PSYCHIATRY Flashcards
(194 cards)
1
Q
what is hyperactive delirium?
A
- inappropriate behaviour
- hallucinations
agitation.
2
Q
what is hypoactive delirium?
A
- lethargy
- reduced concentration
- reduced appetite.
3
Q
what are the clinical features of delirium?
A
- Impaired ability to direct, sustain, and shift attention.
- Global impairment of cognition with disorientation, and impairment of recent memory and abstract thinking.
- Disturbance in sleep–wake cycle with nocturnal worsening.
- Psychomotor agitation.
- Emotional lability.
- Perceptual distortions, illusions, and hallucinations—characteristically visual.
- Speech may be rambling, incoherent, and thought disordered.
- There may be poorly developed paranoid delusions.
- Onset of clinical features is rapid with fluctuations in severity over minutes and hours
4
Q
how is delirium managed?
A
- environmental reorientation
- oral haloperidol or oral lorazepam
5
Q
what are the clinical features of ADHD?
A
- Failure to pay close attention to details or making careless mistakes in school work, work or other activities
- Difficult sustaining attention in tasks or play activities
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish school work, chores or duties in the workplace
- Often has difficult organising tasks and activities
- Avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
- Often loses things
- Easily distracted by extraneous stimuli
- Forgetful in daily activities
- Fidgets
- Leaves seat when remaining seated is expected
- Runs or climbs excessively and inappropriately
- Difficulty plating
- Often in the go
- Talks excessively
- Blurts out answers before question is finished
- Difficulty awaiting turns
- Interrupts and intrudes
6
Q
how are children under 5 with ADHD managed?
A
-Offer an ADHD-focused group parent-training programme
7
Q
how are children aged over 5 with ADHD managed?
A
- environmental modifications
- methylphenidate
- lisdexamfetamine 2nd line
- dexamfetamine 3rd line
- atomoxetine or guanficine 4th line
8
Q
how are adults with ADHD managed?
A
- CBT
- lisdexamfetamine or meythlphenidate first line
- dexamfetamine
- atomoxetine
9
Q
how long does a section 2 last for and which professionals are needed?
A
- 28 days
- 1 doctor, 1 AMHP and 1 section 12 approved doctor
10
Q
how long does a section 3 last for and which professionals are needed?
A
- 6 months
- 1 doctor, 1 AMHP and 1 section 12 approved docto
11
Q
how long does a section 4 last for and which professionals are needed?
A
- 72 hours
- 1 doctor and 1 AMHP
12
Q
how long does a section 5(4) last for and which professionals are needed?
A
- 6 hours
- 1 nurse
13
Q
how long does a section 5(2) last for and which professionals are needed?
A
- 72 hours
- 1 doctor
14
Q
what are the clinical features of GAD?
A
- Excessive worry for at least 6 months
- Anxiety not confined to another condition or substance
- Muscle tension
- Sleep disturbance
- Fatigue
- Restlessness
- Irritability
- Poor concentration
- Headache
- Sweating
- Dizziness
- GI symptoms
- Muscle aches
- Tachycardia and palpitations
- Shortness of breath
- Tremor
15
Q
what is the stepwise management of GAD?
A
- education and active monitoring
- low intensity psychological therapy
- High intensity psychological therapy
- SSRI
- Pregabalin
- tertiary referral
16
Q
what is mania?
A
-A distinct period of abnormally and persistently elevated, expansive, or irritable mood, with 3 or more characteristic symptoms lasting at least 1 week
17
Q
what is hypomania?
A
-Three or more characteristic symptoms lasting at least 4 days, and are clearly different from ‘normal’ mood, that are not severe enough to interfere with social or occupational functioning
18
Q
what is bipolar I disorder?
A
-the occurrence of one or more manic episodes or mixed episodes, with or without a history of one or more depressive episodes (2 manic episodes with no depressive episode or 1 depressive and 1 manic episode)
19
Q
what is bipolar II disorder?
A
-the occurrence of one or more depressive episodes accompanied by at least one hypomanic episode.
20
Q
how is mania/hypomania managed?
A
- stop anti-depressant
- antipsychotic such as haloperidol, olanzapine, quetiapine or risperidone
- lithium
- valproate
21
Q
how is bipolar depression managed?
A
- fluoxetine combined with olanzapine, or quetiapine on its own, or in addition with current bipolar treatment
- lamotrigine with lithium
- lamotrigine and valproate
22
Q
what are the clinical features of cyclothymia?
A
- Persistent instability of mood
- numerous periods of mild depression and mild elation
- not sufficiently severe or prolonged to fulfil the criteria for bipolar affective disorder or recurrent depressive disorder.
- The mood swings are usually perceived by the individual as being unrelated to life events.
23
Q
what are the clinical features of panic disorder?
A
- Unexpected onset
- Apprehension and worry
- Behavioural avoidance
- Tachycardia
- Palpitations and chest discomfort
- Nausea and abdominal pain
- Dizziness
- Perceptual abnormalities
- Hyperventilation, shortness of breath and a feeling of choking
- Paraesthesia
- Muscle shaking
- Sweating
- Fainting
- Chills or hot flushes
24
Q
how is panic disorder managed?
A
- individual non-facilitated self-help
- individual facilitated self-help
- CBT
- SSRIs, SNRIs or TCAs
25
what is agoraphobia?
-Anxiety and panic symptoms associated with places or situations where escape may be difficult or embarrassing leading to avoidance.
26
what are the clinical features of phobia?
- Anticipatory anxiety
- Behavioural avoidance
- Nausea
- Dizziness
- Fainting
- Tachycardia
- Hyperventilation
- Exaggerated startle
27
how are phobias managed?
-Offer psychological interventions including systematic desensitisation and flooding, along with CBT.
28
how is social phobia managed in adults?
