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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What are the different domains of a mental state examination?

A

ASEPTIC
- Appearance and behaviour
- Speech
- Emotion (mood and effect)
- Perception
- Thoughts (form and content)
- Insight and judgement
- Cognition

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2
Q

How is appearance and behaviour assessed in a mental state examination?

A

Appearance:
- personal hygiene (self-neglect?)
- clothing (appropriate for weather/circumstances?)
- physical signs of underlying problems (self-harm scars, IVDU, under/overweight)

Behaviour:
- engagement and rapport (reluctant, distracted, aggressive?)
- eye contact (reduced or intense?)
- facial expression (relaxed, fearful, appropriate?)
- body language (threatening, withdrawn, paranoia?)
- psychomotor activity (retardation, restless?)

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3
Q

How is speech assessed in a mental state examination?

A
  • Rate: rapid (thought abnormalities, mania) or slow (psychomotor retardation, depression)
  • Quantity: poverty of speech (depression), excessive speech (mania)
  • Tone: monotonous (depression, psychosis, autism), tremulous (anxiety)
  • Volume: quiet (depression), loud (mania)
  • Fluency and rhythm: stammering (anxiety, thought block), slurred (major depression, intoxication)
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4
Q

How is mood and affect assessed in a mental state examination?

A

Mood (subjective internal state, what the patient tells you):
- ask them how are you feeling, what is your current mood?
- examples: low, anxious, angry, euphoric, apathetic, elated

Affect (expressed and observed emotion):
- apparent emotion
- range and mobility of emotion (fixed, restricted, liable)
- intensity (heightened, blunted/flat)
- congruency (is affect in keeping with their thoughts)

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5
Q

How is thought assessed in a mental state examination?

A

Thought form:
- speed (fast/racing, or slow processing)
- flow and coherence (lose associations, tangential, flight of ideas, thought blocking, perseveration)

Thought content:
- delusions
- obsessions
- compulsions
- overvalued ideas
- suicidal thoughts
- homicidal/violent thoughts

Thought possession/interface:
- thought insertion (belief that thoughts can be inserted into the patients mind)
- thought withdrawal (belief that thoughts can be removed from patients mind
- thought broadcasting (belief that others can hear the patients thoughts)

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6
Q

How is perception assessed in a mental state examination?

A

Abnormalities of perception:
- hallucinations
- pseudo-hallucinations
- illusions
- depersonalisation
- derealisation

“Do you ever see, hear, smell, feel or taste things that are not really there?”
“Do you ever feel like you or the world around you isn’t real?”

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7
Q

How is cognition assessed in a mental state examination?

A
  • Are they orientated to time, place, and person
  • Using formal tests such as MMSE or AMTS
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8
Q

How is insight and judgement assessed in a mental state examination?

A

Insight (ability to understand they have a mental health problem and their experience is abnormal):
- do you think you have a problem at the moment?
- what do you think is causing the problem?
- do you feel you need help with your problem?

Judgement (ability to make sensible conclusions and consider decisions):
- may gain an understanding of this throughout the assessment
- ask specific scenarios like what would you do if you smell smoke in your house?

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9
Q

How is risk assessed in a mental state examination?

A

Risk to self:
- ask about any thoughts of harming themselves (deliberate self-harm, suicidal intent)
- assess intention, plans to act on thoughts
- any self-neglect? (eating and drinking, personal hygiene)
- any substance misuse?
- are physical health needs attended to?

Risk to others:
- ask about thoughts of harming others
- assess intention and plans to act on thoughts

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10
Q

What are the associated symptoms of a presenting complaint of depression?

A

Three core symptoms: low mood, low energy levels, lack of pleasure (anhedonia)

  • Disturbed sleep (increased or decreased)
  • Change in appetite and/or weight (increased or decreased)
  • Agitation or slowing down of movement and thoughts
  • Poor concentration
  • Lack of hope for the future
  • Feelings of worthlessness
  • Feelings of excessive or inappropriate guilt
  • Thought of self-harm, suicide, death
  • Reduced libido
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11
Q

What are the associated symptoms of a presenting complaint of mania?

A
  • Increased self-esteem
  • Recued social inhibitions
  • Over-familiarity
  • Reduced attention
  • Reckless spending
  • Inappropriate sexual encounters
  • Preoccupation with extravagant or impractical plans
  • Incomprehensible speech
  • Loss of insight
  • Self neglect
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12
Q

What are the associated symptoms of a presenting complaint of anxiety?

A
  • Generalised anxiety (worrying, unsettled, irritable, unable to relax)
  • Panic attacks (short of breath, chest pain, palpitations, specific triggers)
  • Phobias (fears that other people might find irrational)
  • Obsessions (worries that keep coming back)
  • Compulsions (actions that need to be carried out due to obsessive fears)
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13
Q

What are the symptoms of psychosis?

A

Hallucinations:
- auditory (associated with schizophrenia), visual, tactile
Delusions:
- paranoia, somatic, delusions of grandeur
- also thought withdrawal/insertion/broadcasting

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14
Q

What is important about past psychiatric history?

A
  • Existing psychiatric diagnosis (current presentation could indicate relapse, or lead to change in diagnosis)
  • Previous treatments (and their effectiveness)
  • Past contact with mental health services (primary care, community, crisis team, hospital admissions)
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15
Q

What personal history is needed as part of a psychiatric history?

A

Childhood:
- problems during pregnancy and birth
- meeting normal milestones growing up
- type of environment they grew up in
- relationships growing up
- any abuse
Education and school:
- did they enjoy school
- relationships with teachers and students
- problems with bullying
- what age and qualifications they left with
- how they coped leaving home for university
Occupation:
- coping at work
- type of employment/stress levels
- how long they’ve been in current jobs
- why they left previous jobs/were they dismissed
Relationships:
- establish immediate family and partner
- assess social support
- any recent significant events in family
- current or past problems affecting relationships
- any sexual or domestic abuse
Forensic:
- any contact with the police
- any time spent in prison
- history of aggression or violence
Pre-morbid personality:
- how they would be described by themselves or others
- emotional, cognitive, and behavioural personality traits

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16
Q

What social history is needed as part of a psychiatric history?

A

Living circumstances:
- homelessness?
- others at home
- children under their care
Activities of daily living:
- independent and coping looking after themselves (diet, personal hygiene)
- managing housework and financial concerns
Smoking:
- frequency and amount
Alcohol:
- frequency, type, volume
- assess dependence and symptoms of withdrawal
Recreational drugs:
- type and frequency

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17
Q

What are the indications for typical antipsychotics?

A
  • Schizophrenia
  • Mania
  • Agitation
  • Acute psychosis
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18
Q

List some common typical antipsychotics

A
  • Chlorpromazine
  • Haloperidol
  • Fluphenazine
  • Sulpiride
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19
Q

What is the mechanism of action of typical antipsychotics?

A
  • Dopamine receptor antagonists (D1/2) by inhibiting dopaminergic neurotransmission at D1 and D2 receptors
  • Also have noradrenergic, cholinergic, and histaminergic blocking properties
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20
Q

What are the side effects of typical antipsychotics?

A

Extrapyramidal side effects:
- acute dystonia (including oculogyric crisis)
- akathisia
- parkinsonism
- tardive dyskinesia
Anticholinergic side effects:
- dry mouth
- blurred eyes
- tachycardia
- vomiting
- constipation
- urinary retention
Others:
- sedation
- lowers seizure threshold
- neuroleptic malignant syndrome
- prolonged QT interval

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21
Q

What are the indications for atypical antipsychotics?

A
  • Schizophrenia
  • Bipolar affective disorder (acute and maintenance)
  • Adjunctive therapy for major depressive disorder, anxiety disorders, and PTSD
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22
Q

What is the mechanism of action for atypical antipsychotics?

A
  • Dopamine and serotonin antagonists, blocking the D2 dopamine receptors and the 5-HT2A serotonin receptors
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23
Q

List some common atypical antipsychotics

A
  • Clozapine
  • Quetiapine
  • Risperidone
  • Olanzapine
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24
Q

What are the side effects of atypical antipsychotics?

