Psychiatry short Flashcards
A SUMMARY OF MAIN CONDITIONS IN PSYCHIATRY
Lewy-body dementia
Dementia caused by accumulation of misfolded alpha-synuclein protein in the brain.
Clinical features: fluctuating cognition and concentration, visual hallucinations (usually small animals), parkinsonism.
1st line: AChE (Acetylcholinesterase) inhibitor: donepezil
Caution with antipsychotics as exacerbates parkinsonism
Non-pharmacological interventions: cognitive stimulation, physical therapy, and occupational therapy.
Supportive care: progressive disease so palliative and end-of-life care considerations
Alzheimer’s disease
Progressive neurogenerative disorder, apolipoprotein E gene mutation
Accumulation of amyloid plaques and tau tangles in the brain leads to cognitive decline.
4As:
- Amnesia - recent memory lost first
- Aphasia - word-finding difficulties and disjointed/muddled speech
- Agnosia - difficulties with recognition
- Apraxia - difficulties with skilled tasks despite normal motor function
Dx: detailed history and neuro exam, cognitive screening e.g. 10-point cognitive screen (10-CS), GPCog, 6CIT
Mx: education and support for patient and family, memory clinic, cognitive stimulation therapy
Medical: acetylcholinesterase inhibitors e.g. donepezil (duh-neh-puh-zil) or galantamine and NMDA receptor antagonist e.g. memantine (rhymes with clementine) if more severe
Vascular dementia
Cognitive impairment due to cerebrovascular disease - stepwise decline
Clinical features:
- Cerebrovascular risk factors e.g. smoking, high BMI, stroke
- Memory disturbances
- Sensory or motor symptoms
Gait/speech/emotional disturbance
Dx: detailed history and examination, cognitive screening, exclude medication or organic causes e.g. B12 deficiency, MRI to visualise vascular changes
Mx: optimise management of co-morbidities, cognitive stimulation therapy, and medication e.g. donepezil or memantine
Frontotemporal dementia
Neurodegenerative disorder mainly affecting the frontal and temporal lobes of the brain.
Younger onset 60 - 70
- Personality changes: apathy, disinhibition
- Language impairment: word-finding and aphasia
- Cognitive decline
- Motor symptoms: muscle weakness, dysarthria
Associated with ALS
Mx: Counselling, behavioural modification, SSRI, speech and language, physio, OT
Differentiating LBD and PD
- If cognitive and motor symptoms occur within 1 year of each other = LBD
- If motor symptoms develops and cognitive symptoms occur > 1 year after = PD
Mx: memory clinic, cognitive stimulation therapy, physiotherapy
Medical Mx: acetylcholinesterase inhibitors e.g. donepezil
What blood tests are carried out in the investigations for dementia?
Confusion screen in primary care
FBC, U+E, LFTs, CRP/ESR, calcium, TFTs, B12, folate, syphilis, HIV
Schizophrenia
Positive symptoms:
- Auditory hallucinations (narration of patient’s actions, hearing own thoughts out loud, third person)
- Broadcasting of thought - others can hear thoughts -
- Thought insertion + withdrawal
- Control issues (somatic passivity (external entity controlling sensations and actions)
- Delusions - persecutory and perceptions (i.e. ordinary perception: the cat meowed, delusion: so I knew I would meeting the aliens today)
- Idea of reference (false belief that unconnected events or details in the world relate to them)
Negative symptoms (4As): affective flattening (minimal emotional reactions, alogia, anhedonia, avolition
Dx:
Rule out organic causes first always
- ICD11 - symptoms present for at least one month, causing significant distress
- DSM5 - at least 6 months, with one month of active-phase symptoms (at least one ABCD)
Mx: 2nd gen antipsychotics e.g. olanzapine, risperidone, clozapine if resistant (monitor for agranulocytosis)
Bipolar affective disorder
Bipolar type 1: one or more manic episodes at least 1 week, and one or more depressive episodes
Bipolar type 2: episodes of MDD and hypomania (at least 4 consecutive days)
Mania episodes = persistently elevated, expansive or irritable mood, hypomanic symptoms less severe
Mx: Rule out organic causes first always! Otherwise clinical Dx
- Stop SSRI if recently started “manic switch”
- Acute: 2nd gen antipsychotics if psychosis - IM if agitated, PO if not
- Maintenance with lithium and psychotherapy
Anorexia nervosa
- BMI < 17.5kg/m2
- Severe dietary restriction
- Weight and shape preoccupation
- Distorted body image
- Restrictive or bulimic subtype
Blood tests:
- Low K, Ca and Mg
- Metabolic alkalosis if bulimic subtype
- Low FSH, LH, testosterone and oestrogen
- High cortisol and growth factor
- Normal T4, low T3
Mx:
- CBT for eating disorder
- 1st line for under 18s = AN-focused family therapy
- SSRI to help co-existing depression/anxiety
- Sectioning under MHA
Bulimia nervosa
- Patients often have normal BMI
- At least 3 months of cycles binge-eating then inappropriate compensatory behaviours to prevent weight gain e.g. vomiting, laxatives, fasting, excessive exercise
- Dental erosion, parotid gland swelling, Russell’s sign (calluses on knuckles from scraping teeth), amenorrhoea
Mx:
- Adults: 1st line: BN focused guided self-help, and specialist referral
- Children: BN-focused family therapy +/- fluoxetine
Difference between anorexia vs bulimia - EXAM FODDER
BMI is a key distinguishing feature
AN is defined by BMI < 17.5kg/m2
Patients with BN have normal BMI or BMI within the “healthy range”
Emotionally unstable personality disorder (EUPD)
4 domains:
- Unstable self-image
- Difficulties maintaining relationships
- Impulsivity
- Recurrent suicidal or self-harm behaviour
Mx: Dialectical behavioural therapy (DBT)
Depression
Core symptoms over 2 weeks:
- Low mood
- Anhedonia (a lack of pleasure or interest in activities)
Other symptoms: change in sleep, >5% weight gain or loss, excessive guilt, hopelessness, thought of suicide and self-harm
Dx: FBC, TFT, U_E, LFT, Patient Health Questionnaire (PHQ-9)
PHQ-9:
- 5 - 9 = mild
- 10 - 14 moderate
- 15 - 19 moderately severe
- 20 - 27 severe
Mx:
Lifestyle e.g. diet, exercise, stress, alcohol
Mild - low-intensity psychotherapy e.g. self-guided help, online CBT
Moderate to severe:
- 1st line - high-intensity CBT + SSRI
Severe depression with poor oral intake: electroconvulsive therapy
Delirium tremens
Severe alcohol withdrawal characterised by acute confusion, hallucination (visual/tactile), sweating, hypertension, seizures
Occurs around 72 hours after stopping drinking alcohol
Mx:
- Acute: 1st line is oral lorazepam
- Maintenance: chlordiazepoxide, eventually tapered, adequate hydration, Pabrinex, referral to local drug and alcohol liasion team
Define the Mental Health Act
The Mental Health Act 1983 as amended by the Mental Health Act 2007 sets out a legal framework for the care and treatment of individuals with mental health disorders.
