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Psychiatry Flashcards

1
Q

Key features of Generalised Anxiety Disorder

A
  • Anxiety >6 months not restricated to a particular circumstance.
  • Aetiology - genetics, life stressor, F>M, brain damage, reduced ANS response, more in 45-59y
  • Dx= 4 of: (*including 1 ANS hyperstimulation)
    • Palpitations*
    • Sweating*
    • Shaking*
    • Dry mouth*
    • Dizzy
    • Derealisation/ depersonalisation
    • Fear of losing control
    • Fear of dying
    • ‘On edge’
    • Difficulty concentrating
    • Difficulty going to sleep
    • SOB
    • Lump in throat
    • Chest pain
    • N+V
    • Hot flushes/ chills
    • Numbness/ tingling
    • Muscle tension
    • Restlessness
    • Irritability
  • Tx:
    • Education
    • CBT/ pscyhotherapy
    • Medical - 1st line= SSRI eg citalopram
    • BDZ in acute eg lorazepma
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2
Q

Key features of panic disorder

A
  • Panic disorder= recurrent panic attacks.
  • Panic attack= period of intense fear. Rapid onset, peak 10 mins, lasts <30 mins. Spont. + situational.
  • Aetiology: F>M, esp teens/ middle age. More post-synaptic response to seratonin.
  • Presentation: ANS hyperstimulation
    • Tremor
    • Tachycardia
    • Tachypnoea
    • Hyertension
    • Sweating
    • GI upset
  • Tx:
    • CBT
    • 1st line: SSRI
    • 2nd line - TCA, SNRI, MAOi
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3
Q

Key features of phobic disorder

A
  • Recurrent Sx on anxiety in presence of specific object –> avoidance.
  • Eg acoraphobia, social phobia
  • Aetiology- F>M, onset 7-20y, conditioned theory.
  • Tx:
    • Behavioural - graded exposure
    • Cognitive - educational + coping strategies
    • Medication if severe - SSRI (?PRN BDZ eg flying)
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4
Q

Key features of obsessive compulsive disorder

A
  • Obsessionsal thoughts and/or compulsive acts. Repeated rituals interfere with functioning.
  • Aetiology- F>M, esp 20s. Dysregulation of seratonin.
  • Tx:
    • CBT, psychotherapy
    • 1st line= SSRI –> alt SSRI –> clomipramine
    • ECT
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5
Q

Key features of PTSD

A
  • Severe psychological disturbance <6m after traumatic even –> re-experiencing of elements of event + ++arousal, avoidance, emotional numbing, interfering with functioning.
  • ICD-10:
    • >2 persistent Sx of increased pscyhological sensitivity + arounsal, difficulty sleeping, irritability, anger, poor concentration, hypervigillance, increased startle response.
    • Persistent reliving of stressor - flashbacks, dreams, memories.
    • Avoidance.
    • Inability to recall.
  • Tx:
    • 1st line= Rapid eye movement desensitisation
    • CBT
    • Exposure therapy
    • Meds - SSRIs eg paroxetine, amitrptylline
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6
Q

Key features of somatoform disorder

A
  • = Repeated presentation of physical Sx + requests for medical Ix despite -ve results + reassurance.
  • At least 6 Sx in 2 different body systems.
  • Hypochondrical disorder= >6m preoccupation with having >1 serious dosrder
  • Tx:
    • Ix - rule out DDx
    • Try to avoid meds. Only effective when co-morbid anxiety.
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7
Q

State and Trait anxiety

A
  • State= Temp. Condition due to percieved threat
  • Trait= Personality characteristic
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8
Q

Anxiety management

A
  1. Dx - rule out physical condition, meds, co-morbidities
  2. Low intensity CBT, pscyhoeducation
  3. 1st line - high intensity psychological intervention. 2nd line drugs
  4. Psychological Tx + drugs
  • Drugs:
    • 1st line = SSRI
    • 2nd line GAD - pregabalin
    • BDZ short term
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9
Q

