Psychiatry Flashcards
1
Q
what is an Illusion?
A
an illusion is the false perception of a real world stimulus
2
Q
name and describe the three types of Illusions
A
affect- illusion with heightened emotions (EG seeing a tree moving at night and perceiving it as an attacker)
completion- the brain filling in missing parts of an object to create a complete percept
pareidolic- meaningful percepts gathered from unclear stimuli (EG seeing a face in a cloud)
3
Q
what is a hallucination?
A
a hallucination is a false internal percept with no external stimulus. It is experienced by someone in the same way a real percept is experienced.
4
Q
name four characteristics of a hallucination?
A
- perceived in external space
- different from imagined images
- out of the control of the patient
- has relative permanence
5
Q
what is a pseudo-hallucination?
A
a hallucination that lacks one of the four values-
- perceived in external space
- different from imagined images
- out of the control of the patient
- has relative permanence
6
Q
what is an over-valued idea?
A
an abnormal belief. These beliefs are usually quite reasonable and understandable but dominate the patients life disproportionately
7
Q
what is a delusion?
A
an abnormal belief that is held with absolute certainty. It is held when there is contradictory evidence and no supporting evidence and is important to the patient.
8
Q
what are primary and secondary delusions?
A
primary delusions- a direct result of psychopathology
secondary delusions- a product of an underlying psychiatric disorder (EG a person with depression developing delusions of poverty)
9
Q
what is a delusional perception?
A
a delusions arising from a real perception (EG a person seeing a pigeon in their garden and being convinced that pigeon has a camera in it)
10
Q
what is concrete thinking?
A
a thought process entirely focused on reality and the physical world. Takes things literally and focuses on facts, objects and literal definitions
11
Q
what is loosening of association?
A
a symptom of a formal thought disorder where there a lack of connection between sequential thoughts
12
Q
what is circumstantiality?
A
a symptom of thought disorder where irrelevant details and tangents steer the direction of the conversation and thought process, even if the patient gets around to the answer. Can be seen in mania.
13
Q
what is perseveration?
A
where a verbal response or action which was appropriate initially is continue past the point of being appropriate (EG giving the same answer to two questions where it was only the answer to the first)
14
Q
what is confabulation?
A
the process of describing fake memories in a period of time when the patient had amnesia.
15
Q
what is somatic passivity?
A
where the patient believes that sensations are imposed by an outside force (EG picking up a cup)
16
Q
what is pressure of speech?
A
a speech pattern caused by pressure of thought. the speech is hard to interrupt, rapid, and in more complex cases involves a loosening of association
17
Q
what is anhedonia?
A
absent or significantly decreased enjoyment in activities that used to be pleasurable. a core depressive symptoms and a negative symptom of schizophrenia
18
Q
what is incongruity of affect?
A
the objective impression that the displayed emotion is not the same as the the current thoughts or actions. occurs in schizophrenia
19
Q
what is blunting of affect?
A
the person does not show the normal degree of emotional response and can lose the sense of what emotional response is appropriate to events. a negative symptom of schizophrenia
20
Q
what is belle indifference?
A
a rare and non-specific symptom that does not hold any diagnostic significance, but describes a surprising lack of concern or denial of severe functional disability. not specific to psychiatry
21
Q
what is depersonalisation?
A
a subjective experience where a person feels like things are not real, can occur in many psychiatric disorders and in the normal population
22
Q
what is thought alienation?
A
where a person believes that their thoughts are no longer under their control and are being controlled by something external. a 1st rank symptom of schizophrenia
23
Q
what is thought insertion?
A
a belief that thoughts are being placed into the persons head by an external force. a 1st rank symptom of schizophrenia
24
Q
what is thought withdrawal?
A
a belief that thoughts are being taken from the persons head by an external force. a 1st rank symptom of schizophrenia
25
what is thought broadcast?
a belief that a persons thoughts are accessible by other people. a 1st rank symptom of schizophrenia
26
what is thought echo?
an auditory hallucination where the content is the individuals current thoughts that repeat. a 1st rank symptom of schizophrenia
27
what is thought block?
where a person experiences a sudden break in the train of thought that they might attribute to thought withdrawal. without attributing it to thought withdrawal, it is NOT a 1st rank symptom of schizophrenia
28
what is akathisia?
a subjective sense of a desire to move that can be uncomfortable, relieved when the affected part of the body is moved, which is usually the legs. can be a side effect of neuroleptic/anti-psychotic drugs
29
what is clouding of consciousness?
a consciousness level somewhere between full consciousness and a coma, covers a range of loss of function with drowsiness and impaired perception and concentration
30
what is catatonia?
increased resting muscle tone not present on active or passive movement. a motor symptom of schizophrenia
31
what is a stupor?
absence of movements and speech when there is no impairment to consciousness. can be attributed to many different psychiatric diagnoses or be organic and caused by a midbrain lesion
32
what is psychomotor retardation/ slowing?
decreased spontaneous movement and more difficulty starting and completing movements. usually associated with thinking actions take more effort and slowing of thought. occurs in depressive illnesses
33
what is flight of ideas?
a subjective experience of thoughts being more rapid and having more tangents and related thoughts that normal, however there is no loosening of association intrinsically
34
what is a formal thought disorder?
1. all pathological disturbance in the form of thought
2. a synonym for schizophrenic thought disorder
3. 1st rank symptoms that are delusions regarding thought interference.
the first is usually the preferred definition.
35
what is derealisation?
a subjective experience where the patient feels as if the world has become unreal, and can be associated with changes in the perception of size, colour and shape
36
what is conversion?
the development of features that suggest a physical illness but the cause is psychiatric illness or emotional disturbance
37
what is dissociation?
separating unpleasant emotions and memories from conscious awareness with a related disruption to the normal integration of consciousness and memory. association with conversion but where conversion produces physical symptoms as a response to unpleasant emotions and memories, dissociation involves an impairment of mental functioning as an escape
38
what are mannerisms?
abnormal or bizarre performance of voluntary, goal-directed activity (EG walking strangely)
39
what is stereotyped behaviour/ stereotypy?
a repetitive and bizarre movement that is not goal-directed and may have a delusional significance to the patient (EG rubbing hands together). occurs in schizophrenia.
40
what is an obsession?
an idea, image or impulse recognised as the patients own, but which is experience intrusively and repetitively and is accompanied by anxiety if prevented which can be relieved by compulsions. often associated with the idea that something bad will happen if they don't act on the obsession
41
what is a compulsion?
a behaviour or action recognised as unnecessary or purposeless but the person cannot resist performing repetitively. the drive to perform a compulsion is an obsession
42
define dementia
a syndrome characterised by progressive , usually irreversible, global cognitive deficits.
43
name 7 signs/ symptoms of dementia
1. memory problems
2. dysphasia- deficient generation of speech
3. agnosia- unable to interpret sensations and recognise things
4. apraxia- difficulty in motor planning to perform functions
5. impaired executive functioning
6. personality disintegration
7. delusions and hallucinations
44
what are the 3 most common causes of dementia?
1. Alzheimer's disease 55%
2. vascular dementia 20%
3. reversible causes
15% (subdural, NPH, B12 deficiency, hypothyroid)
45
name 4 differential diagnoses for dementia
1. delirium
2. depression
3. amnestic disorders
4. normal ageing
46
what investigations should be included for dementia?
FBC, LFT, U+E, glucose, ESR, TSH, calcium, magnesium, phosphate, HIV, B12, folate, blood culture
47
name 3 cognitive enhancement treatments for dementia
1. acetylcholinesterase inhibitors (donepezil, rivastigmine)
2. antioxidants (Vit E)
3. hormonal (oestrogen, HRT)
48
how do you medically treat psychosis/ agitation in dementia?
consider antipsychotics (olanzapine, clozapine, risperidone, aripiprazole ETC)
49
how do you medically treat depression/ insomnia in dementia?
