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Phase 3a Revision > Psych COPY > Flashcards

Psych COPY Flashcards

1
Q

PHENOMENOLOGY

Define illusion

A

The false perception of a real external stimulus

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2
Q

PHENOMENOLOGY

Define hallucination

A

An internal perception occurring without a corresponding external stimulus.

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3
Q 
PHENOMENOLOGY
In terms of hallucinations, what are...
i) the main senses?
ii) somatic?
iii) hypnogogic/hypnopompic
iv) autoscopic?
v) reflex?
vi) extracampine?
A

i) Auditory, visual, olfactory, gustatory, tactile
ii) within the person
iii) when going to sleep/when waking up = normal
iv) seeing oneself
v) production of a hallucination in one sensory modality by a stimulus in a different modality
vi) hallucinations which are experienced outside the normal sensory field (seeing something behind them)

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4
Q

PHENOMENOLOGY
What is Charles-Bonnet Syndrome?
What conditions may it be seen in?

A
  • Complex visual hallucinations in a patient with partial/severe blindness (macular degeneration, diabetic retinopathy).
  • Pts understand that the hallucinations are not real + so often have insight
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5
Q

PHENOMENOLOGY

Define pseudo-hallucination

A

A perception in the absence of an external stimulus

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6
Q

PHENOMENOLOGY

Define over-valued idea

A

A false or exaggerated belief held with conviction but not with delusional intensity.

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7
Q

PHENOMENOLOGY

Define delusion

A

A fixed, false, unshakable belief which is out of keeping with the patient’s educational, cultural + social norms. It’s held with extraordinary conviction + certainty (even despite contradictory evidence)

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8
Q 
PHENOMENOLOGY
In terms of delusions, what are...
i) persecutory?
ii) grandiose?
iii) nihilistic?
A

i) the idea that someone/something is trying to inflict harm on them (being followed, poisoned)
ii) idea that the person themselves are powerful/crucially important beyond truth

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9
Q

PHENOMENOLOGY
In terms of delusions, what are…
i) nihilistic?
ii) reference?

A

i) theme involves intense feelings of emptiness, sense of everything being unreal
ii) false belief that insignificant remarks/objects in one’s environment have personal meaning/significance (newspaper has hidden text related to them)

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10
Q

PHENOMENOLOGY

What are the 3 delusional misidentification syndromes?

A
  • Capgras = idea someone has been replaced by an imposter.
  • Fregoli = idea various people are the same person
  • Intermetamorphosis = one significant relative is replaced by another (father is son).
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11
Q

PHENOMENOLOGY

Define delusional perception and give an example

A

A primary delusion of two components – where a normal perception is subject to delusional interpretation
E.g. – traffic light changed red so that means I am the son of God

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12
Q

PHENOMENOLOGY

Define thought alienation. What are the 3 components of this?

A

Sx of psychosis in which patients feel that their own thoughts are in some way no longer in their control
Insertion = delusional belief thoughts placed into pts head from external
Withdrawal = delusional belief thoughts removed from head from external
Broadcast = delusional belief thoughts are accessible directly to others without expressing them

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13
Q

PHENOMENOLOGY

Define concrete thinking

A

Loss of ability to understand abstract concepts + metaphorical ideas leading to a strictly literal form of speech

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14
Q

PHENOMENOLOGY

Define thought disorder and formal thought disorder

A 
TD = disorganised thinking as evidenced by disorganised speech/beliefs
FTD = pts expressive language (form) indicates that the links between consecutive thoughts aren't meaningful (disorganised speech evident from disorganised thinking)
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15
Q 
PHENOMENOLOGY
In terms of thought disorders, what is...
i) flight of ideas?
ii) pressure of speech?
iii) poverty of speech/alogia?
A

i) Abrupt leaps between topics as thoughts present more rapidly than can be articulated. Each thought = more associations. ?Discernible links between successive ideas. Presents as pressure of speech.
ii) Rapid speech w/out pauses which is difficult to interrupt
iii) Lack of spontaneous speech

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16
Q 
PHENOMENOLOGY
In terms of thought disorders, what is...
i) tangentiality?
ii) thought block?
iii) clang association (± alliteration)
iv) circumstantiality?
A

i) Wandering from the topic + never returning to it
ii) Sudden + unintentional break in chain of thought
iii) Severe form of flight of ideas whereby ideas are related only by similar/rhyming sounds rather than meaning
iv) Irrelevant wandering in conversation (going around the point).

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17
Q 
PHENOMENOLOGY
In terms of thought disorders, what is...
i) loosening of association?
ii) perseveration?
iii) echolalia?
A

i) Aka derailment/Knight’s move thinking = a lack of logical association between sequential thoughts, often leading to incoherent speech
ii) Persistent repetition of words/ideas that were initially appropriate but continue past this point
iii) repeating other’s words/phrases

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18
Q 
PHENOMENOLOGY
In terms of thought disorders, what is...
i) neologisms?
ii) incoherence/word salad?
iii) poverty of thought?
A

i) Making up new words
ii) Confused or unintelligible mixture of seemingly random words and phrases
iii) Subjective experience of being devoid of thoughts

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19
Q

PHENOMENOLOGY

Define confabulation + state what conditions you would find this in

A

Giving a false account to fill in a gap in memory.

Korsakoff’s psychosis + dementia

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20
Q

PHENOMENOLOGY

Define passivity phenomena?

A
  • Delusion that one is a passive recipient of actions from an external agency against their will
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21
Q

PHENOMENOLOGY

Define psychomotor retardation + state what conditions you would find this in

A
  • Slowing down of mental or physical activities

- Parkinson’s, depression

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22
Q

PHENOMENOLOGY

Define incongruity of affect

A

Emotional responses that differs markedly from the expected emotion for the situation/subject like laughing whilst discussing trauma

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23
Q

PHENOMENOLOGY

hat is the difference between blunting and flattening of affect?

A
  • Blunting = dulled response to emotional stimuli

- Flattening = no response to emotional stimuli

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24
Q

PHENOMENOLOGY

Define depersonalisation + derealisation

A
  • Where a person doesn’t believe themselves to be real

- Where a person doesn’t believe the world/people around them to be real

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25
Q

PHENOMENOLOGY

Define obsession

A
  • Unwanted intrusive thought, image or urge that repeatedly enters a person’s mind. Recognised as person’s own thoughts (insight)
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26
Q

PHENOMENOLOGY

Define compulsion

A
  • Repetitive behaviours or mental acts that a person feels driven to perform
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27
Q

PHENOMENOLOGY

Define thought echo

A

Experience of an auditory hallucination in which the content is the individual’s current thoughts spoken aloud as if next to them

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28
Q

PHENOMENOLOGY

Define catatonia/stupor

A

Abnormality of movement + behaviour arising from a disturbed mental state, typically severe depression or schizophrenia

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29
Q

PHENOMENOLOGY

Define anhedonia

A

Inability to feel pleasure in normally pleasurable activities

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30
Q

PHENOMENOLOGY

Define belle indifference

A

A surprising lack of concern for, or denial of, apparently severe functional disability (not specific to psych)

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31
Q

PHENOMENOLOGY

Define dissociation

A

When a person feels disconnected from themselves or their surroundings (including emotions)

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32
Q

PHENOMENOLOGY

Define conversion

A

Development of features suggestive of physical illness but which are attributed to psych illness or emotional disturbance rather than organic pathology

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33
Q

PHENOMENOLOGY

What is the difference between stereotypy and mannerism?

A
  • Stereotypy = persistent repetition of an act for no obvious purpose
  • Mannerism = gesture which is peculiar to the individual
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34
Q

PHENOMENOLOGY

Define projection + give an example

A

What is emotionally unacceptable in the self is unconsciously rejected + projected to others (e.g. mother projects anxiety on children claiming they’re anxious)

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35
Q

MENTAL HEALTH ACT 1983

What are the main principles of the MHA?

A
  • Respect for pts wishes + feelings (past + present)
  • Minimise restrictions on liberty
  • Public safety
  • Pts well-being + safety
  • Effectiveness of treatment
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36
Q

MENTAL HEALTH ACT 1983

What is does an individual have to show to be sectioned?

A
  • Evidence of MH disorder
  • Evidence they’re serious risk to self, safety or others
  • Evidence there is good reason to warrant attention in hospital
  • Appropriate treatment must be available for a S3
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37
Q

MENTAL HEALTH ACT 1983
What is a…
i) section 12 approved dr?
ii) approved mental health professional?

A

i) ≥ST4 Dr who has done extra training in MH to get S12 approved to section pts
ii) AMHPs are often social workers who have done extra training in MH

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38
Q

MENTAL HEALTH ACT 1983

Who can remove sections?

A
  • Consultant psychiatrist
  • MH review tribunal (MHT) if pt disagrees w/ section
  • Nearest relative can make an order to discharge pt from hospital with 72h written notice
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39
Q

MENTAL HEALTH ACT 1983

What is the purpose, duration, location + professionals involved for a Section 2?

A

P – admission for assessment, treatment can be given w/out consent
D – 28d, cannot be renewed, can be converted to S3
L – anywhere in community (airports, jail, A+E, etc)
Prof – 2 Drs (1x S12), 1 AMHP, or nearest relative

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40
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 3?
Who is involved if a pt is medicated without consent?

A

P – admission for treatment
D – 6m, can be renewed
L – anywhere in community
Prof – 2 Drs (1x S12), 1 AMHP, nearest relative
Second opinion appointed doctor (SOAD) – after 3m

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41
Q

MENTAL HEALTH ACT 1983

What is the purpose, duration, location + professionals involved for a Section 4?

A

P – emergency order where waiting for S2 would lead to undesirable delay
D – 72h
L – anywhere in community
P – 1 S12 Dr, 1 AMHP, nearest relative

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42
Q

MENTAL HEALTH ACT 1983
Where can you apply a S5?
What can the team not do?

A
  • Voluntary pt in hospital that wants to leave (NOT A+E as not admitted)
  • Coercively treat the pt
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43
Q

MENTAL HEALTH ACT 1983

What is the purpose, duration + professionals involved for a Section 5(2)?

