Block 33 Week 4

Question 1

what does the sural nerve supply?

Answer 1

lateral foot and posterolateral leg

Question 2

what does the lateral femoral cutaneous nerve supply?

Answer 2

lateral thigh

Question 3

what does the superficial fibular nerve supply?

Answer 3

antero-lateral aspect of the leg along with the greater part of the dorsum of the foot (with the exception of the first web space, which is innervated by the deep peroneal nerve)

Question 4

first web space innervation?

Answer 4

deep peroneal nerve

Question 5

deep fib nerve supplies?

Answer 5

webbing between first and second digits

Question 6

pulmonary haemorrhage can lead to an elevated?

Answer 6

• TLCO
• to the presence of extra haemoglobin in the lungs that is able to bind to the carbon monoxide due to the high affinity of the molecule.

Question 7

what arises from the endoderm?

Answer 7

thyroid, parathyroid, thymus

Question 8

deficiency in which vitamin can lead to impaired collagen synthesis and disordered connective tissue?

Answer 8

vitamin C

Question 9

hallucinations =

Answer 9

• Perception experienced in the absence of an external stimulus to the corresponding sense organ

Question 10

Visual hallucinations?

Answer 10

• seeing faces, scenes, images

Question 11

auditory hallucinations?

Answer 11

• = hearing voices
• 2nd person/ 3rd

Question 12

Gedankenlautwerden hallucinations?

Answer 12

hallucination where a patient hears voices which anticipate what he or she is about to think, or which state what the patient is thinking as he thinks it.

Question 13

Echo de la pense hallucinations?

Answer 13

hear voices which echo thoughts just after they have occured

Question 14

Types of delusions?

Answer 14

Question 15

reflex hallucinations?

Answer 15

stimulus in one sensory field producing hallucinations in another

Question 16

disorders of thought involves?

Answer 16

form, flow and content

Question 17

retardation of thinking?

Answer 17

• Retardation of thinking/Poverty of content is often seen in depression, the train of thought
  is slowed down, although still goal directed.

Question 18

pressure of speech =

Answer 18

seen in mania

Question 19

disorders of form?

Answer 19

• loosening of association
• flight of ideas
• knights move thinking
• talking past point
• word salad

Question 20

loosening of association?

Answer 20

(loss of normal structure of thinking - discourse appears (Muddled / illogical)

Question 21

flight of ideas?

Answer 21

• when the content of speech moves quickly from one idea to another so that one train of thought is not carried to completion before another takes its place.
• • The normal logical sequence of ideas is generally preserved although ideas may be linked by distracting cues in the surroundings and from distractions from the words that have beenspoken.

Question 22

knights move thinking??

Answer 22

odd associations between ideas

Question 23

word salad?

Answer 23

speech is senseless and repetitive

Question 24

delusions =

Answer 24

• False belief based on incorrect inference about external reality that is firmly sustained.
• It is a belief that is not one ordinarily accepted by other’s of the person’s culture or religion.

Question 25

types of delusion?

Answer 25

* delusions of jealousy - delusions that ones partner is unfaithful without having any proof * grandiose delusions - inflated sense of self

Question 26

delusional mood?

Answer 26

change in mood preceding a delusion - 'something is going on'

Question 27

delusional perception?

Answer 27

-> Delusional perception (linking a normal sensory perception to a bizarre conclusion, e.g. seeing an aeroplane means the patient is the president

Question 28

delusional memory ?

Answer 28

Memory + delusional significance e.g. Man believes he is of royal decent because the spoon he was fed with as a baby had a crown on it

Question 29

epidemiology of schizophrenia?

Answer 29

* one in 100 * ages 15-45, but may develop at any age

Question 30

men tend to develop schiz ?

Answer 30

* males and females equally affected but men tend to develop it earlier at around 20 but women 30

Question 31

genetics of schiz?

Answer 31

* Genetics- high genetic linkage to schizophrenia. * One parent with Schizophrenia 10% lifetime(10% increased chance if you have member of family with the condition.

Question 32

environmental insuts and schiz?

Answer 32

winter or spring births and infections, obstetric complications

Question 33

personality inc schiz risk?

Answer 33

* Personality – person with underlying Schizotypalpersonality disorder.

Question 34

stress and schiz?

Answer 34

* upbringing and stressful life events - increased risk of relapse rates * social stresses - social drift hypothesis

Question 35

cannabis and schiz?

Answer 35

* substance miuse - heavy cannabis intake at 18 associated w inc risk of psyhcosis

Question 36

structural brain abn and schiz?

Answer 36

Decreased cortical volume,enlarged ventricles, hypo frontality (associated with negative symptoms and autism.

Question 37

positive symptoms of schiz?

Answer 37

* presence of problematic behaviours * Hallucinations (illusory perceptions), especially auditory * Delusions (illusory beliefs), especially persecutory * Disorganized thought and nonsensical speech * Bizarre behaviours

Question 38

Negative symptoms of schiz?

Answer 38

* absence of healthy behaviours * Flat affect (no emotion showing in the face) * Reduced social interaction * Anhedonia (no feeling of enjoyment) * Avolition ((less motivation, initiative, focus on tasks) * Alogia (speaking less) * catatonia - moving less

Question 39

3 major phases of schiz?

