Psychiatry Flashcards
1
Q
What is the DSM - V definition of ADHD?
A
A condition that incorporates features relating to inattention and/or hyperactivity/impulsivity that is persistent
2
Q
Which lobe of the brain has been shown to be a cause of ADHD
A
Reduced function of the frontal lobe specifically impacting executive function
3
Q
What are the diagnostic criteria for ADHD?
A
- Element of developmental delay
- <16 years, six of these features have to be present
- 17+ years the threshold is five features
4
Q
What are the diagnostic features of inattention in ADHD?
A
- Not follow instructions
- Poor engagement
- Easily distracted
- Diorganised
- Often loses things that are necessary for tasks and activities
- Poor Listening
5
Q
What are the diagnostic features of hyperactivity in ADHD?
A
- Can’t play quietly
- Talks excessively
- Can’t wait their turn easily
- Interruptive/ intrusive of others
- Answers Prematurley
6
Q
What is the management of ADHD
A
1st) Ten-week wait-and-watch period
2) CAMHS Referral
3) Drug therapy >5yrs Only
* First line = Methylphenidate
* Second line = Lisdexamfetamine
* Third line = Dexafetamine
7
Q
What are four medications offered in ADHD
A
- Methylphenidate
- Lisdexamfetamine
- Dexafetamine
- Atomoxetine
8
Q
When is it appropriate to switch Methylphenidate to Atomoxetine in a patient w/ ADHD
A
Development of Facial Tics
Side Effects
Risk Factors
9
Q
What should be monitored for patients on ADHD medication
A
Height due to the medication being known to stunt growth through appetite suppression
Monitor every 6 months
10
Q
What are some side effects of Methylphenidate?
A
- Growth Impairment
- Abdominal pain
- Nausea
- Dyspepsia
- Insomnia
11
Q
What are the criteria for diagnosis of depression?
A
- Symptoms >2 weeks (No causes such as alcohol, drugs, medication, or bereavement)
- The patient experiencing ≥ 5 symptoms, which must include either depressed mood AND/OR anhedonia
- Symptoms must cause sig distress or impairment in social, occupational, or other areas of functioning
12
Q
What are the core symptoms of depression? (SAGECAPS)
A
S –> Sleep changes
A –> Anhedonia
G –> Guilt or feeling of worthlessness
E –> Energy changes, feeling tired
C –> Concentration changes
A –> Appetite changes
P –> Psychomotor agitation or retardation
S –> Suicidal thoughts or acts
13
Q
What are the somatic symptoms found in depression?
A
- Early morning awakening
- GI upset
- Headaches
- Weight Change
14
Q
What are the psychotic symptoms of depression
A
- Delusions
- Hallucination
- Catatonic symptoms
- Marked psychomotor retardation
15
Q
What is the DSM-V grading for depression severity?
A
MILD DEPRESSION
- 5 core symptoms + minor social/occupational impairment
MODERATE DEPRESSION
- ≥5 core symptoms + variable degree of social/occupational impairment
SEVERE DEPRESSION
- ≥5 core symptoms + significant social/occupational impairment
At least 1 core symptom must be depressed mood OR anhedonia.
16
Q
What are the subtypes of depression?
A
- Dysthymic disorder
- Post-natal depression
- Seasonal affective disorder
17
Q
Describe the investigations for depression
A
1) Psych Hx +MSE w/ PHQ-9/HADS
2) Bloods/ TFT and U+E
OTHER
* ANA/ABG
* Dexamethasone suppression test
* CT/MRI head
18
Q
What is the treatment for depression?
A
MILD/MODERATE
1st) Group CBT -> Personal CBT -> Interpersonal Therapy
2nd) Sertraline (SSRI) for 4 week trial
-If remission? Continue for 6 months w/ dose weakening
SEVERE
1st) Sertraline w/ Therapy
2nd) Add Lithium (Unless poor oral intake)
3rd) ECT (Electroconvulsive Therapy)
CHILDREN
Mild) Watch and Wait
Severe) CAMHS referral -> Therapy-> Fluoxetine
(Can add Sertraline or Citalapram)
19
Q
Which antidepressant SSRI should be used in patients with chronic health conditions?
A
Citalopram or Sertraline
20
Q
Which SSRI antidepressant is associated with a higher incidence of discontinuation symptoms
A
Paroxetine
21
Q
Which antidepressant should be given to children as a first line?
A
Fluoxetine
22
Q
Which antidepressant has a risk of prolonging the QT interval?
A
Citalopram/Escitalopram
23
Q
Which SSRI should be given in pregnant patients?
A
Use citalopram or sertraline
Others lead to fetal cardiovascular abnormalities
24
Q
What are the side effects of SSRIs
A
- GI Upset
- Prescribe PPI (GI Bleed Risk)
- Increased Agitation at start
- Sexual Dysunction
25
What drugs should you avoid with SSRIs
**NSAIDs** (Prescribe PPI if needed)
**Heparin and Warfarin** (Prescibe Mirtazipine)
**Triptans** ( Increased risk of Seretonin Syndrome)
**Monoamine Oxidase Inhibitor** (Risk of Seretonin Syndrome)
26
What happens if SSRIs are stopped abruptly?
Discontinuation Syndrome
27
What are the features of Discontinuation Syndrome?
* Mood change/ Restlesness
* Difficulty Sleeping
* Sweating
* GI Symptoms
* Electric Shock Feeling
28
What is Seretonin Syndrome?
Excess amounts of seretonin due to SSRI/MAOi/Amphetamines
29
What are the features of Seretonin Syndrome?
* Agitation/ Restless
* Muscle Rigidity
* Hyperreflexia
* Dilated Pupils
* Flushed Skin
30
What are the TCA anticholinergic effects
Dry mouth
Constipation
Urinary retention/ Bowel obstruction
Dilated pupils/ Blurred Vision
Increased heart rate
Decreased sweating
31
Which TCA's have the most and the least side effects such as cardiotoxicity and anticholinergic effects?
Lofepramine - least
Imipramine - most
32
Which antidepressants can help with weight gain in a patient with a low BMI?
Alpha 2 adrenorecepetor antagonist - **Mirtazepine**
33
Which type of food should patients avoid if they are taking MAOi and why?
