Psych Core conditions Flashcards
(314 cards)
1
Q
Examples of organic disorders
A
Secondary to Known disease- Dementia, Delirium, Frontal Lobe tumour
2
Q
Examples of non-psychotic disorders
A
Depression, Anxiety, Maladaptive behaviours, MUS
3
Q
Examples of functional psychosis
A
SZ, BPD, Sevre depression with psychotic symptoms
4
Q
Psychosis vs Neurosis
A
Psychosis- Limited insight, don’t understand behaviour/reality appropriately
Neurosis- Symptoms closer to normal experiences, Better understanding of reality
5
Q
Triad psychosis related symptoms
A
Hallucinations, Delusions and Thought disorder
6
Q
Examples for screening tests for cognitive impairment
A
AMTS, 6-CIT, 4-AT, GPCOG, Clock drawing
7
Q
What are the 5 cognitive domains?
A
Orientation Attention/Concentration Memory Language Construction
8
Q
What are the domains of Orientation
A
Time- day, date, season
Place- Location, City, County, Country
Person- Name, Age, DoB, Address
9
Q
What are the domains of Memory
A
Anterograde- Name, remember and recall 3 objects
Retrograde- Where were you born?
10
Q
What is the difference between attention and concentration?
A
Attention is the ability to focus cognitive processes
Concentration is the ability to sustain attention over time
11
Q
How do you assess attention and concentration
A
WORLD Backwards, 20->1, Serial 7s, Months Backwards
12
Q
How do you assess language?
A
Via history taking
13
Q
What is Perseveration?
A
Getting stuck on a topic
A domain of language
14
Q
What is confabulation?
A
Fills empty gap in a memory with a memory from another time
15
Q
What is Normal Dysphasia?
A
Not knowing the name of something despite being able to describe what it is
16
Q
What are the 11 points of an AMTS assessment?
A
Age DoB Year Time Address given Where we are Identify 2X people WW2 Monarch 20-1 Repeat address
17
Q
How do you assess Construction?
A
MMSE- Intersecting pentagons
Clock faces
Intersecting infinity
Cube
18
Q
DDX Mnemonic DEMENTIA for old age psych problems
A
Drugs, Delirium, Depression Emotions Metabolic Eye/Ear Nutritional Tumours/Toxins Infections Alcohol/Arteriosclerosis
19
Q
ICD-10 definition of dementia
A
Chronic, progressive brain disease, consciousness not clouded
Deterioration in cognitive function
Minimum 6 months
20
Q
What is the absence of intelligible ideation seen in severe dementia?
A
The inability to form new concepts and ideas
21
Q
What is included in a dementia blood test screen?
A
FBC, U&Es, LFTs, TFTs, Glucose, ESR, CRP, Ca, MG, P, B12, Folate,
+/- Imaging +/- Syphilis `
22
Q
What treatable conditions can exacerbate dementia symptoms?
A
Pain, Infection, Constipation, Hydration, Medication, Environment
23
Q
What are the 3 variants of Fronto-Temporal Dementia?
A
Behavioural
Semantic
Progressive Non-fluent Aphasia
24
Q
Age at presentation of FTD?
A
45-65
25
What is the behavioural variant of FTD?
Inappropriate behaviour, Loss of inhibition, No motivation, Repetition, Compulsion, Loss of control, No insight, Hygiene deteriorates
26
What is the Semantic variant of FTD?
Loss of vocabulary but fluency of speech is retained
Will ask the meaning of familiar words
Cannot recognise or find the right words
27
What is the progressive non-fluent aphasic variant of FTD?
Slow, Hesitant, Difficult speech, Grammatical errors, Decreased orofacial movements, stuttering, cannot write or read
28
What cognitive tests are useful for the Dx of FTD?
What may be spared?
```
Words and categorical fluency
Design fluency
Copying tasks
Rhythm tapping
Luria Hand sequencing task
```
MAY HAVE MEMORY AND VISUOSPATIAL SPARING
29
What causes the memory loss in FTD?
Impaired attention and thinking rather than amnesia
30
What medications should be stopped in FTD?
Anticholinergics, CNS drugs, AchE inhibitors, memantine
31
Averagr survival of FTD
8-10 years
32
Risks factors for AD?
```
FHx 3.5X if 1st degree
Apope4
HTN, DM, inc Chol
Down's
Female
Caucasian
```
33
Pathophysiology of AD
Widespread cortical atrophy particularly of the medial temporal lobes
Amyloid plaques and neurofibrillary tangles
Decreased Ach
34
What are the 5 As of AD?
```
Amnesia
Aphasia
Agnosia
Apraxia
Associated behavioural change +/- Psychotic symptoms
```
35
What are the signs of late AD?
Wandering, Disorientation, Apathy, Psychotic symptoms, Aggression, Disinhibition, severely disrupted ADLs
36
Diagnostic criteria for probable AD
Deficits in >/=2 areas of cognition
Insidious progressive onset
No disturbance to consciousness
Absence of other brain disease/cause
37
Non-pharmacological interventions for AD/LBD/VaD?
```
Structured group cognitive stimulation
Reminder notes
+/- CBT for comorbid anxiety/depression
OT input
Education
Social prescribing
Social care involvement
Watch for complications like Pressure Ulcers
```
38
1st and 2nd line Pharmacological intervention for AD?
1) MILD-MOD= AcetylCholinesterase inhibitors
- Tacrine, Donepezil
2) NMDA Antagoonists- Memantine
39
How does pharmacological intervention impact AD?
Does not slow progression
| May improve functioning
40
Treatment of Agitation or behavioural threat in AD
Agitation/Psychotic- Short term Risperidone
| Threat- IM lorazepam or Haloperidol
41
Prognosis of AD?
Course varies 5-20 years
No cure
Progressive
Infection most common cause of death
42
Pathophysiology of LBD?
