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3A Revision > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Describe the pathophysiology behind depressive disorders.

A
  • likely to be heritable with multiple gene involvement (twin studies)
  • monoamine hypothesis: deficiency of noradrenaline, serotonin and dopamine
  • over activity of the hypothalamic-pituitary-adrenal axis
  • psychosocial input: personality type, life stressors and failure of effective stress control mechanisms increase likelihood of depression
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2
Q

Name biological factors that predispose you to depression

A
  • female gender
  • post natal period
  • genetics ( fam history)
  • neurochemical - low serotonin, dopamine and noradrenaline
  • endocrine: increased hypothalamic pituitary adrenal axis activity
  • physical co morbidity
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3
Q

Name psychosocial factors that predispose you to depression

A
  • personality type
  • failure of effective stress control mechanisms
  • poor coping strategy
  • mental health co-morbidity e.g dementia
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4
Q

Name social factors that predispose you to depression

A
  • stressful life event
  • lack of social support
  • social situations e.g asylum seekers
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5
Q

Name biological factors that precipitate depression

A
  • poor compliance with medication

- corticosteroids

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6
Q

Name psychosocial factors that precipitate depression

A

Acute stressful life events often precede depression eg loss of a loved one, injury, bankruptcy, unemployment, divorce

Non-acute stressful life events: poverty

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7
Q

Name factors that perpetuate (maintain) depression

A

Biological: chronic health problems
Psychosocial: poor insight, negative thoughts about self, the world and future (becks triad)
Social: alcohol and substance abuse, poor social support and low social status

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8
Q

Name 3 typical (1st generation) antipsychotics

A

Haloperidol
Chlorpromazine
Sulpiride

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9
Q

Name 4 atypical (2nd gen) antipsychotics

A 
Olanzapine 
Risperidone 
Quetiapine 
Amisulpride 
Clozapine
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10
Q

What is the difference between typical and atypical antipsychotics

A

Not much, apart from atypical antipsychotics cause less extrapyramidal (motor) side effects

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11
Q

Which antipsychotic is only used for treatment resistant schizophrenia when two previous antipsychotics have failed?

A

Clozapine

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12
Q

Name 3 indications for anti psychotic use

A
  1. 1st line treatment schizophrenia
  2. Other conditions with positive psychotic symptoms ( hallucinations / delusions ) such as mania, acute psychotic disorders, depression, dementia
  3. Violent or dangerously impulsive behaviour and psychomotor agitation
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13
Q

How do antipsychotics work

A

By blocking dopamine (D2 mainly) in the brain, namely the Mesolimbic and mesocortical pathways

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14
Q

Name extrapyramidal side effects of antipsychotics

A

Parkinsonism - bradykinesia and tremor
Akanthisia- restlessness
Dystonia - acute painful contractions and spasms of muscles mainly in neck jaw and eyes

Tardive dyskinesia - abnormal involuntary movements (choreoathetoid) mainly looks like a pouting and chewing jaw

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15
Q

Name the anti-muscarinic side effects of antipsychotics

A

Can’t see can’t wee can’t spit can’t shit

Blurred vision, urinary retention, dry mouth and constipation

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16
Q

Name cardiac side effects of antipsychotics

A

PROLONGED QT INTERVAL- particularly with pimozide and haloperidol

Postural hypotension
Tachycardia

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17
Q

Name endocrine / metabolic side effects of antipsychotics

A

HYPERPROLACTINAEMIA:
Causes gallactorhoea, breast enlargement, reduced mineral bone density and sexual dysfunction)

Impaired glucose intolerance

Hypercholesterolaemia

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18
Q

Definition of schizophrenia

A

A psychotic disorder characterised by hallucinations, delusions and thought disorders.
Must occur in the absence of organic disease or drug or alcohol related disorder
and isn’t secondary to depression or elevation of mood

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19
Q

Name 4 poor prognostic indicators in schizophrenia

A 
Strong family history
Low IQ
Lack of obvious precipitation
Premorbid history of social withdrawal
Gradual onset
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20
Q

Describe the pathophysiology behind schizophrenia

A

Overactivity of the Mesolimbic dopamine pathways

This is why antipsychotics aim to block D2 receptors

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21
Q

Name biological factors that are a risk factor for schizophrenia

A

Being male
Strong family history
High dopamine in the brain, low GABA glutamate and serotonin

Neurodevelopmental issues eg birth trauma, intrauterine infection, prematurity, fetal brain injury

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22
Q

What is a neologism

A

Making up and using a new word

Or using a word that we all know but using it in an inappropriate sense

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23
Q

Name the positive symptoms of schizophrenia

A 
Delusions 
Hallucinations 
Formal thought disorder
Thought interference 
Passitivity phenomenon
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24
Q

Name 8 risk factors for depression

A 
Female
family history of depression
alcohol use
adverse life event
past history of depression
physical co-morbidity 
low socioeconomic status
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25
Q

Name the 3 core symptoms of depression

A

anhedonia
anergia
low mood

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26
Q

Name 4 cognitive symptoms of depression

A

lack of concentration
negative thoughts - becks triad
excessive guilt
suicidal ideation

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27
Q

name 5 biological symptoms of depression

A 
early morning wakening
loss of libido
diurnal variation in mood
psychomotor retardation
weight loss/loss of appetite
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28
Q

ICD-10 Diagnostic criteria for depression?

