PSYCHIATRY Flashcards
1
Q
What is schizophrenia?
A
“Fragmentation of the mind”
More common in makes than females
- tends to occur in males 20-28 and females 26-32
2
Q
What is the ICD10 classification of schizophrenia?
A
- FUNDAMENTAL AND CHARCTERISTIC distortions of thinking and perception affects that are inappropriate or blunted.
- Clear consciousness and intellectual capacity are usually maintained
- Can also be present with symptoms of affect- schizoaffective disorder
- Must be present for at least 2 weeks
3
Q
What are the positive symptoms of schizophrenia?
A
- HALLUCINATIONS (esp auditory)
- DELUSIONS
- THOUGHT DISORDER
- FOCUS OF DRUG TREATMENT
- GOOD PROGNOSIS
4
Q
What are the negative symptoms of schizophrenia?
A
- AVOLITION: lack of motivation
- ANHYDONIA: unable to experience pleasure
- ALOGIA: poverty of speech
- ASOCIALTY: lack of desire for relationships
- Affect BLUNT
- LESS RESPONSIVE
5
Q
What are the Schneider’s First Rank Symptoms?
A
- 3rd person auditory hallucinations discussing the patient
- Thought: echo, insertion, withdrawn, broadcast
- Passivity
- Delusional perception
- Somatic (experiences of bodily influence)
- Experiences imposed upon the patient or influenced by others (acts, impulses, affects)
6
Q
What are the subtypes of schizophrenia?
A
1) PARANOID
2) HEBEPHRENIC/DISORGANISED
3) CATATONIC
4) RESIDUAL
5) SIMPLE
6) UNDIFFERENTIATED
7) CHRONIC SCHIZOPHRENIA
7
Q
What are the prominent symptoms of paranoid schizophrenia?
A
- Delusions
- Auditory hallucinations
8
Q
What are the prominent symptoms of hebephrenic/disorganised schizophrenia?
A
- Disorganised speech or behavior
- Flat or inappropriate affect
9
Q
What are the prominent symptoms of catatonic schizophrenia?
A
- Catalepsy or stupor
- excessive motor activity
- extreme negativity or mutism
- automatic obedience
- Dream state with vivid scenic hallucinations
- Violent excitement
- Posturing or stereotypy mannerisms, grimacing
- Echolalia or echopraxia
10
Q
What are the prominent symptoms of residual schizophrenia?
A
- Previous full blown acute episode in the past
- Currently negative symptoms or attenuated forms of more generic symptoms
11
Q
What are the symptoms of simple schizophrenia?
A
- insidious development of negative symptoms in the absence of positive symptoms
- gradual deterioration of personality with increased emotional bluntness
- Decline in total performance
12
Q
What are the symptoms of undifferentiated schizophrenia?
A
- generic symptoms not conforming to one subtype
13
Q
What are the symptoms of chronic schizophrenia?
A
- Persistent disability for 2 years or longer
14
Q
What are the environmental causes and risk factors for schizophrenia?
A
- Winter births
- Viral infections
- Association with other CNS pathologies
- Neurosyphilis
- Encephalitis
- Temporal lobe epilepsy
15
Q
What are the social causes and risk factors for schizophrenia?
A
- Social exclusion
- economic adversity
- childhood trauma/ abuse
- migration
- urban environment
- negative attitudes
- high expressed emotion
16
Q
What are the toxic causes and risk factors of schizophrenia?
A
- Cannabis
- Amphetamines
17
Q
What are the perinatal causes and risk factors for schizophrenia?
A
- Hypoxia
- Maternal stress
18
Q
What is the pathogenesis of schizophrenia involving dopamine?
A
- ANTIPSYCHOTICS act at DA receptors
- increased MESOLIMBIC activity= POSITIVE symptoms
- decreased MESOLIMBIC activity = NEGATIVE symptoms
- Amphetamines act here and MIMIC PSYCHOSIS
19
Q
What is the pathogenesis of schizophrenia involving 5-HT (serotonin)?
A
- LSD acts here and causes hallucinations
- Clozapine binds to 5-HT2a
20
Q
What is the pathogenesis of schizophrenia involving glutamate?
A
- Phenycyclidine causes psychosis (via NMDA receptors)
- Reduced glutamate activity = negative symptoms
21
Q
What other neurotransmitters are possibly involved in the pathogenesis of schizophrenia?
A
- Acetyl choline
- GABA
22
Q
What is the medical management for schizophrenia?
A
SHORT TERM:
- Antipsychotics
LONG TERM:
- Antipsychotic
- Antidepressant
- Lithium
23
Q
What is the psycho-social management for schizophrenia?
A
SHORT TERM
- education
- CBT
- family interventions
LONG TERM
- CBT
- supported employment
- family interventions
- reduce expressed emotion
- replies signature
- art therapy for negative symptoms
24
Q
What investigations should be done before starting antipsychotics?
A
- General examination
- Bloods: FBC, U+Es, LFT, RBS, HbA1c, Prolactin, lipids, cholesterol
- ECG: prolonged QT/arrhythmias
25
What is generally best practice when starting antipsychotic medications?
1) START with 2nd gen antipsychotics (SGA), but change if poor response/ SEs.
- Continue for 1-2 years
- Reduce slowly and monitor
26
What are the three dopamine pathways affected within schizophrenia?
1) MESOCORTICAL/MESOLIMBIC (related to behaviour
2) NIGRO-STRIATAL- coordination of voluntary movements
3) TUBERO-INFUNDIBULAR- prolactin secretion
27
What are the additional effects of anti-cholinergic drugs?
CAN'T SPIT CAN'T PEE, CAN'T POOP CAN'T SEE
- dry mouth
- blurred vision
- constipation
- urinary retention
28
What are the additional effects of anti-adrenergic drugs?
- postural hypotension
| - sexual dysfunction
29
What are the additional effects of anti-histamine drugs?
- sedation
| - anti-emetic
30
When should CLOZAPINE be offered?
- To those who have NOT responded to 2 different anti-psychotic drugs, one of which is 2nd gen.
31
What are the side effects of CLOZAPINE?
- agranulocytosis
- myocarditis
- weight gain
- salivation
- seizures
- sedation
32
What is the Depot in relation to schizophrenia?
- IM slow release of antipsychotic preparation
- Good to use if poor compliance with tablets
- RISPERIDONE
- PALIPERIDONE
- OLANZEPINE
- given every 2-4 weeks
33
What are delusional disorders in general?
- Patients present with delusions but with NO accompanying prominent hallucinations, thought disorder, mood disorder or significat flattening of affect
34
What are non-bizarre delusions?
- Fixed false beliefs that involve situations that COULD potentially occur in real life, such as being harmed or poisoned.
35
What excludes a diagnosis of delusional disorder?
- Clear and persistent auditory hallucinations
- Delusions of control
- Marked blunting of affect (no emotional expression)
- Brain disease
- Due to a drug
- Previous diagnosis of schizophrenia
36
What are the different types of delusional disorder?
1) De Clerambault's syndrome
2) Othello syndrome
3) Capgras syndrome
4) Fregoli's syndrome
5) Cotards syndrome
6) Folie a deux
7) Ekboms syndrome
37
What are the features of De Clerambault's syndrome?
- ERTOMANIA= delusional belief someone is in love with them
| - secret signs/ communication
38
What are the features of Othello syndrome?
- Morbid jealousy
- Delusional belief that partner having affair
- Associated with alcohol dependence/ sexual dysfunction
- Risk of stalking and violence
39
What are the features of Capgras syndrome?
- Delusional misidentification
- Relative or friend replaced by IMPOSTER
- F>M
40
What are the features of Fregoli's syndrome?
- Different people are a single person
| - Often believe they are being persecuted by that person
41
What are the features of Cotard's syndrome?
- Delusion of being dead, dying, nonexistent, rotting, lost parts of body/organs
- Associated with depression
42
What are the features of Folie a deux?
- induced by delusional disorder
| - Psychosis shared by two people
43
What are the features of Ekboms syndrome?
