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Year 5 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Physical signs of anxiety

A
  • Tachycardia
  • Palpitations
  • Hypertension
  • SOB/tachypnoea
  • chest pain
  • choking sensation
  • tremors/shaking
  • muscle tension
  • dry mouth
  • sweating
  • cold skin
  • nausea/vomiting
  • diarrhoea
  • ‘butterflies in the stomach’
  • dizziness, lightheadedness
  • mydriasis
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2
Q

Risk factors and triggers for Hyperventilation Syndrome

A
  • Female
  • Age 15-55
  • Emotional distress
  • Sodium lactate
  • Caffeine
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3
Q

Clinical features of hyperventilation syndrome

A
  • agitation
  • confusion
  • dizziness
  • weakness
  • depersonalisation
  • visual hallucinations
  • syncope
  • parasthesia: usually bilateral upper limbs
  • peri-oral numbness
  • atypical chest pain
  • tachypnoea
  • hyperpnoea
  • dyspnoea
  • wheeze
  • bloating
  • belching
  • flatus
  • epigastic pressure
  • dry mouth
  • acute hypocalcaemia
  • acute hypokalemia
  • acute hypophosphatemia
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4
Q

Investigations to rule out an organic cause of hyperventilation syndrome

A
  • FBC
  • U&Es
  • TFTs
  • glucose
  • calcium
  • ABG: normal pH, normal CO2, low bicarb
  • Toxicology
  • ELISA
  • D-dimer
  • ECG
  • CXR
  • V/Q scan
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5
Q

Acute management of hyperventilation syndrome

A
  • Reassurance
  • alleviation of anxiety e.g. benzos
  • establishment of normal breathing pattern
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6
Q

Long-term management of hyperventilation syndrome

A
  • Education
  • Formal breathing retraining
  • B-blockers and benzos
  • Treatment of any underlying medical disorder
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7
Q

Prevalence of GAD

A

3%

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8
Q

Risk factors for GAD

A
  • family history
  • female
  • age 35-54
  • divorced/separated
  • living alone
  • single parents
  • unemployment
  • childhood phobias
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9
Q

Description of GAD

A

Long-standing, free-floating excessive anxiety - excessive worries about minor matters on most days for 6 months, not limited to specific situations

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10
Q

Symptoms of GAD

A
  • Edginess/restlessness
  • difficulty concentrating
  • irritability
  • GI upset
  • muscle aches/tension
  • difficulty sleeping and chronic fatigue/easy fatiguability
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11
Q

ICD-10 criteria for diagnosis of GAD

A

Key elements:

1) Apprehension
2) Motor tension
3) Autonomic overactivity

Diagnosis requires at least 4 of the following criteria (with at least 1 from autonomic arousal):

  • symptoms of autonomic arousal
  • physical symptoms of anxiety
  • mental state symptoms
  • generalised symptoms
  • symptoms of tension
  • other: exaggerated response to minor startles
  • concentration difficulties
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12
Q

Management of GAD

A
  • CBT
  • SSRIs
  • beta-blockers for symptomatic relief
  • benzos
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13
Q

Prevalence of panic attacks

A

8%

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14
Q

Describe a panic attack

A

A sudden period of intense fear or discomfort that something bad is going to happen and there is some imminent threat or danger, often accompanied by physical symptoms. Symptoms peak in the first 10-20 minutes.

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15
Q

Physical symptoms of a panic attack

A
  • Pounding heart/tachycardia
  • chest pain
  • sweating
  • trembling
  • SOB
  • nausea
  • dizziness
  • chills or hot flushes
  • numbness/tingling
  • feelings of choking
  • derealisation or depersonalisation
  • fear of losing control
  • fears of dying
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16
Q

Acute management of a panic attack

A
  • Reassurance
  • Consider benzos if symptoms are severe and distressing
  • Exclusion of medical causes if first presentaiton
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17
Q

Describe a panic disorder

A

Recurrent panic attacks that occur unpredictably and are not restricted to any particular situation or objective danger.

Not secondary to substance misuse, a medical condition or other psychiatric disorder.

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18
Q

Prevalence of panic disorders

A

2%

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19
Q

Risk factors for panic disorder

A
  • Female sex
  • Family history
  • Age: 15-24, 45-54
  • Widowed
  • Divorced/separated
  • Living in a city
  • Limited education
  • Early parental loss
  • Physical/sexual abuse
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20
Q

Investigations to rule out a organic cause in panic disorder

A
  • FBC
  • U&Es
  • glucose
  • TFTs
  • ECG
  • Toxicology
  • Calcium
  • Echo
  • EEG
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21
Q

Describe anticipatory anxiety

A

When patients get anxious about the possibility of having a panic attack

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22
Q

Management of panic disorder

A
  • CBT
  • SSRIs
  • Benzodiazepines
  • continue treatment for 12-18 months before trial discontinuation with tapering doses
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23
Q

Poor prognostic factors for panic disorder

A
  • very severe initial symptoms
  • marked agoraphobia
  • low SES
  • low education level
  • long duration of untreated symptoms
  • restricted social networks
  • personality disorder
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24
Q

Prevalence of phobic disorders

A

10%

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25
Q

Describe a phobia

A

Intense unreasonable irrational fear of an object, activity or situation.

Patients recognise this fear as irrational but will go to extreme lengths to avoid the trigger

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26
Q

Management of a phobia

A
  • Gradual exposure therapy

- SSRIs

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27
Q

Prevalence of a specific phobia

A

6%

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28
Q

Describe agoraphobia

A

A fear of entering crowded spaces where an immediate escape is difficult or embarrassing, or in which help may not be available in the event of a panic attack

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29
Q

Prevalence of agoraphobia

A

2%

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30
Q

Risk factors for agoraphobia

A
  • Female
  • Family history
  • Age: 15-35
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31
Q

Describe social anxiety/social phobia

A

> 6 months of anxiety causing individuals to fear acting in a certain way which might make them get judged and can cause anxiety which interferes with their normal routine and relationships.

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32
Q

Prevalence of social anxiety

A

2.3%

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33
Q

Management of social anxiety

A
  • CBT
  • SSRIs
  • Beta-blockers for symptomatic relief
  • SNRIs
  • MAOIs
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34
Q

Prevalence of Bipolar disorder

A

1%

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35
Q

Risk factors for bipolar disorder

A
  • Age
  • Family history
  • Childbirth
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36
Q

Clinical features of bipolar disorder

A
  • hypomanic/manic episodes
  • increased energy
  • decreased need for sleep
  • elevated sense of self-esteem or grandiosity
  • poor concentration
  • accelerated thinking and speech
  • impaired judgement and insight
  • disordered thought form
  • abnormal beliefs
  • perceptual disturbance
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37
Q

Investigations to rule out organic causes of mania

A
  • FBC & inflammatory markers
  • TFTs
  • HIV screen
  • blood glucose
  • Infection screen
  • Vitamin B12
  • Urine drug screen
  • Brain CT/MRI
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38
Q

Indications for hospitalisation in a manic episode

A
  • Impaired judgement endangering the patient or others around them
  • Significant psychotic symptoms
  • Excessive psychomotor agitation with risk for self-harm, dehydration or exhaustion
  • thoughts of harming self or others
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39
Q

Treatment of acute mania

A
  • Discontinuation of any antidepressants
  • Short-term benzodiazepines
  • Antiemetic agents
  • Antipsychotics
  • Continue any current mood stabilisers
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40
Q

Treatment of acute depression in bipolar disorder

A
  • Co-prescription of antidepressants and anti-manic agents e.g. quetiapine OR fluoxetine + olanzapine
  • Ensure doses of lithium or valproate are at a high level
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41
Q

Maintenance treatment in bipolar disorder

A

Maintenance treatment recommended for at least 2 years

  • Lithium
  • Augmentation with valproate
  • Lamotrigine or carbamazepine
  • Physical health monitoring due to increased CVD risk: annual weight, pulse, glucose, HbA1c, lipids, LFTs
  • Family therapy, CBT/interpersonal therapy/avoidance of stimulation
  • ECT
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42
Q

Indications for maintenance treatment in bipolar disorder

A
  • Manic episode associated with severe adverse risk or consequences
  • manic episodes and another disordered mood episode
  • repeated hypomanic and depressive episodes with significant functional impairment or risk
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43
Q

Monitoring required for patients on lithium

A
  • Baseline ECG and bloods
  • 3 monthly lithium levels
  • Annual U&Es, TFTs, calcium
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44
Q

Risk factors for suicide

A
  • Male
  • Depression
  • Bipolar disorder
  • Alcohol misuse e.g. intoxication
  • Eating disorders
  • Schizophrenia
  • Adjustment disorder
  • Personality disorders
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45
Q

