors of dementia?
Learning difficulties Age Downs syndrome Genetics CVD Parkinsons Strokes Depression Alcohol abuse
Investigations used to diagnose dementia? HC3ABE
History, Consent, Capacity, Cognition, ADL, Examine
Examine - Gait, Balance, CVD sights, Weight loss, focal neurological signs, Visual fields, Hemiparesis, Urine
Management of Dementia?
MDT + Orientation + Reassurance
Acetylcholinesterase
Memantine
Lorazepam
MOA of Memantine?
NMDA receptor agonist - Blocks glutamine receptors to improve BPS of dementia e.g hallucinations, aggression + delirium
What is delirium?
Acute, transient and reversible state of confusion as the result of an organic process. It is sudden onset and fluctuates
Types of delirium?
Hyperactive, Hypoactive + Mixed
Causes of delirium?
Constipation Hypoxia Infection/ Impaction/ Intracranial Metabolic disturbances/ Myocardial problems Pain Sleepiness Prescription Hyopthermia/ Pyrexia Nutrition Environmental changes Drugs
Differences between delirium and dementia?
Delirium
- Sudden onset
- Fluctuations
- Lasts hours to weeks
- Disrupted sleep
- Impaired alertness + orientations
- Altered behaviour
- Incoherent speech rather than word-finding problems
- Disorganised/ Delusional thought
2 ways of assessing the mental state of a patient?
MMSE
Addenbrooke’s cognitive assessment
Schizoaffective disorder?
Where symptoms of schizophrenia and mood disorder and equally prominent
Prodromal phase of schizophrenia?
Emotional and behavioural changes affecting personal functioning and social withdrawal
Anhedonia + decreased cognition
Transient Low intensity symptoms lasting <1 week proceeded by acute psychotic episode
+ve symptoms of Schizophrenia?
Auditory hallucinations
Persecutory delusions
Disorganised speech/ thought alienation
-ve symptoms of Schizophrenia?
Emotional Blunting Reduced speech Loss of Motivation Self-neglect Social Withdrawal
Complications of schizophrenia?
Premature death Increased risk of suicide CVD T2DM Smoking related illness Cancer Infection Social exclusion
Management of Schizophrenia?
Risk Assessment
Early intervention services or Home treatment team or Crisis resolution
Sectioning
Anti psychotic medication
What medication is used to manage treatment resistance psychosis?
Clozapine
Side effects of antipsychotics?
Weight gain Dyslipidaemia Sedation Hypertension Dry mouth Blurred vision Impotence Urinary retention Constipation Flushing Reduced seizure threshold QT prolongation Impaired glucose tolerance Neuroleptic Malignant Syndrome
Neuroleptic Malignant Syndrome?
Fever Encephalopathy Vital dysregulation Enzyme elevation Rigidity + Hyperreflexia
EPSE of antipsychotics?
Acute Dystonic reactions - Jaw jerk, oculogyric crisis
Pseudoparkinsons
Akathesia (Restlessness)
Tardive Dyskinesia
Tardive Dyskinesia?
Late onset movement disorder due to long term antipsychotic use
Dopamine receptors become hypersensitive due to long term inhibition
Protrusion on the tongue, Tongue rolling, Chewing motion, Facial dyskinesia
Symptoms are persistent and worse with withdrawal
What increases the metabolism of clozapine?
Smoking + grapefruit juice
What decreases the metabolism of clozapine and causes it to be more potent?
Caffeine
Side Effects of clozapine?
Agranulocytosis Neutropenia Drooling Constipation QT prolongation Hyperprolactinaemia Myocarditis or Cardiomyoapthy
What is the difference between a manic episode and a hypomanic episode?
Manic episode - 1 week, Persistent fluctuation in extreme mood, can lead to hospitalisation and delusions/ hallucinations may be present
Hypomanic - 4 days, no impairment in functioning or evidence of psychosis
Bipolar I?
1 Manic episode + History of major depressive episodes
Bipolar II?
1+ Major depressive episodes + 1 Hypomania but no mania
4 types of Bipolar?
Mania
Hypomania
Depressive
Mixed
Management of Bipolar disorder
HTT + CRT
Compulsory admission
Antipsychotic: Haloperidol, Olanazapine, Quetiapine or Risperidone
What drugs can be added alongside antipsychotics to manage bipolar?
Lithium or Sodium Valporate
MOA of lithium?
Stimulates NMDA receptors increasing excitatory glutamate for post-synaptic neurones
Chronically causes NMDA downregulation to modulate glutamate neurotransmission
Which groups of people have the greatest risk of lithium toxicity?
Hypertension DM CCF CKD Schizophrenia Addison's disease
GAD?
Disproportionate, uncontrollable widespread worry + a range of cognitive and behavioural symptoms e.g. muscle tensions, trembling, nervousness, sweating
Why are SSRI or SNRI CI in pregnancy?
Can cause persistent pulmonary hypertension in newborns
PTSD key symptoms?
Re-experiencing, Hyperarousal and Avoidance
Specific features of PTSD in children?
Re-living trauma while playing, Nightmares, Anhedonia, Expressing belief they will not live long enough to grow up, Stomach ache, Headache, Secondary enuresis, Separation anxiety
Screening tool used for PTSD?
Trauma Screening questionnaire or Impacts of events scale
Management of PTSD?
Trauma-focused CBT
Exposure therapy CBT
Trauma-Focused Cognitive Therapy
Eye movement Desensitization + Reprocessing therapy
Pharmacological therapy used in PTSD?
SSRI or Venlaxafine or Risperidone
OCD?
Recurrent obsessional thoughts or compulsive acts which can cause functional impairment + distress
Diagnostic tool used for OCD?
Yale-Brown Obsessive Compulsive Scale
Management of OCD?
Risk Assessment
CBT + Exposure response therapy
SSRI or TCA
SSRI used for OCD?
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
TCA used to manage OCD?
Clomipramine
Section 2 duration and purpose?
28 days
Assessment
Section 3 duration and purpose?
6 months
Treatment
Section 4 duration and purpose?
72 hours and if there is no time to wait for a second doctor
Section 5(4)?
6 hours
Patient already admitted to hospital and wanting to leave - Nurse waiting for doctor
Section 5(2)?
72 hours
Patient already admitted but wanting to leave
Allow time for section 2 or 3
Difference between S136 and S135?
S136 - person suspected of having mental disorder in public place
S135 - Needs court order to access patients’ home and remove them
Generalised anxiety disorder?
Disproportionate, uncontrollable widespread worry + a range of cognitive and behavioural symptoms
Eating disorder?
Persistent disturbance or eating related behaviour which leads to altered intake and absorption of food causing a significant impact on physical and psychological functioning
Anorexia Nervosa?
Body image disturbance and fear of gaining weight
BMI <15 and denial of a sense of malnutrition
Bulimia Nervosa?
Recurrent episodes of uncontrolled eating of large amounts of food followed by compensatory behaviour
once a week for 3 months
Examples of compensatory behaviours of Bulimia Nervosa?
Vomiting, Purging, Fasting, Excessive exercise, Laxative intake, Diuretic, Diet pill use
Finding on examinations that could indicate Bulimia Nervosa?
Russell sign - Knuckle calluses from induced vomiting
Dental Enamel Erosions
Salivary Gland Enlargement
Difference between Binge Eating and Bulimia Nervosa?
Binge eating is the same as Bulimia Nervosa without the compensatory behaviour
SCOFF Questions?
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you lost > One stone in 3 months?
Do you believe yourself to be fat when others say you are too thin?
Would you say Food dominates your life?