Eosinophilic intracytoplasmic neuronal inclusion bodies in the brainstem
Particularly impact the SN, Paralimbic and neocortical systems
Parkinsonian features...
43
Age of onset of LBD?
50-85
44
Key presenting features of LBD
Fluctuating awareness and attention, Memory loss
2/3rds have have HALLUCINATIONS usually visual
Mild Parkinsonsian features- Tremor, Bradykinesia Rigidity and festinating gait
45
How can you distinguish between PD associated dementia and LBD?
In PD the dementia will likely follow a year of movement disorder, unlikely to do this in LBD
46
Key diagnostic features of LBD
Progressive cognitive decline
+2 of: Fluctuating cognition/Recurrent visual hallucinations/Parkinsonsism
+/- REM sleep behaviour disorder, Severe neuroepileptic sensitivity, Image evidence of low D uptake in basal ganglia
47
Pharmacological management of LBD
```
1st= Acetylcholinesterase inhibitor= RIVASTIGMINE
2nd= NMDA Antagonists= MEMANTINE
```
48
What drugs should be avoided in LBD
Neuroepileptic antipsychotics as they worsen motor symptoms and mental impairment
49
Average survival from Dx of LBD patients?
5-8 years
50
Key features regarding the onset/progression of VaD?
Deterioration may be sudden
Progression in a step wise manner
Hx should extend back months-years
51
NICE criteria for a probable VaD diagnosis
- Cognitive decline in higher level of functioning (Think the 5 domains + Motor)
- Cerebrovascular disease- Neuro exam, Imaging
- Relationship between the above...Onset within 3 months of a stroke/Abrupt deterioration/Fluctuating step wise progression
52
What presenting features of dementia could suggest vascular involvement and ?VaD
Focal neurology- Visual, Dysphasia, Hemiparesis, Dystonia, EPS
Seizures
Loss of bladder control, Emotional stability, Motor control
Frequent falls
No control of facial movements
53
Pharmacological management of VaD?
Treat causative factors like DM
+/- Antiplatelets, Anticoags
No specific treatment approved yet
54
Prognosis of VaD?
3-5 years
| Worse than AD
55
How do you manage emotional symptoms and challenging behaviour in a patient with VaD?
Avoid antipsychotics unless Very severe symptoms like Agitation and Psychosis
B/C increased risk of adverse Cerebrovascular events
Urgent: IM Haloperidol or Lorazepam
56
The 3 Most common causes of delirium
Infection
Medication
Drug withdrawal
57
What are the different variants of delirum
Hypoactive
Hyperactive
Mixed
58
Define Delirum? What is the state of consciousness in deirium?
Acute confusional state
Fluctuating cognitive impairment
Behavioural abnormalities
Clouded consciousness
59
Symptoms of Delirium as per the DELIRIUM Mnemonic
```
Disordered thinking (Slow, Irrational)
Euphoric/Fearful/Angry
Language impaired
Illusions, Delusions, Hallucinations
Reversal of sleep Wake
Inattention
Unaware/Disorientated
Memory deficits
```
60
What investigations are included in a confusion screen?
```
Vital signs + Hydration status
Urinalysis
FBC, U&Es, LFTs,TFTs. GLucose, Folate, B12, Ca, INR
?CT head ?LP
EEG if doubt (Diffuse slowing)
```
61
What must be promptly reviewed in delirum?
Time course of the disease
Recent interventions
Drug chart- Stop any unnecessary ones
Pre-morbid functional level
62
What is an abnormal AMTS?
<8
63
In Primary care how does the Confusion Assessment Method detect delirum?
Acute onset and fluctuating
Inattention (20-1)
+ Either: Disorganised/Incoherent Speech or changed level of consciousnesses
64
Supportive interventions for delirum?
```
Reminders- Clocks, Date
Staff consistency
Family/carer involvement
Relaxation- control noise and light
Single room
Maintain competence
Restrict in the least amount possible
Temp of room 21-23
```
65
Pharmacological management for delirum?
Must be considered carefully as they can worsen the condition... Lowest dose + Least amount of time
1) Antipsychotics like Haloperidol or Olanzapine
2) Lorazepam Review 2-4 hourly
66
What must be optimised in the management of delirium?
Pain, Hydration, Nutrition and Orientation
67
What is an organic mental disorder?
Demonstrable pathology arising directly from a medical disorder (Non-functional)
Presents as delirum, Depression, Anxiety, Mania Psychosis
68
Broad causes of Organic mental disorders?
```
Trauma
Infection
Degerative
Metabolic- Thyroid, Adrenal
Medication induced- Particularly for psychosis
```
69
The Key features of Dependence
```
Compulsion
Continue despite negative consequences
Relapse post-detox
Repertoire narrows
Tolerance
Loss of control
Withdrawal symptoms and abuse to avoid this
Salience
```
70
Define Harmful use of a substance?
Misuse of a substance associated with health and social consequences without dependence
71
Define at risk consumption of a substance?
Intake at a level associated with increased risk of harm
72
Guidelines for weekly alcohol intake
<14 units
Both sexes
3-4 drink free days
73
Hazardous drinking? What is harmful drinking?
Hazardous >14 units a week
| Harmful >35 units
74
MoA of alcohol
GABA agonist
Glutamate Antagonist
Disinhibition, Subjective Elevation of mood, Socialisation
+/- Sexual dysfunction, LoC, Mood change
75
Long term sequela of alcohol use?
Liver disease, Cardiomyopathy. HTN, Peptic ulcers, Oesophageal varices, Neoplasms, Macrocytic anaemia
76
What is Wernicke's Encephalopathy?
Thiamine/B1 Deficiency
| Confusion, Ataxia, Peripheral neuropathy, Nystagmus, Ophthalmalgia
77
How do you treat Wernicke's Encephalopathy?
