Psych Flashcards
(206 cards)
1
Q
What is the aim of the mental state exam?
A
To give a description that is so accurate that someone else is able to walk onto the ward and pick the patient you’ve described out.
This is a snapshot of a persons mental state at the TIME OF ASSESSMENT
2
Q
What are the components of the mental state exam?
A
Appearance and Behaviour
Speech
Mood and Affect - subjective, objective, affect
Thoughts - Form, Content, Possession
Perceptions - illusions vs hallucinations
Cognition
Insight
Risk
3
Q
Define mood
A
The sustained, subjective, experienced emotion over a period of time.
(the climate)
4
Q
Define affect
A
Immediate expressions of emotions e.g. smiling at a joke
the weather
5
Q
Define formal thought disorder
A
An impairment in the ability to form thoughts from logically connected ideas
6
Q
What is thought form?
A
Are they able to form thoughts in a logical and linear pattern
7
Q
What are some examples of thought form pathology?
A
Loosening of associations (derailment, tangentiality, word salad)
Circumstantiality
Flight of ideas
Neologism
Perseveration
8
Q
What is loosening of associations?
A
A lack of connection between ideas
Examples -
Derailment
Tangential = conversation drifts without focus and never comes back to the point
Word salad = just saying random words (quite rare)
9
Q
What is circumstantiality?
A
Conversation drifts and eventually comes back to the point
10
Q
What is perseveration?
A
Repetition of a particular response in the absence/cessation of the stimulus
11
Q
What is neologism?
A
Creation of new words
12
Q
What are the components that make up thought stream?
A
Acceleration
Retardation
Blocking
13
Q
What are examples of thought acceleration?
A
Pressure of speech = speak rapidly and with an unapparent urgency
Flight of Ideas = Abrupt leaps from one topic to another. Might have connections, might be puns or rhymes etc.
14
Q
Define a delusion
A
A fixed, false belief which is firmly held despite evidence suggesting otherwise. The delusion goes against the normal social and cultural belief system of the individual.
15
Q
How do primary and secondary delusions differ?
A
Primary = unconnected to previous events or ideas
Secondary = arise from and are understandable in the context of previous events or ideas
16
Q
Describe a grandiose delusion
A
Feel they are ‘special’ / the best at something / really important/ a religious figure
17
Q
Describe a persecutory delusion
A
Feel that others are conspiring against them to cause harm/ steal money/ destroy their reputation
18
Q
Describe a delusion of reference
A
Feel that random events, objects or behaviours of other people have a special significance to themselves
19
Q
Describe a delusion of guilt
A
Feel they have done something sinful or shameful
20
Q
Describe a nihilistic delusion
A
Feel they are worthless/dying/decaying
Common in depression+ psychosis
21
Q
What is Cotard’s syndrome?
A
Severe case of nihilism
Believe that everything is non-existent incl. themselves
22
Q
Define thought interference
A
A person can experience thoughts that they don’t perceive to be their own and have been put there by an external element
23
Q
Define thought withdrawal
A
A person can experience what they perceive to be the removal of their own thoughts
24
Q
Define thought broadcast
A
A person can experience what they perceive to be their thoughts out loud
25
Define the passivity phenomenon
The perception that they (mood or actions) are being controlled by someone else
26
Define an illusion
A misinterpretation of an existing external stimulus
27
Define a hallucination
A perception in the absence of an external stimulus
28
Define depersonalisation
Feeling detached from normal sense of self
29
Define derealisation
Feeling of unreality in which the environment/people in it are experienced as unreal
30
Define psychosis
A mental state in which reality is greatly distorted
31
How does psychosis commonly present? (in very simple terms)
Hallucinations
Formal Thought Disorder
Delusions
32
Give 6 non-organic causes of psychosis
Schizophrenia
Acute Psychotic Episode
Mood Disorder + Psychosis
Drug-induced psychosis
Schizoaffective disorder
Delusional disorder
33
Give 6 organic causes of psychosis
Drug induced/iatrogenic medication
Delirium
Dementia
Endocrine disturbances - Cushing's, Hyperthyroidism,
Metabolic disturbances - B12 deficiency
Neurosyphyllis
34
Which drugs can cause psychosis? (recreational and iatrogenic please)
Recreational - Cannabis, cocaine, alcohol [withdrawal], LSD
Iatrogenic - Steroids, dopamine agonists e.g. Methyldopa, anti-malarial
35
How could you differentiate non-organic causes of psychosis?
