Psychiatry Flashcards
(43 cards)
Dementia
Define Prevalence RF's Presentation Investigations Mx
What?
Chronic, progressive global cognitive impairment with retained consciousness
Prevalence: Over 65s = 5% 65-69 age group= 1% 80-84 age group = 12 % Over 95 age group = 30%
Risk factors:
- FH
- African-carribean
- Sedentary lifestyle
- T2DM
- Strokes/CVD
- Metabolic syndrome
- Smoking
- Females
Presentation:
Alzheimers: Loss of episodic memory + forgetfulness –> Anxiety and social decline
Later Visuospatial difficulties (parietal lobe) and changes to personality (frontal lobe)
Vascular= Stepwise deterioration, mainly speech and language decline
DLB= At first Lilliputian hallucination and fluctuating consciousness. Followed by motor symptoms of Parkinsonisms and loss of sleep paralysis in REM
Fronto-temporal dememtia: Behavioural and semantic decline. In 40-60yrs with FH.
Investigations:
MOCA (26/30 cut-off for cognitive impairment)
Imaging: DAT, SPECT, MRI, CT
The Montreal Cognitive Assessment is a 30-question test that tells whether a person shows signs of dementia. It is not meant to make a diagnosis, but studies have shown it is extremely reliable for predicting whether or not someone will be diagnosed with Alzheimer’s disease or another dementia.
Management: FOR ALL Cognitive enhancers (1st line AChEIs monotherapy e.g. Rivastigmine, galantamine, donepezil. 2nd line Add memantine ) Address BPSD (1st line non-pharma therapies. 2nd line Trazodone for insomnia, Risperidone for psychosis, citalopram for aggression)
Delirium
Define RF's Presentation Classification Mx Mortality
What?
Acute, transient fluctuation in cognition which is reversible. Likely secondary to new illness or medication change
Note: If alongside alcohol withdrawal = Delirium tremens medical emergency
Risk factors:
Vascular - CVA
Infection - UTI, Resp, sepsis etc
Drugs - Diuretics, benzo’s, antihypertensives, anti-cholinergics
Metabolic - Liver encephalopathy, anaemia, DM, cardiac failure, uraemia
Trauma - head injury
Presentation
- Acute onset
- Fluctuating consciousness
- Cognitive impairment (Disorientation, recent memory loss, abstract thinking)
- Sleep-wake cycle disturbance
- Visual disturbances
- Speech disturbance: Incoherent, rapid, slow
Common classification
- Hyperactive / agitated delirium: Psychomotor agitiation, increased arousal, inappropriate behaviour, psychosis
- Hypoactive delirium: Psychomotor retardation, lethargy, excess somnolence
- Mixed delirium: Varied presentation
Management: -Treat underlying cause -Optimise environment - Medication (Avoid sedation e.g. benzo's. Consider regular or PRN haloperidol) Course: Average duration of 7 days
30% mortality
ADHD
Define RF's Assessment Diagnosis requirement Mx Monitoring
What? Attention deficit hyperactivity disorder presenting with 1. Inattention 2. Hyperactivity 3. Impulsiveness
Risk factors:
- FH
- Co-morbid illness (ODD, ASD, LD, tic disorder)
- Maternal smoking or drug use
- Low birth weight
Assessment:
Rating scale examples Connor’s rating scale and Strengths and Difficulties Questionnaire (SDQ)
Diagnosis Requirement
- Onset before <7yrs
- Minimum of 6 month symptom history
- 2 points of view required
- Pervasive across all settings
Management:
Children <5yrs = 1st line ADHD focused group parent training programme. 2nd line Referral to specialist
Children >5 years= 1st line Parent training programme. 2nd line Medication (1. Methylphenidate 2. Lisdexamfetaine 3. Dexamfetamine 3. Atomoxetine or Guanfacine). 3rd line Add on CBT if medication showed benefit.
Adults with ADHD: 1st line medications (1. Lisdexamfetamine or Methylphenidate 2. Dexamfetamine). 2nd line Add-on non-pharmacological Tx.
Monitoring: - Height ○ Every 6 moths in children and young people - Weight ○ At months 3 and 6 after starting medication in children over 10 ○ Every 3 months in Children <10 ○ Every 6 months in adults - CV: BP and HR - Tic development - Sexual dysfunction - Seizures - Sleep - Worsening behaviour
Prognosis:
By mid twenties….
