Psychiatry Flashcards
1
Q
What are the two main classification systems for mental disorders?
A
- ICD-10
- DSM-5
2
Q
Give 2 examples of biological approaches to psychiatric management
A
- Pharmacological therapy
- Electroconvulsive therapy (ECT)
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
4
Q
Give 2 examples of psychological approaches to psychiatric management
A
- Counselling
- Psychoeducation
- Psychotherapies e.g. CBT
5
Q
Give 2 examples of social approaches to psychiatric management
A
- Support groups/self-help groups
- social services input e.g. financial, housing
6
Q
Definition: Mood
A
Refers to a patient’s sustained, experienced emotional state over a period of time
7
Q
Definition: Affect
A
Immediately expressed and observed emotion in response to stimulus (how we perceive someone else’s emotion)
8
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
When the disturbance of mood is severe enough to cause impairment in the ADLs
9
Q
Give 2 examples of mood disorders
A
- Depression
- Bipolar disorder
10
Q
Definition: Depression
A
Mood disorder characterized by persistent:
* Low mood
* Anhedonia
* Lack of energy
11
Q
Definition: Dysthymia
A
A milder, but more chronic form of depression for more than 2 years
Or for 1 year in adolescents or children
12
Q
Name some risk factors for depression
A
Biological:
* Chronic conditions - Parkinson’s, MS, hypothyroidism
* Meds - beta-blockers, steroids
* family Hx
* female
Psychological:
* childhood abuse/neglect
* Low self-esteem
Social:
* homeless
* unemployed
* divorced
* Poor social support
13
Q
Clinical features: Name 5 biological symptoms of depression
(Biological meaning the physical manifestation of depression that arise due to impact of body’s physiological systems)
A
- Sleep disturbance
- Psychomotor retardation / agitation
- Loss of libido
- Weight & appetite change
- Nihilistic thoughts / worthlessness / guilt
14
Q
Clinical features: Name 2 psychotic symptoms of depression
A
- Delusions
- Hallucinations
15
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
16
Q
DDx: Name 3 organic illness differentials of depression
A
- Hypothyroidism
- Cushing’s disease or syndrome
- Vitamin B12 deficiency
17
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)
18
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
19
Q
Tx: What is the 1st line drug treatment for depression?
A
SSRI: Fluoxetine
20
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)
21
Q
Who would you not give olanzapine to?
A
A diabetic because it can cause high blood sugar
22
Q
When should Electroconvulsive therapy (ECT) be considered? (5)
A
- Severe depressive illness:
-treatment resistant depression
-catatonia
-depression with psychotic sx - Mania: In cases of manic episodes that do not respond to medication
- Schizophrenia: When antipsychotic medication proves ineffective in treating schizophrenia,
- Prolonged or severe episodes of agitation
- Urgent situations where rapid symptom reduction is needed such as high suicide risk or refusal to eat/drink.
23
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.
24
Q
Aetiology: Give 5 risk factors for bipolar disorder
A
- Genetics
- 1st degree family Hx
- Anxiety disorders
- Drug or alcohol abuse
- thyroid disorders
- Stressful life events e.g divorce
- Post-partum period - hormonal fluctuations
- low socioeconomic status
25
What are the two main forms of bipolar disorder?
* **type 1**
-at least episode of **mania**
-no depression needed
* **type 2**
-One episode of **hypomania**
-Experienced at least one MAJOR episode of depression - for at least 2 Weeks
26
What is cyclothymia?
chronic mood disorder characterized by numerous periods of hypomanic symptoms and depressive symptoms that are not severe or long enough to meet the criteria for a hypomanic or major depressive episode
## Footnote
Milder but more chronic form of bipolar disorder
27
Clinical Features: Name 5 symptoms of **mania**
* 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**
28
Clinical Features: Name 4 symptoms of **hypomania**
* Persistent, **mild** elevation of mood
* Increased energy and activity
* Increased sociability, talkativeness
* Increased libido
* impulsivity
29
DDx: Name some differentials for bipolar disorder
* **Schizophrenia** (delusions and hallucinations)
* **Organic brain disorder** (frontal lobe pathologies can result in a loss of social inhibitions)
* **substance use disorders e.g alcohol and stimulants**
* **Recurrent depression**
* **Emotionally unstable personality disorder**
* **Cyclothymia**
* **hyperthyroidism**
30
What clinical
investigations would you do for bipolar disorder?
* Baseline blood tests: FBC,U&E,LFTs,TFTs,CRP,B12,folate,vitD
* HIV testing
* Toxicology screen - detect substance misuse
* Neurological exam
* CT head
31
Tx: Name 3 medications to treat bipolar disorder
* Antipsychotics: **olanzapine, risperidone, quetiapine, haloperidol**
* Mood stabilisers: **lithium**, sodium valproate can be added
* Benzodiazepines: **lorazepam**
* SSRIs - fluoxetine
32
Tx: What non-pharmacological treatments are used for bipolar disorder?
* ECT
* CBT
* support groups
33
What do you need to monitor for when treating a patient with lithium?
Kidney function and thyroid function and calcium
## Footnote
Every **6 months**
34
Definition: Psychosis
A mental state in which **reality is greatly distorted**
35
Name some causes of psychosis
* **Schizophrenia**/ Schizoaffective disorder
* **Mood disorders** with psychosis
* **Drug-induced** psychosis - alcohol, cocaine, amphetamine, MDMA
* **Delerium**
* **Dementia**
36
Aetiology: Name 4 medicitions that can cause psychosis
* Levodopa
* Methyldopa
* Steroids
* Antimalarials - chloroquine enters the BBB
37
Clinical features: How does psychosis present?
"abnormality of perception/thought"
* **Delusions**
* **Hallucinations**
* **Thought disorder**
38
Definition: Delusion
A **fixed, false** belief in something that is **not within their usual belief system**
39
Definition: Hallucination
A **perception** in the **absence of an external stimulus**
40
Definition: Pseudohallucination
**Involuntary sensory experience** vivid enough to be regarded as a hallucination, but is **recognised** by the person as being **subjective and unreal**
41
Definition: Illusion
An incorrect perception of a 'real' external stimulus
42
Name 5 types of delusions
* **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)
43
Definition: Schizophrenia
Most common **psychotic condition** characterised by **hallucinations, delusions and thought disorders**, which lead to **functional impairment**
44
Definition: Schizoaffective disorder
Characterised by both symptoms of **schizophrenia** and a **mood disorder** (depression/mania) in the **same episode of illness**
45
Aetiology: Name 4 risk factors for developing schizophrenia
* Family Hx
* Obstetric complications/fetal injury/intrauterine infection
* Stressful life events
* Substance misuse e.g. cannabis
46
What are the 6 subtypes of schizophrenia?
