1
Q
What are some risk factors for mild cognitive impairment (MCI)?
A
- Age - 65+
- diabetes
- smoking
- HTN
- elevated cholestrol
- obesity
- depression
- lack of physical exercise
- low education level
- lack of mental or social stimulation
2
Q
What are some differential diagnoses of someone presenting with increased forgetfulness and a lower than average score on MMSE?
A
- mild cognitive impairment
- delirium
- depression
- pseudo dementia
- vitamin B12 deficiency
- drug side effects/interactions
- hypothyroidism
- infections (think UTI in women)
3
Q
How would you investigate someone with MCI?
A
- Bloods - FBC, vit B12, random + fasting blood glucose
- full physical examination
- full Hx
- CT/MRIb/SPECT
- cognitive assessment - MMSE, addenbrookes & MOCA
- MMSE <10 = severe, <23 mild.
4
Q
How would you manage someone with MCI?
A
- no meds indicated for MCI, however Tx of underlying causative medical condition if there is one
- employ routine early, regular exercise, healthy diet, reduce alcohol, avoid stress, keep social active
5
Q
What 4 things are necessary for Capacity? Can it change?
A
- understand the decision to be made
- retain the information
- weigh up the pros and cons
- communicate the decision
capacity is DECISION & TIME specific
6
Q
Define Phenomenology.
A
Description of signs and symptoms through an empathetic assessment of subjective experience.
7
Q
Define an illusion.
A
illusions are misperceptions of real external stimuli
8
Q
Define a hallucination.
A
Hallucinations are perceptions occurring in the absence of an external physical stimulus. Auditory, visual, olfactory, gustatory, tactile, somatic.
9
Q
What’s the difference between 2nd and 3rd person auditory hallucinations?
A
- 2nd = YOU are a bad person, YOU are the next messiah, YOU are going to die
- 3rd = Running commentary (suggestive of schizophrenia)& voices discussing/commenting
10
Q
What is a reflex hallucination?
A
A stimulus in one sensory field causes a hallucination in another sensory modality.
11
Q
What’s the difference between an over-valued idea and a delusion?
A
Over-valued idea is a false/exaggerated belief that is sustained by logic but is NOT as rigid as a delusion
12
Q
Define Delusion.
A
A false unshakeable idea or belief which is out of keeping with the patients educational, cultural and social background. Something that is outside of normal experience.
13
Q
Briefly describe some common delusions.
A
persecutory - everything bad is your fault - depression
grandiose - believe you’re jesus, superman, cured cancer. - schizo
paranoid - FBI are after you - schizo
self-referential - newspaper/TV talking to you,
Nihilistic - already dead, bowels rotted - depression
14
Q
What are some examples of thought disorders?
A
Alienation - catch all term for the below Insertion Withdrawal Broadcast Echo Block
15
Q
What are examples of disorders of expression?
A
Concrete thinking Loosening of association circumstantiality perseveration confabulation
16
Q
Define perseveration.
A
repetition of a word, theme or action that is more than deemed relevant or appropriate.
17
Q
Define confabulation.
A
Telling a false account of events in order to fill a gap in memory.
18
Q
What are some passive phenomenology?
A
Somatic passivity - passive recipient of thoughts, feelings, sensations, LIFE
catatonia
psychomotor retardation
19
Q
describe some features of catatonia
A
it’s a state of excited or inhibited motor activity in the absence of a mood or neuro disorder.
- waxy flexibility - patients limbs moved into a position and they stay there
- echolalia - repetition of words heard by the patient
- echopraxia - automatic repetition of movements that the examiner made the patient do
20
Q
Define psychomotor retardation
A
- slowing of thoughts & movements, to a variable degree.
- Occurs in depression but may be drug induced (antipsychotics) or structural (Parkinson’s)
21
Q
What is pressure of speech?
A
very rapid delivery of speech with a wealth of associations which may be unusual and often wanders off point. (suggestive of mania)
22
Q
What is flight of ideas?
A
Rapid skipping from one thought to another that is distantly related. Can be very tenuously related.
23
Q
Define Anhedonia.
A
The inability to take pleasure from something one would usually find enjoyable.
24
Q
Define incongruity of affect.
A
emotional responses which seem grossly out of tune with the situation or subject being discussed.
25
Define depersonalisation.
A feeling of some change in self, associated with a sense of detachment from one's own body.
26
define derealisation.
A sense of one's surroundings lacking reality, often appearing dull, grey and lifeless.
27
What is the difference between obsession and compulsion?
```
Obsession = a recurrent persistent thought, image or impulse that happens without voliation that is seen as being ones own & remains despite efforts to resist
Compulsion = repetitive, apparently purposeful behaviour performed in a stereotyped way accompanied by a subjective sense that it must be carried out despite acknowledgement of it's purposelessness.
