Psychiatry Flashcards
Explain Fixed affect, Restricted affect, Labile affect
- Fixed affect: the patient’s affect remains the same throughout the interview, regardless of the topic.
- Restricted affect: the patient’s affect changes slightly throughout the interview, but doesn’t demonstrate the normal range of emotional expression that would be expected.
- Labile affect: characterised by exaggerated changes in emotion which may or may not relate to external triggers. Patients typically feel like they have no control over their emotions.
MSE Exam: In healthy individuals, thoughts flow at a steady pace and in a logical order. However, in several mental health conditions, the flow and coherence of thoughts can become distorted.
Abnormalities of thought flow and coherence include:
- **Loose associations: **moving rapidly from one topic to another with no apparent connection between the topics.
- Circumstantial thoughts: these are thoughts which include lots of irrelevant and unnecessary details but do eventually come back to the point.
- Tangential thoughts: digressions from the main conversation subject, introducing thoughts that seem unrelated, oblique, and irrelevant.
- Flight of ideas: seen with fast, pressured speech. Ideas run into one another, making it difficult for the observer to follow the flow of speech.
- Thought blocking: sudden cessation of thought, typically mid-sentence, with the patient unable to recover what was previously said.
- Perseveration: refers to the repetition of a particular response (such as a word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a patient is asked what their name is, and they then continue to repeat their name as the answer to all further questions).
- Neologisms: words a patient has made up which are unintelligible to another person.
- **Word salad: **speaking a random string of words without relation to one another.
MSE Exam: Abnormalities of thought possession include
- Thought insertion: a belief that thoughts can be inserted into the patient’s mind.
- Thought withdrawal: a belief that thoughts can be removed from the patient’s mind.
- Thought broadcasting: a belief that others can hear the patient’s thoughts.
MSE Exam: Preception
What sort of things do you look for in the persons perception?
Abnormalities of perception include:
- Hallucinations: a sensory perception without any external stimulation of the relevant sense that the patient believes is real (e.g. the patient hears voices, but no sound is present).
- Pseudo-hallucinations: the same as a hallucination, but the patient knows it is not real.
- Illusions: the misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).
- Depersonalisation: the patient feels that they are no longer their ‘true’ self and are someone different or strange.
- Derealisation: a sense that the world around them is not a true reality.
What is PTSD?
Post-traumatic stress disorder (PTSD)
PTSD may develop following exposure to an extremely threatening/horrific event or series of events. It is thought to result from impaired memory consolidation of experiences too traumatic to be processed normally, which leads to a chronic hyperarousal of fear circuits.
Characteristic features of PTSD include (remember using the mnemonic HARD):
- Hyperarousal: persistently heightened perception of current threat (may include enhanced startle reaction)
- Avoidance of situations/activities reminiscent of the events, or of thoughts/memories of the events
- Re-experiencing the traumatic events (vivid intrusive memories, flashbacks, or nightmares).
- Distress: strong/overwhelming fear and physical sensations when re-experiencing
Major traumatic abuse, shell shock. Symptoms have to present for >1m
Management for PTSD
1st: Watchful waiting 4w if mild, trauma focused CBT (70% effective) if moderate. EMDR Eye-Movement Desensitization and Reprocessing (EMDR) therapy
2nd: Venlafaxine or SSRI or Risperidone ?Mitazipine
What is an acute stress reaction?
An acute stress reaction occurs when a person experiences certain symptoms after a particularly stressful event. The word ‘acute’ means the symptoms develop quickly but do not last long. The events are usually very severe and an acute stress reaction typically occurs after an unexpected life crisis. This might be, for example, a serious accident, sudden bereavement, or other traumatic events. Acute stress reactions may also occur as a consequence of sexual assault or domestic violence.
Acute stress reactions have been seen in people who experience terrorist incidents, major disasters, or war. Military personnel are at more risk as a result of extreme experiences during conflicts.
An acute stress reaction usually resolves within 2 to 3 days (often hours).
What are presentations of acute stress reaction?
Acute stress, within 4 weeks after traumatic event
Intrusive thought, dissociation, negative mood, avoidance
What is the Ix for acute stress reaction?
Detailed history
Management for acute stress reaction?
