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Psychiatry > Psych Core conditions > Flashcards

Psych Core conditions Flashcards

1
Q

Examples of organic disorders

A

Secondary to Known disease- Dementia, Delirium, Frontal Lobe tumour

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2
Q

Examples of non-psychotic disorders

A

Depression, Anxiety, Maladaptive behaviours, MUS

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3
Q

Examples of functional psychosis

A

SZ, BPD, Sevre depression with psychotic symptoms

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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

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5
Q

Triad psychosis related symptoms

A

Hallucinations, Delusions and Thought disorder

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6
Q

Examples for screening tests for cognitive impairment

A

AMTS, 6-CIT, 4-AT, GPCOG, Clock drawing

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7
Q

What are the 5 cognitive domains?

A 
Orientation
Attention/Concentration
Memory
Language
Construction
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8
Q

What are the domains of Orientation

A

Time- day, date, season
Place- Location, City, County, Country
Person- Name, Age, DoB, Address

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9
Q

What are the domains of Memory

A

Anterograde- Name, remember and recall 3 objects

Retrograde- Where were you born?

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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

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11
Q

How do you assess attention and concentration

A

WORLD Backwards, 20->1, Serial 7s, Months Backwards

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12
Q

How do you assess language?

A

Via history taking

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13
Q

What is Perseveration?

A

Getting stuck on a topic

A domain of language

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14
Q

What is confabulation?

A

Fills empty gap in a memory with a memory from another time

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15
Q

What is Normal Dysphasia?

A

Not knowing the name of something despite being able to describe what it is

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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
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17
Q

How do you assess Construction?

A

MMSE- Intersecting pentagons
Clock faces
Intersecting infinity
Cube

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18
Q

DDX Mnemonic DEMENTIA for old age psych problems

A 
Drugs, Delirium, Depression
Emotions
Metabolic
Eye/Ear
Nutritional
Tumours/Toxins
Infections
Alcohol/Arteriosclerosis
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19
Q

ICD-10 definition of dementia

A

Chronic, progressive brain disease, consciousness not clouded
Deterioration in cognitive function
Minimum 6 months

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20
Q

What is the absence of intelligible ideation seen in severe dementia?

A

The inability to form new concepts and ideas

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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 `

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22
Q

What treatable conditions can exacerbate dementia symptoms?

A

Pain, Infection, Constipation, Hydration, Medication, Environment

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23
Q

What are the 3 variants of Fronto-Temporal Dementia?

A

Behavioural
Semantic
Progressive Non-fluent Aphasia

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24
Q

Age at presentation of FTD?

A

45-65

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25
Q

What is the behavioural variant of FTD?

A

Inappropriate behaviour, Loss of inhibition, No motivation, Repetition, Compulsion, Loss of control, No insight, Hygiene deteriorates

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26
Q

What is the Semantic variant of FTD?

A

Loss of vocabulary but fluency of speech is retained
Will ask the meaning of familiar words
Cannot recognise or find the right words

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27
Q

What is the progressive non-fluent aphasic variant of FTD?

A

Slow, Hesitant, Difficult speech, Grammatical errors, Decreased orofacial movements, stuttering, cannot write or read

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28
Q

What cognitive tests are useful for the Dx of FTD?

What may be spared?

A 
Words and categorical fluency
Design fluency
Copying tasks
Rhythm tapping 
Luria Hand sequencing task

MAY HAVE MEMORY AND VISUOSPATIAL SPARING

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29
Q

What causes the memory loss in FTD?

A

Impaired attention and thinking rather than amnesia

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30
Q

What medications should be stopped in FTD?

A

Anticholinergics, CNS drugs, AchE inhibitors, memantine

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31
Q

Averagr survival of FTD

A

8-10 years

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32
Q

Risks factors for AD?

A 
FHx 3.5X if 1st degree
Apope4
HTN, DM, inc Chol
Down's 
Female
Caucasian
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33
Q

Pathophysiology of AD

A

Widespread cortical atrophy particularly of the medial temporal lobes
Amyloid plaques and neurofibrillary tangles
Decreased Ach

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34
Q

What are the 5 As of AD?

A 
Amnesia
Aphasia
Agnosia
Apraxia
Associated behavioural change +/- Psychotic symptoms
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35
Q

What are the signs of late AD?

A

Wandering, Disorientation, Apathy, Psychotic symptoms, Aggression, Disinhibition, severely disrupted ADLs

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36
Q

Diagnostic criteria for probable AD

A

Deficits in >/=2 areas of cognition
Insidious progressive onset
No disturbance to consciousness
Absence of other brain disease/cause

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37
Q

Non-pharmacological interventions for AD/LBD/VaD?

A 
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
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38
Q

1st and 2nd line Pharmacological intervention for AD?

A

1) MILD-MOD= AcetylCholinesterase inhibitors
- Tacrine, Donepezil

2) NMDA Antagoonists- Memantine

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39
Q

How does pharmacological intervention impact AD?

A

Does not slow progression

May improve functioning

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40
Q

Treatment of Agitation or behavioural threat in AD

A

Agitation/Psychotic- Short term Risperidone

Threat- IM lorazepam or Haloperidol

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41
Q

Prognosis of AD?

A

Course varies 5-20 years
No cure
Progressive
Infection most common cause of death

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42
Q

Pathophysiology of LBD?

A

Eosinophilic intracytoplasmic neuronal inclusion bodies in the brainstem
Particularly impact the SN, Paralimbic and neocortical systems
Parkinsonian features…

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43
Q

Age of onset of LBD?

