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Psych content Flashcards

1
Q

risk factors for suicide

A
  • previous self harm
  • young male
  • occupation (doctor, vet)
  • live alone
  • mental illness
  • substance abuse
  • lower social class
  • unmarried
  • widowed/divorced
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2
Q

protective factors against suicide

A
  • married
  • lithium medication
  • faith in a religion
  • no substance abuses
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3
Q

indicators for high suicide intent after DSH

A
  • preplanning
  • attempts at concealment
  • stated wish to die
  • lack of help seeking following the act
  • on going suicidal intent
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4
Q

Delirium (DSM-V)

A

A: disturbance in attention and awareness
B: disturbance develops over a short period of time (hours to days), represents a change from baseline
C: an additional disturbance in cognition
D: disturbances in Criteria A and C are not better explained by another condition
E: evidence from history, physical exam or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal

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5
Q

how can delirium be categorised?

A

hyper or hypoactive or mixed

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6
Q

aetiology of delirium

A
  • infection
  • change in environment
  • medication
  • alcohol withdrawak
  • surgery
  • pain
  • liver/renal impairment
  • hypoxia
  • hyponatraemia
  • stroke
  • encephalitis
  • constipation
  • urine retention
  • dehydration
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7
Q

Psychosocial causes of delirium

A
  • depression
  • change in environment
  • vision/hearing disturbance
  • stress
  • sleep disturbance
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8
Q

how to investigate delirium?

A

Confusion Assessment Method (CAM)

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9
Q

investigations of delirium

A
  • CAM
  • full physical exam and obs (DRE if hx of constipation)
  • MSE
  • medication chart review
  • cognitive assessment (more common in dementia pt)
  • collateral hx
  • Bloods: FBC, U&Es, LFTs, TFTs, CBG, Vit B12 or folate def, HIV/syphillis serology
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10
Q

MSE in delirium

A
  • Appearance: agitated, plucking curtains, fearful, smell of urine
  • Speech: screaming, incoherent
  • Mood: refuse to comment
  • Affect: frightened, irritable, suspicious
  • Thought: persecutory delusions
  • Perception: visual hallucinations, insects of bed, illusions, curtains as ghosts
  • Cognition: does not engage in MMSE, disorientate in time/place/person
  • Insight: refuse all intervention
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11
Q

behavioural management in delirium

A
  • modify risk factors
  • exclude undiagnosed dementia
  • treat causes
  • single room, well lit, familiar staff/family
  • minimise change
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12
Q

medication management in delirium

A
  • avoid anticholinergics
  • PO antipsychotics (short term in dementia with infection) e.g. haloperidol/ olanzapine
  • small night time dose of BDZ could promote sleep
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13
Q

prognosis of delirium

A
  • 37% die within 6 months
  • 43% reversible cognitive impairment
  • only 25% had clinically important recovery in ADLs
  • may take days to weeks to resolve
  • some patients do not return to pre-morbid levels
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14
Q

what are affective disorders?

A
  • spectrum from severe mania to severe depression
  • euthymia = normal mood
  • unipolar affective disorder = recurrent episodes of depression
  • bipolar affective disorder = recurrent episodes of mania and depression
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15
Q

ICD-10 core features of depression

A

low mood
anhedonia
anergia

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16
Q

what are core symptoms of depression?

A

if >=1 present for most days, most of the time, for at least 2 weeks, ask about adjuncts…

  • during last month have you often been feeling down, depressed or hopeless (low mood)
  • do you have little interest or pleasure in doing things (anhedonia)
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17
Q

what are the adjunct symptoms

A

FICASAG

  • Fatigue (anergia)
  • Insomnia/ early waking
  • Poor Concentration
  • Increased or decreased appeitie/weight
  • Suicidal thoughts or acts
  • Agitation or slowing of movements
  • Guilt or self blame
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18
Q

medications that may cause depression

A
  • steroids
  • methyldopa
  • COCP
  • beta blockers
  • statins
  • ranitidine
  • retinoids (isotretinoin)
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19
Q

how is the severity of depression assessed?

