ECP Flashcards
1
Q
What things would you look for in a patients appearance?
A
Distinguishing features (scars, tattoos, sign of IV drug use) Weight Stigmata of disease Personal hygiene Clothing Objects
2
Q
What would you be looking at in the behaviour assessment of an MSE?
A
Engagement and rapport Eye contact Facial expression Body language Psychomotor activity Abnomrla movements or postures
3
Q
How might you describe the engagement and rapport of a pt with schizophrenia?
A
Might be engaging with hallucinations e.g. replying to auditory hallucinations
4
Q
What is psychomotor retardation?
A
Paucity of movement and delayed responses to questions
5
Q
Give exmaple abnormal movements or postures
A
Involuntary movements Tremors Tics Lip-smacking Akathisias Rocking
6
Q
What are you looking for in the speech assessment in an MSE
A
Rate of speech Quantity of speech Tone Volume Fluency and rhythm
7
Q
Where might you see excessive speech?
A
Mania and schizophrenia
8
Q
Where might you see monotonous speech?
A
Depression, schizophrenia and ASD
9
Q
Where would you see tremulous speech?
A
Anxiety
10
Q
Where might you find slurred speech?
A
Major depression due to psychomotor retardation
11
Q
What is the difference between mood and affect?
A
Mood = what the pt tells you about their predominant subjective internal state
Affect is what is immediately expressed and observed emotion
12
Q
How do we assess affect?
A
Apparent emotion
Range and mobility of affect
Intensity of affect
Congruency of affect
13
Q
What is meant by range and mobility of affect?
A
Range and mobility of affect refer to the variability observed in the patient’s affect during the assessment.
14
Q
What is fixed affect?
A
The patient’s affect remains the same throughout the interview, regardless of the topic.
15
Q
What is restricted affect?
A
The patient’s affect changes slightly throughout the interview, but doesn’t demonstrate the normal range of emotional expression that would be expected
16
Q
What is labile affect?
A
Characterised by exaggerated changes in emotion which may or may not relate to external triggers. Patients typically feel like they have no control over their emotions
17
Q
Where might you see heightened intensity of affect?
A
Associated with mania and some PDs
18
Q
What is meant by congruency of affect?
A
Note if the patient’s affect appears in keeping with the content of their thoughts (known as congruency). A patient sharing distressing thoughts whilst demonstrating a flat affect or laughing would be described as showing incongruent affect. Incongruent affect is typically associated with schizophrenia.
19
Q
What is meant by thought form?
A
Refers to the processing and organisation of thoughts
20
Q
What might you be looking for with regards to thought form?
A
Speed of thoughts
Flow and coherence of thoughts
21
Q
What are loose associations?
A
Moving rapidly from one topic to another with no apparent connection between the topics
22
Q
What is meant by circumstantiality?
A
Thoughts which include lots of irrelevant and unnecessary details
23
Q
What are tangential thoughts?
A
Digressions from the main conversation subject, introducing thoughts that seem unrelated, oblique, and irrelevant.
24
Q
What is flight of ideas?
A
There is an accelerated tempo of speech often referred to as ‘pressure of speech’. In addition to the increased rate of delivery, the language employed is characterised by a wealth of associations, many of which seem to be evoked by more or less accidental connections… the excited speech wanders off the point following the arbitrary connections, and the coherent progression of ideas tends to become obscured
25
What is thought blocking?
sudden cessation of thought, typically mid-sentence, with the patient being unable to recover what was previously said.
26
What is perserveration?
Refers to the repetition of a particular response (such as a word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a patient is asked what their name is and they then continue to repeat their name as the answer to all further questions)
27
What are neologisms?
Words a patient has made-up which are unintelligible to another person.
28
How do we assess patient thought?
Form, content and possession
29
How do we assess thought content?
```
Delusions
Obsessions
Compulsions
Overvalued ideas
Suicidal thoughts
Homicidal/violent thoughts
```
30
What is a delusion?
