Psychiatry (Quesmed) Flashcards
1
Q
What is Korsakoff’s Syndrome?
What condition leads to it and what type of Amnesia is seen?
What 3 other symptoms are seen in addition to amnesia? (VCA)
What underlies the symptoms?
A
Wernicke’s Encephalopathy progresses to Korsakoff’s Syndrome if left untreated
It presents as Profound Anterograde Amnesia with Limited Retrograde Amnesia
Therefore patients may fabricate memories to mask memory deficits
In addition to memory issues:
1) Issue with coordination and balance
2) Issue with Vision
3) Apathy
It is thought to occur due to Mammillary Body degeneration
2
Q
Which questionnaire quickly screens for Alcohol Abuse?
A
CAGE
Cut down? (Have YOU ever felt the need to cut down)
Annoyed? (other people annoyed you saying you drink too much?)
Guilt?
Eye Opener? (Drinking in the morning to calm down your nerves)
then AUDIT
3
Q
Where is alcohol absorbed in the body?
A
Proximal small intestine
4
Q
What is Transient Global Amnesia?
A
It is the temporary destruction of both long and short term memory (hence GLOBAL AMNESIA)
All other cognitive functions are normal
5
Q
What is the presentation of Transient Global Amnesia?
A
Patients are found wandering the street far away from their home as they forget RECENT and OLD memories
But this may be TRANSIENT as
This may last for hours before resolving on its own
6
Q
What are the 3 criteria that must be met for a patient to be treated under the Mental Health Act?
(Treated without their consent)
A
They must have a Mental Disorder
They must be a risk to their own Health and Safety or someone else’s health and safety
There must be a treatment (including Nursing Care or drugs)
(Only for mental health conditions UNLESS a physical condition is the cause or result of a mental health condition)
7
Q
What are the 5 principles of the Mental Capacity Act?
A
1) A person is assumed to have capacity unless proven otherwise
2) HELP- Steps must be taken to help a person have capacity
3) UNWISE- An Unwise decision does not mean that the person lacks capacity
4) BEST- Any decision made under the MCA must be made in the person’s best interests
5) LEAST- Any decisions made must be the LEAST RESTRICTIVE decision to the person’s rights and freedom
8
Q
How is capacity assessed?
A
A person has capacity if they show a disturbance in the functioning of the mind AND they are unable to:
- Understand the information
- Retain the information
- Weight up the information
- Communicate a decision
9
Q
What is Section 2 of the Mental Health Act?
What is a requirement that must be met by at least one of the other doctors?
A
- Admission for assessment for up to 4 weeks
- This decision is made by an Approved Mental Health Professional or the patient’s nearest relative
- Requires the recommendation of 2 doctors (one of whom must be approved under Section 12(2) of the MHA)
10
Q
What is Section 3 of the Mental Health Act?
A
- Admission for up to 6 months, renewable
- It requires an Approved Mental Health Professional and 2 doctors- both of who must have seen the patient in the past 24 hours
Also after 3 MONTHs an independent doctor must review
11
Q
What is Section 4 of the Mental Health Act?
A
- Used in Emergencies if the doctor is NON-PSYCHIATRIC where Section 2 would cause an “Undesirable Delay”
- You need the recommendation of only 1 doctor and either an AMHP or their nearest relative
- They can be detained for up to 72 hours, where it is then converted to a Section 2
12
Q
What is Section 5(2) of the Mental Health Act?
A
- A voluntary patient in HOSPITAL can be legally detained by a doctor for 72 hours
13
Q
What is Section 5(4) of the Mental Health Act?
A
Like Section 2 but it is used by Nurses and only for 6 hours
14
Q
What is Section 17 of the Mental Health Act?
A
It is a Supervised Community Treatment
(You can get leave but you can get recalled to the hospital if you stop taking medication or if your condition worsens)
15
Q
What is Section 135 of the Mental Health Act?
A
It is a court order that allows Police to enter a property and move a patient to a place of safety (Police Station or A&E)
16
Q
What is Section 136 of the Mental Health act?
A
The police can bring someone from a public place who appears to have a mental health condition to a place of safety
17
Q
What are the side effects of First Generation Antipsychotics (HALOPERIDOL)?
(All 4 are MOVEMENT RELATED- uncontrollable movements)
A
Extra Pyramidal Effects
- Akasthisia (inability to sit still)
- Dystonia (spasms and contractures)
- Parkinsonism
- Tardive Dyskinesia (twitching, jerking, involuntary blinking)
18
Q
What are 5 examples of Second Generation Antipsychotics?
(ARIP, RIZ and the PINEs)
A
- Ariprazole
- Risperidone
- Quetiapine
- Olanzapine
- Clozapine
19
Q
What are the 3 main side effects of Second Generation Antipsychotics?
(Uncontrollable Sugar, Lipids and Weight)
What can Clozapine in particular cause?
A
Weight Gain
Worsening Glycaemic Control
Dyslipidaemia
Clozapine- leads to Agranulocytosis, Confusion, Ataxia
20
Q
What are the side effects of ALL Antipsychotics?
Stopping Insanity Comes with High Stakes, Remember NMS
A
- Sedation
- Increased Risk of Stroke
- Cardiac Arrhythmias
- Hyperprolactinaemia (Switch to Aripiprazole)
- Sexual Dysfunction
- Reduction in Seizure Threshold
- Neuroleptic Malignant Syndrome (Measure CK)
21
Q
What are the signs of Neuroleptic Malignancy Syndrome?
