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MD3 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Antidepressant classes

A

SSRIs
SNRI/Dual acting agents

1st gen: TCA and MAOi

Multimodal agents

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2
Q

MX of OCD

A

Lifestyle - cut down caffeine, alch, drugs, smoking, incr exercise, activity scheduling etc

Psychotherapy: psychoeducatin, Exposure and response prevention therapy, cognitive therapy, relaxation therapy

Meds
High dose SSRIs

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3
Q

Medication for GAD

A

Venlafaxine (SNRI/dual uptake inhibitor)

Benzodiazepines

Buspirone

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4
Q

Broad management of different severity of depression

A

○ Sadness: reassurance, psychotherapy
○ Mild depression: psychotherapy
○ Moderate depression: psychotherapy +/- medication
○ Severe depression: medication + psychotherapy +/- ECT
○ Psychotic depression: medication +/- antipsychotic/ECT

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5
Q

Side effects of TCAs

A

Seizures and cardiotoxicity (arrhythmias) - lethal in overdose!

Anti-cholinergic (anti-slud) side-effects
Adrenergic block -> hypotension
Sedation and weight gain (anti-histamine)

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6
Q

Side effects of MAOi

A

Seizures and cardiotoxicity
Anti-cholinergic side effects
Adrenergic block (hypotension)
Sedation and weight gain (anti-histamine)

The Cheese Effect due to build up of tyramine following ingestion of cheese, red wine, choc, vegemite etc

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7
Q

What is the Cheese Effect

A

Build up of tyramine resulting in toxicity following ingestion of cheese, red wine, choc, vegemite etc because tyramine is ALSO broken down by MAO

Results in Incr BP, stiff neck, sweating, N&V, occipital headache

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8
Q

Examples of dual uptake inhibitors
How do they work

When do you use these ?

A

Block reuptake of serotonin at low doses and NA at higher doses
= SNRIs

Venlafaxine, Duloxetine, Desvenlafaxine

2nd line, in SSRI non-responders .

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9
Q

How does Mirtazepine work?

What effects does it has - what is it’s use?

A

It is a multimodal agent
- alpha2 antagonist w indirect effects on serotonin, NA, histamine (H1R)

Anti-anxiety and sedation

Use at night, low dose, in conjunction with another antidepressant

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10
Q

Classes of anxiety meds

A

Benzodiazepines
Buspirone
Antidepressants (SSRIs, SNRIs, TCA, MAOi)
Beta blockers

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11
Q

Meds for panic disorder

A

TCA, MAOi, SSRIs

Benzodiazepines

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12
Q

Meds for phobias

A

SSRIs

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13
Q

Meds for PTSD

A

SSRIs

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14
Q

Indications for benzodiazepines

A

GAD
Panic attacks - rapid alleviation
Sleep

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15
Q

Risks/side effects of benzodiazepines

A 
Behavioural disinhibition
Psychomotor impairment
Cognitive impairment
Rebound insomnia
Withdrawal phenomena (for short term use only; taper dose at end of therapy)
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16
Q

Buspirone

  • how does it act
  • indications
  • benefits
  • side effects
A

Serotonin partial agonists w some D2 antagonism

Indications: mild-mod GAD only (efficacy similar to benzos but not for panic disorder)

No/Low abuse potential or withdrawal phenomena

SE: Drowsiness, dizziness, headache, nausea, restlessness

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17
Q

Which symptoms of schizophrenia respond to medication, which don’t tend to?

A

Positive symptoms respond well; negative and cognitive SX don’t

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18
Q

What is the recommended treatment time for schizophrenic patients with antipsychotics

A

Optimal therapy takes 6 weeks, then swap to lower ‘maintenance dose’

College suggests treatment for 2-5 years, then stop and reassess

With a second episode after this, need indefinite tx -> high risk of relapse w non-compliance

Treatment ‘resistant’ if have failed 2 doses over 8 years -> next step is to trial Clozapine (req strict haematological monitoring due to risk of agranulocytosis)

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19
Q

Side effects of antipsychotics

A

Extrapyramidal parkinsonian-like SX

  • Bradykinesia
  • Tremor
  • Rigidity

Tardive dyskinesia

Postural hypotension

Metabolic syndrome (olanzapine and clozapine)

Falls risk

Hyperprolactinatemia

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20
Q

Examples of atypical antipyshotics

A

Olanzapine
Risperidone
Clozapine

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21
Q

Side-Effects of atypical antipsychotics

A

EPS
Weight gain -> T2DM and CVD
Postural hypotension
Anticholinergic effects

Sedation, insomnia, agitation
Cardiotoxicity
Neuroleptic malignant syndrome

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22
Q

What are the extreme risks of Clozapine?

A

Agranulocytosis, so need strict haematological monitoring - weekly for first 18 months, then monthly
-> Neutropenia

Cardiomyopathy/myocarditis/arrhyhmias

Bowel ileus -> obstruction

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23
Q

What are the symptoms neuroleptic malignant syndrome?
What causes it?
Serum marker for this?

Mx?

