Psychiatry Flashcards

Question

Treatment of an Overdose Paracetamol Opioids Benzodiazepines Beta Blockers Cocaine Carbon Monoxide others...

Answer 1

Generally, the first step when a patient presents with an overdose is to check TOXBASE for recommendations about treating an overdose of almost any substance. They also have a contact number for advice. Activated charcoal may be given **within one hour of overdose** of various substances to reduce the absorption (e.g., aspirin, SSRIs, tricyclic antidepressants, antipsychotic drugs, benzodiazepines and quinine). **Paracetamol - N-Acetylcysteine** - TESTED Opioids - Naloxone Benzodiazepines- Flumazenil Beta blockers- Glucagon for heart failure or cardiogenic shock, Atropine for symptomatic bradycardia Calcium channel blockers - Calcium chloride or calcium gluconate Cocaine- Diazepam Cyanide- Dicobalt edetate Methanol (e.g., solvents or fuels); Ethylene glycol (e.g., antifreeze) - Fomepizole or ethanol (alcohol) Carbon monoxide - 100% oxygen

Answer 2

Bipolar disorder is characterised by recurrent episodes of depression and mania or hypomania. The symptoms often start at a younger age (under 25 years). It has a particularly high rate of suicide. Depressive episodes feature low mood, anhedonia and low energy and can be severe. Manic episodes involve excessively elevated mood and energy, significantly impacting their normal functions (e.g., caring and work responsibilities). Me - I think manic episodes last for several weeks, if just a manic day then could be EUPD. Hypomanic episodes involve milder symptoms of mania without having a significant impact on their function. Mixed episodes can involve a mix of symptoms or rapid cycling between mania and depression.

Answer 3

Potential features of mania include: **Abnormally elevated mood** Significant irritability Increased energy **Decreased sleep** (sometimes going days without sleeping) - TESTED IN THE MOCK **Grandiosity**, ambitious plans, excessive spending and risk-taking behaviours **Disinhibition** and sexually inappropriate behaviour **Flight of ideas** (rapidly generating and jumping between ideas) **Pressured speech** (rapid and unrelenting speech) Psychosis (delusions and hallucinations)

Answer 4

Bipolar I disorder involves at least one episode of mania. Bipolar II disorder involves at least one episode of major depression and at least one episode of hypomania. Cyclothymia involves milder symptoms of hypomania and milder low mood. The symptoms are not severe enough to significantly impair their function. Unipolar depression refers to when the person only has episodes of depression, without hypomania or mania. ## Footnote ME - Note Unipolar depression includes Major Depressive Disorder (MDD): A clinical condition marked by episodes of major depression; and Persistent Depressive Disorder (Dysthymia): A chronic form of depression with less severe symptoms but lasting for two years or longer.

Answer 5

Secondary care specialists should manage acute episodes of bipolar disorder. Patients require a referral for an urgent mental health assessment or hospital admission. Treatment of an acute manic episode: - Antipsychotic medications (e.g., olanzapine, quetiapine, risperidone or haloperidol) are first-line - Other options are lithium and sodium valproate - Existing antidepressants are tapered and stopped Treatment of an acute depressive episode: - Olanzapine plus fluoxetine - Antipsychotic medications (e.g., olanzapine or quetiapine) - Lamotrigine

Answer 6

Lithium is the usual long-term treatment for Bi-polar affective disorder: Serum lithium levels (taken 12 hours after the most recent dose) are closely monitored to ensure the dose is correct. The usual initial target range is 0.6–0.8 mmol/L. They are taken weekly until they are stable and then every three months. Lithium toxicity can occur if the dose and levels are too high (usually >1.5): Notable potential adverse effects of lithium include - LITHIUM: - Leucocytosis - insipidis - Nephrogenic diabetes insipidus (polyuria and polydipsia - Tremor - FINE - Hypothyroid - Increased Weight - U - Metalic taste - and... chronic kideny disease Monitoring: - serum lithium - U+E - TFTs - calcium - BMI ECG before treatment if CVD risk factors. Toxicity: 3Cs and 1V (triple penetration) - **Coarse** tremor - CNS disturbance- seizure, impaired co-ordination, dysarthria - cardiac arrhythmia - visual disturbance Management - largely supportive: STOP LITHIUM... - monitor electrolytes - IV fluids - BZD for agitation - haemodylisis for severe renal impairment Basically... Management is supportive and monitoring lithium levels until they return back down to normal range. Alternatives to lithium for long-term treatment include sodium valproate and olanzapine. Remeber the issues with prescribing valproate though! Lasting power of attorney and advanced decisions can be helpful, particularly for future episodes of mania where the person’s judgement and decision-making may be impaired, resulting in harmful outcomes (e.g., excessive spending or gambling).

Answer 7

Generalised anxiety disorder (GAD) is a mental health condition that causes excessive and disproportional anxiety and worry that negatively impacts the person’s everyday activity. Symptoms should be persistent, occurring most days for at least six months, and not caused by substance use or another condition. Panic disorder involves recurrent panic attacks. The panic attacks are unexpected (they appear randomly, often without a trigger) and result in worry about further attacks and maladaptive behaviour changes relating to the attacks (e.g., avoiding activities). Me - The other form of episodic anxiety disorder is phobia disorder, where episodes are caused by specific triggers Secondary Causes of anxiety: Substance use (e.g., caffeine, stimulants, bronchodilators and cocaine) Substance withdrawal (e.g., alcohol or benzodiazepine withdrawal) Hyperthyroidism Phaeochromocytoma Cushing’s disease - cortisol = stress hormone

Answer 8

Emotional and cognitive symptoms of GAD include: Excessive worrying Unable to control the worrying Restlessness Difficulty relaxing Easily tired Difficulty concentrating Physical symptoms (caused by overactivity of the sympathetic nervous system) include: Muscle tension Palpitations (e.g., a feeling of their heart racing) Sweating Tremor Gastrointestinal symptoms (e.g., abdominal pain and diarrhoea) Headaches Sleep disturbance

Answer 9

Panic attacks involve a sudden onset of intense physical and emotional symptoms of anxiety. They come on quickly (within minutes) and last a short time (e.g., 10 minutes) before the symptoms gradually fade. The duration and frequency vary between individuals. Panic attacks are relatively common and do not always indicate a panic disorder. Physical symptoms include tension, palpitations, tremors, sweating, dry mouth, chest pain, shortness of breath, dizziness and nausea. Emotional symptoms include feelings of panic, fear, danger, depersonalisation (feeling separated or detached) and loss of control.

Answer 10

Phobia involves an extreme fear of certain situations or things, causing symptoms of anxiety and panic. There are many types, including fear of animals, heights, pathogens, flying, injections or environments. Examples of common specific phobias include: Claustrophobia (fear of closed spaces) Acrophobia (fear of heights) Arachnophobia (fear of spiders) Glossophobia (fear of public speaking) Trypanophobia (fear of needles) Agoraphobia is a fear of situations in which they may be unable to escape if something goes wrong. For example, this could be a fear of busy places, public transport, or anywhere outside their home. Social phobia involves a fear of social situations (also called social anxiety disorder).

Answer 11

The Generalised Anxiety Disorder Questionnaire (GAD-7) can help assess the severity. It involves seven questions, each scored depending on how often the symptoms are experienced. The total score indicates the severity: 5-9 indicates mild anxiety 10-14 indicates moderate anxiety 15-21 indicates severe anxiety Me - also do TFTs for hyperthyroidism, FBC

Answer 12

Mild anxiety: active monitoring and advice about **self-help strategies** (e.g., meditation), sleep, diet, exercise and avoiding alcohol, caffeine and drugs. Moderate to severe anxiety may require more intervention. Options include: **Cognitive behavioural therapy Medication** Medication: SSRIs (particularly **sertraline**) are the first-line medication for generalised anxiety disorder and panic disorder. Other options for generalised anxiety disorder mentioned in the NICE guidelines (2020) are: SNRIs (e.g., **venlafaxine**) **Pregabalin** Propranolol is a non-selective beta-blocker often used to treat physical symptoms of anxiety. It helps reduce sympathetic nervous system overactivity, improving symptoms such as palpitations, tremors, and sweating. However, it does not treat the underlying anxiety and only has a short-term effect. The main contraindication is asthma (it can cause bronchoconstriction in asthmatic patients). Benzodiazepines (e.g., diazepam) work by stimulating GABA receptors (similar to the effects of alcohol). GABA receptors have a relaxing effect on the rest of the brain, giving relief from anxiety. However, prolonged use quickly results in down-regulate GABA receptors, leading to tolerance (reduced effects at the same dose) and dependence (significant withdrawal symptoms on stopping). The NICE guidelines (2020) recommend not offering benzodiazepines for GAD. The exception is using them for a short duration during a crisis, stopping them as soon as possible. **Panic and Phobia Disorder management - also CBT and Sertraline **

