Psychiatric Conditions Flashcards
What are some features of psychosis ?
Hallucinations ( auditory )
Delusions
Thought disorganisation
Agitation
What are some conditions where psychotic symptoms present ?
Schizophrenia
Depression ( psychotic depression - subtype in the elderly )
Bipolar disorder
Neurological conditions ( parksinons or huntingtons )
Certain illicit drugs ( cannabis )
What are Schneider’s first rank symptoms for schizophrenia ?
Auditory hallucinations
Thought disorders
Passivity phenomena
Delusional perceptions
What are some thought disorders ?
Thought insertion
Thought withdrawal
Thought broadcasting
What is passivity phenomena ?
Bodily sensations being controlled by an external influence
Actions / impulses / feelings - experiences which are imposed on the individual or influenced by others
What is delusional perception ?
It’s a 2 stage process
- a normal object is perceived
- then there is a sudden intense delusional insight into the object
( the traffic light is green so i am the king )
What are some other features of schizophrenia not in the first rank symptoms ?
Impaired insight
Negative symptoms
- blunting of affect
- anhedonia
- social withdrawal
Catatonia
Neologisms ( made up words )
What is needed for a diagnosis of schizophrenia ?
At least 2 of the following symptoms must be present for at least a month :
- persistent delusions
- persistent hallucinations
- disorganised thinking - formal thought disorder
- experiences of passivity phenomena
- negative symptoms
- psychomotor disturbances
What is the management for schizophrenia ?
Oral antipsychotics
CBT
Close monitoring - regular blood tests when on antipsychotics
What are some risk factors for schizophrenia ?
Afro-Caribbean ethnicity
UK migrants
Family history
Winter births
Illicit drug use
Genetics
What features are present in manic psychosis ?
Grandiose delusions
2nd person auditory hallucinations
What are some features in depressive psychosis ?
Guilt, poverty and nihilistic delusions
2nd person auditory hallucinations
What is formal thought disorder ?
A problem of speech ( and flow of thought ) which means that each sentence ( or phrase or word ) does not follow on from the next.
What is a delusion ?
A fixed firmly held belief that is usually false, that cannot be reasoned away, that is held despite evidence to the contrary and is out of keeping with with a persons sociocultural norms
What is a hallucination ?
The perception f an object in the absence of an external stimulus.
What are some types of mood disorder ?
Depression
Bipolar
Persistent mood disorder
What are the core symptoms of depression ?
Continuous low mood for 2 weeks
Lack of energy
Anhedonia ( lack of interest or enjoyment )
What are some somatic symptoms of depression ?
Sleep changes - early morning wakening
Appetite and weight changes
Diurnal variation of mood - worse in the morning
Psychomotor retardation / agitation
Loss of libido
What are some cognitive symptoms of depression ?
Low self esteem
Guilt / self blame
Hoplessness
Hypochondrial thoughts
Poor concentration / attention
Suicidal thoughts
What is needed for a diagnosis of mild depression ?
2 core symptoms.
+
2 others
( able to function )
What is needed for a diagnosis of moderate depression ?
2 core + 3/4 others
What is needed for a diagnosis of severe depression ?
3 core and at least 4 others
What are some risk factors for post natal depression ?
Personal or family history
Older age
Single mother
Unwanted pregnancy
Poor social support
Previous PND
What are some symptoms of hypomania ?
( considerable interference with work/social activity )
Mildly elevated, expansive or irritable mood
Increased energy / activity
Sociability, talkativeness, over familiarity
Increased sex drive
Reduced need for sleep
Difficulty in focusing on one task
What are some symptoms for mania ?
1 week of elevated, expansive or irritable mood
Increased energy / activity -agitated
Grandiosity
Pressure of speech
Flight of ideas
Distractible
Reduced need for sleep
Increased libido
Loss of social inhibitions
Psychotic symptoms
What is cyclothymia ?
Mild periods of elation / depression
Early onset / chronic course
what is dysthymia ?
Chronic low mood not fulfilling the criteria of depression
What is bipolar 1 ?
1 or more manic episodes
With or without
1 or more depressive episodes
What is bipolar 2 ?
1 or more depressive episodes with at least 1 hypomanic episode
What are some biological causes of mood disorders ?
