Psych Conditions Flashcards
Dementia with Lewy Bodies core features
Fluctuating cognition
Parkinsonism
Visual hallucinations
Also: delusions, depression, falls LOC, syncope
Management Dementia with Lewy Bodies
Acetyl cholinesterase inhibitors e.g Rivastigmine
N.B. Do not give APs as worsen parkinsonian Sx
Frontotemporal Dementia - core diagnostic features
- Insidious onset with gradual decline in social function.
- Unable to regulate personal conduct
- emotional blunting
- early loss of insight
- language impairment
3 subtypes of FTD
Behavioural - frontal lobe
Progressive non-fluent aphasia - temporal
Semantic - loss of the knowledge of things and concepts
Treatment FTD
SSRI, supportive and carers
5 A’s of Alzheimers
Amnesia Aphasia Agnosia Apraxia Associated behaviors - BPSD
What are examples of the behavioral and psychological symptoms of Dementia
Delusions, hallucinations, depression, sleepiness, aggression, crying, screaming, pacing, hoarding etc
How long do you need to be Sx of Dementia for a diagnosis
6 months
ICD- 10 mild dementia
- Memory loss sufficient to interfere with everyday activities
- Compatible with independent living
- Difficulty registering, storing and recalling elements in daily living
ICD-10 moderate dementia
- Memory loss represents serious handicap to independent living
- Only highly learned or very familiar material is retained
- Unable to function w/o assistance of another
ICD-10 severe dementia
- Complete inability to retain new information
- Mind can no longer tell the body what to do
Pharmocological management Dementia
o Acetylcholinesterase Inhibitors: Donepezil, rivastigmine, galantamine
- Mild to moderate
o Memantine
- Moderate to severe
o Antipsychotics not recommended for BPSD
What are the four dopamine pathways?
Mesolimbic - positive Sx
Mesocortical -Negative Sx
Nigrostriatal - EPSE
Tuberoinfundibular - Prolactin secretion
Criteria for Anorexia Nervosa
Anorexia Nervosa
BMI <17.5
Core psychopathology
Amenorrhoea
Criteria for Bulimia
BMI >17.5
Binge – purge cycle >2x/week
Core psychopathology
How common is Bulimia
F: 1 in 50
M: 1 in 500
How common is AN
F: 1 in 250
M: 1 in 2000
Core psychopathology of eating disorders
o Fear of fatness o Pursuit of thinness o Body dissatisfaction o Body image distortion: overvalued idea o Self-evaluation based on perceived weight and shape
SCOFF Questionnaire
S Do you ever make yourself SICK because you feel uncomfortably full?
C Do you ever worry you’ve lost CONTROL over how much you eat
O Have you recently lost more than ONE stone in a 3month period?
F Do you believe yourself to be FAT when others say you’re too thin?
F Would you say that FOOD dominates your life?
Stages of the cycle of change
o Precontemplation o Contemplation o Preparation o Action o Maintenance o Relapse
Clinical risk assessment in eating disorders
o Clinical Hx o Physical Ex - Irregular pulse - Bradycardia - Hypotension (may be postural) - Hypothermia - Proximal myopathy o BMI (kg/m2) - <17.5 = AN - <15 = moderate risk - <13 = high risk o ECG -Most deaths due to cardiac arrest - T wave changes hypokalaemia - Bradycardia <40bpm - Prolonged QT >450s o Blood investigations - FBC, U+E, LFTs, Glucose, TFT, CK, Phos, Mg, Ca
Management AN
o Ideally done as outpatients
- Nutritional rehabilitation
- Psychological intervention
- CBT
- Cognitive Analytic Therapy
- Interpersonal Therapy (IPT)
- Family Interventions - decrease high expressed emotion
Management BN
- Guided self Help
- CBT
- IPT
- Fluoxentine
Classic sign in BN
Russell’s sign: calluses on dorsum of hand from purging
Delusion
o Fixed belief that is held with unshakeable conviction despite overwhelming evidence to the contrary and cannot be explained by the subjects culture or religious background
Delusions of control
o Belief that ones thoughts, feelings or actions are being replaced by an external agency
o Thought Insertion
o Thought withdrawal
o Thought broadcast
o Passivity of affect, volition or actions
o Somatic passivity
Persecutory delusion
o Belief that they are being persecuted e.g. being spied upon by secret service
Overvalued idea
o Belief which in itself is acceptable and comprehensible but dominates thinking and behaviour e.g. desire for thinness in eating disorders
Ideas of reference
