Psych 2 Flashcards
1
Q
Risk factors/ aetiology for Anorexia nervosa
A
Bio: Genetics Female (mid-adolescence Early menarche Starvation (endocrine) perpetuates Psycho: Sexual abuse Dieting in adolescence Low self esteem Premorbid anxiety or depression Perfectionism/ anankastic personality Criticism regarding eating/body shape/weight Social: Western society Stress Bullting at school involving weight Occupatione.g. ballet, models
2
Q
Clinically defining features of Anorexia nervosa as defined by ICD10 and other features
A
Fear of weight gain
Amenorrhoea and loss of sexual interest and impotence in male.
BMI 15% below expected weight
Deliberate weight loss (food or exercise)
Distorted body image
All features present for 3 months and must be absence of binge eating and a preoccupation with eating/ craving to eat. (if not consider bulimia or EDNOS.
Other
Physical: Fatigue, hypothermia, bradycardia, arrhythmias, peripheral oedema, headache, lanugo hair.
Preoccupation with food: Dieting, making meals for ohers
Socially isolated, sexuality feared
Symptoms of depression and obsession
Anorexia features
bradycardia
hypotension
enlarged salivary glands
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
3
Q
Appearance and behaviour
A
x
4
Q
Speech
A
x
5
Q
Appearance and behaviour
A
Tics Rapport Psychomotor activity e.g. retardation Abnormal behaviours e.g. distracted Physical state Hygiene Eye contact - staring in parkinsonism and averting gaze in depression Body language
6
Q
Speech
A
Rate - Latency. Pressured/slow
Quantity of speech – minimal (e.g. only in response to questions) /excessive speech / complete absence of speech
Tone - monotomous (dep), tremulous (anx)
Volume - mania loud, depression low
Fluency and rhythm of speech – articulate / clear / slurred
Formal thought disorder e.g. word salad, tangientality, derailment of thought e.g. knight’s move thinking
7
Q
Mood
A
Mood - a patient’s sustained, subjective, experienced emotion over a period of time.
Elated, euthymic or depressed.
May be diurnal e.g. dep
8
Q
Affect
A
Affect is assessed on:
Range - restriced, blunted (more severe than restricted), flat (almost no expression)
Appropriateness - appropriate, inappropriate, incongruous
Stability - stable, labile (fluctuating)
If affect is normal = reactive
9
Q
Perception and good questions to ask
A
Hallucinations - modalities
Different from:
Pseudohallucinations - Voices in head - no external stimuli reported (know it’s not real?)
Illusion- A false mental image produced by misinterpretation of external stimulus
Depersonalisation - detachment of normal sense of self (neurosis = stress)
Derealization - (neurosis), unreality feeling, people and experiences are unreal/ on a stage.
See things others cant hear or can’t explain?
Hear things others cant hear or explain?
Feel things cant explain?
Voices in head?
Feel like things you see or heard or experience aren’t real?
10
Q
Thought and questions
A
Thought
Form:
• Loosening of association (x3 in speech)
• Circumstantiality - drifts but comes back to same idea.
• Perservation (same idea)
• Neologisms - giving words new meanings
Content
• Delusions, preoccupations/ overvalued ideas (Strongly held beliefs but can be put out of mind with some effort).
• Obsessions (distressing thoughts that enter the mind despite the patient’s effort to resist them), compulsions, ruminations
Stream
• Acceleration (pressure of speech/ flight of ideas)
• Retardation (Poverty of thought)
• Thought blocking
Suicidal ideation?
11
Q
Difference between normal grief and depression?
A
a normal grief reaction lasts under 6 months whereas depression can last longer.
12
Q
Side effects of antipsychotics
A
Extrapyramidal side-effects
Parkinsonism
acute dystonia (e.g. torticollis, oculogyric crisis)
akathisia (severe restlessness)
tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Other side-effects
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin: galactorrhoea, impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
13
Q
Describe Insight?
A
Intact - accept disorder and treatment
Partial - accept disorder but not treatment or vice versa
Non-existent
14
Q
Cognition and questions
A
General - Conscious level Hyper/ hypoactive - sleepy? Orientation Attention Language (right ear with left hand) Calculation Right sided function - draw clock face Abstract thinking - take a horse to water but... Memory Praxis - e.g. copying/ drawing
Where are you? When are you? Touch your right ear with your left hand? Draw a clock face? Take a horse to water... 10x5?
15
Q
Reporting of MSE
A
Appeared to be hygienic, suitably dressed, no psuychomotor abnormality
No abnormal behaviours such as staring or distracted with good rapport
Speech
Rate - normal (not pressured or slow)
Normal quantity (not minimal or excessive)
Volume normal
Tone normal (not monotomous or tremulous)
Mood
Objectively
Subjectively - euthymic, low, elated
Affect
Reactive/ restricted/ bluted/ flat range
Appropriate/Congruous
Stabile
Perception
No hallucinations, illusions or derealization/ depersonalization
Thoughts
Normal structure (no neologisms, loosening of association, circumstantiality, formal thought disorder)
No delusions, obsessions or overvalued ideas
No accelaration/ retardardation
No suicidal ideation
Insight present
Cognition
Well orientated, good attention and no obvious impairment of higher functioning. (memory not impaired or trouble understanding language)
16
Q
Psych history structure
A
Presenting complaint History of PC Psych history Medical history Medication Family history Personal history: • Infancy • Adolescence • Forensic • Occupational • Sexual and relationships • Living Drugs and Alcohol Premorbid personality MSE
17
Q
How to get presenting complaint
A
Ask patient to describe atypical day
Onset, severity, duration, agg/ relieve, associated symptoms.
Patient’s view of the problem
Ask about other symptoms e.g. core in depression, positive and negative in psychosis, biological, psychological, avoidance in anx.
