Psych Flashcards
Give 4 risk factors for depression
Female, family history, past history, alcohol, adverse events, psychical comorbidities, lack of social support, low SES
4 cognitive symptoms of depression
Feelings of guilt/worthlessness/hopelessness, lack of concentration, negative thoughts, suicidal ideation
Type of hallucinations in psychotic depression?
2 types of delusions you might get?
2nd person derogatory auditory hallucinations
Persecutory, hypochondriacal, guilt, nihilistic
What is Beck’s cognitive triad?
Negative thoughts about the self, the world, the future
How to define mild/mod/severe/psychotic depression?
Mild = 2 core Sx + 2 others
Mod = 2 core + 3-4 others
Severe = 3 core + >=4 others
Severe psychotic = above + psychosis
Give a biopsychosocial management plan for depression
Bio = SSRI
Psycho = CBT
Social = Social support groups
Suicide risk assessment
4 indications for psych referral for depression?
- Severe depression
- Suicide risk is high
- Recurrent depression
- Initial treatments have failed
When to stop SSRI following recovery of depression
Continued for 6 months after resolution of depression
Definiton of bipolar affective disorder?
A chronic episodic mood disorder characterised by at least one episode of mania, and another episode of either mania or depression
What is BAD type 2?
1+ depressive episode with at least hypomanic
4 risk factors for BAD?
Age in early 20s, anxiety disorders, after depression
Substance misuse, strong FHx, stressful life events
3 features of a hypomanic episode?
- > =4 days of mildly elevated mood or irritability
- manic symptoms but to a lesser extent
- Inters with work/social life but not severe disruption
- Partial insight
How long do symptoms of mania have to last for it to be a manic episode?
> 1 week
When to suspect mania with psychosis?
Psychotic features e.g. grandiose/persecutory delusions, auditory hallucinations (mood congruent), aggression, suspicion.
Definitoin of rapid cycling?
> 4 mood swings in 12 months with no asymptomatic period between
Give stepwise pharmacological management of a manic episode.
1) Antipsychotic e.g. olanzapine, risperidone, quetiapine. If first isn’t effective, try a different one.
2) Lithium (or valproate)
3) Benzos
4) Rapid tranq e.g. haloperidol, lorazepam
Treatment options for bipolar depression?
Olanzapine + fluoxetine/olanzapine/quetiapine
Or mood stabiliser e.g. lamotrigine, lithium
CBT
Biopsychosocial approach to bipolar?
Bio = mood stabilisers, antipsychotics, benzos, ECT if severe uncontrolled mania
Psycho = psychoeducation, CBT
Social = social support groups, self help groups, calming activities.
Full risk assessment, ask about driving
What is used first line for long term management of bipolar to prevent relapses?
How long after resolution of an acute episode should you start it?
What are alternative options?
Lithium, start 4 weeks following resolution
Other options = valproate, olanzapine, quetiapine
4 possible indications for hospitalisation with bipolar?
- Reckless behaviour causing risk to self or others
- Significant psychotic sx
- Impaired judgement
- Psychomotor agitation
4 tests to do before starting lithium?
U&Es, pregnancy test, TFTs, ECG
Give 5 signs of lithium toxicity
N+V, coarse tremor, muscle weakness, ataxia, nystagmus, hypereflexia, convulsions, coma
3 things to monitor during lithium therapy and how often?
Lithium levels - every 3 months once established
U&Es - every 6 months
TFTs - every 12 months
Define a delusion
A fixed, false belief, that is firmly held despite evidence to the contrary, and goes against a person’s normal social and cultural belief system.
Define a hallucination
A perception in the absence of an external stimulus
What is schizoaffective disorder?
depressive illness/manic episode + 1/2 classical schizophrenia symptoms, at the same time. Schizophrenia + a mood disorder
What is persistent delusional disorder?
