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Phase 3a - Arun&Erin > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What are the two main classification systems for mental disorders?

A
  • ICD-10
  • DSM-5
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2
Q

Give 2 examples of biological approaches to psychiatric management

A
  • Pharmacological therapy
  • Electroconvulsive therapy (ECT)
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3
Q

Definition: ECT

A

Electroconvulsive therapy
* done under general anesthesia
* small electric currents are passed through the brain, triggering a brief seizure
* causes change in brain chemistry

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4
Q

Give 2 examples of psychological approaches to psychiatric management

A
  • Counselling
  • Psychoeducation
  • Psychotherapies e.g. CBT
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5
Q

Give 2 examples of social approaches to psychiatric management

A
  • Support groups/self-help groups
  • social services input e.g. financial, housing
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6
Q

Definition: Mood

A

Refers to a patient’s sustained, experienced emotional state over a period of time

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7
Q

Definition: Affect

A

Immediately expressed and observed emotion in response to stimulus (how we perceive someone else’s emotion)

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8
Q

When are fluctuations in mood considered as a mood disorder?

A

When the disturbance of mood is severe enough to cause impairment in the ADLs

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9
Q

Definition: Mood disorder

A

Any condition characterized by distorted, excessive or inappropriate moods or emotions for a sustained period of time
* also known as an affective disorder

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10
Q

Give 2 examples of affective disorders

A
  • Depression
  • Bipolar disorder
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11
Q

Definition: Depression

A

Mood disorder characterized by persistent:
* Low mood
* Anhedonia
* Lack of energy

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12
Q

Definition: Dysthymia

A

A milder, but more chronic form of depression (>2 years)

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13
Q

Name 7 risk factors for depression

A

Biological:
* Chronic conditions - Parkinson’s, MS, hypothyroidism
* Meds - beta-blockers, steroids
* Genetic factors - family Hx, female

Psychological:
* Trauma - e.g.childhood abuse/neglect
* Low self-esteem

Social:
* Psychosocial issues - homeless, unemployed, divorced
* Poor social support

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14
Q

Clinical features: Name the 3 core symptoms of depression

A
  1. Low mood
  2. Anhedonia: lack of interest in previously enjoyed things
  3. Lack of energy
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15
Q

Clinical features: Name 5 biological symptoms of depression

A
  • Sleep disturbance
  • Psychomotor retardation / agitation
  • Loss of libido
  • Weight & appetite change
  • Nihilistic thoughts / worthlessness / guilt
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16
Q

Clinical features: Name 2 psychotic symptoms of depression

A
  • Delusions
  • Hallucinations
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17
Q

DDx: Name some psychiatric differentials of depression

A
  • Depressive episode linked to substance/medication use
  • Bipolar affective disorder
  • Premenstrual dysphoric disorder
  • Bereavement
  • Anxiety disorders
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18
Q

DDx: Name 3 organic illness differentials of depression

A
  • Hypothyroidism
  • Cushing’s disease or syndrome
  • Vitamin B12 deficiency
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19
Q

What clinical investigations should you do for depression?

A
  • PHQ-9 questionnaire
  • FBC: anaemia
  • TFTs: hypothypothyroidism - elevated TSH
  • Vit B12 deficiency
  • Glucose: diabetes can cause anergia

MRI / CT (where there is atypical presentation or features of an intracranial lesion)

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20
Q

Tx: What is the management for depression?

A
  • Low -> high intensity psychosocial interventions: counselling -> CBT
  • FIRST LINE MEDS: Antidepressants: SSRIs (sertraline/fluoxetine/citalopram) in conjunction with psychoeducation
  • ECT in severe cases
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21
Q

Tx: What is the 1st line drug treatment for depression?

A

SSRI: Fluoxetine

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22
Q

What SSRI is best to give to someone after an MI?

A

Sertraline - doesn’t affect conduction of the heart (doesn’t prolong QT)

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23
Q

Who would you not give olanzapine to?

A

A diabetic because it can cause high blood sugar

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24
Q

When should Electroconvulsive therapy (ECT) be considered?

A

In severe cases of depression where:
* Rapid Tx is needed e.g. life-threatening where Pt isn’t eating or drinking
* Pt has a strong preference to ECT
* Multiple other Tx have been unsuccessful (treatment resistant)

In severe schizophrenia

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25
Q

Definition: Bipolar disorder

A

Chronic episodic mood disorder characterized by at least one episode of mania (or hypomania) and a further episode of mania or depression.

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26
Q

Aetiology: Give 5 risk factors for bipolar disorder

A
  • Genetics/family Hx
  • Anxiety disorders
  • Drug or alcohol abuse
  • Stressful life events (not specific to bipolar)
  • Post-partum period
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27
Q

What are the two main forms of bipolar disorder?

A
  • Bipolar I: Pt has experienced at least one episode of mania - no depression needed
  • Bipolar II: Pt has experienced at least one episode of hypomania, but never an episode of must also have experienced at least one episode of ** depression**
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28
Q

What is cyclothymia?

A

A disorder characterised by a persistent instability of mood involving numerous periods of depression and mild elation

None of which are sufficiently severe or prolonged enough to justify a diagnosis of bipolar affective disorder

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29
Q

Clinical Features: Name 5 symptoms of mania

A
  • Elevated mood
  • Increased activity level
  • Grandiose delusions of self-importance
  • flight of ideas
  • Pressure of speech - fast speech
  • Decreased need for sleep
  • Marked distractibility
  • Increased libido
  • Reckless behaviour and spending
  • Can also occur alongside psychotic symptoms
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30
Q

Clinical Features: Name 4 symptoms of hypomania

A
  • Persistent, mild elevation of mood
  • Increased energy and activity
  • Increased sociability, talkativeness
  • Increased libido
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31
Q

DDx: Name some differentials for bipolar disorder

A
  • Schizophrenia (delusions and hallucinations)
  • Organic brain disorder (frontal lobe pathologies can result in a loss of social inhibitions)
  • Drug use
  • Recurrent depression
  • Emotionally unstable personality disorder (EUPD)/borderline personality disorder (characterised by affective instability)
  • Cyclothymia
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32
Q

What clinical
investigations would you do for bipolar disorder?

A
  • Baseline blood tests: FBC,U&E,LFTs,TFTs,CRP,B12,folate,vitD
  • HIV testing
  • Toxicology screen
  • Neurological exam
  • CT head
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33
Q

Tx: Name 3 medications to treat bipolar disorder

A
  • Antipsychotics: olanzapine, risperidone, quetiapine, haloperidol
  • Mood stabilisers: lithium (sodium valproate can be added)
  • Benzodiazepines: lorazepam
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34
Q

Tx: What non-pharmacological treatments are used for bipolar disorder?

A
  • ECT
  • CBT
  • support groups
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35
Q

What do you need to monitor for when treating a patient with lithium?

A

Kidney function and thyroid function and calcium

Every 6 months

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36
Q

Definition: Psychosis

A

A mental state in which reality is greatly distorted

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37
Q

Aetiology: Name 4 non-organic causes of psychosis

A
  • Schizophrenia
  • Schizoaffective disorder
  • Mood disorders with psychosis
  • Drug-induced psychosis
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38
Q

Aetiology: Name 5 organic causes of psychosis

A
  • Drug-induced psychosis: alcohol, cocaine, amphetamine, MDMA
  • Iatrogenic (medication)
  • Delerium
  • Dementia
  • Huntington’s disease
  • Endocrine disturbance e.g. Cushing’s syndrome
  • Systemic lupus erythematosus
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39
Q

Aetiology: Name 4 medicitions that can cause psychosis

A
  • Levodopa
  • Methyldopa
  • Steroids
  • Antimalarials - chloroquine enters the BBB
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40
Q

Clinical features: How does psychosis present?

A

“abnormality of perception/thought”
* Delusions
* Hallucinations
* Thought disorder

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41
Q

Definition: Delusion

A

A fixed, false belief in something that is not within their usual belief system

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42
Q

Definition: Hallucination

A

A perception in the absence of an external stimulus

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43
Q

Definition: Pseudohallucination

A

Involuntary sensory experience vivid enough to be regarded as a hallucination, but is recognised by the person as being subjective and unreal

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44
Q

Definition: Illusion

A

An incorrect perception of a ‘real’ external stimulus

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45
Q

Name 5 types of delusions

A
  • Persecutory: believing others want to harm them
  • Grandiose: exaggerated sense of one’s importance/power/knowledge/identity
  • Somatic: believing something is wrong with/missing on their body
  • Jealous: believing partner is unfaithful without reason (people with chronic alcohol abuse)
  • Erotomanic: believing someone of a higher social status is in love with them
  • reference: believing that they can pick up on other peoples thoughts, or things are directed against you (schizophrenia)
  • nihilistic: believing that there is no future for themself and very negative (severe depression)
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46
Q

Definition: Schizophrenia

A

Most common psychotic condition characterised by hallucinations, delusions and thought disorders, which lead to functional impairment

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47
Q

Definition: Schizoaffective disorder

A

Characterised by both symptoms of schizophrenia and a mood disorder (depression/mania) in the same episode of illness

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48
Q

Aetiology: Name 4 risk factors for developing schizophrenia

A
  • Family Hx
  • Obstetric complications/fetal injury/intrauterine infection
  • Stressful life events
  • Substance misuse e.g. cannabis
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49
Q

What are the 6 subtypes of schizophrenia?

