Psychiatry Flashcards
(205 cards)
1
Q
Presenting Complaint: Suicide (overdose)
What questions would you like to ask?
A
Open:
Why have you have come or been sent to hospital today?
I understand you took some extra medications today, tell me more about that?
Focussed:
Had you thought about it before? (planned)
What did you take and how much?
What did you think would happen?
Had you made any preparations beforehand? i.e. will or left a note
How did you come to the attention of medical services? (were found or seeked help)
How do you feel about it all now?
2
Q
Presenting Complaint: Thinks people are poisoning him
What questions would you like to ask?
A
Open:
Is there anything in particular on your mind?
Are you worried about anything in particular?
Clarifying:
How do you know it’s happening?
How can you be sure?
When did it first start?
Could be there any other explanation?
What do others think about it?
Risk:
This sounds frightening, have you ever taken steps to protect yourself?
3
Q
Presenting Complaint: Low mood
What questions would you like to ask?
A
Have you noticed any changes to your mood recently? (Low mood)
Do you have any hobbies that you enjoy or make you happy? (Anhedonia)
How would you describe your energy levels, 1-10? (Anergia)
Weight changes
Appetite changes
Mood changes
Sleep changes
Any high mood
Risk Assessment
4
Q
Presenting Complaint: Psychosis
What questions would you like to ask?
A
Do you have any worries or feel like you are unsafe or in danger? (delusions)
Do you ever see or hear things that other people seem unable to? (hallucinations)
Do you have a voice talking about you (third person) or directly to you (second person) or someone telling you to certain things?(running commentary)
(auditory hallucinations)
5
Q
Presenting Complaint: Anxiety
What questions would you like to ask?
A
Would you say you were in anxious person?
Do you feel on edge?
Do you worry or feel like you are unable to relax?
Do you ever suffer from:
SOB
Chest pain
Palpitations
Sweating
Tremors
Do you have any fears that others would think are silly/irrational?
Do any thoughts keep returning even when you try ignore them or push them away?
6
Q
In what order do you take a psychiatric history?
A
1) Presenting Complaint
2) Past Psych Hx
3) Past medical/drug Hx
4) Family Hx
5) Alcohol/Substance Misuse
6) Social Hx
7) Personal Hx
8) Forensic Hx
9) Premorbid Personality
10) Mental State Examination
7
Q
What is the order of Mental State Examination?
A
1) Appearance and Behaviour
2) Speech
3) Mood and Affect
4) Thought
5) Perception
6) Cognition
7) Insight
8) Risk
8
Q
What are you looking for in Appearance and Behaviour in the MSE?
A
Well kempt
Eye contact
Level of rapport
Psychomotor retardation or agitation
9
Q
What are you looking for in Speech in the MSE?
A
Rate
Tone
Volume
Dysarthria or dysphasia
10
Q
What are you looking for in Mood in the MSE?
A
Subjective: patient rates on a scale of 1-10
Objective: interviewer’s opionion
11
Q
What are you looking for in Affect in the MSE?
A
Emotional response is:
Blunted (decreased)
Flat (absence)
Incongrous (emotions don’t match thoughts)
Labile (rapidly changes)
Reactive (normal)
12
Q
What are you looking for in Thought in the MSE?
A
Form - if their is a formal thought disorder or not
(flight of ideas, circumstantiality, tangenital, neologisms)
Content - any delusions, obsessions, overvalued ideas
13
Q
What are you looking for in Perception in the MSE?
A
Illusions
Hallucinations
Pseudohallucinations
14
Q
What are you looking for in Cognition in the MSE?
A
Orientation to
time
place
person
15
Q
What are you looking for in Insight in the MSE?
A
Is patient aware they are mentally unwell
Their thoughts on treatment and would they take/use if prescribed
16
Q
What are you looking for in Risk in the MSE?
A
Risk to self, others and own health
17
Q
When was the Mental Health Act published?
A
1983 but amended in 2007
18
Q
What are the guiding principles of MHA?
A
Minimise the undesirable effects of mental illness
Least restrictive
Participation of patient
Equity, effectiveness and efficiency
19
Q
What is the criteria for implementing the MHA?
A
The presence of a mental disorder as defined by law
◼ Disorder is of a certain nature or degree
◼ Significant risk to the persons health,
safety, or safety of others
◼ No alternative to hospital admission as a means of safeguarding that risk – so cannot manage in a less restrictive setting
20
Q
What is the definition of mental disorder?
A
Any disorder or disability of the mind
21
Q
What is section 5 (4) of the MHA?
A
- Emergency detainment of a inpatient
- lasts for 6 hrs
- done by registered mental health nurse
22
Q
What is section 5 (2) of the MHA?
A
- Emergency detainment of a inpatient
- lasts for 72 hrs
- done by registered medical officer (dr)
- To allow mental health act assessment to be completed
23
Q
What is section 2 of the MHA?
A
- Person detained for assessment (and treatment) of mental disorder
- Lasts for 28 days
- Signed by 2 doctors (1 is section 12 approved)
- Results in either discharge or section 3 when up
24
Q
What is section 3 of the MHA?
A
- Person detained for treatment of mental disorder
- Lasts for 6 MONTHS
- Signed by 2 doctors (1 is section 12 approved)
- Can be renewed
25
What is section 136 of MHA?
- Police can remove a person with 'mental disorder' from public to a place of safety
- Can be held for 24 hrs
- Police need to contact AMHP and 1 doctor for mental health act assessment
26
What is section 17 of MHA?
A patient detained under S2 or S3 may leave care for walks or overnight stays
27
What is section 117 of MHA?
Any patient who was under a section 3 is entitled to aftercare from local authority
28
What is a community treatment order (CTO)?
