Psychiatry Flashcards
1
Q
What is an Illusion?
A
Misperception of real external stimulus
Affect driven
2
Q
What is a hallucination?
A
Disorder of perception
Percept experienced in absence of external stimuli
3
Q
Describe the types of Hallucinations
A
Auditory Visual Olfactory Gustatory = taste Tactile = feeling things
Hypnogogic = on falling asleep
Hypnopompic = on waking up
Autoscopic = seeing oneself
Reflex = stimulation in one modality produces hallucination in other
Extracampine - hallucinations outside of sensory fields
Charles Bonnet = visual hallucinations associated with eye disease
4
Q
What is a Delusion?
A
Disorder of thought
A belief that is:
1) firmly held
2) Not affected by rational argument/evidence
3) Not a conventional belief
5
Q
Types of Delusions?
A
▪ Persecutory (think someone is going to hurt them)
▪ Grandiose - inflated self-importance (e.g. I am God)
▪ Delusions of Reference – events/actions take on special significance to patient (e.g. black cars
monitoring me)
▪ Nihilistic – delusion of almost nothingness (e.g. nothing in bank account, insides rotting)
▪ Hypochrondriacal - firm belief they have a disease
6
Q
What is Psychosis?
A
Severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality
7
Q
Neurosis?
A
Mild mental illness involving symptoms of stress but not a radical loss of touch with reality
8
Q
Passivity Phenomena?
A
Controlled by someone else
9
Q
Catatonia?
A
Significantly excited/ inhibited motor activity
10
Q
Psychomotor retardation?
A
Slowing of thoughts/movements
11
Q
State the 5 types of Thought Alienation
A
Thought Insertion
Thought Withdrawal = someone removing their thoughts
Thought broadcast
Thought Echo
Thought Block = can’t continue idea
12
Q
Concrete thinking?
A
lack of abstract thinking = aspergers
13
Q
What is Confabulation?
A
Korsakoff = most common
give false account to fill gap in memory
14
Q
What is a Neologism?
A
New word formation = to them it seems like it fits
15
Q
Anhedonia?
A
Inability to experience pleasure
16
Q
Akathisia?
A
Inner restlessness and always in motion (rocking)
17
Q
Pharmacokinetics?
A
What the body does to the drug (Absorption, distribution, metabolism, elimination)
ADME
18
Q
Pharmacodynamics?
A
what the drug does to the body (receptor sensitivity, agonism/antagonism)
19
Q
4 key neurotransmitters?
A
Dopamine
Serotonin
Acetylcholine
Glutamate
20
Q
Where do the dopamine and serotonin pathways begin?
A
Dopamine = substantia nigra
Serotonin = Raphe Nuclei
21
Q
SCHIZOPHRENIA
How is it caused?
A
Excess dopamine production
over activity of neurones = Mesolimbic = Hallucinations/delusions
Under activity of neurones = Mesocortical = blunted, anhedonia, apathy
22
Q
What is Mesolimbic/ Mesocortical
A
Mesolimbic = positive symptoms
mesocortical = negative symptoms
23
Q
SCHIZOPHRENIA
Treatments can cause side effects - Extra pyramidal side effects (EPSEs)
Name the EPSEs (from anti-psychotics)
A
Hours = Acute dystonic reaction (muscle spasms)
4 weeks = Parkinsonism (tremor, bradykinesia)
6-60 days = Akasthesia (inner restlessness)
Long term use = Tardive dyskinesia
24
Q
SCHIZOPHRENIA
treatment of EPSEs?
A
Procycladine
Propanolol +/- cyproheptadine
Tetrabenazine
25
SCHIZOPHRENIA
What is Procycladine used for?
Treatment of the EPSE of Acute Dystonia/ Parkinsonism
26
SCHIZOPHRENIA
What is propanalol/ cyproheptadine used for?
Treatment of the EPSE of Akathesia
27
SCHIZOPHRENIA
What is Tetrabenazine used for?
Treatment of EPSE of Tardive Dyskinesia although its generally irreversible
28
SCHIZOPHRENIA
typical / 1st gen antipsychotics?
Haloperidol
Chlorpromazine
29
SCHIZOPHRENIA
Atypical/ new antipsychotics?
Olanzapine
Risperidone
Quetiapine
Aripiprazole
Clozapine
30
SCHIZOPHRENIA
Main dopamine and serotonin receptors?
D = D2
S = 5HT2a
31
SCHIZOPHRENIA
What does dopamine inhibit?
Prolactin = therefore dopamine antagonism increases prolactin
Hyperprolactinaemia Side Effects:
- Galactorrhoea
- Amenorrhoea and infertility
- Sexual dysfunction
32
SCHIZOPHRENIA
Hyperprolactinaemia is a common SE of antipsychotics.
What is it generally not seen in?
Aripiprazole
Quetiapine
Clozapine
33
SCHIZOPHRENIA
What is the SE of weight gain seen in?