A

Muscular rigidity, fever, altered consciousness, autonomic dysfunction, labile BP

Side-effect of atypical antipsychotics (1% incidence but 20% mortality)

Raised CPK (creatinine phosphokinase)

Mx - dantrolene or bromocryptine(DA agonist) + supportive + cease antipsychotic +/- ICU

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24
Q

Classes of mood stabiliser for bipolar disease

A

Lithium
Anticonvulsants
Atypical antipsychotics

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25
Q

Examples of anticonvulsants for bipolar disease

A

Sodium valproate
Lamotrigine
Carbamazepine

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26
Q

Indictions for Lithium

A
  • Schizophrenia and schizoaffective disorder
  • Bipolar and unipolar depression as prophylaxis/mood stabiliser
  • hypomanic episodes
  • Acute depressed episodes as 3rd line after antidepressants and ECT
  • Augmentation of antidepressants in case of treatment resistance
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27
Q

What must be done before starting Lithium?

A

Medical HX and physical exam to establish baseline

Biochemical screening:
- TFTs (every 6 months)
- UEC (Serum creatinine every 6mo)
as Li affects kidney and thyroid function

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28
Q

How is lithium excreted and what does this mean you have to be careful with?

A

Really excreted so take care with impaired renal function

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29
Q

Side effects of Lithium

A 
Polyuria, polydipsia
Weight gain
Memory problems
Sexual dysfunction 
Metallic taste
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30
Q

What do you have to be careful with for lamotrigine?

A

Steven Johnson syndrome (Severe drug reaction)

Potentially lethal to stop drugs immediately

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31
Q

Sodium Valproate contrainidications

A

Liver disease

Pregnancy (passes into pregnancy)

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32
Q

Side effects of sodium valproate

A 
Thinned hair
Facial flushing, skin rashes
Anaemia
Slurred speech
Weight gain
Ataxia 
Lethargy
Nausea, diarrhoea, stomach cramps
50% women get irregular menses
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33
Q

What is CBT?

A

○ Interpretation of events (not the event itself) drives our emotional state - but this is an automated response for most people -> unhelpful thinking patterns (ex: catastrophisation of events, overestimation of risk)
§ Unhelpful thinking patterns are responses that produce distress
§ CHALLENGING unhelpful thinking patterns

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34
Q

Non-pharmacological management of depression/anxiety/insomnia etc

A

Exercise
Diet (?omega 3 fatty acids)
Men’s sheds etc
Activity scheduling
Relaxation exercises (breathing control, progressive muscle relaxation, cognitive slowing/mindfulness)
Graded exposure (for phobias)
Motivational interviewing (for behavioural change)

ECT
Transmagnetic stimulation

CBT
Problem solving thinking
Interpersonal therapy
Supportive psychotherapy
Psychoeducation
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35
Q

Indications for ECT

A

Major depressive disorder or episode

Bipolar - Mania

Clonidine-resistant schizophrenia or schizoaffective disorder

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36
Q

Side effects of ECT

A

Cognitive (amnesia, post-octal confusion, persistent memory disturbance)

Headache, muscle aches

Nausea

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37
Q

Diagnosis of depression

A

2 definition symptoms must occur for at least 2 weeks

  1. Depressed mood (pervasive and diurnal)
  2. Anhedonia (unable to experience pleasure)
Sleep disturbance (terminal insomia/early morning waking)
Anergia 
Anorexia 
Psychomotor agitation or retardation 
Negative thought content 
- feelings of worthlessness, guilt
- suicidal ideation, recurrent thoughts of death, suicidal plan/attemps
- hopelessness 
- nihilism
- Depersonalisation, derealisation
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38
Q

Risk factors for suicidality

A 
Insomnia/sleep deprivation
Weight/appetite loss
Feelings of worthlessness, guilt and hopelessness
Thoughts of death 
Impulsive/agressive personality traits
Early phase of recovery
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39
Q

Features of psychotic depression

A

Delusions: of guilt, self-criticism, poverty, hyperchondrial, nihilism etc (often mood congruent)

Auditory hallucinations - mood congruent

Catatonia

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40
Q

What medical conditions present w depression as a prodrome?

A

Endocrine - hypothyroid, Cushings, Addisons, HypoCa/HypoMg

Cancers (small cell lung cancer, pancreatic; paraneoplastic phenomena)

SLE
MS
HIV

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41
Q

What neuro conditions can present w depression

A 
Post-stroke
Parkinsons 
Dementia 
Intracerebral neoplasia
ABI, trauma
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42
Q

Drugs assoc w depression

A 
Steroids
Propanolol
GABA-ergic drugs (ex: alcohol)
Chemotherapy agents, IFN
OCP
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43
Q

What is melancholic depression?

A

Severe depression with MARKED psychomotor retardation OR agitation (as main SX)

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44
Q

How does depression often start out?

A

Starts w changes in sleep/energy with other changes accumulating over time

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45
Q

What are you concerned about with postpartum depression?

