Psych Flashcards
(369 cards)
1
Q
List the headings of the MSE
A
Appearance and Behaviour Speech Affect/Mood Thought Perception Cognition Insight
2
Q
How do you assess capacity?
A
- Understand the information
- Retain the information
- Weight up the pros and cons of the decision
- Communicate the decision back
3
Q
What is a Section 5(4)?
A
A authorised mental health nurse can detain a ‘psych’ patient who is trying to leave hospital against advice and is likely to cause harm for up to 6 hours. During this 6 hours the nurse must find someone do do a section 5(2) or the patient can leave.
4
Q
What is a Section 5(2)?
A
A doctor can detain a hospitalised patient for up to 72 hours, if they suspect they have a mental health problem and they or others are at risk. In this 72 hours a plan for the patient should be created with a psychiatrist.
Note - A&E is NOT a ward, so you cannot place someone under a 5(2) who is in A&E.
5
Q
What is a Section 2?
A
Admission for assessment (and treatment) for up to 28 days.
AMHP makes the application on recommendation from 2 doctors. 1 of which must be ‘section 12 approved’ e.g. consultant or reg.
Patients can appeal within 14 days
6
Q
What is a Section 3?
A
Admission for treatment for up to 6 months.
The exact mental disorder must be stated and treatment must be available and specified.
2 doctors must sign the form and have seen the patient within 24 hours.
Detention is renewable after 6 months (then yearly)
7
Q
What is a Section 4?
A
Emergency admission for up to 72 hours.
Used when a section 2 may take too long.
A AMHP or relative (rare) makes the application after recommendation by a doctor (usually GP).
The patient must be seen by a second doctor within 72 hours - then be put on a section 2 or 3 or discharged or they may choose to remain as a voluntary patient.
8
Q
What is a Section 136?
A
Allows the police to arrest a person from a PUBLIC PLACE who they believe to have a mental health problem and take them to a place of safety.
A person can be held for a maximum of 72 hours.
9
Q
What is a Section 135?
A
Allows the police to force entry into someones home to allow a MHA to be made.
A warrant is required.
10
Q
What is a Section 17?
A
The allowance of a sectioned patient to leave the hospital.
To spent time with family or trial a return to the community.
11
Q
What is a Section 117?
A
Provision of after-care for patients who have been detained for a long period of time.
Patient cannot be discharged until this is done.
12
Q
What is a community treatment order?
A
Patient on section 3 and well enough to leave hospital but requires ongoing treatment.
The patient can be recalled to hospital if they do not comply with treatment and appointments.
13
Q
What is a hallucination?
A
A perception in the absence of an external stimulus that has the qualities of a real perception
14
Q
What is psychosis?
A
A state of impaired reality made up of hallucinations and delusions.
15
Q
What is an illusion?
A
An involuntary misinterpretation of a real stimulus transformed or distorted.
Often bought on my tiredness or emotion.
16
Q
What is a pseudohallucination?
A
A hallucination that the patient knows is NOT real
e.g. a voice heard within themselves
17
Q
What is a hypnagogic hallucination?
A
Hallucination as you are falling asleep
Non-pathogenic
18
Q
What is a hypnopompic hallucination?
A
A hallucination as you are waking up
Non-pathogenic
19
Q
What are 1st person auditory hallucinations?
A
Audible thoughts - thoughts spoken aloud
20
Q
What are 2nd person auditory hallucinations?
A
Voices talking directly to the patient, can be persecutory, highly critical or complimentary.
Associated with mood disorders
21
Q
What are 3rd person auditory hallucinations?
A
Voices heard speaking about the patient, arguing or giving a running commentary.
22
Q
What is it called when 1st person auditory hallucinations happen as thoughts occur?
A
Gedankelautwerden
23
Q
What is it called when 1st person auditory hallucinations happen just after the thought occurred?
A
Écho de la pensée
24
Q
What are some organic causes of visual hallucinations?
A
Delirium, occipital lobe tumours, epilepsy, dementia, drugs (e.g. LSD, alcohol, glue sniffing)
25
What is Charles Bonnet syndrome?
loss of sight --> hallucinations
26
How do most hallucinations start?
Simple brief experiences in one modality
27
What are some negative symptoms of psychosis
```
Apathy
Poverty of thought and speech
Blunting of affect
Social isolation
Poor self care
Cognitive deficit
```
28
What is an overvalued idea?
A plausible idea that patients become preoccupied with and causes them distress
29
What is an extracampine hallucination?
A hallucination outside normal sensory limits
| e.g. hearing something 100s of miles away
30
What is a delusion?
A belief that is strongly held despite evidence to the contrary and that is out of keeping with a persons educational or cultural background
31
What is a mood congruent delusion?
Seen is affective psychosis
Depressed person --> nilhilistic delusion
Manic person --> grandiose delusion
32
What is a primary delusion?
A delusion that occurs suddenly without an abnormal event leading up to it
33
What is a mood incongruent delusion?
Often seen in schizophrenia
| Horrific beliefs discussed without commensurate distress
34
What is a secondary delusion?
Arises from some previous abnormal idea or experience
35
What are three characteristics of a delusion?
Incorrect - because of faulty reasoning
Incorrigibility - not changeable by compelling counterargument
Incompatible - with patients social, cultural or religious background
36
What is a persecutory delusion?
Being harmed, threatened, cheated, harassed
37
What is a grandiose delusion?
Exceptionally powerful, talented, important
38
What is a delusion of reference?
Certain object, people or events have significance to oneself
e.g. TV presenter speaking directly to them
39
What is a religious delusion?
Religious theme, often grandiose
40
What is a delusion of love?
Another (often of higher social status) is in love with them
41
What is a delusion of infidelity? and give and example
Lover has been unfaithful BUT with no evidence
| Othello syndrome
42
What is capgras syndrome?
familiar person replaced with exact double
43
What is fregoli syndrome?
A single person is impersonating multiple familiar people
44
What is a nihilistic delusion?
Oneself, others or the world is about to end
| E.g. you are rotting away
45
What is a somatic delusion?
Concern over one’s body and its functioning
46
What is a delusion of infestation? and whats is called
One is infested
| Ekbom's syndrome
47
What is the delusions of thought control? and what do they mean
Thought insertion - One’s thoughts are being implanted by an external agent
Thought withdrawal - thoughts are being extracted from one’s head
Thought broadcasting - thoughts are being broadcast to others
48
What is Jerusalem syndrome?
On visiting Jersualem a person develops religious delusions.
Can happen in people of all religions.
49
Give some examples of disordered thinking (formal thought disorder)
```
Circumstantial and tangential thinking
Flight of ideas
Loosening of association
Neologisms
Thought blocking
Perservations
Logocolonia
Echolalia
Irrelevant answers
```
50
Define circumstantial thinking
An inability to answer a question without giving excessive, unnecessary detail. This differs from tangential thinking, in that the person does eventually return to the original point.
51
Define tangential thinking
Speaker never returns to the original point
52
Define flight of ideas
Thinking is accelerated causing a stream of connected concepts
53
Define loosening of association (derailment)
Patients train of thought shifts between unconnected ideas
54
Define neologisms
Use of new words created by the patient
55
Define thought blocking
Sudden stop to the patients flow of thought, often mid sentence
56
Define preservations
Patients repeat a word or phrase
Palilalia – repetition of the last word of their sentence
Logocolonia – repetition of the last syllable
Suggestive of organic brain disease
57
Define echolalia
Patient repeats words or phrases spoken around them
58
What is thought form?
