1
Q
What are the two main classification systems for mental disorders?
A
- ICD-10
- DSM-5
2
Q
Give 2 examples of biological approaches to psychiatric management
A
- Pharmacological therapy
- Electroconvulsive therapy (ECT)
3
Q
Definition: ECT
A
Electroconvulsive therapy
* done under general anesthesia
* small electric currents are passed through the brain, triggering a brief seizure
* causes change in brain chemistry
4
Q
Give 2 examples of psychological approaches to psychiatric management
A
- Counselling
- Psychoeducation
- Psychotherapies e.g. CBT
5
Q
Give 2 examples of social approaches to psychiatric management
A
- Support groups/self-help groups
- social services input e.g. financial, housing
6
Q
Definition: Mood
A
Refers to a patient’s sustained, experienced emotional state over a period of time
7
Q
Definition: Affect
A
Refers to the transient flow of emotion in response to a particular stimulus
8
Q
When are fluctuations in mood considered as a mood disorder?
A
When the disturbance of mood is severe enough to cause impairment in the ADLs
9
Q
Definition: Mood disorder
A
Any condition characterized by distorted, excessive or inappropriate moods or emotions for a sustained period of time
* also known as an affective disorder
10
Q
Give 2 examples of affective disorders
A
- Depression
- Bipolar disorder
11
Q
Definition: Depression
A
Affective mood disorder characterized by persistent low mood, loss of pleasure and lack of energy accompanied by emotional, cognitive and biological symptoms
12
Q
Definition: Dysthymia
A
A milder, but more chronic form of depression (>2 years)
13
Q
Aetiology: Give 5 biological risk factors for depression
A
- Family Hx of depression
- Female
- Parkinson’s, MS, hypothyroidism
- Neuroendocrine: overactive HPA axis
- Medications: beta-blockers, steroids
14
Q
Aetiology: Give 5 psychological risk factors for depression
A
- Personality traits: dependent, anxious, obsessional, impulsive
- Childhood trauma
- Traumatic life events
- Low self-esteem
- Lack of education
15
Q
Aetiology: Give 3 examples of social risk factors for depression
A
- Poor social support
- Poor socioeconomic status
- Marital status: separated/divorced
16
Q
Clinical features: Name the 3 core symptoms of depression
A
- Low mood
- Anhedonia: lack of interest in previously enjoyed things
- Lack of energy
17
Q
Clinical features: Name 5 biological symptoms of depression
A
- Diurnal mood changes (DVM): usually worse in the morning
- Early morning wakening: 2-3 hrs earlier than usual
- Psychomotor retardation: slow speech/movement
- Loss of libido
- Weight loss
- Appetite loss
18
Q
Clinical features: Name 4 cognitive symptoms of depression
A
- Lack of concentration
- Negative thoughts
- Excessive guilt
- Suicidal ideation
19
Q
Clinical features: Name 2 psychotic symptoms of depression
A
- Delusions
- Hallucinations
20
Q
DDx: Name 5 psychiatric differentials of depression
A
- Depressive episode linked to substance/medication use
- Bipolar affective disorder
- Premenstrual dysphoric disorder
- Bereavement
- Anxiety disorders
21
Q
DDx: Name 3 organic illness differentials of depression
A
- Hypothyroidism
- Cushing’s disease or syndrome
- Vitamin B12 deficiency
22
Q
Investigations: how to form a clinical diagnosis of depression
A
- Diagnostic questionnaires e.g. PHQ-9
- Blood tests: FBC (anaemia), TFTs (hypothypothyroidism - elevated TSH ), glucose (diabetes can cause anergia)
- Imaging: MRI or CT (where there is atypical presentation or features of an intracranial lesion)
23
Q
Tx: What is the short-term management for mild depression?
A
Low-intensity psychosocial interventions:
* Group/individual CBT
* Counselling
* Selective serotonin reuptake inhibitor antidepressants (SSRI): only if Hx of moderate/severe depression or mild depression present for at least 2 years/present after other interventions
24
Q
Tx: What is the 1st line drug treatment for depression?
A
SSRI: Fluoxetine
25
What SSRI is best to give to someone after an MI?
Sertraline - doesn't affect conduction of the heart (doesn't prolong QT)
26
Tx: What is the long-term management for depression?
* Risk assessment
* Ongoing review of psychosocial intervention
* Relapse prevention plan
* Assess for social support
* Review antidepressant compliance, side effects etc
27
Tx: What is the short-term management for moderate/severe depression?
* Combination of CBT and an antidepressant
* Individual CBT
* Individual behavioural activation
* Antidepressants alone
* Counselling
* Psychodynamic psychotherapy
* If presenting with psychotic Sx, then antipsychotic should be used
28
Name 2 antipsychotic drugs
* Quetiapine
* Olanzapine
29
Who would you not give olanzapine to?
A **diabetic** because it can cause **high blood sugar**
30
When should Electroconvulsive therapy (ECT) be considered?
In severe cases of depression where:
* Rapid Tx is needed e.g. life-threatening where Pt isn't eating or drinking
* Pt has a strong preference to ECT
* Multiple other Tx have been unsuccessful
31
Definition: Bipolar disorder
**Chronic episodic mood disorder** characterized by at least one episode of **mania** (or **hypomania**) and a further episode of mania or depression.
32
Aetiology: Give 5 risk factors for bipolar disorder
* Genetics/family Hx
* Anxiety disorders
* Drug or alcohol abuse
* Stressful life events (not specific to bipolar)
* Post-partum period
33
What are the two main forms of bipolar disorder?
* **Bipolar I**: Pt has experienced at least one episode of **mania**
* **Bipolar II**: Pt has experienced at least one episode of **hypomania**, but never an episode of mania.
* Both must also have experienced at least one episode of **major depression**
34
What is cyclothymia?
A disorder characterised by a persistent **instability of mood** involving numerous periods of depression and mild elation
## Footnote
None of which are sufficiently severe or prolonged enough to justify a diagnosis of bipolar affective disorder
35
# ****
Clinical Features: Name 5 symptoms of **mania**
* Elevated mood
* Increased activity level
* Grandiose delusions of self-importance
* Pressure of speech
* Decreased need for sleep
* Marked distractibility
* Increased libido
* Reckless behaviour and spending
* Can also occur alongside **psychotic symptoms**
36
Clinical Features: Name 4 symptoms of **hypomania**
* Persistent, **mild** elevation of mood
* Increased energy and activity
* Increased sociability, talkativeness
* Increased libido
37
DDx: Name 6 differentials for bipolar disorder
* **Schizophrenia** (delusions and hallucinations)
* **Organic brain disorder** (frontal lobe pathologies can result in a loss of social inhibitions)
* **Drug use**
* **Recurrent depression**
* **Emotionally unstable personality disorder (EUPD)/borderline personality disorder** (characterised by affective instability)
* **Cyclothymia**
38
Investigations: Name 5 investigations for bipolar disorder
* Baseline blood tests: FBC,U&E,LFTs,TFTs,CRP,B12,folate,vitD
* HIV testing
* Toxicology screen
* Neurological exam
* CT head
39
Tx: Name 3 types of biological treatments for bipolar disorder
* Antipsychotics: **olanzapine, risperidone, quetiapine, haloperidol**
* Mood stabilisers: **lithium** (sodium valproate can be added)
* Benzodiazepines: **lorazepam**
40
Tx: Name 3 other treatments for bipolar disorder
* ECT
* CBT
* support groups
41
What do you need to monitor for when treating a patient with lithium?
Kidney function and thyroid function
## Footnote
Every **6 months**
42
Definition: Psychosis
A mental state in which **reality is greatly distorted**
43
Aetiology: Name 4 non-organic causes of psychosis
* Schizophrenia
* Schizoaffective disorder
* Mood disorders with psychosis
* Drug-induced psychosis
44
Aetiology: Name 5 organic causes of psychosis
* Drug-induced psychosis: alcohol, cocaine, amphetamine, MDMA
* Iatrogenic (medication)
* Delerium
* Dementia
* Huntington's disease
* Endocrine disturbance e.g. Cushing's syndrome
* Systemic lupus erythematosus
45
Aetiology: Name 4 medicitions that can cause psychosis
* Levodopa
* Methyldopa
* Steroids
* Antimalarials
46
Clinical features: How does psychosis present?
