Psychiatry - Level 3 Flashcards
Definition of Huntington’s Disease?
- Autosomal dominant with 100% penetration, combination of progressive dementia and worsening chorea
Epidemiology of Huntington’s Disease?
- Males : Females
- Age of onset 30-40
Pathology of Huntington’s Disease?
o Trinucleotide repeat CAG expansion on c4
o Decreased GABA neurons in basal ganglia
o Increase in stimulation of thalamus and cortex of globus pallidus
Symptoms of Huntington’s Disease?
- Onset of symptoms usually after reproductive age
- Insidious onset
- Involuntary choreiform movements
o Typically start in face, hands, shoulders, gait (ataxia)
o Slurring of speech, extrapyramidal rigidity and epilepsy - Psychiatric symptoms
o Depression, risk of suicide, delusional, schizophrenia
o Subcortical dementia – slowing, apathy, amnesia
Investigations of Huntington’s Disease?
- Pre-symptomatic diagnostic test o CAG repeats – Over 40 abnormal - EEG slowing - CT/MRI o Atrophy of basal ganglia o Boxing of caudate - PET scan – decreased metabolism
Management of Huntington’s Disease?
- No curative treatment
o Haloperidol (or other antipsychotics) may reduce abnormal movements
o Depression treated with SSRIs - Emotional and physical support
Definition of Creutzfeldt-Jakob Disease?
- Progressive dementia transmitted by infection with prion – a glycoprotein viral sub-particle lacking RNA
- New variant CJD
o Transmitted via food chain – neuropathologically related bovine disease (bovine spongiform encephalopathy)
o Disease affects younger people (20 year)
o Anxiety and depression followed by personality changes and then dementia
Epidemiology of Creutzfeldt-Jakob Disease?
- Rare
- 50-70 years old
- Male : Female
Transmission of Creutzfeldt-Jakob Disease?
o 85% spontaneous , 10% genetic mutation, 5% iatrogenic
o Infected humans through corneal transplantation, depth EEG with contaminated electrodes, neurosurgery with contaminated needles
Histology of Creutzfeldt-Jakob Disease?
o Neuronal degeneration without inflammation
o Astrocytic proliferation
o Vacuoles in grey matter – status spongiosus
Symptoms and signs of Creutzfeldt-Jakob Disease?
- Rapidly deteriorating dementia, cerebellar and extrapyramidal signs o Memory impairment o Personality change o Fatigue o Depression o Progressive spastic paralysis of limbs o Tremor, rigidity, choreoathetoid movements - Myoclonus and death within a year
Investigations of Creutzfeldt-Jakob Disease?
- EEG shows triphasic, periodic complexes
- CT atrophy of cortex and cerebellum, ventricular dilatation
Management of Creutzfeldt-Jakob Disease?
- No cure
- Supportive treatment
Prognosis of Creutzfeldt-Jakob Disease?
- Death usually within 1-2 years
Defintion of AIDS related dementia?
- Histological evidence of brain damage
- Picomolar concentrations on HIV surface is neurotoxic
Symptoms of AIDS related dementia?
- Insidious concentration and memory affected
- Apathy, social withdrawal
- Increasing motor problems and affecting ADLs
o Psychomotor retardation – progressive and severe
Management of AIDS related dementia?
- No treatment
- ART used to prevent progression of HIV/AIDs
Definition of learning disability?
o IQ < 70, significant impairment of social or adaptive functioning and onset in childhood
Classification of learning disability?
o Mild – 50-69
o Moderate – 35-49
o Severe – 20-34
o Profound - <20
Risk factors of learning disability?
o Chromosomal anomalies – Down’s, William’s, Rhett, Fragile X
o Congenital malformations – spina bifida, hydrocephalus, microcephaly
o Prenatal exposure – alcohol, sodium valproate, congenital rubella infection, zika virus
o Birth – Hypoxic brain injury, cerebral palsy
o Prematurity (<33 weeks)
o Meningitis, encephalitis, measles
o Childhood neglect
Associations with learning disability?
o ASD
o ADHD
Symptoms of learning disability?
o Mild - some learning difficulties in school, many will be able to work and maintain good social relationships
o Moderate – marked developmental delays, most can learn some independence in self-care and adequate communication and academic skills, may need support to live and work
o Severe – continuous support
o Profound – severe limitation in self-care, continence, communication and mobility
How to interact with people of learning disability?
