Psychology diagnosis+management Flashcards

Question

Generalised anxiety disorder diagnosis/investigations

Answer 1

DSM-5 criteria: At least 6 months of excessive, difficult to control worry about everyday issues that is disproportionate to any inherent risk and causes distress or impairment Worry is not confined to features of another mental disorder or as result of substance abuse, general medical condition Person experiences at least 3 of following symptoms most of the time: restlessness, nervousness, easy fatigue, poor concentration, irritability, muscle tension, sleep disturbance ICD-10 criteria: anxiety generalised and persistent but not restricted to or even strongly predominating in any particular environmental circumstances Variable symptoms include: nervousness, trembling, muscle tension, sweating, light headed, palpitations, dizziness and epigastric discomfort Expression of fears such as that the person or relative will shortly become ill or have an accident GAD-7 questionnaire: Allow assessment to see if you do have anxiety and how severe (5-9 mild; 10-14 mod, 15+ severe) Questions ask how the person has felt over the last 2 wks

Answer 2

Mild: CBT low intensity (self guided or group etc) Moderate: CBT high intensity and medications: SSRI, SNRI, pregabalin can be offered is other meds are CI or not tolerated Severe: refer for specialist treatment (complex drug and/or psychological interventions). Regular exercise and sleep hygiene can really improve symptoms

Answer 3

Alteration in persons mood, behavior Precise cause unknown but multifactorial from social, environmental and genetic factors May be preceded by prodromal period can last from few days to 18 months, followed by acute psychotic episode often including hallucinations, delusions and behavioural disturbances often with agitation and distress Risk factors: +ve family history (particularly first degree relative with psychosis or schizophrenia) Recent or past stressful or traumatic experiences

Answer 4

Characterised by emotional and behavioural changes leading to deterioration in personal functioning and social withdrawal leading to deterioration in personal function and social withdrawal Transient low intensity psychotic symptoms <1wk (hallucinations, perceptual experiences, unusual thoughts, paranoia) Reduced interest in daily activities Problems with mood, sleep, memory, concentration, communication, affect and motivation Anxiety, irritability or depressive features Incoherent speech suggestive of thought disturbance

Answer 5

Seeing/hearing things that aren’t there Hallucinations: perceptions in absence of stimulus, auditory are most common, voices heard may be running commentary on actions, argue with self, commanding, or echoing thought. Visual hallucinations, smell, taste or tactile occur less commonly Delusions: fixed or falsely held beliefs. Delusion of reference (belief that ordinary events, objects or behaviour of others has a meaning specifically for them), delusions of control (belief that thought, feelings, behaviour are controlled by others. May include thought insertion, thought withdrawal and thought broadcasting). Delusions of persecution (belief that others are plotting against them) Disorganised behaviour, speech, thoughts (thought disturbance)

Answer 6

``` Emotional blunting/affective flattening (lack of spontaneity or reactivity of mood) Reduced/ impoverishment speech Avolition (loss of motivation) Self-neglect Social withdrawal Anhedonia (lack of pleasure) Attention deficit ```

Answer 7

Suspect frank psychosis in person with +ve symptoms and -Ve symptoms. Positive symptoms may not be readily disclosed by the person so must ask directly Medication review: anticonvulsants, high dose steroids, levodopa and dopamine agonists or opioids may cause Urine drug screen: recreational drugs HIV and/or syphilis screening as both infections can cause psychosis symptoms FBC for anaemia as potential cause of negative symptoms

Answer 8

With intervention many symptoms will regress or resolve however some negative symptoms may remain and psychotic episodes may recur Factors associated with poor prognosis: longer duration of untreated psychosis, early or insidious onset of schizophrenia, Male sex, negative symptoms, family history of schizophrenia, low IQ, low socioeconomic status or social isolation, significant psychiatric history, continued substance misuse *best to know where to signpost pts: hospital admission, psychiatry referral etc.

Answer 9

Schizoaffective disorder — where symptoms of schizophrenia and a mood disorder (depressed or manic) are equally prominent. Drug-induced psychosis — substance-induced and usually remits within a month of cessation of use. Persistent delusional disorder — where the most pervasive symptom is delusion. Schizophrenia

Answer 10

Most common psychotic disorder Hereditary around 85% from twin studies 7.5 fold increased risk of disorder in people with parent with schizophrenia Risk factors: Stressful life events Childhood adversity Family heritage - south asian and black populations Migration (esp from developing country) Urban living Cannabis use (40% increased risk) Other substance use Medications (high dose steroids) Early life factors (in-utero meds, maternal stress, nutrition deficiency) Parental age >40 years or <20 years Exposure to protozoan parasite toxoplasma gondii (cat little and pork; pregnancy women advised to not handle cat litter)

Answer 11

ICD-10 criteria: symptoms present most of time for at least 1 month with one or more of following features: Hallucinatory voices Thought echo, thought insertion or withdrawal and thought broadcasting Delusions of control, influence, passivity, clearly referred to body or limb movements or specific thought, actions or sensations Persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, superhuman powers and abilities or being in communication with aliens Or any two of the following: Persistent hallucinations in any form, when accompanied by fleeting or half-formed delusions without clear affective content, or by persistent overvalued ideas (similar to preoccupations), or when occurring every day for weeks or months on end. Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms (invented words). Catatonic behaviour, such as excitement, posturing, or waxy flexibility; negativism; mutism; and stupor. Negative symptoms, such as marked apathy, reduced speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to antipsychotic medication. A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

Answer 12

CBT and family intervention with oral antipsychotics (1st or 2nd generation) Arts therapies particularly to help -ve symptoms Inform person they must not drive during acute episodes and must tell DVLA about their illness

Answer 13

``` Haloperidol (1st gen) Prochlorperazine (1st gen) Aripiprazole (2nd gen) Clozapine (2nd gen) Olanzapine (2nd gen) Quetiapine (2nd gen) Risperidone (2nd gen) ```

Answer 14

There is no first-line antipsychotic drug suitable for all people with psychosis, and (bar clozapine) little meaningful difference in efficacy. • Clozapine is generally offered to people who do not respond adequately to two other antipsychotics and is always initiated and monitored in secondary care. Response to antipsychotics is variable Dosage and intervals are decided on case by case basis according to persons response 1st gen: thought to work by blocking dopamine 2 receptors in brain and can cause extrapyramidal symptoms (EPS) and wide range of other adverse effects 2nd gen: act on range of receptors and associated with fewer EPS than 1st gen. Associated with several other important adverse effects: weight gain, glucose intolerance, hyperprolactinaemia Have significant effects on acetylcholine, histamine, noradrenaline and serotonin pathways! Never quickly remove drugs, always taper off!! ``` Choice depends on: Patient preference Medication history, Degree of sedation required, Risk of particular adverse effects Degree of negative symptoms (2nd-generation antipsychotics may be more beneficial). ```

Answer 15

Caused by antipsychotics Dystonic reactions (abnormal movement of face and body) and pseudoparkinsonism (tremor, bradycardia, rigidity) these can be alleviated by antimuscarinic drugs like procyclidine (not routinely prescribed) Akathisia (motor restlessness): improved by reducing dosage Tardive dyskinesia: rhythmic involuntary movements, usually lip-smacking, tongue rotating, although can affect limbs and trunk. Late onset symptoms that can worsen on treatment withdrawal!

Answer 16

BMI at 6 wks then 3 months then every 12 months or more U+Es/FBC/LFTs annually Blood lipids/BG/HbA1c 3 months after starting then annually Pulse and BP during dose titration and at each dose change (not for amisulpride, aripiprazole, trifluoperazine and sulpiride) ECG: after dose change and ideally annually too (mandatory for haloperidol, pimozide, sertindole but not needed for antipsychotics with no/low to mod effect on QT interval with no other arrhythmia risk factors Prolactin: 6 months after starting treatment then annually. Not needed for aripiprazole, clozapine, quetiapine or olanzapine (less than 20mg daily) Creatine kinase if neuroleptic malignant syndrome is suspected - rare but potentially fatal

Answer 17

Premature death Increased suicide risk Increased risk of disorders including: CV disease, T2DM, smoking related illness, cancers, infections such as HIV, hep C and TB Social exclusion

