Psychiatry Flashcards
(88 cards)
1
Q
What is involved in a mental state examination?
A
A + B = Appaerance and Behaviour
Speech
Mood
Perceptions
Thought Content
Thought form
Insight
Cognition
2
Q
Features of Adjustment disorder
A
- Recemt psychosocial stress
- Mood lability and preoccupation on stress
- Typically resolves after 6 months
- Psychotic symptoms not normally seen
3
Q
Features of psychotic depression
A
- recent psychosocial stressors
-Older age and chronic medical condition
-Core features of depression
-Mood congruent psychosis seen (delusions of nihilsm, guilt, Cotard’s syndrome)
4
Q
Behavioural and psychological symptoms of dementia
A
- Known history of recent vascular insult to brain
-Delusions and hallucinations
-Ongoing vascular risk factors - Abnormal MoCA score
Cognitive concerns
5
Q
Post stroke psychosis
A
- Most commonly seen in right sided middle cerebral artery lesions of frontal and temporal lobe
- delusions mostly persecurtory or jealou type ( Othello’s syndrome)
- auditory hallucinations followed by visual
(maybe psychotics but increase risk of stroke)
6
Q
What mental health presentations do these conditions often show?
-Thyrotoxicosis
- Thyroid deficiency
- Cushing’s disease
- Infections (syphilis, HIV)
- Cancer
- Parkinson’s disease
A
Thyrotoxicosis → anxiety, mania
- Thyroid deficiency → depression, dementia
- Cushing’s disease → depression
- Infections (syphilis, HIV) → psychosis
- Cancer → depression
- Parkinson’s disease → depression, anxiety, dementia
7
Q
Three classifications of delirium and their presentation
A
Hyperactive - agitation, hallucination, inappropriate behaviour
Hypoactive - lethargy, reduced concentration, reduced alertness, reduced oral intake
Mixed
8
Q
Short term extreme treatment for delirium
A
Haloperidol 0.5mg < 7 days
9
Q
What factors affect the diagnosis of physical disorders in people with mental illness?
A
- Stigma
- Lack of resources/ access to services
-Illness behaviour
-Diagnostic overshadowing
10
Q
What three categories of psychosis symptoms are there?
A
Disorganisation, Negative , Positive symptoms
11
Q
What are examples of disorganisation symptoms in psychosis?
A
Bizarre behaviour
Formal thought disorder
12
Q
What is the scale of severity for formal thought disorder?
A
- Circumstantial thought
- Tangential thought
- Flight of ideas
- Derailment
- Word Salad
13
Q
What are the two categories of positive symptoms?
A
Hallucinations
Delusions
14
Q
What examples of hallucinations exist?
A
Auditory
Visual
Somatic
Olfactory
Gustatory
15
Q
What are examples of negative symptoms?
A
Alogia - poverty of speech
Anhedonia/ asociality
Avolition/ Apathy
Affective flattening face
16
Q
What prodromal symptoms coincided with psychosis?
A
Increasing isolation
Poor self care
Social withdrawal
Declining academic performance
17
Q
What is the name of the history taken from relatives and friends?
A
Corroborative history
18
Q
What pharmacological treatment exist for psychosis and explain the side effects
A
Dopamine antagonist (mesolimbic dopamine system) - Risperidone
Extra pyramidal side effects (nigrostriatal) : Parkinsonian , Acute dystonic reactions, tardive dyskinesia, akathisia
Other side effects: Most systems including pituitary
19
Q
What other drugs can be used for psychosis treatment?
A
Aripiprazole
20
Q
What psychological support can be offered for people with schizophrenia
A
Avator therapy
CBT
21
Q
DSM 5 criteria for depressive episode
A
2 weeks or more of depressive mood and 4/8
- Sleep alterations (insomnia or hypersomnia)
- Appetite alterations (increased or decreased)
- Diminished interest or anhedonia
- Decreased concentration
- Low energy
- Guilt
- Psychomotor changes ( agitation or redartation)
- Suicidal thoughts
22
Q
Subtypes of DSM 5 MDD
A
Atypical - increased appetite, sleep, mood reactivity levels
Psychotic- delusions, hallucinations
Melancholic features - no mood reactivity, marked psychomotor retardation and anhedonnia
23
Q
Manic episodes DSM-5 criteria
A
Euphoric or irritable mood with 3 or more of 7 criteria:
Decreased need for sleep with increased energy
Distractibility
Grandiosity or inflated self-esteem
Flight of ideas or racing thoughts
Increased talkativeness or pressured speech
Increased goal-directed activities or psychomotor agitation
Impulsive behaviour
24
Q
According to DSM-v when would you diagnose bipolar I or II
A
minimum 1 week with notable functional impairment, a manic episode is diagnosed, leading to a DSM-5 diagnosis of type I bipolar disorder.