A

2 core symptoms plus 2 other symptoms (mild depression)

2 core + 3-4 others = moderate

3 core + over 4 other symptoms = severe depression

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29
Q

what is becks triad

A

negitive thoughts about self, the world and the future

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30
Q

what diagnostic questionnaires can be used in depressive disorder

A

PHQ-9
HADS
becks depression inventory

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31
Q

What tests should you do to rule out organic causes of depression

A 
FBC (anaemia for fatigue)
TFT (for hypothyroidism)
LFTS
Calcium levels
Glucose levels (for anergia)
CT head if atypical presentation
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32
Q

describe clinical presentation of atypical depression

A

weight gain, increased appetite
hypersomnia (excessive sleep)
delusions/hallucinations in severe depression

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33
Q

name 3 psychiatric differentials for depression and 2 organic differentials

A

psych: BPAD, anxiety disorders, secondary to substance use, normal bereavement
organic: hypothyroidism, diabetes, Anaemia, biochemical abnormalities

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34
Q

Define recurrent depressive disorder

A

when a patient has another depressive episode after their 1st episode

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35
Q

define seasonal affective disorder

A

depressive episodes recurring annually at the same time each year, usually during the winter months.

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36
Q

Define masked depression

A

a state in which depressed mood isn’t particularly prominent, but other features are present e.g EMW, diurnal variation

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37
Q

define atypical depression

A

occurs with mild-moderate depression with reversal of symptoms e.g over eating, weight gain and hypersomnia

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38
Q

define dysthymia

A

a depressive state that lasts for at least 2 years, which doesn’t meet the criteria for mild, moderate or severe depression and is not the result of a partially treated depressive illness.

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39
Q

what is dysthymia

A

a chronic depressive state lasting longer than 2 years, where your low mood can fluctuate between mild to severe but characterised by low-self esteem, hopeless feelings, lack of concentration/productivity e.g the non-core symptoms

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40
Q

define cyclothymia

A

chronic mood fluctuation over at least a 2 year period with episodes of elation and episodes of depression, but the symptoms do not meet the criteria for a hypomanic or depressive disorder

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41
Q

define baby blues

A

anxious, tearful and irritable mothers typically onset 3-7 days after birth. more common in primiparae women

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42
Q

what is biological management of depression

A

Mild-moderate: watchful waiting, antidepressants not recommended for mild depression unless it has gone on for months, if they have a past history of severe depression or if other interventions have failed.

Moderate - severe: SSRI’S 1st line, adjuvants include antipsychotics or lithium.

ECT can be considered as a last option if other interventions fail in acute severe depression

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43
Q

psychological management of depression?

A

CBT, interpersonal therapy, psychoeducation, counselling , behavioural activation, psychodynamic therapy

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44
Q

social management of depression

A

social support groups

exercise

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45
Q

Management options for mild-moderate depression?

A
  • watch and wait
  • self-help programmes
  • online CBT
  • exercise programmes (social prescribing)
  • psychotherapy: counselling, behavioural activation, IPT, psychodynamic therapy

note: antidepressants not recommended unless other options have failed or they have a history of severe depression

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46
Q

Management of moderate-severe depression

A
  • do suicide risk assessment
  • consider mental health act
  • antidepressants - SSRI first line
  • Adjuvants e.g lithium, antipsychotics
  • psychotherapies e.g CBT, IPT, counselling, psychodynamic therapy
  • social support groups
  • exercise groups
  • ECT (last option)
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47
Q

give 5 indications for electroconvulsive therapy

A
  1. severe depression that is life threatening
  2. rapid response needed
  3. depression with psychosis
  4. psychomotor retardation
  5. other treatments have failed
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48
Q

how long should you prescribe antidepressants for after 1st depressive episode has ended

A

6 months

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49
Q

Define bipolar affective disorder

A

a chronic mood disorder characterised by at least 1 episode of mania and one further episode of depression or mania

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50
Q

pathophysiology of BPAD?

A

Monoamine hypothesis: elevated mood is a result of increased central monoamines (serotonin, dopamine and noradrenaline) and depressed mood is a result of low monoamines

Hypothalamis pituitary adrenal axis dysfunction

strong heritability

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51
Q

Name precipitating factors for a first mania episode

A

stressful or significant life event

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52
Q

Name the symptoms of mania

A

I DIG FASTER

Irritability
Disinhibition/distracted
Grandiose delusions
Flight of ideas
Appetite increased
sleep decreased
talkative
elevated mood/energy increased
reduced concentration/reckless
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53
Q

define hypomania

A

mildly irritable/elevated mood lasting for 4+ days. Interferes with work and social life but not severely.
Partial insight

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54
Q

define mania

A

A state of irritable/elevated mood lasting for more than 1 week with complete disruption of work and social activities.
Likely to have grandiose ideas, excessive spending and sexual disinhibition and lack of sleep

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55
Q

define mania with psychosis

A

a severely elevated or suspicious mood with the addition of psychotic features e.g grandiose or persecutory delusions, auditory hallucinations that are mood congruent.

may be aggressive

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56
Q

define bipolar type 1 characteristics

A

periods of severe mood episodes from mania to depression

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57
Q

define bipolar type 2 characteristics

A

milder form of mood elevation with mild hypomania that alternate with periods of severe depression

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58
Q

define rapid cycling BPAD

A

more than 4 mood swings in a 12 month periods with no intervening asymptomatic periods.

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59
Q

what is the ICD-10 criteria for a diagnosis of Mania

A 
requires 3/9 symptoms, including:
Grandiosity
reduced sleep
pressure of speech
flight of ideas
distractibility 
psychomotor agitation
reckless behaviour
social disinhibition
marked sexual energy
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60
Q

what is the ICD-10 diagnostic criteria for Bipolar Affective disorder diagnosis

A

need at least TWO episodes in which a persons mood and activity levels are significantly disturbed.

