33 Flashcards

Question

Define compulsions

Answer 1

Repetitive behaviours or mental acts that a person feels compelled to perform in response to an obsession. Involuntary.

Answer 2

Mental acts repeated endlessly in response to intrusive ideas and doubts

Answer 3

1.6% of the population Equal in gender Age in men = late adolescent Age in women = early 20s

Answer 4

Obsessional symptoms and compulsive acts Most days for at least 2 weeks Source of distress or interferes with activities

Answer 5

Mild - low intensity psychological therapy or CBT. If no response SSRI Moderate - choice between CBT and ERP (exposure and response prevention) OR SSRI Severe - CBT and ERP and SSRI Then can trial clomipramine alone Then can add clomipramine to SSRI

Answer 6

``` Depressed mood Energy Loss Pleasure loss (anhedonia) Retardation/Agitation Eating changes Sleep disturbance Suicidal thoughts I'm a failure (loss of self-esteem/confidence) Only me to blame (guilt) No concentration ```

Answer 7

PHQ9 Patient health questionnaire | HAD - hospital anxiety and depression scale

Answer 8

``` 25% women, 10% men Female PMHx of depression Significant physical illness causing disability or pain Other mental health problems African-Caribbean, Asian Refugees, asylum seekers Family history ```

Answer 9

1 core symptom: low mood or anhedonia plus some of other symptoms Mild - 4 symptoms Moderate - 5 to 6 symptoms Severe - 7+ symptoms or any psychotic symptoms

Answer 10

``` Drugs = steroids, contraceptive pill, digoxin, beta blockers Hypothyroid Heart disease Stroke Cancer MS Dementia Alcohol abuse Illicit drug use Child birth (post-natal depression) Life events - unemployment, divorce, bereavement ```

Answer 11

``` U+Es LFTs TFTs Calcium FBC glucose inflammatory markers Magnesium Syphilis Drug screen ```

Answer 12

MILD - low intensity psychological therapies MODERATE Antidepressant or CBT SEVERE Antidepressant and CBT Antidepressant choice - SSRIs- fluoxetine, sertraline, citalopram - SNRI - venlafaxine - TCAs (high risk in OD) Note - increased risk of suicide in first 2 weeks

Answer 13

Chronic illness associated with episodes of mania and depression At least 2 episodes in which a persons mood are significantly disturbed (1 of which MUST be mania or hypomania)

Answer 14

Type 1 - manic episodes. they are severe and result in impaired functioning and frequent hospital admission Type 2 - not full mania - hypomanic episodes. No psychotic symptoms

Answer 15

At least 3 of the following symptoms: - Grandiosity - Decreased need for sleep - Pressured speech - Flight of ideas - Distractibility - Psychomotor agitation - Excess pleasurable activity with no thought for consequences

Answer 16

2% Type 1 higher in males, type 2 in females Onset between 13 and 30 Strong family history relation ``` Drug or alcohol use Major life changes Abuse in childhood Early onset depression Periods of high stress ```

Answer 17

``` Grandiose ideas Pressure of speech Excessive energy Racing thoughts Flight of ideas Over activity Less sleep Easily distracted Unkempt Increased appetite Sexual disinhibition Recklessness financially ``` SEVERE Auditory hallucinations Delusions of persecution Lack of insight

Answer 18

4+ cycles of depression and mania in 1 year with no asymptomatic episodes Associated with longer course of illness, earlier age of onset, increase suicide, increased drug and alcohol abuse TEST THYROID FUNCTION

Answer 19

1. Haloperidol, olanzapine,quetiapine, risperidone 2. If one is not effective swap to another 3. If the second doesn't work - add lithium STOP all antidepressants

Answer 20

Use antidepressants carefully as can tip into mania - only used with anti-mania medication Don't treat if mild Moderate to severe 1. Fluoxetine and olanzapine or quetiapine alone 2. Lamotrigine alone

Answer 21

Stop all antidepressnats Anti-mania therapy maximises Lithium + valproate

Answer 22

1. Lithium 2. Add valproate Continue for 2 years but may need for 5 years. ECT can provide rapid improvement in severe mania but is short lived

Answer 23

Average 10 episodes in a lifetime High risk of recurrence Symptom free episodes get shorter with increased time 25-55% have at least 1 suicide attempt Highest rate of suicides

Answer 24

- Seeing or hearing things others do not - Having unusual thoughts or beliefs - Feeling confused or suspicious

Answer 25

1. Prodromal phase Unclear, drop in functioning, sleep or mood disturbance 2. Psychosis and threshold Frank symptoms of psychosis - can occur at any age but most likely to occur in late teens, women tend to be older 3. Remission 4. Relapse

Answer 26

Reduce the impact of psychosis by offering interventions at the earliest stage of condition as the longer the duration of the untreated psychosis = worse prognosis Early intervention work with 14-35 year olds for first occurrence for up to 3 years Reduce the impact

Answer 27

``` Suicide Self-harm Aggressive behaviour Neglect Exploitation by others Self-neglect ```

Answer 28

``` Male Older age or teen Previous attempt Mental illness in 90% Divorced, single or widowed Bereavement Social isolation Physical ill health Unemployed ```

Answer 29

Failed suicide attempt - high risk of re-attempting. Likely to have mental health problems. Impulsive self-harm with ambivalence to death = overdose taken after a stressful event. No real suicidal intent. Tend to be young and female. Repeated self-harm without suicidal intent.

Answer 30

Events preceding the event Details of the act themselves Intentions Current thoughts about suicide Was it planned? What happened after? Any previous attempts?

Answer 31

``` Denial (and isolation) Anger Bargaining Depression Acceptance ```

Answer 32

Pathological reaction to loss associated with long term physical and psychological dysfunction Longer than 6 months and stuck in maladaptive state! Significant deviation from cultural norm or increase intensity of impairment

Answer 33

``` Parental abuse Parental death controlling parents Close relationship with deceased Insecure attachment styles Emotional dependency Sudden death Death in hospital ```

Answer 34

Transient states of distress and emotional disturbance which arises in the course of adapting to a significant life change, serious physical illness or possibility of serious illness. Stressor is not of unusual or catastrophic type. - Must start within 3 months of stressful life event (usually within 1 month) - Course does not exceed 6 months - Depressive or anxiety symptoms that cause functional impairments

Answer 35

``` Relationship break up Unemployment Occupational dispute Bereavement Illness ```

Answer 36

- Depressed mood - Anxiety - Worrying - Feeling or irritability to cope, plan ahead or continue - Difficulty in daily living - Liable to dramatic behaviour or violence - Palpitations, rapid breathing, diarrhoea, tremor - Aggression, deliberate self-harm, alcohol abuse, drug misuse, social difficulties

Answer 37

Brief depressive reaction Prolonged depressive reaction Mixed anxiety and depressive reaction Adjustment disorder - emotion/conduct/mixed

Answer 38

Usually resolve within a few months

Answer 39

At least one must be present most of the time for 1 month: - Thought echo, insertion, withdrawal or broadcast - Delusions of control referred to body parts, actions or sensations - Delusional perception - Hallucinatory voices giving running commentary, discussing the patient or coming from a part of the patient's body - Persistent bizarre or culturally inappropriate delusions OR 2 of the following for most of the time for 1 month: - Persistent daily hallucinations accompanied by delusions - Incoherent or irrelevant speech - Catatonic behaviours - stooping and posturing - Negative symptoms such as marked apathy, blunted or incongruous mood

