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4th Year > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

MSE component sections?

A

Appearance & Behaviour
- Assessed as going along

Speech
- Flow, form (speed, tone), content

Mood

  • Subjective (pt) then objective (yours)
  • Assess Sleep, eating, interest, attention, SUICIDE/SELF HARM, energy levels etc.

Affect

  • Reactive/non-reactive (can be on spectrum)
  • Congruent/non-congruent
  • Normal/Flattened/Blunted

Thought Form
- Ordered free flowing, making sense

Thought Content

  • Preoccupations/obsessions, self-harm/suicide, delusions
  • Ask are your thoughts your own.

Perceptual disturbances
- Have you seen/felt/heard anything that others have not that scares you or seems a bit intimidating?

Cognition
- Orientation, Memory, concentration, MMSE if appropriate.

Insight

  • Understanding of illness - what do you think is going on, do you think this is a mental illness?
  • Agreeing to treatment
  • Capacity to consent to treatment (if appropriate)
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2
Q

First order symptoms for schizophrenia?

A

Auditory hallucinations (Commentary, thoughts spoken aloud and 3rd person)

Thought withdrawal, insertion and broadcasting.

Somatic hallucinations (touched, strangled, sexual pleasure)

Delusional perception - see something real but make a delusion about it.

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3
Q

Three types of delirium?

A

Hypoactive: lethargy, reduced motor activity - most common

Hyperactive: agitation, irritability, restlessness

Mixed

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4
Q

Clinical features of delirium?

A

DELIRIUM:

Disordered thinking: slowed, irrational and incoherent thoughts

Euphoric, fearful, depressed or angry

Language impaired: rambling speech, repetitive or disruptive

Illusions, delusions and hallucinations

Reversal of sleep-wake cycle

Inattention

Unaware/disorientated

Memory deficits

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5
Q

ICD-10 criteria for diagnosis of delirium?

A

Impairment of consciousness and attention

Global disturbances in cognition

Psychomotor disturbance

Disturbance of sleep-wake cycle

Emotional disturbances

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6
Q

Rough pathophysiological changes in Alzheimers disease?

A

Degeneration of cholinergic neurones in the nucleus basalis of Meynert (leading to a deficiency of acetylcholine)

Microscopic changes: neurofibrillary tangles (intracellular) and B-amyloid plaque formation (extracellular).

Macroscopic: cortical atrophy (globally), widened sulci and enlarged ventricles

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7
Q

Types of dementia?

A

Alzheimers

Vascular

Dementia with lewy bodies

Fronto-temporal

Other causes: Infections (CJD, HIV), vitamin deficiencies and some others.

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8
Q

Causes of Lewy body dementia?

A

Abnormal deposition of protein (lewy body) within the neurones of the brainstem, substantia nigra and neocortex. Loss of acetylcholine outside of the brainstem and loss of dopamine within (some parkinsonian symptoms)

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9
Q

Pathophysiology in fronto-temporal dementia?

A

Specific atrophy of frontal and temporal lobes.

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10
Q

Main divisions of the types of dementias, in terms of dysfunction?

A

Cortical: Alzheimers, fronto-temporal.

Subcortical: Lewy body

Vascular is mixed.

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11
Q

Differences in cortical dementia and subcortical dementia?

A

Severe memory loss in cortical, moderate in sub

Mood is low in subcortical, normal in cortical

Speech and lang shows early aphasia in cortical and dysarthria in subcortical

Coordination is impaired in subcortical dementia, normal in cortical

Dyspraxia in cortical dementia, normal in subcortical dementia

Motor speed slow in subcortical dementia

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12
Q

Genetic basis in Alzheimers?

A

Presenilin 1 and 2 and amyloid precursor protein associated with early onset alzheimers

Apoe-4 susceptibility for late onset AD.
ApoE-2 is protective.

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13
Q

ICD-10 classification for dementia?

A

A: Evidence of the following:
1. decline in memory: anterograde amnesia. (can be retro)

  1. Decline in other areas of cognition

B: preserved consciousness

C: Decline in emotional control or motivation, change in social behaviour:
- Emotional lability, irritability, apathy, reduced social behaviour

D: For at least 6 months

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14
Q

Raja’s criteria for dementia diagnosis

A

Dysfunction in at least 2 cognitive functions

Present in normal consciousness

With evidence of functional decline

For 6 months.

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15
Q

Cognitive dysfunction in early alzheimers?

A

Memory lapses, difficulty finding words, forgetting names of places/people.

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16
Q

Cognitive dysfunction in progressing alzheimers?

A

Dyspraxia, speech and language dysfunction, difficulty with executive functioning

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17
Q

Cognitive dysfunction in late stage alzheimers?

A

Disorientation to time and place

Incontinence

Apathy

Depression

Agitation

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18
Q

Definition of a delusion?

A

A fixed, false belief which is firmly held despite evidence to the contrary and goes against the individuals social and cultural belief system.

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19
Q

Definition of a hallucination?

A

A perception in the absence of an external stimulus.

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20
Q

Definition of a thought disorder?

A

Inability to form thoughts from logically connected ideas.

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21
Q

Cuases of psychosis?

A

Organic:

  • Drug induced
  • Iatrogenic
  • Complex partial epilepsy
  • Delirium
  • Dementia
  • HD
  • SLE
  • Syphilis
  • Endocrine disturbances & metabolic disorders

Non-organic causes

  • Schizophrenia
  • Schizotypal disorder
  • Schizoaffective disorder
  • Acute psychotic episode
  • Mood disorders
  • Drug-induced
  • Delusional disorder
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22
Q

What is schizotypal disorder?