A

P – Drs holding power, allows for S2/3 assessment
D – 72h
Prof – 1 Dr (FY2 or above)

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44
Q

MENTAL HEALTH ACT 1983

What is the purpose, duration + professionals involved for a Section 5(4)?

A

P – nurses holding power until Dr attends to assess
D – 6h
Prof – 1 registered nurse

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45
Q

MENTAL HEALTH ACT 1983

What are the 2 police sections and their differences? What is the duration and purpose of these?

A
  • S135 – needs magistrates court order to access pts home + remove them
  • S136 –person suspected of having mental disorder in a public place
    D – 24h (extend to 36h if intoxicated but should be seen sooner)
    P – taken to place of safety (local psych unit, police cell) for further assessment
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46
Q

ANTI-PSYCHOTICS
What are the two types of anti-psychotics?
Give examples.

A
  • Typical/1st gen = haloperidol, zuclopenthixol, chlorpromazine
  • Atypical/2nd gen = olanzapine, risperidone (depot), clozapine, aripiprazole (depot), quetiapine
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47
Q

ANTI-PSYCHOTICS
What is the mechanism of action of typical anti-psychotics?
What is the issues?

A
  • Antagonism of Dopamine D2 receptor

- Not selective so can bind to other dopaminergic pathways causing generalised dopamine receptor blockade

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48
Q

ANTI-PSYCHOTICS
What pathway do typical anti-psychotics work on to…

i) have anti-psychotic effect?
ii) cause side effects?

A

i) Mesolimbic pathway (reduces +ve Sx)

ii) Nigrostriatal (Parkinsonism), tuberoinfundibular (prolactin)

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49
Q

ANTI-PSYCHOTICS
What is the mechanism of action of atypical anti-psychotics?
What is the benefit of atypical anti-psychotics?
What anti-psychotic has a reduced SE profile and why?

A
  • Antagonists at dopamine D2 receptors but more selective in dopamine blockade + so block serotonin 5-HT2a
  • More useful in treating -ve Sx of schizophrenia + less likely to cause EPSEs
  • Aripiprazole as partial dopamine agonist
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50
Q

ANTI-PSYCHOTICS
What is the most crucial adverse effect of clozapine?
What is the most common adverse effect?
What other adverse effects may it have?

A
  • Severe life-threatening agranulocytosis
  • Constipation (big issue in elderly)
  • Reduced seizure threshold, hypersalivation (Rx hyoscine hydrobromide)
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51
Q

ANTI-PSYCHOTICS

What are the 5 broad categories of SEs caused by anti-psychotics?

A
  • Extra-pyramidal side effects (EPSEs)
  • Hyperprolactinaemia
  • Metabolic
  • Anticholinergic
  • Neurological
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52
Q

ANTI-PSYCHOTICS

What are the EPSEs?

A
  • Acute dystonic reaction
  • Parkinsonism
  • Akathisia
  • Tardive dyskinesia
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53
Q

ANTI-PSYCHOTICS
How does Parkinsonism present?
How is it managed?

A
  • Bradykinesia, rigid, resting pill-rolling tremor + postural instability
  • Reduce dose or switch to atypical anti-psychotic
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54
Q

ANTI-PSYCHOTICS
How does akathisia present?
What is a risk of this?
How is it managed?

A
  • Motor restlessness, typically lower legs (can’t sit still)
  • Massive RF for suicide in young men with schizophrenia
  • Reduce dose, introduce beta-blocker (propranolol)
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55
Q

ANTI-PSYCHOTICS
How does tardive dyskinesia present?
When does it present?
How is it managed?

A
  • Purposeless involuntary movements (chewing, lip smacking, blinking, tongue protrusion)
  • After months-years of Tx
  • Prevention crucial, switch to atypical anti-psychotic, tetrabenazine used if mod–severe but unlikely to completely resolve
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56
Q

ANTI-PSYCHOTICS

What are the SEs from hyperprolactinaemia?

A
  • Sexual dysfunction (+ anti-adrenergic)
  • Osteoporosis risk
  • Amenorrhoea
  • Galactorrhoea, gynaecomastia + hypogonadism in men
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57
Q

ANTI-PSYCHOTICS

What are the metabolic SEs?

A
  • Weight gain (esp. olanzapine)
  • Hyperlipidaemia, risk of stroke + VTE in elderly
  • T2DM risk + metabolic syndrome
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58
Q

ANTI-PSYCHOTICS

What are the anticholinergic SEs?

A 
Can't see, pee, spit, shit –
- Blurred vision
- Urinary retention
- Dry mouth
- Constipation
\+ tachycardia
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59
Q

ANTI-PSYCHOTICS

What are the neurological SEs?

A
  • Seizures
  • Postural hypotension (anti-adrenergic)
  • Sedation
  • Headaches
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60
Q

ANTI-PSYCHOTICS

What baseline investigations are done for people starting on anti-psychotics?

A
  • FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin, BP, ECG (QTc prolongation) + smoking status (can reduce effects by enhancing metabolism so issues if suddenly stop)
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61
Q

ANTI-PSYCHOTICS

What regular investigations are done for people on anti-psychotics?

A
  • Lipids + BMI at 3m
  • Fasting glucose + prolactin at 6m
  • Frequent BP during dose titration
  • FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin + CV risk yearly
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62
Q

ANTI-PSYCHOTICS
What specific monitoring is required for clozapine?
What happens if they miss a dose?

A
  • FBC at baseline + weekly for 18w, fortnightly until 1y + monthly after
  • If not taken for 48h needs retitrating
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63
Q

ANTI-DEPRESSANTS
What monitoring is needed when starting someone on an anti-depressant?
When can an anti-depressant be stopped?

A
  • 2 weekly to ensure dose working + patient stable (risk of suicidality), may take up to 6w to start working
  • Carried on 6m after Sx resolved even if patient feels better to reduce risk of relapse
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64
Q

ANTI-DEPRESSANTS
How should anti-depressants be stopped?
Why?

A
  • Gradual dose reduction over 4w
  • Sudden cessation can cause severe withdrawal effects (mostly GI) – abdo pain, D+V, difficulty sleeping, sweating + mood change
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65
Q

ANTI-DEPRESSANTS
What is the mechanism of action of SSRIs?
Give some examples

A
  • Prevents reuptake of serotonin from synaptic cleft so prolonged serotonin in synaptic cleft = prolonged neuronal activity
  • Citalopram, sertraline (#1 post MI), fluoxetine (#1 CAMHS)
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66
Q

ANTI-DEPRESSANTS

What are the side effects of SSRIs?

A
  • GI = N+V, diarrhoea, constipation
  • Hyponatraemia
  • Anxiety + agitation
  • Citalopram + QTc prolongation (dose-dependent)
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67
Q

ANTI-DEPRESSANTS

What are some cautions for SSRIs?

A
  • May precipitate manic phase in bipolar

- 1st trimester risk of CHD, 3rd trimester risk of persistent pulmonary HTN

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68
Q

ANTI-DEPRESSANTS

What are some interactions for SSRIs?

A
  • NSAIDs + aspirin = increased risk of bleeding, co-prescribe PPI
  • Can lower seizure threshold
  • Avoid triptans > serotonin syndrome
  • Do not start until 2w after stopping MAOI + vice-versa as increased risk of serotonin syndrome
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69
Q

ANTI-DEPRESSANTS
What is the mechanism of action of SNRIs?
Give some examples

A
  • Prevents reuptake of serotonin AND noradrenaline from synaptic cleft
  • Venlafaxine, duloxetine
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70
Q

ANTI-DEPRESSANTS
What are some side effects of SNRIs?
What are some interactions of SNRIs?

A
  • GI (N+V, constipation)

- NSAIDs + warfarin (increased risk of bleeding), lower seizure threshold

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71
Q

ANTI-DEPRESSANTS
What is the mechanism of action of monoamine oxidase inhibitors (MAOI)?
Give some examples.

A
  • Inhibits monoamine oxidase enzyme which reduces breakdown of adrenaline, noradrenaline + serotonin so increases level
  • Selegiline is selective MAO-B inhibitor which also increases dopamine
  • Isocarboxazid, phenelzine
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72
Q

ANTI-DEPRESSANTS

What are some side effects from MAOIs?

A
  • Sexual dysfunction, weight gain + postural hypotension
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73
Q

ANTI-DEPRESSANTS

What are some cautions with MAOIs?

A
  • Increased risk of serotonin syndrome if used with other serotonergic drugs
  • Hypertensive crisis with ingestion of foods containing tyramine (aged cheeses, smoked/cured meats, pickled herring, Bovril, Marmite)
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74
Q

ANTI-DEPRESSANTS
What is the mechanism of action of tricyclic antidepressants (TCAs)?
Give some examples

A
  • Prevents reuptake of serotonin + noradrenaline from synaptic cleft
  • Amitriptyline, dosulepin, imipramine
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75
Q

ANTI-DEPRESSANTS
What are the side effects of TCAs?
What cautions are there for TCAs?

A
  • Anticholinergic (can’t see, pee, spit, shit)
  • Caution in CVD, avoid following MI
  • Cardiotoxic in overdose so caution in suicidal patients (QTc prolongation)
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76
Q

ANTI-DEPRESSANTS
In terms of TCA overdose…

i) mild-moderate Sx?
ii) severe Sx?
iii) ECG signs?
iv) management?

A

i) Dilated pupils, dry mouth, urinary retention
ii) Fits, coma, arrhythmias > arrest
iii) Sinus tachy, wide QRS, prolonged QT interval
iv) IV sodium bicarbonate

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77
Q

ANTI-DEPRESSANTS
What is the mechanism of action of mirtazapine?
What are some side effects?

A
  • Blocks alpha-2 adrenergic receptors > increased release of neurotransmitters
  • Increased appetite + weight gain + sedation are big ones, also increased triglyceride levels
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78
Q

MOOD STABILISERS
What are some examples of mood stabilisers?
What is the mechanism of action?
What is the therapeutic range of the most common mood stabiliser?

