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Y5 Psychiatry > General > Flashcards

General Flashcards

1
Q

Define hallucination.

A

A perception in the absence of a stimulus.

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2
Q

What are hypnagogic and hypnopompic hallucinations?

A

Hypnagogic – state before falling asleep

Hypnopompic – state before waking up

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3
Q

What are the 4 main kinds of hallucinations?

A
  1. Auditory
  2. Visual
  3. Olfactory
  4. Gustatiry - taste (often unpleasant)
  5. Tactile - i.e. sense of bugs crawling all over you
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4
Q

Define extracapine hallucinations.

A

A sense of presence/movement in the absence of such a stimulus (i.e. someone is near you)

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5
Q

Define elemental hallucinations.

A

Ssimple hallucinations - e.g. flashing lights, noises etc

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6
Q

Define Charles de bonnet hallucinations.

A

Recurring hallucinations in someone with impaired vision.

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7
Q

Define illusion.

A

An altered perception of a real object

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8
Q

Define pareidolic illusion.

A

Perceived meaningful images from vague stimuli (i.e. seeing a face in a fire)

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9
Q

Define delusion.

A

A fixed, false belief, held despite evidence to the contrary that is not explained by the patient’s background.

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10
Q

Define mood incongruent.

A

Behaviours that are not consistent with a patient’s current mindset or are at conflict with current situational factors.

  • Laughing at a funeral/in depressive state
  • Manic state patient believing a news disapproves of them
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11
Q

Define mood congruent.

A

Behaviours that are consistent with a patient’s current mindset or are at conflict with current situational factors.

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12
Q

Define persecutory/paramoid delusions.

A

Patient, or a loved one, are being hunted by the FBI

  • most common type of delusion
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13
Q

Define passivity/control delusions.

A

Patient belives someone else is controlling them

  • somatic passivity = sensations being imposed on them
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14
Q

Define grandiose delusions.

A

A delusion in which one believes they are someone of great importance

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15
Q

Define reference delusion.

A

Patient thinks they are receiving messages in the dialogue of a TV programme (the reference)

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16
Q

Define somatic delusions.

A

Delusion related to the body and functions rather than mind

  • Ekbom’s syndrome = a belief that one is infested with parasites
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17
Q

Define Ekbom’s syndrome.

A

Belief that one is infested with parasites

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18
Q

Define hypochondriasis.

A

Unconsciously pretending they have a medical illness

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19
Q

Define Munchausen.

A

Consciously pretending they have a medical illness as they have satisfaction in taking a sick role

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20
Q

Define Munchausen by proxy.

A

A person abusing another person to take them in for care

  • Mother abuses child to take child in for care
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21
Q

Define malingering delusions.

A

Lying or exaggerating symptoms for some gain

  • often for financial gain
  • can be to get medications
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22
Q

Define Othello syndrome.

A

One believes their partner is being unfaithful

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23
Q

Define De Clerembault’s syndrome/erotomania

A

Excessive sexual desire

  • often believing a VIP is in love with them
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24
Q

Define Capgras delusions.

A

Believing a close acquaintance has been replaced by an imposter

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25
Q

Define Fregoli syndrome.

A

Belief that 2 or more people are the same person changing disguises in order to deceive

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26
Q

Define Folie á deux.

A

Shared delusions/hallucinations between people

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27
Q

Define Cotard syndrome.

A

Nihilistic delusion (severe depression)

– Believe your body is rotting away/you are dead

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28
Q

Define depersonalisation/derealisation.

A

Feeling disconnected or detached from one-self

  • “I feel as if I’m not real”
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29
Q

What is Knight’s move thinking?

A

No clear links between successive thoughts

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30
Q

What is flight of ideas?

A

Jumping thoughts with links between successive thoughts

  • feature of mania, not of psychosis
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31
Q

What is flight of ideas a sign of?

A

Mania

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32
Q

Define circumstantiality thinking.

A

Inability to answer a question without giving excessive, unnecessary detail.

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33
Q

Define tangentiality thinking.

A

Wandering from a topic without returning to it.

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34
Q

Define perseveration thinking.

A

Repetition of ideas or words despite an attempt to change the topic.

