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6. Nervous (Neuro & Psych) > Psychiatry - Mood, Anxiety & Memory > Flashcards

Psychiatry - Mood, Anxiety & Memory Flashcards

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1
Q

Describe the prevalence of psychiatric illness in the general population [2].

A
  • 25% across their life will develop a mental health problem, most of which are mild
  • 30% of patients on general wards have a degree of dementia
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2
Q

Name the core clinical problems in psychiatry [11].

A
  • altered mood
  • anxiety
  • arrested intellectual development
  • behavioural problems
  • deliberate self harm (DSH)
  • eating disorders
  • medically unexplained symptoms
  • memory problems
  • drug/alcohol abuse
  • psychological response to trauma
  • psychosis
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3
Q

Describe the 4P and 2P/2S model of psychiatric aetiologies.

A
  • predisposing, precipitating, perpetuating, protective

- physical, psychological, social, spiritual

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4
Q

Define delusion, and describe how it may occur in depression, schizophrenia, and mania.

A
  • a false belief (or held on false grounds), firmly held in the face of logical argument or with evidence to the contrary.
  • depression: disease, nihilism, poverty, sin, guilt
  • schizophrenia: control, persecution, reference, religion, love
  • mania: grandiosity, persecution, religion
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5
Q

Define hallucination.

A

A perception that occurs in the absence of external stimuli, experienced in real space. these are vivid, solid, compelling only in the context of other symptoms.

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6
Q

Define the terms thymia, euthymic, hyperthymic, and cyclothymic.

A
  • thymia: the emotional part of the psyche
  • euthymic: normal mood
  • hyperthymic: increased mood
  • cyclothymic: variable mood
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7
Q

Give the diagnostic criteria for depression.

A 
3 core [2 required]. All about 'MEE':
- 1 depressed (M)ood
- 2 loss of interest or (E)njoyment [anhedonia]
- 3 reduced (E)nergy, increased fatigue
Additional symptoms:
- loss of self-esteem
- unreasonable self-reproach/guilt
- thoughts of death or suicide
- decreased concentration
- psychomotor agitiation
- sleep disturbance
- appetite/weight change
moderate = 2 core + 4
severe = 3 core + 5
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8
Q

Name the main presenting complaints of depression.

A

SIG-E-CAPS
- sleep (reduced, early rising)
- interest (anhedonia)
- guilt (worthlessness, devaluation of self)
- energy (reduced, fatigue)
- concentration (reduced)
- appetite (changed)
- perception [of self and future]
- suicidality

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9
Q

Describe the three proposed biologic theories of depression.

A
  • monoamine deficiency theory: depression proposed to be related to a chronic and ongoing depletion of monoamines (e.g. ACh, NA, DA)
  • HPA axis: increased cortisol associated with depression (e.g. corticosteroid use). thought to have a direct effect on neuronal plasticity and lower resistance to neuronal damage
  • BDNF (brain-derived neurotropic factor): a protective hormone, promoting growth and long-term potentiation; lower concentrations of BDNF associated with stress and depressive illness
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10
Q

Describe the four cognitive characteristics of depression.

A
  • arbitrary interference: drawing a conclusion with no evidence (someone hates you with no evidence)
  • selective abstraction: focussing on a detail while missing the broader context (remembering an awkward conversation at a party but forgetting how pleased everyone was to see you)
  • overgeneralisation: coming to a conclusion based on a single event (making one mistake and thinking you will be bad at every task)
  • personalisation: attributing external events to oneself in an unjustified way (someone is rude to you and you believe you must have done something wrong)
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11
Q
A
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12
Q

What is Cotard’s syndrome?

A
  • delusion that one’s body parts are dead, dying, or do not exist
  • usually elderly, often with nihilistic delusion
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13
Q

What is the difference between bipolar I and II?

A
  • bipolar I meets criteria for mania

- bipolar II meets criteria for hypomania

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14
Q

Give the criteria for mania and hypomania.

