Psych Flashcards

Question

Management of bulimia presentation at GP?

Answer 1

- Treat medical condition (dental review regularly for acid wear on teeth) - Treat co-morbid psychiatric illness (depression, OCD, substance misuse)

Answer 2

SSRIs (high dose 60mg fluoxetine) --> reduce binging and purging and helps impulses

Answer 3

Children: 1st line - family therapy Adults: 1st line - Guided self-help programmed; 2nd line - CBT-ED

Answer 4

Check electrolytes and ECG changes.

Answer 5

- Seen in eating disorder patients - Characterised by electrolyte imbalance (principally low serum phosphate, potassium, and magnesium) caused by their sudden intracellular movement due to the switch from fat to carbohydrate metabolism and associated increased secretion of insulin - Defined mainly by low phosphate - Low K (arrythmias) > Low PO4 (hypophosphatemic HF) > Low Mg - Signs: fatigue, weakness, confusion, high BP, seizures, arrhythmia, heart failure

Answer 6

OCD Childhood feeding difficulties Family history

Answer 7

Secondary to malnutrition (restricting subtype) and binge-purging

Answer 8

Yes if they are underweight. Normal weight is bulimia.

Answer 9

- Medical causes of weight loss (e.g. hyperthyroidism, malignancy, gastrointestinal disease, Addison’s disease, chronic infection, inﬂammatory conditions, and AIDS) - Depression - BN - Psychosis (self-starvation might occur if food is believed to be poisoned) - Eating disorder not otherwise specified - Body dysmorphic disorder (BDD is a condition characterised by body image distortion (e.g.belief that the nose is misshapen. Deliberate weight loss in BDD would be unusual)

Answer 10

Urgent medical treatment is needed in high-risk patients with nutritional decompensation. Markers of this include: • BMI <13 • weight loss >1kg/week • purpuric rash • cold peripheries • core body temperature <34.5°C • hypotension (systolic <80mmHg, diastolic <50mmHg) • bradycardia (<40bpm) with prolonged QT interval on ECG

Answer 11

-Monitor/advice/support for 8 weeks -Beat charity support FEATURES: BMI>17, no additional co-morbidity - Routine referral fo CEDS if failure to respond

Answer 12

- Routine referral to CEDS | FEATURES: BMI 15-17, no evidence of system failure

Answer 13

- Urgent referral to CEDS (community eating disorder service) FEATURES: BMI<15, rapid weight loss, evidence in system failure

Answer 14

- Engage and educate (stop laxatives/diuretic use as it does not reduce calorie intake) - Signpost support (beat charity, MIND, NHS) - Treat co-morbid psychiatric illness (depression, OCD, substance misuse)

Answer 15

SCOFF questionnaire - Do you make yourself Sick (induce vomiting) because you feel uncomfortably full? - Do you worry that you have lost Control over how much you eat? - Have you recently lost more than One stone (14 lb [6.4 kg]) in a three-month period? - Do you think you are too Fat, even though others say you are too thin? - Would you say that Food dominates your life? One point for every yes answer; a score 2 indicates a likely case of anorexia nervosa or bulimia nervosa (sensitivity: 100 percent; specificity: 87.5 percent).

Answer 16

- Nutrition and weight restoration (set target weight + make eating plan to gain 0.5-1kg/week) - CBT-ED, MANTRA or SSCM (or family therapy if less than 18 years)

Answer 17

The hypothalamic–pituitary–gonadal axis is affected, causing amenorrhoea in women and impotence in men. Libido is lost in both sexes. If AN begins before puberty, menarche and breast development are delayed or arrested.

Answer 18

After 10 years, 50% recover, 10% die and 40% ongoing problems

Answer 19

- Very low weight - Later onset - Bulimic features - Longer illness duration

Answer 20

- Infertility - Early death - Osteoporosis - Cardia arrhythmias and failure

Answer 21

1st line: Family therapy | 2nd line: ED-CBT

Answer 22

When: If physical symptoms such as rapid weight loss and BMI<13.5 What: Fluoxetine (especially if there are preoccupations with food)

Answer 23

- Short history of illness | - Young onset (less than 19)

Answer 24

- Longer history of illness | - Onset older (later-onset disease)

Answer 25

- All if 1st line is unacceptable - Eating-disorder-focussed Focal Psychodynamic Therapy (FPT) - Adolescent-focussed psychotherapy (AFP) - Motivational interviewing

Answer 26

Offer any of these: 1) CBT-ED - 40 weekly sessions (address low self-esteem, perfectionism and control issues) 2) Maudsley Anorexia Nervosa Treatment in Adults (MANTRA) - 20 weekly sessions (focus on what the cause of anorexia is) 3) Specialist Supportive Clinical Management (SSCM) - 20 weekly sessions led by practitioner (explore problems of anorexia, educate on nutrition and eating habits, explore a future beyond anorexia)

Answer 27

1. Height, weight, and BMI. 2. Squat test: Ask the patient to squat down and rise to standing without using their arms (difﬁcult with proximal myopathy). 3. Essential blood tests • ESR, TFTs—exclude most organic causes of weightloss, e.g. hyperthyroidism. ESR is normal or low in anorexia. • FBC, U&E, phosphate, albumin, LFT, creatininekinase, glucose—evaluate nutritional state and risk. 4. ECG: Bradycardia, arrhythmias, and a prolongedQT interval. 5. Other tests as indicated, e.g. DEXA scans (low bonedensity).

Answer 28

Psychotherapies • Motivational interviewing is an important approach when trying to engage ambivalent patients who lack insight into their disorder—or hold positive views of their illness • Family therapy—rather than simply focusing on the patient, this involves the whole family. Patients with a short history of early onset anorexia (onset before 19 years) show greatest response. • Interpersonal therapy aims at improving social functioning and interpersonal skills. This is better for patients with later onset or longer duration of illness. • Cognitive behavioural therapy—addresses control, low self-esteem, and perfectionism

Answer 29

- BMI <13 or extremely rapid weight loss - serious physical complications - high suicide risk

Answer 30

- Pervasive: occurs in all/most areas of life - Persistent: evident in adolescence and continues through adulthood - Pathological: cause distress to self or others, impairs function

Answer 31

- Odd or eccentric "Weird" - Paranoid, schizoid, schizotypal

Answer 32

- Dramatic, erratic or emotional "Wild" - Dissocial, borderline (EUPD), histrionic, narcissistic

Answer 33

- Anxious and fearful "Worried" - Anankastic, anxious-avoidant, dependant

Answer 34

- A set of consistent thoughts, feelings and behaviours shown across in time in a variety of settings which may lead to suffering of the individual or others "exaggerated personality traits"

Answer 35

R- relationships affected (pathological) E - enduring (persistent) P - Pervasive O - Onset in childhood/adolescence (Persistent) R - Results in distress (Pathological) T - Trouble in occupational/social performance (Pathological)

Answer 36

``` O - openess to imagination C - Conscientiousness E - Extraversion A - Agreeableness N - Neuroticism ```

Answer 37

M > F in cluster A, anankastic, dissocial types F > M in histrionic, emotionally unstable types Around 10% of the population and 2% have EUPD

Answer 38

Low 5-HT/seretonin levels.

Answer 39

- There are some positive schizophrenia symptoms - Eccentric thoughts and ideas (main difference between this and schizoid) - Paranoid or bizarre ideas - Social withdrawal - Cold/inappropriate affect

Answer 40

- Negative schizophrenia symptoms

Answer 41

``` S- Sensitive U- Unforgiving S- Suspicious P- Posessive and jealous personality disorder E- Excessive self-importance C- Conspiracy theories T- Tenacious sense of rights Differentials: Schizophrenia, delusional disorder ```

Answer 42

A- Anhedonic L- Limited emotional range L- Little sexual interest A- Apparent indifference to praise/criticism L- Lack close relationships O- One player activities N- Normal social conventions ignored E- Excessive fantasy world Differentials: Depression, autism spectrum, psychosis, phobia JUST NEGATIVE SYMPTOMS AND SIGNS OF SCHIZOPHRENIA

Answer 43

``` A - Attention seeking C - Concerned with appearance T - Theatrical O - Open to suggestion R - Racy and suggestive S - Shallow affect Differentials: BAPD 1/2, substance ```

Answer 44

A - Affective instability E - Explosive behaviour I - Impulsive (inc self harm) O - Outburts of anger U - Unable to plan/consider consequences Differentials: affective disorder, psychosis

Answer 45

F - Forms, but cannot maintain relations I - Irresponsible G - Guiltless H - Heartless T - Temper easily lost S - Someones else's fault Differentials: Substance misuse, psychosis, manic

Answer 46

- Borderline (disturbance in self-thoughts) | - Impulsive (mainly impulsivity)

Answer 47

``` D - Doubtful E - Excessive detail T - Tasks not completed A - Adheres to rules I - Inflexible L - Likes own way E - Excludes pleasure and relationships D - Dominated by intrusive thoughts Differentials: OCD, autism spectrum ```

Answer 48

A - Avoids social contact F - Fear rejection/criticism R - Restrictive lifestyle A - Apprehensiveness I - Inferiority D - Does not get involved unless sure of acceptance Differentials: phobia, autism, schizophrenia, depression

Answer 49

``` S - Subordinate U - Undemanding F - Fears abandonment F - Feels helpless when alone E - Encourages others to make decisions R - Reassurance needed Differentials: Cognitive impairment, anxiety disorder ```

Answer 50

An immature response where a person cannot reconcile the good and bad in someone and only views people as all good or all bad (often cannot maintain relationships)

Answer 51

An immature ego defence where one assumes a different identity with a situation

Answer 52

A mature ego defence where one takes an unacceptable personality trait and uses it to drive a respectable work that does not conflict with their ego/values (eg youth with anger issues signs up to a boxing academy)

Answer 53

An immature ego defence where one suppresses unacceptable emotions and replaces them with their exact opposite (eg a man with homoerotic desires becomes a champion of anti-homo policy)

Answer 54

Revert to an immature behaviour in a stressful situation (bang desk in frustration)

Answer 55

Someone models the behaviour of someone else (eg an older brother playing with a dead younger brothers toys)

Answer 56

Defence mechanism when someone takes out their emotions on a neutral person (not likely to respond to them)

Answer 57

A person assumes an innocent/neutral character is responsible or as guilty as the patient, for the patient's actions

Answer 58

- Collateral history - Check for REPORT criteria - List personality traits and match to cluster criteria (> 3 and REPORT required)

Answer 59

1st Line: Crisis plan (contact numbers, sedative antihistamies) Biopsychosocial approach: Meds: Antipsychotics, Antidepressants, Anticonvulsants

Answer 60

Antipsychotics

Answer 61

Antidepressants (SSRIs)

Answer 62

Anticonvulsants (Lithium)

Answer 63

Group based CBT

Answer 64

- Dialectical behaviour therapy (subtype of CBT) | - 1st line of Emotionally unstable PD

Answer 65

- Focuses on factors contributing to emotional instability

Answer 66

Validation: emotions are acceptable Dialectics: Showing you things in life are rarely black or white, helping be more open

Answer 67

- Similar to CBT - Cognitive analytics therapy - Focuses on specific issues to describe, understand their origins, and develop methods to change ideas surrounding the specific problems

Answer 68

For emotionally unstable PD - Integrative psychotherapy; bringing together aspects of psychodynamic, CBT and systemic approaches - Teaches you how to think about thinking - This can help you understand other people's viewpoints as you can examine their thinking

Answer 69

- Impatient, aggressive, competitive people, thought to be at higher risk of heart disease

Answer 70

Personality disorder is associated with a family history of personality disorder, as well as a history of depression and alcohol dependency

Answer 71

Children with ‘difﬁcult’ temperaments have greater problems coping as adults, possibly because they ﬁnd it harder to develop supportive relationships, and are more distressed by negative events. Early attachment difﬁculties are also associated with personality disorder

Answer 72

Personality disorder is associated with insecure attachment and traumatic, neglectful, or chaotic upbringing.Many people experience traumatic childhoods, and it is not understood why most are resilient, whilst others develop a personality disorder or another mental illness(e.g. depression, eating disorders, or schizophrenia).

Answer 73

Impulses are expressed through actions, without conscious awareness of the underlying emotion (e.g. Phoebe’s self-harm rather than sadness)

Answer 74

Using imagination to escape from the painfulness of reality (e.g. Masson’s daydreams prevent him from feeling lonely).

Answer 75

There is evidence of lower serotonin levels in dissocial personality disorder. Serotonin has been implicated in regulation of impulsivity and aggression

Answer 76

S - Self-image unclear C -Chronic empty feelings A -Abandonment fears R - Relationships are intense and unstable S - Suicides and self harm Differentials: adjustment disorder, depression, psychosis (patients occasionally experience ﬂeeting psychotic features)

Answer 77

L - Lacks impulse control O - Outbursts or threats of violence S - Sensitivity to being thwarted or criticized E - Emotional instability I - Inability to plan ahead T - Thoughtless of consequences Differentials: Adult ADHD, affective disorder, adjustment disorder

Answer 78

A pattern of substance use causing physical, mental, social and occupational dysfunction

Answer 79

A transient state of emotional and behavioural change after psychoactive substance use: dose dependant and time limited

Answer 80

1. Alcohol 2. Opiates 3. Benzodiazepines

Answer 81

A pattern of use likely to cause physical or psychological damage.

Answer 82

A cluster of physiological, behavioural and cognitive symptoms in which the use of a substance takes a much higher priority than other behaviours that once had a greater value (ICD-10)

Answer 83

A transient state occurring while readjusting to lower levels of a drug in the body.

Answer 84

Psychotic symptoms occurring during or immediately after PS use, characterised by vivd hallucinations, abnormal affect, psychomotor disturbances, persecutory delusions and delusions of reference.

Answer 85

Memory and other cognitive impairments cause by substance use (ie. Wernickes)

Answer 86

Where effects on behaviour, affect or cognition lasting beyond the period during which direct PS effect might be expected.

Answer 87

Any loss of abnormality of psychological, physiological or anatomical structure of function.

Answer 88

Any restriction or lack of ability (from impairment) to perform an activity considered normal

Answer 89

A disadvantage for a given individual that limits or prevents the fulfilment of a role that is normal

Answer 90

- IQ of less than 70 - Impaired social/adaptive functioning - Onset in childhood

Answer 91

Mild - IQ 50-70 Moderate - IQ 35-50 Severe - IQ 20-35 Profound - IQ < 20

Answer 92

LD register LD school Difficulty reading and writing Special Education Needs Assessment

Answer 93

Milestone delay Difficulty managing schoolwork Poor sleep-wake cycle

Answer 94

Difficulty with peers Inappropriate sexual behaviours Difficulty transitioning

Answer 95

Difficult day-to-day functioning | Needs extra support

Answer 96

- Intellectual impairment: WAIS III (Wechsler Adult Intelligence Scale) - Verbal IQ + Performance IQ = Full scale IQ ``` - Adaptive and social functioning: ABAS II (Adaptive behaviour assessment system) Clinical Interview (leave plenty of time) - establish presence in childhood Physical examinations (sight and hearing) School reports ```

Answer 97

- Biopsychosocial MDT (psychiatrist, OT, SALT, specialist nurse, educational support, social support) General help: - Choice board - Scheduling board - Self-help board - Communication aids Medications: Start slow, go slow (treat co-morbid medical and psychiatric problems) - Melatonin - helps with poor sleep cycles Psychosocial interventions: - CBT - Family therapy - Psychodynamic therapy - Art therapy Challenging behaviours: (identify/remove cause --> behavioural analysis --> antipsychotics) - Risperidone - short-term use, last line if no cause can be found

Answer 98

- Patients with LD have a higher prevalence of psychological symptoms than general population - Can be difficulty diagnosing other psychological conditions due to language difficulties and atypical presentations

Answer 99

