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Psych Flashcards

1
Q

List the headings of the MSE

A 
Appearance and Behaviour 
Speech 
Affect/Mood
Thought 
Perception 
Cognition 
Insight
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2
Q

How do you assess capacity?

A
  1. Understand the information
  2. Retain the information
  3. Weight up the pros and cons of the decision
  4. Communicate the decision back
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3
Q

What is a Section 5(4)?

A

A authorised mental health nurse can detain a ‘psych’ patient who is trying to leave hospital against advice and is likely to cause harm for up to 6 hours. During this 6 hours the nurse must find someone do do a section 5(2) or the patient can leave.

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4
Q

What is a Section 5(2)?

A

A doctor can detain a hospitalised patient for up to 72 hours, if they suspect they have a mental health problem and they or others are at risk. In this 72 hours a plan for the patient should be created with a psychiatrist.
Note - A&E is NOT a ward, so you cannot place someone under a 5(2) who is in A&E.

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5
Q

What is a Section 2?

A

Admission for assessment (and treatment) for up to 28 days.
AMHP makes the application on recommendation from 2 doctors. 1 of which must be ‘section 12 approved’ e.g. consultant or reg.
Patients can appeal within 14 days

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6
Q

What is a Section 3?

A

Admission for treatment for up to 6 months.
The exact mental disorder must be stated and treatment must be available and specified.
2 doctors must sign the form and have seen the patient within 24 hours.
Detention is renewable after 6 months (then yearly)

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7
Q

What is a Section 4?

A

Emergency admission for up to 72 hours.
Used when a section 2 may take too long.
A AMHP or relative (rare) makes the application after recommendation by a doctor (usually GP).
The patient must be seen by a second doctor within 72 hours - then be put on a section 2 or 3 or discharged or they may choose to remain as a voluntary patient.

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8
Q

What is a Section 136?

A

Allows the police to arrest a person from a PUBLIC PLACE who they believe to have a mental health problem and take them to a place of safety.
A person can be held for a maximum of 72 hours.

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9
Q

What is a Section 135?

A

Allows the police to force entry into someones home to allow a MHA to be made.
A warrant is required.

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10
Q

What is a Section 17?

A

The allowance of a sectioned patient to leave the hospital.

To spent time with family or trial a return to the community.

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11
Q

What is a Section 117?

A

Provision of after-care for patients who have been detained for a long period of time.
Patient cannot be discharged until this is done.

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12
Q

What is a community treatment order?

A

Patient on section 3 and well enough to leave hospital but requires ongoing treatment.
The patient can be recalled to hospital if they do not comply with treatment and appointments.

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13
Q

What is a hallucination?

A

A perception in the absence of an external stimulus that has the qualities of a real perception

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14
Q

What is psychosis?

A

A state of impaired reality made up of hallucinations and delusions.

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15
Q

What is an illusion?

A

An involuntary misinterpretation of a real stimulus transformed or distorted.
Often bought on my tiredness or emotion.

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16
Q

What is a pseudohallucination?

A

A hallucination that the patient knows is NOT real

e.g. a voice heard within themselves

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17
Q

What is a hypnagogic hallucination?

A

Hallucination as you are falling asleep

Non-pathogenic

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18
Q

What is a hypnopompic hallucination?

A

A hallucination as you are waking up

Non-pathogenic

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19
Q

What are 1st person auditory hallucinations?

A

Audible thoughts - thoughts spoken aloud

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20
Q

What are 2nd person auditory hallucinations?

A

Voices talking directly to the patient, can be persecutory, highly critical or complimentary.
Associated with mood disorders

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21
Q

What are 3rd person auditory hallucinations?

A

Voices heard speaking about the patient, arguing or giving a running commentary.

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22
Q

What is it called when 1st person auditory hallucinations happen as thoughts occur?

A

Gedankelautwerden

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23
Q

What is it called when 1st person auditory hallucinations happen just after the thought occurred?

A

Écho de la pensée

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24
Q

What are some organic causes of visual hallucinations?

A

Delirium, occipital lobe tumours, epilepsy, dementia, drugs (e.g. LSD, alcohol, glue sniffing)

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25
Q

What is Charles Bonnet syndrome?

A

loss of sight –> hallucinations

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26
Q

How do most hallucinations start?

A

Simple brief experiences in one modality

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27
Q

What are some negative symptoms of psychosis

A 
Apathy 
Poverty of thought and speech 
Blunting of affect 
Social isolation 
Poor self care
Cognitive deficit
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28
Q

What is an overvalued idea?

A

A plausible idea that patients become preoccupied with and causes them distress

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29
Q

What is an extracampine hallucination?

A

A hallucination outside normal sensory limits

e.g. hearing something 100s of miles away

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30
Q

What is a delusion?

A

A belief that is strongly held despite evidence to the contrary and that is out of keeping with a persons educational or cultural background

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31
Q

What is a mood congruent delusion?

A

Seen is affective psychosis
Depressed person –> nilhilistic delusion
Manic person –> grandiose delusion

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32
Q

What is a primary delusion?

A

A delusion that occurs suddenly without an abnormal event leading up to it

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33
Q

What is a mood incongruent delusion?

A

Often seen in schizophrenia

Horrific beliefs discussed without commensurate distress

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34
Q

What is a secondary delusion?

A

Arises from some previous abnormal idea or experience

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35
Q

What are three characteristics of a delusion?

A

Incorrect - because of faulty reasoning
Incorrigibility - not changeable by compelling counterargument
Incompatible - with patients social, cultural or religious background

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36
Q

What is a persecutory delusion?

A

Being harmed, threatened, cheated, harassed

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37
Q

What is a grandiose delusion?

A

Exceptionally powerful, talented, important

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38
Q

What is a delusion of reference?

A

Certain object, people or events have significance to oneself
e.g. TV presenter speaking directly to them

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39
Q

What is a religious delusion?

A

Religious theme, often grandiose

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40
Q

What is a delusion of love?

A

Another (often of higher social status) is in love with them

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41
Q

What is a delusion of infidelity? and give and example

A

Lover has been unfaithful BUT with no evidence

Othello syndrome

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42
Q

What is capgras syndrome?

A

familiar person replaced with exact double

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43
Q

What is fregoli syndrome?

A

A single person is impersonating multiple familiar people

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44
Q

What is a nihilistic delusion?

A

Oneself, others or the world is about to end

E.g. you are rotting away

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45
Q

What is a somatic delusion?

A

Concern over one’s body and its functioning

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46
Q

What is a delusion of infestation? and whats is called

A

One is infested

Ekbom’s syndrome

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47
Q

What is the delusions of thought control? and what do they mean

A

Thought insertion - One’s thoughts are being implanted by an external agent
Thought withdrawal - thoughts are being extracted from one’s head
Thought broadcasting - thoughts are being broadcast to others

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48
Q

What is Jerusalem syndrome?

A

On visiting Jersualem a person develops religious delusions.
Can happen in people of all religions.

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49
Q

Give some examples of disordered thinking (formal thought disorder)

A 
Circumstantial and tangential thinking
Flight of ideas
Loosening of association 
Neologisms 
Thought blocking
Perservations
Logocolonia
Echolalia
Irrelevant answers
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50
Q

Define circumstantial thinking

A

An inability to answer a question without giving excessive, unnecessary detail. This differs from tangential thinking, in that the person does eventually return to the original point.

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51
Q

Define tangential thinking

A

Speaker never returns to the original point

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52
Q

Define flight of ideas

A

Thinking is accelerated causing a stream of connected concepts

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53
Q

Define loosening of association (derailment)

A

Patients train of thought shifts between unconnected ideas

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54
Q

Define neologisms

A

Use of new words created by the patient

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55
Q

Define thought blocking

A

Sudden stop to the patients flow of thought, often mid sentence

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56
Q

Define preservations

A

Patients repeat a word or phrase
Palilalia – repetition of the last word of their sentence
Logocolonia – repetition of the last syllable
Suggestive of organic brain disease

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57
Q

Define echolalia

A

Patient repeats words or phrases spoken around them

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58
Q

What is thought form?