A firm, fixed belief based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms. These may include persecutory delusions, in which the patient erroneously believes another individual or group is trying to harm them or ideas of reference, in which the individual incorrectly believes specific events relate to them.
31
What is an obsession?
Thoughts, images or impulses that occur repeatedly and feel out of the person’s control. The patient is aware these obsessions are irrational, but the thoughts continue to enter their head.
32
What are compulsions?
Repetitive behaviours that the patient feels compelled to perform despite recognising the irrationality of the behaviour
33
What are overvalued ideas?
A solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer’s life (e.g. the perception of being overweight in a patient with anorexia nervosa).
34
How do we assess thought possession?
Thought insertion: a belief that thoughts can be inserted into the patient’s mind.
Thought withdrawal: a belief that thoughts can be removed from the patient’s mind.
Thought broadcasting: a belief that others can hear the patient’s thoughts.
35
Define perception
Perception involves the organisation, identification and interpretation of sensory information to understand the world around us
36
Give five abnormalities of perception
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Hallucinations
Pseudo-hallucinations
Illusions
Depersonalisation
Derealisation
```
37
What is a hallucination?
A sensory perception without any external stimulation of the relevant sense that the patient believes is real (e.g. the patient hears voices but no sound is present)
38
What is a pseudo-hallucination?
The same as a hallucination but the patient is aware that it is not real.
39
What is an illusion?
The misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).
40
What is meant by depersonalisation
The patient feels that they are no longer their ‘true’ self and are someone different or strange.
41
What is derealisation?
A sense that the world around them is not a true reality.
42
What is meant by cognition?
Cognition refers to “the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses”.
43
How do we assess cognition?
Whether they are oriented in time, place and person
What their attention span and concentration levels are like
w]What their short-term memory is like
44
What is meant by insight?
Insight, in a mental state examination context, refers to the ability of a patient to understand that they have a mental health problem and that what they’re experiencing is abnormal.
45
What is meant by judgement?
Judgement refers to the ability to make considered decisions or come to a sensible conclusion when presented with information.
46
How might you assess judgement?
You may get some idea of the patient’s judgement abilities as you move through the mental state examination, but you can also specifically assess judgement by presenting the patient a scenario such as:
“What would you do if you could smell smoke in your house?”
47
How do psychotropics compare to general medical medications?
Effect size is similar to other treatments in medicine
48
Give three example TCAs
Amitriptyline, lofepramine, clomipramine
49
How do TCAs produce therapeutic effect in depression?
Inhibit serotonin and noradrenaline uptake
50
Give an example noradrenaline reuptake inhibitor (NaRI)
Reboxetine
| Lofepramine (TCA) is similar
51
How do noradrenaline reuptake inhibitors produce their therapeutic effect, what side effects are associated with them and how does their use compare to SSRIs?
Inhibit noradrenaline uptake
Produces anticholinergic-like side effects
Well tolerated, but on average not as effective as SSRIs so give as second line
52
Give two example SNRIs and describe when they are used
Venlafaxine and duloxetine
Serotonin and noradrenaline reuptake inhibitors
Better tolerated than TCAs and probably more effective than SSRIs for severe depression therefore good second/third line tx
53
Give an example noradrenaline and serotonin selective antagonist (NaSSA)
Mirtazepine
54
How do NaSSAs work?
Blocks a2 receptors - produced antidepressant effect as increases 5-HT release
Blocks 5-HT2 receptors so produces decreased anxiety
55
Describe the pharmacology behind NaSSAs SEs
Blocks H1 receptors - produces sedation
| Blocks 5-HT2 and H1 - produces weight gain
56
When do we use NaSSAs?
Possibly more potent than SSRIs plus lacks sexual SEs. Can cause marked weight gain. Used second line.
57
How do TCAs produce their SEs?
