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Sharon's Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is ADHD?

A

ADHD is a neurodevelopmental disorder characterised by persistent inattention, hyperactivity, and impulsivity. It is a chronic condition that begins in childhood and persists into adulthood.

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2
Q

What are the risk factors for ADHD?

A
  • Family history of ADHD
  • Male sex
  • Low birth weight
  • Psychosocial adversity
  • Obstetric complications in pregnancy or labour
  • Lead exposure
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3
Q

What other conditions is ADHD usually comorbid with?

A

Anxiety, depression, personality disorders, substance use disorder

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4
Q

What are the investigations for ADHD?

A

Screening: Conners adult ADHD rating scale, Brown Attention Deficit Disorder scale

Diagnosis: diagnostic interview for ADHD in adults

Neuropsychological testing: possible impairments in executive functions

Children: child psychiatric or paediatric evaluation,
and educational psychologist assessment.

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5
Q

Management for ADHD

A

1st line: psychoeducation - info and support around ADHDto patient and families

Meds if ineffective: stimulants e.g. methylphenidate

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6
Q

Differential diagnoses for ADHD

A
  • Depression
  • Bipolar disorder
  • Borderline personality disorder
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7
Q

What is depression?

A

Depression is mental health disorder.

ICD-11 criteria:

Key symptoms:

  • persistent sadness or low mood; and/or
  • marked loss of interests or pleasure.

At least one of these, most days, most of the time for at least 2 weeks.

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8
Q

What are the risk factors for depression?

A
  • older age
  • recent childbirth
  • stress, or trauma
  • co-existing medical conditions (diabetes, cancer, stroke, myocardial infarction, and obesity)
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9
Q

Clinical features of depression

A

Key symptoms

  • Depressed mood
  • Diminished interest/capacity for pleasure

Associated symptoms

  • Change in sleep
  • Psychomotor change: agitation
  • Reduced energy; fatigue
  • more than 5% weight change/ appetite
  • Feelings of worthlessness; excessive or inappropriate guilt
  • Hopelessness
  • Difficulty concentrating
  • Recurrent thoughts of death or suicide.

Additional Features (Severe Depression)

  • Psychotic Features: Delusions (e.g. nihilistic delusions, Cotard’s syndrome) and hallucinations.
  • Depressive Stupor: Profound immobility, mutism, and refusal to eat or drink, sometimes necessitating electroconvulsive therapy (ECT).
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10
Q

Differentials for depression

A

Organic (always rule those out first): Parkinson’s, dementia, hypothyroidism etc.
- Bipolar disorder
- Anxiety disorder
- Psychotic disorders

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11
Q

What are the criteria for mild, moderate and severe depression?

A

Mild depression: at least 5 symptoms, but only minor functional impairment

Moderate depression: symptoms or level of functional impairment is between mild and severe

Severe depression: most depressive symptoms are present, with marked functional impairment +/- psychotic symptoms

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12
Q

What are the investigations for depression?

A
  • Clinical diagnosis
  • FBC
  • TFT, LFT, U&E
  • Patient Health Questionnaire (PHQ-9)
    (screening in GP)
  • Hospital Anxiety and Depression (HAD) Scale
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13
Q

What is the management for depression?

A
  • Usually managed in primary care, refer to psych if high suicide risk, bipolar symptoms, psychosis
  • Mild to moderate depression: 1st line is low-intensity psychological help (self-help, online CT)
  • Treatment-resistant mild depression or moderate to severe depression: psychological intervention (CBT, self-help etc.) + antidepressants (e.g. SSRI)
  • Severe depression and poor oral intake/psychosis: 1st line is electroconvulsive therapy
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14
Q

What is autism spectrum disorder?

A

A neurodevelopmental disorder that is increasingly being viewed as a neurological and cognitive variation among people.

It is characterized by a spectrum of social, language, and behavioural deficits.

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15
Q

Risk factors for autism

A
  • FHx of ASD
  • Boys are more frequently affected than girls (4:1)
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16
Q

Clinical features of autism

A

In children

  • Language delay/regression or develop language very early
  • Verbal/non-verbal impairment - e.g. baby does not play peek-a-boo with parents. Older children/adults might develop adaptive mechanisms to manage social communication (e.g., learning social ‘rules’ by imitating their peers).
  • Social impairment - playing alone/uninterested in playing with others
  • Repetitive, rigid interests, behaviours and activities
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17
Q

What are the investigations for ASD?

A
  • ASD screening tests - useful in primary care but should not be standalone
  • Childhood Autism Rating Scale (CARS) - screening tool for children
  • Multidisciplinary assessment - psychological evaluation, speech and language assessment, cognitive assessment, and a thorough review of the child’s behaviour in different settings (home, school, etc.)
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18
Q

What is the management for ASD?

A

Management with multidisciplinary team:

  • Child psychology and child and adolescent psychiatry (CAMHS)
  • Speech and language specialists
  • Dietician
  • Paediatrician
  • Social workers
  • Specially trained educators and special school environments
  • Charities such as the national autistic society

(From zero to finals)

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19
Q

Define bipolar disorder

A

Bipolar disorder is a mood disorder characterised by episodes of depression and mania or hypomania. There are two types: bipolar 1 disorder and bipolar 2 disorder.

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20
Q

What is bipolar I disorder?

A

Bipolar I disorder is characterised by manic episodes, which are distinct periods of abnormally and persistently elevated, expansive, or irritable mood, with abnormally and persistently increased energy or activity, lasting for at least 1 week.

Occurance of major depressive episode is not required for diagnosis, most people with bipolar I disorder will experience a major depressive episode at some point during their lives

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21
Q

What is bipolar II disorder?

A

Bipolar II disorder is characterised by a current or past hypomanic episode and a current or past major depressive episode. Hypomanic episodes present with similar symptoms as mania but cause less impairment and are of shorter duration, lasting for at least 4 consecutive days.

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22
Q

What are the risk factors for bipolar disorder?

A
  • Early age of mood disorder onset
  • Family history of bipolar disorder or suicide,
  • Poor or limited response to traditional antidepressants
  • Highly recurrent mood episodes
  • Comorbid anxiety or substance misuse disorders
  • psychosocial instability.
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23
Q

Differential diagnoses for bipolar disorder

A
  • Major Depressive Disorder
  • Cyclothymic Disorder: Chronic mood fluctuations over 2 years with episodes of hypomania and depression.