Answer 40

15 per 100,000 incidence 7 per 1000 prevalence Starts in adolescence and early 20s Peak age of onset is later in women More common in men More common in Blacks and ethnic minorities FHx association

Answer 41

Paranoid - delusions or hallucinations prominent Hebephrenic - sustained, flattened or incongruous affect, lack of goal directed behaviour, prominent thought disorder Catatonic - sustained evidence over at least 2 weeks of catatonic behaviour including: stupor, excitement, posturing, rigidity. Simple - considerable loss of personal drive, progressive deepening of negative symptoms

Answer 42

"Factors associated with poor prognosis - Strong family history - Gradual onset - Low IQ - Premorbid history of social withdrawal - Lack of obvious precipitant - Early intervention services - MDT - Health promotion - Increased compliance with medication Medical: usually risperidone or olanzapine 1. Agree choice of antipsychotic 2. Titrate as necessary to minimum effective dose 3. Assess over 6-8 weeks 4. If not suitable, change drug and repeat steps 1-3 5. If not suitable use clozapine"

Answer 43

First rank symptoms: - Lack of insight - Auditory hallucinations: thought echo, 3rd person commentary - Thought disorder (insertion, withdrawal, interruption, broadcasting) - Delusional perceptions (abnormal significance for normal event) - External control of emotions - Somatic passivity: thoughts, sensations and actions are under external control

Answer 44

Negative symptoms: - Underactivity - Low motivation - Social withdrawal - Emotional flattening - Self-neglect

Answer 45

Multifactorial: genetic, environmental and social - Greatest risk factor is FHx (40% in monozygotic twins) - NRG1 has some part - Dopamine in mesolimbic system plays a key role - Excessive dopamine adds salience to mundane and insignificant thoughts or perceptions - Amphetamine misuse increases synaptic dopamine and can cause delusions and hallucinations

Answer 46

"Appearance Behaviours: withdrawal, suspicion, repetitive purposeless movements Speech: interruptions to the flow of thought (thought blocking), loosing of associations, knight's move thinking Mood/affect: flattening, incongruous or odd Thoughts: word salad, derailment, knights move thinking, thought insertion, thought withdrawal, thought broadcast Beliefs: delusion perceptions, delusions regarding thought control or broadcasting, passivity of experiences Hallucinations Cognition: attention, concentration, orientation and memory should be assessed and is often impaired"

Answer 47

"Risk factors: - FHx - Premature birth or low birth weight - Perinatal hypoxia - Intrauterine infection (influenza in 2nd trimester) - Abnormal early cognitive neuromuscular development - Social isolation - Urban lifestyle - Illicit drug use - Migrants - Abnormal family interactions - Black and ethnic minority"

Answer 48

``` "FBC and LFTs Check for alcohol abuse Urine screening for drug misuse Serological tests for syphilis Check for intoxication or drug overdose ``` ``` Rule out: Organic causes: - Drug induced psychosis: amphetamine, LSD, cannabis - Temporal lobe epilepsy - Encephalitis - Alcoholic hallucinosis - Dementia - Delirium - Cerebral syphilis ``` Psychiatric causes: - Mania - Psychotic depression - Personality disorder - Panic disorders - Dissociative identity disorder"

Answer 49

"Factors associated with poor prognosis - Strong family history - Gradual onset - Low IQ - Premorbid history of social withdrawal - Lack of obvious precipitant - Early intervention services - MDT - Health promotion - Increased compliance with medication Medical: usually risperidone or olanzapine 1. Agree choice of antipsychotic 2. Titrate as necessary to minimum effective dose 3. Assess over 6-8 weeks 4. If not suitable, change drug and repeat steps 1-3 5. If not suitable use clozapine"

Answer 50

More than 80% of patients with their first episode will recover 20% will never have another episode Worse prognosis with: poor premorbid adjustment, slow insidious onset, long duration of untreated psychosis, prominent negative symptoms

Answer 51

Organic - Drug Induced Psychosis - Amphetamine, LDS, Cannabis - Temporal Lobe Epilepsy - Encephalitis - Alcoholic Hallucinosis - Dementia - Delirium - Cerebral Syphilis Psychiatric - Mania - Psychotic Depression - Personality Disorder - Panic Disorders - Dissociative Identity Disorder

Answer 52

Severe mental disorder in which there is extreme impairment of ability to think clearly, respond with appropriate motion, communicate effectively, understand reality and behave appropriately.

Answer 53

False, fixed strange or irrational belief with is firmly held

Answer 54

Sensory perception without an appropriate stimulus

Answer 55

Delusion of control - someone else controlling feelings, behaviours and thoughts Delusional jealousy Delusion of guilt Thought insertion Delusion of reference Erotomania - belief that someone is in love with them Grandiose Grandiose religious - person is god or chosen to act as god Persecutory - followed/harassed/cheated or conspired against

Answer 56

Thought or belief that they don't exist or that they have died

Answer 57

Insignificant remarks or events have personal significance to patient

Answer 58

Hallucinations: - Visual: more common in organic illness e.g. TLE, epilepsy, Parkinson's. - Auditory: more common in functional psychiatric illness. - Tactile: cocaine bugs, simple partial seizures, somatic passivity experiences. - Olfactory: epileptic aura, tumours, schizophrenia. - Gustatory: epileptic aura and attack, functional illness.

Answer 59

Seen in TLE (temporal lobe epilepsy) Size distortion Alice in Wonderland syndrome Also seen in migraines, brain tumours and EBV

Answer 60

Paucity of thought Thought block Rapid uncontrollable thoughts Formal thought disorders - Derailment - Loosening of association - Knight's move thinking - Word salad

Answer 61

Delirium - infections, electrolyte disturbance Epilepsy Medications - steroids, antibiotics, antivirals, dopamine agonists, stimulants Cancer MS SLE Neurodegenerative disorders e.g. Parkinson's Drug or alcohol withdrawal

Answer 62

``` Schizophrenia Schizoaffective disorder Bipolar disorder Major depression Acute psychosis Dementia Personality disorders ```

Answer 63

Suicide rate is 10-15% High in early stages of disease Self-neglect Risk to others - mild increased in minor aggressive acts.

Answer 64

Dystonia Pseudoparkinsonism Akathisia Tardive dyskinesia Sedation Hyperprolactinaemia Decreased seizure threshold Postural hypotension

Answer 65

Late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw.

Answer 66

SEVERE RESTLESSNESS Akathisia is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting.

