Psychiatry Flashcards
(354 cards)
1
Q
What are addictive behaviours?
A
Repeated behaviours that dominant a patient’s life to the detriment of social/occupational/material/family values and commitments
2
Q
What are risk factors for addictive behaviours?
A
- Stress
- Fhx
- Peer pressure
- Low self esteem
- Anxiety
- Previous abuse
3
Q
What are some common addictive behaviours?
A
- Gambling
- Eating
- Internet
- Sex
- Shopping
- Alcohol/drug use
- Smoking/nicotine use
4
Q
What is the pathophysiology of addiction?
A
Mediated via the mesolimbic dopamine reward pathway
5
Q
What are clinical features of addiction?
A
- Continuation despite harm
- Difficulty to stop
- Withdrawal symptoms if stopped
- Denial of problem
- Hiding behaviour
- Vocational/social/recreational activities given up/reduced because of addiction
6
Q
What is the management for addictive behaviours?
A
- CBT
- Support groups e.g. alcoholics anonymous
- Aversion therapy
- Self-control training
- Managed detox
7
Q
Describe ADHD
A
- Attention Deficit Hyperactivity Disorder
- Characterised by inattentiveness, hyperactivity and impulsiveness
- Usually manifests before the age of 7
- More common in males
- Risks = genetics/prematurity/foetal alcohol syndrome
- Symptoms of impaired attention, hyperactivity and/or impulsivity
- Symptoms evident in more than one situation e.g. school and home
- Symptoms present for at least 6 months
- CNS stimulant = methylphenidate (ritalin)
8
Q
What are 3 situations in which ADHD may be falsely diagnosed?
A
- Age-appropriate behaviours in young active children
- Children placed in academic settings inappropriate to their intellectual ability e.g. due to intellectual disabilities/highly intelligent children
- Other mental illness e.g. pervasive developmental disorder, depression
9
Q
What other medications may be used for ADHD?
A
- CNS stimulants - blocks reuptake up dopamine and noradrenaline:
- Methylphenidate (ritalin)
- Dexamphetamine
- Lisdexamfetamine
Non-stimulants:
- Atomoxetine
- Guanfacine
10
Q
What is ADD?
A
- Attention deficit disorder
- Difficulties with concentration without the presence of other ADHD symptoms e.g. impulsiveness/hyperactivity
11
Q
What are some side effects of methylphenidate?
A
- Growth suppression association (6 months height and weight)
- Anxiety
- Increased BP
- Arrhythmias
- Appetite loss
12
Q
What is anxiety?
A
Subjective, unpleasant sense of unease and worry of something bad happening
13
Q
Describe GAD
A
- Generalised anxiety disorder
- Excessive worry/feelings of apprehension about everyday events/problems
- More common in females
- Nervousness
- Restlessness/irritability
- Easily fatigued
- Difficulty concentrating/’mind blank’
- Muscle tension
- Sleep disturbance
- Sweating/palpitations/dry mouth
- Excessive anxiety/worry about everyday events/activities and difficulty controlling worry for >6 months
- Causes significant distress/impairment in social/occupational/other areas of functioning
- At least 3 associated symptoms
- GAD-7 questionnaire
- Counselling/CBT
- SSRI
14
Q
What is a panic attack and what is the management?
A
- Short lived episode (approximately 20 minutes) characterised by severe anxiety, palpitations, rapid breathing and existential fears
- SSRI
- Beta blocker
15
Q
Describe panic disorder
A
- Recurrent, episodic, severe panic attacks that are unpredictable and not restricted to particular situations/circumstances
- More common in females
- Symptoms peak within 10 minutes (crescendo)
PANICSD: - Palpitations
- Abdominal distress
- Numbness/nausea
- Intense fear of death
- Choking/chest pain
- Sweating/shaking/SOB
- Depersonalisationn/derealisation
- SSRIs
- TCAs
- CBT and self-help methods
16
Q
What is phobic anxiety?
A
Recurring excessive and unreasonable symptoms of anxiety in the (anticipated) presence of specific feared objects, situations or person leading, wherever possible, to avoidance
17
Q
What are features of phobic anxiety?
A
- Anticipatory anxiety
- Palpations/sweating/trembling
- SOB/chest pain
- Dizziness
- Chills/hot flushes
18
Q
What is the management for phobic anxiety?
A
- Behavioural therapy e.g. graded exposure therapy
- Benzodiazepines
- Education/anxiety management
19
Q
Describe PTSD
A
- Post-Traumatic Stress Disorder
- Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
- Reliving the situation
- Avoidance (of reminders)
- Hyperarousal (irritability/outbursts)
- Emotional numbing
(May also have dissociative amnesia) - Exposure to traumatic event
- Features present within 6 months
- Features last >1 month
- Trauma screening questionnaire (TSQ)
- Trauma focused CBT
- Eye movement desensitisation and reprocessing (EMDR)
- Sertraline/venlafaxine
- Zopiclone (for sleep disturbance)
20
Q
What is the difference between typical and complex PTSD?
A
Typical = arises after a traumatic episode and is generally related to a single traumatic event
Complex = related to a series of traumatic events over time or one prolonged event
21
Q
Describe OCD
A
- Obsessive compulsive disorder
- Chronic condition associated with marked anxiety and depression, characterised by ‘obsessions’ and/or ‘compulsions’
- Obsessions –> anxiety –> compulsive behaviour –> temporary improvement in anxiety –> obsession then reappears
- Associated with other mental health conditions
- Presence of either obsessions/compulsions/both
- Are time consuming (>1hr/day) or cause significant distress/functional impairment
- Patient recognises them to be excessive/unreasonable
- CBT
- Exposure and response prevention (ERP)
- Behavioural therapy/psychotherapy
- SSRI, TCA (clomipramine)
22
Q
What is an obsession?
A
An idea/image/impulse recognised by patient as their own but which is experienced as repetitive, unwanted, intrusive and distressing. Patients may try to resist but this often causes a lot of anxiety
23
Q
What is a compulsion?
A
A behaviour/action recognised by patient as unnecessary and purposeless but which they cannot resist performing repeatedly
24
Q
What is a phobia?
A
Fear of a specific situation/object
25
What is agoraphobia?
Fear of public spaces e.g. shops
26
What is social phobia?
Fear of social situations/scrutiny/being ridiculed in social situations
27
What is the management for phobias?
- CBT
- Exposure therapy
- Potentially SSRI ?
28
What is ASD?
- Autism spectrum disorder
- Neuro-developmental disorder characterised by abnormal social interaction, communication and restricted, repetitive behaviours
29
Describe the epidemiology of ASD
- More common in males
- Infantile autism associated with development of seizures in adolescence
30
Describe the autistic spectrum
- On one end, patients have normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others (previously known as Asperger syndrome)
- On the other end, patients can be severely affected and unable to function in normal environments
31
What are the 3 main features of ASD?
1. Social interaction deficits
2. Communication deficits
3. Behaviour deficits
32
What is bipolar disorder/bipolar affective disorder?
Depression and mania/hypomania occurring in episodes usually with months separating them
33
Describe the epidemiology of bipolar disorder
Bimodal distribution with peaks at 15-24 years and 45-54 years
34
What are risk factors for bipolar disorder?
- Genetics/family history
- Prenatal exposure to toxoplasma gondii
- Premature birth (<32 weeks)
- Childhood maltreatment
- Traumatic life events/experiences
- Postpartum period
- Cannabis use
35
What is the difference between mania and hypomania?
Mania = elevated/expansive/euphoric/irritable mood with >3 characteristic symptoms on most days for >1 week - often occurs with psychotic symptoms
Hypomania = >3 characteristic symptoms lasting >4 days and present most of the day, almost every day - essentially less severe mania without psychosis
36
What are the types of bipolar disorder?
Bipolar I = episodes of depression, mania or mixed states separated by periods of normal mood
Bipolar II = episodes of depression, hypomania or mixed states (no mania)
37
What is cyclothymic disorder?
