PSYCH Flashcards
(338 cards)
1
Q
MENTAL HEALTH ACT 1983
What does the main part of the MHA allow for?
A
- ‘Sectioning’ = compulsory admission to hospital for those that are mentally ill.
- Drs should persuade pts to come in voluntarily if they have capacity, but not always possible (esp if they lack insight)
2
Q
MENTAL HEALTH ACT 1983
What are the main principles of the MHA?
A
- Respect for pts wishes + feelings (past + present)
- Minimise restrictions on liberty
- Public safety
- Pts well-being + safety
- Effectiveness of treatment
3
Q
MENTAL HEALTH ACT 1983
What is does an individual have to show to be sectioned?
A
- Evidence of MH disorder
- Evidence they’re serious risk to self, safety or others
- Evidence there is good reason to warrant attention in hospital
- Appropriate treatment must be available for a S3
4
Q
MENTAL HEALTH ACT 1983
What is a…
i) section 12 approved dr?
ii) approved mental health professional?
A
i) ≥ST4 Dr who has done extra training in MH to get S12 approved to section pts
ii) AMHPs are often social workers who have done extra training in MH
5
Q
MENTAL HEALTH ACT 1983
Who can remove sections?
A
- Consultant psychiatrist
- MH review tribunal (MHT) if pt disagrees w/ section
- Nearest relative can make an order to discharge pt from hospital with 72h written notice
6
Q
MENTAL HEALTH ACT 1983
If a relative requests a section removal how can the clinician respond if they disagree?
A
- Issue a barring report within 72h which stops discharge up to 6m from then
- Can still apply to MHT if disagrees
7
Q
MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 2?
A
P – admission for assessment, treatment can be given w/out consent
D – 28d, cannot be renewed, can be converted to S3
L – anywhere in community (airports, jail, A+E, etc)
Prof – 2 Drs (1x S12), 1 AMHP, or nearest relative
8
Q
MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 3?
Who is involved if a pt is medicated without consent?
A
P – admission for treatment
D – 6m, can be renewed
L – anywhere in community
Prof – 2 Drs (1x S12), 1 AMHP, nearest relative
Second opinion appointed doctor (SOAD) – after 3m SOAD reviews if medication w/out consent is necessary
9
Q
MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved, evidence needed for a Section 4?
A
P – emergency order
D – 72h
L – anywhere in community
P – 1 S12 Dr, 1 AMHP, nearest relative
E – same as S2 but only in an urgent necessity when waiting for a second dr (for a S2) would lead to undesirable delay/outcome
10
Q
MENTAL HEALTH ACT 1983
Where can you apply a S5?
What can the team not do?
A
- Voluntary pt in hospital that wants to leave (NOT A+E as not admitted)
- Coercively treat the pt
11
Q
MENTAL HEALTH ACT 1983
What is the purpose, duration + professionals involved for a Section 5(2)?
A
P – Drs holding power, allows for S2/3 assessment
D – 72h
Prof – 1 Dr (usually in charge of their care or nominated deputy
12
Q
MENTAL HEALTH ACT 1983
What is the purpose, duration + professionals involved for a Section 5(4)?
A
P – nurses holding power until Dr attends to assess
D – 6h
Prof – 1 registered nurse
13
Q
MENTAL HEALTH ACT 1983
What are the 2 police sections and their differences? What is the duration and purpose of these?
A
- S135 – needs magistrates court order to access pts home + remove them
- S136 –person suspected of having mental disorder in a public place
D – 24h (extend to 36h if intoxicated but should be seen sooner)
P – taken to place of safety (local psych unit, police cell) for further assessment
14
Q
ECT
What are the reasons why ECT can be done?
When is electroconvulsive therapy (ECT) recommended?
A
- Rapid improvement of severe Sx after adequate trial of other Tx proven ineffective and/or condition potentially life threatening
- Severe mania or depression, suicide risk, catatonia, Rx resistant psychosis
15
Q
ECT
What are some contraindications to ECT?
A
- NO absolute, all relative
- General anaesthesia (reactions)
- Cerebral aneurysm
- Recent MI, arrhythmias
- Intracerebral haemorrhage
16
Q
ECT
What are some adverse effects of ECT?
A
- Short-term retrograde amnesia
- Headache
- Confusion + clumsiness
17
Q
DEPRESSION
What is depression?
How common is it?
A
- Persistent low mood ± loss of pleasure in activities – unipolar depression.
- 2–6% prevalence globally, F>M but men more likely to be substance misusers + commit suicide
18
Q
DEPRESSION
What are 2 theories speculating the causes of depression?
A
- Stress vulnerability = someone with high vulnerability will withstand less stress before becoming mentally unwell
- Monoamine hypothesis = depression caused by deficiency in monoamines (serotonin, noradrenaline) hence why Tx works
19
Q
DEPRESSION
What are the biological causes of depression?
A
- Personal/FHx + genetics
- Personality traits (dependent, anxious, avoidant)
- Physical illness (hypothyroid, anaemia, childbirth)
- Iatrogenic (beta-blockers, steroids, substance misuse)
20
Q
DEPRESSION
What are the…
i) psychological
ii) social
causes of depression?
A
i) Disrupted relationships, child abuse, poor coping mechanisms
ii) Low socioeconomic status, poor social support, discrimination, divorce, refugee
21
Q
DEPRESSION
What are some risk factors for depression?
A
- Physical co-morbidities, esp. chronic + painful (MS, stroke, DM)
- Genetics + FHx, female, older age, substance abuse
- Traumatic events (+ve/-ve) like divorce/marriage, (un)employment, poverty, loss
- Adverse childhood experiences like abuse, poor parent relationships
22
Q
DEPRESSION
What are the 3 diagnostic criteria for depression?
A
- Sx present most days ≥2 weeks + change from baselines
- Sx not attributable to other organic or substance causes
- Sx impair daily function + cause significant distress
23
Q
DEPRESSION
What are the three core symptoms of depression?
A
- Low mood
- Anhedonia
- Anergia
24
Q
DEPRESSION
What are some psychological symptoms of depression?
A
- Guilt, worthlessness, hopelessness
- Self-harm/suicidality
- Low self-esteem
25
DEPRESSION
What are some cognitive symptoms of depression?
- Beck's triad = negative views about oneself, the world + the future
- Poor concentration + impaired memory
- Avoiding social contact + performing poorly at work (social Sx too)
26
DEPRESSION
What are some somatic, or biological, symptoms of depression?
- Disturbed sleep (EMW, initial insomnia, frequent waking)
- Disturbed appetite + weight
- Loss of libido
- Diurnal mood variation (worse in morning)
- Psychomotor retardation
27
DEPRESSION
What are the 4 classifications of depression?
- Mild = ≥2 core + ≥2 other (minimal interference)
- Mod = ≥2 core + ≥3 other (variable interference)
- Severe = all core + ≥4 other (marked interference)
- Psychotic = Sx of depression + psychosis
28
DEPRESSION
What are some features of psychotic depression?
- Mood congruent hallucinations (auditory = derogatory or accusatory voices, olfactory = bad smells)
- Nihilistic delusions
- Delusions of poverty, guilt, hypochondriacal
- Catatonia or marked psychomotor retardation (depressive stupor)
29
DEPRESSION
What is Cotard's syndrome?
- Delusional belief that they are dead, do not exist, are rotting or have lost their blood + internal organs
30
DEPRESSION
What are some...
i) psychiatric
ii) organic
differentials for depression?
i) Dysthymia, stress-related disorders, bipolar, schizophrenia, anxiety, substance misuse/withdrawal
ii) Dementia, Parkinson's, anaemia, hypoglycaemia, Addison's, Cushing's
31
DEPRESSION
What are some complications of depression?
- Reduce QOL
- Increased morbidity + mortality (IHD, DM)
- Suicide (20x more likely than gen pop)
32
DEPRESSION
What are some investigations for depression?
- FBC, ESR, B12/folate, U+Es, LFTs, TFTs, glucose, Ca2+
- ECG, MSE + risk assessment
- Urine drug screen
- PHQ-9 + HADS to screen for depression
33
DEPRESSION
When would you consider hospital admission ± MHA in depression?
- Serious risk of suicide or harm to others
- Severe depressive or psychotic symptoms
- Initiation of ECT
34
DEPRESSION
What is the management of mild depression?
- Watchful waiting
- Low-intensity psychosocial interventions first line (computerised CBT, individual-guided CBT, structured group physical activity programme) + psychoeducation
35
DEPRESSION
Should biological therapy be used in mild depression?
No unless...
- Consider if PMH mod-severe depression
- Mild depression for 2y or persists after interventions
36
DEPRESSION
What is the management of moderate–severe depression?
- Combination of SSRI + high-intensity psychosocial interventions first line
- CBT with professional, interpersonal therapy, behavioural activation therapy
- Psychoeducation
37
DEPRESSION
What is the CAMHS management of depression?
- Watch + wait, lifestyle
- First-line = CBT ± family ± interpersonal therapy (may need intensive if no response)
- 1st line antidepressant = fluoxetine
- Mood + feelings questionnaire (MFQ) to follow-up monitoring in secondary care to assess progress
38
DEPRESSION
What is the management for resistant depression?
- Different antidepressants (SNRI, MAOI, mirtazapine) or sometimes two
- Augmentation with lithium, atypical antipsychotic or tryptophan
39
DEPRESSION
What is the management of psychotic depression?
- ECT first line + v effective in severe cases followed by antidepressant
- Antipsychotic initiated before antidepressant if ?primary psychotic disorder then add SSRI
40
DEPRESSION
What is atypical depression?
What is the management?
