Psychiatry Flashcards
Define psychosis
Symptom of several mental illnesses which causes the patient to perceive or interpret things differently from those around them, may include hallucinations and delusions
List causes of psychosis
Schizophrenia - most common psychotic disorder
Depression
Bipolar affective disorder - mania with psychotic symptoms
Delusional disorder
Acute and transient psychotic disorders
Schizoaffective disorder
Neurological conditions e.g. Parkinson’s disease, Huntington’s disease
Substance induced psychosis - prescribed or illicit drugs e.g. steroids, cannabis, amphetamines or alcohol
Organic cause - stroke, temporal lobe epilepsy, brain tumours
Describe the presentation and main clinical features of psychosis
Most present between 15-30
Positive symptoms - delusions, hallucination, disorganised thought, speech, behaviour
Negative symptoms - emotional blunting, reduced speech, loss of motivation, self neglect, emotional withdrawal
Describe the presentation and main clinical features of psychosis
Peak age of first episode is between 15-30
May follow major/traumatic life event/stress
Hallucinations - auditory most common
Delusions - paranoid, grandiose, jealous, guilt, referential, somatic, religious
Thought, speech or behaviour disorganisation - tangentiality, word salad, repetitive/odd movements, catatonia
Negative symptoms - reduced emotional expression, decreased motivation, reduced spontaneous speech
Define acute and chronic psychosis
Acute (brief) psychotic disorder - sudden onset psychotic behaviour lasting less than 1 month, followed by complete remission with possible future relapses
Chronic - psychotic behaviour >1 month, or chronic mental illness e.g. schizophrenia where psychotic symptoms are a significant part of the illness picture, requiring treatment
Compare the features of acute and chronic psychosis
Acute
Lack of insight
Auditory hallucinations
Ideas of reference
Suspiciousness
Thought disorder
Flat affect
Voices speaking to patient
Delusions - often of persecution
Thoughts spoken aloud
Chronic - can have features of acute +
Social withdrawal
Lack of conversation
Slowness
Over activity
Odd ideas/behaviour
Depression
Neglect of appearance
Odd postures/movements
Threats or violence
Describe the aetiology of schizophrenia
Combination of psychological, environmental, biological and genetic factors - some people have susceptibility and life experiences act as trigger
Genetic - family history, ethnicity (Afro-Caribbean)
Developmental - obstetric complications (malnutrition, pre-eclampsia, infections), winter birth, reduced brain volume, enlarged ventricles, young cannabis use
Environmental - low socioeconomic status, urban areas, migration, social isolation, adverse life events, family relationships, drug abuse
Neurotransmitters - excess of dopamine in mesocorticolimbic system (positive symptoms), less dopamine in mesocortical tracts (negative symptoms)
Also serotonin and glutamate abnormalities.
List the subtypes of schizophrenia and their defining features
Paranoid schizophrenia - most common, paranoid delusions and auditory hallucinations
Hebephrenic schizophrenia - adolescents and young adults, mood changes, unpredictable behaviour, fragmented hallucinations, poor prognosis with rapidly developing negative symptoms
Simple schizophrenia - negative symptoms only (never experienced positive)
Catatonic schizophrenia - psychomotor features e.g. posturing, rigidity, stupor
Undifferentiated schizophrenia - symptoms do not fit with other categories
Residual schizophrenia - negative symptoms, positive symptoms have ‘burnt out’
Describe the clinical features of schizophrenia
Positive symptoms
Thought echo - hearing own thoughts out loud*
Thought insertion or withdrawal*
Thought broadcasting*
3rd person auditory hallucinations*
Delusional perception*
Passivity and somatic passivity*
Odd behaviour
Thought disorder
Lack of insight
- = first-rank symptoms
Negative symptoms
Blunted affect
Apathy
Social isolation
Poverty of speech
Poor self-care
Alogia - poverty of speech
Avolition - lack of motivation/interest
Describe the typical natural course of schizophrenia
Psychosis may be preceded by prodromal period that can last from days - year
Prodromal symptoms - sleep disturbance, problems with memory, concentration, communication, affect and motivation, transient low-intensity psychotic episodes with hallucinations or delusions
Prodrome usually followed by acute psychotic episode with hallucinations, delusions and behavioural disturbances
Usually present at this point, brought in by family, police or self, and will have interventions which lead to regression/resolution of symptoms - may still have negative symptoms
Most common course is initial improvement of symptoms with ongoing recurrent acute psychotic episodes or relapses over many years - 15% have symptoms unresponsive to treatment initially
Describe the diagnostic criteria for schizophrenia
- First-rank symptom or persistent delusion present for at least one month
Auditory hallucinations
Delusions of thought interference
Passivity
Delusional perception - No other causes for psychosis e.g. drug intoxication or withdrawal, brain disease, extensive depressive or manic symptoms
Describe the treatment strategy for schizophrenia
First episode psychosis - oral antipsychotic medication (usually atypical 1st line) + psychological interventions (family therapy, CBT)
May need inpatient care, may be under Mental Health Act
Start antipsychotic dose low and titrate up
Ongoing management - monitor for side effects of pharmacological management, if treatment resistant can try alternatives (clozapine used when others ineffective), important to consider social aspects e.g. housing, crisis resolution for relapses
List the pharmacological options for management of psychosis and schizophrenia, describe their MOA and give examples
D2 (dopamine) receptor antagonists
Typical - generalised dopamine receptor blockade
Haloperidol
Chlorpromazine
Flupentixol decanoate (depot injection)
Atypical - more selective dopamine blockade, also block serotonin 5-HT2 receptors
Olanzapine
Risperidone (depot injection)
Clozapine
Amisulpride
Quetiapine
List side effects of typical antipsychotics
Extra-pyramidal side effects - Parkinsonism, akathisia (restlessness), dystonia, dyskinesia
Hyperprolactinaemia - sexual dysfunction, osteoporosis, amenorrhoea, galactorrhoea, gynocomastia and hypogonadism in men
Metabolic - weight gain, increased risk T2DM, hyperlipidaemia
Anticholinergic - tachycardia, blurred vision, dry mouth, constipation, urinary retention
Neurological - seizures, neuroleptic malignant syndrome
Cardiovascular - tachycardia, arrhythmias, QT prolongation, postural hypotension
List side effects of atypical antipsychotics and compare these to typical antipsychotics
Less likely to cause extra-pyramidal side effects and hyperprolactinaemia than typicals
Clozapine - agranulocytosis (requires monitoring for neutrophil levels)
Metabolic - weight gain, T2DM, hyperlipidaemia
Anticholinergic - tachycardia, blurred vision, dry mouth, constipation, urinary retention
Neurological - seizures, neuroleptic malignant syndrome (lower risk than typicals)
Cardiovascular - tachycardia, arrhythmias, QT prolongation, postural hypotension
List factors which are associated with a poorer prognosis in schizophrenia
Delayed diagnosis/management - longer initial psychotic episode/prodromal period
Lack of clear precipitant
Low IQ
Drug misuse
Low social functioning prior to onset of disease
Prominent negative symptoms
Poor response to antipsychotic medication
List complications of schizophrenia
Suicide
CVD
Cancer
Substance misuse
Social isolation
Describe the indications, side effects and monitoring required for clozapine
Used in treatment-resistant schizophrenia - if not responded to treatment with at least two other antipsychotics (usually one first-generation and one second-generation), or not tolerated other options
Common side effects
Sedation
Constipation
Tachycardia
Weight gain
Hypersalivation
Hypo/hypertension
Hyperglycaemia
Rare but serious side effects
Neutropaenia, agranulocytosis
Seizures
Cardiac - myocarditis, cardiomyopathy
Constipation can lead to ileus, bowel obstruction
Monitoring
Initially weekly FBC
Plasma clozapine levels sometimes monitored - compliance, high dose, smoking status changes (rises with reduction/cessation)
Seek urgent medical assessment if develop flu-like symptoms
List contraindications/cautions for antipsychotic medications
Atypical (e.g. haloperidol) - congenital long QT, history of torsades de pointes, recent acute MI, uncorrected hypokalaemia, uncompensated heart failure, with other drugs which prolong QT
Cautions for all antipsychotic drugs:
CNS depression, other drugs which cause CNS depression e.g. benzodiazepines
Cardiovascular disease
Conditions predisposing to seizures, epilepsy
Diabetes
Parkinson’s disease, Lewy body disease
Prostatic hypertrophy or history of urinary retention
Elderly, frail, prone to falls
Prolactin-dependent tumours
Risk factors for stroke
Risk of closed angle glaucoma
Pregnancy, especially first trimester
List the indications for antipsychotic drug treatment
Schizophrenia and schizoaffective disorders - typical and atypical for acute episodes and maintenance therapy (typical better for positive symptoms, atypical for both positive and negative)
Acute mania - typical and atypical (except clozapine) + mood stabilisers
Major depressive disorder with psychotic features - typical and atypical + antidepressant
Delusional disorder - typical
Severe agitation - short-term, where other methods have failed
Tourette disorder - haloperidol, pimozide
Borderline personality disorder with psychotic symptoms
Dementia and delirium - low dose, short-term, where other methods have failed
Substance-induced psychotic disorder - caution with typicals in alcohol withdrawal
List risk factors which contribute to the aetiology of depression
Biological:
FH
Female sex
Age - teens-40s
Substance misuse
Physical health problems - Parkinson’s, MS, hypothyroidism, chronic illness
Psychological:
Personality traits - dependent, anxious, obsessional
Low self esteem
Childhood trauma
Traumatic life events
Social:
Lack of social support
Low socioeconomic status
Marital status - divorced
Unemployment
Describe the clinical features of depression
Symptoms >2 weeks, not attributable to organic or substance causes, impair daily function and cause significant distress
Core symptoms:
Low mood
Anhedonia
Lack of energy
Cognitive symptoms:
Feelings of guilt, uselessness, worthlessness
Suicidal thoughts
Poor concentration
Functional/somatic symptoms:
Sleep disturbance - early waking, insomnia
Weight loss/gain, appetite loss
Loss of libido
Psychomotor agitation or retardation
Memory problems
Can have hallucinations and delusions - usually mood congruent
List the differential diagnoses for depression
Depressive episode due to substance/medication
Bipolar affective disorder
Pre-menstrual dysphoric disorder
Bereavement/normal reaction to life event
Anxiety disorder
Organic cause - hypothyroidism, Cushing’s
How is depression managed?
