Conditions Flashcards
(100 cards)
1
Q
List the possible aetiology of depression
A
Genetics Early life experience Personality Acute stress Chronic stress Neurobiology (early onset: decrease volume in the hippocampus, late onset: white matter intensely stained on MRI)
2
Q
What are the main abnormalities observed in depression
A
- Overactivity of the hypothalamic-pituitary-adrenal axis
- Deficiency of monamines
- Noradrenaline
- Serotonin
- Dopamine
3
Q
Alternative causes of low mood
A
Chronic disease: MS, Parkinsons, Spinal cord injury, Cushings, Addisions, Thyroid disorders, Malignancy,Chronic pain, Rheumatoid, Renal failure
Medications: Anti-HTN, Steroids, Oral contraceptives, Levadopa, Opiates
4
Q
Name the criteria that measure the severity of depression
A
ICD-10
5
Q
What are the core and other symptoms of depression
A
Core:
- Low mood, present everyday for most of the day
- Anhedonia, diminished interest in all things
- Anergia, decrease concentration, decrease self esteem, ideas of guilt and worthlessness, bleak views of the future, ideas/acts of self harm or suicide, disturbed sleep (early waking), decrease appetite, weight loss, reduced libido
Others:
Low mood not secondary to drugs, alcohol, medication, medical disorder
Significant distress or social impairment, struggling to function
6
Q
Define the levels of depression
A
MILD: 4+ symptoms (2 core + 2 other)
MODERATE: 5+ symptoms (2 core + 3 others) difficulty in carrying out activities of daily living
SEVERE: 7 symptoms (3 core + 4 others) unable to carry out activities of daily living
7
Q
List the possible differentials of low mood
A
Mood disorder (depressive episodes, recurrent illness, dysthymia,bipolar affective diorder)
Schizophrenia (general medical disorder, psychoactive substance use, psychiatric disorder)
Psychotic disorder
Anxiety disorder
Adjustment disorders
Eating disorder
Dementia
8
Q
Treatment approach to depression
A
BIOPSYCHOSOCIAL
Pharmacological:
Moderate to severe depression, first line anti depressants or for persistent sub threshold depression
SSRI’S (Sertraline, Paxoteine,Citolopram,Fluoxetine,)
Choose based on potential side effects, safety overdose, previous good results, cannot give TCA in the case of MI/arrthymias
Psychological: First line for mild depression or in conjunction with antidepressant for moderate depression CBT Interpersonal treatment Psychodynamic therapy Family therapy Mindfullness
Social: Avoid alcohol/drugs Eat healthily Exercise repeatedly Good sleep hygenie
9
Q
Elements of substance dependence
A
Desire or compulsion to take a substance
Difficulties in controlling a substance
Withdrawal symptoms
Signs of tolerance
Persistent use despite clear harm
time spent seeking, taking recovering from substance over ADL
10
Q
Safe units of alcohol for male and female
A
14 units a week
11
Q
Signs of alcohol dependence
A
Palpable liver edge Jaundice Spider navi Ascites Palmer erythema peripheral neuropathy ataxic gait
12
Q
What blood test would you do if you suspected alcohol dependence in a patient and what would you expect to see
A
LFTS:
- Increase in MCV
- Increase in GGT
- Increase in ALP and ASt
- Carbohydrate deficient transferin
**Urinary ethyl-glucourinde
13
Q
Treatment of alcohol dependence
A
