My Phase 3a Revision > PSYCH > Flashcards

PSYCH Flashcards

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1
Q

MENTAL HEALTH ACT 1983
What does the main part of the MHA allow for?

A
  • ‘Sectioning’ = compulsory admission to hospital for those that are mentally ill.
  • Drs should persuade pts to come in voluntarily if they have capacity, but not always possible (esp if they lack insight)
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2
Q

MENTAL HEALTH ACT 1983
What are the main principles of the MHA?

A
  • Respect for pts wishes + feelings (past + present)
  • Minimise restrictions on liberty
  • Public safety
  • Pts well-being + safety
  • Effectiveness of treatment
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3
Q

MENTAL HEALTH ACT 1983
What is does an individual have to show to be sectioned?

A
  • Evidence of MH disorder
  • Evidence they’re serious risk to self, safety or others
  • Evidence there is good reason to warrant attention in hospital
  • Appropriate treatment must be available for a S3
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4
Q

MENTAL HEALTH ACT 1983
What is a…
i) section 12 approved dr?
ii) approved mental health professional?

A

i) ≥ST4 Dr who has done extra training in MH to get S12 approved to section pts
ii) AMHPs are often social workers who have done extra training in MH

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5
Q

MENTAL HEALTH ACT 1983
Who can remove sections?

A
  • Consultant psychiatrist
  • MH review tribunal (MHT) if pt disagrees w/ section
  • Nearest relative can make an order to discharge pt from hospital with 72h written notice
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6
Q

MENTAL HEALTH ACT 1983
If a relative requests a section removal how can the clinician respond if they disagree?

A
  • Issue a barring report within 72h which stops discharge up to 6m from then
  • Can still apply to MHT if disagrees
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7
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 2?

A

P – admission for assessment, treatment can be given w/out consent
D – 28d, cannot be renewed, can be converted to S3
L – anywhere in community (airports, jail, A+E, etc)
Prof – 2 Drs (1x S12), 1 AMHP, or nearest relative

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8
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 3?
Who is involved if a pt is medicated without consent?

A

P – admission for treatment
D – 6m, can be renewed
L – anywhere in community
Prof – 2 Drs (1x S12), 1 AMHP, nearest relative
Second opinion appointed doctor (SOAD) – after 3m SOAD reviews if medication w/out consent is necessary

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9
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved, evidence needed for a Section 4?

A

P – emergency order
D – 72h
L – anywhere in community
P – 1 S12 Dr, 1 AMHP, nearest relative
E – same as S2 but only in an urgent necessity when waiting for a second dr (for a S2) would lead to undesirable delay/outcome

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10
Q

MENTAL HEALTH ACT 1983
Where can you apply a S5?
What can the team not do?

A
  • Voluntary pt in hospital that wants to leave (NOT A+E as not admitted)
  • Coercively treat the pt
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11
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration + professionals involved for a Section 5(2)?

A

P – Drs holding power, allows for S2/3 assessment
D – 72h
Prof – 1 Dr (usually in charge of their care or nominated deputy

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12
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration + professionals involved for a Section 5(4)?

A

P – nurses holding power until Dr attends to assess
D – 6h
Prof – 1 registered nurse

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13
Q

MENTAL HEALTH ACT 1983
What are the 2 police sections and their differences? What is the duration and purpose of these?

A
  • S135 – needs magistrates court order to access pts home + remove them
  • S136 –person suspected of having mental disorder in a public place
    D – 24h (extend to 36h if intoxicated but should be seen sooner)
    P – taken to place of safety (local psych unit, police cell) for further assessment
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14
Q

ECT
What are the reasons why ECT can be done?
When is electroconvulsive therapy (ECT) recommended?

A
  • Rapid improvement of severe Sx after adequate trial of other Tx proven ineffective and/or condition potentially life threatening
  • Severe mania or depression, suicide risk, catatonia, Rx resistant psychosis
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15
Q

ECT
What are some contraindications to ECT?

A
  • NO absolute, all relative
  • General anaesthesia (reactions)
  • Cerebral aneurysm
  • Recent MI, arrhythmias
  • Intracerebral haemorrhage
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16
Q

ECT
What are some adverse effects of ECT?

A
  • Short-term retrograde amnesia
  • Headache
  • Confusion + clumsiness
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17
Q

DEPRESSION
What is depression?
How common is it?

A
  • Persistent low mood ± loss of pleasure in activities – unipolar depression.
  • 2–6% prevalence globally, F>M but men more likely to be substance misusers + commit suicide
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18
Q

DEPRESSION
What are 2 theories speculating the causes of depression?

A
  • Stress vulnerability = someone with high vulnerability will withstand less stress before becoming mentally unwell
  • Monoamine hypothesis = depression caused by deficiency in monoamines (serotonin, noradrenaline) hence why Tx works
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19
Q

DEPRESSION
What are the biological causes of depression?

A
  • Personal/FHx + genetics
  • Personality traits (dependent, anxious, avoidant)
  • Physical illness (hypothyroid, anaemia, childbirth)
  • Iatrogenic (beta-blockers, steroids, substance misuse)
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20
Q

DEPRESSION
What are the…

i) psychological
ii) social

causes of depression?

A

i) Disrupted relationships, child abuse, poor coping mechanisms
ii) Low socioeconomic status, poor social support, discrimination, divorce, refugee

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21
Q

DEPRESSION
What are some risk factors for depression?

A
  • Physical co-morbidities, esp. chronic + painful (MS, stroke, DM)
  • Genetics + FHx, female, older age, substance abuse
  • Traumatic events (+ve/-ve) like divorce/marriage, (un)employment, poverty, loss
  • Adverse childhood experiences like abuse, poor parent relationships
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22
Q

DEPRESSION
What are the 3 diagnostic criteria for depression?

A
  • Sx present most days ≥2 weeks + change from baselines
  • Sx not attributable to other organic or substance causes
  • Sx impair daily function + cause significant distress
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23
Q

DEPRESSION
What are the three core symptoms of depression?

A
  • Low mood
  • Anhedonia
  • Anergia
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24
Q

DEPRESSION
What are some psychological symptoms of depression?

