Psychiatry Flashcards
What are the concept of neuroses?
- symptoms are understandable and with which one can emphathise
- insight is maintained
- Different to delusions which are not understandable and cannot be emphasised with
- Neuroses are quantitively but not qualitively different from normal
Epidemiology of anxiety, obsessions and stress reactions
- most prodominantly female
- affects up to 10% of all individuals
- comorbidity with depression, substance misuse and personality disorder common
- if individual presents after age 35-40 yrs more likely due to depressive disorder or organic disease
Associated factors of anxiety, obsessions and stress reactions
lower social class, unemployment, divorced, renting rather than owing, no educational qualfications, urban living aetiology
Genetic factors for anxiety, obsessions and stress reactions
Family history often seen, people with high neuroticism scores
Symptoms of anxiety
psychological: fears, worries, poor concentration, irritabiliy, depersonalisation, derealisation, insomnia, night terrors
motor symptoms: restlessness, fidgeting, feeling on edge
Neuromuscular: tremor, tension, headache, muscle ache, dizziness, tiniitus
GI: dry mouth, cant swallow, nausea, indigestion, butterflies, flatulence, frequent or loose motions,
CVS: chest discomfort, palpitations
Respiratory: difficulty inhaling, tight constricted chest
GI: urinary frequency, erectile dysfunction, amenorrhoea
Features of generalised anxiety disorder (GAD)
ICD-10 criteria
Generalised and persistent ‘free floating’ anxiety symptoms:
- apprehension (worries about future, feeling on edge, difficulty concentrating)
- motor tension (restless fidgeting, tension headaches, trembling, inability to relax)
- autonomic overactivity (light-headedness, sweating, tachycardia, epigastric discomfort, dizziness)
Epidemiology of GAD
1.6% suffering from GAD at any one point
very rarely begins after 35
Clinical features of GAD
Depersonalisation, derealisation
Differentials of GAD
- hyperthyroidism (goitre, tremor, tachycardia, weight loss, arrhythmia, exophthalmos)
- substance misuse (intoxication, amphetamines, withdrawal, benzo, alcohol)
- excess caffeine
- depression
- anxious avoidant personality disorder
- early dementia
- early schizophrenia
- phaeochromocytoma (tumour of adrenal glands)
Management of GAD
- Advice and reasurance
- counselling
- self help materials
- CBT
- anxiety management training, relaxation techniques
- Medications: 1st line SSRI or SNRI
- also Busipirone (5HT1A- agonist) short term management
- Beta blockers effective in pts with somatic asthma symptoms (contra-indication in asthma and heart block)
Features of panic disorder
ICD-10 criteria
- recurrent attacks of severe anxiety not restricted to any particular situation or set of circumstances and therefore unpredictable
- secondary fears of dying, losing control, or going mad
- attacks usually last for minutes, often crescendo of fear and autonomic symptoms
- comparative freedom from anxiety symptoms between attacks
Epidemiology of panic disorder
1-2% general population
2-3x more common in females
bimodal: peaks at 20yo and 50yo
agoraphobia occurs in 30-50%
risk of suicide raised when comorbid depression, alcohol misuse or substance misuse
Clinical features of panic disorder
breathing difficulties
chest discomfort
palpitations
tingling or numbness in hands, feet or around mouth
shaking, sweating, dizziness
depresonalisation, derealisation
can lead to fear of situation
conditioned fear of fear pattern develops
Differentials for panic disorder
other anxiety disorders: GAD, agoraphobia
depression
alcohol or drug withdrawal
organic cause: CVS or resp disease
hypoglycaemia, hyperthyroidism, phaeochromocytoma
psychological management of panic disorder
reassurance
CBT 1st line
initial education about nature of panic attacks and fear of fear cycles
cognitive restructuring, detecting flaws in logic
interoceptive exposure techniques
secondary agoraphobic avoidance: treat by situational exposure and anxiety management techniques
Drug management of panic disorder
SSRIs 1st line
clomipramine (tricyclic with similar action to serotonin)
Features of mixed anxiety and depressive disorder
ICD-10 criteria: symptoms of anxiety and depression are both present but neither clearly predominates
treat with counselling, CBT or psychotherapy, interpersonal therapy
SSRIs medication
Features of specific/isolated phobias
icd-10 criteria: restricted to highly specific situations: proximity to certain animals, heights, thunder, flying, blood etc
often clear in early adulthood
result in avoidance
Features of agoraphobia
ICD-10 criteria: fear not only open spaces but also of related aspects such as presence of crowds, difficulty of immediate easy escape back to a safe place
common in 20s or mid 30s
may be gradual or precipitated by a sudden panic attack
comorbid depression common
higher incidence of sexual problems
Differentials of agoraphobia
Depression
Social phobia
OCD
Schizophrenia
Features of social phobia
most common anxiety disorder
ICD-10 criteria: fear of scrutiny by other people in compartively small groups, leading to avoidance of social situations
may be specific (public speaking) or generalised (any social setting)
physical symptoms: blushing, fear of vomiting
Symptoms: blushing, palpitations, trembling, sweating
can be precipitated by stressful or humiliating siutations: death of parent, seperation, chronic stress
Differentials for phobias
Shyness
agoraphobia
anxious personality disorder
poor social skills/autistic spectrum disorder
benign essential tremor
Investigations of phobias
history and exam
rating scales of anxiety
social and occupational assessments for effect on quality of life
Collateral hx
Management of phobias
Behavioural therapy is treatment of choice
Exposure techniques: flooding, modelling
Agoraphobia and panic disorders: CBT
Social phobia: CBT
Drug management:
- SSRIs and MAOIs (phenelzine) most useful in agoraphobia and social phobia
- tricyclics best for those with depressive component
- Benzodiazepines can be used before a phobic situation
B-blockers useful if somatic symptoms present
A 25 year old student presents to the GP complaining of palpitations. He describes them as his heart suddenly beating very fast and sometimes it feels like it skips a beat. When this happens he also feels dizzy, as though he may faint, but never has. They have occurred on occasion during exercise. He tells you they are very worrying and he feels ‘on edge all the time’.
