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P3A Med > Psychiatry - Key Conditions > Flashcards

Psychiatry - Key Conditions Flashcards

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1
Q

How does schizophrenia present?

A

Delusions, hallucinations, thought disorder, lack of insight

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2
Q

What are the most common hallucinations in schizophrenia?

A

Auditory

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3
Q

What thought disorders do you see in schizophrenia?

A 
Thought insertion, removal or interruption - delusions about external control of thought.
Thought broadcasting - the delusion that others can hear one's thoughts.
Delusional perceptions (ie abnormal significance for a normal event) - eg, 'The rainbow came out and I realised I was the son of God.'
External control of emotions.
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4
Q

What are the negative symptoms seen in schizophrenia?

A

Underactivity (also affects speech), low motivation, social withdrawal, emotional flattening, self-neglect, loss of interests, alogia (poverty of speech)

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5
Q

Give some organic differentials of schizophrenia.

A

Drug-induced psychosis - amphetamine, LSD, cannabis.
Temporal lobe epilepsy.
Encephalitis.
Alcoholic hallucinosis.
Dementia.
Delirium due to infection, metabolic or toxic disturbance, neurological disease, endocrine cause, etc.

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6
Q

Give psychiatric differentials of schizophrenia.

A 
Mania.
Psychotic depression.
Some personality disorders.
Panic disorders.
Dissociative identity disorder.
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7
Q

What investigations would you order for someone first presenting with schizophrenia?

A

LFTs and FBC. Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse.

Screening for AIDS should be preceded by counselling.

Urine screen for drugs of abuse. Light recreational use of cannabis can produce a positive test for the subsequent fortnight. Heavy and chronic use can produce a positive result for months after the last use.

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8
Q

What is the first-line pharmacological treatment of schizophrenia?

A

First-line treatment in newly diagnosed schizophrenia now involves the use of the newer atypical antipsychotics - eg, risperidone or olanzapine.

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9
Q

What positive symptoms do you see in schizophrenia?

A

Delusions, hallucinations, disorganised speech (e.g. word salad), disorganised behaviour (bizarre, no purpose), catatonic behaviour

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10
Q

What are the three phases of schizophrenia?

A

Prodromal (withdrawn), active (severe symptoms), residual (cognitive symptoms)

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11
Q

How do we diagnose schizophrenia?

A

Two of the following: delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour, negative symptoms; with one of the first three. Must be ongoing for 6 months, with at least one month in the active phase.

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12
Q

Describe the epidemiology behind schizophrenia.

A

M > F, mid 20’s for men late 20’s for women, ? due to oestrogen regulation in women

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13
Q

What is bipolar disorder?

A

A disease characterised by episodes of mania (or hypomania) and depression.

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14
Q

What is bipolar I?

A

This type presents with manic episodes (most commonly interspersed with major depressive episodes). The manic episodes are severe and result in impaired functioning and frequent hospital admissions.

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15
Q

What is bipolar II?

A

Here, patients do not meet the criteria for full mania and are described as hypomanic. Hypomania in comparison to mania has no psychotic symptoms and results in less associated dysfunction. This type is often interspersed with depressive episodes.

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16
Q

How does the manic phase of bipolar present?

A

Grandiose ideas, pressure of speech, excessive amounts of energy, racing thoughts and flight of ideas, overactivity, needing little sleep, or an altered sleep pattern, easily distracted - starting many activities and leaving them unfinished, bright clothes or unkempt, increased appetite, sexual disinhibition, recklessness with money.

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17
Q

What is hypomania?

A

Hypomania is a lesser degree of mania with persistent mild elevation of mood and increased activity and energy but without hallucinations or delusions. There is also no significant effect on functional ability.

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18
Q

What must you ask a pt who is ? bipolar?

A

Any previous episodes of mania or depression.
Any suicidal or homicidal thoughts.
Any self-neglect.
Family history.
Substance misuse, smoking and alcohol intake.
General physical health.

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19
Q

How do we manage an acute manic episode?

A

If pt is already on an antipsychotic, increase to maximum dose. Drugs commonly used are haloperidol, olanzapine, quetiapine and risperidone. If one antipsychotic is ineffective it is worth changing to a different one. If the second one is ineffective, start lithium. If not permitted, use valproate.

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20
Q

Which patients should we not use valproate in?

A

Valproate should not be used routinely in females of child-bearing potential and if it is used then patients need to be counselled about alternative forms of contraception.

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21
Q

How do we manage an acute depressive episode?

A

Usually refer to secondary care. If depression develops rapidly in a patient with a previous manic episode who is not on treatment then an anti-manic drug should be started. Patients with moderate-to-severe depression should be offered fluoxetine combined with olanzapine or quetiapine on its own.