SSRI's (citalopram, sertraline)
| hypnotic/ sedative drugs
50
what are 3 risk factors for alzheimer's disease?
1. down's syndrome
2. head injury
3. hypothyroidism
51
what are 3 protective factors from Alzheimer's disease?
1. smoking
2. oestrogen
3. NSAIDS
52
explain the pathophysiology of Alzheimer's disease with 3 key points
1. amyloid plaques in hippocampus, amygdala and cerebral cortex.
2. neurofibrillary tangles in the cortex, hippocampus and substantia nigra.
3. loss of neurones and synapses in the cortex and hippocampus (up to 50%)
53
name 3 factors associated with poor prognosis in Alzheimer's disease
1. male
2. onset <65 y/o
3. parietal lobe damage
54
describe 3 features seen on brain imaging with Alzheimer's disease
1. CT- cortical atrophy especially parietal and temporal
2. MRI- atrophy of grey matter (hippocampus, amygdala and temporal lobes)
3. reduced blood flow and oxygen in parietal lobes
55
describe 6 important assessments for Alzheimer's disease
1. mental state exam
2. cognitive testing
3. physical examination
4. blood tests
5. EEG
6. brain imaging
56
name 4 medications that can be used to treat Alzheimer's disease
1. donepezil (AChEI)
2. rivastigmine (AChEI)
3. galantamine (AChEI)
4. memantine (NMDA receptor antagonist)
57
name 3 common symptoms of lewy body dementia
1. dementia
2. parkinsonism (70%)
3. hallucinations are more common
58
describe the pathophysiology of lewy body dementia
lewy bodies are abnormally phosphorylated neurofilament proteins which will be found in brainstem nuclei (particularly basal ganglia), paralimbic and neocortical structures. vascular disease in 30%
59
how do you treat lewy body dementia?
antipsychotics can be used very cautiously as there are severe sensitivity reactions in 40-50%. AChEI's not yet recommended. cautiously use anti-parkinsonian medication.
60
what is the diagnostic criteria for lewy body dementia?
progressive cognitive decline sufficient enough to impair functioning with 2 of-
1. fluctuating congition, attention and alertness
2. recurrent well formed, detailed visual hallucinations
3. spontaneous motor features of parkinsonism.
61
what is the diagnostic criteria for Alzheimer's disease?
1. presence of dementia (deficits in 2 of cognition, progressive deterioration, no consciousness change, age 40-90, absence of systemic disorder)
2. supported by-progressive deterioration, worsened ADL's, family Hx, normal lumbar puncture and EEG, and evidence of atrophy on CT scan
3. consistent features-plateaus in course, psychiatric symptoms, neurological signs, seizures, normal CT
4. definite diagnosis is criteria 1-3 is filled and there is histological evidence of the disorder
62
what is the diagnostic criteria for fronto-temporal dementia/ pick's disease?
1. insidious onset and progression
2. early decline in interpersonal conduct
3. early emotional blunting
4. early loss of insight
supportive features-
1. behavioural disorder (decline in hygiene, mental rigidity, distractible, perseverative)
2. speech and language changes (altered output, stereotypy of speech, perseveration, mutism, repetition of others)
3. physical signs (primitive reflexes, incontinence, akinesia, rigidity, tremor, low and labile blood pressure)
63
describe 3 investigations and findings that can be done in fronto-temporal dementia/ pick's disease
1. neuropsychological- impairment in frontal love, absence of amnesia, aphasia
2. EEG- normal with conventional testing despite evident dementia
3. brain imaging- predominant frontal and temporal abnormalities
64
describe the pathophysiology of fronto-temporal dementia/ pick's disease
atrophy of the frontal and temporal lobes. degeneration of the striatum.
common fronto-temporal (60%)- loss of large cortical nerve cells and spongiform degeneration
pick's disease (25%)- loss of large cortical nerve cells, gliosis, minimal spongiform changes, tau and ubiquitin presence
65
how do you treat fronto-temporal dementia/ pick's disease?
no specific treatments, however SSRI's might be able to help behavioural symptoms. AChEI's unlikely to help as the cholinergic system is not abnormal.
66
describe the three syndromes of vascular dementia
1. deficits following a single stroke- depend on site of stroke, cognitive deficits worse with midbrain and thalamic strokes. can recover.
2. multi-infarct dementia- stepwise deterioration in cognition with multiple strokes. often risk factors for CVD.
3. progressive small-vessel disease- microvascular infarcts of perforating vessels causing lacunae formation and white matter leukoariosis. subcortical dementia.
67
name 4 risk factors for vascular dementia?
1. cardiovascular disease
2. smoking
3. diabetes mellitus
4. hypertension
68
what are the clinical features of vascular dementia?
emotional and personality changes are early and followed by cognitive deficits that fluctuate in severity. depression and anxiety can occur. 10% can have seizures. course is stepwise
69
what investigations should be done vascular dementia?
1. routine dementia screen
2. ECG, CXR, CT and MRI essential
3. serum cholesterol, clotting and vasculitis screens in unusual cases
4. can do echocardiography and carotid artery doppler ultrasound
70
how do you treat vascular dementia?
1. establish the causative factors
2. treat medical or surgical diseases that may be contributing
3. daily aspirin can delay course
4. change diet, stop smoking, manage hypertension
71
what is normal pressure hydrocephalus?
a syndrome where there is dilation of the cerebral ventricles, especially the 3rd ventricle, and normal cerebrospinal fluid pressure when a lumbar puncture is taken
72
what causes normal pressure hydrocephalus?
50% idiopathic
| 50% mechanical obstruction of CSF flow across the meninges- meningitis, SAH, trauma, radiotherapy
73
what are the clinical features of normal pressure hydrocephalus?
triad of dementia, gait ataxia and urinary incontinence. dementia can be reversible
74
what investigations can diagnose normal pressure hydrocephalus?
1. CT scan shows increased size of lateral ventricles and thinning of the cortex
2. 24 hour intracranial pressure monitoring shows 'beta' pattern
75
how do you treat normal pressure hydrocephalus?
ventriculo-peritoneal shunt when secondary to mechanical obstruction
76
how common is HIV-associated dementia in the +ve population?
30% at some point develop HAD, 90% have CNS changes post mortem, and 70-80% develop a cognitive disorder
77
what is the pathophysiology of HIV-associated dementia?
1. direct CNS infection resulting in neuronal death and increase apoptosis in the basal ganglia, and subcortical and limbic white matter
2. opportunistic infections and tumours such as toxoplasmosis, herpes simplex virus, Hodgkin's lymphoma, cytomegalovirus
78
what is the clinical presentation of HIV- associated dementia?
can have early cognitive disorder due to direct CNS infection involving cognitive and motor slowing and memory deficits. full blown HAD has cognitive (sub-cortical dementia, amnesia, mutism), motor (tremor, ataxia, chorea), and affective (depression, apathy, agitation, disinhibition) characteristics.
79
what investigations must be done in HIV-associated dementia, and what will be seen?
1. CT/MRI- atrophy
2. CSF testing- opportunistic infection
3. EEG- generalised slowing
80
how do you treat HIV-associated dementia?
reverse transcriptase inhibitor Zidovudine can delay HAD progression, and protease inhibitors can reduce HIV load
81
what is the clinical presentation of Creutzfeldt-Jakob disease?
1. 50-70 years old
2. rapidly progressive dementia
3. cerebellar and extrapyramidal signs
4. myoclonus
82
what is the prognosis of CJD?
death within a year
83
what are 3 causes of CJD?
1. spontaneous development (80%)
2. genetic mutation (10%)
3. iatrogenic transmission due to dura transplant, corneal grafts and pituitary growth hormone (5%)
84
what investigations must be done in CJD and what will be seen?