A

It’s latent schizophrenia

  • eccentric behaviour
  • suspiciousness
  • unusual speech
  • deviations of thinking
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23
Q

What is schizoaffective disorder?

A

A disorder characterized by both symptoms of schizophrenia and a mood disorder in the same episode of illness. Mood symptoms need to meet criteria for depression or mania, as well as two symptoms of schizophrenia.

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24
Q

Pathophysiology of schizophrenia? (5)

A
  1. Genetic role - monozygotic twin studies show 48% concordance rate.
  2. Dopamine hypothesis - mesolimbic pathway has overactive dopamine stimulation - positive symptoms.
    Mesocortical pathway has underactive stimulation leading to negative symptoms.
  3. Factors that interfere with early neurodevelopment e.g. low birth weight, fetal injury. Lead to abnormalities in teh developing brain.
  4. Adverse life events and stress. Different fluffy psychological arguments here:

Stress-vulnerability model predicts that schizophrenia occurs due to environment stressors interacting with a genetic predisposition or brain injury.

  1. Some involvement of glutamate - perhaps a reduction of glutamate in the frontal lobe, leading to negative symptoms
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25
Q

Positive symptoms of schizophrenia? (5)

A
  1. Delusions, including gradiose, persecutory, nihlistic (everything is meaningless) or religious. Also includes ideas of reference (common events refer directly to them).
  2. Hallucinations: a perception in the absence of external stimulus.
  3. Formal thought disorder
  4. Thought interference (insertion, withdrawal, broadcast)
  5. Passivity phenomena (actions, feelings or emotions controlled by external force).
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26
Q

Negative symptoms of schizophrenia? (6)

A

The A’s:

  1. Avolition (inability to initiate and persist in goal-driven behaviour)
  2. Asocial behaviour
  3. Anhedonia
  4. Alogia (poverty of speech)
  5. Affect blunted
  6. Attention deficits
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27
Q

Types of schizophrenia?

A

Paranoid schizophrenia (most common- positive symptoms)

Postschizophrenic depression (depression after a schizophrenic episode in the past 12 months)

Hebephrenic schizophrenia (early onset and thought disorganization dominates)

Catatonic schizophrenia

Simple schizophrenia

Undifferentiated (meets criteria but not a subtype)

Residual schizophrenia (1 year of chronic negative symptoms preceded by a clear cut episode)

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28
Q

Management of schizophrenia?

A

Bio:

  • Atypical Antipsychotics (resperidone or olanzipine)
  • Clozapine in tteatment resistance
  • Depot of there are compliance issues
  • Adjuvants such as benzos or mood stabilisers/SSRIs
  • ECT in catatonia, and treatment resistance

Psychological:

  • CBT
  • Family intervention
  • Art therapy (for neg. symptoms)
  • Social skill training.

Social:

  • Support groups and peer support
  • supported employment programmes
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29
Q

Things to ask/rule out in psychiatric history for depression, psychosis and anxiety disorders?

A

Depression:

  • Low mood
  • Anhedonia
  • Anergia

Psychosis:

  • Delusions (any specific worries? Do you feel safe)
  • Hallucinations (signpost, then do you ever see or hear things that other people are unable to?)
  • Auditory hallucinations: are the voices talking about you or directly to you? Are they doing a running commentary?

Anxiety:

  • GAD: would you say you are an anxious person, do you worry about everyday things?
  • Panic attacks
  • Phobias: any fears that others may consider irrational
  • Obsessions: any thoughts that keep coming back into your mind?
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30
Q

What is a personality disorder? (6)

A

(1) A deeply ingrained enduring pattern of inner experiences and behaviour that (2) deviates markedly from expectations in the individuals culture, that is also (3) pervasive and inflexible, (4) has an onset in adolescence or early childhood and (5) is stable over time, and (6) leads to distress or impairment.

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31
Q

R/Fs for Personality disorders?

A

Societal:
- Low SES

Genetics:

  • Monozygotic twin studies
  • Family history

Dysfunctional family:

  • Poor parenting
  • Parental deprivation

Abuse during childhood:
-Physical, sexual, emotional and neglect

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32
Q

Prevalence of personality disorders?

A

4-13% General population

20% of GP attendees

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33
Q

Types of WEIRD personality disorders? (2)

A

WEIRD - odd/eccentric

Paranoid:

  • suspicious of others/no trust
  • Unforgiving/doesn’t like criticism
  • Spouse fidelity questioned
  • Envious of others

Schizoid (like asperges):

  • Flattened affect
  • Low libido
  • Absence of close friends
  • No emotion
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34
Q

Types of WILD personality disorders?

A

WILD - Dramatic/emotional

EUPD:

  • Mood unstable
  • Fear of abandonment
  • Short unstable and intense relationships
  • Feel empty
  • Impulsive and no temper control
  • Usually grow out of when older

Anti-social

  • Callous, unfeeling, no guilt
  • Blames others
  • No regard for safety
  • Deceitful
  • Impulsive
  • Within this you get psychopathic and sociopathic

Narcissistic

  • Trump
  • Need admiration, don’t give a shit about others

Histronic:

  • Provocative behaviour, attention seeking, seductive
  • Concern for physical attractiveness and vain
  • Influenced easily
  • Need drama all the time
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35
Q

Types of WORRIER personality disorders?

A

WORRIERS - Anxious/Fearful

Dependent:

  • Requires reassurance
  • Lack self-confidence
  • Abandonment feared

Anxious (avoidant):

  • Restricts lifestyle in order to maintain security
  • Feels inadequate
  • Social inhibition

Obsessional:

  • Preoccupied with detail, to the point where this is damaging
  • Can’t complete tasks
  • Workaholic
  • inflexible/stubborn
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36
Q

Management of personality disorders?