All Atypical
most with olanzapine/ clozapine
lowest with Aripiprazole
34
SCHIZOPHRENIA
Clozapine side effects?
Agranulocytosis - high risk of infection
Reduced seizure threshold
Sedating
Postural Hypotension
Toxic Megacolon (1 in 1800)
Cardiomyopathy (1 in 2500)
Extreme salivating
35
SCHIZOPHRENIA
which pathway causes excess prolactin?
Tuberoinfundibular
36
SCHIZOPHRENIA
| Which pathway causes movement disorders?
Nigrostriatal
37
SCHIZOPHRENIA
Signs and symptoms of neuroleptic malignant syndrome?
REDUCED ACTIVITY
fever, altered mental status, muscle rigidity, and autonomic dysfunction.
Biological:
Elevated CK, WCC, metabolic acidosis
38
SCHIZOPHRENIA
which drugs can cause neuroleptic malignant syndrome?
Most frequently in patients taking haloperidol and chlorpromazine
39
What is Echolalia?
meaningless repetition of another persons spoken words
40
What is Incongruity of affect?
emotional responses that don't match the situation
41
What is flat affect?
No emotional expression
42
mannerism?
repeated involuntary movements
43
Belle indifference?
Lack of concern for implications of symptoms
44
DEPRESSION
Name types of antidepressants
SSRIs
Serotonin Noradrenaline Reuptake Inhibitor (SNRIs)
Monoamines Oxidase Inhibitors
Tricyclics
45
Name types of SSRIs
Sertraline
Citalopram
Fluoxetine
Paroxetine
46
Name types of SNRIs
Venlafaxine
| Duloxetine
47
Name types of MAO inhibitors
Rasagiline
Selegiline
Isocarboxazid
Phenelzine
avoid high fat diet as contains tyramine = hypertensive crisis
48
Name types of Tricyclics
Side effects?
Amitriptyline
Clomipramine
Tachycardic
dry mouth
blurred vision
(anti-cholinergic/muscarinic)
49
What is bipolar disorder?
Periods of elevated mood and depression
Hypomania/mania
50
Treatment of Neuroleptic Malignant Syndrome?
Bromocriptine – to reduce dopamine blockade (dopamine agonist)
Dantrolene – to reduce muscle spasms
51
treatment of Bipolar?
Lithium
Sodium Valproate, carbamazepine, lamotrigine
Antipsychotics
52
What is Lithium used for?
Acute treatment of mania
53
how does lithium work?
Inhibits cAMP production
| cAMP inhibits monoamines
54
Side effects of lithium?
```
Fine tremor
Impaired renal function
Nephrogenic DI (thirst)
Weight gain
Oedema
Hypothryoidism
```
Cardiac - t wave flattening/inversion
Leucocytosis
Teratogenicity
55
Signs of Lithium toxicity?
• Levels >1.0mmol/L
```
• Onset = sudden
• Course tremor,
- Ataxia
- Weakness
- N&V
```
56
Signs of Lithium toxicity?
• Levels >2.0mmol/L
```
Nystagmus
Dysarthria
Impaired consciousness
Hyperactive tendon reflexes
Oliguria
Hypotension
Convulsions / coma
```
57
Cause of Serotonin syndrome?
SSRIs
MAO inhibitors
ecstasy
58
Symptoms of Serotonin syndrome
INCREASED ACTIVITY
- Clonus/myoclonus
- Hyperreflexia
- Tremor
- Muscle ridgity
- Dilated pupils
- Autonomic dysfunction (tachycardia/ unstable BP)
59
Signs of Serotonin Syndrome after testing?
Similar to NMS
- Elevated CK, WCC
- Deranged LFTs
Metabolic acidosis
60
Treatments for serotonin syndrome?
Benzodiazepines
Cyproheptidine- 5HT-2a antagonist
61
Differences between Serotonin syndrome and Neuroleptic malignant syndrome?
Serotonin = increased activity and acute onset
Neuroleptic = reduced activity and insidious onset (4-11 days)
similar signs (CK,WCC, LFTs, metabolic acidosis)
62
Definition of Dependance?
Cluster of physiological, behavioural and cognitive phenomena in which a substance takes on a higher priority than other behaviours that once had greater value
63
Name the features of Dependance
Compulsion to drink
Tolerance - need more to get same effect
Difficulties controlling alcohol consumption
Physiological withdrawal
Neglect of alternatives to drinking
Persistent use of alcohol despite harm
64
Risk for factors for Dependance
```
o Higher risk in men
o Low standard of education o Unemployment
o Younger age of usage o Mental illness
o Peer pressure
o Low self esteem
o High stress
o FHx of alcoholism / substance addiction
o Genetic susceptibility
```
65
Alcohol dependance assessments?
CAGE (cut down, annoyed, guilt, eye-opener)
Audit
66
What does Tweak stand for
Tolerance (>6 drinks = 2pts)
Worried (yes = 2pts)
Eye-opener = 1pt
Amnesia = 1pt
Cut down = 1pt
>3 = problem with alcohol
67
Investigation results of an alcohol dependant patient?
