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brs missed out > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is involved in a mental state examination?

A

A + B = Appaerance and Behaviour
Speech
Mood
Perceptions
Thought Content
Thought form
Insight
Cognition

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2
Q

Features of Adjustment disorder

A
  • Recemt psychosocial stress
  • Mood lability and preoccupation on stress
  • Typically resolves after 6 months
  • Psychotic symptoms not normally seen
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3
Q

Features of psychotic depression

A
  • recent psychosocial stressors
    -Older age and chronic medical condition
    -Core features of depression
    -Mood congruent psychosis seen (delusions of nihilsm, guilt, Cotard’s syndrome)
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4
Q

Behavioural and psychological symptoms of dementia

A
  • Known history of recent vascular insult to brain
    -Delusions and hallucinations
    -Ongoing vascular risk factors
  • Abnormal MoCA score
    Cognitive concerns
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5
Q

Post stroke psychosis

A
  • Most commonly seen in right sided middle cerebral artery lesions of frontal and temporal lobe
  • delusions mostly persecurtory or jealou type ( Othello’s syndrome)
  • auditory hallucinations followed by visual
    (maybe psychotics but increase risk of stroke)
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6
Q

What mental health presentations do these conditions often show?
-Thyrotoxicosis
- Thyroid deficiency
- Cushing’s disease
- Infections (syphilis, HIV)
- Cancer
- Parkinson’s disease

A

Thyrotoxicosis → anxiety, mania
- Thyroid deficiency → depression, dementia
- Cushing’s disease → depression
- Infections (syphilis, HIV) → psychosis
- Cancer → depression
- Parkinson’s disease → depression, anxiety, dementia

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7
Q

Three classifications of delirium and their presentation

A

Hyperactive - agitation, hallucination, inappropriate behaviour
Hypoactive - lethargy, reduced concentration, reduced alertness, reduced oral intake
Mixed

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8
Q

Short term extreme treatment for delirium

A

Haloperidol 0.5mg < 7 days

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9
Q

What factors affect the diagnosis of physical disorders in people with mental illness?

A
  • Stigma
  • Lack of resources/ access to services
    -Illness behaviour
    -Diagnostic overshadowing
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10
Q

What three categories of psychosis symptoms are there?

A

Disorganisation, Negative , Positive symptoms

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11
Q

What are examples of disorganisation symptoms in psychosis?

A

Bizarre behaviour
Formal thought disorder

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12
Q

What is the scale of severity for formal thought disorder?

A
  1. Circumstantial thought
  2. Tangential thought
  3. Flight of ideas
  4. Derailment
  5. Word Salad
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13
Q

What are the two categories of positive symptoms?

A

Hallucinations
Delusions

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14
Q

What examples of hallucinations exist?

A

Auditory
Visual
Somatic
Olfactory
Gustatory

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15
Q

What are examples of negative symptoms?

A

Alogia - poverty of speech
Anhedonia/ asociality
Avolition/ Apathy
Affective flattening face

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16
Q

What prodromal symptoms coincided with psychosis?

A

Increasing isolation
Poor self care
Social withdrawal
Declining academic performance

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17
Q

What is the name of the history taken from relatives and friends?

A

Corroborative history

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18
Q

What pharmacological treatment exist for psychosis and explain the side effects

A

Dopamine antagonist (mesolimbic dopamine system) - Risperidone
Extra pyramidal side effects (nigrostriatal) : Parkinsonian , Acute dystonic reactions, tardive dyskinesia, akathisia

Other side effects: Most systems including pituitary

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19
Q

What other drugs can be used for psychosis treatment?

