Psychiatry Flashcards
(261 cards)
1
Q
Describe the pathophysiology behind depressive disorders.
A
- likely to be heritable with multiple gene involvement (twin studies)
- monoamine hypothesis: deficiency of noradrenaline, serotonin and dopamine
- over activity of the hypothalamic-pituitary-adrenal axis
- psychosocial input: personality type, life stressors and failure of effective stress control mechanisms increase likelihood of depression
2
Q
Name biological factors that predispose you to depression
A
- female gender
- post natal period
- genetics ( fam history)
- neurochemical - low serotonin, dopamine and noradrenaline
- endocrine: increased hypothalamic pituitary adrenal axis activity
- physical co morbidity
3
Q
Name psychosocial factors that predispose you to depression
A
- personality type
- failure of effective stress control mechanisms
- poor coping strategy
- mental health co-morbidity e.g dementia
4
Q
Name social factors that predispose you to depression
A
- stressful life event
- lack of social support
- social situations e.g asylum seekers
5
Q
Name biological factors that precipitate depression
A
- poor compliance with medication
- corticosteroids
6
Q
Name psychosocial factors that precipitate depression
A
Acute stressful life events often precede depression eg loss of a loved one, injury, bankruptcy, unemployment, divorce
Non-acute stressful life events: poverty
7
Q
Name factors that perpetuate (maintain) depression
A
Biological: chronic health problems
Psychosocial: poor insight, negative thoughts about self, the world and future (becks triad)
Social: alcohol and substance abuse, poor social support and low social status
8
Q
Name 3 typical (1st generation) antipsychotics
A
Haloperidol
Chlorpromazine
Sulpiride
9
Q
Name 4 atypical (2nd gen) antipsychotics
A
Olanzapine Risperidone Quetiapine Amisulpride Clozapine
10
Q
What is the difference between typical and atypical antipsychotics
A
Not much, apart from atypical antipsychotics cause less extrapyramidal (motor) side effects
11
Q
Which antipsychotic is only used for treatment resistant schizophrenia when two previous antipsychotics have failed?
A
Clozapine
12
Q
Name 3 indications for anti psychotic use
A
- 1st line treatment schizophrenia
- Other conditions with positive psychotic symptoms ( hallucinations / delusions ) such as mania, acute psychotic disorders, depression, dementia
- Violent or dangerously impulsive behaviour and psychomotor agitation
13
Q
How do antipsychotics work
A
By blocking dopamine (D2 mainly) in the brain, namely the Mesolimbic and mesocortical pathways
14
Q
Name extrapyramidal side effects of antipsychotics
A
Parkinsonism - bradykinesia and tremor
Akanthisia- restlessness
Dystonia - acute painful contractions and spasms of muscles mainly in neck jaw and eyes
Tardive dyskinesia - abnormal involuntary movements (choreoathetoid) mainly looks like a pouting and chewing jaw
15
Q
Name the anti-muscarinic side effects of antipsychotics
A
Can’t see can’t wee can’t spit can’t shit
Blurred vision, urinary retention, dry mouth and constipation
16
Q
Name cardiac side effects of antipsychotics
A
PROLONGED QT INTERVAL- particularly with pimozide and haloperidol
Postural hypotension
Tachycardia
17
Q
Name endocrine / metabolic side effects of antipsychotics
A
HYPERPROLACTINAEMIA:
Causes gallactorhoea, breast enlargement, reduced mineral bone density and sexual dysfunction)
Impaired glucose intolerance
Hypercholesterolaemia
18
Q
Definition of schizophrenia
A
A psychotic disorder characterised by hallucinations, delusions and thought disorders.
Must occur in the absence of organic disease or drug or alcohol related disorder
and isn’t secondary to depression or elevation of mood
19
Q
Name 4 poor prognostic indicators in schizophrenia
A
Strong family history Low IQ Lack of obvious precipitation Premorbid history of social withdrawal Gradual onset
20
Q
Describe the pathophysiology behind schizophrenia
A
Overactivity of the Mesolimbic dopamine pathways
This is why antipsychotics aim to block D2 receptors
21
Q
Name biological factors that are a risk factor for schizophrenia
A
Being male
Strong family history
High dopamine in the brain, low GABA glutamate and serotonin
Neurodevelopmental issues eg birth trauma, intrauterine infection, prematurity, fetal brain injury
22
Q
What is a neologism
A
Making up and using a new word
Or using a word that we all know but using it in an inappropriate sense
23
Q
Name the positive symptoms of schizophrenia
A
Delusions Hallucinations Formal thought disorder Thought interference Passitivity phenomenon
24
Q
Name 8 risk factors for depression
A
Female family history of depression alcohol use adverse life event past history of depression physical co-morbidity low socioeconomic status
25
Name the 3 core symptoms of depression
anhedonia
anergia
low mood
26
Name 4 cognitive symptoms of depression
lack of concentration
negative thoughts - becks triad
excessive guilt
suicidal ideation
27
name 5 biological symptoms of depression
```
early morning wakening
loss of libido
diurnal variation in mood
psychomotor retardation
weight loss/loss of appetite
```
28
ICD-10 Diagnostic criteria for depression?
