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Year 5 > Psych 2 > Flashcards

Psych 2 Flashcards

1
Q

Delirium: signs and symptoms

A
  • Disorientation, inattention (difficulty focusing) , disturbed sleep and cognitive skills
  • Disorganised thinking (rambling), altered level of consciousness
  • Hallucinations - visual or auditory
  • Memoryproblems
  • Change in mood or personality.Sundowningis agitation and confusion worsening in the late afternoon or evening.
  • Presentation can fluctuate over time, harder to spot hypoactive delirium as they may just seem more withdrawn. Acute onset
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2
Q

Delirium: investigations

A
  • 4AT and CAM for delirium assessment
  • MSE, collateral history
  • Physical + neuro examination
  • May need additional tests due to clinical suspicion like bloods and urine dip (don’t do if >65)
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3
Q

Delirium management

A
  • Providing an environment with good lighting
  • Maintaining a regular sleep-wake cycle
  • Regular orientation and reassurance
  • Ensuring the patient’s glasses and hearing aids are used if needed
  • CAUTION with antipsychotic meds used for distressing sx
  • Residual sx may take up to 6 months to resolve
  • Treat underlying cause
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4
Q

Delusions

A
  • Fixed, false beliefs that are maintained despite contradictory evidence.
  • Can be classified as bizarre (very strange and highly unusual), non-bizarre (plausible but incorrect) and mood-congruent (consistent with the individual’s emotional state) or mood-neutral.
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5
Q

Types of delusions 1

A
  • Nihilistic delusions: negative delusions, congruent with the individuals depressed mood i.e. dead or world ended.
  • Cotard’s delusions: believes that oneself is dead or rotting
  • Grandiose delusions: patients believe they posses extraordinary traits or powers. Common in manic phase of bipolar
  • Delusions of control: external entity is controlling their thoughts or actions. Common in psychotic conditons
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6
Q

Types of delusions 2

A
  • Persecutory delusions: believe they are being persecuted. Common in schizophrenia
  • Somatic delusions: believe they have a medical problem despite no evidence. Wide range of physical symptoms
  • Delusions of perceptions: delusions arising from a real perception (e.g. bunch of flowers -> martians are about to land,) and can be self-referential.
  • Delusions of reference: things that are mundane (words in a newspaper) actually mean a special message to the patient.
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7
Q

Management of delusions

A
  • Antipsychotics: dont work well
  • Psychotherapy: CBT
  • Psychoeducation: providing information about the nature and management of the condition
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8
Q

Delusional disorder

A
  • Narrower range of symptoms then schizophrenia
  • Prescence of just one or more delusion
  • Last longer then a month and tend not to be bizarre and could happen in real life
  • No prominent hallucinations, thought disorder, mood disorder or significant flattening effect
  • Tend to be erotomanic (someone is in love with them), grandiose, jealous, somatic or persecutory
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9
Q

Depression

A
  • Depressed mood, loss of interest (anhedonia), and reduced energy (fatigue) persisting for at least two weeks.
  • Can be mild, moderate or severe. More severe depression is a PHQ-9 >16
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10
Q

Depression symptoms

A
  • Depressed mood or irritability
  • Anhedonia, hopelessness about the future
  • Significant weight change or change in appetite
  • Sleep alterations: insomnia or hypersomnia
  • Reduced activity levels, fatigue, loss of energy
  • Guilt or feels of worthlessness, low self esteem
  • Reduced cognition: hard to concentrate
  • Suicidality
  • Severe depressions: psychotic features, depressive stupor (immobility, mutism, refusal to eat or drink)
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11
Q

Depression investigations

A
  • Hospital Anxiety and Depression (HAD) Scale and Patient Health Questionnaire (PHQ-9).
  • Refer to secondary care; if high suicide risk, unresponsive to initial treatment, symptoms of bipolar disorder or psychosis
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12
Q

Management of mild to moderate depression

A
  • 1st line = Low-intensity psychological interventions (individual self-help, computerised CBT).
  • 2nd line = High-intensity psychological interventions (individual CBT, interpersonal therapy)
  • 3rd line = Consider antidepressants
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13
Q

Treatment for depression: other

A
  • Moderate to severe: High intensity psychological intervention + antidepressant (SSRI)
  • Severe depression with poor oral intake/psychosis/stupor: ECT
  • Recurrent: antidepressant + lithium
  • Give Crisis number
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14
Q