Raised MCV - macrocytic anaemia
▪VitaminB12+folate deficiency=withALCOHOL
o Deranged LFTs – GGT, AST/ALT
o Thrombocytopenia - reduced platelets
o Breath test
o Screening
68
Management of Alcohol dependance
▪ Acomprosate – reduces craving
▪ Disulfiram – gives hangover SE if alcohol consumed (alcohol intake causes inhibition of of
acetaldehyde dehydrogenase
▪ Naltrexone reduces pleasure alcohol brings
▪ Support groups / CBT / motivational interviewing
69
Management of alcohol withdrawal
▪ Chlordiazepoxide - Benzodiazepine
▪ IV Pabrinex 5 days - vitamin supplementation
▪ Thiamine 100mg BD
70
Alcohol withdrawal symptoms?
```
▪ Tremors
▪ Sweating
▪ Nausea/vomiting
▪ Sound sensitivity (hyperacusis)
▪ Insomnia / sleep disturbance
▪ Mood disturbance – eg anxiety,
on edge, depression
▪ Autonomic hyperactivity –
tachycardia, HTN, pyrexia,
myadriasis
▪ Seizures seen - at 36 hours
```
71
What is Lilliputian?
Visual hallucinations of small animals
72
What is Formication?
Insects crawling on skin
73
KORSAKOFF'S SYNDROME
Triad?
Treatment?
▪ Anterograde amnesia
▪ Confabulation
▪ Psychosis (Lilliputian/formication)
o IV Pabrinex (high potency B1 replacement) and chlordiazepoxide
74
Management of Opioid overdose/ dependance?
• IV/IM naloxone - rapid onset + short
• Opioid dependance - detoxification (last up to 4weeks in residential / 12weeks in community)
o Methadone
o Buprenorphrine
75
Complications of Opioid misuse?
Infection due to sharing needles
VTE
Overdose- respiratory depression
Crime/prostitution
76
Opiate Intoxication symptoms?
Drowsy
Mood change
Bradycardia
HTN
Pupil constriction
Respiratory depression
Decreased body temperature
77
Opiate withdrawal symptoms?
muscle cramps
low mood
insomnia
agitation
Diarrhoea
Shivering
Flu like symptoms
78
DELIRIUM
Causes of delirium?
Pain
Infection/ Intoxication
Nutrition (vit deficiency- thiamine, B12, folate)
Constipation
Hypoxia/hydration
Medication/ substance abuse (benzodiazepines, anticholinergics, opiates, anticonvulsants)
Environmental
PINCH ME
79
DELIRIUM
Features?
inattention
disorientated
visual hallucinations
paranoia
80
DELIRIUM
3 clinical syndromes seen?
```
▪ Hypoactive
• Apathy
• Withdrawal
• Quiet confusion
• Easily missed – o:en misdiagnosed as depression
```
```
▪ Hyperactive
• Agitation
• Lack of co-operation
• Delusions
• Disorientation
• Confused with schizophrenia
```
▪ Mixed
81
DELIRIUM
Ddx?
```
Dementia
anxiety
Psychosis
withdrawal
post-ictal
```
82
DELIRIUM
How can you differentiate from dementia?
Delirium vs Dementia
Acute vs gradual
outside of brain vs brain pathology
can improve vs can't improve
inattention vs still alert
impaired consciousness vs conscious
fluctuating symptoms
treatable vs untreatable
83
DELIRIUM
Lifestyle Management?
Treat precipitating cause
Educate family and make environment safe
Avoid sedation unless severely agitated
Regular follow ups
84
DELIRIUM
Medication Management?
Consider
- Haloperidol
- Olanzapine
- BDZs = Chlordiazepoxide (ONLY in alcohol withdrawal otherwise worsens delirium)
85
GENERALISED ANXIETY DISORDER
What is it?
Anxiety not specific to an environmental circumstance
Excessive worry about every day events/problems
86
GENERALISED ANXIETY DISORDER
Clinical features?
3 or more of :
- Restlessness / on edge
- Easily fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
87
GENERALISED ANXIETY DISORDER
Clinical features can be put into 5 categories :
```
Autonomic
Chest/Abdomen
General
Mental State
Non specific
```
state some features using these categories
```
Autonomic :
Increased HR
Sweating
heart palpitations
Dry mouth
shaking/trembling
```
Chest/Abdo :
Difficulty breathing
chest pain
N+V
```
General:
Hot flushes/cold chills
Numbness/tingling
Restlessness
muscle tension
Lump in throat
on edge
```
```
Mental state:
Dizzy/faint
Derealisation
Depersonalisation
Losing control
Fear of death
```
```
Non-specific:
Sleep disturbance
irritability
Difficulty concentrating
Exaggerated response to normal stimuli
```
88
GENERALISED ANXIETY DISORDER
risk factors?