A

Aripiprazole

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20
Q

What psychological support can be offered for people with schizophrenia

A

Avator therapy
CBT

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21
Q

DSM 5 criteria for depressive episode

A

2 weeks or more of depressive mood and 4/8
- Sleep alterations (insomnia or hypersomnia)
- Appetite alterations (increased or decreased)
- Diminished interest or anhedonia
- Decreased concentration
- Low energy
- Guilt
- Psychomotor changes ( agitation or redartation)
- Suicidal thoughts

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22
Q

Subtypes of DSM 5 MDD

A

Atypical - increased appetite, sleep, mood reactivity levels
Psychotic- delusions, hallucinations
Melancholic features - no mood reactivity, marked psychomotor retardation and anhedonnia

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23
Q

Manic episodes DSM-5 criteria

A

Euphoric or irritable mood with 3 or more of 7 criteria:
Decreased need for sleep with increased energy
Distractibility
Grandiosity or inflated self-esteem
Flight of ideas or racing thoughts
Increased talkativeness or pressured speech
Increased goal-directed activities or psychomotor agitation
Impulsive behaviour

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24
Q

According to DSM-v when would you diagnose bipolar I or II

A

minimum 1 week with notable functional impairment, a manic episode is diagnosed, leading to a DSM-5 diagnosis of type I bipolar disorder.

If such symptoms are present for at minimum 4 days, but without notable functional impairment, a hypomanic episode is diagnosed.

If not a single manic episode had occurred ever, but only hypomanic episodes are present, along with at least one major depressive episode, then the DSM-5 diagnosis of type II bipolar disorder is made.

If manic symptoms occur for less than 4 days, or if other specific thresholds are not met for manic or hypomanic episodes, then the DSM-5 diagnosis:

“Unspecified Bipolar Disorder”

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25
Q

Is insight usually preserved more in bipolar or depression?

A

Depression

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26
Q

What biases are present in depression?

A

Attention
Memory
Perceptual - facial emotion recognition
passive viewing of facial expression (amygdala)

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27
Q

What does the monoamine deficiency hypothosis of depression suggest?

A

depressive symptoms arises from a decrease in the monoamine neurotransmitters of serotonin (or 5-hydroxytryptamine , 5-HT), norepinephrine, and/or dopamine

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28
Q

Indirect evidence for the monoamine deficiency hypothesis

A
  1. Reduced levels of 5 HT in brains of people who commited suicide
  2. Reduced 5 HT receptors
  3. Clinically beneficial drugs work by increasing sunaptic monoamines
  4. Drugs causing redution in 5 HT show causal relationship with depressive symptoms
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29
Q

How would we measure receptor and transmission in living human brain

A

PET + radioactive tracer

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30
Q

Measuring release of cerebral 5-HT

A

using a 5-HT2A agonist PET tracer

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31
Q

What system in the brain do psychadelics work on?

A

Serotonin

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32
Q

Positive reinforcements and negative reinforcement in drug use

A

Positive: to gain positive experience
Negative: to overcome adverse experience

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33
Q

Dependence syndrome ICD 10

A

3 or more in the past year
1. a strong desire or sense of compulsion to take the substance

2.difficulties in controlling substance taking behaviour in terms of its onset, termination, or levels of use

3.a physiological withdrawal state when substance use has stopped or been reduced

  1. evidence of tolerance: need to take more to get same effect
  2. progressive neglect of alternative interests
  3. persisting with substance use despite clear evidence of overtly harmful consequences
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34
Q

Addiction vs dependence

A

Addiction - compulsive drug use despite harmful consequences, characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, (depending on the drug) tolerance and withdrawal.

In biology/pharmacology, dependence refers to a physical adaptation to a substance
so would see Tolerance/withdrawal

Eg opioid, benzodiazepine, alcohol

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35
Q

3 levels of problems to look for in alcohol abuse

A
  1. Quantity / Frequency: Hazardous use
  2. Consequences: Harmful use
  3. Pattern: Dependence/addiction
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36
Q

Acute alcohol affect on brain

A

NMDA receptor - Blocks excitatory system
- Impaired memory (alcoholic blackouts)

GABA A receptor - Boosts inhibitory system
-Anxiolysis
-Sedation

37
Q

Chronic alcohol affect in brain

A

Upregulation of stimulatory system
Switched subunits on GABA A receptor making it less sensitive to alcohol- tolerance

38
Q

Alcohol withdrawal state

A

Treat with benzodiazepines to boost GABA function

NMDA receptor:
increase in Ca2+

  • toxic leading to hyperexcitability (seizures) and cell death (atrophy)
39
Q

Three components of model of addiction

A

Impulsivity / Compulsivity
Reward deficiency
Overcoming adverse state

40
Q

How can you assess the reward/ motive pathway?