- Mood depressed but reactive
- Hypersomnia (>10h/day)
- Hyperphagia (excessive eating + weight gain)
- Leaden paralysis (heaviness in limbs ≥1h/day)
- Oversensitivity to perceived rejection
- Phenelzine or another MAOI, if not SSRI
41
DEPRESSION
What is dysthymia?
What is the management?
- Chronic, low-grade or sub-threshold depressive Sx which don't meet diagnostic criteria over a long period of time
- Typically >2y of mildly depressed mood + diminished enjoyment, less severe but more chronic
- SSRIs + CBT first line
42
DEPRESSION
What is seasonal affective disorder?
What is the management?
- Episodes of depression which recur annually at same time each year (Jan-Feb) with remission in between
- Light therapy + SSRI
43
SELF-HARM
What is self-harm?
- Act of intentionally injuring yourself
44
SELF-HARM
What are some causes of self-harm?
Bullying,
bereavement,
homophobia,
low self-esteem
45
SELF-HARM
Why do people self harm?
Feel in control,
reduces feelings of tension or distress,
if they feel guilty can be a punishment
46
SELF-HARM
What are some methods of self-harm?
- Self-poisoning (paracetamol),
cutting,
head banging
47
SELF-HARM
What are some risk factors for self-harm?
Female
Social deprivation,
Single or divorced,
LGBTQ+,
mental illness
48
SELF-HARM
What does previous self-harm indicate?
Greatest predictor of future self-harm + increased suicide risk
49
SUICIDE
What is suicide?
- Act of intentionally ending your life
50
SUICIDE
What are some methods?
Overdose,
violent means (jumping from height, into traffic, hanging, cutting)
51
SUICIDE
Why is depression higher in females but suicide higher in males?
Men tend to use violent means which are irreversible
52
SELF-HARM + SUICIDE
What is parasuicide?
Why might this occur?
- Act that mimics suicide but does not result in death
- Someone interrupts them, not enough pills, vomited some of the substances out
53
SELF-HARM + SUICIDE
What are some risk factors for suicide?
SAD PERSONS –
- Sex (M>F)
- Age (peaks in young + old)
- Depression
- Previous attempt
- Ethanol
- Rational thinking loss (psychotic illness)
- Social support lacking (unemployed, homeless)
- Organised plan (avoid discovery, plan, notes, final acts)
- No spouse
- Sickness (physical illness)
0–4 low, 5–6 mod (?hospital), ≥7 high
54
SELF-HARM + SUICIDE
What are some protective factors for suicide?
- Married men
- Active religious beliefs
- Social support
- Good employment
55
SELF-HARM + SUICIDE
What are some indicators someone may commit suicide?
- Obsessive thoughts of death, feelings of hopeless/helplessness
- Active planning (buy equipment, manage affairs, leave notes
56
SELF-HARM + SUICIDE
How should a suicide assessment be conducted?
- Before (?trigger) – amount of planning, notes, final acts?
- During – method, attempt to avoid discovery, lethality?
- After – regret? Intend to re-attempt? Evidence of hopelessness?
57
SELF-HARM + SUICIDE
How should paracetamol overdose be managed?
- Acetylcysteine if staggered (>1h) or above treatment line
- Rarely if present <1h then activated charcoal can be used
58
SELF-HARM + SUICIDE
What is the general management for suicide?
- Plan for further suicidal thoughts + coping strategies
- Reduce social isolation, regular contact with services
- Manage depression (if present)
- ?Inpatient stay or ECT
59
BIPOLAR DISORDER
What is bipolar affective disorder?
When is the peak age of onset?
- Recurrent episodes of altered mood + activity involving both upswings or (hypo)mania + downswings or depression
- Early 20s
60
BIPOLAR DISORDER
What are the 4 types of bipolar?
- Bipolar 1 = mania + depression in equal proportions, M>F
- Bipolar 2 = more episodes of depression, mild hypomania (easy to miss), F>M
- Cyclothymia = chronic mood fluctuations over ≥2y (episodes of depression + hypomania, can be subclinical)
- Rapid cycling = ≥4 episodes of (hypo)mania or depression in 1 year
61
BIPOLAR DISORDER
What are some potential causes of bipolar?
- Structural brain abnormalities, neurotransmitter imbalances
62
BIPOLAR DISORDER
What are some risk factors?
FHx of depression or bipolar,
genetics,
traumatic life event (abuse),
drugs + other meds (antidepressants, BDZs, steroids)
sleep deprivation
63
BIPOLAR DISORDER
What is the diagnostic criteria for bipolar?
- ≥2 episodes of mood disturbance (1 or which MUST be [hypo]manic)
64
BIPOLAR DISORDER
What is the clinical presentation of hypomania?
>4d with ≥3 Sx –
- Elevated mood (euphoria)
- Increased energy
- Increased talkativeness
- Poor concentration
- Mild reckless behaviour (overspending)
- Over-familiar, increased self-esteem
- Increased libido
- Decreased need for sleep
- Appetite change
- Partial insight
65
BIPOLAR DISORDER
What is the clinical presentation of mania?
>1w with ≥3 Sx –
- Extreme elation or irritability
- Overactivity + distractibility
- Pressure of speech + flight of ideas
- Impaired judgement
- Extreme risks (jump off buildings, spending spree)
- Social disinhibition + grandiosity
- Sexual disinhibition
- Decreased need for sleep, restless
- MOOD CONGRUENT PSYCHOTIC Sx
- TOTAL loss of insight
66
BIPOLAR DISORDER
In order to differentiate a manic and hypomanic episode, psychotic symptoms must be present.
What are some of these?
- Grandiose idea may be delusional
- Persecutory delusions sometimes
- Pressure speech may become so great that it's incomprehensible
- Irritability > violence
- Preoccupation with thoughts > self-neglect
- Catatonia 'manic stupor'
67
BIPOLAR DISORDER
What are some...
i) psychiatric
ii) organic
differentials for bipolar?
i) substance abuse (cocaine, amphetamines), schizophrenia, schizoaffective disorder, ADHD
ii) Hyperthyroidism, steroid-induced psychosis, Cushing's
68
BIPOLAR DISORDER
What investigations would you perform in suspected bipolar?
- Full Hx, MSE + physical exam to exclude organic
- FBC, U+Es, LFTs, glucose, TFTs, calcium, syphilis serology, urine drug test, ?neuroimaging if SOL
69
BIPOLAR DISORDER
What is the acute biological management of bipolar disorder?
- Antipsychotic (olanzapine, risperidone)
- Lithium (both acutely + long-term) is first-line
- ?Stop any antidepressants as can precipitate mania
- ?ECT if severely psychotic, catatonic or suicide risk
70
BIPOLAR DISORDER
What is the long-term biological management of bipolar disorder?
- Lithium first-line (antipsychotics in pregnancy)
- Fluoxetine SSRI of choice if depressive episode
71
BIPOLAR DISORDER
What type of referral would you do in bipolar?
What is the psychological management of bipolar disorder?
- Hypomania = routine CMHT referral,
- mania or severe depression = urgent
- CBT for depression, bipolar support groups + psychoeducation
72
SCHIZOPHRENIA
What is schizophrenia?
- Splitting or dissociation of thoughts, loss of contact with reality
73
SCHIZOPHRENIA
What area of the brain is most affected?
Temporal lobe
74
SCHIZOPHRENIA
What is the neurodevelopmental hypothesis in schizophrenia?
- Hypoxic brain injury, viral infections in-utero, TLE + cannabis smoking = risk of schizophrenia indicating brain development link
- Imaging has showed enlarged ventricles (poor prognostic feature), small amounts of grey matter loss + smaller, lighter brains
75
SCHIZOPHRENIA
What is the neurotransmitter hypothesis in schizophrenia?
- Excess dopamine + overactivity in mesolimbic tract = +ve Sx
- Lack of dopamine + underactivity in mesocortical tracts = -ve Sx
- Overactivity of dopamine, serotonin, noradrenaline + underactivity of glutamate + GABA
76
SCHIZOPHRENIA
What is the epidemiology of schizophrenia?
- 1% lifetime risk, M=F, mortality 25y before gen pop.
- Affects 1/100, 2 incidence peaks – men earlier (18–25), women (25–35)
77
SCHIZOPHRENIA
What are some risk factors?
Strongest RF = FHx,
others = Black Caribbean, migrants, urban areas, cannabis use + traumatic pregnancy (emergency c-section)
78
SCHIZOPHRENIA
What are the 6 different types of schizophrenia?
- Paranoid (most common)
- Hebephrenic
- Simple
- Catatonic
- Undifferentiated
- Residual ('burnt out')
79
SCHIZOPHRENIA
What are the features of paranoid schizophrenia?
Persecutory delusions + auditory hallucinations
80
SCHIZOPHRENIA
What are the features of hebephrenic schizophrenia?
Dx in adolescents with mood changes, unpredictable behaviour, shallow affect + fragmentary hallucinations, poor outlook as -ve Sx may develop rapidly
81
SCHIZOPHRENIA
What are the features of simple schizophrenia?
Pts never really experienced +ve Sx, mostly -ve
82
SCHIZOPHRENIA
What are the features of...
i) catatonic
ii) undifferentiated
iii) residual
schizophrenia?
i) Psychomotor disturbance such as posturing, rigidity + stupor
ii) Sx do not fit neatly into other subtypes
iii) Previous +ve symptoms less marked, prominent -ve Sx
83
SCHIZOPHRENIA
What can cause schizophrenia?
- Thought to be combination of biopsychosocial factors
- Schizophrenia susceptibility + emotional life experiences may = trigger
84
SCHIZOPHRENIA
What are the first rank symptoms of schizophrenia?
What is the relevance?