2 core symptoms plus 2 other symptoms (mild depression)
2 core + 3-4 others = moderate
3 core + over 4 other symptoms = severe depression
29
what is becks triad
negitive thoughts about self, the world and the future
30
what diagnostic questionnaires can be used in depressive disorder
PHQ-9
HADS
becks depression inventory
31
What tests should you do to rule out organic causes of depression
```
FBC (anaemia for fatigue)
TFT (for hypothyroidism)
LFTS
Calcium levels
Glucose levels (for anergia)
CT head if atypical presentation
```
32
describe clinical presentation of atypical depression
weight gain, increased appetite
hypersomnia (excessive sleep)
delusions/hallucinations in severe depression
33
name 3 psychiatric differentials for depression and 2 organic differentials
psych: BPAD, anxiety disorders, secondary to substance use, normal bereavement
organic: hypothyroidism, diabetes, Anaemia, biochemical abnormalities
34
Define recurrent depressive disorder
when a patient has another depressive episode after their 1st episode
35
define seasonal affective disorder
depressive episodes recurring annually at the same time each year, usually during the winter months.
36
Define masked depression
a state in which depressed mood isn't particularly prominent, but other features are present e.g EMW, diurnal variation
37
define atypical depression
occurs with mild-moderate depression with reversal of symptoms e.g over eating, weight gain and hypersomnia
38
define dysthymia
a depressive state that lasts for at least 2 years, which doesn't meet the criteria for mild, moderate or severe depression and is not the result of a partially treated depressive illness.
39
what is dysthymia
a chronic depressive state lasting longer than 2 years, where your low mood can fluctuate between mild to severe but characterised by low-self esteem, hopeless feelings, lack of concentration/productivity e.g the non-core symptoms
40
define cyclothymia
chronic mood fluctuation over at least a 2 year period with episodes of elation and episodes of depression, but the symptoms do not meet the criteria for a hypomanic or depressive disorder
41
define baby blues
anxious, tearful and irritable mothers typically onset 3-7 days after birth. more common in primiparae women
42
what is biological management of depression
Mild-moderate: watchful waiting, antidepressants not recommended for mild depression unless it has gone on for months, if they have a past history of severe depression or if other interventions have failed.
Moderate - severe: SSRI'S 1st line, adjuvants include antipsychotics or lithium.
ECT can be considered as a last option if other interventions fail in acute severe depression
43
psychological management of depression?
CBT, interpersonal therapy, psychoeducation, counselling , behavioural activation, psychodynamic therapy
44
social management of depression
social support groups
| exercise
45
Management options for mild-moderate depression?
- watch and wait
- self-help programmes
- online CBT
- exercise programmes (social prescribing)
- psychotherapy: counselling, behavioural activation, IPT, psychodynamic therapy
note: antidepressants not recommended unless other options have failed or they have a history of severe depression
46
Management of moderate-severe depression
- do suicide risk assessment
- consider mental health act
- antidepressants - SSRI first line
- Adjuvants e.g lithium, antipsychotics
- psychotherapies e.g CBT, IPT, counselling, psychodynamic therapy
- social support groups
- exercise groups
- ECT (last option)
47
give 5 indications for electroconvulsive therapy
1. severe depression that is life threatening
2. rapid response needed
3. depression with psychosis
4. psychomotor retardation
5. other treatments have failed
48
how long should you prescribe antidepressants for after 1st depressive episode has ended
6 months
49
Define bipolar affective disorder
a chronic mood disorder characterised by at least 1 episode of mania and one further episode of depression or mania
50
pathophysiology of BPAD?
Monoamine hypothesis: elevated mood is a result of increased central monoamines (serotonin, dopamine and noradrenaline) and depressed mood is a result of low monoamines
Hypothalamis pituitary adrenal axis dysfunction
strong heritability
51
Name precipitating factors for a first mania episode
stressful or significant life event
52
Name the symptoms of mania
I DIG FASTER
```
Irritability
Disinhibition/distracted
Grandiose delusions
Flight of ideas
Appetite increased
sleep decreased
talkative
elevated mood/energy increased
reduced concentration/reckless
```
53
define hypomania
mildly irritable/elevated mood lasting for 4+ days. Interferes with work and social life but not severely.
Partial insight
54
define mania
A state of irritable/elevated mood lasting for more than 1 week with complete disruption of work and social activities.
Likely to have grandiose ideas, excessive spending and sexual disinhibition and lack of sleep
55
define mania with psychosis
a severely elevated or suspicious mood with the addition of psychotic features e.g grandiose or persecutory delusions, auditory hallucinations that are mood congruent.
may be aggressive
56
define bipolar type 1 characteristics
periods of severe mood episodes from mania to depression
57
define bipolar type 2 characteristics
milder form of mood elevation with mild hypomania that alternate with periods of severe depression
58
define rapid cycling BPAD
more than 4 mood swings in a 12 month periods with no intervening asymptomatic periods.
59
what is the ICD-10 criteria for a diagnosis of Mania
```
requires 3/9 symptoms, including:
Grandiosity
reduced sleep
pressure of speech
flight of ideas
distractibility
psychomotor agitation
reckless behaviour
social disinhibition
marked sexual energy
```
60
what is the ICD-10 diagnostic criteria for Bipolar Affective disorder diagnosis
need at least TWO episodes in which a persons mood and activity levels are significantly disturbed.