1. EEG- periodic complexes
| 2. CT- atrophy of cortex and cerebellum/ generalised atrophy
85
what is a prion disease?
a rapidly progressive, dementing disease caused by deposition of prion proteins throughout the brain
86
what is the cause of new variant Creutzfeldt-Jakob disease?
consuming cattle with brain matter that contains bovine spongiform encephalopathy
87
what is the clinical presentation of new variant Creutzfeldt-Jakob disease?
1. mainly young people in their 20's
2. early anxiety and depressive symptoms
3. personality changes
4. progressive dementia
5. ataxia and myoclonus can develop
6. death in 1-2 years
88
describe delirium?
a clinical syndrome of fluctuating cognitive impairment with behavioural abnormalities
89
list the 7 most common causes of delirium
```
P- pain
I- infection
N- nutrition
C- constipation
H- hydration
M- medication
E- environmental
```
90
name the three types of delirium
1. hyperactive delirium
2. hypoactive delirium
3. mixed delirium
91
what are 3 clinical signs of hyperactive delirium?
1. psychomotor agitation
2. increased arousal
3. inappropriate behaviour
92
what are 3 clinical signs of hypoactive delirium?
1. psychomotor retardation
2. decreased arousal
3. excess sleepiness
93
what are 3 differentials for delirium?
1. mood disorder
2. dementia
3. post-ictal behaviour
94
what are 3 substances that can cause delirium?
1. alcohol
2. benzodiazepines
3. psychotropics
95
what are 3 metabolic causes of delirium?
1. anaemia
2. hepatic encephalopathy
3. cardiac failure
96
what are three endocrine causes of delirium?
1. pituitary dysfunction
2. thyroid dysfunction
3. hypoglycaemia
97
what are three at risk groups for delirium?
1. elderly
2. very young
3. alcohol dependents
98
what are three organic causes of delirium?
1. frontal lobe syndrome
2. complex partial seizures
3. endocrine disorders with psychiatric symptoms
99
what are the 4 principles of management of delirium?
1. identify and treat cause and worsening factors
2. environmental and supportive measures
3. avoid sedation unless severely agitated
4. regular clinical reviews and follow ups
100
what are the 8 principles of dependence syndrome?
1. drug-seeking
2. narrowing drug range
3. tolerance
4. no control
5. withdrawal
6. avoiding withdrawal
7. use despite consequences
8. rapid relapses
101
what are the 6 stages of change relating to addiction?
1. pre-contemplation
2. contemplation
3. decision
4. action
5. maintenance
6. potential relapse
102
what is delirium tremens?
an acute confusional state secondary to alcohol withdrawal
103
how often does delirium tremens occur?
in 5% of withdrawals
104
what is the clinical presentation of delirium tremens?
1. clouded consciousness
2. disorientation
3. amnesia
4. agitation
5. visual, auditory and tactile hallucinations
6. fluctuation in severity, usually worse at night
7. in severe cases, increased temperature, sweaty and cardiac collapse
105
what is the mortality of delirium tremens?
5-10%
106
how do you treat delirium tremens?
reducing regime of chlordiazepoxide and pabrinex (vitamin b,c)
107
what are 2 examination findings in alcoholic dementia?
1. cortical atrophy
| 2. ventricular enlargement
108
what are the 4 clinical features of wernicke's encephalopathy?
```
acute onset of-
1. acute confusional state
2. ophthalmoplegia
3. nystagmus
4. ataxic gait
(ataxia, neuropathy and nystagmus can be permanent)
```
109
what is the most common cause of ophthalmoplegia in wernicke's encephalopathy?
6th nerve palsy
110
what is the aetiology of wernicke's encephalopathy?
deficiency in vitamin B/ thiamine. heavy drinkers are vulnerable due to reduced intake, absorption and hepatic storage. anorexia also vulnerable
111
what is the pathophysiology of wernicke's encephalopathy?
haemorrhages caused by gliosis in grey matter
112
how do you treat wernicke's encephalopathy?
1. intravenous pabrinex
| 2. thiamine to prevent in alcoholics
113
what is Korsakoff psychosis?
impaired ability to form new memories with retrograde amnesia
114
what is the aetiology of Korsakoff psychosis?
thiamine deficiency secondary to heavy alcohol misuse, head injury, anaesthesia, encephalitis, CO poisoning
115
how do you treat Korsakoff psychosis?
oral thiamine replacement for up to 2 years
116
what are the effects of taking heroin?
1. euphoria
2. relaxation
3. forgetting worries
117
what is the clinical presentation of a heroin overdose?
1. nausea and vomiting
2. constipation
3. respiratory depression
4. loss of consciousness with aspiration
5. abscesses if injected
118
what is the clinical presentation of heroin withdrawal?
1. sweating
2. dilated pupils
3. tachycardia
4. goose flesh
5. cramping
6. nausea and vomiting
119
how do you treat heroin withdrawal?
1. lofexidine (alpha adrenergic agonist)
2. loperamide (anti-constipation)
3. metoclopramide (anti-emetic)
120
what are the effects of taking benzodiazepines?
1. reduced anxiety
| 2. euphoria
121
what is the clinical presentation of a BDZ overdose?
1. forgetfulness
2. drowsiness
3. impaired concentration and coordination
122
what is the clinical presentation of BDZ withdrawal?
1. anxiety
2. insomnia
3. tremor
4. agitation
5. headache
6. nausea
7. sweating
8. seizures
9. depersonalisation
123
what are the effects of taking cocaine?
1. increased energy
2. increased confidence
3. euphoria
4. diminished need for sleep
124
what is the clinical presentation of a cocaine overdose?
1. arrhythmias
2. intense anxiety
3. hypertension
4. impulsivity
5. impaired judgement
125
what are the effects of taking amphetamines?
1. increased energy
2. increased confidence
3. euphoria
4. diminished need for sleep
5. longer acting than cocaine
126
what is the clinical presentation of an amphetamine overdose?
1. tachycardia
2. arrhythmias
3. hyperpyrexia
4. irritability
5. depression
6. quasi-psychotic state
127
what are the effects of ecstasy?
1. increased closeness to other people
2. a pleasurable agitation relieved by dancing
3. decreased fatigue
128
what is the clinical presentation of an ecstasy overdose?
1. sweating
2. nausea and vomiting
3. deaths have occurred associated with hyperthermia and dehydration
129
what are the effects of LSD?
1. situation and expectation dependant
2. initial euphoria and detachment
3. visual distortions
4. synaesthesia
5. NO RISK OF OVERDOSE! but can trigger psychiatric disorders
6. magic mushrooms produce a similar effect
130
what are the effects of taking cannabis?
1. mild euphoria
2. increased appetite
3. enhanced sensation
4. relaxation
5. altered sense of time
131
what are the effects of a cannabis overdose?
1. mild paranoia
2. panic attacks
3. accidents associated with delayed reaction time
132
what are the chronic harmful effects of cannabis?
1. amotivational syndrome
2. anxiety and depression
3. can precipitate an episode or a relapse of schizophrenia
133
what is anorexia nervosa?
pathological desire for thinness and self-induced weight loss by a variety of methods
134
what are the 5 diagnostic criteria for anorexia nervosa?
1. BMI 17.5 or less
2. self induced weight loss
3. body image distortion
4. endocrine disorders
5. delayed puberty
135
what are some differentials of anorexia nervosa?
1. chronic debilitating physical disease
2. brain tumour
3. GI disorder such as malabsorption
4. loss of appetite
5. depression/ OCD
136
how do you calculate BMI?
BMI= weight in kilos/ height in metres ^2
137
what are some cardiac problems in anorexia nervosa?
1. hypotension
2. prolonged QT
3. arrhythmias
4. cardiomyopathy
138
what are some endocrine and metabolic problems in anorexia nervosa?
1. hypokalaemia
2. hyponatraemia
3. hypoglycaemia
4. hypothermia
5. altered thyroid function
139
what are some dermatological problems in anorexia nervosa?