1/3 will require lifelong treatment
2/3 will no longer require medication that results in an intolerance to medication
ASD
Define Types Aetiology Comorbid conditions Diagnosis requirements Primary/secondary care mx Prognosis
ASD= Autism Spectrum Disorder
Definition: A group of lifelong developmental disorders characterised by effect on social and communication skills and restricted/repetitive/stereotyped repertoire of interests and activities
Includes:
Autism
Asberger’s syndrome
PDD-NOS, Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) refers to a group of disorders characterised by impairment in the development of social interaction, verbal and non-verbal communication, imaginative activity and a limited number of interests and activities that tend to be repetitive.
Aetiology: Unknown Comorbid conditions: - AHDH - Mood disorders: Depression, BPAD - Stress disorders: Anxiety, OCD - LD
Diagnosis requirements:
1. Restricted/repetitive/stereotyped interests and activities
2. Impaired social and communication skills
3. Onset from childhood
4. Impairs everyday function
Also seen: Circadian rhythm dysfunction, mood disorder (anxiety), difficulties in executive function (planning, motivation)
Diagnosis:
By a specialist through detailed history from school and care giver + observation at school/clinic
Primary care management:
-Ensure routine specialist review. Reassessment in secondary care prior to transition to adult services
-Initial management if sleep or behaviour problems present:
§ Evidence of OSA –> Refer
§ Due to mental health or behavioural disorder –> Refer
§ Due to medication (e.g. anti-epileptics or stimulants) –> refer to consultant who initiated them
§ Risperidone can be given short term for aggression
§ Melatonin is 2nd line for sleep disturbance to lifestyle changes.
§ SSRI (e.g. sertraline) for co-morbid anxiety or OCD
Secondary care management:
- Compose specialised care plan
- Offer specialist interventions
Prognosis:
Best with early diagnosis, for prompt access to services and support
Conduct disorders
What?
Persistent, repetitive antisocial/aggressive behaviour that violates age appropriate norms
Classification: Conduct disorders and ODD
Onset: Over age 3. If <10 = “early onset”. If >10 = “adolescent onset”
Conduct disorder:
Diagnosis = 6 months history of behaviours, that impacts significantly on schooling and relationships
Who = Boys>, urban population >
Cause = Parents (psychiatric condition, substance misuse), child (low IQ, epilepsy, neuro damage), social disadvantage
Comorbid disease: Neurodevelopmental disorder (ADHD, ASD), anxiety, LD, substance misuse, depression
Complication factors: Substance misuse, neurodevelopmental disorder, LD or mental health problem
Management: If suspected CD then assess presence of complicating factors. If present then specialist referral. If not present then refer to age-appropriate services.
Prognosis: Persistent, esp. if in early childhood. Often misdiagnosed as antisocial PD.
ODD: oppositional defiant disorder
What? Behavioural disorder characterised by defiant/disobedient/hostile behaviour towards authority figures without violating societal norms.
Who? Boys in childhood years
Outcome? 1/4 show no persistence. Many develop CD or substance misuse
quick difference - CD = fights, bullying. ODD = arguments, spite
Panic disorder
Definition:
Recurrence of panic attacks that are no provoked by psychiatric illness, substance misuse or medical condition
Epidiemiolopy:
2.5:1 F:M
Bimodal incidence: 15-20yrs and 45-54yrs
Aetiology: Highly heritable (evidence that that this increases predisposition, stressors required to trigger onset)
Presentation:
- Autonomic arousal
- Hyperventilation syndrome
Management
1st line SSRI
2nd line Change SSRI to SNRI, MAOI, TCA
3rd line Add benzodiazepine (use for 2 weeks during antidepressant induction to cover Sx)
Once medication stabilised disorder, continue for 12-18 months then taper over 2-4 months.
Agoraphobia
What?
Panic disorder associated with situation/places without an easy escape, leading to avoidance
Who?
3:1 Females
Bimodal distribution: 15-35 yrs and older
Management
Medical: 1st line antidepressants. Benzos used short term only (e.g. alprazolam)
Psychological: Behavioural methods (Exposure techniques, relaxation training and anxiety management).