BIO Aversive drugs (Disulfiram) inhibits acetalehyde dehydrogenase Increase in acetaldehyde levels Flushings, headaches, nausea and vomiting
800mg reduce to 100-200mg
Anti-craving: Acamprosate (Campral)
thought to work by normalising GABA neurotransmission in the brain
In RCT, patients on acamprosate have increased % remaining abstinent and double
maintanence time
-dose: 666mg td once abstinence is achieved
-indication: those wanting to remain abstinent
-side effects: GI upset, pruritis, rash, altered libido — however, usually well tolerated
PSYCHO
- Motivational interview
- CBT
- Group therapy
- AA
14
Q
What is the pathology of Wernicke encephalopathy
A
Spectrum of disease resulting from thiamine deficiency
Haemorrhages and secondary gloss in the periventricular and the periaquaductual grey matter
Involves mammilary bodies, hypothalamus,mediodorsal thalamuc nuclei
Thiamine is the cofactor required by three enzymes in the pathway of carbohydrate metabolism
15
Q
Signs and symptoms of Wernicke encephalopathy
A
- Acute confusional state
- Ocular (Ophthalmoplegia (6th nerve palsy), Nystagmus)
- Ataxic gait
- Peripheral neuropathy
- Resting tachycardia
- Nutritional deficiency
16
Q
Ke investigations for Wernickes encephalopathy
A
U&Es: exclude hypernatraemia,hypercalcaemia and uraemia. LFTs ABG: rule out hypercapnia and hypoxia Serum thiamine levels Pyruvate (elevated)
17
Q
Treatment of Wernicke Encephalopathy
A
Pharmacological:
-IV pabrinex (high potency B1 replacement)
Avoid carb loading until thiamine replacement is complete
Multivitamin to be given indefinately
Non-Pharm: Alcohol abuse management Assess and reassess memory and intellectual impairment OT assessment of daily living Mental capacitiy
18
Q
Signs and symptoms of Korsakoff’s syndrome
A
- Acute confusional state
- Ocular (Ophthalmoplegia (6th nerve palsy), Nystagmus)
- Ataxic gait
- Peripheral neuropathy
- Resting tachycardia
- Nutritional deficiency
PLUS CONFABULATIONS
Falsification of memory in clear consciousness
Answer questions promptly with inaccurate and bizarre answers
Impairment to laying down new memories
Variable length of retrograde amnesia
19
Q
Patient presents in an acute confusional state having recently started alcohol withdrawal
State the diagnosis
A
Delirium tremens
20
Q
What are the signs and symptoms of delirium tremens
A
Severe agitation Confusion Paranoid delusions Hallucinations (visual, auditory and tactile) Clouding of consciousness Disorientation Amnesia of recent events
Malignant hyperthermia Sweating Tachycardia hypertension Tachypnoea Tremor Mydriasis CV collapse
21
Q
Treatment of delirium tremens
A
ABCD Hypoglycaemia Sedation Benzodiapenies Parbinex 500mg IV Mg to prevent arrthymias
22
Q
Explain alcohol dependence syndrome as per the Edwards &Cross Model?
A
- Narrowing of repertoire
- Increased salience of drinking
- Increased tolerance to alcohol
- Withdrawal of symptoms
- Relief or avoidance of withdrawal symptoms by further drinking
- Subjective awareness of the compulsion to drink
- Rapid reinstatement after abstinence
23
Q
Medical management of the withdrawal of herion
A
1) Methadone: Synthetic opioid, longer half life 24 hours. Less in pregnancy
2) Lofexidine: alpha-2-adrenergic receptor agonist, relieves symptoms of withdrawal.
