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3A > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is ADHD?

A

It is characterised by 3 main symptoms of inattention, hyperactivity and impulsiveness

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2
Q

How is it defined by the DSM-IV and ICD-10 differently?

A
  • DSM-IV recognises 3 subtypes of ADD, combined when all 3 features are present and just a hyperactive subtype
  • ICD-10 definition is that symptoms should be present across time and situations for at least 6 months and starting before the age of 7

1% with ICD criteria and 5% with DSM-IV. It is 4 times more common in males

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3
Q

What are the risk factors for ADHD?

A
  • 80% are genetically inherited
  • Low birth weight
  • Drug, alcohol or tobacco use pregnancy
  • Head injury
  • Genetic/metabolic disorders
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4
Q

What are the clinical features of ADHD?

A

Inattention: Careless with detail, fails to sustain attention, appears not to listen, fails to finish tasks, poor self-organization, loses things,
forgetful, easily distracted, and avoids tasks requiring sustained attention.

  • Hyperactivity Most evident in structured situations, fidgets with hands or feet, leaves seat in class, runs/climbs about, cannot play quietly, ‘always on the go’.
  • Impulsiveness Talks excessively, blurts out answers, cannot await turn,
    interrupts others, intrudes on others.
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5
Q

What are some complications associated with ADHD?

A

Short term:
- Sleep
- Low self-esteem
- Family and peer relationship problems

Long term:
- Increased criminal activity
- Antisocial personality disorder
- Problems with getting jobs

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6
Q

What is ADHD assesed?

A
  • Interview with family and child
  • Observe the child in variety of environments
  • Collateral information from school
  • Rating scales
  • Physical examination
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7
Q

What are the rating scales for ADHD?

A
  • Strengths and difficulties questionnaire
  • Connor’s rating scale
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8
Q

What are the medications used to treat ADHD?

A
  • Methylphenidate: a CNS stimulant
  • Atomoxetine
  • Dexamphetamine:
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9
Q

What are some side effects of ADHD medication?

A

Headache, insomnia, loss of appetite, stomach ache, dry mouth, nausea

Can Can stunt growth
Need to Monitor weight, height and BP
Methylphenidate is Not recommended to take during pregnancy

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10
Q

What are the triad of symptoms that characterise autism?

A
  • Abnormal reciprocal social interaction
  • Communication and language impairment
  • Repetitive repertoire of interests and activities
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11
Q

What is the prevalence of autism?

A

5-10 per 1000 individuals

Ratio of 3:1 boys to girls

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12
Q

What are the clinical features of autism?

A
  • Abnormal social interactions: impaired non-verbal behaviour, poor eye contact, failure to develop peer relationships
  • Abnormal communication or play: delay or lack of spoken language, difficulty in initiating or sustaining conversation
  • Restricted interests or activities: Encompassing preoccupations and interests, adherence to non-functional routines or rituals, resistance to change
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13
Q

What are some neurological features of autism?

A
  • Seizures
  • Motor tics
  • Increase head circumference
  • Abnormal gaze monitoring
  • Increased ambidexterity
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14
Q

What are some physiological features of autism?

A
  • Intense sensory responsiveness
  • Absence of typical response to pain or injury
  • Abnormal temperature regulation
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15
Q

What are the rating scales for autism?

A
  • Autism behaviour checklist
  • Child autism rating scales
  • Autism diagnosis observation schedule
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16
Q

What is bipolar disorder?

A
  • Periods of depression and mania
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17
Q

What are the risk factors for bipolar disorder?

A

Genetic links and environmental stressors/triggers

  • Hypothalamic-pituitary-adrenal axis abnormalities which are consistent with reduced HPA axis feedback
  • Prolonged psychosocial stressors during childhood, such as neglect or abuse, are associated with HPA axis dysfunction in later life
  • People with a history of sexual abuse or physical abuse appear to be more at risk and have a worse prognosis
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18
Q

What is a key question to ask someone presenting with depression?

A

Whether they have had manic or hypomanic episodes because treating bipolar as depression will cause the patient to become high

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19
Q

What is needed for a diagnosis of bipolar?

A
  • Single episode of mania= Manic episode
  • Two manic episodes= Bipolar disorder
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20
Q

What is the definition of a manic episode?

A

A distinct period lasting at least one week with 3 or more characteristic symptoms of mania:

  • Elevated mood
  • Increased energy
  • Increased self-esteem
  • Reduced attention
  • Grandiose, overconfident, marked social/sexual disinhibited, reckless
  • Severe impact on social functioning / poor or absent insight
  • Could also have features of psychosis
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21
Q

What is hypomania?

A

Elated, overactive, social/sexual disinhibition, overspending, poor sleep

Continues to function

Partial insight retained

NO psychotic symptoms

Tend to last about 4 days

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22
Q

What is the management of acute mania?

A
  • Atypical antipsychotics (Olanzapine/quetiapine)
  • Semi-sodium valproate
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23
Q

What is used for long term mood stabilisation?

A
  • Lithium
  • Valproate
  • Carbamazepine
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24
Q

What are the different types of bipolar?

A

Bipolar 1 - mania & depression, sometimes more episodes of mania
Bipolar 2 - more episodes of depression and only mild hypomania (easy to miss, always ask Sx of mania in person presenting with depression)

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25
Q

What is cyclothymia?

A

Cyclothymia - chronic mood fluctuations over 2+ yrs, episodes of depression and hypomania (not mania). Rapid cycling, episodes only lasting few days

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26
Q

What are some differentials that you need to rule out in bipolar disorder?

A

Substance abuse (amphetamines, cocaine)
Endocrine disease - Cushing’s, steroid-induced psychosis
Schizophrenia
Schizoaffective disorder - Dx when affective and first rank schizophrenic Sx equally prominent
Personality disorders - emotionally unstable, histrionic
ADHD in younger people

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27
Q

What is the treatment of bipolar, for a depressive episode?

A

– For depression –> Treat with antipsychotics alone or in combination with SSRI’s

– 1st line is Olanzapine, Lamotrigine or Quetiapine and Fluoxetine

– Do not just prescribe SSRIs by themselves as they can precipitate mania

If a patient is taking an antidepressant at the onset of an acute manic episode, the antidepressant should be stopped.

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28
Q

What are some of the side effects of lithium?

A

L- Leukocytosis
I- Insipidus diabetes (nephrogenic)
T- tremors (if coarse think toxicity)
H- Hydration ( easily dehydrates, need to drink lots
I- increased GI motility
U- Underactive thyroid
M- metallic taste (warning of toxicity), mums beware- teratogenic

lithium and diuretics= dehydration

Lithium + NSAIDs= kidney damage

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29
Q

What are some risk factors for depression?

A

Prior depression
Family history
Female
Abuse
Drug and alcohol use
Low socioeconomic status
Recent bereavement, stress or medical illness, traumatic life event
Co-existing medical conditions (chronic disease)

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30
Q

What are the 3 key symptoms of depression?

A

Low mood
Loss of energy
Anhedonia (loss of enjoyment of formerly pleasurable activities)

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31
Q

What are some things you may find on consultation/examination/investigations for depression?

A

Carry out mental state examination
- Appearance may be normal, or evidence of self beglect. substnace abuse, tearfulllness, anxious, fidegty

Speach may be monotonic and slow - patient may appear distracted

Psychotic features - eg auditory hallucinations, loss of insight

Baseline tests for FBC and TFT may be useful for ruling out anaemia and hypothyroidism, that can lead to depression

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32
Q

What is the name of the questionnaire used in depression?

A

The Patient Health Questionnaire-9 (scored out of 27) is used to grade depression

– It asks patients to report over the last 2 weeks how often they have been experiencing symptoms

– Made of 9 items which is scored from 0-3

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33
Q

What are the scores for the PHQ-9?

A

– Mild = 5-9 – Moderate = 10-14 – Moderate/Severe = 15-19 – Severe = >19

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34
Q

What is the treatment for moderate/severe depression?

A

Moderate/severe depression
* Antidepressants (SSRIs, TCAs) - continued for 6+ mths after Sx stop
* Combination therapy e.g. meds + talking therapy

SSRI - Selective serotonin reuptake inhibitors eg Sertraline, paroxetine, fluoxetine, citalopram
Fluoxetine 1L in children

TCAs (Tricyclic antidepressants):
Imipramine, amitriptyline

SNRIs (Serotonin-noradrenaline reuptake inhibitors):
Venlafaxine, duloxetine, Mirtazapine

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35
Q

What is some treatment for very severe depression

A

Resistant depression Tx w/ combo of antidepressants +
Lithium
Atypical antipsychotic
Another antidepressant

ECT very effective in severe cases (Electroconvulsive Therapy)

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36
Q

What are some conditions you would want to which have similar symptoms to GAD?