IV pabrinex 3/7 then switch to oral
78
ICD-10 Dx criteria for alcohol dependence
>/=3 in last 12/12
Compulsion, Control, Withdrawal, Tolerance, Neglect, Continue despite harm
79
How do the symptoms of alcohol withdrawal change with time?
6-12 hours= Tremor
24hrs= Anxiety, Agitation, Sweating
24-48hours = Delirium Tremens for 3-4 days
36 hours= Seizures
80
What are the symptoms of Delirium Tremens?
```
Acute confusional state
Anxiety, Agitation, Confusion
Tremors
Visual illusions and hallucinations
Dehydration= Tachycardia
HTN, CV collapse, Seizures
```
81
What type of Hallucinations/Illusions do people with Delirium Tremens usually have?
Lilliputian hallucinations where things are small
82
What is a classic deulsion seen in delirium tremens?
Persecutory Delusion
83
Define a Delusion
A fixed firm belief
| Not correlating with reality
84
Hallucinations vs Illusions
Both are false perceptions
| Hallucination lacks an external stimuli
85
How do you manage Delirium Tremens
A TO E (Check for hypoglycaemia!)
Sedation- Chlordiazepoxide or Diazepam if need rapid onset
+ 500mg Pabrinex 3X day IV for 3/7
+MG to protect vs seizures
86
What is Korsakoff's Psychosis?
A complication of untreated Wernicke's Encephalopathy
| Memory deficits, Behavioural change and Confusion
87
What CAGE score permits further investigation?
>/=1
88
What AUDIT score for alcoholism permits further investigation?
>15 points
89
What questions do you ask to investigate someone's drinking pattern?
Times, Place, Who with, Days of the week, Type, Units
CAGE
Explore dependence symptoms
90
When would you consider admission for Alcoholism?
```
Hx of seizures or AN overactivity
<18 years
Failed detox at home
Social problems
DT or WE
```
91
Why is DT a serious complication of alcoholism?
Hyperadrenergic state
| Can lead to CV collapse + Seizures
92
Treatment principles for dealing with alcohol withdrawal
Chlordiazepoxide over 5-7 days reducing dose gradually (Diaz is an Alt)
One pair of pabrinex ampoules IM or IV once daily for 3-5 days (250mg) can extend to 500mg
+/- CBZ for seizures
93
How can you prevent an alcoholism relapse?
```
AA + CBT + Education + Motivational interviewing
Consider Disulfiram (causes sicknes)/Acamprosate (Anti-craving)/Nalmefere
Dry houses
```
94
What drug is used in a Benzo OD
Flumazenil
| Then need long acting Diaze with a slowly tapered off dose to treat the addiction
95
Withdrawal symptoms of a Benzo addiction?
Rebound anxiety/insomnia
Visual/Auditory hallucinations
Seizures
96
What are Hypnagogic hallucinations?
Happen just as you fall asleep
97
What are Hynopompic hallucinations?
Happen just as you wake up
98
What is schizophrenia (Sz)?
Functional psychoses with fragmentation of thinking
99
Epidemiology of Sz?
Increased in Males vs Females
Males 20-28 years
Females 26-32 years
up to 1% of the population
100
What are the 4 variants of Sz?
Paranoid
Hebephrenic
Catatonic
Simple
101
What is Paranoid Sz?
Paranoid delusions + Hallucinations
| Relatively stable though
102
What is Hebephrenic Sz?
Strong -ve symptoms- Shallow and inappropriate mood
Irresponsible behaviour
Fragmentary delusions and hallucinations
103
What is a fragmentary delusion?
a disorganized, undeveloped false belief or a series of such beliefs that are disconnected, inconsistent, and illogical
Seen in Hebephrenic Sz
104
What is Catatonic Sz?
Psychomotor disturbance so doesnt interact or more
Muscles in sustained contraction
Rhabdomyolysis risk
105
What is simple Sz?
No delusions or hallucinations
| -ve symptoms gradually arise without an acute episode
106
What is the neurochemistry behind the +ve and -ve symptoms in Sz?
+ve= Increased mesolimbic Dopamine activity
-ve= Decreased mesocortical Dopamine activity
Likely complex neurochemistry also involving 5-HT, Ach GABA, Glutamate
107
What are the 4 first rank +ve symptoms of Sz?
Delusions, Hallucinations, Thought disorder, Lack of Insight
108
Examples of the Delusions/Thought disorder seen in Sz?
Delusional perceptions about non-significant events- seeing a rainbow and thinking it is a sign from God
Delusions about someone else controlling their emotions
Somatic passivity- All under external control
Thought insertion, Removal, Interruption
Thought broadcasting
109
Examples of the hallucinations seen in Sz?
Auditory- Echoing of thought
| Third person commentary of one's action
110
What are the negative symptoms associated with Sz?
Avolition, Anhedonia, Alogia, Asociality, Affect blunt
111
What is the state of one's cognition in Sz?
Usually retained intellectual capacity
| Clear Consciousness
112
ICD-10 stated duration of Sz symptoms for diagnosis?
>1 month
113
ICD-10 diagnosis of Sz
one of: Thought disorder, Delusions of control/influence/passivity, Hallucinatory voices
or 2 of: Persistent hallucinations of any modality, Catatonic, -ve symptoms, Interpolations
114
Scheider's first rank symptoms of Sz
Delusional perception
3rd person auditory hallucinations
Thought- Echo, Broadcast, Insertion, Withdrawal
Passivity/Delusions of control
115
Psychological therapies to treat Sz (Short and Long term)
Short- Psychoeducation, CBT, Family interventions,
| Long- Supported employment, Art therapy, Relapse signature
116
Treatment principles for pharmacological management of Sz?