A
  • Lithium (first line), AEDs such as valproate, carbamazepine, lamotrigine
  • Lithium inhibits cAMP production which inhibits monoamines
  • Narrow therapeutic range 0.4–1.0mmol/L
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79
Q

MOOD STABILISERS

What are the side effects of lithium?

A

LITHIUM –
- Leukocytosis
- Insipidus (diabetes, nephrogenic)
- Tremors (fine if SE, coarse if toxicity)
- Hydration (easily dehydrates, renally cleared)
- Increased GI motility (N+V, diarrhoea)
- Underactive thyroid
- Mums beware (Ebstein’s anomaly)
Can cause weight gain + derm (acne, psoriasis) long-term too

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80
Q

MOOD STABILISERS

What drugs does lithium interact with?

A
  • NSAIDs, ACEi, ARBs + diuretics may increase lithium levels

- Diuretics = dehydration, NSAIDs = renal damage

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81
Q

MOOD STABILISERS

What baseline measurements are taken for lithium?

A
  • FBC, U+Es (eGFR), TFTs, BMI + ECG
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82
Q

MOOD STABILISERS

What regular monitoring is done for lithium?

A
  • Weekly serum lithium after initiation + dose changes until stable then every 3m for a year, then every 6m (sample taken 12h after dose)
  • 6m = TFTs, U+Es (eGFR)
  • Annual = BMI
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83
Q

BDZs
What is the mechanism of action of anxiolytics/benzodiazepines (BDZs)?
Give some examples of BDZs

A
  • Enhance effect of inhibitory GABA by increasing frequency of Cl- channels (hyperpolarisation prevents further excitation)
  • Diazepam (longer action), lorazepam (shorter action), clonazepam, chlordiazepoxide
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84
Q

BDZs
What are some adverse effects of BDZs?
How would you reverse BDZs if necessary but what is a risk of this?

A
  • Confusion, drowsiness, dizziness next day (hangover effect), tolerance, dependence
  • Monitor for resp depression (caution in resp disease)
  • IV flumazenil but danger of inducing status epilepticus or death
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85
Q

BDZs

What drugs can BDZs interact with?

A
  • Anti-hypertensives as enhanced hypotensive effect
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86
Q

HYPNOTICS
What is the mechanism of action of hypnotics?
Give some examples
What are the adverse effects?

A
  • GABA agonists
  • Zopiclone, zolpidem
  • Same as BDZs
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87
Q

ECT
What are the reasons why ECT can be done?
When is electroconvulsive therapy (ECT) recommended?

A
  • After adequate trial of other treatments ineffective and/or condition potentially life threatening
  • Severe mania or depression, suicide risk, catatonia, Rx resistant psychosis
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88
Q

ECT

What are some contraindications to ECT?

A
  • NO absolute, all relative
  • General anaesthesia (reactions)
  • Cerebral aneurysm
  • Recent MI, arrhythmias
  • Intracerebral haemorrhage
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89
Q

ECT

What are some adverse effects of ECT?

A
  • Short-term retrograde amnesia
  • Headache
  • Confusion + clumsiness
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90
Q

DEPRESSION
What is depression?
What is the epidemiology?

A
  • Persistent low mood ± loss of pleasure in activities – unipolar depression.
  • F>M but men more likely to be substance misusers + commit suicide
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91
Q

DEPRESSION

What are some risk factors for depression?

A
  • Physical co-morbidities, esp. chronic + painful (MS, stroke, DM)
  • Genetics + FHx, female, substance abuse
  • Traumatic events (+ve/-ve) like divorce/marriage, (un)employment, poverty, loss
  • Adverse childhood experiences like abuse, poor parent relationships
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92
Q

DEPRESSION

What are the 3 diagnostic criteria for depression?

A
  • Sx present most days ≥2 weeks + change from baselines
  • Sx not attributable to other organic or substance causes
  • Sx impair daily function + cause significant distress
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93
Q

DEPRESSION

What are the three core symptoms of depression?

A
  • Low mood
  • Anhedonia
  • Anergia
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94
Q

DEPRESSION

What are some psychological symptoms of depression?

A
  • Guilt, worthlessness, hopelessness
  • Self-harm/suicidality
  • Low self-esteem
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95
Q

DEPRESSION

What are some cognitive symptoms of depression?

A
  • Beck’s triad = negative views about oneself, the world + the future
  • Poor concentration + impaired memory
  • Avoiding social contact + performing poorly at work (social Sx too)
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96
Q

DEPRESSION

What are some somatic, or biological, symptoms of depression?

A
  • Disturbed sleep (EMW, initial insomnia, frequent waking)
  • Disturbed appetite + weight
  • Loss of libido
  • Diurnal mood variation (worse in morning)
  • Psychomotor retardation
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97
Q

DEPRESSION

What are the 4 classifications of depression?

A
  • Mild = ≥2 core + ≥2 other (minimal interference)
  • Mod = ≥2 core + ≥3 other (variable interference)
  • Severe = all core + ≥4 other (marked interference)
  • Psychotic = Sx of depression + psychosis
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98
Q

DEPRESSION

What are some features of psychotic depression?

A
  • Mood congruent hallucinations (auditory = derogatory or accusatory voices, olfactory = bad smells)
  • Nihilistic delusions
  • Delusions of poverty, guilt, hypochondriacal
  • Catatonia or marked psychomotor retardation (depressive stupor)
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99
Q

DEPRESSION

What is Cotard’s syndrome?

A
  • Delusional belief that they are dead, do not exist, are rotting or have lost their blood + internal organs
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100
Q

DEPRESSION

What are some investigations for depression?

A
  • PHQ-9 + HADS to screen for depression

- Risk assessment

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101
Q

DEPRESSION

What is the management of mild depression?

A
  • Watchful waiting
  • Low-intensity psychosocial interventions first line (computerised CBT, individual-guided CBT, structured group physical activity programme) + psychoeducation
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102
Q

DEPRESSION

Should biological therapy be used in mild depression?

A

No unless…

  • Consider if PMH mod-severe depression
  • Mild depression for 2y or persists after interventions
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103
Q

DEPRESSION

What is the management of moderate–severe depression?

A
  • Combination of SSRI + high-intensity psychosocial interventions first line
  • Options = CBT with professional, interpersonal therapy, behavioural activation therapy
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104
Q

DEPRESSION
What is the CAMHS management of depression?
What tool is used to follow-up monitoring in secondary care to assess progress?

A
  • Watch + wait, lifestyle
  • First-line = CBT ± family ± interpersonal therapy (may need intensive if no response)
  • 1st line antidepressant = fluoxetine
  • Mood + feelings questionnaire (MFQ)
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105
Q

DEPRESSION

What is the management for resistant depression?

A
  • Different antidepressants (SNRI, MAOI, mirtazapine) or sometimes combination
  • Augmentation with lithium
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106
Q

DEPRESSION

What is the management of psychotic depression?

A
  • ECT first line + v effective in severe cases followed by antidepressant
  • Antipsychotic initiated before antidepressant if ?primary psychotic disorder then add SSRI
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107
Q

DEPRESSION
What is atypical depression?
What is the management?

A
  • Mood depressed but reactive
  • Hypersomnia + hyperphagia
  • Leaden paralysis (heaviness in limbs)
  • Phenelzine or another MAOI, if not SSRI
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108
Q

DEPRESSION
What is dysthymia?
What is the management?

A
  • Chronic, sub-threshold depressive Sx which don’t meet diagnostic criteria over a long period of time
  • Typically >2y of mildly depressed mood + diminished enjoyment, less severe but more chronic
  • SSRIs + CBT first line
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109
Q

DEPRESSION
What is seasonal affective disorder?
What is the management?

A
  • Episodes of depression which recur annually at same time each year (Jan-Feb) with remission in between
  • Light therapy + SSRI
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110
Q

SELF-HARM + SUICIDE
What is self-harm?
What are some causes?
Why do people self harm?

A
  • Act of intentionally injuring yourself
  • Bullying, bereavement, homophobia, low self-esteem
  • Feel in control, reduces feelings of tension or distress, if they feel guilty can be a punishment
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111
Q

SELF-HARM + SUICIDE
What are some risk factors?
What does previous self-harm indicate?

A
  • F, social deprivation, single or divorced, LGBTQ+, mental illness
  • Greatest predictor of future self-harm + increased suicide risk
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112
Q

SELF-HARM + SUICIDE
What is suicide?
What is parasuicide?
Why is depression higher in females but suicide higher in males?

A
  • Act of intentionally ending your life
  • Act mimics suicide but does not result in death
  • Men tend to use violent means which are irreversible
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113
Q

SELF-HARM + SUICIDE

What are some risk factors for suicide?

A

SAD PERSONS –

  • Sex (M>F)
  • Age (peaks in young + old)
  • Depression
  • Previous attempt
  • Ethanol
  • Rational thinking loss (psychotic illness)
  • Social support lacking (unemployed, homeless)
  • Organised plan (avoid discovery, plan, notes, final acts)
  • No spouse
  • Sickness (physical illness)
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114
Q

SELF-HARM + SUICIDE
What are some protective factors for suicide?
What are some indicators that someone may commit suicide?

A
  • Married men, active religious beliefs, social support, good employment
  • Active planning (buy equipment, manage affairs, leave notes
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115
Q

BIPOLAR DISORDER
What is bipolar affective disorder?
When is the peak age of onset?

A
  • Recurrent episodes of altered mood + activity involving both upswings or (hypo)mania + downswings or depression
  • Early 20s
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116
Q

BIPOLAR DISORDER

What are the 4 types of bipolar?

A
  • Bipolar 1 = mania + depression in equal proportions, M>F
  • Bipolar 2 = more episodes of depression, mild hypomania (easy to miss), F>M
  • Cyclothymia = chronic mood fluctuations over ≥2y (can be subclinical)
  • Rapid cycling = ≥4 episodes of (hypo)mania or depression in 1 year
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117
Q

BIPOLAR DISORDER

What are some risk factors of bipolar?

A
  • FHx of depression or bipolar
  • Traumatic life event
  • Hx of abuse
  • Substance abuse
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118
Q

BIPOLAR DISORDER

What is the diagnostic criteria for bipolar?