Look for other symptoms e.g....
Schizoaffective – presence of a mood disorder too. This psychosis is mood congruent!
Mood disorders + Psychosis – depression or mania symptoms also present
Puerperal – there will be a baby about (usually happens within first 2 weeks of birth)
Delusional disorder – single/set of delusions for >3 months. Usually persecutory, grandiose, hypochondriacal. No hallucinations or thought disorder
36
What are Schneider's first rank symptoms of Schizophrenia? (5)
- Persecutory delusions
- 3rd Person Auditory Hallucinations
- Formal thought Disorder
- Passivity phenomenon
- Thought interference
37
What are the negative symptoms of schizophrenia? (6As)
Alogia
Apathy (blunted affect)
Anhedonia
Asocial behaviour
Avolition
(reduced motivation)
Attention
deficits
38
What are the hypothesised biological causes of Schizophrenia?
Dopamine hypothesis (overactivity of mesolimbic pathway - D2 receptors
Genetics (risk increases with FHx)
Obstetric complications, low birth weight
39
What are the environmental risk factors for the development of Schizophrenia?
Psychological stressors
Migrant status
Urban living
Substance misuse (esp cannabis)
Low socioeconomic status
40
What are 4 poor prognostic factors for Schizophrenia?
Strong FHx
Gradual onset/long prodromal phase
Lower IQ
No obvious precipitating factor
41
What are the bedside investigations when a patient presents with Psychosis and why?
Causative Factors = Urine drug test (rule out psychosis)
Factors affecting management = ECG (Antipsychotics can cause prolonged QT)
Weight/BMI - APs cause metabolic syndrome
42
What are the blood tests to investigate causative factors for psychosis?
TFTs (hyperthyroidism)
Serum Calcium (Hypocalcaemia)
B12 and Folate (deficiency can cause neuropsychiatric symptoms)
43
What are the blood tests that will aid management options in a patient presenting with psychosis?
FBC - baseline for anaemia or infection
HbA1c and Cholesterol = Atypical APs cause metabolic syndrome
U&E and LFT – check function before starting
44
What is the biological management of Schizophrenia/psychosis?
Atypical Antipsychotics e.g. Risperidone or Olanzapine. Clozapine for treatment resistant.
Adjuvant Benzodiazepines (agitation)
ECT – catatonia is an indication
45
What is the psychological management of Schizophrenia/psychosis?
CBT can reduce residual symptoms
Family intervention + psychoeducation
46
What is the social management of Schizophrenia/psychosis?
Support groups - Referral to Early Psychosis Team if first presentation
Support worker
47
What is the definition of an affective disorder?
Any condition characterized by distorted, excessive or inappropriate moods/emotions for a sustained amount of time
48
What is the definition of a depressive disorder?
An affective disorder characterized by persistent low mood, loss of pleasure and/or lack of energy ALONG WITH emotional, cognitive and biological symptoms
49
What are the 3 core symptoms of depression?
Anhedonia
Low energy
Low mood (for at least 2 weeks)
50
What are 5 biological symptoms of depression?
Diurnal Variation of Mood (mood worse in morning)
Early morning wakening (2 hours before normal and can't get back to sleep)
Loss of libido
Loss of appetite +/- weight
Psychomotor retardation
51
What are 3 cognitive symptoms of depression?
Poor concentration/memory
Suicidal ideation
Negative thoughts (beck's cognitive triad)
52
What is the criteria for a mild depression (ICD-10)?
2 core symptoms + 2 other symptoms
53
What is the criteria for a moderate depression (ICD-10)?
2 core symptoms + 3-4 other symptoms
54
What is the criteria for a severe depression (ICD-10)?