A

requires >3 symptoms with impairment to function. [indicates mania]

  • increased activity or restlessness
  • increased talkativeness
  • distractibility
  • dec need for sleep
  • inc sexual energy
  • mild spending sprees or reckless behaviour
  • [flight of ideas, thought racing]
  • [loss of normal social inhibition]
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15
Q

Describe the MSE findings in manic bipolar disorder (appearance, behaviour, speech, thought).

A
  • appearance: bright clothes
  • behaviour: distractibility, loss of social inhibition, overfamiliarity
  • speech: increased talkativeness, punning, clang association
  • thought: inc flow, flight of ideas, Knight’s move thinking, grandiosity etc.
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16
Q

Describe the general considerations of mood disorder medication.

A
  • escitalopram best all rounder SSRI, sertraline well-tolerated, safe, and has easy dose titration, mirtazapine promotes sleep
  • if medication does not work, consider concordance, diagnosis, substance abuse and physical illness
  • increase dose, swap, combine, augment
  • review after 1-2 weeks, continue >6m after recovery
  • ECT ‘last option’, given with general anaesthetic and muscle relaxant to induce seizure
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17
Q

Define gender incongruence.

A

marked and persistent incongruence between experienced gender and assigned sex, which may lead to transition.

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18
Q

Give the medical conditions that may cause intersex.

A
  • Turner’s [X]
  • Klinefelter’s [XXY]
  • CAH [XX female]
  • androgen insensitivity [XY male]
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19
Q

Describe the transition process (between sexes) [3].

A
  • psychotherapy to surgery; helps set realistic goals; should be offered but is not mandatory (worse outcomes)
  • after a full social gender role transition hormones are given
  • surgery includes vaginoplasty, breast augmentation, thyroid chondroplasty, hysterectomy, bilateral salpingoophorectomy, phalloplasty etc.
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20
Q

Define the following:

  • syndrome
  • disorder
  • condition
  • disease
  • dimensional
A
  • syndrome: cluster of symptoms
  • disorder: abnormality of function
  • condition: all diseases, illnesses, and injuries.
  • disease: definite pathological process with characteristic signs and symptoms
  • dimensional: at a certain point on a continuum
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21
Q

Describe the prevalence, investigations, and management of anorexia nervosa.

A
  • 4-12 / 100,000 (women), 1 / 100,000 (men)
  • assessments of physical and psych health, muscle wasting, weight, height, physical exam, blood tests, ECG
  • FBT, dietician, monitor refeeding risk, individual therapies
    • olanzapine, SSRIs
    • CBT/psychological
    • inpatient: MDT, oral supplements > NG feeding, meal time support individual or group therapy
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22
Q

Describe the pathology and management of refeeding syndrome [5].

A
  • the body switches from carbohydrate to fat and protein metabolism
  • serum electrolytes remain normal, but intracellular electrolytes decrease.
  • refeeding causes insulin production, shifting K / Mg / PO4 intracellularly
  • Mx: 1000kcal/day with high PO4 content, increasing by 1000kcal every 2-3 days and blood electrolyte monitoring
  • supplement with vitamin B1 and 6
23
Q

Describe the key points of ARFID [4].

A
  • avoidant-restrictive food intake disorder
  • causes restriction to ‘safe foods’ with fear of N&V, and little interest in eating and poor appetite
  • can cause failure to grow, weight loss, physical health and psychiatric impact
  • CBT/SSRIs can help with anxiety, sensory issue management with ASDs
24
Q

Describe the key points of bulimia nervosa [2].

A
  • outpatient management recommended, unless very low weight or with complications such as hypokalaemia
  • self-help CBT, fluoxetine, family therapy, regular eating
25
Q

Define ‘personality disorder’, and give the diagnostic criteria.

A
  • an individual’s characteristics and enduring patterns of inner experience / behaviour, deviating markedly as a whole from the culturally expected and accepted range.
  • pervasive, inflexible
  • stable (lasts a long time)
  • distress and impairment of functioning in most areas
26
Q

Describe the classification of personality disorders (and give examples from fiction).