Overall prevalence of dementia

A

1%

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46
Q

Risk factors for dementia

A
  • Age
  • Sex: AD is more common in women, vascular dementia more common in men
  • Previous cognitive impairment
  • family history
  • previous stroke
  • AF
  • smoking
  • hypertension
  • diabetes
  • hypercholesterolaemia
  • previous MI
  • obesity
  • late onset depression
  • head injury
  • low educational attainment
  • Down syndrome
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47
Q

Causes of dementia

A
  • AD
  • Frontotemporal dementia
  • Lewy body dementia
  • Parkinson disease
  • Huntington disease
  • Progressive supranuclear palsy
  • Vascular dementia
  • Space-occupying lesions
  • Trauma
  • Infection
  • Metabolic disturbance
  • Endocrine disease
  • Nutritional deficiencies
  • Drugs and toxins
  • Chronic hypoxia
  • Inflammatory disease
  • Normal pressure hydrocephalus
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48
Q

Characteristic pathological changes in AD

A

beta amyloid plaques and neurofibrillary tangles of hyperphosphorylated tau protein

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49
Q

Clinical features of dementia

A
  • Symptoms present for 6 months
  • Normal conscious levels
  • Progressive functional impairment
  • Progressive memory impairment
  • Aphasia
  • Apraxia
  • Agnosia
  • Impaired executive functioning
  • Behavioural changes
  • Mood changes
  • Psychosis
  • Neurological symptoms
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50
Q

Distinguishing features of AD

A
  • Gradual, insidious onset of progressive cognitive decline with early memory loss
  • Personality changes
  • Langauge difficulties
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51
Q

Distinguishing features of vascular dementia

A
  • Focal neurological changes
  • Evidence of cerebrovascular disease or risk factors
  • May be uneven or stepwise deterioration
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52
Q

Distinguishing features of Lewy Body dementia

A
  • Day to day fluctuations in cognitive performance
  • Recurrent visual hallucinations
  • Motor signs of Parkinsonism
  • REM sleep behaviour disturbance
  • Recurrent falls and syncope
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53
Q

Distinguishing features of frontotemporal dementia

A
  • early decline in social and personal conduct
  • dietary changes
  • early emotional blunting and loss of insight
  • attenuated speech output, echolalia, preservation, mutism
  • loss of semantic knowledge and naming
  • relative sparing of other cognitive function
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54
Q

Investigations to exclude reversible causes of dementia

A
  • Vitamin B12/folate
  • TFTs
  • Calcium
  • Glucose
  • U&Es
  • CT/MRI head
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55
Q

Management of dementia

A

Mild/moderate AD:
Lewy Body dementia: Cholinesterase inhibitors

Moderate/severe AD: NMDA receptor antagonists

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56
Q

Contraindications for cholinesterase inhibitors

A
  • bradycardia
  • caution in PUD
  • COPD
  • hepatic impairment
  • arrhythmias
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57
Q

Prevalence of depression

A
  • 20% in women

- 12% in men

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58
Q

Risk factors for depression

A
  • Family history
  • Early life stressors
  • Acute or chronic stress
  • Age: late 20s
  • Female sex
  • Neurotic personality traits
  • Personality disorders
  • Separation or divorce
  • Unemployment
  • Illness
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59
Q

Clinical features of depression

A
  • Early morning waking
  • Difficulty falling asleep
  • Frequent awakening
  • Hypersomnia
  • Dramatic reduction in appetite with weight loss >5% of body weight in last month
  • Psychomotor retardation or agitation
  • loss of libido
  • reduced concentration and memory
  • poor self esteem
  • guilt
  • hopelessness
  • suicide/self harm
  • psychotic symptoms
  • loss of emotional reactivity
  • diurnal mood variation
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60
Q

Investigations to rule out organic causes of depression

A
  • FBC
  • ESR
  • B12/folate
  • U&Es
  • LFTs
  • TFTs
  • Glucose
  • Calcium
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61
Q

ICD-10 criteria for depressive episodes

A

Episodes must last >2 weeks and represent a change from normal

Must have at least 2/3 of:

  • depressed mood
  • loss of interest or pleasure
  • reduced energy or increased fatiguability

Must have at least 2 of the following symptoms:

  • disturbed sleep
  • diminished appetite
  • psychomotor retardation or agitation
  • reduced concentration and attention
  • reduced self-esteem and self-confidence
  • ideas of guilt
  • bleak and pessimistic views of the future
  • ideas of self harm or suicide
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62
Q

Management of depression

A

Lifestyle advice

  • physical activity
  • diet
  • avoidance of alcohol and drugs
  • good sleeping habits

Psychotherapy

  • CBT
  • Interpersonal therapy
  • Psychodynamic therapy
  • Family counselling
  • Mindfulness

Antidepressants (in moderate/severe depression) for at least 6 months after remission of symptoms is achieved e.g. SSRIs

ECT

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63
Q

Indications for ECT

A
  • Poor response to adequate trials of antidepressants
  • Intolerance of antidepressants due to side effects
  • Depression with severe suicidal ideation
  • Depression with psychotic features, severe psychomotor retardation or stupor
  • Depression with severe self neglect
  • Previous good response to ECT
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64
Q

Poor prognostic factors for depression include

A
  • Insidious onset
  • Neurotic depression
  • Elderly patient
  • Residual symptoms
  • Low self-confidence
  • Comorbidity
  • Lack of social supports
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65
Q

Prevalence of eating disorders

A

6.4%

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66
Q

Risk factors for eating disorders

A
  • Female
  • Age
  • Family history
  • Familial habits
  • Premature birth
  • Perinatal complications
  • Childhood adversity
  • Relationship difficulties
  • Certain personality traits
  • OCD, depression, anxiety
  • Increased exposure to media
  • certain careers e.g. dancers
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67
Q

Clinical features of anorexia nervosa

A
  • Self imposed low body weight
  • Preoccupation with being thin
  • Restrictive food behaviours and food rituals
  • Amenorrhoea
  • Loss of libido, impotence
  • Impaired growth spurt during puberty or arrested or delayed pubertal changes
  • Generalised endocrine abnormalities
  • Physical symptoms e.g. palpitations, syncope, fatigue, cold sensitivity, muscle weakness
  • Overvalued ideas concerning body, intrusive dread of fatness
  • Anxiety
  • Purging behaviours
  • Abnormal weighing behaviours
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68
Q

Clinical features of bulimia nervosa

A
  • Normal/slightly above normal weight
  • Preoccupation with eating and irresistible craving for food
  • Binge eating followed by a sense of control and feelings of shame and disgust
  • Overvalued ideas around body image
  • Anxiety
  • Purging behaviours
  • Abnormal weighing behaviour
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69
Q

Examinations to undertake in a person with an eating disorder

A
  • BMI
  • Presence of lanugo hair
  • Loss of head hair
  • Russell’s signs (callouses on hands from frequent vomiting)
  • Dental abrasions or tooth decay
  • lying and standing BP and pulse
  • Muscle wasting
  • SUSS test
  • Temperature
  • Mucous membranes for signs of dehydration
  • Facial glands (swollen parotids in frequent vomiting)
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70
Q

Red flag signs in an eating disorder

A
  • Extreme weight loss (>30% expected weigh or BMI <14)
  • Bradycardia (<40 bpm)
  • Marked postural hypotension (>20mmHg systolic) or postural tachycardia (>30bpm)
  • Prolonged QT
  • Severe dehydration
  • Hypothermia (<35.5)
  • Unable to get up form squatting or lying flat without using hands
  • Confusion
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71
Q

Investigations to consider in a patient with an eating disorder

A
  • FBC
  • U&Es
  • LFTs and amylase
  • Glucose
  • Cholesterol levels
  • Endocrine screen: GH, cortisol, TFTs, LH and FSH
  • ECG
  • DEXA scan
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72
Q

Biochemical profile in a person with an eating disorder

A
  • Normocytic anaemia
  • Leukopenia
  • Hypokalemia
  • Hypochloraemia
  • Acidosis
  • Hyponatremia
  • Hypomagnesaemia
  • Hyophosphatemia
  • Raised transaminases
  • Hypoglycaemia
  • Low creatinine
  • Hypercholesterolaemia
  • Raised amylase
  • Raised GH
  • Raised cortisol
  • Low T3
  • Low FSH an LH
  • Long QT
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73
Q

ICD-10 criteria for anorexia nervosa

A

A patient must have ALL of the following:

  • Low BMI
  • Self-induced weight loss
  • Overvalued idease
  • Endocrine disturbances
  • Failure to make expected weight gains, delayed or arrested pubertal events (in pre-pubertal patients)
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74
Q

