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3 - Psychiatry > Clinical > Flashcards

Clinical Flashcards

1
Q

A psychological therapy that is particularly good for depression, anxiety, phobias, OCD and PTSD

Short term, problem focused and goal oriented

A

Cognitive Behavioural Therapy (CBT)

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2
Q

Cognitive behavioural therapy (CBT) method

A

Therapist helps client to identify “thinking errors”

Client engages in “homework” which challenges the thinking erroes

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3
Q

A psychological therapy that focuses on scheduling avoided activities

A

Behavioural Activation

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4
Q

Behavioural activation method

A

Client is taught to analyse the unintended consequences of their way of responding
(e.g. not answering phone –> more isolation)

Focus on avoided activities as a guide for activity scheduling

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5
Q

A psychological therapy for depression/anxiety

Short-term, focused on the present

Focuses on resolving interpersonal problems

A

Interpersonal Psychotherapy (IPT)

grade A evidence for treating depression

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6
Q

Method of interpersonal psychotherapy

A

Sick role given
Construct an interpersonal map (depressive symptoms linked to interpersonal events)

No homework
Requires some ability to reflect

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7
Q

a psychological therapy that promotes behaviour change in a wide range of healthcare settings

Used when the patient is unmotivated to change

A

Motivational interviewing

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8
Q

Method/principles of motivational interviewing

A

Express empathy
Avoid argument
Support self-efficacy

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9
Q

Stages of change

A 
Pre-contemplation
Contemplation
Planning
Action
Maintenance
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10
Q

Indications for antidepressants

A

Unipolar depression,
organic mood disorders,
schizoaffective disorder,
anxiety disorders (inc. OCD, panic, social phobia, PTSD)

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11
Q

Pros and Cons of tricyclic antidepressants (TCAs)

A

PROS:
- very effective

CONS

  • lethal in overdose
  • big side effect profile (antihistaminic, anticholinergic, antiadrenergic)
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12
Q

Monoamine oxidase inhibitors (MAOIs) mechanism of action

A

Bind irreversibly to monoamine oxidase

so prevent inactivation of amines (such as norepinephrine, dopamine and serotonin)

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13
Q

PROs and CONs of Monoamine Oxidase Inhibitors (MAOIs)

A

PROS:
- very effective for depression

CONS:

  • side effects
  • hypertensive crisis when taken with tyramine rich foods (e.g. cheese, beans, red wine, processed meat)
  • serotonin syndrome if taken with SSRI so must wait 2 weeks before switching
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14
Q

PROs and CONs of Selective Serotonin Reuptake inhibitors

and examples

A

PROs:

  • treat both anxiety & depression symptoms
  • very little risk of cardiotoxicity in overdose
  • usually 1st line for treatment naive depression

CONs:

  • side effects
  • discontinuation syndrome (nausea, agitation…)
  • activation syndrome (anxiety, agitation…) esp. on starting

E.g. sertraline, fluoxetine (prozac)

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15
Q

PROs of Serotonin/Norepinephrine reuptake inhibitors (SNRIs)

e.g. duloxetine , venlafaxine

A

Inhibit serotonin and noradrenergic uptake (like TCAs) but without the antihistimine, antiadrenergic or anticholinergic side effects!*

((*side effects still present in high doses))

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16
Q

Indications for mood stabilisers

A

Bipolar
Cyclothymia
Schizoaffective

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17
Q

PRO’s and CON’s of Lithium (a mood stabiliser)

A

PRO’s:

  • only medication to reduce suicide rate
  • effective in long term prophylaxis
  • best in pure mania/ mania followed by depression

CON’s:

  • teratogenic (preg test before starting)
  • many side effects*
  • toxicity
  • nephrotoxic and may cause hyperthyroidism (so must get baseline U&Es and TSH before starting + monitor)

*GI irritation common in early treatment but usually settles

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18
Q

Classes of mood stabilisers:

