Psychiatry Flashcards
1
Q
What is depression?
A
A mood disorder characterized by persistent low mood and loss of interest for ≥2 weeks. Can be episodic or chronic.
2
Q
What is the DSM-5 diagnostic criteria for depression?
A
≥2 weeks of low mood and/or anhedonia + ≥4 symptoms:
-reduced appetite
-fatigue
-reduced concentration
-disturbed sleep
-psychomotor agitation/retardation
-worthlesness/guilt
-recurrent thoughts of death/suicide
3
Q
What is the ICD-10 diagnostic criteria for depression?
A
≥2 core symptoms (low mood, anhedonia, fatigue) + additional symptoms similar to DSM-5.
4
Q
What is the monoamine theory of depression?
A
Depression is caused by low levels of serotonin (5-HT) and noradrenaline (NAdr) in the brain.
5
Q
How is depression classified? DSM-5
A
- Mild: 5 symptoms, minimal impairment
- Moderate: 6+ symptoms, moderate impairment
- Severe: Most symptoms, significant impairment (+/- psychosis)
6
Q
What are risk factors for depression?
A
AFFECT:
Anxious personality
Female
Family history
Events
Chronic illness
Traumatic childhood
7
Q
What are key clinical features of depression?
A
Low mood
Anhedonia
Fatigue
Sleep disturbance
Reduced appetite
Wothlessness/guilt
Suicidal thoughts
8
Q
How does postnatal depression differ from baby blues?
A
- Baby blues: Lasts <1 week → reassure & support
- Postnatal depression: Lasts weeks/months → CBT ± SSRI (if severe)
- Puerperal psychosis: Psychotic symptoms & mood swings → ADMIT
9
Q
What are important differentials for depression?
A
- Bipolar disorder → Ask about previous manic episode
- Drug use
- Schizoaffective disorder
- Hypothyroidism, Addison’s, Cushing’s, anaemia, Parkinson’s, dementia
- Seasonal Affective Disorder (SAD) (winter depression)
10
Q
How is depression assessed?
A
- PHQ-9: Score 15+ = moderate, 20+ = severe
- History screening:
“In the past month, have you felt down, depressed, or hopeless?”
“In the past month, have you had little interest in doing things?”
11
Q
What investigations should be done in ?depression
A
- Bloods: FBC (anaemia), LFTs, TFTs (hypothyroidism), U&Es
ECG - before starting SSRI
12
Q
What is the first-line treatment for mild depression?
A
Guided self-help (CBT, talking therapy, mindfulness)
Consider SSRI if unsuccessful.
13
Q
What is the first-line treatment for moderate/severe depression?
A
CBT + SSRI (or SNRI if needed)
14
Q
When is electroconvulsive therapy (ECT) used?
And when should it be avoided?
A
Severe depression with catatonia or refractory symptoms
🚫 Avoid if raised ICP
SE: Headache, nausea, arrythmia, memory impairment
15
Q
How long should antidepressants be continued after remission?
A
- Low risk: 6 months
- Medium risk: 1 year
- High risk (5+ episodes or 2+ in last year): 2+ years/lifetime
16
Q
What is the difference between self-harm and suicide?
A
- Self-harm: No intent to die
- Suicide: Intent to kill oneself
17
Q
What are the main risk factors for suicide?
A
- Men
- Previous attempt
- Unemployment
18
Q
What are protective factors against suicide?
A
- Family support
- Having children at home
- Religious beliefs
19
Q
classification of depression ICD-10
A
mild: 4 symptoms
Moderate: 5/6 symptoms
severe: 7+ symptoms
20
Q
what scale is used to screen for post natal depression?
A
edinburgh
21
Q
post birth psychotic with mood swings is likely?
A
puerperal psychosis - admission
22
Q
What is bipolar disorder?
A
A chronic mental health condition with periods of mania/hypomania and episodes of depression.
23
Q
What are the types of bipolar disorder?
A
- Type 1: Mania + Depression
- Type 2: Predominant depression + hypomania
24
Q
What are some DD for depression?
A
- Infective
o LRTI
o Chronic ninfection
o Lyme disease - Endocrine
o Thyroid
o Addison’s
o Cushing’s
o Menopause
o Hyper parathyroid
o Hypopituitarism
o Hypogonadism - Haematological
o Anaemia - Metabolic
o Hypo or hyperglycaemia - Pharmacological
o Antihypertensives
o Steroids
o H2 blockers
o Benzo
o Alcohol
o Antipsychotics
o Agents affecting sex hormones
o Cholesterol-lowering - Neurological
o Dementia
o Huntington’s
o Parkinson’s
o Epilepsy
o MS
o Stroke - Psychiatric
o Bipolar
o Psychosis and schizophrenia
o Personality disorder
o Eating disorder
25
How does mania differ from hypomania?
**Mania**
>7 days
-severe functiomal impairment (no sleep, no eating, no self care)
-Psychotic symptoms posible (hallucinations, delusions of grandeur)
**Hypomania**
>4 days
-milder functional impairment
-NO psychotic symptoms
26
What are key clinical features of bipolar?
- Elated mood & irritability
- Poor functional status (no sleep, no eating, can’t sit down)
- Impulsivity
- Distractability
- Racing thoughts
- Grandiose delusions
- Psychotic symptoms possible (mania only)
27
How is bipolar disorder managed long-term?