Answer 18

If pt. Needs to be admitted to hospital it is better they are encouraged to go voluntarily If admission is needed but person declines, compulsory admission may be arranged under sections 2, 3 or 4 of the mental health act Mental health act 1983/2007 allows compulsory admission of those who: Have mental disorder of nature or degree warranting assessment or treatment in hospital and Needs to be admitted in interests of their own health and safety or for protection of others Section 2: for 28 days for assessment. Needs application from approved mental health professional or persons nearest relative and recommendations from two Drs (one section 12 approved and one acquainted with pt) Section 3: for up to 6 months for treatment. Needs application from approved mental health professional or persons nearest relative, recommendations from two Drs (one section 12 approved and one acquainted with pt) Section 4: for up to 72 hrs in exceptional urgent cases where delay while trying to arrange admission under normal procedure Section 136: may be used by police to take people from public place to place of safety where they can be assessed

Answer 19

Deliberate act undertaken by someone mimicking the act of suicide but not resulting in fatal outcome Multicentre study on self harm shows 57% pts female, 66% <35 years Largest numbers by age group are 15-19 years females and 20-24 years males F:M ratio decreases with age Approx. 80% self harm episodes involve self poisoning (paracetamol common, antidepressants, benzodiazepines and sedatives, alcohol) Common presentation in hospital between 10pm and 2am Two main methods: Drug overdose Self injury

Answer 20

Medical emergency Common causes: paracetamol, alcohol, salicylate (commonly aspirin), opioid overdose Caustic agents: agents with potential to cause tissue destruction, alkaline substances cause liquefactive necrosis, resulting in deep tissue penetration ``` Investigations: Bloods: paracetamol, salicylate levels, blood glucose ABG U+Es LFTs and eGFR Urine sample Gastric aspirate or vomitus ABCDE assessment of pt status ```

Answer 21

ABCDE: Eyes (dilated pupils indicate tricyclics, cocaine, amphetamine; pinpoint pupils indicate opiates; nystagmus indicates alcohol, benzodiazepines, phenytoin) Breath (bitter almond smell of cyanide indicates alcohol or organic solvents) burns around mouth (corrosive substances like paraquat, glue) hyperventilation (salicylates) needle marks (recreational drug abuse) Identify substance: if pt is unconscious, third party evidence of what has been taken. Time of ingestion, associated alcohol consumption, past and current medical history (esp if renal or liver disease), symptoms noticed since poisoning (vomiting may have removed some substance already, hematemesis caused by iron overdose, salicylates, alcohol) Elimination: activated charcoal (decontamination) decreases absorption within 1 hr of digestion (preferred), antidote administration, gastric lavage (no longer recommended due to aspiration risk; only indicated in life threatening amount ingested within previous hr and poison cannot be removed via other methods. May be useful for drugs such as lithium and iron which aren’t charcoal absorbed), dialysis (peritoneal, haemodialysis), diuresis (alkaline, acid change urinary pH to increase substance excretion in urine) whole bowel irrigation (when substance would not be absorbed by activated charcoal) Specific and general treatment of pt condition Period of observation Psychiatric assessment

Answer 22

Single-dose activated charcoal is the preferred method of decontamination in many cases. Patients should have had a significant overdose, be co-operative, without impairment of consciousness and not thought to be likely to fit imminently. Ideally it is used in a 10:1 ratio with the ingested drug - the usual dose is 50 g for an adult (children: 1 g/kg). It may be repeated in one hour if necessary (oral, nasogastric tube). Its large surface area adsorbs many drugs but has its limitations. It may not be be effective if given after the first hour or in cases of poisoning with iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon or strong acids or alkalis.

Answer 23

Given for certain poisons which can either prevent poison working or reverse it’s effects N-Acetylcysteine for paracetamol Digoxin-specific antibody fragments for digoxin Flumazenil injection for benzodiazepines. Reverses CNS and respiratory depression. However if person has also taken tricyclic antidepressant or has epilepsy must be cautions as can cause seizures or arrhythmias Glucagon injection for insulin and beta-blockers Naloxone injection for heroin, opiates. Administration of IV used for rapid diagnosis of opiate poisoning. Should show significant improvement in condition within 1-2 mins Fomepizole for ethylene glycol or methanol

Answer 24

Is there an immediate suicide risk? Is there subsequent risk of further deliberate self harm or suicide? What are the current medical and social problems? *Always refer for psychiatric assessment management: referral to specialist after stabilisation and treatment as needed Assessment to be done by specialist mental health professional: Events preceding episode Reasons Assessment of possible suicide intent (plan/not) Current personal difficulties and life issues Whether they have a psychiatric disorder Personality traits Family history Psychiatric history and history of self harm Whether they have been exposed to self harm in others eg family or friends or through social media Risk of further self harm and suicide Persons social support and coping resources Whether person is willing to accept help and what would benefit them the most

Answer 25

Actions towards a child that violates social definitions of acceptable caretaking practice Unacceptable in degree and/or in type ad represent an end point of actions towards children ``` Types: Physical Neglect Emotional Sexual ``` Risk factors: Parental or carer drug or alcohol misuse Parental/carer mental health problem Intra-familial violence or history of violent offences Previous child mistreatment in members of family Known maltreatment of animals by parent/carers Vulnerable and unsupported parents or carers Pre-existing disability in child

Answer 26

Commonly find multiple soft tissue bruises and skin lesions May involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to child Mouth injuries: torn lips, gums, frenulum Ear injuries/recurrent ear infections (although this is common in children normally) Genitalia injury Bilateral black eyes/black eyes or eye bruising Intra Ocular or retinal haemorrhage Recurrent UTI in infants <1 years Buckle fracture Multiple bruisings on difficult to injure sites Skull fractures Multiple bilateral posterior and lateral rib fractures

Answer 27

Commonly defined as injury to psychological capacity or emotional stability of child leading to changes in behavior or cognition Signs include: behavioral extremes, delayed development or learning delays, suicide attempts, lack of parental attachment Caregivers may poverty reject or blame children, view them as worthless or be unconcerned about the child's wellbeing. Also will deny obvious problems All forms of abuse place the individual at increased risk for life of alcoholism, smoking, PTSD, depression and drug use

Answer 28

Listen and observe: Any history given: social, educational, living arrangements Reports of maltreatment or disclosure from child or young person or third person Child’s appearance Child's behaviour Symptoms of maltreatment Physical signs Results of investigation Interaction between parent or carer and child/young person Seek an explanation: In non-judgemental manner form both parent or carer and child Record: Note in clinical record exactly what has been observed and heard from whom and when Record why this is of concern Consider, suspect or exclude maltreatment

Answer 29

If there are discrepancies in child’s history, physical or psychological presentations or findings of assessments, examinations or investigations and one or more of the following is present Reported symptoms and signs only appear or reappear when parent/carer is present Reported symptoms only observed by parent/carer Inexplicably poor response to medications or treatments New symptoms reported as soon as previous have resolved History of events biologically unlikely (eg infants with history of large blood losses who do not become anaemic or unwell) Parent/carer may manipulate test results eg add glucose to urine to indicate diabetes Deliberately induces symptoms of illness eg poisoning with unnecessary medications or substances WHY? Personality disorders? Playing role of caring mothers Psychological and behavioural problems, self-harming, drug and alcohol abuse

Answer 30

Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between people aged 16 or over who have been intimate partners, or family members Vulnerable adults: Adults with care or support needs who may be at increased risk/less able to protect themselves from harm Safeguarding is protection of rights to those at risk Care act 2014 sets out duties for local councils to protect these rights by preventing abuse, stopping abuse and neglect in children or vulnerable adults If you suspect abuse then raise concern with NHS safeguarding team

Answer 31

Can occur if carer is not giving person the necessary help and attention required Can led to medical side effects if medication is missed and worsening psychological harm for elderly person in question Can be unintentional and may be a sign the caregiver is suffering in their role. Third party witnesses may want to speak to carer to check up on them if neglect suspected (common in care home settings) TYPES OF ABUSE/NEGLECT: Financial: fraudulent scams, money or property misuse or theft Physical Psychological Sexual Discriminatory: harassment, racial, disability, sexual orientation, religion Domestic abuse

Answer 32

Frequent appointments for vague symptoms Frequently missed appointments including antenatal clinics Non-concordance with treatment or premature discharge from hospital Repeated health consultations with no clear diagnosis. Person may describe themselves as accident prone or silly and provide vague explanation of injuries Injuries inconsistent with explanations Repeated injury all at different stages of healing all with vague explanations Traumatic injury esp if repeated (burns, bites, cutes, fractures) Unexplained chronic gastrointestinal symptoms Unexplained genitourinary symptoms including frequent bladder or kidney infections Chronic unexplained pain Problems with CNS (headaches, cognitive problems, hearing loss)

Answer 33

Facilitate disclosure in private with no third parties present (ensure they feel safe) Advise person that discussion is confidential and information will only be shared with consent, subject to adult safeguarding and child protection (only share with those who must know) If suspected abuse in NHS facility eg care home or specialist NHS nursing home, raise matter with safeguarding team for that service or local authority safeguarding team •Explain that you are concerned (or, if it is a routine enquiry, that you ask everyone), and ask direct questions, such as: •'Has anyone ever hit you? Who was it? What happened? When? What help did you seek?' •'Are you afraid of your husband (or partner)?' •'Has your husband (or partner) or someone else at home ever threatened to hurt you or physically harm you in some way? If so, when has it happened?' •'Does your husband (or partner) or someone at home bully you or insult you?' •'Does your husband (or partner) try to control you, for example, not letting you have money or go out of the house?'