3 core symptoms + >4 other symptoms
55
What is the criteria for a severe depression + psychosis (ICD-10)?
3 core symptoms + >4 other symptoms + psychosis
56
What are the modifiable risk factors for depression? (5)
Poor coping
Stress
Low socioeconomic status
Unemployment
Substance misuse
57
What are the non-modifiable risk factors for depression? (4)
Female
Fix
Personality Type
Neurotransmitter imbalance
58
What are the bedside tests to do when investigating depression and why?
ECG - Sertraline can prolong QT
59
What are the blood tests to do when investigating depression and why?
TFTs (rule out hypothyroid)
Calcium (rule out hypocalcaemia)
FBC (rule out anaemia)
U&E, LFT (baseline)
60
What are 2 diagnostic questionnaires for depression?
PHQ-9
Hospital Anxiety and Depression Scale (HADS)
61
What is the biopsychosocial management of MILD depression?
Bio - antidepressant not routinely offered
Psycho - Low intensity psychosocial intervention e.g. CBT. (Let's talk Leicester)
Social - Support groups, physical exercise programme
62
What is the biopsychosocial management of MODERATE depression?
Bio - Antidepressant
Psycho - High intensity psychosocial intervention (see therapies)
Social - Support groups
63
What is the biopsychosocial management of SEVERE depression?
Bio - Try other ADs or an adjuvant e.g. Lithium. ECT (treatment resistant depression/ with psychosis)
Psycho – Assess risk
Psych referral if risk is high, depression is severe or recurrent or no response to treatment
64
What is the definition of Bipolar Affective Disorder?
A chronic, episodic mood disorder characterized by at least one period of elevated mood (mania) and a further episode of mania or depression (can also be hypomania).
65
What are the biological symptoms of mania?
Increased appetite
Reduced sleep (*)
66
What are the cognitive symptoms of mania?
Increased irritability
Delusions (grandiose usually)*
Flight of ideas*
Easily distracted*
Impaired insight
67
What are the behavioural symptoms of mania?
Disinhibition (*) - sexually, socially, spending
Elevated mood*
TALKATIVE/Pressure of speech*
Restless*
'marked' sexual energy
68
What are the non-modifiable risk factors for BPAD?
Fix
Age (~19)
BAME Ethnicity
Neurochemical imbalances (Monoamine hypothesis)
69
What are the modifiable risk factors for BPAD?
Substance misuse
Stressful live events
Postpartum
70
What is the diagnostic criteria for BPAD?
At least TWO episodes of significantly disturbed mood
One has to be MANIA or HYPOMANIA
71
What is the definition of hypomania?
Mildly elevated mood/irritable for more than 4 days
Symptoms are present but to a lesser extent
Interferes with NDAs but not severely
Might still have insight
72
How long do symptoms have to be present for to diagnose mania?
Over 1 week
73
What is bipolar 1?
Periods of SEVERE mood episodes
Can be mania or depression
74
What is bipolar 2?
Milder form so get hypomania that alternates with periods of severe depression
75
What is rapid cycling?
More than 4 mood swings in a 12 month period
No asymptomatic periods in between
76
What investigations should be done for a patient presenting with mania/depression/bpad?
Bed - Urine drug test – illicit drugs can mimic mania
Bloods:
Baselines: U&Es (for starting Lithium), LFTs (for starting mood stabilisers), FBC
Rule out other differentials: TFTs, Calcium, Glucose
77
What is the short term biological management of BPAD?
An antipsychotic.
Benzos can be used for sleep/agitation
ECT can be used if severe and unresponsive
78
What is the long term biological management of BPAD?
Lithium 4 weeks after resolution of an acute episode
Can consider Valproate or Olanzapine if no response
79
What is the psychological management of BPAD?
High intensity CBT (only depression)
Psychoeducation
Self-help – recognizing symptoms of relapse
80
What are 3 really important things to remember when managing BPAD?