o Belief that objects, events or other people have special significance pertaining to them. E.g. watching the TV and it has a special message just for them
o If it becomes a fixed belief it is a delusion of reference
Delusions of misidentification
o Capgras: belief that a familiar individual has been replaced by an identical imposter
o Fregoli Syndrome: familiar individual is disguising as multiple people
Grandiose delusion
o Delusion of being of special status of significance of having special powers or attributes or a special mission or purpose
Nihilistic delusion
o Delusion of extreme negativity, they no longer exist or are about to die
o Cotards Syndrome: belief that they are dead
Delusion of infestation/parasistosis
o Belief that the skin is infested by parasites
o Ekbom’s syndrome
Delusions of Jealousy
o Delusion of infidelity of partner
o Othello’s Syndrome
Delusions of love
o Delusion of being loved by someone who is inaccessible or with whom they have little contact
o Erotomania/De clerambault’s: someone of higher status is in love with them
Pressure of thought
o Thoughts arise in unusual variety and abudnace and pass through the mind quickly
o Experienced as pressure of speech
Flight of ideas
o Thoughts move quickly from one idea to the next and are loosely connected
Thought blocking
o Sudden loss of thoughts often mid-sentence
Loosening of associations
o Thoughts move quickly from one idea to another but seem not to be connected at all
o Experienced as muddled or illogical speech
Concrete thinking
o Inability to understand abstract concepts and metaphorical ideas – take literal understanding of things (autism)
Three types of illusion
o Affect Illusion: arise during periods of heightened emotion
o Completion illusion: arise during periods of inattention
o Paraidolic illusion: arise from poorly defined stimuli e.g. seeing shapes in the clouds
Illusion
False perception of a real stimulus
Hallucination
o Perception which occurs in the absence of an object, arises from the 5 senses and not from the mind and is indistinguishable from reality
Hypnogogic hallucination
As going to sleep
Hyponpompic hallucination
As waking up
Derealisation
o Alteration in the perception of the environment that it is strange or unreal
Depersonalisation
o Altered perception of self, feel as if they are unreal and acting a part
Sx of alcohol withdrawal
o Agitation/restless o Tremor o Sweating o Nausea o Palpitations o Anxiety o Anorexia o Tachycardia o Insomnia
Symptoms and timing of delerium tremens
o Usually 48-72hours after stopping o Sx of Withdrawal AND - Hallucinations - Delusions - Severe agitation - HTN - Pyrexia - Altered mental state
Sx of alcohol dependance
Tolerance – drink large amounts to have same effect
continue despite knowing harm
Anhedonia in anything unrelated to alcohol
Withdrawal Sx
Explosive – unable to control amount Desire/compulsion to drink
Recommendations for alcohol consumption in the UK
o Males and Females: 14 units/week
o 2 alcohol free days a week
o No more than ½ total units should be consumed in 1 sitting
o Pregnancy: avoid alcohol in first 3 months, no more than 2 units once or twice a week after this
Triad of wernickes encephalopathy and cause
o Thiamine B1 deficiency o Triad - Confusion - Ataxia - Opthalmoplegia
CAGE
o Have you ever felt that you should cut down the amount of alcohol you drink
o Have you ever felt annoyed by comments someone has made about the amount you drink
o Have you ever felt guilty about the amount of alcohol you drink
o Have you ever needed a drink first thing on a morning
Management alcohol withdrawal
ABCDE
o Chlordiazepoxide
- over 5-7 days with reducing dose
Management wernickes
Pabrinex
Medicines to help stop drinking alcohol
o Acamprosate - Decrease cravings
- Enhances GABA transmission so mimics the CNS depressant effects of alcohol
o Disulfiram
- Alcohol sensitising deterrent
- Sx of flushing, palpitations, headache, and nausea
Refeeding Syndrome
Decrease in phosphate, Magnesium, Calcium, Potassium
Caution when giving people nutrition who have been starving themselves
Learning Disability definition
1) IQ under 70
2) Loss of adaptive social functioning
3) onset before age 18
Mild learning difficulty
IQ 50-69 language fair, fairly independant
Moderate learning disability
IQ 35-49 better receptive than expressive