A

Attachment issues

Infanticide

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46
Q

How does depression in the following subgroups present:

  • children
  • teens
  • elderly
A

Children: Enuresis, encopresis, school refusal, behavioural problems

Teens: substance use or antisocial behaviour

Elderly: Withdrawal, constipation, weight los, anhedonia, agitation

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47
Q

Management of depression

A

Psychological therapy

  • problem-solving therapy
  • CBT
  • Interpersonal or family therapy

Lifestyle (diet, exercise, sleep, reduce alcohol and illicit drugs)

Pharmacotherapy

  • start w SSRI
  • SNRI (enlafaxine or duloxetine) or Mirtazepine 2nd line
  • TCA 3rd line, or 2nd line if melancholic-type
  • Lithium or atypical antipsychotics as augmenting agents

ECT for melancholic, psychotic, puerperal, bipolar depression or in cases of prominent suicidality or poor oral intake

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48
Q

Risk factors for Bipolar

A

Genetics
Head injury and organic CNS disease
AIDs
Triggers - childbirth, spring and summer (trigger mania), circadian rhythm disruptions (trigger mania)

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49
Q

Symptoms of mania

A

Elevated and/or irritable mood (incongrous to life circumstances)
Grandiosity, increased self esteem
Increased talkativeness
Decr need for sleep
Flight of ideas, tangentiality, pressured speech
Distractibility
Impulsive (incr spending, gambling, regret)
Increased social activities
Risk taking behaviour and sexual activities (run ins w police common)

+/- psychotic features (delusions often of grandiosity, religious, sexual)

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50
Q

Hypomania vs mania

A

Hypomania SX for 2-4 days + can keep it together in daily life

Mania - SX >1 week and impacts on life and relationships

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51
Q

Natural history of bipolar

A

Usually begins in adolescence as an atypical, brief episode of depression.
Depression comes first, then 1st manic episode follows around ~5 years later
3x more time spent in depressed than manic states

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52
Q

Management of bipolar

A

Mood stabilisation (Li or anticonvulsant) and Quetiapine as 1st line

2nd line - atypical antipsychotics

Antidepressants secondary to mood stabilisers in depression (start go slow because don’t want to trigger a manic episode!)

Benzos as an adjunct for treating mania w marked hyperarousal

Clozapine for treatment-resistant cases

ECT for severe/intractable mania and depression

Psychological

  • psychoeducation
  • family, marital and interpersonal therapy
  • relaxation exercises/stress management

Lifestyle
- regular exercise, decr alcohol and drugs

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53
Q

dysthymia

A

Proposed personality type characterised by:

○ Chronic low-grade depressive-type state
○ Brooding, self-critical, lacking confidence, pessimistic, tired easily, sluggish, bound to routine, shy, sensitive etc individual

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54
Q

Cyclothymia

A

Proposed personality type characterised by:
○ Moods swing between short periods of mild depression and hypomania, an elevated mood. The low and high mood swings never reach the severity or duration of major depressive or full mania episodes.

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55
Q

Hyperthymia

A

Proposed personality type characterised by:

○ Relentlessly cheerful throughout life

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56
Q

What are pseudo hallucinations vs true hallucinations?

A

Pseudo: recognised by patient as unreal (voices coming from inside head - recognised by patient as not coming from an external stimulus; or seeing something that ‘seemed like a dream’)
-> grief,

True: voices coming from external source (ex in the room around you)
-> Schizofrenia

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57
Q

DDX for psychosis

A

Psychotic disorders (schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder)

Personality disorder (schizoid, schizotypal)

Mood disorders (severe depression w psychosis, bipolar w psychotic features)

Drug-induced or withdrawal

Organic pathology
Causes of delirium

Pervasive developmental disorders (autism, aspergers’s etc)

58
Q

What are Schneider’s “first rank” symptoms

A

Classic positive symptoms of Schizophrenia

Auditory hallucinations

  • third person
  • running commentary
  • audible thoughts

Delusional phenomena (red traffic light = world is doomed)

Passivity phenomena of

  • Behaviours (puppet/their behaviours are controlled by external source)
  • Thoughts (thought insertion, withdrawal and broadcast)
59
Q

Psychotic disorders

A
  • Brief psychotic disorder (>1day and <1month) Often associated with a stressful life event
  • Schizophreniform disorder (symptoms for >1mo but <6mo)
  • Schizophrenia (Symptoms for >6mo)
  • Drug induced psychosis (main presentation due to drugs)
  • Schizoaffective disorder
  • Delusional disorder (delusions but no other positive symptoms)
60
Q

Schizophrenia common co-morbidities

A

Depression
Anxiety disorders
PTSD
Substance abuse (alcohol, cannabis most commonly)

Physical (CV risk factors elected w Clozapine, olanzapine, sedentary lifestyles, poor diet -> Obesity, HTN, diabetes, HTN); higher cancer mortality)

61
Q

Management of schizophrenia

A

Early intervention and multidisciplinary care

Manage co-morbidities (depression, anxiety, substance abuse risk management plans for suicidality) and physical health

Lifestyle - exercise, social activities, hobbies

Dietician and food diary - manage SE of clozapine

Social work and OT - vocation help
- employment, volunteering

Pharmacotherapy

  • atypical antipsychotics (low dose for elderly)
  • Clozapine for non or under-responders to 2 trials antipsychotics