- Delusional parasitosis (infestation)
- Associated with formication (insects crawling on skin)
- Risk of self harm trying to get rid of parasites
- House or home infested: delusional cleptoparasitosis
44
What are the various risk factors of depression?
BIO: family history, gender, physical health
PSYCH: personality, lack of confidant, low self esteem
SOCIAL: cumulative childhood disadvantage, separation/ divorce, adverse life events, unemployment, poor social support
45
What are the core clinical symptoms of depression?
1) LOW MOOD: diurnal variation
2) ANHEDONIA: inability to derive pleasure
3) REDUCED ENERGY
- for at least 2 weeks
- not secondary to the substance misuse, bereavement or illness
46
What additional symptoms associated with depression?
- Weight change
- Appetite change
- Loss of concentration
- Sleep disturbance- early morning wakening
- Guilt
- Worthlessness
- Suicidal thoughts
- Loss of libido
- Irritability/restlessness
47
What are the ICD10 classifications of severity for depression?
- MILD: 2 core + 2 other
- MODERATE: 2 core + 3 other
- SEVERE: 3 core + 4 other
48
What are the treatment management options for depression?
- ANTIDEPRESSANTS
- ELECTROCONVULSIVE THERAPY
- COGNITIVE BEHAVIOURAL THERAPY
- INTERPERSONAL THERAPIES
- SOCIAL MANAGEMENT
49
What are the 3 broad categories of antidepressants?
1) MONOAMINE REUPTAKE INHIBITORS (most common)
2) RECEPTOR ANTAGONISTS
3) MONOAMINE OXIDASE INHIBITORS
50
What are examples of monoamine reuptake inhibitors?
- TRICYCLICS: amitriptyline, lofepramine
- SSRIs: fluoxetine, citalopram (1st line)
- NARIs: Reboxetine
- SNRIs: venlafaxine
- NaSSa: Mirtazepine
51
What are the side effects of SSRIs:
- agitation
- GI: nausea, loss of appetite, diarrhea, contipation
- SEXUAL: libido/ erectile dysfunction
- ANTICHOLINERGIC: dizziness, dry mouth, blurred vision, sweatiness, headaches
- suicidal ideas
52
What are the side effects of antidepressants:
- SSRI specific (see card
- Suicidal ideas
- Serotonin syndrome (restlessness, fever, tremor, myoclonus, confusion, fits, arrhythmias)
- Hyponatraemia
- Priapism
53
What should be done if there is no response to medication of depression?
- TRY FOR AT LEAST 4-6 WEEKS
- Check compliance
- Mixing with alcohol and drugs?
- Switch or augment therapy
- NEVER STOP SUDDENLY
- Try lithium
54
What combinations are contraindicated in depression management?
TCA+ SSRI
55
When and how can ECT be used in management of depression?
- for severe, life threatening or treatment resistant depression
- 12 sessions in total- twice per week
56
What are the side effects of ECT?
- headache
- nausea
- muscle pain
57
When is psychological therapy offered as a mode of treatment in depression?
for MILD to MODERATE disease
58
What is low intensity psychological intervention?
- Advice: sleep hygiene and exercise
| - CBT self help: books, computer packages, apps etc
59
What should be given if there is no response to low intensity intervention?
- High intensity psychological intervention or antidepressant medication
60
What is the cognitive triad according to Beck?
NEGATIVE VIEW OF:
- SELF
- WORLD
- FUTURE
61
What are the cognitive biases according to Beck?
- Catastrophising
- Jumping to conclusions
- All or nothing/ black-white thinking
- Personalising
- Generalising
62
What are the 5 main techniques explored in CBT?
1) clarify the problem (when, where, duration, frequency, triggers)
2) Describe patients problem in terms of thought (cognitions), actions (behavior), physical sensations (physiological reactions) and mood
3) Thought diaries
4) Behavioural experiments e.g. does exercise lift my mood?
5) Graded exposure to avoided situations with anxiety management strategies
63
What are some examples of defence mechanisms?
- Denial
- Projection
- Dissociation (detach from specific function)
- Somatisation (move psychic pain into bodily function)
- Regression
- Repression
- Displacement (transfer emotions to a more acceptable object)
- Humour
- Altruism
64
When are interpersonal therapies (IPT) offered in depression?
For MODERATE to SEVERE disease
65
What is the focus of IPT?
- conflicts
- life changes
- grief and loss
- relationship problems
66
What is psychodynamic therapy?
Focus on past conflicts contributing to current difficulties- "insight orientated"
67
What are the areas to address in social management of depression?
- ADLs
- Living situation
- Isolation
- Support at hone
- Working? Problems at work?
- Carers
- Finances
68
When should secondary care referral be made for depression?
- Significant risk of self-harm, danger to others, psychotic symptoms or severe agitation
- Significant depression with functional impairment persists despite adequate treatment
- When additional comment support is required
- Indication for specialist psychological treatment
69
Summary of management for depression:
1) PSYCHOLOGICAL THERAPIES for mild-moderate
2) ANTIDEPRESSANTS for moderate to severe
3) Antidepressants have efficacy but not in drug/alcohol misuse
4) Antidepressants are NOT effective for adjustment disorder/ stress response syndrome
5) VENLAFAXINE has best efficacy in severe depression
6) SSRIs should be first line
7) CITALOPRAM is good choice if hepatic/ renal impairment
8) FLUOXETINE should be considered if poor compliance
70
What is bipolar affective disorder?
- 2 OR MORE EPISODES in which the patient's mood and activity levels are significantly disturbed
1) elevation of mood and increased energy and activity (MANIA)
2) lowering of mood and decreased energy and activity (DEPRESSION)
71
How is mania classified?
ELEVATED/EXPANSIVE/ IRRITABLE MOOD for at least 1 week, unless unwell enough for hospital admission
ADDITIONAL, at least 3:
- increased activity/ physical restlessness
- increased talkativeness
- flight of ideas/ racing thoughts
- loss of social inhibitions resulting in inappropriate behavior
- reduced need for sleep
- inflate self-esteem or grandiosity
- distractibility/ flitting from one activity to another
- reckless or foolish behaviour without insight
- marked raised libido/ indiscretions
72
What is hypomania?
lesser state, existing for at least 4 days, where symptoms affect activities of daily living
73
What is the management for acute bipolar disorder?
- BENZODIAZEPINES e.g. lorazepam
| - ANTIPSYCHOTICS e.g. quetiapine, asenapine
74
What is the long term management for bipolar disorder?
MOOD STABILISERS
- Lithium
- Valproate
- Carbamazepine
- Lamotrigine
75
What are the indications for lithium?
- MANIA: treatment and prophylaxis
- Bipolar Affective Disorder
- Recurrent depression
- Aggressive or sel-mutilating behavior
76
What baseline investigations should be done before administering lithium?
- Physical and weight
- U+Es
- renal function
- TFTs
- Ca2+
- ECG
- Pregnancy test, as it is teratogenic
77
What are the early side effects of lithium?
- Dry mouth
- Metallic taste
- Nausea
- Fine tremor
- Fatigue
- Polyuria
- Polydipsia
78
What are the late side effects of lithium?
- Diabetes insipidus
- Hypothyroidism
- Arrhythmias
- Ataxia
- Dysarthria
- Weight gain
79
What are the causes of lithium toxicity?
- Drugs
- NSAID
- diuretics
- renal failure
- UTI
- dehydration
80
What is the management for lithium toxicity?
- STOP LITHIUM
- give fluids
- start diuresis/ dialysis
81
What is anxiety?
An emotion accompanied by physiological changes that prepare the body to 'fight or flight'
Only problematic when it starts to interfere with our daily life
82
What are panic attacks?
- An abrupt discrete episode of intense fear or discomfort
- Reaches a maximum within a few minutes
- At least 4 specific symptoms of anxiety
83
What are the autonomic symptoms associated with anxiety?
- Palpitations/ increased HR
- sweating
- trembling
- dry mouth
84
What are the chest and abdomen symptoms associated with anxiety?
- difficulty breathing/ feeling of choking/ chest pain
| - nausea/ abdominal distress
85
What are the mental state symptoms associated with anxiety?