- CBT
- SSRI
- SNRI
- MAOI
29
how is social phobia managed in children?
-Offer individual or group CBT focused on social anxiety
30
what are the clinical features of OCD?
- Intrusive, unwanted, anxiogenic thoughts that result in marked distress.
- Patient typically recognises that these thoughts are irrational.
- Repetitive behavioural or mental acts that are designed to neutralise the anxiety that results from obsessions.
31
how is OCD managed in adults?
- CBT
- ERP
- SSRIs
32
how is OCD managed in children?
- CBT
- SSRI
- Clomipramine
33
what are the clinical features of depression?
- Depressed mood
- Anhedonia
- Fatigue or loss of energy.
- Weight change associated with change in appetite
- Disturbed sleep with early morning wakening
- Psychomotor agitation or retardation
- Reduced libido
- Feelings of worthlessness or excessive guilt
- Diminished ability to think or concentrate or indecisiveness
- Recurrent thoughts of death or suicide
- Delusions: poverty, personal inadequacy, guilt over presumed misdeeds, responsibility for world events, deserving of punishment or nihilistic delusions
- Hallucinations – auditory, olfactory, visual that may be mood congruent or incongruent
34
how is depression managed?
- Individual guided self-help based CBT
- Computerised CBT
- A structured group physical activity programme
- Group CBT
- SSRIs
- SNRI, TCA or MAOI
- augmentation
- ECT
35
what are the clinical features of paranoid PD?
- Sensitive
- Suspicious
- Preoccupied with conspiratorial explanations
- Self-referential
- Distrust of others
36
what are the clinical features of schizoid PD?
- Emotionally cold
- Detachment
- Lack of interest in others
- Excessive introspection
- Fantasy
37
what are the clinical features of schizotypal PD?
-Interpersonal discomfort with peculiar ideas, perceptions, appearance and behaviour
38
what are the clinical features of anti-social PD?
- Callous lack of concern for others
- Irresponsibility
- Irritability
- Inability to maintain enduring relationships
- Disregard and violation of other’s rights
- evidence of childhood conduct disorder
39
what are the clinical features of emotionally unstable PD?
- Unclear identity
- Intense and unstable relationships
- Unpredictable affect, threats or acts of self harm
- Impulsivity
- Chronic feelings of emptiness
- Thoughts and acts of self harm/ suicide
- Fear of/ attempts to avoid abandonment
- Intense/ unstable relationships
- Uncertainty regarding self image, aims and preferences
40
what are the clinical features of histrionic personality disorders?
- Self-dramatization
- Shallow affect
- Egocentricity
- Craving attention and excitement
- Manipulative behaviour
41
what are the clinical features of narcissistic personality disorders?
- Grandiosity
- Lack of empathy
- Need for admiration
42
what are the clinical features of anxious personality disorders?
- Tension
- Self-consciousness
- Fear of negative evaluation by others
- Timid
- Insecure
43
what are the clinical features of anankastic personality disorders?
- Doubt
- Indecisiveness
- Caution
- Pedantry
- Rigidity
- Perfectionism
- Pre-occupation with orderliness and control
44
what are the clinical features of dependent personality disorders?
- Clinging
- Submissive
- excess need for care
- Feels helpless when not in a relationship
45
how is paranoid, schizoid or schizotypal PD managed?
- Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.
- Offer a low dose antipsychotic such as arirpiprazole, haloperidol or perphenazine
- Offer fluoxetine, sertraline or venlafaxine if there is self-harm or suicidality
46
how is borderline PD managed?
- For women with borderline personality disorder for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme.
- Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder
- Provide people with borderline personality disorder who have sleep problems with general advice about sleep hygiene
- Offer treatment with zapleplon, zolpidem or zopiclone for insomnia
47
how is anti-social PD managed?
- Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.
- Offer contingency management treatment or CBT
48
how is avoidant, dependent and anankastic PD managed?
- Offer social skills training, CBT and psychodynamic approaches
- Offer pharmacotherapy with fluoxetine, sertraline or venlafaxine for issues with self-harm and suicidality
49
define illusion
-perception that occurs when a sensory stimulus is present but is incorrectly perceived and misinterpreted
50
define hallucination
-a perception in the absence of external stimulus that has qualities of real perception
51
define overvalued idea
-a false or exaggerated and sustained belief that is maintained with much less than with delusional intensity (the individual can accept that the idea may not be true)
52
define delusion
-an unshakeable false belief that is strongly held, even with evidence to the contrary, not in sync with regional, cultural and educational background
53
define delusional perception
-a true perception to which the patient attributes a false meaning
54
define thought alienation
-patients feel that their thoughts are in some way no longer within their control
55
define loosening of association
-a thought disorder consisting of a sequence of unrelated or remotely related ideas
56
define circumstantiality
a disturbed pattern of speech or writing characterised by delay in getting to the point because of the interpolation of unnecessary details and irrelevant remarks
57
define perseveration
-the repetition of a particular response regardless of the absence or cessation of a stimulus
58
define confabulation
-a memory error defined as the production of fabricated, distorted or misinterpreted memories about oneself or the world
59
what are the first rank symptoms of schizophrenia?
- Thought alienation
- Passivity phenomena
- 3rd person auditory hallucinations
- Delusional perception
60
what are the second rank symptoms of schizophrenia?
- Delusions
- 2nd person auditory hallucinations
- Hallucinations in any other modality
- Thought disorder
- Catatonic behaviour
- Negative symptoms
61
how is first episode psychosis managed?
- oral antipsychotic medication (second generation anti-psychotics are preferred)
- psychological interventions (family intervention and individual CBT).
62
how is an exacerbation of schizophrenia managed?
oral antipsychotic medication or review existing medication.
63
how is resistant schizophrenia managed?
-clozapine
64
what are the clinical features of schizoaffective disorder?