ONE of such episodes must be MANIA or HYPOMANIA
note: for a diagnosis of mania you need 3/9 symptoms
61
what are the 5 types of bipolar states
```
currently hypomanic
currently manic
currently depressed
mixed disorder
in remission
```
62
what questionnaire can you use to aid the diagnosis of BPAD
mood disorder questionnaire
63
what investigations would you do to rule out organic causes associated with BPAD
```
FBC (routine)
TFT - hypo/hyperthyroidism
Do U+E's for a baseline renal function with view to starting lithium
Calcium levels
Urine drug test
CT head for space occupying lesion
```
64
Give 4 differential diagnoses for BPAD
```
depression
schizoaffective disorder
schizophrenia
cyclothymia
hyper/hypothyroidism
e.g frontal lobe lesion (cerebral)
illicit drug use
corticosteroid side effect
```
65
Describe management of an acute manic/mixed BPAD episode
antipsychotic e.g olanzipine/quetiapine. used bc have a more rapid onset of action than mood stabilisers. Add lithium too. Benzodiazipines can be used to calm agitation/aid sleep.
Sodium valporate can be offered as a 2nd line alternative to lithium as a mood stabiliser.
If the 1st antipsychotic doesn't work a 2nd will be offered.
66
what is the 1st line treatment of an acute manic episode
antipsychotic e.g olanzipine/quetiapine plus lithium
67
what drug can be used as an alternative to lithium as a mood stabilizer
sodium valporate or lamotrigene long term
68
what drug can be used for calming of agitation/to aid sleep
benzodiazepines e.g diazepam or lorazepam
69
what drugs are used for a bipolar depressive episode
atypical antipsychotics e.g olanzipine/quetiapine
| lithium or lamotrigine as a mood stabiliser
70
Why should antidepressants be avoided in BPAD patients
because they can induce mania if used alone. should be used carefully if prescribed with an antipsychotic
71
What tests should you do before starting a patient on lithium
U+E's -bc lithium is excreted renally
TFT
pregnancy status
Baseline ECG
72
Name side effects of lithium
polydipsia, polyuria, fine tremor, weight gain, oedema,
HYPOTHYROIDISM
memory problems
impaired renal function
73
what therapeutic level should you aim for with lithium
between 0.5-1.0mmol/L
74
How often should you check lithium levels
- 12 hours after 1st dose
- THEN weekly until lithium levels have been stable between 0.5-1.0 for 4 weeks in a row
- once stable check every 6 months
75
what is the first line treatment for rapid cycling BPAD
a combination of lithium and sodium valporate
76
Name symptoms of lithium toxicity
```
Nausea, diarrhoea and vomiting
COARSE tremor (not fine)
ataxia
muscle weakness
fasciculations
clonus
nystagmus
dysarthria
hyperreflexia
oliguria
hypotension
convulsions
coma
```
77
Define psychosis
a mental state in which reality is greatly distorted.
| Typically presents with delusions, hallucinations and thought disorder.
78
define a delusion
a fixed, firmly held false belief that deviates from the individuals normal social and cultural beliefs.
79
define a hallucination
a perception in the absence of an external stimulus
80
define a pseudohallucination
a perception in the presence of an external stimulus
81
what is a thought disorder
an inability to form thoughts from logically connected ideas
82
name 6 non-organic causes of psychosis
```
schizophrenia
schizoaffective disorder
acute psychotic episode
delusional disorder
drug induced psychosis
mood disorder with psychosis
```
83
name 6 organic causes of psychosis
```
dementia
delirium
drug induced
complex partial epilepsy
SLE
cushings syndrome
vitamin B12 and folate deficiency
huntingtons disease
```
84
what is schizotypal disorder
a disorder very similar to schizophrenia whereby the individual acts weird, suspicious, with unusual speech and affect, however there is NO HALLUCINATIONS OR DELUSIONS
85
what is an acute/transient psychotic disorder
an acute episode of psychosis lasting less than 1 month therefore not meeting the criteria for schizophrenia
86
what is schizoaffective disorder
characterised by both symptoms of a mood disorder and schizophrenia in an episode of the same illness. e.g mania and schizophrenia or depression and schizophrenia. Mood symptoms should meet the criteria for depressive illness or mania with one or 2 symptoms of schizophrenia
Schizophrenia symptoms persist with the occasional episode of mood disorder
87
what is persistent delusional disorder
a single or set of delusions held for at least 3 months. This should be the only symptom with other areas of thinking and functioning preserved
88
What is induced delusional disorder aka Folie a deux
a disorder where 2 or more people share the same delusional belief
a person primarily forms the delusion in a psychotic episode and passes it onto another person
89
what is puerperal psychosis
the acute onset of manic or psychotic episode shortly after childbirth (usually in the 1st 2 weeks)
90
what is late paraphrenia
late-onset schizophrenia. not coded for in icd-10
91
What are schneiders first rank symptoms of schizophrenia
1. delusional perception
2. third person auditory hallucination (usually running commentary)
3. thought interference (e.g withdrawal, boradcast, insertion)
4. passivity phenomenon - actions feelings or thoughts are being controlled by an external force
92
define schizophrenia
psychotic disorder characterised by delusions, hallucinations and thought disorders which lead to functional impairment.
Always in the absence of organic disease, alcohol or drug related disorders and isn't secondary to mood depression or elevation.
93
pathophysiology of schizophrenia
dopamine hypothesis: overactivity of mesolimbic dopamine pathways in the brain
factors that interfere with neurodevelopment including low birthweight, obstetric complications, fetal injury.
