Psych Flashcards
1
Q
PHENOMENOLOGY
Define illusion
A
The false perception of a real external stimulus
2
Q
PHENOMENOLOGY
Define hallucination
A
An internal perception occurring without a corresponding external stimulus.
3
Q
PHENOMENOLOGY In terms of hallucinations, what are... i) the main senses? ii) somatic? iii) hypnogogic/hypnopompic iv) autoscopic? v) reflex? vi) extracampine?
A
i) Auditory, visual, olfactory, gustatory, tactile
ii) within the person
iii) when going to sleep/when waking up = normal
iv) seeing oneself
v) production of a hallucination in one sensory modality by a stimulus in a different modality
vi) hallucinations which are experienced outside the normal sensory field (seeing something behind them)
4
Q
PHENOMENOLOGY
What is Charles-Bonnet Syndrome?
What conditions may it be seen in?
A
- Complex visual hallucinations in a patient with partial/severe blindness (macular degeneration, diabetic retinopathy).
- Pts understand that the hallucinations are not real + so often have insight
5
Q
PHENOMENOLOGY
Define pseudo-hallucination
A
A perception in the absence of an external stimulus
6
Q
PHENOMENOLOGY
Define over-valued idea
A
A false or exaggerated belief held with conviction but not with delusional intensity.
7
Q
PHENOMENOLOGY
Define delusion
A
A fixed, false, unshakable belief which is out of keeping with the patient’s educational, cultural + social norms. It’s held with extraordinary conviction + certainty (even despite contradictory evidence)
8
Q
PHENOMENOLOGY
In terms of delusions, what are…
i) persecutory?
ii) grandiose?
A
i) the idea that someone/something is trying to inflict harm on them (being followed, poisoned)
ii) idea that the person themselves are powerful/crucially important beyond truth
9
Q
PHENOMENOLOGY
In terms of delusions, what are…
i) nihilistic?
ii) reference?
A
i) theme involves intense feelings of emptiness, sense of everything being unreal
ii) false belief that insignificant remarks/objects in one’s environment have personal meaning/significance (newspaper has hidden text related to them)
10
Q
PHENOMENOLOGY
What are the 3 delusional misidentification syndromes?
A
- Capgras = idea someone has been replaced by an imposter.
- Fregoli = idea various people are the same person
- Intermetamorphosis = one significant relative is replaced by another (father is son).
11
Q
PHENOMENOLOGY
Define delusional perception and give an example
A
A primary delusion of two components – where a normal perception is subject to delusional interpretation
E.g. – traffic light changed red so that means I am the son of God
12
Q
PHENOMENOLOGY
Define thought alienation. What are the 3 components of this?
A
Sx of psychosis in which patients feel that their own thoughts are in some way no longer in their control
Insertion = delusional belief thoughts placed into pts head from external
Withdrawal = delusional belief thoughts removed from head from external
Broadcast = delusional belief thoughts are accessible directly to others without expressing them
13
Q
PHENOMENOLOGY
Define concrete thinking
A
Loss of ability to understand abstract concepts + metaphorical ideas leading to a strictly literal form of speech
14
Q
PHENOMENOLOGY
Define thought disorder and formal thought disorder
A
TD = disorganised thinking as evidenced by disorganised speech/beliefs FTD = pts expressive language (form) indicates that the links between consecutive thoughts aren't meaningful (disorganised speech evident from disorganised thinking)
15
Q
PHENOMENOLOGY In terms of thought disorders, what is... i) flight of ideas? ii) pressure of speech? iii) poverty of speech/alogia?
A
i) Abrupt leaps between topics as thoughts present more rapidly than can be articulated. Each thought = more associations. ?Discernible links between successive ideas. Presents as pressure of speech.
ii) Rapid speech w/out pauses which is difficult to interrupt
iii) Lack of spontaneous speech
16
Q
PHENOMENOLOGY In terms of thought disorders, what is... i) tangentiality? ii) thought block? iii) clang association (± alliteration) iv) circumstantiality?
A
i) Wandering from the topic + never returning to it
ii) Sudden + unintentional break in chain of thought
iii) Severe form of flight of ideas whereby ideas are related only by similar/rhyming sounds rather than meaning
iv) Irrelevant wandering in conversation (going around the point).
17
Q
PHENOMENOLOGY In terms of thought disorders, what is... i) loosening of association? ii) perseveration? iii) echolalia?
A
i) Aka derailment/Knight’s move thinking = a lack of logical association between sequential thoughts, often leading to incoherent speech
ii) Persistent repetition of words/ideas that were initially appropriate but continue past this point
iii) repeating other’s words/phrases
18
Q
PHENOMENOLOGY In terms of thought disorders, what is... i) neologisms? ii) incoherence/word salad? iii) poverty of thought?
A
i) Making up new words
ii) Confused or unintelligible mixture of seemingly random words and phrases
iii) Subjective experience of being devoid of thoughts
19
Q
PHENOMENOLOGY
Define confabulation + state what conditions you would find this in
A
Giving a false account to fill in a gap in memory.
Korsakoff’s psychosis + dementia
20
Q
PHENOMENOLOGY
Define passivity phenomena?
A
- Delusion that one is a passive recipient of actions from an external agency against their will
21
Q
PHENOMENOLOGY
Define psychomotor retardation + state what conditions you would find this in
A
- Slowing down of mental or physical activities
- Parkinson’s, depression
22
Q
PHENOMENOLOGY
Define incongruity of affect
A
Emotional responses that differs markedly from the expected emotion for the situation/subject like laughing whilst discussing trauma
23
Q
PHENOMENOLOGY
What is the difference between blunting and flattening of affect?
A
- Blunting = dulled response to emotional stimuli
- Flattening = no response to emotional stimuli
24
Q
PHENOMENOLOGY
Define depersonalisation + derealisation
A
- Where a person doesn’t believe themselves to be real
- Where a person doesn’t believe the world/people around them to be real
25
PHENOMENOLOGY
| Define obsession
- Unwanted intrusive thought, image or urge that repeatedly enters a person's mind. Recognised as person's own thoughts (insight)
26
PHENOMENOLOGY
| Define compulsion
- Repetitive behaviours or mental acts that a person feels driven to perform
27
PHENOMENOLOGY
| Define thought echo
Auditory hallucination in which the content is the individual's current thoughts spoken aloud as if next to them
28
PHENOMENOLOGY
| Define catatonia/stupor
Abnormality of movement + behaviour arising from a disturbed mental state, typically severe depression or schizophrenia
29
PHENOMENOLOGY
| Define anhedonia
Inability to feel pleasure in normally pleasurable activities
30
PHENOMENOLOGY
| Define belle indifference
A surprising lack of concern for, or denial of, apparently severe functional disability (not specific to psych)
31
PHENOMENOLOGY
| Define dissociation
When a person feels disconnected from themselves or their surroundings (including emotions)
32
PHENOMENOLOGY
| Define conversion
Development of features suggestive of physical illness but which are attributed to psych illness or emotional disturbance rather than organic pathology
33
PHENOMENOLOGY
| What is the difference between stereotypy and mannerism?
- Stereotypy = persistent repetition of an act for no obvious purpose
- Mannerism = gesture which is peculiar to the individual
34
PHENOMENOLOGY
| Define projection + give an example
What is emotionally unacceptable in the self is unconsciously rejected + projected to others (e.g. mother projects anxiety on children claiming they're anxious)
35
MENTAL HEALTH ACT 1983
| What are the main principles of the MHA?
- Respect for pts wishes + feelings (past + present)
- Minimise restrictions on liberty
- Public safety
- Pts well-being + safety
- Effectiveness of treatment
36
MENTAL HEALTH ACT 1983
| What does an individual have to show to be sectioned?
- Evidence of MH disorder
- Evidence they're serious risk to self, safety or others
- Evidence there is good reason to warrant attention in hospital
- Appropriate treatment must be available for a S3
37
MENTAL HEALTH ACT 1983
What is a...
i) section 12 approved dr?
ii) approved mental health professional?
i) ≥ST4 Dr who has done extra training in MH to get S12 approved to section pts
ii) AMHPs are often social workers who have done extra training in MH
38
MENTAL HEALTH ACT 1983
| Who can remove sections?
- Consultant psychiatrist
- MH review tribunal (MHT) if pt disagrees w/ section
- Nearest relative can make an order to discharge pt from hospital with 72h written notice
39
MENTAL HEALTH ACT 1983
| What is the purpose, duration, location + professionals involved for a Section 2?
P – admission for assessment, treatment can be given w/out consent
D – 28d, cannot be renewed, can be converted to S3
L – anywhere in community (airports, jail, A+E, etc)
Prof – 2 Drs (1x S12), 1 AMHP, or nearest relative
40
MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 3?
Who is involved if a pt is medicated without consent?
P – admission for treatment
D – 6m, can be renewed
L – anywhere in community
Prof – 2 Drs (1x S12), 1 AMHP, nearest relative
Second opinion appointed doctor (SOAD) – after 3m
41
MENTAL HEALTH ACT 1983
| What is the purpose, duration, location + professionals involved for a Section 4?
P – emergency order where waiting for S2 would lead to undesirable delay
D – 72h
L – anywhere in community
P – 1 S12 Dr, 1 AMHP, nearest relative
42
MENTAL HEALTH ACT 1983
Where can you apply a S5?
What can the team not do?