A

50-85

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44
Q

Key presenting features of LBD

A

Fluctuating awareness and attention, Memory loss
2/3rds have have HALLUCINATIONS usually visual
Mild Parkinsonsian features- Tremor, Bradykinesia Rigidity and festinating gait

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45
Q

How can you distinguish between PD associated dementia and LBD?

A

In PD the dementia will likely follow a year of movement disorder, unlikely to do this in LBD

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46
Q

Key diagnostic features of LBD

A

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

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47
Q

Pharmacological management of LBD

A 
1st= Acetylcholinesterase inhibitor= RIVASTIGMINE 
2nd= NMDA Antagonists= MEMANTINE
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48
Q

What drugs should be avoided in LBD

A

Neuroepileptic antipsychotics as they worsen motor symptoms and mental impairment

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49
Q

Average survival from Dx of LBD patients?

A

5-8 years

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50
Q

Key features regarding the onset/progression of VaD?

A

Deterioration may be sudden
Progression in a step wise manner
Hx should extend back months-years

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51
Q

NICE criteria for a probable VaD diagnosis

A
  • 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
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52
Q

What presenting features of dementia could suggest vascular involvement and ?VaD

A

Focal neurology- Visual, Dysphasia, Hemiparesis, Dystonia, EPS

Seizures

Loss of bladder control, Emotional stability, Motor control

Frequent falls

No control of facial movements

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53
Q

Pharmacological management of VaD?

A

Treat causative factors like DM
+/- Antiplatelets, Anticoags
No specific treatment approved yet

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54
Q

Prognosis of VaD?

A

3-5 years

Worse than AD

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55
Q

How do you manage emotional symptoms and challenging behaviour in a patient with VaD?

A

Avoid antipsychotics unless Very severe symptoms like Agitation and Psychosis
B/C increased risk of adverse Cerebrovascular events

Urgent: IM Haloperidol or Lorazepam

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56
Q

The 3 Most common causes of delirium

A

Infection
Medication
Drug withdrawal

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57
Q

What are the different variants of delirum

A

Hypoactive
Hyperactive
Mixed

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58
Q

Define Delirum? What is the state of consciousness in deirium?

A

Acute confusional state
Fluctuating cognitive impairment
Behavioural abnormalities
Clouded consciousness

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59
Q

Symptoms of Delirium as per the DELIRIUM Mnemonic

A 
Disordered thinking (Slow, Irrational)
Euphoric/Fearful/Angry
Language impaired
Illusions, Delusions, Hallucinations
Reversal of sleep Wake
Inattention
Unaware/Disorientated
Memory deficits
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60
Q

What investigations are included in a confusion screen?

A 
Vital signs + Hydration status
Urinalysis
FBC, U&Es, LFTs,TFTs. GLucose, Folate, B12, Ca, INR
?CT head ?LP 
EEG if doubt (Diffuse slowing)
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61
Q

What must be promptly reviewed in delirum?

A

Time course of the disease
Recent interventions
Drug chart- Stop any unnecessary ones
Pre-morbid functional level

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62
Q

What is an abnormal AMTS?

A

<8

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63
Q

In Primary care how does the Confusion Assessment Method detect delirum?

A

Acute onset and fluctuating
Inattention (20-1)

+ Either: Disorganised/Incoherent Speech or changed level of consciousnesses

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64
Q

Supportive interventions for delirum?

A 
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
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65
Q

Pharmacological management for delirum?

A

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

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66
Q

What must be optimised in the management of delirium?

A

Pain, Hydration, Nutrition and Orientation

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67
Q

What is an organic mental disorder?

A

Demonstrable pathology arising directly from a medical disorder (Non-functional)
Presents as delirum, Depression, Anxiety, Mania Psychosis

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68
Q

Broad causes of Organic mental disorders?

A 
Trauma 
Infection 
Degerative 
Metabolic- Thyroid, Adrenal 
Medication induced- Particularly for psychosis
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69
Q

The Key features of Dependence

A 
Compulsion
Continue despite negative consequences
Relapse post-detox
Repertoire narrows
Tolerance
Loss of control
Withdrawal symptoms and abuse to avoid this
Salience
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70
Q

Define Harmful use of a substance?

A

Misuse of a substance associated with health and social consequences without dependence

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71
Q

Define at risk consumption of a substance?

A

Intake at a level associated with increased risk of harm

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72
Q

Guidelines for weekly alcohol intake

A

<14 units
Both sexes
3-4 drink free days

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73
Q

Hazardous drinking? What is harmful drinking?

A

Hazardous >14 units a week

Harmful >35 units

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74
Q

MoA of alcohol

A

GABA agonist
Glutamate Antagonist
Disinhibition, Subjective Elevation of mood, Socialisation
+/- Sexual dysfunction, LoC, Mood change

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75
Q

Long term sequela of alcohol use?

A

Liver disease, Cardiomyopathy. HTN, Peptic ulcers, Oesophageal varices, Neoplasms, Macrocytic anaemia

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76
Q

What is Wernicke’s Encephalopathy?

A

Thiamine/B1 Deficiency

Confusion, Ataxia, Peripheral neuropathy, Nystagmus, Ophthalmalgia

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77
Q

How do you treat Wernicke’s Encephalopathy?