Mild depression (2 typical core symptoms and two other core symptoms):
Short-term - low-intensity psychosocial interventions (CBT, mindfulness and meditation), SSRI antidepressants if patient preference, history of more severe depression, depression >2 years, continuing symptoms after other interventions
Moderate or severe depression (two typical core symptoms + >3 other core symptoms):
Short-term - high-intensity psychosocial interventions (CBT, counselling, psychotherapy), antidepressants (e.g. SSRI, SNRI)
If depressive episode with psychotic symptoms - antipsychotic also given (quetiapine or olanzapine)
ECT if severe, unresponsive to treatment, life-threatening
Long-term for mild, moderate or severe - risk assessment, review response to pyschosocial and drug treatment, assess social support, relapse prevention plan
When is ECT offered for treatment of depression?
Patient has strong preference - usually have responded well before
Rapid treatment required - life-threatening depression where patient is not eating/drinking, while waiting for effects of antidepressant therapy
Multiple other treatments have been trialled unsuccessfully
Describe the indications, contraindications of SSRIs
Indications - first-line for moderate-severe depression, may be used in mild depression if long-term/other interventions failed
Also used in EDs, anxiety disorders
Contraindications:
Bipolar affective disorder, manic episode or history of mania
Poorly controlled epilepsy
Known QT prolongation, congenital long QT or concurrent use of drugs which prolong QT (citalopram and escitalopram)
Severe hepatic impairment (sertraline)
Describe the cause and presentation of neuroleptic malignant syndrome
Rare adverse effect of all antipsychotics
Fever
Sweating
Rigidity
Confusion
Fluctuating consciousness
Fluctuating blood pressure
Tachycardia
Raised CK
Leucocytosis
LFT derangement
Which drugs commonly interact with antipsychotics?
Sedatives e.g. sedating antihistamines
Drugs which cause hypotension
Drugs which prolong QT e.g. erythromycin
Azole antifungals - increase levels of some antipsychotics (e.g. haloperidol)
Carbamazepine - decreases levels of antipsychotics
Grapefruit juice - increases levels of pimozide
SSRI - increase levels of some antipsychotics (e.g. haloperidol and fluoxetine)
Smoking cessation - increases level of olanzapine and clozapine
Give examples of SSRIs
Fluoxetine
Sertraline
Citalopram
Escitalopram
Paroxetine
List important adverse effects of SSRIs
Cardiac - palpitations, QT prolongation (citalopram and escitalopram), torsade de pointes
GI - reduced appetite, diarrhoea, nausea, constipation, vomiting, weight changes, hepatitis (rare)
CNS - sleep disorders (insomnia common), headache, dizziness, reduced seizure threshold, drowsiness, serotonin syndrome (rare)
Psychiatric - anxiety, memory problems, suicidal thoughts
Skin - hyperhidrosis (common)
Other - menstrual cycle abnormalities, sexual dysfunction, hyponatraemia (especially in elderly), impaired diabetic control, bleeding
List the risk factors for bipolar affective disorder
Genetic:
Very heritable - 5x greater lifetime risk if first degree relative with bipolar disorder
Environmental:
Maternal infections - toxoplasma gondii
Premature birth
Early life stress - childhood abuse/trauma
Cannabis and cocaine use
Describe the types of bipolar affective disorder
Bipolar I - has had at least one episode of mania
Bipolar II - has had at least one episode of hypomania (but never an episode of mania), and at least one episode of major depression
Describe the clinical features of bipolar affective disorder
Mania - >7 days, usually begin abruptly, caused marked impairment of social/occupational functioning
Abnormally elevated mood, extreme irritability, increased energy or activity, restlessness, decreased need for sleep
Pressure of speech, flight of ideas, racing thoughts, poor concentration
Increased libido, disinhibition, sexual indiscretions
Psychotic symptoms - delusions (usually grandiose) or hallucinations (usually voices)
Hypomania - not severe enough to cause functional impairment, no psychotic features, 4-7 days
Mild elevation or mood or irritability
Increased energy and activity, may lead to increased performance at work/socially
Increased sociability
Depression - persistent low mood, anhedonia, low energy (+ other features)
What are the differential diagnoses for bipolar affective disorder? How are these distinguished from bipolar affective disorder?
Unipolar depression - no manic/hypomanic episodes
Cyclothymia - chronic disturbance of mood where symptoms do not meet criteria for bipolar disorder or depression
Schizophrenia - absence of prominent mood symptoms, auditory hallucinations usually 3rd person rather than 2nd person
Mood disorder due to underlying medical condition e.g. thyroid
Substance misuse - symptoms subside within 7 days
Personality disorders - rapid mood changes, do not occur in cycles
How is bipolar affective disorder managed?
Risk assessment - include potential consequences of poor judgement/actions during acute episodes (employment, relationships, finance, sexual activity, alcohol/drug use)
Acute phase management:
Mania - antipsychotic (haloperidol, olanzapine, quetiapine or risperidone), if two antipsychotics are tried and do not give response may add lithium or sodium valproate (unless pre-menopausal woman)
Depression - antipsychotic +/- antidepressant (fluoxetine), lamotrigine
Long-term management:
Relapse prevention - continue treatment for mania, start long term lithium or add valproate if lithium alone not effective
Psychological therapies specifically for bipolar depression
Important to take measures e.g. appointing power of attorney, advance statement to ensure wishes are known during possible future episodes
List risk factors for generalised anxiety disorder
Female sex
Comorbid anxiety disorder e.g. social phobia
Childhood adversity - maltreatment, neglect, domestic violence, bullying
History of physical, sexual or emotional trauma
Sociodemographic factors - divorce, unemployment, low socioeconomic status, low education level
Chronic physical condition e.g. cancer
Describe the physical features of generalised anxiety disorder
Psychological symptoms:
Chronic, excessive feelings of worry not related to particular circumstances
Restlessness
Sense of dread
Feeling constantly on edge
Difficulty concentrating, easily distracted
Feelings of detachment - derealisation, depersonalisation
Fear of losing control
Fear of dying
Panic attacks
Sleep disturbance
Physical symptoms:
Chest/abdo -
Nausea/churning stomach
Palpitations
Chest pain
Tachypnoea
Lightheadedness
Arousal symptoms -
Sweating
Dry mouth
Difficulty swallowing
Muscle stiffness/aches
Tremor
List the differential diagnoses of generalised anxiety disorder
Situational anxiety - controllable, no pathological symptoms, related to particular situation
Adjustment disorder - temporary anxiety in response to a life stressor, <6 months
Depression
Panic disorder - recurrent episodes of sudden onset anxiety, absence of multi-themed worry, physical symptoms during episodes, avoidance behaviours (often comorbid)
Social phobia - limited to social situation, avoidance behaviour common
Obsessive-compulsive disorder - anxiety due to compulsions/obsessions
Post-traumatic stress disorder - anxiety caused by exposure to reminders of past trauma, flashbacks and nightmares
Anorexia nervosa - anxiety related to fear of gaining weight
Substance or drug-induced anxiety disorder, or withdrawal related anxiety
How is generalised anxiety disorder managed?
Step 1 - education about GAD and treatment options, active monitoring
Step 2 - low-intensity psychological interventions (individual self-help, psychoeducational groups)
Step 3 - high-intensity psychological intervention (e.g. CBT) or drug treatment (SSRI - sertraline usually offered first, other SSRI or SNRI if ineffective)
Step 4 - complex drug and/or psychological treatment regimen, inpatient care
List features of phobic anxiety disorders
Anxiety evoked only/predominantly by a specific external situation, e.g.
Agoraphobia - crowds, public places, leaving home
Social phobia - low self esteem, fear of criticism/embarrassment
Claustrophobia
Anticipatory anxiety - about exposure to precipitant and anxiety itself
Somatic symptoms - palpitations, sweating etc.
List features of panic disorder
Recurrent unpredictable episodes of severe acute anxiety, not restricted to particular stimuli or situations
Crescendo of anxiety
Somatic symptoms
Secondary fear of dying/losing control - often related to somatic symptoms
List features of post-traumatic stress disorder
Develops following exposure to extremely traumatic event/series of events
Features - HARD:
Hyperarousal - persistently heightened perception of current threat
Avoidance of situations reminiscent of events or memories of events
Re-experiencing events - intrusive memories, flashbacks, nightmares
Distress - strong/overwhelming fear and physical sensations when re-experiencing
How is PTSD managed?
Prevention (for those with acute stress disorder or symptoms of PTSD within 1 month exposure to traumatic events) - psychological interventions e.g. cognitive processing therapy
> 1 month from traumatic events - treatment
Psychological treatment - trauma-focused CBT
Eye movement densensitisation and reprocessing (EDMR)
Drug treatment - SSRI or venlafaxine, antipsychotics only if no response to other treatments and psychotic symptoms
How is social anxiety disorder managed?
