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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What are addictive behaviours?

A

Repeated behaviours that dominant a patient’s life to the detriment of social/occupational/material/family values and commitments

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2
Q

What are risk factors for addictive behaviours?

A
  • Stress
  • Fhx
  • Peer pressure
  • Low self esteem
  • Anxiety
  • Previous abuse
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3
Q

What are some common addictive behaviours?

A
  • Gambling
  • Eating
  • Internet
  • Sex
  • Shopping
  • Alcohol/drug use
  • Smoking/nicotine use
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4
Q

What is the pathophysiology of addiction?

A

Mediated via the mesolimbic dopamine reward pathway

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5
Q

What are clinical features of addiction?

A
  • Continuation despite harm
  • Difficulty to stop
  • Withdrawal symptoms if stopped
  • Denial of problem
  • Hiding behaviour
  • Vocational/social/recreational activities given up/reduced because of addiction
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6
Q

What is the management for addictive behaviours?

A
  • CBT
  • Support groups e.g. alcoholics anonymous
  • Aversion therapy
  • Self-control training
  • Managed detox
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7
Q

Describe ADHD

A
  • Attention Deficit Hyperactivity Disorder
  • Characterised by inattentiveness, hyperactivity and impulsiveness
  • Usually manifests before the age of 7
  • More common in males
  • Risks = genetics/prematurity/foetal alcohol syndrome
  • Symptoms of impaired attention, hyperactivity and/or impulsivity
  • Symptoms evident in more than one situation e.g. school and home
  • Symptoms present for at least 6 months
  • CNS stimulant = methylphenidate (ritalin)
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8
Q

What are 3 situations in which ADHD may be falsely diagnosed?

A
  • Age-appropriate behaviours in young active children
  • Children placed in academic settings inappropriate to their intellectual ability e.g. due to intellectual disabilities/highly intelligent children
  • Other mental illness e.g. pervasive developmental disorder, depression
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9
Q

What other medications may be used for ADHD?

A
  • CNS stimulants - blocks reuptake up dopamine and noradrenaline:
  • Methylphenidate (ritalin)
  • Dexamphetamine
  • Lisdexamfetamine

Non-stimulants:
- Atomoxetine
- Guanfacine

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10
Q

What is ADD?

A
  • Attention deficit disorder
  • Difficulties with concentration without the presence of other ADHD symptoms e.g. impulsiveness/hyperactivity
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11
Q

What are some side effects of methylphenidate?

A
  • Growth suppression association (6 months height and weight)
  • Anxiety
  • Increased BP
  • Arrhythmias
  • Appetite loss
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12
Q

What is anxiety?

A

Subjective, unpleasant sense of unease and worry of something bad happening

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13
Q

Describe GAD

A
  • Generalised anxiety disorder
  • Excessive worry/feelings of apprehension about everyday events/problems
  • More common in females
  • Nervousness
  • Restlessness/irritability
  • Easily fatigued
  • Difficulty concentrating/’mind blank’
  • Muscle tension
  • Sleep disturbance
  • Sweating/palpitations/dry mouth
  • Excessive anxiety/worry about everyday events/activities and difficulty controlling worry for >6 months
  • Causes significant distress/impairment in social/occupational/other areas of functioning
  • At least 3 associated symptoms
  • GAD-7 questionnaire
  • Counselling/CBT
  • SSRI
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14
Q

What is a panic attack and what is the management?

A
  • Short lived episode (approximately 20 minutes) characterised by severe anxiety, palpitations, rapid breathing and existential fears
  • SSRI
  • Beta blocker
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15
Q

Describe panic disorder

A
  • Recurrent, episodic, severe panic attacks that are unpredictable and not restricted to particular situations/circumstances
  • More common in females
  • Symptoms peak within 10 minutes (crescendo)
    PANICSD:
  • Palpitations
  • Abdominal distress
  • Numbness/nausea
  • Intense fear of death
  • Choking/chest pain
  • Sweating/shaking/SOB
  • Depersonalisationn/derealisation
  • SSRIs
  • TCAs
  • CBT and self-help methods
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16
Q

What is phobic anxiety?

A

Recurring excessive and unreasonable symptoms of anxiety in the (anticipated) presence of specific feared objects, situations or person leading, wherever possible, to avoidance

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17
Q

What are features of phobic anxiety?

A
  • Anticipatory anxiety
  • Palpations/sweating/trembling
  • SOB/chest pain
  • Dizziness
  • Chills/hot flushes
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18
Q

What is the management for phobic anxiety?

A
  • Behavioural therapy e.g. graded exposure therapy
  • Benzodiazepines
  • Education/anxiety management
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19
Q

Describe PTSD

A
  • Post-Traumatic Stress Disorder
  • Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
  • Reliving the situation
  • Avoidance (of reminders)
  • Hyperarousal (irritability/outbursts)
  • Emotional numbing
    (May also have dissociative amnesia)
  • Exposure to traumatic event
  • Features present within 6 months
  • Features last >1 month
  • Trauma screening questionnaire (TSQ)
  • Trauma focused CBT
  • Eye movement desensitisation and reprocessing (EMDR)
  • Sertraline/venlafaxine
  • Zopiclone (for sleep disturbance)
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20
Q

What is the difference between typical and complex PTSD?

A

Typical = arises after a traumatic episode and is generally related to a single traumatic event

Complex = related to a series of traumatic events over time or one prolonged event

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21
Q

Describe OCD

A
  • Obsessive compulsive disorder
  • Chronic condition associated with marked anxiety and depression, characterised by ‘obsessions’ and/or ‘compulsions’
  • Obsessions –> anxiety –> compulsive behaviour –> temporary improvement in anxiety –> obsession then reappears
  • Associated with other mental health conditions
  • Presence of either obsessions/compulsions/both
  • Are time consuming (>1hr/day) or cause significant distress/functional impairment
  • Patient recognises them to be excessive/unreasonable
  • CBT
  • Exposure and response prevention (ERP)
  • Behavioural therapy/psychotherapy
  • SSRI, TCA (clomipramine)
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22
Q

What is an obsession?

A

An idea/image/impulse recognised by patient as their own but which is experienced as repetitive, unwanted, intrusive and distressing. Patients may try to resist but this often causes a lot of anxiety

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23
Q

What is a compulsion?

A

A behaviour/action recognised by patient as unnecessary and purposeless but which they cannot resist performing repeatedly

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24
Q

What is a phobia?

A

Fear of a specific situation/object

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25
Q

What is agoraphobia?

A

Fear of public spaces e.g. shops

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26
Q

What is social phobia?

A

Fear of social situations/scrutiny/being ridiculed in social situations

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27
Q

What is the management for phobias?

A
  • CBT
  • Exposure therapy
  • Potentially SSRI ?
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28
Q

What is ASD?

A
  • Autism spectrum disorder
  • Neuro-developmental disorder characterised by abnormal social interaction, communication and restricted, repetitive behaviours
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29
Q

Describe the epidemiology of ASD

A
  • More common in males
  • Infantile autism associated with development of seizures in adolescence
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30
Q

Describe the autistic spectrum

A
  • On one end, patients have normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others (previously known as Asperger syndrome)
  • On the other end, patients can be severely affected and unable to function in normal environments
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31
Q

What are the 3 main features of ASD?

A
  1. Social interaction deficits
  2. Communication deficits
  3. Behaviour deficits
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32
Q

What is bipolar disorder/bipolar affective disorder?

A

Depression and mania/hypomania occurring in episodes usually with months separating them

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33
Q

Describe the epidemiology of bipolar disorder

A

Bimodal distribution with peaks at 15-24 years and 45-54 years

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34
Q

What are risk factors for bipolar disorder?

A
  • Genetics/family history
  • Prenatal exposure to toxoplasma gondii
  • Premature birth (<32 weeks)
  • Childhood maltreatment
  • Traumatic life events/experiences
  • Postpartum period
  • Cannabis use
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35
Q

What is the difference between mania and hypomania?

A

Mania = elevated/expansive/euphoric/irritable mood with >3 characteristic symptoms on most days for >1 week - often occurs with psychotic symptoms

Hypomania = >3 characteristic symptoms lasting >4 days and present most of the day, almost every day - essentially less severe mania without psychosis

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36
Q

What are the types of bipolar disorder?

A

Bipolar I = episodes of depression, mania or mixed states separated by periods of normal mood

Bipolar II = episodes of depression, hypomania or mixed states (no mania)

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37
Q

What is cyclothymic disorder?

A
  • Condition related to bipolar disorder
  • Recurring mild depressive and hypomanic states
  • Lasts for at least 2 years
  • Does not meet the diagnostic threshold for a major affective episode
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38
Q

What medications can cause medication-induced mania/hypomania?