A
  • number/severity of symptoms and degree of functional impairment
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20
Q

cognitive and psychological symptoms of depression

A
  • Beck’s cognitive triad: worthlessness, hopelessness, helplessness
  • guilt
  • concentration/memory/thinking
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21
Q

biological symptoms of depression

A

sleep, appetitie, libido

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22
Q

how to remember the diagnostic criteria for major depressive disorder?

A 
SIGE CAPS
Sleep changes
Interest loss
Guilt (worthlessness)
Energy loss (fatigue)
Cognition/concentration difficulties
Appetite loss and/or weight loss
Psychomotor (agitation)
Suicidal ideations
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23
Q

depression severity

A
  • sub-threshold: 2-5 symptoms (no functional impariment)
    (is persistent if >2 years)
  • mild: around 5 symptoms (mild functional impairment)
  • moderate: mild through to severe functional impairment
  • severe: most symptoms (severe +/- psychotic symptoms)
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24
Q

subtypes of depression

A
  • seasonal affective disorder: episodes of depression, recur annually
  • atypical depression: somatic symptoms (weight gain, hypersomnia)
  • anxiety induced insomnia: increased sleep and eating = inc mood
  • agitated depression: psychomotor agitation instead of retardation
  • depressive stupor: psychomotor retardation so bad that they grind to a halt
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25
Q

biological causes of depression (most likely to respond to medication)

A
  • genetics (serotonin receptor gene. S allele greater risk of depression following life events compared to L allele)
  • neurochemical (monoamine hypothesis. Def in brain of MA NTs –> antidepressants increase them)
  • endocrine (chronic stress = increased cortisol = decreased neutrophin expression = damaged hippocampal neurones)
  • illness (direct e.g. Cushing’s or indirect e.g. cancer)
  • medication (steroids, anti-HTN e.g. beta blockers, COCP)
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26
Q

psychosocial causes of depression

A
  • childhood (adverse events)
  • vulnerability (reduce resilience e.g. unemployment, isolation)
  • life events (death, divorce, jail)
  • substance abuse
  • Beck’s -ve triad (negative views about self, world views and future views)
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27
Q

Investigations in depression

A
  • full history, collateral history, physical exam, MSE (check for mood elevation)
  • Bloods: FBC (anaemia), TFT (hypothyroid), glucose/HbA1c (diabetes), calcium
  • Rating scale: PHQ9, HADS, BDI-II (adults) or CDI (children), EPDS (pregnancy)
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28
Q

MSE in depression

A

Appearance/behaviour: signs of neglect, dehydration, miserable, disinterested, anxious movements, poor eye contact, posture
Speech (quantity, rate, rhythm, tone, appropriateness): slow, quiet, mute
Emotion (mood and affect): restricted range of effect, nihilism
Perception (hallucinations and delusions): severe –> hallucinations, nihilistic, persecutory delusions, evil images, guilt
Thought (form, content, possession): Beck’s triad = worthlessness, hopelessness, helplessness
Insight: nil
Cognition: psychomotor retardation mimics cognitive impaitment
RISK ASSESS

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29
Q

differentials for depression

A
  • physical: hypothyroid, head injury, quiet delierium
  • adjustment disorder: mild affected symptoms following life events
  • bereavement: normal grief for <6 months
  • BPAD, schizoaffective, schizophrenia: previous mania or psychotic features
  • substance withdrawal
  • postnatal depression
  • dementia
30
Q

management of mild depression in children and young people

A

treated in primary care

  1. watchful waiting for 2 weeks (self help, lifestyle advice, IAPT 6-8 sessions, psychoeducation)
  2. CBT (digital, group)
  3. Needs not met (2-3 months) = referral to CAMHS
31
Q

management of moderate to severe depression in children/young people

A

treated with CAMHS

  • 5-11 y/o: psychological intervention (family based IPT, family therapy, individual CBT)
  • 12-18yo: individual CBT +/- SSRIs (fluoxetine)
  • Needs not met = family therapy, IPT-A, psychodynamic psychotherapy
32
Q

depression unresponsive to treatment management in children/ young people

A

CAMHS

- intensive psychological therapy

33
Q

management of depression in adults

A

Stepped Care model

  • check suicide risk
    1. watchful wait, 2 week follow up, education (info, support, sleep hygiene)
    2. group CBT< computerised CBT, guided self help, structured group physical activity programme
34
Q

when are medications given in depression?