A

Identify and treat co-morbid mental health disorders

Treat any co-existing substance misuse

Risk assessment. Crucial. Crisis plan.

Psychological intervention:
- CBT, DBT and psychodynamic

Social:

  • Support groups
  • Supported employment programmes

Biological:

  • Atypical antipsychotics for transient psychotic periods
  • Mood stabilisers
  • Antidepressants
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37
Q

Definition of deliberate self-harm?

A

(1) Intentional act of (2) self-poisoning and injury, (3) irrespective of the motivation or apparent purpose of the act, (4) usually an expression of emotional distress.

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38
Q

R/Fs for self harm?

A 
Divorced/single/living alone
Life stressors
Drug alcohol abuse
<35
Chronic physical health
Domestic violence or childhood abuse
SES disadvantage
Psychiatric diagnosis (depression/psychosis)
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39
Q

Investigations for self harm? (5)

A
  1. Intentions before and during the act?
  2. Suicidal ideation now?
  3. Current life stressors
  4. Psychiatric disorders?
  5. Collateral history?
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40
Q

Clinical R/Fs for suicide?

A

History of DSH or attempted suicide

Psychiatric illness

Childhood abuse

Family history

Medical illness

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41
Q

Socio-demographic R/Fs for suicide?

A

Male gender

40 to 44 (men)

low SES or unemployed

Occupation: Vets, doctors, nurses and farmers.

Access to lethal means (guns)

Low social support

Single/divorced marital status

Recent life crisis (e.g. bereavement)

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42
Q

Protective factors for suicide?

A

Children at home

Pregnancy

Strong religious beliefs

Strong social support

Positive therapeutic relationship

Fear of act of suicide (i’ma coward)

Hope for the future

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43
Q

Questions to determine risk of second suicide attempt?

A

Note Planned Attempts Are Very Frightening

Note left

Planned attempt

Attempts to avoid discovery

Afterwards help not sought

Violent method

Final acts: sorting out finances, writing a will.

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44
Q

Risk assessment areas to cover for a suicidal person?

A
  1. Explore suicidal ideation
  2. Explore suicidal intent
  3. Exploring R/Fs
  4. Protective factors
  5. Risk to others
  6. MSE
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45
Q

Management of suicidal patient?

A

Ensure safety

Medically stabilised

Risk assessment

Admission to hospital - section if appropriate

Referral to appropriate centre of care

Psychiatric treatment

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46
Q

Treatment for alcohol withdrawal?

A

Hospital treatment: Give benzo then taper it down in hospital. Chlordiazepoxide. Similar receptor action, short course. Safely manage withdrawal.

Community
1. Disulfuram - to maintain it, makes you feel rubbish when you drink, inhibits the break-down of alcohol. Some cardiac risk if drinking on top.

  1. Naltrexone - partial agonist, doesn’t give pleasure and reward of alcohol
  2. Acamposate - safest. Possible liver damage. Stops craving
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47
Q

R/Fs for PTSD?

A

Exposure to major traumatic event

Pre-trauma: previous trauma, Low SES, female

Peri-trauma: Severity of trauma, perceived threat to life, adverse emotional reaction.

Post-trauma: concurrent life stressors, absence of social support.

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48
Q

Management of PTSD, within first 3 months?

A

Within 3 months:

  • Watchful waiting at first
  • Trauma focused CBT
  • Short term drug treatment e.g. of sleep
  • Risk assessment
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49
Q

Management of PTSD, > 3 months?

A

Trauma-focused psychological greeting:

  • CBT
  • EMDR

Drug treatment:

  • Paroxetine
  • Mirtazipine
  • Amitrypiline
  • Phenelzine
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50
Q

Clinical features of depression?

A

Core symptoms:

  1. Anhedonia
  2. Low mood
  3. Anergia

Cognitive symptoms:

  1. Lack of concentration
  2. Guilt
  3. Suicidal ideation

Biological symptoms:

  1. Diurnal variation in mood
  2. Early morning wakening
  3. Loss of libido
  4. Weight loss/appetite loss
  5. Psychomotor retardation

Psychotic symptoms (hallucinations/delusions)

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51
Q

Management of mild-moderate depression?

A

Watchful waiting should be considered

Antidepressants not recommended unless:

  1. long-lasting depression
  2. past history of moderate-severe depression
  3. failure of other interventions
  4. complicated the care of other physical health issues.

Self-help manual with a healthcare professional

CBT

Physcial activity

Psychotherapies

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52
Q

Management of moderate-severe depression?

A

Suicide risk assessment

Psychiatric referral:

  • suicide risk is high
  • severe depression
  • recurrent
  • unresponsive to treatment

Mental health act detention

Antidepressants:
- SSRI (e.g. citalopram, sertraline)
- TCAs
- SNRI
- MAOI - by specialists
Continued for 6 months after resolution of symptoms if first episode, 2 years if second episode.

adjuvants to antidepressants include lithium or antipsychotics

Psychotherapy: CBT/IPT/counselling/behavioural activation/psychodynamic therapy.

Social support

ECT if:

  • Failure of other treatments
  • Psychomotor retardation
  • Rapid response required
  • Psychotic features
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53
Q

Difference in typical and atypical antipsychotics?

A

Atypical are the second generation drugs that are specific for D2 receptors, but also for other receptors such as serotonin, histamine, adrenergic, acetylcholine:

  • EPSEs (less of)
  • Anti-muscarinic: ‘can’t see, wee, spit or shit’
  • Anti-adrenergic: postural hypotension, tachycardia
  • Endocrine/metabolic
  • Neuroleptic malignant syndrome
  • Prolonged QT interval
  • Clozapine comes with agranulocytosis
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54
Q

ICD-10 criteria for substance misuse disorder?