A

Depression and OCD

Hyperthyroidism
Pheochromocytoma
Lung disease- excessive salbutamol use
CHF medication
Hypoglycaemia
Do bloods and BP

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37
Q

What are some risk factors/causes of developing GAD?

A

Family Hx anxiety
Physical/emotional stress
Financial, bereavement etc
Hx physical/sexual/emotional trauma (in childhood)
Excessively pushy parents in childhood
Other anxiety disorder - coexisting depression
Chronic physical health condition
Worries about physical health
Female 2:1 Male

Environmental triggers/contributors: family relationships, friendships, bullies, school pressures, alcohol and drug use e.g. benzodiazepines

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38
Q

What is the neuropathology of GAD?

A

Low levels of GABA, contribute to anxiety. The frontal cortex and amygdala undergo structural remodelling due to maternal separation and isolation

  • Heightened amygdala activation occurs in response to disorder-relevant stimuli in post-traumatic stress disorder, social phobia and specific phobia

Basically overfiring/activation of the amygdala

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39
Q

What is the non pharmalogical management of GAD?

A

Mild anxiety can be managed with watchful waiting and advice about self-help strategies (e.g. meditation), diet, exercise and avoiding alcohol, caffeine and drugs.

Moderate to severe anxiety can be referred to CAMHS services to initiate:

Counselling
CBT

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40
Q

What is the pharmacological management of GAD?

A

SSRI (sertraline is first-line SSRI)
– Be careful in young people as the SSRI increases anxiety initially and can lead to suicidal thoughts
Pre-gabalin

– If acutely anxious –> Benzodiazepine (but not for > 4 weeks)

Beta blockers e.g. bisoprolol for physical Sx

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41
Q

What is meant by obsessions and give some examples?

A

Obsessions= unwanted/uncontrolled thoughts and intrusive images

Aggressive impulses
contamination e.g. – becoming contaminated by shaking hands with another person
need for order e.g. – intense distress when objects are disordered or asymmetric
religious e.g. – blasphemous thoughts, concerns about unknowingly sinning
repeated doubts e.g. – wonder if a door was left unlock

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42
Q

What is meant by compulsions in OCD?

A

Repetitive actions someone feels like they must do, generates anxiety if this action is not done

checking e .g. – repeatedly checking locks, alarms, appliances
cleaning e.g. – hand washing
hoarding e.g. – saving trash or unnecessary items

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43
Q

What are some risk factors for OCD?

A

Genetic predisposition (twins, especially monozygotic)

Developmental factors
Emotional/physical/sexual abuse
Neglect
Social isolation
Teasing, bullying
Parental over protection

Psychological factors
Over-inflated sense of responsibility
Intolerance of uncertainty
Belief in controllability of intrusive
Stressors
Pregnancy
Postnatal period
Rarely
In adults: neurological conditions e.g. brain tumour, Huntington’s chorea, frontotemporal dementia, complication of brain injury to frontal lobe/basal skull

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44
Q

What is the pharmacological treatment of OCD?

A

or drug therapy (SSRI, e.g. fluoxetine 20–40mg od)
* Severe functional impairment Offer psychological therapy + drug treatment.

If inadequate response at 12wk, offer a different SSRI or
clomipramine (a TCA that also acts as a serotonin reuptake inhibtior).

Refer if symptoms persist

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45
Q

What are the 3 types of phobias?

A

Simple phobias: inappropriate anxiety

Social phobias: intense/persistent fear of being scrutinized or negatively evaluated by others leads to fear and avoidance of social situations

Agoraphobia: fear of fainting and/or loss of control are experienced in crowds away from home

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46
Q

What is the treatment for phobias?

A

For simple phobias - Treatment is only needed if symptoms are frequent, intrusive, or prevent necessary activities. Exposure therapy is effective.

For social and agoraphobia -
drug therapy SSRIs, and TCAs eg Clomipramine
Psychological therapies CBT (cognitive restructuring) +/- exposure

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47
Q

What is PTSD?

A

Develop (immediately/delayed) post exposure to stressful event/threatening, catastrophic situation

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48
Q

What are the common causes of PTSD?

A

Serious accident
Witness of violence: school, domestic, torture, terrorist attack and rape
Combat exposure
Natural disaster
Sudden death of a loved one

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49
Q

What are the clinical features of PTSD?

A

Symptoms: must be present for at least a month

  • Persistent intrusive thoughts and re-experiencing
  • Autonomic hyperarousal: overaction to a stimulus such as being startled, hypervigilance or insomnia
  • Emotional detachment- feeling detached from people and lacking the ability to experience feelings
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50
Q

What are some non-pharmalogical managements for PTSD?

A

CBT- education about nature of PTSD and management of symptoms

Eye movement desensitisation and reprocessing (EDMR): using voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts

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51
Q

What are the pharmalogical treatments of PTSD?

A

SSRIs

It may be helpful to target specific symptoms such as sleep being improved with mirtazapine

For Hyperarousal/anxiety: consider BDZs clonazepam and propranolol

  • Intrusive thoughts/hostility/impulsiveness: some evidence for use of carbamazepine, valproate, or lithium.
  • Psychotic symptoms/severe aggression or agitation: may warrant use of an antipsychotic (some evidence for olanzapine, risperidone etc)
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52
Q

What are some primary causes of insomnia?

A

Fear/anxiety about falling asleep
Change of environment
Inadequate sleep hygiene
Idiopathic insomnia

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53
Q

What are some secondary causes of insomnia?

A

Sleep related breathing disorder e.g. sleep apnoea
Circadian rhythm disorders
Shift work

REM behavioural disorder e.g. Lewy body dementia, PD

Psychiatric disorders - depression (early morning waking), anxiety (early/middle insomnia)

Drugs/alcohol - steroids, antidepressants, stimulants

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54
Q

What are some nonpharmacological management options for insomnia?

A

Encourage good sleep hygiene

Sleep restriction

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55
Q

What are some pharmalogical management options for insomnia?

A

Medication (once good sleep hygiene proved unsuccessful)

Z drugs: Zopiclone, Zolpidem, Zaleplon

Sedating antidepressants: mirtazapine, amitriptyline

Melatonin

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56
Q

What is paraphrenia?

A

Psychotic illness characterised by delusions and hallucinations, without changes in affect

It’s the most common form of psychosis in old age

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57
Q

What are some things you might see in paraphrenia?

A

*no evidence of dementia w/ later onset cases - no memory problems

Delusions, hallucinations - often about neighbours
Paranoid - often re. neighbours spying, taking things
can also be misidentification, hypochondraical, religious
Partition delusion - believe people/objects can go through walls
Less -ve Sx (blunting/apathy) and formal thought disorder compared to early onset

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58
Q

What is the treatment steps in paraphrenia?

A

Relieve isolation and sensory deficits.
Low-dose atypical antipsychotics preferred as elderly are very sensitive
to side-effects, but non-compliance secondary to lack of insight is often
an issue.

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59
Q

What is seen in cognitive impairment?

A

Minor problems with cognition- mental abilities: memory, thinking

Not severe enough to interfere with everyday life

Mild cognitive impairment= pre-dementia

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60
Q

What are some causes of cognitive decline?

A

Depression
Sleep apnoea and other sleep disorders
Physical illness
Vitamin and thyroid deficiencies
Medications
Drugs and alcohol

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61
Q

What are some causes of delirium?

A
  • Infection- UTI, pneumonia
  • Toxicity- substance misuse, intoxication, withdrawal
  • Vascular
  • Epileptic
  • Metabolic - hyper/othyroidism, hyper/oglycaemia, hypoxia, hypercortisolaemia
  • Medications - anticholinergics, Parkinson’s meds, benzodiazepines, drug accumulation, polypharmacy, post surgery, steroids
  • Nutritional/dehydration - thiamine B1 deficiency, B12 deficiency, folate deficiency
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62
Q

What health conditions can cause delirium and can be differentiated from schizophrenia?

A

Bipolar disorder – often may present with symptoms of schizophrenia
Psychotic Depression
Alcohol hallucinations, due to withdrawal
Drugs - especially Cannabis, Cocaine, LSD, magic Mushrooms (Psilocybin)
Dopamine Agonists, like Levo Dopa in Parkinsons

Encephalitis
Epilepsy’s
Dementia

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63
Q

What are the 4 main things seen in schizophrenia?