Answer 13

Post-traumatic stress disorder (PTSD) describes a constellation of symptoms and experiences that an individual develops after exposure to a traumatic event or multiple events. These include: - Re-experiencing the traumatic event (e.g. memories, flashbacks, nightmares). - Avoiding thoughts and memories: individuals typically try to avoid thoughts and memories of the traumatic event or avoid activities, situations, or people that remind them of the traumatic event. - Negative changes in mood and thoughts (e.g. amnesia for details of trauma, self-blame, negative self-perception, low mood, losing interest and enjoyment in activities). - Hyperarousal, hyperreactivity, or hypervigilance (e.g. exaggerated startle response, insomnia, hypervigilance to threat, angry outbursts). PTSD cannot be diagnosed within the first month of a traumatic event that differentiates it from an acute stress disorder (lasts less than 1 month, immediate onset)

Answer 14

he history will contain exposure to one or repeated traumatic events. Key symptoms include: Intrusive thoughts relating to the event Re-experiencing (experiencing flashbacks, images, sensations and nightmares of the event) Hyperarousal (feeling on edge, irritable and easily startled) Avoidance of triggers that remind them of the event (e.g., people, places or talking about the event) Negative emotions (e.g., fear, anger, guilt or worthlessness) Negative beliefs (e.g., the world is dangerous) Difficulty with sleep Depersonalisation (feeling separated or detached) - PHENOMONOLOGY Derealisation (feeling the world around them is not real) - PHENOMONOLOGY Emotional numbing (unable to experience feelings)

Answer 15

The Trauma Screening Questionnaire (TSQ) can be used as a screening tool, prompting a referral for further assessment. Like most anxiety and depressive disorders, the Ix is a questionnaire.

Answer 16

Management is tailored to the individual. Options include: Psychological therapy (e.g., trauma-focused CBT) Eye movement desensitisation and reprocessing (EMDR) Medication (e.g., SSRIs, venlafaxine or antipsychotics) Eye movement desensitisation and reprocessing (EMDR) involves processing traumatic memories while performing specific eye movements. The theory is that the improperly stored traumatic memories are reprocessed and stored again in a more normal way so that they no longer cause as much negative emotion and distress.

Answer 17

Obsessive compulsive disorder (OCD) is characterised by obsessions and compulsions. Obsessions are unwanted and uncontrolled thoughts and intrusive images that the person finds very difficult to ignore. Examples of this are an overwhelming fear of contamination with dirt or germs or violent or explicit images that keep appearing in their mind. Compulsions are repetitive actions the person feels they must do, **generating anxiety if they are not done.** Often, these compulsions are a way for the person to handle their obsessions. For example, they check that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down. Although this behaviour can be normal and appropriate, a person with OCD may check every plug in the house ten times before being reassured. The obsessions and compulsions are present daily and are not something the person will enjoy or do willingly. They impact other areas of life, such as their social life or other interests. There is a cycle in OCD involving: Obsessions Anxiety Compulsion Temporary relief The obsessions lead to anxiety, which leads to compulsive behaviours, which leads to a temporary improvement in the anxiety. Shortly after the temporary improvement in anxiety, the obsession reappears, and the cycle reoccurs. Each time, the cycle gets more ingrained in the person’s behaviour. Without completing the compulsions, the person feels no relief from their anxiety about the obsessions.

Answer 18

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) can be used to assess the severity of symptoms

Answer 19

Mild OCD may be managed with education and **self-help resources**. More significant OCD may require: Cognitive behavioural therapy (**CBT**) with **exposure and response prevention** (ERP) **SSRIs** - First line **Clomipramine** (a tricyclic antidepressant) Exposure and response prevention involves gradually facing the obsessive thoughts and anxiety without completing the compulsions.

Answer 20

Personality disorder covers a variety of maladaptive personality traits that cause significant psychosocial **distress **and interfere with **functioning**. These traits remain relatively persistent in the person over time and impact their life and relationships. Personality disorders are characterised by **patterns of thought, behaviour and emotion that differ from what is normally expected**. It leads to difficult relationships, reduced quality of life and poor physical health. Personality disorders are thought to result from a combination of genetic and environmental factors. Patients often have a history of early childhood trauma and difficult circumstances. Me - Attachement theory have a poor foundation for healthy relationships and are not taught how to regulate their emotions. A wide range of symptoms and behaviours occur with personality disorders. The symptoms typically emerge during the teenage or early adult years. Symptoms vary depending on the type and individual.

Answer 21

possible symptoms in someone with borderline personality disorder include: Strong and intense emotions (e.g., anger) Emotional instability (rapidly changing emotions) Difficulty managing emotions Difficulty maintaining relationships Poor sense of identity Feelings of emptiness Fear of abandonment Impulsive and risky behaviour Recurrent self-harm Recurrent suicidal behaviours

Answer 22

There are many different types of personality disorders based on the dominant features. In the DSM-5, they fall into three categories: Cluster A – Suspicious Cluster B – Emotional or impulsive Cluster C – Anxious ABC SEA - mnemonic

Answer 23

Suspicious Personality Disorders: Paranoid personality disorder features difficulty in trusting or revealing personal information to others. Schizoid personality disorder features a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them. Schizotypal personality disorder features unusual beliefs, thoughts and behaviours, as well as social anxiety that makes forming relationships difficult. mnemonic - the unusal **type** Emotional and Impulsive Personality Disorders Antisocial personality disorder features reckless and harmful behaviour, with a lack of concern for the consequences or the impact of their behaviour on other people. It often involves criminal misconduct. Includes psychopath (calculated) and sociopath (impulsive) Borderline personality disorder features fluctuating strong emotions and difficulties with identity and maintaining healthy relationships. Histrionic personality disorder involves the need to be the centre of attention and performing for others to maintain that attention. Narcissistic personality disorder features feelings that they are special and need others to recognise this, or else they get upset. They put themselves first. Believe they are better than others Anxious Personality Disorders Avoidant personality disorder features severe anxiety about rejection or disapproval and avoidance of social situations or relationships. Dependent personality disorder features a heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach. Obsessive-compulsive personality disorder features unrealistic expectations of how things should be done by themselves and others and catastrophising about what will happen if these expectations are not met. If confused the mind page is really useful.

Answer 24

Management of personality disorder can be challenging. The patterns of thinking and behaviours are deeply ingrained and are difficult to change. Pyschoeducation - Patient and carer education is very important to help them understand the condition. Risk management is important, considering short and long-term risks (e.g., ongoing self-harm, suicide and harm to others). Risks are reviewed regularly and managed across the multidisciplinary team. Supportive care is provided during crises to help keep the patient safe. Psychological treatment is the main treatment for EUPD: - dialectical behaviour therapy - EUPD developing strategies for managing distress other than self harm - Mentalisation-based therapy (MBT) – aims to help you recognise and understand your and other people's mental states, and to examine your thoughts about yourself and others. **Medications are not recommended for the long-term treatment of personality disorders.** Sedative medications (e.g., sedative antihistamines) are sometimes used short-term (e.g., for less than one week) in a crisis. Personality disorders can co-exist with other psychiatric problems (e.g., depression), where medications may be beneficial - antipsychotics, antidepressants, and mood stabilisers

Answer 25

Normally, people experience their consciousness, body, perceptions, memories, identity and emotions as connected and integrated. Dissociative symptoms involve a sense of disruption to how these things fit together. They often occur in response to stress or a traumatic event and can last anywhere from a few minutes to many years. The three types of dissociative disorder are described below (although dissociative symptoms can occur in other conditions, such as borderline personality disorder and post-traumatic stress disorder). Depersonalisation-derealisation disorder involves depersonalisation, which is a feeling of being separated or outside their body, and derealisation, which is a feeling that the world is not real. Dissociative amnesia involves forgetting autobiographical information (details about themselves and events that have happened to them), typically following a traumatic experience and leading to gaps in their memory. Dissociative identity disorder was previously called multiple personality disorder. It involves a lack of a clear individual identity, with multiple separate identities with unique names, personalities and memories. It is often associated with severe stress and trauma in childhood.