A

Cluster A (odd, eccentric), Cluster B (dramatic, emotional), Cluster C (anxious, dependent, anankastic)

  • cluster A: paranoid, schizoid (e.g. Batman), schizotypal (e.g. Willy Wonka)
  • cluster B: dis/antisocial (e.g., the Grinch), emotionally unstable/borderline, histrionic (e.g. Regina George), narcissistic (e.g. Walter White)
  • cluster C: anxious/avoidant (e.g. Charlie Brown), dependent, anankastic (obsessive-compulsive, e.g. Monica from friends)
27
Q

Describe the management of personality disorders.

A
  • treat co-morbid conditions (depression, anxiety)
  • pharmacological management not recommended (impedes personal responsibilities)
    • antipsychotics: cluster A
    • SSRIs: cluster B, anxiety in cluster C
    • mood stabilisers and sedatives can be considered
28
Q

Describe the physical, cognitive, and behavioural symptoms of anxiety.

A
  • physical: dizziness, lump in throat, dyspnoea, palpitation, chest pain, nausea, sweating, flushing, trembling, numbness, epigastric discomfort
  • cognitive: fear of losing control, on edge, difficulty concentrating, derealisation, hypervigilance, racing thoughts
  • behavioural: avoidance, exagerrated responses, difficulty sleeping, alcohol/drugs, persistent irritability, seeking reassurance, checking
29
Q

Describe the four main symptom focuses of anxiety disorders.

A
  • obsessions (ideas and images entering the mind in a stereotyped way, recognised as own thoughts and unpleasant, most commonly contamination and fear of harm) and compulsions (repeated rituals/stereotypes, ‘neutralising’ behaviour)
  • uncontrollable worry (not restricted to / predominating in any particular environment)
  • panic (social phobia, discrete object/situation, some spontaneous / panic disorder)
  • trauma history, flashbacks (PTSD)
30
Q

Describe the general management of anxiety disorders.

A

CBT / SSRIs or SNRIs

  • OCD: CBT for response prevention
  • pregabalin, MAOIs, BZDs further use
  • graded exposure for specific phobias
31
Q

Describe the neurobiology and diagnosis of PTSD.

A
  • hippocampal atrophy, increase amygdala, hemisphere lateralisation (accounting for ‘timelessness’), deactivation of Broca’s area
  • acute response: numb shock, denial, fear, depression / elation, anger, irritability, guilt, intrusive experiences
  • diagnosis:
    • > 1 intrusive (recollection, nightmares, distress etc.)
    • 1/2 avoidance (thoughts/feelings, external reminders)
    • > 1 of cognition mood
    • > 2 of increased arousal and reactivity
    • functional impairment for >1 month
32
Q

Describe the management options for PTSD.

A
  • mild: watchful waiting
  • <3m from exposure event: CBT, hypnotic medications for sleep disturbance
  • > 3m: CBT, EMDR, 3MDR, antipsychotics, antidepressants, mood stabilisers
33
Q

Describe the two types of trauma, and the brain’s responses to these traumas, including neurobiological.

A
  • type 1: single, sudden, unexpected incident
  • type 2: complex, repetitive, ongoing, abusive / hostage / betrayal events etc.
  • fight, flight, freeze, hide and seek, avoid, attach, submit, despair, uncontrolled activation states
  • activity shifts from the rostral anterior angulate and medial corteces to the PAG (brainstem)
34
Q

Describe the triune brain.

A
  • human brain: regulatory abilities, cognitive and executive functions.
  • mammalian brain (limbic): emotional, somatosensory, memory, attachment
  • reptilian brain: autonomic arousal, instinctive responses
35
Q

Describe how different brain areas may contribute to the fear response.

A
  • amygdala: integrates sensory and cognitive information
  • anterior cingulate cortex, orbitofrontal cortex: affect of fear
  • hypothalamus: increased release of cortisol
  • locus coerulus: autonomic, increase BP and HR
  • hippocampus: re-experiencing trauma
  • CSTC: worry, anxiety, apprehension, obsession
36
Q

Describe the main binding sites on the GABA receptor and what their functions may be.

