Selected Notes psych Flashcards
What is an illusion
Misenterpretation of an external stimulus
What is a hallucination
Perception without an external stimulus
What is a pseudo-hallucination?
Hallucination where the patient is aware it’s not real
What is an overvalued idea?
Solitary, abnormal belief that is not delusional or obsessional but preoccupying to the extent of dominating the persons life
What is a delusion?
Fixed, false belief maintained despite contrary evidence
What is delusional perception?
A true perception to which a patient attributes a false meaning.<br></br>E.g. traffic lights turning red means aliens are coming
What is concrete thinking?
Literal thinking focused on the physical world
What is meant by loosening of association?
AKA derailment, knight’s move thinking<br></br>No connection between topics
What is cirumstiantiality when describing thought patterns
Adds in irrelevent details but eventually returns to topic
What is meant by tangential thoughts?
Digress from subjecy with unrelated thoughts
What is thought blocking?
Sudden cessation of thought
What is meant by flight of ideas?
Pressured speech with shifts in topic with only a loose connection between ideas
What is perserveration?
Repitition of specific response despite removal of stimulus<br></br>
What are neologisms?
Made up words, unintelligible
What is meant by word salad?
Random string of words with no relation
What is meant by confabulation?
Generation of a fabricated memory without the intention of deceiving someone else
What is somatic passivity?
Experiene of one’s body or bodily sensations being controlled or influencfed by an external force
What is meant by pressure of speech?
Person speaks rapidly and continuously, often without pauses
What is anhedonia?
Inability to enjoy things/experience pleasure
What is incongruity of affect?
Mismatch between a person’s emotional expression and content of thoughts of speech
What is meant by blunting of affect?
Reduction in intensity and range of emotional expression<br></br>-Limited facial expressions, monotone speech etc
What is meant by the belle indifference?
Patient shows indifference/a lack of concern toward their symptoms depsite severity
What is meant by depersonalisation?
Detatched from own thoughts, feeling or body
What is thought alienation?<br></br>
Group of symptoms where patients feel thoughts are not their own. Includes:<br></br>1. Thought insertion<br></br>2. Thought withdrawal<br></br>3. Though broadcasting
Define thought insertion
Belief that thoughts are being placfed into one’s mind by an external source
What is thought withdrawal?
Belief that thoughts are being removed from one’s mind
What is thought broadcasting?
Belief that one’s thoughts are being broadcasted or shared with others
What is meant by thought echo?
Auditory hallucinations of their own thoughts being spoken aloud shortly after thinking them
What is akathisia?
Movement disorer characterised by intense restlessness and inability to stay still.<br></br>Side effect of antipsychotics
Define catatonia
Psychomotor disorder that can affect a person’s ability to move normally
What is stupor?
A symptom of catatonia in which the patient is unresponsive and unable to move, speak or react to external stimuli
What is psychomotor retardation?
Noticeable slowing down of thought processes and physical movements
What is flight of ideas?
Rapid and continuous speech with frequent shifts in topic with only a loose connection between ideas
What is a formal thought disorder?
Disruption in the organisation and expression of thought rather than the content
Define derealisation
Dissociative symptom where a person feels detached from their surroundings
What is a mannerism in psychiatry?
Habitual, often repetitive movement or gesture that appears to have some significance but may be out of context or exaggerated
What is stereotyped behaviour psychiatry?
Repetitive non functional motor movements, vocalisations or behaviours<br></br>-Often seen un individuals with developmental disorders like ASD
Define obsessions
Intrusive, unwnted thought, image or urge that repeatedly enters a person’s mind causing significant anxiety or distress
Define compulsion
Repetitive behaviour or mental act that a patient feels compelled to perform in response to an obsession or according to specific rules
What is the criteria for sectioning under the MHA?
<ul><li>Must have a MENTAL disorder</li><li>Must be a risk to their health/safety or the safety of others</li><li>Must be a treatment(including nursing/social care0</li></ul>
What is the one physial illness a patient could be sectioned and treated for?
Anorexia nervosa->re-feeding is allowed
Who carries out a mental health act assessment?
<ul><li>>=2 doctors, 1 of whom must be section 12(2) approved</li><li>1 approved mental health professional(AMHP)</li></ul>
Can a patient be considered for sectioning under the mental health act if under the influence of drugs/alcohol?
No-under the influence excludes patients from detainment
What is section 2 of the MHA?
<ul><li>Compulsory detention for assessment</li></ul>
What is the citeria for detention under section 2 of the MHA?
<ul><li>Mental disorder AND risk to self/others</li></ul>
How long can you hold a patient for under Section 2 of the MHA?
Max 28 days
Is section 2 of the MHA renewable?
No
Which healthcare professionals are required to detain a patient under Section 2 of the MHA?
AMHP or NR+2 doctors(one S12 approved)
Section 3 of the MHA<br></br>What is it: {{c1::Compulsory detention for treatment}}<br></br>Criteria: {{c2::Mental disorder+risk to self/others+treatment available}}<br></br>Last for maximum: {{c2::6 months}}<br></br>Renewable yes/no: {{c2::Yes}}<br></br>Healthcare professionals required: {{c2::2 drs(one S12)++AMHP/NR+seen in last 24 hours}}<br></br><br></br>
Section 4 of the MHA<br></br>For: {{c1::admission for assessment in emergency}}<br></br>Last for max: {{c2::72 hours, then usually put on section 2}}<br></br>Healthcare professionals required: {{c3::Single doctor +AMHP/NR}}
What is section 5(2) of the MHA and how long does it last for?
<ul><li>Detainment of voluntary inpatient in hospital</li><li>Max 72 hours, only 1 dr needed</li></ul>
What is the difference between section 5(2) and 5(4) of the MHA?
<ul><li>Both detainment of voluntary inpatient in hospital</li><li>5(2) required dr, 5(4) requires registerend nurse and only lasts 6 hours</li></ul>
What is section 17 a of the MHA for?
<ul><li>Community treatment order-patient on section 3 can leave for treatment in the community</li></ul>
Who makes a section 17a of the MHA decision?
Responsible clinician and AMHP
When can a section 17a mof MHA be recalled and if recalled, how long can patients be held?
<ul><li>Recalled if non-compliant with treatment and missing appointments</li><li>If recalled, can be held for up to 72 hours for assessment</li></ul>
What is section 135 of the MHA for?
<ul><li>Police can enter proerpty to escort someone to a Place of Safety(police station or A&e)</li></ul>
What is section 136 of the MHA for?
<ul><li>Can take someone from ma public place to a Place of Safety</li></ul>
What is section 131 of the MHA?
<ul><li>Informal admission-voluntary</li></ul>
What is the criteria for a section 131 admission?
<ul><li>Must have capacity</li><li>Must consent to admission</li><li>Must not resist admissions</li></ul>
What are the key principles of the Mental capacity act?
<ol><li>Assumed to have capacity unless proven otherwise</li><li>Steps should be taken to help someone have capacity</li><li>Unwise decisions doesn'[t mean someone lacks capacity</li><li>Any decisions made under the MCA must be in the patient's best interests</li><li>Any decisions made must be the least restrictive to a patient's rights/freedom</li></ol>
How is mental capacity assessed?
<ol><li>Impairment of or isturbance of functioning of mind/;brain?</li><li>Are they unable to:</li></ol>
<ul><li>Understand relevant information</li><li>Retain relevant information</li><li>Weight up and reach a decision</li><li>Communicate that decison</li></ul>
<div><ol><li>How urgent is the clinical decision?</li><li>Do they have LPA, advanced directive/statement</li><li>Should a best interest meeting be held</li></ol></div>
What is a Deprivation of Liberty Safeguard(DoLS) and when is it used?
Used when necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment or care to keep them safe from harm<br></br><ul><li>Common in acute medical/geriatric wards</li></ul>
What criteria must be met before considering DoLS for a patient
<ul><li>>18yrs</li><li>Patient in hospital/care home with a mental disorder</li><li>Considered separately for detention under a MHA</li><li>Lacks capacity</li></ul>
Name some uses for antidepressants besides depression
<ul><li>AQnxiety</li><li>OCD</li><li>PTSD</li><li>Eating disorders</li><li>Menopause</li><li>Neuropathic pain</li><li>Fibro</li><li>Smoking cessation</li><li>Sleep</li><li>Parkinson's</li><li>Nocturnal enuresis</li></ul>
What does SSRI stand for?
Seelctive serotonin reuptake inhibitors
What is the MOA of SSRI’s?
Inhibit serotonin reuptake to increase availabilty and improve mood regulation
What conditions are SRIS’s typically used to treat?
1st line for:<br></br><ul><li>Depression</li><li>GAD</li><li>OCD</li><li>PTSD</li><li>Panic disorder and phobias</li></ul>
Give some exampples of SSRIS
<ul><li>Sertraline</li><li>Fluoxetine</li><li>Citalopram</li><li>Paroxetine</li></ul>
Which SSRI is mostly only used for PTSD?
Paroxetine
Name some side effects of SSRIs
<ul><li>GI upset</li><li>Anxiety</li><li>Insomnia</li><li>Weight gain</li><li>Palpitations</li><li>HYPOnatraemia</li><li>QT prolongation(citalopram)</li><li>GI bleed(anti-platelet affect)</li></ul>
What is a key side effect of citaloparm?
QT prolongation
What is the most important mthing to wathc out for in patients on SSRI’s?
Serotonin syndrome
What should you be cautious of when prescribing SSRIs?
<ul><li>Shouldn't be used in mania</li><li>Fine for patients with IHD</li><li>In aptients aged 18-25: increased risk of suicide->follow up after 1 week</li></ul>
What do SNRI’s stand for?
Serotonin and noradrenaline reuptake inhibitors
Describe the MOA of SNRI?
<ul><li>Increase serotonin and noradrenaline levels, improve mood and reduce anxiety</li></ul>
When are SNRI’s commonly used?
2nd line after truing SSRIs for depression<br></br>Also used for GAD and panic disorder
Name some examples of SNRI’s
<ul><li>Duloxetine</li><li>Venlafaxine</li></ul>
Name some side effects of SNRI’s
<ul><li>Nausea</li><li>Insomnia</li><li>Agitation</li><li>Tachycardia</li></ul>
What should you be cautious about when prescribing SNRI’s?
CI in patints with a history of heart disease and hypertension
Descirbe the MOA of TCA’s
<ul><li>Block reuptake of serotonin and noradrenaline(anti-muscarinic)</li></ul>
When might TCA’s be used as a treatment?