- Voluntary pt in hospital that wants to leave (NOT A+E as not admitted)
- Coercively treat the pt
43
MENTAL HEALTH ACT 1983
| What is the purpose, duration + professionals involved for a Section 5(2)?
P – Drs holding power, allows for S2/3 assessment
D – 72h
Prof – 1 Dr (FY2 or above)
44
MENTAL HEALTH ACT 1983
| What is the purpose, duration + professionals involved for a Section 5(4)?
P – nurses holding power until Dr attends to assess
D – 6h
Prof – 1 registered nurse
45
MENTAL HEALTH ACT 1983
| What are the 2 police sections and their differences? What is the duration and purpose of these?
- S135 – needs magistrates court order to access pts home + remove them
- S136 –person suspected of having mental disorder in a public place
D – 24h (extend to 36h if intoxicated but should be seen sooner)
P – taken to place of safety (local psych unit, police cell) for further assessment
46
ANTI-PSYCHOTICS
What are the two types of anti-psychotics?
Give examples.
- Typical/1st gen = haloperidol, zuclopenthixol, chlorpromazine
- Atypical/2nd gen = olanzapine, risperidone (depot), clozapine, aripiprazole (depot), quetiapine
47
ANTI-PSYCHOTICS
What is the mechanism of action of typical anti-psychotics?
What is the issues?
- Antagonism of Dopamine D2 receptor
| - Not selective so can bind to other dopaminergic pathways causing generalised dopamine receptor blockade
48
ANTI-PSYCHOTICS
What pathway do typical anti-psychotics work on to...
i) have anti-psychotic effect?
ii) cause side effects?
i) Mesolimbic pathway (reduces +ve Sx)
| ii) Nigrostriatal (Parkinsonism), tuberoinfundibular (prolactin)
49
ANTI-PSYCHOTICS
What is the mechanism of action of atypical anti-psychotics?
What is the benefit of atypical anti-psychotics?
What anti-psychotic has a reduced SE profile and why?
- Antagonists at dopamine D2 receptors but more selective in dopamine blockade + also block serotonin 5-HT2a
- More useful in treating -ve Sx of schizophrenia + less likely to cause EPSEs
- Aripiprazole as partial dopamine agonist
50
ANTI-PSYCHOTICS
What is the most crucial adverse effect of clozapine?
What is the most common adverse effect?
What other adverse effects may it have?
- Severe life-threatening agranulocytosis
- Constipation (big issue in elderly)
- Reduced seizure threshold, hypersalivation (Rx hyoscine hydrobromide)
51
ANTI-PSYCHOTICS
| What are the 5 broad categories of SEs caused by anti-psychotics?
- Extra-pyramidal side effects (EPSEs)
- Hyperprolactinaemia
- Metabolic
- Anticholinergic
- Neurological
52
ANTI-PSYCHOTICS
| What are the EPSEs?
- Acute dystonic reaction
- Parkinsonism
- Akathisia
- Tardive dyskinesia
53
ANTI-PSYCHOTICS
How does Parkinsonism present?
How is it managed?
- Bradykinesia, rigid, resting pill-rolling tremor + postural instability
- Reduce dose or switch to atypical anti-psychotic
54
ANTI-PSYCHOTICS
How does akathisia present?
What is a risk of this?
How is it managed?
- Motor restlessness, typically lower legs (can't sit still)
- Massive RF for suicide in young men with schizophrenia
- Reduce dose, introduce beta-blocker (propranolol)
55
ANTI-PSYCHOTICS
How does tardive dyskinesia present?
When does it present?
How is it managed?
- Purposeless involuntary movements (chewing, lip smacking, blinking, tongue protrusion)
- After months-years of Tx
- Prevention crucial, switch to atypical anti-psychotic, tetrabenazine used if mod–severe but unlikely to completely resolve
56
ANTI-PSYCHOTICS
| What are the SEs from hyperprolactinaemia?
- Sexual dysfunction (+ anti-adrenergic)
- Osteoporosis risk
- Amenorrhoea
- Galactorrhoea, gynaecomastia + hypogonadism in men
57
ANTI-PSYCHOTICS
| What are the metabolic SEs?
- Weight gain (esp. olanzapine)
- Hyperlipidaemia, risk of stroke + VTE in elderly
- T2DM risk + metabolic syndrome
58
ANTI-PSYCHOTICS
| What are the anticholinergic SEs?
```
Can't see, pee, spit, shit –
- Blurred vision
- Urinary retention
- Dry mouth
- Constipation
+ tachycardia
```
59
ANTI-PSYCHOTICS
| What are the neurological SEs?
- Seizures
- Postural hypotension (anti-adrenergic)
- Sedation
- Headaches
60
ANTI-PSYCHOTICS
| What baseline investigations are done for people starting on anti-psychotics?
- FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin, BP, ECG (QTc prolongation) + smoking status (can reduce effects by enhancing metabolism so issues if suddenly stop)
61
ANTI-PSYCHOTICS
| What regular investigations are done for people on anti-psychotics?
- Lipids + BMI at 3m
- Fasting glucose + prolactin at 6m
- Frequent BP during dose titration
- FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin + CV risk yearly
62
ANTI-PSYCHOTICS
What specific monitoring is required for clozapine?
What happens if they miss a dose?
- FBC at baseline + weekly for 18w, fortnightly until 1y + monthly after
- If not taken for 48h needs retitrating
63
ANTI-DEPRESSANTS
What monitoring is needed when starting someone on an anti-depressant?
When can an anti-depressant be stopped?
- 2 weekly to ensure dose working + patient stable (risk of suicidality), may take up to 6w to start working
- Carried on 6m after Sx resolved even if patient feels better to reduce risk of relapse
64
ANTI-DEPRESSANTS
How should anti-depressants be stopped?
Why?
- Gradual dose reduction over 4w
- Sudden cessation can cause severe withdrawal effects (mostly GI) – abdo pain, D+V, difficulty sleeping, sweating + mood change
65
ANTI-DEPRESSANTS
What is the mechanism of action of SSRIs?
Give some examples
- Prevents reuptake of serotonin from synaptic cleft so prolonged serotonin in synaptic cleft = prolonged neuronal activity
- Citalopram, sertraline (#1 post MI), fluoxetine (#1 CAMHS)
66
ANTI-DEPRESSANTS
| What are the side effects of SSRIs?
- GI = N+V, diarrhoea, constipation
- Hyponatraemia
- Anxiety + agitation
- Citalopram + QTc prolongation (dose-dependent)
67
ANTI-DEPRESSANTS
| What are some cautions for SSRIs?
- May precipitate manic phase in bipolar
| - 1st trimester risk of CHD, 3rd trimester risk of persistent pulmonary HTN
68
ANTI-DEPRESSANTS
| What are some interactions for SSRIs?
- NSAIDs + aspirin = increased risk of bleeding, co-prescribe PPI
- Can lower seizure threshold
- Avoid triptans > serotonin syndrome
- Do not start until 2w after stopping MAOI + vice-versa as increased risk of serotonin syndrome
69
ANTI-DEPRESSANTS
What is the mechanism of action of SNRIs?
Give some examples
- Prevents reuptake of serotonin AND noradrenaline from synaptic cleft
- Venlafaxine, duloxetine
70
ANTI-DEPRESSANTS
What are some side effects of SNRIs?
What are some interactions of SNRIs?
- GI (N+V, constipation)
| - NSAIDs + warfarin (increased risk of bleeding), lower seizure threshold
71
ANTI-DEPRESSANTS
What is the mechanism of action of monoamine oxidase inhibitors (MAOI)?
Give some examples.
- Inhibits monoamine oxidase enzyme which reduces breakdown of adrenaline, noradrenaline + serotonin so increases level
- Selegiline is selective MAO-B inhibitor which also increases dopamine
- Isocarboxazid, phenelzine
72
ANTI-DEPRESSANTS
| What are some side effects from MAOIs?
- Sexual dysfunction, weight gain + postural hypotension
73
ANTI-DEPRESSANTS
| What are some cautions with MAOIs?
- Increased risk of serotonin syndrome if used with other serotonergic drugs
- Hypertensive crisis with ingestion of foods containing tyramine (aged cheeses, smoked/cured meats, pickled herring, Bovril, Marmite)
74
ANTI-DEPRESSANTS
What is the mechanism of action of tricyclic antidepressants (TCAs)?
Give some examples
- Prevents reuptake of serotonin + noradrenaline from synaptic cleft
- Amitriptyline, dosulepin, imipramine
75
ANTI-DEPRESSANTS
What are the side effects of TCAs?
What cautions are there for TCAs?
- Anticholinergic (can't see, pee, spit, shit)
- Caution in CVD, avoid following MI
- Cardiotoxic in overdose so caution in suicidal patients (QTc prolongation)
76
ANTI-DEPRESSANTS
In terms of TCA overdose...
i) mild-moderate Sx?
ii) severe Sx?
iii) ECG signs?
iv) management?
i) Dilated pupils, dry mouth, urinary retention
ii) Fits, coma, arrhythmias > arrest
iii) Sinus tachy, wide QRS, prolonged QT interval
iv) IV sodium bicarbonate
77
ANTI-DEPRESSANTS
What is the mechanism of action of mirtazapine?
What are some side effects?
- Blocks alpha-2 adrenergic receptors > increased release of neurotransmitters
- Increased appetite + weight gain + sedation are big ones, also increased triglyceride levels
78
MOOD STABILISERS
What are some examples of mood stabilisers?