Key features of Mental Health Act 2007

A
  • Part 1 = Mental disorder (not substances or LD) and at risk to self or others
  • Part 2= Sections + holding orders
    • Section 2= 28d. MD + risk. No capacity/ consent. AMHP, section 12 doctor + other doctor
    • Section 3= 6 months. Same + nearest relative agreement.
    • Section 4= emergency. 72h. 1 doctor + 1 AMHP.
    • Holding powers - already admitted. 5(2)= 72h, awaiting assessment. 5(4)= 6h - by nurses.
    • Police powers - 135 inside home, 136 outside house –> place of safety for 48h
    • S17= approved leave
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10
Q

Key features of the Mental Capacity Act

A
  • Capacity= situational
  • Assessing capacity:
    • Understand the consequences
    • Retain and repeat information
    • Weigh up the options
    • Communicate
  • –> Lack any one of these –> act in best interests.
  • Assume a person has the capacity to make a decision themselves, unless it’s proved otherwise
  • Wherever possible, help people to make their own decisions
  • Don’t treat a person as lacking the capacity to make a decision just because they make an unwise decision
  • If you make a decision for someone who doesn’t have capacity, it must be in their best interests
  • Treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms
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11
Q

Definition of delirium and causes

A
  • = Acute onset of fluctuating cognitive impairment
  • Types:
    • Hyperactive - agitation, arousal. Risk of falls
    • Hypoactive - Lethargy, psychomotor retardation. Risk of sores, dehydration
    • Mixed- variable.
  • Causes= PINCH ME
    • Pain
    • Infection/ Intracranial
    • Neoplasm/ Nutrition
    • Constipation
    • Hydration
    • Medications - psychoactive, sedating, steroids, L-dopa, opiates, alcohol.
    • Metabolic - Electrolytes, thyroid, glucose
    • Environment - esp sensory impairment
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12
Q

Presentation of delirium

A
  • Incoherent speech
  • Disorganised thinking
  • Impaired consciousness
  • Impaired cognitions
  • Reduced attention
  • Impaired sleep-wake cycle
  • Drowsy
  • Agitation/ retardation
  • Emotional lability
  • Anxiety/ depression
  • Delusions - paranoid, persecutory
  • Hallucinations es pvisual
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13
Q

Ix an Tx of delirium

A
  • Ix:
    • 4-AT (delirium test), MMSE, AMTS, CAM (confusion assessment method)
    • Bedside - o2, BM, ECG, urine dip, sputum
    • Bloods - FBC, U+Es, glucose
    • Imaging- CXR
  • Tx:
    • ID + Tx cause
    • Optimise condition - hydration, nutrition, elimination, pain
    • Optimise environment - lighting, clocks, pics
    • Support and involve family - re-orientation
    • Avoid sedation - quiet room. If needed- Haloperidol or clozapine in PD
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14
Q

Bloods in confusion screen

A
  • FBC
  • U+Es
  • LFTs
  • TFTs
  • B12
  • Folate
  • HbA1c
  • Vit D
  • Calcium, phosphate, magnesium
  • CRP
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15
Q

Confusion Assessment Method - Identification of delirium

A
  • Confusion - acute and fluctuating
  • Inattention
    • Either:
      • Disorganised thinking - disorganised, incoherent, illolgical
      • Altered level of consciousness - lethargy, stupor, comatose, hypervigilant
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16
Q

Dementia - what is it, presentation, Ix and Tx

A
  • = Progressive global cognitive deficits with functional impairment. DDx excluded. Sx at least 6m.
  • Presentation:
    • Hallucinations + deliusions
    • Anxiety/ depression
    • Personality changed
    • Reduced cognition
    • Pathological emotion
    • Seizures
    • Functional impairment
    • Memory loss
  • Ix:
    • Bedside - ECG, MMSE, Adden-Brookes, EEG
    • Bloods - FBC, LFTs, U+Es, glucose, ESR, TFTs, calcium, Mg, phosphate, B12, folate, CRP, cultures
    • Imaging - CT/ MRI head, CXR
  • Tx: Bio-Psycho-Social!
    • Cons - support, OT, physio, NB driving
    • Meds- SSRI for depression/ anxiety. Cognitive enhancement based on type of dementia
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17
Q