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22
Q

Why should you be careful about antidepressant use in bipolar?

A

Antidepressants may be less effective in bipolar disorder, even if depression is the main feature. They should be used carefully, as they may induce mania or hypomania or rapid cycling. If antidepressants are required then they should be prescribed with anti-manic medication.

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23
Q

How do we manage an acute mixed episode?

A

During an acute mixed episode antidepressants should be avoided and the aim should be to try to stabilise patients on anti-manic medication.

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24
Q

How often do we review manic patients?

A

Once patients begin treatment they should be reviewed at least weekly and then annually once they are stable.

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25
What is depression?
Depression refers to both negative affect (low mood) and/or absence of positive affect (loss of interest and pleasure in most activities) and is usually accompanied by a variety of emotional, cognitive, physical and behavioural symptoms.
26
How do we diagnose depression?
At least one of the core symptoms: Persistent sadness or low mood nearly every day. Loss of interest or pleasure in most activities. Plus at least three or four of the following symptoms to a minimum total of 5 depressive symptoms: Fatigue or loss of energy. Worthlessness, excessive or inappropriate guilt. Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts. Diminished ability to think/concentrate or increased indecision. Psychomotor agitation or retardation. Insomnia/hypersomnia. Changes in appetite and/or weight loss.
27
Give five RFs for depression.
Female gender, PMH of depression, significant physical illnesses, other mental health problems, psychosocial problems, childhood factors
28
What are the two screening questions for depression?
During the past month, have you: Felt low, depressed or hopeless? Had little interest or pleasure in doing things?
29
Give a screening tool for depression.
The Patient Health Questionnaire (PHQ-9)
30
Why do we use SSRIs as a first line treatment?
Selective serotonin reuptake inhibitors (SSRIs) are used as first-line antidepressants in routine care because they are as effective as tricyclic antidepressants and less likely to be discontinued because of side-effects; also because they are less toxic in overdose.
31
Which SSRI should you start with?
At the moment escitalopram has the highest probability of remission and may be the most effective and cost-effective. Use sertraline if other comorbidities due to lower risk of drug interactions. Use fluoxetine if young.
32
Why might you consider prescribing omeprazole with an SSRI?
Increased risk of bleeding with SSRIs, and consider co-prescribing a gastric protection agent, particularly in older people who are on aspirin or other NSAIDs
33
When should you consider reviewing a pt who has just started antidepressant medication?
After 2 weeks. See patients who are considered to be at increased risk of suicide or who are younger than 30 years old, within one week of starting treatment. Regularly review (every 2-4 weeks) in the first three months or until the risk is no longer significant.
34
Give RFs for postnatal depression
Previous history of mental health problems. Psychological disturbance during pregnancy. Poor social support. Poor relationship with partner. Baby blues. Recent major life events.
35
How would you treat a pt with mild postpartum depression but a history of severe depression?
Give an antidepressant
36
How would you treat moderate-severe postpartum depression?
High-intensity psychological intervention such as cognitive behavioural therapy (CBT). Antidepressant treatment if: Risks are understood and accepted, particularly if breastfeeding. The woman declines psychological therapy. Psychological therapies have failed.
37
How would you manage a woman who has ideas of either suicide or of harming her newborn child?
Immediate referral to psychiatric services, ? involve social services
38
What is postpartum psychosis?
A severe mental illness which develops acutely in the early postnatal period, usually within the first month following delivery. It is a psychiatric emergency.
39
When are women most likely to suffer from psychosis?
In the month after giving birth
40
Which women are more likely to suffer from postpartum psychosis?
Those with: A past history of postpartum psychosis. A past history of bipolar disorder. A family history of postpartum psychosis or bipolar disorder.
41
How do we manage postpartum psychosis?
Immediate admission to psych unit, and pharmacologically similar to psychosis.
42
How do we treat anxiety pharmacologically?
Short term: The sedative antihistamines may be effective or the benzodiazepines. The latter should not be used beyond four weeks. Long term: NICE recommends a selective serotonin reuptake inhibitor (SSRI) or venlafaxine as the first choice.
43
Name some SSRIs
Citalopram, escitalopram, sertraline, fluoxetine,
44
What is schizoaffective disorder?
A mental disorder characterized by abnormal thought processes and an unstable mood. The diagnosis is made when the person has symptoms of both schizophrenia (usually psychosis) and a mood disorder—either bipolar disorder or depression
45
What investigations would you order for someone with schizoaffective disorder?