A

IV pabrinex 3/7 then switch to oral

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78
Q

ICD-10 Dx criteria for alcohol dependence

A

> /=3 in last 12/12

Compulsion, Control, Withdrawal, Tolerance, Neglect, Continue despite harm

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79
Q

How do the symptoms of alcohol withdrawal change with time?

A

6-12 hours= Tremor
24hrs= Anxiety, Agitation, Sweating
24-48hours = Delirium Tremens for 3-4 days
36 hours= Seizures

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80
Q

What are the symptoms of Delirium Tremens?

A 
Acute confusional state
Anxiety, Agitation, Confusion
Tremors
Visual illusions and hallucinations 
Dehydration= Tachycardia
HTN, CV collapse, Seizures
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81
Q

What type of Hallucinations/Illusions do people with Delirium Tremens usually have?

A

Lilliputian hallucinations where things are small

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82
Q

What is a classic deulsion seen in delirium tremens?

A

Persecutory Delusion

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83
Q

Define a Delusion

A

A fixed firm belief

Not correlating with reality

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84
Q

Hallucinations vs Illusions

A

Both are false perceptions

Hallucination lacks an external stimuli

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85
Q

How do you manage Delirium Tremens

A

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

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86
Q

What is Korsakoff’s Psychosis?

A

A complication of untreated Wernicke’s Encephalopathy

Memory deficits, Behavioural change and Confusion

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87
Q

What CAGE score permits further investigation?

A

> /=1

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88
Q

What AUDIT score for alcoholism permits further investigation?

A

> 15 points

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89
Q

What questions do you ask to investigate someone’s drinking pattern?

A

Times, Place, Who with, Days of the week, Type, Units
CAGE
Explore dependence symptoms

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90
Q

When would you consider admission for Alcoholism?

A 
Hx of seizures or AN overactivity
<18 years
Failed detox at home
Social problems
DT or WE
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91
Q

Why is DT a serious complication of alcoholism?

A

Hyperadrenergic state

Can lead to CV collapse + Seizures

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92
Q

Treatment principles for dealing with alcohol withdrawal

A

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

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93
Q

How can you prevent an alcoholism relapse?

A 
AA + CBT + Education + Motivational interviewing 
Consider Disulfiram (causes sicknes)/Acamprosate (Anti-craving)/Nalmefere
Dry houses
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94
Q

What drug is used in a Benzo OD

A

Flumazenil

Then need long acting Diaze with a slowly tapered off dose to treat the addiction

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95
Q

Withdrawal symptoms of a Benzo addiction?

A

Rebound anxiety/insomnia
Visual/Auditory hallucinations
Seizures

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96
Q

What are Hypnagogic hallucinations?

A

Happen just as you fall asleep

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97
Q

What are Hynopompic hallucinations?

A

Happen just as you wake up

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98
Q

What is schizophrenia (Sz)?

A

Functional psychoses with fragmentation of thinking

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99
Q

Epidemiology of Sz?

A

Increased in Males vs Females
Males 20-28 years
Females 26-32 years
up to 1% of the population

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100
Q

What are the 4 variants of Sz?

A

Paranoid
Hebephrenic
Catatonic
Simple

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101
Q

What is Paranoid Sz?

A

Paranoid delusions + Hallucinations

Relatively stable though

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102
Q

What is Hebephrenic Sz?

A

Strong -ve symptoms- Shallow and inappropriate mood
Irresponsible behaviour
Fragmentary delusions and hallucinations

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103
Q

What is a fragmentary delusion?

A

a disorganized, undeveloped false belief or a series of such beliefs that are disconnected, inconsistent, and illogical
Seen in Hebephrenic Sz

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104
Q

What is Catatonic Sz?

A

Psychomotor disturbance so doesnt interact or more
Muscles in sustained contraction
Rhabdomyolysis risk

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105
Q

What is simple Sz?

A

No delusions or hallucinations

-ve symptoms gradually arise without an acute episode

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106
Q

What is the neurochemistry behind the +ve and -ve symptoms in Sz?

A

+ve= Increased mesolimbic Dopamine activity
-ve= Decreased mesocortical Dopamine activity
Likely complex neurochemistry also involving 5-HT, Ach GABA, Glutamate

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107
Q

What are the 4 first rank +ve symptoms of Sz?

A

Delusions, Hallucinations, Thought disorder, Lack of Insight

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108
Q

Examples of the Delusions/Thought disorder seen in Sz?

A

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

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109
Q

Examples of the hallucinations seen in Sz?

A

Auditory- Echoing of thought

Third person commentary of one’s action

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110
Q

What are the negative symptoms associated with Sz?

A

Avolition, Anhedonia, Alogia, Asociality, Affect blunt

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111
Q

What is the state of one’s cognition in Sz?

A

Usually retained intellectual capacity

Clear Consciousness

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112
Q

ICD-10 stated duration of Sz symptoms for diagnosis?

A

> 1 month

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113
Q

ICD-10 diagnosis of Sz

A

one of: Thought disorder, Delusions of control/influence/passivity, Hallucinatory voices

or 2 of: Persistent hallucinations of any modality, Catatonic, -ve symptoms, Interpolations

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114
Q

Scheider’s first rank symptoms of Sz

A

Delusional perception
3rd person auditory hallucinations
Thought- Echo, Broadcast, Insertion, Withdrawal
Passivity/Delusions of control

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115
Q

Psychological therapies to treat Sz (Short and Long term)

A

Short- Psychoeducation, CBT, Family interventions,

Long- Supported employment, Art therapy, Relapse signature

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116
Q

Treatment principles for pharmacological management of Sz?