- Condition related to bipolar disorder
- Recurring mild depressive and hypomanic states
- Lasts for at least 2 years
- Does not meet the diagnostic threshold for a major affective episode
38
What medications can cause medication-induced mania/hypomania?
- TCAs
- SNRIs
- SSRIs
- Benzodiazepines
- Antipsychotics
- Lithium
- Anti-Parkinsonian medications e.g. AChE inhibitors (rivastigmine)
39
What are the investigations for bipolar disorder?
- Bloods (FBC, U&Es, LFTs, TFTs, CRP, B12, folate. vitamin D, ferritin)
- HIV testing
- Physical examination (neuro exam)
- CT/MRI head
40
What are differential diagnoses for bipolar disorder?
- Schizophrenia
- Organic brain disorder
- Drugs
- Recurrent depression
- Emotionally unstable/borderline personality disorder (EUPD/BPD)
- Cyclothymia
41
What is the management for bipolar disorder?
Maintenance = lithium
Mood stabilisers = lithium, sodium valproate, carbamazepine
Depression = SSRIs
Psychotic symptoms = antipsychotics
Acute mania = quetiapine + lithium + benzodiazepine
Psychoeducation/CBT/IPT/support groups
42
What is the RC?
Responsible clinician - approved clinician with overall responsibility of the patient's care. Only the RC can make certain decisions e.g. discharge from section, S17 leave, consent to treatment
43
What are SOADs?
Second opinion appointed doctors - doctors external to the organisation and appointed by the care quality commission (CQC). They review the treatment plans for patients who are detained for >3 months who do not have capacity to consent to or are refusing treatment
44
What is a mental health tribunal?
Legal proceedings that decide whether a patient should be discharged from their section or not
45
What is a S12 approved doctor?
A doctor (usually a senior psych trainee or consultant but occasionally a GP) who has undergone the accredited training to complete mental health act assessments
46
When can a patient be detained?
If they have a mental disorder that poses significant risk to themselves or others, and treatment in the community is not possible because of this
47
What is a AMHP?
Approved mental health practitioner - professional who has undergone the training to take part in mental health act assessment and can be from any background (usually social workers) but importantly CANNOT be doctors
48
What is a section 2?
- Admission for assessment for up to 28 days
- Requires MHA assessment - 1 AMHP + 2 section 12 approved doctors
- Cannot be renewed
- Can be transferred to section 3
- Patient can be treated against their wishes
- Patients can appeal within first 14 days
49
What is a section 3?
- Admission for assessment for up to 6 months days
- Requires MHA assessment - 1 AMHP + 2 section 12 approved doctors
- Can be renewed for 6 months then annually
- Patient can be treated against their wishes - proposed treatment plan for mental disorder required
- Patients can appeal once per period of detention
50
What is a section 5(2)?
- Holding power of informal patients by doctors
- MHA not required
- Lasts 72 hours
- Not renewable
- Patients cannot appeal
51
What is a section 5(4)?
- Holding power of informal patients by nurses
- MHA not required
- Lasts 6 hours (time for doctor to arrive)
- Not renewable
- Patients cannot appeal
52
What is a section 136?
- Allows police to detain an individual they believe is suffering from a mental disturbance in a public place and take them to a place of safety (usually ED or 136 suite)
- Maximum 72 hours detention to allow MHA assessment
53
What is a section 135?
- Warrant for search for and removal of patients in private premises
- Issued by magistrates
- Patient taken to a place of safety
54
What is a community treatment order?
- Patients under section 3 can be discharged from hospital subject to them being liable to be recalled to hospital if required
- Specific conditions to which the patient must adhere
55
What is a section 17?
Authorised leave from hospital
56
What is a section 117?
- Statutory duty on health and social services to provide aftercare for those detained under section 3
57
What is nearest relative?
- Not next of kin - determines a proxy to act as a safety mechanism within the MHA
1. Husband/wife/civil partner
2. Son/daughter
3. Mother/father
4. Brother/sister
- Can apply to section patient
- Can object to section/appeal to tribunal
58
What is mental capacity?
The ability to understand information and make decisions about one's life or the ability to communicate decisions about one's life
59
Describe the Mental Capacity Act (2005)
- All adults are assumed to have capacity
- Capacity can fluctuate
- If capacity is questioned, patients need to meet the criteria:
1. Understand the options
2. Retain information
3. Weigh up pros and cons
4. Communicate decision
60
What is lasting power of attorney?
Patients can legally nominate a person of their choice to make decisions based on their behalf if they lack mental capacity
61
What is Deprivation of liberty safeguards (DoLS)?
- Application made by a hospital or care home for patients who lack capacity to allow them to provide care and treatment
- Whilst in hospital or a care home, the patient is under control and not able to leave
62
What is an illusion?
Misinterpretation of real stimulus in the context of emotional state e.g. misperceiving a shadow on the wall as an intruder
63
What is a hallucination?
Internal experiences/perceptions without an external stimulus. Can be visual/auditory/tactile/olfactory/gustatory
64
What is a pseudo-hallucination?
A type of illusion when feelings of anxiety or fear are projected on external objects e.g. misperceiving a shadow on the wall as an intruder
65
What is an over-valued idea?
A false belief that is maintained despite strong evidence that it is untrue - similar to delusions but may seem less strange and have an element of truth
66
What is a delusion?
A false, unshakeable idea/belief that is firmly held despite evidence to the contrary that is not consistent with the person's educational, cultural and social background
67
What is a delusional perception?
A true perception to which a patient attributes a false meaning e.g. traffic light turns red is interpreted by patient as martians about to land (schizophrenia)
68
What is concrete thinking?
More literal form of thinking that focuses on the physical world - take information at face value without thinking beyond or generalising the information to other meanings/situations
69
What is loosening of association?
Lack of connection between ideas - thoughts may appear loosely connected or unrelated (schizophrenia)
70
What is circumstantiality?
Circuitous and non-direct thinking or speech that digresses from the main point of conversation (but finally makes its way back to the main point)
71
What is perseveration?
Persistent and inappropriate repetition of the same thought via speech or actions (frontal lobe dysfunction)
72
What is confabulation?
Memory error consisting of the production of fabricated/distorted/misinterpreted memories about oneself or the world e.g. person with dementia tells a story about their childhood which isn't true but they think it is
73
What is somatic passivity?
a.k.a passivity phenomena
The belief that outside influences are playing on the body - the event is experienced as alien by the patient in that it is not experienced by the patient as their own but inserted into the self from outside
74
What is pressure of speech?
Unusually rapid, abundant and varied speech (mania)
75
What is anhedonia?
Lack of interest, enjoyment or pleasure from life's experiences
76
What is incongruity of affect?
Emotion is inappropriate to content of speech
77
What is blunting of affect?
Difficulty expressing emotions, characterised by diminished facial expressions/expressive gestures/vocal expressions in reaction to emotion provoking stimuli
78
What is belle indifference?
Apparent lack of concern shown by some patients towards their symptoms - often regarded as typical of conversion symptoms/hysteria
79
What is depersonalisation and derealisation?
Depersonalisation = feeling of being outside oneself and observing own actions, feelings or thoughts from a distance
Derealisation = feeling that the world is unreal
80
What is thought alienation?
Thoughts are no longer within patient's control (insertion/withdrawal/broadcast)
81
What is thought insertion?
Thoughts have been implanted by an external agency
82
What is thought withdrawal?
Thoughts have been taken away
83
What is thought broadcast?
Thoughts are known to others via telepathy or the media
84
What is thought echo?
Patient hears their own thoughts as if they were being spoken aloud
85
What is thought block?
Mind suddenly becomes empty of thoughts (paranoid schizophrenia)
86
What is akathisia?
Inability to remain still
87
What are made acts, feelings and drives?
The delusional belief that one's free will has been removed and an external agency is controlling one's actions and feelings
88
What is clouding of consciousness?
a.k.a brain fog
Inattention and reduced wakefulness
89
What is catatonia/stupor?