Severe learning disability
IQ 20-34 severe motor and sensory deficits. 50% epilepsy
Profound learning disability
IQ <20 development approx 12m
very vulnerable
Causes of learning disability
Prenatal - Downs, Fragile X, Fetal alcohol
Peri natal - O2 deprivation, prem baby, birth complications
Post-natal - Illness, injury or environment
Symptoms of autism
sensory and perceptual distortion organisation and planning difficulties inflexibility of thought and actions, transitions difficult social interactions challenging concrete thinking
Latency in PTSD
1-6months
Formulation components
Presenting, precipitating, perpetuating, predisposing and protective
GAD
6 months of varying concerns/worries
persistent free floating anxiety not related to external stimulus
Managment GAD
self help, applied relaxation, sleep hygiene
CBT
SSRI
Beta blocker for tachy/palps
Benzos short term e.g. flight/funeral, max 2-4w
Phobia anxiety disorder
1) restricted to specific phobia
2) fear out of proportion with stimulua
3) cannot be reasoned or explained away
4) Anticipatory anxiety
5) avoidance behaviour
Phobia management
Psychoeducation
exposure - systematic desensitisation
Sx Panic attack
Need 4 Sx
Autonomic arousal - tachy, sweating, shaking, dry mouth
Chest/Abdo - SOB, chest pain, claustrophobia, nausea
Mental state - dizzy, faint, derealisation, fear
General - hot flush, numbness, tingling
Panic attack
- Rapid onset of severe anxiety lasting for about 20 – 30 minutes
- Occur recurrently and unexpectedly
Panic attack disorder
Need 4 attacks in 4 weeks.
N.B. can’t be primary diagnosis if also have depression
Obsession
o Recurrent idea, image or impulse
o Recognised as being a product of one’s own mind
o Usually perceived as being senseless
o Unsuccessful if resisted
o Results in marked anxiety and distress/impairment of functioning
Compulsion
o Recurrent stereotyped behaviour
o Reduces anxiety but isn’t useful or enjoyable
o Usually perceived as being senseless but unsuccessful if resisted
o Results in marked anxiety and distress/impairment of functioning
Management OCD
o CBT
- Exposure and response prevention
o High dose SSRIs
- Can use adjuncts if necessary e.g. gabapentin, lamotrigine, olanzapine, risperidone
o Combo of CBT and SSRIs is most effective
Predisposing factors PTSD
Personality traits e.g. compulsive, asthenic
Past psych Hx
Genetic
Sx PTSD
Reexperiencing catastrophic event
Hypersrousal/ Startle reaction
Emotional blunting
Depression and Suicide
Treatment PTSD
Trauma focussed CBT
Eye movement desensitisation and reprocessing
Antidepressant - paroxetine or mirtazipine
Paranoid personality disorder
Cluster A (MAD) - patient has excessive sence of own importance, and blames others for mistakes and problems. Big on conspiracy theories, and mistrusts others.
Schizoid personality disorder
Cluster A (MAD) - Emotionally cold, finding little pleasure in any activities. Solitary and introspective, and indifferent to expectations of others within society.
Disocial personality disorder
Cluster B (BAD) - Disregard for people’s feeling and social norms, with a failure to feel guilt. Easily frustrated, with low threshold for anger/violence.
Histrionic personality disorder
Cluster B (BAD) - Exaggerated emotions, and craves attention. Shallow personality, easily influences by others/circumstances.
Emotionally unstable personality disorder: borderline type
Cluster B (BAD) - uncertain about personal and sexual identity. Feeling of emptiness. Forms intense unstable relationships, with big rejection issues. Recurrent suicidal/self harm threats. Violent and threatening behaviour.
Emotionally unstable personality disorder: impulsive type
Cluster B (BAD) - impulsive and lack self control, with sudden outbursts of anger.
Anankastic personality disorder
Cluster C (SAD) - rigid, stubborn, excessively organised. Perfectionist. Insist people do things their way or not at all.
Anxious (avoidant) personality disorder
Cluster C (SAD) - persistent tension and apprehension. Low self esteem. Avoid situations where they may feel criticised, rejected or disapproved.
Dependant personality disorder
Cluster C (SAD) - Feel unable to cope and make decisions on own, fear being left alone, and put the needs of those they are dependent on ahead of their own.