Speed – accelerated / racing / retarded
Flow/ coherence:
Linear – in a logical order
Incoherent – makes no logical sense
Circumstantial – lots of irrelevant/unnecessary details (not to the point)
Tangential – the patient goes off on tangents relating loosely to the initial thought (flight of ideas)
Perseveration – repetition of a particular response despite the absence/removal of the stimulus
59
What is thought content?
Abnormal beliefs/ delusions
Obsessions – patient is aware they are irrational, but obsessive thoughts continue to enter their head
Overvalued ideas – e.g. the perception of weight in a patient with anorexia nervosa
Suicidal thoughts
Homicidal/violent thoughts
60
What is passivity phenomenon?
The belief that your actions, thoughts and impulses are controlled by someone else.
Incorporates thought broadcast, insertion and withdrawal.
61
What is Schizophrenia?
A chronic relapsing condition that often presents in early adulthood.
Characterised by positive symptoms (delusions and hallucinations) and negative symptoms (apathy, poverty of thought and speech, blunting of affect, social isolation, poor self care)
Affects more men than women
62
How long to symptoms have to last to be diagnosed with Schizophrenia?
At least 6 months
| With symptoms present most of the time for 1 month
63
What are the criteria for diagnosing Schizophrenia?
At least 1 very clear symptom (1st rank)
| Or at least 2 2nd rank symptoms
64
What are the first rank symptoms of Schizophrenia?
There are four
Thought disorder (insertion, broadcast or withdrawal)
Delusions that thoughts, feelings, impulses or actions are being influences or controlled by external forces.
Auditory hallucinations
Persistent delusions
65
What are the second rank symptoms of Schizophrenia?
Persistent hallucinations in any modality
Breaks or interpolations in the train of thought, flighting off in tangents, neologisms or odd logics
Catatonic behaviour
Negative symptoms
66
What are some negative symptoms of Schizophrenia?
```
Apathy
Paucity of speech
Blunting of affect
Laughing at bad news
Social withdrawal
```
67
What are prodromal symptoms of Schizophrenia?
Symptoms that precede the first episode of psychosis (months to days)
--> Gradual deterioration in functioning
68
What are some potential causes of Schizophrenia?
Genetic
Early cannabis consumption
Environmental (urban birth, pregnancy abnormalities, maternal influenza, migration)
Dopamine hypothesis (alterations in glutamate transmission --> Increased D2 transmission in Basal Ganglia + decreased D2 transmission in the Prefrontal Cortex)
69
What are precipitating and maintaining factors of Schizophrenia?
Precipitating Factors: Stress
| Maintaining Factors: High expressed emotion
70
How is Schizophrenia managed?
```
Start antipsychotics (2nd generation - first line)
Psychsocial intervention
Support for families
```
71
How can you improve adherence to antipsychotics?
Depots
72
What is paranoid Schizophrenia?
Prominent hallucinations and/or delusions (often persecutory)
May develop at a later age than other types of schizophrenia.
Speech and emotions may be unaffected.
73
What is hebephrenic Schizophrenia?
Behaviour is disorganised and without purpose (Pranks, giggling, health complaints, grimacing).
Thoughts are disorganised, other people may find it difficult to understand you.
Delusions and hallucinations are fleeting.
74
What is catatonic Schizophrenia?
Unusual movements, often switching between extremes of over-activity and stillness.
You may not talk at all.
75
What is undifferentiated Schizophrenia?
Your illness meets the general criteria for a diagnosis and may have some characteristics of paranoid, hebephrenic or catatonic schizophrenia, but does not obviously fit one of these types.
76
What is residual Schizophrenia?
You may be diagnosed with this if you have a history of psychosis but only have negative symptoms.
77
What is simple Schizophrenia?
Rarely diagnosed in the UK.
Negative symptoms are prominent early and get worse quickly.
Positive symptoms are rare.
78
What is cenesthopathic Schizophrenia?
People experience unusual bodily sensations.
79
Why might someone with Schizophrenia be depressed?
Integral part of the disorder
Response to increasing insight
Side affect of meds
80
What is Schizoaffective disorder?
This involves both schizophrenic and mood (depressive or manic) symptoms. All symptoms should be severe enough to meet the ICD classification. It can be sub classed into manic type or depressed type.
81
What is delusional disorder?
Involves the development of a delusion for at least 3 months, where delusions are the only symptom. However, delusions of thought control, which is a first rank symptom of schizophrenia, aren’t normally present. The typical onset is later than schizophrenia, normally in middle age.
82
What is schizotypal disorder?
A personality disorder which may represent a partial expression of schizophrenia
Usually treated without meds
83
What is schizophreniform disorder?
Fail to meet threshold for Schizophrenia (usually duration of psychosis) but have symptoms of Schizophrenia and deterioration in function.
Do treat with meds
84
What organic conditions can cause Schizophrenia?
Cerebral neoplasm, infarct, infection, trauma, endocrine (thyroid, parathyroid, adrenal), epilepsy, SLE, Huntington’s, vitamin B12 and thiamine deficiency
85
What drugs can cause psychosis?
Alcohol, Amphetamine, Cocaine, Inhalants/solvents, Corticosteroids, Anticholinergics, Anti- Parkinson's drugs
86
What other differentials are there for psychosis?
Manic episode with psychosis, Depressive episode with Psychosis, Delirium and dementia, Personality disorder
87
What classes of antipsychotics are there and give examples.
1st generation - Haloperidol, Chlorpromazine
2nd generation - Olanzapine, Risperidone, Clozapine, Quetiapine
3rd generation - Aripirazole
88
What is the mechanism of action of 1st generation antipsychotics?
Act as D2-antagonists in the CNS. They bind strongly to post synaptic receptors
Affect is via the MESOLIMBIC PATHWAY
Causes EPS
89
What is the mechanism of action of 2nd generation antipsychotics?
Act as D2-antagonists in the CNS and antagonise 5-HT, alpha-1 and muscarinic receptors
More metabolic side effects
90
How does Aripirazole work?
Stabilises the dopamine system
91
What are some ADRs of generation antipsychotics?
Excessive weight gain (especially Olanzapine),
Increased prolactin secretion (amenorrhoea, gynaecomastia, sexual dysfunction)
Extra-pyramidal side effects -
due to effect at NIGTOSTRIATAL PATHWAY (especially 1st generation)
Diabetes
Cardiac toxicity (long QT syndrome→↑ risk of Torsades de Pointes)
EPS refers to a cluster of symptoms consisting of akathisia, parkinsonism, dystonia and tardive dyskinesia
92
When are antipsychotics contraindicated?
Myasthenia gravis, Addison’s, glaucoma and bone marrow depression
93
How can you manage the parkinsonian side effects of antipsychotics?
Anticholinergics (e.g. procyclidine)
Plus decrease dose as much as you can
94
Describe Clozapine
Has a higher affinity for D4 receptors
Prolactin sparing, best at reducing negative symptoms
Only used for treatment resistant schizophrenia (failure of 2 medications, one of which should be an atypical antipsychotic over 6-8 weeks each)
```
Side effects (Agranulocytosis -requires regular haematological monitoring, Myocarditis) -
Monitor bloods weekly for 18 weeks then fortnightly
```
95
What should you check before starting antipsychotics?