Antipsychotics +/- Lithium +/- Antidepressant
Start an SGA at lowest effective dose, continue 1-2 years, monitor regularly
117
1st line Antipsychotic for Sz?
Second Gens- Risperidone or Olanzapine
118
What is the prognosis of Schizophrenia?
1/3rd good, 1/3rd middle, 1/3rd poor
119
What is Schizoaffective disorder?
Where classification into either Schizophrenia or mood disorder would not be entirely correct
Essentially Sz with prominent mood symptoms
120
What are the diagnostic criteria for Schizoaffective disorder?
Delusions/Hallucinations when mood disturbance not there for a minimum of 2 weeks
Mood disturbance for a significant length of time - Major depressive, Manic, Mixed
No organic cause
121
When would you consider admission for schizoaffective disorder?
Threat to themselves or others
| Cannot self care
122
How do you manage Schizoaffective disorder?
Psychological interventions like CBT etc
+/- Long term SGAs like Risperidone/Olanzapiune
+/- Sertraline/Fluoxetine
+/- Lithium to stabilise mood
123
Which type of schizoaffective disorder carries the worst prognosis?
Bipolar type (>Depressive type)
124
What is Delusional Disorder?
Delusions are the primary symptoms
Hallucinations uncommon
3+ months
125
What features are incompatible with delusional disorder?
Clear persistent hallucinationd
Delusions of control
Marked blunting of affect
Evidence of brain disease
126
What are the classic features of the delusions present in delusional disorder?
Single or set of related delusions usually persistent and lifelong
Acute or insidious onset
Variable content
127
De Clerembault's syndrome
Erotomania- Famous person is in love with them
128
Fregoli's syndrome
Different people are the same person +/- Persecuted by this disguised person
129
Ekboms syndrome
Delusional parasitosis
Formication- Insects on skin
Infested with parasites
Self-harm risk...
130
Persecutory delusions
Someone is out to get them
| Most common presentation of delusional disorder
131
Othello Syndrome
Morbid jealousy
Misinterprets minor evidence and thinks partner is having an affair
Violence/Stalking risk
132
Capgras syndrome
Delusional misidentification
| Someone close to them is replaced by an identical looking imposter
133
Cortad's syndrome
Delusions of being dead, dying, not exisiting, rotting parts of their body
Associated with depression
134
Folie a Deux
Induced delusional disorder, psychosis shared by two people
135
How is delusional disorder managed?
Removal from source of delusions
| Antipsychotics and Antidepressants
136
Epidemiology of depression
2X more common in Females
2/3rds comorbid psych disorder
Very common 1/5
Longer hospital stays as they perceive symptoms as worse
137
Core symptoms of depression
Low mood
Low energy
Anhedonia
138
Non-core symptoms of depression
```
Sleep disturbance
Appetite change
Weight change
Decreased concentration/Libido/Confidence
Worthlessness
Excessive guilt
Thoughts of suicide/Self-harm
Psychomotor retardation
+/- Delusions- Personal inadequacy
+/- Hallucinations
```
139
Investigations to exclude organic causes of depression
FBC, ESR, B12/Folate, U&Es, LFTs, TFTs, Glucose, Calcium
Think: Hypothyroid, Addisons, Cushings, Hypoglycaemia, Hyerpcalcaemia
140
What is PHQ-9
Assessment tool for depression
141
ICD Diagnosis of depression
| Mild, Moderate and Severe
>2 weeks
Mild= 2 core + 2 other
Moderate= 2 core + 3 other
Severe= 3 core + 4 other
Represents a change from normal
142
For a diagnosis of depression what must the symptoms not be secondary to?
Drugs, Alcohol, Medication, Bereavement, Medical disorders
143
Treatment plan for Mild-Moderate depression?
Low intensity psychosocial interventions
- Sleep hygiene - Regular exercise - CBT based self-help
-Structured group physical activity programme -Group CBT
-Tackle social problems like employment, finances etc
Escalate to pharmacological management if non-responsive
144
Treatment plan for mod-severe depression
High intensity psychosocial interventions (CBT, Interpersonal therapy, Behavioural activation)
PLUS an antidepressant
145
Treatment plan for severe/complex/life threatening depression?
CRISIS service
Inpatient care
MDT approach
146
When would you consider an emergency referral for depression?
Self-harm risk is significant
Danger to others
Psychotic symptoms
Severe agitation
147
What is CBT?
16-20 sessions over 3-4 months
Investigates and manages how we deal with and appraise events
Considers behaviour, thoughts, physiology and emotions
148
What is interpersonal therapy?
Discuss symptoms in response to current difficulties in everyday interactions
Focuses on interpersonal difficulties and grief
149
What are the Biological interventions for depression?
1) SSRIs- Fluoxetine/Citalopram
2) TCA, SNRIs, NaSSAs, Lithium, MAOIs
3) ECT if no response after 2 drugs or life-threatening
150
Prognosis of depression
6/12= Average length
Median 4 episodes in a lifetime
80% >1 episode
Major risk factor for suicide
151
ICD-10 symptoms associated with Mania
```
Elevation of mood +/- Grandiose delusions
Emotional lability
Constant change of plan
Poor concentration
Overactivity, Sexual overactivity
Pressure of speech
Flight of ideas
Infectious gaiety
Psychotic symptoms
```
152
What is the difference between mania and hypomania
Hypomania is 4+ days with no psychotic symptoms and partial insight DOES NOT DISRUPT WORK OR = SOCIAL REJECTION
Mania is 7+ days with substantial dysfunction, potential psychosis and minimal almost absent insight DISRUPTS WORK AND =SOCIAL REJECTION OCCURS
153
What causes of mania can be excluded with blood tests?
Hyperthyroidism
Steroids- Medical/Idiopathic Cushing's
Drug induced
Lithium adherence
154
How do you manage an acute manic episode?
