Psychiatry Flashcards
(189 cards)
1
Q
WHAT IS DELERIUM?
A
- Abrupt change in the brain that causes mental confusion and emotional disruption.
- It makes it difficult to think, remember, sleep, pay attention, and more.
2
Q
What are the different types of delerium?
A
Delirium tremens
Severe form of the condition experienced by people who are trying to stop drinking
Hyperactive delirium
Characterized by being highly alert and uncooperative
Hypoactive delirium
More common. With this type, you tend to sleep more and become inattentive and disorganized with daily tasks. You might miss meals or appointments
Mixed delerium
Switch between hyperactive and hypoactive states
3
Q
What is the cause of delerium?
A
When the normal signals entering exiting the brain become impaired
Certain causes include:
- Certain medications or drug toxicity
- Alcohol or drug intoxication or withdrawal
- A medical condition, such as a stroke, heart attack, worsening lung or liver disease, or an injury from a fall
- Metabolic imbalances, such as low sodium or low calcium
- Fever and acute infection, particularly in children
- Urinary tract infection, pneumonia or the flu, especially in older adults
- Exposure to a toxin, such as carbon monoxide, cyanide or other poisons
- Malnutrition or dehydration
- Sleep deprivation or severe emotional distress
4
Q
How do you diagnose delerium?
A
Confusion Assessment Method (CAM)
-
Acute onset and fluctuating course
Is there evidence of an acute change in mental status from the patient’s baseline? Did this behaviour fluctuate during the past day -
Inattention
Does the patient have difficulty focusing attention; for example, being easily distracted or having difficulty keeping track -
Disorganized thinking
Is the patient’s speech disorganized or incoherent; for example, rambling or irrelevant conversation, unclear or illogical flow -
Altered level of consciousness
Overall, how would you rate this patient’s level of consciousness: alert (normal); vigilant (hyperalert); lethargic (drowsy, easily aroused); stupor (difficult to arouse); coma (unarousable)?
5
Q
What are the symptoms of delerium?
A
Cognitive impairment
Reduced awareness of the environment
Emotional disturbances
Behaviour changes
6
Q
What is the investigations for delerium?
A
Mental status assessment
Confusion assessment method
Physical and neurological examinations
Biochemical tests
Head scans - focal deficits, seizure
Drug and alcohol tests
Thyroid and glucose tests
Liver tests
Chest X-ray
Urine tests
7
Q
What is the treatment for delirum?
A
Treat the undelying cause
Promote good sleeping habits
Healthy environment/secure environment
May prescribe some of the following:
Antidepressants to relieve depression
Sedatives to ease alcohol withdrawal
Dopamine blockers to help with drug poisoning
Thiamine to help prevent confusion
8
Q
WHAT IS DEMENTIA?
A
It describes a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life.
It isn’t a specific disease, but several different diseases may cause dementia.
9
Q
What are the different types of dementia?
A
Alzheimer’s disease
Vascular dementia
Lewy body dementia
Frontotemporal dementia
Mixed dementia
10
Q
What are the rules with telling the DVLA when diagnosed with dementia?
A
As soon as diagnosis occurs the individual needs to tell them of their diagnosis
If not informed you as the doctor inform them
11
Q
What are the early warning signs of dementia?
A
4A’s – Amensia, Agnosia, Apraxia, Aphasia
12
Q
WHAT IS ALZHEIMER’S DISEASE?
A
Most common cause of dementia
Causes the brain cells to degenerate and die
13
Q
What causes alzheimer’s disease?
A
Exact cause is unknown
Brain proteins fail to function properly, disrupt brain neurons and unleash a series of toxic events
14
Q
What are the two proteins involved with alzheimers disease?
A
Plaques
Beta-amyloid is a leftover fragment of a larger protein. When these fragments cluster together, they appear to have a toxic effect on neurons and to disrupt cell-to-cell communication. These clusters form larger deposits called amyloid plaques, which also include other cellular debris.
Tangles
Tau proteins play a part in a neuron’s internal support and transport system to carry nutrients and other essential materials. In Alzheimer’s disease, tau proteins change shape and organize themselves into structures called neurofibrillary tangles. The tangles disrupt the transport system and are toxic to cells
15
Q
What are the symptoms of alzheimer’s disease?
A
Memory
Early sign of the disease, difficulty remembering recent events
Thinking and reasoning
Making judgements and decisions
Planning and performing familiar tasks
Changes in personality and behaviour
Preserved skills
Reading or listening to books
16
Q
What are the risk factors for developing alzheimer’s disease?
A
Age
Family history and genetics
Apolipoprotein E gene (APOE)
Down syndrome
Three copies of chromosome 21, appear 10 to 20 years earlier
Woman
Live longer than men
17
Q
How do you diagnose alzheimer’s disease?