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35
Q

Define neologism.

A

New word formations

  • Often includes the combining of two words
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36
Q

Define clang association.

A

When ideas or words are related to each other only by the fact they sound similar or rhyme.

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37
Q

Define word salad.

A

Completely incoherent speech where real words are strung together into nonsense sentences.

  • aka Broca’s aphasia
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38
Q

Define echolalia.

A

The repetition of someone else’s speech, including the question that was asked.

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39
Q

Define neurosis.

A

An inappropriate emotional or behavioural response to a perceived stressor (i.e. phobia, GAD, OCD)

  • unlike psychotic conditions, a neurotic person never loses touch with reality and has normal mental functioning
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40
Q

Describe the Mental Capacity Act 2005.

A

Consent and capacity laws (for those aged 16 and 17 and adults that lack capacity)

Concerns capacity rather than mental health (i.e. use for those aged 16 to treat them)

Added advance decisions, LPAs (health & welfare, finance)

– n.b. MHA can overrule advance decisions

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41
Q

Describe the Mental Health Act 2007.

A

Compulsory admission and treatment of mental illness laws

Limited to treatment of mental disorder (not for physical disorders; that is covered by MCA 2005)

People can only be detained if appropriate treatment is available

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42
Q

What is Section 2 of the Mental Health Act 2007?

A

Sectioning someone for admission for assessment

  • Lasts for 28 days and cannot be renewed
  • Can only be applied by approved mental health professionals (recommended at least 2 doctors) or a nearest relative - Section 12 approved/with mental health disorder trained
  • Discharge possible by nearest relative to mental health review tribunal with first 14 days or the responsible clinician
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43
Q

What is Section 3 of the Mental Health Act 2007?

A

Sectioning someone for admission for treatment

  • Lasts for 6 months and can be renewed at 6 months and then every year if needed
  • Patient can be forcibly medicated until 3 months of detention - after this if still not consenting a Second Opinion Appointed Doctor (SOAD) assessment is needed
  • Can only be applied by approved mental health professionals (recommended at least 2 doctors) or a nearest relative - Section 12 approved/with mental health disorder trained
  • Discharge possible by patient to mental health review tribunal, section 17, nearest relative to hospital (can be barred by clinician) or responsible clinician
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44
Q

What is Section 5(2) of the Mental Health Act 2007?

A

Detention of an inpatient by a doctor

  • Lasts for 72hrs
  • Only 1 doctors is needed according to recommendation (must be FY2 or above with or without Section 12)
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45
Q

What are Section 135 and 136 of the Mental Health Act 2007?

A

135 = Police order to remove a person appearing to be suffering from a mental disorder from a private place to a ‘place of safety’

  • Applied for my magistrate’s court if evidence from 1 doctor of a potential mental health disorder
  • Lasts 24-36 hours if needed

136 = Police order to remove a person appearing to be suffering from a mental disorder from a public place to a ‘place of safety’

  • Only 1 police officer is needed according to recommendation
  • Lasts for 24-36hrs
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46
Q

What is Section 4 of the Mental Health Act 2007?

A

Section for admission for emergency treatment

  • Lasts for 72 hours and can be converted to Section 2 (28 day assessment) if another doctor agrees
  • Can only be applied by a doctor (FY2 or above) or a nearest relative
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47
Q

What is Section 5(4) of the Mental Health Act 2007?

A

Detention of an inpatient by a nurse

  • Lasts for 6 hrs
  • The nurse applying it must be a registered mental health nurse
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48
Q

What is Section 17 of the Mental Health Act 2007?

A

Allows leave from a current section for a specified time

  • Is not permanent discharge
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49
Q

What is Section 35 of the Mental Health Act 2007?

A

Assessment of patient accused of committing a crime

  • Lasts 28 days but can be extended by 28 days per renewal up to a maximum of 12 weeks
  • Applied for my magistrate’s court if evidence from a doctor of a potential mental health disorder
  • Often used to check if an accused has any mental health conditions
  • Cannot be appealled
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50
Q

What is Section 37 of the Mental Health Act 2007?