```
28
Define Akathisia.
A condition marked by motor restlessness, ranging from anxiety to an inability to lie or sit quietly or to sleep
29
What are the 3 core symptoms of depression?
- low mood
- loss of energy (anergia)
- loss of pleasure (anhedonia)
30
What are some other common symptoms associated with depression?
- changes in sleep (typically early morning waking)
- changes in libido
- changes in appetite
- diurnal mood variation
- agitation
- loss of confidence
- loss of concentration
- guilt
- hopelessness
- suicidal ideation
31
How do you tell between mild & moderate depression?
```
mild = core + 2-3 symptoms
moderate = core + 4 other symptoms + functioning affected
```
32
How do tell between moderate and severe depression?
```
moderate = core + 4 Sx + functioning affected
Severe = several symptoms + suicidal + marked loss of functioning
```
33
What are the 2 types of severe depression?
- With or Without psychotic symptoms
| - typically mood congruent (nihilistic & guilty delusions, derogatory voices)
34
What are some possible presentations of depression?
- Post natal - 13% of women
- recurrent depression
- part of bipolar illness
35
What's the difference between bipolar I and II?
```
I = both mania + depression (sometimes only mania)
II = more episodes of depression, only mild hypomania EASY TO MISS
```
36
What's the duration & symptoms of hypomania?
- between 4-7 days
- elevated mood (euphoric/dysphoric/angry)
- increased energy
- poor concentration
- increased talkativeness
- mild reckless behaviour
- sociability/overfamiliarity
- increased libido/sexual disinhibition
- increased confidence
- decreased sleep need
- change in appetite
37
What's the duration & symptoms of Mania?
- Greater than 1 week of Sx
- extreme uncontrollable elation
- over activity
- pressure of speech
- impaired judgment
- Extreme risk taking behaviour
- social disinhibition
- inflated self-esteem
- with psychotic Sx
- mood congruent/incongruent
38
What are some psychotic disorders?
- Schizophrenia - MAIN ONE
- delusional disorder
- Schizotypal disorder
- depressive psychosis
- manic psychosis
-organic psychosis
39
Describe the epidemiology of Schizophrenia?
- 1% lifetime risk
- stable incidence across the world
- 1:1 F:M
- onset typically 2nd-3rd decade second small peak in late middle age
- increase suicide risk
- increased risk of death from CVD, Resp disease and infection (x2, 3, 4)
40
What are the first rank Sx of Schizophrenia?
need greater than 1 Sx
- thought alienation
- passivity phenomena
- 3rd person auditory hallucination
- delusional perceptions
41
What are the second rank symptoms of Schizophrenia?
Need 2 or more
- delusions
- 2nd person auditory hallucinations
- hallucinations in other modalities
- thought disorder
- catatonic behaviour
- negative Sx
42
What are the negative Sx associated with schizophrenia?
- blunting affect
- amotivation
- poverty of speech
- poverty of thought
- poor non-verbal communication
- clear deterioration in functioning
- self neglect
- lack of insight
43
What are some features of generalised anxiety disorder?
- excessive anxiety across different situations
- >6 months
- tiredness
- poor concentration
- irritability
- muscle tension
- sleep changes (initially insomnia)
44
What are some physical Sx of panic disorder?
- palpations
- chest pain
- choking
- tachypnoea
- Dry mouth
- Urgency of micturition
- Dizziness
- blurred vision
- Parathesiae
45
What are some psychological Sx of panic disorder?
- feeling of impending doom
- fear of dying
- fear of losing control
- depersonalisation
- derealisation
46
Define OCD.
Obsessive thoughts with compulsive acts
47
What are some examples of obsessions?
Obsessive thoughts or images
- often unpleasant - death/sexual/blasphemous
- repetitive
- intrusive
- irrational
- recognised as patient's own thoughts
48
What are compulsion actions?
- Checking
- washing
- counting
- symmetry
- repeating certain words or phrases
49
A patient believes that a close relative has been replaced by an identical looking impostor. Which is this known as?
Capgras delusion.
50
A patient describes meeting the same person but they are in lots of different disguises. What is this phenomena known as?
Fregoli delusion
51
What are the physiological abnormalities seen in Anorexia nervosa?
- hypokalaemia
- low FSH, LH, oestrogens & testosterone
- raisied cortisol & growth hormone
- impaired glucose tolerance
- hypercholestrolaemia
- hypercarotinaemia
- low T3
52
What are some clinical features of Anorexia Nervosa?
- reduced BMI
- bradycardia
- hypotension
- enlarged salivary glands
53
What questionnaire would you use to determine the likelihood of Anorexia?
