Psychiatry Flashcards

Question

______ ______ is the fifth biggest risk factor for death across all ages.

Answer 1

**alcohol misuse** is the fifth biggest risk factor for death across all ages.

Answer 2

* Impaired control over substance use * Increasing priority over other aspects of life or responsibility * Psychological features suggestive of tolerance and withdrawal

Answer 3

When an individual consumes a substance, this affects the **mesolimbic dopamine system** in the n**ucleus accumbent and dorsal striatum** in the basal ganglia.4 The release of **dopamine** gives off pleasurable feelings which trigger the reward system and positively reinforce the behaviour of substance consumption. This process is known as **operant conditioning** and is the basis of **addiction** and cravings. Some substances, such as alcohol and opioids, interact with the **inhibitory neurotransmitter GABA,** which disrupts the equilibrium between GABA and glutamate. It is believed that the number of natural stimulants (glutamate) and natural sedatives (GABA) are roughly the same. When an individual consumes substances, this **disrupts the equilibrium** as there are more** sedative hormones (GABA).** When exposed chronically, this results in neuroadaptation. The brain will **upregulate the natural stimulants** to achieve equilibrium. **Withdrawal symptoms** occur when there is a sudden drop in GABA, resulting in disrupted homeostasis and too much glutamate. The excess natural stimulants lead to withdrawal symptoms such as anxiety, sweating, and shaking.

Answer 4

* Full blood count: raised MCV, raised platelets, anaemia * Liver function tests: increased GGT, AST:ALT > 2:1 * Haematinics (B12/folate): alcohol can cause folate deficiency * Thyroid function tests

Answer 5

The **AUDIT-C questionnaire** is a common screening tool that looks at the risk of dependency of alcohol misuse.7 Other questionnaires include the **SAD-Q** questionnaire which looks at the severity of alcohol dependence and the **CAGE** questionnaire. For more information, see the Geeky Medics guide to **alcohol history taking.**

Answer 6

Naltrexone is an opiate blocker that makes **alcohol less enjoyable** and less rewarding. It can be administered as an injection once a month or oral tablets. Common side effects are nausea, vomiting, decreased appetite, pain at the injection site, and increased liver enzymes. It is contraindicated in opiate use and patients with liver failure.

Answer 7

Acamprosate is a medication that increases GABA and decreases excitatory glutamate which **reduces cravings. ** It has a good side effect profile and is generally well tolerated.

Answer 8

**Disulfiram** inhibits acetaldehyde dehydrogenase which causes the accumulation of acetaldehyde with alcohol. It causes **unpleasant symptoms** such as flushing, sweating, headache, nausea and vomiting, arrhythmias, and hypotensive collapse. Patients should avoid alcohol for 24 hours before taking disulfiram and 1 week after cessation of the medication. When taking the medication, they must a**void all contact with alcohol**. Disulfiram is contraindicated in patients with heart disease, psychosis, and those felt to be at high risk of suicide

Answer 9

* Neurological: ischaemic stroke, encephalopathy, seizures, peripheral neuropathy * Cardiovascular: increased rate of myocardial infarction and stroke, hypertension, dilated cardiomyopathy * Hepatology: alcoholic liver disease, liver cirrhosis, liver fibrosis, pancreatitis * Oncology: increased risk of head and neck cancer, oesophageal cancer, liver cancer, breast cancer, colorectal cancer * Psychiatric: alcoholic hallucinosis, delirium tremens, Wernicke-Korsakoff syndrome

Answer 10

* HIV and hepatitis B/C: due to the increased risk of blood-borne infection is greater through needle sharing * Tuberculosis testing * Urea & electrolytes * Liver function tests and clotting screen: to check hepatic function * Drug levels: to check for drug toxicity

Answer 11

* Drug abuse screening test (DAST): assess drug use in the past 12 months * CAGE-AID (adapted to include drugs) * Addiction severity index (ASI): looks at the effect of the use of substances on law, family, social life, work and mental health * Clinical opiate withdrawal scale (COWS): rates common signs and symptoms of opiate withdrawal and monitors symptoms *

Answer 12

The main intervention for opioid misuse is opioid detox using **methadone reduction. **An alternative to this is **buprenorphine reduction**. It can be helpful to refer the patient for counselling and rehabilitation.

Answer 13

Opioid misuse also increases the risk of blood-borne diseases such as **HIV, hepatitis B, and C.**

Answer 14

Benzodiazepine misuse includes the use of **diazepam, oxazepam and lorazepam.**

Answer 15

Benzodiazepines are another example of central nervous system **depressants.**

Answer 16

* **Physiological effects:** altered mental status, slurred speech, ataxia, respiratory distress, hypothermia, and coma if overdosed * **Psychological effects: **euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood Withdrawal from benzodiazepines may result in a wide range of clinical features including tremor, nausea & vomiting, tachycardia, postural hypotension, headache, agitation, malaise, transient illusions or hallucinations, paranoid ideation and seizures.

Answer 17

The clinical institute withdrawal assessment scale – benzodiazepines (CIWA-B) can be used to determine the severity of withdrawal from the substance.

Answer 18

The main intervention for benzodiazepine misuse is **assisted withdrawal **and supportive treatments.

Answer 19

Amphetamine use (e.g. Adderall and methylphenidate) and cocaine

Answer 20

stimulant, powder. Acute seizures and psychotic episodes, ischaemic colitis, vasospastic ACS. Mx: Benzodiazepines (short term) + GTN. Support groups.