A
  • Guilt, worthlessness, hopelessness
  • Self-harm/suicidality
  • Low self-esteem
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25
DEPRESSION What are some cognitive symptoms of depression?
- Beck's triad = negative views about oneself, the world + the future - Poor concentration + impaired memory - Avoiding social contact + performing poorly at work (social Sx too)
26
DEPRESSION What are some somatic, or biological, symptoms of depression?
- Disturbed sleep (EMW, initial insomnia, frequent waking) - Disturbed appetite + weight - Loss of libido - Diurnal mood variation (worse in morning) - Psychomotor retardation
27
DEPRESSION What are the 4 classifications of depression?
- Mild = ≥2 core + ≥2 other (minimal interference) - Mod = ≥2 core + ≥3 other (variable interference) - Severe = all core + ≥4 other (marked interference) - Psychotic = Sx of depression + psychosis
28
DEPRESSION What are some features of psychotic depression?
- Mood congruent hallucinations (auditory = derogatory or accusatory voices, olfactory = bad smells) - Nihilistic delusions - Delusions of poverty, guilt, hypochondriacal - Catatonia or marked psychomotor retardation (depressive stupor)
29
DEPRESSION What is Cotard's syndrome?
- Delusional belief that they are dead, do not exist, are rotting or have lost their blood + internal organs
30
DEPRESSION What are some... i) psychiatric ii) organic differentials for depression?
i) Dysthymia, stress-related disorders, bipolar, schizophrenia, anxiety, substance misuse/withdrawal ii) Dementia, Parkinson's, anaemia, hypoglycaemia, Addison's, Cushing's
31
DEPRESSION What are some complications of depression?
- Reduce QOL - Increased morbidity + mortality (IHD, DM) - Suicide (20x more likely than gen pop)
32
DEPRESSION What are some investigations for depression?
- FBC, ESR, B12/folate, U+Es, LFTs, TFTs, glucose, Ca2+ - ECG, MSE + risk assessment - Urine drug screen - PHQ-9 + HADS to screen for depression
33
DEPRESSION When would you consider hospital admission ± MHA in depression?
- Serious risk of suicide or harm to others - Severe depressive or psychotic symptoms - Initiation of ECT
34
DEPRESSION What is the management of mild depression?
- Watchful waiting - Low-intensity psychosocial interventions first line (computerised CBT, individual-guided CBT, structured group physical activity programme) + psychoeducation
35
DEPRESSION Should biological therapy be used in mild depression?
No unless... - Consider if PMH mod-severe depression - Mild depression for 2y or persists after interventions
36
DEPRESSION What is the management of moderate–severe depression?
- Combination of SSRI + high-intensity psychosocial interventions first line - CBT with professional, interpersonal therapy, behavioural activation therapy - Psychoeducation
37
DEPRESSION What is the CAMHS management of depression?
- Watch + wait, lifestyle - First-line = CBT ± family ± interpersonal therapy (may need intensive if no response) - 1st line antidepressant = fluoxetine - Mood + feelings questionnaire (MFQ) to follow-up monitoring in secondary care to assess progress
38
DEPRESSION What is the management for resistant depression?
- Different antidepressants (SNRI, MAOI, mirtazapine) or sometimes two - Augmentation with lithium, atypical antipsychotic or tryptophan
39
DEPRESSION What is the management of psychotic depression?
- ECT first line + v effective in severe cases followed by antidepressant - Antipsychotic initiated before antidepressant if ?primary psychotic disorder then add SSRI
40
DEPRESSION What is atypical depression? What is the management?
- Mood depressed but reactive - Hypersomnia (>10h/day) - Hyperphagia (excessive eating + weight gain) - Leaden paralysis (heaviness in limbs ≥1h/day) - Oversensitivity to perceived rejection - Phenelzine or another MAOI, if not SSRI
41
DEPRESSION What is dysthymia? What is the management?
- Chronic, low-grade or sub-threshold depressive Sx which don't meet diagnostic criteria over a long period of time - Typically >2y of mildly depressed mood + diminished enjoyment, less severe but more chronic - SSRIs + CBT first line
42
DEPRESSION What is seasonal affective disorder? What is the management?
- Episodes of depression which recur annually at same time each year (Jan-Feb) with remission in between - Light therapy + SSRI
43
SELF-HARM What is self-harm?
- Act of intentionally injuring yourself
44
SELF-HARM What are some causes of self-harm?
Bullying, bereavement, homophobia, low self-esteem
45
SELF-HARM Why do people self harm?
Feel in control, reduces feelings of tension or distress, if they feel guilty can be a punishment
46
SELF-HARM What are some methods of self-harm?
- Self-poisoning (paracetamol), cutting, head banging
47
SELF-HARM What are some risk factors for self-harm?
Female Social deprivation, Single or divorced, LGBTQ+, mental illness
48
SELF-HARM What does previous self-harm indicate?
Greatest predictor of future self-harm + increased suicide risk
49
SUICIDE What is suicide?
- Act of intentionally ending your life
50
SUICIDE What are some methods?
Overdose, violent means (jumping from height, into traffic, hanging, cutting)
51
SUICIDE Why is depression higher in females but suicide higher in males?
Men tend to use violent means which are irreversible
52
SELF-HARM + SUICIDE What is parasuicide? Why might this occur?
- Act that mimics suicide but does not result in death - Someone interrupts them, not enough pills, vomited some of the substances out
53
SELF-HARM + SUICIDE What are some risk factors for suicide?
SAD PERSONS – - Sex (M>F) - Age (peaks in young + old) - Depression - Previous attempt - Ethanol - Rational thinking loss (psychotic illness) - Social support lacking (unemployed, homeless) - Organised plan (avoid discovery, plan, notes, final acts) - No spouse - Sickness (physical illness) 0–4 low, 5–6 mod (?hospital), ≥7 high
54
SELF-HARM + SUICIDE What are some protective factors for suicide?
- Married men - Active religious beliefs - Social support - Good employment
55
SELF-HARM + SUICIDE What are some indicators someone may commit suicide?
- Obsessive thoughts of death, feelings of hopeless/helplessness - Active planning (buy equipment, manage affairs, leave notes
56
SELF-HARM + SUICIDE How should a suicide assessment be conducted?
- Before (?trigger) – amount of planning, notes, final acts? - During – method, attempt to avoid discovery, lethality? - After – regret? Intend to re-attempt? Evidence of hopelessness?
57
SELF-HARM + SUICIDE How should paracetamol overdose be managed?
- Acetylcysteine if staggered (>1h) or above treatment line - Rarely if present <1h then activated charcoal can be used
58
SELF-HARM + SUICIDE What is the general management for suicide?
- Plan for further suicidal thoughts + coping strategies - Reduce social isolation, regular contact with services - Manage depression (if present) - ?Inpatient stay or ECT
59
BIPOLAR DISORDER What is bipolar affective disorder? When is the peak age of onset?
- Recurrent episodes of altered mood + activity involving both upswings or (hypo)mania + downswings or depression - Early 20s
60
BIPOLAR DISORDER What are the 4 types of bipolar?
- Bipolar 1 = mania + depression in equal proportions, M>F - Bipolar 2 = more episodes of depression, mild hypomania (easy to miss), F>M - Cyclothymia = chronic mood fluctuations over ≥2y (episodes of depression + hypomania, can be subclinical) - Rapid cycling = ≥4 episodes of (hypo)mania or depression in 1 year
61
BIPOLAR DISORDER What are some potential causes of bipolar?
- Structural brain abnormalities, neurotransmitter imbalances
62
BIPOLAR DISORDER What are some risk factors?
FHx of depression or bipolar, genetics, traumatic life event (abuse), drugs + other meds (antidepressants, BDZs, steroids) sleep deprivation
63
BIPOLAR DISORDER What is the diagnostic criteria for bipolar?
- ≥2 episodes of mood disturbance (1 or which MUST be [hypo]manic)
64
BIPOLAR DISORDER What is the clinical presentation of hypomania?
>4d with ≥3 Sx – - Elevated mood (euphoria) - Increased energy - Increased talkativeness - Poor concentration - Mild reckless behaviour (overspending) - Over-familiar, increased self-esteem - Increased libido - Decreased need for sleep - Appetite change - Partial insight
65
BIPOLAR DISORDER What is the clinical presentation of mania?
>1w with ≥3 Sx – - Extreme elation or irritability - Overactivity + distractibility - Pressure of speech + flight of ideas - Impaired judgement - Extreme risks (jump off buildings, spending spree) - Social disinhibition + grandiosity - Sexual disinhibition - Decreased need for sleep, restless - MOOD CONGRUENT PSYCHOTIC Sx - TOTAL loss of insight
66
BIPOLAR DISORDER In order to differentiate a manic and hypomanic episode, psychotic symptoms must be present. What are some of these?
- Grandiose idea may be delusional - Persecutory delusions sometimes - Pressure speech may become so great that it's incomprehensible - Irritability > violence - Preoccupation with thoughts > self-neglect - Catatonia 'manic stupor'
67
BIPOLAR DISORDER What are some... i) psychiatric ii) organic differentials for bipolar?
i) substance abuse (cocaine, amphetamines), schizophrenia, schizoaffective disorder, ADHD ii) Hyperthyroidism, steroid-induced psychosis, Cushing's
68
BIPOLAR DISORDER What investigations would you perform in suspected bipolar?
- Full Hx, MSE + physical exam to exclude organic - FBC, U+Es, LFTs, glucose, TFTs, calcium, syphilis serology, urine drug test, ?neuroimaging if SOL
69
BIPOLAR DISORDER What is the acute biological management of bipolar disorder?
- Antipsychotic (olanzapine, risperidone) - Lithium (both acutely + long-term) is first-line - ?Stop any antidepressants as can precipitate mania - ?ECT if severely psychotic, catatonic or suicide risk
70
BIPOLAR DISORDER What is the long-term biological management of bipolar disorder?
- Lithium first-line (antipsychotics in pregnancy) - Fluoxetine SSRI of choice if depressive episode
71
BIPOLAR DISORDER What type of referral would you do in bipolar? What is the psychological management of bipolar disorder?
- Hypomania = routine CMHT referral, - mania or severe depression = urgent - CBT for depression, bipolar support groups + psychoeducation
72
SCHIZOPHRENIA What is schizophrenia?
- Splitting or dissociation of thoughts, loss of contact with reality
73
SCHIZOPHRENIA What area of the brain is most affected?
Temporal lobe
74
SCHIZOPHRENIA What is the neurodevelopmental hypothesis in schizophrenia?
- Hypoxic brain injury, viral infections in-utero, TLE + cannabis smoking = risk of schizophrenia indicating brain development link - Imaging has showed enlarged ventricles (poor prognostic feature), small amounts of grey matter loss + smaller, lighter brains
75