SCOFF
-do you ever make yourself SICK because you feel too full?
-do you every worry you've lost CONTROL over your eating?
-have you recently lost more than ONE stone in 3 months?
-do you ever believe you're FAT when people say you're thin?
-does FOOD dominate your life?
<2 yes = likely diagnosis of anorexia
54
What's the difference between bulimia and anorexia?
- bulimia = 5x more common and can present with a normal weight - eating pattern binge then purge (laxative abuse, vomiting, starving)
- anorexia = calorie restriction and significantly low BMI, intense fear of fatness, delayed puberty if below pubertal age.
55
What are some impacts of low body weight?
- thinking slowed/inflexible, find it difficult to switch topics or make decisions
- concentration poor - partly due to lack of nutrition and partly because of thoughts about food
- mood - somewhat low and get very irritated
- lose interest in things that aren't to do with food
- behaviour - heightened obsessiveness, eating becomes ceremonial, hoarding of objects/food. no explanation for actions.
56
What happens during refeeding syndrome?
- reinstitution of nutrition at too quick of a rate
- Person no longer needs to utilise fat and protein stores
- causes a spike in insulin secretion and massive cellular uptake of electrolytes
- causes a drop in serum phosphate (and other electrolytes) which produces the clinical Sx of refeeding syndrome
57
when treating anorexia how do you avoid refeeding syndrome?
- Thiamine and vitamin B complexes given when feeding resumes
- biochemistry should be closely monitored
- abnormalities in K+, Po4- and MG2+ should be corrected.
58
When and how does refeeding syndrome present?
- 3-4 days from commencement of nutrition
- muscle weakness
- confusion
- coma
- seizures
- death
59
What are key features of a dependence syndrome?
- Tolerance - do you need more a of a substance ot make you feel how you want to.
- Primacy - Does your substance habit come before anything else?
- Physical and mental withdrawal - craving and shaking
- Loss of control - do you feel in control anymore?
- Continued use after harmful consequences.
60
What are the symptoms of a alcohol withdrawal?
- starts 1-7 days after the last drink
- anxiety
- sweating
- insomnia
- hallucinations (Lilliputian)
- seizures
- Delirium Tremens (5%)
61
Describe what happens during Delirium Tremens.
- other Sx of withdrawal
- vivid hallucinations
- delusional beliefs
62
What is the treatment regime for someone withdrawing from alcohol?
- IVI
- thiamine given stat then daily
- Benzos - increase GABA effect serving to replace alcohol - ween
- Treat psychologically first to assess motivation - prep for detox
63
What are the long term complications of alcohol dependence?
- Wernicke-Korsakoff Syndrome
- Wernicke triad = Ataxia, ophalmoplegia and acute confusion
- Korsakoff - anterograde amnesia (can't make new memories) and confabulate to fill in the gaps
64
What is the pathophysiology of Wernicke-Korsakoff's syndrome?
- Happen due to thiamine deficiency
- Most calories come from alcohol so less B12 intake
- alcohol disrupts the absorption of B12 in the stomach
- alcohol disrupts liver enzymes that converts B12 into active form
65
Define tolerance.
A state which an organism no longer responds to a drug - requires higher dose to achieve same effect
66
Define Dependence.
A state which an organism functions normally only in the presence of a drug
67
Define withdrawal.
physical and psychological disturbance when drug is removed.
68
How would you treat alcohol related hepatitis? or pancreatitis?
- corticosteroids
- nutritional support
- pancreatic enzyme supplements
69
Pinpoint pupils + track marks + passed out. immediate Tx?
- IV/IM naloxone
| - bloods for tox screen
70
What treatments are available for anxiety disorders?
- first line Tx - self taught CBT
- second line - CBT guided
- Third line - high-intensity CBT or Drugs: SSRI = sertraline or SNRI - Venlafaxine
- fourth line - specialist centre referral and maybe offer pregabalin
71
What are the A-H criteria of PTSD?
```
A = exposure to trauma
B = persistent re-experiencing of trauma
C = avoidance of trauma related stimuli
D = negative thoughts that began or worsened after trauma
E = arousal or reactivity tht began or worsened after trauma
F = symptoms lasting longer than 1 month
G = creating stress or functional impairment
H = not due to medication, substance abuse or organic illness
```
72
Define Generalised anxiety disorder.
Persistent or excessive worry about a number of different things. Happening for most of the day lasting for longer than 6 months.
73
Define Panic Disorder.
Panic attacks with no specific stimulus.
74
How do you treat panic disorder?
- Beta-blocker - propranolol
- benzos acutely (addictive)
- mindfulness based therapies
- psychoed
- CBT
75
Define a phobic disorder.
Anxiety triggered by exposure to a stimulus.
76
How do you treat a phobic disorder?