3) Naltrexone: Long acting opiate treatment, helps with the cravings
24
Q
Explain the triple vulnerability model
A
1) Genetic: neurobiological ( decreased atomic nervous system response, loss of regulatory cortisol)
2) Generalised psychological vulnerability: childhood trauma/ method of parenting, attachment issues
3) Specific psychological vulnerability: traumatic event
25
List the risk factors for suicide
```
Male
LGBT
Prisioners
Single
Unemployment
Occupation
Low socioeconomic status
```
```
Psych illness
Previous self harm
Substance use
Family hx of mental conditions
Recent adverse life events
```
26
Measurements of suicide attempts
Evidence of advanced planing
Precautions taken to avoid discovery
Dangerous/lethal method used
No help sought after the act
27
List the anecdote for the following overdoses
- Paracetamol
- Morphine
- TCA
N-acetylcysteine
Naloxone
IV sodium bicarbonate
28
Clinical features of anorexia
General
- Emaciation
- Lanugo hair
- Brittle hair
- Dry skin
- Dental caries
- Fatigue
- Cold intolerance
- Constipation
- Amenorrhea
Cardio
- Prolonged QT
- Arrhythmias
- Low BP
Endocrine/Metabolic
- Low potassium
- High amylase
- Reduced renal function
- Osteoporosis
29
Diagnostic criteria for anorexia
1. Weight <85% less the predicated for height and weight or BMI <17.5
2. Intense fear of gaining weight or becoming fat with persistent behaviour to prevent weight gain
3. Feeling fat when thin
SCOFF can be used as a screening tool
30
Red flags for anorexia
- BMI <13
- Wt loss >1kg/week
- T<34.5C
- Vascular Bp 80/50, pulse <40, O2<92%
- Limbs blue and cold
- Proximal muscle weakness
- ECG long QT, flat T waves
- Blood K+ <2.5, Na+ <130
31
Treatment of anorexia
```
Psychoeduction about nutrition and weight
Nutritional and weight management
CBT
Family therapy
Psychodynamic psychotherapy
```
32
Discuss the signs and treatment of refeeding syndrome
Potentially fatal condition due to a fall in phosphate
Signs
- Rhabdomyolysis
- Resp or cardiac failure
- Arrhythmias
- Seizures
- Sudden death
Treatment
- Slow referring according to a careful nutrition plan
- Monitor electrolytes ( potassium, Mg, glucose and phosphate)
Prescribe a thiamine complex
33
Define bulimia
1. Recurrent episodes of binge eating characterised by uncontrolled eating
2. Preoccupation with control of body weight
3. Regular use of mechanisms to overcome the fattening effect of binges e.g. starvation, vomit induction
4. BMI >17.5
34
Symptoms of bulimia
General
- Fatigue
- Lethargic
- Feeling bloated
- Constipation
- Oesophagitis
- Cardiomyopathy (laxative use)
- Irregular menstruation
- Erosion of dental enamel
- Russells signs ( callouses on the back of the hands due to teeth marks from vomiting)
```
Metabolic alkalosis
Metabolic acidosis ( if using laxatives)
```
35
List the ICD-10 criteria for diagnosing bulimia
1. Binge eating
2. Strong cravings for food
3. Methods to counter act weight gain
4. Overvalued idea
36
List the differential dx in a patient presenting with psychosis
1. Organic disease
- Delirium
- Delirium tremens
- Metabolic disease
2. Psychoactive substance abuse
- Cannabis
- Mushrooms
- LSD
3. Schizophrenia & schizoaffective disorders & delusional disorders
4. Affective disorders (depression and mania)
37
List the 1st rank symptoms which would lead to a diagnosis of schizophrenia
- 3rd person auditory hallucinations
- Passive delusions (figure controlling patients actions)
- Somatic delusions
- Thought insertion, withdrawal and broadcast.
```
Not 1st rank symptoms
Negative symptoms
- apathy
- blunting of response
- social withdrawal
- self-neglect
- anhedonia
- avolition
```
38
Explain the pathophysiology of schizophrenia
Dopamine theory
Higher occupancy of dopamine receptors
Increase mesolimbic: +ve symptoms
Increase mesocortical: -ve symptoms
39
List the types of schizophrenia
Paranoid: paranoid delusion
Often auditory
Per conceptual disturbance
Hebephrenic: Flattening of affect, aviolation, thought is disorganised , speech is incoherent , hallucinations are fleeting and fragment.
40
Management of schizophrenia
1. Antipsychotics
2. CBT
3. Family intervention
4. Art therapy
41
Define schizoaffective disorders
The presence of an affective disorder and schizophrenia simultaneously (during the same period)
Rx with antipsychotics
42
Types of anti-psychotics and mode of action
**1st generation: D2 antagonist
Cause extra pyramidal side effects
Haloperidol
Chloriproniazine
**2nd generation: 5H2TA and D2 antagonist
Reduced risk of EPSE and increased risk of metabolic
Eg Olanzapine
Risperidone
Zotepine
Amsulperide
**3rd generation
Dopamine partial agonists
Aripiprazole
Clozapine
For treatment resistant schizophrenia, when a patient does not respond to 2 trials of different drugs.
