Psychiatry Flashcards
(262 cards)
1
Q
What are the 3 core symptoms of depression
A
Low/depressed mood
Anhedonia - loss of interest/pressure
Anergia
2
Q
What are other typical symptoms of depression
A
- Poor Appetite
- Disrupted Sleep
- Psychomotor Retardation (sluggish) or agitation
- Decreased Libido
- Reduced ability to concentrate
- Feeling of worthlessness and inappropriate guilt
- Recurrent suicidal thoughts/attempts
3
Q
What is the Diagnosis of Depression
A
- 2 core symptoms (Severe = 3) + 2 or more typical symptoms
- Symptoms present throughout the day
- For every/nearly every day
- For > 2 weeks
- Must represent change from normal personality
- Without drugs/alcohol, medical disorders or bereavement
4
Q
What are the causes of depression
A
Biological - Hereditary, Familial, Low monoamine (Low serotonin, Low dopamine, Low noradrenaline)
Psychological - Personality trait, Low self esteem
Social - Disruption due to life events, stress and social isolation
5
Q
What may be symptoms of severe depression
A
Cotard Syndrome - Nihilistic Delusions
Auditory and Visual Haluucinations
Delusions
6
Q
What are differentials for depression
A
Psychotic Disorders Dysthymia Substance Misuse Dementia Sleep and Neurological Disorders Physical Illness Medication SE e.g Beta Blockers
7
Q
What conservative management can be done for depression
A
Exercise Engaging in productive activity Socialising Improving Sleep - good sleep hygiene Relaxation Techniques
8
Q
How is mild depression managed
A
Low intensity psychological interventions - sleep hygiene, anxiety management, guided self help (books, websites and apps), computerised CBT
9
Q
How is moderate depression managed
A
Combination of Antidepressant + high intensity psychological intervention (CBT), group therapy, family therapy
10
Q
How is severe depression managed
A
This includes psychotic depression, increased risk of suicide and atypical depression - THINK: S uicide plan U nexplained guilt or worthlessness I nability to function C concentration impaired I mpaired appetite D creased sleep E energy low
Urgent - Rapid mental health assessment and maybe inpatient admission - Give ECT &/or rapid prescription of Antidepressants
11
Q
What are the NICE guidelines for Antidepressants
A
1st line: SSRI e.g Sertraline, Citralopram and Fluoxetine (<18yrs)
2nd line: Alternative SSRI
3rd line: SNRI (venlafaxine) or NaSSA/Tetracyclic (mirtazapine) if two SSRIs haven’t worked
4th line: Lithium, TCA, Monamine Oxidase Inhibitors
12
Q
What are side effects from ECT
A
Amnesia
Headaches
Confusion
13
Q
When is ECT used
A
When other treatments have been ineffective and a condition is life threatening (severe manic episode, severe depression, catatonia)
14
Q
What is one contraindication for ECT
A
Cochlear Implant
15
Q
What are the SE of SSRIs
A
The 8S’s
- Sodium (low)
- Serotonin Syndrome
- Sexual Dysfunction
- Sleep (insomnia)
- Sickness (nausea/vomiting) and Stomach Upset (diarrhoea, constipation, abdo pain)
- Size (weight gain)
- Stress
- Suicide (first 2 weeks increased risk of suicide)
16
Q
How long do SSRIs take to work and what should you be aware of when starting them
A
Can take up to 4 weeks to work there may be initial worsening of symptoms and increased risk of suicide
17
Q
Once effective dose of antidepressant how long should they be continued for and what symptoms can occur if you stop them suddenly
A
6 months
Flu like symptoms, headaches, shock like sensations, dizziness, insomnia - withdraw over 4 weeks or longer to reduce these
18
Q
How do SSRIs work
A
Prevent reuptake of serotonin in the synaptic cleft therefore increasing Serotonin levels
19
Q
What does mirtazapine do
A
Mirtazzzzapine makes you sleepy (Zzz)
Weight Gain
20
Q
What is serotonin Syndrome
A
A life threatening condition caused by to much serotonin (co-administration of some antidepressants or not cross tapering can cause it) Classic Triad: - Neuromuscular Excitability - Autonomic Dysfunction - Altered Mental Status
Symptoms: Hyperthermia, Diaphoresis, Hypertension, Tachycardia, N/V, diarrhoea, Tremor, Hypertonia/rigidity, Hyperreflexia, Confusion, Seizure
21
Q
How is serotonin syndrome managed
A
Immediately stop Antidepressants
Supportive care: fluid replacement, antihypertensives
Benzodiazepines: to sedate
Cooling Methods
22
Q
What can antidepressants sometimes induce
A
A manic episode
23
Q
What is a side effect of Citralopram
A
Dose dependent prolongation of QT interval so check ECG - unnoticed can lead to Torsades de Pointes
24
Q
What is Mania
A
- Abnormally elevated, expansive or irritated mood and increased goal directed behaviour, energy and activity not attributable to organic psychic disorder or psychotropic substances
- Lasting for at least a week
- Significantly impairs function
- Patient requires hospitalisation
- There may be psychotic symptoms
25
What is hypomania
- Abnormally elevated, expansive or irritated mood and increased goal directed behaviour, energy and activity not attributable to organic psychic disorder or psychotropic substances
- Lasting at least 4 days
- Does not significantly impair function, hospitalisation or present
- No psychotic features
26
What symptoms may be seen in mania/hypomania
Mood:
- Irritability, Euphoria, Elevated mood
Behavior:
- Increased goal directed activity (Hyperactivity, Hyper-sexuality, increased libido, increased socialising, new projects)
- Increased talkativeness and pressure of speech
- Loss of social inhibition ( socially and sexually inappropriate, reckless actions)
- Decreased need to sleep
Cognition:
- Flight of Ideas and Racing thoughts
- Heightened self esteem/grandiosity
- Distractibility/Poor Concentration
Psychotic Symptoms: (definite manic)
- Delusions
- Hallucinations
27
What is the main difference between mania and hypomania
The severity of symptoms e.g significant impairment of function, hospitalisation etc.