State in which someone is awake but does not seem to respond to other people and their environment/state of near unconsciousness or insensibility
90
What is flight of ideas?
Thoughts are moving so quickly that one train of thought is not completed before the next one starts thus the topic might be difficult to follow
91
What is psychomotor retardation?
Slowing down of thought and a reduction of physical movements in an individual - can cause a visible slowing of physical and emotional reactions including speech and affect
92
What is formal thought disorder?
Disorganised thinking evidenced in speech (psychosis and schizophrenia)
93
What is conversion/dissociation?
Conversion = emotional stress manifests as physical symptoms
Dissociation = mental process of disconnecting from one's thoughts/feelings/memories/sense of identity
94
What is a mannerism?
Normal actions carried out in peculiar fashions, usually in an attempt to draw attention to oneself (schizophrenia)
95
What is a stereotyped behaviour?
Repetitive movements or sounds carried out by individuals with cognitive dysfunction or severely impaired sensory function
96
What is substance misuse?
The consumption of substances that leads to the involvement of social/psychological/physical/legal problems
97
What is alcohol dependence?
Craving, tolerance and preoccupation with alcohol with continued drinking in spite of harmful consequences
98
Describe the epidemiology of alcohol misuse
- 5th biggest risk factor for death across all ages
- More common in males
- Recommended units = 14 units/week spread evenly over 3 days or more
99
How do you calculate units of alcohol?
ABV x volume (ml) / 1000
100
What are risk factors for alcohol misuse?
- Male
- Genetics/family history
- Occupation
- Cultural influences
- Cost of drinks
- Social reinforcement/association
- Chronic illness
- Traumatic life event
101
What are clinical features of intoxication?
- Slurred/impaired speech
- Ataxia/impaired coordination
- Impaired judgement
- Labile affect
- Hypoglycaemia
- Stupor
- Coma
102
What are signs of alcohol dependence?
CANT STOP
- Compulsion to drink
- Aware of harms
- Neglect of other activities
- Tolerance
- Stopping causes withdrawal
- Time preoccupied with alcohol
- Out of control use
- Persistent, futile wish to cut down
SAW DRINk
- Subjective awareness of compulsion to drink
- Avoidance/relief of withdrawal by further drinking
- Withdrawal sx
- Drink-seeking behaviour
- Reinstatement of drinking after attempted abstinence
- Increased tolerance
- Narrowing of drinking repertoire
103
What are signs of alcohol withdrawal?
Appear 6-12 hours after last drink
- Malaise/sweating
- Tremor
- Nausea/vomiting/diarrhoea
- Insomnia
- Irritability/anxiety
- Transient hallucinations
- Seizures (tonic clonic)
- Palpitations
104
What medical emergency can alcohol withdrawal lead to?
Delirium tremens - 72 hours after alcohol cessation
105
What are clinical features of delirium tremens?
- Cognitive impairment
- Lilliputian hallucination (spiders/snakes/tiny figures)
- Paranoid delusions
- Tremor
- Fever/sweating
- Tachycardia
- Dehydration
106
What is the treatment for delirium tremens?
IV pabrinex and lorazepam
107
What are the investigations for alcohol misuse?
- History and MSE
- Physical exam (signs of chronic liver disease e.g. palmar erythema, spider naevi, etc.)
- Questionnaires (AUDIT, CAGE, SADQ, FAST)
- CT head
- ECG
- Bloods
108
What is the acute treatment for alcohol misuse/abuse (detoxification)?
Chlordiazepoxide (benzodiazepine), IV pabrinex, water and food (protein-rich, high calorie diet)
109
What is pabrinex and why is it used for alcohol misuse/abuse/withdrawal?
Synthetic thiamine/vitamin B1 - chronic alcohol consumption causes deficiency (leads to Wernicke-Korsakoff syndrome)
110
What 3 medications are used for maintenance/relapse prevention in alcohol withdrawal?
- Acamprosate (reduces cravings)
- Naltrexone (reduces pleasurable effects of alcohol)
- Disulfiram (causes unpleasant symptoms when drinking)
111
What are other management plans for alcohol withdrawal?
- Motivational interviewing/CBT
- Support groups e.g. alcoholics anonymous
112
What is Wernicke's encephalopathy?
Acute neurological condition characterised by a triad of confusion, ataxia and oculomotor dysfunction
113
What is Korsakoff syndrome?
Chronic amnesia syndrome characterised by defects in both anterograde and retrograde memory
114
What are the causes of Wernicke's encephalopathy?
Thiamine/vitamin B1 deficiency due to:
- Chronic alcoholism
- Prolonged fasting/starvation
- Anorexia nervosa
- Hyperemesis gravidarum
- Systemic malignancy
- End-stage renal failure
- GI disease/malabsorption
115
What are the causes of Korsakoff syndrome?
Untreated Wernicke's encephalopathy
116
What are clinical features of Wernicke's encephalopathy?
- Ataxia
- Delirium/confusion
- Ophthalmoplegia/nystagmus
117
What are clinical features of Korsakoff syndrome?
- Irreversible short term memory loss
- Confabulation
- Time disorientation
118
How is Wernicke's encephalopathy/Korsakoff syndrome treated?
IV pabrinex
119
What are the complications of Wernicke's encephalopathy?
- Permanent horizontal nystagmus
- Inability to walk
- Deficit in learning/memory
120
What are the complications of Korsakoff syndrome?
Permanent neurological damage - recovery is rare
- Progressive reduced level of consciousness
- Coma
- Death
121
Describe the epidemiology of substance abuse
- Most common are alcohol, cannabis, cocaine, ecstasy
- Other common substances are tobacco, benzos, stimulants, hallucinogens, solvents
122
Describe the pathophysiology of depressants
Act on GABA - main inhibitory neurotransmitter in the brain
123
What are the 5 main categories of drugs?
- Opioids (heroin/morphine/codeine)
- Stimulants (cocaine/caffeine/amphetamines/caffeine)
- Depressants (alcohol/benzodiazepines)
- Cannabinoids (cannabis)
- Hallucinogens (magic mushrooms/PCP/LSD)
124
What are risk factors for substance abuse?
- Genetics
- Environmental stressors
- Social pressures
- Psychiatric problems
125
What are indications of substance abuse?
- Desire for substance
- Preoccupation with substance use
- Withdrawal state
- Incapability to control substance
- Tolerance to substance
- Evidence of harmful effects
126
What are clinical features of opioid withdrawal?
- Yawning
- Runny eyes/nose
- Abdominal cramps
- Vomiting
- Cold skin
127
What are the investigations for substance abuse?
- History and MSE
- Physical exam (weight/dentition/signs of IVDU)
- Signs of withdrawal
- Bloods
- Urinalysis (toxicology)
- ECG/CXR/echo
128
What are signs of IVDU?
- Phlebitis
- Abscess
- Old scarring
129
What are signs of substance withdrawal?
- Sweating
- Dilated pupils
- High HR/BP
- N+V
- Tremor
- Muscle cramps
130
What are management options for substance abuse?
Key steps = substitution, detoxification and relapse prevention
- Motivational interviewing/CBT
- Support groups e.g. narcotics anonymous
- Oral substitution therapies
- Medications
131
What are examples of oral substitution therapies in substance abuse?
- Methadone
- Buprenorphine
- Dihydrocodeine
132
What other medications are used in substance abuse?
- Lofexidine (withdrawal symptoms)
- Naltrexone (relapse prevention)
- Naloxone (opioid overdose)
133
What are risks of prolonged IVDU?
- Abscesses
- Collapsed veins
- Significant weight loss
- Skin ulcers
- Overdose
- Infections
134
What are clinical features of a drug overdose?
- Pin point pupils (very common with opioids)
- Drowsiness
- Respiratory depression/acidosis
- Hypotension
- Tachycardia
135
How is a drug overdose managed?