Answer 21

Injected, strong sense of relaxation. Risk of overdose. Withdrawal: sweating, watery eyes, anxiety. Mx: Lofexidine (a2 agonist) +/- Benzodiazepines for symptom. Opioid substitution using Methadone

Answer 22

Hallucinogens include lysergic acid diethylamide (LSD – ‘acid’), marijuana, ecstasy and phencyclidine or phenylcyclohexyl piperidine (PCP). When consumed, they can cause **euphoria, visual and auditory hallucinations and psychosis.**

Answer 23

**LSD:** lethargy, psychomotor agitation, craving, insomnia, and unpleasant dreams **Marijuana:** increased appetite and conjunctival injection **Ecstasy: **bruxism, hyperthermia, hyponatremia, and hepatotoxicity **PCP: **loss of painful stimuli, vertical nystagmus, psychosis with hallucination, violence, and agitation

Answer 24

the drug abuse screening test (DAST), CAGE-AID (adapted to include drugs) and addiction severity index (ASI).

Answer 25

Opioid and benzodiazepine misuse cause **sympathetic depression** resulting in drowsiness, respiratory depression, and lethargy

Answer 26

In patients with anorexia nervosa, the person feel they are overweight despite evidence of normal or low body weight. It involves obsessively restricting calorie intake with the intention of losing weight. Often the person exercises excessively and may use diet pills or laxatives to restrict absorption of food.

Answer 27

* Excessive weight loss * Amenorrhoea * **Lanugo hair** is fine, soft hair across most of the body * Hypokalaemia * Hypotension * Hypothermia * Changes in mood, anxiety and depression * Solitude

Answer 28

arrhythmia, cardiac atrophy and sudden cardiac death

Answer 29

Unlike with anorexia, people with bulimia often have a normal body weight. Their body weight tends to fluctuate. The condition involves binge eating, followed by **“purging”** by inducing vomiting or taking laxatives to prevent the calories being absorbed.

Answer 30

* Alkalosis, due to vomiting hydrochloric acid from the stomach * Hypokalaemia * Erosion of teeth * Swollen salivary glands * Mouth ulcers * Gastro-oesophageal reflux and irritation * Calluses on the knuckles where they have been scraped across the teeth. This is called Russell’s sign.

Answer 31

Look out for the teenage girl with a normal body weight that presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas. The presenting complaint may be abdominal pain or reflux.

Answer 32

Binge eating disorder is characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress. This is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight. Binges may involve: * A planned binge involving “binge foods” * Eating very quickly * Unrelated to whether they are hungry or not * Becoming uncomfortably full * Eating in a “dazed state”

Answer 33

Patient and carer education is key to the condition. Management is centred around changing behaviour and addressing environmental factors: * Self help resources * Counselling * Cognitive behavioural therapy (CBT) * Addressing other areas of life, such as relationships and past experiences Severe cases may require **admission** for observed refeeding and monitoring for **refeeding syndrome.** **SSRI medication** may be used by a specialist in child and adolescent mental health.

Answer 34

Refeeding syndrome occurs in people that have been in a severe nutritional deficit for an extended period, when they start to eat again. Patients are at higher risk if they have a BMI below 20 and have had little to eat for the past 5 days. The lower the BMI and the longer the period of malnutrition, the higher the risk.

Answer 35

Hypomagnesaemia Hypokalaemia Hypophosphataemia These patients are also at risk of cardiac arrhythmias, heart failure and fluid overload

Answer 36

Management will be according to the local protocol under specialist supervision: * Slowly reintroducing food with restricted calories * **Magnesium, potassium, phosphate and glucose** monitoring along with other routine bloods * **Fluid balance** monitoring * **ECG monitoring** may be required in severe cases * **Supplementation** with electrolytes and vitamins, particularly B vitamins and thiamine

Answer 37

1st: CBT-ED. Maudsley Anorexia Nervosa Treatment, Specialist supportive clinical management 10% of patients will eventually die

Answer 38

Bipolar disorder is a mood disorder characterised by episodes of depression and mania or hypomania.

Answer 39

15-24 years and 45-54 years.

Answer 40

The aetiology of bipolar disorder is complex and involves **genetic, environmental**, and **neurobiological** components.

Answer 41

The genetic risk associated with bipolar disorder is a type of **polygenic** inheritance

Answer 42

* Genetic factors: combined effect of many single nucleotide polymorphisms (SNPs) * Prenatal exposure to Toxoplasma gondii (the parasite that causes toxoplasmosis) * Premature birth <32 weeks gestation * Childhood maltreatment * Postpartum period * Cannabis use

Answer 43

Type 1: Mania and depression Type 2: Hypomania and depression

Answer 44

* In **bipolar I**, the person has experienced at least one episode of **mania** * In **bipolar II**, the person has experienced at least one episode of **hypomania,** but never an episode of **mania. ** They must have also experienced at least one episode of major depression.

Answer 45

**elevated mood, increased activity** level and **grandiose ideas** of self-importance. In the ICD-10, mania is characterised by: * **Elevated mood **out of keeping with the patient’s circumstances * Elation accompanied by **increased energy** resulting in overactivity, pressure of speech, and a decreased need for sleep * Inability to maintain attention, often with marked distractibility * Self-esteem which is often inflated with **grandiosity **and increased confidence * Loss of normal social inhibitions

Answer 46

For a diagnosis, the manic episode should last for at least **seven days** and have a **significant negative functional effect** on work and social activities. Mood changes should be accompanied by an **increase in energy** and several of the other symptoms mentioned above. As well as these features, mania can also occur alongside psychotic symptoms such as delusions and hallucinations, which are often auditory

Answer 47

Hypomania is less severe than mania and is characterised by an **elevation of mood** to a lesser extent than that seen in mania. In ICD-10, an episode of hypomania is characterised by:8 * Persistent, mild **elevation of mood** * **Increased energy** and activity, usually with marked feelings of wellbeing * Increased sociability, talkativeness, over-familiarly, increased sexual energy and a decreased need for sleep (but not to the extent that there is a significant negative effect on functioning regarding work or social activities) * Irritability may be present * Absence of psychotic features (delusions or hallucinations)

Answer 48

For a diagnosis, more than one of these features should be present for at least several days. Although hypomania does involve some extent of **functional impairment,** this is lesser than that seen in mania and is not severe enough to cause the more marked impairment in occupational or social activities.