A

fMRI ventral striatum
50p if you click this, - 50p if you click this

41
Q

What region of brain involved in:
-binge/intoxication,
- withdrawal/negative affect,
- preoccupation/anticipation ‘craving’.

A

-Thalamus
-Hypothalamus
-Hippocampus, Pre frontal cortex

42
Q

How do you assess emotional processing of adverse images?

A

fMRI amygdala

43
Q

How do you assess neurocircuitry involved in inhibitory control

A

fMRI putamen and inferior frontal gyrus
go-no go

44
Q

Define these terms:
Intoxication
Withdrawal state
Tolerance
Harmful use

A

Intoxication

In both the DSM and ICD, intoxication is considered to be a transient syndrome due to recent substance ingestion that produces clinically significant psychological or physical impairment. These changes disappear when the substance is eliminated from the body

Withdrawal state

This refers to a group of signs and symptoms that occur when a drug is reduced in dose or withdrawn entirely

Tolerance

This is a state in which, after repeated administration, a drug produces a decreased effect. Increasing doses are therefore required to produce the same effect

Harmful use

A pattern of psychoactive substance use that is causing damage to health (physical or mental)

45
Q

Harmful Use ICD 10

A

A pattern of substance use that causes damage to health

The damage may be: (1) physical or (2) mental

Adverse social consequences

Harmful use includes bingeing on substances. Does not include ‘hangover’ alone

Does not fulfil any other diagnosis within substance use (e.g. dependence)

ICD 11 ( Harm to others health)

46
Q

ICD 11 Dependence

A

Impaired control over substance use (i.e. onset, frequency, intensity, duration, termination, context)

Increasing precedence of substance use over other aspects of life (e.g. repeated relationship disruption, occupational or scholastic consequences, negative impact on health)

Physiological features indicative of neuroadaptation to the substance, (e.g. tolerance, withdrawal, use of pharmacologically similar substances to prevent or alleviate withdrawal symptoms.

The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if use is continuous (daily or almost daily) for at least 3 months

47
Q

DSM5 dependence and harmful use

A

Mild Moderate Severe
Opioid Use Disorder

Alcohol Use Disorder#

48
Q

Substance misuse history

A

Length of current use and when last used

Current amount (units/grams/£ per day) and for how long at this level

Total length of use, maximum use and any periods of abstinence

Mode/method of administration (e.g. inhalation, ingestion, IV)

Evidence of withdrawal syndrome and severity (e.g. seizures, admissions)

Any previous treatments - medication, psychotherapy, detox/rehab admissions

Any previous substance overdoses (accidental vs deliberate)

Assess triggers to use substances/alcohol

Assess motivation to change/engage in treatment

49
Q

Unit equation alcohol

A

Unit equation: % strength x ml /1000 = units

50
Q

Pharmacology of alcohol
Absorption
Pharmacodynamics
Metabolism

A

Absorption
Alcohol is well absorbed
maximum blood concentration is reached within 60 minutes of ingestion.
slowed by food
sped up by the ingestion of effervescent drinks
widely distributed in all bodily tissues

Pharmacodynamics
enhances neurotransmission at GABA-A receptors (causing anxiolysis).
stimulates dopamine release in the mesolimbic system (causing reward)

inhibits NMDA mediated glutamate release (leads to its amnesic effects)

