Deck 7 Flashcards
(95 cards)
1
Q
What is self harm?
A
An intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act. It is usually an expression of emotional distress
2
Q
What are the different forms of self harm?
A
Self-poisoning 90% Self injury (cutting, burning, slashing) 10%
3
Q
What’s the incidence of self harm?
A
2 in 1000
4
Q
What’s the male to female ration of self harm?
A
1:1.5, more common in female
5
Q
What’s the peak incidence of SH?
A
Males 20-24 years
Females 15-19 years
6
Q
What are the risk factors for self harm?
A
DSH Largely Comes Via Self-Poisoning
Divorced/single/living alone Severe life stressor Harmful drug/alcohol use Less than 35 Chronic physical health problems Violence (domestic) or childhood maltreatment Socioeconomic disadvantage Psychiatric illness e.g depression, psychosis
7
Q
What proportion of people have consumed alcohol within 6 hours prior to the act?
A
50% of men
25% of women
8
Q
What are 2 common complications?
A
Permanent scarring of skin and damage to tendons and nerves
Acute liver failure
9
Q
What are possible motives for self harm?
A
DRIPS
Death wish Relief Influencing others Punishment to oneself Seeking attention
10
Q
What symptom of psychosis might cause SH?
A
Command hallucinations
11
Q
What investigations would you do after someone has self-harmed?
A
Bloods
- paracetamol levels (accurate between 4 and 15 hours after ingestion)
- salicylate levels if suspected OD
- U&Es (renal function)
- LFTs and clotting (synthetic hepatic function)
Urinalysis for possible toxicological analysis
CT head for intracranial cause for altered consciousness is suspected
LP if intracranial infection is suspected
12
Q
DDx for SH
A
Head trauma Intracranial haemorrhage Intracranial infection Metabolic abnormalities (hypoglycaeia) Liver disease Clotting disorders
13
Q
Management for self harm
A
- Acute: antidotes, suturing
- Risk assess for suicide risk and further SH (MHA s2?)
- Treat other psychiatric disorder that predispose SH
- Manage psychosocial needs, refer to drug/alcohol service, financial and occupational rehabillitation
- Arrange follow up and remove means of SH
Biological (use mental capacity act if refuse treatment)
- antidote
- suturing
- treat other psychiatric condition
Psychological
- counselling and CBT for underlying depressive illness
- psychodynamic therapy if PD present
Social
- social service input
voluntary organizations (samaritans, mind)
Follow up within 48 hours of discharge
14
Q
What proportion of people who come to A&E after self harm will harm again the following year?
A
1 in 6
15
Q
When can activated charcoal be used in overdose?
A
If it is given within one hour of ingestion
16
Q
What are protective factors against suicide?
A
- children at home
- pregnancy
- strong religious beliefs
- belief that suicide is immoral
- social support
- positive coping skills
- positive therapeutic relationship
- supportive living arrangement
- life satisfaction
- fear of the physical act of suicide
- fear of disapproval by society
- responsible for others
- hope for the future
17
Q
Risk factors for suicide
A
I’M A SAD PERSON
Institutionalized
Mental health disorder (schizophrenia, substance misuse, PD)
Medical illness (disabling, painful or terminal)
Alone (single, widowed, separated, divorced)
Sex (male) 3 x more likely than females
Age (middle) 40-44 males
Abuse as a child
Depression, death (bereavement)
Previous attempt
Ethanol use
Rational thinking lost
Sickness
Occupation (vets, doctors, nurses, farmers)
No Job
18
Q
What increases the risk of suicide following self harm?
A
Note: Planned Attempts Are Very Frightening
- note left behind
- planned attempt of suicide
- attempts to avoid discovery
- afterwards help was not sort
- violent method
- final acts: sorting out finances, writing a will
19
Q
What investigation could you do to see how suicidal someone is?
A
TASR (tool for assessment of suicide risk)
Beck suicide intent scale
20
Q
When do you refer a person to secondary care for patient at risk of suicide?
A
Considered if:
- suicidal ideation clearly stated
- underlying psychiatric illness is severe
- social support lacking
- presentation change for an individual who has repeatedly self harmed
21
Q
Following discharge from hospital for attempted suicide who should be involved?
A
Crisis resolution and home treatment team
22
Q
Define delirium
A
An acute, transient, global organic disorder of CNS functioning resulting in impaired consciousness and attention.
23
Q
What are the types and frequency of delirium?