Another 2nd line choice ofr depression/anxiety
Give some examples of TCAs
<ul><li>Amitryptaline</li><li>Clomipramine</li><li>Imipramine</li></ul>
What are the side effects of TCA’s?
Anti-cholinergic<br></br>Can’t see, pee, shit or spit<br></br><ul><li>Urinary retention</li><li>Blurred vision</li><li>Constipation</li><li>Dry mouth</li><li>Dizziness</li></ul><div><br></br></div><div>TCA TOXICITY*****</div>
When are TCA’s contraindicated?
Patients with heart disease, diabetes, urinary retention, long QT syndrome, liver damage, CP450 medications
When should TCA’s be prescirbed with caution?
<ul><li>In the elderly-risk of falls</li></ul>
What are MAO-I’s and what is their mechanism of action?
Monoamine Oxidase Inhibitors<br></br><ul><li>Inhibit monoamines which are responsible for metabolism of serotoning and noradrenaline in the presynaptic cleft-> increae serotonin and noradrenaline</li></ul>
When are MAO-Is used?
Sometimes sued to treat depression-not first line
Give some examples of MAO-I’s?
Moclobemide<br></br>Phenelzine
Name some side effects of MAO-I’s?
<ul><li>Hypertensive reaction with tyramine-containing foods</li></ul>
<div>Marmite, cheese, salami etc</div>
When are MAO-Is contraindicated?
<ul><li>Cerebrovascular disease</li><li>Mania in bipolar</li><li>Phaeochromocytoma</li><li>CVR disease</li></ul>
What drug class does mitrazapine belong to?
Noradrenergic and specific seretonergic antidepressant(NaSSA’s)<br></br><br></br><ul><li>Modulate serotonin and nordrenaline levels in the brain</li></ul>
What are the indications for using mirtazapine as a treatment?
2nd line for depression<br></br>Especially helpful in patients with sleep and low weight problems
Name some side effects of mirtazapine
<ul><li>Sedation</li><li>Increased appetite</li><li>Weight gain</li><li>Constipation/diarrhoea</li></ul>
What are antipsychotics used to treat?
<ul><li>Bipolar</li><li>Depression</li><li>Delirium</li><li>Personality disorders</li><li>Eating disorders</li><li>Huntington's</li><li>Tic disorders</li><li>Intractable hiccups</li><li>Nausea and hyperemesis</li></ul>
How do typical/1st gen antipsychotics work?
Antagonists to D2 receptors on cholinergic, adrenergic and histaminergic receptors
Give some examples of 1st gen/typical antipsychotics
<ul><li>Haloperidol</li><li>Chlorpromazine</li><li>Flupentixol</li></ul>
What kind of symptoms to typical/1st gen antipsychotics cause?
Extra-pyramidal
Side effects of 1st gen/typical antipsychotics:<br></br>Dopamine 2 receptor blockade:<br></br><ol><li>{{c1::Acute dystonia}}->spasms/involuntary movements</li><li>{{c2::Akathisia->}}restlessness and inability to sit still</li><li>{{c3::Parkinsonism}}->Tremors, rigidity, bradykinesia</li><li>{{c4::Tardive dyskinesia}}->involuntary,repetitive movements particulary of face lip smackin etc</li></ol>
What is acute dystonia?
Involuntary muscle contractions/spasms
What is tardive dyskinesia?
Involuntary repetitive movements, particulary of face<br></br>Lip smacking, tongue movements etc
What is a side effect of antipsychotics with regards to the histamine 1 receptor blockade?
Sedation->drowsiness/sleepiness
What is a side effect of antipsychotics with regards to the alpha 1-adrenergic receptor blockade?
Orthostatic hypotension
What is a side effect of antipsychotics with regards to the muscarinic receptor blockade?
Anticholinergic effect:<br></br>Can’t pee, see,shit or spit<br></br><ul><li>Dry mouth</li><li>Constipation</li><li>Blurre vision</li><li>Urinary retention</li></ul>
What is 1st line for psychosis?
2nd gen/atypical antipsychotics
Why are 2nd gen antipsychotics now preferred to 1st gen?
Fewer extrapyramidal side effects
What is a disadvantage of using 2nd gen antipsychotics compared to 1st gen
Increased metabolic side effects
How do 2nd gen/atypical antipsychotics work?
D2, D3, D5 and HT2A antagonists
Give some examples of 2nd gen/atypical antipsychotics
<ul><li>Risperidone</li><li>Quetiapine</li><li>Olanzapine</li><li>Aripiprazole</li><li>Clozapine</li></ul>
What are some of the metabolic side effects of 2nd gen/atypical antipsychotics?
<ul><li>Weight gain</li><li>Impaired glucose metabolism/diabetes</li><li>Increase levels of lipids</li><li>Increased levels of prolactin</li></ul>
What are some general side effects of 2nd generation/atypical antipsychotics?
<ul><li>Seizures</li><li>QT prolongation</li><li>Increase VTE and stroke risk in elderly</li></ul>
What monitoring should be done in patients on 2nd gen/atypical antispychotics?
<ul><li>Weight</li><li>Blood glucose</li><li>HbA1c</li><li>Lipids</li><li>BP</li><li>ECG</li></ul>
When is clozapine used as a treatment?
<ul><li>Treatment resistant schizophrenia once 2 others have failed-treats both positive and negative symptoms</li></ul>
What are the side effects of clozapine?
AGRANULOCYTOSIS<br></br><ul><li>Neutropenia</li><li>Decreased seizure threshold</li><li>Myocarditis</li><li>Slurred speech</li><li>Constipation</li></ul>
What monitoring should be done for patients on clozapine?
<ul><li>Weekly FBC looking at WCC for first 18 weeks, then fortnightly</li><li>Bloods</li><li>Lipids</li><li>Weight</li><li>Fasting blood glucose</li></ul>
Name some common mood stabilisers
<ul><li>Lithium</li><li>Sodium valproate</li><li>Carbamazepine</li><li>Lamotrigine</li></ul>
What is lithium used to treat?
<ul><li>Bipolar disorder and mania</li><li>Depression</li><li>Aggression/self harm</li></ul>
When is lithium contraindicated?
<ul><li>Addison's disease</li><li>Arrhythmias</li><li>Brugada</li><li>Hypothryoidism</li></ul>
Side effects of lithium:<br></br><ul><li>L-{{c1::leukocytosis}}</li><li>I-{{c2::Insipidus(diabetes)}}</li><li>T{{c3::-tremor(fine)}}</li><li>H-{{c4::hypothryoidism}}</li><li>I-{{c5::Increased weight}}</li><li>M-{{c6::Metallic taste}}</li></ul>
What should be given to women of childearing age who are on lithium and why?
<ul><li>Contraception</li><li>Causes cardiac malformations in the 1st trimester</li></ul>
Monitoring for patients on lithium<br></br><br></br>At the start:<br></br><ol><li>{{c1::U&E’s}}</li><li>{{c1::ECG}}</li><li>{{c1::TFT’s}}</li><li>{{c1::BMI}}</li><li>{{c1::FBC}}</li></ol><div>Throughout:</div><div><ol><li>{{c2::}}Electroytes</li><li>{{c2::eGFR}}</li><li>{{c2::TFT’s}}</li><li>{{c2::BMI}}</li></ol></div>
Name some side effects of sodium valproate
<ul><li>Nausea</li><li>Gastric irritation</li><li>Diarrhoea</li><li>Weight gain</li></ul>
What are carbamazepine and sodium valproate used for in psychiatry?
Mood stabilisers:<br></br><ul><li>Both used for bipolar disorder prophylaxis</li></ul>
What is lamotrigine used for in psychiatry?
Mood stabiliser<br></br><ul><li>Useful in preventing depressive episodes</li></ul>
Name some side effects of lamotrigine
<ul><li>Steven Johnson syndrome</li><li>Dizziness</li><li>Rashes</li></ul>
What is important to remember about prescribing mood stabilisers to women of child bearing age?
Teratogenic
<b>Lithium toxicity:</b><br></br>Therapeutic dose symptoms: {{c1::fine tremor, dry mouth, GI disturbance, Increased thirst and urination}}<br></br><br></br>Toxicity symptoms{{c2::: Coarse tremor, CNS dysfunction(seizures, impaired co-ordination, dysarthria), arrhythmias, visual disturbance}}<br></br><br></br>Investigations: <br></br><ul><li>For diagnosis:{{c3::Serum lithium levels}}</li><li>For assessment: {{c4::electrolyes, LFT’s U&Es, ECG}}</li></ul><div>Treatment:</div><div><ul><li>{{c5::</li><li>Supportive</li><li>Maintain electrolytes, monitor renal function, IV fluids</li>}}<br></br></ul></div>
Describe some symptoms of TCA toxicity
<ul><li>Drowsiness</li><li>Confusion</li><li>Arrhythmia</li><li>Seizures</li><li>Vomiting</li><li>Headache</li><li>Flushing</li><li>Dilated pupils</li></ul>
What investigations should be done to diagnose and assess TCA toxicity?
<ul><li>FBC</li><li>U&E</li><li>CRP</li><li>LFT'S</li><li>VBG</li><li>ECG-QT prolongation</li></ul>
How is TCA toxicity treated
<ul><li>Generally supportive care and management</li><li>Consider activated charcoal withint 2-4 hours of OD and intensive care review if severe</li></ul>
<br></br>
What is neuroloeptic malignant syndrome?
<ul><li>Rare, life threatening reaction to antipsychotics</li></ul>
When does neuroleptic malignant condition occur?
After the introduction of or increase in neuroleptic medications (antipsychotics)
How do patients with neuroleptic malignany syndrome present?
<ul><li>Hyperthermia</li><li>Altered mental state</li><li>'Lead pipe rigidity' </li><li>Autonomic dysregulation</li></ul>
Name some differentials for neuroleptic malignant syndrome
<ul><li>Malignant hyperthermia</li><li>Serotonin syndrome</li></ul>
What are some investigations to investigate neuroleptic malignant syndrome?
<ul><li>Creatine kinase!</li><li>FBC</li><li>Renal and liver function</li></ul>
What is the treatment for neuroleptic malignant syndrome?