``` Learning disability usually presents in childhood, but may be missed if mild. Abilities can be delayed, reduced ,or absent in: • language • schooling • motor ability • independent living • employment • social ability ``` Behavioural difﬁculties may arise, secondary to a combination of communication problems, psychiatric or physical illness, epilepsy, or suboptimal support for individual needs. ‘Behavioural phenotypes’ are commonly recognized behaviours in particular syndromes, e.g. self-harm in Lesch-Nyhan syndrome.

Answer 100

- Language is usually reasonably good, although its development may be delayed. - Problems may go undiagnosed, although individuals struggle through school or may be labelled with behavioural problems. - With appropriate support, many people live and work independently.

Answer 101

- Language and cognitive abilities are less developed. - Reduced self-care abilities and limited motor skills may necessitate support. - May need long-term accomodation with their family or in a staff-supported group home. - Simple practical work should be achievable in supported settings.

Answer 102

- Marked impairment of motor function. - Little/no speech during early childhood (some may develop during school years). - Simple tasks can be performed with assistance. - Likely to require their family home or 24-hour-staffed home.

Answer 103

- Severely limited language, communication, self-care, and mobility. - Signiﬁcant associated medical problems. - Usually require higher levels of support.

Answer 104

Diagnostic overshadowing describes the tendency to attribute everything to the learning disability itself. Changes in behaviour, mental state, or ability are dismissed, despite usually indicating physical or mental illness in people without a learning disability.

Answer 105

1. Autistic spectrum disorders: people with Asperger’s syndrome (autism with normal intelligence) may have signiﬁcant social deﬁcits, communication difﬁculties, and difﬁculties in living independently 2. Epilepsy may cause transient cognitive impairment. Very frequent uncontrolled seizures can mimic persistent cognitive impairment. 3. Adult brain injury or progressive neurological conditions: learning disabilities are neurodevelopmental disorders, occurring while the brain is still developing. If the patient presents late, it is important to decide whether or not impaired intellect was present before any adult illness. 4. Psychiatric: severe and enduring mental illness such as schizophrenia can lead to chronic cognitive impairment, reduced social functioning, and associated speech disorders—mimicking a learning disability. Exclude intellectual impairment prior to the onset of psychiatric symptoms. 5. Educational disadvantage/neglect: lacking the opportunity to learn must be distinguished from a learning disability

Answer 106

1. IQ testing 2. Functional assessment of skills, strengths and weakness 3. Detailed developmental history from parents 4. FBC, U&E, LFT, TFT, bone proﬁle—to exclude reversible disturbances. 5. Additional blood tests for known LD causes 6. Investigations for associated physical illnesses, e.g.EEG for epilepsy 7. Genetic testing if appropriate

Answer 107

1. Prevention - Education - Improved antenatal/perinatal care - Genetic counselling - Early detection and treatment of reversible causes 2. Treat physical comorbidity 3. Treat psychiatric comorbidity 4. Educational support 5. Psychological therapy 6. Other support

Answer 108

A physical complaint without evidence of underlying organic cause

Answer 109

Partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations and control of bodily movements.

Answer 110

Disorders of physical functions under voluntary control and loss of sensation - 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

Answer 111

An internal conflict which is converted into physical manifestations - 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

Answer 112

Disorders involving pain or autonomically-controlled sensations - multiple physical SYMPTOMS present for at least 2 years - patient refuses to accept reassurance or negative test results

Answer 113

- Dissociative amnesia: Loss of memory (too great to be explained by ordinary forgetfulness) - Dissociative fugue: Dissociative amnesia + purposeful travel beyond everyday range ("Travel far and wide") - Dissociative stupor: Lack of voluntary movement/normal responses to external stimuli. Evidence of stress from recent events - Trance and possession disorder: Temporary loss of personal identity and full sense of awareness of surroundings - Dissociative motor disorders: Loss of ability to move whole/part of limbs. Close resemblance to ataxia, apraxia, akinesia, aphonia, dysarthria, dyskinesia and seizures. - Dissociative convulsions: Mimic epileptic seizures (tongue biting, bruising from falls and incontinence is rare). Consciousness maintained or replace by a state of stupor or trance - Dissociative anaesthesia: Areas of anaesthesia do not follow normal dermatomal distribution. May be accompanied by paresthesia.

Answer 114

- Traumatic events - Intolerable problems - Disturbed relationships

Answer 115

Onset = acute, specific, dramatic, following sudden stress of conflict Presentation: - Paralysis - Aphonia (cannot speak) - Blindness - Seizures - Multiple personalities - Stupor - Fugue (loss of memory and wonder away from home) - Psychogenic amnesia (loss of all memories, including own identity)

Answer 116

1st: Exclude organic cause - raised prolactin after real seizure - normal prolactin after dissociative convulsion 2nd: Identify and treat any co-morbid depression

Answer 117

- 75% of people have self-limiting spontaneous recovery - Supportive therapy: Encourage return to normal activity Avoid reinforcing behaviour (providing a wheelchair for dissociative stupor/motor disorder) Address physical stressors rather than focus on physical manifestations

Answer 118

- Multiple, recurrent and frequently changing physical symptoms of > 2 years. - Have complicated history of contact with medical care --> many negative investigations carried out - Symptoms may be referred to any part or system of the body - The disorder is chronic and fluctuating --> disruption of social, interpersonal and family behaviour

Answer 119

10:1 Female to male

Answer 120

- Undifferentiated somatoform disorder: Multiple varying and persistent complaints of <2 years - Hypochondrial disorder: Persistent preoccupation with idea of having a serious/progressive physical disorders. Normal sensations interpreted as abnormal or distressing. Co-morbid anxiety and/or depression common. Patient maintains their belief depite being told otherwise (overvalued idea) - Often cancer, pre-occupation with a single problem - Somatoform autonomic dysfunction: Symptoms presented as if due to physical disorder of system/organ largely or completely under control of the ANS. Objective autonomic arousal (palpitations, sweating, flushing, tremor). Subjective non-specific (fleeting aches/pains, burning sensation, bloating) - Persistent somatoform pain disorder: Persistent, severe and distressing pain (not otherwise explained). Evidence of emotional conflict of psychological problems

Answer 121

- Multiple recurrent and frequently changing physical symptoms - History of interactions with medical professionals without outcomes - Social and occupational impacts

Answer 122

- Full history and MSE (with physical examination) - Exclude organic cause (eg stroke) - Exclude co-morbid conditions (eg. with HADS for potential depression)

Answer 123

Make sure continuity of care - see by the same doctor each time 1st: Explain and reassure 2nd: CBT Also treat co-morbid conditions (eg depression)

Answer 124

This is the unconscious expression of psychological distress through physical symptoms ,e.g. rather than anger, a patient experiences abdominal pain

Answer 125

1. Assessment - history and examination 2. Explain and reassure - Use the Reattribution Model: • Ensure they feel understood. • Broaden the agenda from a physical cause to a physical and psychological explanation. • Make the link between symptoms and psycho-logical factors. 3. Avoid over-investigation, unnecessary specialist referral or medications 4. Emotional support 5. Encourage normal function 6. Antidepressants - even without depression symptoms 7. Treat co-morbid conditions 8. CBT 9. Graded exercise - helpful in some conditions eg fibromyalgia and CFS

Answer 126

Shorter duration of MUS and milder symptoms are linked to better prognosis.

Answer 127

Repetitive and persistent pattern of antisocial behaviour with violates basic rights of others that are not in line with age appropriate social norms

Answer 128

Childhood and adolescence | Less than 18 years old

Answer 129

- Unknown: parental (violence, failure to set rules) | - Child: (low IQ, CNS impairment)

Answer 130

5-10 y/o: 7% boys and 3% girls | 11-16 y/o: 8% boys and 5% girls

Answer 131

- Low socioeconomic status - Deprived living - Children in the care system - ADHD - Substance misuse - Male

Answer 132

Repetitive and persistent pattern of dissocial, aggressive or defiant conduct: - Excessive levels of fighting or bullying - Cruelty to other people or animals - Severe destructiveness of property -Fire-setting More severe than ordinary mischief or adolescent rebelliousness

Answer 133

- Reports from parents/teachers | - Developmental assessment

Answer 134

1st: Parent management training programmes (Triple-P or Webster-Stratton) - Needs strong parental cooperation and motivation - If weak outcome due to lack of parental engagement, move to 2nd line 2nd: Child individual or group interventions focussed on problem solving and anger management - Often, affected children do not have the motivation to engage with these well Remedial educational teaching (for missed school) Alternative peer activities