- ABCDE
- Naloxone
- Activated charcoal
136
Name 7 psychiatric emergencies
- Alcohol withdrawal
- Delirium tremens
- Wernicke's encephalopathy
- Lithium toxicity
- Acute dystonic reaction
- Neuroleptic malignant syndrome
- Serotonin syndrome
137
What are side effects of lithium?
- Polyuria/polyidisia
- Weight gain
- Oedema
- Fine tremor
- Hypothyroidism
138
What should be avoided when prescribing lithium?
- NSAIDs
- ACE inhibitors
- Diuretics
139
What is a contraindication for lithium?
Teratogenic - causes Ebstein's anomaly (congenital malformation of tricuspid valve)
140
What are symptoms of lithium toxicity?
TOXICCC
- Tremor (coarse)
- Oliguric renal failure
- ataXia
- Increased reflexes
- Convulsions
- Consciousness decreased
- Coma
141
What are the investigations for lithium toxicity?
- U&Es
- TFTs
- Lithium levels
142
What is the management for lithium toxicity?
- Stop lithium
- Fluids and IV NaCl
- Haemodialysis (if severe)
143
What is acute dystonic syndrome?
Acute movement disorder characterised by involuntary muscle contractions in either sustained or intermittent patterns that lead to abnormal movements or postures
144
What is a common cause of acute dystonic syndrome?
Typical antipsychotics
145
What are clinical features of acute dystonic syndrome?
- Painful contraction in eyes/neck/jaw
- Arm held in dystonic posture
- Neck spasm to side
- Mouth open
- Upward eye gaze
- Pain/distress
146
What is the management for acute dystonic syndrome?
- IM procyclidine 5-10mg
- IV diazepam (if life-threatening emergency)
147
What is neuroleptic malignant syndrome?
Life-threatening neurological disorder characterised by confusion, fever and rigidity
148
What is the common cause of neuroleptic malignant syndrome?
- Adverse reaction to dopamine receptor agonists (antipsychotics)
- Abrupt withdrawal of dopaminergic medication (e.g. bromocriptine/cabergoline - Parkinsons)
149
What are the clinical features of neuroleptic malignant syndrome?
- Altered mental state (confusion/delirium)
- Hypertonia/muscle rigidity
- Fever
- Autonomic dysfunction (high HR/RR)
150
What results would be seen in a patient with neuroleptic malignant syndrome?
- Raised creatine kinase
- Raised WCC
- Deranged LFTs
- Acute renal failure (abnormal U&Es)
- Metabolic acidosis (low pH, how HCO3)
151
What are common differential diagnoses for neuroleptic malignant syndrome?
- Sepsis
- Brain problems
- Renal failure
152
What is the management for neuroleptic malignant syndrome?
- Withdraw causative medication
- Supportive treatment (rehydration, correct electrolyte imbalances, antipyretic)
153
What are complications of neuroleptic malignant syndrome?
- PE
- Renal failure
- Shock
154
What is serotonin syndrome?
Life-threatening neurological disorder due to increased serotonergic activity in the central nervous system characterised by altered mental status, autonomic hyperactivity and neuromuscular abnormalities
155
What are common causes of serotonin syndrome?
- SSRIs/SNRIs
- Opioid analgesics
- MAOIs
- Lithium
- TCAs
156
What are the clinical features of serotonin syndrome?
- Altered mental state (anxiety/agitation/confusion)
- Neuromuscular dysfunction (clonus/hyperreflexia/hypertonia/tremor)
- Autonomic dysregulation (fever/D+V/high HR/RR)
157
What is a common differential diagnosis for serotonin syndrome?
Neuroleptic malignant syndrome
NMS = high WCC
SS = normal WCC
158
What is the management for serotonin syndrome?
- Withdraw causative medication
- Supportive treatment (benzos for agitation, activated charcoal if overdose)
159
What is deliberate self-harm?
An act not intended to cause death but to gain relief from psychological stress/pain
160
What is suicide?
An act with the intention of causing death
161
Describe the epidemiology of self-harm
- Peaks in 16-24 year old women
- Peaks in 25-34 year old men
162
Describe the epidemiology of suicide
- More common in men
- 1/3 of people who attempt suicide haven't had any contact with mental health services
163
What are risk factors for self-harm/suicide?
- Alcohol/substance misuse
- History of self-harm/suicide
- Incarceration/involvement with criminal justice system
- Socio-economic disadvantage (homeless/unemployed)
- Social isolation
- Stressful life events (e.g. relationships/armed forces/child maltreatment/domestic violence)
- Bereavement by suicide
- Mental health problems
- Chronic physical health problems
164
What are common types of self-harm?
- Cutting/burning skin
- Punching/hitting themselves
- Poisoning with tablets/toxic chemicals
- Misusing drugs/alcohol
- Starving themselves/binge eating
- Overexercising
165
What are common features of someone at risk of suicide?
- Young male
- Divorced
- Mental illness
- Chronic illness
- Substance misuse
166
What is the management for patients at risk of suicide?
High risk = inpatient treatment
Medium/low risk = home crisis plan and crisis team involvement
167
What is the management for self-harm?
CBT/counselling:
- Understand patterns (triggers/urgers/distractions)
- Identify emotions and what self-harm helps to achieve
- Music
- Guided imagery/meditation
168
What are types of somatoform disorders?
- Conversion disorder
- Somatisation disorder
- Hypochondriasis
- Dysmorphophobia
- Somatoform pain disorder
169
What is conversion disorder?
a.k.a hysteria
- Single sign/symptom affecting voluntary function which cannot be explained by a medical condition
- Psychological factors e.g. conflict/stress associated with deficits
170
What is somatisation disorder?
- Multiple physical symptoms caused by psychological or emotional factors
- Usually persist long-term
171
What is hypochondriasis?
- Preoccupation with fancied bodily illness
- Fear of conviction or having a serious disease based on a misinterpretation of bodily symptoms
172
What is dysmorphophobia?
Patients convinced that part of their body is too large/small/deformed
173
What is somatoform pain disorder?
Suffering of pain for longer than 6 months for which there is no physical cause and no specific mental disorder
174
What are risk factors for dysmorphophobia?
- Low self-esteem
- Critical parents/significant others
- Early childhood trauma
- Unconscious displacement of emotional conflict
175
What is the management for somatoform disorders?
- CBT
- Group therapy
- Relaxation training
- Medication e.g. SSRIs
176
What is electroconvulsive therapy (ECT)?
Treatment that involves sending electric currents through a patient's brain
177
Describe the pathophysiology of ECT
Electric current sent through the brain which causes a brief surge of electrical activity within the brain (seizure)
178
What is ECT used for?
- Severe depression
- Severe/long-lasting episode of mania
- Catatonia
179
When might ECT be used?
- If patient has a preference for ECT based on previous experience
- If all other treatment options have been considered/tried/unsuccessful
180
What are contraindications for ECT?
- Cannot be given to children under 11 (and rarely effective for 11-18 year olds)
- Higher risk of negative effects in patients who are older, pregnant or have cardiovascular conditions
181
What are side effects of ECT?
- Memory loss
- Drowsiness
- Confusion
- Headache
- Nausea
- Aching muscle
- Loss of appetite
182
What are rare side effects of ECT?
- Teeth/jaw/muscle injury
- Extreme confusion/agitation/restlessness
- Prolonged seizures
- Permanent/temporary memory loss
183
What are talking therapies?
Psychological treatments for mental and emotional problems like stress, anxiety and depresion
184
Give some types of psychological therapies
- Cognitive behavioural therapy (CBT)
- Interpersonal therapy (IPT)
- Counselling
- Guided self-help
- Behavioural activation
- Eye movement desensitisation and reprocessing
- Mindfulness-based cognitive therapy (MBCT)
- Psychodynamic psychotherapy
- Couple therapy
185
What are the main groups of antidepressants?