Schizoaffective Disorder: Combines mood symptoms with hallucinations or delusions

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24
Q

Investigations for bipolar disorder

A

Important to rule out organic causes first especially if first presentation or no previous psychiatric history.

  • Substance misuse (e.g. urine toxicology, amphetamine levels).
  • Delirium
  • Thyroid dysfunction (TFTs)
  • Vitamin deficiencies (B12/folate)
  • Then bipolar disorder is a clinical diagnosis with the aid of questionnaires e.g. PHQ9
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25
Q

Symptoms of mania

A
  • Pressured speech.
    Lots of projects/things going on.
  • Delusions.
  • Increased energy/activity
  • Decreased need for sleep
  • Overfamiliarity.
  • Impulsivity.
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26
Q

Symptoms of depression

A
  • Low mood.
  • Lacking energy.
  • Loss of pleasure.
  • Sleep disturbance.
  • Appetite change.
  • Feelings of guilt, hopelessness.
  • Suicidal thoughts.
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27
Q

Acute management for bipolar disorder

A

Hypomania - routine ref to CMHT

Severe mania/depression - urgent ref to CMHT

Taper down new SSRI as could have caused manic switch.

Mania with Agitation: IM neuroleptic or benzodiazepine, potential psychiatric admission.

Mania without Agitation: Oral antipsychotic (haloperidol, olanzapine, quetiapine, or risperidone).

Acute Depression: Mood stabilizer increase if already on. If not, consider SSRI and atypical antipsychotic cover.

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28
Q

Long-term management of bipolar disorder

A
  • About 4 weeks after acute episode resolution
  • Maintenance therapy: mood stabilizers such as Lithium (first line) or Valproate (second line), and psychotherapy (high-intensity - CBT, Interpersonal Therapy).
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29
Q

Define generalised anxiety disorder (GAD)

A

A common condition defined as chronic, excessive worry for at least 6 months that causes distress or impairment, and is hard to control.

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30
Q

What are the risk factors for GAD?

A
  • Family history of anxiety
  • Physical or emotional stress
  • History of physical, sexual, or emotional trauma
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31
Q

Clinical features of GAD

A
  • ≥ 6m excessive worry, difficult to control that is disproportionate to the inherent risk
  • Not confined to another mental disorder, substance abuse or medical condition

At least 3 out of:

  • Restlessness/nervousness
  • Being easily fatigued
  • Poor concentration
  • Irritability
  • Muscle tension
  • Sleep disturbance
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32
Q

Differential diagnosis for GAD

A
  • Hyperthyroidism
  • Medication induced anxiety (e.g. salbutamol)
  • Substance misuse
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33
Q

Investigations for GAD

A

Rule out organic causes - TFT (hyperthyroidism), urine drug screen (e.g. alcohol)

  • Clinical diagnosis after other causes ruled out
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34
Q

Management for GAD

A

NICE recommends step-wise approach:

Step 1: for all people with GAD

  • Education about GAD and
    active monitoring

Step 2:

  • Low-intensity psychological interventions : e.g. self-help, guided self-help or psychoeducational groups

Step 3:

  • High-intensity psychological interventions (CBT or applied relaxation) or SSRI, 1st line is sertraline

Step 4 : refer for specialist treatment

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35
Q

What is obessive-complusive disorder (OCD)?

A

A mental health disorder characterised by the presence of persistent obsessions and/or compulsions. These are time consuming (e.g., take more than 1 hour per day) and/or cause clinically significant distress or impairment in daily functioning.

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36
Q

What are the risk factors for OCD?

A
  • Family history of OCD

-PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)

  • Pregnancy
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37
Q

What causes OCD?

A

Biological Factors: Genetic predisposition, neurobiological abnormalities.

Psychological Factors: Early life experiences. Often co-exists with other mental health conditions.

Environmental Factors: Trauma, stressors

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38
Q

What are the clinical features of OCD?

A

Obsessions: Intrusive, unwanted thoughts or images causing distress.

Compulsions: Repetitive behaviors or mental acts aimed at reducing anxiety.

These obsession and complusions take significant time investment and have a significant impact on daily life.

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39
Q

What criteria can be used for OCD?

A

Symptom severity assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS).

Scores:

  • 8 - 15 = Mild OCD
  • 16 - 23 = Moderate OCD
  • 24 - 31 = Severe OCD,
  • 32 - 40 = extremely severe OCD
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40
Q

Differentials for OCD

A

GAD
Major depressive disorder
Body dysmorphic disorder

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41
Q

Management for OCD

A

Mild functional impairment:

  • Low-intensity CBT, including exposure and response prevention (ERP)

Moderate functional impairment:

  • Offer a choice of intensive CBT including ERPoran SSRI (e.g. serataline, fluxotine)

Severe functional impairment:

  • Combined treatment with intensive CBT (including ERP)andan SSRI
  • Continue effective med for 12 months, then review if needs to continue
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42
Q

What is postpartum psychosis?

A

Postpartum psychosis is a severe mental health disorder that typically occurs within the first two weeks postpartum, characterised by symptoms including paranoia, delusions, hallucinations, mania, depression, and confusion.

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43
Q

Risk factors for postpartum psychosis

A

Postpartum psychosis is a severe mental health disorder that typically occurs within the first two weeks postpartum, characterised by symptoms including paranoia, delusions, hallucinations, mania, depression, and confusion.

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44
Q

What is postpartum psychosis?

A

Postpartum psychosis is a severe mental health disorder that typically occurs within the first two weeks postpartum, characterised by symptoms including paranoia, delusions, hallucinations, mania, depression, and confusion.

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45
Q

Risk factors for postpartum psychosis

A
  • significant life stressor
  • personality disorder
  • family history of psychotic disorder
  • pregnancy or 4 weeks postnatal
  • previous psychiatric symptoms in women
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46
Q

Differential diagnoses for postpartum psychosis

A

Postpartum depression: insidious onset, low mood, tearfulness, anxiety

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47
Q

What are the investigations for post-partum psychosis?