A

Speed – accelerated / racing / retarded

Flow/ coherence:

Linear – in a logical order
Incoherent – makes no logical sense
Circumstantial – lots of irrelevant/unnecessary details (not to the point)
Tangential – the patient goes off on tangents relating loosely to the initial thought (flight of ideas)
Perseveration – repetition of a particular response despite the absence/removal of the stimulus

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59
Q

What is thought content?

A

Abnormal beliefs/ delusions

Obsessions – patient is aware they are irrational, but obsessive thoughts continue to enter their head

Overvalued ideas – e.g. the perception of weight in a patient with anorexia nervosa

Suicidal thoughts

Homicidal/violent thoughts

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60
Q

What is passivity phenomenon?

A

The belief that your actions, thoughts and impulses are controlled by someone else.
Incorporates thought broadcast, insertion and withdrawal.

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61
Q

What is Schizophrenia?

A

A chronic relapsing condition that often presents in early adulthood.
Characterised by positive symptoms (delusions and hallucinations) and negative symptoms (apathy, poverty of thought and speech, blunting of affect, social isolation, poor self care)
Affects more men than women

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62
Q

How long to symptoms have to last to be diagnosed with Schizophrenia?

A

At least 6 months

With symptoms present most of the time for 1 month

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63
Q

What are the criteria for diagnosing Schizophrenia?

A

At least 1 very clear symptom (1st rank)

Or at least 2 2nd rank symptoms

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64
Q

What are the first rank symptoms of Schizophrenia?

There are four

A

Thought disorder (insertion, broadcast or withdrawal)

Delusions that thoughts, feelings, impulses or actions are being influences or controlled by external forces.

Auditory hallucinations

Persistent delusions

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65
Q

What are the second rank symptoms of Schizophrenia?

A

Persistent hallucinations in any modality

Breaks or interpolations in the train of thought, flighting off in tangents, neologisms or odd logics

Catatonic behaviour

Negative symptoms

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66
Q

What are some negative symptoms of Schizophrenia?

A 
Apathy
Paucity of speech 
Blunting of affect 
Laughing at bad news 
Social withdrawal
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67
Q

What are prodromal symptoms of Schizophrenia?

A

Symptoms that precede the first episode of psychosis (months to days)
–> Gradual deterioration in functioning

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68
Q

What are some potential causes of Schizophrenia?

A

Genetic
Early cannabis consumption
Environmental (urban birth, pregnancy abnormalities, maternal influenza, migration)
Dopamine hypothesis (alterations in glutamate transmission –> Increased D2 transmission in Basal Ganglia + decreased D2 transmission in the Prefrontal Cortex)

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69
Q

What are precipitating and maintaining factors of Schizophrenia?

A

Precipitating Factors: Stress

Maintaining Factors: High expressed emotion

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70
Q

How is Schizophrenia managed?

A 
Start antipsychotics (2nd generation - first line)
Psychsocial intervention 
Support for families
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71
Q

How can you improve adherence to antipsychotics?

A

Depots

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72
Q

What is paranoid Schizophrenia?

A

Prominent hallucinations and/or delusions (often persecutory)

May develop at a later age than other types of schizophrenia.

Speech and emotions may be unaffected.

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73
Q

What is hebephrenic Schizophrenia?

A

Behaviour is disorganised and without purpose (Pranks, giggling, health complaints, grimacing).

Thoughts are disorganised, other people may find it difficult to understand you.

Delusions and hallucinations are fleeting.

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74
Q

What is catatonic Schizophrenia?

A

Unusual movements, often switching between extremes of over-activity and stillness.

You may not talk at all.

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75
Q

What is undifferentiated Schizophrenia?

A

Your illness meets the general criteria for a diagnosis and may have some characteristics of paranoid, hebephrenic or catatonic schizophrenia, but does not obviously fit one of these types.

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76
Q

What is residual Schizophrenia?

A

You may be diagnosed with this if you have a history of psychosis but only have negative symptoms.

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77
Q

What is simple Schizophrenia?

A

Rarely diagnosed in the UK.

Negative symptoms are prominent early and get worse quickly.

Positive symptoms are rare.

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78
Q

What is cenesthopathic Schizophrenia?

A

People experience unusual bodily sensations.

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79
Q

Why might someone with Schizophrenia be depressed?

A

Integral part of the disorder

Response to increasing insight

Side affect of meds

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80
Q

What is Schizoaffective disorder?

A

This involves both schizophrenic and mood (depressive or manic) symptoms. All symptoms should be severe enough to meet the ICD classification. It can be sub classed into manic type or depressed type.

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81
Q

What is delusional disorder?

A

Involves the development of a delusion for at least 3 months, where delusions are the only symptom. However, delusions of thought control, which is a first rank symptom of schizophrenia, aren’t normally present. The typical onset is later than schizophrenia, normally in middle age.

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82
Q

What is schizotypal disorder?

A

A personality disorder which may represent a partial expression of schizophrenia
Usually treated without meds

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83
Q

What is schizophreniform disorder?

A

Fail to meet threshold for Schizophrenia (usually duration of psychosis) but have symptoms of Schizophrenia and deterioration in function.
Do treat with meds

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84
Q

What organic conditions can cause Schizophrenia?

A

Cerebral neoplasm, infarct, infection, trauma, endocrine (thyroid, parathyroid, adrenal), epilepsy, SLE, Huntington’s, vitamin B12 and thiamine deficiency

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85
Q

What drugs can cause psychosis?

A

Alcohol, Amphetamine, Cocaine, Inhalants/solvents, Corticosteroids, Anticholinergics, Anti- Parkinson’s drugs

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86
Q

What other differentials are there for psychosis?

A

Manic episode with psychosis, Depressive episode with Psychosis, Delirium and dementia, Personality disorder

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87
Q

What classes of antipsychotics are there and give examples.

A

1st generation - Haloperidol, Chlorpromazine
2nd generation - Olanzapine, Risperidone, Clozapine, Quetiapine
3rd generation - Aripirazole

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88
Q

What is the mechanism of action of 1st generation antipsychotics?

A

Act as D2-antagonists in the CNS. They bind strongly to post synaptic receptors

Affect is via the MESOLIMBIC PATHWAY

Causes EPS

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89
Q

What is the mechanism of action of 2nd generation antipsychotics?

A

Act as D2-antagonists in the CNS and antagonise 5-HT, alpha-1 and muscarinic receptors

More metabolic side effects

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90
Q

How does Aripirazole work?

A

Stabilises the dopamine system

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91
Q

What are some ADRs of generation antipsychotics?

A

Excessive weight gain (especially Olanzapine),

Increased prolactin secretion (amenorrhoea, gynaecomastia, sexual dysfunction)

Extra-pyramidal side effects -
due to effect at NIGTOSTRIATAL PATHWAY (especially 1st generation)

Diabetes

Cardiac toxicity (long QT syndrome→↑ risk of Torsades de Pointes)

EPS refers to a cluster of symptoms consisting of akathisia, parkinsonism, dystonia and tardive dyskinesia

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92
Q

When are antipsychotics contraindicated?

A

Myasthenia gravis, Addison’s, glaucoma and bone marrow depression

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93
Q

How can you manage the parkinsonian side effects of antipsychotics?