Patient is rigid and sweating and all readings are high
A
Confusion
Diaphoresis (Sweating)
Rigidity
Pyrexia (Fever)
Tachycardia
Tachypnoea
Hypertension
22
Q
What are the 6 side effects of SSRIs?
QA GG SS
A
1) QT Prolongation
2) Anxiety and Agitation
3) GI Upset
4) Gastric Ulcer
5) (Salt) Hyponatraemia
6) Sexual Dysfunction
23
Q
What are the side effects of Tricyclic Antidepressants?
SAD DOWNS
A
S - Sedation/ Dizziness
A - Arrhythmia
D - Dry mouth
D - Difficulty urinating/ Constipated
O - Orthostatic hypotension
W - Weight gain
N - Nausea
S - Sexual dysfunction
24
Q
What are the 4 cautions of SSRIs?
A
Should be omitted in Mania
Should be used with caution in Children and Adolescents
Sertraline is BEST for Ischaemic Heart Disease
Do NOT use with anticoagulants- Give Mirtazapine instead
25
What are the cautions of Tricyclic Antidepressants?
DRILLER, USE C4 to SQuasH their HEARTS!!
Diabetes, _Urinary Retention_, Cytochrome 4 (_liver disease_, warfarin, statins, antiepileptics), _Schizophrenia_, Long QT, "hypertension- BP- actually stands for Breastfeeding and Pregnancy" , Heart disease
- CONTRAINDICATED in Previous Heart Disease
- Can exacerbate Schizophrenia
- May exacerbate Long QT Syndrome
- Use with caution in Breastfeeding and Pregnancy
- May alter blood sugar in Type 1 and Type 2 Diabetes
- May precipitate Urinary Retention (so careful with people with Large Prostates)
- It uses the Cytochrome P450 pathway so AVOID in LIVER DISEASE, WARFARIN, STATINS and ANTIEPILEPTICS
26
What is a side effect of SNRIs?
High Blood Pressure
So contraindicated in uncontrolled BP
27
What are the signs of Serotonin Syndrome?
Remember the TRIAD of:
1) Mental status changes
2) Autonomic hyperactivity
3) Neuromuscular abnormalities.
S - Sweating
E - Elevated temperature
R - Restlessness/ Agitation
O - Oculation _(dilated pupils)_
T - Tremor/ Rigidity/ Clonus
O - _Overreactive reflexes_
N - Nausea
28
What is Postpartum Psychosis?
How is it different from Postpartum Depression with Psychosis?
What is the management of Postpartum Depression?
It develops in the first 2 weeks after birth
A woman may experience Paranoia, Delusions, Hallucinations, Mania, Depression or Confusion
A differential is Postpartum Depression with Psychosis but this presents with a more Insidious onset of Low Mood, Tearfulness and Anxiety
_PAROXETENE_ is used to manage postpartum depression
29
What are the signs of Postpartum Psychosis (What warrants admission)?
What increases the risk of this occurring?
Woman with previous history of severe mental illness are at high risk
If the risk is high to the mother or baby (like if the mother has command hallucinations, self harm or has beliefs about the baby's identity)- then ADMIT TO MENTAL HEALTH UNIT
30
What is the management of Postpartum Psychosis?
Antipsychotics and sometimes _Mood Stabilisers_
31
What are the signs of Cannabis Intoxication?
DDP-ABIS
(Cannabinoid Receptors)
_Drowsiness_
Dry Mouth
Paranoia
Appetite increased
Bloodshot Eyes
Impaired Memory
_Slowed Reflexes_
32
What are the signs of LSD Intoxication?
(Dopamine Receptors)
LABILE MOOD (EXAGGERATED MOODS)
_Sweating_
_Dry Mouth_
Pyrexia
_Hallucinations_
_Insomnia_
Tachycardia
Hypertension
33
What are the signs of Stimulant (Cocaine and Meth) Intoxication?
(Cocaine- Dopamine Receptors and Meth- TAAR Receptors)
Tachycardia
Pyrexia
Hypertension
Euphoria
(High Heart, High Temp and High Mood)
and _RED EYES_
Cocaine- Diarrhoea (Dopamine starts with D as well)
Meth- Usually taken for Concentration (ConcenTAARation)
34
What are the signs of Opiate Withdrawal (like Heroin Withdrawal)?
RRS-DA-G/G
Runny Nose
Runny Eyes
Sweating
_Dilated Pupils_
Agitation
Goosebump Skins
GI Disturbance- Abdominal Cramps, Nausea, Diarrhoea and Vomiting
35
How do you treat Opiate Withdrawal?
Symptomatic Management Acutely and give Methadone or Buprenorphine for Long Term
Meth----orphine
36
What are 6 examples of Medically Unexplained Symptoms?
Somatoform/ Somatisation Disorder-
- Physical Symptoms that can not be explained by Medical Condition or Drug
- Usually GI, MSK, Weakness
- Leads to loss of functioning
_Conversion Disorder_- Loss of Motor/ Sensory
- _Neurological Symptoms_ without any cause (Paralysis, Sensory Changes, Pseudoseizures)
- It is linked to emotional stress
Hypochondriasis/ Illness Anxiety Disorder-
- Concern that they will develop a serious illness despite lack of evidence
- Usually No or Limited Symptoms
- If there are symptoms that they are worried about- this may be Somatisation DIsorder
Munchausen's Syndrome/ Factitious Disorder-
- They fake signs (adding blood to urine) to get attention and play the role of the patient
Malingering-
- Faking for secondary gain (Drugs, Avoiding Work etc.)