Inform DVLA as cannot drive within 3 months of an acute manic episode
Don't use antidepressants by themselves if presenting with severe depression as can make them swing the other way
Valproate absolutely contraindicated in women of child bearing age. Lithium can be monitored during pregnancy but contraindicated in breastfeeding
81
What is the CALMER mnemonic for managing BPAD?
C onsider hospitalisation (section)
A typical antipsychotic
L orazepam
M ood Stabiliser (Teratogenic)
E CT
R isk
82
What are SSRIs? What is their indication and method of action?
Selective Serotonin Reuptake Inhibitor
Block 5HT3 reuptake into pre-synaptic neurone = increasing amount of serotonin in synaptic cleft
Depression, panic disorder, social phobia,, OCD, PTSD
83
What are the side effects of SSRIs?
GI
```
STRESSS:
Sweating
Tremor
Rashes
Extrapyramidal SE
Sexual dysfunction
Suicidal Ideation
Somnolence (drowsy)
```
84
Give 4 cautions when using SSRIs? And 1 absolute contraindication
Cautions: Cardiac disease, Acute angle closure glaucoma, breast feeding, using with other drugs that cause GI bleeds
Absolute CI: MANIA/Hx OF MANIA
85
What is serotonin syndrome?
Rare but life threatening condition due to increased serotonin activity
Happens within minutes
Usually SSRIs but also TCAs or Lithium
86
What are the clinical features of serotonin syndrome?
Cognitive - agitation, confusion, hallucinations
Autonomic - sweating, tachycardia, hyperthermia, hypertension
Somatic - Myoclonus, hyperrelfexia, tremor
87
What is the management of serotonin syndrome?
Stop the drug
Supportive
88
Which SSRI should be prescribed if the patient has a history of cardiac disease/post MI?
Sertraline
89
Which SSRIs should NOT be prescribed in a person with a history of cardiac disease/QT prolongation?
Citalopram
Escitalopram
90
Which drugs should not be prescribed alongside SSRIs?
Think bleeding
NSAIDs (give a PPI as well if you have to)
Warfarin
Heparins
91
What is an SNRI? Give 2 examples
Selective Noradrenaline Reuptake Inhibitor
Venlafaxine
Duloxetine
More rapid onset + more effective
92
What is the mechanism of action of SNRIs?
Prevents noradrenaline and serotonin reuptake but do not prevent acetylcholine reuptake
93
In which group of patients should SNRIs be avoided?
Cardiac disease
Uncontrolled hypertension
Have to do BP before starting
94
What is a NASSA? Give an example
Noradrenaline Serotonin Specific Antidepressant
Mirtazapine
95
What is the MOA of a NASSA?
Weak inhibition of noradrenaline reuptake
Anti-histaminergic (sedating and increases appetite)
A1 and A1 blocker
96
In which group of people is Mirtazapine a good option for?
Those who need to gain weight or need help with sleeping
97
What are the side effects of Mirtazapine?
Increased appetite/weight gain
Drowsy
Postural hypotension
Abnormal dreams
98
What is a TCA? Give some examples
Tri-cyclic antidepressant
Amitriptyline, Nortriptyline
99
What is the MOA of TCAs?
Inhibit adrenaline, serotonin reuptake
Also have cholinergic and 5HT2 affinity
100
What are the side effects of TCAs?
Anticholinergic - can't see, can't wee, can't shit, can't spit
CVS - arrhythmias, postural hypotension
Weight gain
Dyskinesia?
101
What are contraindications to TCA use?
Cardiac disease - recent MI, arrhythmia
Liver disease
Agranulocytosis
102
Which foods should be avoided if taking an MOAI? What are the signs if someone has been eating these?
Tyramine rich foods e.g. cheese, marmite, red wine
Can cause a hypertensive crisis - headache, fever, convulsions
103
What is the difference between a typical and atypical antipsychotic?
Mainly the extent to which they cause EPSE (typical are more likely)
104
What are some examples of typical antipsychotics?
Haloperidol
Zuclopenthixol
Chlorpromazine
105
What are some examples of atypical antipsychotics?
Risperidone
Olanzapine
Quetiapine
Aripriprazole
Clozapine
106
When should clozapine be prescribed?
