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Common Conditions Flashcards

1
Q

What is generalised anxiety disorder (GAD)?

A

GAD = causes excessive + disproportional anxiety and worry that negatively impacts the person’s everyday activity.

Symptoms = should be persistent, occurring most days for at least 6 months - and not caused by substance use or other condition

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2
Q

Name some secondary causes of anxiety

A
  • Substance use (e.g., caffeine, stimulants, bronchodilators and cocaine)
  • Substance withdrawal (e.g., alcohol or benzodiazepine withdrawal)
  • Hyperthyroidism
  • Phaeochromocytoma
  • Cushing’s disease
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3
Q

What is panic disorder?

A

Panic disorder = involves recurrent panic attacks
* Panic attacks = unexpected (appear randomly, often without trigger) → result in worry about further attacks + maladaptive behaviour changes relating to the attacks (e.g. avoiding activities)

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4
Q

What are the emotional + cognitive symptoms of GAD?

A
  • Excessive worrying
  • Unable to control the worrying
  • Restlessness
  • Difficulty relaxing
  • Easily tired
  • Difficulty concentrating
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5
Q

What are the physical symptoms of GAD?

A

Physical symptoms = caused by the overactivity of the sympathetic nervous system

  • Muscle tension
  • Palpitations (e.g., a feeling of their heart racing)
  • Sweating
  • Tremor
  • Gastrointestinal symptoms (e.g., abdominal pain and diarrhoea)
  • Headaches
  • Sleep disturbance
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6
Q

How do panic attacks present?

A

Sudden onset of intense phsyical + emotional symptoms of anxiety
* They come on quickly (within minutes) and last a short time (e.g., 10 minutes) before the symptoms gradually fade.

Physical symptoms:
* Tension
* Palpitations
* Tremors
* Sweating
* Dr mouth
* Chest pain
* Shortness of breath
* Dizziness
* Nausea

Emotional symptoms:
* Feelings of panic, fear, danger
* Depersonalisation (feeling separated or detached)
* Feeling of loss of control

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7
Q

Define phobia

A

Phobia = extreme fear of certain situations or things → causing symtoms of anxiety + panic

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8
Q

Examples of common specific phobias

A
  • Claustrophobia (fear of closed spaces)
  • Acrophobia (fear of heights)
  • Arachnophobia (fear of spiders)
  • Glossophobia (fear of public speaking)
  • Trypanophobia (fear of needles)

Agoraphobia = a fear of situations in which they may be unable to escape if something goes wrong. E.g. this could be a fear of busy places, public transport, or anywhere outside their home.

Social phobia involves a fear of social situations (also called social anxiety disorder).

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9
Q

What questionnaire can assess the severity of generlalised anxiety disorder (GAD)?

A

Generalised Anxiety Disorder Questionnaire (GAD-7)
* It consists of 7 questions

The total score indicates the severity:
* 5-9 indicates mild anxiety
* 10-14 indicates moderate anxiety
* 15-21 indicates severe anxiety

Literally just the condition name with 7 on the end

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10
Q

Management for GAD

A

Mild anxiety:
* Active monitoring
* Self-help strategies (e.g. meditation), sleep, diet, exercise, avoiding alcohol, caffeine and drugs

Moderate-severe anxiety:
* CBT
* Medication

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11
Q

Medication management for GAD

A
  • First line: SSRIs (particularly sertraline) (for GAD + panic disorder)
  • Other options: SNRIs (e.g. venlafaxine), pregabalin
  • Propanolol = a non-selective beta-blocker - used to treat phsycial symptoms → reduce sympathetic nervous system overactivity → improves palpitations, tremors, sweating. Only has short-term effect. Main contraindication = asthma (can cause bronchoconstriction in asthmatic patients)
  • Benzodiazepines (e.g. diazepam) - only in crisis → stimulating GABA receptors (similar effects to alcohol) → relaxing effect on brain. Prolonged use = quickly results in down-regulated GABA receptors → leading to tolerance (reduced effects at same dose) + dependence (significant withdrawal symptoms on stopping)

The NICE guidelines (2020) recommend not offering benzodiazepines for GAD. The exception is using them for a short duration during a crisis, stopping them as soon as possible.

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12
Q

Define depression

A

Depression = a disorder that causes persistent feeling of low mood + low energy + reduced enjoyment of activities

Affects everyone

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13
Q

Pathophysiology of depression

A

Mechanism not fully understood

Involves a disturbance in neurotransmitter activity in the central nervous system - particular serotonin AKA 5-hydroxytryptamine (5-HT)

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14
Q

Causes of depression

A

Can occur with:
* No apparent triggers
* Life events (e.g. loss of loved one)
* Physical health conditions (e.g stroke, MI, MS, and Parkinson’s)

Consider:
* Genetic
* Psychological
* Biological
* Environmental

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15
Q

What are the core symptoms of depression?