- Patient on a S3 who is well enough to leave hospital but may not adhere to treatment
- Leaves with conditions (adherence to tx and attending appts) if breaks conditions they can be recalled to hospital
29
Who can discharge a sectioned patient?
Responsible Clinician
A succesfull tribunal appeal
Hospital Managers
The next of kin power of discharge
30
How do you complete a mental capacity assessment?
1) Able to understand information regarding decision
2) Able to retain information
3) Able to use or weigh that info as part of the decision making process
4) Able to communicate the decision by any means
31
What are the key principles of the Mental Capacity Act (2005)?
A person must be assumed to have capacity unless it's established he doesn't
A decision must be made in the patient's best interests
A person should be able to make unwise decisions if they have capacity
Any decision made on behalf of an incapacitated patient should be done in the least restive way of the patients freedom of action and rights
All practical steps should be used before saying a patient lacks capacity
32
Who is a LPA?
Lasting Power of Attorney
Somebody a person has appointed to act on behalf if they ever lack capacity in the future
33
What are Advance Decisions (ADs)?
A person can refuse certain treatments in the future if they lack capacity in the future and are unable to consent at the time
Can only refuse treatments not demand them
34
What should we consider when making a decision in a patient's best interests?
1) Whether the patient's capacity may return and the decision can wait.
2) Can we encourage the participation of the person as much as possible
3) The person's beliefs and feelings
4) The views of other relevant people
35
What is the prevalence of depression?
10-20%
>350 million people worldwide
36
What are some risk factors/causes of depression?
Bio:
Female
Post-natal
Genetic link
Poor compliance with meds
Long term health problems
Psycho:
Personality type
Failure of stress coping mechanisms
Acute stressful live events
Social:
Lack of social support
Unemployed
Poverty
Alcohol and Substance misuse
37
What are the core symptoms of depression?
Continuous low mood for 2 weeks
Anhedonia
Lack of energy
38
What are some biological symptoms of depression?
Sleep changes (early morning waking)
Appetite or weight changes
Diurnal variation of mood
Loss of libido
Psychomotor retardation/agitation
39
What are the cognitive symptoms of depression?
Low self esteem
Excessive guilt
Lack of concentration
Feeling hopelessness
Suicidal ideation
40
How does the ICD-10 classify the severity of depression?
Mild - 2 core + 2 others
Moderate - 2 core + 3/4 others
Severe - 3 core + >4 others
Severe w/ psychosis - 3 core + >4 others + psychosis
41
What investigations can we do when somebody comes in with a depressed like symptoms?
TFT
FBC
U+Es
PHQ-9
HADS
Beck's Depression Inventory
42
How do you manage mild-moderate depression?
1) Watchful waiting w/ a 2 week appt review
2) Self guided help (1st line)
CBT
Psychotherapies (including CBT)
Exercise programmess
Generally avoid meds unless tried other options or has been depressed for a while or has been depressed before
43
How do you manage moderate-severe depression?
1) Risk Assessment - does patient need sectioning
2) Referral to psych if severe
3) CBT + Antidepressant
Other options include:
CBT
Antidepressant
Psychotherapy
Antidepressant + lithium
ECT (neuromodulation) for life threatening depression or depression that has tried every other avenue of treatment
44
What are some differentials for depression?
Hypothyroidism
Bereavement
Depression secondary to other psychotic disorders
Other mood disorders
45
Why might depression be more common in females?
Fluctuating hormone levels
Social roles (stay at home mums feel devalued by society)
More likely to suffer from physical, sexual, psychological abuse
Greater stresses (childcare)
Women are more likely to be diagnosed as will seek help
Premenstrual/postpartum depression
Women are more sensitive to changes in inter-personal relationships (research suggests)
46
What is the prevalence of bipolar disorder?
1-2%
47
What are the risk factors for bipolar disorder?
Bio:
Family Hx
19-25 yrs
M=F
Black or ethnic minority
Psycho:
Anxiety disorders
Previous depression
Personality type
Social:
Substance misuse
Stressful life evens
Adverse childhood experiences
Post partum
48
What are the symptoms of hypomania?
Present for 4-7 days
Elevated or irritable mood
Increased energy
Increased self esteem
Sociability/talkativeness
Increased libido
Reduced need for sleep
Difficulty in concentration
49
What are the symptoms for mania?
Symptoms present for more than 1 week
I DIG FASTER
Irritability
Disinhibition
Increased libido
Grandiose delusions
Flight of ideas
Activity/Appetite ^
Sleep reduced
Talkative (pressure of speech)
Elevated mood/energy
Reduced concentration or Reckless
50
What is the ICD criteria when it comes to bipolar?
Bipolar type 1 - mania + depression
Bipolar type - hypomania + severe depression
Bipolar Affective Disorder - 2 episodes in which a persons mood and activity levels are significantly disturbed (one must be hypo or mania)
51
How do we manage bipolar disorder (mania)?
1) Risk assessment and/or section under MCA
2) inform DVLA (mania)
Bio:
1) Antipsychotic (olanzapine)
2) Mood stabiliser (lithium)
3) Benzodiaepines (lorazepam)
4) ECT
Psycho:
CBT
Social:
Social support activities
52
How do we manage bipolar disorder (depressive episode)?
1) Olanzapine
2) Olanzapine + fluoxetine
3) Lamotrigine or lithium
Avoid anti-depressants as can send patient into mania
53
How do we manage bipolar disorder (long term)?
Lithium (for prophylaxis)
Can add sodium valproate or olanzapine if not controlled
54
What do we need to do when starting a patient on lithium?
Before hand:
U + Es
TFT
ECG
Pregnancy test
Lithium levels:
12 hours post first dose
weekly until at therapeutic level for 4 weeks
Then 3 monthly
After:
U&Es 6 monthly (nephrogenic diabetes inspidus or renal damage)
TFTs - 12 monthly (hypothyroidism/goitre)
55
What is the prevalence of schizophrenia?