Answer 67

Dystonia is a movement disorder in which a person's muscles contract uncontrollably. The contraction causes the affected body part to twist involuntarily, resulting in repetitive movements or abnormal postures E.g. torticollis, oculogyric crisis)

Answer 68

Psychological distress manifests as physical and mental signs e.g. paralysis and amnesia

Answer 69

- Psychiatric symptoms can be a consequence of physical illness e.g. organic - Physical symptoms are manifestations of psychiatric disorder e.g. MUS and somatisation - Psychiatric symptoms that are manifestations of underlying physical illness e. g. hypothyroid - Psychiatric symptoms precipitating physical illness Anxiety, depression can precipitated seizures, MS relapses, pain

Answer 70

Physical symptoms not explained by organic disease and there is positive evidence or assumption that the symptoms are linked to psychological factors - Not a diagnosis of exclusion - requires positive psychological factors - Most are transient and not deliberately produced

Answer 71

Behaviours to avoid the stigma Inability to accept the physical or mental illness

Answer 72

Behaviours that inappropriately affirm the illness Disproportionate disability in relation to signs and symptoms

Answer 73

Manifestation of psychological stress as physical complaints with medical consultation. Can be acute or chronic often associated with psychiatric diagnosis Not a conscious process

Answer 74

2 years of multiple and various physical symptoms Persistent refusal to accept advice and reassurance that there is no physical aetiology Some degree of impaired functioning Temporal relationship to stresses

Answer 75

Many unexplained symptoms (often pain) Multiple investigations Frequent consultations Excessively disabled Polypharmacy Thick case notes Dissatisfied with care odd beliefs Unrealistic expectations of care Denial or minimise life problems

Answer 76

Psychological distress manifests as physical mental signs Mental symptoms e.g. amnesia, fatigue states Caused by stressful life events, child hood neglect or abuse.

Answer 77

Psychological distress manifests as physical signs PHYSICAL symptoms e.g. paralysis, blindness Caused by stressful life events, childhood neglect or abuse.

Answer 78

20% of general population 10-33% of GP presenting complaints Secondary care 30-50% 50% recede in 12 months 2.5% persist and lead to repeated consultation Conversion and dissociation disorders recover quickly

Answer 79

- Symptoms do not fit with existing disease models - Patient is unable to give clear and precise description of symptoms - Symptom or disability seems excessive in comparison to pathology - Temporal relationship to stressful life events - Patient attends frequently with different symptoms - Patient over anxious about the meaning of symptoms - Patient complains of pain in various sites

Answer 80

- Acknowledge that symptoms are genuine - Provide clear explanation of investigations, results and conditions excluded - Avoid extra investigations of referrals unless clinically indicated - Address the patients concerns - Set up brief regular meetings every 6-8 weeks (they need to feel they are being taken seriously) - Symptom management e.g. analgesics, laxatives, antispasmodics, weight loss and exercise - Treat any anxiety or depression if present +/- IAPT - Counsellor if required Aim for patient coping and decreased impact on life rather than symptom cure.

Answer 81

- Provide safe, secure, familiar, consistent environment - Encourage the child to ask questions - Listen to child without being critical - Use encouragement and affection - Use positive encouragement not punishment - Allow child to make choices and have some control - Recognise signs of unresolved stress

Answer 82

``` Mini mental state exam (MMSE) MOCHA ACE-III DEMTECT AMTS ```

Answer 83

- Affects ability to function in normal activities - Represents a decline from a previous level of function - Cannot be explained by delirium or other psychiatric disorder - Has been established from history and cognitive assessment - Involve impairment of at least 2 cognitive domains"

Answer 84

Out of 30 Cut off 24 - Most commonly used for complaints of problems of memory - Used for diagnosis and assesses progression and severity - Tests memory, attention and language - Not good for mild impairment X doesn't test frontal function X not designed to measure change

Answer 85

Out of 30 Cut off 26 - Aimed at detection of mild cognitive impairment - Relatively comprehensive but brief - Not biased towards a particular cognitive domain - Not suitable for patients in advanced stages

Answer 86

Out of 100 Cut off 82-88 - Robust validation in various neurodegenerative conditions - Appropriate for longitudinal studies - Sensitive to subtle impairments - Not sensitive to behavioural impairments

Answer 87

``` Out of 10 Cut off 6-8 - Widely used in hospital settings - 10 questions - Easy to use - Insufficient for more detailed assessment of cognition ```

Answer 88

Syndrome that is chronic and progressive in nature where there is a deterioration of cognitive function beyond what might be expected in normal aging. Affects: memory, thinking, orientation, comprehension, calculation, learning capacity. Impairment in cognitive function is commonly accompanied and occasionally preceded by deterioration in emotional, social control or motivation

Answer 89

"- Ensure no treatable cause has been missed - FBC, ESR or CRP, U+Es, LFTs, glucose, calcium, TFTs, B12 and folate - MSU - VDRL/TPHA (syphilis) - Consider blood cultures, CXR, MRI and psychometric testing - Specialised assessment required to determine subtype - Can use HMPAO-SPECT to distinguish Alzheimer's from other types - CSF if ?CJD - Imaging: MRI preferred"

Answer 90

"1.5% of 65-69 22% of over 85s - Increases with age - Similar prevalence in males and females - Alzheimer's more common in women. - Vascular and mixed more common in men - More common in Caucasians"

Answer 91

Potentially treatable disease: - Substance abuse - Hypothyroidism - Space occupying lesions - Normal pressure hydrocephalus - Syphilis - Vitamin B12 deficiency"

Answer 92

"Diagnostic criteria for dementia: - Affects ability to function in normal activities - Represents a decline from a previous level of function - Cannot be explained by delirium or other psychiatric disorder - Has been established from history and cognitive assessment - Involve impairment of at least 2 cognitive domains"

Answer 93

1.5% of 65-69 22% of over 85s ``` Increases with age Similar prevalence in males and females Alzheimer's more common in women. Vascular and mixed more common in men More common in Caucasians ```

Answer 94

``` Alzheimer's (50%) Vascular dementia (25%) Dementia with Lewy bodies (15%) Frontotemporal dementia (5%) Mixed dementia Parkinson's disease ``` Potentially treatable disease: - Substance abuse - Hypothyroidism - Space occupying lesions - Normal pressure hydrocephalus - Syphilis - Vitamin B12 deficiency

Answer 95

``` Alzheimer's (50%) Vascular dementia (25%) Dementia with Lewy bodies (15%) Frontotemporal dementia (5%) Mixed dementia Parkinson's disease ``` Potentially treatable disease: - Substance abuse - Hypothyroidism - Space occupying lesions - Normal pressure hydrocephalus - Syphilis - Vitamin B12 deficiency

Answer 96

- Person centred care - Discuss options - Valid consent where possible - Cognitive stimulation programmes - Music/Art/Dance therapy - Structured exercise program

Answer 97

"- Formation of senile plaques and neurofibrillary triangles - Excess amyloid beta peptides due to over production or decreased clearance - Formation of dense amyloid plaques - Plaques cause inflammatory process - cytokines, complement cascade - Synaptic and neuronal injury and cell death - Decreased brain weight - Cortical atrophy: temporal, frontal and parietal areas - Beta amyloid plaques - Neurofibrillary triangles - Neurotransmitter deficiencies"

Answer 98

"Risk factors: - Increase in women - Increases with age - FHx (x3.5 if 1st degree family member) - Apolipoprotein E4 - Head injury - Hypercholesterolaemia - Hypertension - Diabetes - Down's syndrome"

Answer 99

"Early stages: - Memory lapses - Nominal dysphasia - Difficulty finding the right words - Inability to remember recent events - Forgetting appointments Progresses to: - Language difficulties - Apraxia - Difficulty planning - Confusion Late Stage: - Wandering, disorientation - Apathy - Psychiatric depression, hallucination delusions - Incontinence - Altered eating habits - Behavioural changes - disinhibition, aggression, agitation

Answer 100

- Dementia established by examination and testing - Deficits in 2 areas of cognition - Insidious onset (months-years) - Progressive worsening - No change in consciousness - Onset between 40 and 90 with no other cause

Answer 101

"1. Acetylcholinesterase (AChE) inhibitors - Donepezil, galantamine, rivastigmine - For mild-moderate disease as long as benefit 2. NDMA antagonist - Memantine - For moderate disease intolerant to AChE and severe disease No cure."