A

Treatment of patient convicted of committing a crime

  • Lasts 6 months - can be extended by 6 months then by 1 year per renewal thereafter
  • Applied for my magistrate’s court if evidence from 2 doctors of a potential mental health disorder
  • Can be appealled (within 21 days to court or then after 6m to MHRT)
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51
Q

What are Section 41, 47 and 48 of the Mental Health Act 2007?

A

41 = Restriction order that is apllied for by the Crown Court

  • Affects leave of absence, discharge and transfer between hospitals
  • No appeal within the first 6 months

47 = Transfer serving prisoner to hospital (Section 49 adds those of 41)

48 = Transfer of unsentenced prisoner to hospital

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52
Q

What is defined by Section 26 and 29 of the Mental Health Act 2007?

A

26 – defines who the patient’s nearest relative is

29 – defines the patient’s rights to change the nearest relative

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53
Q

What is the Community Treatment Order?

A

Allows discharge from previous section on agreement certain conditions are met:

  • May be living in a certain place, going somewhere for medical treatment, taking medications etc
  • If conditions breached, can be recalled to hospital for up to 72 hours for assessment
  • Requires renewal every 6 months (can be appealed at a MHRT)
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54
Q

What is an Approved Mental Health Professional?

A

Responsible for coordinating the assessment/admission of a patient to hospital if sectioned

  • 95% are social workers
  • MHPs approved by a local social services authority to carry out duties under the Mental Health Act
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55
Q

What is an Independent Mental Health Advocate?

A

An advocate trained to help the patient find out their rights under the MHA and provide support

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56
Q

Which patients have the right to an Independent Mental Health Advocate?

A

Under a section that is NOT 4, 5, 135 and 136

Under MHA guardianship, conditional discharge and CTO

Discussing treatments such as ECT

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57
Q

What is a Mental Health Advocate Guardianship?

A

Helps a patient live independently in the community.

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58
Q

What is Deprivation of Liberty Safeguards (DoLS)?

A

Depriving liberty within a care home or hospital (appropriately; not at home)

Urgent application = 7 days DoLS

Needed for restraint/restrictions used to safeguard people under the MCA which deprive liberties

  • Part of the MCA 2005
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59
Q

Name 2 typical antipsychotics.

A

Haloperidol

Chlorpromazine

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60
Q

Name 5 atypical antipsychotics.

A

Quetiapine

Olanzapine

Clozapine

Risperidone

Aripiprazole

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61
Q

What is the mechanism of antipsychotics?

A

Block D2 receptors

  • Clozapine blocks D1 and D4
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62
Q

How do the mechanism of atypical antipsychotics differ from typicals?

A

Atypicals are more selective

  • Atypicals block D2 and 5-HT2 receptors
  • This means they have less side effects
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63
Q

What conditions management can contain an antidepressant?

A
  • Depression
  • Dysthymia
  • Anxiety disorders
  • Eating disorders
  • Personality disorders
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64
Q

What group of patients can respond ‘too well’ to antidepressants?

A

Patients in mania - undiagnosed bipolar

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65
Q

What are the consequencies of sudden discontinuation of antidepressants?

A

FIRM STOP

  • Flu-like symptoms
  • Insomnia
  • Restlessness
  • Mood swings
  • Sweating
  • Tummy problems (pain, cramps, D&V)
  • Off balance (ataxia)
  • Paraesthesia (shocks, tingles, etc.)
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66
Q

What is the mechanism of SSRIs?

A
  • Block reuptake of serotonin/5-HT
  • Causes more serotonin in synaptic cleft
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67
Q

What is the immediate effect of SSRIs?

A
  • Make you feel WORSE before they make you feel better (1-2 weeks)
    • Serotonin immediately increases but glutamate takes a while longer
    • The difference in timing leads to slightly worse symptoms
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68
Q

What drugs interact with SSRIs?

A

Triptans - can cause serotonin syndrome

  • NSAIDs and Aspirin must be taken with PPI
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69
Q

Name 6 SSRIs.

A
  • “Effective For Sadness, Panic, Compulsion”
    • Escitalopram
    • Fluoxetine, Fluvoxamine
    • Sertraline
    • Paroxetine
    • Citalopram
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70
Q

What are the side effects of SSRIs?