- feeling dizzy/ faint
- derealisation- feeling that objects are not real
- depersonalisation- feeling that people are not real
- fear of losing control/ going crazy/ passing out/ dying
86
What are the general symptoms associated with anxiety?
- hot flushes/ cold chills
| - numbness/ tingling
87
What is generalized anxiety disorder?
A period of at least 6 months with prominent tension, worry and feelings of apprehension about everyday events and problems.
88
What are the symptoms associated with generalised anxiety disorder?
- worry, nervousness, poor concentration, irritability
- hyper-vigilance, restlessness, increased startle response
- muscle tension
- headaches
- trembling
- sweating, sleep disturbance, derealisation, depersonalization
- fears of impending danger, illness, or accidents, negative thoughts, 'unable to cope'
89
What are the autonomic symptoms associated with generalised anxiety disorder?
- CVS- palpitations, tightness, pain
- RESP- over breathing, difficulty inhaling
- GI- dry mouth loose stools, epigastric discomfort, butterflies
- GUS- frequent micturition
- NEURO- blurred vision, light headed, dizzy
90
What is episodic paroxysmal anxiety (panic disorder)?
- Recurrent attacks of severe anxiety and panic attacks, not restricted to any particular situation or set of circumstances
- Unpredictable
- 4 panic attacks in 4 weeks, which lasts up to 10 minutes with a sudden onset
91
What is phobic anxiety disorder?
1) Anxiety symptoms restricted to specific situation or objects
2) Fear out of proportion to the situation
3) Fear cannot be reasoned or explained away
4) Anticipatory anxiety
5) Avoidance behaviour
92
What are the features of agoraphobia?
- F>M
- 20-35
- Fear of space and crowds
- difficulty travelling
- feeling of being trapped
- better if with company
- increased risk with panic attacks
93
What are the features of social phobia?
- F>M
- Adolescence
- Fear of interaction in social situations
- being scrutinized
- worse if few people
94
What are the features of specific phobias?
- F-M
- childhood
- animals
- flying
- dentists etc
95
What is the psychological management for generalised anxiety panic disorder?
- Self help
- CBT
- Applied relaxation
96
What is the psychological management for phobias?
- psycho education
| - exposure (systematic desensitization)
97
What is the medical management for generalised anxiety panic disorder?
- SSRIs
- beta blockers for symptoms
- Benzodiazepines avoided apart from short term
98
What is obsessive compulsive disorder?
- Obsessional thoughts are ideas, images, or impulse that enters the patient's mind again and again in a stereotyped form.
- The patient often tries, unsuccessfully, to resist them
99
What are some examples of obsessional thoughts/ rumination?
- fear of acquiring disease
- coming to harm
- causing harm to others
- an indecisive, endless consideration of alternatives, associated with an inability to make trivial but necessary decisions in day to day living
100
What are features of compulsive acts/rituals?
- Stereotyped behaviors that are repeated again and again
- Activities that are not enjoyable or useful
- Done to prevent some objectively unlikely event involving harm or danger
- Recognised by the patient as symbolic, pointless or ineffectual
- Anxiety is present
101
What are the psychotherapy treatments of OCD?
- CBT
- Exposure and response prevention
- Repeated graded exposure to anxiety provoking stimuli
102
What are the drug treatments for OCD?
- SSRI (fluoxetine, sertraline)
- TCA (clomipramine)
- Combined psychotherapy and drug treatment generally better than each alone)
103
What are additional treatments for OCD?
- Referral to National Service for Refractory OCD
| - ECT/ psychotherapy
104
What is an acute stress reaction?
- Transient disorder that develops is an individual without any apparent mental disorder in response to exceptional stress
- Symptoms usually appear within minutes of the impact of the stressful stimulus
105
What are the symptoms of acute stress reaction?
- being in a daze
- disorientation
- panic
- annesia
106
What is post traumatic stress disorder (PTSD)?
- Delayed or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.
107
What are the features of PTSD?
- Re-experiencing symptoms e.g. flashbacks, nightmares, intrusive memories
- avoidance of activities and situations associated with trauma
- Hyperarousal/anxiety with hyper vigilance and increased startle reaction
- Numbness, emotional blunting, detachment from others
- associated depression and suicidal ideation
- onset follows the trauma with a latency period of 1-6 months
- The course is fluctuating but prognosis is good
108
What are the predisposing factors for PTSD?
- personality traits- compulsive
- previous neurotic illness
- genetic (oversensitive amygdala and hippocampus, decreased hippocampal size on MRI)
- scale of trauma
- patients previous experience
- level of social support available
109
What is the treatment for PTSD?
- CBT
- Repeated graded exposure
- Testimony based techniques
- EMDR (eye movement desensitization and reprocessing)
- antidepressant- paroxetine or mirtazepine
110
What is adjustment disorder?
- adaptation to a significant or stressful life change
111
What are the symptoms of adjustment disorder?
- depression
- anxiety
- inability to cope
112
What is the treatment for adjustment disorder?
- supportive psychotherapy
| - antidepressants
113
What is the definition of bereavement?
- Any loss of event
| - usually the death of someone
114
What is the definition of grief?
- feelings
- thoughts
- behaviour associated with bereavement
115
What are the 'normal' reactions associated with bereavement?
- disbelief, shock, numbness, and feelings of unreality
- anger, feelings of guilt, sadness, tearfulness
- preoccupation with the deceased, disturbed sleep and appetite weight loss
- seeing or hearing the voice of the deceased.
- Gradual reduce in intensity, with acceptance of the loss and readjustment
- a typical 'grief reaction' lasts up to 12 months but cultural differences exist
116
What are 'abnormal' reactions to bereavement?
- very intense, prolonged, delayed (or absent)
- symptoms outside normal range are seen
- preoccupation with feelings of worthlessness
- thoughts of death
- excessive guilt
- marked slowing of thoughts and movements
- a prolonged period of not being able to function normally, hallucinatory experiences
117
What are the risk factors for abnormal reactions to bereavement?
- history of depression
- intense grief or depressive symptoms early in the grief reaction
- few social supports
- little experience of death
- 'traumatic' or unexpected death
118
What is the management of abnormal reactions to bereavement?
- Benzodiazepines may be used to reduce severe autonomic arousal or treat problematic sleep disturbance in the short term
- 'abnormal' grief: consider antidepressants and counseling
119
What are dissociative disorders?
Conditions that involve disruptions or breakdowns of memory, awareness, identity or perception
- it is triggered by psychological trauma, may be preceded only by stress, psychoactive substances, or no identifiable trigger at all
120
What is conversion disorder?
Patients who present with neurological symptoms, such as numbness, blindness, paralysis or fits which do NOT have organic cause, caused by a psychological trigger
121
What are somatoform disorders?
- A repeated presentation of physical symptoms
- Persistent requests for medical investigations, in spite of repeated negative findings and reassurances
- If any physical disorders are present, they do not explain the symptoms or distress
122
What are the symptoms associated with somatisation disorder?
- Multiple, recurrent and frequently changing physical symptoms of at least TWO years duration
- long and complicated history of contact with both primary and specialist medical care services
- symptoms may be referred to any part or system of the body
- chronic and fluctuating- associated with disruption of social, interpersonal and family behaviour
- F>M onset usually <30yrs
123
What is hypochondriasis?
- A persistent belief of at least 6 months of the presence of a minimum of two serious physical disease
- Persistent preoccupation with a presumed deformity or disfigurement
- Persistent refusal to accept medical advice that there is no adequate physical cause for the symptoms or physical abnormality.
124
What is dysmorphophobia?
related to hypochondriac disorder. It is excessive preoccupation with imagined or barely noticeable defects in physical appearance.
125
What is the management for hypochondriasis?
- CBT
| - SSRI
126
What are the three different types of eating disorders?
1) Anorexia nervosa
2) Bullimia nervosa
3) EDNOS (eating disorder not otherwise specified)
127
What are the features of anorexia nervosa?