Or
- patient is persistently hostile or suicidal
- a trial of each drug should last 6/52
beaware an increased risk of agranulocytosis
43
Clinical features of bipolar disorder
ICD-10 Criteria
- >2 episodes of of disturbed mood or activity ( complete resolution between episodes)
- Disturbed mood can be
1. Elation of mood, activity and or energy ( hypomania or mania)
2. low mood, activity or energy
- Episode of mania lasting = 4 months
- Episode of depression = 6 months
44
Clinical features of hypomania and mania in bipolar affective disorder
Hypomania ( lesser degree of mania)
- Elevation of mood, activity and energy ( not cyclothymia)
- Symptoms for days - weeks, not so severe they disrupt work or lead to social rejection
- Persistent wellbeing, physical and mental efficieny, increased sociability, talkativeness, sexual disinhibition.
- Decreased need for sleep
- Impaired concentration due to restlessness
- Mild spending
Mania: elation unkeeping with the persons environment
- Last of a week or more
- Carefree joy or over excitability
- Decreased sleep
- Normal social inhibitions are lost
- Distracted and attention can not be maintained
- Self esteem massively inflated (GRANDIOSE IDEAS)
- Perceptual disorders ) over appreciation of colours or textures)
- Overspending
May also be accompanied by psychotic symptoms
- Grandiose ideas ( type of delusion): I AM JESUS
- Suspicions: nihilistic or persecutory delusions
- Flight of ideas
- Pressured speech
- Hallucinations
- Violent excitement
45
Define delusion and list the types of delusions
An unshakeable belief, held on illogical grounds and out of keeping with the patient's culture.
Delusions can be mood congruent ( affective disorder) or mood incongruent ( schizophrenia)
46
Define persecution delusions
Most common type of delusion
| A theme of being followed, spied on, followed.
47
Define infestation delusion
Belief the skin is infested with parasites, causing skin itching ( formation) Common in cocaine withdrawal
48
Define delusional misidentification
Belief that those close to them have been replaced by a double ( Capgras syndrome)
Single person is impersonating multiple people ( Fregoli syndrome)
49
Define a delusion of jealousy
Firm belief a partner is unfaithful without proof (Othello syndrome)
50
Define a delusion of reference
Bizarre unfeasible interpretations EG a dogs bark carries a code
51
Define an hallucination
```
A false perception which has the quality as a real perception but which occurs in the absences of any external stimulus.
Auditory
- First person
- Third person
- Complex
- Elementary
```
Visual
- Not common in psychosis
Pseudohallucination: person knows the stimulus is in their mind
52
Differential diagnosis for bipolar affective disorder
Substance induced mood disorder: blood test confirm high levels of substances
Major depressive disorder ( will not have any mania)
Dysthymic disorder: Depression for 2 yrs
Cyclothymic disorder: Disturbances of mood with hypomania not classifying as mania and depressive episodes not classifying for major depressive disorder.
Patient is rarely symptoms free for 2 months
Psychotic disorders: present without the severe mood symptoms
OCD
ADHD
53
Treatment of acute mania in bipolar disorder
Assess
- cycling speed
- psychotic symptoms
- suicide risk
Moderate/Severe mania
- SGA (Olanzapine, Risperidone)
- Valproate/ Iamotrigine
54
Management of bipolar disorder
1. Lithium carbonate (refer to lithium notes on prescribing)
2. Olanzapine
3. Aripiprazole
4. Iamotrigine
Psychoeducation therapy: reduces relapse rates, improves therapy compliance & social functioning.
