Psychiatry - General Flashcards

Question

ICD-10 definition of schizophrenia

Answer 1

* Symptoms must have persisted for at least one month and are not due to organic causes * The course can be continuous, or episodic or there can be one or more episodes with complete or incomplete remission

Answer 2

``` In schizophrenia there is lack of: weight change sleep problems guilt/hopelessness/low self-worth social withdrawal ``` e.g. delusion in depression “I am responsible for all the bad things” delusion in schizophrenia “People want to harm me” • Post-psychotic depression  prolonged depressive episode that occurs on resolution of psychosis. Can be distinguished from negative symptoms of schizophrenia bc: o Schizophrenia – negative symptoms increase/decrease in conjunction with the severity of the positive symptoms. No insight o Post-psychotic depression – depressive type symptoms do not change in concordance with any positive symptoms. Patient has a good degree of insight. Can be a result of neuroleptic medication

Answer 3

• Paranoid o Most common type o Prominent hallucinations + delusions (usually persecutory) • Catatonic o Dominated by psychomotor disturbance o Catatonia can kill – people can stop eating + drinking - this is an indication for ECT o Stupor – immobility, mutism, unresponsiveness despite being conscious (eyes are open + can track movement) o Excitement – periods of extreme, purposeless motor activity (may alternate with stupor) o Posturing – assuming + holding inappropriate/bizarre positions o Rigidity – holding a rigid posture against efforts to be moved o Waxy flexibility – person’s limbs offer minimal resistance to being placed in seemingly uncomfortable positions, which are maintained for unusually lengthy periods o Automatic obedience – to any instructions o Preservation – inappropriate repetition of words or movements • Hebephrenic o Predominantly disorganized and chaotic mood, behaviour and speech o Shallow or inappropriate affect o Aimless behaviour o Delusions and hallucinations less prominent • Simple o Negative features only o Never showing positive psychotic symptoms • Residual o Prominent negative symptoms that remain after delusions + hallucinations subside

Answer 4

• Treatment resistance = failure to respond to 2 or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks

Answer 5

``` Organic causes (organic psychosis) • Dementia or delirium ``` * Cerebral pathology – stroke, SOL, encephalitis, epilepsy, MS, cerebral lupus, HIV, neurosyphilis * Systemic illness – Wilson's disease, porphyria, Cushing’s syndrome, hypo-/hyperthyroidism * Medication side effects – steroids, DA agonists, levetiracetam • Drugs causing psychosis through intoxication – amphetamines, cocaine, LSD, ecstasy, ketamine, GHB/GBL (gamma-hydroxybutrate/gamma-butyrolactone – can cause psychotic symptoms during withdrawal), phencyclidine (PCP), NPS, Cannabis, khat o Can acutely induce paranoia + thought disorder o Rarely produce negative symptoms but might produce neg symptoms o Symptoms resolve with drug cessation o Look at time frame --> how long does it last, when did symptoms start? • Heavy use of alcohol can cause: alcoholic hallucinosis, delirium tremens (hallucinations, delusions)

Answer 6

Non-organic causes (functional psychosis) Can be considered once organic causes have been excluded • Affective psychosis o Congruous affect – depressed/elated o Less likely to have 1st rank symptoms o Increased volume of speech, flight of ideas, punning o Disinhibition in BPAD not seen in schizophrenia o BPAD - grandiose delusions o Schizophrenia - persecutory delusions • Schizoaffective disorder o Picture of schizophrenia but with a mood disorder (moderate/severe depressive or mania) developing either simultaneously or within a few days of each other. o In contrast, in primary mood disorders (e.g. BPAD) psychotic symptoms emerge only as mood becomes more extreme e.g. psychotic depression, mania with psychotic symptoms o Prominent symptoms of schizophrenia (e.g. delusions, hallucinations, disorganisation in the form of thought, experiences of influence, passivity and control) are accompanied by typical symptoms of a moderate or severe depressive episode (e.g. depressed mood, loss of interest, reduced energy), a manic episode (e.g. an extreme mood state characterised by euphoria, irritability, or expansiveness; increased activity or a subjective experience of increased energy) or a mixed episode. o Psychomotor disturbances, including catatonia, may be present. o Symptoms must have persisted for at least one month. o The symptoms are not a manifestation of another medical condition (e.g. a brain tumor) and are not due to the effect of a substance or medication on the central nervous system (e.g. corticosteroids), including withdrawal (e.g. alcohol withdrawal). • Schizotypal disorder o Enduring state lasting several years or more (classed under personality disorders in DSM-5) o Eccentricity is central to the dx: people may dress, behave, think, speak oddly o They may be suspicious, aloof and struggle to make close relationships o They have unusual ideas, may experience fleeting delusions or hallucinations (not sufficient to diagnose another psychotic illness) o Increased risk of developing schizophrenia • Acute and transient psychotic disorder o Psychotic symptoms occur suddenly + relatively briefly o Symptoms peak within 2 weeks + usually resolve within a month – maximum duration is 3 months o Symptoms can fluctuate rapidly, might be acutely disabling o Not diagnosed if there is a hx of another psychotic illness e.g. schizophrenia o Often associated with acute stress ``` • Delusional disorder o Delusions (either a single or a set of delusions) lasting more than 3 months without a clear mood disturbance and lacking other schizophrenia symptoms e.g. thought disorder, persistent hallucinations or negative symptoms o Usually absence of auditory hallucinations, delusions of control, blunting of affect and brain disease - There may also be auditory hallucinations, but there are usually no other schizophrenia-like symptoms o Level of functionality – low in schizophrenia, well kempt, good functionality in delusional disorder (no thought disorder, no chaoticness in delusional disorder) The delusions are usually either persecutory or grandiose. Three particularly common delusions are: o Dysmorphophobia – a delusion that their body is particularly deformed (e.g. they think they have a massive nose when they clearly don’t), to that it is always giving off a particularly foul smell o Morbid Jealousy – a delusion that the patient’s partner is cheating on them, despite very little evidence – e.g. they were late home one night o Erotomania – this is where the patient loves another individual, and believes the other individual also loves them – but that they are unable to show it ``` • Puerperal (postpartum) psychosis o Psychosis triggered by childbirth o Usually occurs within a few weeks of delivery • Personality disorder o Should be considered when there is lifelong pattern of interpersonal difficulties o Fleeting psychotic like symptoms o Insight preserved  Paranoid PD – prominent detachment + negative affectivity traits – suspiciousness + paranoia  Schizoid PD – prominent detachment traits – lack of interest in others or social norms (can resemble ARMS or negative symptoms)  Borderline personality pattern – brief psychotic or psychotic-like symptoms can occur at times of stress e.g. hearing voices, paranoia • Delirium o Visual hallucinations o Disorientated in time, place and person – pt with schizophrenia are not disorientated in time, place and person o “Clouding of consciousness”

Answer 7

Organic psychoses were believed to result from a physical defect of or damage to the brain. Functional psychoses were believed to have no physical brain disease evident upon clinical examination

Answer 8

Disinhibition in BPAD not seen in schizophrenia BPAD - grandiose delusions Schizophrenia - persecutory delusions BPAD less likely to have first rank symptoms of schizophrenia

Answer 9

o Trauma/head injury - In trauma and head injury, the patient may hear voices that they can ‘talk to’. In psychiatric disease, this does usually not occur (or if the patient claims it does occur, it is often fictitious)

Answer 10

* Rare idiosyncratic life-threatening medical emergency that can happen in response to any antipsychotics * Classically develops insidiously around 4-11 days after initiation or increased dose of an antipsychotic * Caused by lack of dopamine

Answer 11

``` o Typical antipsychotics (in particular haloperidol) o High dose o Rapid increase in dose o Withdrawing anticholinergics o Depot o Males (2:1) o Past history NMS o Dehydrated ```

Answer 12

Similarities Rare and potentially lethal Sx: altered consciousness, neuromuscular status and autonomic dysfunction Require ABCDE approach and supportive measures Differences NMS Caused by lack of DA Treatment: Raise DA (bromocriptine, ECT) SS Caused by excessive serotonin Treatment: Serotonin antagonist e.g. cyproheptadine Distinguishing factors NMS - lead pipe rigidity SS - myoclonus, tremor, hyperreflexia (less rigidity) NMS - develops over time SS - acute timeframe

Answer 13

failure to respond to 2 adequate trials of different classes of antidepressants at adequate doses and for a period of 6-8 weeks

Answer 14

* Subthreshold depressive symptoms = at least 2 symptoms but <5 symptoms, able to cope with everyday life * Mild depression = few, if any, symptoms in excess of the 5 required to make the dx. Symptoms result in only minor functional impairment (2-3 symptoms) * Moderate depression = symptoms of functional impairment between mild and severe * Severe depression = most symptoms. Symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms * Persistent subthreshold depressive symptoms = persistence of subthreshold depressive symptoms for more than 2 years. Cannot be a consequence of a partially resolved depression. At least 2 but less than 5 symptoms required for dx.

Answer 15

• DSM-V = The individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure. 2 core symptoms, present most of the time for at least 2 weeks • Low mood • Anhedonia Other symptoms • Fatigue/loss of energy • Worthlessness/excessive or inappropriate guilt • Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts • Diminished ability to think/concentrate or indecisiveness • Psychomotor agitation or retardation • Insomnia/hypersomnia • Significant appetite and/or weight loss Diagnosis – at least 1 core symptom + at least 5/9 symptoms

Answer 16

Must last at least 2 weeks + represent a change from normal 2/3 core symptoms must be present for a dx of depression to be made (ICD-10)

Answer 17

o Criterion A – excessive anxiety + worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) o Criterion B – individual finds it difficult to control the worry o Criterion C – anxiety + worry are associated with at least 3/6 key features  Only 1 key feature required in children  BESKIM - Blank mind, Easily fatigued, Sleep disturbance, Keyed Up/Restless/On Edge, Irritability, Muscle tension o Criterion D – the anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning o Criterion E – the disturbance is not attributable to the physiological effects of a substance or another medical condition o Criterion F – the disturbance is not explained by another mental disorder

Answer 18

o Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is "free-floating"). o The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. o Fears that the patient or a relative will shortly become ill or have an accident are often expressed.

Answer 19

• Organic o Hyperthyroidism – continuous anxiety symptoms o Dementia – anxiety may be an early presentation o Intoxication – amphetamines, coffee – determine if onset of anxiety is related to when the drug is used o Withdrawal – BZD, alcohol, opioids o Episodes of hypoglycaemia – diet related, diabetes treatment related o Tachyarrhythmias e.g. SVT o B12 deficiency o Heavy metal toxicity o Phaeochromocytoma – tumour of the adrenal medulla resulting in secretion of excessive amounts of catecholamines e.g. adrenaline, NA ``` • Other mental disorders: o Panic disorder o Social anxiety disorder o Separation anxiety disorder o PTSD o Anorexia nervosa o Somatic symptom disorder o Body dysmorphic disorder o Illness anxiety disorder o Schizophrenia or delusional disorder ``` o Psychosis  Free floating anxiety may precede delusions and hallucinations, in the “at risk mental state” o Depression  Often co-morbid  Generally diagnose the disorder which came first + is more prominent, but don’t be afraid to diagnose both if criteria are met  Mixed depressive + anxiety disorder  low level anxiety + depressive symptoms present equally together, neither justifying diagnosis alone o Personality disorder o OCD o Adjustment disorder – the anxiety occurs in response to an identifiable stressor within 3 months of onset + does not persist for more than 6 months after the termination of the stressor

Answer 20

