Corrections pt. 2 Flashcards
When do most cases of postnatal depression start?
When do they peak?
Most start within a month.
Most typically peak around 3 months.
Management of postnatal depression?
- reassurance & support
- CBT
- SSRIs if symptoms are severe
Which SSRI is typically recommended in postnatal depression? Why?
Paroxetine: because of the low milk/plasma ratio (safety in breastfeeding)
Which SSRI is typically avoided in postnatal depression? Why?
Fluoxetine: due to a long half life (safety in breastfeeding)
Most appropriate treatment option in acute episodes of mania/hypomania?
Antipsychotics e.g. olanzapine, quetiapine, risperidone
What is ‘anankastic’ personality disorder also known as?
Obsessive compulsive personality disorder
OCD vs OCPD?
OCD:
- recurrent, intrusive, unwanted thoughts and repetitive behaviours
- marked anxiety or distress due to symptoms
- symptoms can fluctuate with anxiety
OCPD:
- someone always wants to be in control
- does not experience anxiety or distress due to symptoms
- strict orderliness & perfectionism
- traits are persistent over time
What is conversion disorder?
Which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology.
Symptoms of frontotemporal dementia?
- behaviour and/or personality changes e.g. swearing, stealing, increased interest in sex, deterioration in personal hygiene habits
- socially inappropriate, impulsive, or repetitive behaviors.
- apathy
- lack of empathy
- language problems e.g. words in wrong order, using words incorrectly
- memory problems (tend to occur later on compared to other forms of dementia)
What condition is associated with ventricular enlargement and cortical atrophy on a head CT?
Alzheimer’s dementia (also normal with aging).
1st line medical management of Alzheimer’s disease?
Actetylcholinesterase inhibitors:
- donepezil
- galantamine
- rivastigmine
What are the 3 acetylcholinesterase inhibitors licensed for use in AD?
1) donepezil
2) galantamine
3) rivastigmine
2nd line medical management of AD?
Memantine (an NMDA receptor antagonist)
Who is memantine reserved for in AD?
1) moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
2) as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
3) monotherapy in severe Alzheimer’s
What class of drug is rivastigmine?
acetylcholinesterase inhibitor
What are the 5 stages of grief?
1) denial
2) anger
3) bargaining
4) depression
5) acceptance
What is typically seen in the ‘denial’ stage of grief?
- feeling of numbness
- pseudohallucinations of the deceased (auditory and visual)
- people may focus on physical objects that remind them of their loved one or even prepare meals for them
Who are abnormal or atypical grief reactions more likely to occur in?
- women
- if death is sudden and unexpected
- problematic relationship before death
- if the patient has not much social support.
What are some features of atypical grief reactions?
- delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
- prolonged grief: difficult to define as normal grief reactions may take up to and beyond 12 months
- suicidal thoughts
- depression, deep sadness, guilt or self blame
What is acute intermittent prophyria (AIP)?
A rare autosomal dominant condition caused by a defect in porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem.
This results in the toxic accumulation of delta aminolaevulinic acid and porphobilinogen
Which enzyme is defected in porphyria?
Porphobilinogen deaminase: an enzyme involved in the biosynthesis of haem
What accumulates in porphyria?
Delta aminolaevulinic acid and porphobilinogen
How does porphyria typically present?
Abdo & neuro symptoms in 20-40 years olds.
- abdo: abdo pain & vomiting
- neuro: motor neuropathy
- psych: depression
- HTN & tachycardia common
What is classical finding in porphyria?
Urine turns deep red on standing.
Investigations in porphyria?
- urine turns deep red on standing
- raised urinary porphobilinogen
- assay of red cells for porphobilinogen deaminase
- raised serum levels of delta aminolaevulinic acid and porphobilinogen
Which drugs may precipitate an attack of porphyria?
barbiturates
halothane
benzodiazepines
alcohol
oral contraceptive pill
sulphonamides
Which type of delusional disorder is characterised by the false absolute certainty of the infidelity of a partner?
Othello syndrome
Dysthymia vs major depressive disorder?
Dysthymia (also called persistent depressive disorder) –> fewer symptoms but lasts longer (>2 years)
Depression –> more symptoms but can be diagnosed after 2 weeks
What is dissociative fugue?