28
What is Bipolar Disorder
A disorder characterised by two or more episodes in which patients mood/activity levels are significantly disturbed consisting of episodes of mania/hypomania +/- depression
29
What is Bipolar 1
Manic episodes WITH OR WITHOUT major depressive episodes
30
What is Bipolar 2
Hypomanic episodes AND major depressive episodes
31
What is Cyclothymia
- Cyclical moods of hypomania and depression but not severe enough to meet diagnosis of bipolar
- Symptoms have to last at least 2 years, present at least half the time and never absent for longer than 2 months
32
What is rapid cycling
Patients have 4 or more episodes of depression, mania or hypomania in one year
33
What could be a differential for bipolar
Substance/Medication induced bipolar/mania
- occurs during/shortly after intoxication/ withdrawal
- Alcohol
- Steroids
- Illicit Substances e.g amphetamines, cocaine
- Antidepressants
34
What Ix should be done for bipolar
```
Clinical Diagnosis
ALWAYS assess suicide risk
Screen for drugs and toxins e.g urine
Infections
Past Fx - strong genetic component
CT
```
35
How should acute mania be managed
Any SG Antipsychotics - rapid onset of action for agitated patients
36
After successful management of a manic/depressive episode what needs to be given for long term maintenance of bipolar
A Mood Stabiliser
- Lithium
- Sodium Valproate (SE: hair)
- Lamotrigine (SE: rash/SJS)
- Carbamazepine (SE :rash/neutropenia)
- 2nd Line: Olanzapine
Psycho: Talking therapy
Social: Family or carer support/employment/ activity support/education
37
Why does lithium blood concentration have to be checked regularly
It has a narrow therapeutic index (small changes in dose/blood concentration can have severe effects)
- Elderly show increased sensitivity to lithium
38
What adverse effects can lithium cause
Lithium toxicity from impaired renal function/nephrotoxicity from lithium
- Loss of vision
- D&V
- Ataxia
- Tremor
- Dysarthria
- Coma
39
How can severe depressive episodes be managed in Bipolar
Antidepressants should not be given before initiating therapy with mood stabilisers and it may lead to a manic episode
(Antidepressants may be given after initiating mood stabilising therapy)
40
What are causes of anxiety
```
Genetic Predisposition
Disruption of Serotonin System
Substance Use
Stress (work, home)
Events (divorce, job loss, moving)
Smoking
Psychological Trauma e.g child abuse
Medical conditions e.g CVS, hyperthyroidism, respiratory illness
```
41
How can anxiety present
Cognitive: Agitation, feeling of doom, poor concentration, insomnia, fatigue, obsessions, compulsions, worry, depression
Somatic: Tension, trembling, sense of collapse, hyperventilation, headache, butterflies, sweating, palpitations, nausea
Behaviours: Reassurance seeking, avoidance, dependence on person
42
What is generalised anxiety disorder
Prolonged and excessive anxiety which is generalised and not focused on a single specific fear for at least 6 months
43
What are non medical treatments for anxiety
- Symptom control: understanding somatic symptoms are not life threatening
- Regular Exercise
- Meditation - Mindfullness
- Progressive Relaxation Training e.g deep breathing and relaxation of muscle groups
- CBT
- Behavioral Therapy - exposure and response therapy
- Hypnosis
44
What are the medical treatments for anxiety
- 1st line: SSRIs + CBT (gold standard)
- 2nd line: Pregablin
- Benzodiazapines for short term management until SSRIs become effective (DO NOT USE IN GENERALISED ANXIETY DISORDER PEOPLE BECOME DEPENDENT ONLY SHORT TERM)
- Beta Blockers can help somatic symptoms
45
What is panic disorder
1) Recurrent and unexpected panic attacks that occur without known trigger
2) Persistent worry/change in behaviour due to fear of recurrent attacks for at least a month
3) Not effects of substance
4) Not another Disorder
46
What is panic disorder often associated with
Agoraphobia (can't predict attacks which leads to avoidance)
47
How does Panic Disorder present
STUDENTS FEAR the 3Cs
```
Sweating
Trembling
Unsteadiness
Derealisation
Elevated HR
Nausea
Tingling
SOB
```
FEAR of dying, losing control, going crazy
Chest pain
Choking
Chills
48
How is Panic Disorder managed
CBT
SSRIs
Benzodiazepines - for managing acute attacks
49
What are phobic disorders
Anxiety experienced only or predominantly in certain well defined situations that aren't dangerous - resulting in situation being avoided or endured with dread
50
What are examples of Phobias
Agoraphobia
Social Anxiety Disorder/ Phobia
Simple Phobia
51
What is Agoraphobia
Pronounced fear of being in situations that are perceived difficult to escape from or difficult to seek help
e.g crowds, travel, events away from home, open spaces, enclosed spaces for at least 6 months
52
What is social anxiety disorder/phobia
Pronounced anxiety for 6 months or longer of social situations that may involve scrutiny from others (don't want to be embarrassed or judged)
Can be SAD (meeting new people, eating in front of people) or Performance only SAD (public speaking)
53
What are simple/specific phobias
Intense and persistent fears of one or more situations or objects when encountered or anticipation for encounter e.g arachnophobia, claustrophobia, haematophobia
54
How may phobias present
Catastphohic thoughts
Panic Attacks
Avoidance
55
How are phobias treated
Psychologial Therapy - exposure and response prevention
SSRIs
Beta Blockers and Benzodiazepines in acute situations
56
How can a new diagnosis of a psychiatric illness affect driving
DVLA need informing of a diagnosis of a psychiatric disorder and medication you are on