CBT
SSRI - escitalopram or sertraline
How is OCD managed?
Step 1 - Low intensity psychological treatment - brief individual CBT, group CBT
Step 2 - SSRI
Step 3 - Combined CBT + SSRI
List drugs which act as mood stabilisers
Lithium
Carbamazepine
Sodium valproate
List the indications for lithium treatment
Acute treatment of mania or hypomania in bipolar disorder
Prophylaxis/maintenance in bipolar disorder and schizoaffective disorder
Prophylaxis in recurrent depressive illness
Augmentation of antidepressants in acute depressive illness
Treatment of depression in bipolar disorder
List the contraindications to treatment with lithium
Addison’s disease
Cardiac disease associated with rhythm disorder - ECG required prior to treatment
Cardiac insufficiency
Dehydration
Family or personal history of Brugada syndrome
Low sodium diet
Untreated hypothyroidism - TFTs required prior to treatment
Pregnancy - causes tricuspid deformity
List adverse effects of lithium
LITHIUM -
L - lethargy
I - insipidus (diabetes insipidus - increased thirst, excessive urination)
T - tremor
H - hypothyroidism, hyperparathyroidism
I - insides (GI - nausea, vomiting, diarrhoea)
U - urine (increased)
M - metallic taste, muscle weakness
Others -
Weight gain
Renal tubular necrosis - renal failure
Confusion, drowsiness, feeling dazed
Seizures
List adverse effects of lithium
LITHIUM -
L - lethargy
I - insipidus (diabetes insipidus - increased thirst, excessive urination)
T - tremor
H - hypothyroidism, hyperparathyroidism
I - insides (GI - nausea, vomiting, diarrhoea)
U - urine (increased)
M - metallic taste, muscle weakness
Others -
Weight gain
Renal tubular necrosis - renal failure
Confusion, drowsiness
Seizures
Toxicity
Describe the presentation of lithium toxicity. What level of lithium in serum is toxic?
Initially -
Fine tremor
Nausea/vomiting
Dizziness
Progresses to -
Course tremor
Ataxia
Dysarthria
Drowsiness
Confusion
Seizures
Coma
Death
Serum level >1.2mmol/L
What investigations and management is required in lithium overdose?
Investigations - serum lithium level, U&Es, ECG
Management -
Increase clearance via IV fluids
Reduce absorption via gastric lavage, whole bowel irrigation
Describe the clinical features of serotonin syndrome
Neurological - myoclonus, nystagmus, headache, tremor, rigidity, seizures
Mental state - irritability, confusion, agitation, hypomania, coma
Other - hyperpyrexia, sweating, diarrhoea, cardiac arrhythmias, death
List key drugs which interact with lithium and what the result of these interactions is
Thiazide (and loop to a lesser extent) diuretics, ACE inhibitors - increase lithium levels by reducing clearance, can cause toxicity
NSAIDs - increase lithium levels
Haloperidol, carbemazepine, serotonergic antidepressants - can cause severe neurotoxicity
How is a patient on lithium monitored?
Serum lithium levels measured one week after starting treatment/changing dose and once weekly until levels stable, then usually every 3 months (12 hours post-dose)
6 monthly -
Weight/BMI
U&Es including eGFR
Calcium
Thyroid function tests
What are the indications for anticonvulsants in bipolar affective disorder? Which drugs are used?
When lithium is ineffective/poorly tolerated in long-term prophylaxis for bipolar disorder
As an alternative to antipsychotic/lithium for mania/hypomania (valproate only)
1st line - valproate (unless woman of childbearing age)
Other options - lamotrigine, carbemazepine
List the contraindications to treatment with valproate
Active liver disease
Personal or family history of severe, drug-related hepatic dysfunction
Acute porphyria
Mitochondral disorders of polymerase gamma enzyme e.g. Alpers-Hutternlocher syndrome
List adverse effects of valproate
Gastric irritation, nausea
Lethargy/confusion
Weight gain
Hair loss, curly regrowth
Peripheral oedema
Rarely hepatic failure
Hyperandrogenism in women - menstrual cycle abnormalities, PCOS, fertility dysfunction
Thrombocytopaenia, leucopaenia, red cell hypoplasia
Pancreatitis
Seizures
Suicidal thoughts
What are the contraindications to treatment with lamotrigine?
Myoclonic seizures - may exacerbate
Parkinson’s disease - may exacerbate
Brugada syndrome
List adverse effects of lamotrigine
Skin rash - can be severe e.g. Stevens-Johnson syndrome/TEN
GI - nausea, vomiting, diarrhoea
Aggression, agitation
Diplopia, blurred vision, conjunctivities
Confusion, nightmares, hallucinations
Suicidal thoughts
List contraindications to carbemazepine treatment
Acute porphyrias
AV conduction abnormalities (unless paced)
History of bone marrow depression
Acute liver disease
Some HLA alleles predispose to cutaneous reactions e.g. Stevens-Johnson syndrome
List adverse effects of carbamazepine
GI discomfort, nausea
Dizziness
Drowsiness, fatigue
Headache
Leucopaenia, thrombocytopaenia
Skin reactions
Weight gain
Movement disorders e.g. ataxia
Describe the clinical features of cyclothymia
Similar to bipolar disorder with periods of depression and hypomania, but no episodes which meet criteria for a major depressive episode or manic episode
Symptoms >2 years
Describe the clinical features of catatonic depression
Usually underlying diagnosis of psychiatric illness - will present with worsening depression, mania or psychosis and catatonic symptoms
Motor disturbance - reduction in movement, agitation or mixture of both
Repetitive or purposeless movements and mannerisms
Rigidity, waxy flexibility
Mutism, echolalia (repetition of others speech), verbigeration (repeating meaningless phrases)
Refusal to eat/drink
Malignant catatonia - life-threatening autonomic dysfunction including fever, abnormalities in blood pressure, heart rate, respiratory rate, sweating, delirium
Describe the clinical features of seasonal affective disorder
Multiple depressive episodes (low mood, anhedonia, lack of energy, sleep and appetite problems, poor concentration, decreased libido) which have occurred during the same season in different years, usually winter
Define dementia
Progressive, irreversible clinical syndrome with impairment of more than one aspect of higher brain function (concentration, memory, language, personality, emotion), without impairment of consciousness
Range of cognitive and behavioural symptoms including memory loss, problems in reasoning and communication, change in personality and reduction in ability to carry out daily activities
Not attributable to normal ageing
List the most causes of dementia and their pathophysiology
Alzheimer’s dementia - amyloid plaques and tau neurofibrillary tangles
Vascular dementia - multiple small cerebrovascular infarcts
Lewy body dementia - Lewy body protein (alpha-synuclein) deposits
Fronto-temporal dementia (including Pick’s disease) - deposition of abnormal proteins (often tau) in frontal and temporal lobes
Prion protein diseases (CJD) - eating cattle meat infected with bovine spongiform encephalopathy
HIV-related dementia
Parkinson’s disease dementia - loss of dopaminergic neurons in substantia nigra
Describe the clinical presentation of dementia generally
Usually insidious onset with non-specific signs/symptoms
Cognitive impairment - memory loss, problems with reasoning and communication, difficulty making decisions, dysphagia, difficult carrying out coordinated movements, disorientated and unawareness of time and place, impairment of executive function (planning, judgement, problem solving)
Behavioural and psychological symptoms - psychosis (delusions, hallucinations), agitation and emotional lability, depression and anxiety, withdrawal or apathy, disinhibition, motor disturbance, sleep cycle disturbance and insomnia
Describe symptoms related to specific subtypes of dementia
Alzheimer’s - loss of short term and episodic memory, difficulty with executive dysfunction, aphasia, apraxia, agnosia
Vascular dementia - stepwise increases in severity of symptoms, may have focal neurological signs e.g. hemiparesis
Dementia with Lewy bodies - fluctuating cognition, recurrent visual hallucinations, features of Parkinsonism (bradykinesia, rest tremor, rigidity)
Frontotemporal dementia - personality change and behavioural disturbance with other cognitive functions relatively preserved initially
How should a patient presenting with dementia be assessed?
History from patient and collateral e.g. from family member
Blood tests to exclude reversible causes - FBC, ESR, CRP, U&Es, calcium, HbAlc, LFTs, TFTs, serum B12 and folate
May need urinalysis, CXR, ECG, syphilis serology, HIV testing
Assess cognition with scoring system e.g. 10-point cognitive screener or memory impairment screen
Specialist diagnosis of dementia subtype - can do further testing e.g. CSF analysis, PET scanning
Structural imaging e.g. MRI/CT
What are the principles of dementia management?