Answer 39

- prodomal - active phase - residual phase

Question 40

Prodomal phase?

Answer 40

* non specific symptoms can be present for weeks or months preceding the first acute symptoms of Schizophrenia in a young person. - subclinical symptoms - IEPT usually involved here

Question 41

active phase of schiz?

Answer 41

- psychotic symptoms, e.g. delusions, hallucinations are prominent with strong affect of distress, anxiety and fear. - These may resolve spontaneously ( after 4-8 weeks) or continue indefinitely cycling, which means relapse might occur.

Question 42

residual phase of schiz?

Answer 42

- no longer having any of the prominent psychotic symptoms. - However, there are some remaining symptoms of the disorder such as eccentric behaviour, emotional blunting, illogical thinking or social withdrawal.

Question 43

prognosis of schiz?

Answer 43

* 1/3 make complete recovery * 1/3 experience recurrent episodes of psychosis with some degree of social disability * 1/3 may remain chronically disabled.

Question 44

features indicating good prognosis?

Answer 44

* abrupt onset, * an absence of prodromal disturbances, * onset in midlife, * presence of identifiable life stresses, * absence of blunting/flat affect * and/or early treatment

Question 45

schizophrenia involves disruptions in the following dopamine pathways:

Answer 45

- mesolimbic pathway - mesocortical pathway - nigrostriatal pathway - tuberoinfundibular pathway

Question 46

mesolimbic pathway?

Answer 46

key role in motivation, emotions, rewards andpositive symptoms

Question 47

mesocortical pathway?

Answer 47

- physiological cognition and executive function (Dorsolateral prefrontal cortex) - underactivity of dopamine -> negative symptoms

Question 48

mesocortical pathway - emotions and affect?

Answer 48

- ventomedial prefrontal cortex - Hypofunction maybe linked to cognitive and negative symptomsn

Question 49

nigrostriatal pathway?

Answer 49

- contains 80% of brains Dopamine - involved in motor pathway and Dopaminergic neurons stimulate purposeful movement

Question 50

tuberoinfundibular pathway?

Answer 50

- influences prolactin release (Dopamine in the tuberoinfundibular pathway inhibit prolactin release)

Question 51

dopamine role?

Answer 51

(DA is a neurotransmitter found in the mesolimbic-mesocortical system) and feelings of bliss and pleasure, euphoric, appetite control, controlled motor movements, feel focused

Question 52

Amphetamine?

Answer 52

dopamine agonist (so can mimic acute schizophrenia)

Question 53

serotonin?

Answer 53

* setrotonin promotes and improves sleep, improves self esteem, diminishes craving, prevents agitation in depression.> psychosis and agitation

Question 54

glutamate hypothesis of schiz?

Answer 54

* excitatory amino acid NT * hypoglutamatergic state can predispose for schizopgrenia

Question 55

what can block glutamate receptors?

Answer 55

Drugs such as Angel dust, the hallucinogenic drug phencyclidine hydrochloride blocks NMDA Glutamate receptors

Question 56

DDs of psychosis?

Answer 56

* Schizophrenia (Most common) * Schizotypal Disorder- and other Personality disorders * Persistent Delusional Disorder * Schizoaffective Disorder - psychotic and affective symptoms present in the same episode - mania, depressive or mixed presentation * brief psychotic disoerder * Mood disorder with psychotic symptoms like mania with psychosis

Question 57

specific delusional disorders?

Answer 57

capgras, fregoli delusions, folie a deux, erotomania

Question 58

management of psychosis?

Answer 58

* assess risk level * Reducing symptoms and disturbed behaviours * biological interventions * psychological interventions * social interventions

Question 59

biological management of schiz?

Answer 59

* antipsychotics * used to treat psychotic symptoms e.g. with bipolar, Tourette's and medical illnesses like aggression in Dementia

Question 60

typical AP?

Answer 60

* chlorpromazine * Haloperidol * Flupentixol

Question 61

Typical AP mechanism?

Answer 61

* D2 antagonists * better for positive symptoms * cause increased incidence of EPS and NMS

Question 62

Atypical AP examples?

Answer 62

* risperidone * olanzapine * clozapine - Tx resistant cases

Question 63

mechanism of atypical AP?

Answer 63

* low D2 antagonistic effect * Acts on Serotonin arid Histamine receptors * Better on negative symptoms

Question 64

Atypical AP side effects?

Answer 64

* Cause anticholinergic and metabolic side effects

Question 65

EPS side effects - 3 hrs?

Answer 65

* through nigrostriatal pathway * 3 hrs - Acute Dystonia

Question 66

EPS side effects - 3 days - weeks?

Answer 66

* 3 days – weeks - Bradykinesia

Question 67

EPS side effects - 3 months?

Answer 67

* 3 months - Akathisia

Question 68

EPS side effects - tardive dyskinesia?

Answer 68

usually after years

Question 69

Antihistaminic side effects of AP?