<ul><li>Stop causative agent</li><li>Cooling blankets and IV fluids to prevent renal failure and hyperthermia</li><li>Benzodiazepines for muscle rigidity</li><li>Dantrolene in severe cases</li><li>Intensive monitoring</li></ul>
What is serotonin syndrome?
<ul><li>Life threatening emergency characterised by an increase in serotonergic activity in the CNS</li></ul>
When does serotonin syndrome occur?
Typically first few months after starting an SSRI/increasing the dose<br></br><ul><li>Can also happen with SNRI’s, MAO-I’s, TCA’s, MDMA/cocaine</li></ul>
Describe the presentation of a patient with serotonin syndrome
<ul><li>Hyperthermia</li><li>Altered mental state</li><li>Neuromuscular hyperactivity-> tremors, clonus, hyperreflexia</li><li>NOT rigidity</li></ul>
Name some differentials for serotonin syndrome
<ul><li>Neuroleptic malignant syndrome</li><li>Malignant hyperthermia</li><li>Anti-cholinergic toxicity->decreased bowel sounds, urinary retention</li></ul>
How can serotonin syndrome and neuroleptic malignant syndrome be differentiated?
<ul><li>Neuroleptic malignant syndrome: slower onset, longer duration</li></ul>
How is serotonin syndrome diagnosed?
<ul><li>Mostly based on clinical exam and history</li><li>Bloods to monitor organ function</li></ul>
How is serotonin syndrome managed?
<ul><li>Stop causative agent</li><li>Supportive care and symptom management</li><li>In severe cases: antidotes like cypropheptadine</li></ul>
What are the features of addiction?
<ul><li>Tolerance</li><li>Withdrawal</li><li>Persistent desire/unsuccessful attempts to stop</li><li>Substance taken in large amounts/used for longer periods then intended</li><li>Vocational/social/recreational activities given up or reduced because of substance us</li><li>More time spent seeking/recovering from meffects of substance</li><li>Repeated use despite awareness of damage from substance</li></ul>
Which pathway is addiction medicated by?
Dopamine reward pathway
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Descirbe the general management of addiction
<ul><li>Maintainence vs abstinence</li><li>Treat co-morbidities(mental and physical)</li><li>Psychological interventions(CBT, motivational interviewing, AA)</li><li>Pharmacological intervention(manage detox, maintainence etc)</li><li>Social intervention(work, housing, family)</li></ul>
Descirbe the symptoms of acute alcohol intoxication
<ul><li>Ataxia</li><li>Nausea and vomiting</li><li>Decreased GCS</li><li>Respiraotyr depression</li><li>Impaired judgement</li><li>Anterograde amnesia</li><li>Dysarthria</li></ul>
When does alcohol withdrawal typically occur?
12 hours after the last drink
What scoring system is used to monitor signs of alcohol withdrawal and guide treatment?
CIWA score<br></br>Clinical institute withdrawal assessment
<b>Symptoms of alcohol withdrawal:</b><br></br><ul><li>>6 hours: {{c1::tremor, nausea, sweating, vomiting, anxiety, insomnia, tachycardia, hypertension, pyrexia}}</li><li>7-48 hours: {{c2::Seizures, risk of status epilepticus}}</li><li>48-72 hours: {{c3::Tremor, hallucintations, delusions, confusion, agitation}}</li></ul>
How many hours after the last drink is a patient going through alcohol withdrawal most at risk of seizures or status epilepticus?
7-48 hours
Descirbe the pharmacological management of alcohol withdrawal
<ul><li>Short acting benzodiazepines</li></ul>
<div>Chlordiazepoxide reducing regine (20-40mg qds reducing to 0 over 1 week)</div>
<div><br></br></div>
<div><ul><li>Pabrinex-prevent Wernicke-Korsakoff's syndrome</li></ul></div>
<div><br></br></div>
<div><ul><li>Oxazepam if evidence of liver injury</li></ul></div>
Describe the supportive management of alcohol withdrawal
<ul><li>Fluids</li><li>Anti-emetics</li><li>Referral to local drug and alcohol liasion teams</li></ul>
What is delirium tremens?
Life threatening emergency characterised by extreme autonomic hyperactivity and neuropsychiatric symptoms
How long after alcohol cessation is delirium tremens most likely to set in?
About 72 hours
What are the triggers for developing delirium tremens
<ul><li>Cessation of alcohol</li><li>Cna be precipitated by infeciton, trauma or illness</li></ul>
Describe the symptoms of delirium tremens
<ul><li>Confusion and disorientation</li><li>Hallucinations (visual or tactile, formication)</li><li>Autonomic hyperactivity-> sweating, hypertension</li><li>Rarely seizures</li></ul>
When do symptoms of delirium tremens typically peak?
<ul><li>Between 4th and 5th day post withdrawal</li></ul>
Give some differentials for delirium tremens
<ul><li>Alcohol withdrawal(no hallucinations)</li><li>Wernicke-korsakoff(no autonomic instability)</li><li>Encephalitis/meningitis(no focal neurological signs)</li></ul>
Describe the management of delirium tremens
<ul><li>1st line: lorazepam</li><li>If symptoms persist: parenteral lorazepam or haloperidol</li><li>Maintainence therapy of alcohol withdrawal</li></ul>
What is Wernicke’s encephalopathy?
<ul><li>Acute neurological syndrome from a thiamina(B1) deficiency</li></ul>
Name some causes of Wernicke’s encephalopathy
<ul><li>Most common: chornic alcohol abuse</li><li>Malabsorption, eating disorders</li></ul>
What are the 3 core symptoms of Wernicke’s encephalopathy?
<ul><li>Confusion</li><li>Ataxia</li><li>Ophthalmoplegia/nystagmus</li></ul>
<div>Don;t need all 3 to make a diagnosis</div>
How is Wernicke’s encephalopathy investigated?
<ul><li>Thiamine level testing</li><li>Bloods-FBC's, U&E's, liver and bone profile, magensium, clotting</li><li>Neuroimaging->MRI</li></ul>
How is Wernicke’s encephalopathy managed?
<ul><li>Treat underlying cause</li><li>Thiamine supplementation->pabrinex</li></ul>
What is Korsakoff’s syndrome?
<ul><li>Chronic memory disorder that arises as a late complication og untreated Wernicke's</li></ul>
What is the main complication of Wernicke’s encephalopathy?
<ul><li>Korsakoff's syndrome(becomes permanent)</li><li>Also coma, death</li></ul>
What is the aetiology of Korsakoff’s syndrome?
<ul><li>Degeneration of mamillary bodies(part of circuit of papez involved in memory formation) due to thiamine deficiency</li></ul>
What are the symptoms of a patient with Korsakoff’s syndrome?
<ul><li>Profoound anterograde amnesia</li><li>Limited retrograde amnesia</li><li>Confabulation(fabricate memories to mask deficit)</li></ul>
How is Korsakoff’s syndrome treated?
<ul><li>Ongoing thiamine supplementation</li><li>Cognitive rehabilitation</li><li>Treat underlying cause(like alcoholism)</li></ul>
What are some symptoms of opiate intoxication?
<ul><li>Drowsiness</li><li>Confusion</li><li>Constricted pupils</li><li>Bradypnoea</li><li>Bradycardia</li></ul>
How many hours after the last dose might opiate withdrawal symptoms begin, and when does it peak?
<ul><li>Can begin as early as 6 hours after last dose</li><li>Symptoms peak at 36-72 hours</li></ul>
Is opiate withdrawal typically life threatening?
No
Describe the symptoms of opiate withdrawal
<ul><li>Agitation</li><li>Chills</li><li>Cramps</li><li>Sweating</li><li>Increased salivation</li><li>Insomnia</li><li>GI disturbance</li><li>Dilated pupils</li><li>Piloerection</li><li>Tachycardia and hypertension</li></ul>
How is opiate withdrawal managed acutely?
<ul><li>Methadone(can cause prolonged QT syndrome)</li><li>Lofexedine(alpha 2 receptor agonist)</li><li>Loperamide(for diarrhoea)</li><li>Anti-emetics(nausea)</li><li>Benzodiazepines(only for agitation, should be avoided)</li></ul>
What is used in opiate detox programmes?
<ul><li>Methadone and bupernorphine</li></ul>
What is used as opiate addiction relapse prevention?
Neltrexone once detox done
What is an opiate overdose treated with?
Naloxone
Give some examples of stimulants
<ul><li>Cocaine</li><li>meth</li><li>MDMA</li></ul>
What are some symptoms of stimulant intoxication?
<ul><li>Euphoria</li><li>Hypertensive crisis</li><li>Tachycardia</li><li>Dilate pupils</li><li>Pyr4exia</li><li>Agitation</li><li>Psychosis</li></ul>
What are some potential consequences of stimulant intoxication?
<ul><li>Rhabodymolisis</li><li>SIADH and water overload</li><li>Cocaine-> Ischaemic events due to vasospasm</li><li>Death</li></ul>
What causes death in patients with stimulant intoxication?
<ul><li>Hyperpyrexia</li><li>Hypertension</li></ul>
How is stimulant intoxication managed?
Deaths due to hyperpyrexia and hypertension so:<br></br><ul><li>Cooling</li><li>Antihypertensives like nitroprusside or GTN</li><li>Benzodiazepines</li></ul>
What is the criteria for an ADHD diagnosis?
<ul><li>Neurodevelopmental disorder-symptoms affetc daily functioning in >1 setting and symptoms last for >6 months</li><li>Symptoms present before age of 12 years</li></ul>
What are the cardinal features of ADHD?
<ol><li>Inattention</li><li>Impulsivity</li><li>Hyperactivity</li></ol>
Describe the aetiology of ADHD
<ul><li>Decreased activity in the frontal lobe-> impaired executive function</li></ul>
How might inattention manifest in a patient with ADHD
<ul><li>Difficult sustaining attention to tasks that aren't rewarding or stimulating or require sustained mental effort</li><li>Easily distracted by external stimuli</li><li>Loses things</li></ul>
How might hyperactivity/impulsivity manifest in a patient with ADHD?
<ul><li>Excessive motor activity</li><li>Difficult engaging in activities quietly</li><li>Blurts out answers in school/work</li><li>Tendency to act in response to immediate stimuli without deliberation or consideration of risk/consequence</li></ul>
How is ADHD diagnosed?
According to the DSM-5 clinical criteria<br></br><ul><li>Behavioural observation</li><li>Comprehensive history and physical exam</li><li>Teacher and parent reports</li><li>Neuropsychological testing</li></ul>
How is ADHD treated?