Involve family members and make care plan early
Non-pharmacological interventions - cognitive stimulation therapy, group reminiscence therapy, cognitive rehabilitation, occupational therapy
Pharmacological management - acetylcholinesterase inhibitors +/-memantine for mild to moderate Alzheimer’s, vascular dementia with Alzheimer’s and Lewy body dementia
Management of behavioural symptoms - attempt non-pharmacological first, give antipsychotics if risk of harm/severe distress
Describe the pharmacological options for management of dementia
Three acetylcholinesterase inhibitors - donepezil, galantamine, rivastigmine
Memantine - glutamate receptor antagonist
Acetylcholinesterase inhibitors are first line for mild - moderate Alzheimer’s and mild, moderate or severe Lewy body dementia
Memantine for those intolerant/contraindication to AChE inhibitors, first line for severe Alzheimer’s
AChE + memantine for moderate - severe disease
Describe the contraindications and side effects of acetylcholinesterate inhibitors
AChE inhibitors contraindications:
Galantamine - severe renal/hepatic impairment, urinary outflow obstruction, GI obstruction
All - hypersensitivity to drugs, pregnancy/breastfeeding, history of bradycardia/heart block
Adverse effects:
Vomiting, nausea, anorexia, weight loss
Dizziness, drowsiness
Arrhythmias
Headache
Hallucinations
Rarely - neuroleptic malignant syndrome
Describe the contraindications and adverse effects of memantine
Contraindications - severe hepatic/renal impairment, history of seizures/predisposing factors for epilepsy, hypersensitivity
Adverse effects -
Constipation
Hypertension
Dyspnoea
Headache
Dizziness
Impaired balance
Drowsiness
Rarely - seizures, depression, suicidal ideation
Define delirium
Acute, fluctuating, transient disturbance in level of consciousness, attention, global cognition and perception with an organic, reversible cause
List predisposing and precipitating factors for delirium
Predisposing:
Older age
Cognitive impairment e.g. dementia
Frailty/multi-morbidity
Significant injuries
Functional impairment
History of, or current, alcohol excess
Sensory impairment
Poor nutrition
Precipitating:
Infection e.g. UTI, pneumonia
Metabolic disturbance e.g. hypoglycaemia
Cardiovascular, respiratory or neurological disorders - MI, PE, stroke
Urinary retention
Hepatic failure, constipation
Severe pain
Alcohol intoxication or withdrawal
Medication - opioids, benzodiazepines, antihistamines, antipsychotics
Psychosocial factors - sleep deprivation, emotional stress, change of environment
Describe the clinical features of delirium
Acute - hours - days
Evidence of precipitating factor e.g. infection
Fluctuating symptoms - usually worse at night
Altered cognitive function - disorientated, memory/language impairment, poor concentration, confusion
Inattention
Disorganised thinking
Altered perception - delusions, visual/auditory hallucinations
Altered social behaviour - mood changes, inappropriate behaviour
Altered level of consciousness, sleep-cycle disturbance
How is delirium managed?
Identify and manage underlying cause
Gentle reorientation and reassurance
Short-term haloperidol for distress only if other measures have failed and patient is a risk to themselves or others
Describe the clinical features of schizoaffective disorder
Symptoms of schizophrenia (usually psychosis) and a mood disorder - usually bipolar disorder and depression
Have to have episodes of mood disorder-free psychosis in the context of a long term mood disorder
(If only psychotic symptoms during mood episode it is mood disorder with psychotic features not schizoaffective disorder)
Psychosis including delusions, hallucinations, disorganised thinking/speech/behaviour and negative symptoms
Mood symptoms - mania, hypomania, mixed or depression
Describe the classification of personality disorders and list disorders which belong to each type
Cluster A - ‘odd or eccentric’
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality
Cluster B - ‘dramatic, emotional or erratic’
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Cluster C - ‘anxious or fearful’
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
Describe the features of paranoid personality disorder
Suspicious
Hypersensitivity, easily offended
Unforgiving
Questions loyalty
Preoccupation with conspiratorial beliefs and hidden meaning
Perceives attacks on their character
Describe the features of schizoid personality disorder
Socially withdrawn
Preference for solitary activities
No emotional pleasure from activities
Emotional coldness
Indifferent to praise or criticism
Little interest in sexual interactions
Few friends/confidants
Describe the features of schizotypal personality disorder
Odd beliefs and magical thinking
Inappropriate affect
Odd speech but coherent
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Social and interpersonal deficits
Describe the features of antisocial personality disorder
No regard for social norms, rules and obligations e.g. the law
Unable to maintain relationships, consistent work, honour financial obligations
Lack of remorse
Deception - repeated lying, conning others
Impulsiveness
Irritability and aggressiveness
Reckless disregard for safety of self or others
Unable to experience guilt, no concern for others feelings
Describe the clinical features of borderline personality disorder
Intense, unstable relationships
Impulsivity
Unstable mood, angry outbursts
Unstable self imaging
Avoidance of real or imagined abandonment
Self harm, suicidal behaviour
Feelings of emptiness
Quasi-psychotic thoughts - short-lived, less bizarre than real psychosis
Describe the clinical features of histrionic personality disorder
Dramatic/theatrical
Inappropriately seductive
Need to be the centre of attention
Easily influenced
Preoccupied with physical appearance
Describe the clinical features of narcissistic personality disorder
Grandiose sense of self importance
Sense of entitlement
Lack of empathy
Very sensitive
Preoccupied with fantasies of success, power, beauty
Belief they are ‘special’ and ‘unique’
Need for admiration
Envious of others
Interpersonally exploitative
Arrogant/haughty attitude
Describe the clinical features of avoidant personality disorder
Feelings of being socially inhibited, criticised or rejected
Reluctance to take risks due to fear of embarrassment
Views self as inferior or inadequate to others
Tense and apprehensive
Restraint in intimate relationships due to fear of being ridiculed
Describe the features of dependent personality disorder
Pervasive need to be cared for by others
Difficulty making decisions without reassurance and advice
Unrealistic fears of being left to care for themselves
Uncomfortable/helpless alone
Describe the features of obsessive-compulsive personality disorder
Preoccupied with details, rules, lists, order, organisation
Perfectionism that hampers with completing tasks
Meticulous, scrupulous and rigid about ideas of morality, ethics and values
Unwilling to pass on tasks to others
Dedicated to work and efficiency, no time for leisurely activities
Displays stiffness and stubbornness
How are personality disorders managed? Describe their prognosis.
Assess and manage risk
Psychotherapy interventions - individual, family, group CBT
Pharmacotherapy -
Antipsychotics - may be helpful in schizotypal, borderline
Antidepressants - borderline
Mood stabilisers - borderline
Cluster A - poor prognosis
Cluster B - high risk for suicide, antisocial particularly poor prognosis, variable response for others
Cluster C - better prognosis
Describe the clinical features of adjustment disorder
Reaction to life stressor/traumatic event which is greater than the expected normal or significantly impairs their functional ability
Usually begin within 3 months of event, do not last longer than 6 months after the event
Can have features of depression, anxiety, PTSD, misconduct
Can have prominent suicidal behaviour
How is adjustment disorder managed?
Psychotherapy e.g. CBT
Pharmacotherapy e.g. antidepressants, benzodiazepines only with severe symptoms
Describe the presentation of self harm/suicidal behaviour
Self-harm - usually cutting, can also be self-poisoning (usually with OTC, less often with illicit drugs), burning, hanging, drowning, swallowing objects, jumping from height/in front of vehicles
Self harm can include suicide attempts as well as acts with little or no suicidal intent - to communicate distress, release internal tension, feel relief when overwhelmed
Self harm rates peak in 16-24 year old females, 25-34 year old males
Suicide rates highest in both aged 45-49
Associated with:
Low socioeconomic status
Social isolation
Stressful life events
Bereavement
Mental health disorders
Chronic physical health problems
Alcohol/drug misuse
Involvement with criminal justice system
How should self harm be managed acutely?
Examine physical injuries
Assess emotional and mental state, risk assessment - suicidal intent
Likely to need emergency department assessment if self-poisoned
May require treatment/admission against their wishes under Mental Health Act
Referral to community mental health team
How is self-harm managed long term?
Psychological interventions e.g. CBT
Harm minimisation strategies - use less harmful methods of self-injury e.g. pinching, ice cubes, rubber bands
Manage mental health problems e.g. anxiety, depression, addiction
Prevent access to means of self-harm - least dangerous drugs prescribed (e.g. SSRIs) and few tablets once
List indicators of serious intent in self-harm/suicidal behaviours
Final acts e.g. making a will, saying goodbye to family/friends
Planning of method (premeditation) - buying tablets, rope etc.
Measures to prevent interruption e.g. lonely spot, timing when others out of house
Patient’s perception of method most likely to be successful/lethal - even if this is not medically accurate it is the patient’s intent which matters
Active symptoms of mental illness especially severe depressive disorder
Absence of intoxicants at time of act (doesn’t mean attempt is less dangerous)
Regret over failure, indifference to being found/alive
Continuing means to commit suicide
Hopelessness
Ongoing intent
How is suicide risk managed acutely and long-term?
Admission to psychiatry ward if necessary
Diagnosis and treatment of mental illness and substance misuse problems
After acute crisis:
Discharge planning - follow-up in secondary care (community psychiatry, outpatient psychiatry) or primary care
How should the risk of harm to others be assessed? What factors should be considered and which factors indicate increased risk?
History:
Previous violence, known to criminal justice system
Poor concordance with treatment, discontinuation of disengagement
Impulsivity
Alcohol and substance use
Triggers, changes in behaviour or mental state which have occurred prior to previous violence or relapse
Anything which is likely to occur to change risk
Evidence of recent stressors or losses
Factors which have stopped them acting violently in the past
History of domestic violence
Lack of empathy
Environment:
Access to potential victims - children or other vulnerable people, caring for someone, occupation
Risk of harm via neglect - dependents
Access to weapons, violent means
Involvement in radicalisation
Mental state:
Delusions of persecution by others
Passivity - mind or body controlled by external forces
Voicing emotions related to violence or emotional arousal
Specific threats or ideas of retaliation
Thoughts linking violence and suicide (homicide-suicide)
Thoughts of sexual violence
Restricted insight
What do they think they are capable of? Do they think they could kill?