What is the mechanism of action?
What is the therapeutic range of the most common mood stabiliser?
- Lithium (first line), AEDs such as valproate, carbamazepine, lamotrigine
- Lithium inhibits cAMP production which inhibits monoamines
- Narrow therapeutic range 0.4–1.0mmol/L
79
MOOD STABILISERS
| What are the side effects of lithium?
LITHIUM –
- Leukocytosis
- Insipidus (diabetes, nephrogenic)
- Tremors (fine if SE, coarse if toxicity)
- Hydration (easily dehydrates, renally cleared)
- Increased GI motility (N+V, diarrhoea)
- Underactive thyroid
- Mums beware (Ebstein's anomaly)
Can cause weight gain + derm (acne, psoriasis) long-term too
80
MOOD STABILISERS
| What drugs does lithium interact with?
- NSAIDs, ACEi, ARBs + diuretics may increase lithium levels
| - Diuretics = dehydration, NSAIDs = renal damage
81
MOOD STABILISERS
| What baseline measurements are taken for lithium?
- FBC, U+Es (eGFR), TFTs, BMI + ECG
82
MOOD STABILISERS
| What regular monitoring is done for lithium?
- Weekly serum lithium after initiation + dose changes until stable then every 3m for a year, then every 6m (sample taken 12h after dose)
- 6m = TFTs, U+Es (eGFR)
- Annual = BMI
83
BDZs
What is the mechanism of action of anxiolytics/benzodiazepines (BDZs)?
Give some examples of BDZs
- Enhance effect of inhibitory GABA (agonists) by increasing frequency of Cl- channels (hyperpolarisation prevents further excitation)
- Diazepam (longer action), lorazepam (shorter action), clonazepam, chlordiazepoxide
84
BDZs
What are some adverse effects of BDZs?
How would you reverse BDZs if necessary but what is a risk of this?
- Confusion, drowsiness, dizziness next day (hangover effect), tolerance, dependence
- Monitor for resp depression (caution in resp disease)
- IV flumazenil but danger of inducing status epilepticus or death
85
BDZs
| What drugs can BDZs interact with?
- Anti-hypertensives as enhanced hypotensive effect
86
HYPNOTICS
What is the mechanism of action of hypnotics?
Give some examples
What are the adverse effects?
- GABA agonists
- Zopiclone, zolpidem
- Same as BDZs
87
ECT
What are the reasons why ECT can be done?
When is electroconvulsive therapy (ECT) recommended?
- After adequate trial of other treatments ineffective and/or condition potentially life threatening
- Severe mania or depression, suicide risk, catatonia, Rx resistant psychosis
88
ECT
| What are some contraindications to ECT?
- NO absolute, all relative
- General anaesthesia (reactions)
- Cerebral aneurysm
- Recent MI, arrhythmias
- Intracerebral haemorrhage
89
ECT
| What are some adverse effects of ECT?
- Short-term retrograde amnesia
- Headache
- Confusion + clumsiness
90
DEPRESSION
What is depression?
What is the epidemiology?
- Persistent low mood ± loss of pleasure in activities – unipolar depression.
- F>M but men more likely to be substance misusers + commit suicide
91
DEPRESSION
| What are some risk factors for depression?
- Physical co-morbidities, esp. chronic + painful (MS, stroke, DM)
- Genetics + FHx, female, substance abuse
- Traumatic events (+ve/-ve) like divorce/marriage, (un)employment, poverty, loss
- Adverse childhood experiences like abuse, poor parent relationships
92
DEPRESSION
| What are the 3 diagnostic criteria for depression?
- Sx present most days ≥2 weeks + change from baselines
- Sx not attributable to other organic or substance causes
- Sx impair daily function + cause significant distress
93
DEPRESSION
| What are the three core symptoms of depression?
- Low mood
- Anhedonia
- Anergia
94
DEPRESSION
| What are some psychological symptoms of depression?
- Guilt, worthlessness, hopelessness
- Self-harm/suicidality
- Low self-esteem
95
DEPRESSION
| What are some cognitive symptoms of depression?
- Beck's triad = negative views about oneself, the world + the future
- Poor concentration + impaired memory
- Avoiding social contact + performing poorly at work (social Sx too)
96
DEPRESSION
| What are some somatic, or biological, symptoms of depression?
- Disturbed sleep (EMW, initial insomnia, frequent waking)
- Disturbed appetite + weight
- Loss of libido
- Diurnal mood variation (worse in morning)
- Psychomotor retardation
97
DEPRESSION
| What are the 4 classifications of depression?
- Mild = ≥2 core + ≥2 other (minimal interference)
- Mod = ≥2 core + ≥3 other (variable interference)
- Severe = all core + ≥4 other (marked interference)
- Psychotic = Sx of depression + psychosis
98
DEPRESSION
| What are some features of psychotic depression?
- Mood congruent hallucinations (auditory = derogatory or accusatory voices, olfactory = bad smells)
- Nihilistic delusions
- Delusions of poverty, guilt, hypochondriacal
- Catatonia or marked psychomotor retardation (depressive stupor)
99
DEPRESSION
| What is Cotard's syndrome?
- Delusional belief that they are dead, do not exist, are rotting or have lost their blood + internal organs
100
DEPRESSION
| What are some investigations for depression?
- PHQ-9 + HADS to screen for depression
| - Risk assessment
101
DEPRESSION
| What is the management of mild depression?
- Watchful waiting
- Low-intensity psychosocial interventions first line (computerised CBT, individual-guided CBT, structured group physical activity programme) + psychoeducation
102
DEPRESSION
| Should biological therapy be used in mild depression?
No unless...
- Consider if PMH mod-severe depression
- Mild depression for 2y or persists after interventions
103
DEPRESSION
| What is the management of moderate–severe depression?
- Combination of SSRI + high-intensity psychosocial interventions first line
- Options = CBT with professional, interpersonal therapy, behavioural activation therapy
104
DEPRESSION
What is the CAMHS management of depression?
What tool is used to follow-up monitoring in secondary care to assess progress?
- Watch + wait, lifestyle
- First-line = CBT ± family ± interpersonal therapy (may need intensive if no response)
- 1st line antidepressant = fluoxetine
- Mood + feelings questionnaire (MFQ)
105
DEPRESSION
| What is the management for resistant depression?
- Different antidepressants (SNRI, MAOI, mirtazapine) or sometimes combination
- Augmentation with lithium
106
DEPRESSION
| What is the management of psychotic depression?
- ECT first line + v effective in severe cases followed by antidepressant
- Antipsychotic initiated before antidepressant if ?primary psychotic disorder then add SSRI
107
DEPRESSION
What is atypical depression?
What is the management?
- Mood depressed but reactive
- Hypersomnia + hyperphagia
- Leaden paralysis (heaviness in limbs)
- Phenelzine or another MAOI, if not SSRI
108
DEPRESSION
What is dysthymia?
What is the management?
- Chronic, sub-threshold depressive Sx which don't meet diagnostic criteria over a long period of time
- Typically >2y of mildly depressed mood + diminished enjoyment, less severe but more chronic
- SSRIs + CBT first line
109
DEPRESSION
What is seasonal affective disorder?
What is the management?
- Episodes of depression which recur annually at same time each year (Jan-Feb) with remission in between
- Light therapy + SSRI
110
SELF-HARM + SUICIDE
What is self-harm?
What are some causes?
Why do people self harm?
- Act of intentionally injuring yourself
- Bullying, bereavement, homophobia, low self-esteem
- Feel in control, reduces feelings of tension or distress, if they feel guilty can be a punishment
111
SELF-HARM + SUICIDE
What are some risk factors?
What does previous self-harm indicate?
- F, social deprivation, single or divorced, LGBTQ+, mental illness
- Greatest predictor of future self-harm + increased suicide risk
112
SELF-HARM + SUICIDE
What is suicide?
What is parasuicide?
Why is depression higher in females but suicide higher in males?
- Act of intentionally ending your life
- Act mimics suicide but does not result in death
- Men tend to use violent means which are irreversible
113
SELF-HARM + SUICIDE
| What are some risk factors for suicide?
SAD PERSONS –
- Sex (M>F)
- Age (peaks in young + old)
- Depression
- Previous attempt
- Ethanol
- Rational thinking loss (psychotic illness)
- Social support lacking (unemployed, homeless)
- Organised plan (avoid discovery, plan, notes, final acts)
- No spouse
- Sickness (physical illness)
114
SELF-HARM + SUICIDE
What are some protective factors for suicide?
What are some indicators that someone may commit suicide?
- Married men, active religious beliefs, social support, good employment
- Active planning (buy equipment, manage affairs, leave notes
115
BIPOLAR DISORDER
What is bipolar affective disorder?
When is the peak age of onset?
- Recurrent episodes of altered mood + activity involving both upswings or (hypo)mania + downswings or depression
- Early 20s
116
BIPOLAR DISORDER
| What are the 4 types of bipolar?
- Bipolar 1 = mania + depression in equal proportions, M>F
- Bipolar 2 = more episodes of depression, mild hypomania (easy to miss), F>M
- Cyclothymia = chronic mood fluctuations over ≥2y (can be subclinical)
- Rapid cycling = ≥4 episodes of (hypo)mania or depression in 1 year
117
BIPOLAR DISORDER
| What are some risk factors of bipolar?