Answer 49

Schizophrenia Organic brain disorder Drug use Recurrent depression Emotionally unstable personality disorder (EUPD)/borderline personality disorder Cyclothymia

Answer 50

Investigations can be used to exclude organic causes of a patient’s clinical presentation and are largely context-dependent. Relevant investigations may include: * Baseline blood tests: FBC, U&Es, LFTs, TFTs, CRP, B12, folate, vitamin D, ferritin * HIV testing * Toxicology screen * Physical examination including neurological examination * CT head

Answer 51

Bipolar disorder should be considered when there is evidence of: * **Mania: **symptoms should have lasted for at least seven days * **Hypomania:** symptoms should have lasted for at least four days * **Depression** (characterised by low mood, loss of interest or pleasure, and low energy) with a history of manic or hypomanic episodes To confirm a diagnosis of bipolar disorder, a referral should be made to a **specialist mental health service**. This varies regionally but may take the form of a bipolar disorder service, a psychosis service, or a specialist integrated community-based service

Answer 52

a mixed affective state.

Answer 53

Child and Adolescent Mental Health Services (CAMHS).

Answer 54

n an acute episode of mania, people with a new diagnosis of bipolar disorder should be managed in secondary care with a trial of oral antipsychotics:11 * Haloperidol * Olanzapine * Quetiapine * Risperidone If the patient is on **antidepressant medication**, this should be tapered off and discontinued.11 **Benzodiazepines** may be used as an adjunct to manage symptoms of increased activity and allow for better sleep.

Answer 55

The recommended pharmacological options for managing depressive episodes in the context of bipolar disorder are:11 * Fluoxetine + olanzapine * Quetiapine alone * Olanzapine alone * Lamotrigine alone As well as these pharmacological options, psychological interventions such as cognitive behaviour therapy (CBT) may also be useful.11

Answer 56

After the acute episode has resolved, long-term pharmacological management usually involves a** mood stabilising medication **such as **lithium.** If lithium is not effective, **sodium valproate** may be added.11 Sodium valproate should not be used in pregnant women due to its **teratogenic effects** and is not recommended in women of childbearing age unless the illness is very severe and there is no effective alternative. In this circumstance, the patient should have a **pregnancy prevention plan.** **Lithium** is associated with a **significant reduction** in the risk of relapse with a manic episode, though evidence for its effectiveness in preventing depressive relapse is less clear. The use of lithium is also associated with a **significant reduction in death by suicide**.13 Around half of patients will show a good response to lithium, although those with rapid-cycling bipolar disorder, mixed affective states or mood-incongruent features of psychosis may be less likely to respond well.1

Answer 57

* Increased risk of death by **suicide** * Increased risk of death by general **medical conditions** such as cardiovascular disease * **Side effects** of antipsychotic drugs: these can include metabolic effects, weight gain and extrapyramidal symptoms * **Socioeconomic effects**: major mental illness is associated with a negative drift down the socioeconomic ladder

Answer 58

Consider initiation of a mood stabiliser after remission of a manic episode. * First-line treatment for mood stabilisation is **Lithium Carbonate** or Depakote (Depakote must not be used in women of childbearing potential because of its teratogenicity - significantly increased risk of neural tube defects). * Second-line - **Carbamazepine** (= CYP450 inducer and so can lower serum level of some medications and make them less effective). * **Lamotrigine** should be considered if the patient is more prone to bipolar depressive episodes rather than manic / hypomanic episodes

Answer 59

Recurrent hallucinations with visual impairment

Answer 60

RF: Age, peripheral visual impairment, social isolation, sensory deprivation

Answer 61

Treat age related macular degeneration, glaucoma or cataracts

Answer 62

Depression is a mood (affective) disorder characterised by persistent low mood, low energy and loss of interest/enjoyment in everyday activities (anhedonia)

Answer 63

Depression can be **unipolar** (first occurrence or recurrent) or **bipolar **(with occurrences of mania and depression).

Answer 64

* Genetics: family history of depression in the nuclear family increases the risk to almost 30-40% and up to 50% in monozygotic twins * Personality: dependent, anxious, impulsivity and obsessional traits * Physical illness: neurological illnesses such as Parkinson’s disease and multiple sclerosis, hypothyroidism or chronic illnesses * Biochemical theories/monoamine deficiency: serotonin imbalance causes depressive symptoms * Neuroendocrine: hypothalamic-pituitary-adrenal axis * Co-morbid substance misuse * Medications: beta-blockers, steroids * History of other mental illnesses: anxiety

Answer 65

* Traumatic life events/childhood experiences: adverse experiences including loss of a loved one, lack of parental care and childhood sexual abuse * Environmental factors (e.g. support) * Low self-esteem and negative automated thoughts (e.g. helplessness, hopelessness, worthlessness) * Lack of education

Answer 66

* Poor social support * Poor economic status or support * Marital status: separated or divorced

Answer 67

* The presence of symptoms for at least 2 weeks (this may be less if depression is severe) * The symptoms are not attributable to other organic or substance causes (e.g. normal bereavement) * The symptoms impair daily function and cause significant distress

