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Selected Notes psych Flashcards

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1
Q

What is an illusion

A

Misenterpretation of an external stimulus

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2
Q

What is a hallucination

A

Perception without an external stimulus

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3
Q

What is a pseudo-hallucination?

A

Hallucination where the patient is aware it’s not real

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4
Q

What is an overvalued idea?

A

Solitary, abnormal belief that is not delusional or obsessional but preoccupying to the extent of dominating the persons life

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5
Q

What is a delusion?

A

Fixed, false belief maintained despite contrary evidence

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6
Q

What is delusional perception?

A

A true perception to which a patient attributes a false meaning.<br></br>E.g. traffic lights turning red means aliens are coming

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7
Q

What is concrete thinking?

A

Literal thinking focused on the physical world

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8
Q

What is meant by loosening of association?

A

AKA derailment, knight’s move thinking<br></br>No connection between topics

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9
Q

What is cirumstiantiality when describing thought patterns

A

Adds in irrelevent details but eventually returns to topic

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10
Q

What is meant by tangential thoughts?

A

Digress from subjecy with unrelated thoughts

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11
Q

What is thought blocking?

A

Sudden cessation of thought

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12
Q

What is meant by flight of ideas?

A

Pressured speech with shifts in topic with only a loose connection between ideas

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13
Q

What is perserveration?

A

Repitition of specific response despite removal of stimulus<br></br>

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14
Q

What are neologisms?

A

Made up words, unintelligible

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15
Q

What is meant by word salad?

A

Random string of words with no relation

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16
Q

What is meant by confabulation?

A

Generation of a fabricated memory without the intention of deceiving someone else

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17
Q

What is somatic passivity?

A

Experiene of one’s body or bodily sensations being controlled or influencfed by an external force

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18
Q

What is meant by pressure of speech?

A

Person speaks rapidly and continuously, often without pauses

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19
Q

What is anhedonia?

A

Inability to enjoy things/experience pleasure

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20
Q

What is incongruity of affect?

A

Mismatch between a person’s emotional expression and content of thoughts of speech

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21
Q

What is meant by blunting of affect?

A

Reduction in intensity and range of emotional expression<br></br>-Limited facial expressions, monotone speech etc

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22
Q

What is meant by the belle indifference?

A

Patient shows indifference/a lack of concern toward their symptoms depsite severity

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23
Q

What is meant by depersonalisation?

A

Detatched from own thoughts, feeling or body

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24
Q

What is thought alienation?<br></br>

A

Group of symptoms where patients feel thoughts are not their own. Includes:<br></br>1. Thought insertion<br></br>2. Thought withdrawal<br></br>3. Though broadcasting

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25
Define thought insertion
Belief that thoughts are being placfed into one's mind by an external source
26
What is thought withdrawal?
Belief that thoughts are being removed from one's mind
27
What is thought broadcasting?
Belief that one's thoughts are being broadcasted or shared with others
28
What is meant by thought echo?
Auditory hallucinations of their own thoughts being spoken aloud shortly after thinking them
29
What is akathisia?
Movement disorer characterised by intense restlessness and inability to stay still.
Side effect of antipsychotics
30
Define catatonia
Psychomotor disorder that can affect a person's ability to move normally
31
What is stupor?
A symptom of catatonia in which the patient is unresponsive and unable to move, speak or react to external stimuli
32
What is psychomotor retardation?
Noticeable slowing down of thought processes and physical movements
33
What is flight of ideas?
Rapid and continuous speech with frequent shifts in topic with only a loose connection between ideas
34
What is a formal thought disorder?
Disruption in the organisation and expression of thought rather than the content
35
Define derealisation
Dissociative symptom where a person feels detached from their surroundings
36
What is a mannerism in psychiatry?
Habitual, often repetitive movement or gesture that appears to have some significance but may be out of context or exaggerated
37
What is stereotyped behaviour psychiatry?
Repetitive non functional motor movements, vocalisations or behaviours
-Often seen un individuals with developmental disorders like ASD
38
Define obsessions
Intrusive, unwnted thought, image or urge that repeatedly enters a person's mind causing significant anxiety or distress
39
Define compulsion
Repetitive behaviour or mental act that a patient feels compelled to perform in response to an obsession or according to specific rules
40
What is the criteria for sectioning under the MHA?
  • Must have a MENTAL disorder
  • Must be a risk to their health/safety or the safety of others
  • Must be a treatment(including nursing/social care0
41
What is the one physial illness a patient could be sectioned and treated for?
Anorexia nervosa->re-feeding is allowed
42
Who carries out a mental health act assessment?
  • >=2 doctors, 1 of whom must be section 12(2) approved
  • 1 approved mental health professional(AMHP)
43
Can a patient be considered for sectioning under the mental health act if under the influence of drugs/alcohol?
No-under the influence excludes patients from detainment
44
What is section 2 of the MHA?
  • Compulsory detention for assessment
45
What is the citeria for detention under section 2 of the MHA?
  • Mental disorder AND risk to self/others
46
How long can you hold a patient for under Section 2 of the MHA?
Max 28 days
47
Is section 2 of the MHA renewable?
No
48
Which healthcare professionals are required to detain a patient under Section 2 of the MHA?
AMHP or NR+2 doctors(one S12 approved)
49
Section 3 of the MHA
What is it: {{c1::Compulsory detention for treatment}}
Criteria: {{c2::Mental disorder+risk to self/others+treatment available}}
Last for maximum: {{c2::6 months}}
Renewable yes/no: {{c2::Yes}}
Healthcare professionals required: {{c2::2 drs(one S12)++AMHP/NR+seen in last 24 hours}}

50
Section 4 of the MHA
For: {{c1::admission for assessment in emergency}}
Last for max: {{c2::72 hours, then usually put on section 2}}
Healthcare professionals required: {{c3::Single doctor +AMHP/NR}}
51
What is section 5(2) of the MHA and how long does it last for?
  • Detainment of voluntary inpatient in hospital
  • Max 72 hours, only 1 dr needed
52
What is the difference between section 5(2) and 5(4) of the MHA?
  • Both detainment of voluntary inpatient in hospital
  • 5(2) required dr, 5(4) requires registerend nurse and only lasts 6 hours
53
What is section 17 a of the MHA for?
  • Community treatment order-patient on section 3 can leave for treatment in the community
54
Who makes a section 17a of the MHA decision?
Responsible clinician and AMHP
55
When can a section 17a mof MHA be recalled and if recalled, how long can patients be held?
  • Recalled if non-compliant with treatment and missing appointments
  • If recalled, can be held for up to 72 hours for assessment
56
What is section 135 of the MHA for?
  • Police can enter proerpty to escort someone to a Place of Safety(police station or A&e)
57
What is section 136 of the MHA for?
  • Can take someone from ma public place to a Place of Safety
58
What is section 131 of the MHA?
  • Informal admission-voluntary
59
What is the criteria for a section 131 admission?
  • Must have capacity
  • Must consent to admission
  • Must not resist admissions
60
What are the key principles of the Mental capacity act?
  1. Assumed to have capacity unless proven otherwise
  2. Steps should be taken to help someone have capacity
  3. Unwise decisions doesn'[t mean someone lacks capacity
  4. Any decisions made under the MCA must be in the patient's best interests
  5. Any decisions made must be the least restrictive to a patient's rights/freedom
61
How is mental capacity assessed?
  1. Impairment of or isturbance of functioning of mind/;brain?
  2. Are they unable to:
  • Understand relevant information
  • Retain relevant information
  • Weight up and reach a decision
  • Communicate that decison
  1. How urgent is the clinical decision?
  2. Do they have LPA, advanced directive/statement
  3. Should a best interest meeting be held
62
What is a Deprivation of Liberty Safeguard(DoLS) and when is it used?
Used when necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment or care to keep them safe from harm
  • Common in acute medical/geriatric wards
63
What criteria must be met before considering DoLS for a patient
  • >18yrs
  • Patient in hospital/care home with a mental disorder
  • Considered separately for detention under a MHA
  • Lacks capacity
64
Name some uses for antidepressants besides depression
  • AQnxiety
  • OCD
  • PTSD
  • Eating disorders
  • Menopause
  • Neuropathic pain
  • Fibro
  • Smoking cessation
  • Sleep
  • Parkinson's
  • Nocturnal enuresis
65
What does SSRI stand for?
Seelctive serotonin reuptake inhibitors
66
What is the MOA of SSRI's?
Inhibit serotonin reuptake to increase availabilty and improve mood regulation
67
What conditions are SRIS's typically used to treat?
1st line for:
  • Depression
  • GAD
  • OCD
  • PTSD
  • Panic disorder and phobias
68
Give some exampples of SSRIS
  • Sertraline
  • Fluoxetine
  • Citalopram
  • Paroxetine
69
Which SSRI is mostly only used for PTSD?
Paroxetine
70
Name some side effects of SSRIs
  • GI upset
  • Anxiety
  • Insomnia
  • Weight gain
  • Palpitations
  • HYPOnatraemia
  • QT prolongation(citalopram)
  • GI bleed(anti-platelet affect)
71
What is a key side effect of citaloparm?
QT prolongation
72
What is the most important mthing to wathc out for in patients on SSRI's?
Serotonin syndrome
73
What should you be cautious of when prescribing SSRIs?
  • Shouldn't be used in mania
  • Fine for patients with IHD
  • In aptients aged 18-25: increased risk of suicide->follow up after 1 week
74
What do SNRI's stand for?
Serotonin and noradrenaline reuptake inhibitors
75
Describe the MOA of SNRI?
  • Increase serotonin and noradrenaline levels, improve mood and reduce anxiety
76
When are SNRI's commonly used?
2nd line after truing SSRIs for depression
Also used for GAD and panic disorder
77
Name some examples of SNRI's
  • Duloxetine
  • Venlafaxine
78
Name some side effects of SNRI's
  • Nausea
  • Insomnia
  • Agitation
  • Tachycardia
79
What should you be cautious about when prescribing SNRI's?
CI in patints with a history of heart disease and hypertension
80
Descirbe the MOA of TCA's
  • Block reuptake of serotonin and noradrenaline(anti-muscarinic)
81
When might TCA's be used as a treatment?
Another 2nd line choice ofr depression/anxiety
82
Give some examples of TCAs
  • Amitryptaline
  • Clomipramine
  • Imipramine
83
What are the side effects of TCA's?
Anti-cholinergic
Can't see, pee, shit or spit
  • Urinary retention
  • Blurred vision
  • Constipation
  • Dry mouth
  • Dizziness