Trauma based CBT
Benzodiazepines, for acute symptoms, sleep disturbance
What is Generalised anxiety disorder
Generalised anxiety disorder (GAD) is a mental health condition that causes excessive and disproportional anxiety and worry that negatively impacts the persons everyday activity. Symptoms are present on a daily basis for months at a time.
What is the assessment for generalised anxiety disorder?
- The GAD-7 anxiety questionnaire can help establish the severity of the diagnosis
- Assess for co-morbid mental health problems, such as depression and obsessive compulsive disorder
- Assess for environmental triggers and contributors, such as family relationships, friendships, bullies, school pressures, alcohol and drug use
What is the management for generalised anxiety disorder?
**Mild anxiety **can be managed with watchful waiting and advice about self-help strategies (e.g. meditation), diet, exercise and avoiding alcohol, caffeine and drugs.
Moderate to severe anxiety can be referred to CAMHS services to initiate:
- Counselling
- Cognitive behavioural therapy
- Medical management. Usually an SSRI such as sertraline is considered. (Sertraline, Duloxetine) + Propanolol
What is phobias?
Specific fear, avoidance. Agoraphobia – fear of being in helpless situation.
What is Mx for phobias?
Lifestyle, avoid caffeine. Exposure therapy, Agoraphobia, social anxiety: CBT. CBT, SSRI. BZD for specific phobias
What is the risk factors for panic disorders?
Mx?
FHx, Female, Episodes of trauma.
Mx: CBT, SSRI
What does alcohol withdrawal look like?
6-12 hrs: Tremor, sweating, tachycardia, anxiety
36 hrs: Seizures
48-72 hrs: Coarse tremor, confusion, delusions, tachycardia
Chronic alcohol, ________ (inhibits CNS), and inhibits _______ _______ receptors
Chronic alcohol, GABA (inhibits CNS), and inhibits NMDA Glutamate receptors
How to do assess alochol withdrawal?
Monitor complications, delirium tremens, seizures, blackouts
Mx for alochol withdrawal?
1st: Long acting benzodiazepines, chlordiazepoxide or diazepam. Pabrenix.
Carbamazepine for alcohol withdrawal symptoms
Safe: 14 units / week. Harmful > 35 units a week women, 50 units a week men.
Acamprosate – reduces craving
Disulfiram – induces flushing
How to calculate unit of alcohol
Unit of Alcohol = (Volume) x (Percentage) / 1000
What is Substance misuse disorder
is the consumption of substances that leads to the involvement of social, psychological, physical, or legal problems.1
Among people aged 16-59, What is the most common used substance and what it its functions?
cannabis, followed by cocaine and ecstasy
Cannabis: Exacerbates existing mood. Slowed memory, reflexes,
______ ______ is the fifth biggest risk factor for death across all ages.
alcohol misuse is the fifth biggest risk factor for death across all ages.
Substance dependence requires at least two of the following:
- Impaired control over substance use
- Increasing priority over other aspects of life or responsibility
- Psychological features suggestive of tolerance and withdrawal
Pathophysiology of addiction
When an individual consumes a substance, this affects the mesolimbic dopamine system in the nucleus accumbent and dorsal striatum in the basal ganglia.4 The release of dopamine gives off pleasurable feelings which trigger the reward system and positively reinforce the behaviour of substance consumption. This process is known as operant conditioning and is the basis of addiction and cravings.
Some substances, such as alcohol and opioids, interact with the inhibitory neurotransmitter GABA, which disrupts the equilibrium between GABA and glutamate. It is believed that the number of natural stimulants (glutamate) and natural sedatives (GABA) are roughly the same. When an individual consumes substances, this disrupts the equilibrium as there are more** sedative hormones (GABA).**
When exposed chronically, this results in neuroadaptation. The brain will upregulate the natural stimulants to achieve equilibrium. Withdrawal symptoms occur when there is a sudden drop in GABA, resulting in disrupted homeostasis and too much glutamate. The excess natural stimulants lead to withdrawal symptoms such as anxiety, sweating, and shaking.