- Delusional perceptions
- Auditory hallucinations (3 types)
- Thought alienation (insertion, withdrawal + broadcasting)
- Passivity phenomenon, incl. somatic
- ≥1 for at least 1m is strongly suggestive Dx
85
SCHIZOPHRENIA
What are the three types of auditory hallucinations that count as a first rank symptom?
- 3rd person = talking about the patient (he/she)
- Running commentary = often on person's actions or thoughts
- Thought echo = thoughts spoken aloud
86
SCHIZOPHRENIA
What are some secondary symptoms of schizophrenia?
What is the relevance?
- 2nd person auditory or hallucinations in other modalities
- Other delusions (persecutory, reference)
- Formal thought disorder
- Lack of insight
- Negative Sx (incl. catatonia)
- ≥2 for at least 1m is strongly suggestive Dx
87
SCHIZOPHRENIA
What is the difference between positive and negative symptoms of schizophrenia?
- +ve = presence of change in behaviour or thought, something added (all of the first rank + secondary Sx)
- -ve = decline in normal functioning, something removed
88
SCHIZOPHRENIA
What are the negative symptoms of schizophrenia?
Often early prodromal, 5As –
- Affect blunting, flattening or incongruity
- Anhedonia + amotivation
- Asociality
- Alogia (poverty of speech)
- Apathy
(Delusional mood = ominous feeling of something impending)
89
SCHIZOPHRENIA
What are some...
i) psychiatric
ii) organic
iii) substance
differentials for schizophrenia?
i) Delusional disorder, transient psychosis, mania, psychotic depression
ii) TLE, encephalitis, delirium, syphilis/HIV, SOL
iii) Drug-induced psychosis, alcoholic hallucinosis, steroid-induced
90
SCHIZOPHRENIA
What are the investigations for first-episode psychosis?
- Full Hx, MSE + risk assessment
- FBC, CRP/ESR, U+Es, LFTs, TFTs, fasting glucose, Ca2+, phosphate, B12 + folate
- Urine + serum drugs screen
- ?Serological syphilis + HIV
- CT/MRI head if ?SOL
91
SCHIZOPHRENIA
What teams would be involved in the management of schizophrenia?
- Early intervention team = initial referral after first episode psychosis
- CMHT = provide daily support + treatment
- Crisis resolution team = pts with acute psychotic episode, often pre-existing diagnosis
92
SCHIZOPHRENIA
What would warrant hospital admission ± MHA in schizophrenia?
- High risk of suicide or homicide
- Severe psychotic, depressive or catatonic Sx
- Failure of OP treatment or non-compliance
93
SCHIZOPHRENIA
What is the biological management of schizophrenia?
- Anti-psychotic (tailor SE profile to patient)
- Aim for minimal effective dose, use depot if non-compliant to prevent relapse
94
SCHIZOPHRENIA
What is treatment resistant schizophrenia?
What is the management?
- ≥2 antipsychotics (1 atypical) trialled for ≥6w but ineffective
- Clozapine
- ECT is last line if resistant to therapy or catatonic
95
SCHIZOPHRENIA
What is the psychological management for schizophrenia?
- All patients offered CBT
- Family therapy + psychoeducation to reduce or notice relapses
96
SCHIZOPHRENIA
What is the social management of schizophrenia?
- Social work + housing involvement may be needed
- Drop-in community centres + support groups
- Substance misuse service if needed
- Depot non-attendance at GP/CPN appt may act as early warning system
97
SCHIZOPHRENIA
After a Mental Health Act detention, what approach should be taken to their care?
What does it involve?
- Care programme approach
- Assess health + social needs, create care plan, appoint key worker as point of contact + review treatment
98
PARAPHRENIA
What is paraphrenia?
How does it compare to schizophrenia?
- Late-onset schizophrenia >45y
- Less emotional blunting + personality decline, F>M
99
PARAPHRENIA
Why is it often undiagnosed?
What are some risk factors?
- Older patients tend to be socially isolated
- Social isolation, poor eyesight + hearing, reclusive + suspicious pre-morbid personality
100
PARAPHRENIA
What is the clinical presentation of paraphrenia?
How is it managed?
- Delusions, hallucinations + paranoia usually about neighbours
- Partition delusions where they believe people + objects can go through walls
- Less -ve Sx + formal thought disorder
- Low dose antipsychotics
101
TRANSIENT PSYCHOSIS
What is transient psychosis?
What may cause it?
What is it associated with?
- Brief psychotic episodes that last less than time required to diagnose schizophrenia (<1m)
- Usually resolves within that time
- Acute stressor (loss, marriage, unemployment)
- Paranoid, borderline + histrionic personality disorders
102
DELUSIONAL DISORDER
What is a delusional disorder?
- Pt experiences strong delusional beliefs (often non-bizarre) + perceptions but with the absence of prominent hallucinations, thought or mood disorder or significant flattened affect
- ICD 10 ≥3m (if less it's persistent delusional disorder)
103
DELUSIONAL DISORDER
What is erotomania or De Clerambault's syndrome?
- Delusion in which patient (usually single woman) believes another person (typically higher social status) is in love with them
104
DELUSIONAL DISORDER
What is Othello syndrome?
- Delusional jealousy
- Patients (typically men) possess fixed belief that their partner has been unfaithful + often try to collect evidence
105
DELUSIONAL DISORDER
How else might delusional disorder present?
- Delusions about illness, cancer or skin infestation
- Grandiose delusions
- Persecutory delusions
106
DELUSIONAL DISORDER
What is the management of delusional disorder?
- Antipsychotics, ?SSRIs
- Individual therapy = establish therapeutic alliance, maybe CBT
107
SCHIZOAFFECTIVE
What is schizoaffective disorder?
- Features of both affective disorder + schizophrenia present in equal proportion
108
SCHIZOAFFECTIVE
What are the two types of schizoaffective disorder?
Manic type or depressive type
109
SCHIZOAFFECTIVE
How does it differ to schizophrenia?
Psychotic Sx tend to wax + wane, unlike in schizophrenia
110
SCHIZOAFFECTIVE
What is the prognosis of schizoaffective disorder?
What is the management of it?
- Better than schizophrenia but worse than primary mood disorders
- Antipsychotics, mood stabilisers of antidepressants (depends on affective disorder)
111
GAD
What is Generalised Anxiety Disorder (GAD)?
What can it be comorbid with?
- Syndrome of excessive, persistent worry + apprehensive feelings about everyday events that the patient recognises as excessive + inappropriate
- Other anxiety disorders, depression, substance abuse, IBS
112
GAD
What are 3 cardinal features of GAD?
- Symptoms of muscle + psychic tension
- Causes significant distress + functional impairment
- No particular stimulus
113
GAD
What is the epidemiology of GAD?
- Highest prevalence 45–69y, F>M
- Early onset = childhood fears + marital or sexual disturbance
- Late onset = stressful event, single, unemployment
114
GAD
What model can be used to explain the causes of GAD?
Triple vulnerability –
- Generalised biological
- Generalised psychological (diminished sense of control)
- Specific psychological (stressful events)
115
GAD
What are some organic differentials for GAD?
- Endo = hyperthyroidism, pheochromocytoma, hypoglycaemia
- CVS = arrhythmias, cardiac failure, anti-hypertensives, MI
- Resp = asthma (excessive salbutamol), COPD, PE
116
GAD
What are some risk factors for GAD?
- Alcohol, BDZs or stimulants (particularly withdrawal)
- Co-existing depression, FHx, female
- Child abuse/neglect or excessively pushy parents
- Life stresses (finance, divorce)
- Physical health problems
117
GAD
What is the ICD criteria of GAD?
What are the groups of symptoms present in GAD?
- Difficulty controlling worry, present for more days than not for ≥6m
- ≥4 symptoms with ≥1 from autonomic arousal section
- Autonomic arousal, physical, mental, general, tension, other
118
GAD
What symptoms in GAD come under the following categories...
i) autonomic arousal?
ii) physical?
iii) mental?
iv) general?
v) tension?
vi) other?
i) Palpitations, tachycardia, sweating, tremor
ii) Breathing issues, choking, CP, nausea, abdo distress
iii) Dizzy, derealisation + depersonalisation, fear of losing control, impending death
iv) Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking)
v) Muscle aches + pains, restless, lump in throat
vi) Exaggerated responses to minor surprises/startled
119
GAD
What are the investigations for GAD?
- History, MSE + risk assessment
- GAD-7 + Hospital Anxiety + Depression Scale (HADS) questionnaire
- Exclude organic (FBC, U+Es, LFTs, TFTs, fasting glucose, PTH)
120
GAD
What is the stepwise management for GAD?
- Education + active monitoring, exercise
- Low-intensity psychological interventions like individual self-help or groups
- High-intensity psychological interventions (CBT, applied relaxation, arts + music therapy) or biological management
121
GAD
What is the role of CBT in GAD?
- Cognitive = educate about bodily response to anxiety
- Behavioural = use of relaxation to overcome
122
GAD
What is the biological management used in GAD?
- Sertraline first line, if ineffective offer alternative SSRI or SNRI
- If SSRI/SNRI not tolerated then pregabalin
- Beta-blockers like propranolol for physical Sx sometimes
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GAD
What is the CAMHS management of GAD?
- Watch + wait
- Self-help (meditation, mindfulness), diet + exercise
- CBT, counselling + SSRI like sertraline may be considered if more severe (specialists)
124
PANIC DISORDER
What is panic disorder?
- Recurrent panic attacks that are unpredictable + unrestricted in terms of situation, ≥4/week for ≥4w
- Usually persistent worry about having another attack
- Chronic relapsing condition > distress + social dysfunction
125
PANIC DISORDER
What is a panic attack?
- Period of intense fear characterised by range of physical Sx that develop rapidly, peak intensity at 10m, generally no longer than 20–30m
126
PANIC DISORDER
What is the epidemiology of panic disorder?