Answer 34

Broad range of phenotypes which include ‘strict’ autism, atypical and asperger syndrome Characterised by: impaired reciprocal social interaction and communication, stereotyped (rigid and repetitive) behaviour and interests, onset typically before age 3 Mostly affects children (1%); 2-8% prevalence among siblings More boys diagnosed than girls More heritable of childhood onset neuropsychiatric disorders (90%) 70% those diagnosed have other impaired psychological functioning such as ADHD and Anxiety disorders Can be diagnosed in young people and adults if meet criteria (ICD-10 and DSM-5) DSM-5 refers to autism spectrum disorder as a single condition with different levels of symptom severity in 2 core domains: •1) deficits in social communication and social interaction and •2) restricted repetitive behaviours (RRBs), interests, and activities and sensory anomalies Learning disability: IQ <70 occurs in approx 50% people with autism Others may not have learning disability or learning delay but just need special educational needs (SEN)

Answer 35

Sibling affected Birth defect associated with CNS malformation or dysfunction including CP Gestational age <35 wks Parental schizophrenia like psychosis or affective disorder Maternal use of sodium valproate in pregnancy Learning disability Attention deficit hyperactivity disorder (ADHD) Neonatal encephalopathy or eipleptic encephalopathy, including infantile spasms

Answer 36

Preschool child if any of following signs and symptoms present: language delay, babbling, speech regression or loss of speech. Delayed response to others: when called, non-smiling no response to others facial expressions and unusual response to others when requesting or rejecting Reduced social interaction with others: annoyed to share space, intolerant of people entering personal space, prefer to play alone, absent social play, absent enjoyment like other children Reduced eye contact, pointing, special gestures: reduced or absent imagination from play, unusual or restricted interests and/or rigid and repetitive behaviours, excessive insistence on their own agenda Over or under reaction to sensory stimuli eg sounds, smells, taste, textures *be aware there are many differentials such as learning or cognitive impairments that may also present like this. *be aware of children from deprived backgrounds and those with history of maltreatment which can also caused delayed development

Answer 37

Arrange immediate referral to autism team if available (or pediatrician or child adolescent psychiatrist dependent on local referral policy) if child is < 3 years, language impairment or developmental delay Consider immediate referral to autism team if there is significant concerns of parents and/or carer about development or functioning Arrange immediate referral to pediatrician or pediatric neurologist of having ASD or another neurodevelopmental conditions If no concerns ‘watch and wait’ and review any symptom progression If referral to be made then include the following information: antenatal and perinatal history, developmental milestones, any risk factors for ASD, information from previous assessments

Answer 38

At least six (five in adults) inattention symptoms and/or at least six (five in adults) hyperactivity-impulsivity symptoms that have: Started before 12 years of age. Occurred in two or more settings such as at home and school. Been present for at least 6 months. Clearly interfered with, or reduced the quality of social, academic or occupational functioning. Not occurred exclusively during course of a psychotic disorder

Answer 39

Inattentive only: person has difficulty paying attention but does not tend to be disruptive Hyperactive and impulsive: person may be able to focus well, but hyperactive and impulsive behaviours can cause disruption Combined: person has all symptoms

Answer 40

Most likely to have inattentive form of ADHD and may be missed due to this. Main ADHD symptoms can apply to both sexes, but hyperactivity symptoms often present differently in girls than boys. Studies show they are more likely to show ‘internal’ symptoms making it difficult to pick up or for others to notice ``` *Other problems girls may experience include: Chronic stress Higher risk of stress related diseases Low self esteem Underachievement Anxiety and depression ```

Answer 41

Include: Failing to give close attention to detail or making careless mistakes in schoolwork, work, or other activities. Difficulty in maintaining concentration when performing tasks or play activities. Appearing not to listen to what is being said, as if the mind is elsewhere, without any obvious distraction. Failing to follow through on instructions or finish a task (not because of oppositional behaviour or failure to understand). Difficulty in organizing tasks and activities. Reluctance, dislike, or avoidance of tasks that require sustained mental effort. Losing items necessary for tasks or activities such as pencils, mobile phones, or wallets. Easy distraction by extraneous stimuli Forgetfulness with regards to daily activities Girls may show distractibility easily by things around them or their own thought Organisational skills may be challenging: poor time management, hard to follow multi step directions or complete a task. May often lose items

Answer 42

Include: tapping hands or feet, or squirming when seated. Leaving the seat where remaining seated is expected, such as in a classroom. Running about or climbing in situations where inappropriate. In adolescents or adults this may be limited to a feeling of restlessness. An inability to play or engage in leisure activities quietly. Being 'on the go' or acting as if 'driven by a motor'. Others may experience the person to be restless or difficult to keep up with. Talking excessively. Blurting out an answer before a question has been completed. Difficulty waiting his or her turn. Interrupting or intruding on others. Girls are likely to move around and fidget more quietly, shuffling in chairs, doodling etc. Girls may experience strong emotions and this may leave them unable to slow own or think about what they say. Can be hard for them to know the difference of what is and isn’t socially appropriate leading to difficulty making and keeping friends

Answer 43

If ADHD is suspected in a child: Assess the social and educational impact of their symptoms Assessment using the Strengths and Difficulties questionnaire or the Conners' rating scale. Watchful wait (10 wk-few months) & Family support and encouraging self-help , offer referral to group-based ADHD-focused support. Usually school teachers offer helpful records of progressions and behavioural symptoms also. If symptoms severe, refer to child psychiatrist , specialist pediatrician

Answer 44

Mean age presentation is 27 More common in women than men during reproductive years Vulnerability increases with living further from equator Genetic component Seasonal pattern observed in 15% pts with recurrent mood disorders, including unipolar and bipolar forms Evolves from complex interactions between circadian rhythm and biological clocks

Answer 45

``` Difficulty waking Decreased energy, lethargy Increased appetite Increased sleep Weight gain Decreased libido Withdrawal from friends and family depression/anxiety/irritability Tearful Headache, palpitations, generalised aches and pains ``` Classifications: SAD with autumn or winter onset depression: symptoms remit or hypomania or mania symptoms during spring or summer (most common) Sub-syndromal SAD: characterised by seasonal mood disruptions with milder functional impairment. Symptoms may not be as severe and may not meet diagnostic standard ICD-10 however still experience significant mood changes SAD with summer onset depression: remission or hypo/mania symptoms in winter months (less common)

Answer 46

TFTs Bloods for illicit substances and alcohol Important to assess suicide intent and self harm intent as well as mechanisms of coping and support network availability Diagnosed using DSM-5 criteria: Criteria: Depression cycles on regular basis during season Full remission of symptoms in opposite seasons Seasonal symptoms for at least 2 consecutive years Atypical features which may or may not be present

Answer 47

Managed in the same way as non-seasonal depression Pt education and reassurance Support groups and therapies Light therapy for symptom improvements

Answer 48

Development of depressive illness following or during childbirth May form part of a bipolar or more usually unipolar illness Not yet recognised as a condition in its own right but often considered if onset of episodes is within four weeks of childbirth (some consider between 6-12 months also as see this criteria as too narrow) No solid evidence of hormonal changes causing

Answer 49

Previous history of mental health problems Psychological disturbance during pregnancy Poor social support Poor relationship with partner Baby blues: during first week postpartum, feel low, burst into tears, irritable, anxious and restless Recent major life events Unplanned pregnancy Antenatal stress Presentation: Same of unipolar depression

Answer 50

Diagnosis: History taking: alcohol, drug use, mother baby relationship, risk of self harm or harm to infant, social networks etc DSM-5 criteria for depression PHQ-9 for severity

Answer 51

Empower self decision for care Encourage communication with loved ones to gain support and understanding Psychological therapies CBT, IPT Antidepressants if needed IF PREGNANT: decisions made based on nature and severity of depression, previous personal or family history, stage of pregnancy, benefits v risks of medications Subthreshold, mild or moderate symptoms consider referral to facilitated self helps and therapies For severe history of depression presenting with mild depression; consider TCA, SSRI or SNRIs, ensure safe for pregnancy For moderate to severe depression consider high intensity CBT or therapies, if medicational preference also stated then can use antidepressants also If a woman with depression decides to stop taking medications during pregnancy: carefully monitor mental status and risk of relapsing. Question as to why she’s stopping, educate on benefits v risks of medications during pregnancy and advise other options if she still would like cessation of medications as well as outlining risks to her and baby with no medications

Answer 52

Severe is the most fatal mental illness (20% fatality) F:M ratio 10:1 Men more likely to go undiagnosed, misdiagnosed and under-referred Typical onset is early adolescence to mid adolescence (16-17 years) After diagnosis condition usually continues for over 20 years Characterised by low self esteem and a compulsive need to control eating Multifactorial causes of biological, developmental and social factors Two types: Restrictive type: extremely restricted dieting constantly Binge-purge type: Restricted eating with binge eating then vomiting

Answer 53