A
  • GABA(A) binding site
  • benzodiazepine binding site
  • barbiturate binding site
  • general anaesthetic binding site (propofol, steroids, halothane, ethanol etc.)
  • GABA is the main inhibitory neurotransmitter in the brain. It decreases amygdala and CSTC function
  • BZDs enhances the inhibitory response of GABA, but we do not know why we have a BZD binding site
37
Q

Describe the indications for antidepressant drugs in anxiety disorders.

A
  • SSRIs: panic disorder, OCD, PTSD, phobias, GAD
  • TCAs: second line panic disorder, OCD
  • SNRIs: GAD (venlafaxine)
  • MAOIs: social phobia
  • pregabalin (a CCB and GABA enhancer): non-responders
  • beta-blockers: for somatic symptoms, e.g. tremor
38
Q

Define ‘functional disorder’, and give examples for some body systems.

A
  • ‘software’ rather than ‘hardware’ problem; one cannot easily associate symptoms with a classically identifiable process
  • previously described as ‘medically unexplained’, psychogenic’, ‘conversion disorder’
  • neuro: weakness, non-epileptic seizures, hemisensory
  • ENT: functional dysphonia, globus pharyngeus
  • cardiology: atypical chest pain, unexplained palpitation
  • MSK: fibromyalgia
  • GI: IBS, non-ulcer dyspepsia, chronic abdominal pain
  • post-viral chronic fatigue syndrome (long covid?)
  • O&G: chronic pelvic pain, PMS
39
Q

Describe the key features regarding management of functional disorders.

A
  • a patient view that things may be amenable to change is a good predictor
  • ensure the patient is examined - how can you exclude pathology if you don’t examine the patient?
  • 5 key steps:
    • normalisation: this is common, we see this often, you are not wierd
    • validation: your symptoms are genuine, not imaginary
    • reversibility: many make good progress, this can potentially be treated
    • remove blame
    • but: you will need to put some effort into getting better
  • some options include CBT, TCAs, breathing exercises, retraining etc.
40
Q

Name the neurobiological changes seen in Alzheimer’s [2]

A
  • neurofibrillary tangles, amyloid plaques
  • reduced function of the cholinergic projections (striatal interneurones, nucleus basalis of Meynert, medial septal nucleus, and brainstem nuclei),
41
Q

Describe the investigations and outcomes associated with memory testing.

A
  • tests include MoCA, MMSE, ACE-III, FAB, 6-CIT etc.
  • OT assessment may be helpful regarding daily activities (e.g., shopping)
  • subjective: patient feels they are impaired but testing is normal and day-to-day function intact
  • mild: ACE-III of 75-90 or MoCA 24-26
42
Q

Describe the holistic and medical management options for dementia [4+2].

A
  • encourage advice and planning while patient has residual capacity
  • nurse-led memory clinic, consultant review & imaging (which type of dementia?)
  • SALT, OT, physio, CMHT for support etc.
  • cholinesterase inhibitors slow cognitive decline by boosting cholinergic transmission, but do not treat the underlying pathology
    • e.g. donepezil, galantamine, rivastigmine
    • s/e: GI, headache, muscle cramps, bradycardia, increased COPD/asthma
43
Q

Define delirium and give the key symptoms [7].

A
  • impaired consciousness with intrusive abnormalities of perception and affect
  • rapid onset, transient/fluctuating course, may last days to months
  • consciousness: clouding, drowsiness, sopor, coma
  • cognition: reduced to time, place, and person; reduced memory and perception
  • psychomotor: may be hyperalert, hypoalert (can be confused for depression), or mixed (fluctuant)
  • sleep: sleep loss, insomnia, reversal of sleep cycle, sundowning, aggression etc.
  • emotional: anxiety, fear, irritability, fear, euphoria, apathy, perplexity, aggression
44
Q

Give some of the common causes of delirium [6].