Baseline bloods: FBC, renal and liver function, TFTs, HIV test. Urine or plasma toxicology. CXR to exclude pneumonia in the elderly.
46
Which pts with schizoaffective disorder should you admit?
Those who are thought to be a threat to themselves or others, or who are too disabled to care for themselves.
47
What is obsessive compulsive disorder?
It's a disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions) that make them feel driven to do something repetitively (compulsions)
48
How do we diagnose OCD?
Obsessions and/or compulsions on most days for a period of at least two weeks, where no pleasure is derived from carrying out the obsession/compulsion.
49
How do we screen for OCD?
Ask: Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you would like to get rid of but cannot? Do your daily activities take a long time to finish? Are you concerned about putting things in a special order or are you very upset by mess? Do these problems trouble you?
50
How do we treat mild OCD?
CBT, exposure and response prevention (ERP)
51
How do we treat moderate OCD?
CBT/ERP, SSRI or clomipramine (more SEs)
52
How do we treat OCD in children?
Self-help if mild, refer to CAMHS if moderate/severe
53
What is panic disorder?
Recurrent unexpected panic attacks
54
What is agoraphobia?
The avoidance of exposed situations for fear of panic or inability to escape
55
Describe the pathophysiology behind panic disorder.
Gamma-aminobutyric acid (GABA) receptor dysfunction is thought to play an important role in panic disorder pathophysiology
56
How do we define panic attack?
A panic attack is defined as a discrete episode of intense subjective fear, where at least four of the characteristic symptoms, arise rapidly and peak within 10 minutes of the onset of the attack
57
How do we diagnose panic disorder?
Panic attacks must be associated with >1 month's duration of subsequent, persisting anxiety about recurrence of the attacks, the consequences of the attacks, or significant behavioural changes associated with them.
58
Give 7 characteristics of a panic attack.
Palpitations, pounding heart or accelerated heart rate. Sweating. Trembling or shaking. Dry mouth. Feeling short of breath, or a sensation of smothering. Feeling of choking. Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, light-headed or faint. Derealisation or depersonalisation (feeling detached from oneself). Fear of losing control or 'going crazy'. Fear of dying. Numbness or tingling sensations. Chills or hot flushes
59
How do we treat panic disorder?
Advise avoiding anxiety-producing substances - eg, caffeine. Consider using abdominal/diaphragmatic breathing during attack. Offer CBT. Consider offering an SSRI.
60
What is somatic symptom disorder?
Patient who suffer from 'unexplained somatic complaints,' which is a term that was introduced to describe patients presenting with any physical symptom and frequent medical visits in spite of negative investigations
61
Briefly explain what the BATHE technique is?
A framework for exploration of psychosocial stressors in less than five minutes
62
Describe the BATHE technique.
Background: 'What is going on in your life?' Affect: 'How do you feel about it?' Trouble: 'What troubles you the most about that situation?' Handle: 'What helps you handle that?' Empathy: 'This is a tough situation to be in. Your reaction makes sense to me.'
63
Define personality disorder.
Personality disorder (PD) is an umbrella term that covers a number of variations of maladaptive personality traits that cause significant psychosocial distress and interfere with everyday functioning. It is characterised by patterns of thought, behaviour and emotions that differ from what is normally expected by society. It leads to difficult relationships, reduced quality of life and poor physical health.
64
Give RFs for personality disorder.
``` Sexual abuse Physical abuse Emotional abuse Neglect Being bullied ```
65
What is avoidant personality disorder?
Where an individual has severe anxiety about rejection or disapproval and avoidance of social situations or relationships.
66
What is dependent personality disorder?
Individuals here have heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach.
67
What is obsessive compulsive personality disorder?
This features unrealistic expectations of how things should be done by themselves and others, and catastrophising about what will happen if these expectations are not met.
68
What is paranoid personality disorder?
This features difficulty in trusting or revealing personal information to others.
69
What is schizoid personality disorder?
This features a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them.
70
What is schizotypal personality disorder?
This features unusual beliefs, thoughts and behaviours, as well as social anxiety that makes forming relationships difficult.
71
What is borderline personality disorder?
This features fluctuating strong emotions and difficulties with identity and maintaining healthy relationships.
72
What is histrionic personality disorder?
This features the need to be at the centre of attention and having to perform for others to maintain that attention.
73
What is narcissistic personality disorder?
This features feelings that they are special and need others to recognise this or else they get upset. They put themselves first.
74
How do we treat personality disorders?
CBT and psychotherapy
75
What is suicide?
Suicide can be described as a fatal act of self-harm initiated with the intention of ending one's own life.
76