Individuals with dissociative disorders may embark on unexpected travels without any recollection of the journey or their original identity. They may adopt a new identity during the fugue state and only regain awareness of their primary identity upon resolution.
Somatic-type delusional condition vs hypochondriasis?
Somatic type: people are utterly convinced that the cause of their ailments is physical.
Hypochondriasis: can consider the possibility that the feared illness is not actually present.
1st line management of phobias?
CBT
Management of manic episode in patient with bipolar disorder?
1st line: lithium
2nd line: sodium valproate
Why are SSRIs avoided in GI bleeding?
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs.
Side effects of SSRIs?
1) GI symptoms (most common)
2) increased risk of GI bleeding: consider prescribing PPI if patient is also taking NSAID
3) hyponatraemia
4) potential for initial increase in agitation & anxiety
When should you consider prescribing a PPI for patients taking SSRIs?
If they are also taking NSAIDs
What are the most common substances that cause substance-induced psychotic disorder?
- amphetamines
- alcohol
- cannabis
- cocaine
Stepwise management of OCD?
1) CBT including exposure and response prevention (ERP)
2) SSRIs
3) Consider clomipramine (alternative 1st line to an SSRI)
What is an alternative to SSRIs in OCD?
Clomipramine
Describe dose & duration of SSRI in OCD vs depression
SSRI usually requires a higher dose and a longer duration of treatment in OCD.
How long does it typically take for an initial response to SSRIs in OCD?
at least 12 weeks
What PHQ-9 score indicates ‘less severe’ depression?
<16
What PHQ-9 score indicates ‘more severe’ depression?
> /= 16
How can infections or inflammation predispose to clozapine toxicity?
Cloxapine is metabolised by the P450 enzymes. Downregulation of these enzymes by cytokines in infection/inflammation decreases the metabolism of clozapine, leading to a raised clozapine level.
Side effects of memantine?
- sleepy/dizzy
- headaches
- constipation
- SOB
Side effects of acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)?
- diarrhoea
- N&V
- bradycardia
- increased salivary production
- urinary incontinence
- insomnia (donepezil)
Remember –> opposite of anticholinergics
What is the delusional disorder in which the patient believes that someone close to them has been replaced by a clone?
Capgras delusion
What is the delusional disorder where a patient believes that everyone they meet is the same person but with different disguises?
Fregoli delusion
What characterises histrionic personality disorder?
Excessive displays of emotions and attention seeking behaviours
- may be sexually inappropriate
- may consider relationships more intimate than they really are
Where in the digestive system is the majority of alcohol absorbed?
The proximal small intestine
How long does a section 5(2) last up to?
72 hours
What ECG finding is common in a patient with anorexia?
Prolonged QT interval (>450ms).
It is important to detect this as it can predispose to potentially fatal arrhythmias
What are the main side effects of sodium valproate?
Mneumonic: VALPROATE
V - vomiting
A - alopecia (hair loss)
L - liver toxicity
P - pacreatitis/panctyopenia
R - retention of fats (i.e. weight gain)
O - oedema
A - anorexia
T - tremor
E - enzyme inhibition
What investigation should you always do before starting patients on anti-cholinesterase inhibitors (e.g. donepezil)?
ECG
Contraindications for anti-cholinesterase inhibitors (e.g. donepezil)?
1) QT prolongation
2) 2nd or 3rd degree heart block
3) sinus bradycardia <50 bpm
1st line treatment of manic episodes?
Lithium, or atypical antipsychotics.
What class of drug is clomipramine?
TCA
How can tardive dyskinesia present?
- chewing
- pouting of jaw
- excessive blinking
What characterises acute dystonia?
Sustained often painful muscle contractions, leading to abnormal postures or movements.
1st line management of acute alcohol withdrawal?
Chlordiazepoxide (or diazepam)
If prescribing a patient an SSRI and an NSAID, what else should you give?
PPI
Give the 3 indications for ECT
1) catatonia
2) life-threatening depression
3) prolonged or severe manic episode
Which atypical antipsychotic reduces the seizure threshold?
Clozapine
1st line for acute stress disorder?
Trauma focused CBT
When stopping an SSRI, how long should the dose be reduced over?