BP, weight, fasting BMs, lipid profile and FBC
+ECG if starting clozapine
96
What should you monitor every 6 months if you are taking antipsychotics?
LFTs, U&Es, prolactin, weight, HbA1C
97
Why do 2nd generation antipsychotics cause postural hypotension?
Alpha-1 adrenoceptor blockade
98
What causes a mood disorder?
Monoamine hypothesis (Manic episode = increase in noradrenaline and serotonin, Depressive episode = decrease in noradrenaline and serotonin)
Predisposing- genetic factors (5HTT gene polymorphism), childhood experiences
Precipitating- life events, substance abuse, bereavement (Prolonged adversity, then a final acute stressor)
Perpetuating- relationships, finance, work, housing, support
Physical conditions e.g. influenza, childbirth, Parkinson’s
99
How do you treat a mood disorder?
Biological: Antidepressants: (SSRIs, SNRIs, TCAs, NASSAs, MAOIs), Mood Stabilisers (Lithium), Combination therapies, ECT
Psychological- psychoeducation (about illness, relapse, medication, supportive psychotherapy), CBT, interpersonal therapy,
Social- targeted interventions (family, housing, finance, employment
100
Who is depression more common in? Men or women
Women 2:1
101
What causes depression?
Psychological: (Interpreting facial expressions as negative; remember unhappy events more easily; unrealistic beliefs)
Social: Disruption to life events, stress
Biochemical: (Decreased 5-HT in CSF and brain, neuroendocrine function involving 5-HT reduced, tryptophan (5-HT precursor) depletion via diet, decreased NA)
Endocrine abnormalities: (cushings, addisons and hyperparathyroidism)
102
What are the core symptoms of depression?
Continuous low mood for at least 2 weeks, lack of energy, anhedonia (lack of enjoyment from anything)
103
List some depressive cognitions
Decreased self-esteem, guilt and self-blame, hopelessness, hypochondriacal thoughts, poor concentration/ attendance, suicidal thoughts
104
What are some somatic manifestations of depression?
Early morning wakening (patient lie pessimistic about the day), decreased appetite, weight loss, psychomotor agitation/ retardation (retarded depression or depressive stupor), loss of libido, can cause amenorrhoea
105
How is atypical depression characterised?
Reversal of somatic symptoms
106
What is the ICD10 classification of depression?
Mild= 2 core + 2 others (able to function)
Moderate= 2 core + 3+ others
Severe = 3 core + at least 4 others
With/without:
- Somatic symptoms
- Psychotic symptoms
- Manic episodes
Only use in first episode - the define as recurrent depressive disorder
107
How do you treat the different types of depression?
Mild - reassess in 2 weeks, exercise, lifestyle changes, computerised CBT/self-help books
Moderate - CBT (first line) and/or antidepressant (SSRI)
Severe - Rapid MHA (may need admission), CBT, antidepressant and maybe ECT
108
What is Dysthymia?
The same cognitive and physical problems as depression but less severe and longer lasting
?Depressive PD
109
What is Cyclothymia?
Cyclical mood swings with sub-clinical features
110
Define mild depression following childbirth
Occurs in the first few days, is normal and self limiting. Peaks 3-4 days post delivery.
111
What is Postnatal depressive disorder?
Occurs in first three month following delivery. Tiredness, irritability and anxiety more prominent. Causes include previous psychiatric illness, stress during pregnancy, loss of sleep and fatigue. Edinburgh postnatal depression scale used. Can have negative affect on bonding.
112
What is Puerperal psychosis?
A severe episode of mental illness, which begins suddenly in the days or weeks after having a baby. Symptoms vary and can change rapidly. They can include high mood (mania), depression, confusion, hallucinations and delusions. If antipsychotics or lithium are prescribed breast feeding
113
What is Seasonal Affective Disorder?
Depression in winter months (due to decreased sunlight). With hypersomnia and increased appetite.
114
What differentials should you have in mind when talking to a depressed person?
```
Bipolar
Schizophrenia
Anorexia nervosa
Anxiety
Dysthymia
Substance misuse
Dementia
Sleep disorders
Physical illness
Medication ADRs (e.g. Beta-blockers)
```
115
What self help things can you do to improve depression?
```
Increased activity
Socialising
Sleep hygiene
Mindfulness
'self soothing'
Improve diet
```
116
When should you use antidepressants in mild depression?
When symptoms persist for greater than 8 weeks
117
What is IAPT?
Improving access to psychological treatment
A way to get people into CBT and interpersonal therapy quicker
118
How often should you follow up a patient with depression?
Regularly at first (monthly) then less so
119
What is St Johns wort?
Herbal remedy for depression
Does actually work
Up regulates CYP450, affective drug metabolism --> decreased OCP effeciency
120
What are the factors suggest a high suicide risk?
```
S - suicide plan
U - unexplained guilt
I - Inability to function
C - Concentration impaired
I - Impaired appetite
D - Decreased sleep
E - Energy low
```
Greater or equal to 4/7 = high suicide risk
121
How does ECT work?
It interrupts the hyperconnectivity between the various areas of the brain that maintain depression
122
What are the indications for ECT?
A prolonged sever manic episode
Severe depression
Catatonia
123
How good is ECT?
Works for 80%
124
How many ECT sessions do you need?
6/12 session
| Two per week
125
What are the side effects of ECT?
Memory loss: short term reterograde amnesia, confusion, headache and clumsiness
Plus common GA side effects (MI, arrhythmias, aspiration pneumonia, prolonged apnoea, malignant hyperthermia, muscle aches, death)
126
What are the cautions in ECT?
Recent subdural/subarachnoid bleed, stoke, MI, arrhythmia, CNS vascular anomalies
127
What are the classes of antidepressants?
```
SSRIs
SNRIs
TCAs
MAOIs
Noradrenergic and specific serotonergic antidepressant (NaSSA)
```
128
What is the mechanism of action of SSRIs?
Prevent re-uptake of serotonin by pre-synaptic membrane, increasing [serotonin] in the synaptic cleft available to bind to the postsynaptic receptor
129
Give some examples of SSRIs
Fluoxetine (licensed for under 18s, long half life), Citalopram (prolonged QTC), Sertraline (first line, best for IHD, short half life)
130
What should be monitored when taking SSRIs?
FBC (risk of anaemia due to GI bleeding, therefore avoid NSAID use)
U&E (risk of hyponatraemia)
131
What is a specific ADR with citalopram?
Prolongation of QTC interval (so check ECG)
132
What are the ADRs of SSRIs?
nausea, mania, sexual dysfunction, suicidal thoughts, diarrhoea, sleep disturbance, serotonin syndrome, bleeding (dont use NSAID or asprin), hyponatraemia
133
Which antidepressant is safest in overdose?
SSRIs
134
What is serotonin syndrome?
Caused by antidepressants, tramadol
Symptoms: Restlessness, sweating, tremor, shivering, myoclonus, confusion, convulsions
135
What happens if antidepressants are suddenly discontinued?
discontinuation syndrome (flu symptoms, sleep, senses, movement, mood problems)
136
What antidepressant are 1st, 2nd, 3rd and 4th line?