A
  • infection (meningitis, encephalitis)
  • trauma (SDH, MI, PE, CHF)
  • GI/GU (liver failure, pancreatitis, UTI, renal failure)
  • drugs (alcohol, drugs, BZDs, barbiturates, opiates, steroids, TCAs, anticonvulsants, digoxin, antiparkinsonians, anticholinergics)
  • metabolic (hypoxia, hypoglycaemia, reduced liver/kidney function, hyper/hypothyroidism, electrolyte abnormalities, porphyria, carcinoid syndrome)
  • vascular (TIAs, thrombosis, embolism, migraine, tumours, epilepsy)
45
Q

Describe the key features of hyperactive and hypoactive delirium.

A
  • hyperactive: elderly with recent injury (e.g. NOF#), sudden onset new confusion, agitation, restlessness, disruptive dramatic behaviour, delusion or hallucination of persecution
  • hypoactive: suddenly quiet or withdrawn or sleepy, may not eat, drink, care for self; unmotivated, lazy, uncooperative, depressed
46
Q

Describe the investigations that should be performed in the setting of delirium [4+4].

A
  • biochemical: urinalysis, FBC, U&Es, LFT-s, TFTs, glucose, CRP, B12, folate
  • with focal neuro signs, reduced LOC, recent fall, head injury, anticoagulants: consider CT
  • if suspicious of epilepsy of non-convulsive status epilepticus: consider EEG
  • the 4AT is the gold standard.
    • Alertness [4]
    • Age, DOB, place, year [1 if 1 mistake, 2 if >1]
    • Attention (months of year backward) [<7 is 1, untestable is 2]
    • Acute change (paranoia, hallucination) [4]
47
Q

Describe the management options of delirium [5].

A
  • sedation may be required
  • reality orientation (clear communication, clock/calendar)
  • bright side room with reduced noise and removal of unsafe objects
  • correct sensory impairments (e.g., glasses, hearing aids)
  • lorazepam 0.5-2mg may be useful
48
Q

Describe the types of memory.

A
  • sensory (<1s)
  • short-term, working (<1m)
  • long-term, split into implicit (unconscious, procedural) and explicit (conscious, declarative)
    • episodic (events, experience)
    • semantic (facts, concepts)
49
Q

Describe the clinical features and diagnostic criteria of dementia.

A
  • dementia is usually of a chronic or progressive nature, with disturbance of multiple higher cortical functions
  • 2+ of forgetfulness, memory loss, confusion, poor reasoning/logic, personality change, poor judgement, poor ability to focus, poor visual perception.
  • difficulty in day-to-day function (burning food, use of microwave, remote, remembering the news, driving etc.)
50
Q

Describe the epidemiology and risk factors for deliberate self-harm (DSH), which should be used as a term instead of ‘attempted suicide’.

A
  • rate is 10.7 / 100,000
  • female is 8, male is 1.5 (although male DSH is more likely to be violent)
  • risks: being born in spring, further from the equator, single / separated / isolated, poor health, psychiatric diagnosis
51
Q

Why is restricting methods of DSH effective in preventing it?

A

restricting access to methods of suicide, particularly more toxic methods, decreases number and rate of DSH as people do not substitute methods (or do so to a less toxic method)

52
Q

Describe the management of DSH [5].

A
  • calm the patient and allow release of emotion (crying, not anger)
  • direct the interview, ensuring privacy, asking about antecedents, the episode itself, and mental state then and now
  • bolster self-esteem; any relief from discussing problems is proof that further discussions with the right person will help more.
  • use past episodes where problems have been solved as a template
  • consider psychiatry, counselling, social work, addiction services, Samaritans etc.
53
Q

Describe the biological / endocrine systems leading to mood disorders.

A
  • decreased cortisol receptors by desensitisation
  • this leads to increased CRF secretion and disturbed NA / 5-HT transmission
  • CRF leads to adrenal hypertrophy and increased release of proinflammatory cytokines (TNFa, IL-6) and macrophages
54
Q

Describe the role of the hippocampus in depression symptoms.

A
  • amygdala: emotion, fear
  • PFC: working memory, cognition, mood
  • hippocampus proper: learning, cognition, anxiety, HPA axis, vegetative functions, decreased growth

6. Nervous (Neuro & Psych) (8 decks)

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