Do not eat food or drinks that contain **TYRAMINE** because this can cause hypertensive crisis
E.g., cheese, liver and yoghurt
34
What is dysthymic disorder?
- Chronic (>2 years) with less severe depressive symptoms
35
What are the clinical features of dysthymic disorder?
- Clinical features similar to depression
- Depressed mood
- Reduced/increased appetite
- Insomnia/hypersomnia
- Reduced energy/fatigue
- Low self-esteem
- Poor concentration
- Difficulties making decisions
- Thoughts of hopelessness
36
What is the management for dysthymic disorder?
SSRI/TCA, CBT may be useful
37
What are the clinical features of seasonal affective disorder?
Clear seasonal pattern to recurrent depressive episodes
Usually January/February (‘winter depression’)
Low self-esteem, hypersomnia, fatigue, increased appetite/weight gain
Decreased social and occupational functioning
Symptoms mild-moderate
38
What is the management for seasonal affective disorder?
Light therapy
2hrs 2500lux light in the morning for 1-2 weeks
Maintenance 30 mins 2500lux every 1-2days
then SSRI
39
What is the definition of post-natal depression?
Significant depressive episode related to childbirth (<6 months post-partum)
40
What are the **biological** causes of Postnatal Depression?
Hormonal changes - Drop in Oestrogen/ Progesterone and Thyroid
Melatonin and Cortisol changes
Inflammatory Processes
Genetic Predisposition
41
What are the **Psychological** causes of Postnatal Depression?
Mood Disorders
Previous Post Natal Depression
Neuroticism - Emotional Instability
42
What are the Social causes of Postnatal Depression?
Lack of Social Support
Single Motherhood
Low Socioeconomic Background
Poor Maternal Relationship
43
What are the risk factors for postnatal depression?
- Family History and Older age
- Single mother/poor maternal relationship
- Poor social support/ Low socioeconomy
- Severe baby blues (low mood after childbirth 30-80% of patients get this in the first-week post-delivery)
44
What are the clinical features found in post-natal depression?
- SAGECAPS in Depression
- Worries about baby's health
- Worries about ability to cope adequately with the baby
45
What is the assessment for post-natal depression?
Psychiatric screen
MSE
Edinburgh postnatal depression screen (EPDS) then PHQ-9
Bloods and TFT
46
What is the treatment for post-natal depression?
1) Self help/ CBT
2) SSRI (Paroxetine/ Sertraline/ citalopram
3) Inpatient admission to mother and baby unit
47
What is the definition of generalized anxiety disorder?
Excessive worry about everyday events
- 6+ months
- w/ Significant distress
- w/ Functional impairment (Restless/ Muscle Tension and Fatigue)
48
What are the criteria for diagnosis of generalised anxiety disorder?
- Excessive anxiety and worry about everyday events/activities
- Can't control worry for 6 months
- Clinically significant distress/impairment in social and occupational impairment
- At least 3 associated symptoms
49
What are the Psychological Features in Generalised Anxiety?
- Excessive Fears and Worries
- Poor Concentration
- Irritability
- Depersonalisation/Derealisation
- Insomnia/ Night Terrors
- Feeling on edge
50
What is meant by Depersonalisation/ Derealisation?
Feeling of being dissociated from one's body and mind
51
What are the **phsyical** generalised anxiety disorder-associated symptoms?
**MOTOR**
Restless
Fidgeting
Feeling on Edge
**NEURO**
Tremor/Tension
Headache
Muscleache
Dizziness/ Tinitus
**GASTRO**
Dry Mouth
Dysphagia
Nausea
Indigestion
Flatulence/ Hypermotion
**CARDIO/RESP**
Chest Tightness
Palpitations
Dyspnoea
**GENITOURINAL**
Urinary Frequency
Eerctile Dysfunction
52
What are some motor features in Anxiety
Restlessness
Fidgeting
53
What are some neurological features found in Anxiety
Tremor and tension
Headache and Muscleache
Dizziness
Tinitus
54
What are some Gastrointestinal features in Anxiety
Dry mouth/ Dysphagia
Nausea
Indigestion
Flatulence
Bowel Hyper-motion
55
What are some Cardio/Resp features of Generalised Anxiety?
Chest Tightness
Palpitations
Dyspnoea
56
What are the Genitourinary features of Generalised Anxiety?
Urinary Frequency
Erectile Dysfunction
Stress Incontinence
57
What are some early features of anxiety in children
- Thumb Sucking
- Bed Wetting
- Nail Biting
- Food Fads
58
Give 3 Diagnostic measures that can be used for Anxiety
**Clinical History + MSE**
**GAD-7**
Beck Anxiety Inventory Scale
Hospital Anxiety and Depression Scale
59
What is the NICE stepwise care model for treating generalised anxiety disorder?
1) Education and Guided Self Help or CBT
2) High Intensity CBT w/ SSRI
- Sertraline
- Venlafaxine or Duloxetine
- Pregabalin
3) Offer Propranolol for Palpitations
60
Which drugs **should not be offered** to patients presenting with generalised anxiety disorders?
Benzodiazepines
Antipsychotics
61
What is the definition of panic disorder?
Recurrent, episodic, severe panic attacks that are unpredictable and **not restricted to a particular situation/circumstance**
62
What is the clinical presentation of panic disorder?
| PANICS D
- Symptoms peak within 10mins
- Discrete episodes of intense fear
- Autonomic arousal
P – Palpitations
A – Abdominal distress
N – Numbness/nausea
I – Intense fear of death
C – Choking/chest pain
S – Sweating/shaking/SOB
D- Depersonalisation
63
What are the investigations for panic disorder?
1) Psychiatric Hx + MSE
Blood: FBC, TFTs and glucose
**ECG: sinus tachycardia**
Rule out GAD with GAD-7
64
What is the treatment for panic disorder?
SSRIs (Sertraline) > TCA (Imipramine)
**Don’t give BDZ!**
CBT and self-help methods
65
Define phobic anxiety
Recurring excessive and unreasonable psychological or autonomic symptoms of anxiety in the (anticipated) **presence of specific feared objects, situation, place or person leading,** wherever possible to avoidance’
66
what are the subtypes of phobic anxiety?
Animals
Aspects of the natural environment
Blood
Injury
Injection
Situation
67
What is the management for phobic anxiety?