- BMI <18.5
- core psychopathology
- amenorrhoea
- 1/200 males, 1/250 females
- there can be bingeing and purging in anorexia too
128
What are the features of bulimia nervosa?
- BMI >18.5
- core psychopathology
- regular binge/ purge 1x/ week
- 1/500 males, 1/50 females
129
What are EDNOS?
- eating disorder not otherwise specified
- subclinical disorders
- binge eating disorder
130
What is the core psychopathology of eating disorders?
- fear of fatness
- pursuit of thinness
- body dissatisfaction
- body image distortion
- self-evaluation based on weight and shape
131
What is the general psychopathology of eating disorders?
- Depression
- anxiety, social phobia
- suicidal ideation
- OCD symptoms
132
What are the differentials for eating disorders?
- Depression
- Somatoform disorders
- OCD
- Hypopituitarism
- Addison's disease
- Thyrotoxicosis
- IBD/ malabsorption
- Diabetes mellitus
- Carcinoma
- TB
133
What are common behaviors of those with eating disorder?
- dieting, fasting, calorie counting
- excessive exercise
- water loading
- diet pills, thyroxine, diuretics appetite supplements
- excessive weighing
- culinary behaviours
- avoidance and isolation
- bingeing and purging
- starve-binge-purge cycle
- misuse of insulin, laxatives, DSH, drugs
134
What are the effects of starvation on the CVS?
- bradycardia
- hypotension
- sudden death
135
What are the effects of bingeing/purging on the CVS?
- arrhythmias (hypokalaemic)
- cardiac failure
- sudden death
136
What are the effects of starvation on the renal system?
- edema
- electrolyte abnormalities
- renal calculi
- renal failure
137
What are the effects of starvation on the GI system?
- parotid swelling
- delayed gastric emptying
- nutritional hepatitis
- constipation
138
What are the effects of bingeing/purging on the GI system?
- parotid swelling
- dental erosion
- esophageal erosion/ perforation
- constipation
139
What are the effects of starvation on the skeletal system?
- osteoporosis
- pathological fractures
- short stature
140
What are the effects of bingeing/purging on the skeletal system?
- osteoporosis
| - pathological fractures
141
What are the effects of starvation on the endocrine system?
- Amenorrhoea
- infertility
- hypothyroidism
142
What are the effects of bingeing/ purging on the endocrine system?
- oligomenorrhoea
| - amenorrhoea
143
What are the effects of starvation on the haematological system?
- anaemia
- leukopenia
- thrombocytopenia
144
What are the effects of bingeing/ purging on the hematological system?
- leukopenia
| - lymphocytosis
145
What are the effects of starvation on the neurological system?
- Generalised seizures, confusional state
146
What are the effects of starvation on the metabolic system?
- impaired temperature regulation
| - hypoglycemia
147
What are the effects of starvation on dermatological system?
- lanugo
- brittle hair
- brittle nails
148
What are the effects of bingeing/ purging on the dermatological system?
- calluses on dorsal of hands (RUSSELL'S SIGN)
149
What is the SCOFF method of diagnosing an eating disorder?
- S: do you make yourself SICK because you feel uncomfortably full?
- C: do you worry you have lost CONTROL over how much you eat?
- O: have you recently lost more than ONE stone in a 3 month period
- F: do you believe yourself to be FAT when others say you are too thin?
- F: would you sat that FOOD dominates your life?
150
What investigations done in eating disorder?
1. Clinical history and physical examination
- rapid weight loss, CVS, palpitations, blackouts, bradycardia, irregular pulse, hypothermia, proximal myopathy
2. BODY MASS INDEX
- <17.5 is anorexia nervosa
- <15 is moderate risk
- <13 is high risk
3. ELECTROCARDIOGRAM
- most deaths due to cardiac arrest
- cardiac abnormalities in up to 86% of patients
- T wave changes (hypokalemia)
- Bradycardia (<40bpm)
- QTc prolongation
4. BLOOD INVESTIGATIONS
- FBC (neutropenia)
- U+Es
- LFTs
- Glu (hypoglycaemia)
- CK
- Phos
- Mg
- Ca
- TFT
- Zn
151
What is the treatment for eating disorders?
- Usually done as an outpatient
- Combination of nutritional rehabilitation and psychological intervention
- Guided self-help, CBT, IPT, psychodynamic psychotherapy, family interventions.
- Fluoxetine 60mg daily in BN
- NG feeding last resort
- BN + EDNOS will mainly be treated either in primary care or secondary services
152
When should patients be sectioned for their eating disorders?
- Only section severe anorexia nervosa for NG feeding, need ECG and blood investigations, not just BMI
153
What are the psychological treatment options for eating disorders?
- Individual eating disorder focused cognitive behavioral therapy
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- Specialist supportive clinical management (SSCM)
154
What is factitious disorder (Munchausen's syndrome)?
Patients intentionally falsify their symptoms and past history and fabricate signs of physical signs or mental disorder with the primary aim of obtaining medical attention and treatment
155
What are the three main types of Munchausen syndrome?
1) WANDERING- mostly males who move from hospital to hospital, job to job, place to place, producing dramatic and fantastic stories. Aggressive personality, comorbid drug or alcohol symptoms
2) NON-WANDERING- mostly females, more stable lifestyles and less dramatic presentations.Often in paramedic professions; overlap with chronic somatisation disorder.
3) BY PROXY- mostly female, mothers, carers, paramedical/nursing staff who stimulate or prolong illness in their dependents
156
What behaviors are associated with Munchausen's disorder?
- self induced infections
- simulated illnesses
- interference with existing lesions
- self medication
- altering records
- reporting false physical or psychiatric symptomatology
157
What are the differentials associated with Munchausen's disorder?
- Somatization disorder
- Malingering (secondary gain for the patient)
- Substance misuse
- Depressive illness
158
What are psychosexual disorders?
- Disturbances in sexual function secondary to emotional and or mental causes and is separate from sexual disorders that may arise from an underlying medical condition
159
What is a personality disorder and how does it manifest?
When characteristics of an individual are such as to cause distress or significant impairment in social functioning.
- COGNITION
- AFFECT
- BEHAVIOUR
160
What are the ICD-10 classifications of personality disorder?
- PARANOID
- SCHIZOID
- SCHIZOTYPAL
- DISSOCIAL
- EMOTIONALLY UNSTABLE: Impulsive type
- EMOTIONALLY UNSTABLE: Borderline type
- HISTRIONIC
- NARCISSISTIC
- ANXIOUS
- ANANKASTIC
- DEPENDENT
161
What are the causes of cognitive problems?
- Neurodegenerative dementia
- Delirium
- Depression: pseudo-dementia co-morbid
- Psychosis
- Other organic brain diseases
- Psychoactive substance misuse
162
What are the domains of cognition?
1. ORIENTATION
- Time
- Place
- Person
2. ATTENTION and CONCENTRATION
3. MEMORY
4. LANGUAGE
5. CONSTRUCTION
163
What are the features of orientation in a cognitive assessment?
At least 3 domains
TIME- day, date, month, year, season
PLACE- location, city, county, country
PERSON- name, age, DOB, address
164
What are the features of attention in a cognitive assessment?
- ability to focus and direct cognitive processes
| - use the tests in the concentration section
165
What are the features of concentration in a cognitive assessment?
- ability to focus and sustain attention over time
- WORLD backwards
- Serial sevens
- 20-1
- months of the year backwards
166
What are the features of memory in a cognitive assessment?
- short term vs. long term
- anterograde: learning new information e.g. recall of address
- retrograde: recall of previously learned information
167
What are the features of language in a cognitive assessment?
- assess when taking the history
- confabulation
- word finding problems
168
What are the features of construction in a cognitive assessment?
- simple figures
- complex figures
- formal tests
169
What are examples of cognitive screening tests?
1. AMTS
2. 4AT
3. 6-CIT
4. GPCOG
5. Clock drawing
6. MMSE
7. ACE-III
170
What is the AMTS?