TCA TOXICITY*****
84
When are TCA's contraindicated?
Patients with heart disease, diabetes, urinary retention, long QT syndrome, liver damage, CP450 medications
85
When should TCA's be prescirbed with caution?
  • In the elderly-risk of falls
86
What are MAO-I's and what is their mechanism of action?
Monoamine Oxidase Inhibitors
  • Inhibit monoamines which are responsible for metabolism of serotoning and noradrenaline in the presynaptic cleft-> increae serotonin and noradrenaline
87
When are MAO-Is used?
Sometimes sued to treat depression-not first line
88
Give some examples of MAO-I's?
Moclobemide
Phenelzine
89
Name some side effects of MAO-I's?
  • Hypertensive reaction with tyramine-containing foods
Marmite, cheese, salami etc
90
When are MAO-Is contraindicated?
  • Cerebrovascular disease
  • Mania in bipolar
  • Phaeochromocytoma
  • CVR disease
91
What drug class does mitrazapine belong to?
Noradrenergic and specific seretonergic antidepressant(NaSSA's)

  • Modulate serotonin and nordrenaline levels in the brain
92
What are the indications for using mirtazapine as a treatment?
2nd line for depression
Especially helpful in patients with sleep and low weight problems
93
Name some side effects of mirtazapine
  • Sedation
  • Increased appetite
  • Weight gain
  • Constipation/diarrhoea
94
What are antipsychotics used to treat?
  • Bipolar
  • Depression
  • Delirium
  • Personality disorders
  • Eating disorders
  • Huntington's
  • Tic disorders
  • Intractable hiccups
  • Nausea and hyperemesis
95
How do typical/1st gen antipsychotics work?
Antagonists to D2 receptors on cholinergic, adrenergic and histaminergic receptors
96
Give some examples of 1st gen/typical antipsychotics
  • Haloperidol
  • Chlorpromazine
  • Flupentixol
97
What kind of symptoms to typical/1st gen antipsychotics cause?
Extra-pyramidal
98
Side effects of 1st gen/typical antipsychotics:
Dopamine 2 receptor blockade:
  1. {{c1::Acute dystonia}}->spasms/involuntary movements
  2. {{c2::Akathisia->}}restlessness and inability to sit still
  3. {{c3::Parkinsonism}}->Tremors, rigidity, bradykinesia
  4. {{c4::Tardive dyskinesia}}->involuntary,repetitive movements particulary of face lip smackin etc
99
What is acute dystonia?
Involuntary muscle contractions/spasms
100
What is tardive dyskinesia?
Involuntary repetitive movements, particulary of face
Lip smacking, tongue movements etc
101
What is a side effect of antipsychotics with regards to the histamine 1 receptor blockade?
Sedation->drowsiness/sleepiness
102
What is a side effect of antipsychotics with regards to the alpha 1-adrenergic receptor blockade?
Orthostatic hypotension
103
What is a side effect of antipsychotics with regards to the muscarinic receptor blockade?
Anticholinergic effect:
Can't pee, see,shit or spit
  • Dry mouth
  • Constipation
  • Blurre vision
  • Urinary retention
104
What is 1st line for psychosis?
2nd gen/atypical antipsychotics
105
Why are 2nd gen antipsychotics now preferred to 1st gen?
Fewer extrapyramidal side effects
106
What is a disadvantage of using 2nd gen antipsychotics compared to 1st gen
Increased metabolic side effects
107
How do 2nd gen/atypical antipsychotics work?
D2, D3, D5 and HT2A antagonists
108
Give some examples of 2nd gen/atypical antipsychotics
  • Risperidone
  • Quetiapine
  • Olanzapine
  • Aripiprazole
  • Clozapine
109
What are some of the metabolic side effects of 2nd gen/atypical antipsychotics?
  • Weight gain
  • Impaired glucose metabolism/diabetes
  • Increase levels of lipids
  • Increased levels of prolactin
110
What are some general side effects of 2nd generation/atypical antipsychotics?
  • Seizures
  • QT prolongation
  • Increase VTE and stroke risk in elderly
111
What monitoring should be done in patients on 2nd gen/atypical antispychotics?
  • Weight
  • Blood glucose
  • HbA1c
  • Lipids
  • BP
  • ECG
112
When is clozapine used as a treatment?
  • Treatment resistant schizophrenia once 2 others have failed-treats both positive and negative symptoms
113
What are the side effects of clozapine?
AGRANULOCYTOSIS
  • Neutropenia
  • Decreased seizure threshold
  • Myocarditis
  • Slurred speech
  • Constipation
114
What monitoring should be done for patients on clozapine?
  • Weekly FBC looking at WCC for first 18 weeks, then fortnightly
  • Bloods
  • Lipids
  • Weight
  • Fasting blood glucose
115
Name some common mood stabilisers
  • Lithium
  • Sodium valproate
  • Carbamazepine
  • Lamotrigine
116
What is lithium used to treat?
  • Bipolar disorder and mania
  • Depression
  • Aggression/self harm
117
When is lithium contraindicated?
  • Addison's disease
  • Arrhythmias
  • Brugada
  • Hypothryoidism
118
Side effects of lithium:
  • L-{{c1::leukocytosis}}
  • I-{{c2::Insipidus(diabetes)}}
  • T{{c3::-tremor(fine)}}
  • H-{{c4::hypothryoidism}}
  • I-{{c5::Increased weight}}
  • M-{{c6::Metallic taste}}
119
What should be given to women of childearing age who are on lithium and why?
  • Contraception
  • Causes cardiac malformations in the 1st trimester
120
Monitoring for patients on lithium

At the start:
  1. {{c1::U&E's}}
  2. {{c1::ECG}}
  3. {{c1::TFT's}}
  4. {{c1::BMI}}
  5. {{c1::FBC}}
Throughout:
  1. {{c2::}}Electroytes
  2. {{c2::eGFR}}
  3. {{c2::TFT's}}
  4. {{c2::BMI}}
121
Name some side effects of sodium valproate
  • Nausea
  • Gastric irritation
  • Diarrhoea
  • Weight gain
122
What are carbamazepine and sodium valproate used for in psychiatry?
Mood stabilisers:
  • Both used for bipolar disorder prophylaxis
123
What is lamotrigine used for in psychiatry?
Mood stabiliser
  • Useful in preventing depressive episodes
124
Name some side effects of lamotrigine
  • Steven Johnson syndrome
  • Dizziness
  • Rashes
125
What is important to remember about prescribing mood stabilisers to women of child bearing age?
Teratogenic
126
Lithium toxicity:
Therapeutic dose symptoms: {{c1::fine tremor, dry mouth, GI disturbance, Increased thirst and urination}}

Toxicity symptoms{{c2::: Coarse tremor, CNS dysfunction(seizures, impaired co-ordination, dysarthria), arrhythmias, visual disturbance}}

Investigations:
  • For diagnosis:{{c3::Serum lithium levels}}
  • For assessment: {{c4::electrolyes, LFT's U&Es, ECG}}
Treatment:
  • {{c5::
  • Supportive
  • Maintain electrolytes, monitor renal function, IV fluids
    • }}
127
Describe some symptoms of TCA toxicity
  • Drowsiness
  • Confusion
  • Arrhythmia
  • Seizures
  • Vomiting
  • Headache
  • Flushing
  • Dilated pupils
128
What investigations should be done to diagnose and assess TCA toxicity?
  • FBC
  • U&E
  • CRP
  • LFT'S
  • VBG
  • ECG-QT prolongation
129
How is TCA toxicity treated
  • Generally supportive care and management
  • Consider activated charcoal withint 2-4 hours of OD and intensive care review if severe