1%
56
What is thought broadcast?
The belief that others can hear your thoughts
57
What are the core symptoms of paranoid schizophrenia according to ICD10?
Paranoid schizophrenia is dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances. Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.
58
What is a delusion and how can it be distinguished from normal experience?
A firmly held belief that doesn't go alongside social norms and is still held despite strong evidence to the contrary
59
What is the difference between second person and third person auditory hallucinations?
2nd: A voice is talking directly to the patient
3rd: A voice is talking about the patient (can be running commentary)
60
What forms of hallucinations are characteristic of paranoid schizophrenia?
Auditory
61
What forms of hallucinations are characteristic of organic disorders?
Visual
62
Why is an assessment of insight important in schizophrenia?
They usually lack insight
Helpful to differentiate from other causes of psychosis
63
What is formal thought disorder?
An impairment in the ability to form thoughts as logically connected ideas. Will present as disorganised speech
64
In what conditions can hallucinations occur?
Cushings
TLE
Alcohol withdrawal
Schizophrenia
Infection
Grief
Parkinson's
Charles Bonnet syndrome
SoL
65
What are the positive symptoms of schizophrenia?
Hallucinations (usually auditory)
Delusions
Formal Thought Disorder
Passivity phenomena
Thought broadcast/insertion/withdrawl
66
What are the negative symptoms of schizophrenia?
Avolition - loss of motivation in goal directed behaviour
Anhedonia
Alogia- quantitive and qualitive decrease in speech
Affective flattening - unable to express feelings
Attention deficitis - reduced function of attention, language, memory and normal functioning
67
What are Schneider's first rank symptoms?
Delusional perception
Third person auditory hallucinations
Thought withdraws/insertion/broadcast
Passivity phenomena
Somatic hallucinations
68
What is meant by prodrome phase in schizophrenia?
Precedes the symptoms of psychosis
irritable
reduced concentration
anxious
suspicious
69
What are some of the different classifications of schizophrenia according to ICD 10?
Paranoid - most common
Hebephrenic - thought disorder mostly
Catatonic - psychomotor disturbances
Simple - -ve symptoms only
Undifferentiated - doesn't fit into other sub groups
Residual - previous psychosis with now 1 yr of -ve symptoms
Postschizophrenic depression - depressed with previous psychosis. Some psychotic symptoms still present
70
What is the criteria for diagnosis of schizophrenia via ICD 10?
Group A:
Thought insertion/withdrawl/broadcast
Deleusions of control/influence
Passivity phenomena
Running commentary
Persistent delusions
Group B:
Persistent hallucinations
Thought disorganisation
Catotonia
-ve symotoms
Need 1 from group A or 2 from group B for 1 month+
71
How do we manage schizophrenia?
Risk assessment/section
Early intervention in psychosis team
Bio:
Antipsychotics (olanzapine, risperidone)
Clozapine for tx-resistant
Psych:
CBT
Social:
Support groups
Peer support worker
Family interventions
72
What are some risk factors for schizophrenia?
Bio:
Family hx
Born in winter
Premature birth
Intrauterine infection
Obstetric complications
Intsrumental delivery
Extremes of parental age
Onset 15-35 yrs
Psych:
ACEs
Childhood stress/abuse
Social:
Substance misuse (especially cannabis)
Migrants
Living in urban area
73
What are some organic causes of psychosis?
Drug induced
Iatrogenic (medication)
TLE (temporal lobe epilepsy)
Delirium
Dementia
Huntingtons
SLE
Syphilis
Cushings
B12 deficiency
74
What are some non-organic causes of psychosis?
Schizophrenia
Schizoaffective disorder
Purperal psychosis
Depressive psychosis
Schizotypal disorder
75
What do you do when changing from one SSRI to another?
Stop fluoxetine, wait 4-7 days, and then start sertraline at a low dose
76
How long should anti-depressants be continued after symptoms disappear?
6 months to prevent relapse
77
What is a neurotic disorder?
Psychiatric disorders characterised by distress, that are non-organic, have a discrete onset and where delusions and hallucinations are absent
78
What disorders are included under the umbrella term 'neuroses/neurotic disorders'?
Generalised Anxiety Disorder
Panic Disorder
Specific Phobia
Agoraphobia
Social phobia
Mixed anxiety and depressive disorder
OCD
PTSD
Acute stress reaction
Adjustment reaction
Dissociative disorders
Somatoform disorders
79
What is the prevalence of Generalised Anxiety Disorder?
2-4%
80
What are some risk factors for GAD?
Bio:
Female (2:1)
Family Hx
Chronic health conditions
Psych:
Child abuse
Anxious personality disorder
Other Neurotic disorder co-existing
Social:
Divorced
Living alone
Low socioeconomic status
Stressful life events
Substance dependence
81
How does GAD present?
Psych:
Restless
Irritable
Excessive worry
Unable to concentrate
Sensitive
Tired
Physical:
Headaches
Nausea
Palpitations
Chest pain/tightness
Abdo pain/diarrhoea
Tremors
Muscle pain/tension/aches
Sweating/hot flushes
Sleep disturbance (unable to fall asleep)
82
What is the ICD 10 criteria for diagnosis of GAD?
6 MONTHS of tension, worry and feelings of apprehension
1 of:
Palpitations
Sweating
Shaking/tremor
Dry mouth
4+ of physical symptoms
83
What are some differentials for anxiety disorders?
Schizophrenia
Depression
Other neuroses
Personality disorder
Substance abuse
Excessive caffeine
Anaemia
Hyperthyroidism
Phaeochromocytoa
Hyperglycaemia
84
What is the mx of GAD?
