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Phase 3a > Psych > Flashcards

Psych Flashcards

1
Q

Acute presentation of opiate overdose

A

DROWSINESS
- Resp depression leading to acidosis
- Hypotension
- possible Tachycardia
- PINPOINT PUPILS

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2
Q

Chronic opiate presentation

A

Constipation

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3
Q

Treatment for opiate overdose

A

ABCDE

IV NALOXONE IF COMA OR RESP DEPRESSION (Or IM if bad veins)

Oral activated charcoal if invested a lot

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4
Q

What are characteristics of OCD compulsions/obsessions

A
  • present most days
  • have lasted at least 2 weeks

Acknowledge they originate in the mind
- try to resist but it’s unsuccessful
- the act is unpleasurable

Interferes with functioning

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5
Q

Treatment for OCD

A

Mild - CBT/group CBT or Exposure and Response Prevention therapy. SSRIs only if not responding to treatment.

Moderate - high intensity CBT or ERP. Can have SSRIs instead of therapy.

Severe - high intensity CBT or ERP AND SSRIs (in combination)

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6
Q

Schizophrenia

A

Chronic / relapsing remitting for of psychosis caharacterised by both POSITIVE AND NEGATIVE Sx

Symptoms have to be present for AT LEAST 1 MONTH and causing SIGNIFICANT IMPAIRMENT

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7
Q

Subtypes of schizophrenia

A
  • Paranoid schizophrenia (Delusions + hallucinations)
  • Catatonic schizophrenia (motor disturbances + waxy? flexibility)
  • Hebrephenic (disorganised thinking, emotions + behaviour)
  • Residual schizophrenia (some sx persisting after major episode)
  • Simple Sz (gradual decline in function WITHOUT prominent +ve sx)
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8
Q

Cause/RFx of Scz

A
  • Genetic: FHx
    • 50% risk if both parents or identical twin is affected
    • 10% if one parent or sibling
  • Environmental factors
    • Childhood trauma
    • Heavy childhood cannabis use
    • Maternal health issues (malnutrition, infections)
    • Birth trauma (hypoxia / blood loss)
    • Urban living / immigration to more developed countries
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9
Q

Schz Sx

A

Positive:

  • Auditory hallucinations
  • Thought disorder (insertion, withdrawal)
  • Passivity phenomenon etc
  • Delusions

Negative:

  • Speech poverty (Alogia)
  • Anhedonia
  • Affective incongruity / blunting
  • Avolition (lack of motivation)
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10
Q

Risk indicators of Scz Sx

A
  • Command hallucinations
  • Hx of deliberate self-harm / Suicidal ideation
  • Fixation on specific individuals
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11
Q

DDx for Schizophrenia

A
  • Substance -induced psychotic disorder
  • Organic psychosis (physical neuro change)
  • Metabolic disorders
  • Depression + dementia
  • Autoimmune encephalitis
  • Schizoaffective Disorder (mood disorder + psychotic Sx)
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12
Q

Schizophrenia Ix

A

Mainly clinical Dx - then Ix to exclude DDx:

  • Brain imaging
  • Blood tests to exclude infectious (e.g. syphilis) or metabolic causes (e.g. thyroid)
  • DRUG SCREENING
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13
Q

Schezophrenia Mx

A
  1. Atypical (2nd gen) antipsychotics: RISPERIDONE

If acute

-> Sedatives (lorazepam / prometazine) OR Haloperidol - to manage dangerous behaviour
- Oral (sometimes IM/depot injection) ATYPICAL ANTIPSYCHOTICS

Maintainance antipsychotics determined on a person by person basis

Consider CLOZAPINE if resistant - INTENSIVE MONITORING due to potentially LETHAL SE

+ Psychotherapy

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14
Q

Schitzoaffective disorder

A

A disorder which is a combination of scz Sx alongside mood disorder Sx

2 types:

  • Bipolar type (Mania + sometimes major depression)
  • Depressive type (only major depression)
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15
Q

What is the bidirectional relationship to old age mental health

A
  • Physical illnesses can cause/put at risk of mental health disorders
    • Esp SENSORY IMPAIRMENT (direct risk factor)
  • Consequences of mental health on physical health
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16
Q

Considerations for Tx in older adults

A
  • ↑body fat; ↓ body muscle; ↓ relative body water
  • ↓ renal blood flow and function
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17
Q

Bipolar definition

A

Chronic + combination of manic/hypomanic and Depressive episodes.

  • Manic/hypomanic episodes should be characterised by a PRESISTENTLY ELEVATED, Expansive / Irritable mood
  • Major depressive episode should last at least 2 wks
  • There should be a marked disturbance of mood during episodes
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18
Q

Suptypes of Bipolar Affective Disorder

A
  • BPAD Type 1: One or more manic episodes lasting longer than a week with or without depressive episodes.
    • most common type
  • BPAD Type 2: At least one major depressive episode (at least 2 weeks) AND hypomanic episodes (lasting at least 4 days).
    • NO mania
  • Cyclothymia: episodic depression and hypomania over the course of 2 years or more which doesn’t meet the criteria for BPD 1 or 2 diagnosis (symptoms usually less severe)
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19
Q

Mania vs hypomania

A
  • Mania - severe functional impairment OR psychotic changes lasting AT LEAST 7 DAYS
  • Hypomania - Change in functioning WITHOUT psychotic Sx or severe social/occupational impairment for at least 4 DAYS (but usually <7 days)