- Females 2–3x more likely
- Bimodal distribution
127
PANIC DISORDER
What is panic disorder associated with?
What are some risk factors?
- Meds like SSRIs, BDZs, zopiclone withdrawal
- Widowed, divorced or separated, living in city, limited education, physical or sexual abuse, FHx
128
PANIC DISORDER
What are the 3 key elements of panic disorder?
- Sudden onset panic attack with ≥4 characterised Sx
- Not necessarily associated with a specific stimulus
- Pt preoccupied with suffering death or severe life-threatening illness
129
PANIC DISORDER
What are the features of panic attacks?
Same as GAD but in discrete attacks –
- Palpitations, tachycardia, sweating, tremor
- Breathing issues, choking, CP, nausea, abdo distress
- Dizzy, derealisation + depersonalisation, fear of losing control, impending death
- Numbness + tingling, hot flushes + chills, muscle aches + pains
130
PANIC DISORDER
What is the stepwise management of panic disorder?
- Recognition + diagnosis with treatment in primary care
- CBT or drug therapy (SSRIs 1st line, if C/I or no response after 12w then imipramine or clomipramine)
- Psychodynamic psychotherapy + specialist MH services if severe
131
PANIC DISORDER
What is the social management of panic disorder?
- Healthy eating, exercise, avoid caffeine.
- Meditation, mindfulness, self-help groups
132
SIMPLE PHOBIAS
What is a simple or specific phobia?
- Recurring excessive + unreasonable anxiety attacks, in the (anticipated) presence of a specific feared object or situation, leading to avoidance if possible
133
SIMPLE PHOBIAS
What might people be phobic of?
Give some examples.
- Animals, blood, injection or injury, situational, natural environment
- Emetophobia, claustrophobia, arachnophobia, iatrophobia
134
SIMPLE PHOBIAS
What is the epidemiology of simple phobias?
- F>M
- Mean age is 15 (animal phobias can be as young as 7)
135
SIMPLE PHOBIAS
What are some potential causes of phobias?
- Psychoanalytical = phobia is symbolic representation of repressed unconscious conflict
- Learning theory = conditioned fear response to traumatic situation with learned avoidance
136
SIMPLE PHOBIAS
What is the clinical presentation of simple phobias?
Same features as GAD but to a specific stimulus –
- Palpitations, tachycardia, sweating, tremor
- Breathing issues, choking, CP, nausea, abdo distress
- Dizzy, derealisation + depersonalisation, fear of losing control, impending death
- Numbness + tingling, hot flushes + chills, muscle aches + pains
137
SIMPLE PHOBIAS
What is the management of simple phobias?
- Exposure + response prevention (ERP)
- CBT (education + anxiety management, coping strategies)
- BDZs in severe cases to reduce avoidance
138
SIMPLE PHOBIAS
What are the two methods of ERP?
Which is preferred?
- Desensitisation with relaxation + graded exposure
- Flooding where exposed to most frightening situation instantly
- Desensitisation as flooding can be highly traumatic
139
AGORAPHOBIA
What is agoraphobia?
- Anxiety + panic symptoms associated with places or situations where escape may be difficult or embarrassing leading to avoidance.
- ≥2 from: crowds, public places, travelling alone or away from home.
140
AGORAPHOBIA
What may be seen in patients with agoraphobia?
What is the epidemiology?
- Predisposition towards overly interpreting situations as dangerous
- F>M, 15–35y, may have co-morbid panic disorder
141
AGORAPHOBIA
What is the clinical presentation of agoraphobia?
Same as GAD but to the specific situations –
- Palpitations, tachycardia, sweating, tremor
- Breathing issues, choking, CP, nausea, abdo distress
- Dizzy, derealisation + depersonalisation, fear of losing control, impending death
- Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking)
142
AGORAPHOBIA
What is the biological management of agoraphobia?
- SSRIs as for panic disorder
- BDZs for short-term use only (clonazepam)
143
AGORAPHOBIA
What is the psychological management of agoraphobia?
- CBT (teach about bodily responses related to anxiety and exposure + desensitisation techniques, relaxation training)
144
SOCIAL PHOBIA
What is social phobia?
- Sx of incapacitating anxiety that are restricted to particular social situations, leading to a desire for escape or avoidance (may reinforce belief of social inadequacy)
145
SOCIAL PHOBIA
What is the epidemiology of social phobia?
- Bimodal distribution with peaks at 5y + 11–15y, may present in 30s
146
SOCIAL PHOBIA
What is the clinical presentation of social phobia?
≥2 Somatic Sx in response to the situation –
- Blushing, trembling, dry mouth, sweating
- Excessive fear of humiliation, embarrassment, micturition or others noticing how anxious they are.
- Characteristically self-critical + perfectionist
147
SOCIAL PHOBIA
What is the impact of social phobia?
- Avoiding situations may lead to relationship issues, education + vocational problems (difficulty interacting with others, presentations)
148
SOCIAL PHOBIA
What is the biological management of social phobia?
- SSRIs (sertraline) > SNRIs > MAOIs
- Beta-blockers like propranolol
- Clonazepam may be useful short-term
149
SOCIAL PHOBIA
What is the psychological management of social phobia?
- Either individual or group CBT first-line with SSRI (relaxation training, social skills, graded exposure)
- Psychodynamic psychotherapy
150
OCD
What is obsessive compulsive disorder (OCD)?
- Condition characterised by obsessions + compulsions which must cause distress or interfere with their social or individual functioning (usually by wasting time)
151
OCD
What are some examples of obsessions and compulsions?
- Obsessions = being followed, everything being dirty or contaminated
- Compulsions = checking, washing, doubting, bodily fears, counting, symmetry, aggressive thoughts
152
OCD
What are the two types of compulsions?
What is the natural cycle in OCD?
- Overt = can be observed (checking the door)
- Covert = can't be observed (repeating a phrase in their mind)
- Obsession > anxiety > compulsion > relief
153
OCD
What is the epidemiology of OCD?
- Adolescents or early adulthood (20y mean age), M=F
154
OCD
What is a potential cause of OCD?
Neurochemical dysregulation of 5-HT system
155
OCD
What are some risk factors for OCD?
- Genetics = FHx of OCD or tic disorder
- Abuse, neglect, teasing + bullying
- Parental overprotection
- Paediatric neuropsychiatric disorders associated with streptococci (PANDAS)
156
OCD
What are the key features of OCD?
- Obsessions ± compulsions present most days >2w
- Acknowledged as excessive + unreasonable + originate from inside patient's mind (not influenced by outside)
- Repetitive or unpleasant + pt tries to resist them unsuccessfully
- Time consuming, interferes with ADLs, distress to pt
- Avoidance of stimuli that trigger Sx
157
OCD
What is the biological management of OCD?
- 1st line SSRIs = sertraline
- 2nd line = clomipramine (TCA) with specific anti-obsessional action
- ?Psychosurgery (stereotactic cingulotomy if intractable > 2 antidepressants, 3 combination Tx, ECT + behavioural therapy
158
OCD
What is the psychological management of OCD?
- CBT but behavioural approach
- ERP (stop carrying out compulsion in response to stimulus)
- Psychotherapy (incl. family, groups)
159
OCD
What is the OCD management for CAMHS?
- Mild can be managed with psychoeducation or self-help
- Referral to CAMHS, CBT + initiation of SSRI with CAMHS specialist guidance
160
PTSD
What is post-traumatic stress disorder (PTSD)?
What counts as a traumatic event?
- Severe psychological disturbance following a traumatic event (within 6m usually).
- Catastrophic event where there is threat to security or physical integrity (life-threatening) such as war, surviving tsunami, sexual assault, not everyday trauma (divorce)
161
PTSD
What are some risk factors for PTSD?
- Low education or social class
- F>M
- Previous PTSD/psych issues
- First responders (ambulance, police, fire)
- Military (dependent on duration of combat exposure, lower rank, low morale)
162
PTSD
What are the 4 core symptoms of PTSD?
How long do they need to be present for to diagnose?
HEAR (≥1m) –
- Hyperarousal
- Emotional numbing
- Avoidance + rumination
- Re-experiencing (involuntary)
163
PTSD
In terms of PTSD, what are signs of...
i) hyperarousal?
ii) emotional numbing?
i) Hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating or sleeping (falling + staying asleep)
ii) Difficulty experiencing emotions, restricted range of affect, detachment from others
164
PTSD
In terms of PTSD, what are signs of...
i) avoidance + rumination?
ii) re-experiencing?
i) Avoiding people, situations, thoughts or circumstances resembling or associated to event
ii) Flashbacks, nightmares, vivid memories, distressing images or other sensory impressions from event which intrude during waking day, reminders of event = distress
165
PTSD
What is the mainstay of management in PTSD?
Psychological therapy –
- Trauma-focused CBT
- Eye movement desensitisation and reprocessing (EMDR)
166
PTSD
What is trauma-focused CBT?
- Education about nature of PTSD, self-monitoring of Sx, anxiety management, breathing techniques + exposure in supportive setting
167
PTSD
What is EMDR?
- Voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts + help process emotions
168
PTSD
What is the medical management of PTSD?
- Venlafaxine or SSRI like sertraline
- Risperidone for severe cases where resistant to treatment or psychotic
169
ANOREXIA NERVOSA
What are the 2 types of anorexia nervosa?
- Restrictive = limit food intake
- Binge/purge = binge eat + purge straight away (different from bulimia due to BMI)
170
ANOREXIA NERVOSA
How is anorexia classified based on BMI?
- Anorexia = <17.5kg/m^2
- Medium risk = 13–15
- High risk = <13
171
ANOREXIA NERVOSA
What is the outcome of anorexia nervosa?