Answer 69

* hyperprolaxtinaemia * anti-alpha adrenergic side effects * antimuscarinic * abn liver function * seizures

Question 70

neuroleptic malignant syndrome?

Answer 70

* Neuroleptic malignant syndrome - medical emergency, needs to be taken to A&E * occurs in minutes - hours

Question 71

Psycho-education?

Answer 71

accepting the illness, addressing routine/activity scheduling, sleep hygiene, breathing techniques, mindfulness

Question 72

CBT for schiz?

Answer 72

- psycho-education - family therapy

Question 73

family therapy for schiz?

Answer 73

- awareness of relapse symptoms, supporting structure, looking after the patient

Question 74

social interventions?

Answer 74

- rehabiliation - social support

Question 75

rehabilitation?

Answer 75

- Return to education/work, re-establishing family functioning, management of substance-misuse etc.

Question 76

social support for schiz?

Answer 76

- Housing & Accommodation Issues, Access to benefits etc.

Question 77

approach for chronic enduring psychosis

Answer 77

CPA - Care Programme Approach

Question 78

First rank symptoms of schiz?

Answer 78

- auditory hallucinations: - hearing thoughts spoken aloud hearing voices referring to himself / herself, made in the third person - auditory hallucinations in the form of a commentary - thought withdrawal, insertion and interruption - thought broadcasting - somatic hallucinations - delusional perception - feelings or actions experienced as made or influenced by external agents

Question 79

psychosis may be present in:

Answer 79

–Severe depression –Mania –Delirium (acute presentation, not chronic) –Dementia –Neuropsychiatric disorders such as Parkinson’s - Side-effects of drugs eg steroids, amphetamines

Question 80

epidemiology of schizophrenia?

Answer 80

* 1% lifetime prevalence of schizophrenia * incidence: around 15 new cases per 100000 per annum

Question 81

onset of schiz: the prodome?

Answer 81

* begins in young adulthood * Children who go on to develop schizophrenia often have subtle premorbid motor, linguistic and social dysfunction * Gradual functional decline: fall off in school/college, loss of friends, odd behaviours, ideas, beliefs etc * May go on for months or years

Question 82

Schiz MSE - appearance

Answer 82

may be dishevelled, neglected, wearing special or inappropriate clothes or things that are not clothes

Question 83

Schz MSE - behaviour?

Answer 83

may be overactive or underactive: may make strange gestures or odd purposeless movements: may be responding to hallucinations

Question 84

Schiz - mood?

Answer 84

usually not depressed or elated: can be angry, suspicious, withdrawn, fatuous, vacant, perplexed or ‘flat’ with facial expression to match

Question 85

Schiz - talk?

Answer 85

may be fluent but unintelligible, or very limited: may be preoccupied with abnormal mental content

Question 86

Schiz - cognition is often?

Answer 86

impaired

Question 87

DDs for schiz - always consider?

Answer 87

* Always consider drug induced psychosis: cannabis, stimulants, hallucinogens

Question 88

psychosis could also be?

Answer 88

* Psychosis can be brief, stress related and not schizophrenia

Question 89

affective psychosis?

Answer 89

* Affective psychosis – look for elation/depression

Question 90

organic psychosis?

Answer 90

- rare - temporal lobe epilepsy, SOL, brain trauma, ICU, dementia in older ppl

Question 91

psychosis - managemet plan?

Answer 91

* AP are mandatory in established cases * Most relapses are caused by non-compliance and/or substance abuse * Early intervention in psychosis services

Question 92

For ppts with first episode of psychosis offer:

Answer 92

*oral antipsychotic medication in conjunction with psychological interventions (family intervention and individual CBT,

Question 93

the first episode of psychosis?

Answer 93

* education abt disorder and treatment * Need to help patient and family resolve related matters: education, training, finances, social integration * Need to determined if this is bona fide schizophrenia or persistant substance induced psychotic disorder, and treat accordingly

Question 94

stigma =

Answer 94

refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illnesses.

Question 95

common/ case law is ?

Answer 95

the development of legal standards that have been tested in a court of law over time.

Question 96

statute law =

Answer 96

law passed by Acts of Parliament.

Question 97

common law?

Answer 97

*A person with a mental illness is an autonomous individual, ie is presumed to have capacity to consent to or refuse treatment, unless it is shown to be otherwise.

Question 98

To have capacity to give informed consent a person must be able to:

Answer 98

–Understand the information given –Retain that information long enough to make a decision –Weigh it in the balance free from either internal or external pressures –Communicate the decision

Question 99

mental capacity act?

Answer 99

- enshires principals of common law as regards to the treatment of persons who lack capacity into statute law

Question 100

Mental Health Act (1983)?

Answer 100

* The MHA allows for assessment, treatment and in-patient care for persons with a mental disorder and governs the procedure by which that care is given. * The use of the Mental Health Act is not determined by an assessment of capacity, but rather by the presence or absence of a mental disorder.

Question 101

suicide risk in schiz?

Answer 101

* to oneself - about 10-15% suicide risk in schizophrenia * particularly high in young, educated people early in the course of their illness.

Question 102

risk to others in schiz?

Answer 102

* to others - risk of violence, minor aggression

Question 103

other risks w schiz?