If there has been no response to two other antipsychotics
107
What is the MOA of antipsychotics?
Antagonise D2 receptors = reducing dopamine transmission (typical)
Atypical also acts on other receptors e.g. serotonergic receptors
108
What are 2 side effects that are specific to clozapine?
Agranulocytosis
Hypersalivation
109
What are the extrapyramidal side effects?
PAD-T
Within weeks:
Parkinsonism
Akathisia (restlessness)
Dystonia (acute, painful muscle spasms)
Tardive dyskinesia (lip smacking/chewing - longer term use)
110
What are 3 contraindications to antipsychotic use?
CNS depression, phaeochromocytoma, comatose state
111
What is neuroleptic malignant syndrome?
Rare but life threatening condition seen in patients taking an antipsychotic/ dopaminergic drugs e.g. levodopa
more common in young males and typical AP use
112
What are the clinical features of NMS?
within 10 days of starting
Pyrexia, muscle rigidity, autonomic instability
Bloods: Raised CK, Leucocytosis (maybe), Deranged LFTs
113
What is the management of NMS?
Stop drug and supportive - fluids, cooling
Can give dantrolene or bromocriptine
114
What are 3 complications of NMS?
PE
Renal failure
Shocl
115
What are 4 cautions when using antipsychotics?
Parkinsons
Cardiovascular disease
Epilepsy
Myasthenia graves
116
Which blood tests should be done prior to starting an Antipsychotic?
FBC, U&E, LFT (baseline)
Fasting blood glucose , cholesterol (atypicals cause metabolic syndrome)
?prolactin
Baseline CK
117
Which bedside tests should be done prior to starting an Antipsychotic?
ECG - looking for QT prolongation
Blood pressure
BMI/weight (metabolic syndrome)
118
What is a depot and what are the advantages?
Long acting, slow release antipsychotics given IM every 1-4 weeks
Improve adherence e.g. if not complying
Bypass first pass metabolism
flupenthixol, zuclopenthixol, risperidone, olanzapine, aripriprazole = examples
119
What are 3 side effects of atypical antipsychotics?
Weight gain
T2DM
More likely to cause stroke in elderly
120
What are the indications for the use of Lithium?
Long term management of Bipolar/ prophylaxis of Mania
Can also be used for prophylaxis of recurrent depression
Start 4 weeks after an acute episode
121
What are the NORMAL side effects of Lithium? (6)
Fine tremor
Polydipsia, Polyuria, Oedema (Lithium is a SALT)
Weight gain
Teratogenic (in 1st Trimester)
Impaired Renal Function
Hypothyroidism
122
What are the signs of lithium toxicity?
Coarse tremor
N&V
Ataxia
Muscle weakness
123
What are the signs of severe lithium toxicity?
Nystagmus
Dysarthria
Hyperreflexia
Oligura
Hypotension
124
How should mood stabilisers be managed during pregnancy?
Seek expert advice
Reduce Valproate gradually over 4 weeks
Monitor Lithium levels during pregnancy? BUT contraindicated in breastfeeding
125
Which investigations should be done before starting lithium? What is important to remember?
```
Pregnancy Test
Baseline ECG (QT Elongation)
```
Bloods
U&E
LFT
TFTs
Lithium has a really narrow therapeutic window so needs close monitoring!
126
What is ECT?
The passage of a small electrical current through the brain with a view to inducing a modified epileptic seizure which is therapeutic.
Used under general anaesthetic and with a muscle relaxant
127
What are the indications for ECT?
ECT
Euphoria – prolonged or severe mania
Catatonia
Tearfulness – treatment resistant depression, serious risk to self or others, life threatening depression e.g. refusing to drink
128
What are the contraindications to ECT?
MARS
MI (<3 months) or major unstable fracture
Aneurysm (cerebral)
Raised ICP (absolute CI)
Stroke (<1 month), Severe anaesthetic risk, Hx of Status Epilepticus
129
What are the short term effects of ECT?