A
  1. Paranoid (most common)
  2. Hebephrenic
  3. Catatonic
  4. Undifferentiated
  5. Simple
  6. Residual
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50
Q

Clinical features: What are Schneider’s first rank symptoms? (4)

A
  • Delusional perception
  • 3rd person auditory hallucinations
  • Thought interference: insertion, withdrawal, broadcasting
  • Passivity phenomenon/somatic passivity: feelings/actions/impulses are controlled by an external agent
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51
Q

Definition: Delusional perception

A

Person believes that a normal percept has a special meaning for them

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52
Q

Clinical features: What is the difference between positive and negative symptoms of schizophrenia?

A
  • Positive symptoms represent an excess or distortion of normal function (i.e. a change in behaviour or thought)
  • Negative symptoms refer to a decline in normal functioning
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53
Q

Clinical features: Name 5 positive symptoms of schizophrenia

A
  • Delusions
  • Hallucinations
  • Formal thought disorder
  • Thought interference
  • Passivity phenomenon
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54
Q

Clinical features: Name 5 negative symptoms of schizophrenia

A
  • Social isolation
  • Decreased motivation
  • Blunted affect
  • Alogia: poverty of speech
  • Anhedonia
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55
Q

Ix: What investigations are used to rule out other causes of psychotic symptoms in schizophrenia? (7)

A
  • Blood tests (FBC,TFTs,U&E,LFTs,CRP, fasting glucose)
  • Urine culture: rule out UTI causing delirium
  • Urine drug screen: rule out drug intoxication
  • HIV testing
  • Syphilis serology
  • Serum lipids: before starting antipsychotics
  • Relevant imaging: CT head
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56
Q

What is required to form a diagnosis of schizophrenia?

A
  1. A first-rank symptom or persistent delusion present for at least one month
  2. No other cause for psychosis e.g. drug intoxication/withdrawal, brain disease, extensive depressive or manic symptoms
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57
Q

Tx: What is the general management of schizophrenia?

A

Care programme approach
* Assessing health and social needs
* Creating a care plan
* Appointing a key worker to be the first point of contact
* Reviewing treatment

Several MDTs may be involved: early intervention team, community mental health team, crisis resolution team

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58
Q

Tx: What drug type is used to treat schizophrenia?

A

D2 receptor antagonists

D2 = dopamine

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59
Q

Tx: What is the difference between typical and atypical antipsychotics?

A
  • Typical antipsychotics cause generalised dopamine receptor blockade
  • Atypical antipsychotics are more selective in their dopamine blockade. They also block serotonin 5-HT2 receptors
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60
Q

Tx: Name 3 typical antipsychotics

A
  • Haloperidol
  • Chlorpromazine
  • Loxapine
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61
Q

Tx: Name 4 atypical antipsychotics

A
  • Olanzapine
  • Risperidone
  • Clozapine
  • Quetiapine
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62
Q

Tx: Why are atypical antipsychotics preferred over typical antipsychotics?

A

Fewer and less severe side effects

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63
Q

Tx: Name 5 side effects of typical antipsychotics

A
  • Extrapyramidal side effects (EPSEs): parkinsonism, akathisia, dystonia, dyskinesia
  • Hyperprolactinaemia: sexual dysfunction, increased risk of osteoporosis, amenorrhoea, gynaecomastia & hypogonadism in men
  • Metabolic SEs: weight gain, hyperlipidaemia
  • Anticholinergic SEs: tachycardia, dry mouth, urinary retention
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64
Q

Tx: What drug is used when both typical and atypical antipsychotics have been ineffective in treating schizophrenia?

A

Clozapine

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65
Q

What can clozapine cause?

A
  • Agranulocytosis
  • Reduced seizure threshold
  • hypersalivation
  • constipation
  • cardiomyopathy
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66
Q

Definition: Neurosis

A

Collective term for psychiatric disorders characterised by distress that are:

  • non-organic
  • have a discrete onset
  • where delusions and hallucinations are absent
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67
Q

Definition: Anxiety

A

An unpleasant emotional state involving subjective fear and somatic symptoms

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68
Q

When is anxiety described as an illness?

A

If it becomes excessive or inappropriate

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69
Q

What does the Yerkes-Dodson law state?

A

Anxiety can actually be beneficial up to a plateau of optimal functioning. Beyond this level, performance deteriorates

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70
Q

Clinical features: Name 5 common symptoms of neuroses

A
  • Psychological: fear of impending doom, worrying thoughts, restlessness, poor concentration/attention, irritability
  • Cardiovascular: palpitations, chest pain
  • Respiratory: hyperventilation, tight chest
  • GI: abdominal pain, N+V, loose stools
  • GU: more frequent urination, failure of erection
  • Neuromuscular: tremor, myalgia, headache, parasthesia
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71
Q

What are the 2 main categories anxiety disorders can be divided into?

A
  1. Generalised anxiety: present most of the time, not associated with specific objects/situations, typically longer duration
  2. Paroxysmal anxiety: has an abrupt onset, occurs in short-lived, discrete episodes
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72
Q

Name 5 medical conditions associated with anxiety

A
  • Hyperthyroidism
  • Hypoglycaemia
  • Anaemia
  • Phaeochromocytoma
  • Cushing’s disease
  • COPD
  • Malignancies
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73
Q

Name 3 substance-related conditions associated with anxiety

A
  • Intoxication: alcohol, cannabis, caffeine
  • Withdrawal: alcohol, caffeine
  • Side effects: thyroxine, steroids, adrenaline
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74
Q

Name 5 psychiatric conditions associated with anxiety

A
  • Eating disorders
  • Depression
  • Schizophrenia
  • OCD
  • PTSD
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75
Q

Definition: Generalised anxiety disorder

A

A syndrome of ongoing, uncontrollable, widespread worry about events or thoughts that the patient recognises as excessive and inappropriate

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76
Q

How long must symptoms be present for to be classified as GAD?

A

Most days for at least 6 months

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77
Q

Aetiology: Name 2 biological causes of GAD

A
  • Genetics: 5-fold increase in GAD in first degree relatives of Pt with GAD
  • Neurophysiological: autonomic NS dysfunction, exaggerated responses in amygdala and hippocampus
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78
Q

Aetiology: Name 2 environmental causes of GAD

A
  • Stressful life events: Hx of child abuse, relationship problems, personal illness, employment/finances, living alone/as a single parent
  • Substance dependence
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79
Q

Clinical features: Name some symptoms of GAD

A
  • Difficulty breathing
  • Chest pain/discomfort
  • Nausea
  • Abdominal pain
  • Feeling dizzy/light-headed
  • Fear of dying
  • Muscle tension, aches, pains
  • Restlessness
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80
Q

Ix: Name some investigations for GAD

A
  • Bloods: FBC (infection/anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia)
  • ECG: may show sinus tachycardia
  • Questionnaires: GAD-7, Beck anxiety inventory (BAI), Hospital anxiety and depression scale (HADS)
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81
Q

DDx: Name some differentials for GAD

A
  • Other neurotic disorders: panic disorder, specific phobias, OCD, PTSD
  • Depression
  • Schizophrenia
  • Personality disorder: anxious PD, dependent PD
  • Excessive caffeine or alcohol consumption
  • Withdrawal from drugs
  • Organic: anaemia, hyperthyroidism, hypoglycaemia, phaeochromocytoma
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82
Q

Tx: What is the stepped care model for the management of GAD?

A
  1. Psychoeducation and active monitoring
  2. Low-intensity psychological interventions: self-help
  3. High-intensity psychological interventions: CBT or drug treatment
  4. Combination of drug and psychological therapies
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83
Q

Tx: What is the first line drug used to treat GAD?

A

SSRI: sertraline

Has anxiolytic effects

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84
Q

Tx: What is the drug treatment of GAD?

A
  • SSRI: sertraline
  • If this doesn’t help –> SNRI: venlafaxine/duloxetine
  • If both ineffective –> pregabalin

Symptomatic tx is propranolol
## Footnote

Meds should be used for at least a year

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85
Q

Tx: When should benzodiazepines be offered to treat GAD?

A

Only as short-term measures during crises as they can cause dependence

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86
Q

Definition: Phobia

A

An intense, irrational fear of an object, situation, place or person that is recognised as excessive or unreasonable

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87
Q

Definition: Agoraphobia

A

Fear of public spaces from which immediate escape would be difficult in the event of a panic attack

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88
Q

Definition: Social phobia/ Social anxiety disorder

A

A fear of social situations which may lead to humiliation, critisism or embarrassment

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89
Q

Definition: Specific (isolated) phobia

A

A fear restricted to a specific object or situation e.g. animals, injury

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90
Q

Aetiology: Name 6 risk factors for phobias

A
  • Adverse experiences (with specific objects/situations)
  • Stress/ negative life events
  • Mood disorders
  • Other anxiety disorders
  • Substance misuse
  • Family Hx
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91
Q

Clinical features: Name 5 symptoms of phobias

A
  • Tachycardia (however in phobias of blood/injury/illness a vasovagal response is produced - bradycardia which can lead to syncope)
  • Unpleasant anticipatory anxiety
  • Inability to relax
  • Urge to avoid the feared situation
  • Fear of dying
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92
Q

Ix: What questionnaires are used when diagnosing phobias?

A
  • Social phobia inventory
  • Liebowitz social anxiety scale
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93
Q

DDx: Name 5 differentials of phobias

A
  • Panic disorder
  • PTSD
  • Anxious PD
  • Depression
  • Schizophrenia
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94
Q

Tx: What is the management of the 3 phobic anxiety disorders?