- Female
- 35-54
- Divorced / alone
89
GENERALISED ANXIETY DISORDER
Investigations?
Rule out physical illness
- Thyroid
- B12/folate
- medication
- alcohol/ bento use (withdrawal symptoms)
90
GENERALISED ANXIETY DISORDER
management?
Step 1:
- Educate
- Exercise
- Stop smoking/drinking
Step 2:
- Psychological support/groups
Step 3:
- high intensity support CBT/ medication
91
GENERALISED ANXIETY DISORDER
what medication?
Rapid response:
Benzodiazepine
Long term:
Sertraline/SSRIs
Clomipramine
92
what is a panic attack?
period of intense fear characterised by group of symptoms that develop rapidly, reach peak at 10mins and generally don’t last longer than 20-30mins.
93
PANIC DISORDER
Risk factors?
- Loneliness
- Living in a city
- Poor education
- Early parental loss
- Sexual/physical abuse
94
PANIC DISORDER
Management?
CBT
1st - SSRIs (Sertraline)
2nd- Clomipramine
95
What is Agoraphobia?
Anxiety/panic over public. places that are difficult to escape
96
management of Agoraphobia?
Short term = BDZ
SSRIs
Relaxation and exposure training/techniques
97
OCD
What are obsessions?
Obsessions are unwanted intrusive thoughts, images or urges that repeatedly enter the person’s mind
98
OCD
What are compulsions?
Compulsions are repetitive behaviours or mental acts that the person feels drive to perform
99
OCD
Treatment?
▪ CBT - exposure + response
prevention - ERP
▪ SSRI – fluoxetine / sertraline
▪ TCA - Clomipramine - has specific non-obsessional action
100
PTSD
Clinical features?
- re-experiencing (flashbacks, nightmares)
- Avoidance (avoiding people or circumstances resembling the traumatic event)
- Hyperarousal (exaggerates responses to small threats)
- Emotional numbing (feeling detached)
101
PTSD
ICD-10?
Symptoms arise within 6mnths of traumatic event
Symptoms present for at least 1 month —> w/ significant distress / impairment in daily functioning
102
PTSD
Treatment?
1st - • CBT
• EMDR - Eye movement desensitisation and reprocessing
2nd - SSRIs
103
PTSD
Treatment of sleep disturbance?
Mirtazapine
104
PTSD
Tx of anxiety symptoms?
BDZs
Antidepressants
Propanolol
105
PTSD
tx of Intrusive thoughts / impulsiveness?
Carbamazepine, valproate, lithium
106
PTSD
tx of psychotic symptoms?
Antipsychotics
107
ANOREXIA
Diagnostic criteria?
Weight <85% of predicted
BMI <17.5
Intense fear of gaining weight
feeling fat when actually underweight
108
ANOREXIA
What is the SCOFF questionnaire?
```
Sick (make yourself)
Control (lost over eating)
One stone lost in 3 months
Feel fat
Food (dominates life)
```
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone in a 3 month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say that Food dominates your life?
109
ANOREXIA
Red flags?
o BMI <13 or below 2nd centile o Weight loss >1kg / week
o Temperature <34.5
o BP <80/50
o Sa02 <92%
o Long QT, flat T waves
o Weakness in muscles
110
ANOREXIA
management?
Restore nutritional balance
Involve carers
PSYCHOLOGICAL THERAPIES
- Eating disorder focussed CBT (ED-CBT)
- Maudsley anorexia nervosa treatment for adults (MANTRA)
111
Signs of Re-feeding syndrome?
Drop in phosphate due to rapid initiation of food after >10 days of undernutrition
```
▪ Rhabdomyolysis
▪ Respiratory / cardiac failure
▪ LowBP
▪ Arrhythmias
▪ Seizures
```
112
Management of re-feeding syndrome?
Slow refeeding
thiamine / vit B and multivits
Monitor for:
- Low phosphate
- Low potassium
- high glucose
- high magnesium
113
BULIMIA
Signs?
Same as anorexia +
- Oesophagitis (vomiting)
- Russell's sign (callouses on back of hands)
- Oedema
- Cardiomyopathy (laxatives)
114
BULIMIA
What can laxatives and vomiting cause metabolically?
Metabolically alkalosis = vomiting (hypochloraemia/ hypokalaemia)
Metabolic acidosis = laxatives
115
BULIMIA
Management?
EDU for severe
Self-help books
SSRIs
116
DEPRESSION
3 core symptoms?
- Low mood
- low energy (anergia)
- loss of enjoyment (anhedonia)
117
DEPRESSION
Clinical features?
```
DEADSWAMP:
• Depressed mood most of day
• Energy low
• Anhedonia
• Death thoughts -suicide
```
```
• Sleep disturbance (insomnia / hypersomnia)
• Worthlessness / guilt / hopelessness
• Appetite / weight change
• Mentation decreased - i.e. lack of
concentration
• Psychomotor agitation / retardation
```
118
DEPRESSION
Criteria?