He has no past medical history and there is no relevant family history. He smokes 5 cigarettes a day, occasionally uses marijuana and admits to drinking in excess on weekends because of ‘student life’.
examination, his observations and a cardiovascular examination are normal.
What is the most important next step management?
Refer for 48-hr holter monitor ECG
Generally all pts who present with new onset of palpitations with no clear cause should be referred for further investigation.
1st line is 24 or 48 hr holter monitor ECG.
A 49 year old woman presents to her GP with a 9 month history of nervousness. She feels generally tense and worried most of the time, experiencing palpitations, muscular tension, and fears of something bad happening to her on a daily basis. She is able to continue with her usual activities and this is the first time she has sought help. What is the most appropriate intervention?
psychoeducation and active monitoring
Nice suggests that treatment for GAD is a step approach. Step 1 is to provide education on this condition and its treatment options as well as active monitoring.
Diagnostic criteria for depression
DSM-5
1. depressed mood or irritable most of the day (nearly every day, feels sad or empty, appears tearful)
2. decreased interest or pleasure (anhedonia)
3. significant weight change (5)% or change in appetite
4. change in sleep
5. change in activity
6. fatigue
7. guilt/worthlessness
8. concentration
9. suicidality
if 5 of these are present, for nearly every day for 2 weeks or longer then a diagnosis of depression can be made
Risk factors for depression
female gender
past hx of depression
significant physical illness
other mental health problems
social issues (divorce, unemployment, poverty)
Investigations for depression
history and screening questions
further tests may be required: thyroid function tests, FBC, metabolic panel, brain imaging
Organic differentials for depression
- neurological: Parkinson’s, dementia, multiple sclerosis
- endocrine disorder: thyroid dysfunction, hypo/hyperadreanlism (cushing’s and addison’s disease)
- drugs (steroids, isotretinoin, alcohol, beta blockers, benzodiazepines, methyldopa
-chronic conditions: diabetes, obstructive sleep apnoea - neoplasms and cancers
psychiatric differentials of depression
bipolar disorder
schizophrenia
dementia
seasonal affective disorder
bereavement
anxiety
initial management of depression
1st line - low intensity psychological interventions or group based CBT
then move onto either pharmacological therapy or high intensity psychological intervention such as CBT or interpersonal therapy
pharmacological therapy should start with an SSRI such as sertraline
Severe depression, lithium can be augumented (after trying therapy and medication together)
Electroconvulsive therapy is recommended by nice for severe depressive episodes that are life threatening or require rapid response
Depression in children
CAHMs
full assessment
psychological therapy 1st line
Fluoxetine 1st line antidepressant in children followed by sertralin and citalopram
What is a delusion of guilt?
characterised by belief that one deserves to be punished. Usually the sin is an innocent error out of proportion to the guilt felt. Typically associated with severe depression.
What is a delusion of persecution
paranoid delusions. patients believed they are being followed, spied on or conspired against. Classically seen in schizophrenia.
What is delusion of grandeur?
Characterised by exaggerated beliefs about one’s self worth, power or identity for example believing one is a king or queen. Classically associated with mania.
What is delusion of thought posession?
false beliefs surrounding ownership of your own thoughts. Subdivided into insertion, withdrawal and broadcasting. Classically seen in schizophrenia.
What is cotard’s syndrome?
rare syndrome seen in severe depression, where the patient believes they are dead, decaying or do not really exist.
A 50 year old man attends the GP for a mental health review. He was diagnosed with moderate depression two months ago after losing his job and has been taking Sertraline since then. He tells you he feels much better now, he is eating and sleeping well, and that he is finally ready to stop taking medication. He no longer has thoughts of self-harm, and he has started looking for work. You concur that his mood is much improved in clinic today.
What is the most appropriate advice to give regarding cessation of treatment?
To continue sertraline for a further six months
NICE recomends antidepressants should be continues for at least six months AFTER the patient recovers to reduce the risk of relapse.
What is phaeochromocytoma?
A catecholamine secreting tumour that arises in the adrenal medulla.
What are the symptoms of an phaeochromocytoma?
episodic hypertension
anxiety
weight loss
fatigue
Palpitations
Sweating
headaches
flushing
pyrexia
dyspnoea
abdominal pain
What are the signs of a phaeochromocytoma?
hypertension
postural hypotension
tremor
hypertensive retinopathy
What are the precipitants of a phaeochromocytoma?
stress
exercise
surgery
straining and various drugs e.g beta blockers
anaesthetic agents and opiates
Investigations for a phaeochromocytoma?
Establish catecholamine excess using tests with adequate sensitivity and specificity
plasma metanephrines followed by urinary metanephrines have best diagnostic accuracy
adrenal imaging should not take place until biochemical diagnosis has been made
Management of a phaeochromocytoma?