ICD-10 criteria for bulimia nervosa

A

A patient must have ALL of the following:

  • Regularly occurring episodes of binge eating
  • Pre-occupation with and strong cravings for food
  • Methods to counteract weight gain
  • Overvalued ideas
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75
Q

Management of anorexia nervosa

A

Psychotherapy

1) Family therapy in children OR CBT-ED or MANTRA or SSCM in adults
2) CBT-ED or focussed psychotherapy in children OR trial of a different first line therapy

Multivitamin supplementation

Monitoring of weight and physical complications

Treatment of co-morbid anxiety/depression

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76
Q

Management of bulimia nervosa

A

Psychotherapy

1) Family therapy in children OR Guided self help in adults
2) CBT-ED

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77
Q

Indications for hospital inpatient treatment in anorexia nervosa

A
  • BMI <13.5
  • Rapid weight loss
  • Severe electrolyte abnormalities
  • Syncope
  • Suicide risk
  • Social crisis
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78
Q

Indications for hospital inpatient treatment in bulimia nervosa

A
  • Electrolyte disturbances from purging

- Suicide risk

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79
Q

Electrolyte abnormalities seen in refeeding syndrome

A
  • Hyophosphatemia
  • Hypokalemia
  • Hypomagnesamia
  • Hyponatremia
  • Metabolic acidosis
  • Thiamine deficiency
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80
Q

Clinical manifestations of refeeding syndrome

A
  • Muscle weakness
  • Seizures
  • Peripheral oedema
  • Cardiac arrhythmias
  • Hypotension
  • Delirium
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81
Q

Poor prognostic indicators in anorexia nervosa

A
  • Long duration of illness
  • Age of onset before puberty or after 17
  • Male sex
  • Very low weight
  • Binge-purge symptoms
  • Personality difficulties
  • Difficult family relationships
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82
Q

Poor prognostic indicators in bulimia nervosa

A
  • Severe binge-purge behaviour
  • Low weight
  • Comorbid depression
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83
Q

Complications of eating disorders

A
  • Emaciation
  • Cold intolerance
  • Lethargy
  • Amenorrhoea
  • Infertility
  • Reproductive tract atrophy
  • Cardiomyopathy
  • Bradycardia
  • Hypotension
  • Cardiac arrhythmias
  • Heart failure
  • Constipation
  • Abdominal pain
  • Oesophageal tears
  • Gastric rupture
  • Lanugo hair
  • Loss of head hair
  • Russell’s sign
  • Proximal muscle weakness
  • Osteoporosis
  • Peripheral oedema
  • Seizures
  • Impaired concentration
  • Depression
  • Dental problems
  • Deranged blood chemistry
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84
Q

Describe somatoform disorders

A

A class of disorders where patients are unduly concerned about physical symptoms or illness, despite examinations and investigations showing no detectable structural or physiological abnormalities

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85
Q

Describe conversion disorders

A

A term which describes the hypothetical process where psychic conflict or pain undergoes ‘conversion’ into somatic or physical form to produce physical symptoms

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86
Q

Describe somatisation disorder

A

Multiple, recurrent and frequently changing physical symptoms with the absence of an identifiable physiological explanation

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87
Q

Describe hypochondriacal disorders

A

Misinterpretation of normal bodily sensations, leading patients to believe they have a serious and progressive physical disease, despite normal examinations and investigations and frequent reassurance.

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88
Q

Describe body dysmorphic disorder

A

A variant of hypochondriacal disease in which patients are preoccupied with an imagined or minor defect in their physical appearance, causing significant distress or impairment in functioning

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89
Q

Describe Munchausen disorder

A

Physical or psychological symptoms are produced intentionally or feigned for primary gain.

Munchausen by proxy is when a carer will seek help for fabricated or induced symptoms in a dependent

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90
Q

Describe malingering

A

Physical or psychological symptoms are produced intentionally or feigned for secondary gain e.g. benefits, illicit drugs

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91
Q

Risk factors for medically unexplained symptoms

A
  • Age
  • Female sex
  • Childhood sexual abuse
  • Growing up in environments where physical distress is more readily acknowledged than psychological distress
  • Stressor
  • Minor physical injury
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92
Q

Examples of medically unexplained symptoms

A
  • Atypical chest pain
  • Hyperventilation syndrome
  • IBS
  • Dissociative seizures
  • Weakness and sensory symptoms
  • Fibromyalgia
  • Chronic fatigue syndrome
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93
Q

Risk factors for PMS

A
  • Significant psychosocial stress
  • History of trauma
  • Obesity
  • Family history
  • History of depression or anxiety
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94
Q

Clinical features of PMS

A

Symptoms occur in the 10 days prior to menstruation, peaking 2 days before menses begin and remit in the 2 weeks following

  • Low mood
  • Labile mood/irritability
  • Concentration difficulties
  • Anxiety
  • Fatigue
  • Headaches
  • Abdominal bloating
  • Breast tenderness
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95
Q

Management of mild PMS

A
  • Healthy eating
  • Stress reduction
  • Regular sleep
  • Regular exercise
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96
Q

Management of moderate/severe PMS

A
  • COCP
  • Analgesia
  • CBT
  • SSRI
  • GnRH analogues with HRT
  • Surgical treatment with add-back HRT
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97
Q

Prevalence of psychiatric disorders in pregnant women

A

10%

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98
Q

Indications for referral to the perinatal psychiatric services

A
  • Preconception counselling for women with mental illness
  • Pregnant women who are severely psychiatrically unwell
  • Pregnant women at high risk of puerperal mental illness
  • Women expressing ideas of self-harm, suicide or homocide
  • Women with a history of puerperal psychosis
  • Psychiatrically unwell women who are the main carer for babies <6 months old
  • Pregnant women with harmful or dependent substance use
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99
Q

Risks of SSRI use in pregnancy and breastfeeding

A
  • Withdrawal symptoms in the neonate
  • Small risk of congenital heart disease if used in 1st trimester
  • Rarely associated with persistent pulmonary hypertension when given after 1st trimester

Fluoxetine and sertraline considered safest in pregnancy

Sertraline considered safest in breast-feeding but all are considered safe. Breastfeeding should NOT be discouraged.

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100
Q

Risks of tricyclics use in pregnancy and breastfeeding

A
  • Withdrawal symptoms in the neonate
  • Risk of toxicity in overdose

Considered safe in breastfeeding (except doxepin)

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101
Q

Risks of mood stabilisers use in pregnancy and breastfeeding

A

ALL ARE ASSOCIATED WITH TERATOGENICITY:

  • Valproate and carbamazepine increase risk of neural tube defects
  • Valproate also increases the risk of congenital abnormalities and developmental disorders
  • Lithium increases risk of cardiac defects and Epstein’s anomaly, but CAN be used in pregnancy

Lithium is NOT advised in breastfeeding - risk of neonatal toxicity

Valproate and carbamazepine may be associated with neonatal hepatotoxicity

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102
Q

Risks of antipsychotic use in pregnancy and breastfeeding

A
  • May cause EPSE in neonates
  • Olanzapine increases risk of gestational diabetes
  • AVOID large doses in infants due to risk of lethargy
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103
Q

Risks of benzodiazepines use in pregnancy and breastfeeding

A

Associated with floppy infant syndrome (hypotonia, breathing and feeding difficulties)

Neonatal withdrawal syndrome

Use benzos with a short half life in breastfeeding if necessary

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104
Q

Prevalence of ‘postnatal blues’

A

50-80% of pregnant women

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105
Q

Symptoms of the baby blues

A

Presents within 10 days post delivery and symptoms peak between days 3-4

  • Episodes of tearfulness
  • Mild depression or anxiety
  • Emotional lability and irritability
  • Feeling exhausted or overwhelmed
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106
Q

Management of baby blues

A

Reassurance - symptoms resolve spontaneously in 2 weeks

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107
Q

Prevalence of postnatal depression

A

12% of pregnant women

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108
Q

Risk factors for postnatal depression

A
  • Lack of a close confiding relationship
  • Intimate partner violence
  • Low income
  • Young maternal age
  • Previous history of depression
  • History of antenatal depression
  • Discontinuation of antidepressants
  • Obstetric complications during delivery
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109
Q

Clinical features of postnatal depression

A

Symptoms onset within 3 months of delivery and peak at 3-4 weeks

  • Low mood
  • Anhedonia
  • Fatiguability, sleep disturbance
  • Low self confidence/low self esteem
  • Suicidal ideation
  • Anxious preoccupation with the baby’s health, often associated with feelings of guilt and inadequacy
  • Reduced affection for the baby with possible impaired bonding/loss of interest
  • Difficulty coping with care of the baby
  • Obsessional phenomena: typically recurrent intrusive thoughts of harming the baby
  • Infanticidal ideas
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110
Q

Management of postnatal depression

A

Mild:
- facilitated self help

Moderate:

  • High intensity psychotherapy e.g. CBT
  • Antidepressant e.g. SSRI

Severe:

  • Hospital admission to mother and baby unit
  • Consider ECT
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111
Q

Prevalence of postpartum psychosis

A

1 in 500

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112
Q

Risk factors for postpartum psychosis

A
  • Primiparity
  • Personal history of bipolar of postpartum psychosis
  • Family history of bipolar or postpartum psychosis
  • Obstetric complications
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113
Q

Clinical features of postpartum psychosis

A

Episodes onset rapidly and deteriorate quickly. Usually occur within 2 weeks of delivery, often within a few days. Symptoms often fluctuate dramatically over a short space of time.