"abnormality of perception/thought"
* **Delusions**
* **Hallucinations**
* **Thought disorder**
47
Definition: Delusion
A **fixed, false** belief in something that is **not within their usual belief system**
48
Definition: Hallucination
A **perception** in the **absence of an external stimulus**
49
Definition: Pseudohallucination
**Involuntary sensory experience** vivid enough to be regarded as a hallucination, but is **recognised** by the person as being **subjective and unreal**
50
Definition: Illusion
An incorrect perception of a 'real' external stimulus
51
Name 5 types of delusions
* **Persecutory**: believing others want to harm them
* **Grandiose**: exaggerated sense of one's importance/power/knowledge/identity
* **Somatic**: believing something is wrong with/missing on their body
* **Jealous**: believing partner is unfaithful without reason
* **Erotomanic**: believing someone of a higher social status is in love with them
52
Definition: Schizophrenia
Most common **psychotic condition** characterised by **hallucinations, delusions and thought disorders**, which lead to **functional impairment**
53
Definition: Schizoaffective disorder
Characterised by both symptoms of **schizophrenia** and a **mood disorder** (depression/mania) in the **same episode of illness**
54
Aetiology: Name 4 risk factors for developing schizophrenia
* Family Hx
* Obstetric complications/fetal injury/intrauterine infection
* Stressful life events
* Substance misuse e.g. cannabis
55
What are the 6 subtypes of schizophrenia?
1. Paranoid (**most common**)
2. Hebephrenic
3. Catatonic
4. Undifferentiated
5. Simple
6. Residual
56
Clinical features: What are Schneider's first rank symptoms? (4)
* **Delusional perception**
* 3rd person **auditory hallucinations**
* **Thought interference**: insertion, withdrawal, broadcasting
* **Passivity phenomenon/somatic passivity**: feelings/actions/impulses are controlled by an external agent
57
Definition: Delusional perception
Person believes that a **normal percept** has a **special meaning** for them
58
Clinical features: What is the difference between positive and negative symptoms of schizophrenia?
* **Positive symptoms** represent an **excess** or **distortion** of normal function (i.e. a change in behaviour or thought)
* **Negative symptoms** refer to a **decline** in normal functioning
59
Clinical features: Name 5 positive symptoms of schizophrenia
* Delusions
* Hallucinations
* Formal thought disorder
* Thought interference
* Passivity phenomenon
60
Clinical features: Name 5 negative symptoms of schizophrenia
* Social isolation
* Decreased motivation
* Blunted affect
* Alogia: poverty of speech
* Anhedonia
61
Ix: What investigations are used to rule out other causes of psychotic symptoms in schizophrenia? (7)
* Blood tests (FBC,TFTs,U&E,LFTs,CRP, fasting glucose)
* Urine culture: rule out UTI causing delirium
* Urine drug screen: rule out drug intoxication
* HIV testing
* Syphilis serology
* Serum lipids: before starting antipsychotics
* Relevant imaging: CT head
62
What is required to form a diagnosis of schizophrenia?
1. A **first-rank symptom** or **persistent delusion** present for at least **one month**
2. No other cause for psychosis e.g. **drug intoxication/withdrawal, brain disease, extensive depressive or manic symptoms**
63
Tx: What is the general management of schizophrenia?
**Care programme approach**
* Assessing health and social needs
* Creating a care plan
* Appointing a key worker to be the first point of contact
* Reviewing treatment
Several MDTs may be involved: early intervention team, community mental health team, crisis resolution team
64
Tx: What drug type is used to treat schizophrenia?
D2 receptor antagonists
D2 = dopamine
65
Tx: What is the difference between **typical** and **atypical** antipsychotics?
* **Typical antipsychotics** cause generalised dopamine receptor blockade
* **Atypical antipsychotics** are more selective in their dopamine blockade. They also block **serotonin 5-HT2 receptors**
66
Tx: Name 3 typical antipsychotics
* Haloperidol
* Chlorpromazine
* Loxapine
67
Tx: Name 4 atypical antipsychotics
* Olanzapine
* Risperidone
* Clozapine
* Quetiapine
68
Tx: Why are atypical antipsychotics preferred over typical antipsychotics?
Fewer and less severe side effects
69
Tx: Name 5 side effects of typical antipsychotics
* **Extrapyramidal side effects** (EPSEs): parkinsonism, akathisia, dystonia, dyskinesia
* **Hyperprolactinaemia**: sexual dysfunction, increased risk of osteoporosis, amenorrhoea, gynaecomastia & hypogonadism in men
* **Metabolic SEs**: weight gain, hyperlipidaemia
* **Anticholinergic SEs**: tachycardia, dry mouth, urinary retention
70
Tx: What drug is used when both typical and atypical antipsychotics have been ineffective in treating schizophrenia?
**Clozapine**
71
What can clozapine cause?
* **Agranulocytosis**
* hypersalivation
* constipation
* cardiomyopathy
72
Definition: Neurosis
Collective term for psychiatric disorders **characterised by distress** that are:
* **non-organic**
* have a **discrete onset**
* where delusions and hallucinations are **absent**
73
Definition: Anxiety
An **unpleasant emotional state** involving **subjective fear** and **somatic symptoms**
74
When is anxiety described as an illness?
If it becomes **excessive** or **inappropriate**
75
What does the **Yerkes-Dodson law** state?
Anxiety can actually be beneficial up to a **plateau of optimal functioning**. Beyond this level, performance deteriorates
76
Clinical features: Name 5 common symptoms of neuroses
* **Psychological**: fear of impending doom, worrying thoughts, restlessness, poor concentration/attention, irritability
* **Cardiovascular**: palpitations, chest pain
* **Respiratory**: hyperventilation, tight chest
* **GI**: abdominal pain, N+V, loose stools
* **GU**: more frequent urination, failure of erection
* **Neuromuscular**: tremor, myalgia, headache, parasthesia
77
What are the 2 main categories anxiety disorders can be divided into?
1. **Generalised anxiety**: present **most of the time**, not associated with specific objects/situations, typically **longer duration**
2. **Paroxysmal anxiety**: has an **abrupt onset**, occurs in **short-lived, discrete episodes**
78
Name 5 **medical** conditions associated with anxiety
* Hyperthyroidism
* Hypoglycaemia
* Anaemia
* Phaeochromocytoma
* Cushing's disease
* COPD
* Malignancies
79
Name 3 **substance-related** conditions associated with anxiety
* Intoxication: alcohol, cannabis, caffeine
* Withdrawal: alcohol, caffeine
* Side effects: thyroxine, steroids, adrenaline
80
Name 5 **psychiatric** conditions associated with anxiety
* Eating disorders
* Depression
* Schizophrenia
* OCD
* PTSD
81
Definition: Generalised anxiety disorder
A syndrome of **ongoing, uncontrollable, widespread worry** about events or thoughts that the patient recognises as **excessive** and **inappropriate**
82
How long must symptoms be present for to be classified as GAD?
**Most days** for at least **6 months**
83
Aetiology: Name 2 biological causes of GAD
* **Genetics**: 5-fold increase in GAD in first degree relatives of Pt with GAD
* **Neurophysiological**: autonomic NS dysfunction, exaggerated responses in amygdala and hippocampus
84
Aetiology: Name 2 environmental causes of GAD
* **Stressful life events**: Hx of child abuse, relationship problems, personal illness, employment/finances, living alone/as a single parent
* **Substance dependence**
85
Clinical features: Name 6 symptoms of GAD concerning the chest and abdomen
* Difficulty breathing
* Feeling of choking
* Chest pain/discomfort
* Nausea
* Abdominal pain
* Loose motions
86
Clinical features: Name 4 symptoms of GAD concerning the brain/mind
* Feeling dizzy/light-headed
* Fear of dying
* Fear of losing control
* Derealisation and depersonalisation
87
Clinical features: Name 3 general symptoms of GAD
* Hot flushes / cold chills
* Numbness / tingling
* Headache
88
Clinical features: Name 5 symptoms of tension in GAD
* Muscle tension, aches, pains
* Restlessness
* Feeling on edge
* Difficulty swallowing
* Sensation of lump in throat
89
Clinical features: Name 4 non-specific symptoms of GAD
* Being startled
* Concentration difficulty / mind blanks
* Persistent irritability
* Sleep problems
90
Ix: Name 5 investigations for GAD
* **Bloods**: FBC (infection/anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia)
* **ECG**: may show sinus tachycardia
* **Questionnaires**: GAD-7, Beck anxiety inventory (BAI), Hospital anxiety and depression scale (HADS)
91
DDx: Name 7 differentials for GAD
* Other **neurotic disorders**: panic disorder, specific phobias, OCD, PTSD
* **Depression**
* **Schizophrenia**
* **Personality disorder**: anxious PD, dependent PD
* **Excessive caffeine or alcohol consumption**
* **Withdrawal from drugs**
* **Organic**: anaemia, hyperthyroidism, hypoglycaemia, phaeochromocytoma
92
Tx: What is the stepped care model for the management of GAD?
1. Psychoeducation and active monitoring
2. Low-intensity psychological interventions: self-help
3. High-intensity psychological interventions: CBT or drug treatment
4. Combination of drug and psychological therapies
93
Tx: What is the first line drug used to treat GAD?