A

A form of psychosis is characterised by distortion to thinking and perception and inappropriate or blunted affect

See hallucinations and delusions, thought and speech disorders and negative symptoms

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64
Q

What are hallucinations?

A

Perceptions in the absence of stimuli. Most commonly auditory but may be visual or affect smell, taste or tactile senses

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65
Q

What are delusions?

A

A fixed or false belief no in keeping with cultural and educational background

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66
Q

What is thought to cause schizophrenia?

A

Increased size of ventricles and reduced whole brain volume

There is an increased activity of dopamine in the mesolimbic region

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67
Q

What are some risk factors for developing schizophrenia?

A
  • Genetic link
  • Affected brain development in early ;life
  • Smoking cannabis in adolescence
  • Severe childhood bullying/physical abuse
  • Adverse life events
  • Social isolation
  • Typical age onset 20-30s
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68
Q

What are the positive (psychotic) symptoms of schizophrenia ?

A
  • Delusions
  • Hallucinations
  • Disorganised speech
  • Disorganised behaviour
  • Cationic behaviour

They are all things that add to someone’s character

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69
Q

What are the negative symptoms of schizophrenia (removal of normal processes)?

A
  • Less emotions
  • Loss of interest
  • Poverty/decreased speech
  • Less motivation
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70
Q

What are the cognitive symptoms of schizophernia?

A
  • Decline in cognition
  • Decline in memory
  • Bad learning
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71
Q

How can schizophrenia be diagnosed?

A

At least ** 1 first rank symptom** or 2 second rank symptoms

FOR AT LEAST A MONTH

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72
Q

What are the first rank symptoms of schizophrenia?

A
  • Delusional perceptions- Do you ever see or hear things that you feel are giving a message that is specific to you
  • Persecutory of delusions: do you have any enemies/ do you feel anyone is out to get to you
  • Thought insertion/withdrawal/broadcast- are your thoughts being interfered with or controlled
  • Passitivity: can another person control what you do/feel directly
  • Third-person auditory hallucinations: do you hear people talking whom others can’t hear
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73
Q

What are the second rank symptoms of schizophrenia?

A

Formal thought disorder (words come out wrong, thoughts muddled)
Catatonic behaviour - excitement, posturing or waxy flexibility, negativism, mutism and stupor.
Negative symptoms - marked apathy, paucity of speech, and blunting or incongruity of emotional responses (it must be clear that these are not due to depression or to neuroleptic medication).
Any other type of hallucination, not third person auditory

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74
Q

What are some tests you would do on someone with suspected schizophrenia?

A

Bloods for organic causes of psychosis
FBC
LFT
TFT
Syphilis screen
Bloodborne virus screen

Autoimmune causes -anti–NMDA receptor antibodies for autoimmune encephalitis,ANA, anti-DS DNA for Lupus

Collateral Hx from someone else

Blood, hair or urinary screens may be used for illicit drugs and alcohol, particularly in those presenting with acute psychosis of unknown cause.
MSE, risk assessment

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75
Q

What are some atypical anti psychotics and how do they work?

A

They work by blocking dopamine and serotonin

Quetiapine
Olanzapine
Risperidone
Clozapine
Aripiprazole

They are first lone other than clozapine

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76
Q

What are some typical anti-psychotics and how do they work?

A

They work by dopamine blockade of D2 receptors:
- Haloperidol
- Chlorpromazine

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77
Q

When should you trial clozapine as an antipsychotic?

A

If 2 others have not been effective.

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78
Q

Why is clozapine not used as a first-line treatment?

A

It requires close monitoring as it has a tendency to cause aplastic anaemia

CPMS – Clozepine monitoring system. A national service in the UK, that gives advice on the drug dosage to use, depeninding on the blood test results you send to them. Compulsory for anyone on clozepine. Only consultant psychiatrists can prescribe clozapine

Check for agranulocytosis

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79
Q

What checks need to be done regularly for people on antipsychotics?

A

ECG- as QTC prolongation can occur

Glucose and lipids- antipsychotics can lead to diabetes and metabolic syndrome

If on CLOZAPINE: regular FBCs to check for AGRANULOCYTOSIS

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80
Q

What are some other side effects of antipsychotics?

A
  • Urinary retention
  • Blurred vision
  • Dry mouth
  • Weight gain
  • Hyperprolactinaemia (due to dopamine blockade and dopamine down regulates prolactin)
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81
Q

What are the extra-pyramidal side effects of antipsychotics?

A

Muscle spasm, eyes rolling back

Parkinsonism

Akathisia- “inner restlessness, pacing and agitated, often intolerable. They literally can’t stop moving e.g. shaking legs, touching table
Massive RF for suicide in young males with schizophrenia

Tardive dyskinesia (months to years)
Grimacing, tounge protrusion, lipsmacking
Very difficult/impossible to treat as you’ve upregulated all the D2 receptors
These side effects are worse and more common in the older antipsychotics

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82
Q

What is the treatment for the side effects of the antipsychotics?

A

Procyclidine an anticholinergic drug

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83
Q

What are some non pharmacological treatments of schizophrenia?

A

Individual CBT: normally consists of at least 16 one-on-one sessions. It helps patients create links between their thoughts, feelings and actions with their experience of schizophrenia.

Family intervention: should include the patient suffering from schizophrenia if possible as well as their main carer. Normally consists of 10 sessions over 3 months - 1 year.

Art therapies can be particularly helpful for negative symptoms.
Self-help groups and forums (e.g. Hearing Voices groups) enable people with psychosis to share experiences and ways to cope with symptoms

This should be done alongside antipsychotic medications

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84
Q

What is somatisation disorder?

A

Characterised by at least 2 years of physical symptoms with no physical explanation

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85
Q

What are some causes/risk factors for somatisation disorder?

A

More common in women
Hx of sexual or physical abuse
Adverse childhood events
Hx trauma related disorders

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86
Q

What are the most common symptoms in somatisation disorder?

A

Speech disturbance
Swallowing disturbance
Distractible

Often GI/skin complaints
Cognitive complaints - forgetfulness, short term memory problems
Refusing to believe no organic cause

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87
Q

What is seen in conversion disorder?

A

Physical signs

Would prevent with neurological signs rather than symptoms

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88
Q

What are some signs seen in conversion disorder?

A

Paralysis
Loss of speech
Sensory loss
Seizures
Amnesia

The examinations and findings will be inconsistent

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89
Q

What is the difference between somatisation and conversion disorder?

A

-Dissociative disorders differ from somatisation in that they more often present with signs rather than only symptoms and are often acute in their presentation.

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90
Q

What is hypochondrial disorder?

A
  • Where patients believe they have a serious underlying disease
  • There are no physical signs or symptoms of the disease
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91
Q

Who is hypochondrial disorder most common in?

A
  • It’s more common in men and people who have more contact with disease
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92
Q

What is hypochondria also associated with?

A

Dysmorphophobia

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93
Q

What is dysmorphophobia?

A

It is an excessive preoccupation with imagined or barely noticeable defects in physical appearance. For example, patients may
become preoccupied by the size of their nose, believing an objectively normal nose to be ugly and deformed

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94
Q

What is the management of hypochondria?

A

Allow patient time to ventilate their illness anxiet-ies. Clarify that symptoms with no structural basis are real and severe.

Explain negative tests and resist the temptation to be drawn into further exploration

Uncontrolled trials demonstrate antidepressant
benefit, even in the absence of depressive symptoms. Try fluoxetine 20mg, and CBT

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95
Q

What are dissociative disorders?

A

This is a group of conditions that involve disruptions or breakdowns in memory, identity or perception

  • In these disorders, psychiatric symptoms occur in the absence of pathology
  • More painful memories are cut-off from conscious self and instead converted into more bearable ones. It is seen as a way to cope with previous emotional trauma
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96
Q

What are some different types of dissociative disorders?

A
  • Dissociative amnesia- A patient has no recollection of upsetting and personal information
  • Dissociative fugue- A form of dissociative amnesia in which the patient flees away from their home. They will have no idea of actual self
  • Dissociative identity disorder- It is a condition where the patient develops multiple personalities which can take over
    – It is strongly linked to early childhood trauma e.g. sexual abuse
    – Patient has amnesia for when the different personalities take over, but maybe aware of their existence
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97
Q

What is the management of dissociative disorder?

A
  • Involves checking if there is an organic cause
  • Psychotherapy (e.g. hypnosis) is the main line to explore trauma and recall true identity
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98
Q

What is cortards syndrome?

