Psych Flashcards
Tangentiality
Wandering off of a topic without ever returning to it
Circumstantiality
Excessive and unnecessary detail but eventually returns to point.
Schizophrenia: Prognosis
Poor:
Strong FHx
Gradual Onset
Low IQ
Prodromal phase of social withdrawal
Lack of cause
Lewy Body Dementia
20% of all cases, death within 7 years
Lewy bodies in the substantia nigra, paralimbic and neocortical areas
Link - Alzheimer’s, Parkinson’s
= progressive cognitive impairment (normally before parkinsonism), fluctuating cognition (early loss of attention and exec function), visual hallucinations
*In PD - motor symptoms come >1yr before dementia
Management of Lewy Body dementia
Inv - normally clinical, may use SPECT
-> AChE inhibitors (donepazil, rivastigmine) and memantine
Avoid antipsychotics - cause irreversible parkinsonism
Alzheimer’s
Progressive degenerative disease of the brain
RF - age, white, FHx, Down’s, 5% AD (amyloid precursor protein), apoprotein E allele E4
Changes:
Macro - widespread cerebral atrophy (cortex and hippocampus, temporal lobe)
Micro - cortical plaques (deposition of beta amyloid protein and neurofibrillary triangles, aggregation of tau protein)
Bio - Ach deficit
Alzheimer’s: Management
-> Group cognitive stimulation therapy and activities
-> Drugs
- AChE inhibitors e.g., donepezil (not if v HR. SE: insomnia), galantamine and rivastigmine.
- NMDA antagonist e.g., memantine
- AP only if risk of self harm or harming others (^mort)
Vascular Dementia
Second most common, cognitive impairment caused by ischaemia/ haemorrhage 2nd to cerebrovascular disease
Subtypes: stroke-related (infarct), subcortical (small vessel disease) or mixed (VD and AD)
RF - same as CVD, inherited rarely (CADASIL)
= months or years of sudden or stepwise deterioration in cognitive function
Vascular Dementia: Management
Inv - NINDS-AIREN criteria, MRI
-> manage CVD to slow progression
Only use AChE inhibitors or memantine if co-existing lewy body, AD or PD
Frontotemporal Lobar Degeneration
Types:
1 - FT dementia (picks)
2 - Progressive non fluent aphasia
3 - Semantic
= onset <65yrs, insidious, personality change and social conduct issues but preserved memory and visuospatial skills
Pick’s Disease
Most common FTD
= personality change, social conduct issues, hyperorality, disinhibition, ^appetite, perseveration
Inv - focal gyral atrophy with knife-blades, macro FT atrophy, micro (pick bodies, gliosis, NF triangles, senile plaques)
Avoid AChE inhibitors and memantine
CPA
= non fluent speech, comprehension is preserved
Semantic dementia
= fluent progressive aphasia, fluent but empty meaning, memory is better for recent events than longer term
Schizophrenia
Psychotic disorder
RF - FHx, black, migration, urban area, cannabis
Schneiders first rank symptoms
- 3rd person auditory hallucinations
- Thought disorder: insertion, withdrawal, BC
- Passivity phenomenon: external control
- Delusional perception: meaning of normal object
Others = impaired insight, negative (alogia, blunt affect, anhedonia and avolition, withdrawal), neologisms, catatonia
-> oral atypical AP, offer CBT to all, consider ^CVD risk
Alcohol Withdrawal
Less inhibitory GABA and more NMDA glutamate
6-12 hours - tremor, headache, nausea and agitation
12-24 hours - hallucinations
36 hours - seizures
72 hours - delirium tremens (coarse tremor, confused, delusions, hallucinate, fever, tachy)
High mort without treatment
Anorexia Nervosa
Restriction of energy intake relative to requirement, fear of weight gain/ fatness, disturbance in experience of weight
RF - 90% F, teenage/ young adult
G’s and C’s are high
Growth hormone
Glucose
Glands - salivary
Cortisol
Cholesterol
Carotene
Low - HR, BP, potassium, FSH, LH, oes, T, T3