1) Graded Exposure Therapy
Education/anxiety management
BDZ e.g diazepam can help engage pt in exposure
68
What is the definition of PTSD?
Intense prolonged or delayed reaction <6mths of exposure to an exceptionally traumatic event w/ symptoms lasting >4 weeks
69
What is the clinical presentation (classic quadrad) for PTSD?
**Reliving the situation**
Nightmares and Flashbacks
**Avoidance**
Avoiding reminders of the event
**Hyperarousal**
Irritability, outbursts and difficulty sleeping/concentrating
**Emotional Detachment** Negative thoughts about oneself, difficulty expressing emotion and feeling detached from others.
70
What is Dissociative Amnesia?
inability to remember an important aspect
71
What is the criteria for a diagnosis of PTSD?
- Exposure to a traumatic event
- Classic quadrad features
- <6 months of the event
- Features last > 1 month
72
What are the causes of PTSD?
Developmental factors Psychological factors
73
What are the investigations for PTSD?
1) Psychiatry history and MSE
2) Trauma screening questionnaire (TSQ)
74
What is the treatment for PTSD?
1st) **Venalafaxine** (Sertraline can be used)
2) Zopiclone or Risperidone
75
What is the definition of OCD?
A chronic condition, associated with marked anxiety and depression, **characterised by ‘obsessions’ and/or ‘compulsions'**
76
What is an obsession?
An idea, image or impulse recognized by patients as their own, but which is experienced as repetitive, intrusive and distressing
77
Give some examples of Obsessions
**Aggressive**
Images of hurting a child or parent
**Contamination**
Becoming contaminated by shaking hands with another person
**Need for order**
Intense distress when objects are disordered or asymmetric
**Repeated doubts**
Wonder if a door was left unlock
**Sexual imagery**
Recurrent pornographic images
78
What is a compulsion?
Behaviour or action **recognised by patient** as unnecessary and purposeless but which they cannot resist performing repeatedly.
**There is non passivity, differentiating it from schizophrenia**
79
Give some examples of Compulsions
**Repetitive ritualistic activities**
Performed to alleviate anxiety from obsession
**Self Recognition**
Drive to perform action is recognised by the patient as their own
**Checking**
Repeatedly checking locks, alarms, appliances
**Cleaning**
Hand washing, which is typically overt due to obvious dermatological symptoms
**Mental acts**
Counting and repeating words silently
**Ordering**
Reordering objects to achieve symmetry
80
What is the criteria for diagnosis of OCD?
* Obsessions
* Compulsions
* Time Consuming
* Functional Impairment
* Patient Aware
81
What is the treatment for OCD
****MILD IMPAIRMENT**
1) CBT w/ Exposure and Response Prevention
2) SSRI w/ Exposure and Response Prevention
**MODERATE IMPAIRMENT**
1) Invasive CBT or SSRI or Clomipramine
**SEVERE IMPAIRMENT**
1) Secondary Care Assessment w/ SSRI and CBT
82
What is the definition of Bipolar disorder?
Episodic depression w/ at least one episode of mania/hypomania
83
What are the possible causes of Bipolar disorder?
Personality
Childhood experiences
Life events
Biochemical/endocrine
84
What are some risk factors for Bipolar Disorder
* Family Hx/ 25+
* Stressful Past
* Substance Misuse
* Anxiety or Depression
* SSRI triggering Mania- **Stop SSRI in patient and initiate Antipsychotic**
85
What is Mania?
Elevated, expansive, euphoric, or irritable mood with ≥3 characteristic symptoms of mania on most days for 1 week
86
What are the symptoms of Mania?
**Marked disruption of work, social activities and family life**
- Elevated Mood/ Energy and Self Esteem
- Reduced Attention
- Pressure of Thought and Speech
- Flight of Ideas
- Word Salad
- Engaged in risky behaviour
87
What are the psychotic symptoms seen in manic episodes?
Grandiose and Persecutory Delusions
Auditory and visual hallucinations
Catatonia
Total loss of insight
88
What is meant by Catatonia?
A state in which someone is awake but does not seem to respond to other people and their environment
89
What is the criteria for a diagnosis of hypomania?
≥3 characteristic symptoms lasting ≥4 days and be present most of the day, almost every day
90
What are the symptoms of hypomania?
Shares mania symptoms
Symptoms evident to lesser degree
Not severe enough to interfere with social or occupational functioning
Does not result in hospital admission
No psychotic features
Mildly elevated, expansive, or irritable mood
Increased energy
Increased self-esteem
Sociability
Talkativeness
Over-familiarity
Reduced need for sleep
Difficulty focusing
91
What is Bipolar I disorder?
Characterised by episodes of **depression**, **mania** or **mixed states** separated by periods of normal mood
92
What is Bipolar II disorder?
**Do not experience mania** but have periods of hypomania, depression or mixed states
93
What is Cyclothymic disorder?
Characterised by **recurring depressive and hypomanic states, lasting for at least 2 years**, that do not meet the diagnostic threshold for a major affective episode
94
Give examples of medication that can induce mania/hypomania
TCAs/NSRIs > SSRIs
benzodiazepines
antipsychotics
anti-Parkinsonian medications
95
What is the pharmacological treatment for Bipolar disorder?
Manic episode: Lithium ± Benzodiazepine (e.g., clonazepam or lorazepam)
Depressive episode: SSRI - least likley to induce mania
Maintenance: Lithium/ Carbamazepine
96
What are the side effects of Lithium and why can they be common?
**Lithium has a narrow therapeutic range**
- Weight gain
- Subclinical/clinical hypothyroidism
- Renal impairment
- Teratogenic - Ebstein's anomaly - congenital malformation of the tricuspid valve
97
What is the therapeutic level for Lithium?
0.6-0.8 mmol/L
98
What type of drug is Lithium/carbamazepine?
mood stabilisers
99
What are the psychotherapeutic interventions for Bipolar disorder?
Psychoeducation
CBT
IPT
Support groups
100
What are the risk factors for Schizophrenia?
**Genetic** - Increased prevalence with increased relation to affected family
**Early Life**
- Maternal Health Issues
- Birth Trauma (Hypoxia/Blood loss)
- Childhood Trauma
**Environment**
- Cannabis use
- Urban Living and Immigration
- Pre Morbid Social Isolation
101
How can the symptoms of schizophrenia be grouped?
