1
Q
What are the core symptoms of depression?
A
- Low mood > 2 weeks
- Anhedonia (lack of interest)
- Lack of energy
2
Q
What are the biological symptoms of depression?
A
- Sleep disturbance
- Early morning wakening
- Diurnal variation of mood (low in morning)
- Reduced appetite
- Weight loss
- Psychomotor retardation / agitation
- Loss of libido
3
Q
What are the psychological symptoms of depression?
A
- Low self esteem
- Guilt/self-blame
- Hopelessness
- Suicidal thoughts
- Hypochondriacal thoughts
- Lack of concentration
4
Q
Name the ICD-10 diagnosis for depression
A
- Mild = 2 core + 2 others
- Moderate = 2 core + 3-4 others
- Severe = 3 core + more than 4 others
5
Q
What are the symptoms of psychotic depression?
A
Delusions
- Hypochondriacal
- Guilt
- Nihilistic
- Persecutory
Hallucinations
- Auditory
- Olfactory
- Visual
6
Q
Name some risk factors for developing depression
A
- Genetics/family history
- Childhood experiences
- Personality traits (anxiety, impulsivity, obsessionality)
- Social circumstances (marital status, employment, life events)
- Physical illness
7
Q
Name some differentials for depression
A
- Other mood disorders - bipolar
- Endocrine - hypothyroidism, cushing’s
- Psychoactive substance/alcohol abuse
- Other psychiatric disorders
- Anxiety
- Eating disorders
- Schizophrenia
- Dementia
- Bereavement
8
Q
How is depression managed?
A
- Biological
- Anti-depressants (for 6 months after episode)
- SSRIs (fluoxetine, sertraline)
- SNRIs
- TCAs (amitriptyline)
- MAOIs
- Adjuvants (antipsychotics, mood stablisers)
- ECT
- Anti-depressants (for 6 months after episode)
- Psychological
- CBT
- Mindfulness
- Psychoeducation
- Social - family, housing, finances, support groups
- Risk assessment
9
Q
Name some reasons for hospital admission in a depressed patient
A
- Risk of suicide
- Risk of harm to others
- Self-neglect
- Severe depressive/psychotic symptoms
- No social support
- ECT
- Treatment resistant
- Co-morbidity
10
Q
What are the indications for ECT?
A
- Severe depressive illness (failed other treatments)
- Life threatening
- Prolonged and severe manic episode
- Catatonia
- High suicide risk
- Stupor
- Severe psychomotor retardation
11
Q
How long is treatment continued for in depression?
A
- 6 months after resolution of symptoms if 1st episode
- 2 years after resolution of symptoms if 2nd episode
- Long term if multiple episodes
12
Q
What is bipolar?
A
Periods of prolonged and profound depression with periods of excessive elevated and/or irritable mood
13
Q
Name some causes of mood disorders
A
- Predisposing
- Genetics
- Childhood experiences
- Previous history
- Neurochemical imbalances
- Precipitating
- Bereavement
- Social circumstances - unemployment, divorce
- Perpetuating (maintaining)
- Difficult relationships
- Financial difficulties
- Alcohol/drug misuse
- Chronic health problems
14
Q
What are the clinical features of mania?
A
I DIG FASTER
- Irritability
- Disinhibition
- Increased libido
- Grandiose delusions
- Flight of ideas
- Activity/appetite increased
- Sleep decreased
- Talkative - pressure of speech
- Elevated mood/energy increased
- Reduced concentration
15
Q
What is the ICD-10 criteria for bipolar?
A
- Mania - 3/9 symptoms to be present
- Bipolar requires 2 episodes of mania and depression
- 1 must be mania
- At least 1 week of symptoms
16
Q
How is bipolar treated?
A
- Risk assessment
- Suicide/self-harm
- Risks to self - eg. risk of excessive debt
- Biological
- Mood stabilisers (lithium, valproate, carbamazepine)
- Avoid in women of child-bearing age
- Benzodiazepines (short term)
- Antipsychotics (olanzapine)
- Avoid antidepressants!
