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Psychiatry 4th year > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Acute stress reaction vs PTSD

A

Acute stress reaction within 4 weeks of traumatic event

PTSD >4 weeks since traumatic event

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2
Q

Features of Acute stress reaction/ PTSD

A 
Intrusive thoughts 
Dissociation 
Negative mood 
Avoidance 
Arousal
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3
Q

Diagnosis of ASR/ PTSD

A

Clinical diagnosis - may be by specialist

Trauma screening questionnaire

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4
Q

If clinically significant ASR/ PTSD managemnet

A

Specialist referral
1st line - trauma focused CBT
2nd line (various reasons) - SSRI (sertraline or paroxetine) or venlafaxine

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5
Q

What is agoraphobia

A

Well defined cluster of phobias embracing fears of losing home etc
Avoidance prominent therefore little anxiety
Fear recognised as irrational

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6
Q

What is the progression of alcoholic liver disease

A

Alcohol related fatty liver –> Alcoholic hepatitis –> cirrhosis

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7
Q

Is alcoholic liver disease reversible?

A

Alcohol related fatty liver - usually reversible in 2 weeks if drinking stops
Alcoholic hepatitis - mild usually reversible with permanent abstinence
Cirrhosis - liver made of scar tissue - avoiding alcohol prevents further damage but can’t be reversed

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8
Q

Signs of alcoholic liver disease

A 
Jaundice
Hepatospenomegaly 
Spider naevi 
Gynaecomastia 
Bruising - due to abnormal clotting 
Ascites
Caput medusae
Asterixis
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9
Q

Bloods of alcoholic liver disease

A

FBC - raised BCV
LFT - raised GGT
AST:ALT normally >2 a ratio of >3 strongly suggestive of acute alcoholic hepatitis
Low albumin due to reduced synthetic function
Elevated bilirubin in cirrhosis
Clotting - elevated prothrombin time due to reduced synthetic function of liver
U+E - may show hepatorenal syndrome

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10
Q

What does a fibroscan show

A

Elasticity of the liver

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11
Q

What confirms alcoholic liver disease

A

Liver biopsy

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12
Q

Name screening tests used in assessing alcohol consumption

A

CAGE
FAST
AUDIT

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13
Q

What does cage stand for

A

Cut down?
Annoyed?
Guilty
Eye opener

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14
Q

What can be used during acute episodes of alcoholic hepatitis

A

Steroids

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15
Q

What are the guidelines on alcohol consumption

A

No more than 14 units per week for men and women spread over 3 days

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16
Q

How are the number of units in alcoholic calculated

A

Total volume in ml x percentage alcohol volume (ABV) / 1000

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17
Q

What is alcohol dependence characterised by

A

Strong desire or sense of compulsion to take drug
Difficulty in controlling use of substance in terms of onset, termination or level of use
Physiological withdrawal state
Evidence of tolerance
Progressive neglect of other pleasures/ interests because of use
Persistence despite clear evidence of harmful consequences

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18
Q

Outline features of delirium tremens

A 
Worsening moderate symptoms plus confusion/ delirium 
Generalised tonic-clonic seizures
Visual or tactile hallucinations 
Hyperthermia 
Subsequent to psychomotor agitation
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19
Q

What type of drug is chlordiazepoxide

A

Long acting benzodiazepine

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20
Q

What drug is given to prevent features of alcohol withdrawal

A

Benzodiazepine e.g. chlordiazepoxide

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21
Q

What should be given in addition to chlordiazepoxide for alcohol dependence

A

Thiamine prophylaxis - increase dose if wernicke’s suspected

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22
Q

What is the triad for wernicke’s encephalopathy

A

Altered mental status
Ophthalmoplegia
Ataxic gait

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23
Q

What is the first line drug to prevent relapse in alcoholics and what does it do

A

Naltrexone

Reduce reward

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24
Q

What drug to help alcoholics causes side effects if alcohol consumed and what are the side effects

A

Disulifram
Antabuse
Flushes skin, tachycardia, N+V, arrhythmia, hypotension

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25
Q

What makes anxiety pathological

A

Its extent or context causing significant impairment of social/ occupation/ other functions

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26
Q

What constitutes generalised anxiety

A

Generalised and persistent but not restricted to or event strongly predominating in any particular environmental circumstance i.e. its free floating

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27
Q

How long must GAD persist to meet the criteria

A

Most days for at least 6 months
Not controllable
Causing significant distress/ impairment in functioning

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28
Q

What is the treatment for GAD

A
  1. Psychoeducation
  2. Self help/ psychoeducation groups
  3. High intensity psychological intervention CBT or drug treatment SSRI
  4. SNRI
  5. Pregablin
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29
Q

How long may an SSRI take to work in GAD

A

Up to 12 weeks

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30
Q

How long should SSRI be continued on improvement of GAD

A

18 months

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31
Q

What are symptoms of PTSD

A 
Intrusive thoughts 
Dissociation e.g. gaze
Negative mood 
Avoidance Arousal e.g. hyper vigilance
Emotional numbing
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32
Q