A

Acute intoxication

Harmful use
- recurrent use associated with biopsychosocial consequences

Dependence - addiction, tolerance

Withdrawal state

Psychotic disorder within 2 weeks of substance use

Amnesic syndrome

Residual disorder

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55
Q

Pathophysiology/aetiology of substance misuse disorder?

A

Biological

  • Genetic variability in the enzymes that metabolise drugs causing different effects
  • Abnormalities in the dopamine, GABA and opioid systems.

Environmental

  • peer pressure
  • life stressors
  • parental use
  • cultural acceptability
  • personal vulnerability, incompetent coping mechanisms

Positive reinforcement (behavioural)

  • psychosocial factors from peers
  • biological reinforcement - mesolimbic dopamine reward pathways

Eventually dependence

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56
Q

Four features of dependence?

A

Drug Problems Will Continue To Harm

Desire to consume

Preoccupation

Withdrawal state

Inability to Control use

Tolerance

Harmful effects

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57
Q

Management of substance dependence (non-pharmacological?

A

Keyworker with therapeutic alliance

Hep B immunization

Motivational interviewing and CBT

Contingency management

Supportive help in terms of housing, finance and employment

Self-help groups

58
Q

Biological therapies in opioid dependence for detox, maintenance and in acute OD?

A

Methadone or buprenorphine for detox, and maintenance (slowly tapered down)

59
Q

Risk factors for alcohol abuse?

A

Male

Younger adult

Some genetic role

Antisocial behaviour

No facial flushing - less in east asian pops

Life stressors - financial issue, marital issues

60
Q

When does delirium tremens strike?

A

Between 24 hrs to 7 days

Peak is at 72 hours

61
Q

Features of delirium tremens?

A

Dehydration and electrolyte disturbances

Cognitive impairment

Perceptual abnormalities, hallucinations or illusions

Paranoid delusions

Marked tremor

Autonomic arousal - tachycardia, fever, mydriasis

62
Q

Management of delirium tremens?

A

Large doses of BDZ, haloperidol for psychosis and pabrinex

63
Q

What are the two neuropsychiatric complications of alcohol dependence?

A

Wernicke’s encephalopathy - acute encephalopathy due to thiamine deficiency:

  • Delirium
  • Nystagmus
  • Opthalmoplegia
  • hypothermia
  • ataxia

Korsakoff’s psychosis

  • Profound irreversible STM loss
  • Confabulation (to fill gaps)
  • Disoriented to time
64
Q

What is the acute detox regime for alcohol patients?

A

High dose benzos (chlordiazepoxide), then dose tapered down over 5-9 days

In addition to thiamine orally or IV (pabrinex)

65
Q

Long term alcohol dependence management?

A

Disulfuram
- unpleasant reactions to alcohol

Acamposate
- enhances GABA - reduces craving

Naltrexone
- Blocks opioid receptors and reduces the pleasurable effects of alcohol

Motivational interviewing and CBT as psychological interventions

AA and support

66
Q

What does neurosis, anxiety and when does this become an anxiety disorder?

A

Neuroses are psychiatric disorders characterised by distress, non-organic with a discrete onset, no delusions or hallucinations.

Anxiety is the unpleasant emotional state involving fear and somatic symptoms

When anxieties become excessive or inappropriate they are classed as a disorder

67
Q

What is the ICD-10 classification of neurotic and stress related disorders?

A

Phobic anxiety disorders

  • Agoraphobia (with or without panic)
  • Social phobia
  • Specific phobias

Other anxiety disorders

  • Panic disorder
  • GAD
  • Mixed anxiety and depression

OCD

Reaction to stress and adjustment disorders

  • PTSD
  • Adjustment disorder
  • Abnormal grief?
68
Q

Clinical features of GAD, ICD criteria?

A

WATCHERS

Worry - uncontrollable. excessive

Autonomic arousal - sweating, mydriasis, tachycardic

Tension/Tremor - in muscles

Concentration difficulty/chronic aches

Headache/hyperventilation

Energy loss

Restlessness

Sleep disturbances

ICD-10:

6 months of worry, tension and feelings of apprehension

Four symptoms of

  • autonomic arousal (one HAS to be)
  • the others (above)
69
Q

R/Fs for GAD?

A

Predisposing

  • Genetics
  • Childhood
  • Personality type (high achiever demands)
  • Divorced
  • Living alone
  • Low SES

Precipitating

  • Stressful life events e.g. domestic violence
  • Unemployment
  • illness
  • relationship difficulties

Perpetuating

  • Chronic illness, continuing stressful events
  • Living alone
  • unhelpful thinking patterns (anxious about being anxious)
70
Q

Management of GAD?

A

Biological

  • First line treatment is SSRI (sertraline)
  • Then SNRI (venlafaxine)
  • Pregabalin
  • BDZ are only for short term relief during crises

Psychological

  • Psychoeducational groups - low intensity
  • High intensity e.g. CBT and applied relaxation

Social

  • Self-help and support groups
  • Encourage exercise
71
Q

Investigations for GAD?

A

Bloods

  • FBC for infection or anaemia
  • TFTs (hyperthyroidism)
  • Glucose for hypoglycaemia

ECG

  • Tachycardia
  • Palpitation origins?

Questionnaires

  • GAD-2/GAD-7
  • Becks anxiety inventory
  • hospital anxiety and depression scale
72
Q

What is a phobia? What are the types of phobia?