Answer 102

Group of syndromes of cognitive impairment caused by ischaemia or haemorrhage secondary to cerebrovascular disease

Answer 103

"- Stroke related: single infarct or multi-infarct - Subcortical: small vessel disease or Binswanger's disease - Mixed: Alzheimer's and vascular - Leukoaraiosis: subcortical leukoencephalopathy - Haemorrhage - SPORADIC: most are sporadic, some familial traits - CADASIL: most common inherited"

Answer 104

"- Focal neurological abnormalities: visual disturbances, sensory or motor symptoms - Extrapyramidal symptoms - Difficulty with attention and concentration - Seizures - Depression and/or anxiety - Early presence of disturbance in gait, unsteadiness, increased falls - Bladder symptoms without urological dysfunction - Emotional liability, psychomotor retardation, depression"

Answer 105

"Group of syndromes of cognitive impairment caused by ischaemia or haemorrhage secondary to cerebrovascular disease - Once infarct or bleed reaches a certain volume, it will exhaust brains compensation - Small infarcts are due to arteriosclerosis secondary to hypertension"

Answer 106

``` Hx of stroke or TIA AF Hypertension Diabetes Hyperlipidaemia Smoking Obesity CHD Fhx of stroke or CHD ```

Answer 107

- Diagnosed dementia - Deficits interfere with ADLs - Cerebrovascular disease - signs or imaging - A relationship between disorders - Onset of dementia within 3 months of stroke - Abrupt deterioration in cognitive functions - Fluctuating stepwise progression of cognitive defects

Answer 108

Focal neurological abnormalities - visual disturbances, sensory or motor symptoms EPS - extrapyramidal symptoms Difficulty with attention and concentration Seizures Depression and/or anxiety Early presence of disturbance in gait, unsteadiness, increased falls Bladder symptoms without urological dysfunction Emotional liability, psychomotor retardation, depression

Answer 109

No specific pharmacological treatment | Modify vascular risk factors

Answer 110

``` Behavioural problems - wandering, delusions, hallucinations, poor judgement Depression Falls and gait abnormalities Decubitus ulcers Aspiration pneumonia ``` Prognosis worse than Alzheimer's - 3-5 years

Answer 111

Diagnostic criteria of Lewy body dementia: 1. Presence of dementia 2. At least two core features: - Fluctuating attention and concentration - Recurrent well formed visual hallucinations - Spontaneous parkinsonism

Answer 112

"Characterised by eosinophilic intracytoplasmic neuronal inclusion bodies (LEWY BODIES) in brainstem and neocortex. - Pathology mimics Parkinson's - Lewy body inclusions are composed of a protein called alpha-synuclein"

Answer 113

"- Dementia: memory loss, decline in problem solving and spatial awareness - Fluctuating levels of awareness and attention - Visual hallucinations - Sleep disorders"

Answer 114

" Signs of mild Parkinsonism: - Tremor - Rigidity - Poverty of facial expression - Festinating gait"

Answer 115

Avoid neuroleptic drugs Cholinesterase inhibitors (Rivastigmine) can help treat cognitive decline Average survival 5-8 years

Answer 116

Also known as Picks disease Affects frontal and/or temporal lobes It is one of the more common causes of dementia before the age of 65

Answer 117

More common in men Mean presentation 53-58 years No difference in ethnicity 15 per 100,000

Answer 118

"- Affects frontal and/or temporal lobes - Is one of the more common causes of dementia before the age of 65 - Patients sometimes lose inhibitions - Atrophy of frontal and temporal lobes - Focused - No increased plaques - Protein inclusions in neurons and glial cells (TAU, TDP, FUS)"

Answer 119

3 main clinical syndromes defined by predominant symptom at presentation Behavioural variant FT dementia (50%): - Loss of inhibition - Inappropriate social behaviour - Decrease motivation - Loss of empathy and sympathy - Change in preferences - Repetitive compulsive behaviour - Decreased memory - Echolalia - Mutism Progressive non-fluent aphasia: - Slow, hesitant - Difficult speech - Grammatical errors in speech - Loss of literary skills - Impaired understanding of complex sentences - Impairment of swallowing and coughing on demand Semantic dementia: - Loss of vocab with fluency or maintained speech - Difficulty finding right word - Loss of recognition - Preserved memory and visuospatial skills - Asking meaning of familiar words

Answer 120

"- Stop cholinergics or CNS drugs - SSRIs may help with behavioural symptoms - Can use atypical antipsychotics if psychosis and agitation - Levodopa/carbidopa if Parkinson's symptoms"

Answer 121

"Aetiologically non-specific organic cerebral syndrome characterised by concurrent disturbances of consciousness and attention, perception, memory, behaviour, emotion and sleep wake cycle Duration is variable, as is severity

Answer 122

Types of delirium: - Prevalent: condition present on admission - Incident: occurs during admission - Hypoactive: apathy and quiet confusion. Can be confused with depression - Hyperactive: agitation, delusions, disorientation"

Answer 123

- 0.4% of population - Increases with age - More common in males - 30% of ED patients - Only 20-50% detected by medical professionals - Most common complication of hospital stay in elderly Prognosis: - Short term has no effect on mortality - Long term has 2-3x mortality - Some do not return to baseline

Answer 124

Risk factors - Elderly - Malignancy - HIV/AIDS - Pre-existing cognitive issue - Past delirious episode - Burns - Emergency surgery - Orthopaedic surgery (hip) - Drug/substance abuse - Social isolation - Poor mobility - Terminally ill - Change of environment

Answer 125

"- Acute infections: e.g. Malaria, septicaemia - Medications: benzos, analgesia, anticholinergics, anticonvulsants, steroids, digoxin - Toxic substances: alcohol, CO, barbiturates, drug or alcohol withdrawal - Vascular: stroke, cardiac failure, ischaemia, subdural, subarachnoid, vasculitis, migraine - Metabolic: hypoxia, electrolyte disturbance, hypo/hyperglycaemia, hepatic failure, CKD - Vitamin deficiencies: B12, thiamine, nicotinic acid - Endocrine: hypo/hyperthyroid, hypopituitarism, Cushing's syndrome - Intracranial: epilepsy, tumour, trauma, subarachnoid haemorrhage - Post-operative state - Drug/alcohol withdrawal"

Answer 126

"- Clouded consciousness (absent in other causes of psychosis) - Impaired cognition/ disorientation - Poor concentration - Memory deficits - Abnormalities in sleep wake cycle - Abnormalities of perception (hallucinations and illusions) - Agitation - Emotional lability - Psychotic ideas - Neurological signs (tremor and unsteady gait)"

Answer 127

"Confusion assessment (must have 3/4): - Acute onset and fluctuating course - Inattention - Disorganised thinking OR Changed level of consciousness ``` Full examination FBC U+Es Glucose LFTs TFTs Troponin Vitamin B12 Syphilis PSA Urine dipstick and microscopy Blood cultures and serology ECG Pulse ox (and ABG if indicated) CXR and AXR ``` Other - head CT, LP, EEG"