1. Paranoid (**most common**)
2. Hebephrenic
3. Catatonic
4. Undifferentiated
5. Simple
6. Residual
47
Clinical features: What are Schneider's first rank symptoms? (4)
* **Delusional perception**
* 3rd person **auditory hallucinations**
* **Thought interference**: insertion, withdrawal, broadcasting
* **Passivity phenomenon/somatic passivity**: feelings/actions/impulses are controlled by an external agent
48
Definition: Delusional perception
Person believes that a **normal percept** has a **special meaning** for them
49
Clinical features: What is the difference between positive and negative symptoms of schizophrenia?
* **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
50
Clinical features: Name 5 positive symptoms of schizophrenia
* Delusions
* Hallucinations
* Formal thought disorder
* Thought interference
* Passivity phenomenon
51
Clinical features: Name 5 negative symptoms of schizophrenia
* Social isolation
* Decreased motivation
* Blunted affect
* Alogia: poverty of speech
* Anhedonia
52
Ix: What investigations are used to rule out other causes of psychotic symptoms in schizophrenia? (7)
* 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
53
What is required to form a diagnosis of schizophrenia?
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**
54
Tx: What is the general management of schizophrenia?
**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
55
Tx: What drug type is used to treat schizophrenia?
D2 receptor antagonists - first line pharmacological is ATYPICAL antipsychotics
D2 = dopamine
56
Tx: What is the difference between **typical** and **atypical** antipsychotics?
* **Typical antipsychotics** cause generalised dopamine receptor blockade
* **Atypical antipsychotics** are more selective in their dopamine blockade. They also block **serotonin 5-HT2 receptors**
57
Tx: Name 3 typical antipsychotics
* Haloperidol
* Chlorpromazine
* Loxapine
58
Tx: Name 4 atypical antipsychotics
* Olanzapine
* Risperidone
* Clozapine
* Quetiapine
59
Tx: Why are atypical antipsychotics preferred over typical antipsychotics?
Fewer and less severe side effects
60
Tx: Name 5 side effects of typical antipsychotics
* **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
61
Tx: What drug is used when both typical and atypical antipsychotics have been ineffective in treating schizophrenia?
**Clozapine**
62
What can clozapine cause?
* **Agranulocytosis**
* **Reduced seizure threshold**
* hypersalivation
* constipation
* cardiomyopathy
63
Definition: Neurosis
Collective term for psychiatric disorders **characterised by distress** that are:
* **non-organic**
* have a **discrete onset**
* where delusions and hallucinations are **absent**
64
Definition: Anxiety
An **unpleasant emotional state** involving **subjective fear** and **somatic symptoms**
## Footnote
If it becomes **excessive** or **inappropriate** = illness
65
What does the **Yerkes-Dodson law** state?
Anxiety can actually be beneficial up to a **plateau of optimal functioning**. Beyond this level, performance deteriorates
66
Name some common symptoms of neuroses based on the system e.g. cardiovascular, psychological etc..
* **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
67
What are the 2 main categories anxiety disorders can be divided into?
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**
68
Name some causes of anxiety
* **Medical conditions** e.g. hyperthyroidism, phaeochromocytoma, Cushing's disease
* **Substance use**: alcohol, caffeine, withdrawal
* **Psychiatric conditions**: ED, depression, OCD, PTSD, schizophrenia
69
Definition: Generalised anxiety disorder
A syndrome of **ongoing, uncontrollable, widespread worry** about events or thoughts that the patient recognises as **excessive** and **inappropriate**
70
How long must symptoms be present for to be classified as GAD?
**Most days** for at least **6 months**
71
Name some causes of GAD
* **Genetics**
* **Stressful life events** - Hx of abuse, employment issues etc.
* **Substance dependence**
72
Clinical features: Name some symptoms of GAD
* Difficulty breathing
* Chest pain/discomfort
* Nausea
* Abdominal pain
* Feeling dizzy/light-headed
* Fear of dying
* Muscle tension, aches, pains
* Restlessness
73
Ix: Name some investigations for GAD
* **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)
74
DDx: Name some differentials for GAD
* 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
75
Tx: What is the stepped care model for the management of GAD?
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
76
Tx: What is the first line drug used to treat GAD?
SSRI: sertraline
## Footnote
Has anxiolytic effects
77
Tx: What is the drug treatment of GAD?
* **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
78
Tx: When should **benzodiazepines** be offered to treat GAD?
Only as **short-term measures** during crises as they can cause **dependence**
79
Definition: Phobia
An **intense, irrational** fear of an **object, situation, place** or **person** that is recognised as **excessive** or **unreasonable**
80
Definition: Agoraphobia
Fear of **public spaces** from which immediate escape would be difficult in the event of a panic attack
81
Definition: Social phobia/ Social anxiety disorder
A fear of **social situations** which may lead to **humiliation, critisism** or **embarrassment**
82
Definition: Specific (isolated) phobia
A fear restricted to a **specific object** or **situation** e.g. animals, injury
83
Aetiology: Name 6 risk factors for phobias
* Adverse experiences (with specific objects/situations)
* Stress/ negative life events
* Mood disorders
* Other anxiety disorders
* Substance misuse
* Family Hx
84
Clinical features: Name 5 symptoms of phobias
* **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**
85
Ix: What questionnaires are used when diagnosing phobias?
* Social phobia inventory
* Liebowitz social anxiety scale
86
DDx: Name 5 differentials of phobias
* Panic disorder
* PTSD
* Anxious PD
* Depression
* Schizophrenia
87
Tx: What is the management of the 3 phobic anxiety disorders?
* **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
88
What are SNRIs?
**Serotonin-noradrenaline reuptake inhibitors**
## Footnote
venlafaxine, duloxetine
89
Tx: What drug is used to treat **social phobia** if SSRIs and SNRIs are ineffective?
**MAOI**: moclobemide
## Footnote
monoamine oxidase inhibitors
90
Definition: Panic disorder
Disorder characterised by **recurrent, episodic, severe** panic attacks, which are **unpredictable** and **not restricted** to any particular situation.