A
  • TCAs
  • SNRIs
  • SSRIs
  • Benzodiazepines
  • Antipsychotics
  • Lithium
  • Anti-Parkinsonian medications e.g. AChE inhibitors (rivastigmine)
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39
Q

What are the investigations for bipolar disorder?

A
  • Bloods (FBC, U&Es, LFTs, TFTs, CRP, B12, folate. vitamin D, ferritin)
  • HIV testing
  • Physical examination (neuro exam)
  • CT/MRI head
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40
Q

What are differential diagnoses for bipolar disorder?

A
  • Schizophrenia
  • Organic brain disorder
  • Drugs
  • Recurrent depression
  • Emotionally unstable/borderline personality disorder (EUPD/BPD)
  • Cyclothymia
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41
Q

What is the management for bipolar disorder?

A

Maintenance = lithium
Mood stabilisers = lithium, sodium valproate, carbamazepine
Depression = SSRIs
Psychotic symptoms = antipsychotics
Acute mania = quetiapine + lithium + benzodiazepine

Psychoeducation/CBT/IPT/support groups

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42
Q

What is the RC?

A

Responsible clinician - approved clinician with overall responsibility of the patient’s care. Only the RC can make certain decisions e.g. discharge from section, S17 leave, consent to treatment

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43
Q

What are SOADs?

A

Second opinion appointed doctors - doctors external to the organisation and appointed by the care quality commission (CQC). They review the treatment plans for patients who are detained for >3 months who do not have capacity to consent to or are refusing treatment

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44
Q

What is a mental health tribunal?

A

Legal proceedings that decide whether a patient should be discharged from their section or not

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45
Q

What is a S12 approved doctor?

A

A doctor (usually a senior psych trainee or consultant but occasionally a GP) who has undergone the accredited training to complete mental health act assessments

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46
Q

When can a patient be detained?

A

If they have a mental disorder that poses significant risk to themselves or others, and treatment in the community is not possible because of this

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47
Q

What is a AMHP?

A

Approved mental health practitioner - professional who has undergone the training to take part in mental health act assessment and can be from any background (usually social workers) but importantly CANNOT be doctors

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48
Q

What is a section 2?

A
  • Admission for assessment for up to 28 days
  • Requires MHA assessment - 1 AMHP + 2 section 12 approved doctors
  • Cannot be renewed
  • Can be transferred to section 3
  • Patient can be treated against their wishes
  • Patients can appeal within first 14 days
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49
Q

What is a section 3?

A
  • Admission for assessment for up to 6 months days
  • Requires MHA assessment - 1 AMHP + 2 section 12 approved doctors
  • Can be renewed for 6 months then annually
  • Patient can be treated against their wishes - proposed treatment plan for mental disorder required
  • Patients can appeal once per period of detention
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50
Q

What is a section 5(2)?

A
  • Holding power of informal patients by doctors
  • MHA not required
  • Lasts 72 hours
  • Not renewable
  • Patients cannot appeal
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51
Q

What is a section 5(4)?

A
  • Holding power of informal patients by nurses
  • MHA not required
  • Lasts 6 hours (time for doctor to arrive)
  • Not renewable
  • Patients cannot appeal
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52
Q

What is a section 136?

A
  • Allows police to detain an individual they believe is suffering from a mental disturbance in a public place and take them to a place of safety (usually ED or 136 suite)
  • Maximum 72 hours detention to allow MHA assessment
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53
Q

What is a section 135?

A
  • Warrant for search for and removal of patients in private premises
  • Issued by magistrates
  • Patient taken to a place of safety
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54
Q

What is a community treatment order?

A
  • Patients under section 3 can be discharged from hospital subject to them being liable to be recalled to hospital if required
  • Specific conditions to which the patient must adhere
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55
Q

What is a section 17?

A

Authorised leave from hospital

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56
Q

What is a section 117?

A
  • Statutory duty on health and social services to provide aftercare for those detained under section 3
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57
Q

What is nearest relative?

A
  • Not next of kin - determines a proxy to act as a safety mechanism within the MHA
    1. Husband/wife/civil partner
    2. Son/daughter
    3. Mother/father
    4. Brother/sister
  • Can apply to section patient
  • Can object to section/appeal to tribunal
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58
Q

What is mental capacity?

A

The ability to understand information and make decisions about one’s life or the ability to communicate decisions about one’s life

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59
Q

Describe the Mental Capacity Act (2005)

A
  • All adults are assumed to have capacity
  • Capacity can fluctuate
  • If capacity is questioned, patients need to meet the criteria:
    1. Understand the options
    2. Retain information
    3. Weigh up pros and cons
    4. Communicate decision
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60
Q

What is lasting power of attorney?

A

Patients can legally nominate a person of their choice to make decisions based on their behalf if they lack mental capacity

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61
Q

What is Deprivation of liberty safeguards (DoLS)?

A
  • Application made by a hospital or care home for patients who lack capacity to allow them to provide care and treatment
  • Whilst in hospital or a care home, the patient is under control and not able to leave
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62
Q

What is an illusion?

A

Misinterpretation of real stimulus in the context of emotional state e.g. misperceiving a shadow on the wall as an intruder

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63
Q

What is a hallucination?

A

Internal experiences/perceptions without an external stimulus. Can be visual/auditory/tactile/olfactory/gustatory

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64
Q

What is a pseudo-hallucination?

A

A type of illusion when feelings of anxiety or fear are projected on external objects e.g. misperceiving a shadow on the wall as an intruder

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65
Q

What is an over-valued idea?

A

A false belief that is maintained despite strong evidence that it is untrue - similar to delusions but may seem less strange and have an element of truth

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66
Q

What is a delusion?

A

A false, unshakeable idea/belief that is firmly held despite evidence to the contrary that is not consistent with the person’s educational, cultural and social background

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67
Q

What is a delusional perception?

A

A true perception to which a patient attributes a false meaning e.g. traffic light turns red is interpreted by patient as martians about to land (schizophrenia)

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68
Q

What is concrete thinking?

A

More literal form of thinking that focuses on the physical world - take information at face value without thinking beyond or generalising the information to other meanings/situations

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69
Q

What is loosening of association?

A

Lack of connection between ideas - thoughts may appear loosely connected or unrelated (schizophrenia)

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70
Q

What is circumstantiality?

A

Circuitous and non-direct thinking or speech that digresses from the main point of conversation (but finally makes its way back to the main point)

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71
Q

What is perseveration?

A

Persistent and inappropriate repetition of the same thought via speech or actions (frontal lobe dysfunction)

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72
Q

What is confabulation?

A

Memory error consisting of the production of fabricated/distorted/misinterpreted memories about oneself or the world e.g. person with dementia tells a story about their childhood which isn’t true but they think it is

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73
Q

What is somatic passivity?

A

a.k.a passivity phenomena
The belief that outside influences are playing on the body - the event is experienced as alien by the patient in that it is not experienced by the patient as their own but inserted into the self from outside

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74
Q

What is pressure of speech?

A

Unusually rapid, abundant and varied speech (mania)

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75
Q

What is anhedonia?

A

Lack of interest, enjoyment or pleasure from life’s experiences

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76
Q

What is incongruity of affect?

A

Emotion is inappropriate to content of speech

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77
Q

What is blunting of affect?

A

Difficulty expressing emotions, characterised by diminished facial expressions/expressive gestures/vocal expressions in reaction to emotion provoking stimuli

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78
Q

What is belle indifference?

A

Apparent lack of concern shown by some patients towards their symptoms - often regarded as typical of conversion symptoms/hysteria

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79
Q

What is depersonalisation and derealisation?

A

Depersonalisation = feeling of being outside oneself and observing own actions, feelings or thoughts from a distance

Derealisation = feeling that the world is unreal

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80
Q

What is thought alienation?

A

Thoughts are no longer within patient’s control (insertion/withdrawal/broadcast)

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81
Q

What is thought insertion?

A

Thoughts have been implanted by an external agency

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82
Q

What is thought withdrawal?

A

Thoughts have been taken away

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83
Q

What is thought broadcast?

A

Thoughts are known to others via telepathy or the media

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84
Q

What is thought echo?

A

Patient hears their own thoughts as if they were being spoken aloud

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85
Q

What is thought block?

A

Mind suddenly becomes empty of thoughts (paranoid schizophrenia)

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86
Q

What is akathisia?

A

Inability to remain still

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87
Q

What are made acts, feelings and drives?

A

The delusional belief that one’s free will has been removed and an external agency is controlling one’s actions and feelings

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88
Q

What is clouding of consciousness?

A

a.k.a brain fog
Inattention and reduced wakefulness

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89
Q

What is catatonia/stupor?

A

State in which someone is awake but does not seem to respond to other people and their environment/state of near unconsciousness or insensibility

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90
Q

What is flight of ideas?