Answer 128

"Treat underlying cause If cannot provide consent then treat in best interests - Supportive management: clear communication, reminder of day/time/place, clocks, familiar staff and objects from home - Environmental measures: single room control noise, lights and temperature, maintain abilities, attention to incontinence - Medical management: antipsychotics if aggressive and not responding to de-escalation (haloperidol and olanzapine) Chlordiazepoxide used in delirium tremens (result of alcohol withdrawal following dependency)"

Answer 129

Short term has no effect on mortality Long term - 2-3x mortality Some do not return to baseline Complications - hospital acquired infections, pressure sores, fractures, residual impairment, stupor, coma, death

Answer 130

- Severe depression where fluid intake is so poor that it is life threatening - Depressive stupor - Psychomotor retardation - Psychotic depression - Depression with strong suicidal features - Treatment resistant

Answer 131

``` Recent MI Arrhythmias Heart failure Stroke Respiratory problems GORD ```

Answer 132

``` Mortality 1 in 10,000 Prolonged seizures Headache, nausea, muscular aches Post ictal - confusion, impaired attention Some memory issues ```

Answer 133

``` Interest in people Start to learn and recognise their primary caregivers Can be comforted by familiar adults Respond positively to touch Smiles ```

Answer 134

Plays peek a boo Pays attention to own name Smiles spontaneously Laughs out loud

Answer 135

Wider emotional range, strong preferences for familiar people Expresses several emotions Distinguishes friends from strangers Shows displeasure at loss of toys

Answer 136

Able to feed themselves with fingers Can hold a cup with 2 hands and drink with assistance Hold out arms and legs when dressed Anxious when separated from primary caregiver

Answer 137

``` Intense feelings for parents Play by themselves, initiate own play Express negative feelings Begins to be helpful e.g. put things away Assertive ```

Answer 138

Assertive about preferences Awareness of emotions and feelings or others Rapid mood shifts Displays aggression Enjoys parallel play, solitary actions near other children Begins to play house Defends positions

Answer 139

``` Becomes more independent Completes simple tasks Wash hands unassisted More interested in other children More likely to share ```

Answer 140

Range of conditions with varying degrees of severity. Includes Asperger's and Rhett's It is a developmental disorder which affects 4 domains and starts before the age of 3. Domains: - Repetitive behaviours - Imagination - Language/communication - Social 6 abnormalities, 2 from B1

Answer 141

``` Symptoms of autism (categories): B1 - SOCIAL - Eye contact, gesture, body language - Failure to develop peer relationships - Empathy and social responses - Lack of seeking to share interest and pleasure ``` B2 - COMMUNICATION - delay in language development (without gesture compensation) - conversational reciprocity - repetitive or unusual language - imagination B3 - BEHAVIOUR - preoccupation with abnormal intensity/content - Compulsions, rituals, sameness - Mannerisms or stereotypes - Sensory preoccupations or fears"

Answer 142

Same as autism BUT - No delay in language - No significant delay in cognitive development - Other associations: - Motor clumsiness - Some have isolated special skills

Answer 143

"- Prevalence 6 in 1000 - Under 3 - More common in males - No racial associations - Positive family history Increasing prevalence over the last few years due to increasing diagnosis"

Answer 144

"- Language delay or regression - Verbal and non-verbal communication impairment - Social impairment - Repetitive, rigid or stereotyped interests, behaviours and activities - Placid or irritable as baby - Unusual posturing - Motor stereotypies - Sensory interests"

Answer 145

``` Genetic factors Maternal rubella Meningitis/encephalitis Fragile X syndrome Tuberous sclerosis Down's syndrome ``` NOT parental or environmental

Answer 146

UNKNOWN 3 Neurocognitive theories of autism - THEORY OF MIND Difficulties in considering how others may think and react in certain situations. Cannot put themselves into the minds of others - WEAK CENTRAL COHERENCE Failure to integrate information into meaningful whole. Can't make meaning of things, can't get the gist - EXECUTIVE FUNCTION Difficulties with problem solving and forward planning in order to achieve a goal

Answer 147

"MDT approach - Multiple assessments: play based, school observations - Exclude other causes: deafness, abuse, attachment disorder, OCD, LD etc. - Develop social communication and learning and problem solving - Teach idiom and metaphor - Support routines of learning - Provide support and respite care and sibling support"

Answer 148

"- Childhood autism rating scale - Diagnostic questionnaires - Observational assessment (multiple) - Fragile X and chromosome microarray testing - EEG/MRI"

Answer 149

ADHD Social communication disorder Schizoid personality disorder

Answer 150

"Attention Deficit Hyperactivity Disorder - Begins in childhood with functional impairment, most often in home and school - ? dysfunction of NA and dopamine - 85% respond to stimulants - ? dysfunction in frontal subcortical circuits due to executive dysfunction - Decreased activation in basal ganglia and anterior frontal lobe Types of ADHD: - Hyperactive impulse type (15%) - Inattentive type 20-30% - Combined type (50-75%)"

Answer 151

"Risk factors: - Family history - Low birth weight - Maternal smoking in pregnancy - Poverty - Lead exposure - Iron deficiency"

Answer 152

"ADHD rating scale or attention deficits disorders evaluation scale Consider neuropsychological testing"

Answer 153

``` Hyperactive impulse type (15%) Inattentive type 20-30% Combined type (50-75%) ```

Answer 154

"Hyperactive impulse type ADHD (15%): - Fidgets with hands or feet/squirms in seat - Leaves classroom when remaining seated is expected - Runs or climbs excessively when inappropriate - Difficulty playing or engaging in activities quietly - On the go - Talks excessively - Blurts out answers before questions fished - Difficulty waiting turn - Interrupts or intrudes on others"

Answer 155

"Inattentive type ADHD (20-30%): - Fails to given attention to detail/careless mistakes - Difficulty sustaining attention in tasks or play - Doesn't listen when spoken to directly - Doesn't follow through on instruction e.g. homework - Difficulty organising tasks and activities - Avoids/dislikes tasks requiring sustained mental effort - Loses things necessary for tasks - Easily distracted - Forgetful in daily activities"

Answer 156

"Pre-school: no drug treatment School with moderate impairment: - Group based parent education programmes - CBT and social skills training School with severe impairment: 1. Methylphenidate + psychoeducation + adjunct behavioural therapy 2. Atomoxetine 3. Guanfacine or clonidine 4. Antidepressant Parent training in communication, positive feedback, effective time outs and co-ordination of school behavioural plan"

Answer 157

1% in children 3% post-puberty Twice as common in girls Prevalence increasing

Answer 158

- Running away from home - Separation anxiety - School refusal - Complaints of boredom - Poor school performance - Antisocial behaviour - Insomnia or hypersomnia * Somatic complaints * Irritability * Social withdrawal

Answer 159

Midl psychological therapy used 1st line Moderate - refer to CAMHS Medication only alongside psychological therapies FLUOXETINE is the only drug where benefits>risks ECT only if very severe with life threatening symptoms (aged over 12)

Answer 160

Risk factors: - Family discord - Bullying - History of parental depression - Physical, sexual or emotional abuse - Homelessness - Ethnic and cultural factors - Refugee - Living in institutional setting