Answer 68

* Low mood * Anhedonia: low interest or pleasure in most activities of the day * Lack of energy (anergia)

Answer 69

* Weight change: exclusion of intentional dieting * Disturbed sleep: insomnia or hypersomnia * Psychomotor retardation (slowed down actions) or psychomotor agitation (increased restlessness) * Reduced libido * Worthlessness or guilt feelings * Decreased concentration * Recurring thoughts of harm, death or suicide: nihilistic thoughts

Answer 70

* Anhedonia * Loss of emotional reactivity * Diurnal mood changes: mood often worse in the morning * Early morning wakening: typically 2-3 hours earlier than usual * Psychomotor retardation or psychomotor agitation * Appetite loss * Weight loss

Answer 71

* Delusions: often revolving around guilt and personal inadequacy * Hallucinations: can be auditory, olfactory or visual

Answer 72

* **Risk to self: **self-harm, suicide or neglect (commonest in depression) * **Risk to others:** when depression presents with psychotic features, such as command hallucinations, they may be at risk of harming others * **Risk from others:** patients with depressive symptoms may be more vulnerable to abuse, criminal acts or neglect

Answer 73

* Depressive episode linked to substance/medication use * Bipolar affective disorder * Premenstrual dysphoric disorder * Bereavement * Anxiety disorders * Alcohol-use disorder * Hypothyroidism * Cushing’s disease or syndrome * Vitamin B12 deficiency

Answer 74

Screening questionnaires such as the **patient-health-questionnaire-9 (PHQ-9)** can be used to screen for symptoms of a depressive episode. Investigations may be considered to **exclude physical/organic causes **of the patient’s symptoms. These may include: * **Full blood count:** anaemia * **Thyroid function test:** hypothyroidism (elevated thyroid stimulating hormone) * **Vitamin B12:** vitamin b12 deficiency **Imaging and other investigations** (e.g. a CT head) may be performed in patients with** atypical features** and signs indicative of an **organic pathology** (e.g. low mood associated with a sudden loss of memory and change in personality).

Answer 75

* **Mild depression** requires two typical core symptoms plus two other core symptoms * **Moderate depression** requires two typical core symptoms plus at least three other core symptoms * **Severe depression** requires all three typical core symptoms plus at least four other core symptoms. ICD-11 further classifies depressive episodes as 1. **Mild depressive** episode, with or without somatic symptoms 1. **Moderate depressive** episode, with or without somatic symptoms 1. **Severe depressive **episode, with or without psychotic symptoms: these may be mood-congruent or incongruent psychotic symptoms 1. Recurrent depressive disorder: when one has two more depressive episodes

Answer 76

First-line management should involve initiating primarily** low-intensity psychosocial interventions.** In the United Kingdom, the 2022 NICE guidelines recommend the following interventions, based on implementation, clinical and cost-effectiveness:3 * Guided self-help * Group cognitive-behavioural therapy (CBT) * Group behavioural activation * Individual CBT * Group behavioural activation * Structured group physical activity programme * Group mindfulness and mediation * Interpersonal psychotherapy * Selective serotonin reuptake inhibitor (SSRI) antidepressants * Counselling * Short-term psychodynamic psychotherapy

Answer 77

* Past history of moderate or severe depression * Presence of mild depression that has been present for at least 2 years * Presence of mild depressive symptoms after other interventions

Answer 78

* Risk assessment * Ongoing review: response to low-intensity psychosocial intervention, compliance and symptoms. An SSRI antidepressant should provide benefit within 4-6 weeks. * Measurement scales to assess response to treatment and quality of life * Relapse prevention plan * Assess for social support, and review previous issues flagged up during consultations * If taking antidepressant therapy review compliance, side effects and adjust doses if appropriate

Answer 79

**First-line **management involves a number of treatment options, which may include a combination of antidepressant therapy (biological treatment) and high-intensity psychosocial interventions. In the United Kingdom, the 2022 NICE guidelines recommend the following interventions in descending order, based on implementation, clinical and cost-effectiveness:3 * Combination of individual CBT and an antidepressant (e.g. SSRI) * Individual CBT * Individual behavioural activation * Antidepressants (e.g. SSRI) alone * Individual problem-solving * Counselling * Short-term psychodynamic psychotherapy * Interpersonal psychotherapy * Guided self-help * Group exercise

Answer 80

augmented with an antipsychotic (quetiapine or olanzapine).

Answer 81

* The patient has a strong preference for ECT: this usually applies when patients have responded to ECT well before * Rapid treatment of the patient is needed: cases of life-threatening depression where the patient is not eating or drinking * Multiple other treatments have been trialled unsuccessfully

Answer 82

* Risk assessment * Review their response to high-intensity psychosocial intervention compliance and symptoms * Review their response to antidepressant therapy, compliance, side effects and adjust doses if appropriate * Measurement scales to assess response to treatment and quality of life * Relapse prevention plan * Assess social support and previous issues flagged up during the consultation

Answer 83

* Suicide: the risk of suicide in patients with depression is four times higher than in patients without depression * Substance misuse and alcohol use problems: patients are at increased risk of becoming dependent on substances * Persistent symptoms: 10-20% of patients will have persistent symptoms over 2 years * Recurrence of depressive episodes: most patients have a recurrence in later life * Reduced quality of life: patients may struggle with employment and relationships * Antidepressant side effects: may include sexual dysfunction, risk of self-harm, weight gain, hyponatraemia and agitation

Answer 84

Difficulty initiating or maintaining sleep

Answer 85

Females, Increase age, Economic inactivity, unemployment, lower educational attainment. Corticosteroids, alcohol abuse, chronic conditions

Answer 86

Patient history Sleep Diaries, actigraphy

Answer 87

Identify causes, advise person to not drive, good sleep hygiene Hypnotics if severe: Short acting benzodiazepines, non benzodiazepines (Zopiclone, Zolpidem, Zaleplon). Diazepam Use lowest effective dose for shortest period possible

Answer 88

Loss of contact with reality. Associated features: agitation, aggression, neurocognitive impairment, depression Hallucinations, delusions, fixed beliefs, world salad. Thought insertion, withdrawal or broadcast. Social withdrawl.