Mania is more likely to require hospital admission due to risk of harm

Both have EXPANSIVE, ELEVATED mood OR intense IRRITABILITY +/- PHYSICAL Sx (Increased energy / Decreased sleep)

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20
Q

Bipolar epid

A
  • Typically develops in late teens
  • Both genders affected equally
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21
Q

Causes/RFx of Bipolar/BPAD episodes

A
  • GENETIC (FHx)
  • TRIGGERS:
    - stress / childhood trauma, physical illness, DRUG ABUSE, DEPRESSION/Anxiety
  • MEDICATION-INDUCED: antidepressants taken for a depressive episode can trigger a manic switch
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22
Q

Bipolar Sx

A

Depression:

  • Low mood, ANHEDONIA, worthlessness, Decreased energy, Suicidal ideation

Mania/hypomania:

Mood:

  • Elevated mood / Irritability
  • expansive mood (unrestrained emotional expression)

Speech and thought:

  • Inflated self-esteem
  • PRESSURED speech
  • Flight of ideas
  • Poor attention

Behaviour:

  • INSOMNIA (can also trigger an episode)
  • IMPULSIVITY (pursuit of more dangerous activities)
    • believes capable of more than they are actually able to do
  • DISTRACTIBLE
  • Psychomotor agitation (Pacing, wringing hands)
  • LOSS OF INHIBITION (risk taking, overspending, sexual promiscuity)

Other features:

  • Psychosis
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23
Q

DDx for mood disorder Sx

A
  • Major depressive disorder
  • Cyclothymic Disorder (chronic mood fluctuations over 2 yrs)
  • Schizoaffective Disorder
  • Generalised Anxiety Disorder
  • Substance-induced Mood DIsorder (use OR withdrawal)
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24
Q

Bipolar Ix

A
  • If first presentation -> RULE OUT DDx:
    • Bloods
    • CT/MRI
    • Urine dip / toxicology
    • TFTs
    • Vitamin levels
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25
Q

Bipolar Mx

A
  • Hypomania -> ROUTINE referral to COMMUNITY MENTAL HEALTH TEAM (CMHT)
  • Mania / severe depression -> URGENT referral to CMHT
    • if ACUTELY AGITATED -> admission + IM Benzodiazepine / neuroleptic (e.g haloperidol, risperidone) if the benzo doesn’t work

New/Acute:

  • Stop SSRIs if recently started
  • Mania with AGITATION:
    • IM NEUROLEPTIC / BENZODIAZEPINE
    • Consider psych admission
  • Mania WITHOUT agitation:
    • Oral Antipsychotic MONOtherapy
      - Haloperidol, Olanzepine, Quetiapine, Risperidone
      • Switch to diff one in same class if first unsuccessful
      • Consider adding SEDATIVES / MOOD STABILISERS (e.g. LITHIUM)
      • Electroconvulsive therapy
  • Acute DEPRESSION: Mood stabiliser; consider SSRIS + atypical antipsychotic

Chronic/Maintanence:

  • MOOD STABILISERS: Lithium 1st , Valproate 2nd
    • NB: NOT IN PREGNANCY they are teratogenic - Just use antipsychotics
  • High-intensity Psychological Therapies: CBT; IPT
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26
Q

Complications of Bipolar

A
  • Suicide Risk: Estimated at 10%.
    • Also can unintentionally be danger to self if v impulsive
  • Recurrence: Approximately 90% experience recurrence of manic episodes.
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27
Q

Types of depression

A
  • 3-4 Sx = Mild
  • 5-6 Sx = Mod
  • 7-8 Sx = Severe
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28
Q

Bulimia Mx

A
  • Bulimia Nervosa Focused Guided Self-Help: First-line treatment, targeting eating behaviors, thought patterns, body image, and self-esteem.
  • Specialist Referral: Essential for ongoing management.
  • Consider fluoxetine
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29
Q

Konrad Lorenz

A

Geese imprinting experiment

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30
Q

Harry harlow

A

Wire mother cloth mother
- emotional needs are crucial
- Poor emotional comfort in the baby monkeys led to behavioural issues later on

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31
Q

Attachment

A

A unique emotional bond between caregiver and child: involves exchange of comfort, care + pleasure

Evolutionary function to improve survival

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32
Q

Strange assessment stages

A
  1. Mother, baby, and experimenter
  2. Mother and baby alone
  3. A stranger joins the mother and infant
  4. Mother leaves baby and stranger alone
  5. Mother returns and stranger leaves
  6. Mother leaves; infant left completely alone
  7. Stranger returns
  8. Mother returns and stranger leaves
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33
Q

Secure attachment characteristics in children and adult

A

Child:

  • Separates from parent
  • Self-confident, good self-esteem
  • Seeks comfort when frightened
  • Greets return with positive emotions
  • Prefers parents to strangers

Adult:

  • Trusting, lasting relationships
  • Good self-esteem
  • Comfortable sharing feelings with partners/friends
  • Seeks out social support
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34
Q

Insecure avoidant characteristics in child and adult

A

Child - Occurs when caregiver largely emotionally unavailable/unresponsive / has Unrealistic expectations of child emotional independence (‘stop crying’ ‘grow up’ ‘toughen up’):