A

Anticholinergics (e.g. procyclidine)

Plus decrease dose as much as you can

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94
Q

Describe Clozapine

A

Has a higher affinity for D4 receptors

Prolactin sparing, best at reducing negative symptoms

Only used for treatment resistant schizophrenia (failure of 2 medications, one of which should be an atypical antipsychotic over 6-8 weeks each)

Side effects (Agranulocytosis -requires regular haematological monitoring, Myocarditis) -
Monitor bloods weekly for 18 weeks then fortnightly
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95
Q

What should you check before starting antipsychotics?

A

BP, weight, fasting BMs, lipid profile and FBC

+ECG if starting clozapine

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96
Q

What should you monitor every 6 months if you are taking antipsychotics?

A

LFTs, U&Es, prolactin, weight, HbA1C

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97
Q

Why do 2nd generation antipsychotics cause postural hypotension?

A

Alpha-1 adrenoceptor blockade

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98
Q

What causes a mood disorder?

A

Monoamine hypothesis (Manic episode = increase in noradrenaline and serotonin, Depressive episode = decrease in noradrenaline and serotonin)

Predisposing- genetic factors (5HTT gene polymorphism), childhood experiences

Precipitating- life events, substance abuse, bereavement (Prolonged adversity, then a final acute stressor)

Perpetuating- relationships, finance, work, housing, support

Physical conditions e.g. influenza, childbirth, Parkinson’s

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99
Q

How do you treat a mood disorder?

A

Biological: Antidepressants: (SSRIs, SNRIs, TCAs, NASSAs, MAOIs), Mood Stabilisers (Lithium), Combination therapies, ECT

Psychological- psychoeducation (about illness, relapse, medication, supportive psychotherapy), CBT, interpersonal therapy,

Social- targeted interventions (family, housing, finance, employment

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100
Q

Who is depression more common in? Men or women

A

Women 2:1

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101
Q

What causes depression?

A

Psychological: (Interpreting facial expressions as negative; remember unhappy events more easily; unrealistic beliefs)

Social: Disruption to life events, stress

Biochemical: (Decreased 5-HT in CSF and brain, neuroendocrine function involving 5-HT reduced, tryptophan (5-HT precursor) depletion via diet, decreased NA)

Endocrine abnormalities: (cushings, addisons and hyperparathyroidism)

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102
Q

What are the core symptoms of depression?

A

Continuous low mood for at least 2 weeks, lack of energy, anhedonia (lack of enjoyment from anything)

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103
Q

List some depressive cognitions

A

Decreased self-esteem, guilt and self-blame, hopelessness, hypochondriacal thoughts, poor concentration/ attendance, suicidal thoughts

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104
Q

What are some somatic manifestations of depression?

A

Early morning wakening (patient lie pessimistic about the day), decreased appetite, weight loss, psychomotor agitation/ retardation (retarded depression or depressive stupor), loss of libido, can cause amenorrhoea

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105
Q

How is atypical depression characterised?

A

Reversal of somatic symptoms

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106
Q

What is the ICD10 classification of depression?

A

Mild= 2 core + 2 others (able to function)

Moderate= 2 core + 3+ others

Severe = 3 core + at least 4 others

With/without:

  • Somatic symptoms
  • Psychotic symptoms
  • Manic episodes

Only use in first episode - the define as recurrent depressive disorder

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107
Q

How do you treat the different types of depression?

A

Mild - reassess in 2 weeks, exercise, lifestyle changes, computerised CBT/self-help books

Moderate - CBT (first line) and/or antidepressant (SSRI)

Severe - Rapid MHA (may need admission), CBT, antidepressant and maybe ECT

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108
Q

What is Dysthymia?

A

The same cognitive and physical problems as depression but less severe and longer lasting

?Depressive PD

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109
Q

What is Cyclothymia?

A

Cyclical mood swings with sub-clinical features

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110
Q

Define mild depression following childbirth

A

Occurs in the first few days, is normal and self limiting. Peaks 3-4 days post delivery.

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111
Q

What is Postnatal depressive disorder?

A

Occurs in first three month following delivery. Tiredness, irritability and anxiety more prominent. Causes include previous psychiatric illness, stress during pregnancy, loss of sleep and fatigue. Edinburgh postnatal depression scale used. Can have negative affect on bonding.

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112
Q

What is Puerperal psychosis?

A

A severe episode of mental illness, which begins suddenly in the days or weeks after having a baby. Symptoms vary and can change rapidly. They can include high mood (mania), depression, confusion, hallucinations and delusions. If antipsychotics or lithium are prescribed breast feeding

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113
Q

What is Seasonal Affective Disorder?

A

Depression in winter months (due to decreased sunlight). With hypersomnia and increased appetite.

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114
Q

What differentials should you have in mind when talking to a depressed person?

A 
Bipolar
Schizophrenia
Anorexia nervosa
Anxiety
Dysthymia
Substance misuse
Dementia
Sleep disorders
Physical illness
Medication ADRs (e.g. Beta-blockers)
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115
Q

What self help things can you do to improve depression?

A 
Increased activity 
Socialising
Sleep hygiene 
Mindfulness 
'self soothing' 
Improve diet
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116
Q

When should you use antidepressants in mild depression?

A

When symptoms persist for greater than 8 weeks

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117
Q

What is IAPT?

A

Improving access to psychological treatment

A way to get people into CBT and interpersonal therapy quicker

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118
Q

How often should you follow up a patient with depression?

A

Regularly at first (monthly) then less so

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119
Q

What is St Johns wort?

A

Herbal remedy for depression

Does actually work

Up regulates CYP450, affective drug metabolism –> decreased OCP effeciency

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120
Q

What are the factors suggest a high suicide risk?

A 
S - suicide plan
U - unexplained guilt
I - Inability to function
C - Concentration impaired
I - Impaired appetite
D - Decreased sleep 
E - Energy low

Greater or equal to 4/7 = high suicide risk

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121
Q

How does ECT work?

A

It interrupts the hyperconnectivity between the various areas of the brain that maintain depression

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122
Q

What are the indications for ECT?

A

A prolonged sever manic episode
Severe depression
Catatonia

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123
Q

How good is ECT?

A

Works for 80%

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124
Q

How many ECT sessions do you need?

A

6/12 session

Two per week

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125
Q

What are the side effects of ECT?

A

Memory loss: short term reterograde amnesia, confusion, headache and clumsiness

Plus common GA side effects (MI, arrhythmias, aspiration pneumonia, prolonged apnoea, malignant hyperthermia, muscle aches, death)

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126
Q

What are the cautions in ECT?

A

Recent subdural/subarachnoid bleed, stoke, MI, arrhythmia, CNS vascular anomalies

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127
Q

What are the classes of antidepressants?

A 
SSRIs
SNRIs
TCAs
MAOIs
Noradrenergic and specific serotonergic antidepressant (NaSSA)
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128
Q

What is the mechanism of action of SSRIs?

A

Prevent re-uptake of serotonin by pre-synaptic membrane, increasing [serotonin] in the synaptic cleft available to bind to the postsynaptic receptor

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129
Q

Give some examples of SSRIs

A

Fluoxetine (licensed for under 18s, long half life), Citalopram (prolonged QTC), Sertraline (first line, best for IHD, short half life)

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130
Q

What should be monitored when taking SSRIs?

A

FBC (risk of anaemia due to GI bleeding, therefore avoid NSAID use)
U&E (risk of hyponatraemia)

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131
Q

What is a specific ADR with citalopram?

A

Prolongation of QTC interval (so check ECG)

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132
Q

What are the ADRs of SSRIs?

A

nausea, mania, sexual dysfunction, suicidal thoughts, diarrhoea, sleep disturbance, serotonin syndrome, bleeding (dont use NSAID or asprin), hyponatraemia

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133
Q

Which antidepressant is safest in overdose?

A

SSRIs

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134
Q

What is serotonin syndrome?