Answer 161

Prognosis: - 10% recover spontaneously in 3 months - 50% depressed at 12 months - 30% will have recurrence within 5 years - Worse prognosis with females, previous episodes of depression - 1-3% attempt suicide with 5- 15% recurrence

Answer 162

Psychological disorder diagnosed during childhood or adolescence that presents itself through a repetitive and persistent pattern of behaviour in which age appropriate norms are violated. Aggressive behaviour/deceitfulness/destruction of property/violation of rules

Answer 163

- Socialised conduct disorder - Unsocialised conduct disorder Conduct disorders confined to family context Oppositional defiant disorder

Answer 164

More common in males 8% of boys, 5% girls Appears in early to middle childhood Oppositional defiant disorder is more common in the under 10s RFs - Second hand smoking - Male - Non contact or mobile family - Coercive/ineffective parenting - Hyperactivity/ inattention - Smoking in pregnancy - Low birth weight

Answer 165

Must be under 18 At least 3 out of 15 criteria in past 12 months, at least 1 in last 6 months Aggression to people/animals - bullies, threatens, intimidates - initiates physical fights - use of a weapon - physically cruel to people or animals - stolen something while confronting victim - forced someone into sexual activity Destruction of property - deliberately fire setting, aiming to cause damage - Deliberately destroyed property Deceitfulness or left - Broken into house or car - Often lies to obtains goods, favours or void obligations - Stolen items without confronting victim Serious violation of rules - stays out at night desperate parental prohibitions - run away from home overnight (2+) - truant from school aged under 13

Answer 166

Usually frequent or severe tantrums Often argues with adults Actively refuses adult request or defied rules Deliberately does things to annoy others Blames others for their mistakes Touchy or easily annoyed by others Angry or resentful Spiteful

Answer 167

Multi-axial approach Deal with psychological illness, cognitive functioning, development, physical illness and psychosocial issues - May have developmental delay - Discrepancy between age and development - May have physical problems - Hunter's Comprehensive assessment Parent training programs Child group social and cognitive problem solving programmes If oppositional defiant disorder 0 given methyphenidate or atomoxetine - Clear rules or commands - Promoting play and positive relationships

Answer 168

Mild IQ 50-70 Language fair. little sensory or motor deficits. reasonable level of independence Moderate IQ 35-49 Better receptive than expressive language Severe IQ 20-34 Increasing sensory and motor deficits. 50% will have epilepsy. Profound IQ<20 Increase need. Vulnerable. Developmental level at about 12 months

Answer 169

- More common in males - Prevalence 2% - Decrease life expectancy

Answer 170

- IQ < 70 - Loss of adaptive social functioning - Onset before age 18

Answer 171

Genetics: Down's, Fragile X, Turner's, Klinefelter's Metabolic: phenylketonuria, galactosaemia, Tay-Sachs disease, Hurler's syndrome Structural disorders: tuberous sclerosis, hydrocephalus, neurofibromatosis Intrauterine: iodine deficiency, infection (CMV, rubella, toxoplasmosis) Drugs - phenytoin, alcohol Cerebral malformations Pre-eclampsia, premature labour, APH Prologned labour, trauma, asphyxia Neonatal - hypoglycaemia, severe neonatal jaundice, meningitis, encephalitis anoxia, hypothyroid, malnutrition

Answer 172

Physical: - Motor and mobility problems - Abnormalities in movement - Speech, vision and hearing problems - Epilepsy - Urinary and faecal incontinence - Increase risk of obesity, fractures, GORD, constipation Psychological (all increased in LD): - Schizophrenia - Anxiety and depression - Personality disorder - Early onset dementia - ADHD - Autism Behavioural: - Threatening own and others safety - Violent but harmless behaviour - Temper tantrums Sleep disorders Communication difficulties

Answer 173

No lab investigations Diagnosis made by history, observations and assessment - If developmental delay then chromosome and fragile X testing - TFTs - If severe delay, head MRI and CK

Answer 174

MDT support: - Social worker - Psychologist - SALT - Physiotherapist - Nurses - Occupational therapist - Annual check with GP - Direct support and coaching - Psychotropic drugs rarely used - Behaviour support plan (identify reactive and preventative strategies) - Anger management programmes

Answer 175

- Agitation - Weight changes - Appetite changes - Poor sleep - Psychomotor retardation - Tearfulness Biological problems more relevant when expression of feelings is difficult

Answer 176

CAGE questionnaire AUDIT SADQ

Answer 177

CAGE questionnaire AUDIT SADQ

Answer 178

Cut Down? Annoyed by people criticising your drinking? Guilty about drinking? Eye-opener

Answer 179

AUDIT for alcohol Alcohol Use Disorders Identification Test 10 items, 4 levels of risk 0-7 - alcohol education 8-15 = simple advice on cutting down 16-19 = simple advice + brief counselling and continued monitoring 20-40 = referral to specialist for diagnostic evaluation and treatment

Answer 180

Assesses severity and degree of dependence once a problem is identified Covers - physical withdrawal symptoms - affective withdrawal symptoms - relief drinking - frequency of alcohol consumption - speed of onset <16 = mild dependence 16-30 = moderate >30 severe dependence

Answer 181

Physiological and behavioural and cognitive phenomena in which use of a substance takes a higher priority than other behaviours. 3 or more in past year: - A strong desire to take a substance - Difficulties in controlling substance taking behaviour - Physiological withdrawal - Evidence of tolerance - Neglect of other interests - Persisting with substance use despite clear evidence its harmful - Narrowing of drinking repertoire (alcohol only)

Answer 182

Clear evidence or recent cessation or reduction plus 3 of: - tremor - sweating - nausea, retching, vomiting - tachycardia - hypertension - headache - psychomotor agitation - malaise, weakness - insomnia - transient hallucinations or illusions - Grand mal convulsions

Answer 183

9% men and 4% women show signs More common in males RFs - higher income - older people

Answer 184

- More likely in younger population 16-19 - More common in men - Increased in urban living - Increased in those visiting night clubs - Increased in homosexuals - Increased in mixed ethnic backgrounds Most commonly cannabis, then opiates then cocaine

Answer 185

GI - oesophagitis, varices, peptic ulcers, pancreatitis, hepatitis, cirrhosis, cancer (stomach, liver, oesophagus) CV - HTN, arrhythmia, cardiomyopathy, IHD, stroke Neuro - amnesia, seizures, peripheral neuropathy, cerebellar degeneration, optic atrophy, central pontine myelinosis Other - episodic hypoglycaemia, vitamin deficiencies, anaemia, accidents, aspiration pneumonia, increased infection risk, impotence

Answer 186

- Behavioural and learning theories: drug acts as positive reinforce - Psychodynamic theory: needs more satisfied by drug. reliable outcome. Influence of child abuse - Social: increased if FHx. Peer pressure from friends - Occupation: stressful job - Life events: separation, bereavement

Answer 187

Social complications of alcohol misuse - Family and marital difficulties - Employment difficulties - Accidents - Financial problems - Vagrancy - Homelessness - Crime Psychiatric complications of alcohol misuse - Mood and anxiety disorders - Suicide - Deliberate self-harm - Alcoholic hallucinosis - Othello syndrome (pathological jealousy) - Cognitive impairment

Answer 188

Medical emergency ``` Clouding of consciousness Disorientation in time and space Impaired short term memory Fear, agitation, restlessness Vivid visual hallucinations Paranoid delusions Insomnia Autonomic disturbances Coarse tremor nausea and vomiting Seizures Dehydration and electrolyte imbalance ```