91
Aetiology: Name 3 biological causes of panic disorder
* **Genetics**
* **Neurochemical**: post synaptic hypersensitivity to serotonin and adrenaline
* **Sympathetic NS**: fear/worry stimulates SNS --> increased cardiac output --> further anxiety
92
Aetiology: Name 8 risk factors for panic disorder
* Family Hx
* Female
* White ethnicity
* Age 20-30
* Major life events
* Recent trauma
* Asthma
* Medication e.g. benzodiazepine withdrawal
93
Clinical features: How long do panic disorder symptoms usually last?
Symptoms usually peak **within 10 minutes** and **rarely persist beyond an hour**
94
Clinical features: Name some symptoms of panic disorder
* Palpitations
* Intense fear of death
* Chest pain
* Sweating
* Shaking
* Shortness of breath
* Abdominal distress
* Depersonalisation/derealisation
* Numbness
* Nausea
95
DDx: Name some psychiatric and organic differentials for panic disorder
* **Psychiatric**: other anxiety disorders, bipolar, depression, schizophrenia
* **Organic**: Phaeochromocytoma, hyperthyroidism, hypoglycaemia, arrhythmias, alcohol/substance withdrawal
96
Tx: What is the drug management of panic disorder?
* **SSRI** is 1st line
* If these don't work after **12 weeks**, then consider a **TCA** (imipramine/clomipramine)
97
Tx: Name 2 examples of a TCA used to treat panic disorder
* **Imipramine**
* **Clomipramine**
98
Definition: Post traumatic stress disorder
An **intense, prolonged, delayed** reaction following exposure to an **exceptionally traumatic event**
99
Definition: Abnormal bereavement
Grief that Has a **delayed onset**, is **more intense** and is **prolonged** (>6 months)
100
Definition: Acute stress reaction
An abnormal reaction to **sudden stressful events**
101
Definition: Adjustment disorder
When there is **significant distress** accompanied by an **impairment in social functioning** when adapting to new circumstances
102
Give 5 risk factors for PTSD
* **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
103
Clinical features: Name the 4 categories of PTSD symptoms
## Footnote
Must occur **within 6 months** of the event
* **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
104
Ix: Name 3 investigations for PTSD
* Trauma screening questionnaire (**TSQ**)
* ** Post-traumatic diagnostic scale**
* **CT head** (if head injury suspected)
105
DDx: Name 5 differentials for PTSD (8)
* Adjustment disorder
* Acute stress reaction
* Bereavement
* Dissociative disorder
* Mood or anxiety disorders
* Personality disorder
* Head injury
* Alcohol/substance misuse
106
Tx: What is the management of PTSD where symptoms are present **within 3 months** of trauma?
* 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)
107
Tx: What is the management of PTSD where symptoms have been present **> 3 months** after trauma?
**Trauma-focused psychological intervention**
2 options:
* **CBT**
* **EMDR**
**Drug Tx** considered when:
* Little benefit from psychological therapy
* Patient preference
* Co-morbid depression / severe hyperarousal
108
Tx: What is EMDR?
**Eye Movement Desensitisation and Reprocessing**
* helps patient access and process traumatic memories
* involves recalling emotionally traumatic material while focusing on an external stimulus
109
Tx: Name 4 drugs used to treat PTSD
* **velafaxine = 1st line**
* **Sertraline**
* **Paroxetine**
* Venlafaxine
* Fluoxetine
110
Definition: Obsessive-compulsive disorder (OCD)
Disorder characterised by **recurrent obsessional thoughts** and/or **compulsive acts**
111
Definition: Obsessions
**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**
112
Definition: Compulsions
**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)
113
Aetiology: Name 3 potential causes of OCD
* Family Hx
* Streptococcal infections
* Stressful life events
114
Clinical features: Name the 4 features that obsessions/compulsions always share
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
115
What is the OCD cycle?
**Obsession** > **Anxiety** > **Compulsion** > **Relief**
116
Name 4 common obsessions in OCD
* **Contamination**
* **Fear of harm** (door locks)
* Excessive concern with **order/symmetry**
* Others: **sex, blasphemy, violence, doubt**
117
Name 5 common compulsions in OCD
* **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**
118
Ix: What investigations are used to diagnose OCD?
**Yale-Brown obsessive-compulsive scale** (Y-BOCS)
119
DDx: Name 5 differentials for OCD (9)
* Both obsessions and compulsions: **eating disorders**
* Primarily obsessions: **anxiety disorders, depression, schizophrenia**
* Primarily compulsions: **Tourette's syndrome, kleptomania**
* Organic: **Dementia, epilepsy, head injury**
120
Tx: What is the management for OCD?
* **CBT** including **ERP** (exposure and response prevention)
* **SSRIs**: fluoxetine, sertraline
* **Clomipramine** (TCA)
121
Definition: Somatisation disorder
**Multiple, recurrent** and **frequently changing** physical symptoms **not explained by a physical illness** over 6 months
122
Definition: Dissociation
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.
123
Definition: Conversion (in terms of psychiatric Sx)
**Distressing events** are **transformed** into **physical symptoms**
E.g anxiety may manifest into GI symptoms
124
Name 6 risk factors for somatoform and dissociative disorders
## Footnote
CRAMPS
* **C**hildhood abuse
* **R**einforcement of illness behaviours
* **A**nxiety disorders
* **M**ood disorders
* **P**ersonality disorders
* **S**ocial stressors
125
Tx: Name 4 managements for somatoform and dissociative disorders
* SSRIs (antidepressants)
* Physical exercise
* CBT
* Encouraging stress-relieving activities
126
Definition: Acute intoxication
The**acute**, usually **transient**, effect of the substance
127
Definition: Dependence syndrome
**Prolonged, compulsive** substance use leading to **addiction**, **tolerance** and the potential for **withdrawal symptoms**
128
Definition: Withdrawal state
**Physical** and/or **psychological** effects from complete (or partial) **cessation** of a substance after **prolonged, repeated** or **high level of use**
129
Definition: Substance-induced psychotic disorder
Onset of psychotic symptoms **within 2 weeks** of substance use.
Must persist for **> 48 hrs**
130
Name 5 environmental factors that can lead to substance dependence
* Peer pressure
* Life stressors
* Parental drug use
* Cultural acceptability
* Personal vulnerability
131
What is the chain of events leading to substance dependence?