Psychological

  • CBT for persistent delusions/hallucinations non-responsive to meds
  • social skills training workshops
  • cognitive remediation to enhance cognitive function
  • psychoeducation and support for family
  • family therapy and IPT
62
Q

Features of schizophrenia

A

Positive symptoms (delusions, hallucinations-commonly auditory)

Negative symptoms (anhedonia, affect bluntening/restriction, avolition, alogia/poverty of speech, social withdrawal)

Disorganisation (speech, behaviour; inappropriate affect)

Thought disorder

  • tangentiality
  • circumstantially
  • clanging/rhyming
  • neologicism (making up new words)
  • punning

Cognitive deficits (attention, memory, executive functioning, verbal fluency, social and work functioning)

Mood symptoms (agression, depression//anxiety, suicidality)

63
Q

Flat vs blunted affect

A

Flat (awareness but little capacity for emotional response) = Depression

Blunted (loss of awareness/empathy/sensitivity for an emotional event) = psychosis

64
Q

Aetiology of schizophrenia

A

Genetics
Environment
Neurodevelopment
Altered neural chemistry and structural pathology in brain (neuronal migration, brain vol, ventricular vol)

65
Q

Egodystonic vs egosyntonic and example of a mental illness that characterises

A

Ego-syntonic refers to instincts or ideas that are acceptable to the self; that are compatible with one’s values and ways of thinking. They are consistent with one’s fundamental personality and beliefs.
ex: Anorexia

Ego-dystonic refers to thoughts, impulses, and behaviors that are felt to be repugnant, distressing, unacceptable or inconsistent with one’s self-concept.
ex: OCD

66
Q

Psychopathology of obsessions in OCD

A 
Egodystonic thoughts
Recurrent
Intrusive
Cause distress
Recognised as abnormal and UNWANTED (at least initially)
67
Q

Psychopathogy of compulsions in OCD

A

Ritual performed to reduce or neutralise the distress of obsessions in OCD
May be mental or physical actions

68
Q

When does OCD usually develop?

A

Usually develops in adolescence (although they may not present for decades after)

If it develops later in life, you think of it coming as secondary to depression or substance misuse

69
Q

What drug-drug interaction do you have to be wary of due to risk of serotonin syndrome

A

Tramadol and SSRIs can be a bad combination -> risk of serotonin syndrome

SSRIs + Li, MAOi, tryptophan

70
Q

What are specific risks of SSRIs in elderly people?

A

Serotonin syndrome - interaction w tramadol

Hyponatraemia due to SiADH

Gastric bleeding

71
Q

Relapse vs recurrence

A

Relapse - patient is in partial remission and develops another episode of depression

Recurrence - patient is in full remission and then have another episode of symptoms

72
Q

Health monitoring of atypical antipsychotics

A 
BMI (weight, height)
BP
Weight circumference
BSL and lipids 
Smoking and alcohol use assessment
73
Q

What is tardive dyskinesia

A

Side effect of typical antipsychotics

Continuous Involuntary movements of tongue, cheeks, lips, facial muscles. only absent in sleep.

74
Q

Acute management of mania

A

Antipsychotics
+/- Mood stabilisers
+/- Benzodiazepines

Then mood stabilisers once they have been stabilised.

75
Q

When would you not use Li as a mood stabiliser?

A

Family planning/fertile ages
Pregnancy
Breastfeeding

Children, elderly - lower doses and close monitoring required

76
Q

Effect of clozapine on OCD . Treatment

A

Can make latent OCD worse or trigger OCD

77
Q

Features of serotonin syndrome

A 
Tremor, hyperreflexia, myoclonus muscle tremor, rigidity
Agitation, irritability, confused
Hyperthermia
Tachycardia, arrhythmias
HTN
Sweating 
Fever

Mx - supportive, stop psychotropic medication, serotonin R antagonist

78
Q

Risk factors for drug-drug interactions

A

Elderly and debilitated
Medically ill treated w many drugs
Renal or liver disease
Treatment w potent isoenzyme inhibitors

79
Q

Features of Steven Johnson syndrome

A 
Rash
Fever
Sore throat
General malaise
Conjunctivitis
Mucosal vesicular lesions
80
Q

Antidepressant discontinuation syndrome features

A

Withdrawal SX from sudden cessation of psychotropic drug, esp venlafaxine

Dizziness
Tiredness
Headache
Depression
Anxiety
Insomnia
Nausea
Diarrhoea
Emotional lability
Poor concentration
Flu-like symptoms
Paraesthesia
Visual disturbance
81
Q

When does anxiety become pathological?