E.g: Do you see/ hear things others can't? Help me to understand this… Do you feel you have any special abilities or powers? Test delusions People interfering with your thoughts? Heard/ seen anything you can't explain. You look a little nervous today? Just get the patient talking
Assess risk - may wait until good time in the conversation - the how and what about killing yourself.
e.g: Sometimes when people feel low… Response to the people following you? Ever hurt so bad that you've thought about killing yourself? What stopped you?
18
Q
Past psych history
A
Previous admissions.
Mental Health Act.
Previous self harm
Treatments
19
Q
Family history
A
x
20
Q
Drugs and alcohol use
A
Always ask about cannabis specifically which naturally follows from smoking.
Cost
21
Q
Personal history
A
xInfancy - development/ milestones, serious illnesses. “were you a healthy child”
Adolescence - how was school for you? Friends? Bullying? Teachers? Qualifications?
Occupation - Leaving school going forward. What jobs they prefered? Relationships? Reasons for job changes?
Social - House, finances, changes in circumstances, support network,
Forensic - ever been in trouble with the police? Or not caught for?
22
Q
Pre morbid personality
A
How person was before so you can compare to how they are now.
How have experiences impacted on them as a person?
23
Q
Anorexia thought findings
A
Preoccupation with food and overvalued ideas concerning dieting, appearance and weight loss (preoccupation differs from obsession in that with severe difficulty the thought can be put out of the mind).
24
Q
Complication of AN
A
Metab
Osteoporosis (DEXa), Proximal myopathy (upper and lower limbs)
Arrhythmias e.g. brady, Prolonged QT, changed caused by hypokalemia.
Hypoglycaemia, Hypercholesterolaemia, Hypothyroidism (TFTs)
GI
Hepatitis/ LFTs Pancreatitis (amylase) Renal failure/ stones Enlarged salivary glands Constipation Peptic ulcers
Anaemia (iron), thrombocytopenia, leucopenia
Dry slin, brittle nairs, infections, suicide
25
Management of anorexia
Risk assessment for suicide and medical comps.
Bio: Treat medical complications. SSRIS for dep or OCD. Graded exposure to food.
Gain 0.5-1kg per week as inpatient and .5kg as outpatient
Psycho: CBT, psychotherapy, DBT, mindfulness, groups, meal plannning, psychoeducation, interpersonal psychotherapy, family therapy
Social: Volunatary organisations or Self-help groups.
26
Risks of weight gain with anorexia
Refeeding syndrome:
After prolonged starvation or malnourishment due to changes in phosphate, magnesium and potassium.
Insulin surge
Hypokalaemia, hypomag,, hypophos, abnormal glucose metab.
Phosphate depletion causes cardiac failure
27
How to prevent refeeding symdrome
Dailey bloods, start at 1200cals and gradually increase every 5 days, monitor for tacchycardia and oedema.
If low then oral or IV electrolyte replacement
28
WHen to hospitalise
```
MHA if health at serious risk
e.g. medical inpatient
No absolute threshold
Indicators
>1kg weight loss a week
Needed to observe blood, ECG
If carers can support
```
29
Define BN
Repeated episodes of binge eating followed by compensatory weight loss behaviours with overvalued ideas regarding ideal body shape/ weight
30
How does BN aetiology and epidemiology differ from AN?
Less clear role of genetics
Vicous cycle of compensatory weight loss behaviours, sense of compulsion to eat, binge eating, fear of fatness.
AN in higher social class, BN in all.
31
Common psychiatric disease with BN
```
Depression
Anxiety
DSH
Substance misuse
Emotionally unstable personality disorder
```
32
Clinical features of BN
ICD 10:
Compensatory behaviours - vomiting, starvation, drugs, omit insulin, exercise
Preoccupation with eating - compulsion followed by regret and shame.
Fear of fatness
Overeating - x2 per week for 3 months.
Other:
Normal weight
Depression/ low self esteem
irregular periods
dehydration - low bp, increased cap refil, low turgor, sunken eyes.
Hypokalaemia -
33
Subtypes of BN
Purging and non purging (drugs/ vomiting vs diet and exercise)
34
Signs of BN and ECG
Russell's sign - calluses on back of hands from repeated self-induced vomiting
Parotid swelling
Sunken eyes
Dental erosion
ECG - Increased PR, depressed/ inverted T, U wave, tall P
35
Complications of repeated vomiting
Arrythmias, mitral valve prolapse, peripheral oedema
Mallory-Weiss tears of the oesophagus, increased parotid
Dehydration, renal stones, renal failure
Erosion of teeth
Russells sign
Aspiration pneumonitis
Cognitive impairment, peripheral neuropathy, seizures.
36
Management of BN
Bio: Fluoxitine can reduce binge
Psycho: CBT, Psychoeducation, interpersonal therapy
Social: Food diary, techniques to avoid binging (eat with others, distractions), small regular meals, self-help programs
Monitor electrolytes.
If suicide risk or electrolyte imbalance then admit to hospital (same as anorexia)
37
Prognosis in eating disorders
50% full recovery in BN
| 20% in AN.
38
Define PD
Deeply ingrained enduring pattern of behaviour that deviates markedly from a persons culture, is pervasive and inflexible, present from adolescenece/ early adulthood (as brain still develops until 17). Leads to distress or impairment
A pervasive inflexible pattern of behaviour and inner experience that deviates from an individuals' cultural norms. Present from adolescence/ early adulthood. Stable over time and leads to distress or impairment
39
Clinical features of panic disorder
Severe, unpredictable, episodic panic attacks not associated with a specific situation or object.
Must last more than a couple of minutes (most peak at 10 and last less than one hour).
Starts abruptly.
Intense fear (fear of death often)
1 autonomic manifestation: palpitations, sweating, shaking/ tremor, dry mouth,
Other anxiety symptoms of GAD
40
Clinical features of GAD (ICD10)
Persistent feeling of worry, agitation for greater than 6 months.
Presence of four symptoms including one autonomic.