A

A phobia is an intense irrational fear of an object, place, situation or person that is excessive or unreasonable

Agoraphobia
- fear of public spaces where immediate escape would be difficult (in the event of a panic attack)

Social phobia (SAD)
- Fear of social situations which may lead to humiliation criticism or embarrassment

Specific phobia
- a phobia isolated to a specific thing (that is not agoraphobia or social phobia

73
Q

Clinical features of phobic anxiety disorders?

A

Biological

  • Tachycardia, however vasovagal responses in some phobias leading to syncope.
  • Other autonomic symptoms as in GAD

Psychological
- Include unpleasant anticipatory anxiety, urge to avoid the situation and a fear of dying

74
Q

management of phobic anxiety disorders?

A

Avoid anxiety inducing substances e.g. caffeine

screen for co-morbidities such as substance misuse and Personality disorders

Agoraphobia

  • CBT inc. graduated exposure
  • SSRIs

SAD

  • CBT inc graduated exposure
  • SSRI
  • SNRI
  • MAOI
  • Psychodynamic therapy (if they decline CBT or medication)

Specific phobias

  • Exposure self help or CBT
  • BDZ for short term management of acute stressful events (i.e. CT scan in claustrophobia)
75
Q

Summary of operant conditioning?

A

Positive reinforcement
- following wanted behaviour something is added in

Negative reinforcement
- following wanted behaviour something is taken away

Positive Punishment
- Following unwanted behaviour something is added

Negative punishment
- Following unwanted behaviour something is taken away

76
Q

Levels of validation?

A

Level 1
- Be 100% present in the conversation

Level 2
- Accurate reflection including summarising, check that you have it right

Level 3
- Draw inferences as to their unspoken emotions, check accuracy

Level 4

  • Acknowledge safe behaviour
  • i.e. not self-harm or suicide

Level 5
- Acknowledge thoughts and feelings

Level 6

  • Radical openness
  • Own feelings in open, honest and optimistic talk
77
Q

What is panic disorder, what are the clinical features and ICD diagnostic criteria?

A

Recurrent, episodic, severe panic attacks, unpredictable and not restricted to any particular situation or circumstance.

ICD-10
A - recurrent panic attacks not consistently associated with a specific situation or object, often occur spontaneously.

B - Need ALL

  1. Discrete episode of intense fear or discomfort
  2. Starts abruptly
  3. Reaches peak within a few minutes and lasts at leasts some minutes
  4. Autonomic arousal
  5. Other symptoms of Panic like in GAD
78
Q

Risk factors and aetiology of Panic disorder?

A

Risk factors

  • FH
  • Major life events
  • Age 20-30
  • White
  • Female
  • Co morbid mental health disorders
  • Asthma
  • Smoking
  • Medication

Aetiology

  • Most heritable anxiety disorder along with OCD, so some genetic component
  • Sympathetic nervous system negative spiral as more stimulation can lead to more worry (adrenaline, increased HR etc.)
  • Some cognitive component in the misinterpretation of somatic symptoms - palpitations means i’m gonna die
  • Environmental - life stressors
79
Q

Management of Panic disorder

A

SSRIs are first line trial for 12 weeks and if no improvement then can prescribe a TCA (e.g. imipramine)

CBT

Self-help, including written info, support groups and encourage exercise

Referred to specialty if two interventions have been trialed without improvement

80
Q

PTSD definition and ICD 10 diagnosis?

A

PTSD is an intense prolonged, delayed reaction following exposure to an exceptionally traumatic event

ICD 10

A Exposure to a stressful event or situation that is extremely threatening or catastrophic

B persistent remembering or reliving of the event

C Actual or preferred avoidance of similar situations to the precipitating event

D Either 1 or 2:

  1. inability to recall some of the important aspects
  2. Persistent symptoms of increased psychological arousal

E The above must have occurred within 6 months of the event or at the end of a period of stress

Another clinical feature is emotional numbing, difficulty feeling emotions and distancing themselves from others

81
Q

Features of abnormal bereavement?

A

> 6 months

Delayed onset

More intense

82
Q

What is OCD, what are the features and the ICD 10 diagnostic criteria?

A

A disorder characterised by recurrent (1) obsessional thoughts and (2) compulsive acts

Obsessional thoughts are unwanted thoughts, images or urges that repeatedly enter the individuals mind, are distressing.

Compulsions are repetitive, stereotyped behaviours or mental acts that a person feels driven to performing, can be overt or covert (mental acts)

ICD 10

A:
Obsessions/compulsions on most days for at least 2 weeks

B:
- Obsessions and/or compulsions must have some features:

  • FORD CAR
  • Failure to resist
  • Originate from the patients mind
  • Repetitive
  • Distressing
  • CARrying out obsessive thought or act is not in itself pleasurable, but reduces anxiety levels.

C
- The obsessions and compulsions all must interfere with the patients social or individual functioning.

83
Q

Pathophysiological and aetiological factors of OCD?

A

Biological

  • Some evidence of serotonin dysfunction in the frontal cortex and basal ganglia
  • Twin and family studies suggest a genetic contribution
  • Group A strep infection link - autoimmune reaction in basal ganglia (PANDAS)

Psychoanalytic
- filling the mind with obsessional thoughts in order to prevent undesirable ideas from entering the consciousness

Behavioural
- Operant conditioning maintains the behaviour, as anxiety is reduced upon performing the behaviour: negative reinforcement

84
Q

Management of OCD?

A
  1. CBT including ERP (exposure and response prevention)
    - exposed to anxiety causing situation and prevented from doing compulsive behaviour
  2. Pharmacological therapy
    - SSRIs e.g. fluoxetine
    - Clomipramine as alternative

Systemic

  • Self-help
  • psychoeducation

Mild - low intensity psychological therapy

Moderate - High intensity psychological therapy or pharmacotherapy

Severe - CBT with ERP and SSRI

85
Q

What are somatoform disorders, and what are dissociative (conversion) disorders?