How long must the symptoms of PTSD last for a diagnosis

A

More than 1 month

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33
Q

What may show on a suffer of PTSD’s bloods

A

LFT derangement is alcohol a problem as a possible coping mechanism

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34
Q

What is the treatment of PTSD

A

If sub-clinical - period of watchful waiting and arrange regular review

If clinically important referral to specialist mental health service
1st line - trauma based psychological therapies - CBT focusing on exposure to. traumatic event in a controlled way and EMDR
2nd line - antidepressants SSRI (paroxetine or sertraline) or venlafaxine

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35
Q

What is anorexia

A

Fear of being fat
The person feels they are overweight despite evidence of normal or low body weight
Obsessively restricting calorie intake with the intention of losing weight

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36
Q

What conditions does anorexia have a strong correlation with

A

Personality disorders
OCD
Anxiety

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37
Q

Features of anorexia

A 
Excessive weight loss
Amenorrhoea
Lanugo hair - fine, soft hair across most of body 
Changes in mood, anxiety and depression
Solitude 
Cardiac complications - prolonged QT, cardiac atrophy and sudden cardiac death 
Hypotension 
Bradycardia
Enlarged salivary glands
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38
Q

Anorexia nervosa blood results

A 
Hypokalaemia 
Low FSH, LH, oestrogen, testosterone 
Low T3
Low urea - function of low protein intake
Raised cholesterol and growth hormone 
Impaired glucose tolerance
Hypercholesterolaemia
Hypercarotenamia
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39
Q

Learning Disability/ Arrested Intellectual Development

A

IQ <70

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40
Q

Categories to meet LD

A

Significant impairment of intellectual functioning

Significant impairment of adaptive/ social function

Age of onset before adulthood

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41
Q

What test is used to measure IQ

A

Wechsler Intelligence Scale for Adult WAIS score

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42
Q

Features of Attention deficit hyperactivity disorder

A

Hyperactivity

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43
Q

What is the treatment of ADHD

A

10 week watch and wait period before referring to CAMHS

Parental and child education essential

Medication if conservative management failed
1st line - methylphenidate
If inadequate 2nd line - lisdexamfetamine
Dexamfetamine if benefit from lisdexamfetamine but can’t tolerate side effects

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44
Q

What is required for ADHD drugs

A

ECG as cardiotoxic

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45
Q

What is autism

A

Deficit in social interaction, communication and flexible behaviour

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46
Q

What is the treatment of autism

A

No cure but managed via MDT approach

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47
Q

What is ARFID

A

Avoidance and restriction of certain foods and types of food

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48
Q

What does ARFID often overlap with

A

Autism

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49
Q

What is the treatment of ARFID

A

Tailored to individual needs

If anxiety - CBT or SSRI

If comorbid ASD - help with sensory problems

Dietetic input

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50
Q

What are baby blues

A

Transient lability in mood for around 3 days after birth and usually resolve within 2 week

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51
Q

Features of baby blues

A

Irritability
Anxiety about parenting
Tearfulness

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52
Q

How many mothers with baby blues develop post natal depression

A

About 10%

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53
Q

What is the treatment of baby blues

A

Supportive

reassuring measures

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54
Q

What is binge eating disrder

A

Episodes where person excessively overeats often as an expression of underlying psychological distress

Not restrictive and patient likely to be overweight

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55
Q

What is bulimia nervosa

A

Binge eating followed by purging by inducing vomiting or taking laxatives to prevent calories being absorbed

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56
Q

Features of bulimia

A 
Alkalosis - due to vomiting HCl acid from the stomach 
Hypokalaemia 
Erosion of teeth 
Swollen salivary glands
Mouth ulcers
GORD 
Calluses on knuckles - Russel's signs

Presenting complaint may be abdominal pain or reflux

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57
Q

Treatment of bulimia

A

Referral to specialist care

Adults - guided self help if ineffective or unacceptable –> CBTED

Child –> FBT

Pharmacological Tx limited role - high dose fluoxetine

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58
Q

What is complex regional pain syndrome

A

Condition related to continuing pain that is more severe than would be expected and lasts beyond the expected time period following an injury/ trauma

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59
Q

Features of complex regional pain syndrome

A 
Usually felt in 1 limb 
Assoc with hyoersensitivity to area of skin affected 
Area may become stiff
Chronic pain 
Radiating pain 
Sensitivity to non-noxious stimuli 
Limb weakness
Oedema 
Radiating pain
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60
Q

Treatment of complex regional pain syndrome

A 
Patient education 
Self-management 
Medical pharmacotherapy 
Physical rehab 
Psychological support
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61
Q

Factors assoc with deliberate self harm

A 
Female 
younger
chronic social and family problems
May have physical illness or personality disorder
Alcohol withdrawal
Past DSH 
Impulsive
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62
Q

Factors assoc with suicide

A 
Male 
Older 
Living alone 
Single, divorced, separated
Unemployed
Major psychiatric illness
Physical illness
Drug and alcohol abuse
Special high risk groups e.g. doctors
Planned
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63
Q