``` Healthy: BMI 18.5-24.9 Mild: BMI 17-18.5 Mod: BMI 16-17 Severe: 15-16 Extreme: <15 ```

Answer 54

Female Age Living in western society Family history of eating disorders or substance misuse Substance misuse Sexual abuse Occupational pressure (model, dancers, gymnasts, jockeys and athletes etc) Low self esteem Obsessional traits Anxiety Emotionally unstable personality disorder or other mental health disorder

Answer 55

Believe themselves to be fat, terrified at thought of becoming larger Follow heavily restricted diet (semi-starvation) Over exercise Induced vomiting Appetite suppressants Laxative abuse Diuretics Exhibit perfectionist behaviour or overreact to stressful situations Obsessive food rituals (cutting into small pieces, hides eating from others) Episodes of binge eating followed by remorse, vomiting and concealment Tend to avoid eating around others Denys problem Weakness Fatigue Bradycardia Hypotension and orthostatic hypotension Dizziness Oedema (pedal mostly) Amenorrhea (>3months) GI symptoms (constipation, bloating, nausea from inability to metabolise meals well)

Answer 56

SCOFF questionnaire for prevention Sick: Do you make yourself sick because you feel full? Control: do you worry you’ve lost control? One stone: have they recently lost 1 stone in 3 months? Fat: do they believe/worry about being fat Food: does food dominate life? Investigations: BMI Vascular exam of circulation, oedema Postural hypotension BP Sit up test: lay person flat ask them to sit up without use of hands Squat test: ask person to squat then stand without using hands Bloods: ESR, TFTs, FBC, Creatina, glucose, LFTs rule out other causes of weight loss U+Es for those with vomiting, taking laxatives, diuretics or water loading DEXA scan for fractures, bone pain or 2 years underweight (1 year if <18 year) ECG: bradycardia or prolonged QT interval

Answer 57

BMI <17.5 Weight <85% of predicted for <18 years (considering height, sex, ethnicity) Body mass distortion Fear of gaining weight even when lightweight, leading to starvation, vomit-induction, laxative, direct misuse and over exercise Amenorrhea (absence of 6 consecutive periods unless on pill) or decreased libido in males

Answer 58

Any red flags: urgent/immediate referral to mental health or eating disorder service. Very low weight: hospitalisation Review medications Medical and nutritional therapy aiming to restore weight gain 1.5kg/wk back to BMI of 20-25 Treat complications of starvation Explore comorbidities Psychotherapy, CBT, IPT, family therapy for 6 months if outpatient Involve family/support network Address and identify main issues causing illness to persist (self esteem, social pressures etc)

Answer 59

``` Osteoporosis (severe long term) Dry scaly skin, hair loss Atrophy and encephalopathy of brain Cardiac arrhythmias Refeeding syndrome ``` Prognosis: 43% recover completely 36% cases improve 20% remain with chronic eating disorder for life 5% die within 11 years due to suicide or medical complications (hypokalaemia, prolonged QT, arrhythmias) Mortality risk is increased if age 20-29 at presentation, binge/purge type or delayed access to treatment

Answer 60

BMI <13 or <2nd centile in <18 years (13-15 moderate risk) Weight loss >0.5kg/wk Core temp <35 (hypothermic) Hypotensive HR <40 Low O2 saturation Unable to perform sit up or squat test Bloods: Potassium <2.5, Na <130, PO4 <0.5 ECG: long QT and flat T waves (hypocalcaemia and hypokalaemia) Purpura skin (decreased platelet)

Answer 61

Can be fatal Rare during home refeeding Rapid intake of calories after long starvation period Show a number of electrolyte imbalances: Hypokalaemia, hypomagnesemia, decreased PO4 and B1, hyperglycaemia + water and salt retention Can lead to rhabdomyolysis, respiratory failure, cardiac failure, hypotension, arrhythmias, seizure, coma and sudden death Prevention: Refeeding started at no more than 50% energy requirements in pts who have eaten little to nothing for >5 days with rate increasing if no refeeding problems are detected on intense clinical and biochemical monitoring Pts with BMI <14 with little/no food intake for >2 wks should be started at max 0.021MJ/kg/24 hrs with cardiac monitoring (arrhythmia risk)

Answer 62

F:M ratio 9:1 Mostly young women Chronic mental health issue of uncontrolled overeating and fear of becoming overweight causing induced vomiting to cope with overeating BMI and weight is normal: much easier to hide than anorexia Can develop anorexia via long term bulimia

Answer 63

In UK; young muslim asian women most at risk Homosexuality or bisexuality in males Urbanisation Premorbid obesity Common in relatives with anrectics Other mental health issues such as OCD, anxiety

Answer 64

Onset usually around 18 years Binge eats large amount of food, then feels guilt, remorse or anxiety and is highly preoccupied with body weight or shape Purge follows binge eating Often low self esteem and feeling of loss of control/wishes to regain control of food or weight Excessive exercise Fatigue, lethargy Bloating, abdominal pain, constipation Mallory Weiss syndrome causing Hemotemesis and abdominal pains from tears in gastric lining Oesophagitis, gastric abnormalities Arrhythmias; tachycardia; hypotension Cardiomyopathy Tetany Oedema (feet and hands) from laxative and diuretic misuse Menstruation disturbances or amenorrhea Erosion of dental enamel (from acidic vomit) Enlarged parotid glands Russell’s sign: calluses on backs of hands from tooth marks during vomit induction) Metabolic alkalosis Decreased CL and K, Mg, PO4, Na (K leading to muscle weakness and arrhythmias) Metabolic acidosis (if laxative use)

Answer 65

BMI >17.5 Preoccupation with control of body weight Recurrent episodes of binge eating (uncontrolled overeating) Regular starvation, vomit-induction, laxatives and over exercise to overcome binges Abuse of medications like laxative, diuretics, thyroxine, amphetamines

Answer 66

Mild: support, self help, CBT, food diary, SSRIs Nor response or mod/severe symptoms: referral to CMHT or EDU and fluoxetine or other antidepressants alongside therapies (CBT for 16-20 sessions or 4-5 months; IPT for 8-12 months) Medical unit admission for complications or risk of self harm Complications: Diabetes: worsens starvation state further

Answer 67

Relatively new diagnosis Shares many symptoms of bulimia nervosa but without compensational behaviours of starvation, purging, laxative or overexercise

Answer 68

Repeated episodes of binge eating (once/wk for 3 months, large amount rapidly eaten uncontrollably) Associated with: rapid eating, eating when not hungry, eating alone (hides), feels guilt or disgust after eating, feels distressed No compensation behaviours shown after eating

Answer 69

Therapies, self help groups or books CBT, IPT, dialectical behavioural therapy SSRI or other antidepressants

Answer 70

Intense fear triggered by stimulus or group of stimuli that are predictable and of no concern to others Knows the fear is irrational but cannot control behaviour Often leads to avoidance behaviour Fears can be considered phobias when anxiety suffered is intense enough to handicap the individual in their everyday life Similar to a panic attack (but with attack there is no stimulus present) Many patients have more than 1 phobia Definition of phobia: Fear out of proportion to objective risks Cannot be reasoned or explained away Beyond voluntary control Leads to avoidance of feared situation Presence of anticipatory anxiety

Answer 71

Arachnophobia: The fear of spiders. This phobia tends to affect women more than men. Ophidiophobia: The fear of snakes. Acrophobia: The fear of heights. Agoraphobia: The fear of situations in which escape is difficult. This may include crowded areas, open spaces, or situations that are likely to trigger a panic attack. People will begin avoiding these trigger events, sometimes to the point that they cease leaving their home. Approximately one third of people with panic disorder develop agoraphobia. Cynophobia: The fear of dogs. This phobia is often associated with specific personal experiences, such as being bitten by a dog during childhood. Astraphobia: The fear of thunder and lightning. Trypanophobia: The fear of injections. Like many phobias, this fear often goes untreated because people avoid the triggering object and situation. Social Phobias: The fear of social situations. In many cases, these phobias can become so severe that people avoid events, places, and people that are likely to trigger an anxiety attack. Pteromerhanophobia: The fear of flying. Often treated using exposure therapy, in which the client is gradually and progressively introduced to flying. [Denis Bergcamp] Mysophobia: The fear of germs or dirt. May be related to obsessive-compulsive disorder.

Answer 72

Inappropriate anxiety when confronted with particular object, situation or person (spiders, flying, dentists) Strong desire to avoid the stimulus Prospect of experiencing stimulus provokes anticipatory anxiety Prevalence around 7% Most common being arachnophobia, particularly in women Other phobias: insects, moths, bats, dogs, snakes, heights, thunderstorms, the dark, burglars Children often show simple phobias that are grown out of with age

Answer 73

2% prevalence Fear of being scrutinised, ridiculed or humiliated by others Worry consumes individual before, at the time and after social event Leads to avoidance of social situations: crowds, strangers, parties, meetings, public speaking In generalised social phobia pt will avoid contact with all people outside family circle Other social phobias can be more focussed: public speaking, eating in public, using public toilets

Answer 74

Most common phobia Fear of being away from home, avoidance of travelling, walking down roads and supermarkets etc Usually multiple fears eg travelling, cowds, closed and open spaces, shops etc with consequent restriction of activities Associated symptoms of dizziness, depersonalisation, panic attacks and depression are common Symptoms fluctuate throughout Can be very disabling condition since pt avoids leaving the house particularly by themselves Often associated with claustrophobia

Answer 75