Resect the tumour
pre operatively: alpha blockade with phenoxybenzamine is started first followed by consideration of beta blockade to expand blood volume and prevent hypertensive crisis
What does high catecholamine levels do in the body?
High circulating catecholamine levels stimulate alpha receptors on blood vessels and cause vasoconstriction
Why is phenoxybenzamine (a non selective alpha blocker) used in the 1st line management of somebody with phaeochromocytoma?
used prior to surgery to control hypertension and prevent a hypertensive crisis.
A disadvantage to phenoxybenzamine is that is blocks presynaptic alpha-2 receptors enhancing the release of noradrenaline, resulting in reflex tachycardia.
A 65 year old gentleman is diagnosed with Medullary Thyroid Carcinoma, he has previously had a history of palpitations, sweating and malignant hypertension.
What is the most likely underlying condition?
Multiple endocrine neoplasia type 2 b
The abdo surgery here points to phaeochromocytoma, which is idiopathic up to 30% but can also be caused due to underlying inherited syndromes such as multiple endocrine neuromas.
A 54 year old female with type 1 diabetes is under investigation in the endocrine clinic as she has been having palpitations, excessive sweating, losing weight and has been receiving treatment for high blood pressure, hay fever, T1DM and is on the oral contraceptive pill. She has a healthy diet and eats a lot of fruit and vegetables.
She is thought to have hyperthyroidism, but her thyroid function tests are normal.
The registrar suspects that she may have a phaeochromocytoma and wishes to investigate her.
What should be discontinued prior to her further investigations?
methyldopa - an antihypertensive drug (pempidene e.g), as it interferes with the catecholamine system and can lead to a spurious result and a failure to correctly diagnose adrenergic tumours.
Stimulants, dopamine agonists and several food stuffs (cocoa) should also be avoided while testing for this condition
In a young person with high BP, sweating, anxiety and maybe a generalised constant headache, what suspicion should you have?
phaeochromocytoma
What is a mental disorder
any disorder or disability of the mind (excluding alcohol and drugs)
What are the principles of the mental health act
minimise restrictions on liberty
public safety
others - pt wellbeing and safety
What’s first line for depression?
SSRI - citalopram, fluxetine, paroxetine, sertraline
Types of SNRI
mirtazapine, venlafaxine, duloxetine
Types of tricyclics
amitriptyline, imipramine, anticholinergic
Types of monoamine oxidase inhibitors
iproniazid, phenelzeine
What’s seasonal affective disorder
recurr annually at same time each year.
Mx: light therapy, SSRI
What’s dysthymic disorder?
lasting >2yrs, subthreshold depressive symptoms.
Mx: SSRI, CBT
What’s postnatal depression?
peak 3-4wk postpartum.
Mx: CBT, SSRI - if breastfeeding, paroxetine /sertraline preferred
What are the different types of bipolar affective disorder?
type 1 - mania + depression
Type 2 - hypomania
+ depression
cyclothymic disorder - recurrent depressive and hypomanic states lasting >2yrs
What is mania (in bipolar affective disorder)
mania >1 week, impaired functioning +/- psychosis.
Irritability/elevated mood, distractibility, inhibition loss, grandiosity, flight of ideas, activity increased, sleep not needed, talkative (pressure of speech)
What is hypomania in bipolar affective disorder
4+ days, doesn’t affect functioning
elevated mood, increased energy, increased talkativeness, poor concentration, mild reckless behaviour, sociability / ovarfamilarity, increased libido, increased confidence, decreased sleep
Management for bipolar
psychosocial - psychotherapy - CBT, interpersonal therapy, social/family/financial support
Medications - mood stabilisers (lithium), sodium valporate (not for women of childbearing age), carbamazepine
antidepressants - SSRIs
antipsychotics - olanzapine, risperidone
emergency - acute mania: quetiapine + lithium +/- benzodiazepines
Dx of anorexia nervosa
SCOFF screening tool
Low body weight BMI <17.5
self induced weight loss: calorie restrictions, vomiting, laxatives, excess exercise
- body image distortion
- endocrine disorders: HPA axis: amenorrhoea, decreased libido, delayed/arrested pubery
- social withdrawal
Complications of anorexia nervosa
oral: dental caries
CVS: hypotension, long QT, arrhythmia, bradycardia, cardiomyopathy
Endocrine: hypokalaemia, hyponatreamia, hypoglycaemia, hypothermia, altered TFTs, increased cortisol, increased growth hormone, amenorrhoea, osteoporosis, osteopenia
dermatology: dry scaly skin, brittle hair, fine body hair
haem: anaemia, leukopenia, thrombocytopenia
Management of anorexia nervosa
refer to community based ED service if eating disorder suspected
psychological: CBT, MANTRA, family therapy
- oral multivitamins
- prevent refeeding syndrome by: electrolytes monitoring, thiamine supplements, slow refeeding
Mx: IV electrolyte replacement, monitor bloods and ecg
What is the presentation for PTSD
hyperarousal
emotional numbing
avoidance
reliving situation
Positive symptoms of schizophrenia
delusions, hallucinations, formal thought disorder, thought interference, passivity
‘delusions held firmly think psycho’
Negative symptoms of schizophrenia
A6C
anhedonia, affect blunted, asocial, alogia, attentia deficit, avolition, catatonia
ICD10 group A schizophrenia
delusion perception
3rd person audio hallucination
thought interference
passivity
ICD 10 group b schizophrenia
2nd person audio hallucination
negative symptoms
other delusions
Investigations for schizophrenia
CT/MRI head
bloods(FBC, U+E, LFT)
B12 + folate
Toxicology
Hx + MSE
Atypical antipsychotics
1st line - improves negative symptoms, more tolerable
Quetiapine, aripriprazole, olanzapine, clzapine, risperidone
Side effects of atypical antipsychotics
raised glucose, T2DM, stroke, metabolic syndrome, weight gain
Side effects of clozapine
hypersalivation, agranulocytosis (fever, chills, weakness, tachycardia, hypotension)
Side effects of risperidone
hyperprolactinaemia
What are typical antipsychotics
haloperidol, chlorpromazine, flupentixol (depo for pts that don’t like oral tablets)
Side effects for typical antipsychotics
parkinsonism
akathisia
dystonia
tardive dyskinesia
Side effects for both typical and atypical antipsychotics and what needs monitoring
antimuscarinic (can’t see, can’t pee, can’t shit, can’t spit)
neuroleptic malignant syndrome
prolonged QT
Needs monitoring: FBC, prolactin, U+E, ECG, LFT, Hb1AC
Types of schizophrenia
- paranoid - just positive symptoms
- post-schizophrenic depression: depression with schiz hx in last 12 months
- hebephrenic: thought disorganisation
- catatonic: 1 or more negative symptoms
- simple: no psychotic symptoms, with neg symptoms
- undifferentiated: meet dx criteria but doesn’t fit other types
- residual: neg symptoms lasting one year following psychotic episode
What is the definition for personality disorders?