A
  • Five S’s – S, S, S, S, S”
    • Suicidal ideation (for 1-2 weeks)
    • Stomach - weight gain, N&V*, diarrhoea*, headaches, dyspepsia (*for 5-10 days
    • Sexual dysfunction
    • Sleep/Insomnia (for 5-10 days)
    • Serotonin syndrome
  • Others - hyponatraemia, blurred vision, akathisia, tremor, dizziness, headache, sweating
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71
Q

What is a specific adverse effect of citalopram?

A

QT prolongation

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72
Q

Which SSRI should be used for a depressed patient with cardiac pathology?

A

Sertaline

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73
Q

Which antidepressants should be prescribed for patients with suicidal thoughts?

A

SSRIs

Mirtazapine

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74
Q

How long do SSRI’s tkae to have an effect?

What can happen during this initial time period?

A

4 to 6 weeks

  • Anxiety can worsen during this initial time period
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75
Q

How long should SSRI’s be taken for?

A
  • 6 months after remission of 1st episode
  • 2 years if a recurrence
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76
Q

What medication are advised not to take with SSRI’s?

A
  • Triptans - can be allowed for migraines
  • NSAIDs/Aspirin - if need to be taken à combine with a PPI
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77
Q

What is the mechanism of SNRI’s?

A

Block reuptake of serotonin/5-HT and NA (lesser extent) leading to more 5-HT and NA in synaptic cleft

  • At high doses, blocks DA re-uptake
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78
Q

Name 2 SNRI’s.

A

Venlafaxine

Duloxetine

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79
Q

What are the side effects of SNRI’s?

A
  • Headaches
  • 5 S’s
    • Suicidal ideation
    • Stomach issues
    • Sexual dysfunction
    • Sleep (insomnia)
    • Serotonin syndrome
  • Constipation
  • Hypertension
  • Raised cholesterol
80
Q

What antidepressants shouldn’t be prescribed for patients at risk of suicide?

A

TCA’s

MAOi’s

Venlafaxine

81
Q

What is the mechanism of TCAs?

A

Block reuptake of serotonin/5-HT and NA (lesser extent) leading to more 5-HT and NA in synaptic cleft

  • High doses = blocks all receptors and is used in depression
  • Low doses (25-50mg) = blocks H1 and 5-HT and is used for aiding sleep
82
Q

What are the clinical uses of TCAs?

A
  • Depression
    • High doses blocks all receptors
  • Sleeping Aid
    • Low doses (25-50mg) they block H1 and 5-HT
83
Q

What are the side/adverse effects of TCA’s?

A
  • Thrombocytopaenia
  • Cardiac (arrhythmias, MI, stroke, postural hypotension)
  • Anticholinergic (tachycardia, urinary retention, dry mouth, blurry vision, constipation)
  • Seizures
  • Hyponatraemia
84
Q

What are the anticholinergic effects on the body?

A
  • Tachycardia
  • Blurry Vision
  • Urinary Retention
  • Dry Mouth
  • Constipation
    • “Can’t see, can’t pee – can’t spit, can’t shit”
85
Q

Name 6 TCA’s.

A

Amitrityline

Clomipramine

Imipramine

Lofepramine

Dosulepin

Doxepin - sleeping

86
Q

Name a Noradrenergic and Specific Serotonin Antidepressant (NaSSA).

A

Mirtazapine

87
Q

What is the inidcation for mirtazapine?

A

A depressed patient with insomnia and loss of appetite

88
Q

What are the common side effects of Noradrenergic and Specific Serotonin Antidepressant (NaSSA’s)?

A

Sedation/Sleepiness

Increased appetite/Weight gain

Oedema

89
Q

Name 2 Noradrenaline Reuptake Inhibitors (NARI’s).

A

Reboxetine

Atomoxetine

90
Q

What are the side effects of Noradrenaline Reuptake Inhibitors (NARI’s)?

A
  • Anticholinergic (blurry vision, urinary retention, dry mouth, constipation, tachycardia, excess sweat)
  • Insomnia
91
Q

What is the mechanism of MAOi’s?