A
  • CBT
  • Gradual exposure
  • SSRIs for agoraphobia and social phobia
  • Benzodiazepines may be used in the short-term for specific phobias e.g. claustrophobic but need a CT scan
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95
Q

What are SNRIs?

A

Serotonin-noradrenaline reuptake inhibitors

venlafaxine, duloxetine

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96
Q

Tx: What drug is used to treat social phobia if SSRIs and SNRIs are ineffective?

A

MAOI: moclobemide

monoamine oxidase inhibitors

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97
Q

Definition: Panic disorder

A

Disorder characterised by recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situation.

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98
Q

Aetiology: Name 3 biological causes of panic disorder

A
  • Genetics
  • Neurochemical: post synaptic hypersensitivity to serotonin and adrenaline
  • Sympathetic NS: fear/worry stimulates SNS –> increased cardiac output –> further anxiety
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99
Q

Aetiology: Name 8 risk factors for panic disorder

A
  • Family Hx
  • Female
  • White ethnicity
  • Age 20-30
  • Major life events
  • Recent trauma
  • Asthma
  • Medication e.g. benzodiazepine withdrawal
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100
Q

Clinical features: How long do panic disorder symptoms usually last?

A

Symptoms usually peak within 10 minutes and rarely persist beyond an hour

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101
Q

Clinical features: Name some symptoms of panic disorder

A
  • Palpitations
  • Intense fear of death
  • Chest pain
  • Sweating
  • Shaking
  • Shortness of breath
  • Abdominal distress
  • Depersonalisation/derealisation
  • Numbness
  • Nausea
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102
Q

DDx: Name some psychiatric and organic differentials for panic disorder

A
  • Psychiatric: other anxiety disorders, bipolar, depression, schizophrenia
  • Organic: Phaeochromocytoma, hyperthyroidism, hypoglycaemia, arrhythmias, alcohol/substance withdrawal
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103
Q

Tx: What is the drug management of panic disorder?

A
  • SSRI is 1st line
  • If these don’t work after 12 weeks, then consider a TCA (imipramine/clomipramine)
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104
Q

Tx: Name 2 examples of a TCA used to treat panic disorder

A
  • Imipramine
  • Clomipramine
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105
Q

Definition: Post traumatic stress disorder

A

An intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event

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106
Q

Definition: Abnormal bereavement

A

Grief that Has a delayed onset, is more intense and is prolonged (>6 months)

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107
Q

Definition: Acute stress reaction

A

An abnormal reaction to sudden stressful events

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108
Q

Definition: Adjustment disorder

A

When there is significant distress accompanied by an impairment in social functioning when adapting to new circumstances

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109
Q

Give 5 risk factors for PTSD

A
  • Exposure to a major traumatic event: professions at risk (army, police, doctors), groups at risk (refugees, asylum seekers)
  • Previous trauma
  • Hx of mental illness
  • Childhood abuse
  • Post-trauma –> absence of social support, concurrent life stressors
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110
Q

Clinical features: Name the 4 categories of PTSD symptoms

Must occur within 6 months of the event

A
  • Reliving the situation: flashbacks, vivid memories, nightmares
  • Avoidance: avoiding reminders of trauma (e.g. associated people/locations), inability to recall aspects of the trauma
  • Hyperarousal: irritability/outbursts, difficulty concentrating, difficulty sleeping, hypervigilance, exaggerated startle response
  • Emotional numbing: negative thoughts about oneself, difficulty experiencing emotions, feeling detached from others, giving up previously enjoyed activities
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111
Q

Ix: Name 3 investigations for PTSD

A
  • Trauma screening questionnaire (TSQ)
  • ** Post-traumatic diagnostic scale**
  • CT head (if head injury suspected)
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112
Q

DDx: Name 5 differentials for PTSD (8)

A
  • Adjustment disorder
  • Acute stress reaction
  • Bereavement
  • Dissociative disorder
  • Mood or anxiety disorders
  • Personality disorder
  • Head injury
  • Alcohol/substance misuse
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113
Q

Tx: What is the management of PTSD where symptoms are present within 3 months of trauma?

A
  • Watchful waiting (< 4 weeks)
  • Trauma-focused CBT (8-12 sessions)
  • Short-term drug Tx for managing sleep disturbance (e.g. zopiclone)
  • Risk assessment (assess risk for neglect/suicide)
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114
Q

Tx: What is the management of PTSD where symptoms have been present > 3 months after trauma?

A

Trauma-focused psychological intervention
2 options:
* CBT
* EMDR

Drug Tx considered when:
* Little benefit from psychological therapy
* Patient preference
* Co-morbid depression / severe hyperarousal

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115
Q

Tx: What is EMDR?

A

Eye Movement Desensitisation and Reprocessing
* helps patient access and process traumatic memories
* involves recalling emotionally traumatic material while focusing on an external stimulus

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116
Q

Tx: Name 4 drugs used to treat PTSD

A
  • velafaxine = 1st line
  • Sertraline
  • Paroxetine
  • Venlafaxine
  • Fluoxetine
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117
Q

Definition: Obsessive-compulsive disorder (OCD)

A

Disorder characterised by recurrent obsessional thoughts and/or compulsive acts

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118
Q

Definition: Obsessions

A

Unwanted intrusive thoughts, images or urges that repeatedly enter the individual’s mind.

They are distressing for the Pt who attempts to resist them and recognises them as absurd (egodystonic) and a product of their own mind

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119
Q

Definition: Compulsions

A

Repetitive, stereotyped behaviours or mental acts that a person feels driven to perform.

  • They are overt (observable by others) or covert (mental acts not observable)
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120
Q

Aetiology: Name 3 potential causes of OCD

A
  • Family Hx
  • Streptococcal infections
  • Stressful life events
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121
Q

Clinical features: Name the 4 features that obsessions/compulsions always share

A
  1. Failure to resist
  2. Originate from the patient’s mind
  3. Repetitive and distressing
  4. Carrying out the obsessive thought/compulsive act is not in itself pleasurable, but reduces anxiety levels
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122
Q

What is the OCD cycle?

A

Obsession > Anxiety > Compulsion > Relief

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123
Q

Name 4 common obsessions in OCD

A
  • Contamination
  • Fear of harm (door locks)
  • Excessive concern with order/symmetry
  • Others: sex, blasphemy, violence, doubt
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124
Q

Name 5 common compulsions in OCD

A
  • Checking (e.g. taps, doors)
  • Cleaning/washing
  • Repeating acts (e.g. counting/arranging objects)
  • Mental compulsions (e.g. special words repeated in a set manner)
  • Hoarding
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125
Q

Ix: What investigations are used to diagnose OCD?

A

Yale-Brown obsessive-compulsive scale (Y-BOCS)

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126
Q

DDx: Name 5 differentials for OCD (9)

A
  • Both obsessions and compulsions: eating disorders
  • Primarily obsessions: anxiety disorders, depression, schizophrenia
  • Primarily compulsions: Tourette’s syndrome, kleptomania
  • Organic: Dementia, epilepsy, head injury
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127
Q

Tx: What is the management for OCD?

A
  • CBT including ERP (exposure and response prevention)
  • SSRIs: fluoxetine, sertraline
  • Clomipramine (TCA)
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128
Q

Definition: Somatisation disorder

A

Multiple, recurrent and frequently changing physical symptoms not explained by a physical illness over 6 months

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129
Q

Definition: Dissociation

A

A process of separating off certain memories from normal consciousness.

This is a physiological defence mechanism used to cope with emotional conflict that is so distressing to the patient, it is prevented from entering their conscious mind.

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130
Q

Definition: Conversion (in terms of psychiatric Sx)

A

Distressing events are transformed into physical symptoms

E.g anxiety may manifest into GI symptoms

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131
Q

Name 6 risk factors for somatoform and dissociative disorders

A
  • Childhood abuse
  • Reinforcement of illness behaviours
  • Anxiety disorders
  • Mood disorders
  • Personality disorders
  • Social stressors
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132
Q

Tx: Name 4 managements for somatoform and dissociative disorders

A
  • SSRIs (antidepressants)
  • Physical exercise
  • CBT
  • Encouraging stress-relieving activities
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133
Q

Definition: Acute intoxication

A

Theacute, usually transient, effect of the substance

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134
Q

Definition: Dependence syndrome

A

Prolonged, compulsive substance use leading to addiction, tolerance and the potential for withdrawal symptoms

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135
Q

Definition: Withdrawal state

A

Physical and/or psychological effects from complete (or partial) cessation of a substance after prolonged, repeated or high level of use

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136
Q

Definition: Substance-induced psychotic disorder

A

Onset of psychotic symptoms within 2 weeks of substance use.
Must persist for > 48 hrs

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137
Q

Name 5 environmental factors that can lead to substance dependence

A
  • Peer pressure
  • Life stressors
  • Parental drug use
  • Cultural acceptability
  • Personal vulnerability
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138
Q

What is the chain of events leading to substance dependence?