La Belle Indifference-
- Inappropriate lack of concern over symptoms (usually associated with Conversion Disorder). Patients say there is nothing to worry about despite serious symptoms
37
What are the side effects of Lithium?
Also remember HYPERPARATHYROIDISM and _HYPERCALCAEMIA_
Fine Tremor
+
(imagine drawing a path from mouth down the GI system)
Dry mouth
Thyroid Dysfunction (Lithium affects Thyroid remember)
GI Disturbance
Polyuria and Polydipsia
38
What are the signs of Lithium Toxicity?
4 disturbances
Remember _Dysarthria_
Coarse Tremor
+
(Nerves, Heart and Eyes)
CNS Disturbances- Seizures, Impaired Coordination, Dysarthria
Arrhythmias
Visual Disturbances
39
What is the management of Lithium Toxicity?
3 steps
_Largely Supportive_
- Maintain Electrolyte Balance, Monitor Renal Function and Seizure Control
1) IV Fluids
2) Dialysis may be needed
3) Seizures and Agitation= give Benzodiazepines
40
What should be done if a patient misses a significant number of days of methadone?
Reinduction should be done
41
What are the signs of Frontotemporal Dementia?
3 Earlys
Presents at a Younger Age than other kinds of Dementia
EARLY Personality Change
Language is also affected Early On
It is often misdiagnosed and Neuroimaging may be needed
42
What is Pick's Disease?
It is a cause of Frontotemporal Dementia
- It is when there are TAU Proteins found on the neurons, they are found in the Frontal and Temporal Lobes
It is associated with Motor Neurone Disease- developed later in life
43
What is the management of Frontotemporal Dementia?
Refer to the Psychiatrist and organise Social Support
44
What symptoms are seen in Normal Pressure Hydrocephalus?
The Ventricles will be Disproportionately Dilated to the Cerebral Atrophy
(Can't Walk, Can't Think, Can't even Pee)
Gait Disturbance
Dementia
Urinary Incontinence
45
What are the 8 types of Thought Disorder?
In addition to Echolalia and Neologism
Circumstantiality-
- Patient moves onto different topics and returns to the original one
- There is a train of thought that can be followed
Clang Association-
- Words sound similar so are associated
Word Salad-
- Nonsense sentences built up of random words
Knight's Move-
- The sentences are linked but still unrelated (I went for a jog and saw a dog. Speaking of dogs I really want one for my home. My home is big, I miss it so much)
Derailment/ Tangentiality-
- The Conversation randomly moves from one topic to another
Poverty of Speech-
- Lack of Spontaneous Speech (they struggle to find the words, the speech is brief and they can't think of what to say)
Perseveration-
- Repetition of words or ideas when another person attempts to change topic
Thought Blocking-
- Patients suddenly halt and can not continue
46
What are 6 examples of Eponymous Syndromes?
What are Othello's and Ekbom's associated with (3 each)
Capgras syndrome: "C for copycat" - this syndrome involves the delusional belief that a loved one or familiar person has been replaced by an imposter or duplicate.
Ekbom's syndrome: "E for Eek, bugs!" - this syndrome involves the delusional belief that there are parasites or bugs living in or under the skin. It can be associated with various medical conditions including _B12 deficiency, hypothyroidism, and neurological disorders._
Cotard syndrome: "C for corpse" - this syndrome involves the delusional belief that one is dead or does not exist.
De Clerambault syndrome: "D for delusions of grandeur" - this syndrome involves the delusional belief that a celebrity or authority figure is in love with the patient.
_Fregoli syndrome_: "F for face" - this syndrome involves the delusional belief that everyone the patient encounters is actually the same person in disguise.
Othello Syndrome
- You feel your spouse or partner is unfaithful with no evidence. It is associated with _Alcohol Abuse, psychosis_ and _Right Frontal Lobe Damage_
47
What is Charles Bonnet Syndrome?
It is a condition in the Elderly who have VISUAL DEFECTS
The brain fills in for this defect and produces hallucinations
This is due to AGE RELATED MACULAR DEGENERATION/ GLAUCOMA and CATARACTS (in order of likelihood)
48
What is Acute Stress Reaction?
What 4 symptoms characterise it and PTSD?
How is it managed and what is an important differential?
It is a Transient Disorder and develops in people with no other mental disorder.
This occurs due to Stress. It usually subsides within a few hours or days but should not exceed 4 weeks (otherwise PTSD). Patients may feel Dissociated.
1) _Emotional Numbing_
2) _Avoidance_
3) _Flashbacks/ Re-experiencing_
4) _Hyperarousal_
Managed with TRAUMA FOCUSED CBT- then Benzos
An important differential is Adjustment Disorder
49
What is Adjustment Disorder?
It is a state of Emotional Distress that interferes with someone's social life that occurs in response to a Significant Life Change or Stressful Life Event such as bereavement or separation
The PTSD Features should last for 1-6 months after the stressor and include:
1) Delayed or Prolonged Response to a Catastrophic or Threatening Situation
2) Episodes of Flashbacks in memories or dreams
3) "Numbness" or Detachment from other people
4) Avoidance of Activities or Situations reminiscent of trauma
5) Usually Autonomic Hyperarousal with Hypervigilance= Enhanced Startle Reaction and Insomnia, Poor Concentration
50
What is the first-line treatment of PTSD?