A

Somatoform
- Symptoms take the form of a physical disorder but the patient lacks the physiological illness, can be any number of symptoms e.g. GI pain, bloating Nausea and vomiting to parasthesia, dysuria and frequency.

Dissociative
- symptoms that cannot be explained by a medical disorder, there is a causal link in time to stressful life events the events a ‘converted’ into the symptoms

Examples
- Dissociative convulsions, resemble epilepsy but no loss of consciousness
- Dissociative fugue - unexpected physical journey
Also amnesia and stupor

86
Q

What is a factitious disorder and malingering?

A

Both are faking symptoms

Factitious (munchausen’s syndrome)

  • Faking in order to adopt the ‘sick role’
  • For primary gain

Malingering
- Fakes for advantageous consequences of being diagnosed, e.g. to evade criminal prosecution

87
Q

What is mild cognitive impairment?

A

Complaints of poor memory corroborated by informant

Objective evidence of episodic memory impairment

Largely intact general (non-memory) cognitive abilities

Normal activities of daily living

Not reaching ICD/DSM criteria for dementia

10-20% progress to dementia every year

88
Q

Difficulties in vascular dementia?

A

More impaired on semantic memory, executive/attentional functioning, and visuospatial and perceptual skills.

Some emotional and personality changes.

Less impaired on episodic memory.

89
Q

Difficulties in Dementia w/ lewy bodies and Parkinsons disease dementia?

A

Presnt similarly but DLB within 12 months of parkinsons/dementia onset, PDD is >12 months apart

Fluctuations in cognitive performance

Recurrent visual hallucinations

90
Q

Features of Fronto-temporal dementia?

A

Under the age of 65 FTD is as common as AD

Loss of social awareness and insight

Disinhibition and impulsivity

Apathy, inertia and spontaneity

Mental rigidity and inflexibility

Personal neglect

Stereotypic behaviours and rituals

Change in eating habits and food preference

Loss of empathy and mentalising ability

91
Q

Features of B12 dementia?

A

Signs of peripheral neuropathy and myelopathy can be observed: distal paresthesias, impairment of vibratory and position sense, reduced ankle jerks

Mood changes (agitation, depression, mania) to psychotic episodes (paranoia, auditory and visual hallucinations, delusions) to cognitive impairment (slow mentation, memory deficits, confusion, dementia)

Mental or psychological changes may precede haematological signs by months or years

92
Q

Non-cognitive symptoms of dementia?

A

Affective symptoms:

  • Anxiety
  • Depression
  • Apathy
  • Elation
  • Disinhibition

Psychotic symptoms:

  • Hallucinations
  • Delusions
  • Misidentification

Behavioural Symptoms:

  • Aberrant motor behaviour
  • Agitation/aggression/irritability
  • Sleep disturbance
  • Eating disturbance
  • Hypersexuality
93
Q

Features of Alzheimers?

A

Executive dysfunction
- planning, organization, problem solving.

Visuospatial abilities
- Impairments in copying, driving, may get lost

Dysphasias:

  • Word finding difficulty
  • decreased vocab
  • global aphasia (difficulty in comprehension and production of language).

Dyspraxia:
- inability to carry out previously learned purposeful movements

Agnosia

Disorientation to time and place

hallucinations/delusions/emotion/behaviour

94
Q

Triad of dysfunction in autism?

A

Social interaction impairment

  • few social gestures
  • lack of eye contact
  • lack of interest in others

Restricted interests and lack of imagination

  • Rocking and twisting
  • Upset at any change in daily routine
  • Restricted interests in food, games, telly
  • Fascination in sensory aspects of the environment

Impaired communicative ability

  • Distorted or DELAYED speech
  • Echolalia (repetition of words)
95
Q

Pathophysiology and aetiology of autism?

A

Prenatal

  • Genetics there is a polygenic relationship which is complex, increased risk associated with fragile X and tuberous sclerosis
  • Parental age
  • Drugs e.g. valproate
  • Infection - rubella

Perinatal
- Obstetric complications at birth, hypoxia, preterm and low birth weight

Postnatal

  • Toxins such as lead and mercury
  • pesticide exposure
96
Q

When does autism normally present?

A

Onset is before 3 years, parents will normally have cause for concern by 12-18 years old.

97
Q

ICD 10 diagnostic criteria for ASD?

A

A Presence of abnormal or impaired development before the age of 3

B Qualitative abnormalities in social interaction

C Qualitative abnormalities in communication

D restricted, repetitive and stereotyped behaviour, interests and activities

E not attributable to another type of developmental disorder

98
Q

Management of autism?

A

Local multidisciplinary teams should be employed and a keyworker assigned

CBT is the child is developed enough to engage

Social skill training

Family and carer support

Special schooling

May consider melatonin for sleep disorders persisting despite behavioural interventions

Core features

  • Social-communication intervention (e.g. lego play therapy)
  • DO NOT use pharmacological agents

Behaviour

  • Treat co-morbidities
  • Modification of environmental factors
  • Antipsychotics (e.g. resperidone) for really challenging behaviour
99
Q

Medical conditions associated with autism?

A 
Epileptic seizures (20%)
Visual and hearing impairment
Infections
Constipation
Sleep disorders
PKU, Fragile X, Tuberous sclerosis
Other psychiatric conditions (OCD, mood disorders e.t.c)
100
Q

Features of ADHD? ICD 10 diagnostic criteria?

A

Early onset, persistent pattern of inattention, hyperactivity and impulsivity, more frequent and severe than individuals at a comparable stage of development.