A

Antipsychotics +/- Lithium +/- Antidepressant

Start an SGA at lowest effective dose, continue 1-2 years, monitor regularly

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117
Q

1st line Antipsychotic for Sz?

A

Second Gens- Risperidone or Olanzapine

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118
Q

What is the prognosis of Schizophrenia?

A

1/3rd good, 1/3rd middle, 1/3rd poor

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119
Q

What is Schizoaffective disorder?

A

Where classification into either Schizophrenia or mood disorder would not be entirely correct
Essentially Sz with prominent mood symptoms

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120
Q

What are the diagnostic criteria for Schizoaffective disorder?

A

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

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121
Q

When would you consider admission for schizoaffective disorder?

A

Threat to themselves or others

Cannot self care

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122
Q

How do you manage Schizoaffective disorder?

A

Psychological interventions like CBT etc
+/- Long term SGAs like Risperidone/Olanzapiune
+/- Sertraline/Fluoxetine
+/- Lithium to stabilise mood

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123
Q

Which type of schizoaffective disorder carries the worst prognosis?

A

Bipolar type (>Depressive type)

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124
Q

What is Delusional Disorder?

A

Delusions are the primary symptoms
Hallucinations uncommon
3+ months

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125
Q

What features are incompatible with delusional disorder?

A

Clear persistent hallucinationd
Delusions of control
Marked blunting of affect
Evidence of brain disease

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126
Q

What are the classic features of the delusions present in delusional disorder?

A

Single or set of related delusions usually persistent and lifelong
Acute or insidious onset
Variable content

127
Q

De Clerembault’s syndrome

A

Erotomania- Famous person is in love with them

128
Q

Fregoli’s syndrome

A

Different people are the same person +/- Persecuted by this disguised person

129
Q

Ekboms syndrome

A

Delusional parasitosis
Formication- Insects on skin
Infested with parasites
Self-harm risk…

130
Q

Persecutory delusions

A

Someone is out to get them

Most common presentation of delusional disorder

131
Q

Othello Syndrome

A

Morbid jealousy
Misinterprets minor evidence and thinks partner is having an affair
Violence/Stalking risk

132
Q

Capgras syndrome

A

Delusional misidentification

Someone close to them is replaced by an identical looking imposter

133
Q

Cortad’s syndrome

A

Delusions of being dead, dying, not exisiting, rotting parts of their body
Associated with depression

134
Q

Folie a Deux

A

Induced delusional disorder, psychosis shared by two people

135
Q

How is delusional disorder managed?

A

Removal from source of delusions

Antipsychotics and Antidepressants

136
Q

Epidemiology of depression

A

2X more common in Females
2/3rds comorbid psych disorder
Very common 1/5
Longer hospital stays as they perceive symptoms as worse

137
Q

Core symptoms of depression

A

Low mood
Low energy
Anhedonia

138
Q

Non-core symptoms of depression

A 
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
Q

Investigations to exclude organic causes of depression

A

FBC, ESR, B12/Folate, U&Es, LFTs, TFTs, Glucose, Calcium
Think: Hypothyroid, Addisons, Cushings, Hypoglycaemia, Hyerpcalcaemia

140
Q

What is PHQ-9

A

Assessment tool for depression

141
Q

ICD Diagnosis of depression

Mild, Moderate and Severe

A

> 2 weeks
Mild= 2 core + 2 other
Moderate= 2 core + 3 other
Severe= 3 core + 4 other

Represents a change from normal

142
Q

For a diagnosis of depression what must the symptoms not be secondary to?

A

Drugs, Alcohol, Medication, Bereavement, Medical disorders

143
Q

Treatment plan for Mild-Moderate depression?

A

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
Q

Treatment plan for mod-severe depression

A

High intensity psychosocial interventions (CBT, Interpersonal therapy, Behavioural activation)
PLUS an antidepressant

145
Q

Treatment plan for severe/complex/life threatening depression?

A

CRISIS service
Inpatient care
MDT approach

146
Q

When would you consider an emergency referral for depression?

A

Self-harm risk is significant
Danger to others
Psychotic symptoms
Severe agitation

147
Q

What is CBT?

A

16-20 sessions over 3-4 months
Investigates and manages how we deal with and appraise events
Considers behaviour, thoughts, physiology and emotions

148
Q

What is interpersonal therapy?

A

Discuss symptoms in response to current difficulties in everyday interactions
Focuses on interpersonal difficulties and grief

149
Q

What are the Biological interventions for depression?

A

1) SSRIs- Fluoxetine/Citalopram
2) TCA, SNRIs, NaSSAs, Lithium, MAOIs
3) ECT if no response after 2 drugs or life-threatening

150
Q

Prognosis of depression

A

6/12= Average length
Median 4 episodes in a lifetime
80% >1 episode
Major risk factor for suicide

151
Q

ICD-10 symptoms associated with Mania

A 
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
Q

What is the difference between mania and hypomania

A

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
Q

What causes of mania can be excluded with blood tests?

A

Hyperthyroidism
Steroids- Medical/Idiopathic Cushing’s
Drug induced
Lithium adherence

154
Q

How do you manage an acute manic episode?

A

Contact community mental health team for an urgent referral
Lithium given as first line
+/- AP or Benzo if effect of lithium is delayed

155
Q

What is used as prophylaxis in management of chronic mania?