Autonomic: Palpitations, sweating, tremor,
```
CVS/ GI:
Butterflies/ abdominal discomfort
Palpitations
Lump in throat
Loose stools
```
```
Neuro:
Lightheaded/ Dizzy
Hot flushing or cold chills
numbness or tingling
Headache
```
```
Symptoms of tension:
Muscle tensions
Restlessness
Feeling n edge
Difficulty swallowing
Sensation of lump in throat
```
```
Thoughts/ higher functions:
Sleep problems
Irritability
Fear of dying/ losing control
Derealisation and depersonalisationMind blacks
Startled easily
Poor concentration
```
41
RFs panic disorder
Bio: Asthma, Benzo withdrawal, age 20-30, , female, white, cigarette smoking,
Psycho:adverse life event
Social: Fx
42
What is catatonia?
State of ultered posure, immobility and stupor.
Seen in severe schizophreni.
It may involve repetitive or purposeless overactivity, or catalepsy, resistance to passive movement, and negativism.
43
What is stupor
Inability to respond to internal (e.g. hunger) and external stimuli
44
What is catalepsy
Inability to respond to internal (e.g. hunger) and external stimuli
45
Pathophysiology of schizo and drugs that can mimic this
Overactivity of D2 mesolimbic pathway - amphetamines, parkinsonism medications.
46
Describe dopamine pathways in the brain
```
Mesolimbic/ mesocortical:
Addiction
Reward
Memory
Motivation
Emotional response
(Mesolimbic positive in Schiz and mesocortical = neg)
```
```
Nigrostriatal:
Motor control (Parkinson's)
```
Tuberoinfundibular:
Regular of hormones (particularly prolactin), pregnancy, maternal stuff
47
Describe the neg symptoms of schizophrenia
```
Avolition (low motivation)
Asocial behaviour
Anhedonia
Affect blunted
Alogia (quantiitve and qualiative decrease in speech)
Attention deficit
```
48
Indications for ECT
Depression that is treatment resistant
Depression with high risk e.g. suicidal ideation or serious risk to others.
Life threathening depression when patient refuses to eat or drink
Catatonia
Prolonged, treatment resistant, manic period
Can only be used under the MHA if an emergency to save life or
49
How long should a seizure last in ECT?
30 seconds
50
CI ECT
MI
Severe resp or CVS disease (anaesthetic)
Heart failure/ arrhythmia (hypertension)
History of status
51
Describe the sympathetic and parasympathetic activity after ECT
Transient parasympathetic followed by sympathetic resulting in raised BP hence contraindications
52
How many drugs are given during ECT?
2
A general anaesthetic (etomidate or propofol
A Muscle relaxant (suxamethonium)
53
How is ECT monitored
EEG. Pulse and BP both increase
54
Describe drugs that affect seizure threshold
Minimum electrical stimulus required to induce a seizure,
Increase threshold: Antiepileptics (mood stab), Benzos, anaesthetics
Decrease threshold: Antipsychotics, antidepresants, lithium
55
Side effects of ECT
```
Short term:
N/V, Constipation, laryngospasm, sore throat
Damaged teeth
Muscular aches, headaches
Mania in a depressed patient
Cardiac arrythmias
Confusion
Peripheral erve palsies
Short term memory impairment
Status epilepticus
```
Long term:
Antereograde and reterograde memory loss
56
Describe anxious/ avoidant PD
```
Approval needed before getting involved
Social inhibition
Embarrasment potential inhibits involvement in activites
Restriction in life to maintain security
Inadequacy felt
```
57
Describe anakastic PD
```
Perfectionism
Loses purpose of tasks and focuses on detail
Workaholic at expense of lesure
Subborn
Inflexible
Fussy
```
58
Describe dependency PD
```
Seeks companionship
Low self confidence
Difficulty expressing disagreement
Reassurance requred
Needs other to assume responsibility
```
59
How can agrophobia and social phobias be differentiated
Agrophobia = fear of a public place whereby immediate escape would be difficult in the event of a panic attack. Fear of crowds, large spaces, leaving the house alone.
Social phobia is fear of social situations which may lead to embarrassing oneself, criticism or humiliation. Fear of being the focus of attention.
60
Describe the treatment of GAD
Bio:
SSRI (1st sertraline), SNRI (2nd), Pregabalin (3rd)
Psycho:
Psychoeducation (low intensity)
CBT and applied relaxation
Social:
Self help - writing things down and analysing, support groups, exercise
61
Treatment for phobia
Pharmacological interventions - SSRIs (not for specific). Benzos for specific in emergency.
CBT - graduated exposure (also homework)
Social phobia can benefit from psychodynamic therapy
62
3 differences between GAD, phobias and panic disorders
Response to stimulivs random ep vs most the time
2 Avoidance in phobias vs worry and agitation vs fear of death
3 Cognition - Constant worry about everyday life events vs fear about a particular situation
63
Organic DDX for panic disorder
```
Pheocromocytoma
Hyperthyroidism
Carcinoid syndrome (neuroendocrine tumours)
Arrythmias
Hypoglycaemia
Alcohol/ substance withdrawral
```
64
Differences between PTSD and Adjustment
Catastophic vs non catastrophic event.
Symptom onset within 6 months vs within 1 month.
Symptoms less severe.
Adjustment disorder symptoms end within 6 months.
Adjustment more like depression
PTSD triad of symptoms
65
Symptoms PTSD
Avoidance
Re living - nightmares and flashbacks
Hyperarousal - hypervigilance, insomnia, startle
66
Treatment for PTSD
Within 3 months:
- Watch and wait
- Zopiclone for sleep
- Risk assess
>3 months:
- CBT
- EMDR - Eye movement desensitisation and reprocessing
- Drugs - Paroxetine, Mirtazapine, amitryptilline and phenelzine. Only consider if therapy is not working.
67
What is an acute stress reaction
```
Exposure to an acute stressor.
Symptom onset within 1 hour.??
Symptoms:
- Any of GAD
- Agitation/ aggression
- Narrowing of attention
- Disorientation
- Despair or hopelessness
- Uncontrollable or excessive grief.