Answer 189

Wernicke-Korsakoff syndrome (WKS) is a type of brain disorder caused by a lack of vitamin B1 (thiamine). The syndrome is actually two separate conditions that can occur at the same time, Wernicke’s disease (WD) and Korsakoff syndrome. Usually, people get the symptoms of WD first. WD is also known as Wernicke’s encephalopathy. ** Confusion + ataxia + ocular palsy ** - Impaired consciousness and confusion - Nystagmus - Abducens and conjugate palsies - Pupillary abnormalities - Peripheral neuropathy Results from thiamine B1 deficiency secondary to alcohol dependence! Prognosis: - 20% recover - 10% diet - 70% Korsakoff's

Answer 190

Korsakoff syndrome is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). Korsakoff syndrome is most commonly caused by alcohol misuse, but certain other conditions also can cause the syndrome. Irreversible syndrome of prominent impairment of recent memory resulting from neuronal loss, gliosis and haemorrhage in mammillary bodies and damage to dorsomedial nucleus of thalamus

Answer 191

Wernicke encephalopathy (WE) is the presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (vitamin B1).

Answer 192

Heroin, morphine, codeine, buprenorphine, tramadol, fentanyl - Dreamy/detached/euphoria - Respiratory depression - Sedation - Anorexia - Constipation - Loss of libido - Pruritus

Answer 193

Cocaine, crack cocaine, amphetamines, ice, coaince, methyphenidate, MDMA - Euphoria - Decrease need for sleep and food - increased energy and activity

Answer 194

- Blocks reuptake of serotonin and catecholamines - Especially dopamine - Euphoria - Increased confidence and energy - High disease can cause visual and auditory hallucinations

Answer 195

Benzodiazepines, alcohol, barbiturates ``` Impair consciousness Impair coordination Disinhibition Analgesia Amnesia ```

Answer 196

LSD, cannabis, MDMA - Visual hallucinations - Time distortion - Euphoria - Emotional lability

Answer 197

Partial agonism of 5HT receptors

Answer 198

Extent to which drug effects are shaped by internal and external cues High = LSD, cannabis, solvents Low = heroin, amphetamines

Answer 199

Decrease effect for the same drug dose on repeated exposure

Answer 200

Younger age Living in council or inner city area Male Living in London Single, divorced or cohabiting Unemployed Earning over £30,000 per year Renting accommodation Visiting night clubs

Answer 201

Motivational interviewing - Follows cycles of change - Based on cognitive dissonance theory - Decisional balance, non-confrontational CBT Contingency management - incentives to encourage staying off drugs - rewards 12 step AA Social support: occupation, finance, groups, housing, education

Answer 202

Chlordiazepoxide - prevents DTs, fits and rescue drinking Pabrinex - B vitamins used to treat Wernicke-Korsakoff syndrome Acamprosate -used in abstinence and prevention of relapse. Blocks GABA and NDMA receptors to decrease cravings Naltrexone - competitive antagonist of opioid receptor. Decreases pleasure from drinking alcohol Disulfram - inhibits acetyl dehydrogenase, causes build up of acetaldehyde causing unpleasant effects

Answer 203

Methadone/Buprenorphine - Removes hazards of illicit drug use - removes criminal activity to fund habit - removes risk of injecting street drugs (VTE, sepsis) - Can be used as maintenance and detox with gradual drop in dose Can withdraw cold turkey - Lofexidine (alpha 2 antagonist) can decrease sweats and cramps

Answer 204

Flumazenil - benzodiazepine (selective GABAA antagonist) receptor antagonist

Answer 205

- Advice, self-help materials, referral - individual behavioural counselling - Group therapy - Self-help materials - nicotine replacement therapy - Medications: varencicline, buproprion - Referral to NHS stop smoking services

Answer 206

``` Prepare mentally to stop - set a date, expect it to be hard, list reasons why to stop Involve family and friends Avoid situations associated with smoking Replace smoking with another activity Set targets and rewards for completion Try again if relapse Use medication! ```

Answer 207

``` Young Female Financial/housing/employment/education Personality disorder Alcohol/substance misuse Social isolated Single ```

Answer 208

Medication OD | Self-cutting

Answer 209

``` Male 25-44 Single/widowed/divorced/separated Unemployed/retired Elderly Immigrants and refugees Prisoners Bereaved Vets, pharmacists, doctors, farmers Recent life crisis Victim of abuse Access to means Hx of self-harm Mental illness Physical illness - cancer/aids/epilepsy/MS/stroke ```

Answer 210

- Precipitant - Planned - Method - Alone - Any alcohol - Any precautions against discovery - Help seeking - How did they feel when they were found - RFs for suicide - Examine mental state - Outlook for the future - Current suicidal intent - Homicidal intent - Any protective factors

Answer 211

``` Hypokalaemia Peripheral oedema Hypotension Sudden death Arrhythmia Anaemia and thrombocytopaenia Hypoglycaemia Osteoporosis Constipation Infections Lack of growth or secondary sexual characteristics Infertility AKI or CKD Renal calculi Anxiety and mood disorders Alcoholism Social difficulties ```

Answer 212

``` Mood swings Low self-esteem Suicide Clinical depression Guilt and shame Anxiety Fear of discovery Hypervigilance Obsessional thoughts and pre-occupation Withdrawal from relationships in favour of social isolation Loneliness ```

Answer 213

Eating disorder characterised by low body weight, intense fear of gaining weight and body image disturbance - Weight loss, BMI <17.5 - Weight loss is self-induced by avoidance of fattening food - Self-perception of being fat with intrusive dread of fatness which leads to low self-imposed weight threshold - Endocrine disorder involving hypothalamic-pituitary-gonadal axis

Answer 214

Increase in female Increased in 15-19 years Caucasians 0.3% prevalence 25% get concomitant OCD 50-70% develop dysthymia

Answer 215

- Obsessive and perfectionist traits - exposure to western media - middle and upper socioeconomic class - family dysfunction

Answer 216

- Genetic links - Other psychiatric illness, perfectionism, low self-esteem - A susceptible person will diet - weight loss gives positive reinforcement to continue behaviours - low weight and starvation leads to nutritional imbalances and physiological change - Obsessive behaviours facilitate maintenance of anorexic cycle - Fear of food - Corticotrophin-releasing hormone released during starvation promotes appetite suppression

Answer 217

``` Weight loss Amenorrhoea Orthostatic hypotension Fear of gaining weight Decreased subcut fat Bradycardia Disturbed body image Fatigue Dehydration Calorie restriction Poor concentration Arrhythmia Fainting Hair loss Constipation ```

Answer 218

FBC - normocytic normochromic anaemia mild leukopenia, thrombocytopenia U+Es - low K, Na, Mg, phosphate, Ca, glucose. Raised urea TFTs - low T3 LFTs - raised AST and ALT, low ALP Dipstick - ketonuria ECG Bone densitometry = osteoporosis or osteopenia

Answer 219

Psychological interventions (at least 6 months) - CBT - Interpersonal therapy - Family interventions - Medication is not the sole or primary treatment - Inpatient care if high risk - Measure weight gain - aim for 0.5-1kg per week - May require multi-vitamin supplementation Feeding against will is the last resort and only under Mental Health Act or Children's Act