Consult other sources - carers, criminal record, police, probation reports
Formulating risk:
How serious is the risk?
How immediate is the risk?
Is the risk specific or general?
What are the signs of increasing risk?
Which specific management plan can best reduce the risk?
How should risk of harm to others be managed?
Dependent on level of risk, patient capacity, patient willingness to engage, patient support e.g. family etc.
May require detainment, tranquillisation, restraint if imminent serious risk, patient lacking capacity and not willing to engage
May be able to agree a safety plan with patient with some level of observation, management of mental illness/substance use issues
How should suicide risk be assessed?
- Current episode of self-harm:
Was there a precipitant?
Were precautions taken against discovery?
Did they do any final acts?
Were they intoxicated?
What method of self harm was used?
What was the intention of the self harm - to end life?
Who were they found by?
How do they feel about the attempt now, do they regret it?
Do they still feel suicidal?
What would prevent them doing it again - do they feel they have anything to live for? - Screen for other mental health disorders which increase the risk of suicide - depression, psychosis, anorexia (diagnosed or undiagnosed)
- Previous episodes of self-harm
- Past psychiatric history - diagnoses, previous admissions
- Past medical history
- Drug history
- Family history - any family members with psychiatric conditions, suicidal behaviours
- Social history - living situation (children?), occupation, financial, alcohol, illicit drugs
Describe the model used to assess the stages of addiction and the interventions which can be used at each stage
Stages of change:
Pre-contemplation - patient is not thinking about stopping, doesn’t acknowledge there is a problem (likely to be defensive, may not be receptive to intervention, encourage reflection without pushing)
Contemplation - patient is thinking about stopping, acknowledges there is a problem (likely to be more receptive to intervention, reinforce decision through evaluating pros and cons)
Preparation - patient is making plans to stop (identify obstacles, support system)
Action - patient tries to stop (likely to require close support, emphasise benefits and deal with obstacles)
Maintenance - patient remains abstinent (continuing follow-up, think about coping with relapse)
Relapse - resumption of old behaviours (evaluate triggers, reassess motivation and barriers, plan future coping strategies)
Describe the difference between a factitious disorder, malingering, conversion disorder, somatic symptom disorder and hypochondriasis
Factitious disorder (Munchausen’s) - intentionally feigns, exaggerates or produces symptoms in order to attain care from medical professionals
Malingering - intentionally feigns, exaggerates or produces symptoms for the intention of financial or other gain, e.g. relief from work
Conversion disorder (functional neurological disorder) - genuine neurological symptoms (not fabricated by patient) without an organic cause
Somatic symptom disorder - obsessive thoughts and anxiety over symptoms without an identifiable cause e.g. pain, weakness, fatigue, symptoms present >2 years
Hypochondriasis (illness anxiety disorder) - persistent belief in the presence of an underlying serious disease, refuses to accept reassurance or negative test results
How are medically unexplained symptoms e.g. conversion disorder managed?
Investigate for physical cause
Provide reassurance that symptoms are real and explain how psychological stresses can manifest as physical symptoms
Antidepressants often helpful
CBT
Describe the difference between harmful substance use and dependence
Harmful use - pattern of substance use which causes damage to physical health, mental health or social circumstances
Dependence - physiological, behavioural and cognitive phenomena where the use of a substance takes on a higher priority than other behaviours which previously had greater value, central is the strong/overpowering desire to take the substance
Describe the features of substance dependence syndrome
A strong desire or sense of compulsion to take the substance
Difficulties in controlling substance-taking behaviour in terms of onset, termination or levels of use
A physiological withdrawal state when substance has ceased or been reduced
Progressive neglect of alternative pleasures or interests because of substance use
Persisting with substance use despite clear evidence of overtly harmful consequences
Describe clinical features of benzodiazepine withdrawal
Anxiety
Agitation
Irritability
Diaphoresis
Confusion
Nausea
Palpitations
Insomnia
Seizures
Hallucinations
Psychosis
Describe clinical features of opioid withdrawal
Rhinitis
Lacrimation
Yawning
Dilated pupils
Diaphoresis
Insomnia
Diarrhoea
Nausea & vomiting
Piloerection
Abdominal cramps
Dysphoria
Tachycardia
Hypertension
Describe clinical features of delirium tremens
Hx of Alcohol
Confusion - Nocturnal worsening
Hallucinations - Lilliputian
Illusions - Insects
Anxiety/Fear
Tremulousness
Hypertension
Tachycardia
Tachypnoea
Seizures
List psychosocial interventions used in management of substance misuse and dependence
Motivational interviewing
Brief interventions - useful in misuse/harmful use not dependence
CBT - relapse prevention, anxiety management, coping skills
12-step programmes - AA, NA
Peer support
Therapeutic community/residential rehabilitation
Describe pharmacological options for management of opioid dependence
Detox - lofexidine or buprenophine
(high relapse rates)
Opioid replacement therapy - methadone or buprenorphine
Effective in reducing heroin use, injecting and sharing injecting equipment
Long half life
Respiratory depression in overdose
Prolonged QTc
Rapid loss of tolerance - high risk OD if missed doses and restarted at usual dose
How is benzodiazepine dependence managed?
Low, gradual reduction and withdrawal in licit dependence
Little evidence for use of other anxiolytics or psychological therapies
No evidence to support maintenance prescribing for illicit use
How is amphetamine dependence managed?
Psychological interventions - CBT, contingency management
No effective pharmacological treatment
Describe psychosis classically associated with cocaine use
Delusional parasitosis - skin infected with insects
Describe the psychiatric complications associated with cannabis use
High consumption in teenage years linked to onset of schizophrenia
Long term use - cognitive impairment affecting memory, concentration
Amotivational syndrome
Compare ‘baby blues’, postnatal depression and puerperal psychosis in terms of timing and prevalence
‘Baby blues’ - 60-70% of women, typically in the first 3-7 days after birth, especially in primips
Postnatal depression - 10% of women, most cases within a month of birth, peak at 3 months, last >2 weeks
Puerperal psychosis - 0.2% of women, occurs 2-3 weeks after birth
Describe the features of ‘baby blues’ vs postnatal depression
‘Baby blues’ - anxious, tearful, irritable, mood swings
Postnatal depression - classical depression features (low mood, anhedonia, low energy)
Describe the clinical features of puerperal psychosis
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
List risk factors for postnatal depression
Past psychiatric history
Psychological problems during pregnancy
Poor relationship - domestic violence
Lack of social support
Stressful life events
Low socioeconomic status
Previous miscarriage or termination
Difficult pregnancy/delivery
Unintended pregnancy
List risk factors for postpartum psychosis
History of postpartum psychosis
History of bipolar affective disorder
Family history of either
Primiparity
Obstetric complications during delivery
Discontinuing mood stabilisers
How are women with pre-existing depression managed during pregnancy?
Advise not to stop taking antidepressants abruptly
If taking TCAs, SSRI or SNRI for mild-moderate depression can consider gradually stopping and monitoring response
Can switch to high intensity psychological intervention e.g. CBT
If severe depression need to consider risk of medication vs risk of depressive symptoms to mother and baby - can switch to lower risk drug, stop during 1st trimester only (highest risk teratogenicity) add or switch to CBT
Describe the use and risks of the following drugs during pregnancy:
Valproate
SSRIs
MAOIs
Which antidepressants are first line in pregnancy and breast feeding?
Valproate - organ dysgenesis (craniofacial and cardiac abnormalities), IUGR, neonatal toxicity, neurobehavioural toxicity (SHOULD BE AVOIDED IF POSSIBLE)
SSRIs - cardiac malformations (paroxetine), prematurity, low birth weight, persistent pulmonary hypertension, neonatal withdrawal symptoms (generally mild)
MAOIs - not much info, venlafaxine may be higher risk in overdose and withdrawal
Fluoxetine first line in pregnancy
Sertraline first line for breast feeding
Describe the prognosis of puerperal psychosis
Good prognosis from episode
High risk recurrence - puerperally and non-puerperally
Higher risk if personal or family history of PP or bipolar affective disorder
Describe the risks and use of lithium in pregnancy
Teratogenic - 4-12% risk of congenital abnormalities including cardiac malformation (Ebstein’s anomaly)
Highest risk 1st trimester
IUG - increased weight
Neonatal toxicity - floppy baby syndrome, hypothyroidism, prematurity
Neurobehavioural toxicity
Management during pregnancy:
Early USS and echo
Increase frequency of lithium checks
Increased dose usually required as pregnancy progresses
If stopped during pregnancy restart immediately on delivery if high risk
Very effective for prevention of puerperal psychosis in high risk
How is puerperal psychosis managed?
Monitoring of mother and baby
Usually require admission to mother and baby unit
CBT
Pharmacological - antidepressants, antipsychotics, mood stabilisers
ECT
How is postnatal depression managed?
Mild - reassurance and support, self-help, follow-up with GP
Moderate - antidepressants (e.g. SSRI, paroxetine recommended for breast feeding) and CBT
Severe - may need inpatient care on mother and baby unit
How can women be screened for postnatal depression?