Key features of Alzheimer’s Disease

A
  • RF: Age, Downs, head injury.
  • Pathophysiology- Plaques and tangles. Reduced ACh
  • Presentation;
    • Early - Memory loss, disorientation, behaviour change (agression, wandering, temper, sexual disinhibition)
    • Middle - Loss of intellect, aphasia, apraxia, agnosia, loss of executive function
    • Late - Declining physical condition, change in gait, spasticity, weight loss, seizures
  • Tx:
    • AChEi - Donepezil (urinary incontinence), rivastigmine, galantamine
    • NMDA - memantine
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18
Q

Key features of dementia with Lewy Bodies

A
  • Mixed pathology - lewy bodies, plaques, tangles, vascular
  • Presentation:
    • Dementia
    • Depression
    • Falls + syncope
    • Visual hallucinations
    • REM sleep disorder
    • Parkinsonism
    • Fluctuating cognition
  • Ix: CT, DAT, MRI, SPECT
  • Tx:
    • Avoid antipsychotics
    • AChEi/ memantine trial
    • AntiPD for motor Sx
    • Clonazepam for motor Sx
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19
Q

Key features of fronto-temporal dementia

A
  • Early onset 45-65y. Slow decline.
  • Presentation:
    • Disinhibition - overeating, sexual etc
    • Speech - mutisms
    • Reduced cognition
    • Poor personal hygiene
    • Loss of insight
    • Blunted emotion
    • Wandering
  • Ix: MRI, SPECT. Loss of fronto-temporal. Spared memory!
  • Tx: non-specific
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20
Q

Key features of vasacular dementia

A
  • Cause= thromboembolism/ infarction
  • Presentation:
    • ?Prev stroke
    • Depression
    • Behaviour slowing
    • Seizures
    • Neuro - rigid, brisk reflexes
    • Stepwise
    • Focal neurology and signs
    • Early emotional + personality change
  • Ix: cholesterol, clotting, ?ECHO, carotid doppler
  • Tx: x smoking, Anticoagulation, HTN control
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21
Q

Key features of alcohol dependence

A
  • Reccommended= <14 units/w
  • Assessment:
    • Bedside - CAGE, AUDIT, breathalyser
    • Bloods- FBC, U+Es, LFTs, coags, refeeding (calcium, phosphate), vit B12, folate, HbA1c, magnesium, glucose
  • Affects:
    • Bio - seizures, wernicke’s/ korsikoffs, gout, cirrhoesis, cancer, HTN, pancreatitis
    • Psycho- anxiety, depression, psychosis, self-harm
    • Social - empolyment, family, forensic
  • Tx:
    • CBT
    • Assisted withdrawal- community. Inpatient if >30units/d, epilepsy, LD, vulnerable. Withdrawal Sx 4-12h later
    • BDZ - chlordiazepoxide based on CIWA
    • Thiamine
    • Tx after withdrawal:
      • Acamprosate, naltrexone - less cravings
      • Disulfiram - unpleasant SE
22
Q

Management of opiod dependence

A
  • Drug testing - urine/ saliva
  • Assess bio-psycho-social
  • Opiate substitute:
    • Methadone - Sedating. Liquid. Detox 28d.
    • Buprenorphine - no high. Tabelet.
23
Q

Definition of dependence

A
  • 3 or more present at some time in prev year:
    • Strong desire/ compulsion
    • Difficulty controlling use
    • Withdrawal
    • Tolerance
    • Neglect of other interests
    • Persistence despite clear evidence of harm
  • Harmful use= actuall damage to mental/physical health
  • Hazardous use= More risk of harmful consequences. Pattern of use.
24
Q

Diagnostic criteria for depression

A
  • Dx: Sx for 2 weeks
    • Mild= 2 core + 2 others
    • Mod= 2 core + 4 others
    • Severe= 3 core + 6 others
  • * = Core
  • Depression*
  • Interest - loss of*
  • Tiredness*
  • Suicide*
  • Sleep
  • Concentration
  • Confidence
  • Guilt
  • Appetite
  • Pyschomotor retardation
  • Other Sx - Loss of libido, psychosis, constipation, amenorrhoea, retardation
  • Hx- RISK!!! NB to screen for anxiety, mania, psychosis
25
Q