1) Psychoeducation about GAD + active monitoring
2) Individual non-facilitated or guided help
Psycho-educational group based therapy
3) CBT or applied relaxation or SSRI/SNRI (Sertraline, then duloxetine or venlafaxine)
4) Psych referral
AVOID BENZOS
85
What is the prevalence of panic disorder?
1%
86
What are the risk factors for panic disorder?
Bio:
Females (3x more common)
White ethnicity
Family hx
20-30 yrs
Psych:
Other mental disorders
Social:
Smoking
Major life events
87
How does panic disorder present?
Palpitations/chest pain
Tension
Tremor
Sweating
Dry mouth
Hyperventilation
Dizzines
Nausea
Feeling of Panic
Fear
Danger
Loss of control
88
What is the ICD 10 criteria for Panic disorder?
Recurrent panic attacks that occur spontaneously
Discrete episodes of intense fear or discomfort
Starts abruptly and reaches a crescendo within a few mins
1 symptom of autonomic arousal and other GAD symptoms
89
What investigations should we complete for anxiety disorders?
FBC (infection/anaemia)
TFT (hyperthyroidism)
Glucose (hypoglycaemia)
ECG (chest pain)
GAD-7
Yale Brown Obsessive Compulsive Scale (Y-BOCS)
Trauma Screening Questionnaire
90
How do you manage panic disorder?
1) Recognition and Diagnosis
2) CBT or SSRI (sertraline)
91
What is the typical onset for the different phobic disorders?
Agoraphobia - early adulthood
Social phobia - adolescence
Specific phobia - childhood or later
Agoraphobia the only one more common in females (2:1)
92
Wha are some risk factors for the phobic disorders?
Family hx
Adverse experience w/ relevant phobia
Other anxiety/mood disorders
Substance misuse disorders
93
How does a phobia present?
Anticipatory anxiety
Urge to avoid stimuli
Inability to relax
Autonomic symptoms
(Agoraphobia) Panic disorder
94
What are the ICD 10 criteria for each of the phobic disorders?
Agoraphobia:
Manifest fear or avoidance in 2+ of crowds, public spaces, travelling alone, travelling away from home
Social Phobia:
Marked fear or avoidance ion being the focus of attention or being humiliated
1 of the following: blushing, fear of vomiting, urgency or fear of micturition/defecation
Specific Phobia:
Marked fear or avoidance of specific object to situation
All need to have anxiety symptoms that are restricted to feared situation
95
How do you manage phobic disorders?
Avoid anxiety-inducing substances (caffeine, drugs)
CBT
Exposure/graduated exposure techniques (systematic desensitisation)
SSRI (sertraline or escitalopram)
96
What is the prevalence of OCD?
1-3%
97
What are the risk factors for OCD?
Peak onset (10-20yrs)
Family hx
Pregnancy/post-natal period
Hx of abuse
Depression (30%)
PANDAS (paediatric autoimmune neuropsychotic disorder asscoiated w/ streptococcal infection)
98
What are obsessions and compulsions?
Obsessions:
Unwanted intrusive thoughts, images or urges that repeatedly enter the individuals mind
Compulsions:
Repetitive behaviours or mental acts a person feels they have to carry out to relieve the anxiety caused by obessions
99
What are the ICD 10 classifications of OCD?
Predominately obsessional thoughts
Predominately compulsive acts
Mixed obsessional thoughts and acts
The Os and Cs must interfere with persons social or individual functioning
100
How do you manage OCD?
1) CBT or Exposure and Response Prevention (ERP)
2) SSRI or Intensive CBT
3) SSRI + Intensive CBT
SSRI: Fluoxetine, sertraline
101
What is the prevalence of PTSD?
3%
102
What are the risk factors for PTSD?
Female
Professions at risk (police...)
Groups at risk (refugees
Pre trauma:
Previous trauma
Mental illness
Childhood abuse
Low status
Peri trauma:
Severity of trauma
Perceived threat to life
Post support:
Absence of social support
Concurrent life stressors
103
How does PTSD present?
Reliving:
Flashbacks
Vivid memories
Nightmares
Avoidance:
Avoiding triggers (Associated people/places)
Inability to recall aspect of trauma
Hyperarousal:
Irritablity
Difficulty concentrating
Difficulty sleeping
Exaggerated startle response
Emotional numbing:
Guilty
Feeling worthless
Depersonalisation (feeling detached from others)
Difficulty experiencing emotions
Anhedonia
Rumination (constant thoughts about event)
104
What is the ICD-10 criteria for diagnosis of PTSD?
Exposure to stressful event
Persistent remembering of event
Avoidance of similar situations
Inability to recall important aspects of event
Persistant autonomic symptoms
Must be wishing 6/12 of stressful event
105
How do you manage PTSD?
Watchful waiting if symptoms less than 4 weeks
1) Trauma focused CBT (8-12 sessions)
2) Eye Movement Desensitisation and Reprocessing (EMDR)
3) Sertraline, Venlafaxine, Risperidone
106
What is Somatisation Disorder?
Multiple, recurrent, frequently changing symptoms for 2yrs with no physiological illness
107
What is hypochondriac disorder?
Pt interprets normal bodily sensations as serious physical disease (e.g. cancer)
Body dysmorphic disorder a type of this
108
What is factitious disorder?
Intentional production of symptoms in order to receive the care of a patient
[munchaussen's syndrome]
109
What is malingering?
Patient's seeking advantageous complications of being diagnosed w/ a medical condition
(e.g. gaining benefits or avoiding criminal prosecution)
110
What is a personality disorder?
A deeply ingrained and enduring pattern of inner experience and behaviour that deviates from expected norms leading to stress and impairment
111
What might be the impact of making a diagnosis of personality disorder for the individual and clinician?