Answer 89

Urine: Drug induced CT Head Ca2+, Glucose, FBC, TFT, U&E, B12 & Folate. Before Antipsychotics check HbA1c, LFT, Chol, QTC

Answer 90

Linked to other conditions: Schizophrenia, depression, bipolar disorder, puerperal psychosis, brief psychotic disorder, corticosteroids.

Answer 91

It is a mental disorder characterised by impairments in the way reality is perceived and associated changes in behavhiour

Answer 92

Psychotic Negative Cognitive

Answer 93

Hallucinations - auditory 80% Delusions Disorganised speech Abnormal Movement Thought disorder

Answer 94

Marked apathy * Poverty of thought * Poverty of speech * Blunting of affect * Social isolation * Poor self-care * Cognitive deficits (especially executive functions)

Answer 95

Predictor of day to fay functioning Low attention Poor Decision making Lack of problem solving

Answer 96

- Prodomal phase: gradual cognitive and negative symptoms - followed by first episode of psychosis - Residual phase: Baseline - Then they cycle starts again

Answer 97

Duration of untreated psychosis

Answer 98

DSM 5: At least 2 of these symptoms 1. Delusions 2. Hallucinations 3. Disorganised speech 4. Disorganised/ catatonic behaviour 4. Negative symptoms 1, 2 or 3 must be present active symptoms for > 1 months significant impairment.

Answer 99

Symptoms cannot be due to substances or medical conditions

Answer 100

Exact cause is unknown Neurochemical abnormality: imbalance of Dopamine, glutamat. These are the 4 dopamine pathways. 1. Nigrostriatiatal - 2. Mesocortical - 3. Mesolimbic - 4. Tuberolinfundibular -

Answer 101

Genetic Environmental: low birth weight, gestational diabetes, pre eclampsia , emergency c section, winter birth, cannabis, life events Brain abnormalities more common in african america 25 males 27 females

Answer 102

no response to at least two antipsychotics over 12 weeks - consider clozapine

Answer 103

“…concurrent presence of at least five out of a list of ten symptoms, which must occur **most of the day, nearly every day, for at least 2 weeks**. The mood disturbance must result in significant functional impairment and not be a manifestation of another health condition, due to the effects of a substance or medication

Answer 104

* During the last month have you often been bothered by feeling down, depressed, or hopeless? * Do you have little interest or pleasure in doing things? * - Low mood - Anhedonia - Anergia

Answer 105

* Disturbed sleep (decreased or increased compared to usual). * Decreased or increased appetite and/or weight. * Fatigue/loss of energy. * Agitation or slowing of movements

Answer 106

* Poor concentration or indecisiveness. * Feelings of worthlessness or excessive or inappropriate guilt. * Hopelessness about the future. * Suicidal thoughts or acts.

Answer 107

* Felt down, depressed or hopeless? * Found that you no longer enjoy, or find little pleasure in life? * Been feeling overly tired?

Answer 108

* PHQ-9 (to monitor severity and response to treatment, can help with diagnosis) * HAD Scale (assess both anxiety and depression) * Edinburgh Postnatal Depression Scale (a self-rating scale for puerperal depression) * Geriatric Depression Scale (suitable for older patients)

Answer 109

* “Active monitoring” * Low-intensity psychosocial interventions -individual guided self-help based on the principles of (CBT) - computerised cognitive behavioural therapy (CCBT) - a structured group physical activity programme * Consider Group CBT * Sleep hygiene * Routine use of medication not recommended

Answer 110

* High-intensity psychological intervention (CBT, interpersonal therapy (IPT)) * Antidepressant * Or a combination of both

Answer 111

* First line: SSRI unless specific CI/interactions, previous SE, patient preference * Important points in consultation: timeframe, review points, dose changes, withdrawal symptoms SSRI’s: * Issues: bleeding risk (?PPI), interactions (SJW, serotonin syndrome), hypersensitivity reactions * Side effects: minor sedation, dizziness, anxiety, anti-muscarinic, GI, sexual dysfx, hyponatremia (elderly), increased suicidal ideation (young)

Answer 112

Consider previously successful drugs first. 1st Line – SSRI 2nd Line – Alternative SSRI 3rd Line - Mirtazapine or SNRI or Trazodone or Tricyclic Consider combining/augmenting medications if not fully effective

Answer 113

* Significant co-existing medical or psychiatric problems * Substance Misuse * Significant Psycho-social stressors (relationships, personality) * Treatment Resistance or Recurrent Episodes * Identified Risks (suicide, self-harm, self-neglect) * Psychotic Symptoms

Answer 114

* Referral to specialist mental health services for a programme of coordinated multi-professional care * Collaborative care if chronic physical health problem with associated functional impairment * Discuss place for in-patient care, crisis resolution and home treatment teams * ECT

Answer 115

Personality disorder is characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships) that have persisted over an extended period of time (e.g., 2 years or more)…..”

Answer 116

Basic assessment would include to ask the patient about suicidal thoughts and plans * Other frameworks suggests to look at: * Previous suicidal behavior * Current suicidal thoughts and plans * Hopelessness * Stressors * Presence of mental disorder symptoms * Themes of impulsivity and self control * Ready access to highly lethal methods eg firearms * Protective factors (what are these?)