**Positive symptoms (ABCD)**
- new feature that doesn’t have a physiological counterpart
**Negative symptoms (BAAAD)**
- removal of normal processes, can be a decrease of emotions or loss of interests anhedonia
**Cognitive**
- not being able to remember things, learn new things or understand others, subtle and difficult to notice
102
What are the Positive symptoms of schizophrenia?
**Auditory hallucinations**
- 2nd or 3rd person
- in or out of head
- Command/ derogatory
- Running commentary
**Beliefs**
- Persecutory/ Religous
- False Beliefs
- Grandiose
**+Broadcasting**
**Control Issues**
**Deluded Perception**
103
Give me some types of Auditory Hallucinations
2nd/3rd Person
In/Out of Head
Command
Derogatory
Running Commentary
104
Give examples of Beliefs in Schizophrenia
Reliogous
Persucatory
False Beliefs
Grandiosity
105
What are the Negative symptoms of schizophrenia? BAAAAD
* Blunting/Incongruity of affect
* Avolition – Decreased Motivation
* Anhedonia - Decreased Pleasure
* Asocial Behavior
* Alogia – Poverty of Speech
* Depression
106
What are the Cognitive symptoms of schizophrenia?
Not being able to remember things, learn new things or understand others, subtle and difficult to notice
107
What is the DSM-V diagnostic criteria for schizophrenia?
**Two of the following:**
Delusions -->At least one
Hallucinations --> At least one
Disorganised speech --> At least one
Disorganised/catatonic behaviour
Negative symptoms
**Ongoing for 6 months**
**Not due to another condition**
108
What are the first rank symptoms of schizophrenia?
Thought alienation
Delusional perception
Passivity
3rd person hallucinations
109
What is Thought Alienation
**Thoughts either being inserted or held inside the patient**
- Insertion
- Broadcasting
- Withdrawal
110
What is meant by Passivity Phenomena
Actions, Feelings or Impulses that have been made up by the patient
111
What are the second rank symptoms of Schizophrenia?
Grandiose Delusions
2nd person Hallucinations
Thought Disorder
Catatonia
Negative Symptoms
112
What are some subtypes of Schizophrenia
* Paranoid - Delusions and Hallucinations w/ thoughts of persecution
* Catatonic - Motor disturbances and wavy flexibility
* Hebephrenic - Disordered thinking, emotions and behaviour
* Residual - Residual Sx persist after large episodes
* Simple - Gradual functional decline without strong Positive Sx
113
What is Paranoid Schizophrenia?
Delusions and Hallucinations w/ thoughts of persecution
114
What is Catatonic Schizophrenia?
Motor disturbances and wavy flexibility
115
What is Hebephrenic Schizophrenia?
Disordered thinking, emotions and behaviour
116
What is Residual Schizophrenia?
Residual Sx persist after large episodes
- Unrealistic Ideas
- Bizarre Thinking
117
What are the differentials for Schizophrenia?
Psychotic depression
Schizoaffective disorder
Personality disorder
Bipolar disorder
Substance abuse
118
What are the investigations for schizophrenia?
1) Full psychiatry Hx + MSE
2) Exclude differentials
3) Exclude physical causes
- CT/MRI head
- Toxicology screen
- FBC/U&E/LFT
119
What is schizoaffective disorder?
Major Mood disorder + schizophrenia
120
What are the different types of schizoaffective disorder?
Manic type
- Manic + psychotic symptoms
Depressive type
- Depressive + psychotic symptoms
Mixed type
- Depressive + manic + psychotic symptoms
121
What are the risk factors for schizoaffective disorder?
Family history
Substance abuse
psychological stress/environment
122
What are the symptoms of schizoaffective disorder?
**Negative**
Anhedonia
Social isolation
Blunt affect
**Positive**
Hallucinations (auditory, visual, tactile)
Delusions (Persecutory, nihilistic, grandiose, religious)
Thought disorder (tangential thinking, verbigeration)
Cognition (Memory/executive function deficits)
**PSYCHOTIC DEPRESSION**
123
What is the management of schizoaffective disorder?
1) Antipsychotic
- Risperidone, Aripiprazole, Quetiapine
Anxiolytic – lorazepam
Psychological interventions – CBT
Social intervention – housing, employment, exercise, education
**PSYCHOTIC Depression?**
Medication
- antidepressants + antipsychotics
Non-pharmacological
- CBT, lifestyle changes, housing/employment help
124
What is the pharmacological treatment for Schizophrenia?
Antipsychotics (PO or depot):
Atypical:
-Risperidone
-Quetiapine
-Aripiprazole
-Olanzapine
-Clozapine
Typical:
-Haloperidol
-Chlorpromazine
125
What are the side effects of antipsychotic use?
Extra-pyramidal
akathisia, tardive dyskinesia, dystonia, Neuroleptic Malignant Syndrome
Metabolic
weight gain, diabetes, liver dysfunction
General
dry mouth, constipation, sexual dysfunction, ECG changes
Specific:
Risperidone – hyperprolactinaemia
Clozapine – agranulocytosis, cardiomyopathy
Drowsiness/sedation
QT interval prolongation
GI disturbances
126
Which antipsychotic can cause hyperprolactinaemia?
Risperidone
127
Which antipsychotic can cause agranulocytosis and cardiomyopathy?
Clozapine
128
Name 3 mood stabiliser drugs
Lithium, carbamazepine, sodium valporate
129
Name 2 anxiolytic drugs
Clonazepam/diazepam
130
What are the non-pharmacological management options for schizophrenia?
Manage mental health co-morbidities
CBT
Family therapy
Art therapy
Lifestyle changes
ECT - electroconvulsive therapy
131
What is the duration of section 2 of the mental health act?
28 days and non-renewable
132
What is the purpose of section 2 of the mental health act
assessment and treatment
133
Which professionals can authorise section 2 of the mental health act?
Two doctors one of which who is section 12 approved
One approved mental health professional AMHP
134
Why might a patient be sectioned under section 2 of the mental health act?
Patient may be suffering from mental disorder
and detained for their own health/safety or others protection.
135
What is the duration of section 3 of the mental health act?
6 months and renewable
136
What is the purpose of placing a patient on section 3 of the MHA?
long term treatment
detained for their own health/safety or others protection.