1- SSRI
2- Another SSRI
3- Venlafaxine or mirtazapine
4- Just keep switching (maybe try lithium as an adjunct)
137
What should you do when you want to swap antidepressants?
Cross-taper
Note: When swapping off a MAOI - stop then wait for 2 weeks to allow MAO to replenish
138
Give some examples of TCAs
Amitriptyline, Lofepramine (safest, least cardiotoxic), Imipramine
139
What is the mechanism of action of TCAs
Block both re-uptake of serotonin and NA at pre-synaptic membrane AND H1, α1 and anticholinergic blockage
140
What are the side effects of TCAs?
Sedation, fine tremor, lower seizure threshold, ANS effects (dry mouth, constipation, urinary retention, blurred vision), CVS (tachycardia, postural hypotension, long QT), unsafe in overdose (except lofepramine)
141
Give some characteristics of TCAs
Absorbed by gut
Lipid soluble
Metabolised by liver
Long half life
142
Give an example of a Noradrenergic and specific serotonergic antidepressant (NaSSA)
Mirtazapine
Also classed as a Tetracyclic Antidepressant
143
When is Mirtazapine used?
Severe depression, PTSD
144
What are some ADRs of Mirtazapine?
Increased appetite, weight gain, dry mouth, postural hypotension, confusion, mania, hallucinations, angle closure glaucoma
145
When is Mirtazapine contraindicated?
renal impairment, pregnancy, hepatic impairment, jaundice
146
Give some examples of SNRIs
Venlafaxine (thought to be more affective), Duloxetine
147
What is the mechanism of action of SNRIs?
Blocks the reuptake of serotonin and NA
148
What are the ADRs of SNRIs?
Nausea, dry mouth, headache, dizziness, sexual dysfunction, hypo/hypertension
149
Give some examples of MAOIs
Isocarboxacid, Phenelzine
150
Why are MAOIs rarely used?
Serious ADRs and DDIs
Foods with thymine in (e.g. cheese) → hypertensive crisis
151
Define bipolar
A mental disorder that causes periods of depression and periods of elevated mood
152
Give some signs of mania
Mood: Irritability, euphoria, lability
Cognition: Grandiosity, distractibility, fight of ideas, confusion, lack of insight
Behaviour: Rapid speech, hyperactivity, decreased sleep, hyper-sexuality, extravagance
Psychotic signs: Delusions, hallucinations
153
What is hypomania?
Many of the signs of mania BUT no psychotic signs, impairment in daily functioning or need for hospitalisation
3 or more characteristic symptoms for at least 4 days
154
What are some causes of mania?
Physical: Epilepsy, neoplasm, infection, stroke, MS, hyperthyroidism
Medication: Cocaine, steroids, amphetamines
155
How would you assess a manic person?
ASK about: infections, drug use and family history of mental health problems
DO: Head CT, EEG, screen for drugs
156
What is type 1 bipolar?
At least one manic episode is necessary to make the diagnosis; depressive episodes are common in the vast majority of cases with type 1 bipolar disorder§, but are unnecessary for the diagnosis
157
What is type 2 bipolar?
No manic episodes
One or more hypomanic episodes and one or more major depressive episode
158
In bipolar how long to depressive, manic and hypomanic episodes typically last?
Depressive - at least 2 weeks
Hypomanic - at least 4 days
Manic - at least 1 week
159
What treatments can be used in Bipolar?
Atypical anti-psychotics (mood stabilizers e.g. risperidone, olanzapine, quetiapine)
Anti-depressants (SSRIs) in conjunction with mood stabiliser
Lithium
Sodium valproate
160
What is used to treat an acute episode of mania?
A second generation antipsychotic or valproate semisodium (e.g. Depakote)
161
What is Rapid cycling bipolar?
Manic and depressive symptoms appear together
Diagnosed if four or more episodes of mood disorder happen in one year
162
What should be used for prophylaxis in Bipolar?
If U&Es, ECG and T4 all fine
| --> give Lithium carbonate
163
What plasma level of lithium should you aim for?
0.6-1mmol/L
164
When should you check the lithium levels?
Weekly (12 hours post dose - take at night) until the dose have been constant for 4 weeks
Then monthly for 6 months
Then 3 monthly
165
What group show an increased likelihood of lithium toxicity?
The elderly
166
What should you suspect if lithium levels are progressively rising?
Nephrotoxicity
167
What are the ADRs of Lithium?
Diabetes insipidus, weight gain, renal impairment, fine tremor, leucocytosis, ECG changes (flattened T, wide QRS), metallic taste in mouth, hypothyroidism
168
What are signs of Lithium toxicity? And what should you do to treat it?
Appear above 1.5mmol/l, serious above 2.1mmol/l
Coarse tremor, ataxia, dysarthria (unclear articulation of speech), reduced level of consciousness, convulsions, coma.
Give sodium chloride to stimulate osmotic diuresis
169
What are some DDIs of Lithium?
Haloperidol, thiazide diuretics, muscle relaxants, NSAIDs → Increase lithium concentration
SSRIs and ECT → Serotonin syndrome
170
What are some CI of Lithium treatment?
Low sodium diet, Addison’s disease, untreated hypothyroidism, cardiac rhythm disorder
171
What are the indications of lithium treatment?
Prophylaxis and treatment of mania, hypomania and depression in bipolar disorder, prophylaxis and treatment of recurrent unipolar depression
172
Is Lithium safe in pregnancy and breast feeding?
No
Can cause heart defects in pregnancy and is secreted into breast milk
173
What is the procedure of ECT?
Patients are given general anaesthetic (e.g. methohexital, etomidate, or thiopental) and a muscle relaxant (e.g. succinylcholine) required otherwise patient would be paralysed & conscious.
The passage of a small electrical current through the brain with a view to inducing a tonic-clonic fit which is therapeutic.
Bilateral- 2 electrodes over 2 hemispheres. Effective, quicker action, more cognitive side effects,
Unilateral- 2 electrodes over the non-dominant hemisphere. Slower action, fewer cognitive side effects.
174
How should you discontinue lithium?
Slowly over 2-4 weeks
To avoid causing mania
175
What medication need to be stopped before ECT?
Lithium and Benzodiazepines
176
What is the second line medication in Bipolar prophylaxis? (after Lithium carbonate)
Semisodium valproate or carbamazepine
177
List various potential mood stabilisers
Sodium valproate
Carbamazepine
Lamotrigene
Lithium
178
What is the mechanism of action of Lamotrigene?
Blocks sodium channels
179
What is a big ADR of Lamotrigene?
Steven-Johnston Syndrome
180
When can Lamotrigene be used?
Bipolar prophylaxis and treatment resistance depression
181
When is Carbamazepine indicated?
Epilepsy, trigeminal neuralgia, bipolar disorder unresponsive to lithium
182
What are the ADRs of Carbamazepine?
Dizziness, visual disturbance, hyponatraemia, oedema, GI disturbance, rashes
183
What are the CI of Carbamazepine?
AV node abnormalities, history of bone marrow depression, acute porphyria
184
What is the mechanism of action of Carbamazepine?