A
Hypoactive 40%
Hyperactive 25% (agitation, irritability, restless, aggression, hallucinations, delusions)
Mixed 35%
24
Q
Aetiology of delirium
A
HE IS NOT MAAD
Hypoxia (resp failure, MI, cardiac failure, PE)
Endocrine (hyper/hypothyroidism, hyper/hypoglycaemia, cushings)
Infection (pneumonia, UTI, encephalitis, meningitis)
Stroke and other intracranial events (stroke, raised ICP, intracranial haemorrhage, SOL, head trauma, epilepsy (post-ictal), intracranial infection)
Nutritional (decreased thiamine, nicotinic acid, vit B12)
Others (severe pain, sensory deprivation, relocation, sleep deprivation)
Theatre (post operative period- anaesthetic, opiate analgesics)
Metabolic (electrolyte disturbance- hypogatraemia, hepatic/renal impairment)
Abdo (faecal impaction, malnutrition, urinary retention, bladder catheterization.
Alcohol (intoxication, withdrawal DT)
Drugs (benzos, opioids, anticholinergics, anti-parkinsonian medications, steroids)
25
What proportion of inpatients that experience delirium have dementia?
2/3
26
What proportion of patients above 65 years old are delirious on admission to hospital?
15%
27
What's the ICD-10 criteria for delirium?
- impairment of consciousness and attention
- global disturbance in cognition
- psychomotor disturbance
- disturbance of sleep-wake cycle
- emotional disturbances
28
Investigations for delirium
- ABC
- check vital signs
- nutritional and hydration status
- CV, resp, abdo and neuro examination
- urinalysis (UTI)
- FBC (infection)
- U&Es (electrolyte disturbance)
- LFTs (alcoholism, liver disease)
- calcium (hypercalcaemia)
- glucose
- CRP
- TFTs
- B12, folate, ferritin
- ECG
- CXR (infection)
- infection screen (blood, urine culture)
If required:
- ABG (hypoxia)
- CT head
- LP (meningitis)
- EEG (epilepsy)
Diagnostic:
- AMT
- confusion assessment method (CAM)
- MMSE
29
Differential diagnosis for delirium
- dementia
- mood disorders
- late onset schizophrenia
- dissociative disorders
- hypo/hyperthyroidism
30
What are the questions in an AMT?
1. age
2. time to nearest hour
3. recall address at end
4. what year is it?
5. where are you right now?
6. identify 2 people
7. what is your DOB?
8. Date of first world war
9. who is the current monarch?
10. count backwards from 20 to 1
More than or equal to 8 indicates that cognitive impairment is unlikely.
31
What does the CAM involve?
Confusion assessment method to diagnose delirium
Diagnosis involves the presence of 1 and 2 + either 3 or 4.
1. acute onset and fluctuating course
2. inattention
3 disorganized thinking
4. alteration in consciousness
32
How do you manage delirium?
Treat the underlying cause
Reassurance and re-orientation
- reassure patients to reduce anxiety and disorientation
- remind patients of time, place, day and date regularly
Provide appropriate environment
- quiet, well-lit side room
- consistency in care and staff
- reassuring nursing staff
- encourage presence of friend or family member
- optimize sensory acuity e.g glasses, orientation aids (clock, calendar)
Managing disturbed, violent or distressed behaviour
- encourage oral intake
- verbal and non-verbal de-escalation techniques
- oral low dose haloperidol (0.5-4mg) or olanzapine (2.5-10 mg)
- avoid benzos unless alcohol withdrawal
33
Define dementia
A syndrome of generalized decline of memory, intellect and personality without impairment of consciousness, leading to functional impairment.
34
What are the common types of dementia?
```
Alzheimer's disease 50%
Vascular dementia 25%
Dementia with Lewy bodies 15%
Fronto-temporal dementia <5%
Other causes <5%
```
35
What's the cause of Alzheimer's disease? What are the microscopic and macroscopic features?
Degeneration of cholinergic neurons in the nucleus basalis of Meynert leading to a deficiency of acetylcholine.
Microscopic:
- Neurofibrillary tangles (intracellularly)
- Beta-amyloid plaque formatin (extracellularly)
Macroscopic
- Cortical atrophy (commonly hippocampal)
- Widened sulci and enlarged ventricles.
36
Where is the nucleus basalis? What are the other names?
The nucleus basalis, also known as the nucleus basalis of Meynert or nucleus basalis magnocellularis, is a group of neurons located mainly in the substantia innominata of the basal forebrain.
37
What are the causes of dementia?
Irreversible:
- Neurodegenerative (AD, fronto-temporal dementia, Pick's disease, dementia with Lewy bodies, Parkinson's disease with dementia, Huntington's disease.