A
  • ≥2 episodes of mood disturbance (1 or which MUST be [hypo]manic)
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119
Q

BIPOLAR DISORDER

What is the clinical presentation of hypomania?

A

> 4d with ≥3 Sx –

  • Elevated mood
  • Increased energy
  • Increased talkativeness
  • Poor concentration
  • Mild reckless behaviour (overspending)
  • Over-familiar, increased self-esteem
  • Increased libido
  • Decreased need for sleep
  • Appetite change
  • Partial insight
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120
Q

BIPOLAR DISORDER

What is the clinical presentation of mania?

A

> 1w with ≥3 Sx –

  • Extreme elation or irritability
  • Overactivity + distractibility
  • Pressure of speech + flight of ideas
  • Impaired judgement
  • Extreme risks (jump off buildings, spending spree)
  • Social disinhibition + grandiosity
  • Sexual disinhibition
  • Decreased need for sleep, restless
  • MOOD CONGRUENT PSYCHOTIC Sx
  • TOTAL loss of insight
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121
Q

BIPOLAR DISORDER

How can you differentiate between mani and hypomania?

A
  • Psychotic symptoms e.g., grandiose delusions, catatonia (manic stupor) seen in mania (never hypomania) with marked impairment in functioning
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122
Q

BIPOLAR DISORDER
What are some…

i) psychiatric
ii) organic

differentials for bipolar?

A

i) Substance abuse, schizophrenia, schizoaffective disorder

ii) Hyperthyroidism, steroid-induced psychosis, Cushing’s

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123
Q

BIPOLAR DISORDER

What investigations would you perform in suspected bipolar?

A
  • FBC, U+Es, LFTs, glucose, TFTs, calcium
  • Syphilis serology, urine drug test,
  • ?neuroimaging if SOL
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124
Q

BIPOLAR DISORDER

What is the acute biological management of bipolar disorder?

A
  • Antipsychotic
  • Stop any precipitating antidepressants
  • ?ECT if severely psychotic, catatonic or suicide risk
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125
Q

BIPOLAR DISORDER

What is the long-term biological management of bipolar disorder?

A
  • Lithium first-line (antipsychotics in pregnancy)

- Valproate second line but caution in women

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126
Q

BIPOLAR DISORDER
What type of referral would you do in bipolar?
What is the psychological management of bipolar disorder?

A
  • Hypomania = routine CMHT referral, mania or severe depression = urgent
  • CBT, interpersonal therapy, bipolar support groups
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127
Q

SCHIZOPHRENIA
What is schizophrenia?
What area of the brain is most affected?

A
  • Splitting or dissociation of thoughts, loss of contact with reality
  • Temporal lobe
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128
Q

SCHIZOPHRENIA

What is the neurotransmitter hypothesis in schizophrenia?

A
  • Excess dopamine + overactivity in mesolimbic tract = +ve Sx
  • Lack of dopamine + underactivity in mesocortical tracts = -ve Sx
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129
Q

SCHIZOPHRENIA
What is the epidemiology of schizophrenia?
What are some risk factors?

A
  • 1% lifetime risk

- Strongest RF = FHx, others = Black Caribbean, migration, urban areas, cannabis use, poverty

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130
Q

SCHIZOPHRENIA
What are the first rank symptoms of schizophrenia?
What is the relevance?

A
  • Delusional perceptions
  • Auditory hallucinations (3 types)
  • Thought alienation (insertion, withdrawal + broadcasting)
  • Passivity phenomenon, incl. somatic
  • ≥1 for at least 1m is strongly suggestive Dx
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131
Q

SCHIZOPHRENIA

What are the three types of auditory hallucinations that count as a first rank symptom?

A
  • 3rd person = talking about the patient (he/she)
  • Running commentary = often on person’s actions or thoughts
  • Thought echo = thoughts spoken aloud
132
Q

SCHIZOPHRENIA
What are some secondary symptoms of schizophrenia?
What is the relevance?

A
  • Other hallucinations + delusions (persecutory)
  • Formal thought disorder
  • Negative Sx (incl. catatonia)
  • ≥2 for at least 1m is strongly suggestive Dx
133
Q

SCHIZOPHRENIA

What is the difference between positive and negative symptoms of schizophrenia?

A
  • +ve = presence of change in behaviour or thought, something added (all of the first rank + secondary Sx)
  • -ve = decline in normal functioning, something removed
134
Q

SCHIZOPHRENIA

What are the negative symptoms of schizophrenia?

A

Often early prodromal, As –

  • Affect blunting
  • Anhedonia
  • Alogia
  • Avolition
  • Also, delusional mood = ominous feeling of something impending)
135
Q

SCHIZOPHRENIA
What are some…

i) psychiatric
ii) organic
iii) substance

differentials for schizophrenia?

A

i) Mania, psychotic depression
ii) TLE, encephalitis, delirium, syphilis/HIV, Wilson’s disease
iii) Steroid/drug/alcohol

136
Q

SCHIZOPHRENIA

What are the investigations for first-episode psychosis?

A
  • FBC, CRP/ESR, U+Es, LFTs, TFTs, fasting glucose, Ca2+, phosphate, B12 + folate
  • Urine + serum drugs screen
  • ?Serological syphilis + HIV
  • CT/MRI head if ?SOL
137
Q

SCHIZOPHRENIA

What teams would be involved in the management of schizophrenia?

A
  • Early intervention team = initial referral after first episode psychosis
  • CMHT = provide daily support + treatment
  • Crisis resolution team = pts with acute psychotic episode, often pre-existing diagnosis
138
Q

SCHIZOPHRENIA

What is the biological management of schizophrenia?

A
  • Anti-psychotic (tailor SE profile to patient)

- Use depot if non-compliant to prevent relapse

139
Q

SCHIZOPHRENIA
What is treatment resistant schizophrenia?
What is the management?

A
  • ≥2 antipsychotics (1 atypical) trialled for ≥6w but ineffective
  • Clozapine
  • ECT is last line if resistant to therapy or catatonic
140
Q

SCHIZOPHRENIA

What is the psychological management for schizophrenia?

A
  • All patients offered CBT

- Family therapy + psychoeducation to reduce or notice relapses

141
Q

SCHIZOPHRENIA

What is the social management of schizophrenia?

A
  • Social work + housing involvement may be needed
  • Drop-in community centres + support groups
  • Substance misuse service if needed
  • Depot non-attendance at GP/CPN appt may act as early warning system
142
Q

SCHIZOPHRENIA
After a Mental Health Act detention, what approach should be taken to their care?
What does it involve?

A
  • Care programme approach

- Assess health + social needs, create care plan, appoint key worker as point of contact + review treatment

143
Q

PARAPHRENIA
What is paraphrenia?
What are some risk factors?
What are some features?

A
  • Late-onset schizophrenia >45y
  • Social isolation, poor eyesight/hearing
  • Paranoia + delusions about neighbours
144
Q

DELUSIONAL DISORDER
What is a delusional disorder?
How is it managed?

A
  • Strong delusional beliefs in the absence of hallucinations, thought or mood disorder
  • Antipsychotics + CBT
145
Q

DELUSIONAL DISORDER

What is erotomania or De Clerambault’s syndrome?

A
  • Delusion in which patient (usually single woman) believes another person (typically higher social status) is in love with them
146
Q

DELUSIONAL DISORDER

What is Othello syndrome?

A
  • Delusional jealousy

- Patients (typically men) possess fixed belief that their partner has been unfaithful + often try to collect evidence

147
Q

SCHIZOAFFECTIVE
What is schizoaffective disorder?
What are the two types?
How does it differ to schizophrenia?

A
  • Features of both affective disorder + schizophrenia present in equal proportion
  • Manic type or depressive type
  • Psychotic Sx tend to wax + wane, unlike in schizophrenia
148
Q

SCHIZOAFFECTIVE
What is the prognosis of schizoaffective disorder?
What is the management of it?

A
  • Better than schizophrenia but worse than primary mood disorders
  • Antipsychotics, mood stabilisers or antidepressants (depends on affective disorder)
149
Q

GAD

What is Generalised Anxiety Disorder (GAD)?

A
  • Syndrome of excessive, persistent worry + apprehensive feelings about various situations present most days for ≥6m
150
Q

GAD

What are some risk factors of GAD?

A
  • F>M
  • Substance abuse
  • FHx of anxiety or PMHx of panic disorder, social phobia
  • Domestic violence, child abuse or bullying
151
Q

GAD

What are the core features seen in GAD according to DSM-V?

A
  • ≥3: nervousness, easily fatigued, poor concentration, irritability, muscle tension or sleep disturbance
152
Q

GAD

What general anxiety symptoms may be seen in GAD?

A
  • Psych = depersonalisation, derealisation
  • Autonomic = palpitations, tachycardia, sweating, tremor
  • Physical = SOB, chest pain, nausea, abdo pain
  • Motor = restlessness, fidgeting
153
Q

GAD
What are the investigations for GAD?
Give some differentials

A
  • GAD-7 + Hospital Anxiety + Depression Scale (HADS) questionnaire
  • Exclude organic (FBC, U+Es, LFTs, TFTs, fasting glucose, PTH)
  • Depression, hyperthyroid, substance abuse, caffeine, OCD
154
Q

GAD

What is the stepwise management for GAD?

A
  • 1 = education about GAD + active monitoring
  • 2 = low-intensity psychological interventions = self-help, psychoeducation groups
  • 3 = high-intensity psychological interventions or drug treatment
  • 4 = Highly specialist input = complex drugs, multi-agency teams
155
Q

GAD

What medication is used in GAD?

A
  • First line = sertraline SSRI
  • Second line = alternative SSRI or SNRI
  • Third line = if cannot tolerate SSRI/SNRI ?pregabalin
156
Q

GAD

What is the CAMHS management of GAD?

A
  • Watch + wait
  • Self-help (meditation, mindfulness), diet + exercise
  • CBT, counselling + SSRI may be considered if more severe (specialists)
157
Q

PANIC DISORDER

What is panic disorder?