1. Age
2. Time (nearest hour)
3. 42 West Street
4. Year
5. Name of this place
6. Identify 2 people
7. DOB
8. Year of WWI
9. Present monarch/prime minister
10. Count backwards 20-1
11. Recall address
171
What is delirium?
- Acute confusional state
| - Onset of fluctuating cognitive impairment associated with behavioural abnormalities
172
What are the subtypes of delirium?
- Hypoactive (psychomotor agitation, increased arousal, inappropriate behaviour)
- Hyperactive (psychomotor retardation, lethargy, excess somnolence)
- Mixed
173
What are the causes of delirium?
INFECTIVE: UTI, pneumonia, sepsis, meningitis, encephalitis, cerebral abscess
DRUGS: benzodiazepines, analgesics, anticholinergics, anticonvulsants, steroids
METABOLIC: anaemia, electrolyte disturbance, hepatic encephalopathy, hypothermia, hyponatraemia
INTRACRANIAL VASCULAR: CVA, head injury, encephalitis, primary or metastatic tumour, raised ICP, hemorrhage, ischemia, SLE
ENDOCRINE: pituitary, thyroid, parathyroid, adrenal diseases, hypoglycaemia, DM, vitamin deficiencies
SUBSTANCE INTOXICATION: alcohol, anticholinergics, psychotropics, lithium, antihypertensives, diuretics
HYPOXIA: secondary to any cause
174
What are the clinical features of delirium?
- Impaired ability to direct, sustain and shift attention
- Global impairment of cognition with disorientation
- Impairment of recent memory and abstract thinking
- Disturbance in sleep-wake cycle with nocturnal worsening
- psychomotor agitiation
- Emotional liability
- perceptual distortions, illusions and hallucinations
- Speech may be rambling, incoherent and thought disordered
- Poorly developed paranoid delusions
- Onset of clinical features
175
What are the investigations for delirium?
- full history including collateral
- full examination (looking for sources of infection)
- Bloods- include FBC, U+Es and creatinine, glucose, ca, mg, LFTs, TFTs, cardiac enzyme
- urine dipstick and testing and microscopy
- Blood cultures
- ECG
- Pulse oximetry and ABG
- CXR
- LP
176
What is the management for delirium?
1. IDENTIFY AND TREAT PRECIPITATING CAUSE AND EXACERBATING FACTORS
2. Provide environmental and supportive measures
3. Avoid sedation unless severe agitated
4. Regular clinical review and follow up
177
What is the ICD10 definition of dementia?
- Syndrome due to disease of the brain
- Chronic or progressive in nature
- Disturbance of multiple higher cortical functions
178
What are the causes of dementia?
- Alzheimer's (>50%)
- Vascular (22%)
- Mixed (AD+VaD)
- Lewy Body Dementia (11%)
- Pick's disease/ Frontotemporal dementia (8%)
179
What are the classifications for the severity of dementia?
MILD
- memory loss sufficient to interfere with everyday activities but able to live independently
MODERATE
- Memory loss is serious handicap to independent living needing assistance
- Only highly learned/very familiar material retained
SEVERE
- Complete inability to remain new information
- Virtual absence of intelligible ideation
- The mind can no longer tell the body what to do
180
What is Alzheimer's Disease?
- Progressive degeneration of the cerebral cortex leading to widespread cortical atrophy.
- Irreversible global, progressive impairment of brain function, leading to reduced intellectual ability.
- Neurodegeneration in Alzheimer's disease probably begins at least a decade before clinical onset.
181
What are the risk factors of Alzheimer's disease?
- Ageing
- Caucasian
- Family history
- More common in women
- Apolipoprotein E4 variant
- Head injury
182
What are the early symptoms of Alzheimer's disease?
- Memory lapses
- Forgetting names of people and places
- Difficulty finding words for things
- Inability to remember recent events
- Forgetting appointments
183
What are the symptoms of Alzheimer's disease as the disease progresses?
- Difficulties with language
- Apraxia
- Problems with planning and decision making
- Confusion
184
What are the late stage symptoms of Alzheimer's disease?
- Wandering, disorientation
- Apathy
- Psychiatric symptoms, depression, hallucinations, delusions
- Behavioral problems- disinhibition, aggression, agitation
- Altered eating habits
- Incontinence
185
What are the investigations for Alzheimer's disease?
- MRI to exclude other cerebral pathology
- CT: cortical atrophy
- HMPAO hexamethylpropyleneamine oxime
- Single Photon Emission Computed Tomography (SPECT): shows reduced cerebral blood flow in temporal and posterior parietal
The older a person is, the more likely a false positive with CSF examination
186
What is the treatment for Alzheimer's disease?
- AChE: donazepil, galantamine, rivastigmine
- Memantine- second line for MODERATE Alzheimer's disease
- conservative management: support for family and carers, psychoeducation
187
What is vascular dementia?
Group of syndromes of cognitive impairment caused by different mechanisms causing ischemia or haemorrhage secondary to CVD
188
What are the risk factors of vascular dementia?
- History of stroke or TIA
- atrial fibrilation
- Hypertension
- Diabetes mellitus
- Hyperlipidaemia
- Smoking
- Obesity
- Coronary heart disease
- Family history or stroke or cardiovascular disease
189
What is the presentation of vascular dementia?
Deterioration occurs in a gradual stepwise manner
- Difficulty with attention and concentration
- Seizures
- Depression and/or anxiety accompanying the memory disturbance.
- Early presence of disturbance in gait, unsteadiness and frequent, unprovoked falls
190
What is the management for vascular dementia?
- treatment is symptomatic, addressing the individual's main problems and supporting the carers
- NO PHARMACOLOGICAL TREATMENT
Bio: treat reversible causes, consider anticoagulants, consider meds to modify risks
Psycho: emotional support, cognitive rehab, treatment for comorbidities
Social: emotional and family support
191
What is Lewy Body Dementia?
- Types of progressive dementia closely associated with Parkinson's disease primarily affecting older people.
192
What are the core features of Lewy body dementia?
- Marked fluctuating cognition (attention + alertness)
- Spontaneous motor features of Parkinsonism
- 2/3 visual hallucinations
193
What are the additional features of Lewy body dementia?
- Sleep (REM) disorder
- Neuroleptic sensitivity
- SPECT/PET changes
- 2/3 systematized delusions
- recurrent falls, syncope, LOC
194
What are the treatments of Lew body dementia?
- Acetyl Cholinesterase Inhibitors (AChI): Rivastigmine
| - Psychosocial treatment carers
195
What are the subtypes of frontotemporal dementia?
1. Behavioural-variant: frontal lobe= changes in personality, behaviour, interpersonal and executive skills
2. Progressive Non-Fluent Aphasia: temporal lobe= loss of language skills
3. Semantic Dementia: loss of semantic memory: knowledge of things and concepts, based on accumulative experience of the world. Higher brain function.
196
What are the earlier symptoms of frontotemporal dementia?
- Insidious onset and gradual progression
- Early decline in social interpersonal conduct and regulation of personal conduct
- Emotional blunting
- Early loss of insight
197
What are alternative symptoms of frontotemporal dementia?
- Distractibility
- Impulsivity
- Loss of libido
- Sexual disinhibition
- Stereotyped and preservative behaviour
- Hyperorality/Kluver-Bucy syndrome- ingesting inedible objects
198
What are the investigations for frontotemporal dementia?
- sorting tasks
- abstract thinking and proverb
- trail making tests
- MRI
- EEG: normal
- SPECT
199
What are the differential diagnoses associated with frontotemporal dementia?
- Atypical presentations of functional psychiatric disorders
- Atypical Alzheimers disease
- Cerebrovascular disease
- Tumours
- Delirium
200
What is the treatment for frontotemporal dementia?
- Symptomatic- alleviating symptoms
- STOP DRUGS which may be exacerbating memory problems or confusion
- SSRI
- Carer support
201
What is the ICD10 classification for a learning disability?
- IQ < 70
- Loss of ADAPTIVE SOCIAL FUNCTIONING
- Age of onset <18
202
What is NOT a learning disability?