Genetics
Brain illness
Physical illness
What are some psychological causes of mood disorders ?
Childhood experiences
View of yourself and the world
Personality traits
What are some social causes of mood disorders ?
Work, housing and fiancés
Relationships and supoort
What are some biological treatments for mood disorders ?
Pharmacological
ECT - electroconvulsive therapy
RTMS - repetitive transcranial stimulation
TDCS - transcranial direct current stimulation
What are some examples of anti-depressants ?
SSRI
SNRI
TCA
MAOI
What are some mood stabilisers ?
Lithium
Valproate
Carbamazepine
Lamotrigine
What is ECT ?
A treatment that involves sending an electric current through the brain to trigger an epileptic seizure
Performed twice a week for 6 weeks
What are the indications for ECT ?
Severe depressive illness - treatment resistant
Life threatening illness
Prolonged and severe manic episode
Catatonia
High suicide risk
Severe psychomotor retardation
What is rTMS ?
Repetitive transcranial magnetic stimulation involves placing an electromagnetic coil against your head which sends repetitive pulses of magnetic energy at a fixed frequency
What some be avoided in the management of bipolar disorder ?
Antidepressants
What are some psychological treatments for mood disorders ?
Psychoeducation
CBT
Mindfulness
What are some social interventions for mood disorders ?
Targeted interventions
- family
- housing
- financial advice
- employment
- coping strategies
How long should antidepressants be continued after the first episode of depression ?
At least 6-12 months
When does does anxiety become a problem ?
When the response is to a perceived threat / not an actual threat
What is the threshold on PHQ-9 for severe depression ?
A PHQ-9 score of more than 16
What are the treatment options for mild depression ?
Guided self help
Group CBT
Individual CBT
Group mindfulness
SSRI’s
What is the management options for more severe depression ?
CBT
Antidepressants - SSRI, SNRI
Individual CBT
Counselling
What are the 2 screening questions for depression ?
During the last month, have you often been bothered by feeling down, depressed or hopeless ?
During the last month, have you often been bothered by having little interest or pleasure in doing things ?
When switching between SSRI’s ( excluding fluoxetine ) what should happen ?
The first one should be stopped before starting the next
When switching from fluoxetine to an SSRI what should happen ?
Withdrawal then leave a gap of 4 - 7 days before starting a low dose SSRI
When switching from SSRI to a TCA what should happen ?
Cross tapering is recommended
( current drug dose is reduced slowly whilst the dose of the new drug is slowly increased )
( exception of fluoxetine which should be withdrawal prior to TCAs being started )
When switching from citalopram and Sertraline to venlafaxine what should happen ?
Cross taper cautiously
Start venlafaxine 37.5mg daily and increase very slowly
When switching from fluoxetine to venlafaxine what should happen ?
Withdraw and then start venlafaxine at 37.5mg each day and slowly increase
What is bipolar disorder ?
A chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression
What is the management for bipolar disorder ?
Lithium - first line mood stabiliser
An alternative is valproate
Mania/hypomania - stop antidepressants and start olanzapine or haloperidol
Depression - talking therapies or fluoxetine
What is the mechanism of action of typical antipsychotics ?
Dopamine D2 receptor antagonists blocking dopaminergic transmission in the mesolimbic pathways
What are some common side effects of typical antipsychotics ?
Extra-pyramidal side effects
Hyperprolactinaemia
What are some examples of typical antipsychotics ?
Haloperidol
Chlorpromazine
What is the mechanism of action of atypical antipsychotics ?
Acts on a variety of receptors ( D2, D3, D4 and 5 - HT )
What are some examples of atypical antipsychotics ?
Clozapine
Risperidone
Olanzapine
What are some extra-pyramidal side effects ?
Parkinsonism
Acute Dystonia
Akathisia
Tardive dyskinesia
What is the monitoring required for antipsychotics ?
FBC
U&E’s - start , annually
LFTs
Lipids - start, 3 months and annually
Weight -
BP - baseline and frequent
ECG - baseline
What are some adverse side effects of atypical antipsychotics ?
Weight gain
Hyperprolactinaemia
Clozapine -
- Agranulocytosis
- constipation ( can lead to bowel obstruction )
What are medications that can trigger anxiety ?