Transient stressors then symptoms must begin to diminish within 1 month
```
Dissociative symptoms unlike PTSD - e.g. detatchment/ derealisation
Avoidance of triggers e.g. people/ conversations
Flashbacks
Reaction <48hrs, Disorder >48hrs (DSM IV) <1 month
More stressful event that adjustment
68
Adjustment disorder symptoms
```
Depression symptoms
Loss of interest
Feelings of hopelessness and crying
Not an anxiety disorder
Difficulty coping with life event
```
May get avoidence of fam/friends or anxiety too
69
Describe obsessions and compulsions
Obsessions = Unwanted intrusive thoughts, images or urges that repeatedly enter the mind. Cause distress. Inidiviual tries to resist them and knows them as absurd (egodystonic) and a product of their own mind.
Compulsion: Repetitive, sterotyped behaviours or mental acts that a person feels driven into performing. Overt or Covert. Gives some relief to anxiety. Exacerbates obsession (operant conditioning)
70
Epidemiology of OCD
M=F
Early adulthood
Fx
Abuse in childhood
71
Investigations into OCDx
Questionnaires
72
DDX OCD
```
O & C:
Anorexia, Bulimia, body dysmorphia
Anankastic PD
O:
Anxiety disorder, depressive disorder, hypochondriacal disorder, schizophrenia
C:
Tourette's
Kleptomania (stealing things)
Organic:
Dementia
Epilepsy
Head injury
```
73
Treatment of OCD
xCBT in the form of ERP (exposure and response prevention)
SSRIs (can add cloripramine or an antipsychotic)
Psychoeducation, self help material, distracting techniques
74
Describe Wernike's and Korsakoffs psychosis
```
Caused by a thiamine deficiency (B1)
Wernike's encephalopathy:
Ataxia
Ophthalamoplegia
Nystagmus
Delerium
Hypothermia
Korsakoff psychosis:
Short term memory loss
Confabulation (making up things to explain current events)
DIsorientation to time
```
75
Define delerium
An acute, organically caused impairment of the CNS causing decreased cognition and attention
76
Presentation of conduct disorder
```
Sleep problems.
Feeding problems - faddiness (fussy)
Behaviour problems:
Uncooperative
Temper tantrums
Aggressive, defiant, wilful.
```
Conduct disorder is different to oppositional defiance disorder as it is more severe and more common in children beyond 10 years old.
Socialised and unsocialised types. (socialised tends to be phasic- only wiht friends). Unsocialised tends to lead to antisocial PD
Commonly have comorbid mental health problems
core conduct disorders symptoms including:
patterns of negativistic, hostile, or defiant behaviour in children aged under
11 years
aggression to people and animals, destruction of property, deceitfulness or theft
and serious violations of rules in children aged over 11 years.
Associated with poor education performance, social isolation, substance misuse.
77
Management of conduct disorders
Parenting programmes
Systemic therapy
Agency imput
Psychoeducation and support
78
Describe common emotional disorders in child psych
```
GAD
Separation anxiety disorder
Phobic dis
OCD
PTSD
Depressive disorders
Conduct disorder is the most common psych presentation
```
79
Presentation of GAD in children
Anxiety
Fears of death of themselves or others
Somatic manidestations - Nausea, abdopain, sickness, headaches, sweating, palpitations, tension
Panic attacks - sudden, extreme fear, physical symptoms, faintness
80
Presentation of separation anxiety
Fear of or anxity with separation from attachment figure
Somatic manifestation
Nightmares
School refusal.
81
Management of anxiety disorders in children
Behaviour - systemic desensitisation, flooding (expose to painful memory (fast systematic densensitization), response prevention
Psychotherapy - brief dynamic, family and cognitive therapy
Anxiolytics (last resort include beta blockers and diaepam)
82
Management for Depression in children
CBT, Fluoxitine
83
Define a dissociative disorder and list types
A group of symptoms which cannot be explained by a medical disorder associated with stressful events.
Include
Dissociative...
..amnesia (of stressful events)
..Fugue (unplanned travel, good self care)
... depersonalisation
... motor disorder (conversion disorder classified as dissociative in ICD10 and all below)
... stupor
... convulsions
... Anaesthesia and sensory loss
Trance and possession disorder
84
List some somatoform disorders
Diff from dissociative as normally chronic pain, more specific complaint of higher neurological function not "pain"
Somatotization disorder (Briquet's syndrome)- multiple, recurrent and frequently changing physical symptoms not explained by illness. GI, CVS, GU, skin, muscles, headache.
Somatoform autonomic disorder. Autonomic symtoms only - patients attribute to illness e.g. palp, tremor, hypervent, flush, dry mouth, IBS.
Hypochondriacial (body dysmorphic disorder) - misinterprets normal body sensations - non delusional preoccupation that they have a serious physical disease e.g. cancer. BDD = with small defects in physical appearence.
Persistant somatoform pain disorder
85
List epidemiology of somatoform and dissociative
Female
Abuse
Psych history e.g. PTSD
86
General findings/ history in somatoform disorders
Use of analgesics
Long history of contact with services
Causes physcial distress due to preoccupation with symptoms.
Refusal by patients to accept reassurance.
87
Describe the management of medically unexplained symptoms
```
Bio:
SSRIs for mood disorder
Exercise
Psycho:
CBT
Coping skills
Social:
Family (if reinforcing sick role)
Stress relief - walks, meditation e.c.t.
```
88
Briefly explain psychosexual disorder presentation
sexual dysfunction, paraphilias and gender identity disorders
Dysfunction is a sexual problem characterized by decreased desire, arousal or orgasm and lack of enjoyment or satisfaction derived from sex
unusual or abnormal sexual behavior that does not follow the normal standards. e.g. fetishism, paedophillia, zoophillia, necrophillia
Gender identity disorders exhibit variation between one’s sense of sexual identity and the biological one
May be linked with guilty conscience, stress, anxiety, nervousness, worry, fear, depression, physical or emotional trauma, abuse, rape, religious values, relationship with partner.