SCHIZOPHRENIA What is the neurotransmitter hypothesis in schizophrenia?
- Excess dopamine + overactivity in mesolimbic tract = +ve Sx - Lack of dopamine + underactivity in mesocortical tracts = -ve Sx - Overactivity of dopamine, serotonin, noradrenaline + underactivity of glutamate + GABA
76
SCHIZOPHRENIA What is the epidemiology of schizophrenia?
- 1% lifetime risk, M=F, mortality 25y before gen pop. - Affects 1/100, 2 incidence peaks – men earlier (18–25), women (25–35)
77
SCHIZOPHRENIA What are some risk factors?
Strongest RF = FHx, others = Black Caribbean, migrants, urban areas, cannabis use + traumatic pregnancy (emergency c-section)
78
SCHIZOPHRENIA What are the 6 different types of schizophrenia?
- Paranoid (most common) - Hebephrenic - Simple - Catatonic - Undifferentiated - Residual ('burnt out')
79
SCHIZOPHRENIA What are the features of paranoid schizophrenia?
Persecutory delusions + auditory hallucinations
80
SCHIZOPHRENIA What are the features of hebephrenic schizophrenia?
Dx in adolescents with mood changes, unpredictable behaviour, shallow affect + fragmentary hallucinations, poor outlook as -ve Sx may develop rapidly
81
SCHIZOPHRENIA What are the features of simple schizophrenia?
Pts never really experienced +ve Sx, mostly -ve
82
SCHIZOPHRENIA What are the features of... i) catatonic ii) undifferentiated iii) residual schizophrenia?
i) Psychomotor disturbance such as posturing, rigidity + stupor ii) Sx do not fit neatly into other subtypes iii) Previous +ve symptoms less marked, prominent -ve Sx
83
SCHIZOPHRENIA What can cause schizophrenia?
- Thought to be combination of biopsychosocial factors - Schizophrenia susceptibility + emotional life experiences may = trigger
84
SCHIZOPHRENIA What are the first rank symptoms of schizophrenia? What is the relevance?
- Delusional perceptions - Auditory hallucinations (3 types) - Thought alienation (insertion, withdrawal + broadcasting) - Passivity phenomenon, incl. somatic - ≥1 for at least 1m is strongly suggestive Dx
85
SCHIZOPHRENIA What are the three types of auditory hallucinations that count as a first rank symptom?
- 3rd person = talking about the patient (he/she) - Running commentary = often on person's actions or thoughts - Thought echo = thoughts spoken aloud
86
SCHIZOPHRENIA What are some secondary symptoms of schizophrenia? What is the relevance?
- 2nd person auditory or hallucinations in other modalities - Other delusions (persecutory, reference) - Formal thought disorder - Lack of insight - Negative Sx (incl. catatonia) - ≥2 for at least 1m is strongly suggestive Dx
87
SCHIZOPHRENIA What is the difference between positive and negative symptoms of schizophrenia?
- +ve = presence of change in behaviour or thought, something added (all of the first rank + secondary Sx) - -ve = decline in normal functioning, something removed
88
SCHIZOPHRENIA What are the negative symptoms of schizophrenia?
Often early prodromal, 5As – - Affect blunting, flattening or incongruity - Anhedonia + amotivation - Asociality - Alogia (poverty of speech) - Apathy (Delusional mood = ominous feeling of something impending)
89
SCHIZOPHRENIA What are some... i) psychiatric ii) organic iii) substance differentials for schizophrenia?
i) Delusional disorder, transient psychosis, mania, psychotic depression ii) TLE, encephalitis, delirium, syphilis/HIV, SOL iii) Drug-induced psychosis, alcoholic hallucinosis, steroid-induced
90
SCHIZOPHRENIA What are the investigations for first-episode psychosis?
- Full Hx, MSE + risk assessment - FBC, CRP/ESR, U+Es, LFTs, TFTs, fasting glucose, Ca2+, phosphate, B12 + folate - Urine + serum drugs screen - ?Serological syphilis + HIV - CT/MRI head if ?SOL
91
SCHIZOPHRENIA What teams would be involved in the management of schizophrenia?
- Early intervention team = initial referral after first episode psychosis - CMHT = provide daily support + treatment - Crisis resolution team = pts with acute psychotic episode, often pre-existing diagnosis
92
SCHIZOPHRENIA What would warrant hospital admission ± MHA in schizophrenia?
- High risk of suicide or homicide - Severe psychotic, depressive or catatonic Sx - Failure of OP treatment or non-compliance
93
SCHIZOPHRENIA What is the biological management of schizophrenia?
- Anti-psychotic (tailor SE profile to patient) - Aim for minimal effective dose, use depot if non-compliant to prevent relapse
94
SCHIZOPHRENIA What is treatment resistant schizophrenia? What is the management?
- ≥2 antipsychotics (1 atypical) trialled for ≥6w but ineffective - Clozapine - ECT is last line if resistant to therapy or catatonic
95
SCHIZOPHRENIA What is the psychological management for schizophrenia?
- All patients offered CBT - Family therapy + psychoeducation to reduce or notice relapses
96
SCHIZOPHRENIA What is the social management of schizophrenia?
- Social work + housing involvement may be needed - Drop-in community centres + support groups - Substance misuse service if needed - Depot non-attendance at GP/CPN appt may act as early warning system
97
SCHIZOPHRENIA After a Mental Health Act detention, what approach should be taken to their care? What does it involve?
- Care programme approach - Assess health + social needs, create care plan, appoint key worker as point of contact + review treatment
98
PARAPHRENIA What is paraphrenia? How does it compare to schizophrenia?
- Late-onset schizophrenia >45y - Less emotional blunting + personality decline, F>M
99
PARAPHRENIA Why is it often undiagnosed? What are some risk factors?
- Older patients tend to be socially isolated - Social isolation, poor eyesight + hearing, reclusive + suspicious pre-morbid personality
100
PARAPHRENIA What is the clinical presentation of paraphrenia? How is it managed?
- Delusions, hallucinations + paranoia usually about neighbours - Partition delusions where they believe people + objects can go through walls - Less -ve Sx + formal thought disorder - Low dose antipsychotics
101
TRANSIENT PSYCHOSIS What is transient psychosis? What may cause it? What is it associated with?
- Brief psychotic episodes that last less than time required to diagnose schizophrenia (<1m) - Usually resolves within that time - Acute stressor (loss, marriage, unemployment) - Paranoid, borderline + histrionic personality disorders
102
DELUSIONAL DISORDER What is a delusional disorder?
- Pt experiences strong delusional beliefs (often non-bizarre) + perceptions but with the absence of prominent hallucinations, thought or mood disorder or significant flattened affect - ICD 10 ≥3m (if less it's persistent delusional disorder)
103
DELUSIONAL DISORDER What is erotomania or De Clerambault's syndrome?
- Delusion in which patient (usually single woman) believes another person (typically higher social status) is in love with them
104
DELUSIONAL DISORDER What is Othello syndrome?
- Delusional jealousy - Patients (typically men) possess fixed belief that their partner has been unfaithful + often try to collect evidence
105
DELUSIONAL DISORDER How else might delusional disorder present?
- Delusions about illness, cancer or skin infestation - Grandiose delusions - Persecutory delusions
106
DELUSIONAL DISORDER What is the management of delusional disorder?
- Antipsychotics, ?SSRIs - Individual therapy = establish therapeutic alliance, maybe CBT
107
SCHIZOAFFECTIVE What is schizoaffective disorder?
- Features of both affective disorder + schizophrenia present in equal proportion
108
SCHIZOAFFECTIVE What are the two types of schizoaffective disorder?
Manic type or depressive type
109
SCHIZOAFFECTIVE How does it differ to schizophrenia?
Psychotic Sx tend to wax + wane, unlike in schizophrenia
110
SCHIZOAFFECTIVE What is the prognosis of schizoaffective disorder? What is the management of it?
- Better than schizophrenia but worse than primary mood disorders - Antipsychotics, mood stabilisers of antidepressants (depends on affective disorder)
111
GAD What is Generalised Anxiety Disorder (GAD)? What can it be comorbid with?
- Syndrome of excessive, persistent worry + apprehensive feelings about everyday events that the patient recognises as excessive + inappropriate - Other anxiety disorders, depression, substance abuse, IBS
112
GAD What are 3 cardinal features of GAD?
- Symptoms of muscle + psychic tension - Causes significant distress + functional impairment - No particular stimulus
113
GAD What is the epidemiology of GAD?
- Highest prevalence 45–69y, F>M - Early onset = childhood fears + marital or sexual disturbance - Late onset = stressful event, single, unemployment
114
GAD What model can be used to explain the causes of GAD?
Triple vulnerability – - Generalised biological - Generalised psychological (diminished sense of control) - Specific psychological (stressful events)
115
GAD What are some organic differentials for GAD?
- Endo = hyperthyroidism, pheochromocytoma, hypoglycaemia - CVS = arrhythmias, cardiac failure, anti-hypertensives, MI - Resp = asthma (excessive salbutamol), COPD, PE
116
GAD What are some risk factors for GAD?
- Alcohol, BDZs or stimulants (particularly withdrawal) - Co-existing depression, FHx, female - Child abuse/neglect or excessively pushy parents - Life stresses (finance, divorce) - Physical health problems
117
GAD What is the ICD criteria of GAD? What are the groups of symptoms present in GAD?
- Difficulty controlling worry, present for more days than not for ≥6m - ≥4 symptoms with ≥1 from autonomic arousal section - Autonomic arousal, physical, mental, general, tension, other
118
GAD What symptoms in GAD come under the following categories... i) autonomic arousal? ii) physical? iii) mental? iv) general? v) tension? vi) other?
i) Palpitations, tachycardia, sweating, tremor ii) Breathing issues, choking, CP, nausea, abdo distress iii) Dizzy, derealisation + depersonalisation, fear of losing control, impending death iv) Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking) v) Muscle aches + pains, restless, lump in throat vi) Exaggerated responses to minor surprises/startled
119
GAD What are the investigations for GAD?
- History, MSE + risk assessment - GAD-7 + Hospital Anxiety + Depression Scale (HADS) questionnaire - Exclude organic (FBC, U+Es, LFTs, TFTs, fasting glucose, PTH)
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GAD What is the stepwise management for GAD?
- Education + active monitoring, exercise - Low-intensity psychological interventions like individual self-help or groups - High-intensity psychological interventions (CBT, applied relaxation, arts + music therapy) or biological management
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GAD What is the role of CBT in GAD?
- Cognitive = educate about bodily response to anxiety - Behavioural = use of relaxation to overcome
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GAD What is the biological management used in GAD?