57
What SE can MAOIs cause
Hypertensive Crisis - Cheese and Red Wine
58
What is OCD
Characterised by:
- Persistent and Recurrent Intrusive thoughts, urges and images which cause anxiety/distress (obsessions)
- Leading to repetitive behaviours/rituals to reduce the distress/anxiety of an obsession (compulsion)
- These are time-consuming and significantly impair function/daily life
59
What is OCD caused and associated with
Unknown Genetic + Environment
Associations:
- Tic Disorder
- Personality Disorder
- Mood Disorder
60
What are some examples of rituals
Cleaning
Dressing
Counting
Checking
61
What is the treatment for OCD
Psychotherapy: Exposure & Response Prevention Therapy
Medication: SSRI e.g Fluoxetine TCA e.g Clomipramine
Social: Family Intervention, Support with Engagement, Employment, Education, Involvement in Activities, Carer Support
62
What is an acute stress reaction
A transient condition (hours to days) in reaction to a traumatic event resulting in dissociation and mixed emotions of anger, anxiety and confusion which impairs function
It usually resolves with psyhological intervention e.g talking to friends and family
63
What is an adjustment disorder
A maladaptive behaviour or emotional response to a stressor resulting in impaired function that lasts under 6 months when the stressor is removed e.g cancer diagnosis, divorce
64
What is PTSD
A reaction to a traumatic event which significantly impairs function lasting longer than a month
65
What are the symptoms of PTSD
Intrusions e.g Intrusive thoughts of event, Flashbacks, Nightmares
Avoidance e.g avoidance of thoughts, feelings, external stimuli associated with event
Negative affected mood or cognition e.g guilt, fear and depression, memory loss/distortion, negative beliefs, detachment
Arousal or Reactivity e.g Hyperarousal, Hyper-vigilance, easily startled, sleep disturbance
66
What are the comorbid conditions associated with PTSD
Depression
Emotional Numbness
Drug/Alcohol Abuse
Anger/Violence
67
What can cause PTSD
```
Sexual Abuse - main cause
War
Combat Exposure
Natural Disasters
Accidents
```
68
What is the treatment for PTSD
Psychotherapy: CBT and Eye Movement Desensitisation And Reprocessing (EMDR)
Medications: SSRIs or SNRI
SGA if presenting with psychotic symptoms
Benzo can be used short term but REMEMBER addiction and dependence
69
What is Derealisation
Feeling of detachment from Surroundings
70
What is Depersonalisation
Feeling of detachment from ones body, thoughts and feelings (sometimes described as observing yourself from outside your body like a movie)
71
What can depersonalisation and derealisation lead to
Altered sense of time
Emotionally/Physically numb
Weak sense of self
Trouble recognising people, places and objects
72
What is Dissociative Amnesia
A person is unable to recall periods of their life or events that happened in the past , they may also have forgotten a learned skill or talent
73
What is a symptom of dissociative amnesia
Inability to recall ones past with loss of identity/formation of a new identity with unexpected purposeful travel to a new location and act as a different person in different life (can last hours to months)
74
What can cause dissociation
Childhood Truama
Trauma
Substance Misuse
Anxiety Disorder
75
What is the treatment for dissociation
Psychotherapy: CBT
76
What criteria is used to diagnose Schizophrenia
Schneider
77
What are the 1st rank symptoms of Schizophrenia
1. Thought Disorder e.g. insertion, withdrawal, broadcast
2. 3rd Person Auditory Hallucinations in the form of Running Commentary or talking about them amongst themselves (thought echo)
3. Delusional Perception
4. Passivity
78
What are 2nd rank symptoms of Schizophrenia
1. Persistent hallucinations in any modality (somatic, visual, tactile)
2. Second person auditory hallucinations
3. Paranoid and Persecutory Delusions
4. Delusions of Reference
79
What are positive symptoms of Psychosis
Hallucinations
Delusions
Illusions
Disorganised Thoughts and Speech Process e.g loosening of associations, word salad, neologisms, flight of ideas, circumstantial speech, tangential speech, pressured speech
80
What are negative symptoms of Psychosis
```
Blunted/Flat Effect
Apathy
Alogia/Poverty of Speech
Anhedonia
Emotional and Social Withdrawal
Self Neglect
Catatonia/ Psychomotor Retardation
```
81
What are cognitive symptoms of Psychosis
Impaired Memory
Inattention
poor executive functioning
82
What are differentials for Psychosis
- Schizophrenia - recurrent/chronic disorder
- Affective Psychosis - e.g depression/bipolar
- Transient Psychotic Disorders e.g triggered by stress
- Drug Induced by Psychosis
- Schizoaffective Disorder
- Schizophreniform Disorder
- Delusional Disorder
- Psychosis due to medical condition e.g brain tumour or head injury
- Personality Disorders
- Dementia
83
What is the diagnosis for Schizophrenia
Psychotic Symptoms lasting at least 6 months and are present much of the time
(all other possible cases of psychosis need to be ruled out)
84
How is Schizophrenia managed
Psycho: CBT, Abstinence from drugs
Medication: Antipsychotics
Social: Family intervention, social support (housing, benefits, employment, education) support with engagement, carer support
85
Who are Psychosis patents referred to following the acute phase
The Early Intervention Team
86
What is Schizoaffective Disorder
Features of Schizophrenia and a major mood disorder (depression/bipolar) present at the same time without being caused by any other medical disorder or substance misuse (psychosis is the predominant feature)
(Neither a variant of schizophrenia or mood disorder!!!!)