A
  • Low mood
  • Anhedonia (lack of pleasure or interest in activities)
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16
Q

Emotional symptoms of depression?

A
  • Anxiety
  • Irritability
  • Low self-esteem
  • Guilt
  • Hopelessness about the future
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17
Q

Cognitive symptoms of depression

A
  • Poor concentration
  • Slow thoughts
  • Poor memory
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18
Q

Physical symptoms of depression

A
  • Low energy (tired all of the time)
  • Abnormal sleep (particularly early morning waking)
  • Poor appetite or overeating
  • Slow movements
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19
Q

Name some environmental factors that contribute to depression

A
  • Potential triggers (e.g. stress, grief or relationship breakdown)
  • Home environment (e.g., housing situation, who they live with and their neighbourhood)
  • Relationships with family, friends, partners, colleagues and others
  • Work (e.g., work-related stress or unemployment)
  • Financial difficulties (e.g., poverty and debt)
  • Safeguarding issues (e.g., abuse)
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20
Q

What are some essential factors to explore when taking a history regarding depression?

A
  • Caring responsibilities (e.g., children or vulnerable adults)
  • Social support
  • Drug use
  • Alcohol use
  • Forensic history (e.g., violence or abuse)
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21
Q

Every encounter of depression should include a risk assessment. What does this involve?

A
  • Self-neglect
  • Self-harm
  • Harm to others (including neglect)
  • Suicide
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22
Q

What questionnaire is used to assess the severity of depression?

A

PHQ-9 Questionnaire
There are nine questions about how often the patient is experiencing symptoms in the past two weeks.

  • 5-9 indicates mild depression
  • 10-14 indicates moderate depression
  • 15-19 indicates moderately severe depression
  • 20-27 indicates severe depression

Like anxiety, below 10 then mild. below 15 then moderate, above then severe

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23
Q

Management of depression

A
  • Active monitiring and self-help
  • Address lifestyle factors (exercise, diet, stress, alcohol)
  • Therapy (CBT, counselling, psychotherapy)
  • Antidepressants (SSRIs = first-line)

NICE recommends: NOT offerring antidepressants first-line to patients with less severe depression (less than 16 on the PHQ-9) - unless they have a preference for taking them

  • Severe or psychotic depression → urgent specialist unput → Crisis resolution + home treatment team (no admission)
  • High risk of self-harm, suicide, self-neglect, immediate safeguarding issue → admission
  • Unresponsive or severe depression: antipsychotic medications (e.g. onlazapine or quetiapine), lithium, ECT
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24
Q

Pyschotic depression involves the symptoms of psychosis. What 3 things does psychosis invole?

A
  • Delusions (beliefs that are strongly held and clearly untrue)
  • Hallucinations (hearing or seeing things that are not real)
  • Thought disorder (disorganised thoughts causing abnormal communication and behaviour)

When psychosis accompanies depression, it generally indicates severe depression, although psychosis can occur with mild or moderate depression.