1. **Takes substance**
2. **Positive reinforcement**: psychosocial (from peers/ pleasurable effects of the drug), biological (activates mesolimbic dopaminergic reward pathways)
3. **Dependence**
132
Name 4 examples of opiates
* **Morphine**
* **Heroin**
* **Codeine**
* **Methadone**
133
Name 3 **psychological** effects of opiates
* Apathy
* Disinhibition
* Psychomotor retardation
* Impaired judgement/attention
* Drowsiness
* Slurred speech
134
Name 3 **physical** effects of opiates
* Respiratory depression
* Hypoxia
* Decreased BP
* Hypothermia
* Coma
* Pupillary constriction
135
Name some symptoms of opiate withdrawal
FLAPPY HANDS
Fever and chills
Lacrimation
Agitation
Piloerection
Pupillary dilation
Yawning
Hypertension and tachychardia
Aches
Nausea
Diarrhea
Sweating
136
Name a cannabinoid
**Cannabis**
137
Name 3 psychological effects of cannabinoids
* Euphoria
* Disinhibition
* Paranoid ideation
* Temporal slowing (time passes slowly)
* Imparied judgement/attention/reaction time
* Illusions
* Hallucinations
138
Name 4 physical effects of cannabinoids
* Increased appetite
* Dry mouth
* Conjunctival injection (eye redness)
* Increased HR
139
Name 5 symptoms of cannabinoid withdrawal
* Anxiety
* Irritability
* Tremor of outstretched hands
* Sweating
* Myalgia
140
Name a sedative-hypnotic drug
**Benzodiazepines**
141
Name 3 psychological effects of sedative-hypnotics
* Euphoria
* Disinhibition
* Apathy
* Aggression
* Anterograde amnesia (can't form new memories)
* Labile mood (unpredictable, uncontrollable, rapid shifts in emotions)
142
Name 3 physical effects of sedative-hypnotics
* Unsteady gait
* Difficulty standing
* Slurred speech
* Nystagmus
* Erythematous skin lesions
* Decreased BP
* Hypothermia
* Depression of gag reflex
* Coma
143
Name 5 symptoms of sedative-hypnotic withdrawal (10)
* Tremor of hands/tongue/eyelids
* N+V
* Increased HR
* Postural hypotension
* Headache
* Agitation
* Malaise
* Transient illusions/hallucinations
* Paranoid ideation
* Grand mal convulsions
144
Name 4 examples of stimulants
* Cocaine
* Crack cocaine
* Ecstasy (MDMA)
* Amphetamine
* nicotine
145
Name 3 psychological effects of stimulants
* Euphoria
* Increased energy
* Grandiose beliefs
* Aggression/argumentative
* Illusions/hallucinations
* Paranoid ideation
* Labile mood
146
Name 3 physical effects of stimulants
* Increased HR / BP
* Arrhythmias
* Sweating
* N+V
* Pupillary dilatation
* Psychomotor agitation
* Muscular weakness
* Chest pain
* Convulsions
147
Name some symptoms of stimulant withdrawal
* Dysphoric mood
* Lethargy
* Psychomotor agitation
* Craving
* Increased appetite
* Insomnia / hypersomnia
* Bizarre/unpleasant dreams
148
Name 2 examples of hallucinogens
* **LSD**
* **Magic mushrooms**
149
Name 3 psychological effects of hallucinogens
* Anxiety
* Illusions/hallucinations
* Depersonalisation/derealisation
* Paranoia
* Ideas of reference
* Hyperactivity
* Impulsivity
* Inattention
150
Name 3 physical effects of stimulants
* Increased HR
* Palpitations
* Sweating
* Tremor
* Blurred vision
* Pupillary dilatation
* Incoordination
151
Name 4 examples of volatile solvents
* Aerosols
* Paint
* Glue
* Petrol
152
Name 3 psychological effects of volatile solvents
* Apathy
* Lethargy
* Aggression
* Impaired attention/judgement
* Psychomotor retardation
153
Name 3 physical effects of volatile solvents
* Unsteady gait
* Diplopia
* Nystagmus
* Decreased consciousness
* Muscle weakness
154
Name 3 examples of anabolic steroids
* **Testosterone**
* **Androstenedione**
* **Danazol**
155
Name 3 psychological effects of anabolic steroids
* Euphoria
* Depression
* Aggression
* Hyperactivity
* Mood swings
* Hallucinations
* Delusions
156
Name 3 physical effects of anabolic steroids
* Increased muscle mass
* Reduced fat
* Acne
* Male pattern baldness
* Reduced sperm count/infertility
* Stunted growth
157
Ix: Name 3 investigations for substance misuse
* **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)
158
DDx: Name some differentials of substance misuse
* **Psychiatric**: psychosis, mood disorders, anxiety disorders, delirium
* **Organic**: hyperthyroidism, CVA, intracranial haemorrhage
159
Tx: What is the management of substance misuse?
* **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
160
Tx: Name 3 managements of opioid dependence
* 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**
161
Definition: Alcohol abuse
Consumption of alcohol at a level sufficient to cause **physical**, **psychiatric** and/or **social harm**
162
Definition: Binge drinking
Drinking **over twice the recommended level** of alcohol per day in **one session**
## Footnote
**> 8 units** for men, **> 6 units** for women
163
Definition: Harmful alcohol use
Drinking **above safe levels** with evidence of **alcohol-related problems**
## Footnote
**> 50 units/week** for men, **> 35 units/week** for women
164
Name 5 risk factors for alcohol abuse
* **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
165
Clinical features: Name 4 symptoms of alcohol intoxication
* **Slurred speech**
* **Labile affect**
* **Impaired judgement**
* **Poor coordination**
In severe cases: **hypoglycaemia**, **stupor**, **coma**
166
Clinical features: What are the 7 signs of **Edward and Gross criteria** for alcohol dependence?
* **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)
167
Clinical features: Name 6 symptoms of alcohol withdrawal
* Malaise
* Tremor
* Nausea
* Insomnia
* Transient hallucinations
* Autonomic hyperactivity
## Footnote
Occur at 6-12 hours after abstinence
168
When is peak incidence of seizures after alcohol withdrawal?
**36 hours**
169
Definition: Delirium tremens
* Severe end of the spectrum of withdrawal
* Peak incidence is at **72 hours**
170
Name 5 symptoms of **delirium tremens**
* **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
171
Tx: What is the management of delirium tremens?