H1 antagonist - sedation
A1 antagonist - postural hypotension
M1 antagonist - anticholinergic SEs
58
What are the anticholinergic SEs?
Dry mouth, constipation, urinary retention, blurred vision
59
When do we use TCAs?
Poorly tolerated and toxic in overdose (except lofepramine)
Lofepramine doesn't produce too many SEs so good as 2nd line in primary care (as good NRI but doesn't act on other receptors as much)
Amitriptyline good third or fourth line (? more potent than SSRIs for severe depression)
Clomipramine 2nd or 3rd line for OCD
60
Give an example monoamine oxidase inhibitor
Phenelzine
61
What is a RIMA? Why is it important?
MAOIs have many food and drug interactions
| RIMAs are reversible inhibitors of MAO-A, and doesn't have as many food and drug interactions
62
What is the action of MAOIs? When are they used?
Increase levels of 5-HT, NA and dopamine
| Third/fourth line treatments for severe and/or atypical depression
63
What is the action of ketamine/
Glutamate NMDA receptor antagonist
64
How is ketamine used to treat depression?
Can rapidly reduce acute suicidality and depression, but affects only last a few days
65
Which class of antidepressants can you not use in epilepsy?
TCAs significantly reduce the seizure threshold
66
Which class of drugs can cause prostatism?
Any with an anticholinergic effect
67
What haematological effects can SSRIs have?
Bleeding disorders, as serotonin (blocks 5-HT reuptake) is involved in the clotting cascade
68
How do NARIs work to treat depression?
Blocks a2 receptors which increase both NA and therefore 5-HT release into the synaptic cleft, increasing the serotonin concentration in the post-synaptic cell
69
Other than through the action of 5-HT, what else is seen in patients with depression?
Monoamine abnormalities within the brain
Neuroendocrine abnormalities (e.g. elevated cortisol and abnormal HPA axis function)
Alterations in limbic circuit activity
Structural changes within the brain (e.g. reductions in hippocampal volume)
Altered inflammatory markers (increase pro-inflammatory, and decreased anti-inflammatory, cytokines)
70
How does rapid lowering of brain 5-HT in healthy subjects impact the subjects? What might this show?
Little or no effects on mood
Effects on cognition
- increased response times in attentional task to happy and neutral (but not sad) targets
- impaired recall of happy and neutral (but not sad) targets
- attenuated behavioural bias toward positive stimuli
i.e. lowering brain 5-HT leads to a negative emotional bias
Normally, with an intact 5-HT system, resilience to adversity may be maintained by avoiding a negative bias
71
How do we diagnose depression?
5 or more of the following over a two week period:
- depressed mood*
- markedly diminished interest or pleasure in all activities*
- weight loss, decreased or increased appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or inappropriate guilt
- diminished ability to think or concentrate
- recurrent thoughts of death or suicide
And an impairment of function
Must have one of the first two symptoms
72
With every new presentation of a depressive episode, what should you asked about?
Symptoms of elevated mood, e.g. elation, racing thoughts, lack of need for sleep, increased activity, inappropriate and uncharacteristic behaviour, over-spending etc.
73
When do you treat moderate/severe depression, and mild depression?
AD first line if moderate/severe, or has persisted for 2+ years
Option for mild depression if has persisted for 2-3 months or if there is hx of moderate/severe depression
74
How do we assess the risk of relapse in depression?
Presence of residual symptoms increases the risk significantly
if number of previous episodes >2-3 then high risk
Increased risk if severe or lasting more than 6 months
Consider degreee of treatment resistance of the most recent episode
75
How long do we treat depression for?
6-12m from remission
If any risk factors then longer
if multiple risk factors then review annually
The presence of residual symptoms is the biggest RF
76
What are hypnotics?
Drugs that help you sleep
77
What are anxiolytics?