ONE of such episodes must be MANIA or HYPOMANIA

note: for a diagnosis of mania you need 3/9 symptoms

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61
Q

what are the 5 types of bipolar states

A 
currently hypomanic
currently manic
currently depressed
mixed disorder
in remission
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62
Q

what questionnaire can you use to aid the diagnosis of BPAD

A

mood disorder questionnaire

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63
Q

what investigations would you do to rule out organic causes associated with BPAD

A 
FBC (routine)
TFT - hypo/hyperthyroidism
Do U+E's for a baseline renal function with view to starting lithium
Calcium levels
Urine drug test
CT head for space occupying lesion
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64
Q

Give 4 differential diagnoses for BPAD

A 
depression 
schizoaffective disorder
schizophrenia
cyclothymia 
hyper/hypothyroidism
e.g frontal lobe lesion (cerebral)
illicit drug use 
corticosteroid side effect
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65
Q

Describe management of an acute manic/mixed BPAD episode

A

antipsychotic e.g olanzipine/quetiapine. used bc have a more rapid onset of action than mood stabilisers. Add lithium too. Benzodiazipines can be used to calm agitation/aid sleep.

Sodium valporate can be offered as a 2nd line alternative to lithium as a mood stabiliser.

If the 1st antipsychotic doesn’t work a 2nd will be offered.

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66
Q

what is the 1st line treatment of an acute manic episode

A

antipsychotic e.g olanzipine/quetiapine plus lithium

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67
Q

what drug can be used as an alternative to lithium as a mood stabilizer

A

sodium valporate or lamotrigene long term

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68
Q

what drug can be used for calming of agitation/to aid sleep

A

benzodiazepines e.g diazepam or lorazepam

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69
Q

what drugs are used for a bipolar depressive episode

A

atypical antipsychotics e.g olanzipine/quetiapine

lithium or lamotrigine as a mood stabiliser

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70
Q

Why should antidepressants be avoided in BPAD patients

A

because they can induce mania if used alone. should be used carefully if prescribed with an antipsychotic

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71
Q

What tests should you do before starting a patient on lithium

A

U+E’s -bc lithium is excreted renally
TFT
pregnancy status
Baseline ECG

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72
Q

Name side effects of lithium

A

polydipsia, polyuria, fine tremor, weight gain, oedema,
HYPOTHYROIDISM
memory problems
impaired renal function

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73
Q

what therapeutic level should you aim for with lithium

A

between 0.5-1.0mmol/L

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74
Q

How often should you check lithium levels

A
  • 12 hours after 1st dose
  • THEN weekly until lithium levels have been stable between 0.5-1.0 for 4 weeks in a row
  • once stable check every 6 months
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75
Q

what is the first line treatment for rapid cycling BPAD

A

a combination of lithium and sodium valporate

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76
Q

Name symptoms of lithium toxicity

A 
Nausea, diarrhoea and vomiting
COARSE tremor (not fine)
ataxia
muscle weakness
fasciculations
clonus
nystagmus
dysarthria
hyperreflexia
oliguria
hypotension
convulsions
coma
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77
Q

Define psychosis

A

a mental state in which reality is greatly distorted.

Typically presents with delusions, hallucinations and thought disorder.

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78
Q

define a delusion

A

a fixed, firmly held false belief that deviates from the individuals normal social and cultural beliefs.

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79
Q

define a hallucination

A

a perception in the absence of an external stimulus

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80
Q

define a pseudohallucination

A

a perception in the presence of an external stimulus

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81
Q

what is a thought disorder

A

an inability to form thoughts from logically connected ideas

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82
Q

name 6 non-organic causes of psychosis

A 
schizophrenia
schizoaffective disorder
acute psychotic episode
delusional disorder
drug induced psychosis
mood disorder with psychosis
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83
Q

name 6 organic causes of psychosis

A 
dementia
delirium
drug induced
complex partial epilepsy
SLE
cushings syndrome
vitamin B12 and folate deficiency 
huntingtons disease
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84
Q

what is schizotypal disorder

A

a disorder very similar to schizophrenia whereby the individual acts weird, suspicious, with unusual speech and affect, however there is NO HALLUCINATIONS OR DELUSIONS

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85
Q

what is an acute/transient psychotic disorder

A

an acute episode of psychosis lasting less than 1 month therefore not meeting the criteria for schizophrenia

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86
Q

what is schizoaffective disorder

A

characterised by both symptoms of a mood disorder and schizophrenia in an episode of the same illness. e.g mania and schizophrenia or depression and schizophrenia. Mood symptoms should meet the criteria for depressive illness or mania with one or 2 symptoms of schizophrenia

Schizophrenia symptoms persist with the occasional episode of mood disorder

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87
Q

what is persistent delusional disorder

A

a single or set of delusions held for at least 3 months. This should be the only symptom with other areas of thinking and functioning preserved

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88
Q

What is induced delusional disorder aka Folie a deux

A

a disorder where 2 or more people share the same delusional belief
a person primarily forms the delusion in a psychotic episode and passes it onto another person

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89
Q

what is puerperal psychosis

A

the acute onset of manic or psychotic episode shortly after childbirth (usually in the 1st 2 weeks)

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90
Q

what is late paraphrenia

A

late-onset schizophrenia. not coded for in icd-10

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91
Q

What are schneiders first rank symptoms of schizophrenia

A
  1. delusional perception
  2. third person auditory hallucination (usually running commentary)
  3. thought interference (e.g withdrawal, boradcast, insertion)
  4. passivity phenomenon - actions feelings or thoughts are being controlled by an external force
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92
Q

define schizophrenia

A

psychotic disorder characterised by delusions, hallucinations and thought disorders which lead to functional impairment.
Always in the absence of organic disease, alcohol or drug related disorders and isn’t secondary to mood depression or elevation.

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93
Q

pathophysiology of schizophrenia

A

dopamine hypothesis: overactivity of mesolimbic dopamine pathways in the brain

factors that interfere with neurodevelopment including low birthweight, obstetric complications, fetal injury.