  • Insomnia
  • Restlessness
  • Perplexity
  • Suspiciousness
  • Psychotic symptoms (often related to the baby)
  • Mood symptoms e.g. depression, elation, mood instability, overactivity
  • Rambling, disordered speech
  • Retained degree of insight
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114
Q

Red flag symptoms in postpartum psychosis

A
  • Thoughts of self harm or harming the baby
  • Severe depressive delusions e.g. belief that the baby is/should be dead
  • Command hallucinations instructing the mother to harm herself or the baby
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115
Q

Management of postpartum psychosis

A

PSYCHIATRIC EMERGENCY

  • Hospitalisation in a mother and baby unit
  • Urgent referral to psychiatry
  • DO NOT leave the mother alone with the baby
  • Antidepressants/antipsychotics/mood stabilisers depending on presentation
  • Benzodiazepines in severe behavioural disturbance
  • ECT in severe or treatment resistant cases
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116
Q

Which law are compulsory measures in mental health covered in Scotland?

A

Mental Health (Care and Treatment) (Scotland) Act 2003

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117
Q

5 criteria for the use of MHA

A

1) Patient is suffering from a confirmed or suspected psychiatric disorder
2) Patient’s ability to make decisions about treatment of their mental disorder is significantly impaired by this disorder
3) Treatment is available for said psychiatric disorder
4) There would be considerable risk to the health, safety and welfare of the individual or others without treatment
5) Use of compulsory powers is deemed necessary and lesser restrictive options are deemed inappropriate

118
Q

Conditions of the EDC

A
  • Patient can be detained for 72 hours (must be reviewed with 24 hours)
  • Can be completed by ONE doctor (post-FY1), but a MHO should be consulted if possible, and the patient reviewed by a psychiatrist ASAP
  • Permits life saving medical treatment
  • DOES NOT permit management of the psychiatric disorder or physical disease
119
Q

Conditions of the STDC

A
  • Patient can be detained for 28 days
  • Completed by a psychiatrist but also requires MHO consultation
  • Permits treatment of the psychiatric disorder or underlying cause of the disorder
  • DOES NOT permit artificial feeding, ECT, or drugs controlling sex drive
120
Q

Conditions of the CTO

A
  • Patients detained indefinitely, but should be reviewed each 6 months
  • Completed by a mental health tribunal (psychiatrist and another doctor) submitted by the MHO
  • Permits treatment of the psychiatric illness/underlying cause, community care and drugs given for >2 months
  • DOES NOT permit artificial feeding, ECT, or drugs controlling sex drive
121
Q

Criteria for capacity

A

1) Understands information given to make a particular decision
2) Can retain the information given
3) Can balance or weigh up information to make a decision
4) Can communicate their decision
5) Is over 16 years old

122
Q

Describe an advanced directive

A

A statement of an individual’s wishes regarding health care and medical treatment they would wish/not wish to have if they were to become incapable of making decisions in the future.

An individual must be over 18 and have capacity in order to make this.

123
Q

Describe power of attorney

A

A legal document which enables an individual (who has capacity and is over 18) to nominate another person to make decisions on their behalf in the event that they become incapable of doing so.

124
Q

Prevalence of OCD

125
Q

Risk factors for OCD

A
  • Age
  • Family history
  • Avoidant, dependent or histrionic personality traits
  • Anankastic/OC personality traits
  • Schizophrenia
  • Sydenham’s chorea
  • Other basal ganglionic disorders
126
Q

ICD-10 criteria for OCD

A
  • Obsessions or compulsions must be present for at least 2 successive weeks and are a source of distress or interferes with the patient’s functioning
  • Obsessions/compulsions are acknowledged as coming from the patient’s own mind
  • Obsessions are unpleasantly repetitive
  • At least one thought or act is resisted unsuccessfully
  • A compulsive act is not in itself pleasurable
127
Q

Management of OCD

A

Pyschotherapy:

  • CBT, exposure and response therapy
  • Behavioural therapy
  • Support groups

Medications

  • SSRIs at high dose for at least 12 weeks
  • Clomipramine
  • Antipsychotics
  • ECT
  • Psychosurgery
  • DBS
128
Q

Poor prognostic indicators in OCD

A
  • Giving in to compulsions
  • Longer duration
  • Early onset
  • Male sex
  • Presence of tics
  • Bizarre compulsions
  • Hoarding
  • Symmetry
  • Comorbid depression
  • Delusional beliefs/overvalued idease
  • Personality disorder
129
Q

Good prognostic indicators for OCD

A
  • Good premorbid social and occupational adjustment
  • Precipitating event
  • Episodic symptoms
  • Less avoidance behaviour
130
Q

Prevalence of PTSD

131
Q

Risk factors for PTSD

A
  • Previous trauma
  • Interpersonal trauma
  • Family history of mood or anxiety disorders
  • Personal history of mood or anxiety disorders
  • Female
  • Low education
  • Lower social class
  • Ethnicity: Afro-Caribbean, Hispanic
  • Low self esteem
  • Neurotic traits
  • Increased trauma severity
  • Peri-traumatic emotions or dissociation
132
Q

Protective factors for PTSD

A
  • Effective coping strategies
  • High IQ
  • High social class
  • Caucasian ethnicity
  • Male
  • Psychopathic traits
  • Chance to view the body of a dead person
133
Q

ICD-10 criteria for PTSD

A

Symptoms onset between 1 and 6 months, present for at least 1 month, after exposure to a stressor.

2 or more persistent symptoms of increased psychological sensitivity and arousal:

  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty in concentrating
  • Hyper-vigilance
  • Exaggerated startle response

Persistent remembering/reliving of the stressor in intrusive flashbacks, vivid memories or recurring dreams, and distress when exposed to circumstances resembling or associated with the stressor

Actual/preferred avoidance of circumstances resembling/associated with the stressor

Inability to recall some important aspects of the period of exposure to the stressor

134
Q

Management of PTSD

A
  • 8-12 sessions of EMDR or trauma-focussed CBT or exposure therapy
  • SSRIs, continued long term with trial reduction after 12 months
135
Q

Good prognostic indicators in PTSD

A
  • Good social support
  • Lack of negative responses from others
  • Absence of maladaptive coping mechanisms
  • No further traumatic life events
136
Q

Definition of circumstantiality

A

Over-inclusive speech that is delayed in reaching its final goal, due to excessive detail and diversion.

137
Q

Definition of compulsion

A

Repetitive mental operations or physical acts that a parent feels compelled to perform in response to their own obsessions.