A
  • less likely to cause EPSEs except risperidone
  • Weight gain
  • Drowsiness
  • Hyperprolactinaemia
  • Hypertension or orthostatic hypotension
  • Impaired fasting glucose and lipid profile
  • Specifically clozapine = hypersalivation, anticholinergic side effects, agranulocytosis, leukopenia
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25
Q

Describe neuroleptic malignant syndrome

A
  • Rare but life-threatening condition seen if patients on antipsychotics, from a single dose or if they are increased/switched (also other dopaminergic drugs for Parkinson’s if these are stopped/reduced)
  • Clinical features: pyrexia, muscle rigidity, altered mental state, autonomic dysfunction (tachycardia, fluctuating blood pressure, excessive swelling/saliva)
  • Management: stop antipsychotic, IV fluids, dantrolene (muscle relaxant), bromocriptine (dopamine agonist), benzodiazepine
  • Complications: rhabdomyolysis, shock, kidney failure, seizures, DIC, PE
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26
Q

What monitoring is needed for antipsychotics?

A
  • FBCs, U&Es, LFTs: before initiation then annually, clozapine needs white blood cell monitoring weekly for 18 weeks then fortnightly up to 1 year, then monthly
  • Fasting blood glucose: at baseline, at 4-6 months, then annually, clozapine and olanzapine also at 1 month
  • Lipids: baseline, 3 months, annually
  • ECG: before initiating if cardiovascular risk factors, monitoring advised for haloperidol
  • Blood pressure: before initiation, and frequently during dose titration
  • Prolactin: baseline, 6 months, annually
  • Weight/BMI: baseline, then frequently for 3 months, then annually
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27
Q

What are the classes of antidepressants, list some examples of each drug?

A

SSRIs (selective serotonin reuptake inhibitors)
- fluoxetine
- sertraline
- citalopram
SNRIs (serotonin noradrenaline reuptake inhibitors)
- duloxetine
- venlafaxine
TCAs (tricyclic antidepressants)
- clomipramine
- amitriptyline
- nortriptyline
NASSAs (noradrenaline and specific serotoninergic antidepressants)
- mirtazapine
MAOIs (monoamine oxidase inhibitors)
- phenelzine
- isocarboxazid

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28
Q

What are the indications for different types of antidepressants?

A
  • SSRIs: first line for mild/moderate depression, also used in generalised anxiety disorder, panic disorders, PTSD, OCD, safer in overdoses
  • SNRIs: may have a better effect in more severe depression, also used in anxiety disorders, social phobia, chronic nerve pain, migraine prevention, ADHD
  • TCAs: older with more side effects and dangerous in overdose, may be used in severe depression, OCD, chronic nerve pain
  • MAOIs: used as last line for depression as serious side effects
  • NASSAs: useful in treating depression alongside anxiety disorders or insomnia, cause less sexual dysfunction, used if weight gain would be beneficial
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29
Q

What are the side effects of SSRIs and SNRIs?

A
  • Nausea and vomiting
  • Weight loss or weight gain
  • Diarrhoea or constipation
  • Increased anxiety
  • Loss of libido/sexual dysfunction
  • Dizziness
  • Headaches
  • Palpitations
  • Excessive sweating
  • Drowsiness or insomnia
  • Increased suicide risk (rare, most likely in under 25s)
  • Hyponatraemia (in elderly particularly with SSRIs)
  • Serotonin syndrome (rare)
  • Reduced seizure threshold or prolonged seizures
  • Induction of manic episode if history of mania
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30
Q

What are the side effects of TCAs?

A
  • Dry mouth
  • Blurred vision
  • Constipation
  • Urinary retention
  • Drowsiness
  • Weight gain
  • Excessive sweating
  • Postural hypotension
  • Cardiac arrhythmias and toxicity in overdose
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31
Q

What are the side effects of MAOIs?

A
  • Postural hypotension
  • Drowsiness or insomnia
  • Nausea
  • Weight gain
  • Muscle pain and myoclonus
  • Paraesthesia
  • Sexual dysfunction
  • Hypertensive crisis due to dietary interaction of high-tyramine foods
  • Serotonin syndrome (2 week wash out period if starting new antidepressant)
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32
Q

What are the side effects of NASSAs?

A
  • Nausea or vomiting
  • Dizziness/postural hypotension
  • Drowsiness
  • Increased appetite and weight gain
  • Dry mouth
  • Constipation or diarrhoea
  • Tremor
  • Anxiety or abnormal dreams
  • Serotonin syndrome
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33
Q

What are the contraindications for antidepressants?

A
  • SSRIs: mania (unless with mood stabiliser), on NSAIDs (without PPI), on heparin/warfarin
  • SNRIs: mania, cardiac arrhythmias, uncontrolled hypertension
  • NASSAs: pregnancy/breast feeding, glaucoma, psychoses, history of seizures
  • TCAs: recent MI, cardiac arrhythmias (QT prolongation), mania, agranulocytosis
  • MAOIs: acute confusional states
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34
Q

Describe serotonin syndrome (cause, features, management)

A
  • Rare but life threatening complication of increased serotonin, usually rapidly occurring within minutes of taking the medication
  • Cause: most commonly SSRIs, but also TCAs and lithium
  • Clinical features: cognitive effects (headache, agitation, confusion, hallucinations, hypomania, coma), autonomic effects (shivering, sweating, hyperthermia, hypertension, tachycardia), somatic effects (myoclonus, hyperreflexia, tremor)
  • Management: stop offending drug, supportive measures
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35
Q

What are the different classes of anxiolytics, list some examples?

A

Benzodiazepines:
- lorazepam (short acting), diazepam (long acting)
Azapirones:
- buspirone, gepirone, tandospirone
Sedative antihistamines:
- hydroxyzine
Beta-blockers:
- propranolol, atenolol

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36
Q

What are the indications for benzodiazepines?

A
  • Relieves acute anxiety (short-term management)
  • Used in panic disorders, sleep disorders, acute behavioural disturbance, muscle spasm, and premeditation and sedation for procedures
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37
Q

What is the mechanism of action for benzodiazepines?

A
  • Bind selectively to GABA receptors to improve the binding of GABA to increased the opening of chloride ion channels
  • Higher levels of intracellular chloride makes depolarization more difficult so reduces the excitability of nerve cells to slow the nervous system down
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38
Q

What are the side effects of benzodiazepines?

A
  • Drowsiness and over sedation
  • Light headedness
  • Memory impairment (particularly in elderly)
  • Ataxia
  • Slurred speech
  • Psychomotor effects
  • Paradoxical effects (aggression, anxiety, psychosis)
  • Dependence
  • Respiratory depression
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39
Q

What are the indications and mechanism of action for azapirones?

A
  • Generalised anxiety disorder (safer for longer term use as doesn’t cause dependence like benzodiazepines)
  • Mild antidepressant, used alongside SSRIs
  • Not as effective for panic disorders or phobias
  • Mechanism of action: 5-HT1A receptor agonists (some are also agonists to D2 and 5-HT2A receptors so have antipsychotic effects)
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40
Q

What are the indications and mechanism of action of hydroxyzine?

A
  • Used for insomnia, relief of anxiety, and as premedication prior to procedures
  • Also used to treat pruritis and nausea
  • Mechanism of action: potent H1 receptor blocker responsible for sedative effects
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41
Q

What are the indications and mechanism of action of beta blockers?

A
  • To alleviate physical symptoms (fast heart rate, shaking, sweating, dizziness) of anxiety, panic disorders, and phobias
  • Beta-adrenergic receptors antagonists to slow down sympathetic nervous system and reduce ‘fight or flight’
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42
Q

What are the indications for mood stabilisers?

A
  • Bipolar disorder
  • Mania or hypomania
  • Recurrent severe depression
  • Schizoaffective disorder (bipolar type)
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43
Q

What are the types of mood stabilisers, list some examples

A
  • Lithium (first line)
  • Antiepileptics: carbamazepine, valproate, lamotrigine
  • Antipsychotics: haloperidol, olanzapine, risperidone
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44
Q

What are the mechanisms of action for mood stabilisers?

A
  • Lithium: unknown mechanism, but decreases intracellular sodium in nerve and muscle cells, increases serotonin, and decreases norepinephrine and dopamine
  • Antiepileptics: unknown mechanism, but effects sodium/potassium exchange, and enhancing GABA system
  • Antipsychotics: increase activity of serotonin, and decreases activity of norepinephrine, and dopamine transmission
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45
Q

What are the side effects of lithium?

A
  • Lethargy
  • Muscle weakness
  • Fine tremor
  • Hypothyroidism
  • GI side effects (nausea, vomiting, diarrhoea)
  • Polydipsia and polyuria (nephrogenic diabetes insipidus)
  • Impaired renal function
  • Leucocytosis
  • Memory problems
  • Oedema
  • Weight gain
  • Serotonin syndrome
  • Teratogenic effects
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46
Q

What are the signs of lithium toxicity?