A

Rule out thyroid disorders, sepsis etc.
Clinical diagnosis with full psychiatric evaluation

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48
Q

Management for postpartum psychosis

A
  • Antipsychotic medications - olanzapine and quetiapine are safe to take while breastfeeding
  • Mood stabilisers in some cases
  • Important to consider potential risk to mother or infant, consider referral to specialist mother and baby unit, particularly when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby’s role or identity.
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49
Q

Define psychosis

A

Psychosis is a syndrome associated with dysregulation of the neurotransmitters dopamine and serotonin, and abnormal functioning of key brain circuits.

People with psychosis typically experience hallucinations (e.g., auditory, visual, tactile), delusions, and disorganised thoughts and actions.

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50
Q

What causes psychosis?

A

Primary (“non-organic”)

  • Schizophrenia
  • Schizoaffective disorder
  • Secondary to substance abuse
  • Part of MDD or bipolar

Specific medical (“organic”) aetiologies

  • Withdrawal syndrome
  • Dementia
  • Encephalitis
  • Traumatic brain injury
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51
Q

Investigations for psychosis

A
  • Complete psychiatric and medical history - ask about head injuries, seizures, STIs, new or worsening headaches, and cerebrovascular disease. Collateral hx to chart onset and course
  • Complete mental state exam
  • FBC, comprehensive metabolic profile (U&E), thyroid function tests, urine toxicology, and parathyroid hormone, calcium, vitamin B12, folate, and niacin.
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52
Q

What is schizophrenia?

A

Schizophrenia is a chronic or relapsing and remitting form of psychosis characterized by positive symptoms (such as hallucinations, delusions, thought disorders) and negative symptoms (including alogia (poverty of speech), anhedonia, and avolition (severe lack of motivation).

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53
Q

Risk factors for schizophrenia

A
  • Strong: Family history of schizophrenia
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54
Q

Clinical features of schizophrenia

A

Positive Symptoms (‘ABCD’ Mnemonic) or first rank symptoms:

Auditory Hallucinations: usually third-person auditory experiences

Broadcasting of Thoughts: belief that one’s thoughts are being broadcasted to others.

Control Issues: the sense of external control over one’s thoughts or actions.

Delusional Perception: distorted interpretations of reality, often with false beliefs.

Negative Symptoms:

  • Alogia
  • Anhedonia
  • Affective incongruity
  • Avolition

Risk Indicators:

Potential risks to harm self or others: command hallucinations, a history of deliberate self-harm or suicidal ideation, and fixation on specific individuals.

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55
Q

Criteria for schizophrenia diagnosis

A

ICD-11 Criteria: Symptoms present for at least 1 month, causing significant impairment.

DSM-5 Criteria: Symptoms persist for at least 6 months, encompassing at least one month of active-phase symptoms (one ‘ABCD’ symptom).

Zero to finals say that a specialist will use DSM-5 to make a diagnosis

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56
Q

What are first-rank symptoms?

A

Symptoms that form part of the ICD-11 criteria for schizophrenia.

At least one first-rank symptom must be present for a diagnosis of schizophrenia.

These include:

  • thought echo, thought insertion or withdrawal and thought broadcasting,
  • delusions of control, or passivity
  • delusional perception, other strange delusions,
  • Auditory hallucinations commenting on the patient’s behaviour or talking about the patient in the third person.
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57
Q

Investigations for schizophrenia

A

Clinical diagnosis based on diagnostic criteria.

See “investigations for psychosis” for tests to rule out organic causes

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58
Q

Management for acute psychosis in schizophrenia

A
  • Ensure safety of patient and yourself
  • sedatives like lorazepam, promethazine may be used to manage dangerous behaviour.
  • Oral atypical antipsychotics such as risperidone/olanzapine/quetiapine.
  • Refer for psychiatric liaison review.
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59
Q

Management of ongoing schizophrenia

A

First-line

  • Oral antipsychotic (usually atypical) e.g. risperidone
  • Psychological interventions: such as CBT, art therapy, and family interventions
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60
Q

What is schizoaffective disorder?

A

Schizoaffective disorder is an illness that combines elements of both schizophrenia and mood disorders.

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61
Q

Differentials for schzoaffective disorder

A

Schizophrenia
Drug-induced psy chosis

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62
Q

Differentials for schizophrenia

A

Drug-induced psychosis
Organic psychosis e.g. brain injuries, encephalitis

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63
Q

Clinical features of schizoaffective disorder

A
  • Positive symptoms (see schizophrenia flashcards)
  • Negative symptoms
  • Disorders of perception (e.g. hallucinations)
  • Delusions
  • Emotional disturbance
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64
Q

Investigations for schizoaffective disorder

A
  • urine drug screen
  • STI screening (HIV can cause psyh symptoms)
  • FBC (rule out anaemia as it can cause mood disturbances)
  • TFT (fatigue, anxiety, depression, and irritability can be related to thyroid disorder)
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65
Q

Management for schizoaffective disorder

A

Acute psychotic episode: start oral antipsychotics (e.g. paliperidone)

Multi-episode disorder: atypical antipsychotics (e.g. olanzapine, risperidone except clozapine + psychological therapy (CBT)

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66
Q

Risk factors for schizoaffective disorder

A
  • FHx of schizophrenia
  • Substance misuse
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67
Q

How are personality disorders classified?

A

Cluster A: odd, eccentric presentation
Cluster B: dramatic tendencies
Cluster C: anxious tendencies

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68
Q

List the cluster A personality disorders

A
  • Paranoid personality disorder
  • Schizoid personality disorder
  • Schizotypal personality disorder
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69
Q

List the cluster B personality disorders

A
  • Histrionic
  • Emotionally unstable (borderline)
  • Narcissistic
  • Antisocial
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70
Q

List the cluster C personality disorders

A
  • Avoidant PD
  • Obsessive-complusive PD
  • Dependent PD
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71
Q

Define emotionally unstable personality disorder (EUPD)

A

EUPD is characterised by unstable and intense mood states often occurring in concert with idealisation and devaluation of others; chronic dysphoria (general unease and dissatisfaction) is common

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72
Q

What are the clinical features of EUPD?