If such symptoms are present for at minimum 4 days, but without notable functional impairment, a hypomanic episode is diagnosed.
If not a single manic episode had occurred ever, but only hypomanic episodes are present, along with at least one major depressive episode, then the DSM-5 diagnosis of type II bipolar disorder is made.
If manic symptoms occur for less than 4 days, or if other specific thresholds are not met for manic or hypomanic episodes, then the DSM-5 diagnosis:
“Unspecified Bipolar Disorder”
25
Is insight usually preserved more in bipolar or depression?
Depression
26
What biases are present in depression?
Attention
Memory
Perceptual - facial emotion recognition
passive viewing of facial expression (amygdala)
27
What does the monoamine deficiency hypothosis of depression suggest?
depressive symptoms arises from a decrease in the monoamine neurotransmitters of serotonin (or 5-hydroxytryptamine , 5-HT), norepinephrine, and/or dopamine
28
Indirect evidence for the monoamine deficiency hypothesis
1. Reduced levels of 5 HT in brains of people who commited suicide
2. Reduced 5 HT receptors
3. Clinically beneficial drugs work by increasing sunaptic monoamines
4. Drugs causing redution in 5 HT show causal relationship with depressive symptoms
29
How would we measure receptor and transmission in living human brain
PET + radioactive tracer
30
Measuring release of cerebral 5-HT
using a 5-HT2A agonist PET tracer
31
What system in the brain do psychadelics work on?
Serotonin
32
Positive reinforcements and negative reinforcement in drug use
Positive: to gain positive experience
Negative: to overcome adverse experience
33
Dependence syndrome ICD 10
3 or more in the past year
1. a strong desire or sense of compulsion to take the substance
2.difficulties in controlling substance taking behaviour in terms of its onset, termination, or levels of use
3.a physiological withdrawal state when substance use has stopped or been reduced
4. evidence of tolerance: need to take more to get same effect
5. progressive neglect of alternative interests
6. persisting with substance use despite clear evidence of overtly harmful consequences
34
Addiction vs dependence
Addiction - compulsive drug use despite harmful consequences, characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, (depending on the drug) tolerance and withdrawal.
In biology/pharmacology, dependence refers to a physical adaptation to a substance
so would see Tolerance/withdrawal
Eg opioid, benzodiazepine, alcohol
35
3 levels of problems to look for in alcohol abuse
1. Quantity / Frequency: Hazardous use
2. Consequences: Harmful use
3. Pattern: Dependence/addiction
36
Acute alcohol affect on brain
NMDA receptor - Blocks excitatory system
- Impaired memory (alcoholic blackouts)
GABA A receptor - Boosts inhibitory system
-Anxiolysis
-Sedation
37
Chronic alcohol affect in brain
Upregulation of stimulatory system
Switched subunits on GABA A receptor making it less sensitive to alcohol- tolerance
38
Alcohol withdrawal state
Treat with benzodiazepines to boost GABA function
NMDA receptor:
increase in Ca2+
- toxic leading to hyperexcitability (seizures) and cell death (atrophy)
39
Three components of model of addiction
Impulsivity / Compulsivity
Reward deficiency
Overcoming adverse state
40
How can you assess the reward/ motive pathway?
fMRI ventral striatum
50p if you click this, - 50p if you click this
41
What region of brain involved in:
-binge/intoxication,
- withdrawal/negative affect,
- preoccupation/anticipation ‘craving’.
-Thalamus
-Hypothalamus
-Hippocampus, Pre frontal cortex
42
How do you assess emotional processing of adverse images?
fMRI amygdala
43
How do you assess neurocircuitry involved in inhibitory control
fMRI putamen and inferior frontal gyrus
go-no go
44
Define these terms:
Intoxication
Withdrawal state
Tolerance
Harmful use
Intoxication
In both the DSM and ICD, intoxication is considered to be a transient syndrome due to recent substance ingestion that produces clinically significant psychological or physical impairment. These changes disappear when the substance is eliminated from the body
Withdrawal state
This refers to a group of signs and symptoms that occur when a drug is reduced in dose or withdrawn entirely
Tolerance
This is a state in which, after repeated administration, a drug produces a decreased effect. Increasing doses are therefore required to produce the same effect
Harmful use
A pattern of psychoactive substance use that is causing damage to health (physical or mental)
45
Harmful Use ICD 10
A pattern of substance use that causes damage to health
The damage may be: (1) physical or (2) mental
Adverse social consequences
Harmful use includes bingeing on substances. Does not include ‘hangover’ alone
Does not fulfil any other diagnosis within substance use (e.g. dependence)
ICD 11 ( Harm to others health)
46
ICD 11 Dependence
Impaired control over substance use (i.e. onset, frequency, intensity, duration, termination, context)
Increasing precedence of substance use over other aspects of life (e.g. repeated relationship disruption, occupational or scholastic consequences, negative impact on health)
Physiological features indicative of neuroadaptation to the substance, (e.g. tolerance, withdrawal, use of pharmacologically similar substances to prevent or alleviate withdrawal symptoms.