A
  • Recurrent panic attacks that are unpredictable + unrestricted in terms of the situation, ≥4/week for ≥4 weeks
158
Q

PANIC DISORDER
What is the epidemiology of panic disorder?
What are the risk factors?

A
  • Females 2–3x more likely, bimodal distribution

- Divorced/widowed, FHx, child abuse, domestic abuse

159
Q

PANIC DISORDER

What is the clinical presentation of panic disorder?

A

PANICS

  • Palpitations, Abdo distress, Nausea, Intense fear of death, Chest pain/choking, SOB (resp alkalosis)/sweating
  • Also other anxiety Sx as above
160
Q

PANIC DISORDER

What is the stepwise management of panic disorder?

A
  • 1 = recognition + diagnosis
  • 2 = Primary care Mx = CBT or SSRIs (if SSRIs C/I or no response after 12m = imipramine or clomipramine)
  • 3 = R/v + consideration of alternative treatments
  • 4 = R/v + referral to specialist MH services
  • 5 = Care in specialist MH services
161
Q

PHOBIAS

What is a phobia?

A
  • Intense, irrational fear of an object, situation or place that is recognised as excessive + may lead to avoidance
162
Q

PHOBIAS

What are the three main types of phobias and how they differ?

A
  • Agoraphobia = fear open spaces + related aspects such as presence of crowds + difficulty of immediate escape
  • Social = fear of scrutiny by others in comparatively small groups (opposed to crowds) leading to avoidance
  • Specific phobia = marked fear of a specific object or situation (e.g., animals, heights)
163
Q

PHOBIAS

How does agoraphobia present?

A
  • ≥2 anxiety Sx at ≥2 of: crowds, public spaces, travelling alone, travelling away from home
164
Q

PHOBIAS
When might social phobia manifest?
How does social phobia present?

A
  • Specific (public speaking) or generalised (any social setting)
  • ≥2 anxiety Sx and 1 of: blushing, vomiting, urgency/fear of micturition/defecation
165
Q

PHOBIAS

What is the management of phobias?

A
  • First line = CBT

- Second line = SSRIs > alternative SSRI or SNRI > MAOi like phenelzine

166
Q

PHOBIAS

What might the CBT in phobias include?

A
  • Exposure and response prevention (ERP)
  • Desensitisation with relaxation + graduated exposure = preferred
  • Flooding (most frightening situation instantly) can be traumatic
167
Q

OCD

What is obsessive compulsive disorder (OCD)?

A
  • Condition characterised by obsessions + compulsions which cause distress and/or functional impairment (e.g., time consuming, interferes with ADLs)
168
Q

OCD
What are some risk factors for OCD?
What are some associations with OCD?

A
  • FHx of OCD, psychological trauma

- Depression, paediatric neuropsychiatric disorders associated with streptococcal infection (PANDAS)

169
Q

OCD

What is the clinical presentation of OCD?

A
  • Obsessions = distressing, insight (contamination, symmetry, fear of harm)
  • Compulsions = overwhelming urge to carry out act
  • Cycle of obsession > anxiety > compulsion > relief
170
Q

OCD

How can compulsions be sub-categorised?

A
  • Overt = observed (cleaning, washing hands, checking doors)

- Covert = not observed (counting, repeating phrases in mind)

171
Q

OCD

What is the management of OCD with mild functional impairment?

A
  • Low-intensity psychological interventions = CBT + ERP

- If not sufficient then can offer SSRi or more intensive therapy

172
Q

OCD
What is the management of OCD with…

i) moderate functional impairment?
ii) severe functional impairment?
iii) body dysmorphic features?

A
  • SSRI OR more intensive CBT + ERP
    ii) SSRI AND intensive CBT + ERP
    iii) Fluoxetine is SSRI of choice in body dysmorphic disorder
173
Q

ACUTE STRESS REACTION
What is an acute stress reaction?
What is the management?

A
  • Transient disorder with features of PTSD (trauma, flashbacks, numbness, avoidance, hyperarousal) that occur in first 4w after a traumatic event (RTC, rape, natural catastrophe)
  • Trauma focussed CBT first line
174
Q

ADJUSTMENT DISORDER
What is adjustment disorder?
How does it present?

A
  • Distress 2º to significant life change or stressful life event (e.g., break up) but not to the extent of catastrophe as in acute stress reaction/PTSD
  • More severe reaction to event than expected = suicidality, disturbed sleep
175
Q

GRIEF REACTION

What constitutes an abnormal grief reaction?

A
  • Delayed grief = >2w until grieving starts

- Prolonged grief = hard to define

176
Q

GRIEF REACTION

What are the stages of grief?

A
  • Denial incl. numbness, pseudohallucinations of deceased
  • Anger usually to family or HCPs
  • Bargaining, depression + acceptance (may not go through all 5 stages)
177
Q

PTSD

What is post-traumatic stress disorder (PTSD)?

A
  • Severe psychological disturbance following a traumatic event, often life-threatening (RTC, war, rape) present ≥1m
178
Q

PTSD

What are some risk factors for PTSD?

A
  • Low education or social class
  • F>M
  • Previous PTSD/psych issues
  • First responders (ambulance, police, fire)
  • Military (dependent on duration of combat exposure, lower rank, low morale)
179
Q

PTSD
What are the 4 core symptoms of PTSD?
How long do they need to be present for to diagnose?

A

HEAR (≥1m) –

  • Hyperarousal
  • Emotional numbing
  • Avoidance
  • Re-experiencing (involuntary)
180
Q

PTSD
In terms of PTSD, what are signs of…

i) hyperarousal?
ii) emotional numbing?

A

i) Hypervigilance for threat, exaggerated startle response, difficulty concentrating or sleeping
ii) Difficulty experiencing emotions + detachment from others

181
Q

PTSD
In terms of PTSD, what are signs of…

i) avoidance + rumination?
ii) re-experiencing?

A

i) Avoiding people/situations associated to event

ii) Flashbacks, nightmares, vivid memories

182
Q

PTSD

What is the mainstay of management in PTSD?

A
  • Psychological therapy = trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR)
183
Q

PTSD

What is the medical management of PTSD?

A
  • Venlafaxine or SSRI like sertraline

- Risperidone for severe cases where resistant to treatment or psychotic

184
Q

SUBSTANCE ABUSE
What is an addiction?
What is dependence?

A
  • Compulsive substance taking behaviour with physiological withdrawal state
  • The inability to control the intake of a substance to which one is addicted to
185
Q

SUBSTANCE ABUSE

List 8 features of dependence

A
  • Withdrawal
  • Cravings
  • Continued use despite harm
  • Tolerance
  • Primacy/salience
  • Loss of control
  • Narrowed repertoire
  • Rapid reinstatement
186
Q

SUBSTANCE ABUSE
What is withdrawal?
Give an example

A
  • Physiological withdrawal state when substance stopped with Sx + substance use to prevent
  • Early morning drinking
187
Q

SUBSTANCE ABUSE

What are cravings?

A
  • Very strong desire for the substance
188
Q

SUBSTANCE ABUSE
What is continued use despite harm?
Give an example

A
  • Despite clear problems caused by substance, person cannot stop
  • Injecting heroin despite abscess formation
189
Q

SUBSTANCE ABUSE
What is tolerance?
Give an example

A
  • Larger doses required to gain the same effect as previously (NB: individuals often show no signs of being on a drug at dose ordinary people would)
  • Opiate-dependent people may inject enough heroin to kill a non-tolerant person
190
Q

SUBSTANCE ABUSE
What is primacy/salience?
Give an example

A
  • Obtaining + using substance becomes so important other interests are neglected
  • Not eating to save money for drugs
191
Q

SUBSTANCE ABUSE
What is narrowed repertoire?
Give an example

A
  • Less variation in types of substances used

- Dependent drinker will drink same amount of same drink in same way (usually cheapest)

192
Q

SUBSTANCE ABUSE
What is rapid reinstatement?
Give an example

A
  • When a user relapses after period of abstinence, risk of returning to previous dependent pattern quicker
  • Someone who used to smoke 10/d may quickly return to this after 1 fag
193
Q

ALCOHOL DEPENDENCE
How do you calculate number of units in a drink?
What is 1 unit of alcohol?
What is the recommended weekly units for men and women?

A
  • % ABV x volume (L)
  • 10ml or 8g
  • 14 units/week
194
Q

ALCOHOL DEPENDENCE

What are some risk factors for alcohol dependence?

A
  • FHx, M>F
  • Occupation = armed forces, doctors
  • Social reinforcement
  • Chronic illnesses
  • Psychological distress = bullying, rape, domestic violence
195
Q

ALCOHOL DEPENDENCE
What are the acute effects of alcohol intoxication?
When is it classed as alcohol dependence?

A
  • Euphoria, impaired judgement, reduced anxiety, ataxia, vomiting
  • ≥3 features of dependence
196
Q

ALCOHOL DEPENDENCE

What are the 3 stages of alcohol withdrawal?

A
  • 6–12h = tremors, diaphoresis, tachycardia, anxiety, irritability + aggression
  • 36h = seizures
  • 48–72h = delirium tremens
197
Q

ALCOHOL DEPENDENCE

What are some chronic complications of alcohol dependence?

A
  • Cardiac = dilated cardiomyopathy, arrhythmias
  • Liver etc – fibrosis, cirrhosis, oesophageal varices, pancreatitis
  • Wernicke’s + Korsakoff’s
198
Q

ALCOHOL DEPENDENCE

What are some common causes of death in alcohol dependence?

A
  • Accidents + violence
  • Malignancies (head + neck, pancreatic, stomach, colon, hepatic, breast + gynae)
  • CVA, IHD
199
Q

ALCOHOL DEPENDENCE

What are some blood markers for alcohol consumption?

A
  • Red blood cell mean corpuscular volume (MCV) raised
  • Gamma glutamyl transpeptidase (GGT) raised
  • Carbohydrate deficient transferrin (CDT) raised
200
Q

ALCOHOL DEPENDENCE

What are some clinical tools for assessing alcohol dependence or withdrawal?

A
  • CAGE

- AUDIT

201
Q

ALCOHOL DEPENDENCE

What are the CAGE questions?