Schneiders first rank symptoms
11 in total
Auditory hallucinations - 3rd person discussion or running commentary
Broadcast, echo, withdrawal, insertion
Control - passicity of acts, impulses and affect
Delusional perception
Causes Schizophrenia
Genetic - MZ twins 50%
Environmental - winter birth, urban home, viral infection, TL epilepsy, encephalitis
Life events - social exclusion, economic adversity, childhood trauma, migrant, HEE
Substance misuse - canabis, amphetamines
Peri- natal trauma - hypoxia, maternal stress
Diagnostic hierachy
1) organic disorders - delerium, demnetia
2) functional psychosis - BPAD, SZP
3) Non- psychotic disorders - depression, anxiety
4) Personality disorders
To detain under the MHA
- mental disorder
- risk to self/others/neglect or exploitation
- unwilling to go voluntarily with capacity
Requirements to section someone under MHA
2 doctors - one of which section 12 approved, can’t be on same team
provided tot he applicant - AMHP
detained to the mangaers of the hospital
Voluntary admission to mental health ward
only if have capacity to make decision
Section 2 MHA
For assessment, 28 days.
Pt has right to appeal in the first 14 days
Section 3 MHA
Detained for treatment of their mental health condition - already need diagnosis
Up to 6 months
Section 5(2)
- Doctors holding power for 72hrs
- need to be detained to a bed (not A and E)
- Allows process of section 2/3 to go through
Section 136
Police detention from a public place to a place of safety for assessment
Section 135
Allows police to enter persons property to take hem to hospital them for their own safety
Core Sx of Depression
o Persistent sadness or low mood
o Loss of interests or loss of pleasure or enjoyment (anhedonia)
o Increased fatigue or low energy
For two weeks or more - not secondary to drugs or alcohol
Grading of depression
o Mild - 2 core + 2 other
o Moderate - 2 core + 3 other
o Severe - 3 core + 4 other
Biological Sx of Depression
- Poor sleep or hypersomnia with initial early morning wakening
- Diurnal variation of mood
- Reduced libido
- Reduced attention and concentration
- Psychomotor retardation or agitation
ECT
o 70-80% response - Severe life threatening or treatment resistant depression, catatonia or severe mania
o Need maintenance AD or high rate of relapse
o 2x/week - Preoxygenated, short GA and muscle relaxant by anaesthetist, not painful, (30-40s)
o Bilateral electrodes placed on head then shock
o S/E: nausea, headache, muscle pain, memory loss
Biopsychosocial Mx of depression
Bio - excercise, diet, meds, ECT
Psycho - IAPT, self help, CBT, IPT, Behavioural activation
Social - Manage debts, food banks, socialisation, charity support, carer support, employment
Low intensity psychological therapy
Sleep hygiene and regular excercise
CBT based self help - 6-8w
structured group activity programme
CBT
16-20 sessions over 3-4 months
based on Beck’s cognitive theory to remove cognitive bias.
Talking therapy with homework
Maps out problem, makes goals and deals with problems and thought processes
IPT
16-20 session
foccusses on relationships, grief, conflicts, over reliance, life changes etc
Behavioural activation
Simple goals. act according to plan rather than how feel. small steps for sense of achievement
First line Mx Depression based on severity
Mild - IAPT referral, self help. Advice sleep hygiene and reg excercise, cut down alcohol.
Moderate to severe - SSRI and CBT/IPT. all the lifestyle stuff
Paranoid SZP
- Commonest type
- Paranoid delusions often accompanied by auditory hallucinations and perceptual disturbances
Hebephrenic SZP
- More common in young people
- Affective changes are prominent
- Delusions and hallucinations fleeting and fragmentary
- Behaviour irresponsible and unpredictable
- Mood is shallow and inappropriate
- Disorganised thought and incoherent speech
- Social isolation and rapid development of –ve Sx: flattening of affect and loss of volition
Catatonic SZP
- Presents with psychomotor Sx and can alternate b/w extremes
- Episodes of violent excitement may be a striking feature
Diagnosing SZP
Sx for 1 month at least.