Answer 135

``` - 50% develop antisocial personality disorder Poorer prognosis: - Early onset - Family criminal record - Low IQ - Low socio-economic status - Co-morbidities - Poor parenting ```

Answer 136

- Oppositional-defiant disorder: (characterised by angry, defiant behaviour to authority) - Unsocialised CD (significant abnormality with relationships with other children) - Socialised CD (generally well-integrated into a peer group) - CD confined to family context

Answer 137

Persistent/life-long delusions with few/no hallucinations - <3 months is temporary - >3 permanent Cannot include: - Clear auditory hallucinations - Schizophrenia symptoms (delusions of control, blunting of affect) - Evidence of organic/brain disease NOTE: the presence of an occasional or transitory auditory hallucinations does NOT rule out this diagnosis

Answer 138

- Old age - Low socioeconomic status - Immigration - Substance abuse - Social Isolation - Premorbid personality disorder - Family history - Group delusions - Sensory Impairment - Head injury

Answer 139

Acute onset is better prognosis

Answer 140

- Excess dopamine and ACh activity - Neurological lesions to the temporal lobe, limbic system, Basal ganglia - Cortical damage (persecutory delusions)

Answer 141

- Freud (delusions serve defensive functions) - Distrust, suspicion, jealousy, low self-esteem - Social isolation, seeing own defects in others - Rumination over meaning and motivation

Answer 142

- A - S - E - P (hallucinations and delusions): Non-bizzare delusions, rarely hallucinations - T (forms, content possession): Process un-impaired, content preoccupied, single theme of thoughts - I: Impaired (delusions affect thought and behaviour) - C: Intact

Answer 143

AKA De Clerembault syndrome | Excessive sexual desire, often believe a VIP in love with them

Answer 144

Believe partner is unfaithful

Answer 145

>2 people are same person changing disguises to deceive

Answer 146

Shared delusions/hallucinations between people

Answer 147

Consciously pretending to have a medical illness.

Answer 148

- Full history and collateral history - MSE - Exclude organic causes

Answer 149

- Substance induced - Dementia + delirium - Hypochondriasis - Mood disorder with delusions - Body dysmorphia - Paranoid personality disorder - Schizophrenia - OCD

Answer 150

- Consider admissions if high risk to self or others Biological - Antipsychotics (poor evidence) - SSRI (cover other potential missed differentials) - BDZ (for anxiety) Psychological: - Individual CBT - Pyschoeducation Social: - Social skills training - Pyschoeducation - Family therapy

Answer 151

A transient disorder that develops in an individual without an other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days - does not tend to persist greater than 1 month - DSM-V says symptoms must last greater than 3 days - If they last longer than 1 month, consider PTSD Onset of symptoms within minutes

Answer 152

- PTSD is diagnosed based on symptoms in clusters, not in totality - PTSD has a dissociative sub-type, however, in ASD, depersonalisation and derealisation are symptoms - PTSD includes non-fear based symptoms (risky behaviour) but ASD does not

Answer 153

- Physical or sexual assault - Death - War

Answer 154

Key features: - Initial state of daze (may manifest as stupor) - Constriction of consciousness field - Narrowing attention - Attention to comprehend stimuli; disorientation Other symptoms: - Autonomic signs of panic (fight of flight): occurs in minutes and disappear in hours/days - Tachycardia - Sweating - Hyperactive - Tachypnoea - Hypertension - Partial or complete amnesia may be present - Depersonalisation - Derealisation

Answer 155

- Full history and collateral history - MSE if indicated - Needs to be a clear history between stressor and reaction

Answer 156

- Support and reassurance | - BDZ for short-term distress

Answer 157

- May progress to PTSD | - If formal, immediate, psychological 'debriefing' is undertaken, future PTSD risk increased

Answer 158

States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or stressful life event - Beginning within 1 month of the stressful event - Not lasting longer than 6 months Prolonged abnormal response to stress starting within 1 month of stressful event, not lasting over 6 months

Answer 159

- Maladaptive psychological response to stressful life events - divorce, unemployment - Any age of onset

Answer 160

CONSIDER AN ASSOCIATED CONDUCT DISORDER (ESP IN ADOLESCENCE) - Depressed mood - Anxiety and worry - Feeling of inability to cope - Disability in the performance of daily routine Symptoms of anxiety or depression without biological symptoms to depression. Should not be sufficient severity/prominent in its own right to justify more specific diagnosis Persons reaction deemed greater than expected for the situation, but not as severe to diagnose anxiety or depression

Answer 161

- recognisable sequence of stages that can last up to 2 years eg. shock --> anger --> guilt --> searching --> sadness --> acceptance - vivid dreams of dead person being alive, pseudohallucinations

Answer 162

- Delayed onset, greater intensity of symptoms or prolongation of the reaction, preoccupation with negative thoughts, suicidal ideations, hallucinatory experiences - More likely when relationship with deceased was problematic or there was a sudden death - Distinguish from depression: Sadness and symptoms are focused around the person that was lost In depression, the symptoms are more free-floating and not focussed on anything in particular

Answer 163

- Full history and collateral history | - MSE if needed

Answer 164

- Support, reassurance and problem-solving usually all that are recovered Adjustment disorder: - Biological --> antidepressants, antianxiolytics/hypnotics - Psychosocial --> supportive counselling Grief reaction: - Biological --> antidepressants - Psychosocial --> supportive counselling

Answer 165

- Short-term interruption to life | - Symptoms usually improve after resolution of cause

Answer 166

Arises as a delayed onset or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost everyone - Must last > 1 month - Often begins within 6 months of trauma (often within the 1st month of the trauma)

Answer 167

6.8% lifetime prevalence | F>M

Answer 168

- FHx - Female - Traumatic events - Neurotic personality type - Neuroanatomy - Genetics - Low social class

Answer 169

- Genetics: Some predisposition | - Neuroanatomical: Hyperactive amygdala (emotional processing), atrophied hippocampus (memory storage)

Answer 170

- Traumatic events: 10% extreme trauma sufferers - Neurotic traits - Family history of psychiatric problems

Answer 171

(1) Re-experiencing: intrusive memories (flashbacks, nightmares, repetitive images, physical sensations) (2) Avoidance of triggers: (activities and situations reminiscent of the trauma) (3) Hyperarousal: (hyper-vigilance, enhanced starttle reflex, insomnia, irritability, cannot relax) Other: - mental health problems: depression, anxiety, phobias - self-harming or destructive behaviour: drug or alcohol misuse - Physical symptoms: headaches, dizziness, chest pain, stomach aches - Anhedonia/emotional numbing

Answer 172

- Majority recover | - Some suffer for many years leading to an enduring personality change

Answer 173

- Full history | - Trauma screening questionnaire (10 questions, measure re-experiencing and arousal symptoms)

Answer 174

Begin by classifying the level of functional impairment as mild, moderate and severe MILD: symptoms < 4 weeks --> watchful waiting + treat co-morbid conditions CBT with trauma focus: offer to all patients with moderate-severe PTSD, presenting > 1 month Eye movement desensitisation and reprocessing (EDMR): offer if moderate-severe PTSD, >3 months after non-combat relayed event (patient recalls experience in as much detail as possible in a state of relaxation, whist their eyes are fixed on the therapists finger as it moves from side to side --> aids memory processing)

Answer 175

- Combination of exposure therapy and trauma-focused therapy - Computerised or face-to-face NB: immediate post-trauma formal debriefing actually increases risk of PTSD

Answer 176

Not currently recommended 1st line: SSRI (setraline) or SNRI (venlafaxine) 2nd line: atypical antipsychotics

Answer 177

* Flashbacks: vividly reliving the trauma, feeling as though it is ‘happening all over again’. * Nightmares. * Intrusive memories: being unable to keep the mind clear of memories of what happened.

Answer 178

Avoiding reminders of the event (these often trigger ﬂashbacks and increased anxiety). People often try to avoiding thinking about the trauma

Answer 179

* Persistent inability to relax. * Hypervigilance: the patient feels as though they are always on ‘red alert’. * Enhanced startle reﬂex (exaggerated reaction to the unexpected). * Insomnia. * Poor concentration. * Irritability.

Answer 180

- Depression - Anxiety - Adjustment disorder

Answer 181

- presentation at 2-4 years old - most have decreased IQ - Boys 75% > girls 25%

Answer 182

- Siblings with ASD - parental psychotic/affective disorder - Birth CNS defect - prematurity (<35 weeks gestation age) - sodium valproate - LD - chromosomal disorder (Downs) - genetics disorder (fragile x syndrome) - ADHD

Answer 183

- Fragile X syndrome - Tuberous sclerosis - Neurofibromatosis - Di-george - Rett's syndrome - Mitochondrial disorders - Downs - Prader-willi/Anglemans syndrome - Epilepsy

Answer 184

1.4 per 1000

Answer 185

- Distinguished by no delay in language/cognitive development - 0.3 per 1000 - psychosis in adult life - marked clumsiness

Answer 186

- Medical disorder - X linked - MECP 2 gene - Affects girls more than boy - <0.2 per 1000 - Develop normally till 2 years - sudden deterioration + less social interaction + struggle to feed - Symptoms include impairments in language and coordination and repetitive movements. Those affected often have slower growth, difficulty walking, and a smaller head size.

Answer 187

- <0.2 per 1000 - Childhood disintegrative disorder (CDD), also known as Heller's syndrome and disintegrative psychosis, is a rare condition characterised by late onset of developmental delays—or severe and sudden reversals—in language, social function, and motor skills.

Answer 188

- 4.5 per 1000 | - Most common type of autism

Answer 189

(A) Abnormal or impaired development evident <3 years old - receptive or expressive language - development of selective social attachments or of reciprocal social interaction - functional or symbolic play

Answer 190

(B) A total of >6 symptoms from 1,2,3 with >2 from 1 and >1 from each of 2 and 3: (1) Qualitative impairment in social interaction: - Failure to adequately use eye to eye gaze - Failure to develop peer relationships - Lack of socio-emotional reciprocity - Lack of spontaneous seeking to share enjoyment, interest etc with other people (2) Qualitative abnormalities in communication - delay in or total lack of development of spoken languages (no attempt to compensate) - relative failure to initiation or sustain conversation - stereotyped and repetitive use of language or idiosyncratic use of words or phrases - lack of varied spontaneous make believe play (3) Restricted repetitive and stereotyped pattern of behaviour, interest and activities - Preoccupation with stereotyped and restricted patterns of interest - apparently compulsive adherence to specific routines or rituals - repetitive motor mannerisms involving hand, finger flapping and whole body movements - preoccupation with non-functional elements of play materials (such as their odour)

Answer 191

The clinical picture is not better described by other medical disorders.

Answer 192

Deficits in evident when <3 years old: - verbal and non-verbal communication - reciprocal social interaction - restrictive or repetitive behaviours/interest

Answer 193

- Immediate/delayed (>2 year old) echolalia - immediate non-communicative repetition of words or phrases - the child is simply repeating exactly what was heard without synthesising the intrinsic language

Answer 194

- hearing, speech and language assessment - cognitive assessment (eg WICS, WPPSI) - Autism diagnosis assessment (GOLD STANDARD): - -> ADI-R: autism diagnostic inventory - revised - -> ADOS: Autism diagnostic observatory schedule - Childhood autism rating scale (CARS)

Answer 195

- MDT/patient-centred care is key as this is a spectrum. Everyone is different

Answer 196

- paediatrician - child - adolescent psychiatrist - educational or clinical psychologist - SALT - OT - specialist health visitor/social worker - specialist nurse

Answer 197

- Psychosocial play-based intervention - increase attention, engagement (play specialist) and reciprocal communication (SALT) - increase carers and teachers understanding of patients communication/interaction pattern (EarlyBird <4; EarlyBirdPlus (4-8)) - Include techniques to expand the child's communication, interactive play and social routines

Answer 198

- From behavioural nurses | - Focuses on improving specific behaviours as well as adaptive learning skills

Answer 199

- Offer an assessment of the family/carer needs - Plan for the future including transition for the child - Plan for extra support (educational, social)

Answer 200

- When they are 16 and older - Care plan approach system - Involve the young person and offer a social care assessment at age 18

Answer 201