Blocks sodium channels and is a GABA receptor agonist
185
How does Carbamazepine affect OCP levels?
Enzyme inducer, therefore reduced OCP levels
186
Can you use Carbamazepine in pregnancy and why?
No
Its is a teratogen --> neural tube defects
187
How does Sodium valproate need to be monitored?
Blood monitoring- serum levels when indicated, annual TFT, 6 monthly LFT & FBC
188
What are the indications of Sodium valproate?
Treatment of manic episodes associated with bipolar disorder, migraine prophylaxis
189
What are the ADRs of Sodium valproate?
Tremor, sedation, GI disturbance, headache, thrombocytopenia, hair loss
190
What are the CIs of Sodium valproate?
Family history of hepatic dysfunction
191
What is the mechanism of action of Sodium valproate?
Blocks voltage-dependent sodium channels and increased brain levels of GABA
192
What are some psychological, behavioural and physical manifestations of anxiety disorders?
Psychological - feeling of dread, apprehension, restlessness, narrowing of attention to focus on danger, increased alertness.
Physical – autonomic response (check for thyroid, heart problems, phaeochromocytoma which may be causing physical symptoms), hyperventilation, palpitations
Behaviour - reassurance seeking
193
What is an anxiety disorder?
An abnormal response to a situation which interferes with day-to-day activities and lasts more than 3 weeks
194
What is a panic disorder?
An anxiety disorder characterised by recurrent unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something really bad is going to happen.
They are unpredictable, not restricted to a specific situation
195
What is a phobic anxiety disorder?
Anxiety that happens in a well-defined situation, they are predictable e.g. agoraphobia, social phobias, specific phobias
196
What is Generalised anxiety disorder?
Worries about worries, accompanied by low level symptoms (insomnia, muscle tension, GI problems, headache)
ICD10 Classification: symptoms for 6 months or more
197
What is Social anxiety disorder?
Fear of negative evaluation by others, avoidance of feared situations, use of safety behaviours.
198
What is body dysmorphic disorder?
Preoccupation with an imagined defect in appearance, leads to time consuming behaviours (camouflaging tactics, skin picking, mirror gazing)
199
What is PTSD?
Caused by exposure to event/situation of exceptionally threatening of catastrophic nature which would be likely to cause pervasive distress in almost anyone
Main features: re-experiencing, avoidance, hyperarousal
200
Define neurosis
Mental illness that is not caused by organic disease, involving symptoms of stress (depression, anxiety, obsessive behaviour, hypochondria) but not a radical loss of touch with reality (i.e. pyschosis)
201
What are some signs that a child has anxiety?
Thumb-sucking, nail biting, bed wetting
202
List some possible treatments for anxiety disorders
```
Listening and reassurance
Regular exercise
Meditation
Progressive relaxation training
CBT (best specific measure)
Behavioural therapy (graded exposure to anxiety provoking stimuli)
Hypnosis
Medication
```
203
What is the 1st, 2nd and 3rd line treatments for anxiety disorders?
First line: CBT
Second line: SSRIs
Third line: Benzos
204
List some complications of anxiety disorders
increased autonomic arousal, avoidance, time consuming anxiety reducing behaviours, worry, procrastination, reduced concentration, impact on function, impaired sleep pattern, drug and alcohol dependence
205
What medications can be used in anxiety disorders?
First line: SSRI (also consider SNRI or TCAs)
Benzodiazepines: can build up tolerance and are hard to stop. Not a long term solution
Pregabalin: can be used as mono-therapy or with a SSRI
Antipsychotic: reserved for acute distress or sometimes to augment SSRIs
Beta-blockers: Improves somatic symptoms
206
What is the mechanism of action of Benzodiazepines?
Act on GABA-A receptors
207
What are the indications for Benzodiazepines?
Short term use only for anxiety disorders, alcohol detoxification
208
What are the ADRs of Benzodiazepines?
Drowsiness, light headedness, ataxia, confusion, amnesia
209
What can happen in Benzodiazepines overdose?
Respiratory depression
210
How do you reverse Benzodiazepines?
Flumazenil
211
Give some examples of Benzodiazepines
Lorazepam (fast onset, short acting), Diazepam (slow onset, long acting)
212
Why are beta-blockers giving in anxiety and what is there effect?
Indications- patients with predominantly somatic symptoms
Relieve autonomic symptoms e.g. tachycardia, alleviate tremor
213
How does Buspirone work?
5HT1A agonist
214
What are the indications for Buspirone?
Generalised anxiety disorder (short-term use)
215
What are the CI of Buspirone?
Epilepsy, acute porphyria
216
What are the ADRs of Buspirone?
Light headedness, nausea, dizziness
217
How do Barbiturates work?
Act on GABA-A receptors
Not commonly used due to side effects and dependence
218
How does Pregabalin work?
GABA analogue that binds to Ca2+ channels
Inhibits glutamate, noradrenaline and substance-P
219
What are the side effects of Pregabalin?
dizziness, drowsiness, blurred vision, diplopia, confusion, vivid dreams.
Avoid abrupt withdrawal
220
What are the indications for Pregabalin?
Generalised anxiety disorder, neuropathic pain
221
What hypnotic drugs are used to help sleep?
Zopiclone, Zolpidem, Zalepon, (The Z drugs)
222
How do the 'Z drugs' work?
Act on the omega 1 site on GABA-A complex
Omega 2 is involved in cognitive function
223
What are the indications for the 'Z drugs'?
Used to improve sleep short term once sleep hygiene measures are exhausted
224
Define OCD
Anxiety-related condition where a person experiences frequent intrusive and unwelcome obsessional thoughts, often followed by repetitive compulsions, impulses or urges.
Characterised by obsessions and compulsions
225
What is an obsession?
Involuntary thoughts, images or compulsions. They are often intrusive and distressing for patients.
226
What is a compulsion?
Repetitive mental operations (e.g. counting) or physical acts (e.g. hand washing). Patients feel compelled to perform them, and help reduce anxiety
227
What is the ICD10 definition of OCD?
Obsession and compulsions must be present for at least 2 weeks and be a source of distress
Acknowledged as coming from the patient’s own mind
The obsessions are unpleasantly repetitive
A compulsive act is not pleasurable, except for the relief of anxiety
228
What is the differential diagnosis for someone you suspect has OCD?
Depressive disorder: Obsessions are mood congruent and resolve with treatment
Anxiety disorder: Phobia –stimulus comes from an external object rather than the patient’s own mind. Generalized anxiety – excessive concerns about real life circumstances
Eating disorders: Thoughts and actions aren’t recognized as excessive or unreasonable
Schizophrenia: Thought insertion- patients believe that thoughts are not from their own mind. Lack of insight
229
How can you manage OCD?
Biological: SSRIs or TCA – (e.g. clomipramine)
Psychological: CBT – graded exposure
230
What is the pathophysiology of OCD?
Abnormal orbitofrontal cortex and caudate nucleus
231
What is the aim of CBT?
To change the way you feel by changing the way you think
It helps to teach the patient that some distressing emotions and behaviours are due to cognitive errors
232
What is a common exercise in CBT?
Patients may keep a thought diary to highlight correlation between thoughts, emotions and behaviours. This may help them to deal with situations in the future
233
What is CBT indicated?