``` • Hyperventilation syndrome o Secondary to anxiety o Can occur with prolonged hyperventilation  Dizziness +/or syncope  Palpitations  Sweating  Dry mouth  Agitation  Fatigue  Carpopedal spasm – involuntary muscle contractions in the hands + feet [low CO2  alkalosis  neutralised by H+ from plasma proteins  excess protein anions take up calcium  low calcium  hypocalcaemic tetany o Management – slow, regular breathing ``` • Increased risk for medical disorders (pain syndromes, HTN, CV disorders, GI disorders)

Answer 21

o Changes behaviours and thoughts that maintain anxiety (the thoughts, feelings and behaviours as if the person is in imminent danger when they are not) o Aims to reduce patient’s expectation of threat, and the behaviours that maintain threat-related beliefs o Psychoeducation about the physiology of anxiety + techniques for managing arousal e.g. controlled breathing, relaxation exercises o Arms patient with techniques + thought processes to address negative thought patterns and behaviour o Addresses automatic assumptions  Explore the actual likelihood and impact of the anticipated catastrophe  Test the feared situation and their belief in a catastrophic outcome using behavioural experiments  The outcome helps disprove the worry and informs more realistic thoughts  This gradually increases the patient's confidence in their capacity to cope with the feared situation o Addresses thinking errors e.g. catastrophizing  Therapist challenges a way of thinking  Helps the person look for evidence that proves or disproves it o CBT helps people reassess the level of threat  notice when their anxiety is making them think illogically  relax their SSBs  develop more adaptive coping strategies over time  replace avoidance, escape, SSB (all of these reinforce anxiety) o Discussion of fears + triggers  rational explanation  replacement of these negative fearful thoughts with positive ones o Uses exposure therapy when avoidance + escape are central to the presentation o Can be carried out by an appropriately trained practitioner, can be self-directed online/app

Answer 22

o Used as part of the CBT approach when there are strong elements of avoidance and escape o People escape things they fear through SSBs or substance use disorders o In the absence of actual harm, the body can only remain extremely anxious for a short time (usually < 45 mins) before habituation occurs and anxiety levels drop o Habituation is characterised by a decrease in anxiety until fear dies out (extinction) o Exposure is usually through a gradual (or graded) approach called desensitisation o The patient identifies a goal (e.g. being able to hold a slug) and constructs a hierarchy of feared situations o The patient tackles it from least frightening to most frightening o Repeated exposure to the same stimulus produces lower + lower anxiety levels + faster habituation until there is no response at all  extinction o The aim is to stay in the situation until the anxiety has subsided to induce learning and challenge existing thoughts o Agoraphobia can be treated using this strategy

Answer 23

• The following criteria below apply to anyone >6 years old. • Criterion A – Exposure o Exposure to actual or threatened death, serious injury or sexual violence  Directly experiencing  Witnessing in person  Learning that the traumatic event occurred to a close family member or close friend. • In cases of actual or threatened death of a family member or friend, the events must have been violent or accidental  Experiencing repeated or extreme exposure to aversive details of the traumatic event • Does not apply to exposure through electronic media, TV, movies or pictures unless that exposure is work related  In children, learning that the traumatic event occurred to a parent or caregiving figure • Criterion B – Intrusion Symptoms o Presence of at least 1 of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:  Recurrent, involuntary, and intrusive distressing MEMORIES of the traumatic event(s)  Recurrent distressing DREAMS in which the content and/or affect of the dream are related to the traumatic event(s).  DISSOCIATIVE reactions (flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.  Intense or prolonged psychological DISTRESS at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).  Marked physiological REACTIONS to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) Children >6 --> repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed Spontaneous and intrusive memories may not necessarily appear distressing and my be expressed as play reenactment Frightening dreams without recognizable content • Criterion C – Avoidance o Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred:  Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).  Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) • Criterion D – Negative cognition and mood o Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by at least 2 of the following:  Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).  Persistent and exaggerated negative beliefs/expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”).  Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.  Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).  Markedly diminished interest or participation in significant activities.  Feelings of detachment or estrangement from others.  Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings) • Criterion E – changes in arousal o Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by at least 2 of the following:  Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.  Reckless or self-destructive behavior  Hypervigilance  Exaggerated startle response  Problems with concentration  Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) • In children, this includes extreme temper tantrums ``` • Criterion F – duration o Duration (Criteria B, C, D, E) is more than 1 month ``` • Criterion G o The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning • Criterion H o The disturbance is not attributable to the physiological effects of a substance (e.g. medication, alcohol) or another medical condition

Answer 24

* Delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone * Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence • Typical features include o Episodes of repeated reliving of the trauma in intrusive memories ("flashbacks") o Dreams or nightmares o Sense of "numbness" and emotional blunting o Detachment from other people o Unresponsiveness to surroundings o Anhedonia o Avoidance of activities and situations reminiscent of the trauma o Autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia * Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent * The onset follows the trauma with a latency period that may range from a few weeks to months * Fluctuating course * Recovery can be expected in the majority of cases * Small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change

Answer 25

• Adjustment disorder o The stressor can be of any severity and type and not just a traumatic event o Should be diagnosed when there is trauma but the individual does not meet all other PTSD criteria o the anxiety occurs in response to an identifiable stressor within 3 months of onset + does not persist for more than 6 months after the termination of the stressor • Acute stress disorder o Symptoms last between 3 days to 1 month following the exposure to the traumatic event o Requires the presence of 9 or more symptoms from any of the 5 categories: a) intrusion, b) negative mood, c) dissociation, d) avoidance, e) arousal o If symptoms >1 month --> PTSD • Anxiety disorders – symptoms not linked to a specific traumatic event • OCD o Intrusive thoughts are obsessions and are not related to an experienced traumatic event o Compulsions are absent in PTSD • Major depressive disorder o Does not include any intrusion or avoidance symptoms • Personality disorders – interpersonal difficulties that develop after a trauma would suggest PTSD rather than a personality disorder which is more long standing • Dissociative disorders (dissociative amnesia, dissociative identity disorder, depersonalization-derealization disorder) o An experience of trauma with temporal association is not needed o If PTSD criteria are met, add a specifier --> PTSD with dissociative symptoms • Conversion disorder (functional neurological symptom disorder) o New onset of somatic symptoms within the context of a traumatic event would suggest PTSD over conversion disorder • Psychotic disorders • TBI o PTSD and TBI are not mutually exclusive diagnoses and may occur concurrently o PTSD – reexperiencing + avoidance o TBI – executive dysfunction, disorientation, confusion

Answer 26

• Criterion A – presence of obsessions, compulsions or both. Obsessions defined by 1 and 2: o Recurrent and persistent thoughts, urges or images – experienced at some time during the disturbance as intrusive + unwanted. In most individuals they are caused by marked anxiety or distress o The individual attempts to ignore or suppress such thoughts, urges or images or to neutralize them with some other thought or action – i.e. by performing a compulsion Compulsions are defined by 1 and 2: o Repetitive behaviours (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly o The behaviours or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation. However, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or clearly excessive * Criterion B – the obsessions or compulsions are time-consuming (e.g. take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational or other important areas of functioning * Criterion C – the obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition * Criterion D – the disturbance is not explained by the symptoms of another medical disorder

Answer 27

• Obsessions = intrusive, unwanted and repetitive thoughts, urges or images that don’t go away and are generally unwanted or ego-dystonic o Can be violent, sexual or religious in nature o Can be thoughts, images, impulses, doubts o Obsessions are ego-dystonic – conflict uncomfortable with the person’s self-image o Although the sufferer recognizes that obsessions are irrational or untrue they cause deep discomfort or anxiety, often because they bring a terrible feeling that something bad might happen o This anxiety is neutralised by a compulsion

Answer 28

• Compulsions = repetitive physical behaviours or mental acts performed, meant to reduce the anxiety caused by the obsessions. Individual feels driven to perform these in response to an obsession, according to rigid rules, or to achieve a sense of “completeness”. o Neither pleasant nor useful o May be overt (observable by others) or covert (mentally counting or repeating a phrase) o Usually done in a very particular way – if done “incorrectly” person may have to start all over again, taking hours, causing obsessional slowness and severely affecting QOL