Trauma-focused Psychological Treatments and EMDR
Then _VENLAFAXINE and SSRI_
51
What is the management of Acute Stress Reaction?
Trauma-focused CBT and _Benzodiazepines_
Active Monitoring in case it develops into PTSD
52
What is Stupor? (it is part of Dissociative Disorder)
The patients are unable to move or speak but are fully conscious. This is a severe form of Depressive Retardation
53
What is Depressive Retardation?
It is a Psychomotor Retardation associated with Low Mood. Thoughts, Speech and Movement become Slowed
54
What is Echopraxia?
The person imitates another person's movements. It is an Automatic Process
55
What is Monomania?
It is the preoccupation with a single subject to a Pathological Degree (Severe Obsession)
56
What are Obsessions?
They are repetitive and senseless thoughts and behaviours that are recognised as irrational by the patient but they are unable to resist the behaviours
57
What is Logoclonia?
What condition is it seen in?
The patients repeat the LAST SYLLABLE of a word or phrase. _Seen in Parkinson's_
58
What is Pressure of Speech?
It is an increased Quantity and Speed of Speech- seen in Mania
59
What are Neologisms?
New words made up by patient- only understood by patients
60
What is Word Salad?
Patients use words nonsensically ("Purple Monkey Dishwater? Thursday!")
61
What are Compulsions?
Repetitive and Stereotyped Behaviours that are seemingly Purposeful
62
What are Delusions?
A belief that is held despite Superior Evidence that they are wrong
63
What is _Mitmachen_?
What disease is it associated with?
(MitmachenToribash)
It is a motor symptom of Schizophrenia- the limbs can be moved without resistance but they return to their original position once the limb is released
64
What is _Muddling_?
It is a speech disruption seen in Schizophrenic Patients
There will be Thought Blocking (speaking about 2 unrelated concepts) and Fusions (fusing of 2 different concepts into one) occur at the same time
Speech becomes very difficult to interpret
65
What is Punding?
What 2 things increase the chance of Punding occurring?
It is an obsession with Mechanical tasks- building things and reassembling things
It is associated with Parkinson's Disease medication or with those taking Methamphetamine
66
What is the difference between Knight's Move and Flight of Ideas?
Knights Move- Jumps from one to another
Flight of Ideas- you can make the link between the ideas vaguely
67
What is only seen in Mania but not Hypomania?
Grandiose (almost everything else is seen in Hypomania as well)
68
What is Dementia with Lewy Bodies?
What are the four core signs?
What condition is it associated with?
How can it be diagnose? (The investigation)
It is the 3rd most common type of Dementia
- Four core features= Fluctuating Cognition, _Sleep Disturbance_, Parkinsonism, Visual Hallucinations (Not seen in AD)
- It occurs due to Alpha-Synuclein Cytoplasmic Inclusions (Lewy Bodies) in the Substantia Nigra, Paralimbic and Neocortical Areas
- Associated with Parkinson's. Patients are also Hypersensitive to Neuroleptics (Antipsychotics) which causes a deterioration in Parkinson's
- Progressive Cognitive Impairment
- Diagnosis is clinical but DOPAMINE UPTAKE SCANNING (SPECT DaT Scan) may be used
69
What is the difference between Dementia and Delirium in terms of symptoms?
What is ONLY affected in Delirium?
Consciousness is not disturbed in the early stages in Dementia
In Delirium there is Cognitive Decline associated with an Impaired Conscious
70
What are the 4 types of Delusions?
Nihilistic Delusions- Negative Delusions that are typically mood-congruent and see in depressed patients (they do not exist, they are dead, they are decomposing)- usually due to PHYSICAL ILLNESS, whereas Cotard is due to Psychiatric
Delusions of Grandeur/ Grandiose Delusions- They believe they have highly positive traits (I'm Rich, I'm the Prime Minister). Associated with Mania
Delusions of Control- Sensation that someone else is controlling your thoughts or actions. Seen in Psychosis
Persecutory Delusions- A Set of Delusional Conditions where you believe you are being Persecuted or Hunted down for doing something you're not supposed to be doing. May be seen in Psychosis
71
What is a Somatic Delusion?
It is a Delusion related to bodily function or bodily sensation (like feeling you have a disease that has not been diagnosed- like a defect, condition etc.)
Even if it is parasites, it is Somatic Delusion if they point to real marks and are more willing to accept they are wrong. Ekbom's is when they are more fixed in their beliefs and also have no evidence
72
What is Delirium Tremens and what are the signs of Delirium Tremens?
It is a rapid onset of Confusion precipitated by Alcohol Withdrawal
Signs-
- Confusion
- Delusions
- Hallucination (visual and tactile (Formication- Sensation of crawling Insects on or under the skin)
- Sweating
- Hypertension
- (Rarely) Seizures
73
What is the management of Delirium Tremens?
What is first line? What 2 things can be given if symptoms persist?
What is needed for maintenance- know this roughly for here as emergency med covers this better
_Oral Lorazepam_
(If symptoms persist or they can't have oral- Parenteral Lorazepam or Haloperidol)
Maintenance-
- Chlordiazepoxide
- Fluids
- Anti-emetics
- Pabrinex
- Refer to Local Drug and Alcohol Liaison Teams
74
An Elderly patient has constipation and symptoms of DEPRESSIO lasting a few days. What is it?
Delirium
Constipation can cause Delirium in the elderly
75
Which patient group are most likely to experience Delirium?