- FHx of depression or bipolar
- Traumatic life event
- Hx of abuse
- Substance abuse
118
BIPOLAR DISORDER
| What is the diagnostic criteria for bipolar?
- ≥2 episodes of mood disturbance (1 or which MUST be [hypo]manic)
119
BIPOLAR DISORDER
| What is the clinical presentation of hypomania?
>4d with ≥3 Sx –
- Elevated mood
- Increased energy
- Increased talkativeness
- Poor concentration
- Mild reckless behaviour (overspending)
- Over-familiar, increased self-esteem
- Increased libido
- Decreased need for sleep
- Appetite change
- Partial insight
120
BIPOLAR DISORDER
| What is the clinical presentation of mania?
>1w with ≥3 Sx –
- Extreme elation or irritability
- Overactivity + distractibility
- Pressure of speech + flight of ideas
- Impaired judgement
- Extreme risks (jump off buildings, spending spree)
- Social disinhibition + grandiosity
- Sexual disinhibition
- Decreased need for sleep, restless
- MOOD CONGRUENT PSYCHOTIC Sx
- TOTAL loss of insight
121
BIPOLAR DISORDER
| How can you differentiate between mania and hypomania?
- Psychotic symptoms in mania e.g., grandiose delusions, catatonia (manic stupor) with marked impairment in functioning
122
BIPOLAR DISORDER
What are some...
i) psychiatric
ii) organic
differentials for bipolar?
i) Substance abuse, schizophrenia, schizoaffective disorder
| ii) Hyperthyroidism, steroid-induced psychosis, Cushing's
123
BIPOLAR DISORDER
| What investigations would you perform in suspected bipolar?
- FBC, U+Es, LFTs, glucose, TFTs, calcium
- Syphilis serology, urine drug test,
- ?neuroimaging if SOL
124
BIPOLAR DISORDER
| What is the acute biological management of bipolar disorder?
- Antipsychotic
- Stop any precipitating antidepressants
- ?ECT if severely psychotic, catatonic or suicide risk
125
BIPOLAR DISORDER
| What is the long-term biological management of bipolar disorder?
- Lithium first-line (antipsychotics in pregnancy)
| - Valproate second line but caution in women
126
BIPOLAR DISORDER
What type of referral would you do in bipolar?
What is the psychological management of bipolar disorder?
- Hypomania = routine CMHT referral, mania or severe depression = urgent
- CBT, interpersonal therapy, bipolar support groups
127
SCHIZOPHRENIA
What is schizophrenia?
What area of the brain is most affected?
- Splitting or dissociation of thoughts, loss of contact with reality
- Temporal lobe
128
SCHIZOPHRENIA
| What is the neurotransmitter hypothesis in schizophrenia?
- Excess dopamine + overactivity in mesolimbic tract = +ve Sx
- Lack of dopamine + underactivity in mesocortical tracts = -ve Sx
129
SCHIZOPHRENIA
What is the epidemiology of schizophrenia?
What are some risk factors?
- 1% lifetime risk
| - Strongest RF = FHx, others = Black Caribbean, migration, urban areas, cannabis use, poverty
130
SCHIZOPHRENIA
What are the first rank symptoms of schizophrenia?
What is the relevance?
- Delusional perceptions
- Auditory hallucinations (3 types)
- Thought alienation (insertion, withdrawal + broadcasting)
- Passivity phenomenon, incl. somatic
- ≥1 for at least 1m is strongly suggestive Dx
131
SCHIZOPHRENIA
| What are the three types of auditory hallucinations that count as a first rank symptom?
- 3rd person = talking about the patient (he/she)
- Running commentary = often on person's actions or thoughts
- Thought echo = thoughts spoken aloud
132
SCHIZOPHRENIA
What are some secondary symptoms of schizophrenia?
What is the relevance?
- Other hallucinations + delusions (persecutory)
- Formal thought disorder
- Negative Sx (incl. catatonia)
- ≥2 for at least 1m is strongly suggestive Dx
133
SCHIZOPHRENIA
| What is the difference between positive and negative symptoms of schizophrenia?
- +ve = presence of change in behaviour or thought, something added (all of the first rank + secondary Sx)
- -ve = decline in normal functioning, something removed
134
SCHIZOPHRENIA
| What are the negative symptoms of schizophrenia?
Often early prodromal, As –
- Affect blunting
- Anhedonia
- Alogia
- Avolition
- Also, delusional mood = ominous feeling of something impending
135
SCHIZOPHRENIA
What are some...
i) psychiatric
ii) organic
iii) substance
differentials for schizophrenia?
i) Mania, psychotic depression
ii) TLE, encephalitis, delirium, syphilis/HIV, Wilson's disease
iii) Steroid/drug/alcohol
136
SCHIZOPHRENIA
| What are the investigations for first-episode psychosis?
- FBC, CRP/ESR, U+Es, LFTs, TFTs, fasting glucose, Ca2+, phosphate, B12 + folate
- Urine + serum drugs screen
- ?Serological syphilis + HIV
- CT/MRI head if ?SOL
137
SCHIZOPHRENIA
| What teams would be involved in the management of schizophrenia?
- Early intervention team = initial referral after first episode psychosis
- CMHT = provide daily support + treatment
- Crisis resolution team = pts with acute psychotic episode, often pre-existing diagnosis
138
SCHIZOPHRENIA
| What is the biological management of schizophrenia?
- Anti-psychotic (tailor SE profile to patient)
| - Use depot if non-compliant to prevent relapse
139
SCHIZOPHRENIA
What is treatment resistant schizophrenia?
What is the management?
- ≥2 antipsychotics (1 atypical) trialled for ≥6w but ineffective
- Clozapine
- ECT is last line if resistant to therapy or catatonic
140
SCHIZOPHRENIA
| What is the psychological management for schizophrenia?
- All patients offered CBT
| - Family therapy + psychoeducation to reduce or notice relapses
141
SCHIZOPHRENIA
| What is the social management of schizophrenia?
- Social work + housing involvement may be needed
- Drop-in community centres + support groups
- Substance misuse service if needed
- Depot non-attendance at GP/CPN appt may act as early warning system
142
SCHIZOPHRENIA
After a Mental Health Act detention, what approach should be taken to their care?
What does it involve?
- Care programme approach
| - Assess health + social needs, create care plan, appoint key worker as point of contact + review treatment
143
PARAPHRENIA
What is paraphrenia?
What are some risk factors?
What are some features?
- Late-onset schizophrenia >45y
- Social isolation, poor eyesight/hearing
- Paranoia + delusions about neighbours
144
DELUSIONAL DISORDER
What is a delusional disorder?
How is it managed?
- Strong delusional beliefs in the absence of hallucinations, thought or mood disorder
- Antipsychotics + CBT
145
DELUSIONAL DISORDER
| What is erotomania or De Clerambault's syndrome?
- Delusion in which patient (usually single woman) believes another person (typically higher social status) is in love with them
146
DELUSIONAL DISORDER
| What is Othello syndrome?
- Delusional jealousy
| - Patients (typically men) possess fixed belief that their partner has been unfaithful + often try to collect evidence
147
SCHIZOAFFECTIVE
What is schizoaffective disorder?
What are the two types?
How does it differ to schizophrenia?
- Features of both affective disorder + schizophrenia present in equal proportion
- Manic type or depressive type
- Psychotic Sx tend to wax + wane, unlike in schizophrenia
148
SCHIZOAFFECTIVE
What is the prognosis of schizoaffective disorder?
What is the management of it?
- Better than schizophrenia but worse than primary mood disorders
- Antipsychotics, mood stabilisers or antidepressants (depends on affective disorder)
149
GAD
| What is Generalised Anxiety Disorder (GAD)?
- Syndrome of excessive, persistent worry + apprehensive feelings about various situations present most days for ≥6m
150
GAD
| What are some risk factors of GAD?
- F>M
- Substance abuse
- FHx of anxiety or PMHx of panic disorder, social phobia
- Domestic violence, child abuse or bullying
151
GAD
| What are the core features seen in GAD according to DSM-V?
- ≥3: nervousness, easily fatigued, poor concentration, irritability, muscle tension or sleep disturbance
152
GAD
| What general anxiety symptoms may be seen in GAD?
- Psych = depersonalisation, derealisation
- Autonomic = palpitations, tachycardia, sweating, tremor
- Physical = SOB, chest pain, nausea, abdo pain
- Motor = restlessness, fidgeting
153
GAD
What are the investigations for GAD?
Give some differentials
- GAD-7 + Hospital Anxiety + Depression Scale (HADS) questionnaire
- Exclude organic (FBC, U+Es, LFTs, TFTs, fasting glucose, PTH)
- Depression, hyperthyroid, substance abuse, caffeine, OCD
154
GAD
| What is the stepwise management for GAD?
- 1 = education about GAD + active monitoring
- 2 = low-intensity psychological interventions = self-help, psychoeducation groups
- 3 = high-intensity psychological interventions or drug treatment
- 4 = Highly specialist input = complex drugs, multi-agency teams
155
GAD
| What medication is used in GAD?
- First line = sertraline SSRI
- Second line = alternative SSRI or SNRI
- Third line = if cannot tolerate SSRI/SNRI ?pregabalin
156
GAD
| What is the CAMHS management of GAD?
- Watch + wait
- Self-help (meditation, mindfulness), diet + exercise
- CBT, counselling + SSRI may be considered if more severe (specialists)
157
PANIC DISORDER
| What is panic disorder?