<ul><li>Conservative-> behavioural therapy, CBT, psychoeducation, social skills training</li><li>Medical-stimulants-> methylphenidate, amphetamines</li></ul>
How do stimulants work to treat patients wth ADHD?
<ul><li>Act on frontal lobe to increase executive function and attention and decrease impulsivity</li></ul>
What should be monitored in children on methylphenidate?
Growth
Define autism spectrum disorders
Set of complex neurodevelopmental disorders resulting in social, language and behavioura deficits
How does ASD present?
<ol><li>Social interaction-> plays alone, no eye contact, struggle to perceive others</li><li>Language and communication-> speech and langiage delay, monotonous voice, interpret speech literally</li><li>Behavioural traits-> narrow interests, rituilistic behaviours, routines, stereotyped movements</li><li>Other conditions-> Learning difficulties, genetics, seizures</li></ol>
Name some differentials for ASD
<ul><li>Intellectual disability(no social deficits)</li><li>ADHD(no social/language deficits)</li><li>Specific language impairment</li><li>Childhood schizophrenia(hallucinations/delusions)</li><li>Asperger's-> milder social features and near normal speech development</li></ul>
How is ASD diagnosed?
<ul><li>MDT assessmnt</li><li>Psychological evaluation</li><li>Speech and language assessment</li><li>Cognitive assessment</li></ul>
How is ASD managed?
<ul><li>MDT approach</li><li>Behavioural->applied behavioural analysis(encourage positive behaviours, ignore negative)</li><li>Family and social support</li></ul>
How is ASD different to asperger’s?
Asperger’s has milder social fe3atures and near normal speech development
What are the key features of learning disabilities?
<ul><li>Decreased intellectual ability</li><li>Difficulty with everyday activities</li></ul>
Name some potential causes of learning disabilities
<ul><li>Inherited</li><li>Early childhood illness/brain injury</li><li>Problems during pregnancy/birth</li><li>Smoking/alcohol in pregnancy</li></ul>
What causes Down’s syndrome?
Trisomy 21
Name some risk factors for having Down’s syndrome
<ul><li>High maternal age</li><li>Family history</li></ul>
Descirbe the typical facial features of a patient with Down’s syndrome
<ul><li>Flat occiput</li><li>Oblique palpebral fissures</li><li>Small mouth</li><li>High arched palate</li><li>Broad hands</li><li>Single, transverse palmar crease</li></ul>
What medical conditions are associated with Down’s syndrome?
<ul><li>Complete AV septal defecy</li><li>Hypothyroidism</li><li>Increased risk of Alzheimer's by age of 50</li><li>Learning disability </li><li>Autistic t5raits</li></ul>
What is generalised anxiety disorder?
<ul><li>Chronic and pervasive condition characterised by excessive, uncontrollable worry extending across various life domains</li></ul>
What are the ICD10 criteria for GAD?
<ol><li>6 month history of tension, worry and axiety about everyday issues</li><li>Increase in symptoms(autonomic, chest/abdo, brain, tension)</li><li>Doesn't met criteria for panic disorder, hypochondriasis and OCD</li><li>Can't be explained by a physical condition or medication</li></ol>
Describe the epidemiology of GAD
<ul><li>More common in females, associated with depression, substance misuse and personality disorders</li></ul>
Name some risk factors for developing GAD
<ul><li>Low socioeconomic status</li><li>Unemplyment</li><li>Divorce</li><li>Lack of education</li></ul>
GAD symptoms:<br></br><ul><li>Psychological: {{c1::worries, decreased concentration, insomnia, derealisation}}</li><li>Motor: {{c1::restlessness, feeling on edge}}</li><li>Neuromuscular: {{c1::tremore, tension headache, muscle aches, dizziness}}</li><li>GI: {{c1::dry mouth, nausea, indugestion, nausea and vomiting}}</li><li>CVR: {{c1::chest pain, palpitations}}</li><li>Resp: {{c1::Dsypnoea, tight chest, breathlessness}}</li><li>GU: {{c1::urinary frequency, erectile dysfunction, amenorrhoea}}</li></ul>
How is GAD diagnosed?
<ul><li>Full history and exam(rule out organic causes)</li><li>Questionnaires liked GAD-2/7</li><li>Sucide risk assessment</li></ul>
Name some differentials for GAD
<ul><li>Hyperthyroidism</li><li>Cardiac causes</li><li>Too much caffeine</li><li>Substance abuse</li><li>Depression</li><li>Medication induced anxiety</li><li>Anxious/avoidant mpersonality disorder</li><li>Early stage dementia/schizophrenia</li></ul>
GAD management:<br></br><br></br>1st line: <br></br><ul><li>I{{c1::</li><li>ndividual, non-facilitated help</li><li>Individual, guided mself-help</li><li>Psycho-educational groups-interactive CBT sessions</li>}}</ul><div>2nd line:</div><div><ul><li>{{c2::</li><li>High intensity psychological intervention-CBT,applied r4elaxation</li><li>Medical management-SSRI’s, sertraline 1st line</li>}}<br></br></ul><div>Symtpomatic management: {{c3::propanolol}}</div></div>
What is panic disorder?
<ul><li>Occurence of recurrent unexpected panic attacks, each marked by intense fear/discomoft resulting in avoidant behaviours</li></ul>
What is the criteria for a panic attack disorder diagnosis?
<ol><li>Recurrent unexpected panic attacks</li><li>Persistent concern about future attackd</li><li>Behavioural changes resulting in avoidance of associated situations</li></ol>
Describe the epidemiology of panic disorder
<ul><li>Bimodial incidence, peaks and 20yrs and 50 yrs</li><li>Concurrent agoraphobia in 30-50% of cases</li><li>Increased risk of attempted suicide with comorbid epression/substance abuse</li></ul>
Describe the clinical features of panic disorder
<ul><li>Breathing difficulties, chest pain, palpitations, shaking, sweating</li><li>Hyperventilation-> hypocalcaemia, carpopedal spasm</li><li>Depersonalisation/derealistation</li><li>Agoraphobia</li></ul>
Name some differentials for panic disorder
<ul><li>Other anxiety disorders(GAD, agoraphobia)</li><li>Depression(takes precedence), alcohol/drug withdrawal</li><li>Organic: CVR/resp, hypoglycaemia, hyperthyroidism, phaeocromocytoma</li></ul>
How is panic disorder managed?
<ol><li>CBT(80-100& successful)</li></ol>
<div><ul><li>Psychoeducation and 'fear of fear' cycles</li><li>Interoceptive exposure and techniques</li><li>secondary agoraphobia exposure techniques</li></ul><div>2. SSRI's</div></div>
<div><ul><li>Clomipramine(TCA)</li><li>Propanolol for symptomatic management</li></ul></div>
<div><br></br></div>
What are phobias?
<ul><li>Excessive and irrational fears, restricted to highly specific situations</li></ul>
What are the clinical features of a phobia?
<ul><li>Usually apparent in early childhood</li><li>Leads to avoidance behaviours</li><li>Results in bradycardia or hypotension</li><li>Rule out depression</li></ul>
What is agoraphobia?
<ul><li>Fear of open spaces and associated factors like the presence of crowds or difficulty of immediate escape</li></ul>
At what age does agoraphobia typically start?
<ul><li>20's mor mid 30's</li></ul>
What is social anxiety disorder?
<ul><li>AKA social phobia</li><li>Fear of scrutiny by others in small groups(5-6 people)</li><li>Can be specific(public speaking) or generalised</li></ul>
What are the symptoms of social phobia
<ul><li>BLUSHING(characteristic)</li><li>Palpitations</li><li>Sweating</li><li>Trembling</li></ul>
What can precipitate the development of social phobia?
<ul><li>Stressful/humiliating experiences</li><li>Parental death</li><li>Separation</li><li>Chronic stress</li></ul>
What are come complications of social phobia?
<ul><li>Depression</li><li>Alcohol/drug abuse</li></ul>
How are phobias managed?
<ol><li>CBT</li></ol>
<div><ul><li>Ecposure techniques->systematic desensitization</li><li>Flooding</li><li>Modelling</li></ul><div>2. SRRI's</div></div>
<div><ul><li>Propanolol if somatic symptoms dominate</li></ul></div>
What is an acute stress reaction?
<ul><li>Immediate and intense psychological response following exposure to a traumatic event</li></ul>
How is acute stress reaction differentiated from PTSD?
Sx for <1 month: acute stress reaction<br></br>>1 month: PTSD
What is the criteria needed to diagnose an acute stress reaction?
<ul><li>Exposure: direct/indirect exposure to traumatic event</li><li>Symptoms: Dissociation, low mood, arousal, avoidance</li><li>Duration: 3 days-1 months post event</li></ul>
Name some clinical features of acute stress reaction
<ul><li>Intrusive memories, dissociation, hyperarousal, avoidance, low mood</li><li>Emotional: anxiety, sense of unreality</li><li>Physiological: palpitations, hypervigilance</li><li>Behavioural: effort to escape reality and reminders</li></ul>
Name some differentials for an acute stress reaction
<ul><li>Adjustment disorders</li><li>PTSD(>1 month)</li></ul>
How is acute stress reaction managed?
<ol><li>Trauma focused CBT</li><li>Medications if severe: benzodiazepines</li></ol>
What is adjustment disorder?
<ul><li>Significant emotional distress and disturbance that interferes with social functioning</li></ul>
When does adjustment disorder typically arise?
During a period o adaptation to a major life change/stress<br></br>
How is adjustment disorder different to an acute stress reaction?
Adjustment disorder: stressor doesn’t need ot be severe or life-threatening(e.g., being fired)<br></br>Acute stress reaction: Severe stressor
Describe the clinical features of adjustment disorder
<ul><li>Mood: depression/amxiety</li><li>Behavioural: marked irritability, imapired work/social function</li><li>Interpersonal disruptions and avoidance behaviours</li><li>Cognitive alterations: persistent negative outlook, precoccupations with the stressor </li></ul>
Name some differentials for adjustment disorder
<ul><li>Acute stress reaction</li><li>PTSD</li></ul>
How is adjustment disorder managed?
<ul><li>Psychotherapy(CBT, group, family)</li><li>Medications(anti-anxiety/antidepressants)</li><li>Self care strategies(stress management, activity, social support)</li><li>Treatment usually short term, symptoms improve once stressor is removed or indivdual learns how to cope</li></ul>
What criteria is needed to diagnose PTSD?