Biggest risk factor for suicide

A

Previous attempt/ self harm

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64
Q

Risk of suicide

A 
SADPERSONS
sex - male 
age <19 or >45
Depression or hopelessness
Previous attempts 
Excessive alcohol or drug use
Rational thinking loss - psychosis
Separated/ widowed/ divorced
Organised or planned attempt
No social support 
Stated future intent
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65
Q

Management of deliberate self harm

A

Refer to hospital if considered at risk physically due to consequences of substance or risk of repetition

Minimise physical harm e.g. general supportive measures, charcoal, antidotes
Assess suicide risk
Detect and manage any assoc psychiatric disorder
Identify and manage drug/ alcohol problem

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66
Q

What is bipolar disease according to ICD-10

A

2 or more episodes in which the patient’s mood and energy levels are significantly disturbed, this consists on some occasions of hypomania or mania and on others depression

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67
Q

What is bipolar 1

A

Has to meet mania criteria, although previous episodes may have been hypomanic and/ or depressive

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68
Q

Bipolar 2

A

Current or past hypomanic episode and current or past depressive episode

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69
Q

What may lead to an earlier onset of Bipolar

A

Family history - anticipation

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70
Q

What are indicators of a poor bipolar outcome

A 
Early onset 
Low socioeconomic status 
Subsyndromal mood symptoms 
Long duration of illness
Rapid mood fluctuation 
Mixed presentation 
Psychosis 
Comorbid disorders
Family 
Psychopathology
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71
Q

What defines hypomania

A

Mood elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least 4 consecutive days

At least 3 of the following signs must be present leading to some interference with functioning of daily living
Increased talkativeness, difficulty concentrating, decreased need for sleep, increased sexual drive, mild spending sprees or reckless behaviour

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72
Q

What defines mania

A

Mood predominantly elevated, expansive irritable and definitely abnormal - prominent and sustained for at least 1 week (unless hospital admission)
3 of the following at least - increased talkativeness, loss of normal social inhibitions, decreased need for sleep, inflated self esteem, distractibility, constant changing in plans, behaviour reckless, marked sexual energy or sexual indiscretions

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73
Q

What suggests mania

A

Delusions

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74
Q

What is mania with psychosis

A

Typified by mood congruent content of psychotic symptoms, delusions of grandeur/ special ability, persecution, religiosity
Hallucinations - 2nd person and auditory

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75
Q

What is the treatment of acute mania/ hypomania

A

Maximise antimanic dose if patient already on maintenance
Antidepressants discontinued

If mania - hospital admission likely

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76
Q

What antipsychotics are used in bipolar disorder

A

Olanzapine
Quetiapine
Risperidone

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77
Q

What medication is used in bipolar maintenance

A

Lithium - gold standard
Other options are antipsychotics - lamotrigine (if mainly depression)
Valproate (if mainly mania)
Psychoeducation

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78
Q

When should antidepressants be avoided in bipolar

A

During mania/ hypomania

Rapid cycling

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79
Q

What physical health conditions is bipolar a risk factor for

A

2-3 times increased risk of diabetes, cardiovascular disease and COPD

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80
Q

What is delirium

A

Acute, transient disturbance from the person’s normal cognitive function

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81
Q

How long can delirium last up to

A

Up to 6 months

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82
Q

What points towards delirium over dementia

A 
Impaired consciousness
Fluctuation of symptoms - worse at night 
Periods of normality 
Abnormal perception 
Agitation, fear
Delusions
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83
Q

What type of hallucinations are features of delirium

A

Visual hallucinations +/- auditory hallucinations (often threatening)

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84
Q

What are the different types of delirium

A

Hyperactive - agitation, restlessness, sleep disturbance and hypervigilance

Hypoactive - lethargic, reduced mobility and movemnet

Mixed - combination of signs and symptoms

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85
Q

What is the management of delirium

A

History from person and informed observer

If possible cognitive screening test

Ask about previous intellectual function

A full physical exam and infection screen

Urinalysis - infections, hyperglycaemia

Sputum culture

FBC - anaemia, infection

U+E’s - AKI or electrolyte disturbance (hyponatraemia or hypokalaemia)

HbA1c- hyperglycaemia

Calcium - hypo or hyper

LFTs - hepatic failure and rule out hepatic encephalopathy

Inflammatory markers

Drug levels

Thyroid function test s

CXRray

ECG

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86
Q

Treatment of delirium

A

Treat underlying cause
Maintain environment with good lighting and frequent reassurance

In extremely agitated patients small dose of haloperidol or olanzapine may be considered

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87
Q

What is delirium tremens

A

Life threatening alcohol withdrawal state

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88
Q

What causes delirium tremens

A

Alcohol stimulates GABA receptors in the brain – GABA relaxing effect – alcohol also inhibits glutamate receptors  further inhibitory effect
Chronic alcohol use – GABA down regulated and glutamate up-regulated
When alcohol removed – GABA under functions and glutamate over functions  extreme excitability with excess adrenergic activity

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89
Q

Features of delirium tremens

A 
Acute confusion 
Severe agitation 
Delusions and hallucinations 
Tremor 
Tachycardia 
Hypertension 
Hyperthermia 
Ataxia – difficulties with coordinated movements 
Arrhythmia
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90
Q