130
What is neuroloeptic malignant syndrome?
  • Rare, life threatening reaction to antipsychotics
131
When does neuroleptic malignant condition occur?
After the introduction of or increase in neuroleptic medications (antipsychotics)
132
How do patients with neuroleptic malignany syndrome present?
  • Hyperthermia
  • Altered mental state
  • 'Lead pipe rigidity' 
  • Autonomic dysregulation
133
Name some differentials for neuroleptic malignant syndrome
  • Malignant hyperthermia
  • Serotonin syndrome
134
What are some investigations to investigate neuroleptic malignant syndrome?
  • Creatine kinase!
  • FBC
  • Renal and liver function
135
What is the treatment for neuroleptic malignant syndrome?
  • Stop causative agent
  • Cooling blankets and IV fluids to prevent renal failure and hyperthermia
  • Benzodiazepines for muscle rigidity
  • Dantrolene in severe cases
  • Intensive monitoring
136
What is serotonin syndrome?
  • Life threatening emergency characterised by an increase in serotonergic activity in the CNS
137
When does serotonin syndrome occur?
Typically first few months after starting an SSRI/increasing the dose
  • Can also happen with SNRI's, MAO-I's, TCA's, MDMA/cocaine
138
Describe the presentation of a patient with serotonin syndrome
  • Hyperthermia
  • Altered mental state
  • Neuromuscular hyperactivity-> tremors, clonus, hyperreflexia
  • NOT rigidity
139
Name some differentials for serotonin syndrome
  • Neuroleptic malignant syndrome
  • Malignant hyperthermia
  • Anti-cholinergic toxicity->decreased bowel sounds, urinary retention
140
How can serotonin syndrome and neuroleptic malignant syndrome be differentiated?
  • Neuroleptic malignant syndrome: slower onset, longer duration
141
How is serotonin syndrome diagnosed?
  • Mostly based on clinical exam and history
  • Bloods to monitor organ function
142
How is serotonin syndrome managed?
  • Stop causative agent
  • Supportive care and symptom management
  • In severe cases: antidotes like cypropheptadine
143
What are the features of addiction?
  • Tolerance
  • Withdrawal
  • Persistent desire/unsuccessful attempts to stop
  • Substance taken in large amounts/used for longer periods then intended
  • Vocational/social/recreational activities given up or reduced because of substance us
  • More time spent seeking/recovering from meffects of substance
  • Repeated use despite awareness of damage from substance
144
Which pathway is addiction medicated by?
Dopamine reward pathway
145
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151
Descirbe the general management of addiction
  • Maintainence vs abstinence
  • Treat co-morbidities(mental and physical)
  • Psychological interventions(CBT, motivational interviewing, AA)
  • Pharmacological intervention(manage detox, maintainence etc)
  • Social intervention(work, housing, family)
152
Descirbe the symptoms of acute alcohol intoxication
  • Ataxia
  • Nausea and vomiting
  • Decreased GCS
  • Respiraotyr depression
  • Impaired judgement
  • Anterograde amnesia
  • Dysarthria
153
When does alcohol withdrawal typically occur?
12 hours after the last drink
154
What scoring system is used to monitor signs of alcohol withdrawal and guide treatment?
CIWA score
Clinical institute withdrawal assessment
155
Symptoms of alcohol withdrawal:
  • >6 hours: {{c1::tremor, nausea, sweating, vomiting, anxiety, insomnia, tachycardia, hypertension, pyrexia}}
  • 7-48 hours: {{c2::Seizures, risk of status epilepticus}}
  • 48-72 hours: {{c3::Tremor, hallucintations, delusions, confusion, agitation}}
156
How many hours after the last drink is a patient going through alcohol withdrawal most at risk of seizures or status epilepticus?
7-48 hours
157
Descirbe the pharmacological management of alcohol withdrawal
  • Short acting benzodiazepines
Chlordiazepoxide reducing regine (20-40mg qds reducing to 0 over 1 week)

  • Pabrinex-prevent Wernicke-Korsakoff's syndrome

  • Oxazepam if evidence of liver injury
158
Describe the supportive management of alcohol withdrawal
  • Fluids
  • Anti-emetics
  • Referral to local drug and alcohol liasion teams
159
What is delirium tremens?
Life threatening emergency characterised by extreme autonomic hyperactivity and neuropsychiatric symptoms
160
How long after alcohol cessation is delirium tremens most likely to set in?
About 72 hours
161
What are the triggers for developing delirium tremens
  • Cessation of alcohol
  • Cna be precipitated by infeciton, trauma or illness
162
Describe the symptoms of delirium tremens
  • Confusion and disorientation
  • Hallucinations (visual or tactile, formication)
  • Autonomic hyperactivity-> sweating, hypertension
  • Rarely seizures
163
When do symptoms of delirium tremens typically peak?
  • Between 4th and 5th day post withdrawal
164
Give some differentials for delirium tremens
  • Alcohol withdrawal(no hallucinations)
  • Wernicke-korsakoff(no autonomic instability)
  • Encephalitis/meningitis(no focal neurological signs)
165
Describe the management of delirium tremens
  • 1st line: lorazepam
  • If symptoms persist: parenteral lorazepam or haloperidol
  • Maintainence therapy of alcohol withdrawal
166
What is Wernicke's encephalopathy?
  • Acute neurological syndrome from a thiamina(B1) deficiency
167
Name some causes of Wernicke's encephalopathy
  • Most common: chornic alcohol abuse
  • Malabsorption, eating disorders
168
What are the 3 core symptoms of Wernicke's encephalopathy?
  • Confusion
  • Ataxia
  • Ophthalmoplegia/nystagmus
Don;t need all 3 to make a diagnosis
169
How is Wernicke's encephalopathy investigated?
  • Thiamine level testing
  • Bloods-FBC's, U&E's, liver and bone profile, magensium, clotting
  • Neuroimaging->MRI
170
How is Wernicke's encephalopathy managed?
  • Treat underlying cause
  • Thiamine supplementation->pabrinex
171
What is Korsakoff's syndrome?
  • Chronic memory disorder that arises as a late complication og untreated Wernicke's
172
What is the main complication of Wernicke's encephalopathy?
  • Korsakoff's syndrome(becomes permanent)
  • Also coma, death
173
What is the aetiology of Korsakoff's syndrome?
  • Degeneration of mamillary bodies(part of circuit of papez involved in memory formation) due to thiamine deficiency
174
What are the symptoms of a patient with Korsakoff's syndrome?
  • Profoound anterograde amnesia
  • Limited retrograde amnesia
  • Confabulation(fabricate memories to mask deficit)
175
How is Korsakoff's syndrome treated?
  • Ongoing thiamine supplementation
  • Cognitive rehabilitation
  • Treat underlying cause(like alcoholism)
176
What are some symptoms of opiate intoxication?
  • Drowsiness
  • Confusion
  • Constricted pupils
  • Bradypnoea
  • Bradycardia
177
How many hours after the last dose might opiate withdrawal symptoms begin, and when does it peak?
  • Can begin as early as 6 hours after last dose
  • Symptoms peak at 36-72 hours
178
Is opiate withdrawal typically life threatening?
No
179
Describe the symptoms of opiate withdrawal
  • Agitation
  • Chills
  • Cramps
  • Sweating
  • Increased salivation
  • Insomnia
  • GI disturbance
  • Dilated pupils
  • Piloerection
  • Tachycardia and hypertension
180
How is opiate withdrawal managed acutely?
  • Methadone(can cause prolonged QT syndrome)
  • Lofexedine(alpha 2 receptor agonist)
  • Loperamide(for diarrhoea)
  • Anti-emetics(nausea)
  • Benzodiazepines(only for agitation, should be avoided)
181
What is used in opiate detox programmes?
  • Methadone and bupernorphine
182
What is used as opiate addiction relapse prevention?
Neltrexone once detox done
183
What is an opiate overdose treated with?
Naloxone
184
Give some examples of stimulants
  • Cocaine
  • meth
  • MDMA
185
What are some symptoms of stimulant intoxication?
  • Euphoria
  • Hypertensive crisis
  • Tachycardia
  • Dilate pupils
  • Pyr4exia
  • Agitation
  • Psychosis
186
What are some potential consequences of stimulant intoxication?
  • Rhabodymolisis
  • SIADH and water overload
  • Cocaine-> Ischaemic events due to vasospasm
  • Death
187
What causes death in patients with stimulant intoxication?
  • Hyperpyrexia
  • Hypertension
188
How is stimulant intoxication managed?
Deaths due to hyperpyrexia and hypertension so:
  • Cooling
  • Antihypertensives like nitroprusside or GTN
  • Benzodiazepines
189
What is the criteria for an ADHD diagnosis?
  • Neurodevelopmental disorder-symptoms affetc daily functioning in >1 setting and symptoms last for >6 months
  • Symptoms present before age  of 12 years
190
What are the cardinal features of ADHD?
  1. Inattention
  2. Impulsivity
  3. Hyperactivity
191
Describe the aetiology of ADHD
  • Decreased activity in the frontal lobe-> impaired executive function
192
How might inattention manifest in a patient with ADHD
  • Difficult sustaining attention to tasks that aren't rewarding or stimulating or require sustained mental effort
  • Easily distracted by external stimuli
  • Loses things
193
How might hyperactivity/impulsivity manifest in a patient with ADHD?
  • Excessive motor activity
  • Difficult engaging in activities quietly
  • Blurts out answers in school/work
  • Tendency to act in response to immediate stimuli without deliberation or consideration of risk/consequence
194
How is ADHD diagnosed?
According to the DSM-5 clinical criteria
  • Behavioural observation
  • Comprehensive history and physical exam
  • Teacher and parent reports
  • Neuropsychological testing
195
How is ADHD treated?
  • Conservative-> behavioural therapy, CBT, psychoeducation, social skills training
  • Medical-stimulants-> methylphenidate, amphetamines
196
How do stimulants work to treat patients wth ADHD?
  • Act on frontal lobe to increase executive function and attention and decrease impulsivity
197
What should be monitored in children on methylphenidate?
Growth
198
Define autism spectrum disorders
Set of complex neurodevelopmental disorders resulting in social, language and behavioura deficits
199
How does ASD present?
  1. Social interaction-> plays alone, no eye contact, struggle to perceive others
  2. Language and communication-> speech and langiage delay, monotonous voice, interpret speech literally
  3. Behavioural traits-> narrow interests, rituilistic behaviours, routines, stereotyped movements
  4. Other conditions-> Learning difficulties, genetics, seizures
200
Name some differentials for ASD
  • Intellectual disability(no social deficits)
  • ADHD(no social/language deficits)
  • Specific language impairment
  • Childhood schizophrenia(hallucinations/delusions)
  • Asperger's-> milder social features and near normal speech development
201
How is ASD diagnosed?
  • MDT assessmnt
  • Psychological evaluation
  • Speech and language assessment
  • Cognitive assessment
202
How is ASD managed?
  • MDT approach
  • Behavioural->applied behavioural analysis(encourage positive behaviours, ignore negative)
  • Family and social support
203
How is ASD different to asperger's?
Asperger's has milder social fe3atures and near normal speech development
204
What are the key features of learning disabilities?
  • Decreased intellectual ability
  • Difficulty with everyday activities
205
Name some potential causes of learning disabilities
  • Inherited
  • Early childhood illness/brain injury
  • Problems during pregnancy/birth
  • Smoking/alcohol in pregnancy
206
What causes Down's syndrome?
Trisomy 21
207
Name some risk factors for having Down's syndrome
  • High maternal age
  • Family history
208
Descirbe the typical facial features of a patient with Down's syndrome
  • Flat occiput
  • Oblique palpebral fissures
  • Small mouth
  • High arched palate
  • Broad hands
  • Single, transverse palmar crease
209
What medical conditions are associated with Down's syndrome?
  • Complete AV septal defecy
  • Hypothyroidism
  • Increased risk of Alzheimer's by age of 50
  • Learning disability 
  • Autistic t5raits
210
What is generalised anxiety disorder?
  • Chronic and pervasive condition characterised by excessive, uncontrollable worry extending across various life domains
211
What are the ICD10 criteria for GAD?
  1. 6 month history of tension, worry and axiety about everyday issues
  2. Increase in symptoms(autonomic, chest/abdo, brain, tension)
  3. Doesn't met criteria for panic disorder, hypochondriasis and OCD
  4. Can't be explained by a physical condition or medication
212
Describe the epidemiology of GAD
  • More common in females, associated with depression, substance misuse and personality disorders
213
Name some risk factors for developing GAD
  • Low socioeconomic status
  • Unemplyment
  • Divorce
  • Lack of education
214
GAD symptoms:
  • Psychological: {{c1::worries, decreased concentration, insomnia, derealisation}}
  • Motor: {{c1::restlessness, feeling on edge}}
  • Neuromuscular: {{c1::tremore, tension headache, muscle aches, dizziness}}
  • GI: {{c1::dry mouth, nausea, indugestion, nausea and vomiting}}
  • CVR: {{c1::chest pain, palpitations}}
  • Resp: {{c1::Dsypnoea, tight chest, breathlessness}}
  • GU: {{c1::urinary frequency, erectile dysfunction, amenorrhoea}}
215
How is GAD diagnosed?
  • Full history and exam(rule out organic causes)
  • Questionnaires liked GAD-2/7
  • Sucide risk assessment
216
Name some differentials for GAD
  • Hyperthyroidism
  • Cardiac causes
  • Too much caffeine
  • Substance abuse
  • Depression
  • Medication induced anxiety
  • Anxious/avoidant mpersonality disorder
  • Early stage dementia/schizophrenia
217
GAD management:

1st line: 
  • I{{c1::
  • ndividual, non-facilitated help
  • Individual, guided mself-help
  • Psycho-educational groups-interactive CBT sessions
    • }}
2nd line:
  • {{c2::
  • High intensity psychological intervention-CBT,applied r4elaxation
  • Medical management-SSRI's, sertraline 1st line
    • }}
Symtpomatic management: {{c3::propanolol}}
218
What is panic disorder?
  • Occurence of recurrent unexpected panic attacks, each marked by intense fear/discomoft resulting in avoidant behaviours
219
What is the criteria for a panic attack disorder diagnosis?
  1. Recurrent unexpected panic attacks
  2. Persistent concern about future attackd
  3. Behavioural changes resulting in avoidance of associated situations
220
Describe the epidemiology of panic disorder
  • Bimodial incidence, peaks and 20yrs and 50 yrs
  • Concurrent agoraphobia in 30-50% of cases
  • Increased risk of attempted suicide with comorbid epression/substance abuse
221
Describe the clinical features of panic disorder
  • Breathing difficulties, chest pain, palpitations, shaking, sweating
  • Hyperventilation-> hypocalcaemia, carpopedal spasm
  • Depersonalisation/derealistation
  • Agoraphobia
222
Name some differentials for panic disorder
  • Other anxiety disorders(GAD, agoraphobia)
  • Depression(takes precedence), alcohol/drug withdrawal
  • Organic: CVR/resp, hypoglycaemia, hyperthyroidism, phaeocromocytoma
223
How is panic disorder managed?
  1. CBT(80-100& successful)
  • Psychoeducation and 'fear of fear' cycles
  • Interoceptive exposure and techniques
  • secondary agoraphobia exposure techniques
2. SSRI's
  • Clomipramine(TCA)
  • Propanolol for symptomatic management

224
What are phobias?
  • Excessive and irrational fears, restricted to highly specific situations
225
What are the clinical features of a phobia?
  • Usually apparent in early childhood
  • Leads to avoidance behaviours
  • Results in bradycardia or hypotension
  • Rule out depression
226
What is agoraphobia?
  • Fear of open spaces and associated factors like the presence of crowds or difficulty of immediate escape
227
At what age does agoraphobia typically start?
  • 20's mor mid 30's
228
What is social anxiety disorder?
  • AKA social phobia
  • Fear of scrutiny by others in small groups(5-6 people)
  • Can be specific(public speaking) or generalised
229
What are the symptoms of social phobia
  • BLUSHING(characteristic)
  • Palpitations
  • Sweating
  • Trembling
230
What can precipitate the development of social phobia?
  • Stressful/humiliating experiences
  • Parental death
  • Separation
  • Chronic stress
231
What are come complications of social phobia?
  • Depression
  • Alcohol/drug abuse
232
How are phobias managed?
  1. CBT
  • Ecposure techniques->systematic desensitization
  • Flooding
  • Modelling
2. SRRI's
  • Propanolol if somatic symptoms dominate
233
What is an acute stress reaction?
  • Immediate and intense psychological response following exposure to a traumatic event
234
How is acute stress reaction differentiated from PTSD?
Sx for <1 month: acute stress reaction
>1 month: PTSD
235
What is the criteria needed to diagnose an acute stress reaction?
  • Exposure: direct/indirect exposure to traumatic event
  • Symptoms: Dissociation, low mood, arousal, avoidance
  • Duration: 3 days-1 months post event
236
Name some clinical features of acute stress reaction
  • Intrusive memories, dissociation, hyperarousal, avoidance, low mood
  • Emotional: anxiety, sense of unreality
  • Physiological: palpitations, hypervigilance
  • Behavioural: effort to escape reality and reminders
237
Name some differentials for an acute stress reaction
  • Adjustment disorders
  • PTSD(>1 month)
238
How is acute stress reaction managed?
  1. Trauma focused CBT
  2. Medications if severe: benzodiazepines
239
What is adjustment disorder?
  • Significant emotional distress and disturbance that interferes with social functioning
240
When does adjustment disorder typically arise?
During a period o adaptation to a major life change/stress
241
How is adjustment disorder different to an acute stress reaction?
Adjustment disorder: stressor doesn't need ot be severe or life-threatening(e.g., being fired)
Acute stress reaction: Severe stressor
242
Describe the clinical features of adjustment disorder
  • Mood: depression/amxiety
  • Behavioural: marked irritability, imapired work/social function
  • Interpersonal disruptions and avoidance behaviours
  • Cognitive alterations: persistent negative outlook, precoccupations with the stressor 
243
Name some differentials for adjustment disorder
  • Acute stress reaction
  • PTSD
244
How is adjustment disorder managed?
  • Psychotherapy(CBT, group, family)
  • Medications(anti-anxiety/antidepressants)
  • Self care strategies(stress management, activity, social support)
  • Treatment usually short term, symptoms improve once stressor is removed or indivdual learns how to cope
245
What criteria is needed to diagnose PTSD?
  • Direct/indirect exposure to a traumatic event(actual threatened death, serious injury or sexual violence)
  • Symptoms:intrusion, avoidance, negative alterations in cognition and mood, arousal and reactivity
  • Duration: >1 months(DSM-5) or >6 months(ICD-11)
246
How long do symptoms need to have been present for to make a PTSD diagnosis?
  • ICD 11: >6 months
  • DSM 5: >1 months
247
How common is PTSD?
  • Lifetime rates: 7-9%
248
Describe the clinical features of PTSD
  • Intrusions: recurrent distressing memories/nightmares/flashbacks
  • Avoidance
  • Mood and cognition: distorted blame, negative emotions and beliefs
  • Arousal and activity: Increased vigilance, concentration and sleep troubles, increased startle response
249
How is PTSD classified?
  • Mild: Manageable, limited impact on social/ocupational function
  • Moderate: Mild-severe distress and impact on function, no significant risk of suicide, self harm or risk to others
  • Severe: Unmanageable distress, high risk of self-harm/suicide
250
How is PTSD managed?
  • Moderate-severe; secondary care referral
  • Trauma focussed CBT and EMDR
  • Veterans priority scheme
  • Risk assessment for suicide/self-harm
  • Medications: SSRI's(start with sertraline, paroxetine) or SNRI(venlefaxine)