Contact community mental health team for an urgent referral
Lithium given as first line
+/- AP or Benzo if effect of lithium is delayed
155
What is used as prophylaxis in management of chronic mania?
Lithium
| Valproate or CBZ if lithium poorly tolerated
156
The different types of BPD
BPD1- Mania + Major depression with episodes of hypomania and minor depression
BPD2- Hypomania and depression (NO MANIA)
Cyclothymia- cycles between hypomania and minor depression
157
ICD-10 Diagnostic criteria for BPD
>/= 2 EPISODES OF DISTURBED MOOD AND ACTIVITY WITH AT LEAST ONE BEING MANIC/Hypomanic
Recovery usually complete between said episodes
158
3 of what symptoms confirm mania according to ICD-10
Grandiosity, decreased need for sleep, pressured speech, Flight of ideas, Distractibility, Psychomotor agitation
Excess pleasure e.g spending sprees
159
Pharmacological options for treating BPD; is ECT used?
Lithium generally 1st line +/- Valproate
Valproate can also be used alone
Can try an AP to stabilise then introduce lithium or both together
ECT reserved for drug resistant forms
160
Prognosis of BPD?
~8-10 episodes throughout life
~50% attempt suicide at least once
Self neglect and damage to relationships
161
What is neurosis?
Maladaptive psychological symptoms not due to organic causes or psychosis, usually precipitated by stress
162
GAD vs panic attacks, Phobia and Personality disorder in terms of presentation
Paroxysmal- sudden increase in anxiety... Likely panic attacks
Phobia are situaitonal
Personality disorder is lifelong
GAD is none of these
163
ICD-10 Diagnostic criteria for GAD
Excessive worrying more days than not >6/12
3+ Core symptoms
3+ symptoms of AN arousal or disrupted mental state
164
What are the core symptoms of GAD?
Restlessness, Easily fatigued, Feel keyed up, Difficulty concentrating, Irritability, Muscle tension, Sleep disturbance
165
What symptoms of AN arousal can you get in GAD?
Palpitations, Racing/Pounding heart, Sweating, Trembling, Dry mouth, Lump in the throat, Numbness
166
How can GAD impact someone's mental state?
Faint/Light headed
Loss of control
Derealisation and Depersonalisation
Loss of control
167
Derealisation vs Depersonalisation
Depersonalization is a sense of detachment from oneself and one's identity. Derealisation is when things or people around seem unreal.
168
NICE Stepwise approach to managing GAD
1) Identify, assess, educate, exercise, monitor, sleep hygiene
2) Low intensity psychosocial interventions (Self-help, psychoeducational groups)
3) CBT, Anxiety therapy, DRUGS
4) Specialist drugs, psych referral, in patient care
169
What drugs are 1st line for managing GAD?
Sertraline (SSRI) or Venlafaxine (SSNRI)
170
How do you diagnose panic disorder
4 panic attacks in 4 weeks lasting up to 10 minutes
| It is paroxysmal, a sudden rapid increase in anxiety, peaks rapidly before 10 minutes
171
Features of panic disorder
```
Paroxysmal; rapid peaking anxiety
AN arousal
Desire to escape
No symptoms between attacks
Not predictable/in response to a trigger
Depersonalisation/realisation
```
172
What age group is most at risk of panic disorder?
Early adulthood
| ESPECIALLY GIRLS
173
How do you acutely manage a panic attack?
Exclude medical causes... ECG etc
Reassure, calming... Resolution in 30 mins
?Benzos if extremely severe and distressing
174
Management of panic disorder
1) Recognition and Dx, montior and promote exercise
2) CBT +/- SSRI
3) Alternative meds if no response 3/12
4) Referral
175
What is a phobia?
Situational anxiety in response to a specific trigger
The anxiety may be disproportionate to said stimulus
Presents when it induces a loss of function
176
Key features of social phobia?
```
Fear of scrutiny arising from social situations
Low self-esteem
? Triggered by an embarrassing event
Withdrawal
May progress to panic attacks
```
177
Agoraphobia
Anxiety provoked by open spaces or large crowds
Where escape is difficult
Co-presents with obsessive or depressive symptoms?
178
How do you treat a phobia?
Graded exposure and sensitisation
CBT
Try Paroxetine (SSRI) or Beta blocker
Benzo only if absolutely necessary
179
What are the symptoms of OCD?