How many suicides are male?
75%
77
Give five RFs for suicide.
Male, previous attempts, unemployed, physical health problems, living alone, being unmarried, alcohol/drug dependence, active mental illness
78
Give three protective factors of suicide
Strong religious faith, family support, having a sense of responsibility for others, problem-solving skills, having children at home
79
How do you manage pts who exhibit suicidal ideation?
High risk of imminent suicide attempt: consider inpatient treatment Medium risk: consider home crisis plan & provide details of crisis team
80
What is section 2 of the mental health act?
Admission for assessment. Up to 28 days. Can’t be renewed. They can treat you at the time too if needed.
81
Who can sign a section 2 order?
Signed by 2 doctors/1 doctor 1 Approved Mental Health Professional.
82
What is section 3 of the mental health act?
Admission for treatment. 6 months and can be renewed. Can give you treatment, perform investigations etc.
83
Who can sign a section 3 order?
Signed by 2 doctors/ 1 doctor 1 AMHP.
84
What is section 4 of the MHA?
Emergency treatment. Used in emergency when you are unsafe to go home but only 1 AMPH available. Can hold you in hospital until the other one arrives and you can be sectioned under 2 or 3.
85
How long can a section 4 last for? Can you treat the pt?
Up to 72h. Can’t treat you, can literally only keep you there.
86
What is section 5 of the MHA?
Detention of a patient already in hospital by doctor 5(2) or nurse 5(4). Again, can only stop you from physically leaving until you can be reviewed and sectioned under 2 or 3.
87
What is section 135/136 of the MHA?
Allows the police to take you from your private property and take you to a place of safety (station/hospital) because a doctor things you need help and are unsafe for yourself or others. Up to 72h. Section 136 = from a public place.
88
How does fronto-temporal dementia usually present?
Common in those u65, behavioural changes, progressive non-fluent aphasia (inability (or impaired ability) to understand or produce speech), semantic dementia
89
How does Alzheimer's dementia usually present?
Increased memory loss and confusion. Inability to learn new things. Difficulty with language and problems with reading, writing, and working with numbers.
90
How does vascular dementia usually present?
A progressive disease where deteriorations may be sudden or gradual but tend to progress in a stepwise manner
91
How does Lewy-body dementia usually present?
Dementia is usually the presenting feature, with memory loss, decline in problem solving ability and spatial awareness difficulties. Characteristically there are fluctuating levels of awareness and attention. Signs of mild Parkinsonism (tremor, rigidity, poverty of facial expression, festinating gait). Falls frequently occur. Visual hallucinations. Sleep disorders including rapid eye movement sleep disorder, restless legs syndrome, nocturnal cramps. Fainting spells.
92
What is the stages of change model?
Pre-contemplation – the patient is not yet thinking about drinking Contemplation – the patient is thinking about drinking Preparation – the patient is preparing to drink – e.g. goes and buys alcohol Action – the patient drinks Maintenance – the patient continues in this pattern of behaviour
93
What symptoms of opiate overuse would you see clinically?
Pinpoint pupils, low BP, venepuncture marks
94
How would a pt on benzos present clinically?
Disinhibited or gives the impression of intoxicated, but is not drunk
95
How would a pt on psychostimulants present clinically?
Rapid speech, large pupils, agitation, restlessness, high BP
96
Can heroin withdrawal kill you?
No, but it won't feel great
97
What is the mental state examination?
The mental state examination (MSE) is a structured way of observing and describing a patient's current state of mind, under the domains of appearance, attitude, behaviour, mood, affect, speech, thought process, thought content, perception, cognition, insight and judgement.
98
How do we divide the MSE up?
AB, SM, TP, CI(R) | Appearance and behaviour, speech and mood, thoughts and perceptions; cognition, insight (and risk)
99
Define dysphoric.
Very low mood
100
Define euthymic
Normal mood
101
Define labile
Constantly fluctuating
102
How do we assess pt mood?
Subjective – patient’s opinion of their mood and state | Objective – our opinion of their mood and state
103
How do we assess pt speech?
``` Rate / Rhythm / Tone Accent Language Form Spontaneous? Do they answer questions ```
104
How do we assess pt speech?
``` Rate / Rhythm / Tone / Volume Language Form Fluency / Spontaneity Do they answer questions? ```
105
How do we assess a pts perception?
Have you ever heard anything that other people couldn’t? Do things / people seem different from normal.
106
What is depersonalisation?
A feeling of detachment from the normal sense of self “ As if i’m acting”
107
How do we assess cognitive function?
Mini mental state Orientation – time, place, person Show patient 3 items and ensure they have registered them – test recall after 2mins
108
How do we assess pt insight?
This is the patients understanding of their illness ``` Are they aware of their behaviour? Does it change over time? Do they believe they need treatment? Do they believe they have a mental disorder? Capacity ```
109
What is the MARSIPAN checklist used for?
For really sick pts with anorexia nerviosa

P3A Med (9 decks)

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