Edinburgh postnatal depression scale
10-item questionnaire, indicates how the mother has felt over the previous week
>10 indicates depressive illness
Define learning disability
IQ <70
Impairment in social and adaptive functioning, understanding new or complex information, learning new skills
Reduced ability to cope independently
Onset before 18 years old
Describe the classification of the severity of learning disabilities
By IQ
Mild - 50-69
Moderate - 35-49
Severe - 20-34
Profound - <20
List causes of learning disability
Genetic e.g. Down syndrome, PKU, fragile X
Infective e.g. rubella (antenatal), meningitis, encephalitis (postnatal)
Trauma e.g. birth asphyxia, head trauma
Describe the specific mental health needs of patients with learning disabilities
Increased prevalence of mental health disorders - depression, schizophrenia, anxiety, delirium and dementia, ADHD
May present in different ways compared to general population
Behaviour (e.g. physical aggression) may be a sign of physical, mental or environmental problem
List common physical health problems which are high prevalence in patients with learning disabilities
Epilepsy
GORD
Constipation
Hearing and vision impairments
Problems related to underlying condition e.g. heart abnormalities, endocrine problems
How do the symptoms of depression vary in children/adolescents compared with adults?
Same core symptoms but can present differently
Classical biological symptoms relatively rare
Somatic symptoms
Social withdrawal
Psychotic symptoms rare
Mood - irritable, argumentative, defiant, aggression, angry
Sleep - insomnia and hypersomnia > early morning wakening
Declining school performance/attendance
Slow, insidious onset of symptoms
How should children/adolescents with depression be assessed differently to an adult?
Greater emphasis on collateral history - seek permission from patient
Can get collateral from parents, school, social services
Focus on social history - relationships (peer, family, love life), school, alcohol/drugs, life events/stressors
Protective factors - family relationships, external support (e.g. teachers), individual strengths
Comorbidity - ASD, ADHD, learning difficulties (e.g. dyslexia), learning difficulties
How should risk be assessed in children/adolescents with depression?
Suicidal thoughts
Self-harm
Risky behaviours e.g. alcohol, drug abuse, peer groups
Impulsivity, ambivalence
Risk of exploitation/abuse
How are children/adolescents with depression managed?
Greater school/social services/family involvement
Psycho-education
Psychological therapies - CBT, family therapy, play/art therapy
Pharmacotherapy - fluoxetine only licensed anti-depressant
Describe features of autism spectrum disorder
Usually identifiable <3 years old
Social:
Lack of eye contact
Delay in smiling
Avoids physical contact
Unable to read non-verbal cues
Difficulty establishing friendships
Not playing with others
Communication:
Delay or regression in language development
Lack of appropriate non-verbal communication e.g. smiling, eye contact, responding t others
Difficulty with imaginative or imitative behaviour
Repetitive use of words or phrases
Behaviour:
Greater interest in objects, numbers or patterns than people
Stereotypical repetitive movements e.g. self-stimulating movements used for comfort
Intensive and deep interests that are persistent and rigid
Repetitive behaviour and fixed routines
Anxiety and distress with experiences outside of normal routine
Restricted food preferences
List common comorbidities in ASD
Epilepsy
Bowel disorders
Schizophrenia
Sleep disorders
ADHD
Intellectual impairment
How is ASD managed?
Non-pharmacological:
Specialist education
Occupational therapy
Speech therapy
Psychological interventions
Pharmacological:
Depression/anxiety - SSRIs
Sleep difficulties - melatonin
Describe the features of ADHD
Symptoms present in childhood (<12)
Significantly impair functioning
Present in multiple settings
Inattention:
Difficulty sustaining attention, avoids sustaining attention
Distracted easily
Misplaces things
Organisation problems
Makes mistakes
Finds listening difficult
Forgetful in daily activities
Difficulty completing tasks
Hyperactive/impulsive:
Loud in quiet situations
Fidgets
Restless or overactive
On the go all the time
Seating difficulty
Talks excessively
Finds waiting difficult
Interrupts or intrudes
Blurts out prematurely
Other:
Affective instability
Constant mental activity
Mind wandering - restlessness, unrelated spontaneous thoughts, multiple thoughts at the same time
Hyperfocus
Paradoxical reaction to stimulant drugs
How do adults with ADHD present?
Chaotic, disorganised, late, loses things
Multiple jobs and relationships
Makes careless mistakes
Avoids books/films/queues
Restless, fidgets
Can’t relax
Rude, impatient, can’t wait
Loses train of thought
What is the differential diagnosis for ADHD?
Normal behaviour
Malingering or drug seeking
Hyperthyroidism
Substance abuse
Mania
Cyclothymia
Agitated depression
Anxiety disorder
ASD
Tourette’s syndrome
Describe the principles of ADHD management in children
Watchful waiting for up to 10 weeks to observe change/resolution of symptoms
Referral to CAMHS/paediatrician/child psychiatrist if severe symptoms
Non-pharmacological management:
Healthy diet (food diary), exercise
Behavioural management
Parent training
CBT
Pharmacological management (>5 only usually):
CNS stimulants - methylphenidate, lisdexamfetamine, dexamfetamine, atomoxetine
Describe the principles of ADHD management in adults
Healthy diet and exercise
Self-help
CBT
Occupational therapy
Medication offered if symptoms causes significant impairment after environmental modifications made
What are the first line pharmacological agents for children and adults with ADHD?
Children >5 - methylphenidate
Adults - lisdexamfetamine or methylphenidate
List side effects of methylphenidate (+ other stimulants used for ADHD)
Reduced appetite - weight loss
Insomnia
Headache
Irritability
Tachycardia, arrhythmias
Tics
Seizures
Compare the mechanism of action and uses of stimulants vs non-stimulants in management of ADHD
Stimulants e.g. methylphenidate, dexamfetamine
Dopamine/noradrenaline reuptake inhibitors
Immediate action
Positive effect on attention even without ADHD
More potential for abuse/diversion
(Controlled drugs)
Non-stimulant e.g. atomoxetine
Noradrenaline reuptake inhibitor
Delayed onset of action
No positive effect on attention in those without ADHD (may help with comorbid conditions e.g. anxiety)
Preferable if concern about diversion, unresponsive/intolerant to stimulant
Non-controlled drugs
List side effects of non-stimulant drugs e.g. atomoxetine used in management of ADHD
Reduced appetite
Nausea
Insomnia
Dizziness
Constipation
Sweating
Sexual dysfunction
Seizures
Acute liver failure
Suicidality
Contraindication - phaemochromocytoma
Describe the psychological and behavioural features of anorexia nervosa
Highest prevalence in 13-17 year olds, F>M
Restriction of energy intake resulting in low body weight - BMI <18.5 or less than 5th percentile on growth chart
Intense fear of gaining weight/pursuit of thinness - preoccupation with food and weight, repeated weighing, measuring and checking in the mirror
Behaviour that interferes with weight gain - self-induced purging, excessive exercise, use of appetite suppressant medication
Psychological disturbance - distortion of body imagine, low self-esteem, drive for perfection
Denial of seriousness of malnutrition and impact on physical health
Describe the physical consequences of anorexia nervosa
Hormonal disturbance - amenorrhoea, loss of libido, delayed onset of puberty
Dry skin
Abdominal pain
Pallor
Hair loss
Bradycardia
Orthostatic hypotension
Hypothermia
Loss of muscle strength
Oedema
Constipation
Fainting
Dizziness
Fatigue
Lanugo hair - fine, soft hair across body
Hypokalaemia
Hypoglycaemia
Osteoporosis
Anaemia
Atypical dental wear e.g. erosion
Cardiac complications - arrhythmias, cardiac atrophy, sudden cardiac death
How is anorexia managed in adults?
Psychoeducation - nutrition and affects of malnutrition
Psychological interventions - eating-disorder-focused CBT, Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), SSCM
If these are unacceptable can use focused focal psychodynamic therapy
How is anorexia nervosa managed in children and young people?
Anorexia nervosa focused family therapy for children and young people - single and family sessions
If not acceptable for the patient can consider CBT-ED or adolescent focused psychotherapy
Describe the psychological features and behaviours typical of bulimia nervosa
Recurrent episodes of binge eating occurring on average at least once a week for 3 months - consuming an excessive amount of food in a discreet time period with a sense of loss of control over eating at that time
Recurrent inappropriate compensatory behaviour to prevent weight gain - vomiting, fasting, excessive exercise, laxative, diuretic or diet pill use
Weight often within normal limits or above normal weight range for age
Psychological features - fear of gaining weight, mood disturbance, symptoms of anxiety, persistent preoccupation and craving for food, feelings of guilt and shame about binge eating, self harm
Describe physical consequences of bulimia nervosa
Russel’s sign - knuckle calluses from inducing vomiting
Dental enamel erosion
Salivary gland enlargement
Alkalosis - vomiting
Hypokalaemia
Mouth ulcers
GORD
Mallory-Weiss tears
Aspiration pneumonitis
How is bulimia nervosa managed in adults and children?
Adults:
Bulimia-nervosa-focused guided self help programmes OR
CBT-ED
Children:
Bulimia-nervosa-focused family therapy (FT-BN) OR
CBT-ED
Describe the clinical features of binge eating disorder
Recurrent episodes of binge eating (at least once per week for 3 months) in the absence of compensatory behaviours (no purging/over-exercising etc.)
Binge = consuming an excessive amount of food in a discreet time period accompanied by a feeling of loss of control where the person cannot stop eating or control the amount of food they eat
May eat more quickly than normal, eat until uncomfortably full or when not hungry, and experience significant distress and feelings of guilt and shame
Body weight may be normal, overweight or obese
How is binge eating disorder managed?
Binge-eating-disorder-focused guided self-help programme or group CBT-ED
(weight loss is not a treatment!)
Define atypical eating disorders. How are they managed?