- Sertraline first line, if ineffective offer alternative SSRI or SNRI - If SSRI/SNRI not tolerated then pregabalin - Beta-blockers like propranolol for physical Sx sometimes
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GAD What is the CAMHS management of GAD?
- Watch + wait - Self-help (meditation, mindfulness), diet + exercise - CBT, counselling + SSRI like sertraline may be considered if more severe (specialists)
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PANIC DISORDER What is panic disorder?
- Recurrent panic attacks that are unpredictable + unrestricted in terms of situation, ≥4/week for ≥4w - Usually persistent worry about having another attack - Chronic relapsing condition > distress + social dysfunction
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PANIC DISORDER What is a panic attack?
- Period of intense fear characterised by range of physical Sx that develop rapidly, peak intensity at 10m, generally no longer than 20–30m
126
PANIC DISORDER What is the epidemiology of panic disorder?
- Females 2–3x more likely - Bimodal distribution
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PANIC DISORDER What is panic disorder associated with? What are some risk factors?
- Meds like SSRIs, BDZs, zopiclone withdrawal - Widowed, divorced or separated, living in city, limited education, physical or sexual abuse, FHx
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PANIC DISORDER What are the 3 key elements of panic disorder?
- Sudden onset panic attack with ≥4 characterised Sx - Not necessarily associated with a specific stimulus - Pt preoccupied with suffering death or severe life-threatening illness
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PANIC DISORDER What are the features of panic attacks?
Same as GAD but in discrete attacks – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, muscle aches + pains
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PANIC DISORDER What is the stepwise management of panic disorder?
- Recognition + diagnosis with treatment in primary care - CBT or drug therapy (SSRIs 1st line, if C/I or no response after 12w then imipramine or clomipramine) - Psychodynamic psychotherapy + specialist MH services if severe
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PANIC DISORDER What is the social management of panic disorder?
- Healthy eating, exercise, avoid caffeine. - Meditation, mindfulness, self-help groups
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SIMPLE PHOBIAS What is a simple or specific phobia?
- Recurring excessive + unreasonable anxiety attacks, in the (anticipated) presence of a specific feared object or situation, leading to avoidance if possible
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SIMPLE PHOBIAS What might people be phobic of? Give some examples.
- Animals, blood, injection or injury, situational, natural environment - Emetophobia, claustrophobia, arachnophobia, iatrophobia
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SIMPLE PHOBIAS What is the epidemiology of simple phobias?
- F>M - Mean age is 15 (animal phobias can be as young as 7)
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SIMPLE PHOBIAS What are some potential causes of phobias?
- Psychoanalytical = phobia is symbolic representation of repressed unconscious conflict - Learning theory = conditioned fear response to traumatic situation with learned avoidance
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SIMPLE PHOBIAS What is the clinical presentation of simple phobias?
Same features as GAD but to a specific stimulus – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, muscle aches + pains
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SIMPLE PHOBIAS What is the management of simple phobias?
- Exposure + response prevention (ERP) - CBT (education + anxiety management, coping strategies) - BDZs in severe cases to reduce avoidance
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SIMPLE PHOBIAS What are the two methods of ERP? Which is preferred?
- Desensitisation with relaxation + graded exposure - Flooding where exposed to most frightening situation instantly - Desensitisation as flooding can be highly traumatic
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AGORAPHOBIA What is agoraphobia?
- Anxiety + panic symptoms associated with places or situations where escape may be difficult or embarrassing leading to avoidance. - ≥2 from: crowds, public places, travelling alone or away from home.
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AGORAPHOBIA What may be seen in patients with agoraphobia? What is the epidemiology?
- Predisposition towards overly interpreting situations as dangerous - F>M, 15–35y, may have co-morbid panic disorder
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AGORAPHOBIA What is the clinical presentation of agoraphobia?
Same as GAD but to the specific situations – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking)
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AGORAPHOBIA What is the biological management of agoraphobia?
- SSRIs as for panic disorder - BDZs for short-term use only (clonazepam)
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AGORAPHOBIA What is the psychological management of agoraphobia?
- CBT (teach about bodily responses related to anxiety and exposure + desensitisation techniques, relaxation training)
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SOCIAL PHOBIA What is social phobia?
- Sx of incapacitating anxiety that are restricted to particular social situations, leading to a desire for escape or avoidance (may reinforce belief of social inadequacy)
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SOCIAL PHOBIA What is the epidemiology of social phobia?
- Bimodal distribution with peaks at 5y + 11–15y, may present in 30s
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SOCIAL PHOBIA What is the clinical presentation of social phobia?
≥2 Somatic Sx in response to the situation – - Blushing, trembling, dry mouth, sweating - Excessive fear of humiliation, embarrassment, micturition or others noticing how anxious they are. - Characteristically self-critical + perfectionist
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SOCIAL PHOBIA What is the impact of social phobia?
- Avoiding situations may lead to relationship issues, education + vocational problems (difficulty interacting with others, presentations)
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SOCIAL PHOBIA What is the biological management of social phobia?
- SSRIs (sertraline) > SNRIs > MAOIs - Beta-blockers like propranolol - Clonazepam may be useful short-term
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SOCIAL PHOBIA What is the psychological management of social phobia?
- Either individual or group CBT first-line with SSRI (relaxation training, social skills, graded exposure) - Psychodynamic psychotherapy
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OCD What is obsessive compulsive disorder (OCD)?
- Condition characterised by obsessions + compulsions which must cause distress or interfere with their social or individual functioning (usually by wasting time)
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OCD What are some examples of obsessions and compulsions?
- Obsessions = being followed, everything being dirty or contaminated - Compulsions = checking, washing, doubting, bodily fears, counting, symmetry, aggressive thoughts
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OCD What are the two types of compulsions? What is the natural cycle in OCD?
- Overt = can be observed (checking the door) - Covert = can't be observed (repeating a phrase in their mind) - Obsession > anxiety > compulsion > relief
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OCD What is the epidemiology of OCD?
- Adolescents or early adulthood (20y mean age), M=F
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OCD What is a potential cause of OCD?
Neurochemical dysregulation of 5-HT system
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OCD What are some risk factors for OCD?
- Genetics = FHx of OCD or tic disorder - Abuse, neglect, teasing + bullying - Parental overprotection - Paediatric neuropsychiatric disorders associated with streptococci (PANDAS)
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OCD What are the key features of OCD?
- Obsessions ± compulsions present most days >2w - Acknowledged as excessive + unreasonable + originate from inside patient's mind (not influenced by outside) - Repetitive or unpleasant + pt tries to resist them unsuccessfully - Time consuming, interferes with ADLs, distress to pt - Avoidance of stimuli that trigger Sx
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OCD What is the biological management of OCD?
- 1st line SSRIs = sertraline - 2nd line = clomipramine (TCA) with specific anti-obsessional action - ?Psychosurgery (stereotactic cingulotomy if intractable > 2 antidepressants, 3 combination Tx, ECT + behavioural therapy
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OCD What is the psychological management of OCD?
- CBT but behavioural approach - ERP (stop carrying out compulsion in response to stimulus) - Psychotherapy (incl. family, groups)
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OCD What is the OCD management for CAMHS?
- Mild can be managed with psychoeducation or self-help - Referral to CAMHS, CBT + initiation of SSRI with CAMHS specialist guidance
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PTSD What is post-traumatic stress disorder (PTSD)? What counts as a traumatic event?
- Severe psychological disturbance following a traumatic event (within 6m usually). - Catastrophic event where there is threat to security or physical integrity (life-threatening) such as war, surviving tsunami, sexual assault, not everyday trauma (divorce)
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PTSD What are some risk factors for PTSD?
- Low education or social class - F>M - Previous PTSD/psych issues - First responders (ambulance, police, fire) - Military (dependent on duration of combat exposure, lower rank, low morale)
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PTSD What are the 4 core symptoms of PTSD? How long do they need to be present for to diagnose?
HEAR (≥1m) – - Hyperarousal - Emotional numbing - Avoidance + rumination - Re-experiencing (involuntary)
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PTSD In terms of PTSD, what are signs of... i) hyperarousal? ii) emotional numbing?
i) Hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating or sleeping (falling + staying asleep) ii) Difficulty experiencing emotions, restricted range of affect, detachment from others