A

Excessive
No longer ADAPTIVE
Disruptive to person’s life and daily functioning

In response to situations which shouldn’t normally be anxiety producing

82
Q

Components of anxiety

A

Cognitive
- Thoughts of worry and stress to do with the future
- Fear of losing control
- Inability to concentrate
+/- racing thoughts, feeling of impending doom

Physical
- Fight or flight response/adrenergic bodily arousal (tachycardia, chest pain, tachypnoea, dyspnoea, sweating, tremor, nausea, butterflies, paraesthesia, diarrhoea, derealisation/depersonalisation)

  • Muscle tension (pain, stiffness, tremor)
  • Difficulty sleeping
  • Restless, irritable
  • Increased startle responses
  • Avoidance of situations assoc w anxiety
  • Difficulty concentrating
  • Nervous energy
83
Q

Classifications of anxiety

A
  • GAD - chronic worry about a lot of things all the time. Long-standing and non-specific
    • Panic disorder - recurrent panic attacks; feeling of impending doom/death, sudden onset, settles after a while, tachypnoea, tachycardia, chest tightness, nausea
    • Phobia - focused fear and anxiety on one thing ie snakes, spiders, sharks, blood, infection, claustrophobia
  • assoc w panic attacks in these situations
  • anxiety assoc w anticipation of these things and avoidance
    • PTSD - following a traumatic/stressful precipitant, flashbacks/nightmares assoc w trigger, avoidance, sleep disturbance; >1mo SX ; SX onset often delayed
    • Acute stress disorder if sx onset immediately after event and end within a month.
    • OCD - intrusive recurrent thoughts that cause anxiety, distress in person
  • “do you find you have to check things repetitively? Or become troubled if things aren’t neat and organised?”
    • Social anxiety disorder/social phobia - fear of social situations, worry about what people are saying/thinking about them
    • Agoraphobia - fear of being in a social setting that they can’t leave from (shopping centre, que in supermarket, public transport etc) -> assoc w panic attacks in these situations
84
Q

Elements of stress-related disorders

A

Exposure to serious threat event + TRIAD

  1. Recurrent intrusive memories (flashbacks, nightmares) of event assoc w trigger
  2. Avoidance of things assoc w event
  3. Hyperarousal, hyper vigilance, startle reflexes
    Sleep difficulties
85
Q

Components of OCD

A

Obsessional thoughts/images/impulses +/- compulsive rituals to reduce the distress of the obsessional thought

Recurrent, intrusive phenomena
Lead to anxiety and distress

Resisted at the beginning but in chronic state they start to accept their obsessions as true -> delusions

86
Q

Organic DDX for anxiety

A

Organic:

  • CNS - tumours, migraine/encephalitis
  • Arrhythmias
  • Pulm insufficiency
  • Hyperthyroid
  • Hypoglycaemia
  • Cushing’s disease
  • Carcinoid tumour
  • Pheochromocytoma

INTOXICATION -stimulants, meds, alcohol, caffeine
WITHDRAWAL

Adjustment disorder (ft of anxiety and depression)

87
Q

What is Panic disorder

A

Recurrent/habitual reoccurrence of panic attacks
No clear organic cause and no predictable precipitant
Often assoc w inter panic anxiety and avoidance behaviour

88
Q

Management of panic disorder

A

Lifestyle (exercise, relaxation therapy, decr substances and caffeine)
Psychoeducation
CBT

Meds

  • SSRIs
  • Benzos to attenuate an acute attack (short period of treatment only)
89
Q

what is agoraphobia?

Management

A

Fear of situations in which the individual feels trapped

  • supermarkets
  • heavy traffic
  • public transport etc

MX:

  • lifestyle (exercise, relaxation therapy, decr substances and caffeine)
  • psychoeducation
  • exposure/response therapy
  • SSRIs or SNRIs if required
90
Q

What is exposure/response therapy?

A

Mapping fears, behaviours and avoidances
Help the patient tackle these fears in a structured hierarchical way (Start w something easy then move onto next hardest step etc)

  • used for phobias, agoraphobias
91
Q

Mx of GAD

A

Lifestyle:

  • Exercise
  • Decr caffeine, alcohol and drugs
  • Relaxation techniques

Psychotherapy:

  • Psychoeducation
  • Problem solving therapy or CBT

+/- SSRIs or SNRIs (help w comordbid depression)

92
Q

Organic causes of psychiatric disorders

A 
Delirium (any case)
Dementia
ABI
CVD
Epilepsy
Infectious diseases
Neoplasia
Demyelinating disease
HD 
Autoimmune diseases
Endocrine and metabolic disorders
93
Q

What is delirium?

A

Syndrome characterised by

Fluctuating level of consciousness

Acute onset of

  • cognitive sx
  • psychotic sx
  • altered arousal (incr or decr)
  • sleep cycle reversal
94
Q

Causes of delerium

A

Prescribed drugs

Alcohol/substance intoxication and withdrawal

Medical conditions - post-op hypoxia, febrile illness, sepsis, organ failure, hypoglycaemia, dehydration and electrolyte imbalance, constipation, burns, major trauma

Neurological conditions - epilepsy post-ictal, head injury, space occupying lesion, encephalitis

95
Q

Criteria for anorexia

A

DECR INTAKE
- Restriction of energy (caloric) intake relative to requirements

FEAR
- Intense fear of gaining weight/becoming fat

DISTORTED BODY IMAGE
- See selves as fat when they are actually very thin

96
Q

Types of anorexia

A

Restrictive (no recurrent episodes of binging/purging. dieting, fasting, excessive exercise as means of weight loss)