Salbutamol
Theophylline
Corticosteroid
Antidepressants
Caffeine
What are differentials for anxiety ?
Hyperthyroidism
Cardiac disease
Mediation induced anxiety
What is the stepwise treatment for GAD ?
Step 1 - education about GAD and active monitoring
Step 2 - low intensity psychological interventions
Step 3 - high intensity psychological interventions ( CBT ) or drug treatment
Step 4 - highly specialist input
What drug treatment is used for GAD ?
Sertraline is first line
Second line is other SSRI or SNRI
Third line offer pregabalin
What is the stepwise management for panic disorder ?
Step 1 - recognition and diagnosis
Step 2 - treatment in primary care
Step 3 - review and consideration of alternative treatment
Step 4 - review and referral to specialist mental health service
Step 5 - care in mental health services
What is the primary care treatment for generalised anxiety disorder ?
CBT or drug treatment - SSRI
What is the grief reaction ?
The normal reaction of people feeling sadness and grief following the death of a loved one and is not necessarily medicalised.
What are the five stages of grief ?
Denial
Anger
Bargaining
Depression
Acceptance
What are some features of atypical grief reaction ?
Delayed grief - occurs 2 weeks after passing
Prolonged grief - beyond 12 months
What are some differences between mania and hypomania ?
Mania
- lasts at least 7 days
- severe functional impairment
- may require hospitalisation
- psychotic symptoms
Hypomania
- lesser version of mania
- lasts for less than 7 days
- can be high functioning and does not impair social and work setting
- unlikely to require hospitalisation
- does not exhibit psychotic symptoms
What are some similarities of mania and hypomania ?
Elevated and irritable mood
Pressure of speech
Flight of ideas
Poor attention
Insomnia
Loss of inhibitions
Increased appetite
How does someone present if they have insomnia ?
Decreased daytime functioning
Decreased periods of sleep ( delayed sleep onset or waking in the night)
Increase in accidents often due to poor concentration
What are some risk factors for insomnia ?
Female gender
Increased age
Lower educational attainment
Unemployment
Economic inactivity
Widowed, divorced or separated status
Alcohol and substance abuse
Poor sleep hygiene
Chronic pain
How can a diagnosis of insomnia be made ?
Mainly through interview
Sleep diary
Polysomnography ( not routinely performed )
What is the short term management of insomnia ?
Identify potential cause
Advise not to drive when sleepy
Sleep hygiene
Only consider hypnotics if daytime impairment is severe
What is the drug management for insomnia ?
Short acting benzodiazepine or zopiclone
( diazepam not recommend )
What is OCD ?
The presence of either obsessions or compulsions, commonly both.
These symptoms can cause significant functional impairment and / or distress
What is an obsession ?
It is defined as an unwanted intrusive thought, image or urge that repeatedly enters the persons mind
What is a compulsion ?
Repetitive behaviours or mental acts that the person feels driven to perform. It can be overt or covert
What are some risk factors for OCD ?
Family history
Age - peak onset between 10-20 years old
Pregnancy / post-natal period
History of abuse, bullying, neglect
What is the management for OCD if it is mild ?
Low intensity CBT
SSRI if CBT is ineffective
What is the management for OCD if it is moderate ?
SSRI
Higher intensity CBT
Consider clomipramine
What is the management for OCD if it is severe ?
Refer to mental health team for assessment
SSRI and CBT
What is ERP therapy ?
A psychological method which involves exposing a patient to an anxiety provoking situation and then stopping them engaging in their usual safety behaviour.
What are some psychological symptoms of GAD ?
Fearful anticipation
Irritability
Sensitivity
Restless
Poor concentration
Anxious thoughts
What are some physical symptoms of GAD ?
GI - dry mouth, loose stool, epigastric discomfort
Resp - tight chest, difficulty inhaling
Cardio - palpitations,
Genitourinary - frequent / urgent micturition, ED
Sleep disturbance
What are some risk factors of GAD ?
Genetic
Upbringing
Personality type
Stressful life event
What is a simple phobia ?
Marked fear of specific object or situation with a marked avoidance of the object
What is agoraphobia ?