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PTSD In terms of PTSD, what are signs of... i) avoidance + rumination? ii) re-experiencing?
i) Avoiding people, situations, thoughts or circumstances resembling or associated to event ii) Flashbacks, nightmares, vivid memories, distressing images or other sensory impressions from event which intrude during waking day, reminders of event = distress
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PTSD What is the mainstay of management in PTSD?
Psychological therapy – - Trauma-focused CBT - Eye movement desensitisation and reprocessing (EMDR)
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PTSD What is trauma-focused CBT?
- Education about nature of PTSD, self-monitoring of Sx, anxiety management, breathing techniques + exposure in supportive setting
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PTSD What is EMDR?
- Voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts + help process emotions
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PTSD What is the medical management of PTSD?
- Venlafaxine or SSRI like sertraline - Risperidone for severe cases where resistant to treatment or psychotic
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ANOREXIA NERVOSA What are the 2 types of anorexia nervosa?
- Restrictive = limit food intake - Binge/purge = binge eat + purge straight away (different from bulimia due to BMI)
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ANOREXIA NERVOSA How is anorexia classified based on BMI?
- Anorexia = <17.5kg/m^2 - Medium risk = 13–15 - High risk = <13
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ANOREXIA NERVOSA What is the outcome of anorexia nervosa?
1/3 recover, 1/3 relapse + remit, 1/3 chronic lifelong
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ANOREXIA NERVOSA What is the epidemiology of anorexia?
- F>M - Onset is early to mid adolescence
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ANOREXIA NERVOSA What premorbid experiences may lead to anorexia development?
- Dieting behaviour in family/personal experience, over-protective family - Criticism about weight, personal Hx of obesity, adverse events (abuse) - Perfectionism, low self-esteem, disturbed body image, obsessional traits
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ANOREXIA NERVOSA What is the diagnostic criteria for anorexia?
FEED ≥3m with absence of binge eating – - Fear of fatness - Endocrine disturbance - Extreme weight loss - Deliberate weight loss
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ANOREXIA NERVOSA How may fear of fatness present?
- Over-valued idea - Self-esteem unduly influenced by weight/shape - Intense fear of gaining weight > body image distortion
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ANOREXIA NERVOSA How may endocrine disturbance present?
- Amenorrhoea - Reduced libido/fertility - Abnormal insulin secretion - Delayed/arrested puberty if onset pre-pubertal
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ANOREXIA NERVOSA How may extreme weight loss present?
- >15% below expected for height (BMI ≤17.5kg/m^2)
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ANOREXIA NERVOSA How may deliberate weight loss present?
- Restrictive eating (skipping meals) - Over-exercising - Vomiting - Appetite suppressants - Laxatives
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ANOREXIA NERVOSA What are some physical symptoms of anorexia?
- GI Sx = constipation, dysphagia (vomiting), abdo pains - Dizziness/fainting, headaches, cold intolerance - Polyuria (diuresis), polydipsia
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ANOREXIA NERVOSA What are some clinical signs of anorexia?
- Lanugo hair = fine, soft body hair - Gaunt face, dry skin, loss of muscle mass - Acrocyanosis = blue colouration of peripheries due to slow circulation
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ANOREXIA NERVOSA What are some complications of anorexia?
- Osteoporosis, thyroid issues, cardiac atrophy - Electrolyte disturbances (hypokalaemia > arrhythmias) - Decrease in WBC > increased infections - Death due to health complications or suicide
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ANOREXIA NERVOSA What screening tool can be used in anorexia?
SCOFF – - Do you ever make yourself SICK as too full? - Do you ever feel you've lost CONTROL over eating? - Have you recently lost more than ONE stone in 3m? - Do you believe you're FAT when others say you're thin? - Does FOOD dominate your life?
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ANOREXIA NERVOSA What are some investigations for anorexia?
- Sit up squat stand (SUSS) test /3 - BP (low), temp (low) - ECG (brady, T-wave changes, QTc prolongation) - FBC (anaemia, dehydrated), LFTs, urinalysis, serum proteins - U+Es, Ca2+, Mg2+, phosphate > vomiting, laxatives, diuretics, water loading - DEXA scan after 1y of underweight (osteopenia)
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ANOREXIA NERVOSA In anorexia, most things are low apart from what?
Gs + Cs – - GH, Glucose, salivary Glands - Cortisol, Cholesterol, Carotinaemia
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ANOREXIA NERVOSA What risk assessment tool can be used for assessing if a patient with anorexia needs inpatient psychiatric admission?
Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN)
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ANOREXIA NERVOSA What are the MARSIPAN indicators of admission?
- BMI <13, severe malnutrition or dehydration - HR <40, ECG changes - BP <90 systolic, <70 diastolic esp with postural drop - Temp <35 - Severe electrolyte disturbances (K+, Na+, Mg2+, phosphate = low) - SUSS test of 0 or 1 - Significant suicide or serious self-harm risk
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ANOREXIA NERVOSA How should the physical complications of anorexia be managed?
- Monitor U+Es + ECGs - Oral supplements for electrolytes, thiamine - Multivitamins + mineral supplements, calcium + vitamin D - Safely + slowly re-feed pt + avoid refeeding syndrome
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ANOREXIA NERVOSA What are the biological treatments for anorexia nervosa?
- Fluoxetine, chlorpromazine + TCAs may be used for weight gain
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ANOREXIA NERVOSA What are the psychological therapies for anorexia?
- Individual therapy (eating disorder focussed CBT, CBT-ED) - Maudsley anorexia nervosa treatment for adults (MANTRA) - Specialist supportive clinical management (SSCM)
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ANOREXIA NERVOSA What is the social management for anorexia?
- Avoid over exercise - Food diary/dietary advice - Self-help groups
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ANOREXIA NERVOSA What is the CAMHS treatment for anorexia?
- Family therapy 1st line, pt + carer education, self-help resources - Adolescent-focussed psychotherapy, individual CBT-ED - May require SSRIs
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ANOREXIA NERVOSA What is refeeding syndrome? What are some risk factors?
- Metabolic disturbances due to reintroduction of nutrition to a starving patient who is fed too much, too quickly - Low BMI, poor nutritional intake (>5d), Hx of high alcohol intake, chemo, unintentional weight loss
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ANOREXIA NERVOSA What is the pathophysiology of refeeding syndrome?
- Reduced carb consumption leads to reduced insulin secretion so the body switches from carb > fat + protein metabolism - Electrolyte stores depleted as needed to convert glucose>energy - Reintroducing food causes abrupt shift from fat>carb metabolism + insulin secretion surges, driving electrolytes from serum>cells to help convert glucose>energy causing further serum concentration decrease
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ANOREXIA NERVOSA What is the clinical presentation of refeeding syndrome?
- Fatigue, weakness, confusion, dyspnoea (risk of fluid overload) - Abdo pain, vomiting, constipation, infections
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ANOREXIA NERVOSA What are the consequences of refeeding syndrome?
Can lead to cardiac arrhythmias, convulsions, cardiac failure, coma + death
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ANOREXIA NERVOSA What are the biochemical features of refeeding syndrome?
- Hypophosphataemia main disturbance due to role of converting glucose>energy - Hypokalaemia, hypomagnesaemia + thiamine deficiency too - Abnormal fluid balance
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ANOREXIA NERVOSA What should be monitored before + during refeeding?
- U+Es (Na+, K+), phosphate, magnesium, glucose, ECG, fluid balance
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ANOREXIA NERVOSA What is the management of refeeding syndrome?
- Start up to 10cal/kg/day + increase to full needs SLOWLY over 4–7d - Start PO thiamine, B vitamins + supplements before + during feeding - K+, phosphate + magnesium replacement
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BULIMIA NERVOSA What is bulimia nervosa?
- Characterised by recurrent episodes of binge eating + compensatory behaviours (purges)
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BULIMIA NERVOSA What is a binge?
- Episodes of overeating a large amount of food in a discrete period of time where an individual feels that they cannot control their eating
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BULIMIA NERVOSA What are purges?
- Compensatory behaviours to prevent weight gain like induced vomiting, laxative misuse, diuretics, appetite suppressants, enemas, fasting or excessive exercise
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BULIMIA NERVOSA What is the epidemiology + aetiology of bulimia?
- F>M, common in adolescent, very common premorbid experiences to anorexia (dieting behaviour, weight criticisms, perfectionism)
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BULIMIA NERVOSA What is the diagnostic criteria for bulimia?
BPFO ≥2 a week for ≥3m – - Behaviours to prevent weight gain - Preoccupation with eating (compulsion to eat but regret after) - Fear of fatness - Overeating ≥2/week
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BULIMIA NERVOSA What are some physical symptoms of bulimia?
- Similar to anorexia but less severe - GI (constipation, bloating, sore throat, GORD + dyspepsia from vomiting, abdo pains) - Dizziness/fainting, headaches, cold intolerance - Polyuria (diuresis), polydipsia, lethargy
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BULIMIA NERVOSA What are some clinical signs of bulimia?
- Russel's sign (calluses on dorsum of dominant hand due to vomiting) - Dental enamel erosion - Mouth ulcers - Salivary gland, especially parotid, enlargement