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25
Treatment for psychotic depression
Combination of **antipsychotics** (e.g. olanzapine or quetiapine) + **antidepressants** Other options: **ECT**
26
Name 3 postnatal mental health issues ## Footnote These occur in a spectrum
* **Baby blues** (seen in the majority of women in the **first week** or so after birth) * **Postnatal depression** (**1 in 10** peak around **3 months** after birth) * **Puerperal psychosis** (**1 in 1000**, starts a **few weeks** after birth)
27
When and how does **baby blues** occur?
* Onset: **Affects more than 50% of women in the first week** or so after birth **Presentation - usually mild, last a few days - will resolve within 2 weeks of delivery**: * Mood swings * Low mood * Anxiety * Irritability * Tearfulness **No treatment required** Baby blues = results from: * Significant hormonal changes * Recovery from birth * Sleep deprivation * Increased responsibility * Difficulty with feeding
28
How does **postnatal depression** present?
* Onset: **3 months after birth** Similar to depression out of pregnancy: * **Low mood** * **Anhedonia** * **Low energy** * Symptoms should last at least **2 weeks before diagnosis** **Treatment = similar to depression** (depending on severity)
29
How and when does **puerperal psychosis present?**
Rare * Onset = **2-3 weeks after delivery** Presentation - **psychosis**: * **Delusions** * **Hallucinations** * **Depression** * **Mania** * **Confusion** * **Thought disorder** Treatment: Urgent assessment + possible admission to **mother + baby unit**, **medications**, **ECT**
30
What is the **screening tool** or **postnatal depression**?
**Edinburgh postnatal depression scale** * Assesses how the mother has felt over the **past week** * 10 questions, score out of 30. * **More than 10 points** = suggests **postnatal depression**
31
Define dementia
Dementia = causes **progressive + irreversible** impairment in memory, cognition, personailty and communication. * Associated with older age * Early-onset dementia = refers to when the symptoms start before 65 y/o.
32
What is mild cognitive impairment?
MCI = a deficit in cognition + memory - that is greater than expected with age, but not significant enough for a dementia diagnosis People with MCI = can usually live independently
33
What is Alzheimers dementia?
* Alzheimers disease = most common type Pathophysiology involves: * Brain atrophy * Amyloid plaques * Reduced cholinergic activity * Neuroinflammation
34
What is vascular dementia?
Vascular dementia = second most common type * **Vascular dementia** = caused by **vascular damage + impaired blood supply to brain** * Risk factors = are the same as other cardiovascular diseases (e.g. hypertension, diabetes, smoking)
35
What is Dementia with Lewy bodies?
Dementia with Lewy bodies = type of dementia associated with features of Parkisonism Symptoms: * Cognitive decline * Visua hallucinations * Delusions * REM sleep disorders * Fluctuating consciousness
36
What is frontotemporal dementia?
Frontotemporal dementia = affects people at a younger age (40-60) * Mainly affects the **frontal + temporal lobes** Initial presentation = involves: * Behaviour * Speach * Language Frontotemporal dementia = can be familial
37
Name some **medications** with an **anticholinergic effect** that could cause cognitive impairment, memory impairment, personality changes? (**Differential diagnosis for dementia**)
Medications with an anticholinergic effect: * **Anticholinergic** urological drugs (e.g., **oxybutynin**, solifenacin and tolterodine) * **Antihistamines** (e.g., chlorphenamine and **promethazine**) * **Tricyclic antidepressants** (e.g., **amitriptyline**)
38
Name some **psyhiatric conditions** that are **differential diagnosis** for **dementia**
* **Depression** * **Psychosis** * **Delirium** (e.g. secondary to infection) ## Footnote (DPD) - delivering mems
39
Name some neurological conditions that are differential diagnosis for dementia
* **Brain tumours** (particularly affecting the frontal lobes) * **Parkinson’s disease** * **Huntington’s disease** * **Progressive supranuclear palsy**
40
Name some endocrine conditions that are differential diagnosis for dementia
* **Hypothyroidism** * **Adrenal insufficiency** * **Cushing's syndrome** * **Hyperparathyroidism** (causing **hypercalcaemia**)
41
What nutritional deficiencies that are differential diagnosis for dementia?
* **Vitamin B12 deficiency** * **Thiamine deficiency** (causing **Wernicke-Korsakoff syndrome**)
42
Name some modifiable risk factors for dementia
* **Exercise** * **Mental stimulation** (e.g., a more mentally challenging job) * **Maintaining a healthy weight** (obesity increases the risk) * **Blood pressure control** (hypertension increases the risk) * **Blood glucose control** (diabetes increase the risk)
43
Info: Dementia
* Symptoms = tend to have a **slow + insidious onset** * Having a collateral history from a close contact such as family member is helpful
44
Name some early symptoms of dementia
* Forgetting events * Forgetting names * Difficult remembering words * Repeatedly asking the same questions * Impaired decision making * Reduced flexibility
45
Name some advanced features of dementia
As the condition progresses, memory and cognitive impairment worsen. Eventually, patients **lose the ability to complete self-care tasks** such as cooking, cleaning, and dressing themselves. * Inability to speak or understand speech (**aphasia**) * Swallowing difficulties (**dysphagia**) → lead to **aspiration** + **pneumonia** * **Appetite + weight loss** * **Incontinence**
46
Name some screening tests for memory + cognition