A
  1. Takes substance
  2. Positive reinforcement: psychosocial (from peers/ pleasurable effects of the drug), biological (activates mesolimbic dopaminergic reward pathways)
  3. Dependence
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139
Q

Name 4 examples of opiates

A
  • Morphine
  • Heroin
  • Codeine
  • Methadone
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140
Q

Name 3 psychological effects of opiates

A
  • Apathy
  • Disinhibition
  • Psychomotor retardation
  • Impaired judgement/attention
  • Drowsiness
  • Slurred speech
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141
Q

Name 3 physical effects of opiates

A
  • Respiratory depression
  • Hypoxia
  • Decreased BP
  • Hypothermia
  • Coma
  • Pupillary constriction
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142
Q

Name some symptoms of opiate withdrawal
FLAPPY HANDS

A

Fever and chills
Lacrimation
Agitation
Piloerection
Pupillary dilation
Yawning

Hypertension and tachychardia
Aches
Nausea
Diarrhea
Sweating

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143
Q

Name a cannabinoid

A

Cannabis

144
Q

Name 3 psychological effects of cannabinoids

A
  • Euphoria
  • Disinhibition
  • Paranoid ideation
  • Temporal slowing (time passes slowly)
  • Imparied judgement/attention/reaction time
  • Illusions
  • Hallucinations
145
Q

Name 4 physical effects of cannabinoids

A
  • Increased appetite
  • Dry mouth
  • Conjunctival injection (eye redness)
  • Increased HR
146
Q

Name 5 symptoms of cannabinoid withdrawal

A
  • Anxiety
  • Irritability
  • Tremor of outstretched hands
  • Sweating
  • Myalgia
147
Q

Name a sedative-hypnotic drug

A

Benzodiazepines

148
Q

Name 3 psychological effects of sedative-hypnotics

A
  • Euphoria
  • Disinhibition
  • Apathy
  • Aggression
  • Anterograde amnesia (can’t form new memories)
  • Labile mood (unpredictable, uncontrollable, rapid shifts in emotions)
149
Q

Name 3 physical effects of sedative-hypnotics

A
  • Unsteady gait
  • Difficulty standing
  • Slurred speech
  • Nystagmus
  • Erythematous skin lesions
  • Decreased BP
  • Hypothermia
  • Depression of gag reflex
  • Coma
150
Q

Name 5 symptoms of sedative-hypnotic withdrawal (10)

A
  • Tremor of hands/tongue/eyelids
  • N+V
  • Increased HR
  • Postural hypotension
  • Headache
  • Agitation
  • Malaise
  • Transient illusions/hallucinations
  • Paranoid ideation
  • Grand mal convulsions
151
Q

Name 4 examples of stimulants

A
  • Cocaine
  • Crack cocaine
  • Ecstasy (MDMA)
  • Amphetamine
  • nicotine
152
Q

Name 3 psychological effects of stimulants

A
  • Euphoria
  • Increased energy
  • Grandiose beliefs
  • Aggression/argumentative
  • Illusions/hallucinations
  • Paranoid ideation
  • Labile mood
153
Q

Name 3 physical effects of stimulants

A
  • Increased HR / BP
  • Arrhythmias
  • Sweating
  • N+V
  • Pupillary dilatation
  • Psychomotor agitation
  • Muscular weakness
  • Chest pain
  • Convulsions
154
Q

Name some symptoms of stimulant withdrawal

A
  • Dysphoric mood
  • Lethargy
  • Psychomotor agitation
  • Craving
  • Increased appetite
  • Insomnia / hypersomnia
  • Bizarre/unpleasant dreams
155
Q

Name 2 examples of hallucinogens

A
  • LSD
  • Magic mushrooms
156
Q

Name 3 psychological effects of hallucinogens

A
  • Anxiety
  • Illusions/hallucinations
  • Depersonalisation/derealisation
  • Paranoia
  • Ideas of reference
  • Hyperactivity
  • Impulsivity
  • Inattention
157
Q

Name 3 physical effects of stimulants

A
  • Increased HR
  • Palpitations
  • Sweating
  • Tremor
  • Blurred vision
  • Pupillary dilatation
  • Incoordination
158
Q

Name 4 examples of volatile solvents

A
  • Aerosols
  • Paint
  • Glue
  • Petrol
159
Q

Name 3 psychological effects of volatile solvents

A
  • Apathy
  • Lethargy
  • Aggression
  • Impaired attention/judgement
  • Psychomotor retardation
160
Q

Name 3 physical effects of volatile solvents

A
  • Unsteady gait
  • Diplopia
  • Nystagmus
  • Decreased consciousness
  • Muscle weakness
161
Q

Name 3 examples of anabolic steroids

A
  • Testosterone
  • Androstenedione
  • Danazol
162
Q

Name 3 psychological effects of anabolic steroids

A
  • Euphoria
  • Depression
  • Aggression
  • Hyperactivity
  • Mood swings
  • Hallucinations
  • Delusions
163
Q

Name 3 physical effects of anabolic steroids

A
  • Increased muscle mass
  • Reduced fat
  • Acne
  • Male pattern baldness
  • Reduced sperm count/infertility
  • Stunted growth
164
Q

Ix: Name 3 investigations for substance misuse

A
  • Bloods: blood-bourne infections through needle sharing(HIV screen, Hep B, Hep C, TB), renal function (U+Es), hepatic function (LTFs, clotting), drug levels
  • Urinalysis: drug metabolites can be detected in urine (e.g. cannabis, opioids)
  • ECG: arrhythmias, ECHO if endocarditis suspected (secondary to needle sharing)
165
Q

DDx: Name some differentials of substance misuse

A
  • Psychiatric: psychosis, mood disorders, anxiety disorders, delirium
  • Organic: hyperthyroidism, CVA, intracranial haemorrhage
166
Q

Tx: What is the management of substance misuse?

A
  • Hep B immunisation for those at risk
  • Motivational interviewing/CBT
  • Housing/finance/employment support
  • Self-help groups (e.g. narcotics anonymous and cocaine anonymous)
  • Consider issue of driving: review DVLA
167
Q

Tx: Name 3 managements of opioid dependence

A
  • Biological therapies: methadone (1st line) or buprenorphine for detoxification AND maintenance
  • Naltrexone: formerly opioid-dependent but have now stopped and want to continue abstinence
  • IV naloxone (opioid antagonist): antidote to opioid overdose
168
Q

Definition: Alcohol abuse

A

Consumption of alcohol at a level sufficient to cause physical, psychiatric and/or social harm

169
Q

Definition: Binge drinking

A

Drinking over twice the recommended level of alcohol per day in one session

> 8 units for men, > 6 units for women

170
Q

Definition: Harmful alcohol use

A

Drinking above safe levels with evidence of alcohol-related problems

> 50 units/week for men, > 35 units/week for women

171
Q

Name 5 risk factors for alcohol abuse

A
  • Male: increased metabolism of alcohol
  • Younger adults
  • Antisocial behaviour
  • Lack of facial flushing: risk of alcoholism is decreased in individuals who show alcohol-induced facial flushing
  • Life stressors: e.g. financial problems, marital issues, certain occupations
172
Q

Clinical features: Name 4 symptoms of alcohol intoxication

A
  • Slurred speech
  • Labile affect
  • Impaired judgement
  • Poor coordination

In severe cases: hypoglycaemia, stupor, coma

173
Q

Clinical features: What are the 7 signs of Edward and Gross criteria for alcohol dependence?

A
  • Subjective awareness of compulsion to drink
  • Avoidance or relief of withdrawal Sx by further drinking
  • Withdrawal Sx
  • Drink-seeking behaviour predominates
  • Reinstatement of drinking after attempted abstinence
  • Increased tolerance to alcohol
  • Narrowing of drinking repertoire (i.e. a stereotyped pattern of drinking - fixed times for drinking with reduced influence from environmental cues)
174
Q

Clinical features: Name 6 symptoms of alcohol withdrawal

A
  • Malaise
  • Tremor
  • Nausea
  • Insomnia
  • Transient hallucinations
  • Autonomic hyperactivity

Occur at 6-12 hours after abstinence

175
Q

When is peak incidence of seizures after alcohol withdrawal?

A

36 hours

176
Q

Definition: Delirium tremens

A
  • Severe end of the spectrum of withdrawal
  • Peak incidence is at 72 hours
177
Q

Name 5 symptoms of delirium tremens

A
  • Cognitive impairment
  • Vivid perceptual abnormalities: hallucinations and/or illusions - feel bugs on their skin
  • Paranoid delusions
  • Marked tremor
  • Autonomic arousal: tachycardia, fever, pupillary dilatation, increased sweating
178
Q

Tx: What is the management of delirium tremens?

A
  • Benzodiazepines e.g. chlordiazepoxide
  • Haloperidol for any psychotic features
  • IV Pabrinex contains water soluble vitamins (C,B1,B2,B3,B6)
179
Q

Ix: Name 4 investigations for alcohol abuse

A
  • Bloods: blood alcohol level, FBC, U&Es, LFTs, MCV, hepatitis serology, glucose
  • Alcohol questionnaire: CAGE, AUDIT, SADQ
  • CT head: is head injury suspected
  • ECG: arrhythmias
180
Q

DDx: Name some differentials for alcohol abuse

A
  • Psychiatric: psychosis, mood disorders, anxiety disorders, delirium
  • Medical: head injury, cerebral tumour, CVA (e.g. stroke)
181
Q

Definition: Wernicke’s encephalopathy

A

An acute encephalopathy due to thiamine deficiency

182
Q

Clinical features: Name 5 symptoms of Wernicke’s encephalopathy

A
  • Delirium / altered mental status
  • Nystagmus
  • Ophthalmoplegia
  • Hypothermia
  • Ataxia
183
Q

Tx: What is the management of Wernicke’s encephalopathy?