Mild
Moderate
Severe
Mild = 2 core 2 other
Moderate = 2 core 3+ other
Severe = 3 core 4+ other
119
DEPRESSION
Assessments?
PHQ-9
HADs (Hospital Anxiety and Depression Scale)
120
DEPRESSION
Management of mild?
Lifestyle:
Sleep hygiene
anxiety management
physical activity
Computerised CBT
121
DEPRESSION
Management of moderate?
▪ Lifestyle
▪ Anti-depressants
▪ High intensity psychological therapies eg CBT via IAPT
122
DEPRESSION
Management of severe?
▪ Rapid specialist mental health assessment with inpatient admission consideration
▪ ECT - Electroconvulsive therapy
123
DEPRESSION
Pharmacological management?
1st line - SSRI
(prolonged QT in Citalopram)
2nd - alternative SSRI
3rd - NaSSA - Mirtazapine
4th - TCAs (Amitriptyline)
Moclobemide
124
Side effects of Anti-cholinergics/muscarinics?
- Tachycardia
- Dry mouth
- Blurred vision
- Constipation
- urinary retention
- Drowsiness
125
What are the components of the Mental State Examination
Appearance & Behaviour (body language, abnormal movements, alertness)
Speech (rate, tone, volume)
Emotions (mood)
Perceptions (are they responding to internal stimuli? E.g talking/laughing to themselves) / hallucinations
Thoughts (thought insertion/blocking
Insight (do you think you’re unwell/ need treatment?)
Cognition
126
BIPOLAR
Criteria?
Requires at least two episodes, one of which must be mania/hypomania for a diagnosis
127
BIPOLAR
Describe the types of Bipolar?
Bipolar I = Mania + Depression
Psychotic symptoms
Bipolar II = Hypomania
More episodes of depression and no psychosis
(do not meet full criteria of mania = hypomanic)
Cyclothymia = cyclic mood swings with subclinical features
128
BIPOLAR
Signs of Mania? (over 1 week)
- Uncontrollable elation
- Over activity
- Pressure of speech
- impaired judgement
- risk taking
- social disinhibition
- Grandiosity
- psychotic symptoms
129
BIPOLAR
Signs of Hypomania (over 4 days)
- elevated mood
- increased energy
- increased talking
- poor concentration
- mild reckless behaviour
- overfamiliarity
- increased libido
- increased confidence
- decreased need for sleep
- change in appetite
130
BIPOLAR
possible causes?
- post partum female
- substance misuse
- chronic illness
- past trauma/ mental health problems
131
BIPOLAR
Tx of acute mania?
Severe/ life threatening = ECT
Lithium (up to 2 weeks) +
Antipsychotics/ BDZs due to delayed effect:
- Risperidone
- Olanzapine
- Haloperidol
132
BIPOLAR
long term treatment?
1st = Lithium (inhibits cAMP)
check TSH, U&Es, hydration every 6 months
2nd = Valproate/ Lamotrigine if not tolerated
CBT can be helpful
ECT in SEVERE mania
133
DEMENTIA
Clinical features?
PROGRESSIVE DECLINE
1) Cognitive impairment (memory, language, attention etc)
2) Psychiatric changes
(personality, emotional control, social behaviour, agitation, hallucinations, delusion)
134
DEMENTIA
Types?
Alzheimer's
Vascular
Lewy body (Parkinson's)
Frontotemporal
Mixed
135
DEMENTIA
signs of Alzheimers?
- Cant remember conversations, names, events
Depression
Later: Poor communication, disorientation,
aphasia, apraxia, agnosia
136
DEMENTIA
Alzheimer's brain changes?
o Deposits of beta-amyloid protein fragment plaques
o Twisted strands of the protein tau (tangles)
o Evidence of nerve cell damage and death in the brain
o Reduced cortical ACh
137
DEMENTIA
Presenting variables of Vascular Dementia?
1) Cognitive deficits following single stroke
2) Multi-infarct dementia (stepwise deterioration following multiple strokes)
3) Binswanger's Disease (multiple microvascular infarcts)
138
DEMENTIA
Difference in symptoms between Vascular and Alzheimers
In vascular, impaired:
- Judgement
- Decision-making
- planning and organisation
comes before memory loss
139
DEMENTIA
Signs of Dementia with Lewy bodies?
Quicker onset
Memory loss and thinking problems
DIFFERENCE ; well-formed visual hallucinations
140
DEMENTIA
what are Lewy bodies?
Abnormal aggregations of protein alpha-synuclein in cortex
| same as Parkinson's but they aggregate in substantial nigra in PD
141
DEMENTIA
Describe Frontotemporal Dementia
This includes
FTLD (onset at young age 45-60)
Pick's Disease,
Progressive Supranuclear Palsy
(Change in personality and behaviour)
142
DEMENTIA
Treatment?