Answer 103

* self neglect - due to postive and negatve symptoms * vulnerability of patients to stigma

Question 104

ideas of reference?

Answer 104

the patient receives special messages from the media, or interprets ordinary events as having special meaning.  Not as overwhelming as delusional perception

Question 105

passitivity experiences =

Answer 105

the patient’s thoughts, moods, bodily sensations or behaviour, which they may experience as abnormal for them, are imposed upon them by an outside agency.

Question 106

disorder of mood =

Answer 106

incongruous or inappropriate affect.  Usually causeless laughter or smiling. May be embarrassing eg laughing when a wreath fell off the coffin at a funeral.

Question 107

main diagnostic features of schiz?

Answer 107

* The main diagnostic features are delusions, hallucinations, thought disorder and lack of insight.

Question 108

what to consider in a first presentation of psychosis?

Answer 108

* Consider intoxication (e.g. cannabis, alcohol, amphetamines) or drug overdose (accidental or suicidal) in first presentation of psychosis or in an acute exacerbation in a patient with established schizophrenia.

Question 109

RF for schiz?

Answer 109

* Family history * Social isolation * Migrants * Family problems * Heavy cannabis use in adolescence * Intrauterine and perinatal complications * Intrauterine infection, particularly viral * Abnormal early cognitive/neuromuscular development

Question 110

red flags in schiz - suicidal thoughts?

Answer 110

*    Severe social problems *    Self-neglect *    Hallucinations, especially command in nature *    Passivity phenomena

Question 111

I & C in schiz?

Answer 111

I - Shame and stigmatisation common C - concerns abt social isolation/ losing their job

Question 112

General examination - appearance?

Answer 112

Appearance. Is there evidence of neglect or abuse? Assess the general nutritional state.

Question 113

GE - dystonias?

Answer 113

Acute dystonias and severe systemic reactions to antipsychotics may occur.

Question 114

GE - alcohol?

Answer 114

Look for signs of alcoholic liver disease (e.g. scratch marks, jaundice, palmar erythema, spider naevi).

Question 115

organic psychosis?

Answer 115

*Cognitive impairment is obvious and severe *Conscious impairment *Hallucinations/delusions *Delirium including drug induced, DTs, ITUs

Question 116

What can cause organic psychosis?

Answer 116

*Psychosis owing to an underlying medical condition eg Korsakow, hepatic encephalopathy, herpes encephalitis, cancer, leukodystrophy etc *Dementia *Learning disability

Question 117

not organic psychosis?

Answer 117

*May have cognitive impairment – subtle *Clear consciousness *Not drugs, alcohol, physical illness, brain insult, neurodegenerative disorder, etcetera *Comes down to schizophrenia and related syndromes, mood disorder with psychotic symptoms

Question 118

organic vs inorganic psychosis?

Answer 118

- organic: concious impairment and cognitive impairment severe - inorganic: clear conciousness and subtle cognitive impairment

Question 119

Might be a first episode of schizophrenia if:

Answer 119

Positive family history (not just schizophrenia) *Shy quiet no friends not very bright *Does drugs on their own/to excess/over a lengthy period *Cannabis, stimulants, NMDA antagonists *Gradual fall off in personal and social function *Prodrome of neurotic symptoms – depression, anxiety, OCD etc *No obvious temporal relationship to drug abuse: insidious onset - Fails to resolve itself especially if treated

Question 120

Greater chance of organicity when:

Answer 120

* older patient * greater cognitive impairment * greater impairment of conciousness * more acute onset (includes drug/ alcohol psychoses) * greater fluctations in cognition and psychotic symptoms

Question 121

schiz diagnostic criteria?

Answer 121

*2 of 5 symptom groups (can be less) *Functional impairment *> 6 months

Question 122

Schizophreniform disorder?

Answer 122

*Don’t need functional impairment *Less than 6 months but more than 1

Question 123

affective psychosis - bipolar?

Answer 123

* bipolar - can have dels/ hals but should be mood congruent - although often persecutory

Question 124

affective psychosis - depression?

Answer 124

* depresion - can have depressive delusions and hallucinations but not common and can be dangerous

Question 125

Schizoaffective disorder?

Answer 125

mood disorder most of the time, but have the 2 of 5 with abnormal mood and then > 2 weeks with just delusions or hallucinations

Question 126

what is a delusional disorder?

Answer 126

* disorders with overvalued ideas * Erotomania,  grandiose,  jealous, persecutory, somatic, pseudocyesis etc

Question 127

what can be preserved w delusional disorder?

Answer 127

* Function preserved: beliefs are plausible * Can be part of something else eg bipolar, PD

Question 128

brief psychotic disorder?

Answer 128

*Brief psychotic disorder: 1 of 4 (no neg symps) *> 1 month: may be stress induced

Question 129

For section 2, a person is unable to make a decision for himself if he can't:

Answer 129

(a) to understand the information relevant to the decision, (b) to retain that information, (c) to use or weigh that information as part of the process of making the decision, or (d) to communicate his decision (whether by talking, using sign language or any other means).

Question 130

what are the motor disorders?

