Psychiatry and Psychological disorders Flashcards
1
Q
How is BMI calculated?
A
weight(kg)/height(m)2
2
Q
What is the cause of obesity?
A
this is when calorie intake is greater than calorie expenditure
3
Q
What factors infect obesity?
A
Genetic
Behavioural
Cultural
Environmental
Hormonal
4
Q
What behavioural factors increase the risk of obesity?
A
larger portion sizes
increasingly sedentary lifestyle
eating disorders and mental illness
5
Q
What cultural factors increase the risk of obesity?
A
body image
cuisine
obesity not acknowledged
6
Q
What environmental factors increase the risk of obesity?
A
poor antenatal nutrition
socioeconomic status
7
Q
What hormonal factors increase the risk of obesity ?
A
Hypothyroidism
8
Q
List some broad risk factors for obesity
A
hypothyroidism
hypercortisolism
steroid therapy
>40 years
peri and post menopause
prior pregnancy
married
sleep deprivation
smoking
poorly educated
anternatal nutrition
high alcohol intake
binge eating disorder
night eating syndrome
antidepressant
anti-psychotic therapy
9
Q
What are the ways that an obesity diagnosis can be reached?
A
BMI measurement
Waist circumference
Laboratory Evaluation and imaging
body composition tests
10
Q
BMI is not an accurate index in some instances. Give examples of these
A
pregnancy
high muscle mass
11
Q
What is the most commonly used diagnostic measurement for obesity?
A
BMI
12
Q
Waist circumference is commonly used as an indicator of risk for obesity related diseases. Give examples of these risk related diseases
A
HTN
Dyslipidaemia
T2DM
Metabolic syndrome
13
Q
Give specific examples of laboratory evaluation and imaging carried out for an obesity diagnosis
A
[used to investigate secondary/rare causes of obesity]
FBC, serum electrolytes, serum transaminase, TFTs and LFTs (thyroid and liver function tests)
ECG if clinical signs of heart disease
abdominal ultrasound scan (ID fatty liver)
polysomnography (to diagnose obstructive sleep apnoea)
14
Q
Body composition tests comprise of some of the following …
A
skinfold measurements
hydrodensitometry
bioelectric impedance analysis
DXA (bone density scan)
15
Q
What is the first line management of a BMI >30/ >27 with a comorbidity ? Include adjuncts for obesity management
A
dietary changes
Psychotherapy
Pharmacotherapy (olistat)
16
Q
What is the second line management of a BMI >30/ >27 with a comorbidity? Include adjuncts for obesity management
A
increase in physical exercise
psychotherapy
pharmacotherapy (olistat)
17
Q
What is the first line management of a BMI>40/35 with comorbidities or failed initial management?
A
surgical:
sleeve gastrectomy
gastric bypass
gastric banding
gastric balloon
18
Q
What are the complications of obesity?
A
- pregnancy related complications
- increased VTE risk
- acute coronary syndrome
- T2DM
- hypercholesterolaemia
- hypertension
- non-alcoholic fatty liver disease
- metabolic syndrome
- cancer
- mortality
- malnourishment
19
Q
Give examples of national policies that have been introduced to tackle obesity
A
- soft drinks industry levy
- taking 20% of sugar in childrens products (2020)
- nutrient profile model introduction
- making healthy options available in public sector
- healthy food vouchers for low income families
- free pregnancy vitamins
- increasing physical activity in schools
- Jamie Oliver effect
- change 4 life campaign
- one you campaign
20
Q
What is the most frequent age of onset for anorexia nervosa?
A
in late adolescence
21
Q
What are the common factors that increase the risk of developing anorexia nervosa?
A
- perfectionism
- low self esteem
- lack of close friends
- relentless preoccupatioon with dieting and weight loss
22
Q
What is the pathophysiology of anorexia nervosa?