  • Passive/withdrawn behavior
  • Avoids closeness of others, seldom seek comfort
  • Poor self-esteem
  • Outbursts /erratic behaviors
  • Minimises expectations of others

Adult:

  • Poor self-esteem
  • Can shun intimacy, struggle making emotional connections
  • Often dismissive attitude, may be quick to find fault in others
  • Difficulty seeking support from others, struggle to express emotional needs
  • Perpetuation of trauma in relationships e.g. struggle to form healthy attachment to own children
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35
Q

Insecure resistant characteristics in child + adult

A

Can result from inconsistent/unpredictable caregiver behavior

Child:

  • Can be distrustful of parent but also clingy/desperate
  • Can express distress but difficulty getting comfort from caregiver
  • Fear of abandonment -> anxiety

Adult:

  • Self-critical and insecure
  • Seek approval/reassurance from others
  • Fears of rejection, difficulties trusting in relationships
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36
Q

Attunement meaning

A

How reactive an individual is to another’s emotional needs + moods

esp in context of parental figure responding to child

Not preventing negative feelings in child BUT more to do with how you mend a relationship breakdown - not allowing the breakdown to persist

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37
Q

Risk Fx for Attachments disorder

A
  • Abuse / neglect
  • Loss of caregiver
  • Maternal POSTPARTUM DEPRESSION
  • Frequent change in caregiver (e.g. foster care)
  • Parental issues (substance abuse, mental health, criminal)
  • Prolonged separation from caregivers
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38
Q

Reactive attachment disorder

A
  • Starts in 5 years of life
  • Persistent abnormalities in pattern of social relationships: associated emotional disturbance + reactive to changes in environmental circumstances
    - e.g. not seeking / responsive to comfort when distressed
    - limmited positive affect / unexplained irritibilaty
  • Associated with severe neglect, abuse / serious mishandling
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39
Q

Daumrind’s parenting styles

A
  • Authoritarian (imposing rules, expecting obedience, low warmth)
  • Permissive (low discipline, high warmth, low maturity expectations)
  • Authoritative (high communication, moderate warmth + maturity expectations, high warmth)
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40
Q

What is a personality disorder

A

Ingrained / enduring patterns of behaviour that are abnormal in the culture the individual exists within: leading to subjective distress both to self and others and functional impairment

  • impairments in relating to self and/or others
  • Isn’t developmentally appropriate
  • STABLE OVER TIME (>= 2 yrs) + INFLEXIBLE across diff situations
  • Not due to another underlying condition / meds / drugs

CAN’T be Dx un UNDER 18s

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41
Q

Cluster A personality disorders

A

‘Odd / eccentric’

  • Paranoid
  • Schizoid
  • Schizotypal
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42
Q

Cluster B personality disorders

A

‘Dramatic, Emotional / Erratic’

  • Antisocial
  • BORDERLINE (Emotionally Unstable)
  • Histronic
  • Narcissistic
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43
Q

Cluster C personality disorders

A

‘Anxious and Fearful’

  • Obsessive-Compulsive
  • Avoidant
  • Dependant
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44
Q

(Paranoid personality disorder)

A
  • Pattern of IRRATIONAL suspicion of others - questions loyalty
  • Hypersensitivity to criticism + potential slights
  • Reluctance to confide in others due to fear it will be used against them
  • Preoccupation with CONSPIRATIONAL BELIEFS + HIDDEN MEANING
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45
Q

(Schizoid personality disorder)

A
  • DETACHMENT from SOCIAL relationships + RESTRICTED emotional expression
  • Lack of interest in interpersonal relationships
  • EMOTIONAL COLDNESS / FLATTENED AFFECT
  • Few close relationships outside immediate family
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46
Q

(Schizotypal personality disorder)

A
  • Impaired social interactions AND distorted cognition / perceptions
  • Eccentric behaviours - inappropriate / constrained affect
  • Magical thinking, paranoid ideation, belief in influence of external forces
  • MORE INTACT grasp on reality than in Schz
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47
Q

Types of higher order personality disorder presentations

A

Internalising:

  • Negative affectivity
  • Detachment
  • Anankastia (compulsion)

Externalising:

  • Dissociality
  • Disinhibition
  • Borderline pattern
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48
Q

Borderline Pattern Px

A
  • Unstable affect (temper, quasi psychotic)
  • IMPULSIVITY
  • Self-harm / suicidal
  • Feelings of emptiness
  • Lack of sense of self / UNSTABLE SELF-IMAGE
  • INTENSE UNSTABLE RELATIONSHIPS (including with medics)
    • Fears + attempts to avoid attachment

(Can get transient stress induced paranoia / dissacociation - including hearing voices)

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49
Q

DDx for BPD

A
  • Bipolar - Bio Sx
  • ADHD / ASD (esp in women) - concrete thinking
  • Psychotic conditions
  • cPTSD - presence of PTSD Sx
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50
Q

Main theory for cause of BPD

A

Biosocial model:

Emotional sensitivity + Invalidationg environment (abuse/neglect) = Pervasive emotion dysregulation

(soothing from parent teaches baby how to self-sooth)

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51
Q

Common BPD co-morbidities

A
  • Psychosis
  • Affective/ anxiety disorders
  • Alcohol dependence / Hazardous drinking
  • Substance dependence
  • Eating Disorders
  • Functional Disorders, eg chronic pain, non-epileptic seizures
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52
Q