- Bipolar-focused CBT/therapy
- 1st line mood stabiliser: Lithium
- 2nd line: Sodium Valproate
28
What is the 1st-line treatment for acute mania/hypomania?
Antipsychotic therapy:
- Olanzapine or Haloperidol (also consider Quetiapine or Risperidone)
29
What medication should be stopped in a manic/hypomanic episode?
STOP antidepressants immediately! 🚫
30
How is bipolar depression managed?
- CBT/therapy
- Antidepressants are discouraged!
31
What is GAD?
Excessive worry about different aspects of daily life for most days, for at least 6 months.
32
What are the key risk factors for GAD?
- Female sex
- FH
- Childhood trauma
- Other psychiatric conditions
33
What are the key clinical features for GAD?
- Excessive & persistent worry
- Unable to control worry
- Restlessness
- Difficulty concentrating
- Sleep disturbances
- Fatigue
34
What might be found on examination fro GAD?
Muscle tension
35
How is GAD differentiated from other conditions?
- Panic disorder → Recurrent panic attacks vs persistent worry
- Social phobia/agoraphobia → Worry specific to social situations
- OCD → Worry due to intrusive thoughts & compulsions
- PTSD/Acute stress disorder → Worry linked to past trauma
36
What investigations should be considered for GAD?
- TFTs → Rule out hyperthyroidism
- ECG/cardiac workup → Rule out cardiac causes
- Medication review → Drugs like salbutamol, corticosteroids, theophylline can cause anxiety
37
What is the stepwise management for GAD?
1. Recognition + education
2. Low-intensity psychological intervention (e.g. guided self-help)
3. High-intensity psychological intervention (e.g. CBT ± medication)
4. Specialist input if severe
38
What is the 1st-line medication for GAD?
Sertraline (SSRI)
39
What if sertraline is ineffective in GAD?
- Try another SSRI or SNRI
- If still ineffective → consider pregabalin
40
What is Acute Stress Disorder?
Acute stress in the 4 weeks following a traumatic event. Different from PTSD as it requires a change after 4 weeks.
41
What are the key clinical features of ASD??
- Intrusive thoughts (flashbacks, nightmares)
- Dissociation (feeling detached, daydreaming)
- Low mood
- Avoidance of trauma reminders
- Hypervigilance (easily startled, on edge)
42
How is ASD different from PTSD?
- ASD = symptoms last < 1 month
- PTSD = symptoms persist > 1 month
43
What is the 1st-line treatment for ASF?
Trauma-focused CBT
44
When are medications considered for ASD?
Short-term benzodiazepines may help with acute symptoms (e.g. sleep disturbances).
45
What is PTSD?
A stress reaction following a traumatic event (e.g. abuse, disaster, death), with symptoms lasting >1 month.
46
What are the key clinical features of PTSD?
- Re-experience: flashbacks, nightmares
- Hyperarousal: hypervigilance, sleep issues, difficulty concentrating
- Avoidance: withdrawing from relationships/life
- Emotional numbing
47
How is PTSD different from Acute Stress Disorder?
PTSD lasts > 1 month, whereas Acute Stress Disorder lasts < 1 month.
48
What is the 1st-line treatment for PTSD?
Trauma-focused CBT or EMDR (Eye Movement Desensitisation and Reprocessing)
49
What medications are used for PTSD?
Venlafaxine (SNRI) or an SSRI (e.g. sertraline) if therapy is ineffective.
50
What is Conversion Disorder?
Loss of motor or sensory function inconsistent with medical/neurological findings.
51
What is Somatisation Disorder?
Persistent belief that physical symptoms are present, despite negative tests and reassurance.
52
What is Hypochondriacal Disorder?
Persistent belief that a disease is present (e.g., believing you have cancer despite negative tests).
53
What is Dissociative Disorder?
A condition where a person dissociates memories from their personal identity (e.g., multiple personality disorder).
54
What is Factitious Disorder?
Intentional production of physical or psychological symptoms for attention (e.g., faking illness).
55
What is Malingering?
Exaggerating symptoms for external gain, such as financial benefit or avoiding work.
56
What % of people don't respond to antidepressants?
33%
57
SE of TCA antidepressants?
* Lower **seizure** threshold
* **Cardiotoxic** – prolong QTc interval
* Lethal in **overdose**
* **Anticholinergic**
* Anti adrenergic – postural hypotension, sexual dysfunction, tachycardia
* Antihistamine effect
* Sedation, **weight gain**
58
Examples of tricyclic antidepressants?
amitriptyline
nortriptyline
59
symptoms of serotonin syndrome?
think autonomic dysfunction?
Hyperthermia
Hypertension
Hyper reflexia
Tachycardia
Tremor
Agitation
Irritability
Sweating
Diarrhoea
Dilated pupils
Treat – discontinue meds
Benzo for agitation
Severe – Cyproheptadine
Active cooling
60
Which four presentations should a GP refer to psychiatric services as soon as possible?
* Suicide
* Psychotic problems
* Hx, clinical suspicion of bipolar
* Child or adolescent presenting with major depression
60
1st line for perinatal depression?
sertraline
61
risk of sertraline in pregnant women?
SMALL risk of
-cardiac malformations
-persistent hypertension of the newborn
-poor neonatal adaptation syndrome
-postpartum haemorrhage
pros vs cons
Having a depressed mum cna be bad
62
common meds you should not prescribe to a pregnant woman?
clozapine
sodium valporate
lithium
lamotrigine
carbamezapine
63
scales used in primary care to measure severity of depression and anxiety?