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BULIMIA NERVOSA What are some complications of bulimia?
- Cardiomegaly (ipecac toxicity = plant taken PO + can cause vomiting) - Arrhythmias, cardiac failure - Mallory-Weiss tears from vomiting
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BULIMIA NERVOSA What are some investigations for bulimia?
- SCOFF - BP (low), temp, SUSS test - ECG (arrhythmias from hypokalaemia) - FBC (anaemia), LFTs, urinalysis, serum proteins - Monitor U+Es, calcium, magnesium, phosphate in vomiting, laxative abuse, diuretics or waterloading (for deceitful weighing)
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BULIMIA NERVOSA What metabolic abnormalities may be present?
- Hypochloraemic hypokalaemic metabolic alkalosis due to vomiting - Hypokalaemia > muscle weakness + arrhythmias
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BULIMIA NERVOSA When should bulimia be managed as inpatient?
- Suicidality, physical problems, extreme refractory cases - Pregnancy (risk of spontaneous abortion)
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BULIMIA NERVOSA What is the management of bulimia?
- Guided self-help first line with psychoeducation + support group - CBT-ED - Bulimia focussed family therapy in CAMHS - Limited evidence for high-dose fluoxetine
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BINGE EATING DISORDER What is binge eating disorder?
- Episodes where person excessively overeats, often as expression of underlying psychological distress - Not restrictive so tends to be overweight
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BINGE EATING DISORDER How does binge eating disorder present?
- Planned bine with binge foods - Eating very quickly + becoming uncomfortably full - Eating in "dazed" state - Unrelated to if hungry
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BINGE EATING DISORDER What is the management of binge eating disorder?
- Self-help, CBT-ED, may benefit from SSRIs
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PERSONALITY DISORDERS What are personality disorders?
- Deeply engrained + enduring patterns of behaviour that are abnormal in a particular culture
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PERSONALITY DISORDERS What is the epidemiology of personality disorders?
- Younger adults - Antisocial PD most prevalent amongst prisoners - Dx not made in <18 as personality still developing
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PERSONALITY DISORDERS What are some risk factors for personality disorders?
- FHx of PD or other mental illness - Abusive, unstable or chaotic life - Adverse events - Dx of childhood conduct disorder (antisocial PD)
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PERSONALITY DISORDERS What are cluster A personality disorders?
- Characterised by odd, eccentric thinking or behaviour - MAD
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PERSONALITY DISORDERS What is paranoid personality disorder?
- Pervasive + unwarranted tendency to interpret the actions of others as demeaning or threatening
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PERSONALITY DISORDERS In terms of paranoid personality disorder... i) think the world is? ii) think people are? iii) acts as if? iv) common behaviour? v) least likely to be? vi) emotional hotspot?
i) Conspiracy ii) Devious, trying to cause harm iii) Always on guard + suspicious of others, emotionally cold/distant iv) Watchfulness v) Trusting (fear others will use information against you) vi) Being discriminated against
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PERSONALITY DISORDERS What is schizoid personality disorder?
- Pervasive pattern of indifference to social relationships + restricted range of emotional experience + expression
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PERSONALITY DISORDERS In terms of schizoid personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Uncaring ii) Pointless, replaceable iii) Only person they can depend on iv) Withdrawal, prefer to be alone v) Emotionally available + close vi) Being over-cared for or smothered by others vii) Inability to take pleasure from activities, little interest in sex
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PERSONALITY DISORDERS What is schizotypal personality disorder?
- Pervasive pattern of deficits in interpersonal relatedness + peculiarities of ideation, experience, appearance + behaviour
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PERSONALITY DISORDERS What are some features of schizotypal personality disorder?
- Ideas of reference (not delusions as insight) - Excessive social anxiety with lack of close friends + social withdrawal - "Magical thinking" believing you can influence people/events with thoughts - Unusual perceptions (illusions, overvalued ideas) - Odd/eccentric behaviour, beliefs, speech or appearance - Inappropriate affect with paranoid or suspicious ideas
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PERSONALITY DISORDERS What are some differentials of schizotypal personality disorder?
- Autism - Asperger's - Schizophrenia (50% may develop it)
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PERSONALITY DISORDERS What are cluster B personality disorders?
- Characterised by dramatic, overly emotional or unpredictable thinking or behaviour (BAD)
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PERSONALITY DISORDERS What is dissocial/antisocial personality disorder?
- Childhood conduct disorder before 15 + pattern of irresponsible + antisocial behaviour after age 15
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PERSONALITY DISORDERS What is a psychopath? What is a sociopath?
- When they get in trouble with the law - Same traits but without law involvement
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PERSONALITY DISORDERS In terms of antisocial personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Predatory ii) Weak iii) Autonomous + alone iv) Aggressive/violent v) Gentle + sensitive, conform to social norms vi) Perceiving exploitation vii) Disregard for others' needs, feelings, safety, impulsive + lacks remorse
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PERSONALITY DISORDERS What is borderline/emotionally unstable personality disorder? What is a big risk factor?
- Pervasive pattern of instability of mood, interpersonal relationships + self image - Often Hx of childhood sexual abuse
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PERSONALITY DISORDERS In terms of EUPD... i) think the world is? ii) think people are? iii) common behaviour? iv) least likely to be? v) emotional hotspot? vi) other?
i) Contradictory ii) Untrustworthy iii) Self-harm/suicide (impulsive + unpredictable) iv) Able to show self-compassion v) Abandonment (extreme reactions) vi) Paranoid when stressed, labile mood, unstable + intense relationships
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PERSONALITY DISORDERS In terms of EUPD, what is the difference between... i) impulsive type? ii) borderline type?
i) Difficulties with impulsive + risky behaviours (unsafe sex, gambling) + anger ii) Difficulties with relationships, self-harm + feelings of emptiness
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PERSONALITY DISORDERS What is histrionic personality disorder?
- Pervasive pattern of excessive emotionality + attention seeking
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PERSONALITY DISORDERS In terms of histrionic personality disorder... i) think the world is? ii) think people are? iii) common behaviour? iv) least likely to be? v) emotional hotspot? vi) think they are? vii) think relationships with others are?
i) Their audience (crave attention) ii) In competition for attention iii) Exhibitionism (provocative for attention) iv) Able to listen to others v) Actively or passively side-lined vi) Vivacious, easily influenced by others, excessive concern with physical appearance vii) Closer than what they really are
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PERSONALITY DISORDERS What is narcissistic personality disorder?
- Pervasive pattern of grandiosity, lack of empathy + hypersensitivity to the evaluation of others
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PERSONALITY DISORDERS In terms of narcisssitic personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
THINK LUKE i) Competition ii) Inferior iii) Special + more important than others iv) Competitiveness v) Humble vi) Loss of social rank/status or being embarrassed vii) Failure to recognise other's needs or feelings, arrogance, envy (both ways)
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PERSONALITY DISORDERS What are cluster C personality disorders?
- Characterised by anxious, fearful thinking or behaviour (SAD)
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PERSONALITY DISORDERS What is anxious/avoidant personality disorder?
- Pervasive pattern of social discomfort, fear of negative evaluation + timidity
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PERSONALITY DISORDERS In terms of anxious/avoidant personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Evaluative ii) Judgemental iii) Inept iv) Inhibition (social, avoids this) v) Assertive vi) Exposed, ridicule, criticism or rejection vii) Feeling inadequate or inferior, extreme shyness, fear of disapproval
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PERSONALITY DISORDERS What is dependent personality disorder?
- Pervasive pattern of dependent + submissive behaviour
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PERSONALITY DISORDERS In terms of dependent personality disorder... i) think the world is? ii) think people are? iii) they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Overwhelming ii) Stronger + more competent than themselves iii) Needy iv) Clinging v) Self-sufficient vi) Making a decision, abandonment vii) Requires excessive advice/reassurance, tolerant of abusive treatment, relationship hops, difficult disagreeing with others
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PERSONALITY DISORDERS What is anankastic/obsessive-compulsive personality disorder? What may it be seen in?
- Pervasive pattern of perfectionism + inflexibility lacking insight - Hx of family pressure + wanting approval
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PERSONALITY DISORDERS In terms of anankastic/OC personality disorder... i) think the world is? ii) think people are? iii) think they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Sloppy ii) Irresponsible iii) Responsible iv) Controlling v) Flexible vi) Making a mistake vii) Preoccupied with order, extreme perfectionism, neglect friends due to excessive project commitment, rigid + stubborn