The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if use is continuous (daily or almost daily) for at least 3 months
47
DSM5 dependence and harmful use
Mild Moderate Severe
Opioid Use Disorder
Alcohol Use Disorder#
48
Substance misuse history
Length of current use and when last used
Current amount (units/grams/£ per day) and for how long at this level
Total length of use, maximum use and any periods of abstinence
Mode/method of administration (e.g. inhalation, ingestion, IV)
Evidence of withdrawal syndrome and severity (e.g. seizures, admissions)
Any previous treatments - medication, psychotherapy, detox/rehab admissions
Any previous substance overdoses (accidental vs deliberate)
Assess triggers to use substances/alcohol
Assess motivation to change/engage in treatment
49
Unit equation alcohol
Unit equation: % strength x ml /1000 = units
50
Pharmacology of alcohol
Absorption
Pharmacodynamics
Metabolism
Absorption
Alcohol is well absorbed
maximum blood concentration is reached within 60 minutes of ingestion.
slowed by food
sped up by the ingestion of effervescent drinks
widely distributed in all bodily tissues
Pharmacodynamics
enhances neurotransmission at GABA-A receptors (causing anxiolysis).
stimulates dopamine release in the mesolimbic system (causing reward)
inhibits NMDA mediated glutamate release (leads to its amnesic effects)
Metabolism
Ethanol is oxidised by alcohol dehydrogenase to acetaldehyde --> oxidised by acetaldehyde dehydrogenase to carbon dioxide and water.
1 unit of alcohol (8g) can be metabolized per hour.
Illicit brew may contain methanol which is broken down to formaldehyde and causes marked toxicity on the retina
51
Alcohol impact assessment
Examination:
Jaundice, bruising, clubbing, oedema, ascites, spider naevi
Neurological signs:
Consider Wernicke’s encephalopathy (ataxia, confusion, ophthalmoplegia) and Korsakoff’s syndrome (memory impairment)
Investigations:
Liver Fibro scan / Ultrasound
Bloods (LFTs, FBC, GGT, lipids, clotting, amylase)
Breathalyser
Urine Drug Screen
52
CAGE screening
Have you ever felt you needed to *Cut down* on your drinking?
Have people *Annoyed* you by criticizing your drinking?
Have you ever felt *Guilty* about drinking?
Have you ever felt you needed a drink first thing in the morning (*Eye-opener*)
53
Opiates vs. Opioids
Opiates refer to natural opioids such as morphine and codeine and heroin to some extent
Opioids refer to all natural, semisynthetic and synthetic opioids
54
What do opiods do?
Relieve pain - Analgesic effect
Create a sense of Euphoria in high doses
Endogenous opioids (endorphins) regulate pain and mood
55
Aspect of opiod assessment
Examination:
Collapsed veins / track marks
Endocarditis (murmurs, splinter haemorrhages)
Skin abscesses
Signs of Hepatitis / HIV
Pneumonia
Investigations:
Bloods (FBC, LFT, U&E, GGT, Glucose, CRP, BBB viral screen)
Breathalyser
Urine Drug Screen
Blood cultures (endocarditis)
56
Drug given following opioid overdose
Naloxone
57
What three ways are there to categorise drugs and what is their pros and cons?
1. Chemical structure
WHO classification system does
----Pro- each drug has a unique structure = a fact , easy to allocate data
---Con – no use in clinical decision making
2. Based on what illness it treats
Pros – easy for Drs to choose a drug as docs make diagnosis
Con –1. many psychiatric medicines work in several disorders
Con- 2. most psychiatric disorders have multiple symptoms and a single medicine might not treat them all
3. Based on their pharmacology e.g Beta blockers
58
What psychiatric diseases are associated with excess glutamate?
Epilepsy
Alcoholism
59
What psychiatric diseases are associated with excess dopamine?
Psychosis
60
What psychiatric diseases are associated with excess noradrenaline?
Nightmares
61
What psychiatric disorders are associated with acetylcholine deficiency?
Impaired memory/ dementia
62
What psychiatric conditions are associated with a deficiency in 5 HT?