A delusion or group of delusions held for at least 3m. Delusion is the only/most prominent symptom
Give 3 different types of schizophrenia and their characteristics
Paranoid = most common, dominated by positive sx (hallucinations, delusions) Hebephrenic = thought disorder predominates Catatonic = 1 or more catatonic symptoms Simple = rare, negative sx without positive Residual = 1 year of chronic neg sx preceded by psychotic episode
What are Schneider’s first rank sx of schizophrenia?
3rd person auditory hallucinations
Delusional perception
Thought interference
Passivity phenomenon
What are 4 negative sx of schizophrenia?
The As: Anhedonia Avolition (not motivated) Alogia Asocial Attention/cognitive deficit Affect blunted
What is the ICD-10 diagnostic criteria for schizophrenia?
At least 1 grp A sx (Schneider 1st rank) or 2+ group B (other hallucinations, neologisms/loosening of assoc/incoherence, catatonic sx, negative sx)
For at least 1 month
No organic brain disease
Give 4 organic causes of psychosis?
Drug induced e.g. alc, cocaine, methamphetamine Iatrogenic e.g. levodopa Huntington's SLE Syphilis Vit B12 deficiency Complex partial epilepsy Delirium and dementia
Management of first episode of psychosis?
Biopsychosocial
Early intervention in psychosis team
Bio = antipsychotic, benzos, ECT
Psycho = CBT (NICE strongly recommends), psychoeducation, family education, art therapy
Social = Rethink, peer support, supported employment programmes
Risk assessment and may need MHA
What type of antipsychotics are first line for schizophrenia? Give 2 drug examples.
Which antipsychotic is used for treatment resistant schizophrenia?
Atypical antipsychotics e.g. risperidone, olanzapine
Clozapine
Definition of GAD?
ongoing, widespread, uncontrollable worry, not restricted to certain situations, pt recognises as excessive and inappropriate. Sx present on most days for at least 6 months
What is the ICD-10 criteria for GAD?
A = 6m with prominent tension, worry, feelings of apprehension B = At least 4 symptoms, with at least 1 of autonomic arousal
Give 4 symptoms of autonomic arousal in anxiety
And 4 other symptoms.
AA = palpitations, sweating, tremor, dry mouth Other = tight chest, difficulty breathing, chest pain, N, diarrhoea, dizzy, derealisation/depersonalisation, headache, muscle tension, concentration difficulty, fear of dying/losing control, insomnia
Name 3 questionnaires that could aid diagnosis of generalised anxiety?
GAD-2, GAD-7, HADS, Beck’s anxiety inventory
Biopsychosocial approach to managing GAD?
Bio = SSRI (sertraline), then SNRI. Pregabalin if neither work.
Psycho = psychoeducation, CBT, applied relaxation techniques
Social = self help methods, support groups, exercise.
Screen for depression and substance misuse
Definition of phobia?
Intense irrational fear of a person, object, place, situation that is recognised as excessive or unreasonable.
What are the characteristic features of phobias that are used to define them in ICD-10?
- Marked fear/avoidance of …
- Anxiety symptoms (at least 2)
- Recognised as excessive/unreasonable
- Causes emotional distress
- Sx restricted to that situ/predominate there
Phobia often causes tachycardia. Give 3 psychological symptoms of phobia?
Fear of dying
Anticipatory anxiety
Need to avoid the situation
Inability to relax
What are the 3 features that separate phobia from GAD?
SS AA AA
Specific situations
Anticipatory anxiety
Attempted avoidance of situations
Outline the management for the following:
Agoraphobia
Social phobia
Specific phobia
Agora = CBT w graded exposure, SSRI
Social = CBT w graded exposure, SSRI (or venlafaxine). Psychodynamic psychotherapy if they refuse the above.
Specific = CBT w graded exposure. Benzos short term
ICD-10 criteria for panic disorder
A - recurrent panic attacks, not consistently associated with a specific thing, occur spontaneously
B - All of the following: intense fear/discomfort, starts abruptly, reaches crescendo in few mins and lasts minutes, at least 1 sx of autonomic arousal, other symptoms
3 organic DDx of panic disorder?