Recurrent unpleasant intrusive obsessions
Strong compulsions to perform an action despite a lack of necessity
180
Level of insight in OCD
Patient recognises thoughts as their own
| Therefore not thought insertion
181
How do you manage you OCD
CBT (best evidence) +/- SSRI Fluox/Sertraline then TCA if resistant
+/- Exposure and response prevention
+/- Stimulus control (Allowed to think thoughts at set times)
182
Symptoms of PTSD
Onset months to years post event (Delayed emotional response)
Symptoms >1 month
Involuntary re-experience of stressful event: Hyperarousal, Hypervigilance, exaggerated startle response, avoidance and substance misuse
183
What must you screen for in ?PTSD
Substance misuse
| Underlying depression
184
Management of PTSD
CBT is vital +/- Paroxetine or sertraline
Eye movement desensitisation
Encourage return to work
185
Prognosis of PTSD
Good
| 18 month recovery in 65%
186
Adjustment disorder
Protracted response to a significant life event
187
What is defined as a prolonged adjustment response
>6 months
| >1/12 is a brief depressive reaction
188
How does adjustment disorder present
Depressive and anxiety symptoms but not severe enough to warrant a diagnosis of either
Impacts on social functioning
Angry outbursts and feel as though they cannot cope
189
What features make a bereavement reaction abnormal
Unusually intense-> Looks like depression
Prolonged >6/12
Delayed
Inhibited or distorted (Thoughts of guilt or excess guilt)
190
What is normal bereavement
Numbness, Anger, disturbed Sleep/Appetite
Intensity reduces over time
Typical grief lasts 12 months
191
Counselling vs CBT for adjustment disorder
Counselling is passive listening so is better for something that cannot be changed
CBT addresses repeated patterns
192
Pharmacological management of adjustment disorder
Indicated when psychological management is unsuccessful or symptoms are particularly troublesome
SSRI or Benzos
193
Acute stress reaction
Transient reaction to a highly threatening experience
194
Dissociative/Conversion disorder
Traumatic event leads to loss of memory, identity, control of movement and sensation
195
Symptoms of Dissociative/Conversion disorder
```
Paralysis
Aphonia
None dermatome sensory loss
Amnesia
Fugue (confusion about identity)
Stupor
Convulsions
Possession by an animal
```
196
What is Ganser syndrome
Pretend they have a mental disorder
| Variant of conversion disorder
197
Management principles for Dissociative/Conversion disorder
Acceptance and support but avoid interventions that maintain the sick role
CBT etc
Clearly present the diagnosis
198
Somatisation disorder
Long history of multiple complex changing unaccounted symptoms
Fluctuating
Disrupts social functioning
199
Hypochondrial disorder
Persistent preoccupation with having >/=1 medical disorders
Despite reassurance
Includes Body dysmorphia
200
Persistent somatoform pain
Unaccounted chronic pain
| Likely psychosocial or emotional problems
201
Somatoform AN disorder
Looks like physical symptoms from an organ system entirely under AN control
202
Malingering
Manufacturing symptoms for a purpose other than the sick role
Financial etc
203
Munchausen syndrome
Factitious disorder where symptoms are manufactured for the purpose of the sick role
PRIMARY GOAL: GETTING MEDICAL ATTENTION
204
Anorexia Nervosa definition and epidemiology
BMI<17.5
Less common than BN
90% onset within 1st 5 years of menarche
Higher social classes
205
Bulimia Nervosa definition and epidemiology
```
More common than AN
BMI>17.5
Binge an extremely high number of calories and cannot stop then purge
Regular cycle at least 1x a week
All social classes
```
206
Core Psychopathology of Eating Disorders
Rigidity of thinking
Fear of fatness and body dissatisfaction
Body image distortion
Self evaluation based on Weight and shape
Rumination about food
207
Classical behaviours associated with eating disorders
```
Avoidance
Diet pills
Laxatives, Water loading, Insulin misuse, Thyroxine
Calorie counting
Excessive weighing
```
208
How do eating disorders impact the CVS?
Starvation induces bradycarida and hypotension
| Binging/purgung induces arrhythmias and ?Faulure
209
How do eating disorders impact the renal system?
Electrolyte disturbance
Oedema
?Failure
210
How do eating disorders impact the GI system?
Parotid swelling, constipation
Purging= dental and oes eorsion and haematemesis
211
How do eating disorders impact the Skeletal system?
Pathological fracture risk is increased, OP
212
How do eating disorders impact the Endocrine system?
Amenorrhoea, Thermodysregulation
| Starvation can induce hyppthyroidism
213
How do eating disorders impact the Haemtological system
Low Blood and WCC
214
Neuro sequela of eating disorders?
Seizures and confusiom
215
What is Russell's sign?
Callouses on the hand because of repeated purging
216
What must you ask about in a history of eating disorder?
```
Any CVS symptoms?
Amount of exercise
GI symptoms- Bloating, pain, heart burn, lethargy, haematemesis
Alochol and substance misuse
Screen for other mental health disorders
SCOFF
```
217
What signs can you specifically look for upon examination of a patient with an eating disorder
Hypotension, Irregular pulse, Hypothermia, Myopathy, Russell's
218
What investigations would you do on a patient presenting with an eating disorder and why
ESR/U&Es ?Oragnic cause
ECG ?Arrhythmia
DXA scan
219
What causes hyponatraemia in a patient with an ED?
Water loading, Laxative use, Diuretic
220
What causes hypokalaemia in a patient with an ED?
| How does this look on an ECG?
Vomiting
T wave changes +/- QTc prolongation
221
Refeeding syndrome
Electrolyte disturbance (Low) after eating post-anorexia
222
Bone marrow hypoplasia in ED
Looks like normocytic anemia and leukopenia on bloods
223
BMI and level of risk in Anorexia
<18.5= Low
< 15= Moderate
<13= High
224
What is PREDIX and MARSIPAN
PREDIX- Classifies risk by organ system
MARSIPAN- physical risk
Both used in eating disorders
225
SCOFF screening for Eating Disorders
Sick- Do you ever make yourself feel sick because youre too full
Control- Are you worried you have lost control over what you eat
One stone- Have you lost >/=1 stone over 3 months
Food- Does Food dominate your life?
Fat- Do you think you're too fat?
226
What SCOFF score is likely an ED?
2+
227
Management principles of Eating Disorders?
```
Outpatient usually
Guided self help + CBT/IPT
Food diary
Family intervention
Psychodynamic psychotherapy
Can add fluoxetine to the above but mostly for comorbid psych problems
LAST RESORT= NG tube
```
228
Indications for urgent admission of an individual with an Eating disorder likely AN
```
Electrolyte of glucose disturbance
Severe malnutrition or dehydration
Impending organ failure
ECG changes
BMI <13
>1Kg loss over 2 consecutive weeks
Suicide risk
```
229
How are Eating Disorders managed differently in <18yrs vs Adults
Focus is on family therapy
Restore independence in managing eating over time with heavy family involvement; then maintain
Can still use CBT etc
230
MDT support needed in Managing eating disorders?