Depression, eating disorders, anxiety disorders, OCD, PTSD, chronic psychotic symptoms
234
What is psychodynamic therapy? And what is transference and countertransference?
Discussion of patient’s past experiences allows the patient and therapist to discover the unconscious.
The therapeutic relationship is very important.
Transference- emotions the patient shares with the therapist
Countertransference- emotions the therapist shares with the patient during therapy
235
What are the indications for psychodynamic therapy?
Dissociative disorders, somatoform disorders, psychosexual disorders, certain personality disorders, chronic dysthymia, recurrent depression
236
What are the CIs for psychodynamic therapy?
Antisocial personality disorder, acute psychotic disorders, alcohol/drug dependence, depression with high suicide risk
237
Give some characteristics of motivational interviewing
Useful in substance misuse
Helps identify ‘change talk’
Offers advice but the patient leads the process
238
Define personality
Characteristic patterns of behaviour and modes of thinking that determine a person’s adjustment to the environment
239
What is a personality disorder?
Deeply ingrained and enduring behaviour patterns manifesting themselves as inflexible responses to a broad range of personal and social situations
Significant deviations from average (perception, thinking, feeling & particularly relating to others)
Usually associated with distress and problems of social performance
240
Give four features of personality disorders
Present since adolescence
Stable over time despite fluctuations in mood
Manifest in different environments
Recognise by friends and acquaintances
241
Give the three clusters of personality disorders
Cluster A- odd/ eccentric
Paranoid, schizoid, schizotypal
Cluster B- dramatic/ emotional/ flamboyant
Dissocial, emotionally unstable (impulse or borderline), histrionic, narcissistic
Cluster C- anxious/ fearful
Anakastic, anxious (avoidance), dependent
242
How can you treat PTSD?
CBT
Eye movement desensitisation and reprocessing (EMDR)
Medication is second line but can also be used in combination (SSRIs and 2nd gen antipsychotics favoured)
243
What is paranoid PD?
Suspicious, preoccupied with conspiratorial explanations, distrust in others, holds grudges
244
What is schizoid PD?
Emotionally cold, detached, rich fantasy world, excessive introspection
245
What is schizotypal PD?
Eccentric, unusual ideas (e.g. telepathy, clairvoyance), inappropriate affect
246
What is dissocial PD?
Aggressive, easily frustrated, callous lack of concern for others, irresponsible, impulsive, unable to maintain relationships, criminal activity, lack of guilt
247
What is histrionic PD?
Over-dramatise, self-centred, shallow affect, labile mood, seeks attention and excitement, manipulative, seductive
248
What is narcissistic PD?
High self-importance, lacks empathy, takes advantage, grandiose, needs admiration
249
What is anankastic PD?
Worries and doubts, orderliness, control, perfectionism, sensitive to criticism, rigidity, indecisiveness, pedantry, judgemental
250
What is anxious PD?
Extremely anxious and tense, self-conscious, insecure, fearful of negative evaluation by others, timid, desires to be liked
251
What is dependent PD?
Passive, clingy, submissive, excess need for care, feels helpless when not in a relationship, feels hopeless and incompetent
252
What is boarderline PD?
Feeling of 'emptiness', unclear identity, intense unstable relationships, unpredictable affect, threats of self-harm, impulsivity, pseudohallucinations
most commonly encountered acutely, most troublesome
Aka- Emotionally unstable personality disorder
253
How can you treat personality disorders?
Treat underlying psychiatric conditions
Psychotherapy - group therapy can help
Some medications (NICE guidelines CG78)
254
What are some complications of personality disorders?
distress, adverse effects on society, substance abuse, DSH, suicide, violent behaviours
255
Define alcohol misuse
consumption of alcohol sufficient to cause physical, psychiatric or social harm. Recommended drinking men and women >14 units per week
256
What are some risk factors for alcohol misuse?
genetics, culture, religion, family history, male, availability and cost of alcohol
257
What signs should you look out for in a patient with alcohol misuse?
alcoholic stigmata, signs of alcoholic liver disease (palmar erythema, oedema, portal-systemic hypertension, spider naevi, gynaecomastia)
258
What is the management of alcohol misuse?
Detoxification (benzodiazepines - chlordiazepoxide- prevent seizure & reduce withdrawal symptoms, correction of electrolytes, vitamin supplements)
Motivational interviewing
12 step groups e.g. Alcoholics Anonymous
Address social issues
Treat underlying psychiatric disorders
Medication- Disulfiram, Acamprosate, naltrexone - opioid antagonist- reduces pleasure (specialist services)
259
What are some of the complications of alcohol misuse?
anxiety, depression, DSH/ suicide, memory loss, GI upset, hypertension, cardiomyopathy, hepatitis, jaundice, peripheral neuropathy
260
What is Delirium tremens?
Medical Emergency, hyperadrenergic state
Signs & symptoms- hallucinations, confusion, delusions, severe agitations, seizures, tachycardia, hyperthermia, hypertension, tachypnoea, tremor, mydriasis, ataxia, CVS collapse
Treatment- ABCDE, treat hypoglycaemia, sedation with benzodiazepines, IV thiamine if Wernicke’s suspected.
261
What is Wernicke's encephalopathy?
occurs due to thiamine deficiency causing mental confusion, ataxia and opthalmoplegia. If left untreated (IV thiamine required) this may develop into Korsakoff’s psychosis (amnesic disorder with confabulation)
262
What is the mechanism of action of Disulfiram?
Inhibits alcohol dehydrogenase
263
What happens when you take Disulfiram with alcohol?
facial flushing, headache, palpitations, nausea and vomiting, cardiovascular collapse
264
What are the ADRs of Disulfiram?
fatigue, reduced libido
265
What are the CIs of Disulfiram?
cardiovascular disease, hypertension, previous CVA, psychosis
266
How does Acamprosate work?
Reduces conditioned aspects of drinking, prevents craving-induced relapses
267
What are the ADRs of Acamprosate?
GI disturbance, rash
268
What are the CIs of Acamprosate?
sever hepatic / renal failure
269
Define dementia
A global impairment of cognitive function and personality without impairment of consciousness
270
When would you diagnose early onset dementia?
Dementia under the age of 65
Do an MRI to rule out other causes
271
What are the symptoms of Dementia?
Memory impairment - recent memory id affected first
Aphasia (Echolalia, Palilalia or muteness may occur)
Apraxia
Agnosia
Personality and behavioural changes (introverted, socially withdrawn, hostile)
Impairment of executive function (Difficulty planning complex activities)
Psychiatric symptoms (hallucinations - common, delusions - mainly persecutory, depression, anxiety)
Neurological symptoms (seizures, myoclonic jerks)
272
What is aphasia?
Loss of language
273
What is the difference between receptive and expressive aphasia?
receptive - difficulty understanding commands
expressive - vague speech
274
What is echolalia?
repeating heard words
275
What is palilalia?
repeating own words
276
What is apraxia
Lose the ability to carry out skilled motor movements
277
What is agnosia?
Lose ability to recognize previously familiar objects
278
What is pseudodementia?
Changes in intellect, memory and personality due to other mental illness, commonly depression
279
How does Alzheimers disease present?
Gradual onset with progressive cognitive decline
Clinical diagnosis supported by radiology
280
What causes Alzheimers?