- Selective serotonin reuptake inhibitors (SSRIs)
- Selective noradrenaline reuptake inhibitors (SNRIs)
- Noradrenergic and specific serotonergic antidepressants (NaSSAs)
- Tricyclic antidepressants (TCAs)
- Monoamine oxidase inhibitors (MAOIs)
186
What are antidepressants used for?
- Depression
- OCD
- GAD
- PTSD
- Eating disorders
187
Describe the pathophysiology of SSRIs
Inhibits reuptake of serotonin from presynaptic serotonin pumps so that more serotonin stays in the synapses therefore increasing serotonin activity
188
Give some examples of SSRIs
- Sertraline (1st line for GAD)
- Citalopram
- Fluoxetine (1st line for <18s)
- Paroxetine
- Escitalopram
189
What are side effects of SSRIs?
- GI symptoms
- Anxiety/agitation
- Sexual impotence/anorgasmia
- Insomnia
- Sweating
- Weight gain
- Increased suicidality
- Hyponatraemia
190
What medications do SSRIs interact with?
Fluoxetine and paroxetine = higher risk of interactions
- NSAIDs
- Warfarin/heparin
- Aspirin
- Triptans
191
What are discontinuation symptoms of SSRIs?
- Flu-like symptoms (lethargy/fatigue/headaches/achiness/sweating)
- Dizziness/imbalance
- Tremor
- Hyperarousal (anxiety/irritability/agitation)
- GI issues
192
Describe the pathophysiology of SNRIs
Inhibits presynaptic noradrenaline and serotonin pumps to prevent the reuptake of serotonin and noradrenaline
193
Give some examples of SNRIs
- Venlafaxine
- Duloxetine
194
What are side effects of SNRIs?
- HTN
- Dizziness
- Dry mouth
- Constipation
- Hot flushes
- Hyponatraemia (especially venlafaxine)
195
Describe the pathophysiology of NaSSAs
- Blocks presynaptic alpha 2 receptors to enhance the release of noradrenaline and serotonin
- Histamine antagonist
196
Give an example of a NaSSA
Mirtazapine
197
What are side effects of NaSSAs?
- Increased appetite/weight gain
- Sedation
- Headache
- Postural hypotension
- Dizziness
- Tremor
198
Describe the pathophysiology of TCAs
Inhibit serotonin and noradrenaline reuptake within the presynaptic terminals (block muscarinic/histaminergic/alpha-adrenergic receptors)
199
Give an example of a TCA
Amitriptyline (tend to be used more for pain/migraines)
200
What are side effects of TCAs?
- Anticholinergic (muscarinic) - dry mouth/constipation/blurred vision/urinary retention (can't see, can't pee, can't shit, can't spit)
- Antiadrenergic - sedation/weight gain
- Antihistaminergic - postural hypotension/dizziness/syncope
- Cardiac - prolonged QT/palpitations/arrhythmias/heart blocks
201
What are contraindications of TCAs?
- IHD
- Arrhythmias
- Severe liver disease
- Overdose risk
202
Describe the pathophysiology of MAOIs
- Monoamine oxidase is an enzyme involved in removing noradrenaline, serotonin and dopamine from the brain
- Activity of monoamine oxidase A and B is inhibited, prevented the breakdown of the neurotransmitters and therefore increasing their availability
203
Give an example of a MAOI
Isocarboxazid
204
What are side effects of MAOIs?
- Overdose risk
- Can lead to hypertensive crisis (tyramine cheese reaction)
205
What are disadvantages of antidepressants?
- Can take a while to come into effect
- Can increase suicidal thoughts/make things worse initially
- Only improves some of the symptoms of depression, not all
- Can commonly cause hyponatraemia (especially SSRIs/SNRIs) which presents as N+V/headaches/confusion
206
What are antipsychotics used for?
- Psychosis
- Mania
- Schizophrenia
- Schizoaffective disorder
- Bipolar disorder
- Severe depression
- Personality disorders
- PTSD
207
Describe the pathophysiology of psychosis
Dopamine system becomes overactive, contributing to the production of hallucinations, delusions and thought disorder
208
Describe the pathophysiology of typical antipsychotics
Block dopamine (D2) receptors
209
Give some examples of typical antipsychotics
- Chlorpromazine
- Haloperidol
- Flupentixol
210
What are common side effects of typical antipsychotics?
Parkinsonian symptoms:
- Resting tremor
- Rigidity
- Bradykinesia
- Dystonia
211
Describe the pathophysiology of atypical antipsychotics
Block dopamine receptors but also activate other dopamine and serotonin receptors (= less severe Parkinsonian symptoms)
212
What are side effects of antipsychotics?
- QT segment prolongation
- Parkinsonian symptoms
- Hypotension
- Fatigue
- Weight gain/diabetes
- Dry mouth
- Constipation
- Agitation
213
Give some examples of atypical antipsychotics
- Olanzapine
- Aripiprazole
- Amisulpride
- Quetiapine
- Risperidone
- Clozapine
214
What is clozapine used for?
Treatment resistant schizophrenia - patient needs to have take 2 other antipsychotics previously (and been ineffective) before being prescribed this
215
What are main side effects of clozapine?
- Neutropenia/agranulocytosis
- Myocarditis
- Cardiomyopathy
- Constipation
- Hypersalivation
- Seizures
216
What side effect is most associated with olanzapine?
Weight gain/risk of developing diabetes
217
What side effect is most associated with aripiprazole?
Agitation
218
What regular checks should be done on patients taking antipsychotics?
- ECGs (QTC)
- Glucose/lipid checks
- Bloods - FBCs (especially clozapine)
219
How can antipsychotics be taken?
- Orally (tablet/liquid)
- Intramuscularly (depot injection)
220
What is a depot injection?
Slow-release IM form of medication - given every 2/3/4 weeks and contains a liquid that releases medication slowly
221
What are anxiolytics?
Group of medications used to decrease emotional tension or anxiety
222
What are sedative-hypnotics?
Group of medications used to induce drowsiness/sleep or to reduce psychological excitement/anxiety
223
Describe the pathophysiology of anxiolytics and sedative-hypnotics
Act on the brain by increasing GABA effects which decreases brain activity and produces a relaxing effect
224
Give some types of anxiolytics/sedative-hypnotics
- Barbiturates
- Benzodiazepines
- Non-benzodiazepines (+Z drugs)
225
Give some examples of barbiturates and what they are commonly used for
- Phenobarbital, primidone
- Insomnia/seizures/muscle spasms
226
Give some examples of benzodiazepines and what they are commonly used for
- Diazepam (longer acting), lorazepam (shorter acting), clonazepam, chlordiazepoxide hydrochloride, midazolam
- Anxiety/mania/psychosis/alcohol withdrawal/insomnia/acute aggression/agitation/epilepsy
227
What are side effects/contraindications of benzodiazepines?
- Addictive if taken long term
- Respiratory and CNS depressant effects (avoid in neurological and severe respiratory disease)
228
Give some examples of non-benzodiazepines and what they are commonly used for
- Melatonin, promethazine, zopiclone (Z drug), zolpidem (Z drug)
- Insomnia
229
What are side effects/contraindications of Z drugs?
- Can become dependent/tolerant and lose effect
- Caution in respiratory and neurological disease
230
What are side effects of anxiolytics/sedative-hypnotics?
- Staggering
- Blurred vision
- Impaired perception of time and space
- Slowed reflexes and breathing
- Reduced sensitivity to pain
- Impaired thinking
- Slurred speech
- Anaemia
- Depression
- Impairment of liver function
231
What is cognitive impairment?
Problems with cognitive functions e.g. thinking/reasoning/memory/attention
232
What are clinical features of cognitive impairment?
- Poor memory
- Language problems
- Problems with executive functioning
- Disorientation
233
What do cognitive assessments assess?