Treatment of delirium tremens

A

Chlordiazepoxide – benzodiazepine used to combat effects of alcohol withdrawal
Diazepam – less commonly used alterative
Use on reducing regimen – continued for 5-7 days

IB high dose B vitamins (pabrinex) – followed by regular lower dose oral thiamine

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91
Q

What is dementia

A

Progressive irreversible impairment of intellect, memory and personality
Difficulties with activity of daily living

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92
Q

What is considered early onset dementia

A

Before 65

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93
Q

What is mild cognitive impairment

A

cognitive impairment that does not fulfil the diagnostic criteria for dementia, for example, because only 1 cognitive domain is affected or deficits do not significantly affect daily living

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94
Q

Most common type of Demetia

A

Alzheimer’s disease

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95
Q

Biggest risk factor for Dementia

A

Increasing Age

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96
Q

Other risk factors for dementia

A 
Mild cognitive impairment - 1/3 develop AD within 3 years
Learning disability 
Genetics
Cardiovascular risk factors 
Cerebrovascular 
PD
Smoking 
Anticholinergic burden
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97
Q

What gene is involved in early onset AD

A

Amyloid precursor gene APP or presenilin gene PSEN1 or PSEN2

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98
Q

What gene is involved in late onset AD

A

Apolipoprotein E

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99
Q

What are features of AD

A

Cognitive impairment

Behaviour and psychological

Difficulties with ADL

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100
Q

What is required for a diagnosis of dementia

A

impairment in 2 of the following cognitive domains

Memory, language, behaviour, visuospatial or executive function

101
Q

What tests are required to diagnose dementia

A

Diagnosis of exclusion

Undertake initial assessment and history

Arrange appropriate blood tests to exclude reversible causes of cognitive decline 
FBC
ESR
CRP 
U + E’s
Calcium 
HbA1c 
LFT
TFT 
Serum B12 and folate

Other investigations that may be appropriate if clinically indicated include urine microscopy and culture, chest X-ray, ECG, syphilis serology and HIV testing

Various cognitive assessment tools
Screening – MMSE, MOCA, Addensbrooke

102
Q

Course of action if rapidly progressive dementia

A

Refer to a neuro service with access to tests (including CSF) for CJD

103
Q

What is the non-pharmacological treatment of dementia

A

Non-pharmacological interventions to promote cognition, independence and well-being for people include
Cognitive stimulation therapy
Group reminiscence therapy
Cognitive rehabilitation or IT

104
Q

What is the pharmacological treatment of mild to moderate dementia

A

Acetylcholinesterase inhibitors – donepezil, galantamine and rivastigmine – as monotherapies for managing mild to moderate AD

105
Q

What is the pharmacological treatment for managing people with moderate AD who are intolerant of or have contraindications to AChE inhibitors or for people withs severe AD

106
Q

What drugs should be used with caution in dementia patients

A

Tricyclic antidepressants – amitriptyline
Antiemetics e.g. metoclopramide
Analgesics – e.g. pethidine or tramadol
Sedatives – long acting benzodiazepines or antipsychotics
Antihistamines – e.g. chlorphenamine

107
Q

What can be a result of anticholinesterase + antipsychotics

A

Neuroleptic Malignant Syndrome

108
Q

What should be done before prescribing anti-cholinesterase inhibitor

A

ECG - contraindictaions - prolonged QT, second or third degree heart block in an unpaced patient, bradycardia <50bpm

109
Q

Who should be contacted if a person has dementia

110
Q

What is the pathophysiology of AD

A

Amyloid plaques nad tau proteins

111
Q

Describe the onset of AD

A

Loss of recent memory first - difficulty with executive function

Loss of episodic memory - memory loss for recent events, repeated questions, difficulty with new info

Visuospatial and language deficits - moderate to severe stage

112
Q

Pathology of Vascular dementia

A

Problem with blood flow to brain

113
Q

Features of vascular dementia

A

Stepwise decline

May present insidiously with gait and attention problems, changes in personality, focal neuro signs may be present

Memory loss - secondary to impairment in frontal. executive decline

114
Q

Dementia with Lewy Bodies features

A 
Fluctuating cognition 
Recurrent visual hallucinations
REM sleep disorder
Symptoms of Parkinsonism
Bradykinesia, tremor or rigidity
115
Q

Features of fronto-temporal dementia

A

Personality changes and behavioural disturbance (apathy or social/ sexual disinhibition)

116
Q

Fronto-temporal dementia findings

A

Intracellular TAU proteins and atrophy of frontal and temporal lobes

117
Q

What is the term for loss of memory

118
Q

What is the term for language difficulty

119
Q

What is the term for difficulty with performing motor activities

120
Q

What is the term for visual recognition difficulty

121
Q

What is the minimum time a depressive episode must last to be classed as depression

122
Q

What is required for a diagnosis of moderate depression

A

2 core symptoms + 4 others to give a total of at least 6

123
Q

What is required for a diagnosis of severe depression

A

All 3 core symptoms must be present + 5 additional to give a total of at least 8

124
Q

What are the 3 core symptoms of depression

A

Depressed mood
Anergia
Anhedonia

125
Q

What questionnaires are used in depression

A

PHQ-9
HADS
BDI-II

126
Q

What should be considered for people with persistent subthreshold depression or mild to moderate depression

A

Low intensity psychological intervention

exercise, regulation of sleep, diet

127
Q

What should be considered in people starting an antidepressant

A

Consider suicide risk and toxicity in overdose.
Explain that symptoms of anxiety may initially worsen.
Explain that antidepressants take time to work.