Fear of crowds, open spaces
Anxiety is reduced with support
What is the management of agoraphobia ?
Exposure
Antidepressants
CBT
What is a social phobia ?
Fear of negative evaluation can lead to avoidance of feared situations and use safety behaviours
What is the management of social phobias ?
Exposure
SSRI
Anxiolytics
CBT
What is panic ?
Excessive arousal with fear that the symptoms are evidence of a catastrophe
What is the treatment for panic disorder ?
Imipramine, clomipramine
SSRI
Anxiolytic
CBT
What is PTSD ?
It is caused by exposure to an event or situation of exceptionally threatening or catastrophic nature which would be likely to cause pervasive distress in almost everyone
What are some features of PTSD ?
Re-experiencing - flashbacks, nightmares, intrusive images
Avoidance
Hyperarousal - hypervigilance
Emotional numbing
Depression
Drug or alcohol use
Anger
What is the management of PTSD ?
Watchful waiting may be used for mild symptoms lasting less than 4 weeks
Trauma focused CBT
Drug treatment not used as first line but if needed venlafaxine or an SSRI is used
What is cluster A personality disorders characterised by ?
Odd or eccentric
What is cluster B personality disorders characterised by ?
Dramatic
Emotional
Erratic
What is cluster C personality disorders characterised by ?
Anxious
Fearful
What types of personality disorders fall in cluster A ?
Paranoid
Schizoid
Schizotypal
What types of personality disorders fall in cluster B ?
Antisocial
Borderline
Histrionic
Narcissistic
What types of personality disorders fall in cluster C ?
Obsessive compulsive
Avoidant
Dependent
What is paranoid personality disorder ?
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to question the loyalty of friends
Reluctance to confide in others
What are some features of schizoid personality disorder ?
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lac of desire for companionship
Emotional coldness
Few interests
Few friends
What are some features of schizotypal personality disorder ?
Ideas of reference ( delusion but some insight )
Odd beliefs
Unusual perceptual disturbances
Paranoid ideation
Odd eccentric behaviour
Lack of close friends
What are some features of antisocial personality disorder ?
Failure to conform to social norms
More common in men
Deception
Impulsiveness
Irritable or aggressive
Reckless
Lack of remorse
What are some features of borderline personality disorder ?
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships
Unstable self image
Recurrent suicidal behaviour
Chronic feelings of emptiness
Difficulty controlling anger
What are some features of histrionic personality disorder ?
Inappropriate sexual seductiveness
Need to be the centre of attention
Suggestibility
Self dramatisation
What are some features of narcissistic personality disorder ?
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power or beauty
Sense of entitlement
Lac of empathy
Chronic envy
Arrogant
What are some features of obsessive compulsive personality disorder ?
Occupied with details, rules, lists, order and organisation
Perfectionism
Extremely dedicated
Meticulous
No sentimental meaning
Unwilling to pass on tasks or work
Stingy spending style
What are some features of avoidant personality disorder ?
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism or rejection
Unwillingness to be involved preoccupied with ideas that they are being criticised or rejected
Restraint in intimate relationships
Reluctance to take personal risk
Views self as inept and inferior
What are some features of dependent personality disorder ?
Difficulty in making everyday decisions without excessive reassurance
Need for others to assume responsibility for major areas in their life
Difficulty in expressing disagreement
Lack of initiative
Urgent search for another relationship as a source of care and support
What is the management for personality disorders ?
Psychological therapies
Treatment of any co-existing psychiatric conditions
What is circumstantiality ?
The inability to answer a question without giving excessive, unnecessary detail. However they do return to the original point
What is tangentiality ?
Refers to wandering from a topic without returning to it
What is neologisms ?
New word formations which might include combining of 2 words
What is word salad ?
Describes completely incoherent speech where real words are strung together into nonsense sentences
What is flight of ideas ?
A feature of mania where there are leaps from one topic to another but with discernible links between them.
what are some features of anorexia nervosa ?
Reduced body mass index
Bradycardia
Hypotension
Enlarged salivary glands
What are some physiological abnormalities of anorexia nervosa ?
Hypokalaemia
Low FSH, LH, oestrogen and testosterone
Raised cortisol anal growth hormone
Impaired glucose tolerance
What is bulimia nervosa ?