-> CBT ED in adults and focused family therapy in kids
Refeeding syndrome
Metabolic abnormalities that occur on feeding someone following a period of starvation
Catabolism abruptly switches to carb metabolism
= v PO3 (weak muscles, HF/ resp failure), v K (arrhythmia), hypomagnesaemia (torsades de pointes),
abnormal fluid balance, seizures, coma
-> if hasn’t eaten for >5days, re-feed at no more than 50% of requirements for 2 days
PTSD
Symptoms >4wks
Hyperarousal
Emotional numbing
Avoidance
Re-experiencing
-> watch and wait if mild or symptoms under 4 weeks, trauma CBT or EMDR if severe
Drugs not first line but if used - venlafaxine or SSRI
Acute Stress disorder
Acute stress reaction <4 weeks from traumatic event
= intrusive thoughts (flashback, nightmare), dissociation, negative mood, avoidance, hyperarousal (vigilent, v sleep)
-> trauma focused CBT, benzos
Bipolar Disorder
Periods of mania / hypomania alongside episodes of depression
2% get it, usually late teen
Type 1 (most common): mania and depression
= urgent referral to CMHT
Type 2: hypomania (>4d) and depression
= routine referral
Mania: severe functional impairment or psychotic symptoms >7 days e.g., grandeur, auditory hall
-> lithium best once stable
Mania/ hypomania - stop AD and start AP (olanzapine, haloperidol)
Depressive - talking therapies and fluoxetine
2-3x ^risk of DM, CVD and COPD
Bulimia Nervosa
Episodes of binge eating followed by purgative behaviour
= erosion of teeth, Russell’s sign (calluses on the knuckles)
-> refer all to specialist, BN-focused guided self-help for 4wks, CBT-ED, family therapy in kids, may try fluoxetine
Charles-Bonnet Syndrome
Persistent or recurrent hallucinations in clear consciousness
RF - age, peripheral visual impairment (ARMD), social isolation, sensory deprivation
Cotard Syndrome
Person believes they are dead or non existent
RF - severe depression, psychosis
De Clerambault’s Syndrome
Erotomania, paranoid delusion with an amorous quality
E.g., believe someone famous is in love with them
Delusional Parasitosis
Fixed false belief (delusion) that they are infested with bugs
Presents alone or with other psych conditions
Management of Depression
Less severe - PHQ-9 score <16
-> guided self help, CBT, behavioural activation, SSRI first line drug
More severe - PHQ-9 16+
-> individual CBT and SSRI
ECT
Treatment of severe depression e.g., catatonia or psychosis refractory to medication
Raised ICP is absolute contraindication
SE: headache, nausea, ST memory issues, memory loss of events prior to ECT, arrythmia
GAD Management
Excessive worry about a number of different events associated with heightened tension
- Education, active monitoring
- Low intensity psych (self-help)
- high intensity psych (CBT) or drugs (SSRI, SNRI, pregabalin)
- specialist
Panic Disorder Management
- recognise and diagnose
- primary care (CBT or SSRI, at 12wks try clomipramine)
- review and consider other treatments
- refer
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Grief Reaction
Denial, Anger, Bargaining, Depression, Acceptance
Delayed: occurs >2 weeks since death
Prolonged: normal reaction can be 1yr+
Atypical: more likely if F, sudden/ unexpected death, lack of support
Psuedohallucination: false sensory perception in the absence of external stimuli, insight preserved
Insomnia
Difficulty initiating or maintaining sleep
Acute: related to life event, resolves itself
Chronic: 3x per week for 3 months
RF - F, old, lower education, unemployed, alcohol, stimulants, steroids
Inv - interview, sleep diary
-> identify cause, sleep hygiene, consider hypnotic e.g., benzo or Z drug if daytime impairment is severe (review at 2wks, consider CBT)
OCD
Obsessions and/or compulsions causing significant functional impairment or distress