128
Q

How long should antidepressants be considered following remission of symptoms

A

At least 6 months - 1st time

At least 1 year after that

129
Q

What is the treatment for moderate of severe depression

A

antidepressant and high intensity psychological intervention (CBT) – better response using combined approach

130
Q

What type of antidepressant should be trialled first

A

SSRI for 6-8 weeks at therapeutic dose

131
Q

What should be prescribed if SSRI not helpful

A

Switch to another SSRI for 6-8 weeks at therapeutic dose

132
Q

What to do if 2 SSRIs not helpful

A 
Refer to psychiatrist
Consider different class
Consider ECT in treatment resistant cases
133
Q

What tool is used in ECT

A

MADRAS

Montgomery Asberg Depression Rating Scale

134
Q

What is the treatment of depression in children

A

1st line - psychological therapy - CBT, non-directive supportive therapy, interpersonal therapy and family theraoy

1st line medication in children fluoxetine

135
Q

What anti-depressants should be avoided if risk of overdose

A

Tricyclic or venlafaxine

136
Q

How long does it normally take for symptoms to improve on antidepressants

137
Q

What happens if antidepressants are stopped abruptly, doses are missed or full dose not taken

A

Discontinuation symptoms
Restlessness
Problems sleeping, unsteadiness, sweating, abdo pain, altered sensations e.g. electric shock sensations in the head or altered feelings - irritability, anxiety, confusion

138
Q

When should someone with depression be reviewed

A

If at increased risk of suicide or person under 30 - initial review within 1 week, review frequently thereafter until risk is no longer considered clinically important

For people not considered at an increased risk of suicide - initial review within 2 weeks

139
Q

What is Korsakoff Syndrome

A

A result of low vitamin B1 levels (thiamine) –> brain damage

140
Q

Who is likely to be effected by Korsakoff Syndrome

A

Typically heavy drinking male over 45

Risk of not treating Wernicke’s

141
Q

What are the symptoms of KS

A

Memory impairment
Behavioural change

Inability to form new memories or learn new information
Personality change
Making up stories to fill gaps in memory (confabulation)
Seeing or hearing things that aren’t really there (hallucinations)
Lack of insight into the condition

142
Q

What is the treatment of KS

A

No treatmnet
But give high dose pabrinex
Stop drinking

143
Q

What are medically unexplained symptoms and how long do they need to be present for

A

Persistent bodily complaints for which adequate examination does not reveal sufficient explanatory structural or other specified pathology

Present for >3 months and assoc with impaired functioning

144
Q

What is the management of medically unexplained symptoms

A

Sensitive consultation to talk openly about their experiences and worries

Screen for underlying health problems e.g. depression and anxiety

Psycho-social support and therapies e.g. CBT helpful in reducing symptoms

SSRIs and other antidepressants can be used to treat co-morbid depression and/ or anxiety

Tricyclic antidepressants e.g. amitriptyline probably have the best established role in management of chronic pain

Extensive investigations unlikely to be helpful and may increase patient’s anxiety

145
Q

What is somatoform disorder

A

Presence of physical symptoms that cannot be described by a medical condition, drug or other mental health disorder – starts in early life, chronic and fluctuating course

146
Q

What is conversion disorder

A

presentation of neurological symptoms without any underlying neuro cause e.g. paralysis, pseudoseizures, sensory changes – not intentional and symptoms very much real to patient – linked to emotional stress

147
Q

What is hypochondriasis

A

patients have excessive concern that they have a serious illness despite a lack of evidence – often demand unnecessary tests and can be quite debilitated as a result of constant worry

148
Q

What is factitious disorder

A

intentional production of physical pathology or the feigning of symptoms – does not apparently bring any external reward – Munchausen’s rare and extreme form (want to play patient role)

149
Q

What is malingering

A

patients intentionally fake or induce illness for secondary gain e.g. drug seeking, disability benefits, avoiding work or prison time

150
Q

What is La Belle indifference

A

inappropriate lack of concern over the symptoms they are experiencing

151
Q

What is Neuroleptic Malignant Syndrome

A

Severe disorder caused by an adverse reaction to medications with dopamine receptor antagonist properties e.g. antipsychotics or rapid withdrawal of dopaminergic medications

152
Q

What are the symptoms of neuroleptic malignant syndrome

A

Hyperpyrexia
Autonomic instability
Gradually increasing muscle tone
Rhabdomyolysis -_> acute renal failure –> coma –> death