SSRI: sertraline
## Footnote
Has anxiolytic effects
94
Tx: What is the biological treatment of GAD?
* **SSRI**: sertraline
* If this doesn't help --> **SNRI**: venlafaxine/duloxetine
* If both ineffective --> **pregabalin**
## Footnote
Meds should be used for at least a year
95
Tx: When should **benzodiazepines** be offered to treat GAD?
Only as **short-term measures** during crises as they can cause **dependence**
96
Definition: Phobia
An **intense, irrational** fear of an **object, situation, place** or **person** that is recognised as **excessive** or **unreasonable**
97
Definition: Agoraphobia
Fear of **public spaces** from which immediate escape would be difficult in the event of a panic attack
98
Definition: Social phobia/ Social anxiety disorder
A fear of **social situations** which may lead to **humiliation, critisism** or **embarrassment**
99
Definition: Specific (isolated) phobia
A fear restricted to a **specific object** or **situation**
100
Give 4 types of common specific phobias and examples of each
* **Animals**: spiders, dogs, birds
* **Nature**: thunder, water
* **Injury**: sight of blood, illness, needles
* **Situational**: closed spaces, heights, darkness
101
Aetiology: Name 6 risk factors for phobias
* Adverse experiences (with specific objects/situations)
* Stress/ negative life events
* Mood disorders
* Other anxiety disorders
* Substance misuse
* Family Hx
102
Clinical features: Name 5 symptoms of phobias
* **Tachycardia** (however in phobias of blood/injury/illness a **vasovagal response** is produced - **bradycardia** which can lead to **syncope**)
* Unpleasant **anticipatory anxiety**
* **Inability to relax**
* Urge to **avoid** the feared situation
* **Fear of dying**
103
Ix: What questionnaires are used when diagnosing phobias?
* Social phobia inventory
* Liebowitz social anxiety scale
104
DDx: Name 5 differentials of phobias
* Panic disorder
* PTSD
* Anxious PD
* Depression
* Schizophrenia
105
Tx: What is the management of the 3 phobic anxiety disorders?
* **CBT**
* **Gradual exposure**
* **SSRIs** for agoraphobia and social phobia
* **Benzodiazepines** may be used in the short-term for specific phobias e.g. claustrophobic but need a CT scan
106
What are SNRIs?
**Serotonin-noradrenaline reuptake inhibitors**
## Footnote
venlafaxine, duloxetine
107
Tx: What drug is used to treat **social phobia** if SSRIs and SNRIs are ineffective?
**MAOI**: moclobemide
## Footnote
monoamine oxidase inhibitors
108
Definition: Panic disorder
Disorder characterised by **recurrent, episodic, severe** panic attacks, which are **unpredictable** and **not restricted** to any particular situation.
109
Aetiology: Name 3 biological causes of panic disorder
* **Genetics**
* **Neurochemical**: post synaptic hypersensitivity to serotonin and adrenaline
* **Sympathetic NS**: fear/worry stimulates SNS --> increased cardiac output --> further anxiety
110
Aetiology: Name 8 risk factors for panic disorder
* Family Hx
* Female
* White ethnicity
* Age 20-30
* Major life events
* Recent trauma
* Asthma
* Medication e.g. benzodiazepine withdrawal
111
Clinical features: How long do panic disorder symptoms usually last?
Symptoms usually peak **within 10 minutes** and **rarely persist beyond an hour**
112
Clinical features: Name 10 symptoms of panic disorder
* Palpitations
* Intense fear of death
* Chest pain
* Sweating
* Shaking
* Shortness of breath
* Abdominal distress
* Depersonalisation/derealisation
* Numbness
* Nausea
113
DDx: Name 5 differentials for panic disorder
* **Psychiatric**: other anxiety disorders, bipolar, depression, schizophrenia
* **Organic**: Phaeochromocytoma, hyperthyroidism, hypoglycaemia, arrhythmias, alcohol/substance withdrawal
114
Tx: What is the drug management of panic disorder?
* **SSRI** is 1st line
* If these don't work after **12 weeks**, then consider a **TCA** (imipramine/clomipramine)
115
Tx: Name 2 examples of a TCA used to treat panic disorder
* **Imipramine**
* **Clomipramine**
116
Definition: Post traumatic stress disorder
An **intense, prolonged, delayed** reaction following exposure to an **exceptionally traumatic event**
117
Definition: Abnormal bereavement
Has a **delayed onset**, is **more intense** and is **prolonged** (>6 months)
118
Definition: Acute stress reaction
An abnormal reaction to **sudden stressful events**
119
Definition: Adjustment disorder
When there is **significant distress** accompanied by an **impairment in social functioning** when adapting to new circumstances
120
Give 5 risk factors for PTSD
* **Exposure to a major traumatic event**: professions at risk (army, police, doctors), groups at risk (refugees, asylum seekers)
* **Previous trauma**
* **Hx of mental illness**
* **Childhood abuse**
* Post-trauma --> absence of social support, concurrent life stressors
121
Clinical features: Name the 4 categories of PTSD symptoms
## Footnote
Must occur **within 6 months** of the event
* **Reliving** the situation: flashbacks, vivid memories, nightmares
* **Avoidance**: avoiding reminders of trauma (e.g. associated people/locations), inability to recall aspects of the trauma
* **Hyperarousal**: irritability/outbursts, difficulty concentrating, difficulty sleeping, hypervigilance, exaggerated startle response
* **Emotional numbing**: negative thoughts about oneself, difficulty experiencing emotions, feeling detached from others, giving up previously enjoyed activities
122
Ix: Name 3 investigations for PTSD
* Trauma screening questionnaire (**TSQ**)
* ** Post-traumatic diagnostic scale**
* **CT head** (if head injury suspected)
123
DDx: Name 5 differentials for PTSD (8)
* Adjustment disorder
* Acute stress reaction
* Bereavement
* Dissociative disorder
* Mood or anxiety disorders
* Personality disorder
* Head injury
* Alcohol/substance misuse
124
Tx: What is the management of PTSD where symptoms are present **within 3 months** of trauma?
* Watchful waiting (< 4 weeks)
* **Trauma-focused CBT** (8-12 sessions)
* **Short-term drug Tx** for managing **sleep disturbance** (e.g. zopiclone)
* **Risk assessment** (assess risk for neglect/suicide)
125
Tx: What is the management of PTSD where symptoms have been present **> 3 months** after trauma?
**Trauma-focused psychological intervention**
2 options:
* **CBT**
* **EMDR**
**Drug Tx** considered when:
* Little benefit from psychological therapy
* Patient preference
* Co-morbid depression / severe hyperarousal
126
Tx: What is EMDR?
**Eye Movement Desensitisation and Reprocessing**
* helps patient access and process traumatic memories
* involves recalling emotionally traumatic material while focusing on an external stimulus
127
Tx: Name 4 drugs used to treat PTSD
* **Sertraline**
* **Paroxetine**
* Venlafaxine
* Fluoxetine
128
Definition: Obsessive-compulsive disorder (OCD)
Disorder characterised by **recurrent obsessional thoughts** and/or **compulsive acts**
129
Definition: Obsessions
**Unwanted intrusive thoughts, images** or **urges** that **repeatedly** enter the individual's mind.
They are **distressing** for the Pt who attempts to **resist** them and recognises them as absurd (**egodystonic**) and a product of their **own mind**
130
Definition: Compulsions
**Repetitive, stereotyped behaviours** or **mental acts** that a person feels **driven** to perform.
* They are **overt** (observable by others) or **covert** (mental acts not observable)
131
Aetiology: Name 3 potential causes of OCD
* Family Hx
* Streptococcal infections
* Stressful life events
132
Clinical features: Name the 4 features that obsessions/compulsions always share
1. **Failure to resist**
2. **Originate** from the patient's mind
3. **Repetitive and distressing**
4. **Carrying out the obsessive thought**/compulsive act is **not in itself pleasurable**, but reduces anxiety levels
133
What is the OCD cycle?
**Obsession** > **Anxiety** > **Compulsion** > **Relief**
134
Name 4 common obsessions in OCD
* **Contamination**
* **Fear of harm** (door locks)
* Excessive concern with **order/symmetry**
* Others: **sex, blasphemy, violence, doubt**
135
Name 5 common compulsions in OCD
* **Checking** (e.g. taps, doors)
* **Cleaning/washing**
* **Repeating acts** (e.g. counting/arranging objects)
* **Mental compulsions** (e.g. special words repeated in a set manner)
* **Hoarding**
136
Ix: What investigations are used to diagnose OCD?
**Yale-Brown obsessive-compulsive scale** (Y-BOCS)
137
DDx: Name 5 differentials for OCD (9)
* Both obsessions and compulsions: **eating disorders**
* Primarily obsessions: **anxiety disorders, depression, schizophrenia**
* Primarily compulsions: **Tourette's syndrome, kleptomania**
* Organic: **Dementia, epilepsy, head injury**
138
Tx: What is the management for OCD?