A

Mild (1.5-2.0 mmol/L):
- nausea and vomiting
- coarse tremor
- ataxia
- muscle weakness
- apathy
Severe (>2.0 mmol/L):
- nystagmus
- dysarthria
- hyperreflexia
- oliguria
- hypotension
- seizures
- coma

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47
Q

What monitoring is needed for lithium?

A
  • Before initiation: U&Es (avoid in renal failure), TFTs (contraindicated in untreated hypothyroidism), pregnancy test, ECG (for QT prolongation)
  • Lithium levels: 12 hours after first dose, weekly until therapeutic level (0.4-1.0 mmol/L) stable for 4 weeks, then every 3 months
  • Regular: U&Es every 6 months, TFTs every 12 months
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48
Q

What are the side effects of antiepileptics as mood stabilisers?

A
  • GI side effects (nausea and vomiting)
  • Dizziness
  • Drowsiness and fatigue
  • Ataxia
  • Aggression
  • Weight gain
  • Rash/dermatitis
  • Tremor
  • Teratogenic affects
  • Impaired liver function
  • Agranulocytosis (carbamazepine)
  • Thrombocytopaenia
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49
Q

Define delusion

A

A fixed false belief that is outside the person’s social, cultural, or religious norms

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50
Q

List and define the common types of delusions

A
  • Delusions of grandeur: false belief in one’s superiority of power, wealth, intelligence, talents, or other traits
  • Persecutory delusions: false belief that harm will come, or other intend to harm the individual
  • Delusional jealousy: false belief that a partner is being unfaithful which can lead to violent behaviour
  • Nihilistic delusions: false belief of already being dead, that their body is rotting, or that parts of the body no longer exist
  • Delusions of reference: false belief that un-related occurrences in the external world have special personal significance
  • Somatic delusion: false belief that one or more organs/body parts and injured, diseased, or not functioning
  • Delusional perception: a true perception to which a patient attributes a false meaning
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51
Q

Define paranoia

A
  • Unfounded or exaggerated doubting or mistrusting other people
  • Paranoia may be temporary and soothed by opposing evidence
  • Persecutory delusions and stronger and irrational paranoid beliefs that don’t change with contradiction
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52
Q

Describe the types of formal thought disorder

A
  • Knight’s move thinking: sequence of unrelated or remotely related ideas
  • Tangential thinking: diverts from original train of thought and doesn’t return
  • Circumstantiality: slow thought processing with unnecessary details or digressions before returning to original point
  • Word salad: speech reduces to senseless repetition of sounds or phrases
  • Neologisms: words/phrases devised by the patient, or a new meaning to an existing word
  • Perseveration: uncontrollable and inappropriate repetition of a response
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53
Q

Describe the different types of perception abnormalities

A
  • Hallucinations: perception in the absence of external stimulus (any of 5 senses)
  • Illusion: false mental image produced by misinterpretation of an external stimulus
  • Depersonalisation: feeling detached from normal sense of self
  • Derealisation: feeling of unreality in which the environment or people are experience as unreal
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54
Q

Define psychosis

A

An abnormal mental state involving signification problems with reality testing and impaired higher brain functions, typically presenting with…
- delusions
- hallucinations
- thought disorder

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55
Q

What are some organic causes of psychosis?

A
  • Delirium
  • Dementia
  • Endocrine disturbance (e.g. Cushing’s syndrome)
  • Metabolic disorders (e.g. vitamin B12 deficiency)
  • Huntington’s disease
  • Syphilis
  • Complex epilepsy
  • Iatrogenic
  • Drug-induced (alcohol, cocaine, amphetamines)
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56
Q

What are some non-organic causes of psychosis?

A
  • Schizophrenia
  • Schizotypal disorder
  • Schizoaffective disorder
  • Acute psychotic episode
  • Mood disorders with psychosis
  • Drug-induced psychosis
  • Delusional disorder
  • Puerperal (post-partum) psychosis
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57
Q

Define schizophrenia

A

Most common psychotic condition characterised by disturbance in thinking, emotion, and behaviour in the absence of organic cause, persistent for more than 1 month, with typical onset between late teens and early 30s

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58
Q

What are the risk factors for schizophrenia?

A
  • Genetics: high concordance in monozygotic twin studies, increased incidence with family history
  • Adverse life events
  • Substance misuse (cannabis or stimulants)
  • Neurodevelopmental: premature birth, obstetric complications, fetal brain injury
  • Childhood abuse
  • Low socioeconomic status
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59
Q

What are the first rank symptoms of schizophrenia?

A
  • Delusions (particularly delusional perception)
  • Hallucinations (particularly third person, running commentary, or hearing own thoughts aloud)
  • Thought interference (insertion, withdrawal, broadcasting)
  • Passivity (actions, feelings or emotions controlled by an external force)
    • these are ‘positive’ symptoms
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60
Q

What are the ‘negative’ symptoms of psychosis?

A
  • Antisocial behaviour
  • Poverty of speech
  • Anhedonia
  • Blunted affect
  • Attention deficits
  • Avolition (reduced motivation)
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61
Q

Describe the MSE findings of schizophrenia

A
  • Appearance: normal, or poor self-care (negative)
  • Behaviour: preoccupied, restless, suspicious (positive), or withdrawn, poor eye contact, apathy (negative)
  • Speech: reflects underlying thought disorder (loosening associations, pressured and distractable), poor flow of thought (blocking), poverty of speech (negative)
  • Mood: incongruity of affect, irritability, labile mood, flattened affect (negative)
  • Thought: delusions, possession of thoughts, formal thought disorder (positive)
  • Perception: hallucination (particularly 3rd person, auditory) (positive)
  • Cognition: normal orientation, impaired concentration
  • Insight: poor
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62
Q

What is the management of schizophrenia?

A

Biological:
- antipsychotics
- adjuvants (benzos, antidepressants)
- ECT (if resistant, or catatonic)

Psychological:
- CBT
- Family intervention and psychoeducation

Social:
- support groups
- social skills training
- supported employment

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63
Q

What are the poor prognostic factors for schizophrenia?

A
  • Gradual/insidious onset
  • Longer prodromal/untreated period
  • Negative symptoms
  • Family history
  • Male sex
  • Low IQ
  • Low socioeconomic status
  • Significant psychiatric history
  • Continued substance misuse
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64
Q

Define acute or transient psychotic disorder

A

A psychotic episode presenting similarly to schizophrenia, but of sudden onset and short duration (<1 month)

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65
Q

Define schizoaffective disorder and mood disorder with psychosis

A
  • Schizoaffective disorder: symptoms of schizophrenia and a mood disorder (depression or mania) in the same episode of illness
  • Mood disorder with psychosis: psychosis occurring secondary to depression or mania
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66
Q

Define delusional disorder

A

Development of a single or set of delusions (often persecutory, grandiose, or hypochondrial) as the only or most prominent symptom with other areas of thinking and functioning being preserved

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67
Q

Define personality disorder

A

A group of disorders involving pervasive and inflexible patterns of inner experiences and behaviour that deviates markedly from expectations in the individual’s culture, with usual onset in adolescence or early adulthood

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68
Q

What are the risk factors for personality disorders?

A
  • Social: low socioeconomic status, social reinforcement of abnormal behaviour
  • Genetic: higher concordance in monozygotic twin studies, higher incidence with family history
  • Dysfunctional family: poor parenting or parental deprivation
  • Abuse during childhood: physical, emotional, sexual (particularly EUPD), and neglect
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69
Q

Describe the cluster A personality disorders

A

Paranoid:
- pervasive and unwarranted suspicious and distrusting of others
- hypersensitivity (easily offended, readiness to counterattack)
- restricted emotions (cold affect, no humour)

Schizoid:
- detached or flattened affect with emotional coldness
- absence of close friends and reduced sexual drive
- little pleasure in activities and works alone
- indifferent to praise or criticism

Schizotypal:
- odd or eccentric beliefs and behaviour
- suspiciousness or paranoia
- speech or thought disorder
- lack of close friends
- inappropriate affect

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70
Q

lDescribe the cluster B personality disorders

A

Emotionally unstable (borderline):
- longstanding instability in mood and chronic emptiness
- intense but unstable relationships with fear of abandonment
- self-damaging behaviour (self harm, fights, gambling, substance misuse)

Dissocial (antisocial):
- pervasive disposition to disregard and violate others
- impulsive and reckless disregard of safety
- deceitful and quick to blame other
- lacks remorse and empathy

Histrionic:
- long term self-dramatization and need for attention
- egocentric and exaggerated emotions
- provocative behaviour and concern for physical attractiveness
- influenced by other easily

Narcissist:
- grandiose sense if self importance
- sense of entitlement
- taking advantage of others
- lack of empathy
- excessive need for admiration
- chronic envy

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71
Q

Describe the cluster C of personality disorders

A

Dependent:
- long term pattern of needing others to take responsibility
- requires reassurance and fear of abandonment
- lack of self confidence and self dependence

Anxious (avoidant):
- hypersensitivity to rejection and criticism
- withdrawal and restriction of lifestyle to maintain security
- low self esteem and feelings of inadequacy

Anankastic (obsessional):
- excessive perfectionism reducing ability to complete tasks
- workaholic at the expense of leisure
- stubborn, inflexible, and rigid
- meticulous attention to detail

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72
Q

What is the management of personality disorders?