251
What is the criteria for a diagnosis of OCD?
  • Presence of obsessions, compulsions or both
  • Time-consuming (>1hr/day), OR cause significant impairment
  • Not attributable to another medical/mental disorder
252
How common is OCD?
1-3% of the population
253
At what age does OCD typically present?
  • Adolescence/early adulthood
254
How do patients with OCD present?
Obsessions; intrusive, unwanted distressing thoughts/images
Compulsions: Repetitive behaviours aimed at decreasing anxiety
255
What scoring system is used to assess severeity of OCD?
Yales-Brown OC scale
  • Mild: 8-15
  • Moderate: 16-23
  • Severe: 24-31
  • Extremely severe: 32-40
256
Name some differentials for OCD
  • GAD
  • Major depressive disorder
  • Body dysmorphic disorder
  • Social anxiety disorder
  • Hoarding disorder
  • Trichotillomania
  • PTSD
  • ASD
257
How is OCD managed?
Mild: low intensity CBT
  • Exposure and repsonse prevention: ERP
Moderate: Intensive CBT or SSRI
  • Fluoxetine, citalopram, paroxetine, sertraline
  • Clomipramine as alternative
Severe:
  • Intensive CBT and SSRI

258
If a patient is on a medication for OCD, how long should they continue taking it for?
  • If effective: continue for at least 12 months, then review
259
What is the criteria for a diagnosis of major depressive disorder?
  • Presence of a major depressive episode lasting over 2 weeks
260
What is dysthymia?
  • Persistent depressive disorder-chronic form of depression lasting more than 2 years
261
What are the 9 DSM 5 depression symptoms?
  • Depressed mood/irritability(can be subjective or objective)
  • Anhedonia
  • Weight/appetite changes
  • Sleep changes
  • Activity changes-pscyhomotor agitation/retardation
  • Fatigue/loss og energy
  • Guilt and feelings of worthlessness
  • Cognitive issues
  • Suicidality(thoughts or formulation of a plan
262
What is the DSM-5 criteria for a depression diagnosis?
  • 5/9 symptoms for at least 2 weeks
263
Name 2 additional features that might be seen in severe depression
  • Psychosis->delusions and/or hallucinations
  • Depressive stupor-> immobility, mutism, refusal to eat/drink->ECT
264
What investigations should be done to make a diagnosis of depression?
  • FBC
  • U&E's
  • TFT'S
  • LFT
  • Glucose
  • cortisol
  • B12/folate
  • Toxicology screen
  • CNS imaging in some cases
  • Questionnares: HAD scale and PHQ-9
265
What questionnaires are used to assess depression?
  • HAD scale
  • PHQ-9
266
Name some differential diagnoses for depression
Organic:
  • Neurological: Parkinson's, dementia, MS
  • Endocrine: thryoid, hyoer/hypo-adrenalism
  • Chronic conditions: mdiabetes, obstructuve sleep apnoea, mono
  • Neoplasms and cancer
  • Substance use/medication side effect
267
Management of depression:
  • Refer to secondary care if {{c1::high risk for cuicide, psychosis/bipolar}}
Mild/moderate:
  1. {{c2::Low/high intensity psychological interventions(self-help, CBT, etc)}}
  2. {{c3::Consider antidepressants(SSRI's, SNRI's)}}
Recurrent:
  1. {{c4::Antidepressant+lithium}}
  • Continue for at least {{c4::6 months post remission then taper}}
  • High suicide risk age {{c4::18-25 yrs,}} follow up after {{c4::1 week}}
Severe:
  1. {{c5::ECT}}