89
Treatment of psychosexual disorder
Sex therapy, behaviour therapy, systemic therapy, psychodynamic therpay (both partners).
Androgen blockers (for paraphilias) and SSRIs
Groups e.g. sex addicts annonomous
Hormones and sex change surgery
90
What is a learning disability vs learning difficulty?
Learning disability = IQ
When the term "learning disorder" is used, it describes a group of disorders characterized by inadequate development of specific academic, language, and speech skills.[2] Types of learning disorders include reading (dyslexia), mathematics (dyscalculia) and writing (dysgraphia).
91
What causes a learning disability?
Insult to the brain
92
Describe Fragile X syndrome
```
X linked dominant
Distinctive face - long and narrow
Learning disability
20-30% autism
Hyperactvity/ ADD - behavioural
Risk of other diseases
```
93
Link between Downs and psych
20-30% autism
25-30years dementia (at 60 35% have dementia)
LD
94
Classifications of LDs
Mild IQ 49-69 (mental age 8-12)
Moderate IQ 30-49 (mental 4-8)
Severe mental age
95
Co morbidities with LD
```
20-30 ADHD
30 epilepsy
30-40 behavioural disorders = oppositional defient disorder and conduct disorder
20-30 mobility problems
Sensory impairment
3x risk of schio (3%)
Depression due to adversity
Phobias
Abuse
Metabolic syndrome
```
96
Describe the 4 principles of ethics and law
Non malefice
Benefice
Justice (fair as possible e.g. allocation of resources)
Autonomy
97
Psychosis vs autism vs OCD
OCD - compulsions/ obsessions are egodystonic (dont want them) and they realsie they are from their own head.
Autism - Obsessions/ compulsions are enjoyable
Psychosis - No insight
98
Symptoms of asperger's
Hypersensitive possible to sound, light and other stumuli
Higher functioning autism.
Out of the ABC only A and B present and no impairment in cognition or intelligence. or language development
Asocial/ no emotional reciprical
Behaviour - repetitive and so are interests and activities
99
Epidemiology of autism
```
Male
Genetics
Parental age
Fx psych
Premature
Valporate
```
100
Define intellectual disability
Intellectual disability means a significantly reduced ability to understand new or complex information and to learn and apply new skills (impaired intelligence). This results in a reduced ability to cope independently (impaired social functioning), and begins before adulthood, with a lasting effect on development.
101
Clinical presentation of autism
Present in early childhood (normally <3)
Asocial/ no emotional reciprical
Behaviour - repetitve and so are interests and activities
Cognition (language and intelligence) impaired
102
Describe Rett's syndrome
```
Severe, progressive
Language impairment.
Repetitive hand movements.
Loss of motor skill
Irregular breathing.
Seizures
Girls only (boys due after birth)
Genetics
Scoliosis
Femnales can live to 40 years
```
103
Describe Heller's syndrome (Childhood disintegrative disorder.
2 years of normal developments
Loss of previously learned skills (lang, social and motor)
Repetitive, sterotyped interests and behaviours and cognitive deterioration.
104
Management of autism
Bio
Melatonin for sleep
No pharmacology
Antipsychotics when psychosocial interventions are insufficient
Psycho
CBT if possible and engagment
Daily life skills, coping strategies, and enabling access to education and community facilities
Social
Local autism teams with key worker
All physical mental and behavioural issues addressed
Social and emotional support
Self help - NAS
Special schooling
Social-communication intervention e..g play based
For behaviour:
Modify environment things that create/ maintain behaviour
105
Describe management of LDs
MDT approach - psychiatrist, speech and lang, specialist nurse, psychologist, OT, social worker, teachers
Physical health followed up by GP
Antipsychotics for challenging behaviour
Behavioural techniques e.g. positive behaviour support and CBT
Family education- programmes and organisations
Prevention via genetic counselling and antenatal diagnosis.
106
Presentation of hyperkinetic disorder
Inattention
Hyperactivity
Impulsitity
Early onset before 7, persisent (>6 months), present in more than one situation(home and school or nursery), IQ above 50
107
Management of hyperkinetic disorder
Bio
If severe then give methylphenidate (ritalin)
Atomoxetine second line.
Monitor side effects:
CNS - headache, insomina, loss of appetite, weight loss.
Psycho
Psychoeducation and CBT, social skills training
Social
Food diary - may be linked
Support for parent and teahers including groups.
Parent training and eductation
108
Side effects SSRIs
```
Mania in bipolar
N/V
Constipation/ diorrhea
Suicide (motivation)
Sleep disturbance
Dyspepsia
Weight loss
```
```
STRESS:
Sweating
Tremor
Rash
Extrapyradimal side effects (uncommon)
Sexual dysfunction
Somnolence
Discontinuation syndrome
```
Serotonin syndrome
109
Contraindications SSRIs
Warfarin, heparin, NSAIDs, NAC
```
Epilepsy
Cardiac disease
Glaucoma
DM
Bleeding
```
110
What is serotonin syndrome
Within minutes of taking medication (SSRIs, TCAs, Lithium)
Cognitive - headache, agitation, hypomania confusion, hallucinations, coma
Autonomic - shivering, sweating, hyperthermia, hypertension, tachycardia
Somatic - myoclonus, hyperreflexia, tremor
111
Mirtazapine indications and side effects
Second like, good for weight gain and insomnia.
