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Psychiatry Flashcards

1
Q

What is bipolar disorder?

A

Periods of prolonged and profound depression, alternated with periods of excessively elevated and/or irritable mood.

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2
Q

What are the manic features of bipolar disorder?

A

Elevated mood
Increased energy
Increased self-esteem
Decreased attention/increased distractibility
Tendency to engage in behaviour that could have serious consequences
Marked disruption of work, social and family life
Psychotic symptoms e.g. grandiose delusions

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3
Q

What factors increase risk in bipolar disorder?

A

Reckless behaviour
Aggression
Promiscuous sexual behaviour
Lack of self care

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4
Q

What is the management of bipolar disorder?

A

Acute manic episode: atypical antipsychotic, valproate, lamotrigine or lithium
Depressive episode: avoid antidepressants. Clozapine, consider atypical antipsychotics, anticonvulsant and possible lithium adjunct. In some cases, SSRI may be suitable (be careful)
General maintenance: 1st line - lithium

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5
Q

What are the aetiological theories for schizophrenia?

A 
Dopaminergic overactivity
Glutamatergic hypoactivity 
5-HT overactivity 
alpha-adrenergic overactivity 
GABA hypoactivity
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6
Q

What are the positive symptoms of schizophrenia?

A

Delusions
Hallucinations
Formal thought disorder

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7
Q

What are the negative symptoms of schizophrenia?

A

Impairment of loss of volition, motivation and spontaneous behaviour
Loss of awareness of socially appropriate behaviour and social withdrawing
Flattening of mood
Blunting of affect
Anhedonia
Poverty of thought and speech

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8
Q

What investigations should be done in patients with schizophrenia?

A

Bloods - U&Es, LFTs, calcium, FBC and glucose
CT/MRI head
MSU - drugs screen
ECG

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9
Q

What is the management of schizophrenia?

A

Commence a 2nd gen anti-psychotic and use a long-acting benzodiazepine to control non-acute anxiety behavioural disturbance
Try a different antipsychotic, either 1st gen or 2nd gen
Clozapine

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10
Q

What is schizoaffective disorder?

A

A disorder in which there are features of both affective disorder and schizophrenia which are present in equal proportion.

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11
Q

What is the prognosis for schizoaffective disorder?

A

A chronic course is more likely with depressive symptoms than manic. Good/poor prognostic factors are the same as for schizophrenia. Prognosis is better than schizophrenia but worse than primary mood disorder.

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12
Q

What are the major symptoms of depression?

A

Low mood
Anhedonia
Low energy level
Depression is present when >/=2 of these exist for >2 weeks

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13
Q

What are the minor symptoms of depression?

A 
Feelings of guilt, uselessness, worthlessness 
Thoughts of suicide or self harm 
Poor concentration 
Sleep disturbance (usually early morning wakening)
Weight loss/gain 
Loss of libido 
Psychomotor retardation 
Agitated and fidgety 
Memory problems 
Hallucinations and delusions
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14
Q

What is the diagnostic criteria for depression?

A

Mild: 1 core symptom and 3 other symptoms
Moderate: 1 core symptom and 4-7 other symptoms
Severe: 1 core symptom and >7 other symptoms

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15
Q

What investigations should be done in a patient with depression?

A 
Bloods: FBC, U&Es, haematinics, LFTs,
CXR
ECG
Full history and MSE 
HADS, PHQ-9 or MDI
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16
Q

What is the management of depression?

A

Mild: watchful waiting, CBT, e-CBT, self-help, exercise

Moderate and severe: SSRIs (1st line), psychological interventions, consider getting social support

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17
Q

What is the pathophysiology involved in Alzheimer’s disease?

A 
Amyloid plaques
Neurofibrillary tangles
Up to a 50% loss of neurons and synapses in the cortex and hippocampus 
Genetics 
Cholinergic hypothesis
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18
Q

What are the clinical features of Alzheimer’s disease?

A

Early: failing memory, muddled efficiency with ADLs, spatial dysfunction and changes in behaviour
Middle: intellectual and personality deterioration, BPSD (behavioural and psychological symptoms of dementia), impaired visuospatial skills and executive function
Late: fully dependent, physical deterioration, incontinence, gait abnormality, spasticity, seizures, tremor, weight loss, primitive reflexes, extra-pyramidal signs, psychiatric symptoms, behavioural disturbances, personality change

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19
Q

What are poor prognostic factors of Alzheimer’s disease ?