Phaeochromocytoma, hyperthyroid, alc/drug withdrawal, carcinoid syndrome, hypoglycaemia
1st and 2nd line pharmacotherapy for panic disorder?
What not to prescribe?
1st - SSRI
2nd - TCAs e.g. imipramine (if no improvement after 12 weeks)
Don’t prescribe benzos!
Biopsychosocial approach to panic disorder?
Bio - SSRI
Psycho - CBT
Social - support groups, self help exercise classes
What is the ICD-10 classification of PTSD?
Experience of extremely stressful event
Persistent reliving
Avoidance of similar situations
Either inability to recall certain aspects or hyperarousal
All occur within 6 months of an event. Sx last >1 month
2 other symptoms of PTSD not in the ICD10 definition?
Social withdrawal, emotional numbing, irritability/outburts, difficulty sleeping, difficulty concentrating, distress in similar circumstances, excessive rumination
Normal bereavement shouldn’t extend over ?? months. If it does, should consider which 2 disorders?
6 months
Abnormal bereavement or adjustment disorder
Stages of grief?
DABDA
Denial, Anger, Bargaining, Depression, Acceptance
2 questionnaires for PTSD?
Trauma screening questionnaire
Post-traumatic diagnostic scale
For mild PTSD symptoms <4 weeks long, what approach may be suitable?
Watchful waiting
Outline the biopsycho social management of PTSD
Bio = Venlafaxine (drug treatments aren’t 1st line) (or mirtazepine).
Psycho = trauma-focused CBT or EMDR
Social = employment support
Risk assess for neglect and SI
What is an obsession?
Unwanted intrusive urges, thoughts, images that repeatedly enter the mind. Cause distress to the pt who tries to resist them and recognises them as absurd and a product of their mind.
What is a compulsion?
Repetitive stereotyped behaviours or mental acts that a person feels driven into doing. May be overt or covert
ICD-10 classification of OCD?
A = O and/or C on most days for at least 2 weeks B = O and C share a number of features, all must be present C = O/C cause distress and interfere with functioning
Mnemonic to remember features of obsessions and compulsions?
FORD Car Failure to resist Originate from the pts mind Repetitive and Distressing Carrying out thought/action isn't pleasurable but relieves anxiety
What’s the OCD cycle?
Obsession – anxiety – compulsion – relief – obsession
Give 3 common obsessions and 3 compulsions
O - contamination, fear of harm, order/symmetry, sex
C - checking, cleaning, counting, mental compulsions
Questionnaire to find severity of OCD?
Yale Brown obsessive compulsive scale
Biopsychosocial method for OCD?
Bio = SSRI e.g. fluox, sertraline, citalopram Psycho = Psychoeducation, distracting techniques, CBT - exposure response prevention Social = self-help books, support groups
OCD has a strong association with which other disorder?
Depression (30%)
ICD-10 criteria for anorexia nervosa?
FEEDD
Fear of weight gain
Endocrine disturbance e.g. amenorrhoea
Emaciated (>15% below expected weight or BMI<17.5)
Deliberate weight loss (reduced intake or increased exercise)
Distorted body image.
Features present for 3 month. Absence of recurrent binging or obsession about eating.
5 other symptoms of anorexia nervosa?
Lanugo hair, fatigue, headaches, hypothermia, bradycardia, arrhythmias, peripheral oedema (hypoalbuminaemia), social isolation, depressive sx
Give 5 investigations to do for AN
FBC, U&Es, LFTs, TFTs, glucose, vit B12/folate, lipids, cortisol, sex hormones, amylase VBG DEXA scan ECG Questionnaires e.g. EAT
Biopsychosocial model for AN?