87
What is the treatment for Schizoaffective Disorder
Manage Both Conditions:
- Antipsychotic
- Mood Stabiliser
88
What is Schizotypical disorder and how is it managed
A personality disorder characterised by odd and eccentric behaviour and magical thinking, may present a partial expression to schizophrenia
Management: Treated without Medication
89
What is Schizophreniform and how is it managed
Given to disorders that don't reach the. threshold for Schizophrenia but have some symptoms of it and deterioration of function
Management: Antipsychotics
90
What do antipsychotics do
Dopamine Antagonists - Block the D2 receptor
| Reducing Dopamine Neurotransmission
91
What are the two broad groups of Antipsychotics
First Generation Antipsychotics - D2 Antagonists
| Second Generation Antipsychotics/ Atypical Antipsychotics - D2 & 5HT2A Antagonists
92
What are some examples of second generation antipsychotics
Clozapine
Olanzapine
Risperidone
Quetiapine
93
What are some examples of first generation antipsychotics
Haloperidol
Promethazine
Chlorpromazine
94
What is the difference between first and second generation Antipsychotics
The SE:
- FGA - are associated with higher risk of EPS
- SGA - are associated with a lower risk of EPS but with higher risk of metabolic side effects
95
What are Extrapyramidal SE
Drug induced movement disorders caused by disruption of dopaminergic pathways
Symptoms:
- Acute Dystonia - continuous painful muscle spasms and contractions
- Parkinsonism - Rigidity, Tremor, bradykinesia and shuffling gait
- Akathisia - Restlessness
- Tardive Dyskinesia - involuntary movements generally of the tongue, mouth and jaw e.g repetitive lip smacking and chewing
96
How can you manage EPSE
Try to reach lowest tolerate dose
- Acute Dystonia: Anticholinergics (Procyclidine/Benztropine) or Antihistamines (Cyproheptadine)
- Parkinsonism: Dose reduction, switch to SGA, Anticholinergic (Procyclidine/Benztropine)
- Akathisia: Dose reduction, switch, Propranolol +/- Anticholinergic (Benztropine)
Tardive Dyskinesia - May be irreversible
97
What are metabolic SE
Weight Gain
Hyperglycaemia/Insulin Resistance - Diabetes
Dyslipidaemia
98
What are other SE of Antipsychotics
- Hyperprolactaemia
- Prolonged QT
- Sexual Dysfunction - erectile dysfunction, reduced libido, reduced arousal
- CV effects - Olanazapine & Rispiridone can increase risk of stroke in elderly when used to treat dementia!!!, Myocarditis and Cardiomyopathy
Daytime Drowsiness
99
What is a life threatening emergency associated with antipsychotics
Neuroleptic Malignant Syndrome
100
How does Neuroleptic Malignant Syndrome present
Fever
Muscle Rigidity
Autonomic Instability
Delirium/Mental State Change
101
What will be seen on Investigations of Neuroleptic Malignant Syndrome
Markedly Raised Creatine Kinase
| Leukocytes
102
What is the management of Neuroleptic Malignant Syndrome
Stop Antipsychotic!!!!
Supportive measures - Admit to ICU
Dantrolene - reduces fever/hyperthermia and muscle rigidity
103
What is Clozapine
Most popular drug for treatment resistant Schizophrenia (Wonder Drug)
104
What are Clozapine Risk
- Neutropenia and potentially fatal agranulocytosis
- Prolonged QT complex, Fatal Myocarditis and Cardiomyopathy
- Intestinal Obstruction (can be fatal)
105
Who is at high risk of Suicide
(Most common caused of death in men under 35)
- Previous Suicide attempts
- Mental Illness e.g Depression, Bipolar
- Gender: male
- Age: high risk in elderly
- Marital Status: Widow>Divorced>Single>Married
- Occupation: Highest risk in unemployed and retired
- Ethnicity
- Woman have higher suicide attempts but men have higher suicide success rate due to more lethal methods
106
What is important to assess after suicide attempt
- Circumstances of Act - What happened that day to make you do it
- Background of act - how things have been preceding in months up to event
- Relevant Family and Personal Hx
- The intention behind the act: did they wish to die or did they want to be found/change a circumstance
- Summary: Any plans, Other attempts, Any preparations e.g notes
107
How can survivors of Suicide be helped
Therapy
Family Intervention if they want
Treat Co-morbid conditions e.g Substance misuse, Depression, Anxiety
Prevention Strategies e.g Samaritans, Doctors
Admission???
108
Why do people self harm
```
Communicating a message
Release from Psychological pain
Gaining Power by escalating conflict
Emotional Immaturity
Inability to cope with stress
Availability of Drugs
```
109
What are risk factors for self harm
Witnessed: FHx, Friends, Celebrities
Biological
Development: Child neglect, physical, emotional and sexual abuse
Peer Relations: Bullying, Conflicts
Psychological: Identity Problems (culture, sexual orientation, borderline)
Antisocial Behaviour: conduct disorder, substance misuse
110
How is self harm managed
Prioritise treatment of physical effects of self harm
Assessment
1. Initial risk management: immediate risk of suicide
2. On going risk of subsequent self harm
3. Relevant psychiatric, medical, social issues
111
What is Delirium
Acute AND fluctuating:
- altered level of consciousness
- global impairment of cognitive function/ Disorganised Thinking
- Inattention
112
What are symptoms of Hyperactive Delerium
```
Agitated
Aggressive
Incoherent Speech
Disorganised Thoughts
Delusions and Disorientation
Hallucinations
Sleep Disturbance
```
113
What are symptoms of Hypoactive Delirium
```
Sluggish
Drowsy
Less reactive/slow responses
Sleep Disturbance
Withdrawal
```
114
What are causes of Delirium
PINCH ME
```
Pain e.g post op
Infection
Nutrition
Constipation
Hydration
```
Medication
Environment/Electrolytes
115
What medications can cause delirium
Anticholinergics!!!!