Individual:
Gives them access to treatment to help
Associated stigma that goes with it
Misdiagnosis and the issues that go with it
Suggests an issue with their up bringing
Gives them an explanation for the behaviour
Clinician:
Physchological impact of psychiatry
+ve feeling of helping patient
May misdiagnosis
112
What defines someones personality?
The collection of characteristics that make each person unique and that influence how they think, feel, and behave
113
What principles should be applied in the treatment of personality disorders in primary care or psychiatry?
Primary Care:
Social support
Social prescribers
Risk Assessment
Treat co-morbid personality disorders
Refer to CBT
Psychiatry:
Section under MHA if needed
Off-licencse prescribing
114
What are the risk factors for a personality disorder?
Low socioeconomic status
Social reinforcement of abnormal behaviour
Poor parenting
Neglect/child abuse
Family hx
115
What is the prevalence of personality disorder?
4-13% of adults have PD at mid severity
116
What are the cluster A Personality Disorders (Odd/Eccentric)?
Paranoid:
Suspicious of others/partner
Don't like criticism
Schizoid:
Indifferent to praise or criticism
Distant to others and no emotion/libido
117
What are the cluster B Personality Disorders (Dramatic/Emotional)?
Borderline/Emotionally Unstable:
Fear abandonment with very unstable and intense relationships
Suicidal and instable
Dissocial/Antisocial:
Complete reckless/illegal behaviours
Can't plan ahead
Histrionic:
Egocentric and concerned about physical appearance
Attention seeking and sexual behaviour
Narcissistic:
Grandiose sense of importance that fantasise about success,power and beauty
118
What are the cluster C Personality Disorders (Anxious/Fearful)?
Dependent:
Constantly require reassurance and lack self confidence
Fear abandonment and want a companion
Difficult to express disagreement
Avoidant:
Feel inadequate and like they're gonna embarrass themselves
Restrict lifestyle for safety
Check people out before starting relationship
Ankastic/Obsessive-Compulsive:
Live they're life by a set of rules and order
Want to be perfect
119
How do you manage personality disorder?
Treat co-morbid psych disorders and substance abuse
Risk assessment
Bio:
Antipsychotics, mood stabilsiers, anti deppresants (all off license)
Psych:
CBT
Psychodynamic psychotherapy
Dialectical behavioural therapy
Social:
Support group
120
What is Schizotypal personality disorder?
lack close friends
odd or eccentric behaviour, speech, and beliefs
They may display magical
ideas of reference
121
Why does Anorexia Nervosa cause amenorrhoea?
Hypothalamic amenorrhea
Low levels of leptin contribute to abnormal secretion of GnRH
Negative energy balance leads to hypothalamus dysfunction
GnRH pulses become dysregualted
Leading to less LH/FSH secretion
Reduced oestrogen production from ovaries
122
Why are tricyclic antidepressants potentially dangerous in anorexia?
Increased risk of arrhythmia
Elongated QT is seen both in TCA and anorexia
123
What are the physical complications of anorexia?
Amenorrhea
Arrhythmias
Anaemia
Constipation
Lanugo hair
Heart failure
Severe dehydration
Hypothermia
124
Define anorexia nervosa
Eating disorder characterised by deliberate weight loss, intense fear of fatness, distorted body image and endocrine disturbances
125
What is the aetiology behind anorexia?
Some genetic predisposition
Inter personal factors
Environmental pressures
126
What are some risk factors for anorexia?
Bio:
Family history
Female (10:1)
Early Menarche
Link with ASD (autism)
Psych:
Sexual abuse
Low self esteem
Anakastic personality
Pre-morbid mood/anxiety disorder
Social:
Western society
Weight related bullying
Occupation (ballet, models)
127
In what ways may excessive use of alcohol excess present to a psychiatrist?
Aggressive (head injury/fight/fall)
Wernicke's encephalopathy
Brought in by relative
Concurrent mood/anxiety disorder
Social worker brought in
Recent admission to hospital for intoxication/withdrawl
128
What is the ICD 10 criteria for anorexia nervosa?
FEEDD
Fear of weight gain
Endocrine disturbance
Emaciated (low body weight)
Deliberate weight loss (low or intake or high exercise)
Distorted body image
Must be present for 3 months+
129
What is the management for anorexia nervosa?
Bio:
Tx medical complications
SSRI if co-morbid depression
Feeding (NGT or supplements)
Psych:
Anorexia Focused Family therapy (1st line for CAMHS)
CBT-ED (1st line)
MANTRA (Maudlsey anorexia nervosa treatment for adults)
SSCM (Specialist supportive clinical mx)
Social:
Self help groups
130
What are the outcomes related to anorexia nervosa?
Highest mortality of all mental health disorders
10% will die due to anorexia complications
40% will fully recover
20% develop chronic anorexia nervosa
131
What is the outcomes for bullimia nervosa?
Better recovery and lower mortality than AN
50-60% get full recovery
132
Define bulimia nervosa
Repeated episodes of uncontrolled binge eating followed by compensatory weight loss behaviours and overvalued ideas regarding ideal body shape/weight
133
What is the aetiology behind bulimia nervosa?
Genetic predisposition
Interpersonal factors
Stressful live events and culture trigger
134
What are the risk factors for bulimia nervosa?
Bio:
Young women
Family hx of mental health disorders
Early onset puberty
Co-morbid mental disorder
Psych:
Child abuse (physical/sexual)
Childhood bullying
Parental obesity
Low self esteem
Borderline personality disability
Social:
Living in developed country
Profession (actors, athletes)
Social media pressure
Environmental stress
135
What are the complications of bulimia?