268
Name some side effects of ECT
  • Headaches
  • Muscle aches
  • Memory loss
  • Confusion
  • Death
269
Why should antidepressants be used with caution for depression?
High risk of suicide
270
What are the most common ways in which patients self harm?
  • Cutting
  • Self-poisoning
  • Burning
  • Hitting
  • Hair pulling
271
What groups is self harm most common in?
  • Young people
  • More common in females
272
Name some risk factors for self-harming
  • Mental illness
  • Alcohol/substance misus
  • Social disadvantage/lack of social support
  • Childhood adversity
  • Personality characteristis#(impulsivity, poor problem solving, interpersonal difficulties)
  • Life events-predisporing/precipitating factors(especially relationship problems
273
Give some reasons behind why a patient would self-harm
  • Expression of personal distress
  • May/may not be with lethal intent
  • Attempt to communicate/seek help/care
  • Way of obtaining relief from a difficult and otherwise overwhelming situation
274
Name some of the most common methods by which patients committ suicide
  • Hanging-most common
  • Self-poisoning
  • Jumping
  • Drowning
  • Cutting/stabbing
  • Firearms
275
Risk factors for commiting suicide:
SADPERSON:
S{{c1::ex: male}}
A{{c1::ge}}
D{{c1::epression}}
P{{c1::sychiatric care}}
E{{c1::xcessive drug use}}
R{{c1::ational thinking absent}}
S{{c1::ingle}}
O{{c1::rganised attempy/PREVIOUS SH/ATTEMPTS}}
N{{c1::o support/living alone}}
S{{c1::tates future attempt
}}
Others:
  • {{c1::
  • Poverty and unemployment
  • Prisoners/marginalised groups
  • Family history of mental illness/suicide
  • Childhood adversity and bullying
  • Physical illness
    • }}
276
What are some red flags and important things to assess when carrying out a suicide risk assessment?
  • Level of intent/hopelessness, agitation, lack of sleep
  • Prior attempts/plans/notes
  • Giving away possessions etc
  • Typical: young male/late life white divorced male living alone, social withdrawal
277
What are the different kinds of overdose using paracetemol?
  • Acute: Excessive amounts in <1 hour
  • Staggered: Excessive amount ingested in >1 hour
  • Therapeutic excess: Too much taken  to treat pain/fever without self harm intent
278
How much paracetemol counts as an overdose?
>75mg/kg/24 hours
279
How does a paracetemol overdose cause problems/
  • Normally: NAPQ1 inactivated by glutathione
  • OD: glutathione depleted, so massive excess of NAPQ1 which builds up and causes liver and kidney damage
280
How do patients who have OD's on paracetemol present?
  • N+V
  • Haematuria and proteinuria
  • Jaundice
  • Loin pain
  • Abdominal pain
  • Coma/unconscious
281
What investigations should be done for a patient who has overdosed on paracetemol?
  • fbc
  • u&e
  • lfts
  • clotting screen
  • VBG-severe metabolic acidosis
  • Paracetemol levels
282
What kind of imbalance can a paracetemol overdose cause?
Metabolic acidosis
283
Management of a paracetemol overdose:
  • <1hour ago and dose >150mg/kg: {{c1::activated charcoal}}
  • 1-4 hours: {{c1::wait, check at 4 hours then N-acetylcysteine}}
  • 4-24 hours/staggered OD: {{c1::N-acetylcysteine}}
  • >24 hours: {{c1::N-acetyclysteine if liver failure or high paracetemol levels}}
  • Last line: {{c1::liver transplant}}
284
When would a patient who has overdosed on paracetemol be considered for an urgent transplant?
  • Arterial pH<7.3
OR
  1. Serum creatinine >300micromol/litre
  2. Prothrombin time >100 seconds
  3. Grade 3/4 encephalopathy
285
Which patients are at higher risk of complications after a paracetemol overdose?
  • HIV
  • Mlanutrition
  • Wating disorders
  • Pre-existing liver disease
  • Regular alcohol excess
286
Which blood test results indicate a poor prognosis following a paracetemol overdose?
  • Bilirubin >300micromol
  • INR>6.5
287
What is post partum depression?
  • Significant mood disorder that develops within 1 year post birth
288
How is postpartum depression different to the baby blues?
Baby blues: Less than 2 weeks post birth, resolve spontaneously
Postpartum depression: significant mood disorder up to 1 year post birth
289
Name some risk factors for developing postpartum depression
  • Deprivation
  • History of mental health disorders
  • Lack of support
290
Aetiology of postpartum depression:
  • Biological: {{c1::hormonal fluctuations (lower progesterone, oesrogen etc, changes in melatonin, cortisol, immune and inflammatory processes}}
  • Psychological: {{c1::Stress mfrom transition to parenthood}}
  • Social: {{c1::lack of support, life stressors, low socioeconomic status}}
291
What symptoms might a patient with postpartum depression present with?
  • Persistent low mood, anhedonia, low energy
  • Decreased appetitie, disturbed sleep patterns, insidious onset
  • Concerns about bonding with baby and caring for it
  • Potential thoughts of harm
292
Name some differentials for postpartum depression
  • Baby blues
  • Postpartum psychosis
  • Adjustment disorders
293
What investigations should be done to diagnose postpartum depression?
  • Edinburgh postnatal depression scale(EPDS)
  • Detailed psychiatric history, phhysical exam and rule out organic causes 
294
How is postpartum depression treated?
  1. Self-help and psychological therapies(CBT and IPT(interpersonal))
  2. Antidepressants(sertraline/paroxetine-safer for breastfeeding)
  3. Admission to mother-baby mental health uni
295
Which SSRI's are safest for breastfeeding mothers?
  • Sertraline
  • Paroxetine
296
What is the treatment for baby blues?
  • Reassurance and support
  • Regular health visits to check in on mum and baby
297
What is post partum psychosis and when does it typically occur?
  • Serious psychiatric condition
  • Typically under 2 weeks post birth
298
Name some risk factors for developing post partum psychosis
  • Prior history of psychosis
  • Family history
299
Describe the aetiology of post-partum psychosis
Unknown, combination of:
  • Genetic susceptibility
  • Hormonal changes post birth
  • Psychosocial stressors
Increases risk if history of severe mental illness
300
How do patients with post-partum psychosis present?
  • Paranoia
  • Hallucinations
  • Manic epsiodes
  • Despressive episodes
  • Confusion
  • Delusions(especially capgras-baby replaced by imposter)
301
What investigations should be done in a patient with post partum psychosis?
  • Clinical diagnosis
  • Rule out organic causes-> sepsis, thyroid issues etc
302
How is post partum psychosis managed?
  • Antipsychotics: olanzapine and quetiapine(safe for breastfeeding)
  • Mood stabilisers for some
  • High risk: referral to specialist mother and baby inpatient mental health unit
303
When should a referral be made to a specialist mother and baby inpatient mental health unit in patients with post partum psychosis?
  • If high risk, especially if comman hallucinations and delusions about baby
  • Command->kill baby/not your baby, imposter etc
304
What are eponymous syndromes?
  • Unique and rare manifestations of distorted thinking
305
Capgras delusion?
  • Either oneself or another person has been replaced by an exact clone
306
What causes capgras delusion?
  • Psychotic illness
  • Brain trauma
307
What is Ekbom's syndrome?
  • Patient feels infested with parasites-'crawling' inside skin
308
What causes Ekbom's syndrome?
  • Psychosis
  • B12 deficiency
  • Hypothyroidism
  • Neurological disorders
309
What is cotard delusion?
  • Patient is dead, non-existing or rotten
310
What causes cotard delusion?
  • Psychosis
  • Parietal lobe lesions
311
What is othello syndrome?
Spouse/partner is unfaithful with little ot no proof
312
What causes othello syndrome?
  • Alcohol mabuse
  • Psychosis
  • Frontal lobe damage
313
What is freigoli syndrome?
  • Persecutory beliefs->strangers are persecutors in disguise
314
What is folie a deux?
Delusions shared by 2 or more people
  • One has psychosis, the other is submissive
315
What is de clerembault's syndrome?
  • Delusion of being the object of love
  • 'erotomania'
316
Name some psychiatric conditions that can cause delusions
  • Schizophrenia
  • Bipolar disorder
  • Psychotic depression
317
What are the different classifications of delusions?
  • Bizarre-very unusual
  • Non-bizarre-plausible but not correct
  • Mood congruent
  • Mood neutral
318
What is a nihilistic delusion?
  • Typicallyh congruent with depressed mood
Believes they are dead, world is ending etc(cotard)
319
What are grandiose delusions?
  • Patient believes they possess ext5raordinary trais/power
320
Whne are grandiose delusions most commonly seen?
Manic phase of bipolar disorder
321
What are delusions of control?
  • External entity controlling thoughts/actions
322
Whare are persecutory delsuions and when are they most commonly seen?
  • Patient feels conspired against
  • Schizophrenia-paranoid delusions
323
What are somatic delusions?
Convinced they have a physical, medical, biological problem despite no medical evidence
324
What are delusional perceptions?
  • Delusions from an a real perception
Like seeing a certain flower means aliens are landing
325
What are delusions of reference?
  • Things that are mundane (like words in a newspaper) mean something special to the patient
326
Give some differentials for delusions
  • Mood disorders with psychotic features
  • Neurocognitive disorders->Alzheimer's/Parkinson's
  • Substance induced psychosis
327
How are delusions managed?
  • Pharmacological->antipsychotics(treat underlying disorder)
  • Psychotherapy-> CBT to challenge irrational beliefs
  • Psychoeducation
328
What is schizophrenia?
  • Chronic or relapsing/remitting form of psychosis
329
What is the DSM 5 criteria for a schizophrenia diagnosis?
  • Symptoms for at least 6 months
  • At least 1 month of 'active phase' symptoms(1 'ABCD' symptom)
330
What are the different subtypes of schizophrenia?
  1. Paranoid
  2. Catatonic
  3. Hebephrenic
  4. Residual
  5. Simple
331
Describe the features of paranoid schizophrenia?
  • Delusions and hallucinations, often with a persecutory theme
332
Describe the features of catatonic schizophrenia
  • Motor disturbances and way felxibility
333
Describe the features of hebephrenic schizophrenia
  • Disorganised thinking, emotions and bheaviour
334
Describe the features of residual schizophrenia
  • Symptoms persist after a major episode
335
Describe the features of simple schizophrenia
  • Gradual decline in functioning without prominent positive symptoms
336
Describe the aetiology of schizophrenia
  • Huge genetic component
  • Environmental
337
Name some environemntal risk factors for developing schizophrenia
  • Childhood trauma/birth trauma
  • Urban living and immigration to more developed countries
  • Heavy cannabis use in childhood
338
What are the positive symptoms of schizophrenia?
ABCD
  • Auditory hallucinations(3rd person auditory)
  • Thought Broadcasting
  • Control issues
  • Delusional perceptions
339
What are the negative sympotms of schizophrenia?
  • Alogia
  • Anhedonia
  • Affective incongruity/blunting
  • Avolition
340
What are some risk indicators in patients with schizophrenia?
  • Harm to self/others
  • Command hallucinations
  • Hisotyr of self harm or suicidal ideation
  • Fixation on specific individuals
341
What investigations might be done when making a schizophrenia diagnosis?
  • Brain imaging
  • Drug screening
  • Test to exclude infection(HIV, syphilis) or metabolic (thyroid) causes
342
Name some differentials for schizophrenia
  • Substance induced psychotic disorder
  • Organic psychosis-> infection,l brain injurhy, Wilson's, encephalitis
  • Depression and dementia
  • Schizoaffective disorder(mood episodes independent of psychosis)
343
Describe the acute management of schizophrenia
Sedatives: to manage dangerous behaviour
  • Lorazepam
  • Haloperidol
  • Promethazine
IM/oral atyhpical antipsychotics:
  • Risperidone
  • Olanzapine