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PERSONALITY DISORDERS What are some investigations for personality disorders?
- Assessed (Hx + MSE) more than once - Minnesota Multiphasic Personality Inventory (MMPI) - Eysenck Personality Inventory + Personality Diagnostic Questionnaire
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PERSONALITY DISORDERS What is the biological management of personality disorders?
- Only use to treat comorbid conditions or if Sx distressing (e.g. antipsychotics in group A to reduce suspiciousness)
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PERSONALITY DISORDERS What are the psychological therapies for personality disorders?
- Dialectical behavioural therapy for EUPD - CBT (change unhelpful ways of thinking) - Cognitive analytical therapy (recognise + change unhelpful patterns in relationships + behaviours) - Psychodynamic therapy (looks at how past experiences affect present behaviour)
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DELIRIUM TREMENS What is delirium tremens?
- Acute, toxic confusional state secondary to alcohol withdrawal (48–72h after)
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DELIRIUM TREMENS How does delirium tremens present?
- Clouding of consciousness, disorientation + amnesia of recent events - Autonomic = diaphoresis, fever, tachycardia (risk of CV collapse) - Psychomotor agitation, delusions + coarse tremor - Visual, auditory + tactile hallucinations
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DELIRIUM TREMENS Describe the hallucinations in delirium tremens
- Characteristically of small people or animals (Lilliputian hallucinations) - May feel 'ants crawling'
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DELIRIUM TREMENS What is the management of delirium tremens?
- ABCDE approach as emergency - IV thiamine (pabrinex), supportive fluids - PO lorazepam first line to prevent fitting (IV or haloperidol if refused)
250
WERNICKE'S What is Wernicke's encephalopathy?
- Atrophy of mammillary bodies due to thiamine deficiency, often alcohol abuse
251
WERNICKE'S How does Wernicke's present?
Triad – - Ataxia - Confusion - Ophthalmoplegia + nystagmus
252
WERNICKE'S What is the management of Wernicke's?
- ABCDE approach as emergency - IV pabrinex immediately - Treat high risk patients (alcoholics) with prophylactic vitamins
253
KORSAKOFF'S What is Korsakoff's psychosis?
- Thiamine deficiency causes damage + haemorrhage to the mammillary bodies of the hypothalamus + medial thalamus - Complication of untreated Wernicke's
254
KORSAKOFF'S What are some causes of Korsakoff's?
- Heavy alcohol drinkers - Head injury, post-anaesthesia - Basal or temporal lobe encephalitis - CO poisoning - Other causes of thiamine deficiency (anorexia, starvation, hyperemesis)
255
KORSAKOFF'S What is the clinical presentation of Korsakoff's?
- Profound short-term memory loss with inability to lay down new memories (antero + retrograde amnesia) - Confabulation
256
KORSAKOFF'S What is the management of Korsakoff's?
- ABCDE approach as emergency - PO thiamine replacement + multivitamin supplements (for up to 2y) - OT assessment + cognitive rehab
257
LITHIUM TOXICITY What is lithium toxicity? What can precipitate it?
- Serum lithium >1.5mmol/L - >2mmol/L = life-threatening - Dehydration, renal failure, diuretics, anti-HTNs + NSAIDs
258
LITHIUM TOXICITY What is... i) acute ii) chronic iii) acute-on-chronic lithium toxicity?
i) Acute ingestion in patient not chronically on lithium ii) Patients on long-term lithium without acute OD iii) Ingestion of excess lithium in patients on chronic lithium
259
LITHIUM TOXICITY What is the clinical presentation of lithium toxicity?
- Ataxia, dysarthria, confusion (drunk) - COARSE tremor, blurred vision, hyperreflexia - N+V, diarrhoea - Myoclonus, seizures + coma if severe
260
LITHIUM TOXICITY What are some complications of lithium toxicity?
- Arrhythmias (VT) - Acute renal failure - Syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) after cessation of lithium >2m = truncal ataxia, ataxic gait, scanning speech, incoordination
261
LITHIUM TOXICITY What is the management of lithium toxicity?
- ABCDE approach as emergency - Stop + check lithium levels, serum creatinine, U+Es - IV fluids (bolus + 1.5–2x maintenance - ?Whole bowel irrigation with polyethene glycol for severe, acute ingestion - Haemodialysis
262
LITHIUM TOXICITY When would you do haemodialysis in lithium toxicity?
- Serum [Li] >5mmol/L OR >4 + renal dysfunction OR severe toxicity (seizures, coma, life-threatening arrhythmias)
263
ACUTE DYSTONIA What is an acute dystonic reaction?
- Sustained painful muscle contraction in ≥1 muscle groups
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ACUTE DYSTONIA What may it be caused by?
- ?Imbalance of dopamine + cholinergic transmission where D2 receptors become so blocked that excess output of cholinergics
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ACUTE DYSTONIA What is the clinical presentation of acute dystonic reaction?
- Rapid onset after dose given or changed - Spasm of muscles of tongue, face, neck + back - Oculogyric crisis (prolonged involuntary upward deviation of eyes) - Torticollis (twisted neck) - Tongue protrusion
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ACUTE DYSTONIA What is the life-threatening complication?
Laryngeal dystonia > airway compromised
267
ACUTE DYSTONIA What is the management of acute dystonia?
- ABCDE approach as emergency - Anticholinergic – IM procyclidine - Stop antipsychotic (switch to atypical as less EPSEs)
268
NMS What is the pathophysiology of neuroleptic malignant syndrome (NMS)?
- Dopamine antagonism often due to typical antipsychotic OD or acute withdrawal of Parkinson's meds
269
NMS How quickly does NMS present?
- Onset within 2w of drug or dose change (onset + progression slow) - May last 7–10d after PO or 21d after depot
270
NMS What is the clinical presentation?
Bodybuilder– - Pyrexia >38 + diaphoresis - Muscle rigidity (diffuse "lead-pipe" rigidity) - Confusion, agitation, altered consciousness - Tachycardia, high/low BP - Hyporeflexia
271
NMS What are the complications of NMS?
- Resp failure, CV collapse - Rhabdomyolysis - DIC
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NMS What are some investigations for NMS?
- FBC (leukocytosis) - Low serum iron - U+Es, Ca2+, phosphate - Urinary myoglobin (raised) - Serum creatinine phosphokinase (CPK) may be raised - CK raised
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NMS What is the management of NMS?
- ABCDE approach - Stop antipsychotic (wait >2w before restarting, consider atypical) - Give L-dopa if dopamine withdrawal in Parkinson's - IV dantrolene or lorazepam to reduce rigidity 1st line (amantadine second) - Bromocriptine prophylaxis
274
NMS What is the supportive management for NMS?
- Oxygen, cooling blankets, antipyretics, ice-water enema for pyrexia - IV access to correct volume depletion + reduce risk of rhabdomyolysis with fluids (cooled)
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NMS How is risk of rhabdomyolysis reduced?
- Vigorous hydration - Alkalinisation with IV sodium bicarbonate (target urine pH of 6)
276
SEROTONIN SYNDROME What is serotonin syndrome?
- Disorder caused by excess serotonin in brain
277
SEROTONIN SYNDROME What are some causes of serotonin syndrome?
- Antidepressants = SSRIs (inhibit reuptake), SNRIs, St. John's wart, MAOI (decreased metabolism) - Drugs = ecstasy, amphetamines, LSD, anti-emetics
278
SEROTONIN SYNDROME What is the clinical presentation of serotonin syndrome?
Sx onset + recovery fast – - Neuro = confusion, agitation - Neuromuscular = myoclonus, tremors (incl. shivering), hyperreflexia, ataxia - Autonomic = hyperthermia, diarrhoea, tachycardia, mydriasis
279
SEROTONIN SYNDROME What are some investigations for serotonin syndrome?
- FBC, U+Es, biochemistry (Ca2+, Mg2+, phosphate), CK, drug toxicology scren - ECG monitoring for prolonged QRS or QTc interval
280
SEROTONIN SYNDROME What is the management of serotonin syndrome?
- ABCDE - Stop offending agent - IV access to correct volume + reduce risk of rhabdomyolysis as in NMS - BDZs like slow IV lorazepam for agitation, seizures + myoclonus - Serotonin receptor antagonists like PO cyproheptadine or chlorpromazine if severe
281
SEROTONIN SYNDROME What is the management of serotonergic drug OD?
- ?Gastric lavage ± activated charcoal
282
LEARNING DISABILITIES What is a learning disability?
- Condition of arrested or incomplete development of mind, characterised by impairment of skills that contribute to overall intelligence (language, cognition, social) which has manifested during developmental period
283
LEARNING DISABILITIES How is a learning disability different to learning difficulties?
- Learning difficulties (dyslexia) are difficulties in acquiring knowledge + skills to the normal level expected of those of the same age, especially due to a mental disability or cognitive disorder
284
LEARNING DISABILITIES What is the triad in learning disabilities?
- Low intellectual performance (IQ < 70) - Onset during birth or early childhood - Wide range of functional impairment
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LEARNING DISABILITIES What is the epidemiology of learning disabilities?
- M>F, biggest risk factor is FHx
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LEARNING DISABILITIES What are some causes of learning disabilities?
- Genetic = Down's, Fragile X, Prader-Willi, neurofibromatosis - Antenatal = TORCH - Perinatal = asphyxia, intraventricular haemorrhage - Postnatal = meningitis, kernicterus - Environmental = malnutrition, smoking or alcohol in pregnancy
287
LEARNING DISABILITIES What physical disorders may be present in those with learning disabilities?
- Motor disabilities (ataxia, spasticity) - Epilepsy - Impaired hearing/vision - Incontinence
288
LEARNING DISABILITIES How is mild learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?
i) 50–69 ii) 9–12 iii) Mobile iv) Mostly adequate v) Difficulties reading + writing vi) Most independent
289
LEARNING DISABILITIES How is moderate learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?
i) 35–49 ii) 6–9 iii) Mobile iv) Simple-no speech, may sign, reasonable comprehension v) Limited, some learn to read, write + count vi) Lifelong supervision, may need prompting + support
290
LEARNING DISABILITIES How is severe learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?
i) 20–34 ii) 3–6 iii) Marked impairment iv) Simple-no speech, may sign, reasonable comprehension v) Limited, some learn to read, write + count vi) Lifelong supervision, may need prompting + support
291
LEARNING DISABILITIES How is profound learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?