Answer 26

Catatonia is a state in which someone is awake but does not seem to respond to other people and their environment. Catatonia can affect someone’s movement, speech and behaviour in many different ways The most common causes are severe depression and bipolar disorder. It can also occur with psychosis, such as in schizophrenia. Rarely, physical health conditions, such as strokes or brain tumours, can lead to catatonia. If someone has three or more of these symptoms, they may have catatonia: Sitting very still and staring into space. Holding unusual postures which would normally be uncomfortable. Keeping their arms or legs in whatever position someone else moves them into. Repeating the same movements for a long time. Repeating the same movements as another person (known as ‘echopraxia’). Repeating phrases or words that they hear (known as ‘echolalia’). Holding strange faces. Not speaking, eating or drinking. Doing as they are told or directed without question. Not doing something, or resisting doing something (known as ‘negativism’). Becoming suddenly very agitated or restless. This is called ‘excited catatonia’.

Answer 27

Cotard delusion involves the false belief (delusion) that they are dead or actively dying. It is also known as walking corpse syndrome. It is most often caused by psychiatric conditions, such as depression and schizophrenia, but can be caused by neurological conditions, such as brain tumours and migraines.

Answer 28

The same as a conversion disorder/somatisation disorders. Functional neurological disorder involves sensory and motor symptoms that are not explained by any neurological disease and may be caused by underlying psychosocial factors. Symptoms can include weakness, gait disturbance, seizures, sensory loss and vision disturbances. There may be a history of significant trauma or stress. The symptoms are not under the patient’s control (unlike factitious disorder) and can cause considerable distress and functional impairment. pathophysiology is about the sick roll and dissociationa dn distreaction from stress and emotions.

Answer 29

Schizophrenia is a severe, long-term mental health disorder characterised by **psychosis**. It involves episodes where individuals lose touch with **reality**. Schizophrenia disrupts normal perception, cognition, emotions, and daily functioning. It most often presents between ages 15 and 30 and earlier in men than women. The symptoms must be present for at least six months before schizophrenia is diagnosed. My Understanding - i think people eperiencing pychotic episodes but have residual symptoms in between? Schizoaffective disorder combines the symptoms of schizophrenia with bipolar disorder. Patients have psychosis and symptoms of depression and mania. Management is similar to schizophrneia but also invovles the use of mood stabalisers long term (Lithium first line and then antiepilecptics). Schizophreniform disorder presents with the same features as schizophrenia but lasts less than six months.

Answer 30

A prodrome phase often precedes the full symptoms of psychosis. During this prodrome phase, the patient may experience subtle symptoms, such as poor memory, reduced concentration, mood swings, suspicion of others, loss of appetite, difficulty sleeping, social withdrawal and decreased motivation. Psychosis is the central feature of schizophrenia. The key features of psychosis, called positive symptoms, are: Delusions (beliefs that are strongly held and clearly untrue) Hallucinations (perceiving things that are not real) Thought disorder (disorganised thoughts causing abnormal speech and behaviour) Lack of insight is an important feature of psychosis. They lack awareness that the delusions and hallucinations are not based in reality. Key positive symptoms that are typical in schizophrenia include: Positive Sx: - Auditory hallucinations (hearing voices, particularly a voice narrating the patient’s actions) - Somatic passivity (believing that an external entity is controlling their sensations and actions) - Thought alienation: insertion; withdrawal; broadcasting. - Delusional perceptions- A delusional perception occurs when the patient experiences an ordinary and unremarkable perception (e.g., a cat crossing the road) that triggers a sudden, often self-related delusion (e.g., “and I knew I would be meeting the aliens on behalf of humanity”). - somatic hallucination Not first rank symptoms but still positive symptoms: - Persecutory delusions (a false belief that a person or group is going to harm them) - Ideas of reference (a false belief that unconnected events or details in the world directly relate to them) Negative symptoms refer to a reduction or loss of normal functioning or capacity. Negative symptoms of schizophrenia include the four As: Affective flattening (minimal emotional reaction to emotive subjects or events) Alogia (“poverty of speech” – reduced speech) Anhedonia (lack of interest in activities) Avolition (lack of motivation in working towards goals or completing tasks) A reduced level of functioning is an important feature. This involves reduced or impaired: Social engagement Productivity and achievement at work or school Self-care

Answer 31

These symptoms are viewed as a strong indicator of the disorder and are used to help differentiate schizophrenia from other mental health conditions. The First-Rank Symptoms are as follows: 1. Auditory Hallucinations: a. hearing thoughts spoken aloud b. hearing voices referring to himself/herself made in the third person - "He" not "I" c. a running commentary 2. Thought withdrawal, insertion and interruption - A person's thoughts are under control of an outside agency 3. Thought broadcasting - the false belief that one's thoughts are being broadcasted or transmitted to others, so that other people can hear or know what the individual is thinking. 4. Somatic hallucination - A hallucination involving the perception of a physical experience with the body. E.g. things crawling over me 5. Delusional perception - A true perception, to which a person attributes a false meaning. E.g. traffic light changing means aliens are invading 6. Passivity - Feelings or actions experienced as made or influenced by external agent - Where there is certainty that an action of the person or a feeling is caused not by themselves but by some others or other force. ## Footnote https://pmc.ncbi.nlm.nih.gov/articles/PMC7079421/#CD010653-tbl-0002

Answer 32

Schizophrenia may involve different patterns of symptoms. When observed over time (e.g., over at least one year), the active-phase symptoms of psychosis may be: Continuous Episodic (relapsing and remitting) A single episode only

Answer 33

1. Prodromal symptoms for at least 6 months 2. Active phase symptoms (delusions, hallucinations, and thought disorder) present for at least one month (or less if treatment is successful). Me - Investigations - include urine toxicolgy, ECG for antipsychotic medications....

Answer 34

Treatment involves: **Antipsychotic medications** **Cognitive behavioural therapy** A specialist psychiatry service will manage patients with schizophrenia: Early intervention in psychosis services are available for the first episodes of psychosis Crisis resolution and home treatment teams provide urgent support for patients in a crisis Acute hospital admission (under the Mental Health Act when required) Community mental health team for ongoing monitoring and management

Answer 35

Typical Antipsychotics: - Mechanism of Action: They work primarily by **inhibiting dopamine receptors, specifically D2 receptors**, in various brain regions, including the **mesolimbic pathway**. - Effect: This dopamine blockade helps reduce positive symptoms (hallucinations and delusions), which are thought to be associated with dopamine dysregulation in the mesolimbic pathway. - Side Effects: These medications are more likely to cause extrapyramidal symptoms (EPS) (e.g., tremors, rigidity) due to strong dopamine antagonism in the nigrostriatal pathway, which is involved in motor control. Atypical Antipsychotics: - Mechanism of Action: Atypical antipsychotics are D2 receptor antagonists, but they bind to D2 receptors less strongly and also affect 5-HT2A serotonin receptors. - They affect dopamine receptors in the mesolimbic pathway (for positive symptoms) and the mesocortical pathway (which plays a role in cognition and emotions), potentially improving negative symptoms (e.g., social withdrawal, emotional blunting).5-HT2A receptor antagonism is believed to reduce negative symptoms and improve cognitive function. - Side Effects: Atypicals have a lower risk of extrapyramidal side effects compared to typical antipsychotics.

Answer 36

Key Monitoring requirements: **- Weight and waist circumference - Blood pressure and pulse rate - ECG** **Bloods: - HbA1c - lipid profile - prolactin** ^^^this came up... Side effects of antipsychotic syndrome include: Weight gain - can be huge! Diabetes Prolonged QT interval - hence the ECG Raised prolactin - galactorea, ammenorrhea, sexual dysfunction... Extrapyramidal symptoms Extrapyramidal side-effects include: Akathisia (psychomotor restlessness, with an inability to stay still) Dystonia (abnormal muscle tone, leading to abnormal postures) Pseudo-parkinsonism (tremor and rigidity, similar to Parkinson’s disease) - this got tested!!! Tardive dyskinesia (abnormal tongue movements, particularly affecting the face)

Answer 37

mnemonic - locked in the clozepine Clozapine is used where other treatments do not control the symptoms. It can only be taken by mouth. Clozapine is very effective but comes with significant adverse effects. Patients taking clozapine have very close monitoring for evidence of complications. Key complications include: Agranulocytosis, with a severely **low neutrophil count** (predisposing to severe infections) Myocarditis or cardiomyopathy, which can be fatal Constipation (rarely to the point of intestinal obstruction) Seizures Excessive salivation Lecture: The agranulocytosis is key, needs ongoing FBC monitoring when initiated on clozipine