Metabolism

Ethanol is oxidised by alcohol dehydrogenase to acetaldehyde –> oxidised by acetaldehyde dehydrogenase to carbon dioxide and water.
1 unit of alcohol (8g) can be metabolized per hour.
Illicit brew may contain methanol which is broken down to formaldehyde and causes marked toxicity on the retina

51
Q

Alcohol impact assessment

A

Examination:
Jaundice, bruising, clubbing, oedema, ascites, spider naevi

Neurological signs:
Consider Wernicke’s encephalopathy (ataxia, confusion, ophthalmoplegia) and Korsakoff’s syndrome (memory impairment)

Investigations:
Liver Fibro scan / Ultrasound
Bloods (LFTs, FBC, GGT, lipids, clotting, amylase)
Breathalyser
Urine Drug Screen

52
Q

CAGE screening

A

Have you ever felt you needed to Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt Guilty about drinking?

Have you ever felt you needed a drink first thing in the morning (Eye-opener)

53
Q

Opiates vs. Opioids

A

Opiates refer to natural opioids such as morphine and codeine and heroin to some extent

Opioids refer to all natural, semisynthetic and synthetic opioids

54
Q

What do opiods do?

A

Relieve pain - Analgesic effect
Create a sense of Euphoria in high doses
Endogenous opioids (endorphins) regulate pain and mood

55
Q

Aspect of opiod assessment

A

Examination:
Collapsed veins / track marks
Endocarditis (murmurs, splinter haemorrhages)
Skin abscesses
Signs of Hepatitis / HIV
Pneumonia

Investigations:
Bloods (FBC, LFT, U&E, GGT, Glucose, CRP, BBB viral screen)
Breathalyser
Urine Drug Screen
Blood cultures (endocarditis)

56
Q

Drug given following opioid overdose

A

Naloxone

57
Q

What three ways are there to categorise drugs and what is their pros and cons?

A
  1. Chemical structure
    WHO classification system does
    —-Pro- each drug has a unique structure = a fact , easy to allocate data
    —Con – no use in clinical decision making
  2. Based on what illness it treats
    Pros – easy for Drs to choose a drug as docs make diagnosis
    Con –1. many psychiatric medicines work in several disorders
    Con- 2. most psychiatric disorders have multiple symptoms and a single medicine might not treat them all
  3. Based on their pharmacology e.g Beta blockers
58
Q

What psychiatric diseases are associated with excess glutamate?

A

Epilepsy
Alcoholism

59
Q

What psychiatric diseases are associated with excess dopamine?

A

Psychosis

60
Q

What psychiatric diseases are associated with excess noradrenaline?

A

Nightmares

61
Q

What psychiatric disorders are associated with acetylcholine deficiency?

A

Impaired memory/ dementia

62
Q

What psychiatric conditions are associated with a deficiency in 5 HT?

A

Depression, Anxiety

63
Q

What psychiatric conditions are associated with a deficiency in GABA?

A

Anxiety

64
Q

What medication can you use to treat nightmares?

A

Prazosin - noradrenaline blocker

65
Q

What medication can you use to treat dementia?

A

Acetylcholine esterase enzyme blockers

66
Q

4 Ps formulation in CAMHS

A

Predisposing factors

Precipitating factors

Perpetuating factors

Protective factors

67
Q

Conditions seen in CAMHS (10)

A

Anxiety disorder
Somatisation (bodily distress disorder)
Depressive disorder
Autistic spectrum disorder
ADHD
Obsessive compulsive disorder
Tic disorder/Tourette’s syndrome
Substance misuse
Self-harm
Eating disorder (anorexia nervosa)

68
Q

DSM-5 criteria ADHD core features

A

Persistent pattern of inattention and/or hyperactivity-impulsivity

Present for at least 6 months

Inappropriate for their developmental level

Interferes with functioning or development

Several symptoms present before age 12

Several symptoms present in two or more settings

The symptoms are not better explained by another mental disorder

69
Q

Inattention vs Hyperactivity and Impulsivity

A

Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level

Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level

70
Q

Normal pressure hydrocephalus presentation

A

Hakim-Adams triad;
Cognitive impairment/confusion
Urinary frequency/incontinence
Gait disturbance (magnetic/stuck to the floor gait)