Depression, Anxiety
63
What psychiatric conditions are associated with a deficiency in GABA?
Anxiety
64
What medication can you use to treat nightmares?
Prazosin - noradrenaline blocker
65
What medication can you use to treat dementia?
Acetylcholine esterase enzyme blockers
66
4 Ps formulation in CAMHS
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors
67
Conditions seen in CAMHS (10)
Anxiety disorder
Somatisation (bodily distress disorder)
Depressive disorder
Autistic spectrum disorder
ADHD
Obsessive compulsive disorder
Tic disorder/Tourette’s syndrome
Substance misuse
Self-harm
Eating disorder (anorexia nervosa)
68
DSM-5 criteria ADHD core features
Persistent pattern of inattention and/or hyperactivity-impulsivity
Present for at least 6 months
Inappropriate for their developmental level
Interferes with functioning or development
Several symptoms present before age 12
Several symptoms present in two or more settings
The symptoms are not better explained by another mental disorder
69
Inattention vs Hyperactivity and Impulsivity
Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level
Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level
70
Normal pressure hydrocephalus presentation
Hakim-Adams triad;
Cognitive impairment/confusion
Urinary frequency/incontinence
Gait disturbance (magnetic/stuck to the floor gait)
71
Clinical features of mild dementia
Living independently but some supervision/support often needed
Can participate in community activities and can appear unimpaired to those who do not know them
Judgement and problem solving typically impaired
Social judgement may be preserved
Difficulty making complex plans/decisions and handling finances
72
Clinical features of moderate dementia
Require supports to function outside the home and only simple household tasks are maintained
Difficulties with basic activities of daily living (ADL’s), such as dressing and personal hygiene
Significant memory loss
Judgment and problem solving are typically significantly impaired, and social judgment is often compromised
73
Severe Dementia Clinical features
Severe memory impairment
Often disoriented to time and place
Often unable to make judgments or solve problems
May have difficulty understanding what is happening around them (situational awareness)
Dependent on others for basic personal care )bathing, toileting and feeding)
Urinary and faecal incontinence may emerge at this stage
74
What kind of social history should you take from a person presenting with cognitive impairments?
Collateral
75
What can restricted eating include?
Quantity, Range
76
DSM5 Anorexia Nervosa
A. Restriction of energy intake relative to requirements leading to low body weight in personal context
B. Intense fear of weight gain/ becoming fat, persistent behaviour that interfers with weight gain
C.Disturbance in experience of weight/shape
77
Subtypes of Anorexia Nervosa
Restricting vs Binge - eating/ Purge
78
Bulimia Nervosa vs Binge Eating disorder
Similarities:
Over eating episodes ( sense of lack of control)
Weight : normal --> high
Guilt and shame
Differences:
Bulimia Nervosa - inappropriate compensatory mechanisms (vs none to little)
dietary restriction (vs none to little)
self induced vomiting (vs none to little)
excessive exercise ( vs not)
79
Purging disorder ICD11
Recurrent purging behaviour to influence wieght or shape in the absence of binge eating
Weight: Normal
80
Atypical AN = AN ICD 11
What are examples of this?
Purging disorder
OSFED
Atypical BN
Night eating syndrome
81
ARFID summary
Feeding disturbance not caused by weight/shape concerns
Feeding disturbance:
Significant weight loss
Significant nutritional deficiency
Dependence on enteral feeding/ supplements
82
Three main subtypes of ARFID
1. Individuals who do not eat/ show little interest in eating
2. Individuals who only accept a limited diet in relatio to sensory features
3. Individuals whose food refusal is related to adverse experience
83
What book can be referred to in managing medical emergencies in eating disorders?
What checklist for ED risk?
Medical emergencies in Eating Disorders
Appendix 4: Eating disorder risk checklist for emergencies
84
What clinical information is used to assess risk to live in ED?
Weight Loss
BMI
HR
Cardio vascular health (BP, Syncope etc)
85
T1DE checklist
1. Intense fear of gaining weight , or body image concerns , or fear of insulin promoting weight gain
2. Recurrent inappropriate direct or indirect restriction of insulin to prevent weight gain
3. Presenting with a degree of insulin restrictiton/ concerning behaviour that lead to harmed health
86
Psychological interventions for ED
Children and Young People
ED focussed Family Therapy
CBT
Adolescent focussed therapy (AN only)
Adults
MANTRA (AN only)
SSCM (AN only)
CBT
87
What medication can be used to reduce emotional dysregulation during feeding?
olanzapine or aripiprazole to reduce emotional dysregulation during refeeding
88
What is the triangle of care?
Service user, Carer, Professional