A 
Greater severity of disease at presentation
Being male
Onset <65 years
Parietal lobe damage
Prominent behavioural problems 
Severe focal cognitive deficits
Depression 
Absence of misidentification syndrome
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20
Q

What assessments are needed in order to diagnose Alzheimer’s disease?

A 
Detailed history 
MSE 
Cognitive testing 
Physical examination 
Basic dementia screen - routine haematology and biochemistry, TFTs, MSU, CXR, ECG if needed, CT/MRI brain
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21
Q

What is the management of Alzheimer’s disease?

A

1st gen AChEI’s - tacrine
2nd gen AChEI’s - donepezil, rivastigmine, galantamine
NMDA-receptor partial antagonist - memantine

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22
Q

What is the pathophysiology of Dementia with Lewy Bodies?

A

Lewy bodies (aggregates of alpha-synuclein and ubiquitin), Lewy neurites, Alzheimer-type changes and vascular changes

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23
Q

What are the clinical features of Dementia with Lewy Bodies?

A 
Dementia 
Parkinsonism 
Fluctuating cognitive performance and level of consciousness
Complex hallucinations 
Recurrent falls/syncope 
Significant depressive episode 
Transient disturbances of consciousness 
Antipsychotic sensitivity 
Sleep disorders e.g. REM sleep disorder
Restless leg syndrome
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24
Q

What investigations should be done for Dementia with Lewy Bodies?

A

Basic dementia screen - routine haematology and biochemistry, TFTs, MSU, CXR, ECG if needed, CT/MRI brain
SPECT FP-CIT scan
SPECT-HMPAO scan
ApoE genotype