* Hamilton Rating Scale for Depression (HAM-D)
* Montgomery-Asberg Depression Rating Scale (MADRS)
* Brief Psychiatric Rating Scale (BPRS)
64
What is Section 2?
used when diagnosis is unclear
28 days
65
What is section 4
Emergency admission (up to 72 hours), requires 1 doctor.
66
What is section 5(2)?
Doctor’s holding power (up to 72 hours in hospital)
67
What is section 5(4)?
Nurse’s holding power (up to 6 hours in hospital).
68
What is section 3?
Treatment (up to 6 months, renewable), requires 2 doctors.
69
What is section 17A?
Allows treatment in the community with recall option.
70
🔹 Q: What are the key side effects of lithium?
☁️ Cognitive issues (memory problems, confusion)
🚰 Nephrogenic diabetes insipidus (polyuria, polydipsia)
🦠 Hypothyroidism (weight gain, fatigue)
💓 Cardiac toxicity (T-wave flattening/inversion)
⚡ Tremor (fine postural tremor)
71
🔹 Q: What are the signs of lithium toxicity?
Tremor, ataxia, slurred speech, confusion, seizures.
72
Q: What can trigger lithium toxicity?
Dehydration, NSAIDs, ACE inhibitors, diuretics.
73
How do you manage lithium toxicity?
Stop lithium immediately, give IV fluids, consider haemodialysis if severe.
74
Mnemonic for First-Rank Symptoms of Schizophrenia
👉 "ABC-DT"
🔹 A – Auditory hallucinations (third-person voices, running commentary, thought echo)
🔹 B – Broadcasting of thoughts (thoughts are being broadcasted to others)
🔹 C – Control (passivity phenomena) (thoughts, feelings, or actions controlled by an external force)
🔹 D – Delusional perception (a normal perception has a deeply delusional meaning)
🔹 T – Thought interference (insertion, withdrawal, or broadcasting)
75
lithium levels over 3.5?
haemodialysis
76
pseudodementia memory loss and how it differs from dementia?
Esssemtially it is Severe depressio mimicing dementia but gives a pattern of global memory loss rather than short-term memory loss
77
What key features distinguish Depression from Adjustment Disorder?
Pervasive low mood, biological symptoms (e.g. weight loss, insomnia), and cognitive symptoms (e.g. guilt, poor concentration).
78
What is schizophrenia?
A chronic mental health condition with emotional, behavioural, and cognitive symptoms causing significant functional impairment. Most commonly features psychosis (hallucinations, delusions, etc).
79
What are the core symptom domains in schizophrenia?
1. Positive symptoms (excessive functioning)
2. Negative symptoms (reduced functioning)
3. Cognitive symptoms (thinking/memory difficulties)
80
What are the positive symptoms of schizophrenia?
Hallucinations (auditory), delusions (often persecutory or grandiose), disorganised speech, thought disorder.
81
What are the negative symptoms of schizophrenia?
Blunted affect, anhedonia, alogia (poverty of speech), avolition (lack of motivation), social withdrawal.
82
What are cognitive symptoms in schizophrenia?
Poor memory, trouble planning or understanding, difficulty concentrating.
83
What is the underlying pathophysiology of schizophrenia?
Dopamine and glutamate dysregulation:
* ↑ Dopamine in **mesolimbic** → positive symptoms
* ↓ Dopamine in **mesocortical** → negative symptoms
* ↓ NMDA **glutamate** activity → cognitive symptoms
84
What are the key risk factors for schizophrenia?
- Family history (esp. twin/1st-degree relative)
-Black caribeean ethnicity
- Cannabis
85
How strong is the genetic link in schizophrenia?
- One parent/sibling: ~10–15% risk
- Identical twin: ~50% risk
86
What are Schneider’s 3 first rank symptoms for schizophrenia?
- Thought disorders (insertion, withdrawal, broadcasting)
- Auditory hallucinations (3rd person, running commentary, commands)
- Delusions (esp. persecutory, grandiose, bizarre)
TAD
87
What are common forms of disorganised speech in schizophrenia?
- Circumstantiality (long-winded but eventually gets to the point)
- Tangentiality (goes off-topic, never returns)
- Clanging (rhyming words)
- Word salad (incoherent speech)
- Flight of ideas (rapid shifting between unrelated ideas)
88
What diagnostic criteria must be met for schizophrenia?
Symptoms must be present for 6+ months and include disturbances in functioning.
89
What is passivity phenomenon in schizophrenia?
The belief that one’s thoughts, feelings, or actions are being controlled by an external force.
90
What conditions should be considered as differentials for schizophrenia?
- Bipolar disorder
- Severe depression
- Prescription drugs (steroids)
- Brief psychotic episode (<1 month)
- Parkinsons
91
What is the first-line treatment for schizophrenia?
Atypical antipsychotics (e.g. olanzapine, risperidone, aripiprazole)
92
What is used in treatment-resistant schizophrenia?
Clozapine, after 2 failed antipsychotic trials at therapeutic dose and duration.
93
What are signs of poor prognosis in schizophrenia?
Low IQ, insidious/gradual onset, early social withdrawal.
94
What are the DVLA driving rules for schizophrenia?
Must inform DVLA and stop driving during acute episodes and for 3 months after recovery.
95
What is the definition of a personality disorder?