Screening questions for depression

A
  • ‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
  • ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
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15
Q

Psych- risk assessment

A
  • Suicide – increase risk of suicide
  • Homicide – especially in adults with caring responsibilities to vulnerable individuals (children/elderly/persons with disabilities)
  • Neglect – poor self-care, not eating/decrease hydration. Poor self care may lead to general debility & physical complications esp in individuals with chronic illnesses
  • Alcohol & recreational drug use
  • Misuse of prescription drug or/over the counter prep eg analgesia, benzodiazepines, steroids, antihistamines for sedative properties
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16
Q

Management of less severe depression: treatment options listed in order of preference

A
  • Don’t routinely offer antidepressant medication as first line treatment for less severe depression, unless its their preference
  • guided self-help
  • group cognitive behavioural therapy (CBT)
  • group behavioural activation (BA)
  • individual CBT
  • individual BA
  • group exercise
  • group mindfulness and meditation
  • interpersonal psychotherapy (IPT)
  • selective serotonin reuptake inhibitors (SSRIs)
  • counselling
  • short-term psychodynamic psychotherapy (STPP)
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17
Q

Common overdose management

A
  • Paracetamol: acetylcysteine
  • Opioids: Naloxone
  • Benzodiazepines: Flumazenil
  • Beta blockers: Glucagon for HR or cardiogenic shock, Atropine for symptomatic bradycardia
  • CCB: Calcium chloride or calcium gluconate
  • Cocaine: Diazepam
  • Cyanide: Dicobalt edetate
  • Methanol (solvents or fuels), Ethylene glycol (antifreeze): Fomepizole or ethanol
  • CO: 100% oxygen
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18
Q

Anorexia definition

A
  • A severe psychiatric condition characterised by extreme dietary restriction, an intense fear of gaining weight and distorted body image (view themselves as overweight when they are not)
  • Restrictive Subtype:Characterized by minimal food intake and excessive exercise.
  • Bulimic Subtype:Involves episodic binge eating followed by behaviors like laxative use or induced vomiting.
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19
Q

Anorexia criteria and risk factors

A
  • Significantly low body weight
  • Fear of gaining weight
  • Distorted body image
  • Restrictive eating: often causing malnutrition

Anorexia risk factors: female, adolescents, other psychiatric conditions.

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20
Q

Anorexia clinical features

A
  • Preoccupation with food and calories
  • Starvation via restricting intake, purging (through induced emesis, diuretic or laxative abuse) or excessive exercise
  • Poor insight
  • Overvalued, intrusive obsession with weight, shape and fear of becoming fat
  • Weight/calorie goals in mind regardless of their impact on physical health
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21
Q

Anorexia physical characteristics

A
  • BMI <17.5
  • Hypotension, Bradycardia
  • Enlarged salivary glands
  • Lanugo hair
  • Amenorrhoea (hypogonadotropic hypogonadism)
  • Bulimic subtype: hypokalaemic hypocholeraemic metabolic alkalosis, pitted teeth, parotid swelling, and scarring of the dorsum of the hand (Russell’s sign).
22
Q

Anorexia investigations

A
  • Deranged electrolytes - typically low calcium, magnesium, phosphate and potassium
  • Low sex hormone levels (FSH, LH, oestrogen and testosterone)
  • Leukopenia, low T3
  • Raised growth hormone and cortisol levels (stress hormones)
  • Hypercholesterolaemia, impaired glucose tolerance
  • Metabolic alkalosis, either due to vomiting or use of diuretics
23
Q

Anorexia management: therapy

A
  • CBT-ED (CBT for eating disorders)
  • MANTRA (Maudsley Model of Anorexia Nervosa Treatment for Adults): Targeting the core beliefs behind anorexia.
  • specialist supportive clinical management (SSCM).
  • If <18: AN focused family therapy
24
Q

Anorexia management: other

A
  • Medical: SSRI for comorbid depression
  • Admission under the Mental health act: if life at immediate risk, may need structured feeding and in some nasogastric tube feeding
  • Inpatient admission: severe or rapid weight loss, significant suicide risk, inability to perform the SUSS test (sit-up, squat, and stand), weak respiratory muscle
  • MARSIPAN checklist: to guide management
25
Q

Anorexia: complications

A
  • Malnutrition, electrolyte imbalance, highest mortality rate of all psychiatric conditions
  • Osteoporosis
  • Refeeding syndrome
  • Cardiac arrhythmias: bradycardia and prolonged QTc. Perform ECG periodically especially if cardiac symptoms (dizzyness)
  • Early intervention helps outcomes
26
Q