A

Inhibits MAO inside of the pre-synaptic neurone

  • increases MAO levels
92
Q

Why are MAOi’s falling out of use?

A
  • Dangers of hypertensive “cheese” reaction
    • NA builds up from intake of tyramine-rich food (i.e. cheese)
  • Can’t be combined with other antidepressants
    • Especially SSRIs due to high risk of serotonin syndrome
93
Q

Name 4 MAOi’s.

A
  • PHENomenal Ice Sled Trainer
    • Phenelzine
    • Isocarboxacid
    • Selegiline
    • Tranylcypromine
94
Q

What are the side effects of MAOi’s?

A
  • Hypertensive crisis/Cheese reaction
  • Anticholinergic (blurry vision, urinary retention, dry mouth, constipation, tachycardia, excess sweat)
  • Insomnia
  • Headache
95
Q

Name a Reversible Inhibitor of MOA (RIMA).

A

Moclobemide

96
Q

What are the side effects of Reversible Inhibitors of MOA?

A

Agitation

Sleep disturbance

Nausea

Hypertension

97
Q

How long should benzodiaepines be prescribed for?

A

No longer than 2-4 weeks

98
Q

What are the mechanisms of anxiolytics?

A
  • Enhance GABA transmission at GABA-A receptor
  • Binding sites and mechanisms:
    • Barbiturates increase the Frequency of opening
    • BZDs increase the Duration of opening
99
Q

How does the selectivity of BDZs differ from barbiturates?

A

Barbs are less selective then BDZs, so Barbs have:

  • Less excitatory transmission
  • Barbs are more dangerous (i.e. induction of surgical anaesthesia and small therapeutic window)
100
Q

What are the indications for anxiolytics?

A

Treat anxiety disorders

  • Does so without impairing mantal or physical activity - should be longer-acting to aid withdrawal
101
Q

Name 5 anxiolytics.

A
  • Diazepam (BDZ)
  • Lorazepam (BDZ)
  • Chlordiazepoxide (BDZ)
  • Nitrazepam (BDZ)
  • Oxazepam (BDZ) - if the patient has hepatic impairment
102
Q

How must BZD’s be stopped?

A
103
Q

What are the effects of depressants?

A
  • Sedative
    • Reduce mental and physical activity without producing a loss of consciousness
  • Hypnotic
    • Reduce mental and physical activity AND induce sleep
104
Q

Name some depressants.

A

Shorter acting benzodiazepines or barbiturates:

  • Examples:
    • Temazepam (BDZ)
    • Oxazepam (BDZ)
    • Nitrazepam (BDZ) - hypnotic effect at night followed by an anxiolytic effect during the day
105
Q

How does nitrazepam differ from other other anziolytics and depressants?

A

Hypnotic effect at night followed by an anxiolytic effect during the day

106
Q

What are Z-drugs?

A

Drugs like benzodiazepines that are used to treat insomnia

107
Q

Name a Z-drug.

A

Zopiclone

108
Q

What are the side effects of Z-drugs?

A
  • Agitation
  • Bitter taste
  • Constipation
  • Hypotonia
  • Dizziness
  • Dry mouth
  • Increased risk of falls
109
Q

What are the side effects of BDZs?

A
  • Sedation/Confusion
  • Anterograde amnesia
  • Ataxia
  • Tolerance and Dependence (less intense than barbs)
  • Potentiates other CNS depressants (i.e. alcohol)
  • Free plasma concentration increases when co-administered with aspirin, heparin
  • Cleft lip (1st trimester use) pregnancy
110
Q

What are the advantages of BDZs compared to other drug classes for used for anxiety disorders?

A
  • Wide therapeutic window – an overdose ‘only’ causes prolonged sleep
    • Flumazenil is a BDZ antagonist and can reverse effect
  • Only a mild effect on REM sleep
  • Does not induce liver enzymes
111
Q

What are stimulants used to treat?

A

ADHD

Narcolepsy

112
Q

Name 2 stimulants.

A
  • Methylphenidate
  • Dexamphetamine
113
Q

What are the side effects of stimulants?

