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Phase 3A > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is the Mental Health Act?

A

Law used in England and wales which provides legal framework for informal and formal care/ treatment of patients with a mental disorder

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2
Q

What is a mental disorder?

A

Disorder or disability of the mind
Includes. mental illness, personality disorder, learning disability, disorder of sexual preference

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3
Q

Who is excluded from detainment under MHA?

A

Those under influence of drugs/ alcohol

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4
Q

What is an AMHP?

A

Approved mental health professional
Mental health worker who has undergone additional mental health training and is approved by local authority

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5
Q

What is a Section 12 approved doctor?

A

Medical doctor who is approved under Section 12 of the MHA to make medical recommendations to detain a patient

Usually GP or psychiatry doctors

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6
Q

What is section 131?

A

Covers informal admission
Patient can be admitted for care and treatment without formal restrictions and are free to leave anytime

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7
Q

What conditions need to be met to admit patient under section 131?

A

Patient must have capacity
Patient has given consent for admission
Patient does not resist admission

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8
Q

What isa Section 2?

A

Compulsory detention for assessment

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9
Q

How long does a section 2 last for?

A

28 days

Cannot be renewed

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10
Q

How is a Section 2 or 3 applied for?

A

Application is made by AMHP or nearest relativ supported by medical recommendation of two section 12 approved doctors

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11
Q

When is detention under Section 2 or 3 considered?

A

If patient is suffering from mental disorder that warrants detention in hospital for assessment for a limited period of time

Detention is in the interest of their own and others safety

Appropriate treatment is available

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12
Q

What is a Section 3?

A

Compulsory detention for treatment

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13
Q

How long does a Section 3 last for?

A

6 months

Can be renewed

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14
Q

What is a Section 4?

A

Admission for assessment in emergency situations

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15
Q

When in Section 4 used?

A

Outpatient services when arrangement of section 2 is not possible given time restraint

Purpose is to give time to arrange section 2

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16
Q

How long is a Section 4 valid for ?

A

72 hours

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17
Q

Who applies for Section 4?

A

AMHP with support of one doctor

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18
Q

What is a Section 5(2)?

A

Doctors holding powers where voluntary patient can be stopped from leaving to have a MHA assessment

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19
Q

How long does a section 5(2) last for?

A

72 hours

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20
Q

What is a section 5(4)?

A

Nurses holding powers allowing further assessment of patient

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21
Q

How long is a Section 5(4) valid for?

A

6 hours

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22
Q

Who applies for a Section 5 (4)?

A

Application is made by nurse

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23
Q

When would a 5(4) Section be needed?

A

Patient is suffering from mental health disorder to a degree where health or safety of individual or others is at risk

Not feasible or practical to apply for section 5(2)

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24
Q

What is a Section 135?

A

Court order allowing police to enter private property by force to remove person suffering from mental health disorder and move them to a place of safety

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25
Q

What is considered as a place of safety?

A

Emergency department
Police station

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26
Q

Why may a section 135 be required ?

A

Ill-treated or neglected
Unable to care for themselves
Living alone

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27
Q

How long does a section 135 last for?

A

72 hours

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28
Q

What is a section 136 ?

A

Detainment of patient by police if suspected to suffer from mental health illness from a public place to a place of safety without a warrant

This will allow assessment by medical practioner

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29
Q

How long is a Section 136 valid for?

A

24 hours

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30
Q

What is a Section 17a?

A

Community treatment order
Patients on Section 3 can leave hospital for treatment in community if they are well enough

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31
Q

Who is involved in decisions for section 17 ?

A

AMHP
Responsible clinical

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32
Q

When can section 17 be considered ?

A

Patient is suffering from mental illness to a degree that is appropriate for them to recieve treatment

Necessary for patients health and safety that they recieve treatment

Treatment can be provided without need to detain them

Appropriate medical treatment is available

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33
Q

What can happen if patient is non compliant with community treatment ?

A

Recalled to hospital for assessment and possible detention?

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34
Q

What are primary symptoms?

A

Symptoms arising from pathology of mental illness

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35
Q

What are secondary symptoms?

A

Symptoms arising as an understandable response to some aspect of the disordered mental state

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36
Q

What are objective signs?

A

Signs noted by external observer

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37
Q

What are subjective signs ?

A

Signs reported by patient

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38
Q

What are the components of a psychiatric history?

A

Presenting complaint
History of presenting complaint
Past psychiatric history
Past medical history
Drug history/ current medication
Substance history
Family history
Social history
Personal history
Informant history

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39
Q

What are the components of a MSE?

A

Appearance and behaviour
Speech
Mood
Thoughts
Perception
Cognition
Insight

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40
Q

What is a primary mood disorder?

A

A mood disorder that does not result from another medical or psychiatric condition

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41
Q

How are primary mood disorders classified?

A

Unipolar; depressive disorder, dysthymia
Bipolar; bipolar affective disorder, cyclothymia

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42
Q

What is a secondary mood disorder?

A

A mood disorder as a result of another medical or psychiatric condition

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43
Q

Causes of secondary mood disorders?

A

Anaemia, hypothyroidism, substance misuse

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44
Q

How long do symptoms of depression need to persist for diagnosis?

A

2 weeks

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45
Q

What is dysthymia?

A

Long standing mild depressive symptoms often associated with other psychiatric or physical illness

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46
Q

What is recurrent depressive disorder?

A

Patient has multiple episodes of a depressive disorder

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47
Q

What is psychotic depression?

A

Most severe form of depression with delusions, hallucinations, psychomotor retardation and high risk of suicide

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48
Q

What is atypical depression?

A

Symptoms of depression which respond better to MAO inhibitors compared to SSRI

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49
Q

What is reactive depression?

A

Symptoms of depression bought on by stressful life events

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50
Q

What is endogenous depression?

A

Symptoms of depression originating from the patient with no obvious external cause

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51
Q

Epidemiology of depressive disorders?

A

Lifetime risk of 15%
More common in women
Greater risk if positive family history
Mean age of onset is late 20s

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52
Q

Why are women more likely to suffer from depressive illness

A

Genetic predisposition
Sex hormone influence
Social pleasures
Greater willingness to accept symptoms of depressive nature

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53
Q

Aetiology of depression?

A

Biological
Genes
Medical condition and illness
Neurochemical changes; Monoamine abnormalities, Altered HPA axis function

Psychological
Childhood environment
Parental loss
Abuse
Abnormal cognition
Learned helplessness

Social
Life events
Unemployment
Alcohol and drug use

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54
Q

Pathophysiology of depression?

A

Hypofunction of monoamine neurotransmitter systems; serotonin and noradrenaline with altered HPA axis leads to symptoms of low mood

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55
Q

Risk factors for depression?

A

Postnatal status
Personal or family history of depressive disorder
Dementia
Corticosteroids
Interferon treatment
Oral contraceptives
Female sex
Obesity
Stressful life situations

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56
Q

Diagnostic criteria for depressive disorder?

A

Mild; 2+ from A and 2+ from B
Moderate; 2+ from A and 3+ from B
Severe; All from A and 4+ from B

Group A
Persistent low mood
Anhedonia; loss of interest or pleasure
Anergia; Fatigue or low energy
Functional impairment

Group B
Reduced concentration and attention
Reduced self esteem and self confidence
Ideas of guilt and worthlessness
Hopelessness about the future
Suicidal thoughts
Diminished appetite
Disturbed sleep

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57
Q

Clinical presentation of depression?