94
what is the expressed emotion theory of schizophrenia
people whos relatives who are overly involved in their lives, are overly hostile or critical are more likely to develop schizophrenia
95
what is the stress-vulnerability model
a model that predicts that schizophrenia occurs due to enviornmental factors (e.g adverse life events, abuse, bullying) interacting with a genetic predisposition (e.g family history of mental illness or brain injuries)
96
name biological factors that predispose you to schizophrenia
```
HIGH dopamine
LOW gaba, serotonin and glutamate
birth injuries
prematurity
being aged 15-35
```
97
name psychological factors that predispose you to schizophrenia
family history of mental illness
| childhood abuse
98
name social factors that predispose you to schizophrenia
substance misuse
low socioeconomic status
birth in late winter
99
name biological factors that precipitate schizophrenia
smoking cannabis or taking psychoactive drugs
100
name a psychosocial factor that precipitates schizophrenia
adverse life event/stressful life event
101
name a biological factor that perpetuates schizophrenia
poor compliance to medication
| substance misuse
102
name a social factor that perpetuates schizophrenia
```
low social support
expressed emotion (within the family)
```
103
name a psychological factor that perpetuates schizophrenia
adverse life event
104
name the positive symptoms of schizophrenia
```
Delusions
Hallucinations
Thought disorder
thought interference
passitivity phenomenon
```
105
what is passitivity phenomenon
the thought that your actions feelings or emotions are being controlled by an external force
106
name the negative symptoms of schizophrenia
```
Anhedonia
Affect blunted
Avolition (reduced motivation)
Alogia (poverty of speech)
Asocial behaviour
Attention deficits
```
107
what is the ICD-10 criteria for a schizophrenia diagnosis
one symptoms from group A, or two or more symptoms from group B.
Symptoms must have been present for at least 1 month
Only diagnosed in the absence or organic brain disease.
GROUPA:
1 .Thought echo/insertion/withdrawal/broadcast
2. delusions of control, influence or passitivity phenomenon
3. running commentary third person auditory hallucination
4. Bizzare persistent delusions
GROUP B:
1. hallucinations in other modalities that are persistent (e.g visual/tactile)
2. thought disorganisation e.g loosening of association, incoherence)
3. Catatonic symptoms
4. negative symptoms
108
what are the symptoms of catatonia
- Stupor (where person cant move or speak)
- Waxy flexibility - person stays in the same position for an extended period of time.
- echolalia - person responds to conversatino by echoing the question
- catalepsy (muscular rigidity)
- lack of response to external stimulation
- mutism
- echopraxia - mimicing someone elses movements
109
what are the ICD-10 group A criteria for schizophrenia
1. thought insertion/echo/broadcasting/withdrawal
2. running commentary hallucinations
3. delusions of control, influence of passitivity
4. bizzare persistent delusions
110
what are the ICD-10 group B criteria for schizophrenia
1. hallucinations in other modalities (not auditory)
2. thought disorganisation
3. catatonic symptoms
4. negative symptoms
111
what investigations would you order in a patient with suspected schizophrenia
CT head - rule out space occupying lesion e.g frontal lobe dishinhibition
EEG - to rule out temporal lobe epilepsy
Bloods - B12, folate, cholesterol, U+E, calcium, glucose, TFT, FBC
ECG for QT prolongation
Urine drug anaylsis
112
biological management of schizophrenia
Atypical antipsychotics (1st line)
can add adjuvants e.g benzodiazepines for behavioural symptom relief
ECT may be appropriate for treatment resistant patients
113
How do you treat treatment resistant schizophrenia
Clozapine
| if clozapine doesn't work then use ECT
114
Psychological management of schizophrenia
- CBT
- Family intervention - psychoeducation helps families reduce high levels of expressed emotion
- art therapy helps relieve -ve symptoms
115
social management of schizophrenia
social support groups
peer support schemes
supported employment programmes
116
what is the yerkes dodson law
anxiety can be beneficial up to a plateau of optimal functioning. After that point level of performance deteriorates
117
what is anxiety
an unpleasant emotional state involving subjective fear and somatic symptoms
118
name common features of neuroses
```
anticipating/fear of impending doom
exaggerated startle response
depersonalisation/derealisation
palpitations/chest pain
hyperventilation/ chest tightness
abdo pain, loose stools, nausea vomiting
dysphagia
dry mouth
failure of erection, menstrual discomfort
tremor, myalgia, headache, tinnitus
```
119
how can you classify neurotic/stress related disorders
split into paroxysmal anxiety and continuous anxiety
| can also be situation dependent and situation independent
120
name 5 medical conditions commonly associated with anxiety
```
hyperthyroidism
hypoglycaemia
anaemia
malignancy
substance misuse
eating disorders
somatoform disorders
depression
OCD
PTSD
```
121
define generalised anxiety disorder
a syndrome of ongoing, uncontrollable widespread worry about many events, or thoughts that the patient recognises as excessive and inappropriate. Symptoms are present most days in a 6 month duration.
122
Describe the biological pathophysiology behind generalised anxiety disorder
dysfunction of the autonomic nervous system
exaggerated responses in the amygdala and hippocampus
alterations in GABA, serotonin and noradrenaline.