Benzodiazepines
Antidepressants/Antipsychotics
Opioids
116
Who are at high risk of developing delirium
Post operative patients
Elderly Patients
Multiple Comorbidities
117
What investigations should be performed for Delirium
```
U&Es and LFTs
FBC
Blood Gas
Glucose
Cultures (blood/MSU)
Urine Toxicology
ECG
CT head
CXR
LP
```
118
What are differentials for patients presenting with confusion on a ward
Delirium
Delirium Tremens
Dementia
119
What are the differences between Dementia and Delirium
Dementia:
Slowly Progressive Deterioration
Early on - alert
Clear consciousness
```
Delirium:
Sudden acute onset
Fluctuating levels of cognitive impairment and consciousness
Inattention
Reversible
Often Visual Hallucinations present
```
120
How do you manage Delirium
Identify cause and treat it
Medication: Haloperidol
Avoid Sedation e.g Benzos
Optimize surroundings:
- Good daily routine and sleep hygiene
- Proper lighting for time of day
- Manage Noise
- Engagement - glasses and hearing aids
- Cognitive Stimulation e.g familiar objects and family
121
When may you give Benzodiazepines to treat Delerium
In patients who are delirious due to alcohol and benzodiazepine withdrawal
Haloperidol is contraindicated as it lowers seizure threshold
122
What is Dementia
A chronic and Progressive global impairment of cognitive function (across multiple cognitive domains) that must impact on the general function of the patient
123
What are the Cognitive symptoms of Alzheimer's
```
The 4A's:
Amnesia
Aphasia
Apraxia
Agnosia
```
Executive Dysfunction
Loss of Orientation
124
What are the non cognitive symptoms of Alzheimers
Psychosis: Delusions and Hallucinations
Mood: Anxiety, Depression
Behaviour: Apathy, Agitation, Wandering, Aggression and Repetitive & Purposeless Activity
Personality Change: misidentification, sexual disinhabition
125
what are risk factors for Alzheimers
```
Increasing age
Sex - Female
Low Intelligence/Education
Family Hx
APO E4
Downs Syndrome
Head injury, Smoking, HTN, Diabetes
```
126
What are protective factors for Alzheimers
APO E2
High Intelligence/ Education
Oestrogen
127
When can someone be given a diagnosis of Alzheimers
6 months
128
What medications can be used to slow progression Alzheimer's
Acetyl Cholinesterase Inhibitors - Rivestigmine or Donepezil
NMDA Antagonist - Memantine
129
What is the presentation of Lewy body Dementia
```
Fluctuating Cognitive Impairment
Visual Hallucinations
Parkinsonian Symptoms
REM sleep Disorder
Memory Problems
Autonomic Dysfunction - orthostatic Hypotension (INCREASED RISK OF FALLS), Urinary Incontience, Constipation
```
130
What is important to remember about Lewy body Dementia
They are very sensitive to Antipsychotic Medication - Can lead to severe Parkinsonism, hallucinations and even loss of Consciousness
131
How does Frontal Temporal Dementia present
```
Behaviour/Personality Change
Social and Interpersonal Inhibition
Emotional Blunting/Unconcern
Poor insight
Speech Problems
Poor motivation and loss of attention
```
132
How does Vascular Dementia present
History of Strokes/TIAs - leading to sudden onset and stepwise deterioration
Memory Problems
Mild Decline: in thinking, reasoning and information processing
Evidence of focal brain damage
133
How is Dementia Ix
Full Collateral Hx
Memory Assessment - MOCA, Addenbrookes, ACE 3, (FAB - Frontal temporal dementia)
Functional Assessment
FBC
B12 and Folate - major cause of cognitive impairment
TSH (hypothyroidism)
U&E, LFTs - renal/hepatic failure, alcoholism
Serology - Syphilis/HIV
CT/MRI
134
How is Dementia Managed
- Acetyl Cholinesterase Inhibitors - mainly Alzheimers
- NMDA Antagonists - mainly Alzheimers
- Depression - SSRIs
- Behaviour and Psychological Symptoms of Dementia - Antipsychotics
- Carer Assessment & Support
- Risk Assessment
- Environmental Adaptions - for mobility and accommodation (institutionalised care)
- Therapies - Music, ART etc.
135
What is in the criteria for substance misuse disorder
- Strong Desire to take Substance (craving)
- Impaired Control of substance use
- Withdrawal State: when reducing or ceasing use
- Tolerance - Continuously having to increase dose
- Progressive neglect of self, others, pleasures, interests
- Risky use - persisting use despite harmful consequences snd using in hazardous situations e.g work, driving
136
What is tolerance
Need for individuals to continuously increase the dose of a substance to achieve same desired effect
137
What is withdrawal
Substance dependent collection of symptoms that appear after cessation of prolonged heavy drug use
138
What symptoms may be seen in an opioid overdose
```
Pin point pupils (miosis)
Hypotension
Bradycardia
Respiratory Depression
Altered conscious state
```
139
What symptoms may be seen in a cocaine overdose
```
Mydriasis
Hypertension
Tachycardia
Ataixa
Seizures
```
140
What is complications of cocaine
Tachycardia + Cociane induced vasospasm and vasoconstriction = Causing MI and maybe death
141
What symptoms may be seen in an amphetamine overdose
- Increased Libido
- Mydriasis
- Raised Body Temp and Sweating
- Hypertension
- Tachycardia and Arrhythmias
- Hyponatremia: Dry mouth and sweating leads to increased thirst leading to drinking water without electrolyte repletion leading to hyponatraemia causing seizures and cerebral oedema
- Overdose - Serotonin Syndrome
142
How are cocaine and amphetamine toxicity managed
ABCDE
Fluid Therapy
Control Hypertension and Arrhythmias
Benzodiazepines
143
How may cannabis in-toxicity present
```
Mydriasis
Hallucinations/Confusion
Mild Tachycardia
Dysphoria/ Anxiety
Conjunctival Injection (red eyes)
Increased Appetite
Dry mouth
Impaired concentration, reaction time and concentration
```
144
How do you manage opioid intoxication
ABCDE
IV Naloxone (opioid antagonist)
Manage complications
145
How does opioid withdrawal present
Flu like symptoms
GI complaints: N&V, cramps, diarrhoea
Sympathetic Hyperactivity: Tachycardia, Mydriasis, hypertension, hypertension
CNS stimulation: irritability, insomnia, aggression
146
How do you manage opioid withdrawal
Methadone - daily observed dosing
Nalteroxone - (long duration opioid antagonist) used for withdrawal treatment after acute detoxification
Psychological Support - Counselling, CBT, address triggers
147
What is gambling disorder
Addictive disorder in which individual feels a compulsion to gamble despite the negative consequences &/or multiple attempts to stop
148
What are the diagnostic criteria for gambling
12 month period 4 of below:
- Relying on others for financial support
- Restlessness when attempting to stop
- Constant preoccupation with gambling
- Continuous gambling in attempt to undo losses
- Jepordising relationships and careers as a result of gambling