A

Thoughts are moving so quickly that one train of thought is not completed before the next one starts thus the topic might be difficult to follow

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91
Q

What is psychomotor retardation?

A

Slowing down of thought and a reduction of physical movements in an individual - can cause a visible slowing of physical and emotional reactions including speech and affect

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92
Q

What is formal thought disorder?

A

Disorganised thinking evidenced in speech (psychosis and schizophrenia)

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93
Q

What is conversion/dissociation?

A

Conversion = emotional stress manifests as physical symptoms

Dissociation = mental process of disconnecting from one’s thoughts/feelings/memories/sense of identity

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94
Q

What is a mannerism?

A

Normal actions carried out in peculiar fashions, usually in an attempt to draw attention to oneself (schizophrenia)

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95
Q

What is a stereotyped behaviour?

A

Repetitive movements or sounds carried out by individuals with cognitive dysfunction or severely impaired sensory function

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96
Q

What is substance misuse?

A

The consumption of substances that leads to the involvement of social/psychological/physical/legal problems

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97
Q

What is alcohol dependence?

A

Craving, tolerance and preoccupation with alcohol with continued drinking in spite of harmful consequences

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98
Q

Describe the epidemiology of alcohol misuse

A
  • 5th biggest risk factor for death across all ages
  • More common in males
  • Recommended units = 14 units/week spread evenly over 3 days or more
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99
Q

How do you calculate units of alcohol?

A

ABV x volume (ml) / 1000

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100
Q

What are risk factors for alcohol misuse?

A
  • Male
  • Genetics/family history
  • Occupation
  • Cultural influences
  • Cost of drinks
  • Social reinforcement/association
  • Chronic illness
  • Traumatic life event
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101
Q

What are clinical features of intoxication?

A
  • Slurred/impaired speech
  • Ataxia/impaired coordination
  • Impaired judgement
  • Labile affect
  • Hypoglycaemia
  • Stupor
  • Coma
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102
Q

What are signs of alcohol dependence?

A

CANT STOP
- Compulsion to drink
- Aware of harms
- Neglect of other activities
- Tolerance
- Stopping causes withdrawal
- Time preoccupied with alcohol
- Out of control use
- Persistent, futile wish to cut down

SAW DRINk
- Subjective awareness of compulsion to drink
- Avoidance/relief of withdrawal by further drinking
- Withdrawal sx
- Drink-seeking behaviour
- Reinstatement of drinking after attempted abstinence
- Increased tolerance
- Narrowing of drinking repertoire

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103
Q

What are signs of alcohol withdrawal?

A

Appear 6-12 hours after last drink
- Malaise/sweating
- Tremor
- Nausea/vomiting/diarrhoea
- Insomnia
- Irritability/anxiety
- Transient hallucinations
- Seizures (tonic clonic)
- Palpitations

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104
Q

What medical emergency can alcohol withdrawal lead to?

A

Delirium tremens - 72 hours after alcohol cessation

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105
Q

What are clinical features of delirium tremens?

A
  • Cognitive impairment
  • Lilliputian hallucination (spiders/snakes/tiny figures)
  • Paranoid delusions
  • Tremor
  • Fever/sweating
  • Tachycardia
  • Dehydration
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106
Q

What is the treatment for delirium tremens?

A

IV pabrinex and lorazepam

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107
Q

What are the investigations for alcohol misuse?

A
  • History and MSE
  • Physical exam (signs of chronic liver disease e.g. palmar erythema, spider naevi, etc.)
  • Questionnaires (AUDIT, CAGE, SADQ, FAST)
  • CT head
  • ECG
  • Bloods
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108
Q

What is the acute treatment for alcohol misuse/abuse (detoxification)?

A

Chlordiazepoxide (benzodiazepine), IV pabrinex, water and food (protein-rich, high calorie diet)

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109
Q

What is pabrinex and why is it used for alcohol misuse/abuse/withdrawal?

A

Synthetic thiamine/vitamin B1 - chronic alcohol consumption causes deficiency (leads to Wernicke-Korsakoff syndrome)

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110
Q

What 3 medications are used for maintenance/relapse prevention in alcohol withdrawal?

A
  • Acamprosate (reduces cravings)
  • Naltrexone (reduces pleasurable effects of alcohol)
  • Disulfiram (causes unpleasant symptoms when drinking)
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111
Q

What are other management plans for alcohol withdrawal?

A
  • Motivational interviewing/CBT
  • Support groups e.g. alcoholics anonymous
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112
Q

What is Wernicke’s encephalopathy?

A

Acute neurological condition characterised by a triad of confusion, ataxia and oculomotor dysfunction

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113
Q

What is Korsakoff syndrome?

A

Chronic amnesia syndrome characterised by defects in both anterograde and retrograde memory

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114
Q

What are the causes of Wernicke’s encephalopathy?

A

Thiamine/vitamin B1 deficiency due to:
- Chronic alcoholism
- Prolonged fasting/starvation
- Anorexia nervosa
- Hyperemesis gravidarum
- Systemic malignancy
- End-stage renal failure
- GI disease/malabsorption

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115
Q

What are the causes of Korsakoff syndrome?

A

Untreated Wernicke’s encephalopathy

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116
Q

What are clinical features of Wernicke’s encephalopathy?

A
  • Ataxia
  • Delirium/confusion
  • Ophthalmoplegia/nystagmus
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117
Q

What are clinical features of Korsakoff syndrome?

A
  • Irreversible short term memory loss
  • Confabulation
  • Time disorientation
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118
Q

How is Wernicke’s encephalopathy/Korsakoff syndrome treated?

A

IV pabrinex

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119
Q

What are the complications of Wernicke’s encephalopathy?

A
  • Permanent horizontal nystagmus
  • Inability to walk
  • Deficit in learning/memory
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120
Q

What are the complications of Korsakoff syndrome?

A

Permanent neurological damage - recovery is rare
- Progressive reduced level of consciousness
- Coma
- Death

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121
Q

Describe the epidemiology of substance abuse

A
  • Most common are alcohol, cannabis, cocaine, ecstasy
  • Other common substances are tobacco, benzos, stimulants, hallucinogens, solvents
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122
Q

Describe the pathophysiology of depressants

A

Act on GABA - main inhibitory neurotransmitter in the brain

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123
Q

What are the 5 main categories of drugs?

A
  • Opioids (heroin/morphine/codeine)
  • Stimulants (cocaine/caffeine/amphetamines/caffeine)
  • Depressants (alcohol/benzodiazepines)
  • Cannabinoids (cannabis)
  • Hallucinogens (magic mushrooms/PCP/LSD)
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124
Q

What are risk factors for substance abuse?

A
  • Genetics
  • Environmental stressors
  • Social pressures
  • Psychiatric problems
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125
Q

What are indications of substance abuse?

A
  • Desire for substance
  • Preoccupation with substance use
  • Withdrawal state
  • Incapability to control substance
  • Tolerance to substance
  • Evidence of harmful effects
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126
Q

What are clinical features of opioid withdrawal?

A
  • Yawning
  • Runny eyes/nose
  • Abdominal cramps
  • Vomiting
  • Cold skin
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127
Q

What are the investigations for substance abuse?

A
  • History and MSE
  • Physical exam (weight/dentition/signs of IVDU)
  • Signs of withdrawal
  • Bloods
  • Urinalysis (toxicology)
  • ECG/CXR/echo
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128
Q

What are signs of IVDU?

A
  • Phlebitis
  • Abscess
  • Old scarring
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129
Q

What are signs of substance withdrawal?

A
  • Sweating
  • Dilated pupils
  • High HR/BP
  • N+V
  • Tremor
  • Muscle cramps
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130
Q

What are management options for substance abuse?

A

Key steps = substitution, detoxification and relapse prevention
- Motivational interviewing/CBT
- Support groups e.g. narcotics anonymous
- Oral substitution therapies
- Medications

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131
Q

What are examples of oral substitution therapies in substance abuse?

A
  • Methadone
  • Buprenorphine
  • Dihydrocodeine
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132
Q

What other medications are used in substance abuse?

A
  • Lofexidine (withdrawal symptoms)
  • Naltrexone (relapse prevention)
  • Naloxone (opioid overdose)
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133
Q

What are risks of prolonged IVDU?

A
  • Abscesses
  • Collapsed veins
  • Significant weight loss
  • Skin ulcers
  • Overdose
  • Infections
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134
Q

What are clinical features of a drug overdose?

A
  • Pin point pupils (very common with opioids)
  • Drowsiness
  • Respiratory depression/acidosis
  • Hypotension
  • Tachycardia
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135
Q

How is a drug overdose managed?

