Psychiatry Flashcards
What are the core features/symptoms of depression?
Low mood
Anergia
Anhedonia
List aetiology/risk factors for depression
Genetics, family history Stressful events/life Alcohol/drug use Chronic disease Steroid use, Cushing's syndrome (HPA disruption)
List additional symptoms and signs of depression (not core features)
Negative thoughts and speech Insomnia, early morning wakening Reduced appetite Weight loss Loss of libido Inattention, poor concentration Thought poverty, low pressure of speech Reduced facial expressions Limited body language
What is the criteria for mild-mod depression?
2/3 core symptoms + 4 additional symptoms
What is the criteria for severe depression?
3/3 core symptoms + 5 additional symptoms
What investigations would you order for suspected depression?
Largely clinical diagnosis based on history and mental state
Thyroid function test
Inflammatory markers
CT/MRI brain
List drug classes and examples of drugs used in depression
SSRI (fluoxetine, citalopram, sertraline, paroxetine)
TCA (amitryptiline, clomipramine, imipramine)
MAOi (phenelzine, moclobemide)
SNRI (venlafaxine, duloxetine)
NASSA (mirtazepine)
Anticonvulsants/mood stabilisers (lamotrigine, lithium, sodium valproate)
What are some notable side effects of SSRI?
GI upset
Short-term anxiety/suicidal ideation
Sexual dysfunction
Hyponatraemia
What are some notable side effects of TCA?
Sedation
Anticholinergic side effects (dry mouth, dizziness, blurred vision, urinary retention, constipation)
What are some notable side effects of MAOi?
Hypertensive crisis Postural hypotension Drowsiness Insomnia Nausea, constipation Reaction with tyramine foods
What factors influence suicidal thoughts/intent/behaviour?
Male Older Living alone Recent traumatic event Unemployment, financial struggle Major psych illness Alcohol/drugs addiction Family problems
What factors influence self harm?
Female Young Social issues Personality disorder Alcohol abuse Arguments Stress Child abuse
Define bipolar disorder
2 or more episodes of mood and behaviour disturbance involving hypomania/mania and depressive phases
What are the three types/classifications of bipolar disorder?
I: manic episode + previous hypomanic-depressive episodes
II: 2 or more hypomanic-depressive episodes (no mania)
III: drug-induced hypomania-depression
What is the difference in duration between hypomania and mania?
Hypomania lasts 4 consecutive days
Mania lasts 7 consecutive days
List aetiology/risk factors for bipolar disorder
Genetics, family history Infections Hyperthyroidism SLE Stroke Recreational drugs (amphetamines, cocaine, cimetidine, steroids, levodopa)
List clinical features of bipolar disorder
Elated mood, euphoria Usually depression occupies longer phases Overactivity Restlessness Racing thoughts High pressure speech Irritability Grandiose delusions Flight of ideas Inattention, insomnia Increased libido Irresponsible, reckless behaviour Psychosis more associated with mania
Outline treatment of acute mania/hypomania
Antipsychotic (aripiprazole, olanzapine)_
Detention may be necessary
Mood-stabiliser (valproate)
Which drug is used for bipolar disorder treatment?
Lithium
May use lamotrigine/valproate if ineffective/intolerable
List aetiology/risk factors for anorexia nervosa
Genetics, family history Down-regulated HPA Childhood problems EUPD Social/cultural/occupational factors
What are the specific criteria for diagnosing anorexia nervosa?
Body weight less than 85% expected or BMI less than 17.5
Fear of being fat even when underweight
Purging/vomiting behaviour to lose weight
Endocrine disturbance
List clinical features of anorexia
Cold sensitivity Fatigue Impaired cognition Constipation Osteoporosis Dizziness Fullness after eating Autonomic upset Reduced libido, amenorrhoea
What questions would you particularly ask for investigating anorexia?
Sick because you feel full? Control over eating? One stone loss in 3 months? Fat belief when others say you're thin? Food dominates your life? (SCOFF)
What are the specific criteria for diagnosing bulimia nervosa?
BMI less than 17.5
Recurrent binge-eating behaviour
Preoccupation with weight
Purging mechanisms to overcome fatness
List clinical features of bulimia nervosa
Storage of food Eating large quantities Vomiting, calluses on hands (Russell's sign) Tetanic muscles Swollen salivary glands Endocrine disturbance
Outline treatment for eating disorders
CBT, family therapy Diet management, food diary Treat complications OCP can boost oestrogen SSRI may help
List clinical features of generalised anxiety disorder
Psychological: worry, panic, irritability, reduced concentration, restlessness, distractability
CNS: numbness, tingling, fatigue, insomnia, dizziness, headache, tremor
Autonomic: palpitations, chest pain, hyperventilation, xerostomia, nausea, vomit
“lump in throat” “butterflies” “ringing” nail-biting thumb-sucking
What is the duration of symptoms for diagnosis of generalised anxiety disorder?