A

Caused by antidepressants, tramadol

Symptoms: Restlessness, sweating, tremor, shivering, myoclonus, confusion, convulsions

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135
Q

What happens if antidepressants are suddenly discontinued?

A

discontinuation syndrome (flu symptoms, sleep, senses, movement, mood problems)

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136
Q

What antidepressant are 1st, 2nd, 3rd and 4th line?

A

1- SSRI
2- Another SSRI
3- Venlafaxine or mirtazapine
4- Just keep switching (maybe try lithium as an adjunct)

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137
Q

What should you do when you want to swap antidepressants?

A

Cross-taper

Note: When swapping off a MAOI - stop then wait for 2 weeks to allow MAO to replenish

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138
Q

Give some examples of TCAs

A

Amitriptyline, Lofepramine (safest, least cardiotoxic), Imipramine

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139
Q

What is the mechanism of action of TCAs

A

Block both re-uptake of serotonin and NA at pre-synaptic membrane AND H1, α1 and anticholinergic blockage

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140
Q

What are the side effects of TCAs?

A

Sedation, fine tremor, lower seizure threshold, ANS effects (dry mouth, constipation, urinary retention, blurred vision), CVS (tachycardia, postural hypotension, long QT), unsafe in overdose (except lofepramine)

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141
Q

Give some characteristics of TCAs

A

Absorbed by gut
Lipid soluble
Metabolised by liver
Long half life

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142
Q

Give an example of a Noradrenergic and specific serotonergic antidepressant (NaSSA)

A

Mirtazapine

Also classed as a Tetracyclic Antidepressant

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143
Q

When is Mirtazapine used?

A

Severe depression, PTSD

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144
Q

What are some ADRs of Mirtazapine?

A

Increased appetite, weight gain, dry mouth, postural hypotension, confusion, mania, hallucinations, angle closure glaucoma

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145
Q

When is Mirtazapine contraindicated?

A

renal impairment, pregnancy, hepatic impairment, jaundice

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146
Q

Give some examples of SNRIs

A

Venlafaxine (thought to be more affective), Duloxetine

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147
Q

What is the mechanism of action of SNRIs?

A

Blocks the reuptake of serotonin and NA

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148
Q

What are the ADRs of SNRIs?

A

Nausea, dry mouth, headache, dizziness, sexual dysfunction, hypo/hypertension

149
Q

Give some examples of MAOIs

A

Isocarboxacid, Phenelzine

150
Q

Why are MAOIs rarely used?

A

Serious ADRs and DDIs

Foods with thymine in (e.g. cheese) → hypertensive crisis

151
Q

Define bipolar

A

A mental disorder that causes periods of depression and periods of elevated mood

152
Q

Give some signs of mania

A

Mood: Irritability, euphoria, lability

Cognition: Grandiosity, distractibility, fight of ideas, confusion, lack of insight

Behaviour: Rapid speech, hyperactivity, decreased sleep, hyper-sexuality, extravagance

Psychotic signs: Delusions, hallucinations

153
Q

What is hypomania?

A

Many of the signs of mania BUT no psychotic signs, impairment in daily functioning or need for hospitalisation

3 or more characteristic symptoms for at least 4 days

154
Q

What are some causes of mania?

A

Physical: Epilepsy, neoplasm, infection, stroke, MS, hyperthyroidism

Medication: Cocaine, steroids, amphetamines

155
Q

How would you assess a manic person?

A

ASK about: infections, drug use and family history of mental health problems

DO: Head CT, EEG, screen for drugs

156
Q

What is type 1 bipolar?

A

At least one manic episode is necessary to make the diagnosis; depressive episodes are common in the vast majority of cases with type 1 bipolar disorder§, but are unnecessary for the diagnosis

157
Q

What is type 2 bipolar?

A

No manic episodes

One or more hypomanic episodes and one or more major depressive episode

158
Q

In bipolar how long to depressive, manic and hypomanic episodes typically last?

A

Depressive - at least 2 weeks
Hypomanic - at least 4 days
Manic - at least 1 week

159
Q

What treatments can be used in Bipolar?

A

Atypical anti-psychotics (mood stabilizers e.g. risperidone, olanzapine, quetiapine)

Anti-depressants (SSRIs) in conjunction with mood stabiliser

Lithium

Sodium valproate

160
Q

What is used to treat an acute episode of mania?

A

A second generation antipsychotic or valproate semisodium (e.g. Depakote)

161
Q

What is Rapid cycling bipolar?

A

Manic and depressive symptoms appear together

Diagnosed if four or more episodes of mood disorder happen in one year

162
Q

What should be used for prophylaxis in Bipolar?

A

If U&Es, ECG and T4 all fine

–> give Lithium carbonate

163
Q

What plasma level of lithium should you aim for?

A

0.6-1mmol/L

164
Q

When should you check the lithium levels?

A

Weekly (12 hours post dose - take at night) until the dose have been constant for 4 weeks

Then monthly for 6 months

Then 3 monthly

165
Q

What group show an increased likelihood of lithium toxicity?

A

The elderly

166
Q

What should you suspect if lithium levels are progressively rising?

A

Nephrotoxicity

167
Q

What are the ADRs of Lithium?

A

Diabetes insipidus, weight gain, renal impairment, fine tremor, leucocytosis, ECG changes (flattened T, wide QRS), metallic taste in mouth, hypothyroidism

168
Q

What are signs of Lithium toxicity? And what should you do to treat it?

A

Appear above 1.5mmol/l, serious above 2.1mmol/l

Coarse tremor, ataxia, dysarthria (unclear articulation of speech), reduced level of consciousness, convulsions, coma.

Give sodium chloride to stimulate osmotic diuresis

169
Q

What are some DDIs of Lithium?

A

Haloperidol, thiazide diuretics, muscle relaxants, NSAIDs → Increase lithium concentration

SSRIs and ECT → Serotonin syndrome

170
Q

What are some CI of Lithium treatment?

A

Low sodium diet, Addison’s disease, untreated hypothyroidism, cardiac rhythm disorder

171
Q

What are the indications of lithium treatment?

A

Prophylaxis and treatment of mania, hypomania and depression in bipolar disorder, prophylaxis and treatment of recurrent unipolar depression

172
Q

Is Lithium safe in pregnancy and breast feeding?

A

No

Can cause heart defects in pregnancy and is secreted into breast milk

173
Q

What is the procedure of ECT?

A

Patients are given general anaesthetic (e.g. methohexital, etomidate, or thiopental) and a muscle relaxant (e.g. succinylcholine) required otherwise patient would be paralysed & conscious.

The passage of a small electrical current through the brain with a view to inducing a tonic-clonic fit which is therapeutic.

Bilateral- 2 electrodes over 2 hemispheres. Effective, quicker action, more cognitive side effects,

Unilateral- 2 electrodes over the non-dominant hemisphere. Slower action, fewer cognitive side effects.

174
Q

How should you discontinue lithium?

A

Slowly over 2-4 weeks

To avoid causing mania

175
Q

What medication need to be stopped before ECT?

A

Lithium and Benzodiazepines

176
Q

What is the second line medication in Bipolar prophylaxis? (after Lithium carbonate)

A

Semisodium valproate or carbamazepine

177
Q

List various potential mood stabilisers

A

Sodium valproate
Carbamazepine
Lamotrigene
Lithium

178
Q

What is the mechanism of action of Lamotrigene?

A

Blocks sodium channels

179
Q

What is a big ADR of Lamotrigene?

A

Steven-Johnston Syndrome

180
Q

When can Lamotrigene be used?

A

Bipolar prophylaxis and treatment resistance depression

181
Q

When is Carbamazepine indicated?

A

Epilepsy, trigeminal neuralgia, bipolar disorder unresponsive to lithium

182
Q

What are the ADRs of Carbamazepine?