Cognitive methods (Teaching about body response to anxiety, education about panic attacks, modification of thinking errors. )
Generalised anxiety disorder
Definition: Characteristic disproportionate, pervasive, widespread and uncontrollable worry with somatic, cognitive and behavioural symptoms
Diagnosis: 6month history on most day of at least 4 of…
- Autonomic arousal
- Cognitive Sx
- Mental state Sx
- General Sx
- Tension Sx
- Physical Sx
Who: Women>, 45-59yr olds
Cause: Triple vulnerability model
Mx: Stepped care approach. If comorbidities present, then assess which is more significant and treat.
Anxiety Symptoms Mild= 1st line period of active monitoring. 2nd line Low intensity psychological intervention. 3rd line: High-intensity psychological intervention OR drug therapy (1. SSRI 2. SNRI 3. Pregabalin)
Anxiety symptoms with functional impairment = 1st line High-intensity psychological intervention OR drug therapy (1. SSRI 2. SNRI 3. Pregabalin)
Referral to specialist services indications
- GAD is complex
- Inadequate response to treatment (high intensity psychological interventions and drug treatments)
- Very marked functional impairment
High risk of self-harm, suicide or self-neglect.
The triple vulnerability theory
of David Barlow proposes that anxiety disorders result from the interaction of
generalized biological vulnerability (genetic inheritance), generalized psychological
vulnerability (beliefs that make the person vulnerable to anxiety in general), and
specific psychological vulnerability (specific beliefs that make the person vulnerable
to a particular anxiety disorder).
Acute stress disorder
What? Reaction to exception stress after 48hr, but before 4 weeks.
Symptoms: More dissociative than acute stress reaction
Management:
1st line Simple practical measures (advice and support)
2nd line Psychological (Bebriefing and CBT)
3rd line pharmacological (TCAs, SSRIs, Benzo’s)
Prognosis:
Either self limiting, or if continued >4 weeks then PTSD
PTSD
Definition: Severe psychological disturbance following an extremely traumatic/stressful event
Epidemiology:
Females more at risk
Onset/severity depends on the trauma (rape, torture and prisoners of war have higher risk)
Risk factors:
- Female
- Low SES
- Low education
- Hispanic/African-american
- Low self-esteem
- Psychiatric history
Diagnosis/ Presentation:
From 4 weeks to 6 months of the event, requires all of the following:
- Event occurence
- Re-experiencing (flashbacks or nightmares)
- Avoidance behaviours
-Either: Memory loss around event time OR Hyperarousal symptoms
Management:
If subclinical PTSD –> Watching waiting with regular reveiw
If clinical PTSD, referral to specialist for–>
1st line Psychological (Trauma focused CBT, counselling, EMDR)
2nd line Medical to treat co-morbid symptoms that may be limiting Tx. Not for U18s. See below
Risk management:
If considered high risk (due to severe stress or comorbid depression) –> Referral to crisis resolution of HTT
Care than SNRI and SSRI have slight suicidality risk
Prognosis
2/3 adults symptoms resolve within several months
1/3 symptoms longer lasting, usually enduring and severe
Medical options.... - Anti-depressants ○ Venlafaxine or SSRIs e.g. Paroxetine, Sertraline are licensed for PTSD ○ Other anti-depressants - For sleep disturbances ○ Mirtazapine, levomepromazine, prazosin ○ Hypnotics e.g. zopiclone, zolpidem - For anxiety or hyperarousal ○ Benzo's e.g. clonazepam ○ Buspirone ○ Propranolol - For intrusive thoughts / hostility / impulsiveness ○ Carbamazepine ○ Valproate, Topiramate ○ Lithium - For psychotic symptoms / aggression ○ Anti-psychotic
Adjustment disorder
Response within 1 month to a psychological stress that persists <6 months after stressor removed.
Classification
- Brief depressive reaction (>1month)
- Prolong depressive reaction (>6 months but <2yrs)
- Mixed anxiety and depressive reaction
- Predominant disturbance of emotions or conduct
(Allows inclusion of grief / bereavement reactions)
Managment
1st line Psychological- Supportive psychotherapy to enhance the capacity to cope with a stressor and establish sufficient support
2nd line Medical - Antidepressants / anxiolytics
Prognosis:
70% resolution in 5 yrs
Depersonalisation / Derealisation syndrome
What?