enduring pattern of behaviour different to expectation of pt’s culture
What are the different clusters of personality disorders?
Cluster A: weird
- paranoid (jealous, suspicious)
- schizoid (reduced emotions, no close friends)
Cluster B: Wild
- EUPD (unstable relationships, fear of abandonment, suicidal, poor anger control)
- Histronic (vain, attention seeking)
- dissocial (deceitful, callous, violent)
Cluster C: worriers
- dependent (low self confidence, needs reassurance and companionship)
- anxious (feels inadequate, social inhibitions, needs to be certain they are liked)
- anankastic (workaholic, perfectionist, stubborn)
What is 1st line management for EUPD?
DBT
ICD 10 criteria for addiction and substance misuse
- acute intoxication
- harmful use
- dependence
- withdrawal symptoms
- psychotic disorder
- amnesia
- residual disorder
Investigations for addiction and substance misuse
MSE, physical exam
bloods,
urine toxicology
CXR, ECG, echo
What is treatment for opioid dependence (detox)?
methadone / buprenorphine/dihydrocodeine
What is treatment for opioid dependence (relieve withdrawals)?
lofexidine
What is treatment for opioid dependence (prevent relapse)?
naltrexone
What is treatment for opioid dependence (overdose)?
naloxone
Smoking cessation treatments
- to stop - NRT
- reduce craving - varenicline
- to reduce pleasure - bupropion
Assessment and investigations in alcohol abuse
AUDIT, CAGE, SADQ, FAST, CT head, ECG, bloods
How to treat alcohol withdrawal?
PO chloridiazepoxide + IV thiamine
Long term treatment for alcohol abuse, pharmacological and non-pharmacological
pharm: disulifram (induces bad symptoms when drinking alcohol), Acamprosate (reduces cravings), naltrexone (reduces pleasure).
Non-pharm: CBT + motivational interview , AA meetings, family support
What is neuroleptic malignant syndrome?
Adverse reaction to antipsychotics (DAR agonist), or abrupt domaminergic withdrawal (levodopa)
What are the symptoms of neuroleptic malignant syndrome?
confused, hyperthermic, tachycardic, HTN or hypotensive
Investigations for neuroleptic malignant syndrome
bloods, imagine, infection screen
Management for neuroleptic malignant syndrome
stop antipsychotics, dantolene, bromocriptine, BZD, IV fluids
Complications of neuroleptic malignant syndrome
PE, renal failure, Shock
what is serotonin syndrome?
high synaptic concentration of serotonin caused by SSRI/SNRI, opioids, MAOi, lithium, TCA
Symptoms of serotonin syndrome
confused, hallucinations, tremor, hyperreflexia, HTN, tachycardia, hyperthermia, sweating, shivers
Treatment for serotonin syndrome
stop meds that are causing it, supportive treatment.
If SSRI overdose - activated charcoal
What is a differential of serotinin syndrome and how to differentiate
neuroleptic malignant syndrome
WCC is high in NMS, normal in serotonin syndrome
What is acute dystonic reaction
caused by typical antipsychotics
Symptoms of acute dystonic reaction
painful contraction in the:
eyes - oculogyric crisis, neck - antero/latero/retro/torticollis
- jaw
How to treat acute dystonic reaction
procyclidine
What are complications of alcohol withdrawal
Wernicke’s encephalopathy - due to acute thiamine deficiency
Korsakoff’s psychosis - due to untreated WE
Symptoms and treatment for Wernicke’s enceophalopathy
sx: delerium, nystagmus, hypothermia, ataxia
treatment: Pabrinex (IV thiamine)
symptoms and treatment of Korsakoff’s psychosis
sx: irreversible short term memory loss, confabulation, disorientation to time
treatment = pabrinex (IV thiamine)
What is delerium tremens
72 hrs after alchol cessation
Symptoms of delerium tremens
cognitive impairment, lilliputian hallucination, paranoid delusion, tremor, fever, tachycardia, sweating, dehydration
Treatment for delirium tremens
pabrinex (IV thiamine), lorazepam (both 1st line)
if psychotic features give IM haloperidol (contraindicated if Lewy Body D or Parkinson’s D)
What is lithium toxicity
too much lithium in blood.