A

Biological:
- mood stabilisers (for instability and aggression e.g. in EUPD)
- atypical antipsychotics (for short term transient psychotic episodes e.g. in paranoid PD)
- small role for antidepressants

Psychological:
- cognitive behavioural therapy
- psychodynamic therapy
- dialectical behavioural therapy (emphasis on coping strategies to improve impulse control)

Social:
- support groups
- assistance with housing, finance, employment
- access to education, voluntary work, meaningful occupation

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73
Q

Define bipolar affective disorder

A

A chronic episodic mood disorder categorised as…
- bipolar I: periods of severe mood episodes from mania to depression
- bipolar II: milder form of mood elevation (hypomania) that alternate with periods of severe depression

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74
Q

What are the risk factors for bipolar affective disorder?

A
  • Genetics: high concordance monozygotic twin studies, strong family history
  • Adverse life events (exams, post-partum, bereavement)
  • Age: early 20s
  • Anxiety disorders
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75
Q

What are the features of mania?

A
  • Elevated mood
  • Increased energy
  • Irritability
  • Disinhibition (sexual, social, spending)
  • Grandiose delusions
  • Flight of ideas and pressure of speech
  • Sleep decreased
  • Distractibility and reduced concentration
  • Impaired insight
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76
Q

What are the different forms of mania?

A
  • Hypomania: mildly elevated or irritable mood for >4 days, with symptoms present to a lesser extent, mild disruption to work and social life, partial insight
  • Mania: symptoms present for >1 week, complete disruption of work and social activities, grandiose ideas and disinhibition, reduced sleep leading to exhaustion
  • Mania with psychosis: severely elevated or suspicious mood, with additional grandiose/persecutory delusions and hallucinations, may show aggression
77
Q

Define rapid cycling

A

A mood disturbance that fluctuates usually between manic and depressive symptoms over a short period, with 4 or more episodes in 12 months
* treated with lithium + valproate

78
Q

Define alcohol abuse

A

A pattern of alcohol use above that of the recommended intake (14 units/week) that persists despite consequences of physical, psychological, and/or social harm

79
Q

Define alcohol dependence

A

A pattern of repeated or compulsive use of alcohol despite significant behavioural and psychosocial problems, which may include cravings, tolerance, and withdrawal symptoms if stopped

80
Q

What is the pathophysiology and cause of alcohol use disorders?

A
  • Alcohols affects on GABA causes anxiolytic and sedative effects
  • The dopaminergic pathway mediates the pleasurable and stimulant effects, and repeated intake sensitises this pathway, leading to dependence
  • Long-term exposure causes adaptative changes to several neurotransmitters, including down-regulation of inhibitory neuronal GABA receptors and up-regulation of excitatory glutamate receptors
  • When alcohol is withdrawn it results in central nervous system hyper-excitability
81
Q

What are the risk factors for alcohol abuse?

A
  • Males
  • Younger adults
  • Genetics (high concordance in monozygotic twins, strong family history)
  • Antisocial behaviour
  • Lack of facial flushing
  • Life stressors (financial, marital, work)
82
Q

What are the clinical features of alcohol dependence?

A
  • Compulsions to drink
  • Narrowed repertoire
  • Withdrawal symptoms
  • Increased tolerance
  • Drink-seeking behaviour predominating other behaviour
  • Reinstatement of drinking after attempted abstinence
  • Avoidance/relief of withdrawal symptoms by further drinking
  • Stereotyped drinking pattern (fixed times)
83
Q

What is the screening questionnaire for alcohol dependence?

A
  • C: have you ever felt you should Cut down your drinking?
  • A: have people Annoyed you by criticising your drinking?
  • G: have you ever felt Guilty about your drinking?
  • E: do you ever need a drink early in the morning to calm your nerves or relieve a hangover (Eye-opener)?
84
Q

What are the clinical features of alcohol withdrawal?

A

Symptoms occurring at 6-12 hours after abstinence:
- malaise
- tremor
- nausea
- insomnia
- depression/anxiety
- transient hallucinations
- autonomic hyperactivity
- seizures (peaks at 36 hours)
- delirium tremens (severe end of scale)

85
Q

What are the long term effects of alcohol abuse?

A

Biological:
- fatty liver, hepatitis, cirrhosis, cancer
- peptic ulcers, pancreatitis, oesophageal cancer
- hypertension, cardiomyopathy, arrhythmias
- anaemia, thrombocytopaenia
- seizures, peripheral neuropathy, Wernicke’s encephalopathy, head injuries
- fetal alcohol syndrome

Psychological:
- morbid jealousy
- self harm and suicide
- mood and anxiety disorders
- alcohol related hallucinations/delirium

Social:
- employment and financial difficulties
- homelessness
- relationship problems
- drink driving
- domestic violence

86
Q

Describe delirium tremens (timing, features, treatment)

A
  • Develops between 24 hours and one week after alcohol cessation (peak at 72 hours)
  • Treatment: large doses of benzodiazepine (e.g. chlordiazepoxide), haloperidol for psychosis, IV pabrinex (thiamine)

Clinical features:
- cognitive impairment
- vivid perceptual abnormalities
- paranoid delusions
- marked tremor
- autonomic arousal (tachycardia, fever, sweating, dilated pupils)
- electrolyte disturbances

87
Q

Define Wernicke’s encephalopathy and Korsakoff’s psychosis

A
  • Acute encephalopathy due to thiamine (vitamin B1) deficiency, presenting with delirium, nystagmus, ophthalmoplegia, hypothermia and ataxia, needing urgent treatment with parenteral thiamine (pabrinex)
  • Korsakoff’s psychosis is a late presentation of untreated thiamine deficiency, characterised by profound irreversible short-term memory loss, confabulation (filling gaps of memory with imaginary events), hallucinations, disorientation
88
Q

What is the management of alcohol withdrawal?

A
  • Detoxification regime offers controlled withdrawal
  • High dose benzodiazepines (commonly chlordiazepoxide), tapered down over 5-9 days
  • Also given thiamine (oral or IV) to prevent Wernicke’s encephalopathy
  • Can be in community or inpatient (recommended in more severe cases, risk or suicide, poor social support, history of severe withdrawal reactions)
89
Q

What is the management of alcohol dependence?

A

Biological:
- disulfiram (causes build-up of acetaldehyde when consuming alcohol to cause unpleasant symptoms (e.g. anxiety, headaches, flushing)
- acamprosate (reduces cravings by enhancing GABA transmission)
- naltrexone (blocks opioid receptors to reduce pleasurable effects of alcohol)

Psychological:
- motivational interviewing (most effective in pre-contemplation and contemplation stages)
- CBT

Social:
- support groups (alcoholics anonymous)
- support with finances, housing, employment

90
Q

What are common drugs that are misused?

A
  • Opiates (e.g. morphine, diamorphine/heroin, codeine, methadone)
  • Cannabinoids (e.g. cannabis)
  • Sedatives/hypnotics (e.g. benzodiazepines, barbiturates)
  • Stimulants (e.g. cocaine, crack cocaine, ecstasy, amphetamine)
  • Hallucinogens (e.g. LSD, magic mushrooms)
  • Volatile solvents (e.g. aerosols, paint, glue)
  • Anabolic steroids (e.g. testosterone)
91
Q

What are the different potential features of substance use disorders?

A
  • Acute intoxication: acute and transient effects of the substance
  • Harmful use: recurrent misuse despite physical, psychological, and social problems
  • Dependence: prolonged compulsive use leading to addiction and tolerance
  • Withdrawal state: physical and/or psychosocial effects of cessation after prolonged, repeated or high level or use
92
Q

What are the complications of substance misuse?