1. dry scaly skin
2. brittle hair
3. lanugo body hair
140
what are some neurological problems in anorexia nervosa?
1. peripheral neuropathy
2. loss of brain volume
3. ventricular enlargement
4. cerebral atrophy
141
what are some haematological problems in anorexia nervosa?
1. anaemia
2. leukopenia
3. thrombocytopenia
142
what is the most common pathological cause of death in anorexia nervosa?
cardiac complications, often significant bradycardia and hypotension
143
what skeletal problem can occur in anorexia nervosa and how are they treated?
osteopenia, supplement with calcium and vitamin D
144
how do you assess anorexia?
1. full psychiatric history- concentration, irritability, low self esteem, loss of appetite
2. full medical history- weight changes, dietary patterns and exercise
3. physical examination- weight and height, physical signs of starvation and vomiting, blood tests, ECG
145
how do you treat anorexia nervosa?
1. pharma- fluoxetine
2. psych- family therapy, individual therapy
3. education- nutrition education and self help manuals
4. hospital admission with serious medical problems
146
what is the clinical presentation of refeeding syndrome and why is it dangerous?
excessive bloating, oedema, occasionally congestive heart failure. the body has adapted to a lower cardiac demand so refeeding increases the demand and can result in cardiac decompensation
147
how do you prevent refeeding syndrome?
1. measure U+E's and correct abnormalities before refeeding
2. recheck every 3 days for a week then weekly
3. increase intake slowly
4. monitor patient for tachycardia or oedema
148
what are 3 poor prognostic factors for anorexia nervosa?
1. chronic illness
2. late age of onset
3. bulimic features
149
what is bulimia nervosa?
recurrent episodes of binge eating, with compensatory behaviours, and overvalued ideas about the ideal body shape and weight. often a past history of anorexia nervosa
150
what are the 5 diagnostic criteria for bulimia nervosa?
1. preoccupation with eating
2. craving for food
3. binges
4. attempts to counter the fattening effect
5. morbid dread of fatness
151
what is the clinical presentation of bulimia nervosa?
1. arrhythmias
2. cardiac failure
3. low potassium, sodium and acidosis
4. oesophageal erosions
5. perforation
6. gastroduodenal ulcers
7. pancreatitis
8. constipation
9. dental erosions
152
what are some differentials for bulimia nervosa?
1. upper GI disorders with vomiting
2. brain tumours
3. causes of recurrent overeating
153
how do you treat bulimia nervosa?
1. usually managed as an outpatient
2. high dose SSRI (fluoxetine)
3. CBT, IPT (interpersonal therapy) guided self help
4. admission only for suicidality, increased physical problems or pregnancy
154
what are the SCOFF screening questions for eating disorders?
S- do you make yourself Sick because you feel 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 think you are Fat when others say you are too thin?
F- would you say that Food dominates your life?
155
what is insomnia?
trouble falling asleep, maintaining sleep, or poor quality of sleep 3 days a week for a month. individuals are preoccupied with and distressed by sleep
156
what are three intrinsic causes of insomnia?
1. psychophysiological insomnia
2. restless leg syndrome
3. sleep apnoea syndrome
157
what are three extrinsic causes of insomnia?
1. inadequate sleep hygiene
2. environmental sleep disorder
3. adjustment sleep disorder
158
what are three medical causes of insomnia?
1. pain
2. respiratory disorders
3. diabetes
159
what are three psychiatric causes of insomnia?
1. depression
2. bipolar affective disorder
3. anxiety disorder
160
what are some of the important steps in the management of insomnia?
1. identify underlying problem
2. education
3. sleep hygiene measures
4. relaxation training
5. sleep restriction
6. hypnotic drugs
161
what are the ICD-10 1st rank symptoms of schizophrenia?
1. thought echo, insertion, withdrawal or broadcast
2. delusions of control, influence or passivity
3. 3rd person auditory hallucinations
4. any other persistent delusion
162
what are the ICD-10 2nd rank symptoms of schizophrenia?
1. any hallucination
2. incoherent speech
3. excitement, posturing, negativity, mutism or stupor
4. apathy, paucity of speech, blunting of affect
5. change in personal behaviour
163
what are the DSM-IV 1st rank criteria for schizophrenia?
2 of the following-
1. delusions
2. hallucinations
3. disorganised speech
4. disorganised or catatonic behaviour
5. negative symptoms
or only one if the delusions are bizarre or hallucinations are 3rd person
164
what are the DSM-IV 2nd rank criteria for schizophrenia?
social/ occupational dysfunction for 6 months
165
name 3 differentials for schizophrenia
1. substance induced psychosis
2. psychosis due to general medical condition such as head injury
3. mood disorders with psychotic features (psychotic features usually mood congruent)
166
what are two aetiological theories of schizophrenia?
1. dopaminergic overactivity- antipsychotics are DA receptor antagonists
2. glutaminergic hypoactivity- NMDA receptor antagonists like ketamine can induce psychotic symptoms
167
what is the estimated heritability of schizophrenia?
60-80%
168
what are 3 environmental factors that put someone at risk of schizophrenia?
1. complications of pregnancy
2. delayed neurodevelopment
3. disturbed childhood behaviour
169
what blood tests should be done for schizophrenia?
U+E, LFT, calcium, FBC, glucose
170
what is the treatment for acute psychosis?
1. attempt to diffuse situation
2. atypical antipsychotic (olanzapine, amisulpride, risperidone, quetiapine)
3. long acting BDZ (diazepam) to control non-acute anxiety and behavioural disturbance
171
list 5 conventional antipsychotics
1. chlorpromazine
2. promazine
3. haloperidol
4. pericyazine
5. thioridazine
172
list 5 atypical antipsychotics?
1. olanzapine
2. risperidone
3. amisulpride
4. aripiprazole
5. clozapine
173
what are three extrapyramidal side effects of antipsychotics?
1. acute dystonia
2. parkinsonism
3. akathisia
174
what are three non-extrapyramidal side effects of antipsychotics?
1. weight gain
2. sedation
3. sexual dysfunction
175
what is the most commonly used medication for treatment resistant schizophrenia?
clozapine (atypical)
176
what are the key symptoms of paranoid schizophrenia?
1. paranoid delusions
| 2. hallucinations
177
what are the key symptoms of hebephrenic / disorganised schizophrenia?
1. disorganised speech and behaviour
| 2. flat or inappropriate affect
178
what are the key symptoms of catatonic schizophrenia?
1. psychomotor disturbance
179
what are the key criteria for residual schizophrenia?
1. previous positive symptoms that are less marked
| 2. current prominent negative symptoms
180
what are the key symptoms of simple schizophrenia?
1. no delusions or hallucinations
| 2. gradual rise of negative symptoms without an acute episode
181
what is schizoaffective disorder?
a disorder with features of both affective disorder and schizophrenia in roughly equal proportion
182
what is the ICD-10 criteria for schizoaffective disorder?
1. schizophrenic and affective symptoms present
| 2. excludes patients where the separate episodes are due to substance use or medical disorders
183
what is the DSM-IV criteria for schizoaffective disorder?
1. major depressive, manic or mixed episode alongside 1st rank schizophrenic symptoms
2. >2 weeks of delusions and hallucinations with less prominent mood symptoms
3. mood symptoms present for a majority of the time for active and residual periods
4. excludes substance or medical condition induced symptoms
184
what is the treatment for schizoaffective disorder?
as for schizophrenia but treat manic and depressive symptoms like in bipolar (antipsychotics, antidepressants, lithium ETC)
185
what is delusional disorder?
patients present with non-bizarre delusions, but no prominent hallucinations, mood disorder, thought disorder or flattening of affect. symptoms for 1 month (DSM) or 3 months (ICD)
186
what is the difference between a delusion and an over-valued idea?
a delusion in unshakeable but an over-valued idea can be challenged
187
what are 3 risk factors for delusional disorder?