Hypokalaemia
Arrhytmia
Mallory weiss tear
Parotid gland swelling
Aspiration pneumonia
Dental erosion
136
How does bulimia nervosa present?
Fluctuations in bodyweight
Irregular periods
Binge eating
Purging behaviours (vomiting, laxatives, ^exercise)
Russell's sign
Erosion of teeth
Parotid gland swelling
Feeling of guilt, shame
137
What is the ICD 10 Criteria for diagnosis of bulimia?
Behaviours to prevent weight gain:
(vomiting, drugs, diabetics omitting insulin, exercise)
Preoccupation w/ eating:
compulsion to binge w/ regret and shame after
Fear of fatness:
self perception of being too fat
Overeating:
2+ epodes per week for 3 months
138
How do you manage bulimia nervosa?
Bio:
K replacement if needed
Fluoxetine
Psych:
Focused guided self help (mild)
CBT-ED
FT-BN [bulimia nervosa focused family therapy in CAMHS]
Social:
Techniques to avoid binging
Food diary
139
140
What is meant by the term 'harm reduction'?
Policies, programmes and practices that aim to minimise the negative health, social and legal impacts associated with drug use, drug policies and drug laws.
141
What is the recommended safe weekly intake of alcohol for men and women?
14 units or less
FOR BOTH
142
What are the symptoms of dependence syndrome?
Must last for over a month
Strong compulsions to consume substance
Preoccupation w/ use
Withdrawal state if stopped or reduced
Impaired ability to control substance taking behaviour
Tolerance to substance (needing ^dose)
Persisting w/ it despite harmful evidence
143
What illicit drugs may produce a schizophrenia like state?
1. Cannabis
Stimulants (cocaine, MDMA/Ectasy, amphetamine)
Hallucinogens (LSD, Magic mushrooms)
Methamphetamine
144
What are the physical health risks of illicit opioid use?
Physical:
Respiratory depression
Addiction
Withdrawal and the symptoms that go w/ it
Death
Overdose
^Risk of blood borne viruses, TB, Staph aureus, Infective Endocarditis
Vascular problems (DVT, Superficial thrombophlebitis)
Poor oral hygiene
Poor nutrition
145
What are the physchosocial health risks of illicit opioid use?
Criminality
Homelessness
Prostitution/trafficking
Cost of use
Socially withdrawn
Depression/anxiety
Self harm/suicide
Co-morbid or substance induced psychosis
Loss of memory/cognitive impairment
146
What is the difference between the following:
alcohol abuse
binge drinking
harmful alcohol use?
Abuse: consumption of alcohol at level to cause physical, psychiatric and social harm
Binge: Drinking 2x the recommended levels of alcohol per day in 1 session (>5men,>6women)
Harmful: Driving above safe levels w/ evidence of alcohol related problems
147
What is the pathophysiology behind alcohol dependence and withdrawl?
1) Alcohol is a depressant
2) Stimulates GABAr (inhibitory effect)
3) Inhibits GLUTAMATEr (are excitatory so causes inhibitory effect)
Withdrawl:
1) Dependance causes down regulation of GABAr and up regulation of GLUTAMTAEr
2) So without alcohol to depress this it will cause CNS hyper-excitability (seizures)
148
What are the physical complications of alcohol abuse?
Hepatic (CLD peripheral stigmata, HCC)
Pancreatitis
Oesophageal varices
Oesophageal carcinoma
HTN
Cardiomyopathy/arrhythmia
Anaemia
Thrombocytopenia
Seizures/peripheral neuopathy
Wernickes/Korsakoff
Head injury/falls
Fetal alcohol syndrome
149
What are the psycho social complications of alcohol abuse?
Psych:
Morbid jealousy (Othello syndrome)
Self harm/suicide
Mood/Anxiety disorders
Social:
Domestic violence
Drink driving
Financial issues
Homelessness
Employment and relationship issues
150
What are the screening tools for alcohol dependance?
CAGE - not useful really
AUDIT Questionnaire
(Alcohol Use Disorders Identification Test)
10 questions
8+ = harmful use
151
What are the risk factors for alcohol abuse?
Younh males
Family hx
Pre-morbid antisocial behaviour
Lack of facial flushing when drink (metabolise gene)
Life stressors
152
How would alcohol dependence present?
Smell of alcohol
Bloodshot eyes
Telengectasia
Withdrawal symptoms
Peripheral stigmata of CLD
Increased tolerance
Narrowing of drinking repertoire (from social pub to indoors)
153
How do you manage alcohol dependence?
Bio:
Disulfarim (build up acetaldehyde)
Acamprostate (reduce craving by enhancing GABA transmission)
Naltrexone (blocks opioid receptors to reduce +ve effect of alcohol)
Thiamine
Psych:
Motivational interviewing
CBT
Social:
AA
Tell pt to inform DVLA
154
How does wernicke's encephalopathy present?
Thiamine (B1) deficiency
Nystagmus
Opthalmoplegia
Ataxic gait
Confusion/disorientation
Peripheral sensory neuropathy
mx: thiamine
155
How does Korsakoff syndrome present?
Complication of wernicke's
Short term memory loss
Confabulation (fill in gaps of memory w/ imaginary events)
mx: give thiamine
(irreversible - 20% need institutional care)
156
How does alcohol withdrawl present?
6-12 hrs SYMPTOMS:
Tremor
Maliase
Nausea
Insomnia
Tachycardia
Hallucinations
36 hrs SEIZURES
72 hrs DELIRIUM TREMENS
157
How does delirium tremens present?
Audiory/visual hallucinations
Tremor
Autonomic arousal (sweat,HR,pupil dilate)
Paranoid delusions
Cognitive impairment/confused
Dehydration/electrolyte disturbance
158
What is the ICD 10 criteria for alcohol withdrawl?