123
What can antipsychotics treat and what can't they treat
can treat positive symptoms
| cant treat negative symptoms
124
what are the 3 main actions of antipsychotics
- control psychotic symptoms (within months)
- tranquilisation (within days)
- sedation (within hours)
125
what are the 3 main anxiety disorders
g.a.d.
phobic anxiety disorders
panic disorder
126
define PTSD
a delayed, prolonged and intense reaction to a traumatic event
127
define normal bereavement
a normal reaction to a traumatic event/loss of a loved one that doesnt last longer than 6 months
128
define abnormal bereavement
an abnormal reaction that occurs in response to an identifiable, non-catastrophic event e.g divorce or loss of a job, that occurs within one month usually but usually doesn't last longer than 6 months
129
define acute stress reaction
exposure to an exceptional physical/emotional stressor followed by IMMEDIATE onset of symptoms e.g within one hour. symptoms include anxiety, dissociation, disorientation, anger, uncontrollable/excessive grief.
130
name risk factors for PTSD
profession eg doctor/fire man more likely to be exposed to trauma,
asylum seekers,
previous trauma,
PMH of mental health issues
low SES/ social support
extremely distressing event exposure with perceived threat to life
concurrent life stressors eg happens when going through a divorce
131
name the 4 categories of symptoms of PTSD
reliving - flashbacks, nightmares
avoidance - eg excessive rumination, inability to recall
hyperarousal - difficulty sleeping, irritable outbursts
emotional numbing - negative thoughts, detachment from others
132
icd-10 criteria for PTSD diagnosis
1. occurs within 6 months
2. persistent remembering/reliving
3. exposure to stressful event
4. avoidance of similar situations
5. inability to recall
6. increased arousal
133
psychological management of PTSD
CBT (trauma focused)
| eye movement desensitization and reprocessing
134
biological management of PTSD
SSRI eg paroxetine
| drug therapy used 2nd line after CBT, or in conjunction if evidence of co morbid depression/anxiety is present
135
define OCD
recurrent obsessional thoughts or compulsive acts
136
define obsession
an unwanted intrusive thought that enters the pts mind and is distressing cos they know they are unreasonable
is a product of their own mind
137
define compulsion
a repetitive act that the pt feels driven to carry out
138
pathophysiology behind ocd
a learned behaviour = operant conditioning
| reduced serotonin in basal ganglia ad frontal cortex
139
icd 10 criteria for ocd
1. must be present for most days for at least 2 weeks
2. compulsions/obsessions must be characterised by...
- failure to resist
- originate from pts own mind
- repetitive
- distressing
- carrying them out relieves anxiety but isnt enjoyable
140
what are the 4 components of the ocd cycle
obsession --> anxiety --> compulsion --> relief
141
psychological management of ocd
CBT including exposure and response prevention
142
pharmacological management of OCD
SSRI first line e.g paroxetine, citalopram
clomipramine can also be added to citalopram if severe
143
what should you always screen for in pts with OCD
screen for depression bc highly co-morbid with ocd, also do suicide risk assessment
144
define agorophobia
fear/anxiety relating to public spaces
145
define social phobia
fear/anxiety of being in social situations that may cause embarrassment/criticism/humiliation
146
give examples of specific phobias
```
claustrophobia
arachnophobia
needles
blood
water
heights
flying
```
147
define a phobic anxiety disorder
an intense irrational fear of an object or situation that the individual recognises as irrational or excessive
148
describe features of a phobic anxiety disorder
autonomic response to feared situation e.g palpitations, vasovagal syncope, sweating, tremors
psych: anticipatory anxiety, inability to relax, avoidance and a fear of dying
149
ICD 10 criteria for agorophobia
marked consistent fear or avoidance in..
- crowds
- public spaces
- travelling alone
- travelling away from home
AND
has symptoms of anxiety in the feared situation
AND causes significant emotional distress
is recognised as unreasonable
AND symptoms are restricted to the feared situation on ly
150
ICD 10 criteria for social phobia
```
marked consistent fear or avoidance of being the focus of attention in a social situation
plus two of the following..
- blushing
- fear of vomiting
- urgency or fear of weeing/pooing
```
AND causes significant emotional distress
AND is recognised as unreasonable
AND symptoms are restricted to the feared situation
151
ICD 10 criteria for specific phobia
marked fear or avoidance fo a specific object or situation
plus
symptoms of anxiety in the feared situation
AND causes signitficant emotional distress
AND is recognised as unreasonable
AND symptoms are restricted to the feared situation
152
how do you distinguish a phobic anxiety disorder from generalised anxiety disorder
phobic anxiety ...
- occurs in response to specific stimulus
- there is anticipatory anxiety
- avoidance of stressful situations
in GAD there is no avoidance or anticipatory anxiety bc there is NO TRIGGER
153
how do you distinguish phobic anxiety disorder from panic disorder
panic disorder = panic attacks occur spontaneously with no trigger + no avoidance
phobic anxiety = avoidance of the situation that triggers the panic attack
154
how do you distinguish GAD from panic disorder
in GAD the anxiety and worry is always there whereas in panic disorder feelings are normal in between attacks which are spontaneous
155
icd-10 criteria for GAD
```
at least 6 months of prominent tension, worry and feeling apprehensive about normal every day life events.