A
  • ABCDE
  • Naloxone
  • Activated charcoal
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136
Q

Name 7 psychiatric emergencies

A
  • Alcohol withdrawal
  • Delirium tremens
  • Wernicke’s encephalopathy
  • Lithium toxicity
  • Acute dystonic reaction
  • Neuroleptic malignant syndrome
  • Serotonin syndrome
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137
Q

What are side effects of lithium?

A
  • Polyuria/polyidisia
  • Weight gain
  • Oedema
  • Fine tremor
  • Hypothyroidism
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138
Q

What should be avoided when prescribing lithium?

A
  • NSAIDs
  • ACE inhibitors
  • Diuretics
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139
Q

What is a contraindication for lithium?

A

Teratogenic - causes Ebstein’s anomaly (congenital malformation of tricuspid valve)

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140
Q

What are symptoms of lithium toxicity?

A

TOXICCC
- Tremor (coarse)
- Oliguric renal failure
- ataXia
- Increased reflexes
- Convulsions
- Consciousness decreased
- Coma

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141
Q

What are the investigations for lithium toxicity?

A
  • U&Es
  • TFTs
  • Lithium levels
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142
Q

What is the management for lithium toxicity?

A
  • Stop lithium
  • Fluids and IV NaCl
  • Haemodialysis (if severe)
143
Q

What is acute dystonic syndrome?

A

Acute movement disorder characterised by involuntary muscle contractions in either sustained or intermittent patterns that lead to abnormal movements or postures

144
Q

What is a common cause of acute dystonic syndrome?

A

Typical antipsychotics

145
Q

What are clinical features of acute dystonic syndrome?

A
  • Painful contraction in eyes/neck/jaw
  • Arm held in dystonic posture
  • Neck spasm to side
  • Mouth open
  • Upward eye gaze
  • Pain/distress
146
Q

What is the management for acute dystonic syndrome?

A
  • IM procyclidine 5-10mg
  • IV diazepam (if life-threatening emergency)
147
Q

What is neuroleptic malignant syndrome?

A

Life-threatening neurological disorder characterised by confusion, fever and rigidity

148
Q

What is the common cause of neuroleptic malignant syndrome?

A
  • Adverse reaction to dopamine receptor agonists (antipsychotics)
  • Abrupt withdrawal of dopaminergic medication (e.g. bromocriptine/cabergoline - Parkinsons)
149
Q

What are the clinical features of neuroleptic malignant syndrome?

A
  • Altered mental state (confusion/delirium)
  • Hypertonia/muscle rigidity
  • Fever
  • Autonomic dysfunction (high HR/RR)
150
Q

What results would be seen in a patient with neuroleptic malignant syndrome?

A
  • Raised creatine kinase
  • Raised WCC
  • Deranged LFTs
  • Acute renal failure (abnormal U&Es)
  • Metabolic acidosis (low pH, how HCO3)
151
Q

What are common differential diagnoses for neuroleptic malignant syndrome?

A
  • Sepsis
  • Brain problems
  • Renal failure
152
Q

What is the management for neuroleptic malignant syndrome?

A
  • Withdraw causative medication
  • Supportive treatment (rehydration, correct electrolyte imbalances, antipyretic)
153
Q

What are complications of neuroleptic malignant syndrome?

A
  • PE
  • Renal failure
  • Shock
154
Q

What is serotonin syndrome?

A

Life-threatening neurological disorder due to increased serotonergic activity in the central nervous system characterised by altered mental status, autonomic hyperactivity and neuromuscular abnormalities

155
Q

What are common causes of serotonin syndrome?

A
  • SSRIs/SNRIs
  • Opioid analgesics
  • MAOIs
  • Lithium
  • TCAs
156
Q

What are the clinical features of serotonin syndrome?

A
  • Altered mental state (anxiety/agitation/confusion)
  • Neuromuscular dysfunction (clonus/hyperreflexia/hypertonia/tremor)
  • Autonomic dysregulation (fever/D+V/high HR/RR)
157
Q

What is a common differential diagnosis for serotonin syndrome?

A

Neuroleptic malignant syndrome
NMS = high WCC
SS = normal WCC

158
Q

What is the management for serotonin syndrome?

A
  • Withdraw causative medication
  • Supportive treatment (benzos for agitation, activated charcoal if overdose)
159
Q

What is deliberate self-harm?

A

An act not intended to cause death but to gain relief from psychological stress/pain

160
Q

What is suicide?

A

An act with the intention of causing death

161
Q

Describe the epidemiology of self-harm

A
  • Peaks in 16-24 year old women
  • Peaks in 25-34 year old men
162
Q

Describe the epidemiology of suicide

A
  • More common in men
  • 1/3 of people who attempt suicide haven’t had any contact with mental health services
163
Q

What are risk factors for self-harm/suicide?

A
  • Alcohol/substance misuse
  • History of self-harm/suicide
  • Incarceration/involvement with criminal justice system
  • Socio-economic disadvantage (homeless/unemployed)
  • Social isolation
  • Stressful life events (e.g. relationships/armed forces/child maltreatment/domestic violence)
  • Bereavement by suicide
  • Mental health problems
  • Chronic physical health problems
164
Q

What are common types of self-harm?

A
  • Cutting/burning skin
  • Punching/hitting themselves
  • Poisoning with tablets/toxic chemicals
  • Misusing drugs/alcohol
  • Starving themselves/binge eating
  • Overexercising
165
Q

What are common features of someone at risk of suicide?

A
  • Young male
  • Divorced
  • Mental illness
  • Chronic illness
  • Substance misuse
166
Q

What is the management for patients at risk of suicide?

A

High risk = inpatient treatment
Medium/low risk = home crisis plan and crisis team involvement

167
Q

What is the management for self-harm?

A

CBT/counselling:
- Understand patterns (triggers/urgers/distractions)
- Identify emotions and what self-harm helps to achieve
- Music
- Guided imagery/meditation

168
Q

What are types of somatoform disorders?

A
  • Conversion disorder
  • Somatisation disorder
  • Hypochondriasis
  • Dysmorphophobia
  • Somatoform pain disorder
169
Q

What is conversion disorder?

A

a.k.a hysteria
- Single sign/symptom affecting voluntary function which cannot be explained by a medical condition
- Psychological factors e.g. conflict/stress associated with deficits

170
Q

What is somatisation disorder?

A
  • Multiple physical symptoms caused by psychological or emotional factors
  • Usually persist long-term
171
Q

What is hypochondriasis?

A
  • Preoccupation with fancied bodily illness
  • Fear of conviction or having a serious disease based on a misinterpretation of bodily symptoms
172
Q

What is dysmorphophobia?

A

Patients convinced that part of their body is too large/small/deformed

173
Q

What is somatoform pain disorder?

A

Suffering of pain for longer than 6 months for which there is no physical cause and no specific mental disorder

174
Q

What are risk factors for dysmorphophobia?

A
  • Low self-esteem
  • Critical parents/significant others
  • Early childhood trauma
  • Unconscious displacement of emotional conflict
175
Q

What is the management for somatoform disorders?

A
  • CBT
  • Group therapy
  • Relaxation training
  • Medication e.g. SSRIs
176
Q

What is electroconvulsive therapy (ECT)?

A

Treatment that involves sending electric currents through a patient’s brain

177
Q

Describe the pathophysiology of ECT

A

Electric current sent through the brain which causes a brief surge of electrical activity within the brain (seizure)

178
Q

What is ECT used for?

A
  • Severe depression
  • Severe/long-lasting episode of mania
  • Catatonia
179
Q

When might ECT be used?

A
  • If patient has a preference for ECT based on previous experience
  • If all other treatment options have been considered/tried/unsuccessful
180
Q

What are contraindications for ECT?

A
  • Cannot be given to children under 11 (and rarely effective for 11-18 year olds)
  • Higher risk of negative effects in patients who are older, pregnant or have cardiovascular conditions
181
Q

What are side effects of ECT?

A
  • Memory loss
  • Drowsiness
  • Confusion
  • Headache
  • Nausea
  • Aching muscle
  • Loss of appetite
182
Q

What are rare side effects of ECT?

A
  • Teeth/jaw/muscle injury
  • Extreme confusion/agitation/restlessness
  • Prolonged seizures
  • Permanent/temporary memory loss
183
Q

What are talking therapies?

A

Psychological treatments for mental and emotional problems like stress, anxiety and depresion

184
Q

Give some types of psychological therapies

A
  • Cognitive behavioural therapy (CBT)
  • Interpersonal therapy (IPT)
  • Counselling
  • Guided self-help
  • Behavioural activation
  • Eye movement desensitisation and reprocessing
  • Mindfulness-based cognitive therapy (MBCT)
  • Psychodynamic psychotherapy
  • Couple therapy
185
Q

What are the main groups of antidepressants?