71
Q

Clinical features of mild dementia

A

Living independently but some supervision/support often needed

Can participate in community activities and can appear unimpaired to those who do not know them

Judgement and problem solving typically impaired

Social judgement may be preserved

Difficulty making complex plans/decisions and handling finances

72
Q

Clinical features of moderate dementia

A

Require supports to function outside the home and only simple household tasks are maintained

Difficulties with basic activities of daily living (ADL’s), such as dressing and personal hygiene

Significant memory loss

Judgment and problem solving are typically significantly impaired, and social judgment is often compromised

73
Q

Severe Dementia Clinical features

A

Severe memory impairment

Often disoriented to time and place

Often unable to make judgments or solve problems

May have difficulty understanding what is happening around them (situational awareness)

Dependent on others for basic personal care )bathing, toileting and feeding)

Urinary and faecal incontinence may emerge at this stage

74
Q

What kind of social history should you take from a person presenting with cognitive impairments?

A

Collateral

75
Q

What can restricted eating include?

A

Quantity, Range

76
Q

DSM5 Anorexia Nervosa

A

A. Restriction of energy intake relative to requirements leading to low body weight in personal context

B. Intense fear of weight gain/ becoming fat, persistent behaviour that interfers with weight gain

C.Disturbance in experience of weight/shape

77
Q

Subtypes of Anorexia Nervosa

A

Restricting vs Binge - eating/ Purge

78
Q

Bulimia Nervosa vs Binge Eating disorder

A

Similarities:
Over eating episodes ( sense of lack of control)
Weight : normal –> high
Guilt and shame
Differences:
Bulimia Nervosa - inappropriate compensatory mechanisms (vs none to little)
dietary restriction (vs none to little)
self induced vomiting (vs none to little)
excessive exercise ( vs not)

79
Q

Purging disorder ICD11

A

Recurrent purging behaviour to influence wieght or shape in the absence of binge eating

Weight: Normal

80
Q

Atypical AN = AN ICD 11
What are examples of this?

A

Purging disorder
OSFED
Atypical BN
Night eating syndrome

81
Q

ARFID summary

A

Feeding disturbance not caused by weight/shape concerns

Feeding disturbance:
Significant weight loss
Significant nutritional deficiency
Dependence on enteral feeding/ supplements

82
Q

Three main subtypes of ARFID

A
  1. Individuals who do not eat/ show little interest in eating
  2. Individuals who only accept a limited diet in relatio to sensory features
  3. Individuals whose food refusal is related to adverse experience
83
Q

What book can be referred to in managing medical emergencies in eating disorders?
What checklist for ED risk?

A

Medical emergencies in Eating Disorders

Appendix 4: Eating disorder risk checklist for emergencies

84
Q

What clinical information is used to assess risk to live in ED?

A

Weight Loss
BMI
HR
Cardio vascular health (BP, Syncope etc)

85
Q

T1DE checklist

A
  1. Intense fear of gaining weight , or body image concerns , or fear of insulin promoting weight gain
  2. Recurrent inappropriate direct or indirect restriction of insulin to prevent weight gain
  3. Presenting with a degree of insulin restrictiton/ concerning behaviour that lead to harmed health
86
Q

Psychological interventions for ED

A

Children and Young People
ED focussed Family Therapy
CBT
Adolescent focussed therapy (AN only)

Adults
MANTRA (AN only)
SSCM (AN only)
CBT

87
Q

What medication can be used to reduce emotional dysregulation during feeding?

A

olanzapine or aripiprazole to reduce emotional dysregulation during refeeding

88
Q

What is the triangle of care?

A

Service user, Carer, Professional

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