Reasons why people may self-harm

A
  • Feel concrete pain
  • Inflict punishment
  • Reduce anxiety/ despair
  • Feel in control
    -Express anger
  • Feel something when numb
  • Seek help
  • Keep away bad memories
  • Suicidality
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53
Q

BPD complications / prognosis if untreated

A
  • Poor QoL
  • Substance use
  • Difficulty keeping jobs
  • Increased risk of being victim of violence
  • Self harm / suicide (10%)
  • Poor physical health (20 year reduction in life expectancy)
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54
Q

BPD Mx

A

VALIDATION + Consistancy where possible in services + clinicians

  • Medication NOT MAINSTAY but can help in crisis / comorb
  • Psych therpaies:
    - Dialectical behaviour therapy; Structured clinical management; Mentalisation Based Therapy
    - Cognitive Analytical Therapy / CBT
    - Trauma processing
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55
Q

PTSD aet theory

A

The information from the traumatic experience is retained but not fully processed / not integrated into memories -> flashbacks

  • can be caused / exacerbated by nightmares (which are a form of flashback) waking people up from REM sleep so they are unable to completely integrate the information
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56
Q

PTSD Definition

A
  • Direct or indirect EXPOSURE to TRAUMATIC event
  • Has characteristic Sx
  • Persists for MORE THAN 6 MONTHS
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57
Q

PTSD Px

A

Intrusive Sx:

  • Recurrent distressing memories, NIGHTMARES or FLASHBACKS (hallmarks)

AVOIDANT:

  • Any trauma-related reminders

Negative alerations in mood + cognition:

  • Persistent negative beliefs / Pervasive negative emotions
  • DISTORTED BLAME

AROUSAL:

  • HYPERVIGILANCE
  • Exaggerated startle
  • Poor concentration
  • Disturbed sleep
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58
Q

Classification of severity of PTSD

A
  • Mild - managable distress + social / occupational functioning not significantly impaired
  • Mod - More significant distress / impaired functioning but no significant risk of self-harm, suicide, harm to others
  • Severe - Unmanageable distress AND/OR significantly impaired social AND/OR occupational functioning AND/OR significant risk of harm to self/others or suicide
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59
Q

PTSD DDx

A
  • Acute Stress Reaction (ASR)
    • same Sx but in the days/weeks directly following a traumatic experience (PST lasts >6 months)
  • Adjustment disorder (maladaptive resposnes to stressors - not necessarily linked to major trauma but can persist up to 6 months)
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60
Q

PTSD Mx

A

If moderate / severe -> reffer to specialty psych:

  • TRAUMA-FOCUSED CBT
  • Eye-Movement Desensitisation + Reprocessing if more severe
    + RISK MANAGEMENT for other co-morbs / Mx co-morbs
  • SNRI / SSRI if comorb / declining psychotherapy

Veterans can be referred more rapidly

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61
Q

Panic disorder definition

A
  • Recurrent, unexpected PANIC ATTACKS
  • AVOIDANCE of situations/triggers related to attacks
  • Persistent concern about further attacks after initial attack (for at least 1 month for !CD 11)
62
Q

Panic disorder epid

A
  • 2-3x more prevelant in females
  • Biomodal incidence: peaks at 20 and 50 y/o
  • Oft concurrent Agoraphobia
  • Increased risk of suicide with comorbid depression / substance abuse
  • 1-2% prevalence in general population
63
Q

Panic disorder Px

A
  • DIFFICULTY BREATHING
  • PALPS
  • Chest DISCOMFORT
  • HYPERVENTILATION -> glove and stocking / perioral peristhesia from RAISED blood pH and calcium binidng to albuimin
  • SHAKING, SWEATING, DIZZINESS
  • Depersoalisation / Derealisation

Fear of panic triggering situations / agoraphobia -> Conditioned fear-of-fear pattern

64
Q

Panic disorder Mx

A
  • CBT (effective 80-100%)
  • SSRIs
  • Clomipramine (tricyclic) - 2nd line
    - Propanolol for Sx relief
65
Q

What would CBT for panic disorder involve

A
  • Education
  • Cognitive restructuring + detecting locic flaws
  • Interoceptive exposure techniques (e.g. stimulating somatic Sx, like palps with exercise, in controlled environment)
  • Situational exposure + anxiety Mx techniques if also agoraphobic
66
Q

Phobias definition

A

Anxiety disorders charachterised by excessive / irrational fear restricted to highly specific situations.

Includes:

  • Specific phobia
  • Social Anxiety disorder (impedes daily functioning)
  • Agoraphobia (anxiety in situations where escape would be difficult / help unavailable)

Common features of AVOIDANCE + ADL IMPAIRMENT

67
Q

Clinical features of phobias

A
  • Usually apparent in early adulthood
  • AVOIDANCE BEHAVIOUR
  • Blood/injury related can -> Bradycardia + hypotension on exposure (fainting)
  • Severity dependant on QoL

ALWAYS: rule out co-morb depression

68
Q

Agoraphobia definition

A

Fear of open spaces and associated factors like the presence of crowds or the perceived difficulty of immediate easy escape to a safe place - usually home

(with or without panic disorder)

69
Q

Agoraphobia presentation

A
  • Typically begins in 20s or mid-thirties.
  • Onset may be gradual or precipitated by a sudden panic attack.
  • Comorbid depression is common