138
Q

Definition of a delusion

A

The most severe abnormal idea - a fixed, false belief arrived at illogically and is not amenable to reason, which is not accepted in the patient’s cultural background

139
Q

Definition of delusions of persecution

A

False belief that one is being harmed, threatened, cheated, harassed or is a victim of a conspiracy

140
Q

Definition of delusions of reference

A

The belief that normal perceptions have a special meaning to you

141
Q

Definition of delusional perception

A

Experiencing a normal perception but interpreting it with delusional meaning

142
Q

Definition of dyspraxia

A

Impairment of the ability to carry out skilled motor movements despite intact motor function

143
Q

Definition of dysgnosia

A

Impairment in the ability to interpret sensory information despite intact sensory organ function

144
Q

Definition of echolalia

A

When a patient senselessly repeats words or phrases that have been spoken near them/to them

145
Q

Definition of echopraxia

A

When a patient mimics the movements of another person

146
Q

Definition of flight of ideas

A

Thinking that is markedly accelerated and results in a stream of loosely connected concepts - the links between concepts can be normal, tenuous or through puns and clanging

147
Q

Definition of hallucination

A

Perceptions that occur in the absence of external stimuli and are indistinguishable from normal perception

148
Q

Definition of illusion

A

Misperceptions of real external stimuli

149
Q

Definition of neologism

A

New word created by the patient, often combining syllables

150
Q

Definition of obsession

A

Involuntary thought, image or impulse which is recurrent, intrusive, unpleasant and enters the mind against conscious resistance

151
Q

Definition of overvalued idea

A

Incorrect belief that is not impossible which is held with marked emotional investment but not unshakable conviction, but which takes precedence over all other ideas and maintains this precedence for a long period of time

152
Q

Definition of preservation

A

When a patient inappropriately repeats an initially correct action

153
Q

Definition of Pseudo-hallucination

A

Perceptions that occur in the absence of external stimuli but are experienced in the internal world rather than the external world

154
Q

Definition of psychosis

A

Presence of hallucinations, delusions or thought disorders

155
Q

Definition of rumination

A

Repeatedly thinking about the causes and experience of previous distress and difficulties, voluntary thinking which is not resisted

156
Q

Definition of Knight’s move thinking/derailment/loosening of association

A

When the patient’s train of thinking shifts very suddenly from one very loosely or unrelated idea to the next

157
Q

Definition of thought blocking

A

Patients experience a sudden cessation in their flow of thought, often mid-sentence, and then continue talking about a different topic

158
Q

Definition of grandiose delusions

A

False belief that one is exceptionally powerful, talented or important

159
Q

Definition of erotomania

A

False belief that another person is in love with them

160
Q

Definition of delusions of infidelity (morbid jealousy, Othello syndrome)

A

False belief that one’s lover has been unfaithful

161
Q

Definition of Capgras syndrome

A

Belief that a familiar person has been replaced by an exact double

162
Q

Definition of Fregoli syndrome

A

Belief that a complete stranger is actually a familiar person

163
Q

Definition of Ekborn syndrome

A

False belief that one is infested with small but visible organisms

164
Q

Definition of delusions of control/passivity

A

False beliefs that one’s thoughts, feelings, actions or impulses are controlled or made by external agency, including thought insertion, withdrawal and broadcast

165
Q

Definition of elementary auditory hallucinations

A

Simple unstructured sounds

166
Q

Definition of first person auditory hallucinations

A

Patients hearing their own thoughts spoken out loud as they think them

167
Q

Definition of second person auditory hallucinations

A

Patients hear voices talking directly to them

168
Q

Definition of third person auditory hallucinations

A

Patients hear voices talking about them

169
Q

Definition of autoscopic visual hallucinations

A

Experience of seeing oneself in external space

170
Q

Definition of Charles Bonnet syndrome

A

Condition where patients experience complex visual hallucinations associated with no other psychiatric symptoms or impairment in consciousness, often associated with a loss of vision

171
Q

Definition of Lilliputian hallucinations

A

Hallucinations of miniature people or animals

172
Q

Definition of reflex hallucinations

A

False perception which occurs when a normal sensory stimulus in one modality triggers a hallucination in another

173
Q

Definition of stereotypics

A

A complex identical movement that does not appear to be goal-directed

174
Q

Definition of mannerisms

A

Apparently goal directed movements that are performed repeatedly or at socially inappropriate times

175
Q

Prevalence of schizophrenia

176
Q

Risk factors for schizophrenia

A
  • Age
  • Higher incidence in men
  • Family history: 13% risk if one parent affected, 50% if two parents, 10% if a sibling is affected
  • Complications in pregnancy and birth
  • Prenatal malnutrition
  • Childhood trauma
  • Chronic cannabis use
  • Lower SES
  • Urban areas
  • Migrants
177
Q

ICD-10 diagnostic criteria for schizophrenia

A

One of more of the following symptoms:

  • Thought echo, insertion, withdrawal or broadcast
  • Delusions of control or passivity, delusional perception
  • 3rd person auditory hallucinatory voices

OR two or more of the following symptoms

  • other hallucinations that occur every day for weeks or are associated with fleeting delusions or sustained overvalued ideas
  • Thought disorganisation
  • Catatonic symptoms
  • Negative symptoms
  • Change in personal behaviour

Symptoms present most of the time during at least 1 month

No organic brain disease present, and symptoms not due to drug intoxication or withdrawal

178
Q

Investigations to consider in schizophrenia

A
  • FBC
  • ESR
  • U&Es
  • TFTs
  • LFTs
  • Glucose
  • Lipids
  • Serum calcium
  • Infection screen
  • Urine drug screen
179
Q

Indications for an ECG in patients commencing an antipsychotic

A
  • Hospital admission
  • History of CVD
  • Family history of sudden cardiac death
  • Evidence of CVD on examination
  • Risk of QT prolongation
180
Q

Management of schizophrenia

A
  • Antipsychotics for at least 1-2 years
  • Benzodiazepines for short-term relief of behavioural disturbance, insomnia, aggression, agitation
  • Antidepressants or lithium to augment antipsychotics
  • Baseline health screen and annual CV risk factor screen
  • Regular weight, lipids, glucose, pulse and BP monitoring
  • CBT
  • Family interventions
  • Social support
181
Q

Treatment for treatment resistant schizophrenia

182
Q

Definition of treatment resistant schizophrenia

A

Patients whose schizophrenia, despite at least 2 adequate trials of antipsychotics (one of which is second generation) is still not adequately controlled.

183
Q

Monitoring for clozapine

A
  • Weekly WCC for 18 weeks, then fortnightly for up to one year, then monthly
184
Q

Risk factors for suicide in schizophrenic patients

A
  • Young male
  • High education level
  • Some level of insight
  • Periods of time soon after illness onset or following hospital discharge
185
Q

Good prognostic factors in schizophrenia

A
  • Low income countries
  • Female sex
  • Married
  • Older age of onset
  • Abrupt onset of illness
  • Onset precipitated by life stress
  • Short duration of illness prior to treatment
  • Good response to medication
  • Paranoid schizophrenic subtype
  • Absence of negative symptoms
  • Illness characterised by prominent mood symptoms or family history of mood disorders
  • Good premorbid functioning
186
Q

Reasons for reduced life expectancy in schizophrenia

A
  • Suicide
  • Smoking
  • Socioeconomic deprivation
  • CVD
  • Respiratory disease
  • Accidents
187
Q

Risk factors for substance abuse

A
  • Male sex
  • Young age
  • Social deprivation
  • Childhood adversity
  • Family history
  • Conduct disorder in childhood
  • Antisocial personality disorder
  • Severe mental illness
  • Chronic pain
  • Head injuries
  • Operant conditioning
  • Lack of access to appropriate medical services
  • Pressure from peers/partner/environment
188
Q

Clinical features of opioid intoxicity

A
  • Euphoria
  • drowsiness
  • Apathy
  • Personality changes
  • Miosis
  • Conjunctival injection
  • Nausea
  • Pruritus
  • Constipation
  • Bradycardia
  • Respiratory depression
  • Coma
  • Death
189
Q

Opioid withdrawal symptoms

A

Lasts around a week, onset between 12-24 hours

  • Muscle/bone aches
  • Nausea and vomiting
  • Diarrhoea
  • Insomnia
  • Sneezing
  • Yawning
  • Piloerection
  • Sweating
  • Mydriasis
  • Lacrimation
  • Rhinorrhoea
  • Tachycardia
  • Tremor
  • Anxiety, irritability, restlessness
  • Goosebumps
190
Q

Clinical features of sedative intoxication

A
  • Drowsiness
  • Disinhibition
  • Confusion
  • Poor concentration
  • Reduced anxiety
  • Feeling of wellbeing
  • Hypotension
  • Impaired coordination
  • Respiratory depression
191
Q

Sedative withdrawal symptoms

A
  • Seizures
  • Hallucinations
  • Sweating
  • Tachycardia
  • Nausea
  • Tremor
192
Q

Clinical features of stimulant intoxication

A
  • Alertness
  • Hyperactivity
  • Euphoria
  • Irritability
  • Aggression
  • Paranoid ideas
  • Hallucinations (fornication)
  • Psychosis
  • Hyperthermia
  • Hypertension
  • Mydriasis
  • Tremor
  • Tachycardia
  • Arrhythmia
  • Perspiration
  • Fever
  • Convulsions
  • Perforated nasal septum
193
Q

Stimulant withdrawal symptoms

A

Within a few hours to days of stopping heavy use

  • dysphoria
  • Fatigue
  • Hyperphagia
  • Nightmares
  • Insomnia or hypersomnia
  • Psychomotor retardation or agitation
194
Q

Clinical features of hallucinogen intoxication

A
  • Marked perceptual disturbances
  • Mydriasis
  • Conjunctival injection
  • Hypertension
  • Tachycardia
  • Perspiration
  • Fever
  • Loss of appetite
  • Weakness
  • Tremor
195
Q