must have at least 4 of the following symptoms:
- palpitaitons
- chest tightening
- shaking/tremor
-sweating
- dry mouth
-gi upset
-muscle aches
- feeling dizzy
- derealisation/ depersonalisation
- sleep problems
-irritable
```
156
what investigations would you do in pts that present with GAD to exclude organic cause of the symptom
blood glucose (hypoglycaemia)
FBC - infection/anaemia
TFT hyperthyroidism
ECG for palpitations
157
biological management of GAD
Sertraline = 1st line bc has anxinolytic effects
SNRI eg venlafaxine or duloxetine can be offered 2nd line
dont offer benzos apart from short term symptomatic relief if severe
158
psychological management of GAD
psychoeducation = low intensity psych intervention
CBT = high intensity
applied relaxation techniques
159
describe the steps in treating GAD
1. diagnosis + psychoeducation and monitoring
2. add low intensity psych intervention eg self help, group therapy
3. high intensity psych (CBT or applied relaxation) OR drug treatment
4. drug therapy + CBT + crisis team input
160
define a somatoform disorder
where a pt has symptoms of a physical illness in the absence of psychological illness, but it is presumed the symptoms are caused by psychological factors.
they persistently seek medical attention even though it doesnt help them
161
define a dissociative (conversion) disorder
symptoms that cant be attributed to a medical disorder but there is a convincing association between onset of symptoms and the presence of a stressful life event
- stressful event/problem = converted into physical symptoms
162
describe the pathophysiology behind somatoform/dissociative disorders
- pts adopt the sick role = primary or secondary gain
| - associated with PTSD and sexual abuse
163
describe the process behind developing dissociative disorders
1. distressing life event
2. emotional distress
3. dissociation = separates the distressing event from normal consciousness
4. converts emotional distress into physical symptoms
5. primary gain = stress relief secondary gain = financial rewards eg benefits
164
risk factors for dissociative/somatoform disorders
```
childhood abuse
reinforcement of illness behaviours
anxiety disorders
mood disorders
personality disorders
social stressors
```
165
name types of dissociative disorders (eg symptoms that can manifest from conversion)
dissociative amnesia
dissociative fugue - unexpected physical journey away from normal surroundings
dissociative stupor - reduction in speech/movement/ response to stimuli
trance - temporary altered consciousness
possession - thinks theyve been taken over by a spirit
motor disorder = unexpected movements (involuntary) that look like epilepsy
Anaesthesia/sensory loss - loss of normal sensation
166
what is somatoform disorder aka briquets syndrome
multiple recurrent and frequently changing physical symptoms that dont relate to a physical illness
usually has a long history of contacting medical services.
common presentations include GI upset, dysphagia, chest pain, SOB, dysuria, incontinence, itching, headache, paraesthesia, visual disturbance
167
what is hypochondriachal disorder
pt misinterprets normal body sensations leading to non-delusional pre occupation that they have a serious physical disease
refusal to accept reassurance from doctors
168
what is persistent somatoform pain disorder
persistent and severe pain (longer than 6 months) that cant be explained by physical disorder
often emotional in cause
169
what is malingering
where physical symptoms are intentionally produced = the patient has a motive to produce fake symptoms
the pt seeks advantageous benefits of being diagnosed with a medical condition eg avoiding prison
170
what is factitious disorder (munchausens syndrome)
pt fakes having a disorder intentionally to adopt the sick role to recieve the care of a patient or for internal emotional gain
171
mechanism of action for zopiclone
enhances gaba transmission
172
which drugs can be used to treat insomnia
zopiclone
| benzo in short term
173
give example of short acting benzo
lorazepam
174
give example of long acting benzo
diazepam or chlordiazepoxide
175
give two uses for chlordiazepoxide
- sedetive
| - alchohol withdrawal/delirium tremens
176
what are the symptoms of benzo overdose
ataxia
nystagmus
dysarthria
respiratory depression
177
how do you treat a benzo overdose
ABCDE
| iv flumazemil
178
how does sodium valporate work
inhibits breakdown (catabolism) of GABA
179
when should sodium valporate be used
can be used in BPAD if lithium is ineffective or can be added to lithium for rapid cycling BPAD
180
side effects of sodium valporate
```
hair loss
weight gain
GI disturbance
ataxia
tremor
tiredness
```
181
when can carbamezapine be used in psychiatry
BPAD resistant to lithium
alcohol withdrawal
note: never use in combination with lamotrigene bc neuro toxic
182
how does carbamezapine work
blocks voltage gated sodium channels to prevent excessive neuronal firing
183
what can lamotrigene be used for in psychiatry
bipolar depression
can replace lithium
can be used in pregnancy
184
side effects of lamotrigene
GI disturbance
| RASH
185
give symptoms of lithium toxicity
```
tremor
acute confusion
hyperreflexia
polyuria
seizures
coma
```
186
management of lithium toxicity
usually iv fluids is fine
| if severe = renal dialysis
187
side effects/complications of lithium
```
Gi disturbance
weight gain
impaired renal function
thirst
weeing more often
fluid and weight retention
QT prolongation
reduces seizure threshold
```
188
contraindications to lithium
pregnancy, cardiac issues (long QT), epilepsy, hypothyroidism (destroys thyroid)
189
side effects of carbamezapine
dizziness, dermatitis, hyponatraemia
190
normal lithium levels and levels for toxicity
normal = 0.4-1
| toxicity =over 1.5
191
what monitoring should be done when starting lithium
```
TFT
eGFR
FBC
U+E
baseline ECG
pregnancy status
```
192
mechanism of action for lithium
reduces intracellular sodium and calcium
193
how often should lithium levels be checked
12 hours after 1st dose
then weekly till stable for 4 weeks
when stable for 4 weeks check 3 monthly
194
management of neuroleptic malignant syndrome
ABCDE
IV fluids
bromocriptine
195
symptoms of neuroleptic malignant syndrome
```
acute onset
typically within 10 days of starting treatment or increasing dose
irritable
confusion
PYREXIA
MUSCLE RIGIDITY
AUTONOMIC INSTABILITY = tachycardia and fluctuating BP
fluctuating consciousness
```
196
what do blood tests show in neuroleptic malignant syndrome
derranged LFTs
increased creatinine kinase!!!