Answer 130

> Catatonia > Motor and behavioural aspects of affective disorders > Motor and behavioural aspects of schizophrenia

Question 131

catatonia?

Answer 131

* predominantly motor disorder * thought to be related to affective disorders * Catatonic symptoms may be found as part of chronic schizophrenia and occasionally in organic cerebral disorders.

Question 132

catatonia - symptoms?

Answer 132

- obstruction - Ambitendence - Automatic obedience - Echolalia, echopraxia - Stupor, catalepsy (not making any movement), posturing - stereotypy and mannerism

Question 133

catatonia - obstruction?

Answer 133

Sudden arrest of fluent movement (spoke in the wheel) i.e. shakes hands, rocking backwards and forwards when sitting.

Question 134

catatonia - Ambitendence?

Answer 134

Alternating co-operation and opposition

Question 135

catatonia - characteristic features?

Answer 135

Stupor, catalepsy (not making any movement), posturing

Question 136

Catatonia - sterotypy?

Answer 136

Repetitive purposeless (non-goal directed) movement (includes verbal)

Question 137

catatonia - mannerism?

Answer 137

Repetitive purposeful movement, goal directed (includes grimaces)

Question 138

Motor and Behavioural aspects of affective disorders can involve?

Answer 138

- agitiation - retardation - stupor - manic stupor

Question 139

agitation?

Answer 139

- can occur in depression - repetitive and usually purposeless movement which when marked may be mistaken for manic overactivity. * The difference is that in mania, several different activities are begun and none completed.

Question 140

stupor?

Answer 140

- reduction in activity which accompanies a variety of disorders including depression, mixed affective states and schizophrenia. - Catatonia, depression, dissociation and organic disorders may be underlying.

Question 141

manic stupor?

Answer 141

rare, bipolar mixed state characterised by flight of ideas + gross motor retardation + elevation of mood

Question 142

Motor and Behavioural aspects of schizophrenia?

Answer 142

- in chronic schiz, there is a general reduction of behaviour including speech due to depression, negative symptoms, medication side effects - but ppts prone to impulsivity

Question 143

lability in mania?

Answer 143

* Lability (changeability) may involve brief period of tearfulness and subjective misery but concomitants of true depression are lacking. * Lability refers to changeability of mood and is usually accompanied by pronounced emotional reactions.

Question 144

(emotional disorders in psychosis) - Incontinence

Answer 144

(dramatic displays of emotion, often for no reason, i.e. organic, dementia, head injuries) in which catastrophic emotional displays occur often entirely without precipitants.

Question 145

mood in acute schizo?

Answer 145

- may be variable - * Perplexity (a sense of puzzlement) or suspiciousness may occur.

Question 146

most common emotional disorder in schiz?

Answer 146

* The most common emotional disorder in chronic schizophrenia is apathy * when applied to an emotional response = flattening of affect

Question 147

blunting =

Answer 147

reduction in changeability of mood.

Question 148

incongruity =

Answer 148

refers to the apparent mismatch (in the eye of the observer) between the content of speech and the affect – so ,for example, a person talking about the death of a beloved pet whilst laughing.

Question 149

pressure of speech (mania) =

Answer 149

Difficulty in interrupting – incessant need to talk

Question 150

Flight of ideas (mania) =

Answer 150

Loss of coherent goal-directed thinking with increasingly obscure associations between ideas; connections between thoughts may be based on: -        chance relationships -        clang associations -        distracting stimuli -        verbal associations

Question 151

clang association?

Answer 151

- mania - Linking words because they sound similar      

Question 152

Knights move thinking?

Answer 152

- schiz - Similar to flight of ideas but the omitted connection bears a more tangential relation to the whole – think of the speech as like a knight jumping around on a chess board.                 

Question 153

Loosening of associations, poverty of content ?

Answer 153

- schiz - Mild varieties of spoken schizophrenic FTD where the content seems vague and meaningless despite adequate volume of speech.

Question 154

Schizophasia, word salad (schizophrenia):

Answer 154

Thought disorder so bad that the person is speaking gibberish. Severe variety of Schizophrenic FTD where speech is virtually incomprehensible

Question 155

Derailment (fusion, drivelling)?

Answer 155

- S - Schneider’s subtypes of schizophrenic thought disorder. Difficult to tell apart, sometimes coexist.

Question 156

perseveration?

Answer 156

Uncontrollable repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus, usually caused by brain injury or other organic disorder.

Question 157

Primary vs secondary delusions?

Answer 157

* A primary delusion is one that is not understandable in terms of other psychopathology. * A secondary delusion is comprehensible in terms of altered mood, hallucinosis, cognitive impairment, thought disorder or other delusions.

Question 158

types of primary delusional?

Answer 158

- delusional intuition - delusional mood - delusional memory

Question 159

delusional mood?

Answer 159

not a thought, but a mood, i.e. like being uneasy or a feeling that things have been changed. Usually ends in a delusional perception.

Question 160

delusional memory?

Answer 160

* delusional memory - remember something that happened as a child * both perception and interpretation are retrospective

Question 161

Overvalued ideas?