A

Biological:
- infection (HIV, hepatitis, staph aureus, etc.)
- endocarditis
- DVT or PE
- death

Psychological:
- craving
- anxiety
- cognitive disturbance
- drug induced psychosis

Social:
- crime and imprisonment
- homelessness
- relationship problems
- financial problems

93
Q

What is the management of substance misuse disorders?

A

Biological:
- methadone (or buprenorphine) for detoxification and maintenance
- naltrexone (for former opioid dependence to continue abstinence)
- IV naloxone as an antidote for opioid overdose
- hepatitis B immunisation for those at high risk

Psychological:
- motivational interviewing
- CBT (for comorbid anxiety and depression)
- contingency management (incentives for positive behaviour)

Social:
- support groups
- help with housing, finance, employment

94
Q

Define delirium

A

An acute, transient global organic disorder of central nervous system functioning resulting in impaired consciousness and attention with a fluctuating course

95
Q

What are the different types of delirium?

A
  • Hypoactive: most common, lethargy, decreased motor activity, apathy, confused with depression
  • Hyperactive: agitation, restlessness, aggression, hallucinations, delusions, confused with psychosis
  • Mixed: signs of both hypo and hyperactive delirium
96
Q

What are the causes of delirium?

A

HE IS NOT MAAD
- Hypoxia (Respiratory failure, MI, cardiac failure, PE)
- Endocrine (hypo/hyperthyroid, hypo/hyperglycaemia, Cushing’s)
- Infection (UTI, pneumonia, encephilitis, meningitis)
- Stroke and other intracranial events (space-occupying lesion, epilepsy, head trauma, intracranial bleed)
- Nutritional (low thiamine, low vitamin B12)
- Others (pain, sensory deprivation, changing environment, sleep deprivation)
- Theatre (post-operative complications, anaesthetics, opiate analgesics)
- Metabolic (high/low sodium, high/low calcium, low magnesium)
- Abdominal (constipation, urinary retention, catheterisation, malnutrition)
- Alcohol (intoxication, withdrawal)
- Drugs (benzodiazepines, opioids, anticholinergics, steroids, anti-parkinsonism)

97
Q

What are the risk factors for delirium?

A
  • Older age (>65)
  • Male sex
  • Physical frailty
  • Multiple comorbidities
  • Sensory impairment
  • Dementia
  • Renal impairment
  • Previous episodes
  • Recent surgery
98
Q

What are the clinical features of delirium?

A

DELIRIUM
- Disordered thinking (slowed, irrational, incoherent)
- Emotional changes (euphoric, fearful, depressed, angry)
- Language impaired (rambling speech, repetitive, disruptive)
- Illusions, delusions, hallucinations (often visual)
- Reversal of sleep-wake cycle
- Inattention (lack f focus, clouding of consciousness)
- Unaware/disorientated (to time pace and person)
- Memory deficits

+ abnormal psychomotor activity

99
Q

What investigations are needed for delirium?

A
  • Urinalysis (UTI)
  • FBC (infection
  • U&Es (electrolyte disturbances)
  • LFTs (liver disease, alcoholism)
  • Calcium (low or high)
  • CRP (inflammation/infection)
  • TFTs (high or low)
  • B12, folate, ferritin (nutritional deficiencies)
  • Blood cultures (sepsis)
  • ECG (acute coronary syndrome, cardiac abnormalities)
  • CXR (infection)
  • ABG (hypoxia)
  • CT head (trauma, intracranial bleed, CVA)
  • EEG (epilepsy)
  • Cognitive testing (MMSE, AMT)
100
Q

What is the management of delirium?

A
  • Treat underlying cause (antibiotics, electrolyte disturbance, laxative, catheter, analgesia, stop any causing drugs)
  • Reassurance (reduce anxiety, regular reminder of time, place and day)
  • Appropriate environment (quiet, well-lit, consistency in care/staff, presence of family/friend, optimise sensory acuity)
  • Manage abnormal behaviours (verbal/non-verbal de-escalation), low-dose haloperidol or olanzapine, (avoid benzodiazepines)
101
Q

Define mood

A

Refers to a patient’s sustained and experienced emotional state over a period of time, reported subjectively or objectively (as dysthymic, euthymic, or elated)

102
Q

Define affect

A

Refers to the immediate expression and transient flow of emotion to a particular stimulus

103
Q

How are mood disorders classified?

A

Primary (does not result from other condition):
- unipolar (depressive disorder, dysthymia)
- bipolar (bipolar affective disorder, cyclothymia)

Secondary (results from another condition)
- physical disorder (anaemia, hypothyroid, malignancy, Cushing’s syndrome, MS, parkinsonism)
- psychiatric disorder (schizophrenia, alcoholism, dementia, personality disorder)
- drug induced (corticosteroids, antiepileptics, beta-blockers, antidepressants can induce mania)

104
Q

Define depressive disorder

A

An affective mood disorder characterised by persistent low mood, loss of pleasure (anhedonia), and lack of energy, accompanied by emotional, cognitive, and/or biological symptoms

105
Q

What are the risk factors for depressive disorder?

A
  • Female sex
  • Genetics (high monozygotic twin concordance, family history)
  • Physical or mental co-morbidities
  • Past history
  • Social stressors (unemployment, poverty, divorce, financial struggles, bereavement, post natal period)
  • Alcohol and substance misuse
  • Lack of social support
  • Low socioeconomic status
  • Over activity of HPA axis
106
Q

What are the clinical features of depressive disorder?

A

Core symptoms:
- low mood (for at least 2 weeks)
- anhedonia
- lack of energy

Cognitive symptoms:
- lack of concentration
- negative thoughts (about self, world, future)
- excessive guilt
- suicidal ideation

Biological symptoms:
- diurnal variation in mood
- early morning wakening
- loss of libido
- psychomotor retardation
- changes to appetite and weight

Psychotic symptoms:
- hallucinations (often 2nd person auditory)
- delusions (often guilt, nihilistic, hypochondrial, persecutory)

107
Q

Describe an MSE in depressive disorder

A
  • Appearance: self-neglect, unkempt, decreased facial expression, tearful
  • Behaviour: poor eye contact, psychomotor retardation, slow responses
  • Speech: may be slow, reduced volume and tone
  • Emotion: low and dysthymic (subjectively and objectively)
  • Thought: pessimistic, worthlessness, helpless, suicidal, delusions (if psychotic)
  • Perception: 2nd person auditory hallucinations
  • Cognition: impaired concentration
  • Insight: usually good
108
Q

What is the management of depressive disorder?

A

Biological:
- antidepressants (not usually first line for mild depression, unless lasting a long time, past history of moderate-severe, failure of other interventions, or other physical conditions are compromised)
- adjuvants (e.g. antipsychotics)
- ECT (for severe life-threatening depression, if rapid response is required, failure of other treatments, psychotic features present)

Psychological:
- psychotherapies (CBT, IPT, counselling, psychodynamic)
- self help programs
- physical activity program

Social:
- support groups
- engaging with community activities
- help with housing, finances, work

109
Q

Describe some other depressive disorders

A
  • Recurrent depressive disorder: depressive episodes after their first episode
  • Seasonal affective disorder: depressive episodes recurring annually at the same time each year (often winter months)
  • Dysthymia: lasting for at least 2 years, but not meeting the criteria for mild/moderate/severe depression, and is not the result of partially-treated depressive illness
  • Cyclothymia: chronic mood fluctuation over as least 2 years with episodes of depression and elation that are insufficient to meet the criteria for hypomanic or depressive disorder
  • Postnatal depression: affects approx. 10%, often starting within a month and peaking at 3 months, similar clinical features as other circumstances
110
Q

What are the risk factors for deliberate self harm?

A
  • Severe life stressors
  • Drug or alcohol abuse
  • Age under 35
  • Chronic physical health problems
  • Psychiatric illness (e.g. depression, psychosis)
  • Socioeconomic disadvantage
  • Domestic violence
  • Childhood maltreatment
  • Divorces, or single, or living alone
111
Q

How is deliberate self-harm assessed?

A
  • What were their intentions before and after the act (e.g. relief from problems, punishment, seeking attention, suicidal intent)
  • Does the patient now wish to die? Do they regret their actions?
  • Psychiatric history, previous self-harm?
  • Collateral history from relatives/friends
  • Risk assessment
  • Assess for complications (e.g. nerve/tendon damage, liver damage, intracranial damage)
112
Q

What are the risk factors for suicide?