<ul><li>Direct/indirect exposure to a traumatic event(actual threatened death, serious injury or sexual violence)</li><li>Symptoms:intrusion, avoidance, negative alterations in cognition and mood, arousal and reactivity</li><li>Duration: >1 months(DSM-5) or >6 months(ICD-11)</li></ul>
How long do symptoms need to have been present for to make a PTSD diagnosis?
<ul><li>ICD 11: >6 months</li><li>DSM 5: >1 months</li></ul>
How common is PTSD?
<ul><li>Lifetime rates: 7-9%</li></ul>
Describe the clinical features of PTSD
<ul><li>Intrusions: recurrent distressing memories/nightmares/flashbacks</li><li>Avoidance</li><li>Mood and cognition: distorted blame, negative emotions and beliefs</li><li>Arousal and activity: Increased vigilance, concentration and sleep troubles, increased startle response</li></ul>
How is PTSD classified?
<ul><li>Mild: Manageable, limited impact on social/ocupational function</li><li>Moderate: Mild-severe distress and impact on function, no significant risk of suicide, self harm or risk to others</li><li>Severe: Unmanageable distress, high risk of self-harm/suicide</li></ul>
How is PTSD managed?
<ul><li>Moderate-severe; secondary care referral</li><li>Trauma focussed CBT and EMDR</li><li>Veterans priority scheme</li><li>Risk assessment for suicide/self-harm</li><li>Medications: SSRI's(start with sertraline, paroxetine) or SNRI(venlefaxine)</li></ul>
<div><br></br></div>
What is the criteria for a diagnosis of OCD?
<ul><li>Presence of obsessions, compulsions or both</li><li>Time-consuming (>1hr/day), OR cause significant impairment</li><li>Not attributable to another medical/mental disorder</li></ul>
How common is OCD?
1-3% of the population
At what age does OCD typically present?
<ul><li>Adolescence/early adulthood</li></ul>
How do patients with OCD present?
Obsessions; intrusive, unwanted distressing thoughts/images<br></br>Compulsions: Repetitive behaviours aimed at decreasing anxiety
What scoring system is used to assess severeity of OCD?
Yales-Brown OC scale<br></br><ul><li>Mild: 8-15</li><li>Moderate: 16-23</li><li>Severe: 24-31</li><li>Extremely severe: 32-40</li></ul>
Name some differentials for OCD
<ul><li>GAD</li><li>Major depressive disorder</li><li>Body dysmorphic disorder</li><li>Social anxiety disorder</li><li>Hoarding disorder</li><li>Trichotillomania</li><li>PTSD</li><li>ASD</li></ul>
How is OCD managed?
Mild: low intensity CBT<br></br><ul><li>Exposure and repsonse prevention: ERP</li></ul><div>Moderate: Intensive CBT or SSRI</div><div><ul><li>Fluoxetine, citalopram, paroxetine, sertraline</li><li>Clomipramine as alternative</li></ul><div>Severe:</div></div><div><ul><li>Intensive CBT and SSRI</li></ul></div><br></br>
If a patient is on a medication for OCD, how long should they continue taking it for?
<ul><li>If effective: continue for at least 12 months, then review</li></ul>
What is the criteria for a diagnosis of major depressive disorder?
<ul><li>Presence of a major depressive episode lasting over 2 weeks</li></ul>
What is dysthymia?
<ul><li>Persistent depressive disorder-chronic form of depression lasting more than 2 years</li></ul>
What are the 9 DSM 5 depression symptoms?
<ul><li>Depressed mood/irritability(can be subjective or objective)</li><li>Anhedonia</li><li>Weight/appetite changes</li><li>Sleep changes</li><li>Activity changes-pscyhomotor agitation/retardation</li><li>Fatigue/loss og energy</li><li>Guilt and feelings of worthlessness</li><li>Cognitive issues</li><li>Suicidality(thoughts or formulation of a plan</li></ul>
What is the DSM-5 criteria for a depression diagnosis?
<ul><li>5/9 symptoms for at least 2 weeks</li></ul>
Name 2 additional features that might be seen in severe depression
<ul><li>Psychosis->delusions and/or hallucinations</li><li>Depressive stupor-> immobility, mutism, refusal to eat/drink->ECT</li></ul>
What investigations should be done to make a diagnosis of depression?
<ul><li>FBC</li><li>U&E's</li><li>TFT'S</li><li>LFT</li><li>Glucose</li><li>cortisol</li><li>B12/folate</li><li>Toxicology screen</li><li>CNS imaging in some cases</li><li>Questionnares: HAD scale and PHQ-9</li></ul>
What questionnaires are used to assess depression?
<ul><li>HAD scale</li><li>PHQ-9</li></ul>
Name some differential diagnoses for depression
Organic:<br></br><ul><li>Neurological: Parkinson’s, dementia, MS</li><li>Endocrine: thryoid, hyoer/hypo-adrenalism</li><li>Chronic conditions: mdiabetes, obstructuve sleep apnoea, mono</li><li>Neoplasms and cancer</li><li>Substance use/medication side effect</li></ul>
Management of depression:<br></br><ul><li>Refer to secondary care if {{c1::high risk for cuicide, psychosis/bipolar}}</li></ul><div>Mild/moderate:</div><div><ol><li>{{c2::Low/high intensity psychological interventions(self-help, CBT, etc)}}</li><li>{{c3::Consider antidepressants(SSRI’s, SNRI’s)}}</li></ol><div>Recurrent:</div></div><div><ol><li>{{c4::Antidepressant+lithium}}</li></ol><ul><li>Continue for at least {{c4::6 months post remission then taper}}</li><li>High suicide risk age {{c4::18-25 yrs,}} follow up after {{c4::1 week}}</li></ul><div>Severe:</div><div><ol><li>{{c5::ECT}}</li></ol></div><br></br></div>
Name some side effects of ECT
<ul><li>Headaches</li><li>Muscle aches</li><li>Memory loss</li><li>Confusion</li><li>Death</li></ul>
Why should antidepressants be used with caution for depression?
High risk of suicide
What are the most common ways in which patients self harm?
<ul><li>Cutting</li><li>Self-poisoning</li><li>Burning</li><li>Hitting</li><li>Hair pulling</li></ul>
What groups is self harm most common in?
<ul><li>Young people</li><li>More common in females</li></ul>
Name some risk factors for self-harming
<ul><li>Mental illness</li><li>Alcohol/substance misus</li><li>Social disadvantage/lack of social support</li><li>Childhood adversity</li><li>Personality characteristis#(impulsivity, poor problem solving, interpersonal difficulties)</li><li>Life events-predisporing/precipitating factors(especially relationship problems</li></ul>
Give some reasons behind why a patient would self-harm
<ul><li>Expression of personal distress</li><li>May/may not be with lethal intent</li><li>Attempt to communicate/seek help/care</li><li>Way of obtaining relief from a difficult and otherwise overwhelming situation</li></ul>
Name some of the most common methods by which patients committ suicide
<ul><li>Hanging-most common</li><li>Self-poisoning</li><li>Jumping</li><li>Drowning</li><li>Cutting/stabbing</li><li>Firearms</li></ul>
Risk factors for commiting suicide:<br></br>SADPERSON:<br></br>S{{c1::ex: male}}<br></br>A{{c1::ge}}<br></br>D{{c1::epression}}<br></br>P{{c1::sychiatric care}}<br></br>E{{c1::xcessive drug use}}<br></br>R{{c1::ational thinking absent}}<br></br>S{{c1::ingle}}<br></br>O{{c1::rganised attempy/PREVIOUS SH/ATTEMPTS}}<br></br>N{{c1::o support/living alone}}<br></br>S{{c1::tates future attempt<br></br>}}<br></br>Others:<br></br><ul><li>{{c1::</li><li>Poverty and unemployment</li><li>Prisoners/marginalised groups</li><li>Family history of mental illness/suicide</li><li>Childhood adversity and bullying</li><li>Physical illness</li>}}<br></br></ul>
What are some red flags and important things to assess when carrying out a suicide risk assessment?
<ul><li>Level of intent/hopelessness, agitation, lack of sleep</li><li>Prior attempts/plans/notes</li><li>Giving away possessions etc</li><li>Typical: young male/late life white divorced male living alone, social withdrawal</li></ul>
What are the different kinds of overdose using paracetemol?
<ul><li>Acute: Excessive amounts in <1 hour</li><li>Staggered: Excessive amount ingested in >1 hour</li><li>Therapeutic excess: Too much taken to treat pain/fever without self harm intent</li></ul>
How much paracetemol counts as an overdose?
>75mg/kg/24 hours
How does a paracetemol overdose cause problems/
<ul><li>Normally: NAPQ1 inactivated by glutathione</li><li>OD: glutathione depleted, so massive excess of NAPQ1 which builds up and causes liver and kidney damage</li></ul>
How do patients who have OD’s on paracetemol present?
<ul><li>N+V</li><li>Haematuria and proteinuria</li><li>Jaundice</li><li>Loin pain</li><li>Abdominal pain</li><li>Coma/unconscious</li></ul>
What investigations should be done for a patient who has overdosed on paracetemol?
<ul><li>fbc</li><li>u&e</li><li>lfts</li><li>clotting screen</li><li>VBG-severe metabolic acidosis</li><li>Paracetemol levels</li></ul>
What kind of imbalance can a paracetemol overdose cause?
Metabolic acidosis
Management of a paracetemol overdose:<br></br><ul><li><1hour ago and dose >150mg/kg: {{c1::activated charcoal}}</li><li>1-4 hours: {{c1::wait, check at 4 hours then N-acetylcysteine}}</li><li>4-24 hours/staggered OD: {{c1::N-acetylcysteine}}</li><li>>24 hours: {{c1::N-acetyclysteine if liver failure or high paracetemol levels}}</li><li>Last line: {{c1::liver transplant}}</li></ul>
When would a patient who has overdosed on paracetemol be considered for an urgent transplant?
<ul><li>Arterial pH<7.3</li></ul>
<div>OR</div>
<div><ol><li>Serum creatinine >300micromol/litre</li><li>Prothrombin time >100 seconds</li><li>Grade 3/4 encephalopathy</li></ol></div>
Which patients are at higher risk of complications after a paracetemol overdose?