BEWARE: drugs / alcohol COPING

70
Q

What is the most common anxiery disorder

A

Social anxiety disorder (SAD)

71
Q

Social anxiety definition

A
  • Fear of scrutiny by others in relatively small groups resulting in avoidance of social situations
    - generally from groups ~5-6 ppl (can oft tolerate 1-2 ppl)
  • Specific (public speaking) or General
  • Physical Sx of blushing / fear of vomiting characteristic
72
Q

SAD Sx

A
  • BLUSHING
  • PALPS
  • Trembling
  • Sweating
  • Nausea / fear of vomiting

Differentiated from other forms of anxiety by the fact it is triggered specifically by social situations of some sort

73
Q

RFx/exacerbating factors for SAD

A
  • Stressful / humiliating experiences
  • Parental death / separation
  • Chronic stress
  • Possibly genetic predisposition

Alcohol / drug abuse (which can also be CAUSED BY SAD)

74
Q

Phobias Mx

A
  • CBT
    - Exposure -> Systematic desenitisation (e.g. graded hierarchy approach, Flooding, Modelling - pt watches therapist interacting with phobic stimulus)
  • SSRIs if not responding to CBT / severe impairment
  • Propanolol if persistent somatic Sx
75
Q

Delerium

A

Acute confusional state (fluctuating attention + cognition / change in consiousness) caused by organic factors - commonly seen in elderly

  • usually reversible
76
Q

Delerium subtypes

A
  • Hyperactive = increased PSYCHOMOTOR activity - Agitation, restlessness, hallucinations
  • Hypocative = Decreased activity - LETHARGY, reduced responsiveness, Withdrawal
  • Mixed
77
Q

Causes of delirium

A

DELIRIUMS:

  • Drugs + Alcohol
  • Eyes, Ears + EMOTIONAL DISTURBANCES
  • Low Output state
  • INFECTION
  • RETENTION (urine / stool)
  • ICTAL (seizure related)
  • UNDER-hydration / -nutrition
  • METABOLIC disorders (electrolytes, thyroid, Wernicke’s)
  • Subdural Haematoma, Sleep deprivation
78
Q

Which medications are particularly likely to cause delirium

A
  • ANTI-CHOLINERGICS
  • Opiates
  • ANTI-CONVULSANTS
79
Q

Delerium Sx

A
  • Disorientation
  • Hallucinations
  • Inattention
  • Memory problems
  • Change in mood + personality (e.g. Sundowning)
  • Disturbed sleep

Can be sedated or very agitated depending on subtype

80
Q

Delirium Ix

A

Initial examination + Infection scan

  • Assess delirium:
    - 4AT (alertness, Cognition, Attention, acute change / fluctuating course)
    - Confusion assessment Method (CAM)

Everything else based on clinical suspicion:

  • Bedside:
    - Bladder scan; ECG; Review meds; Urine MC+S (no point urine dipping anyone > 65)
  • BLOODS:
    • FBC, U+E; LFTs; TFTs; CLUTURES
  • Imaging:
    - CXR, US abdo
    - CT / MRI only if no other cause identifiable
81
Q

Delirium Mx

A

NON-PHARM:

  • Well lit environment
  • Regular sleep-wak cycle
  • Regular ORIENTATION + REASSURANCE
  • Ensure any aids (glasses, hearing aids) are used

HALOPERIDOL or LORAZEPAM if v agitated/risky
- Olanzepam = risk of SE but can still use if needed

82
Q

Frontal lobe syndrome

A

Damage to higher functioning process. Areas include:

  • anterior cingulate
  • lateral prefrontal cortex
  • orbitofrontal cortex
  • frontal poles
83
Q

Frontal lobe syndrome Sx

A

Specific Sx depends on area affected - commonly can cause impairment/change in:

  • Motivation
  • Planning / working memory
  • Social behaviour / personality
  • Language / speech production
  • Weakness / impaired motor function

etc think Phineas Gage

84
Q

Causes of lobe syndrome

A
  • Trauma
  • CVD
  • TUmours
  • Neurodegenerative

Also: Focal epilepsy, HIV, MS, Early-onset dementia

85
Q

Lobe syndrome pathophys

A
  • Dorsolateral lesions = APATHETIC / Impaired decision making / impaired WORKING MEMORY
  • Venteromedial orbitofrontal lesions = IMPULSIVITY / personality change
  • Left hemispheric = depression-like assocociation
  • Right hemispheric lesion = more MANIC Px

More significant if bilateral

86
Q

Lobe syndrome Ix

A
  • Neuro + mental status exam
  • RULE OUT DDx
    - BLOODS: B12, thyroid, syphilis serology
    - MRI: atrophy / vascular / microvasc pathology
    - CT = acute bleeds, hydrocephalus
    - Deoxyglucose PET (FDG) if suspected frototemporal demetia
87
Q

Lobe syndrome Mx

A

Tx underlying cause

  • Physio/occupational therapy
  • SALT
  • Support at home if needed
88
Q

Addictive behaviours

A

REPEATED patterns of behaviour that DOMINATE patient’s life to DETRIMENT of social, occupational, material + family values / commitments

89
Q

Features of substance misuse

A
  • Acute intoxication
  • Hazardous use
  • Use despite harmful effects
  • TOLERANCE
  • WITHDRAWAL
  • Dependence
  • Compulsion to take
  • Prioritising over commitments
  • Residual disorder