A

Lithium

Anticonvulsants

- valproic acid
- carbamazepine
- lamotrigine

Antipsychotics

- aripiprazole
- risperdone 
- quetiapine 
- quetiapine XR (only drug for depression)
- olanzapine
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19
Q

Indications for use of antipsychotics

A

Schizophrenia

Schizoaffective disorder

Bipolar disorder- for mood stabilization and/or when psychotic features are present

Psychotic depression (along with antidepressants)

Augmenting agent in treatment resistant anxiety disorders

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20
Q

Antipsychotic adverse effects

A

Tardive Dyskinesia (TD) = involuntary muscle movements

Neuroleptic Malignant Syndrome (NMS)

Extrapyramidal side effects (EPS) = acute dystonia/ parkinson syndrome / akathisia

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21
Q

Adverse effect of antipsychotics characterised by severe muscle rigidity, fever, altered mental status, autonomic instability

A

Neuroleptic Malignant Syndrome (NMS)

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22
Q

Agents to treat Extrapyramidal side effects (EPS)

= acute dystonia/ parkinson syndrome / akathisia
Must treat akathisia as it increases risk of suicide

A

Anticholinergics (e.g. benztropine)

Dopamine facilitators (e.g. amantadine)

Beta-blockers (e.g. propranolol)

(side effects are inevitable when using antipsychotics so must manage them)

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23
Q

Classes of antipsychotics

and their general side effects

A

Typicals
- more extrapyramidal side effects

Atypicals
- more side effects of weight gain and sedation

((All antipsychotics are basically equal in efficacy so choose based on side effect profile))

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24
Q

Indications for use of anxiolytics

A

Panic disorder
Generalised Anxiety disorder
Substance-related disorders and their withdrawal
Insomnias and parasomnias

((often used in combo with SSRIs or SNRIs))

e.g. buspirone

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25
Q

psychiatric indications for use of benzodiazapines

A

Insomnia
Parasomnias
Anxiety disorders

CNS depressant withdrawal
Alcohol withdrawal

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26
Q

Adverse effects of benzodiazapines

A 
Somnolence
Cognitive deficits
Amnesia
Disinhibition
Tolerance
DEPENDENCE!!!
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27
Q

Types of Tricyclic Antidepressants (TCAs)

A

Tertiary:

  • act predominantly on serotonin receptors
  • e.g. amitriptyline
  • more side effects

Secondary:

  • primarily block noradrenaline
  • e.g. nortriptyline
  • less side effects
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28
Q

Antihistaminic, anticholinergic and antiadrenergic effects

side effects of TCAs

A

Antihistaminic: sedation, weight gain

Anticholinergic: dry mouth + eyes, constipation, memory deficits

Antiadrenergic: orthostatic hypotension, sedation, sexual dysfunction

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29
Q

Options in patients resistant to antidepressant therapy

A

Combination with mirtazepine

Adjunctive treatment with lithium/atypical antipsychotic

ECT!

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30
Q

When to take patients off prophylactic antidepressants after symptoms have improved

A

1st depressive episode: after 6 months (80% relapse if come off before 6 months, 20% relapse if after)

2nd episode: after 2 years

3rd episode: possibly life-long prophylaxis

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31
Q

Symptoms of lithium toxicity

and range of therapeutic blood levels

A 
Lethargy 
Tremor (coarse)
Muscle weakness
Ataxia
Blurred vision
Diarrhoea + vomiting

Slurred speech
Confusion
Seizures

((aim for therapeutic blood levels: 0.6-1.2))

(Lithium Treats Mania And Bipolar Disorder - Sometimes Causes Shit)

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32
Q

PRO’s and CON’s of Valproic acid (Depakote) as a mood stabiliser

A

PRO’s:

  • as effective as lithium for mania prophylaxis
  • better tolerated than lithium
  • best for rapid cycling patients
  • good for pts with substance issues
  • target blood level

CON’s:

  • not as good as lithium for depression prophylaxis
  • teratogenic (start folic acid supplement)
  • side effects

((baseline LFTs*, FBC + pregnancy test before started))

*many patients on anticonvulsants experience increased LFTs, as long as they no more than triple no change in therapy is indicated

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33
Q

PRO’s and CON’s of carbamazepine as a mood stabiliser

A

PRO’s:

  • first line for acute mania and mania prophylaxis
  • target blood level: 4-12

CON’s:

  • side effects
  • many drug interactions!