Answer 117

Some examples of risk factors for suicide: * Family history suicide * Mental health disorders, especially depression * Alcohol/substance misuse * Feelings of hopelessness * Isolation * Loss (job, bereavement, relationships etc) * Physical illness * Easy access to lethal methods * Previous attempts and more…

Answer 118

* Good clinical care of mental and physical health conditions * Access to immediate/ongoing support * Family and community support * Learned personal skills with problem solving, anger management etc * Cultural or religious beliefs that discourage suicide

Answer 119

* Refer secondary care – how? * Crisis resolution team – may support in hospital or at home * Ask if family member or friend can take her * Check she arrives at referred location * If refusing admission maybe due to lack of insight or intent on plan, then you may need to section the patient under the Mental Health Act (1983)

Answer 120

Physical symptoms * “Fight or Flight” response, adrenaline causes palpitations, nausea or churning stomach, headache, poor sleep, shaking, dizziness, tiredness, sweating, dry mouth, shortness of breath Psychological symptoms * Eg. Restlessness, fear of impending doom, irritability, difficulty concentrating, feeling “on edge”

Answer 121

Symptoms persist for several months, more days than not Impacting on an individual’s life

Answer 122

* Generalised Anxiety Disorder * Obsessive Compulsive Disorder * Panic disorder * Social phobia * PTSD * Physical cause for symptoms (eg phaeochromocytoma, hyperthyroidism)

Answer 123

GAD-7 Questionnaire This self-administered patient questionnaire can be used to support diagnosis, and for establishing a severity measure for generalised anxiety disorder. For each of the seven criteria there are four possible answers: Not at all = 0 points; several days = 1 point; more than half the days = 2 points; nearly every day = 3 points The scores represent: 0–5 mild anxiety, 6–10 moderate anxiety, 11–15 moderately severe anxiety, 15–21 severe anxiety.

Answer 124

Generalised anxiety disorder is characterized by marked symptoms of anxiety that persist for at least several months, for more days than not, manifested by either general apprehension (i.e. ‘free-floating anxiety’) or excessive worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as muscular tension or motor restlessness, sympathetic autonomic over-activity, subjective experience of nervousness, difficulty maintaining concentration, irritability, or sleep disturbance. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. The symptoms are not a manifestation of another health condition and are not due to the effects of a substance or medication on the central nervous system.”

Answer 125

Low intensity psychological interventions * Individual non-facilitated self-help * Individual facilitated self-help * Psycho-educational groups Follow up – Active monitoring by GP Treat concurrent medical conditions, hyperthyroid, depression etc

Answer 126

Talking to someone the person trusts Managing worries (e.g. writing worries down or allowing specific time to think about them) Look after physical health Breathing exercises Peer support Keep a diary Complementary and alternative therapy e.g. yoga, meditation, aromatherapy…

Answer 127

Psychotherapy – Cognitive Behavioural Therapy or applied relaxation (high-intensity psychological intervention) Medication - SSRI e.g. sertraline, if not tolerated pregabalin If symptoms severe and risk harm to self or others, risk of neglect, has significant co-morbidity inadequate response to treatments refer to specialist mental health team. Note pregabalin is a Class C controlled substance so prescribe with caution and evaluate patients thoroughly before use

Answer 128

Fixed unshakeable belief that is not in keeping with patients social, cultural and educational background

Answer 129

- **Persecutory:** one is about to be harmed or mistreated by others - Delusions of love - Religious - **Grandiose:** one has special powers, wealth, mission, or identity - Delusions of infidelity - Delusions of infestation - Delusions of reference - Delusions of misidentification - **Somatic:** completely convinced there is something medically, physically, or biologically wrong with them

Answer 130

percept experienced in the absence of an external stimulus.

Answer 131

- Auditory - Gustatory - Somatic (e.g. tactile, hygric) - Visual - Olfactory - Pseudohallucinations

Answer 132

* Circumstantial and tangential thinking * Flight of ideas * Loosening of association (derailment / “Knight’s move” thinking) * Thought blocking * Neologisms and idiosyncratic word use * Perseveration * Echolalia * Irrelevant answers

Answer 133

= Motor disturbances: - rigidity - posturing - negativism - waxy flexibility - excitement - stupor

Answer 134

- Schizophrenia - Schizoaffective disorder - Schizotypal disorder - Acute and transient psychotic disorder - Delusional disorder - Symptomatic manifestations of primary psychotic disorders

Answer 135

- Schizophrenia, first episode - Schizophrenia, multiple episodes - Schizophrenia, continuous - Other specified episode of schizophrenia - Schizophrenia, episode unspecified

Answer 136

It is a schizophrenia-like psychotic disorder - Acute onset of psychotic symptoms, which can include delusions, hallucinations, disorganised thinking, or experiences of influence, passivity or control, that emerge without a prodrome, progressing from a non-psychotic state to a clearly psychotic state within two weeks. - **Psychomotor disturbances** may also be present, including catatonia. - **Symptoms change rapidly, both in nature and intensity**. Such changes may occur from day to day, or even within a single day. - **Absence of negative symptoms** - **Duration of the symptoms does not exceed three months, **and most commonly **lasts from a few days to one month**

Answer 137

- All diagnostic requirements for schizophrenia are met concurrently with mood symptoms that meet the diagnostic requirements of a moderate or severe depressive episode, a manic episode, or a mixed episode. - The onset of the psychotic and **mood symptoms is either simultaneous or occurs within a few days** of one another. - Duration of symptomatic episodes is at least one month for both psychotic and mood symptoms. - Symptoms or behaviours are **not a manifestation of another medical condition** and are not due to the effects of a substance or medication on the central nervous system, including withdrawal effects (e.g. from alcohol)

Answer 138

-Presence of a delusion or set of related delusions, typically persisting for at least three months - Delusions are variable in content across individuals, while showing remarkable stability within individuals, although they may evolve over time. - **Absence of clear and persistent hallucinations**, severely disorganised thinking (formal thought disorder), experiences of influence, passivity, or control or negative symptoms characteristic of schizophrenia. - Apart from the actions and attitudes directly related to the delusional system, affect, speech, and behaviour are typically unaffected. - Symptoms are not a manifestation of another medical condition, are not due to the effects of a substance or medication on the central nervous system including withdrawal effects (e.g. from alcohol).