A

Holds the delusional belief that they are dead and do not exist

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99
Q

What is Charles-Bonnet syndrome syndrome?

A

Complex visual hallucinations with partial or severe blindness

Patients understand that the hallucinations are not really and often have insight compared to other disorders

For those experiencing CBS, knowing that they have this syndrome and not a mental illness seems to be the most comforting treatment so far, as it improves their ability to cope with the hallucinations.

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100
Q

What is Munchausen?

A

A condition where patients will produce physical or psychological symptoms to attain a patients role

  • Patients can feign the symptoms, exaggerate them or deliberately hurt themselves to produce symptoms
  • Typically, patients take hallucinogens, inject faeces to make abscesses and contaminate urine samples
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101
Q

What is malingering?

A

This is when a patient feigns or exaggerates their symptoms purely for a financial rewards

  • Unlike Munchhausen syndrome, it is not to play a patient’s role but to receive compensation, personal damages or get off work

– It is not a medical diagnosis, but can lead to a large economic burden on health care systems

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102
Q

What is erotomania?

A

Belief that another person (famous/important) is in love with them

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103
Q

What is a grandiose delusion?

A

overinflated sense self worth, power, identity, believe have talent/made important discovery

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104
Q

What are some other types of delusion?

A

Jealous - spouse/sexual partner unfaithful without any concrete evidence
Persecutory - believe someone/something is mistreating/spying on/attempting to harm them, may repeatedly contact legal authorities
Somatic - physical issue/medical problem e.g. parasite, bad odour

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105
Q

What is the definition of personality?

A

The characteristics and relatively permanent sets of behaviours, cognitions, and emotional patterns that evolve from biological and environmental factors

106
Q

What is personality disoder?

A

Deeply ingrained, repetitive patterns of behaviour abnormal in a particular culture

  • Increase distress and risk to self and others
  • Decrease function typically apparent by adolescence, causes long-term difficulties in personal relationships
107
Q

What are the 3 clusters of personality disorders?

A

Split into cluster A,B,C mad, bad and sad

108
Q

What are the cluster A personality disorders?

A

Paranoid: Characterized by pervasive distrust and suspicion of others, interpreting motives as malevolent, without sufficient basis.

Schizoid Personality Disorder: Involves detachment from social relationships and a restricted range of emotional expression.

Schizotypal Personality Disorder: Features odd beliefs, magical thinking, perceptual distortions, and eccentric behaviour, often leading to social isolation.

109
Q

What are the cluster B personality disorders?

A

Borderline Personality Disorder/ EUPD (BPD): Characterized by instability in mood, self-image, and interpersonal relationships, often accompanied by impulsivity and intense fear of abandonment.

Antisocial Personality Disorder (ASPD): Involves a pervasive pattern of disregard for and violation of the rights of others, along with a lack of empathy and remorse.

Narcissistic Personality Disorder (NPD): Marked by a grandiose sense of self-importance, a need for admiration, and a lack of empathy for others.

Histrionic Personality Disorder: Features excessive emotionality and attention-seeking behaviour, often characterized by dramatic expression, shallow relationships, and a desire to be the centre of attention.

110
Q

What are the cluster C personality disorders?

A

Avoidant Personality Disorder (AVPD): People with AVPD tend to be extremely sensitive to rejection and have a pervasive feeling of inadequacy. They avoid social interactions and relationships due to fear of criticism or disapproval.

Dependent Personality Disorder (DPD): Individuals with DPD have an excessive need to be taken care of, leading to submissive and clinging behaviour. They have difficulty making decisions without reassurance and support from others and fear being alone.

Obsessive-Compulsive Personality Disorder (OCPD): This disorder involves a preoccupation with orderliness, perfectionism, and control. People with OCPD may be overly focused on rules and details, leading to rigid and inflexible behaviour. They often have difficulty delegating tasks and may be seen as stubborn or controlling

111
Q

What are some features of paranoid personality disorder?

A
  • Tendency to interpret the actions of others as demeaning or threatening
  • Thinks the world is a conspiracy
  • Thinks people are devious
  • Reacts severely if they feel like they have been lied to
  • Holds grudges
112
Q

Describe some features of schizoid personality disorder?

A
  • Has an indifference to relationships and a restricted range of emotional experience
  • Often described as aloof
  • Thinks world is uncaring
  • Thinks people are pointless and should depend on themselves
  • Withdrawal and less likely to be emotionally available

SchizoiD - = Distant

113
Q

What are some features of schizotypal personality disorder?

A
  • Pervasive pattern of deficits in interpersonal relatedness and peculiarities of ideation, experience, appearance and behaviour
  • Strong desire to have relationships but unable to maintain them due to poor at gauging other perceptions of them
  • Overconfidence, self-centred speech and socially inappropriate
  • Magical thinking

SchizoTypical -

magical thinking

114
Q

What are some similarities and differences between cluster A personality disorders and schizophrenia?

A

Similarities - can have paranoia, and will experience the negative symptoms - of flat affect, and blunted emotions

indeed, maybe a genetic link between the two? ask about FH of one in relatives when taking a history for the other*

Differences - Paranoia is more intense in schizophrenia, and in schizophrenia, you have delusions, as well as positive symptoms like hallucinations and racing thoughts

115
Q

What are some of the features of BPD/EUPD?

A

Pervasive pattern of instability of mood, interpersonal relationships and self-image

  • Emotionally unstable, intense joy to rage very quickly
  • Self-damaging impulsivity (spending, sex, substance abuse, reckless driving, binge eating)
  • People are untrustworthy
  • Shame
  • Self-harm
  • Terrified of abandonment - might do extreme things to keep from leaving
  • Least likely to be – able to show self-compassion
  • Own self-image is unclear don’t really know what you are, poor relationships with others
116
Q

What are some of the features of antisocial personality disorder?

A
  • Gross irresponsibility
  • Incapable to maintaining relationships
  • Irritability
  • Disregard for moral values
  • Manipulative
  • Often charming
  • Low threshold for frustration and aggression
  • Incapacity for experiencing guilt
  • Deceitfulness
  • Disregard for personal safety

Have to be over 18 to get the diagnosis of this, with a history of conduct disorder

Overrepresented in the prison population

  • Will make friends but won’t keep them
117
Q

What are some features of histrionic personality disorder?

A

Definition = pervasive pattern of excessive emotionality and attention seeking
Thinks the world is – their audience
Thinks people are – in competition for attention
Thinks they are vivacious (attractively lively and animated)
Commonest behaviour – exhibitionism
Least likely to be – able to listen to others

Few meaningful relationships, v superficial

118
Q

What are some features of narcissistic personality disorder?

A

Pervasive pattern of grandiosity, lack of empathy and hypersensitivity to the evaluation of others

  • Thinks the world is a competition
  • Thinks people are inferior
  • Thinks they are special
  • Commonest behaviour- competitiveness
119
Q

What are the features of anankastic/obsessive compulsive personality disorder?

A

Pervasive pattern of perfectionism and inflexibility

  • Excessive doubt, caution, rigidity and stubbornness
  • Preoccupation with details, rules lists order
  • Perfectionism interfering with task completion
  • Excessive conscientiousness
  • Preoccupation with productivity to the exclusion of pleasure and interpersonal relationships

In OCD is ego Dystonic - aka the person wishes they could stop their habits

OCPD is Ego syntonic - they are happy w how they are, and they don’t feel a need to change

120
Q

What are some of the features of avoidant personality disorder?

A
  • Pattern of social discomfort, fear of negative evaluation and timidity
121
Q

How old do you have to be to be diagnosed with a personality disorder?

A

18

122
Q

What are some other criteria and symptoms of Personality disorder?

A
  • Can’t have any other diagnosis
  • Long lasting and is there in every context
  • Appears in childhood and adolescent
  • Ask question about bullying at school
123
Q

What are some examples of SSRIs?

A

Sertraline
Citalopram
Fluoxetine

124
Q

What is the treatment for personality disoder?

A

DBT-dialectal behavioural therapy

125
Q

What are some side effects of SSRIs?

A
  • Nausea
  • Sexual dysfunction
  • Weight gain
  • Suicidal thoughts in younger people
  • Serotonin syndrome
126
Q

What are some drugs that SSRIs interact with and you would need to cover with a PPI?

A

NSAIDs
Aspirin
Heparin

Fluoxetine and paroxetine have higher rates of interactions

127
Q

What are some drugs that can cause serotonin syndrome in people with SSRIs?