A
  • Have you ever felt you need to CUT down on your drinking?
  • Have people ANNOYED you by criticising your drink?
  • Have you ever felt GUILTY about your drinking?
  • EYE-opener – ever felt you need drink first thing in morning to steady your nerves?
202
Q

ALCOHOL DEPENDENCE

What are the AUDIT questions?

A
  • How often do you have a drink containing alcohol?
  • How many units of alcohol do you drink on a typical day?
  • How often did you have >6 units on a single occasion in the past year?
203
Q

ALCOHOL DEPENDENCE

What are the indications for an inpatient detoxification?

A
  • Withdrawal seizures or delirium tremens in past
  • Significant mental/physical illness, including suicidality
  • Lack of stable home environment
204
Q

ALCOHOL DEPENDENCE

What is the regime for acute detoxification?

A
  • Chlordiazepoxide 1st line with reducing regime (2nd = diazepam) for withdrawal Sx + preventing seizures
  • Thiamine (PO or IV)
  • Rehydrate with fluids (often IV), correct electrolyte disturbance
205
Q

ALCOHOL DEPENDENCE

What are the 3 biological treatments used in alcohol dependence?

A
  • Naltrexone
  • Acamprosate
  • Disulfiram
206
Q

ALCOHOL DEPENDENCE

What is the mechanism of action of naltrexone?

A
  • Opioid receptor antagonist
  • Blocks euphoric effects of alcohol
  • Helps people stick to detox programme + avoid relapse
207
Q

ALCOHOL DEPENDENCE

What is the mechanism of action of acamprosate?

A
  • NMDA antagonist acts on GABA to reduce cravings + risk of relapse
208
Q

ALCOHOL DEPENDENCE
What is the mechanism of action of disulfiram?
What affects does it have?

A
  • Inhibits acetaldehyde dehydrogenase > build-up of acetaldehyde
  • Produces hangover-like Sx when alcohol is drunk = deterrent (flushing, headaches, anxiety, nausea, reduced BP)
209
Q

ALCOHOL DEPENDENCE

What are some psychological treatments for alcohol dependence?

A
  • Motivational intervention
  • Aversion therapy
  • CBT, prevention measures (relapse prevention strategies)
210
Q

ALCOHOL DEPENDENCE

What is the social management of alcohol dependence?

A
  • Housing, economical + employment issues
  • Alcoholics anonymous
  • Developing social routines that are not reliant on alcohol
211
Q

OPIATES/OPIOIDS
How do opioids work?
How long does it take for withdrawal symptoms?
Give some examples of opioids?

A
  • Bind to mu-opioid receptors > endogenous endorphins
  • 6h
  • Morphine, diamorphine (heroin), methadone
212
Q

OPIATES/OPIOIDS
What is the clinical presentation of opioid overdose?
What is the clinical presentation of opioid withdrawal?

A
  • Pinpoint pupils, resp depression, drowsiness, low HR

- Unpleasant BUT not dangerous = runs (D+V, lacrimation, rhinorrhoea), raised HR/BP, fever, pupil dilation

213
Q

OPIATES/OPIOIDS

What are some complications from opioid abuse?

A
  • Abscesses, septic arthritis, infective endocarditis, BBV (hep B/C, HIV), VTE
  • Crime, homelessness, death
214
Q

OPIATES/OPIOIDS
What is the management of opioid overdose?
What is the mechanism of action?

A
  • 400mg IV naloxone

- M-receptor inverse agonist > blockade (almost immediate)

215
Q

OPIATES/OPIOIDS
What are some maintenance therapies for opioids?
How is compliance monitored?

A
  • Methadone (full opioid agonist) or buprenorphine (partial agonist/antagonist)
  • Urinalysis
216
Q

OPIATES/OPIOIDS
What is the first line detox management in opioids?
How long does detox last?

A
  • Motivational intervention
  • Alternative therapies = exercise, art therapy, counselling
  • 4w = inpatient, 12w = community
217
Q

ANOREXIA NERVOSA

What is anorexia nervosa?

A
  • Marked distortion of body image, pathological desire for thinness + self-induced weight loss by various methods
218
Q

ANOREXIA NERVOSA

What are some risk factors for anorexia?

A
  • F>M, early-mid adolescence
  • Dieting + FHx of eating disorders
  • PMHx of anxiety, depression or OCD
  • Sportspeople, dancers or models
219
Q

ANOREXIA NERVOSA

What are the diagnostic features of anorexia and how long should they be present for?

A

≥3m:

  • Deliberate restriction of energy intake = low body weight
  • Intense fear of gaining weight or becoming fat despite being underweight
  • Self-esteem unduly influenced by body weight or shape
220
Q

ANOREXIA NERVOSA

What are some endocrine features seen in anorexia?

A
  • Amenorrhoea
  • Reduced libido/fertility
  • Delayed/arrested puberty
221
Q

ANOREXIA NERVOSA

What are some clinical signs of osteoporosis?

A
  • Lanugo hair = fine, soft body hair
  • Enlarged salivary glands
  • Reduced BMI (<17.5kg/m^2)
  • Bradycardia + hypotension
222
Q

ANOREXIA NERVOSA

What are some complications of anorexia?

A
  • Osteoporosis
  • Arrhythmias + cardiomyopathy
  • Decrease in WBC > increased infections
  • Death due to health complications or suicide
223
Q

ANOREXIA NERVOSA

What screening tool can be used in anorexia?

A

SCOFF –

  • Do you ever make yourself SICK as too full?
  • Do you ever feel you’ve lost CONTROL over eating?
  • Have you recently lost more than ONE stone in 3m?
  • Do you believe you’re FAT when others say you’re thin?
  • Does FOOD dominate your life?
224
Q

ANOREXIA NERVOSA

What are some investigations for anorexia?

A
  • Sit up squat stand (SUSS) test /3
  • ECG (brady, T-wave changes, QTc prolongation)
  • FBC (anaemia), U&Es (low K+, Na+), TFTs (low T3), low sex hormones
225
Q

ANOREXIA NERVOSA

In anorexia, most things are low apart from what?

A

Gs + Cs –

  • GH, Glucose, salivary Glands
  • Cortisol, Cholesterol, Carotinaemia
226
Q

ANOREXIA NERVOSA
What risk assessment tool can be used for assessing if a patient with anorexia needs inpatient admission?
What are some features?

A
  • Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN)
  • Extremely rapid weight loss, severe electrolyte imbalances, serious physiological complications (HR<45, temp <36), suicidal
227
Q

ANOREXIA NERVOSA

How should the physical complications of anorexia be managed?

A
  • Monitor U+Es + ECGs
  • Oral supplements for electrolytes, thiamine
  • Multivitamins + mineral supplements, calcium + vitamin D
  • Safely + slowly re-feed pt + avoid refeeding syndrome
228
Q

ANOREXIA NERVOSA
In adults with anorexia nervosa, what are the…

i) biological management choices?
ii) psychological management options?
iii) social management options?

A

i) Fluoxetine
ii) Individual eating disorder focussed CBT (CBT-ED), Maudsley Anorexia Nervosa TReatment for Adults (MANTRA) or Specialist Supportive Clinical Management (SSCM)
iii) Food diary, self-help groups

229
Q

ANOREXIA NERVOSA

What is the CAMHS management for anorexia?

A
  • Family therapy 1st line, psychoeducation, self-help resources
230
Q

ANOREXIA NERVOSA

What is the pathophysiology of refeeding syndrome?

A
  • Metabolic disturbances which occur on feeding a person following a period of starvation.
  • As an extended period of catabolism ends abruptly with switching to carbohydrate metabolism
  • This leads to serum electrolytes to drop as they enter cells
231
Q

ANOREXIA NERVOSA

What are some risk factors for refeeding syndrome?

A
  • Low BMI
  • Poor nutritional intake (>5d)
  • PMHx alcohol abuse
  • Chemo
232
Q

ANOREXIA NERVOSA
What is the clinical presentation of refeeding syndrome?
What are the consequences of refeeding syndrome?

A
  • Fatigue, weakness, fluid overload, vomiting

- Can lead to arrhythmias, convulsions, cardiac failure, coma + death

233
Q

ANOREXIA NERVOSA

What are the classic biochemical features of refeeding syndrome?

A
  • Hypophosphataemia #1
  • Hypokalaemia, hypomagnesaemia + thiamine deficiency too
  • Abnormal fluid balance
234
Q

ANOREXIA NERVOSA

What is the management of refeeding syndrome?

A
  • Frequently monitor all electrolytes + ECG before + during
  • Start up to 10cal/kg/d + increase to full needs slowly over 4–7d
  • Start PO thiamine, B vitamins + electrolytes
235
Q

BULIMIA NERVOSA
What is bulimia nervosa?
What are the risk factors?

A
  • Recurrent episodes of binge eating + compensatory behaviours (purges)
  • Same as anorexia
236
Q

BULIMIA NERVOSA

What is the diagnostic criteria for bulimia?

A
  • Recurrent episodes of binge eating with sense of lack of control during
  • Purges to prevent weight gain = vomiting, laxatives, exercise
  • Self-esteem unduly influenced by weight/shape
  • Occurs at least once a week for 3 months
237
Q

BULIMIA NERVOSA

What are some clinical signs of bulimia?

A
  • Russel’s sign (calluses on dorsum of dominant hand due to vomiting)
  • Dental enamel erosion
  • Mouth ulcers
  • Salivary gland, especially parotid, enlargement
238
Q

BULIMIA NERVOSA

What are some complications of bulimia?

A
  • Cardiomegaly (ipecac toxicity = plant taken PO + can cause vomiting)
  • Arrhythmias, cardiac failure
  • Mallory-Weiss tears from vomiting
239
Q

BULIMIA NERVOSA

What are some investigations for bulimia?

A
  • SCOFF
  • SUSS test, ECG = arrhythmias from hypokalaemia
  • Monitor U&Es and other electrolytes
  • VBG = hypochloraemic hypokalaemic metabolic alkalosis due to vomiting
240
Q

BULIMIA NERVOSA

What is the management of bulimia nervosa?