153
Q

What blood test can indicate neuroleptic malignant syndorme

A

Creatinine Kinase

154
Q

What is the treatment of neuroleptic malignant syndrome

A 
Intensive care unit - medical emergency 
Stop antipsychotics
Rapid cooling 
Renal support 
Skeletal muscle relaxants e.g. dantrolene
Dopamine agonists e.g. bromocriptine
155
Q

What is OCD characterised by

A

Ego-dystonic (unwanted) Obsessions and compulsions

156
Q

What are obsessions in OCD

A

unwanted and uncontrollable thoughts and intrusive images that the person finds it very difficult to ignore e.g. overwhelming fear of contamination

157
Q

What are compulsions in OCD

A

repetitive actions that person feels they must do, generating anxiety if they are not done – often to handle obsession e.g. checking all electrical equipment is turned off to handle obsession that house will burn down

158
Q

How long must OCD persist to get a diagnosis

A

At least 2 weeks AND be a source of distress and interference with activities

159
Q

What is the treatment of OCD in an adult with mild functional impairment

A

Low intensity CBT

160
Q

What is the treatment of OCD in an adult with moderatefunctional impairment

A

Offer CBT including ERP or SSRI

Consider prescribing clomipramine (tricyclic)

161
Q

What is the treatment of OCD in an adult with severe functional impairment

A

Refer to secondary care mental health team for assessment

Consider offering combined treatment with an SSRI and CBT or clomipramine

162
Q

For children with OCD with mild to moderate functional impairment

A

Guided self help

If unavailable or ineffective refer to CMAHS

163
Q

For children with OCD with severe functional impairment

A

Refer to CAMHS

164
Q

What is panic disorder

A

Recurrent attacks of severe anxiety which are not restricted to any particular situations or set of circumstances and are therefore unpredictable

165
Q

What are the features of generalised anxiety disorder

A

Sudden onset palpitations
Chest pain
Choking sensations
Dizziness Feelings of unreality (depersonalisation (outside yourself) or derealisation (detached from surroundings))

Secondary fear of dying, losing control, going mad

166
Q

What is the treatment of GAD

A

Self help
CBT
SSRIs/ SNRIs/ Tricyclics – clomipramine, desipramine, imipramine

167
Q

How long should GAD treatment be continued after remission

168
Q

What are the features of a personality disorder

A

Significant difference in thoughts, feelings and behaviours compared to social norms

Chronic, stable

Present from teenage years

Pervasive across different domains of life

169
Q

What are the type A personality disorder

A

Paranoid
Schizoid
Schizotypal

170
Q

What is a paranoid personality disorder

A

Considerable overlap with conspiracy theory, sensitive to set backs, neutral aspects of others as hostile, bear grudges, strong sense of personal rights, not trusting

171
Q

What is a schizoid personality disorder

A

Quite cold
Indifferent praise or criticism
No drive to have relationships with others
Enjoy their own company

172
Q

What is a schizotypal personality disorder

A 
Schizophrenia like but no full blown illness 
Odd eccentric 
Poor relationship
Odd speech 
Magical thinking
173
Q

What can potentially be given in a type A personality disorder

A

Antipsychotic

174
Q

What are the type B personality disorders

A

Borderline
Antisocial
Histrionic
Narcissistic

175
Q

Give features of borderline personality disorder

A

Driven around on storm of emotions
With emotionally unstable personality changes within minutes unlike bipolar
With impulsive type - act without thinking of actions
Short term gratification of needs
Unstable sense of self
Intense but unstable relationships
Splitting – individuals wholly good or bad

176
Q

Give features of antisocial personality disorder

A

Perceive neutral things as threatening

Rules don’t apply to them

177
Q

What is antisocial personality disorder referred to before 19

A

Conduct disorder

178
Q

Give features of histrionic personality disorder

A 
Need to be in the spotlight 
Bring the attention back to them 
Dramatic, theatrical
Shallow 
Concerned with physical appearance 
Seductiveness
179
Q

Give features of narcissistic personality disorder

A

Exaggerated sense of self-importance
Envious of others and believe others envy them
Belittle look down on others
Sense of entitlement
Expect to be recognised as superior
Inability or unwillingness to recognise the need and feelings of others

180
Q

What are type C personality disorders

A

Anxious/ avoidant
Obsessive compulsive
Dependent

181
Q

What is anxious/ avoidant personality disorder

A

Background of apprehension
Preoccupied with being criticised/ rejected
Only situations they know will be successful

182
Q

What is obsessive/ compulsive personality disorder

A

Ego-syntonic need for order and routine

Obsessions and compulsion not undesirable

183
Q

What is dependent personality disorder

A 
Struggle with small decisions 
Right answer in given situations 
e.g. Heinz or Tesco beans 
Devolve decision making to others 
When on own preoccupation with not being able to look after themselves
184
Q

When can postnatal depression arise

A

Anytime up to 1 year after birth

185
Q

Features of postnatal depression

A

Lowering of mood, reduced enjoyment in activities and lowering of energy levels

Poor appetite, poor sleep

May be assoc concerns from mother about bonding with her baby, caring for her baby or harming herself or baby in extreme circumstances