- Hallucinations, delusional ideation and thought disorder
- Anhedonia, amotivation, social isolation or flat affect
- Disturbances in emotions
- Disorders of thought
- Executive function and working memory abnormalities
65
what are the clinical features of delusional disorders?
- Level of consciousness is unimpaired
- observed behaviour, speech, and mood may be affected by the emotional tone of delusional content
- thought process is generally unimpaired, but thought content reflects preoccupation with circumscribed
- non-bizarre delusions
- hallucinations may occur, but generally are not prominent and reflect delusional ideas
- cognition and memory are generally intact
- insight and judgement are impaired to the degree that the delusions influence thought and behaviour
66
how is delusional disorder managed?
- Separation from source or focus of delusional ideas
- Pharmacological: SSRIs and antipsychotics
- Individual therapy
- Supportive therapy
- Cognitive technique - reality testing and reframing.
- Educational and social interventions, such as social skills training
67
what is the capgras delusion?
-the patient believes others have been replaced by identical or near identical imposters. Can apply to animals and other objects, and often associated with aggressive behaviour.
68
what is the fregoli delusion?
-an individual, most often unknown to the patient, is actually someone they know ‘in disguise’. The individual is often thought to be pursuing or persecuting the patient.
69
what is the cotard delusion?
-belief that patient or patients body parts are dead/rotting
70
what is Charles bonnet syndrome?
-Visual hallucinations in visually impaired people in the absence of a psychiatric disorder
71
what are the criteria required for an anorexia nervosa diagnosis?
- A body weight more than 15% below the standard weight, or a body mass index (BMI) below 17.5 (ICD-10)
- Weight loss is self-induced by avoidance of fattening foods, vomiting, purging, exercise, or appetite suppressants
- A distortion of body image so that the patient regards her/himself as fat when she/he is thin
- A morbid fear of fatness
- Amenorrhoea in women/Delayed or arrested puberty
- Endocrine disorders – HPA axis
72
what are the clinical features of anorexia nervosa?
- Significantly low body weight
- Fear of gaining weight or becoming fat
- Disturbed body image
- Calorie restriction
- Binge eating and/or purging
- Amenorrhoea
- Decreased subcutaneous fat
- General fatigue, weakness and poor concentration
- Significant pre-occupation with thoughts of food
- Orthostatic hypotension
- Non-specific GI symptoms: fullness, bloating, cramping and constipation
- Bradycardia, QT prolongation, first degree AV block and non-specific T wave changes
- Fine, lanugo body hair
- Dry skin and cracked nails
- Oedema
- Osteopenia
73
how is anorexia nervosa managed?
- dietary counselling
- multi-vitamins
- family therapy for CYP
- CBT
- MANTRA
- supportive clinical management
- Consider transdermal 17-B-estradiol, incremental physiological doses of oestrogen or bisphosphonates for women with anorexia nervosa
74
what are the clinical features of bulimia?
- Binge eating
- Inappropriate compensatory behaviours such as vomiting
- Depression and low self-esteem
- Concern about weight and body shape
- Dental erosion
- Parotid hypertrophy
- Scarring over the dorsum of the hands (Russell’s sign)
- Arrhythmias
- Menstrual irregularity
- GORD
- Diarrhoea or constipation
- Abdominal pain
75
how is bulimia managed?
- family therapy
- CBT
- guided self-help
76
what are the clinical features of anti-psychotic induced Parkinsonism?
- Tremor
- Rigidity
- Bradykinesia
- Bradykinesia and resting tremor may be less prominent
- Symptoms are bilateral
- Occurs within 4 weeks of commencing treatment with anti-psychotics
77
how is anti-psychotic induced Parkinsonism managed?
- Reduce the dose of anti-psychotic
- Switch to another anti-psychotic agents e.g. clozapine, quetiapine, olanzapine, aripiprazole and risperidone
- Add an anti-cholinergic agent such as procyclidine or amantadine
78
define akathisia
- Akathisia is an unpleasant, distressing side-effect of antipsychotic treatment.
- Characteristically manifests with a subjective component—a feeling of inner restlessness (with the drive to engage in motor activity), and an objective component—movements: such as pacing constantly; inability to stand, sit, or lie still; rocking; crossing/ uncrossing legs.
79
how is akathisia managed?
- Identify causative agent and reduce the dose
- Change the antipsychotic to a low potency first generation antipsychotic (chlorpromazine) or an SGA with low akathisia liability such as quetiapine
- Consider clozapine if akathisia is intractable
- Consider propranolol or low dose mirtazapine first line
- Alternatively, offer mianserine or cyproheptadine
- If patient has concurrent Parkinsonism consider use of anticholinergic agents (e.g. benzatropine, orphenadrine, procyclidine, trihexyphenidyl).
- Consider benzodiazepines (e.g. clonazepam, diazepam, lorazepam) alone or with propanolol esp. in chronic akathisia.
- Amantadine (100mg/day) or clonidine (up to 0.15mg/day) may be tried if these treatments are ineffective.
80
what are the clinical features of tardive dyskinesia?
- Peri-oral movements
- trunk twisting
- Torticollis
- Retrocollis
- shoulder shrugging
- pelvic thrusting
- rapid movements of the fingers or legs
- hand clenching
- Symptoms can be consciously suppressed, worsen with distraction, are exacerbated by stress and anti- Parkinsonian agents, and disappear during sleep.
- Peripheral TD is more frequently associated with comorbid acute movement disorders (akathisia, tremor, Parkinsonism) than orofacial TD.
81
how is tardive dyskinesia managed?
- Reduce dose of potential causative agent
- stop anti-cholinergics
- switch anti-psychotic: clozapine, quetiapine, olanzapine or risperidone
82
what are the clinical features of SSRI discontinuation?