A

Lithium

Valproate or CBZ if lithium poorly tolerated

156
Q

The different types of BPD

A

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
Q

ICD-10 Diagnostic criteria for BPD

A

> /= 2 EPISODES OF DISTURBED MOOD AND ACTIVITY WITH AT LEAST ONE BEING MANIC/Hypomanic

Recovery usually complete between said episodes

158
Q

3 of what symptoms confirm mania according to ICD-10

A

Grandiosity, decreased need for sleep, pressured speech, Flight of ideas, Distractibility, Psychomotor agitation
Excess pleasure e.g spending sprees

159
Q

Pharmacological options for treating BPD; is ECT used?

A

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
Q

Prognosis of BPD?

A

~8-10 episodes throughout life
~50% attempt suicide at least once
Self neglect and damage to relationships

161
Q

What is neurosis?

A

Maladaptive psychological symptoms not due to organic causes or psychosis, usually precipitated by stress

162
Q

GAD vs panic attacks, Phobia and Personality disorder in terms of presentation

A

Paroxysmal- sudden increase in anxiety… Likely panic attacks
Phobia are situaitonal
Personality disorder is lifelong

GAD is none of these

163
Q

ICD-10 Diagnostic criteria for GAD

A

Excessive worrying more days than not >6/12

3+ Core symptoms
3+ symptoms of AN arousal or disrupted mental state

164
Q

What are the core symptoms of GAD?

A

Restlessness, Easily fatigued, Feel keyed up, Difficulty concentrating, Irritability, Muscle tension, Sleep disturbance

165
Q

What symptoms of AN arousal can you get in GAD?

A

Palpitations, Racing/Pounding heart, Sweating, Trembling, Dry mouth, Lump in the throat, Numbness

166
Q

How can GAD impact someone’s mental state?

A

Faint/Light headed
Loss of control
Derealisation and Depersonalisation
Loss of control

167
Q

Derealisation vs Depersonalisation

A

Depersonalization is a sense of detachment from oneself and one’s identity. Derealisation is when things or people around seem unreal.

168
Q

NICE Stepwise approach to managing GAD

A

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
Q

What drugs are 1st line for managing GAD?

A

Sertraline (SSRI) or Venlafaxine (SSNRI)

170
Q

How do you diagnose panic disorder

A

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
Q

Features of panic disorder

A 
Paroxysmal; rapid peaking anxiety 
AN arousal
Desire to escape
No symptoms between attacks
Not predictable/in response to a trigger
Depersonalisation/realisation
172
Q

What age group is most at risk of panic disorder?

A

Early adulthood

ESPECIALLY GIRLS

173
Q

How do you acutely manage a panic attack?

A

Exclude medical causes… ECG etc
Reassure, calming… Resolution in 30 mins
?Benzos if extremely severe and distressing

174
Q

Management of panic disorder

A

1) Recognition and Dx, montior and promote exercise
2) CBT +/- SSRI
3) Alternative meds if no response 3/12
4) Referral

175
Q

What is a phobia?

A

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
Q

Key features of social phobia?

A 
Fear of scrutiny arising from social situations 
Low self-esteem 
? Triggered by an embarrassing event 
Withdrawal 
May progress to panic attacks
177
Q

Agoraphobia

A

Anxiety provoked by open spaces or large crowds
Where escape is difficult
Co-presents with obsessive or depressive symptoms?

178
Q

How do you treat a phobia?

A

Graded exposure and sensitisation
CBT
Try Paroxetine (SSRI) or Beta blocker
Benzo only if absolutely necessary

179
Q

What are the symptoms of OCD?

A

Recurrent unpleasant intrusive obsessions

Strong compulsions to perform an action despite a lack of necessity

180
Q

Level of insight in OCD

A

Patient recognises thoughts as their own

Therefore not thought insertion

181
Q

How do you manage you OCD

A

CBT (best evidence) +/- SSRI Fluox/Sertraline then TCA if resistant
+/- Exposure and response prevention
+/- Stimulus control (Allowed to think thoughts at set times)

182
Q

Symptoms of PTSD

A

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
Q

What must you screen for in ?PTSD

A

Substance misuse

Underlying depression

184
Q

Management of PTSD

A

CBT is vital +/- Paroxetine or sertraline
Eye movement desensitisation
Encourage return to work

185
Q

Prognosis of PTSD

A

Good

18 month recovery in 65%

186
Q

Adjustment disorder

A

Protracted response to a significant life event

187
Q

What is defined as a prolonged adjustment response

A

> 6 months

>1/12 is a brief depressive reaction

188
Q

How does adjustment disorder present

A

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
Q

What features make a bereavement reaction abnormal

A

Unusually intense-> Looks like depression
Prolonged >6/12
Delayed
Inhibited or distorted (Thoughts of guilt or excess guilt)

190
Q

What is normal bereavement

A

Numbness, Anger, disturbed Sleep/Appetite
Intensity reduces over time
Typical grief lasts 12 months

191
Q

Counselling vs CBT for adjustment disorder

A

Counselling is passive listening so is better for something that cannot be changed

CBT addresses repeated patterns

192
Q

Pharmacological management of adjustment disorder

A

Indicated when psychological management is unsuccessful or symptoms are particularly troublesome

SSRI or Benzos

193
Q

Acute stress reaction

A

Transient reaction to a highly threatening experience

194
Q

Dissociative/Conversion disorder

A

Traumatic event leads to loss of memory, identity, control of movement and sensation