Answer 38

Neuroleptic malignant syndrome is a potentially life-threatening complication of antipsychotic treatment. Key features are: 1.Muscle Rigidity 2.Fever/Hyperthermia (raised body temperature) 3.Altered consciousness and delirium 4.Autonomic dysfunction (e.g., fluctuating blood pressure and tachycardia) THE MNEMONICS ARE FOR LITHIUM NOT THIS!!! Key blood test findings are: **Raised creatine kinase -> can cause Rhabdomyelisis** Raised white cell count (leukocytosis) - Me: wierdly the opposite of clozipine agranulocytosis Management involves stopping the causative medications and supportive care (e.g., IV fluids and sedation with benzodiazepines). Severe cases may require treatment with **bromocriptine** (a dopamine agonist) or dantrolene (a muscle relaxant). Note Lecture- has a slower onset and last longer than SS. Raised CK is also unique to NMS. ## Footnote Me - You'd be forgiven for confusing this with serotonin syndrome, similar Sx and management is identicle. LEARN THE BLOOD TEST RESULTS

Answer 39

Diagnostic Criteria: A person must exhibit three or more of the following features during a 12-month period: 1. A strong **desire** or sense of compulsion to drink alcohol. 2. Difficulty in **controlling** drinking: The individual finds it hard to limit or stop drinking, despite attempts to do so. 3. Physical **withdrawal** symptoms: These occur when alcohol use is reduced or stopped, such as tremors, sweating, anxiety, or more severe symptoms like seizures. 4. **Tolerance**: The need to consume increasing amounts of alcohol to achieve the desired effect, or a reduced effect when drinking the same amount. 5. **Neglect** of other activities: A reduction in involvement in social, occupational, or recreational activities due to alcohol use. 6. **Persistent** consumption despite harmful consequences: Continuing to drink alcohol despite being aware of its negative physical or psychological effects (e.g., liver damage, relationship problems, or legal issues).

Answer 40

Alcohol is a depressant. It stimulates GABA receptors, which have a relaxing effect on the brain. It also inhibits glutamate receptors (also known as NMDA receptors), causing a further relaxing effect on the electrical activity of the brain (glutamate is an excitatory neurotransmitter). Long-term alcohol use results in the GABA system becoming down-regulated and the glutamate system becoming up-regulated to balance the effects of alcohol. The patient must continue drinking alcohol, or they will experience unpleasant, uncomfortable and potentially dangerous withdrawal symptoms.

Answer 41

multiple the % alcohol content by the volume in liters! For 750 mls of 12% wine: 0.75 x 12 = 9 units This is a common exam question.

Answer 42

The UK recommendations (Department of Health, updated 2021) on alcohol consumption are: Not more than 14 units per week Spread evenly over 3 or more days Not more than 5 units in a single day Binge drinking is defined as a single session involving: 6 or more units for women 8 or more units for men Pregnant women should avoid alcohol altogether. Alcohol in early pregnancy can lead to: Miscarriage Small for dates Preterm delivery Fetal alcohol syndrome

Answer 43

Alcohol-related liver disease Cirrhosis and its complications (e.g., oesophageal varices, ascites and hepatocellular carcinoma) Alcohol dependence and withdrawal Wernicke-Korsakoff syndrome (WKS) Pancreatitis Alcoholic cardiomyopathy Alcoholic myopathy, with proximal muscle wasting and weakness Increased risk of cardiovascular disease (e.g., stroke or myocardial infarction) Increased risk of cancer, particularly breast, mouth and throat cancer

Answer 44

The official screening test- The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organisation to screen for harmful alcohol use. It involves ten questions with multiple-choice answers and gives a score. A score of 8 or more indicates harmful use. The quick screen - The CAGE questions can be used to screen for harmful alcohol use quickly: C – CUT DOWN? Do you ever think you should cut down? A – ANNOYED? Do you get annoyed at others commenting on your drinking? G – GUILTY? Do you ever feel guilty about drinking? E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?

Answer 45

Blood results that can occur with alcohol excess include: Raised mean corpuscular volume (MCV) Raised alanine transaminase (ALT) and aspartate transferase (AST) AST:ALT ratio above 1.5 particularly suggests alcohol-related liver disease Raised gamma-glutamyl transferase (gamma-GT) (particularly notable with alcohol-related liver disease)

Answer 46

Alcohol dependence involves a risk of withdrawal symptoms. These range from mild and uncomfortable to delirium tremens. Withdrawal symptoms occur at different times after alcohol consumption ceases: 6-12 hours: tremor, sweating, headache, craving and anxiety 12-24 hours: hallucinations 24-48 hours: seizures 24-72 hours: delirium tremens

Answer 47

Delirium tremens is a medical emergency associated with alcohol withdrawal. Untreated, the mortality rate is 35%. Long-term alcohol use results in the GABA system becoming down-regulated and the glutamate system becoming up-regulated to balance the effects of alcohol. When alcohol is removed, the GABA system under-functions and the glutamate system over-functions, causing extreme excitability and excessive adrenergic (adrenaline-related) activity. Delirium tremens presents with: Acute confusion Severe agitation Delusions and hallucinations Tremor Tachycardia Hypertension Hyperthermia Ataxia (difficulties with coordinated movements) Arrhythmias

Answer 48

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) tool can be used to score the patient on their withdrawal symptoms and guide treatment. Chlordiazepoxide (Librium) is a benzodiazepine used to combat the effects of alcohol withdrawal. Diazepam is a less commonly used alternative. It is given orally as a reducing regime titrated to the required dose based on the local alcohol withdrawal protocol (e.g., 10 – 40 mg every 1 – 4 hours). The dose is reduced over 5-7 days. High-dose B vitamins (Pabrinex) are given intramuscularly or intravenously, followed by long-term oral thiamine. This is used to prevent Wernicke-Korsakoff syndrome.

Answer 49

Interventions in the long-term management of alcohol dependence include: - Specialist alcohol service involvement - Alcohol detoxification programme - a reducing regime of **chlordiazepoxide** - Oral **thiamine** to prevent Wernicke-Korsakoff syndrome - Psychological therapy - e.g. **CBT**, **motivational interviewing** (Mild cases) - **Acamprosate, naltrexone or disulfiram** are medications used to help maintain abstinence - Support groups - **AA** - Informing the DVLA (their driving licence will be revoked until an extended period of abstinence)

Answer 50

Alcohol excess leads to thiamine (vitamin B1) deficiency. Thiamine is poorly absorbed in the presence of alcohol. Alcoholics often have poor diets and get many of their calories from alcohol. Thiamine deficiency leads to Wernicke’s encephalopathy and Korsakoff syndrome. The 3 Features of Wernicke’s encephalopathy include: Confusion Nystagmus / Oculomotor disturbances Ataxia (difficulties with coordinated movements) Wernicke’s encephalopathy is a medical emergency with a high mortality rate. Features of Korsakoff syndrome include: Memory impairment (retrograde and anterograde) Behavioural changes Mnemonic - My Beer CAN Korsakoff syndrome is often irreversible and results in patients requiring full-time institutional care. Management: Prevention and treatment involve thiamine supplementation and abstaining from alcohol. REVISION - Delerium tremens is caused by insufficent GABA in alcohol withdrawal and includes tremour, confusion and ataxia, but no nystagmus. WKS shows no tremour and is due to thiamine deficiency in alcohol dependence. GOT THIS WRONG IN THE EXAM FORGOT NYSTAGMUS IS WK NOT DT

Answer 51

Drug addiction involves **the compulsive use of substances, often leading to harmful physical, psychological and social consequences**. There is debate about whether it is a disease or a choice. It is a long-term condition, typically involving relapses after stopping.

Answer 52

Tolerance refers to a loss of effect when taking the same dose. The person may keep increasing the dose to achieve the desired effects. Tolerance occurs with most psychoactive substances over time. Dependence refers to a physiological and psychological need to keep using a drug. Dependence may occur due to: Physiological changes (notable with alcohol, opiates and benzodiazepines) Psychological factors (e.g., cravings and compulsions to use the drug) Withdrawal symptoms occurs due to physiological adaptations to the drug. For example, benzodiazepines work by stimulating GABA receptors. GABA is an inhibitory neurotransmitter that has a relaxing effect. Long-term use of benzodiazepines results in the body reducing its natural production of GABA to balance the stimulating effects of the drug. When the drug is withdrawn, there is under-activity of the GABA system, causing withdrawal symptoms, such as anxiety, irritability, tremors, insomnia and even seizures.