((test LFTs*, FBC + ECG before starting))

*many patients on anticonvulsants experience increased LFTs, as long as they no more than triple no change in therapy is indicated

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34
Q

Effects of low doses of alcohol

A

Euphoria, reduced anxiety, relaxation, sociability

35
Q

Effects of high doses of alcohol

A

Intoxication:

  • impaired attention + judgement
  • unsteadiness
  • flushing
  • nystagmus
  • mood instability
  • disinhibition
  • slurring
  • stupor
  • unconsciousness
36
Q

A pattern of alcohol use causing damage to physical or mental health.
Use >1 month or repeatedly over 12 months
is called…

A

Harmful use

37
Q

Diagnostic criteria for alcohol dependence

A

3 or more of the following for >1month or repeatedly over 12 months:

  • Cravings/compulsions to take
  • Difficulty controlling use
  • Primacy
  • Increased tolerance
  • Physiological withdrawal on reduction/cessation
  • Persistence despite harmful consequences
38
Q

Commonly used quick screening tool for a possible alcohol problem (used in ED)

(+ other screening tools available)

A

CAGE (2 or more = likely alcohol problem)

  • Have you tried to Cut down?
  • Have you felt Annoyed by people criticising your drinking?
  • Have you felt Guilty about drinking?
  • Have you felt the need to have an Eye-opener*?

*=early morning drink

((other tools include AUDIT, FAST and PAT))

39
Q

Non-pharmacological management of alcohol abuse

A

Support for patient and family
Psychological help (e.g. CBT, group therapy)
Social work input (benefits, housing, child protection)
Skills training
Community Support (eg AA, ADA)
Inpatient or residential treatment

40
Q

Defined as “Reduced responsiveness to a drug caused by previous administration” is called…

A

Tolerance

((develops in response to opioids, ethanol, barbiturates, benzodiazepines))

Can lead to dependence* and therefore withdrawal symptoms

*= the physical component of addiction

41
Q

2 mechanisms of tolerance

A

Dispositional tolerance = less drug reaches active site
- changes in rates of ADME

Pharmacodynamic tolerance = site of action less affected by the drug
- fewer/less efficient drug receptors

42
Q

Neurones that project from the Ventral Tegmental Area (VTA) to the nucleus accumbens & prefrontal cortex make up the…

when these VTA neuroneas are stimulated they release…

A

Reward pathway

They release dopamine when stimulated

((some drugs of abuse use this reward pathway to increase dopamine levels - This produces the psychological component of addiction - “craving”))

43
Q

Cocaine and amphetamine are what type of drug?

A

Stimulants

44
Q

Acute effects of cocaine

A

stimulant and euphoriant

increased alertness and energy

increased confidence and impaired judgement

lessens appetite and desire for sleep

45
Q

Chronic effects of cocaine use

A

damage to nose and airways

convulsions with respiratory failure

cardiac arrhythmia’s, HT, MI, CVA

toxic confusion + paranoid psychosis

46
Q

Cocaine withdrawal effects

A 
Depression 
Irritability
Agitation
Craving
Hyperphagia
Hypersomnia
47
Q

Effects of amphetamine

A

Similar to cocaine but longer lasting

Chronic:

  • toxic confusion w/ occasional convulsions + death
  • amphetamine psychosis
48
Q

Effects of heroin

A 
Analgesia
Drowsiness and sleep
Mood change (euphoria, intense pleasure)
Resp and cough reflex depression
Decreased sympathetic outflow (bradycardia + hypotension)
Lowering of body temp
Pupillary constriction
Constipation 
Sensitisation of the labyrinth w/ nausea + vomiting
49
Q