Refeeding syndrome

A
  • A potentially fatal disorder when nutritional intake is resumed too rapidly after low calory intake
  • Symptoms: oedema, confusion and tachycardia
  • Bloods: Hypomagnesaemia, Hypokalaemia, Hypophosphataemia, Fluid overload
  • Increasing insulin causes shifts of potassium, magnesium and phosphate from extracellular to intracellular spaces‚ these need to be replenished
27
Q

Refeeding syndrome: preventative measures

A
  • High-dose vitamins (eg. Pabrinex) before feeding commences
  • Monitoring with daily bloods and replenishing electrolytes early
  • Building caloric intake gradually with the help of a dietitian‚ refeeding is started at no more than 50% of calorie requirement in ‘patients who have eaten little or nothing for more than 5 days’
28
Q

Effects of refeeding syndrome

A
  • Vitamin deficiency- Wernicke’s/Korsakoffs
  • Sodium balance impaired- oedema, cardiac failure
  • Particularly high risk: very low BMI, complete restriction/ rapid weight loss, co-morbid alcohol dependence, co-morbid physical health problems i.e. sepsis, cancer. Parenteral feeding > NG feeding > Oral diet
29
Q

Eating disorder: other risks

A
  • Driving= Difficulties with concentration, Preoccupation with food, Mood instability – impulsiveness. Guidance is not to drive if BMI <16 or if unstable bloods (esp. low glucose)
  • Duties at work
  • Childcare
  • Activities - horse riding, skiing
  • Universities also have guidance on attending
  • Carer stress/burnout
30
Q

Eating disorder: investigations

A
  • Weight (beware may be falsified), height, BMI, rate of weight loss
  • BP (incl. postural), pulse, temp
  • Sit-Up Squat-Stand (SUSS) test
  • Sit up= patient lies on the floor and sits up without if possible using his/her hands
  • Squat stand= patient squats down and rises without if possible, using his/her hands
  • ECG
  • U&E, LFT, FBC, Glucose, Mg, PO4, Ca
  • Kings College Medical Risk Assessment for ED
31
Q

Management of eating disorders- nutritional

A
  • Dietitian led
  • Regular eating and snacks
  • Aiming for 0.5-1kg weight restoration per week
  • Food preparation, shopping, cooking
  • Eating in different situations
  • Psychoeducation
  • Veganism/vegetarianism= can be difficult in terms of weight restoration, there are no approved vegan nutritional feeds. Respecting beliefs vs part of anorexia, may have to feed against wishes in extreme cases
32
Q

Medical management of eating disorders

A
  • Monitor weight, BMI, signs of starvation/purging: Bloods, ECG, BP, pulse, temperature
  • Monitoring for refeeding syndrome – prescribing supplements
  • Management of bone health
  • No medication for anorexia itself
  • Low dose olanzapine can be used off-licence in AN: Would usually start in inpatient setting
  • Assessment and treatment of psychiatric co-morbidities
33
Q

Eating disorders: recovery

A
  • 50% fully recover
  • 30% improve
  • 20% remain chronically ill
  • Early intervention model – 60% full recovery
  • The earlier the treatment, the better the prognosis
34
Q

Bullimia criteria

A
  • Characterized by recurrent binge-eating episodes with a loss of control, followed by inappropriate compensatory behaviors to prevent weight gain.
  • Compensatory behaviors include self-induced vomiting, laxative or diuretic misuse, fasting, not using insulin or excessive exercise.
  • Purging subtype includes use of laxatives and vomiting. Non purging subtypes is fasting or exercise
  • Behaviours/episodes occur once a week or more for one month (ICD-11) / three months (DSM-V)
  • Unlikely anorexia individuals have normal or slightly above average BMI
35
Q

Severity of bulimia

A
  • Categorised based on the frequency of compensatory behaviour
  • Mild: An average of 1-3 episodes per week.
  • Moderate: An average of 4-7 episodes per week.
  • Severe: An average of 8-13 episodes per week.
  • Extreme: An average of 14 or more episodes per week.
36
Q

Bulimia signs and symptoms psych

A
  • Binge Eating: Loss of control, consuming large amounts of high-caloric food urgently.
  • Purging: Induced vomiting, laxative or diuretic misuse, and excessive exercise.
  • Body Image Distortion: Distorted perception despite maintaining normal or slightly above average weight.
37
Q