- New LD age >18
- brain injury in accidents >18
- Conditions which affect intellect and which develop > 18
- Specific learning difficulties e.g. dyslexia, delayed speech and language development and literacy problems.
203
What are the degrees of Learning Disability?
MILD (50-69): Language fair: sensory or motor deficits slight, reasonable level of independence.
MODERATE (35-49): Generally better receptive than expressive language
SEVERE (20-34): Increased sensory and motor deficits. 50% will have epilepsy
PROFOUND (<20): Increased need and vulnerability. Developmental level about 12 months
204
What are the causes of learning disabilities?
PRE-NATAL: Genetic or congenital e.g. Down's syndrome, Fragile X, maternal drug or alcohol use, Foetal Alcohol Syndrome
PERINATAL: Oxygen deprivation during birth, injury secondary to birth complications difficulties resulting from premature birth
POSTNATAL: Illnesses, injury or environmental conditions
MULTIPLE CAUSES: a combination of before, during and after birth factors
205
What are the biological factors of a learning disability?
- Genetic vulnerability
- brain damage
- infection
- physical disability
- sensory impairment
- tumours
- medication or physical treatment
206
What are the social factors of a learning disability?
- small circle of friends
- limited opportunity for social outings
- reduced employment opportunities
- lack of finance
- lack of support
- reduced access to transport
- exploitation sexual and financial)
- poor housing
- family attitudes
- lack of choice
207
What are the psychological factors of a learning disability?
- Learning experiences
- Personality
- Separation/loss
- Coping style
- Life event
- Self esteem
- Lack of assertiveness
- Feeling helpless
208
What associated conditions are common with learning disability?
- Depression
- Dementia
- Anxiety
- Psychosis
- Epilepsy
- Challenging behaviour
209
What are examples of class A drugs?
- Heroin
- Ecstasy
- LSD
- PCP
- MDMA
- cocaine
- methamphetamine
- Any class B drug prepared for injections
210
What are examples of class B drugs?
- Cannabis
- Synthetic cannabinoids
- Ketamine
- Mephedrone
- Amphetamine
- Codeine
- Methoxetamine
- Methylphenidate
211
What are examples of class C drugs?
- Khat
- GHB/GHL
- Benzodiazepine
- tramadol
- anabolic steroids
212
What are the effects of alcohol?
GABA AGONIST
- depressant
- relaxed disinhibition
- aggressive
213
What are the withdrawal symptoms associated with alcohol?
- DTs
- sweats
- shakes
- nausea
- wretching
- anxiety
- hallucinations
- seizures
- Wernicke's encephalopathy
214
What are the risks and negative effect of alcohol?
- Hangover
- Accidents
- Overdose, addiction
- Depression
- Anxiety
- Memory problems
- dementia
- psychosis
215
What are the effects of amphetamines?
CLASS B
MONOAMINE AGONIST
- wide awake
- talkative
- reduced hunger/appetite
- more energy
216
What are the withdrawal symptoms associated with amphetamines?
- lethargy
- drowsiness
- poor concentration
217
What are the risks and negative effect of amphetamines?
- Dependency
- insomnia
- poor concentration
- anxiety
- depression
- irritability
- aggression
218
What are the effects of amyl nitrate?
- rush
| - high
219
What are the risks and negative effect of amyl nitrate?
- hypotension
- unconsciousness
- nausea
- headache
- confusion
- arrhythmia
- sudden death
220
What are the effects of benzodiazepines?
CLASS C
GABA AGONIST
- Relaxed
- calm
- less anxious
- sedated
221
What are the withdrawal symptoms associated with benzodiazepines?
- decreased concentration
- tremours
- nausea
- vomiting
- headaches
- anxiety
- panic attacks
- confusion
- depression
- manage with gradual dose reduction
222
What are the risks and negative effect of benzodiazepines?
- respiratory depression
- falls
- hangover
- memory loss
- sedation
- death with injection
223
What are the effects of cannabis?
CLASS B
- Chilled out
- relaxed and happy
- giggles
- very talkative
- hungry
224
What are the withdrawal symptoms associated with cannabis?
- irritability
- mood changes
- feeling sick
- loss of appetite
- difficulty sleeping
- sweating
- shaking
- diarrhoea
225
What are the risks and negative effects of cannabis?
- cravings and psychological dependency
- anxiety
- paranoia
- poor concentration
- poor memory
- apathy
- psychosis
- precipitate
- schizophrenia
226
What are the effects of cocaine?
CLASS A
- Feel on top of the world
- Wide awake
- confident
- reduces hunger
- short acting
227
What are the withdrawal symptoms associated with cocaine?
- low mood
- generally unwell
- psychological dependence
228
What are the risks and negative effects of cocaine?
- tachycardia
- raised temperature
- MI
- heart failure
- hypertension
- seizure
- depression
- anxiety
- panic attacks
- paranoia
229
What are the effects of heroin?
CLASS A
OPIOD AGONIST
- warm feeling
- mild euphoria
- relaxed
- drowsiness
- analgesia
- constricted pupils
230
What are the withdrawal symptoms associated with heroin?
- sweating
- malaise
- anxiety
- depression
- akathisia
- excessive yawning or sneezing
- tears
- rhinorrhoea
- sleep difficulties
- cold sweats
- chills
- severe muscle and bone aches
- nausea, vomiting
- watery eyes
- involuntary limb spasms
231
What are the risks and negative effects of heroin?
- constipation
- addiction/dependency
- respiratory depression
- hallucination
232
What are the effects of GHB/GBL?
CLASS B
GABA AGONIST
- euphoria
- reduced inhibitions
- drowsiness
233
What are the withdrawal symptoms associated with GHB/GBL?
- insomnia
- anxiety
- tremor
- delirium
234
What are the risks and negative effects of GHB/GBL?
- nausea
- dizziness
- drowsiness
- agitation
- visual disturbances
- respiratory depression
- unconsciousness
- coma
- death
235
What are the effects of ketamine?
CLASS B
NMDA ANTAGONIST
- relaxation
- altered bodily sensations
- floating feelings
- dissociation
- altered perceptions
- hallucinations
236
What are the risks and negative effects of ketamine?
- anaesthetic
- ulcerative cystitis
- bladder pain
- memory problems
- dependency panic attacks
- confusion
- agitation
237
What are the effects of LSD?
CLASS A
DOPAMINE (+5HT) AGONIST
- hallucinations
- sensory distortions
- altered perceptions
238
What are the risks and negative effects of LSD?
- fear (bad trips)
- anxiety
- panic
- depression
- flashbacks
- accidents
- psychosis
239
What are the effects of MDMA?
CLASS A
INCREASED SEROTONIN, DOPAMINE, NOREPINEPHRINE
- energised
- happy
- alertness
- increased affection
- chatty
- dilated pupils
240
What are the withdrawal symptoms associated with MDMA?
- lethargy
- depression
- memory problems
241
What are the risks and negative effects of MDMA?
- anxiousness
- panic attacks
- confused episodes
- paranoia
- psychosis
- tachycardia
- hyperpyrexia
- electrolyte disturbance
242
What are the effects of mephadrone?
CLASS B
MONOAMINE AGONIST
- feels alert
- confident
- talkative
- euphoric
- increased affection
- reduced appetite
243
What are the risks and negative effects of Mephadrone?
- nausea
- anxiety
- headaches
- vomiting
- agitation
- hallucinations
- seizures
- reduced peripheral circulation
- epistaxis
- addiction
- paranoia
- self harm
244
What are the effects of Psilocybin mushrooms?
5HT PARTIAL AGONIST
- disorientation
- lethargy
- giddiness
- relaxed
- euphorria
- perceptual and sensory changes
- hallucinations
245
What are the risks and negative effects of Psilocybin?
- poisoning
- death
- nausea
- disorientation
- diarrhoea
- stomach pains
- depression
- anxiety
- paranoia
- panic attacks
246
What is the CAGE screening tool?
1) Cutting down?
2) do you get Annoyed at people commenting on your consumption?
3) do you feel Guilty about the amount you drink?
4) Do you have a drink first thing in the morning Eyeopener?
247
How is substance dependence defined?