6 months or more
Outline non-pharmacological treatment of generalised anxiety disorder
Lifestyle - exercise, relaxation, meditation, avoid caffeine and anxiogens
CBT, mindfulness
Graded exposure desensitisation
Hypnosis
Outline pharmacological treatment of generalised anxiety disorder
Anxiolytics (diazepam for less than 6 weeks) SSRI (fluoxetine) Pregabalin Paroxetine for social anxiety Venlafaxine
What is the time criteria for panic disorder?
Panic lasts up to 45 mins and peak anxiety occurs around 10 mins
List clinical features of panic disorder
Hyperventilation Restlessness Palpitations Sweating Fear, horror Helplessness Numbness Features of GAD
What is depersonalisation?
Perception that people/self are unreal or automated
e.g. body like cotton wool
What is derealisation?
Perception that one is detached from reality
What is a phobia?
Irrational fear that is uncontrollable, causing anxiety and avoidant behaviour
What is classical vs imagined conditioning with regards to developing phobias?
Classical: fear develops after stimulus caused emotional shock
Imagined: fear develops in childhood/development
Outline treatment of phobias
Graded exposure desensitisation
Flooding (not routinely done)
CBT
Paroxetine for social phobia
What are obsessions and compulsions?
Obsessions are stereotyped, purposeless behaviours that are unwanted
Compulsions are repeated rituals that reduce anxiety when performed
List clinical features of obsessive compulsive disorder
Constant checking Repetitive thoughts and actions Superstitions Perfectionism Anxiety
Outline treatment of obsessive compulsive disorder
CBT, exposure response therapy
SSRI (fluoxetine)
TCA (clomipramine)
Deep brain stimulation
What is post-traumatic stress disorder?
Protracted response to stressful event/trauma, diagnosed 3 months after the event
List aetiology/risk factors for PTSD
Natural/human disasters, war Accidents Witness death Sexual assault Kidnap
List clinical features of PTSD
Nightmares Flashbacks Insomnia Panic disorder signs become chronic Emotional numbing Detachment Avoidant behaviour Hyperarousal, hypervigilance
Outline treatment of PTSD
Focused psychotherapy, CBT EMDR Correct stress hormone dysregulation SSRI (paroxetine) TCA (amitryptilline) BZD's Venlafaxine
What is a hallucination?
Perceptual experience that does not match reality
What is a delusion?
Fixed firm belief that is illogical and not amenable to change in the face of evidence to the contrary
What is schizophrenia?
Psychotic illness involving cognitive and behavioural disturbance
What is the proposed pathophysiology of schizophrenia?
Increased dopaminergic neurotransmission and activity
List aetiology/risk factors for schizophrenia
Early cannabis use
Altered neurobiology and development
Abnormal brain architecture
Genetics (NRG-1 on c8, dysbindin on c6)
List structural brain abnormalities in schizophrenia
Enlarged lateral ventricles
Reduced cortical volume, esp frontal lobe
Reduced hippocampal volume
List clinical features of schizophrenia
Psychosis (hallucinations, delusions, thought disorder)
-ve symptoms (lack of volition, social withdrawal, apathy, self-neglect, blunted mood/affect)
Outline treatment for schizophrenia
Psychosocial intervention, CBT, family therapy Antipsychotic Acute management (de-escalate, oral/IM haloperidol +/- lorazepam)
What is the ICD-10 criteria for dependence?
Strong desire for the substance Difficulty controlling use of substance Physiological withdrawal state Neglect other pleasure Persist with substance despite evidence of harm
List aetiology/risk factors for drug dependence
Difficult social circumstances Inherited vulnerability Unemployment Depression, anxiety, PTSD Childhood abuse
Give examples of stimulants
Amphetamine Mephedrone Phencyclidine Cocaine MDMA
Give examples of hallucinogens
Cannabis Solvents LSD Mescaline Ketamine
Give examples of depressants
Heroin Morphine Codeine Dihydrocodeine Methadone Benzodiazepines
List clinical features of drug dependence
Disturbed cognition Altered consciousness and perception Dangerous/odd behaviour Arrests for larceny Injection site abscesses/infection Requests for drugs Withdrawal symptoms
Outline treatment for opiate dependence
Detox: methadone, bruprenorphine
Maintenance: lofexidine
Relapse prevention: naltrexone, acamprosate
Psychotherapy
Describe risky and high risk alcohol consumption
Risky: 15-35 u/week regularly
High risk: more than 35 u/week regularly
List clinical features of alcohol dependence
Life revolves around drink Restlessness Irritability, sweaty Jaundice Memory impairment Neuropathy Fits, falls Hallucination Bleeding (varices, MW tears) Anaemia Arrhythmias Hypertension Withdrawal/delirium tremens
List clinical features of delirium tremens
Tachycardia Hypotension Tremor Fits Hallucinations Aggressiveness, violence
How can CAGE or TWEAC be used to identify alcohol dependence?
Cut-down prompts? Awareness? Guilty about drinking? Eye-opener in the morning?
Tolerance? Worry? Eye-openers? Amnesia? Cut-down attempts?