- Psychosocial assessment (anticipate and reduce factors increasing risk of behaviour) - Reduce impairment in communication (consider visual aids) - co-existing physical disorders (otitis media) - co-exsisting mental health problems (ADHD,GAD) - physical environment (lighting, noise) - reduce unintentional reinforcement or behaviour that reinforces

Answer 202

- Pharmacological - used if behaviour making psychosocial training ineffective: - Antipsychotic medication (review at 3-4 weeks; stop at 6 weeks if no clinical indication) - Melatonin for sleep difficulties - Methyphenidate (Ratilin) for attention difficulties - SSRIs for obsessional behaviours

Answer 203

1. Reciprocal social interaction: Autistic children are not interested in people; they appear aloof, tend to play alone, and lack the ability to ‘read’ emotional states in others. Attachments are impoverished, with-out mutuality or warmth; these children do not turn to parents for comfort. Eye contact may be odd, either avoidant or ‘looking through’ you. 2. Communication abnormalities: Expressive speech and comprehension are delayed or minimal. Ideas are taken literally (concrete thinking). Gestures are usually absent (e.g. pointing, waving goodbye). Later, speech may consist of monologues, interminable questions, or echolalia (repeating what has been said), but there is no exchange. Classically ‘I’ and ‘me’ are confused with ‘you’, ‘he’, and ‘she’ (pronominal reversal) 3. Restricted behaviours and routine: Autism is characterised by repetitive, stereotyped behaviours and restricted interests—rather than imaginative play. Even small changes in routine (e.g. the wrong spoon) can result in intense tantrums.

Answer 204

1. Deafness causes poor language acquisition. 2. Asperger’s syndrome 3. Speciﬁc language disorder: delayed speech but normal IQ and social ability. 4. Learning disability: IQ problems but relatively intact social skills. 5. Rare disorders, e.g. childhood schizophrenia, Rett’ss syndrome. 6. Neglect can lead to language delay and poor socialization—reversible unless severe

Answer 205

1. Hearing tests. 2. Speech and language assessment. 3. Neuropsychological testing—assess IQ and conﬁrm diagnosis.

Answer 206

1. Support and advice for families, e.g. the National Autistic Society. 2. Behaviour therapy —reinforce positive behaviours 3. Speech and language therapy. 4. Special education. 5. Treat comorbid problems (e.g. epilepsy). 6. Antipsychotics or mood stabilizers are occasionally used for extreme aggression or hyperactivity.

Answer 207

Only 1–2% of adults gain full independence, with most needing lifelong support and care. Good prognostic indicators are an IQ over 70 and acquisition of some useful language

Answer 208

* An autistic spectrum disorder. * Male:female = 8:1. * Poor social skills and restricted interests. * Normal language and IQ. * Tendency to literal interpretation of language and difﬁculty in reading social cues. * Management: advice, support, routine, social skills training. * Prognosis is much better than for autism.

Answer 209

Tics are repetitive, involuntary, and purposeless movements or vocal utterances. They are categorised as simple(e.g. blinking, throat-clearing) or complex (e.g. self-hitting, swearing). Transient simple tics affect 10% of children, and are three times more common in boys.There is often a family history of problems and obsessive–compulsive disorder is commonly comorbid. Stress or stimulant medications usually worsen tics. They recede when the sufferer is concentrating on something else.Tics can be voluntarily suppressed at the cost of internal tension, which is relieved by their expression. Reassurance and stress management are effective treatments but clonidine (adrenergic agonist) or haloperidol(antipsychotic) are also useful.

Answer 210

A type of hyperkinetic disorder (HKD) defined as persistent and severe impairment of psychological development

Answer 211

Impaired attention and overactivity: - Impaired attention --> lack of persistent task involvement and quick moving on from incomplete tasks - Overactivity --> characterised by restlessness, talkativeness, noisiness and fidgeting - Impulsivity Present prior to 6 years of age, and of long duration (6 months) Impairment present in 2 or more settings (home, classroom, clinic) Exclude organic causes

Answer 212

- Dysfunction of brain neurone circuitry that rely on dopamine as a NT which control self-monitoring/regulation - 3:1 boys vs girls - prevalence 2.5% (double of ASD)

Answer 213

- Family history - prematurity - LBW - FAS - conduct/mood disorder - ASD - LD

Answer 214

- Assess social/educational impact in context of age - Rating scales --> cannot provide a diagnosis : Conners comprehensive behaviour rating scale (age 6-18) Strengths and difficulties questionnaire

Answer 215

MDT focussed

Answer 216

- Paediatrician - Psychiatrist - ADHD SNs - Mental health and learning disability trust - CAMHS - parent groups - social care workers - social/college and school nurses

Answer 217

Manifestation of ADHD will change as child gets older: - hyperactivity tends to becomes less of a problem - inattention becomes more pronounced as the task they face become more complex Outcome: - some may grow out of it - 90% get conduct disorder if untreated - 15% have ADHD as an adult

Answer 218

- not particularly evidence based - importance of balance diet and regular exercise - explore foods that seem to influence behaviour (recommend keeping a food diary) - dietician referral if relationship with certain foods is observed in the dairy

Answer 219

▪ Baseline height, weight, HR, BPand ECG ▪ Monitor: • Response with symptom rating scales (e.g. Conner’s) • Development of tics after taking stimulant medication • Sexual dysfunction, seizures, sleep disturbance and worsening behaviour ▪ Measure weight (BMI for adults) every 3 months (<10yo) or 6months (>10yo) ▪Measure height , HR and BP every 6 months (may suppress appetite and cause growth impairment) • Include plotting on a growth chart • If interruptions to growth → referral and a planned break to allow catch-up growth

Answer 220

1st line in all cases if there is a negative impact on child’s/young person’s development of family life: ▪ Consider period of watchful waiting for up to 10weeks (self-help, simple behavioural management) ▪ Group-based ADHD-focused support for parents ▪ Refer to specialist if severe symptoms of >10w

Answer 221

▪ 1st line: offer ADHD-focused group parent-training programme to parents and carers • 10-16 meetings in a group of 10-12 participants • Education on ADHD, parenting strategies, environmental changes ▪ 2nd line: specialist service referral

Answer 222

▪ 1st line: offer ADHD-focused group parent-training programme to parents and carers • 10-16 meetings in a group of 10-12 participants • Education on ADHD, parenting strategies, environmental changes ▪ 2nd line: specialist service referral and medications if ADHD persists: • 1st line (6 weeks) = methylphenidate → trial for 6 weeks o Pharmacokinetics: CNS stimulant (DA, NA reuptake inhibitor) o SEs: abdominal pain, nausea, dyspepsia • 2nd line (monitor SEs) = lisdexamphetamine → 3rd line if side effects • 3rd line = dexamphetamine • 4th line = atomoxetine (NARI) or guanfacine • Side effects: - Loss of appetite - Palpitations - Mood changes - Tics ▪ 3rd line: CBT if problems in social skills, self-control, active listening, dealing with expressing feelings ▪ Other medications: • Clonidine → sleep disturbance, rages or tics • Antipsychotics→aggression and irritability

Answer 223

- Hyperactivity Children are boisterous with excessive energy. They seem constantly on the move: running, jumping, climb-ing, unable to sit still for any length of time without ﬁdgeting, squirming, or wandering about. They are usually noisy and garrulous. -Inattention Children are distractible and unable to concentrate, ﬂitting chaotically between activities and leaving tasks unﬁnished. -Associated features. These children are impulsive and reckless, rarely stopping to consider the consequences of their actions. This can result in risky behaviour, e.g. poor road safety. They tend to be clumsy and accident prone, and may be dis-obedient, although often through impulsivity rather than deliberate naughtiness. Additionally, they are socially disinhibited, paying little attention to normal social conventions; they interrupt others and ﬁnd it hard to wait their turn. Learning disability and conduct disorder are associated.

Answer 224

1. Depression/anxiety—both can cause agitation. 2. Mania (extremely rare in childhood). 3. Conduct disorder

Answer 225

1. Family: education on ADHD; advice on parenting and boundaries. 2. Behavioural management 3. Support for teachers: appropriate schooling placement. 4. Family therapy. 5. Stimulant medication (e.g. methylphenidate, dexamphetamine). This increases monoamine pathway activity, improving concentration and allowing learning and maturation. Adverse effects include appetite suppression and insomnia. ‘Drug holidays’ (weekends and school holidays) limit growth retardation to 1cm. Stimulant medications are not addictive in ADHD

Answer 226

Behaviour is persistently antisocial, not merely ‘rebellious’,e.g. bullying, stealing, ﬁghting, ﬁre-setting, truancy, and cruelty to animals or people. In socialized CD the child has a peer group (often sharing in the antisocial behaviour). Children with unsocialized CD are rejected by other children, which often makes them more isolated and hostile.

Answer 227

1. Oppositional deﬁant disorder: a milder form of CD, occurring in children under 10, with provocative, angry, and disobedient behaviour towards adults. No extreme antisocial behaviour is present. 2. ADHD 3. Depression: some children present with antisocial behaviour.

Answer 228

1. Family education: the family members need to understand CD and recognize that they may reinforce problems. 2. Parent management training: teaches parents to reward good behaviour and deal constructively with negative behaviours. 3. Family therapy: the family meets with a skilled therapist to discuss current problems. They are helped to cooperate in problem solving. 4. Educational support. 5. Anger management for the child. 6. Treat comorbid problems, e.g. ADHD.

Answer 229

50% develop substance misuse disorder or dissocial personality disorder as adults.

Answer 230

- recurrent attacks of severe anxiety, which is not restricted to any particular situation or set of circumstances and are therefore unpredictable - several within a month - relatively fine with minimal anxiety in between episodes - Panic disorder should not be a main diagnosis if a depressive disorder exists at the time attacks start

Answer 231

Episodic paroxysmal anxiety

Answer 232

- described as 100% anxiety with accompanying physical symptoms - sudden onset, occur out of the blue, lasts less then 30 mins - alarming thoughts (i am going to die) provoke further panic until reassurance or engagement in 'safety behaviour' occurs (call ambulance, take aspirin) - palpitations - chest tightness - choking sensation - pins and needles - depersonalisation - shaking - dizziness/faints - sweating

Answer 233

- Education, reassurance and self-help Step 1: low intensity psychological intervention - self help (individual, non-guided) 6 weeks - self help (individual, guided) 6 weeks with weekly therapist appointment Step 2: high-intensity psychological intervention with or without medication 1st line: CBT and SSRI (citalopram) 2nd line: after 12 weeks change class to TCA (imipramine) or add BDZ (not exceeding 2-4 weeks) Psychodynamic psychotherapy Step 3: refer to psychiatry

Answer 234

65% achieve complete remission | 10-20% continue to have significant symptoms

Answer 235

Phobias restricted to highly specific situation such as proximity to slugs or snails

Answer 236

- Contact can evoke panic - May have a family history of this phobia - most phobias lead to tachycardia, but blood or injury phobia cause an initial tachycardia followed y vasovagal bradycardia and hypotension --> may cause nausea and fainting

Answer 237

- Education, reassurance and self help - Exposure response prevention (ERP): exposing someone to maximal fear until the fear becomes extinct - all at once - Relaxation therapy and breathing techniques - Short-term BDZ for certain specific phobias (never long term)

Answer 238

- Fear scrutiny by other people leading to avoidance of social situation - Associations: low self esteem and fear of criticism - Male and female equally affected

Answer 239

- Shyness - Agoraphobia - need to escape more important - Anxious personality disorder - lifelong - ASD/Aspergers - awkward when relaxed - Schizo - delusions/paranoia

Answer 240

- Complaints of blushing, hand tremor, nausea or urinary urgency in social situations (explore situations) - Self-medicate with alcohol or drugs (to desentise) - Panic attacks NB. Will tolerate anonymous crowds, unlike agoraphobics, but smaller groups may spike anxiety

Answer 241

- Education, reassurance and self-help - Exposure response prevention (ERP) - CBT - SSRIs

Answer 242

They do not respond well to antidepressants. Most people just tend to avoid the situation.

Answer 243

Related to the level of disability.

Answer 244

Social phobias and agoraphobia

Answer 245

- A fairly well defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes

Answer 246

With or without a panic disorder

Answer 247

Inability to escape to safe place --> overwhelming urge to return home to safety

Answer 248