<ul><li>HIV</li><li>Mlanutrition</li><li>Wating disorders</li><li>Pre-existing liver disease</li><li>Regular alcohol excess</li></ul>
Which blood test results indicate a poor prognosis following a paracetemol overdose?
<ul><li>Bilirubin >300micromol</li><li>INR>6.5</li></ul>
What is post partum depression?
<ul><li>Significant mood disorder that develops within 1 year post birth</li></ul>
How is postpartum depression different to the baby blues?
Baby blues: Less than 2 weeks post birth, resolve spontaneously<br></br>Postpartum depression: significant mood disorder up to 1 year post birth
Name some risk factors for developing postpartum depression
<ul><li>Deprivation</li><li>History of mental health disorders</li><li>Lack of support</li></ul>
<b>Aetiology of postpartum depression:</b><br></br><ul><li>Biological: {{c1::hormonal fluctuations (lower progesterone, oesrogen etc, changes in melatonin, cortisol, immune and inflammatory processes}}<br></br></li><li>Psychological: {{c1::Stress mfrom transition to parenthood}}</li><li>Social: {{c1::lack of support, life stressors, low socioeconomic status}}</li></ul>
What symptoms might a patient with postpartum depression present with?
<ul><li>Persistent low mood, anhedonia, low energy</li><li>Decreased appetitie, disturbed sleep patterns, insidious onset</li><li>Concerns about bonding with baby and caring for it</li><li>Potential thoughts of harm</li></ul>
Name some differentials for postpartum depression
<ul><li>Baby blues</li><li>Postpartum psychosis</li><li>Adjustment disorders</li></ul>
What investigations should be done to diagnose postpartum depression?
<ul><li>Edinburgh postnatal depression scale(EPDS)</li><li>Detailed psychiatric history, phhysical exam and rule out organic causes </li></ul>
How is postpartum depression treated?
<ol><li>Self-help and psychological therapies(CBT and IPT(interpersonal))</li><li>Antidepressants(sertraline/paroxetine-safer for breastfeeding)</li><li>Admission to mother-baby mental health uni</li></ol>
Which SSRI’s are safest for breastfeeding mothers?
<ul><li>Sertraline</li><li>Paroxetine</li></ul>
What is the treatment for baby blues?
<ul><li>Reassurance and support</li><li>Regular health visits to check in on mum and baby</li></ul>
What is post partum psychosis and when does it typically occur?
<ul><li>Serious psychiatric condition</li><li>Typically under 2 weeks post birth</li></ul>
Name some risk factors for developing post partum psychosis
<ul><li>Prior history of psychosis</li><li>Family history</li></ul>
Describe the aetiology of post-partum psychosis
Unknown, combination of:<br></br><ul><li>Genetic susceptibility</li><li>Hormonal changes post birth</li><li>Psychosocial stressors</li></ul><div>Increases risk if history of severe mental illness</div>
How do patients with post-partum psychosis present?
<ul><li>Paranoia</li><li>Hallucinations</li><li>Manic epsiodes</li><li>Despressive episodes</li><li>Confusion</li><li>Delusions(especially capgras-baby replaced by imposter)</li></ul>
What investigations should be done in a patient with post partum psychosis?
<ul><li>Clinical diagnosis</li><li>Rule out organic causes-> sepsis, thyroid issues etc</li></ul>
How is post partum psychosis managed?
<ul><li>Antipsychotics: olanzapine and quetiapine(safe for breastfeeding)</li><li>Mood stabilisers for some</li><li>High risk: referral to specialist mother and baby inpatient mental health unit</li></ul>
When should a referral be made to a specialist mother and baby inpatient mental health unit in patients with post partum psychosis?
<ul><li>If high risk, especially if comman hallucinations and delusions about baby</li><li>Command->kill baby/not your baby, imposter etc</li></ul>
What are eponymous syndromes?
<ul><li>Unique and rare manifestations of distorted thinking</li></ul>
Capgras delusion?
<ul><li>Either oneself or another person has been replaced by an exact clone</li></ul>
What causes capgras delusion?
<ul><li>Psychotic illness</li><li>Brain trauma</li></ul>
What is Ekbom’s syndrome?
<ul><li>Patient feels infested with parasites-'crawling' inside skin</li></ul>
What causes Ekbom’s syndrome?
<ul><li>Psychosis</li><li>B12 deficiency</li><li>Hypothyroidism</li><li>Neurological disorders</li></ul>
What is cotard delusion?
<ul><li>Patient is dead, non-existing or rotten</li></ul>
What causes cotard delusion?
<ul><li>Psychosis</li><li>Parietal lobe lesions</li></ul>
What is othello syndrome?
Spouse/partner is unfaithful with little ot no proof
What causes othello syndrome?
<ul><li>Alcohol mabuse</li><li>Psychosis</li><li>Frontal lobe damage</li></ul>
What is freigoli syndrome?
<ul><li>Persecutory beliefs->strangers are persecutors in disguise</li></ul>
What is folie a deux?
Delusions shared by 2 or more people<br></br><ul><li>One has psychosis, the other is submissive</li></ul>
What is de clerembault’s syndrome?
<ul><li>Delusion of being the object of love</li><li>'erotomania'</li></ul>
Name some psychiatric conditions that can cause delusions
<ul><li>Schizophrenia</li><li>Bipolar disorder</li><li>Psychotic depression</li></ul>
What are the different classifications of delusions?
<ul><li>Bizarre-very unusual</li><li>Non-bizarre-plausible but not correct</li><li>Mood congruent</li><li>Mood neutral</li></ul>
What is a nihilistic delusion?
<ul><li>Typicallyh congruent with depressed mood</li></ul>
<div>Believes they are dead, world is ending etc(cotard)</div>
What are grandiose delusions?
<ul><li>Patient believes they possess ext5raordinary trais/power</li></ul>
Whne are grandiose delusions most commonly seen?
Manic phase of bipolar disorder
What are delusions of control?
<ul><li>External entity controlling thoughts/actions</li></ul>
Whare are persecutory delsuions and when are they most commonly seen?
<ul><li>Patient feels conspired against</li><li>Schizophrenia-paranoid delusions</li></ul>
What are somatic delusions?
Convinced they have a physical, medical, biological problem despite no medical evidence
What are delusional perceptions?
<ul><li>Delusions from an a real perception</li></ul>
<div>Like seeing a certain flower means aliens are landing</div>
What are delusions of reference?
<ul><li>Things that are mundane (like words in a newspaper) mean something special to the patient</li></ul>
Give some differentials for delusions
<ul><li>Mood disorders with psychotic features</li><li>Neurocognitive disorders->Alzheimer's/Parkinson's</li><li>Substance induced psychosis</li></ul>
How are delusions managed?
<ul><li>Pharmacological->antipsychotics(treat underlying disorder)</li><li>Psychotherapy-> CBT to challenge irrational beliefs</li><li>Psychoeducation</li></ul>
What is schizophrenia?
<ul><li>Chronic or relapsing/remitting form of psychosis</li></ul>
What is the DSM 5 criteria for a schizophrenia diagnosis?
<ul><li>Symptoms for at least 6 months</li><li>At least 1 month of 'active phase' symptoms(1 'ABCD' symptom)</li></ul>
What are the different subtypes of schizophrenia?
<ol><li>Paranoid</li><li>Catatonic</li><li>Hebephrenic</li><li>Residual</li><li>Simple</li></ol>
Describe the features of paranoid schizophrenia?
<ul><li>Delusions and hallucinations, often with a persecutory theme</li></ul>
Describe the features of catatonic schizophrenia
<ul><li>Motor disturbances and way felxibility</li></ul>
Describe the features of hebephrenic schizophrenia
<ul><li>Disorganised thinking, emotions and bheaviour</li></ul>
Describe the features of residual schizophrenia
<ul><li>Symptoms persist after a major episode</li></ul>
Describe the features of simple schizophrenia
<ul><li>Gradual decline in functioning without prominent positive symptoms</li></ul>
Describe the aetiology of schizophrenia
<ul><li>Huge genetic component</li><li>Environmental</li></ul>
Name some environemntal risk factors for developing schizophrenia
<ul><li>Childhood trauma/birth trauma</li><li>Urban living and immigration to more developed countries</li><li>Heavy cannabis use in childhood</li></ul>
What are the positive symptoms of schizophrenia?
ABCD<br></br><ul><li>Auditory hallucinations(3rd person auditory)</li><li>Thought Broadcasting</li><li>Control issues</li><li>Delusional perceptions</li></ul>
What are the negative sympotms of schizophrenia?
<ul><li>Alogia</li><li>Anhedonia</li><li>Affective incongruity/blunting</li><li>Avolition</li></ul>
What are some risk indicators in patients with schizophrenia?
<ul><li>Harm to self/others</li><li>Command hallucinations</li><li>Hisotyr of self harm or suicidal ideation</li><li>Fixation on specific individuals</li></ul>
What investigations might be done when making a schizophrenia diagnosis?
<ul><li>Brain imaging</li><li>Drug screening</li><li>Test to exclude infection(HIV, syphilis) or metabolic (thyroid) causes</li></ul>
Name some differentials for schizophrenia
<ul><li>Substance induced psychotic disorder</li><li>Organic psychosis-> infection,l brain injurhy, Wilson's, encephalitis</li><li>Depression and dementia</li><li>Schizoaffective disorder(mood episodes independent of psychosis)</li></ul>
Describe the acute management of schizophrenia
Sedatives: to manage dangerous behaviour<br></br><ul><li>Lorazepam</li><li>Haloperidol</li><li>Promethazine</li></ul><div>IM/oral atyhpical antipsychotics:</div><div><ul><li>Risperidone</li><li>Olanzapine</li></ul></div><div><br></br></div>
Describe the long term management of schizophrenia
<ul><li>Psychiatric referral and psychotherapy</li><li>Maintainence therapy with atypical antipsychotics(risperidone, olanzapine)</li><li>Treatment resistant: clozapine</li></ul>
How many antipsychotics need to be trialled to consider schizphrenia treatment resistant?
<ul><li>At least 2 </li></ul>
Describe the prognosis of schizophrenia?
Rule of quarter:<br></br><ul><li>25% never have another episode</li><li>25% improve significantly with treatment</li><li>25% show some improvement</li><li>25% are resistant to treatment</li></ul>
Name some factors associated with a good prognosis in patients with schizophrenia
<ul><li>High IQ/high education</li><li>Sudden onset</li><li>Precipitating factor</li><li>Strong support network</li><li>Mostly positive symptoms</li></ul>
What are the features of mania/hypomania?