* **Benzodiazepines** e.g. chlordiazepoxide
* **Haloperidol** for any psychotic features
* **IV Pabrinex** contains water soluble vitamins (C,B1,B2,B3,B6)
172
Ix: Name 4 investigations for alcohol abuse
* **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
173
DDx: Name some differentials for alcohol abuse
* **Psychiatric**: psychosis, mood disorders, anxiety disorders, delirium
* **Medical**: head injury, cerebral tumour, CVA (e.g. stroke)
174
Definition: Wernicke's encephalopathy
An **acute encephalopathy** due to **thiamine deficiency**
175
Clinical features: Name 5 symptoms of Wernicke's encephalopathy
* **Delirium** / altered mental status
* **Nystagmus**
* **Ophthalmoplegia**
* **Hypothermia**
* **Ataxia**
176
Tx: What is the management of Wernicke's encephalopathy?
**Parenteral thiamine**
177
Definition: Korsakoff's psychosis
Profound, irreversible **short-term memory loss** with:
* **confabulation** (unconscious filling of gaps in momory with imaginary events)
* **disorientation to time**
178
Tx: What is the management of alcohol dependence? (5)
* **Disulfiram** / **Naltrexone** / **Acamprosate**
* **Motivational interviewing**
* **CBT**
* **Alcoholics Anonymous**
* **Social support** including family involvement
179
Tx: What is the management of alcohol withdrawal?
* **Chlordiazepoxide** detox regime
* **Thiamine**
## Footnote
Chlordiazepoxide = high dose benzodiazepine
180
Name some examples of behavioural addictions
* **Food**
* **Exercise**
* **Gambling**
* **Internet**
* **Plastic surgery**
* **Porn**
* **Sex**
* **Shopping**
* **Social media**
* **Video games**
181
Name some signs of behavioural addiction
* 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)
182
Tx: What is the management for addictive behaviours? (2)
* **CBT**
* **Group therapy**
183
Definition: Deliberate self-harm
An **intentional act** of **self-poisoning** or **self-injury**, **irrespective of the motivation**.
Usually an expression of **emotional distress**
184
Name some methods of self-injury
* Cutting
* Burning
* Hanging
* Stabbing
* Swallowing objects
* Shooting
* Jumping from heights/in front of vehicles
185
Name 4 methods of self-poisoning
* Medication
* Illicit drugs
* Household substances
* Plant material
186
Name 8 risk factors for deliberate self-harm
* **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**
187
Ix: Name 4 investigations for ruling out self-harm
* **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)
188
Tx: What is the management of self-harm?
* **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
189
Antidote to **paracetamol** overdose?
**N-Acetylcysteine** within 24 hrs
190
Antidote to **opiates** overdose?
**Naloxone**
191
Antidote to **benzodiazepine** overdose?
**Flumazenil**
192
Antidote to **warfarin** overdose?
**Vitamin K**
193
Antidote to **beta-blocker** overdose?
**Glucagon**
194
Antidote to **TCA** overdose?
## Footnote
e.g. amitriptyline
**Sodium bicarbonate**
195
Definition: Suicide
A fatal act of self-harm initiated with the intention of ending one's own life
196
Definition: Attempted suicide
The act of intentionally trying to take one's own life with the primary aim of dying, but failing to succeed in this endeavour
197
Definition: Risk assessment
## Footnote
In a psychiatric context
Assessing the risk of **self-harm**, **suicide** and/or **risk to others**
198
Name 5 **protective factors** which can reduce the risk of suicide (12)
* 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
199
Name 5 **clinical** risk factors of suicide
* 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
200
Name 5 **socio-demographic** risk factors of suicide (8)
* **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
201
Clinical features: Name 6 characteristics of someone who is suicidal
* **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**
202
Name 6 things that can be used to determine the risk of suicide following DSH
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
203
Tx: What is the management for someone who has attempted suicide?
* **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**
204
Name 3 **individual** suicide prevention strategies
* Detect and treat **psychiatric disorders**
* **Urgent hospitilisation** under the **Mental Health Act**
* Involvement of the **Crisis Resolution and Home Treatment team**
205
Name 5 **population level** suicide prevention strategies
* **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**
206
Definition: Delirium
An **acute**, **transient**, **reversible** state of **confusion** and **impaired consciousness** and **attention**
207
What are the 3 subtypes of delirium?
* **Hypoactive**: lethargy, decreased motor activity, apathy
* **Hyperactive**: agitation, irritability, restlessness, aggression, hallucinations/delusions
* **Mixed**: signs of both
208
Name 10 causes of delirium
## Footnote
mnemonic: HE IS NOT MAAD
* **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
209
Name 5 risk factors for delirium (10)
* Old age **> 65**
* Multiple **co-morbidities**
* **Dementia**
* Physical frailty
* Renal impairment
* Male sex
* Sensory impairment
* Previous episodes
* Recent surgery
* Severe illness
210
Clinical features: Name 8 symptoms of delirium
## Footnote
Mnemonic: DELIRIUM
* **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**
211
Ix: Name 3 investigations for delirium
* 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)
212
DDx: Name 5 differentials for delirium
* **Dementia**
* **Mood disorder**
* **Late onset schizophrenia**
* **Dissociative disorders**
* **Hypo/hyperthyroidism**
213
Tx: What is the management of delirium?
* **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**
214
Definition: Personality disorder
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**
215
What are the 3 clusters of PDs?
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)
216
Name 4 risk factors for personality disorder
* **Low socioeconomic status**
* **Genetics**: family Hx
* **Dysfunctional family**: poor parenting, parental deprivation
* **Childhood abuse**: physical, sexual, emotional, neglect
217
Clinical features: Name the features of **cluster A** PDs
## Footnote
Cluster A (**weird**)
**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
218
Clinical features: Name the features of **cluster B** PDs
## Footnote
Cluster B (**wild**)
**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
219
Clinical features: Name the features of **cluster C** PDs
## Footnote
Cluster C (**worriers**)
**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
220
Ix: Name 3 investigations for PD
* **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
221
DDx: Name 3 differentials for PD
* **Mood disorders**: mania, depression
* **Psychotic disorders**: schizophrenia, schizoaffective disorder
* **Substance misuse**
222
Tx: What is the management for PD?