A
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Selective noradrenaline reuptake inhibitors (SNRIs)
  • Noradrenergic and specific serotonergic antidepressants (NaSSAs)
  • Tricyclic antidepressants (TCAs)
  • Monoamine oxidase inhibitors (MAOIs)
186
Q

What are antidepressants used for?

A
  • Depression
  • OCD
  • GAD
  • PTSD
  • Eating disorders
187
Q

Describe the pathophysiology of SSRIs

A

Inhibits reuptake of serotonin from presynaptic serotonin pumps so that more serotonin stays in the synapses therefore increasing serotonin activity

188
Q

Give some examples of SSRIs

A
  • Sertraline (1st line for GAD)
  • Citalopram
  • Fluoxetine (1st line for <18s)
  • Paroxetine
  • Escitalopram
189
Q

What are side effects of SSRIs?

A
  • GI symptoms
  • Anxiety/agitation
  • Sexual impotence/anorgasmia
  • Insomnia
  • Sweating
  • Weight gain
  • Increased suicidality
  • Hyponatraemia
190
Q

What medications do SSRIs interact with?

A

Fluoxetine and paroxetine = higher risk of interactions
- NSAIDs
- Warfarin/heparin
- Aspirin
- Triptans

191
Q

What are discontinuation symptoms of SSRIs?

A
  • Flu-like symptoms (lethargy/fatigue/headaches/achiness/sweating)
  • Dizziness/imbalance
  • Tremor
  • Hyperarousal (anxiety/irritability/agitation)
  • GI issues
192
Q

Describe the pathophysiology of SNRIs

A

Inhibits presynaptic noradrenaline and serotonin pumps to prevent the reuptake of serotonin and noradrenaline

193
Q

Give some examples of SNRIs

A
  • Venlafaxine
  • Duloxetine
194
Q

What are side effects of SNRIs?

A
  • HTN
  • Dizziness
  • Dry mouth
  • Constipation
  • Hot flushes
  • Hyponatraemia (especially venlafaxine)
195
Q

Describe the pathophysiology of NaSSAs

A
  • Blocks presynaptic alpha 2 receptors to enhance the release of noradrenaline and serotonin
  • Histamine antagonist
196
Q

Give an example of a NaSSA

A

Mirtazapine

197
Q

What are side effects of NaSSAs?

A
  • Increased appetite/weight gain
  • Sedation
  • Headache
  • Postural hypotension
  • Dizziness
  • Tremor
198
Q

Describe the pathophysiology of TCAs

A

Inhibit serotonin and noradrenaline reuptake within the presynaptic terminals (block muscarinic/histaminergic/alpha-adrenergic receptors)

199
Q

Give an example of a TCA

A

Amitriptyline (tend to be used more for pain/migraines)

200
Q

What are side effects of TCAs?

A
  • Anticholinergic (muscarinic) - dry mouth/constipation/blurred vision/urinary retention (can’t see, can’t pee, can’t shit, can’t spit)
  • Antiadrenergic - sedation/weight gain
  • Antihistaminergic - postural hypotension/dizziness/syncope
  • Cardiac - prolonged QT/palpitations/arrhythmias/heart blocks
201
Q

What are contraindications of TCAs?

A
  • IHD
  • Arrhythmias
  • Severe liver disease
  • Overdose risk
202
Q

Describe the pathophysiology of MAOIs

A
  • Monoamine oxidase is an enzyme involved in removing noradrenaline, serotonin and dopamine from the brain
  • Activity of monoamine oxidase A and B is inhibited, prevented the breakdown of the neurotransmitters and therefore increasing their availability
203
Q

Give an example of a MAOI

A

Isocarboxazid

204
Q

What are side effects of MAOIs?

A
  • Overdose risk
  • Can lead to hypertensive crisis (tyramine cheese reaction)
205
Q

What are disadvantages of antidepressants?

A
  • Can take a while to come into effect
  • Can increase suicidal thoughts/make things worse initially
  • Only improves some of the symptoms of depression, not all
  • Can commonly cause hyponatraemia (especially SSRIs/SNRIs) which presents as N+V/headaches/confusion
206
Q

What are antipsychotics used for?

A
  • Psychosis
  • Mania
  • Schizophrenia
  • Schizoaffective disorder
  • Bipolar disorder
  • Severe depression
  • Personality disorders
  • PTSD
207
Q

Describe the pathophysiology of psychosis

A

Dopamine system becomes overactive, contributing to the production of hallucinations, delusions and thought disorder

208
Q

Describe the pathophysiology of typical antipsychotics

A

Block dopamine (D2) receptors

209
Q

Give some examples of typical antipsychotics

A
  • Chlorpromazine
  • Haloperidol
  • Flupentixol
210
Q

What are common side effects of typical antipsychotics?

A

Parkinsonian symptoms:
- Resting tremor
- Rigidity
- Bradykinesia
- Dystonia

211
Q

Describe the pathophysiology of atypical antipsychotics

A

Block dopamine receptors but also activate other dopamine and serotonin receptors (= less severe Parkinsonian symptoms)

212
Q

What are side effects of antipsychotics?

A
  • QT segment prolongation
  • Parkinsonian symptoms
  • Hypotension
  • Fatigue
  • Weight gain/diabetes
  • Dry mouth
  • Constipation
  • Agitation
213
Q

Give some examples of atypical antipsychotics

A
  • Olanzapine
  • Aripiprazole
  • Amisulpride
  • Quetiapine
  • Risperidone
  • Clozapine
214
Q

What is clozapine used for?

A

Treatment resistant schizophrenia - patient needs to have take 2 other antipsychotics previously (and been ineffective) before being prescribed this

215
Q

What are main side effects of clozapine?

A
  • Neutropenia/agranulocytosis
  • Myocarditis
  • Cardiomyopathy
  • Constipation
  • Hypersalivation
  • Seizures
216
Q

What side effect is most associated with olanzapine?

A

Weight gain/risk of developing diabetes

217
Q

What side effect is most associated with aripiprazole?

218
Q

What regular checks should be done on patients taking antipsychotics?

A
  • ECGs (QTC)
  • Glucose/lipid checks
  • Bloods - FBCs (especially clozapine)
219
Q

How can antipsychotics be taken?

A
  • Orally (tablet/liquid)
  • Intramuscularly (depot injection)
220
Q

What is a depot injection?

A

Slow-release IM form of medication - given every 2/3/4 weeks and contains a liquid that releases medication slowly

221
Q

What are anxiolytics?

A

Group of medications used to decrease emotional tension or anxiety

222
Q

What are sedative-hypnotics?

A

Group of medications used to induce drowsiness/sleep or to reduce psychological excitement/anxiety

223
Q

Describe the pathophysiology of anxiolytics and sedative-hypnotics

A

Act on the brain by increasing GABA effects which decreases brain activity and produces a relaxing effect

224
Q

Give some types of anxiolytics/sedative-hypnotics

A
  • Barbiturates
  • Benzodiazepines
  • Non-benzodiazepines (+Z drugs)
225
Q

Give some examples of barbiturates and what they are commonly used for

A
  • Phenobarbital, primidone
  • Insomnia/seizures/muscle spasms
226
Q

Give some examples of benzodiazepines and what they are commonly used for

A
  • Diazepam (longer acting), lorazepam (shorter acting), clonazepam, chlordiazepoxide hydrochloride, midazolam
  • Anxiety/mania/psychosis/alcohol withdrawal/insomnia/acute aggression/agitation/epilepsy
227
Q

What are side effects/contraindications of benzodiazepines?

A
  • Addictive if taken long term
  • Respiratory and CNS depressant effects (avoid in neurological and severe respiratory disease)
228
Q

Give some examples of non-benzodiazepines and what they are commonly used for

A
  • Melatonin, promethazine, zopiclone (Z drug), zolpidem (Z drug)
  • Insomnia
229
Q

What are side effects/contraindications of Z drugs?

A
  • Can become dependent/tolerant and lose effect
  • Caution in respiratory and neurological disease
230
Q

What are side effects of anxiolytics/sedative-hypnotics?

A
  • Staggering
  • Blurred vision
  • Impaired perception of time and space
  • Slowed reflexes and breathing
  • Reduced sensitivity to pain
  • Impaired thinking
  • Slurred speech
  • Anaemia
  • Depression
  • Impairment of liver function
231
Q

What is cognitive impairment?

A

Problems with cognitive functions e.g. thinking/reasoning/memory/attention

232
Q

What are clinical features of cognitive impairment?

A
  • Poor memory
  • Language problems
  • Problems with executive functioning
  • Disorientation
233
Q

What do cognitive assessments assess?

A
  • Attention and concentration
  • Recent and remote memory
  • Language
  • Praxis (planned motor movement)
  • Executive function
  • Visuospatial function
234
Q

Give some examples of cognitive assessments

A
  • Mini-cog
  • Abbreviated mental test score (AMTS)
  • Mini-mental state examination (MMSE)
  • Montreal cognitive assessment scale (MoCA)
  • Addenbrooke’s cognitive examination III (ACE-III)
235
Q

What is mild cognitive impairment?