A
- susceptible person begins dieting
- 30% develop pathological eating habits
- 20-25% develop eating disorder
- weight loss gives positive reinforcement
- nutritional imbalance
- obsessive behaviours and rigid thought patterns
23
Q
Several neurotransmitters have been implicated in causing anorexia nervosa. True or false
A
True
24
Q
What is the diagnostic criteria for anorexia nervosa?
A
- restriction of energy intake leading to a significantly low weight in the context of age, sex, development trajectory and physcal healthj
- intense fear of gaining weight or persistent behaviour that interferes with weight gain
- disturbance in body image
25
What are the specific types of anorexia nervosa?
* restricting ype
* binge eating/purging type
26
What does the restricting type of anorexia nervosa entail?
* no episodes of binge eating or purging in the preceding 3 months
* weight loss can be achieved by dieting, fasting and/or excessive exercise
27
What do the binge eating/ purging types of anorexia nervosa (AN) entail?
* recurrent episodes of binge eating or purging behaviour (i.e. self induced vomiting or the misuse of laxatives, diuretics or enemas) in the preceding 3 months
28
What is the BMI for mild AN in adults?
>17kg/m^2
29
What is the BMI for moderate AN in adults?
16-16.99kg/m^2
30
What is the BMI for severe AN in adults?
15-15.99kg/m^2
31
What is the BMI for extreme AN in adults?
<15kg/m^2
32
What are the signs an symptoms of AN?
* weight loss (BMI <17.5)
* fear of gaining weight
* over-exercising
* disturbed body image
* calorie restriction
* bingeing /purging
* amenorrhea
* fatigue and poor concentration
* fainting and orthostatic hypotension (postural hypotension; blood pressure lowers when standing after sitting or lying down)
* lanugo body hair and hair loss
* muscle wasting
* bradycardia and cardiac arrhythmias
* hypothermia
* increased fractures
33
What are risk factors for developing AN?
* female gender
* adolescence and puberty
* obsessivbe and perfectionist traits
* exposure to western media
* identical twins affected
* middle and upper societal class
* family dysfunction
34
What investigations can be carried out for a diagnosis of AN?
* FBC- normocytic normochromic anaemia
* electrolytes: metaboli alkalosis, hypokalemia (vomiting), hyponatremia (laxatives), low Mg2+, low PO4-ions, hypoglycaemia, elevated urea
* Liver function- elevated ALT, AST (alanine and aspartate transaminase), decreased ALP (alanine phosphatase- dephosphorylating enzyme)
* Pregnancy test- to rule out pregnancy in amenorrhoea
* ECG- conduction defects
* DEXA - bone density scan; osteopenia, osteoporosis
35
What are the goals of AN treatment?
* return to healthy weight
* help patient analyse motivations
* prevent and treat complications
* psycho-education
* enlistf family support
* prevent relapse
36
What is the first line management for all patients with AN?
structured eating plan with oral nutrition ad psychotherapy
Adjunct- potassium repletion
37
What is the management of medically unstable or outpatient AN patients?
* oral , enteral or paraentral nutrition
* fluid intake correction
* potassium, magnesium, calcium and sodium repletion
38
What is the management of AN patients with depression?
SSRI
39
What is the management of AN with OCD?
SSRI
clomipramine
olanzapine
40
When is hospitalisation required for patient with AN?
* suicidal thought s
* inability to eat on theirown
* severe psychiatric disease
* unsupporyibe destructive family environmen
* failure of outpatient care
* HR <50bpm
* B/P <80/50mmHg
* symptomatic hypoglycaemia
* significant hypokalemia/hyponatraemia
* temperature <36.1
* dehydration
* cardiovascular abnormalities other than bradycardia
* marked peripheral oedema
* infection
* weight <75% of expected and/or rapid weight loss a kilogram or more in one week
41
List some complications of AN?