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94
Q

what is the expressed emotion theory of schizophrenia

A

people whos relatives who are overly involved in their lives, are overly hostile or critical are more likely to develop schizophrenia

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95
Q

what is the stress-vulnerability model

A

a model that predicts that schizophrenia occurs due to enviornmental factors (e.g adverse life events, abuse, bullying) interacting with a genetic predisposition (e.g family history of mental illness or brain injuries)

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96
Q

name biological factors that predispose you to schizophrenia

A 
HIGH dopamine
LOW gaba, serotonin and glutamate
birth injuries
prematurity 
being aged 15-35
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97
Q

name psychological factors that predispose you to schizophrenia

A

family history of mental illness

childhood abuse

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98
Q

name social factors that predispose you to schizophrenia

A

substance misuse
low socioeconomic status
birth in late winter

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99
Q

name biological factors that precipitate schizophrenia

A

smoking cannabis or taking psychoactive drugs

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100
Q

name a psychosocial factor that precipitates schizophrenia

A

adverse life event/stressful life event

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101
Q

name a biological factor that perpetuates schizophrenia

A

poor compliance to medication

substance misuse

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102
Q

name a social factor that perpetuates schizophrenia

A 
low social support
expressed emotion (within the family)
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103
Q

name a psychological factor that perpetuates schizophrenia

A

adverse life event

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104
Q

name the positive symptoms of schizophrenia

A 
Delusions
Hallucinations
Thought disorder
thought interference
passitivity phenomenon
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105
Q

what is passitivity phenomenon

A

the thought that your actions feelings or emotions are being controlled by an external force

106
Q

name the negative symptoms of schizophrenia

A 
Anhedonia
Affect blunted
Avolition (reduced motivation)
Alogia (poverty of speech)
Asocial behaviour
Attention deficits
107
Q

what is the ICD-10 criteria for a schizophrenia diagnosis

A

one symptoms from group A, or two or more symptoms from group B.
Symptoms must have been present for at least 1 month
Only diagnosed in the absence or organic brain disease.

GROUPA:
1 .Thought echo/insertion/withdrawal/broadcast
2. delusions of control, influence or passitivity phenomenon
3. running commentary third person auditory hallucination
4. Bizzare persistent delusions

GROUP B:

  1. hallucinations in other modalities that are persistent (e.g visual/tactile)
  2. thought disorganisation e.g loosening of association, incoherence)
  3. Catatonic symptoms
  4. negative symptoms
108
Q

what are the symptoms of catatonia

A
  • Stupor (where person cant move or speak)
  • Waxy flexibility - person stays in the same position for an extended period of time.
  • echolalia - person responds to conversatino by echoing the question
  • catalepsy (muscular rigidity)
  • lack of response to external stimulation
  • mutism
  • echopraxia - mimicing someone elses movements
109
Q

what are the ICD-10 group A criteria for schizophrenia

A
  1. thought insertion/echo/broadcasting/withdrawal
  2. running commentary hallucinations
  3. delusions of control, influence of passitivity
  4. bizzare persistent delusions
110
Q

what are the ICD-10 group B criteria for schizophrenia

A
  1. hallucinations in other modalities (not auditory)
  2. thought disorganisation
  3. catatonic symptoms
  4. negative symptoms
111
Q

what investigations would you order in a patient with suspected schizophrenia

A

CT head - rule out space occupying lesion e.g frontal lobe dishinhibition
EEG - to rule out temporal lobe epilepsy
Bloods - B12, folate, cholesterol, U+E, calcium, glucose, TFT, FBC
ECG for QT prolongation
Urine drug anaylsis

112
Q

biological management of schizophrenia

A

Atypical antipsychotics (1st line)
can add adjuvants e.g benzodiazepines for behavioural symptom relief
ECT may be appropriate for treatment resistant patients

113
Q

How do you treat treatment resistant schizophrenia

A

Clozapine

if clozapine doesn’t work then use ECT

114
Q

Psychological management of schizophrenia

A
  • CBT
  • Family intervention - psychoeducation helps families reduce high levels of expressed emotion
  • art therapy helps relieve -ve symptoms
115
Q

social management of schizophrenia

A

social support groups
peer support schemes
supported employment programmes

116
Q

what is the yerkes dodson law

A

anxiety can be beneficial up to a plateau of optimal functioning. After that point level of performance deteriorates

117
Q

what is anxiety

A

an unpleasant emotional state involving subjective fear and somatic symptoms

118
Q

name common features of neuroses

A 
anticipating/fear of impending doom
exaggerated startle response
depersonalisation/derealisation
palpitations/chest pain
hyperventilation/ chest tightness
abdo pain, loose stools, nausea vomiting
dysphagia
dry mouth
failure of erection, menstrual discomfort
tremor, myalgia, headache, tinnitus
119
Q

how can you classify neurotic/stress related disorders

A

split into paroxysmal anxiety and continuous anxiety

can also be situation dependent and situation independent

120
Q

name 5 medical conditions commonly associated with anxiety

A 
hyperthyroidism
hypoglycaemia
anaemia
malignancy 
substance misuse
eating disorders
somatoform disorders
depression
OCD
PTSD
121
Q

define generalised anxiety disorder

A

a syndrome of ongoing, uncontrollable widespread worry about many events, or thoughts that the patient recognises as excessive and inappropriate. Symptoms are present most days in a 6 month duration.

122
Q

Describe the biological pathophysiology behind generalised anxiety disorder

A

dysfunction of the autonomic nervous system
exaggerated responses in the amygdala and hippocampus
alterations in GABA, serotonin and noradrenaline.