``` Dry mouth, difficulty swallowing Epigastric discomfort, aerophagia (swallowing air) Diarrhoea Chest constriction, SOB Hyperventilation Choking Palpitations, chest pain Fear, irritability, loss of concentration Increased urination frequency Decreased libido Erectile dysfunction Fatigue Blurred vision, dizziness Sensitivity to noise or light Sleep disturbance, restlessness, headache, trembling ```

Answer 76

Psychological treatments: relaxation techniques, anxiety management training, biofeedback (showing pts they are not relaxed) Behavioural therapies like graded or systematic desensitisation exposure are most common and most successful (80% success with some phobias) Medications: advise pt to gradually cease taking recreational drugs including caffeine and alcohol Benzodiazepines (diazepam 5mg twice weekly) Most SSRIs Antipsychotics for more severe cases Beta blockers (propranolol 20-40mg 2-3 x daily) to reduce symptoms

Answer 77

Risk of self harm or suicide Significant comorbidity (substance misuse, personality disorder or complex physical health problems) Self neglect

Answer 78

Lifetime prevalence 5% Overwhelming anxiety accompanied by physical symptoms (hyperventilation and SNS activation; restless, tremor, sweating etc) Defined as discrete episode of intense subjective fear where at least 4 of characteristic symptoms arise rapidly and peak within 10 mins of onset Symptoms must not arise as result of alcohol or substance misuse, medical conditions or other psychiatric disorder (must be otherwise healthy)

Answer 79

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 Numbness or tingling sensations. Chills or hot flushes Derealisation or Depersonalisation (feeling detached from oneself). Fear of losing control or 'going crazy'. Fear of dying.

Answer 80

Diagnosed when pt has multiple sudden panic attacks Must occur regularly without obvious precipitant and in absence of other psychiatric illness First attack may be associated with stressful episode but gradually attacks become disassociated and occur out of the blue Condition coexists with agoraphobia often

Answer 81

Panic attacks must be associated with: >1 month duration of subsequent and persisting anxiety about recurrence of attack and consequences of attack Or significant behavioural changes associated with attacks A fundamental characteristic of panic disorder is the presence of recurring, unforeseen panic attacks followed by at least 1 month of persistent worry about having another panic attack and concern about the consequences of a panic attack, or a significant change in behaviour related to the attacks. At least 2 unexpected panic attacks are necessary for diagnosis. Attacks should not be accounted for by the use of a substance, a general medical condition or another psychological problem.

Answer 82

Provocation test: voluntary hyperventilation for >1 minutes provokes similar symptoms and rebreathing from large paper bag relieves symptoms

Answer 83

Pt education and reassurance Relaxation techniques and slow controlled breathing Breath into paper bag to help relieve episodes Referral to specialist mental health services Psychiatric interventions (CBT, IPT, antidepressants - SSRIs and TCA) Avoid benzodiazepines: associated with less good outcome in long term Do not prescribe sedating antihistamines or antipsychotics!

Answer 84

Traumatic event (usually major threat to physical, emotional or psychological safety of themselves, loved ones etc) causing the person to develop PTSD as a result of overwhelmed coping and defence mechanisms Can be experienced directly, witnessed in person, learning of traumatic events occurring to someone close, or experiencing repeated or extreme exposure to details of traumatic events (common in first responders, emergency personnel, police) 25-30% people experiencing a traumatic event develop PTSD Thought to result from the HPA axis and noradrenaline is main transmitter involved Reconsolidation (the way the brain reconstructs memories and associated emotional responses) appears to be important in PTSD

Answer 85

Re-experiencing Vivid, distressing memories of the event or flashbacks, known as intrusive symptoms. (most common) PTSD cases often have nightmares related to the trauma that affect their sleep. 2.Avoidance or Rumination Avoidance of trauma-related reminders or general social contact. People with PTSD often try to push memories of the event out of their mind and avoid thinking or talking about it in detail. They may also reflect excessively on questions that prevent them from coming to terms with the event - for example, why it happened to them, how it could have been prevented, or how they could take revenge. 3.Hyperarousal or Emotional numbing Alterations in arousal and reactivity: irritable behaviour and angry outbursts - reckless or self destructive behaviour – hypervigilance - exaggerated startle response - problems with concentration etc

Answer 86

Often develop immediately following event But in 15% cases onset is delayed May not present for months, years despite experiencing considerable distress Comorbidities often common with prolonged PTSD suffering (depression, anxiety, substance abuse)

Answer 87

Comprehensive assessment including physical, psychological and social needs and self risk assessment If PTSD and depression suspected: treat PTSD first as depression will often improve following this Management: Treatable even for those presenting years later Multidimensional approach Psychological therapies: trauma focused CBT (TF-CBT), eye movement and reprocessing (EMDR) and stress management Education and supportive measures (emotional hygiene; positive thoughts, self appreciation, less rumination on bad thoughts) Medications: paroxetine, mirtazapine, clonidine

Answer 88

Less common than schizophrenia Controversy around diagnosis as condition may represent form of schizophrenia in which mood symptoms are unusually prominent or could represent co-existence of schizophrenia with an affective mood disorder e.g. bipolar or major depression Types: Bipolar type: manic or mixed episodes occur Depressive type: mainly experience depressive episodes

Answer 89

Delusions or hallucinations must be present for at least 2 wks when mood symptoms are not present Symptoms of mood disturbance present for significant lengths of illness Disturbance is not due to other causes e.g. organic illness, substance misuse, medications

Answer 90

``` Major depressive episode: Low mood Decreased pleasure Weight change or appetite change Sleep disturbance (insomnia or hypersomnia) Psychomotor agitation or retardation Fatigue Decreased concentration Recurrent suicidal thought Manic episode: Inflated self esteem or grandiosity Reduced sleep Pressure of speech Flight of ideas and racing thought Easily distracted Increase in goal directed activities with psychomotor agitation Excessive involvement in high risk activities Mixed episode: Features of both but only for one week Schizophrenia symptoms: Delusions (if bizarre, no other symptoms needed for diagnosis) Hallucinations (if in form of running commentary or two voices no other symptoms needed to diagnose) Speech abnormalities Behavioural abnormalities Negative symptoms (apathy or lack of emotion) ```

Answer 91

``` Baseline bloods: FBC, eGFR, LFTs, TFTs, HIV screening Urine or plasma toxicology CXR exclude pneumonia in elderly CT/MRI scans if indicated Assess threat to themselves and others ```

Answer 92

If threat: hospital admission Acute exacerbation treatment: antipsychotics Long term: antipsychotics as well as psychological therapies and treatments Trial of antidepressants for ongoing depressive symptoms (SSRIs) Mood stabilisers such as lithium may be useful in bipolar type.