A type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as use of laxatives or diuretics or exercising.
What is the diagnostic criteria for bulimia nervosa ?
Recurrent episodes of binge eating
A sense of lack of control over eating during the episode
Recurrent inappropriate compensatory behaviour in order to prevent weight gain
The binge eating and compensatory behaviours occur at least nice a week for 3 months
Self evaluation is unduly influenced by body shape and weight
What is the management of bulimia nervosa ?
Referral for specialist care
Bulimia nervosa focused guided self help for adults
CBT
Children should be offered bulimia focused family therapy
What is autism ?
A neurodevelopmental condition characterised by qualitative impairment in social interaction and communication as well as repetitive stereotyped behaviour, interests and activities.
What are some features of autism ?
Impaired social communication and interaction - children frequently play alone, failure to form relationships and failure to pick up on nonverbal cues
Repetitive behaviours, interests and activities
Associated with intellectual and language impairment
ADHD and epilepsy are common associations
What are the non-pharmacological interventions for autism ?
Applied behavioural analysis
ASD preschool program
Family support and counselling
What are the pharmacological interventions for autism ?
SSRI - help to reduce symptoms like repetitive stereotyped behaviour, anxiety and aggression
Antipsychotics - useful to reduce aggression or self injury
Methylphenidate - for ADHD
What is ADHD ?
Attention deficit hypersensitivity disorder is a condition incorporating features relating to inattention and/or hypersensitivity or impulsivity that is persistent. There has to be an element of developmental delay.
What are some diagnostic features of ADHD ?
Doesn’t follow through on instructions
Reluctance to engage in mentally intense tasks
Easily distracted
Finds it difficult to organise tasks
Unable to play quietly
Talks excessively
Does not wait their turn easily
Is often ‘on the go’
Interruptive
What is the management of ADHD in children ?
Mild / moderate - parents attending education and training programs
Severe - methylphenidate is first line
What is the management for ADHD in adults ?
Methylphenidate or lisdexamfetamine
( switch between if no benefit is seen )
What should be performed before starting mediation for ADHD ?
Baseline ECG as the medications can be cardio toxic
What are some causes of death from alcohol ?
Fights and falls
Liver failure
Pancreatitis
Overdose
Withdrawal
Wernicke’s encephalopathy
What are some worrying symptoms in someone has alcohol dependence ?
Head injury
Confusion
Seizures
Hallucinations
Vomit blood
Severe abdo pain
Jaundice
What are some early signs of alcohol withdrawal ?
Tremor
Sweating
Nausea
Anxiety
Tachycardia
What are some late signs of alcohol withdrawal ?
Delirium tremens
Disorientation
Hallucination
Tremor
What is the triad of Wernicke’s encephalopathy ?
Ataxia
Nystagmus / Ophthalmoplegia
confusion
What are some other symptoms of wernicke’s encephalopathy ?
Vomiting
Altered level of consciousness
Fever
Ptosis
What is the treatment for Wernicke’s encephalopathy ?
Parenteral thiamine
What is Korsakoff’s ?
Prominent impairment of recent and remote memory
Immediate recall is preserved
What is seen in an opiate overdose ?
Not much
Pin point pupils
Decreasing consciousness
Slow breathing
Death
What are some signs of opiate withdrawal ( early )
Sweaty clammy skin
Tachycardia
Rhinnorhea
Dilated pupils
Persistent yawning
What are some signs of opiate withdrawal? ( late )
Nausea and vomiting
Diarrhoea
Insomnia
Abdo cramps
Muscle pains
What treatment is used for opiate withdrawal ?
Methadone
Buprenorphine
What is the treatment for benzodiazepines ?
Reduce on own supply
Pregabalin
What are the most common causes of death in stimulants ?
Acute heart attacks and strokes
What causes Wernicke’s encephalopathy ?
Alcoholic malnutrition leads to vitamin B1 deficiency
What are the 2 types of anorexia nervosa ?
Restrictive type
Binge eating / purging type
What are some diagnostic criteria for anorexia ?
Refusal to maintain or achieve normal body weight BMI under 17.5
Intense fear of gaining weight or becoming fat
Body shape disturbance
Undue influence weight an shape on self evaluation
Amenorrhoea
What are some compensatory behaviours in anorexia ?