- Numerous failed attempts to quit gambling
- Lying to others to conceal extend of gambling
- Belief that gambling helps relieve dysphoria
149
How can Gambling disorder be managed
Group therapy (gambling anonymous)
CBT
Treat underlying psychiatric disorder (often occurs with substance misuse and anxiety)
150
What are features of alcohol addiction
```
Features of increased tolerance and dependence
Features of acute alcohol intoxication
Features of alcohol withdrawal
Difficulty/Failure of Abstinence
Compulsion/Craving to Drink
```
151
What are features of alcohol intoxification
- Increased agitation
- disinhibition
- impaired judgement
- skin flushing
- tachycardia
- significant reduction in attention responsiveness and alertness,
- impaired vision
- Ataxia
- Dysarthria
- dizziness
- N&V
- amnestic gaps
- transition to coma with significantly impaired consciousness, lack of defensive reflexes and respiratory depression
152
What screening tools are used for alcohol dependence
CAGE - Cut Down, Annoyed, Guilt and Eye opener
TWEAK
AUDIT
SADQ- C
153
How do you calculate alcohol units
Percentage x Litres
154
How does alcohol withdrawal present
```
Agitation and Craving
tremor
Insomnia
Sweating and Anxiety
Headache
Tachycardia and Raised BP
Withdrawal Seizures (tonic-clonic)
Visual and Tactile Hallucinations
```
155
What complication can occur if alcohol is withdrawn suddenly
Delirium Tremens
156
What is Delirium Tremens
A&E Emergency (10% mortality rate)
- It is an acute altered state of consciousness and confusional state with autonomic dysfunction (sympathetic hyper activation) due to sudden alcohol withdrawal
157
How does Delirium Tremens present
```
Impaired consciousness
Disorientation and Confusion
Visual Hallucinations (formication)
Tremor
Sweating
Nausea
Tachycardia
Hypertension
Generalied Tonic Clonic Seizures
Hyperreflexia
Death
```
158
How do you treat Delirium Tremens
Admit
Monitor Vital signs
Oral or IV Lorazepam
Prophylactic Thiamine (B1)
159
Why would you give lorazepam for someone with Liver disease
It is metabolised in kidneys instead of liver therefore doesn't become toxic levels in blood
160
How do you manage withdrawal of Alcohol
Chlordiazepoxide - no withdrawal symptoms
Prophylactic IV Thiamine
(if liver failure use Lorazepam instead)
161
What can be used to aid recovery from alcohol misuse
Psychotherapy:
Alcoholics Anonymous
Family Therapy
CBT
Medication
Naltrexone - reduces pleasure that alcohol brings on
Acamprosate - reduces cravings for alcohol
Disulfiram - inhibits the enzyme that metabolises ethanol leading to increased sensitivity to alcohol and amplifying negative symptoms of alcohol (toxic reaction)
162
Why does Disulfiram need to be used with caution
IF you continue to drink with it and ignore toxic reaction it can lead to death
163
What are long term consequences of alcohol
- Liver - Fatty Liver - hepatitis - Cirrhosis
- CNS - poor memory and cognition, falls, accidents
Wernickes Encephalopathy
Korsakoffs Syndrome
- Gut - Pancreatitis
- Heart - Arrhythmias, Stroke, Increased BP
- Skeleton - Osteoporosis (Ca2+ disturbance)
- Sperm - Low fertility
- Cancer: Mouth, Oesophageal, Bowel, Breast
164
What is Wernickes Encephalopathy and Korsakoffs Syndrome both caused by
Chronic Thiamine (B1) deficiency
84% who have Wernickes will progress to Korsakoffs
165
What is the classic triad of Wernickes Symptoms
Confusion
Wide based gait ataxia
Ophthalmoplegia
(Acute, Reversible)
166
What will Wernickes commonly progress to
Korsakoffs Syndrome
- Confabulation
- Anterograde Amnesia (new memories)
- Personality change: apathy, decrease in executive function
- Lack of Insight
(Chronic, Irreversible)
167
How may be Wernickes or Korsakoffs be diagnosed
Bloods - Low thiamine, abnormal LFTs
| MRI - Haemorrhage or Atrophy of Mammillary Bodies
168
How do you manage Wernickes
Medical Emergency - Give IV Thiamine
169
How do you manage Korsakoffs
It is often irreversible
| Give oral Thiamine supplementation to prevent further progression
170
What is an illusion
Misperception of a real stimuli
171
What is a hallucination
Perception in the absence of an external stimuli
172
What is an over valued idea
Belief sustained against logic/reason but held with less rigidity than a delusion
173
What is a delusion
Unshakable beliefs, irrespective of counter argument that are unexpected and out of keeping with patients culture or background
174
What is Delusional Perception
Delusional belief resulting from a real perception
175
What is thought insertion
Thoughts been inserted by external agency
176
What is thought withdrawal
Thoughts been stolen by external agency
177
What is thought broadcast
Thoughts being broadcast so they can be heard by others
178
What is thought echo
Form of auditory hallucinations in which patient hears their thoughts being spoken aloud
179
What is thought block
Sudden interruption in train of thought, leaving a blank
180
What is concrete thinking
Lack of abstract thinking
181
What is loosening of association
Lack of logical association between thought
182
What is circumstantiality speech
Taking a great length around the subject before giving their answer
183
What is tangential speech
Does not return to the topic
184
Confabulation
Giving a false account to fill a memory gap
185
What is passivity
The belief that ones thoughts and actions are being controlled
186
What is somatic passivity
Delusional belief that the bodily sensations are from an external force
187
What is made acts, feelings and drives
The experience being carried out by the patient is considered alien/imposed
188
What is catatonia
Significantly excited or inhibited motor activity (waxy flexibility)
189
What is stupor
Loss of activity with no response to stimuli, may mark progression of motor retardation
190
What is psychomotor retardation
Slowing of thoughts and movements
191
What is flight of ideas
Rapid skipping from one thought to distantly related ideas
192
What is neologisms
Made up words
193
What is pressure of speech
Rapid rate of delivery may be associated with rhymes and puns
194
What is poverty of speech
Reduced amount, range and content of speech
195
What is anhedonia
Lack of pleasure in activities usually enjoyed
196
What is flattening of affect
Reduced range of emotional expression
197
What is incongruity of effect
Mismatch between emotional expression and content of conversation
198
What is an obsession
A recurrent unwanted thought (intrusive)
199
What is a compulsion
An irresistible urge to behave in a certain way
200
What is belle indifference
An apparent lack of concern at symptoms/disability
201
What is stereotypy
Persistent repetition of a behaviour without cause
202
What is mannerism