Answer 161

An overvalued idea is an idea which is in itself comprehensible or socially acceptable which has come to dominate the patient’s life and is pursued by him beyond the bounds of reason.

Question 162

Overvalued ideas are usually associated w?

Answer 162

a disorder of personality (especially paranoid) but may be accentuated by mood disorder.

Question 163

types of delusions - persecution?

Answer 163

- commonest type found in affective disorders, organic disorders, paranoid schizophrenia and delusional disorders of other type.

Question 164

delusions of reference?

Answer 164

The interpretation of events as self-referential in a delusional way. Usually found accompanying other types of delusions e.g. grandiose or persecutory

Question 165

delusions - dysmorphobia?

Answer 165

- The belief that a part of one’s body is appreciably (by others) deformed or misshapen. - May be monosymptomatic or exist with a more widespread delusional disorder or schizophrenia.

Question 166

delusions - jealousy?

Answer 166

- Associated with psychoses and alcohol abuse. May exist monosymptomatically. - CONSIDER RISK.

Question 167

delusions - De Clerambault’s syndrome ?

Answer 167

- the belief that another person loves the patient. - It is a variety of Erotomania (overvalued love for somebody else), which involves the belief by the patient that he/she and another are in love. - Found in delusional disorder – schizophrenia.

Question 168

nihilistic delusions?

Answer 168

- associated w S and depression - Nihilism refers to the belief that a part of the body is absent (i.e. something was there and has gone). - Sometimes associated with delusions of enormity, (e.g. that if the person empties his bladder the whole world will be drowned).

Question 169

Nihilistic delusions said to be associated w visual hallucinations in ?

Answer 169

Cotard's syndrome

Question 170

Grandiose delusions?

Answer 170

- Belief in special powers, purpose, etc. - Found in mania, paranoid schizophrenia and also occasionally in paranoia

Question 171

delusions - Capgras’ syndrome?

Answer 171

involves the belief that a close person has been replaced by a stranger.

Question 172

delusuons - fregoli syndrome?

Answer 172

involves the belief that one familiar individual has replaced various strangers.

Question 173

Communicated delusion?

Answer 173

- folie a deux - madness of 2 - Principal already psychotic, transmits ideas to associate, who then becomes psychotic. - Usually associate’s psychosis remits following separation. - Principal often in a relationship of dominance with associate (e.g. older sister, parent).

Question 174

delusions - hypochondriasis?

Answer 174

Usually found in depression. May be associated with persecutory ideas in schizophrenia.

Question 175

illusions?

Answer 175

* An illusion is an involuntary false perception consequent on a real object in which a transformation of the object takes place. * Illusions often occur at extreme of tiredness and emotion, but may accompany other abnormal perceptions in psychotic, toxic or organic states.

Question 176

hypogognic/ hynopompic hallucinations?

Answer 176

- Hypnogogic (going to sleep) and Hypnopompic (arising from sleep) hallucinations occur at either end of the sleep period. - The commonest is a voice calling the person’s name. Should arise suspicion that people may have narcolepsy.

Question 177

Dysmorphophobia?

Answer 177

belief that a part (or parts) of the body are appreciably deformed, misshapen

Question 178

typical AP?

Answer 178

- D2 antagonists in the mesolimbic pathway - EPS and hyperprolactinaemia common

Question 179

ATypical AP?

Answer 179

- act on variety of receptors - D2,D3, D4, sertonin - EPS side effecs and hyperprolactinaemia less common - metabolic side effects predominate

Question 180

Atypical AP - 3 examples?

Answer 180

- olanzapine - risperidone - clozapine

Question 181

biological model of psychosis?

Answer 181

* most strongly linked: dopamine * The positive symptoms of psychotic disorders are believed to be caused by excess dopamine in the mesolimbic tract.  * overactivation of D2 receptors

Question 182

other NTs in psychosis?

Answer 182

* decreased function of the NMDA glutamate receptor * ACh inbalance

Question 183

indications of AP?

Answer 183

- schizophrenia - acute mania - MDD with psychotic features - delusional disorder - Tourette disorder

Question 184

Clozaepine?

Answer 184

* used when the patient has failed multiple trials of standard AP therapies * useful for the Tx of tardive dyskinesia  

Question 185

typical AP side effects?

Answer 185

* sig EP side effects * H1 blockade -> sedation

Question 186

TAPs - anticholinergic side effects?

Answer 186

dry mouth, constipation, urinary retention are common with low potency dopamine receptor antagonists like chlorpromazine

Question 187

which typical AP paticularly lowers seizure threshold?

Answer 187

chlorpromazine

Question 188

haloperidol cardiac side effects?

Answer 188

abnormal heart rhythm, ventricular arrhythmia, torsades de pointes

Question 189

chlorpromazine side effects?

Answer 189

blue-gray discoloration and benign pigmentation of the lens and cornea

Question 190

TAPs - dopamine blockage in the tuberoinfundibular tract ->

Answer 190

* Increased serum prolactin concentrations along with galactorrhea, breast enlargement, amenorrhea, impotence in men, and anorgasmia in women

Question 191

AP side effects - neuroleptic malignant syndrome

Answer 191

- rare but fatal - * The onset of symptoms is over 24 to 72 hours

Question 192

symptoms of neuroleptic malignant syndrome?