344
Describe the long term management of schizophrenia
  • Psychiatric referral and psychotherapy
  • Maintainence therapy with atypical antipsychotics(risperidone, olanzapine)
  • Treatment resistant: clozapine
345
How many antipsychotics need to be trialled to consider schizphrenia treatment resistant?
  • At least 2 
346
Describe the prognosis of schizophrenia?
Rule of quarter:
  • 25% never have another episode
  • 25% improve significantly with treatment
  • 25% show some improvement
  • 25% are resistant to treatment
347
Name some factors associated with a good prognosis in patients with schizophrenia
  • High IQ/high education
  • Sudden onset
  • Precipitating factor
  • Strong support network
  • Mostly positive symptoms
348
What are the features of mania/hypomania?
  • High mood
  • Increased irritability
  • Excessive energy
  • Little sleep
349
How is hypomania different to mania?
  • Hypomania;  >=4 days, no psychotic symptoms, limited impairment 
  • Main: >=7 days, severe functional impairment and presence of psychosis
350
What criteria is needed for a diagnosis of bipolar affective disorder?
  • >=2 episodes
  • Including one episode of mania/hypomania
351
What are the different type of BPAD?
  • Type 1 and type 2
352
What is the criteria for BPAD type 1?
>=1 depressive episode and >=1 manic episode
353
What is the criteria for BPAD type 2?
Recurrent major depressive episodes and hypomania
354
How long does a depressive episode need to last for it to count towards a bipolar diagnosis?
At least 2 weeks
355
Presentation of patients with BPAD:
  • Depressive: {{c1::low mood, wothlessness, low energy, suicidal ideation}}
  • Manic: {{c2::high mood, inflated self esteem, little sleep, psychosis, impulsivity, rapid speech}}
  • Others; {{c3::risk taking behaviours-violence, money spending, sexual disinhibition}}
356
Name some differentials for BPAD
  • Major depressive disorder(no mania/hypomania)
  • Cyclothymic disorder
  • Schizoaffective disorder
357
What is cyclothymic disorder?
Mood fluctuations over 2 years
358
When are patients with suspected BPAD refffered to CMHT?
  • Hypomania: routine CMHT referral
  • Mania/depression: urgent CMHT referral
359
Describe the management of new/acute BPAD in a patient presenting with mania/hypomania
  • Stop SSRI
  • Mania+agitation: IM benzo/neuroleptic
  • Main: oral antipsychotics(haloperidol, olanzapine
  • 2nd line: different antipsychotic
  • 3rd: Lithium
  • 4th: ECT
360
Describe the management of new/acute BPAD in a patient presenting with depression
  • Mood stabiliser
  • Consider SSRI/atypical antipsychotic
361
When is BPAD considered chronic and maintainence therapy started?
  • 4 weeks post resolution of acute episode
362
How is chronic BPAD managed?
  • Maintainence therapy: mood stabilisers-lithium
  • High intensity psychological therapy(CBGT, interpersonal therapy)
363
What are the broad features of class a personality disorders
  • Odd/eccentric cluster
364
What age do you need to be to be diagnosed with a personality disorder?
At leasy 18 years
365
What are the Class A personality disorders?
  1. Paranoid personality disorder
  2. Schizoid personality disorder
  3. Schizotypal personality disorder
366
What are the features of paranoid personality disorder?
  • Pervasive and enduring irrational suspicion and mistrust of others
  • Hypersensitivity to criticism
  • Reluctance to confide in others for fear of it being used against them
  • Often preoccupied with unfounded beliefs about conspiracies against them
367
What are the features of schizoid personality disorder?
  • Detachemnt of social relationships, lack of interest/desire for interpersonal relationships
  • Prefer solitary activites
  • Few, if any close relationships outside of immediate family
  • Emotional coldness, detachment, flattened affect
368
What are the features of schizotypal personality disorder?
  • Impaired social interacitons, distorted cognitions and perceptions
  • Inappropriate/constricted afdect, eccentric behaviour
  • Odd thinking and speech, magical thinking, peculiar ideas
  • Paranoid ideation and belief in influence of external forces
369
How is schizotypal personality disorder different to schizophrenia?
  • Both have cognitive/perceptual distortions 
  • Schizotypal personality disorder patients have a better grasp on reality
370
How are class A personality disorders managed?
  • Psychotherapy like CBT
  • Medication mangement for associated symptoms
371
What are the broad features of class B personality disorders?
Dramatic/emotional/impulsive cluster
372
What are the disorders included in the clas B personality disorder cluster?
  1. Antisocial personality disorder
  2. Borderline personality disorder/EUPD
  3. Histrionic personality disorder
  4. Narcissistic personality disorder
373
What are the features of antisocial personality deisorder?
  • Disregard for and violation of the rights of others
  • Exhibit a lack of empathy, engage in manipulative and umpulsive actions
  • Unremorseful behaviour
  • Failure to obey social norms and laws
374
What condition in childhood increases the risk of developing antisocial personality disorder in adulthood, and how can this risk be diminished?
  • Conduct disorder
  • CBT treatment
375
What are the features of BPD/EUPD?
  • Abrupt mood swings, unstable relationships, poor self esteem
  • Inability to contro. temper and manage responses effectively
  • History of trauma and higher propensity for self harm
  • Splitting-relationships idealised or devalued
376
How is BPD managed?
Dialectical behavioural therapy (DBT)
377
Describe the features of histrionic personality disorder
  • Attention seeking behaviours and increased displays of emotion
  • Many display innapropriate sexual bhevaiours
  • Shallow, dramatic and exaggerated emotional expressions
  • Distorted perception of interpersonal boundaries
378
Describe the features of narcissistic personality disorder
  • Persistent pattern on grandiosity, lack of empathy and need for admiration from others
  • Sense of entitlement-> exploit other to fulfil own desires
  • Arrogant and preoccupied with eprsonal fantasies and desires, even at the cost of others' feelings and needs
379
What are the broad features of class C personality disorders
  • Anxious/fearful cluster
380
What personality disorders are included in class C personality disorders?
  1. Avoidant personality disorder
  2. Dependent personality disorder
  3. Obsessive-compulsive personality disorder
381
Describe the features of avoidant personality disorder
  • Intense feelings of social inadequacy, fear of rejection and increased sensitivity to criticism
  • Patients often self impose isolation to avoid strong potential criticism, depsite strong desire for social acceptance and interaction
382
Describe the features of dependent personality disorder
  • Pervasive and excessive need ot be taken care of, leading to submissive and clingy bhevaiour
  • Often lack self-confidence and initiative, relying excessively on others for deciison making
  • Patients may seek new relationships as a source of care and support when existing ones end
383
Descirbe the features of obssessive compulsive personality disorder
  • Excessive preoccupation with orderliness, perfectionism and control
  • Strict adherence to tasks and perfectionism
  • Reluctance to delegate
384
How is obsessive compulsive personality disorder different to OCD?
  • Obsessive compulsive personality disorder has no recurrent intrusive thoughts or rituals
  • Ego-syntonic-patient perceives their symptoms as rational unlike OCD
385
What are medically unexplained symptoms?
  • Persistent bodily complaints for which adequate investigations don't reveal sufficient explanatory pathology
386
What are the features of somatoform disorder
  • Unconscious process
  • Common presentations: GI sx, fatigue, weakness, MSK symptoms
  • Can lead to loos of function
387
Describe the features of conversion disorder
  • Neurological symptoms without an underlying neurological cause
  • Commonly: paralysis, pseudoseizures, sensory changes
  • Linked to emotional stress
  • Unconscious process
388
Describe the features of hypochondriasis
  • Excessive concern they will develop  a serious illness depsite a lack of evidence
  • Typically have no/very few symptoms
  • Patients tend to demand lots of investigations which further anxiety
389
Describe the features of Munchausen's syndorme
  • Fictitious disorder where patients intentionally fake symptoms to gain attention and play a patient role 
  • No insight into motivation
390
WHat is malingering?
  • Patients intentionally fake/induce illness for a secondary gain
  • Secondary gain: drug seeking, benefits, avoiding prison/work
391
How are medically unexplained symptoms managed?
  • Screen for underlying health problems
  • Psychological support and therapied like CBT
392
What is delirium?
  • Acute confusional state, mostly in the elderly, usually reversible
393
What are the general symptoms of delirium?
  • Fluctuating attention and cognition
  • Change in consciousness
394
What are the different types of delirium?
Hyperactive
Hypoactive
Mixed
395
What are the features of hyperactive delirium?
  • Increased psychomotor activity
  • Restlessness
  • Hallucinations
396
WHta are the symptoms of hypoactive delirium?
  • Lethargy
  • Decreased responsiveness
  • Withdrawal
397
Describe the aetiology of delirium?
DELIRIUM
  • Drugs and alcohol
  • Eyes, ears and emotional disturbances
  • Low output state(MIR, ARDS, PE, CHF, COPD)
  • Infection
  • Retention(of stool/urine)
  • Ictal(related to seizure activity)
  • Under hydration/malnutrition
  • Metabolic disorders (Wilson's, thyroid, electrolyte imbalances)
  • Subdural haematoma, sleep deprivation
398
Give some examples of metabolic disorders that can cause delirium
  • Wilson's
  • Thyroid problems
  • Electrolyte imbalances
399
Give some examples of drug classess that can cause delirium
  • Anti-cholinergics
  • Anti-convulsants
400
Describe the typical presentation of a patient with delirium?
  • Disorientation
  • Hallucinations(visual or auditory)
  • Inattention
  • Memory problems
  • Change in mood or personality
  • Sundowning
  • Disturbed sleep 
401
What is sundowning?
  • Increased agitation/confusion later on in the day
402
What are some differentials for delirium?
  • Dementia: gradual onset and stable consciousness level
  • Psychosis: Usually preserved orientation and memory
  • Depression: stable consciousness, pervasive low mood
  • Stroke: focal neurological signs
403
What investigations should be done for a patient to diagnose delirium?
  • Tools: 4AT, CAM for delirium assessment
  • Comprehensive physical exam and infection screen
  • Bedside: bladder scan, medication review, ECG, urine MC&S
  • Bloods: FBC, U&Es, LFTs, TFTs, cultures
  • Imaging: abdo US, CXR
  • CT/MRI if no identifiable cause found
404
How is delirium managed?
Treat underlying cause
Non pharamcological strategies:
  • Environment with good lighting
  • Maintaining a regular sleep-wake cycle
  • Regular orientation and reassurance
  • Ensuring glassess and hearing aids are used
If very agitated, low dose lorazepam/haloperidol
405
What is dementia?
  • Syndorme of chronic/progressive nature which involves the impairment of multiple higher cortical functions
406
What quesitonnaire can be useful for assessing dementia?
Mini mental state exam(MMSE)
407
MMSE results dementia:
<24/30: {{c1::dementia}}
20-24: {{c2::mild
}}13-20: {{c3::moderate}}
<12: {{c4::severe}}
408
How can demential be classified?
  1. Primary
  2. Secindary(caused by something else)
409
Name some primary causes of dementia
  • Alzheimer's
  • Fronto-temporal
  • Lewy body
  • Parkinson's
  • Huntington's
  • Vascular
410
Name some secondary causes of dementia
  • Infection
  • Trauma
  • Post-ictal
  • Toxic
  • Autoimmune
  • Metabolic
  • Neoplastic
  • Congential
  • Endocirne
  • Functional
411
How do patients with dementia present
  • Memory loss
  • Language problems
  • Disorientation
  • Difficulty with ADL's
  • Poor judgement
  • Mood/behaviour/personality changes
  • Withdrawal from society
  • Decrease in consciousness
412
What investigations should be done in a patient with suspected dementia?
  • Functional history(including collateral and risk assessment)
  • Cognitive assessments: MMSE, MOCA, IO-CS, MIS, TYM
  • Brain imaging: CT/MRI
  • Bloods=confusion screen
413
What bloods are including in the 'confusion screen'?
  • FBC
  • U&Es
  • LFTs
  • CRP/ESR
  • Calcium
  • TFTs
  • B12 and folate
  • Syphilis and HIV screen
414
Describe the general management of dementia
HOWSAFE
HOme safety
Wandering
Self-neglect
Abuse
Falls
Eating