Postural hypotension
112
describe Trazodone use and side effects
Sedation!! (weight gain)
SARI - serotonin antagonist and reuptake inhibitor
Used in anxiety, dementia, with agitation and insomnia
113
TCA side effects/ contraindication
Cardiotoxicity -arrhythmias, postural hypotension, tachycardia, syncope
Convulsions
Anti cholinergic
Weight gain
Cardiotoxicity -arrhythmias, postural hypotension, tachycardia, syncope
Convulsions
Anti cholinergic
Weight gain
INhibit reuptake of adrenalin and serotonin - affinity fr cholinergic receptors
114
Side effects of MAOIs
CVS - arrythmias
Drowsi/ insomnia
Weight gain
Seual dysfunction
LFTs
Tyramine rich foods such as chees, herring, liver, marmite can cause a hypertensive crisis
Headache, palpitations, fever, convulsions, coma
115
Name typical antipsychotics
Haloperidol
Chlorpromazine
Flupentixol
Sulpiride
116
When should clozapine be prescribed?
Failure to respond to two other antipsychotics (treatment resistant schizophrenia)
117
MoA of antipsychotics
Blocking dopamine receptorsl
| Atypicals have speciic dopaminergic properties (less nigostriatal. Atypicals also have serotonergic effects n
118
Side effects of antipsychotics and explainatios
Antidopaminergic - nigostriatal:
- EPSE
- Bradykinesia
- Hypertonia/ cogwheel rigidity
- Tardive dyskinesia (years)
- Tremor
- Akathisia (restlessness)
- Dystonia - spasms of neck jaw and eyes
Antidopaminergic - tuberoinfundibular
- Osteoporosis
- Gyneaocomastia
- Lactation
- Amennorhea/ menstrual disturbance
- Sexual dysfunction
Antimuscurinic
- cant see, cant wee, cant spit, cant shit
Serotinergic
- Glucose intolerance/ hyperglycaemia?
- N/V
Antihistaminergic:
- Sedation
- Weight gain
Anit-adrenergic
- Postural hypotension
- Tachycardia
- Ejaculation failure
Haloperidol - Prolonged QT
Clozapine- Agranulocytosis and hypersalivation
```
Atypicals = anticholin/ metab
Typical = EPSE and hyperprolactinaemia
```
Neuroleptic malignant syndrome
Metabolic syndrome, diabetes and stroke more likely in atypical.
CIs also include epilepsy (lower seizure threshold)
119
Describe a NARI and side effets
Reboxetine
| CAnt see, cant wee, cant shit cant spit.
120
Describe neuroleptic malignant syndrome
```
Dopamine causes so also levodopa.
Within 10 days of taking antipsychotics
Rigidity, hyperthermia, delerium, convulsions, confusion, autonomic instabolity.
CK, FBCs, LFTs
Stop anti and supportive
C: Renal failure, shock, PE.`
```
121
Antipsychotics that need glucose monitoring?
Clozapine and Olanzapine
122
Baseline investigations for antipsychotics
```
ECG
LFTs
FBCs, Us and Es
Glucose (some)
CK (incase of neurepileptic)
Full physical
Weight
BP
Blood lipids
```
123
Which antipsychotics can be given via depot?
Flupentixol, haloperidol, risperidone, olanzapine and aripiprazole
Chlorpromazine
124
Describe clinical presentation of dementia
Hyperactive, hypoactive or mixed.
Global disturbance in cognition
Impairment of consciousness and attention
Psychomotor disturbance
Emotional disturbance
Disordered sleep/ waking - hypervigilant in night, drowsiness in day
Other symptoms include visual hallucinations and fleeting delusions.
125
Describe the management of delerium
Bio:
Treat underlying cause
Antipsychotics if challenging behaviour
Psycho:
Reassurance and de-escalation techniques e.g. re directing
Social:
Move to quiet well lit room
126
Explain a capacity assessment
Understand
Retain
Weigh up positives and negatives
Communicate decision
127
Describe clinical features of dementia (ICD10) and Alz
```
Bio:
Acetylcholinesterase inhibitors e.g. Galantamine, donepezil, rivastigmine
Memantine
SSRI/ antipsychotic for dep/behaviour
Modifiable RFs for vasc dementia
```
Psycho:
Education
Alternative therapies - music, aromatherapy, animal association
Support:
Groups - alzheimers society
Home support - OT
Future planing e.g. Lasting power of attourney and advanced directives
128
Describe clinical features of vascular dementia
Decreases in stepwise fashion
CVS risk factor/ conditions often present
Emotional and personality changes earlier
Neuro signs/ symptoms as focal
129
Describe clinical presentation of dementia with Lewi Bodies
```
Daily fluctuations
EPSE
Visual hallucinations
Falls, syncope, depression
Protein buildup in neurones
After 50
Life expectancy 8 years
Cognitive function first unlike altzheimers which is memory first
```
130
How to differentiate between Dementia and depression
Which came first
| Depression can cause memory loss
131
Management of Alz
Bio:
Acetylcholinesterase inhibitors early/mide.g. Galantamine, donepezil, rivastigmine
Non competitive antagonism at NMDA e.g. Memantine - late
SSRI/ antipsychotic for dep/behaviour
Modifiable RFs for vasc dementia
Psycho:
Education
Alternative therapies - music, aromatherapy, animal association
Support:
Groups - alzheimers society
Home support - OT
Future planing e.g. Lasting power of attourney and advanced directives
132
CIs and side effects of acetylcholinesterase inhibitors
Arrythmias (brady), myoclonus, EPSE,
| CI: arrythmias, Peptic ulcer asthma
133
Describe types of memory
Short term
Long term:
- Proceedural/ implicit (knowing how to do things)
- Declarative (explicit
- Semantic (knowing things about the world)
- Episodic (remembering specific events)
134
Describe Memantine use and moa
NMDA receptor antagonist *glutamate and glycine)
135
Memantine side effects
• Hypertension, dyspnoea, headache, dizziness, drowsiness
136
Best therapies for EUPD
Dialectical behaviour therapy - coping and control, change pattern of behaviour
Group therapy
137
What is the difference between asperger's syndrome and autism?
No impairment in language, cognition and normal IQ
138
Difference between mood disorder and normal mood?