Answer 53

The brain has a reward pathway called the mesolimbic pathway. The primary neurotransmitter involved in this pathway is dopamine. The key structures involved in this pathway are the ventral tegmental area, nucleus accumbens, amygdala, and prefrontal cortex. At a very basic level, activation of this pathway by a behaviour provides pleasure and reinforces that behaviour. Addictive substances or behaviours release dopamine within the mesolimbic pathway, providing a pleasurable reward. Repeated exposure to this stimulus reduces the number and sensitivity of the dopamine receptors in this pathway, requiring an increasingly strong stimulus (e.g., a higher dose or frequency) to produce the same reward. The response to everyday activities reduces (everyday life becomes less rewarding). As a result, the person increasingly seeks out the substance or behaviour to stimulate the reward pathway. Cues for the substance or behaviour are embedded into the amygdala. People, events, places or objects can act as cues, triggering cravings. Stress is a common trigger, prompting the substance or behaviour as a coping mechanism. Additionally, changes in the prefrontal cortex occur, leading to impaired function. The prefrontal cortex is responsible for executive functions such as decision-making, assessing risk, and controlling impulses.

Answer 54

**Opioids**: Heroin Morphine Oxycodone Codeine Stimulates opioid receptors **Stimulants** Block monoamine reuptake - dopamine, serotonin and noradrenaline Cociane MDMA Meth **Depressants** Alcohol Benzodiazepines Stimulates gamma-aminobutyric acid (GABA) receptors **Hallucinogens** LSD Psilocybin Stimulate serotonin receptors, particularly 5-HT2A receptors **Cannabinoids** Cannabis Stimulates cannabinoid receptors (CB1 and CB2) **Anticonvulsants** Pregabalin Gabapentin Blocks voltage-gated calcium channels in the presynaptic membrane, reducing the release of excretory neurotransmitters **Nicotine** Cigarettes Vapes Stimulates nicotinic acetylcholine receptors

Answer 55

Management requires a multidisciplinary approach. Specialist drug and alcohol services are available, usually with a self-referral option. Management involves: Detoxification (may be coordinated at home or as an inpatient) Medication to help maintain abstinence Psychological and behavioural therapies - **motivational interviewing is 1st line,** cognitive behavioural therapy Ongoing support (e.g., a recovery coordinator and support groups) Medication used for opioid dependence include: Methadone (binds to opioid receptors) Buprenorphine (binds to opioid receptors) Naltrexone (helps prevent relapse) Medication used for nicotine dependence (smoking) include: Nicotine replacement therapy (e.g., patches, gum or lozenges) Bupropion Varenicline

Answer 56

ASEPTIC mnemonic A mental state examination is used to assess patients presenting with mental health symptoms and disorders. It is equivalent to performing an abdominal examination for a patient with abdominal pain. It offers a structure for assessing and documenting the essential features of a mental health presentation. The examination involves observing, assessing and commenting on: Appearance and behaviour Speech Mood and affect Thought Perception Cognition Insight Judgement A risk assessment typically follows a mental state examination, giving an estimate of the risk of self-harm, suicide and harm to others. The features listed below describe typical exam findings in patients with depression, mania and schizophrenia. In reality, patients vary tremendously. For example, depressed patients may appear and sound normal despite having a very low mood and suicidal intentions.

Answer 57

Appearance: Clothing Hygiene Weight Behaviour: Eye contact Rapport Body Language Depressed patients: - signs of poor self-care, with poor hygiene and old clothes. - There may be self-harm scars. - They may have weight loss or weight gain. - They may have slow movements and speech (psychomotor retardation) ; reduced eye contact; downward gaze; stooped posture. - they may be fidgety and restless (psychomotor agitation). - They may be tearful during the consultation Manic patients: - May be dressed in bright colours, extravagant outfits, or inappropriate outfits. Alternatively, they may be dressed chaotically and appear disheveled. - Their behaviour is hyperactive, energetic, talkative, and overly familiar. They may display disinhibition and sexually inappropriate behaviour. - Eye contact may be intense. - They may have psychomotor agitation and appear fidgety and restless. Patients with schizophrenia: - may be unkempt, dressed inappropriately for the environment or show signs of self-neglect. - They may behave agitated, suspicious or aggressive. Alternatively, they may be withdrawn, quiet and blank. - Catatonia may be present, with the patient holding unusual postures, performing odd actions, repeating sounds or words, or remaining blank and unresponsive. Extrapyramidal side-effects from antipsychotic drugs may be observed, including: - Akathisia (psychomotor restlessness, with an inability to stay still) - Dystonia (abnormal muscle tone, leading to abnormal postures) - Pseudo-parkinsonism (tremor and rigidity, similar to Parkinson’s disease) - Tardive dyskinesia (abnormal movements, particularly affecting the face)

Answer 58

Representation of thinking: - tempo - poverty of thought, flight of ideas continuity - clang associations, puns rhythms, perseverations Depressed patients may have slow, quiet, soft and monotone speech. They may have “**poverty of speech**” (alogia). Manic patients have characteristically **pressured speech**, which is fast, unrelenting, and impossible to interrupt. It is typically loud and confident. Patients with schizophrenia may have **poverty of speech** (alogia) or **poverty of content** (speech without meaning). Due to thought disorder, their speech may be incoherent and impossible to understand. They may use invented words (**neologisms**). Thought blocking can cause sudden interruptions to the flow of thoughts and speech. Word salad refers to when speech contains a completely random jumble of words and phrases with no meaning.

Answer 59

Euthymia refers to a normal and neutral mood, not low or elevated. Depressed patients have a low mood. They may describe their mood using many terms, such as sad, depressed, numb, flat, hopeless, empty, miserable or terrible. **Blunted affect** refers to a reduced emotional range (the ability to experience positive and negative emotions). Manic patients have an **elevated mood**. This may be described as euphoric, elated or excited. They can also be irritable and have a labile mood (their mood quickly flips from elevated to angry or depressed). Patients with schizophrenia may display **affective flattening** (reduced emotional reactions), anhedonia (lack of interest in activities) and avolition (lack of motivation). Their **mood may seem odd or incongruent** (e.g., appearing happy when describing upsetting events).

Answer 60

Depressed patients have **negative thoughts**, such as thoughts of guilt, hopelessness, worthlessness, self-harm and suicide, which they may ruminate on. They may have poverty of ideas, with reduced production of thoughts. Manic patients often have thoughts of increased self-worth, self-confidence, optimism and grandiose plans. The typical feature is **flight of ideas**, which refers to rapidly flowing thoughts that jump quickly from one idea to another. There is generally some understandable connection to the flow of ideas. **Grandiose delusions** (e.g., that they have special powers or special importance) may be present. Patients with schizophrenia may have **delusions** (beliefs that are strongly held and clearly untrue) and **formal thought disorde**r (disorganised thoughts causing abnormal speech and behaviour). This makes the things they say difficult or impossible to follow and understand. Specific examples include: - Somatic passivity (believing that an external entity is controlling their sensations and actions) - Thought insertion or thought withdrawal (believing that an external entity is inserting or removing their thoughts) - Thought broadcasting (believing that others are overhearing their thoughts) - Persecutory delusions (a false belief that a person or group is going to harm them) - Ideas of reference (a false belief that unconnected events or details in the world directly relate to them) - Preoccupations (being focused and absorbed with one thought without being able to move to the next) - Loosening of associations (no logical association linking one thought to the next) - Knight’s move thinking (jumping from one thought to another without a logical association or flow) - Tangentiality (goes off on a tangent from the original topic without returning to that topic)

Answer 61

- Memory - attention and concentration, - orientation to person, place and time Depressed patients often experience cognitive symptoms like poor concentration, slow thoughts, impaired memory and difficulty learning new things. Manic patients do not typically have significant cognitive impairment, although their ideas are of lower quality and often disorganised. Cognitive impairment may be difficult to assess accurately, as the patient is easily distracted, excitable, and irritable. Patients with schizophrenia often have some degree of cognitive impairment (e.g., difficulty with attention and memory), although it may be difficult to assess formally. They are usually oriented to person, place and time unless their delusions affect these details. Significant cognitive impairment or disorientation may suggest an alternative diagnosis (e.g., delirium).