123
Q

What can antipsychotics treat and what can’t they treat

A

can treat positive symptoms

cant treat negative symptoms

124
Q

what are the 3 main actions of antipsychotics

A
  • control psychotic symptoms (within months)
  • tranquilisation (within days)
  • sedation (within hours)
125
Q

what are the 3 main anxiety disorders

A

g.a.d.
phobic anxiety disorders
panic disorder

126
Q

define PTSD

A

a delayed, prolonged and intense reaction to a traumatic event

127
Q

define normal bereavement

A

a normal reaction to a traumatic event/loss of a loved one that doesnt last longer than 6 months

128
Q

define abnormal bereavement

A

an abnormal reaction that occurs in response to an identifiable, non-catastrophic event e.g divorce or loss of a job, that occurs within one month usually but usually doesn’t last longer than 6 months

129
Q

define acute stress reaction

A

exposure to an exceptional physical/emotional stressor followed by IMMEDIATE onset of symptoms e.g within one hour. symptoms include anxiety, dissociation, disorientation, anger, uncontrollable/excessive grief.

130
Q

name risk factors for PTSD

A

profession eg doctor/fire man more likely to be exposed to trauma,
asylum seekers,
previous trauma,
PMH of mental health issues
low SES/ social support
extremely distressing event exposure with perceived threat to life
concurrent life stressors eg happens when going through a divorce

131
Q

name the 4 categories of symptoms of PTSD

A

reliving - flashbacks, nightmares
avoidance - eg excessive rumination, inability to recall
hyperarousal - difficulty sleeping, irritable outbursts
emotional numbing - negative thoughts, detachment from others

132
Q

icd-10 criteria for PTSD diagnosis

A
  1. occurs within 6 months
  2. persistent remembering/reliving
  3. exposure to stressful event
  4. avoidance of similar situations
  5. inability to recall
  6. increased arousal
133
Q

psychological management of PTSD

A

CBT (trauma focused)

eye movement desensitization and reprocessing

134
Q

biological management of PTSD

A

SSRI eg paroxetine

drug therapy used 2nd line after CBT, or in conjunction if evidence of co morbid depression/anxiety is present

135
Q

define OCD

A

recurrent obsessional thoughts or compulsive acts

136
Q

define obsession

A

an unwanted intrusive thought that enters the pts mind and is distressing cos they know they are unreasonable
is a product of their own mind

137
Q

define compulsion

A

a repetitive act that the pt feels driven to carry out

138
Q

pathophysiology behind ocd

A

a learned behaviour = operant conditioning

reduced serotonin in basal ganglia ad frontal cortex

139
Q

icd 10 criteria for ocd

A
  1. must be present for most days for at least 2 weeks
  2. compulsions/obsessions must be characterised by…
    - failure to resist
    - originate from pts own mind
    - repetitive
    - distressing
    - carrying them out relieves anxiety but isnt enjoyable
140
Q

what are the 4 components of the ocd cycle

A

obsession –> anxiety –> compulsion –> relief

141
Q

psychological management of ocd

A

CBT including exposure and response prevention

142
Q

pharmacological management of OCD

A

SSRI first line e.g paroxetine, citalopram

clomipramine can also be added to citalopram if severe

143
Q

what should you always screen for in pts with OCD

A

screen for depression bc highly co-morbid with ocd, also do suicide risk assessment

144
Q

define agorophobia

A

fear/anxiety relating to public spaces

145
Q

define social phobia

A

fear/anxiety of being in social situations that may cause embarrassment/criticism/humiliation

146
Q

give examples of specific phobias

A 
claustrophobia
arachnophobia
needles
blood
water
heights
flying
147
Q

define a phobic anxiety disorder

A

an intense irrational fear of an object or situation that the individual recognises as irrational or excessive

148
Q

describe features of a phobic anxiety disorder

A

autonomic response to feared situation e.g palpitations, vasovagal syncope, sweating, tremors
psych: anticipatory anxiety, inability to relax, avoidance and a fear of dying

149
Q

ICD 10 criteria for agorophobia

A

marked consistent fear or avoidance in..

  • crowds
  • public spaces
  • travelling alone
  • travelling away from home

AND
has symptoms of anxiety in the feared situation
AND causes significant emotional distress
is recognised as unreasonable
AND symptoms are restricted to the feared situation on ly

150
Q

ICD 10 criteria for social phobia

A 
marked consistent fear or avoidance of being the focus of attention in a social situation
plus two of the following..
- blushing
- fear of vomiting
- urgency or fear of weeing/pooing

AND causes significant emotional distress
AND is recognised as unreasonable
AND symptoms are restricted to the feared situation

151
Q

ICD 10 criteria for specific phobia

A

marked fear or avoidance fo a specific object or situation
plus
symptoms of anxiety in the feared situation
AND causes signitficant emotional distress
AND is recognised as unreasonable
AND symptoms are restricted to the feared situation

152
Q

how do you distinguish a phobic anxiety disorder from generalised anxiety disorder

A

phobic anxiety …

  • occurs in response to specific stimulus
  • there is anticipatory anxiety
  • avoidance of stressful situations

in GAD there is no avoidance or anticipatory anxiety bc there is NO TRIGGER

153
Q

how do you distinguish phobic anxiety disorder from panic disorder

A

panic disorder = panic attacks occur spontaneously with no trigger + no avoidance

phobic anxiety = avoidance of the situation that triggers the panic attack

154
Q

how do you distinguish GAD from panic disorder

A

in GAD the anxiety and worry is always there whereas in panic disorder feelings are normal in between attacks which are spontaneous

155
Q

icd-10 criteria for GAD

A 
at least 6 months of prominent tension, worry and feeling apprehensive about normal every day life events.
must have at least 4 of the following symptoms:
- palpitaitons
- chest tightening
- shaking/tremor
-sweating
- dry mouth
-gi upset
-muscle aches
- feeling dizzy
- derealisation/ depersonalisation
- sleep problems
-irritable
156
Q

what investigations would you do in pts that present with GAD to exclude organic cause of the symptom