* cardiac failure
* increased fracture rate
* infertility
* electrolyte imbalance
* renal failure
* peripheral oedema
* re-feeding syndrome
42
Patients of AN treated in adolescence have a ____% chance of a full recovery
70%
43
How long does a full recovery from AN take?
3-5 years
44
What kinds of AN patients are more likely to relapse and require treatment as a chronic disease?
older patients
45
What psychiatric illness has the highest mortality rate?
Anorexia nervosa
46
Briefly outline the binge and purge cycle of bulimia nervosa (BN)
1. tension and cravings
2. binge eating
3. purging to avoid weight gain
4. shame and disgust
5. strict dieting --->tension and cravings
47
What are the risk factors of BN?
* female sex
* perfectionism
* body dissatisfaction
* impulsivity
* history of sexual abuse
* family history of alcoholism
* depression
* past obesity
* exposure to media pressure
* early onset of puberty
* personality disorders
*
48
Briefly outline the diagnostic history of BN patients
* recurrent episodes of binge eating
* reccurent inappropriate compensatory behavious
* depression and low self esteem
* concern about body weight/shape
* menstrual irregularity
* insulin abuse
* drug seeking behaviour
* GI symptoms
* marked fluctuations in weight
49
Patients with BN may be normal weight. True or false
true
50
What is the frequency of BN episodes required for a diagnosis??
at least 1 bulimic episode per week for a 3 month period
51
How many episodes a week are observed in a mildly bulimic patient?
1-3 episodes per week
52
How many episodes a week are observed in a moderately bulimic patient?
4-7 episodes per week
53
How many episodes a week are observed in a severely bulimic patient?
8-13 episodes per week
54
How many episodes a week are observed in a extremely bulimic patient?
14 or more episodes per week
55
What are the signs of BN?
Russells signs
Dental complications
Parotid hypertrophy
## Footnote
Parotid hypertrophy- compensatory mechanisms to increase saliva production due to acidic environment brought on by vomiting)
56
What is russell signs?
defined as callusses on the knuckles or back of the hand due to repeated self induced vomiting over a long period of time
57
What is the first line management of BN in all non-pregnant patients?
* cognitive behaviour therapy and nutritional support
* adjunct: SSRI/SNRI, other psychological therapies
58
What is the second line management of BN for all non-pregnant patients?
* SSRI/SNRI
* nutritional support
59
What is the management of BN patients with suicidality, diabetes or physical symptoms?
* immediat referral for specialist evaluation or eating disorder
* glycaemic control
60
What are the complications of BN?
* volume depletion
* electrolyte disturbance
* tooth erosion
* pancreatitis
* ipecac related cardiomyopathy
* cardiac dysrhythmias
* haematemesis (vomiting blood)
* Boerhaave syndrome
* Mallory Weiss Syndrome
* death - mostly by suicide
61
What is Mallory Weiss syndrome?
this is when there is a tear on the gastric side of the gastrooesophageal junction which may extend to the distal oesophagus
an incomplete tear only affects the mucosa and submucosa
leads to hematemesis (vomiting blood)
62
What is boerhaaves syndrome?
this is when there is a forceful rupture at the lower thoracic oesophagus due to forceful emesis (vomiting)
63
How does boerhaave syndrome present?
classically presents as macklers triad of:
* vomiting
* subcutaneous emphysema
* lower thoracic pain (chest pain)
64
List some oral signs of eating disorders
* dental erosion
* perimylolysis
* increased tooth sensitivity
* traumatised oral mucosal membranes and pharynx
* dry mouth
* dental caries
* soft tissue lesions (nutritional deficiencies)- angular cheilitis, candidiasis, glossitis, oral mucosal ulceration (damage to epithelial/mucosal lining)
65
What is perimylolysis and how does it appear?
* chemical erosion to tooth surface due to rejurgitation of stomach contents
* loss of enamel with rounded margins
* notched appearance of incisal surfaces of anterior teeth
* amalgam restorations appear as raised islands
* loss of contours of unrestored teeth
66
What oral management strategies are employed for eating disorders?