- Sensory symptoms: paraesthesia, visual disturbance, shock-like sensations and numbness.
- Disequilibrium symptoms: dizziness, vertigo, and light-headedness.
- General somatic complaints: flu-like symptoms (myalgias and chills), fatigue, headache, sweating, and tremor.
- GI symptoms: diarrhoea, vomiting, and nausea/emesis.
- Affective symptoms: irritability, anxiety/agitation, low mood, and tearfulness.
- Sleep disturbance: nightmares, vivid dreams, and insomnia.
83
what are the clinical features of TCA discontinuation?
- General somatic complaints: flu-like symptoms (myalgias and chills), fatigue, headache, sweating, and tremor.
- GI symptoms: diarrhoea, vomiting, and nausea/emesis.
- Affective symptoms: irritability, anxiety/agitation, low mood, and tearfulness.
- Sleep disturbance: nightmares, vivid dreams, and insomnia.
84
what are the clinical features of MAOI discontinuation?
- More severe than with other antidepressants
- worsening of depressive symptoms
- acute confusion
- hallucinations
- paranoid delusions
- anxiety symptoms with depersonalization.
85
how is anti-depressant discontinuation syndrome managed?
- taper antidepressant
| - If severe, reintroduction of the original antidepressant rapidly resolves the symptoms.
86
what are the clinical features of body dysmorphic disorder?
- preoccupation with the idea that some specified aspect of their appearance is grossly abnormal, markedly unattractive, or diseased.
- Patients believe that the supposed deficit is noticeable to others and attempt to hide or minimize it.
- These beliefs may develop delusional intensity.
- There is associated functional impairment, agoraphobia, and risk of suicide.
- Comorbid behaviours such as skin picking, rubbing, topical applications may cause worse secondary problems.
- Clinically significant disorder causes severe functional impairment, restriction of relationships and employment opportunities, and the risk of iatrogenic morbidity by unwarranted surgical procedures.
87
how is body dysmorphic disorder managed in adults?
- CBT
- Cognitive therapy with exposure response prevention
- fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram.
88
how is body dysmorphic disorder managed in children?
- CBT
- SSRI
- Clomipramine
89
what are the clinical features of acute dystonia?
- torticollis
- trismus
- jaw opening
- forceful protrusion of the tongue
- blepharospasm
- grimacing
- oculogyric spasm
- opisthotonus
- involvement of pharyngeal and laryngeal muscles can cause serious symptoms such as dysphagia and laryngospasm.
- May fluctuate over hours, but most last minutes to hours without treatment.
90
how is acute dystonia managed?
- If severe, discontinue suspected agent.
- Emergency treatment with IM anticholinergic agents (e.g. procyclidine 5mg, benzatropine 2mg).
- Continue use of anticholinergic prophylactically for 5 to 7 days in addition to antipsychotic medication and taper it off over 2–3wks
- Consider switching to antipsychotic with low propensity to cause EPSEs
- Alternative treatment includes use of amantadine.
91
what are the clinical features of Neuroleptic Malignant Syndrome?
- Confusion, delirium and stupor
- Muscle rigidity
- Tachycardia
- Labile hypertension
- Diaphoresis
- Tachypnoea
- Urinary incontinence
- Hyperthermia
92
what do blood tests show in neuroleptic malignant syndrome?
- raised WCC
| - raised CK
93
how is neuroleptic malignant syndrome managed?
- Withdraw anti-psychotics and dopamine antagonists, or restore dopamine agonist
- Administer cooled IV fluids to rehydrate and prevent AKI
- Use physical cooling measures for hyperthermia e.g. ice packs and cooling blankets
- Offer lorazepam or dantrolene, bromocriptine or amantadine to treat rigidity and agitation
- ECT may be useful following failed pharmacotherapy
94
what are the clinical features of serotonin syndrome?
- Clonus
- Hyperreflexia
- Agitation
- Confusion
- Tremor, shivering and myoclonus
- Sweating
- Headache
- Tachycardia
- Hypertonia/rigidity
- Diaphoresis
- Flushing
- Dilated pupils
- Hyperthermia
95
how is serotonin syndrome managed?
- Stop all serotonergic drugs
- If the reaction is severe, it is best to perform early sedation, intubation and ventilation
- Give activated charcoal if serotonin syndrome is associated with an overdose in the last hour
- Give cooled IV fluids and use physical cooling methods
- If there is neuromuscular excitation or agitation, give lorazepam or cyproheptadine
96
what are the clinical features of a conversion disorder?
- Paralysis
- Aphonia
- Sensory loss
- Seizures
- Amnesia
- Fugue
97
what are the clinical features of hypochondriasis?
- the pre- occupation with the idea of having a serious medical condition, usually one which would lead to death or serious disability.
- The patient repeatedly ruminates on this possibility and insignificant bodily abnormalities, normal variants, normal functions, and minor ailments will be interpreted as signs of serious disease.
- The patient consequently seeks medical advice and investigation but is unable to be reassured in a sustained fashion by negative investigations.
- The form of the belief is that of an over-valued idea; the patient may be able to accept that their worries are groundless but nonetheless be unable to stop dwelling and acting on them.
98
how is hypochondriasis managed?
- Allow patient time to ventilate their illness anxieties.
- Aim to plan continuing relationship and review, not contingent upon new symptoms.
- fluoxetine or imipramine
- CBT
99
what is somatisation disorder?
-a disorder in which there is repeated presentation with medically unexplained symptoms, affecting multiple organ systems, first presenting before the age of 40.
100
what are the clinical features of somatisation disorder?
- long, complex medical histories (‘fat-file’ patients)
- Symptoms may occur in any system and are to some extent suggestible.
- most frequent symptoms are non-specific and atypical.
- discrepancy between the subjective and objective findings
- Symptoms are usually concentrated in one system at a time but may move to another system after exhausting diagnostic possibilities in the previous one.
