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!Final Year > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is Bipolar Affective Disorder?

A

A chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression

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2
Q

What is the epidemiology of bipolar affective disorder?

A

Typically develops in the late teen years
lifetime prevalence: 2%

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3
Q

What are the two types of bipolar affective disorder?

A

Type I disorder: mania and depression (most common)
Type II disorder: hypomania and depression

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4
Q

What is the difference between mania and hypomania?

A

Both terms mean abnormally elevated mood or irritability
Mania: severe functional impairment or psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania for >7 days
Hypomania: decreased or increased function for >4 days

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5
Q

What are the referral guidelines for bipolar affective disorder?

A

If symptoms suggest hypomania: NICE recommend routine referral to the community mental health team
If there are features of mania or severe depression then an urgent referral to the CMHT should be made

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6
Q

What is the management for bipolar affective disorder?

A

Psychological interventions
Medication:
lithium remains the mood stabilizer of choice
Management of mania/hypomania or depression

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7
Q

What is the management of mania/ hypermania?

A

Consider stopping antidepressant if the patient takes one
Start antipsychotic therapy e.g. olanzapine or haloperidol

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8
Q

What is the management of depression in BPAD?

A

Talking therapies
Consider SSRIs (1st = fluoxetine) but not encouraged due to risk of manic episode

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9
Q

What co-morbidities are patients with BPAD at risk of getting?

A

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

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10
Q

What is the therapeutic range for lithium?

A

0.4-1.0 mmol/L

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11
Q

What are some of the adverse effects of Lithium?

A

Nausea/vomiting, diarrhoea
Fine tremor
Nephrotoxicity: polyuria, secondary to nephrogenic DI
Thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
Weight gain
Idiopathic intracranial hypertension
Hyperparathyroidism and resultant hypercalcaemia

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12
Q

What are some considerations regarding Lithium monitoring?

A

When checking lithium levels, the sample should be taken 12 hours post-dose
After starting lithium levels should be performed weekly and after each dose change until concentrations are stable
Once established, lithium blood level should ‘normally’ be checked every 3 months
Measure thyroid and renal function every 6 months
Patient should have an alert card and a record book

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13
Q

At what concentration does Lithium toxicity occur?

A

Concentrations > 1.5 mmol/L

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14
Q

What can precipitate Lithium toxicity?

A

Dehydration
Renal failure
Drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole

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15
Q

What are some of the features of Lithium toxicity?

A

Coarse tremor (a fine tremor is seen in therapeutic levels)
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma

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16
Q

What is the management of Lithium toxicity?

A

Mild-moderate toxicity: may respond to volume resuscitation with normal saline
Severe toxicity: haemodialysis may be needed

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17
Q

What are personality disorders?

A

A series of maladaptive personality traits that interfere with normal function in life

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18
Q

What are the three clusters of personality disorders?

A

Cluster A: Odd or eccentric
Custer B: Dramatic, emotional or erratic
Cluster C: Anxious and fearful

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19
Q

What are the three personality disorders in Cluster A (odd or eccentric)?

A
  1. Paranoid
  2. Schizoid
  3. Schizotypal
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20
Q

What is the difference between schizoid and schizotypal personality disorder?

A

Schizoid:
- Preference for solitary activities
- Lack of interest in sexual interactions
- Few interests and friends or confidants other than family
- Emotional coldness
Schizotypal:
- Odd beliefs and magical thinking
- Paranoid ideation and suspicion
- Odd speech

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21
Q

What are the four personality disorders in Cluster B?

A
  1. Antisocial
  2. EUPD
  3. Histrionic
  4. Narcissistic
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22
Q

What are the three personality disorders in Cluster C?

A
  1. Obsessive- compulsive
  2. Avoidant
  3. Dependent
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23
Q

What is the main management of personality disorders?

A

Psychological therapy = dialectical behaviour therapy
Treatment of any coexisting psychiatric conditions

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24
Q

What are the different options in smoking cessation?