Binge-eating/purging (recurrent episodes of binging/purging in last 3 months. Self-induced vomiting, use of laxatives, diuretics, enemas etc)

97
Q

Risk factors for anorexia

A

Family

  • eating disorders
  • parental obesity
  • restrictive dieting
  • concerns about eating, appearance, weight

Personal HX

  • body dissatisfaction
  • childhood obesity
  • restrictive dieting
  • early menarche
  • depression
  • substance abuse or dependence
  • OCD
  • Social anxiety
  • adverse life events

Personal Traits

  • perfectionist, obsessional
  • low self-esteem
  • female
  • occupation (model)
98
Q

DSM criteria for Bulimia

A

Recurrent episodes of binging
Recurrent compensatory behaviour to prevent weight gain
The above 2 things occur at least once a week for 3 months

NOT fitting criteria for anorexia

99
Q

Physical parameters for hospital admission

A

Bradycardia (HR<50)
Hypotension (90/60 with a postural drop of >20)
BMI <14or hospital admission
temp <35.5

Hypoglycaemia
Electrolyte imbalance (low K, Mg, Phosphate)
Several days of no oral intake
Petechial rash and Plt/bone marrow suppression

100
Q

Psych parameters for psych admission

A

Needing supervision - can’t be managed or trusted in community

Active suicidal plan

Other psych. comorbidities requiring admission

Severe family problems

101
Q

Signs and complications of anorexia nervosa

A 
Emaciated frame
Psychomotor retardation
Stupor 
Easy bruising 
Cyanosis, anaemia 
infection 
proximal myopathy (squat)

Lanugo hair to insulate due to hypothermia
Parotid swelling from vomiting
Poor dentition from vomiting and lack of Ca
Fractures, osteoporosis from lack of Ca
Angular stomatitis from lack of Fe, B12
Dry skin, loss of skin turgor from dehydration

Russell’s sign (erosion of knuckles from acid)
Brittle nails
Clubbing
Cold hands

Bradycardia
Arrhythmia
Hypotensive w postural drop

102
Q

Signs and complications of anorexia nervosa

A 
Emaciated frame
Psychomotor retardation
Stupor 
Easy bruising 
Cyanosis, anaemia 
infection 
proximal myopathy (squat)

Lanugo hair to insulate due to hypothermia
Parotid swelling from vomiting
Poor dentition from vomiting and lack of Ca
Fractures, osteoporosis from lack of Ca
Angular stomatitis from lack of Fe, B12
Dry skin, loss of skin turgor from dehydration

Russell’s sign (erosion of knuckles from acid)
Brittle nails
Clubbing`
Cold hands

Bradycardia
Arrhythmia
Hypotensive w postural drop

103
Q

2 important investigations to order w anorexia

A

UEC and CMP (K, Mg, PO4)

ECG

104
Q

Pathophys refeeding syndrome

A
  • Low carb intake -> low insulin secretion -> fat catabolism -> FFA and ketones used over glucose
    • In severe starvation, Mg/K/PO4 stores are depleted whilst serum levels are maintained
    • Refeeding -> CHO metabolism -> incr insulin stimulates PO4/K/Mg into cells -> fall in serum concentration
      Occurs within 3-4 days of refeeding
105
Q

What is somatic symptom disorder

A

KEY: Multiple symptoms, multiple systems, concurrently, with no underlying physical cause

CRITERIA:
- A history of multiple physical complaints/SX
beginning before 30 years of age that
occur over a period of several years (>6mo) and
result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning

  • After inappropriate investigation, each of the SX cannot be explained by a known general medical condition or the direct effects of a substance (medication or drug of abuse)
  • When there is a related general medical condition, the physical complains or resulting functional impairment are in excess of what would be expected form Hx/Ex/Ix
  • SX are not intentionally produced or feigned
106
Q

DDX somatic SX disorder

A

Illness anxiety disorder (intense worry about illness rather than SX)

Delusional disorder (somatic type- belief in delusional intensity i.e. not open to reasoning/reassurance)

Body dysmorphic disorder (excessive concern about perceived defect)

Depressive disorder with somatisation (look for core depressive SX like low mood, anhedonia etc)

GAD (general worries other than health)

Panic disorder (anxiety in acute episodes compared to persistent SX with SSD)

107
Q

What is conversion disorder?

A

Motor (paralysis or functional gait disorders) or sensory (blindness) deficits or non-epileptic seizures suggesting a neurological or medical cause but for which no physical explanation can be found

Psychological factors are assumed to be associated with the SX or deficit because the initiation or exacerbation of the SX or deficit is preceded by conflicts or other stressors

SX or deficit isn’t
○ Intentionally produced or feigned
○ Causes significant distress or impairment
○ After appropriate investigation, can’t be fully explained by general medical condition or affect of a substance

108
Q

What is factitious disorder?