Cholinergic hypothesis - reduction in acetylcholine due to the degeneration of cholinergic neurones
Tau hypothesis - phosphorylation of tau proteins cause neurofibrillary tangles (Intracellular)
Amyloid hypothesis - formation of extracellular β amyloid plaques (Extracellular)
281
How would you investigate Alzheimers?
CT -generalized atrophy - frontal and temporal lobes, widened sulci and enlarged ventricles
282
How would you treat Alzheimers?
Acetylcholine Esterase Inhibitors (Donepezil, Rivastigmine, Galantamine)
Non competitive antagonism at NMDA (Memantine) - Reduces excitotoxcity caused by excess glutamate stimulation
283
What is somatisation disorder?
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
284
What is hypochondrial disorder?
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
285
What is conversion disorder?
typically involves loss of motor or sensory function
the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
286
What is dissociation disorder?
dissociation is a process of 'separating off' certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
287
What is Munchausen's syndrome?
the intentional production of physical or psychological symptoms
also known as factitious disorder
288
What is malingering?
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
289
How does frontotemporal dementia present?
Decline in social and personal conduct → disinhibition, personality change
Emotional blunting
Echolalia, mutism
Lack of insight but sparing of other cognitive functions
290
What would you see on a CT of a patient with frontotemporal dementia?
Bilateral atrophy of the frontal and anterior temporal lobes
291
How is frontotemporal dementia treated?
Disinhibition - SSRI’s and in extreme cases with anti-psychotics (short term)
292
What is pseudodementia?
dementia due to depression so can be reversed with antidepressants
293
What is normal pressure hydrocephalus?
Triad of urinary incontinence, bradykinesia and memory loss
294
How does vascular dementia present?
Evidence of Cerebrovascular disease or stroke and risk factors for Cerebrovascular disease (smoking, drinking, hypertension, male, diabetes, MI, lipid abnormalities, valvular disease)
Stepwise deterioration in cognitive function
295
List the various types of dementia and how common they are
Alzheimers - 50-60%
Vascular - 20-25%
Lewy body - 10-15%
Frontotemporal -7% (2nd most common presenile)
296
What is the cause of vascular dementia?
Multiple cortical infarcts
297
How would you investigate vascular dementia?
CT with contrast shows small vessel disease with multiple infarcted areas
298
How do you treat vascular dementia?
No real pharmacological treatment – manage the cause e.g. statins
299
How does lewy body dementia present?
Day to day fluctuations in cognitive performance
Visual hallucinations
Parkinsonism (rigidity, bradykinesia, tremor)
Degeneration of autonomic sympathetic neurones in the spinal cord
Extreme sensitivity to anti-psychotics
300
What is the cause of lewy body dementia?
Abnormally phosphorylated proteins aggregated with ubiquitin and α-synuclein (in the cytoplasm)
301
How should you investigate lewy body dementia?
DAT scan – measures radioactively labelled dopamine which is diminished in LBD
302
What is the treatment for lewy body dementia?
Cognition treated with acetyl cholinesterase inhibitors and NMDA receptor antagonists (same as Alzheimer's Disease)
Motor symptoms treated with dopamine agonists (same as Parkinson's disease) E.g. Levodopa
303
Give some other causes of dementia?
Neurodegenerative (Parkinson’s disease, Huntington’s disease), Space occupying lesion, Trauma, Infection (CJD, HIV, Neuro-syphilis, Viral encephalitis, Meningitis), Metabolic and endocrine, (Chronic uraemia, Liver failure, Wilsons disease, Hypo and hyperthyroidism, Hypo and hyperparathyroidism, Cushing’s and Addison’s), Nutrition (Thiamine, vitamin B12, folic acid deficiency), Drugs (Alcohol, Benzodiazepine, Barbiturates, Solvents), Inflammatory disorders (Multiple sclerosis, SLE)
These should be excluded before a diagnosis of dementia is made though a dementia blood screen (FBC, U+E, LFT, Glucose, Thyroid function, Vit B12, Folate, Syphilis serology)
304
How does dementia start?
Mild cognitive impairment
305
Give some examples of Acetylcholinesterase Inhibitors
donepezil, galantamine, rivastigmine (Parkinson’s disease)
306
When are Acetylcholinesterase Inhibitors used?
mild to moderate dementia related to Alzheimer’s disease
307
What are the ADRs of Acetylcholinesterase Inhibitors?
nausea, vomiting, gastric & duodenal ulcers, syncope, bradycardia, AV block, MI, hallucinations, agitation, rash
308
What are the CIs of Acetylcholinesterase Inhibitors?
renal impairment (galantamine), cardiac disease, peptic ulcer disease
309
Give an example of a NDMA Receptor Antagonist?
memantine
310
When are NDMA Receptor Antagonists used?
moderate to severe dementia related to Alzheimer’s disease
311
What are the ADRs of NDMA Receptor Antagonists?
constipation, hypertension, seizures, dizziness, depression
312
What are the CIs of NDMA Receptor Antagonists?
renal impairment, seizure history
313
Define delirium
an acute confusional state and is a medical emergency. It involves impaired consciousness and impaired cognitive function.
314
How does delirium present?
Impaired consciousness - reduced awareness of the environment, reduced attention, easily distracted
Impaired cognitive function - short term memory impaired, preservation of long term memory, disorientated to time and place,
language abnormalities - incoherent speech, rambling
Perception and thought disturbances -
misinterpretations, illusions or hallucinations (mainly visual), persecutory delusions
Psychomotor abnormalities - patients may be hypo or hyperactive, sleep wake disturbances, daytime drowsiness and night time hyperactivity
Mood disturbance -depression, euphoria, anxiety, anger, fear
315
What causes delirium?
Underlying medical or drug related cause leading to alterations in cholinergic and noradrenergic neurotransmitters, and disruption of the blood brain barrier.
316
How do you manage delirium?
Treat any underlying cause
Anti-psychotics (low dose in the elderly)
317
How can you differentiate between delirium and dementia?
Delirium - fast onset, shorter duration, fluctuation, consciousness impaired, perceptual disturbance common, sleep-wake cycle disrupted
Dementia - gradual onset, lasts longer, progressive deterioration, normal consciousness, sleep normal
318
What is post-concusional syndrome
Minor head injury --> headache, anxiety, fatigue, dizziness
319
What causes an eating disorder?
Biological – genetic, abnormalities in serotonin metabolism
Psychological – western culture, occupation
Psychological predisposition – low self-esteem, dieting, perfectionism
320
How does ICD 10 diagnose anorexia nervosa?
(all of the following):
1. Low body weight (at least 15% below expected or BMI is lower than 17.5)
2. Self-induced weight loss (low calorie intake, exercise)
3. Overvalued idea (dread of fatness, low target weight)
4. Endocrine disturbance (Amenorrhoea, Raised growth hormone and cortisol, Reduced T3
321
How does ICD10 diagnose bulimia nervosa?
(all of the following):
1. Binge eating
2. Methods of counter weight gain (vomiting, laxatives, fasting, exercise)
3. Overvalued idea (dread of fatness, low target weight)
Often normal weight
322
What medical complications arise due to starvation? And what investigation results would you get?