PC DAMS
```
Peripheral nerve palsies
Confusion
Dental trauma
Anaethetic risk
Muscle/headaches
Short term memory loss
```
130
What are the long term effects of ECT>
Anterograde and retrograde amnesia
131
What is the Mental Health Act?
The Mental Health Act is a law that allows people with a mental disorder** (Important) to be admitted to hospital, detained and treated without their consent (sectioned) either because they are a risk to themselves or a risk to others.
Excluded if under the influence
132
What is a mental disorder defined as?
Any disorder or disability of the mind
DOES NOT include dependence on drugs/alcohol
133
When should the MHA be used?
REVISE OUR MHA
```
Refusal of voluntary treatment
Other options not appropriate
Mental disorder
Harm (risk)
Appropriate treatment available
```
134
Describe section 2 of the MHA
Admission, assessment, and response to treatment
Lasts for 28 days
Can appeal to a tribunal within the first 14 days
135
Describe section 3 of the MHA
Already known to MH services/have a diagnosis/following admission under S2
Lasts 6 months
Can appeal to a tribunal only once within the 6 month period can be done again if the section is renewed
Can be treated without consent for 3 months (get a 2nd opinion after)
136
Who can put a section 2 or 3 in place?
An Approved Mental Health Practitioner (AHMP) or nearest relative (rarely)
On the recommendation of 2 approved clinicians (at least 1 has to be a section 12 approved doctor)
137
Where can a section 2 or 3 be put in place?
Place of safety or hospital
138
Describe a section 5(2)
Urgent detention of an inpatient on any ward (BUT NOT A&E!!)
Assessed for an S2 or S3 or discharge + admittance as an informal pt
Can’t appeal
139
Who can put a section 5(2) in place?
An ‘approved clinician’
| Usually a doctor but can be other things
140
Where can a section 5(2) be put in place?
Any ward
BUT NOT A&E REMEMBER THIS BECAUSE YOU GOT IT WRONG IN EOY3
141
Describe a section 5(4)
Urgent detention of an inpatient for up to 6 hours
Inpatient is already being treated for a mental disorder in hospital
142
Who can put a section 5(4) in place
An ‘approved clinician’
A registered mental health nurse can put in place if a doctor can’t attend immediately
143
Where can a section 5(4) be put in place?
Hospital
144
Describe a section 135
Allows a police officer to enter a person’s property if they are suspected to be suffering from a mental disorder, in order to take them to a place of safety
145
Describe a section 136
Allows a police officer to remove someone from a public place if they are suspected to be suffering from a mental disorder, in order to take them to a place of safety
146
Describe a section 117
Free aftercare given following a section 3
147
What is a Community Treatment Order?
Allows pts on Section 3 to leave an inpatient facility if they are well enough to do so.
Can be recalled if they do not comply upon which they can be detained for up to 72 hours
Can't enforce treatment on them within the community
148
What are the features of Parkinsonism?
Tremor
Bradykinesia
Rigidity
Shuffling gait
149
What is akathisia?
Restlessness
150
What is dystonia?
Painful muscle spasms in face, neck, jaw and eyes*
Eyes = oculogyric crisis
151
What is tardive dyskinesia?
Abnormal, involuntary movements e.g. chewing/pouting
152
Why may antipsychotic use cause lactation/hyperprolactinaemia?
Dopamine inhibits Prolactin
SO giving a dopamine antagonist removes the inhibition on prolactin
= ↑ prolactin
(hyperprolactinaemia) which causes lactation
153
What is the definition of a personality disorder?
A deeply ingrained and enduring pattern of inner experience and behaviour that deviates markedly from expectations in the individual’s culture.
It is pervasive and inflexible, has an onset in early adulthood and is stable over time, leading to distress or impairment.
Pervasive, persistent, problematic
154
What are the non-modifiable risk factors for PD?
family history
155
What are the modifiable risk factors for PD?
Environment - malattachement, abuse/neglect
Social - low socioeconomic status
156
What are the cluster A PDs?
Weird
Paranoias, schizoid, schizotypal
157
What are the cluster B PDs?
Wild
EUPD
Antisocial
Histrionic
158
What are the cluster C PDs?