1/3 recover, 1/3 relapse + remit, 1/3 chronic lifelong
172
ANOREXIA NERVOSA
What is the epidemiology of anorexia?
- F>M
- Onset is early to mid adolescence
173
ANOREXIA NERVOSA
What premorbid experiences may lead to anorexia development?
- Dieting behaviour in family/personal experience, over-protective family
- Criticism about weight, personal Hx of obesity, adverse events (abuse)
- Perfectionism, low self-esteem, disturbed body image, obsessional traits
174
ANOREXIA NERVOSA
What is the diagnostic criteria for anorexia?
FEED ≥3m with absence of binge eating –
- Fear of fatness
- Endocrine disturbance
- Extreme weight loss
- Deliberate weight loss
175
ANOREXIA NERVOSA
How may fear of fatness present?
- Over-valued idea
- Self-esteem unduly influenced by weight/shape
- Intense fear of gaining weight > body image distortion
176
ANOREXIA NERVOSA
How may endocrine disturbance present?
- Amenorrhoea
- Reduced libido/fertility
- Abnormal insulin secretion
- Delayed/arrested puberty if onset pre-pubertal
177
ANOREXIA NERVOSA
How may extreme weight loss present?
- >15% below expected for height (BMI ≤17.5kg/m^2)
178
ANOREXIA NERVOSA
How may deliberate weight loss present?
- Restrictive eating (skipping meals)
- Over-exercising
- Vomiting
- Appetite suppressants
- Laxatives
179
ANOREXIA NERVOSA
What are some physical symptoms of anorexia?
- GI Sx = constipation, dysphagia (vomiting), abdo pains
- Dizziness/fainting, headaches, cold intolerance
- Polyuria (diuresis), polydipsia
180
ANOREXIA NERVOSA
What are some clinical signs of anorexia?
- Lanugo hair = fine, soft body hair
- Gaunt face, dry skin, loss of muscle mass
- Acrocyanosis = blue colouration of peripheries due to slow circulation
181
ANOREXIA NERVOSA
What are some complications of anorexia?
- Osteoporosis, thyroid issues, cardiac atrophy
- Electrolyte disturbances (hypokalaemia > arrhythmias)
- Decrease in WBC > increased infections
- Death due to health complications or suicide
182
ANOREXIA NERVOSA
What screening tool can be used in anorexia?
SCOFF –
- Do you ever make yourself SICK as too full?
- Do you ever feel you've lost CONTROL over eating?
- Have you recently lost more than ONE stone in 3m?
- Do you believe you're FAT when others say you're thin?
- Does FOOD dominate your life?
183
ANOREXIA NERVOSA
What are some investigations for anorexia?
- Sit up squat stand (SUSS) test /3
- BP (low), temp (low)
- ECG (brady, T-wave changes, QTc prolongation)
- FBC (anaemia, dehydrated), LFTs, urinalysis, serum proteins
- U+Es, Ca2+, Mg2+, phosphate > vomiting, laxatives, diuretics, water loading
- DEXA scan after 1y of underweight (osteopenia)
184
ANOREXIA NERVOSA
In anorexia, most things are low apart from what?
Gs + Cs –
- GH, Glucose, salivary Glands
- Cortisol, Cholesterol, Carotinaemia
185
ANOREXIA NERVOSA
What risk assessment tool can be used for assessing if a patient with anorexia needs inpatient psychiatric admission?
Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN)
186
ANOREXIA NERVOSA
What are the MARSIPAN indicators of admission?
- BMI <13, severe malnutrition or dehydration
- HR <40, ECG changes
- BP <90 systolic, <70 diastolic esp with postural drop
- Temp <35
- Severe electrolyte disturbances (K+, Na+, Mg2+, phosphate = low)
- SUSS test of 0 or 1
- Significant suicide or serious self-harm risk
187
ANOREXIA NERVOSA
How should the physical complications of anorexia be managed?
- Monitor U+Es + ECGs
- Oral supplements for electrolytes, thiamine
- Multivitamins + mineral supplements, calcium + vitamin D
- Safely + slowly re-feed pt + avoid refeeding syndrome
188
ANOREXIA NERVOSA
What are the biological treatments for anorexia nervosa?
- Fluoxetine, chlorpromazine + TCAs may be used for weight gain
189
ANOREXIA NERVOSA
What are the psychological therapies for anorexia?
- Individual therapy (eating disorder focussed CBT, CBT-ED)
- Maudsley anorexia nervosa treatment for adults (MANTRA)
- Specialist supportive clinical management (SSCM)
190
ANOREXIA NERVOSA
What is the social management for anorexia?
- Avoid over exercise
- Food diary/dietary advice
- Self-help groups
191
ANOREXIA NERVOSA
What is the CAMHS treatment for anorexia?
- Family therapy 1st line, pt + carer education, self-help resources
- Adolescent-focussed psychotherapy, individual CBT-ED
- May require SSRIs
192
ANOREXIA NERVOSA
What is refeeding syndrome?
What are some risk factors?
- Metabolic disturbances due to reintroduction of nutrition to a starving patient who is fed too much, too quickly
- Low BMI, poor nutritional intake (>5d), Hx of high alcohol intake, chemo, unintentional weight loss
193
ANOREXIA NERVOSA
What is the pathophysiology of refeeding syndrome?
- Reduced carb consumption leads to reduced insulin secretion so the body switches from carb > fat + protein metabolism
- Electrolyte stores depleted as needed to convert glucose>energy
- Reintroducing food causes abrupt shift from fat>carb metabolism + insulin secretion surges, driving electrolytes from serum>cells to help convert glucose>energy causing further serum concentration decrease
194
ANOREXIA NERVOSA
What is the clinical presentation of refeeding syndrome?
- Fatigue, weakness, confusion, dyspnoea (risk of fluid overload)
- Abdo pain, vomiting, constipation, infections
195
ANOREXIA NERVOSA
What are the consequences of refeeding syndrome?
Can lead to cardiac arrhythmias, convulsions, cardiac failure, coma + death
196
ANOREXIA NERVOSA
What are the biochemical features of refeeding syndrome?
- Hypophosphataemia main disturbance due to role of converting glucose>energy
- Hypokalaemia, hypomagnesaemia + thiamine deficiency too
- Abnormal fluid balance
197
ANOREXIA NERVOSA
What should be monitored before + during refeeding?
- U+Es (Na+, K+), phosphate, magnesium, glucose, ECG, fluid balance
198
ANOREXIA NERVOSA
What is the management of refeeding syndrome?
- Start up to 10cal/kg/day + increase to full needs SLOWLY over 4–7d
- Start PO thiamine, B vitamins + supplements before + during feeding
- K+, phosphate + magnesium replacement
199
BULIMIA NERVOSA
What is bulimia nervosa?
- Characterised by recurrent episodes of binge eating + compensatory behaviours (purges)
200
BULIMIA NERVOSA
What is a binge?
- Episodes of overeating a large amount of food in a discrete period of time where an individual feels that they cannot control their eating
201
BULIMIA NERVOSA
What are purges?
- Compensatory behaviours to prevent weight gain like induced vomiting, laxative misuse, diuretics, appetite suppressants, enemas, fasting or excessive exercise
202
BULIMIA NERVOSA
What is the epidemiology + aetiology of bulimia?
- F>M, common in adolescent, very common premorbid experiences to anorexia (dieting behaviour, weight criticisms, perfectionism)
203
BULIMIA NERVOSA
What is the diagnostic criteria for bulimia?
BPFO ≥2 a week for ≥3m –
- Behaviours to prevent weight gain
- Preoccupation with eating (compulsion to eat but regret after)
- Fear of fatness
- Overeating ≥2/week
204
BULIMIA NERVOSA
What are some physical symptoms of bulimia?
- Similar to anorexia but less severe
- GI (constipation, bloating, sore throat, GORD + dyspepsia from vomiting, abdo pains)
- Dizziness/fainting, headaches, cold intolerance
- Polyuria (diuresis), polydipsia, lethargy
205
BULIMIA NERVOSA
What are some clinical signs of bulimia?
- Russel's sign (calluses on dorsum of dominant hand due to vomiting)
- Dental enamel erosion
- Mouth ulcers
- Salivary gland, especially parotid, enlargement
206
BULIMIA NERVOSA
What are some complications of bulimia?
- Cardiomegaly (ipecac toxicity = plant taken PO + can cause vomiting)
- Arrhythmias, cardiac failure
- Mallory-Weiss tears from vomiting
207
BULIMIA NERVOSA
What are some investigations for bulimia?
- SCOFF
- BP (low), temp, SUSS test
- ECG (arrhythmias from hypokalaemia)
- FBC (anaemia), LFTs, urinalysis, serum proteins
- Monitor U+Es, calcium, magnesium, phosphate in vomiting, laxative abuse, diuretics or waterloading (for deceitful weighing)
208
BULIMIA NERVOSA
What metabolic abnormalities may be present?
- Hypochloraemic hypokalaemic metabolic alkalosis due to vomiting
- Hypokalaemia > muscle weakness + arrhythmias
209
BULIMIA NERVOSA
When should bulimia be managed as inpatient?
- Suicidality, physical problems, extreme refractory cases
- Pregnancy (risk of spontaneous abortion)
210
BULIMIA NERVOSA
What is the management of bulimia?
- Guided self-help first line with psychoeducation + support group
- CBT-ED
- Bulimia focussed family therapy in CAMHS
- Limited evidence for high-dose fluoxetine
211
BINGE EATING DISORDER
What is binge eating disorder?
- Episodes where person excessively overeats, often as expression of underlying psychological distress
- Not restrictive so tends to be overweight
212
BINGE EATING DISORDER
How does binge eating disorder present?