A

Depressed mood
Anhedonia
Functional impairment
Weight change
Sleep disturbance
Changes in movement
Low energy
Excessive guilt
Poor concentration
Suicidal ideation
Substance abuse
Loss of pleasure and libido
Difficulty maintaining relationships

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58
Q

Investigations to diagnose depression?

A

Clinical diagnosis from history and ICD diagnostic criteria, PHQ-9,
Bloods; U+E, FBC, TFT, Vit B12/ D, folic acid

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59
Q

Management of depression?

A

Mild depression
Antidepressant ; SSRI, SNRI
Psychotherapy and supportive interventions
If initial antidepressants are not working, consider switching medication
St John’s wart

Moderate depression
Antidepressant
Psychotherapy and CBT
Immediate symptoms management; Benzodiazepine and antipsychotic

Severe depression
Psychiatric referral and hospitalisation
Immediate symptoms management ; Benzodiazepine and antipsychotic
ECT
Antidepressant therapy

Acute presentation
Hospitalisation
Consider sectioning if harm to self and others
Benzodiazepine and antipsychotic for emergency symptoms management
ECT

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60
Q

Monitoring requirements for depression?

A

Follow-up 2 weeks after starting medication
8-12 weeks after initiation
Annual review

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61
Q

Why is it crucial to follow up patient 2 weeks after starting antidepressants?

A

High risk of discontinuation due to worsening of symptoms before stabilisation

High suicide risk

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62
Q

Complications of depression?

A

Sexual side effects of SSRI and SNRI
Risk of self injurious behaviour
Undesired weight gain
Agitation from medications
Unmask mania
Mania due to antidepressant withdrawal
Antidepressant discontinuation syndrome
Suicide risk with SSRI treatment

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63
Q

Prognosis of depression?

A

Once in remission patients should continue medication for a minimum of 6 months
Recurrence in 1/3 of patients
For 3 recurrent depressive episodes long term therapy is recommended

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64
Q

What is bipolar disorder?

A

Episodic mood disorder characterised by mania/ hypomania followed by period of depressed mood

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65
Q

What is bipolar type 1?

A

Manic episodes of distinct period of persistent elevated mood

Followed by period of depressed mood

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66
Q

What is bipolar type 2?

A

History of hypomania and major depressive episode but not met threshold for mania

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67
Q

Epidemiology of bipolar disorder?

A

Lifetime prevalence of 1.7%
Average age of onset between 19 and 31 years

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68
Q

Aetiology of bipolar disorder?

A

Genetic
Neurochemical abnormalities; depletion of monoamine neurotransmitters
Amphetamine and cocaine use

Organic causes
Neurological; Stroke, Alzehimers, Dementia, Parkinson’s disease, Huntington’s disease, Multiple sclerosis, Epilepsy, Intracranial tumours
Endocrine; Cushing’s syndrome, Addison’s disease, Hypothyroidism, Hyperparathyroidism
Metabolic; Iron/ B12/ folate deficiency, hypercalcaemia, hypomagnesaemia
Infection; Influenza, infectious mononucleosis, hepatitis, HIV/AIDS
Neoplasia
Medication

Environmental causes
Loss of parent
Neglect as a child

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69
Q

Pathophysiology of bipolar disorder?

A

Increased dopamine activity contributes to manic behaviour

Increased dopaminergic activity leads to elevated mood, reduced need for sleep and reduced social inhibitions

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70
Q

DSM V classification of bipolar disorder?

A

Bipolar disorder type 1; atleast 1 manic episode

Bipolar disorder type 2; never had full manic episode, 1 hypomanic episode and 1 major depressive episode

Cyclothymic disorder; chronic fluctuating course of mood disorder of insufficient severity to fulfil criteria for major depressive episode

Substance/ medication induced bipolar

Bipolar disorder secondary to medical condition, e.g Hyperthyroidism, cushing’s syndrome

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71
Q

Risk factors for bipolar disorder?

A

Family history of bipolar disorder
Onset of mood disorder before age of 20
Stressful life events
Childhood trauma
Previous history of depression
Substance misuse
Presence of anxiety disorder
Obesity
Cardiovascular disease

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72
Q

Clinical presentation of Bipolar disorder?

A

Major depressive episode:
Depressed mood/ anhedonia, loss of energy
Changes in weight and libido
Difficulty concentrating
Insomnia/ hypersomnia
Psychomotor problems
Excessive guilt, feelings of worthlessness, suicidal ideation

Episode of mania/ hypomania
Inflated self esteem or grandiose thoughts
Decreased need for sleep
Flight of ideas/ racing thoughts
Distractibility
Increased goal directed activity/ psychomotor agitation
Excessive involvement in pleasurable activities ; Excessive spending, sexual indiscretions, unwise business investments
Functional impairment

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73
Q

Investigations to diagnose bipolar disorder?

A

Bloods and urine screen to rule out organic cause
Clinical diagnosis; PHQ-9, MDQ, bipolarity index

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74
Q

Differentials for bipolar disorder?

A

Mood disorder due to general medical condition
Substance induced mood disorder
Major depressive disorder
Dysthymic disorder
Cyclothymic disorder
Psychotic disorder
OCD
ADHD

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75
Q

Management of bipolar disorder?

A

Acute management of mania
Oral antipsychotics; Haloperidol, olanzapine, quetiapine, risperidone
Adjunct benzodiazepines
Taper off and discontinue antidepressant
Consider hospitalisation

Acute management of depression in bipolar disorder
Standard antidepressant management options have lower efficacy and have associated risks of inducing mania or rapid cycling
Pharmacological options include; Fluoxetine + olanzapine, Quetiapine alone, Olanzapine alone, Lamotrigine alone
CBT may also be useful
Consider hospitalisation

Long term management
Mood stabilising medication; Lithium, Sodium valproate

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76
Q

Monitoring requirements for bipolar disorder?

A

Lifelong treatment and monitoring
See patients weekly following recent discharge

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77
Q

Complications of bipolar disorder?

A

Valproate induced hyperammonemic encephalopathy, hepatotoxicity, pancreatitis
Lamotrigine induced rash
Cognitive dysfunction
Weight gain
Lithium nephrotoxicity
Suicide
Disability

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78
Q

What is cyclothymia?

A

Mood disorder characterised by episodes of elevated mood but not severe enough to meet threshold of bipolar diagnosis

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79
Q

Epidemiology of cyclothymia?

A

More common in teenage years and young adulthood
Affects males and females equally

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80
Q

Aetiology of cyclothymia?

A

Genetic
Neurochemical and neurophysiological changes
Environmental issues; Traumatic experiences, prolonged periods of stress

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81
Q

Clinical presentation of cyclothymia?

A

Hypomania symptoms;
Exaggerated feelings of euphoria
Extreme optimism
Inflated self esteem
Talking more than usual
Poor judgement
Racing thoughts
Irritable/ agitated behaviour
Excessive physical activity
Increased drive to perform or achieve goals
Decreased need for sleep
Tendency to be distracted easily
Inability to concentrate

Depressive symptoms;
Feeling sad, hopeless or empty
Tearfulness
Irritability
Anhedonia
Changes in weight
Feeling of worthlessness and guilt
Sleep problems
Restlessness
Fatigue
Problems concentrating
Suicidal

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82
Q

Investigations to diagnose cyclothymia?