A

Four domains:

Unstable self-image

  • Low self-esteem
  • Recurrent suicidal or self-harming behaviour

Impulsivity

  • Self-sabotaging or risk-taking behaviour e.g. risky sexual practices, substance misuse
  • Difficulty controlling temper

Poor interpersonal relationships

  • Short romantic relationships
  • Feelings of abandonment
  • Idealisation and devaluation of others (splitting)

Paranoia

  • Quasi-psychotic thoughts in response to stress: transient psychosis (don’t need meds)
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73
Q

Define illusion

A

A misperception of real external stimuli.

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74
Q

What is a hallucination?

A

Perceptions occurring in the absence of an external physical stimulus. Can be auditory, visual or olfactory.

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75
Q

What is a pseudo-hallucination?

A

Pseudo-hallucinations appear to arise in the subjective inner space of the mind, not through one of the external sensory organs - this is how they differ from hallucinations.

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76
Q

What is meant be the term ‘over-valued idea’?

A

An over-valued idea is a false or exaggerated belief sustained beyond logic or reason e.g. I am the best employee ever.

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77
Q

What is a delusion?

A

A false, unshakable idea which is out of keeping with the patients educational, cultural and social background; it is held with extraordinary conviction and certainty.

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78
Q

Give 5 examples of different types of delusion.

A
  • Persecutory.
  • Grandiose.
  • Nihilistic (Cotard’s syndrome).
  • Religious.
  • Hypochondriacal
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79
Q

What is the Capgras delusion?

A

The idea that someone has been replaced by an impostor.

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80
Q

Diagnostic tools for EUPD

A
  • Clinical diagnosis that requires assessment by a psychiatrist
  • Suicide risk assessment if required
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81
Q

Management for EUPD

A

Before starting treatment:

  • Suicide risk screening
  • PHQ-9 questionnaire
  • GAD7 tool

1st line is psychotherapy: DBT (dialectical behaviour therapy)

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82
Q

What is post traumatic stress disorder (PTSD)?

A

Post-traumatic stress disorder (PTSD) is a disorder that might develop (either immediately or delayed) following exposure to a stressful event or situation of an exceptionally threatening or catastrophic nature.

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83
Q

What are the risk factors for developing PTSD?

A
  • serious accident
  • witness of school violence or domestic violence
  • natural disaster
  • terrorist attack
84
Q

Clinical features of PTSD

A
  • Intrusion symptoms - involuntarily re-experiencing traumatic event e.g. flashbacks, nightmares
  • Avoidance symptoms - avoiding reminders
  • negative changes in mood and cognition e.g. reduced ability to feel happiness
  • Changes in arousal/reactivity - e.g. hypervigilance

Symptom must persist for a mont and cause functional impairment for a diagnosis

85
Q

Investigations for PTSD

A

Clinical diagnosis by a psychiatrist using diagnostic criteria from DSM5 or ICD-11.

Screening tool such as Trauma Screening Questionnaire (TSQ) can be used in primary care.

86
Q

Management for PTSD

A

Moderate/severe PTSD - referral to psych for psychotherapy/pharmacotherapy (e.g. SNRI venlafaxine or SSRI sertraline)

1st line psychotherapy: Trauma-focused CBT)

More severe cases - eye movement desensitisation and reprocessing (EMDR) therapy

Risk assessment for
risk of self-harm/suicide

87
Q

Define intellectual disability

A

Intellectual disability may be either generalised (cognitive impairment) or specific to one area (learning difficulty). Children with cognitive impairment have below-average IQ, at <70.

88
Q

What are the classifications for intellectual disability?

A
  • Normal IQ between 85 and 115
  • Borderline – IQ 70 - 85
  • Mild – 50 - 69
  • Moderate - 35 - 49
  • Severe – 20 - 35
  • Profound - below 20
89
Q

What are some causes of intellectual disability?

A

Prenatal:
- Genetic syndromes (e.g., Down syndrome and Fragile X syndrome)

  • Inborn errors of metabolism
  • Brain malformation (e.g., microcephaly)
  • Environmental influences (e.g., alcohol)

Perinatal:
- Prematurity / birth anoxia

Post natal:
- Hypoxic ischemic injury
- Traumatic brain injury
- Infections

90
Q

Give some examples of intellectual disabilities

A
  • Downs syndrome
  • Turners
  • Phenylketonuria [phenylalanine hydroxylase gene and enzyme dysfunction]
  • Fetal alcohol syndrome
91
Q

What are the investigations for intellectual disability?

A

Thorough history including: antenatal and perinatal Hx, developmental milestones, FHx, SHx, schooling, hospital admissions

Tests for measuring IQ:

  • Wechsler Adult Intelligence Test (WAIS)
  • WISC (Wechsler Intelligence Scale for Children)
  • IQ = (Mental Age / Chronological Age) X 100
92
Q

Management for Intellectual disability

A
  • Primary prevention: education, antenatal care, vaccination,
    social, genetic testing and counselling.
  • Secondary prevention: e.g. phenylketonuria diet
    before development of symptoms
  • Tertiary prevention psychopharmacology: antipsychotics, antiepileptics,
    behavioural strategies
  • Occupational Therapy
  • CBT, mindfulness
  • Mental Health Act
93
Q

What is concrete thinking?

A

A lack of abstract thinking, in adults this may be due to organic disease or schizophrenia.

94
Q

Define loosening of association.

A

A lack of logical association between thoughts, often leads to incoherent speech. It is impossible to follow the patients train of thought.

95
Q

Define circumstantiality.

A

Irrelevant wandering in conversation, patient eventually gets to the point.

96
Q

What is perseveration?

A

Repetition of a word, theme or action.

97
Q

What is confabulation?

A

Giving a false account to fill a gap in memory. This is often seen in dementia patients.

98
Q

Define somatic passivity.

A

The delusional belief that one is a passive recipient of bodily sensations from an external agency.

99
Q

Define catatonia.

A

Excited or inhibited motor activity in the absence of a mood disorder or neurological disease.

100
Q

What is psychomotor retardation and in what conditions would it be present?

A

Slowing of thoughts and movements.

It can be seen in depression, Parkinson’s disease etc.

101
Q

What is Wernicke’s encephalopathy?

A

Wernicke’s encephalopathy is a neurological disorder caused by a deficiency in thiamine (Vitamin B1), most commonly arising from chronic alcohol abuse.

102
Q

What is the classic triad of Wernicke’s encephalopathy?