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25
What is the management of Dementia with Lewy Bodies?
Avoid anti-psychotics or use with caution AChEIs e.g. rivastigmine Non-pharmacological interventions
26
What is the pathophysiology involved in frontotemporal dementia?
Atrophy of the frontal and temporal lobes, distribution is lobar rather than the diffuse atrophy of Alzheimer's disease
27
What are the different types of frontotemporal dementia?
``` Behaviour variant FTD Semantic dementia Progressive non-fluent aphasia Disinhibited form Apathetic form Stereotypic form ```
28
What are the clinical features of frontotemporal dementia?
Profound alteration in character/social conduct Relative preservation of perception, spatial skills, praxis and memory Emotional blunting Impaired insight Dietary changes (overeating, preference for sweet foods) Perseverative behaviours e.g. drinking from an empty cup
29
What investigations are needed to diagnose frontotemporal dementia?
Basic dementia screen - routine haematology and biochemistry, TFTs, MSU, CXR, ECG if needed, CT/MRI brain Genetic testing for Huntington's disease LP for extensive CSF testing
30
What is the management of frontotemporal dementia?
SSRIs may be helpful in modifying behavioural symptoms Atypical antipsychotics are used where there are behavioural problems such as agitation and psychosis Non-pharmacological management
31
What is the aetiology of vascular dementia?
Cognitive deficits following a single stroke, multi-infarct dementia or progressive small vessel disease (Binswanger disease)
32
What are the risk factors for vascular dementia?
``` History of a stroke or TIA AF HTN DM Hyperlipidaemia Smoking Obesity CHD Family history of a stroke or cardiovascular disease ```
33
What is the presentation of vascular dementia?
Vascular dementia is a progressive disease where deteriorations may be sudden or gradual but tend to progress in a stepwise manner. Focal neurological abnormalities, difficulty with attention and concentration, seizures, depression and/or anxiety accompanying the memory disturbance, early presence of disturbance in gait, bladder symptoms without a demonstrable urological cause, pseudobulbar palsy, emotional problems
34
What is the management of vascular dementia?
Establish causative factors Treat contributory medical or surgical conditions Daily aspirin may delay the course of the disease General health interventions
35
What investigations should be done in vascular dementia?
Basic dementia screen - routine haematology and biochemistry, TFTs, MSU, CXR, ECG if needed, CT/MRI brain Serum cholesterol Clotting screen Vasculitis and syphilis screen in unusual cases. (echo and carotid dopplers)
36
What is the classic triad seen in normal pressure hydrocephalus?
Gait disturbance Sphincter disturbance (urinary>bowel) Dementia
37
What signs may be found in normal pressure hydrocephalus?
Pyramidal tract signs may be present, reflexes may be brisk, papilloedema is absent but NPH is associated with glaucoma
38
What investigations should be performed for normal pressure hydrocephalus?
Neuroimaging - MRI or CT Large volume LP - CSF pressure may be normal or slightly elevated Intraventricular pressure monitoring Lumbar infusion test (intrathecal infusion test)
39
What is the management of normal pressure hydrocephalus?
Medical: carbonic anhydrase inhibitors (acetazolamide) and serial LPs Surgical: insertion of a shunt
40
What is a simple or specific phobia?
Recurring excessive and unreasonable psychological or autonomic symptoms of anxiety, in the (anticipated) presence of a specific feared object or situation leading, wherever possible, to avoidance
41
What is the management of simple or specific phobias/
Psychological: Behavioural therapy: exposure therapy, can be graded or use virtual reality techniques. Can also use reciprocal inhibition, flooding and modelling Cognitive methods: education/anxiety management, coping skills/strategies and cognitive restructuring Pharmacological: generally not used except in severe cases to reduce fear/avoidance - use benzodiazepines
42
What is a social phobia?
Symptoms of incapacitating anxiety, are not secondary to delusional or obsessive thoughts and are restricted to particular social situations, leading to a desire for escape or avoidance.
43
What are the symptoms of a social phobia?
Blushing, trembling, dry mouth, perspiration when exposed to the feared situation with excessive fear of humiliation, embarrassment or others noticing anxiety
44
What are the signs of a social phobia?
Self-critical, perfectionistic Difficulty maintaining social/sexual relationships Educational or vocational problems Thoughts of suicide are relatively common
45
What is the management of a social phobia?
Psychological: CBT (with SSRIs or MAOIs), relaxation training, anxiety management, social skills training, integrated exposure methods and cognitive restructuring Pharmacological: beta-blockers e.g. atenolol may reduced autonomic arousal, SSRIs, SNRIs and MAOIs
46
What is generalised anxiety disorder?
"Excessive worry" and feelings of apprehension about everyday events/problems, causes significant distress/functional impairment
47
What is the aetiology of generalised anxiety disorder?
Genetic Neurobiological Generalised psychological vulnerability: diminished sense of control, parenting Specific psychological vulnerability: stressful life events
48
What are the symptoms of generalised anxiety disorder?
Present most days for at least 6 months. Restlessness, easy fatigability, concentration difficulties or "mind going blank", irritability, muscle tension, sleep disturbance ICD-10: symptoms of autonomic arousal, physical symptoms, mental state symptoms, general symptoms , symptoms of tension, concentration difficulties
49
What is the management of generalised anxiety disorder?
Psychological: CBT Pharmacological: psychic symptoms - buspinone, somatic symptoms - benzodiazepines e.g. lorazepam, depressive symptoms - TCAs, SNRIs, SSRIs, cardiovascular or autonomic symptoms - beta blockers
50
What is OCD?