A

Parenteral thiamine

184
Q

Definition: Korsakoff’s psychosis

A

Profound, irreversible short-term memory loss with:
* confabulation (unconscious filling of gaps in momory with imaginary events)
* disorientation to time

185
Q

Tx: What is the management of alcohol dependence?

A
  • Disulfiram / Naltrexone / Acamprosate
  • Motivational interviewing
  • CBT
  • Alcoholics Anonymous
  • Social support including family involvement
186
Q

Tx: What is the management of alcohol withdrawal?

A
  • Chlordiazepoxide detox regime
  • Thiamine

Chlordiazepoxide = high dose benzodiazepine

187
Q

Name some examples of behavioural addictions

A
  • Food
  • Exercise
  • Gambling
  • Internet
  • Plastic surgery
  • Porn
  • Sex
  • Shopping
  • Social media
  • Video games
188
Q

Name some signs of behavioural addiction

A
  • Prioritising time spent engaging in the behaviour
  • Becoming increasingly dependent on the behaviour to cope with emotions
  • Having difficulty changing behaviour despite wanting to do so
  • Continuing behaviour despite attempts to stop
  • Neglecting or avoiding work/family/school to engage in the behaviour or hide its effects on your life
  • Denying, minimising, hiding the full truth about your addiction
  • Experiencing unpleasant feelings/sensations when trying to stop (withdrawal Sx)
189
Q

Tx: What is the management for addictive behaviours?

A
  • CBT
  • Group therapy
190
Q

Definition: Deliberate self-harm

A

An intentional act of self-poisoning or self-injury, irrespective of the motivation.

Usually an expression of emotional distress

191
Q

Name some methods of self-injury

A
  • Cutting
  • Burning
  • Hanging
  • Stabbing
  • Swallowing objects
  • Shooting
  • Jumping from heights/in front of vehicles
192
Q

Name 4 methods of self-poisoning

A
  • Medication
  • Illicit drugs
  • Household substances
  • Plant material
193
Q

Name 8 risk factors for deliberate self-harm

A
  • Divorced/single/living alone
  • Severe life stressors
  • Harmful drug/alcohol use
  • < 35 y.o.
  • Chronic physical health problems
  • DV or childhood abuse
  • Socioeconomic disadvantage
  • Psychiatric illness e.g. depression, psychosis
194
Q

Ix: Name 4 investigations for ruling out self-harm

A
  • Bloods: paracetamol levels, salicylate levels if suspected overdose, U&Es (renal function), LFTs and clotting (hepatic funtion)
  • Urinalysis: toxicological analysis
  • CT head: if an intracranial cause for altered consciousness is suspected
  • Lumbar puncture: if intracranial infection is suspected (e.g. meningitis)
195
Q

Tx: What is the management of self-harm?

A
  • Acute Tx: treating any overdose with specific antidotes, suturing
  • Manage high suicide risk: full risk assessment!
  • Treat any psychiatric disorder: antidepressants/CBT/psychodynamic psychotherapy
  • Psychosocial assessment: offer help for psychosocial needs e.g. counselling/social services input
  • Follow-up within 48 hours
196
Q

Antidote to paracetamol overdose?

A

N-Acetylcysteine

197
Q

Antidote to opiates overdose?

A

Naloxone

198
Q

Antidote to benzodiazepine overdose?

A

Flumazenil

199
Q

Antidote to warfarin overdose?

A

Vitamin K

200
Q

Antidote to beta-blocker overdose?

A

Glucagon

201
Q

Antidote to TCA overdose?

e.g. amitriptyline

A

Sodium bicarbonate

202
Q

Definition: Suicide

A

A fatal act of self-harm initiated with the intention of ending one’s own life

203
Q

Definition: Attempted suicide

A

The act of intentionally trying to take one’s own life with the primary aim of dying, but failing to succeed in this endeavour

204
Q

Definition: Risk assessment

In a psychiatric context

A

Assessing the risk of self-harm, suicide and/or risk to others

205
Q

Name 5 protective factors which can reduce the risk of suicide (12)

A
  • Children at home
  • Pregnancy
  • Strong religious/spiritual beliefs
  • Strong social support
  • Positive coping skills
  • Positive therapeutic relationship
  • Supportive living arrangements
  • Life satisfaction
  • Fear of the physical act of suicide
  • Fear of disapproval from society
  • Responsibility for others
  • Hope for the future
206
Q

Name 5 clinical risk factors of suicide

A
  • Hx of DSH or attempted suicide
  • Psychiatric illness: depression, schizophrenia, substance misuse, alcohol abuse, personality disorder
  • Childhood abuse
  • Family Hx
  • Medical illness: physically disabling/painful/terminal illness
207
Q

Name 5 socio-demographic risk factors of suicide (8)

A
  • Males 3x more likely
  • Age: 40 - 44 in men
  • Unemployed / low socioeconomic status
  • Occupation: vets, doctors, nurses, farmers
  • Access to lethal means: firearms, hanging, strangling, suffocation
  • Low social support, living alone, institutionalised (e.g. prisons, soldiers)
  • Single/widowed/separated/divorced
  • Recent life crisis: bereavement, family breakdown
208
Q

Clinical features: Name 6 characteristics of someone who is suicidal

A
  • Preoccupation with death
  • Sense of isolation and withdrawal from society
  • Emotional distance from others
  • Distraction and lack of pleasure
  • Focus on the past
  • Feelings of hopelessness and helplessness
209
Q

Name 6 things that can be used to determine the risk of suicide following DSH

A
  1. Note left behind
  2. Planned attempt of suicide
  3. Attempts to avoid being discovered
  4. Afterwards help was not sought
  5. Violent method
  6. Final acts: sorting out finances, writing a will
210
Q

Tx: What is the management for someone who has attempted suicide?

A
  • Ensure safety: remove any means for suicide
  • Pt who has attempted and failed suicide should be medically stabilised: Tx of drug overdose/physical injury
  • Risk assessment
  • Admission to hospital
  • Referral to secondary care
  • Psychiatric Tx
  • Support from Crisis Resolution and Home Treatment team
  • Outpatient and community Tx
211
Q

Name 3 individual suicide prevention strategies

A
  • Detect and treat psychiatric disorders
  • Urgent hospitilisation under the Mental Health Act
  • Involvement of the Crisis Resolution and Home Treatment team
212
Q

Name 5 population level suicide prevention strategies

A
  • Public education/discussion
  • Reducing access to means of suicide: e.g. encourage Pts to dispose of unwanted tablets, safety rails at high places
  • Easy, rapid access to psychiatric care/support groups
  • Decreasing social stressors: e.g. unemployment, DV
  • Reducing substance misuse
213
Q

Definition: Delirium

A

An acute, transient, reversible state of confusion and impaired consciousness and attention

214
Q

What are the 3 subtypes of delirium?

A
  • Hypoactive: lethargy, decreased motor activity, apathy
  • Hyperactive: agitation, irritability, restlessness, aggression, hallucinations/delusions
  • Mixed: signs of both
215
Q

Name 10 causes of delirium

mnemonic: HE IS NOT MAAD

A
  • Hypoxia: resp failure, MI, PE
  • Endocrine: hyper/hypothyroidism, hyper/hypoglycaemia, Cushing’s
  • Infection: UTI, pneumonia, meningitis
  • Stroke/intracranial events: raised ICP, haemorrhage, SOL, head trauma, epilepsy
  • Nutritional: decreased thiamine, vit B12
  • Others: severe pain, sensory deprivation, sleep deprivation
  • Theatre/post-op: anaesthetic, opiate analgesics
  • Metabolic: hepatic/renal impairment, electrolyte disturbance
  • Abdominal: urinary retention, bladder catheterisation, malnutrition, faecal impaction
  • Alcohol: intoxication, withdrawal
  • Drugs: benzodiazepines, opioids, steroids, anti-parkinsonian meds, anticholinergics
216
Q

Name 5 risk factors for delirium (10)

A
  • Old age > 65
  • Multiple co-morbidities
  • Dementia
  • Physical frailty
  • Renal impairment
  • Male sex
  • Sensory impairment
  • Previous episodes
  • Recent surgery
  • Severe illness
217
Q

Clinical features: Name 8 symptoms of delirium

Mnemonic: DELIRIUM

A
  • Disordered thinking: slowed, irrational, incoherent thoughts
  • Emotional disturbances: euphoric, fearful, depressed, angry
  • Language impaired: rambling, repetitive, disruptive
  • Illusions, delusions, hallucinations
  • Reversal of sleep-wake pattern: tired during day, hyper-vigilant at night
  • Inattention: inability to focus, clouding of consciousness
  • Unaware/disoriented: to time, place, person
  • Memory deficits
218
Q

Ix: Name 3 investigations for delirium

A
  • Routine Ix: urinalysis, bloods (FBC,U&E,LFT,, glucose,CRP,TFT etc), infection screen (blood & urine culture)
  • Ix based on Hx/examination: ABG (hypoxia), CT head, lumbar puncture (meningitis), EEG (epilepsy)
  • Questionnaires: Abbreviated Mental Test (AMT), Confusion Assessment Method (CAM), Mini-Mental State Examination (MMSE)
219
Q

DDx: Name 5 differentials for delirium

A
  • Dementia
  • Mood disorder
  • Late onset schizophrenia
  • Dissociative disorders
  • Hypo/hyperthyroidism
220
Q

Tx: What is the management of delirium?