leukocytosis (sometimes)
197
name specific clozapine side effects
hypersalavation
agranulocytosis
reduced seizure threshold
198
how do you manage extrapyramidal side effects of antipsychotics (eg tardive dyskinesia, akanthesia, acute dystona)
procyclidine
199
give examples of SSRI's
citalopram, sertraline, fluoxetine, paroxetine
200
how do SSRI's work
inhibiting the REuptake of serotonin from the synaptic cleft = increases serotonin levels in the cleft
201
side effects of SSRI's
```
Gi disturbance
sweating
tremor
rashes
sexual dysfunction
stopping SSRI syndrome
```
202
give examples of SNRI
venlafaxine and duloxetine
203
how to SNRIs work
inhibit the reuptake of serotonin and noradrenaline in the synaptic cleft = increase availability
doesn't have as many cholinergic effects
204
give examples of NSSAs (noradrenaline serotonin specific antidepressants)
mirtazapine
205
how does mirtazapine work
weak noradrenaline reuptake inhibitingeffect and has anti histminergic effects and blocks alpha 1 and 2 receptors
206
when is mirazapine indicated
2nd line depression where weight gain and sedation is needed for insomnia
207
side effect of mirtazapine
weight gain, postural hypotension
208
autism triad
ABC
asocial
behaviour restricted
communication impaired
209
name characteristics of autism
onset before 3 years of age
asocial: few social gestures, gaze avoidance, lack of interest in others, lack of emotional expression
communication impairment - delayed and distorted speech, echolalia
restricted behaviours e.g upset in change in daily routine, repetitive behaviour eg rocking or twisting, obsessively persued interests
210
conditions associated with autism
epilepsy
visual impairment
hearing impairment
learning disability
211
genetic conditions associated with autism
fragile x syndrome
| tuberous sclerosis
212
risk factors for autism
maternal age over 40
birth issues e.g hypoxia, low fetal weight
sodium valporate in pregnancy
prematurity
213
describe aspergers syndrome
impaired social functioning and repetitive interests/behaviours but no impairment in language, cognition or IQ
214
describe retts syndrome
```
severe progressive disorder starting in early life.
language impairment
repetitive hand movements
loss of fine motor skills
irregular breathing
seizures
ONLY GIRLS
```
215
main management of autism
social communication based intervention and assisting with ADLs
speech and language therapist input
autism team
modification of environmental factors that initiate challenging behaviour
216
triad of ADHD symptoms
inattention
hyperactivity
impulsivity
217
icd 10 criteria for autism diagnosis
- onset at 3 years of age (impaired development)
- communication impairment
- social interaction impairment
- restrictive and repetitive behaviours
218
icd 10 criteria for ADHD diagnosis
abnormality of attention, activity and impulsivity at home for the age and developmental level of the child.
abnormality and school/nursery
directly observed abnormality
doesnt meet criteria for another disorder
onset before age 7
duration of at least 6 months
iq above 50
219
1st line management of ADHD
parent training educational program
| CBT/social skills training in older children
220
1st line medical management of severe ADHD
methylphenidate
| 2nd line is atomoxetine/dexamfetamine
221
symptoms of opiate use
respiratory depression, low BP, hypoxia, pupillary CONSTRICTION
222
symptoms of stimulant use
arrythmia, high bp, increased HR, pupillary dilation, psychomotor agitation, muscle weakness
euphoria, grandiose delusions, paranoid ideation, labile
223
name the components of substance dependence
must have all occurred over 1 month:
- preoccupation with the substance use
- strong desire to take it
- withdrawal state if stops using
- impaired ability to control use
- built up a tolerance
- keeps using despite the harmful effects
224
what investigations should you undertake in substance abuse
```
urinalysis for drug levels
bloods - FBC, HIV and hep B and C screen
LFT and clotting to check hepatic function
ECG for arrythmia
Echo if suspect endocarditis
```
225
management of substance abuse
hep B immunization for needle users
MOTIVATIONAL INTERVIEWING - to help stop
contingency management - changes behaviours
plus bio therapy for the substance
226
biological management of opioid use
1st line is methadone or buprenorphine for maintenance and detox
227
management of opioid overdose
IV naloxone
228
what drug is used for opioid users who have completely abstained to maintain abstinence
naltrexone
229
describe the edward gross criteria for alcohol dependency
```
SAW DRINK
subjective awareness of need to drink
avoidance of withdrawal
gets Withdrawal symptoms
has drink seeking behaviour
reinstates drinking behaviours after abstaining
increased tolerance to alcohol
narrowing of drinking repetoire
```
230
symptoms of alcohol withdrawal
```
tremor
nausea
hallucinatios
autonomic hyperactivity
seizures peak at 72 hours after stopping
```
231
what is delirium tremens
```
coarse tremor
delusions
confusion
auditory and visual hallucinations
fever
tachycardia
seizures
```
232
management of delirium tremens