* 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
223
What is DBT?
**Dialectical Behavioural Therapy**
* Emphasis on developing **coping strategies** to **improve impulse control** and **reduce self-harm**
* Used in **EUPD**
224
Definition: Dementia
* A syndrome of generalised decline of **memory**, **intellect** and **personality**
* Without impairment of **consciousness**
* Leading to **functional impairment**
225
What are the 4 types of dementias from most prevalent to least?
* **Alzheimer's disease**
* **Vascular dementia**
* **Dementia with Lewy bodies** (DLB)
* **Fronto-temporal dementia**
226
Name 5 **irreversible** causes of dementia
* **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**
227
Name 3 **reversible** causes of dementia
* **Neurological**: normal pressure hydrocephalus, intracranial tumours, CSH
* **Vitamin deficiencies**: B12, folic acid, thiamine, nicotinic acid
* **Endocrine**: Cushing's, hypothyroidism
228
What is the pathophysiology of Alzheimer's disease?
* Degeneration of **cholinergic neurons** in the **nucleus basalis of Meynert** leading to **acetylcholine deficiency**
229
What are 2 **microscopic** physiological changes seen in Alzheimer's disease?
* **Neurofibrillary tangles** (intracellularly)
* **Beta-amyloid plaque formation** (extracellularly)
## Footnote
These are pathological lesions progressively distributed around the brain
230
What are 3 **macroscopic** physiological changes seen in Alzheimer's disease?
* **Cortical atrophy** (commonly hippocampus)
* **Widened sulci**
* **Enlarged ventricles**
231
Aetiology: What is the cause of **vascular dementia**?
**Cerebrovascular disease** due to:
* stroke
* multi-infarcts
* chronic changes in small vessels (arteriosclerosis)
232
Aetiology: What is the cause of **Lewy body dementia**?
**Abnormal deposition of protein** (Lewy body) within the neurons of the:
* **brainstem**
* **substantia nigra**
* **neocortex**
233
Aetiology: What is the cause of **fronto-temporal dementia**?
Specific degeneration (**atrophy**) of the **frontal** and **temporal** lobes.
234
What is Pick's disease?
A type of **fronto-temporal** dementia, where protein tangles (**Pick's bodies**) are seen histologically
235
What are the **cortical**, **subcortical** and **mixed** dementias?
* **Cortical**: AD, fronto-temporal
* **Subcortical**: DLB
* **Mixed**: vascular
236
Name 7 risk factors for Alzheimer's disease
* Advancing age
* Family Hx
* Genetics
* CAUCASIAN
* Down's syndrome
* Low IQ
* CVD
* Vascular RFs: stroke/MI, smoking, HTN, DM, high cholesterol
237
Clinical features: Name 3 symptoms in **early stages** of AD
* Memory lapses
* Difficulty finding words
* Forgetting names of people/places
238
Clinical features: Name 4 symptoms during **disease progression** of AD
* Apraxia
* Agnosia
* Confusion
* Language problems
* Impairment of executive functions
239
Clinical features: Name 7 symptoms in **later stages** of AD
* Disorientation to time/place
* Wandering
* Apathy
* Incontinence
* Eating problems
* Depression
* Agitation
240
Name 6 clinical features of vascular dementia
* **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**
241
Name 4 clinical features of DLB
* **Day to day fluctuations** in **cognitive performance**
* Recurrent **visual hallucinations**
* Motor signs of **parkinsonism** (tremor, rigidity, bradykinesia)
* **Recurrent falls / syncope**
242
Name 6 clinical features of fronto-temporal dementia
* **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**
243
Name 3 clinical features of Huntington's disease
* **Autosomal dominant**: strong family Hx
* **Abnormal choreiform movements** of face, hands, shoulders and **gait abnormalities**
* Dementia presents **later**
244
Name the triad of clinical features in normal pressure hydrocephalus
1. **Dementia** with prominent frontal lobe dysfunction
2. **Urinary incontinence**
3. **Gait disturbance** (wide gait)
245
Ix: Name 10 investigations for dementia
**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
246
DDx: Name 5 differentials for dementia (9)
* 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
247
After a diagnosis of dementia, what are patients legally obliged to do?
**Contact DVLA**
248
Tx: What are 5 non-pharmacological managements of dementia?
* **Social support**
* Increasing assistance with **day-to-day activities**
* **Education**
* **Community** dementia teams & services
* **Home nursing** and **personal care**
249
What are the aims of dementia treatment?
* **Promote** **independence**
* **Maintain function**
* **Treat** **symptoms**
250
Tx: What is the pharmacological management of dementia?
* **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)
251
Tx: Name 3 AChE inhibitors
* **Donepezil**
* **Galantamine**
* **Rivastigmine**
252
Tx: Name an NMDA receptor antagonist
**Memantine**
253
Definition: Mild cognitive impairment (MCI)
Cognitive impairment **without** **functional** impairment
* Characterised by problems with **language**, **memory** and **thinking**
254
Definition: Frontal lobe syndrome
Impairment of the frontal lobe of the brain due to disease or frontal lobe injury
255
Definition: Autism
**Pervasive developmental disorder** characterised by a triad of:
* impairment in **social interaction**
* impairment in **communication**
* **restricted**, **stereotyped interests** and **behaviours**
256
Aetiology: What are some pre-/ante-/post-natal causes of autism?
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
257
Name the triad of clinical features associated with autism
**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)
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Ix: Name 3 investigations for autism
**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)
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DDx: Name 6 differentials for autism
* Asperger's syndrome
* Rett's syndrome
* Childhood disintegrative disorder
* Learning disability
* Deafness
* Childhood schizophrenia
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Tx: What is the management of autism? (7)
* **Modification of environmental factors**
* Treat **co-existing** disorders
* **Psychoeducation** / **CBT**
* **Social-communication** intervention
* **Special schooling**
* **Antipsychotics** for challenging behaviour
* **Melatonin** for sleep
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Definition: ADHD
## Footnote
Attention deficit hyperactivity disorder
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
262
Name 3 risk factors for developing ADHD
* **Male**: 3x more likely
* **Family Hx**
* Environmental RFs: **social deprivation**, **family conflict**, **parental cannabis/alcohol exposure**
263
Clinical features: Name the 3 core symptoms of ADHD
**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
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Ix: Name 3 investigations for ADHD
* **Bloods** : TFTs (rule out thyroid disease)
* **Hearing tests**
* **Questionnaires**/ Rating scales
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DDx: Name 5 differentials for ADHD (8)
* Learning disabilities/dyslexia
* Oppositional defiant disorder
* Conduct disorder
* Autism
* Sleep disorders
* Mood disorders (bipolar)
* Anxiety disorder
* Hearing impairment
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Tx: What is the management of ADHD?