Aka Other Specified Feeding and Eating Disorders (OFSED) or Eating Disorder Not Otherwise Specified (EDNOS)
Eating disorder which does not fit exactly into a diagnostic category - can have features of anorexia, bulimia or binge eating disorder but not meet diagnostic criteria
No evidence to guide management - follow guidance on treatment of ED which most closely resembles the patient’s presentation
How should physical health complications of eating disorders be managed?
Monitor and treat fluid and electrolyte balance abnormalities
May require ECG monitoring (caffeine, electrolyte imbalance etc.)
Dental care if vomiting - regular dental view, avoid brushing immediately after, rinse with non-acid mouthwash, avoid highly acidic foods and drinks
Monitor weight or BMI
Low bone mineral density - can give oestrogen +/- bisphosphonates
Recognise those at risk of refeeding syndrome and manage appropriately
Which patients are at risk of refeeding syndrome?
BMI <16
Weight loss >15% within last 3-6 months
Little or no nutritional intake for >10 days
Low levels of potassium, phosphate, magnesium prior to feeding
History of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics
Presence of purging behaviours e.g. vomiting, laxative misuse
Describe the pathophysiology of refeeding syndrome and the abnormalities it causes
Starvation - catabolic state, lack of carbohydrate so use of protein and fat metabolism, intracellular minerals (particularly phosphate) become severely depleted, although can have normal serum levels, insulin secretion suppressed, glucagon secretion increased
Refeeding - rapid switch to anabolism, insulin secretion resulting in increased glycogen, fat and protein synthesis
Requires phosphate, magnesium and potassium which are already depleted
Also have tissue ischaemia, intracellular movement of serum electrolytes
Hyperglycaemia
Low thiamine levels
Metabolic disturbances =
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Thiamine deficiency
Salt and water retention
Causes arrhythmia, heart failure, fluid overload
How is refeeding undertaken to prevent refeeding syndome?
Immediately before and during the first 10 days of feeding: oral thiamine 200-300mg daily, vit B Co Strong 1-2 tabs tds and a balanced multivitamin/ trace element eg. Forceval 1 tab once daily
Re-feeding plan prescribed by nutrition support team or dietician, starting at 20kcal/kg/day and gradually increasing based on daily bloods (may be less if high risk for refeeding syndrome but should avoid underfeeding syndrome)
Describe monitoring required during refeeding
Daily Bloods:
U&Es, LFTs, Bone Profile, Glucose
Close monitoring of Mg, K+ & phosphate
Daily ECG
Fluid Balance
Bowels
Monitor for oedema, BP, pulse, Ox sats
What measures may be taken for severely unwell patients with eating disorders who are managed as inpatients?
1:1 observation by experienced nurse to avoid sabotage of care
Bed rest with DVT prophylaxis
Supervised washes
Tissue viability assessment
Fluid input/output charts
Access to toilets/taps restricted
Meal and snack supervision, post-meal and snack supervision
More frequent observations and BMs
List risk factors for criminal behaviour in those with mental illnesses
Psychosis - particularly first episode
Antisocial personality disorder
Alcohol/drug use
Medication non-compliance
Undiagnosed or untreated mental illness
Socio-economic factors - unemployment, homelessness
Cognitive impairment
List indications for ECT
Treatment resistant depression
Acutely depressed - risk to life through suicidality or not eating/drinking
Catatonia
Prolonged/severe mania
Life-threatening mental illness during pregnancy
Postpartum psychosis
Occasionally schizophrenia
Describe the process of ECT
Given twice weekly
EEG monitoring throughout
Pre-oxygenation
General anaesthetic (induction) and muscle relaxant given
Electrodes (usually bitemporal) deliver electric current to brain, which induces seizure - unconscious for approximately 5 minutes
Monitored after treatment to ensure recovery from anaesthetic
What are the contraindications to ECT?
Phaeochromocytoma
Increased intracranial pressure with mass effect
Recent MI, stroke
Uncontrolled HTN
Arrhythmia
Glaucoma
History of cerebral or aortic aneurysm
High-risk pregnancy
List potential adverse effects of ECT
Anaesthetic complications
Cardiovascular complications - arrhythmias, hypo/hypertension, stroke
Respiratory complications - tachypnoea, airway spasm, pneumonia, hypoxia, pulmonary oedema
Prolonged seizure - >2 minutes, requires IV lorazepam or midazolam, can progress to status epilepticus
Dental trauma - use bite block to minimise risk
Headache, muscle ache, nausea
Confusion - post-ictal usually short-lived
Cognitive side effects - memory loss, learning impairment ?
How does consent work for patients being given ECT?
Most can consent themselves
If severely unwell and lacking capacity but ECT is clinically indicated and likely to benefit them - need local second opinion (agree that ECT would be beneficial) then formal second opinion from designated medical practitioner (DMP)
DMP is completely separate from team looking after patient
Which tests are requires prior to ECT?
Bloods - U&Es, FBC, glucose, LFTs, TFTs
Urinalysis
ECG - QTc
CXR
Lithium level
INR if on warfarin
Pregnancy test
COVID-19 test
List the types of psychosurgery and their indications
Anterior capsulotomy - OCD
Subcaudate tractotomy - anxiety, depression, OCD
Limbic leucotomy - OCD, depression
Deep brain stimulation - movement disorders e.g. Parkinson’s, OCD
Anterior cingulotomy - OCD, depression
List the potential adverse effects of psychosurgery
All - haemorrhage, stroke, infection, breathing issues, nausea, seizures
Anterior capsulotomy - weight gain, executive function disorder, apathy, disinhibition
Limbic leucotomy - transient hallucination, amnesia, mania
Anterior cingulotomy - headache, nausea, vomiting, seizures
Deep brain stimulation - paraesthesias, speech/balance problems, mood swings, visual disturbance
List indications for CBT
Depression
Anxiety, panic and phobia disorders
Bipolar affective disorder
Eating disorders
OCD
PTSD
Psychosis
Schizophrenia
Sleep issues
Alcohol and drug misuse
Also used in chronic conditions with psychological aspect e.g. IBS, ME, fibromyalgia, chronic pain
Describe the concepts of CBT
Explore connections between thoughts, feelings, physical sensations and behaviours
Identify negative/unhelpful thoughts, feelings and actions and how to change them
Unhelpful thinking styles e.g. all or nothing thinking, over-generalisation, jumping to conclusions which are more frequent/harder to challenge in conditions e.g. anxiety and depression
Specific strategies for change and how to implement them
List pros and cons of CBT
Pros
Can be done quickly
Highly structured - can be given as group, books, online
Teaches practical strategies which can be used after treatment finished
Different versions tailored to specific conditions e.g. ED-CBT
Cons
Patient needs to be willing to commit to process get something out of it
May not be suitable for more complex issues or those with learning difficulties
Doesn’t address underlying causes of conditions (e.g. childhood events), problems in family which may have significant impact on mental health
List the indications for psychotherapy
Mild to moderate major depressive disorder
Dysthymic disorder
Mild to moderate anxiety disorder
Somatic symptoms with significant psychological component (with some patient insight)
Severe/chronic depression - as adjunct to pharmacotherapy
Bipolar affective disorder (to some extent)
Describe the principles and aim of psychotherapy
Idea that past relationships are recreated in current relationships - including relationship between therapist and patient
Aims:
Improve insight - identify unhelpful conscious processes and defence mechanisms (e.g. projection, repression, rationalisation)
Improvement of management of distress
Describe the principles and aims of counselling
Aims to help patient become clearer about problems, and be able to come up with their own answers
Therapist avoids giving answers/advice
Strengthen existing coping strategies
List the indications for counselling
Mild - moderate depression, anxiety, eating disorder
Mental distress due to physical health condition e.g. infertility or stressful life event e.g. bereavement, work-related stress
Self-esteem or anger issues
Sexual identity
List the individuals who work as part of the community psychiatry team
Psychiatrist
Community psychiatric nurse
Social worker
Occupational therapist
Clinical psychologist
Pharmacists
Responsible medical officer - usually psychiatrist
Mental health officer
Support worker
May also have advocate who is not part of team
List agencies available for psychiatric support in the community
Community mental health teams
Day centres
Residential care - hostels, residential care homes, supported housing schemes
Crisis intervention and home treatment team
Give examples of serotonin/noradrenaline reuptake inhibitors (SNRIs)
Venlafaxine
Desvenlafaxine
Duloxetine
Milnacipran
Levomilnacipran
List the indications for SNRIs
Major depression
Generalised anxiety disorder
Social anxiety disorder
Panic disorder
List contraindications of SNRIs
Uncontrolled hypertension
Hepatic/renal impairment - duloxetine
Caution in:
Bleeding disorders
Epilepsy
Personal or family history mania/bipolar
Cardiac disease, high risk arrhythmias
Diabetes - may affect glucose levels
List adverse effects of SNRIs
Cardiac - palpitations, tachycardia, hypertension
GI - decreased appetite, nausea (very common), constipation, vomiting, diarrhoea, abdominal pain, GI haemorrhage, hepatitis, pancreatitis
CNS - headache, sleepiness (common), tremor, paraesthesia (common), movement disorders, sleep disorder, seizure
Psychiatric - insomnia, confusion, anxiety, agitation, suicidal thoughts
Skin - rash
Other - menstrual cycle irregularities, sexual dysfunctino, hyponatraemia, neuroleptic malignant syndrome, serotonin syndrome
Why is it important to establish if a patient is taking St John’s Wort for depression?