Habitual gesture of language or behaviour
203
What is delusion of reference
A coincidental or innocuous event which is believed to have some special meaning or strong personal significance e.g an earthquake in SE Asia seen on TV was caused by him
204
What are some types of delusions
- Persecutory
- Erotomanic - (belief someone is in love with them usually someone with higher status e.g celebrity)
- Religious
- Grandiose
- Jealous
- Nihilistic
- Delusional Misidentification
205
What are the two types of Delusional Misidentification
Capras - person close to them has been replaced by a double
| Fregoli - Single person impersonating multiple people
206
What is Somatisation Disorder
persistent unexplained somatic/physical symptoms (heartburn, fatigue headache) for > 6 months with a Hx of extensive diagnostic testing and medical procedures
207
What is the diagnostic criteria for Somatisation Disorder and how is treated
1 or more somatic symptom causing significant stress or impairment resulting in excessive thoughts, feeling and behaviours about symptom manifesting in 1 of following:
- constant thinking about severity of symptoms
- constant anxiety about symptom
- excessive amounts of energy/time attending to symptom
Treatment: CBT
208
What is conversion disorder
Neurological symptoms that can't be explained by a neurological condition
- 1 or more neurological conditions which are incompatible with recognised neurological/medical conditions
- Causing significant distress/psychosocial impairment
209
What is a personality disorder
Long lasting rigid and maladaptive personality patterns (thought, affect and behaviour) that lead to significant distress or functional impairment
210
What criteria do all personality disorders meet
- They affect several areas of function e.g impulse, relationships, cognition, affectivity
- they are chronic and stable over time
- They impair function in important areas of life e.g social and work
- Diagnosed at 18 years and above
- Cause considerable personal distress
211
What are the three clusters of personality disorders
A - Odd and Eccentric
B - Emotional, Dramatic and Erratic
C - Fearful, Avoidant and Anxious
212
What are the types of personality disorders in Group A
Paranoid - pervasive distrust
Schizoid - voluntary detachment from individuals
Schizotypical - odd, eccentric and magical thinking
213
What are the types of personality disorder in Group B
Dissocial/ Antisocial (DSM - 5) - conduct disorder, deceitful, agression, lack of remorse
Emotionally Unstable
Histrionic - Attention seeking and Dramatise with excessive emotions
Narcissistic - Grandiosity, need for admiration and lack empathy
214
What are the two types of emotionally unstable personality disorder
Borderline - Fear of abandonment, Mood Swings, Chronic feelings of Emptiness, Unclear self image/identity and unstable relationships, self harm and splitting
Impulsive - Inability to control anger or plan, unpredictable affect or behaviour
215
What are the types of personality disorder in cluster C
Avoidant - fear of rejection, feeling of inadequacy and involuntary social withdrawal
Dependent - requiring others to take responsibility, lack of self confidence, feeling helpless, seeking new relationships
Obsessive - Compulsive - Rigid routines, perfectionists and obsession with control
216
How do you manage personality disorder
Psychotherapy:
- Dialectical Behavioural Therapy - works well in borderline!
- Group Therapy
- CBT - usually ineffective
Medication usually not effective but can be used to manage symptoms e.g
- Mood Stabilisers, Antipsychotics, SSRIs
High rates of Suicide and other mental illness
217
What are some examples of social intervention management
```
Benefits
Cultural Support
Care Package
Help with meaningful activity
Help with housing
Safeguarding
Access/Support with Education
Employment
Social Integration
Support with Engagement/Person Centred Care
Anti Discriminatory Language
Help with abstinence of addictions
```
218
What is the mental health act
Law which allows people with a mental disorder to be admitted to hospital, detained and treated for that mental disorder without consent to protect themselves and others
The treatment implies the treatment of your mental disorder
219
What is Section 2 of the mental health act
Detention in hospital for assessment of your mental health and potentially get treated
Lasts up to 28 days
220
What is Section 3 of the mental health act
Detention in hostile for treatment, necessary for your health, safety and protection of others
Lasts up to 6 months
221
What is section 5(2) of the mental health act
Any Doctors holding power to allow assessment under the MHA
Lasts up to 72 hrs for assessment for a section 2 or 3
222
What is a Section 5 (4) of the mental health act
Nurses holding power to allow assessment under the MHA
Lasts up to 6 hours for assessment for a section 2 or 3
223
What is a section 136 of the mental health act
Police removal from public place to designated place of safety for MHA assessment
224
What is a section 135 of the mental health act
Police removal from home to designated place of safety for MHA assessment
225
Who do you need to undertake an assessment under the mental health act
Approved mental health professional (AMPH)
Section 12 approved doctor
Another registered doctor
226
What conditions must be met regarding their mental health to retain them
Mental Health Disorder
With a nature or degree to warrant detention in hospital
Risk to self or others
227
Who can release someone from their section
Consultant Psychiatrist
Mental Health Tribunal
Nearest Relative
Hospital Manager Hearing
228
What is the mental capacity act
Applies if you have a mental health problem but do not have the mental capacity to make certain decisions about healthcare or residential care
Can be used to give treatment for physical health problems that have nothing to do with mental health problem
229
What are the 5 key principles of the mental capacity act
- You must be treated as if you have capacity until it is proven you don't
- You must be supported to make a decision e.g giving info in different ways
- You have the right to make an unwise decision as long as you have capacity
- Anything done under act must be in the patients best interest
- Anything done under act must be the least restrictive option available
230
What are the 4 key things to assess capacity
Understand information
Weigh up information
Retrain information
Communicate Decision
231
What can be given to tranquillise aggressive behaviour
Lorazepam
OR
Antipsychotic (e.g Olanzapine) - Don't give if patient already on a regular antipsychotic (QT prolongation)
232
What are differentials for weight loss
```
Diabetes!!!!!