Answer 93

``` Complications: Poor social integration Difficulty forming relationships Substance misuse Suicidal behaviour Homicidal thought ``` Prognosis: Bipolar type has better prognosis than depressive type Later usually results in long term mood disturbance

Answer 94

Psychotic disorder characterised by delusions but can often continue normal function/do not tend to behave out of the ordinary Rather rare condition More common in women Most often occurs in mid-late life

Answer 95

Erotomaniac: believes someone is in love with them and may try to contact the person. Can lead to stalking behaviours, ofen is a famous person. Grandiose: over-inflated sense of self worth, power, knowledge or identity. Could believe that they have great talent or made an important discovery Jealous: believes spouse or partner is unfaithful. Becomes highly paranoid Persecutory: believe they or someone close to them are being mistreated, being spied on or planning to harm them. May take repeated complaints to legal authorities Somatic: believe they have a physical defect or medical problem (hypochondriac) Mixed: people presenting with two or more of the delusion types above

Answer 96

Symptoms: Non-bizarre delusions Irritable, angry, low mood Hallucinations Diagnosis: One or more delusions lasting >1 month Person not diagnosed with schizophrenia Hallucinations related to themes of delusions Aside from delusion, daily life and functioning is not impaired significantly Any manic or depressive episodes that they may experience have been present last 1> wk No other psychotic disorders, medications or medical conditions causing these symptoms Management: Psychotherapy and antipsychotics

Answer 97

Form of paranoid delusion with amorous quality Often single women believes exalted person is in love with her Condition described as having phase of hope followed by phase of resentment Victim of delusion is usually older and of higher status, likely only knows them via brief acquaintance Usually little to no contact or reason to believe this delusion Onset usually middle to late adulthood and course is variable Delusional disorders have 3:1 female:male ratio Subjects are often isolated, unemployed with few social contacts

Answer 98

At least >1 month duration of delusion, exclusion of schizophrenia, mood disorder, substance induced toxicity or medical disease Typically pt unaware of condition Believe lover is more in love with them than they are with them, takes pride in this, may feel subject cannot live happily without them Pt may believe that subject of delusion cannot make their feelings known for various reasons Stalking or potentially threatening behaviours directed toward the individual Letters, messages etc May be violent against those they believe stand in the way of delusional love

Answer 99

Investigations: Thorough psychiatric investigations essential for diagnosis Rule out substance abuse Associated disease: Erotomania Occasionally associated with other delusions of grandiose, jealous or somatic Epilepsy or frontal lobe lesions Management: Manage any secondary associated disorder Successful management is difficult: psychotherapies and antipsychotics Pimozide, risperidone and ECT if severe may have varying degrees of success

Answer 100

Alcohol Drugs Tobacco Key points: Higher incidences in areas of social deprivation UK has one of the highest morbidity and mortality rates Heroin most common main problem drug in adults, cannabis and alcohol main problem drugs under age 18 Drug misusers may have multiple social and medical problems (increasing mortality) Drug misusers are at high risk of: hep C, HIV and hep B

Answer 101

Good initial assessment is essential: via MDT, try to engage pt in their own care Gain confirmation of drug history Examine patient for needle marks or signs of withdrawals Urine analysis for drugs testing Bloods: Hep B, C, HIV screening Assess risks to children, risk to themselves or to others Full physical health checks Refer for full psychiatric health checks

Answer 102

Needs assessed in terms of health, social functioning and criminal involvement Draw up individual healthcare plan and review regularly Named person should manage and deliver individuals care (key worker) If detoxification or substitute prescribing needed refer to local specialist community drug services and ensure care plan is shared between facilities Regular drug testing to monitor compliance and treatment outcome Therapies: IPT, CBT high intensity, counselling and supportive care (AA groups etc) If cannabis, hallucinogen and stimulant abuse (including cocaine) then psychological interventions are the main treatment For opioid, alcohol and polydrug misuse psychological interventions can be used in conjunction with drug treatment Medical interventions: Methadone and buprenorphine are both effective as maintenance treatment (recommended NICE) Oral methadone maintenance associated with reduction of drug related behaviours with high risk HIV transmission but less effect on reduced sexual risk taking Combined buprenorphine and naloxone (Suboxone) doesn’t interfere with therapeutic effect of buprenorphine Before prescribing: need to see evidence that patients are drug dependent and motivated to change. Do not prescribe too rapid increase in dose (overdose) Consider Vaccinating against hep A, B, C and HIV, TB and tetanus

Answer 103

``` Physical symptoms caused by psychological or emotional factors. Relationships are complex and not fully understood; however when we somatize somehow mental or emotional problems are expressed partly or mainly as one or more physical symptoms. These symptoms are not imagined Common phenomenon For example, headaches caused by stress Other symptoms include: Chest pains Fatigue Dizziness Back pain Nausea Diarrhoea ```

Answer 104

Somatoform disorders arise at the extreme ends of the scale of somatisation. Physical symptoms persist long term or are severe but no physical disease can fully explain the symptoms Relatively rare, hypochondriasis and body dysmorphic disorder are slightly more common Thought to have some genetic as well as social and environmental factors which all contribute Common in people who abuse drugs and alcohol so these may also both cause and contribute to the disorders themselves as well as sufferers are more likely to misuse substances Types: Hypochondriasis Conversion disorder Pain disorder Body dysmorphic disorder Somatoform disorder not otherwise specified