o Use straight-forward language
o Accommodate sensory impairments
o Different communication methods
Management of suspected learning disability?
o Referral to local community learning disability service/team
o Other referrals: clinical psychologist, mental health service, clinical genetics, safeguarding
Management of confirmed learning disability?
o Annual health check with paediatrician or GP
Standardised Cardiff health check template
General health – weight, height, BMI, BP, cholesterol, urine analysis, smoking status, alcohol intake
Record vaccination status and offer any outstanding
Physical examination
Review mental health, medications
o Information
Access to social and support services
Formal carer’s assessment of needs
Respite care
Definition of PTSD?
- Severe psychological disturbance following a traumatic event characterised by involuntary re-experiencing of elements of the event, with symptoms of hyperarousal, avoidance, emotional numbing
Common traumatic events in PTSD?
- Major traumatic event is stressful event or situation of an exceptionally threatening or catastrophic nature, which would cause pervasive distress Serious accidents Military combat Violent personal assault Terrorist attack Being prisoner-of-war Torture
Definition of acute stress reaction?
o Transient disorder
o Develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress
o Symptoms mixed but could include being in a daze, disorientation, panic, amnesia
o Symptoms usually appear within minutes of the impact of the stressful stimulus /event
o Usually subsides within hours or days (2-3).
o By definition – NOTHING!
Epidemiology of PTSD?
- Risk of developing PTSD after traumatic event around 10-20%, more in women
Risk Factors of PTSD?
Low education Lower social class Afro-Caribbean Females Low self-esteem Family history Previous traumatic events
Aetiology of PTSD?
o Acute stress disorder
o Reduced hippocampal volume
o Dysfunction of amygdala
o Genetic
ICD-10 of PTSD?
o >2 persistent symptoms of increased psychological sensitivity and arousal
Difficulty falling or staying asleep
Irritability or outburst of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Persistent remembering or relieving of the stressor in flashbacks, vivid memories, recurring dreams
Avoidance
Inability to recall
o Onset is usually after 1 month of incident occurring
Management of PTSD - psychological?
- Eye movement desensitisation and reprocessing (EMDR)
o Your therapist will then guide you through a process known as desensitization
o While keeping the memory of a painful or traumatic event in mind, you will follow the therapist’s back-and-forth finger movements with your eyes
o The purpose of this technique is to help you fully process your negative feelings and begin to recognize that you no longer need to hold on to some of them - CBT
- Psychodynamic therapy
o Aims to understand the meaning of the traumatic event and resolve provoke unconscious conflict
Management of PTSD - Pharmacological?
o Depressive – SSRIs, TCAs, MAOIs
o Anxiety – Benzodiazepines
o Sleep – Sedative antidepressants, hypnotics
o Intrusive thoughts – Carbamazepine, lithium
o Impulsivity – Carbamazepine, valproate
Management of PTSD - social?
- Good support
- Good coping strategies – accept problem, talk about experiences
- Self-help books
- Keep life as normal as possible.
- Get back to your usual routine
- Talk about what happened to someone you trust.
- Try relaxation exercises.
- Eat and exercise regularly
Prognosis of PTSD?
- 30% will run chronic course
- 50% will recover within 1st year
Definition of agoraphobia?
- Translated from Greek for fear of the market-place
- Now defined as fear of space (open or close). Includes difficulty travelling (distance away home), worst in queue, travelling alone, crowded areas, feeling of being trapped
- Increased risk with panic attacks
- Leads to avoidance of situation
Epidemiology of agoraphobia?
- Females 3>1 Males
- Peak onset 20-35
Symptoms of agoraphobia?
- Avoidance of feared areas
- Panic attacks often precede or follow agoraphobia
o SOB, tachypnoea, dizziness, suffocation, fear of dying - Often feel worse the further they are from home
Management of agoraphobia - general advice?
o Avoid anxiety-producing substances e.g. caffeine
o Exclude alcohol and drugs
o Exercise
Management of agoraphobia - pharmacological?
o Antidepressants
o Benzodiazepines for short-term use only
Management of agoraphobia - psychological?
o CBT
o Self-help groups
Exposure methods, relaxation training
Prognosis of agoraphobia?