- ECT if severe and uncontrolled
- Mood stabilisers (lithium, valproate, carbamazepine)
- Psychological
- Psychoeducation
- CBT
- Social
- Support/self-help groups
- Calming activities
17
Q
What is a delusion?
A
A fixed, false belief that is held on inadequate grounds and not affected by rational arguments or evidence and is not in keeping with cultural or religious norms
18
Q
Name some different types of delusions
A
- Persecutory = people/organisations are trying to inflict harm on the patient
- Delusions of reference = objects, events or actions of other people have a special significance
- Grandiose
- Guilt/worthlessness
- Nihilistic = world is doomed/career is over etc
- Hypochondriacal
- Jealous
- Sexual/amorous
- Religious
- Control = personal thoughts or actions are controlled by an outside agent
- Posession of thoughts
19
Q
What are the different types of possession of thoughts?
A
- Thought insertion
- Thought withdrawal
- Thought broadcasting
20
Q
What is a hallucination? Name some different types
A
A perception in the absence of an external stimulus
- Auditory
- 2nd person
- 3rd person (schizophrenia)
- Visual
- Olfactory
- Tactile
- Gustatory
21
Q
What is psychosis?
A
A mental state in which reality is greatly distorted, characterised by:
- Delusions
- Hallucinations
- Thought disorder
22
Q
Name some risk factors for developing schizophrenia
A
- Predisposing
- Genetic/family history
- Neurochemical
- Age 15-35
- Childhood abuse
- Low SES
- Precipitating
- Cannabis
- Adverse life events
- Psychostimulants
- Perpetuating
- Lack of social support
- Substance abuse
- Low medication compliance
23
Q
Name Schneider’s first rank symptoms (positive schizophrenia symptoms)
A
- Delusions - grandiose, nihilistic, religious, ideas of reference
- Hallucinations - 3rd person
- Thought disorder - withdrawal, insertion, broadcast
- Passivity phenomenon - actions/feelings controlled by an external force
Symptoms for > 1 month
24
Q
Name some negative symptoms of schizophrenia
A
- Avolition (lack of motivation)
- Asocial behaviour
- Anhedonia
- Alogia (poverty of speech) - quantitative and qualitative decrease in speech
- Affect blunted - decreased capacity to express feelings
- Attention (cognitive) defects - including language, memory, executive functions
May be preceded by a prodome = patient becomes reserved, anxious,suspicious and irritable with a disturbance in everyday functions
25
Name some different types of schizophrenia
* Paranoid = mainly positive symptoms
* Postschizophrenic = depression predominates
* Hebephrenic = thought disorganisation predominates
* Catatonic
* Simple = negative symptoms without psycosis
26
How is schizophrenia managed?
* Biological
* Antipsychotics
* Atypical (olanzapine, risperidone)
* Typical (haloperidol)
* Clozapine if resistant
* Adjuvants
* Benzodiazepines (short term)
* Antidepressants
* Lithium
* ECT if resistant to pharmacology/catatonic)
* Psychological
* CBT
* Family intervention
* Art therapy
* Social
* Support groups
* Supported employment programmes
27
What is anxiety?
An unpleasant emotional state involving subjectic fear and somatic symptoms
28
Name some psychological features of anxiety
* Anticipatory fear of impending doom
* Worrying thoughts
* Restlessness
* Poor concentration and attention
* Irritability
* Depersonalisation = detachment of oneself regarding the body or mind
* Derealisation = detachment with the outside world
29
Name some other common clinical features of anxiety
* CVS - palpiatations, chest pain
* Resp - hyperventilation, cough, chest tightness
* GI - 'butterflies', loose stools, N+V, dry mouth
* GU - Inc micturition, erectile dysfunction
* NM - tremor, headache, parasthesia
* Behaviour - avoidance/escape from situation
30
What is generalised anxiety disorder?