A
  • Treat underlying cause: treat any infections, laxatives for faecal impaction, temporary catheterisation for urinary retention
  • Reassurance and re-orientation
  • Provide appropriate environment
  • Manage disturbed, violent, destressed behaviour: low-dose haloperidol or olanzapine
  • Avoid benzodiazepines
221
Q

Definition: Personality disorder

A

A deeply ingrained and enduring pattern of inner experience and behaviour that deviates from expectations in the individual’s culture.
* It is pervasive and inflexible
* Onset in early adulthood
* Is stable over time and leads to distress or impairment

222
Q

What are the 3 clusters of PDs?

A

Cluster A: odd/eccentric
* Paranoid
* Schizoid

Cluster B: dramatic/emotional
* Emotionally unstable (borderline)
* Dissocial (antisocial)
* Histrionic

Cluster C: anxious/fearful
* Dependent
* Avoidant (anxious)
* Anankastic (obsessional)

223
Q

Name 4 risk factors for personality disorder

A
  • Low socioeconomic status
  • Genetics: family Hx
  • Dysfunctional family: poor parenting, parental deprivation
  • Childhood abuse: physical, sexual, emotional, neglect
224
Q

Clinical features: Name the features of cluster A PDs

Cluster A (weird)

A

Paranoid
* suspicious
* unforgiving
* questions fidelity
* jealous
* doesn’t like criticism
* reduced trust

Schizoid
* detached affect
* indifferent to praise/criticism
* reduced libido
* does tasks alone
* no emotion
* takes pleasure in few activities
* absence of close friends

225
Q

Clinical features: Name the features of cluster B PDs

Cluster B (wild)

A

EUPD
* fear of abandonment
* mood instability
* suicidal behaviour
* unstable relationships
* intense relationships
* poor anger control
* impulsive
* disturbed sense of identity
* chronic emptiness

Dissocial (antisocial)
* callous
* blames others
* reckless - disregard for safety
* lack of guilt (remorseless)
* deceitful
* impulsive
* temper/ tendency to violence

Histrionic
* provocative behaviour
* concern for physical attractiveness
* attention seeking
* easily influenced
* shallow/ inappropriate seductive
* egocentric (vain)
* exaggerated emotions

226
Q

Clinical features: Name the features of cluster C PDs

Cluster C (worriers)

A

Dependent
* reassurance required
* difficulty expressing disagreement
* lack of self-confidence
* difficulty initiating projects
* fear of abandonmnent
* seeks companionship
* exaggerated fears

Anxious (avoidant)
* certainty of being liked needed before becoming involved with people
* restriction to lifestyle in order to maintain security
* feels inadequate
* potential to be embarrassed prevents involvement in new activities
* social inhibition

Anankastic (obsessional)
* loses point of activity due to preoccupation with detail
* compromised ability to complete tasks due to perfectionism
* workaholic at the expense of leisure
* fussy
* inflexible/ rigid
* meticulous attention to detail
* stubborn

227
Q

Ix: Name 3 investigations for PD

A
  • Questionnaires: Personality Diagnostic test, Eysenck Personality test
  • Psychological testing: Minnesota Multiphasic Personality Inventory (MMPI)
  • CT head/MRI: rule out organic causes e.g. frontal lobe tumours/intracranial bleeds
228
Q

DDx: Name 3 differentials for PD

A
  • Mood disorders: mania, depression
  • Psychotic disorders: schizophrenia, schizoaffective disorder
  • Substance misuse
229
Q

Tx: What is the management for PD?

A
  • Identify and treat any psychiatric illness and substance misuse
  • Risk assessment: psychosocial interventions to reduce stressors
  • Pharmacological (control Sx): low-dose antipsychotics, mood stabilisers, antidepressants
  • Psychological: CBT, psychodynamic psychotherapy, Dialectical behavioural therapy (DBT)
  • Social: support groups, assistance with social problems (housing/finance/employment), access to education
230
Q

What is DBT?

A

Dialectical Behavioural Therapy

  • Emphasis on developing coping strategies to improve impulse control and reduce self-harm
  • Used in EUPD
231
Q

Definition: Dementia

A
  • A syndrome of generalised decline of memory, intellect and personality
  • Without impairment of consciousness
  • Leading to functional impairment
232
Q

What are the 4 types of dementias from most prevalent to least?

A
  • Alzheimer’s disease
  • Vascular dementia
  • Dementia with Lewy bodies (DLB)
  • Fronto-temporal dementia
233
Q

Name 5 irreversible causes of dementia

A
  • Neurodegenerative: Alzheimer’s, F-T dementia, DLB, Parkinson’s, Huntington’s
  • Infections: HIV, encephalitis, syphilis
  • Toxins: alcohol, barbiturates, benzodiazepines
  • Vascular: vascular dementia, CVD
  • Head trauma
234
Q

Name 3 reversible causes of dementia

A
  • Neurological: normal pressure hydrocephalus, intracranial tumours, CSH
  • Vitamin deficiencies: B12, folic acid, thiamine, nicotinic acid
  • Endocrine: Cushing’s, hypothyroidism
235
Q

What is the pathophysiology of Alzheimer’s disease?

A
  • Degeneration of cholinergic neurons in the nucleus basalis of Meynert leading to acetylcholine deficiency
236
Q

What are 2 microscopic physiological changes seen in Alzheimer’s disease?

A
  • Neurofibrillary tangles (intracellularly)
  • Beta-amyloid plaque formation (extracellularly)

These are pathological lesions progressively distributed around the brain

237
Q

What are 3 macroscopic physiological changes seen in Alzheimer’s disease?

A
  • Cortical atrophy (commonly hippocampus)
  • Widened sulci
  • Enlarged ventricles
238
Q

Aetiology: What is the cause of vascular dementia?

A

Cerebrovascular disease due to:
* stroke
* multi-infarcts
* chronic changes in small vessels (arteriosclerosis)

239
Q

Aetiology: What is the cause of Lewy body dementia?

A

Abnormal deposition of protein (Lewy body) within the neurons of the:
* brainstem
* substantia nigra
* neocortex

240
Q

Aetiology: What is the cause of fronto-temporal dementia?

A

Specific degeneration (atrophy) of the frontal and temporal lobes.

241
Q

What is Pick’s disease?

A

A type of fronto-temporal dementia, where protein tangles (Pick’s bodies) are seen histologically

242
Q

What are the cortical, subcortical and mixed dementias?

A
  • Cortical: AD, fronto-temporal
  • Subcortical: DLB
  • Mixed: vascular
243
Q

Name 7 risk factors for Alzheimer’s disease

A
  • Advancing age
  • Family Hx
  • Genetics
  • Down’s syndrome
  • Low IQ
  • CVD
  • Vascular RFs: stroke/MI, smoking, HTN, DM, high cholesterol
244
Q

Clinical features: Name 3 symptoms in early stages of AD

A
  • Memory lapses
  • Difficulty finding words
  • Forgetting names of people/places
245
Q

Clinical features: Name 4 symptoms during disease progression of AD

A
  • Apraxia
  • Agnosia
  • Confusion
  • Language problems
  • Impairment of executive functions
246
Q

Clinical features: Name 7 symptoms in later stages of AD

A
  • Disorientation to time/place
  • Wandering
  • Apathy
  • Incontinence
  • Eating problems
  • Depression
  • Agitation
247
Q

Name 6 clinical features of vascular dementia

A
  • Stepwise rather than continuous deterioration
  • Memory loss
  • Emotional and personality changes
  • Confusion
  • Neurological signs/Sx
  • On examination –> focal neurology (UMN signs) and signs of CVD
248
Q

Name 4 clinical features of DLB

A
  • Day to day fluctuations in cognitive performance
  • Recurrent visual hallucinations
  • Motor signs of parkinsonism (tremor, rigidity, bradykinesia)
  • Recurrent falls / syncope
249
Q

Name 6 clinical features of fronto-temporal dementia

A
  • Family Hx is positive
  • onset before 65
  • Early personality changes: disinhibition (reduced control over one’s behaviour), apathy/restlessness
  • Worsening of social conduct
  • Repetitive behaviour
  • Language problems
  • Memory is preserved
250
Q

Name 3 clinical features of Huntington’s disease

A
  • Autosomal dominant: strong family Hx
  • Abnormal choreiform movements of face, hands, shoulders and gait abnormalities
  • Dementia presents later
251
Q

Name the triad of clinical features in normal pressure hydrocephalus

A
  1. Dementia with prominent frontal lobe dysfunction
  2. Urinary incontinence
  3. Gait disturbance (wide gait)
252
Q

Ix: Name 10 investigations for dementia

A

Blood tests: FBC,CRP,U&E,calcium,LFT,glucose,vit B12 & folate,TFT

Non-routine Ix:
* Urine dipstick
* Chest Xray
* Syphilis serology & HIV testing
* CT/ MRI/ SPECT (to differentiate between AD, VascD and F-TD)
* ECG
* EEG
* Lumbar puncture
* Genetic tests
* Cognitive assessment

253
Q

DDx: Name 5 differentials for dementia (9)

A
  • Normal ageing/ mild cognitive impairment
  • Delirium
  • Trauma: stroke, hypoxic, brain injury
  • Depression: poor concentration/impaired memory common in depression in the elderly
  • Late onset schizophrenia
  • Amnesic syndrome: severe disruption in memory with minimal deterioration in cognitive function
  • Learning disability
  • Substance misuse
  • Drug side effects: opiate, benzodiazepine
254
Q

After a diagnosis of dementia, what are patients legally obliged to do?