A
- Physical and neurological examination
-
Lab tests
Thyroid disorders or vitamin deficiencies - Mental status and neuropschological testing
-
Brain imaging
MRI
CT -
PET
Fluorodeoxyglucose (FDG) PET
Amyloid PET imaging
Tau PET imaging
18
Q
What is the treatment for alzheimer’s disease?
A
Treat cognitive symptoms
Cholinesterase inhibitors - preserve acetylcholine
Donepezil, rivastigmine, galantamine
N-methyl-d-aspartate (NMDA) inhibitor - glutamate
Memantine
Safe environment
Alternative medicine
Omega-3 fatty acids
Curcumin
19
Q
WHAT IS VASCULAR DEMENTIA?
A
General term describing problems with reasoning, planning, judgment, memory and other thought processes
20
Q
What is the cause of vascular dementia?
A
Stroke-related VD
Multi-infarct or single-infarct dementia
Subcortical VD
Caused by small vessel disease
Mixed dementia
The presence of both VD and Alzheimer’s disease
21
Q
What are the symptoms of vascular dementia?
A
Several months or several years of a history of a sudden or stepwise deterioration of cognitive function
- Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
- The difficulty with attention and concentration
- Seizures
- Memory disturbance
- Gait disturbance
- Speech disturbance
- Emotional disturbance
22
Q
Can vascular dementia and alzheimer’s disease occur together?
A
Yes
23
Q
How is vascular dementia diagnosed?
A
- A comprehensive history and physical examination
- Formal screen for cognitive impairment
- Medical review to exclude medication cause of cognitive decline
- MRI scan – may show infarcts and extensive white matter changes
24
Q
What is the treatment for vascular dementia?
A
Often involves managing the risk factors
Lower blood pressure
Reduce your cholesterol levels
Prevent your blood from clotting
Help control your blood sugar
25
What is lewy body dementia?
Second most common type of progressive dementia after Alzheimer's disease
Protein deposits, called Lewy bodies, develop in nerve cells in the brain regions involved in thinking, memory and movement (motor control).
26
What is the cause of lewy body dementia?
1. Abnormal buildup of proteins into masses known as **Lewy bodies**
2. This protein is also associated with **Parkinson's disease**
3. People who have Lewy bodies in their brains also have the **plaques and tangles** associated with **Alzheimer's disease**
27
What are the symptoms of lewy body dementia?
**Memory problems**
**Visual hallucinations**
Hallucinations may be one of the first symptoms, and they often recur
**Movement disorders**
Signs of Parkinson's disease
28
How do you investigate lewy body dementia?
1. Usually clinical
**Can use:**
1. Single-photon emission computed tomography (SPECT)
2. OR DaTscan
29
How do you diagnose lewy body dementia?
The diagnostic criteria for dementia with Lewy bodies (BLB) are:
**There must be a progressive cognitive decline**
**Two of the following must be present:**
1. Marked fluctuations in attention and alertness
2. Recurrent visual hallucinations
3. Parkinsonism
30
What is the treatment for lewy body dementia?
**_Medications_**
1. **Cholinesterase inhibitors**
Donepezil, rivastigmine, galantamine
2. **Parkinson's disease medications**
Carvidopa-levodopa, may increase hallucinations
3. **Sleep or movement medication**
**_Therapies_**
1. **CBT**
**_Neuroleptics should be avoided!_**
31
What is frontotemporal dementia?
Umbrella term for a group of uncommon brain disorders that primarily affect the frontal and temporal lobes of the brain
These areas of the brain are generally associated with personality, behavior and language.
32
What is the most common type of frontotemporal dementia?
What are the two other types?
1. **Pick's disease - MOST COMMON**
2. CPA - Chronic progressive aphasia
3. Semantic dementia
33
What is the cause of frontotemporal dementia?
1. Some are related to autosomal dominant mutations
2. Link found between amyotrophic lateral sclerosis (ALS) + Parkinsonism
34
What are the symptoms of frontotemporal dementia?
**Behavioural changes**
**Speech and language problems**
**Movement disorders**
35
How do you diagnose frontotemporal dementia?
**Macroscopic changes seen in Pick's disease include:-**
1. Atrophy of the frontal and temporal lobes
**Microscopic changes include:-**
1. Pick bodies - spherical aggregations of tau protein (silver-staining)
2. Gliosis
3. Neurofibrillary tangles
4. Senile plaques
36
What is the treatment for frontotemporal dementia?
* **Antidepressants**
Trazodone
May reduce the behavioral problems associated with frontotemporal dementia
SSRIs - citalopram, paroxetine or sertraline
* **Antipsychotics**
Olanzapine or quetiapine
Combat the behavioral problems of frontotemporal dementia
37
What is the difference between depression and dementia?