A

Dizziness, visual disturbance, hyponatraemia, oedema, GI disturbance, rashes

183
Q

What are the CI of Carbamazepine?

A

AV node abnormalities, history of bone marrow depression, acute porphyria

184
Q

What is the mechanism of action of Carbamazepine?

A

Blocks sodium channels and is a GABA receptor agonist

185
Q

How does Carbamazepine affect OCP levels?

A

Enzyme inducer, therefore reduced OCP levels

186
Q

Can you use Carbamazepine in pregnancy and why?

A

No

Its is a teratogen –> neural tube defects

187
Q

How does Sodium valproate need to be monitored?

A

Blood monitoring- serum levels when indicated, annual TFT, 6 monthly LFT & FBC

188
Q

What are the indications of Sodium valproate?

A

Treatment of manic episodes associated with bipolar disorder, migraine prophylaxis

189
Q

What are the ADRs of Sodium valproate?

A

Tremor, sedation, GI disturbance, headache, thrombocytopenia, hair loss

190
Q

What are the CIs of Sodium valproate?

A

Family history of hepatic dysfunction

191
Q

What is the mechanism of action of Sodium valproate?

A

Blocks voltage-dependent sodium channels and increased brain levels of GABA

192
Q

What are some psychological, behavioural and physical manifestations of anxiety disorders?

A

Psychological - feeling of dread, apprehension, restlessness, narrowing of attention to focus on danger, increased alertness.

Physical – autonomic response (check for thyroid, heart problems, phaeochromocytoma which may be causing physical symptoms), hyperventilation, palpitations

Behaviour - reassurance seeking

193
Q

What is an anxiety disorder?

A

An abnormal response to a situation which interferes with day-to-day activities and lasts more than 3 weeks

194
Q

What is a panic disorder?

A

An anxiety disorder characterised by recurrent unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something really bad is going to happen.

They are unpredictable, not restricted to a specific situation

195
Q

What is a phobic anxiety disorder?

A

Anxiety that happens in a well-defined situation, they are predictable e.g. agoraphobia, social phobias, specific phobias

196
Q

What is Generalised anxiety disorder?

A

Worries about worries, accompanied by low level symptoms (insomnia, muscle tension, GI problems, headache)

ICD10 Classification: symptoms for 6 months or more

197
Q

What is Social anxiety disorder?

A

Fear of negative evaluation by others, avoidance of feared situations, use of safety behaviours.

198
Q

What is body dysmorphic disorder?

A

Preoccupation with an imagined defect in appearance, leads to time consuming behaviours (camouflaging tactics, skin picking, mirror gazing)

199
Q

What is PTSD?

A

Caused by exposure to event/situation of exceptionally threatening of catastrophic nature which would be likely to cause pervasive distress in almost anyone

Main features: re-experiencing, avoidance, hyperarousal

200
Q

Define neurosis

A

Mental illness that is not caused by organic disease, involving symptoms of stress (depression, anxiety, obsessive behaviour, hypochondria) but not a radical loss of touch with reality (i.e. pyschosis)

201
Q

What are some signs that a child has anxiety?

A

Thumb-sucking, nail biting, bed wetting

202
Q

List some possible treatments for anxiety disorders

A 
Listening and reassurance 
Regular exercise
Meditation 
Progressive relaxation training 
CBT (best specific measure)
Behavioural therapy (graded exposure to anxiety provoking stimuli) 
Hypnosis 
Medication
203
Q

What is the 1st, 2nd and 3rd line treatments for anxiety disorders?

A

First line: CBT
Second line: SSRIs
Third line: Benzos

204
Q

List some complications of anxiety disorders

A

increased autonomic arousal, avoidance, time consuming anxiety reducing behaviours, worry, procrastination, reduced concentration, impact on function, impaired sleep pattern, drug and alcohol dependence

205
Q

What medications can be used in anxiety disorders?

A

First line: SSRI (also consider SNRI or TCAs)
Benzodiazepines: can build up tolerance and are hard to stop. Not a long term solution
Pregabalin: can be used as mono-therapy or with a SSRI
Antipsychotic: reserved for acute distress or sometimes to augment SSRIs
Beta-blockers: Improves somatic symptoms

206
Q

What is the mechanism of action of Benzodiazepines?

A

Act on GABA-A receptors

207
Q

What are the indications for Benzodiazepines?

A

Short term use only for anxiety disorders, alcohol detoxification

208
Q

What are the ADRs of Benzodiazepines?

A

Drowsiness, light headedness, ataxia, confusion, amnesia

209
Q

What can happen in Benzodiazepines overdose?

A

Respiratory depression

210
Q

How do you reverse Benzodiazepines?

A

Flumazenil

211
Q

Give some examples of Benzodiazepines

A

Lorazepam (fast onset, short acting), Diazepam (slow onset, long acting)

212
Q

Why are beta-blockers giving in anxiety and what is there effect?

A

Indications- patients with predominantly somatic symptoms

Relieve autonomic symptoms e.g. tachycardia, alleviate tremor

213
Q

How does Buspirone work?

A

5HT1A agonist

214
Q

What are the indications for Buspirone?

A

Generalised anxiety disorder (short-term use)

215
Q

What are the CI of Buspirone?

A

Epilepsy, acute porphyria

216
Q

What are the ADRs of Buspirone?

A

Light headedness, nausea, dizziness

217
Q

How do Barbiturates work?

A

Act on GABA-A receptors

Not commonly used due to side effects and dependence

218
Q

How does Pregabalin work?

A

GABA analogue that binds to Ca2+ channels

Inhibits glutamate, noradrenaline and substance-P

219
Q

What are the side effects of Pregabalin?

A

dizziness, drowsiness, blurred vision, diplopia, confusion, vivid dreams.

Avoid abrupt withdrawal

220
Q

What are the indications for Pregabalin?

A

Generalised anxiety disorder, neuropathic pain

221
Q

What hypnotic drugs are used to help sleep?

A

Zopiclone, Zolpidem, Zalepon, (The Z drugs)

222
Q

How do the ‘Z drugs’ work?

A

Act on the omega 1 site on GABA-A complex

Omega 2 is involved in cognitive function

223
Q

What are the indications for the ‘Z drugs’?

A

Used to improve sleep short term once sleep hygiene measures are exhausted

224
Q

Define OCD

A

Anxiety-related condition where a person experiences frequent intrusive and unwelcome obsessional thoughts, often followed by repetitive compulsions, impulses or urges.

Characterised by obsessions and compulsions

225
Q

What is an obsession?

A

Involuntary thoughts, images or compulsions. They are often intrusive and distressing for patients.

226
Q

What is a compulsion?

A

Repetitive mental operations (e.g. counting) or physical acts (e.g. hand washing). Patients feel compelled to perform them, and help reduce anxiety

227
Q

What is the ICD10 definition of OCD?

A

Obsession and compulsions must be present for at least 2 weeks and be a source of distress

Acknowledged as coming from the patient’s own mind

The obsessions are unpleasantly repetitive

A compulsive act is not pleasurable, except for the relief of anxiety

228
Q

What is the differential diagnosis for someone you suspect has OCD?

A

Depressive disorder: Obsessions are mood congruent and resolve with treatment

Anxiety disorder: Phobia –stimulus comes from an external object rather than the patient’s own mind. Generalized anxiety – excessive concerns about real life circumstances

Eating disorders: Thoughts and actions aren’t recognized as excessive or unreasonable

Schizophrenia: Thought insertion- patients believe that thoughts are not from their own mind. Lack of insight

229
Q

How can you manage OCD?

A

Biological: SSRIs or TCA – (e.g. clomipramine)

Psychological: CBT – graded exposure

230
Q

What is the pathophysiology of OCD?