A
  • Cardiac – arrhythmias, HTN, stroke
  • Drug-induced psychosis
  • Appetite suppression
  • Risky behaviour
  • Impulsivity
  • Anxiety and panic
  • Insomnia
  • “Crash” (dysphoria and lethargy) on stopping
114
Q

What are mood stabiliser used to treat?

A

BPAD

Schizoaffective Disorder

  • Even out the highs of mania and lows of depression (more effective in mania)
115
Q

Name 4 mood stabilisers.

A
  • Lithium
  • Sodium valporate
  • Carbamazepine
  • Lamotrigine
116
Q

What are the side effects of lithium?

A
  • Fine tremor
  • N&V
  • Nephrogenic DI
  • Arrhythmia
  • Hypothyroidism
  • Weight gain
  • Eyebrow hair loss
117
Q

What are the side effects of sodium valporate?

A
  • N&V as well as diarrhoea
  • Liver failure/DILI
  • Thrombocytopenia
  • Hair loss
  • Weight gain
118
Q

What are the side effects of carbamazepine?

A
  • Skin rash
  • Leucopenia
  • Dizziness
  • Ataxia
  • Drowsiness/Fatigue
  • N&V
  • Oedema
  • Weight gain
  • Hyponatraemia
119
Q

What are the side effects of lamotrigine?

A
  • Severe skin rash
  • Headache
  • Fatigue
  • Nausea
  • Dizziness
  • Insomnia
  • Arthralgia, back pain
120
Q

Which mood stabiliser can you overdose on? And what are the signs/symptoms of its overdose?

A

Lithium

  • Therapeutic Range: 0.6-1.0 mmol/L
  • Overdose: >1.2 mmol/L
  • Coarse tremor
  • Hyperreflexia
  • Nystagmus
  • CNS (seizures, ataxia)
  • GI (N&V)
121
Q

Which mood stabiliser require monitoring? And what type of monitoring is required?

A
  • Lithium
    • 12 hours after first dose and 1 week after changing dose
      • Weekly until the level is steady (about 5 weeks)
    • Every 3m for lithium levels
    • Every 6m for U&Es and TFTs
  • Carbamazepine
122
Q

What are the adverse effects/contraindications of lithium?

A

Benign leucocytosis

Pregnancy - Ebstein’s abnormality (parts of the tricuspid valve separates the right ventricle from the right atrium)

Sudden discontinue - relapse

123
Q

What are the triggers of lithium overdose?

A
  • Dehydration
  • Drugs (NSAIDs, ACEi, diuretics, celecoxib) - interrupts with renal excretion
  • Deliberate overdose
124
Q

What are the adverse effects/contraindications of sodium valporate?

A
  • Pregnancy - spina bifida
    • Cannot be prescribed to any woman of child-bearing age unless a Pregnancy Prevention Programme in place
    • Saying that it can be used if advised in pregnancy and risk is weighed up
      • Folate supplements must be prescribed
125
Q

What are the adverse effects/contraindications of carbamazepine?

A
  • Induces enzymes - may make other medications ineffective (i.e. COCP)
  • Pregnancy - spina bifida
126
Q

What are the adverse effects/contraindications of lamotrigine?

A

Skin rash - Steven-Johnson syndrome

127
Q

What is neuroleptic malignant syndrome?

A

Gradual onset of the triad of:

  • Mental status change (catatonia)
  • Muscular rigidity
  • Autonomic instability
    • Hyperthermia (>40C)
    • Tachycardia
    • Tachypnoea
    • Labile BP
    • Sweating/Fever
  • “MMA” fighters are muscular, mental (crazy) and (autonomically) unstable
128
Q

What is the most likely drug to cause neuroleptic malignant syndrome?

A

Haloperidol

  • 0.2% prevalence to any antipsychotic - usually in 4-11 days
129
Q

What investigations are appropriate for suspected neuroleptic malignant syndrome?

A
  • Leucocytosis
  • Rigidity - muscle breakdown - rhabdomyolysis:
    • U&Es (High CK >1,000)
    • AKI (U&E derangement)
130
Q

What is the management of neuroleptic malignant syndrome?

A
  • ABC
  • Stop antipsychotics
  • Supportive (fluids, dialysis, etc.)
  • Dantrolene (for muscle cramps)
  • Bromocriptine - dopamine agonist
131
Q

What is serotonin syndrome?