A group of chronic mental health conditions where maladaptive behavioural patterns lead to distress and impaired functioning. The person is usually unaware of the problem. Typically begins by early adulthood.
96
What are the three clusters of personality disorders and their general features?
- Cluster A (Weird): Odd/eccentric — includes Paranoid, Schizoid, Schizotypal
- Cluster B (Wild): Dramatic/emotional/erratic — includes Antisocial, Borderline, Histrionic, Narcissistic
- Cluster C (Worried): Anxious/fearful — includes Obsessive-Compulsive, Avoidant, Dependent
97
What are the features of Paranoid Personality Disorder?
- Hypersensitive and unforgiving when insulted
- Pervasive distrust; accusatory (e.g., accusing partner of cheating without reason)
- Doesnt confide in others
98
What are the features of Schizoid Personality Disorder?
SchizoiD - Distant
- Prefers to be alone
-Lacks interest in sexual relationships
- Few friends
- Emotional coldness
- Indifferent to praise or criticism
99
What are the features of Schizotypal Personality Disorder?
- Eccentric appearance
- Odd beliefs/magical thinking
- Odd but coherent speech
100
What are the features of Borderline Personality Disorder (Emotionally Unstable PD)?
- More common in women (75%)
- History of trauma or abuse common
- Splitting (people seen as all good or all bad)
- Instability in mood and relationships
- Recurrent self-harm
- Fear of abandonment
- Impulsivity (e.g. substance abuse, risky sex)
- Chronic feelings of emptiness and irritability
- Treatment: Dialectical Behaviour Therapy (DBT)
101
What are the features of Antisocial Personality Disorder?
- Disregard for others’ rights or well-being
- Lack of remorse
- criminality, aggression, manipulation
- more common in men
- Often preceded by childhood conduct disorder
102
What are the features of Histrionic Personality Disorder?
- Attention-seeking and dramatic
- sexuallyy provocative
- shallow and rapidly shifting emtoions
103
What are the features of Narcissistic Personality Disorder?
- Grandiose self-image
-entitlement
-requires admiration
-lacks empathy
-envious of others
104
What are the features of Obsessive-Compulsive Personality Disorder (OCPD)?
- Preoccupied with rules, order, perfection
-rigid morals/ethics
-excessive devotion to work
-dofficulty delegating or relaxing
105
What are the features of Avoidant Personality Disorder?
- Hypersensitive to criticism
-fear of rejection or ridicule
-social withdrawal due to fear but desires relationships
106
What are the features of Dependent Personality Disorder?
- Clingy and submissive
-needs constany reasurance
-struggles ot make decisions alone
-often stays in abusive relationshisp
107
What is the definition of Anorexia Nervosa?
An eating disorder characterised by excessive restriction of energy intake, resulting in significantly low body weight (low BMI).
108
What are the DSM-5 diagnostic criteria for Anorexia Nervosa?
1. Restriction of energy intake leading to significantly low weight (considering age, sex, development, and physical health).
2. Intense fear of gaining weight or becoming fat, despite being underweight.
3. Distorted perception of body weight or shape, undue influence of weight on self-worth, or denial of severity of low body weight.
109
What are the key risk factors for developing Anorexia Nervosa?
- Female sex
-younger age
110
What are the typical presenting complaints in Anorexia Nervosa?
- Compulsive calorie restriction and excessive dieting
- extreme fear of gaining weight
-excessive exercising
-ritualistic behaviours around food
111
What signs may be seen on examination in Anorexia Nervosa?
- Significantly low BMI
-Amenorrhea (short/absent menstrual periods)
-Low BP
-Bradycadia
-Enlarge salivary glands
112
What is the 1st line management in children with Anorexia Nervosa?
Anorexia-focused family therapy
113
What are 2nd line options in Anorexia Nervosa for children if family therapy is ineffective?
Cognitive Behavioural Therapy (CBT)
114
What are the management options for adults with Anorexia Nervosa?
- CBT-ED (eating-disorder-focused CBT)
- MANTRA (Maudsley Anorexia Nervosa Treatment for Adults)
- SSCM (Specialist Supportive Clinical Management)
115
What is the definition of Bulimia Nervosa?
An eating disorder characterised by binge eating followed by compensatory behaviours such as intentional vomiting, laxative use, or excessive exercise to prevent weight gain.
116
What are the key risk factors for Bulimia Nervosa?
- Female sex
-younger age
117
What are the main presenting complaints in Bulimia Nervosa?
- Recurrent episodes of binge eating at least once a week for ≥3 months
- Inappropriate compensatory behaviours to avoid weight gain:
-self induced vomiting (most common)
-laxative or diuretic misuse
-excrssive exercise or fasting
-distorted self-image with overemphasis on body shape/weigh
118
What clinical signs may be seen on examination in Bulimia Nervosa?
- May have low BMI (not always as severe as in anorexia)
-If vomiting
-dental enamel erosion
- Russell’s sign: calluses on knuckles or back of hand from inducing vomiting
119
What investigations are used in Bulimia Nervosa?
- Primarily a clinical diagnosis
120
What is the initial management step for Bulimia Nervosa?
- Referral to psychiatry
- Guided self-help programme focused on bulimia
121
What is the next step if no improvement after 4 weeks of guided self-help in bulimia nervosa?
- Begin CBT focused on eating disorders (CBT-ED)
122
What is the 1st line psychological therapy for children with Bulimia Nervosa?