195
Q

Symptoms of Dissociative/Conversion disorder

A 
Paralysis 
Aphonia
None dermatome sensory loss
Amnesia 
Fugue (confusion about identity)
Stupor 
Convulsions
Possession by an animal
196
Q

What is Ganser syndrome

A

Pretend they have a mental disorder

Variant of conversion disorder

197
Q

Management principles for Dissociative/Conversion disorder

A

Acceptance and support but avoid interventions that maintain the sick role
CBT etc
Clearly present the diagnosis

198
Q

Somatisation disorder

A

Long history of multiple complex changing unaccounted symptoms
Fluctuating
Disrupts social functioning

199
Q

Hypochondrial disorder

A

Persistent preoccupation with having >/=1 medical disorders
Despite reassurance
Includes Body dysmorphia

200
Q

Persistent somatoform pain

A

Unaccounted chronic pain

Likely psychosocial or emotional problems

201
Q

Somatoform AN disorder

A

Looks like physical symptoms from an organ system entirely under AN control

202
Q

Malingering

A

Manufacturing symptoms for a purpose other than the sick role
Financial etc

203
Q

Munchausen syndrome

A

Factitious disorder where symptoms are manufactured for the purpose of the sick role
PRIMARY GOAL: GETTING MEDICAL ATTENTION

204
Q

Anorexia Nervosa definition and epidemiology

A

BMI<17.5
Less common than BN
90% onset within 1st 5 years of menarche
Higher social classes

205
Q

Bulimia Nervosa definition and epidemiology

A 
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
Q

Core Psychopathology of Eating Disorders

A

Rigidity of thinking
Fear of fatness and body dissatisfaction
Body image distortion
Self evaluation based on Weight and shape
Rumination about food

207
Q

Classical behaviours associated with eating disorders

A 
Avoidance 
Diet pills
Laxatives, Water loading, Insulin misuse, Thyroxine 
Calorie counting 
Excessive weighing
208
Q

How do eating disorders impact the CVS?

A

Starvation induces bradycarida and hypotension

Binging/purgung induces arrhythmias and ?Faulure

209
Q

How do eating disorders impact the renal system?

A

Electrolyte disturbance
Oedema
?Failure

210
Q

How do eating disorders impact the GI system?

A

Parotid swelling, constipation

Purging= dental and oes eorsion and haematemesis

211
Q

How do eating disorders impact the Skeletal system?

A

Pathological fracture risk is increased, OP

212
Q

How do eating disorders impact the Endocrine system?

A

Amenorrhoea, Thermodysregulation

Starvation can induce hyppthyroidism

213
Q

How do eating disorders impact the Haemtological system

A

Low Blood and WCC

214
Q

Neuro sequela of eating disorders?

A

Seizures and confusiom

215
Q

What is Russell’s sign?

A

Callouses on the hand because of repeated purging

216
Q

What must you ask about in a history of eating disorder?

A 
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
Q

What signs can you specifically look for upon examination of a patient with an eating disorder

A

Hypotension, Irregular pulse, Hypothermia, Myopathy, Russell’s

218
Q

What investigations would you do on a patient presenting with an eating disorder and why

A

ESR/U&Es ?Oragnic cause
ECG ?Arrhythmia
DXA scan

219
Q

What causes hyponatraemia in a patient with an ED?

A

Water loading, Laxative use, Diuretic

220
Q

What causes hypokalaemia in a patient with an ED?

How does this look on an ECG?

A

Vomiting

T wave changes +/- QTc prolongation

221
Q

Refeeding syndrome

A

Electrolyte disturbance (Low) after eating post-anorexia

222
Q

Bone marrow hypoplasia in ED

A

Looks like normocytic anemia and leukopenia on bloods

223
Q

BMI and level of risk in Anorexia

A

<18.5= Low
< 15= Moderate
<13= High

224
Q

What is PREDIX and MARSIPAN

A

PREDIX- Classifies risk by organ system
MARSIPAN- physical risk

Both used in eating disorders

225
Q

SCOFF screening for Eating Disorders

A

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
Q

What SCOFF score is likely an ED?

A

2+

227
Q

Management principles of Eating Disorders?

A 
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
Q

Indications for urgent admission of an individual with an Eating disorder likely AN

A 
Electrolyte of glucose disturbance
Severe malnutrition or dehydration 
Impending organ failure
ECG changes
BMI <13
>1Kg loss over 2 consecutive weeks 
Suicide risk
229
Q

How are Eating Disorders managed differently in <18yrs vs Adults

A

Focus is on family therapy
Restore independence in managing eating over time with heavy family involvement; then maintain
Can still use CBT etc

230
Q

MDT support needed in Managing eating disorders?