Need 3 or more Sx for > 1 MONTH

90
Q

Substance misuse Ix

A
  • MSE + Physical exam
  • BLOODS
  • Urine toxicology
  • CXR, ECG, Echo
91
Q

Substance misuse Mx

A
  • CBT
  • Meds for opiod dependance:
    - Detox: METHADONE; Buprenorphine; Dihydrocodeine
    - Lofexidine (for withdrawal)
    - Naltrexone (prevent relapse)
    - NALOXONE (if overdose!)
  • For smoking:
    - NRT
    - Champix/Varenicline (reduce cravings)
    - Bupropion?Zyban (reduce pleasure)
92
Q

Sx of Intoxication

A
  • Slurrded speech
  • Ataxia
  • Impaired judgement
  • If severe:
    - Coma
    - Hypoglycaemia
93
Q

Alcohol withdrawal Sx

A

6-12 hrs after last drink:

  • Insomnia
  • Sweating
  • Anxiety
  • Tremor
  • Palpitations
  • Agitation
  • Nausea + vomiting

12-24 hours after last drink:

  • HALLUCINATIONS

> 36 hours after:

  • SEIZURES

72 hours after = DELERIUM TREMENS

  • Delusions
  • Confusion
  • Seizures
  • TACHYCARDIA
  • HYPERTENSION
  • Hyperthermia
94
Q

Ix for Alcohol abuse / withdrawal

A
  • AUDIT, CAGE, SADQ, FAST
  • BLOODS: LFTs + ELECTROLYTES
  • CT head if seizures persist
  • ECG
95
Q

Alcohol withdrawal Tx

A
  • Reducing regimen of CHLORDIAZEPOXIDE
    - More rapid acting (e.g. IV LORAZEPAM) if having seizures
  • PABRINEX (IV thiamine) to prevent Wernike’s (if already Wernike’s -> increased dose)
  • ORAL LORAZEPAM for Delerium tremens (can give IV if needed)
96
Q

What are the criteria for when inpatient withdrawal Tx should be considered

A
  • Drinking > 30 UNITS per day
  • Score > 30 on SADQ
  • At High risk of SEIZURES
  • Concurrent withdrawal from benzodiazepines
  • Significant CO-MORB (med / psych)
  • Vulnerable patients / Patients < 18
97
Q

Tx options for alcohol abuse

A
  • CBT / AA / Social support
  • Disulifram (N+V if drinking)
  • Naltrezone (decreased pleasure)
  • Acamprosate (reduce cravings)
98
Q

Wernicke’s encephalopathy

A

Acute neuro Sx from THIAMINE (vit B1) def - typically from alcohol abuse

  • thiamine def -> neuronal death
99
Q

Korsakoff syndrome pathophys

A

Prolonged thiamine def -> Neuronal degeneration - most notably in MAMMILLARY BODIES which are part of the CIRCUIT OF PAPEZ - playes role in MEMORY FORMATION

100
Q

Classic signs of Wernicke’s

A
  • CONFUSION
  • Ataxia
  • Ophthalmoplegia (paralysis of ocular muscles) / nystagmus

not all Sx needed for Dx

101
Q

Hallmark Sx of Korsakoff

A
  • ANTEROGRADE AMNESIA
  • Retrograde amnesia (semantic and episodic specifically affected)
  • CONFABULATION (fabricating memories to mask amnesia)

(these 3 things make up the syndrome basically)

Also:

  • lack of insight
  • apathy
  • Minimal content in conversation
102
Q

Wernicke’s Ix

A
  • THIAMINE LEVEL TESTING
  • BLOODS: FBC, U+E, LFTs, CLotting, Bone profile, Mg
  • MRI brain (hyperintensity on T2 weighted due to oedema - usually in mammillary area)
103
Q

Wernicke’s Mx

A
  • THIAMINE SUPP
  • Mx underlying (oft alcohol so counselling / rehabilitation)
104
Q

Korsakoff Mx

A
  • THIAMINE SUPP
  • Cognitive REHAB (cognitive function / memory loss do not return to previous baseline)
  • Control pt environment to reduce confusion
  • Tx underlying (typically alcoholism)
105
Q

Major depressive disorder vs Persistent Depressive Disroder

A

Major dep = Depressive episode lasting AT LEAST 2 WEEKS + desplaying at least 5 of the main Sx nearly every day

Persistent dep = lasts at least 2 YEARS

106
Q

Defining charactersitics of a depressive episode

A
  • LOW MOOD / MOTIVATION
  • ANHEDONIA
  • Reduced energy

All for AT LEAST 2 WKS

107
Q

Depression Sx

A
  • Low mood / irritability
  • Anhedonia
  • Change in WEIGHT / APPETITE
  • Change in SLEEP
  • Change in ACTIVITY LEVELS - oft loss of energy
  • GUILT / FEELINGS of WORTHLESSNESS
  • Cognitive impairment: difficulty thinking/CONCENTRATING or INDECISIVENESS
  • SUICIDALITY

If v severe, can develop:
- psychotic features or
- Depressive stupor (immobile, mutism, not eating / drinking)

108
Q

Depression Dx

A

Rule out:

  • Bloods
    - FBC; TFTs; U+E; LFTs; glucose; B12/folate; cortisol
  • Toxicology screen
  • CNS imaging (potentially)

Usually clinical diagnosis:

  • Interviews
  • Questionnaires (Patient Health Questionnaire 9; Hospital Anxiety and Depression Scale)
109
Q

Depression Mx

A

Usually in community

Mild to moderate:

  1. Individual self help / computerised CBT (low level psych)
  2. individualised CBT / IPT
  3. Consider antidep

Unresponsive / mod-severe:

  1. CBT/IPT + SSRIs
  2. Switch antidep then use adjuncts (SNRI, Tricyclic)

Severe / stupor / psychosis:

  1. ECT

Recurrent:

  • Antidepressant + lithium

N/B: Follow up starting antidep within a week in young adults (<25) - increased risk of suicide/impulsivity

110
Q

Side effects of ECT

A

Short term:

  • Headache
  • Muscle ache
  • Nausea
  • Temporary memory loss
  • Confusion

Long term:

  • Persistent memory loss (potentially)
111
Q

Meaning of PHQ-9 scores

A
  • <16 - less severe
  • > =16 - more severe
112
Q

Anxiety definition

A

Excessive worry about a number of different events associated with heightened tension, extending across various domains of life.

  • difficult to control worry
  • Associated: Restlessness, muscle tension + fatigue
  • LASTING AT LEAST 6 MONTHS
113
Q

Anxiety RFx

A
  • Lower socioecon
  • Unemployment
  • Divorce
  • Renting rather than home owning
  • Lack of educational qulaifications
  • Urban living
114
Q

Anxiety Sx

A

Psych:

  • Worries
  • Poor conc
  • irritability
  • Depersonalisation/Derealisation

Somatic:

  • Tremor
  • Headache / muscle aches
  • Dizziness
  • Tinnitus
  • Dry mouth, Dysphagia, nausea, indegestion, Butterflies, flatulence, increased/loose bowel movements
  • Chest discomfort ; palps
  • SOB
  • Urinary frequency; Amenorrhoea; ED
115
Q

Anxiety DDx

A
  • Hyperthyroid
  • Cardiac
  • Medication induced
    - SALBUTABOL, Theophylline; Corticosteroids; Antidep
  • Substance misuse
    • Amphetamines; benzodiazepine/alcohol withdrawal
      - Or just CAFFEINE
  • personality disorder
  • Early stage dementia or schizophrenia
116
Q

GAD (generalised anxiety disorder) Mx

A
  1. EDUCATE + active monitoring
  2. Low intensity psych (self-help (guided / non-guided); psychoeducational groups)
  3. High intensity psych (CBT; Applied relaxation) OR DRUGS
    - SSRIs then SNRIs (monitor for suicidality in <30s)
    - other = Pregabalin
  4. SPECIALIST MDT INPUT
117
Q

When to refer for specialist Tx of depression

A
  • High suicide risk
  • BIPOLAR Sx
  • PSYCHOSIS Sx
  • Severe, unresponsive depression
118
Q

Psychotic features (Psychosis)

A
  • Hallucinations + Delusions
  • Thought disorganisation
    - Alogia (little info convaeyed by speech)
    - Tangentiality
    - Clanging
    - Loose associations / flight of ideas

Oft associated:

  • Agitation / aggression
  • Neurocog impair
  • Depression
  • Thoughts of self-harm
119
Q

Causes of psychotic Sx

A
  • Schizophrenia
  • Depression
  • Bipolar
  • Postpartum psychosis
  • Neuro conditions e.g. Parkinson’s Huntington’s
  • Prescribed drugs e.g. CORTICOSTEROIDS
  • Illicit drugs e.g. CANNABIS, PHENCYCLIDINE
  • Brief psychotic disorder (Sx last LESS THAN A MONTH)
120
Q

Somatisation disorder definition

A

Multiple, RECURRENT and frequently CHANGING physical Sx lasting at least 2 YEARS.

Oft associated with disruption of social, interpersonal + family behaviour

121
Q

Potentially aets of somatisation disorder

A
  • attempt to cope with stress
    - increased incidence if Hx of ABUSE
  • Heightened sensitivity to internal sensations
  • Catastrophic thinking oversensitising mild ailments
122
Q

Somatisation disorder Tx

A

CBT

123
Q

Ways of assessing risk

A
  • Risk assessment tools eg DRAM, FACE
  • Clinical Assessment - psychiatric history + MSE
  • Static risk factors - do not change
  • Dynamic risk factors - may change

Consider Hx, environment, Mental state + info from other sources, MDT etc -> How serious + immediate is risk

124
Q

Static RFx for harm to self/others

A
  • History of self-harm/ overdoses
  • Seriousness of previous suicidality
  • Previous hospitalisation
  • History of mental disorder
  • History of substance use disorder (overdose or suicide)
  • Personality disorder/traits
  • Childhood adversity
  • Family history of suicide
  • Age, gender and marital status
125
Q

Dynamic RFx

A
  • Suicidal ideation, communication, and intent
  • Hopelessness
  • Psych Sx – ?command hallucinations
  • Treatment adherence
  • Substance use
  • Psychiatric admission and discharge - risk when discharged
  • Psychosocial stress
  • Problem-solving deficits
126
Q

Risk Mx

A
  • Assess risk
  • Risk Mx plan
  • communicate plan with pt
  • Ensure plan is carried out
  • Evaluate outcome
  • Clinical review
127
Q