A
  • ALL referred to specialist care
  • Adults = first > BN focussed guided self help, second > CBT-ED
  • CAMHS = FT-BN
  • High dose fluoxetine currently licensed but limited evidence
241
Q

PERSONALITY DISORDERS
When can personality disorders be diagnosed?
What are some risk factors for personality disorders?

A
  • ≥18 as personality still developing

- FHx of PDs, childhood sexual abuse (especially BPD), childhood conduct disorder (antisocial PD)

242
Q

PERSONALITY DISORDERS

What are the broad types of personality disorders?

A
  • Class A = odd + eccentric (MAD) > paranoid, schizoid + schizotypal
  • Class B = dramatic, emotional or erratic (BAD) > antisocial, borderline, histrionic + narcissistic
  • Class C = anxious + fearful (SAD) > obsessive-compulsive, avoidant, dependent
243
Q

PERSONALITY DISORDERS

Cluster A: what are the key features of paranoid personality disorder?

A
  • Irrational suspicion + mistrust of others
  • Hypersensitivity to criticism
  • Preoccupation with perceived conspiracies against themselves
244
Q

PERSONALITY DISORDERS

Cluster A: what are the key features of schizoid personality disorder?

A
  • Lack of interest in others, apathy
  • Has few friends + does not form relationships, including sexual
  • Prefers solitary activities
245
Q

PERSONALITY DISORDERS

Cluster A: what are the key features of schizotypal personality disorder?

A
  • Odd appearance + beliefs, magical thinking
  • Features of schizophrenia like ideas of reference, paranoia but more insight
  • Extreme difficulties interacting socially so lack close friends
246
Q

PERSONALITY DISORDERS

Cluster B: what are the key features of antisocial personality disorder?

A
  • More common in men, failure to conform to social norms
  • Patterns of disregard + violation of rights of others
  • Aggressive + unremorseful
  • Manipulative + lack empathy
247
Q

PERSONALITY DISORDERS

Cluster B: what are the key features of borderline/EU personality disorder?

A
  • Mainly young women
  • Abrupt mood swings, unstable relationships + instability in self-image
  • Impulsivity in behaviours
  • Recurrent self-harm + suicidal behaviour
248
Q

PERSONALITY DISORDERS

Cluster B: what are the key features of histrionic personality disorder?

A
  • Attention seeking behaviours + excessive displays of emotions
  • Relationships considered more intimate than they are, sexually inappropriate
  • Desire to be centre of attention + dramatisation
249
Q

PERSONALITY DISORDERS

Cluster B: what are the key features of narcissistic personality disorder?

A
  • Grandiose sense of self-importance + lack of empathy
  • Takes advantage of others to achieve own wants
  • Arrogant + preoccupied by their own desires + fantasies (success, power)
250
Q

PERSONALITY DISORDERS

Cluster C: what are the key features of obsessive-compulsive personality disorder?

A
  • Preoccupied by rules, details + organisation to detriment of other aspects of life
  • Perfectionist, often eliminating leisure + activities to ensure work complete
  • Controlling + inflexible
251
Q

PERSONALITY DISORDERS

Cluster C: what are the key features of avoidant personality disorder?

A
  • Strong feelings of inadequacy + fear social situations where they may be criticised
  • Extremely sensitive to criticism
  • Self-impose isolation while craving acceptance + social contact
252
Q

PERSONALITY DISORDERS

Cluster C: what are the key features of dependent personality disorder?

A
  • Difficulty making everyday decisions without reassurance from others
  • Lack of initiative + unrealistic feelings they cannot care for themselves
  • Intense need to be cared for by others so urgently searches new relationships
253
Q

PERSONALITY DISORDERS

What investigations would you do in personality disorders?

A

Questionnaires –

  • Minnesota Multiphasic Personality Inventory (MMPI)
  • Eysenck Personality questionnaire
  • Personality diagnostic questionnaire
254
Q

PERSONALITY DISORDERS

What is the management of personality disorders?

A
  • Biological = often SSRI to control Sx

- Psychological = DBT for EUPD, other therapy (CBT #1, CAT, support groups)

255
Q

DELIRIUM TREMENS

What is delirium tremens?

A
  • Acute, toxic confusional state secondary to alcohol withdrawal (48–72h after)
256
Q

DELIRIUM TREMENS

How does delirium tremens present?

A
  • Confusion
  • Hallucinations = visual (Lilliputian = small people/animals) + tactile (crawling insects on/under skin)
  • Sweating
  • Tachycardia
257
Q

DELIRIUM TREMENS

What is the management of delirium tremens?

A
  • ABCDE approach as emergency
  • PO lorazepam first line, if not parenteral lorazepam or haloperidol
  • IV thiamine (B1, Pabrinex), IV fluids
258
Q

WERNICKE’S
What is Wernicke’s encephalopathy?
How does it classically present?

A
  • Mammillary body atrophy 2º to thiamine deficiency, often due to alcohol abuse
  • Triad = ataxia, confusion + ophthalmoplegia/nystagmus
259
Q

WERNICKE’S

What is the management of Wernicke’s?

A
  • ABCDE approach as emergency

- IV Pabrinex

260
Q

KORSAKOFF’S

What is Korsakoff’s psychosis?

A
  • Degeneration of mammillary bodies, complication of untreated Wernicke’s encephalopathy
261
Q

KORSAKOFF’S

What is the clinical presentation of Korsakoff’s?

A
  • Profound short-term memory loss with inability to lay down new memories (antero + retrograde amnesia)
  • Confabulation
262
Q

LITHIUM TOXICITY
What is lithium toxicity?
What can precipitate it?

A
  • Serum lithium >1.5mmol/L, >2mmol/L = life-threatening

- Dehydration, renal failure, diuretics, ACEi/ARBs + NSAIDs

263
Q

LITHIUM TOXICITY

What is the clinical presentation of lithium toxicity?

A
  • COARSE tremor
  • Ataxia + acute confusion
  • Myoclonus + hyperreflexia
  • Seizures + coma
264
Q

LITHIUM TOXICITY

What are some complications of lithium toxicity?

A
  • Arrhythmias (VT)

- Acute renal failure

265
Q

LITHIUM TOXICITY

What is the management of lithium toxicity?

A
  • ABCDE approach as emergency
  • Mild-mod = IV fluid resus with 0.9% NaCl
  • Severe = haemodialysis
266
Q

ACUTE DYSTONIA
What is an acute dystonic reaction
How does it present?

A
  • Sustained painful muscle contraction, rapid onset after dose given
  • Oculogyric crisis = prolonged involuntary upward deviation of eyes
  • Torticollis = tilted/twisted neck
267
Q

ACUTE DYSTONIA

What is the management of acute dystonia?

A
  • ABCDE approach as emergency
  • Anticholinergic – IM procyclidine
  • Stop antipsychotic (switch to atypical as less EPSEs)
268
Q

NMS

What is neuroleptic malignant syndrome (NMS)?

A
  • Occurs days after taking antipsychotics/dose rise or acute withdrawal of PD meds
269
Q

NMS

What is the clinical presentation of NMS?

A
  • Pyrexia + muscle rigidity = “lead-pipe”
  • Autonomic lability = HTN, tachycardia, tachypnoea
  • Confusion, HYPOreflexia + NORMAL pupils
270
Q

NMS

What are the complications of NMS?

A
  • Respiratory failure
  • CV collapse
  • Rhabdomyolysis > AKI
  • DIC
271
Q

NMS

What are some investigations for NMS?

A
  • Urinary myoglobin (raised)

- Serum creatinine phosphokinase (CPK) + CK raised

272
Q

NMS

What is the management of NMS?

A
  • ABCDE approach
  • Stop antipsychotic or give L-dopa if dopamine withdrawal
  • IV fluids (AKI), cooling blankets, antipyretics
  • IV dantrolene or lorazepam to reduce rigidity 1st line (amantadine second)
  • Bromocriptine prophylaxis
273
Q

SEROTONIN SYNDROME
What is serotonin syndrome?
What are the causes?

A
  • Increased serotoninergic activity in CNS
  • Antidepressants = SSRIs esp. St. John’s wort, SNRIs, MAOI
  • Drugs = ecstasy, amphetamines, LSD, antiemetics
274
Q

SEROTONIN SYNDROME

What is the clinical presentation of serotonin syndrome?

A

Sx onset + recovery fast–

  • Confusion
  • Neuromuscular = myoclonus, HYPERreflexia, DILATED pupils
  • Autonomic = hyperthermia, tachycardia, HTN
275
Q

SEROTONIN SYNDROME

What are some investigations for serotonin syndrome?

A
  • CK, urinary drug screen

- ECG monitoring for wide QRS or prolonged QTc interval

276
Q

SEROTONIN SYNDROME

What is the management of serotonin syndrome?

A
  • ABCDE
  • Stop offending agent, IV fluids
  • BDZs like IV lorazepam for agitation, seizures + myoclonus
  • Serotonin receptor antagonists like PO cyproheptadine or chlorpromazine if severe
277
Q

LEARNING DISABILITIES

What is a learning disability?

A
  • Condition of arrested or incomplete development of mind, triad of –
  • Low intellectual performance (IQ<70)
  • Onset during birth or early childhood
  • Wide range of functional impairment
278
Q

LEARNING DISABILITIES

What are some causes of learning disabilities?

A
  • Genetic = Down’s, Fragile X, Prader-Willi, neurofibromatosis
  • Antenatal = TORCH
  • Perinatal = asphyxia, intraventricular haemorrhage
  • Postnatal = meningitis, kernicterus
279
Q

LEARNING DISABILITIES
How is mild learning disability characterised by…

i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?

A

i) 50–69
ii) 9–12
iii) Mobile
iv) Mostly adequate
v) Difficulties reading + writing
vi) Most independent

280
Q

LEARNING DISABILITIES
How is moderate learning disability characterised by…

i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?

A

i) 35–49
ii) 6–9
iii) Mobile
iv) Simple-no speech, may sign, reasonable comprehension
v) Limited, some learn to read, write + count
vi) Lifelong supervision, may need prompting + support

281
Q

LEARNING DISABILITIES
How is severe learning disability characterised by…

i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?