Gradually over a 4 week period
What drug is indicated in acute dystonia?
Procyclidine (an anticholinergic)
What is the commonset electrolyte abnormality in anorexia nervosa?
Hypokalaemia
How is cholesterol impacted in anorexia?
Typically high cholesterol levels
Which hormones are increased in anorexia?
Cortisol & GH
Which hormones are decreased in anorexia?
low FSH, LH, oestrogens and testosterone
What should be monitored at initiation and dose titration of venlafaxine (and other SNRIs)?
BP –> SNRIs can cause HTN
What are clang associations?
ideas related only by rhyme or being similar sounding
After initiation of lithium or a change in dose, when should levels be taken?
a week later and then weekly until the levels are stable
When can chronic insomnia be diagnosed?
if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer.
How can lithium affect WBCs?
Lithium can precipitate a benign leucocytosis.
What can the use of SSRIs in pregnancy result in?
a) first trimester
b) third trimester
a) congenital heart defects
b) persistent pulmonary hypertension of the newborn
Which SSRI has an increased risk of congenital malformations, particularly in the first trimester?
Paroxetine
Symptoms of SSRI discontinuation syndrome?
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- GI symptoms: pain, cramping, diarrhoea, vomiting
- paraesthesia
What is the phenomenon called where patients believe that someone familiar to them (eg friend or relative) has been replaced by an exact clone?
Capgras syndrome
What is the 1st line treatment for autoimmune encephalitis?
Steroids & IV immunoglobulin
Management of mild-moderate lithium toxicity caused by bendroflumethiazide?
Fluid resuscitation with saline
Management of severe lithium toxicity?
Haemodialysis
Which drug can be used in the treatment of anorexia?
Mirtazapine
What is echopraxia?
In echopraxia, the patient involuntarily imitates another person’s movements.
What class of drug is imipramine?
TCA
What are the main side side effects of TCAs?
Antimuscarinic e.g. dry mouth, blurred vision etc
What do antipsychotics increase the risk of in the elderly?
Cerebrovascular events e.g. stroke.
This increased risk is particularly relevant for those with dementia-related psychosis.
What is management for more severe OCD or OCD that is unresponsive to CBT/exposure and response prevention?
CBT/ERP and add SSRI
What medication may be used to treat moderate/severe tardive dyskinesia?
Tetrabenazine
What class of drug is clomipramine?
TCA
Which antipyschotic notably reduces the seizure threshold?
Clozapine
1st line management of acute stress disorder?
Trauma focused CBT
1st line antidepressant post MI?
Sertraline
What foods should be avoided in patients taking MAOIs?
Tyramine containing foods e.g. cheese –> can cause a hypertensive crisis.
What is the risk of developing schizophrenia if one monozygotic twin is affected?
50%
What is tangentiality?
Wandering from a topic without returning to it.
Note - this differs from flight of ideas. FoI is usually associated with mania, pressured speech etc
How can long term lithium use affect calcium?
Can result in hyperparathyroidism and resultant hypercalcaemia.
Type 1 vs type 2 bipolar?
Type 1 –> associated with mania & depression
Type 2 –> associated with hypomania & depression
Which personality disorder displays the negative symptoms of schizophrenia?
Schizoid personality disorder
What are some risk factors for Charles-Bonnet symdrome?
- Advanced age
- Peripheral visual impairment
- Social isolation
- Sensory deprivation
- Early cognitive impairment
What is the persistent belief in the presence of an underlying serious disease, e.g. cancer called?
Illness anxiety disorder (hypochondriasis)
For moderate/severe OCD, what may be used as an alternative to an SSRI?
Clomipramine
This is the only TCA licensed to manage OCD.
What is the only TCA licensed to manage OCD?
Clomipramine
What class of drug is mirtazapine?
noradrenergic and specific serotonergic antidepressant
Knight’s move vs flight of ideas?
Knight’s move thinking there are illogical leaps from one idea to another.
Flight of ideas there are discernible links between ideas.
What is a normal MMSE score?
≥25
What is the most effective antipsychotic for dealing with negative symptoms of schizophrenia?
Clozapine
What are the negative symptoms suggestive of schizophrenia?