Bulimia signs and symptoms

A
  • Physical symptoms: dental erosion, parotid gland swelling, Russell’s sign, Amenorrhoea
  • Non-specific physical signs: fatigue, bloating, abdo pain, constipation, irregular menstrual periods
  • Electrolytes: Hypokalaemia, hyponatraemia, hypocholeraemia, hypomagnaesmia
38
Q

Bulimia investigations

A
  • The Eating Disorder Examination
  • Self reported questionaires: Eating disorder inventory
  • Bloods: FBC, U&E, LFT, HBA1c
  • ECG, DEXA
  • Comprehensive mental health assessment
39
Q

Bulimia management

A
  • Bulimia Nervosa Focused Guided Self help: first line
  • Specialist referral: Dietician referral
  • Inpatient treatment: if medically unstable
  • If self help inappropriate: CBT-ED
  • Medication: SSRI (especially fluoxetine) in addition to psychotherapy
  • Children: Bulimia Nervosa Focused Family therapy, high dose fluoxetine
40
Q

Bulimia complications

A
  • Excessive vomiting complications: Boerhaave syndrome, Mallory-Weiss tear
  • Psychological: depression, suicidal idealation, substance abuse
  • GI: gastritis, peptic ulcer, oesophagitis, Barrett’s oesophagus
41
Q

Physical health complications of laxatives and exercise

A
  • Laxatives: affects the large bowel leading to increased loss of water and electrolytes. Including Dehydration, Electrolyte imbalance, Rectal bleeding, Abdo cramps, rebound constipation and rarely pseudo-obstruction
  • Exercise: physical exhaustion, muscle damage, elevated CK, rhabdomyolysis, injuries. Other cardiac abnormalities i.e. bradycardia, heart block, chest pain
42
Q

Binge eating disorder

A
  • as with BN but without the recurrent use of compensatory behaviour, not occurring during the course or AN or BN.
  • recurrent episodes of binge eating (eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances)
  • a sense of lack of control over eating during the episode
  • self-evaluation is unduly influenced by body shape and weight.
43
Q

What may binge eating disorder involve

A
  • A planned binge involving “binge” foods
  • Eating very quickly
  • Unrelated to feelings of hunger
  • Becoming uncomfortably full
  • Eating in a dazed state
44
Q

ARFID: Avoidant restrictive food intake disorder

A
  • Restricted eating (types or quantity of food) which can lead to weight loss and same physical risks as anorexia
  • Fear isn’t of weight gain or fatness
  • g. fear of choking, vomiting, certain textures etc.
  • May have low interest in eating
45
Q

OSFED: Other Specified Feeding and Eating Disorder

A
  • An umbrella term
  • Difficulties with eating that do not meet the diagnostic criteria of another eating disorder but that do have a significant impact on the health and functioning of a person
46
Q

Personality disorder

A
  • > 18
  • Enduring patterns of behaviour that are abnormal in a particular culture
  • Have an onset in adolescence or early adulthood, are stable over time, and lead to distress or impairment.
  • Often due to combination of genetic and environmental factors, patients may have history of early childhood trauma and difficult circumstances
47
Q

Different clusters of personality disorder

A
  • Cluster A (suspicious): Paranoid, Schizoid, Schizotypical
  • Class B (emotional and impulsive): Antisocial, Borderline, Histrionic, Narcissistic
  • Class C (anxious): Avoidant, Dependent and Obsessive-Compulsive personality disorder
48
Q

Paranoid personality disorder

A
  • Characterised by pattern of irrational suspicion and mistrust of others
  • Hypersensitivity to criticism
  • Reluctance to confide in other
  • Preoccupied with unfounded beliefs about perceived conspiracies against themselves
49
Q

Schizoid personality disorder

A
  • Pattern of detachment from social relationships and a restricted range of emotional expression
  • Lack of interest in interpersonal relationship, often preferring solitary activities
  • Shows an emotional coldness, detachment, or flattened affectivity
  • Often has few, if any, close relationships outside of immediate family
50
Q

Schizotypical personality disorder

A
  • Impaired social interactions, distorted cognitions and perceptions, and eccentric behaviours
  • Symptoms: odd thinking and speech, such as magical thinking, peculiar ideas, paranoid ideation, and belief in the influence of external forces
  • Shares certain cognitive or perceptual distortions with schizophrenia, but maintains a more intact grasp on reality

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