A

Physical exam
Psychological examination
Mood diary

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83
Q

Differentials for cyclothymia?

A

Major depressive disorder
Bipolar disorder
Generalised anxiety
Neurodevelopmental disorder
Personality disorder

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84
Q

Management for cyclothymia?

A

Psychotherapy, support groups
Social support
CBT
Medications;
Mood stabilisers;
Lithium, sodium valproate, carbamazepine
Antidepressants

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85
Q

Complications of cyclothymia?

A

Progression to bipolar disorder
Substance misuse
Anxiety disorder
Suicidal

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86
Q

Prognosis of cyclothymia?

A

Some patients go onto to develop bipolar disorder
Some continue with chronic illness

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87
Q

What is peurpeural depression?

A

Mood problems following childbirth and tend to be unipolar in nature

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88
Q

How long after childbirth can peurpeural depression occur?

A

12 months

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89
Q

Risk factors for peurpaural mood problems?

A

Psychosocial; poor support, obstetric complications, domestic abuse, low income, migration status
Psychiatric illness
Personality trait; Type A, low self esteem
Family History
Young maternal age
Sleep deprivation

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90
Q

Pathophysiology of peurpeural mood problems?

A

Hormonal changes and adverse obstetric events trigger mood problems
Neurochemical changes triggered by labour and delivery result in symptoms

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91
Q

Classification of peurpeural mood problems?

A

Minor mood disturbance; symptoms of insomnia, anxiety, irritability usually resolve in a few weeks
Postnatal depression; episodes of clinical depression following delivery causing significant disturbance to woman and family
Postnatal psychosis; most severe form with acute onset mania and is a psychiatric emergency

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92
Q

Clinical presentation of puerperal mood problems?

A

Depressed mood
Anhedonia
Decrease energy or increased fatigability
Loss of confidence and self-esteem
Excessive and inappropriate guilt
Poor concentration
Change in sleep, appetite, weight

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93
Q

Differentials for puerperal mood problems?

A

Minor mood disorder
OCD
Bipolar disorder
Thyroid dysfunction
Anaemia
Organic brain dysfunction
Post natal symptoms unrelated to depression

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94
Q

Management of puerperal mood problems?

A

Facilitated self help groups
CBT
Admission to psychiatric unit
Antidepressants; caution with breastfeeding

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95
Q

Monitoring requirements for puerperal mood problems?

A

Regular follow-up to assess symptoms and current mental state
Monitor babies if mother is breastfeeding and on medication

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96
Q

Complications of puerperal mood problems?

A
  • Impaired bonding with infant
    • Neglect of baby or infanticide
    • Suicide
    • Bipolar disorder in mother
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97
Q

Prognosis of puerperal mood problems?

A

Higher risk of post natal depression in future pregnancies
14% can have conversion to bipolar

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98
Q

What is OCD?

A

Mental health disorder characterised by obsessions and compulsions

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99
Q

What is an obsession in OCD?

A

Recurrent/ persistent thoughts, urges or images experience as intrusive and unwanted resulting in marked anxiety or distress which patient tries to ignore/ suppress with compulsive thoughts/ actions

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100
Q

What is a compulsion in OCD?

A

Repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rules that must be applied rigidly to reduce anxiety

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101
Q

Epidemiology of OCD?

A

Affects 2% of population
4th most common mental illness
Equal prevalance in males and females, but males develop symptoms before females
Typical age of onset is late teens, early 20s

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102
Q

Aetiology of OCD?

A

Genetics; Autosomal dominant
Obstetrics events
Childhood adversity

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103
Q

Pathophysiology of OCD?

A

Dopaminergic and Glutamatergic overactivity in frontostraital pathwa and reduced serotonergic and GABAergic neurotransmission in fronto limbic system
Can be induced by brain lesion or stroke so symptoms can be localised to specific lesion

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104
Q

Risk factors for OCD?

A

Family history of OCD
PANDAS
Male gender
Pregnancy adversity
Childhood adversity

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105
Q

Clinical presentation of OCD?

A

Obsessions; Intrusive, unwanted, anxiogenic, thoughts
Compulsions
Poor motor coordination
Difficulty in sequencing of complex motor tasks
Sensory perceptual difficulties

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106
Q

Investigations for OCD?

A

Clinical diagnosis
Yale-Brown obsessive compulsive scale
Clinical global impression

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107
Q

Differentials for OCD?

A

Obsessive compulsive personality disorder
Body dismorphic disorder
Somatic symptom disorder
Delusional disorder
Severe social phobia
Panic disorder
Autism spectrum disorder

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108
Q

Management of OCD?

A

CBT
Pharmacotherapy; SSRI, clomipramine, antipsychotics

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109
Q

What is treatment resistant OCD?

A

Patients who have failed to respond to atleast 2 adequet trials of clomipramine or SSRI for atleast 12 weeks

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110
Q

Monitoring requirements for OCD?

A

Yale-Brown obsessive compulsive scale repeated periodically
Patients on psychotropic drugs should have levels checked every 6 months

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111
Q

Complications of OCD?

A

20% chance of developing tics
7% risk of developing tourette syndrome
Suicidal ideation

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112
Q

Features associated with treatment resistant OCD?

A

High frequency of compulsions
Early age of onset
Previous hospitalisation
Male gender

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113
Q

Prognosis of OCD?

A

Causes significant disability and morbidity requiring lifelong treatment
Average time between onset of symptoms and appropriate treatment is 17 years

114
Q

What is autism spectrum disorder (ASD)?

A

Lifelong neurodevelopmental condition characterised by persistent impairment in social communication and restrictive, repetitive stereotyped patterns of behavior, interests, activities

115
Q

Epidemiology of ASD?

A

More common in boys
Earlier diagnosis in those from more affluent and higher socio-economic groups
40-80% will have intellectual disability

116
Q

Aetiology of ASD?

A

Genetic; Fragile X syndrome, NF1, Tuberous sclerosis, Down’s syndrome
Environmental; maternal health factors, children of mothers on sodium valproate

117
Q

Pathophysiology of ASD?

A

Modified neural development resulting in reorganised neural networks in underlying cognition and behavior

118
Q

Neurocognitive theories of ASD?

A

Executive function; difficulty problem solving and forward planning to achieve a goal
Impaired central coherence; difficulties in integration of information into meaningful wholes
Theory of mind hypothesis; difficulties in the consideration of how other people think and react to a particular situation

119
Q

Classification of ASD?

A

With or without disorder of intellectual development

With mild or no impairment of functional language

With impaired functional language (i.e., not able to use more than single words or simple phrases)

With complete, or almost complete, absence of functional language

With or without loss of previously acquired skills

120
Q

Risk factors for ASD?

A

Male sex
Positive family history
Gestational valproate exposure
Increasing parental age
Prematurity

121
Q

Clinical presentation of ASD?

A
  • Language delay/ regression
    ○ Lack of vocalisation/ babble
    ○ May not acquire first word at expected age
  • Verbal/ non verbal communication imapirement
    ○ Do not interact with parents
  • Social impairment
    ○ Play alone/ not interested in other people
  • Repetitive, rigid, or stereotyped interests, behaviour or activities
  • Irritable as a baby
  • Feeding difficulties
  • Unusual posturing
122
Q

Investigations to diagnose ASD?