Ongoing, uncontrollable, widespread worry about events or thoughts that the patient recognises as excessive or inappropriate
* Symptoms on most days for \> 6 months
31
Name some symptoms of generalised anxiety disorder
WATCHERS:
* Worry
* Autonomic hyperactivity
* Tremor
* Concentration difficulty
* Headache/hyperventilation
* Energy loss
* Restlessness
* Sleep disturbance
32
How is generalised anxiety disorder managed?
1. Psychoeducation and active monitoring
2. Low intensity psychological interventions
* Self help
* Group therapy
3. High-intensity psychological interventions
* CBT
* Drugs
* SSRI - sertraline
* SNRI - venlafaxine/duloxetine
* Pregabalin
4. Specialist input
* Crisis team
* MDT
33
What is a phobia? Name some types
Intense, irrational fear of an object, situation, place or person that is recognised as excessive or unreasonable
* Agoraphobia
* Social phobia
* Specific phobia (animals, heights, flying)
34
How is specific phobia managed?
* Self-help
* CBT
* Desensitisation therapy (graded exposure)
* Benzodiazepines for short term
35
What is panic disorder?
Recurrent, episodic, severe panic attacks which are unpredictable and are not restricted to any particular situation
36
How is panic disorder treated?
* SSRIs
* TCA if not tolerated or no improvement in 12 weeks
* CBT
* Self help
* Bibliotherapy
* Support groups
* Exercise
37
What is PTSD?
Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
38
Name some clinical features of PTSD
Within 6 months:
* Relieving - flashbacks, vivid memories, nightmares, distress when exposed to similar cicumstances
* Avoidance - of reminders (people, locations)
* Hyperarousal - irritability, difficulty with concentration and sleep, hypervigilance
* Emotional numbing - negative thoughts about oneself, difficulty experiencing emotions, detachment, anhedonia
39
How is PTSD managed?
* Trauma screening questionnaire
* Watchful waiting if \< 3 months
* CBT
* EMDR (eye movement desensitisation and reprocessing)
* Sleep management - zopiclone
* Risk assessment
* Drugs (if little benefit from psychological therapy, patient preference or severe hyperarousal)
* Mirtazapine (NaSSA)
* Paroxetine (SSRI)
* Amitriptyline (TCA)
40
What is OCD?
Recurrent obsessional thoughts or compulsive acts or both
41
What are obsessions?
Unwanted, intrusive thoughts, images or urges that repeatedly enter the individuals mind
42
What are compulsions?
Repetitive, stereotyped behaviours or mental acts that a person feels driven into performing
* Overt = observable by others
* Covert = mental acts not observable
43
How is OCD managed?
1. Low intensity psychological intervention
* Psychoeducation
* Distracting techniques
* Self-help
2. CBT/ERP (exposure and response prevention)
3. Pharmacology
* SSRI - fluoxetine, sertaline, citalopram
* Clomipramine (TCA)
* +/- antipsychotic
44
What is anorexia nervosa?
Eating disorder characterised by:
* Deliberate weight loss
* An intense fear of fatness
* Distorted body image
* Endocrine disturbances
45
Name some causes of anorexia nervosa
* Predisposing
* Genetics
* Female
* Early menarche
* Sexual abuse
* Low self-esteem
* Percipitating
* Puberty/adolescence
* Criticism regarding weight/eating
* Perpetuating
* Occupational pressure
* Western society
46
Name some complications of anorexia nervosa
* Metabolic - **hypokalaemia,** hypoglycaemia, hypercholesterolaemia
* Endocrine - high cortisol, GH, low T3/4, LH/FSH
* GI - large, salivary glands, pancreatitis
* CVS - **cardiac failure,** arrythmias, hypotension
* Renal - renal failure, stones
* Neuro - seizures
* Iron deficiency anaemia
* Lanugo hair
47
How is anoerxia managed?