Outline treatment of delirium tremens/alcohol withdrawal
Parenteral thiamine
Oral diazepam/chlordiazepoxide
Prophylaxis - B blocker, carbamazepine, phenytoin
Outline treatment of alcohol dependence
Psychotherapy, CBT, AA meetings
Relapse prevention (naltrexone)
Post-detox abstinence, acamprosate
What is personality disorder?
When personality is abnormal/deviates from social or cultural norm and causes harm to self and/or others
Describe paranoid personality disorder and give an example of someone from Harry Potter who fits the description
Distrust of others and their motives, constantly suspicious and reluctant to confide or share info
Mad Eye Moody
Describe schizoid personality disorder and give an example of someone from Harry Potter who fits the description
Detached from social relationships and restricted range of emotion
Severus Snape
Describe histrionic personality disorder and give an example of someone from Harry Potter who fits the description
Excessive emotionality and attention-seeking behaviour
Draco Malfoy
Describe antisocial personality disorder and give an example of someone from Harry Potter who fits the description
Disregard for rights and health of others with lack of remorse for others’ feelings
Bellatrix Lestrange
Describe emotionally unstable personality disorder and give an example of someone from Harry Potter who fits the description
Pattern of unstable relationships, self-esteem with fluctuating mood
Lavender Brown
Describe narcissistic personality disorder and give an example of someone from Harry Potter who fits the description
Inflated sense of self-importance with deep need for admiration, often with underlying fragile self-esteem
Luscious Malfoy
Describe avoidant personality disorder and give an example of someone from Harry Potter who fits the description
Social inhibition and feelings of personal inadequacy
Neville Longbottom
Describe dependent personality disorder and give an example of someone from Harry Potter who fits the description
Need to be in care or with people, leading to clinging/submissive behaviour
Ron Weasley
Describe obsessive personality disorder and give an example of someone from Harry Potter who fits the description
Preoccupation with perfection and orderliness with little flexibility
Dolores Umbridge
What is delirium?
Acute confusional state with cognitive impairment and fluctuating course
List aetiology/risk factors for delirium
Elderly in hospital Head injury Infection Alcohol excess, withdrawal Sleep deprivation Unfamiliar environment Surgery Drugs (BZD, opioids, anticonvulsants, digoxin, levodopa, illicit drugs)
List clinical features of delirium
Inattention Abnormal perception and mood Worse at night Impaired memory Incoherent speech Hallucinations Fear, terror
What tool is used to assess delirium?
4AT (Alertness, Attention, AMT4 (age, dob, place, year), Acute onset)
Outline treatment of delirium
Treat underlying cause
Optimise environment and review drugs
Haloperidol/risperidone if severe (oral/IM)
BZD if alcohol withdrawal
What is the IQ cut-off for mild learning disability? What would you notice in the patient?
IQ between 50 and 70
Useful development of language, LD noticed in school
What is the IQ cut-off for moderate learning disability? What would you notice in the patient?
IQ between 35 and 49
Most can talk and get by but basic function
What is the IQ cut-off for severe learning disability? What would you notice in the patient?
IQ between 20 and 34
Limited social activity
What is the IQ cut-off for profound learning disability? What would you notice in the patient?
IQ less than 20
Simple speech is difficult, need special counselling and schooling
List aetiology/risk factors for learning disability
Brain trauma
Antenatal trouble (infection, alcohol, hypoxia, hypothyroidism)
Genetics (Down’s, fragile X)
List clinical features of learning disability
Sensory/motor disability Epilepsy Incontinence Below expected intellect, struggle at school Abnormal behaviour in public
Outline management of learning disability
Speech and language therapy
Support nutrition, care, learning, social areas
Antipsychotic may lower seizure threshold
Behavioural therapy
What is attention deficit hyperactivity disorder (ADHD)?
Behavioural disorder incorporating triad of inattention, hyperactivity and impulsive behaviour
List aetiology/risk factors for ADHD
Reduced frontal lobe function
Premature birth
Genetics
Smoking/alcohol during pregnancy
List clinical features of ADHD
Unable to focus/listen to detail Unable to follow instructions or finish tasks Restlessness Disorganised Forgetfulness Insomnia Mood disorder Family stress
Outline management of ADHD
Cognitive and behavioural therapy Parental education School support Stimulant drugs (methylphenidate (Ritalin) or dexamfetamine) Atomoxetine Antidepressant TCA Antipsychotic
What is autism spectrum disorder?
Lifelong developmental disorder affecting social interaction, communication and behaviour
List clinical features of social interaction in autism
Unaware of feelings/existence of others (treat people like furniture)
Abnormal response to hurt
Impaired imitation
Lack of empathy
List clinical features of communication in autism
Limited facial expressions and gestures Avoids gaze No social smiles or babbling in infancy Stiffens when held, doesn't like to be hugged Lack of speech No interest in stories or fantasy play Repetitive speech Doesn't pick up on social cues/sarcasm
List clinical features of behaviour in autism
Stereotypical movements Preoccupied with parts of objects Inflexible thoughts Distress over changes in environment Routine Precision, fixative behaviour
What is the criteria for diagnosing autism?
6 or more symptoms, including 2 from social interaction, 1 from behaviour, 1 from communication