<ul><li>High mood</li><li>Increased irritability</li><li>Excessive energy</li><li>Little sleep</li></ul>
How is hypomania different to mania?
<ul><li>Hypomania; >=4 days, no psychotic symptoms, limited impairment </li><li>Main: >=7 days, severe functional impairment and presence of psychosis</li></ul>
What criteria is needed for a diagnosis of bipolar affective disorder?
<ul><li>>=2 episodes</li><li>Including one episode of mania/hypomania</li></ul>
What are the different type of BPAD?
<ul><li>Type 1 and type 2</li></ul>
What is the criteria for BPAD type 1?
>=1 depressive episode and >=1 manic episode
What is the criteria for BPAD type 2?
Recurrent major depressive episodes and hypomania
How long does a depressive episode need to last for it to count towards a bipolar diagnosis?
At least 2 weeks
<b>Presentation of patients with BPAD:</b><br></br><ul><li>Depressive: {{c1::low mood, wothlessness, low energy, suicidal ideation}}<br></br></li><li>Manic: {{c2::high mood, inflated self esteem, little sleep, psychosis, impulsivity, rapid speech}}</li><li>Others; {{c3::risk taking behaviours-violence, money spending, sexual disinhibition}}</li></ul>
Name some differentials for BPAD
<ul><li>Major depressive disorder(no mania/hypomania)</li><li>Cyclothymic disorder</li><li>Schizoaffective disorder</li></ul>
What is cyclothymic disorder?
Mood fluctuations over 2 years
When are patients with suspected BPAD refffered to CMHT?
<ul><li>Hypomania: routine CMHT referral</li><li>Mania/depression: urgent CMHT referral</li></ul>
Describe the management of new/acute BPAD in a patient presenting with mania/hypomania
<ul><li>Stop SSRI</li><li>Mania+agitation: IM benzo/neuroleptic</li><li>Main: oral antipsychotics(haloperidol, olanzapine</li><li>2nd line: different antipsychotic</li><li>3rd: Lithium</li><li>4th: ECT</li></ul>
Describe the management of new/acute BPAD in a patient presenting with depression
<ul><li>Mood stabiliser</li><li>Consider SSRI/atypical antipsychotic</li></ul>
When is BPAD considered chronic and maintainence therapy started?
<ul><li>4 weeks post resolution of acute episode</li></ul>
How is chronic BPAD managed?
<ul><li>Maintainence therapy: mood stabilisers-lithium</li><li>High intensity psychological therapy(CBGT, interpersonal therapy)</li></ul>
What are the broad features of class a personality disorders
<ul><li>Odd/eccentric cluster</li></ul>
What age do you need to be to be diagnosed with a personality disorder?
At leasy 18 years
What are the Class A personality disorders?
<ol><li>Paranoid personality disorder</li><li>Schizoid personality disorder</li><li>Schizotypal personality disorder</li></ol>
What are the features of paranoid personality disorder?
<ul><li>Pervasive and enduring irrational suspicion and mistrust of others</li><li>Hypersensitivity to criticism</li><li>Reluctance to confide in others for fear of it being used against them</li><li>Often preoccupied with unfounded beliefs about conspiracies against them</li></ul>
What are the features of schizoid personality disorder?
<ul><li>Detachemnt of social relationships, lack of interest/desire for interpersonal relationships</li><li>Prefer solitary activites</li><li>Few, if any close relationships outside of immediate family</li><li>Emotional coldness, detachment, flattened affect</li></ul>
What are the features of schizotypal personality disorder?
<ul><li>Impaired social interacitons, distorted cognitions and perceptions</li><li>Inappropriate/constricted afdect, eccentric behaviour</li><li>Odd thinking and speech, magical thinking, peculiar ideas</li><li>Paranoid ideation and belief in influence of external forces</li></ul>
How is schizotypal personality disorder different to schizophrenia?
<ul><li>Both have cognitive/perceptual distortions </li><li>Schizotypal personality disorder patients have a better grasp on reality</li></ul>
How are class A personality disorders managed?
<ul><li>Psychotherapy like CBT</li><li>Medication mangement for associated symptoms</li></ul>
What are the broad features of class B personality disorders?
Dramatic/emotional/impulsive cluster
What are the disorders included in the clas B personality disorder cluster?
<ol><li>Antisocial personality disorder</li><li>Borderline personality disorder/EUPD</li><li>Histrionic personality disorder</li><li>Narcissistic personality disorder</li></ol>
What are the features of antisocial personality deisorder?
<ul><li>Disregard for and violation of the rights of others</li><li>Exhibit a lack of empathy, engage in manipulative and umpulsive actions</li><li>Unremorseful behaviour</li><li>Failure to obey social norms and laws</li></ul>
What condition in childhood increases the risk of developing antisocial personality disorder in adulthood, and how can this risk be diminished?
<ul><li>Conduct disorder</li><li>CBT treatment</li></ul>
What are the features of BPD/EUPD?
<ul><li>Abrupt mood swings, unstable relationships, poor self esteem</li><li>Inability to contro. temper and manage responses effectively</li><li>History of trauma and higher propensity for self harm</li><li>Splitting-relationships idealised or devalued</li></ul>
How is BPD managed?
Dialectical behavioural therapy (DBT)
Describe the features of histrionic personality disorder
<ul><li>Attention seeking behaviours and increased displays of emotion</li><li>Many display innapropriate sexual bhevaiours</li><li>Shallow, dramatic and exaggerated emotional expressions</li><li>Distorted perception of interpersonal boundaries</li></ul>
Describe the features of narcissistic personality disorder
<ul><li>Persistent pattern on grandiosity, lack of empathy and need for admiration from others</li><li>Sense of entitlement-> exploit other to fulfil own desires</li><li>Arrogant and preoccupied with eprsonal fantasies and desires, even at the cost of others' feelings and needs</li></ul>
What are the broad features of class C personality disorders
<ul><li>Anxious/fearful cluster</li></ul>
What personality disorders are included in class C personality disorders?
<ol><li>Avoidant personality disorder</li><li>Dependent personality disorder</li><li>Obsessive-compulsive personality disorder</li></ol>
Describe the features of avoidant personality disorder
<ul><li>Intense feelings of social inadequacy, fear of rejection and increased sensitivity to criticism</li><li>Patients often self impose isolation to avoid strong potential criticism, depsite strong desire for social acceptance and interaction</li></ul>
Describe the features of dependent personality disorder
<ul><li>Pervasive and excessive need ot be taken care of, leading to submissive and clingy bhevaiour</li><li>Often lack self-confidence and initiative, relying excessively on others for deciison making</li><li>Patients may seek new relationships as a source of care and support when existing ones end</li></ul>
Descirbe the features of obssessive compulsive personality disorder
<ul><li>Excessive preoccupation with orderliness, perfectionism and control</li><li>Strict adherence to tasks and perfectionism</li><li>Reluctance to delegate</li></ul>
How is obsessive compulsive personality disorder different to OCD?
<ul><li>Obsessive compulsive personality disorder has no recurrent intrusive thoughts or rituals</li><li>Ego-syntonic-patient perceives their symptoms as rational unlike OCD</li></ul>
What are medically unexplained symptoms?
<ul><li>Persistent bodily complaints for which adequate investigations don't reveal sufficient explanatory pathology</li></ul>
What are the features of somatoform disorder
<ul><li>Unconscious process</li><li>Common presentations: GI sx, fatigue, weakness, MSK symptoms</li><li>Can lead to loos of function</li></ul>
Describe the features of conversion disorder
<ul><li>Neurological symptoms without an underlying neurological cause</li><li>Commonly: paralysis, pseudoseizures, sensory changes</li><li>Linked to emotional stress</li><li>Unconscious process</li></ul>
Describe the features of hypochondriasis
<ul><li>Excessive concern they will develop a serious illness depsite a lack of evidence</li><li>Typically have no/very few symptoms</li><li>Patients tend to demand lots of investigations which further anxiety</li></ul>
Describe the features of Munchausen’s syndorme
<ul><li>Fictitious disorder where patients intentionally fake symptoms to gain attention and play a patient role </li><li>No insight into motivation</li></ul>
WHat is malingering?
<ul><li>Patients intentionally fake/induce illness for a secondary gain</li><li>Secondary gain: drug seeking, benefits, avoiding prison/work</li></ul>
How are medically unexplained symptoms managed?
<ul><li>Screen for underlying health problems</li><li>Psychological support and therapied like CBT</li></ul>
What is delirium?
<ul><li>Acute confusional state, mostly in the elderly, usually reversible</li></ul>
What are the general symptoms of delirium?
<ul><li>Fluctuating attention and cognition</li><li>Change in consciousness</li></ul>
What are the different types of delirium?
Hyperactive<br></br>Hypoactive<br></br>Mixed
What are the features of hyperactive delirium?
<ul><li>Increased psychomotor activity</li><li>Restlessness</li><li>Hallucinations</li></ul>
WHta are the symptoms of hypoactive delirium?
<ul><li>Lethargy</li><li>Decreased responsiveness</li><li>Withdrawal</li></ul>
Describe the aetiology of delirium?
DELIRIUM<br></br><ul><li>Drugs and alcohol</li><li>Eyes, ears and emotional disturbances</li><li>Low output state(MIR, ARDS, PE, CHF, COPD)</li><li>Infection</li><li>Retention(of stool/urine)</li><li>Ictal(related to seizure activity)</li><li>Under hydration/malnutrition</li><li>Metabolic disorders (Wilson’s, thyroid, electrolyte imbalances)</li><li>Subdural haematoma, sleep deprivation</li></ul>
Give some examples of metabolic disorders that can cause delirium
<ul><li>Wilson's</li><li>Thyroid problems</li><li>Electrolyte imbalances</li></ul>
Give some examples of drug classess that can cause delirium
<ul><li>Anti-cholinergics</li><li>Anti-convulsants</li></ul>
Describe the typical presentation of a patient with delirium?
<ul><li>Disorientation</li><li>Hallucinations(visual or auditory)</li><li>Inattention</li><li>Memory problems</li><li>Change in mood or personality</li><li>Sundowning</li><li>Disturbed sleep </li></ul>
What is sundowning?
<ul><li>Increased agitation/confusion later on in the day</li></ul>
What are some differentials for delirium?