Persistent episodes of distressing feeling of unreality or detachment. Can be in relation to outside world (derealisation) or the person themselves (depersonalisation).
Viewed as a dissociative disorder (DSM-5) or an anxiety/stress-related disorder (ICD-10)
Who? Rare Up to 1/2 of normal population may experience depersonalisation, with 1-2% having more chronic symptoms. Adolescent/early adulthood onset. Risk factors: - Women> in clinical populations - Psychiatric populations
Co-morbidity:
- Anxiety disorders (OCD, phobias, panic disorder)
- Depressive disorders
- Personality disorders (anankastic, obsessional, EUPD)
Differential Diagnosis:
Can be result of..
- Sleep/ sensory deprivation
- Being in unfamiliar surroundings
- Acute stress or trauma
Symptom of..
- Schizophrenia / psychosis (usually with delusional justification)
- Mood / anxiety disorder
- Acute intoxication / alcohol withdrawal
- Substance misused (esp cannabis or hallucinogens)
- Organic disorders
Investigations:
Exclude organic cause, can include brain imaging and EEG
Management:
Rating e.g. The Cambridge Depersonalisation Scale.
Approach
- Exclude organic cause
- Identify and treat psychiatric condition if present
- No licenced drugs un UK.
○ SSRIs have some evidence (escitalopram or citalopram) alone in combo with lamotrigine
- Psychological intervention
○ CBT has shown benefit.
Course:
Sudden onset, with gradual resolution.
Chronic symptoms run a fluctuating course, and may be treatment resistant.
OCD
Definition: Characterised by obsession and delusions that cause distress and functional impairment. Thoughts are seen as own and patient has insight. Obsessions are intrusive, repetitive and distressing thoughts/images recognised as one’s own. Compulsions are stereotyped and purposeless actions performed to reduce anxiety of obsession
Who?
F:M
Typical onset at age 20
Aetiology:
GAS association
Presentation:
Clusters of symptoms: Pre-occupation with hygiene, worry about safety, abhorrent thoughts/impulsesab
Symptoms: Contamination, checking, aggressive/violent thoughts, washing, symmetry, counting
DDx
- Anankastic PD
- Depressive disorder
- Bodily dysmorphic disorder
- Anxiety
- Alcohol and substance misuse
Diagnostic criteria: 3/3 required 1. Obsessions 2. Compulsions 3.Anxiety or functional impairment (No time frame)
Management:
Adults with MILD impairment = Low intensity CRT + ERP
Adults with MODERATE impairment = High intensity CRT + ERP OR SSRI (2nd line TCA e.g. clomipramine)
Adults with SEVERE impairment / at risk / comorbid illness = Refer for specialist assessment and treatment. Consider Moderate Mx whilst waiting.
Child with MILD impairment = 1st line Refer for self-help therapy. No improvement? Refer to CAMHS
Child with MODERATE-SEVERE impairment = CAMHS referral
Note: SSRI initial dose higher in OCD so expect initial response after 12 weeks. Caution of increased suicidality risk so arrange follow-up after 1 week
Somatisation Disorder
What?
Disorder where there is repeated presentation with medically unexplained symptoms, affecting multiple organ systems.
First presenting before the age of 40yrs.
Who?
Adults = Usually chronic
Children = Impacts 1-3 organ systems for a shorter period of time
Associations
Psychological distress
Functional impairment
Risk of iatrogenic harm
Management
- Make, document, and communicate the diagnosis. - Acknowledge symptom severity and experience of distress as real, but emphasize negative investigations and lack of structural abnormality. - Reassure the patient of continuing care. - Attempt to reframe symptoms as emotional. - Assess for, and treat, psychiatric comorbidity as appropriate. - Reduce and stop unnecessary drugs. - Consider a case conference involving the GP and treating physicians. Educate the parents/family. - For children and adolescents: Rehabilitation and return to usual activities.
Prognosis
Poor in the full disorder, tendency is for chronic morbidity, with periods of relative remission.