Answer 105

``` Headaches Nausea Abdominal pains Bowel problems Menstruation issues Fatigue Sexual issues Tend to be emotional about their symptoms, described as ‘terrible and unbearable’ etc. ```

Answer 106

Fearing minor symptoms may be due to serious disease Eg minor headache may be caused by brain tumour or mild rash is sign of skin cancer Even normal bodily functions such as stomach noises may be thought of as illnesses People with disorder have many fears and spend a lot of time thinking about their symptoms This disorder is similar to somatisation disorder but the difference being hypochondirasis pts may accept the symptoms are minor but believe or fear they’re caused by serious disease. Doctoral reassurance usually does not help as they often fear they just haven’t found the diagnosis

Answer 107

Condition where person has symptoms suggesting serious disease of brain or nerves e.g. loss of vision, deafness, weakness, paralysis or numbness of arms or legs Symptoms usually develop quickly in response to stress Unconsciously convert stress into physical symptom Tends to occur between ages 18-30 years Symptoms often last no longer than few weeks but persist long term in some people Many cases there is only ever one episode and no treatments are needed once resolved Some people experience repeated episodes from time to time

Answer 108

Body dysmorphic disorder: Person spends a lot of time worrying about their appearance Pain disorder: Condition where person has persistent pain that cannot be attributed to a physical disorder

Answer 109

Very difficult as they often do not accept their symptoms are psychologically caused Treat and screen for any other mental health disorders which may or may not be present CBT therapy and other psychiatric interventions may help pt to understand their symptoms and develop appropriate coping mechanisms to prevent these effects Medications for underlying anxiety or depression if present and needed but not often related to these disorders

Answer 110

Alcohol abuse: consumption of alcohol at a level sufficient to cause physical, psychiatric and/or social harm Binge drinking: drinking over twice the recommended level of alcohol per day (>8 units male />6 units females Harmful alcohol use: drinking above safe levels with evidence of alcohol-related problems (>50 units/wk males and >35 females) Recommended unit intake per wk for both sexes is 14 units/wk Social learning theory suggests that drinking behaviour is modelled on imitation of relatives or friends. Operant condition states positive or negative reinforcements from effects of drinking will either perpetuate or deter drinking habits Males have increased risk of alcohol abuse and increased metabolism of alcohol allowing consumption of higher quantities Younger adults are more prone to alcohol abuse Higher risk of dependency with relatives also affected Premorbid antisocial behaviour has been found to predict alcoholism Risk of alcoholism decreases in those who show facial flushing with alcohol as this indicates they metabolise more slowly so less likely (more common in east asian populations)

Answer 111

Affects neurotransmitter GABA systems causing anxiolytic and sedative effects Pleasure effects from mediation via dopaminergic pathway Repeated excessive alcohol ingestion sensitises this pathways leading to development of dependence on alcohol Long-term exposure can cause adaptive changes in neurotransmitters (dow regulation of inhibitory neuronal GABA, up regulation of excitatory glutamate receptors causing hyperexcitability when alcohol is withdrawn) Pt with alcohol use disorders often experience craving linked to dopaminergic, serotonergic and opioid systems that mediate positive reinforcement and to GABA, glutamatergic and noradrenergic systems that mediate withdrawal

Answer 112

Alcohol intoxication: Characterised by slurred speech, labile affect, impaired judgment and poor coordination In severe cases there may be hypoglycaemia, stupor and coma Alcohol dependence: SAW DRINk Subjective awareness of compulsion to drink Avoidance or relief of withdrawal symptoms by further drinking (AKA relief drinking) Withdrawal symptoms Drink-seeking behaviour predominates Reinstatement of drinking after attempted abstinence Increased tolerance to alcohol Narrowing of drinking repertoire (ie stereotyped pattern of drinking - individuals have fixed as opposed to variable times for drinking, with reduced influence from environmental cues) ``` Withdrawal: Malaise Tremor Nausea Transient hallucinations Autonomic hyperactivity Occur at 6-12 hrs after abstinence Peak incidence of seizures at 36 hrs Severe end of spectrum of withdrawal is also termed delirium tremens and the peak incidence is at 72 hrs ```

Answer 113

Hepatic: fatty liver, hepatitis, cirrhosis, hepatocellular carcinoma GIT: peptic ulcer disease, esophageal varices, pancreatitis, esophageal carcinoma Cardiovascular: HTN, cardiomyopathy, arrhythmias Haematological: anaemia, thrombocytopenia Neurological: seizures, peripheral neuropathy, cerebellar degeneration, Wernick’s encephalopathy, Korsakoff’s psychosis, head injury (secondary to falls) Obstetrics: fetal alcohol syndrome Psychiatric: morbid jealousy, mood disorders, self harm and suicide, anxiety disorders, alcohol-related dementia, hallucinations, delirium tremens Social: domestic violence, drink driving, employment difficulties, homlessness, accidents, relationship problems

Answer 114

ICD-10 for intoxication: clear evidence of psychoactive substance at high dose, disturbed consciousness, cognition, perception or behaviour. Not accounted for by medical or mental disorder. Also evidence of disinhibition, argumentativeness, aggression, labile mood, impaired attention, interference with personal functioning and one of following signs: unsteady gait, difficulty standing, slurred speech, nystagmus, flushing, decreased consciousness, conjunctival injection ICD-10 for alcohol withdrawal: clear evidence of recent cessation or reduction of substance after prolonged or high level use, not accounted for by medical or mental health issues. Any three of the following: tremor, sweating, nausea/vomiting, tachycardia, increased BP, headache, psychomotor agitation, insomnia, malaise, transient hallucinations, grand mal convulsions

Answer 115

Withdrawal delirium develops between 24hr to1 wk after alcohol cessation Peak incidence within 72 hrs Physical illness is predisposing factor Dehydration and electrolyte disturbances are feature Characterised by: cognitive impairment, vivid perceptual abnormalities (psychosis features), paranoid delusions, marked tremor, autonomic arousal (tachycardia, fever, pupil dilation, sweating) Medical treatment can be with large doses of benzodiazepines, haloperidol for psychotic features and IV pabrinex.

Answer 116

History taking CAGE: C: have you ever felt you should Cut down drinking? A: Have people Annoyed you by criticizing or commenting on your drinking? G: have you ever felt Guilty about drinking? E: Do you ever have a drink Early in the morning to steady your nerves or wake yourself up? Establish drinking pattern and quantity consumed: How much in a typical day When do you drink most/least How much money do you spend on drinking Do you drink steadily or binge? Do you often feel the urge to drink? Have you noticed you need to drink more to feel the effects? Do you ever feel shaky when you are sober? Family history of alcohol related problems? Has it affected your mental or medical health? Has it caused any social problems (work, relationships, law) Units of alcohol = [strength (alcohol by volume) x volume (ml)] / 1000 One unit = ½ pint or bottle of beer (500ml), one small glass of wine, single measure of spirits etc. ``` Bloods: FBC, U+Es, LFTs, alcohol conc, MCV, Vit B, folate, TFTs, amylase (pancreatitis), hepatitis serology, glucose Alcohol questionnaires AUDIT SADQ FAST screening tool CT head (injury suspected) ECG: arrhythmias ```

Answer 117

Patient must inform DVLA of alcohol dependence or any misuse Short term: High dose benzodiazepines (chlordiazepoxide) given initially and dose is tapered over 5-9 days Thiamine (Vit B) also given to prevent Wernike’s encephalopathy (orally 200-300mg in daily divided doses or IV in form of pabrinex) Long term: Disulfiram: causes unpleasant symptoms by allowing byproduct build up from alcohol consumption (flushing, anxiety, headaches) Acamprosate: reduced craving by enhancing GABA transmission Naltrexona: blocks opioid receptors reducing pleasure effect Motivational interviewing CBT

Answer 118

Acute encephalopathy due to thiamine deficiency Presents with delirium, nystagmus, ophthalmoplegia, hypothermia and ataxia Needs urgent treatment with parenteral thiamine May progress to Korsakoff’s psychosis

Answer 119

Profound and irreversible short-term memory loss with confabulation (filling in gaps in memory with imaginary events) and disorientation to time

Answer 120

``` Exmaples: Cocaine Crack cocaine Ecstasy (MDMA) Amphetamine ``` Effects: Euphoria, increased energy, grandiose beliefs, aggression, illusions, hallucinations, intact orientation, paranoia, labile mood Increased HR and BP, arrhythmias, nausea and vomiting, pupillary dilatation, psychomotor agitation, muscular weakness, chest pain, convulsions Dysphoric mood (must be present), lethargy, psychomotor agitation, craving, increased appetite, insomnia or hypersomnia, bizarre or unpleasant dreams Management: Cocaine and amphetamines: benzodiazepines (lorazepam) for seizure, high BP or extreme agitation Cocaine: Needs extreme caution and monitoring with rehabilitation as tend to become very depressed/suicidal Amphetamines: can also give labetalol for high BP

Answer 121

Examples: LSD Magic mushrooms Effects: Anxiety, hallucinations, illusions, depersonalisation, derealisation, paranoia, ideas of reference (destiny), hyperactivity, impulsivity and inattention Increased HR, palpitations, sweating, tremors, blurred vision, pupillary dilatation, incoordination No withdrawal symptoms Management: Calming environment Antianxiety drugs: benzodiazepines Psychiatric care if needed

Answer 122

``` Examples: Aerosols Paint Glue Petrol ``` Effects: Apathy, lethargy, aggression, impaired attention and judgement, psychomotor retardation, Unsteady gait, diplopia, nystagmus, decreased consciousness, muscle weakness No withdrawal symptoms Management: Treat damaged organs Drug counselling

Answer 123

Examples: Testosterone Androstenedione Danazol Effects: Euphoria, depression, aggression, hyperactivity, mood swings, hallucinations, delusions Increased muscle mass, reduced fat, acne, male pattern baldness, reduced sperm count/infertility, stunted growth No withdrawal symptoms Management: Main treatment is cessation of use - no physical dependence occurs but psychological dependence may need CBT etc Gynecomastia may need surgery

Answer 124

``` Examples: Morphine Diamorphine (heroin) Codeine Methadone ``` Effects: Apathy, disinhibition, psychomotor retardation, impaired judgement, drowsiness, slurred speech Respiratory depression, hypoxia, decreased BP, hypothermia, coma, papillary constriction Withdrawals: Craving, rhinorrhoea, lacrimation, myalgia, abdominal cramps, Nausea and vomiting, diarrhoea, pupillary dilatation, piloerection, increased HR and BP Management: 1st line: methadone or buprenorphine for detox and maintenance therapies Naltrexone for ex-dependencies who wish to stay abstinent IV naloxone used as antidote in overdose

Answer 125

Examples: Cannabis Effects: Euphoria, disinhibition, agitation, paranoia, temporal slowing, impaired judgement, attention/reaction time slows, hallucinations Increased appetite, dry mouth, conjunctival injection, increased HR Withdrawals: Anxiety, irritability, tremor of outstretched hands, sweating, myalgia ``` Management: IV sedatives (benzodiazepines) IV fluids for hypotension Treat hyperthermia Beta blockers for HR ```

Answer 126

Examples: Benzodiazepines Barbiturates Effects: Euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood Unsteady gait, difficulty standing, slurred speech, nystagmus, erythematous skin lesions, decreased BP, hypothermia, depression of gag reflex, coma Withdrawals: Tremor of hands, tongue or eyelids, nausea and vomiting, postural hypotension, decreased BP, increased HR, agitation, malaise, transient illusions/hallucinations, paranoia, grand mal convulsions Management: Overdose antidotes: Flumazenil injection Breathing assistance if needed Social and psychological support for rehabilitation

Answer 127

Smoking increases risk of cardiac disease, lung disease, cancers and many other health problems Nicotine is addictive substance present in tobacco Remains leading cause of preventable disease and death globally 2 out of 3 long term smokers will die prematurely of disorders caused by smoking Immediate nicotine effects: Activates pleasure centre in brain Increases energy, concentration Decreases appetite Once addicted, will cause relaxation feeling from relieving nicotine withdrawal Overdosing: nausea, vomiting, diarhoea, sweating and weakness (green tobacco sickness)