* Short history, rapid onset
* Biological symptoms e.g. weight loss, sleep disturbance
* Patient worried about poor memory
* Reluctant to take tests, disappointed with results
* Mini-mental test score: variable
* Global memory loss (dementia characteristically causes recent memory loss)
38
What is the difference between dementia and delerium?
Dementia develops over time, with a slow progression of cognitive decline.
Delirium occurs abruptly, and symptoms can fluctuate during the day.
The hallmark separating delirium from underlying dementia is inattention.
The individual simply cannot focus on one idea or task.
39
What is frontal lobe syndrome?
Frontal lobe syndrome is a broad term used to describe the damage of higher functioning processes of the brain such as motivation, planning, social behavior, and language/speech production
40
What is the cause of frontal lobe syndrome?
1. Head injury
2. Cerebrovascular event
3. Infection
4. Neoplasm
5. Degenerative disorders
41
What are the symptoms of frontal lobe syndrome?
**Cognitive**
Tremor
Apraxia
Dystonia
**Behavioural**
Utilization behavior
Perseveration behavior
Social inhibition
Compulsive eating
**Emotional**
Difficulty in inhibiting emotions, anger, excitement.
Depression
42
How do you diagnose frontal lobe syndrome?
1. Check B12 levels, thyroid function, serology for syphilis and antinuclear antibodies.
2. Consider MRI/CT scanning if there is the possibility of a tumour.
3. Patients often have a specialist neurological assessment and, following this, further investigations such as lumbar puncture may be performed.
43
What is the treatment for frontal lobe syndrome?
As patients may have lost their inhibitions or appreciation of danger, a high level of supervision may be required
If the patient can be supported at home, visiting assistance could be sought from physiotherapists, occupational therapists and/or speech therapists
Respite care may be needed
Assessment by a social worker may also be helpful
44
WHAT IS SCHIZOPHRENIA?
Schizophrenia (splitting of mind) is a serious mental disorder in which people have peculiar ways of thinking, behaviour and perception
45
What is the cause of schizophrenia?
Combination of genetics, brain chemistry and environment
Dopamine and glutamate
46
What are the symptoms of schizophrenia?
**Positive symptoms**
1. Delusions
2. Hallucinations
3. Disorganised thinking
4. Extremely unorganised or abnormal motor behaviour
5. **Insomnia**
**Negative symptoms**
1. Lack of motivation
2. Not saying much
47
What are the first rank symptoms of schizophrenia?
1. **S**omatic hallucinations
2. **T**hought withdrawal and thought broadcasting
3. **E**xperience feelings or actions as made or influenced by external agents (passivity phenomena)
4. **A**uditory hallucinations
5. **D**elusional perception
48
How do you diagnose schizophrenia?
1. Diagnosis of exclusion
2. Exclusion of organic causes e.g. temporal-lobe epilepsy, metabolic disturbances, toxic substances
3. Differentiation from other psychiatric disorders e.g. an affective disorder with psychotic symptoms must be made
## Footnote
**Use the American Psychiatric Association diagnostic criteria**
49
What is included in the diagnostic criteria for the diagnosis of schizophrenia?
1. **Characteristic symptoms** (flat or grossly inappropriate affect, delusions, marked loosening of association) for a period of greater than or equal to one week.
2. **Social relation deteration** and/or self-care during the course of the illness.
3. If there is an **affective component** to the illness then the episodes are brief in comparison to the psychotic component.
4. **A six month period** with signs of the disturbance.
5. **No organic factor** can be identified that initiated and maintained the disturbance.
50
What are the poor prognosis factors for schizophrenia?
1. Strong family history
2. Gradual onset
3. Low IQ
4. Prodromal phase of social withdrawal
5. Lack of obvious precipitant
51
What is the treatment for schizophrenia?
1. Oral atypical antipsychotics are first-line
Olanzapine, Rispiridone, Clozapine
2. **CBT should be offered to all patients**
N.B Close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
52
What is the risk of developing schizophrenia if a monozygotic twin is affected?
50%
53
WHAT IS SCHIZOAFFECTIVE DISORDER?
Combination of schizophrenia symptoms, such as hallucinations or delusions
**AND**
Mood disorder symptoms, such as depression or mania
54
What are the different types of schizoaffective disorder?
**Bipolar type**
Which includes episodes of mania and sometimes major depression
**Depressive type**
Which includes only major depressive episodes
55
What are the symptoms of schizoaffective disorder?
1. Delusions
2. Hallucinations
3. Impaired communication and speech, such as being incoherent
4. Bizarre or unusual behavior
5. Depression
6. Manic mood
7. Impaired occupational, academic and social functioning
8. Problems with managing personal care, including cleanliness and physical appearance
56
How do you diagnose schizoaffective disorder?
The diagnosis of schizoaffective disorder is made when there is a roughly equal proportion of psychotic and affective features in a mental illness
Diagnostic criteria for schizoaffective disorder
57
What is the treatment for schizoaffective disorder?