A

Cognitive deficits in one or more of the major cognitive domains but the deficit is insufficient to interfere with independence in daily activities

236
Q

What can cause mild cognitive impairment?

A
  • Early sign of dementia
  • Sleep disorders
  • Side effects of medication (confusion/drowsiness)
  • Hypotension
  • Mental health problems
  • Infections
  • Excess alcohol consumption
237
Q

What is the difference between learning disabilities and learning difficulties?

A

Learning disability - condition which affects learning and intelligence across all areas of life

Learning difficulty - condition which creates an obstacle to a specific form of learning but does not affect the overall IQ of an individual

238
Q

What is the difference a hate crime and a mate crime?

A

Hate crime = abuse due to disability/race/gender/sexual orientation

Mate crime = abuse from a person who pretends to be a friend so that they can use/abuse them

239
Q

What are risk factors for learning disabilities?

A
  • Family history
  • Environmental factors (abuse/neglect/trauma/toxins)
  • Other mental health conditions
240
Q

What conditions have a strong association with learning disabilities?

A
  • Genetic disorders e.g. Down’s syndrome
  • Antenatal problems e.g. foetal alcohol syndrome
  • Problems at birth e.g. prematurity/hypoxic ischaemia
  • Problems in early childhood e.g. meningitis
  • Autism
  • Epilepsy
241
Q

What is dyslexia, dysgraphia and dyspraxia?

A

Dyslexia - difficulty in reading, writing and spelling

Dysgraphia - difficulty in writing

Dyspraxia - difficulty in physical coordination

242
Q

What is an auditory processing disorder?

A

Difficulty in processing auditory information

243
Q

What is a non-verbal learning disability?

A

Difficulty in processing non-verbal information e.g. body language/facial expressions

244
Q

How are learning disabilities classified?

A

Severity based on IQ:
- Mild = 55-70
- Moderate = 40-55
- Severe = 25-40
- Profound = <25

245
Q

What are the investigations for learning disabilities?

A
  • Psychometric testing by a clinical psychologist
  • Genetic tests e.g. karyotyping
246
Q

What is fragile X syndrome?

A

Genetic disorder characterised by an X chromosome that is abnormally susceptible to damage especially by folic acid deficiency - affected individuals tend to have limited intellectual functions

247
Q

Describe the epidemiology of fragile X syndrome

A

More common in males

248
Q

Describe the pathophysiology of fragile X syndrome

A
  • X-linked
  • Caused by a mutation in the FMR1 (fragile X mental retardation 1) gene
  • This gene codes for the fragile X mental retardation protein which plays a role in cognitive development in the brain
249
Q

What are clinical features of fragile X syndrome?

A
  • Delay in speech and language development
  • Intellectual disability
  • Long, narrow face
  • Large ears
  • Large testicles after puberty
  • Hypermobile joints
  • ADHD
  • Autism
  • Seizures
250
Q

What is Down Syndrome?

A

Genetic condition caused by trisomy 21 which causes characteristic dysmorphic features

251
Q

What are the biggest risk factors for Down syndrome?

A
  • Genetics
  • Older maternal age
252
Q

What are the clinical features of Down Syndrome?

A
  • Hypotonia
  • Brachycephaly (small head with a flat back)
  • Short neck
  • Short stature
  • Flattened nose/face
  • Prominent epicanthic folds
    ○ Folds of skin covering the medial portion of the eye/eyelid
  • Upward sloping palpebral fissures
    ○ Gaps between lower and upper eyelid
  • Single palmar crease
  • Intellectual disability
253
Q

Briefly describe the investigations for Down Syndrome

A
  • Antenatal screening
  • Antenatal testing
  • Non-invasive prenatal testing
254
Q

Describe antenatal screening for Down Syndrome

A
  • Measurements taking from fetus using ultrasound combined with mother’s age and blood result to calculate risk
  • Ultrasound measures nuchal translucency (thickness >6mm)
  • Bloods = high beta-HCG/inhibin-A, low PAPPA/AFP/serum oestriol
  • Combined test/triple test/quadruple test
255
Q

Describe antenatal testing for Down Syndrome

A
  • Done when screening risk score is greater than 1/150
  • Sample of foetal cells taken to undergo karyotyping
  • Chorionic villus sampling (ultrasound-guided biopsy of placental tissue)
  • Amniocentesis (ultrasound-guided aspiration of amniotic fluid)
256
Q

Describe non-invasive prenatal testing for Down Syndrome

A
  • Blood test from mother will contain fragments of DNA from placental tissue
  • DNA fragments analysed
257
Q

What routine checks do people with Down Syndrome require?

A
  • Thyroid
  • Echo
  • Audiometry
  • Eye checks
258
Q

What conditions are people with Down Syndrome more at risk of developing?

A
  • Recurrent otitis media
  • Eustachian tube abnormalities –> deafness
  • Visual problems (myopia/strabismus/cataracts)
  • Hypothyroidism
  • Cardiac defects (ASD/VSD/patent ductus arteriosus/tetralogy of Fallot)
  • Impaired spermatogenesis –> infertility
  • Polycythaemia
  • Increased risk of ALL/AML
  • Dementia
259
Q

What is brain damage?

A

Destruction/degeneration of brain cells which can cause cognitive, behavioural and physical disabilities

260
Q

What are causes of brain damage?

A

Traumatic:
- Blow/shaking/strong rotational injury to the head (concussion/contusion/shaken baby syndrome/etc.) due to falls/motor vehicle accidents/etc.

Acquired:
- Stroke/tumour/infections/hypoxic injury/etc. due to choking/drowning/drug overdose/infection/alcohol

261
Q

What are clinical features of brain damage?

A

Frontal lobe - difficulty concentrating/personality changes/impulsivity
Temporal lobe - affected memory/difficulty understanding spoken words/affected hearing
Parietal lobe - affected senses
Occipital lobe - loss of sight/visual disturbances
Brain stem - affected breathing/heart rate/sleep cycle

262
Q

What are the investigation for brain damage?

A
  • CT head
  • Bloods
  • Brain evaluations
263
Q

Describe the management for brain damage

A
  • Surgery if tumour/significant bleeding/foreign object
  • Occupational therapy
  • Physical therapy
  • Psychotherapy
  • Speech and language therapy
264
Q

Describe the requirements for a diagnosis of a depressive episode

A
  • Minimum duration of 2 weeks
  • At least 2 out of 3 core symptoms
  • At least 2 other additional symptoms
265
Q

How are depressive episodes classified?

A
  • Mild = >4 symptoms with most normal activities continued
  • Moderate = >5 symptoms with great difficulty in continuing normal activities
  • Severe = >7 symptoms (including all 3 core symptoms) and unable to continue normal activities
  • Severe with psychotic features = hallucinations/delusions/depressive stupor alongside depressive episode
266
Q

What is recurrent depressive disorder?

A

Multiple depressive episodes after first

267
Q

What is dysythmia?

A
  • Chronic low grade depression for >2 years
  • Does not meet the diagnostic criteria for major depression/depressive episode
268
Q

What is the management for dysthymia?

A
  • SSRI/TCA
  • CBT
269
Q

What is unipolar depression?

A

Patient’s mood varies between depressed and normal

270
Q

What are some causes of depression?

A
  • Hypothyroidism
  • Physical health problems/chronic disease
  • Medications e.g. beta blockers/isotretinoin (roaccutance)
  • Childbirth
271
Q

What are some differential diagnoses for depression?

A
  • Normal sadness
  • Schizophrenia
  • Alcohol/drug withdrawal
  • Bipolar affective disorder
  • Anxiety disorders
  • Vitamin B12 deficiency
272
Q

What are biological risk factors of depression?

A
  • Family history
  • Age (teenage-early 40s)
  • Female
  • Substance misuse
  • Physical health problems
273
Q

What are psychological risk factors of depression?

A
  • Childhood trauma
  • Traumatic life events
  • Low self esteem
  • Ongoing loss/failure to cope with loss
274
Q

What are social risk factors of depression?

A
  • Lack of social support
  • Poor socioeconomic status
  • Marital status (separated/divorce)
275
Q

What is the diagnostic criteria for depression?

A
  • Sx >2 weeks
  • Sx not secondary to alcohol/drugs/medication/bereavement
  • Patient experiencing at least 2 of 3 core sx plus 3 other additional sx
  • Sx impair daily function/cause significant distress
  • Sx present every day
276
Q

What are the 3 core symptoms of depression?

A
  • Depressed mood
  • Anhedonia (loss of interest)
  • Fatigue/anergia
277
Q

What are other main symptoms of depression?