Answer 128

``` Coronary artery disease Lung cancers COPD Stroke Bladder, cervical, colorectal, esophageal, kidney, liver, pancreatic, throat and stomach cancers pneumonia , asthma Osteoporosis Periodontitis (gum disease) Peptic ulcer disease Cataracts Erectile dysfunction and fertility problems Long term effects of E-cigarettes and vaping are currently unknown ```

Answer 129

Smoking cessation clinics: talk about the cost of smoking, reasons to quit healthwise, social wise (increase activity and longevity or seeing family etc) Treatment of symptoms of withdrawal via nicotine patches, routine hygiene (change routine to avoid smoking triggers eg coffee in the morning if they always smoke after having a coffee, have no smoking around them, engage in rewarding activities smoke free to encourage good feelings) Withdrawal symptoms: nausea, irritability, lack of concentration, restlessness, tremor, sweating, dizziness, headaches, abdominal pains, disrupted sleep (tend to be most intense within first 2-3 days then subside within 2-4 weeks) Pts quitting may gain weight, food will taste and smell better, exercise helps prevent weight gain and may reduce nicotine cravings Drinking water recommended along with other strategies for oral cravings: toothpicks, chewing on straw or carrot sticks etc or nicotine gum to help delay weight gain Temporary cough may develop as lungs begin to heal themselves Nicotine replacement therapy: Variety of formulations: patch, gum, lozenge, inhaler, nasal spray All provide nicotine to brain without cigarette quick hit feeling Speed of drug reaching the brain increases addictive potential therefore very unlikely to become addicted to replacement therapies Cautions: jaw disorders cannot chew gum, skin sensitivity should not use patch, may be harmful in pregnancy, those with recent MI or blood vessel disorders should discuss with dr before going on one of these products Bupropion or nortriptyline: antidepressant helps with smoking cessation if used in combo with nicotine replacement. Varenicline: lessens cravings and withdrawal symptoms works by blocking nicotinic receptors and stopping nicotine attaching to receptors so they find it less rewarding

Answer 130

When personality traits become so pronounced, rigid and maladaptive that it affects their life (social, educational etc) Usually involving several areas of personality and nearly always associated with considerable personal and social disruption Enduring pattern of inner experience and behaviour that differ markedly from the expectations of individuals culture Those with personality disorders have a limited range of feelings, attitudes and behaviours with which to cope with stresses of everyday life More common for people with PD offend against the law and commonly associated with other mental health disorders (depression, anxiety, substance misuse) ``` Schizoid Schizotypal Borderline Histrionic Narcissistic Avoidant ```

Answer 131

Remains unknown Believed to be mostly environmental factors preventing evolution of adaptive patterns of perception, response and defence Heritability ranges from 30-60% Family and early childhood experiences play important role ``` Risk factors: Sexual abuse Psychical abuse Emotional abuse Neglect Being bullied ```

Answer 132

ICD-10 and DSM-V diagnosis Cluster A: odd - Schizoid - Schizotypal - Paranoid Cluster B: dramatic - Borderline (emotionally unstable) - Histrionic - Narcissistic Cluster C: Anxious - Avoidant - Dependent - Obsessive compulsive

Answer 133

Display pervasive distrust and suspicion Common beliefs that others are exploiting or deceiving them, friends/others are untrustworthy, information will be used maliciously, hidden meaning in remarks or events, spouse or partner is unfaithful. Pathological jealousy is sometimes called Othello syndrome. Reacts severely if they feel they've been lied to

Answer 134

Rare but more common in homeless population Characterised by withdrawal from affectional, social and other contacts Isolated and limited capacity to experience pleasure and express feelings Little to no social involvement Tend to be solitary and have no sense of humour, felt to be dull Cold and aloof, tend to miss social cues introspective, misanthropic Pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings, beginning by early adulthood Frequently seen as onset prior to schizophrenia

Answer 135

Feel extreme discomfort maintaining close relationships with people and avoid forming them Mainly think peers harbour negative thought towards them Peculiar speech mannerisms and odd modes of dress often also present May react oddly in conversations, may not respond or talk to themselves Frequently interpret situations as strange or having unusually meaning to them Paranormal and superstitious beliefs are common DSM-5 definition: pattern of social and interpersonal deficits marked by: acute discomfort with and reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities of behaviour beginning early in adulthood. Characterised by severe social anxiety thought disorder, paranoid ideation, derealisation, transient psychosis and often unconventional beliefs Unlike schizophrenia: they are able and willing to consider facts contradicting their strange ideals or beliefs (not typically full fledged delusions) also don’t tend to experience hallucinations like schizophrenia. These pt often will not progress to schizophrenia also No medications for this specific disorder. May be prescribed SSRIs for underlying depression or antipsychotics for any psychotic episodes they may experience. Treatment mostly therapy (CBT, IPT etc)

Answer 136

Similarity being inability to initiate or maintain relationships both friendly and romantic Notable difference: schizotypal avoid social interaction because of deep seated fear of people Schizoid simply feel no desire to form relationships because they see no point

Answer 137

``` Antisocial behaviours Lacks guilt and empathy Recklessness and impulsivity Commonly have inflictions with law Disregard for moral and societal values Willing to hurt others if it benefits them No remorse Aggressive and impulsive ```

Answer 138

(emotionally unstable): Tend to be impulsive and unpredictable May act without appreciating consequences Outbursts of emotion and quarrelsome behavior may be exhibited Relationships tend to be unstable and may be suicidal gestures and attempts Tend to form intense relationships and rapid fluctuations in mood with impulsivity Chronic feelings of emptiness Unstable self image, relationships and mood Possible transient psychotic symptoms Splitting tendency: absolute bad and absolute good Stable instability: extreme joy and extreme rage Unstable relationships: fall in love fast then start a war SSRIs can be used for impulsive behaviours Follow up pt and call if not keeping in contact IPT, CBT and therapies

Answer 139

Characterised by shallow and labile affectivity and theatricality Lack of consideration for others and a tendency for egocentricity Crave excitement and attention Self centred, sexually provocative (but frigid) person who enjoys (but does not feel) angry scenes surface/appearance is everything: exhiitionist behaviour Attention seeking Being easily influenced by others especially those who treat them approvingly Lots of relationships but all are shallow

Answer 140

``` Grandiose ideas and self beliefs Self centred Lack of empathy Exploit others for their own sake Very vulnerable to criticism and will have extreme reaction to any given to them (image in superficial and fragile) Unlikely to understand others ```

Answer 141

Characterised by feelings of tension and apprehension, insecurity and inferiority Yearn to be liked and accepted, sensitive to rejection Tendency to exaggerate potential dangers and risks leading to avoidance of everyday activities Willing to form relationships but: shy, timid, low self esteem, hypersensitive to rejection so avoid any social risks

Answer 142

Characterised by reliance on others to take decisions and a fear of abandonments Excessive reliance on authority figures and difficulty in acting independently Can affect capacity to deal with intellectual and emotional demands of daily life Formal diagnostic criteria: crippling indecision, loathes responsibility and avoids at all cost, can't disagree absence of self confidence, suffers for others, loathes being alone, requires close relationships and is constantly preoccupied with fear of being alone. Therapies needed to build confidence and to build independence Higher risk in dominating authoritarian or overprotective parenting Crucial loved ones pla part in recovery forming safe relationships

Answer 143

DSM-V diagnostic criteria: An enduring pattern of inner experience and behaviour that deviated markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: Cognition, Affectivity, Interpersonal Functioning, Impulse Control The enduring pattern is inflexible and pervasive across a broad range of personal and social situations The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma).

Answer 144

Referral Borderline and antisocial are two exceptions in management Immediate suicide risk assessment Mental state examination Follow up regularly to assess state Intensive psychological therapies (CBT, IPT, STEPPS program for borderline) Medications: SSRIs for impulsive behaviours, low dose antipsychotics for paranoia, mood stabilisers for emotional instability

Answer 145

I’M A SAD PERSON: ``` Institutionalised Mental health disorders Alone (lack of social support) Sex (male) Age (middle aged) Depression Previous suicidal attempts Ethanol use Rational thinking lost Sickness Occupation No job ``` ``` Note: planned attempts are very frightening: Note left behind Planning suicide attempt Attempt to avoid discovery Afterwards help not sought Violent method used Final acts: sorting finance, will etc. ```

Psychology diagnosis+management Flashcards

(169 cards)