- Attention and concentration
- Recent and remote memory
- Language
- Praxis (planned motor movement)
- Executive function
- Visuospatial function
234
Give some examples of cognitive assessments
- Mini-cog
- Abbreviated mental test score (AMTS)
- Mini-mental state examination (MMSE)
- Montreal cognitive assessment scale (MoCA)
- Addenbrooke's cognitive examination III (ACE-III)
235
What is mild cognitive impairment?
Cognitive deficits in one or more of the major cognitive domains but the deficit is insufficient to interfere with independence in daily activities
236
What can cause mild cognitive impairment?
- Early sign of dementia
- Sleep disorders
- Side effects of medication (confusion/drowsiness)
- Hypotension
- Mental health problems
- Infections
- Excess alcohol consumption
237
What is the difference between learning disabilities and learning difficulties?
Learning disability - condition which affects learning and intelligence across all areas of life
Learning difficulty - condition which creates an obstacle to a specific form of learning but does not affect the overall IQ of an individual
238
What is the difference a hate crime and a mate crime?
Hate crime = abuse due to disability/race/gender/sexual orientation
Mate crime = abuse from a person who pretends to be a friend so that they can use/abuse them
239
What are risk factors for learning disabilities?
- Family history
- Environmental factors (abuse/neglect/trauma/toxins)
- Other mental health conditions
240
What conditions have a strong association with learning disabilities?
- Genetic disorders e.g. Down's syndrome
- Antenatal problems e.g. foetal alcohol syndrome
- Problems at birth e.g. prematurity/hypoxic ischaemia
- Problems in early childhood e.g. meningitis
- Autism
- Epilepsy
241
What is dyslexia, dysgraphia and dyspraxia?
Dyslexia - difficulty in reading, writing and spelling
Dysgraphia - difficulty in writing
Dyspraxia - difficulty in physical coordination
242
What is an auditory processing disorder?
Difficulty in processing auditory information
243
What is a non-verbal learning disability?
Difficulty in processing non-verbal information e.g. body language/facial expressions
244
How are learning disabilities classified?
Severity based on IQ:
- Mild = 55-70
- Moderate = 40-55
- Severe = 25-40
- Profound = <25
245
What are the investigations for learning disabilities?
- Psychometric testing by a clinical psychologist
- Genetic tests e.g. karyotyping
246
What is fragile X syndrome?
Genetic disorder characterised by an X chromosome that is abnormally susceptible to damage especially by folic acid deficiency - affected individuals tend to have limited intellectual functions
247
Describe the epidemiology of fragile X syndrome
More common in males
248
Describe the pathophysiology of fragile X syndrome
- X-linked
- Caused by a mutation in the FMR1 (fragile X mental retardation 1) gene
- This gene codes for the fragile X mental retardation protein which plays a role in cognitive development in the brain
249
What are clinical features of fragile X syndrome?
- Delay in speech and language development
- Intellectual disability
- Long, narrow face
- Large ears
- Large testicles after puberty
- Hypermobile joints
- ADHD
- Autism
- Seizures
250
What is Down Syndrome?
Genetic condition caused by trisomy 21 which causes characteristic dysmorphic features
251
What are the biggest risk factors for Down syndrome?
- Genetics
- Older maternal age
252
What are the clinical features of Down Syndrome?
- Hypotonia
- Brachycephaly (small head with a flat back)
- Short neck
- Short stature
- Flattened nose/face
- Prominent epicanthic folds
○ Folds of skin covering the medial portion of the eye/eyelid
- Upward sloping palpebral fissures
○ Gaps between lower and upper eyelid
- Single palmar crease
- Intellectual disability
253
Briefly describe the investigations for Down Syndrome
- Antenatal screening
- Antenatal testing
- Non-invasive prenatal testing
254
Describe antenatal screening for Down Syndrome
- Measurements taking from fetus using ultrasound combined with mother's age and blood result to calculate risk
- Ultrasound measures nuchal translucency (thickness >6mm)
- Bloods = high beta-HCG/inhibin-A, low PAPPA/AFP/serum oestriol
- Combined test/triple test/quadruple test
255
Describe antenatal testing for Down Syndrome
- Done when screening risk score is greater than 1/150
- Sample of foetal cells taken to undergo karyotyping
- Chorionic villus sampling (ultrasound-guided biopsy of placental tissue)
- Amniocentesis (ultrasound-guided aspiration of amniotic fluid)
256
Describe non-invasive prenatal testing for Down Syndrome
- Blood test from mother will contain fragments of DNA from placental tissue
- DNA fragments analysed
257
What routine checks do people with Down Syndrome require?
- Thyroid
- Echo
- Audiometry
- Eye checks
258
What conditions are people with Down Syndrome more at risk of developing?
- Recurrent otitis media
- Eustachian tube abnormalities --> deafness
- Visual problems (myopia/strabismus/cataracts)
- Hypothyroidism
- Cardiac defects (ASD/VSD/patent ductus arteriosus/tetralogy of Fallot)
- Impaired spermatogenesis --> infertility
- Polycythaemia
- Increased risk of ALL/AML
- Dementia
259
What is brain damage?
Destruction/degeneration of brain cells which can cause cognitive, behavioural and physical disabilities
260
What are causes of brain damage?
Traumatic:
- Blow/shaking/strong rotational injury to the head (concussion/contusion/shaken baby syndrome/etc.) due to falls/motor vehicle accidents/etc.
Acquired:
- Stroke/tumour/infections/hypoxic injury/etc. due to choking/drowning/drug overdose/infection/alcohol
261
What are clinical features of brain damage?
Frontal lobe - difficulty concentrating/personality changes/impulsivity
Temporal lobe - affected memory/difficulty understanding spoken words/affected hearing
Parietal lobe - affected senses
Occipital lobe - loss of sight/visual disturbances
Brain stem - affected breathing/heart rate/sleep cycle
262
What are the investigation for brain damage?
- CT head
- Bloods
- Brain evaluations
263
Describe the management for brain damage
- Surgery if tumour/significant bleeding/foreign object
- Occupational therapy
- Physical therapy
- Psychotherapy
- Speech and language therapy
264
Describe the requirements for a diagnosis of a depressive episode
- Minimum duration of 2 weeks
- At least 2 out of 3 core symptoms
- At least 2 other additional symptoms
265
How are depressive episodes classified?
- Mild = >4 symptoms with most normal activities continued
- Moderate = >5 symptoms with great difficulty in continuing normal activities
- Severe = >7 symptoms (including all 3 core symptoms) and unable to continue normal activities
- Severe with psychotic features = hallucinations/delusions/depressive stupor alongside depressive episode
266
What is recurrent depressive disorder?
Multiple depressive episodes after first
267
What is dysythmia?
- Chronic low grade depression for >2 years
- Does not meet the diagnostic criteria for major depression/depressive episode
268
What is the management for dysthymia?
- SSRI/TCA
- CBT
269
What is unipolar depression?
Patient's mood varies between depressed and normal
270
What are some causes of depression?
- Hypothyroidism
- Physical health problems/chronic disease
- Medications e.g. beta blockers/isotretinoin (roaccutance)
- Childbirth
271
What are some differential diagnoses for depression?
- Normal sadness
- Schizophrenia
- Alcohol/drug withdrawal
- Bipolar affective disorder
- Anxiety disorders
- Vitamin B12 deficiency
272
What are biological risk factors of depression?
- Family history
- Age (teenage-early 40s)
- Female
- Substance misuse
- Physical health problems
273
What are psychological risk factors of depression?
- Childhood trauma
- Traumatic life events
- Low self esteem
- Ongoing loss/failure to cope with loss
274
What are social risk factors of depression?
- Lack of social support
- Poor socioeconomic status
- Marital status (separated/divorce)
275
What is the diagnostic criteria for depression?
- Sx >2 weeks
- Sx not secondary to alcohol/drugs/medication/bereavement
- Patient experiencing at least 2 of 3 core sx plus 3 other additional sx
- Sx impair daily function/cause significant distress
- Sx present every day
276
What are the 3 core symptoms of depression?