- Recurrent panic attacks that are unpredictable + unrestricted in terms of the situation, ≥4/week for ≥4 weeks
158
PANIC DISORDER
What is the epidemiology of panic disorder?
What are the risk factors?
- Females 2–3x more likely, bimodal distribution
| - Divorced/widowed, FHx, child abuse, domestic abuse
159
PANIC DISORDER
| What is the clinical presentation of panic disorder?
PANICS
- Palpitations, Abdo distress, Nausea, Intense fear of death, Chest pain/choking, SOB (resp alkalosis)/sweating
- Also other anxiety Sx as above
160
PANIC DISORDER
| What is the stepwise management of panic disorder?
- 1 = recognition + diagnosis
- 2 = Primary care Mx = CBT or SSRIs (if SSRIs C/I or no response after 12w = imipramine or clomipramine)
- 3 = R/v + consideration of alternative treatments
- 4 = R/v + referral to specialist MH services
- 5 = Care in specialist MH services
161
PHOBIAS
| What is a phobia?
- Intense, irrational fear of an object, situation or place that is recognised as excessive + may lead to avoidance
162
PHOBIAS
| What are the three main types of phobias and how they differ?
- Agoraphobia = fear open spaces + related aspects such as presence of crowds + difficulty of immediate escape
- Social = fear of scrutiny by others in comparatively small groups (opposed to crowds) leading to avoidance
- Specific phobia = marked fear of a specific object or situation (e.g., animals, heights)
163
PHOBIAS
| How does agoraphobia present?
- ≥2 anxiety Sx at ≥2 of: crowds, public spaces, travelling alone, travelling away from home
164
PHOBIAS
When might social phobia manifest?
How does social phobia present?
- Specific (public speaking) or generalised (any social setting)
- ≥2 anxiety Sx and 1 of: blushing, vomiting, urgency/fear of micturition/defecation
165
PHOBIAS
| What is the management of phobias?
- First line = CBT
| - Second line = SSRIs > alternative SSRI or SNRI > MAOi like phenelzine
166
PHOBIAS
| What might the CBT in phobias include?
- Exposure and response prevention (ERP)
- Desensitisation with relaxation + graduated exposure = preferred
- Flooding (most frightening situation instantly) can be traumatic
167
OCD
| What is obsessive compulsive disorder (OCD)?
- Condition characterised by obsessions + compulsions which cause distress and/or functional impairment (e.g., time consuming, interferes with ADLs)
168
OCD
What are some risk factors for OCD?
What are some associations with OCD?
- FHx of OCD, psychological trauma
| - Depression, paediatric neuropsychiatric disorders associated with streptococcal infection (PANDAS)
169
OCD
| What is the clinical presentation of OCD?
- Obsessions = distressing, insight (contamination, symmetry, fear of harm)
- Compulsions = overwhelming urge to carry out act
- Cycle of obsession > anxiety > compulsion > relief
170
OCD
| How can compulsions be sub-categorised?
- Overt = observed (cleaning, washing hands, checking doors)
| - Covert = not observed (counting, repeating phrases in mind)
171
OCD
| What is the management of OCD with mild functional impairment?
- Low-intensity psychological interventions = CBT + ERP
| - If not sufficient then can offer SSRI or more intensive therapy
172
OCD
What is the management of OCD with...
i) moderate functional impairment?
ii) severe functional impairment?
iii) body dysmorphic features?
i) SSRI OR more intensive CBT + ERP
ii) SSRI AND intensive CBT + ERP
iii) Fluoxetine is SSRI of choice in body dysmorphic disorder
173
ACUTE STRESS REACTION
What is an acute stress reaction?
What is the management?
- Transient disorder with features of PTSD (flashbacks, numbness, avoidance, hyperarousal) that occur in first 4w after a traumatic event (RTC, rape, natural catastrophe)
- Trauma focussed CBT first line
174
ADJUSTMENT DISORDER
What is adjustment disorder?
How does it present?
- Distress 2º to significant life change or stressful life event (e.g., break up) but not to the extent of catastrophe as in acute stress reaction/PTSD
- More severe reaction to event than expected = suicidality, disturbed sleep
175
GRIEF REACTION
| What constitutes an abnormal grief reaction?
- Delayed grief = >2w until grieving starts
| - Prolonged grief = hard to define
176
GRIEF REACTION
| What are the stages of grief?
- Denial incl. numbness, pseudohallucinations of deceased
- Anger usually to family or HCPs
- Bargaining, depression + acceptance (may not go through all 5 stages)
177
PTSD
| What is post-traumatic stress disorder (PTSD)?
- Severe psychological disturbance following a traumatic event, often life-threatening (RTC, war, rape) present ≥1m
178
PTSD
| What are some risk factors for PTSD?
- Low education or social class
- F>M
- Previous PTSD/psych issues
- First responders (ambulance, police, fire)
- Military (dependent on duration of combat exposure, lower rank, low morale)
179
PTSD
What are the 4 core symptoms of PTSD?
How long do they need to be present for to diagnose?
HEAR (≥1m) –
- Hyperarousal
- Emotional numbing
- Avoidance
- Re-experiencing (involuntary)
180
PTSD
In terms of PTSD, what are signs of...
i) hyperarousal?
ii) emotional numbing?
i) Hypervigilance for threat, exaggerated startle response, difficulty concentrating or sleeping
ii) Difficulty experiencing emotions + detachment from others
181
PTSD
In terms of PTSD, what are signs of...
i) avoidance + rumination?
ii) re-experiencing?
i) Avoiding people/situations associated to event
| ii) Flashbacks, nightmares, vivid memories
182
PTSD
| What is the mainstay of management in PTSD?
- Psychological therapy = trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR)
183
PTSD
| What is the medical management of PTSD?
- Venlafaxine or SSRI like sertraline
| - Risperidone for severe cases where resistant to treatment or psychotic
184
SUBSTANCE ABUSE
What is an addiction?
What is dependence?
- Compulsive substance taking behaviour with physiological withdrawal state
- The inability to control the intake of a substance to which one is addicted to
185
SUBSTANCE ABUSE
| List 8 features of dependence
- Withdrawal
- Cravings
- Continued use despite harm
- Tolerance
- Primacy/salience
- Loss of control
- Narrowed repertoire
- Rapid reinstatement
186
SUBSTANCE ABUSE
What is withdrawal?
Give an example
- Physiological response when substance stopped with Sx + substance use to prevent
- Early morning drinking
187
SUBSTANCE ABUSE
| What are cravings?
- Very strong desire for the substance
188
SUBSTANCE ABUSE
What is continued use despite harm?
Give an example
- Despite clear problems caused by substance, person cannot stop
- Injecting heroin despite abscess formation
189
SUBSTANCE ABUSE
What is tolerance?
Give an example
- Larger doses required to gain the same effect as previously (NB: individuals often show no signs of being on a drug at dose ordinary people would)
- Opiate-dependent people may inject enough heroin to kill a non-tolerant person
190
SUBSTANCE ABUSE
What is primacy/salience?
Give an example
- Obtaining + using substance becomes so important other interests are neglected
- Not eating to save money for drugs
191
SUBSTANCE ABUSE
What is narrowed repertoire?
Give an example
- Less variation in types of substances used
| - Dependent drinker will drink same amount of same drink in same way (usually cheapest)
192
SUBSTANCE ABUSE
What is rapid reinstatement?
Give an example
- When a user relapses after period of abstinence, risk of returning to previous dependent pattern quicker
- Someone who used to smoke 10/d may quickly return to this after 1 cigarette
193
ALCOHOL DEPENDENCE
How do you calculate number of units in a drink?
What is 1 unit of alcohol?
What is the recommended weekly units for men and women?
- % ABV x volume (L)
- 10ml or 8g
- 14 units/week
194
ALCOHOL DEPENDENCE
| What are some risk factors for alcohol dependence?
- FHx, M>F
- Occupation = armed forces, doctors
- Social reinforcement
- Chronic illnesses
- Psychological distress = bullying, rape, domestic violence
195
ALCOHOL DEPENDENCE
What are the acute effects of alcohol intoxication?
When is it classed as alcohol dependence?
- Euphoria, impaired judgement, reduced anxiety, ataxia, vomiting
- ≥3 features of dependence
196
ALCOHOL DEPENDENCE
| What are the 3 stages of alcohol withdrawal?
- 6–12h = tremors, diaphoresis, tachycardia, anxiety, irritability + aggression
- 36h = seizures
- 48–72h = delirium tremens
197
ALCOHOL DEPENDENCE
| What are some chronic complications of alcohol dependence?
- Cardiac = dilated cardiomyopathy, arrhythmias
- Liver etc – fibrosis, cirrhosis, oesophageal varices, pancreatitis
- Wernicke's + Korsakoff's
198
ALCOHOL DEPENDENCE
| What are some common causes of death in alcohol dependence?
- Accidents + violence
- Malignancies (head + neck, pancreatic, stomach, colon, hepatic, breast + gynae)
- CVA, IHD
199
ALCOHOL DEPENDENCE
| What are some blood markers for alcohol consumption?
- Red blood cell mean corpuscular volume (MCV) raised
- Gamma glutamyl transpeptidase (GGT) raised
- Carbohydrate deficient transferrin (CDT) raised
200
ALCOHOL DEPENDENCE
| What are some clinical tools for assessing alcohol dependence or withdrawal?