Signs of opiate overdose

A 
Respiratory arrest with a pulse
Pinpoint pupils unreactive to light
Snoring (shallow respiration), RR<8
Bradycardia and hypotension
Varying degree of reduced consciousness/ coma
50
Q

Immediate effects of opiates

A

“a rush”
Almost orgasmic
Physical + emotional anaesthetic

51
Q

Side effects of opiates

first time, medium term and long term

A

First time - nausea/vomiting and headache

Medium term

  • phlebitis
  • Anorexia
  • Constipation

Longer term

  • tolerance
  • Withdrawal
  • Social and health problems
52
Q

Symptoms of opiate withdrawal syndrome

A 
craving
insomnia
yawning
muscle pain and cramps
increased salivary, nasal and lacrimal secretions
dilated pupils
piloerection (hence ‘cold turkey’)
53
Q

Pro’s and Con’s of methadone maintenance

A

PRO’s:
decriminalises drug use
allows normalisation of lifestyle
reduces iv misuse

Con’s:
leakage on to the illicit market

54
Q

Effects of Ecstasy (MDMA)

A

Euphoria followed by feeling of calm
Increased sociability
Inability to distinguish between what is and isn’t desirable
Effects after 20 mins lasting 2-4 hours

55
Q

Side effects of ecstasy (MDMA)

A 
Nausea and dry mouth
Increased blood pressure and temperature
In clubs users risk dehydration
Large doses can cause anxiety and panic 
drug induced psychosis
? liver and brain cell damage
56
Q

Effects of cannabis (marijuana, hashish…)

A

relaxing or stimulating, euphoriant , increases sociability and hilarity, increases appetite, changes in time perception, synaesthesia

In higher dose - anxiety , panic , persecutory ideation, hallucinatory activity

57
Q

ill effects of cannabis

A

Respiratory problems as with tobacco
Toxic confusion
Exacerbation of major mental illness
? cannabis psychosis

58
Q

Side effects of anabolic steroids

testosterone and synthetic analogues

A

Physical:
Skin – acne, stretch marks, baldness
Feminisation in males
Virilisation in females (hirsutism, deep voice, clitoral enlargement, menstrual irregularities, hair thinning)
CV– increased cholesterol and hypertension
Liver – cholestatic jaundice, liver tumours

Psychological:
Irritability and anger – ‘roid rage’
Hypomania and mania
Depression and suicidality on withdrawal

59
Q

Clinical presentation of psychosis (a symptom)

A

Hallucinations
Delusions

Lack of insight
- an inability to distinguish between symptoms of delusion, hallucination and disordered thinking from reality

60
Q

an unshakeable idea or belief which is out of keeping with the person’s social and cultural background, held with extraordinary conviction

A

A delusion

61
Q

Treatment of acute mania

e.g. on wards

A

antipsychotics in combo with benzodiazepines

mood stabilisers are for prophylaxis

62
Q

Which antipsychotic should be used in treatment resistance

A

Clozapine
(Only drug shown to be beneficial in treatment resistance)

If still resistant…

  • add another antipsychotic
  • add lithium / anticonvulsant
  • ECT
63
Q

Before prescribing antipsychotics, what blood tests should you do?