A Abnormality of attention, activity and impulsivity at HOME - for age and developmental level

B Abnormality of attention activity and impulsivity at SCHOOL or NURSERY

C Directly observed abnormality of attention or hyperactivity

D does not meet criteria for other psychiatric conditions

Onset before 7

Duration of atl 6 months

IQ above 50

101
Q

Risk factors for ADHD?

A

Male

FH (70% in twin studies)

Environmental:
- Social deprivation, family conflict, cannabis and alcohol exposure

102
Q

Symptoms of inattention, hyperactivity and impulsivity?

A

Inattention

  • Not listening when being spoken to
  • Highly distractible
  • Reluctant to engage in activities that require persistent effort

Hyperactivity

  • Restlessness, fidgeting or tapping
  • recklessness
  • Won’t do quiet things
  • Excessive talking or noisiness

Impulsivity

  • Difficulty waiting their turn
  • Interrupting others
  • Prematurely blurting out answers
  • Disobedient
103
Q

Management of ADHD?

A

General

  • Support groups (parents and teachers)
  • There is a clear link between diet and behaviour

Pre-school

  • Parent training and education programmes - first line
  • Parent training is behavioural, helped to use operant conditioning and reinforcement as well as dealing with troubling behaviour
  • No pharmacotherapy at this age

School-goers

  • Psychoeducation and CBT (and or social skills training)
  • If severe then methyphenidate (CNS stimulant)
  • If Methylphenidate fails then atomoxetine (norad reuptake inhibitor)
  • Has S/Es of nausea, headache, insomnia, loss of appetite and weight loss - need to do some measurements.
104
Q

Common co-morbidities of ADHD?

A

70% have co-morbidities e.g. ASD, Dyslexia, dyspraxia and mood disorders

Conduct disorder

  • 50% of ADHD
  • Severe, repetitive antisocial behaviour
  • Violations of law, physical aggression e.t.c.

ODD

  • less severe than conduct disorder
  • Defiance against authority
  • Less violations of law and physical abuse than conduct disorder
105
Q

What are the two types of attachment disorder?

A

Reactive
- Cant form intimate relationships with others

Disinhibited
- Form attachments to pretty much anyone who will have them

These form from lack of a proper bond to their attachment figure, normally displaying disorganised attachment (in the SST). Start <5 years old.

106
Q

Risk factors for depression?

A

FF AA PP SS

Female/Family history

Alcohol/Adverse life events

Past depression/Physical co-morbidities

Lack of social support/Low SES

107
Q

How do you stratify depression to mild-severe?

A

Mild
2 core symptoms and 2 others

Moderate
2 core with 3-4 others

Severe depression
3 core and >4 others

Severe with psychosis
3 core, >4 others and psychosis

108
Q

Bipolar disorder classifications?

A

Bipolar I
- Periods of severe mood episodes from mania to depression

Bipolar II
- Milder form, basically may have hypomania, both still have depression though

Rapid cycling

  • More than 4 mood swings in a 12 month period, no no intervening free periods
  • Bad prognosis
109
Q

Symptoms of mania?

A

I DIG FASTER

Irritability

Distracted/disinhibited
Insight impaired/increased libido
Grandiose delusions

Flight of ideas
Activity increased
Sleep decreased
Talkative
Elevated mood
Reduced concentration
110
Q

Pathophysiology of bipolar?

A

Biological and environmental factors

Monoamine hypothesis

Dysfunction of the HPA axis

40-70% heritability (in monozygotic twin studies)

May be precipitated by adverse life events, exams, grief

Substance misuse

Male to female ratio is actually equal

111
Q

ICD 10 criteria for bipolar diagnosis?

A

3/9 symptoms

Needs at least two episodes in which a persons mood and anxiety levels are disturbed, one needs to be mania or hypomania (don’t need depression as it will inevitably come)

112
Q

Management of bipolar?

A

Full risk assessment

Consider section under MHA

CBT can be used for bipolar depression

Pharmacologically :

Mania/mixed:

  • Antipsychotic (olanzipine best)
  • Then mood stabiliser: Lithium or valproate
  • Benzos for sleep or agitation
  • If rapid tranquillisation required then haloperidol or lorazepam

Depressive disorder

  • Atypical antipsychotics e..g olanzipine (can also give quetiapine)
  • Mood stabiliser e.g. Lithium or lamotrigine
  • Can give antidepressants but with caution as they may induce mania
113
Q

Extra risks/precautions when using lithium?

A

Has narrow therapeutic window so you need to monitor its blood levels

Before starting need Us and E, TFTs and pregnancy status and ECG

114
Q

Difference in mania and hypomania?

A

Hypomania

  • Mildly elevated mania
  • > 4 days
  • interference with social and work life but not severe

Mania

  • > 1 week
  • Complete disruption of work and social activities
  • grandiose ideas, sexual inhibition, exhaustion due to decreased sleep
115
Q

ICD 10 criteria for anorexia nervosa?

A

FEED

Fear of weight gain
Endocrine disturbances e.g. amenorrhoea 
Emaciated (low BMI)
Deliberate weight loss
Distorted body image

Present for at least 3 months

Does not have:

  1. Recurrent episodes of binging
  2. Preoccupation or craving to eat
116
Q

Differences in Anorexia and Bulimia?

A

Anorexia

  • Significantly underweight
  • More likely to have endocrine abnormalities
  • Do not have cravings for food
  • Do not binge eat
  • Other weight loss behaviours

Bulimia

  • Normal or overweight
  • Less likely to have endocrine abnormalities
  • Strong cravings
  • Episodes of binge eating
  • Other weight loss behaviours
117
Q

What is binge eating disorder?

A

New diagnosis consisting of recurrent episodes of binge eating without compensatory behaviour such as vomiting, fasting or excessive exercise

118
Q

Management of anorexia?