Personality disorders
Definition: Inflexible, enduring and disruptive behaviour patterns that cause distress or impaired function. Tends to impair functions in affect, behaviour and cognition. Sufferer can have insight but not necessary for Dx.
Risk factors:
- FH: Relative of schizophrenic. Can develop into overt schizophrenia
- 4% population
- Female prisoners 7%
- Poor upbringing
Classifications:
Paranoid= Sensitive/suspicious
Schizoid = Emotionally cold, detached, disinterested in other
Schizotypical with schizophrenia = Interpersonal discomfort with peculiar ideas etc
EUPD (Types: impulsive / borderline) = Emotional instability managed with outbursts of rage or self-destructive behaviour
Histrionic = Dramatisation, attention-seeking, risk taking behaviour, manipulative
Narcissistic = Lack of empathy, need for admiration
Dissocial = Callous, lack of concernfor others. Unable to maintain relationships.
Anxious = Tension, self-consciousness, fear of criticism
Dependent = Clinging / submissive. Feels helpless without partner
OCD
Anankastic = Preoccupation with control, perfectionism, rigidity, doubt/indecisiveness
Clusters:
A (Weird) e.g. Paranoid, schizoid, schizotypical
B (Wild) e.g. Narcisistic, EUPD, Dissocial, histrionic
C (Worried) e.g. Anankastic, Anxious, OCD
Psychopathy
Presentation:
EMOTIONAL FEATURES
- Interpersonal e.g. Glibness, manipulative, grandiose sense of self-worth, lying
- Affective e.g. Failed responsibility, callous, lack of guilt, shallow effect
-Romantic e.g. promiscuous sexual behaviour, short martial history
BEHAVIOURAL FEATURES
- Lifestyle e.g. irresponsibly, impulsive, needs stimulation, lack of long term goals
- Antisocial e.g. poor behavioural control
Diagnosis:
Scoring on the PCL-R (psychopathy classification- revised)
Requires a score >25/40
Requires features of emotional AND behavioural nature
Puerperal disorders
3 classification: Baby blues, post-partrum depression, post-partrum psychosis, pre-existing psychiatric illness
BABY BLUES
3/4 women get it
Occurs 3-4 days after delivery, for 1-2 days
Px: Irritability, labile mood, tearfullness
Mx: Reassure and observe until resolution
POSTPARTUM DEPRESSION
Who: 1-2% women
Risk factors: Depression history, eating disorder history, FH, single mother, unwanted pregnancy, baby blues
Occurs: Peak 3-4 weeks after delivery, within 6 months of birth
Features: Symptoms of depression
Management: Early detection and Risk assess with EPDS. Always ask about self-harm and harm to baby. Mild - CBT. Moderate - SSRI. Severe= Consider admission
POSTPARTUM PSYCHOSIS
What? Acute psychosis after delivery
Who? 1.5/1000 births. 30% recurrence
Risk factor: Previous of postpartum psychosis, FH of psychosis, Single parenthood, little social support
Presentation: 80% affective symptoms, 15% Schizophreniform
Management: Consider admission to psychiatric mother and baby unit. If Major affective disorder: ECT, mood stabilisers (esp carbamazepine) and early antidepressant use.
CHILDBEARING IN PATIENTS WITH PRE-EXISTING MENTAL DISORDERS
Schizophrenia: Patients are less likely to relapse post-partum if they stay on treatment.
Bipolar: 2/3 will relapse post-partum. Increased risk is FH of post-partum psychosis, 4+ illness episodes pre-pregnancy or medications discontinuation mid-pregnancy
Eating disorders: Risk of postnatal depression and poorer health outcomes for baby.