Depression - RF, subtypes, organic causes

A
  • RF:
    • F>M
    • Genetic
    • Childhood abuse
    • Personality traits eg neuroticism
    • Relationshiop/ employment status
    • Adverse life event
  • Organic causes - Med, hypothyroid, Addison’s, Cancer
  • Subtypes:
    • Without somatic Sx
    • With somatic Sx
    • With Psychotic Sx
  • 80% recurrent depressive disorder
  • Dysthymia= chronically depressed mood
  • Monamine oxidase theory - due to less monoamines - seratonin, dopamine, noradrenaline
26
Q

Depression - Ix and Tx

A
  • Ix:
    • Screening - PHQ-9. “During the last month have you felt down/ had loss of interest?”
    • Bloods - U+Es, TSH, FBC, LFTs, B12/folate, calcium, CRP
  • Tx:
    • Mild - Stop precipitating factors, CBT
    • Mod-severe- CBT, psychodynamic therapy, drugs
    • Severe - ECT
    • Drugs:
      • SSRIs - sertraline, citalopram, fluoxetine, paroxetine
      • SNRIs - Venlafaxine
      • NaSSAs- Mirtazapine
      • TCAs - Amitryptylline, imipramide
      • MAOi - Macobemide, phenelezine
27
Q

Causes of dementia

A
  • Neurodegenerative - AD, frontotemporal, PD, Huntington’s
  • Cerebrovascular disease
  • SOL
  • Head injury
  • Infection - CJD, HIV related, neurosyphilis, meningitis
  • Drugs + alcohol - BDZs, barbituates
  • Inflamm - MS, SLE
  • Nutritional - thiamine, B12
  • Normal pressure hydrocephalus
  • Metabolic/ endocrine:
    • Liver failure
    • Wilson’s
    • Thyroid
    • Cushings
    • Addisons
28
Q

Definition of Bipolar affective disorder and mania

A
  • Bipolar= at least 2 episodes, 1 of which must be manic/ hypomanic/ mixed. Complete recovery between eps.
  • Mania= 3/9 of: For at least 1 week
    • Elated mood
    • More activity/ energy
    • Pressure of speech
    • Flight of ideas
    • Less need for sleep
    • Disinhibition
    • Distractability
    • Reckless bahaviour
    • Marked sexual behaviour
  • Severe mania + psychotic Sx= grandiose, persecutory, delusions, pressured speech, catatonia, loss of insight.
  • Hypomania - >3Sx >4 days not severe enough to interfere with functioning.
29
Q

Management of bipolar affective disorder

A
  • Promote routine
  • Antipsychotics - olanzapine, quetiapine, haloperidol
  • Mood stabilisers - lithium, sodium valproate
  • Anti-depressant mood stabiliser - lamotrigine
  • Rapid cyclers - carbamazepine
30
Q

Behaviours associated with eating disorders

A
  • Starvation, calorie counting
  • Denial of weight loss
  • Change in habits eg veganism
  • Wearing bagging clothes
  • Rituals/ obsessions
  • Rules on eating
  • Socially isolated
  • Low mood
  • More exercise
  • Self-harm
  • Bathroom after meals
31
Q

Difference between mood and affect

A
  • Mood= climate
  • Affect= weather
32
Q

Key features of anorexia nervosa

A
  • Weight loss 15% or more below expected
  • BMI <17.5
  • 2 types: restrictive, binge-purging type
  • +/- other features - appetite suppressants, excessive exercise, diuretics.
  • Obsession with being thin, fear of gaining weight
  • Endocrine disturbance –> amenorrhoea, loss of libido, impotence in men, raised growth hormone/ cortisol, reduced T3
  • Atypical AN - BMI >17.5, some insight
33
Q