A

Abnormal orbitofrontal cortex and caudate nucleus

231
Q

What is the aim of CBT?

A

To change the way you feel by changing the way you think

It helps to teach the patient that some distressing emotions and behaviours are due to cognitive errors

232
Q

What is a common exercise in CBT?

A

Patients may keep a thought diary to highlight correlation between thoughts, emotions and behaviours. This may help them to deal with situations in the future

233
Q

What is CBT indicated?

A

Depression, eating disorders, anxiety disorders, OCD, PTSD, chronic psychotic symptoms

234
Q

What is psychodynamic therapy? And what is transference and countertransference?

A

Discussion of patient’s past experiences allows the patient and therapist to discover the unconscious.

The therapeutic relationship is very important.

Transference- emotions the patient shares with the therapist

Countertransference- emotions the therapist shares with the patient during therapy

235
Q

What are the indications for psychodynamic therapy?

A

Dissociative disorders, somatoform disorders, psychosexual disorders, certain personality disorders, chronic dysthymia, recurrent depression

236
Q

What are the CIs for psychodynamic therapy?

A

Antisocial personality disorder, acute psychotic disorders, alcohol/drug dependence, depression with high suicide risk

237
Q

Give some characteristics of motivational interviewing

A

Useful in substance misuse

Helps identify ‘change talk’

Offers advice but the patient leads the process

238
Q

Define personality

A

Characteristic patterns of behaviour and modes of thinking that determine a person’s adjustment to the environment

239
Q

What is a personality disorder?

A

Deeply ingrained and enduring behaviour patterns manifesting themselves as inflexible responses to a broad range of personal and social situations

Significant deviations from average (perception, thinking, feeling & particularly relating to others)

Usually associated with distress and problems of social performance

240
Q

Give four features of personality disorders

A

Present since adolescence

Stable over time despite fluctuations in mood

Manifest in different environments

Recognise by friends and acquaintances

241
Q

Give the three clusters of personality disorders

A

Cluster A- odd/ eccentric

Paranoid, schizoid, schizotypal

Cluster B- dramatic/ emotional/ flamboyant

Dissocial, emotionally unstable (impulse or borderline), histrionic, narcissistic

Cluster C- anxious/ fearful

Anakastic, anxious (avoidance), dependent

242
Q

How can you treat PTSD?

A

CBT
Eye movement desensitisation and reprocessing (EMDR)

Medication is second line but can also be used in combination (SSRIs and 2nd gen antipsychotics favoured)

243
Q

What is paranoid PD?

A

Suspicious, preoccupied with conspiratorial explanations, distrust in others, holds grudges

244
Q

What is schizoid PD?

A

Emotionally cold, detached, rich fantasy world, excessive introspection

245
Q

What is schizotypal PD?

A

Eccentric, unusual ideas (e.g. telepathy, clairvoyance), inappropriate affect

246
Q

What is dissocial PD?

A

Aggressive, easily frustrated, callous lack of concern for others, irresponsible, impulsive, unable to maintain relationships, criminal activity, lack of guilt

247
Q

What is histrionic PD?

A

Over-dramatise, self-centred, shallow affect, labile mood, seeks attention and excitement, manipulative, seductive

248
Q

What is narcissistic PD?

A

High self-importance, lacks empathy, takes advantage, grandiose, needs admiration

249
Q

What is anankastic PD?

A

Worries and doubts, orderliness, control, perfectionism, sensitive to criticism, rigidity, indecisiveness, pedantry, judgemental

250
Q

What is anxious PD?

A

Extremely anxious and tense, self-conscious, insecure, fearful of negative evaluation by others, timid, desires to be liked

251
Q

What is dependent PD?

A

Passive, clingy, submissive, excess need for care, feels helpless when not in a relationship, feels hopeless and incompetent

252
Q

What is boarderline PD?

A

Feeling of ‘emptiness’, unclear identity, intense unstable relationships, unpredictable affect, threats of self-harm, impulsivity, pseudohallucinations

most commonly encountered acutely, most troublesome

Aka- Emotionally unstable personality disorder

253
Q

How can you treat personality disorders?

A

Treat underlying psychiatric conditions

Psychotherapy - group therapy can help

Some medications (NICE guidelines CG78)

254
Q

What are some complications of personality disorders?

A

distress, adverse effects on society, substance abuse, DSH, suicide, violent behaviours

255
Q

Define alcohol misuse

A

consumption of alcohol sufficient to cause physical, psychiatric or social harm. Recommended drinking men and women >14 units per week

256
Q

What are some risk factors for alcohol misuse?

A

genetics, culture, religion, family history, male, availability and cost of alcohol

257
Q

What signs should you look out for in a patient with alcohol misuse?

A

alcoholic stigmata, signs of alcoholic liver disease (palmar erythema, oedema, portal-systemic hypertension, spider naevi, gynaecomastia)

258
Q

What is the management of alcohol misuse?

A

Detoxification (benzodiazepines - chlordiazepoxide- prevent seizure & reduce withdrawal symptoms, correction of electrolytes, vitamin supplements)

Motivational interviewing

12 step groups e.g. Alcoholics Anonymous

Address social issues

Treat underlying psychiatric disorders

Medication- Disulfiram, Acamprosate, naltrexone - opioid antagonist- reduces pleasure (specialist services)

259
Q

What are some of the complications of alcohol misuse?

A

anxiety, depression, DSH/ suicide, memory loss, GI upset, hypertension, cardiomyopathy, hepatitis, jaundice, peripheral neuropathy

260
Q

What is Delirium tremens?

A

Medical Emergency, hyperadrenergic state

Signs & symptoms- hallucinations, confusion, delusions, severe agitations, seizures, tachycardia, hyperthermia, hypertension, tachypnoea, tremor, mydriasis, ataxia, CVS collapse

Treatment- ABCDE, treat hypoglycaemia, sedation with benzodiazepines, IV thiamine if Wernicke’s suspected.

261
Q

What is Wernicke’s encephalopathy?

A

occurs due to thiamine deficiency causing mental confusion, ataxia and opthalmoplegia. If left untreated (IV thiamine required) this may develop into Korsakoff’s psychosis (amnesic disorder with confabulation)

262
Q

What is the mechanism of action of Disulfiram?

A

Inhibits alcohol dehydrogenase

263
Q

What happens when you take Disulfiram with alcohol?

A

facial flushing, headache, palpitations, nausea and vomiting, cardiovascular collapse

264
Q

What are the ADRs of Disulfiram?

A

fatigue, reduced libido

265
Q

What are the CIs of Disulfiram?

A

cardiovascular disease, hypertension, previous CVA, psychosis

266
Q

How does Acamprosate work?

A

Reduces conditioned aspects of drinking, prevents craving-induced relapses

267
Q

What are the ADRs of Acamprosate?

A

GI disturbance, rash

268
Q

What are the CIs of Acamprosate?

A

sever hepatic / renal failure

269
Q

Define dementia

A

A global impairment of cognitive function and personality without impairment of consciousness

270
Q

When would you diagnose early onset dementia?

A

Dementia under the age of 65

Do an MRI to rule out other causes

271
Q

What are the symptoms of Dementia?

A

Memory impairment - recent memory id affected first
Aphasia (Echolalia, Palilalia or muteness may occur)
Apraxia
Agnosia
Personality and behavioural changes (introverted, socially withdrawn, hostile)
Impairment of executive function (Difficulty planning complex activities)
Psychiatric symptoms (hallucinations - common, delusions - mainly persecutory, depression, anxiety)
Neurological symptoms (seizures, myoclonic jerks)

272
Q

What is aphasia?

A

Loss of language

273
Q

What is the difference between receptive and expressive aphasia?

A

receptive - difficulty understanding commands

expressive - vague speech

274
Q

What is echolalia?