- Diagnosis is usually only suspected after negative findings begin to emerge because normal medical practice is to take a patient’s complaints at face value.
- The key diagnostic feature is multiple, atypical, and inconsistent medically unexplained symptoms in a patient under the age of 40.
101
define somatoform pain disorder
-there is a complaint of persistent severe and distressing pain which is not explained or not adequately explained by organic pathology.
102
what are the clinical features of factitious disorder?
- History of unexplained complaints or inconsistency over time
- Unusual presentation relative to demographic
- Symptoms more exaggerated when aware of observation
- Presentation for care at many different hospitals
- Evidence of the patient manipulating findings
103
what are the risk factors for development of factitious disorder?
- Female
- Medically related employment
- Cluster B personality subtypes
- Single
- Aged 40-50
104
how is factitious disorder managed?
- Treat any objective findings (such as infection or hypoglycaemia induced by the patient) as medically indicated
- Offer psychological treatments such as psychoanalytic psychotherapy, CBT and supportive therapy
- If there is factitious disorder by proxy, report to appropriate authorities to ensure the safety of the dependent involved.
105
what are the clinical features of acute stress disorder?
- Exposure to trauma
- Intrusion symptoms: flashbacks
- Avoidance symptoms: avoiding people, situations or circumstances resembling or associated with the event
- Negative alterations in cognitions and mood
- Alterations in arousal and reactivity, including hypervigilance, exaggerated startle response, angry outbursts and self-destructive behaviours
106
what are the clinical features of PTSD?
- Exposure to trauma
- Intrusion symptoms: flashbacks
- Avoidance symptoms: avoiding people, situations or circumstances resembling or associated with the event
- Negative alterations in cognitions and mood
- Alterations in arousal and reactivity, including hypervigilance, exaggerated startle response, angry outbursts and self-destructive behaviours
107
how is PTSD managed in adults?
- trauma focussed CBT
- EMDR
- venlafaxine or an SSRI
- risperidone for severe hyperarousal
108
how is PTSD managed in children?
- trauma focussed CBT
- Group trauma focussed CBT for a large scale event
- EMDR
109
what are the clinical features of post-natal affective disorders?
- Depressed mood
- Anhedonia
- Decreased energy or increased fatigability
- Suicidal ideation
- Unreasonable feelings of self-reproach or excessive guilt
- Poor concentration
- Change in psychomotor activity
- Sleep disturbance
- Change in appetite
- Change in weight
- Obsessive thoughts
- Self-harm or neglect or mistreatment of children
- Psychotic symptoms
110
what are the risk factors for post-natal affective disorders?
- History of a mental illness
- Poor social support
- Discontinuation of psychopharmacological treatments
- Sleep deprivation
- Family history
- Domestic violence
- Birth complications
- Poor socio-economic status
- Age less than 16 years
111
How are postnatal affective disorders managed?
- facilitated self-help.
- TCA
- SSRI
- SNRI
- CBT
- Refer to a secondary mental health service, ideally a specialist perinatal mental health service, for immediate assessment (within 4 hours of referral) if a woman has a sudden onset of symptoms suggestive of postpartum psychosis.
- admit to mother baby unit
112
what are the clinical features of narcolepsy?
- Excessive daytime sleepiness
- Cataplexy
- Hypnagogic and hypnopompic hallucinations
- Sleep paralysis
- Chronic fatigue
- Poor memory and concentration
- Sleep attacks
- Fragmented nocturnal sleep
113
how is narcolepsy disguised on multiple sleep latency testing?
sleep latency ≤8 minutes plus ≥2 sleep-onset rapid eye movement (REM) periods (SOREMS)
114
How are adults with narcolepsy managed?
- Promote sleep hygiene
- Offer modafinil or CNS stimulants such as methylphenidate or dexamfetamine
- If there is associated cataplexy give sodium oxybate, an SSRI/SNRI or TCAs
- If the patient is resistant to this treatment, consider MAOIs as a last resort
115
How are children with narcolepsy managed?
- Promote sleep hygiene
- Offer modafinil or methylphenidate
- For cataplexy, avoid triggers and give SSRI/SNRI or TCAs
116
what are the clinical features of periodic limb movement disorder?
- Poor sleep
- Daytime somnolence and fatigue
- Periodic limb movements
117
how is periodic limb movement disorder diagnosed on EMG/EEG
- PLMS index (number of PLMS per hour of sleep) >15 for the whole night
- PLMS predominantly during non-rapid eye movement (REM) stages 1 and 2 of sleep, and progressively diminishing during deep sleep stages 3 to 4
118
define insomnia
-difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality.
119
what are the clinical features of insomnia?
- Complaints from the sleep partner
- Delayed sleep onset
- Multiple or long awakenings
- Impaired functioning
- Accidents
- Decreased sleep time
- Daytime napping
- Symptoms of sleep apnoea
120
how is insomnia managed?
- sleep hygiene advice
- short course of hypnotic such as zopiclone
- CBT-insomnia
- a z-drug or prolonged released melatonin if over 55 years of age
121
what are the clinical features of jet lag/shift work sleep disorders?
- History of travel across 2 time zones or shift work
- Difficulty initiating and maintaining sleep
- Daytime sleepiness
- Reduced daytime alertness
- Nausea and constipation
122
how is shift work sleep disorder managed?
- Advise on the use of a sleep diary to assess the nature of any suspected sleep disturbance.
- Advise on measures to promote sleep
- Advise the person to consider the use of caffeinated drinks just before, and during shifts to counteract sleepiness.
- Advise the person on optimal working schedules and environment, and the need to liaise with the Occupational Health department if appropriate.
- Encourage the person to balance family, social, work, and sleep commitments
- Consider seeking advice or arranging referral to the local sleep clinic if there are ongoing troublesome symptoms
123
how is jet lag managed?