Bio = Treat medical problems, SSRI if depressed
Psycho = family therapy, CBT-ED, IPT, CAT, psychoeducation
Social = voluntary organisations, self-help groups
Risk assessment for suicide and medical complications is vital
May need hospitalisation and use of MHA
Aim of weight gain for AN :
a) Inpatient
b) outpatient?
a) 0.5-1kg/wk
b) 0.5kg/wk
5 disorders that BN commonly is assoc with?
Depression Anxiety Substance misuse Self-harm EUPD
ICD-10 criteria for BN?
Bulimia Patients Fear Obesity
Behaviours to compensate - exercise, laxatives, vomiting
Preoccupation with eating
Fear of fatness
Overeating - at least twice a week for 3 months
Potentially life threatening complication of vomiting?
Hypokalaemia
3 complications of repeated vomiting that may be seen in a patient with BN?
Russell’s sign (calluses on back of hand)
Dental erosion
Bilateral parotid swelling
Biopsychosocial model for BN?
Bio = fluoxetine, treat medical complications
Psycho = Psychoeducation, CBT-BN, IPT
Social = support groups, self-help programmes, food diary, eat with others
Risk assess for suicide and screen for comorbid conditions
May need hospitalisation, unlikely to need MHA as usually have insight and are motivated to change
Recovery % from BN vs AN?
50% vs 20% full recovery
Mnemonic to remember substance dependence features?
Drugs Probably Will Continue To Harm Desire/craving Preoccupation with substance Withdrawal if stop/reduce Can't control use Tolerance Harmful effects don't stop use Need 3 or more, lasting for at least 1 month
How to divide history of substance misuse in an OSCE?
Current use - TRAP Signs of dependency Risk assessment - suicide, self harm, needle sharing Possible triggers Past substance use Physical, psycho, social impact of use Coping mechanisms
5 investigations to do for substance misuse?
LFTs, clotting, U&Es, drug blood levels, HIV, Hep B and C, TB.
Urinalysis
ECG
ECHO if suspecting infective endocarditis
Biopsychosocial approach for substance misuse?
Bio = hep B immunisation, treat any medical complications e.g. infection. Psycho = motivational interviewing, CBT Social = keyworker assigned to each patient, support groups e.g. narcotics anonymous, help with employment/housing/finance
First and second line drugs for opioid detox and maintenance?
Methadone
Buprenorphine
What is the Edward and Goss criteria for alcohol dependence?
SAW DRIN(k) Subjective experience of craving Avoidance/relief of withdrawal sx by drinking Withdrawal symptoms Drink-seeking behaviour predominates Reinstatement after abstinence Increased tolerance Narrowing of repertoire
When is peak incidence of seizures following alcohol withdrawal?
Peak incidence of delirium tremens?
36 hours
72 hours
Investigations to do for a patient with alcohol misuse?
FBC, U&Es, LFTs and clotting, B12/folate, TFTs, blood alcohol concentration, amylase, glucose
ECG if arrhythmias
CT head if head injury
3 questionnaires that can be used for alcohol abuse?
AUDIT
SADQ
FAST
Equation to work out how many units of alcohol a drink is?
[% strength x volume (ml)]/ 1000
What is the biopsychosocial approach to managing alcohol abuse?
Bio = chlordiazepoxide and thiamine. Then disulfiram/naltrexone/acamprosate. Treat medical/psych comps Psycho = Motivational interviewing + CBT. Social = AA, family support
Give 3 indications for inpatient alcohol withdrawal
- High suicide risk
- Previous severe withdrawal symptoms
- poor social support
5 characteristic features of delirium tremens?
- Perceptual abnormalities e.g. hallucinations
- Paranoid delusions
- Autonomic arousal
- Tremor
- Cognitive impairment
What are the 3 clusters of personality disorders and give 3 PDs in each type.
1) Odd/eccentric - schizoid, schizotypal, paranoid
2) Dramatic/emotional - EUPD, histrionic, dissocial
3) Anxious/fearful - anankastic, anxious avoidant, dependent
(Weird, wild, worriers)
Give 5 features of EUPD?