- Family therapy focused on bulimia (FT-BN)
123
Is medication used in Bulimia Nervosa? If so, which one?
- Yes, fluoxetine (SSRI) may be trialled if indicated
124
What is Refeeding Syndrome?
A potentially life-threatening metabolic disturbance that occurs when nutrition is reintroduced after a period of starvation, leading to organ dysfunction due to shifts in fluids and electrolytes.
125
What is the underlying pathophysiology of Refeeding Syndrome?
- During starvation, the body switches to catabolism (fat/protein breakdown).
- Refeeding introduces carbohydrates, triggering insulin release.
POMK
- This causes intracellular shifts of electrolytes (K⁺, Mg²⁺, PO₄³⁻) and leads to sudden metabolic imbalances.
126
What are key features of presentation of refeeding syndrome?
- May present with arrhythmias (can be fatal)
- General signs may include weakness, seizures, oedema, confusion, and organ failure
127
What investigations are important for refeeding syndrome?
- U&Es: ↓ potassium (K⁺)
- Bone profile: ↓ phosphate (PO₄³⁻), ↓ magnesium (Mg²⁺)
- ECG: check for QT prolongation (risk of torsades de pointes)
128
What electrolyte abnormalities are seen in Refeeding Syndrome?
- Hypokalaemia
- Hypophosphataemia
- Hypomagnesaemia
- Abnormal fluid balance
129
What is the key management strategy Refeeding Syndrome?
- If high risk and no nutritional intake for ≥5 days:
→ Start feeding at 50% of caloric requirements for the first 2 days
- Monitor and replace electrolytes regularly
130
What is alcohol use disorder (AUD)?
A condition characterized by compulsive drinking, inability to control alcohol consumption, and difficulty stopping, leading to physical symptoms such as neurological and hepatic damage.
131
What are the clinical features of AUD?
PC:
-compulsion to drink
-tolerance to alcohol
-inability to control consumption
-neglect of self care
- Withdrawal symptoms.
132
What investigations are used for AUD?
- AUDIT questionnaire:
- >8 for men, >7 for women = harmful consumption.
- >15 for men, >13 for women = alcohol dependence.
CAGE Questionaire
-Felt the the need to CUT down
-Felt ANNOYED when criticized about use
-Felt GUILTY about drinking
-Eye opener
133
What is the management for AUD?
- Acute management: Oral thiamine replacement for thiamine deficiency.
- Acute withdrawal: Benzodiazepines.
Chronic management:
- Disulfiram: Promotes abstinence by causing severe reactions if alcohol is ingested.
- Acamprosate: Reduces cravings.
134
What is Wernicke-Korsakoff Syndrome?
A neuropsychiatric disorder primarily seen in alcoholics, caused by thiamine deficiency (vitamin B1). It consists of two phases: Wernicke encephalopathy (acute) and Korsakoff syndrome (chronic).
135
What is Wernicke Encephalopathy?
A condition characterized by the classic triad of:
-Confusion (encephalopathy)
-Ataxia (gait issues)
-Oculomotor dysfunction
136
What is Korsakoff Syndrome?
A chronic progression of Wernicke encephalopathy, leading to:
- Irreversible memory loss (anterograde and retrograde amnesia).
- Confabulation (fabricated memories).
- Personality changes, apathy, and lack of insight.
137
What are the clinical features of Wernicke-Korsakoff Syndrome?
O/E: TRIAD
-encephalopathy (confusion, disorientation)
-gait ataxia
-oculomotor dysfunction (nystagmus, opthalmoplegia)
138
What is the management for Wernicke-Korsakoff Syndrome?
- Urgent thiamine replacement (vitamin B1) to prevent progression.
- If untreated, Wernicke encephalopathy can progress to Korsakoff syndrome with irreversible memory issues and confabulation.
139
O/E of alcohol use disorder
- Hepatic damage (e.g., palmar erythema, gynaecomastia, spider naevi, Dupuytren's contractures).
- If acute withdrawal: Thiamine deficiency → risk of Wernicke's encephalopathy & Korsakoff syndrome.
- Delirium tremens: 48-72 hours after withdrawal.
140
What is serotonin syndrome?
An emergency condition caused by excessive serotonin (5-HT), often due to SSRIs, MOAIs, or certain recreational drugs.
141
What are common drugs that RF for serotonin syndrome?
- SSRIs combined with St John’s Wort.
- Monoamine oxidase inhibitors (MOAIs).
- MDMA (Ecstasy) & amphetamines.
142
What is the typical onset of serotonin syndrome?
The onset is rapid, occurring over hours.
143
What are the common clinical features?
- Confusion.
-hyperthermia
-hyperplexia/clonus/rigidity
-tachy and elevated BP
144
How is serotonin syndrome managed?
- STOP the causative medication.
- Mild cases: IV fluids and benzodiazepines.
- Severe cases: Administer serotonin antagonists such as cyproheptadine or chlorpromazine.
- Monitor U&Es (electrolytes).
145
What is neuroleptic malignant syndrome (NMS)?
An acute emergency condition caused by antipsychotic medications, occurring days after initiation of the drug.
146
What is the pathophysiology of NMS?
Dopamine blockade → Excess glutamate release, leading to neurotoxicity and rhabdomyolysis.
147
What are common causative factors for NMS?
- Antipsychotic medications.
-Abrupt discontinuat of levodopa
148
What are the clinical features of NMS?