Elderly Patients
76
What is Acamprosate?
It is an example of a medication given for _Alcohol Dependence_
77
What are the signs of Delirium?
(They are OUT of it (confused and inattention) and are not themselves. They are seeing things and not getting enough sleep. They are not as active and are agitated)
Disorientation
Hallucinations
Inattention
Change in Mood or Personality
Disturbed Sleep
Memory Problems
Patients may be very agitated or very sedated and hypoactive
78
What are the causes of Delirium?
DELIRIUMS
- Drugs and Alcohol (_Anticholinergics, Opiates, Anticonvulsants, Recreational, Chlorphenamine_- an anithistamine) (CROC C)
- Eyes, Ears and Emotional
- Low Output State (MI, ARDS, PE, CHF, COPD)
- Infection
- Retention (Urine or Stool)
- *Ictal*
- Underhydration/ Undernutrition
- Metabolic- Electrolyte Imbalance, Thyroid, Wernickes
- _Subdural Haemorrhage, Sleep Deprivation)_
79
What investigations should be ordered in Delirium?
Do a Full examination and Infection Screen
80
What is the management of Delirium?
Treating the underlying cause is the obvious one but what 2 medications can be given if they are extremely agitated?
and what condition would mean they can't be given these and must be given something else? and what is that something else?
Treat the Underlying cause
Maintain an environment with good lighting and Reassurance
In EXTREMELY AGITATED Patients- small doses of _HALOPERIDOL or OLANZAPINE_ may be considered
Give _LORAZEPAM_ if they have Parkinson's or Dementia with Lewy Bodies (anything where the antipsychotic movement side effects would make things worse)
81
What is Creutzfeldt-Jakob Disease?
When should it be suspected?
It is a rapidly progressive Neurological condition caused by a MISFOLDED PROTEIN known as a PRION
RAPID ONSET DEMENTIA with MYOCLONUS (remember NOT tremors- sudden jerky movements not repeated ongoing ones)
It is super rare
82
What are the signs of Creutzfeldt-Jakob Disease?
Ingestion of what causes it?
(a RAPIDLY PROGRESSIVE Dementia with NEUROLOGICAL signs such as MYOCLONUS)
What is seen in MRI? What is seen in brain tissue sampling which is done AFTER DEATH?
There are 3 types
- Sporadic= 85% of cases
- Familial= 10-15%
- Acquired= Ingesting contaminated beef
Prion causes Cell Death in the brain which progresses from Mild Memory and Mood Changes to Myoclonus, Speech and Language Impairment, Seizures and Death
MRI= Basal Ganglia Hyperintensity
Definitive Diagnosis- The brain tissue samples show _Prominent and widespread Vacuole Development which makes it look like a Sponge_
The life expectancy is only 5 months
83
What does an MRI show in CJD?
Basal Ganglia Hyperintensity
84
What are Class A Personality Disorders?
What are the 3 types?
"Odd or Eccentric Disorders"
Paranoid Personality Disorder
- Irrational Suspicion and Mistrust of others
- Hypersensitive to Criticism
- Reluctant to Confide and is preoccupied with Perceived Conspiracies against themselves
Schizoid Personality Disorder
- Characterised by a Lack of Interest in Others, Apathy and lack of Emotional Breadth
- They have few friends and do not form relationships, leading a Solitary Life
Schizotypal Personality Disorder
- Extreme Difficulty interacting socially, bizarre or magical thinking
- Inappropriate behaviour and strange system and affect can cause others to perceive them as Strange
- They share some features with Schizophrenics but maintain a Better grasp on reality
85
What are Class B Personality Disorders?
What are the 4 types?
"Dramatic, Emotional or Erratic Disorders"
Antisocial Personality Disorder-
- Patterns of Disregard and Violation of the rights of others. Individuals LACK EMPATHY and are often manipulative and impulsive
- Aggressive and Unremorseful
- Consistently irresponsible with failure to obey laws and social norms
Borderline Personality Disorder-
- Pattern of Abrupt Mood Swings, Unstable relationships and Instability in Self-image
- Relationships alternate between Idealization and Devaluation (Splitting)
- _Inability to Control Temper and General Affect_
Histrionic Personality Disorder-
- Attention seeking behaviours and Excessive display of Emotions
- Often Sexually Inappropriate
- Shallow and Self-dramatising
- Relationships are considered more dramatic than they actually are
Narcissistic Personality disorder-
- Grandiosity/ seeking admiration/ lack of empathy
- Sense of entitlement and will take advantages of others to achieve their own wants
- Arrogant and preoccupied by their own fantasies and desires
86
What are Class C Personality Disorders?
What are the 3 types?
"Anxious or Fearful" disorders
Avoidant Personality Disorder-
- Strong feelings of inadequacy and fears of Social Situations where they may be criticised
- Patients are sensitive to Criticism
- They often self impose Isolation while craving acceptance and social contact
_Dependent Personality Disorder_-
- Characterised by an Intense Psychological Need to be cared for by others
- Lack Initiative and need others to make a decision on their behalf
- Urgently search for new relationships as soon as one ends to provide care for them
Obsessive-Compulsive Personality Disorder-
- Preoccupied by rules, details and organization to the detriment of other aspects of life
- Perfectionist, often eliminating leisure activities to ensure work is completed
- In contrast to OCD, these activities are seen as PLEASURABLE and DESIRABLE rather than stressful or anxiety inducing
87
What is Bulimia?