A

Intentional production or feigning of physical or psychological signs and symptoms

Motivation for behaviour is to assume the sick role (obtain the sympathy and special attention given to people who are truly medically ill)

No external incentives for the behaviour (economic gain, avoid legal responsibility, improving physical well-being etc), as in malingering, are absent

109
Q

What is factitious disorder associated with?

A

Associated with

  • disturbed early attachments (emotional neglect, loss, abuse)
  • Cluster B personality
  • early illness and hospitalisation in childhood
  • Women > Men
  • Health professionals
110
Q

What is illness anxiety disorder and how does this differ from somatic symptom disorder?

A

Illness anxiety disorder = hypochondriasis

Preoccupation with fears of having, or the idea that one has, a serious physical disease based on person’s misinterpretation of normal bodily symptoms leading to seeking medical help, but failing to be reassured by negative medical examination and tests.

  • Often focused on a specific disease
  • May or may not actually have any physical SX

Duration >=6 months
Causes significant distress/impairment in life functioning

111
Q

DSM5 definition of personality disorder

A 
Personality disorder
	- Enduring over time
	- Inflexible and rigid (hard to change these people because they don’t have insight)
	- Manifests over multiple situations
	- Detrimental to self and others
	- Started in childhood, stable and long duration 
	- Also effects 
		○ Cognition/perception
		○ Affect
		○ Impulse control
		○ Interpersonal functioning
112
Q

DSM5 criteria for BPD

A

I DESPAIRR’ - SYNDROME (need around 3 of these)

- Identity disturbances (confused w sexual, gender identity, as a person etc)
- Dissociation - mind feels disconnected from body
- Emptiness (feel empty and lonely even in a crowd of friends nad family)
- Suicidal, self-injurious behaviour
- Paranoid ideation (mistrust in relationships due to past traumatic events)
- Abandonment (feel of real or imagined abandonment/rejection etc - extremely sensitive)
- Impulsivity (self injurious behaviours, shopping sprees, unstable relationships, alcohol and drug use, promiscuity)
- Rocky on-off relationships
- Rage (inability to regulate emotions - anxiety, depression, rage)
113
Q

Ego defence mechanisms in BPD

A

Splitting: Idolisation (best person) and devaluing (worst person in the world)

Projection: - projecting difficult, unconscious feelings onto the surgeon

114
Q

Mainstays of treatment for BPD

A 
PSYCHOTHERAPY:
Dialectical behavioural therapy to help regulate emotions
Mindfulness 
ACT
Interpersonal/group therapy

+ Risk management plan in place

MEDICATIONS
used in MX in context of comorbid mood disorder and psychosis which they are prone to developing.
- Quetiapine and/or SSRI or benzo to take edge of anxiety

115
Q

Cluster A, B and C disorders

A

Cluster A “weird”: Schizoid (aloof), paranoid (accusatory), schizotypal (awkward) personality disorder

Cluster B “wild”: BPD, antisocial, Narcissistic

Cluster C “worried”: avoidant, dependent, obsessive-compulsive

116
Q

Common comorbid psych problems with personality disorders

A 
Substance abuse
Bipolar w cluster B
Depressive disorders
Schizophrenia w cluster A
Anxiety w cluster C
117
Q

Schizoid vs Schizotypical PD

A

Schizotypal (typal -> thinking) : weird thinking and behaviour (magical thoughts, ideas of reference etc) . Don’t want to be alone, but often are because they have trouble maintaining relationships due to odd thinking and lack of insight.

Schizoid (oid -> ODD) individuals simply feel no desire to form relationships, because they see no point in sharing their time with others.
-DISTANT

118
Q

Narcissistic vs antisocial PD

A

NPD: pervasive pattern of grandiosity, need for admiration, and lack of empathy for others

ASPD: pervasive pattern of disregard for and violation of rights of others, often in criminal justice system

119
Q

What is malingering?

A

Faking SX for external rewards (medication, money, time off work etc)

120
Q

Explain the physical symptoms of a panic attack

A

Cycle of anxiety:

  1. Thoughts (something terrible will happen and i will not be able to cope)
    - >
  2. Feelings (of apprehension, tension, fearfulness)
    - >
  3. Physical symptoms (tachycardia, palpitations, flushing, dry mouth, diarrhoea, urinary freq, sweating, fatigue, tremor, chest tightness etc)
    - > 1. (experiencing SX leads to avoidance -> anticipatory anxiety -> further catastrophic thoughts)

Hyperventilation in itself leads to hypocapnoea (blowing off CO2) which leads to feelings on anxiety

121
Q

Investigations as a part of routine initial assessment

A

FBE, UEC, LFTs, TFTs
Lipids, BSL
Weight, height, BP
Urine drug screen
+/- EEG, CT or MRI if organic aetiology suspected
+/- CXR, ECG if suggested by clinical picture

122
Q

DDX depression

A 
Primary depression
Bipolar
Adjustment disorder
Comorbid depression 
Organic aetiology
123
Q

Define: delusion

A

Fixed, unshakable beliefs, unamenable to reason

Impossible and unreasonable

Cannot be challenged

Out of keeping with education, cultural, social background

124
Q

Examples of common types of obsessions and accompanying compulsions (OCD)

A
  • Contamination fears -> cleanliness rituals
    • Obsessional doubt -> compulsive checking
    • Order -> ordering, rearranging
    • Aggressive impulses -> checking safety of others
    • Sexual impulses -> mental rituals
125
Q

What might visual hallucinations be more likely to be caused by?