``` travelling queueing supermarkets crowds parks ```

Answer 249

Some may have little anxiety as they can avoid specific triggers well.

Answer 250

20-35 year olds | Gradual or precipitated by a panic attack

Answer 251

- Panic attacks | - Avoidance of phobic situations with or without isolation behaviour

Answer 252

- Depressive/obsessional symptoms | - Social phobias

Answer 253

- Education, reassurance and self-help - Exposure response prevention (ERP) Therapy: Desensitisation approach (1) : patient identifies goal and constructs hierarchy of feared situations (2) patient tackles hierarchy from least to most frightening (3) aim to stay in situation until anxiety subsidised --> challenges existing thoughts CBT: reduce patient's expectation of threat, and behaviours that maintain threat-related beliefs - explore the actual likelihood and impact of the anticipated catastrophe - test the feared situation and their belief in a catastrophic outcome using behavioural experiments - improves self confidence of the patient

Answer 254

- At least 6 months of excessive, difficult to control worry about everyday issues, that is disproportionate to any inherent risk, and causes distress or impairment - worry not due to mental disorder, substance abuse or other conditions.

Answer 255

at least 6 months

Answer 256

At least 3 of the following most of the time: - restlessness/nervousness - irritability - being easily fatigued - muscle tension - poor concentration - sleep disturbance

Answer 257

- Divorced - Lone parents - Living alone - 35-54 y/o

Answer 258

- 16-24 - married - cohabiting

Answer 259

Defining feature: free floating anxiety, no specific threat, >6 months Symptoms: psychological and physical Coping mechanisms: avoidance, alcohol, drugs and depression

Answer 260

- GAD-7 questionnaire (5=mild, 10=moderate and 15=severe) - Becks anxiety inventory - Hospital anxiety and depression scale (HADS)

Answer 261

Based on assessed severity and a stepwise approach: Step 1: written information on GAD + active monitoring + regular exercise Step 2: Low intensity psychological interventions psychological intervention - self help (individual, non-guided) 6 weeks - self help (individual, guided) 6 weeks with weekly therapist appointment - psychoeducational groups, 6 weeks and less than 12 per groups Step 3: (a) high intensity psychological interventions CBT: 12-15 weeks, 16-20 hours a week - testing the predictions of worry with behavioural experiments - looking further into errors of thinking Applied relaxation: 12-15 weeks (b) medications stepwise: Step 1: SSRI (NICE=setraline; only SSRI licensed=paroxetine) - weekly follow up due to increased risk of suicidal thinking/self harm initially Step 2: different SSRI after 8 weeks of step 1 Step 3: SSRI --> SNRI (venlafaxine) - weekly follow up due to increased risk of suicidal thinking/self harm initially Step 4: Pregabalin (antiepileptic) Step 5: quetiapine (atypical antipsychotic) Adjunct: propanolol (physical symptoms) --> never give BDZ to people with anxiety

Answer 262

Genetics - unknown genes Neurochemical - dysregulated serotonin, NA, GABA Early experiences/life events - threatening events Behavioural/cognitive theories - conditioning, negative reinforcement, cognitive theory (worrying NATs repeated), attachment theory (insecure as a child --> anxiety

Answer 263

Autonomic arousal Psychological - worries, insomnia, night terrors Motor - restlessness Neuromuscular - tremor, tension headache Gastro - dry mouth, nausea, flatulence Cardio - palpitations Resp - tight chest, dysponoea Genitourinary - urinary frequency, erectile dysfunction

Answer 264

History and physical exam - focus on social and occupational history to gauge effect on QoL ``` S - symptoms of anxiety E - episodic or continuous D - drink and drugs A - avoidance and escape T - timing anf triggers E - effect on life D - depression ``` Collateral history

Answer 265

- Becks anxiety inventory | - Hospital anxiety and depression scale (HADS)

Answer 266

- Education, reassurance and self-help: all anxiety disorders - Exposure therapy: phobias - CBT: GAD, phobias, panic disorder, OCD - SSRIs: GAD, phobia, panic disorder, OCD

Answer 267

Starting or suddenly stopping SSRIs cause anxiety symptoms for a short while

Answer 268

Recurrent obsessional thoughts or compulsive acts - obsessional thoughts and/or compulsive acts, present on most days for >2 consecutive weeks - must be a source of stress plus/minus interfere with ADLS

Answer 269

Involuntary thoughts, images, impulses which are: - self-recognised as a product of own mind - >1 thought or act resisted unsuccessfully - thoughts of carrying out the act are not pleasureable - thoughts must be unpleasantly repetitive - themed commonly (contamination, aggression, infection, sex, religion) - egodystonic (themes/ideas against that which the personal associates with their ego)

Answer 270

Repetitive mental operations or physical acts: - Compelled to perform in response to own obsessions or irrationally defined rules - Performed to reduce anxiety through irrational belief they will prevent a dreaded event

Answer 271

Obsessions and compulsions: - Body dysmorphic disorder (appearance peroccupation) - Anankastic personality disorder (lifelong personality - rigid, orderliness, hygienic) Mainly obsessions: - depressive disorder (Beck's -ve triad, 50% OCD co-morbid) - Other anxiety disorders - Hypochondrial disease - Schizo Mainly compulsions: - Habit and impulse control disease

Answer 272

If symptoms develop together, prioritise what developed first If unknown, depression priority

Answer 273

1% M>F 70% <25 yo Biological: - Genetics: relatives = 3x increased risk - Neurological: Basal ganglia implicated and affected by Sydenham's chorea, encephalitis lethergica and tourette's syndrome - Infection: streptococcal; throat --> anti-BG ABs Psychosocial: - Personality: 25% have premorbid anankastic personality (rigid, orderliness)

Answer 274

- Obsessional thoughts - Compulsions (rituals repeated over and over): = tension/discomfort ofter neutralised by compulsion (these are not inherently enjoyable) = find out how many times a day = find out how many times a day they get these and how often they do it for - Anxiety (which gets worse then longer they ignore the compulsion)

Answer 275

Bloods: FBC, TSH Rating scale: Yale-Brown OCD scale OCD screening questions: - Do you wash and clean a lot? - Do you check the time a lot? - Is there any thought that keeps bothering you that you would like to get rid of? - Do your daily activities take a long time to finish? - Are you concerned about putting things in a special order or are you very upset by a mess? - Do these problems trouble you?

Answer 276

- 25% significantly improve - 50% have moderate improvement - 25% have chronic or worsening symptoms - Co-morbid depression is common (50%)

Answer 277

- Relabel - Reattribute - Refocus - Revalue

Answer 278

CBT with ERP (exposure and response prevention) Background: CBT aims to prevent compulsive behaviour as a tool to reduce obsessions allowing the tolerated anxiety to be habituated and eventually, extinguished Therapy: ERP=gradual/graded approach (1) Pt supported to (ie) touch something dirty and, instead of immediately washing hands, is supported and talks the experience through with the therapist (2) pt constructs hierarchy of feared situations and works through them

Answer 279

- Intensive CBT with ERP - SSRI (continue for 12 months after remission) - Depression --> 20mg - Anxiety --> 40mg - OCD, BM --> 60 or 80 g Fluoxetine > setraline After 12 weeks of SSRI: TCA (Clomipramine) or alternative SSRI

Answer 280

A pattern of substance use causing physical, mental, social or occupational dysfunction

Answer 281

(1) the substance | (2) the type of disorder

Answer 282

Transient state of emotional & behavioural change after psychoactive substance (PS) use - Dose dependent - Time limited

Answer 283

a pattern of use likely to cause physical or psychological damage

Answer 284

a cluster of physiological, behavioural and cognitive symptoms in which the use of a substance takes on a much higher priority than other behaviours that once had a greater value (ICD-10)

Answer 285

transient state occurring while re-adjusting to lower levels of a drug in the body

Answer 286

psychotic symptoms occurring during or immediately after PS use, characterised by vivid hallucinations, abnormal affect, psychomotor disturbances, persecutory delusions and delusions of reference

Answer 287

memory and other cognitive impairments caused by substance use (i.e. Wernicke’s)

Answer 288

where effects on behaviour, affect, personality or cognition lasting beyond the period during which direct PS effect might be expected

Answer 289

Alcohol: 2:1 | Substance misuse: 4:1

Answer 290

1. Current use: a. T (Type) b. R (Route) c. A (Amount) d. P (Pattern) 2. Current use: a. Dependency b. Effect on life 3. Past use 4. Future use

Answer 291

- Classical conditioning – association (i.e. seeing a needle --> craving heroin) - Operant conditioning – rewarding behaviours are repeated (i.e. drug provide pleasure) and behaviours that relieve unpleasant experiences are repeated - Social learning theory – we copy behaviour of others (i.e. Vietnam Heroin use) - Activation of dopaminergic reward centres: •Block DA re-uptake – cocaine, amphetamines •Increase DA and other NTs – alcohol, opiates - Blunted reward system deficiency

Answer 292

>/= 2 episodes, 1 must be manic associates (hypomania, mania, mixed and the other depressive) AND - mania lasts around 4 m - depression lasts about 6m Complete recovery between episodes

Answer 293

Mania is more associated with irritability than elevated mood Appearance and behaviour - excitable, irritable, distracted, inappropriate clothing Speech - pressured --> mutism (in extreme cases) Emotion (mood and affect) - increased self-esteem, grandiose, labile mood, insomnia, loss of inhibition, increased appetite Perception (hallucinations and delusions) - grandiose delusions, paranoia, catatonic stupour Thought (form, content, possession) - flight of ideas, racing thought, over-optimism, suicidal ideas, 1st rank symptoms Insight - minimal --> reckless behaviour Cognition - Nil impact Decreased need for sleep and food Increased libido

Answer 294

A distinct period of abnormally and persistently elevated, expansive or irritable mood with > 3 characteristics of mania, lasting at least 7 days - impact occupational/social functioning +/- psychosis - 1st rank symptoms are not likely to persist past the acute episode

Answer 295

>3 characteristic symptoms of mania lasting >/= 4 days - no impact on occupational/social functioning - no psychosis or delusions - slightly less exaggerated mania symptoms

Answer 296

- Mixture of rapid alternation (within a few hours) of manic/hypomania and depressive symptoms

Answer 297

Manic episodes interspersed with depressive episodes

Answer 298

Recurrent depressive episodes with less prominent hypomanic episodes

Answer 299

>/= 4 episodes a year cycling between mania and depression (responds well to sodium valproate)

Answer 300

- Genetic - 1st degree relative to 7x increase risk - Anatomical - decreased grey matter mass in emotional regulation areas, increased ventral limbic area activity - Transmitters - Increased NA, DA, serotonin trigger mania - Stressful life events

Answer 301

Organic - drugs, dementia, frontal lobe disease, delirium, cerebral HIV, Myoxedema Madness - Schizo/schizoaffective disorder - Puerperal disorders - Cyclothymia (persistent mild mood instability - never sufficiently severe to BPAD/depression)

Answer 302

Refer to specialist care for diagnosis (urgent or non-urgent) as cannot be diagnosed in primary care: Referral options: - symptoms of hypomania --> routine referral to CMHT - symptoms of mania or severe depression --> urgent referral to CMHT / admission to psych ward

Answer 303

Acute mania or hypomania management: - gradually taper off and stop inducing medications (eg. SSRI) - Monitor fluid/food intake - Sedation may be required (clozepam, lorazepam) - ECT only if mania is not responsive to treatment If not on treatment aim to stabilise them before starting lithium: - 1st line: antipsychotic (olanzapine > haloperidol, quetiapine, risperidone) - 2nd line: different antipsychotic (switch to different antipsychotic from list above) - 3rd line: add lithium or sodium valproate (lithium is not as effective acutely and you might need higher doses and risk toxicity) If on treatment: - Optimise medication / stop antidepressants - Check compliance - Check lithium levels --> add atypical - Short term sedative (benzos)

Answer 304

4 weeks after the acute episode: - 1st: Lithium alone (monitor lithium toxicity and may take 5 weeks to titre correctly) - Lithium not effective: Lithium + Valproate (Valproate no monitoring) - Lithium poorly tolerated --> Valproate alone or Olanzapine alone

Answer 305

- Hair loss - Weight gain - Nausea

Answer 306

- Hair loss - Weight gain - Nausea

Answer 307

You cannot use antidepressants by themselves as they may cause a switch to mania. To reduce the risk, only give antidepressants with mood stabilisers or antipsychotics: 1st line: Fluoxetine and olanzepine 2nd line: Quetiapine alone 3rd line: Olanzapine or Lamotrigine ALONE If presenting in a manic episode on any antidepressants --> taper and stop them

Answer 308

Indications and purpose: - May improve compliance with medications long term - Offered after the acute manic event has resolves CBT: test excessively positive thoughts and gain a sense of perspective - identify relapse indicators - Create relapse prevention strategies (developing routine, ensuring good-quality sleep, promoting a healthy lifestyle, avoiding excessive stimulation/stress, addressing substance misuse, ensuring drug compliance) - Pyschodynamic psychotherapy

Answer 309

Can aid return to education and/or work | - Family support and therapy

Answer 310

- Manic episodes begin abruptly and are often shorter than depressive episodes - Recovery is usually complete between episodes - Remissions become shorter with are and depressions become more frequent - 15% with BPAD will commit suicide (lithium reduces this to same levels as general population)

Answer 311

- Recurrent episodes of depression | - Recurrent episodes of mania and depression

Answer 312

- low mood - anhedonia - anergia

Answer 313

Ask when core symptoms >/= 1 present for most days, most of the time, for at least 2 weeks ``` F - Fatigue (anergia) I - Insomnia/early waking C - Poor concentration A - Increased or decreased appetite/weight S - Suicidal thoughts or acts A - Agitation or slowing of movements G - Guilt or self -blame ```

Answer 314

- Steroids - COCP - Beta-blockers - Statins - Ranitidine - Retinoids (isotretinoin) - HIV meds

Answer 315

Between 2 and 5 symptoms | For at least 2 years

Answer 316

Around 5 or more symptoms | Mild functional impairment

Answer 317

Around 5 or more symptoms | Mild through to severe functional impairment

Answer 318

Most symptoms | Severe functional impairments and can have psychotic symptoms

Answer 319

1. Seasonal affective disorder - episodes of depression, recur annually at the same time with remission in between 2. Atypical depression - somatic symptoms (weight gain, hypersomnia) 3. Anxiety-induced insomnia - increased sleep + eating = increased mood 4. Agitated depression - psychomotor agitation instead of retardation 5. Depressive stupor - psychomotor retardation so bad that they grind to a halt

Answer 320

NA - mood and energy 5-HT - sleep, appetite, memory, mood DA - psychomotor activity, reward

Answer 321

Very common, 16.8% | Females 2x more common than males

Answer 322

- Full history (check for mood elevation) - Collateral history - Physical exam - MSE - Bloods: FBC (anaemia), LFTs (hypothyroid), glucose/HBA1C (diabetes) - Rating scale: PHQ9, HADS, BID-II (adults) or CDI (children) - EPDS (pregnancy)

Answer 323

1. Physical - hyperthyroid, head injury, quiet delirium 2. Adjustment disorder - mild affective symptoms following life events --> do not reach the severity of depression 3. Bereavement - normal grief for <6months (look for numbness, pining, depression and recovery) 4. BPAD, schizoaffective disorder, schizo - previous mania or psychotic episodes 5. Substances withdrawal 6. Postnatal depression/puerperal illness 7. Dementia - depression may mimic dementia, but dementia can start with affective disorders. (global memory loss in severe depression can cause pseudodementia and has a quicker onset, short-term memory loss in alzheimers)