Caused if lithium in blood> 1.5mmol/L
Symptoms of lithium toxicity
TOXICCC
tremor (coarse), oliguric renal failure, ataxia, increased reflexes, convulsions, coma, consciousness reduced
Treatment for lithium toxicity
stop lithium immediately, high fluid + IV NaCl
if severe, renal dialysis
How do the kidneys get damaged in lithium toxicity
renal damage due to lithium action on parathyroid -> increased PTH -> increase Ca2+ -> kidney damage
You can treat patients without their consent under the section 2 mental health act.
T/F?
true
Which is 1st line for pt with new diagnosis of depression?
paroxetine, amitryptiline, propanalol, venlafaxine, quetiapine?
paroxetine
What mood stabaliser should be avoided in women of childbearing age?
Sodium valporate
A 20yr old finding it difficult to concentrate last few weeks, has exams coming up. Most likely diagnosis?
Situational anxiety
What biochemical changes would you expect to see in someone with anorexia nervosa?
hypercortisolaemia
What’s the cause of alcohol withdrawal symptoms?
CNS hyperexcitability
What is bipolar affective disorder
mental disorder characterised by periods of depression and periods of elevated moods (mania)
Clinical features of bipolar affective disorder
periods of depression - withdrawn, tearful, low mood, poor sleep and anhedonia. Suicidal attempts or thoughts
manic episodes - elevated mood or irritability. Impulsive or dangerous decisions with little thought of consequences. Need for sleep often reduced. Pressured speech and flight of ideas
Dx criteria bipolar affective disorder
at least 1 episode of a manic or hypomanic state and one major depressive episode
What is mania?
distinct period of abnormally and persistent elevated, expanisive or irrtiable mood. Must last at least 1 week and have at least 3 of following sx:
- elevated self esteem
- reduced need for sleep
- increased rate of speech
- flight of ideas
- easily distracted
- increased interest in goals or activities
- pyschomotor agitation (pacing, hand wringing etc)
- increased pursuit of activities with high risk of danger
What is hypomania
the episode should not be severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitlisation, no psychotic sx
What is depression in DSM criteria for bipolar affective disorder
major depressive episode must have at least 4 of sx: and should be new or suddenly worse and must last for atleast 2 weeks
- changes in appetite or weight, sleep, psychomotor activity
- decreased energy
- feelings of worthlessness or guilt
- trouble thinking or concentrating or making decisions
- thoughts of death or suicidal plans or attempts
Acute mx of acute mania with agitation in bipolar affective disorder
IM therapy
Neuroleptic or a benzodiazepine
urgent admission to secure unit
Acute mx of acute mania without agitation in bipolar affective disorder
oral monotherapy can be attempted with antipsychotic (risperidone)
sedation and mood stabiliser such as lithium can be added if necessary
mx of acute depression in bipolar affective disorder
mood stabiliser and/or antipsychotic and or antidepressant with appropiate psychosocial support
long term follow up and maintance therapy
Chronic mx of bipolar affective disorder
high risk of relapse into either depression or mania
Require careful follow up and ongoing maintainence
lithium - gold standard
valporate - 2nd line
CBT, interpersonal therapy or couples/family therapy
A 35-year-old banker with bipolar affective disorder is admitted to hospital after being found behaving unsafely on a busy road, stepping in front of cars. She is thought to be having a manic relapse, and it is agreed that lithium is the best treatment option for her.
Which of the following blood tests should be performed when starting lithium?
Thyroid function tests - important to measure baseline before starting lithium, can interfere with thyroid function. untreated hypothyroidism is CI for lithium.
Also necessary to measure U&Es inc Ca and eGFR and FBC
What are sensory depictions
illusions
Hallucinations
Define illusion
misperception of a real life stimuli
Define hallucination
perception of something that isnt there - without stimuli
What are 2nd person auditory hallucinations
voices directly talking to the person
What are 3rd person auditory hallucinations
running commetary, voices talking about that person but not directly to them
What is an extracampine hallucination
hallucination that is outside the limits of the sensory field e.g someone talking in paris
What are hypnagogic and hypnapopmic hallucinations
hallucinations that occur when someone is falling asleep or waking up (respectively(
What is flight of ideas thought disorder
disorder of tempo
thoughts racing and following each other rapidly, not necessarily related
What is circumstantiality thought disorder
ideas get around and round, taking a long time to get to the point
What is thought insertion?
someone planting thoughts inside your head
What is thought withdrawal?
thoughts have been taken out of your head
What is thought broadcasting?
other people can hear your thoughts
disorders of content of thoughts: delusions. What is a eromatic delusion?