Relevant laboratory investigations in the context of alcohol misuse include:
- Full blood count: raised MCV, raised platelets, anaemia
- Liver function tests: increased GGT, AST:ALT > 2:1
- Haematinics (B12/folate): alcohol can cause folate deficiency
- Thyroid function tests
What are some screening questionnaires that can be used for dependency of alcohol misuse?
The AUDIT-C questionnaire is a common screening tool that looks at the risk of dependency of alcohol misuse.7
Other questionnaires include the SAD-Q questionnaire which looks at the severity of alcohol dependence and the CAGE questionnaire. For more information, see the Geeky Medics guide to alcohol history taking.
How can naltrexone be used in alcohol detox?
Name some side effects?
Naltrexone is an opiate blocker that makes alcohol less enjoyable and less rewarding. It can be administered as an injection once a month or oral tablets.
Common side effects are nausea, vomiting, decreased appetite, pain at the injection site, and increased liver enzymes. It is contraindicated in opiate use and patients with liver failure.
How can Acamprosate be used in alcohol detox?
Name some side effects?
Acamprosate is a medication that increases GABA and decreases excitatory glutamate which **reduces cravings. **
It has a good side effect profile and is generally well tolerated.
How can Disulfiram be used in alcohol detox?
Disulfiram inhibits acetaldehyde dehydrogenase which causes the accumulation of acetaldehyde with alcohol. It causes unpleasant symptoms such as flushing, sweating, headache, nausea and vomiting, arrhythmias, and hypotensive collapse. Patients should avoid alcohol for 24 hours before taking disulfiram and 1 week after cessation of the medication. When taking the medication, they must avoid all contact with alcohol. Disulfiram is contraindicated in patients with heart disease, psychosis, and those felt to be at high risk of suicide
Alcohol misuse can cause multiple physiological complications including:
- Neurological: ischaemic stroke, encephalopathy, seizures, peripheral neuropathy
- Cardiovascular: increased rate of myocardial infarction and stroke, hypertension, dilated cardiomyopathy
- Hepatology: alcoholic liver disease, liver cirrhosis, liver fibrosis, pancreatitis
- Oncology: increased risk of head and neck cancer, oesophageal cancer, liver cancer, breast cancer, colorectal cancer
- Psychiatric: alcoholic hallucinosis, delirium tremens, Wernicke-Korsakoff syndrome
Relevant laboratory investigations in the context of opioid misuse include:
- HIV and hepatitis B/C: due to the increased risk of blood-borne infection is greater through needle sharing
- Tuberculosis testing
- Urea & electrolytes
- Liver function tests and clotting screen: to check hepatic function
- Drug levels: to check for drug toxicity
There are several drug screening questionnaires which can be used:
- Drug abuse screening test (DAST): assess drug use in the past 12 months
- CAGE-AID (adapted to include drugs)
- Addiction severity index (ASI): looks at the effect of the use of substances on law, family, social life, work and mental health
- Clinical opiate withdrawal scale (COWS): rates common signs and symptoms of opiate withdrawal and monitors symptoms
*
The main intervention for opioid misuse is opioid detox using _____________ _____. An alternative to this is _______________ _______. It can be helpful to refer the patient for counselling and rehabilitation.
The main intervention for opioid misuse is opioid detox using **methadone reduction. **An alternative to this is buprenorphine reduction. It can be helpful to refer the patient for counselling and rehabilitation.
Opioid misuse also increases the risk of blood-borne diseases such as ____ ______ ____ __
Opioid misuse also increases the risk of blood-borne diseases such as HIV, hepatitis B, and C.
Benzodiazepine misuse includes the use of _________ ________ ___ ________
Benzodiazepine misuse includes the use of diazepam, oxazepam and lorazepam.
Benzodiazepines are another example of central nervous system ____________
Benzodiazepines are another example of central nervous system depressants.
The clinical features of benzodiazepine misuse include:
- Physiological effects: altered mental status, slurred speech, ataxia, respiratory distress, hypothermia, and coma if overdosed
- **Psychological effects: **euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood
Withdrawal from benzodiazepines may result in a wide range of clinical features including tremor, nausea & vomiting, tachycardia, postural hypotension, headache, agitation, malaise, transient illusions or hallucinations, paranoid ideation and seizures.