* recognition of problem
* treat as medically compromiosed
* thorough clinica assessment and medical history
* blood pressure and heart rate (low in AN patients)
* essential restorative work only whilst patient still purging
* dental hygienist- polish (non- abrasive fluoride paste), fluoride varnish application
* remineralisation products
* xylitol products to stimulate saliva flow
* brush 3x a day with soft brush
* advise not to brush directly after vomiting
* neutral oral pH with bicarb of soda after vomiting
67
What are the 2 peak of onset for depression?
* 12-24 years
* >65 years
68
What are the causes of depression?
* Abnormal concentrations of NTs (dopamine, serotoning and noradrenaline)
* disregulation of the hypothalamic- pituitary- adrenal axis
* abnormalities of second messenger systems (cAMP, other kinases?)
69
List symptoms of depression
* anhedonia - reduced ability to experience pleasure
* functional impairment- social/occupational
* weight change
* reduced libido
* sleep disturbance - early morning waking
* psychomotor retardation
* low energy
* excessive guilt
* poor concentration
* suicidal ideation
* psychosis
70
For a diagnosis of depression, what must you exclude?
* bipolar disorder
* medical illness
71
What are the risk factors for developing depression?
* older age
* recent child birth
* stres/trauma
* co-existing medical conditions
* personal or family history of depression
* female sex
72
What investigations can be carried out for a depression diagnosis?
* PHQ-9 questionnaire
* Geriatric depression scale
* Edinburgh post- natal depression scale
73
What other investigations can be carried out to rule other causes of depression?
* FBC
* Thyroid function tests
* vitamin B12
* metabolic panel
* folic acid
74
What are the goals for the management of depression?
* eradicate symptoms
* improve daily functioning and quality of life
* reduce suicidality
* minimise treatment adverse effects
* prevent relapse
75
When are patients with depression managed?
* suicidal intent
* intent to harm others
* psychosis
* unable to care for selves
* severe impairment of ADL (activities of daily living) - catatonia
## Footnote
catatonia- a state where a person is awake but does not respond to people or their environment
76
What is the management of depression?
* consider hospitalisation if necessary
* CBT (cognitive behaviour therapy)
* anti-depressant
* +/- anti-psychotic
* electroconvulsive therapy
* psychotherapy
77
How long does the treatment for depression take to be effective?
weeks to months
78
What is generalised anxiety disorder (GAD)?
defined as at least 6 months of excessive worry about everyday issues that is disproportionate to any inherent risk, causing distress or impairment
excessive
persistent
unreasonable
79
What are the symptoms of GAD?
* irritability
* edginess
* difficulty concentrating
* muscle tension
* chronic fatigue
80
GAD does not occur alongside other disorders. True or false
false
usually occurs with other disorders
81
What is the common onset of GAD?
childhood
adolescence
82
There is no single cause of GAD. List some causes
* increase in minor life stressors
* presence of physical or emotional trauma
* genetic factors
* bullying
83
The pathophysiology of GAD is not clearly understood. Outline some of hypothesised pathophysiology for GAD
* abnormal responses to stress (hyperactive brain circuitry)
* multiple NT involvement
* neurohormone alterations (hypothalamic pituitary axis)
* sleep disturbances
84
What is the presentation of GAD?
* excessive worrying for at least 6 months
* anxiety not medically related
* muscle tension
* sleep disturbance
* fatigue
* restlessness
* irritabilty
* poor concentration
* headache
* sweating
* dizziness
* GI symptoms - diarrhoea, nausea, IBS
* tachycardia
* shortness of breath
* trembling
* chest pain
85
What are the risk factors of GAD?
* family history of anxiety
* physical or emotional stress
* female gender
* diabetes
* adolescence
* substance abuse
86
How is a GAD diagnosis arrived at?