- 1 in 3 will have underlying depression
- 1 in 5 will attempt suicide
Definition of social phobia?
- Characterised by the persistent fear of situations in which person is subject to possible scrutiny by others and fears they may act in humiliating or embarrassing way (e.g. eating in public)
- More pervasive social phobias are usually associated with low self-esteem and fear of criticism
- Leads to avoidance of social situations
Epidemiology of social phobia?
- 3-4% of population
- Male:Females
- Peak between 11-15 years but can present through adulthood
Precipitating factors of social phobia?
o Stressful or humiliating experiences, death of a parent, separation or chronic exposure to stress
o Genetic vulnerability
Symptoms of social phobia?
- May present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, the patient sometimes being convinced that one of these secondary manifestations of their anxiety is the primary problem
- May progress to panic attack
- Difficulty in maintaining relationships, educational/vocational problems
- High level of psychiatric comorbidity
Management of social phobia - psychological?
o CBT (first line)
Components include relaxation techniques/anxiety management
o Social skills training
Management of social phobia - pharmacological?
o Beta-blockers
o SSRIs and MAOIs
o Benzodiazepines (if needed – could be given 1 hour before social event)
Definition of specific phobia?
- Recurring excessive and inappropriate psychological or autonomic symptoms of anxiety, restricted to highly specific situations such as:
o Proximity to animals, heights, thunder, darkness, flying, closed spaces
o Urinating or defecating in public toilets, eating certain foods, dentistry, or the sight of blood or injury - Though the triggering situation is discrete, contact with it can evoke panic as in agoraphobia or social phobia
Epidemiology of specific phobia?
- About 10% of population have clinically significant phobia
- Begin in early childhood
- In childhood, males=females, but more females in adulthood
Symptoms of specific phobia?
- Avoidance
- Panic symptom upon exposure
- Blood and bodily injury may make you go bradycardic, hypotensive and faint
Management of specific phobia?
- Psychological
o CBT
Reduce fear response, graded exposure
o Anxiety management - Pharmacological
o Not used unless severe – Benzodiazepines, beta-blockers
Definition of personality disorder?
- Severe disturbance in the characterological constitution and behavioural individual
- Associated with considerable personal and social disruption
Epidemiology of personality disorder?
• Affects about 10% of population
Types of personality disorder - Cluster A (Weird, Odd)?
o Paranoid
o Schizoid
o Schizotypal
Types of personality disorder - Cluster B (wild, dramatic)?
o Antisocial
o Borderline (Emotionally Unstable)
o Histrionic
o Narcissistic
Types of personality disorder - Cluster C (worried, anxious)?
o Avoidant
o Dependent
o Obsessive-Compulsive
Symptoms of paranoid personality disorder?
o Irrational suspicion and mistrust of others
o Interpret motivations as malevolent
o Accusatory without evidence
o Pathologically jealous
Symptoms of schizoid personality disorder?
o Prefer to be on own, detached from social relationships
o Restricted emotional expression
o Voluntary social withdrawal
Symptoms of schizotypal personality disorder?
o Odd, eccentric thoughts & behaviours - distorted cognition
o Magical thinking, peculiar appearance
o Uncomfortable interacting socially
Symptoms of antisocial personality disorder?
o Disregard for rights of others, lack empathy
o Manipulative
o Impulsive, break rules, often criminal
o Conduct disorder predisposes to antisocial
Symptoms of borderline personality disorder?
o Abrupt mood swings, unstable relationships/self-image/indentity
o Often self-harm/impulsive
o Abuse in childhood
Symptoms of histrionic personality disorder?
o Attention-seeking, excessive emotions, provocative, flamboyant
o Sexually inappropriate
o Cannot form meaningful relationships
Symptoms of narcissistic personality disorder?
o Grandiosity, superiority, inflated ego, entitled
o Lack of empathy, exploit others, criticise others
Symptoms of avoidant personality disorder?
o Social inhibition and inadequacy
o Fear of rejection, sensitive to negative evaluation
o Desire relationships
Symptoms of dependent personality disorder?
o Need to be cared for by others
o Poor confidence, others make decisions for them
o Fear being alone
Symptoms of obsessive-compulsive personality disorder?
o Rigid conformity to rules, perfectionist, control
o Excludes leisurely activities and friendships
o Accepts their thoughts (unlike OCD)