A

blood glucose (hypoglycaemia)
FBC - infection/anaemia
TFT hyperthyroidism
ECG for palpitations

157
Q

biological management of GAD

A

Sertraline = 1st line bc has anxinolytic effects
SNRI eg venlafaxine or duloxetine can be offered 2nd line
dont offer benzos apart from short term symptomatic relief if severe

158
Q

psychological management of GAD

A

psychoeducation = low intensity psych intervention
CBT = high intensity
applied relaxation techniques

159
Q

describe the steps in treating GAD

A
  1. diagnosis + psychoeducation and monitoring
  2. add low intensity psych intervention eg self help, group therapy
  3. high intensity psych (CBT or applied relaxation) OR drug treatment
  4. drug therapy + CBT + crisis team input
160
Q

define a somatoform disorder

A

where a pt has symptoms of a physical illness in the absence of psychological illness, but it is presumed the symptoms are caused by psychological factors.
they persistently seek medical attention even though it doesnt help them

161
Q

define a dissociative (conversion) disorder

A

symptoms that cant be attributed to a medical disorder but there is a convincing association between onset of symptoms and the presence of a stressful life event

  • stressful event/problem = converted into physical symptoms
162
Q

describe the pathophysiology behind somatoform/dissociative disorders

A
  • pts adopt the sick role = primary or secondary gain

- associated with PTSD and sexual abuse

163
Q

describe the process behind developing dissociative disorders

A
  1. distressing life event
  2. emotional distress
  3. dissociation = separates the distressing event from normal consciousness
  4. converts emotional distress into physical symptoms
  5. primary gain = stress relief secondary gain = financial rewards eg benefits
164
Q

risk factors for dissociative/somatoform disorders

A 
childhood abuse
reinforcement of illness behaviours
anxiety disorders
mood disorders
personality disorders
social stressors
165
Q

name types of dissociative disorders (eg symptoms that can manifest from conversion)

A

dissociative amnesia

dissociative fugue - unexpected physical journey away from normal surroundings

dissociative stupor - reduction in speech/movement/ response to stimuli

trance - temporary altered consciousness
possession - thinks theyve been taken over by a spirit
motor disorder = unexpected movements (involuntary) that look like epilepsy

Anaesthesia/sensory loss - loss of normal sensation

166
Q

what is somatoform disorder aka briquets syndrome

A

multiple recurrent and frequently changing physical symptoms that dont relate to a physical illness

usually has a long history of contacting medical services.

common presentations include GI upset, dysphagia, chest pain, SOB, dysuria, incontinence, itching, headache, paraesthesia, visual disturbance

167
Q

what is hypochondriachal disorder

A

pt misinterprets normal body sensations leading to non-delusional pre occupation that they have a serious physical disease

refusal to accept reassurance from doctors

168
Q

what is persistent somatoform pain disorder

A

persistent and severe pain (longer than 6 months) that cant be explained by physical disorder

often emotional in cause

169
Q

what is malingering

A

where physical symptoms are intentionally produced = the patient has a motive to produce fake symptoms

the pt seeks advantageous benefits of being diagnosed with a medical condition eg avoiding prison

170
Q

what is factitious disorder (munchausens syndrome)

A

pt fakes having a disorder intentionally to adopt the sick role to recieve the care of a patient or for internal emotional gain

171
Q

mechanism of action for zopiclone

A

enhances gaba transmission

172
Q

which drugs can be used to treat insomnia

A

zopiclone

benzo in short term

173
Q

give example of short acting benzo

A

lorazepam

174
Q

give example of long acting benzo

A

diazepam or chlordiazepoxide

175
Q

give two uses for chlordiazepoxide

A
  • sedetive

- alchohol withdrawal/delirium tremens

176
Q

what are the symptoms of benzo overdose

A

ataxia
nystagmus
dysarthria
respiratory depression

177
Q

how do you treat a benzo overdose

A

ABCDE

iv flumazemil

178
Q

how does sodium valporate work

A

inhibits breakdown (catabolism) of GABA

179
Q

when should sodium valporate be used

A

can be used in BPAD if lithium is ineffective or can be added to lithium for rapid cycling BPAD

180
Q

side effects of sodium valporate

A 
hair loss
weight gain
GI disturbance 
ataxia
tremor
tiredness
181
Q

when can carbamezapine be used in psychiatry

A

BPAD resistant to lithium
alcohol withdrawal
note: never use in combination with lamotrigene bc neuro toxic

182
Q

how does carbamezapine work

A

blocks voltage gated sodium channels to prevent excessive neuronal firing

183
Q

what can lamotrigene be used for in psychiatry

A

bipolar depression
can replace lithium
can be used in pregnancy

184
Q

side effects of lamotrigene

A

GI disturbance

RASH

185
Q

give symptoms of lithium toxicity

A 
tremor
acute confusion 
hyperreflexia
polyuria
seizures 
coma
186
Q

management of lithium toxicity

A

usually iv fluids is fine

if severe = renal dialysis

187
Q

side effects/complications of lithium

A 
Gi disturbance 
weight gain
impaired renal function
thirst
weeing more often
fluid and weight retention
QT prolongation
reduces seizure threshold
188
Q

contraindications to lithium

A

pregnancy, cardiac issues (long QT), epilepsy, hypothyroidism (destroys thyroid)