Lithium SE

A

Common: Nausea, diarrhoea, dry mouth, metallic taste, thirsty, mild tremor

Rare: RENAL DYSFUNCTION, HYPO/HYPERTHYROIDISM, TERATOGENICITY

128
Q

Lithium TOXICITY Px

A
  • Polyuria / Incontinence ; Nausea
  • Drowsey, Confusion, Blackouts, Faints, Blurred vision
  • Shaking / muscle SPASMS in face, neck + tongue

TOXICCC:

  • coarse TREMOR
  • OLIGURIC RENAL failure
  • ATAXIA
  • INCREASED REFLEXES
  • CONVULSIONS
  • decreased CONSIOUSNESS
  • COMA
129
Q

Lithium toxicity Ix

A
  • U+E
  • TFTs
  • LITHIUM LEVELS
130
Q

Lithium toxicity Mx

A
  • STOP LITHIUM
  • High FLUID + IV NaCL
  • Haemodialysis if severe
131
Q

Neuroleptic Malignant Syndrome

A

Adverse reaction to ANTIPSYCHOTICS (dopamine receptor agonists) or; ABRUPT DOPAMINERGIC WITHDRAWAL (levodopa)

132
Q

Neuroleptic Malignant Syndrome Sx

A
  • Altered mental state, CONFUSION
  • FEVER
  • TACHYCARDIC
  • HTN / HypOtension
  • Muscular HYPOactivity
  • Severe lead pipe RIGIDTY
133
Q

Neuroleptic malignant syndrome Ix

A
  • BLOODS
    - CK, LFTs, FERRITIN (LOW)
  • CT/MRI head
  • INFECTION SCREEN (exclude sepsis)
    - WCC
134
Q

Neuroleptic malig syndrome Mx

A

STOP CAUSATIVE DRUG + SUPPORTIVE Mx

135
Q

Neuroleptic malig syndrome Complications

A
  • PE (due to immobilisation?)
  • RENAL FAILURE
  • SHOCK
136
Q

Serotonin syndrome

A

High SYNAPTIC CONC of serotonin caused by SSRIs/SNRIs, OPIOIDS, MAOi, Lithium, Tricyclics etc

137
Q

Serotonin sydrome Sx

A
  • CONFUSION
  • HALLUCINATIONS
  • Tremor
  • Hyperreflexia
  • HTN
  • Tachycardia
  • Hyperthermia
  • Sweating + shivers

N/B can differentiate from NMS as WCC NORMAL in Serotonin Sydrome

138
Q

WHat is the acute Tx of SSRi overdose

A

Activated charcoal

139
Q

Acute Dystonic Syndrome

A

Painful contraction in:

  • Eyes = Oculogyric crisis
  • Neck = TORTICOLLIS
  • Jaw

Classic Px = Arm held in dystonic posture, neck spasm to side, mouth open, upward eye gaze, pain and distress

Tx = IM PROCYCLIDINE 5-10 mg

140
Q

PHQ-9 (for depression) score catagories

A
  • 0-4 no depression identified
  • 5-9 mild depression
  • 10-14 moderate depression
  • 15-19 moderately severe depression
  • 20-27 severe depression
141
Q

Indications for ECT + absolute contraindication

A
  • treatment resistant severe depression
  • manic episodes
  • an episode of moderate depression know to respond to ECT in the past
  • life threatening catatonia

Contraindication = raised ICP

142
Q

Side effects of ECT

A
  • headache
  • nausea
  • short term memory impairment
  • memory loss of events prior to ECT
  • cardiac arrhythmia

usually only gets short term side effects but some people get long-term memory impairment

143
Q

Cotard syndrome: meaning

A

Rare condition where an individual has the irrational, unshakable belief that they (or part of their body) is dead, rotting or non-existent

144
Q

Complications of Cotard syndrome

A

Patients can stop eating and drinking as they deem it unnecessary

145
Q

Cotard syndrome is associated with which conditions

A
  • Severe depression + psychotic disorders
  • Schizophrenia
  • Parietal lobe lesions
146
Q

Capgras delusion meaning + possible causes

A

Fixed, false belief that a close relative/partner has been replaced by an imposter

Could be psychotic illness or brain trauma

147
Q

Ekbom syndrome meaning + Px

A

Delusional belief that patient feels that they are infected with parasites.

Often complain of crawling feeling under skin

Can appear as part of psychotic illness or 2ndry to organic disease e.g. B12 def, hypOthyroid, neuro disorder

148
Q

Othello syndrome + complications + associations

A

An individual has the fixed belief that their partner is unfaithful despite the absence of proof

  • Oft presents in males
  • Can result in stalking / homicide
  • Associated with alcohol abuse, psychosis and right frontal lobe damage
149
Q

De clerambault’s syndrome

A

AKA eratomania

The patient has a specific, fixed, false belief that someone else is in love with them. The patient is usually a woman and the person they are fixated upon is usually of a higher social status, despite only a brief or non-existent acquaintance.

There is not normally any unusual behaviour or hallucinations accompanying the delusion

AKA parasocial stalker behaviour

150
Q

Fregoli’s syndrome

A

The fixed, false belief that strangers are familiar to the individual or a group of different people are in fact a single person who is in disguise

(think the ‘umbra meets aliens’ scene from vy spy)

151
Q

Folie a deux

A

A shared delusion between two people in close association

152
Q
A

Phase 3a (26 decks)

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