**Medications**
_Antipsychotics_
Paliperdione
_Mood-stablising medications_
Lithium, sodium valporate, carbamazapine
_Antidepressants_
TCA - amitriptyline
SSRIs - fluoxetine, citalopram, paroxetine
**Psychotherapy**
**Life training skills**
58
WHAT IS BIPOLAR DISORDER?
Chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
59
What are the different type of bipolar disorder?
**Bipolar I disorder**
You've had at least one manic episode that may be preceded or followed by hypomanic or major depressive episodes. In some cases, mania may trigger psychosis
**Bipolar II disorder**
You've had at least one major depressive episode and at least one hypomanic episode, but you've never had a manic episode.
**Cyclothymic disorder**
You've had at least two years — or one year in children and teenagers — of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression)
60
How do you diagnose bipolar disorder?
1. Physical exam
2. Psychiatric assessment
3. Mood charting
4. **Criteria for bipolar disorder**
DSM-5
61
What is the treatment for bipolar disorder?
Lithium OR valproate
**Management of mania**
Consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
```
**Management of depression**
Talking therapies (see above); fluoxetine is the antidepressant of choice
```
address co-morbidities - there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD
62
What is the difference between mania and hypomania?
**Mania**
Lasts for at least 7 days
May require hospitalization due to risk of harm to self or others
**May present with psychotic symptoms**
**Hypomania**
Lasts for \< 7 days, typically 3-4 days.
Unlikely to require hospitalization
**Does not exhibit any psychotic symptoms**
A lesser version of mania
63
What are the referral choices with indivuals with bipolar disorder?
**Hypomania**
Routine referral to the community mental health team (CMHT)
**Mania or severe depression**
Urgent referral to the CMHT should be made
64
What do you do if a patient is having a manic episode and on an antidepressant?
Stop antidepressant and start antipsychotic
Lithium for whe nstable
65
WHAT IS NEUROLEPTIC MALIGNANT SYNDROME?
Rare but dangerous condition seen in patients taking antipsychotic medication
Can also be seen with levodopa when stopped
66
What is the cause of neuroleptic malignant syndrome?
What are examples of drugs?
* Dopamine blockade induced by antipsychotics and antiemetics
* Triggers massive glutamate release and subsequent neurotoxicity and muscle damage.
- First gen antipsychotics e.g. Haliperidol, fluphenazine
- Second gen antipsychotics e.g. Clozapine, risperidone, olanzipine
- Antiemetics - Metoclopramide, promethazine
67
What are the symptoms of neuroleptic malignant syndrome?
**Pyrexia**
**Muscle rigidity**
**Autonomic lability**
Hypertension, tachycardia and tachypnoea
**Agitated delirium with confusion**
68
How do you diagnose neuroleptic malignant syndrome?
1. **Creatine kinase**
Raised
2. **Acute kidney injruy**
Deranged U&Es
3. **Leukocytosis**
69
What is the management for neuroleptic malignant syndrome?
1. Stop antipsychotic
2. IV fluids to prevent renal failure
3. **Dantrolene**
Thought to work by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor, and decreasing the release of calcium from the sarcoplasmic reticulum
4. **Bromocriptine**
Dopamine agonist, may also be used
70
What are the factors for an increased risk of completed suicide at a later date?
1. Efforts to avoid discovery
2. Planning
3. Leaving a written note
4. Final acts such as sorting out finances
5. Violent method
71
What factors increase the risk of suicide?
1. Male sex (hazard ratio (HR) approximately 2.0)
2. History of deliberate self-harm (HR 1.7)
3. Alcohol or drug misuse (HR 1.6)
4. History of mental illness
5. History of chronic disease
6. Advancing age
7. Unemployment or social isolation/living alone
8. Being unmarried, divorced or widowed
72
If a patient has attempted suicide what are the risks associated with them attempting suicide at a later date?
1. Efforts to avoid discovery
2. Planning
3. Leaving a written note
4. Final acts such as sorting out finances
5. Violent method
73
What are the protective factors of suicide?
1. Family support
2. Having children at home
3. Religious belief
74
What are the causes of alcohol withdrawal?
Suddenly stop drinking
Reduce their alcohol use too quickly
Don’t eat enough when reducing alcohol use
Have a head injury
Are sick or have an infection
75
What are the symptoms of alcohol withdrawal?
1. Symptoms start at 6-12 hours:
Tremor
Sweating
Tachycardia
Anxiety
2. Peak incidence of seizures at 36 hours
3. Peak incidence of **delirium tremens** is at 48-72 hours
76
What are the symptoms of delerium tremens?
Hallucinations (auditory, visual, or olfactory).
Confusion.
Delusions.
Severe agitation.