- CAGE
| - AUDIT
201
ALCOHOL DEPENDENCE
| What are the CAGE questions?
- Have you ever felt you need to CUT down on your drinking?
- Have people ANNOYED you by criticising your drink?
- Have you ever felt GUILTY about your drinking?
- EYE-opener – ever felt you need drink first thing in morning to steady your nerves?
202
ALCOHOL DEPENDENCE
| What are the AUDIT questions?
- How often do you have a drink containing alcohol?
- How many units of alcohol do you drink on a typical day?
- How often did you have >6 units on a single occasion in the past year?
203
ALCOHOL DEPENDENCE
| What are the indications for an inpatient detoxification?
- Withdrawal seizures or delirium tremens in past
- Significant mental/physical illness, including suicidality
- Lack of stable home environment
204
ALCOHOL DEPENDENCE
| What is the regime for acute detoxification?
- Chlordiazepoxide 1st line with reducing regime (2nd = diazepam) for withdrawal Sx + preventing seizures
- Thiamine (PO or IV)
- Rehydrate with fluids (often IV), correct electrolyte disturbance
205
ALCOHOL DEPENDENCE
| What are the 3 biological treatments used in alcohol dependence?
- Naltrexone
- Acamprosate
- Disulfiram
206
ALCOHOL DEPENDENCE
| What is the mechanism of action of naltrexone?
- Opioid receptor antagonist
- Blocks euphoric effects of alcohol
- Helps people stick to detox programme + avoid relapse
207
ALCOHOL DEPENDENCE
| What is the mechanism of action of acamprosate?
- NMDA antagonist acts on GABA to reduce cravings + risk of relapse
208
ALCOHOL DEPENDENCE
What is the mechanism of action of disulfiram?
What affects does it have?
- Inhibits acetaldehyde dehydrogenase > build-up of acetaldehyde
- Produces hangover-like Sx when alcohol is drunk = deterrent (flushing, headaches, anxiety, nausea, reduced BP)
209
ALCOHOL DEPENDENCE
| What are some psychological treatments for alcohol dependence?
- Motivational intervention
- Aversion therapy
- CBT, prevention measures (learning relapse prevention strategies)
210
ALCOHOL DEPENDENCE
| What is the social management of alcohol dependence?
- Housing, economical + employment issues
- Alcoholics anonymous
- Developing social routines that are not reliant on alcohol
211
OPIATES/OPIOIDS
How do opioids work?
How long does it take for withdrawal symptoms?
Give some examples of opioids?
- Bind to mu-opioid receptors > endogenous endorphins
- 6h
- Morphine, diamorphine (heroin), methadone
212
OPIATES/OPIOIDS
What is the clinical presentation of opioid overdose?
What is the clinical presentation of opioid withdrawal?
- Pinpoint pupils, resp depression, drowsiness, low HR
| - Unpleasant BUT not dangerous = runs (D+V, lacrimation, rhinorrhoea), raised HR/BP, fever, pupil dilation
213
OPIATES/OPIOIDS
| What are some complications from opioid abuse?
- Abscesses, septic arthritis, infective endocarditis, BBV (hep B/C, HIV), VTE
- Crime, homelessness, death
214
OPIATES/OPIOIDS
What is the management of opioid overdose?
What is the mechanism of action?
- 400micrograms IV naloxone
| - M-receptor inverse agonist > blockade (almost immediate)
215
OPIATES/OPIOIDS
What are some maintenance therapies for opioids?
How is compliance monitored?
- Methadone (full opioid agonist) or buprenorphine (partial agonist/antagonist)
- Urinalysis
216
OPIATES/OPIOIDS
What is the first line detox management in opioids?
How long does detox last?
- Motivational intervention
- Alternative therapies = exercise, art therapy, counselling
- 4w = inpatient, 12w = community
217
ANOREXIA NERVOSA
| What is anorexia nervosa?
- Marked distortion of body image, pathological desire for thinness + self-induced weight loss by various methods
218
ANOREXIA NERVOSA
| What are some risk factors for anorexia?
- F>M, early-mid adolescence
- Dieting + FHx of eating disorders
- PMHx of anxiety, depression or OCD
- Sportspeople, dancers or models
219
ANOREXIA NERVOSA
| What are the diagnostic features of anorexia and how long should they be present for?
≥3m:
- Deliberate restriction of energy intake = low body weight
- Intense fear of gaining weight being underweight
- Self-esteem unduly influenced by body weight or shape
220
ANOREXIA NERVOSA
| What are some endocrine features seen in anorexia?
- Amenorrhoea
- Reduced libido/fertility
- Delayed/arrested puberty
221
ANOREXIA NERVOSA
| What are some clinical signs of anorexia nervosa?
- Lanugo hair = fine, soft body hair
- Enlarged salivary glands
- Reduced BMI (<17.5kg/m^2)
- Bradycardia + hypotension
222
ANOREXIA NERVOSA
| What are some complications of anorexia?
- Osteoporosis
- Arrhythmias + cardiomyopathy
- Decrease in WBC > increased infections
- Death due to health complications or suicide
223
ANOREXIA NERVOSA
| What screening tool can be used in anorexia?
SCOFF –
- Do you ever make yourself SICK as too full?
- Do you ever feel you've lost CONTROL over eating?
- Have you recently lost more than ONE stone in 3m?
- Do you believe you're FAT when others say you're thin?
- Does FOOD dominate your life?
224
ANOREXIA NERVOSA
| What are some investigations for anorexia?
- Sit up squat stand (SUSS) test /3
- ECG (brady, T-wave changes, QTc prolongation)
- FBC (anaemia), U&Es (low K+, Na+), TFTs (low T3), low sex hormones
225
ANOREXIA NERVOSA
| In anorexia, most things are low apart from what?
Gs + Cs –
- GH, Glucose, salivary Glands
- Cortisol, Cholesterol, Carotinaemia
226
ANOREXIA NERVOSA
What risk assessment tool can be used for assessing if a patient with anorexia needs inpatient admission?
What are some features?
- Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN)
- Extremely rapid weight loss, severe electrolyte imbalances, serious physiological complications (HR<45, temp <36), suicidal
227
ANOREXIA NERVOSA
| How should the physical complications of anorexia be managed?
- Monitor U+Es + ECGs
- Oral supplements for electrolytes, thiamine
- Multivitamins + mineral supplements, calcium + vitamin D
- Safely + slowly re-feed pt + avoid refeeding syndrome
228
ANOREXIA NERVOSA
In adults with anorexia nervosa, what are the...
i) biological management choices?
ii) psychological management options?
iii) social management options?
i) Fluoxetine
ii) Individual eating disorder focussed CBT (CBT-ED), Maudsley Anorexia Nervosa TReatment for Adults (MANTRA) or Specialist Supportive Clinical Management (SSCM)
iii) Food diary, self-help groups
229
ANOREXIA NERVOSA
| What is the CAMHS management for anorexia?
- Family therapy 1st line, psychoeducation, self-help resources
230
ANOREXIA NERVOSA
| What is the pathophysiology of refeeding syndrome?
- Metabolic disturbances which occur on feeding a person following a period of starvation.
- As an extended period of catabolism ends abruptly with switching to carbohydrate metabolism
- This leads to serum electrolytes to drop as they enter cells
231
ANOREXIA NERVOSA
| What are some risk factors for refeeding syndrome?
- Low BMI
- Poor nutritional intake (>5d)
- PMHx alcohol abuse
- Chemo
232
ANOREXIA NERVOSA
What is the clinical presentation of refeeding syndrome?
What are the consequences of refeeding syndrome?
- Fatigue, weakness, fluid overload, vomiting
| - Can lead to arrhythmias, convulsions, cardiac failure, coma + death
233
ANOREXIA NERVOSA
| What are the classic biochemical features of refeeding syndrome?
- Hypophosphataemia #1
- Hypokalaemia, hypomagnesaemia + thiamine deficiency too
- Abnormal fluid balance
234
ANOREXIA NERVOSA
| What is the management of refeeding syndrome?
- Frequently monitor all electrolytes + ECG before + during
- Start up to 10cal/kg/d + increase to full needs slowly over 4–7d
- Start PO thiamine, B vitamins + electrolytes
235
BULIMIA NERVOSA
What is bulimia nervosa?
What are the risk factors?
- Recurrent episodes of binge eating + compensatory behaviours (purges)
- Same as anorexia
236
BULIMIA NERVOSA
| What is the diagnostic criteria for bulimia?
- Recurrent episodes of binge eating with sense of lack of control during
- Purges to prevent weight gain = vomiting, laxatives, exercise
- Self-esteem unduly influenced by weight/shape
- Occurs at least once a week for 3 months
237
BULIMIA NERVOSA
| What are some clinical signs of bulimia?
- Russel's sign (calluses on dorsum of dominant hand due to vomiting)
- Dental enamel erosion
- Mouth ulcers
- Salivary gland, especially parotid, enlargement
238
BULIMIA NERVOSA
| What are some complications of bulimia?
- Cardiomegaly (ipecac toxicity = plant taken PO + can cause vomiting)
- Arrhythmias, cardiac failure
- Mallory-Weiss tears from vomiting
239
BULIMIA NERVOSA
| What are some investigations for bulimia?
- SCOFF
- SUSS test, ECG = arrhythmias from hypokalaemia
- Monitor U&Es and other electrolytes
- VBG = hypochloraemic hypokalaemic metabolic alkalosis due to vomiting
240
BULIMIA NERVOSA
| What is the management of bulimia nervosa?