- incongruity/blunting of affect
- anhedonia (inability to derive pleasure)
- alogia (poverty of speech)
- avolition (poor motivation)
- social withdrawal
What is the most common ophthalmological condition associated with Charles Bonnet syndrome?
Age related macular degeneration
How should antidepressants be adjusted prior to starting ECT?
Reduced to minimum dose but not stopped.
How does akathisia typically present?
A subjective feeling of restlessness often accompanied by fidgeting movements or pacing around.
What condition needs to be routienly checked for before diagnosing anxiety?
Thyroid disease
ECG features of hypokalaemia?
1) Tall P waves
2) Flattened T waves
3) 1st degree heart block
How can lithium use affect PTH?
Long term use can cause hyperparathyroidism –> resultant hypercalcaemia.
What is the 2nd line drug for GAD?
Buspirone
What are the 3 key traits seen in histrionic personality disorder?
1) Very emotional
2) Attention seeking
3) Sexually provocative
What is the treatment of choice for delirium tremens?
Benzos
What medication is given to patients on MAOI inhibitors that have eaten tyramine containing foods?
Phentolamine (alpha blocker)
What 2 neurotransmitters are associated with ADHD?
Dopamine & norepinephrine
What model of major depressive disorder specifies that a pre-existing vulnerability can be activated by stressful life events?
The diathesis-stress model
What are 2 medications used in the treatment of severe Tourettes?
What is their mechanism?
1) Guanfacine
2) Clonidine
A2 agonists
Length of time of schizophrenic symptoms in schizophrenia vs schizophreniform disorder?
Schizophrenia –> >6 months
Schizophreniform disorder –> >1 month but <6 months
Which atypical antidepressant is used more commonly for insomnia?
Trazodone
What term describes a phenomenon in Parkinson’s Disease where the patient gets ‘stuck’ on a particular word of a sentence and repeats it?
Logoclonia
What is 1st line for managing the behavioural and psychological symptoms of frontotemporal dementia, including disinhibition, apathy, aggression, and impulsivity?
Non-pharmacological interventions, such as behavioural interventions and environmental modifications e.g. structured routines, physical activity, cognitive stimulation, socialisation, and caregiver education and support.
1st line management of acute manic episode?
Antipsychotics
What is there a risk of with chlorphenamine use in the elderly?
Acute delirium or other anti-cholinergic actions.
This is a H1 antagonist that is able to cross the BBB and can lead to anti-depressant/anxiety effects.
1st line management of SEVERE Alzheimer’s?
Memantine
MMSE scores for mild, moderate, moderately severe and severe Alzheimer’s?
Normal: >26
Mild: 21-16
Moderate: 10-20
Moderately severe: 10-14
Severe: <10
What is the correct length and quantity of symptoms needed for a diagnosis of mild depression to be made according to the ICD-10?
Patient must have two of the first three symptoms (depressed mood, loss of interest in everyday activities, reduction in energy) plus at least two of the remaining seven symptoms over a duration of 2 weeks.
Which is the SSRI of choice in people with unstable angina or recent MI?
Sertraline
What is Hoover’s sign?
A quick and useful clinical tool to differentiate organic from non-organic leg paresis.
In non-organic paresis, pressure is felt under the paretic leg when lifting the non-paretic leg against pressure, this is due to involuntary contralateral hip extension.
After how long can chronic insomnia be diagnosed?
After 3 months, if a person has trouble falling asleep or staying asleep at least 3 nights per week.
What are some short term side effects of ECT?
1) headache
2) nausea
3) short term memory impairment
4) memory loss of events prior to ECT
5) cardiac arrhythmia
What is a potential long term side effect of ECT?
some patients report impaired memory
What class of drug is phenelzine?
MAOI
When initiating lithium, when should levels first be checked?
1 week later, 12 hours after last dose
Assisted withdrawal (e.g. with chlordiazepoxide) is recommended for patients who drink how many units of alcohol per day?
> 15
1st line management for harmful drinkers and those with a mild alcohol dependence?
CBT
What is the 1st line in managing a distressed patient with delirium?
Employ verbal and non-verbal de-escalation techniques
What is derailment?
A type of formal thought disorder where the speech consists of a series of unrelated or reotely related ideas.
