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
2
Q
protective factors against suicide
A
- married
- lithium medication
- faith in a religion
- no substance abuses
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
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
5
Q
how can delirium be categorised?
A
hyper or hypoactive or mixed
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
7
Q
Psychosocial causes of delirium
A
- depression
- change in environment
- vision/hearing disturbance
- stress
- sleep disturbance
8
Q
how to investigate delirium?
A
Confusion Assessment Method (CAM)
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
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
11
Q
behavioural management in delirium
A
- modify risk factors
- exclude undiagnosed dementia
- treat causes
- single room, well lit, familiar staff/family
- minimise change
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
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
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
15
Q
ICD-10 core features of depression
A
low mood
anhedonia
anergia
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)
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
18
Q
medications that may cause depression
A
- steroids
- methyldopa
- COCP
- beta blockers
- statins
- ranitidine
- retinoids (isotretinoin)
19
Q
how is the severity of depression assessed?
A
- number/severity of symptoms and degree of functional impairment
20
Q
cognitive and psychological symptoms of depression
A
- Beck’s cognitive triad: worthlessness, hopelessness, helplessness
- guilt
- concentration/memory/thinking
21
Q
biological symptoms of depression
A
sleep, appetitie, libido
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
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)
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
25
biological causes of depression (most likely to respond to medication)
- 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)
26
psychosocial causes of depression
- 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)
27
Investigations in depression
- 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)
28
MSE in depression
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
29
differentials for depression
- 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
management of mild depression in children and young people
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
management of moderate to severe depression in children/young people
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
depression unresponsive to treatment management in children/ young people
CAMHS
| - intensive psychological therapy
33
management of depression in adults
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
when are medications given in depression?
- 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
step 3 treatment of depression / indications
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
step 4 treatment of depression and indications
- severe depression, risk to life, neglect
- high intensity psychosocial interventions
- medications --> ECT if necessary
37
how long should medications be continued for?
- 6-9 months after recovery to prevent relapse
| - recurrent, depressive disorder --> tx for >2 years
38
what is the catch up phenomena?
if someone recovers from depression and then medication is suddenly stopped, experience depression again and they will be in worse state
39
first line drug and dose
1. SSRIs (sertraline, citalopram, fluoxetine, partoxetine)
Sertraline: stepped increase from 50mg to 200mg
2 trials of SSRIs before moving to 2nd line
40
2nd line drug and dose
2. Taper down SSRI and switch to SNRI (venlafaxine, duloxetine)
Venlafaxine: stepped increase from 37.5mg to 75,g BD
41
3rd line treatment for depression
- high intensity CBT
- interpersonal therapy
- medications (and review every 2 weeks for 3 months, every week if suicidal)
42
step 4 in management of depression and indications
- high intensity psychosocial interventions
- medications --> ECT if necessary
indications: severe depression, risk to life, neglect
if suicidal = urgent referral to crisis team
43
medications for depression
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
3. ECT
44
side effects of mirtazapine
symptoms of insomnia and appetite reduction
45
side effects of sertraline
smallest side effect profile (i.e. for those with co-morbid conditions e.g. IHD)
46
indication profile of fluoxetine
children
47
indication profile of paroxetine
major depressive episode
48
primary vs secondary depression
primary: no precipitating factor, stable premorbid personality, unresponsive to environmental influences
- secondary: precipitating factor, predisposing personality trait, fluctuates according to environmental factors
49
antidepressant use in pregnancy
- no antidepressent is specifically liscenced however no antidepressant has found to have negative effects
- lowest effective dose used
50
issues of paroxetine use in pregnancy
1st trimester: congenital heart defects
| 3rd trimester: persistent pulmonary HTN
51
tx of mild, moderate and severe depression in pregnancy
```
mild = facilitated self help
moderate = CBT
severe = continue antidepressant or switch to a drug with lower risk of adverse effects
```
52
complications experienced in depression
- psychotic depression: severe depression with delusions and hallucinations (Cotard syndrome, delusion)
- serotonin syndrome (from large serotonin increase in body from SSRI or SNRI)
53
what is cotard syndrome?
- set of nilhistic delusions where patient believes they are dead and their body parts are rotting
54
how do delusions differ in psychotic depression vs schizophrenia?
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
what is the ICD-10 definition of Bipolar Affective Disorder?
- 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
MSE of a manic episode
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
define mania
- 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
define hypomania
>= 3 characteristic symptoms of mania lasting >= 4 days
- does not impair occupational/social functioning
- no psychosis or delusions
- slightly less exaggerated mania symptoms
59
define mixed mania
mixture or rapid alternation (within a few hours) of manic/hypomanic and depressive symptoms
60
classification of BPAD
- 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
biological causes of BPAD
- 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
psychosocial causes of BPAD
stressful life events (i.e. pregnancy)
63
investigations of BPAD
- 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
what is important to ask in BPAD?
most BPAD present in their depressive episodes so always ensure you ask about manic symptoms
65
differential diagnosis of BPAD
- organic: drugs, dementia, frontal lobe disease, delirium, cerebral HIV, myxodema madness
- schizophrenia/ schizoaffective disorder
- cyclothymia (persistent mild mood instability)
- puerperal disorders
66
management of BPAD - referral process
- 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
acute mania or hypomania management
- 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
medications to use in BPAD
1. antipsychotic (olanzapine, quetiapine, risperidone)
2. different antipsychotic
3. add lithium or sodium valproate
69
what to do if on treatment?
- optimise medication/ stop antidepressants
- check lithium levels --> add atypical
- check compliance
- short-term sedatives (Benzos)
70
long term management of BPAD (4 weeks after acute episode)
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
what is the management if depression co-exists?
- 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
what do you do if they present in a manic episode on any antidepressants?
- taper them and stop them