<ul><li>Dementia: gradual onset and stable consciousness level</li><li>Psychosis: Usually preserved orientation and memory</li><li>Depression: stable consciousness, pervasive low mood</li><li>Stroke: focal neurological signs</li></ul>
What investigations should be done for a patient to diagnose delirium?
<ul><li>Tools: 4AT, CAM for delirium assessment</li><li>Comprehensive physical exam and infection screen</li><li>Bedside: bladder scan, medication review, ECG, urine MC&S</li><li>Bloods: FBC, U&Es, LFTs, TFTs, cultures</li><li>Imaging: abdo US, CXR</li><li>CT/MRI if no identifiable cause found</li></ul>
How is delirium managed?
Treat underlying cause<br></br>Non pharamcological strategies:<br></br><ul><li>Environment with good lighting</li><li>Maintaining a regular sleep-wake cycle</li><li>Regular orientation and reassurance</li><li>Ensuring glassess and hearing aids are used</li></ul><div>If very agitated, low dose lorazepam/haloperidol</div>
What is dementia?
<ul><li>Syndorme of chronic/progressive nature which involves the impairment of multiple higher cortical functions</li></ul>
What quesitonnaire can be useful for assessing dementia?
Mini mental state exam(MMSE)
MMSE results dementia:<br></br><24/30: {{c1::dementia}}<br></br>20-24: {{c2::mild<br></br>}}13-20: {{c3::moderate}}<br></br><12: {{c4::severe}}
How can demential be classified?
<ol><li>Primary</li><li>Secindary(caused by something else)</li></ol>
Name some primary causes of dementia
<ul><li>Alzheimer's</li><li>Fronto-temporal</li><li>Lewy body</li><li>Parkinson's</li><li>Huntington's</li><li>Vascular</li></ul>
Name some secondary causes of dementia
<ul><li>Infection</li><li>Trauma</li><li>Post-ictal</li><li>Toxic</li><li>Autoimmune</li><li>Metabolic</li><li>Neoplastic</li><li>Congential</li><li>Endocirne</li><li>Functional</li></ul>
How do patients with dementia present
<ul><li>Memory loss</li><li>Language problems</li><li>Disorientation</li><li>Difficulty with ADL's</li><li>Poor judgement</li><li>Mood/behaviour/personality changes</li><li>Withdrawal from society</li><li>Decrease in consciousness</li></ul>
What investigations should be done in a patient with suspected dementia?
<ul><li>Functional history(including collateral and risk assessment)</li><li>Cognitive assessments: MMSE, MOCA, IO-CS, MIS, TYM</li><li>Brain imaging: CT/MRI</li><li>Bloods=confusion screen</li></ul>
What bloods are including in the ‘confusion screen’?
<ul><li>FBC</li><li>U&Es</li><li>LFTs</li><li>CRP/ESR</li><li>Calcium</li><li>TFTs</li><li>B12 and folate</li><li>Syphilis and HIV screen</li></ul>
Describe the general management of dementia
HOWSAFE<br></br>HOme safety<br></br>Wandering<br></br>Self-neglect<br></br>Abuse<br></br>Falls<br></br>Eating<br></br><br></br><ul><li>Lifestyle-encourage activity</li><li>Social-include OT assessment</li><li>Psychological-group stimulation therapy</li><li>Pharmacological</li></ul>
What is the most common cause of dementia?
Alzheimer’s disease
Descirbe the pathophysiology of alzheimer’s disease
<ul><li>Build up of amyloid plaques and neurofibrially tangles within the brain</li></ul>
Name one risk factor for Alzheimer’s disease
Down’s syndrome
Describe the features of alzheimer’s disease
4A’s:<br></br>Amnesia (most recent memories lost first)<br></br>Aphasia (word finding problems, muddled speech)<br></br>Agnosia (recognition problem)<br></br>Apraxia (inability to carry out skilled tasks despite intact motor)
What is the treatment for dementia?
<ul><li>Mild-moderate: cholinesterase inhibitors(rivastigmine, galantamine, donezepil)</li><li>Severe: NMDA inhibitor: memantine</li></ul>
What is the 2nd most common cause of dementia?
<ul><li>Vascualr dementia</li></ul>
Descirbe the pathophysiology of vascular dementia
<ul><li>Impaired blood flow to areas of the brain due to vascular damage</li></ul>
What is the key symptoms of vascualr dementia?
<ul><li>'Step-wise' cognitive decline due to progressive infarcts</li></ul>
How is vascular dementia diagnosed?
<ul><li>Clinical</li><li>Neuro-imaging can show evidence of significant small vessel disease</li></ul>
How is vascular dementia treated?
<ul><li>Manage underlying vascular risk factors, e.g. statins</li></ul>
What is the 3rd most common cause of ementia?
Lewy body dementia
Describe the aetiology of lewy body dementia
<ul><li>Lewy bodies(alpha synuclein) deposits in cells as inclusions</li></ul>
What are the key symptoms of lewy body dementia
<ul><li>Cogniitive decline and Parkinsonism(rigidity, tremor, bradykinesia)</li><li>Associated with liliputian hallucinations</li></ul>
Desribe the timing of symptom onset in patients with lewy body dementia
<ul><li>Dementia, then movement problems both begin within a year of each other </li></ul>
Why does dementia present before parkinsonisn in lewy body dementia?
<ul><li>Inclusions affect paralimbic and neocortical areas first, then progress to the substantia nigra</li></ul>
How can lewy body dementia be distinguished from dementia due to parkinson’s?
<div>Lewy body: dementia first and parkinsonism begin within a year of each other</div>
<div>Parkinson's: Parkisonism first then dementia, develops a year apart</div>
Which medications might be used to treat lewy body dementia?
<ul><li>Rivastigmine</li><li>Neuroleptics(haloperidol) can help with hallucinations but worsen rigidity</li><li>Dopaminergics(amantadine) help rigidity but worsen hallucinations</li></ul>
Describe the pathophysiology of fronto-temporal dementia
<ul><li>Atrophy of frontal and temporal lobes </li></ul>
What are the key symptoms of fronto-temporal dementia?
<ul><li>Behavioural changes</li><li>Disinhibition</li><li>Cognitive impairment</li></ul>
What age is fronto temporal dementia usually diagnosed?
Age 45-65<br></br>Most other types of demenita affect those >65 years
<b>Fronto-temporal dementia subtypes:</b><br></br><br></br>Behavioural variant(60%): loss of social skills, personal conduct awareness, disinhibition and repetitive behaviour<br></br><br></br>Semantic dementia(20%): Inability to remember words for things<br></br><br></br>Progressive non-fluent aphasia(20%): patients can’t verbalise. Genetic tests<br></br><br></br>Pick’s disease: diagnosed post portem
What is Pick’s disease?
Type of fronto temporal dementia where tau proteins that damage frontal and temporal lobes<br></br>Diagnosed post mortem
How is fronto temporal dementia diagnosed?
<ul><li>SPECT imaging: decreased metabolic function in frontal lobe</li><li>MRI: increased T2 signal in frontal lobe</li></ul>
What is anorexia nervosa?
<ul><li>Self imposed starvation and relentless pursuit if extreme thinnes</li><li>Distorted body image</li></ul>
What are the subtypes of anorexia nervosa?
<ul><li>Restrictive: minimal food intake and excessive exercise</li><li>Bulimic: Episodic binge eating then behaviours like induce vomiting/laxative use</li></ul>
What is the criteria for an anorexia nervosa diagnosis?
<ul><li>Restrictive energy/food intake</li><li>Distorted body image</li><li>Intense fear of gaining weight</li></ul>
<div>ICD-11 ONLY: low BMI</div>
Describe the epidemiology of anorexia nervosa
<ul><li>Mostly adolescents and young adults</li><li>F>M</li><li>Associated with other psychiatric disorders</li></ul>
How is anorexia nervosa diagnosed?
<ul><li>Full physical exam and history(including collateral)</li><li>Bloods</li></ul>
What bloods might be different in patients with anorexia nervosa?
<ul><li>Deranged electrolyes: low calcium, magnesium, postassium and phosphate</li><li>Low FSH, LH oestrogen and testosterone</li><li>Leukopenia</li><li>Increased GH, and cortisol</li><li>High cholesterol</li><li>Metabolic alkalossi</li></ul>
What might you see when taking a history of a patient with anorexia nervosa?
<ul><li>Preoccupation with food and calories</li><li>Starvation via restricting intake, purgking or excessive exercise</li><li>Poor insight, calories in mind regardless of physical health</li></ul>
What might you seen on a physical exam in a patient with anorexia nervosa?
<ul><li>BMI <17.5kg/m2</li><li>Hypotension</li><li>Bradycardia</li><li>Enlarged salivary glands</li><li>Lanugo hair</li><li>Amenorrhoea</li><li>Pitted teeth</li><li>Parotid swelling</li><li>Russel's sign</li><li>Failed SUSS test</li></ul>
What is Russel’s sign?
<ul><li>Lesions on hand from inducing vomiting</li></ul>
How might an examination of someone with anorexia nervosa be different to one with bulimia nervosa?
<ul><li>Anorexia: BMI<17.5kg/m2</li><li>Bulimia: might have normal BMI</li></ul>
Describe the management of anorexia nervosa?
<ul><li>CBT-ED</li><li>SSCM</li><li>MANTRA(maudsley model of AN treatment for adults</li><li>Family therapy if underage</li><li>Admission under MHA ofr structured re-feeding</li><li>MARSIPAN checklist</li></ul>
What symptoms might promt inpatient treatment when it comes to anorexia nervosa?
<ul><li>Severe/rapid weight loss</li><li>Suicide risk</li><li>Failed SUSS test</li></ul>
What is the SUSS test anorexia?
<ul><li>Sit up squat stand test</li><li>Assesses proximal muscle weakness which might hint at respiratory muscle weakness</li></ul>
Name some complications of anorexia
<ul><li>Re-feeding syndrome</li><li>Arrhythmias</li><li>Osteoporosis</li></ul>
What arrhythmias might you see as a result of anorexia nervosa?
<ul><li>Bradycardia</li><li>Prolonged QTc</li></ul>
What is refeeding syndrome?
Rapid increase in insulin shifts potassium, magnesium and phosphate into cells leading to oedema, tachycradia and confusion
How can re-feeding syndrome be prevented?
<ul><li>Pabrinex</li><li>Pre-feeding</li><li>Monitor and replensih electrolyed</li><li>Build caloric intake gradually</li></ul>