1. advanced age
2. social isolation
3. low socio-economic status
4. sensory impairment (particularly deafness)
188
what is an erotomanic delusion?
a delusion that some important person is secretly in love with them
189
what is a grandiose delusion?
a delusion where the person believes they hold a special purpose, have a special relationship, or a special ability. might be involved with a social or religious organisation
190
what is a delusion of jealousy?
a delusion where a person possesses the belief that their partner has been unfaithful and may try to collect evidence or restrict their partners activities
191
what is a persecutory delusion?
a delusion where the person believes they are in danger of harm, often attempting to obtain legal recourse
192
what is a somatic delusion?
a delusion where a patient believes they have a body infestation, deformity, odour ETC and routinely visit physicians
193
what are 3 differentials for delusional disorder?
1. substance induced delusional disorder
2. mood disorders with delusions
3. schizophrenia
194
how do you treat delusional disorder?
1. gather information and exclude underlying causes
2. admission if clear risk of violence or self harm
3. antipsychotics have some use
4. SSRI's can be effective
5. BDZ's with marked anxiety
6. individual therapy and supportive therapy
195
what are acute and transient psychotic disorders?
sudden onset, variable presentations of psychosis usually resolving within less than 1 month (DSM) or 3 months (ICD)
196
what is the clinical presentation for acute and transient psychotic disorders?
1. psychotic symptoms
| 2. often perplexity, inattention, thought disorder, delusions, hallucinations, and disorganised/ catatonic behaviour
197
what are 3 differentials for acute and transient psychotic disorders?
1. dementia/ delirium
2. bipolar affective disorder (delusions of guilt and persecution)
3. drug or alcohol abuse
198
how do you treat acute and transient psychotic disorders?
1. assessment to make appropriate diagnosis
2. short-term admission to provide support, nursing care and assistance
3. short-term use of BDZ/ anti-psychotics
4. antidepressants/ mood-stabilisers can prevent relapse or further episodes
199
what is post-partum psychosis?
an acute psychotic episode that occurs at peak 2 weeks after giving birth
200
what is the clinical presentation of post-partum psychosis?
1. 80% prominent affective
2. 15% schizophreniform disorder
3. 5% acute organic psychosis
lability of symptoms, insomnia, bewilderment, thoughts of suicide
201
how do you treat postpartum psychosis?
1. admission to hospital, ideally a specialist mother-baby unit
2. ECT and mood stabilisers for prominent affective disorder
3. antipsychotics for psychotic symptoms
4. antidepressants for depressive symptoms
202
what is hypomania?
three or more symptoms of hypomania that are present for at least 4 days and are clearly different from normal behaviour, but not significant enough to be mania
203
what are 5 symptoms of hypomania?
1. elevated or irritable mood
2. increased energy
3. marked feeling of wellbeing
4. increased self esteem
5. overfamiliarity
204
what are 3 differentials of hypomania?
1. agitated depression
2. OCD/ anxiety disorder
3. substance misuse
205
how do you treat hypomania?
1. exclude other causes with investigations
2. address psychosocial stressors
3. hypnotics if there is sleep disturbance
4. possible mania medication if the episode is prolonged (potentially lithium or anti-psychotics)
206
what is mania?
distinct period of abnormally persistently elevated/ irritable mood, with 3 or more mania symptoms. the episode should last 1 week or more
207
what are 5 symptoms of mania?
1. increased energy (can manifest as pressured speech, racing thoughts)
2. increased self esteem (grandiosity, ideation, reduced inhibitions)
3. increased distractibility
4. increased risk-taking behaviour
5. excitement
208
what are 3 psychotic symptoms of mania?
1. grandiose delusions
2. speech so pressured it becomes incomprehensible
3. total loss of insight
209
what are 3 differentials of mania?
1. schizophrenia
2. anxiety disorder
3. substance misuse
210
what are three classes of medication that can induce mania/ hypomania?
1. antidepressants
2. anti-psychotics (olanzapine, risperidone)
3. anti-parkinsonian medications (levodopa, bromocriptine)
211
what are the three classes of medication that are 1st line for an acute manic episode?
1. lithium- response rate of 80%, may take 2 weeks to function
2. anti-psychotics- haloperidol, chlorpromazine. can control agitation and may be necessary to tide over until lithium works.
3. benzodiazepines- lorazepam and clonazepam. can reduce the use of anti-psychotics to sedate the patient.
212
what clinical procedure can be performed to treat acute mania and when would this be performed?
electroconvulsive therapy in instances where the patient cannot take medication such as pregnancy
213
what are two medications that are 2nd line treatments for acute mania?
1. carbamazepine
| 2. sodium valproate
214
what is the criteria for bipolar spectrum disorder?
one major depressive episode and no spontaneous mania/ hypomania and one other bipolar spectrum criteria (family hx, hyperthymia, antidepressant induced mania, brief or recurrent depressive episodes, postpartum depression, lack of response to antidepressants)
215
how do you treat bipolar spectrum disorder?
these patients rarely respond to anti-depressants and an anti-convulsant may be the drug of choice
216
what is the criteria for bipolar affective disorder?
at least 2 affective episodes, one of which must be hypomania, mania or mixed, with usually complete recovery inbetween. criteria for depressive episodes the same as for depressive illness.
217
what is the difference between the DSM classification of bipolar I and bipolar II?
bipolar I involved mania, bipolar II involves hypomania
218
what % of bipolar affective disorder patients attempt suicide?
25-50%
219
what are 3 differentials for bipolar affective disorder?
1. drug induced mania
2. dysthymia
3. anxiety disorders
220
how do you treat bipolar affective disorder?
mania- lithium, anti-psychotics, anti-convulsants
depression- anti-depressants, lithium
(lithium is a more general mood stabiliser)
221
how do you prevent relapses in bipolar affective disorder?
learn to recognise triggers and subtle signs of depression and mania and treat them before they are pronounced
222
what are the 3 criteria for depressive illness?
1. present for 2 weeks and a change from normal
2. not secondary to medication, substances, medical condition or bereavement
3. may cause significant distress or social, occupational or general impairment
223
what are the 10 core symptoms of depressive illness?
1. depressed mood
2. anhedonia
3. anergia
4. weight change
5. disturbed sleep
6. psychomotor agitation
7. reduced libido
8. worthlessness
9. reduced concentration
10. recurrent suicidal thoughts
224
what are 2 psychotic symptoms that can manifest in severe depression?
1. delusions- poverty, inadequacy, guilt
| 2. hallucinations- negative voices, bad smells
225
what is the criteria for mild depression?
2 typical symptoms and 2 other core symptoms
226
what is the criteria for moderate depression?
2 typical symptoms and 3+ other core symptoms
227
what is the criteria for severe depression?
3 typical symptoms and 4+ other core symptoms
228
what are the 3 typical symptoms of depression?
1. depressed mood
2. anhedonia
3. anergia
229
what is the criteria for postnatal depression?
significant depressed episode occurring within 6 months of giving birth. thought content may include worries about coping or worries about the babies health
230
what are three risk factors for depression?
1. genetic
2. childhood experiences
3. chronic, severe or painful physical illness
231
what are 2 theories about the aetiology of depression?
1. structural brain changes- chronic cases have changes in left hippocampus, left parietal lobe and frontal association
2. neurotransmitters- all antidepressants increase monoamine release or reduce re-uptake, so monoamine dysfunction may cause depression
232
what are 3 differentials for depression?
1. dysthymia
2. stress-related disorders such as PTSD
3. dementia
233
what are 3 factors that lead to a good outcome in depression?
1. acute onset
2. earlier onset
3. endogenous depression
234
what are 3 factors that lead to a bad outcome in depression?
1. insidious onset
2. comorbidity
3. elderly
235
what should be included in the initial assessment of depression?