* **CBT** including **ERP** (exposure and response prevention)
* **SSRIs**: fluoxetine, sertraline
* **Clomipramine** (TCA)
139
Definition: Somatisation disorder
**Multiple, recurrent** and **frequently changing** physical symptoms **not explained by a physical illness**
140
Definition: Dissociation
A process of **separating off** certain memories from normal consciousness.
This is a **physiological defence mechanism** used to cope with **emotional conflict** that is so **distressing** to the patient, it is prevented from entering their conscious mind.
141
Definition: Conversion
**Distressing events** are **transformed** into **physical symptoms**
142
Name 6 risk factors for somatoform and dissociative disorders
* **C**hildhood abuse
* **R**einforcement of illness behaviours
* **A**nxiety disorders
* **M**ood disorders
* **P**ersonality disorders
* **S**ocial stressors
143
Tx: Name 4 managements for somatoform and dissociative disorders
* SSRIs (antidepressants)
* Physical exercise
* CBT
* Encouraging stress-relieving activities
144
Definition: Acute intoxication
The**acute**, usually **transient**, effect of the substance
145
Definition: Dependence syndrome
**Prolonged, compulsive** substance use leading to **addiction**, **tolerance** and the potential for **withdrawal symptoms**
146
Definition: Withdrawal state
**Physical** and/or **psychological** effects from complete (or partial) **cessation** of a substance after **prolonged, repeated** or **high level of use**
147
Definition: Substance-induced psychotic disorder
Onset of psychotic symptoms **within 2 weeks** of substance use.
Must persist for **> 48 hrs**
148
Name 5 environmental factors that can lead to substance dependence
* Peer pressure
* Life stressors
* Parental drug use
* Cultural acceptability
* Personal vulnerability
149
What is the chain of events leading to substance dependence?
1. **Takes substance**
2. **Positive reinforcement**: psychosocial (from peers/ pleasurable effects of the drug), biological (activates mesolimbic dopaminergic reward pathways)
3. **Dependence**
150
Name 4 examples of opiates
* **Morphine**
* **Heroin**
* **Codeine**
* **Methadone**
151
Name 6 **psychological** effects of opiates
* Apathy
* Disinhibition
* Psychomotor retardation
* Impaired judgement/attention
* Drowsiness
* Slurred speech
152
Name 6 **physical** effects of opiates
* Respiratory depression
* Hypoxia
* Decreased BP
* Hypothermia
* Coma
* Pupillary constriction
153
Name 6 symptoms of opiate withdrawal
* Craving
* Rhinorrhoea
* Lacrimation
* Myalgia
* Abdominal cramps
* N+V
* Diarrhoea
* Pupillary dilation
* Piloerection (hair raising)
* Increased HR / BP
154
Name a cannabinoid
**Cannabis**
155
Name 7 psychological effects of cannabinoids
* Euphoria
* Disinhibition
* Paranoid ideation
* Temporal slowing (time passes slowly)
* Imparied judgement/attention/reaction time
* Illusions
* Hallucinations
156
Name 4 physical effects of cannabinoids
* Increased appetite
* Dry mouth
* Conjunctival injection
* Increased HR
157
Name 5 symptoms of cannabinoid withdrawal
* Anxiety
* Irritability
* Tremor of outstretched hands
* Sweating
* Myalgia
158
Name a sedative-hypnotic drug
**Benzodiazepines**
159
Name 6 psychological effects of sedative-hypnotics
* Euphoria
* Disinhibition
* Apathy
* Aggression
* Anterograde amnesia (can't form new memories)
* Labile mood (unpredictable, uncontrollable, rapid shifts in emotions)
160
Name 5 physical effects of sedative-hypnotics (9)
* Unsteady gait
* Difficulty standing
* Slurred speech
* Nystagmus
* Erythematous skin lesions
* Decreased BP
* Hypothermia
* Depression of gag reflex
* Coma
161
Name 5 symptoms of sedative-hypnotic withdrawal (10)
* Tremor of hands/tongue/eyelids
* N+V
* Increased HR
* Postural hypotension
* Headache
* Agitation
* Malaise
* Transient illusions/hallucinations
* Paranoid ideation
* Grand mal convulsions
162
Name 4 examples of stimulants
* Cocaine
* Crack cocaine
* Ecstasy (MDMA)
* Amphetamine
163
Name 7 psychological effects of stimulants
* Euphoria
* Increased energy
* Grandiose beliefs
* Aggression/argumentative
* Illusions/hallucinations
* Paranoid ideation
* Labile mood
164
Name 5 physical effects of stimulants (9)
* Increased HR / BP
* Arrhythmias
* Sweating
* N+V
* Pupillary dilatation
* Psychomotor agitation
* Muscular weakness
* Chest pain
* Convulsions
165
Name 7 symptoms of stimulant withdrawal
* Dysphoric mood
* Lethargy
* Psychomotor agitation
* Craving
* Increased appetite
* Insomnia / hypersomnia
* Bizarre/unpleasant dreams
166
Name 2 examples of hallucinogens
* **LSD**
* **Magic mushrooms**
167
Name 5 psychological effects of hallucinogens (8)
* Anxiety
* Illusions/hallucinations
* Depersonalisation/derealisation
* Paranoia
* Ideas of reference
* Hyperactivity
* Impulsivity
* Inattention
168
Name 7 physical effects of stimulants
* Increased HR
* Palpitations
* Sweating
* Tremor
* Blurred vision
* Pupillary dilatation
* Incoordination
169
Name 4 examples of volatile solvents
* Aerosols
* Paint
* Glue
* Petrol
170
Name 5 psychological effects of volatile solvents
* Apathy
* Lethargy
* Aggression
* Impaired attention/judgement
* Psychomotor retardation
171
Name 5 physical effects of volatile solvents
* Unsteady gait
* Diplopia
* Nystagmus
* Decreased consciousness
* Muscle weakness
172
Name 3 examples of anabolic steroids
* **Testosterone**
* **Androstenedione**
* **Danazol**
173
Name 7 psychological effects of anabolic steroids
* Euphoria
* Depression
* Aggression
* Hyperactivity
* Mood swings
* Hallucinations
* Delusions
174
Name 6 physical effects of anabolic steroids
* Increased muscle mass
* Reduced fat
* Acne
* Male pattern baldness
* Reduced sperm count/infertility
* Stunted growth
175
Ix: Name 3 investigations for substance misuse
* **Bloods**: blood-bourne infections through needle sharing (**HIV** screen, **Hep B**, **Hep C**, **TB**), renal function (**U+Es**), hepatic function (**LTFs**, **clotting**), **drug levels**
* **Urinalysis**: drug metabolites can be detected in urine (e.g. cannabis, opioids)
* **ECG**: arrhythmias, **ECHO** if endocarditis suspected (secondary to needle sharing)
176
DDx: Name 7 differentials of substance misuse
* **Psychiatric**: psychosis, mood disorders, anxiety disorders, delirium
* **Organic**: hyperthyroidism, CVA, intracranial haemorrhage
177
Tx: What is the management of substance misuse?
* **Hep B immunisation** for those at risk
* **Motivational interviewing/CBT**
* **Housing/finance/employment** support
* **Self-help groups** (e.g. narcotics anonymous and cocaine anonymous)
* Consider issue of **driving**: review DVLA
178
Tx: Name 3 managements of opioid dependence
* Biological therapies: **methadone** (1st line) or **buprenorphine** for detoxification AND maintenance
* **Naltrexone**: formerly opioid-dependent but have now stopped and want to continue abstinence
* **IV naloxone** (opioid antagonist): antidote to **opioid overdose**
179
Definition: Alcohol abuse
Consumption of alcohol at a level sufficient to cause **physical**, **psychiatric** and/or **social harm**
180
Definition: Binge drinking
Drinking **over twice the recommended level** of alcohol per day in **one session**
## Footnote
**> 8 units** for men, **> 6 units** for women
181
Definition: Harmful alcohol use
Drinking **above safe levels** with evidence of **alcohol-related problems**
## Footnote
**> 50 units/week** for men, **> 35 units/week** for women
182
Name 5 risk factors for alcohol abuse
* **Male**: increased metabolism of alcohol
* **Younger adults**
* **Antisocial behaviour**
* **Lack of facial flushing**: risk of alcoholism is decreased in individuals who show alcohol-induced facial flushing
* **Life stressors**: e.g. financial problems, marital issues, certain occupations
183
Clinical features: Name 4 symptoms of alcohol intoxication
* **Slurred speech**
* **Labile affect**
* **Impaired judgement**
* **Poor coordination**
In severe cases: **hypoglycaemia**, **stupor**, **coma**
184
Clinical features: What are the 7 signs of **Edward and Gross criteria** for alcohol dependence?