Key features of bulimia nervosa

A
  • Craving + recurrent binges (>2/w) –> guilt + compensatory behaviour (vomiting, laxatives, exercising)
  • Other compensatory behaviour - misuse of thyroid drugs, not administering insulin)
  • BMI almost normal
34
Q

ICD-10 for anorexia nervosa

A

All of the following:

  • Low BMI <17.5 kg/m2
  • Self-induced weight loss
  • Overvalued ideas: dread of fatness, low target weight, self-perception of being fat
  • Endocrine disturbance - amenorrhoea, raised cortisol, growth hormone
  • Pre-pubertal - failure to make expected weight gains, delayed pubertal events
35
Q

ICD-10 of bulimia nervosa

A

All of following:

  • Bing eating
  • Strong cravings for food
  • Methods to counteract weight gain - vomiting, laxatives, fasting, exercise
  • Overvalued ideas
36
Q

What is EDNOS?

A
  • = Eating disorder not otherwise specified
  • Residual mild/ chronic forms of AN + BN
37
Q

Medical complications of eating disorders

A
  • Related to starvation:
    • Emaciation
    • Amenorrhoea + infertility
    • Cardiomyopathy
    • Constipation
    • Cold intolerance
    • Bradycardia
    • Lanugo - fine, downy hair
    • Dry and brittle skin
    • Peripheral oedema
    • Proximal myopathy + muscle wasting
    • Osteoporosis
    • Seizures
    • Electrolyte disturbance - NB hypokalaemia!
  • Related to vomiting:
    • Permenant erosion dental enamel
    • Enlargement of salivary glands
    • Calluses on back of hands
    • Oesophageal rupture
38
Q

Eating disorder - Ix and Tx

A
  • Ix:
    • Bedside - SCOFF questionaire, ECG (*QTC*), BMI, pulse, proximal muscle strength
    • Bloods - FBC, U+Es, LFTs, glucose, cortisol, TFTs, FSH, LH, cholesterol. Refeeding bloods- calcium, phosphate
  • Tx:
    • Cons - support groups, psychoeducation, weight restoration, CBT
    • Med- correct electrolyte disturbance, cautiously re-introduce food (refer + follow protocol)
39
Q

What is psychosis and what disorders might you get it in?

A
  • = Perceive reality in a very different way from those around you. Characteristically:
    • Hallucinations - abnormal perception
    • Delusions - fixed, false beliefs outside cultural norm
    • +/- Disorganised thinking
  • May get in schizophrenia, delusional disorder
40
Q

Schizophrenia ICD-10 criteria

A
  • 1 of:
    • Thought alienation
    • 3rd person auditory hallucinations
    • Delusions of control/ passivity
    • Persistent delusions
  • 2 of:
    • Persistent hallucinations
    • Breaks in speech (poverty)
    • Catatonic behaviour
    • -ve Sx eg apathy, blunted affect
    • Significant + persistent change in overall quality of some aspects of personal behaviour
41
Q

Types of schizophrenia + DDx

A
  • Parnoid
  • Catatonic - ++ psychomotor disturbance
  • Simple - oddity of conduct
  • Undifferentiated
  • Post-schizophrenic depression
  • Residual - chronic
  • Hebephrenic - ++ change in affect (flattened/ incongruent). Less delusions and hallucinations
  • DDx- depression, mania, alcohol/ drugs, organic brain
42
Q

Dopamine theory of schizophrenia

A
  • Cauesed by ++ dopamine.
  • Proven as antipsychotics are dopamine antagonists
43
Q

Management of schizophrenia

A
  • CBT, family therapy
  • Social care and housing
  • MDT- CPN, social work, OT
  • Antipsychotics:
    • Typical/ 1st generation - Haloperidol. CI- PD, LBD
    • Atypical/ 2nd generation - Respiradol, olanzapine, clozapine, quetiapine, aripiprazole. Wider therapeutic range, less EPSE
  • SE of antipsychotics - EPSE, neuroleptic malignant syndrome (fever, muscular rigidity, change in mental state) –> tx= procyclidine
44
Q