A

Organic pathology
Alcoholic hallucinosis
Drug intoxication

126
Q

What Qs to ask to enquire about a patient’s insight?

A 
▪	Do you think you are unwell?
	▪	Do you know in what way you are ill?
	▪	Early warning sign/relapse awareness 
	▪	Do they know how they became ill?
	▪	Compliance
127
Q

DDX OCD

A

depressive disorder (can present w obsessions and compulsions)

SCZ (in early phase obsessional SX can be common, and thought insertion can appear similar to an obsession although in this case the individual is only recognising the thoughts as their own)

Cluster C personality disorder (high level perfectionism, obsession w rules and details)

128
Q

DDX PTSD

A

Acute stress disorder (sx last <1mo following stressful event)

Adjustment disorder (reaction to a change in life circumstances rather than to a specific stressful event)

Depression

Panic disorder

GAD

129
Q

High risk anxiety

A

Panic attacks + depression

130
Q

DDX low mood after birth

A

◦ Postpartum blues - 80% experience this but should only last a few days, in first week after birth
◦ Adjustment problems/disorders (Difficulty bonding with child - feelings of guild, sadness etc)
◦ Postpartum depression (Develops between 1 month and up after birth of baby)

131
Q

Impact of mental illness in pregnancy on

  1. Pregnancy
  2. Baby itself
A

Impact on pregnancy
▪ Poor self care
▪ Quality of maternal care
▪ Less likely to attend antenatal appointments
▪ Smoking, alch
▪ Incr risk of spontaneous abortion, pre-eclampsia, gestatonal HTN etc

Impact on baby
	▪	Developmental delay
	▪	Lower IQ
	▪	ADHD
	▪	Impaired language
	▪	Impaired emotional development
132
Q

Medications CI in breastfeeding

A

◦ Fluoxetine (infant jitteriness)- other SSRIs ok
◦ TCAs - low level in breast milk
◦ Anticonvulsants
◦ Clozapine (Risk-agranulocytosis)
◦ Li only If severely necessary - affects thyroid (need close monitoring of infant and serum levels)

◦	Short-acting benzos ok for short course (avoid long-acting agents)
133
Q

Risk of Lithium use in pregnancy

A

Epstein’s anomaly (neural tube defect) in the infant

134
Q

Use of medications for mental illness in pregnancy (safe vs unsafe)

A

SSRIs (Sertraline is safe)
ANtivconvulsnat - Lamotrigine is safe (sodium valproate is not)
2nd gen atypical antipsychotics safe (1st gen not)
ECT safe

Li not safe
TCAs not safe

135
Q

DSM 5 criteria for SCZ

A

A) At least 2 of the following, present most of the time for at least one month

  • Hallucinations
  • Delusions
  • Disorganised speech
  • Disorganised or catatonic behaviour
  • Neg SX

B) Social/occupational disruption

C) Continuous signs of disturbance persist for at least 6 months

136
Q

DA hypothesis of Schizophrenia

A
  • mesolimbic pathway involves DA - overactivity of this results in positive SX
  • mesocortical pathway involves DA - overactivity results in negative SX, hypoactivity, cognitive impairment
  • blocking nigrostriatal pathway incidentally w antipsychotics causes movement disorders (parkinsonian SX)
  • blocking tuberoinfundibulnar pathway (inhibits prolactin release) w antipsychotics causes hyperprolactinaemia as a SE
137
Q

Requirements for the MHA

A

▪ must be deemed to be mentally unwell (disturbance in mood, thought, perception etc)
▪ requiring immediate treatment
▪ risk to self/health or others
•
▪ if you aren’t sure you can detain them for a max of 72 hours = inpatient assessment order
▪ compulsory treatment as an inpatient or at a community mental health service - can occur for 28 days until they must have a tribunal hearing

138
Q

Criteria for involuntary admission

A

Person appears to have a mental illness
Person at imminent danger to self or others (or risk of deterioration)
Appropriate treatment available at site
This is the least restrictive method available
Person is incapable of providing informed consent or is unwilling to do so

139
Q

3 orders under MHA to know about

A

Assessment order - by any medical condition
- transfer to psych facility within 72 hours, once there lasts 24 hours but can be extended up to 72 hours.

Temporary treatment oder - by a psychiatrist

Treatment order
- up to 6 mo inpatient or 12 mo outpatient

140
Q

DSM alcohol use disorder

A

Alcohol is often taken in larger amounts or over a longer period than was intended.

There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

Craving, or a strong desire or urge to use alcohol.

Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

Recurrent alcohol use in situations in which it is physically hazardous.

Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol.

Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to criteria A and B of the criteria set for alcohol withdrawal) b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

MD3 (7 decks)

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