Psych Flashcards
Risk factors/ aetiology for Anorexia nervosa
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
Clinically defining features of Anorexia nervosa as defined by ICD10 and other features
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
Thought in MSE of Anorexia nervosa
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).
Complications of Anorexia nervosa
Osteoporosis (DEXa), Proximal myopathy (upper and lower limbs)
Arrhythmias e.g. brady, Prolonged QT, changed caused by hypokalemia.
Hypoglycaemia, Hypercholesterolaemia, Hypothyroidism (TFTs)
Hepatitis/ LFTs Pancreatitis (amylase) Renal failure/ stones Enlarged salivary glands Constipation Peptic ulcers
Anaemia (iron), thrombocytopenia, leucopenia
Dry slin, brittle nairs, infections, suicide
Management of anorexia
Risk assessment for suicide and medical comps.
CBT, psychotherapy, DBT, mindfulness, groups, meal plannning, psychoeducation, interpersonal psychotherapy, family therapy
Treat medical complications. SSRIS for dep or OCD.
Volunatary organisations or Self-help groups.
Graded exposure to food.
Gain 0.5-1kg per week as inpatient and .5kg as outpatient
Risks of gaining weight in 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
How to prevent refeeding syndrome
Dailey bloods, start at 1200cals and gradually increase every 5 days, monitor for tacchycardia and oedema.
If low then oral or IV electrolyte replacement
When to hospitalise Anorexia nervosa
BMI
Define Bulimia nervosa
Repeated episodes of binge eating followed by compensatory weight loss behaviours with overvalued ideas regarding ideal body shape/ weight
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.
Common psychiatric diseases with BN
Depression Anxiety DSH Substance misuse Emotionally unstable personality disorder
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 -
Subtypes of BN (not ICD10)
Purging and non purging (drugs/ vomiting vs diet and exercise)
Signs of BN
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
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.
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
Out of interest, improvement in eating disorders?
50% full recovery in BN
20% in AN.
Describe the cluster C personality disorders
Dependent: Seeks companionship Low self confidence Difficulty expressing disagreement Reassurance requred Needs other to assume responsibility
Anxious/avoidant: Approval needed before getting involved Social inhibition Embarrasment potential inhibits involvement in activites Restriction in life to maintain security Inadequacy felt
Anankastic: Perfectionism Loses purpose of tasks and focuses on detail Workaholic at expense of lesure Subborn Inflexible Fussy Rigid
Define Personality disorder
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
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
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 Mind and brain: Lightheaded/ Dizzy Fear of dying/ losing control Derealisation and depersonalisation General symptoms: 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 Non specific: Startled Poor concentration Sleep problems Irritability Mind blacks
Risk factors for panic disorders
Bio: Asthma, Benzo withdrawal, age 20-30, , female, white, cigarette smoking,
Psycho:adverse life event
Social: Fx
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.
What is stupor
Inability to respond to internal (e.g. hunger) and external stimuli
What is catalepsy
State of the body which is in a trace with loss of sensation and consciousness and is rigid.
Pathophysiology of Schizo and drugs that could mimic this
Overactivity of D2 mesolimbic pathway - amphetamines, parkinsonism medications.
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
Term for low motivation
Avolition
Term for a quanitative and qualitative decrease in speech
Alogia or poverty in speech
Describe the negative symptoms of schizophrenia
Avolition Asocial behaviour Anhedonia Affect blunted Alogia Attention deficit
Describe the 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
How long should a seizure last in ECT?
30 seconds
Contraindications to ECT?
MI
Severe resp or CVS disease (anaesthetic)
Heart failure/ arrhythmia (hypertension)
History of status
Describe the sympathetic and parasympathetic activity after ECT
Transient parasympathetic followed by sympathetic resulting in raised BP hence contraindications
How many drugs are given during ECT?
2
A general anaesthetic (etomidate or propofol
A Muscle relaxant (suxamethonium)
How is ECT monitored
EEG. Pulse and BP both increase
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
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
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.
Describe the treatment of GAD
Bio: SSRI, SNRI, Pregabalin Psycho: Psychoeducation (low intensity) CBT and applied relaxation Social: Self help - writing things down and analysing, support groups, exercise
Treatment for phobias
CBT - graduated exposure (also homework)
Pharmacological interventions - SSRIs (not for specific).
Social phobia can benefit from psychodynamic therapy
Benzos for specific in emergency
3 differences between GAD and phobias and panic disorder
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
Organic DDX for panic disorder
Pheocromocytoma Hyperthyroidism Carcinoid syndrome (neuroendocrine tumours) Arrythmias Hypoglycaemia Alcohol/ substance withdrawral
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.
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.
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
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)
Epidemiology of OCD
M=F
Early adulthood
Fx
Abuse in childhood
Clinical features of OCD
Obsessions, compulsions or both most days for 2 weeks.
Cause distress or interfere with the patient’s social or indiviual functioning e.g. waste time.
Features of O/C:
Failure to resist (at least 1)
Originate from patient’s mind
Repetitive and distressing
Carryout reduces anxiety
Investigations into OCD
Questionnaires
DDX of 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
Treatment of OCD
CBT in the form of ERP (exposure and response prevention)
SSRIs (can add cloripramine or an antipsychotic)
Psychoeducation, self help material, distracting techniques
Describe Wernike’s and Kosakoffs 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
Define delerium
An acute, organically caused impairment of the CNS causing decreased cognition and attention
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.
Management of conduct disorders
Parenting programmes
Systemic therapy
Agency imput
Psychoeducation and support
Prevalence of conduct disorders
Most common child psychiatric issue
Describe common emotional disorders in child psych
GAD Separation anxiety disorder Phobic dis OCD PTSD Depressive disorders
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
Presentation of separation anxiety
Fear of or anxity with separation from attachment figure
Somatic manifestation
Nightmares
School refusal.
Management of anxiety disorders in children
Behaviour - systemic desensitisation, flooding, response prevention
Psychotherapy - brief dynamic, family and cognitive therapy
Anxiolytics (last respore include beta blockers and diaepam)
Management for Depression in children
CBT, Fluoxitine
Medacation for psychosis and severe resistant behavioural disturbance with LD
Risperidone
can use lithium in Bipolar but very rare
Define somatoform disorder
An illness with a group of symptoms that closely resembles physical illness however there is no underlying physiological explaination.
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 (journey, good self care) ... motor disorder ... stupor ... convulsions ... Anaesthesia and sensory loss Trance and possession disorder
List some somatoform disorders
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
List epidemiology of somatoform and dissociative
Female
Abuse
Psych history e.g. PTSD
General findings 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.