- Infections (HIV, encephalitis, syphilis, CJD)
- Toxins (alcohol, barbituarates, benxos)
- Vascular (VaD, multi-infarct dementia, CVD)
- Traumatic head injury
Reversible
- Neurological (normal pressure hydrocephalus, intracranial tumours, chronic subdural haematoma)
- Vitamin deficiencies (B12, folic acid, thiamine, nicotinic acid (pellagra).
Endocrine (cushing's syndrome, hypothyroidism)
38
What causes vascular dementia and what are the clinical features?
Occurs as a result of cerebrovascular disease, either due to stroke, multi-infarcts (multiple smaller unrecognized strokes) or chronic changes (arteriosclerosis) in the small vessels.
Clinical features;
- usually presents in late 60s/early 70s
- stepwise rather than continuous deterioration
- memory loss
- emotional (depression, apathy) and personality changes (earlier than memory loss)
- confusion
- neurological symptoms or signs
- on examination there may be focal neurology (often upper motor neurone signs) and signs of CV disease elsewhere.
39
What causes Lewy body dementia (LBD) and what are the clinical features?
Abnormal deposition of a protein (Lewy body) within the neurons of the brainstem, substantia nigra and neocortex. Outside the brainstem LBs are associated with more profound cholinergic loss than in AD. Within the brainstem, they are associated with dopaminergic loss and parkinsonian-like symptoms.
Clinical features:
- day to day fluctuations in cognitive performance
- recurrent visual hallucinations
- motor signs of parkinsonism (tremor, rigidity, bradykinesia)
- recurrent falls, syncope, depression
- severe sensitivity to neuroleptic drugs (antipsychotics)
40
When are patients diagnosed as having parkinson's disease with dementia rather than DLB?
If the parkinson's disease was present for 12 months without dementia.
41
What causes fronto-temporal dementia and what are the clinical features?
Atrophy of the frontal and temporal lobes of the brain.
One type is Pick's disease where protein tangles (Pick's bodies) are seen histologically.
Clinical features
- usually occurs between 50-60 years and develops insidiously
- FH in 50%
- early personality changes e.g disinhibition, apathy/restless
- worsening of social behaviour
- repetitive behaviour
- language problems (finding words, problems naming/understanding words)
- memory is preserved in early stages whereas insight is lost early
42
What are the features of cortical dementia?
```
Memory loss: severe
Mood: normal
Speech and language: early aphasia
Personality: indifferent
Coordination: normal
Praxis: apraxia
Motor speed: normal
```
43
What are the features of subcortical dementia?
```
Memory loss: moderate
Mood: low
Speech and language: can be dysarthria
Personality: apathetic
Coordination: impaired
Praxis: normal
Motor speed: slow
```
44
What proportion of people have dementia?
5-10% of >65 year olds
| 20% if over 80
45
Is dementia more common in men or women?
Overall similar prevalence.
AD more common in women
VaD more common in men
46
What are the risk factors for AD?
- Advancing age
- FH (lifetime risk of AD in first degree relatives is 25-50%)
- Genetics
- presenilin 1 (chromosome 14) associated with early onset
- presenilin 2 (chromosome 2) associated with early onset
- amyloid precursor protein (chrosome 21) associated with early onset
- ApoE-4 (chromosome 19) is a susceptiility gene that contributes to late onset AD
- ApoE-2 is thought to be protective
- Down's syndrome (trisomy 21 associated with pre-senile AD)
- low IQ
- Cerebrovascular disease is a strong risk factor for VaD which can co-exist with AD
- vascular risk (past stroke/MI, smoking, hypertension, diabetes, high cholesterol)
47
What's the ICD10 criteria for dementia?
A. Evidence of the following:
1. A decline in memory, which is most evident in the learning of new information, although in more severe cases, the recall of previously learned information may also be affected.
2. A decline in other cognitive abilities, characterized by deterioration in judgement and thinking, such as planning and organizing, and in general processing of information.
B. Preserved awareness of the environment for a period of time long enough to demonstrate (A)
C. A decline in emotional control or motivation or a change in social behaviour, manifested by one of the following:
1. emotional lability
2. irritability
3. apathy
4. coarsening of social behaviour
D. For a confident diagnosis (A) must have been present for at least 6 months
48
What are the progression stages of AD?
Early stages
- memory lapses
- difficulty finding words
- forgetting names of people/places
Disease progression
- apraxia
- confusion
- language problems
- difficulty with executive thinking
Later stages
- disorientation to time and place
- wandering
- apathy
- incontinence
- eating problems
- depression
- agitation
49
When AD classified as pre-senile or early onset?
<65 years
50
What's the most common presenting problem of AD?
Loss of memory
Initially there is inability to recall new info, and remote memory (long term memory) declines with disease progress
51
What are the features of AD?