A 
Dentists
Specialist advice if Bone Mineral Density starts to fall 
Dietician 
Mental Health Nursing 
Community team
231
Q

Personality Disorder

A

A personality that persistently causes dysfunctional relationships or distress to themselves or those around them
STABLE AND ALWAYS PRESENT

232
Q

Temperament of Cluster A personality disorder

A

Eccentric, Aloof, Suspicious, Solitary

233
Q

Variants of Cluster A personality disorders + Key feature of each

A

Paranoid (Suspicious and distrusting)
Schizoid (Social isolation)
Schizotypical (Odd beliefs)

234
Q

Difference between schizoid and schizotypical

A

Both cluster A

Schizoid- Isolation, do not want companionship

Schizotypical- Odd beliefs, eccentric behaviour, derealisation, Ideas of reference

235
Q

Ideas of reference

A

Ideas that unrelated things refer to them directly

“OMG this song is written about me”

236
Q

Temperament of Cluster B personality disorder

A

Dramatic, Emotionally labile, Intense

237
Q

Variants of Cluster B Personality disorder

A

Antisocial
Emotionally unstable
Histrionic
Narcissistic

238
Q

Antisocial personality disorder

A

Cluster B

Easily frustrated, Lack of guilt, Criminal, doesn’t accept responsibility

239
Q

Borderline/Emotionally unstable personality disorder

A

Cluster B

Recurrent emotional crises, Intense mood, Impulsive, Disturbed self image, YOUNG WOMEN

240
Q

Histrionic personality disorder

A

Cluster B
Exaggerated theatrical expression
Attention seeking, Vain, Needs others’ approval

241
Q

Narcissistic personality disorder

A

Cluster B
Grandiose self-importance
Exaggerates abilities
Resents the success of others

242
Q

Paranoid personality disorder

A 
Cluster A
Suspicion
Bears grudges
Cannot take criticism 
Unforgiving 
Obsession with conspiracy theories
243
Q

Temperament of Cluster C personality disorders

A

Anxious, Timid, Dependent, Low-self esteem

244
Q

Anakastic/Obsessional Personality Disorder

A 
Cluster C
Inflexible 
Mistakes cause intense worry
Humourless
Unrealistic high standards
245
Q

Anxious/Avoidant personality disorder

A

Cluster C
Tension and apprehension
Fears rejection
Avoids personal contact

246
Q

Dependent Personality disorder

A

Cluster C
Excessive need to be cared for
Allows others to take responsibility for many areas of their life

247
Q

What length of time is required for a Dx of personality disorder?

A

The History must be longstanding likely from around childhood

248
Q

What tool can be used to assess ?Personality disorders

A

Minnesota Multiphasic Personality Inventory

249
Q

Management principles for Personality disorder

A

Help them find a lifestyle suited to them
Consistency of care
Education of insight to prevent blaming others
psychotherapy +/- AP +/- AD

250
Q

What is Psychotherapy

A

Aims to improve perceptions and responses to social situations
CBT, Psychodynamic psychotherapy

251
Q

CBT vs Psychodynamic psychotherapy

A

CBT reformulates behaviours and perceptions based on long standing beliefs inducing cognitive errors

Psychodynamic psychotherapy Examines how we perceive events

252
Q

When are antipsychotics indicated in people with personality disorder?

A

Transient psychosis

253
Q

Which children are at risk of developing a personality disorder

A

Parents with mental health or misuse problems
Mums <18 years
Criminal parents
Parents with a history of residential care

254
Q

Learning disability

A

IQ<70
Loss of adaptive social functioning
Onset BEFORE 18 years at birth/early childhood

255
Q

Causes of Learning disability

A 
Maternal substance abuse, phenytoin
Antenatal insult
Genetic
Metabolic disturbance like PKU 
Deprivation 
Post-natal/Neonatal insult
256
Q

IQs of the different severity grades of learning disability

A

Mild= 50-69
Moderate= 35-49
Severe= 20-34
Profound <20

257
Q

What disease is commonly comorbid with learning disability

A

Epilepsy

258
Q

Development level of someone with profound learning disability

A

~12 months

259
Q

What are the features of learning disability

A 
Difficulty coping with stress
Limited language 
Poor self-care
Incontinence
Inappropriate sexual behaviour 
Inability to walk
Lesch-Nyhan (Self harm)
260
Q

How are individuals with learning difficulty at risk?

A

Increased chance of abuse

More commonly develop psychiatric problems- E.G. Anxiety because of lack of confidence

261
Q

Assessment of learning difficulty

A

Hx- Childhood and Birth
Evaluate functioning
Baseline skill level- Can then detect any regression
Screen for other psychiatric illness

262
Q

How can pain manifest itself in those with learning disability?

A

Challenging behaviour

263
Q

Communicating with a patient with learning difficulties

A 
Greet them 1st
Involve them in the discussion
They are in control 
Short sentences 
Allow them time to process
264
Q

Monitoring those with learning difficulties

A

Annual Health Checks

265
Q

MMSE scores and the corresponding severity of Alzheimer’s Disease

A

Normal 24+
Mild 20-23
Moderate 13-20
Severe if <12

266
Q

What is Zopiclone

A

Used to treat Insomnia

Similar MoA to Benzos

267
Q

CI to the use of Zopiclone

A

Obstructive Sleep Apnoea
Respiratory muscle weakness/Depression
Caution in Elderly

268
Q

Side effects of Zopiclone

A

Daytime sleepiness
Headache/Confusion/Nightmares
Taste Disturbance
Rebound insomnia after stopping

269
Q

Prolonged used of Zopiclone

A

Facilitates dependence

Particularly if >4 weeks

270
Q

Zopiclone Withdrawal

A

Headache, Muscle Pain, Anxiety

271
Q

OD of Zopiclone

A

Drowsiness, Coma, Respiratory depression

272
Q

Zopiclone and CYP450 enzymes

A

Metabolised by these

Inhibitors will therefore increase sedation

273
Q

How does Zopiclone interact with other drugs?