Purging behaviours
- self induced vomiting
- laxatives
Medications
- diuretics
- slimming aids / fat blockers
What are some diagnostic criteria for bulimia nervosa ?
Recurrent episodes of overeating
Persistent preoccupation with eating and a strong desire to eat ( craving )
The patient attempts to counteract the fattening effects of food by compensatory behaviours
A self perception of being too fat, with an intrusive dread of fatness
What are some features of a binge ?
Subjective loss of control
Large amounts, typically calorie laden ( forbidden food )
Associated with guilt afterwards
Secretive
Alone
What are some compensatory mechanisms for bulimia nervosa ?
Purging
- self induced vomiting and laxative use
Non purging
- exercise
- fasting
How can eating disorders affect the endocrine system ?
Amennorhoea
Sick euthyroid syndrome ( low T4 normal TSH )
How can eating disorders affect the cardiovascular system ?
Myocardial thinning
Bradycardia
Hypotension
Arrhythmias
Cardiomyopathy
Mitral prolapse
Heart failure
How can eating disorders affect the skeletal system ?
Osteopenia / osteoporosis
Fractures
How can eating disorders affect the GI system ?
Delayed gut motility / delayed gastric emptying
Constipation
Mallory Weiss tears
Hepatitis
Pancreatitis
How can eating disorders affect the liver ?
Fatty liver / hepatitis
Liver failure a risk of re feeding
What is the management for anorexia nervosa ?
CBT and MANTRA
What is the management for bulimia nervosa ?
Guided self help for milder cases
CBT
What are the aims of therapy for eating disorders ?
Motivation
Restore to healthy weight
Help patients to cope with life and express themselves without resort to dietary restrictions
Get life back on track
What is the outcome of bulimia nervosa ?
50 - 70 % recover completely
Relapsing and remitting course
Increasing recognition of long term impact on QOL
What is re feeding syndrome ?
It can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial re feeding.
What patients are at risk of re-feeding syndrome ?
Patients with anorexia nervosa
Patients with chronic alcoholism
Oncology patients
Post op patients
Elderly patients
Patient with chronic malnutrition
What can cause patients with delirium tremens to die ?
Respiratory and cardiovascular collapse
Cardiac arrhythmia
What are the symptoms and signs of delirium tremens ?
Severe tremor
Clouding of consciousness
Delusions
Confusion
Tachycardia
Agitation
Fever
Hallucinations
What are some risk factors of delirium tremens ?
Abnormal liver function
Old age
Severity of withdrawal symptoms
Concurrent medical illness
Heavy alcohol use
What is the treatment of delirium tremens ?
Benzodiazepine
- oral Chlordiazepoxide
- IV diazepam or lorazepam
What is the ICD 10 diagnostic guidelines for anxiety ?
Patients must have primary symptoms of anxiety most days for several weeks at a time, and usually for at least 6 months duration.
These symptoms involve :
- apprehension
- motor tension
- autonomic overactvity
What is the management of anxiety ?
CBT
Medication -
First line - SSRI
Second line - SNRI
What is a panic attack ?
A discrete episode of intense anxiety. It starts abruptly, reaches a peak within few minutes (10 minutes ) then starts to subside within 20-30 minutes. The attacks tend to occur spontaneously with no obvious precipitants.
When is the panic disorder graded as severe according to ICD 10 ?
If more than 4 attacks per week in a 4 week period
What is the management of panic disorder ?
CBT
SSRI
What is OCD according to ICD 10 ?
Obsessional symptoms or compulsive acts, or both, must be present for most days for at least 2 successive weeks and be a source of distress or interference with activities.
What are some clinical features of OCD ?
Checking
Washing
Contamination
Doubting
Bodily fears
Counting
What are the 2 types of bipolar ?
Type 1 - characterised by full blown mania or mixed mania or depression
Type 2 - characterised by recurrent depression and hypomania without episodes of either mania or mixed states
What is mania ?
A distinct period of abnormally and persistently elevated and/or irritable mood, with 3 or more characteristic symptoms of mania. The disturbance sufficiently impairs occupational and social functioning.