A

ASD screening tools
Childhood autism rating scale/ screening test
Modified checklist for autism in toddlers

123
Q

Differentials for ASD?

A

Other neurodevelopmental disorders
ADHD
Social communication disorder
Schizoid personality disorder

124
Q

Management of ASD?

A
  • Behavioural and parent mediated intervention
    ○ Social communication intervention
    ○ Sensory and play stimulation
    ○ Behavioural intervention
  • Early input from educational services
  • Counselling and education to family
  • Manage physical and other mental health problems
125
Q

Monitoring for ASD?

A

Regular monitoring with paediatric/ psychiatric specialist with frequency determined on a case by case basis

126
Q

Complications of ASD?

A

Developmental regression
Intellectual disability
Epilepsy
Anxiety
Depression

127
Q

Prognosis of ASD?

A

Lifelong neurodevelopmental condition with a variable clinical course

Around 15% of adults live independent lives but many require full time care

128
Q

What is schizophrenia?

A
  • Mental health condition in which persons perceptions, thoughts, mood and behaviour are significantly altered
  • Characterised by positive symptoms
    ○ Auditory hallucinations, bizarre delusions and disrupted speech
  • And negative symptoms
    ○ Social withdrawal, demotivation, self neglect, flat affect
129
Q

Epidemiology of schizophrenia?

A
  • Age of onset is typically <25 years in males and <35 years in females
  • More common in males
  • Higher incidence in urban and lower income populations
130
Q

Cause of schizophrenia?

A
  • Same causes as bipolar disorder and schizophrenia
  • Genetics suggests chromosome 1q42
131
Q

Pathology of schizophrenia?

A
  • Reduction in grey and white matter matter predominantly in frontal and temporal region, hippocampus and parahippocampal gyrus
    • Electrophysiological and neurochemical abnormalities result in disease
    • Deficits in inflammation processing as with schizophrenia
    • Deficits in emotion regulation as with bipolar
132
Q

Risk factors for schizophrenia?

A

Family history
Obstetric complications; malnutrition, viral infection, pre-eclampsia, emergency C-section
Cannabis use
Lower IQ
Motor dysfunction
Childhood abuse
Birth in winter/ early
Migrant status

133
Q

Types of schizophrenia?

A

Paranoid
Catatonic
Hebephrenic
Simple
Residual
Undifferentiated

134
Q

Features of paranoid schizoprenia?

A

Most common type
Delusions and auditory hallucinations

135
Q

Features of catatonic shizophrenia?

A

Psychomotor disturbance, often alternating between motor immobility and excessive activity

Rigidity, posturing, echolalia and echopraxia

136
Q

Features of hebephrenic schizophrenia?

A

Early onset and poor prognosis
Irresponsible and unpredictable behaviour
Inappropriate mood and incongruent affect
Incoherent thoughts, fleeting hallucinations and delusions

137
Q

Features of simple schizophrenia?

A

Uncommon
Negative symptoms without preceeding overt psychotic symptoms

138
Q

Features of residual schizophrenia?

A

History of one of the types of schizophrenia but negative and cognitive symptoms

139
Q

Features of undifferentiated schizophrenia?

A

Symptoms that do not fit a particular type

140
Q

Features of schizophrenia?

A

Hallucinations; most commonly auditory, patients may respond to hallucinations

Delusions; persecutory/ paranoid delusions, thought withdrawal/ echo/ insertion/ block/ block/ broadcast

Passivity phenomena; thoughts and actions are controlled by external force

Negative symptoms; flattened affect apathy, social withdrawal

Disorganised thinking; tangentiality, word salad, circumstantiality

Altered cognition

141
Q

Differentials for schizophrenia?

A
  • Schizoaffective disorder
    • Substance induced psychotic illness
    • Bipolar disorder
    • Dementia with psychosis
    • Depression with psychosis
    • Delusional disorder
    • Brief psychotic disorder
    • Organic psychosis
    • Medicine induced psychosis
    • Hyperthyroidism, hyperparathyroidism
142
Q

Criteria for diagnosing schizophrenia?

A

Atleast 1 of the following symptoms for 1 month;
Thought insertion, echo, broadcast or withdrawal
Delusions of control, influence or passivity
Hallucinatory voices proving running commentary of the patient
Persistent delusions that are culturally inappropriate

At least 2 of the following with symptoms lasting for 1 month;
Persistent hallucinations in any modality
Catatonic behaviour
Breaks of interpolations in thought resulting in incoherence
Significant and consistent transformation in quality of behaviour

143
Q

Management of schizophrenia?

A

MDT approach; early intervention team, community mental health team, crisis resolution team

Hospital admission

Antipsychotic mediations
CBT

144
Q

Monitoring requirements for patients with schizophrenia?

A

Check-up within 1 week from hospital discharge by psychiatrist
Crisis plan and family management plan

145
Q

Complications of schizophrenia?

A
  • Antipsychotic medications side effects
    • Suicidal tendencies
    • Substance abuse
    • Tobacco abuse
    • Depression
    • Prolonged QT interval
    • Tardive dyskinesia
146
Q

Prognosis of schizophrenia?

A

Good recovery following first psychotic episode
Upto 20% of patients make full recovery
Increased risk of suicide due to hallucinations and delusions

147
Q

What is schizoaffective disorder?

A

Illness with features of both schizophrenia and mood disorder

148
Q

Epidemiology of schizoaffective disorder?

A

Less common than schizophrenia
More prevalent in women

149
Q

Risk factors for schizoaffective disorder?

A

Family history of schizophrenia
Substance abuse
Paternal age below 20 and over 35
Psychological stress
Child abuse

150
Q

Clinical presentation of schizoaffective disorder?

A

Positive symptoms; hallucinations, delusional ideation, thought disorder
Negative symptoms; anhedonia, social isolation, flat affect
Emotional disturbance; anxiety, depression, elation
Incongruent affect
Thought form and stream disorder
Cognitive abnormalities
Majore depressive episode
Manic episode

151
Q

Differentials for schizoaffective disorder

A
  • Schizophrenia
    • Substance induced psychotic disorder
    • Dementia with psychosis
    • Mood disorders with psychosis
    • Delusional disorder
    • Heavy metal poisoning
    • Medication induced psychosis
    • Carbon monoxide poisoning
152
Q

Management of schizoaffective disorder?

A

Acute psychotic episode; antipsychotic, benzodiazepine, rapid tranquilisation, ECT

Chronic; psychosocial intervention, general health intervention, atypical antipsychotic, anxiolytic, mood stabiliser

153
Q

Complications of schizoaffective disorder?

A
  • Antipsychotic side effects
    • Neuroleptic malignant syndrome
    • Suicidality
    • Substance misuse/ tobacco addiction
    • Tardive dyskinesia
    • Prolonged QT interval
154
Q

What investigation is required for monitoring when using antipsychotics?

A

ECG- can cause long QT

155
Q

Prognosis of schizoaffective disorder?

A

Better prognosis than schizophrenia but poor compared to mood disorder

Poor prognostic factors;
Insidious course
Prior history of poor functioning
Family history of schizophrenia
Mood incongruent psychotic symptoms
Duration of psychosis

156
Q

What is bulimia nervosa?