Occupational support (living at home)
Medications: Donepazil mainly
1) Cholinesterase inhibitors
2) Glutamate regulators
143
DEMENTIA
Medication treatment
Alzheimer's =
Donepazil/ Rivastigmine/ Galantamine (cholinesterase inhibitors)
Rivastigmine = Tx for Parkinsons/Dementia = Lewy body
3) Glutamate regulators = Memantine = Severe Alzheimer's
144
DEMENTIA
What may delay course of vascular dementia?
Daily aspirin
145
What is the Biopsychosocial formulation?
| P's
An approach to understanding a patient that takes into account biological, psychological and social perspectives.
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors
146
How could you breakdown the component of thought?
Stream- thought blocking?
Form- poverty of thought, thought disorder. Do they make sense?
Content - obsessions, delusions
(Insertion, withdrawal, broadcast)
147
What may a CT/MRI scan show on a dementia patient
CT = areas of infarct in vascular dementia
MRI = cerebral atrophy in Alzheimer's
Imaging can rule out space occupying lesions and chronic haemorrhage
148
SCHIZOPHRENIA
What is the strongest risk factor?
Family history
149
SCHIZOPHRENIA
First Rank Symptoms?
Passivity phenomena
Thought disorders (withdrawal, insertion, broadcasting)
Hallucinations - 3rd person auditory
Delusional perception - delusions of passivity, influence or control
150
SCHIZOPHRENIA
What is the ICD-10?
ONE or more of:
- Passivity phenomena
- Thought disorders
- Hallucinations (3rd person auditory)
- Delusional perception
OR TWO or more of:
- Any hallucination
- Catatonic behaviour
- negative symptoms ( no talking, acting incorrectly, no pleasure/motivation)
- Breaks in train of thought
- change in behaviour
- impaired insight
- neologisms
151
SCHIZOPHRENIA
subtypes?
- Paranoid
- Hebephrenic / Disorganised
- Catatonic
- Undifferentiated
- Residual (low intensity)
- Simple (progressive)
152
SCHIZOPHRENIA
Investigations?
Rule out drugs = urine screen
Rule out alcohol = LFTs, FBC, macrocytosis, thrombocytopenia
Rule out syphilis = sero test
Rule out brain lesion = CT head
153
SCHIZOPHRENIA
What is the Psychosis risk assessment?
risk to self
risk to others
risk from others
risk of criminal damage to property
154
SCHIZOPHRENIA
1st line Management?
CBT early on 3rd person hallucinations
- Atypical 2nd Gen D2 and 5HT antagonist:
- Olanzapine
- Resperidone
- Quetiapine
- Paliperidone
- Aripiprazole
155
SCHIZOPHRENIA
Side effects of first line treatment
- Atypical 2nd Gen D2 and 5HT antagonist:
- weight gain
- sudden cardiac arrest
- HTN, hyperlipidaemia/ hypercholesterolaemia
156
SCHIZOPHRENIA
2nd line management?
- Typical 1st gen D2 antagonist:
- Haloperidol
- Chlorpromazine
157
SCHIZOPHRENIA
Side effects of 2nd line management?
- Typical 1st gen D2 antagonist:
EPSEs!
- raised prolactin
- risk of stroke/VTE in elderly
158
SCHIZOPHRENIA
3rd line management?
Clozapine for treatment resistant schizophrenia
159
What is Schizoaffective disorder?
Mixture of schizophrenia and mood disorders
symptoms of both mania and depression in small time frame
treatment = mood stabilisers and anti-psychotics
160
PERSONALITY DISORDERS
Definiton?
Severe disturbance of a persons characteristics and behavioural tendencies of the individual
161
PERSONALITY DISORDERS
Diagnosis?
- Requires inhibition of self and social functioning
- One or more pathological personality traits
- Impairments are stable across most situations
- The impairments cannot be explained as "normal" for the individual's developmental stage or socio-cultural environment
162
PERSONALITY DISORDERS
Risk factors?
- Past abuse
- bullying
- childhood trauma
- expelled
- Self-harm
163
PERSONALITY DISORDERS
Management?
non-pharmacological = BEST
- Dialectical behavioural therapy (DBT) - especially borderline / cluster B personalities
Benzos for short term
164
What is meant by Cluster A, B and C personalities?
```
A = Eccentric MAD
B = Flamboyant BAD
C = Fearful/anxious SAD
```
165
Describe a simple overview of cluster A
- Paranoid (delusional, jealousy, conspiracies)
- schizotypal (weird and magical, circumstantial, bizarre and peculiar)
- schizoid (voluntarily withdraw from social interaction)
166
Describe a simple overview of cluster B
- Antisocial (impulsive, lack of guilt, low anger tolerance)
- Borderline (act without regard of consequences, unstable affect, mood swings, self harm/suicide)
- Histrionic (dramatic, shallow, extrovert, sexually inappropriate)
- Narcissistic (grandiosity, egotistical)
167
Describe a simple overview of cluster C
- Avoidant (tense and apprehensive)
- Dependant (need to be cared for, can't make own decisions)
- Anankastic (stubborn, perfectionism, egosyntonic, inflexibility) OCPD
168
What is the difference between Avoidant and Schizoid?