1. history- psychological precipitants, drugs/alcohol, history of mood, previous treatments
2. MSE
3. physical examination
4. baseline investigations
236
what are 3 reasons for a hospital admission for a patient with depression?
1. serious suicide risk
2. serious risk of harming others
3. psychotic symptoms
237
what is the first line pharmacological treatment for depression?
antidepressant drugs
238
what is the second line pharmacological treatment for depression?
an alternative antidepressant drug
239
what is the first line therapy for depression with severe biological features, such as weight loss?
electroconvulsive therapy
240
what is the first line therapy for depression with psychotic features?
electroconvulsive therapy
241
what is the first line pharmacological treatment for depression with psychotic features?
an antidepressant and an anti-psychotic
242
what are some approaches that can be taken for treatment resistant depression?
1. review diagnosis
2. check understanding and compliance
3. continue monotherapy at maximum tolerable dose
4. consider changing anti-depressant
5. consider augmenting with lithium
6. consider use of ECT
243
what are the symptoms of an atypical depressive episode
1. mood depressed but can enjoy activities but not as much as before
2. hypersomnia
3. hyperphagia
4. leaden paralysis- heaviness in limbs
5. oversensitivity to perceived rejection
6. severe motor retardation
244
how do you treat an atypical depressive episode?
best evidence for phenelzine (MAO-I)
| can use an SSRI (sertraline, citalopram)
245
what are the symptoms of seasonal affective disorder?
1. a clear seasonal pattern to recurrent depressive episodes
| 2. symptoms generally mild to moderate with low self-esteem, weight gain, hypersomnia, and fatigue
246
how do you treat seasonal affective disorder?
1. light therapy- 2 hours of 2500 lux light on waking
2. fluoxetine (SSRI)
3. propranolol can be effective
247
what is dysthymia?
the presence of chronic, low-grade depressive symptoms that are often longstanding but can have superimposed depressive episodes
248
what are the symptoms of dysthymia?
the same symptoms as depression, less severe but more chronic
249
how do you treat dysthymia?
1. best evidence for phenelzine (MAO-I)
2. can use an SSRI or a TCA
3. CBT may be useful
250
what is the general assumed pharmacology of antidepressants?
increase the availability of monoamines (5HT, NA, DA)
251
name 3 tricyclic antidepressants
1. amitriptyline
2. clomipramine
3. imipramine
252
what are some contraindications to tricyclic antidepressants?
acute MI, heart block, arrhythmias
253
what is the main drawback of tricyclic antidepressants?
they are toxic in overdose
254
name 3 monoamine oxidase inhibitors
1. phenelzine
2. moclobemide
3. isocarboxazid
255
list 3 side effects of monamine oxidase inhibitors
1. risk of hypertensive crisis with foods and meds high in tyramine (cheese, fish)
2. insomnia
3. anxiety
256
when are monoamine oxidase inhibitors used for depression?
2nd line therapy for treatment resistant depression
257
what are some contraindications for monoamine oxidase inhibitors?
cardiovascular disease, hepatic failure, hypertension
258
name 3 selective serotonin re-uptake inhibitors
1. sertraline
2. citalopram
3. escitalopram
259
list 3 side effects of selective serotonin re-uptake inhibitors?
1. nausea
2. GI upset
3. headache
260
what are some contraindications for selective serotonin re-uptake inhibitors?
has an effect on CYP450 so avoid when patient is already taking drugs heavily excreted by the liver
261
name 2 selective noradrenaline re-uptake inhibitors
1. venlafaxine
| 2. duloxetine
262
list 3 side effects of selective noradrenaline re-uptake inhibitors
1. nausea
2. GI upset
3. headache
263
list 3 indications for the use of electroconvulsive therapy?
1. severe depressive episodes with need for rapid response
2. treatment resistant psychosis or mania
3. neurological crises such as extreme parkinsonism
264
what is a panic attack?
a period of intense fear with associated symptoms that lasts for 20-30 minutes. attacks can be spontaneous, situational or occur during sleep
265
what are 6 symptoms of having a panic attack?
1. palpitations
2. sweating
3. trembling
4. shortness of breath
5. derealisation
6. feeling dizzy
266
what is panic disorder?
a disorder involving recurrent primary panic attacks. usually persistent worry about having an attack and behavioural changes related to the attack
267
what 2 factors can raise the risk of suicide attempts in someone with panic disorder?
1. co-morbid depression
| 2. substance abuse
268
what are 3 differentials for panic disorder?
1. other anxiety related disorders
2. substance misuse
3. hyperthyroidism
269
what are the 2 most common co-morbid conditions with panic disorder?
1. agoraphobia 30-50%
| 2. other anxiety related disorders such as OCD up to 50%
270
what are two aetiological models for the cause of panic disease?
1. exaggerated post-synaptic response to serotonin
| 2. decreased inhibition of GABA
271
what are 3 ways to manage panic disorder pharmacologically?
1. SSRI (eg fluoxetine) - 1st line
2. alternative antidepressant
3. BDZ (eg clonazepam) - can be good for severe symptoms
272
what are 2 ways to manage panic disorder psychologically?
1. behavioural management to treat phobic avoidance
| 2. cognitive management with education about bodily responses to anxiety and modification of thinking errors
273
how do you treat an acute panic attack in an emergency?
1. maintain a reassuring and calm approach as most attacks resolve within 30 minutes
2. if symptoms are severe consider the use of a BDZ
3. if first presentation, exclude medical causes
4. if recurrent, consider diagnosis of panic disorder
274
what is agoraphobia?
anxiety and panic symptoms associated with places or situations where escape could be difficult or embarrassing leading to avoidance
275
what are 3 co-morbid conditions with agoraphobia?
1. panic disorder
2. depressive disorder
3. other anxiety related disorder
276
what are 3 differentials for agoraphobia?
1. other anxiety related disorder
2. depressive disorder
3. avoidance due to delusions in psychosis
277
what is the pharmacological and psychological management for agoraphobia?
1. pharma- antidepressants, possibly short term BDZ
| 2. psych- exposure techniques, relaxation training, anxiety management, teaching about bodily responses to anxiety
278
what is a phobia?
recurring unreasonable psych or autonomic symptoms of anxiety in response to a feared object or situation, leading to avoidance
279
what is the lifetime risk of someone with a phobia experiencing another psychiatric condition?
80%
280
what are 3 differentials for a phobia?
1. panic disorder
2. agoraphobia
3. OCD
281
how do you treat phobias?
behavioural therapy to reduce fear response, education about the effects of anxiety on the body
282
what is social phobia?
symptoms of anxiety related to specific social situations leading to a desire to escape and avoidance
283
how do you treat social phobia?
1. psych- CBT individual or group 1st line - involved relaxation training and anxiety management
2. pharma- beta- blockers (eg atenolol) can reduce autonomic arousal. for more generalised social anxiety use MAO-i's and SSRI's.
284
what is generalised anxiety disorder?
'excessive worry' and apprehension with anxiety symptoms about everyday events/ problems causing distress and functional impairment
285
what is the DSM-IV diagnostic criteria for generalised anxiety disorder?
present most days for at least 6 months
at least 3 symptoms of-
1. restlesness
2. feeling on edge
3. easy fatiguability
4. concentration difficulties
5. irritability
6. muscle tension
7. sleep disturbance
286
what are 3 differentials for generalised anxiety disorder?
1. depression
2. thyroid problems
3. substance misuse
287
how do you manage generalised anxiety disorder psychologically?
1. some evidence for CBT
2. avoidance by exposure
3. relaxation techniques
4. teaching about bodily responses
5. modification of thinking errors
288
how do you manage generalised anxiety disorder pharmacologically?
1. psych symptoms- buspirone
2. somatic symptoms- diazepam
3. autonomic symptoms- beta blockers
289
name 3 medical conditions that can be associated with anxiety like symptoms?