A
  • hx of moderate to severe depression
  • subthreshold depressive symptoms lasting >2 years
  • mild depressive complicating care of chronic physical health problems (i.e. cancer)
35
Q

step 3 treatment of depression / indications

A

indicated if persistent subthreshold symptoms or moderate depression

  • high intensity psychosocial interventions (individual CBT, IPT)
  • medications and review every 2 weeks for 3 months, every week if suicidal
36
Q

step 4 treatment of depression and indications

A
  • severe depression, risk to life, neglect
  • high intensity psychosocial interventions
  • medications –> ECT if necessary
37
Q

how long should medications be continued for?

A
  • 6-9 months after recovery to prevent relapse

- recurrent, depressive disorder –> tx for >2 years

38
Q

what is the catch up phenomena?

A

if someone recovers from depression and then medication is suddenly stopped, experience depression again and they will be in worse state

39
Q

first line drug and dose

A
  1. SSRIs (sertraline, citalopram, fluoxetine, partoxetine)
    Sertraline: stepped increase from 50mg to 200mg
    2 trials of SSRIs before moving to 2nd line
40
Q

2nd line drug and dose

A
  1. Taper down SSRI and switch to SNRI (venlafaxine, duloxetine)
    Venlafaxine: stepped increase from 37.5mg to 75,g BD
41
Q

3rd line treatment for depression

A
  • high intensity CBT
  • interpersonal therapy
  • medications (and review every 2 weeks for 3 months, every week if suicidal)
42
Q

step 4 in management of depression and indications

A
  • high intensity psychosocial interventions
  • medications –> ECT if necessary
    indications: severe depression, risk to life, neglect
    if suicidal = urgent referral to crisis team
43
Q

medications for depression

A
  1. SSRI e.g. sertraline (2 trials of SSRIs before moving to 2nd line)
  2. taper down SSRI, switch to SNRI e.g. venlafaxine
  3. tx resistant –> augment treatment with antipsychotic e.g. quetiapine, lithium or other anti-depressant e.g. mirtazapine
  4. ECT
44
Q

side effects of mirtazapine

A

symptoms of insomnia and appetite reduction

45
Q

side effects of sertraline

A

smallest side effect profile (i.e. for those with co-morbid conditions e.g. IHD)

46
Q

indication profile of fluoxetine

A

children

47
Q

indication profile of paroxetine

A

major depressive episode

48
Q

primary vs secondary depression

A

primary: no precipitating factor, stable premorbid personality, unresponsive to environmental influences
- secondary: precipitating factor, predisposing personality trait, fluctuates according to environmental factors

49
Q

antidepressant use in pregnancy

A
  • no antidepressent is specifically liscenced however no antidepressant has found to have negative effects
  • lowest effective dose used
50
Q

issues of paroxetine use in pregnancy

A

1st trimester: congenital heart defects

3rd trimester: persistent pulmonary HTN

51
Q

tx of mild, moderate and severe depression in pregnancy

A 
mild = facilitated self help
moderate = CBT
severe = continue antidepressant or switch to a drug with lower risk of adverse effects
52
Q

complications experienced in depression

A
  • psychotic depression: severe depression with delusions and hallucinations (Cotard syndrome, delusion)
  • serotonin syndrome (from large serotonin increase in body from SSRI or SNRI)
53
Q

what is cotard syndrome?

A
  • set of nilhistic delusions where patient believes they are dead and their body parts are rotting
54
Q

how do delusions differ in psychotic depression vs schizophrenia?

A

Delusion = “he wants to kill me with an axe” –> why is that?

  • psychotic depression = “the world is better off without me”
  • schizophrenia = “I have no idea, but I got the message”
55
Q

what is the ICD-10 definition of Bipolar Affective Disorder?