189
Q

side effects of carbamezapine

A

dizziness, dermatitis, hyponatraemia

190
Q

normal lithium levels and levels for toxicity

A

normal = 0.4-1

toxicity =over 1.5

191
Q

what monitoring should be done when starting lithium

A 
TFT
eGFR
FBC
U+E
baseline ECG
pregnancy status
192
Q

mechanism of action for lithium

A

reduces intracellular sodium and calcium

193
Q

how often should lithium levels be checked

A

12 hours after 1st dose
then weekly till stable for 4 weeks
when stable for 4 weeks check 3 monthly

194
Q

management of neuroleptic malignant syndrome

A

ABCDE
IV fluids
bromocriptine

195
Q

symptoms of neuroleptic malignant syndrome

A 
acute onset
typically within 10 days of starting treatment or increasing dose
irritable
confusion
PYREXIA
MUSCLE RIGIDITY 
AUTONOMIC INSTABILITY = tachycardia and fluctuating BP
fluctuating consciousness
196
Q

what do blood tests show in neuroleptic malignant syndrome

A

derranged LFTs
increased creatinine kinase!!!
leukocytosis (sometimes)

197
Q

name specific clozapine side effects

A

hypersalavation
agranulocytosis
reduced seizure threshold

198
Q

how do you manage extrapyramidal side effects of antipsychotics (eg tardive dyskinesia, akanthesia, acute dystona)

A

procyclidine

199
Q

give examples of SSRI’s

A

citalopram, sertraline, fluoxetine, paroxetine

200
Q

how do SSRI’s work

A

inhibiting the REuptake of serotonin from the synaptic cleft = increases serotonin levels in the cleft

201
Q

side effects of SSRI’s

A 
Gi disturbance
sweating
tremor
rashes
sexual dysfunction
stopping SSRI syndrome
202
Q

give examples of SNRI

A

venlafaxine and duloxetine

203
Q

how to SNRIs work

A

inhibit the reuptake of serotonin and noradrenaline in the synaptic cleft = increase availability
doesn’t have as many cholinergic effects

204
Q

give examples of NSSAs (noradrenaline serotonin specific antidepressants)

A

mirtazapine

205
Q

how does mirtazapine work

A

weak noradrenaline reuptake inhibitingeffect and has anti histminergic effects and blocks alpha 1 and 2 receptors

206
Q

when is mirazapine indicated

A

2nd line depression where weight gain and sedation is needed for insomnia

207
Q

side effect of mirtazapine

A

weight gain, postural hypotension

208
Q

autism triad

A

ABC
asocial
behaviour restricted
communication impaired

209
Q

name characteristics of autism

A

onset before 3 years of age
asocial: few social gestures, gaze avoidance, lack of interest in others, lack of emotional expression

communication impairment - delayed and distorted speech, echolalia

restricted behaviours e.g upset in change in daily routine, repetitive behaviour eg rocking or twisting, obsessively persued interests

210
Q

conditions associated with autism

A

epilepsy
visual impairment
hearing impairment
learning disability

211
Q

genetic conditions associated with autism

A

fragile x syndrome

tuberous sclerosis

212
Q

risk factors for autism

A

maternal age over 40
birth issues e.g hypoxia, low fetal weight
sodium valporate in pregnancy
prematurity

213
Q

describe aspergers syndrome

A

impaired social functioning and repetitive interests/behaviours but no impairment in language, cognition or IQ

214
Q

describe retts syndrome

A 
severe progressive disorder starting in early life.
language impairment
repetitive hand movements
loss of fine motor skills
irregular breathing
seizures
ONLY GIRLS
215
Q

main management of autism

A

social communication based intervention and assisting with ADLs
speech and language therapist input
autism team
modification of environmental factors that initiate challenging behaviour

216
Q

triad of ADHD symptoms

A

inattention
hyperactivity
impulsivity

217
Q

icd 10 criteria for autism diagnosis

A
  • onset at 3 years of age (impaired development)
  • communication impairment
  • social interaction impairment
  • restrictive and repetitive behaviours
218
Q

icd 10 criteria for ADHD diagnosis

A

abnormality of attention, activity and impulsivity at home for the age and developmental level of the child.
abnormality and school/nursery
directly observed abnormality
doesnt meet criteria for another disorder
onset before age 7
duration of at least 6 months
iq above 50

219
Q

1st line management of ADHD

A

parent training educational program

CBT/social skills training in older children

220
Q

1st line medical management of severe ADHD

A

methylphenidate

2nd line is atomoxetine/dexamfetamine

221
Q

symptoms of opiate use

A

respiratory depression, low BP, hypoxia, pupillary CONSTRICTION

222
Q

symptoms of stimulant use

A

arrythmia, high bp, increased HR, pupillary dilation, psychomotor agitation, muscle weakness
euphoria, grandiose delusions, paranoid ideation, labile

223
Q

name the components of substance dependence

A

must have all occurred over 1 month:

  • preoccupation with the substance use
  • strong desire to take it
  • withdrawal state if stops using
  • impaired ability to control use
  • built up a tolerance
  • keeps using despite the harmful effects
224
Q

what investigations should you undertake in substance abuse

A 
urinalysis for drug levels
bloods - FBC, HIV and hep B and C screen
LFT and clotting to check hepatic function
ECG for arrythmia
Echo if suspect endocarditis
225
Q

management of substance abuse

A

hep B immunization for needle users
MOTIVATIONAL INTERVIEWING - to help stop
contingency management - changes behaviours
plus bio therapy for the substance

226
Q

biological management of opioid use

A

1st line is methadone or buprenorphine for maintenance and detox

227
Q

management of opioid overdose

A

IV naloxone

228
Q

what drug is used for opioid users who have completely abstained to maintain abstinence