1. arrhythmias
2. COPD
3. hyperthyroidism
290
what is obsessive compulsive disorder?
a condition associated with anxiety and depression involving 'obsessions' and 'compulsions' that cause distress and interfere with functioning. the person should recognise at some point that their symptoms are excessive or unreasonable
291
what are four common obsessions?
1. checking
2. washing
3. contamination
4. doubting
292
what are 3 differentials for OCD?
1. 'normal' but recurrent thoughts
2. anankastic personality disorder
3. schizophrenia
293
how do you treat OCD psychologically?
1. supportive psychotherapy
| 2. behavioural therapy with response prevention and thought stopping
294
how do you treat OCD pharmacologically?
1. antidepressants- SSRI's are 1st line
2. TCA- clomipramine has anti-obsessional factors and can be 1st or 2nd line
3. MAO-i 3rd line
295
what are 3 poor prognostic factors for OCD?
1. giving in to compulsions
2. early onset
3. longer duration
296
what are 3 good prognostic factors for OCD?
1. good adjustment
2. a precipitating event
3. episodic symptoms
297
what is adjustment disorder?
occurs within 1-3 months of a psychosocial stressor and do not persist longer than 6 months. involves marked distress, impairment of functioning, and can be sub-threshold manifestations of other psych disorders
298
what is the ICD-10 criteria for adjustment disorder?
brief or long-standing depressive reaction, anxiety reaction, mixed reaction, or disturbance of other emotions with a predominant disturbance of emotion and/or conduct. includes bereavement and grief reactions
299
how do you treat adjustment disorder psychologically?
1. supportive psychotherapy to enhance ability to cope with the stressor
2. establish sufficient support
3. verbalisation of feelings
300
how do you treat adjustment disorder pharmacologically?
anti-depressants or hypnotics with particularly longstanding or distressing symptoms
301
what is post-traumatic stress disorder?
severe psych disturbance following a traumatic event characterised by involuntary re-experiencing with symptoms of hyper-arousal, avoidance and emotional numbing. symptoms arise within 6 months of the event with significant impairment in areas of functioning
302
what is the ICD-10 and DSM-IV (they are mostly the same) criteria for post-traumatic stress disorder?
2 or more persistent symptoms of increased psychological sensitivity and arousal-
1. difficulty falling asleep or staying asleep
2. irritability or outbursts of anger
3. difficulty in concentrating
4. hyper-vigilance
5. exaggerated startle response
303
what are 3 differentials for post-traumatic stress disorder?
1. acute stress reaction
2. adjustment disorder
3. substance induced disorder
304
how do you treat post-traumatic stress disorder psychologically?
1. CBT with elements of education, self-monitoring and anxiety management
2. eye movement desensitisation and reprocessing
3. psychodynamic therapy
305
how do you treat post-traumatic stress disorder pharmacologically?
1. depressive symptoms- SSRIs, TCAs or MAO-is
2. anxiety symptoms- BDZs, antidepressants
3. hyper-arousal- beta blockers
4. sleep disturbance- sedative antidepressants like trazodone
little evidence for effectiveness of pharmacological therapy
306
what is the rate of recovery for post-traumatic stress disorder?
50% recover within the first year, 30% run a chronic course
307
what is depersonalisation syndrome?
persistent or recurrent episodes of a feeling of detachment and unreality, can be in relation to the outside world (derealisation) or the persons own body, thoughts and feelings (depersonalisation)
308
what are 3 differentials of depersonalisation syndrome?
1. psychosis
2. sleep deprivation
3. intoxication/ withdrawal from alcohol
309
what is somatisation disorder?
a disorder involving repeated presentations with medically unexplained symptoms associated with significant psychological distress, functional impairment, and risk of iatrogenic harm
310
what is the clinical presentation of somatisation disorder?
1. patients will have long medical files with unresolved complaints
2. patients tend to minimise all but the most recent symptoms
3. patients will have had a lot of tests that come back with no medically promising results
4. 2/3 of patients experience psychiatric disorders that can be combined with substance abuse, but often blame this on the somatic symptoms
311
how do you manage somatisation disorder?
1. regular reviews by a single, named doctor
2. make, document and communicate the diagnosis
3. symptoms examined and explored with a view to their meaning
4. disseminate management plan
312
what is somatoform pain disorder?
a disorder involving a persistent severe and distressing pain that is medically unexplainable, and the cause is attributed to psychological factors
313
what are 2 common co-morbid conditions with somatoform pain disorder?
1. major depressive disorders
| 2. substance abuse
314
what are 2 differentials for somatoform pain disorder?
1. genuine organic pain with no other manifestation (sickle cell crisis, angina)
2. elaboration of organic pain
315
how do you manage somatoform pain disorder?
treat occult co-morbid depression, psychological treatments and pain clinics can be helpful
316
what is munchausen's syndrome?
a disorder where patients falsify symptoms and past history and fabricate signs of physical and mental disorders. can be associated with aggressive personality, dissocial and borderline personality disorders
317
what are 3 differentials for munchausen's syndrome?
1. genuine medical or psychiatric condition
2. somatisation disorder
3. substance misuse
318
what is munchausen's syndrome by proxy?
the same as munchausen's syndrome but enforced on a person by another person, usually a person with assumed authority over the other person, such as a parent and a child
319
what is generalised learning disability?
lower intellectual ability (IQ<70), impairment of functioning and childhood onset. reduced ability to understand new or complex information and to cope independently
320
what is fragile X syndrome?
a genetic condition associated with learning disability which may also involve-
1. large testicles and ears
2. smooth skin
3. high forehead
4. large jaw
5. facial asymmetry
321
what is the cause of fragile X syndrome?
a large sequence of CGG repeats at a fragile site on the X chromosome
322
what is a common neurological condition affecting people with fragile X syndrome?
epilepsy is present in 25% of cases
323
what are some autism-like behaviours that can be present in fragile X syndrome?
hand flapping, repetitive mannerisms, shyness, poor peer relationships and communication difficulties
324
what are 2 common psychiatric problems in people who have fragile X syndrome?
anxiety and depression
325
how do you diagnose fragile X syndrome?
a blood sample can be sent to the lab for genetic testing
326
how do you treat fragile X syndrome?
1. speech therapy
2. special needs education
3. behavioural therapy
4. ADHD- dextroamphetamine
5. depression- antidepressants
6. anxiety- SSRI
7. antipsychotics
8. epilepsy- anticonvulsants
327
what is down's syndrome?
a genetic condition associated with learning disability. physical characteristics include-
1. short stature, overweight, muscular hypotonia
2. underdeveloped nose bridge, close together eyes, epicanthic folds, low set ears, high arched palate and protruding tongue
3. congenital heart (ASD/VSD) and GI (hirschprung's) abnormalities
328
what are the statistics for the prevalence of psychiatric conditions in people with down's syndrome?
18% of children and 30% of adults most commonly have depression (10%) or other disorders such as bipolar, OCD, tourette's, schizophrenia, autism
329
what is a common neurological condition in people with down's syndrome of an older age?
dementia, but can be hard to diagnose due to pre-existing intellectual disability
330
what are 3 risk factors for having a child with down's syndrome?
1. maternal age over 40 years
2. previous child with down's syndrome
3. mother with down's syndrome
331
what are autism-spectrum disorders?
developmental disorders characterised by their impact on social and communication skills. involve a restricted and repeated repertoire of interests and activities.
332
what percentage of people with childhood autism have learning disabilities?
80%
333
what percentage of the population of people with autism have learning disabilities overall?
20%
334
what are the three main clinical features of autism spectrum disorders?
1. difficulties with social relationships- few or no sustained relationships, persistent aloof or awkward reactions, usually egocentric and unaware of social rules
2. problems in communication- can be odd or monotonous voice at unusual volumes with little awareness of responses, language can be too formal or pedantic, difficulty grasping meanings that aren't literal, awkward body language and few gestures
3. absorbing and narrow interests- obsessively pursued and unusually circumscribed interests, a set, routine approach to everyday life where changes can be upsetting
335
what are 3 common comorbidities with autism spectrum disorder?