* 6 months of excessive worry
* 3 months of the following symptoms
1. * restlessness or nervousness
2. easily fatigues
3. poor concentration
4. irritability
5. muscle tension
6. sleep disturbance
87
What investigations can be carried out to rule out organic causes of GAD?
* EEG- electroencephalogram
* urine drug screen
* thyroid function
* 24hour urinary catecholamines (NA, A, dopamine)
* ECG and echo
88
What is the management of GAD?
* pharmacotherapy
* cognitive behavioural therapy
* meditation training
* sleep hygiene
* exercise
89
What is Schizophrenia?
the breakdown in relation between thought, emotion and behaviour, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion and a sense of mental fragmentation
90
The pathophysiology of schizophrenia results from ________ and ________ abnormalities
functional
structural
91
What are the strucutural abnormalities observed in schizophrenia?
* global reduction in brain volume by 5-10%
* enlarged lateral and third ventricles
* decreased volume of amygdala, hippocampus, pre-frontal cortex and subcortical structures
* asymmetry between cerebral hemispheres
92
What are the functional abnormalities observed in schizophrenia?
* reduced prefrontal activation when performing executive functioning
* imbalance of neurotransmitters (dopamine, 5HT and glutamate); hyperdopaminergic theory =
93
What are the positive symptoms of schizophrenia?
* auditory hallucinations- command, derogatory conversing or running commentaries
* delusion
* somatisation- expressionof physical symptoms
* bizzare/disorganised behaviour
* flights of thought/speech "word salad"
* anxiety
Non auditory hallucinations (uncommon)
* deja- vu
* elation
Psychotic symotoms
94
What are the negative symptoms of schizophrenia?
* avolition - reduced abilition to initiate and persist in goal directed behaviour
* anhedonia- lack of capacity to enjoy
* asocial behaviour- loss of drive to engage
* affective blunting - reduced capacity to express feeling
* alogia- quantitative and qualitative slowing of speech
* cognitive deficits
* catatonia- awake but no response to people or environment
95
What is a delusion?
a belief held with complete conviction even though its based on a mistaken, strange or unrealistic view
persectory, grandiose, nihilistic, thought insertion, thought broadcasting
96
What are Schneiders first rank symptoms?
* Delusion- real perception interpreted in a delusional manner
* thought disorders
* auditory hallucinations
All other passivity- feelings of being under external control
97
What are the 3 kinds of thought disorders?
thought insertion
thought withdrawal
thought broadcasting- thoughts broadcast to others, no longer private
98
What are the 3 kinds of auditory hallucinations ?
* thought echos (audible thoughts)
* 3rd person voices discussing/arguing about patient
* running commentary
99
What are the risk factor for schizophrenia?
* family history
* increasing paternal age
* cannabis use
* obstetric complications
* low IQ
* Psychological stress
* childhood abuse
* migrant populations
100
What investigations are used to determine alternative causes of symotoms of schizophrenia ?
* plasma drug level monitoring
* HIV test
* syphllis testing
* CT/MRI head
* urine drug screen
101
What are the goals of schizophrenia treatment?
* stable maintenance of anti-psychotic regime
* pyschosocial interventions
* lifelong management
102
What is the management of schizophrenia ?
* oral anti-psychotic medication
* IM antipsychotic
* IM lorazepam for acute psychosis (sedative)
* ECT
* Mood stabilisers
* Anti depressants
* anxiolytics
## Footnote
Lorazepam- benzodiazepine- facilitates inhibitory action of GABA on GABAa
103
What percentage of schizophrenia patients are resistant to treatment?
30%
104
Lifespan of a schizophrenia patients is reduced on average by ...
14.5 years
105
What are some oral considerations for patients with schizophrenia?
* prone to poor oral hygiene (50% of patients brush once or less a day)
* lack of motivation to brush
* tremor associated with anti-psychotics
* deprivation of liberty may lead to decreased contact with dentist
delusions surrounding teeth