A
  • suspect in someone with S/S of mania, hypomania, depression or mixed
  • > =2 episodes, 1 must be manic associated
    AND
  • mania lasts around 4 months
  • depression lasts around 6 months
    complete recovery between 2 episodes
56
Q

MSE of a manic episode

A

A: excitable, irritable, distracted, inappropriate clothing
S: pressured –> mutism
E: inc self esteem, grandiose, labile mood, irritable, insomia, loss of inhibition, inc appetitie
P: grandiose delusions, paranoia, catatonic
T: flight of ideas, racing thought, over-optimism, suicidal deas, Schneider’s 1st rank
I: minimal –> reckless behaviour
C: cognition

57
Q

define mania

A
  • distinct period of abnormally and persistently elevated, expansive or irritable mood with >= 3 characteristics of mania
  • lasting at least 7 days
  • impair occupational/social/functioning +/- psychosis
58
Q

define hypomania

A

> = 3 characteristic symptoms of mania lasting >= 4 days

  • does not impair occupational/social functioning
  • no psychosis or delusions
  • slightly less exaggerated mania symptoms
59
Q

define mixed mania

A

mixture or rapid alternation (within a few hours) of manic/hypomanic and depressive symptoms

60
Q

classification of BPAD

A
  • type 1 BPAD: manic episodes interspersed with depressive episodes
  • type 2 BPAD: recurrent depressive episodes with less prominent hypomanic episodes
  • rapid cycling BPAD: >=4 episodes/year (repsond to sodium valproate well)
61
Q

biological causes of BPAD

A
  • genetic: 1st degree relative to 7x inc risk
  • anatomical: dec grey matter mass in emotional regulation areas, increased ventral limbic area activity
  • transmitters: inc NA, DA, serotonin trigger mania
62
Q

psychosocial causes of BPAD

A

stressful life events (i.e. pregnancy)

63
Q

investigations of BPAD

A
  • collateral history
  • bloods: FBC, TSH, U&E, LFT, ECG
  • rating scale: Young Mania Rating Scale
  • Physical exam (establish baseline status)
  • urine drug screen
  • risk assessment
64
Q

what is important to ask in BPAD?

A

most BPAD present in their depressive episodes so always ensure you ask about manic symptoms

65
Q

differential diagnosis of BPAD

A
  • organic: drugs, dementia, frontal lobe disease, delirium, cerebral HIV, myxodema madness
  • schizophrenia/ schizoaffective disorder
  • cyclothymia (persistent mild mood instability)
  • puerperal disorders
66
Q

management of BPAD - referral process

A
  • refer to specialist care for diagnosis (cannot be diagnosed in primary care)
  • referral options from primary care: symptoms of hypomania = routine referral to CMHT, symptoms of mania/severe depression = urgent referral to CMHT/ admit to psych ward
67
Q

acute mania or hypomania management

A
  • gradually taper off and stop inducing medications (i.e. SSRIs)
  • monitor fluid/fluid intake
  • sedation may be required (clonazepam, lorazepam)
  • ECT only if mania is not responsive to treatment
68
Q

medications to use in BPAD

A
  1. antipsychotic (olanzapine, quetiapine, risperidone)
  2. different antipsychotic
  3. add lithium or sodium valproate
69
Q

what to do if on treatment?

A
  • optimise medication/ stop antidepressants
  • check lithium levels –> add atypical
  • check compliance
  • short-term sedatives (Benzos)
70
Q

long term management of BPAD (4 weeks after acute episode)

A

1: lithium alone (monitor for toxicity)
2. if lithium not effective = lithium and valproate (no monitoring but SEs = hair loss, weight gain, nausea)
3. if lithium is poorly tolerated = valproate or olanzapine ALONE

71
Q

what is the management if depression co-exists?

A
  • can’t use antidepressants on their own as may cause a switch to mania
  • only give ADs with a mood stabiliser or anti-psychotic
    1. Fluoxetine and olanzapine
    2. Quetiapine alone
    3. Olanzapine alone or Lamotrigine alone
72
Q

what do you do if they present in a manic episode on any antidepressants?

A
  • taper them and stop them

PACES management (7 decks)

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