```
Dentists
Specialist advice if Bone Mineral Density starts to fall
Dietician
Mental Health Nursing
Community team
```
231
Personality Disorder
A personality that persistently causes dysfunctional relationships or distress to themselves or those around them
STABLE AND ALWAYS PRESENT
232
Temperament of Cluster A personality disorder
Eccentric, Aloof, Suspicious, Solitary
233
Variants of Cluster A personality disorders + Key feature of each
Paranoid (Suspicious and distrusting)
Schizoid (Social isolation)
Schizotypical (Odd beliefs)
234
Difference between schizoid and schizotypical
Both cluster A
Schizoid- Isolation, do not want companionship
Schizotypical- Odd beliefs, eccentric behaviour, derealisation, Ideas of reference
235
Ideas of reference
Ideas that unrelated things refer to them directly
| "OMG this song is written about me"
236
Temperament of Cluster B personality disorder
Dramatic, Emotionally labile, Intense
237
Variants of Cluster B Personality disorder
Antisocial
Emotionally unstable
Histrionic
Narcissistic
238
Antisocial personality disorder
Cluster B
| Easily frustrated, Lack of guilt, Criminal, doesn't accept responsibility
239
Borderline/Emotionally unstable personality disorder
Cluster B
| Recurrent emotional crises, Intense mood, Impulsive, Disturbed self image, YOUNG WOMEN
240
Histrionic personality disorder
Cluster B
Exaggerated theatrical expression
Attention seeking, Vain, Needs others' approval
241
Narcissistic personality disorder
Cluster B
Grandiose self-importance
Exaggerates abilities
Resents the success of others
242
Paranoid personality disorder
```
Cluster A
Suspicion
Bears grudges
Cannot take criticism
Unforgiving
Obsession with conspiracy theories
```
243
Temperament of Cluster C personality disorders
Anxious, Timid, Dependent, Low-self esteem
244
Anakastic/Obsessional Personality Disorder
```
Cluster C
Inflexible
Mistakes cause intense worry
Humourless
Unrealistic high standards
```
245
Anxious/Avoidant personality disorder
Cluster C
Tension and apprehension
Fears rejection
Avoids personal contact
246
Dependent Personality disorder
Cluster C
Excessive need to be cared for
Allows others to take responsibility for many areas of their life
247
What length of time is required for a Dx of personality disorder?
The History must be longstanding likely from around childhood
248
What tool can be used to assess ?Personality disorders
Minnesota Multiphasic Personality Inventory
249
Management principles for Personality disorder
Help them find a lifestyle suited to them
Consistency of care
Education of insight to prevent blaming others
psychotherapy +/- AP +/- AD
250
What is Psychotherapy
Aims to improve perceptions and responses to social situations
CBT, Psychodynamic psychotherapy
251
CBT vs Psychodynamic psychotherapy
CBT reformulates behaviours and perceptions based on long standing beliefs inducing cognitive errors
Psychodynamic psychotherapy Examines how we perceive events
252
When are antipsychotics indicated in people with personality disorder?
Transient psychosis
253
Which children are at risk of developing a personality disorder
Parents with mental health or misuse problems
Mums <18 years
Criminal parents
Parents with a history of residential care
254
Learning disability
IQ<70
Loss of adaptive social functioning
Onset BEFORE 18 years at birth/early childhood
255
Causes of Learning disability
```
Maternal substance abuse, phenytoin
Antenatal insult
Genetic
Metabolic disturbance like PKU
Deprivation
Post-natal/Neonatal insult
```
256
IQs of the different severity grades of learning disability
Mild= 50-69
Moderate= 35-49
Severe= 20-34
Profound <20
257
What disease is commonly comorbid with learning disability
Epilepsy
258
Development level of someone with profound learning disability
~12 months
259
What are the features of learning disability
```
Difficulty coping with stress
Limited language
Poor self-care
Incontinence
Inappropriate sexual behaviour
Inability to walk
Lesch-Nyhan (Self harm)
```
260
How are individuals with learning difficulty at risk?
Increased chance of abuse
| More commonly develop psychiatric problems- E.G. Anxiety because of lack of confidence
261
Assessment of learning difficulty
Hx- Childhood and Birth
Evaluate functioning
Baseline skill level- Can then detect any regression
Screen for other psychiatric illness
262
How can pain manifest itself in those with learning disability?
Challenging behaviour
263
Communicating with a patient with learning difficulties
```
Greet them 1st
Involve them in the discussion
They are in control
Short sentences
Allow them time to process
```
264
Monitoring those with learning difficulties
Annual Health Checks
265
MMSE scores and the corresponding severity of Alzheimer's Disease
Normal 24+
Mild 20-23
Moderate 13-20
Severe if <12
266
What is Zopiclone
Used to treat Insomnia
| Similar MoA to Benzos
267
CI to the use of Zopiclone
Obstructive Sleep Apnoea
Respiratory muscle weakness/Depression
Caution in Elderly
268
Side effects of Zopiclone
Daytime sleepiness
Headache/Confusion/Nightmares
Taste Disturbance
Rebound insomnia after stopping
269
Prolonged used of Zopiclone
Facilitates dependence
| Particularly if >4 weeks
270
Zopiclone Withdrawal
Headache, Muscle Pain, Anxiety
271
OD of Zopiclone
Drowsiness, Coma, Respiratory depression
272
Zopiclone and CYP450 enzymes
Metabolised by these
| Inhibitors will therefore increase sedation
273
How does Zopiclone interact with other drugs?
Additive sedation if alcohol/Opioids/Benzos
Additive Hypotension if antihypertensive drugs used
274
Max Zopiclone use
4 weeks
| 1/2 dose if elderly
275
Advice to patient when prescribing Zopiclone
Only take when needed
SHORT TERM MEASURE
Explore reasons for poor sleep
Avoid driving and using heavy machinery
276
Adverse effects of Cannabis
Anxiety, Paranoid, Nausea, Amnesia, Psychosis, poor concentration, apathy, Cravings
277
What is Ketamine
NMDA antagonist
278
What is Dissociative Anaesthesia
Caused by Ketamine
1) Catatonia 2) Analgesia 3) Amnesia 4) Catalepsy
Also alters perceptions
279
Catatonia
Abnormality of movement and behaviour arising from a disturbed mental state. It may involve repetitive or purposeless overactivity, or catalepsy, resistance to passive movement, and negativism.