Answer 29

The link between obsessions and compulsions may seem vaguely logical or completely unrelated

Answer 30

Obsessions + compulsions lasts >2 weeks obsessions and compulsions must be time consuming (e.g. taking >1h per day) or result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. (ICD-11)

Answer 31

* Poor prognostic factors: early onset, poor insight, schizotypal features, thought/action compulsions * 60-90% of individuals with OCD also have a comorbid mental disorder o Lifetime prevalence for any comorbid anxiety disorder – 76%, mood disorder 63%, personality disorder 23-32% * Tends to run a chronic course, with symptoms worsening at times of stress * Without treatment it’s often disabling and commonly comorbid with depression • Children o Children with OCD have a 5-7% incidence of Tourette’s and up to 30% life-time history of tics o OCD+ADHD are highly comorbid

Answer 32

• Organic – movement disorders with repetitive, stereotyped movements resembling compulsions o Tourette syndrome o Sydenham’s chorea o Huntington disease o PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection) • Autism spectrum disorder o Repetitive patterns of behaviours – these are lifelong with social and communication difficulties o ASD increases the risk of OCD • Anxiety disorders o GAD – focus of the worry is upcoming problems. Involves real-life concerns. o OCD – obsessions are intrusive and unwanted thoughts, urges or images. Does not involve real-life concerns. Presence of both obsessions and compulsions • BDD o Obsessions + compulsions are limited to concerns about physical appearance o Behaviours (e.g. looking in the mirror) will further increase distress whereas in OCD checking behaviours usually decrease distress • Hoarding disorder o Individual holds a strong sentimental value and attachment towards the hoarded objects o If an individual has obsessions that are typical of OCD (e.g. about incompleteness or harm) and these obsessions lead to compulsive hoarding behaviours (to prevent harm) person has OCD and not a hoarding disorder * Complex tics * Eating disorders – obsessions and compulsions only concern wright, body image, food • Psychosis o Absence of other symptoms of schizophrenia/schizoaffective disorder e.g. hallucinations or thought disorder o In psychosis delusions are believed absolutely +/- thoughts may feel alien (thought insertion) o OCD – people recognize their obsessions as being irrational on some level (even if only when calm) + they also know that the thoughts come from their own mind • Substance/medication induced OCS – atypical antipsychotics • Anankastic personality disorder o Rigidity, inflexibility, liking of order o Shouldn’t include obsessions and compulsions

Answer 33

• Criterion A – the development of emotional or behavioural symptoms in response to an identifiable stressor occurs within 3 months of the onset of the stressor • Criterion B – the symptoms or behaviours are clinically significant, as evidenced by 1 of the following o Marked distress that is out of proportion to the severity or intensity of the stressor (taking into account the external context and the cultural factors that might influence symptom severity and presentation) o Significant impairment in social, occupational or other important areas of functioning * Criterion C – the stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder * Criterion D – the symptoms do not represent normal bereavement * Criterion E – once the stress or its consequences have terminated, the symptoms do not persist for more than an additional 6 months

Answer 34

* States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event * The stressor may - have affected the integrity of an individual's social network (bereavement, separation experiences) or - have affected the wider system of social supports and values (migration, refugee status) or - represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement) • Individual predisposition or vulnerability plays an important role in the risk of occurrence and the shaping of the manifestations of adjustment disorders, but it is nevertheless assumed that the condition would not have arisen without the stressor • The manifestations vary and include depressed mood anxiety or worry (or mixture of these) a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine * Conduct disorders may be an associated feature, particularly in adolescents * The predominant feature may be a brief or Prolonged depressive reaction, or a disturbance of other emotions and conduct

Answer 35

o Acute stress reaction – timing for symptoms to go away hours-days o Adjustment disorder – timing for symptoms to go away months

Answer 36

Bio serious physical illness ``` Psycho Response to loss bereavement problem with close relationship unwanted move disappointment, job failure, loss parental separation, divorce, new birth in family, loss of attachment figure or object ``` social migration or refuge status stressor may involve individual or the whole group/community

Answer 37

• The essential feature is recurrent obsessional thoughts or compulsive acts • Obsessional thoughts o Ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form o They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them o They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant • Compulsive acts or rituals o Stereotyped behaviours that are repeated again and again o Not inherently enjoyable, nor do they result in the completion of inherently useful tasks o Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur o Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. o Anxiety is almost invariably present o If compulsive acts are resisted the anxiety gets worse

Answer 38

Criterion A- Death of someone close at least 12 months earlier (6 months for children/adolescents) Criterion B - a person experiences intense yearning or preoccupation Criterion C - plus at least 3 of 8 symptoms of Identity disruption (e.g., feeling as though part of oneself has died). Marked sense of disbelief about the death. Avoidance of reminders that the person is dead. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death. Difficulty with reintegration (e.g., problems engaging with friends, pursuing interests, planning for the future). Emotional numbness. Feeling that life is meaningless. Intense loneliness (i.e., feeling alone or detached from others). Criterion D - for at least one month, that cause distress or disability Criterion E - exceed cultural and contextual norms Criterion F - not better explained by another mental disorder

Answer 39

o The death is sudden and unexpected o Circumstances have prevented normal grief at an early stage (e.g. Unable to see the body) o The relationship before the deceased died was hostile / there were unresolved problems o The loss involves a child of the affected (even if ‘child’ is now adult) o The patient has a small social circle, and/or few relatives

Answer 40

* Acute stress disorder is a mental disorder that arises in response to experiencing or witnessing a traumatic event that induces a strong emotional response within the individual * It is a “precursor” to the dx of PTSD as symptoms last less than a month * If symptoms last longer than 1 months  PTSD * Formal immediate, psychological debriefing (describing trauma and emotional response to it) can increase the risk of PTSD * Acute stress reaction  immediate casual temporal relationship with the trigger event

Answer 41

• Criterion A – Exposure to actual or threatened death, serious injury or sexual violence in at least 1 of the following ways o Directly experiencing the traumatic event o Witnessing, in person, the event as it occurred to others o Learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or accidental o Experiencing repeated or extreme exposure to aversive details of the traumatic event (e.g. first responders collecting human remains or police officers repeatedly exposed to details of child abuse)  Does not apply to exposure through electronic media, TV, movies or pictures unless that exposure is work related • Criterion B – presence of at least 9 of the following symptoms from any of the 5 categories of (1) intrusion, (2) negative mood, (3) dissociation, (4) avoidance, (5) arousal beginning or worsening after the traumatic event occurred o Intrusion symptoms  Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.  Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). In children, there may be frightening dreams without recognizable content.  Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) • In children, trauma-specific reenactment as well as spontaneous and intrusive memories may not necessarily appear distressing and my be expressed as play reenactment.  Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). o Negative mood  Persistent inability to experience positive emotions – inability to experience happiness, satisfaction, loving feelings o Avoidance symptoms  Efforts to avoid distressing memories, thoughts or feelings closely associated with the traumatic event  Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts or feelings about or closely associated with the traumatic events o Arousal symptoms  Sleep disturbance – difficulty falling or staying asleep, restless sleep  Irritable behaviour + angry outbursts – with little or no provocation, typically expressed as verbal or physical aggression toward people or objects  Hypervigilance  Problems with concentration  Exaggerated startle response o Dissociative symptoms  An altered sense of the reality of one’s surroundings or oneself (e.g. seeing oneself from another’s perspective, being in a daze, time slowing)  Depersonalisation/derealisation • Depersonalisation • Derealisation  Inability to remember an important aspect of the traumatic event – typically due to dissociative amnesia and not to other factors such as head injury, alcohol or drugs • Criterion C o Duration of disturbance is 3 days to 1 month after trauma experience o (symptoms typically begin immediately after the trauma but persistence for at least 3 days to a month is needed to meet disorder criteria) • Criterion D o The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Criterion E o The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder

Answer 42

* A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress * Usually subsides within hours or days * Individual vulnerability, personality structure and coping capacity play a role in the occurrence and severity of acute stress reactions * Must be an immediate and clear temporal connection between impact of exceptional stressor +onset of symptoms – usually within a few minutes if not immediate • Symptoms – typically mixed + changing picture o Initial state of “daze” with some constriction of the field of consciousness + narrowing of attention, inability to comprehend stimuli, disorientation o State of “daze” may be followed by either  Further withdrawal from the surrounding situation to the extent of a dissociative stupor or by  Agitation and over-activity (flight reaction or fugue) o Autonomic signs of panic anxiety (tachycardia, sweating, flushing) o Partial or complete amnesia for the episode may be present • Symptoms usually appear within minutes of the impact of the stressful stimulus or event + disappear within 2 to 3 days (often within hours) o If the symptoms persist, a change in dx should be considered • This dx should not be used to cover sudden exacerbations of symptoms in individuals already showing symptoms that fulfil the criteria of any other psychiatric disorder except those with personality disorders o A history of previous psychiatric disorders does not invalidate the use of his diagnosis

Answer 43

• PTSD can develop after ASD but can also develop even if ASD does not occur o PTSDH can only be diagnosed if the symptoms have lasted longer than 1 month o Dissociative symptoms are the common differentiator of PTSD from ASD

Answer 44

* Recurrent unexpected panic attacks in the absence of triggers * Unpredictable • Persistent concern about additional panic attacks and/or maladaptive change in behaviour related to the attacks o Panic attacks can occur in the context of other anxiety disorders as well, other mental disorders and medical conditions o Panic attacks in and of themselves are not pathological and do not require treatment