Thought that a person is in love with you - dangerous as you may attempt to contact them - stalking, could be someone you’ve never met
What is a grandiose delusion
pt experiencing thoughts that they are better than others, can be power, worth or wealth
What is persectory delusion
believe that they or someone close to them is mistreated or people are spying on them to hurt them
What is a nihilistic delusion
pt denies the existant of their body, mind, loved ones and the world around them
What is the DSM IV & V criteria for personality disorder
enduring pattern inner experience and behaviour
deviates from cultural expectation
pervasive and inflexible
onset adolescence/ early adulthood
stable over time
leads to distress
impairments in SELF and INTERPERSONAL function
What are cluster A personality disorders
‘odd and ecentric’
Schizoid
paranoid
schizotypical
What are cluster B personality disorders
dramtic or erratic
emotionally unstable
histrionic
narcissitic
dissocial
What are cluster C personality disorders
anxious or fearful
obsessive- compulsive
dependent
avoidant
Clinical features of EUPD
Impulsivity - acts without thinking of consequences, substance misuse, disordered eating, risky sexual behaviours, self harm, overspending
Intense unstable relationships
Fear of and attempts to avoid abandonment
unstable mood
chronic feelings of emptiness
thoughts of suicide and self harm
uncertainty around self image, aims and preferences
Differentials of EUPD
Bipolar affective disorder
neurodevelopmental disorders (autism, ADHD) - esp in women
psychosis (schizophrenia, schizoaffective disorder)
complex ptsd
Mx in EUPD
validating, compassionate services
consistency
DBT gold standard
Forms of DBT (dialectical behaviour therapy)
self soothing techniques
distraction techniques
wise mind vs emotional mind
radial appearance
group with individual support
course
Risk factors for schizophrenia
bimodal age distribution
family hx
pre-morbid schizoid personality
abuse
delayed developmental milestones
obstetric risk fx
substance abuse
sig life event
cerebral injury
acute psychosis
sx of schizophrenia
appearance & behaviour (MSE) - bizzaire, disorganised, catatonic
mood: anhedonia, depression, blunting, neg symptoms prodromal
speech: pressured, distractable
Thoughts: delusions, thought alienation (insertion, withdrawal, broadcast)
perception: auditory hallucinations - 2nd or 3rd person
passivity: feelings, impulses, acts
insight: present or absent
invx for schizophrenia
full hx and MSE
Exclude differentials - bipolar, substance misuse, psychotic depression, personality disorder, schizoaffective disorder
CT/MRI head
Toxicology screen
Bloods - FBC, U&E, LFT
Mx for schizophrenia
atypical or typical antipsychotics (normally atypical 1st)
atypical: risperidone, quetiapine, olanzapine, clozapine
typical: haloperidol, chlorpromazine
Side effects of antipsychotics
extra-pyramidal sx: akathisia, tardive dyskinesia, dystonia (parkinsonism sx)
metabolic: weight gain, diabetes, liver dysfunction
general: dry mouth, constipation, sexual dysfunction, ECG changes
Monitoring while on antipsychotics
FBC, prolactin, U&E, LFT, ECG, HbA1c, weight measurement
Side effects of risperidone and clozapine
risperidone: hyperprolactinaemia
Clozapine - agranulocytosis, cardiomyopathy
What is bipolar disorder
Depression + mania/hypomania occuring in episodes with months separating them.
dx: at least 1 episode of mania or hypomania
What is mania and give examples of sx
elevated, expansive, euphoric or irritable mood with > 3 sx for most days for 1 week
- elevated mood, increased energy
- pressure of thoughts, flight of ideas, pressure of speech, word salad
- increased self esteem and reduced attention
- tendency to engage in risky behaviour
- marked disruption of work, social activities and family life
What is hypomania and give some examples of sx
> 3 sx lasting >4 days and be present most days almost every day
- shares mania sx
- symptoms evident to lesser degree
- not severe enough to interfere with social or occupational functioning #
- does not result in hosp admission
- no psychotic features
What is bipolar 1 disorer
characterised by episodes of depression and mania or mixed and states separated by periods of normal mood
What is bipolar 2 disorder
Do not experience mania but have periods of hypomania, depression or mixed states
What is cyclothymic disorder
characterised by recurrent depressive and hypomania states, lasting for 2 years that do not meet diagnostic criteria for major affective disorder
Pharmacological treatment for bipolar disorder
manic episodes: lithium +/- benzodiazeoine (clonazepam, lorazepam)
Depressive episodes: SSRI
maintanence: lithium
Lithium side effects
weight gain, subclinical/clinical hypothyroidism, renal impairment, teratogenic
Non-pharm tx for bipolar disorder
psychoeducation
CBT
IPT
support groups
1st line treatment of a manic episode
olanzapine or aripiprazole
What is a Fregoli delusion
fixed, false belief that strangers are familiar to the individual and may even be all the same person
Which antidepressant class is contra-indicated in previous heart disease
Anti-tricyclic antidepressants
What are 1st rank sx in psychosis
thought alienation
passivity phenomena
3rd person auditory hallucinations
delusional perception
What are 2nd rank sx in psychosis
delusions
2nd person auditory hallucinations
hallucinations in any other modulality
thought disorder
catatonic behaviour
negative symptoms
Management for opioid addiction
substitue prescribing/detoxification: methadone, buprenorphine, dihysrocodeine
withdrawal sx relief: lofexidine
Relapse prevention: nalrexone
Overdose: Naloxone
Sx of alcohol withdrawal
6-12hrs after drink: malaise, tremor, nausea, insomnia, transient hallucination, autonomic hypersensitivity
36hrs: seizures
72 hrs: delerium tremens
Sx of delirium tremens
dehydration +/- electrolyte dysfunction
cognitive impairment
hallucination/illusion
paranoid delusion
marked tremor
autonomic arousal
What is Wernicke’s encephalopathy, what is presentation and management
thiamine defiency
ataxia, delierium, hypothermia, nystagmus, ophthalmoplegia
IV pabrinex (thiamine)
What is Korsakoff’s syndrome
inability to lay down new memories
working memory impaired with confabulation
ante/retrograde amnesia
disorientation to time
Mx for alcohol withdrawal/addiction
1st line: chloradizepoxide + IV thiamine
maintainence and relapse prevention: acamprosate, naltrexone or disulfiram
Motivational interviewing/CBT
AA
Causes of delerium
drugs and alcohol (Anti-cholingeric, anti-convulsants, recreational)
Eyes, ears, and emotional
Low output state (MI, ARDS, PE, CHF, COPD)
Infection
Retention or urine or stool
Ictal
Underhydration, under nutrition
metabolic (electrolyte imbalance, thyroid, Wernickes
Subdural haemorrhage, sleep deprivation
Causes of neuroleptic malignant syndreom
Anti-psychotics
Causes of serotonin reuptake syndrome
SSRIs
Low levels of which neurotransmitter are associated with the development of anxiety
Gamma-aminobutyric acid (GABA)
inhibitory effect on the brain and reduced neuronal excitability.