- ALL referred to specialist care
- Adults = first > BN focussed guided self help, second > CBT-ED
- CAMHS = FT-BN
- High dose fluoxetine currently licensed but limited evidence
241
PERSONALITY DISORDERS
When can personality disorders be diagnosed?
What are some risk factors for personality disorders?
- ≥18 as personality still developing
| - FHx of PDs, childhood sexual abuse (especially BPD), childhood conduct disorder (antisocial PD)
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PERSONALITY DISORDERS
| What are the broad types of personality disorders?
- Class A = odd + eccentric (MAD) > paranoid, schizoid + schizotypal
- Class B = dramatic, emotional or erratic (BAD) > antisocial, borderline, histrionic + narcissistic
- Class C = anxious + fearful (SAD) > obsessive-compulsive, avoidant, dependent
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PERSONALITY DISORDERS
| Cluster A: what are the key features of paranoid personality disorder?
- Irrational suspicion + mistrust of others
- Hypersensitivity to criticism
- Preoccupation with perceived conspiracies against themselves
244
PERSONALITY DISORDERS
| Cluster A: what are the key features of schizoid personality disorder?
- Lack of interest in others, apathy
- Has few friends + does not form relationships, including sexual
- Prefers solitary activities
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PERSONALITY DISORDERS
| Cluster A: what are the key features of schizotypal personality disorder?
- Odd appearance + beliefs, magical thinking
- Features of schizophrenia like ideas of reference, paranoia but more insight
- Extreme difficulties interacting socially so lack close friends
246
PERSONALITY DISORDERS
| Cluster B: what are the key features of antisocial personality disorder?
- More common in men, failure to conform to social norms
- Patterns of disregard + violation of rights of others
- Aggressive + unremorseful
- Manipulative + lack empathy
247
PERSONALITY DISORDERS
| Cluster B: what are the key features of borderline/EU personality disorder?
- Mainly young women
- Abrupt mood swings, unstable relationships + instability in self-image
- Impulsivity in behaviours
- Recurrent self-harm + suicidal behaviour
248
PERSONALITY DISORDERS
| Cluster B: what are the key features of histrionic personality disorder?
- Attention seeking behaviours + excessive displays of emotions
- Relationships considered more intimate than they are, sexually inappropriate
- Desire to be centre of attention + dramatisation
249
PERSONALITY DISORDERS
| Cluster B: what are the key features of narcissistic personality disorder?
- Grandiose sense of self-importance + lack of empathy
- Takes advantage of others to achieve own wants
- Arrogant + preoccupied by their own desires + fantasies (success, power)
250
PERSONALITY DISORDERS
| Cluster C: what are the key features of obsessive-compulsive personality disorder?
- Preoccupied by rules, details + organisation to detriment of other aspects of life
- Perfectionist, often eliminating leisure + activities to ensure work complete
- Controlling + inflexible
251
PERSONALITY DISORDERS
| Cluster C: what are the key features of avoidant personality disorder?
- Strong feelings of inadequacy + fear social situations where they may be criticised
- Extremely sensitive to criticism
- Self-impose isolation while craving acceptance + social contact
252
PERSONALITY DISORDERS
| Cluster C: what are the key features of dependent personality disorder?
- Difficulty making everyday decisions without reassurance from others
- Lack of initiative + unrealistic feelings they cannot care for themselves
- Intense need to be cared for by others so urgently searches new relationships
253
PERSONALITY DISORDERS
| What investigations would you do in personality disorders?
Questionnaires –
- Minnesota Multiphasic Personality Inventory (MMPI)
- Eysenck Personality questionnaire
- Personality diagnostic questionnaire
254
PERSONALITY DISORDERS
| What is the management of personality disorders?
- Biological = often SSRI to control Sx
| - Psychological = DBT for EUPD, other therapy (CBT #1, CAT, support groups)
255
DELIRIUM TREMENS
| What is delirium tremens?
- Acute, toxic confusional state secondary to alcohol withdrawal (48–72h after)
256
DELIRIUM TREMENS
| How does delirium tremens present?
- Confusion
- Hallucinations = visual (Lilliputian = small people/animals) + tactile (crawling insects on/under skin)
- Sweating
- Tachycardia
257
DELIRIUM TREMENS
| What is the management of delirium tremens?
- ABCDE approach as emergency
- PO lorazepam first line, if not parenteral lorazepam or haloperidol
- IV thiamine (B1, Pabrinex), IV fluids
258
WERNICKE'S
What is Wernicke's encephalopathy?
How does it classically present?
- Mammillary body atrophy 2º to thiamine deficiency, often due to alcohol abuse
- Triad = ataxia, confusion + ophthalmoplegia/nystagmus
259
WERNICKE'S
| What is the management of Wernicke's?
- ABCDE approach as emergency
| - IV Pabrinex
260
KORSAKOFF'S
| What is Korsakoff's psychosis?
- Degeneration of mammillary bodies, complication of untreated Wernicke's encephalopathy
261
KORSAKOFF'S
| What is the clinical presentation of Korsakoff's?
- Profound short-term memory loss with inability to lay down new memories (antero + retrograde amnesia)
- Confabulation
262
LITHIUM TOXICITY
What is lithium toxicity?
What can precipitate it?
- Serum lithium >1.5mmol/L, >2mmol/L = life-threatening
| - Dehydration, renal failure, diuretics, ACEi/ARBs + NSAIDs
263
LITHIUM TOXICITY
| What is the clinical presentation of lithium toxicity?
- COARSE tremor
- Ataxia + acute confusion
- Myoclonus + hyperreflexia
- Seizures + coma
264
LITHIUM TOXICITY
| What are some complications of lithium toxicity?
- Arrhythmias (VT)
| - Acute renal failure
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LITHIUM TOXICITY
| What is the management of lithium toxicity?
- ABCDE approach as emergency
- Mild-mod = IV fluid resus with 0.9% NaCl
- Severe = haemodialysis
266
ACUTE DYSTONIA
What is an acute dystonic reaction
How does it present?
- Sustained painful muscle contraction, rapid onset after dose given
- Oculogyric crisis = prolonged involuntary upward deviation of eyes
- Torticollis = tilted/twisted neck
267
ACUTE DYSTONIA
| What is the management of acute dystonia?
- ABCDE approach as emergency
- Anticholinergic – IM procyclidine
- Stop antipsychotic (switch to atypical as less EPSEs)
268
NMS
| What is neuroleptic malignant syndrome (NMS)?
- Occurs days after taking antipsychotics/dose rise or acute withdrawal of PD meds
269
NMS
| What is the clinical presentation of NMS?
- Pyrexia + muscle rigidity = "lead-pipe"
- Autonomic lability = HTN, tachycardia, tachypnoea
- Confusion, HYPOreflexia + NORMAL pupils
270
NMS
| What are the complications of NMS?
- Respiratory failure
- CV collapse
- Rhabdomyolysis > AKI
- DIC
271
NMS
| What are some investigations for NMS?
- Urinary myoglobin (raised)
| - Serum creatinine phosphokinase (CPK) + CK raised
272
NMS
| What is the management of NMS?
- ABCDE approach
- Stop antipsychotic or give L-dopa if dopamine withdrawal
- IV fluids (AKI), cooling blankets, antipyretics
- IV dantrolene or lorazepam to reduce rigidity 1st line (amantadine second)
- Bromocriptine prophylaxis
273
SEROTONIN SYNDROME
What is serotonin syndrome?
What are the causes?
- Increased serotoninergic activity in CNS
- Antidepressants = SSRIs esp. with St. John's wort, SNRIs, MAOI
- Drugs = ecstasy, amphetamines, LSD, antiemetics
274
SEROTONIN SYNDROME
| What is the clinical presentation of serotonin syndrome?
Sx onset + recovery fast –
- Confusion
- Neuromuscular = myoclonus, HYPERreflexia, DILATED pupils
- Autonomic = hyperthermia, tachycardia, HTN
275
SEROTONIN SYNDROME
| What are some investigations for serotonin syndrome?
- CK, urinary drug screen
| - ECG monitoring for wide QRS or prolonged QTc interval
276
SEROTONIN SYNDROME
| What is the management of serotonin syndrome?
- ABCDE
- Stop offending agent, IV fluids
- BDZs like IV lorazepam for agitation, seizures + myoclonus
- Serotonin receptor antagonists like PO cyproheptadine or chlorpromazine if severe
277
LEARNING DISABILITIES
| What is a learning disability?
- Condition of arrested or incomplete development of mind, triad of –
- Low intellectual performance (IQ<70)
- Onset during birth or early childhood
- Wide range of functional impairment
278
LEARNING DISABILITIES
| What are some causes of learning disabilities?
- Genetic = Down's, Fragile X, Prader-Willi, neurofibromatosis
- Antenatal = TORCH
- Perinatal = asphyxia, intraventricular haemorrhage
- Postnatal = meningitis, kernicterus
279
LEARNING DISABILITIES
How is mild learning disability characterised by...
i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?
i) 50–69
ii) 9–12
iii) Mobile
iv) Mostly adequate
v) Difficulties reading + writing
vi) Most independent
280
LEARNING DISABILITIES
How is moderate learning disability characterised by...
i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?
i) 35–49
ii) 6–9
iii) Mobile
iv) Simple-no speech, may sign, reasonable comprehension
v) Limited, some learn to read, write + count
vi) Lifelong supervision, may need prompting + support
281
LEARNING DISABILITIES
How is severe learning disability characterised by...
i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?
i) 20–34
ii) 3–6
iii) Marked impairment
iv) Simple-no speech, may sign, reasonable comprehension
v) Limited, some learn to read, write + count
vi) Lifelong supervision, may need prompting + support
282
LEARNING DISABILITIES
How is profound learning disability characterised by...
i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?
i) <20
ii) <3
iii) Severe impairment
iv) Basic non-verbal comms, understands basic commands
v) None
vi) Complete dependency
283
AUTISM SPECTRUM
What is autism?