Impairment in activities of daily living
139
Core symptoms of depression
Anhedonia
Low mood persistant (2 weeks)
lack of energy (anergia)
140
pathophysiology of altz
Cholinergic hypothesis - reduction in acetylcholine due to the degeneration of cholinergic neurones
Tau hypothesis - phosphorylation of tau proteins cause neurofibrillary tangles
Amyloid hypothesis - formation of extracellular β amyloid plaques
141
Define dementia
Dementia in general is a global impairment of cognitive function and personality without impairment of consciousness. Early onset is classified if the symptoms start before the age of 65. Younger patients have an MRI to rule out another cause for their dementia symptoms such as a tumour.
142
Dementia symptoms
• Memory impairment -recent memory is first affected, but as the disease progresses all memories can be affected.
• Loss of language (aphasia) -both receptive (difficulty understanding commands)and expressive (vague speech) may occur
o Echolalia (repeating heard words), palilalia (repeating their own words) or muteness may occur.
• Apraxia - Lose the ability to carry out skilled motor movements
• Agnosia - Lose ability to recognize previously familiar objects
• Impairment of executive function - Difficulty planning complex activities
• Personality and behavioural changes - May become introverted and socially withdrawn or hostile, irritable and socially disinhibited
• Psychiatric symptoms
o Hallucinations - visual are the most common
o Delusions -mainly persecutory
o Depression and anxiety
• Neurological symptoms – Seizures, Myoclonic jerks
143
Pathophysiology of LBD
Abnormally phosphorylated proteins aggregated with ubiquitin and α-synuclein
144
Investigation into Lewy body dementia
DAT scan – measures radioactively labelled dopamine which is diminished in LBD
145
Treatment of Lewy Body dementia
Cognition treated with acetyl cholinesterase inhibitors and NMDA receptor antagonists (same as Alzheimer's Disease)
Motor symptoms treated with dopamine agonists (same as Parkinson's disease) E.g. Levodopa
146
WHhat is frontotemporal dementia? diagnosis and treatment
o Presentation:
Decline in social and personal conduct disinhibition, personality change
Emotional blunting
Echolalia, mutism
Lack of insight but sparing of other cognitive functions
o Unknown cause
o Investigation findings
Bilateral atrophy of the frontal and anterior temporal lobes on CT scan
o Treatment
Disinhibition - SSRI’s and in extreme cases with anti-psychotics (short term)
147
Symptoms of normal pressure hydrocephalus?
o Triad of urinary incontinence, bradykinesia and memory loss
148
What is a dementia blood screen involve?
Neurodegenerative (Parkinson’s disease, Huntington’s disease), Space occupying lesion, Trauma, Infection (CJD, HIV, Neuro-syphilis, Viral encephalitis, Meningitis), Metabolic and endocrine, (Chronic uraemia, Liver failure, Wilsons disease, Hypo and hyperthyroidism, Hypo and hyperparathyroidism, Cushing’s and Addison’s), Nutrition (Thiamine, vitamin B12, folic acid deficiency), Drugs (Alcohol, Benzodiazepine, Barbiturates, Solvents), Inflammatory disorders (Multiple sclerosis, SLE)
These should be excluded before a diagnosis of dementia is made though a dementia blood screen (FBC, U+E, LFT, Glucose, Thyroid function, Vit B12, Folate, Syphilis serology)
149
WHat is mild cognitive impairment?
* There is increasing emphasis on early detection and treatment of dementia- neuropsychological impairments can detectable up to 20 years before the onset of symptoms.
* Functional brain imaging can precede symptoms by several years.
* Dementia often begins with focal cognitive deficits - initially be too mild to fulfil a diagnosis of dementia, therefore called Mild Cognitive Impairment.
* Cognitive changes can be noticed by the individuals experiencing them or to other people, but are not severe enough to interfere with daily life or independent function.
* 10-15% of people suffering with MCI develop dementia
150
Diagnosis of alzheimers
CT -generalized atrophy - frontal and temporal lobes, widened sulci and enlarged ventricles.
151
Diagnosis of vascular dementia
CT with contrast shows small vessel disease with multiple infarcted areas
152
Cognitive symptoms of depression
```
Lack of motivation
Negative thoughts
Excessive guilt
Suicidal ideation
hypochondriacal thoughts
poor conc/ attendance
```
153
Biological symptoms of depression
Psychomotor retardation/ agitation
Weight loss
appetite loss
Loss of libido
Early morning waking
(Diurnal variation in mood (usually morning is worse) - not in other)
(may get hallucinations and delusions too)
154
Stages of depression
Mild = 2 core + 2 other
Mod = 2 core +3-4
Sev = 3 core and >4 other
Sev with psychosis = sev + psychosis
155
Describe cyclothymia
Chronic mood fluctuations over 2 years with elation and depression insufficient to met bipolar
156
Most common presentation of baby blues
primiparae
- reassure and support
3-7 days following birth
Anxious, tearful, irritable
157
What is perseveration
x
158
What is perseveration
Uncontrollable and inappropriate repetition of a particular response, word, phrase or gesture
159
Aetiology/ RFs of bipolar
```
Stressful life events
Genetic
19 years is average age of onset
Higher in minorites
Anxiety, depression
Substance misus
```
160
Difference between hypomania and mania and symptoms
Mildly elevated or iritable mood present for >4 days. No severe disruption. Partial insight
Mania: Symptoms >1 week, complete disruption of work, grandiose, sexual disinhibition, exhaustion
Also mania with psychosis
o Reckless behaviour
o Psychotic symptoms
o Impaired judgement -sexual indiscretion, overspending
o Psychomotor agitation - risk of self-injury, dehydration
o Thoughts of self harming self or others
161
What is rapid cycling?
More than 4 mood swings in a 12 month eriod with no asymptomatic periods, poor prognosis
162
Treatment for bipolar
Bio: Antipsychotic (rapid onset, stop after 4 weeks for lithium), mood stabaliser (lamotrigene or lithium- lam in depress, lith inbetween and in mania).
Can add other stabalisers or atypicals if lithium does not work.