Answer 192

* with increased temperature, * severe muscular rigidity, * confusion, agitation, * elevation in white blood cell count, * elevated creatinine phosphokinase concentrations, * elevated liver enzymes, myoglobinuria, and acute renal failure.

Question 193

risk of neuroleptic malignant syndrome is higher w?

Answer 193

TAPs but can also occur w atypicals

Question 194

Atypical APs are associated w ?

Answer 194

* associated w sig weight gain and development of metabolic syndrome

Question 195

risperidone is assoc w ?

Answer 195

dizziness, anxiety, sedation, and extrapyramidal side effects

Question 196

Olanzapine is associated w?

Answer 196

weight gain, increased appetite, and somnolence

Question 197

clozapine is associated w?

Answer 197

- hypersalivation, tachycardia, hypotension, and anticholinergic side effects

Question 198

clozapine - monitoring required?

Answer 198

* Clozapine can cause clinically important agranulocytosis, leukopenia, and therefore requires monitoring of white blood cells and absolute neutrophil count. 

Question 199

rehabilitation for psychosis is for thos w ?

Answer 199

* for those w complex psychosis * treatment resistant psychosis * recurrent admissions or extended stays

Question 200

principles of rehabilitation for psychosis?

Answer 200

* recovery-orientated approach - shared ethos and agreed goals, sense of optimism and aims to reduce stihma * deliver individualised, person-centred care through collaboration and shared decision making 

Question 201

rehab for psychosis - be offered the ? envir?

Answer 201

* be offered in the least restrictive environment and aim to help people progress from more intensive support to greater independence * recognise need for supported accomodation

Question 202

MDTs for psychosis rehabiliatation services - who is involved??

Answer 202

* rehabilitation psychiatrists * practitioner psychologists * nurses * occupational therapists * social workers * support workers (including peer support workers) * specialist mental health pharmacists.

Question 203

programmes and interventions for psychosis should develop a ? and offer ? group activities?

Answer 203

* services should develop a culture that promotes improving daily living skills * offer structured group activities (social, leisure or occupational) aimed at improving interpersonal skills. 

Question 204

interventions that can be offered for psychosis rehab?

Answer 204

* educational opportunities such as recovery colleges * substance misuse interventions

Question 205

managing relapse?

Answer 205

* Risk of harm to the person - self harm, suicide, accidental injury, command hallucinations * level of family/ social support * Timing — be aware that the highest risk of suicide tends to be around the time of a psychotic episode and shortly after hospital discharge.

Question 206

risk - history?

Answer 206

* Previous violence, whether investigated, convicted or unknown to the criminal justice system * Relationship of violence to mental state * Lack of supportive relationships * Poor concordance with treatment, discontinuation or disengagement * Impulsivity * Alcohol or substance use, and the effects of these * Early exposure to violence or being part of a violent subculture * stable RF or a change in them? * evidence of recent stressors, losses or threat of loss * Are the family/carers at risk? History of domestic violence * Lack of empathy

Question 207

risk - envir?

Answer 207

* risk on release from restricted settings * Access to potential victims, particularly individuals identified in mental state abnormalities * Access to weapons, violent means or opportunities * Involvement in radicalisation.

Question 208

risk - mental state?

Answer 208

* Evidence of symptoms related to threat or control, delusions of persecution by others, or of mind or body being controlled or interfered with by external forces, or passivity experiences * Voicing emotions related to violence or exhibiting emotional arousal (e.g. irritability, anger, hostility, suspiciousness, excitement * Specific threats or ideas of retaliation * Grievance thinking * Thoughts linking violence and suicide (homicide–suicide) * Thoughts of sexual violence * Evolving symptoms and unpredictability * Signs of psychopathy * restricted insight

Question 209

rates of S across ethnic groups?

Answer 209

* rates of psychotic disorders like schizophrenia can be as much as 5x higher in some ethnic minority groups such as people of black Caribbean or African heritage in the UK.  * Ethnic minority status was associated with more than double the odds of psychotic disorders.

Question 210

what can explain the inc risk of psychosis in ethnic minorties?

Answer 210

* Linguistic distance from the majority group, and social disadvantage, were both associated with nearly double the odds of psychosis, which appeared to mostly explain the increased risk faced by ethnic minority groups

Question 211

culture and schiz diagnosis?

Answer 211

* variation between countries when it comes to diagnosing schizophrenia - overdiagnosis due to ethnic background

Question 212

culture - acceptance of S symptoms in certain cultires?

Answer 212

* One issue is that positive symptoms such as the hallucination or hearing voices may be more acceptable in African cultures because of cultural beliefs in communication with ancestors, and therefore people are more ready to acknowledge such experiences - when reported to psychiatrists this is seen as abnormal, ethnocentric approach

Question 213

culture - over-interpretation of symptoms?

Answer 213

* over-intrepretation of the symptoms of black people during diagnosis - cultural differences in language and mannerisms, difficulties in relating between black patients and white therapists, 

Question 214

schiz diagnosis - age?