137
Which professionals can authorise section 3 of the mental health act?
Two doctors one of which who is section 12 approved
One approved mental health professional AMHP
138
What is the duration of section 4 of the mental health act?
72 hours, non-renewable
139
What is the purpose of placing a patient on section 4 of the MHA?
To hold the patient until assessment by a s12 doctor
140
Which professionals can authorise section 4 of the mental health act?
One doctor
One AMHP
141
What are the two different types of Section 5 MHA?
Section 5(4)
Section 5(2)
142
What is the purpose of section 5 MHA?
patient is in hospital but wants to leave, cannot be treated coercively
143
What is the duration of section 5(4) and who is it initiated by?
6 hours
Nurse
144
What is the duration of section 5(2) and who is it initiated by?
72 hours
doctor in charge of the patient care
145
What are the two police orders?
135 and 136
146
What is the duration and purpose of order 135?
Duration – 36 hours
Purpose - police allowed to enter patient’s home to move to a place of safety
147
What is the duration and purpose of order 136?
Duration – 24 hours
Purpose – police can move patient with mental disorder in a public place to place of safety
148
What is the pathophysiology of neuroleptic malignant syndrome?
Adverse reaction to dopamine receptor agonists - anti-psychotics
Abrupt withdrawal of dopaminergic medication - parkinsons
149
What are the symptoms of neuroleptic malignant syndrome?
Altered mental state – confusion, delirium, stupor
Hypertonia/muscle rigidity – lead pipe rigidity!!
Autonomic dysfunction – high HR, high RR, urinary incontinence, labile BP, sweating
Hyperthermia - high fever
150
What are the investigations for Neuroleptic malignant syndrome?
Rule out differentials (sepsis, brain problems, renal failure):
Bloods – FBC (WCC high in NMS), CK (NMS -> rhabdomyolysis), U and Es
Imaging – CT/MRI head
Infection screen - urine/blood culture, LP
151
What is the management of neuroleptic malignant syndrome?
Withdraw anti-psychotic medication
Supportive treatment - rehydration, correct U and E imbalances, antipyretics
152
What is the pathophysiology of Serotonin Syndrome?
increased intrasynaptic serotonin concentration
153
What are the causes of Serotonin Syndrome?
Antidepressants – SSRI and SNRI
Others – opioid analgesics, MAOI, lithium
154
What are the symptoms of serotonin syndrome?
Altered mental state - anxiety, agitation, confusion
Neuromuscular – clonus, hyperreflexia, hypertonia, tremors IMPORTANT
Autonomic – high HR and RR, sweating, shivering, D and V, hyperthermia
155
What are the investigations for serotonin syndrome?
Look for other causes
156
What is the management for serotonin syndrome?
Withdraw offending medication
Supportive treatment – benzos for agitation, cool pt down
If a recent overdose – activated charcoal
157
What is the definition of personality disorders?
An enduring pattern of inner experience and behaviour that deviated markedly from the expectations of the individual’s culture.
158
According to DSM-5 generally, the diagnosis of personality disorder includes...
long-term marked deviation from cultural expectations that leads to significant distress or impairment in at least two of these areas:
- Cognition = the ways of perceiving and interpreting self, other people and events
- Affectivity = the range, intensity, lability, and appropriateness of the patient's -
- emotional responses
- Interpersonal functioning
- How well the patient controls their impulses
159
What are cluster A personality disorders?
Paranoid
Schizoid
Schizotypal
160
What can be the causes of personality disorders?
Socioeconomic status
Family history
Parenting/deprivation
Abuse
161
What would you see in someone with a paranoid personality disorder?
--> Irrational belief that others are harmful or deceptive
--> Doubts the trustworthiness of close individuals
--> Reluctance to confide in others, fearing it may be used against oneself
--> Sees hidden threats in everyday scenarios
--> Hold prolonged grudges
--> Constantly feels attacked
--> suspicious of partners fidelity
--> not explained by any other condition or substance
162
What would you see in someone with a schizoid personality disorder?
--> does not want/enjoy close relationships
--> prefers solitude
--> lack of interest in sexual activities
--> Hard to please
--> lacks close friends
--> unbothered by other's comments
--> flat affect/emotional blunting
--> not explained by any other condition/substance
163
What would you see in someone with a schizotypal personality disorder?
--> ideas of reference - everything relates to destiny
--> magical thinking that changes behaviour - random events are linked
--> altered perception
--> unusual thinking/talking
--> suspiciousness/paranoia
--> Inappropriate/flat affect
--> eccentric/unusual behaviour
--> lack of close friends
--> social anxiety - paranoia
164
What are the cluster B personality disorders?
Antisocial
Borderline
Histrionic
narcissistic
165
What would you see in someone with an antisocial personality disorder?
--> does not conform to societal norms and disregards moral values
--> Deceitful
--> impulsive/aggressive
--> reckless
--> irresponsible
--> unremorseful
--> little empathy
166
What would you see in someone with a borderline personality disorder?
--> Frantic avoidance of abandonment
--> Unstable, intense relationships
--> unstable self-image
--> Self-destructive impulsivity
--> Suicidal/Self-harming behaviour
--> Emotional instability
--> feeling empty
--> anger management issues
--> transient paranoid thinking
--> splitting, extreme perspective on important things such as good or bad
167
What would you see in someone with a histrionic personality disorder?
--> attention seeking must be the centre of attention
--> inappropriate such as provocative interactions
--> fast changing shallow emotions
--> uses appearance to draw attention
--> vague speech
--> exaggerated manner
--> easily affected by others/situation
--> mistakes relationships as being more intimate
168
What would you see in someone with a narcissistic personality disorder?
--> grandiose self-image
--> fantasies of grandiosity
--> Believes they are special
--> Seeks admiration
--> sense of entitlement
--> exploitative
--> envious/jealous
--> arrogant
169
What are cluster C personality disorders?
Avoidant
Obsessive-compulsive
dependant
170
What would you see in someone with an avoidant personality disorder?
--> avoids social situations
--> unwillingness to interact
--> limits intimate relationships
--> Preoccupation with rejection, criticism
--> low self-esteem
--> fears embarrassment associated with social risk-taking
171
What would you see in someone with Obsessive-compulsive personality disorder?