Tetrad of symptoms:
-pyrexia (fever)/hyperthermia
-muscle rigidity
-altered mental status (confusion, delirium)
-autonomic instability (tachy, hypertension)
-hyporeflexia
149
What investigations should be done for NMS?
- U&E (electrolyte disturbances).
- FBC (elevated WCC - leukocytosis).
- Creatine Kinase (CK) - ↑ CK due to muscle breakdown.
150
How is NMS managed?
- Stop antipsychotic medication.
- Mild cases: IV fluids and benzodiazepines.
- Severe cases: Administer dantrolene (muscle relaxant).
151
What is Attention Deficit Hyperactivity Disorder (ADHD)?
A neurodevelopmental disorder characterized by persistent inattention and/or hyperactivity, leading to developmental delays.
152
What are the criteria for diagnosing ADHD?
- Children (< 16 years): 6+ features of inattention and/or hyperactivity that are persistent.
- Adults (> 17 years): 5+ features of inattention and/or hyperactivity that are persistent.
153
What are the clinical features of ADHD?
- Inattention: Difficulty focusing on tasks or completing them.
- Hyperactivity: Fidgeting, inability to stay still.
- Symptoms often manifest in multiple settings (home, school, hobbies).
154
What are the differential diagnoses for ADHD?
- Conduct Disorder: Aggression, social rule-breaking, theft, and physical harm to others.
- Oppositional Defiant Disorder (ODD): Defiance towards authority, hostility, and blaming others for personal mistakes.
155
What investigations are used for ADHD?
- Watch & wait: A 10-week observation period to see if symptoms change.
- Referral to CAMHS (Child & Adolescent Mental Health Services): Includes Qb test and SNAP questionnaire for assessment.
156
How is ADHD managed?
- Education and training programs: These are the first-line interventions.
- Drug therapy: Only considered as a last resort if non-pharmacological measures are not effective.
157
What are the first-line medications for ADHD?
- Children:
1st line → Methylphenidate.
2nd line → Lisdexamfetamine (or Dexamfetamine if there are too many side effects).
- Adults: 1st line → Methylphenidate or Lisdexamfetamine.
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What are the main differences between Conduct Disorder, ODD, and ADHD?
- Conduct Disorder: Aggressive behavior and social rule-breaking.
- ODD: Defiance towards authority and hostility.
- ADHD: Inattention and/or hyperactivity that are persistent.
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What are the potential complications of ADHD if left untreated?
- Academic difficulties, low self-esteem, relationship issues, and increased risk of substance abuse or conduct problems.
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What is Obsessive-Compulsive Disorder (OCD)?
A condition characterized by recurrent, intrusive obsessions and/or compulsive behaviors or mental acts, causing significant distress and functional impairment.
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What is the difference between obsessions and compulsions?
- Obsessions: Repeated, unwanted thoughts, images, or urges that cause anxiety or distress.
- Compulsions: Repetitive behaviors or mental acts that the individual feels compelled to perform to reduce the anxiety caused by the obsession.
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What are common examples of compulsions?
- Physical compulsions: Checking locks, hand washing, ordering items.
- Mental compulsions: Counting, repeating phrases or prayers mentally.
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What are the risk factors for OCD?
- Family history of OCD.
- Age: Onset often occurs between 10-20 years.
- History of abuse or neglect.
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What are the clinical features of OCD?
- Recurrent, persistent thoughts, impulses, or images that are intrusive and unwanted.
- Compulsive behaviors (e.g., hand washing, checking) or mental acts (e.g., counting, repeating phrases) that reduce anxiety but cause distress.
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How is OCD diagnosed?
- Y-BOCS scale: Used to assess the severity of OCD symptoms. Severe cases involve high time spent on obsessions and compulsions, with functional impairment and minimal control over these behaviors.
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What is the treatment for mild OCD?
- First-line: Cognitive Behavioral Therapy (CBT) with a focus on Exposure and Response Prevention (ERP).
- If ineffective, ERP combined with SSRI.
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What is the treatment for moderate OCD?
- First-line: Either ERP or an SSRI.
- If SSRI is contraindicated or ineffective, consider clomipramine (a TCA).
- For body dysmorphic OCD, fluoxetine is the SSRI of choice.
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What is the treatment for severe OCD?
- Referral for psychiatric assessment.
- SSRI combined with ERP.
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How is the use of SSRIs in OCD different from depression treatment?
- Treatment duration for OCD is longer (at least 12 weeks).
- Higher doses of SSRIs are required in OCD compared to depression.
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What is Autism Spectrum Disorder (ASD)?
A neurodevelopmental disorder characterized by impaired social communication, repetitive behaviours, and restricted interests, typically presenting in early childhood.
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What are the subtypes of ASD?
One subtype is Asperger's Syndrome, where language development is usually spared, but motor skills may be impaired. The child is often bright and focused on specific areas of interest.
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What are the risk factors for ASD?
- Boys are more likely to be affected.
- Fh
- Older parental age
- environmental factors during pregnancy
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At what age is ASD typically diagnosed?
ASD is often diagnosed in children 2-3 years old.
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What are the clinical features of ASD?
- Impaired social communication: Difficulty in making friends, poor eye contact, lack of facial expression.
- Repetitive behaviors and restricted interests: Insistence on routines, resistance to change, repetitive mannerisms.
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What are common findings on examination (O/E)?
- Intellectual and/or language impairment may be present, though some individuals may have average or above-average intelligence.
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How is ASD diagnosed?