Worried
Dependent
Avoidant
Anankastic/obsessional
159
What is the biopsychosocial management of PDs?
Bio - symptom management. not really much you can do otherwise.
Psycho - Dialectial Behavioural Therapy (DBT), CBT, IPT, Psychodynamic Psychotherapy
Social - manage comorbidities, risk asses + crisis plan. Find them something that makes them feel good about themselves
160
Describe the paranoid PD
Irrational suspicion and mistrust of others
Interpret motivations as malevolent.
161
Describe the schizoid PD
Lack of interest and detachment from social relationships
apathy
restricted emotional expression
162
Describe EUPD
More common in women
Self harm V common, as are several suicide attempts
Impulsive behaviours V common e.g. substance abuse, “indiscriminate sex”, reckless spending
Chronic emptiness
Fear abandonment
Intense and unstable relationships
163
Describe antisocial PD?
More common in men than women
Callous, blame others, remorseless, impulsive, violent tendencies
Often co-morbid with other things like:
Substance abuse
Poor reading
Really common amongst people in prison!
164
Define anxiety
An unpleasant emotional state involving SUBJECTIVE fear and somatic symptoms
165
How can the types of anxiety be categorised?
Paroxysmal > situation dependent > phobic (specific, agoraphobia, social phobia)
Paroxysmal > situation independent > panic
Continuous > Generalised anxiety disorder
166
Describe generalised anxiety
Symptoms present most of the time and aren't situation/stimulus specific
Excessive worry about normal things
Long duration
167
Describe the common features of paroxysmal anxiety disorders
Abrupt onset of discrete episodes
Episodes are severe and have strong autonomic symptoms
Short duration usually with a stimulus/trigger
168
What is the definition of GAD?
A syndrome of ongoing, uncontrollable and widespread worry about events/thoughts that pt recognises as excessive/inappropriate
Symptoms present on most days for at least 6 months
More common in females
169
What are 3 predisposing factors for GAD?
Genetics/FHx
Living alone
High achieving personality
170
What are 3 precipitating factors for GAD?
Stressful life events
Unemployment
Relationship problems
171
What are 3 maintaining factors for GAD?
Living alone
Stress
Ways of thinking
172
Give 5 common features of GAD
Excessive worry
Autonomic hyperactivity
Restlessness
Sleep disturbance
Muscle tension
173
What is the biopsychosocial management of GAD?
BIO = SSRI (sertraline as is also anxiolytic)
Psycho = CBT, mindfulness
Social = Support, self help, exercise!
174
Define a phobia
An intense, irrational fear of an object/situation/place that is recognised as disproportionate or unreasonable
175
What is agoraphobia?
Fear of public spaces/entering public spaces from when immediate escape would be hard
176
What is social phobia?
Fear of social situations which may lead to humiliation, criticism or embarrassment e.g. speaking to a crowd
177
What do social phobia, specific phobia and agoraphobia all have in common?
Avoidance is a very common feature
178
What are some clinical features of phobic anxiety disorders?
Autonomic response - tachycardia, vasovagal +/- syncope
Tight chest, breathing fast, feeling of impending doom
Psycho = anticipatory anxiety, can't relax, avoidance, fear of dying
179
What is the general management of phobic anxiety disorders?
Bio - SSRI (escitalopram or sertraline). Benzo (not long term)
Psycho - CBT +/- exposure, psychodynamic
Screen for substance misuse
180
What is panic disorder?
Recurrent, episodic and severe panic attacks
These attacks are unpredictable and do not have a trigger
181
What are the symptoms of a panic attack?
PANICS D
```
Palpitations
Abdo symptoms
Numb/nausea
Intense fear of death
Choking feeling
Sweating/short of break
Depersonalisation/derealisation
```
Crescendo within a few minutes then reaches peak
182
What is the general management of panic disorder?
Bio - SSRI (no improvement after 12 weeks = stop). Not Benzos.
Psycho - CBT (focus on triggers). Psychoeducation. Mindfulness.