A
  • Change in weight/appetite
  • Psychomotor agitation/retardation
  • Disturbed sleep
  • Loss of confidence/self-esteem
  • Feelings of excessive/inappropriate guilt
  • Inability to concentrate
  • Suicidal thoughts/acts
278
Q

What is Cotard’s syndrome?

A

Belief that parts of body are missing or that self is dying/dead/doesn’t exist - common delusional symptom seen in depression with psychotic symptoms

279
Q

How is depression severity graded?

A

ICD-10
- Must have at least 2 core sx + at least 2 others
- Mild = 4 sx
- Moderate = 5-6 sx
- severe = 7+ sx

280
Q

What are the investigations for depression?

A
  • Rule out differentials
  • History and MSE
  • PHQ-9 (Patient Health Questionnaire)
  • HADS (Hospital Anxiety and Depression Scale)
  • BDI-II (Becks Depression Inventory-2)
  • Bloods
  • Risk assessment
281
Q

What is the management for depression?

A
  • CBT
  • Antidepressants
  • Antipsychotics
  • Interpersonal therapy
282
Q

What is post-partum depression and what are the types?

A
  • Low mood in post-partum period (<6 months)
  • Baby blues (mild and short-term)
  • Post-natal depression
  • Puerperal psychosis (delusions/hallucinations/mania/etc. alongside depressive sx)
283
Q

What are risk factors for post-partum depression?

A
  • Family history of depression
  • Older age
  • Single mother/poor maternal relationship
  • Ambivalence to pregnancy
  • Poor social support
284
Q

What are the investigations for post-partum depression?

A
  • History and MSE
  • Edinburgh Postnatal Depression Scale (EPDS)
  • Sx last longer than 2 weeks in post-partum period
285
Q

What is the management for post-partum depression?

A
  • SSRI (paroxetine/sertraline - lowest levels present in breast milk)
  • CBT
286
Q

What is the management for puerperal psychosis?

A
  • Admit to mother and baby unit
  • CBT
  • Medications (antidepressants/antipsychotics/mood stabilisers)
  • ECT
287
Q

What are the clinical features of seasonal affective disorder?

A
  • Clear seasonal pattern to recurrent depressive episodes (sx fully remit once season over)
  • Usually January/February (winter depression)
  • Low self-esteem
  • Hypersomnia
  • Fatigue
  • Increased appetite/weight gain
  • Decreased social and occupational functioning
288
Q

What is the management for seasonal affective disorder?

A
  • Light therapy
  • SSRI
289
Q

Give some examples of neurological medical conditions associated with increased risk of depression

A
  • MS
  • Parkinson’s
  • Huntington’s
  • Spinal cord injury
  • Stroke
  • Head injury
  • Cerebral tumours
290
Q

Give some examples of endocrine medical conditions associated with increased risk of depression

A
  • Cushing’s disease
  • Addison’s disease
  • Thyroid disorders (especially hypothyroidism)
  • Parathyroid disorders
  • Menstrual cycle related
291
Q

Give some examples of infection-related medical conditions associated with increased risk of depression

A
  • Hepatitis
  • Infectious mononucleosis
  • Herpes simplex
  • Brucellosis
  • Typhoid
  • HIV/AIDS
  • Syphilis
292
Q

Give some examples of other medical conditions associated with increased risk of depression

A
  • Malignancies
  • Chronic pain states
  • SLE
  • RA
  • Renal failure
  • Porphyria
  • Vitamin deficiencies
  • IHD
293
Q

Give some examples of medications that can cause depressive symptoms

A
  • Beta blockers
  • Corticosteroids
  • Oral contraceptives
  • L-dopa
  • Carbamazepine
  • Opiates
  • Indometacin
  • Antipsychotics
  • Interferon
294
Q

What is psychosis?

A

Severe mental disturbance characterised by a loss of contact with external reality

295
Q

What are organic causes of psychosis?

A
  • Brain tumour
  • Cysts
  • Parkinson’s disease
  • Huntington’s disease
  • Brain injury
  • Severe systemic infection
296
Q

What are clinical features of psychosis?

A
  • Delusions
  • Hallucinations
  • Thought disorder
  • Abnormalities of behaviour
  • Lack of insight
297
Q

What are investigations for psychosis?

A
  • History and MSE
  • Collateral history
  • Bloods
  • Risk assessment
298
Q

What is the management for psychosis?

A
  • Antipsychotics
  • ECT
299
Q

Give some risk factors for schizophrenia

A
  • Family history
  • Pre-morbid schizoid personality (abnormal shyness/eccentricity/fanaticism)
  • Abuse
  • Delayed developmental milestones
  • Obstetric risk factors (LBW/prematre/hypoxia)
  • Substance abuse
  • Traumatic childhood/life events
  • Cerebral injury
  • Low IQ
300
Q

Give some types of schizophrenia

A
  • Paranoid (most common - paranoid delusions and auditory hallucinations)
  • Hebephrenic/disorganised (mood changes/shallow affect/disordered thought/chaotic behaviour)
  • Catatonic (psychomotor features e.g. posturing/rigidity/stupor)
  • Undifferentiated (sx do not fit into any category)
  • Residual (negative sx after positive sx have ‘burnt out’)
  • Simple (only negative sx)
301
Q

What are positive and negative symptoms in schizophrenia?

A

Positive = any change in behaviour or thoughts (e.g. hallucinations/delusions)

Negative = absence of normal behaviours related to motivation and interest or expression (e.g. anhedonia/blunted affect)

302
Q

What are Schneider’s first rank symptoms of schizophrenia?

A
  • Thought disorder
  • Delusional perceptions
  • Passivity phenomenon
  • Third person auditory hallucinations
303
Q

What are investigations for schizophrenia?

A
  • History and MSE
  • Exclude differential diagnoses
  • CT/MRI head
  • Toxicology screen
  • Bloods
304
Q

Give some differential diagnoses for schizophrenia

A
  • Psychotic depression
  • Schizoaffective disorder
  • Personality disorder
  • Bipolar disorder
  • Substance abuse
305
Q

What is the management for schizophrenia?

A
  • Antipsychotics
  • CBT
  • Family therapy
  • Lifestyle changes (exercise/drugs/alcohol/smoking/housing/employment)
  • ECT
  • Monitoring
306
Q

What is schizoaffective disorder?

A

Mood disorder and schizophrenia (psychotic episodes of schizophrenia combined with affect from bipolar)

307
Q

What are risk factors for schizoaffective disorder?

A
  • Family history of schizophrenia
  • Substance abuse
  • Psychological stress/environmental factors
308
Q

What are the types of schizoaffective disorder?

A
  • Manic (manic + psychotic sx)
  • Depressive (depressive + psychotic sx)
  • Mixed
309
Q

What are clinical features of schizoaffective disorder?

A
  • Schizophrenic symptoms e.g. delusions/hallucinations/thought disorder
  • Mood symptoms (depressive/manic)
310
Q

What is the management for schizoaffective disorder?

A
  • Antipsychotics
  • Anxiolytic/benzo (e.g. lorazepam)
  • CBT
  • Social intervention (housing/employment/exercise/education)
311
Q

What are clinical features of delusional disorders?

A
  • Delusions
  • Anger
  • Irritability
  • Depression
312
Q

What are common delusions?

A
  • Skin infestation
  • Illness/cancer
  • Being spied on/followed/poisoned
  • Infidelity
313
Q

What are risk factors for personality disorders?

A
  • Socioeconomic status
  • Family history
  • Poor parenting/deprivation
  • Attachment issues in childhood
  • Abuse/trauma/neglect
314
Q

What do personality disorders mainly affect?

A
  • Cognition
  • Affectivity
  • Interpersonal functioning
  • Impulse control
315
Q

What make a personality disorder a disorder?

A

When patients’ behaviour causes significant distress or impairment in social/occupational/other important areas of functioning

316
Q

What are the 3 main categories of personality disorder?