A
  • Linezolid
  • Monoamine oxidase inhibitors
  • Lithium
  • MDMA
  • Tramadol
  • St. John’s wort
  • TCAs
  • SNRIs
128
Q

Give some roles of serotonin in the brain?

A

CNS
Modulates thermoregulation, behaviour and attention

PNS
Regulates GI motility, Vasoconstriction, bronchoconstriction and uterine contraction

Other
Promotes platelet aggregation (combined use with antiplatelet can increase bleeding risk

129
Q

What is serotonin syndrome?

A

A group of symptoms that may occur with the use of certain serotonergic drugs

A diagnosis is made based off a person’s symptoms and medication use

130
Q

What should be ruled out in serotonin syndrome?

A

Meningitis

131
Q

What are the symptoms of serotonin syndrome?

A

Triad of abnormalities

Cognitive affects: Headache, agitation, mental confusion, hallucinations, coma

Autonomic effects: Shivering, sweating, hyperthermia, vasoconstriction, tachycardia, diarrhoea

Neuromuscular hyperactivity: Muscle twitching, hyperreflexia, tremor

132
Q

What is the treatment for serotonin syndrome?

A

IV fluids, cooling measures
Benzodiazepines
Consider cyproheptadine (serotonin antagonist if symptoms persist)

133
Q

What are some SNRIs

A

Venlafaxine
Duloxetine

134
Q

How do SNRIs work?

A

Lead to the increased concentration of norepinephrine in the synaptic cleft

At low doses, they act like an SSRI - noradrenaline changes don’t occur much at low doses

135
Q

What are some of the side effects of SNRIs?

A

Raise BP
Sweating
Dose-dependant hypertension

136
Q

What are some examples of tricyclic antidepressants?

A

Amitriptyline
Imipramine
Clomipramine
Dosulepin

High dose for depression, lower dose used for pain

137
Q

How do tricyclic antidepressants work?

A

The inhibit the uptake of monoamines at the presynaptic membrane

This increases serotonin and noradrenaline

Decreases acetylcholine, histamine, sodium and calcium

138
Q

What are some side effects of tricyclic antidepressants?

A

Dangerous due to it affecting sodium and calcium very cardiotoxic

Check ECG

Anticholinergic side effects:
- Blurred vision- pupil dilation
- Urinary retention
- Dry mouth
- Constipation
- Confusion
- Agitation

139
Q

When would you consider using monoamine oxidase inhibitors?

A

MAOIs are seldom used, then only in treatment of:
- Resistant depression or atypical depression
- Depression with increased sleep, increased appetite and phobic anxiety

140
Q

How do monoamine oxidase inhibitors work?

A

MAOIs inactivate monoamine oxidase enzymes that oxidase the monoamine neurotransmitters, such as dopamine, noradrenaline, serotonin and tyramine

This creates more of them in the CNS

141
Q

What are some side effects of MAOIs?

A

Can cause v. v. high BP if taken with tyramine (aged cheese, cured meats, broad beans). Tyramine reaction crisis can lead to SAH

anticholinergic side - effects, weight gain, insomnia, postural hypotension, tremor, paraesthesia of the limbs, and peripheral oedema

142
Q

Name some MAOIs?

A

Selegiline, phenelzine

143
Q

Name a atypical antidepressant

A

Mirtazapine

144
Q

What are some side effects of mirtazapine?

A

Drowsiness
Weight gain

145
Q

When would you prescribe lithium?

A

Acute manic episode and long-term prophylaxis of bipolar affective disorder

It should only be prescribed if there is a clear intention to carry on treatment for at least 3 years otherwise can cause rebound mania

146
Q

What are some side effects of lithium at a lower dose?

A

Side effects between 0.4-1:
- Nausea
- Fine tremor
- Weight gain
- Oedema
- Polydipsia
- Hypothyroidism

147
Q

What are some side effects of higher dose lithium/lithium toxicity?

A

Above 1.0 mmol/L

Vomiting
Diarrhoea
Coarse tremor
Slurred speech
Ataxia
Drowsiness and confusion

Lithium is also teratogenic

148
Q
A
149
Q

What psychiatric disorder could you use sodium valproate and carbamazepine, and lamotrigine for?

A

Bipolar, prophylactically

They are Teratogenic!!

150
Q

What are some side effects of sodium valproate and lamotrigine?

A

Lamotrigine
Skin reactions (including Stevens–
Johnson syndrome)
aseptic meningitis drowsiness
diplopia
leukopenia
insomnia

Sodium valproate
Nausea
Gastric irritation
diarrhoea
Weight gain

They are Teratogenic!!

151
Q

Name 3 broad kinds of psychological therpies?

A
  1. Supportive
  2. Cognitive behaviour
  3. Psychodynamic
152
Q

What is seen in supportive therapy and what is it used for?

A

Explanation and reassurance

Establishing rapport, and facilitating emotional expression

  • Non-directive problem-solving,
    e.g. for adjustment disorders, stress, bereavement
  • Mild depression or anxiety

Counselling is similar to supportive therapy
in that it involves explanation, reassurance, and support.

153
Q

What is CBT?

A

his is a therapy with works on the interplay between thoughts, emotions and behaviours. Its aim it to tackle both negative the cognitive thinking and behaviour in mental illness.

a) Cognitive –> Aim is to help people identify and challenge automatic negative thoughts and abnormal beliefs

b) Behaviour –> This is based on learning theory of operant condition (positive and negative reinforcement)

– If people have habitual wrong behaviours (e.g. avoidance in anxiety) it teaches people relaxation techniques and gradual exposure with positive reinforcement to change their behaviour.

154
Q

What are psychodynamic/psychoanalytic therapies?

A

psychoanalysis stems from the work of Sigmund Freud.

  • views human behaviour as determined by unconscious forces derived from primitive emotional needs.

Therapy aims to resolve longstanding underlying conflicts and unconscious defence mechanisms (e.g. denial, repression).

Helping the person to become more aware of the unconscious processes which are giving rise to
symptoms or to difficult repeating patterns

Helping the person construct a narrative of their life and give meaning to symptoms

155
Q

What is seen in eye movement desensitisation and reprocessing?

A

– Patients then recall the disturbing events and the emotion they felt at the time (e.g. sexual abuse and feeling powerless

– They then work together to create a positive belief about the event (“I am stronger now and so not powerless”)

– The therapist then activates both sides of your brain using Dual Activation Stimulation (DAS) by making they do eye movements usually involves the therapist directing the patients’ lateral eye movements by asking them to look first one way then the other
(saccadic eye movements)

– This allows the brain to reprocess the upsetting memories by removing the old emotion and replacing it with the more positive, empowering emotion

– This means the memory is no longer experienced as a traumatic

156
Q

What is ECT? For what can it be used for?

A

It uses electrodes to induce a modified cerebral seizure

Severe depression
Prolonged episode of mania that hasn’t responded to treatment
Catatonia

ECT should be used to induce fast and short-term improvement of severe symptoms after all other treatment options have failed, or when the situation is thought to be life-threatening (because of high risk of suicide or not eating and drinking).

157
Q

How does ECT work?

A

It uses electrodes in the brain to induce a modified cerebral seizure in the brain

  • This leads to neurotransmitter release, hormone secretion and an increase in the permeability of the blood brain barrier
  • It is used if all other treatment options have failed
158
Q

When can ECT be given under the mental health act?

A

Patient gives informed consent
(before every treatment)

The patient lacks capacity, and it does not conflict with
advance decision
AND
It’s an emergency, and the independent consultant has
not yet assessed (Section 62 of Mental Health Act)
OR
An Independent Consultant (appointed by Mental Health Act Commission) agrees to it

IF A PATIENT HAS CAPACITY AND REFUSES, IT CANNOT BE GIVEN

159
Q

What are some contraindications for ECT?

A
  • Raised intracranial pressure
  • Previous stroke or MI
160
Q

What are some side effects of ECT?

A

Can cause cognitive impairment and function should be assessed prior to, during and after a course of treatment

161
Q

What is neuroleptic malignant syndrome?

A

It is a psychiatric emergency that is caused by an excess of neuroleptic medications e.g. antipsychotics which reduce dopamine

Can also be caused by withdrawal from dopamine agonists like Parkinson’s medications

Also caused by cocaine and ecstasy

162
Q

What are the symptoms of neuroleptic malignant syndrome?

A

Occurs over hrs to days

  • Hyporeflexia
  • Hyperpyrexia
  • Sweating
  • Palpitations
  • Reduced consciousness
  • Diffuse rigidity
  • Raised CK can cause rhabdomyolysis
163
Q

What is the management of neuroleptic syndrome?