Cannot make diagnosis of schizophrenia in the presence of - Overt brain disease
- During drug intoxication, use of psychoactive substances/withdrawal
- Extensive depressive or manic Sx unless clearly predates current Sx
Positive Symptoms of SZP
Hallucinations
Delusions
Thought disorder
Negative Symptoms SZP
- Taken away from the normal mental state e.g. reduced speech
- More debilitating and less responsive to Rx
- Avolition: loss of motivation
- Anhydonia: unable to experience pleasure
- Alogia: poverty of speech
- Asociality: lack of desire of relationships
- Affect blunt: part of a continuum of normal traits, often late feature
Prevalence SZP
1% population
Prognosis SZP
Rule of thirds -
one-third of all people will recover completely
one-third will have some relapses but generally well managed
one-third will have have resistant szp
Where do you refer the first presentation of psychotic Sx to?
local community based mental health service e.g. CMHT, HTT, EIS
Need full assessment by psychiatrist and care plan
Psychosocial management of SZP
o Offer CBT to all people with Schiz
o Family Intervention
- Educate and support those who live with or are in close contact
- Reduces relapses
- Especially with high expressed emotion families
o Art therapy for negative Sx
o Distraction techniques
o Avatar therapy
o If acute phase aim to start ASAP to improve outcome
What factors increase your chance of relapse in SZP
o Presence of persistant Sx o Poor adherence to Rx o Lack of insight o Substance use o Stopping AP abruptly
Baseline investigations before starting an AP med
o Bloods - FBC, U+E. LFT, HbA1c, prolactin, lipids and cholesterol
o Physical - Weight, BP, pulse
o ECG - Risk of prolonged QT and arrhythmias
Components of a mental capacity assessment
o Weigh up the information
o Retain
o Understand
o Communicate
Deprivation of liberty safeguard (DoLS)
Apply to an incapacitous person who needs to be deprived of their liberty in their best interests
Urgent (up to 7days) or standard application (up to 1year)
Best interests decision
- Consider persons past/present/future wishes
- Beliefs and values
- Views of anyone named by person
- Anyone engaged in caring for the person
- Lasting power of attorney
- Deputy appointed by the court
- IMCA
Mania Sx
Mania Acronym - DIG FAST
Disorganised
Insomnia, ↓ need for sleep
Grandiose/expansive ideas
Fast thoughts
Activity ↑
Speech: Pressured, need to talk
Taking risks: money, sex,substance misuse, driving…
Psychosocial Mx BPAD
Psycho education about BAD
- Mood monitoring
- CBT for depressive episodes
- Education about Sx and identifying early signs of relapse
- Importance of drug compliance
- Lifestyle advice: avoid stressful situations or learning how to cope better
- Involve family
- Balance between work/leisure and relaxation
- Reduced caffeine
Hypomania
Mood is elevated, expansive or irritable but no psychotic features
No marked impairment of social or occupational functioning
How long do you need Sx for mania diagnosis
1 week
How long to manic and depressive episodes typically last in BAD
Mania tends to start abruptly and last 3-6months
Depression tends to last 6-12months
BAD I and BAD II definitions
Bipolar I - Episodes of major depression and mania
Bipolar II- Episodes of major depression and hypomania
Risk factors for BAD
Genetic: first degree relative
Life events and environmental factors (severe stress, disruption todaily routine) can trigger episodes
Risk factors for DSH/suicide
- Hx of DSH is very strong RF
- Mental health disorder especially affective disorders, schizophrenia and personality disorders
- Physical illness
- FHX of DSH or suicide
- single, male, unemployed, life stresses, poor social support
Abnormal grief reaction
- Unusually intense
- Unusually prolonged
- Meets criteria for depressive disorder
- Lasts >6months
- Delayed, inhibited or distorted
Dissociative/Conversion Disorders
Traumatic event results in a disruption of the usually integrated functions of consciousness, memory, identity or perception of the environment
Dissociative Amnesia
Loss of memory commonly for a traumatic or stressful event
Dissociative Fugue
Memory loss or confusion about personal identity or assumption of another identity
May last several months
When it ends the memory of the fugue is lost
Dissociative Stupor
Motionless and mute, no response to stimulation
Hypochondria Disorder
Fear or belief of having a serious physical disorder despite medical reassurance to the contrary
Includes body dysmorphic disorder
RF: male, medical students
Somatisation Disorder
Long history of multiple and severe physical symptoms that cannot be accounted for by a physical or psychiatric disorder
F > M
Briquet’s syndrome, St louis hysteria
Malingering
Sx which are manufactured or exaggerated for a purpose other than assuming the sick role e.g. to evade to police, get compensation
Class A drugs
Heroin (diamorphine), cocaine (including crack), methadone, ecstasy (MDMA), LSD, and magic mushrooms.
Class B drugs
amphetamines, barbiturates, codeine, cannabis, cathinones (including mephedrone) and synthetic cannabinoids.
Class C drugs
benzodiazepines (tranquilisers), GHB/GBL, ketamine, anabolic steroids and benzylpiperazines (BZP).