A

Eating disorder characterised by recurrent episodes of binge eating followed by behaviours aimed to compensate the binge such as self induced vomiting, fasting, excessive exercise, misuse of laxative, diuretics, enema or other medications

Usually symptoms occur for atleast 3 months

157
Q

Epidemiology of bulimia nervosa?

A

Higher prevalence in white women compared to black

Uncommon in childhood and tends to start in teenage years

158
Q

Aetiology of bulimia nervosa?

A

Genetic predisposition
Abnormalities in receptors/ neurotransmitters
Psychological/ social factors

159
Q

Pathophysiology of bulimia nervosa?

A

Low self esteem and psychosocial adversity leads to behaviours causing patient to binge eat

Pressure to conform to specific body type

160
Q

Risk factors for bulimia nervosa?

A
  • Female sex
  • Perfectionism
  • Body dissatisfaction
  • Childhood obesity
  • Impulsivity
  • History of abuse/ bullying
  • Family history/ personal history of mental illness
  • Exposure to social media
  • Early onset puberty
161
Q

Presentation of bulimia nervosa?

A

Current episodes of binge eating; average one episode per week for atleast 3 months
Recurrent inappropriate compensatory behaviour
Depression and low self esteem
Concern about body weight and shape
Dental erosion
Parotid hypertrophy
Russell’s sign
Arrhythmias

162
Q

Blood tests performed in bulimia nervosa?

A

U+E, creatinine, LFT, FBC, magnesium
Exclude pregnancy

163
Q

Differentials for bulimia nervosa?

A
  • Other specified feeding or eating disorders
  • Anorexia nervosa
  • Binge eating disorder
  • Rumination regurgitation disorder
  • Major depressive disorder
  • Hyperemesis gravidarum
164
Q

Management of bulimia nervosa?

A

CBT, self help groups
Nutrition and meal support
Consider SSRI or SNRI
Fluoxetine in children

165
Q

Complications of bulimia nervosa?

A
  • Volume depletion
  • Hypomagnesaemia
  • Tooth erosion
  • Pancreatitis
  • Cardiovascular disease
  • Oesophageal rupture
  • Attempted suicide and death
166
Q

Prognosis of bulimia nervosa?

A

45-73% recover completely and under 23% have a chronic course
Most common cause of death is suicide

167
Q

What is anorexia nervosa?

A

Eating disorder characterised by restriction of caloric intake leading to low body weight, intense fear of gaining weight, body image disturbance

168
Q

Epidemiology of anorexia nervosa?

A

90% of diagnosed patients are women
More common in white women
Risk drops after age of 21

169
Q

ICD-11 diagnostic criteria for anorexia nervosa?

A
  • Significantly low body weight
    ○ BMI <18.5
  • Rapid weight loss, more than 20% within 6 months
  • Persistent pattern of restrictive eating or behaviours aimed at achieving lower weight
  • Excessive pre-occupation with weight or shape of body
170
Q

Pathophysiology of anorexia nervosa?

A

Weight loss leads to abnormalities in cardiac, reproductive, hematopoietic, gastrointestinal and renal function

171
Q

Risk factors for anorexia nervosa?

A
  • Female sex
  • Adolescence and puberty
  • Obsessive and perfectionist traits
  • Exposure to social media
  • Genetic influence
  • Middle and upper socio-economic class
172
Q

Clinical presentation of anorexia nervosa?

A
  • Significantly low body weight
    ○ Decreased subcutaneous fat
  • Fear of gaining weight or becoming fat
  • Disturbed body image
  • Calorie restriction
  • Misuse of laxatives, diuretics or diet pills
  • Amenorrhoea if body weight falls below 48kgs
  • General fatigue, weakness, poor concentration
  • Non specific gastrointestinal problems
  • Cardiac signs and symptoms
  • Changes to hair, skin and nails
173
Q

Investigations for diagnosis of anorexia nervosa?

A
  • Clinical diagnosis from history
  • Bloods
    ○ FBC; normocytic normochromic anaemia, mild leukopenia, thrombocytopenia
    ○ U+E; metabolic alkalosis and hypokalaemia (if vomiting), metabolic acidosis, hyponatraemia, hypokalaemia (if laxative use)
    ○ TFT; to rule out thyroid dysfunction
    ○ LFT; raised ALT, AST, cholesterol
174
Q

Differentials for anorexia nervosa?

A
  • Bulimia nervosa
    • Avoidant restrictive food intake disorder
    • Depression
    • Hyperthyroidism
    • T1DM
    • Crohn’s disease
    • Ulcerative colitis
    • Obsessive compulsive disorder
    • Systemic illness with weight loss
      ○ Neoplasm, infection, autoimmune
175
Q

Management of anorexia nervosa?

A

Structured meal plan with oral nutrition
Psychotherapy; CBT, specialist supportive clinical management
Oral potassium supplementation
If unstable; inpatient management, fluid and electrolyte, olanzapine

176
Q

Why is onlanzapine given in anorexia nervosa?

A

Increase rate of weight gain

177
Q

Monitoring requirements for anorexia nervosa?

A
  • If outpatient, weekly weight monitoring until safe weight is reached
    • Consider monthly follow-up once weight stabilises
    • Yearly bone scans could be considered
    • Serum chemistry, FBC, LFT, TFT repeated if weight is not improving
178
Q

Complications of anorexia nervosa?

A
  • Refeeding syndrome
    ○ Peripheral oedema
    ○ Hypophosphataemia
    ○ Hypomagnesaemia
    ○ Thiamine deficiency
    • Anaemia
    • Primary amenorrhoea
    • Infertility
    • Osteopenia, osteoporosis, skeletal fractures
    • Growth retardation
    • Lip and mouth fissures, glossitis
    • Acute and chronic renal failure
    • Congestive heart failure
179
Q

Prognosis of anorexia nervosa?

A

Improved prognosis if early identification, full weight restoration

10-15 years after diagnosis 75% make full recovery

180
Q

Triad for ADHD?

A

Inattention
Hyperactivity
Impulsivity

181
Q

Epidemiology of ADHD?

A

3-4% prevalence
More commonly diagnosed in men and boys as girls are more likely to internalise symptoms and present with innatentive subtypes later in life

182
Q

Aetiology of ADHD?

A

Genetic; D2 dopamine receptor gene, dopamine beta- hydroxlase gene

Environmental; childhood adversity, low birth weight, pregnancy/ delivery complications, maternal smoking during pregnancy, antenatal antidepressant use in mother

183
Q

Pathophysiology of ADHD?

A

Reduced inhibitory function of prefrontal cortex due to noradrenaline receptor downregulation

Reduced glucose metabolism in the premotor cortex and superior prefrontal cortex and inhibited activation of the anterior cingulate gyrus

184
Q

Risk factors for ADHD?

A

FHx of ADHD
Male sex
Psychosocial adversity
Environmental factors
Obstetrics complications

185
Q

Presentation of ADHD?

A
  • Onset of symptoms before the age of 12
    • Past or present academic dysfunction
      ○ Multiple work placements
      ○ Evidence of termination as a result of poor performance or problems with authority
    • Familial and relationship problems
      ○ Family rifts, multiple short sexual relationships
    • Drug and alcohol misuse
    • Thrill seeking behaviour, driving accidents
    • Unable to pay attention to details resulting in careless mistakes at work/ school
    • Difficulty maintaining attention in tasks
    • Seems to not listen when being spoken to
    • Does not follow instructions
    • Organisational difficulties
    • Avoids/ dislikes tasks requiring mental effort
    • Frequently loses things
    • Frequently forgetful in daily activities
    • Restlessness
    • Excessive talking
    • Has difficulty waiting for turn, interrupts before person has finished talking
186
Q

Differentials for ADHD?