A
  1. Nicotine replacement therapy
  2. Varenicline (a nicotinic receptor partial agonist)
  3. Bupropion (nicotine antagonist)
    2 + 3 contraindicated in pregnancy and breastfeeding
    3 also contraindicated in epilepsy (due to risk of seizure) and eating disorders (relative)
25
What are the two main eating disorders?
1. Anorexia nervosa 2. Bulimia nervosa
26
What is anorexia nervosa?
Restriction of energy intake relative to requirements leading to a significantly low body weight
27
How is the diagnosis of anorexia nervosa made?
Based on the DSM 5 criteria 1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health 2. Intense fear of gaining weight or becoming fat, even though underweight. 3. Disturbance in the way in which one's body weight or shape is experienced
28
What are the features of anorexia nervosa?
Reduced body mass index Bradycardia Hypotension Enlarged salivary glands Lanugo hair
29
What are some physiological abnormalities seen in anorexia nervosa?
Hypokalaemia Low FSH, LH, oestrogens and testosterone Raised cortisol and growth hormone Impaired glucose tolerance Hypercholesterolaemia Hypercarotinaemia Low T3
30
What is the management of anorexia nervosa in children and young people?
First line: NICE recommend 'anorexia focused family therapy' Second-line: cognitive behavioural therapy- eating disorder focused
31
What is the management of anorexia nervosa in adults?
1. Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) 2. Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) 3. Specialist supportive clinical management (SSCM)
32
What is the prognosis for people with anorexia nervosa?
Poor Up to 10% of patients will eventually die because of the disorder
33
What is Bulimia nervosa?
A type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising
34
What is the DSM 5 criteria for bulimia nervosa?
1. recurrent episodes of binge eating 2. a sense of lack of control over eating during the episode 3. recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise These episodes occur at least once a week for 3 months
35
What signs might you see in a patient with bulimia nervosa?
Erosion of teeth (from recurrent vomiting) Russell's sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting
36
What is the management of bulimia nervosa?
Referral for specialist care is appropriate in all cases 1. Bulimia-nervosa-focused guided self-help for adults 2. If 1 is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) 3. Limited role of high dose fluoxetine as a trial (long term data is lacking) (Family therapy for children)
37
What is dementia?
A syndrome characterised by a decline in cognition
38
What is the most common cause of dementia in the UK?
Alzheimer’s disease
39
What are the three main causes of dementia?
Alzheimer’s disease Cerebrovascular disease: multi-infarct dementia (c. 10-20%) Lewy body dementia (c. 10-20%)
40
What are some important differentials in dementia?
Endocrine: hypothyroidism, Addison’s Deficiency: B12/folate/thiamine Syphilis Brain tumour Normal pressure hydrocephalus Subdural haematoma Depression Chronic drug use e.g. Alcohol, barbiturates
41
What would support a diagnosis of depression over dementia?
Short history, rapid onset Biological symptoms e.g. weight loss, sleep disturbance Patient worried about poor memory Reluctant to take tests, disappointed with results Mini-mental test score: variable Global memory loss (dementia characteristically causes recent memory loss)
42
What are the risk factors for Alzheimer’s disease?
Increasing age FH of Alzheimer’s disease 5% of cases are inherited as an autosomal dominant trait Mutations in the amyloid precursor protein (chromosome 21) and others Caucasian ethnicity Down’s syndrome
43
What are the macroscopic pathological changes in Alzheimer’s?
Widespread cerebral atrophy, particularly involving the cortex and hippocampus (temporal lobe)
44
What are the microscopic pathological changes in Alzheimer’s?
1. Cortical plaques due to deposition of type A-Beta-amyloid protein 2. Intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
45
What are the medical management options for Alzheimer’s?
Mild to moderate = acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) Severe or moderate and tolerant to AChEi = memantine (an NMDA receptor antagonist)
46
What is the management for the non-cognitive symptoms in Alzheimer’s?
For mild to moderate depression = NICE does not recommend antidepressants Antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress
47
What is vascular dementia?
A group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease
48
What are the three main subtypes of vascular dementia?
1. Stroke-related VD – multi-infarct or single-infarct dementia 2. Subcortical VD – caused by small vessel disease 3. Mixed dementia – the presence of both VD and Alzheimer’s disease
49
What are the risk factors for vascular dementia?
History of stroke or transient ischaemic attack (TIA) AF HTN DM Hyperlipidaemia Smoking Obesity Coronary heart disease FH of stroke or cardiovascular disease
50
What are the main symptoms of vascular dementia?
‘Stepwise’ progression Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms Difficulty with attention and concentration Seizures Memory disturbance Gait disturbance Speech disturbance Emotional disturbance
51
What imaging may be done for vascular dementia?
MRI scan – may show infarcts and extensive white matter changes
52
What is the management for vascular dementia?
Mainly symptomatic Important to detect and address cardiovascular risk factors – for slowing down the progression
53
What is Lewy body dementia?
A common cause (20%) of dementia
54
What is the pathology of Lewy body dementia?
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas
55
What two diseases are associated with Lewy body dementia?
Parkinson's disease Alzheimer's: up to 40% of patients will also have Lewy bodies
56
What are the features of Lewy body dementia?
Progressive cognitive impairment (typically occurs before parkinsonism, but both features occur within a year of each other) - early impairments in attention and executive function Parkinsonism Visual hallucinations (lilliputian)
57
What are the investigations for Lewy body dementia?
Usually clinical single-photon emission computed tomography (SPECT)- also known as DaTscan
58
What is the management for Lewy body dementia?
If co-existent Alzheimers: acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism
59
What factors would suggest delirium over dementia?
Acute onset Impairment of consciousness Fluctuation of symptoms: worse at night, periods of normality Abnormal perception (e.g. illusions and hallucinations) Agitation, fear Delusions

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