77
What are the investigations for alcohol withdrawl?
**Carbohydrate-deficient transferrin (CDT)** HIGH
**gammaglutamyl transferase (GGT)** HIGH
78
What is the treatment of alcohol withdrawal and delerium tremens?
**Alcohol withdrawl**
_Benzodiazepines_
Chlordiazepoxide
Carbamazepine
Lorazepam may be preferable in patients with hepatic failure
**Delerium tremens**
_Lorazepam or Haloperidol_
79
What are the side effects of tri-cyclic antidepressants (TCA)?
Drowsiness
Dry mouth
Blurred vision
Constipation
Urinary retention
Lengthening of QT interval
80
What are the different types of antidepressants?
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin–norepinephrine reuptake inhibitors (SNRIs)
- Tricyclic antidepressants (TCAs)
- Tetracyclic antidepressants (TeCAs)
- Monoamine oxidase inhibitors (MAOIs)
81
What are the side effects of citalopram?
Prolonged QT interval
82
What are some adverse effects of antidepressants?
1. Serotonin syndrome
2. Weight change
3. Hyponatraemia
4. Increased anxiety and agitation
83
What is serotonin syndrome?
A group of symptoms which may occur with certain serotonergic medications or drugs.
84
What causes serotonin syndrome?
1. Monoamine oxidase inhibitors
2. SSRIs
St John's Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome
3. Ecstasy
4. Amphetamines
5. **TRIPTANS**
85
How do you diagnose serotonin syndrome?
Symptom observation and person history
86
What is the management for serotonin syndrome?
1. Stop serotonin drug
2. Administer serotonin antagonists
Cyproheptadine
87
What is the difference between serotonin syndrome and neuroleptic malignant syndrome?
**Serotonin syndrome**
Short duration
**Neuroleptic malignant syndrome**
HIGH creatine kinase
88
What is the SSRI of choice for adolesants?
Fluoxetine
89
What is the SSRI used post MI?
Sertraline
90
What is normally the SSRI of choice?
Citalopram
91
Why is paroxetine contraindicated in pregnancy?
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
92
What is PTSD?
Post-traumatic stress disorder is a mental health condition caused by a traumatic experience.
93
When can PTSD develop?
Can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse
94
What are the symptoms of PTSD?
1. Hyperarousal
2. Avoidance
3. Re-experiencing
4. Emotional numbing
95
How long do symptoms for PTSD need to last to be diagnosed?
1. **1 month**
96
What is the management of PTSD?
1. Watchful waiting may be used for mild symptoms lasting less than **4 weeks**
2. T**rauma-focused cognitive behavioural therapy (CBT)** or **eye movement desensitisation and reprocessing (EMDR)** therapy may be used in more severe cases
3. **Venlafaxine** or a selective **serotonin reuptake inhibitor (SSRI)**, such as sertraline should be tried
97
WHAT IS ACUTE STRESS DISORDER?
Acute strss reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event.
98
What is the treatment for acute stress disorder?
1. Trauma-focused cognitive-behavioural therapy (CBT)
2. Benzodiazepines
99
What are the indications for ECT use?
Treatment resistant severe depression
Manic episodes
An episode of moderate depression know to respond to ECT in the past
Life threatening catatonia
100
What are the side effects of ECT?
1. Headache
2. Nausea
3. Short term memory impairment
4. Memory loss of events prior to ECT
5. **Cardiac arrhythmia**
101
What should you do with a patients SSRI when about to commence ECT therapy?
Reduce the dose but not stop
102
What are the different types of anxiety?
Agoraphobia
Generalized anxiety disorder
Panic disorder
Social anxiety disorder (social phobia)
103
What is GAD?
Generalised anxiety disorder is where you feel anxious most of the time.
104
What are the risk factors for generalised anxiety disorder?
Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent
105
What are the protective factors for generlaised anxiety disorder?
Aged 16 - 24
Being married or cohabiting
106
What are the symptoms of generalised anxiety disorder?
1. Feeling nervous, restless or tense
2. Having a sense of impending danger, panic or doom
3. Having an increased heart rate
4. Breathing rapidly (hyperventilation)
5. Sweating
6. Trembling
7. Feeling weak or tired
8. Trouble concentrating or thinking about anything other than the present worry
9. Having trouble sleeping
10. Experiencing gastrointestinal (GI) problems
11. Having difficulty controlling worry
12. Having the urge to avoid things that trigger anxiety
107
How do you diagnose generalised anxiety disorder?
* DSM-5 criteria
* Excessive anxiety 90 days out of 180
* Hard to control anxiety
* Have 3 anxiety symptoms in men, 1 in children
108
What is the treatment for generalised anxiety disorder?
1. Step 1: education about GAD + active monitoring
2. step 2: low intensity psychological interventions (CBT)
3. step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.