- For short travel stays (of two days or less), advise to consider continuing activities such as sleeping and eating on ‘home time’, to minimise disruption to the normal sleep/wake cycle.
- pre-flight sleeping and consider moving bedtimes at home to be more similar to abroad
- eat light meals and maintain hydration
- Try to get as much sleep as normal during a 24-hour period, with a minimum block of four hours during the local night-time period in the new time zone.
- Take naps in response to sleepiness.
- Try to get timely exposure to light and darkness (scheduled sleep), and consider the use of sunglasses to help this.
124
what are the clinical features of restless legs syndrome?
- Dysaesthesias
- Evening symptoms
- Relieving factors: movement, stretching and massage
- Occurring in lower extremities
125
how is restless leg syndrome managed?
- treat any underlying cause
- self-help advice
- non-ergot dopamine agonist e.g. pramipexole
- alpha-2-delta ligand (pregabalin or gabapentin)
126
define parasomnia
-Parasomnias are undesirable sleep-related events that may occur during sleep or during the transition into sleep or out of sleep
127
what are the clinical features of parasomnias in children?
- Disturbed cognition during the events (confusional arousals, sleep terrors and sleepwalking)
- Vigorous activity or violent behaviour (confusional arousals, sleepwalking, sleep terrors, RBD)
- Episodes of inability to move (sleep paralysis)
- Autonomic hyperactivity during event (sleep terrors)
- Amnesia
- Abnormal demeanour and facial expressions (confusional arousals, sleep walking, sleep terrors)
128
what are the clinical features of parasomnias in adults?
- Cognitive disturbances between episodes (RBD)
- Sensation of sudden loud noise in the head (exploding head syndrome)
- Eating behaviour during the night (sleep related eating disorder)
- Evidence of external injuries (RBD)
129
how are confusional arousals, sleep walking and sleep terrors managed?
- Educate and encourage good sleep hygiene
- Implement safety measures
- Consider scheduled awakening
- For children with very frequent episodes, biofeedback and relaxation techniques
- Avoid sleep deprivation and treat other sleep disorders
- In adults, consider CBT or hypnosis
- low dose hypnotics on benzodiazepines or TCAs
- Sleep related eating disorder is managed by offering topiramate or dopamine agonists such as pramipexole
130
how are REM behaviour disorders managed?
- Avoid precipitating factors and implement environmental protective measures
- Offer melatonin in children and adults
- CBT with systematic desensitisation and relaxation techniques may be useful in nightmare disorder
131
what are the clinical features of simple alcohol withdrawal?
- Alcohol dependence
- Cessation or reduction in alcohol intake
- Anxiety
- Nausea and vomiting
- Tremor
- Tachycardia
- Sweating
- Palpitations
- Insomnia
- Hypertension
132
what are the clinical features of delirium tremens?
- 48 to 72 hours after last alcoholic drink
- Profound confusion that fluctuates
- Clouding of consciousness
- Hallucinations: classically Lilliputian hallucinations that can be visual, auditory or tactile
- Coarse tremor
- Autonomic dysfunction
133
what is seen VBG in alcohol withdrawal?
- respiratory alkalosis in DT
- hypochloraemic metabolic acidosis with vomiting
- metabolic acidosis with a high anion gap if alcoholic ketoacidosis
- hypoglycaemia
134
how is acute alcohol withdrawal managed?
- offer chlordiazapoxide or clomethiazole
| - lorazepam in liver disease
135
how are alcohol withdrawal seizures managed?
- consider offering a quick-acting benzodiazepine (such as lorazepam)
136
how is delirium tremens managed?
- offer oral lorazepam as first-line treatment.
| - If symptoms persist or oral medication is declined, offer parenteral lorazepam or haloperidol
137
what are the clinical features of an alcohol use disorder?
- Withdrawal symptoms on cessation of alcohol
- Tolerance
- Signs of alcoholic liver disease
- Peripheral Neuropathy
- Impaired nutritional status
138
how is alcohol use disorder. diagnosed?
- AUDIT >15
- raised carbohydrate deficient transferrin
- Raised LFTs
- Low MCV and thrombocytopenia
139
how is alcohol use disorder managed?
- prophylactic thiamine
- CBT
- Nalmefene
- detox with chlordiazepoxide or diazepam
140
How is abstinence maintained following alcohol detox?
- Acamprosate
- naltrexone
- Disulfiram
141
what are the side effects of acamprosate?
- GI upset
- pruritus
- rash
- altered libido
142
what are the side effects of naltrexone?
- GI upset
- anxiety
- headache
- fatigue
- sleep disturbance
- flu-like symptoms
143
what are the side effects of disulfiram?
- Halitosis
| - headache
144
what are the clinical features of cocaine abuse?
- Hypertension
- Tachycardia
- Chest pain
- Mydriasis
- Diaphoresis
- Tremor
- Agitation
- Mood changes
- Anxiety
- Tactile hallucinations
145
what are the clinical features of opioid abuse?
- Blunting of pleasurable effects
- Miosis
- Dilated pupils
- Shallow and slow respirations
- Needle track marks
- Chronic constipation
- Weight loss
146
what are the symptoms of opioid withdrawal?
- Nausea/vomiting
- Sedation
- Insomnia
- Memory impairment
- Yawning
- Abdominal cramps
- Hypotension
- Shallow and slow respirations
- Aggressive behaviour
- Rhinorrhoea
- Restlessness
- Piloerection
147
how is opioid withdrawal managed?
- substitute prescribing: methadone or buprenorphine
| - lofexidine
148
what are the clinical features of wernicke's encephalopathy?
- Mental slowing, impaired concentration and apathy
- Confusion
- Ocular motor findings, most commonly gaze palsies, 6th nerve palsies, impaired vestibulo-ocular reflexes, nystagmus and ophthalmoplegia
- Ataxia
- Tachycardia
149
how is wernicke's encephalopathy managed?