186
Q

What is the treatment of postnatal depression

A

Depends on severity - tailor to individual

Reassurance and support important
CBT may be beneficial
Certain SSRIs - sertraline and paroxetine may be used if symptoms severe

187
Q

When does postpartum psychosis usually present

A

Within first 2 weeks after birth

188
Q

What increases the risk of postpartum psychosis

A

previous history of mental illness e.g. schizophrenia or bipolar affective disorder, family history of postpartum psychosis, previous episode of postpartum psychosis monitored by perinatal health team

189
Q

What are features of postpartum psychosis

A

Paranoia, delusions, hallucinations, mania, depression, confusion

190
Q

What is the treatment of postpartum psychosis

A

Referral to mother and baby unit particularly important in cases where mother experiencing command hallucinations, has thoughts of self-harm or suicide or has delusional beliefs about the baby’s role or identity

Antipsychotics + sometimes mood stabilisers
Prescribed in consideration with breast feeding – olanzapine, quetiapine

191
Q

What causes Wernicke’s encephalopathy

A

Thiamine - vitamin B1 deficiency

Normally alcoholics

192
Q

What are the features of Wernicke’s encephalopathy

A

Confusion
Oculomotor disturbance (disturbance of eve movements)
Ataxia (difficulties with coordinated movements)

193
Q

What is used to prevent Wernicke’s from developing

A

Thiamine
Pabrinex
Stop drinking

194
Q

What are specific phobias

A

Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation e.g.

195
Q

What is the treatment of specific phobia

A

Behavioural Therapy – exposure
Graded exposure/ systematic desensitisation
Add CBT if necessary

SSRIs/ SNRIs if required

196
Q

What are social phobias/ social anxiety disorder

A

Persistent fear of 1 or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others

Fears he or she will act in a way that is embarrassing and humiliating

Typically small social settings

197
Q

What is the treatment of social phobia/ social anxiety

A

Individual CBT
SSRI (escitalopram or sertraline) – review at 12 weeks
SSRI plus CBT
Alternative SSRI or SNRI

198
Q

What is serotonin syndrome

A

Adverse reaction to high levels of serotonin in body

199
Q

What causes serotonin syndrome

A

Anti-depressants (especially using more than 1)
Anti-migraine drugs – work on 5HT – triptans
Especially irreversible MAOIS (tyrosine containing foods)
St John’s Wart
Mu receptor opioid agonist – tramadol

200
Q

What is the triad of serotonin syndrome

A

Mental state changes
Autonomic hyperactivity
Tremor

201
Q

What is the treatment of serotonin syndrome

A

Usually conservatively managed
Not necessarily hospital

Stop all serotonin medications
Supportive, symptomatic treatment

202
Q

What is refeeding syndrome

A

Potentially fatal shifts in fluids and electrolytes

On refeeding  increased insulin secretion  Increases protein and glycogen synthesis  increases glucose uptake, thiamine use, uptake of potassium, magnesium and phosphate  hypokalaemia, hypo magnesia, hypophosphatemia, thiamine deficiency, salt and water retention  oedema

203
Q

What are the risk factors of developing refeeding syndrome

A

Severe nutritional deficit for an extended period of time, when they start to feed again

Higher risk if BMI <20 and have had little to eat for past 5 days

Lower BMI and longer risk of malnutrition greater risk

Risk for anyone who has not been eating well

204
Q

What are the risks of refeeding syndrome

A

Cardiac arrhythmias
Heart failure
Fluid overload

205
Q

What is the treatment of refeeding syndrome

A

Local protocol

Correct electrolyte and fluid abnormalities – phosphate Sandoz, Sandoz k – IV may be required

206
Q

What is done to prevent refeeding syndrome

A

Slowly reintroducing foods with restricted calories

Start with low energy replacement, with high phosphate content e.g. milk and build up every 2-3 days
Supplement with multivitamin e.g. forceval and thiamine for at least 10 days

Daily bloods
Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods, fluid balance monitoring, ECG monitoring, supplementation with electrolytes and vitamins – particularly B vitamins and thiamine

207
Q

What are hallucinations

A

Perceptions in absence of a stimulus - auditory, visual, smell, taste, tactile

208
Q

What are delusions

A

fixed or falsely held beliefs

209
Q

What are De Clerambault

A

delusional belief that one is loved by another person of, generally of a higher social status

210
Q

What is Othello syndrome

A

Spouse infidelity

211
Q

What is Capgrass syndrome

A

identical duplicate has replaced someone significant to the patient

212
Q

What is fregoli syndrome

A

mistaken belief that some person currently present in the deluded person’s environment (typically a stranger) is a familiar person in disguise

213
Q

What is nihilistic/ cotard delusion

A

any one of a series of delusions that range from a belief that one has lost organs, blood, or body parts to insisting that one has lost one’s soul or is dead.