* Biological
* Treat complications (low K+)
* SSRIs if co-morbid depression
* Psychological (\> 6 months)
* Nutrition education
* Family therapy
* CBT
* Social
* Self-help groups
* Voluntary organisations
* Hospitalisation if BMI\<14, severe electrolyte abnormalities or suicidal ideation
48
What is refeeding syndrome?
* Insulin surge causes :
* Low phosphate
* Low magnesium
* Low potassium
* Leads (mainly phosphate) to heart failure
49
What is the ICD-10 criteria for bulimia nervosa?
* Behaviours to prevent weight gain
* Self-induced vomiting
* Starvation
* Drugs
* Excess exercise
* Preoccupation with eating (sense of compulsion)
* Fear of fatness
* Overeating (\>/=2 episodes per week for 3 months)
50
What other features of bulimia may be present?
* Normal weight
* Depression/low self-esteem
* Irregular periods
* Dehydration
* Hypokalaemia
* Signs of repeated vomiting
* Russel's sign (calluses on knuckles)
* Dental erosion
* Malloy-Weiss tear
* Bilateral parotid swelling
51
How is bulimia managed?
* Biological
* Treat complications of vomiting
* SSRI if depressive symptoms (fluoxetine)
* Psychological
* Psychoeducation about nutrition
* CBT
* Psychotherapy
* Social
* Food diary
* Techniques to avoid bingeing (company, distractions)
* Small, regular meals
* Self-help programmes
* Risk assessment
* Admit if suicidal ideation or severe electrolyte imbalances
52
What is delirium? Name some types
Acute transient, global organic disorder of CNS functioning resulting in impaired consciousness and attention
* Hypoactive (40%) = lethargy, decreased motor activity, apathy, sleepiness
* Hyperactive (25%) = agitation, irritability, restlessness, aggression
* Mixed (35%)
53
Name some causes of delirium
HE IS NOT MAAD
* Hypoxia (resp failure, MI, PE, cardiac failure)
* Endocrine (dec or inc thyroid/glucose, cushings)
* Infection (pneumonia, UTI, meningitis)
* Stroke/intracranial injury (RICP)
* Nutritional (low thiamine, nicotinic acid, B12)
* Others (pain, sensory deprivation, relocation, sleep deprivation)
* Theatre (anaesthetic, opiates)
* Metabolic (low Na+, glucose)
* Abdominal (constipation, malnutrition)
* Alcohol (withdrawal)
* Drugs (benzos, opioids, steroids)
54
What are the clinical features of delirium?
DELIRIUM
* Disordered thinking
* Emotions - euphoric/fearful/depressed/angry
* Language impaired
* Illusions, delusions and hallucinations
* Reversal of sleep-wake pattern
* Inattention
* Unaware/disorientated
* Memory deficit
55
How is delirium managed?
* Treat underlying cause (infection, electrolyte, drugs, laxatives)
* Reassurance
* Re-orientation (time, place, day, date)
* Appropriate environment
* Quiet, well-lit side room
* Consistency in care and staff
* Presence of friend/family
* Optimise sensory acuity (glasses, hearing aids)
* Manage behaviour
* De-escalation techniques
* Haloperidol or olanzapine
* Avoid benzos (unless alcohol withdrawal)
56
What is dementia? Name some common types
Generalised deterioration of memory, intellect and personality, without impairment of consciousness, leading to functional impairment
* Alzheimers (50%)
* Vascular (25%)
* Lewy Body (15%)
* Fronto-temporal (\<5%)
57
Name some irreversible causes of dementia
* Neurodegeneration
* Alzheimers
* Pick's disease
* Fronto-temporal
* Vascular
* Infections - HIV, syphilis, CJD, encephalitis
* Toxins - alcohol, benzos, barbiturates
* Vascular
* Head injury
58
Name some reversible causes of dementia
DEMENNTIA
* Drugs (barbiturates)
* Eyes and ears (visual/hearing impairment)
* Metabolic - Cushings, hypothyroid
* Emotional (pseudodementia)
* Nutritional - B12, folic acid, thiamine
* Normal pressure hydrocephalus
* Tumours
* Infections
* Alcoholism
59
Describe the microscopic and macroscopic features of dementia
Microscopic:
* Neurofibrillary tangles
* B-amyloid plaques
Macroscopic:
* Cortical atrophy
* Widened sulci
* Enlarged ventricles
60
What is the ICD-10 criteria for dementia
Symptoms \> 6 months
* Decline in memory (mainly anterograde)
* Decline in other cognitive abilities (judgement and thinking)
* Preserved awareness of the environment long enough to demonstrate symptoms
* Decline in emotional control or motivation or a change in social behaviour
* Emotional lability
* Irritability
* Apathy
* Coarsening of social behaviour
61
What is the ICD-10 criteria for Alzheimers?