A
  • History of deliberate self-harm or attempted suicide
  • Psychiatric illness
  • Family history of suicide/attempts
  • Medical illness (e.g. disabling, painful, terminal)
  • Male
  • Unemployed
  • Low socioeconomic status
  • Occupations (vets, doctors, nurses, farmers)
  • Access to lethal means (firearms, hanging, suffocation)
  • Lack of social support (e.g. living alone)
  • Institutionalised (e.g. prisoners)
  • Recent life crisis
  • Childhood abuse
113
Q

What factors determine a high risk of suicide following deliberate self-harm?

A
  • Violent method
  • Planned attempt of suicide
  • Attempts to avoid discovery
  • Not seeking help afterwards
  • Final acts (e.g. sorting out finances, writing will)
  • Leaving note
114
Q

Describe a suicide risk assessment?

A
  • Explore suicidal ideation: hope for future, life worth living, thoughts about ending own life
  • Explore suicidal intent: degree of premeditation, method, plans to avoid discovery, seeking help, regretfullness, feelings about being found/receiving help
  • Explore risk factors: recent life stressors, previous attempts, psychiatric and medical history, family history
  • Explore protective factors: what would stop them, social support
  • Explore risk to other and from others: any children/dependents, thoughts of harming others, threatened by others
  • Mental state examination
115
Q

What is the management of deliberate self-harm and suicide?

A

Biological:
- treatment of overdoses, suturing wounds
- medication for underlying psychiatric illness

Psychological:
- CBT for underlying depression
- other forms of psychotherapies
- inpatient admission if high suicide risk

Social:
- helps with finances, housing etc.
- referral to drug/alcohol services
- improve social network

116
Q

Define neurosis

A

A collective term for psychiatric disorders characterised by significant anxiety or other distressing emotional symptoms, in the absence of hallucinations, delusions, or personality disorders

117
Q

What are the different types of anxiety disorders?

A

Paroxysmal…
- situation dependent: phobic disorders (e.g. specific phobia, social phobia)
- situation independent: panic disorders

Continuous…
- generalised anxiety disorder

118
Q

Define generalised anxiety disorder

A

A syndrome of ongoing, uncontrollable, and widespread worry about many events of thoughts, recognised as excessive and inappropriate, present for over 6 months

119
Q

What are the causes/risk factors for generalised anxiety disorder?

A

Biological…
- genetic: higher concordance in monozygotic twins, family history
- neurophysiological: dysfunction of autonomic nervous system, alteration in GABA, serotonin and noradrenaline

Environmental…
- stressful life events: difficulties in childhood upbringing, problems with relationships, employment, finances, personal illness
- substance dependence

120
Q

What are the associated symptoms of generalised anxiety disorder?

A
  • Difficulty breathing or chest pain/discomfort
  • Tremor/shaking
  • Palpitations
  • Sweating
  • Dry mouth
  • Abdominal pain or nausea
  • Dizziness
  • Fear of loosing control or dying
  • Depersonalisation or derealisation
  • Headache
  • Numbness or tingling
  • Hot/cold flushes
  • Muscle tension, aches or pains
  • Restlessness or feeling on edge
  • Easily startled
  • Concentration difficulties
  • Irritability
  • Sleep problems
121
Q

What is the management of generalised anxiety disorder?

A

Biological:
- SSRI (sertraline)
- SNRI (venlafaxine)
- pregabalin
- benzodiazepines (only for short-term during crises)

Psychological:
- psychoeducation
- CBT
- applied relaxation

Social:
- self help
- support groups
- exercise

122
Q

Define phobic anxiety disorders

A
  • Phobia = intense irrational fear of an object, situation, place, or person that is recognised as excessive/unreasonable
  • Agoraphobia = fear of being in open or unfamiliar spaces, resulting in avoidance of public situations from which escape may be difficult (often accompanied by panic disorder)
  • Social phobia = fear of social situations which may lead to humiliation, criticism, or embarrassment
  • Specific phobia = fear restricted to a specific object or situation
123
Q

What are the risk factors for phobias?

A
  • Aversive experiences (prior negative experiences with specific objects/situations)
  • Stress and negative life events
  • Other anxiety disorders
  • Mood disorders
  • Substance misuse
  • Family history
124
Q

What are the clinical features of phobic disorders?

A

Biological:
- autonomic response (most often tachycardia)
- other symptoms of anxiety
- in phobias of blood/needles/injury can have vasovagal response and syncope
- in social phobia fear of vomiting, urgency or fear of micturition/defecation

Psychological:
- anticipatory anxiety
- inability to relax
- urge to avoid feared situation

125
Q

What is the management for phobic anxiety disorders?

A
  • Psychotherapies are first line (CBT with graduated exposure or desensitisation)
  • Medications: SSRIs for agoraphobia or social phobia or SNRIs, benzodiazepines for short term management of specific phobia (e.g. needing a CT scan if claustrophobic)
126
Q

Define panic disorder

A

Recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situations or circumstances

127
Q

What are the clinical features of panic disorders?

A
  • Discrete episode of intense fear or discomfort
  • Starting abruptly, peaking within a few minuets, and lasting less than 1 hour
  • Autonomic arousal (palpitations, shaking, sweating, dry mouth)
  • Other symptoms of anxiety
128
Q

What is the management of panic disorders?

A
  • Recognition and identifying co-morbidities (depression, substance misuse)
  • Psychological therapy: CBT
  • Self-help: education, support groups, exercise, avoid caffeine
  • Medications: SSRI, or if no effect after 12 weeks TCA (clomipramine)
129
Q

Define PTSD

A

An intense, prolonged, delayed reaction following exposure to a traumatic event (e.g. assault, natural disaster, RTA, involvement in war, unexpected/violent death of family member/friend), occurring within 6 months of the event

130
Q

What are the risk factors of PTSD?

A
  • Professions at risk (armed forces, emergency services, doctors)
  • Groups at risk (refugees, asylum seekers)
  • Previous trauma (childhood abuse)
  • History of mental illness
  • Low socioeconomic background
  • Perceived threat to life
  • Concurrent life stressors
  • Absence of social support
  • Adverse emotional reaction during or immediately after the event
131
Q

What are the clinical features of PTSD?

A
  • Re-living the situation (persistent, intrusive, involuntary): flashbacks, vivid memories, nightmares, distress around similar circumstances
  • Avoidance: to avoid reminders trauma, inability to recall aspects of the trauma
  • Hyperarousal: irritability, outbursts, difficulty concentrating, difficulty sleeping, hypervigilance, exaggerated startle response
  • Emotional numbing: negative thoughts about self, difficulty experiencing emotions, feeling detached from others, anhedonia
132
Q

Define acute stress reaction

A

Exposure to exceptional physical or mental stressor followed by an immediate onset (within 1 hour) of symptoms (including those of anxiety, narrowing of attention, disorientation, uncontrollable/excessive grief, anger/aggression), which diminish with 8/48 hours (for transient/continued stressors)

133
Q

What is the management for PTSD?

A

Biological:
- short term treatment for sleep disturbance (e.g. zopiclone)
- antidepressants (if no benefit from psychological therapies, or comorbid depression) e.g. paroxetine, venlafaxine, mirtazapine

Psychological:
- trauma focused CBT
- eye movement desensitisation and reprocessing (EMDR)

Social:
- support groups
- help with housing, finances, employment, and meaningful occupation

134
Q

Define OCD

A

Recurrent obsessional thoughts (unwanted intrusive thoughts or urges that repeatedly enter the individual’s mind despite trying to resist them) and/or compulsions (repetitive ritual behaviours or mental acts that a person feels driven to perform)

135
Q

What are some common obsessions and compulsions?

A

Obsessions:
- contamination (e.g. from dirt, germs, bodily fluids)
- fear of harm (e.g. door locks not safe)
- excessive concern with order or symmetry
- doubts about performing actions (e.g. not turned off oven)

Compulsions:
- checking things (e.g. taps, doors, appliances)
- cleaning, washing, decontamination
- repeating actions (e.g. counting, arranging objects)
- mental compulsions (e.g. special phrases repeated in set manner)
- hoarding

136
Q

What is the management for OCD?