A

Contact DVLA

255
Q

Tx: What are 5 non-pharmacological managements of dementia?

A
  • Social support
  • Increasing assistance with day-to-day activities
  • Education
  • Community dementia teams & services
  • Home nursing and personal care
256
Q

What are the aims of dementia treatment?

A
  • Promote independence
  • Maintain function
  • Treat symptoms
257
Q

Tx: What is the pharmacological management of dementia?

A
  • Acetylcholinesterase inhibitors (mild/moderate AD)
  • N-methyl-D-aspartate receptor antagonist (moderate AD in those who are intolerant/contraindication to AChE inhibitors / severe AD)
  • Antipsychotic for challenging behaviour (risperidone)
  • Antidepressant for low mood (sertraline)
258
Q

Tx: Name 3 AChE inhibitors

A
  • Donepezil
  • Galantamine
  • Rivastigmine
259
Q

Tx: Name an NMDA receptor antagonist

A

Memantine

260
Q

Definition: Mild cognitive impairment (MCI)

A

Cognitive impairment without functional impairment
* Characterised by problems with language, memory and thinking

261
Q

Definition: Frontal lobe syndrome

A

Impairment of the frontal lobe of the brain due to disease or frontal lobe injury

262
Q

Definition: Autism

A

Pervasive developmental disorder characterised by a triad of:

  • impairment in social interaction
  • impairment in communication
  • restricted, stereotyped interests and behaviours
263
Q

Aetiology: What are some pre-/ante-/post-natal causes of autism?

A

Prenatal:
* Genetics
* Parental age: 40 y.o.
* Drugs: sodium valproate
* Infection

Antenatal:
* Hypoxia during childbirth
* Prematurity: before 35 weeks’ gestation
* Very low birthweight

Postnatal:
* Toxins: lead, mercury

264
Q

Name the triad of clinical features associated with autism

A

Asocial:
* Few social gestures
* Lack of eye contact
* Lack of interest in others
* Lack of emotional expression

Behaviour restricted:
* Restricted, repetitive and stereotyped behaviour
* Upset at any change in daily routine
* May prefer same foods/same clothes/same games
* Fascination with sensory aspects of environment

Communication impaired:
* Distorted / delayed speech
* Echolalia (repetition of words)

265
Q

Ix: Name 3 investigations for autism

A

Full developmental assessment:
- family Hx
- pregnancy
- birth
- medical Hx
- developmental milestones
- daily living skills
- assessment of communication/social interaction/stereotyped behaviours

Hearing tests

Screening tools: CHAT (checklist for autism in toddlers)

266
Q

DDx: Name 6 differentials for autism

A
  • Asperger’s syndrome
  • Rett’s syndrome
  • Childhood disintegrative disorder
  • Learning disability
  • Deafness
  • Childhood schizophrenia
267
Q

Tx: What is the management of autism? (7)

A
  • Modification of environmental factors
  • Treat co-existing disorders
  • Psychoeducation / CBT
  • Social-communication intervention
  • Special schooling
  • Antipsychotics for challenging behaviour
  • Melatonin for sleep
268
Q

Definition: ADHD

Attention deficit hyperactivity disorder

A

Characterised by an early onset, persistent pattern of inattention, hyperactivity and impulsivity that are more frequent and severe than in individuals at a comparable stage of development

269
Q

Name 3 risk factors for developing ADHD

A
  • Male: 3x more likely
  • Family Hx
  • Environmental RFs: social deprivation, family conflict, parental cannabis/alcohol exposure
270
Q

Clinical features: Name the 3 core symptoms of ADHD

A

Inattention
* Not listening when spoken to
* Highly distractable
* Reluctant to engage in activities that require persistent mental effort
* Forgetting/regularly losing belongings

Hyperactivity
* Restlessness/fidgeting/tapping
* Recklessness
* Running/jumping around in inappropriate places
* Difficulty engaging in quiet activities
* Excessive talking/noisiness

Impulsivity
* Difficulty waiting their turn
* Interrupting others
* Prematurely blurting out answers
* Temper tantrums/aggression
* Disobedient
* Running into the street without looking

271
Q

Ix: Name 3 investigations for ADHD

A
  • Bloods : TFTs (rule out thyroid disease)
  • Hearing tests
  • Questionnaires/ Rating scales
272
Q

DDx: Name 5 differentials for ADHD (8)

A
  • Learning disabilities/dyslexia
  • Oppositional defiant disorder
  • Conduct disorder
  • Autism
  • Sleep disorders
  • Mood disorders (bipolar)
  • Anxiety disorder
  • Hearing impairment
273
Q

Tx: What is the management of ADHD?

A
  • Psychoeducation
  • CBT and/or social skills training
  • In severe ADHD in school-age children, drug Tx is first line (CNS stimulant)
274
Q

Tx: Name the drugs used to treat ADHD

A
  • Methylphenidate
  • if this fails: Atomoxetine
  • if this fails: dexamfetamine
275
Q

Name 4 side effects of CNS stimulants

A
  • Headache
  • Insomnia
  • Loss of appetite
  • Weight loss
    -stunted growth due to suppressed appetite
276
Q

Definition: Learning disability

A

incomplete development of the mind, characterised by impairment of skills manifested during the developmental period

277
Q

What are the 4 categories of LD?

A

Mild: IQ 50-70
Moderate: IQ 35-49
Severe: IQ 20-34
Profound: IQ < 20

278
Q

What is the triad that must exist to constitute a LD?

A
  • Low intellectual performance
  • Onset at birth or during early childhood
  • Wide range of functional impairment
279
Q

Aetiology: Name 7 causes of LD

A
  • Genetic: Down’s, fragile X syndrome, Cri du chat
  • Antenatal: congenital infection, nutritional deficiency, intoxication, endocrine disorders, pre-eclampsia
  • Perinatal: birth asphyxia, intraventricular haemorrhage, neonatal sepsis
  • Neonatal: hypoglycaemia, meningitis
  • Postnatal: infection, metabolic, anoxia, cerebral palsy
  • Environmental: neglect/non-accidental injury, malnutrition
  • Psychiatric: autism, Rett’s syndrome
280
Q

What are the clinical features of LDs ranging from mild to profound?

A

Mild:
* Adequate language abilities, social skills, self-care
* May be difficulties in academic work
* Most live independently, but may need housing/employment support

Moderate:
* Limited language
* May need supervision for self-care

Severe:
* Motor impairment
* Little/no speech in early childhood
* May have associated physical disorders

Profound:
* Severe motor impairment
* Severe difficulties in communication
* Little/no self-care
* Frequently have physical disorders

281
Q

Ix: Name 4 investigations for LDs before birth

A
  • Amniocentesis
  • Chorionic villus sampling
  • Genetic testing
  • Karyotyping
282
Q

Ix: Name 3 investigations for LDs after birth

A
  • Bloods: FBC, TFTs, glucose, serology
  • Brain imaging: CT head / MRI
  • IQ test
283
Q

Tx: What is the management of learning disabilities?

A
  • Multidisciplinary approach
  • Treat co-morbid medical/psychiatric conditions
  • Behavioural techniques: applied behavioural analysis, positive behaviour support, CBT
  • Family education]
  • Prevention: genetic counselling, antenatal diagnosis
284
Q

Definition: Down’s syndrome

A

A genetic disorder (trisomy 21) characterised by:
* LD
* Dysmorphic facial features
* Multiple structural abnormalities

285
Q

What are 5 physical features of Down’s syndrome? (11)

A
  • Palpebral fissure (up slanting of eye)
  • Round face
  • Occipital + nasal flattening
  • Brushfield spots (pigmented spots on iris)
  • Brachycephaly
  • Low-set small ears
  • Epicanthic folds (monolid)
  • Mouth open and protruding tongue
  • Strabismus (squint)
  • Sandal gap deformity (space between big toe and other toes)
  • Single palmar crease
286
Q

Name 7 medical problems associated with Down’s syndrome

A
  • Heart defects: ventricular/atrial septal defects, ToF
  • Hearing loss
  • Visual disturbance: cataracts, strabismus
  • GI problems: oesophageal/duodenal atresia, coeliac
  • Hypothyroidism
  • Haematological malignancies: AML, ALL
  • Increased incidence of Alzheimer’s
287
Q

Ix: Name 3 investigations for Down’s syndrome

A
  • Serum screening: beta-HCG & pregnancy-associated plasma protein A
  • Nuchal translucency
  • Quad test: beta-HCG, alpha-fetoprotein, inhibin A, estriol
288
Q

What is the MOA for SSRIs?

A
  • Inhibit reuptake of serotonin from the synaptic cleft into pre-synaptic neurones
  • Increase the concentration of serotonin in the synaptic cleft
289
Q

Definition: Serotonin syndrome

A
  • Rare, life-threatening complication of increased serotonin activity
  • Usually rapidly occuring - within minutes of taking meds
290
Q

Clinical features: What are the cognitive/autonomic/somatic effects of serotonin syndrome?

A
  • Cognitive effects: headache, agitation, hypomania, confusion, hallucinations, coma
  • Autonomic effects: shivering, sweating, hyperthermia, HTN, tachycardia
  • Somatic effects: myoclonus, hyperreflexia, tremor
291
Q

What is the MOA for SNRIs?