4. step 4: highly specialist input e.g. Multi agency teams
**Drug treatment**
1. **Sertraline**
**if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI)**
1. Duloxetine and venlafaxine
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
109
What is a panic disorder?
Panic disorder is a mental health condition where you have regular panic attacks.
110
What are the symptoms of a panic disorder?
1. Recurrent and unexpectant panic attacks
2. Persisitant worry
3. Change of behaviour
111
How do you diagnose a panic disorder?
In the DSM-5
Must have 4 out of 13 symptoms
112
What is the management of a panic disorder?
1. Step 1: recognition and diagnosis
2. Step 2: treatment in primary care - see below
3. Step 3: review and consideration of alternative treatments
4. Step 4: review and referral to specialist mental health services
5. Step 5: care in specialist mental health services
**Treatment in primary care**
1. NICE recommend either cognitive behavioural therapy or drug treatment
2. SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
113
How can a panic disorder lead to agoraphobia?
Avoid going to social situations and stay inside which lead to them developing a fear of social situations and crowded places
114
What is agoraphobia?
Fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong
115
What is clang association?
Ideas are related to each other only by the fact they sound similar or rhyme
116
What is a somatisation disorder?
Multiple physical SYMPTOMS present for at least 2 years
Patient refuses to accept reassurance or negative test results
117
What are the symptoms for somatisation disorder?
1. **Specific sensations**, such as pain or shortness of breath, or more general symptoms, such as fatigue or weakness
2. **Unrelated to any medical cause that can be identified**, or related to a medical condition such as cancer or heart disease, but more significant than what's usually expected
3. **A single symptom, multiple symptoms or varying symptoms**
4. **Mild, moderate or severe**
118
What is a conversion disorder?
Nervous system (neurological) symptoms that can't be explained by a neurological disease or other medical condition.
However, the symptoms are real and cause significant distress or problems functioning.
119
What are the symptoms of a conversion disorder?
Weakness or paralysis
Abnormal movement, such as tremors or difficulty walking
Loss of balance
Difficulty swallowing or feeling "a lump in the throat"
Seizures or episodes of shaking and apparent loss of consciousness (nonepileptic seizures)
Episodes of unresponsiveness
120
What is the difference between a somatisation disorder and conversion disorder?
Somatisation disorder lasts for at least 2 years and refuses to accept negative result
Conversion disorder short lived invlolving loss of motor or sensory function
121
What is Muchausen's syndrome?
Munchausen's syndrome is a psychological disorder where someone pretends to be ill or deliberately produces symptoms of illness in themselves.
122
What are the symptoms of Muchausen's syndrome?
**Pretending to have psychological symptoms**
For example, claiming to hear voices or claiming to see things that are not really there
**Pretending to have physical symptoms**
For example, claiming to have chest pain or a stomach ache
**Actively trying to get ill**
Such as deliberately infecting a wound by rubbing dirt into it
123
What is antisocial parsonality disorder?
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
124
What are the symptoms of antisocial personaltiy disorder?
1. **Deception**, as indicated by repeatedly lying
2. **Impulsiveness or failure to plan ahead**
3. **Irritability and aggressiveness**
4. Reckless **disregard for safety** of self or others
5. **Consistent irresponsibility**
6. **Lack of remorse**
125
What are the symptoms of paranoid personality disorder?
1. Hypersensitivity and an unforgiving attitude when insulted
2. Unwarranted tendency to questions the loyalty of friends
3. Reluctance to confide in others
4. Preoccupation with conspirational beliefs and hidden meaning
5. Unwarranted tendency to perceive attacks on their character
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What is borderline personaltiy disorder?
Borderline personality disorder (BPD) is a disorder of mood and how a person interacts with others.
It's the most commonly recognised personality disorder.
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What are the symptoms of borderline personality disorder?
1. Efforts to avoid real or imagined abandonment
2. Unstable interpersonal relationships which alternate between idealization and devaluation
3. Unstable self image
4. Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
5. Recurrent suicidal behaviour
6. Affective instability
7. Chronic feelings of emptiness
8. Difficulty controlling temper
9. Quasi psychotic thoughts
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What are the symptoms of schizoid personality disorder?
1. Indifference to praise and criticism
2. Preference for solitary activities
3. **Lack of interest in sexual interactions**
4. **Lack of desire for companionship**
5. Emotional coldness
6. Few interests
7. Few friends or confidants other than family
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What are the symptoms of schizotypal personality disorder?
1. Ideas of reference (differ from delusions in that some insight is retained)
2. Odd beliefs and magical thinking
3. Unusual perceptual disturbances
4. Paranoid ideation and suspiciousness
5. **Odd, eccentric behaviour**
6. Lack of close friends other than family members
7. Inappropriate affect
8. Odd speech without being incoherent
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What is the difference between schizoid and schizotypal personality idsorder?