```
C= Compulsion
A= withdrAwal
N= Neglect of other activities
T= Tolerance
```
```
S= Stopped you from doing something?
T= prioriTy
O= Out of control
P= Persistent use despite problems
```
248
What is the criteria for dependence (3+ in the last 12 months)?
- Tolerance
- Withdrawal
- Using more or for longer than was intended
- Unsuccessful attempts to reduce use
- Large amount of time spent seeking, using and recovering from use
- Drug use taking priority over social work and recreational activities
- Persistent use despite harm
249
What are the various types of substance disorder?
1. Acute intoxication
2. Harmful use
3. Dependence
4. Withdrawal state
5. Psychotic disorder
6. Amnesic disorder
7. Residual and late onset psychotic disorders
250
What are the drug treatments for substance disorder?
METHADONE
- Synthetic opioid
- Liquid, tablets, injection
- long half life
BUPRENORPHINE
- Semi-synthetic opioid
- agonist opioid receptor modulator
- sub-lingual tablet
- suboxone
LOFEXIDINE
- alpha2-adrenergic receptor agonist
- used to relieve withdrawal symptoms, particularly those cause by noradrenaline
- can be used in conjunction with naltrexone for detox
NALTREXONE
- long acting opiate antagonist
- oral, depot, implant
- blocks euphoric effects, little effect on cravings
251
What are the features of uncomplicated alcohol withdrawal syndrome?
- 4-12 hours after the last alcoholic drink?
- coarse tremor, sweating, insomnia, tachycardia, nausea and vomiting, psychomotor agitation
- transitory visual, tactile or auditory hallucination or illusions
- symptoms increase in severity in rough proportion
- peaking at 48hrs and lasting 2-5 days
TREATED WITH DIAZEPAM 5-10mg
252
What is delirium tremens?
- Acute confusion state secondary to alcohol withdrawal
- a medical emergency requiring inpatient medical care
- clouding of consciousness
- disorientation
TREATED WITH LORAZEPAM 1-3mg
253
What are the long term medications used to treat alcohol withdrawal?
- DISULFIRAM: blocks alcohol metabolism, inducing acetaldehyde accumulation
- ACAMPROSATE: acts on y-aminobutyric acid (GABA) system to reduce cravings and risk of relapse
- NALTREXONE: an opioid-receptor antagonist
- IV PABRINEX then ORAL THIAMINE (used to treat Wernicke-Korsakoff
254
What is neuroleptic malignant syndrome?
Rare but potentially life threatening idiosyncratic reaction to neuroleptic drugs
e.g. haloperidol, fluphenazine
255
What are the four core symptoms of neuroleptic malignant syndrome?
1. FEVER
2. MUSCULAR RIGIDITY (breathlessness, speech, swallowing, walking, tremor, oculogyric crises, chorea, opisthotonus)
3. ALTERED MENTAL STATE (agitation, confusion)
4. AUTONOMIC DYSFUNCTION (fluctuating BP, tachycardia, sweating, incontinence, pallor, salivating, shaking)
256
What are investigations associated with neuroleptic malignant syndrome?
1. Obs, vital signs
2. Bloods and urine
- FBC
- U&E
- LFT
- Lactate
- increased creatinine
- leukocytosis
- urinary myoglobin
3. ECG- diffuse slowing inc. prolonged QT
257
What is the management for neuroleptic malignant syndrome?
1. ABCDE
2. Stop medication
3. Treat symptoms
(IV fluids- 500ml STAT prevent AKI from rhabdomyolysis)
- Rigidity: muscle relaxant: DANTROLENE
- Lorazepam
- Fever: antipyretic
258
What is serotonin syndrome?
- rare but potentially fatal
- initiation or dose increase of serotonin
- onset is usually acute
259
What are the symptoms of serotonin syndrome?
1. Neuromuscular
2. Altered mental state
3. Autonomic dysfunction
260
What is the management for serotonin syndrome?
1. ABCDE
2. STOP medication
3. Gastric lavage/ activated charcoal
4. Rhabdomyolysis
5. Temperature- antipyretics cool down
261
How can you tell the difference between neuroleptic malignant syndrome and serotonin syndrome?
NM: Antipsychotic
S: serotonergic
NM: slow onset
S: rapid onset
NM: slow progression
S: rapid progression
NM: severe muscle rigidity
S: less rigidity
NM: bradykinesia
S: hyperkinesia
262
What are the main principles of the MHA?
1. Least restrictive option and maximizing independence
2. Empowerment and involvement
3. Respect and dignity
4. Purpose and effectiveness
5. Efficiency and equity
263
What are the conditions for a person to be detained under MHA?
- must be suffering from metal disorder AND
- must be at risk to self/others/health/self-neglect AND
- unwilling to go to hospital voluntarily
- all alternatives to detention must have been considered
- recommendations by 2 doctors.
264
What are the main important sections within the mental health act?
SECTION 2- Admission for assessment
SECTION 3- Admission for treatment
SECTION 5- detention of informal patients already in hospital
SECTION 136- mentally disordered persons found in public place
265
What are the features of section 2?
- Mental disorder of a nature or degree, which warrants detention in hospital for assessment
- Interests of patients own health safety with a view to the protection of others
- Requirement: AMHP + 2 doctors
- lasts for up to 28 days
- can be appealed
266
What are the features of section 3?
- Mental disorder of a nature or degree, which makes it appropriate for the patient to receive medical treatment in hospital
- Interests of patients own health safety with a view to the protection of others
- Requirement: AMHP + 2 doctors
- lasts for up to 6 months
- can be appealed (twice within the first 6 months and then yearly after this)
267
What are the features of section 5?
- doctor's holding power
- in patients only
- demonstrate a mental disorder
- patients health
- state why continued informal admission is not possible
- holding power so that a MHA assessment can be carried out
- Lasts up to 72 hours
Section 5(2)
- no rights to treat
- cannot be used to treat physical health problems
- application by consultant in charge of care or nominated deputy must be F2 or above
268
What are the features of section 135?
Warrant to search and remove patient
| - must be mentally disordered and being neglected or unable to care themselves
269
What are the features of section 136?
- Mentally disordered persons in areas that are not private dwellings
- must be a public area
- lasts for up to 24 hours
270
What are the 5 statutory principles of the MCA?
1. A person is assumed to have capacity
2. All practicable steps must be taken to help the person to make a decision
3. Do not treat people as unable to make decisions if they make and unwise decision
4. Any actions or decisions made on behalf of a person who lacks capacity must be in the person's best interests
5. Before acting in a person's best interests it must be established there is no other less restrictive option to achieve the outcome
271
What is STEP ONE in making a decision about a persons capacity?
- Diagnostic test
| - At the time of the decision the person has an impairment of, or disturbance in functioning of, the mind or brain
272
What is STEP TWO in making a decision about a persons capacity?
- can they understand the information relevant to the decision
- can they retain that information (for as long enough to relay their decision back to you)
- can they weigh that information
- can they communicate their decision
273
How to determine somebody's 'best interests':
1) the person's past and present wishes and feelings
2) beliefs and values
3) views of anyone named by the person
4) anyone engaged in caring for the person or interested in their welfare
5) any lasting power of attorney
6) any deputy appointed for the person by the court
7) IMCA
274
What is Lasting Power of Attorney?
Allows a person to stipulate who they would wish to manage their personal welfare decisions, as well as decisions about their finances and property. When capacity is lost.
275
What is the court of protection?
Can be used to make declarations concerning capacity and can appoint deputies to make decisions on behalf of others
276
What is IMCA?
Independent Mental Capacity Advocates: if the person who lacks capacity does not have anyone else to advocate for them, an INCA must become involved if the decision is about 'serious medical treatment'.
277
What are the 5 A’s of Alzheimer’s disease?
- Aphasia
- Amnesia
- Agnosia
- Apraxia
- Associated behaviours
278
Dysthymia:
A chronic state of low mood, usually with an insidious onset and lasting at least 2 years.