A

Additive sedation if alcohol/Opioids/Benzos

Additive Hypotension if antihypertensive drugs used

274
Q

Max Zopiclone use

A

4 weeks

1/2 dose if elderly

275
Q

Advice to patient when prescribing Zopiclone

A

Only take when needed
SHORT TERM MEASURE
Explore reasons for poor sleep
Avoid driving and using heavy machinery

276
Q

Adverse effects of Cannabis

A

Anxiety, Paranoid, Nausea, Amnesia, Psychosis, poor concentration, apathy, Cravings

277
Q

What is Ketamine

A

NMDA antagonist

278
Q

What is Dissociative Anaesthesia

A

Caused by Ketamine
1) Catatonia 2) Analgesia 3) Amnesia 4) Catalepsy
Also alters perceptions

279
Q

Catatonia

A

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
Q

Catalepsy

A

A trance or seizure with a loss of sensation and consciousness accompanied by rigidity of the body.

281
Q

Cocaine

A

Inhibits Monoamine reuptake

Increases confidence, Stimulates, Belief in great mental capacity

282
Q

Adverse effects of Cocaine

A 
Tachycarida and Arrhythmias 
Pupil dilate 
MI and HF
Panic attacks
Septum necrosis 
Persecutory delusions 
Paranoia
283
Q

MDMA/Ecstasy

A

Synthetic Amphetamine Analogue

Increases Monoamines

284
Q

Pupil changes from recreational drugs

A

Dilate- MDMA, Ecstasy, Cocaine, Amphetamines

Pinpoint- Heroin

285
Q

Risks of MDMA use

A

Overhydration
Adverse electrolyte changes
Psychosis
Affect change

286
Q

LSD

A

Hallucinogen lasts 8-14 hours

287
Q

Risks of LSD

A

Post-Hallucinogenic perception disorder
Persistent Psychosis
Beliefs cause them to harm others
Flashbacks

288
Q

Large doses of Psyilocybin Mushrooms

A

Euphoria, Hallucinations, Perceptual changes
Synaesthesia
Hallucinations
Slurred Speech

289
Q

Amphetamines (Crystal Meth, Speed, Whizz)

A 
Increases NorA and Dopamine 
Talkative, Excited, Pipils dilate, HR/BP/T increases 
Concentration improves 
Appetite decreases 
Dry mouth
290
Q

Heroin withdrawal onset

A

From 8-10 hours after last dose

Lasts 7-10 days

291
Q

Symptoms of Heroin withdrawal

A 
Akathisia Affect change
Sweating 
Tachycardia
Diarrhoea
Goose pimple skin
Limb spasms 
OD risk is increased as tolerance decreases
292
Q

How do you manage a Heroin OD

A

0.4mg of IM Naloxone

This is an Opiate antagonist that induces rapid detox

293
Q

Presentation of a Heroin OD

A 
Pinpoint pupils
Shallow breathing 
Bradycardia 
Hypotension
Delirum
294
Q

Naltrexone

A

Opioid antagonist

Used to maintain Heroin abstinence if highly motivated

295
Q

How do you manage the symptoms of Heroin Withdrawal

A 
N&amp;V= Metclopramide 
Diarrhoea= Loperamide 
Agutation/Anxiety= Diazepam 
Pain= NSAIDS or Paracetamol
296
Q

Amyl Nitrate Poppers

A

Imitates illegal highs
Enhances sexual experiences
Relaxation of involuntary SM

297
Q

Risks of Amyl Nitrate Poppers

A

Hypotension
LoC
Arrhythmia +/- Sudden death

298
Q

What is MCAT

A

Stimulative recreational drug
Makes them alert, talkative, euphoric
Can lead to agitation, self harm and a reduction in peripheral circulation

299
Q

Key principles of the Mental Health Act

A 
Least restrictive
Empower
Maximise independence
Dignity
Puporse
Efficiency
300
Q

Who is needed for an assessment under the MHA

A 
2 doctors (one with prior knowledge of patient and one with section 12 approved)
1 AMHP
301
Q

Criteria for detention under the Mental Health Act

A

Suffering from a mental disorder which warrants detention
Risk to safety of themselves, others or society
Unwilling to go to the hospital voluntarily

302
Q

Learning disability and detention under the MHA

A

The learning disability must be associated with abnormally aggressive or seriously irresponsible conduct

303
Q

Willing patient who lack capacity and consent to voluntary admission- By what means are they admitted?

A

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
Q

Section 2 of the MHA

A

Lasts up to 28 days
Appeal within 1st 14 days
Not renewable

305
Q

Section 3 of the MHA

A

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
Q

Section 5 (2)

A

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
Q

Who implements Section 5 (2) of the MHA (Dr’s holding power)

A

Consultant in charge

or grade >FY2

308
Q

How long does Nurse’s holding power last

A

6 hours

re-evaluated by Dr

309
Q

Section 136 of the MHA

A

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
Q

Principles of the Mental Capacity Act 2005

A 
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
Q

2 stage process of the MCA 2005 (To assess capacity)

A

Diagnostic test to diagnose disorder of mind

Functional test- Understand/retain/Use/Communicate

DECISION AND TIME SPECIFIC

312
Q

How do you decide best interests in relation to the MCA?

A 
Past/Present views
Beliefs/Values
Those engaged in the person's care
Deputy appointed by the court
Independent mental capacity advocate
313
Q

Deprivation of Liberty Safeguards

A

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
Q

Describe different indications for the MCA vs MHA

A

Degree of Overlap
Dependent on what you are primarily treating:

Physical illness- MCA
Mental illness- MHA

Psychiatry (2 decks)

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