Ix for benzodiazepines misuse
The clinical institute withdrawal assessment scale – benzodiazepines (CIWA-B) can be used to determine the severity of withdrawal from the substance.
The main intervention for benzodiazepine misuse is _________ _____________ and supportive treatments.
The main intervention for benzodiazepine misuse is **assisted withdrawal **and supportive treatments.
Name some Central nervous system (CNS) stimulants.
Amphetamine use (e.g. Adderall and methylphenidate) and cocaine
Cocaine
Mx
stimulant, powder. Acute seizures and psychotic episodes, ischaemic colitis, vasospastic ACS.
Mx: Benzodiazepines (short term) + GTN. Support groups.
Heroin:
Mx
Injected, strong sense of relaxation. Risk of overdose. Withdrawal: sweating, watery eyes, anxiety.
Mx: Lofexidine (a2 agonist) +/- Benzodiazepines for symptom. Opioid substitution using Methadone
What are hallucinogens
Hallucinogens include lysergic acid diethylamide (LSD – ‘acid’), marijuana, ecstasy and phencyclidine or phenylcyclohexyl piperidine (PCP). When consumed, they can cause euphoria, visual and auditory hallucinations and psychosis.
Hallucinogens mainly cause visual or auditory hallucinations and the feeling of euphoria.
Specific clinical features depend on the substance used:
LSD:
Marijuana:
**Ecstasy: **
**PCP: **
LSD: lethargy, psychomotor agitation, craving, insomnia, and unpleasant dreams
Marijuana: increased appetite and conjunctival injection
**Ecstasy: **bruxism, hyperthermia, hyponatremia, and hepatotoxicity
**PCP: **loss of painful stimuli, vertical nystagmus, psychosis with hallucination, violence, and agitation
Screening tools used for hallucinogens are
the drug abuse screening test (DAST), CAGE-AID (adapted to include drugs) and addiction severity index (ASI).
Opioid and benzodiazepine misuse cause ________ ____________ resulting in drowsiness, respiratory depression, and lethargy
Opioid and benzodiazepine misuse cause sympathetic depression resulting in drowsiness, respiratory depression, and lethargy
What is Anorexia Nervosa
In patients with anorexia nervosa, the person feel they are overweight despite evidence of normal or low body weight. It involves obsessively restricting calorie intake with the intention of losing weight. Often the person exercises excessively and may use diet pills or laxatives to restrict absorption of food.
What are the features of anorexia nervosa:
- Excessive weight loss
- Amenorrhoea
- Lanugo hair is fine, soft hair across most of the body
- Hypokalaemia
- Hypotension
- Hypothermia
- Changes in mood, anxiety and depression
- Solitude
With anorexia nervosa there can be cardiac complications which include:
arrhythmia, cardiac atrophy and sudden cardiac death
What is Bulimia Nervosa
Unlike with anorexia, people with bulimia often have a normal body weight. Their body weight tends to fluctuate. The condition involves binge eating, followed by “purging” by inducing vomiting or taking laxatives to prevent the calories being absorbed.
What are the features of bulimia nervosa:
- Alkalosis, due to vomiting hydrochloric acid from the stomach
- Hypokalaemia
- Erosion of teeth
- Swollen salivary glands
- Mouth ulcers
- Gastro-oesophageal reflux and irritation
- Calluses on the knuckles where they have been scraped across the teeth. This is called Russell’s sign.
What does a typical exam question look like with Bulimia nervosa?
Look out for the teenage girl with a normal body weight that presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas. The presenting complaint may be abdominal pain or reflux.
What is Binge Eating Disorder?
Binge eating disorder is characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress. This is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight.
Binges may involve:
- A planned binge involving “binge foods”
- Eating very quickly
- Unrelated to whether they are hungry or not
- Becoming uncomfortably full
- Eating in a “dazed state”
Management of Binge Eating Disorder
Patient and carer education is key to the condition. Management is centred around changing behaviour and addressing environmental factors:
- Self help resources
- Counselling
- Cognitive behavioural therapy (CBT)
- Addressing other areas of life, such as relationships and past experiences
Severe cases may require admission for observed refeeding and monitoring for refeeding syndrome.
SSRI medication may be used by a specialist in child and adolescent mental health.