Answer 220

``` Highest mortality of all psychiatric conditions 50% full recovery 33% improve 20% chronic Mortality rate 4% ```

Answer 221

Eating disorder characterised by recurrent episodes of binge eating, followed by behaviours aimed at compensating for the binge - Recurrent episodes of over eating (2x/week over a 3 month period) - Persistent preoccupation with eating and irresistible food craving - Patients attempt to counteract fattening effects of food by: self-induced vomiting, purging, alternating periods of starvation or use of drugs: diuretics, laxatives, appetite suppressants, thyroid preparations

Answer 222

``` 0.5-1% More common in females (x10) Caucasian 20-35 years High heritability ```

Answer 223

``` Severe life stresses Personality disorder Physical/sexual abuse Substance misuse Fhx of depression Early menarche Parental/childhood obesity Family dieting Fhx of eating disorder Premorbid psychiatric disorder Disruptive events in childhood = parental death, alcoholism Perceived pressure to be thin ```

Answer 224

``` Regular binge eating Attempts to counteract binges Preoccupation with weight/imaging Preoccupation with food/diet Mood disturbance/anxiety Low self esteem Self-harm Irregular periods GI symptoms Hx of dieting ```

Answer 225

``` Usually normal if no complications Weight, height, BP Swollen parotid gland Russell's sign - callus on back of hand from teeth and vomiting Dental erosions Oedema if laxative or diuretic misuse ```

Answer 226

CBT adapted for bulimia Nutritional and meal support Medication - fluoxetine Manage physical aspects

Answer 227

MEDICAL EMERGENCY Life threatening neurological disorder most often caused by adverse reaction to neuroleptic or antipsychotics. Thought to be due to decreased levels of dopamine activity due to dopamine receptor blockage - Muscle cramps - Tremor - Fever - Unstable BP - Diaphoresis - Rigidity - Sudden changes in mental status - agitation, delirium, coma Cause: - Haloperidol - Promethazine - Chlorpromazine - Levodopa To a lesser extent: clozapine, olanzapine, risperidone, quetiapine Stop antipsychotics Aggressive treatment of hyperthermia Supportive intensive care

Answer 228

SSRIs ``` Chlorpropamide Carbamazepine Tricyclic antidepressants, Lithium, MDMA/ecstasy, Tramadol, Haloperidol, Vincristine, Desmopressin, Fluphenazine ```

Answer 229

- Congenital long QT syndrome - Known pre-existing QT interval -prolongation - In combination with other medicines that prolong QT interval Avoid all SSRIs with triptans

Answer 230

Thyroid disease (hyperthyroidism) Other differentials: - Pheochromocytoma - Wilson's disease - Depression

Answer 231

Fluoxetine - persistent pulmonary hypertension of the newborn Paroxetine - congenital malformations, particularly in the first trimester

Answer 232

Anticholinergic effects Tachycardia, Dry mouth, Mydriasis Urinary retention.

Answer 233

If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. ``` Features include: insomnia irritability anxiety tremor loss of appetite tinnitus perspiration perceptual disturbances seizures ```

Answer 234

Benzodiazepines increase the frequency of chloride channels Barbiturates increase the duration of chloride channel opening

Answer 235

Short-term side-effects - Headache - Nausea - Short term memory impairment - Memory loss of events prior to ECT - Cardiac arrhythmia Long-term side-effects - Some patients report impaired memory

Answer 236

``` "Haloperidol Chlorpromazine Flupentixol Sulpiride Loxapine" ```

Answer 237

``` "Risperidone Paliperidone Clozapine Olanzapine Quetiapine Aripiprazole Amisulpride" ```

Answer 238

Smoking cessation can cause a significant rise in clozapine levels, and so it should be discussed with a psychiatrist before stopping smoking. Starting smoking, or smoking more, can reduce clozapine levels. Stopping drinking can also reduce levels, as alcohol binges can increase the level. Omitting doses will cause a reduction in clozapine levels, and stress and weight gain won't have major effects on the level

Answer 239

Agranulocytosis (1%), neutropaenia (3%) Reduced seizure threshold - can induce seizures in up to 3% of patients

Answer 240

Most things low! - Hypokalaemia - Low FSH, LH, oestrogens and testosterone - Low T3 G's and C's raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia

Answer 241

Anterograde amnesia. Falls risk. Lots of withdrawal symptoms after LT use.

Answer 242

``` Sedation Hypnotic Anxiolytic Anticonvulsant Muscle relaxant ```

Answer 243

Steroid-induced psychosis

Answer 244

Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale

Answer 245

Atypical Examples of atypical antipsychotics: - Clozapine - Olanzapine - Risperidone - Quetiapine - Amisulpride - Aripiprazole

Answer 246

Mirtazapine is a noradrenergic and specific serotonergic antidepressant which increases release of neurotransmitters by blocking alpha-2-adrenoreceptors Used in severe depression.

Answer 247

Lorazepam Haloperidol for those who do not respond to oral lorazepam.

Answer 248

Flashbacks are an immersive experience, so would not be an accurate description of this scenario. Perseveration is a sign which may be associated with Parkinson's Disease. It refers to a patient needlessly repeating a word or phrase which they had previously expressed. Anergia is not a speech abnormality. It describes a lack of energy- or increased fatigability with minimal exertion. This may be a symptom of unipolar depression. Flight of Ideas is a phenomenon which may be seen during a manic phase. It is a rapid shifting of ideas with only superficial associations between them, such that the speech is difficult to follow. Circumstantiality is the correct answer. This refers to overinclusive speech that is delayed in reaching its final goal. It can be a sign of anxiety or hypomania. It is still possible to follow the speech, and it does eventually reach its goal.

Answer 249

Having a personality disorder is a predisposing factor for brief psychotic disorder. It does often result in a return to baseline functioning. This condition most often affects people in their 20s, 30s, and 40s. The duration of an episode is at least one day but less than one month. Patients are not always aware of the change in their behaviour.

Answer 250

Having a personality disorder is a predisposing factor for brief psychotic disorder. It does often result in a return to baseline functioning. This condition most often affects people in their 20s, 30s, and 40s. The duration of an episode is at least one day but less than one month. Patients are not always aware of the change in their behaviour.

Answer 251

1. Mirtazapine is an antidepressant preferred in patients with anorexia nervosa as it also elevates the appetite and produces weight gain. 2. Fluoxetine is a selective serotonin reuptake inhibitor and it is not contraindicated in anorexia nervosa. It can produce gastrointestinal distress or sexual dysfunction as side-effects, and young patients can therefore not be compliant with the medication. 3. Amitriptyline is a tricyclic antidepressant and is used mostly for major depression. It has a worse side-effect profile than selective serotonin reuptake inhibitors. 4. Bupropion is an atypical antidepressant which is commonly used for smoking cessation. It is however contraindicated in anorexia nervosa or bulimia nervosa as it lowers the seizure threshold and predisposed these patients to seizures. 5. Milnacipran is a serotonin-norepinephrine reuptake inhibitor and it is not contraindicated in anorexia nervosa. It has stimulant properties and the most common side effect is an increase in blood pressure.

Answer 252

This test is a marker of hepatocellular carcinoma and certain non-seminoma testicular cancers

Answer 253

Reactivation of TB in an important complication of biologic therapy and an IGRA is a test for TB latency.