IBS/IBD/Coeliac
Hyperthyroidism
CHD
Neoplasm
Anorexia Nervosa
Depression/OCD/Anxiety
Substance Misuse
Autism
CF
```
233
What is the criteria for Anorexia Nervosa
- Low weight: <85% predicted or BMI = 17.5
- Intense fear of gaining weight/fatness
- Deliberate restriction of weight through calories or exercise
- Endocrine changes e.g amenorrhoea, reused libido
234
What may cause Anorexia
Biological: Genetics, Serotonin Dysregulation
Psychological: Depression, Anxiety, OCD, perfectionism and personality type
Developmental: Adverse life events, parents with eating disorder
Sociocultural: Substance abuse, media exposure, image awareness activities (ballet), bullying
235
What are weight loss techniques used in anorexia
- Exercise
- Amphetamines
- Calorie Restriction
- Not taking Medication e.g propylthiouracil or Carbimazole or taking too much thyroxine
- Purging
- Laxatives
- Vomiting
- Cold Showers
236
How does anorexia present
General: Fatigue, reduced cognition, sleep disturbance, hypothermia, dizzy
GI: Constipation
Reproductive: Sub-fertility, Secondary Amenorrhoea
Haematological: Anaemia, Low WCC + platelets
Endocrine/Electrolytes: Raised cortisol and adrenaline,
hypokalaemia, low phosphate and low magnesium
Cardiovascular: Low BP, Bradycardia, prolonged QT, arrhythmias
Bone: Osteoporosis and Fractures
Other: Dental caries, Dry skin, Russells Sign, Brittle hair
237
What can be used to screen for Anorexia
SCOFF Questionnaire
Sick (make yourself sick if you feel full)
Control (worry about losing control)
One stone (in 3 months)
Fat (think you're fat but others say you're thin)
Food (dominate your life)
238
What are red flags for Anorexia Nervosa
```
BMI <13
Temp <34.5
Vascular BP <80/50 and pulse <40
Muscles - failure to so SUSS
Blood: Low potassium and low phosphate
ECG: prolonged QT complex
```
239
How is Anorexia managed
Psychotherapy: CBT
Bio: BMI<15, unstable vital signs (hypothermia, electrolyte imbalance and bradycardia) - admit to hospital hospitalisation for re-feeding via NG or parenteral
Dietician/Nutritional Support
SSRIs, Antipsychotics?
Social: Family Intervention, Addressing family dynamics, carer support
240
What can severe anorexia lead to
Low potassium can lead to prolonged QT - arrhythmias and death
241
What is a complication of Anorexia treatment
Refeeding Syndrome
Very rapid increase in food intake causes massive insulin release - increased displacement of potassium, magnesium and phosphate massive shift intracellular - causing low potassium, magnesium and phosphate
242
How does referring syndrome present
```
Rhabdomyolysis
Respiratory or Cardiac Failure
Low BP
Arrhythmias (torsades de points)
Seizures and Death
```
243
How is referring syndrome managed and how is it prevented
Electrolyte Substitution
Consult dietician to develop slow referring plan
Monitor Electrolytes: Mg, PO4 and K+
244
What risks need to be assessed for anorexia
```
Cardiac risk
Refeeding risk
Falls risk
Seizure risk
Self Harm risk
```
245
What is the criteria for Bulimia
Recurrent Episodes of Binge eating (uncontrolled eating)
Preoccupation of control of body weight
Regular use of mechanism to overcome fattening effects e.g laxatives, exercise
BMI - >17.5
246
What symptoms may be seen in Bulimia
```
Fatigue
Dental Caries
Gastritis
Russells Sign
Cardiomyopathy
Swelling of hands and feet
Low potassium, metabolic alkalosis, hypochloraemia
```
247
How is Bulimia managed
Psychotherapy: CBT, self help books, food diary
Nutritional Rehabilitation
Medication: SSRIs (fluoxetine)
248
What are risk factors for autism and what may be associated with autism
Risk: Strong underlying genetic component
Associations: Epilepsy and ADHD
249
What are the two core symptoms of Autism
1. Impairment in communication and social interaction
2. Restricted repetitive patterns of behaviour, interests and activities
Other symptoms: impaired language and intellectual impairment
250
What symptoms are you going to get due to impairment in communication and social interaction
- Inability to form relationships and make friends
- Unaware of the existence and feelings of others
- Lack of desire/motivation to communicate and interact with others
- Communicating needs only
- Disordered or delayed language
- Repeats Speech
- Reduced Empathy
- Difficulties in adjusting behaviour to social situations
- Poor eye contact
251
What symptoms are you going to get due to restricted repetitive patterns of behaviour
- Stereotyped movement's: Hand flapping
- Preoccupation with parts of objects: excessive smelling/touching
- Inability to play or write imaginatively
- Resists change/distress over change
- Obsessions/Rituals likes a strict routine
- Plays same game over and over
- Narrow fixations e.g lining up toys
- Odd speech e.g echolalia
252
What is the management of Autism
- Early intensive behavioural intervention
- Speech Therapy
- Education and Information
- School Liaison/Support
- ASD Parent Training/Workshop
- Supportive tools e.g PECs, visual cues, timetables, visual behaviour support
- Medication to manage comorbities e.g Risperidone
253
How does Ashbergers Differ on the Autism Spectrum
No intellectual or language impairment
254
What are the three core symptoms of ADHD
Impulsivity
Inattention
Hyperactivity
255
What is needed for the diagnosis of ADHD
Present before 12 years
Developmentally inappropriate
Several Symptoms in 2 or more settings
Interfere with normal levels of functioning
256
What are symptoms of inattention
- Poor Attention/easily distracted
- Difficulty sustaining attention during activities and tasks
- Inability to complete tasks
- Struggles to organise tasks
- Forgetful/Loses things
257
What are symptoms of hyperactivity
- Squirms and figets
- Restless
- Talks Excessively
- No Quiet hobbies
258
What are symptoms of Impulsivity
- Blurts out answers
- Interrupts others
- Cannot take turns
259
What can ADHD be associated with
```
Disruptive and Impulsive Behaviour
Aggression and Antisocial Behaviour
Conduct Disorder
Alcohol and Drug Problems
Accidents
Self harm and Suicide
```
260
How is ADHD assessed
Collateral Hx doctors, teachers, parents
| Behavioural Observation in varying contexts
261
What is the cause of ADHD
Genetics
Environmental Factors
Neurobiological
CNS insults (prematurity, fetal alcohol syndrome)
262
How is ADHD managed
```
Education and Information
ADHD parenting programme
School support and Liaison
Medications
- 1st line: Methylphenidate
- 2nd line: Atomoxetine
```