A
  • Stopping the drug and supportive measures such as oxygen, fluids and cooling blankets
  • Can also use lorazepam for muscle rigidity
164
Q

What are the symptoms of an opiate overdose?

A
  • Drowsiness
  • Respiratory depression
  • Hypotension
  • Tachycardia
  • Pinpoint pupils
  • Constipation
165
Q

What is the management of an opiate overdose?

A

ABCDE approach

Give naloxone

166
Q

What are some signs of opioid withdrawal?

A

Withdrawal is mediated by noradrenaline overactivity:

  • Dilated pupil
  • Tachycardia and hypertension
  • Insomnia
  • Abdo pain
  • Diarrhoea and vomiting
  • Watering eyes
  • Muscle aches
167
Q

What is the treatment for opioid withdrawal?

A

Lofexidine

168
Q

What is used to help with opioid withdrawal?

A
  • Methadone (opioid agonist) or buprenorphine (opioid partial agonist) are first line; they are less euphoriant and have a
    relatively long half-life than opioids of abuse.
  • Lofexidine is sometimes used for short detoxification treatments or where abuse is mild or uncertainNaltrexone (opioid antagonist) blocks the euphoric effects and
    is occasionally used to help prevent relapse.
169
Q

What are the different substances that can be abused and there classes?

A

ICD - 10
F10 Alcohol
F11 Opioids
F12 Cannabinoids
F13 Sedatives or hypnotics
F14 Cocaine
F15 Other stimulants, including caffeine
F16 Hallucinogens
F17 Tobacco
F18 Volatile solvents
F19 Multiple drug use and other

170
Q

What are the different types of substance abuse disorders?

A

ICD - 10
.0 Acute intoxication
.1 Harmful use
.2 Dependence syndrome
.3 Withdrawal state
.4 Withdrawal state with delirium
.5 Psychotic disorder
.6 Amnesic syndrome
.7 Residual and late-onset psychotic disorder
.8 Other mental and behavioural disorders

171
Q

What are some risk factors for substance abuse?

A

Addiction liability - depends on:
How substance taken: orally, injection, inhaling
Rate substance crosses blood brain barrier and triggers reward pathway in brain
Time takes to feel effect of substance
Substance ability to induce tolerance ± withdrawal symptoms

Male
Aged ~ 18-25
Mental health conditions: ADHD, bipolar, depression, GAD, panic disorder, PTSD
Adverse childhood experiences: childhood abuse/neglect, witnessing domestic violence, family members with SUD

172
Q

How many g and ml is one unit if alcohol?

A

10ml or 8g of pure alcohol

173
Q

Outline the physiological effects that alcohol has on the body?

A
  • Alcohol increases the GABA function
  • GABA is the main inhibitory neurotransmitter in the brain
  • Glutamate is inhibited, it is the main excitatory neurotransmitter in the brain
174
Q

What are some signs of alcohol dependance>

A

CANT STOP

C- Compulsion to drink
A- Aware of harms but persists
N- Neglect of other activities
T- tolerance to alcohol
S- Stopping causes withdrawal
T- time preoccupied with alcohol
O- Out of control use
P- Persistent, futile wish to cut down

175
Q

What are some signs of alcohol withdrawal?

A

Tremors
Anxiety
Nausea
Headache
Tachycardia
Irritability
Delirium

176
Q

What are some investigations/questionnaires to screen for alcohol dependency?

A

CAGE questionnaire screening
C - do you ever think about cutting down
A - do you get annoyed when others comment on drinking habit
G - ever feel guilty about drinking
E - ever drink in morning (eye-opener)

AUDIT questionnaire
Developed by WHO
Multiple choice for harmful alcohol use screen

177
Q

What are some blood test results you would see in an alcoholic?

A

Bloods:
- Raised MCV
- Raised ALT and AST ( AST:ALT ratio above 1.5 suggests ALD
Raised GGT
Raised bilirubin
Low albumin
Deranged U+Es in hepatorenal syndrome

178
Q

What is the management for someone who is alcohol dependant?

A
  • Disulfiram- this inhibits acetaldehyde dehydrogenase, so people feel hungover as soon as they drink alcohol
  • Acamprosate- this is a weak NMDA antagonist which is used to reduce alcohol craving
179
Q

Outline the pathophysiology behind delirium tremors?

A

Alcohol boosts GABA, which inhibits the brain and dampens excitatory glutamate receptors. Over time the brain adapts, becoming more sensitive to excitatory signals

When alcohol stops, the brain becomes overactive, causing symptoms like confusion and agitation

180
Q

What are some symptoms of delirium tremors?

A

0-12 hours: increased anxiety, with sweating and agitation

After 24 hours: seizures with visual hallucinations

From 48-72 hours: coarse tremors, agitation, delusions and severe visual hallucinations

181
Q

What is the management for delirium tremens?

A

Management – 1st line is benzodiazepine chlordiazepoxide

182
Q

How can we gauge the severity of alcohol withdrawal?

A

The CIWA-Ar is used to guide the pharmacological management of alcohol withdrawal

Clinicians add up scores for all ten criteria. The total CIWA score can be used to assess the presence and severity of alcohol;

Absent or minimal withdrawal: score 0-9
Moderate withdrawal: score 10-19
Severe withdrawal: score > 20

The total CIWA score influences the frequency at which further observations are made:

Initial score >8: repeat hourly for 8 hours
Then if stable 2-hourly for 8 hours then if stable 4-hourly

Initial score <8: assess 4 hourly for 72 hours and if score <8 for 72 hours, discontinue assessment.

The total CIWA score guides clinicians with regards to the need for pharmacological management of alcohol withdrawal:

Symptom-triggered regimen (not prescribed regular withdrawal medication): give PRN medication when CIWA score is ≥ 8
Fixed-dose reducing regime with PRN medication (prescribed regular withdrawal medication): give additional PRN medication if CIWA score is ≥ 15

183
Q

What is Wernicke’s encephalopathy?

A

It is a neurological emergency resulting from thiamine deficiency with varied neurocognitive manifestations

184
Q

What is Korsakoff’s syndrome? How is it related to Wernickes?

A

Hypothalamic damage& cerebral atrophy due to thiamine (vitamin B1 deficiency)

Wernicke’s encephalopathy is the acute, reversible stage of the syndrome, and if left untreated it can later lead to Korsakoff syndrome, which is chronic and irreversible

185
Q

How can chronic alcoholism lead to thiamine?

A

It block the phosphorylation of thiamine stopping it from being converted into its active form

Ethanol reduces gene expression of thiamine transporter, so can stop it getting absorbed in the duodenum

Alcoholic tend to have a poor diet, relying on alcohol for calories so will not get enough thiamine (b1) anyway

186
Q

How can a lack of thiamine (Vit B1) affect the brain?

A
  • Thiamine deficiency impairs glucose metabolism and this leads to a decrease in cellular energy
  • The brain is particularly vulnerable to impaired glucose metabolism since it utilises so much energy
187
Q

What is the classical triad seen in Wernicke’s encephalopathy?

A
  1. Confusion
  2. Ataxia
  3. Ophthalmoplegia (nystagmus, lateral rectus or conjugate gaze palsies)
188
Q

What does Wernicke- Korsakoff syndrome predominantly target? What symptoms does this cause?

A
  • Mainly targets the limbic system, causing severe memory impairment:
  • Anterograde amnesia inability to create new memories
  • Retrograde amnesia inability to recall previous memories
  • Confabulation creating stories to fill in the gaps in their memory which they believe to be true
  • Behavioural changes
189
Q

What investigations would you do in suspected Wernicke’s encephalopathy?

A
  • Diagnosis is typically made based in clinical presentation
  • Bloods including LFTs: measure thiamine levels, measure blood alcohol levels, liver function may be deranged in alcoholism
  • MRI/CT: can confirm diagnosis by showing degeneration of the mammillary bodies

Lumbar puncture to rule out other causes of the symptoms of wernickes

190
Q

What is the management for Wernicke’s encephalopathy?

A

Urgent replacement to prevent irreversible Korsakoff’s syndrome. Give thiamine

Oral supplementation

Correct magnesium deficiency as well if there is coexisting deficiency as well

191
Q

Why do you need to give thiamine before you give glucose in a patient with Wernicke’s?

A

It’s important to normalise the thiamine levels first, because without thiamine pyrophosphate most of the glucose will become lactic acid and that can lead to metabolic acidosis

Make sure thiamine is given before glucose as Wernicke’s can be caused by glucose administration to thiamine-deficient patient

192
Q

How do cocaine and amphetamines work?