* General dementia criteria
* No evidence of any other possible cause
Early onset/pre-senile:
* Age \< 65
* Relatively rapid onset and progression
* Memory impairment, aphasia, agraphia (writing), alexia (reading), acalcula (maths) or apraxia
Late onset/senile:
* Age \> 65
* Slow, gradual onset and progression
* Predominance of memory impairment over intellectual impairment
62
How is dementia investigated?
* Bloods - FBC, CRP, U+E, calcium, LFTs, glucose, vit B12, folate, TFT
* Urine dip
* CXR
* Syphilis/HIV testing
* ECG
* Brain imaging
* CT
* MRI
* SPECT (differentiate)
* EEG (fronto-temporal)
* Lumbar puncture (meningitis, CJD)
* Genetic tests (huntingtons)
* Cognitive assessment
63
How is dementia managed?
1. Cognitive enhancement
* Acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine)
* If severe = NMDA antagonist (memantine)
2. Treat agitation (risperidone - antipsychotic)
3. Treat low mood and insomnia (sertraline, trazadone)
4. Functional support
* Home nursing/personal care/assistance
* Care homes
* OT input
* Information/education
* Motion sensors (if wanderer)
5. Social support (therapy/meals on wheels/support groups)
6. Carer support
64
What is vascular dementia? Name some clinical features
Cerebrovascular disease (stroke, multi-infarcts, arteriosclerosis) in the small vessels
* Late 60s or 70s
* Memory loss
* Stepwise deterioration
* Confusion
* Early emotional and personality changes
* Neurological
* Unilateral weakness
* Babinski
* Hyperreflexia
* Other signs of CVS disease
65
What is Lewy Body dementia? Name some clinical features
Abnormal deposition of Lewy Body proteins within the neurons of the brainstem, substantia nigra and neocortex
* Day to day fluctuations
* Visual hallucinations
* Parkinsonism (tremor, rigidity, bradykinesia)
* Falls/syncope
* Depression
* Severely sensitive to neuroleptic drugs
66
What is fronto-temporal dementia? Name some clinical features
Atrophy of the frontal and temporal lobes
* 50s and 60s
* 50% family history
* Early personality changes (disinhibition, apathy, restlessness)
* Worsening social behaviour
* Repetitive behaviour
* Language problems
* Preserved memory (until late stages)
67
What are the side effects of ECT?
PC DAMS
* Peripheral nerve palsies
* Cardiac arrhythmias / Confusion
* Dental/oral trauma
* Anaesthetic risks
* Muscular aches
* Short term memory impairment
* Both anterograde and retrograde
68
Name some contraindications of ECT
MARS
* MI \< 3 months
* Aneurysm (cerebral)
* Raised ICP
* Stroke / status epilepticus / severe anaesthetic risk
69
How do SSRIs work?
Inhibit reuptake of serotonin from synaptic cleft into the pre-synaptic neurones - increases concentration of serotonin in the synaptic cleft
* Fluoxetine
* Sertraline
* Citalopram
* Paroxetine
70
What SSRI is used in children? Why?