- Schizoid VOLUNTARILY withdraw
Avoidant - desire companionship but too afraid of rejection
169
Difference between OCPD and OCD?
Obsessive compulsive personality disorder = they're okay with how they are
OCD = do not like the obsessions/ compulsions = egodystonic
170
What is Egosystonic and Egodystonic?
Egosystonic = behaviour is consistent with ones ideal self image (does like their own thoughts/behaviours)
Egodystonic = conflict with ones ideal self image (does not like their own thoughts / behaviours)
171
Name 4 types of Sleep Disorders
Narcolepsy
sleep apnoea
Circadian rhythm disorder
Parasomnia
172
What is Narcolepsy?
Always tired through the day that they cannot resist
173
what is sleep apnoea?
repeated and intermittent upper air collapse during sleep
174
what is circadian rhythm disorder?
Mismatch between sleep-wake cycle and circadian rhythms (jet lag/shift work)
175
What is parasomnia?
restless leg syndrome
nightmares/ night tremors
sleep walking/talking
176
State some sleep hygiene advice?
1) Limit : Caffiene, alcohol, cigarettes
2) Less noise/lights/screen use
3) Reduce sleep
4) regular pattern
177
Name some short acting benzodiazepines
Chlorazepate
Midazolam
Triazolam
178
Name some non-benzodiazepine hypnotic agents
Zopiclone
Zaleplon
Zolpiderm
179
State the suicide risk assessment
SADPERSONS
o Sex - (males > females)
o Age – peaks in young and old
o Depression
o Previous attempts and severity of means
o Ethanol abuse - ALCOHOL
o Rational thinking loss – eg Schizophrenia
o Support network loss
o Organised plans – eg note, alone, avoid detection, planned/impulsive
o No significant others
o Sickness – eg physical disease
o 0-2 – no real problems, keep watch
o 3-4 – send home, but check frequently
o 5-6 – consider hospitalisation, involuntary or voluntary
o 7-10 – definitely hospitalise, involuntary or voluntary
180
MENTAL HEALTH ACT
For each section state the:
- Duration
- Reason
- Approved by
- Evidence
SECTION 2
Duration: 28 days
Reason: Assessment
Approved by: 2 Drs + 1 AMHP
Evidence: Patient suffers from disorder and detained for own and others safety
181
MENTAL HEALTH ACT
For each section state the:
- Duration
- Reason
- Approved by
- Evidence
SECTION 3
Duration: 6 months
Reason: Treatment
Approved by: 2 Drs + 1 AMHP
Evidence: Patient suffers from disorder and detained for own and others safety
182
MENTAL HEALTH ACT
For each section state the:
- Duration
- Reason
- Approved by
- Evidence
SECTION 4
Duration: 72hrs
Reason: emergency order- urgent when waiting for 2nd Dr would cause undesirable delay
Approved by: 1 Dr and 1 AMHP
Evidence: Patient suffers from disorder and detained for own and others safety and not enough time for 2nd Dr
183
MENTAL HEALTH ACT
For each section state the:
- Duration
- Reason
- Approved by
- Evidence
SECTION 5 (4)
Duration: 6hrs
Reason: Patient admitted but wanting to leave
Approved by: Nurse holding power
Evidence: Cannot be coercively treated
184
MENTAL HEALTH ACT
For each section state the:
- Duration
- Reason
- Approved by
- Evidence
SECTION 5 (2)
Duration: 72hrs
Reason: Allows time for section 2&3
Approved by: Doctors holding power
Evidence: Cannot be coercively treated
185
MENTAL HEALTH ACT
For each section state the:
- Duration
- Reason
- Approved by
- Evidence
SECTION 136
Reason: Mental disorder in public - further assessment - section 2/3
Approved by: Police sections
Evidence:
186
MENTAL HEALTH ACT
For each section state the:
- Duration
- Reason
- Approved by
- Evidence
SECTION 135
Reason: Mental disorder at home - further assessment - section 2/3
Approved by: Police sections
Evidence: Needs court order to access Patient home and remove them
187
5 Principles of Mental Health Act?
▪ 1. Assume capacity
▪ 2. Individual supported to make own decision
▪ 3. Unwise decisions do not mean lack of capacity
▪ 4. Best interests
▪ 5. Least restrictive practice
188
what does having capacity mean?
Able to:
1) Understand
2) Retain
3) weigh up
4) Communicate decision
189
What are advanced statements and advanced decisions?
Statements: NOT legally binding. Person documents their wishes should they lack capacity in the future
Decisions: LEGALLY binding document.
Made with capacity
may be refusing medical interventions - witness
190
What is a last power of attorney?