- loss of memory (short term first)
- disorientation to time and place (closely related to memory impairment
- impairment of cognitive and executive functions:
• executive functions (problem solving, abstract thinking, reasoning, decision making, judgement, planning, organization and processing)
• visuospatial abilities (getting lost, impaired driving, copying figures)
• language disturbances (dysphasia): word finding difficulties, decreased vocab, perseveration, global aphasia (impairment of language, affecting the production or comprehension of speech and the ability to read or write)
• apraxia (inability to carry out previously learned purposeful movements despite normal coordination and strength e.g buttons)
• agnosia (impaired recognition of sensory stimuli not attributed to sensory loss or language disturbance
```
- non-cognitive symptoms:
• perceptions (hallucinations)
• thought content (delusions)
• emotion (depression, apathy)
• behaviour (wandering, aggression, restlessness)
```
52
What is huntington's disease?
- autosomal dominant
- abnormal choreiform movements of face, hands and shoulders and abnormal gait
- dementia presents later
53
What's the age of onset and presentation of normal pressure hydrocephalus?
- age 70
- Triad of:
• dementia with prominent frontal lobe dysfunction
• urinary incontinence
• gait disturbance (wide)
54
What's the usual age of onset for CJD?
What's the prognosis?
What are the clinical features?
Before 65 years
Rapid progression and death within 2 years
Clinical features:
- disintegration of virtually all higher cerebral functions
- dementia associated with neurological signs (pyramidal, extrapyramidal, cerebellar)
55
Which areas are impaired in dementia?
```
Memory
Cognition
Language
Executive functioning
Personality
```
56
Which type of dementia is associated with low mood?
VaD
57
Investigations for dementia
```
Blood tests:
• FBC (infection, anaemia)
• CRP
• U+Es (renal disease)
• calcium (hypercalcaemia)
• LFTs (alcoholic liver disease)
• glucose
• vit B12 and folate deficiencies
• TFT
```
If indicated:
- urine dip
- CXR
- syphilis serology and HIV testing
- brain imaging (CT scan, MRI identifies posterior circulation vascular pathology with greater sensitivity)
- ECG if CV disease suspected
- EEG if fronto-temporal lobe dementia or CJD suspected
- LP if meningitis or CJD suspected
- Genetic testing for HD
- cognitive assessments
58
DDx for dementia
- normal ageing and mild cognitive impairment
- delirium
- trauma: stroke, hypoxia, brain injury
- depression/pseudodementia
- late onset schizophrenia
- amnesic syndrome
- learning disability
- substance misuse
- drug side effects: opiates, benzos
59
When is brain imaging indicated for suspected dementia?
- <60 years
- sudden decline
- risk of structural pathology
- focal CNS signs or symptoms
- monitor disease progression
60
What are the frontal lobe tests?
- verbal fluency and initiation (e.g how many words beginning with s can you say within a minute
- cognitive estimates (ask questions they are unlikely to know but which they can have an educated guess)
- clock drawing test
- similarities (conceptualization): ask how 2 objects are similar
- motor sequencing
61
How do you manage dementia?
Initial:
- community dementia teams
- information and education for patients and their families
- supportive treatment to promote independence and maintain function (e.g OT to assess home safety)
- environmental control measures (e.g motion sensors for patients at risk of wandering)
- social support (e.g Alzheimer's society)
- after diagnosis patients must inform DVLA. May be able to continue driving with annual reviews.
- discuss advanced planning prior to cognition deteriorating (advance statements or decisions, lasting power of attorney, care plans)
Pharmalogical treatment:
- cognitive enhancement (AChE inhibitors)
- treat agitation
- treat low mood and insomnia
- functional support
- social support
- support carers
Vascular: target CV risk factors
Later
- may have to use mental capacity act
- increasing assistance with day-to-day activities
- home nursing and personal care
- community services e.g meals on wheels, befriending, day centres, respite care and care homes
62
What pharmacological management is available for dementia?
For mild to moderate Alzheimer's disease (can also be used in dementia with Lewy body where non-cognitive symptoms cause distress):
- Three acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine)
Memantine (NMDA receptor antagonist) is used in:
- moderate Alzheimer's disease in those who are intolerant or have a CI to AChE inhibitors
- severe AD
Antipsychotics (e.g risperidone) for behaviour challenges
Antidepressants (e.g sertraline) for low mood
63
What scan can be done for Lewy body dementia?
DAT scan
64
What medications can be used for Lewy body dementia?
Rivastigmine
L-dopa
Antipsychotics
65
Where do acetylcholinesterase inhibitors act?