A
  • Depression
    • Bipolar disorder
    • Generalised anxiety disorder
    • Psychosis
    • Learning disorder
    • Intellectual disability
187
Q

Investigations to diagnose ADHD?

A
  • Clinical assessment from history
    ○ Conners adult ADHD rating scale
    ○ Brown attention deficit disorder scale
188
Q
A
  • Psychoeducation program providing support to patient and family
  • Cognitive Behavioral Therapy
  • Stimulant therapy
    ○ Methylphenidate, lisdexamfetamine, dexamfetamine
    ○ Atomoxetine; selective noradrenaline reuptake inhibitor
  • Specialist treatment from tertiary services
    ○ Bupropion; antidepressant with dopaminergic effects
    ○ Venlafaxine, Risperidone
189
Q

Monitoring requirements for ADHD?

A
  • Weekly/ fortnightly follow-up initially, and extend to monthly/ quarterly once stability is achieved
  • Assess
    ○ Medication use and effectiveness
    ○ Psychiatric status for changes in mood and anxiety
    ○ Substance use or misuse of prescription
    ○ Cardiovascular status; BP and pulse reading
190
Q

Complications of ADHD?

A
  • Stimulant induced mania, weight loss, insomnia, cardiac events
  • Obesity
  • Substance misuse
  • T2DM
  • Sexually transmitted infection
  • Suicidal behaviour/ premature death
191
Q

Prognosis of ADHD?

A

Treatment response of ADHD in adults with stimulant therapy provides adequet QOL
Psychological training can help patients manage symptoms

192
Q

Epidemiology of substance use?

A

1 in 10 UK adults and 17% of children aged 11-15 have used illicit substances

Cannabis is the most common illicit substance used

193
Q

Causes of substance use?

A

Availability
Peer pressure
Prescribed drugs
Psychiatric illness

194
Q

Types of substances abused?

A

Opiates
Stimulants; cocaine, amphetamines, methamphetamines
Hallucinogens; ecstacy, LSD, magic mushroom
Cannabis

195
Q

Examples of opiates?

A

Heroin
Morphine
Methadone

196
Q

Signs of opiate dependance?

A

Miosis
Tremor
Malaise
Apathy
Constipation
Weakness
Neglect

197
Q

Signs of opiate overdose?

A

Miosis
Respiratory depression
Death

198
Q

Type of substance abuse disorders?

A
  • Acute intoxication; Transient disturbance of consciousness, cognition, perception, affect for behaviour
  • Harmful use; Damage to the individuals health and adverse effects on family and society
  • Dependance; Patient requires the substance and often neglect important social, occupational or recreational activities
  • Withdrawal state; Physical and psychological symptoms occurring on Absolute or relative withdrawal of a substance after repeated, prolonged use at a high dose
  • Psychotic disorder; Psychosis during or immediately after use, with vivid hallucinations, abnormal affect, psychomotor disturbance and delusions of persecution and reference
  • Amnesic disorder; Memory and other cognitive impairments caused by substance

Residual and late onset psychotic disorders; Effect on behaviour, affect, personality or cognition that last beyond the duration of substance use

199
Q

Signs of substance dependance?

A
  • Compulsion to take substance
  • Aware of harm but persists
  • Neglect of other activities
  • Tolerance
  • Stopping causes withdrawal
  • Time preoccupied with substance
  • Out of control use
  • Persistent, futile wish to cut down
200
Q

Substances that can be used in opiate detox?

A

Methadone, buprenorphine - first line
Lofexidine is used short term and for milder use
Naltrexone- used to prevent relapse
Naloxone- in signs of overdose

201
Q

Effects of alcohol on the body?

A

Stimulates release of dopamine from ventral tegmental area part of the mesolimbic dopamine system associated with behavioral motivation and reward

Exposure to alcohol releases dopamine, serotonin and other stimulant neurotransmitters

Neural plasticity promotes reward based learning leading to addiction

Discontinuation of alcohol leaves excitatory state unopposed leading to nervous system hyperactivity

202
Q

Risk factors for alcohol dependence?

A

Genetic
Occupation; higher risk in armed forces, doctors, journalist, politician
Cultural influence
Affluent lifestyle
Peer pressure
To avoid withdrawal symptoms

203
Q

Classification of alcohol misuse?

A
  • Acute intoxication; slurred speech, impaired coordination and judgement, labile affect
    ○ In severe cases can have hypoglycemia, stupor, coma
  • Acute withdrawal; reflects degree of previous dependance and occurs within 48 hours of abstinence
  • Alcohol dependence
204
Q

Clinical presentation of alcohol dependance?

A
  • Agitated, irritable
    • Unsteady
    • Craving alcohol
    • Withdrawal
    • Malar flushing
    • Signs of liver failure
    • Delirium tremens
      ○ Seizures, agitation, aggression
205
Q

Investigations performed in alcohol intoxication?

A

Breath/ blood/ serum alcohol
Tox screen
CAGE questionnaire
Bloods; LFT, U+E, FBC, TFT, glucose

206
Q

Differentials for alcohol abuse?

A

Psychiatric disorder
Substance use disorder

207
Q
A
  • Abstinence is the goal for treatment of dependence
  • Acute detoxification
    ○ Should be in a hospital if risk of delirium tremens
    ○ Naltrexone; opioid receptor antagonist
    ○ Sedation with benzodiazepine can be used to control withdrawal symptoms
    ○ Delirium tremens is often treated with Lorezapam or antipsychotics
208
Q

Complications of alcohol use

A
  • Neuropsychiatric complications
    ○ Wernike’s encephalopathy
    ○ Peripheral neuropathy
    ○ Erectile or ejaculatory impotence
    ○ Cerebellar degeneration
    ○ Dementia
  • Social complications
    ○ Unemployment
    ○ Marital difficulties
    ○ Criminality, domestic violence
    ○ Prostitution, homicide
    ○ Accidental death, road accident, suicide
  • Fetal alcohol syndrome if consumed during pregnancy
209
Q

What is self harm?

A

The act of harming oneself on purpose

210
Q

Epidemiology of self harm?

A
  • 40% of cases have a major psychiatric disorder
  • 20-25% of cases repeat self harm act within first year
211
Q

Methods of self harm?

A
  • Overdose
  • Cutting yourself
  • Burning yourself
  • Banding head or throwing yourself
  • Punching yourself
  • Sticking things to your body
  • Swallowing things that shouldn’t be swallowed
212
Q

Psychopathology of self harm?

A

Emotional disturbance in patients life and surrounding can lead to overwhelming feelings of anxiety, depression and self worthlessness
This can lead to patients harm themselves as a way of releasing anger, frustration and guilt that is building up

213
Q

Risk factors for self harm?

A

*Male gender
Problems at home, work or in educations
* Poor relationships
* Poor sleep
* Alcohol or substance misuse
* Previous suicide attempt
* Co-existing mental illness
○ Schizophrenia, personality disorder

214
Q

Presentation of self harm?

A

Injuries; cuts, burns, lacerations
Low mood and depression

215
Q

Differentials for self harm?