Drugs that treat anxiety
78
How do benzodiazepines and Z-drugs work/
When GABA binds to the GABA-A receptor, the chloride channel widens, increasing the number of chloride ions that can travel through the cell and inhibiting the activity of the cell
BZ increase this affect
Benzodiazepines are relatively safe as, in the absence of GABA produced by the body, they don't work
This leads to anxiolysis, sedation, muscle relaxation, anticonvulsant, amnesia and reduction of alcohol withdrawal symptoms
79
How does bz use over time impact on the brain GABA function
The receptors adapt, so brain GABA functions decrease, and then if stopped there can be a large rebound anxiety period
However, the after the rebound their brain GABA function increases back to a level higher than it was pre-treatment
80
What is first order pharmacokinetics
The rate of elimination is proportional to the plasma concentration, therefore half-life
81
What is buspirone?
5-HT1A receptor agonist
Anxiolytic effects and weak antidepressant effects
Takes a couple of weeks to have effects
82
What are the side effects of buspirone?
No issues with tolerance or dependency
SEs: exacerbation of panic attacks, akathisia (restlessness as metabolite blocks dopamine receptors)
83
What are the SEs of gabapentinoids?
Drowsiness, fatigue
Ataxia, blurred vision, diplopia, dizziness
Constipation
84
When are benzodiazepines indicated?
BZs are indicated for the short-term relief (2-4 weeks only) of anxiety that is severe, disabling or causing the pt unacceptable distress, occuring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness
85
How can BZs be used to treat panic disorder?
Can be used "in the pocket/bag" can have a positive psychological benefit
86
Can propanolol worsen panic attacks?
Good question
87
What are the first rank symptoms?
```
Delusional perception *
Passivity and somatic passivity*
Thought echo (hearing your own thoughts out loud)*
Thought insertion or withdrawal*
Thought broadcasting*
3rd person auditory hallucinations*
```
88
What are the negative symptoms in schizophrenia?
```
Blunted affect
Apathy
Social isolation
Poverty of speech
Poor self-care
```
89
How is schizophrenia diagnosed?
According to ICD-10, a diagnosis of schizophrenia requires:
1. A first-rank symptom or persistent delusion present for at least one month:
Delusional perception
Passivity
Delusions of thought interference: thought insertion, thought withdrawal and/or thought broadcasting
Auditory hallucinations: thought echo, third-person voices and/or running commentary
2. No other cause for psychosis such as drug intoxication or withdrawal, brain disease (including dementia/delirium/epilepsy), or extensive depressive or manic symptoms (unless it is clear that schizophrenic symptoms antedate the affective disturbance).
90
How do FGAs work?
Strong D2 antagonists
91
How do SGAs work?
D2 antagonists and 5-HT2A antagonists
92
How do antipsychotics treat schizophrenia?
1. Mesolimbic pathway - increase in DA causes positive symptoms
2. Mesocortical pathway - DA hypoactivity causes negative, cognitive and affective symptoms
93
How do SGAs compare to FGAs?
SGAs less EPS than FGAs
SGAs less hyperprolactinaemia cf FGAs
SGAs higher risk of weight gain, metabolic syndrome and diabetes
Differences in potency
Clozapine can cause neutropenia
94
Which antipsychotics can be used to treat bipolar depression?
Quetiapine, olanzapine + fluoxetine, lurasidone, cariprazine
95
How do we monitor antipsychotic use?
```
Weight and waist
Pulse & BP
Fasting glucose and HbA1C
Lipids
Prolactin
Assess for movement disorders
Diet and physical activity
ECG if indicated
```
96
How do we treat acute mania in bipolar?
Stop any antidepressant the pt is on
Give antipsychotic - haloperidol, olanzapine, quetiapine or risperidone
If ineffective, consider adding lithium or valproate
97
How do we treat acute depression in bipolar?
Olanzapine plus fluoxetine, quetiapine, lamotrigine
98
What are the best treatments for bipolar long-term?
Lithiu, and olanzapine prevent mania and depression equally
99
How do we monitor lithium?