- Depressed mood
- Anhedonia (loss of interest)
- Fatigue/anergia
277
What are other main symptoms of depression?
- Change in weight/appetite
- Psychomotor agitation/retardation
- Disturbed sleep
- Loss of confidence/self-esteem
- Feelings of excessive/inappropriate guilt
- Inability to concentrate
- Suicidal thoughts/acts
278
What is Cotard's syndrome?
Belief that parts of body are missing or that self is dying/dead/doesn't exist - common delusional symptom seen in depression with psychotic symptoms
279
How is depression severity graded?
ICD-10
- Must have at least 2 core sx + at least 2 others
- Mild = 4 sx
- Moderate = 5-6 sx
- severe = 7+ sx
280
What are the investigations for depression?
- Rule out differentials
- History and MSE
- PHQ-9 (Patient Health Questionnaire)
- HADS (Hospital Anxiety and Depression Scale)
- BDI-II (Becks Depression Inventory-2)
- Bloods
- Risk assessment
281
What is the management for depression?
- CBT
- Antidepressants
- Antipsychotics
- Interpersonal therapy
282
What is post-partum depression and what are the types?
- Low mood in post-partum period (<6 months)
- Baby blues (mild and short-term)
- Post-natal depression
- Puerperal psychosis (delusions/hallucinations/mania/etc. alongside depressive sx)
283
What are risk factors for post-partum depression?
- Family history of depression
- Older age
- Single mother/poor maternal relationship
- Ambivalence to pregnancy
- Poor social support
284
What are the investigations for post-partum depression?
- History and MSE
- Edinburgh Postnatal Depression Scale (EPDS)
- Sx last longer than 2 weeks in post-partum period
285
What is the management for post-partum depression?
- SSRI (paroxetine/sertraline - lowest levels present in breast milk)
- CBT
286
What is the management for puerperal psychosis?
- Admit to mother and baby unit
- CBT
- Medications (antidepressants/antipsychotics/mood stabilisers)
- ECT
287
What are the clinical features of seasonal affective disorder?
- Clear seasonal pattern to recurrent depressive episodes (sx fully remit once season over)
- Usually January/February (winter depression)
- Low self-esteem
- Hypersomnia
- Fatigue
- Increased appetite/weight gain
- Decreased social and occupational functioning
288
What is the management for seasonal affective disorder?
- Light therapy
- SSRI
289
Give some examples of neurological medical conditions associated with increased risk of depression
- MS
- Parkinson's
- Huntington's
- Spinal cord injury
- Stroke
- Head injury
- Cerebral tumours
290
Give some examples of endocrine medical conditions associated with increased risk of depression
- Cushing's disease
- Addison's disease
- Thyroid disorders (especially hypothyroidism)
- Parathyroid disorders
- Menstrual cycle related
291
Give some examples of infection-related medical conditions associated with increased risk of depression
- Hepatitis
- Infectious mononucleosis
- Herpes simplex
- Brucellosis
- Typhoid
- HIV/AIDS
- Syphilis
292
Give some examples of other medical conditions associated with increased risk of depression
- Malignancies
- Chronic pain states
- SLE
- RA
- Renal failure
- Porphyria
- Vitamin deficiencies
- IHD
293
Give some examples of medications that can cause depressive symptoms
- Beta blockers
- Corticosteroids
- Oral contraceptives
- L-dopa
- Carbamazepine
- Opiates
- Indometacin
- Antipsychotics
- Interferon
294
What is psychosis?
Severe mental disturbance characterised by a loss of contact with external reality
295
What are organic causes of psychosis?
- Brain tumour
- Cysts
- Parkinson's disease
- Huntington's disease
- Brain injury
- Severe systemic infection
296
What are clinical features of psychosis?
- Delusions
- Hallucinations
- Thought disorder
- Abnormalities of behaviour
- Lack of insight
297
What are investigations for psychosis?
- History and MSE
- Collateral history
- Bloods
- Risk assessment
298
What is the management for psychosis?
- Antipsychotics
- ECT
299
Give some risk factors for schizophrenia
- Family history
- Pre-morbid schizoid personality (abnormal shyness/eccentricity/fanaticism)
- Abuse
- Delayed developmental milestones
- Obstetric risk factors (LBW/prematre/hypoxia)
- Substance abuse
- Traumatic childhood/life events
- Cerebral injury
- Low IQ
300
Give some types of schizophrenia
- Paranoid (most common - paranoid delusions and auditory hallucinations)
- Hebephrenic/disorganised (mood changes/shallow affect/disordered thought/chaotic behaviour)
- Catatonic (psychomotor features e.g. posturing/rigidity/stupor)
- Undifferentiated (sx do not fit into any category)
- Residual (negative sx after positive sx have 'burnt out')
- Simple (only negative sx)
301
What are positive and negative symptoms in schizophrenia?
Positive = any change in behaviour or thoughts (e.g. hallucinations/delusions)
Negative = absence of normal behaviours related to motivation and interest or expression (e.g. anhedonia/blunted affect)
302
What are Schneider's first rank symptoms of schizophrenia?
- Thought disorder
- Delusional perceptions
- Passivity phenomenon
- Third person auditory hallucinations
303
What are investigations for schizophrenia?
- History and MSE
- Exclude differential diagnoses
- CT/MRI head
- Toxicology screen
- Bloods
304
Give some differential diagnoses for schizophrenia
- Psychotic depression
- Schizoaffective disorder
- Personality disorder
- Bipolar disorder
- Substance abuse
305
What is the management for schizophrenia?
- Antipsychotics
- CBT
- Family therapy
- Lifestyle changes (exercise/drugs/alcohol/smoking/housing/employment)
- ECT
- Monitoring
306
What is schizoaffective disorder?
Mood disorder and schizophrenia (psychotic episodes of schizophrenia combined with affect from bipolar)
307
What are risk factors for schizoaffective disorder?
- Family history of schizophrenia
- Substance abuse
- Psychological stress/environmental factors
308
What are the types of schizoaffective disorder?
- Manic (manic + psychotic sx)
- Depressive (depressive + psychotic sx)
- Mixed
309
What are clinical features of schizoaffective disorder?
- Schizophrenic symptoms e.g. delusions/hallucinations/thought disorder
- Mood symptoms (depressive/manic)
310
What is the management for schizoaffective disorder?
- Antipsychotics
- Anxiolytic/benzo (e.g. lorazepam)
- CBT
- Social intervention (housing/employment/exercise/education)
311
What are clinical features of delusional disorders?
- Delusions
- Anger
- Irritability
- Depression
312
What are common delusions?
- Skin infestation
- Illness/cancer
- Being spied on/followed/poisoned
- Infidelity
313
What are risk factors for personality disorders?
- Socioeconomic status
- Family history
- Poor parenting/deprivation
- Attachment issues in childhood
- Abuse/trauma/neglect
314
What do personality disorders mainly affect?
- Cognition
- Affectivity
- Interpersonal functioning
- Impulse control
315
What make a personality disorder a disorder?
When patients' behaviour causes significant distress or impairment in social/occupational/other important areas of functioning
316
What are the 3 main categories of personality disorder?