i) <20 ii) <3 iii) Severe impairment iv) Basic non-verbal comms, understands basic commands v) None vi) Complete dependency
292
AUTISM SPECTRUM What is autism?
- Pervasive development disorder which manifests before age 3
293
AUTISM SPECTRUM What is associated with autism?
- Learning difficulties
294
AUTISM SPECTRUM What is Asperger's syndrome?
- ASD without cognitive impairment + fewer problems with language
295
AUTISM SPECTRUM What are some risk factors for autism?
- M>F - Obstetric complications - Perinatal infection (rubella) - Genetic disorders (Fragile X, Down's)
296
AUTISM SPECTRUM What are the 3 areas of impaired functioning that need to be present in autism?
- Social interaction - Communication (speech + language) - Behaviour (imposition of routine with ritualistic or repetitive behaviour)
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AUTISM SPECTRUM Give some examples of impaired social interaction
- Failure to notice + respond to social cues + others' emotional states - Difficulty establishing friendships - Lack of eye contact - Delay in smiling
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AUTISM SPECTRUM Give some examples of impaired communication
- Expressive speech + comprehension usually delayed or minimal - Concrete thinking (lack imagination) - Absence of gestures - Later speech consists of monologues, endless questions, echolalia
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AUTISM SPECTRUM Give some examples of impaired behaviours
- Inability to adapt to new environments (distress) - Tendency to have rigid routine with resistance to change - Greater interest in objects, numbers + patterns than people - Stereotypical repetitive movements which may be self-stimulating movements to comfort themselves (rocking, hand-flapping)
300
AUTISM SPECTRUM What is the management of autism?
- No cure so MDT for best environment to support child + parent - CAMHS, paediatrician, SALT, dieticians, social workers, specially trained educators, special school environments - Picture based timetables - Charities for support (national autistic society)
301
TIC DISORDERS What are tics?
- Repetitive, involuntary, purposeless movements + sounds
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TIC DISORDERS What might cause them?
- Stress, gestational + perinatal insults, PANDAS
303
TIC DISORDERS What is Tourette's syndrome?
- Development of tics that are persistent for >1y - More severe expression of the spectrum of tic disorder
304
TIC DISORDERS How does Tourette's syndrome present?
- Multiple motor tics + at least 1 phonic tic (coprolalia)
305
ADHD What is attention deficit hyperactivity disorder (ADHD)?
- Extreme end of hyperactivity + inability to concentrate, affecting person's ability to carry out everyday tasks, develop normal skills + perform well in school
306
ADHD What are some risk factors for ADHD?
- Epilepsy, low socioeconomic status, learning difficulties - Premature or LBW - Brain damage (in vitro or after severe head injury later)
307
ADHD What is the epidemiology of ADHD?
- M>F - Dx between 6–12y (must be ≥6y but show Sx before 12y)
308
ADHD What is the triad of symptoms in ADHD?
- Inattention - Impulsivity - Hyperactivity
309
ADHD How does inattention present?
- Short attention span - Quickly changes task as loses interest - Easily distracted - Loses important items - Careless mistakes
310
ADHD How does impulsivity present?
- Blurts answer before questions completed - Difficulty awaiting turn - Interrupts others - Teenagers have impulsive behaviours (car accidents, pregnancy)
311
ADHD How does hyperactivity present?
- Constantly fidgeting - Constant "on the go" or "driven by a motor" - Excessive talking
312
ADHD How is a diagnosis of ADHD reached?
- Features consistent across ≥2 settings (home, school) - Diagnosed ≥6y when Sx present continuously for ≥6m - Information from teachers, school reports, family etc used
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ADHD What is the management of ADHD?
Conservative initially (watch + wait) – - Family education on ADHD + parenting advice - Establish normal balanced diet, exercise can improve Sx - Food diary to identify any triggers + eliminate with dietician
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ADHD What is the management for severe ADHD?
- CNS stimulants like methylphenidate (increase monoamine pathway activity, not addictive) - S/E = appetite suppression, insomnia, psychosis, important to monitor growth, baseline ECG (cardiotoxic) - Atomoxetine (SE = liver dysfunction, suicidality) - (Lis)dexamfetamine
315
SOMATISATION DISORDER What is somatisation disorder?
- Multiple, atypical + inconsistent presentations with MUS, affecting multiple organ systems. - Symptoms present ≥2y, F>>M
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SOMATISATION DISORDER What is the clinical presentation of somatisation disorder?
- Non-specific + atypical Sx (usually derm, GI) - Discrepancy between subjective + objective findings (S = Sx) - Sx often in one system, may move to another once Dx possibilities exhausted - Often results in multiple needless investigations + operations (pt refuses to accept -ve results)
317
SOMATISATION DISORDER What is the management of somatisation disorder?
- Rule out all organic illnesses - Communicate Dx but acknowledge Sx severity - Reassure patient of continuing care - May benefit from CBT, group therapy or psychotherapy
318
COUNSELLING What is counselling?
- Relieving distress via dialogue between 2 people - Therapist listens + helps patient find own solutions
319
PSYCHOEDUCATION What is psychoeducation?
- Briefing patients about their illness so they understand it better - Problem solving training so they know how to deal with it better - Communication training so they can express their emotions better - Self-assertiveness training, relatives included
320
CBT What is the role of cognitive behavioural therapy (CBT)?
- Identify + challenge negative thoughts + modify abnormal core beliefs - Based on idea disorder not caused by life events but way patient views these events > better emotional regulation
321
DBT What is dialectical behavioural therapy (DBT)?
- Helps to change unhelpful ways of thinking (anger) + behaving (self-harm) like CBT but also focuses on accepting who you are at same time (accept + change
322
DBT What are the two components to DBT?
- Individual therapy = therapist validates pt's responses, reinforces adaptive behaviours + facilitates analysis of maladaptive behaviours + their triggers - Group therapy = teaching on mindfulness, interpersonal effectiveness skills (problem solving, communication), emotional modulation skills
323
PSYCHOANALYTICAL PSYCHOTHERAPY What is psychoanalytical psychotherapy?
- Childhood experiences, past conflicts + relationships influence individual's current situation - Once inner struggles brought to light, behaviour + feelings improve
324
GROUP PSYCHOTHERAPY What is group psychotherapy? Give some examples
- Individuals brought together under therapist's guidance with goals of reducing distress + Sx, increasing coping or improving relationships - Support groups, activity groups (art, music), self-help groups (AA)
325
FAMILY THERAPY What is family therapy?
- Enables those in close relationships to better understand, support each other better, explore each other's thoughts + build on family strengths together
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INTERPERSONAL THERAPY What is interpersonal therapy? What is it used in?
- Identify + address problems in their relationships with idea that poor relationships can leave you depressed + depression in turn can make relationships worse - Depression (severe or not responded to other therapies)
327
BEHAVIOURAL ACTIVATION What is behavioural activation therapy? What is it used for?
- Aim to give patients motivation to make simple, practical steps towards enjoying life again - Also teaches problem-solving skills - Depression
328
GENDER DYSPHORIA What is gender dysphoria?
- Mismatch between biological sex + gender identity of an individual causing distress
329
GENDER DYSPHORIA Define... i) transsexual ii) trans woman iii) trans man
i) Person who emotionally + psychologically feels that they belong to opposite sex ii) Assigned male sex 46XY at birth who later identifies as a woman iii) Assigned female sex 46XX who later identifies as a man
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GENDER DYSPHORIA What act is relevant to gender dysphoria?
- Gender recognition act 2004 - Allows transsexual people to legally change their gender - Have to demonstrate Dx of gender dysphoria + have lived as gender role for ≥2y
331
GENDER DYSPHORIA What is the clinical presentation of gender dysphoria?
- Low self-esteem, self-neglect, social isolation - Depression, anxiety + suicidality - Only comfortable when in preferred gender role - Strong desire to hide physical signs + dislike of genitals of biological sex
332
GENDER DYSPHORIA What is the management of gender dysphoria in... i) <18? ii) >18?
i) Referral to gender identity development service (GIDS) with MDT (CAMHS, clinical psychologist, social worker, family therapist) ii) Referral to gender dysphoria clinic (GP or self-referral)
333
GENDER DYSPHORIA What surgical procedures may be offered?
- TM = mastectomy, hysterectomy, nipple repositioning, phalloplasty or penile implant, scrotoplasty + testicular implants - TW = orchidectomy, penectomy, vaginoplasty, vulvoplasty or clitoroplasty
334
GENDER DYSPHORIA What biological treatment can be used in <16y?
- Very few young people who meet strict criteria may have gonadotropin-releasing hormone analogues (hormone blockers) as reach puberty
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GENDER DYSPHORIA What biological treatment can be used >16?
- Cross-sex/gender-affirming hormones if on hormone blockers for ≥12m – Oestrogen for breasts + feminine features – Testosterone for deep voice + masculine features (body hair)
336
GENDER DYSPHORIA What psychological treatment can be given to... i) <18y? ii) >18y?
i) Family therapy, individual child psychotherapy, parental support/counselling ii) Counselling, SALT to help sound like gender identity
337
GENDER DYSPHORIA What social management is there for gender dysphoria?
- Quit smoking (may increase risks of side effects from treatments) - Lose weight if overweight to reduce risks from cross-sex hormones) - Social transitioning incl. changing name by deed poll
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GENDER DYSPHORIA What are some risks of the hormone therapy?
- Oestrogen = clots, gallstones, high triglycerides - Testosterone = polycythaemia, acne, dyslipidaemia - Both = elevated LFTs, infertility, weight gain
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