Answer 139

- First episode: **Early Intervention in Psychosis Team** (for individuals aged 14 to 65, duration of follow-up is up to 3 years) - Chronic psychotic illness: Care transferred to local **CMHT** - Early stage of relapse: **Crisis Resolution and Home Treatment** Team (short-term only)

Answer 140

1st line: * Second generation (get to optimum dosage). Commonly **Olanzapine.** * Preferably oral rather than depot preparation. * 2nd line: * Review the diagnosis, check concordance with antipsychotic medication and screen for any concomitant use of illicit substances. * Try a different oral second generation (get to optimum dosage). **Risperidone** * Could consider a **depot** if the patient is adamant he / she does not want to take oral medication **Also consider Benzodiazepines for acute phase **

Answer 141

depot injection is a slow-release form of medication. The injection uses a liquid that releases the medication slowly, so it lasts a lot longer. A depot injection might be a good option for you if: you find it difficult to swallow medication you find it difficult remembering to take medication regularly you prefer not to have to think about taking medication every day.

Answer 142

patient’s weight, waist circumference, B.P, pulse rate, ECG, HbA1c level, serum cholesterol level, lipid profile and serum prolactin level

Answer 143

1. Essential hypertension 2. Truncal obesity 3. Insulin resistance (hyper-insulinaemia) 4. Low glucose tolerance 5. Dyslipidaemia

Answer 144

* Patient’s weight, B.P, pulse rate, HbA1c level, serum cholesterol level and lipid profile checked **at 12 weeks**, then **at one yea**r and then **annually** thereafter. * Patient’s weight should be checked weekly for the **first six weeks, then at 12 weeks,** then at one year and then **annually** thereafter. * Waist circumference should be measured on an **annual basis**. * Mental health services should assume responsibility for monitoring patient’s physical health for at least the **first 12 months**following initiation of antipsychotic treatment. Thereafter, responsibility for this may pass to the G.P under shared care arrangements

Answer 145

baseline FBC, CRP and Troponin-T level; weekly FBC for first 18 weeks, then fortnightly up to one year of treatment, then four-weekly thereafter. CRP and Troponin-T to be checked weekly for first six weeks)

Answer 146

Psychoeducation (awareness of diagnosis, relapse prevention and early warning signs of becoming unwell). Useful starting point, especially in the early stages following the diagnosis being made. * Cognitive behavioural therapy (CBT). * Family therapy. Useful not only for the patient, but also the family. May help reduce high expressed emotion (a risk factor for relapse in schizophrenia). * NICE guidelines recommend that CBT and family therapy should be available for all patients with schizophrenia and those at increased risk of developing psychosis

Answer 147

- Single episode depressive disorder - Recurrent depressive disorder - Dysthymic disorder - Mixed anxiety and depressive disorder

Answer 148

Characterised by the presence or history of one depressive episode when there is no history of prior depressive episodes

Answer 149

A depressive episode is characterised by a period of depressed mood or diminished interest in activities occurring most of the day, nearly every day during a period lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue.

Answer 150

Psychotic symptoms: - Delusions (commonly delusions of guilt, nihilistic delusions, delusions of poverty, persecutory delusions, self-referential or hypochondrical delusions) - Hallucinations (typically second person, derogatory in content) - Depressive stupor - Occur in severe depressive episodes only

Answer 151

* Start with SSRI antidepressant (typically Sertraline, Fluoxetine or Citalopram). * Assess within two weeks of initiation. * Increase the dose if no response after three - four weeks (check concordance!). * Warn about risk of suicidal thoughts in patients < 30. * If no response, try an alternative SSRI * Augment the antidepressant with an antipsychotic (Quetiapine, Risperidone or Aripiprazole are the recommended options)

Answer 152

- If no response with a second SSRI, try an SNRI (Venlafaxine). - If no response, refer to secondary care for specialist opinion. - Could try Mirtazapine (helps with sleep disturbance and appetite disturbance). - Then, combination of antidepressants - either Venlafaxine + Mirtazapine or SSRI + Mirtazapine. - Lithium Carbonate can be added in (can help to reduce suicidality)

Answer 153

* Avoid MAO inhibitors (tyramine-containing foods can provoke hypertensive crisis). * Avoid tricyclic antidepressants (cardiotoxic in overdose and poorly tolerated)

Answer 154

Electroconvulsive therapy (ECT)

Answer 155

**Low-intensity psychological interventions** - for mild depression: * Individual guided self-help, based on principles of CBT. Usually consists of 6 - 8 sessions. * Computerised CBT. Usually takes place over 9 - 12 weeks. * Structured group-based physical activity programme. Usually consists of 2 - 3 sessions per week of moderate duration (45 mins to 1 hour), over 3-month period. * Group-based peer support. Usually consists of one session per week over 8 - 12 weeks. **High-intensity psychological interventions** - for moderate or severe depression: * Group based CBT, Usually consists of 12 x 2-hour sessions over 8 - 12 weeks. * Individual CBT. Usually given over 16 - 20 sessions over 3 - 4 months. For severe depression, 2 sessions per week might be provided for the first 2 or 3 weeks. * Interpersonal therapy. Duration and no. of sessions similar to CBT. * Behavioural activation. Duration and no. of sessions similar to CBT. Psychological treatment