Social - self help. exercise. support groups
183
Define PTSD
An intense, prolonged, delayed reaction following exposure to a particularly traumatic event
184
Define an acute stress reaction
An abnormal reaction to sudden stressful events. Symptoms same as PTSD but have an immediate onset and diminish after ~48 hours
185
Define adjustment disorder
Significant distress and impaired social functioning when adapting to new circumstances
symptoms within one month of event
have to be present for 6 months
186
What are the 4 main features of PTSD?
Reliving - flashbacks, nightmares, distress in similar situations
Avoidance - rumination, can't recall specific details
Hyperarousal - irritability, jumping at loud noises, hyper vigilance, can't concentrate
Emotional numbing - detached, anhedonia, negative thoughts about oneself
187
What are the stages of grief?
```
Denial
Anger
Bargaining
Depression
Acceptance
```
188
How should PTSD be managed within 3 months of the trauma?
Watchful waiting + risk assessment
Manage sleep (zopiclone)
189
How should PTSD be managed after 3 months since the trauma?
Trauma focussed psychological intervention e.g. CBT, eye movement desensitisation and reprocessing (EMDR)
Paroxetine, mirtazapine, amitryptiline
190
What characterises OCD?
Recurrent obsessional thoughts and compulsive acts
191
Define an obsession
Unwanted, intrusive thoughts/images/urges that repeatedly enter the individual's mind
They are distressing for the individual who also recognises them as egodystonic (absurd) and a product of their own mind
Then tries to resist them
192
Define a compulsion
Repetitive, stereotyped behaviours/mental acts that a person feels driven into performing
Do not bring pleasure, more relief
Covert or overt
193
Roughly, what is the ICD-10 criteria for OCD?
Obsessions and/or compulsions present on most days for at least 2 weeks
Obsessions/compulsions share a number of features (see features card) ALL have to be present
Cause distress/interfere with ADLs
194
Which features must obsessions and compulsions show?
FORD CAR
Failure to resist
Originate from patient's mind
Repetitive
Distressing (but acknowledged as unreasonable)
CARrying out the obsessive thought is not pleasurable but reduces anxiety
195
What is the management of mild OCD?
Low intensity psychological intervention (exposure with response prevention)
196
What is the management of moderate OCD?
SSRI (fluoxetine, paroxetine, sertraline, citalopram)
or High intensity psychological intervention (ERP)
197
What is the management of severe OCD?
SSRI + CBT+ERT
198
Define anorexia nervosa
An eating disorder characterised by (FEEDD):
```
Fear of weight gain
Endocrine disturbances e.g. amenorrhoea
Emaciated appearance
Deliberate weight loss
Distorted body image
```
199
What are the physical effects of anorexia nervosa?
Fatigue
Hypothermia
Electrolyte imbalances - hypokalaemia, hyponatraemia
peripheral oedema due to hypoalbuminaemia
200
What is refeeding syndrome?
A life-threatening syndrome that results from food intake following a period of prolonged starvation/malnourishment
Caused by a spike in insulin = protein and glycogen synthesis = increased electrolyte uptake
Leads to Hypokalaemia, hypophosphataemia, hypomagnesiumaemia, thiamine deficiency
201
What are the features of Bulimia Nervosa?
BULIMIA
```
Binge eating
Use of drugs to prevent weight gain/purging
Low K
Irregular periods
Mood disturbance
Irrational fear of being fat
Alternating periods of starvation
```
202
Define substance abuse
Frequent/excessive use of a substance for a non-medical reason
Consumption of the substance to a harmful level without the compulsion to repeatedly to do so
Impairs daily functioning e.g. relationships
203
Define addiction
Inability to consistently abstain from consuming a substance (or an activity e.g. gambling)
Impairs behavioural control
Have cravings
Loss of insight
Dysfunctional emotional response
204
What are the signs of alcohol withdrawal within 6-12 hours?
Tremor, sweating, tachycardia, anxiety
205
What are the signs of alcohol withdrawal at around 36 hours?
Seizures
206
What are the signs of alcohol withdrawal at around 72 hours?
Delirium Tremens (coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia)