A

Biopsychosocial

Risk assessment, consider section if <14 BMI or severe electrolyte disturbances and psychiatric reasons

Aim of inpatient treatment is weight gain of 0.5 - 1kg a week, 0.5 in outpatient

Have to be aware of refeeding syndrome

Biological

  • Treat medical complications
  • SSRIs for co-morbid depression or OCD

Psychological

  • Psychoeducation
  • CBT
  • Cognitive analytic therapy
  • Interpersonal psychotherapy
  • Family therapy

Social

  • Voluntary organizations
  • Self-help groups
119
Q

Features and ICD 10 criteria for bulimia diagnosis?

A

ICD 10 Bulimia Patients Fear Obesity

Behaviours to prevent weight gain

  • Vomiting
  • Starvation for alternating periods
  • Drugs e.g. laxatives
  • excessive exercise
  • Diabetics may try to omit their insulin

Preoccupation with eating
- Craving to eat which leads to bingeing typically with regret or shame afterwards

Fear of fatness
- self-perception of being too fat

Overeating

  • Two episodes per week
  • Period of 3 months

Others

  • Normal weight
  • Depression or low self-esteem
  • Irregular periods
120
Q

Aetiology of anorexia just generally?

A

Quite a big genetic link, twin studies and family history

Can have psychological factors such as sexual abuse, low self-esteem pre-morbid anxiety and depression

Societal factors such as (social media), bullying at school around weight, may have an occupational pressure to be slim such as ballet or modelling

Higher SES

121
Q

Aetiology of bulimia?

A

Role of genetics is unclear

There is a vicious cycle:
1. Sense of compulsion to eat
2. Binge eating
3. Fear of fatness
4. Compensatory weight loss behaviour (e.g. vomiting or drugs)
1 and so forth

Bulimia is equal across SES

Similar precipitating and predisposing to anorexia:

Can have psychological factors such as sexual abuse, low self-esteem pre-morbid anxiety and depression

Societal factors such as (social media), bullying at school around weight, may have an occupational pressure to be slim such as ballet or modelling

T1DM

122
Q

Management of bulimia?

A

Risk assessment and possible section/inpatient admission in severe issues

Biopsychosocial

Biological

  • Trial of antidepressants, usually fluoxetine
  • Treat medical complications, e.g. hypokalaemia

Psychological

  • CBT specific for bulimia
  • Psychoeducation
  • Interpersonal psychotherapy

Social

  • Food diary to monitor eating/purging patterns
  • Techniques to avoid bingeing
  • Small regular meals
  • Self-help programmes
123
Q

Prognosis of BN and AN?

A

Bulimia - 50% make full recovery

Anorexia - 20% will make a full recovery

124
Q

Examples of typical, first gen antipsychotics

A

Chlorpromazine (first 1951)

Haloperidol

Sulpiride

125
Q

Examples of atypical second gen antipsychotics?

A

Olanzipine

Risperidone

Quetiapine

Aripriprazole

Clozapine

126
Q

What are the extra pyramidal side effects?

A

Parkinsonism

  • Bradykinesia
  • Rigidity
  • Coarse tremor

Akathisia

  • Unpleasant feeling of restlessness
  • First months of treatment

Dystonia
- Acute painful spasms of muscles in the neck, jaw and eyes

Tardive dyskinesia
- jaw thrust type stuff

127
Q

What is neuroleptic malignant syndrome? How does it present, how is it managed?

A

Rare, but life threatening SE of antipsychotics. (also other dopaminergic drugs)

Normally after starting or upping dose of antipsychotic

Pyrexia, muscle rigidity, confusion, fluctuating consciousness and autonomic instability.

CK is raised

Stop drug, monitor signs, IV fluids, cooling, could use bromocriptine - a dopamine agonist

128
Q

What things may you have to monitor when putting patients on antipsychotic medication?

A

FBC, U&Es and LFTs

Fasting blood glucose

Blood lipids

ECG

BP

Prolactin

Weight

Physical health

Creatine kinase

129
Q

Antipsychotics associated with weight gain?

A

Olanzipine

Quetiapine

Lozapine

130
Q

Antipsychotics less associated with weight gain?

A

Aripriprazole

Amisulpiride

Lurasidone

131
Q

What antipsychotics can be given by depot?

A

Atypicals

  • Risperidone
  • Paliperidone
  • Olanzipine
  • Aripriprazole
132
Q

What is the biggest contraindication to donepezil use in dementia, what would you use instead?

A

CVD - hypotension/bradycardia?

133
Q

Risk factors for serotonin syndrome?

A

Old, female, overweight, decreased renal function.

134
Q

What antidepressant has the least discontinuation symptoms due to its really long half-life?

A

Fluoxetine

135
Q

What antidepressant do you need to monitor blood pressure on?

A

Venlafaxine

136
Q

What antidepressant can cause weight gain, but unlikely to cause sexual dysfunction?

A

Mirtazipine

137
Q

What antidepressant is less likely to cause cognitive problems?

A

Vortioxetine

138
Q

What antidepressant is dangerous in OD and can be used for neurological pain in low doses?

A

Amitriptyline

139
Q

What are the significant antidepressant interactions that you should be aware of?

A

Risk of bleeding with NSAIDS (normally prescribe PPI, or stop NSAID)

Risk of serotonin syndrome when combining with serotonergic drugs e.g. tramodol

Risk of hyponatraemia with carbamazepine or diuretics

140
Q

How long do you have to stay an an antidepressant once symptoms have subsided?

A

6 months after in first episode, 2 years in second, and just forever if more than 2 severe episodes

4th Year (15 decks)

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