A
  • DSM-5 Cluster A - paranoid/schizoid/schizotypal
  • DSM-5 Cluster B - antisocial/borderline/emotionally unstable/histrionic/narcissistic
  • DSM-5 Cluster C - avoidant/dependent/obsessive compulsive
317
Q

Describe paranoid personality disorder

A

Difficulty in trusting or revealing personal information to others

318
Q

Describe schizoid personality disorder

A
  • Lack of interest/desire to form relationships with others
  • Emotionally cold/detached
  • Indifferent to praise/criticism
319
Q

Describe schizotypal personality disorder

A
  • Unusual beliefs/thoughts/behaviours
  • Social anxiety - makes forming relationships difficult
  • Inability to maintain friendships and lack of companionship
320
Q

Describe antisocial personality disorder

A
  • Callous lack of concern for others
  • Disregard to rules and responsibility
  • Irritability/aggression
  • Incapacity to maintain relationships
  • Evidence of childhood conduct disorder
321
Q

Describe borderline/emotionally unstable personality disorder

A
  • Fluctuating strong emotions
  • Difficulties with identity and maintaining healthy relationships
  • Impulsive/violent/poor response to criticism
  • Self-destructive behviours
  • Borderline = self-image/feelings of emptiness, self-harm/suicidal attempts
322
Q

Describe histrionic personality disorder

A
  • Need to be centre of attention
  • Having to perform for others to maintain attention
  • Manipulative behaviour
323
Q

Describe narcissistic personality disorder

A
  • Feeling that they are special and need others to recognise this or else they get upset (grandiosity)
  • Put themselves first
  • Lack of empathy
324
Q

Describe avoidant personality disorder

A
  • Severe anxiety about rejection or disapproval
    -Self-consciousness/insecure
    -Timid
  • Social inhibition/avoidance of social situations/relationships
325
Q

Describe dependent personality disorder

A
  • Heavy reliance on others to make decisions and take responsibility for their lives
  • Passive approach
  • Reassurance required
  • Lack of self-confidence
  • Abandonment fears
  • Companionship sought
326
Q

Describe obsessive compulsive personality disorder

A
  • Unrealistic expectations of how things should be done by themselves and others
  • Catastrophising about what will happen if these expectations are not met
327
Q

What are investigations for personality disorders?

A
  • History and MSE
  • PPDQ-IV (Personality Diagnostic Questionnaire)
  • Minnesota multiphasic personality inventory
  • MRI/CT head
  • Risk assessment
  • Diagnoses can typically only be made at 18 years old (earliest - personality doesn’t fully develop until 25)
328
Q

What is the management for personality disorders?

A
  • Treat sx
  • Dialectal behavioural therapy (DBT)
  • CBT/psychotherapy
  • Mentalisation-based therapy (MBT)
  • Antidepressants
  • Mood stabilisers/antipsychotics
329
Q

What are the main types of attachment styles in children?

A
  • Secure (carers are engaged appropriately)
  • Anxious ambivalent (carers are engaged but on own terms)
  • Anxious avoidant (carers do not engage/neglect)
  • Disorganised (carers are both source of comfort and fear to children - causes confusion)
330
Q

What is delirium?

A

Acute confusional state causing disturbed consciousness/attention/cognition/perception

331
Q

Give some causes of delirium

A
  • Neurological (brain injury/stroke/subdural haematoma)
  • Cardiovascular (HF/MI/AF)
  • Respiratory (aspiration/pneumonia/COPD)
  • GI (constipation/malnutrition/bleeding)
  • Urological (urinary retention/UTI)
  • Skin/joints (cellulitis/pressure sores)
  • Metabolic/endocrine (thyroid disease/hypo/hyper-glycaemia/natraemia)
  • Medications (antihistamines/TCAs/anticholinergics)
  • Other (alcohol/pain/sleep deprivation/change in environment/hearing impairment)
332
Q

What are risk factors for delirium?

A
  • Age >65
  • Co-morbidities
  • Frailty
  • Malnutrition
  • Sensory impairment (vision/hearing)
  • Functional impairment
  • Alcohol excess
  • Major injury (e.g. hip fracture)
  • Cognitive impairment (e.g. dementia)
333
Q

What are clinical features of delirium?

A
  • Acute onset
  • Fluctuating symptoms
  • Disturbance in awareness/attention
  • Disturbance in cognition
  • Evidence of organic cause
334
Q

What is the difference between dementia and delirium?

A

Dementia = slowly progressive changes with limited fluctuation. Attention is usually intact and very early memories may be preserved

Delirium = acute, transient and usually reversible changes. Often an associated acute illness

335
Q

What are investigations for delirium?

A
  • DSM-5 criteria
  • CAM (Confusion assessment method)
  • 4As test (alertness; age/DOB/place/year; attention; acute change or fluctuating course)
  • AMT (abbreviated mental test)
  • Observations
  • ECG
  • Sputum/urine/stool cultures
  • Bloods
  • CXR
  • CT head
  • Echo
336
Q

What is the management for delirium?

A
  • Determine and treat underlying precipitating cause(s)
  • Rapid tranquilisation (benzodiazepines e.g. lorazepam; antipsychotics e.g. haloperidol/olanzapine)
  • De-escalation methods
337
Q

What are the most common types of dementia?

A
  1. Alzheimer’s
  2. Vascular
  3. Dementia with Lewy-body
  4. Frontotemporal dementia (a.k.a Pick’s disease)
338
Q

Describe the pathophysiology of Alzheimer’s

A
  • Mostly affects temporal lobes
  • Senile plaques (deposits of beta-amyloid outside of neurons)
  • Neurofibrillary tangles (aggregation of hyperphosphorylated tau proteins inside neurons)
339
Q

Describe the pathophysiology of vascular dementia

A
  • Subcortical VD (disease affected small vessels of brain)
  • Stroke-related VD (following large cortical stroke)
  • Single/multi-infarct VD (following single/multiple small strokes)
340
Q

Describe the pathophysiology of dementia with Lewy-body

A

Histopathological findings of intracytoplasmic inclusions (Lewy bodies) that contain alpha-synuclein - essentially Parkinson’s

341
Q

Describe the pathophysiology of frontotemporal dementia

A
  • Tissue deposition of aggregated proteins (phosphorylated tau or transactive response DNA-binding protein 43)
  • Atrophy around frontal/temporal lobes
342
Q

What are general clinical features of dementia?

A
  • Slow onset sx
  • Lack of insight
  • Cognitive impairment
  • Behavioural and psychological sx
  • Decreased ability to carry out ADLs
343
Q

What are key clinical features of Alzheimer’s?

A
  • Early impairment of memory
  • Short-term memory loss/difficultly learning new information
344
Q

What are key clinical features of vascular dementia?

A
  • Stepwise decline in function
  • Gait/attention/personality changes
345
Q

What are key clinical features of Dementia with Lewy-body?

A
  • Parkinsonism sx (tremor/rigidity/bradykinesia/postural instability)
  • Falls/syncope/hallucinations
346
Q

What are key clinical features of frontotemporal dementia?

A
  • Personality changes and behavioural disturbances (disinhibition)
  • Memory and perception relatively preserved
347
Q

What is sundowning?

A

Increase in certain symptoms (e.g. distress/agitation/hallucinations/delusions) in dementia patients that often occur in the late afternoon/evening

348
Q

What are investigations for dementia?

A
  • Exclude alternative diagnoses
  • Cognitive assessments
  • Bloods
  • ECG
  • Virology
  • Syphilis testing
  • CXR
  • CT/MRI head
349
Q

What are some differential diagnoses for dementia?

A
  • Depression
  • Drugs with anticholinergic effects
  • Delirium
350
Q

What is the management for dementia?

A
  • Assess capacity
  • Inform DVLA
  • Cognitive stimulation therapy
  • Cognitive rehabilitation
  • Reminiscence work
  • Admiral nurses
  • Reduce risk factors (e.g. for VD) - stop smoking/exercise/statins/etc.
  • Medications
351
Q

What medications can be used for patients with dementia?

A

Mostly for Alzheimer’s:
- Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine
- N-methyl-D-aspartic acid receptor antagonists (NMDA) e.g. memantine (for memory loss)
- Antipsychotics

352
Q

What is the difference between ego syntonic and ego dystonic thoughts?

A

Ego syntonic = thoughts align with personal values/goals

Ego dystonic = thoughts inconsistent with beliefs, seen as unwanted/intrusive

353
Q

Describe anorexia nervosa

A
  • Patients feel they are overweight
  • Obsessively restrict calorie intake
  • Excessive exercise/diet pills/laxatives
  • Low BMI
  • Amenorrhoea
  • Lanugo hair
  • Bradycardia
  • Hypokalaemia
  • Hypotension
  • Hypothermia
  • ECG = hypokalaemia = flattened T waves/prolonged QT/ST depression/tall P waves
  • G&Cs raised = growth hormone/glucose/parotid glands/cortisol/cholesterol
  • CBT/family-based therapy
  • Observed refeeding (–> refeeding syndrome)
  • SSRI
354
Q

Describe bulimia nervosa

A
  • Normal body weight that fluctuates
  • Compulsive uncontrollable bingeing followed by compensatory behaviour (purging/fasting/excessive exercising)
  • Metabolic alkalosis (hypochloraemia)
  • Hypokalaemia
  • Teeth erosion/mouth ulcers
  • Swollen salivary glands
  • GORD
  • Russell’s sign = calluses on knuckles
  • ECG = hypokalaemia = flattened T waves/prolonged QT/ST depression/tall P waves
  • CBT/family-based therapy
  • SSRI

Phase 3a (21 decks)

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