* **Subjective awareness** of compulsion to drink
* **Avoidance or relief of withdrawal Sx** by further drinking
* **Withdrawal Sx**
* **Drink-seeking behaviour** predominates
* **Reinstatement** of drinking after attempted abstinence
* **Increased tolerance** to alcohol
* **Narrowing of drinking repertoire** (i.e. a stereotyped pattern of drinking - fixed times for drinking with reduced influence from environmental cues)
185
Clinical features: Name 6 symptoms of alcohol withdrawal
* Malaise
* Tremor
* Nausea
* Insomnia
* Transient hallucinations
* Autonomic hyperactivity
## Footnote
Occur at 6-12 hours after abstinence
186
When is peak incidence of seizures after alcohol withdrawal?
**36 hours**
187
Definition: Delirium tremens
* Severe end of the spectrum of withdrawal
* Peak incidence is at **72 hours**
188
Name 5 symptoms of **delirium tremens**
* **Cognitive impairment**
* **Vivid perceptual abnormalities**: hallucinations and/or illusions
* **Paranoid delusions**
* **Marked tremor**
* **Autonomic arousal**: tachycardia, fever, pupillary dilatation, increased sweating
189
Tx: What is the management of delirium tremens?
* **Benzodiazepines** e.g. chlordiazepoxide
* **Haloperidol** for any psychotic features
* **IV Pabrinex** contains water soluble vitamins (C,B1,B2,B3,B6)
190
Ix: Name 4 investigations for alcohol abuse
* **Bloods**: blood alcohol level, FBC, U&Es, LFTs, MCV, hepatitis serology, glucose
* **Alcohol questionnaire**: CAGE, AUDIT, SADQ
* **CT head**: is head injury suspected
* **ECG**: arrhythmias
191
DDx: Name 7 differentials for alcohol abuse
* **Psychiatric**: psychosis, mood disorders, anxiety disorders, delirium
* **Medical**: head injury, cerebral tumour, CVA (e.g. stroke)
192
Definition: Wernicke's encephalopathy
An **acute encephalopathy** due to **thiamine deficiency**
193
Clinical features: Name 5 symptoms of Wernicke's encephalopathy
* **Delirium**
* **Nystagmus**
* **Ophthalmoplegia**
* **Hypothermia**
* **Ataxia**
194
Tx: What is the management of Wernicke's encephalopathy?
**Parenteral thiamine**
195
Definition: Korsakoff's psychosis
Profound, irreversible **short-term memory loss** with:
* **confabulation** (unconscious filling of gaps in momory with imaginary events)
* **disorientation to time**
196
Tx: What is the management of alcohol dependence?
* **Disulfiram** / **Naltrexone** / **Acamprosate**
* **Motivational interviewing**
* **CBT**
* **Alcoholics Anonymous**
* **Social support** including family involvement
197
Tx: What is the management of alcohol withdrawal?
* **Chlordiazepoxide** detox regime
* **Thiamine**
## Footnote
Chlordiazepoxide = high dose benzodiazepine
198
Name 10 types of behavioural addictions
* **Food**
* **Exercise**
* **Gambling**
* **Internet**
* **Plastic surgery**
* **Porn**
* **Sex**
* **Shopping**
* **Social media**
* **Video games**
199
Name 7 signs of behavioural addiction
* Prioritising time spent engaging in the behaviour
* Becoming increasingly dependent on the behaviour to cope with emotions
* Having difficulty changing behaviour despite wanting to do so
* Continuing behaviour despite attempts to stop
* Neglecting or avoiding work/family/school to engage in the behaviour or hide its effects on your life
* Denying, minimising, hiding the full truth about your addiction
* Experiencing unpleasant feelings/sensations when trying to stop (withdrawal Sx)
200
Tx: What is the management for addictive behaviours?
* **CBT**
* **Group therapy**
201
Definition: Deliberate self-harm
An **intentional act** of **self-poisoning** or **self-injury**, **irrespective of the motivation**.
Usually an expression of **emotional distress**
202
Name 7 methods of self-injury
* Cutting
* Burning
* Hanging
* Stabbing
* Swallowing objects
* Shooting
* Jumping from heights/in front of vehicles
203
Name 4 methods of self-poisoning
* Medication
* Illicit drugs
* Household substances
* Plant material
204
Name 8 risk factors for deliberate self-harm
* **Divorced**/single/living alone
* **Severe life stressors**
* Harmful **drug/alcohol** use
* **< 35 y.o.**
* **Chronic physical health problems**
* **DV** or **childhood abuse**
* **Socioeconomic disadvantage**
* Psychiatric illness e.g. **depression, psychosis**
205
Ix: Name 4 investigations for ruling out self-harm
* **Bloods**: paracetamol levels, salicylate levels if suspected overdose, U&Es (renal function), LFTs and clotting (hepatic funtion)
* **Urinalysis**: toxicological analysis
* **CT head**: if an intracranial cause for altered consciousness is suspected
* **Lumbar puncture**: if intracranial infection is suspected (e.g. meningitis)
206
Tx: What is the management of self-harm?
* **Acute Tx**: treating any overdose with specific antidotes, suturing
* **Manage high suicide risk**: full risk assessment!
* **Treat any psychiatric disorder**: antidepressants/CBT/psychodynamic psychotherapy
* **Psychosocial assessment**: offer help for psychosocial needs e.g. counselling/social services input
* **Follow-up** within 48 hours
207
Antidote to **paracetamol** overdose?
**N-Acetylcysteine**
208
Antidote to **opiates** overdose?
**Naloxone**
209
Antidote to **benzodiazepine** overdose?
**Flumazenil**
210
Antidote to **warfarin** overdose?
**Vitamin K**
211
Antidote to **beta-blocker** overdose?
**Glucagon**
212
Antidote to **TCA** overdose?
## Footnote
e.g. amitriptyline
**Sodium bicarbonate**
213
Definition: Suicide
A fatal act of self-harm initiated with the intention of ending one's own life
214
Definition: Attempted suicide
The act of intentionally trying to take one's own life with the primary aim of dying, but failing to succeed in this endeavour
215
Definition: Risk assessment
## Footnote
In a psychiatric context
Assessing the risk of **self-harm**, **suicide** and/or **risk to others**
216
Name 5 **protective factors** which can reduce the risk of suicide (12)
* Children at home
* Pregnancy
* Strong religious/spiritual beliefs
* Strong social support
* Positive coping skills
* Positive therapeutic relationship
* Supportive living arrangements
* Life satisfaction
* Fear of the physical act of suicide
* Fear of disapproval from society
* Responsibility for others
* Hope for the future
217
Name 5 **clinical** risk factors of suicide
* Hx of **DSH** or **attempted suicide**
* **Psychiatric illness**: depression, schizophrenia, substance misuse, alcohol abuse, personality disorder
* **Childhood abuse**
* **Family Hx**
* **Medical illness**: physically disabling/painful/terminal illness
218
Name 5 **socio-demographic** risk factors of suicide (8)
* **Males** 3x more likely
* Age: **40 - 44** in men
* **Unemployed** / **low socioeconomic status**
* **Occupation**: vets, doctors, nurses, farmers
* **Access to lethal means**: firearms, hanging, strangling, suffocation
* **Low social support, living alone, institutionalised** (e.g. prisons, soldiers)
* **Single/widowed/separated/divorced**
* **Recent life crisis**: bereavement, family breakdown
219
Clinical features: Name 6 characteristics of someone who is suicidal
* **Preoccupation with death**
* Sense of **isolation and withdrawal** from society
* **Emotional distance** from others
* **Distraction** and **lack of pleasure**
* Focus on the **past**
* Feelings of **hopelessness** and **helplessness**
220
Name 6 things that can be used to determine the risk of suicide following DSH
1. **Note** left behind
2. **Planned** attempt of suicide
3. Attempts to **avoid being discovered**
4. Afterwards **help was not sought**
5. **Violent** method
6. **Final acts**: sorting out finances, writing a will
221
Tx: What is the management for someone who has attempted suicide?
* **Ensure safety**: remove any means for suicide
* Pt who has attempted and failed suicide should be **medically stabilised**: Tx of drug overdose/physical injury
* **Risk assessment**
* **Admission to hospital**
* Referral to **secondary care**
* **Psychiatric Tx**
* Support from **Crisis Resolution and Home Treatment team**
* **Outpatient and community Tx**
222
Name 3 **individual** suicide prevention strategies
* Detect and treat **psychiatric disorders**
* **Urgent hospitilisation** under the **Mental Health Act**
* Involvement of the **Crisis Resolution and Home Treatment team**
223
Name 5 **population level** suicide prevention strategies
* **Public education**/discussion
* **Reducing access to means of suicide**: e.g. encourage Pts to dispose of unwanted tablets, safety rails at high places
* **Easy, rapid access** to psychiatric care/support groups
* Decreasing **social stressors**: e.g. unemployment, DV
* Reducing **substance misuse**
224
Definition: Delirium
An **acute**, **transient**, **reversible** state of **confusion** and **impaired consciousness** and **attention**
225
What are the 3 subtypes of delirium?