A
  • confusion
  • ataxia,
  • ophthalmoplegia (weakness of eye muscles) or nystagmus

All three signs do not need to coexist in a single patient for diagnosis

103
Q

What can Wernicke’s develop into?

A

Korsakoff’s syndrome

  • Profound anterograde amnesia
  • Limited retrograde amnesia
  • Confabulation (patients fabricate memories to mask their memory deficit)
104
Q

Investigations for Wernicke’s

A

Thiamine level: low

Blood tests: FBC, U+E, Liver Profile, Clotting, Bone Profile, Magnesium

Neuroimaging: MRI shows typical changes and mamillary body atrophy in Korsakoff’s syndrome.

105
Q

Management for Wernicke’s + Korsakoff’s syndrome

A
  • Thiamine supplement
  • Counselling and rehabilitation for
    alcohol use disorders.

Korsakoff’s syndrome

  • Ongoing thiamine supplement
  • Cognitive rehabilitation
  • Treatment of underlying causes, like alcoholism through counselling and support
106
Q

Define somatic symptom
disorder

A

A group of mental disorder that manifest as patient-experienced physical symptoms that suggest illness. However, these symptoms cannot be explained by an underlying medical condition or other mental disorder (e.g. anxiety, depression)

107
Q

What are the different types of somaisation disorder?

A

Divided into whether patients voluntarily or involuntarily experiences symptoms

Involuntary:
- Somatisation disorder
- Functional neurological (conversion) disorder

Voluntary:
- Malingering
- Factitious disorders

108
Q

What is functional neurological disorder?

A

Functional neurological disorder (FND), involves symptoms of impaired motor or sensory function, which cannot be explained by medical evaluation.

E.g. psychogenic non-epileptic seizures : no tongue-biting or incontinence and no abnormal EEG findings

109
Q

What is somaisation disorder?

A

The experience of multiple physical symptoms that persist for at least 2 years despite no organic explanation.

Hypothesised that patients might have difficulty expressing emotional distress and instead attribute their distress to physical symptoms.

Typical symptoms include:

  • Pain
  • Gastrointestinal upset
  • Sexual problems
  • Pseudoneurologic symptoms
    The patient will refuse to accept reassurance or negative test results.
110
Q

What is factitious disorder?

A

Factitious disorder imposed on self (Munchausen syndrome)

  • Deliberately producing, feigning, or exaggerating symptoms, intention = sick role and centre of attention

Factitious disorder imposed on another (Munchausen’s by proxy)

  • caregiver fabricates, embellishes or causes an illness or injury in a person under their care
111
Q

What is malingering?

A

Intentional production of false or exaggerated physical or psychological symptoms, motivated by external incentives e.g. avoiding work, financial gain.

112
Q

What is illness anxiety disorder?

A

Excessive worry about having a serious illness, despite having no or only mild symptoms.

Main concern = fear of illness not symptoms themselves.

Persistent belief that they have an underlying serious illness despite negatibe tests e.g. lung cancer because they have a cough

113
Q

What is the general management plan for somatic symptoms disorder?

A
  • Managing associated psychiatric or physical conditions
  • CBT
  • Family therapy
114
Q

Define “Mental health act”

A

In England and Wales, the Mental Health Act 1983 as
amended by the Mental Health Act 2007 (MHA) provides
a legal framework for the care and treatment of individuals
with mental disorders.

Divided into “sections “.

115
Q

What is section 135 and 136?

A

S135 – allows police with court order to access patient’s home and remove them

S136 – allows police to remove person with suspected/confirmed mental
disorder in a public place

to a place of safety for assessment and treatment

116
Q

Define “Mental capacity act”

A

Mental Capacity Act 2005 (MCA) defines mental capacity as the ability of an individual to make their own decisions. An individual (aged 16years or older) has the capacity to make a specific decision if they can:

  • communicate their decision,
  • understand information given to them to make a
    particular decision,
  • retain that information, and
  • Balance or weigh up the information to make the
    decision.
117
Q

Acronym for capacity assessment

A

CURB

(Communicate, Understand, Retain, Balance)

118
Q

Key parts of the mental capacity act

A
  • Assume capacity – until proven otherwise
  • Maximise decision-making capacity by providing support
  • Freedom to make seemingly unwise decisions

Best interests - if decision made on person’s behalf

  • Least restrictive option – if making decision on someone’s behalf, the one that achieves the goal while interferes least with person’s freedom must be chosen
119
Q

Define psychotherapy

A

Psychological therapy describes the interaction between a therapist and a client that aims to impart beneficial changes in the client’s thoughts, feelings and behaviours.

120
Q

Name examples of MHA sections that doctors can enforce

A

Section 2 - 28 days. Compulsory detention for assessment, diagnosis, and treatment unknown, can be extended into section 3

Section 3 - 6 months. compulsory detention for assessment, diagnosis and treatment known

Section 5(2) - doctor’s holding powers - 72hrs. Allows time for Section 2 or Section 3 assessment.

121
Q

What is cognitive behavioural therapy?

A

CBT is a type of talking therapy that helps the patient learn more helpful ways of thinking and reacting in everyday situations. Changing the way they think, and what they do.

It combines behavioural and cognitive therapy, and focuses on current challenges rather than past experiences.

122
Q

What is CBT indicated for?

A

Depression, generalised anxiety, OCD,
PTSD, Eating disorder, psychosis.

123
Q

What is dialectical behavioural therapy?

A

DBT is based on CBT, but specifically designed for people with EUPD.

AIms to teach patients to:

  • Understand and accept difficult feelings
  • Learn skills to manage these feelings
124
Q

What is psychodynamic psychotherapy?

A

A type of talking therapy that focuses on connecting the past and present, and therefore helping the patient to understand unconscious processes that are giving rise to symptoms or difficult repeating patterns.

125
Q

What does “Dialectics” in DBT mean?

A

‘Dialectics’ means trying to balance seemingly contradictory positions

Balancing accepting yourself and your
experiences as you are and changing your behaviour at the same time

126
Q

What is family therapy?

A

Family attend together.

Therapist works with a family’s strengths to help family members think
about and try different ways of behaving with each other.

127
Q

What are SSRIs and their mechanism of action?