Lack sleep is key
BAD is a lifelong condition
55
Risk factors for suicide in BAD
```
Previous suicide attempt
Family history
Early onset of bipolar disorder
Extent of depressive symptoms
Increasingly bad affective signs
Rapid cycling
Abuse of alcohol or drugs
```
56
Defining features of neurological malignant syndrome and serotonin syndrome
```
TRIAD
- Neuromuscular abnormalities
- Altered consciousness
- Autonomic dysfunction
(Hyperthermia, sweating, tachycardia, unstable blood pressure)
```
57
List the blood results commonly found in NMS and SS
Increased creatine kinase
Increased WCC
Increased hepatic transaminase
METABOLIC ACIDOSIS
58
List the neuromuscular abnormalities found in NMS
Reduced activity
Rigidity
Bradyreflexia
59
List the neuromuscular abnormalities found in SS
Clonus
Hyperreflexia
Tremor
Slight muscular rigidity
60
Treatment of NMS
Bromocryptine
| Dantrolone
61
Treatment of Serotonin Syndrome
Cyproheptadine
62
Define depression
Low mood persisting for >2 weeks without the causes such as bereavement or organic disease ( hypothyroid/drug induced)
63
Risk factors for depression
```
Female
Pregnancy/postnatal period
Asian/ Afrocarribean
Asylum seeker/ refufee descent
Past medical history of mental health illness
Chronic disease
```
64
List the clinical features of depression, dividing them into core, biological and other symptoms
CORE
- Low mood
- Anhedonia
- Low energy
BIOLOGICAL
- Sleeplessness ( early morning waking)
- Loss of concentration
- Reduced appetite
- Reduced weight
- Constipation
- Irritability
- Loss of libido
- Psychomotor retardation
- Reduced apathy
- Anxiety
- Suicidal thoughts
OTHER
- Feeling of guilt ( past)
- Feelings of worthlessness (present)
- Hopelessness/ Low self esteem ( future)
65
Classify the levels of depression
Mild
- 2 core + 2 others
Moderate
- 2 core + 3 others
Severe
- 3 core + 4 others
66
Differential diagnosis for depression
Organic disease
- Hypothyroidism
- Drug induced
- Dementia
- Bereavement
Functional psychotic disorders
- Bipolar affective disorder
- Depression with psychotic symptoms
Seasonal Affective Disorder
Associated disease
- Dysthymia
- OCD
- Parkinsons
- Hyperthyroid
- Eating disorders
- PTSD
- Anxiety disorders
- Personality disorders
67
Management of mild- moderate depression
Low intensity psychological interventions
Not all patients are suitable for psychological interventions
- Sleep hygiene
- Exercise
- Self help books
- CBT ( computerised or IAPT)
Unsuccessful refer for
- Interpersonal activation
- Behavioural activation
- Psychodynamic therapy
Beware of social management
- Accommodation
- Money
- Relationships
68
Management of moderate to severe depression
```
Antidepressants
Contraindicated in substance misuse
Not suitable in adjustment disorder
1. SSRI
2. Different SSRI
3. TGA/ SNRI
4. Lithium ( recurrent or resistant depression)
```
Do not give TGA in suicidal people are overdose will kill.
69
Diagnostic criteria for severe depression
Persistent low mood or anhedonia for >2 weeks
1. Suicide plan or ideas of self harm
2. Unexplained guilt or worthlessness
3. Inability to function ( psychomotor retardation)
4. Concentration impaired
5. Decreased sleep/early waking
6. Energy low/ unaccountable fatigue
70
Criteria for ECT as a treatment for depression
Severe life threatening, treatment resistant depression
CONSISTS OF
- x2 weekly ECT
- Short acting GA and muscle relaxant
71
Define self harm and suicide
Self harm: intentional act done with knowledge that it may be harmful
Suicide: Act of intentionally and successfully ending one's life
72
Risk factors for suicide
```
Male
LGBT
Prisoners
Single
Unemployment
Occupation ( farmer/vet/nurse)
Poor
Previos history of self harm
Substance use
Recent adverse life events
```
73
Key areas which highlight suicide intent
1. Advanced planing
2. Precautions taken to avoid discovery
3. Dangerous method used
4. N help sought after the act
74
Clinical features of postnatal depression