* **Psychoeducation**
* **CBT** and/or **social skills training**
* In severe ADHD in school-age children, **drug Tx** is first line (CNS stimulant)
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Tx: Name the drugs used to treat ADHD
* **Methylphenidate**
* if this fails: **Atomoxetine**
* if this fails: **dexamfetamine**
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Name 4 side effects of CNS stimulants
* Headache
* Insomnia
* Loss of appetite
* Weight loss
-**stunted growth** due to suppressed appetite
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Definition: Learning disability
**incomplete development of the mind**, characterised by **impairment of skills** manifested during the developmental period
270
What are the 4 categories of LD?
**Mild**: IQ 50-70
**Moderate**: IQ 35-49
**Severe**: IQ 20-34
**Profound**: IQ < 20
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What is the triad that must exist to constitute a LD?
* **Low intellectual performance**
* Onset at **birth** or during **early childhood**
* Wide range of **functional impairment**
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Aetiology: Name 7 causes of LD
* **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
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What are the clinical features of LDs ranging from mild to profound?
**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
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Ix: Name 4 investigations for LDs before birth
* **Amniocentesis**
* **Chorionic villus sampling**
* **Genetic testing**
* **Karyotyping**
275
Ix: Name 3 investigations for LDs after birth
* **Bloods**: FBC, TFTs, glucose, serology
* **Brain imaging**: CT head / MRI
* **IQ test**
276
Tx: What is the management of learning disabilities?
* **Multidisciplinary** approach
* Treat co-morbid **medical/psychiatric conditions**
* **Behavioural techniques**: applied behavioural analysis, positive behaviour support, CBT
* **Family education**]
* **Prevention**: genetic counselling, antenatal diagnosis
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Definition: Down's syndrome
A genetic disorder (**trisomy 21**) characterised by:
* **LD**
* **Dysmorphic facial features**
* **Multiple structural abnormalities**
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What are 5 physical features of Down's syndrome? (11)
* **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**
279
Name 7 medical problems associated with Down's syndrome
* **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**
280
Ix: Name 3 investigations for Down's syndrome
* **Serum screening**: beta-HCG & pregnancy-associated plasma protein A
* **Nuchal translucency**
* **Quad test**: beta-HCG, alpha-fetoprotein, inhibin A, estriol
281
What is the MOA for SSRIs?
* Inhibit **reuptake of serotonin** from the synaptic cleft into **pre-synaptic neurones**
* **Increase the concentration of serotonin** in the synaptic cleft
282
Definition: Serotonin syndrome
* Rare, life-threatening complication of **increased serotonin activity**
* Usually rapidly occuring - within minutes of taking meds
283
Clinical features: What are the cognitive/autonomic/somatic effects of **serotonin syndrome**?
* **Cognitive effects**: headache, agitation, hypomania, confusion, hallucinations, coma
* **Autonomic effects**: shivering, sweating, hyperthermia, HTN, tachycardia
* **Somatic effects**: myoclonus, hyperreflexia, tremor
284
What is the MOA for SNRIs?
* Prevent reuptake of **noradrenaline** and **serotonin**, but **don't block cholinergic receptors**
* Therefore don't have as many **anti-cholinergic SEs** as TCAs
285
What is the MOA for TCAs?
* Inhibit reuptake of **adrenaline** and **serotonin** in the synaptic cleft
286
What is the MOA for MAOIs?
Inactivate **monoamine oxidase enzymes** that oxidise the monoamine neurotransmitters **dopamine**, **noradrenaline**, **serotonin** and **tyramine**
287
Definition: Lithium toxicity
Medical emergency which can lead to **seizures**, **coma**, **death**
Enhanced by 4D's:
* **Dehydration**
* **Drugs** (ACE inhibitors, NSAIDs, metronidazole)
* **Diuretics** (thiazide)
* **Depletion of sodium**
288
Tx: What is the management of lithium toxicity?
* **Stop** lithium immediately
* High **fluid** intake inc **IV sodium chloride** to stimulate **osmotic diuresis**
* **Renal dialysis** may be needed in severe cases
289
Definition: Neuroleptic malignant syndrome
* 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
290
Clinical features: Name 5 symptoms of neuroleptic malignant syndrome
* Pyrexia
* Muscular rigidity
* Confusion
* Fluctiating consciousness
* Autonomic instability (e.g. tachycardia, fluctuating BP)
* May have delirium
291
Ix: Name 3 investigations for neuroleptic malignant syndrome
* **Creatinine kinase**: increased
* **FBC**: leucocytosis may be seen
* **LFTs**: deranged
* **ECG**: prolonged QT - ventricular arrhythmia
292
Tx: What is the management of neuroleptic malignant syndrome? (5)
* Stop antipsychotic
* Monitor vital signs
* IV fluids to prevent renal failure + rhabdomyolysis
* cooling - antipyrexials, ice packs
* Dantrolene (muscle relaxant)
* Bromocriptine (dopamine agonist)
293
Definition: Acute dystonic reaction
**Medication induced** movement disorder characterised by **involuntary muscle contractions**
294
Clinical features: What are the symptoms of acute dystonic reaction?
**Extrapyramidal side effects**
* Onset of atypical posture / position of muscles
* torticolis
* oculogyric crisis - involuntary upward of lateral deviation of eyes
*opisothotonos - involuntary arching of back
* facial grimacing
295
Tx: What is the treatment of acute dystonic reaction?
* **IV meds**: anticholinergic agents **procyclidine**, benzodiazepines
* Stop triggering medication
296
Definition: Mental capacity
* One's ability to **make decisions**
* **Time** specific
* **Decision** specific
297
What is section 2 of the MHA?
Admission for **assessment**
Duration: 28 days
298
What is section 3 of the MHA?
Admission for **treatment**
Duration: 6 months
299
What is section 136 of the MHA?