--> preoccupation with details
--> Disruptive perfectionism
--> Work eclipses personal life
--> Rigid, loud beliefs (religious, ethical)
--> tendency of hoard possesions
--> refuses to delegate
--> excessively frugal
--> stubborness
172
What is the difference between Obsessive-compulsive disorder and obsessive-compulsive personality disorder?
OCD --> anxiety disorder - repetition of ritualistic actions, Ego-dystonic - patient wishes they could stop
OCPD --> Ego-syntonic - happy with how they are
don't want to change
173
What would you see in someone with a dependent personality disorder?
--> cant make everyday decisions
--> overly dependent on others
--> Scared to disagree with others
--> Lacks self-motivation
--> craves approval
--> uncomfortable/afraid of being alone
--> Quick to replace lost relationships
174
What investigations would you carry out for personality disorders?
Psychiatric history + MSE
Personality diagnostic questionnaire (PDQ-IV)
Minnesota multiphasic personality inventory
MRI/CT head
175
At what age can a diagnosis of personality disorder be made and why?
>18 years
as this is when the personality has developed
176
What is the management of someone with a personality disorder?
--> Risk assessment
--> No specific pharmacological treatment- Can help treat symptoms, Antidepressants/beta-blockers (propranolol) to treat depression or anxiety, Mood stabilisers/antipsychotics can be prescribed to help mood swings, alleviate psychotic symptoms or reduce impulsive behaviour
--> Dialectical behavioural therapy (DBT)
--> Mentalisation-based therapy (MBT)/CBT/psychodynamic therapy
--> Crisis team
177
What are two examples of physiological dependence in drug abuse?
--> sign of tolerance
--> Withdrawal symptoms
178
What are the criteria for diagnosing a patient with drug abuse?
THREE OR MORE OF THE FOLLOWING MUST OCCUR FOR >1MONTH
Desire for substance
Preoccupation with substance use
Withdrawal state
Incapability to control substance
Tolerance to substance
Evidence of harmful effects
179
What are the potential complications of drug abuse?
--> Death
--> infection (e.g., IE)
--> DVT
--> PE
--> craving
--> anxiety
--> cognitive disturbance
--> drug-induced psychosis, crime
--> imprisonment
--> homelessness
180
What are the investigations for substance (drug) abuse?
Psychiatric Hx + MSE
Physical exam: weight, dentition, signs of IVDU
Signs of withdrawal
Bloods: FBC, U&Es, LFTs, clotting profile, drug level and screen for blood-borne infections (Hep B&C, HIV)
Urinalysis: toxicology
ECG, echocardiogram and CXR
181
What are the signs of opiate withdrawal?
Appear 6-24hours after the last dose
Last 5-7 days
Sweating, dilated pupils, tachycardia, high BP, watering eyes/nose, abdominal cramps, N&V, tremor and muscle cramps
182
What is the management of substance (drug) abuse?
Self-help groups
Motivational interviewing/CBT
Pharmacological intervention: opioid dependence
Substitute prescribing/detoxification: Methadone, buprenorphine ( withdrawal side effects lower) or dihydrocodeine
Withdrawal symptom relief: Lofexidine - used in younger patients
Relapse prevention: Naltrexone
Overdose: Naloxone
Benzodiazepine substitute prescribing/detoxification: long-acting diazepam
183
How do you calculate alcoholic units?
(ABV (%) X volume (ml)) /1000
184
What is the recommended unit intake of alcohol per week?
14 units/week
185
What is the clinical presentation of intoxication?
Impaired speech, labile affect, impaired judgement, poor coordination, hypoglycaemia, stupor and coma
186
What are the clinical signs of alcohol dependence?
S – Subjective awareness of compulsion to drink
A – avoidance or relief of withdrawal by further drinking
W – Withdrawal symptoms
D – Drink-seeking behaviour
R – Reinstatement of drinking after attempted abstinence
I – Increased tolerance
N – Narrowing of drinking repertoire - Start off by drinking beers, cider, ales and wine, then only drinks spirits
187
What occurs in alcohol withdrawal?
Symptoms appear 6-12hrs after the last drink
--> Malaise, tremors, nausea, insomnia, transient hallucination and autonomic hypersensitivity
At 36 hours
--> Seizures
At 72 hours
--> Delirium tremens
188
What are the signs of Delirium tremens (DT)
Acute confusional state
Dehydration ± electrolyte disturbances
Cognitive impairment
Hallucinations/illusions
Paranoid delusions
Marked tremor
Autonomic arousal
189
Why can alcohol withdrawal cause delirium tremens?
chronic alcohol consumption enhances GABA-mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
190
Name 2 complications of alcohol misuse
Wernickes encepahlopathy
Wernick-Korsakoff syndrome
191
Why does Wernicke's encephalopathy occur?
Thiamine Vitamin B1 deficiency
192
What is the clinical presentation of Wernicke's encephalopathy?
--> confusion
--> ophthalmoplegia
--> ataxia
--> Delirium
--> hypothermia
--> nystagmus
193
What is the treatment for Wernicke's encephalopathy?
IV Pabrinex (thiamine)
194
What can untreated Wernicke's encephalopathy lead to?
Wernick-Korsakoff syndrome
195
What is the clinical presentation of Wernick-Kosakoff syndrome?
--> Retrograde amnesia - loss of memories that have been already formed
--> Anterograde amnesia - inability to form new memories
--> Confabulation - the creation of false memories without the intent to deceive
--> disorientation to time
196
What is the management of Wernick-Korsakoff syndrome?
- not curable
- PO thiamine and multivitamins for 2 years
197
What is the assessment for alcohol misuse?
--> Psychiatric Hx + MSE
--> Physical exam - attention to chronic liver disease peripheral stigmata - palmar erythema, Dupuytrens contracture, spider naevi, gynae
--> Questionnaires: AUDIT (Alcohol Use Disorders Identification Test)
, CAGE (cut down, annoyed when questioned, guilty drinking, eye-opening event)
, SADQ (severity of alcohol dependence questionnaire)
and FAST (fast alcohol screening test)
--> Clinical Institute Withdrawal Assessment (CIWA) - determines withdrawal severity
--> CT head
--> ECG
--> Bloods: FBC, U&Es, LFTs (gamma-GT^), TFTs, vitamin B12/folate, blood alcohol level, amylase/lipase, glucose and hepatitis serology
198
What is the treatment for alcohol misuse?