Reduced GABA, means reduced inhibitory effect, allowing neurones to activate at an increased rate
A 50-year old man presents to the Emergency Department. He is known to be a heroin user.
On examination he is unresponsive and has pin-point pupils.
His heart rate is 58bpm, blood pressure 108/62mmHg, respiratory rate is 6/minute and oxygen saturations 94% on room air.
What is the first initial step in management?
pt suffering from morphine overdose; reduced responsiveness, pinpoint pupils, resp depression.
Mx: Naloxone
Mx of moderate-to-severe OCD
SSRI ; sertraline
A 33-year-old man presents to the Emergency Department with self-harm behaviours. He had made a few cuts on both of his forearms following a quarrel with his girlfriend because she wanted to end the relationship. He says it is wrongful for her to have a new partner. His family says he is verbally abusive to his girlfriend if she does not do what he wants. He defends himself by saying that he only does this for his girlfriend’s good and has done nothing wrong. He has been arrested a few times when he attacked other rival supporters at rugby matches. He says his mood is ‘okay’ and is adamant about getting his girlfriend back. His family says his personality has been the same since he was a teenager.
Which is the most likely diagnosis?
dissocial personality disorder - lack of remorse, being easily angered, impulsivity, being callous and a tendency to blame others.
What is dissocial personality disorder
lack of remorse, being easily angered, impulsivity, being callous, tendency to blame others.
People with dissocial may have intense relationships, and a hx of criminality.
Suicidal behaviours are not uncommon in people with dissocial personality disorders.
A 26-year-old woman presents with a 2-month history of amenorrhoea. She previously had regular menstrual cycles. She is sexually active and uses barrier contraception but admits that she has reduced libido. She has gained over 3 kg in weight over the past 3 months. She was diagnosed with bipolar affective disorder 3 months ago and is taking risperidone. She denies having symptoms of mania or depression. Her urine pregnancy test is negative.
Which is the most appropriate investigation to confirm the diagnosis?
prolactin
hyperprolactinaemia - side effect to risperidone (anti-psychotic)
Which subtype of dementia is caused by the misfiling of beta-amyloid proteins, which accumulate to form plaques in the brain, causing neuronal death and loss of cortex which can be seen on an MRI scan.
Alzheimer’s
A 23 year old woman with a 12 month history of Anorexia Nervosa is admitted to the acute medical unit, due to rapid recent weight loss and concerns about her very low calorie intake (less than 500 kcals per day). In the absence of the ward dietitian, she is initiated on a mealplan of 2000kcal per day. After 3 days, she develops tachycardia and pedal oedema. What is the most appropriate treatment?
Phosphate replacement - refeeding syndrome.
What is refeeding syndrome?
Nutritional intake resumed too rapidly after a period of low caloric intake.
Rapidly increasing insulin levels leads to a shift of potassium, magnesium and phosphate from extracellular to intracellular spaces.
Must be treated with phosphate replacement.
A 78-year-old woman is on the ward after a hemicolectomy. She is not rousable, is flushed and has excoriations over her hands. She has decreased bowel sounds and a respiratory rate of 8 breaths per min.
What is the best treatment?
Naloxone boluses titrated
Opiate overdose.
Pruritis arises from histamine release that morphine can provoke and low resp rate due to depressive effects of opiate.
Naloxone is lipophilic non-selective and competitive opioid receptor antagonist and is required to reverse opioid overdose.
What is naloxone?
Naloxone is lipophilic non-selective and competitive opioid receptor antagonist and is required to reverse opioid overdose.
A 39 year old man presents to A&E saying that he feels unwell. He appears drowsy and confused. On further questioning he admits to having injected heroin. On examination his vital observations are: pulse 40bpm, respiratory rate 10/min, temperature 37.0 degrees, BP 126/84, O2 sats 98% on room air. He has constricted pupils and there is evidence of needle marks in his left antecubital fossa and an abscess around this area.
What is he presenting with?
opiate intoxication
She sometimes forgets where she was going when she is deep in thought about her husband. She sometimes sees her husband in the crowds.
Her appetite is normal, and she has not lost weight. She lives alone and manages housechores on her own. Her son and grandchildren visit her once a week, and they will usually have dinner together. She does not have suicidal thoughts or plans.
What is the most likely diagnosis?
uncomplicated grief
waves of low mood when reminded of husband, preoccupation with thoughts about husband and wishes she had done something better for him.