It is an eating disorder that involves Binging followed by Purging (Either Induced Vomiting or Laxative Use)
Unlike Anorexia Nervosa, the sufferers may have a NORMAL BMI
88
What are the signs of Bulimia?
Binge Eating
Purging (Binging causes shame or guilt so they want to undo the damage (vomiting, laxatives or exercise)
Body image distortion- feeling fat or hating their body
BMI>17.5 (Normal or even slightly raised weight with normal periods)
Signs of DEHYDRATION
And the THREE ADDITIONAL FEATURES (_EPR_)
(Dental Erosion
Parotid Gland Swelling
Russell’s Sign (Scarring in the fingers from inducing vomiting))
89
What are the THREE ADDITIONAL FEATURES of Bulimia?
Dental Erosion
Parotid Gland Swelling
Russell's Sign (Scarring in the fingers from inducing vomiting)
90
What metabolic state are Purging patients often in?
Hypokalaemia with Metabolic Alkalosis
91
What is Bipolar Disorder?
What are the 2 types and the potential triggers?
It consists of periods of Depression and periods of Mania
Type 1- Mania and Depression
Type 2- Hypomania (no psychotic symptoms) and Depression
This may be triggered by Stress, Illness or Substance Abuse
92
What are the signs of Bipolar Disorder?
Patients may experience periods of being withdrawn and tearful with low mood, poor sleep and anhedonia. They may experience suicidal thoughts or make attempts
Manic episodes are characterised by episodes by Elevated Mood or Irritability. They may make impulsive and dangerous decisions with little thought for consequence. The need for sleep is reduced. Mood congruent delusions may be present. they have pressured speech and flight of ideas usually
93
What is needed for the diagnosis of Mania?
Elevated Randy Is Freakishly Excited In Pursuit of Insanity
At least 1 week long episode of Mania which consists of 3 of:
1) Elevated Self Esteem
2) Reduced Need for Sleep
3) Increased Rate of Speech
4) Flight of Ideas
5) _Easily Distracted_
6) Increased Interest in Goals or Activities
7) _Psychomotor Agitation_
8) Increased Pursuit of Activities with a High Risk of Danger
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What makes it Hypomania and not Mania?
The episode should not be severe enough to cause a marked impairment in social or occupational functioning or necessitate hospitalisation
And there should be No Psychotic Features and no grandiose
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What is the management of Acute Bipolar Disorder?
You manage the Mania and the Depression, depending on which is presenting. But there are two ways to manage the Mania depending on whether something is present. What is that something and how is it managed?
Depends on the Acute Presentation=
1) Acute Mania with Agitation
- IM Therapy- either a _Neuroleptic or a Benzodiazepine_. They may need urgent admission to a secure unit
2) Acute Mania without Agitation
- Oral _Monotherapy_ with an _Antipsychotic_ (Olanzapine, Quetiapine, Risperidone, Haloperidol). Sedation and a Mood Stabiliser such as Lithium can be added if necessary
3) Acute Depression
- Mood Stabiliser and/or Atypical Antipsychotic and/or Antidepressant with appropriate psychosocial support
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What is the Chronic Management of Bipolar Disorder?
Lithium Monotherapy is the gold standard
_Valproate_ is a suitable second-line alternative. _Antipsychotics and Anticonvulsants_ may be used in treatment-resistant people
NICE also recommends High Intensity psychological therapies (CBT, Interpersonal)
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What should be done in Pregnancy to the Lithium Dose?
Should be stopped in the first trimester to avoid Ebstein's Anomaly
98
What is Autoimmune Encephalitis and what are the signs?
A Rapid-onset condition with Multiple Neurological symptoms
Look out for Diarrhoea and URTI as well
It is a form of Autoimmune Neuroinflammation
Signs-
- FEVER
- HEADACHE
- DIARRHOEA
- UPPER RESP TRACT INFECTION
- Confusion
- Seizures
- Movement Disorders
- Behavioural Changes
- Emotional LABILITY
- Psychosis
- Cognitive Impairment
- Reduced Conscious Level
The onset is faster in young people than in adults
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What are the 4 subtypes and differentials of Autoimmune Encephalitis?
Subtypes
- Definite Limbic Encephalitis (Hippocampus and Amygdala are affected)- _memory_ commonly affected
- Acute Disseminated Encephalomyelitis (_Demyelination_ caused by Viral Infection)
- anti-NMDA receptor Encephalitis (associated with Ovarian Teratoma)- more _PSYCHIATRIC SYMPTOMS and MOTOR SYMPTOMS_
- Hashimoto's Encephalopathy (associated with Autoimmune Thyroiditis)- _memory_ commonly affected
Differentials
- Non Convulsive Status Epilepticus
- Space Occupying Lesion
- Meningoencephalitis
- Acute Demyelinating Encephalomyelitis (usually preceded by viral infection or vaccination)
- Stroke and Trauma (including non-accidental injury)
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What investigations should be ordered in Autoimmune Encephalitis?
Full Neurological Exam
Blood Tests
- _Low Sodium_ is associated with LG1 (Limbic) Encephalitis
- Antibodies- LGI1, NMDA receptor, _CASPR2 (also Limbic)_
MRI
Lumbar Puncture (_High Lymphocytes_)
EEG is sensitive but not specific (Lateralised periodic discharges at 2Hz)
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What is the treatment of Autoimmune Encephalitis?
What are the side effects of plasma exchange in the first line therapy?
When should the second line therapy be started?