Person to make decisions for them if they lack capacity in future
191
What is the court of protection?
Makes decisions if no lasting power of attorney
192
What is DOLS?
Deprivation of Liberty Guards
Allows deprivation of someones liberty who lacks capacity under legal framework in hospital or care environment if its in patients BEST interests
193
Causes of Delirium?
```
Pain
Infection/ intoxication
Nutrition (metabolic imbalance)
Constipation
Hydration
```
Medication
Environment
194
management of Delirium?
Haloperidol
Olanzapine
Risperidone
quetiapine
195
Ddx for Dementia?
```
o Alzheimer’s Disease
o Vascular Dementia
o Lewy Body Dementia
o Pick’s Disease
o Creutzfeldt-Jacob Disease
o Huntington’s Disease
o HIV infection (AIDS)
o Neurosyphilis
o Wilson’s disease
o Normal pressure hydrocephalus
o Alcohol-induced dementia
```
196
Ddx of Psychosis?
```
o The difference in presenting symptoms between a psychosis and a neurosis
o The difference between positive and negative psychotic symptoms
o Schizophrenia
▪ Paranoid
▪ Hebephrenia
▪ Catatonic
▪ Residual
▪ Simple
o Positive and negative psychotic symptoms
o Acute and transient psychosis
o Persistent delusional disorder
o Schizoaffective disorder
o Puerperal psychosis
```
197
Ddx for Neuroses?
```
o Generalised Anxiety Disorder
o Phobias
▪ Specific
▪ Agoraphobia
▪ Social
o Panic Disorder
o Obsessive Compulsive Disorder (OCD)
o Post-traumatic stress disorder (PTSD)
o Adjustment Disorder
o Malingering
o Dissociative (conversion) Disorder
o Somatisation Disorder
o Hypochondriacal Disorder
o Persistent Somatoform Pain Disorder
```
198
Ddx for mood disorder?
```
o Hypomania
o Mania and bipolar disorder o Depressive disorder
o Mild; Moderate; Severe
o Persistent mood disorder
o Cyclothymia; Dysthymia
o “Baby blues”
o Post-natal depression
```
199
Name types of Therapies
* Counselling
* Behavioural Therapy
* Cognitive Therapy
* Psychodynamic Therapy
* Electro-convulsive Therapy
200
What are the 4 core features of PTSD?
1) Hyperarousal
2) Emotional numbing
3) Avoidance
4) Re-experiencing
201
Give an example of a NaSSAs and its side effects
Mirtazapine
- Sedation
- Weight gain
202
Name side effects of SSRIs
- Headache
- Nausea
- Insomnia
203
Name side effects of TCAs
Anti-cholinergic
Postural hypotension
sedation
weight gain
204
Side effect of MAO- inhibitors
Tyramine- cheese reaction (hypertensive crisis)
205
Contraindication of Electroconvulsive Therapy?
Raised ICP!!
- Arrhythmias
- Headache
- Nausea
206
Name some side effects of hyperprolactinaemia?
Galactorrhoea
Amenorrhoea
Infertility
Sexual dysfunction (vaginal dryness)
LONG TERM = osteoporosis
207
Features of Mania?
I DIG FASTER
Irritability
Disinhibited (sexual, financial)
Insight impaired
Grandiose delusions
```
Flight of ideas
Activity/Appetite increased
Sleep decreased
Talkative (pressure of speech)
Elevated mood/energy increase
Reduced conc/ reckless/ risk taking
```
208
Diagnostic criteria of Mania?
>1 week elevated mood + >3 of:
Increased Energy or Activity
Distractibility
Decreased need to sleep
Increased libido
Grandiosity
Talkativeness (Pressured Speech)
Flight of ideas
Psychomotor Agitation (Aggressiveness) / Irritability
I DDIG FP
209
Lithium side effects?
- Leukocytosis
- Interstitial nephritis/ Insipidus (Diabetes)
- Tremor (Fine -> Coarse)
- Hydration decreased (Dry mouth, Diarrhoea, Thirst), causes Polyuria
- Increased GI, skin and memory problems
- Underactive thyroid
- Mum’s beware (Teratogenic)
210
Lithium Toxicity signs?
Plasma levels >1.5mmol/L
Coarse Tremor
N+V, Diarrhoea
```
Neuro complications (Fasiculation/Myoclonus, Hyperreflexia, Ataxia, Dysarthria,
Confusion/ Delirum)
```
Seizures
Renal failure
Death
211
Signs of Wernicke's encephalopathy?
triad
1) ophthalmoparesis with nystagmus
2) Ataxia
3) Confusion
212
Cause of Wernicke's encephalopathy?
Thiamine deficiency (vit B1)
213
what is hebephrenic schizophrenia?
predominated by thought. disorders with a poor prognosis
214
What are the different features between paranoid and simple schizophrenia?
Paranoid = Lots of positive symptoms
Simple = mainly negative symptoms with a history of psychosis