A

Suicide attempt
Depression
Bipolar depression

216
Q

Management of self harm?

A

Treat injuries
Counsell patients
Provide medication
Consider sectioning and admission to psychiatric hospital

217
Q

Epidemiology of suicide?

A

More common in men
Highest rate in middle aged between 40 and 50
Most common method is hanging, poisoning, drug overdose, jumping in front of train/ car and exsanguination

218
Q

Risk factors for suicide?

A
  • Mental illness
    ○ Schizophrenia, substance misuse, severe depression, personality disorder
  • Chronic painful illness
  • Availability of means
  • Family history of suicide
  • Lack of social support
  • Recent adverse events in life
    ○ Loss of a loved one, unemployment, homelessness, divorce/ family breakdown
219
Q

What is PTSD?

A

Mental illness developed following exposure to one or more traumatic events involving actual or threatened death, serious illness or sexual violence

220
Q

Epidemiology of PTSD?

A

Varies based on geographical location
Direct attributable cause can be identified

221
Q

Aetiology of PTSD?

A

Exposure to traumatic event;
Intentional act of violence, physical and sexual abuse, natural disaster, military action, threat to life while receiving medical care

222
Q

Pathophysiology of PTSD?

A
  • Areas of brain associated with fear processing
    ○ Amygdala, hippocampus, medial prefrontal cortex, anterior cingulate gyrus
  • Dysregulation in fear pathway leads to heightened fear and anxiety
223
Q

Risk factors for PTSD?

A
  • Serious accident
    • Witness of school violence/ domestic violence
    • Natural disaster
    • Terrorist attack
    • Torture
    • Combat exposure
    • Traumatic brain injry
    • Sudden death of loved one
    • molestation/ rape
    • Victimisation by attacker
    • Previous trauma
    • Multiple major life stressors
    • Low social support
    • History of drug and alcohol abuse
    • Female sex
    • Younger age
223
Q

Classification of PTSD?

A
  • Mild
    ○ Distress caused by symptoms is manageable
    ○ Social and professional occupation is not significantly impaired
  • Moderate
    ○ Distress and impact on functioning lie somewhere between mild and severe
    ○ No significant risk of harm to others or self
  • Severe
    ○ Distress and symptoms are unmanageable by patient causing significant impairement in social/ occupational functioning
    ○ Significant risk of suicide or harm to others
224
Q

Clinical presentation of PTSD?

A
  • Exposure to traumatic life event
  • Intrusion symptoms
    ○ Involuntary re-experiencing of aspects of the traumatic event in vivid and distressing way (flashbacks, intrusive images, sensory impressions, dreams, nightmares)
  • Avoidance symptoms
    ○ Effortful avoidance of reminders to trauma
    ○ Avoid people, situations or circumstances that resemble association to event
  • Negative alterations in cognition and mood
    Alterations in arousal and reactivity
225
Q

Investigations to diagnose PTSD?

A
  • PTSD checklist
    • Trauma screening checklist
    • Post-traumatic diagnostic scale
    • Intentional trauma questionnaire
226
Q

Differentials for PTSD?

A
  • Depression
    • Specific phobias
    • Panic disorder
    • Adjustment disorders
    • Dissociative disorders
    • OCD
    • Psychosis
227
Q

Management of PTSD?

A

Trauma focused CBT
Eye movement desensitisation and reprocessing
Non trauma focused psychological therapy

228
Q

Complications of PTSD?

A

Increase in stress due to exposure therapy
Cardiovascular disease
Dementia
Autoimmune disease
Anxiety
Depression
Psychosis
Psychological barriers to exposure therapy
Substance misuse
Suicide
Life threatening infections

229
Q

What is generalised anxiety disorder?

A

Atleast 6 months of excessive worry about everyday issues disproportionate to any inherent risk causing distress/ impairment

230
Q

Epidemiology of of GAD?

A

9% of lifetime prevalence
More common in high income countries
More common in women, especially in post partum partum women

231
Q

Causes of GAD?

A

Minor life stressors
Presence of physical or emotional trauma

232
Q

Pathophysiology of GAD?

A

Abnormal response to fear
Abnormalities in brain corticotropin releasing factor secretion affects HPA axis affecting neurotransmitter balance and arousal

Overactivity in amygdala, insula

233
Q

Risk factors for GAD?

A
  • Family history of anxiety
  • Physical or emotional stress
  • History of physical, sexual or emotional trauma
  • Other anxiety disorder
  • Chronic physical health condition
  • Female sex
234
Q

Clinical presentation of GAD?

A
  • Excessive worry for atleast 6 months
  • Anxiety not confined to another mental health condition
  • Anxiety not due to medication or substance
  • Muscle tension
  • Sleep disturbance
  • Fatigue
  • Restlessness
  • Irritability
  • Poor concentration
235
Q

Differentials for GAD?

A
  • Panic disorder
    • Social anxiety disorder
    • OCD
    • PTSD
    • Somatic symptom and related disorders
    • Depression
    • Substance/ drug induced anxiety
    • CNS depressant withdrawal
    • Situational anxiety
    • Adjustment disorder
    • Cardiac disease
    • Pulmonary conditions
    • Hyperthyroidism
    • Infections

Phaeochromocytoma

236
Q

Investigations to diagnose GAD?

A

Clinical diagnosis
Blood and urine test to rule out organic cause
ECG

237
Q

Management of GAD?

A

CBT
Applied relaxation, mindfulness, meditation
Sleep and lifestyle change
SSRI, SNRI

238
Q

Monitoring requirement for GAD?

A

Review every 12 weeks until stable
Then annually once stable

239
Q

Complications of GAD?

A
  • Comorbid depression
  • Comorbid substance misuse or dependance
  • Behavioral and mental health problems in offspring
  • Inappropriate utilisation of healthcare resources
  • Comorbid anxiety disorder
    Suicidal behavior
240
Q

Prognosis of GAD?

A

Chronic, fluctuating, relapsing, remitting disorder generally requiring long term follow up

241
Q

Mental health issues experience by old patients?

A

○ Cognitive impairment
○ Dementia
○ Functional disorders; depression, psychosis
○ Organic disorders; memory loss
○ Personality disorders
○ schizophrenia

242
Q

What is psychosis?

A
  • Syndrome of dysregulated neurotransmitters dopamine and serotonin and abnormal functioning of brain circuits involving frontal, temporal and mesostriatal brain regions
  • Patients experience hallucinations, delusion and disorganised thoughts and actions
243
Q

Causes of schizophrenia?

A
  • Schizophrenia
  • Brief psychotic disorder
  • Schizoaffective disorder
  • Schizophreniform disorder
  • Personality disorder
  • Substance/ medication induces psychosis
  • Bipolar disorder/ major depressive episode
  • Medical condition
    ○ Alzheimer’s disease, endocrine disorders, CNS infection, lupus, lyme disease, multiple sclerosis, stroke
244
Q

What is a phobia?

A

Intense fear of specific objects or situations that are triggered upon actual or anticipated exposure to phobic stimuli

Excessive phobias can cause functional impairment to lifestyle

245
Q

Epidemiology of phobias?

A

Most treatable psychiatric disorder
Most common anxiety disorder
More common in adolescents and lower incidence in adults
More prevalent in women and white ancestry

246
Q

Aetiology of phobia?

A

Disgust/ fear towards a particular stimulus
Past experience

247
Q

Pathophysiology of phobias?