Clinical features of cannabinoid intoxication

A
  • Euphoria
  • Relaxation
  • Altered time perception
  • Psychosis
  • Impaired coordination and reaction time
  • conjunctival injection
  • nystagmus
  • dry mouth
196
Q

Cannabinoid withdrawal symptoms

A

Generally mild/moderate symptoms lasting 2-4 weeks

  • Irritability/anxiety
  • Low mood
  • Restlessness
  • Insomnia
  • Tremors
  • Headaches
197
Q

Clinical features of dissociative anaesthetic intoxication

A
  • Hallucinations
  • Paranoid ideas
  • Thought disorganisation
  • Aggression
  • Mydriasis
  • Tachycardia
  • Hypertension
  • Ulcerative cystitis
198
Q

Clinical features of inhalants intoxication

A
  • disinhibition
  • confusion
  • euphoria
  • hallucinations
  • stupor
  • headache
  • nausea
  • slurred speech
  • loss of motor coordination
  • muscle weakness
  • nystagmus
  • arrhythmia
  • pneumonitis
199
Q

Inhalant withdrawal symptoms

A
  • Hypersomnia
  • Low mood
  • Nausea
200
Q

Investigations to consider in substance misuse

A
  • Urine or saliva drug screening test
  • Hair testing
  • Breath alcohol level
  • FBC and MCV
  • U&Es
  • LFTs
  • ECG
  • BBV serology after most recent injection
  • Brain imaging
201
Q

Signs of opioid overdose

A
  • Dilated pupils
  • Diarrhoea
  • Tachycardia
  • Hypertension
  • Yawning
  • Runny nose
  • Fine tremor
  • Cool, clammy skin
  • Nausea
202
Q

Side effects of methadone

A
  • Constipation
  • Sedation
  • Euphoria
  • Nausea
  • QT prolongation
203
Q

Management of substance misuse

A
  • Psycho-education
  • Substitution prescription
  • Child protection
  • Take home naloxone kit
  • Needle exchange
  • BBV screening
  • Group support
204
Q

Prevalence of alcohol misuse

205
Q

Risk factors/triggers/causes for alcohol misuse

A
  • genetic influence
  • epigenetic changes
  • combination of positive and negative reinforcement
  • learned behaviours
  • associated psychiatric or physical illness
  • cultural influence
  • occupational associations
  • stressful event
206
Q

Diseases which alcohol increases the risk of

A
  • Cancer
  • Stroke
  • Heart disease
  • Liver disease
  • Death through accidents
207
Q

Investigations to consider in a patient with alcohol misuse

A
  • Breathalyser/blood alcohol use
  • FBC: raised MCV, decreased Hb, decreased neutrophils, decreased platelets
  • U&Es: decreased magnesium, potassium and sodium
  • LFTs: increased GGT, transaminases
  • Clotting screen: increased PT
  • ECG
  • CT head
208
Q

Lifestyle advice for keeping health risks from alcohol use to a minimum

A
  • No more than 14 units per week
  • Spread out weekly consumption over 3 or more days
  • Limit the total amount consumed on one single occasion
  • Drink slowly, with food, or alternate with water
  • Plan ahead to protect yourself from problems while intoxicated
209
Q

Factors which influence blood alcohol concentration

A
  • Amount of ethanol consumed
  • Person’s blood volume
  • How much they’ve had to eat/drink
  • Other substance use/medications
  • How well the body is prepared for alcohol
210
Q

Features of alcohol intoxication

A
  • Enhanced sense of wellbeing
  • Improved confidence/relief of anxiety
  • Disinhibition
  • Inappropriate sexual or aggressive behaviour
  • Sullen behaviour/withdrawn
  • Incoordination
  • Slurred speech
  • Ataxia, difficulty with balance
  • Amnesia, memory impairment
  • Impaired reaction time
211
Q

Consequences of harmful alcohol use

A
  • Substance-related disorders
  • Self-harm or suicidal behaviour
  • Absenteeism or poor behaviour at work
  • Victim of theft
  • Unprotected sex e.g. STIs, pregnancy
  • Legal problems
  • Interpersonal problems
  • Financial problems
  • Homelessness
  • Increased incidence of trauma
  • CNS disease: delirium, withdrawal, cerebella degeneration, hemorrhagic stroke, peripheral and optic neuropathy, Wernicke-Korsakoff syndrome
  • GI disease: ALD, pancreatitis, PUD, GI cancer
  • Cardiac disease: hypertension, arrhythmia,s IHD, alcoholic cardiomyopathy
  • Immune disease: immunocompromise
  • Metabolic/endocrine disease: hypoglycaemia, gout, hyperlipidaemia, electrolyte imbalance
  • Haematological disease: macrocytic anaemia, neutropenia, thrombocytopenia
  • MSK disease: myopathy, OP
  • Reproductive disease: IUGR, FAS, ED, infertility
212
Q

ICD-10 criteria for substance dependence

A

3 or more of the following criteria present together or at some time during the previous year:

  • A strong desire or compulsion to take the substance
  • Stereotyped pattern of use
  • Abstinence/reinstatement
  • Difficulties in controlling substance taking behaviour
  • Physiological withdrawal state when substance use is ceased/reduced OR continued substance use to relieve or avoid withdrawal symptoms
  • Tolerance
  • Priority given to the substance with neglect of other interests and activities
  • Persistence despite harm
213
Q

Management of alcohol dependence

A

Individual and group therapy

  • Motivational interviewing
  • CBT
  • Peer support programmes

Medication

  • Naltrexone (blocks euphoric effects of alcohol and feelings of intoxication)
  • Acamprosate (aids withdrawal symptoms)
  • Disulfiram (prevents breakdown of ethanol, leading to an instant ‘hangover’)
214
Q

Symptoms of uncomplicated alcohol withdrawal

A

Symptoms onset within 4-12 hours

  • Tremulousness
  • Sweating
  • Clammy skin
  • Nausea and vomiting
  • Mood disturbances
  • Fatigue
  • Headaches
  • Hyperacusis
  • Autonomic hyperactivity
  • Sleep disturbance
  • Psychomotor agitation

(can be complicated with illusions or hallucinations, typically visual, auditory or tactile)

215
Q

Symptoms of withdrawal seizures

A

Occurs 6-48 hours after cessation

Affects 5-15% of alcohol-dependent drinkers

Generalised tonic clonic seizures

216
Q

Risk factors for withdrawal seizures

A
  • Previous withdrawal seizures
  • Concurrent epilepsy
  • Low K+ or Mg2+
217
Q

Symptoms of delirium tremens

A

Occurs 1-7 days after cessation, usually ~48 hours.

  • Altered consciousness and marked cognitive impairment
  • Vivid hallucinations and illusions in any sensory modality e.g. Lilliputian
  • Marked tremor
  • Autonomic arousal
  • Paranoid delusions
  • Mortality
218
Q

Risk factors for delirium tremens

A
  • Hepatitis
  • Pancreatitis
  • Pneumonia
219
Q

Management of delirium tremenes

A
  • Benzodiazepines e.g. chlordiazepoxide

- IV Pabrinex

220
Q

Triad of symptoms of Wernicke’s encephalopathy

A

1) Ophthalmoplegia
2) ataxia
3) acute cognitive impairment/delirium

221
Q

Indications for management of alcohol withdrawal in hospital

A
  • Severe dependence
  • History of withdrawal seizures or delirium tremens
  • Pregnancy
  • Older patients
  • Poor social support
  • Psychiatric or physical comorbidities
222
Q

Describe a traumatic stressor

A

A stressor which occurs outside the range of normal human experience, and its magnitude means it would be perceived as traumatic by most people - typically occurs in situations where people feel their own or a loved one’s physical or psychological health is under serious threat

223
Q

Define an adjustment disorder

A

Symptoms significant enough to be out of proportion with the original stressor, or causing disturbance of social or occupational function

224
Q

Prevalence of adjustment disorder

225
Q

Symptoms of adjustment disorder

A
  • Low mood
  • Sleep disturbance
  • Anxiety
  • Anger
  • Disturbances of conduct
  • Suicidal ideation
226
Q

Diagnostic criteria of adjustment disorder

A

Diagnosis should only be made when patients do not meet the criteria for a more specific psychiatric diagnosis or a normal bereavement reaction

Symptoms occur within 1 month of the stressor

227
Q

Management of adjustment disorder

A

Symptoms should resolve within 6 months

  • Support psychotherapy
  • Antidepressants or anxiolytics: if symptoms are persistent and distressing or psychotherapy has failed
228
Q