* **Hypoactive**: lethargy, decreased motor activity, apathy
* **Hyperactive**: agitation, irritability, restlessness, aggression, hallucinations/delusions
* **Mixed**: signs of both
226
Name 10 causes of delirium
## Footnote
mnemonic: HE IS NOT MAAD
* **Hypoxia**: resp failure, MI, PE
* **Endocrine**: hyper/hypothyroidism, hyper/hypoglycaemia, Cushing's
* **Infection**: UTI, pneumonia, meningitis
* **Stroke**/intracranial events: raised ICP, haemorrhage, SOL, head trauma, epilepsy
* **Nutritional**: decreased thiamine, vit B12
* **Others**: severe pain, sensory deprivation, sleep deprivation
* **Theatre**/post-op: anaesthetic, opiate analgesics
* **Metabolic**: hepatic/renal impairment, electrolyte disturbance
* **Abdominal**: urinary retention, bladder catheterisation, malnutrition, faecal impaction
* **Alcohol**: intoxication, withdrawal
* **Drugs**: benzodiazepines, opioids, steroids, anti-parkinsonian meds, anticholinergics
227
Name 5 risk factors for delirium (10)
* Old age **> 65**
* Multiple **co-morbidities**
* **Dementia**
* Physical frailty
* Renal impairment
* Male sex
* Sensory impairment
* Previous episodes
* Recent surgery
* Severe illness
228
Clinical features: Name 8 symptoms of delirium
## Footnote
Mnemonic: DELIRIUM
* **Disordered thinking**: slowed, irrational, incoherent thoughts
* **Emotional disturbances**: euphoric, fearful, depressed, angry
* **Language impaired**: rambling, repetitive, disruptive
* **Illusions, delusions, hallucinations**
* **Reversal of sleep-wake pattern**: tired during day, hyper-vigilant at night
* **Inattention**: inability to focus, clouding of consciousness
* **Unaware/disoriented**: to time, place, person
* **Memory deficits**
229
Ix: Name 3 investigations for delirium
* Routine Ix: **urinalysis**, **bloods** (FBC,U&E,LFT,, glucose,CRP,TFT etc), **infection screen** (blood & urine culture)
* Ix based on Hx/examination: **ABG** (hypoxia), **CT head**, **lumbar puncture** (meningitis), **EEG** (epilepsy)
* Questionnaires: **Abbreviated Mental Test** (AMT), **Confusion Assessment Method** (CAM), **Mini-Mental State Examination** (MMSE)
230
DDx: Name 5 differentials for delirium
* **Dementia**
* **Mood disorder**
* **Late onset schizophrenia**
* **Dissociative disorders**
* **Hypo/hyperthyroidism**
231
Tx: What is the management of delirium?
* **Treat underlying cause**: treat any infections, laxatives for faecal impaction, temporary catheterisation for urinary retention
* **Reassurance and re-orientation**
* Provide **appropriate environment**
* Manage **disturbed, violent, destressed** behaviour: low-dose **haloperidol** or **olanzapine**
* **Avoid benzodiazepines**
232
Definition: Personality disorder
A **deeply ingrained** and **enduring pattern of inner experience and behaviour** that deviates from expectations in the individual's culture.
* It is **pervasive** and **inflexible**
* **Onset** in **early adulthood**
* Is **stable** over time and leads to **distress** or **impairment**
233
What are the 3 clusters of PDs?
Cluster A: odd/eccentric
* **Paranoid**
* **Schizoid**
Cluster B: dramatic/emotional
* **Emotionally unstable** (borderline)
* **Dissocial** (antisocial)
* **Histrionic**
Cluster C: anxious/fearful
* **Dependent**
* **Avoidant** (anxious)
* **Anankastic** (obsessional)
234
Name 4 risk factors for PD
* **Low socioeconomic status**
* **Genetics**: family Hx
* **Dysfunctional family**: poor parenting, parental deprivation
* **Childhood abuse**: physical, sexual, emotional, neglect
235
Clinical features: Name the features of **cluster A** PDs
## Footnote
Cluster A (**weird**)
**Paranoid**
* suspicious
* unforgiving
* questions fidelity
* jealous
* doesn't like criticism
* reduced trust
**Schizoid**
* detached affect
* indifferent to praise/criticism
* reduced libido
* does tasks alone
* no emotion
* takes pleasure in few activities
* absence of close friends
236
Clinical features: Name the features of **cluster B** PDs
## Footnote
Cluster B (**wild**)
**EUPD**
* fear of abandonment
* mood instability
* suicidal behaviour
* unstable relationships
* intense relationships
* poor anger control
* impulsive
* disturbed sense of identity
* chronic emptiness
**Dissocial** (antisocial)
* callous
* blames others
* reckless - disregard for safety
* lack of guilt (remorseless)
* deceitful
* impulsive
* temper/ tendency to violence
**Histrionic**
* provocative behaviour
* concern for physical attractiveness
* attention seeking
* easily influenced
* shallow/ inappropriate seductive
* egocentric (vain)
* exaggerated emotions
237
Clinical features: Name the features of **cluster C** PDs
## Footnote
Cluster C (**worriers**)
**Dependent**
* reassurance required
* difficulty expressing disagreement
* lack of self-confidence
* difficulty initiating projects
* fear of abandonmnent
* seeks companionship
* exaggerated fears
**Anxious** (avoidant)
* certainty of being liked needed before becoming involved with people
* restriction to lifestyle in order to maintain security
* feels inadequate
* potential to be embarrassed prevents involvement in new activities
* social inhibition
**Anankastic** (obsessional)
* loses point of activity due to preoccupation with detail
* compromised ability to complete tasks due to perfectionism
* workaholic at the expense of leisure
* fussy
* inflexible/ rigid
* meticulous attention to detail
* stubborn
238
Ix: Name 3 investigations for PD
* **Questionnaires**: Personality Diagnostic test, Eysenck Personality test
* **Psychological testing**: Minnesota Multiphasic Personality Inventory (MMPI)
* **CT head/MRI**: rule out organic causes e.g. frontal lobe tumours/intracranial bleeds
239
DDx: Name 3 differentials for PD
* **Mood disorders**: mania, depression
* **Psychotic disorders**: schizophrenia, schizoaffective disorder
* **Substance misuse**
240
Tx: What is the management for PD?
* Identify and treat any **psychiatric illness** and **substance misuse**
* **Risk assessment**: psychosocial interventions to reduce stressors
* **Pharmacological** (control Sx): low-dose antipsychotics, mood stabilisers, antidepressants
* **Psychological**: CBT, psychodynamic psychotherapy, Dialectical behavioural therapy (DBT)
* **Social**: support groups, assistance with social problems (housing/finance/employment), access to education
241
What is DBT?
**Dialectical Behavioural Therapy**
* Emphasis on developing **coping strategies** to **improve impulse control** and **reduce self-harm**
* Used in **EUPD**
242
Definition: Dementia
* A syndrome of generalised decline of **memory**, **intellect** and **personality**
* Without impairment of **consciousness**
* Leading to **functional impairment**
243
What are the 4 types of dementias from most prevalent to least?
* **Alzheimer's disease**
* **Vascular dementia**
* **Dementia with Lewy bodies** (DLB)
* **Fronto-temporal dementia**
244
Name 5 **irreversible** causes of dementia
* **Neurodegenerative**: Alzheimer's, F-T dementia, DLB, Parkinson's, Huntington's
* **Infections**: HIV, encephalitis, syphilis
* **Toxins**: alcohol, barbiturates, benzodiazepines
* **Vascular**: vascular dementia, CVD
* **Head trauma**
245
Name 3 **reversible** causes of dementia
* **Neurological**: normal pressure hydrocephalus, intracranial tumours, CSH
* **Vitamin deficiencies**: B12, folic acid, thiamine, nicotinic acid
* **Endocrine**: Cushing's, hypothyroidism
246
What is the pathophysiology of Alzheimer's disease?
* Degeneration of **cholinergic neurons** in the **nucleus basalis of Meynert** leading to **acetylcholine deficiency**
247
What are 2 **microscopic** physiological changes seen in Alzheimer's disease?
* **Neurofibrillary tangles** (intracellularly)
* **Beta-amyloid plaque formation** (extracellularly)
## Footnote
These are pathological lesions progressively distributed around the brain
248
What are 3 **macroscopic** physiological changes seen in Alzheimer's disease?