A
  • Prevent reuptake of noradrenaline and serotonin, but don’t block cholinergic receptors
  • Therefore don’t have as many anti-cholinergic SEs as TCAs
292
Q

What is the MOA for TCAs?

A
  • Inhibit reuptake of adrenaline and serotonin in the synaptic cleft
293
Q

What is the MOA for MAOIs?

A

Inactivate monoamine oxidase enzymes that oxidise the monoamine neurotransmitters dopamine, noradrenaline, serotonin and tyramine

294
Q

Definition: Lithium toxicity

A

Medical emergency which can lead to seizures, coma, death

Enhanced by 4D’s:
* Dehydration
* Drugs (ACE inhibitors, NSAIDs, metronidazole)
* Diuretics (thiazide)
* Depletion of sodium

295
Q

Tx: What is the management of lithium toxicity?

A
  • Stop lithium immediately
  • High fluid intake inc IV sodium chloride to stimulate osmotic diuresis
  • Renal dialysis may be needed in severe cases
296
Q

Definition: Neuroleptic malignant syndrome

A
  • Rare, life-threatening condition seen in patients taking dopamine antagonist (e.g antipsychotics) or withdrawal of dopamine agonist
  • Onset of Sx usually in first 10 days of Tx or after increasing dose/ abrupt withdrawal
297
Q

Clinical features: Name 5 symptoms of neuroleptic malignant syndrome

A
  • Pyrexia
  • Muscular rigidity
  • Confusion
  • Fluctiating consciousness
  • Autonomic instability (e.g. tachycardia, fluctuating BP)
  • May have delirium
298
Q

Ix: Name 3 investigations for neuroleptic malignant syndrome

A
  • Creatinine kinase: increased
  • FBC: leucocytosis may be seen
  • LFTs: deranged
  • ECG: prolonged QT - ventricular arrhythmia
299
Q

Tx: What is the management of neuroleptic malignant syndrome? (5)

A
  • Stop antipsychotic
  • Monitor vital signs
  • IV fluids to prevent renal failure + rhabdomyolysis
  • cooling - antipyrexials, ice packs
  • Dantrolene (muscle relaxant)
  • Bromocriptine (dopamine agonist)
300
Q

Definition: Acute dystonic reaction

A

Medication induced movement disorder characterised by involuntary muscle contractions

301
Q

Clinical features: What are the symptoms of acute dystonic reaction?

A

Extrapyramidal side effects
* Onset of atypical posture / position of muscles
* Within minutes/hours of taking medications

302
Q

Tx: What is the treatment of acute dystonic reaction?

A
  • IV meds: anticholinergic agents procyclidine, benzodiazepines
  • Stop triggering medication
303
Q

Definition: Mental capacity

A
  • One’s ability to make decisions
  • Time specific
  • Decision specific
304
Q

What is section 2 of the MHA?

A

Admission for assessment
Duration: 28 days

305
Q

What is section 3 of the MHA?

A

Admission for treatment
Duration: 6 months

306
Q

What is section 136 of the MHA?

A

Someone found in a public place who appears to have a mental disorder can be taken by the police to a place of safety

307
Q

Definition: Overvalued idea

A

False belief that is maintained despite strong evidence that is is untrue

308
Q

Definition: Loosening of association

A

Type of formal thought disorder characterised by speech that shifts between topics only minimally related to one another.

309
Q

Definition: Circumstantiality

A

when the focus of a conversation drifts, but often comes back to the point

310
Q

Definition: Perseveration

A

Inappropraite repetition of behaviour

e.g. rocking from side to side, finger wiggling, repetition of words

311
Q

Definition: Confabulation

A

When a person generates a false memory without the intention of deceit

312
Q

Definition: Incongruity of affect

A

Lack of correlation between a person’s affect and their stated mood

e.g. may have happy thoughts/look happy when talking about a sad event

313
Q

Definition: Blunted affect

A

Demonstrating limited intensity of emotions

314
Q

Definition: La Belle indifference

A

A state of being indifferent to physical symptoms or abnormalities that are usually associated with anxiety

315
Q

Definition: Depersonalisation

A

A feeling of being outside yourself and observing your actions/feelings/thoughts from a distance

316
Q

Definition: Derealisation

A

Feel the world is unreal. Things around you may seem foggy/lifeless

317
Q

Definition: Flight of ideas

A

When someone talks quickly and erratically, jumping rapidly between ideas and thoughts

-associated with Mania

318
Q

Definition: Catatonia

A

State in which someone is awake but doesn’t respond to other stimuli

Psychomotor disorder that affects speech and behaviour functions

319
Q

Definition: Stupor

A
  • State of decreased cognitive functioning, sensory capacity and awareness
  • State of lethargy and impaired consciousness
320
Q

Definition: Akathisia

A

Movement disorder causing a feeling of restlessness and an inability to stay still

321
Q

What is neologism

A

Commonly seen in schizophrenia- when they make up new words and think they make sense

322
Q

Circumstantial thinking definition

A

Where someone starts off with thought goes around the houses with thoughts and then returns to original thought

323
Q

What is capgras syndrome

A

A delusional misidentification syndrome where a close member of there life have been replaced by imposters

324
Q

Definition of thought insertion

A

Think that their thoughts are not their own but someone else’s and have been inserted into ones mind

325
Q

Definition: thought withdrawal

A

the delusion that thoughts have been taken out of the patient’s mind.
Often has thought block where the missing piece of information is believed to have been withdrawn

326
Q

Definition: thought broadcasting

A

Type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence.

327
Q

What is a passivity experience

A

Feelings and thoughts and actions thought to be controlled by an external agency

328
Q

How does disulfuram work

A

Blocks enzymes that metabolise alcohol. Increasing the acetaldehyde which is toxic and causing illness and vomiting used for alcohol addiction

329
Q

What type of antipsychotic is aripiprazole

A

Partial dopamine agonist - regulate dopamines receptors

330
Q

48 hour rule for clozapine

A

If they miss dose for 48 hours then they have to get dose retitrated

331
Q

Tx for mania

A

1st line olanzapine for acute attacks
Mood stabilisers:
Lithium
Sodium valproate
Carbamazepine

332
Q

Lithium side effects

A

Nephrogenic diabetes

Leucocytosis

Tremors

DeHydration - must drink water

Acne

Hypothyroidism

Ebstein anomaly

333
Q

When can you stop antidepressants

A

-6 months after a remission

-if side effects too severe

334
Q

What is a section 2 in the mental health act

A

Where a patient is admitted to hospital for mental health assessment by 2 doctors and an AMPH for UP TO 28 DAYS

335
Q

What is a section three of the mental health act

A

Where a patient who has a mental health disorder is detained for treatment up to 6 months due risk to yourself or others

336
Q

What is a section 5.4 in mental health act

A

nurses holding power can keep patient in hospital until doctor can assess them - up to 6 hours only mental health nurse or learning disability nurse

337
Q

What is section 5.2 in mental health act

A

doctor/ approved clinician can detain patients for up to 72 hours pending a MHA assessment

338
Q

What is a section 135.1 in the mental health act

A

warrant provides police officers with power to enter premises to remove them and assess them or get them to a place of safety - lasts 24 hours

339
Q

What is a section 135.2 in mental health act

A

Warrant allows police to enter private property if they have previously escaped and they need returning

340
Q

What is a section 136

A

if person appears to a constable to be suffering from mental disorder and to be in immediate need of care of control - up to 24 hours. Used anywhere other than a house or flat

341
Q

Citalopram main side effect

A

Long QT

342
Q

First line SSRI given for teens and children

A

Fluoxetine

Think fluoxeteeeen

343
Q

SNRI main side effect

A

Hypertension - measure BP should be monitored

344
Q

Citalopram side effect and how do you monitor them

A

*monitor using ECG
-QT prolongation
-torsades de pointes

345
Q

Main side effect monitored for in SSRI and how do you monitor

A

*monitor using U+Es
Hyponatraemia

346
Q

What is the most common cause of serotonin syndrome

A

SSRI e.g setraline, fluoxetine, citalopram

347
Q

Causes of serotonin syndrome

A

SSRI
MOA inhibitors - most severe
SNRI
TCA
Drugs - opioids, cocaine, amphetamines

348
Q

Investigations for serotonin syndrome

A

Bloods - FBC, renal function, creatine kinase

Urinalysis - myoglobinuria (rhabdomyolysis)
- toxicology - which drug is causing it

349
Q

Side effects of lithium

A

GI- N+V
- diarrhoea

ADH blocked - nephrogenic diabetes insipidus leads to polydypsia and Polyuria

Hypothyroidism sx

Ataxia

350
Q

Methanol poisoning tx

A

fomepizole or ethanol
haemodialysis

351
Q

What makes Schizophrenia a worse prognosis (4)

A

-low IQ
-gradual onset of
-lack of cause
-social withdrawal

352
Q

Haloperidol main contraindications and side effect

A

Main side effect - QT prolongation
Contraindication - people with heart problems

353
Q

Four drug treatment for people with alcohol abuse (4)

A

Disulfuram
Alcomposate
Diazepam
Naltrexone

354
Q

At what age can personality disorders be diagnosed

A

Over the age of 18

355
Q

What is a section 4

A

72 hours emergency outpatient section when waiting for a section 2 would involve an unacceptable delay by 1 AMP and 1 Dr

356
Q

What is tangeniality

A

Going from one idea to the next with no relevance to the actual question at hand

Phase 3a - Arun&Erin (15 decks)

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