Prevalence of acute stress reaction

229
Q

Risk factors for an acute stress reaction

A
  • Physical exhaustion
  • Presence of other organic factors
  • Elderly age
230
Q

Define an acute stress reaction

A

Transient disorder which may occur in an individual as an immediate response to exceptional stress

231
Q

Symptoms of an acute stress reaction

A

Develops within a few minutes of a traumatic event (within 48 hours)

  • Initial ‘dazed’ state
  • Disorientation and a narrowing of attention, inability to process external stimuli
  • Diminished responsiveness OR psychomotor agitation and overactivity
  • Amnesia
  • Depression/anxiety
  • Anger
  • Despair
232
Q

Management of acute stress reaction

A

None usually required

Symptoms usually resolve within a few hours of removal of the stressor. If the stressor persists, symptoms tend to diminish within 24-48 hours and are usually minimal after 3 days

233
Q

Risk factors for acute stress disorder

A
  • History of a psychiatric disorder
  • Previous traumatic events
  • Premorbid depression
  • Dissociative symptoms
234
Q

Symptoms of acute stress disorder

A

Symptoms onset within 4 weeks of trauma

  • Dissociative features
  • Derealisation or depersonalisation
  • Amnesia
  • Re-experiencing the event
  • Avoidance behaviours
  • Negative mood
  • Hyperarousal
235
Q

Management of acute stress disorder

A

Symptoms typically last 3 days to 4 weeks - if symptoms last longer, patients can be diagnosed with PTSD.

  • Simple practical measures e.g. support, advice regarding police procedure
  • De-briefing
  • CBT
  • TCAs, SSRIs, benzodiazpines
236
Q

Describe dissociation

A

Disruption in the usually integrated functions of consciousness and cognition with no clear stressor

237
Q

5 phases of a normal grief reaction

A

1) Alarm: accompanied by physiological arousal
2) Numbness
3) Pining: hypnagogic and hypnopompic pseudohallucinations and illusions may occur
4) Depression and despair
5) Recovery and reorganisation

238
Q

Clinical features of a typical grief reaction

A
  • Disbelief, shock, numbness
  • Feelings of anger, guilt, sadness, tearfulness
  • Low mood
  • Change in appetite and weight
  • Sleep disturbance
  • Psychomotor retardation
  • Memory impairment
  • Pseudohallucinations/illusions about the deceased
  • Suicidal ideation

Gradually reduce in intensity, lasting up to 12 months

239
Q

Clinical features of an ‘atypical’ grief reaction

A
  • Very intense, prolonged, delayed or absent
  • Symptoms outwith normal range
  • Prolonged period of not being able to function normally
  • Marked slowing of thoughts or movements
  • Hallucinatory experiences
240
Q

Risk factors for depression after a beareavement

A
  • History of depression
  • Intense early grief/depressive symptoms
  • Lack of social support
  • Little experience of death
  • Traumatic or unexpected death
241
Q

Describe personality traits

A

Enduring patterns of perceiving, thinking about, and relating to both self and the environment, exhibited in a wide range of social and personal concepts

242
Q

Describe a personality disorder

A

When an individual has an enduring pattern of traits that are:

  • Persistently inflexible and maladaptive
  • Stable over time
  • Appeared in adolescence or early adulthood
  • Cause significant personal distress or functional impairment to the individual or those around them
  • Cause disturbance in relationships
  • Deviate markedly from the expectation of the individual’s culture
  • Often involves problems with cognition, affect and behaviour
243
Q

Prevalence of personality disorders

244
Q

Risk factors for personality disorders

A
  • Family history of personality disorders of other psychiatric illness: Cluster A type linked to schizophrenia, EUPD linked to depression
  • Early adverse social circumstances
  • Childhood abuse
  • Disordered attachment between infants and their caregivers
  • Male sex: RF for paranoid, schizoid, antisocial, narcissistic and OC personality disorders
  • Female sex: EUPD
  • Lower SES: paranoid
  • Offenders: schizoid, antisocial, narcissistic
  • Highly educated: OC
  • Married: OC
245
Q

Traits of paranoid personality disorder

A
  • Suspicious, suspects others are exploiting/harming/deceiving them
  • Doubts about spouse’s fidelity
  • Bears grudges
  • Tenacious sense of personal right
  • Litigious
  • Fear of confiding in orders
  • Strong reaction to being lied to
246
Q

Traits of schizoid personality disorder

A
  • Emotional coldness and detachment - neither enjoys or desires close/sexual relationships
  • Prefers solitary activities, enjoys few activities
  • Indifferent to praise or critiscism
  • Lacks confidence
247
Q

Traits of schizotypal personality disorder

A
  • Eccentric behaviours
  • Odd belief or magical thinking - can lead to overconfidence in their belief
  • Unusual perceptual experiences
  • Ideas of reference
  • Suspicious or paranoid ideas
  • Vague or circumstantial thinking
  • Social withdrawal
248
Q

Traits of BPD/EUPD

A
  • Intense unstable relationships (fluctuates between idealisation and devaluation) with repeated emotional crises
  • Unstable self image, identity disturbances
  • Impulsive behaviour
  • Chronic feelings of emptiness
  • Repetitive suicidal or self-harm behaviour
  • Fluctuations in mood
  • Frantic efforts to avoid abandonment
  • Transient paranoid ideation
  • Pseudohallucinations
  • Dissociation
249
Q

Traits of antisocial personality disorder

A
  • Repeated unlawful/aggressive behaviour
  • Deceitfulness/lying
  • Reckless irresponsibility
  • Lack of remorse or incapacity to experience guilt
  • Disregard of other’s rights
  • Willing to hurt others to benefit themselves
250
Q

Traits of histrionic personality disorder

A
  • Dramatic, exaggerated expression of emotions
  • Attention seeking
  • Seductive behaviour
  • Labile, shallow emotions, can’t maintain relationships
  • Manipualtive
  • Occasional self harm
  • Obsessed with physical appearance
251
Q

Traits of narcissistic personality disorder

A
  • Grandiose sense of self-importance, often pretentious and boastful
  • Need for admiration
  • Fragile self esteem, vulnerable to criticism
  • Only gets involved in activities that benefit themselves
  • Callous, little regard for other’s feelings
252
Q

Traits of dependent personality disorder

A
  • Excessive need to be cared for, needs others to assume responsibility for major life events
  • Clingy behaviour
  • Forms quick new relationships
  • Fear of separation
253
Q

Traits of avoidant personality disorder

A
  • Hypersensitivity to critical remarks/rejection
  • Inhibited in social situations
  • Fears of inadequacy
  • Avoids contact jobs
254
Q

Traits of obsessive compulsive personality disorder

A
  • Preoccupation with orderliness, perfectionism and control
  • Devoted to work at the expense of leisure
  • Pedantic, rigid and stubbon
  • Overly cautious
255
Q

Management options for personality disorders

A
  • Consider detention under MHA if necessary
  • Preparation of a crisis plan
  • Encourage autonomy
  • Dialectical behavioural therapy (or CBT or cognitive analytical therapy)
  • Medications for symptomatic relief
  • Social assistance
256
Q

Prevalence of delirium

A

10-20% of inpatients

257
Q

Risk factors for delirium

A
  • Pre-existing dementia
  • Previous serious head injury
  • Alcohol/benzodiazepine misuse
  • Age
  • Polypharmacy
  • Multiple medical problems
  • Sensory impairment
  • Recent surgery
  • Burns victims
  • Underlying disease
  • Chronic fatigue
258
Q

Causes of delirium

A
  • Environmental change or stress
  • Drugs e.g. anticholinergics, benzos, opiates, anti-Parkinsonian drugs, steroids, alcohol, cannabis, amphetamines
  • Posions
  • Infection/sepsis
  • Hypoxia
  • Metabolic/endocrine disturbance e.g. dehydration, anaemia, electrolyte imbalance, renal impairment, thyroid disease
  • Nutritional deficiencies
  • Trauma
  • Intracranial space-occupying lesion
  • Head injury
  • Brain infection
  • Epilepsy
  • Cerebrovascular disease
259
Q

Clinical features of delirium

A

Acute onset and fluctuating symptoms

  • Impaired consciousness
  • Impaired attention
  • Impaired cognitive function
  • Perceptual and thought disturbance
  • Sleep-wake cycle disturbance
  • Mood disturbances
  • Psychomotor agitation
  • Emotional lability
260
Q

4 key diagnostic features of delirium

A

1) Impaired consciousness
2) Impaired attention
3) Impaired cognition
4) Acute or fluctuating onset of symptoms