- Planned bine with binge foods
- Eating very quickly + becoming uncomfortably full
- Eating in "dazed" state
- Unrelated to if hungry
213
BINGE EATING DISORDER
What is the management of binge eating disorder?
- Self-help, CBT-ED, may benefit from SSRIs
214
PERSONALITY DISORDERS
What are personality disorders?
- Deeply engrained + enduring patterns of behaviour that are abnormal in a particular culture
215
PERSONALITY DISORDERS
What is the epidemiology of personality disorders?
- Younger adults
- Antisocial PD most prevalent amongst prisoners
- Dx not made in <18 as personality still developing
216
PERSONALITY DISORDERS
What are some risk factors for personality disorders?
- FHx of PD or other mental illness
- Abusive, unstable or chaotic life
- Adverse events
- Dx of childhood conduct disorder (antisocial PD)
217
PERSONALITY DISORDERS
What are cluster A personality disorders?
- Characterised by odd, eccentric thinking or behaviour
- MAD
218
PERSONALITY DISORDERS
What is paranoid personality disorder?
- Pervasive + unwarranted tendency to interpret the actions of others as demeaning or threatening
219
PERSONALITY DISORDERS
In terms of paranoid personality disorder...
i) think the world is?
ii) think people are?
iii) acts as if?
iv) common behaviour?
v) least likely to be?
vi) emotional hotspot?
i) Conspiracy
ii) Devious, trying to cause harm
iii) Always on guard + suspicious of others, emotionally cold/distant
iv) Watchfulness
v) Trusting (fear others will use information against you)
vi) Being discriminated against
220
PERSONALITY DISORDERS
What is schizoid personality disorder?
- Pervasive pattern of indifference to social relationships + restricted range of emotional experience + expression
221
PERSONALITY DISORDERS
In terms of schizoid personality disorder...
i) think the world is?
ii) think people are?
iii) thinks they are?
iv) common behaviour?
v) least likely to be?
vi) emotional hotspot?
vii) other?
i) Uncaring
ii) Pointless, replaceable
iii) Only person they can depend on
iv) Withdrawal, prefer to be alone
v) Emotionally available + close
vi) Being over-cared for or smothered by others
vii) Inability to take pleasure from activities, little interest in sex
222
PERSONALITY DISORDERS
What is schizotypal personality disorder?
- Pervasive pattern of deficits in interpersonal relatedness + peculiarities of ideation, experience, appearance + behaviour
223
PERSONALITY DISORDERS
What are some features of schizotypal personality disorder?
- Ideas of reference (not delusions as insight)
- Excessive social anxiety with lack of close friends + social withdrawal
- "Magical thinking" believing you can influence people/events with thoughts
- Unusual perceptions (illusions, overvalued ideas)
- Odd/eccentric behaviour, beliefs, speech or appearance
- Inappropriate affect with paranoid or suspicious ideas
224
PERSONALITY DISORDERS
What are some differentials of schizotypal personality disorder?
- Autism
- Asperger's
- Schizophrenia (50% may develop it)
225
PERSONALITY DISORDERS
What are cluster B personality disorders?
- Characterised by dramatic, overly emotional or unpredictable thinking or behaviour (BAD)
226
PERSONALITY DISORDERS
What is dissocial/antisocial personality disorder?
- Childhood conduct disorder before 15 + pattern of irresponsible + antisocial behaviour after age 15
227
PERSONALITY DISORDERS
What is a psychopath?
What is a sociopath?
- When they get in trouble with the law
- Same traits but without law involvement
228
PERSONALITY DISORDERS
In terms of antisocial personality disorder...
i) think the world is?
ii) think people are?
iii) thinks they are?
iv) common behaviour?
v) least likely to be?
vi) emotional hotspot?
vii) other?
i) Predatory
ii) Weak
iii) Autonomous + alone
iv) Aggressive/violent
v) Gentle + sensitive, conform to social norms
vi) Perceiving exploitation
vii) Disregard for others' needs, feelings, safety, impulsive + lacks remorse
229
PERSONALITY DISORDERS
What is borderline/emotionally unstable personality disorder?
What is a big risk factor?
- Pervasive pattern of instability of mood, interpersonal relationships + self image
- Often Hx of childhood sexual abuse
230
PERSONALITY DISORDERS
In terms of EUPD...
i) think the world is?
ii) think people are?
iii) common behaviour?
iv) least likely to be?
v) emotional hotspot?
vi) other?
i) Contradictory
ii) Untrustworthy
iii) Self-harm/suicide (impulsive + unpredictable)
iv) Able to show self-compassion
v) Abandonment (extreme reactions)
vi) Paranoid when stressed, labile mood, unstable + intense relationships
231
PERSONALITY DISORDERS
In terms of EUPD, what is the difference between...
i) impulsive type?
ii) borderline type?
i) Difficulties with impulsive + risky behaviours (unsafe sex, gambling) + anger
ii) Difficulties with relationships, self-harm + feelings of emptiness
232
PERSONALITY DISORDERS
What is histrionic personality disorder?
- Pervasive pattern of excessive emotionality + attention seeking
233
PERSONALITY DISORDERS
In terms of histrionic personality disorder...
i) think the world is?
ii) think people are?
iii) common behaviour?
iv) least likely to be?
v) emotional hotspot?
vi) think they are?
vii) think relationships with others are?
i) Their audience (crave attention)
ii) In competition for attention
iii) Exhibitionism (provocative for attention)
iv) Able to listen to others
v) Actively or passively side-lined
vi) Vivacious, easily influenced by others, excessive concern with physical appearance
vii) Closer than what they really are
234
PERSONALITY DISORDERS
What is narcissistic personality disorder?
- Pervasive pattern of grandiosity, lack of empathy + hypersensitivity to the evaluation of others
235
PERSONALITY DISORDERS
In terms of narcisssitic personality disorder...
i) think the world is?
ii) think people are?
iii) thinks they are?
iv) common behaviour?
v) least likely to be?
vi) emotional hotspot?
vii) other?
THINK LUKE
i) Competition
ii) Inferior
iii) Special + more important than others
iv) Competitiveness
v) Humble
vi) Loss of social rank/status or being embarrassed
vii) Failure to recognise other's needs or feelings, arrogance, envy (both ways)
236
PERSONALITY DISORDERS
What are cluster C personality disorders?
- Characterised by anxious, fearful thinking or behaviour (SAD)
237
PERSONALITY DISORDERS
What is anxious/avoidant personality disorder?
- Pervasive pattern of social discomfort, fear of negative evaluation + timidity
238
PERSONALITY DISORDERS
In terms of anxious/avoidant personality disorder...
i) think the world is?
ii) think people are?
iii) thinks they are?
iv) common behaviour?
v) least likely to be?
vi) emotional hotspot?
vii) other?
i) Evaluative
ii) Judgemental
iii) Inept
iv) Inhibition (social, avoids this)
v) Assertive
vi) Exposed, ridicule, criticism or rejection
vii) Feeling inadequate or inferior, extreme shyness, fear of disapproval
239
PERSONALITY DISORDERS
What is dependent personality disorder?
- Pervasive pattern of dependent + submissive behaviour
240
PERSONALITY DISORDERS
In terms of dependent personality disorder...
i) think the world is?
ii) think people are?
iii) they are?
iv) common behaviour?
v) least likely to be?
vi) emotional hotspot?
vii) other?
i) Overwhelming
ii) Stronger + more competent than themselves
iii) Needy
iv) Clinging
v) Self-sufficient
vi) Making a decision, abandonment
vii) Requires excessive advice/reassurance, tolerant of abusive treatment, relationship hops, difficult disagreeing with others
241
PERSONALITY DISORDERS
What is anankastic/obsessive-compulsive personality disorder?
What may it be seen in?
- Pervasive pattern of perfectionism + inflexibility lacking insight
- Hx of family pressure + wanting approval
242
PERSONALITY DISORDERS
In terms of anankastic/OC personality disorder...
i) think the world is?
ii) think people are?
iii) think they are?
iv) common behaviour?
v) least likely to be?
vi) emotional hotspot?
vii) other?
i) Sloppy
ii) Irresponsible
iii) Responsible
iv) Controlling
v) Flexible
vi) Making a mistake
vii) Preoccupied with order, extreme perfectionism, neglect friends due to excessive project commitment, rigid + stubborn
243
PERSONALITY DISORDERS
What are some investigations for personality disorders?
- Assessed (Hx + MSE) more than once
- Minnesota Multiphasic Personality Inventory (MMPI)
- Eysenck Personality Inventory + Personality Diagnostic Questionnaire
244
PERSONALITY DISORDERS
What is the biological management of personality disorders?
- Only use to treat comorbid conditions or if Sx distressing (e.g. antipsychotics in group A to reduce suspiciousness)
245
PERSONALITY DISORDERS
What are the psychological therapies for personality disorders?
- Dialectical behavioural therapy for EUPD
- CBT (change unhelpful ways of thinking)
- Cognitive analytical therapy (recognise + change unhelpful patterns in relationships + behaviours)
- Psychodynamic therapy (looks at how past experiences affect present behaviour)
246
DELIRIUM TREMENS
What is delirium tremens?
- Acute, toxic confusional state secondary to alcohol withdrawal (48–72h after)
247
DELIRIUM TREMENS
How does delirium tremens present?
- Clouding of consciousness, disorientation + amnesia of recent events
- Autonomic = diaphoresis, fever, tachycardia (risk of CV collapse)
- Psychomotor agitation, delusions + coarse tremor
- Visual, auditory + tactile hallucinations
248
DELIRIUM TREMENS
Describe the hallucinations in delirium tremens
- Characteristically of small people or animals (Lilliputian hallucinations)
- May feel 'ants crawling'
249
DELIRIUM TREMENS
What is the management of delirium tremens?