Answer 324

Treated in primary care: 1st line: - Watchful waiting (for 2 weeks, and follow-up) - Self help (mind.org, youngminds.org) - Lifestyle advice (ie. sleep hygiene, diet, exercise) 2nd line: - CBT (digital or group) Needs no net (2-3m) --> referral to CAMHS

Answer 325

Treated in CAMHS: 5-11 years: psychological intervention: - family-based IPT (interpersonal therapy) or - Family therapy OR - Individual CBT 12-18 years: psychological intervention - Individual CBT Needs not met --> family therapy, IPT-A (adolescents), psychodynamic psychotherapy

Answer 326

Treated in CAMHS: | - Intensive psychological therapy

Answer 327

CHECK SUICIDE RISK: - suicidal act or intent - risk factors: young male, occupation (doctor, vet), live alone, mental illness, unmarried Step 1: - Indications: initial suspected depression, subthreshold symptoms - watchful waiting with follow up in 2 weeks - Education - sleep hygiene, self help, information, support (MIND UK, depression UK) Step 2: - Indications: presistant subtreshold symptoms, mild depression - Low intensity psychological interventions: 1. Group CBT 2. Computerised CBT (online material supported by trained practitioners to review progress, over 9-12 weeks including follow up) 3. Guided self-help (written materials supported by trained practitioner to review progress, 6-8 sessions over 9-12 weeks including follow-up) 4. Structured group (delivered in groups with support from a trained practitioner, 3 sessions per weeks over 10-14 weeks) 5. Medications only if: - history of moderate to severe depression - sub-threshold depressive symptoms lasting >2 years - mild depression complicating care of chronic physical health problems Step 3: - Indications: presistant subtreshold symptoms refractory to step 2, moderate depression - High-intensity psychosocial interventions: 1. Individual CBT - 16-20 sessions over 3-4months (talking therapy based on idea that thoughts, mood and behaviour intertwined) 2. Interpersonal therapy / IPT - 16-20 sessions over 3-4months and IPT > CBT if due to death (identifies how interactions with others are affecting the patients mood and ways of improving these interactions) Medications: (and regular review every 2 weeks for 3 months or every week if suicidal) Step 4: - Indications: severe depression, risk to life, neglect - High intensity psychosocial interventions - Medications --> ECT if necessary

Answer 328

Urgent referral to crisis team

Answer 329

SSRI (setraline, citalopram, fluoxetine, paroxetine) - Setraline: stepped increase from 50mg to 200mg (50mg increase every 2 weeks, over 6 weeks) - 2 trails of SSRIs before moving to 2nd line

Answer 330

Taper down SSRI, switch to SNRI (venlafaxine, duloxetine) - Venlafaxine: stepped increase from 37.5mg BD --> 75mg BD --> 75mg morning / 150mg evening - SNRI pharmacology does not switch from SSRI effect to SNRI effect until reach max dose

Answer 331

Treatment resistance = augment treatment with - Antipsychotic (ie quetiapine 150-300mg) - Lithium (blood level of 0.4-0.8) - Other antidepressant (eg. mirtazapine or mianserin)

Answer 332

- Weight gain | - Increase sleep

Answer 333

- Smallest side effect profile | - For those with co-morbid conditions like IHD

Answer 334

Major depressive episode

Answer 335

Recover from depressive, treatment is subsequently stopped, and that person falls back into depression leads to a worse depression state than before

Answer 336

- Large seretonin increase in the body - Cause by SSRI or SNRI - increased mood change - restlessness - difficulty sleeping - unsteadiness - sweating - gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting - paraesthesia

Answer 337

A severe form of depression with delusions and hallucinations Cotard syndrome - a set of nihilistic delusions where the patient believes they are dead, and their body parts are rotting

Answer 338

"He wants to kill me with an axe" --> ask why Psychotic depression = "the world is better off without me" Schizo = "I have no idea, I got a message"

Answer 339

None is specifically liscenced to be use in pregnancy but: Paroxetine may have mild risk: 1st trimester = congenital heart defects 3rd trimester = persistant pulmonary hypertension

Answer 340

Encourage to taper down anti-depressants and switch to: - Mild: Facilitated self help - Moderate: CBT

Answer 341

Continue antidepressant or switch to a drug with lower risk of adverse effects

Answer 342

Delusional disorder = persistent/life long delusions with few/no hallucinations - <3 months = temporary; >/= 3 months = persistent Cannot include: - clear auditory hallucinations - schizo symptoms (delusions of control, blunting of affect) - evidence of organic/bran/ disease NOTE: occasional or transitory auditory hallucinations does NOT rule out the diagnosis

Answer 343

- Old age - Social isolation - Group delusions - Low socioeconomic status - Immigration - Substance abuse - Permorbid personality disorder - FHx - Sensory impairment - Head injury

Answer 344

- Acute has a better diagnosis | - insidious has a worse diagnosis

Answer 345

Excess DA and ACh activity - Neurological lesions to the temporal lpobe, limbic system, BG - Cortical damage (persecutory delusions)

Answer 346

- Freud (delusions serve defensive functions) - Distrust, suspicion, jealousy, low self-esteem - Social isolation, seeing own defects in others - Rumination over meaning and motivation

Answer 347

A - Nil S - Nil E - Nil P - Non-bizarre delusions, rarely hallucinations T - Process unimpaired, content preoccupied, single theme of thoughts I - Impaired (delusions affect thought and behaviour) C - Intact

Answer 348

- Erotomaniac (excess sexual desire, often believe a VIP in love with them - De Clerembault's syndrome) - Othello syndrome (believe partner is unfaithful) - Fergoli syndrome (>/= 2 people are same person changing disguises to deceive) - Folle a deux (shared delusions/hallucinations between people) - Factitious disorder (consciously pretending you have a medical illness)

Answer 349

- Full history, collateral history + MSE | - Exclude organic causes

Answer 350

- Substance-induced - Dementia + delirium - Hypochondriasis - Mood disorders with delusions - Body dysmorphia - Paranoid personality disorder - Schizo - OCD

Answer 351

- Consider admission (if high risk to self, to other or from others) Biological (limited evidence) - Antipsychotics (poor evidence) - SSRI (cover other potential missed differential) - BDZ (for anxiety) Psychological: - Individual CBT - Psychoeducation Social: - Social skills training - Psychoeducation - Family therapy

Answer 352

Sudden onset psychosis (tend to lack insight), resolving in <3 months

Answer 353

Same as schizophrenia

Answer 354

- Organic - demential or delirium - Substance misuse (steroids) - BPAD/depression - Schizo - Personality disorder

Answer 355

Bio: - Short term antipsychotic/BDZ eg. high dose olanzapine (acute behavioural disturbance) - Antidepressants/mood stabalisers useful to prevent relapse eg. low dose aripiprazole Pycho: - Specific social issues - Reality - orientated, adaptive, supportive psychotherapy Eg 1st line "start low, go slow" - Low dose aripiprazole - Education and support

Answer 356

Depression | Psychosis

Answer 357

- Better prognosis if short interval between onset and full-blown symptoms - Better prognosis if perplexity or confusion, good premorbid social and occupational functioning, blunted affect

Answer 358

A group of disorders in which BOTH affective and schizo (psychotic) symptoms are prominent equally (50/50) but do not justify a full diagnosis of either schizo or depression/manic episodes Manic type: - Both schizo and manic symptoms prominent (develop at the same time) - Single episode. or recurrent disorder (majority manic episodes) Depressive type: - Both schizo and depressive symptoms prominent (develop at the same time) - Single episode. or recurrent disorder (majority depressive episodes)

Answer 359

- Psychotic states to persis for >/= 2 weeks without concurrent affective symptoms - Requires 2 episodes of psychosis: 1. 1 episode lasting >2 weeks without mood disorder symptoms 2. 1 episode requires obvious overlap of mood and psychotic symptoms

Answer 360

- Treat as per schizo (add a mood stabiliser if the affective component is not being controlled) BPAD (mania + depression): - 1st line: fluoxetine (SSRI) + olanzapine (antipsychotic) - 2nd line: lamotragine

Answer 361

A severe mental illness characterised by disintegration of the process of thinking, of contact with reality, and of emotional responsiveness - Hallucinations - a perception in the absence of stimulus - Delusion - a fixed, false belief, held despite evidence to the contrary (not explained by the patient's background)

Answer 362

(A) >/= 1 Scheider's 1st rank symptoms, >/= 1 month duration: - Delusions (false and fixed beliefs) - Passivity (delusions of control) - Thought disorders: thought insertion, thought withdrawal, thought broadcasting - Auditory disorder: thought echo, 3rd person voice, running commentary OR (B) >/=2 of the following: - Paranoid = persistent hallucinations in any modality - Hebephrenic = incoherent or irrelevant speech (neologisms, Knight's move thinking) - Catatonic = catatonic behaviour (excitement, posturing, waxy flexibility, negativism, mutism, stupour) - Simple = negative symptoms (apathy, paucity of speech, blunted/incongruent emotional response) AND (C) Present, most of the time, >/= 1 month AND (D) Not causes by substance use or organic disease

Answer 363

Previous schizo (+ve & -ve S/S) --> just -ve symptoms

Answer 364

+ve: - hallucinations - delusions - Due to excess domapines in the mesolimbic tracts - ve: - apathy - social withdrawal - due to declined dopamine in the mesocortical tracts

Answer 365

Prodrome / At-risk mental state / ARM (negative symptoms dominant): - social withdrawal - loss of interest in work and relationships Acute phase (positive symptoms dominant): - delusions - hallucinations - thought inteference Chronic phase: (negative symptoms dominant): - apathy - blunted affect - social withdrawal - anhedonia - poverty of thought/speech

Answer 366

Paranoid: - most common - prominent delusions - prominent hallucinations Hebephrenic/disorganised: - mainly focused on speech/thought - disorganised mood and speech - neologism, knights move thinking - inappropriate affect Catatonia: - psychomotor disturbance - stupor, waxy flexibility (retain any shape you put into them), automatic obedience, forced grasping, opposition Simple: - negative symptoms only - apathy - social withdrawal

Answer 367

1% of UK pop M=F 15-45 y/o onset

Answer 368

- Collateral history - Physical exam - Bloods (FBC, U&E, LFT, VDRL, 5-HIAA) - Urine (Drug screen and MSU) - MRI (hypofunction in the prefrontal cortex) - Rating scale - Brief Psychiatric Rating Scale - ADL Assessment and Housing and Finance

Answer 369

- Organic - substance misuse, demential, delirium, epilepsy, steroids, tumours - Acute/transient psychotic episodes - Mood disorder - depression and mania can cause psychotic symptoms - Schizo affective disorder - schizophrenic and affective symptoms develop together and are balanced - Persistent delusional disorder - only delusions - Schizotypal disorder - eccentricity with abnormal thoughts

Answer 370

Urgent = crisis resolution team and home treatment team Not-urgent = early intervention in psychosis team (>14 y/o, CAMHS can tx = 17 y/o) - psychosis is toxic, the longer a patient is psychotic, the more is will affect them - early treatment leads to a better prognosis - Aim to keep duration of untreated psychosis <3 months - Tx: antipsychotics, psychosocial interventions Rapid tranq: - 1st line: Lorazepam (oral --> IM) - 2nd line: Haloperidol (5mg) + Lorazepam (1mg)

Answer 371

- Suicide/homocide risk - Lack capacity - Significant medication changes - Severe symptoms - Failure of OPD (outpatient department) treatment - Address comorbid conditions

Answer 372

1st line: (6 weeks, atypical antipyschotics, "start low, go slow": - (LESS STRONG, LESS SIDE EFFECTS) Aripiprazole (initial akanthisia), quetiapine (sedation, weight gain) - (STRONGER, MORE SIDE EFFECTS) Olanzapine (weight gain), Risperidone (hyperprolactinemia, EPSEs, sedation) - 1st: low-dose aripirazole / high-dose olanzapine + education and support - Augmentation: BDZ (diazepam) if non-acute anxiety, Mood stabaliser (lithium) if schizoaffective disorder suspected - Non-compliance: once monthly IM depot injection (zuclophenthixol decanoate 200mg depot injection) 2nd line: (6 weeks, typical antipsychotics) 3rd line: (treatment resistance, clozapine) - Failure to respond to >/2 antipsychotics, at least one if atypical, each given at a therapeutic dose for at least 6 weeks

Answer 373

1st line: CBT (offer to all patients, regardless of level of schizo) - at least 16 sessions - emphasis of testing reality 1st line: Family therapy (if needed, esp if young) - at least 10 sessions - to help control the highly expressed emotions of schizo (helps family cope)