A

These drugs block the reuptake of dopamine and noradrenaline (and 5-HT) increasing transmission at synapses

193
Q

What are some signs of a cocaine/amphetamine overdose?

A

Main effect- Increased energy and concentration and hyperactivity

Side effects:

  • Cardiovascular -> increased pulse, blood pressure, hyperthermia, can lead to aortic dissection
  • Heart -> QRS widening and QT prolongation
  • GI -> reduced appetite and ischaemic colitis

– Psychological –> Insomnia, agitation and hallucinations e.g. formication (sensation of ants under the skin)

– If you take a prolonged large dose, the euphoria can turn to depression and anxiety

– Can get psychosis –> delusions, visual and auditory hallucinations

194
Q

What is the management of a cocaine overdose?

A
  • IV benzodiazepines+ treat complications
195
Q

What are the 5 key principles you must consider when assessing mental capacity?

A

1) A person is assumed to have capacity until it is established the person does not have it

2) A person should not be treated as unable to decide unless all practicable steps to help them have failed

3) A person should not be treated as unable to decide just because it is unwise

4) Decisions made on behalf if an incapable person must be in their best interests

5) Regard should be taken to find the solution which is least restrictive of the person’s rights and freedom of action

196
Q

Under the MCA what are the 3 reasons why you may provide treatment for someone who does not have capacity?

A
  • If a valid advanced decision to refuse treatment exists
  • If a valid lasting power of attorney for health and welfare exists
  • If neither exists, then person providing treatment should act in the patient’s best interests
197
Q

What are the 2 stages of a MCA?

A
  1. Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?
  2. Does the impairment mean the person is unable to make a specific decision when they need to? People can lack capacity to make some decisions but capacity to make others.
198
Q

When is a person said to be unable to make a decision for themselves?

A
  • Understand the information relevant to the decision
  • Retain the information relevant to the decision
  • Use or weigh up that information as part of the process of the making the decision
  • Communicate their decision in any way
199
Q

In order to section someone (forcibly admit someone to hospital/secure setting), for assessment what is grounds/personal is required and for how long? What part of the MHA?

A

Under section 2 of the mental health act

Need 2 Drs: One section 12 approved, one ideally previous contact with the patient and then approval from approved mental health professional to confirm the section

Patient suffering from mental disorder to degree that warrants detention in hospital for assessment

Pt should be detained for own health/safety or the protection of others

Lasts 28 days, cannot be Cannot be renewed

200
Q

In order to section someone (forcibly admit someone to hospital/secure setting), for treatment what is grounds/personal is required and for how long? What part of the MHA?

A

Under section 3 of the mental health act

Again, Need 2 Drs: one section 12 approved, one ideally previous contact w/ pt, and then approval from approved mental health professional (AMHP) to confirm the section.

Patient suffering from mental disorder to degree that warrants detention in hospital for treatment.
Pt should be detained for own health/safety or the protection of others
The treatment needed cannot be effectively provided unless the patient is detained.
Appropriate medical treatment is available to them.

lasts 6 months, can be renewed

201
Q

What is outlined in section 4 of the MHA?

A

Patient suffering from mental disorder to degree that warrants the detention in hospital for assessment

Pt detained for own safety/safety of others. Not enough time for 2nd Dr to attend

1 Dr (does not need to be section 12 approved)

Lasts for 72 hours

202
Q

What is outlined in section 5 of the mental health act, both in 5(2) and 5(4)?

A

For pt already admitted (to psychiatric/general hospital) but wanting to leave

Section 5(4) says nurses can detain patients in hospital (this is their holding power until a Dr can attend) for 6 hours

Section 5(2) says doctors (this is their holding power until section 2/3 can be put place)
NB- has to be DR on a specific ward, cannot be done in A&E lasts for 72 hours

203
Q

What is outlined in section 135 of the mental health act

A

135- allows police to enter a house and move a patient to a place of safety

136 allows police to take someone to a place of safety for an assessment

Both can be done by police, but t

204
Q

If a patient has been detained under section 2,3,35,36 or 37, is consent required for treatment

A

onsent to Treatment
As a general rule, once a patient is detained under S2, 3, 35, 36 or 37 of the MHA, consent is not required for the administration of psychiatric treatment.

– The justification for treatment is provided by S63 which states that:

“The consent of a patient shall not be required for any medical treatment given to him for the mental disorder from which he is suffering”

Treatments are Covered by S63

All medical treatment for the mental disorder, including:

Treatments for the disorder itself (e.g. antipsychotics for schizophrenia)

Treatment for conditions causing the disorder (e.g. hypothyroidism causing depression)

Treatments for the physical consequences of the disorder (e.g. NG in anorexia)

Safe holds and physical control and restraint (when necessary)

205
Q

What is self-harm and what are some of the reasons for it?

A

Intentional non-fatal sel-ifnflicted harm

a desire to interrupt a sequence of events seen as inevitable and undesirable
* a need for attention
* an attempt to communicate/express themselves
* a true wish to die

206
Q

What are some risk factors for self-harm?

A
  • It is more frequent in women
  • More common in under 35s
  • Associated with psychiatric illness, particularly depression and personality disorder
207
Q

What are some clinical signs of self-harm?

A
  • Cuts on arms and legs
  • Picking at skin
  • Burns
  • Bruising
  • Weight loss/gain
  • Hair loss (pulling at hair)
208
Q

When assessing self harm/suicide attempt, what are the 3 domains you should split factors into?

A

Before
During
After

209
Q

Suicide and self-harm risk assessment - what things should you try to find out about BEFORE they attempted suicide/self-harm?

A

Precipitants - specific event/build up?

Planned/impulsive?

Precautions taken against discovery? (left the house, turned off phone etc)

Alcohol/recreational drugs at time of event? - suggests more impulsive

210
Q

Suicide and self-harm risk assessment - what things should you try to find out about DURING they attempted suicide/self-harm?

A

Method (if drugs - what did they take, how much)
Was pt alone
Where was it - more remote = higher risk
What went through mind at the time
Did they think their self-harm would end their life?
What did they do straight after the self-harm?

211
Q

Suicide and self-harm risk assessment - what things should you try to find out about AFTER they attempted suicide/self-harm?

A

Did pt call anyone? Go to A&E?
Who were they found by
How they felt when help arrived
Current mood
Still feel suicidal? - would they attempt again

212
Q

What are some management options for self harm?

A

A good first step is to agree with patients what their problems
are and what immediate interventions are both feasible and
acceptable to them.
* Ensure that they know who they can turn to if suicidal intent
returns (e.g. A & E).
* Crisis Resolution Team referral may be necessary if suicidal
ideation is present.
* Think about reducing access to means of suicide if possible –
for example, by encouraging patients to dispose of unneeded tablets from the home, and by prescribing antidepressants of lower
lethality (e.g. SSRIs rather than tricyclics) and in small batches.
* Consider psychological therapy and encouraging engagement
in self-help and community social and support organisations.

213
Q

What are some risk factors for suicide?

A

SAD PERSONS

Sex (male)
Age <19 or >45
Depression

Previous suicide attempt
Excess alcohol or substance use
Rational thinking loss
Separated or single
Organised plan
No social support
Sickness

214
Q

What are some clinical signs of suicidal behaviour?

A

Warning signs:
* Obsessive thinking about death
* Feelings of hopelessness, worthlessness, helplessness
* Behaviours suggestive of absolute death wish:
○ Put financial affairs in order
○ Visiting people to say goodbye

in community, awareness of pts who:
Frequently, repeatedly attend
Disengaged w/ services
Prescribed several antidepressants
Heightened concern from family members

215
Q

what are some principles around suicide prevention?

A
  • Detect and treat psychiatric disorders.
  • Be alert to risk and respond appropriately to it.
  • Prescribe safely
  • Give urgent care at appropriate level of patients with suicide intent – refer to Crisis Resolution and Home Treatment Teams.
  • Can also admit for hospitalization (consider detention under the Mental Health Act) if patients considered unsafe outside hospital even with intensive support.

*Provide careful management of deliberate self-harm (DSH)

  • Act at the population level, tackling unemployment and reducing access to methods of self-harm.
216
Q

What are the questions to ask someone to screen for an eating disorder?

A
  • Do you ever throw up after eating food
  • Do you eat food to have a sense of control
  • Have you lost more than 1 stone in 3 months
  • Do you feel like you’re fat when other people tell you you’re not
  • Does food dominate your life

SCOFF

217
Q

What are the findings on FBC and U&Es in someone with anorexia?