Answer 45

``` Criterion A • Recurrent unexpected panic attacks • Panic attack = abrupt surge of intense fear or intense discomfort, either from a calm or an anxious state, that reaches peak within minutes and during which time >4 of the following symptoms: [mnemonic – students fear the 3 Cs] o Sweating o Trembling or shaking o Unsteady, dizziness, light-headed or faint o Derealization or depersonalization o Excessive/accelerated HR, palpitations, pounding heart o Nausea or abdominal distress o Tingling, numbness, paraesthesia o SOB o Fear of loosing control or going crazy o Fear of dying o Choking feelings o Chest pain or discomfort o Chills or heat sensations ``` Criterion B • >1 of the attacks has been followed by > 1 month of >1 of the following o Persistent concern or worry about additional panic attacks or their consequences (e.g. losing control, having a heart attack or going crazy) o A significant maladaptive change in behaviour related to the attacks (e.g. behaviours designed to avoid having panic attacks e.g. avoidance of exercise or unfamiliar situations) Criterion C • The disturbance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, medication) or another medical condition (e.g. hyperthyroidism, cardiopulmonary disorders) Criterion D • The disturbance is not better explained by another mental disorder • The panic attacks do not occur only in response to o Feared social situations – social anxiety disorders o Circumscribed phobic objects or situations – specific phobia o Obsessions – OCD o Reminders of traumatic events – PTSD o Separation from attachment figures – separation anxiety disorder

Answer 46

* Also known as episodic paroxysmal anxiety * Recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable * As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization) * There is often also a secondary fear of dying, losing control, or going mad * Panic disorder should not be given as the main diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are probably secondary to depression.

Answer 47

Social • ACEs • Smoking • Other stressors Psychological ``` Biological • Thyroid disease • Cancer • Chronic pain • Cardiac disease • IBS • Migraine • Allergic diseases • Respiratory diseases • Agents – sodium lactate, yohimbine, caffeine, isoproterenol, CO2, cholecystokinin • Family history ```

Answer 48

• Anxiety disorder due to another medical condition o Onset after 45 y/o age o Presence of atypical symptoms during panic attack (e.g. vertigo, loss of consciousness, loss of bladder or bowel control, slurred speech, amnesia) o ^ suggest the possibility of another medical condition or a substance may be causing panic attack symptoms o Examples of conditions = hyperthyroidism, hyperparathyroidism, phaeochromocytoma (headaches, excessive sweating, palpitations), vestibular dysfunctions, seizure disorders, cardiopulmonary conditions (arrythmia, AF, flutter, palpitations, SOB, dyspnoea, SVT, asthma , COPD) * ACS or MI * Endocrinopathies • Substance/medication-induced anxiety disorder o Intoxication with CNS stimulants – cocaine, amphetamines, caffeine o Withdrawal from CNS depressants – alcohol, barbiturates, benzodiazepines o Cannabis o Detailed history to see if the individual had panic attacks prior to excessive substance use • Other mental disorders with panic attacks as an associated feature (e.g. other anxiety disorders and psychotic disorders) o Panic attacks can occur as a symptom of other anxiety disorders as expected o In panic disorder it is the unexpected nature of panic attacks that is the defining feature of the disorder o If the panic attacks typically occur in response to specific triggers, then only the relevant anxiety disorder is assigned o If the individual experiences unexpected attacks as well and then begins to show persistent concern and worry or begins making behavioural change because of the attacks – an additional dx of panic disorder may be considered

Answer 49

Paranoid PD have difficulty trusting others, even without any reasonable suspicion • Pervasive distrust or suspiciousness of others to the point that their motives are interpreted as malevolent • Individuals negatively interpret the actions, words and intentions of others o They suspect that others intend to harm or deceive them with little supporting evidence • Hold grudges for long periods of time • Reluctant to confide in others Schizoid PD – reluctant to be around others, making them seem cold + unapproachable. Cannot pick up on social cues, find happiness in everyday activities or express emotion • Characterized by pervasive pattern of detachment from social relationships + restricted range of emotions in interpersonal settings • Begins by early adulthood • Individuals appear to be socially isolated or loners, do not desire intimacy • Like spending time online, don’t have friends, researching about fantastic things Schizotypal PD Not in ICD-10 (in ICD-10 is classified as associated with schizophrenia and not as a PD) * Characterised by pervasive patterns of strange or odd behaviour, appearance thinking * These peculiarities are not so severe they can be diagnosed as schizophrenia + there is no hx of actual psychotic episodes * Individuals will often have ideas of reference but not to a delusional quality * Symptoms may first be apparent in childhood  peculiar thoughts, unusual language and/or bizarre fantasies

Answer 50

• Personality disorder characterised by o Suspiciousness and a tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous o Excessive sensitivity to setbacks o Unforgiveness of insults/Tendency to bear grudges persistently o Recurrent suspicions without justification, regarding the sexual fidelity of the spouse or sexual partner o Combative and tenacious sense of personal rights out of keeping with the actual situation o Preoccupation with unsubstantiated “conspiratorial” explanations of event both immediate to the patient and in the world at large • There may be o Excessive self-importance o Excessive self-reference

Answer 51

• Criterion A – A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of context as indicated by 4 or more of the following o Suspect that others are exploiting, harming or deceiving them, without sufficient basis o Are preoccupied with unjustified doubts about the loyalty and trustworthiness of friends or associates o Are reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her o Read hidden demeaning or threatening meanings into benign remarks or events o Persistently bear grudges o Perceive attacks on their character or reputation that are not apparent to others + is quick to react angrily or counterattack o Have recurrent suspicions, without justification regarding fidelity of spouse or sexual partner • Criterion B – does not occur exclusively during the course of schizophrenia/bipolar disorder/depressive disorder with psychotic features + is not attributable to the physiological effects of another medical condition

Answer 52

* Withdrawal from affectional, social and other contacts * Preference for fantasy, solitary activities, introspection * Limited capacity to express feelings * Limited capacity to experience pleasure • All of the DSM-V criteria plus o Limited capacity to express warm, tender feelings for others as well as anger o Excessive preoccupation with fantasy and introspection o Marked insensitivity to prevailing social norms and conventions * Few, if any, activities provide pleasure. * Displays emotional coldness, detachment, or flattened affectivity. * Limited capacity to express warm, tender feelings for others as well as anger. * Appears indifferent to either praise or criticism from others. * Little interest in having sexual experiences with another person (taking into account age). * Almost always chooses solitary activities. * Excessive preoccupation with fantasy and introspection. * Neither desires, nor has, any close friends or confiding relationships (or only one). * Marked insensitivity to prevailing social norms and conventions; if these are not followed this is unintentional.

Answer 53

• Criterion A – Characterized by pervasive pattern of detachment from social relationships + restricted range of emotions in interpersonal settings. Begins by early adulthood. Present in a variety of contexts, as indicated by 4 or more of the following: o Neither desires nor enjoys close relationships, incl. being part of a family o Almost always chooses solitary activities o Has little, if any, interest in having sexual experiences with another person o Takes pleasure in a few, if any, activities o Lacks close friends or confidants other than first-degree relatives o Appears indifferent to praise or criticism of others o Shows emotional coldness, detachment, flattened affectivity • Criterion B – does not occur exclusively during the course of schizophrenia/bipolar disorder/depressive disorder with psychotic features, another psychotic disorder, ASD + is not attributable to the physiological effects of another medical condition

Answer 54

• Criterion A – Characterized by pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: o Ideas of reference (excluding delusions of reference) o Odd beliefs or magical thinking that influences behaviour + is inconsistent with subcultural norms o Unusual perceptual experiences, incl. somatosensory/bodily illusions, depersonalisation or derealization o Odd thinking and speech – vague, circumstantial, metaphorical, over-elaborate, stereotyped o Suspiciousness or paranoid ideation o Inappropriate or constricted affect o Behaviour or appearance that is odd, eccentric or peculiar o Lack of close friends or confidants other than first-degree relatives o Excessive social anxiety that does not diminish with familiarity + tends to be associated with paranoid fears rather than negative judgments about self * Criterion B – does not occur exclusively during the course of schizophrenia/bipolar disorder/depressive disorder with psychotic features, another psychotic disorder, ASD + is not attributable to the physiological effects of another medical condition * Socially withdrawn * Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, delusion-like ideas usually occurring without external provocation

Answer 55

Paranoid PD • Schizophrenia • Persistent delusional disorder

Answer 56

``` Idea vs delusion Idea – you can challenge Delusion – cant really challenge it Idea – generalised, vague, ambiguous Delusions – descriptive, clear, detailed ```

Answer 57

Antisocial/Dissocial PD Borderline PD/Emotionally unstable PD Histrionic PD Narcissistic PD

Answer 58

* Disregard for social obligations, morals and the rights of others * Gross disparity between behaviour and the prevailing social norms * Gross and persistent attitude of irresponsibility disregard for social norms, rules and obligations * Unconcern for the feelings of others (“psychopath”/”sociopath”) * Incapacity to maintain enduring relationships but no difficulty in establishing them * Incapacity to experience guilt * Behaviour not readily modifiable by adverse experience, incl. punishment * Low tolerance to frustration * Low threshold for discharge of aggression, incl. violence * Tendency to blame others * Tendency to offer plausible rationalizations for the behaviour brining the patient into conflict with society

Answer 59

• Criterion A – a pervasive pattern of disregard for and violation of the rights of others, occurring since the age of 15 years, as indicated by 3 (or more) of the following: o Failure to conform to social norms with respect to lawful behaviours, as indicated by repeatedly performing acts on the grounds of arrest o Deceitfulness, as indicated by repeated lying, use of aliases, or conning other for personal profit of pleasure o Impulsivity or failure to plan ahead o Irritability and aggressiveness, as indicated by repeated physical fights or assaults o Reckless disregard for safety of self or others o Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations o Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another • Criterion B – the individual must be at least 18 years old o It is the only PD that cannot be diagnosed before age 18 * Criterion C – there is evidence of conduct disorder before age 15 * Criterion D – the occurrence of antisocial behaviour is not exclusively during the course of schizophrenia or BPAD