Answer 374

- Sudden onset, late - Stressful event - No FHx - Higher IQ

Answer 375

- Gradual onset, early - Lack of precipitant - FHx - Low IQ

Answer 376

- Gradual onset, early - Lack of precipitant - FHx - Low IQ

Answer 377

Baseline measurements before starting an anti-psychotic: - Basic obs: weight, wast circ, pulse and BP - Bloods: FBC, U&E, LFTs, fasting BM, HbA1c, lipid profile, prolatin (more frequently in clozapine) - Assessment of any movement disorders - Assessment of nutritional status, diet and physical activity (CVD assessment) - ECG (if CVD risk present or recommended by the chosen medication) Monitoring - there is a high risk of CVD in patients on schizo meds: - response to treatment and side-effects - emergence of movement disorders - adherence - overall physical health Monitoring apps at: 1) 1,2,3,4,5,6 weeks = weight + waist 2) 12 weeks = weight, waist, HR, BP 3) Annual = weight, waist, HR, BP Basic obs: - weight and waist circumference (weekly for 6 weeks, at 12 weeks, annual thereafter) - Pulse and BP (at 12 weeks, annual thereafter)

Answer 378

Autosomal dominant (50% chance of children inheriting the condition) Onset 30-50 years old: - Trinucleotide expansion disorder --> genetic anticipation = onset and severity may be younger and greater in successive generations

Answer 379

HTT/huntingtin gene

Answer 380

Picture: clumsy, speech difficulties - Movement: chorea, speech/swallowing, stumbling/clumsiness - Cognitive: organising tasks, flexibility, impulse control, learning new information, difficulty concentrating - Psychiatric: depression, irritablity/mood swings, suicide in 9% of cases, personality change - Lack of insight: they don't care that anything is wrong - tends to indicate organic pathology

Answer 381

- Genetic analysis (HTT gene) | - MMSE may be normal

Answer 382

Atrophy of fronto-temporal regions - early onset - 40-60 y/o - 60% sporadic, 40% autosomal inheritence

Answer 383

3 clinical presentation: (1) frontotemporal dementia: frontal lobe syndrome (disinhibition, social/personality changes) (2) Semantic dementia: progressive loss of understanding of verbal and visual meaning (3) Progressive non-fluent aphasia: 1st, naming difficulties and 2nd, mutism Memory tends to be affected much later unlike AD which is the first thing affected

Answer 384

1) Cognitive impairment: - Screening --> AMTS (<7 suggest cognitive impairment), GPCOG (GP assessment of cognition) - Detailed --> Addenbrooke's (ACE-R - 100 questions, MMSE - not widely used, MoCA) 2) Dementia/delirium screen: - TFTs (hypo --> cognitive decline) - LFTs (Korsakoff's) - U&Es and dipstick (infection, diabetes) - HbA1c (diabetes) - Vitamin B12 and folate Further tests: - Alzheimers: FDG-PET, CSF, MRI (grey matter atrophy, wide ventricles & sulci, temporal lobe atrophy) - Vascular: ECG (AF with emboli), MRI/CT - Lewy body: FP-CIP SPECT, I-MIBG - Frontotemporal: FDG-PET, perfusion SPECT, MRI (frontal lobe shrinkage) Memory assessment clinical referral after GP: - Take collateral history and check bloods - Risk assess the patient - Cognitive assessment - MMSE - Brain scan (check organic pathology)

Answer 385

Biological: - Antidepressants (treat frontal lobe syndrome) Psychosocial: - Same as AD - OT, SALT, physiotherapy

Answer 386

Death in 5-10 years

Answer 387

2 pathologies with no correlation to clinical presentation: (1) Tau positive - Pick's bodies (hyperphosphorylated tau) = Pick's disease (3R), CBD (4R), PSP (4R) (2) Tau negative - no Tau = FTLD-U (frontotemporal lobar dementia with Uniquinated inclusions)

Answer 388

Infarcts cause by thromboemboli or narrowing of arteries due to HTN

Answer 389

Same as CVD RFs: - Age - Male - Obesity - Lack of exercise - Smoking - AF - DM - HTN - CVA history (stroke, TIA)

Answer 390

- Sudden onset (may follow CVA), stepwise deterioration 1st: emotional and minor changes (labile emotion - tearful --> elation) 2nd: cognitive deficit - Focal neuro signs (S/S reflect site of infacrt) - Co-morbid depression - Relatively preserved personality

Answer 391

1) Cognitive impairment: - Screening --> AMTS (<7 suggest cognitive impairment), GPCOG (GP assessment of cognition) - Detailed --> Addenbrooke's (ACE-R - 100 questions, MMSE - not widely used, MoCA) 2) Dementia/delirium screen: - TFTs (hypo --> cognitive decline) - LFTs (Korsakoff's) - U&Es and dipstick (infection, diabetes) - HbA1c (diabetes) - Vitamin B12 and folate Further tests: - Alzheimers: FDG-PET, CSF, MRI (grey matter atrophy, wide ventricles & sulci, temporal lobe atrophy) - Vascular: ECG (AF with emboli), MRI/CT - Lewy body: FP-CIP SPECT, I-MIBG - Frontotemporal: FDG-PET, perfusion SPECT, MRI (frontal lobe shrinkage) Memory assessment clinical referral after GP: - Take collateral history and check bloods - Risk assess the patient - Cognitive assessment - AMTS/ACE-R - Brain scan (check organic pathology)

Answer 392

Biological: - Daily aspirin (if indicated due to CVA/AF risk) - Reduce risk factors (exercise, less alcohol, treat HTN, stop smoking, treat AF, control DM) Psychosocial: - Same as AD

Answer 393

- Lewy body = alpha-synclein with ubiquitin - Spectrum of diseases including Lewy bodies > In parkisons, LB are found in the brainstems > In LBD, LB are found in the brainstem, cingulate gyrus and neocortex

Answer 394

- Age | - Unknown

Answer 395

>/= 2 of 3, general gradual decline: - Fluctuating confusion with marked variations in alertness levels (has some lucid intervals unlike other dementias) - Vivid visual hallucinations (Lilliputin hallucinations) - animals or humans - Parkinsonims (shuffling gait, bradykinesia, rigidity, animia) - Frequent falls - Comorbid depression

Answer 396

1) Cognitive impairment: - Screening --> AMTS (<7 suggest cognitive impairment), GPCOG (GP assessment of cognition) - Detailed --> Addenbrooke's (ACE-R - 100 questions, MMSE - not widely used, MoCA) 2) Dementia/delirium screen: - TFTs (hypo --> cognitive decline) - LFTs (Korsakoff's) - U&Es and dipstick (infection, diabetes) - HbA1c (diabetes) - Vitamin B12 and folate Further tests: - Alzheimers: FDG-PET, CSF, MRI (grey matter atrophy, wide ventricles & sulci, temporal lobe atrophy) - Vascular: ECG (AF with emboli), MRI/CT - Lewy body: FP-CIP SPECT, I-MIBG - Frontotemporal: FDG-PET, perfusion SPECT, MRI (frontal lobe shrinkage) Memory assessment clinical referral after GP: - Take collateral history and check bloods - Risk assess the patient - Cognitive assessment - MMSE - Brain scan (check organic pathology)

Answer 397

Bio: 1st line: Ach inhibitors (Donepezil or Rivistigmine) - Do not offer antipsychotics (increased risk of cerebrocascular disease) Psychosocial: - Same as AD

Answer 398

Acquired, chronic, and progressive cognitive impairment, sufficient to impair ADLs

Answer 399

- <65 y/o = early onset dementia | - Alzheimers dementia (70%) > Vascular dementia > Lewy body dementia

Answer 400

1st: forgetfulness (stepwise or progressive) 2nd: Disorientation (time --> place --> person) - wandering - delusions - calling out - sleep-disturbance - hallucinations - inappropriate behaviour/aggression

Answer 401

Behaviour and psychological symptoms of dementia 1) Mood changes 2) Abnormal behaviour 3) Hallucinations/delusions

Answer 402

24-30 = no impairment 18-23 = mild cognitive impairment < 18 = severe cognitive impairment

Answer 403

1) Cognitive impairment: - Screening --> AMTS (<7 suggest cognitive impairment), GPCOG (GP assessment of cognition) - Detailed --> Addenbrooke's (ACE-R - 100 questions, MMSE - not widely used, MoCA) 2) Dementia/delirium screen: - TFTs (hypo --> cognitive decline) - LFTs (Korsakoff's) - U&Es and dipstick (infection, diabetes) - HbA1c (diabetes) - Vitamin B12 and folate Further tests: - Alzheimers: FDG-PET, CSF, MRI (grey matter atrophy, wide ventricles & sulci, temporal lobe atrophy) - Vascular: ECG (AF with emboli), MRI/CT - Lewy body: FP-CIP SPECT, I-MIBG - Frontotemporal: FDG-PET, perfusion SPECT, MRI (frontal lobe shrinkage) Memory assessment clinical referral after GP: - Take collateral history and check bloods - Risk assess the patient - Cognitive assessment - MMSE - Brain scan (check organic pathology)

Answer 404

- Confusion Assessment Method (CAM) | - Observational Scale of Level of Arousal (OSLA)

Answer 405

Active ingredient delta-9-tetrahydrocannabinol - Grass/weed - made from dried cannabis leaves - Hash - squidgy, brown-black lump made from resin and flowes - Skunk and sinsemilla - particularly strong varieties (MOST COMMONLY USED)

Answer 406

Effects largely depend on expectations and original mood state: - Euphoria, relaxation to paranoia, anxiety and panic - Perceptual/time distortion, hunger pangs - Nausea and vomitting ('greening')

Answer 407

Urine drug screen - in urine for up to 4 weeks

Answer 408

- Smoking --> peak at 30 mins, last 2-5 hours | - PO --> slower onset, last longer

Answer 409

- Abstinence (in those with major mental illness) | - Clinical experience suggest that irregular use can be free from major problems

Answer 410

Acute implications: - paranoia, panic attacks, accidents associated with delayed reaction time (driving) - cannabis can precipitate an episode of psychosis or schizo Chronic implications: - dysthymia, anxiety/depressive illness, amotivational syndrome No physical dependancy: - there is a mild withdrawal syndrome in heavy users eg. insomnia, anxiety, irritability

Answer 411

Hallucinogens produce psychological (heightened perseption, illness) and psychological (dilated pupils, peripheral vasoconstriction, increased temp) effects but NO DEPENDANCE LSD: (lysergic acid diethylamide, acid) - Affect DA and 5-HT transmitter systems - Impregnated on tabs --> trips last up to 12 hours (perceptual changes and euphoria) Phencyclidine (PCP, angel dust): - liquid or powder--> snorted or smoked in a joint - associated with violent outburst and ongoing psychosis Ketamine (special K): - anaesthetic effect can lead to unknowingly self-harming - unique anaesthesia in that in blocked cortical awareness of pain - Small doses = dissociation - Large doses = hallucinations, synaesthesia Magic mushrooms (liberty cap/psylocybin semilanceata): - eaten raw or drunk (cooked, dried and made into a drink) - small doses = euphoria - large doses = hallucinations similar to LSD - tolerance develops so continued use unlikely

Answer 412

- Visual illusions, hallucinations, depersonalisation, derealisation - Synaesthesia ( experience sensation in another modality - eg. hear a smell) - Behavioural toxicity (ie. acting on drug-induced beliefs such as being able to fly) Side effects: - LSD: acute SEs due to behavioural toxicity, chronic SEs include flashbacks, anxiety and depression - Ketamine - LARGE amounts --> nausea, ataxia, slurred speech - Magic mushrooms - behvaioural toxicity, accidental poison consumption - Phencyclidine - serotoninergic/cholinergic effects (confusion/violence)

Answer 413

14.7% in the UK smoke

Answer 414

CO level of = 10ppm indicates abstinence from smoking

Answer 415

Very brief advice (VBA) - offer at any interaction in any healthcare setting: - ask about current and past smoking behaviour - provide verbal and written information on risks of smoking and benefits of stopping smoking - risks: cancer, bronchitis, COPD, hosp admission - Benefits of stopping: cost savings, better heath - advise options for quitting smoking including behavioural support and medication - refer the person to their local stop smoking service - If they do not want to quit, enquire to a harm reduction policy 1st advice: - stopping is best done through behavioural support + medication - set a quit date, and commit to it - the first few days are often the most difficult (may experience withdrawal), but passes by 3-4 days - stop smoking but use NRT) 2nd medications: (depends on individual preference, cannot give NRT in combo with meds): 1) NRT (lozenges, mouth spray, patches) - start on agreed quit date - patches (24 hour) useful if: smoking shortly after waking, on combo NRT 2) Varenicline: - Mechanism: partial nicotine receptor agonist - Dose: 1mg, BD, titrated up from 500mcg OD over 1 week. (started 7-14 days before quit date, whilst they are still smoking) - Contraindications: <18y/o, renal disease 3) Bupropion: - Mechanism: selective Da and NA reuptake inhibitor - Dose: 150mg BD, titrated up from 150mg OD over 1 week (started 7-14 days before quit date, whilst they are still smoking, max use 7-9 weeks) - Contraindications: <18y/o, seizures, CNS disorders, eating disorder, BPAD, cirrhosis 3rd FOllow-up: - 2 weeks if on NRT, 3-4 weeks if on medications - Measure CO levels 4 weeks after quitting - Check progress, withdrawal symptoms - Of relapse, or partial relapse, provide encouragement and set new quit date