Obsession - repeated unwanted intrusive thought
Compulsions - acts that they feel drive to perform
RF - FHx, 10-20yrs, preg/ post-natal, abuse
-> Y-BOCS scale
Mild: low intensity psych (CBT, ERP), then SSRI
Moderate: SSRI (consider clomipramine) or more intensive CBT
Severe: refer to secondary care for assess, offer SSRI and CBT (w/ ERP) whilst waiting
Othello’s Syndrome
Pathological jealousy and socially unacceptable behaviour linked to this claim
SAD
Depression that occurs in winter months
-> same as depression, do not give sleeping tabs
Sleep Paralysis
Transient paralysis of skeletal muscles which occurs when awakening from sleep or when falling to sleep
-> clonazepam if troublesome
Unexplained symptoms
Somatisation Disorder
= multiple physical symptoms present >2 years, don’t accept reassurance/ neg test results
Illness Anxiety (Hypochondriasis)
= persistent belief of serious underlying disease
Conversion Disorder
= Loss of motor or sensory function, not factitious, may be la belle indifference
Dissociative disorder
= psychiatric symptoms e.g., amnesia, fugue, stupor, DID most severe form
Factitious Disorder (Munchausen’s)
= intentional production of symptoms
Malingering
= fraudulent simulation of symptoms for gain
MHA Sectioning
2 - admit for assessment <28 days, 2 doctors recommend (1 ‘approved’) and AMHP applies, can treat against wishes
3 - treatment for 6 months, , 2 doctors (seen <24hrs) and AMHP
4 - emergency 72 hour assessment order (GP + AMHP), change to 2 when in hopsital
5(2) - detained by doctor for 72 hours (voluntarily in hosp)
5(4) - detained by a nurse for 6 hours (voluntarily in hosp)
17a - supervised community treatment order, recall to hosp for treatment e.g., if not complying with meds
135 - court order to remove person from their property to place of safety (police)
136 - from public space to place of safety, <24hrs
Cluster A Personality Disorders
Paranoid: hypersensitive and unforgiving when insulted, reluctant to confide, hidden meanings
Schizoid: indifference to praise or critique, lack interest in sex, emotionally cold, few interests/ friends
Schizotypal: odd beliefs and magical thinking, lack friends, paranoid/ suspicious, eccentric
Cluster B
Antisocial: repeatedly break laws, impulsive, reckless, lack of remorse, deceptive, ^M
Borderline (EUPD): unstable interpersonal relationships, affective instability, impulsive (spending, sex), chronic emptiness, suicidal
Histrionic: inappropriate seductiveness, centre of attention, shallow emotions, self dramatisation
Narcissistic: grandiose self importance, entitled, take advantage of others for own gain, arrogant
Cluster C
Obsessive-compulsive: occupied with rules, rigid about morality and ethics, perfectionist
Avoidant: fears of criticism or rejection socially, views self as inept/ inferior, isolated but crave social contact
Dependent: need constant reassurance, others to take responsibility, lack initiative, fear being alone
Serotonin Syndrome
Excessive serotonin, normally due to combined use of serotonin based drugs (SSRI, MAOI)
= NM excitability (rigidity, myoclonus, hyperreflexia), autonomic excitability (fever, HTN), confusion
-> IV fluids, BZ
Alcohol Binge and Sodium
Alcohol binge suppresses ADH release from the posterior pituitary leading to hypernatraemia
Korsakoff’s Syndrome
Marked memory disorder, ^alcoholics due to thiamine deficiency
= anterograde and retrograde amnesia, confabulation
Other causes of psychosis
Brief psychotic disorder: symptoms <1mth, return to baseline
Steroid-induced psychosis: sudden onset
Depression with psychosis: ^elderly
Suicide Risk
RF - M, Hx self-harm, alcohol/ drugs, depression, schizophrenia, older age, unemployed, not married
-> family support, children at home, religion