-thiamine
150
what are the clinical features of korsakoff's psychosis?
- Absence or significant impairment in the ability to lay down new memories, together with a variable length of retrograde amnesia.
- Working memory (e.g. ability to remember a sequence of numbers) is unimpaired as is procedural and ‘emotional’ memory.
- Confabulation for the episodes of amnesia may be prominent.
151
how is wernicke-korsakoff's syndrome managed?
-supported living
152
what are the clinical features of autism spectrum disorder?
- Language delay or regression
- Verbal and non-verbal communication impairment
- Social impairment
- Repetitive, rigid or stereotyped interests, behaviour or activities
- Motor stereotypies
- Sensory interests
153
how is autism managed?
- offer the child or young person a psychosocial intervention (informed by a functional behavioural analysis)
- anti-psychotic medication
- CBT
- sleep plan
- supported schooling and employment
154
what are the clinical features of dyspraxia?
- handwriting, which is typically awkward, messy, slow, irregular and poorly spaced
- dressing (buttons, laces, clothes)
- cutting up food
- poorly established laterality
- copying and drawing
- messy eating from difficulty in coordinating biting, chewing and swallowing (oromotor dyspraxia). Dribbling of saliva is common.
155
how is gender non-conformity managed?
- Observation in changed sex role for >1 year
- For male-to-female, give spironolactone, cyproterone acetate or GnRH agonists as anti-androgens, and oestrogen replacement either orally, IM or by patch
- For female-to-male, give oral or transdermal testosterone
- For male-to-female, offer thyroid cartilage reduction, craniofacial surgery, augmentation mammoplasty, and removal of penis with formation of vulva
- For female-to-male, offer bilateral mastectomy, hysterectomy, bilateral oophorectomy and phalloplasty
156
what are the risks of feminising hormone therapies?
- VTE
- Gallstones
- Elevated liver enzymes
- Weight gain
- Hypertriglyceridaemia
- Cardiovascular disease
- Hypertension
- Hyperprolactinaemia
- Type 2 diabetes
- Breast cancer
157
what are the risks of masculinising hormone therapies?
- Polycythaemia
- Weight gain
- Acne
- Androgenic alopecia
- Sleep apnoea
- Elevated liver enzymes
- Hyperlipidaemia
- Destabilisation of psychiatric disorders
- Cardiovascular disease
- Hypertension
- Type 2 diabetes
-Loss of bone density
Cancer of breast, cervix, ovary and uterus
158
what are the clinical features of chronic fatigue?
- Persistent disabling fatigue
- Post-exertional malaise and fatigue
- Short-term memory and concentration impairment
- Sore throat
- Generalised arthralgia without inflammation
- Headache/migraine
- Unrefreshing sleep
- Orthostatic intolerance
- Diffuse muscular, tendon and fascial pain
159
how is chronic fatigue managed?
- manage nausea with conservative advice and anti-emetics
- tailored sleep management advice
- Advise on the role of rest, how to introduce rest periods into their daily routine, and the frequency and length appropriate for each person
- relaxation techniques
- CBT
- graded exercise therapy
- low dose TCA if pain or poor sleep
- melatonin
160
what are the clinical features of foetal alcohol spectrum disorders?
- Gestation <37 weeks
- Low height, weight and head circumference
- Characteristic facial dysmorphology: short palpebral fissure, thin upper lip or vermillion border and smooth philtrum
- Presence of cardiac anomalies: ASD, VSD, tetralogy of Fallot
- Presence of MSK anomalies: hypoplastic nails, shortened 5th finger, radioulnar synostosis, flexion contractures, camptodactyly, pectus excavatum or carinatum, scoliosis and hockey-stick palmar creases
- Presence of renal anomalies
- Presence of ocular anomalies: strabismus, retinal vascular anomalies
- Developmental delay
- Mental health problems
- Poor feeding
- Irritability
161
how are foetal alcohol spectrum disorders managed?
- education and learning strategies
- child friendship training
- surgery for organ defects
162
by which 3 mechanisms does Down's syndrome arise?
- meiotic non-disjunction
- translocation
- mosaicism
163
what are the head and neck features of Down's syndrome?
- Brachycephaly and reduced anteroposterior (AP) diameter
- maxilla reduced more than mandible
- underdeveloped bridge of nose
- eyes close together
- Brushfield’s spots—grey or very light yellow spots of the iris
- epicanthic fold
- low-set ears
- high-arched palate
- protruding tongue
- instability of atlanto-axial joint
- narrowed hypopharynx (may lead to sleep apnoea).
164
what congenital defects are associated with Down's syndrome?
- AVSD
- Mitral valve disease
- PDA
- Oesophaeal atresia
- Duodenal atresia
- Hirschprung’s disease
- Hernias
165
what are the hand features of downs syndrome?
- Short broad hands with a single palmar crease (simian crease)
- syndactyly (webbed fingers)
- clinodactyly (incurving of fingers)
- altered dermatoglyphics.
166
what are the eye and ear features of Down's syndrome?
- Strabismus
- Myopia
- blocked tear ducts
- nystagmus
- late-life cataracts
- Keratoconus
- Structural anomalies may lead to recurrent otitis media, sensorineural deafness.
167
how is Down's syndrome managed?
- management of associated congenital defects
- physiotherapy
- occupational therapy
- SALT
- educational plan
- regular hearing, thyroid, ophthalmic and dental examinations
168
which drugs increase the plasma concentration of lithium?
- ACE inhibitors/angiotensin-II receptor antagonists
- analgesics (esp. NSAIDs)
- antidepressants (esp. SSRIs)
- anti-epileptics
- antihypertensives (e.g. methyldopa)
- antipsychotics (esp. haloperidol)
- calcium-channel blockers
- diuretics
- metronidazole.