- DSM-5 Cluster A - paranoid/schizoid/schizotypal
- DSM-5 Cluster B - antisocial/borderline/emotionally unstable/histrionic/narcissistic
- DSM-5 Cluster C - avoidant/dependent/obsessive compulsive
317
Describe paranoid personality disorder
Difficulty in trusting or revealing personal information to others
318
Describe schizoid personality disorder
- Lack of interest/desire to form relationships with others
- Emotionally cold/detached
- Indifferent to praise/criticism
319
Describe schizotypal personality disorder
- Unusual beliefs/thoughts/behaviours
- Social anxiety - makes forming relationships difficult
- Inability to maintain friendships and lack of companionship
320
Describe antisocial personality disorder
- Callous lack of concern for others
- Disregard to rules and responsibility
- Irritability/aggression
- Incapacity to maintain relationships
- Evidence of childhood conduct disorder
321
Describe borderline/emotionally unstable personality disorder
- Fluctuating strong emotions
- Difficulties with identity and maintaining healthy relationships
- Impulsive/violent/poor response to criticism
- Self-destructive behviours
- Borderline = self-image/feelings of emptiness, self-harm/suicidal attempts
322
Describe histrionic personality disorder
- Need to be centre of attention
- Having to perform for others to maintain attention
- Manipulative behaviour
323
Describe narcissistic personality disorder
- Feeling that they are special and need others to recognise this or else they get upset (grandiosity)
- Put themselves first
- Lack of empathy
324
Describe avoidant personality disorder
- Severe anxiety about rejection or disapproval
-Self-consciousness/insecure
-Timid
- Social inhibition/avoidance of social situations/relationships
325
Describe dependent personality disorder
- Heavy reliance on others to make decisions and take responsibility for their lives
- Passive approach
- Reassurance required
- Lack of self-confidence
- Abandonment fears
- Companionship sought
326
Describe obsessive compulsive personality disorder
- Unrealistic expectations of how things should be done by themselves and others
- Catastrophising about what will happen if these expectations are not met
327
What are investigations for personality disorders?
- History and MSE
- PPDQ-IV (Personality Diagnostic Questionnaire)
- Minnesota multiphasic personality inventory
- MRI/CT head
- Risk assessment
- Diagnoses can typically only be made at 18 years old (earliest - personality doesn't fully develop until 25)
328
What is the management for personality disorders?
- Treat sx
- Dialectal behavioural therapy (DBT)
- CBT/psychotherapy
- Mentalisation-based therapy (MBT)
- Antidepressants
- Mood stabilisers/antipsychotics
329
What are the main types of attachment styles in children?
- Secure (carers are engaged appropriately)
- Anxious ambivalent (carers are engaged but on own terms)
- Anxious avoidant (carers do not engage/neglect)
- Disorganised (carers are both source of comfort and fear to children - causes confusion)
330
What is delirium?
Acute confusional state causing disturbed consciousness/attention/cognition/perception
331
Give some causes of delirium
- Neurological (brain injury/stroke/subdural haematoma)
- Cardiovascular (HF/MI/AF)
- Respiratory (aspiration/pneumonia/COPD)
- GI (constipation/malnutrition/bleeding)
- Urological (urinary retention/UTI)
- Skin/joints (cellulitis/pressure sores)
- Metabolic/endocrine (thyroid disease/hypo/hyper-glycaemia/natraemia)
- Medications (antihistamines/TCAs/anticholinergics)
- Other (alcohol/pain/sleep deprivation/change in environment/hearing impairment)
332
What are risk factors for delirium?
- Age >65
- Co-morbidities
- Frailty
- Malnutrition
- Sensory impairment (vision/hearing)
- Functional impairment
- Alcohol excess
- Major injury (e.g. hip fracture)
- Cognitive impairment (e.g. dementia)
333
What are clinical features of delirium?
- Acute onset
- Fluctuating symptoms
- Disturbance in awareness/attention
- Disturbance in cognition
- Evidence of organic cause
334
What is the difference between dementia and delirium?
Dementia = slowly progressive changes with limited fluctuation. Attention is usually intact and very early memories may be preserved
Delirium = acute, transient and usually reversible changes. Often an associated acute illness
335
What are investigations for delirium?
- DSM-5 criteria
- CAM (Confusion assessment method)
- 4As test (alertness; age/DOB/place/year; attention; acute change or fluctuating course)
- AMT (abbreviated mental test)
- Observations
- ECG
- Sputum/urine/stool cultures
- Bloods
- CXR
- CT head
- Echo
336
What is the management for delirium?
- Determine and treat underlying precipitating cause(s)
- Rapid tranquilisation (benzodiazepines e.g. lorazepam; antipsychotics e.g. haloperidol/olanzapine)
- De-escalation methods
337
What are the most common types of dementia?
1. Alzheimer's
2. Vascular
3. Dementia with Lewy-body
4. Frontotemporal dementia (a.k.a Pick's disease)
338
Describe the pathophysiology of Alzheimer's
- Mostly affects temporal lobes
- Senile plaques (deposits of beta-amyloid outside of neurons)
- Neurofibrillary tangles (aggregation of hyperphosphorylated tau proteins inside neurons)
339
Describe the pathophysiology of vascular dementia
- Subcortical VD (disease affected small vessels of brain)
- Stroke-related VD (following large cortical stroke)
- Single/multi-infarct VD (following single/multiple small strokes)
340
Describe the pathophysiology of dementia with Lewy-body
Histopathological findings of intracytoplasmic inclusions (Lewy bodies) that contain alpha-synuclein - essentially Parkinson's
341
Describe the pathophysiology of frontotemporal dementia
- Tissue deposition of aggregated proteins (phosphorylated tau or transactive response DNA-binding protein 43)
- Atrophy around frontal/temporal lobes
342
What are general clinical features of dementia?
- Slow onset sx
- Lack of insight
- Cognitive impairment
- Behavioural and psychological sx
- Decreased ability to carry out ADLs
343
What are key clinical features of Alzheimer's?
- Early impairment of memory
- Short-term memory loss/difficultly learning new information
344
What are key clinical features of vascular dementia?
- Stepwise decline in function
- Gait/attention/personality changes
345
What are key clinical features of Dementia with Lewy-body?
- Parkinsonism sx (tremor/rigidity/bradykinesia/postural instability)
- Falls/syncope/hallucinations
346
What are key clinical features of frontotemporal dementia?
- Personality changes and behavioural disturbances (disinhibition)
- Memory and perception relatively preserved
347
What is sundowning?
Increase in certain symptoms (e.g. distress/agitation/hallucinations/delusions) in dementia patients that often occur in the late afternoon/evening
348
What are investigations for dementia?
- Exclude alternative diagnoses
- Cognitive assessments
- Bloods
- ECG
- Virology
- Syphilis testing
- CXR
- CT/MRI head
349
What are some differential diagnoses for dementia?
- Depression
- Drugs with anticholinergic effects
- Delirium
350
What is the management for dementia?
- Assess capacity
- Inform DVLA
- Cognitive stimulation therapy
- Cognitive rehabilitation
- Reminiscence work
- Admiral nurses
- Reduce risk factors (e.g. for VD) - stop smoking/exercise/statins/etc.
- Medications
351
What medications can be used for patients with dementia?
Mostly for Alzheimer's:
- Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine
- N-methyl-D-aspartic acid receptor antagonists (NMDA) e.g. memantine (for memory loss)
- Antipsychotics
352
What is the difference between ego syntonic and ego dystonic thoughts?
Ego syntonic = thoughts align with personal values/goals
Ego dystonic = thoughts inconsistent with beliefs, seen as unwanted/intrusive
353
Describe anorexia nervosa
- Patients feel they are overweight
- Obsessively restrict calorie intake
- Excessive exercise/diet pills/laxatives
- Low BMI
- Amenorrhoea
- Lanugo hair
- Bradycardia
- Hypokalaemia
- Hypotension
- Hypothermia
- ECG = hypokalaemia = flattened T waves/prolonged QT/ST depression/tall P waves
- G&Cs raised = growth hormone/glucose/parotid glands/cortisol/cholesterol
- CBT/family-based therapy
- Observed refeeding (--> refeeding syndrome)
- SSRI
354
Describe bulimia nervosa
- Normal body weight that fluctuates
- Compulsive uncontrollable bingeing followed by compensatory behaviour (purging/fasting/excessive exercising)
- Metabolic alkalosis (hypochloraemia)
- Hypokalaemia
- Teeth erosion/mouth ulcers
- Swollen salivary glands
- GORD
- Russell's sign = calluses on knuckles
- ECG = hypokalaemia = flattened T waves/prolonged QT/ST depression/tall P waves
- CBT/family-based therapy
- SSRI