Schizotypal has odd and essentric behaviour
Being paranoid and suspicious of others
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What is depression?
Depression is a low mood that lasts for weeks or months and affects your daily life
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How long do depression symptoms have to be present before it can be called depression?
2 weeks
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What are the core depression symptoms?
Anhedonia - inability to feel pleasure
Anergia - lack of energy
Low mood
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What are the somatic symptoms of depression?
1. Loss of emotional reactivity
2. Diurnal mood variation
3. Anhedonia
4. Early morning waking
5. Psychomotor agitation or retardation
6. Loss of appetite and weight
7. Loss of libido
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What are the screening questions for depression?
'During the last month, have you often been bothered by feeling down, depressed or hopeless?'
'During the last month, have you often been bothered by having little interest or pleasure in doing things?'
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What are two screening questionaires you can do for depression?
HAD
PHQ-9
Beck's
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What are atypical symptoms of depression?
An atypical symptom is one that is unusual in depressive patients and may include increased appetite and hypersomnia.
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What are psychotic symptoms of depression?
A psychotic symptom includes examples such as hallucinations or delusions.
These would be features similar to a presentation of psychotic condition such as schizophrenia or schizoaffective disorder.
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What is a delusional perception?
* A two stage process
* First
A normal object is perceived
* Secondly
There is a sudden intense delusional insight into the objects meaning for the patient
* e.g. 'The traffic light is green therefore I am the King'.
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What is catatonia?
Stopping of voluntary movement or staying still in an unusual position
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How long must SSRIs be slowly reduced for when stopping?
Which SSRI does not need this?
4 weeks
Fluoxetine
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What is OCD?
Defined as obsessions or compulsions, or both, persisting for greater than 2 weeks
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What are the symptoms of OCD?
1. Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
2. Demonstrates perfectionism that hampers with completing tasks
3. Is extremely dedicated to work and efficiency to the elimination of spare time activities
4. Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
5. Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
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What is the treatment of OCD?
1. **If functional impairment is mild**
* Low-intensity psychological treatments: **cognitive behavioural therapy (CBT)** including **exposure and response prevention (ERP)**
2. **If moderate functional impairment**
* Offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
3. **If severe functional impairment**
* Offer combined treatment with an SSRI and CBT (including ERP)
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What is dialectical behaviour therapy (DBT)?
This is a targeted therapy that is based CBT, but has been adapted to help people who experience emotions very intensely.
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What are the symptoms of narcissistic personality disorder?
1. Grandiose sense of self importance
2. Preoccupation with fantasies of unlimited success, power, or beauty
3. Sense of entitlement
4. Taking advantage of others to achieve own needs
5. Lack of empathy
6. Excessive need for admiration
7. Chronic envy
8. Arrogant and haughty attitude
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What are the symptoms of histrionic personality disorder?
* Inappropriate sexual seductiveness
* Need to be the centre of attention
* Rapidly shifting and shallow expression of emotions
* Suggestibility
* Physical appearance used for attention seeking purposes
* Impressionistic speech lacking detail
* Self dramatization
* Relationships considered to be more intimate than they are
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What is dependent personality disorder?
* Difficulty making everyday decisions without excessive reassurance from others
* Need for others to assume responsibility for major areas of their life
* Difficulty in expressing disagreement with others due to fears of losing support
* Lack of initiative
* Unrealistic fears of being left to care for themselves
* Extensive efforts to obtain support from others
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What drugs can SSRIs interact with to cause serotonin syndrome?
**Triptans**
Increased risk of serotonin syndrome
**Monoamine oxidase inhibitors (MAOIs)**
Increased risk of serotonin syndrome
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What are some SSRI disconintuation symptoms?
1. **Increased mood change**
2. Restlessness
3. Difficulty sleeping
4. **Unsteadiness / Dizziness**
5. Sweating
6. Gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
7. **Paraesthesia**
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What side effects do SSRIs have in pregnancy?
1. Use during the **first trimester** gives a small increased risk of **congenital heart defects**
2. Use during the **third trimester** can result in **persistent pulmonary hypertension** of the newborn
3. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
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How do benzodiazepines work?
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels
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What is Knight move thinking?
Describes a phenomenon where a patient’s thoughts move from one topic to another, without any logical connection between them
## Footnote
**E.g. I like the sound of that. Or should I simply add -- guilty? One look at my blog posts and well, maybe it's just creative lateral thinking..**
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What is flight of ideas?
Flight of ideas is similar to knight’s move thinking.
However, there is increased rate of thought and there is at least some logical links between the frequent changes of topics that a patient is talking about.
It more commonly a feature of mania/hypomania
**E.g. My father sent me here. He drove me in a car. The car is yellow in color. Yellow color looks good on me**
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What is circumstantiality?