```
Amenorrhoea, infertility
Constipation and abdominal pain
Cold intolerance
Bradycardia, hypotension and arrhythmias
Peripheral oedema
OsteoporosisSeizures
Depression
```
```
Investigation results:
o Abnormal liver function
o Raised urea (dehydration)
o Raised cortisol and growth hormone
o Reduced T3, FSH and LH
o Hypercholesterolaemia
o Hypoglycaemia
o Normocytic anaemia
o Leucopoenia
```
323
What medical complication you arise due to vomiting? And what investigation results would you get?
Erosion of dental enamel
Enlargement of salivary glands
Calluses of the back of the hands
Oesophageal tears
```
Investigation results
o Hypokalaemia (ECG - tall P waves, flattened T waves)
o Hypochloraemic alkalosis
o Hyponatremia
o Hypomagnesaemia
o Raised serum amylase
```
324
What investigations would you do fro someone with and eating disorder?
Bloods (U+E, FBC, LFT, thyroid, glucose, amylase, cholesterol)
Dexamethasone suppression test
ECG
DEXA bone scan
325
What is the management for someone with an eating disorder?
Biological (Fluoxetine – reduced binging and purging behaviour)
Psychological (Psychoeducation about nutrition and weight, CBT, Family therapy)
Hospitalization for those with a BMI <13.5, rapid weight loss, electrolyte disturbance and suicide risk
326
What is sleep paralysis?
Transient paralysis of skeletal muscle that occurs on waking of falling asleep (rare)
Can --> hallucinations
Hx - Clonazepam
327
What is oppositional defiance disorder?
A recurrent pattern of negativistic, defiant, disobedient and hostile behaviour towards authority figures.
328
What is conduct disorder?
A persistent pattern of antisocial behaviour in which the individual repeatedly breaks social rules and carries out aggressive acts. Can become antisocial personality disorder in adults.
329
What is ADHD? (+ symptoms)
A behavioural syndrome characterised by hyperactivity, impulsivity and inattention. These characteristics must be present in two or more settings. Symptoms are present since childhood and are age inappropriate. They will result in functional impairment for the child (psychological, social and educational). Symptoms must start before the age of 7.
330
What is the epidemiology of ADHD?
2.4% of children in UK, typically diagnosed 3-7 years old, more common in boys
331
How is ADHD diagnosed?
requires referral and assessment by a specialist (paediatrician/ child psychiatrist/ CAMHS)
332
How is ADHD treated?
Methylphenidate (first line, aka ritalin), dexamphetamine (second line) Stimulants that block monoamine reuptake. ADRs: Nausea, appetite loss, weight loss, reduced growth, headaches, insomnia
Atomoxetine -Non-stimulant, takes longer to have an effect
Parent education programmes
CBT
Social skills training
Individual psychological treatment
333
What are some complications of ADHD?
difficulties in education, risk of accidents, low self-esteem, rejection by peers
334
What is a tic?
A sudden repetitive, non-rhythmic, stereotyped motor movement or vocalization involving discrete muscle groups. Can be transient or chronic (greater than 12 months).
335
What is tourette's syndrome?
A common neuropsychiatric disorder with onset in childhood, characterized by multiple motor tics and at least one vocal (phonic) tic.
336
When does tourette's usually start and when does it peak?
usually begins between 3-8 years old, with severity peaking around 20 years old
337
How can tourette's be treated?
Anti-psychotics and alpha-2 agonists can reduced the severity of tics (e.g. clonidine and guanfacine).
338
What is the triad of impairments seen in Autism?
1. Social interaction (reduced social interpretation, sensory seeking)
2. Communication (literal, reduced expressive language, non-verbal problems)
3. Rigid and repetitive behaviour (need for sameness, rituals, routine, less empathy, no theory of mind, less imaginative play)
339
How does ICD10 define autism?
Onset before 3 years old. Must have a minimum of 6 symptoms (developmental, social, communication and behaviour)
340
What score can be used to assess depression?
PHQ-9
341
What is a normal grief reaction?
Can last up to 6 months
| with physical and psych symptoms (hallucinations)
342
Who gets autism more boys or girls?
Boys
343
What are the three underlying cognitive deficiency seen in autism?
1. Lack of theory of mind – cant see things from other peoples point of view
2. Lack of executive functioning – problems planning and organising
3. Lack of central coherence – cant link things to make a core idea/statement
344
What is asperger's syndrome?
Similar to autism but fewer communication problems, no LD, normal IQ
345
What is atypical autism?
After 3 years old OR doesn’t fit all three impairments
346
Define suicide
An unnatural death due to the victim’s own action with the intention to kill themselves
347
What is para-sucide?
victim survives although suicide was the intention (different from self harm)
348
What is death by misadventure?
death caused by a person accidentally while performing a legal act without negligence or intent to harm.
349
What are suicide risk factors?
```
Male
Living alone
Unemployed
Drug/alcohol misuse
Mental illness
Recent bereavement
```
350
What score can be used to assess suicide risk?
SADPERSON score
351
Define deliberate self harm
Act with a non-fatal outcome in which an individual deliberately initiates a behaviour that will cause self-harm.
352
What are the two types of deliberate self harm?
self-poisoning (ingestion of toxins) or self-injury (cutting, burning, scratching)
353
Who is more likely to self harm men or women?
women
354
What motivates self harm?
wish to die, communication with others, unbearable symptoms, guilt, distraction from emotional saddness
355
What must you never forget in a psych history?
Risk assessment
356
Define mania
Elevated/ expansive/ irritable mood (for at least 1 week) + 3 other symptoms (e.g. increased energy, grandiosity, pressure of speech, flight of ideas, distractible, reduced need for sleep, increased libido, lost of social inhibitions, psychotic symptoms)
357
How long should you continue antidepressants?
first episode - 6 months
multiple episode - 2 years
358
What is adjustment disorder?
An individual is unable to adjust to or cope with a particular stress or a major life event.
Since people with this disorder normally have symptoms that depressed people do, such as general loss of interest, feelings of hopelessness and crying, this disorder is sometimes known as situational depression.
Unlike major depression, the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation
359
How long do antidepressants take to work?
3-6 weeks
360
How do you treat neuroleptic malignant syndrome?
Dantrolene, bromocriptine and diazepam
361
What EGC changes can lithium cause?
T wave flattening
| Widening of the QRS
362
What vitamin supplement should be given during alcohol withdrawal?
Pabrinex
363
What physiological changes are seen during ECT?
EEG changes
CVS - initial PSNS then SNS = bradycardia and BP decrease the tachycardia and BP increase
Cerebral blood flow increase (increased ICP)
Hormone changes
364
What is a lasting power of attorney?
The LPA allows a person to make appropriate arrangements for family members or trusted friends to be authorised to make decisions on their behalf. It must be made when the person has capacity.
365
What are the principals of the Mental Capacity Act?
Presumption of capacity
All steps must be taken to support people to make their own decisions
A right to make 'bad' decisions
366
Define capacity
the ability to make a decision
367
What is an anticipatory refusal?
Only relate to medical treatments
Can only refuse
Person must be over 18 and have capacity
368
What is Deprivation of Liberty Safeguard (DOLS)?
For patient in hospital or care homes who lack capacity
369
What are you assessing in a cognitive assessment?
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Orientation
Attention and concentration
Language
Calculation
Right hemisphere function
Abstraction
Memory
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