214
Q

What is tangentiality

A

Never comes back to original point

215
Q

What is circumfrenaliality

A

Come back to the point

216
Q

What is knight’s move of thinking

A

Illogical jump between ideas

217
Q

What is flight of ideas

A

Thought disorder - connections can be made

218
Q

What is schizophrenia

A

Most common psychotic disorder

219
Q

What is the most common type of schizophrenia

220
Q

What is hebephrenic schizophrenia

A

Shallow and inappropriate emotional response, foolish or bizarre behaviour, delusions and hallucinations

221
Q

What is catatonic schizophrenia

A

affects movement in extreme ways (lack and lots) with schizophrenia features

222
Q

Define schizoafective

A

schizophrenia and significant mood component (could be classified as bipolar or depression)

223
Q

What are risk factors for schizophrenia

A

Stressful life
Childhood adversity
Family heritage – South Asian and black communities
Migration
Urban living
Cannabis use
Other substances – amphetamines, cocaine, ketamine, LSD or inhaled substances
Medication use – high dose corticosteroids
Early life actors
Paternal age >40 or <20
Exposure to Toxoplasma gondii

224
Q

How long do schizophrenia symptoms need to present for a diagnosis

A

Symptoms present most of the time for 1 month

225
Q

What is passivity

A

bodily sensation being controlled by external influence, actions/ impulses/ feelings imposed on individual or influenced by others

226
Q

Identify poor prognostic factors

A 
Longer duration of untreated psychosis 
Early or insidious onset of schizophrenia
Male sex
Negative symptoms
Family history of schizophrenia 
Low IQ
No precipitating cause
Low socioeconomic status 
Social isolation 
Significant psychiatric history 
Continued substance misuse
227
Q

What increases the risk of premature death in schizophrenic patients

A

Premature death
Suicide (worse if insight remains_)
Increased risk of CVD, type 2 diabetes mellitus, smoking and smoking related illness

228
Q

What is the management of someone with psychosis

A

Undertake an assessment of risk
If at high risk to themselves or others - same day specialist mental health assessment
All others - refer without delay
Oral antipsychotics are first line
CBT should also be offered to all patients

229
Q

What is the pharmacological management of antipsychotics

A

1st line - 2nd generation antipsychotic (6-8 weeks)
2nd line - 1st or 2nd generation antipsychotic

If not working
Check diagnosis – consider psychological input, optimise social supports, check compliance – depot?
Final – clozapine

230
Q

What are first rank symptoms of schizophrenia

A

Auditory Hallucinations
Thought abnormalities
Delusional perception
Passivity

231
Q

What is a reversible cause of cognitive memory decline

A

Vitamin B12 deficiency

232
Q

How is ECT normally given

A

Usually given twice weekly, majority bilateral

Always under GA with a muscle relaxant

233
Q

What is the most common complication of ECT

A

2/3 some memory problem
Loss is autobiographical and most accentuated from the time period closest to new information and non-cognitive memory domains not affected

234
Q

What are indications for ECT

A

Treatment resistant severe depression
Manic episodes
An episode of moderate depression known to respond to ECT in the past
Catatonia

235
Q

If pt who has capacity is denying ECT can it be given

236
Q

What is the MOA of typical antipsychotics and what pathways do they block

A

Non-selectively block D2 receptors
Block dopamine pathway
Mesolimbic pathway - decrease positive symptoms
Mesocortical pathway - increase negative symptoms
Nigrostriatal – tardive dyskinesia, parkinsonian features, EPS
Tuberoinfundibular – increase prolactin – galactorrhoea, gynaecomastia, sexual dysfunction

237
Q

How are extra pyramidal side effects treated

A

Use anti-cholinergics to bring ACh and dopamine back in balance

Procyclidine PO/IM

238
Q

What is acute dystonia

A

Rapid increase in muscle tone causing sustained contraction

239
Q

Give examples of acute dystonia

A

Torticollis - head tilt down

Oculogyric crisis - spasmodic position of the eyeballs into a fixed position usually upwards

Tongue protrusion

240
Q

What is akathisia and what is the treatmnet

A

Severe restlessness
1st line - beta blocker
2nd line - longa acting bezodiazepine

241
Q

What are the features of drug induced parkinsonism

A

bradykinesia, cogwheel rigidity, resting tremor, shuffling gait, deep-pan facial expression
Bialteral

242
Q

What is tardive dyskinesia and what is the treatment

A

long term often permanent, involuntary repetitive oro-facial movements, blinking, grimacing, pouting, lip-smacking, may involve limbs +/or trunk – tetrabenazine

243
Q

What is the effect of anti-psychotics on the bones

A

Reduced bone density –> osteoporosis, falls, fractures

244
Q

What are the effects by antispychotics on the tuberoinfundibular pathway

A

Women - galactorrhoea, reduced libido/ arousal, anorgasmia, amenorrhoea, anovulation

Men - gynaecomastia, erectile dysfunction, oligospermia, reduced libido

245
Q

Give examples of typical antipsychotics

A

Haloperidol

Chlorpromazine

246
Q

Give examples of atypical antipsychotics

A

Risperidone
Clozapine
Olanzapine
Quetiapine

247
Q

What is the best atypical antipsychotic for non responders

248
Q

How do atypical antipsychotics differ

A

Atypical antipsychotics Block D2 receptors and serotonin receptors
Occupy D2 receptors transiently

Psychiatry 4th year (1 decks)

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