A
  • Hypokalaemia
  • Low white cell count neutropenia
  • Anaemia (either of chronic disease or iron deficient)
218
Q

What will an ECG show on a patient with an eating disroder?

A
  • Will often show long Qt syndrome as as result of hypokalaemia
219
Q

What is a bedside test used as a good indicator for cardiac health in an eating disorder?

A

Sick squat test: Should be able to deep squat, if they can’t do this without using hands, proximal muscles must be weak therefore so must the heart.

220
Q

What is important to monitor if refeeding a patient with an eating disorder?

A

Magnesium and phosphate. Can both go low when refeeding. Known as refeeding syndrome

221
Q

What is done to assess risk in an eating disorder in an emergency setting?

A

MEED risk assessment for eating disorders:
Red flags: Recent weight loss more than a 1kg over 2 weeks, under 13 BMI, Postural drop, MUAC <18cm, other clinical state, ECG abnormalities, duration.

222
Q

What is the most common eating disoder

A

1) Binge eating disorder is the most common form of eating disorder.

2) Anorexia

3) Bulimia

223
Q

What is the treatment for different eating disorders?

A

Anorexia: CBT, SSCM
Bulimia: Fluoxetine 60mg once a day, CBT

224
Q

What are some long term problems of eating disorders?

A

Hormonal problems, loss of periods and erections, bone scans and calcium levels

225
Q

What is used to treat delirum?

A

Haloperidol

226
Q

Definitions: Concrete thinking

A

Concrete thinking refers to a cognitive process characterized by a focus on literal, tangible, and specific details rather than abstract or hypothetical concepts.

This type of thinking is grounded in the here-and-now, dealing with concrete objects and straightforward facts rather than ideas or possibilities that require imaginative or theoretical consideration.

227
Q

Definitions: Loosening of associations (LOA)

A

Loosening of associations (LOA), also known as derailment, is a cognitive disturbance where there is a significant disconnection or fragmentation in the logical flow of thoughts and ideas.

This phenomenon is often observed in certain psychiatric conditions, most notably schizophrenia, and is characterized by speech that is disorganized and difficult to follow.

228
Q

Definitions: Circumstantiality

A

a communication disorder characterized by an overabundance of unnecessary and irrelevant details in conversation or writing

229
Q

Definitions: Perseveration

A

Perseveration is a cognitive and behavioural phenomenon where an individual repeatedly performs the same action, says the same words, or persists in the same thought despite the absence or cessation of the original stimulus.

230
Q

Definitions: Confabulation

A

Confabulation is a memory disturbance where a person creates false memories without intending to deceive.

These fabricated or distorted memories can include incorrect details about real events or entirely invented scenarios. Confabulation often occurs in individuals with certain brain injuries or neurological conditions and is typically not recognized by the person as false.

231
Q

Definitions: Somatic passivity

A

Somatic passivity is a symptom often associated with certain psychiatric conditions, particularly schizophrenia. It refers to a sensation where an individual feels that their bodily experiences, movements, or sensations are being controlled or influenced by an external force or entity.

This can include feelings of physical sensations, movements, or even thoughts that seem imposed upon the person, rather than originating from their own will.

232
Q

Definitions: Belle indifference

A

Belle indifference is a term used in psychiatry to describe a paradoxical lack of concern or apparent indifference to significant physical symptoms.

This phenomenon is often observed in individuals with certain psychological disorders, particularly conversion disorder (also known as functional neurological symptom disorder).

233
Q

Definitions: Akathisia

A

is a distressing neurological condition characterized by an intense feeling of inner restlessness and an irresistible urge to move. It is a common side effect of certain medications, particularly antipsychotic drugs, although it can also occur spontaneously or as a result of other medications.

Akathisia can significantly impair a person’s quality of life and may lead to agitation, anxiety, and difficulty sitting still or relaxing.

234
Q

Definitions: Catatonia

A

Catatonia is a neuropsychiatric syndrome characterized by a range of motor disturbances that can include immobility, excessive motor activity, negativism, mutism, and peculiarities of voluntary movement.

It is associated with various psychiatric and medical conditions, including schizophrenia, bipolar disorder, major depressive disorder, and neurological disorders.

235
Q

Definitions: Stupor

A

Stupor is a serious mental state where people don’t respond to normal conversation, but only to physical stimulation.

236
Q

What is the criteria of learning disability?

A

Global impairment, below 18, IQ below 70

237
Q

What are the IQ test used for children?

A

Wechsler scale for adults and children

Mean IQ: 100
Genius: 145
LD: below 70

238
Q

What is the life expectancy for people with LD’s?

A

66 for men
67 for women

239
Q

What are the causes of LD’s?

A

Infective, Infections, toxic, trauma, genetic, metabolic

240
Q

What are some features of anorexia

A

Anorexia features
most things low: hypokalaemia
low FSH, LH, oestrogens and testosterone

G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, Cholesterol, carotinaemia

241
Q

What are some issues with anti-psychotic medications?

A
  • Parkinsonism
  • Akathisia
  • Tardive dyskinesia
  • Dystonic reactions
  • Neuroleptic malignant syndrome
242
Q

What are the symptoms are the pathophysiology behind drug induced parksionism?

A
  • Bradykinesia
  • Ridgity
  • Resting tremor

Although less pronounced and symptoms are always bilateral

Caused by D2 receptor blockade by the medications

243
Q

What is the treatment of drug-induced parkinsonism?

A
  • Dose reduction
    Switching to a different medication
  • Use procyclidine
244
Q

What is Akathisia?

A
  • It means to not be able to sit still
  • A subjecitve component of feeling like they need to move
  • Manifests with symptoms such as pacing, inability to stand, sit or lie still
245
Q

What are the different types of Akathisia?

A
  • Acute which occurs within hours to weeks of starting medication
  • Acute persistant
  • Tardive akathisia: usually develops after 3 months of treatment
246
Q

What is the treatment for Akathisia?

A
  • Try choloropromazine/quitiapine
  • Try beta-blocker
  • Mitrzapine
247
Q

What is tardive dyskinesia?

A
  • Involuntary, repetitive purposeless movements, occuring with long-term antipsychotic treatment
248
Q

What are the signs and symptoms of tardive dyskinesia?

A
  • Tongue, lips and jaw movements
  • Trunk twisiting
  • Torticollis
  • Pelvic thrusting
249
Q

What are the treatments of tardive dyskinesia?

A
  • Tertrabenazine
  • Dopamine agonists
  • Clonazepam if dystonia also present
250
Q

When does a dystonic reaction occur?

A
  • Usually occurs within 1wk of commencing or rapidly increasing the dose of the antipsychotic medication
251
Q

What are the signs and symptoms of a dystonic reaction?

A
  • Muscles of head and neck are most commonly affected
  • Forceful protrusion of tongue
  • Occurs in the mouth most commonly
252
Q

What is the treatment of a dystonic reactions?

A
  • IM Procyclidine
253
Q

What is neuroleptic malignant syndrome?

A
  • A rare life-threatning reaction to anti-psychotic medication
254
Q

What are the characteristics of neuroleptic malignant syndrome?

A
  • Fever
  • Muscle ridigity
  • Alterned mental status
  • Autonomic dysfunction
255
Q

What are the signs and symptoms of neuroleptic malignant syndrome?

A
  • Hyperthermia
  • Muscle ridigity
  • Confusion
  • Hyporeflexia
  • tremor
  • Raised CK (can cause rhabdomyolsis)
256
Q

What is the treatment for neurolepetic malignant syndrome?

A
  • Stop drug
  • Give fluids and oxygen
  • Cool body temperature
  • Lorzepam/Dantrolene
  • Can also give bromocriptine
  • Give bicarbonate to prevent alkalisation of urine
257
Q

What is De Clerambault syndrome?

A

De Clerambault’s: This is the presence of a delusion that a famous person is in love with them, with the absence of other psychotic symptoms as is the case, here.

258
Q

What is Capgras syndrome?

A

Capgras syndrome: This is the delusion that a person closely related to the patient has been replaced by an impostor.

259
Q

What is De Fregoli syndrome?

A

De Fregoli syndrome: This is the delusion of identifying a familiar person in various people they encounter.

260
Q

What is Othello syndrome?

A

Othello syndrome: This is a delusion of sexual infidelity on the part of a sexual partner.

261
Q

What is Ekbom syndrome?

A

Ekbom syndrome is: This is delusional parasitosis and describes the delusion of infestation.

262
Q

What are the hormonal changes in anorexia?

A

most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia

3A (11 decks)

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