Self-harm and suicide behaviours Intense, unstable relationships Mood instability Fear of abandonment Impulsivity Disturbed sense of self Chronic feelings of emptiness
Often there is a history of abuse as a child
How to differentiate cluster A personality disorders and schizophrenia/psychotic disorders?
Hallucinations and true delusions are absent in personality disorders
2 questionnaires/tests to look for personality disorders?
Personality diagnostic questionnaire, Eysenck personality questionnaire, Minnesota Multiphasic personality inventory
What are 3 general management principles for patients with personality disorders?
What is the biopsychosocial approach to management
- Education and support for family and friends
- Written crisis plan and may need input from crisis team
- Manage co-existing psychiatric or substance misuse problems.
Bio - antidepressants/mood stabilisers in EUPD. Antipsychotics if ideas of reference, impulsivity.
Psycho - CBT, DBT (EUPD), psychodynamic psychotherapy, psychoeducation
Social - Support groups, substance misuse services
What is self harm?
A deliberate act of self-injury/poisoning regardless of the intent/motivation
4 risk factors for self-harm?
Alcohol Divorced/single/live alone <35 yrs old History of child abuse Stressful life events psychiatric illness e.g. depression Chronic physical health problems
What are the 5 key motives behind self harm?
DRIPS
Death wish
Relief
Influence others (e.g. to change a decision)
Punishment of self
Seeking attention (expression of emotional distress)
Biopsychosocial management of self harm?
What is mandatory in the management of self harm?
Bio = antidote for poisoning, sutures, SSRI if depressed Psycho = counselling, CBT, psychodynamic psychotherapy if PD Social = social services input, voluntary organisations (Samaritans, MIND)
Risk assessment is mandatory may need Crisis team/hospitalisation +/- MHA
Ensure follow up 48hrs after discharge from hospital
What antidote is used in overdose of:
a) Benzodiazepines
b) beta blockers
c) TCAs
a) Flumazenil
b) Glucagon
c) Sodium bicarbonate
Give 5 risk factors for suicide
Male, middle-aged, unemployed, mental health problems e.g. depression, previous attempts at suicide/DSH, alcohol use, lack of social support, lives alone, psychically disabling or painful illness.
What mnemonic helps to remember how to assess risk of suicide following DSH?
Note Planned Attempts Are Very Frightening
Note left, Planned attempt, Attempts to avoid discovery, Avoided seeking help, Violent methods, Final acts (finances, wills etc)
2 questionnaires for assessing suicide risk?
Tool for Assessment of Suicide Risk (TASR)
Beck suicide intent scale
Outline the management following a suicide attempt
- Ensure safety and medically stablised
- Risk assessment, then depending on risk may manage in hospital (may need MHA) or in community
- Psychiatric treatment for depression or psychosis
- Crisis Resolution and Home Treatment Team involvement
Give 3 macroscopic changes seen in Alzheimer’s
- Widened sulci
- Cortical atrophy (particularly hippocampal)
- Enlarged ventricles
What are 3 genes associated with early onset AD?
Before what age is classed early onset?
What is the susceptibility gene that predisposes to late onset AD?
Presenilin 1 and 2, and amyloid precursor protein
65 yrs
ApoE-4
ICD-10 classification of dementia?
A = a decline in memory, a decline in other cognitive functions B = preserved awareness of environment for A to be evident C = decline in emotional control/motivation/change in behaviour e.g. irritability, lability, apathy, coarsening of behaviour D = A present for at least 6 months
5 cognitive areas impaired by dementia?
My Cat Loves Eating Pigeons
Memory, cognition, language, executive functioning, personality
3 indications for brain imaging in dementia?
Early onset, rapid decline, focal CNS signs, monitor disease progression
Gve 3 examples of a frontal lobe test
Clock drawing exercise
Similarities e.g. in what way are these two objects similar
Luria 3 step hand test
Ask for as many words starting with S in a minute
ICD-10 criteria for diagnosis of autism?