Fluoxetine
Other SSRIs increase risk of suicide
71
Name some side effects of SSRIs
GI + STRESS
* GI - nausea, dyspepsia, bloating, diarrhoea, constipation
* Sweating
* Tremors
* Rashes
* Extrapyramidal
* Sexual dysfunction
* Sommolence (drowsy)
72
Name some contraindications/cautions to using SSRIs
* Mania
* Epilepsy
* Cardiac disease (use fluoxetine)
* Closed angle glaucoma
* Diabetes
* GI bleeding
73
Name some examples of SNRIs
* Venlafaxine
* Duloxetine
74
What are the side effects of SNRIs?
* Nausea
* Dry mouth
* Headache
* Sexual dysfunction
* Hypertension
75
Name some examples of a TCA and its indications
Amitriptyline, clomipramine, nortriptyline
Depression (3rd line) neuropathic pain, migraine prophylaxis
76
Name some side effects of TCAs
* Anti-cholinergic - dry mouth, constipation, urinary retention
* CVS - arrhythmias, postural hypotension
* Hypersensitivity
* Mania
* Increased appetite
77
Name some examples of MAOIs and its indications
Phenelzine, isocarboxide
Atypical or treatment-resistant depression, social phobia
78
Name some examples of antipsychotics
* Typical = haloperidol, chlorpromazine, sulpiride
* Atypical = olanzapine, risperidone, quetiapine, aripiprazole, clozapine
79
Name some side effects of antipsychotics
* Extrapyramidal (mainly typical)
* Parkinsonism (bradykinesia, rigidity, tremor, masked facies)
* Akathesia (restlessness)
* Dystonia (spasms)
* Tardive dyskinesia (involutary movements)
* Anti-muscarinic (can't see, can't wee, can't spit, can't shit) - blurred vision, urinary retention, dry mouth, constipation
* Anti-histaminergic - sedation, weight gain
* Anti-adrenergic - postural hypotension, tachycardia
* Prolonged QT interval
* Increased prolactin - sexual dysfunction, menstrual disturbances
* Neuroleptic malignant syndrome
80
What is neuroleptic malignant syndrome?
Life-threatening reaction to neuroleptic drugs:
* Pyrexia
* Muscle rigidity
* Confusion
* Decreased consciousness
81
Name some examples of mood stabilisers
* Lithium
* Sodium valproate
* Carbamazepine
* Lamotrigine (child-bearing age/breastfeeding)
82
Name some anxiolytic drugs
ANXIOLYTICs (anxiety disorders)
* Benzodiazepine
* Beta blockers
* Antipsychotics
* Pregabalin
HYPNOTICS
* Benzos
* Zopiclone
83
Name some examples of benzodiazepines
Long acting (\>24 hours)
* Diazepam
* Chlordiazepoxide
Short acting (\< 12 hours)
* Lorazepam
* Midazolam
* Temazepam
84
Name the indications of benzodiazepines
* Insomnia
* Acute psychosis
* Anxiety disorders
* Violent behaviour
* Delirium tremens / alcohol detoxification
85
Name some side effects of benzodiazepines
* Drowsiness / lightheadedness
* Amnesia
* Confusion
* Dependence
* Ataxia
* Muscle weakness
* Respiratory depression
86
What is a personality disorder?
Deeply ingrained and enduring pattern of inner experience and behaviour that deviates markedly from expectations in the individual's culture
* Inflexible
* Onset in adolescence or early adulthood
* Leads to distress or impairment
Cluster A: Weird - odd/eccentric
Cluster B: Wild - dramatic/emotional (incl borderline)
Cluster C: Worriers - anxious/fearful
87
How are personality disorders managed?