Answer 214

* most commonly diagnosed between the ages 15-35 * women tend to present when older (peak in the late twenties, compared to a peak in the early twenties in men).

Question 215

ICD crieria: in patients suffering from psychotic episodes lasting for at least one month, it can be diagnised if 1+ of the following is present:

Answer 215

* Thought echo, thought insertion or withdrawal, or thought broadcasting. * Delusions of control, influence or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception. * Hallucinatory voices giving a running commentary on the patient's behaviour, or discussing him between themselves, or other types of hallucinatory voices coming from some part of the body. * Persistent delusions of other kinds that are culturally inappropriate and completely impossible

Question 216

ICD - can be diagnosed in patients suffering from a psychotic episode lasting for at least one month if two (or more) of the following are present:

Answer 216

* Persistent hallucinations in any modality, when occurring every day for at least one month, when accompanied by delusions (which may be fleeting or half-formed) without clear affective content, or when accompanied by persistent over-valued ideas. * Neologisms, breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech. * Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor. * "Negative" symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses (it must be clear that these are not due to depression or to neuroleptic medication).

Question 217

types of schiz?

Answer 217

- paranoid - hebephrenic - catatonic - undiffereniated

Question 218

Paranoid S?

Answer 218

* Predominant symptom is that of what are stable, normally paranoid delusions. * These are often accompanied by hallucinations (often auditory)

Question 219

what is usually absent in paranoid S?

Answer 219

catatonic symptoms and those of abnormal affect, volition and speech are normally absent.

Question 220

Hebephrenic schizophrenia?

Answer 220

* Affective symptoms are prominent with abnormal behaviour. * Negative symptoms are significant and social isolation may result.

Question 221

Cataonic schiz?

Answer 221

* Predominant symptoms are those of psychomotor disturbance, and may exhibit both hyperkinesis and stupor as well as automatic obedience and negativism. * Other features may include episodes of violent excitement.

Question 222

Ix for schiz?

Answer 222

* ECG - evaluate for long QT if considering antipsychotics * Thyroid function * Syphilis serology * Bloodborne virus screen * Autoimmune screen (e.g. ANA, anti-DS DNA for Lupus)

Question 223

preventing psychosis - referral to specialist services in patients who are distressed with declining social function and:

Answer 223

* Transient or attenuated psychotic symptoms or * Other experiences or behaviour suggestive of possible psychosis or * A first-degree relative with psychosis or schizophrenia

Question 224

Role of EIPs?

Answer 224

* EIP teams are often the first group to review patients with a new episode of psychosis or schizophrenia. * The teams consist of psychiatrists, psychologists, community psychiatric nurses, social workers and support workers.

Question 225

Baseline Ix before starting AP:

Answer 225

* Weight * Height * Waist circumference * Pulse and blood pressure

Question 226

smoking and AP?

Answer 226

smoking can impact the efficacy of antipsychotics (particularly clozapine and olanzapine)

Question 227

CBT for schiz?

Answer 227

- indiv - family

Question 228

indiv CBT?

Answer 228

* CBT aims to help patients explore their conditions. * It looks to help patients create links between their thoughts, feelings and actions with their experience of schizophrenia.

Question 229

CBT - patients are encouraged to?

Answer 229

re-evaluate how their perceptions may relate to symptoms.

Question 230

family CBT?

Answer 230

- should include the patient suffering from schizophrenia if possible as well as their main carer - have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work.

Question 231

First line for psychotic symptoms?

Answer 231

- oral atypical AP * cognitive behavioural therapy should be offered to all patients

Question 232

what should be modified when considering use of AP?

Answer 232

* close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)

Question 233

for ppl w first episode psychosis offer:

Answer 233

* oral AP * psych interventions - family CBT and individual CBT

Question 234

Mx - ppl at risk of psychosis?

Answer 234

* For people who are at risk of developing a psychotic disorder, specialist mental health services will usually offer treatment with individual CBT with or without family intervention.

Question 235

monitoring for AP?

Answer 235

should be monitored for effects for 12 months or until the person's condition has stabilised (whichever is the longest)

Question 236

Mx of an acute behavioural disturbance - de-escalation?

Answer 236

* calming techniques and distractions * offer the child or young person the opportunity to move away from the situation in which the violence or aggression is occurring, for example to a quiet room or area * aim to build emotional bridges and maintain a therapeutic relationship.

Question 237

Mx of an acute behavioural disturbance - restrictive interventions?

Answer 237

* only use if all attempts to defuse the situation have failed and child or young person becomes aggressive or violent. * monitor wellbeing closely

Question 238

what is used for rapid tranquilisation?

Answer 238

* IM lorezepam * IM haloperidol combined with iM promethazine

Question 239

complications of psychotic disorders include:

Answer 239

* An increased risk of premature death due higher rates of suicide, cardiovascular disease, and type 2 diabetes. * Difficulties in social functioning. * Substance misuse.

Question 240

high vs low risk of harm w a psychotic disorder?

Answer 240

* high risk of harm: same-day mental health assessment by the early intervention in psychosis  * not at high risk of harm: EIP team