- Abnormalities noted before the age of 3
- Abnormalities in social interaction
- Abnormalities in communication
- Restrictive, repetitive and stereotyped patterns of behaviour, activity and interests
Give 5 symptoms you may see in autism?
Lack of eye contact, inability to pick up on social cues, lack of interest in others, upset when change to daily routine, obsessively pursued interests, repetitive behaviours e.g. banging head, waving arms, echolalia, distorted and delayed speech
Who may be involved in an MDT for and austistic child?
Paediatricians, psychiatrists, educational psychologist, SALT, occupational therapists
Biopsychosocial approach to autism?
Bio = treat co-existing disorders e.g. methylphenidate for hyperkinetic disorder, may use melatonin for sleep disorders Psycho = Psychoeducation for families/carers, may use CBT Social = support groups (NAS), modify environmental factors, social-communication intervention, special schooling
What are the 3 core features of ADHD?
Hyperactivity, inattention and impulsivity
ICD-10 criteria for the 3 core features of ADHD?
- Present in more than one setting e.g. school and home
- Directly observed
- Out of keeping of development
- Lasting at least 6 months
- Onset before age of 7
- IQ above 50
Give 3 symptoms for each of the core features of ADHD
Inattention - not listening, losing things, lots of easy mistakes in homework, highly distractible
Hyperactivity - restlessness, excessive running/jumping on things, excessive talking, recklessness, inability to do quiet activities.
Impulsivity - interrupts people talking, blurts out answer prematurely, inability to await turn, disobedient, runs into street without looking
Biopsychosocial management of ADHD?
Bio = methylphenidate, atomoxetine, dexamphetamine (if severe and at school) Psycho = Parent training and psychoeducation (first line!). For school goers- psychoeducation, CBT Social = support groups (add+up), school support
What triad must exist to constitute a learning disability?
1) Intellectual impairment (IQ <70)
2) Onset from birth or early childhood
3) Wide range of functional impairment
What is the commonest cause of LD?
Second commonest?
Down syndrome
Fragile X
What are 4 common psychiatric comorbidities in patients with LD?
Depression, anxiety Alzheimer's Schizophrenia Eating disorders Autism/ADHD Personality disorders
Biopsychosocial approach to LD?
Bio = GP involved in managing health conditions. Antipsychotics for challenging behaviour (but overused) Psycho = family education, positive behaviour support, CBT Social = support groups, social worker, school support
4 criteria for gambling addiction in ICD-10?
- Impaired control over gambling
- Priority given to gambling so it takes precedence over other activities
- Continuation despite negative consequences
For 12+ months, with significant impairment in personal/social/occupational functioning.
DSM-V diagnosis of gambling addiction requires 4+ symptoms. Give the possible symptoms
Spending increasing money for same excitement
Restless/irritable when trying to cut down
Unsuccessful attempts to stop
Preoccupied by gambling
Lies to conceal extent
Jeopardized a relationship/job
Borrows money to relieve financial situation
Goes back to get even after loss
Management of gambling addiction?
Motivational interviewing, CBT, gamblers anonymous
What is the treatment for:
a) acute dystonia
b) akathisia
c) tardive dyskinesia
a) procyclidine
b) propranolol
c) tetrabenazine
Features of neuroleptic malignant syndrome?
Treatment of neuroleptic malignant syndrome?
Pyrexia, rigidity, hypertension, tachycardia, agitated delirium with confusion, hyporeflexia
Stop antipsychotic, IV fluids, severe - dantrolene, bromocriptine
What is the triad of serotonin syndrome?
Treatment?
Altered mental state, autonomic nervous system stimulation, neuromuscular abnormalities (hyperreflexia, clonus, rigidity)
Stop serotonergic drugs, IV fluids, benzos, severe- cyproheptadine/chlorpromazine
Timing of onset of neuroleptic malignant syndrome vs serotonin syndrome?
Neuroleptic is slower e.g. hours- days, serotonin syndrome is within hours