Someone found in a **public place** who appears to have a **mental disorder** can be taken by the **police** to a place of safety up to 72 hours
300
Definition: Overvalued idea
**False belief** that is maintained despite strong evidence that is is untrue
301
Definition: Loosening of association
Type of formal thought disorder characterised by **speech that shifts between topics** only **minimally related** to one another.
302
Definition: Circumstantiality
when the focus of a conversation drifts, but often comes back to the point
303
Definition: Perseveration
Inappropraite **repetition** of behaviour
e.g. rocking from side to side, finger wiggling, repetition of words
304
Definition: Confabulation
When a person **generates a false memory** without the intention of deceit
305
Definition: Incongruity of affect
**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
306
Definition: Blunted affect
Demonstrating **limited intensity** of emotions
307
Definition: La Belle indifference
A state of being **indifferent** to physical symptoms or abnormalities that are usually associated with **anxiety**
308
Definition: Depersonalisation
A feeling of **being outside yourself** and observing your actions/feelings/thoughts from a distance
309
Definition: Derealisation
Feel the **world is unreal**. Things around you may seem **foggy**/**lifeless**
310
Definition: Flight of ideas
When someone talks **quickly** and **erratically**, jumping rapidly between ideas and thoughts
-associated with Mania
311
Definition: Catatonia
State in which someone is awake but **doesn't respond** to other stimuli
Psychomotor disorder that affects **speech** and **behaviour** functions
312
Definition: Stupor
* State of decreased **cognitive functioning**, **sensory capacity** and **awareness**
* State of **lethargy** and **impaired consciousness**
313
Definition: Akathisia
Movement disorder causing a feeling of **restlessness** and an **inability to stay still**
314
What is neologism
Commonly seen in schizophrenia- when they make up new words and think they make sense
315
Circumstantial thinking definition
Where someone starts off with thought goes around the houses with thoughts and then returns to original thought
316
What is capgras syndrome
A delusional misidentification syndrome where a close member of there life have been replaced by imposters
317
Definition of thought insertion
Think that their thoughts are not their own but someone else’s and have been inserted into ones mind
318
Definition: thought withdrawal
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
319
Definition: thought broadcasting
Type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence.
320
What is a passivity experience
Feelings and thoughts and actions thought to be controlled by an external agency
321
How does disulfuram work
Blocks enzymes that metabolise alcohol. Increasing the acetaldehyde which is toxic and causing illness and vomiting used for alcohol addiction
322
What type of antipsychotic is aripiprazole
Partial dopamine agonist - regulate dopamines receptors
323
48 hour rule for clozapine
If they miss dose for 48 hours then they have to get dose retitrated
324
Tx for mania
1st line olanzapine for acute attacks
Mood stabilisers:
Lithium
Sodium valproate
Carbamazepine
325
Lithium side effects
LITHIUM
L-leukocytosis
I-idiopathic intracranial HTN
T-tremor
H-hypothyroidism
I-insipidus (diabetes)
U-upset stomach (N+V)
M-metabolic - weight gain
326
When can you stop antidepressants
-6 months after a remission
-if side effects too severe
327
What is a section 2 in the mental health act
Where a patient is admitted to hospital for mental health assessment by 2 doctors and an AMPH for **UP TO 28 DAYS**
328
What is a section three of the mental health act
Where a patient who has a mental health disorder is detained for treatment up to **6 months** due risk to yourself or others
329
What is a section 5.4 in mental health act
**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
330
What is section 5.2 in mental health act
doctor/ approved clinician can detain patients for up to 72 hours pending a MHA assessment
331
What is a section 135.1 in the mental health act
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
332
What is a section 135.2 in mental health act
Warrant allows police to enter private property if they have previously escaped and they need returning
333
What is a section 136
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
334
Citalopram main side effect
Long QT
335
First line SSRI given for teens and children
Fluoxetine
Think fluoxeteeeen
336
SNRI main side effect
Hypertension - measure BP should be monitored
337
Citalopram side effect and how do you monitor them
*monitor using ECG
-QT prolongation
-torsades de pointes
338
Main side effect monitored for in SSRI and how do you monitor
*monitor using U+Es
**Hyponatraemia**
339
What is the most common cause of serotonin syndrome
SSRI e.g setraline, fluoxetine, citalopram
340
Causes of serotonin syndrome
SSRI
MOA inhibitors - most severe
SNRI
TCA
Drugs - opioids, cocaine, amphetamines
341
Investigations for serotonin syndrome
Bloods - FBC, renal function, creatine kinase
Urinalysis - myoglobinuria (rhabdomyolysis)
- toxicology - which drug is causing it
342
Side effects of lithium
GI- N+V
- diarrhoea
ADH blocked - nephrogenic diabetes insipidus leads to *polydypsia and Polyuria*
Hypothyroidism sx
Ataxia
343
Methanol poisoning tx
fomepizole or ethanol
haemodialysis
344
What makes Schizophrenia a worse prognosis (4)
-low IQ
-gradual onset of
-lack of cause
-social withdrawal
345
Haloperidol main contraindications and side effect
Main side effect - QT prolongation
Contraindication - people with heart problems and Parkinsons
346
Four drug treatment for people with alcohol **abuse** (4)
Disulfuram
Alcomposate
Diazepam
Naltrexone
347
At what age can personality disorders be diagnosed
Over the age of 18
348
What is a section 4
72 hours emergency outpatient section when waiting for a section 2 would involve an unacceptable delay by 1 AMP and 1 Dr
349
What is tangeniality
Going from one idea to the next with no relevance to the actual question at hand
350
Lithium toxicity effects
TRUCKS
T- tremor that is coarse
R-reflexes increase/ hyperreflexia
U-urination increase
C-coma
K-
S-seizures
351
Short term side effects of ECT (5)
-headache
-nausea
-short term memory impairment
-memory loss of events prior to ECT
-cardiac arrhythmia
352
Long term side effects of ECT
impaired memory
353
Co morbidities for bipolar disorder
T2 diabetes
cardiovascular disease
COPD
354
Management for bipolar disorder
Mood stabiliser - lithium
Alternative is sodium valproate
management of mania/hypomania
- stopping antidepressant
- antipsychotic therapy e.g. olanzapine or haloperidol
management of depression
-talking therapies - CBT
-fluoxetine is the antidepressant of choice
355
In bipolar why must caution be taken when using antidepressants
Fluoxetine usually used
- they can precipitate manic episodes so should undergo close monitoring
356
Symptomatic Mx of GAD
Propranalol