* Biological
* Short term atypical antipsychotics (paranoid)
* Mood stabilisers (borderline)
* Antidepressants
* Psychological
* CBT
* Psychodynamic psychotherapy
* Dialectical behavioural therapy - coping strategies/control impulses
* Social
* Support groups
* Substance misuse service
* Housing/finance/employment assistance
88
How is opioid dependence treated pharmacologically?
* Methadone/buprenorphine - detoxification and maintenance
* Naltrexone - continue abstinence
* IV naloxone - antidote for overdose
89
What is the Edward-Gross criteria for determining alcohol dependence
SAW DRINk
* Subjective awareness of compulsion to drink
* Avoidance or relief of withdrawal symptoms by drinking
* Withdrawal symptoms
* Drink-seeking behaviour
* Reinstatement of drinking after attempted abstinence
* Increased tolerance
* Narrowing of drink repetoire
90
What is the CAGE questionnaire?
* Felt like you need to Cut down?
* People Annoyed you by criticising drinking?
* Felt Guilty about drinking?
* Eye opener - drink early in morning?
91
How is alcohol dependence managed?
* Pharmacology
* Disulfarim - increases acetaldehyde to increase effects of hangover
* Acamprosate - decrease craving (increase GABA transmission)
* Naltrexone - decrease pleasure from drinking (blocks opioid receptors)
* Motivational interviewing/CBT
* Alcoholics anonymous
92
What is autism?
Developmental disorder characterised by:
* Impairment in social interaction
* Impairment in communication
* Restricted, stereotyped interests and behaviours
93
Name some causes of autism
* Prenatal
* Genetics
* Older parental age
* Parental psychiatric history
* Drugs (valproate)
* Infecton (rubella)
* Antenatal
* Hypoxia
* Premature (\<35 weeks)
* Low birth weight
* Post natal
* Toxins (lead, mercury)
* Pesticide exposure
94
What is the ICD-10 criteria for autism?
1. Abnormal/impaired development before age 3
2. Abnormalities in social interactions
* Avoids eye contact
* Difficult to express emotions
* Limited interest in others
3. Abnormalities in communication
* Delayed/distorted speech
* Echolalia (word repetition)
4. Restrictive, repetitive and stereotyped patterns of behaviour, interests and activities
* Rocking/twisting
* Needs daily routine
* Same foods/clothes/games
* Obsessive interests
5. Not attributable to other developmental disorders
95
How is autism managed?
* Biological (treat co-existing disorders)
* Hyperkinetic disorder = methylphenidate
* Challenging behaviour = antipsychotic
* Sleep disorders = melatonin
* Pscyhological
* Psychoeducation for families/carers
* Assessment of behaviour
* CBT (if able to communicate)
* Social
* Environment modification (lighting, noise, social circumstances)
* Social-communication intervention
* Self-help groups
* Special schooling
96
Name some causes of ADHD
* Genetics and family history
* Neurochemical - abnormal dopaminergic pathways
* Neurodevelopment - abnormalities in pre-frontal cortex
* Social
* Deprivation
* Family conflict
* Parental cannabis/alcohol exposure
97
Name the clinical features of ADHD
* Inattention
* Not listening
* Distractable
* Forgetting/losing belongings
* Hyperactivity
* Restlessness
* Recklessness
* Excessive talking/noisiness
* Impulsivity
* Interrupting
* Temper tantrums
* Disobedient
98
What is the ICD-10 classification of ADHD
1. Abnormality of attention, activity and impulsivity at home
2. Abnormality of attention, activity and impulsivity at school/nursery
3. Directly observed abnormality of attention or activity
4. Does not meet criteria for other developmental disorders
5. Onset before age 7
6. Duration of \> 6 months
7. IQ \> 50
99
How is ADHD managed?
* Pre-school age
* Parent-training and education programmes
* Reinforce positive behaviour
* Managing disruptive behaviour
* Drugs not recommended
* School age
* If severe - methylphenidate/ritalin (CNS stimulant)
* Or atomoxetine as alternative
* Psychoeducation/CBT
* Social skills training
100
Name some side effects of ritalin
* Headache
* Insomnia
* Loss of appetite
* Weight loss
* Cardiac - chest pain, dyspnoea, syncope
101
How are learning disabilities classified?