A

Biological:
- SSRIs (escitalopram, fluoxetine, etc.)
- Can add clomipramine (TCA) in severe cases

Psychological:
- CBT with exposure and response prevention (ERP)
- psychoeducation

Social:
- support groups
- self-help

137
Q

Define somatoform disorders

A

A group of disorders marked by physical illness or a specific medical condition, in the absence of physiological evidence

138
Q

Define somatisation disorder

A

A type of somatoform disorder involving at least 2 years of multiple physical symptoms that cannot be explained by any detectable physical disorder, where preoccupation with symptoms causing distress, repeated seeking of medical attention, and refusal to accept reassurance

139
Q

Define persistent somatoform pain disorder

A

A type of somatoform disorder characterised by persistent prolonged pain that cannot be fully explained by a physical disorder, often resulting from psychosocial stressors, and that significantly interferes with a person’s ability to function

140
Q

Define hypochondrial disorder

A

A type of somatoform disorder characterised by preoccupation with the fear or belief that one has a serious physical disease based on the incorrect and unrealistic interpretation of bodily symptoms

141
Q

Define dissociative disorders

A

A group of disorders characterised by a sudden or gradual disruption in normal consciousness, memory, or perception of the environment, associated in time with psychosocial stressors, categorised as dissociative amnesia, fugue, trance, motor disorder, convulsions etc.

142
Q

Define conversions disorder

A

Also known as functional neurological disorder, a type of somatoform disorder characterised by one or more neurological deficit in the absence of physiological evidence, including symptoms like paralysis, loss of voice, blindness, seizures, loss of sensation, which are not intentionally produced or under voluntary control

143
Q

What are the risk factors for somatoform disorders?

A
  • Childhood abuse
  • Reinforcement of illness behaviours
  • Anxiety disorders
  • Mood disorders
  • Personality disorders
  • Social stressors
144
Q

Define malingering and facticious disorders

A
  • Malingering disorder: symptoms are intentionally produced (faked) or exaggerated to seek advantageous consequences for personal gain (e.g. avoiding criminal persecution, receive benefits), associated with antisocial/dissociative/borderline personality disorders, substance use disorders)
  • Factitious (Munchausen) disorder: mental health disorder involving intentionally produced or exaggerated symptoms, with no obvious motivation or reward, other than internal emotional gain/adopting the ‘sick role’
145
Q

What is the management for somatoform disorders?

A

Biological:
- antidepressants for any underlying mood disorder
- promote physical health (e.g. exercise)

Psychological:
- CBT
- developing coping strategies

Social:
- stress-relieving activities
- family support

146
Q

Define autism spectrum disorder

A

A pervasive developmental disorder characterised by impaired social interaction, deficits in communication, and restricted/repetitive interests and behaviours, which typically occur during preschool years

147
Q

What are the causes of autism spectrum disorder?

A

Prenatal:
- genetics (complex relationship with multiple chromosomes e.g. 7, and genetic conditions such as fragile X syndrome)
- parental age (higher risk with over 40s)
- drugs (intrauterine exposure e.g. sodium valproate)
- infection (e.g. rubella)

Antenatal:
- hypoxia during childbirth
- preterm birth
- low birthweight

Postnatal:
- toxin exposure (e.g. lead, mercury)
- pesticide exposure (may affect those genetically predisposed)
- NOT MMR VACCINE

148
Q

What are the clinical features of autism?

A

Asocial:
- lack of eye contact, response to name
- lack of emotional expression
- unstained relationships
- unawareness of social rules
- few social gestures (e.g. waving, nodding)

Behaviour:
- restricted, repetitive and stereotyped behaviours (e.g. rocking, swaying)
- upset by change in routine
- preferring same food, clothes, games etc.
- obsessively pursued interests
- fascination with sensory aspects on environment

Communication:
- distorted and delayed speech
- echolalia (repetition of words)
- other speech anomalies (e.g. perseveration, monosyllabic/monotonic, louder/quieter, etc.)

Other features:
- intellectual disability
- problems with temper
- impulsivity
- cognitive impairment

149
Q

What is the management of autism spectrum disorder?

A

Biological:
- management of co-existing disorders (e.g. ADHD, depression, physical health)
- for sleep problems (e.g. melatonin)
- antipsychotics for severely challenging behaviours

Psychological:
- support for families
- CBT (depending on verbal and cognitive ability)

Social:
- modification of environmental factors
- intervention for life skills and communication
- specialist education
- self help groups

150
Q

Define ADHD

A

Attention deficit hyperactivity disorder, characterised by and early onset (before age 7) of persistent pattern of inattention, hyperactivity and impulsivity, which impair social, academic, or occupational functioning

151
Q

What are the causes of ADHD?

A
  • Genetic: high concordance in monozygotic twins, linked with certain genes
  • Abnormalities in dopaminergic pathways
  • Neurodevelopmental abnormalities in pre-frontal cortex
  • Social factors: deprivation, family conflict, parental cannabis and alcohol
152
Q

What is the management for ADHD?

A

Biological:
- methylphenidate (only over age of 5, switched if not effective after 6 weeks, needs baseline ECG and cardiovascular assessment)

Psychological:
- psychoeducation and parent-training
- CBT

Social:
- support groups
- social skills training

153
Q

Define learning disability

A

A state of arrested or incomplete development of the mind, characterised by a low intellectual performance (IQ<70) and a wide range of functional impairment (including social and adaptive skills e.g. ADLs)

154
Q

List some causes of learning disabilities

A
  • Genetic: Down’s syndrome, fragile X syndrome, Prader-Willi, hydrocephaly
  • Antenatal: congenital infections (rubella, CMV), intoxication, physical damage, nutritional deficiencies
  • Postnatal: infection (meningitis, encephalitis), metabolic (hypothyroidism, hypernatraemia), cerebral palsy
  • Environmental: neglect, injury, malnutrition, socioeconomic deprivation
155
Q

What does the management of learning disabilities include?

A
  • Multidisciplinary approach (psychiatrists, SALT, specialist nurses, OT, social worker, teachers, GP)
  • Treatment of co-morbid medical conditions
  • Behavioural techniques e.g. positive behaviour support, CBT
  • Family education and support
  • Antipsychotics for severely challenging behaviour
156
Q

Define anorexia nervosa

A

An eating disorder characterised by deliberate weight loss, an intense fear of fatness, distorted body image, and endocrine disturbances

157
Q

What are the aetiological factors for eating disorders ?

A
  • Genetics (high concordance in monozygotic twin studies for anorexia nervosa)
  • Family history
  • Female
  • Adolescence and puberty
  • Early onset of puberty/menarche
  • Anxiety or depressive symptoms
  • Perfectionism, or anankastic personality
  • Occupational/recreational pressure (e.g. dancers, athletes, models)
  • Bullying/criticism about eating, body shape or weight
  • Stressful life events
  • Physical or sexual abuse
158
Q

What are the clinical features of anorexia nervosa?

A
  • Low body weight (>15% below expected, or BMI<17.5)
  • Restricted eating patterns or dieting
  • Deliberate weight loss (e.g. over exercise)
  • Distorted body image
  • Dread of gaining weight
  • Social withdrawal
  • Fatigue
  • Fainting and dizziness
  • Delay in secondary sexual development
  • Amenorrhoea
  • GI symptoms: constipation, pain, fullness after meals
  • Physical signs: hypothermia, bradycardia, hypotension, peripheral oedema, sings of anaemia, lanugo hair, proximal muscle weakness (sit up, squat, stand test)
159
Q

What are the investigations needed for anorexia nervosa?

A
  • FBC (low hb, platelets, leukocytes)
  • U&Es (raised urea and creatinine, low potassium, phosphate, magnesium, chloride)
  • TFTs (low T3/4)
  • LFTs (low albumin)
  • High cortisol
  • Low sex hormones
  • Low glucose
  • DEXA scan (rue out osteoporosis)
  • ECG (arrhythmias e.g. bradycardia, prolonged QT)
160
Q

What is the management of anorexia nervosa?

A

Biological:
- treatment of complications (e.g. electrolyte imbalances)
- refeeding (with caution of refeeding syndrome)
- SSRIs for co-morbid depression or OCD

Psychological:
- CBT (eating disorder focused)
- Family therapy
- Psycho-education

Social:
- self help groups
- reduced isolation

161
Q

When is urgent admission required in anorexia nervosa?

A
  • Severe electrolyte imbalance
  • Severe malnutrition or dehydration
  • Cardiac arrhythmias
  • BMI below 13
  • Rapid weight loss (more than 1kg a week)
  • Significant suicide risk
162
Q

Describe refeeding syndrome

A
  • Potentially life threatening syndrome resulting from food intake after prolonged starvation or malnourishment
  • Insulin surge causes increased uptake of phosphate, potassium, and magnesium into cells, and the depletion of phosphate causes reduction in cardiac muscle activity leading to failure
  • Management: low calorie diet that is slowly increased, electrolyte monitoring and replacement
163
Q

Define bulimia nervosa

A

An eating disorder characterised by repeated episodes of uncontrolled binge eating followed compensatory weight loss behaviours

164
Q

What are the clinical features of bulimia nervosa?