Answer 60

• Histrionic PD o Histrionic PD – individuals tend to be more exaggerated in their emotions + do not typically engage in antisocial behaviours o Histrionic PD – individuals may manipulate others to gain emotional connections o ASPD – the motivation to manipulate is to gain profit, power or some other material gratification • Paranoid PD o Paranoid PD – antisocial behaviour seen, however it is not typically motivated by personal gain or wish to exploit others as in ASPD but rather for revenge • BPD o ASPD – individuals have less emotional dysregulation + are more aggressive • Narcissistic PD o Both PD may have tendency for the individual to be superficial, exploitative, tough-minded, glib and/or lack empathy o Narcissistic PD – individuals do not have characteristic impulsivity, aggression, deceit. Lack the hx of conduct disorder in childhood or criminal behaviour in adulthood o ASPD – individuals require less admiration + envy from others • Criminal behaviour o Just because an individual is involved in criminal behaviour doesn’t mean that they have ASPD o ASPD – antisocial personality features are inflexible, maladaptive, persistent, cause significant functional impairment or subjective distress • Acute psychotic episode • Manic episode

Answer 61

``` Borderline PD • Disturbances in self image/aims/internal preferences (incl. sexual) • Liability to become involved in intense + unstable relationships, often emotional crises • Excessive efforts to avoid abandonment • Recurrent threats or acts of self-harm • Chronic feelings of emptiness • Emotional instability • Lack of impulse control ``` EUPD • Tendency to act impulsively + without consideration of the consequences • Mood is unpredictable + capricious • Liability to outbursts of emotion • Incapacity to control behavioural explosions • Quarrelsome behaviour, conflict with others esp. when impulsive acts are thwarted or censored • Two types o Impulsive  emotional instability, lack of impulse control o Borderline • NICE guidelines – assessment + diagnosis o If a person persists in primary care who has repeatedly self-harmed/shown persistent risk-taking behaviour or marked emotional instability – refer to CAMHS for assessment for BPD

Answer 62

• A pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity, beginning by early adulthood and present in a variety of contexts as indicated by at least 5 of the following o Frantic efforts to avoid real or imagined abandonment (does not include suicidal or self-harming behaviour) o Pattern of unstable + intense interpersonal relationships characterized by alternating between extremes of idealization + devaluation o Identity disturbance – markedly + persistently unstable self image or sense of self o Impulsivity in at least 2 areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating) (does not include suicidal or self-harming behaviour) o Recurrent suicidal behaviour, gestures, threats, self-mutilating behaviour o Affective instability due to a marked reactivity of mood (e.g. - intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) o Chronic feelings of emptiness o Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights) o Transient, stress-related paranoid ideation or severe dissociative symptoms

Answer 63

• Histrionic PD o Histrionic PD also characterized by attention seeking, manipulative behaviour and rapidly shifting emotions o BPD – self-destructiveness, angry disruptions in close relationships, chronic feelings of deep emptiness and loneliness • Dependent PD o Both dependent PD + BPD – characterised by fear of abandonment o BPD – individual reacts to abandonment with feelings of emotional emptiness, rage, demands, unstable + intense relationships o Dependent PD – submissiveness • BPAD o Similarity – change in mood o BPD – faster fluctuation in mood than in BPAD (In BPAD mood change can last a couple of days (sustained changes in mood), in BPD mood may change many times a day) o BPD – mood change related to events, never escalates to level of mania

Answer 64

• PD characterised by o shallow and labile affectivity o self-dramatization, theatricality, exaggerated expression of emotions o suggestibility, easily influenced by circumstances o inappropriately seductive in appearance or behaviour o overly concerned with physical attractiveness o continually seeks appreciation, excitement, attention and activities in which the subject is the centre of attention Criteria that complete the clinical picture but are not required for the dx: o egocentricity, self-indulgence, continuous seeking for appreciation o easily hurt feelings o lack of consideration for others o persistent manipulative behaviour o self-centred

Answer 65

• a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following o Is uncomfortable in situations in which he/she is not the center of attention o Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour o Displays rapidly shifting + shallow appearance to draw attention to self o Has a style of speech that is excessively impressionistic + lacking in detail o Shows self-dramatization, theatricality, and exaggerated expression of emotion o Is suggestible (i.e. easily influenced by others or circumstances o Considers relationships to be more intimate than they actually are

Answer 66

Differentials • Narcissistic PD o Narcissistic PD – individuals will want attention + praise for their “superiority”, may over-report the intimacy of their relationships with others, more likely to emphasize the VIP status or wealth of their friends o Histrionic PD – individuals are willing to be viewed as fragile or dependent if this helps in receiving attention • Dependent PD o Dependent PD – individual is overly dependent on others for praise + guidance. No associated flamboyant, exaggerated or emotional features • BPD o BPD – also characterised by attention-seeking, manipulative behaviour + emotional dysregulation but distinguished by self-destructive behaviours, fragile relationships and chronic emptiness, identity disturbance

Answer 67

* A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration and lack of empathy, beginning by early adulthood and persistent in a variety of contexts, as indicated by 5 (or more) of the following * Has grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) * Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love * Believes that they are special + unique + can only be understood by or should associate with other special or high-status people (or institutions) * Requires excessive and continual admiration * Has a sense of entitlement (i.e. unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations) * Is interpersonally exploitative (i.e. takes advantage of others to achieve his or her own ends) * Lacks empathy – is unwilling to recognize or identify with the feelings and needs of others * Is often envious of others or believes that others are envious of him or her * Shows arrogant, haughty behaviours or attitudes

Answer 68

* BPD * Narcissistic PD – stable self-image, lack of self-destructiveness/impulsivity/abandonment concerns * Histrionic PD * Narcissistic PD – excessive pride in achievements, lack of emotional display, disdain from others’ sensitivities * Mania/hypomania * Grandiosity is associated with mood change or functional impairments * In mania usually grandiose delusions, not based on real-life achievements/scenarios * OCPD * OCPD + Narcissistic PD – perfectionism + belief that others cannot do things as well * OCPD – frequent self-criticism * Narcissistic PD – more likely to believe that they have already achieved perfection * High achieving individuals * Can have personality traits that are considered narcissistic * Only when these traits are inflexible, maladaptive, persisting + cause significant impairment or subjective distress do they constitute a narcissistic PD

Answer 69

Anxious/Avoidant • Timid and shy • Uncomfortable + afraid of rejection or criticism  avoid social contact • The do wish to have friends (unlike individuals with schizoid personality) o If given strong guarantees of uncritical acceptance, they will make friends and participate in social gatherings • Self-critical, low self-esteem Obsessive-Compulsive/Anankastic – patients take perfectionism to extreme levels, may obsess over rules, cleanliness, order. They fear that if they do not complete certain tasks, something terrible will happen; this keeps them from living their full lives * Individuals may be perfectionistic, inflexible, unable to express warm, tender feelings * Preoccupation with trivial details and rules * Difficulty adapting to changes in routine * Individuals with anxiety disorders and OCD are at increased odds to meet criteria for OCPD Dependent motivated by fear of having to take care of themselves or make decisions; depend on others to take care of their needs/make decisions + give them constant approval. Risk of staying in abusive relationships * Clingy and submissive behaviour * Individuals are passive + allow others to direct their lives because they are unable to do so themselves * Other people e.g. spouses, parents make all the major life decisions (incl. where to live and what type of employment to obtain) * Individuals fear separation + tend to be indecisive + unable to take the initiative * Often reoccupied with the thought of being left to fend for themselves * Want others to assume responsibility for all major decision making * Difficulty expressing disagreement because they fear abandonment

Answer 70

* PD characterised by feelings of tension + apprehension, insecurity + inferiority * Belief that oneself is socially inept, personally unappealing or inferior to others * Continuous yearning to be liked + accepted * Hypersensitivity and excessive preoccupation to rejection + criticism in social situations * Restricted personal attachments * Unwillingness to get involved with people unless they are certain of being liked * Restrictions in lifestyle because if need for security * Tendency to avoid certain social or occupational activities that involve interpersonal contact because of fear of criticism, disapproval or rejection and by habitual exaggeration of potential dangers/risks in everyday situations

Answer 71

• A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following o Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejection o Is unwilling to get involved with people unless certain of being liked o Shows restraint with intimate relationships because of fear of being shamed or ridiculed o Is preoccupied with being criticized or rejected in social situations o Is inhibited in new interpersonal situations because of feelings of inadequacy o Views self as socially inept, personally unappealing or inferior to others o Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Answer 72

• Dependent PD o Both avoidant + dependent PD are characterized by feelings of inadequacy, hypersensitivity to criticism and need for reassurance o Avoidant personality – avoidance of humiliation + rejection o Dependent PD – focus is being taken care of, intense fear of abandonment o Can commonly co-occur • Schizoid and Schizotypal o All these PDs are characterized by social isolation o Avoidant PD – individuals want to have relationships with others, feel their loneliness deeply o Schizoid/schizotypal – may be content with and even prefer their social isolation • Paranoid PD o Avoidant PD – fear to confide in others due to fear of being embarrassed or being found inadequate o Paranoid PD – fear to confide in others because of fear of malicious intent by others

Answer 73

* Pervasive passive reliance on other people to make one’s major and minor life decisions * Limited capacity to make everyday decisions without excessive external advice and reassurance * Great fear of abandonment * Feelings of helplessness, incompetence, lacking stamina * Feeling uncomfortable/helpless when alone, due to exaggerated fears of inability to care for oneself * Weak response to the demands of daily life * Preoccupation with fears of being left to take care of oneself * Passive compliance with the wishes of elders + others * Subordination of one’s own needs to those of others on whom one is dependent * Unwillingness to make even reasonable demands on the people one depends on * Lack of vigour – may show itself in the intellectual or emotional spheres * Tendency to transfer responsibility to others

Answer 74

• A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following o Has difficulty making everyday decisions without an excessive amount of advice + reassurance from others o Needs others to assume responsibility for most major areas of his or her life o Has difficulty expressing disagreement with others because of fear of loss of support or approval o Has difficulty initiating projects or doing things on his or her own (lack of self-confidence in judgment or abilities rather than lack of motivation or energy) – weak response to the demands of daily life o Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant o Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself o Urgently seeks another relationship as a source of care and support when a close relationship ends o Is unrealistically preoccupied with fears of being left to take care of himself or herself

Answer 75

• Avoidant PD o Both disorders – feelings of inadequacy, hypersensitivity to criticism, need for reassurance o Dependent PD – will seek to maintain connections to others rather than avoiding and withdrawing o Avoidant PD – strong fears of rejection that they can withdraw until they are certain they will be accepted • BPD o Both disorders – fear of abandonment o BPD – one reacts to abandonment with feelings of emotional dysregulation, emptiness, rage and/or demands, chronic pattern of intense + unstable relationships o Dependent PD – increasing appeasement and submissiveness, urgently seeks replacement relationship to provide support • Histrionic PD o Both – strong need for reassurance and approval, may appear clingy o Histrionic PD – flamboyant behaviour, active demands attention o Dependent PD – self-effacing and docile behaviour