If co-prescribe an SSRI or other 5-HT potentiating drugs with St John’s wort can induce serotonergic syndrome
Describe the aversive drugs which can be used in the management of substance dependence
Disulfram - aldehyde dehydrogenase inhibitor, produces acute sensitivity to alcohol e.g. flushing, headache, nausea, vomiting, palpitations, tachycardia, hypotension, anxiety
Acamprosate - manages alcohol cravings, used with psychosocial support
Opiate antagonists:
Nalmefene - alcohol (reduced enjoyment)
Naltrexone - opiate or alcohol abuse, reduces cravings and enjoyment
List tricyclic antidepressants
Amitriptyline
Clomipramine
Dosulepin
Imipramine
Lofepramine
Nortriptyline
List contraindications of tricyclic antidepressants
Acute porphyrias
Arrhythmias
Heart block
Severe hepatic/renal impairment
Manic episode in bipolar
Immediate period after MI
With MAOI
List potential adverse effects of tricyclic antidepressants
Cardiac - palpitations, arrhythmias, tachycardia, AV block, bundle branch block, QT prolongation, MI, sudden cardiac death
Vision - accommodation disorder, mydriasis, blurred vision
GI - reduced appetite, constipation, nausea, diarrhoea, vomiting, abdominal pain, paralytic ileus
CNS - tremor, dizziness, reduced concentration, drowsiness, movement disorders, peripheral neuropathy, seizure
Psychiatric - aggression (very common), confusion, anxiety, delirium, hallucinations, suicidality
Other - bone marrow depression, hyponatraemia, neuroleptic malignant syndrome, sexual dysfunction
Dangerous in overdose
List monoamine oxidase inhibitors and describe their mechanism of action
Phenelzine, isocarboxazid, tranylcypromine - inhibit MAOA and B irreversibly
Moclobemide - inhibits MAOA reversibly
Inhibit monoamine oxidase, enzyme which breaks down neurotransmitters
A - noradrenaline, serotonin, dopamine, tyramine
B - dopamine, tyramine etc.
List contraindications to monoamine oxidase inhibitors
Cerebrovascular disease
Manic episodes
Phaeochromocytoma
Severe cardiovascular disease
Caution in elderly
List potential adverse effects of monoamine oxidase inhibitors
CNS - confusion, dizziness, drowsiness, hallucination, headache, insomnia, paraesthesias, tremor, blurred vision
Psychiatric - suicidal
GI - appetite increased, weight increased, vomiting, constipation, jaundice
Cardiovascular - arrhythmia, postural hypotension, hypertensive (tyramine) reaction
Tyramine reactions - high levels of tyramine in fish, some meats, overripe fruits including avocados, bananas, raisins, figs, cheeses, alcohol, fava beans
MAO usually breaks down tyramine in the gut, high levels cause hypertensive reaction which can trigger cerebral haemorrhage
Describe the mechanism of tricyclic antidepressants
Primary action is serotonin and noradrenaline reuptake inhibition
More minimal action as dopamine reuptake inhibitors, acetylcholine and antihistamine antagonists
How should SSRIs be discontinued? Why?
Gradually decrease dose over 4 weeks (except fluoxetine - can be stopped immediately)
Prevent discontinuation symptoms:
Mood change
Restlessness
Insomnia
Unsteadiness
Sweating
GI symptoms - pain, cramping, diarrhoea, vomiting
Paraesthesia
Describe the mechanism of action of benzodiazepines
Increase activity of GABA through increasing frequency of chloride channels
List the psychiatric indications for benzodiazepines
Short-term relief (2-4 weeks) of severe, disabling anxiety causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness
Inappropriate to treat ‘mild’ anxiety
Insomnia only if severe, disabling, causing extreme distress
List examples of benzodiazepines
Diazepam
Lorazepam
Loprazolam
Temazepam
Describe dependence and withdrawal in benzodiazepines
Dependence - long term use >4 weeks, even with low doses
Withdrawal occurs one day - 3 weeks after stopping (3 weeks if long acting)
Symptoms:
Insomnia
Anxiety
Loss of appetite/weight loss
Tremor
Sweating
Tinnitus
Abrupt withdrawal can produce confusion, toxic psychosis, convulsions - should be withdrawn gradually
Describe the mechanism of action, indications and examples of Z-drugs
Zolpidem tartrate and zopiclone
Non-benzodiazepine hypotics - act to modify the GABA receptor
Used for insomnia
List contraindications to benzodiazepines
Acute pulmonary insufficiency
Neuromuscular respiratory weakness
Not for use alone to treat chronic psychosis, depression, obsessional state, phobic states, sleep apnoea syndrome, unstable myasthenia gravis
Caution in elderly, history of alcohol/drug dependence
List potential adverse effects of benzodiazepines
Sedative effect - drowsiness, ataxia, fatigue, impaired motor ability, confusion, deceased alertness (may impair ability to drive)
Enhanced sedation when prescribed with opioids, taken with alcohol
Paradoxical effects - agitation, aggression, antisocial behaviour
Headache
Vertigo
Tremor
Slurred speech
Decreased libido
Gynaecomastia
Sleep apnoea
Tolerance and dependence
Withdrawal syndrome
Who does the Mental Health (Care and Treatment) (Scotland) Act 2003
Includes - mental illness, learning disability, personality disorder
Excludes - sexual orientation, sexual deviancy, gender identify, dependence on/use of alcohol of drugs, behaviour that causes harassment, alarm or distress to another person, acting as no prudent person would act
List the types of detention detailed in the Mental Health (Scotland) Act 2003 and describe the conditions of each
Emergency detention - to keep/bring patient to hospital for assessment, lasts up to 72 hours, any full registered doctor but should be reviewed by senior psychiatrist ASAP, should have MHO consent if possible but not mandatory if essential, treatment not covered, cannot be appealed
Short term detention - to keep/bring patient to hospital for assessment and treatment, approved medical practitioner only, lasts up to 28 days, MHO consent essential, can be appealed, must be reviewed and revoked timeously
Compulsory treatment order - to bring/keep patient to hospital for treatment or to continue treatment in the community, two medical recommendations (one must be AMP), lasts up to six months and is renewable, MHO is the applicant, can be appealed, must be reviewed and revoked timeously
List the criteria for detention under Thee Mental Health (Scotland) Act 2003
Mental disorder
Significant risk to health, safety or welfare of the patient or safety of another person
Detainment is necessary to determine what medical treatment should be given or to give medical treatment
Seriously impaired decision making ability (SIDMA) in relation to medical treatment
Which treatments are safeguarded under The Mental Health (Scotland) Act 2003? What does this mean?
Artificial feeding
ECT
Treatments which directly act on the brain
Medications where the purpose is to reduce sex drive
Cannot be given without consent without a second opinion from a designated medical practitioner
How are patient’s rights protected by The Mental Health (Scotland) Act 2003?
Have to:
Take past and present wishes into account
Take views of carer, named person, guardian or welfare attorney into account
Make sure patients get the information and support needed to take part in decisions
Look at the full range of options for care
Give treatment that provides maximum benefit
Take account of background, beliefs and abilities
Make sure any restrictions on freedom are the minimum necessary in the circumstances
Carers needs taken into account
Make sure they are not treated less favourably than other patients
Take special care of welfare if <18
List the main sections of a full psychiatric history
Presenting complaint
History of presenting complaint
RISK ASSESSMENT
Past psychiatric history - diagnoses, previous admissions, detention/treatment under Mental Health Act, care in community
Past medical history
Drug history - compliance
Family psychiatric history
Social history - living situation, employment, finances, family/relationships, alcohol/drugs
Personal history - birth, developmental milestones, school, friends, criminal justice system involvement, work
Pre-morbid personality/functional level - how would you describe yourself, how would others describe you?
List the main sections in a mental state examination
Appearance
Behaviour
Mood and affect
Speech
Thoughts - form and content, passivity
Perception
Cognition - MMSE, AMTS, ACE-III, MoCA
Insight and judgement
Which legislation describes the ability to detain and treat patients with mental disorders against their will?
The Mental Health (Care and Treatment) (Scotland) Act 2003
List the requirements for capacity and incapacity
Assume all adults (>16) have capacity
Can:
Understand information relevant to the decision
Retain the information
Use the information to make decision
Communicate decision
What legislation is used if a patient does not have capacity?
Adults with Incapacity (Scotland) Act 2000
Give examples of selective noradrenaline reuptake inhibitors and list their indications
Reboxetine - major depressive disorder
Atomoxetine - ADHD
List contraindications to selective noradrenaline reuptake inhibitors
Phaeochromocytoma
Severe cardiovascular disease
Severe cerebrovascular disease
List potential adverse effects of selective noradrenaline reuptake inhibitors
GI - decreased appetite, constipation, nausea, vomiting
Cardiovascular - palpitations, tachycardia
Neurological - headache, insomnia, paraesthesia
Other - sexual dysfunction, urinary disorders, urinary tract infection
Describe the cause and clinical features of Wernicke’s encephalopathy and Korsakoff’s syndrome
Caused by thiamine deficiency, most commonly seen in alcoholics
Wernicke’s
Oculomotor dysfunction - nystagmus, ophthalmoplegia
Gait ataxia
Encephalopathy - confusion, disorientation, indifference, inattentiveness
Peripheral sensory neuropathy
Can develop Korsakoff’s if not treated -
Antero- and retrograde amnesia
Confabulation
What is avoidant and restrictive food intake disorder? List triggers for ARFID.
Restriction of eating to small amounts or avoidance of certain foods or food groups - without altered beliefs about size/shape of body, not for specific purpose of losing weight, no behaviours associated with anorexia/bulimia e.g. over-exercising
Triggers - choking or vomiting episodes, anxiety disorders, ADHD, ASD