A common, chronic condition often associated with marked anxiety and depression, characterised by obsessions and compulsions. Obsessions/compulsions must cause distress or interfere with the person's social or individual functioning
51
What can be the content of the obsessions/compulsions?
``` Checking Washing Contamination Doubting Bodily fears Counting Insistence on symmetry Aggressive thoughts ```
52
What is the management of OCD?
Psychological: CBT including exposure and response prevention, behavioural therapy, cognitive therapy, psychotherapy including family therapy or group therapy Pharmacological: antidepressants e.g.g SSRIs, clomipramine, augmentative strategies e.g. antipsychotics Physical: ECT - consider if patient is suicidal or severely incapacitated
53
What is PTSD?
A severe psychological disturbance following a traumatic event characterised by involuntary re-experiencing of elements of the event with symptoms of hyperarousal, avoidance, emotional numbing.
54
What are the risk factors for PTSD?
Vulnerability factors: low education, lower social class, Afro-Caribbean/Hispanic, female gender, low self-esteem/neurotic traits, Hx or FHx of psychiatric problems, previous traumatic events. Peri-traumatic factors: trauma severity, perceived life threat, peri-traumatic emotions, peri-traumatic dissociations
55
What are the signs/symptoms of PTSD?
Symptoms arise within 6 months of the traumatic event or are present for at least 1 month with clinically significant distress or impairment in social, occupational or other important areas of functioning. Difficulty falling or staying asleep, irritability of outbursts of anger, difficulty in concentrating, hypervigilance, exaggerated startle response
56
What is the management of PTSD?
Psychological: CBT, eye movement desensitisation and reprocessing, psychodynamic therapy, stress management, hypnotherapy, supportive therapy Pharmacological: SSRIs, TCAs, MAOIs Sleep disturbance - mirtazapine, levomepromazine, prazosin Anxiety - benzodiazepines Intrusive thoughts - carbamazepine, valproate, topiramate, lithium Psychotic symptoms/severe aggression - anti-psychotics
57
What is a panic attack?
A period of intense fear characterised by a constellation of symptoms that rapidly develop, reach a peak intensity (approx 10 mins), generally don't last longer than 20-30 mins
58
What is panic disorder?
Recurrent panic attacks which are not secondary to substance misuse, medical condition or other psychiatric disorders
59
What are the symptoms of panic disorder?
Physical symptoms/signs related to autonomic arousal (e.g. tremor, tachycardia, tachypnoea, HTN, sweating, GI upset), concerns of death from cardiac or respiratory problems, may be undiagnosed in patients with "unexplained" medical symptoms, thoughts of suicide
60
What investigations need to be done for panic disorder?
Rule out physical causes: FBC, U&Es, BM, TFTs, ECG
61
What is the management for panic disorder?
Psychological: CBT, psychodynamic psychotherapy Pharmacological: SSRIs, SNRIs, TCAs, MAOIs, benzodiazepines
62
What is somatisation disorder?
A disorder in which there is repeated presentation with medically unexplained symptoms, affecting multiple organ systems, first presenting before the age of 40.
63
What are the clinical features of somatisation disorder?
Patients may have long, complex medical histories although at interview they may minimise all but the most recent symptomatology. May be a discrepancy between the subjective and objective findings. Diagnosis is usually only suspected after negative finding begin to emerge. Key feature: multiple atypical and inconsistent medically unexplained symptoms in a patient <40y.
64
What is the management of somatisation disorder?
Make, document and communicate the diagnosis. Acknowledge the symptom severity and experience of distress as real. Emphasize negative investigations and lack of structural abnormality. Reassure patient. Reduce and stop unnecessary drugs. Psychotherapy including CBT or group therapy
65
What is a section 2 for?
Assessment order. Allows patient to be detained for up to 28 days. Must be signed by 2 doctors and AMHP. Applied for by the AMHP and nearest relative. Treatment can be given without the patients consent. Right to appeal within 7 days of the section. Converted to a section 3, regrade to informal or allowed to expire.
66
What is a section 3 for?
Treatment order. Duration is 6 months, can be renewed for 6 months and then yearly after that. Can treat for 3 months without consent, after 3 months if not consenting or incapable you require a SOAD. For ECT: consent or SOAD For psychosurgery: consent or 2nd opinion Involves 2 doctors and 1 AMHP
67
What is a section 4 for?
Emergency order. Lasts 72 hours. No power to treat. Only used in an "urgent necessity" when waiting for a second doctor would lead to an "undesirable delay". Need 1 doctor and 1 AMHP. Assess and convert to a 2, 3 or discharge.
68
What is a section 5(4)?
Nurses hold. For a patient ALREADY admitted (psych or general) but wanting to leave. Nurse MUST be a registered MH or LD nurse. Lasts 6 hours. Cannot be treated coercively whilst under section. Ends when the patient is seen by a doctor for a S5(2).
69
What is a section 5(2)?
Doctors hold For a patient ALREADY admitted (psych or general) but wanting to leave. Lasts 72 hours, allows time for a section 2 or 3 assessment. No right to medicate (unless an emergency), no leave. Patient needs to be seen by MHA team within 72 hours
70
What is a section 135?
Police section - need a court order to access the patients home and remove them Take to a place of safety e.g. 136 suite in psychiatric unit. Lasts up to 24 hours
71
What is a section 136?
Police section - for a person suspected of having a mental disorder in a public place Take to a place of safety e.g. 136 suite in psychiatric unit. Lasts up to 24 hours
72
What is a section 37?
Hospital order. | Criminal court apply and the patient goes to hospital rather than prison
73
What is a section 41?
Restrictions due to concerns for public safety

Phase 3A (9 decks)

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