A
  • Selective Serotonin Reuptake inhibitor
  • Selective presynaptic blockade of serotonin reuptake pumps.
  • Antidepressant to treat depression, anxiety disorders, OCD
128
Q

Give examples of SSRIs

A
  • Fluoxetine
  • Sertraline
  • Citalopram
129
Q

What are SNRIs and their mechanism of action?

A
  • Serotonin and noradrenaline reuptake inhibitor.
  • Presynaptic blockade of both noradrenaline and serotonin reuptake pumps.
  • Treatment of depression, anxiety disorder
130
Q

Examples of SNRIs

A
  • Venlafaxine, duloxetine
131
Q

Name the drugs classed as mood stabilisers

A
  • Lithium
  • Valproate (epilepsy, acute mania)
  • Lamotrigine (epilepsy)
  • Carbamazepine (epilepsy)

Antipsychotics such as olanzapine and quetiapine are increasingly used too.

132
Q

Indications for lithium

A
  • Acute mania
  • Prophylaxis of bipolar affective disorder (prevention of
    relapse)
  • Treatment-resistant depression
133
Q

What is the therapeutic index for lithium and its side effects

A

0.4–1.0 mmol/L

  • Thirst, polydipsia, polyuria, weight gain

Toxic levels: >1.5 mmol/L

  • Nausea and vomiting, coarse tremor, ataxia, muscle weakness
  • Dangerously toxic levels: >2 mmol/L

nystagmus, dysarthria, impaired consciousness, hypotension, convulsions, coma

134
Q

Management of lithium toxicity

A

Supportive: adequate hydration, renal function and electrolyte balance.

  • Anticonvulsants for convulsions and haemodialysis if renal failure
135
Q

Name commonly used atypical (2nd gen) antipsychotics

A
  • Olanzapine
  • Quetiapine
  • Risperidone
  • Aripiprazole
  • Clozapine (if other antipsychotics fail)

Lower risk of extrapyramidal side effects (EPSE) than typical (1st gen) antipsychotics

136
Q

Antipsychotics MOA

A

Typical antipsychotics work as dopamine D2 receptor antagonists in the brain

Atypical antipsychotics work mainly as dopamine receptor antagonists ,as well as other receptors.

137
Q

Antipsychotics have major side effects and have a huge impact on patients’ QoL and concodence. What are the side effects?

A

Extrapyramidal side effects:

  • Parkinsonism (rigidity, bradykinesia, resting tremor)
  • Dystonia (involuntary muscle spasms/contractions)
  • Akathisia (restlessness)
  • Tardive dyskinesia (rhythmic involuntary movements)

Atypical antipsychotics

  • Metabolic syndrome (highest risk is olanzapine)
  • Diabetes, Hypertension, Obesity
  • Hyperprolactinaemia : highest risk with risperidone
  • QTc prolongation

Aripiprazole has a generally good side-effect profile

138
Q

What is a hynoptic?

A

A drug that induces sleep. Please note that hypnotics can also reduce anxiety at lower doses (e.g. benzos, anxiolytic at low dose, hypnotics at higher dose)

139
Q

What is an anxiolytic?

A

A drug that helps reduce anxiety. Please note that anxiolytics can also induce sleep at higher doses

140
Q

Give examples of benzodiazepines

A
  • Diazepam (long-acting)
  • Nitrazepam
  • Lorezepam (short-acting)
  • Chlordiazepoxide
141
Q
A
142
Q

Symptoms of alcohol withdrawal

A

Simple withdrawal (6-12 hours after last drink):

  • Insomnia
  • Tremor
  • Anxiety
  • Agitation
  • Nausea and vomiting
  • Sweating
  • Palpitations

Alcohol hallucinosis (12-24 hours post-drink):

  • Hallucinations of visual, tactile or auditory origin.
143
Q

Symptoms of delirium tremens

A

72 hours post-drink:

  • Delusions
  • Confusion
  • Seizures
  • Tachycardia
  • Hypertension
  • Hyperthermia
144
Q

Management of alcohol withdrawal

A

If > 15 units/ day or > 20 on AUDIT questionnaire (identifies alcohol dependency)

  • Chlordiazepoxide in a reducing regimen,based on CIWA score (severity of withdrawal) and local protocol.
  • Rapid-acting benzodiazepines (IV lorazepam) for seizures.
  • Pabrinex to prevent Wernicke’s encephalopathy.

1st line for delirium tremens - oral lorazepam

145
Q

Management of antipsychotic extrapyramidal side effects

A
  • Parkinsonism/dystonia - Anticholinergics e.g. procycline and consider reducing or switching meds
  • Akathisia - Propranolol or short-term benzo
  • Tardive dyskinesia - no effective treatment, consider benzo, withdraw antipsychotics
146
Q

What is neuroleptic malignant syndrome (NMS)?

A

A rare, life-threatening reaction to antipsychotics.

Hyperthermia is a hallmark feature.

Altered consciousness (confusion to catatonia), fluctuating BP, profuse sweating, “lead-pipe” rigidity

147
Q

Management of neuroleptic malignant syndrome

A

Discontinuation of causative med.

Supportive Care:

  • Cooling blankets and IV fluids
  • Bromocriptine: dopamine agonist
  • Dantrolene: muscle relaxant

Continuous monitoring of vital signs, and fluid balance

148
Q

Differentials for NMS

A

Serotonin Syndrome similar to NMS but associated with serotonergic medications.

Presents with hyperthermia, autonomic dysregulation, and altered mental status.

149
Q

What is serotonin syndrome?

A

A potentially life-threatening condition linked with increased serotonergic activity in the central nervous system.

Usually presents within few months of starting SSRI or drug interaction.

150
Q

Clinical features of serotonin syndrome

A

Triad of mental status changes, autonomic hyperactivity, neuromuscular abnormalities.

Mental status changes: agitation, restlessness, and disorientation.

Autonomic hyperactivity: hyperthermia, tachycardia, hypertension

Neuromuscular abnormalities: tremor, clonus, hyperreflexia, and in severe cases, seizures.

151
Q

Management of serotonin syndrome

A
  • Discontinue causative med
  • ABCDE
  • Supportive care
  • Hospitalisation if needed
  • Benzo or antiserotonergic agent cyproheptadine in moderate/severe cases
152
Q

What is delirium?