279
Euthymia:
Happy, contented mood
280
Mood:
A word used to describe sustained and pervasive emotion
281
Affect:
Short lived observable pattern of behavior that expresses the subjective emotional state of an individual. It is subject to variation over brief periods of time.
282
Alexithymia:
An inability to verbally express one's emotions
283
Anhedonia:
A total inability to enjoy anything in life or even get the accustomed satisfaction from everyday events/objects, a 'loss of ability to experience pleasure'.
284
Psychomotor retardation:
The subject sits abnormally still or walks abnormally slowly or takes a long time to initiate movement.
285
Flight of ideas:
Rapid flow of thought, manifested by accelerated speech with abrupt changes from topic to topic although there is often some form of link between topics. There is loss of the normal structure of thought, appearing illogical or muddled.
Often seen in manic patients
286
Pressure of speech:
The subject talks too much and fast, with a sense of urgency. The speech is often difficult to interrupt.
Often seen in mania
287
Depersonalisation:
A peculiar change in the awareness of self, in which the individual feels as if they are not real and detached
They may feel that they have changed or the world around them is vague, dreamlike or lacking in significance. The subject retains a measure of understanding and knows the condition is abnormal.
288
Derealisation:
An alteration in the perception or experience of the external world so that it seems unreal. the subject may experience everything as colourless and artificial. An office or bus or a street seems like a stage set with actors, rather than real people going about their business. The subject retains a measure of understanding and knows the condition is abnormal.
289
Illusion:
A false perception of a real stimulus. There are three types:
- affect
- completion
- pareidolia
290
Psuedohallucination:
A sensory experience vivid enough to be regarded as a hallucination but recognized by the subject not to be the result of external stimuli and therefore not real.
291
Hallucination:
A perception which occurs in the absence of a stimulus. the perceptual experience is false but to the person experiencing it, has the full force and impact of a real perception and is consequently indistinguishable from a real perception. It occurs in external space and not in the mind's eye.
292
Thought echo:
The subject experiences his own thoughts as if they were being spoken aloud. The repetition may not be a simple echo but subtly or grossly changed in quality
293
Thought insertion:
The subject experiences thoughts which are not his own intruding into his mind. In the most typical case the alien thought are said to have been inserted into the mind from outside, by means of radar telepathy or some other means.
294
Thought withdrawal:
The subject believes that his thoughts have been removed from his mind by an external agency and they have no control over this
295
Thought broadcast:
The subject experiences his thoughts as actually being shared with others, often with large numbers of people. the subject often claims this sharing is via telepathy, radio and television.
296
Delusions of control/passivity:
The subject believes that their thoughts, feelings and/or actions are not their own but are being imposed/ controlled by an outside force.
For example, they may believe that someone else's words are coming out using their voice or the are being made to walk in a certain way.
297
Delusional perception:
The patient receives a normal perception which is then interpreted with delusional meaning and has immense personal meaning.
E.g. on seeing a traffic light change from red to green, a man declared that he was the King of Mars. A type of primary delusion.
298
Negative symptoms:
Describes a cluster of symptoms that often occur together in chronic schizophrenia:
- poverty of speech
- flat affect
- poor motivation
- poor attention
This can result in low activity levels and poor self care
299
Clouding of consciousness:
This represents a step down from normal alertness. There is deterioration in thinking, attention, perception and memory and usually drowsiness and reduced awareness of environment.
300
Lability:
The subject's affect is rapidly changeable and there are marked fluctuations. The subject may be cheerful and smiling, then shortly after- crying.
In it's extreme form this is known as emotional incontinence
301
Delusion:
A fixed firmly held belief that is held with unshakeable conviction despite overwhelming evidence to the contrary and cannot be explained by the subject's cultural or religious background.
302
Nihilistic delusions:
Delusion of extreme negativity- no longer existing, about to die or even being dead, about to experience a terrible doom.
303
Grandiose delusions:
Delusions of being of special status or significance, of having special powers or attributes, or special a mission or purpose.
304
Aphasia:
No speech, inability to produce words orally
305
Concrete thinking:
The inability to understand abstract ideas or concepts. Subjects will be focused on the here and now, physical objects and literal meanings/ definitions
306
2nd person auditory hallucinations:
The subject hears voices which appear to talk to them directly. "You're going to die, you're going to die"
307
3rd person auditory hallucinations:
The subject hears voices talking about him/her, referring to them in the third person. "the voices are talking to each other about me, they say I am evil and mad"
308
Ideas of reference:
A delusional belief that innocuous events or coincidences are directly linked and have persona significances to the subject.
Common clinical examples are subjects believing that the television or radio is talking to or about them.
309
Loosening of associations:
Loss of normal structured thought. The subjects discourse seems muddled and illogical and does not become clearer with further questioning.
As interviewer, it may feel like the more questions asked for clarity- the more difficult it is to understand them.
It is a form of thought disorder
310
Neologisms:
New words that have no real meaning.
311
Perseveration:
The repetition of a particular response (for example a phrase, word, utterance or gesture) despite the absence or cessation of stimulus.
Often seen in organic brain disorders
312
Which class of antidepressant may cause hyponatraemia?
SSRI
313
Which class of antidepressant may cause GI bleeds?
SSRI
314
Which class of antidepressant may cause hypotension, tachycardia, QTc prolongation?
TCA
315
Which class of antidepressant may cause hypertensive crises?
MAOI
316
Which class of antidepressant may cause discontinuation symptoms?
SSRI (and venlafaxine)
317
Which class of antidepressant may cause suicidality?
SSRI
318
Which class of antipsychotic may cause changes to seizure threshold?
Both FGA and SGA
319
Which class of antipsychotic may cause weight gain?
SGA
320
Which class of antipsychotic may cause dyslipidaemia?
SGA
321
Which class of antipsychotic may cause plasma glucose /diabetes disturbances?
SGA
322
Which class of antipsychotic may cause QTc prolongation?
Both FGA and SGA (more FGA)
323
Which class of antipsychotic may cause tardive dyskinesia?
Both FGA and SGA
324
What are the effects of clozapine and carbamazepine?
AGRANULOCYTOSIS (avoid)
325
What are the effects of Risperidone doses >6mg/day?
Decreases tolerability, increases risks of hypertension and seizure
326
What are the effects of an antipsychotic and metoclopramide?
Both dopamine receptor blockers, therefore increased ACh- therefore increased extrapyramidal symptoms (stiffness, rigidity)
327
What are the effects of rapid dose changes of antipsychotics?
decreased tolerability
328
What are the effects of combining IV erythromycin and Quetiapine?
QTc prolongation
329
What are the effects of combining lithium with SSRI?
Can cause mania in those with bipolar due cyclical nature of the disorder (effects of lithium AND antidepressant in a state of mania could lead to hypermania)
Therefore only use short term
330
What are the effects of combining lithium with thiazide diuretics?
- Hyponatraemia
- potential for Li toxicity
- would be better to use loop diuretics as these work on a different part
331
What are the effects of combining lithium with NSAIDs?
- Li toxicity due to reduced clearance (AVOID)
332
What are the side effects of valproate use?
- Gastric irritation (therefore take with food/ try alternative formulation)
- Dose related tremor (titrate dose as necessary)
- Thrombocytopenia (monitor bloods)
- Hair loss with curly regrowth
333
What drugs are compatible with carbamazepine?
- valproate
| - lorazepam (but may need increased dose of lorazepam)
334
What drugs are not compatible with carbamazepine?
- clozapine
- paroxetine (discontinuation symptoms)
- furosemide (hyponatraemia)
- lithium (hyponatraemia)
335
When is it inappropriate to use a hypnotic?
- mild insomnia (try alternate therapies)
- excessive alcohol use (increased sedately effect)
- severe hepatic impairment (may increase levels of hypnotic, as these are usually cleared by the liver)
336
What is the treatment algorithm for antidepressant medication?
1. SSRI
2. Check adherence to meds and SE
3. Dose escalation
4. Switch to different SSRI
5. Switch to different class of drug such as SNRI or Mirtazapine
6. Augmentation e.g. add lithium or antipsychotic or another antidepressant
7. Combinations