- Referral to CAMHS if <3 years old with language/social issues or signs of ASD.
Diagnostic tools include:
- Diagnostic Interview for Social and Communication Disorder (DISCO)
- Autism Diagnostic Interview-Revised (ADI-R)
- Autism Diagnostic Observation Schedule (ADOS)
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What is the management approach for ASD?
- Focus on improving functional independence and quality of life.
- Learning and development programs.
- Social skills and communication enhancement.
- Behavioral therapy: Applied Behavioral Analysis (ABA) and educational programs.
- Support for families to manage care.
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What is Alzheimer’s Disease?
A neurodegenerative disease and the most common cause of dementia, which is defined as a progressive decline in one or more of: memory, executive function, language, attention, and visuospatial function.
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What is the pathophysiology of Alzheimer's Disease?
- Cortical plaques from beta-amyloid protein accumulation
- Neurofibrillary tangles of hyperphosphorylated tau protein
- Leads to cerebral atrophy, especially in the hippocampus and cortex
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What are the 4 main types of dementia?
1. Alzheimer’s
2. Vascular
3. Lewy body
4. Frontotemporal
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What are risk factors for Alzheimer's Disease?
- ↑ Age
- Family history (esp. if autosomal dominant mutation)
- Down syndrome
- Caucasian ethnicity
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What is the pattern of onset in Alzheimer’s?
Insidious, gradual decline over months to years
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What are the key presenting symptoms?
- Amnesia: memory loss (recent memory first)
- Aphasia: expressive language problems
- Agnosia: inability to recognise people or objects
- Apraxia: difficulty with learned motor tasks (e.g., dressing)
- Decline in executive function, visuospatial ability, and possible psychotic symptoms (apathy, hallucinations, etc.)
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What duration of symptoms is required for a dementia diagnosis?
Symptoms must be present for 6 months or more
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What are key differentials for cognitive decline in Alzheimer's?
- Pseudodementia from depression
- Delirium (acute onset, fluctuating, impaired consciousness, often due to infection)
- Parkinsonism-related dementia, vitamin deficiencies, or drug effects
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What cognitive assessment tools are used for Alzheimer's?
- ACE-III (Addenbrooke’s Cognitive Examination III)
- MoCA (Montreal Cognitive Assessment)
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What blood tests help rule out reversible causes of dementia in Alzheimer's ix?
- FBC, ESR/CRP → infection/inflammation
- U&E, LFTs → renal/hepatic causes
- TFTs → hypothyroidism
- B12/Folate → deficiency
- Glucose, Calcium, HIV/syphilis serology
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What neuroimaging is done for Alzheimer's and why?
- MRI/CT brain to rule out other structural pathology (e.g. subdural, tumour)
- May show global cerebral atrophy, especially in hippocampus
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What non-pharmacological treatments are recommended for Alzheimer's?
- Cognitive stimulation therapy
- Encouraging physical, mental and social activities
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What is 1st-line pharmacological treatment in mild-to-moderate Alzheimer's?
- Acetylcholinesterase inhibitors:
-Donepezil
-Calantamine
-Rivastigmine
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What are key side effects or contraindications of Donepezil?
- SE: Insomnia, GI upset, muscle cramps
- Contraindicated in bradycardia
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When is Memantine used in Alzheimer's?
- Moderate–severe AD:
* If AChEi not tolerated → use alone
* Or add-on to AChEi if progressing despite treatment
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Are antidepressants or antipsychotics recommended in Alzheimer's?
- Not routinely used
* Antidepressants only if severe comorbid depression
* Antipsychotics only for severe psychosis or risk of harm, due to ↑ mortality risk in dementia
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How to differentiate Alzheimer’s from delirium?
Delirium: acute onset, impaired consciousness, fluctuating course, often caused by infection or drugs
Alzheimer’s: slow onset, alertness preserved early, progressive decline
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What is Vascular Dementia?
The second most common form of dementia, characterised by progressive cognitive decline due to cerebral ischemia or haemorrhage, often following stroke or transient ischemic attack (TIA). Early detection and prevention can slow progression.
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What are the types of Vascular Dementia?
- Stroke-related: Due to single or multiple infarcts.
- Sub-cortical: Due to small-vessel disease.
- Mixed: A combination of vascular dementia and Alzheimer’s disease.
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What are the risk factors for Vascular Dementia?
- History of stroke or TIA
-AF
-Vascular risk conditions (diabetes, HTN, hyperlipidaemia, CAD, obesity)
-smoking
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What is the hallmark clinical feature of Vascular Dementia?
- Sudden and stepwise cognitive decline: abrupt cognitive decline followed by periods of stability, then another sudden decline
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What other clinical features are seen in vascular dementia ?
- Focal neurological signs (e.g., visual, motor, sensory disturbances)
- Memory, speech, gait, and emotional difficulties
- Personality and insight are usually preserved
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What is the diagnostic criteria for Vascular Dementia?
- NINDS-AIREN Criteria:
1. Dementia (cognitive decline)
2. CVA (evidence of stroke in neurological exam or imaging)
3. Relation between dementia and CVA:
- Onset of dementia within 3 months of CVA
- Abrupt cognitive decline
- Fluctuating, stepwise progression of deficits
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What investigations are used to diagnose Vascular Dementia?
- Neuroimaging (CT or MRI) to identify stroke or infarcts
- Neuropsychological testing to assess cognitive decline
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How is Vascular Dementia managed?