A

Fasting lipid profile
Fasting blood sugar
LFTs
FBC

((Many atypical antipsychotics can cause dyslipidemia, abnormal LFT’s and elevated blood sugars))

64
Q

Hallucinations are…

A

Perceptions in the ABSENCE of stimulus

65
Q

Difference btw neurotic and psychotic disorders

A

Neurotic: anxiety + mood disorders etc…

Psychotic: disconnected from reality

66
Q

An individual’s reaction to stress will depend on a balance between their cognitive processing of any perceived threat and perceived ability to cope

A

The psychological (transactional) model of stress

67
Q

Methods of coping with stress

A

Problem focused (modify stressor)

Emotion focused (modify emotional reaction)

68
Q

Features of anxiety disorders (3A’s)

A

Anxious thoughts and feelings (e.g. impending doom)
Autonomic symptoms
Avoidant behaviour

69
Q

Examples of organic mental disorders

A

ACUTE:
- delirium/ encephalopathy*

CHRONIC:

  • dementia
  • amnesic syndrome

*encephalopathy + delirium = different descriptions of the same presentation

70
Q

the 3 categories of “mental disorders”

can overlap/coexist in one patient

A

Mental illness
Personality disorder
Learning disability

71
Q

3 criteria for diagnosing a learning disability

A
  1. Intellectual impairment (IQ <70)
  2. Social or adaptive dysfunction*
  3. Onset in the developmental period (<18yrs)

((*Impairments in 2 or more of: communication, self-care, home living, social skills, community use, self direction, health and safety, functional academics, leisure & work))

72
Q

Classification of severity of learning disabilities

A

Using IQ

Mild: 50 - 69
Moderate: 35 - 49
Severe: 20 - 34
Profound: <20

73
Q

Aetiology of learning disabilities

A 
Unknown (for most individuals)
Genetic
Infective
Toxic
Trauma
74
Q

When presenting symptoms are put down to a patient’s learning disability, rather than seeking another, potentially treatable cause,
this is called…

A

“Diagnostic Overshadowing”

75
Q

Normal expected side effects of lithium

A 
Fine tremor 
Dry mouth 
Altered taste sensation 
Increased thirst 
Urinary frequency 
Mild nausea 
Weight gain
76
Q

Categories of functional disorders

A 
Dissociative disorders (involuntary disconnection form reality)
Somatoform disorders (unexplained physical symptoms)
77
Q

Difference btw a factitious disorder and malingering

A

Factitious disorder = pathogenic need of sick role (a mental illness)

Malingering = faking illness for a rationally understandable reason (not a mental illness)

78
Q

5 criteria for detention under the mental health act

A
  1. Pt. must have a mental disorder
  2. Treatment must be available
  3. risk to themselves/ others
  4. No less restrictive option available
  5. SIDMA (significantly impaired decision making ability)

((must meet all 5))
((can only treat their mental disorder/ consequences of it))

79
Q

3 types of order under the mental health act
(for non-criminals)

How long is detention authorised for + who can order it

A

Emergency Detention Certificate

  • up to 72hrs (pt. needs to LIKELY have a mental disorder)
  • anyone above FY1

Short Term Detention Certificate

  • up to 28 days
  • MHO and an Approved Medical Practitioner (AMP)

Compulsory Treatment Order

  • up to 6 months
  • MHO + AMP + a Designated Medical Practitioner (DMP = any other doctor)
80
Q

Investigations etc. for a patient admitted with psychosis

A

Drugs screen

Examination/ investigation for potential causes

81
Q

3 types of order under the mental health act through the courts
(for criminals)

+ criteria for detention

A 
Assessment Order (up to 28 days)
Treatment Order (up to 28 days)
Compulsory Order (up to 6 months)

*Same criteria as normal orders except NO SIDMA needed

82
Q

More concern about a suicide attempt if…

A 
More planning
Violent methods
Severity of method (from patient's POV)
Don't tell anyone beforehand
Resist healthcare professionals help
83
Q

4AT delirium Assessment Tool

for >65s

A
  1. Alertness
    • 4 if clearly abnormal
  2. AMT4 (Location? Age? Date of birth?Year?)
    - 1 if 1 mistake, 2 if 2 or more
  3. Attention (months of the year backwards)
    • 0 if >7 correct, 1 if <7, 0 if unable
  4. Acute change? (evidence of significant change in alertness/cognition/mental function in last 2 weeks)
    • 4 if yes

((4 or above = possible delirium)

3 - Psychiatry (2 decks)

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