Answer 156

* Regular exercise * Sleep hygiene * Healthy diet * Reduce alcohol intake * Address any financial worries * Address any housing issues

Answer 157

* Male * Age > 45 years * Unemployed * Divorced, widowed or single * Physical illness * Mental disorder present * Substance misuse * Previous suicide attempt * Family history of mental disorder * Family history of suicide attempt

Answer 158

* Take a thorough history of the suicide attempt. * Screen for any evidence of any illicit substance use or alcohol abuse. * Do a mental state examination and formulate a risk assessment. * If the suicide attempt is an OD of a psychotropic medication(s), consult Toxbase on how best to manage the patient medically. * Ensure the patient is medically fit to undergo a mental health assessment!

Answer 159

1) The patient is discharged with advice to be reviewed by the G.P within the next couple of weeks. 2) The patient is discharged with a referral made to the local CMHT to monitor the patient’s mental health. 3) The patient is discharged with follow-up from the Crisis Team (can visit daily if required). They may then refer to the CMHT for ongoing follow- up. 4) The patient is admitted to a psychiatric inpatient unit - either voluntarily or detained under the Mental Health Act 1983 (usually section 2).

Answer 160

* Impairment in intellectual function affecting more than one cognitive domain *Interferes with social or occupational function * Decline from a previous level * Not explained by delirium or major psychiatric disease

Answer 161

*Executive function (frontal, hemispheric white matter) * Memory (medial temporal lobes / hippocampus) * Language (left hemisphere, usually) *Visuospatial (occipital, parietal)

Answer 162

Requires impairment in two or more cognitive domains, sufficient to interfere with social or occupational functioning

Answer 163

* Cognitive decline abnormal for age and education but does not interfere with function and activities. * = “At risk” state to develop a degenerative dementia. * When memory loss predominates, it is termed amnestic MCI. * 10-15% per year of conversion to Alzheimer’s dementia.

Answer 164

Mild Cognitive Impairment (MCI).

Answer 165

Huntington’s disease, Parkinsons’s Disease, Focal Thalamic & Basal Ganglia Lesions, Multiple Sclerosis.

Answer 166

Alzheimer’s disease, Frontotemporal dementias

Answer 167

Vascular dementia, Dementia with Lewy Bodies, corticobasal degeneration, neurosyphilis

Answer 168

AD = Alzheimer’s dementia LBD = Lewy Body dementia PDD = Parkinson’s disease dementia FTD = Frontotemporal dementia Vascular dementia FTD = Frontotemporal dementia

Answer 169

Alzheimer’s disease (AD) *Prevalence doubles every five years after the age of 65; ~50% of those older than 85

Answer 170

Age!! * Mild cognitive impairment (MCI) *ApoE4 positivity * Family Hx in first degree relative (especially if younger onset) *Vascular risk (diabetes, heart disease, etc.) * Low education and physical / social activity * Female gender

Answer 171

*Earliest cognitive symptoms are usually poor short-term memory and loss of orientation *Smooth, usually slow decline without dramatic short-term fluctuations * Other domains involved with time *So common that many variations are seen

Answer 172

* Depression, anxiety *Irritability, hostility, apathy * Delusions, hallucinations *Sleep-wake changes *“Sundowning” *Agitation

Answer 173

* Relatively earlier occipital and basal ganglia degeneration *Similar to Parkinson’s disease dementia * α-synuclein aggregates into Lewy bodies * Concurrent AD pathology is common

Answer 174

* Dementia (early on, visuospatial and executive) + * Core features *Parkinsonism * Recurrent early visual hallucinations * Fluctuations (clue: recurrent delirium evaluations) *Suggestive features include REM sleep disorder (dream enactment) and neuroleptic sensitivity

Answer 175

Frontotemporal Dementia (FTD) *Average age of onset is only 58

Answer 176

TDP43 (DNA binding protein) TAU

Answer 177

*Suspected when : 1. Abrupt onset and / or stepwise decline 2. Fluctuating course 3. Hx of stroke 4. Focal neurologic symptoms or signs 5. Usually see bilateral infarcts 6. Often associated with executive dysfunction, gait disorder, apathy, incontinence

Answer 178

Structural brain lesion (subdural bleed) * Thyroid disease * Vitamin B12 deficiency * Untreated obstructive sleep apnoea * Depression or anxiety * Alcoholism * Medications: benzos, opioids, anticholinergics (diphenhydramine, bladder drugs, tricyclics), neuroleptics, dopaminergics, other sedatives

Answer 179

* General neurological exam *Any signs of stroke? *Signs of parkinsonism or a gait disorder? * Cognitive screen bloods * Mini-Mental State Examination (MMSE) *ACE-R (Addenbrooke’s) * Mini-cog * Montreal Cognitive Assessment (MoCA)

Answer 180

Vitamin B12, TFTs, neuroimaging (CT is o.k)

Answer 181

* No current treatment slows down neuronal loss in the brain * Cholinesterase inhibitors (donepezil, rivastigmine, galantamine)? - Modest symptom improvement in AD - Sometimes marked improvements in PDD / DLB * Memantine? Modest benefit in AD

Answer 182

* Denial, shock, irritability, anger, fear, isolation, shame * Avoidance, not talking about it, clamming up vs preoccupation, nightmares, flashbacks, enacted through play

Psychiatry Flashcards

(213 cards)