-Graded exposure therapy
77
Define social phobia.
Debilitating fear of humiliation in social interaction.
78
Define agoraphobia.
Extreme fear of public places.
79
What are some differences between dementia and delirium?
Delirium vs Dementia
- acute onset vs insidious
- fluctuating & usually reversible vs slow progressive
- days to weeks vs years
- condition/medication vs neurological/cerebrovascular disease
- attention greatly impaired vs only impaired in severe disease
- varied memory loss vs memory loss evident (particularly recent events)
- immediate medical attention vs nonemergency
- visual and tactile hallucination vs delusions in 40%
80
What are the 3 main criteria of a delusional belief?
- Certainty - patient believes delusion absolutely
- incorrigibility - belief cannot be shake with explanation
- impossibility - belief is untrue without doubt
81
What investigations may be useful in query schizophrenia?
- LFTs + FBC could indicate alcohol abuse
- serological test of syphilis
- screening for AIDS (HAND)
- Urine analysis - substance abuse
- CT head for SOL if focal Sx present
82
What is recommended as first line Tx for schizophrenia?
- olanzapine or quetiapine
| - atypical anti-psychotics
83
what is the MOA of atypical (2nd gen) anti-psychotics?
- D2 receptor blockers in mesolimbic/mesocortical pathways
| - lower extrapyramidal Sx
84
Define treatment resistant schizophrenia. What treatment would you use in this case?
- no relief of Sx after a trial of 2 antipsychotic drugs
| - clozapine
85
What precautions must be taken when starting a patient on clozapine? Why?
- weekly blood tests for 18 weeks then every 2 weeks for a year
- causes agranulocytosis
86
What are some common side effects of antipsychotics?
- weight gai causing secondary diabetes
- hyperprolactinaemia
- gynaecomastia
- sedation
- headaches
- dizziness
- parkinsonisms
- dystonia
- Akathisia -restlessness
- tardive dyskinesia
- acute dystonia
87
What are some risk factors for schizophrenia?
- medication non-adherence
- past psychiatric history
- alcohol and drug use
- Family Hx
- young black male
88
What are the risks of starting an elderly person on an antipsychotic?
- increased risk of Stroke
| - increased risk of VTE
89
What is a delusional perception?
-a true perception which the patient attributes a false meaning.
FIRST RANK SCHIZOPHRENIA SX
90
How do you treat acute dystonia reactions in antipsychotic usage?
-IM procyclidine
91
What are the features of fragile X syndrome?
- development delay - learning diabilities and cognitive impairment
- usually affects males
- delayed speech and language development
- 1/3rd have ASD
92
What are some causes of learning disabilities?
- genetics - down's (most common), Edwards, turners
- perinatal - infection (EBV), bacterial (meningitis), parasites, delivery (hypoxic brain injury), maternal alcohol or drug use
- Trauma - RTA
- CNS tumour
93
Define learning disability.
Significant life long condition that starts before adulthood that affects development and leads to help being required to understand information, learn skills and cope independently.
-NHS says IQ <70
94
Define learning difficulty.
any learning or emotional problem that affects a persons ability to learn, get along with others and follow convention. Can be overcome with adjustments.
95
When factors should be considered when a person with a learning disability is going to be going through a bereavement?
- prepare the person and involve them if this is possible
- they might display challenging behaviour as routine/mood of environment changes
- explain clearly what is happening to the person with terminal illness
- explain death without using euphemisms
96
What's the criteria for diagnosing Anorexia?
- <85% expected body weight
- fear of weight gain
- disproportionate idea of body
- amenorrhoea or decreased libido
97
What questions do you ask when trying to assess suicide risk?
- Did you attempt?
- Did you think it was going to work?
- Did you plan/write a note?
- Have you tried to take your life before?
98
Briefly describe attachment theory.
-The idea that babies for an attachment in early life with 1 care giver and this forms the basis of all social interactions in the future.
-lack of secure attachment causes developmental consequences:
~decline in IQ
~depression
~aggression
~delinqunincy
~affectionless psychopathy
99
What impact does early life trauma have on a person?
-impairs development of brain function
-impairs thinking, relationships, memory and health
-Problematic development of effect executive function:
~controlling impulses
~organisation
~planning
~initiation
~motivation
100
What are the A,B & C categories of personality disorders?
A - Odd or eccentric
B - dramatic or emotional
C - Anxious or avoidant
101
How would you treat mania?
ACUTE
mild/moderate - lithium monotherapy OR atypical antipsychotic
Severe - mood stabilizer (lithium or valporate) PLUS antipsychotic
CHRONIC
lithium, valporate, carbamazepine, lamotrigine.
Phase 3a
flashcards
Decks in class (15)
# Cards