- ABCDE approach as emergency
- IV thiamine (pabrinex), supportive fluids
- PO lorazepam first line to prevent fitting (IV or haloperidol if refused)
250
WERNICKE'S
What is Wernicke's encephalopathy?
- Atrophy of mammillary bodies due to thiamine deficiency, often alcohol abuse
251
WERNICKE'S
How does Wernicke's present?
Triad –
- Ataxia
- Confusion
- Ophthalmoplegia + nystagmus
252
WERNICKE'S
What is the management of Wernicke's?
- ABCDE approach as emergency
- IV pabrinex immediately
- Treat high risk patients (alcoholics) with prophylactic vitamins
253
KORSAKOFF'S
What is Korsakoff's psychosis?
- Thiamine deficiency causes damage + haemorrhage to the mammillary bodies of the hypothalamus + medial thalamus
- Complication of untreated Wernicke's
254
KORSAKOFF'S
What are some causes of Korsakoff's?
- Heavy alcohol drinkers
- Head injury, post-anaesthesia
- Basal or temporal lobe encephalitis
- CO poisoning
- Other causes of thiamine deficiency (anorexia, starvation, hyperemesis)
255
KORSAKOFF'S
What is the clinical presentation of Korsakoff's?
- Profound short-term memory loss with inability to lay down new memories (antero + retrograde amnesia)
- Confabulation
256
KORSAKOFF'S
What is the management of Korsakoff's?
- ABCDE approach as emergency
- PO thiamine replacement + multivitamin supplements (for up to 2y)
- OT assessment + cognitive rehab
257
LITHIUM TOXICITY
What is lithium toxicity?
What can precipitate it?
- Serum lithium >1.5mmol/L
- >2mmol/L = life-threatening
- Dehydration, renal failure, diuretics, anti-HTNs + NSAIDs
258
LITHIUM TOXICITY
What is...
i) acute
ii) chronic
iii) acute-on-chronic
lithium toxicity?
i) Acute ingestion in patient not chronically on lithium
ii) Patients on long-term lithium without acute OD
iii) Ingestion of excess lithium in patients on chronic lithium
259
LITHIUM TOXICITY
What is the clinical presentation of lithium toxicity?
- Ataxia, dysarthria, confusion (drunk)
- COARSE tremor, blurred vision, hyperreflexia
- N+V, diarrhoea
- Myoclonus, seizures + coma if severe
260
LITHIUM TOXICITY
What are some complications of lithium toxicity?
- Arrhythmias (VT)
- Acute renal failure
- Syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) after cessation of lithium >2m = truncal ataxia, ataxic gait, scanning speech, incoordination
261
LITHIUM TOXICITY
What is the management of lithium toxicity?
- ABCDE approach as emergency
- Stop + check lithium levels, serum creatinine, U+Es
- IV fluids (bolus + 1.5–2x maintenance
- ?Whole bowel irrigation with polyethene glycol for severe, acute ingestion
- Haemodialysis
262
LITHIUM TOXICITY
When would you do haemodialysis in lithium toxicity?
- Serum [Li] >5mmol/L
OR >4 + renal dysfunction
OR severe toxicity (seizures, coma, life-threatening arrhythmias)
263
ACUTE DYSTONIA
What is an acute dystonic reaction?
- Sustained painful muscle contraction in ≥1 muscle groups
264
ACUTE DYSTONIA
What may it be caused by?
- ?Imbalance of dopamine + cholinergic transmission where D2 receptors become so blocked that excess output of cholinergics
265
ACUTE DYSTONIA
What is the clinical presentation of acute dystonic reaction?
- Rapid onset after dose given or changed
- Spasm of muscles of tongue, face, neck + back
- Oculogyric crisis (prolonged involuntary upward deviation of eyes)
- Torticollis (twisted neck)
- Tongue protrusion
266
ACUTE DYSTONIA
What is the life-threatening complication?
Laryngeal dystonia > airway compromised
267
ACUTE DYSTONIA
What is the management of acute dystonia?
- ABCDE approach as emergency
- Anticholinergic – IM procyclidine
- Stop antipsychotic (switch to atypical as less EPSEs)
268
NMS
What is the pathophysiology of neuroleptic malignant syndrome (NMS)?
- Dopamine antagonism often due to typical antipsychotic OD or acute withdrawal of Parkinson's meds
269
NMS
How quickly does NMS present?
- Onset within 2w of drug or dose change (onset + progression slow)
- May last 7–10d after PO or 21d after depot
270
NMS
What is the clinical presentation?
Bodybuilder–
- Pyrexia >38 + diaphoresis
- Muscle rigidity (diffuse "lead-pipe" rigidity)
- Confusion, agitation, altered consciousness
- Tachycardia, high/low BP
- Hyporeflexia
271
NMS
What are the complications of NMS?
- Resp failure, CV collapse
- Rhabdomyolysis
- DIC
272
NMS
What are some investigations for NMS?
- FBC (leukocytosis)
- Low serum iron
- U+Es, Ca2+, phosphate
- Urinary myoglobin (raised)
- Serum creatinine phosphokinase (CPK) may be raised
- CK raised
273
NMS
What is the management of NMS?
- ABCDE approach
- Stop antipsychotic (wait >2w before restarting, consider atypical)
- Give L-dopa if dopamine withdrawal in Parkinson's
- IV dantrolene or lorazepam to reduce rigidity 1st line (amantadine second)
- Bromocriptine prophylaxis
274
NMS
What is the supportive management for NMS?
- Oxygen, cooling blankets, antipyretics, ice-water enema for pyrexia
- IV access to correct volume depletion + reduce risk of rhabdomyolysis with fluids (cooled)
275
NMS
How is risk of rhabdomyolysis reduced?
- Vigorous hydration
- Alkalinisation with IV sodium bicarbonate (target urine pH of 6)
276
SEROTONIN SYNDROME
What is serotonin syndrome?
- Disorder caused by excess serotonin in brain
277
SEROTONIN SYNDROME
What are some causes of serotonin syndrome?
- Antidepressants = SSRIs (inhibit reuptake), SNRIs, St. John's wart, MAOI (decreased metabolism)
- Drugs = ecstasy, amphetamines, LSD, anti-emetics
278
SEROTONIN SYNDROME
What is the clinical presentation of serotonin syndrome?
Sx onset + recovery fast –
- Neuro = confusion, agitation
- Neuromuscular = myoclonus, tremors (incl. shivering), hyperreflexia, ataxia
- Autonomic = hyperthermia, diarrhoea, tachycardia, mydriasis
279
SEROTONIN SYNDROME
What are some investigations for serotonin syndrome?
- FBC, U+Es, biochemistry (Ca2+, Mg2+, phosphate), CK, drug toxicology scren
- ECG monitoring for prolonged QRS or QTc interval
280
SEROTONIN SYNDROME
What is the management of serotonin syndrome?
- ABCDE
- Stop offending agent
- IV access to correct volume + reduce risk of rhabdomyolysis as in NMS
- BDZs like slow IV lorazepam for agitation, seizures + myoclonus
- Serotonin receptor antagonists like PO cyproheptadine or chlorpromazine if severe
281
SEROTONIN SYNDROME
What is the management of serotonergic drug OD?
- ?Gastric lavage ± activated charcoal
282
LEARNING DISABILITIES
What is a learning disability?
- Condition of arrested or incomplete development of mind, characterised by impairment of skills that contribute to overall intelligence (language, cognition, social) which has manifested during developmental period
283
LEARNING DISABILITIES
How is a learning disability different to learning difficulties?
- Learning difficulties (dyslexia) are difficulties in acquiring knowledge + skills to the normal level expected of those of the same age, especially due to a mental disability or cognitive disorder
284
LEARNING DISABILITIES
What is the triad in learning disabilities?
- Low intellectual performance (IQ < 70)
- Onset during birth or early childhood
- Wide range of functional impairment
285
LEARNING DISABILITIES
What is the epidemiology of learning disabilities?
- M>F, biggest risk factor is FHx
286
LEARNING DISABILITIES
What are some causes of learning disabilities?
- Genetic = Down's, Fragile X, Prader-Willi, neurofibromatosis
- Antenatal = TORCH
- Perinatal = asphyxia, intraventricular haemorrhage
- Postnatal = meningitis, kernicterus
- Environmental = malnutrition, smoking or alcohol in pregnancy
287
LEARNING DISABILITIES
What physical disorders may be present in those with learning disabilities?
- Motor disabilities (ataxia, spasticity)
- Epilepsy
- Impaired hearing/vision
- Incontinence
288
LEARNING DISABILITIES
How is mild learning disability characterised by...
i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?
i) 50–69
ii) 9–12
iii) Mobile
iv) Mostly adequate
v) Difficulties reading + writing
vi) Most independent
289
LEARNING DISABILITIES
How is moderate learning disability characterised by...
i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?
i) 35–49
ii) 6–9
iii) Mobile
iv) Simple-no speech, may sign, reasonable comprehension
v) Limited, some learn to read, write + count
vi) Lifelong supervision, may need prompting + support
290
LEARNING DISABILITIES
How is severe learning disability characterised by...
i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?
i) 20–34
ii) 3–6
iii) Marked impairment
iv) Simple-no speech, may sign, reasonable comprehension
v) Limited, some learn to read, write + count
vi) Lifelong supervision, may need prompting + support
291
LEARNING DISABILITIES
How is profound learning disability characterised by...
i) IQ?
ii) mental age?
iii) mobility?
iv) speech?
v) academia?
vi) self-care?
i) <20
ii) <3
iii) Severe impairment
iv) Basic non-verbal comms, understands basic commands
v) None
vi) Complete dependency
292
AUTISM SPECTRUM
What is autism?