Answer 62

Hallucinations (hearing or seeing things (perception) without an external stimulus) may be found in: Psychotic depression Mania with psychosis Schizophrenia (particularly a voice narrating the person’s actions) Usually third person auditory hallucinations are seen in psychosis. Note - hypnogogic and hypnopompic hallucinations are seen when falling asleep and waking up and are experienced by normal people. A delusional perception (seen in schizophrenia and psychosis) occurs when the patient experiences an ordinary and unremarkable perception (e.g., a cat crossing the road) that triggers a sudden, often self-related delusion (e.g., “and I knew I would be meeting the aliens on behalf of humanity”). Me - perception is normal in depression , but some patients may report pseudo-hallucinations or misinterpretations (e.g., "hearing their own critical thoughts loudly") - located in the head not heard outside the head

Answer 63

Insight and Judgement Depressed patients generally have insight into their low mood. They may not realise the severity of their depression. Sometimes, patients may present with other symptoms (e.g., worsening physical symptoms or memory impairment) without realising they are caused by depression. Judgment may be impaired, for example, in a hopeless patient who sees no solution to their problems and no chance of improvement. Manic patients typically lack insight and have poor judgement. Their poor judgement often leads to issues such as gambling, sexually inappropriate behaviour, excessive spending, aggression and criminal acts. Patients with schizophrenia typically lack insight and have impaired judgment.

Answer 64

I GOT THIS WRONG Section 2 - Admission for assessment Section 2 involves compulsory admission for assessment following a Mental Health Act assessment, with a maximum period of 28 days. It cannot be renewed. It ends in either discharge or further detention under Section 3. Section 3 - Admission for treatment Section 3 involves compulsory admission for treatment. The maximum period is six months, after which the Responsible Clinician can arrange to renew it for further treatment. Detention under Section 3 requires a Mental Health Act assessment. Patients that are well-known to mental health services may be detained under Section 3 straight from the community. Alternatively, patients may be detained under Section 3 following assessment under Section 2. Section 4 - Emergnecy Admission Section 4 is used to detain patients for up to 72 hours in urgent scenarios where other procedures cannot be arranged in time. It requires an AMHP and one doctor. It is followed by a Mental Health Act assessment. Section 5(2) - Doctor's Holding Power (Already informally admitted) Section 5(2) is used in an emergency to detain patients who are already in hospital voluntarily. It lasts up to 72 hours and requires only one doctor. It is followed by a Mental Health Act assessment. Section 5(4) - Nurse's Holding Power Section 5(4) is used in an emergency to detain patients who are already in hospital voluntarily - me: admitted for a mental health problem already. It lasts up to 6 hours and requires only one nurse. It is followed by a Mental Health Act assessment. Section 136 - Police Power to detain Section 136 is used by the police to remove someone that appears to have a mental health disorder from a public place and take them to a place of safety where they can be assessed. It lasts up to 24 hours. It is followed by a Mental Health Act assessment. Mental health hospitals often have 136 suites that act as a place of safety and are used for assessment.

Answer 65

A Mental Health Act assessment involves a detailed evaluation to determine whether to detain someone under the Mental Health Act. The Approved Mental Health Professional (AMHP) is the primary person making the application and organising the admission. The Nearest Relative can also make the application. The decision needs to be recommended by two registered medical practitioners (doctors): A Section 12 doctor Another doctor (e.g., their GP) A Mental Health Act assessment can result in compulsory admission under Section 2 or Section 3.

Answer 66

The Mental Health Act (1983) (updated in 2007) provides a legal framework for keeping patients in hospital against their wish for assessment and treatment of a mental health disorder. This is called being detained or sectioned under the Mental Health Act. When a patient with capacity agrees to be admitted to hospital voluntarily, this is called a voluntary or informal admission. An informal admission does not involve detention under the Mental Health Act. Section 131 of the MHA explains that patients can be admitted without involving the MHA.

Answer 67

Autistic spectrum disorder (ASD) includes a range of impairments in social interaction, communication and behaviour. On one end of the autistic spectrum, patients have normal intelligence and the ability to function in everyday life but display difficulties with reading emotions and responding to others. This was previously known as Asperger’s disorder. On the other end, patients can be severely affected and unable to function in typical environments. Features The features of ASD vary significantly between individuals along the spectrum. They can be categorised as deficits in social interaction, communication and behaviour. Features are usually observable before the age of 3 years. This is shortened- expl on Z2F if these arent clear Deficits in social interaction include, difficulty/delayed: - eye contact - smiling - physical contact - non-verbal cues - establishing frienships - sharing attention Deficits in communication include: - language development - non-verbal communication - imaginative behavoir - repetitive phrases Deficits in behaviour include: - interest in objects > people - repeative movements - hand flap/rocking (stiming) - depp interests - anxiety outside routine - restricted food preferences Diagnosis usually involves assessment by psychiatrists and clinical psychologists. It involves a detailed evaluation of the patient’s current and historical behaviour and communication. Management Patients with mild impairments may be highly functioning and not require any formal support. A multidisciplinary team can help support patients and carers (e.g., parents) with greater impairments. For example: - specialist education - psychosocial interventions - techniques to expand communication, play and social routines - speech therapy **NICE recomends against using any drugs for the management of autism**, including the use of antipsychotics for challanging behavoir. However, patients with symptoms of depression and/or anxiety may benefit from behavioural and pharmacological intervention (e.g. SSRIs). In addition, children with sleep difficulties which may benefit from a trial of melatonin if behavioural management/sleep hygiene proved to be unsuccessful.

Answer 68

A state of arrested or incomplete development of the mind, characterised by impaired skills during the developmental period and skills that contribute to the overall level of intelligence. 3 criteria: - IQ below 70 - onset from birth or early childhood - functional impairment - e.g. social handicap, ADLs There are different ranks from mild to profound based on IQ testing. Can have autism and a LD but they are seperate, autism is about the social and behavoirs from above, LD is about IQ. Common physical disorders include motor disabilities (e.g. ataxia, spasticity), epilepsy, impaired hearing and/or vision and incontinence (faecal and urinary). Down’s syndrome: A genetic disorder (trisomy 21) characterized by LD, dysmorphic facial features and multiple structural abnormalities. It is the commonest cause of LD. Fragile X syndrome is the second most commmon cause of learning disability. It is a X-linked disorder (females get it but less severe) that usually presents with a delay in speech and language development. Other features are: Intellectual disability Long, narrow face Large ears ADHD seizures autism large testicles after puberty Prada willi - developmental delay, constant hunger that leads obesity, poor muscle tone hypogonadism, behavoiral problems Cri du chat: high pitched cat-like cry, small head and learning disability.

Answer 69

The aim of psychotherapy is to support patients in changing the way that that they interact with and percieve the world, come to terms with past stressors and to cope more effectively with current and future stressors. Most common forms are cognitive behavoiral therapy and psychodynamic psychotherapy. CBT - Disorders caused not by life events but by the way the patients views them. The aim of CBT is initially to help individuals to identify and challenge their automatic negative thoughts and then to modify any abnormal underlying core beliefs. The latter is important in reducing risk of relapse. **Used in everything ** Psychodynamic therapies - Rationale that childhood experiences and past unresolved conflicts significantly influence an individuals current situation. Aim - the unconcious is explored using free association (whatever comes to their mind) and the therapist interprets these statements. As the conflicts are epxlored the patient develops insight into how to change their behavoir. Mainly used in depression and boderline PD. Psychoeducation - delivery of information to help people understand and cope with their mental illness. **Used for everything!** Councelling - less complicated, talking through issues with a patient and allowing them find their own solutions to problems, while being supported to do so and being guided by appropriate advice. Used for depression and adverse life events - loss, grief. Eye movement desensitization and reprocessesing - for PTSD. Helps patient access and process their grief (emotionally resolve) DBT - used for boderline personality disorder. It is simialr to CBT and aims to provide the individual with alternative coping stragies (rather than deliberate self harm) when gaced with emotional instability. Exposure and Response prevention - used for OCD

Answer 70

Pyschosis is defined as a mental state with distorted reality. It typically presents with 1. delusions - false beliefs despite evidence to the contrary and against the normal cultural belief system 2. hallucinations - perception in the absense of an external stimulus 3. thought disorder- impaired ability to form thoughts from logically connected ideas. Schizophrenia - most common, characterised by hallucinations, delusions and thought disorders, in the absence of mood disorder, organic disease or drug induced disorder. Shizoaffective disorder - symptoms of schizophrenia in the same episode as mood disorder (depression or mania) Acute and transient psychotic disorders - similar to schizoprenia but lasting <1 month Persistant delusional disorder - the development of a single or set of delusions for a period of at least 3 months and other areas of thinking are well preserved. De;usions are often persecutory, grandiose or hypochondriacal in nature. Rx with antipsychotics - think of the old jamacan lady x Induced delusional disorder - a person suffering from pyshcotic episode forms a delusional belief and imposes it on another person mood disorders with psychosis - psychosis occouring secondary to depression or mania. Puerperal pyshcosis - 2 weeks after childbirth