What should be done regarding the first line therapy when the second line is started?
_(Cortico)Steroids and Intravenous Immunoglobulins_. Can also give Plasma Exchange in addition to this (complications of this= Infection, Hypotension and _Electrolyte Imbalances_)
Second Line (after 2 weeks)- Immunosuppressants (Rituximab and Cyclophosphamide). Continue the first line therapy
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What 3 cancers should be screened for in Autoimmune Encephalitis?
Anti-Hu= Small cell Lung Cancer
NMDA receptor antibodies= Ovarian Teratoma
Anti-Yo= Breast and Ovarian Tumours
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What are Neuroses?
Symptoms (anxiety or fear) that are both understandable and with which one can empathize- like work or school or relationships etc.
Insight is maintained
This is different to delusions which are not understandable and can not be empathised with
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What are the signs of Anxiety?
Psychological- Fears, Worries, Poor Concentration, Depersonalisation, Derealization, Insomnia, Night Terrors
Motor Symptoms- Restlessness, Fidgeting, Feeling on Edge
Neuromuscular- Tremor, Tension, Headache, Muscle Ache, Dizziness, Tinnitus
GI- Dry Mouth, Can't Swallow, Nausea, Indigestion, Butterflies, Flatulence, Frequent or Loose Motion
Cardiovascular- Palpitations, Chest discomfort
Respiratory- Difficulty inhaling, Tight/ Constricted Chest
GI- Urinary Frequency, Erectile Dysfunction, Amenorrhoea
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What are the 5 signs of Generalised Anxiety Disorder?
DAMAD
Apprehension (difficulty concentrating, worries about future, feeling on edge)
Motor Tension (Restless Fidgeting, Tension Headaches, Trembling, Inability to relax)
Autonomic Overactivity can manifest in a range of symptoms, such as increased heart rate, sweating, trembling, flushing, and high blood pressure.(Lightheadedness, Sweating, Tachycardia, Epigastric Discomfort, Dizziness)
Depersonalisation (altered or lost sense of personal reality or identity) and Derealization (surroundings feel unreal). This is also seen in Depression, Schizo, Alcohol, Drugs and Epilepsy
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What is the 6 step management of General Anxiety Disorder?
2, BB, Antipsychotic and Pregabalin
Advice and Reassurance can help early or mild problems from worsening
CBT has good evidence
1) First Line- SSRI or SNRI
2) SSRI plus CBT may superior to either alone
3) Busipirone is suitable for Short Term
4) Beta Blockers are good in Somatic Anxiety Symptoms (Contraindicated in Asthma and Heart Block)
5) Low dose _Antipsychotics_ can also be used
6) _Pregabalin_ can also be used
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What are notes on Sedatives in Anxiety Management? What are the 3 signs of benzo withdrawal?
Which Benzo is usually preferred and why?
Do not prescribe Benzodiazepines for more than 10 days due to risk of dependency and sedation. ONLY use them to overcome symptoms that are severe enough to affect initiation of psychological treatment
_Diazepam_ is preferred as there is less risk of withdrawal symptoms (_Ataxia, Paresthesia, Hyperacusis_ (sensitivity to sound))
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What are the Differential Diagnoses for Anxiety?
1 Metabolic Condition, Substances, 4 Other Psych Conditions
Hyperthyroidism
Substance Misuse (Intoxication (Amphetamines), Withdrawal (Benzos, Alcohol)
Excess Caffeine
Depression
Anxious (Avoidant Personality Disorder)- the person describes themselves as being anxious and there is _no major increase in anxiety levels_
Early Dementia or Schizophrenia
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What are the signs of Panic Disorder?
Recurrent attacks of Sever Anxiety not restricted to any particular situation or set of circumstances so it is UNPREDICTABLE
Secondary Fears of Dying, Losing Control or Going Mad
Attacks usually last for minutes- there is a crescendo of fear and autonomic symptoms
There is a comparative freedom from anxiety symptoms between attacks
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What are the 2 signs of Panic Disorder?
What is the pH and Calcium Level of these patients and why?
What is seen in Extreme Cases?
Signs of Anxiety
Tingling or Numbness in Hands, Feet or around Mouth.
_Hyperventilation blows of CO2 and raises the pH_
_Calcium binds to Albumin which leads to Hypocalcaemia_
If Extreme= Carpopedal Spasm (Curling of Fingers and Toes)
Can lead to Fear of Situation where Panic Attack or Agoraphobia develops
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What is the differential diagnosis for Panic Disorder?
Is it Hypo or Hyperglycaemia that's one of the organic causes?
Other Anxiety Disorders- GAD and Agoraphobia
Depression
Alcohol or Drug Withdrawal
Organic Causes= Cardiovascular System or Respiratory Disease. Also _Hypoglycaemia_ and Hyperthyroidism. Rarely also Pheochromocytoma
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What is the management of Panic Disorder?
What is the second-line medication that is usually just given for Panic Disorders? (everything else is similar to anxiety)
Psychological-
1) Reassurance and CBT (CBT is FIRST LINE)
2) Education about nature of panic attacks
3) Cognitive Restructuring- detecting flaws in logic
4) Situational Exposure and Controlled Exposure to somatic Symptoms (like Breathing in CO2 and Physical Exercise)
Drug Management-
1) SSRIs are First Line (after CBT)
2) _Clomipramine_ (a Tricyclic) is also given
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What are the signs of Specific Phobia?
What happens to heart rate and blood pressure?