* **Cortical atrophy** (commonly hippocampus)
* **Widened sulci**
* **Enlarged ventricles**
249
Aetiology: What is the cause of **vascular dementia**?
**Cerebrovascular disease** due to:
* stroke
* multi-infarcts
* chronic changes in small vessels (arteriosclerosis)
250
Aetiology: What is the cause of **Lewy body dementia**?
**Abnormal deposition of protein** (Lewy body) within the neurons of the:
* **brainstem**
* **substantia nigra**
* **neocortex**
251
Aetiology: What is the cause of **fronto-temporal dementia**?
Specific degeneration (**atrophy**) of the **frontal** and **temporal** lobes.
252
What is Pick's disease?
A type of **fronto-temporal** dementia, where protein tangles (**Pick's bodies**) are seen histologically
253
What are the **cortical**, **subcortical** and **mixed** dementias?
* **Cortical**: AD, fronto-temporal
* **Subcortical**: DLB
* **Mixed**: vascular
254
Name 7 risk factors for Alzheimer's disease
* Advancing age
* Family Hx
* Genetics
* Down's syndrome
* Low IQ
* CVD
* Vascular RFs: stroke/MI, smoking, HTN, DM, high cholesterol
255
Clinical features: Name 3 symptoms in **early stages** of AD
* Memory lapses
* Difficulty finding words
* Forgetting names of people/places
256
Clinical features: Name 4 symptoms during **disease progression** of AD
* Apraxia
* Agnosia
* Confusion
* Language problems
* Impairment of executive functions
257
Clinical features: Name 7 symptoms in **later stages** of AD
* Disorientation to time/place
* Wandering
* Apathy
* Incontinence
* Eating problems
* Depression
* Agitation
258
Name 6 clinical features of vascular dementia
* **Stepwise** rather than continuous deterioration
* **Memory loss**
* **Emotional** and **personality changes**
* **Confusion**
* **Neurological signs/Sx**
* On examination --> **focal neurology** (UMN signs) and signs of **CVD**
259
Name 4 clinical features of DLB
* **Day to day fluctuations** in **cognitive performance**
* Recurrent **visual hallucinations**
* Motor signs of **parkinsonism** (tremor, rigidity, bradykinesia)
* **Recurrent falls / syncope**
260
Name 6 clinical features of fronto-temporal dementia
* **Family Hx** is positive
* Early personality changes: **disinhibition** (reduced control over one's behaviour), **apathy/restlessness**
* **Worsening** of **social behaviour**
* **Repetitive behaviour**
* **Language problems**
* **Memory is preserved** in early stages, but **insight is lost early**
261
Name 3 clinical features of Huntington's disease
* **Autosomal dominant**: strong family Hx
* **Abnormal choreiform movements** of face, hands, shoulders and **gait abnormalities**
* Dementia presents **later**
262
Name the triad of clinical features in normal pressure hydrocephalus
1. **Dementia** with prominent frontal lobe dysfunction
2. **Urinary incontinence**
3. **Gait disturbance** (wide gait)
263
Ix: Name 10 investigations for dementia
**Blood tests**: FBC,CRP,U&E,calcium,LFT,glucose,vit B12 & folate,TFT
Non-routine Ix:
* Urine dipstick
* Chest Xray
* Syphilis serology & HIV testing
* CT/ MRI/ SPECT (to differentiate between AD, VascD and F-TD)
* ECG
* EEG
* Lumbar puncture
* Genetic tests
* Cognitive assessment
264
DDx: Name 5 differentials for dementia (9)
* Normal **ageing**/ mild cognitive impairment
* **Delirium**
* **Trauma**: stroke, hypoxic, brain injury
* **Depression**: poor concentration/impaired memory common in depression in the elderly
* Late onset **schizophrenia**
* **Amnesic syndrome**: severe disruption in memory with minimal deterioration in cognitive function
* **Learning disability**
* **Substance misuse**
* **Drug side effects**: opiate, benzodiazepine
265
After a diagnosis of dementia, what are patients legally obliged to do?
**Contact DVLA**
266
Tx: What are 5 non-pharmacological managements of dementia?
* **Social support**
* Increasing assistance with **day-to-day activities**
* **Education**
* **Community** dementia teams & services
* **Home nursing** and **personal care**
267
What are the aims of dementia treatment?
* **Promote** **independence**
* **Maintain function**
* **Treat** **symptoms**
268
Tx: What is the pharmacological management of dementia?
* **Acetylcholinesterase inhibitors** (mild/moderate AD)
* **N-methyl-D-aspartate receptor antagonist** (moderate AD in those who are intolerant/contraindication to AChE inhibitors / severe AD)
* **Antipsychotic** for challenging behaviour (risperidone)
* **Antidepressant** for low mood (sertraline)
269
Tx: Name 3 AChE inhibitors
* **Donepezil**
* **Galantamine**
* **Rivastigmine**
270
Tx: Name an NMDA receptor antagonist
**Memantine**
271
Definition: Mild cognitive impairment (MCI)
Cognitive impairment **without** **functional** impairment
* Characterised by problems with **language**, **memory** and **thinking**
272
Definition: Frontal lobe syndrome
Impairment of the frontal lobe of the brain due to disease or frontal lobe injury
273
Definition: Autism
**Pervasive developmental disorder** characterised by a triad of:
* impairment in **social interaction**
* impairment in **communication**
* **restricted**, **stereotyped interests** and **behaviours**
274
Aetiology: What are some pre-/anti-/post-natal causes of autism?
Prenatal:
* **Genetics**
* **Parental age**: 40 y.o.
* **Drugs**: sodium valproate
* **Infection**
Antenatal:
* **Hypoxia** during childbirth
* **Prematurity**: before 35 weeks' gestation
* **Very low birthweight**
Postnatal:
* **Toxins**: lead, mercury
275
Name the triad of clinical features associated with autism
**Asocial**:
* Few social gestures
* Lack of eye contact
* Lack of interest in others
* Lack of emotional expression
**Behaviour** restricted:
* Restricted, repetitive and stereotyped behaviour
* Upset at any change in daily routine
* May prefer same foods/same clothes/same games
* Fascination with sensory aspects of environment
**Communication** impaired:
* Distorted / delayed speech
* Echolalia (repetition of words)
276
Ix: Name 3 investigations for autism
**Full developmental assessment**:
- family Hx
- pregnancy
- birth
- medical Hx
- developmental milestones
- daily living skills
- assessment of communication/social interaction/stereotyped behaviours
**Hearing tests**
**Screening tools**: CHAT (checklist for autism in toddlers)
277
DDx: Name 6 differentials for autism
* Asperger's syndrome
* Rett's syndrome
* Childhood disintegrative disorder
* Learning disability
* Deafness
* Childhood schizophrenia
278
Tx: What is the management of autism? (7)
* **Modification of environmental factors**
* Treat **co-existing** disorders
* **Psychoeducation** / **CBT**
* **Social-communication** intervention
* **Special schooling**
* **Antipsychotics** for challenging behaviour
* **Melatonin** for sleep
279
Definition: ADHD
## Footnote
Attention deficit hyperactivity disorder
Characterised by an early onset, persistent pattern of **inattention**, **hyperactivity** and **impulsivity** that are more frequent and severe than in individuals at a comparable stage of development
280
Name 3 risk factors for developing ADHD
* **Male**: 3x more likely
* **Family Hx**
* Environmental RFs: **social deprivation**, **family conflict**, **parental cannabis/alcohol exposure**
281
Clinical features: Name the 3 core symptoms of ADHD
**Inattention**
* Not listening when spoken to
* Highly distractable
* Reluctant to engage in activities that require persistent mental effort
* Forgetting/regularly losing belongings
**Hyperactivity**
* Restlessness/fidgeting/tapping
* Recklessness
* Running/jumping around in inappropriate places
* Difficulty engaging in quiet activities
* Excessive talking/noisiness
**Impulsivity**
* Difficulty waiting their turn
* Interrupting others
* Prematurely blurting out answers
* Temper tantrums/aggression
* Disobedient
* Running into the street without looking
282
Ix: Name 3 investigations for ADHD
* **Bloods** : TFTs (rule out thyroid disease)
* **Hearing tests**
* **Questionnaires**/ Rating scales
283
DDx: Name 5 differentials for ADHD (8)
* Learning disabilities/dyslexia
* Oppositional defiant disorder
* Conduct disorder
* Autism
* Sleep disorders
* Mood disorders (bipolar)
* Anxiety disorder
* Hearing impairment
284
Tx: What is the management of ADHD?