A

repeating heard words

275
Q

What is palilalia?

A

repeating own words

276
Q

What is apraxia

A

Lose the ability to carry out skilled motor movements

277
Q

What is agnosia?

A

Lose ability to recognize previously familiar objects

278
Q

What is pseudodementia?

A

Changes in intellect, memory and personality due to other mental illness, commonly depression

279
Q

How does Alzheimers disease present?

A

Gradual onset with progressive cognitive decline

Clinical diagnosis supported by radiology

280
Q

What causes Alzheimers?

A

Cholinergic hypothesis - reduction in acetylcholine due to the degeneration of cholinergic neurones

Tau hypothesis - phosphorylation of tau proteins cause neurofibrillary tangles (Intracellular)

Amyloid hypothesis - formation of extracellular β amyloid plaques (Extracellular)

281
Q

How would you investigate Alzheimers?

A

CT -generalized atrophy - frontal and temporal lobes, widened sulci and enlarged ventricles

282
Q

How would you treat Alzheimers?

A

Acetylcholine Esterase Inhibitors (Donepezil, Rivastigmine, Galantamine)

Non competitive antagonism at NMDA (Memantine) - Reduces excitotoxcity caused by excess glutamate stimulation

283
Q

What is somatisation disorder?

A

multiple physical SYMPTOMS present for at least 2 years

patient refuses to accept reassurance or negative test results

284
Q

What is hypochondrial disorder?

A

persistent belief in the presence of an underlying serious DISEASE, e.g. cancer

patient again refuses to accept reassurance or negative test results

285
Q

What is conversion disorder?

A

typically involves loss of motor or sensory function

the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)

patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

286
Q

What is dissociation disorder?

A

dissociation is a process of ‘separating off’ certain memories from normal consciousness

in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor

dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

287
Q

What is Munchausen’s syndrome?

A

the intentional production of physical or psychological symptoms

also known as factitious disorder

288
Q

What is malingering?

A

fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

289
Q

How does frontotemporal dementia present?

A

Decline in social and personal conduct → disinhibition, personality change

Emotional blunting

Echolalia, mutism

Lack of insight but sparing of other cognitive functions

290
Q

What would you see on a CT of a patient with frontotemporal dementia?

A

Bilateral atrophy of the frontal and anterior temporal lobes

291
Q

How is frontotemporal dementia treated?

A

Disinhibition - SSRI’s and in extreme cases with anti-psychotics (short term)

292
Q

What is pseudodementia?

A

dementia due to depression so can be reversed with antidepressants

293
Q

What is normal pressure hydrocephalus?

A

Triad of urinary incontinence, bradykinesia and memory loss

294
Q

How does vascular dementia present?

A

Evidence of Cerebrovascular disease or stroke and risk factors for Cerebrovascular disease (smoking, drinking, hypertension, male, diabetes, MI, lipid abnormalities, valvular disease)

Stepwise deterioration in cognitive function

295
Q

List the various types of dementia and how common they are

A

Alzheimers - 50-60%
Vascular - 20-25%
Lewy body - 10-15%
Frontotemporal -7% (2nd most common presenile)

296
Q

What is the cause of vascular dementia?

A

Multiple cortical infarcts

297
Q

How would you investigate vascular dementia?

A

CT with contrast shows small vessel disease with multiple infarcted areas

298
Q

How do you treat vascular dementia?

A

No real pharmacological treatment – manage the cause e.g. statins

299
Q

How does lewy body dementia present?

A

Day to day fluctuations in cognitive performance

Visual hallucinations

Parkinsonism (rigidity, bradykinesia, tremor)

Degeneration of autonomic sympathetic neurones in the spinal cord

Extreme sensitivity to anti-psychotics

300
Q

What is the cause of lewy body dementia?

A

Abnormally phosphorylated proteins aggregated with ubiquitin and α-synuclein (in the cytoplasm)

301
Q

How should you investigate lewy body dementia?

A

DAT scan – measures radioactively labelled dopamine which is diminished in LBD

302
Q

What is the treatment for lewy body dementia?

A

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

303
Q

Give some other causes of dementia?

A

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)

304
Q

How does dementia start?

A

Mild cognitive impairment

305
Q

Give some examples of Acetylcholinesterase Inhibitors

A

donepezil, galantamine, rivastigmine (Parkinson’s disease)

306
Q

When are Acetylcholinesterase Inhibitors used?

A

mild to moderate dementia related to Alzheimer’s disease

307
Q

What are the ADRs of Acetylcholinesterase Inhibitors?

A

nausea, vomiting, gastric & duodenal ulcers, syncope, bradycardia, AV block, MI, hallucinations, agitation, rash

308
Q

What are the CIs of Acetylcholinesterase Inhibitors?

A

renal impairment (galantamine), cardiac disease, peptic ulcer disease

309
Q

Give an example of a NDMA Receptor Antagonist?

A

memantine

310
Q

When are NDMA Receptor Antagonists used?

A

moderate to severe dementia related to Alzheimer’s disease

311
Q

What are the ADRs of NDMA Receptor Antagonists?

A

constipation, hypertension, seizures, dizziness, depression

312
Q

What are the CIs of NDMA Receptor Antagonists?

A

renal impairment, seizure history

313
Q

Define delirium

A

an acute confusional state and is a medical emergency. It involves impaired consciousness and impaired cognitive function.

314
Q

How does delirium present?

A

Impaired consciousness - reduced awareness of the environment, reduced attention, easily distracted

Impaired cognitive function - short term memory impaired, preservation of long term memory, disorientated to time and place,

language abnormalities - incoherent speech, rambling

Perception and thought disturbances -
misinterpretations, illusions or hallucinations (mainly visual), persecutory delusions

Psychomotor abnormalities - patients may be hypo or hyperactive, sleep wake disturbances, daytime drowsiness and night time hyperactivity

Mood disturbance -depression, euphoria, anxiety, anger, fear

315
Q

What causes delirium?

A

Underlying medical or drug related cause leading to alterations in cholinergic and noradrenergic neurotransmitters, and disruption of the blood brain barrier.

316
Q

How do you manage delirium?

A

Treat any underlying cause

Anti-psychotics (low dose in the elderly)

317
Q

How can you differentiate between delirium and dementia?

A

Delirium - fast onset, shorter duration, fluctuation, consciousness impaired, perceptual disturbance common, sleep-wake cycle disrupted

Dementia - gradual onset, lasts longer, progressive deterioration, normal consciousness, sleep normal

318
Q

What is post-concusional syndrome

A

Minor head injury –> headache, anxiety, fatigue, dizziness

319
Q

What causes an eating disorder?

A

Biological – genetic, abnormalities in serotonin metabolism

Psychological – western culture, occupation

Psychological predisposition – low self-esteem, dieting, perfectionism

320
Q

How does ICD 10 diagnose anorexia nervosa?

A

(all of the following):

  1. Low body weight (at least 15% below expected or BMI is lower than 17.5)
  2. Self-induced weight loss (low calorie intake, exercise)
  3. Overvalued idea (dread of fatness, low target weight)
  4. Endocrine disturbance (Amenorrhoea, Raised growth hormone and cortisol, Reduced T3
321
Q

How does ICD10 diagnose bulimia nervosa?

A

(all of the following):

  1. Binge eating
  2. Methods of counter weight gain (vomiting, laxatives, fasting, exercise)
  3. Overvalued idea (dread of fatness, low target weight)

Often normal weight

322
Q

What medical complications arise due to starvation? And what investigation results would you get?