Restricted to specific situations such as Flying, Animals etc.
Often clear in Early Adulthood
Result of Avoidance
Phobias of Blood and Bodily Injury lead to Bradycardia and Hypotension upon Exposure
Exclude Comorbid Depression
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What are the signs of Agoraphobia?
What adjunctive diagnosis should you be wary of?
What are the 4 other differentials?
Fear of not only open spaces but also related aspects such as crowds and difficulty of immediate escape to safe place (like home)
It is common in 20s or mid-30s
Comorbid depression is common (be wary of them taking drugs and alcohol to overcome this)
May be Gradual or precipitated by a Sudden Panic Attack
Higher Incidence of Sexual Problems
Differentials:
1) Depression
2) Social Phobia
3) OCD
4) Schizophrenia (may stay indoors to avoid Persecutors)
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What are the signs of Social Phobia?
Why may the MSE appear normal?
It is the most common Anxiety Disorder
Fear of SCRUTINY by other people in comparatively small groups (compared to crowds) leading to avoidance of social situations
Usually 5-6 people (they may be fine with 1-2)
Physical symptoms= Blushing or Fear of Vomiting
Also Palpitations, Trembling and Sweating
Can be precipitated by Humiliating Experience, Death of a Parent, Separation, Chronic Stress
MSE may appear normal as Phobia object is not present
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What are the Differentials for Social Phobia?
Shyness (In Social Phobia there is Fear)
Agoraphobia
Anxious Perosnality Disorder
Poor Social Skills/ Autism Spectrum Disorder
Benign _Essential Tremor_ (Worse in Social Situations and is Familial. Alcohols and Benzos help with this)
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What investigations should be conducted for Social Phobia?
What are the 2 anxiety scales used in Social Phobia?
History and examination
Rating Scales of Anxiety (_Beck Anxiety Inventory and the HADS score_)
Social and Occupational Assessments for effect on Quality on Life
Collateral History
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What is the management of Phobias?
For which phobias are SSRIs and MAOIs (Phenelzine) most useful?
When are TCAs usually used?
When can Benzodiazepines and Beta Blockers be used?
Flooding- taking someone with a fear of heights to a tower
Modelling- the individual observes the therapist dealing with the phobia (like holding a spider)
Agoraphobia and Panic Disorders- CBT is First Line
Social Phobia- CBT is the treatment of choice
_SSRIs and MAOIs (Phenelzine) is most useful in Agoraphobia and Social Phobia_
TCAs are best for those with a depressive component
_Benzodiazepines can be used BEFORE a Phobic Situation_
Beta-blockers can be used if someone's Somatic Symptoms predominate their prognosis
Animal Phobias do best, Agoraphobias respond worst
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What is Anorexia Nervosa?
What 10 signs are seen as a result of the starvation?
What is the blood pressure and heartrate?
What is the cholesterol and growth hormone/ cortisol level?
What metabolic association is seen?
Deliberate weight loss- Induced and sustained by the patient
There must be clear concerns from the individual regarding their weight and shape, with a fear of becoming fat as an Intrusive Overvalued thought
They are determined to achieve this, regardless of the impact on their physical health
1) Low BMI
2) Hypotension and _Bradycardia_ (Admit if severe or if super weak and struggling)
3) Enlarged Salivary Glands
4) Lanugo Hair (fine hair covering the skin)
5) Amenorrhoea
6) _Hypokalaemia_
7) _Low Sex Hormones_ (FSH, LH, Oestrogen, Testosterone)
8) Raised Growth Hormone and Cortisol
9) Hypercholesterolaemia
10) _Low WCC due to the Malnutrition_
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What is the management of Anorexia Nervosa?
What is refeeding syndrome? What 3 types of ions are affected by this?
What are patients with Anorexia Nervosa most at risk of? Which Arrythmia in particular?
Aiming to return to a healthy weight and using Psychological Therapies to treat the underlying thought processes
- If nutritional intake is resumed too rapidly, the patient is at risk of developing Refeeding Syndrome. Rapidly increasing Insulin Levels lead to shifts of Potassium, Magnesium and Phosphate from extracellular to intracellular spaces. This can be fatal
Symptoms of Refeeding Syndrome= _Oedema, Confusion and Tachycardia_. Blood tests initially show Hypophosphataemia which is managed with Phosphate Supplementation
- Patients with Anorexia Nervosa are at risk of _Cardiac Arrhythmias and sudden Death_. An ECG should be performed on patients with Anorexia Nervosa especially those complaining of Light Headedness or Fainting.
There may also be Hypotension, Bradycardia and a _Prolonged QT Interval_ which increases the risk of Ventricular Fibrillation
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What can predispose patients to Anorexia Nervosa?
Standard Dieting
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What are the 4 signs of Alzheimer's?
Amnesia
Aphasia
Agnosia
Apraxia
123
What is the management of Alzheimer's?
What is the first and second line pharmacological management and when is Donepazil contraindicated?
Non Pharmacological-
1) Range of activities to promote wellbeing- tailored to person's preference
2) Group Cognitive stimulation therapy
3) Group Reminiscence Therapy and Cognitive Rehabilitation
Pharmacological-
1) Acetylcholinesterase Inhibitors (Donepezil, Galantimine, Rivastigimine)
2) Second Line- Memantine (_Monotherapy if Severe Alzheimer's_)
When is Donepezil Contraindicated?
- _Bradycardia (Relatively contraindicated)_
- Side Effects= _Insomnia_