1) IV Chlordiazepoxide
2) Naltrexone (Opioid Inhibitor)
3) Acampronate (NDMA Inhibitor)
4) Disulfiram (AAD Inhibitor)
199
What is the definition of Dementia?
progressive neurological disorder impacting cognition that leads to functional impairment
200
What are the different types of dementia?
--> Alzheimer’s disease - senile plaques, neurofibrillary tangles, neuronal loss
--> Vascular dementia - microinfarcts in cerebral blood vessels -> poor blood supply
--> Lewy body dementia - abnormal deposits of alpha-synuclein -> Lewy bodies
Others:
-Frontotemporal
-Parkinson’s related
-Alcohol-related
-Mixed (Alzh + vasc)
201
What are the risk factors for dementia?
Age > 65
Family history
Genetics – presenilin
Down’s syndrome
Cerebrovascular disease
Hyperlipidaemia
Lifestyle – smoking, obesity, high-fat diet, alcohol
Poor education
202
What are the general symptoms of dementia?
Memory decline – new memories lost first
Disoriented in time and place
Nominal dysphasia – can’t name objects/people
Visuospatial dysfunction – misplacing things/getting lost
Change in emotions – apathy or disinhibition
Change in personality
Prosopagnosia – unable to recognise faces
203
What are the symptoms of Alzheimer's disease?
Gradual onset + progressive
No insight into the condition
- Agnosia
- Apraxia
- Aphasia
- Amnesia
204
What are the symptoms of vascular dementia?
Stepwise progression
Insight into condition
205
What are the symptoms of Lewy-body dementia?
Hallucinations common
Parkinsonian signs - hypertonia, bradykinesia, resting tremor
206
What are the investigations for dementia?
--> Full history – personal and collateral
--> Cognitive screening tools:
- MMSE
- ACE III
- MoCA
--> Rule out medical causes:
- Bloods – FBC, metabolic panel, B12, LFT, BM
- Urinalysis
- CT/MRI head
--> Differential diagnosis:
-Delirium
-Depression
207
What is the management of dementia
--> Advance care plan – LPA, advance statement, preferred place of care
--> Pharmacological:
Acetylcholinesterase inhibitors:
- **Donepezil**
- Galantamine
- Rivastigmine
Other psychiatric disturbances antipsychotics/antidepressants/anxiolytic
--> Non-pharmacological:
- Lifestyle changes - diet, exercise, maintaining social contacts
- Cognitive rehabilitation/occupational therapy
208
What is delirium?
acute, fluctuating change in mental state
209
What are the different types of Delirium?
hyperactive - restlessness, agitation, delusion/hallucination
hypoactive - lethargy, sedation, slow to respond
mixed - hyperactive + hypoactive
210
What are the potential causes of Delirium?
PINCH ME
--> Pain – MI, surgery, iatrogenic, neurological problem
--> Infection – meningitis, UTI, fever, pneumonia, sepsis
--> Nutrition – decreased oral intake, metabolic abnormalities
--> Constipation
--> Hydration – dehydration
--> Medication – polypharmacy, change in medication, withdrawal (benzo, alcohol)
--> Environment – dementia, use of restraints, catheter
211
What is the management of Delirium?
Treat the cause
212
What is autism spectrum disorder?
A developmental disorder is characterised by difficulties with social interactions, and communication as well as restricted repetitive behaviours, interests and activities
The spectrum encompasses Aspergers syndrome, childhood disintegrative disorder
213
Describe the theories behind autism spectrum disorder?
Mind Blindness Theory
- Inability to attribute mental skills to one self
Weak Central Coherence Theory
- Focus on minor details and local elements of information instead of a bigger picture
Empathising Systemising Theory
- Low empathising to systematising ratio in individual
214
What are the signs and symptoms of autism spectrum disorder?
* Social Isolation
* Lack of Perspective (Theory of Mind)
* Speech and Language Delay
* Lack of Pronoun/ Idiom Understanding
* Narrow Interests and Restricted Habits
* Learning Difficulty and Seizures (25%)
215
What are the complications of autism spectrum disorder?
Reduced success in various areas of life such as social and academic
216
What is the management for autism spectrum disorder?
* Applied Behavioural Analysis
* Psycho Education
* Employment Support
* Life Skills
* Support w/ Sensory Sensitivity
* Medication (Stimulants, SSRI, Antipsychotic)
217
What is Somatisation disorder?
Extended periods of unexplained physical symptoms, normally over 2 years. Not faking symptoms, unlike factitious disorder.
the patient refuses to accept reassurance or negative test results
218
What are the signs and symptoms of somatisation disorder?
- Somatic symptoms --> pain, sexual, gastrointestinal problems which can change over time
- Cognitive symptoms --> worry and anxiety due to the physical symptoms not being able to be explained, excessive thought about the severity of symptoms, anxiety about symptoms/health.
219
What does somatisation disorder have a high co-morbidity with?
depression and anxiety disorders
220
What is the diagnostic criteria for somatisation disorder?
One or one+ somatic symptoms and distress in other areas of life related to the anxiety and worry caused by the unexplained symptoms lasting more than 6 months
221
How is the severity of somatisation disorder determined?
- determined by changes in cognitive symptoms
- mild --> one change
- moderate --> two or more changes
- severe --> two or more changes with multiple physical symptoms/one severe symptom
222
What is the treatment for somatisation disorder?
Psychotherapy - to improve cognitive symptoms e.g group therapy.
223
What is psychosis?
is a term used to describe a person experiencing things differently from those around them.
224
name some psychotic features
Psychotic features include:
hallucinations (e.g. auditory)
delusions
thought disorganisation
alogia: little information conveyed by speech
tangentiality: answers diverge from the topic
clanging
word salad: linking real words incoherently → nonsensical content
225
Which neurological conditions can present with psychotic symptoms?
Parkinson's disease
Huntingtons disease
226
Give an example of a prescribed drug that can induce psychosis.
corticosteroids
227
Which neurological conditions can present with psychotic symptoms?
Parkinson's disease
Huntington's disease
228
What is the ECT?
Electroconvulsive therapy
- Inducing a minor seizure during sleep to alter an individual's state of mind (Depression and Catatonia)
229
What can ECT be used to treat?