- Preventive: Target and manage vascular risk factors (HTN, diabetes, smoking, AF, hyperlipidemia)
- Symptomatic: Addressing individual cognitive or functional issues as they arise
- Medications: Antiplatelet therapy for stroke prevention (e.g., aspirin, clopidogrel)
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What is the prognosis for Vascular Dementia?
- Prognosis is often worse than Alzheimer’s, as ongoing vascular events can lead to further cognitive decline. Slowing the progression depends on managing vascular risk factors.
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What is Lewy Body Dementia?
The third most common type of dementia, characterized by progressive cognitive decline and fluctuating cognitive states, often confused with Parkinson’s disease due to the overlapping features, including Lewy body deposits (alpha-synuclein) in the substantia nigra.
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What is the pathophysiology of Lewy Body Dementia?
Alpha-synuclein cytoplasmic deposits (Lewy bodies) accumulate in the substantia nigra, leading to cognitive and motor dysfunction.
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What are the key clinical features of Lewy Body Dementia?
- Fluctuating cognitive decline: Cycles of lucidity followed by periods of diminished cognition (intervals shorten as the disease progresses).
-visual hallucinations
- REM sleep disorder: Dream reenactment during sleep.
- Cognitive impairment before or within 1 year of motor symptoms (distinguishing it from Parkinson’s).
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How does Lewy Body Dementia differ from Parkinson’s Disease?
- Cognitive impairment occurs before or within 1 year of motor symptoms (in Parkinson’s, cognitive decline generally occurs later).
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What are the physical examination findings in Lewy Body Dementia?
- Parkinsonism: Rigidity, tremor, and gait disturbances (similar to Parkinson’s).
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What investigations are used to diagnose Lewy Body Dementia?
- Diagnosis is primarily clinical.
- SPECT imaging can be used to support the diagnosis.
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How is Lewy Body Dementia managed?
- Acetylcholinesterase inhibitors: e.g., donepezil, rivastigmine.
- NMDA receptor antagonist: memantine (useful for advanced stages).
- AVOID antipsychotics: Can worsen Parkinsonism and cause irreversible motor symptoms.
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What is the prognosis of Lewy Body Dementia?
The disease has a progressive course with fluctuating cognitive decline and motor symptoms. Management aims to alleviate symptoms but there is no cure, and prognosis can vary based on symptom severity.
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What is Frontotemporal Lobar Degeneration (FTLD)?
A type of dementia characterized by the degeneration of the frontal and temporal lobes, leading to cognitive and behavioral changes. It often presents with earlier onset (before age 65).
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What are the clinical features of FTLD?
- Personality changes: Often an early sign.
- Improper conduct: Disinhibition (e.g., inappropriate behaviors).
- Relatively preserved memory (early stages, unlike Alzheimer’s).
- Apathy (lack of motivation).
- Aphasia (language difficulties, especially in advanced stages).
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What investigations are used in FTLD?
- CT/MRI brain: Shows frontal and temporal lobe atrophy.
- Cognitive testing: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA).
- Routine bloods to rule out reversible causes: FBC, coagulation, LFTs, U&E, B12/B9, TFTs.
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How is FTLD managed?
- Non-pharmacological therapies: Group therapy and support groups are first-line.
- Pharmacological therapy: If non-drug therapies fail:
- Benzodiazepines: For acute agitation and distress.
- SSRIs: For depression, anxiety, irritability, and disinhibition.
- Antipsychotics: Only at very low doses and as a last resort.
- Oxytocin: Emerging evidence suggests it may help with empathy but is not yet approved.
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Are acetylcholinesterase inhibitors or memantine used in FTLD?
No, these are not recommended for FTLD as they have not shown significant benefit in this type of dementia.
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What is the prognosis of FTLD?
FTLD generally has a progressive course with early onset of symptoms. Management focuses on symptomatic control but there is no cure. The course can be highly variable depending on the specific form and severity of symptoms.
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Which psychiatric illness has the highest risk of mortality ?
eating disorder
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ARFID (avoidant restrictivr food intake disorder) is often linked with?
autism
-often due to not liking certain textures and tastes
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triad of autism?
social relationships
social communication
rigidity of thoughts
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autism is pervasive what does this mean?
across home and school
or work and school
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how common is autism?
more than 1 in 100
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important opening q for autism Hx?
what are parents/teachers/care givers main concern?
224
FH to ask about in ASD?
consanguinity
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standardised tools used in investigation of ASD?
Griffith mental developmental scales
ADOS2
MSe
Autism diagnostic interview (ADI)
Diagnostic interview for Social and communcation disorders (DISCO)
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how do we sub divide defence mechanisms?
primitive
less primitive
mature
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for someone to demonstrated dependence on a substance thye have to have 3 of the following within a period of 12 months
-Craving
-Tolerance
-Withdrawal
-Saliance over other things in their life
-Narrowing of their repertoire of substances used
-Loss of control
-Reinstatement despite knowing it is doing you harm
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questionnaire used for ADHD
SNAP
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what test is used in ADHD diagnosis
Qb
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how long to pts with ADHD stay on methylphenidate for?
depending on annual efficacy review
some have a treatment holiday to compare symptyoms on and off meds
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what therapy is used for young people with serious behaviour prpobems often as risk of outof home placement or involvement with juvenile justice system
multisystemic therapy
232
two most common genetic causes of intellectual disabilities ?
down
fragile X
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