What is delusional disorder? Different types + Tx

A
  • = Long-standing (>3m) delusions are the only characteristic. Organic, affective and schizophrenic causes eexcluded.
  • Subtypes:
    • Grandiose
    • Persecutory
    • Somatic
    • Capras syndrome - someone they know is replaced by an imposter
    • Fregoli syndrome - believe stranger is a loved one
    • Erotomania - delusion that a person of higher social standing is inlove with them.
    • Foli a deux - delusion shared by 2 people in close association
    • Orthello syndrome- delusion that spouse is unfaithful
  • Tx:
    • Psychoeducation
    • Antipsychotics
45
Q

Key features of post-natal depression

A
  • Develops <3m of delivery. Lasts 2-6m.
  • Screening tool= Edinburgh
  • Depressive Sx +:
    • Anxious preoccupation with baby’s health
    • Less affection and bonding with baby
    • Obsessional phenomena eg harming baby
    • Infanticidal thoughts
    • Often feelings of guilt/inadequacy
  • Tx:
    • Cons- mother-baby groups, relationship councelling, health visitors
    • Med- antidepressants
    • Severe - hosp + ECT
  • Post-natal blues - eps of tearfullness, mild depression, irritability, emotional lability. Self-limiting
46
Q

Key features of puerperal psychosis

A
  • Rapid onset 4d-3w
  • 1 in 500 births. RF: PMH/Fhx of bipolar/ puerperal psychosis, primip, traumatic delivery
  • Presentation:
    • Insomnia
    • Restlessness
    • Perplexity
    • Suspiciousness
    • Marked pschotic Sx
    • Polymorphic/ fluctuating Sx
    • Affective + psychotic thoughts may occur at separate times
  • RISK!! Thoughts of self-harm/ harm to baby, thoughts baby should be dead, command hallucinations
  • Tx:
    • Hospital in mother-baby unit
    • Meds- antipsychotics, anti-depressants, mood stabilisers, BDZ (acute)
    • ECT
47
Q

Biological causes of depression

A
  • Medications:
    • Beta blockers
    • L-dopa
    • Steroids
    • Antipsychotics
    • Opiates
  • Neuro- MS, PD, Huntington’s
  • Thyroid
  • Cushing’s
  • Addison’s
  • LTC/ chronic pain
48
Q

What are personality disorders?

A
  • Personality= Traits/ characteristics –> attitude, thoughts, behaviour
  • PD= Enduring, persistent + pervasive –> distress and impaired functioning
    • Start childhood
    • Manifest as problems in cognition, affect, behaviour
    • Outkeeping with cultural norms
    • Not attributed to other mental health disorders
49
Q

Types of personality disorders

A
  • Paranoid - sensitive, distrust
  • Schizoid - emotionally cold, introspection
  • Dissocial - agression, callous, can’t maintain relationships
  • EUPD- unable to control affect, self-harm, umpulse, unstable relationships, substances
  • Dependent - clingy, need care, helpless when not in relationships
  • Anxious - timid, insecure, self-conscious
  • Anakastic- indecisive, cautious, perfectionism
  • Histrionic - craves attention, self-damatication
50
Q

Aetiology and management of personality disorders

A
  • Aetiology - Genetic, lower seratonin, poor childhood development, dysfunctional environment, maladaptive environment
  • Management:
    • Support groups
    • CBT
    • No admission - only crisis
    • No meds (unless co-morbid)
51
Q

Key features of self-harm

A
  • = Intentional act done with the knowledge that it is potentially harmful Eg overdose, self-injury (cutting, burning, hitting)
  • Motives- emotional relied, self-punishment, attention seeking
  • Patients with self-harm at 100-fold greater chance of completing suicide. NB risk assessment.
  • Associated mental health disorders - depression, bi-polar, schizophrenia, alcohol dependent, personality disorders, eating disorders
  • Assessment
    • Thorough risk assessment - pre-morbid, triggers, protective
    • Medically stabilise
    • Recent adverse events/ triggers?
    • Planning/ spontaneous
    • Precautions to avoid discovery
    • Help soughts after?
    • Protective factors?

Finals!!! (19 decks)

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