Psycho: psychoeducation, CBT
Social: Groups, self help, calming activities
163
Tests before starting lithium
TFTs, pregnancy, Us Es, ECG (arrythmia e.g. SCD/ Brugarda)
164
Side effects of lithium
polydipsia, polyuria, tremor, weight gain, oedema, hypothyroid, memory. tetatorogenic. Dehydration
Toxicity: N/V, coarse tremor, ataxia, muscle weakness, apathy, nystag, dysarthria, hyperreflexia, oligouria, hypotensio, convulsions, coma
165
Describe monitoring of lithium
12 hours first dose, weekly until .5-1mmol/L. Stable 4 weeks. Check every 3. UE every 6, tft every 12
166
Treatment of cyclothymia
Lithium and sodium valporate
167
Describe why DOLS might be used instead of a section
x
168
alcohol withdrawal timeline
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
hysical effects may include shaking, shivering, irregular heart rate, and sweating.[1] People may also see or hear things other people do not.[2] Occasionally, a very high body temperature or seizures may result in death
169
SSRI post MI
Sertraline
170
What is a community treatment order
* Patient on Section 3
* Patient is well enough to leave hospital but may default from treatment/ follow-up
* Treatment is necessary for patients health/ safety/ protection of others
* Patient can be recalled to hospital if they don’t comply with treatment/ attend appointments
171
Who needs to be present to do a section 2/3
xAMHP - Approved medical health proffessional (not doctor) or NR (nearest relative)
AC: Section 12 approved clinician
Another doctor
172
What is an IMCA
Independent mental capacity advocate, appointed to peak on behalf if there is no next of kin or lasting power of attourney)
173
What is a section 5.4
Power granted to registered mental nurse to detain a patient for up to 6 hours for medical assessment where mental illness is suspected
174
What is a section 5.2
Responsible clinician (or nominated deputy) can detain a patient for up to 72h under MHA (no appeal)
175
What is a section 2
2 Doctors (1 section 12.2 approved), 1 approved mental health practitioner (AMHP). Section for maximum 28 days for assessment (+ treatment) of a mental disorder. Appeal within 14 days, heard usually within 7 days by tribunal.
176
What is a section 3
. 2 Doctors (1 section 12.2 approved), 1 AMHP. Section for max 6 months for treatment of mental disorder
177
What is section 136 (135)
Police power to remove to a place of safety from a public place for an assessment. Held for 72 hours. (private = 135)
178
what is section 17
A provision for leave whilst detained in hospital under Section 2 or 3.
179
What is section 117
Anyone who has been on Section 3 is entitled to Section 117 aftercare (funding to support them in the future)
180
Why do you get sedation and increased appetite with mirtazapine?
Histamine
181
Tardive dyskinesia more commonly affects hands or feet?
nvoluntary, repetitive body movements e.g. slow writhing movements
hands
182
Drugs excreted in breast milk?
Mood stabalisers, antipsychotics, benzos
183
Anti-adrenergic side effects of antipsychotics
postural hypo, tachycardia, ejaculatory failure
184
How long does it take for SSRIs to work?
2-3 days but not noticed until 2-6 weeks
185
Name TCAs
amitryptilline, lofepramine, doxepin, dosulepin, clomipramine
186
4 groups of symptoms in PTSD
Avoidance
Re living - nightmares and flashbacks
Hyperarousal - hypervigilance, insomnia, startle
Emotional blunting
187
Withdrawral symptoms of opiates
```
Pilarerection
Lacrimation
Rhinnorrhea
N/V
Diarrhoea
Myalgia
Cramps
Increased HR and BP
```
188
withrawal symptoms of cannabis use
```
Tremor when outstreched
Myalgia
Anxiety
Irritability
Sweating
```
189
Withdrawal symptoms of sedatives/ hypnotics
```
Agitation
Grand mal convulsions
Tremor
Low BP (postural)
Increased HR
Paranoid
Hallucinations
```
190
What can be used in Bio treatment opiod dependence
Bupramorphine or methadone (partial) for detox and maintainance.
Naltrexone (antagonist) after (Naloxone is for OD) to prevent relapse
191
Symptoms of alcohol withdrawal
```
Irritation
Agitation
Seizure
Coma
Death
Tremor
Nausea
Insomina
Autonomic overactity
transient hallucinations
6-12 hours after abstinence
COg impairment
Paranoid delusions
Sweating
```
192
What is a binge and recommended limits
>8 uits men or 6 female (twice daily allowance
| 14 units per week (Jan 16)
193
Treatment for delirium tremens
```
Chlordiazepoxide
Haloperidol for any psychotic features
IV Pabrinex (vitamins)
```
194
Long term treatment for alcohol dependence
Disulfram (mod or severe)
Naltrexone or
Acamprosate - reduces GABA transmission (craving)
Psycho: MI, CBT
SOcial: AA
195
types of delusion seen in severe depression with psychosis
Nihilistic (worthless/ everything is non-existent), Guilt, hypochondriacal
196
What is Capgras' syndrome
A familiar person or place has been replaced with an exact duplicate
197
What are schindler's first rank symptoms
Hallucination
Delusion
Passivity phenomoenon
THought intertherence
198
Describe presentation of frontotemporal dementia
```
50-60
FX in 50%
Early personality chnages e.g. disinhibition, apathy, restlessness
Worsening of social behaviour
Repetitive behaviour
Language problems
Memory is preserved
```
199
What is dysthymia
Persistent mild depression for at least 2 years which is not depression or the reslult of partially treated depression
200
Define neurosis
Group of psychiatric disorders characterised by distress, non-organic, discrete onset, psychosis absent
201
What is transferance
unconscious redirection of a patient's feelings for a significant person to the therapist
202
What is paraphrenia?
araphrenia is a mental disorder characterized by an organized system of paranoid delusions with or without hallucinations (the positive symptoms of schizophrenia) without deterioration of intellect or personality
203
What is an encapsulated delusion?
a delusion that usually relates to one specific topic or belief but does not pervade a person's life or level of functioning