What is Refeeding Syndrome?
Refeeding syndrome occurs in people that have been in a severe nutritional deficit for an extended period, when they start to eat again. Patients are at higher risk if they have a BMI below 20 and have had little to eat for the past 5 days. The lower the BMI and the longer the period of malnutrition, the higher the risk.
Refeeding Syndrome
Metabolism in the cells and organs dramatically slows during prolonged periods of malnutrition. As the starved cells start to process glucose, protein and fats again they use up magnesium, potassium and phosphorus. This leads to:
Hypomagnesaemia
Hypokalaemia
Hypophosphataemia
These patients are also at risk of cardiac arrhythmias, heart failure and fluid overload
Refeeding Syndrome Mx
Management will be according to the local protocol under specialist supervision:
- Slowly reintroducing food with restricted calories
- Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods
- Fluid balance monitoring
- ECG monitoring may be required in severe cases
- Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine
Mx of Anorexia Nervosa
1st: CBT-ED. Maudsley Anorexia Nervosa Treatment, Specialist supportive clinical management
10% of patients will eventually die
What is Bipolar disorder
Bipolar disorder is a mood disorder characterised by episodes of depression and mania or hypomania.
The incidence of bipolar disorder follows a bimodal distribution, with two peaks in the age of onset at around?
15-24 years and 45-54 years.
Aetiology of bipolar disorder
The aetiology of bipolar disorder is complex and involves genetic, environmental, and neurobiological components.
The genetic risk associated with bipolar disorder is a type of ________ inheritance
The genetic risk associated with bipolar disorder is a type of polygenic inheritance
RF for bipolar disorder?
- Genetic factors: combined effect of many single nucleotide polymorphisms (SNPs)
- Prenatal exposure to Toxoplasma gondii (the parasite that causes toxoplasmosis)
- Premature birth <32 weeks gestation
- Childhood maltreatment
- Postpartum period
- Cannabis use
How many types of bipolar disorders are there? What are they?
Type 1: Mania and depression
Type 2: Hypomania and depression
What is the difference between bipolar 1 and 2?
- In bipolar I, the person has experienced at least one episode of mania
- In bipolar II, the person has experienced at least one episode of hypomania, but never an episode of **mania. ** They must have also experienced at least one episode of major depression.
The characteristic clinical features of mania are
elevated mood, increased activity level and grandiose ideas of self-importance. In the ICD-10, mania is characterised by:
- **Elevated mood **out of keeping with the patient’s circumstances
- Elation accompanied by increased energy resulting in overactivity, pressure of speech, and a decreased need for sleep
- Inability to maintain attention, often with marked distractibility
- Self-esteem which is often inflated with **grandiosity **and increased confidence
- Loss of normal social inhibitions
Diagnosis for Mania
For a diagnosis, the manic episode should last for at least seven days and have a significant negative functional effect on work and social activities. Mood changes should be accompanied by an increase in energy and several of the other symptoms mentioned above.
As well as these features, mania can also occur alongside psychotic symptoms such as delusions and hallucinations, which are often auditory
Clinical features of Hypomania?
Hypomania is less severe than mania and is characterised by an elevation of mood to a lesser extent than that seen in mania. In ICD-10, an episode of hypomania is characterised by:8
- Persistent, mild elevation of mood
- Increased energy and activity, usually with marked feelings of wellbeing
- Increased sociability, talkativeness, over-familiarly, increased sexual energy and a decreased need for sleep (but not to the extent that there is a significant negative effect on functioning regarding work or social activities)
- Irritability may be present
- Absence of psychotic features (delusions or hallucinations)
Diagnosis for hypomania
For a diagnosis, more than one of these features should be present for at least several days.
Although hypomania does involve some extent of functional impairment, this is lesser than that seen in mania and is not severe enough to cause the more marked impairment in occupational or social activities.
Differential diagnoses of bipolar disorder?
Schizophrenia
Organic brain disorder
Drug use
Recurrent depression
Emotionally unstable personality disorder (EUPD)/borderline personality disorder
Cyclothymia
Investigations for bipolar disorder?