Clear evidence of cessation or reduction in prolonged or high alcohol use
Not accounted by another medical or mental disorder
Any 3 of:
Sweat
N+V
^HR
^BP
Headache
Psychomotor agitation
Insomnia
Malaise
Transient hallucinations
Grand mal confusions
159
What screening system is available for the severity of alcohol withdrawal?
CIWA-Ar
(Clinical institute Withdrawl Assessment for Alcohol)
8-10: mild
10-15: mod
15+: severe
160
How do we manage alcohol withdrawl?
1) Secure airway if needed
2) Chordiazepoxide (diazepam alternative)
Lorazepam in hepatic failure
3) thiamine + multivitamins
161
What is the mechanism behind drug dependance?
1) Genetic predisposition + environmental triggers/learnt behaviour
2) Takes substance
3) Cues for taking drug are embedded into amygdala and act as triggers
4) +ve reinforcement from peers and mesolimbic reward dopamine pathways
-ve reinforcement from withdrawl symptoms
162
What are the risk factors for drug disorders?
Bio:
Young male
Family hx
Psych:
Mental illness
Addictive personality
Poor methods to cope w/ stress
Social:
Peer pressure
Life stressors
Parental drug use
Low social status
ACEs
Availability of drugs
Low academic achievement
163
How would substance misuse present?
Bio:
Death
Infection (HIV, Hep, TB)
DVT/PE
Needle marks/scars
Weight loss
Skin infection/necrosis/abscess
Psych:
Craving
Anxiety
Drug induced psychosis
Cognitive disturbance
Social:
Crime
Homeless
Prosititution
Relationship issues
164
How does opiate withdrawl present?
Watery eyes
Rhinorrhea
Piloerection
Pupil dilation
N+V
Diarrhoea
Tremor
Restless
Anxious/irritable
165
How do you manage drug dependence?
Bio:
Hep B Vaccine
Psych:
Motivational interviewing
CBT (for co-morbid disorders)
Contingency mx (e.g. financial incentive for stopping)
Social:
Keyworker
Self help groups
DVLA
Alcohol/smoking cessation services
166
How do you manage opioid withdrawl and dependance?
Withdrawl:
IV Naloxone
Dependence:
Methadone (1st line)
Buprenorphine
Naltrexone (prevent relapse in cessation)
167
How do you manage Benz dependence and withdrawl?
Withdrawal:
Diazepam
Dependance:
Should gradually lower dose over time
Can switch to diazepam and taper down if prefer
168
What are the ASD causes?
Prenatal:
Rubella
Smoking
Sodium valproate
mums > 40
Fragile X Syndrome
Tuberous Sclerosis
Antenatal:
Hypoxia during birth
Low birthweight
Low gestational age
Postnatal:
Toxins e.g. lead, mercury
Pesticide exposure
169
What are the risk factors for ASD?
Male (4:1)
Family hx
Advancing parental age
<35 wks gestation
Sodium valproate during pregnancy
170
How does ASD present?
ABC
Asocial
Lack of eye contact
Delay in smiling
Playing alone
Lack emotional expression
Behaviour restricted
Restricted, repetitive stereotyped behaviours (rocking)
Receptive and fixed routine
Anxious/upset if routine changes
Restricted food, game and clothes preferances
Fascination with sensory aspects of environment
Communication impaired
Distorted and delayed speech
Echolalia (repetition of words)
Unable to read non verbal cues
Reduced non verbal communication (smiling, eye contact)
A minority will get intellectual disability (temper tantrums, impulsivity, cognitive impairment)
171
What is the ICD-10 criteria for diagnosis?
Abnormal/impaired development before age of 3
Qualitative abnormalities in social interactions
Qualitative abnormalities in communication
Restrictive, repetitive + stereotyped patterns of behaviour, interests + activities
Clinical picture not attributable to other varies of pervasive developmental disorder
172
How do you manage ASD?
MDT of paediatrician, psychiatrist, educational psychologist, SLT, OT
Bio:
Treat co-existing disorders
Antipsychotics
Melatonin for sleeping disorders
Psych:
CBT
Modification of
Social:
Special schooling
Self help groups
173
What are the risk factors for ADHD?
Male (3x more likely)
Family hx
Maternal smoking
Premature birth
Low birth weight
Epilepsy/acquired brain injury
Adverse maternal mental health
174
How does ADHD present?
I'm Hyper Inside
Inattention:
Not listening when spoken too
Easily distracted/lose interest
Inability to engage/persist/complete tasks
Forgetting belongings
Difficulty managing time
Hyperactivity:
Restless/fidget
Reckless
Running in inappropriate places
Excessive talking/noise
Impulsivity:
Difficulty waiting turn
Interrupts there
Premature answers questions
Temper tantrums
Disobedient
Run into road w/out looking
175
What is the ICD-10 criteria for diagnosis of ADHD?
Onset before age of 7
Duration of 6 months+
IQ above 50
Abnormality of attention, activity and impulsivity at home AND school
Directly observed abnormality of attention or activity
Doesn't meet criteria for pervasive developmental disorder, mania, depressive or anxiety disorder
176
What is the management for ADHD?
10 wk watch+wait to see if symptoms change/resolve
If not then refer to CAMHS for assessment
Bio:
Methylphenidate (Ritalin)
(only 5yrs+)
Psych:
Parent training + education
Psychoeducation
CBT
Social skills training
Social:
Support groups
Food diary - find some foods might exacerbate
177
What is the difference between dementia and delirium?
Sleep-wake cycle disrupted in delirium not dementia
Arousal changed in delirium not dementia
Autonomic features in delirium not dementia
State fluctuates in delirium whereas in dementia it is stable or slowly progressive
Psychomotor activity more likely to be abnormal in delirium
Consciousness level is impaired in delirium
Hallucinations more common in delirium
178
What is paraphrenia?