  • Lifestyle-encourage activity
  • Social-include OT assessment
  • Psychological-group stimulation therapy
  • Pharmacological
415
What is the most common cause of dementia?
Alzheimer's disease
416
Descirbe the pathophysiology of alzheimer's disease
  • Build up of amyloid plaques and neurofibrially tangles within the brain
417
Name one risk factor for Alzheimer's disease
Down's syndrome
418
Describe the features of alzheimer's disease
4A's:
Amnesia (most recent memories lost first)
Aphasia (word finding problems, muddled speech)
Agnosia (recognition problem)
Apraxia (inability to carry out skilled tasks despite intact motor)
419
What is the treatment for dementia?
  • Mild-moderate: cholinesterase inhibitors(rivastigmine, galantamine, donezepil)
  • Severe: NMDA inhibitor: memantine
420
What is the 2nd most common cause of dementia?
  • Vascualr dementia
421
Descirbe the pathophysiology of vascular dementia
  • Impaired blood flow to areas of the brain due to vascular damage
422
What is the key symptoms of vascualr dementia?
  • 'Step-wise' cognitive decline due to progressive infarcts
423
How is vascular dementia diagnosed?
  • Clinical
  • Neuro-imaging can show evidence of significant small vessel disease
424
How is vascular dementia treated?
  • Manage underlying vascular risk factors, e.g. statins
425
What is the 3rd most common cause of ementia?
Lewy body dementia
426
Describe the aetiology of lewy body dementia
  • Lewy bodies(alpha synuclein) deposits in cells as inclusions
427
What are the key symptoms of lewy body dementia
  • Cogniitive decline and Parkinsonism(rigidity, tremor, bradykinesia)
  • Associated with liliputian hallucinations
428
Desribe the timing of symptom onset in patients with lewy body dementia
  • Dementia, then movement problems both begin within a year of each other 
429
Why does dementia present before parkinsonisn in lewy body dementia?
  • Inclusions affect paralimbic and neocortical areas first, then progress to the substantia nigra
430
How can lewy body dementia be distinguished from dementia due to parkinson's?
Lewy body: dementia first and parkinsonism begin within a year of each other
Parkinson's: Parkisonism first then dementia, develops a year apart
431
Which medications might be used to treat lewy body dementia?
  • Rivastigmine
  • Neuroleptics(haloperidol) can help with hallucinations but worsen rigidity
  • Dopaminergics(amantadine) help rigidity but worsen hallucinations
432
Describe the pathophysiology of fronto-temporal dementia
  • Atrophy of frontal and temporal lobes 
433
What are the key symptoms of fronto-temporal dementia?
  • Behavioural changes
  • Disinhibition
  • Cognitive impairment
434
What age is fronto temporal dementia usually diagnosed?
Age 45-65
Most other types of demenita affect those >65 years
435
Fronto-temporal dementia subtypes:

Behavioural variant(60%): loss of social skills, personal conduct awareness, disinhibition and repetitive behaviour

Semantic dementia(20%): Inability to remember words for things

Progressive non-fluent aphasia(20%): patients can't verbalise. Genetic tests

Pick's disease: diagnosed post portem
436
What is Pick's disease?
Type of fronto temporal dementia where tau proteins that damage frontal and temporal lobes
Diagnosed post mortem
437
How is fronto temporal dementia diagnosed?
  • SPECT imaging: decreased metabolic function in frontal lobe
  • MRI: increased T2 signal in frontal lobe
438
What is anorexia nervosa?
  • Self imposed starvation and relentless pursuit if extreme thinnes
  • Distorted body image
439
What are the subtypes of anorexia nervosa?
  • Restrictive: minimal food intake and excessive exercise
  • Bulimic: Episodic binge eating then behaviours like induce vomiting/laxative use
440
What is the criteria for an anorexia nervosa diagnosis?
  • Restrictive energy/food intake
  • Distorted body image
  • Intense fear of gaining weight
ICD-11 ONLY: low BMI
441
Describe the epidemiology of anorexia nervosa
  • Mostly adolescents and young adults
  • F>M
  • Associated with other psychiatric disorders
442
How is anorexia nervosa diagnosed?
  • Full physical exam and history(including collateral)
  • Bloods
443
What bloods might be different in patients with anorexia nervosa?
  • Deranged electrolyes: low calcium, magnesium, postassium and phosphate
  • Low FSH, LH oestrogen and testosterone
  • Leukopenia
  • Increased GH, and cortisol
  • High cholesterol
  • Metabolic alkalossi
444
What might you see when taking a history of a patient with anorexia nervosa?
  • Preoccupation with food and calories
  • Starvation via restricting intake, purgking or excessive exercise
  • Poor insight, calories in mind regardless of physical health
445
What might you seen on a physical exam in a patient with anorexia nervosa?
  • BMI <17.5kg/m2
  • Hypotension
  • Bradycardia
  • Enlarged salivary glands
  • Lanugo hair
  • Amenorrhoea
  • Pitted teeth
  • Parotid swelling
  • Russel's sign
  • Failed SUSS test
446
What is Russel's sign?
  • Lesions on hand from inducing vomiting
447
How might an examination of someone with anorexia nervosa be different to one with bulimia nervosa?
  • Anorexia: BMI<17.5kg/m2
  • Bulimia: might have normal BMI
448
Describe the management of anorexia nervosa?
  • CBT-ED
  • SSCM
  • MANTRA(maudsley model of AN treatment for adults
  • Family therapy if underage
  • Admission under MHA ofr structured re-feeding
  • MARSIPAN checklist
449
What symptoms might promt inpatient treatment when it comes to anorexia nervosa?
  • Severe/rapid weight loss
  • Suicide risk
  • Failed SUSS test
450
What is the SUSS test anorexia?
  • Sit up squat stand test
  • Assesses proximal muscle weakness which might hint at respiratory muscle weakness
451
Name some complications of anorexia 
  • Re-feeding syndrome
  • Arrhythmias
  • Osteoporosis
452
What arrhythmias might you see as a result of anorexia nervosa?
  • Bradycardia
  • Prolonged QTc
453
What is refeeding syndrome?
Rapid increase in insulin shifts potassium, magnesium and phosphate into cells leading to oedema, tachycradia and confusion
454
How can re-feeding syndrome be prevented?
  • Pabrinex
  • Pre-feeding
  • Monitor and replensih electrolyed
  • Build caloric intake gradually

3A med mine (12 decks)

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