What is Asperger's syndrome?
- Neurodevelopmental disorder associated with LDs, often manifests before 3, M>F
- Social impairment of ASD but milder + near normal speech development
284
AUTISM SPECTRUM
| What are the 3 areas of impaired functioning that need to be present in autism?
- Social interaction
- Communication (speech + language)
- Repetitive behaviours
285
AUTISM SPECTRUM
| Give some examples of impaired social interaction
- Play alone + uninterested in others
- Failure to notice/respond to social cues
- Lack of eye contact + delay in smiling
286
AUTISM SPECTRUM
| Give some examples of impaired communication
- Speech + comprehension usually delayed/minimal
- Concrete thinking (lack imagination)
- Absence of gestures (lack non-verbal comm)
287
AUTISM SPECTRUM
| Give some examples of repetitive behaviours
- Inability to adapt to new environment or change to routine
- Greater interest in objects, numbers + patterns than people
- Stereotypical repetitive movements
288
AUTISM SPECTRUM
| What is the management of autism?
- MDT support for child + parent
| - Charities for support (national autistic society)
289
TIC DISORDERS
What are tics?
What are they associated with?
- Repetitive, involuntary, purposeless movements + sounds
| - OCD, ADHD, ASD, M>F
290
TIC DISORDERS
| What is Tourette's syndrome?
- Tics persist >1y, more severe + usually multiple motor tics and at least 1 phonic tic e.g., coprolalia
291
TIC DISORDERS
What is the management of mild tics?
What is the management of troublesome tics?
- Watch + wait, psychoeducation, avoid caffeine stress
| - Habit reversal training, ERP
292
ENURESIS
| What is enuresis?
- Involuntary release of urine by day, night or both in child aged ≥5y, in the absence of an organic cause
- Common, M>F
293
ENURESIS
What are the 2 types of enuresis?
Why may it occur?
- Primary = bladder control never mastered
| - Secondary = follows at least 6m of continence > DM, UTI, constipation
294
ENURESIS
| What is the management of enuresis?
- Toileting patterns = before sleep, restrict fluids before bed
- Reward systems (e.g., star charts for going to toilet before bed NOT dry nights)
- 1st line = enuresis alarm, afterwards if >7y can trial desmopressin
295
ADHD
What is attention deficit hyperactivity disorder (ADHD)?
What is the epidemiology?
- Condition with features of inattention and/or hyperactivity/impulsivity that are persistent, M>F
296
ADHD
| What is the triad of symptoms in ADHD?
- Inattention
- Impulsivity
- Hyperactivity
297
ADHD
| How does inattention present?
- Decreased concentration
- Short attention span
- Easily distracted
- Loses important items
298
ADHD
| How does impulsivity present?
- Difficulty taking turns
- Interrupts
- Risk taking behaviours
299
ADHD
| How does hyperactivity present?
- Fidgeting
- Excessive activity
- Talkative
300
ADHD
| How is a diagnosis of ADHD reached?
- Features consistent across ≥2 settings (home, school)
- Sx present continuously for ≥6m
- Information from school reports, interviews
301
ADHD
| What is the initial management of ADHD?
Conservative initially (watch + wait) –
- Family education on ADHD + parenting advice
- Establish normal balanced diet + exercise
- Food diary to identify any triggers + eliminate with dietician
302
ADHD
What is the management for severe ADHD?
What is the mechanism of action?
- CNS stimulants like methylphenidate
- Increase monoamine pathway activity
- Inadequate response = lisdexamfetamine
303
ADHD
| What are some side effects of methylphenidate?
- Appetite suppression + insomnia
| - Weight and height monitored every 6m
304
CONDUCT DISORDERS
| What is conduct disorder?
- Patients <18 that show behaviour + attitudes that continuously disrespect + violate the rights of other people
305
CONDUCT DISORDERS
| What is the clinical presentation of conduct disorder?
- Physical aggression
- Destructive behaviour
- Stealing
- Boys > girls
306
CONDUCT DISORDERS
| What is oppositional defiant disorder?
- Patients <18 show persistent defiant + hostile behaviour towards figures of authority but not serious enough to cause disruption in social functioning
307
CONDUCT DISORDERS
| How is conduct and oppositional defiant disorder managed?
- 3–11y = group parent training programme (focus on parenting skills)
- 7–14y = child-focused programmes (focus on child's behaviours)
- 11–17y = multimodal interventions
308
MEDICALLY UNEXPLAINED SYMPTOMS
| What are the features of somatisation disorder?
- Multiple varied physical Symptoms (Somatisation) present for ≥2y
- Pt refuses to accept reassurance or negative test results
309
MEDICALLY UNEXPLAINED SYMPTOMS
| What are the features of hypochondriasis?
- Persistent belief in presence of a serious DISEASE (Cancer for hypoChondriasis)
- Pt refuses to accept reassurance or negative test results
310
MEDICALLY UNEXPLAINED SYMPTOMS
| What are the features of conversion disorders?
- Typically, loss of motor or sensory function, can be 2º to stress
- Does NOT consciously feign symptoms or seek material gain
- May be indifferent to their apparent disorder = la belle indifference
311
MEDICALLY UNEXPLAINED SYMPTOMS
What is dissociation?
What are the features of dissociative disease?
- Process of separating off certain memories from normal consciousness
- Contrasts conversion as involves psychiatric symptoms = amnesia, stupor
- Dissociative identity disorder = most severe form
312
MEDICALLY UNEXPLAINED SYMPTOMS
| What are the features of Munchausen's syndrome?
- Intentional production of physical or psychological symptoms
- By proxy = individual who simulates illness in their dependents
313
MEDICALLY UNEXPLAINED SYMPTOMS
| What is malingering?
- Fraudulent simulation/exaggeration of symptoms with intention of personal gain
314
GENDER DYSPHORIA
What is gender dysphoria?
What is meant by the term transsexual?
- Mismatch between biological sex + gender identity of an individual causing distress
- Person who emotionally + psychologically feels that they belong to opposite sex
315
GENDER DYSPHORIA
| What act is relevant to gender dysphoria?
- Gender recognition act 2004
- Allows transsexual people to legally change their gender
- Have to demonstrate Dx of gender dysphoria + have lived as gender role for ≥2y
316
GENDER DYSPHORIA
| What is the clinical presentation of gender dysphoria?
- Low self-esteem, depression, anxiety + suicidality
- Only comfortable when in preferred gender role
- Strong desire to hide physical signs + dislike of genitals of biological sex
317
GENDER DYSPHORIA
What is the management of gender dysphoria in...
i) <18?
ii) >18?
i) Referral to gender identity development service (GIDS) with MDT (CAMHS, clinical psychologist, social worker, family therapist)
ii) Referral to gender dysphoria clinic (GP or self-referral)
318
GENDER DYSPHORIA
| What surgical procedures may be offered?
- TM = mastectomy, hysterectomy, phalloplasty or penile implant, scrotoplasty + testicular implants
- TW = orchidectomy, penectomy, vaginoplasty, vulvoplasty or clitoroplasty
319
GENDER DYSPHORIA
| What biological treatment can be used in <16y?
- Very few young people who meet strict criteria may have gonadotropin-releasing hormone analogues (hormone blockers) as reach puberty
320
GENDER DYSPHORIA
| What biological treatment can be used >16?
- Cross-sex/gender-affirming hormones if on hormone blockers for ≥12m
– Oestrogen for breasts + feminine features
– Testosterone for deep voice + masculine features (body hair)
321
GENDER DYSPHORIA
| What social management is there for gender dysphoria?
- Quit smoking (may increase risks of side effects from treatments)
- Lose weight if overweight to reduce risks from cross-sex hormones)
- Social transitioning incl. changing name by deed poll
322
GENDER DYSPHORIA
| What are some risks of the hormone therapy?
- Oestrogen = clots, gallstones, high triglycerides
- Testosterone = polycythaemia, acne, dyslipidaemia
- Both = elevated LFTs, infertility, weight gain
323
SLEEP DISORDERS
| What is insomnia?
- Issues with – falling to, maintaining or poor quality of sleep (≥3d/week for 1m)
324
SLEEP DISORDERS
What is narcolepsy?
What is cataplexy?
- Hypersomnolence, sleep paralysis, hypnogogic + hypnopompic hallucinations
- Cataplexy = sudden loss of muscle tone caused by strong emotion (laughter, being frightened)
325
SLEEP DISORDERS
| What is the management of narcolepsy?
- Multiple sleep latency EEG, early onset REM sleep
| - Rx with daytime stimulants (modafinil) + night-time sodium oxybate
326
SLEEP DISORDERS
| What is some sleep hygiene advice?
- Limit caffeine, alcohol + cigarettes
- Reduce noise, lights + phone use, wind down before bed
- Reduce sleep during day + try establish regular pattern