1. anxiety disorders
2. depression
3. bipolar disorder
336
what are some ways to assess someone with autism spectrum disorder?
1. history of problem
2. level of impact on daily life
3. comorbidity
4. cognitive ability
5. specialist assessment
6. observation of child
7. consider diagnostic tools like the autism diagnostic interview
337
how do you manage autism spectrum disorder?
1. information and support
2. liaison with education services
3. parenting programmes
4. adaptation of environment
5. communication interventions
6. treat co-morbidity
7. risperidone can be used for short term treatment of serious aggression (atypical antipsychotic)
8. melatonin can help sleep disturbance
338
what is tourette's syndrome?
a developmental neuropsychiatric disorder characterised by the presence of multiple motor and one or more vocal tics, present for at least a year, that cause distress and impact functioning
339
what are 3 common co-morbidities with tourette's syndrome?
1. OCD
2. ADHD
3. depression
340
what are 2 aetiological theories of tourette's syndrome?
1. heightened HPA axis and NA system reactivity
| 2. exposure to psychosocial stressors
341
what are some key aspects of assessment in tourette's syndrome?
1. assess degree of interference with life
2. perinatal, developmental, family and medical history
3. screen for associated difficulties
342
how do you manage tourette's syndrome?
1. psycho education for child and family
2. liaison with education system
3. behavioural intervention- habit training, self-monitoring
4. consider anti-psychotics or alpha-adrenergics for severe and impairing tics
343
what is asperger's syndrome?
a syndrome characterised by severe, persistent impairment in reciprocal social interactions, repetitive behaviour and restricted interests. IQ and language are normal. male predominance and can involve a degree of mild motor clumsiness
344
what is separation anxiety disorder?
a disorder involving inappropriate increased anxiety around separation from attachments such as family members or the home, resulting in impaired functioning
345
what are 3 causes of separation anxiety disorder?
1. genetic vulnerability
2. anxious
3. over-involved parenting
346
what are 3 co-morbid conditions often present with separation anxiety disorder?
1. anxiety disorders
2. depression
3. ADHD
347
what is enuresis?
a disorder in the age of acquisition of bladder control, up to 15-22% of boys and 7-15% of girls by age 7 have nocturnal enuresis
348
what are 3 factors that contribute to enuresis?
1. genetics
2. structural and functional urinary tract disorders
3. anxiety disorders
349
how do you treat enuresis?
1. careful assessment
2. psycho-education
3. treat organic causes
4. nocturnal- enuresis alarms, desmopressin
5. diurnal- body alarms, anxiety management
350
what is ADHD?
a disorder characterised by a triad of inattention, hyperactivity and impulsiveness
351
what are the three subtypes of ADHD according to the DSM-IV?
1. combined- all 3 features
2. inattentive
3. hyperactive-impulsive
352
what are 3 aetiological factors in ADHD?
1. genetic inheritance
2. babies born to mothers who abused substances during pregnancy
3. head injury
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what are 3 differentials for ADHD?
1. learning disability
2. hearing impairment
3. a high IQ child with inadequate stimulation/ challenge
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what are 3 common co-morbid conditions with ADHD?
1. learning disorders
2. tic disorders
3. autism spectrum disorders
355
what are 3 short term problems associated with ADHD?
1. sleep problems
2. low self esteem
3. relationship problems with family and peers
356
what are 2 long term problems with ADHD?
1. reduced academic and employment success
| 2. increased criminal activity
357
how do you assess whether a child has ADHD?
1. interview family and child
2. observe the child in multiple situations
3. collateral information
4. rating scales
358
what are 4 ways to treat ADHD?
1. psycho-education
2. behavioural intervention
3. school intervention
4. medication- methylphenidate (CNS stimulant), atomoxedine (NA re-uptake inhibitor)
359
what are 4 signs of paranoid personality disorder?
1. sensitive
2. suspicious
3. preoccupied with conspiratorial explanations
4. distrust of others
360
what are 4 signs of schizoid personality disorder?
1. emotionally cold
2. detachment
3. lack of interest in others
4. excessive introspection and fantasy
361
what are 4 signs of antisocial personality disorder?
1. callous lack of concern for others
2. inability to maintain relationships
3. disregard to violating the rights of others
4. aggression
362
what are 4 signs of anankastic/ obsessive- compulsive personality disorder?
1. indecisiveness
2. caution
3. perfectionism
4. preoccupation with orderliness and control
363
what are 4 signs of avoidant personality disorder?
1. tension
2. self-consciousness
3. fear of negative evaluation by others
4. timid
364
what are 4 signs of dependent personality disorder?
1. excess need for care
2. feels helpless when not in a relationship
3. clingy
4. submissive
365
what are 2 signs of EUPD- impulsive type?
1. inability to control anger or plan
| 2. unpredictable affect and behaviour
366
what are 4 signs of EUPD- borderline type?
1. unclear identity
2. intense and unstable relationships
3. unpredictable affect
367
what are 4 signs of histrionic personality disorder?
1. self-dramatisation
2. shallow affect
3. egocentricity
4. craving attention and excitement
368
what is the definition of a personality disorder?
an enduring disorder of inner experience and behaviour that causes distress or significant impairment in social functioning. they manifest in problems with cognition, affect and behaviour
369
what are 4 aetiological theories for the formation of personality disorders?
1. genetic
2. neurophysiology
3. childhood development
4. psychodynamic theories
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describe the neurophysiological aetiological theory for personality disorders
1. functional imaging abnormalities in psychopathy
| 2. low 5-HT levels in impulsive violent individuals
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describe the childhood development aetiological theory for personality disorders
1. may be preceded by difficult infant temperament
2. ADHD can be a risk factor for antisocial personality disorder
3. insecure attachments and harsh and inconsistent parenting
372
describe the psychodynamic aetiological theory for personality disorder?
internalisation of and defence mechanisms against parental abuse/ abuse during developmental years
373
what is the rate of personality disorder in the community?
2-18%
374
what are the 3 cluster A personality disorders?
odd and eccentric behaviour-
1. paranoid
2. schizoid
3. schizotypal
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what are the 4 cluster B personality disorders?
dramatic, emotional or erratic behaviour-
1. histrionic
2. borderline
3. antisocial
4. narcissistic
376
what are the 3 cluster C personality disorders?
anxious or fearful behaviours-
1. avoidant
2. dependent
3. anankastic/ obsessive-compulsive
377
what are 2 common co-morbidities with cluster B personality disorders (histrionic, borderline, antisocial, narcissistic)?
1. substance misuse
| 2. eating disorders
378
what are 2 common co-morbidities with cluster C personality disorders (avoidant, dependent, anankastic)?
1. eating disorders
| 2. somatoform disorders
379
what are some ways to diagnose personality disorders?
1. detailed psychiatric history
2. pre-designed instruments such as self-report questionnaires, structured clinical interviews, and specific instruments
3. functional assessment involving listing abnormal personality traits, describing associated distress, and describing interference with functioning
380
how do you treat personality disorders?
1. managing co-morbid disorders
2. support and monitoring
3. crisis intervention
4. admission to hospital during crisis but this has limited effectiveness
5. medication
6. therapy
381
what are 3 medication options for treating personality disorders?
1. antipsychotics- some benefit with cluster B (specifically borderline) and cluster A (schizotypal and paranoid)
2. antidepressants- can benefit impulsive, depressed and self-harming patients and cluster C disorders
3. anticonvulsants and lithium- can benefit affective instability or impulsivity
382
what are 3 therapeutic options for treating personality disorders?
1. dialectical behavioural therapy
2. cognitive-analytical therapy
3. cognitive-behavioural therapy