* Six Item Cognitive Impairment Test (6CIT) * 10-point Cognitive Screener (10-CS) * Mini-Cog * General Practitioner Assessment of Cognition (GPCOG) * Montreal Cognition Assessment (MoCA)
47
What are some investigations that are required to exclude a physical cause before you refer to the memory clinic, when you suspect dementia?
Blood tests: * Full blood count * Urea and electrolytes * Liver function tests * Inflammatory markers (e.g., CRP and ESR) * Thyroid profile * Calcium * HbA1c * B12 and folate Additional tests: * **Mid-stream urine (MSU)** if infection is suspected * **Chest x-ray** (if lung cancer is suspected) (+?pneumonia) Structural pathology: * Imaging (e.g. **MRI brain**)
48
What are the 5 domains that are tested in the ACE-III (comprehensive assessment tool for memory impairment)?
* Attention * Memory * Language * Visuospatial function * Verbal fluency * Less than 88/10 → indicates possible dementia * Even lower → severe impairment
49
What can be put into place in the early stages of dementia to support the patients and carers?
* **Lasting power of attorney** (nominating a person to make decisions on their behalf when they are no longer able) * **Advanced decisions** (around treatments they would want or not want) * **Planning future care** (including places and end-of-life care)
50
What are the 2 medication options for Alzheimer's disease to help improve symptoms?
* **Acetylcholinesterase inhibitors** (e.g. **donepezil, rivastigime**, galantamine) * **Memantine** (blocks NMDA receptors)
51
Name some **behavioural and psychological symptoms of dementia (BPSD)**
* Depression * Anxiety * Agitation * Aggression * Disinhibition (e.g., sexually inappropriate behaviour) * Hallucinations * Delusions * Sleep disturbance
52
Name some of the **initial steps** to manage **BPSD**
* **Treating underlying causes** (e.g., pain, constipation or urinary retention) * **Environmental factors** (e.g., providing a calming setting and removing triggers) * **Appropriately trained carers** * **Appropriate supervision** (one-to-one observation may be required) * **Music therapy**
53
Name some medication options for managing BPSD
* ** SSRI antidepressants** for depressive symptoms * **Antipsychotic drugs** (typically **risperidone = first-line**) * **Benzodiazepines** (only for **crisis management**)
54
Define delirium
**Delirium** = an **acute + fluctuating disturbance** in level of **consciousness, attention, global cognition**
55
Why is delirium so important?
* Prompt treatment = required to avoid **potential brain damage** * The underlying mechanism = poorly understood - but believed to involve **neurotransmitter abnormalities + inflammation**
56
Who does delirium occur in?
Mostly in the **elderly + very young** * It is predicted that 10% of patients over 65 show signs of delirium on admission to hospital. * Affects 15% of in-patients.
57
Signs + symptoms of delirium
**Reduced level of consciousness** **Psychiatric symptoms:** * Disorientation (time/place/person) * Inattention * Illusions/hallucinations * Altered personality * Mood disorders * Speech disorders (slurred speech/aphasic error/chaotic pattern) **Lacking insight** **Symptoms = fluctuate over the course of the day** + tend to be **worse at night** ## Footnote Patients may show signs of hyperactivity (typically in withdrawal states) or lethargy (common in hepatic encephalopathy).
58
Causes of delirium
P - Pain. I - Infection. N - Nutrition. C - Constipation. H - Hydration. E - Endocrine + Electrolyte. S - Stroke. M - Medication and Alcohol. E - Environmental.
59
Causes of delirium
* **CNS**: Stroke, abscess, tumour, subdural haematoma * **Drugs/withdrawal**: Anticholinergics, antiemetics, antipsychotics, corticosteroids, digoxin, opioids, alcohol * **Endocrine**: Hyperparathyrodism, hyper/hypothyroidism * **Infection/injury**: Encephalitis, meningitis, pneumonia, sepsis, UTI, burns, hypothermia * **Metabolic**: Acid-base disturbance, hepatic encephalopathy, uraemia, hypo/hyperglycaemia, electrolyte abnormalities, thiamine/vitamin B12 deficiency * **Other**: Post-operative states, other mental disorders, sleep depravation
60
Delirium vs dementia
Delirium: * Sudden onset + fluctuating course over days - weeks * Variation in level of consciousness * Impaired attention * Psychomotor changes Dementia: * Gradual onset, slowly progressive over months - years * Consciousness unimpaired * Attention preserved
61
Diagnosis of delirium
* **Collateral history**: determine if the changes in mental status are recent and the patients normal level of functioning. * **Drug + aclcohol history**: consider any with CNS effects or new additions as a potential cause * **Mini-mental state examination**: Likely to show **deficits in attention** (e.g. immediate repitation of 3 objects)
62
Diagnostic features of delirium
* **Acute change in cognition** - which **fluctuates** during the day * **Inattention** * **Disturbance of consciousness** * **Disorganised thinking**
63
What 2 things you should examine in a patient that presents with delirium?
* Potential sites of **infection** * **Focal neurological signs** (suggesting a strutural CNS disorder)
64
Treatment of delirium
* Treating the **underlying cause** or **removing aggravating drugs** = principle treatment * **Environmental management**: nurse patients in a quiet and well-lit room. * **Minimise sensory deficits**: check hearing aids/glasses etc * **Agitation** can be managed with **haloperidol** (0.5-1.0mg PO) or **lorazepam** (0.5-1.0mg PO), however, they should be **AVOIDED** as they may **worsen** or **prolong delirium**.
65
Name some symptoms of SSRI withdrawal
* GI symptoms * Restlessness * Mood changes * Insomnia

3a Psychiatry (9 decks)

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