Common for those in grief to have transient visual hallucinations.
Follow up is essential to observe for potentially signs of depression
A 34 year old man with paranoid schizophrenia was started on Risperidone 6 months ago. He presents to his GP complaining of development of breast tissue, loss of libido and erectile dysfunction and blood tests show hyperprolactinaemia. Which medication is the most appropriate to change to?
Aripiprazole
- hyperprolactianemia - stop causative agent (risperidone), start new antipsychotic, Aripiprazole is one antipsychotic with a much lower risk of inducing hyperprolactaemia
Serotonin syndrome vs neuroleptic malignant syndrome (NMS)
Both have similar clinical features - restlessness, diaphoresis, clonus, hyperthermia, rigidity
SS - antidepressants; SSRI
NMS - antipsychotic
SS - acute onset - hours
NMS - gradual onset e.g days or weeks
A 16 year old girl attends the GP asking for laxatives. When asked why, she tells you that she has been constipated for some time. She refuses to be examined, but you notice calluses on her knuckles. On further questioning, she becomes tearful and eventually tells you that she needs the laxatives to lose weight because she is ‘fat and ugly’. She describes feeling like she ‘loses control’, eating large amounts of snack foods, and feels remorseful afterwards. She knows all her problems would go away if she could ‘just be skinny’. You calculate her BMI to be 25.
Which of the following clinical features points to a diagnosis of bulimia nervosa rather than anorexia nervosa?
BMI of 25
Anorexia normally 17.5
Bulimia - normally normal weight range (18.5-30)
A 38-year-old male is found wandering around the ward. He seems very distant and is hard to interact with, but he allows nurses to sit with him for the evening. He talks about how life is a pointless pursuit, and now he is on the ‘other side’, everything suddenly makes sense. When asked what he means about being ‘on the other side’, he tells the nurses he died last week and has been living in the afterlife since. No amount of reasoning or demonstration from the nurses can convince him he is still alive.
What delusion is being demonstrated here?
Cotard delusion
Rare, pt believes they are dead or have had their organs removed.
A 23-year-old woman presents to the Emergency Department with a 1-hour history of dizziness and sweating. She is known to suffer from anorexia nervosa. Her capillary blood glucose is 3.1 mmol/l, and she is being treated for hypoglycaemia. Based on the initial assessment and blood tests, she has a number of significant risk factors for severe illness and requires inpatient treatment. However, she refuses further treatment, as she believes she has no illness and wants to leave the Emergency Department despite knowing the possible risks of treatment refusal.
Which is the most appropriate section in the Mental Health Act applicable in this situation?
section 4
emergency section, pts can be detained up to 72hrs at outpatient services including emergency department.
Done by doctor or approved mental health professional or nearest relative.
A 23-year-old male has created concern among his family. They say he has very few friends and chooses to spend the majority of his time during the day alone in his room. They say he had one girlfriend when he was 19, but this was a very short-term relationship. However, they say he dresses sensibly, and with family, he can hold a conversation but does not participate in family activities and rarely shows affection. He does well in university, where he studies computer programming, but does not attend anything bar his classes, and when prompted to do so by his family, he states ‘he doesn’t care about all that stuff’. His positive feedback is met with indifference, even though he is top of the year. They are worried he could be depressed.
What personality disorder is this patient most likely to have?
schizoid
pt not experiencing disturbances in thought or any hallucinations. Logical thought pattern that enables him to have conversations with family.
Choosing to withdraw, avoiding family, not showing affection towards them.
Indifference to praise is another significant symptom.
1st line mx for Panic disorder
SSRI - escitalopram, sertraline, citalopram, paroxetine
Venlafaxine can also be used
Police section used to detain somebody for violent behevahiour in public
Section 136 allows police officer to section a person suspected of having a mental disorder in a public place - can be held for 72 hrs
What is a Ekbom syndrome delusion?
pt believes been infested with parasite
crawling sensation on skin
psychological or B12 defieciency
What is Fregoli delusion
pt believes everyone they meet is same person in different disguises
associated with injury to right frontal area, left temporoparietal areas or fusiform gyrus
What is cotard delusion
pt believes they are dead or had organ removed
What is capgras delusion
misidentification syndrome in which pt believes that someone close to them has been replaced by a clone
Which of the following blood test results may be seen in a patient with purge-type bulimia?
hypokalaemia with metabolic alkalosis
A 26-year-old woman presents with a 2-day history of diarrhoea, nausea, vomiting, drowsiness and tremor. She has bipolar affective disorder and is taking lithium and olanzapine. In addition, she has been taking ibuprofen for dysmenorrhoea for the past 5 days.
Which is the most likely investigation finding in this patient?
raised creatinine
Features of lithium toxicity
coarse tremor
CNS disturbance; seizures, impaired cognition, dysarthria
arrhythmias
visuals disturbance
lithium is mainly excreted by KIDNEYS - renal impairment common in lithium toxicity -> RAISED CREATININE, REDUCED eGFR, RAISED SERUM LITHIUM
TOXICITY MAY BE PRECIPITATED BY RECENT DEHYDRATION/ILLNESS - EXAM q PT MAY BE POORLY 5 DAYS BEFORE.
ACUTE LITHIUM TOXICITY; GI DISTURBANCES
Mx of lithium toxicity
Fluid resus in mild toxicity; nausea, diarrhoea, blurred vision, polyuria, dizziness, fine resting tremor, muscle weakness or drowsiness