A

i) 20–34
ii) 3–6
iii) Marked impairment
iv) Simple-no speech, may sign, reasonable comprehension
v) Limited, some learn to read, write + count
vi) Lifelong supervision, may need prompting + support

282
Q

LEARNING DISABILITIES
How is profound learning disability characterised by…

i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?

A

i) <20
ii) <3
iii) Severe impairment
iv) Basic non-verbal comms, understands basic commands
v) None
vi) Complete dependency

283
Q

AUTISM SPECTRUM
What is autism?
What is Asperger’s syndrome?

A
  • Neurodevelopmental disorder associated with LDs, often manifests before 3, M>F
  • Social impairment of ASD but milder + near normal speech development
284
Q

AUTISM SPECTRUM

What are the 3 areas of impaired functioning that need to be present in autism?

A
  • Social interaction
  • Communication (speech + language)
  • Repetitive behaviours
285
Q

AUTISM SPECTRUM

Give some examples of impaired social interaction

A
  • Play alone + uninterested in others
  • Failure to notice/respond to social cues
  • Lack of eye contact + delay in smiling
286
Q

AUTISM SPECTRUM

Give some examples of impaired communication

A
  • Speech + comprehension usually delayed/minimal
  • Concrete thinking (lack imagination)
  • Absence of gestures (lack non-verbal comm)
287
Q

AUTISM SPECTRUM

Give some examples of impaired behaviours

A
  • Inability to adapt to new environment or change to routine
  • Greater interest in objects, numbers + patterns than people
  • Stereotypical repetitive movements
288
Q

AUTISM SPECTRUM

What is the management of autism?

A
  • MDT support for child + parent

- Charities for support (national autistic society)

289
Q

TIC DISORDERS
What are tics?
What are they associated with?

A
  • Repetitive, involuntary, purposeless movements + sounds

- OCD, ADHD, ASD, M>F

290
Q

TIC DISORDERS

What is Tourette’s syndrome?

A
  • Tics persist >1y, more severe + usually multiple motor tics and at least 1 phonic tic e.g., coprolalia
291
Q

TIC DISORDERS
What is the management of mild tics?
What is the management of troublesome tics?

A
  • Watch + wait, psychoeducation, avoid caffeine stress

- Habit reversal training, ERP

292
Q

ENURESIS

What is enuresis?

A
  • Involuntary discharge of urine by day, night or both in child aged ≥5y, in the absence of an organic cause
  • Common, M>F
293
Q

ENURESIS
What are the 2 types of enuresis?
Why may it occur?

A
  • Primary = bladder control never mastered

- Secondary = follows at least 6m of continence > DM, UTI, constipation

294
Q

ENURESIS

What is the management of enuresis?

A
  • Toileting patterns = before sleep, restrict fluids before bed
  • Reward systems (e.g., star charts for going to toilet before bed NOT dry nights)
  • 1st line = enuresis alarm, afterwards if >7y can trial desmopressin
295
Q

ADHD
What is attention deficit hyperactivity disorder (ADHD)?
What is the epidemiology?

A
  • Condition with features of inattention and/or hyperactivity/impulsivity that are persistent, M>F
296
Q

ADHD

What is the triad of symptoms in ADHD?

A
  • Inattention
  • Impulsivity
  • Hyperactivity
297
Q

ADHD

How does inattention present?

A
  • Decreased concentration
  • Short attention span
  • Easily distracted
  • Loses important items
298
Q

ADHD

How does impulsivity present?

A
  • Difficulty taking turns
  • Interrupts
  • Risk taking behaviours
299
Q

ADHD

How does hyperactivity present?

A
  • Fidgeting
  • Excessive activity
  • Talkative
300
Q

ADHD

How is a diagnosis of ADHD reached?

A
  • Features consistent across ≥2 settings (home, school)
  • Sx present continuously for ≥6m
  • Information from school reports, interviews
301
Q

ADHD

What is the initial management of ADHD?

A

Conservative initially (watch + wait) –

  • Family education on ADHD + parenting advice
  • Establish normal balanced diet + exercise
  • Food diary to identify any triggers + eliminate with dietician
302
Q

ADHD
What is the management for severe ADHD?
What is the mechanism of action?

A
  • CNS stimulants like methylphenidate
  • Increase monoamine pathway activity
  • Inadequate response = lisdexamfetamine
303
Q

ADHD

What are some side effects of methylphenidate?

A
  • Appetite suppression + insomnia

- Weight and height monitored every 6m

304
Q

CONDUCT DISORDERS

What is conduct disorder?

A
  • Patients <18 that show behaviour + attitudes that continuously disrespect + violate the rights of other people
305
Q

CONDUCT DISORDERS

What is the clinical presentation of conduct disorder?

A
  • Physical aggression
  • Destructive behaviour
  • Stealing
  • Boys > girls
306
Q

CONDUCT DISORDERS

What is oppositional defiant disorder?

A
  • Patients <18 show persistent defiant + hostile behaviour towards figures of authority but not serious enough to cause disruption in social functioning
307
Q

CONDUCT DISORDERS

How is conduct and oppositional defiant disorder managed?

A
  • 3–11y = group parent training programme (focus on parenting skills)
  • 7–14y = child-focused programmes (focus on child’s behaviours)
  • 11–17y = multimodal interventions
308
Q

MEDICALLY UNEXPLAINED SYMPTOMS

What are the features of somatisation disorder?

A
  • Multiple varied physical Symptoms (Somatisation) present for ≥2y
  • Pt refuses to accept reassurance or negative test results
309
Q

MEDICALLY UNEXPLAINED SYMPTOMS

What are the features of hypochondriasis?

A
  • Persistent belief in presence of a serious DISEASE (Cancer for hypoChondriasis)
  • Pt refuses to accept reassurance or negative test results
310
Q

MEDICALLY UNEXPLAINED SYMPTOMS

What are the features of conversion disorders?

A
  • Typically, loss of motor or sensory function, can be 2º to stress
  • Does NOT consciously feign symptoms or seek material gain
  • May be indifferent to their apparent disorder = la belle indifference
311
Q

MEDICALLY UNEXPLAINED SYMPTOMS
What is dissociation?
What are the features of dissociative disease?

A
  • Process of separating off certain memories from normal consciousness
  • Contrasts conversion as involves psychiatric symptoms = amnesia, stupor
  • Dissociative identity disorder = most severe form
312
Q

MEDICALLY UNEXPLAINED SYMPTOMS

What are the features of Munchausen’s syndrome?

A
  • Intentional production of physical or psychological symptoms
  • By proxy = individual who simulates illness in their dependents
313
Q

MEDICALLY UNEXPLAINED SYMPTOMS

What is malingering?

A
  • Fraudulent simulation/exaggeration of symptoms with intention of personal gain
314
Q

GENDER DYSPHORIA
What is gender dysphoria?
What is meant by the term transsexual?

A
  • Mismatch between biological sex + gender identity of an individual causing distress
  • Person who emotionally + psychologically feels that they belong to opposite sex
315
Q

GENDER DYSPHORIA

What act is relevant to gender dysphoria?

A
  • Gender recognition act 2004
  • Allows transsexual people to legally change their gender
  • Have to demonstrate Dx of gender dysphoria + have lived as gender role for ≥2y
316
Q

GENDER DYSPHORIA

What is the clinical presentation of gender dysphoria?

A
  • Low self-esteem, depression, anxiety + suicidality
  • Only comfortable when in preferred gender role
  • Strong desire to hide physical signs + dislike of genitals of biological sex
317
Q

GENDER DYSPHORIA
What is the management of gender dysphoria in…

i) <18?
ii) >18?

A

i) Referral to gender identity development service (GIDS) with MDT (CAMHS, clinical psychologist, social worker, family therapist)
ii) Referral to gender dysphoria clinic (GP or self-referral)

318
Q

GENDER DYSPHORIA

What surgical procedures may be offered?

A
  • TM = mastectomy, hysterectomy, phalloplasty or penile implant, scrotoplasty + testicular implants
  • TW = orchidectomy, penectomy, vaginoplasty, vulvoplasty or clitoroplasty
319
Q

GENDER DYSPHORIA

What biological treatment can be used in <16y?

A
  • Very few young people who meet strict criteria may have gonadotropin-releasing hormone analogues (hormone blockers) as reach puberty
320
Q

GENDER DYSPHORIA

What biological treatment can be used >16?

A
  • Cross-sex/gender-affirming hormones if on hormone blockers for ≥12m
    – Oestrogen for breasts + feminine features
    – Testosterone for deep voice + masculine features (body hair)
321
Q

GENDER DYSPHORIA

What social management is there for gender dysphoria?

A
  • Quit smoking (may increase risks of side effects from treatments)
  • Lose weight if overweight to reduce risks from cross-sex hormones)
  • Social transitioning incl. changing name by deed poll
322
Q

GENDER DYSPHORIA

What are some risks of the hormone therapy?

A
  • Oestrogen = clots, gallstones, high triglycerides
  • Testosterone = polycythaemia, acne, dyslipidaemia
  • Both = elevated LFTs, infertility, weight gain
323
Q

SLEEP DISORDERS

What is insomnia?

A
  • Issues with – falling to, maintaining or poor quality of sleep (≥3d/week for 1m)
324
Q

SLEEP DISORDERS
What is narcolepsy?
What is cataplexy?

A
  • Hypersomnolence, sleep paralysis, hypnogogic + hypnopompic hallucinations
  • Cataplexy = sudden loss of muscle tone caused by strong emotion (laughter, being frightened)
325
Q

SLEEP DISORDERS

What is the management of narcolepsy?

A
  • Multiple sleep latency EEG, early onset REM sleep

- Rx with daytime stimulants (modafinil) + night-time sodium oxybate

326
Q

SLEEP DISORDERS

What is some sleep hygiene advice?

A
  • Limit caffeine, alcohol + cigarettes
  • Reduce noise, lights + phone use, wind down before bed
  • Reduce sleep during day + try establish regular pattern

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