- Pervasive development disorder which manifests before age 3
293
AUTISM SPECTRUM
What is associated with autism?
- Learning difficulties
294
AUTISM SPECTRUM
What is Asperger's syndrome?
- ASD without cognitive impairment + fewer problems with language
295
AUTISM SPECTRUM
What are some risk factors for autism?
- M>F
- Obstetric complications
- Perinatal infection (rubella)
- Genetic disorders (Fragile X, Down's)
296
AUTISM SPECTRUM
What are the 3 areas of impaired functioning that need to be present in autism?
- Social interaction
- Communication (speech + language)
- Behaviour (imposition of routine with ritualistic or repetitive behaviour)
297
AUTISM SPECTRUM
Give some examples of impaired social interaction
- Failure to notice + respond to social cues + others' emotional states
- Difficulty establishing friendships
- Lack of eye contact
- Delay in smiling
298
AUTISM SPECTRUM
Give some examples of impaired communication
- Expressive speech + comprehension usually delayed or minimal
- Concrete thinking (lack imagination)
- Absence of gestures
- Later speech consists of monologues, endless questions, echolalia
299
AUTISM SPECTRUM
Give some examples of impaired behaviours
- Inability to adapt to new environments (distress)
- Tendency to have rigid routine with resistance to change
- Greater interest in objects, numbers + patterns than people
- Stereotypical repetitive movements which may be self-stimulating movements to comfort themselves (rocking, hand-flapping)
300
AUTISM SPECTRUM
What is the management of autism?
- No cure so MDT for best environment to support child + parent
- CAMHS, paediatrician, SALT, dieticians, social workers, specially trained educators, special school environments
- Picture based timetables
- Charities for support (national autistic society)
301
TIC DISORDERS
What are tics?
- Repetitive, involuntary, purposeless movements + sounds
302
TIC DISORDERS
What might cause them?
- Stress, gestational + perinatal insults, PANDAS
303
TIC DISORDERS
What is Tourette's syndrome?
- Development of tics that are persistent for >1y
- More severe expression of the spectrum of tic disorder
304
TIC DISORDERS
How does Tourette's syndrome present?
- Multiple motor tics + at least 1 phonic tic (coprolalia)
305
ADHD
What is attention deficit hyperactivity disorder (ADHD)?
- Extreme end of hyperactivity + inability to concentrate, affecting person's ability to carry out everyday tasks, develop normal skills + perform well in school
306
ADHD
What are some risk factors for ADHD?
- Epilepsy, low socioeconomic status, learning difficulties
- Premature or LBW
- Brain damage (in vitro or after severe head injury later)
307
ADHD
What is the epidemiology of ADHD?
- M>F
- Dx between 6–12y (must be ≥6y but show Sx before 12y)
308
ADHD
What is the triad of symptoms in ADHD?
- Inattention
- Impulsivity
- Hyperactivity
309
ADHD
How does inattention present?
- Short attention span
- Quickly changes task as loses interest
- Easily distracted
- Loses important items
- Careless mistakes
310
ADHD
How does impulsivity present?
- Blurts answer before questions completed
- Difficulty awaiting turn
- Interrupts others
- Teenagers have impulsive behaviours (car accidents, pregnancy)
311
ADHD
How does hyperactivity present?
- Constantly fidgeting
- Constant "on the go" or "driven by a motor"
- Excessive talking
312
ADHD
How is a diagnosis of ADHD reached?
- Features consistent across ≥2 settings (home, school)
- Diagnosed ≥6y when Sx present continuously for ≥6m
- Information from teachers, school reports, family etc used
313
ADHD
What is the management of ADHD?
Conservative initially (watch + wait) –
- Family education on ADHD + parenting advice
- Establish normal balanced diet, exercise can improve Sx
- Food diary to identify any triggers + eliminate with dietician
314
ADHD
What is the management for severe ADHD?
- CNS stimulants like methylphenidate (increase monoamine pathway activity, not addictive)
- S/E = appetite suppression, insomnia, psychosis, important to monitor growth, baseline ECG (cardiotoxic)
- Atomoxetine (SE = liver dysfunction, suicidality)
- (Lis)dexamfetamine
315
SOMATISATION DISORDER
What is somatisation disorder?
- Multiple, atypical + inconsistent presentations with MUS, affecting multiple organ systems.
- Symptoms present ≥2y, F>>M
316
SOMATISATION DISORDER
What is the clinical presentation of somatisation disorder?
- Non-specific + atypical Sx (usually derm, GI)
- Discrepancy between subjective + objective findings (S = Sx)
- Sx often in one system, may move to another once Dx possibilities exhausted
- Often results in multiple needless investigations + operations (pt refuses to accept -ve results)
317
SOMATISATION DISORDER
What is the management of somatisation disorder?
- Rule out all organic illnesses
- Communicate Dx but acknowledge Sx severity
- Reassure patient of continuing care
- May benefit from CBT, group therapy or psychotherapy
318
COUNSELLING
What is counselling?
- Relieving distress via dialogue between 2 people
- Therapist listens + helps patient find own solutions
319
PSYCHOEDUCATION
What is psychoeducation?
- Briefing patients about their illness so they understand it better
- Problem solving training so they know how to deal with it better
- Communication training so they can express their emotions better
- Self-assertiveness training, relatives included
320
CBT
What is the role of cognitive behavioural therapy (CBT)?
- Identify + challenge negative thoughts + modify abnormal core beliefs
- Based on idea disorder not caused by life events but way patient views these events > better emotional regulation
321
DBT
What is dialectical behavioural therapy (DBT)?
- Helps to change unhelpful ways of thinking (anger) + behaving (self-harm) like CBT but also focuses on accepting who you are at same time (accept + change
322
DBT
What are the two components to DBT?
- Individual therapy = therapist validates pt's responses, reinforces adaptive behaviours + facilitates analysis of maladaptive behaviours + their triggers
- Group therapy = teaching on mindfulness, interpersonal effectiveness skills (problem solving, communication), emotional modulation skills
323
PSYCHOANALYTICAL PSYCHOTHERAPY
What is psychoanalytical psychotherapy?
- Childhood experiences, past conflicts + relationships influence individual's current situation
- Once inner struggles brought to light, behaviour + feelings improve
324
GROUP PSYCHOTHERAPY
What is group psychotherapy?
Give some examples
- Individuals brought together under therapist's guidance with goals of reducing distress + Sx, increasing coping or improving relationships
- Support groups, activity groups (art, music), self-help groups (AA)
325
FAMILY THERAPY
What is family therapy?
- Enables those in close relationships to better understand, support each other better, explore each other's thoughts + build on family strengths together
326
INTERPERSONAL THERAPY
What is interpersonal therapy?
What is it used in?
- Identify + address problems in their relationships with idea that poor relationships can leave you depressed + depression in turn can make relationships worse
- Depression (severe or not responded to other therapies)
327
BEHAVIOURAL ACTIVATION
What is behavioural activation therapy?
What is it used for?
- Aim to give patients motivation to make simple, practical steps towards enjoying life again
- Also teaches problem-solving skills
- Depression
328
GENDER DYSPHORIA
What is gender dysphoria?
- Mismatch between biological sex + gender identity of an individual causing distress
329
GENDER DYSPHORIA
Define...
i) transsexual
ii) trans woman
iii) trans man
i) Person who emotionally + psychologically feels that they belong to opposite sex
ii) Assigned male sex 46XY at birth who later identifies as a woman
iii) Assigned female sex 46XX who later identifies as a man
330
GENDER DYSPHORIA
What act is relevant to gender dysphoria?
- Gender recognition act 2004
- Allows transsexual people to legally change their gender
- Have to demonstrate Dx of gender dysphoria + have lived as gender role for ≥2y
331
GENDER DYSPHORIA
What is the clinical presentation of gender dysphoria?
- Low self-esteem, self-neglect, social isolation
- Depression, anxiety + suicidality
- Only comfortable when in preferred gender role
- Strong desire to hide physical signs + dislike of genitals of biological sex
332
GENDER DYSPHORIA
What is the management of gender dysphoria in...
i) <18?
ii) >18?
i) Referral to gender identity development service (GIDS) with MDT (CAMHS, clinical psychologist, social worker, family therapist)
ii) Referral to gender dysphoria clinic (GP or self-referral)
333
GENDER DYSPHORIA
What surgical procedures may be offered?
- TM = mastectomy, hysterectomy, nipple repositioning, phalloplasty or penile implant, scrotoplasty + testicular implants
- TW = orchidectomy, penectomy, vaginoplasty, vulvoplasty or clitoroplasty
334
GENDER DYSPHORIA
What biological treatment can be used in <16y?
- Very few young people who meet strict criteria may have gonadotropin-releasing hormone analogues (hormone blockers) as reach puberty
335
GENDER DYSPHORIA
What biological treatment can be used >16?
- Cross-sex/gender-affirming hormones if on hormone blockers for ≥12m
– Oestrogen for breasts + feminine features
– Testosterone for deep voice + masculine features (body hair)
336
GENDER DYSPHORIA
What psychological treatment can be given to...
i) <18y?
ii) >18y?
i) Family therapy, individual child psychotherapy, parental support/counselling
ii) Counselling, SALT to help sound like gender identity
337
GENDER DYSPHORIA
What social management is there for gender dysphoria?
- Quit smoking (may increase risks of side effects from treatments)
- Lose weight if overweight to reduce risks from cross-sex hormones)
- Social transitioning incl. changing name by deed poll
338
GENDER DYSPHORIA
What are some risks of the hormone therapy?
- Oestrogen = clots, gallstones, high triglycerides
- Testosterone = polycythaemia, acne, dyslipidaemia
- Both = elevated LFTs, infertility, weight gain