A
  • Binge eating (cravings with sense of compulsion and loss of control)
  • Compensatory weight loss behaviours (vomiting, laxatives, diuretics, fasting,, excessive exercise)
  • Preoccupation with weight, body shape and body image
  • Depression, low self-esteem, anxiety
  • Usually normal weight (any loss is counteracted by gain from binging)
  • Irregular periods
  • GI symptoms: bloating, heartburn, abdominal pain
  • Physical signs: low blood pressure, dehydration, enlarged salivary glands, oedema, abrasions on back of hands, dental erosions
165
Q

What are the investigations needed for bulimia nervosa?

A
  • Bloods are often normal: except low potassium
  • VBG: metabolic alkalosis
  • ECG: ventricular arrhythmias (due to hypokalaemia), prolonged PR interval,
166
Q

What is the management of bulimia nervosa?

A

Biological:
- treat medical complications (e.g. potassium replacement)
- treat co-morbid conditions (e.g. depression, anxiety)
- antidepressant (fluoxetine) in combination with other treatments

Psychological:
- psychoeducation about nutrition
- CBT for bulimia nervosa

Social:
- food diary
- techniques to avoid binging (distractions, company, small regular meals)
- self help

167
Q

Describe ECT

A
  • Electroconvulsive therapy is an electric current applied via electrodes to the skull to induce a seizure (for at least 30 seconds)
  • General anaesthesia and muscle relaxant are used to limit the motor effects
  • Can be bilateral (most effective) or unilateral (if previous cognitive side effects)
  • Indicated in prolonged/severe mania, catatonia, severe depression (treatment resistant, life-threatening, risk to self/others)
  • Needs written informed consent, or a second opinion if lacking under MHA
  • Contraindicated in recent MI or stroke, major unstable fracture, raised ICP, severe anaesthetic risk, cerebral aneurysm
168
Q

What are the side effects of ECT?

A
  • Confusion
  • Short term memory impairment
  • Anaesthesia risks
  • Muscle aches
  • Dental/oral trauma
  • Cardiac arrhythmias
  • Peripheral nerve palsies
  • Long term anterograde and retrograde amnesia
  • Status epilepticus
169
Q

What is section 2 of the MHA?

A
  • Admission for assessment, followed by necessary treatment for mental illness
  • For up to 28 days (can’t be renewed)
  • Can appeal within the first 14 days, and apply to hospital manager for discharge at any time
170
Q

What is section 3 of the MHA?

A
  • Admission for treatment of mental illness
  • For up to 6 months
  • Can be renewed for another 6 months, then annually
  • Can appeal once in each period, can apply to hospital manager for discharge at any time
  • Nearest relative can object and prevent detention
171
Q

What is section 4 of the MHA?

A
  • Used when there is an urgent necessity for detention under S2
  • Only need 1 medical recommendation
  • Lasts 72 hours until 2nd doctor is sought
172
Q

What is section (5)2 of the MHA?

A
  • Urgent detention of inpatient by one doctor on any ward (except A&E), pending a MHA assessment
  • Lasts up to 72 hours
  • No right to appeal
173
Q

What is section 5(4) of the MHA?

A
  • Urgent detention of inpatient by a nurse on any ward (except A&E), pending a MHA assessment or arrival of a doctor
  • Must be registered mental health or learning disability nurse
  • Lasts up to 72 hours
  • No right to appeal
174
Q

What is section 135 of the MHA?

A
  • Allows a police officer to enter a person’s premises, who is suspected of suffering from a mental disorder
  • Patient is removed to place of safety (including being kept at home)
  • Lasts for 24 hours
175
Q

What is section 136 of the MHA?

A
  • Allows a police officer to remove an individual from a public space, who appears to be suffering from a mental disorder
  • Patient is removed to place of safety
  • Lasts for 24 hours
176
Q

What are some other commonly used sections of the MHA?

A
  • s17: allows responsible clinician to give detained patients leave from hospital under certain conditions
  • s35/37: used by the court to remand criminals to hospital for psychiatric assessment
  • s41/47/49: used by ministry of justice to order transfers/leave/return to prison
  • s117: legal duty of social services and health authorities to provide free aftercare for patients discharged from s3 (and others)
  • CTO: community treatment order allows patients on s3 to be treated at home if well enough, to be recalled if they do not comply
177
Q

Describe cognitive behavioural therapy

A
  • Indications: mild-moderate depression, eating disorders, anxiety disorders, substance misuse disorders, schizophrenia, chronic medical conditions
  • Rationale: the disorder is not caused by life events but by the way the patient views the events
  • Aim: help patients identify and challenge negative thoughts, maladaptive behaviour, and modify underlying beliefs
178
Q

Describe behavioural therapies

A
  • Relaxation training: useful in stress-related and anxiety disorders, uses muscle relaxation and relaxing situations (e.g. walking)
  • Systemic desensitisation: used for phobic anxiety disorders, gradual exposure to a hierarchy of anxiety-producing situations
  • Exposure and response prevention: used for OCD and phobias, repeated exposure to anxiety-producing situations and prevented from preforming compulsive actions to reduce anxiety
179
Q

Describe psychodynamic therapy

A
  • Indications: dissociative/somatoform disorders, personality disorders, recurrent depression, psychosexual disorders
  • Rationale: childhood experiences, past unresolved conflicts, previous relationships significantly influence current situations
  • Aim: conflicts and defence mechanisms are explored, patient develops insight to change maladaptive behaviours
180
Q

Describe psychoeducation

A
  • Delivers information about the nature of their illness, likely causes, what help is available (from services, or themselves)
  • Can be individually or in groups
181
Q

Describe interpersonal therapy

A
  • Indication: depression, eating disorders
  • Focus on problems such as bereavement, relationship difficulties, or interpersonal deficits, and how these impact the individual
  • Some overlap with CBT and psychodynamic therapy, but focuses on problems which may cause difficulty initiating or maintaining relationships
182
Q

Describe eye movement desensitisation and reprocessing

A
  • Helps patients access and process traumatic memories with the aim to resolve them emotionally, using and eternal stimulus to direct the patients eye movement
  • Effective treatment for PTSD
183
Q

Describe dialectical behavioural therapy

A
  • Used for EUPD
  • Uses components of CBT and provides group skills training, and alternative coping strategies during emotional instability
184
Q

What are the key principles of the mental capacity act?

A
  • Decisions made on behalf of the patient must be in their best interests
  • People must be given appropriate help to make decisions (e.g. interpreters, multiple attempts), before concluding a lack of capacity
  • Capacity is determine by the ability to make decisions, not the decision itself (unwise decisions are allowed)
  • The least restrictive intervention should be used
  • Capacity is assumed to be present until proven otherwise
185
Q

What are the effects of a mental illness of the physical health of people with mental illnesses?

A

Schizophrenia/psychosis:
- delusional belief of physical health
- paranoia about healthcare staff or treatments
- thought disorder leading to challenging engagement
- negative symptoms of social withdrawal, amotivation

Depression:
- lack of motivation
- apathy
- negative thinking (worthlessness/hopelessness/guilt)

Anxiety:
- social anxiety (not leaving home)
- healthcare anxiety

Dementia:
- cognitive impairment
- lack of concordance with medication

186
Q

What are the effect of psychiatric medications on the physical health of people with mental illnesses?

A
  • Metabolic syndrome (central obesity, hypertension, dyslipidaemia, glucose intolerance)
  • Type 2 diabetes
  • Cardiovascular disease
  • Bone mineral density loss
  • Renal disease
  • Thyroid disease
187
Q

What are the effects of social circumstances on the physical health of people with mental illnesses?

A
  • Social deprivation (poverty, homelessness, crime, financial difficulties)
  • Isolation (reduced contact with healthcare)
188
Q

What are the effects of lifestyle on the physical health of people with mental illnesses?

A
  • Smoking
  • Poor diet
  • Lack of exercise
  • Drug and alcohol use
    • due to amotivation, isolation, cognitive dysfunction, stigma
    • leading to direct illness (liver disease, accidental overdose, brain damage), or related illnesses (VTE, HIV, hepatitis)
189
Q

What is the effects of the healthcare system on the physical health of people with mental illnesses?

A
  • Division of healthcare system into psychiatry and physical health (de-skilling, poor communication, etc.)
  • Diagnostic overshadowing (assumption that behaviour is due to mental illness without ruling out physical causes)

Phase 3a (10 decks)

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