A

Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking and altered consciousness. Often seen in the elderly and can be life-threatening.

  • Hyperactive Delirium: increased psychomotor activity, restlessness, agitation, and hallucinations.
  • Hypoactive Delirium: lethargy, reduced responsiveness, and withdrawal.
  • Mixed Delirium
153
Q

Investigations for delirium

A
  • 4 As Test (alertness, AMT, attention, acute/fluctuating)
  • ECG, urine MC+S (not if > 65)
  • Bloods: FBC, U+E, LFT, TFT, cultures
  • Imaging: CXR, abdo US, MRI/CT head if no identifiable cause
154
Q

Management of delirium

A
  • Hospital admission for treatment and monitoring
  • 1st line: correct any precipitating factors : such as infection, medications, constipation, urinary retention, dehydration and pain
  • Optimise management of co-morbidities

Antipsychotics/ benzodiazepines: avoid if possible.

155
Q

What rare disease can clozapine cause?

A

Bone marrow suppression with agranulocytosis (severe neutropenia).

PAtients need FBC prior to treatment, then weekly FBCs for a few weeks then monthly FBCs for duration of treatment.

156
Q

Risk factors for suicide

A
  • Current suicidal plan
  • Hx of self harm
  • Hx of mental illness including substance misuse
  • Hx of childhood abuse/neglect
  • FHx
  • Male sex
  • Physical illness (e.g. chronic pain)
  • Marital status - single/widowed/divorced
  • Professions (un/self-employed, doctors, dentists, farmers)
157
Q

What is the management plan for a patient presenting to A+E with self harm/suicidal ideation/suicide attempt?

A

Firstly, ensure the patient’s and your safety.

Psychiatric assessment covering:

  • Current suicide intent
  • Access to lethal means
  • Risk and protective factors using biopsychosocial model
  • FInal acts: making a will, goodbye texts, giving possessions away.
158
Q

After the psychiatric assessment and ensuring safety, what is the ongoing management plan for patients with suicidal ideation/self harm/suicide attempt?

A
  • Determine treatment setting - section if needed
  • Safety plan - regular reviews
  • Assessment for psychotherapy
  • Treat any underlying psychiatric illness
159
Q

What is electroconvulsive therapy?

A

A treatment that involves sending electric currents through the patient’s brain. Carried out under general anesthesia.

Once anesthesia is applied - lasting 5 mins.

  • Psychiatrist attaches 2 electrodes to patient’s head and electric current passed through for 15 secs - induces seizure.

Done with patient consent, or if patient does not have capacity and ET is in their best interest then opinion from second psychiatrist is needed.

160
Q

What are the indications for ECT?

A
  • Treatment resistant depression
  • Severe mania
  • Certain types of schizophrenia - catatonic states, positive psychotic symptoms and schizoaffective disorder.
161
Q

Side effects of ECT

A

Loss of memory, confusion, headache, nausea and muscle pains

162
Q

Tests prior to starting antipsychotics

A
  • FBC
  • TFT
  • Lipid profile
  • HbA1c
  • ECG (antipsychotics can cause QT interval prolongation
163
Q

Clinical features of opioid overdose

A
  • Drowsiness
  • Confusion
  • Decreased respiratory rate
  • Decreased heart rate
  • Constricted pupils
  • Track marks (if IVDU)
164
Q

What to give in acute opioid overdose?

A

Naloxone

165
Q

Clinical features of cocaine overdose?

A
  • Tachycardia
  • Hypertension, - Hyperthermia
  • Diaphoresis (excessive sweating)
  • Mydriasis (dilated pupils)
  • Agitation.
166
Q

What to give when a patient has cocaine toxicity (overdose)?

A

-Non-body packer

  • Benzos e.g. diazepam for seizure, HTN, agitation
  • IV saline
  • External cooling
  • Monitoring until vitals have returned to baseline
  • Body packer - bowel irrigation or surgery
167
Q

Clinical features of amphetamine overdose

A

Tachycardia, hyperthermia, volume depletion, agitation (sometimes aggression), seizures, and rhabdomyolysis

Diagnosis = high index of suspicion and urine drug screen.

168
Q

Management of amphetamine overdose

A

If mild - supportive care + reassurance

Otherwise - active cooling, IV fluids, sedation with benzodiazepine

169
Q

Clinical features of benzodiazepine overdose

A

Risk factor presence - depression, alcohol and illicit drug use

  • Main symptom is excessive sedation but excessive sedation, bit coma, respiratory depression, and even death present if larger doses.
170
Q

Management of benzo overdose

A

ABCDE assessment, fluid resus, supportive symptom management e.g. assisted ventilation in resp depression

171
Q

Clinical features of tricyclic antidepressant overdose

A
  • Drowsiness
  • Confusion
  • Cardiac arrhythmias
  • Seizures
  • Vomiting
  • Headache
  • Flushing
  • Dilated pupils
172
Q

Management for tricyclic antidepressant overdose

A
  • Consider ICU admission
  • Check ECG for QRS prolongation - administer sodium carbonate bolus then infusion
  • Consider activated Charcoal within 2-4 hours of overdose
  • Consider invasive ventilation
  • IV fluids
173
Q

Clinical features of paracetamol overdose

A

Broad symptoms

  • No symptoms
  • Nausea and vomiting
  • Haematuria and proteinuria
  • Jaundice
  • Abdominal pain
  • Coma
174
Q

Investigations for paracetamol overdose

A

FBC, U+E, LFT, clotting, VBG (severe metabolic acidosis), blood paracetamol levels.

Treatment decisions guided by nomogram

175
Q

Management of paracetamol overdose if ingestion < 1 hr ago and > 150mg/kg

A

Administer activated charcoal

176
Q

Paracetamol OD: management if ingestion < 4 hrs ago

A

Wait until 4 hours to take level and treat with N-acetylcysteine based on level

177
Q

Paracetamol OD: management of ingestion 4 - 8 hrs ago + DOSE >150mg/kg

A

N-acetylcysteine immediately if ≥8 hrs getting levels

178
Q

Define tolerance

A

Tolerance in substance misuse is when the body gets used to the substance after long term and they consume higher doses of the drug to obtain the same drug-reinforcing effect

179
Q

Paracetamol OD: management if Ingestion within 8-24 hours + dose >150mg/kg

A

Start N-acetylcysteine immediately

180
Q

Define withdrawal

A

A group of symptoms that occur upon cessation or reduction in the use of a drug.