They compensate the depletion of ACh in the cerebral cortex and hippocampus
66
When are the use of acetylcholinesterase inhibitors cautioned?
- Arrhythmias (sick sinus syndrome, SV conduction problems)
- Peptic ulcer disease
- asthma/COPD
67
When is galantamine contraindicated?
Severe renal or hepatic impairment
68
What are the side effects of the acetylcholinesterase inhibitors?
- GI disturbances
- bradycardia
- muscle spasms
Rivastigmine:
- extrapyramidal side effects
69
What are the early signs of lewy body dementia?
- falls
- syncope
- black outs
- vivid dreams
70
What are the main differences between autism and Asperger's syndrome?
Both:
- abnormal social interaction
- repetitive interests and behaviours
Asperger's:
- no impairment in language or cognition
- normal IQ
71
What's the condition?
Severe, progressive disorder starting early in life. Language impairment, repetitive stereotyped hand movements, loss of fine motor skills, irregular breathing and seizures. Mostly in girls
Rett's syndrome
72
What gene is implicated in Rett's syndrome
MECP2
73
What's the condition?
Two years of normal development followed by loss of previously learned skills and cognitive deterioration
Childhood disintegratve disorder (Heller's syndrome)
74
What's the first line treatment for challenging behaviour in autism?
Modification of the environment.
Antipsychotics (risperidone) if psychosocial interventions are insufficient
75
Is hyperkinetic disorder more common in males of females?
3 x more common in males
76
What is the normal age of onset of hyperkinetic disorder?
3 to7
77
What is the heritability of hyperkinetic disorder?
70%
78
What are the core symptoms of hyperkinetic disorder?
Inattention
Hyperactivity
Impulsiveness
79
What duration of behaviour is necessary to diagnose hyperkinetic disorder?
6 months
80
What's the treatment for hyperkinetic disorder in school-goers?
- psychoeducation and CBT
- if severe methylphenidate
- if methylphenidate is not working try atomoxetine, then dexamfetamine
Side effects of drugs:
- headache
- insomnia
- loss of appetite and weight loss
81
What triad must be present for a learning disability?
1. low intellectual performance (IQ <70)
2. onset at birth or during early childhood
3. wide range of functional impairment
82
What are the categories of learning disability?
Mild IQ 50-70, mental age 9-12
Moderate IQ 35-39, mental age 6-9
Severe IQ 20-34, mental age 3-6
Profound IQ <20, mental age of <3
83
What's the prevalence of LDs?
2%
85% mild
10% moderate
5% severe or profound
84
What's the ration of M:F LD?
3:2
85
What's the most common risk factor for a LD?
FH
86
What are the physical disorders associated with LD?
- motor disabilities (ataxia, spasticity)
- epilepsy
- impaired hearing and/or vision
- incontinence
87
What medical problem is associated with fragile X syndrome?
Mitral valve prolaps
88
What's the condition?
Deletion of part of chromosome 15.
Hypotonia, developmental delay, obesity, hypogonadism, behavioural problems
Prader-Willi
89
What's the condition?
Partial deletion of chromosome 5.
High-pitched cry. Low birth weight and feeding difficulties.
Cri du chat
90
What's triple and quad tests for downsyndrome?
Triple:
- nuchal thickness
- B-HCG
- PAPPA
Quad:
- Inhibin A
- B-HCG
- oestradiol
- AFP
91
What are the TORCH infections?
```
Toxoplasmosis
Other (HIV, hepatitis viruses, varicella, parvovirus)
Rubella (German measles)
Cytomegalovirus
Herpes simplex
Syphilis
```
92
What are behavioural therapies based on? What are the types of behavioural therapes?
Operant conditioning
- relaxation training (stress and anxiety)
- systemic desensitization (phobic anxiety disorders, gradually exposed to a hierarchy of anxiety producing situations, e.g think about spider, see a picture, see spider in glass, see it outside glass, touch it)
- flooding (continued exposure until anxiety diminishes, not commonly used)
- exposure and response prevention, ERP (OCD, phobias)
- behavioural activation (depressive illness, realistic achievable plans to carry out activity)
93
What is psychoeducation?
Deliver info to patient to help them manage their condition.
1. name and nature of their illness
2. likely cause
3. what health service can do to help
4. what they can do to help
94
What is interpersonal therapy and when is it used?
- used to treat depression and eating disorders
- focus is on an interpersonal problem such as complicated bereavement, relationship difficulties or interpersonal deficit
95
What is dialectical behavioural therapy and when is it used?
- Borderline PD
- the therapy adopts components of CBT and also provides group skills training to provide the individual with alternative coping strategies when faced with emotional instability.