* **Psychoeducation**
* **CBT** and/or **social skills training**
* In severe ADHD in school-age children, **drug Tx** is first line (CNS stimulant)
285
Tx: Name the drugs used to treat ADHD
* **Methylphenidate**
* if this fails: **Atomoxetine**
* if this fails: **dexamfetamine**
286
Name 4 side effects of CNS stimulants
* Headache
* Insomnia
* Loss of appetite
* Weight loss
287
Definition: Learning disability
State of arrested or **incomplete development of the mind**, characterised by **impairment of skills** manifested during the developmental period
288
What are the 4 categories of LD?
**Mild**: IQ 50-70
**Moderate**: IQ 35-49
**Severe**: IQ 20-34
**Profound**: IQ < 20
289
What is the triad that must exist to constitute a LD?
* **Low intellectual performance**
* Onset at **birth** or during **early childhood**
* Wide range of **functional impairment**
290
Aetiology: Name 7 causes of LD
* **Genetic**: Down's, fragile X syndrome, Cri du chat
* **Antenatal**: congenital infection, nutritional deficiency, intoxication, endocrine disorders, pre-eclampsia
* **Perinatal**: birth asphyxia, intraventricular haemorrhage, neonatal sepsis
* **Neonatal**: hypoglycaemia, meningitis
* **Postnatal**: infection, metabolic, anoxia, cerebral palsy
* **Environmental**: neglect/non-accidental injury, malnutrition
* **Psychiatric**: autism, Rett's syndrome
291
What are the clinical features of LDs ranging from mild to profound?
**Mild**:
* Adequate language abilities, social skills, self-care
* May be difficulties in academic work
* Most live independently, but may need housing/employment support
**Moderate**:
* Limited language
* May need supervision for self-care
**Severe**:
* Motor impairment
* Little/no speech in early childhood
* May have associated physical disorders
**Profound**:
* Severe motor impairment
* Severe difficulties in communication
* Little/no self-care
* Frequently have physical disorders
292
Ix: Name 4 investigations for LDs before birth
* **Amniocentesis**
* **Chorionic villus sampling**
* **Genetic testing**
* **Karyotyping**
293
Ix: Name 3 investigations for LDs after birth
* **Bloods**: FBC, TFTs, glucose, serology
* **Brain imaging**: CT head / MRI
* **IQ test**
294
Tx: What is the management of learning disabilities?
* **Multidisciplinary** approach
* Treat co-morbid **medical/psychiatric conditions**
* **Behavioural techniques**: applied behavioural analysis, positive behaviour support, CBT
* **Family education**]
* **Prevention**: genetic counselling, antenatal diagnosis
295
Definition: Down's syndrome
A genetic disorder (**trisomy 21**) characterised by:
* **LD**
* **Dysmorphic facial features**
* **Multiple structural abnormalities**
296
What are 5 physical features of Down's syndrome? (11)
* **Palpebral fissure** (up slanting of eye)
* **Round face**
* **Occipital** + **nasal flattening**
* **Brushfield spots** (pigmented spots on iris)
* **Brachycephaly**
* **Low-set small ears**
* **Epicanthic folds** (monolid)
* **Mouth open** and **protruding tongue**
* **Strabismus** (squint)
* **Sandal gap deformity** (space between big toe and other toes)
* **Single palmar crease**
297
Name 7 medical problems associated with Down's syndrome
* **Heart defects**: ventricular/atrial septal defects, ToF
* **Hearing loss**
* **Visual disturbance**: cataracts, strabismus
* **GI problems**: oesophageal/duodenal atresia, coeliac
* **Hypothyroidism**
* **Haematological malignancies**: AML, ALL
* Increased incidence of **Alzheimer's**
298
Ix: Name 3 investigations for Down's syndrome
* **Serum screening**: beta-HCG & pregnancy-associated plasma protein A
* **Nuchal translucency**
* **Quad test**: beta-HCG, alpha-fetoprotein, inhibin A, estriol
299
What is the MOA for SSRIs?
* Inhibit **reuptake of serotonin** from the synaptic cleft into **pre-synaptic neurones**
* **Increase the concentration of serotonin** in the synaptic cleft
300
Definition: Serotonin syndrome
* Rare, life-threatening complication of **increased serotonin activity**
* Usually rapidly occuring - within minutes of taking meds
301
Clinical features: What are the cognitive/autonomic/somatic effects of **serotonin syndrome**?
* **Cognitive effects**: headache, agitation, hypomania, confusion, hallucinations, coma
* **Autonomic effects**: shivering, sweating, hyperthermia, HTN, tachycardia
* **Somatic effects**: myoclonus, hyperreflexia, tremor
302
What is the MOA for SNRIs?
* Prevent reuptake of **noradrenaline** and **serotonin**, but **don't block cholinergic receptors**
* Therefore don't have as many **anti-cholinergic SEs** as TCAs
303
What is the MOA for TCAs?
* Inhibit reuptake of **adrenaline** and **serotonin** in the synaptic cleft
304
What is the MOA for MAOIs?
Inactivate **monoamine oxidase enzymes** that oxidise the monoamine neurotransmitters **dopamine**, **noradrenaline**, **serotonin** and **tyramine**
305
Definition: Lithium toxicity
Medical emergency which can lead to **seizures**, **coma**, **death**
Enhanced by 4D's:
* **Dehydration**
* **Drugs** (ACE inhibitors, NSAIDs)
* **Diuretics** (thiazide)
* **Depletion of sodium**
306
Tx: What is the management of lithium toxicity?
* **Stop** lithium immediately
* High **fluid** intake inc **IV sodium chloride** to stimulate **osmotic diuresis**
* **Renal dialysis** may be needed in severe cases
307
Definition: Neuroleptic malignant syndrome
* Rare, life-threatening condition seen in patients taking **antipsychotics**
* Onset of Sx usually in first 10 days of Tx or after increasing dose
308
Clinical features: Name 5 symptoms of neuroleptic malignant syndrome
* Pyrexia
* Muscular rigidity
* Confusion
* Fluctiating consciousness
* Autonomic instability (e.g. tachycardia, fluctuating BP)
* May have delirium
309
Ix: Name 3 investigations for neuroleptic malignant syndrome
* **Creatinine kinase**: increased
* **FBC**: leucocytosis may be seen
* **LFTs**: deranged
310
Tx: What is the management of neuroleptic malignant syndrome? (5)
* Stop antipsychotic
* Monitor vital signs
* IV fluids to prevent renal failure
* Dantrolene (muscle relaxant)
* Bromocriptine (dopamine agonist)
311
Definition: Acute dystonic reaction
**Medication induced** movement disorder characterised by **involuntary muscle contractions**
312
Clinical features: What are the symptoms of acute dystonic reaction?
**Extrapyramidal side effects**
* Onset of atypical posture / position of muscles
* Within minutes/hours of taking medications
313
Tx: What is the treatment of acute dystonic reaction?
* **IV meds**: anticholinergic agents, benzodiazepines
* Stop triggering medication
314
Definition: Mental capacity
* One's ability to **make decisions**
* **Time** specific
* **Decision** specific
315
What is section 2 of the MHA?
Admission for **assessment**
Duration: 28 days
316
What is section 3 of the MHA?
Admission for **treatment**
Duration: 6 months
317
What is section 136 of the MHA?
Someone found in a **public place** who appears to have a **mental disorder** can be taken by the **police** to a place of safety
318
Definition: Overvalued idea
**False belief** that is maintained despite strong evidence that is is untrue
319
Definition: Loosening of association
Type of formal thought disorder characterised by **speech that shifts between topics** only **minimally related** to one another.
320
Definition: Circumstantiality
Including lots of **unnecessary** and **insignificant** details in conversation/writing
321
Definition: Perseveration
Inappropraite **repetition** of behaviour
e.g. rocking from side to side, finger wiggling, repetition of words
322
Definition: Confabulation
When a person **generates a false memory** without the intention of deceit
323
Definition: Incongruity of affect
**Lack of correlation** between a person's **affect** and their **stated mood**
e.g. may have happy thoughts/look happy when talking about a sad event
324
Definition: Blunted affect
Demonstrating **limited intensity** of emotions
325
Definition: La Belle indifference
A state of being **indifferent** to physical symptoms or abnormalities that are usually associated with **anxiety**
326
Definition: Depersonalisation
A feeling of **being outside yourself** and observing your actions/feelings/thoughts from a distance
327
Definition: Derealisation
Feel the **world is unreal**. Things around you may seem **foggy**/**lifeless**
328
Definition: Flight of ideas
When someone talks **quickly** and **erratically**, jumping rapidly between ideas and thoughts
329
Definition: Catatonia
State in which someone is awake but **doesn't respond** to other people/ their environment.
Psychomotor disorder that affects **speech** and **behaviour** functions
330
Definition: Stupor
* State of decreased **cognitive functioning**, **sensory capacity** and **awareness**
* State of **lethargy** and **impaired consciousness**
331
Definition: Akathisia
Movement disorder causing a feeling of **restlessness** and an **inability to stay still**