Answer 76

• PD characterized by o feelings of excessive doubt and caution o perfectionism that interferes with task completion o excessive conscientiousness, scrupulousness and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships o excessive pedantry and adherence to social conventions o checking o preoccupation with details, rules, lists, order, organisation or schedule o stubbornness, caution and rigidity o unreasonable insistence that others submit to exactly his or her way of doing things, or unreasonable reluctance to allow others to do things • there may be insistent and unwelcome thoughts or impulses that do not attain the severity of an OCD

Answer 77

control at the expense of flexibility, openness and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following o is preoccupied with details, rules, lists, order, organization or schedules to the extent that the major point of the activity is lost o shows perfectionism that interferes with task completion (e.g. is unable to complete a project because his or her own overly strict standards are not met) o is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) o is overconscientious, scrupulous and inflexible about matters of morality, ethics or values (not accounted for by cultural or religious identification) o is unable to discard worn-out or worthless objects even when they have no sentimental value o is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things o adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catarstrophes o shows rigidity and stubbornness

Answer 78

• OCD o OCD – presence of true obsessions and compulsions o OCDP – there may be obsessions but they are not as severe as in OCD and are not followed by compulsions • Narcissistic PD o Both disorders express perfectionism o Narcissistic – believe that they have already achieved perfection o OCPD – usually self-critical, not satisfied with their work • Schizoid PD o Both disorders – apparent formality and social detachment o OCPD – this stems from discomfort with emotions and excessive devotion to work o Schizoid PD – fundamental lack of interest or capacity for intimacy

Answer 79

Antisocial/Dissocial ADPD PD • Childhood onset of conduct disorder + ADHD • Child abuse or neglect, unstable or erratic parenting, inconsistent parental discipline Paranoid PD • Relatives with schizophrenia or delusional disorder • Childhood trauma • If the criteria are met prior to the onset of schizophrenia, add “premorbid” to the dx (paranoid PD (premorbid))

Answer 80

• Panic attack o Abrupt surge of intense fear or intense discomfort, either from a calm or an anxious state, that reaches peak within minutes and accompanied by a cluster of physical symptoms o panic attack must be unexpected o peak abruptly – rapid onset under 10 minutes o a typical panic attack is relatively short and lasts no more than 15 minutes

Answer 81

* Asperger’s syndrome * Agoraphobia * Social phobia * Psychosis * Depression • Obsessive-compulsive PD o Obsessive-compulsive PD – may show social detachment but this stems from devotion to work and discomfort with emotions. Have an underlying capacity and desire for intimacy. • Avoidant PD o In avoidant PD, individuals have an active desire for relationships but are paralysed by the fear of rejection, fear of being embarrassed or being found inadequate o Schizoid PD  little to no desire for social intimacy, do not actually want to/care about having friends • Schizotypal PD o Schizotypal PD – behaviours are more odd o Schizoid PD – lack the cognitive and perceptual distortions seen in schizotypal PD * Delusional disorder/schizophrenia/BPAD w psychotic features – To diagnose schizoid PD, the PD must have been present before the onset of psychotic symptoms and persist even when the psychotic symptoms are in remission * ASD – more severely impaired social interaction, stereotyped behaviour, fixed interests

Answer 82

* ASD – have greater lack of social awareness + emotional reciprocity + more stereotyped behaviours and interests * Delusional disorder – individuals with schizotypal PD are likely to consider alternative explanations for their odd beliefs * Delusional disorder/schizophrenia/BPAD w psychotic features – To diagnose schizotypal PD, the PD must have been present before the onset of psychotic symptoms and persist even when the psychotic symptoms are in remission • Avoidant PD o In avoidant PD, individuals have an active desire for relationships but are paralysed by the fear of rejection o Schizotypal  lack of desire for relationships in the first place • Borderline personality disorder o Social isolation can also be seen in BPD – this is secondary to repeated interpersonal failures from emotional dysregulation rather than from the lack of desire for intimacy o Schizotypal – do not usually demonstrate the impulsive or manipulative behaviours in BPD o BPD – psychotic like symptoms usually connected to affective shifts in response to stress + usually dissociative o Schizotypal – more likely to have ongoing psychotic like symptoms that may worsen under stress but are less likely to be associated with affective disturbances

Answer 83

Prognosis • Depends on the specific PD o Antisocial + borderline PD – tend to improve or distinguish with age o Obsessive-compulsive + schizotypal PD – less likely to remit over time • PDs are highly co-morbid with other PDs + there is high overlap between the different clusters • PDs disrupt relationships, education and employment • Although they are persistent, they may change in severity over time

Answer 84

• Personality change due to another medical condition e.g. TBI, brain mets

Answer 85

o PDs should be diagnosed only when the features appear before early adulthood, are typical of the individual’s long-term functioning and do not occur exclusively during an episode of another mental disorder • For a PD dx to be made in individuals under the age of 18  features must have been present for at least 1 year o Exception: antisocial PD  cannot be dx in individuals <18 y/o  dx as conduct disorder instead

Answer 86

• Criterion A – an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in 2 or more of the following areas o Cognition – way of perceiving and interpreting self/people/events o Affectivity – the range/intensity/lability/appropriateness of emotional response o Interpersonal functioning o Impulse control * Criterion B – the enduring pattern is inflexible and pervasive across a broad range of personal + social situations * Criterion C – the enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning * Criterion D – the pattern is stable and of long duration, and its onset can be traced back to at least adolescence or early adulthood * Criterion E – the enduring pattern is not better explained as a manifestation or consequence of another mental disorder * Criterion F – the enduring pattern is not attributable to the physiological effects of a substance (e.g. drug of abuse, a medication) or any other medical condition (e.g. head trauma)

Answer 87

* Severe disturbances in the personality and behavioural tendencies of the individual * Not resulting from disease, damage or other insult to the brain or from another psychiatric disorder * Usually involve several areas of the personality * Nearly always associated with considerable personal distress + social disruption * Usually manifest in childhood or adolescence and continue throughout adulthood * Markedly disharmonious attitudes and behaviour, involving usually several areas of functioning e.g. affectivity, arousal, impulse control, ways of perceiving/thinking, style of relating to others * Abnormal behaviour pattern is enduring, long standing, not limited to episodes of mental illness * Abnormal behaviour pattern is pervasive, clearly maladaptive to personal and social situations * Above manifestations always appear during childhood or adolescence, continue into adulthood * Disorder leads to considerable personal distress (may only become apparent later on) * Disorder usually associated with significant problems in occupational and social performance * REPORT = Relationships affected, Enduring, Pervasive, Onset in childhood/adolescence, Results in distress, Trouble in occupation/social functioning

Answer 88

Psychdb – PD = enduring patterns of behaviours and inner experiences that deviate significantly from the expectations of an individual’s culture Personality disorder can be distinguished from traits with 3 Ps: - Pervasive – occurs in all/most areas of life - Persistent – evident in adolescence, follows into adulthood - Pathological – cause distress to self/others, impairs function

Answer 89

Progressive neurocognitive decline of sufficient magnitude to interfere with normal social or occupational functions or with usual daily activities Rapidly progressive dementia but fully reversible if the aetiology is correctly identified Range of cognitive (memory, thinking, language, orientation, judgement) and behavioural (emotional control, motivation) symptoms that can include memory loss, problems with reasoning and communication and change in personality, a reduction in a person’s ability to carry out daily activities e.g. shopping, washing, dressing, cooking • Early onset or young onset dementia – dementia that develops <65

Answer 90

• Impairment in least 2 cognitive domains (memory, language, behaviour, visuospatial or executive function) leading to significant functional decline (enough to affect ADLs) that cannot be explained by another disorder or adverse effects of medication

Answer 91

• For a confident clinical diagnosis, the following should have been present for >6 months to avoid confusion with reversible states • Decline in memory o Most evident in learning of new information o In severe cases the recall of previously learned information may also be affected o Decline should be objectively verified – collateral hx, neuropsychological tests, quantified cognitive assessments • Decline in other cognitive abilities o Deterioration in judgement and thinking – planning, organising, general processing of information • Preserved awareness of the environment • Decline in emotional control or motivation or a change in social behaviour o May manifest as – emotional lability, irritability, apathy, coarsening of social behaviour

Answer 92

1. Interfere with the ability to function at work or at usual activities a. Household tasks, nutrition, personal hygiene, grooming, mistakes at work, dressing, eating, walking 2. Represent a decline from previous levels of functioning and performing 3. Are not explained by delirium or major psychiatric disorder 4. Cognitive impairment is detected and diagnosed through a) history taking from the patient + collateral history and b) a objective cognitive assessment, either a bedside mental status examination or neuropsychological testing 5. The cognitive or behavioural impairment involves a minimum of 2 of the following domains a. Impaired ability to acquire and remember new information – repetitive questions or conversations, misplacing personal belongings, forgetting events or appointments, getting lost on a familiar route b. Impaired reasoning + handling of complex tasks, poor judgement – poor understanding of safety risks, inability to manage finances, poor-decision making ability, inability to plan complex or sequential activities c. Impaired visuospatial abilities – inability to recognise faces or common objects or to find objects in direct view despite good acuity, inability to operate simple implements or orient clothing on the body d. Impaired language functions – speaking, reading, writing problems – difficulty thinking of common words while speaking, hesitations, speech, spelling, writing errors, receptive/expressive dysphasia e. Changes in personality, behaviour, comportment – uncharacteristic mood fluctuations such as agitation, impaired motivation, initiative, apathy, loss of drive, social withdrawal, decreased interest in previous activities, loss of empathy, compulsive or obsessive behaviours, socially unacceptable behaviours, psychosis, sleep cycle disturbance, insomnia

Answer 93

• Decline in problem-solving, processing speed, minor delays in word-finding, retrieval-type memory deficits • Semantic memory + visuospatial functioning is generally preserved in contrast to dementia o Semantic memory = a category of long-term memory that involves the recollection of ideas, concepts and facts commonly regarded as general knowledge e.g. factual information such as grammar and algebra, naming animals etc o Visuospatial functioning refers to cognitive processes necessary to “identify, integrate and analyze space and visual form, details, structure and spatial relations” o Visuospatial skills are needed for movement, depth and distance perception and spatial navigation.

Answer 94

• Factors exacerbating BPSD o Emotional upset of carer o Communication difficulties with person/carer o Environmental issues – clutter, changes to the environment, over or under stimulation, lack of established routine o Co-morbidities and acute illnesses – pain, UTI, constipation, dehydration, anaemia o Underlying psychiatric illness o Drug adverse effects o Sensory deficits o Inability of person to communicate verbally

Answer 95

Early onset AD (<65) – APP (Chr 21), PSEN1 (Chr 14), PSEN2 (Chr 1), DS Late onset AD (>65)– APOE4 gene

Answer 96

* Clear evidence of decline in memory (mild neurocognitive disorder) and learning and at least 1 other cognitive domain (major neurocognitive disorder) * Steadily progressive, gradual decline in cognition without extended plateaus * No evidence of mixed aetiology (absence of other neurodegenerative/cerebrovascular disease or other neurological/mental/systemic disease or condition likely contributing to cognitive decline Probable AD = diagnosed when there is evidence of a causative AD genetic mutation from either genetic testing or FHx Possible AD = no evidence ^^

Answer 97