A

naltrexone

229
Q

describe the edward gross criteria for alcohol dependency

A 
SAW DRINK
subjective awareness of need to drink
avoidance of withdrawal
gets Withdrawal symptoms
has drink seeking behaviour
reinstates drinking behaviours after abstaining
increased tolerance to alcohol
narrowing of drinking repetoire
230
Q

symptoms of alcohol withdrawal

A 
tremor
nausea
hallucinatios
autonomic hyperactivity
seizures peak at 72 hours after stopping
231
Q

what is delirium tremens

A 
coarse tremor
delusions
confusion
auditory and visual hallucinations
fever 
tachycardia
seizures
232
Q

management of delirium tremens

A

iv chlordiazepoxide (long acting benzo) bc phenytoin not as helpful in seizures in alcohol withdrawal

233
Q

long term management of alcohol dependency - eg inducing abstinence

A

inpatient detox recommended for those at risk of suicide or a severe history of withdrawal reactions

give high dose chlordiazepoxide tapered down over 10 days plus iv thiamine to prevent wernickes encephalopathy

Disulfiram - causes unpleasant symptoms when the pt drinks alcohol
acomprosate - reduces cravings by enhancing GABA transmission
Naltrexone - reduces pleasurable effects of alcohol by blocking opioid receptors

234
Q

describe paranoid personality disorder

A

suspicious of others
questions partners faithfulness
thinks others are attacking them
no trust

235
Q

describe schizoid personality disorder

A

LONER

flat, cold affect, no emotion, no close friends, likes to be alone, no pleasure in anything

236
Q

describe emotionally unstable personality disorder

A 
unstable relationships
unstable mood
easily gets angry
suicidal
impulsive
237
Q

describe histrionic personality disorder

A

emily williams

attention seeking, cares about looks, easily influences

238
Q

describe dissocial personality disorder

A

gets violent easily
blames others and holds grudges so has no friends
impulsive
remorseless - doesnt care when they do things wrong

239
Q

describe anxious avoidant personality disorder

A

needs to be known that they are liked, avoids situations where they could be embarrassed, feels inadequate, restricts lifestyle to feel safe

240
Q

describe dependant personality disorder

A 
needs constant reassurance
fears abandonment
no self confidence
doesnt like conflict
needs a companion all the time
needs others to be responaible
241
Q

describe akanistic personality disorder

A 
DAD
workaholic
stubborn
fussy with minor details
ability to complete tasks is compromised due to attention to detail
242
Q

section 2

A

for assessment
lasts 72 hours
need 2x doctor and 1 AMHP
evidence = pt has mental health issue that needs assessing + for own/public safety

243
Q

section 3

A

for treatment
lasts 6 months and can be renewed
needs 2x dr and 1 AMHP
evidence = pt has mental health issue that needs hospital tx + for own or other safety + treatment must be availanle

244
Q

section 4

A

emergency section done when waiting for 2nd doctor to confirm section 2/3
lasts 72hrs
needs 1 dr and 1 AMHP

245
Q

section 136

A

in public place police can detain for public safety

246
Q

section 135

A

court order needed to remove pt from own home to psych assessment/tx

247
Q

section 5(4)

A

nurses holding power for 6 hours whilst a doctor comes to assess
must be on a ward not emergency department
CANNOT TX

248
Q

section 5(2)

A

doctors holding power for 72 hours until doctor comes to assess.
must be on a ward not A+E
CANNOT TX

249
Q

icd-10 criteria for anorexia diagnosis

A 
FEED
fear of weight gain
endocrine disturbance - e.g amennorhoea
emaciated (skinny)
deliberate weight loss
distorted body image
250
Q

difference between anorexia and bulimia

A

anorexia: no binge eating, no compensatory behaviours, usually more skinny and more likely to have endocrine disturbance, usually no food cravings

bulimia = episodes of binge eating followed by compensatory behaviour, usually normal weight or can be over weight, strong cravings for food

251
Q

complications of having an extremely low BMI

A 
amenorrhoea
anaemia
impaired immune system
pancreatitis
metabolic alkalosis from vomiting 
osteoporosis
metabolic acidosis from laxative use
arrythmias
bradycardia
dehydration - constipation
hypothyroid
252
Q

management of anorexia

A

risk assessment for suicide
6 months of psycholical intervention eg CBT
aim to gain weight of 0.5-1kg per week in hospital to avoid refeeding syndrome

253
Q

indications for hospitalization of pt with anorexia

A

severe anorexia with bmi below 14

suicidal ideation

254
Q

what is refeeding syndrome

A

causes changes to phosphate and magnesium when feeding after prolonged starvation/malnourishment
causes an insulin surge
causes = hypokalaemia, hypomagnesium, hypophosphataemia, and absnormal glucose metabolism

phosphate depletion can lead to heart failure!

255
Q

how do you manage/prevent refeeding syndrome

A

slow feeds increasing by 0.5-1kg per week
monitor blood electrolytes, BP and pulse daily

if electrolytes drop low then need to be replaced intravenously

256
Q

what is bulimia

A

repeated episodes of uncontrolled binge eating followed by compensatory weight loss behaviours eg vomiting or laxatives
have overvalued ideas about body shape

257
Q

icd 10 criteria for bulemia diagnosis

A
  1. compensatory behaviours to prevent weight gain
  2. preoccupation with eating
  3. fear of being fat
  4. over eating
258
Q

complications of bulimia

A

irregular periods
signs of dehydration eg sunken eyes
depression/low self esteem
hypokalaemia due to repeated vomiting

259
Q

investigations to do in bulimia

A

VBG for metabolic alkalosis from vomiting
ECG for hypokalaemia
U+E, FBC, amylase for pancreatitis, glucose etc

260
Q

management of bulimia

A 
Fluoxetine 1st line
psychoeducation
CBT
food diary to monitor eating habits
risk assessment for suicide
261
Q

indications for admitting a bulimia pt

A

suspicion of dehydration or electrolyte disturbance

risk of suicide

3A Revision (5 decks)

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