```
Low mood
Anhedonia
Anergia
Preoccupying thoughts to do with the baby
Infanticidal thoughts
```
75
Treatment of postnatal depression
Low threshold for referral to hospital
CBT
Antidepressants
76
Clinical features of puerperal psychosis
```
Insomnia
Restlessness
Suspiciousness
Marked psychosis
Patients retain a degree of insight
```
77
Treatment of puerperal psychosis
```
Assess risk of infanticide and suicide
Hospitalisation ( mother and baby unit)
Antipsychotics
Antidepressants
Mood stabilisers
If needed Benzos
```
78
Clinical features of anxiety
ICD 10 >4 symptoms
Cognitive
- Agitation
- Feelings of impending doom
- Poor concentration
- Insomnia
Somatic
- Tension
- Trembling
- Headache
- Sweating
- Palpitations
- Vomiting
Behaviour
- Reassurance seeking
- Avoidance
79
Treatment of anxiety
Symptom control
- Listening
- Beta blockers
Exercise
CBT
Meditation
Medication
- Avoid benzos if possible
- Try SSRI
80
Diagnostic criteria for PTSD
1 month = adjustment disorder
6 months = PTSD
```
Avoidance
Intrusions
Hypersensitivity ( to stimuli)
Stresor ( identifiable)
Negative alteration in mood and cognition
```
81
Management of PTSD
CBT
EMDR ( eye movement and desensitisation reprocessing)
SSRI (Paroxetine)
82
Define obsessions and compulsions
Obessions: sterotyped purposeless words, ideas or phrases that come into the mind
Compulsions: senseless repeated actions/rituals.
NOT DELUSIONAL BELIEFS
83
Treatment of OCD
CBT
SSRIs
Clomipramine ( 25mg OD) TGA
84
Briquets syndrome
Chronic medically unexplained symptoms, affecting any body part, multiple medically unexplained symptoms.
Difficult to treat.
Psychological causes
85
Hypochondrial syndrome
Misinterpretation of normal body sensations on illness
| Refusal to accept reassurance that they are fine
86
Body dysmorphic disorder
Patients are preoccupied with an imagined or minor defect in their physical appearance
87
Diagnostic criteria for personality diorders
Disharmonious attitudes and behaviour, involving several areas of functioning
Chronic abnormal behaviour patterns
Present in a broad range of personal and social situations
Manifestations < 18
Considerable personal distress
88
List the different types of personality disorders
Cluster A
- Paranoid
- Schizoid
Cluster B
- Histronic
- Narcissitic
- Dissocial
- Emotionally unstable personality disorder
Cluster C
- Obessive compulsive disorder
- Anxious
- Dependent
89
Features of a paranoid/delusional PD
Sensitive
Easily offended
Suspicious
90
Features of a schizoid PD
Socially withdrawn
No pleasure from activities
Emotional coldness
Indifferent to praise or criticism
91
Features of a histrionic PD
Self dramatisation
Easily influenced
Attention seeking
92
Features of a narcissistic PD
Increased self importance
Lack empathy
Grandiose ideas
Need attention
93
Features of a discoidal/antisocial PD
Agressive/ easily frustrated
Callous lack of concern for others
Cannot maintain relationships
Lack of guilt
94
Features of an emotionally unstable PD
```
Impulsive
Irresponsible
Impulsive
Unable to control emotions
Unpredictable behaviour
```
95
Features of an OCD PD
Worries
Doubts
Control
Ordiness
96
What does ICD-10 define as a learning disability
IQ <70
Onset is pre <18
Development >18 : chronic brain injury
97
Downs syndrome
```
I in 600
Increase risk with increase maternal age
Increase risk of Alzheimer's disease
Extra Chromosome
47, XX (+21)
```
98
Foetal alcohol syndrome
```
Smaller patients
Pointy face
Preventable causes of LD
Growth retardation
Facial dysmorphia
( small head, low nasal bridge, epicanthic fold)
```
99
Autism spectrum disorder
```
Affects all abilities
Lack of social instinct
- Social interaction
- Communication
- Imagination
Inflexible thinking
Rigid routines
Dislikes change
Special interests
```
100
Aspergers syndrome
```
Sensory distortion
Perceptual disorientation
Executive function difficulties
Central coherence
Inflexible thought/ action
```