``` Smoking Diabetes Hypertension Hyperlipidaemia History may reveal past TIAs or MI ```

Answer 98

LBD = cognitive and/or psychiatric symptoms followed by typical symptoms of PD within one year Lewy bodes are eosinophilic intracytoplasmic neuronal structures composed of α-synuclein with ubiquitin LBD – abnormal deposits of α-synuclein in the brain PD – brainstem, LBD – also in cingulate gyrus + neocortex Implicated genes – alpha synuclein (Chr 4), novel gene (Chr 2), APOE4 in men

Answer 99

PDD = dementia occurring >12 months after the onset of PD motor symptoms

Answer 100

``` • Dementias that progress quickly – over the course of weeks to months • Treatment is dependent on the aetiology of the dementia • Some are fully treatable • Different aetiologies o Prion disease  Creutzfeldt-Jakob disease = rapid progressive mental deterioration with myoclonus and abnormal eye movements o Neurodegenerative diseases  Early onset AD o AI o Infectious o Psychiatric o Neoplastic o Toxic-metabolic o Vascular o Leukoencephalopathies  MS  Progressive multifocal leukoencephalopathy ```

Answer 101

• Take a history from the person + someone who knows the person well about – cognitive, behavioural, psychological symptoms + the impact symptoms have on their daily life o Hx taking from someone who knows the person with suspected dementia – supplement this with a structured instrument e.g. IQCODE (informant questionnaire on cognitive decline in the elderly), FAQ (functional activities questionnaire) o Hx  Symptoms – concerns, cognitive symptoms, BPSD, impact on ADLs  Comorbidities – stroke, depression, epilepsy (alternative causes)  RF – CVD RF, FHx genetic causes, LDs, stroke, PD  Drugs – affect cognition e.g. BDZ, anticholinergic drugs, analgesics  Septic screen – MSU, CXR, cultures, wound swabs, sputum/stool samples

Answer 102

* Dementia * Delirium * Most psychiatric illnesses – depression, anxiety, psychosis * Learning disability * Sensory impairment * Language barrier * Feeling unwell, tired, irritable

Answer 103

Cardinal feature Dementia - memory loss Delirium - confusion or inattention Onset dementia - insidious delirium - acute or subacute Course dementia - chronic, progressive, stable over the course of a day delirium - fluctuating, often worse at night Duration dementia - months to years delirium - hours to months Level of Consciousness (LOC) dementia - normal in early stages delirium - impaired, flactuates Attention (ability to focus on tasks) dementia- normal except in late stages delirium - poor Orientation (date, location) dementia - poor delirium - fluctuates Memory (short term memory) dementia - poor delirium - poor Hallucinations dementia - rare except in late stages (+depends on type of dementia) delirium - common (visual) Delusions Dementia - often absent delirium - fleeting, non-systematized Psychomotor dementia - no delirium - increased (hyperactive), decreased (hypoactive) Reversibility dementia- rarely delirium - yes EEG findings dementia - normal or mild diffuse slowing delirium - moderate to severe background slowing

Answer 104

``` Biological • Aspiration pneumonia – cause of death • UTI – due to catheterisation • Falls and their complications – fractures, head injury, prolonged immobilisation • Weight loss • Decubitus ulceration (bed sores) ``` Psychological • BPSD symptoms ``` Social • Disability, dependency, morbidity o Reduced ability to carry out ADLs o Complex care needs o Mobility difficulties o Social isolation + restriction of activities • Carer morbidity o Can impact physical + mental health/employment/education prospects/finances/ social + community life • Financial hardship • Institutionalization o People should be supported to stay in own home for as long as possible • Elder abuse ``` LBD • Dysphagia – related to parkinsonism/behavioural + autonomic symptoms, cognitive state • Antipsychotic sensitivity – increased rigidity, immobility, confusion, sedation, postural falls, increased mortality

Answer 105

AD - 11.7y FTD - 11 y LBD - 3y

Answer 106

• Medication does not alter disease process but delays progression by 6 months • Dementia progresses more rapidly following an episode of delirium • Progression o First 1-2 years – mild/early stage – forgetful, have some language difficulties o 2-5 years – moderate stage – very forgetful, increasing speech difficulty, help with care o 5th year onwards – severe or late stage – near total dependence of inactivity • 5 year mortality of people diagnosed with dementia o 65% men, 59% women o Significantly higher for people who have been admitted to hospital for any cause o This is due to a combination of frailty, comorbid medical conditions, complications (e.g. aspiration pneumonia) + the disease process itself

Answer 107

• Delirium o Patient present suddenly with altered or clouded consciousness o Losing touch with surroundings (poor attention is a good marker of this) o Presentation fluctuates and there may be evidence of underlying physical problems o Symptoms resolve when cause is treated • Reversible dementias o Brain – SDH, SOL, NPH  NPH – triad – dementia, unsteady gait, urinary incontinence  Mx of NPH – a ventriculo-peritoneal shunt may allow CSF drainage from the brain ventricles into the hear o Endocrine – hypothyroidism, hyperparathyroidism, Addison’s disease, Cushing’s syndrome o Vitamin Deficiency – B12, folate, thiamine, niacin • Pseudodementia o Severe depression can cause memory problems  Low mood precedes cognitive symptoms  May be a PMH of depression  Depressed people lack motivation to answer qs – commonly say I don’t know  People with dementia are keen but make mistakes Pseudodementia – More likely to complain of memory loss Dementia – more likely to confabulate to try + hide the memory loss

Answer 108

Histopathology AD -- plaques and tangles, neuronal (cholinergic) loss VD - multiple cortical infarcts, arteriosclerosis LBD - Lewy bodies Onset AD -- insidious VD - sudden LBD - varies course AD -- gradual decline VD - stepwise LBD - gradual decline main features AD -- 4As - amnesia, apraxia, agnosia, aphasia VD - depression, labile LBD - depression personality AD -- eroded, socially withdrawn VD - relatively preserved LBD - more apathetic other suggestive features AD -- absent physical signs VD - focal neurology LBD - neuroleptic insensitivity, autonomic instability (falls + syncope) CT changes AD -- generalised atrophy, especially medial, temporal parietal VD - multiple lucencies, atrophy, cerebrovascular lesions LBD - mild atrophy (less than AD)

Answer 109

``` • Multiple bereavements, social isolation, poverty, physical illness, chronic pain • Modifiable essentials o Sensory impairment o Immobilisation (catheters, restraints) o Environment o Pain o Emotional distress o Sustained sleep deprivation • Modifiable medical o Medications (sedative hypnotics, narcotics, anticholinergic drugs, corticosteroids, polypharmacy, alcohol withdrawal, other drugs) o Acute neurological diseases (acute stroke, intracranial haemorrhage, meningitis, encephalitis) o Ongoing illness (infection, iatrogenic complications, acute illness, anaemia, dehydration, poor nutrition, trauma, fractures, HIV) o Metabolic derangement o Surgery – e.g. hip fracture • Non-modifiable o Dementia or cognitive impairment o Advancing age >65 o History of delirium, stroke, neurological disease, falls or gait disorder o Multiple comorbidities o Male sex o Chronic renal or hepatic disease ```

Answer 110

* A - Disturbance in attention (reduced ability to direct focus, sustain and shift attention) and awareness (reduced orientation to the environment) * B – disturbance develops over a short period of time (usually hours to few days), represents a change from baseline attention and awareness, tends to fluctuate in severity during the course of a day * C – an additional disturbance in cognition – memory deficit, disorientation, language, visuospatial ability, perception * D – A + C are not better explained by another preexisting/established/evolving neurocognitive disorder + do not occur in the context of a severely reduced level of arousal e.g. coma * E – there is evidence form the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or to a medication), or exposure to toxin or is due to multiple aetiologies

Answer 111