261
Q

Memory test used to identify people with delirium

262
Q

Core investigations in a patient with delirium

A
  • General obs
  • Bloods: FBC, CRP, U&Es, LFTs, creatinine, TFTs
  • Blood glucose
  • Blood lactate
  • Vitamin B12/folate
  • Calcium/phosphate
  • Urinalysis, urine culture
  • Blood culture
  • CXR
  • ECG
263
Q

Prevention methods for delirum

A
  • Identify at risk patients
  • Help orientate patients and ensure they are comfortable
  • Maintain a good daily routine
  • Avoid opiates
  • Avoid predisposing medications
  • Ensure patient feels in control
  • Prevention, early identification and treatment of post-op complications
  • Medication review
264
Q

Management options for delirium

A

Identification and management of precipitating causes and exacerbating factors

Optimisation of patient’s condition

  • Nutrition
  • Fluids
  • Pain control

Environmental and supportive measures

  • Education
  • Safe environment
  • Stimulating environment
  • Reality orientation
  • 1 on 1 nursing

Avoid sedation unless severely agitated or is necessary to minimise risk to patient or facilitate investigation/treatment
- Consider oral haloperidol, oral lorazepam or oral risperidone
AVOID BENZOS

Regular clinical review and follow up

Consider capacity

265
Q

Complications of delirium

A
  • Falls
  • Longer hospital stays
  • More medical complications
  • Development of dementia
  • Mortality: 1/3rd
266
Q

Prevalence of ASD

267
Q

Risk factors for ASD

A
  • Male

- Family history

268
Q

Causes of autism

A
  • Tuberous sclerosis
  • Fragile X syndrome
  • PKU
  • Chromosomal micro-deletion syndrome
  • Obstetric complications
  • Toxic agents
  • Pre or postnatal infection
  • Autoimmune disease
  • Association with neurological disorders
269
Q

3 characteristic features of autism

A

Manifest within first 3 years of life:

1) Impairment of social interaction
- Poor use of non-verbal behaviour
- Failure to develop and to share in enjoyment of peer relationships
- Reduced interest in shared enjoyment
- Lack of social or emotional reciprocity and empathy
- Attachment to unusual objects

2) Impairment in communication
- Poor language development
- Extreme difficulty in initiating or sustaining conversation
- Repetitive use of idiosyncratic language
- Lack of imitative or make-believe play

3) Restricted stereotyped interests and behaviours
- Intense preoccupation with interests
- Inflexible adherence to routine and rituals, resistance to change
- Repetitive stereotyped movements
- Unusual interest in parts of hand or moving objects

270
Q

Clinical features of ASD

A
  • Hyper-reactivity to environmental stimuli
  • Delayed/lack of pointing
  • Delayed speech
  • Lack of response to name
  • Poor eye contact
  • Delayed and disordered development
  • Strong dislike for routine change
  • Motor mannerisms
  • Regression
  • Good memory
  • Aggression/irritability/temper tantrums
  • Hyperactivity
  • Impulsivity
  • Self-injurious behaviour
  • Seizures
  • Motor tics
  • Increased head circumference
  • Abnormal gaze monitoring
  • Ambidexterity
  • Unusually intense sensory responsiveness
  • Absence of typical response to pain or injury
  • Abnormal temperature regulation
  • Increased paediatric illness
271
Q

Define Asperberger’s syndrome

A

A subtype of autism where there are no significant abnormalities in language acquisition and ability or cognitive development and intelligence

272
Q

Management of ASD

A

NO PHARMACOLOGICAL INTERVENTIONS

1) Play-based social communication intervention

  • Self-help or support groups
  • Social learning programmes
  • Implementation of structure, routine and predictability
  • Aids to improve communication
  • Sleep management
  • Supported employment programs
  • SALT
  • Behavioural intervention
  • Structured leisure activity
  • Anger management
  • Anti-victimisation intervention
  • Crisis plan
273
Q

Good prognostic factors in ASD

A
  • IQ >70
  • Communicative language by age 5
  • Absence of epilepsy
274
Q

Prevalence of ADHD

A

5% in children

2-3% of UK population

275
Q

Risk factors for ADHD

A
  • Male
  • Family history
  • Maternal smoking during pregnancy
  • Maternal alcohol use during pregnancy
  • Prematurity
  • LBW
  • Perinatal hypoxia
  • Emotional neglect
  • Brain insult
276
Q

Diagnostic criteria for ADHD

A

Symptoms present from childhood, persistent for >6 months and impaired and pervasive symptoms (requires some symptoms from each domain):

1) Inattention (pays more attention to cues and unable to eliminate unnecessary cues)
- Lack of attention to detail
- Difficulty sustaining attention
- Difficulty listening
- Trouble completing tasks
- Problems with organisation
- Avoidance or dislike of sustained mental effort
- Losing things
- Easily distracted
- Forgetful

2) Hyperactivity
- Fidgeting/restlessness
- Leaving seat when not supposed to
- Always on the go
- Talks excessively, can’t engage in quiet activities
- Insomnia

3) Impulsivity
- Blurting out answers in class
- Interrupting or intruding on others
- Difficulty waiting
- Disinhibited behaviours

Severity is based on functional impairment

277
Q

Management of ADHD

A
  • Psychoeducation
  • OT input
  • School/work support
  • Skills training
  • Psychological therapy e.g. family therapy, CBT, social skills training, environmental modification
  • Medication
    1) Stimulants e.g. methylphenidate, lisdexamfeatime
    2) Atomoxetine, guanfacine
278
Q

Definition of intellectual disability

A

Diverse afflictions which manifest as significant intellectual impairment associated with an impaired ability to adapt to the normal demands of daily living, with onset before 18 years old

279
Q

Prevalence of intellectual disabilities

280
Q

Risk factors for intellectual disability

A
  • Male

- Comorbid psychiatric illness

281
Q

Specific causes of intellectual disability include

A
  • Genetic conditions e.g. Down syndrome, Fragile X, Prader-Willi, PKU, neurofibromatosis,
  • Congenital infection
  • Substance use during pregnancy
  • Pregnancy complications
  • Birth trauma
  • Prematurity
  • Neglect/malnutrition
  • Poor linguistic and social stimulation
  • Pervasive developmental disorders
  • Childhood infections
  • Childhood head injury
  • Childhood exposure to toxins
282
Q

Medical conditions associated with intellectual disability

A
  • Epilepsy
  • GORD
  • Constipation
  • Heart abnormalities
  • Hearing loss
  • Dementia
  • Delirium
  • Schizophrenia
  • Schizo-affective disorders
  • Anxiety disorders
  • Personality disorders
  • Depression (but suicide is LESS common)
283
Q

Features of mild intellectual disability

A
  • IQ 50-69
  • Subtle functional difficulties
  • Often identified at a later age
  • Difficulties in academic work, greatly helped by educational programmes
  • Usually capable of unskilled or semi-skilled manual labour
  • May be able to live independently or with minimal support
284
Q

Features of moderate intellectual disability

A
  • IQ 35-49
  • Limited language and comprehension skills
  • Self-care and motor skills impaired, may need supervision
  • May be able to do simple practical work with supervision
  • Rarely able to live completely independently
285
Q

Features of severe intellectual disability

A
  • IQ 20-34
  • Marked degree of motor impairment
  • Little/no speech in early childhood, may learn to talk at school
  • Capable of elementary self-care skills
  • May be able to perform simple tasks under close supervision
286
Q

Features of profound intellectual disability

A
  • IQ <20
  • Severely limited ability to communicate
  • Severe motor impairment with restricted mobility and incontinence
  • Little or no self care ability
  • Often require residential care
287
Q

Primary prevention of intellectual disability

A
  • Genetic screening and counselling for high risk groups
  • Prenatal testing
  • Improved perinatal and neonatal care
  • Early detection of metabolic abnormalities which may contribute
288
Q

Management options for intellectual disability

A
  • Family support
  • Educational support
  • Vocational guidance
  • Housing and social support
  • Medical care
  • Psychiatric care e.g. behavioural therapy
289
Q

Clinical features of dyslexia

A
  • Slow, inaccurate and effortful reading
  • Difficulty spelling
  • Difficulty understanding what they’ve read
290
Q

Clinical features of dysgraphia

A
  • Poor spelling
  • Difficulty with grammar
  • Poor handwriting
  • Mixing of print and cursive writing
  • Misuse of capital and lowercase letters
  • Slow, laboured writing
  • Difficulty putting thoughts down on paper
  • Difficulty thinking and writing at the same time
291
Q

Clinical features of dyscalculia

A
  • Difficulty memorising math formulas and equations
  • Difficulty following mathematical reasoning
  • Difficulty measuring out ingredients for a recipe
  • Difficulty reading graphs/charts

Year 5 (9 decks)

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