A 
Amenorrhoea, infertility 
Constipation and abdominal pain
Cold intolerance
Bradycardia, hypotension and arrhythmias 
Peripheral oedema
OsteoporosisSeizures
Depression
Investigation results:
o      Abnormal liver function
o	Raised urea (dehydration)
o	Raised cortisol and growth hormone
o	Reduced T3, FSH and LH
o	Hypercholesterolaemia
o	Hypoglycaemia
o	Normocytic anaemia
o	Leucopoenia
323
Q

What medical complication you arise due to vomiting? And what investigation results would you get?

A

Erosion of dental enamel
Enlargement of salivary glands
Calluses of the back of the hands
Oesophageal tears

Investigation results
o	Hypokalaemia (ECG - tall P waves, flattened T waves)
o	Hypochloraemic alkalosis
o	Hyponatremia
o	Hypomagnesaemia
o	Raised serum amylase
324
Q

What investigations would you do fro someone with and eating disorder?

A

Bloods (U+E, FBC, LFT, thyroid, glucose, amylase, cholesterol)
Dexamethasone suppression test
ECG
DEXA bone scan

325
Q

What is the management for someone with an eating disorder?

A

Biological (Fluoxetine – reduced binging and purging behaviour)

Psychological (Psychoeducation about nutrition and weight, CBT, Family therapy)

Hospitalization for those with a BMI <13.5, rapid weight loss, electrolyte disturbance and suicide risk

326
Q

What is sleep paralysis?

A

Transient paralysis of skeletal muscle that occurs on waking of falling asleep (rare)
Can –> hallucinations
Hx - Clonazepam

327
Q

What is oppositional defiance disorder?

A

A recurrent pattern of negativistic, defiant, disobedient and hostile behaviour towards authority figures.

328
Q

What is conduct disorder?

A

A persistent pattern of antisocial behaviour in which the individual repeatedly breaks social rules and carries out aggressive acts. Can become antisocial personality disorder in adults.

329
Q

What is ADHD? (+ symptoms)

A

A behavioural syndrome characterised by hyperactivity, impulsivity and inattention. These characteristics must be present in two or more settings. Symptoms are present since childhood and are age inappropriate. They will result in functional impairment for the child (psychological, social and educational). Symptoms must start before the age of 7.

330
Q

What is the epidemiology of ADHD?

A

2.4% of children in UK, typically diagnosed 3-7 years old, more common in boys

331
Q

How is ADHD diagnosed?

A

requires referral and assessment by a specialist (paediatrician/ child psychiatrist/ CAMHS)

332
Q

How is ADHD treated?

A

Methylphenidate (first line, aka ritalin), dexamphetamine (second line) Stimulants that block monoamine reuptake. ADRs: Nausea, appetite loss, weight loss, reduced growth, headaches, insomnia

Atomoxetine -Non-stimulant, takes longer to have an effect

Parent education programmes

CBT

Social skills training

Individual psychological treatment

333
Q

What are some complications of ADHD?

A

difficulties in education, risk of accidents, low self-esteem, rejection by peers

334
Q

What is a tic?

A

A sudden repetitive, non-rhythmic, stereotyped motor movement or vocalization involving discrete muscle groups. Can be transient or chronic (greater than 12 months).

335
Q

What is tourette’s syndrome?

A

A common neuropsychiatric disorder with onset in childhood, characterized by multiple motor tics and at least one vocal (phonic) tic.

336
Q

When does tourette’s usually start and when does it peak?

A

usually begins between 3-8 years old, with severity peaking around 20 years old

337
Q

How can tourette’s be treated?

A

Anti-psychotics and alpha-2 agonists can reduced the severity of tics (e.g. clonidine and guanfacine).

338
Q

What is the triad of impairments seen in Autism?

A
  1. Social interaction (reduced social interpretation, sensory seeking)
  2. Communication (literal, reduced expressive language, non-verbal problems)
  3. Rigid and repetitive behaviour (need for sameness, rituals, routine, less empathy, no theory of mind, less imaginative play)
339
Q

How does ICD10 define autism?

A

Onset before 3 years old. Must have a minimum of 6 symptoms (developmental, social, communication and behaviour)

340
Q

What score can be used to assess depression?

A

PHQ-9

341
Q

What is a normal grief reaction?

A

Can last up to 6 months

with physical and psych symptoms (hallucinations)

342
Q

Who gets autism more boys or girls?

A

Boys

343
Q

What are the three underlying cognitive deficiency seen in autism?

A
  1. Lack of theory of mind – cant see things from other peoples point of view
  2. Lack of executive functioning – problems planning and organising
  3. Lack of central coherence – cant link things to make a core idea/statement
344
Q

What is asperger’s syndrome?

A

Similar to autism but fewer communication problems, no LD, normal IQ

345
Q

What is atypical autism?

A

After 3 years old OR doesn’t fit all three impairments

346
Q

Define suicide

A

An unnatural death due to the victim’s own action with the intention to kill themselves

347
Q

What is para-sucide?

A

victim survives although suicide was the intention (different from self harm)

348
Q

What is death by misadventure?

A

death caused by a person accidentally while performing a legal act without negligence or intent to harm.

349
Q

What are suicide risk factors?

A 
Male
Living alone 
Unemployed 
Drug/alcohol misuse 
Mental illness
Recent bereavement
350
Q

What score can be used to assess suicide risk?

A

SADPERSON score

351
Q

Define deliberate self harm

A

Act with a non-fatal outcome in which an individual deliberately initiates a behaviour that will cause self-harm.

352
Q

What are the two types of deliberate self harm?

A

self-poisoning (ingestion of toxins) or self-injury (cutting, burning, scratching)

353
Q

Who is more likely to self harm men or women?

A

women

354
Q

What motivates self harm?

A

wish to die, communication with others, unbearable symptoms, guilt, distraction from emotional saddness

355
Q

What must you never forget in a psych history?

A

Risk assessment

356
Q

Define mania

A

Elevated/ expansive/ irritable mood (for at least 1 week) + 3 other symptoms (e.g. increased energy, grandiosity, pressure of speech, flight of ideas, distractible, reduced need for sleep, increased libido, lost of social inhibitions, psychotic symptoms)

357
Q

How long should you continue antidepressants?

A

first episode - 6 months

multiple episode - 2 years

358
Q

What is adjustment disorder?

A

An individual is unable to adjust to or cope with a particular stress or a major life event.

Since people with this disorder normally have symptoms that depressed people do, such as general loss of interest, feelings of hopelessness and crying, this disorder is sometimes known as situational depression.

Unlike major depression, the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation

359
Q

How long do antidepressants take to work?

A

3-6 weeks

360
Q

How do you treat neuroleptic malignant syndrome?

A

Dantrolene, bromocriptine and diazepam

361
Q

What EGC changes can lithium cause?

A

T wave flattening

Widening of the QRS

362
Q

What vitamin supplement should be given during alcohol withdrawal?

A

Pabrinex

363
Q

What physiological changes are seen during ECT?

A

EEG changes

CVS - initial PSNS then SNS = bradycardia and BP decrease the tachycardia and BP increase

Cerebral blood flow increase (increased ICP)

Hormone changes

364
Q

What is a lasting power of attorney?

A

The LPA allows a person to make appropriate arrangements for family members or trusted friends to be authorised to make decisions on their behalf. It must be made when the person has capacity.

365
Q

What are the principals of the Mental Capacity Act?

A

Presumption of capacity
All steps must be taken to support people to make their own decisions
A right to make ‘bad’ decisions

366
Q

Define capacity

A

the ability to make a decision

367
Q

What is an anticipatory refusal?

A

Only relate to medical treatments
Can only refuse
Person must be over 18 and have capacity

368
Q

What is Deprivation of Liberty Safeguard (DOLS)?

A

For patient in hospital or care homes who lack capacity

369
Q

What are you assessing in a cognitive assessment?

A 
Orientation
Attention and concentration 
Language 
Calculation 
Right hemisphere function 
Abstraction 
Memory

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