``` Acute = lasting a few hours/days Persistent = lasting weeks or months ``` Hyperactive delirium = hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation and/or refusal to cooperate with medical care, agitated, hallucinating, inappropriate behaviour Hypoactive delirium = hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor Mixed level of activity = normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates between agitation and lethargy

Answer 112

* Myth – if the patient is orientated to person, place and time they are not delirious * Fact – delirium evaluation minimally requires assessing attention, orientation memory and thought process ideally at least once per nursing shift to capture daily fluctuations in mental status * Myth – the goal of delirium workup is to find the main cause of delirium * Fact – delirium aetiology is typically multifactorial * Myth – it is often best to let quiet patients rest * Fact – hypoactive delirium is common and often under-recognised

Answer 113

``` • May take days to weeks to resolve • Patients may need weeks or months to recover • Associated with o Increased mortality o Longer admissions o Higher readmission rates o Subsequent nursing home placement • Patients do not return to pre-morbid levels ```

Answer 114

* Psychotic symptoms can occur in many conditions in older people (e.g. delirium, dementia) * May occur secondary to sensory impairment * Sensory deficits are a RF * Positive symptoms (delusions, hallucinations) more prominent than negative symptoms * Charles Bonnet syndrome – complex visual hallucinations, secondary to visual impairment alone

Answer 115

Cluster B • Not in ICD-10 • Grandiose sense of their own-self importance • Extremely sensitive to criticism • Little ability to empathize with others • More concerned about appearance than substance • Arrogance, grandiosity, need for admiration, tendency to exploit others • Sense of excessive entitlement • May demand special treatment Narcissistic psychopathology can be broken into 3 concepts • Overt – grandiose, stereotypical loud • Covert – more fragile, self effacing, overly aware of others • Malignant – a combination of narcissistic PD + ASPD

Answer 116

Cluster B little or no regard for the needs/emotions of others; may not think about safety of themselves or others; often lie/cheat/steal/con others in order to get their ways; impulsive behaviours often violate rights of others + can turn aggressive; do not feel remorse when they commit violent acts, sociopaths * Chronic and continuous behaviour where there is disregard for and violation of the rights of others * Individuals repeatedly engage in unlawful activities, endanger the well being of others, frequently lie * Aggressive + impulsive * Find it difficult to maintain employment for long * They have a superficial charm + can be very deceptive  have friends * Conduct disorder becomes antisocial disorder once an individual turns 18 * For individuals older than 18, a dx of conduct disorder is given only if the criteria for ASPD are not met * The dx of ASPD is made even if some antisocial behaviours were a consequence of the substance use disorder (e.g. selling illegal drugs, stealing to obtain money to drugs etc) * Most dangerous of all PD

Answer 117

Cluster B fragile egos, believe that people they love will abandon them  unstable relationship, both with romantic partners + others • Emotional dysregulation • Pattern of unstable interpersonal relationships o Patients oscillate quickly between devaluing and idealizing relationships (commonly known as “splitting”) • High impulsivity/recklessness • Difficulty controlling anger • Difficulties managing emotion and behaviour • Recurrent suicidal/self-harm behaviours • Identity disturbance • Chronic feelings of emptiness

Answer 118

Cluster B – constant need for attention, dramatic outbursts/sexual promiscuity to get it. Speak in hyperbole and experience quick, dramatic shifts in emotions. Think their relationships are deeper than the other person believes * PD characterized by individuals who are flamboyant, seek attention and demonstrate an excessive emotionality * Emotions are shallow and shift rapidly * Typically, they are attractive + seductive + overly concerned with their appearance * Often use their physical appearance to draw attention of others * May behave in a sexually provocative manner * Exaggerate + dramatize their emotions * Emotions lack depth

Answer 119

ICD-10 • A disorder characterized by deliberate weight loss, included and sustained by the patient • Occurs most commonly in adolescent girls and young women • Dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea • Patients impose a low weight threshold on themselves • There is usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function • Symptoms include o Restricted dietary choice o Excessive exercise o Induced vomiting + purgation o Use of appetite suppressants o Use of diuretics ICD-10 (notebank) • Body weight is maintained at least 15% below that expected • BMI is 17.5 or less • Weight loss is self-induced by avoidance of “fattening foods” • Body-image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea + the patient imposes a low weight threshold on themselves • One or more of the following may also be present o Self-induced vomiting o Self-induced purging (incl. laxative use) o Excessive exercise o Use of appetite suppressants and/or diuretics • Prepubertal patients o Failure to make the expected weight gain during the period of growth o Sequence of pubertal events is delayed/arrested o Girls – breasts do not develop, primary amenorrhoea o Boys – genitals remain juvenile o With recovery, puberty is often completed normally but menarche is late • Widespread endocrine disorder o Involving the HPG axis – manifests in amenorrhoea in women (may have persistent vaginal bleeds if receiving hormonal therapy e.g. OCP), loss of sexual interest + impotence in men o  GH, cortisol o Changes in the peripheral metabolism of the thyroid hormone, abnormalities in insulin secretion • Does not meet criteria A + B or bulimia nervosa

Answer 120

• Criterion A – restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory and physical health o Significantly low weight = weight less than minimally normal or for children + adolescents, less than that minimally expected • Criterion B – intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight • Criterion C – disturbance in the way one’s bodyweight or shape is experienced, undue influence of body weight or shape on self-evaluation or persistent lack of recognition of the seriousness of the current low body weight * Criterion B - Behaviour interfering with weight gain even if denying the fact that they are worried about weight still counts as criterion B – e.g. I’m not worried about my weight but I am always going to choose the low fat yoghurt * Amenorrhoea is not in DSM-V

Answer 121

``` Severity BMI (kg/m2) Normal >18.5 Mild >17 Moderate 16-16.99 Severe 15-15.99 Extreme <15 ```

Answer 122

o BMI-for-age below the 5th percentile  underweight o However, children + adolescents with a BMI above this cut off may still be judged to be significantly underweight if there is failure to maintain their expected growth trajectory o To determine whether criterion A or anorexia nervosa is met, the clinician needs to also consider the individual’s body build, weight history, and any physiological changes e.g. amenorrhea o Another problem is that a child or adolescent may fail to gain in weight (and this may be the onset of anorexia nervosa) and thus his or her height growth may cease as well. In this situation, the patient may not be underweight for his or her height, but is still underweight in terms of what is needed for continued appropriate growth and development; therefore, the onset of anorexia nervosa can sometimes be missed because the child is not gaining height as well as not gaining weight.

Answer 123

• Refeeding syndrome can occur in significantly malnourished patients who have a sudden increase in calorie intake • Mechanism o  calorie intake   insulin release   phosphate, potassium, magnesium o Intracellular shift of ions due to switching from fat to carbohydrate metabolism • Biochemical features -  phosphate, Mg, K, thiamine, salt + water retention • Clinical features – fatigue, weakness, confusion, high BP, seizures, arrhythmia, HF • Can lead to cardiac complications, rhabdomyolysis, seizures • Risk of Wernicke’s encephalopathy o During the refeeding process, serum glucose may rise while B1 vitamin thiamine may drop o Offer IV thiamine during refeeding • Follow MARSIPAN/junior MARSIPAN (under 18) guidelines (management of really sick patients with AN)

Answer 124

• Bulimia nervosa o Both disorders – can have recurrent episodes of binge eating + engage in inappropriate behaviour to avoid weight gain + are overly concerned with body shape and weight o Individuals with bulimia nervosa maintain a body weight at or above a minimally normal level o Bulimia nervosa – complain more of bloating, abdominal pain, sore throat, feeling full • ARFID (Avoidant/restrictive food intake disorder) o May have significant weight loss or nutritional deficiency o Do not have a fear of gaining weight or of becoming fat o Do not have a disturbance in the way they experience their body shape and weight • Social anxiety disorder, OCD, BDD o Share similar features with anorexia nervosa o Should only be diagnosed if the social fears/OCD behaviours/BDD thoughts are not limited to the eating behaviour/body image alone o BDD – deliberate weight loss is unusual • Binge eating behaviour o Recurrent episodes of binging in a short period of time (usually <2h), episodes marked by lack of control o In binge eating there is no compensatory behaviour o Binge eating is essentially bulimia nervosa without the purging • Organic – hyperthyroidism, GI disease, malignancy, addisons disease • Depression • BDD

Answer 125

* hypothyroidism * Death * Growth stunting (if prepubertal onset) * Infertility * Osteoporosis * Pregnancy complications * Dental erosion * Mental health comorbidities incl. Substance misuse

Answer 126

* 80% go into remission * 10% death * Approximately 50% completely recover, 33% improve, 20% develop chronic eating disorder * After 10 years, 10% have no eating disorder and 10% have died (suicide = cause of 1/3 deaths) * 1/3 full recovery, 1/3 partial recovery, 1/3 chronic problems

Answer 127

unilateral/asymetrical=PD | bilat/symmetrical=parkinsonism (more likely to be drug related)

Answer 128

Subthreshold depressive symptoms: Fewer than 5 symptoms of depression. Mild depression: Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment. Moderate depression: Symptoms of functional impairment are between 'mild' and 'severe'. Severe depression: Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms. https://www.nice.org.uk/guidance/cg90/chapter/Recommendations

Psychiatry - General Flashcards

(152 cards)