1. Patient talks about details that are irrelevant to the question asked
2. There is a logical progression of thought.
3. This differs to knight’s move thinking as understandable associations are preserved in circumstantiality. Circumstantiality differs from flight of ideas in that the rate of thought is normal in circumstantiality.
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What is Tangentiality?
1. Wandering from a topic without returning to it
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What is perseveration?
Perseveration is the repetition of a certain word/phrase/thought after the absence or cessation of a stimulus (e.g. a question).
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What is methadone?
Opioid
Maintenance for opioid withdrawal e.g. heroin
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What is naloxone?
Opoid emergency overdose drug
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What is naltrexone?
How does it work?
Opoid antagonist
Part of maintenance therapy
Removes pleasure from alcohol and opioids
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What is postpartum depression?
Depression after the birth of your baby
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What are the symptoms of postpartum depression?
* Usual features of depression
* Fears about baby's health
* Maternal deficiencies
* Marital tensions including loss of sexual interest
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When does postpartum depression occur?
Between 1 month and 3 months
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How do you diagnose postpartum depression?
**Edinburgh Postnatal Depression Scale - Score 11-12**
**Evaluation of mother's mood and feelings for and attachment to the baby**
Order blood tests to determine whether an underactive thyroid is contributing to your signs and symptoms
Order other tests, if warranted, to rule out other causes for your symptoms
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What is the treatment for postpartum depression?
1. CBT
2. Certain SSRIs such as sertraline and paroxetine\* may be used if symptoms are severe\*\* - whilst they are secreted in breast milk it is not thought to be harmful to the infant
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What is postpartum psychosis?
Postpartum psychosis (or puerperal psychosis) is having pschosis symptoms after having a baby.
It starts suddenly in the days, or weeks, after having a baby.
Symptoms vary, and can change rapidly.
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What is the cause of postpatrum psychosis?
1. Family history
2. Genetic factors are important - you are more likely to have postpartum psychosis if a close relative has had it.
3. Hormone levels and disturbed sleep patterns may also be involved
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What are the symptoms of postpatrum psychosis?
1. Confusion and disorientation
2. Obsessive thoughts about your baby
3. Hallucinations and delusions
4. Sleep disturbances
5. Excessive energy and agitation
6. Paranoia
7. Attempts to harm yourself or your baby
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What is the treatment of postpartum psychosis?
Benzodiazepine - Lorazepam
Antipsychotic - Haloperidol or Olanzapine
Lithium (to achieve serum level of 0.8-1.2 mmol/L)
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What is the risk of developing postpartum psychosis again after a previous pregnancy with it?
25-50%
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What is an alternative to methadone for opoid dependance?
1. Buprenorphine
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Which drug would you start a patient on if they had depression and they wanted something to stimulate their appetite
Mirtazipine
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What are the characteristic features of anorexia?
1. Raised cortisol
2. Low FSH
3. Raised growth hormone levels
4. Impaired glucose tolerance
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What endocrine conditions can anorexia cause?
1. Hypothyroidism
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What can purging behaviours be?
1. Exercising, laxatives or diuretics
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What test is used to differentiate organic from non-organic leg paresis?
1. Hoover's sign
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What is Brudzinski's sign?
What is it indicative of?
1. Flexion of hips occur with flexion of the neck
2. Meningitis, subarachnoid haemorrhage
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What is capgras delusion?
Person believes family or friend has been replaced by identical imposter
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What is Cotard's delusion?
Limb is dying or dead.
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What is delusional parasitosis?
1. Fixed, flase belief that patinet holdm where parasites or bugs infest them.
2. They take radical steps to try and kill the insects
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What is Othello syndrome?
1. Delusional jealousy, usually believing their partner is unfaithful
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What is Fregoli syndrome?
People changing faces
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What is erotomania/De Clerambault's syndrome?
1. When a person is loved by a person in a higher social status
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What is the difference between obsession and compulsion?
An **obsession** is an i**ntrusive, unpleasant** and **unwanted thought.**
A **compulsion** is a senseless **action** taken to **reduce the anxiety** caused by the obsession
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WHAT IS CHARLES-BONNET SYNDROME?
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis).
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What are the risk factors for charles-bonnet syndrome?
1. Advanced age
2. Peripheral visual impairment
3. Social isolation
4. Sensory deprivation
5. Early cognitive impairment
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WHAT IS A PSEUDOHALLUCINATION?
CD10 definition of hallucination: false sensory perception in the absence of an external stimulus. Maybe organic, drug-induced or associated with mental disorder.
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When do pseudohallucinations most commonly occur?
When people are grieving
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WHAT IS THE DIFFERENCE BETWEEN FELT STIGMA AND ENACTED STIGMA?
1. Felt stigma - people can't see her symptoms so her social rejection is 'felt'
2. Enacted - people can see symptoms and therefore social rejection because of that