iv chlordiazepoxide (long acting benzo) bc phenytoin not as helpful in seizures in alcohol withdrawal
233
long term management of alcohol dependency - eg inducing abstinence
inpatient detox recommended for those at risk of suicide or a severe history of withdrawal reactions
give high dose chlordiazepoxide tapered down over 10 days plus iv thiamine to prevent wernickes encephalopathy
Disulfiram - causes unpleasant symptoms when the pt drinks alcohol
acomprosate - reduces cravings by enhancing GABA transmission
Naltrexone - reduces pleasurable effects of alcohol by blocking opioid receptors
234
describe paranoid personality disorder
suspicious of others
questions partners faithfulness
thinks others are attacking them
no trust
235
describe schizoid personality disorder
LONER
| flat, cold affect, no emotion, no close friends, likes to be alone, no pleasure in anything
236
describe emotionally unstable personality disorder
```
unstable relationships
unstable mood
easily gets angry
suicidal
impulsive
```
237
describe histrionic personality disorder
emily williams
| attention seeking, cares about looks, easily influences
238
describe dissocial personality disorder
gets violent easily
blames others and holds grudges so has no friends
impulsive
remorseless - doesnt care when they do things wrong
239
describe anxious avoidant personality disorder
needs to be known that they are liked, avoids situations where they could be embarrassed, feels inadequate, restricts lifestyle to feel safe
240
describe dependant personality disorder
```
needs constant reassurance
fears abandonment
no self confidence
doesnt like conflict
needs a companion all the time
needs others to be responaible
```
241
describe akanistic personality disorder
```
DAD
workaholic
stubborn
fussy with minor details
ability to complete tasks is compromised due to attention to detail
```
242
section 2
for assessment
lasts 72 hours
need 2x doctor and 1 AMHP
evidence = pt has mental health issue that needs assessing + for own/public safety
243
section 3
for treatment
lasts 6 months and can be renewed
needs 2x dr and 1 AMHP
evidence = pt has mental health issue that needs hospital tx + for own or other safety + treatment must be availanle
244
section 4
emergency section done when waiting for 2nd doctor to confirm section 2/3
lasts 72hrs
needs 1 dr and 1 AMHP
245
section 136
in public place police can detain for public safety
246
section 135
court order needed to remove pt from own home to psych assessment/tx
247
section 5(4)
nurses holding power for 6 hours whilst a doctor comes to assess
must be on a ward not emergency department
CANNOT TX
248
section 5(2)
doctors holding power for 72 hours until doctor comes to assess.
must be on a ward not A+E
CANNOT TX
249
icd-10 criteria for anorexia diagnosis
```
FEED
fear of weight gain
endocrine disturbance - e.g amennorhoea
emaciated (skinny)
deliberate weight loss
distorted body image
```
250
difference between anorexia and bulimia
anorexia: no binge eating, no compensatory behaviours, usually more skinny and more likely to have endocrine disturbance, usually no food cravings
bulimia = episodes of binge eating followed by compensatory behaviour, usually normal weight or can be over weight, strong cravings for food
251
complications of having an extremely low BMI
```
amenorrhoea
anaemia
impaired immune system
pancreatitis
metabolic alkalosis from vomiting
osteoporosis
metabolic acidosis from laxative use
arrythmias
bradycardia
dehydration - constipation
hypothyroid
```
252
management of anorexia
risk assessment for suicide
6 months of psycholical intervention eg CBT
aim to gain weight of 0.5-1kg per week in hospital to avoid refeeding syndrome
253
indications for hospitalization of pt with anorexia
severe anorexia with bmi below 14
| suicidal ideation
254
what is refeeding syndrome
causes changes to phosphate and magnesium when feeding after prolonged starvation/malnourishment
causes an insulin surge
causes = hypokalaemia, hypomagnesium, hypophosphataemia, and absnormal glucose metabolism
phosphate depletion can lead to heart failure!
255
how do you manage/prevent refeeding syndrome
slow feeds increasing by 0.5-1kg per week
monitor blood electrolytes, BP and pulse daily
if electrolytes drop low then need to be replaced intravenously
256
what is bulimia
repeated episodes of uncontrolled binge eating followed by compensatory weight loss behaviours eg vomiting or laxatives
have overvalued ideas about body shape
257
icd 10 criteria for bulemia diagnosis
1. compensatory behaviours to prevent weight gain
2. preoccupation with eating
3. fear of being fat
4. over eating
258
complications of bulimia
irregular periods
signs of dehydration eg sunken eyes
depression/low self esteem
hypokalaemia due to repeated vomiting
259
investigations to do in bulimia
VBG for metabolic alkalosis from vomiting
ECG for hypokalaemia
U+E, FBC, amylase for pancreatitis, glucose etc
260
management of bulimia
```
Fluoxetine 1st line
psychoeducation
CBT
food diary to monitor eating habits
risk assessment for suicide
```
261
indications for admitting a bulimia pt
suspicion of dehydration or electrolyte disturbance
| risk of suicide