181
Q

Paracetamol OD: management if ingestion > 24.hrs ago

A

Start N-acetylcysteine immediately if patient has:

  • Jaundice, right upper quadrant tenderness, elevated ALT, INR >1.3 or detectable paracetamol conc
182
Q

Physical consequences of excess alcohol consumption

A

Weight gain
Malnutrition
Liver cirrhosis

Withdrawal symptoms

  • Increased autonomic activity, agitation, and nervousness.
  • Generalised seizures and a confusional state (delirium) = severe cases.
183
Q

Management of paracetamol staggered overdose

A

Start N-acetylcysteine immediately

184
Q

Social consequences of excessive alcohol consumption

A

Adverse impacts on interpersonal relationships
Failure to fulfil obligations at home, school or work
Violence when under the influence leading to domestic violence etc.

185
Q

Paracetamol OD: when should liver transplant be considered?

A

If blood tests are worsening

The King’s College Criteria predicts mortality from paracetamol overdose and advises urgent liver transplant when:

- Arterial pH Less than 7.3

OR,allof:
- Serum creatinine > 300 µmol/L (3.4 mg/dL)
- Prothrombin time >100 s
- Grade III or IV encephalopathy

186
Q

What is the harmful use of a substance according to ICD10?

A

A pattern of psychoactive substance use that is causing damage to health including physical and mental.

187
Q

What is dependency syndrome?

A

A cluster of behavioural, cognitive, and physiological patterns that develop after repeated substance use:

  • A strong desire to take the drug
  • Difficulties in controlling use
  • Persisting in its use despite harmful consequences
  • Higher priority given to drug use than to other activities
  • Increased tolerance
188
Q

Management for alcohol dependence

A

Assisted alcohol withdrawal if needed

Psychotherapy/psychosocial treatment e.g. CBT or outpatient addiction treatment programmes & naltrexone

189
Q

What are the short-term effects of heroine use?

A

Euphoria, drowsiness, apathy, personality change

190
Q

What are the long-term effects of heroine use?

A
  • Infective endocarditis
  • Increased risk of infections such as HIV/hep B due to needle sharing
  • Abscesses
  • Severe constipation.
  • Depression
  • Heroin use disorder.
191
Q

MOA of benzodiazepines

A

Benzodiazepines potentiate the action of GABA (γ- aminobutyric acid), the main inhibitory neurotransmitter in the brain, by being positive allosteric modulators of GABA.

192
Q

Indications of benzos

A
  • Insomnia, especially short-acting benzodiazepines (short-term use only)
  • Anxiety disorders (short-term use only)
  • Alcohol withdrawal, especially chlordiazepoxide
  • Acute mania or psychosis (sedation)
193
Q

Side effects of benzos

A

Risk for developing dependence, especially with prolonged use and shorter acting drugs (e.g. lorazepam)

194
Q

What are phobias?

A

Phobias represent a cluster of anxiety disorders characterized by excessive and irrational fears.

It encompresses specific phobia, social anxiety disorder (SAD), and agoraphobia.

195
Q

What is agoraphobia?

A

ICD-11 criteria: Fear of open spaces, presence of crowds or the perceived difficulty of immediate easy escape to a safe place.

196
Q

What is social anxiety disorder?

A

ICD-11 criteria: Fear of scrutiny by others in relatively small groups (as opposed to crowds), resulting in the avoidance of social situations.

Might be specific (public speaking) or generalised (any social setting)

197
Q

Management of agoraphobia/social anxiety disorder/ other phobias

A

CBT is 1st line for all phobias

Exposure techniques - aiming for systematic desensitization (using a graded hierarchy approach, for example).

Flooding - exposing someone with a fear of heights to a tower

Modelling - individual observes therapist interacting with phobic stimulus.

198
Q

Define panic disorder

A

Recurrent unpredictable episodes of severe acute anxiety, which are not restricted to particular stimuli or situations.

ICD-11 Criteria:

  • Recurrent, unexpected panic attacks.
  • At least one attack followed by a month of persistent concern.
  • Avoidance behaviors related to attacks.
199
Q

Clinical features of panic disorder

A
  • Difficulties in breathing
  • Chest discomfort
  • Palpitations
  • Hyperventilation
  • Shaking, sweating, dizziness
  • Depersonalization/derealization.
  • Fear of triggering situations
  • Development of a conditioned fear-of-fear pattern.
  • Concurrent agoraphobia in 30 - 50%
200
Q

Differential diagnosis for panic disorder

A
  • GAD, agoraphobia
  • Depression
  • Alcohol or drug withdrawal.

-Organic causes like cardiovascular/respiratory diseases, hypoglycemia

201
Q

Management of panic disorder

A

1st line is CBT

1st line pharmacotherapy (2nd line to CBT) is SSRI like sertraline

Propranolol for physical symptoms

202
Q

What is attachment theory?

A

It is the theory that the bond between a child and their primary caregiver can set the tone for the child’s expectations of interpersonal relationships for the rest of their life.

203
Q

What is secure attachment?

A

Caregivers were responsive, understanding, consistent.

Child behaviour: happy, curious

Adult attachment style: autonomous

Adult behaviour: able to self-soothe, but also able to maintain relationships.

204
Q

What is avoidant attachment?

A

Caregivers were aloof, unresponsive, ridiculing

Child behaviour: emotionally distant, withdrawn

Adult attachment: ‘Dismissive’

Adult behaviour: Desire to be independent. Avoidance of intimacy.

205
Q

What is ambivalent/resistant attachment style?

A

Caregivers were sometimes sensitive, sometimes ignores

Child was anxious, uncertain, angry

Adult attachment: ‘Preoccupied’

Adult behaviour: Hypersensitive to rejection, care-seeking.

206
Q

What is disorganised attachment style?

A

Caregivers were abusive, scary, scared

Child was sad, angry, fearful

Adult attachment style: ‘Disorganized’

Adult behaviour: Fearful, abusive, dissociative.

207
Q

What is phenomenology?

A

Phenomenology is the understanding and description of abnormal psychological events, the internal experiences of the patient and the resulting behaviour.

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