Lithium levels - narrow therapeutic index
Renal and thyroid dysfunction - renal function and TFTs 3-6 monthly
Sudden discontinuation has a 50% risk of mania
Teratogenic - can cause Epstein's anomaly
100
What are the issues with lamotrigine use?
Can cause Stevens-Johnson syndrome, so slow dose titration needed
101
What are the pharmacokinetic changes with age?
Renal function decreases
Hepatic function worsens
Increased body fat and decreased body water
102
How is lithium excreted?
Renally
103
Why must you be careful with anticholinergics in the elderly?
Can cause delirium - especially with polypharmacy
104
What can citalopram use increase the risk of?
GI bleeding
105
What are the phases seen in schizophrenia?
Prodromal - withdrawn
Active - severe symptoms
Residual - cognitive symptoms
106
What is flupentixol decanoate?
Depot injection, FGA
107
What is paranoid schizophrenia?
The most common type and is characterised by paranoid delusions and auditory hallucinations.
108
What is hebephrenic schizophrenia?
Hebephrenic schizophrenia is usually diagnosed in adolescents and young adults. It is characterised by mood changes, unpredictable behaviour, shallow affect and fragmentary hallucinations.
The outlook is often poor as negative symptoms may develop rapidly.
109
What is simple schizophrenia?
Simple schizophrenia is similar to hebephrenic schizophrenia in that it is characterised by negative symptoms.
However, in simple schizophrenia, patients have never experienced positive symptoms.
110
What is catatonic schizophrenia?
Characterised by its psychomotor features, such as posturing, rigidity and stupor.
111
What is undifferentiated schizophrenia?
Patients are designated as having undifferentiated schizophrenia when their symptoms do not fit neatly into one of the other categories of schizophrenia.
112
What is residual schizophrenia?
Residual schizophrenia is again characterised by negative symptoms. It usually occurs when the positive symptoms have ‘burnt out’.6
113
What drug can increase risk of schizophrenia?
Cannabis mainly
| Also amphetamines, cocaine and LSD
114
Can ethnicity increase risk of schizophrenia?
Afro-Caribbean men are more affected than other ethnicities
115
Define hallucination
A perception in the absence of an external stimulus that has qualities of real perception
116
What might you want to ask about auditory hallucinations?
Do you ever hear noises or voice when there is nobody else there?
Do you recognise the voices? How many are there?
What do they say? Do they tell you to do things?
Are they present all the time?
Does anything make them better or worse?
Do you smell or see anything at the same time as syou hear these voices?
117
What is a somatic/tactile hallucination?
A perception of being touched in the absence of a sensory stimulus is termed a somatic hallucination. This may result in hallucinations of being touched, assaulted or that insects are beneath the skin.
118
What is thought blocking?
Dudden cessation of thought, typically mid-sentence, with the patient being unable to recover what was previously said.
119
How might you ask about thought blocking?
“Do you ever experience your thoughts suddenly stopping as though there were no thoughts left?”
120
What is thought withdrawal?
Thought withdrawal refers to a patient’s belief that thoughts can be removed from their mind by others.
121
What is thought insertion?
Thought insertion refers to a patient’s belief that thoughts can be inserted into their mind by others.
122
How might you ask about thought insertion?
“Are your thoughts your own?”
“Is there anyone/anything putting thoughts into your head that you know are not your own?”
“How do you know they aren’t yours? Where do they come from?
123
What is thought broadcasting?
Thought broadcasting refers to a patient’s belief that others can hear their thoughts.
124
What are delusions?
Delusions are firm, fixed beliefs based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms.
125
What are persecutory delusions?
Where the patient erroneously believes another individual or group is trying to harm them
126
What are ideas of reference?
Where the individual incorrectly believes specific events relate to them.
127
What is passivity?
People who experience passivity do not feel in control of their actions, thoughts and perceptions, believing them to influenced by an external agent.