A
  • Anterior cingulate cortex and insula hyperactivity is part of the mechanism
  • Significant reduction in site specific neural activity in these areas upon exposure to phobic events leads to symptoms
248
Q

Classification of phobias?

A
  • Animals
    ○ Most commonly dogs, snakes, insects
  • Situations
    ○ Most commonly lifts, flying, enclosed spaces
  • Natural environment
    ○ Most commonly storms, heights, water
  • Blood, injections, medical environment
  • Other
    ○ Such as choking, vomiting, clowns
249
Q

Risk factors for phobia?

A
  • Somatisation disorder
  • Anxiety disorder
  • Mood disorder
  • First degree relative with phobia
  • Adverse experiences
  • Female sex
  • White ethnicity
  • Parental anxiety and overprotective behaviour
250
Q

Clinical presentation of phobia?

A
  • Anticipatory anxiety
    ○ Anticipation of contact with phobic stimuli leading to spiraling of thoughts
  • Behavioral avoidance
  • Nausea, dizziness, hyperventilation, startleable state
251
Q

Differentials for phobia?

A
  • Agoraphobia
    • Panic disorder
    • Social anxiety disorder
    • Post traumatic stress disorder
      Separation anxiety disorder
252
Q

Management of phobia?

A

Education and monitoring
CBT with exposure therapy
Benzodiazepine

253
Q

Complications of aphobia?

A
  • Anxiety disorder
    • Depression
    • Non compliance with medical regimens
    • Apprehension towards mental health referral
    • Resistance to exposure therapy
254
Q

Prognosis of phobia?

A

Course of disease is phobia specific
Upto 90% of patients show significant improvement Improvement is engagement dependant

255
Q

Features of agoraphobia?

A
  • Fear and avoidance of crowded places
  • Diagnosis requires anxiety to be restricted to
    ○ Crowds
    ○ Public places
    ○ Travelling away from home
    ○ Travelling alone
  • CBT is main treatment, consider SSRI

Often comorbid with panic disorder

256
Q

What is a learning disability ?

A
  • Can be generalised (cognitive impairment) or localised (learning difficulty)
    • Children with cognitive impairment depends on underlying disorder and its severity
    • Examples
      ○ Difficulty with speech; specific language impairment
      ○ Reading and writing difficulty; dyslexia
      ○ Use of numbers; dyscalculia
257
Q

Epidemiology of learning disability?

A
  • Cognitive impairment affects 2-3% of children
    ○ Downs syndrome and foetal alcohol syndrome
  • More likely to affect males
  • Dyslexia is most common specific learning disability
258
Q

Causes of learning disability?

A
  • Developmental (congenital)
    ○ Downs syndrome
    ○ Autism spectrum disorders
    ○ Foetal alcohol syndrome
    ○ Teratogenic drugs
    ○ Premature birth
    ○ Congenital hypothyroidism
  • Acquired
    ○ CNS infections
    ○ CNS tumours
    ○ Hypoxia
    ○ Traumatic brain injury
    ○ Psychosocial deprivation
259
Q

What is dyslexia?

A
  • Impaired cognitive skills related to reading
  • Difficulty in written language, especially spelling
  • Strengths in non-language visual processing
  • Genetic susceptibility leads to deficit in language areas of brain
260
Q

What is dyscalculia?

A

Impaired arithmetic skills

261
Q

What is specific language impairment?

A
  • Disordered use of language across modalities (spoken, written, sign)
    • May be associated with delayed speech
262
Q

What is central auditory processing disorder?

A
  • Impaired ability to localise, differentiate, recognise elements of sounds which may lead to specific difficulties with learning
263
Q

Classification of personality disorders?

A

Cluster A; odd or eccentric
Paranoid
Schizoid
Schizotypical

Cluster B; dramatic, emotional, erratic
Antisocial
Borderline (EUPD)
Histrionic
Narcissistic

Cluster C; anxious, fearful
Obsessive- Compulsive
Avoidant
Dependent

264
Q

Features of paranoid personality disorder?

A

Hypersensitivity and an unforgiving attitude when insulted

Unwarranted tendency to questions the loyalty of friends

Reluctance to confide in others

Preoccupation with conspirational beliefs and hidden meaning

Unwarranted tendency to perceive attacks on their character

265
Q

Features of schizoid personality disorder?

A

Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family

266
Q

Features of schizotypal personality disorder?

A

Ideas of reference (differ from delusions in that some insight is retained)
Odd beliefs and magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent

267
Q

Features of antisocial personality disorder?

A

Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;

More common in men;

Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;

Impulsiveness or failure to plan ahead;

Irritability and aggressiveness, as indicated by repeated physical fights or assaults;

Reckless disregard for the safety of self or others;

Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;

Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

268
Q

Features of borderline personality disorder?

A

Efforts to avoid real or imagined abandonment

Unstable interpersonal relationships which alternate between idealization and devaluation

Unstable self image

Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)

Recurrent suicidal behaviour

Affective instability

Chronic feelings of emptiness

Difficulty controlling temper

Quasi psychotic thoughts

269
Q

Features of histrionic personality disorder?

A

Inappropriate sexual seductiveness

Need to be the centre of attention

Rapidly shifting and shallow expression of emotions

Suggestibility

Physical appearance used for attention seeking purposes

Impressionistic speech lacking detail

Self dramatization

Relationships considered to be more intimate than they are

270
Q

Features of narcissistic personality disorder?

A

Grandiose sense of self importance

Preoccupation with fantasies of unlimited success, power, or beauty

Sense of entitlement

Taking advantage of others to achieve own needs

Lack of empathy

Excessive need for admiration

Chronic envy

Arrogant and haughty attitude

271
Q

Features of obsessive compulsive personality disorder?

A

Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone

Demonstrates perfectionism that hampers with completing tasks

Is extremely dedicated to work and efficiency to the elimination of spare time activities

Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values

Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning

Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things

Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness

272
Q

Features of avoidant personality disorder?

A

Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.

Unwillingness to be involved unless certain of being liked

Preoccupied with ideas that they are being criticised or rejected in social situations

Restraint in intimate relationships due to the fear of being ridiculed

Reluctance to take personal risks due to fears of embarrassment

Views self as inept and inferior to others

Social isolation accompanied by a craving for social contact

273
Q

Features of dependant personality disorder?

A

Difficulty making everyday decisions without excessive reassurance from others

Need for others to assume responsibility for major areas of their life

Difficulty in expressing disagreement with others due to fears of losing support

Lack of initiative

Unrealistic fears of being left to care for
themselves

Urgent search for another relationship as a source of care and support when a close relationship ends

Extensive efforts to obtain support from others

Unrealistic feelings that they cannot care for themselves

274
Q

Management of personality disorders?

A

Dialectual behaviour therapy
Treatment of co-existing psychiatric conditions

275
Q

Adverse effects of clozapine?

A

Agranulocytosis
Reduced seizure threshold
Constipation
Myocarditis
Hypersalivation

276
Q

features of schizophrenia?

A

Through disorder
Third person auditory hallucinations
Passivity
Delusional perceptions

277
Q

Neuroleptic malignant syndrome?

A

pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion

278
Q

management of neuroleptic malignant syndrome?

A

Stop medication
IV fluid
Dantrolene
Bromocriptine

279
Q
A

Phase 3A (7 decks)

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