Alcohol misuse
Alcohol physiology:
GABA-A agonist —> Anxiolytic
NMDA antagonist –> Amnesia
Dopamine agonist –> Euphoric
Assessment:
Alcohol-related problems: CAGE questionarires
Alcohol dependence: SADQ
Alcohol withdrawal: CIWA-Ar
Presentation: Alcohol abstinence Alcohol withdrawal Alcohol withdrawal seizures Delrium Tremens Korsakoffs syndrome (if severe with Wernicke's encephalopathy --> Wernicke-korsakoff syndrome. Wernicke's presents with Ataxia, confabulation and visual problems)
Investigations:
BAC
Bloods (elevated MCV, G-GT, CDT sign of excessive consumption)
Urinary alcohol level (remains elevated for days)
Management:
- Acute withdrawal = Alcohol reducing regime
- Alcohol withdrawal seizures = Consider lorazepam
- DT = Oral lorazepam
- Wernicke’s encephalopathy= Pabrinex 2 x vials TDS for 3 days
Maintaining abstinence treatment options
- Disulfram “Antabuse”
- Acamprosate (NMDA antagonist that reduces cravings)
- Naltrexone (Opioid receptor antagonist that reduces Dopamine release to reduce pleasure of alcohol consumption
Alcohol reducing regime:
Using? Diazepam if inpatient. Chlordiazepoxide if outpatient.
Duration: 5-7 days
Indications: >10 units in last 10 days, Hx of dependence, withdrawal symptoms
Complications:
Delirium Tremens
Definition: Acute confusional state associated with alcohol withdrawal. Occurs 1-7 days after cessation and peaks after 48hrs.
Risk: 10-15% mortality
Management: 1st line Oral lorazepam. 2nd line parenteral Lorazepam or haloperidol
Substance misuse: Depressants
Depressants
o Drugs: Benzodiazepines, barbiturates, alcohol, Chlordiazepoxide, pregabalin, gabapentin
o BZDs
○ MoA: GABA agonist
○ Effect: Anxiolysis and euphoria
○ Tolerance: Develops quickly
○ Dependency: Develops after 3-6 weeks of regular use
○ Withdrawal: Complicated by seizures and delirium
○ Side effects:
§ Acute: Forgetful, drowsy, impaired concentration + co-ordination
§ Chronic: Impaired concentration, memory and depressed mood
○ Risk:
Limb ischaemia if IV route of melted tablet use
Substance misuse: Stimulants moA Eg's Effects Risk Withdrawal
Stimulants
o Drugs: Amphetamines, cocaine, MDMA, caffeine
o MoA: Prevents NMDA reuptake
o Effect: Increased alertness and endurance, insomnia and subjective sense of well-being
o Risk: In overdose can cause cardiac and cerebrovascular problems
o Dependence: No physical dependence symptoms
Withdrawal: Rebound lowering in mood and intense craving
Substance misuse: Hallucinogens
o Drugs: LSD, mescaline, psilocybin, PCP, Ketamine
o Psychoses common
Risk: Prolonged heavy use links to schizophrenia
Substance misuse: Opiates
Opiates
- Drugs: Morphine, heroin, methadone, buprenorphine, dihydrocodeine, fentanyl, pethidine
- MoA: Agonist of delta, kappa and mau receptors.
- Manifestations: Physical dependence, tolerance and withdrawal syndrome.
o IV opioids withdrawal: Craving, rhinorrhoea, lacrimation, vomiting etc. Examination reveals tachycardia, hypertension, mydriasis and facial flushing
-Withdrawal: COWS (Clinical Opioid Withdrawal Scale)
-Risk: Respiratory depression in overdose
- Opiate overdose
o Signs: Pinpoint pupils, unrousable, pale skin, blue lips, shallow / slow breathing, snoring /rasping breaths
oNaloxone is an inverse opiate agonist that is can be given in emergencies. IM injection given in 0.4ml doses. Brand name is Prenoxad (contains Naloxone hydrochloride). Wait 2-3 mins for response before next dose.
Substance misuse: Cannabinoids
Cannabinoids
- Drugs: Cannabis
- Psychoactive component: Tetrahydrocannabinol (THC)
- Effects
o Immediate: Mild euphoria (“the giggles”), a sense of enhanced well-being, enhanced subjective sensation, relaxation, altered time sense and increased appetite
o Physically: Mild tachycardia, variable dysarthria and ataxia
o Harmful acute affects: Paranoia, panic attacks and delayed reaction time induced accidents
o Harmful chronic effects: Dysthymia, anxiety/depression, amotivational syndrome
- Duration: Immediate effect after smoking, lasting 2-5hrs.
- Testing: Urine sample contains positive for up to 4 weeks after regular use due to metabolite distribution in to fat.
- No physical dependency
Mild withdrawal for chronic users e.g. irritability, insomnia and anxiety