169
which drugs decrease the plasma concentration of lithium?
- antacids
| - theophylline.
170
what are the contraindications to the use of lithium?
- Addison’s disease
- cardiac disease associated with rhythm disorder
- cardiac insufficiency
- Dehydration
- family history of Brugada syndrome
- low sodium diets
- personal history of Brugada syndrome
- untreated hypothyroidism
171
what are the side effects of lithium?
- Polyuria/polydipsia
- weight gain
- cognitive problems
- tremor
- sedation or lethargy
- impaired co-ordination
- GI distress (e.g., nausea, vomiting, dyspepsia, diarrhoea)
- hair loss
- benign leucocytosis
- acne
- oedema.
172
how are the adverse effects of lithium managed?
- B-blockers (tremor)
- thiazide or loop diuretics (polyuria, polydipsia or oedema)
- topical antibiotics or retinoic acid (acne).
173
what are the long term effects of lithium?
- Renal impairment
- Hypothyroidism
- Ebstein’s anomaly in children born to mothers taking lithium
174
what are the clinical features of lithium toxicity?
-Marked tremor, anorexia, nausea/vomiting, diarrhoea (sometimes bloody), with dehydration and lethargy.
-Severe neurological complications—restlessness, muscle fasciculation/myoclonic jerks, choreoathetoid movements, marked hypertonicity.
This may progress to ataxia, dysarthria, increased lethargy, drowsiness, and confusion/delirium.
-Hypotension and cardiac arrhythmias precede circulatory collapse, with emerging seizures, stupor, and eventual coma
175
how is lithium toxicity managed?
- forced diuresis with intravenous isotonic saline
| - in cases where toxicity is severe or accompanied by significant renal failure, haemodialysis.
176
what are the side effects of SSRIs?
- nausea
- anorexia
- insomnia
- loss of libido
- failure of orgasm
- serotonin syndrome
- risk of bleeding
- hyponatraemia
177
what are the contraindications to SSRI use?
- manic episodes
- concomitant use of MAOIs
- poorly controlled epilepsy
178
what are the side effects of TCAs
- dry mouth
- blurred vision
- constipation
- urinary retention
- postural hypotension
- QT prolongation in overdose.
- Drowsiness
- Tachycardia
- sexual dysfunction.
- sedation.
179
what are the contraindications to TCA use?
- acute MI
- heart block
- Arrhythmias
- IHD
- severe liver disease
- Pregnancy
- lactation
180
what are the side effects of venlafaxine?
- arrhythmias
- asthenia
- depersonalisation
- movement disorders
- mydriasis
- palpitations
181
what are the side effects of duloxetine?
- dry mouth
- GI discomfort
- sexual dysfunction
- skin reactions
- sleep disorders
- sweat changes
- vision changes
- weight changes
182
what are the side effects of mirtazapine?
- Sedation
- increased appetite
- weight gain.
- transaminase elevation
- jaundice
- oedema
- orthostatic hypotension
- tremor
- myoclonus
- blood dyscrasias
183
in which patients should mirtazapine be used with cautions?
- cardiac disease
- DM
- elderly
- history of bipolar
- seizures
- urinary retention
- hypotension
- psychoses
- susceptibility to angle closure glaucoma
184
what are the side effects of MAOIs?
- Cheese reaction with foods high in tyramine - acute hypertension, giving rise to a severe throbbing headache and occasionally even to intracranial haemorrhage.
- Anticholinergic effects - urinary retention, blurred vision, dry mouth, constipation
- drowsiness
- postural hypotension
- tachycardia
- sexual dysfunction.
- sedation
- weight gain
185
in which patients should MAOIs be used with caution?
- cardiovascular disease
- hepatic failure
- poorly controlled hypertension
- Hyperthyroidism
- Porphyria
- phaeochromocytoma
186
what are the side effects of benzodiazepines?
- Sedation and memory problems.
- Dependence and tolerance, particularly in those with dependent personalities.
- A withdrawal syndrome can occur after 3 weeks of continuous use a
- Interaction with alcohol, producing a long-lasting ‘hangover syndrome’.
- Ethanol enhances the action of GABA on GABAA receptors
187
what are the contraindications to benzodiazepines?
- Acute pulmonary insufficiency
- marked neuromuscular respiratory weakness
- not for use alone to treat chronic psychosis
-not for use alone to treat depression,
obsessional states, phobic states
- sleep apnoea syndrome
- unstable myasthenia gravis
188
what are the indications for ECT?
- severe depressive episode
- need for rapid antidepressant response
- failure of drug treatments
- treatment resistant psychosis and mania
- catatonia
- NMS
- intractable seizure disorders
189
what are the relative contraindications to ECT?
- cerebral aneurysm
- recent MI
- cardiac arrhythmias
- intracerebral haemorrhage
- retinal detachment
- phaeochromocytoma
190
what are the side effects of ECT?
- retrograde amnesia
- headache
- temporary confusion
- nausea/vomiting
- clumsiness
- muscular aches
- loss of long-term memory
191
what are the contra-indications to light therapy?
- agitation
- insomnia
- history of hypomania and mania
192
with which drugs does clozapine interact?
- lithium
- acetylcholinesterase inhibitors
- smoking cigarettes
- caffeine
- anti-hypertensives
- H2 blockers
- phenothiazines
- TCAs
- digoxin
- heparin
- phenytoin
- warfarin
193
what are the contraindications to clozapine use?
- Previous/current neutropenia or other blood dyscrasias
- previous myocarditis, pericarditis and cardiomyopathy
- severe renal or cardiac disorders
- active or progressive liver disease/hepatic failure.
194
what are the side effects of clozapine?
- agranulocytosis
- constipation
- hypersalivation