Answer 416

Uses: sedation, hypnotic, anxiolytic, anticonvulsant, muscle relaxant - should only be used for a short time (2-4 weeks) - Risks: 1) Short-term: drowsiness, reduced concentration 2) Long-tern: cognitive impairment, anxiety and depression, sleep, disruption, dependance

Answer 417

Similar to alcohol: - calm and mild euphoria - slurred speech, ataxia, stupor

Answer 418

- Resp depression (TREAT with IV flumazenil) | - Low GCS, low BP, mydriasis, hyporeflexia

Answer 419

- ANXIETY (biggest SE) - insomnia - tachnyponea - tremor - hyperreflexia - palpitations - derealisation - irritability - tachycardia - tinnitus - seizures - delusions - depersonalisation - ataxia - sweating - mydriasis - depression - anterograde amnesia Sudden withdrawal can lead to a delirium tremens like picture

Answer 420

- Address underlying need for BDZ - Address long term complications of use (cognitive impairment, anxiety, depression, insomnia) - Check willingness to withdraw from use and weather it can be done successfully in primary care Withdrawal management: (1) slow-dose reduction (2) switch to equivalent dose of diazepam, and slow-dose reduction used in: difficult to physically taper down the dose, on short-acting potent BDZ such as lorazepam

Answer 421

- If done properly, there will be few, if any, withdrawal side effects: (1) anxiety is most common side effect and is normal (2) treat with non-pharma management (relaxation breathing techniques) - may take 3m to 1y or longer - assess driving risk and advise cannot drive on certain levels of BDZs

Answer 422

- 1/8th daily dose reduction every 2 weeks | - Estimated time = 30-60 weeks

Answer 423

Chlordiazepoxide, diazepam

Answer 424

1. Cocaine (Charlie, coke, snow) - Intranasal or IV 2. Crack cocaine (rock, base, freebase) - inhalational - Immediate, extreme high --> wears off quickly (5-10 mins) - highly addictive 3. Amphetamine (speed) - IV, PO, intranasal - Withdrawal medications include dexamphetamine 4. Khat (quat, chat) - Mild stimulant, used in east african communities - causes psychosis 5. Ectasy (3,4-methylenedioxymethamphetamine, E, MDMA) - causes seretonin release and blocks reuptake - hallucinogenic as well as stimulant properties - S/S: inital 3 hour rush, agitation relieved by dancing/movement, bruxism (teeth-grinding) - Hangover at 24-48 hours (fatigue, anorexia, depressed mood) Potentiate neurotransmission and increase cortical excitability --> increased alertness, endurance, diminished need for sleep and subjective sense of well-being

Answer 425

- Increased alertness, endurance and confidence - Risky behaviour - Unpleasant crash period (dysphoria and lethargy)

Answer 426

No dependence but can become a habit: - Acute: arrhythmia, intense anxiety, hypertension --> CVA, impulsivity, impaired judgment - Chronic: nasal septum necrosis, foetal damage, panic and anxiety, delusions, psychosis

Answer 427

No dependence but can become a habit: - Acute: arrhythmia, intense anxiety, hypertension --> CVA, impulsivity, impaired judgment - Chronic: nasal septum necrosis, foetal damage, panic and anxiety, delusions, psychosis

Answer 428

Very regular use associated with dependance: - Acute: tachycardia, arrhythmia, hyperpyrexia, irritability, post-use depression - Quasi-psychotic state with visual, auditory and tactile hallucinations

Answer 429

Tolerance but no dependence: - Acute: increased sweating, nausea, vomiting, diminished potency despite increased libido - Death associated with dehydration and hyperthermia (some chronic liver and cognitive issues)

Answer 430

2 stages: (1) Crash phase - from 3 hours - depression, exhaustion, agitation, irritability (2) Withdrawal: - cravings, irritability, anergia, poor concentration, insomnia, slowed movements (can last 1-10 weeks)

Answer 431

- Urine drug screen - cocaine in urine for up to 5-7 days

Answer 432

- Harm reduction | - Short-term withdrawal symptoms relief as an inpatient with BDZ

Answer 433

Derived from poppy seed, papaver somniferum types: - Heroin - Pethidine - Morphine, diamorphine - Codeine, dihydrocodeine Heroin profile (mu) opiate agonist --> immediate euphoria, diminished pain sensation, feelings of detachment Routes: - smoking - sniffing - oral - IV - IM or SC

Answer 434

Local complications: - Abscess - Cellulitis - DVT - Emboli Systemic complications: - septecaemia - infective endocarditis - blood-bourne infection - increased risk of overdose Intoxication symptoms: - euphoria and warmth --> sedation, bradycardia - Overdose: miosis + low RR (treat with naloxone which is an opiate antagonist, immediate start of withdrawal symptoms) - Low-dose SEs: constipation, anorexia, decreased libido

Answer 435

Begins 6 hours after injection, peak 36-48 hours, last 5-7 days: - raving, nausea, insomnia, agitation - Flu-like symptoms - Runs - D+V, macrimation, rhinorrhoaea - Goose-flesh - pilomotor unit erection, yawning - Mydriasis (dilation)

Answer 436

- Physical exam (establish baseline physical state) - Urine drug screen (2 days in urine) - U&E (features of malnutrition) - FBC (anaemia due to malnutrition or signs of infection) - LFTs (may impact medication dosing) - Blood bourne infections (RPR, hepatitis serology, HIV test)

Answer 437

General recommendations: 1) Appointment a key worker (single point of contact) and develop a care plan: - agreed treatment and recovery goals - specific, clear, action to be taken to achieve those goals - clarity about who is takeing the actions - monitoring of progress 2) Harm reduction: - needle exchanges for IVDUs - Offer vaccinations and testing for blood-bourne pathogens 3) Health education: - smart recovery - narcotic anonymous Discuss if they want to undergo Opioid Substitution therapy (OST) withdrawal or maintenance regimen: 1st) maintenance - the goal = stabilise lifestyle and reduce harm 2nd) detoxification - the goal = detoxification and abstinence ``` Replacement: Methadone - long acting synthetic opiate(liguid) Bupronopephrine - partial opiate antagonist (sublingual) Lofexidine - alpha 2 antagonist ```

Answer 438

Admission may be necessary: 1st) OST given in controlled environment for 3-6months 2nd) if suitable, take home some medications Maintenance: 1st) Methadone (liquid) or buprenorphine (sublingual) - if still using heroin --> low-dose methadone - If wanting to stop heroin completely --> high-dose methadone or buprenorphine - Offer naloxone to take home with them and training on when/how to use it Detoxification: (must be committed to stopping) - Must be on stable OST maintenance before you start detox - Last 12 weeks as an outpatient - Inform them they will lose tolerance so if they start again, they should take a lot less - 1st line: Methadone (liquid) or buprenorphine (sublingual) and offer naloxone to take home with them and training on when/how to use it - 2nd line: Lofexidine (alpha 2 agonist), indications: rapid detox, mild dependance, preference Withdrawal symptom medications: - Clonidine or lofexidine (alpha 2 agonist) - Anti-diarrheals (loperamide), anti-emetics (metoclopramide) Ultra-rapid detoxing regimens do exist but are not pleasant and not routinely offered (using naloxone)

Answer 439

With drugs and alcohol services for at least 6 months: - Look for signs of withdrawal - ECG (QTc) for those with methadone - Check other drug use (urine drug screens) - CBT (to reduce relapse chance) - Contingency management (through frequent screening --> less frequent screenings as time goes on) - incentive for -ve drug test results, urinalysis preferred

Answer 440

- Most common form of dementia with steady progression | - APP= amyloid precursor protein

Answer 441

1. APP cleaved by alpha-secretase 2. sAPP(alpha) released and the C83 fragment remains 3. C83 is then digested by (gamma)-secretase 4. Products are then removed

Answer 442

1. APP cleaved by beta-secretase 2. sAPP(beta) released and the C99 fragment remains 3. C99 is then digested by (gamma)-secretase releasing (beta)-amyloid (Alpha-beta) protein 4. Alpha-beta protein forms the toxic aggregates

Answer 443

- Tau proteins is a soluble protein present in axons | - Tau important for assembly and stability of microtubules

Answer 444

1. Hyperphosphyrylated tau is insoluble --> self-aggregates 2. The self-aggregates from neurofibrillary tangles (neurotoxic) 3. The tangles result ultimately in microtubule instability and neurotoxic damage to neurones

Answer 445

- Microglial cells are specialist CNS macrophages

Answer 446

1. Increased inflammatory mediators and cytotoxic proteins 2. Increased phagocytosis 3. Decreased levels of neuroprotective proteins

Answer 447

Present due to 4 key elements of pathophysiology: - Atrophy from neuronal loss - Plague formation - Neurofibrillary tangle formation - Cholinergic loss Presentation: - Amnesia (recent memories loss first) - Aphasia (problems finding the correct words, muddled, disjointed speech without disturbance to illelect) - Agnosia (difficulty remembering faces) - Apraxia (difficulty dressing and doing skilled tasks, despite normal motor functioning) BPSD= mood change, abnormal behaviour, hallucinations/delusions

Answer 448

1) Cognitive impairment: - Screening --> AMTS (<7 suggest cognitive impairment), GPCOG (GP assessment of cognition) - Detailed --> Addenbrooke's (ACE-R - 100 questions, MMSE - not widely used, MoCA) 2) Dementia/delirium screen: - TFTs (hypo --> cognitive decline) - LFTs (Korsakoff's) - U&Es and dipstick (infection, diabetes) - HbA1c (diabetes) - Vitamin B12 and folate Further tests: - Alzheimers: FDG-PET, CSF, MRI (grey matter atrophy, wide ventricles & sulci, temporal lobe atrophy) - Vascular: ECG (AF with emboli), MRI/CT - Lewy body: FP-CIP SPECT, I-MIBG - Frontotemporal: FDG-PET, perfusion SPECT, MRI (frontal lobe shrinkage) Memory assessment clinical referral after GP: - Take collateral history and check bloods - Risk assess the patient - Cognitive assessment - Brain scan (check organic pathology)

Answer 449

- Male - Depression - Behavioural problems - Severe focal cognitive deficit

Answer 450

1st: Anticholinesterases (mild to moderate AD:) - Donepezil - reversible AcH inhibitor - Galantamine - reversible AcH inhibitor - Rivastigmine - pseudo-reversible AChe inhibitor and butylcholinesterase (BChe) inhibitor 2nd: (moderate or 1st line in severe AD) - NMDA (glutamate) partial receptor antagonist - Memantine - use-dependant non-competitve NMDA receptor blocker with low channel affinity

Answer 451

1st: Structural group cognitive stimulation sessions (mild to moderate AD) - Exclude depression of GAD (pseudo-dementia) - Other: group reminiscence therapy, validation therapy, multisensory therapy

Answer 452

- Explain diagnosis ("AD causes dementia which describes a set of symptoms including memory loss and difficulties with thinking, problem-solving or language. AD is a physical disease that affects the brain") - Optimise health in other areas (eg. hearing aids) - Identify future wishes (eg. advance directives, lasting power of attorney) Follow-up: every 6 months with yourself and a single named care manager with a clearly defined care plan General: always wear ID, Dossett Boxes, change gas to electricity, assistive technology in the house Carers: identify and support any carers involved (signpost information and support, carer's assessment) Social support: personal care support, meal support, day centre availability Legally required: to form DVLA and insurers

Answer 453

1st: ECG Side effect: - GI (N&V, diarrhoea, anorexia), other (fatigue, dizziness, headache) Absolute contraindications: - Anticholinergics (block ACh from binding) - Beta-blockers - NSAIDs - Muscle relaxants Relative contraindications: - asthma - COPD - GI disease - Bradycardia - sick sinus syndrome - AV block

Answer 454

- multiple physical SYMPTOMS present for at least 2 years | - patient refuses to accept reassurance or negative test results

Answer 455

- persistent belief in the presence of an underlying serious DISEASE, e.g. cancer - patient again refuses to accept reassurance or negative test results

Answer 456

- 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

Answer 457

- 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

Answer 458

- also known as Munchausen's syndrome | - the intentional production of physical or psychological symptoms

Answer 459

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

Answer 460

new word formations, which might include the combining of two words

Answer 461

when ideas are related to each other only by the fact they sound similar or rhyme.

Answer 462

completely incoherent speech where real words are strung together into nonsense sentences

Answer 463

severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia

Answer 464

thought disorder where there are leaps from one topic to another but with discernible links between them.

Answer 465

repetition of ideas or words despite an attempt to change the topic

Answer 466

repetition of someone else's speech, including the question that was asked.

Answer 467

wandering from a topic without returning to it.

Answer 468

inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point.