Investigations can be used to exclude organic causes of a patient’s clinical presentation and are largely context-dependent. Relevant investigations may include:
- Baseline blood tests: FBC, U&Es, LFTs, TFTs, CRP, B12, folate, vitamin D, ferritin
- HIV testing
- Toxicology screen
- Physical examination including neurological examination
- CT head
Diagnosis for bipolar disorder
Bipolar disorder should be considered when there is evidence of:
- **Mania: **symptoms should have lasted for at least seven days
- Hypomania: symptoms should have lasted for at least four days
- Depression (characterised by low mood, loss of interest or pleasure, and low energy) with a history of manic or hypomanic episodes
To confirm a diagnosis of bipolar disorder, a referral should be made to a specialist mental health service. This varies regionally but may take the form of a bipolar disorder service, a psychosis service, or a specialist integrated community-based service
Bipolar disorder
A mixture of both manic and depressive features is sometimes called?
a mixed affective state.
When a child or young person under the age of 18 is suspected of having bipolar disorder, they should be referred to
Child and Adolescent Mental Health Services (CAMHS).
Acute management of mania
n an acute episode of mania, people with a new diagnosis of bipolar disorder should be managed in secondary care with a trial of oral antipsychotics:11
- Haloperidol
- Olanzapine
- Quetiapine
- Risperidone
If the patient is on antidepressant medication, this should be tapered off and discontinued.11 Benzodiazepines may be used as an adjunct to manage symptoms of increased activity and allow for better sleep.
Acute management of depression in bipolar disorder
The recommended pharmacological options for managing depressive episodes in the context of bipolar disorder are:11
- Fluoxetine + olanzapine
- Quetiapine alone
- Olanzapine alone
- Lamotrigine alone
As well as these pharmacological options, psychological interventions such as cognitive behaviour therapy (CBT) may also be useful.11
Long-term management of bipolar disorder
After the acute episode has resolved, long-term pharmacological management usually involves a** mood stabilising medication **such as lithium.
If lithium is not effective, sodium valproate may be added.11 Sodium valproate should not be used in pregnant women due to its teratogenic effects and is not recommended in women of childbearing age unless the illness is very severe and there is no effective alternative. In this circumstance, the patient should have a pregnancy prevention plan.
Lithium is associated with a significant reduction in the risk of relapse with a manic episode, though evidence for its effectiveness in preventing depressive relapse is less clear.
The use of lithium is also associated with a significant reduction in death by suicide.13 Around half of patients will show a good response to lithium, although those with rapid-cycling bipolar disorder, mixed affective states or mood-incongruent features of psychosis may be less likely to respond well.1
Complications of bipolar disorder include
- Increased risk of death by suicide
- Increased risk of death by general medical conditions such as cardiovascular disease
- Side effects of antipsychotic drugs: these can include metabolic effects, weight gain and extrapyramidal symptoms
- Socioeconomic effects: major mental illness is associated with a negative drift down the socioeconomic ladder
Prophylaxis in bipolar disorder
Consider initiation of a mood stabiliser after remission of a manic episode.
* First-line treatment for mood stabilisation is Lithium Carbonate or Depakote
(Depakote must not be used in women of childbearing potential because
of its teratogenicity - significantly increased risk of neural tube defects).
* Second-line - Carbamazepine (= CYP450 inducer and so can lower serum
level of some medications and make them less effective).
* Lamotrigine should be considered if the patient is more prone to bipolar
depressive episodes rather than manic / hypomanic episodes
What is Charles Bonnet Syndrome
Recurrent hallucinations with visual impairment
Rf for Charles Bonnet Syndrome
RF: Age, peripheral visual impairment, social isolation, sensory deprivation
Mx Charles Bonnet Syndrome
Treat age related macular degeneration, glaucoma or cataracts
Causes of Schizophrenia
Exact cause is unknown
Neurochemical abnormality: imbalance of Dopamine, glutamat. These are the 4 dopamine pathways.
1. Nigrostriatiatal -
2. Mesocortical -
3. Mesolimbic -
4. Tuberolinfundibular -
Brainstorm the key features in the history for a patient with Depression
Brainstorm the key features in the exam for a patient with Depression
What does Patient Health Questionnaire 9 (PHQ-9) results suggest
The donts of Risk assessment?
Rating the severity of a depressive episode