Severe depression which is resistant to multiple antidepressants
Severe depressive disorder which is causing harm to the patient (e.g. associated with self-neglect/suicide risk)
Catatonia
230
What is the duration of an ECT course?
usually comprises of 6-12 treatments given twice weekly and the patient is reassessed after every treatment. If improvements aren’t noted after 6 sessions of ECT, the course may be stopped.
231
What are some of the side effects of ECT?
Short-term memory loss
Retrograde amnesia (memory loss immediately before/after ECT)
Post ECT headache
Brief confusion/drowsiness following administration of the anaesthetic
232
What would you see in a patient with a learning disability?
Difficulty with developing/learning certain skills
233
What are the different types of learning disabilities?
Dyslexia - difficulty reading
Dysgraphia - difficulty writing
Dyscalculia - difficulty with mathematics
234
What is the complications of learning disabilities?
Reduced success in various areas of life
235
What are the signs and symptoms of learning disabilities?
Dyslexia - slow, effortful reading and poor understanding
Dysgraphia - poor spelling, grammar, handwriting
Dyscalculia - poor arithmetic
often co-morbid with anxiety, depression
236
How is a diagnosis of a learning disability reached?
more than or one of the following for 6 months or more
--> Poor reading skills
--> Poor reading comprehension
--> difficulties with spelling
--> other difficulties with written language
--> trouble with mathematics
--> trouble with mathematical reasoning
--> academic skills significantly lower than what would be expected through testing
--> Must be present during school years, may not be problematic later on
--> not caused by any other condition or environmental condition
237
What are the treatment options for learning disabilities?
--> modified approaches to education e.g 1-1 tuition
--> specific techniques/workarounds dependant on symptoms such as using specific fonts to alleviate dyslexia
238
What are persecutory delusions?
This type causes a person to believe that someone or something is "out to get them." This can include another person, a machine, or an entire institution or organisation.
considered to be an extreme form of paranoia
239
What are erotomanic delusions?
Erotomanic delusions cause a person to believe (falsely) that another person—or many people—are in love with them. The person who is the target of erotomanic delusions is usually of "higher status" than the person with the delusions, and the targets are often celebrities
240
What are grandiose delusions?
People who have grandiose delusions believe that they are superior to other people. These beliefs can give a person a sense of belonging and self-worth.
241
What are delusions of reference?
A delusion of reference is the belief that un-related occurrences in the external world have a special significance for the person who is being diagnosed
242
What are nihilistic delusions?
the delusional belief of being dead, decomposed or annihilated, having lost one's own internal organs or even not existing entirely as a human being
243
What is passivity?
in which patients report that their actions or thoughts are influenced by, or under the control of, some external entity.
244
What is verbigeration?
obssesive repition of random words
245
What is perseveration?
staying on the same topic despite a change in stimulus
246
What is bulimia nervosa?
Recurrent binge eating compensated by expulsion from the body at least once a week for a month
247
What is the management of Bulimia Nervosa?
**CHILD MANAGEMENT**
1) Family Therapy
2) High dose Fluoxetine
**ADULT MANAGEMENT**
1) Guided Self Help
2) Specialist Referral
248
What are the signs and symptoms of Bulimia Nervosa?
- Binge Eating w/ Purging
- Body Dysmorphia
- Dental Erosion
- Parotid Swelling
- Amenorrhea
- Russel's Sign (Scarred Knuckles)
249
What Investigations acan be used for Bullimia Nervosa?
1) Medical History
2) Physical Signs
3) Urea and Electrolytes
250
What are the electrolyte changes in Bullimia Nervosa?
Hypokalemia
Hypophosphatemia
Hypomagnesemia
Metabolic Alkalosis
251
What are 5 expulsion methods used in Bullimia Nervosa?
Vomiting
Laxatives
Diuretics
Fasting
Exercise
252
What two conditions are associated with Bullimia Nervosa?
**Kleine Levine**
Hypersomnia
Hypersexuality
Hyperphagia
**Kleine Bucy**
Compulsive Eating
Bilateral Medial Temporal Lesions
253
What is Kleine Levine?
"Sleeping beauty" syndrome charecetrised by overeating and oversleeping
- Hypersomnia
- Hypersexuality
- Hyperphagia
254
What is Anorexia Nervosa?
An eating disorder characterised by restrictive food intake leading to significantly low body weight. Patients experience fear of weight gain and have a distorted view of body, often beings in teens or early adulthood
255
What are the three different types of anorexia nervosa?
--> Atypical anorexia Nervosa
--> Restricting anorexia nervosa
--> Binge-eating/purging anorexia nervosa
256
What is atypical anorexia nervosa?
Label for individuals with anorexia symptoms without significantly low body weight
257
What is restricting anorexia nervosa?
individual loses weight by purging such as vomiting, using laxatives/diuretics/enemas
258
What are the potential complications of anorexia nervosa?
--> refeeding syndrome
--> difficulty breathing
--> heart failure
--> brain damage
--> suicidal ideation
--> death
259
What are the signs and symptoms of anorexia nervosa?
**Fear of weight gain = Restrictive weight behaviours** purging, excessive exercise, weight checks and food rituals
**Restrictive food intake**
electrolyte abnormalities, vitamin deficiencies, muscle loss, low creatinine levels, fatigue --> brain damage, weakened bones, dry/scaly skin, menstruation stops, difficulty breathing, slow heartbeat, hypotension, congestive heart failure, oedema, bone marrow shuts down - dampened immune system, low energy and easily bruised
**Vomit Purging**
Enamel erosion, parotid gland swelling, bad breath, bruised/calloused knuckles (Russell's sign), stomach tearing, fast heartbeat, depletion of electrolytes
260
What is the diagnostic criteria for anorexia nervosa
Restrictive food intake = Weight Loss
Normal or raised BMI? Atypical Anorexia
Fear of weight gain
Distorted view of the body
**Restricting type:** the individual has not repeatedly binge-eaten or purged over 3 months (instead attempts to restrict food intake/exercising excessively)
**Binge-eating/purging anorexia nervosa :** Repeated binge-eating/ purging over three months
261
What are the psychological changes in depression?
- Loss of emotional reactivity
- Diurnal mood variation
- Anhedonia