Answer 71

Fixed false beliefs, which are firmly held despite evidence to the contrary and go against the individual’s normal social and cultural belief system Grandiose - special powers, choosen by god persecutory - other people are conspiring against them reference - objects or events having a special significance to them personally - TV or radio is personal to them Guilt- done something shameful hypocondrical - belief of having an illness despite evidence to the contrary othello syndrome/morbid jealous - convinced that their partner is unfaithful despite lack of evidence. De Clérambault’s syndrome - someone is in love with them cotards- belief they are actively dying or a part of them is dead

Answer 72

Obsessional thoughts: Distressing thoughts that enter the mind despite the patient’s effort to resist them. This is a feature of obsessive–compulsive disorder. ‘Do certain ideas or images keep entering your mind, even when you try to keep them out?’ Preoccupations/overvalued ideas: Strongly held beliefs which are particularly important in four disorders: depressive, anxiety, eating and sexual. Preoccupations differ from obsessions in that they can be put out of the mind with effort, whereas obsessions repeatedly enter the patient’s mind despite their attempted resistance.

Answer 73

Mood – predominant subjective internal state; e.g. depressed (sad or numb), elated (euphoric or ecstatic), anxious, angry Affect - immediately expressed , observable; e.g. reactive (normal) flat, blunt ,incongruous

Answer 74

Hallucination is a perception in the absence of an external stimulus. It is a common feature of psychosis. Hallucinations may be visual, auditory, olfactory, gustatory or somatic. Auditory hallucinations are the most common in mental health disorders. Visual are more common in organic brain disease and substance missues. Pseudohallucination: Would include the experience of hearing voices inside your head. They are not true external hallucinations.

Answer 75

‘Do you ever feel that your mood or actions are being controlled by someone or something else?’ One of the first rank sym[ptoms, alongisde third person auditory hallucinations, persecutory delusional perception (true perception attributed with false meaning), thought interference (insertion, withdrawal or broadcasting).

Answer 76

Thought alienation : insertion, withdrawal, broadcasting, blocking

Answer 77

Mild cognitive impairment (MCI) invovles a deficint in cognition (language, reasoning, visual perception) and memory in individuals who maintain the ability to independently perform most activities of daily living - it is milder than dementia (support not required). Basically it is congitive impairmenet but with preserved function. MCI can develop for multiple reasons, and individuals living with MCI may go on to develop dementia (I think about half at 5 years); others will not. For neurodegenerative diseases, MCI can be an early stage of the disease continuum including for Alzheimer's if the hallmark changes in the brain are present. There are currently no medicines that are licensed to treat MCI or which reduce the chances of developing dementia.

Answer 78

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopment disorder featuring the core features of: - difficulty maintaining attention - excessive energy and activity - impulsivity. It is more than twice as common in males. It is thought to result from a combination of factors: Genetic (there is significant heritability) Pregnancy-related factors (e.g., maternal smoking, premature birth and low birth weight) Environmental factors **The symptoms start in childhood and should be consistent across settings.** When a person displays symptoms only at work or school but is calm and focused at home, this is suggestive of an environmental effect rather than an underlying diagnosis. All the features of ADHD can be part of a normal spectrum of behaviour. When many of these features are present, and they are adversely affecting the person, ADHD may be considered. Symptoms include: Short attention span Easily distracted Quickly moving from one activity to another Quickly losing interest in a task Inability to persist with and complete tasks Constantly moving or fidgeting Impulsive behaviour Disruptive behaviour Difficulty managing time

Answer 79

The Adult ADHD Self-Report Scale (ASRS) can be used as a screening test to support a referral. A specialist will make the diagnosis after a detailed assessment, including a history dating back to childhood. Management: **Self-management strategies** for adults to help manage symptoms include organisation techniques, a healthy diet, exercise, and a sleep routine. Reasonable adjustments to the workplace may be helpful. Managing strategies for parents - structured routines, physical activity, boundries Medication is an option after conservative management has failed, or in severe cases. This should be coordinated by a specialist. The medication are central nervous system stimulants. Examples are: **Methylphenidate Lisdexamfetamine Dexamfetamine Atomoxetine** Monitoring requirements whilst taking medications include heart rate, blood pressure, weight and mood changes.

Answer 80

Eating disorders are psychiatric conditions involving an unhealthy and distorted obsession with body image and food. The main types are: Anorexia nervosa Bulimia nervosa Binge eating disorder Eating disorders are more common in females and young people.

Answer 81

With anorexia nervosa, the person feels they are overweight despite evidence of normal or low body weight. It involves obsessively restricting calorie intake to lose weight. Often, the person exercises excessively and may use diet pills or laxatives to limit the absorption of food. Features of anorexia nervosa include: Weight loss (e.g., 15% below expected or BMI less than 17.5) Amenorrhoea (absent periods) Lanugo hair (fine, soft hair across most of the body) Hypotension (low blood pressure) Hypothermia (low body temperature) Mood changes, including anxiety and depression Cardiac complications - below Amenorrhea (absence of periods) occurs due to disruption of the hypothalamic-pituitary-gonadal axis. There is a lack of gonadotrophins (LH and FSH) from the pituitary, leading to reduced activity of the ovaries (hypogonadism). Cardiac complications include arrhythmia, cardiac atrophy and sudden cardiac death. Low bone mineral density is another complication. Anorexia nervosa has the highest mortality of any psychiatric condition.

Answer 82

Possible blood test findings in restrictive eating disorders include: Anaemia (low haemoglobin) Leucopenia (low white cell count) Thrombocytopenia (low platelets) Hypokalaemia (low potassium – due to vomiting or excessive laxatives) Reduced bone marrow activity causes normocytic normochromic anaemia, leucopenia (with low neutrophils and low lymphocytes) and thrombocytopenia.

Answer 83

Binge eating disorder is characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress. The person typically feels a loss of control. It is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight. Binges may involve: A planned binge involving “binge” foods Eating very quickly Unrelated to feelings of hunger Becoming uncomfortably full Eating in a dazed state

Answer 84

Unlike anorexia, people with bulimia often have a normal body weight. Their body weight tends to fluctuate. The condition involves binge eating, followed by purging by inducing vomiting or taking laxatives to prevent the calories from being absorbed. Features of bulimia nervosa include: Erosion of teeth Swollen salivary glands Mouth ulcers Gastro-oesophageal reflux Calluses on the knuckles where they have been scraped across the teeth (called Russell’s sign) Alkalosis can occur after repeated vomiting of hydrochloric acid from the stomach. TOM TIP: Unique examination findings in bulimia make it a popular spot diagnosis in exams. A teenage girl with an average body weight that presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas may indicate bulimia. The presenting complaint may be abdominal pain or reflux.

Answer 85

Eating disorders can be challenging to manage and will involve specialist services and a multidisciplinary team. Particularly with anorexia nervosa, the patient may not recognise the need or be motivated to treat the condition. Management is centred around changing behaviour and addressing environmental factors: Self-help resources Psychological therapies (e.g., cognitive behavioural therapy) Addressing other psychosocial factors, such as depression, anxiety and relationships Severe cases may require compulsory admission for observed refeeding and monitoring for refeeding syndrome. Consider admission: - Unsafe BMI or rate of weight loss (>1kg per week) - hypothermia - bradycardia/hypotension - risk of refeeding syndrome (Fasting 5+ days, laxative use, BMI below 16) - concurrent illness - risk of acute mental health crisis

Answer 86

Refeeding syndrome occurs when someone with an extended severe nutritional deficit resumes eating. The lower the BMI and the longer the period of malnutrition, the higher the risk. It should be suspected in anyone with minimal nutritional intake for more than five days. Mechanism: During prolonged starvation, intracellular potassium, phosphate and magnesium are depleted. These electrolytes move from inside the cells to the blood to maintain normal serum levels in the absence of dietary intake. Cell metabolism reduces to conserve energy, resulting in a loss of intracellular electrolytes. For example, the action of the sodium/potassium ATP-pump slows, which normally pumps potassium into the cell and sodium out of the cell. During refeeding, various mechanisms shift magnesium, potassium and phosphate out of the blood and sodium into the blood. Carbohydrate intake causes an increase in insulin, which drives glucose, potassium and phosphate into cells. The sodium/potassium ATP-pump actively pumps potassium into the cells and sodium out of the cells. Insulin causes extra sodium reabsorption in the kidneys. The overall effects are: Hypomagnesaemia (low serum magnesium) Hypokalaemia (low serum potassium) Hypophosphataemia (low serum phosphate) Fluid overload (due to water following the extra sodium into the extracellular space) There is a risk of arrhythmia and heart failure. Rarely, it can be fatal. Management will be according to the local protocol under specialist supervision: Slowly reintroducing food with limited calories Magnesium, potassium, phosphate and glucose monitoring Fluid balance monitoring ECG monitoring in severe cases Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine

Answer 87

Dementia is a condition that causes progressive and irreversible impairment in memory, cognition, personality and communication. It is particularly associated with older age. Early-onset dementia refers to when the symptoms start before aged 65. Early symptoms of dementia include: Forgetting events Forgetting names Difficult remembering words Repeatedly asking the same questions Impaired decision making Reduced flexibility As the condition progresses, memory and cognitive impairment worsen. Eventually, patients lose the ability to complete self-care tasks such as cooking, cleaning, and dressing themselves. Features of advanced dementia include: Inability to speak or understand speech (aphasia) Swallowing difficulties (dysphagia), which can lead to aspiration and pneumonia Appetite and weight loss Incontinence Behavioural and psychological symptoms of dementia (BPSD) include (worsen with time, later Sx): Depression Anxiety Agitation Aggression Disinhibition (e.g., sexually inappropriate behaviour) Hallucinations Delusions Sleep disturbance

Answer 88

Alzheimers dementia is the most common type of dementia. The underlying pathophysiology involves brain atrophy, amyloid plaques, reduced cholinergic activity and neuroinflammation. Vascular dementia is the second most common type. It is caused by vascular damage and impaired blood supply to the brain. Risk factors are the same as other cardiovascular diseases (e.g., hypertension, diabetes and smoking). Dementia with Lewy bodies is a type of dementia associated with features of Parkinsonism. It causes a progressive cognitive decline. There are associated symptoms of **visual hallucinations**, delusions, REM sleep disorders and fluctuating consciousness. LEARN THESE SPECIFIC 4 THINGS Frontotemporal dementia is a rarer type that notably affects people at a younger age (starting aged 40-60). It mainly affects the frontal and temporal lobes. The initial presentation typically involves abnormalities in behaviour, speech and language. It can be familial (inherited). ME- Other cognitive functions (such as memory and perception) may be relatively preserved. LEARN THAT IT AFFECTS BEHAVOIR MORE THAN COGNITIVE PERFORMANCE - APATHY, DISINHIBITION...

Answer 89

Many conditions can cause cognitive impairment, memory impairment or personality changes. Medications with an anticholinergic effect, particularly: Anticholinergic urological drugs (e.g., oxybutynin, solifenacin and tolterodine) Antihistamines (e.g., chlorphenamine and promethazine) Tricyclic antidepressants (e.g., amitriptyline) Psychiatric conditions include: Depression Psychosis Delirium (e.g., secondary to infection) Neurological conditions include: Brain tumours (particularly affecting the frontal lobes) Parkinson’s disease Huntington’s disease Progressive supranuclear palsy Endocrine conditions include: Hypothyroidism Adrenal insufficiency Cushing’s syndrome Hyperparathyroidism (causing hypercalcaemia) Nutritional deficiencies include: Vitamin B12 deficiency Thiamine deficiency (causing Wernicke-Korsakoff syndrome)

Answer 90

Various lifestyle factors have been shown to significantly reduce the risk of developing dementia: Exercise Mental stimulation (e.g., a more mentally challenging job) Maintaining a healthy weight (obesity increases the risk) Blood pressure control (hypertension increases the risk) Blood glucose control (diabetes increase the risk)

Answer 91

**Initial blood tests**, required to exclude a physical cause before referring to the memory clinic, include: Full blood count Urea and electrolytes Liver function tests Inflammatory markers (e.g., CRP and ESR) Thyroid profile Calcium HbA1c B12 and folate Also Urinalysis and CXR for lung cancer **Actual investigations: - The Addenbrooke’s Cognitive Examination-III (ACE-III) is a detailed and comprehensive assessment tool for memory impairment, typically used by specialist memory services. ** DONT NEED TO KNOW THIS -Five domains are tested: Attention Memory Language Visuospatial function Verbal fluency It is scored out of 100 points. Answering perfectly scores 100. A score of 88 or less is typically considered to indicate possible dementia. Lower scores indicate more severe impairment. Me - CT head can be used for early onset or where a structural pathology is suspected (it often shows hypocampal atrophy). MRI is better for vascular

Answer 92

Alzheimer’s disease has drug options to help improve symptoms: - FIRST LINE - Acetylcholinesterase inhibitors (e.g., **donepezil**, **rivastigmine** or **galantamine**) - SEVERE ALZHEIMER'S - **Memantine**, which works by blocking N-methyl-D-aspartic acid (NMDA) receptors BPSD - first treat cause, modifiy environmental factors, music therapy... Medication options for managing BPSD are only used where necessary and cause significant side effects. Options include: **SSRI antidepressants for depressive symptoms** Antipsychotic drugs (typically **risperidone** first-line) - behavoiral symptoms Benzodiazepines (only for crisis management) ME Non-pharmalogical - Cognitive stimulation therapy - Group reminiscence therapy - Cognitive rehabilitation or occupational therapy to support functional ability Vascular demmentia- target the cardiovascular risk factors.

Answer 93

I made this based on nice cks - effect on daily function - current lifestyle - diet, sleep, alcohol and substance use - past history of self harm or suicde - co-exsisting mental health problems - including psychotic symptoms - supportive relationships - Forensic history - Risk assessmenet: Risk of harm to self, others

Answer 94

First-Line Management: - Always attempt non-pharmacological de-escalation first. If this fails, pharmacological intervention may be needed. Preferred Pharmacological Options: - NICE recommends using oral medication first where possible: Lorazepam (oral) is recommended If oral medication is not feasible or effective, consider IM medication: - Lorazepam IM or haloperidol IM combined with promethazine IM

Answer 95

In the exam An excessive response to a significant life stressor or change. It is characterized by emotional or behavioral symptoms that are disproportionate to the stressor and cause significant distress or impairment in daily functioning. It persists for no longer than 6 months after the stressor ends. ME: Management is with self help, psychotherapy (CBT) or councelling) and short term medication if severe (SSRI or anxylotics) Differentials: It resolves quicker than PTSD, and is ofetn about a life stressors such as divorce, job loss, death whereas PTSD is about a near-death experience/violence. It is similar to Acute stress reaction (baby PTSD - 1 month max). Acute Stress Reaction occurs after a traumatic event, causing intense psychological symptoms like flashbacks, nightmares, and hyperarousal. If the symptoms persist for longer than 4 weeks, the diagnosis may change to Post-Traumatic Stress Disorder (PTSD).

Answer 96

Depression masking ask demmentia- the most common differential diagnosis Pseudodementia refers to cognitive impairment caused by underlying depression, often mimicking dementia. It is not a true neurodegenerative process and is reversible with appropriate treatment. Key Features: 1. Cognitive Symptoms: * Memory issues (especially short-term memory). * Difficulty concentrating and thinking clearly. * Often responds with “I don’t know” to questions during cognitive tests. 3. 2. Associated Features: * Symptoms of depression: low mood, fatigue, sleep disturbances, loss of interest. * Aware of memory problems (insight is preserved). * Social withdrawal and poor motivation. 3. Functional Abilities: * Daily living activities (e.g., managing finances) remain relatively intact compared to dementia. Differentiation from Dementia: Reversibility: Improves with treatment of depression. Effort: Patients may appear uninterested in testing, while true dementia patients often try hard despite mistakes. Insight: Present in pseudodementia but lacking in many dementias. Management: 1. Psychiatric Evaluation: To confirm depression as the underlying cause - PHQ-9 2. Treatment: * Antidepressants (e.g., SSRIs). * Psychotherapy (e.g., cognitive-behavioral therapy). * Address social isolation and stressors. With appropriate management, cognitive function in pseudodementia can fully recover.

Answer 97

Z-drugs bind to the benzodiazepine site of the GABA-A receptor complex. Me: GABA receptors allow more chloride to enter the neuroone reducing the neuronal excitability (hyperpolarised) -inhibitory - Lower risk of dependence compared to benzodiazepines - but still a risk - May cause side effects like dizziness, headache, or sleepwalking.

Psychiatry Flashcards

(122 cards)