280
Catalepsy
A trance or seizure with a loss of sensation and consciousness accompanied by rigidity of the body.
281
Cocaine
Inhibits Monoamine reuptake
| Increases confidence, Stimulates, Belief in great mental capacity
282
Adverse effects of Cocaine
```
Tachycarida and Arrhythmias
Pupil dilate
MI and HF
Panic attacks
Septum necrosis
Persecutory delusions
Paranoia
```
283
MDMA/Ecstasy
Synthetic Amphetamine Analogue
| Increases Monoamines
284
Pupil changes from recreational drugs
Dilate- MDMA, Ecstasy, Cocaine, Amphetamines
Pinpoint- Heroin
285
Risks of MDMA use
Overhydration
Adverse electrolyte changes
Psychosis
Affect change
286
LSD
Hallucinogen lasts 8-14 hours
287
Risks of LSD
Post-Hallucinogenic perception disorder
Persistent Psychosis
Beliefs cause them to harm others
Flashbacks
288
Large doses of Psyilocybin Mushrooms
Euphoria, Hallucinations, Perceptual changes
Synaesthesia
Hallucinations
Slurred Speech
289
Amphetamines (Crystal Meth, Speed, Whizz)
```
Increases NorA and Dopamine
Talkative, Excited, Pipils dilate, HR/BP/T increases
Concentration improves
Appetite decreases
Dry mouth
```
290
Heroin withdrawal onset
From 8-10 hours after last dose
| Lasts 7-10 days
291
Symptoms of Heroin withdrawal
```
Akathisia Affect change
Sweating
Tachycardia
Diarrhoea
Goose pimple skin
Limb spasms
OD risk is increased as tolerance decreases
```
292
How do you manage a Heroin OD
0.4mg of IM Naloxone
| This is an Opiate antagonist that induces rapid detox
293
Presentation of a Heroin OD
```
Pinpoint pupils
Shallow breathing
Bradycardia
Hypotension
Delirum
```
294
Naltrexone
Opioid antagonist
| Used to maintain Heroin abstinence if highly motivated
295
How do you manage the symptoms of Heroin Withdrawal
```
N&V= Metclopramide
Diarrhoea= Loperamide
Agutation/Anxiety= Diazepam
Pain= NSAIDS or Paracetamol
```
296
Amyl Nitrate Poppers
Imitates illegal highs
Enhances sexual experiences
Relaxation of involuntary SM
297
Risks of Amyl Nitrate Poppers
Hypotension
LoC
Arrhythmia +/- Sudden death
298
What is MCAT
Stimulative recreational drug
Makes them alert, talkative, euphoric
Can lead to agitation, self harm and a reduction in peripheral circulation
299
Key principles of the Mental Health Act
```
Least restrictive
Empower
Maximise independence
Dignity
Puporse
Efficiency
```
300
Who is needed for an assessment under the MHA
```
2 doctors (one with prior knowledge of patient and one with section 12 approved)
1 AMHP
```
301
Criteria for detention under the Mental Health Act
Suffering from a mental disorder which warrants detention
Risk to safety of themselves, others or society
Unwilling to go to the hospital voluntarily
302
Learning disability and detention under the MHA
The learning disability must be associated with abnormally aggressive or seriously irresponsible conduct
303
Willing patient who lack capacity and consent to voluntary admission- By what means are they admitted?
Cannot be voluntary admitted if you lack capacity
E.G if there is cognitive impairment or severe depression
Must be admitted under the MHA
304
Section 2 of the MHA
Lasts up to 28 days
Appeal within 1st 14 days
Not renewable
305
Section 3 of the MHA
Lasts up to 6 months
Appeal 2X in first 6 months then yearly after that
Mental disorder of a degree where patient cannot be treated in hospital B/C safety risk
Renewable for 6 months then yearly after that- Back to back possible
306
Section 5 (2)
Must already be an inpatient
Informal admission not possible B/C things like capacity
DR'S HOLDING POWER TO ALLOW FOR MHA ASSESSMENT TO BE CARRIED OUT
Lasts 72 hours
307
Who implements Section 5 (2) of the MHA (Dr's holding power)
Consultant in charge
| or grade >FY2
308
How long does Nurse's holding power last
6 hours
| re-evaluated by Dr
309
Section 136 of the MHA
Mentally disorders persons in areas that aren't private dwelling s
Lasts 24 hours
Police officer discusses with mental health professional
Taken to place of safety for assessment
310
Principles of the Mental Capacity Act 2005
```
Capacity is assumed unless proven otherwise
Help them make decision if possible
Right to unwise decisions
No capacity= Best interests
Least restrictive way to achieve outcome
```
311
2 stage process of the MCA 2005 (To assess capacity)
Diagnostic test to diagnose disorder of mind
Functional test- Understand/retain/Use/Communicate
DECISION AND TIME SPECIFIC
312
How do you decide best interests in relation to the MCA?
```
Past/Present views
Beliefs/Values
Those engaged in the person's care
Deputy appointed by the court
Independent mental capacity advocate
```
313
Deprivation of Liberty Safeguards
Those who lack capacity and are deprived of liberty in their best interests
E.G. Care Homes
Not free to leave, Under complete supervision
314
Describe different indications for the MCA vs MHA
Degree of Overlap
Dependent on what you are primarily treating:
Physical illness- MCA
Mental illness- MHA