Paranoid delusions (and sometimes hallucinations) that start after the age of 40
The +ve symptoms of schizophrenia but not the -ve symptoms
Rare but important mental disorder affecting the elderly
179
What is an encapsulated delusion?
Somebody holds a delusional belief
But no impairment on other mental functions and can go about functioning normally in every day life
180
Why is a MDT approach important in old age psychiatry?
More likely to have physical health issues
More vulnerable to side effects of drugs
OT may be needed due to changes in house needed
181
How would you define delirium?
Acute, transient, global organic disorder of CNS functioning resulting in impaired consciousness and attention
182
What are the causes of delirium?
HE IS NOT MAAD
Hypoxia
Endocrine (thyroid,glu,cushings)
Infection
Stroke/Intracranial (^ICP,SOL)
Metabolic (hyponatraemia/liver or renal impairment)
Alcohol (intoxication/withdrawl)
Abdominal (faecal impaction/urinary incontinence)
Drugs (benzos, opioids, anticholinergics, steroids, diuretics)
183
What are the risk factors for delirium?
Old age
Dementia
Multiple co-morbidity/fraility
Male
Sensory impairment
184
How does delirium present?
Hypoactive:
Lethargy/sleepiness w/ reduced motor activity
Hyperactive:
Agitated/irritable, aggressive w/ hallucinations + delusions
Acute onset
Worse in evening
Disorientated to T,P,P
Disturbed sleep-cycle
Change in mood
Hallucinations (tactile or visual)
Delusions
Reduced consciousness
Repetitive speech
185
What investigations should you request in delirium?
FBC, CRP, U+Es, LFTS, TFTs
Ca
Glucose
B12 and Folate
Urinalysis/urine dip
CXR
186
How do we manage delirium?
1) Tx underlying cause:
Infection
Catheterise (retention)
Laxatives (impaction)
2) Modify environment:
Well, lit side room
Clocks in room
Consistent staff members
Family member present
3) if aggressive:
De-escalation techniques
0.5mg haloperidol
(quetiapine or clozapine in parkinsons)
187
What are the differences between psychodynamic therapy and CBT?
P focuses on unconscious mind, CBT on cognitive
P focuses more on past and childhood experiences
188
What is transference?
The patient projects -ve emotions/feelings from the past to their therapist
189
Why is motivation important in assessing a patient's suitability for psychodynamic therapy?
Need to be willing to adapt and change behaviour
Need to build therapeutic relationship with therapist
190
Why do patients in some forms of therapy get better before they get worse?
Confronting difficult emotion or uncovering difficult thoughts for the first time
Begininning to build therapeutic relationship with therapist
191
What specific techniques may be used in CBT?
Socratic questioning - open questions to explore origin and current status of issue
Formulation - therapist and patient come up with origin, current status and maintenance behind issue
Collaboration - patient and therapist work actively together
Homework - patient uses new techniques and ways of thinking outside session and reports back
Making patient their own therapeutic - teaches patient to understand thoughts and how to affect them/change them
192
Why may some patients be viewed as unsuitable for psychotherapy?
Actively psychotic
Severe depression
Severe substance abuse
Actively suicidal (sometimes)
193
What are the chapters included in ICD-10?
Organic, including symptomatic, mental disorders
Mental and behavioural disorders due to psychoactive substance use
Schizophrenia, schizotypal and delusional disorders
Mood [affective] disorders
Neurotic, stress-related and somatoform disorders
Behavioural syndromes associated with physiological disturbances and physical factors
Disorders of adult personality and behaviour
Mental retardation
Disorders of psychological development
Behavioural and emotional disorders with onset usually occurring in childhood and adolescence
Unspecified mental disorder
194
Describe the interactions between mental and physical health
Many people with chronic, long term physical issues develop mental health problems
Mentally ill patients are less likely to take care of themselves and so will get physical health issues
More likely to smoke, drink or take drugs that will increase the risk of physical illness
195
What problems are associated with Long term use of benzodiazepines?
Dependence
Misuse
Memory issues
Sedation (falls in elderly)
196
Why are anticholinergic drugs used to treat Parkinsonism?
Help to treat tremor
Less acetylcholine so less movement
197
What is neuroleptic malignant syndrome?
Life threatening complication of antipsychotics
Muscle rigidity
Pyrexia
Tachycardia and hypertension
Confusion
Stop antipsychotic
Dantrolene (muscle relaxant)
Bromocriptine (dopamine agonist)
Benzos (sedation)
198
What are the side effects of TCAs?
Sexual dysfunction
Long QT
Dry mouth
Conspitation
Urinary Retention
Blurred vision
199
Why should chlorpromazine be avoided in the elderly?
Increased risk of stroke/vte in elderly
Risk of confusion, hypotension (and falls)
Extra-pyramidal side effects
Risk of urinary retention in prostate hyperplasia
200
What are the extra-pyramidal side effects of antipsychotics?
Parkinsonism
Dystonia (torticolis and oculogyric crisis)
Tardive dyskinesia
Akathsia (restless)
201
What are the dangers of rapid tranquillisation?
Excessive sedation
Respiratory depression
Loss of conciousness
Seizures
Neuroleptic malignant syndrome
CVS collapse
202
What are the symptoms of lithium toxicity?
N+V
Diarrhoea
Confusion
Ataxia
Seizures
Hyper-reflexia
203
What are the common causes of acute confusional states?
Infection
Intoxication
Electrolyte disturbance
Medication ADR
Hypoglycaemia
Stroke/TIA/Head injury
204
How does wernicke's encephalopathy present and how do you manage it?
Nystagmus
Confusion
Disorientation
Ataxia
Thiamine (parenteral)
205