* Mild (IQ 50-70)
* Moderate (IQ 35-49)
* Severe (IQ 20-34)
* Profound (IQ \< 20)
102
What are the clinical features of learning disability?
* Low intellect (IQ \< 70)
* Onset \< 18 years
* Wide range of functional impairment
* Academic difficulties
* Limited language
* Self-care difficulties
* Motor impairment if severe
* Communication difficulties
* Associated physcial disorders
103
Name some causes of learning disability
* Genetics - Fragile X, Downs
* Antenatal
* Infection (rubella, CMV, toxoplasmosis)
* Nutritional deficiency
* Alcohol
* Endocrine (hypothyroid)
* Perinatal
* Asphyxia
* Sepsis
* Haemorrhage (intraventricular)
* Postnatal
* Infection
* Cerebral palsy
* Environmental
* Neglect/NAI
* Malnutrition / deprivation
104
What is the mental capacity act?
Identifies those people who may lack capacity to consent to or refuse treatment and protect them (I HELP)
1. In Best Interest
2. Help to make decisions (interpreters, time etc)
3. Eccentric/unwise decisions are allowed
4. Least restrictive intervention
5. Preseumption of capacity (until proven otherwise)
105
Describe the process of capacity
* Understands the information
* Retain the information long enough to make a decision
* Uses the information to process the decision
* Can communicate the decision
106
When should lack of capacity be suspected?
CARD
* Cognitive impairment
* Refusing treatment
* Abnormal behaviour
* Delirium
107
What is Lasting Power of Attorney?
Person with capacity can make future decisions on someone's behalf if they lose capacity
* Property and affairs
* Personal welfare
108
What is an Advance Directive?
Instructions to refuse a specific treatment if a person loses capacity
109
What is an Advance Statement?
General statements about someone's wishes or preferences if they lose capacity
110
What is a Deprivation of Liberty Safeguard?
Ensures people in care homes/hospitals/supported living who lack capacity are looked after in a way that does not restrict their freedom inappropriately
111
What is the Mental Health Act?
Allows pepole with a mental disorder to be sectioned (admitted to hospital, detained and treated without consent)
* Refusal to voluntary treatment
* Other options not appropriate
* Mental disorder
* Risk of harm (self harm, neglect, harm to others)
* Appropriate treatment is available
112
Describe section 2 of the MHA
Administration, assessment and response to treatment up to 28 days
* Application by Approved Mental Health Professional (AMHP)
* On recommendation of 2 approved clinicians
* Patient can appeal to a tribunal during the first 14 days
113
Describe section 3 of the MHA
Treatment of a mental disorder up to 6 months
* By AMHP and 2 approved clinicians
* Can appeal once during 6 months
* After 3 months - second opinion appointed doctor (SOAD) reassesses
* Can be renewed
114
Describe section 4 of the MHA
Emergency when section 2 involved delay
115
Describe section 5(2) of the MHA
Detention of **inpatients** (excluding A&E) by an approved clinician
116
Describe section 5(4) of the MHA
Detention (up to 6 hours) of **inpatients** already receiving treatment for a mental disorder by a registered mental health nurse
117
Describe section 135 of the MHA
Allows a police officer with a Magistrates warrant to enter a person's premises and remove them to a place of safety
118
Describe section 136 of the MHA
Allows a police officer to remove a person from a public place to a place of safety
119
Describe section 117 of the MHA
Free aftercare provided for patients after discharge from S3
120
What is a community treatment order?
Allows patients on S3, who are well enough, to leave hospital for treatment in the community
* Made by the Responsible Clinician
* Can be recalled to hospital if they do not comply with treatment or attend appointments
IPE
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