A
  • Abrupt/Sudden onset of the triad of:
    • Mental status change (catatonia)
    • Muscular rigidity
    • Autonomic instability
      • Hyperthermia (>40C)
      • Tachycardia
      • Tachypnoea
      • Labile BP
      • Sweating/Fever
    • Diarrhoea and Vomiting
132
Q

What is the management of serotonin syndrome?

A
  • ABC
  • Stop antidepressants
  • BDZ (reduced neurologic excitability)
  • Supportive (fluids, dialysis, etc.)
133
Q

Define Electroconvulsive Therapy (ECT).

A

Passage of a small electric current through the brain with a view of an inducing a generalised tonic-clonic seizure under ga and muscle relaxants

134
Q

What are the short-term side effects of ECT?

A
  • Headache and nausea
  • Muscle aches
  • Cardiac arrhythmia
  • Memory problems
    • Retrograde amnesia (far more common) = memories before the ECT
    • Anterograde amnesia = problems forming new memories
135
Q

What are the long-term side effects of ECT?

A

Impaired memory - poor evidence

136
Q

What is an absolute contraindication of ECT?

A

Raised ICP

137
Q

What are the indications for ECT?

A

Mood disorders - Major Depressive disorers, Bipolar

Schizophrenia

Non-psychiatric = Parkinson’s, Neuroleptic malignant syndrome, Status epilepticus, Catatonia

138
Q

What is CBT?

A
  • Targets thoughts that lead to emotions and behaviours by challenging a persons own thoughts/being their own therapist
    • Especially Negative Automatic Thoughts
  • Challenges negative beliefs
  • Knock-on effect on mood
139
Q

What is Beck’s negative cognitive triad?

A
  • Self-perpetuating:
    • Negative self-view
    • Negative future view
    • Negative world view
140
Q

What is the background principle of CBT?

A
  • Identify an Event that Trigger thoughts
  • Understand the emotions/behaviours behind the trigger
  • Step back and take a look at your own thoughts
  • Methods to challenge these thoughts…
    • Longitudinal format
    • Hot-cross bun methods
141
Q

Describe the a CBT session using Longitudinal Formulation.

A
  1. ​Get a detailed history including early life
    • Use it to identify early experiences, critical incidents, etc.
  2. Use a ‘sleep schedule’ to link the mood to activities/lack of energy
    • Build in activities that generate a sense of pleasure
  3. Identify Negative Automatic Thoughts:
    • Identify situations that lead you to feel worse
    • Where you were, what was happening
    • Describe the emotion and rate from 0-10
    • What was going through your mind at the time (words / images)​
  4. Challenging distortions:
    • Tools/techniques
    • Guided discovery​
  5. Core beliefs:
    • Beck’s negative cognitive triad
    • Often have to dig deep into childhood experiences
142
Q

What is the Hot-cross Bun Method?

A
143
Q

Define Psychodynamic Psychotherapy.

A

Therapeutic process which helps patients understand and resolve their problems by increasing awareness of their inner world and its influence over relationships both past and present

144
Q

What are is psychodynamic psycotherapy based on?

A
  • Alfred Adler Techniques
    • Problems were shaped by childhood experiences and the family environment
      • This causes conflicts between the conscious and unconscious mind
145
Q

How does psychodynamic pyschotherapy work?

A
  • Therapy helps reveal the unconscious mind
    • Psychoanalytics = internal conflicts
    • Psychodynamics = inter-personal conflicts
  • The first few sessions are aimed at building the relationship between the client and the therapist
  • Later sessions try to reveal the unconscious
  • Therapy aims for a deep-seated change in personality and emotional development
  • By changing one’s personality and emotional development, one can reduce their symptoms
146
Q

How does CBT differ from Psychodynamic psychotherapy?

A

CBT = Aims to examine and undertstand thoughts and how it impacts the patient

Psychodynamic psychotherapy = Change personality and emotional development

147
Q

What are the risk factors for suicide?

A
  • Previous self-harm (70x increased risk if <1 year since self-harm)
  • Young male (Overall suicide risk = M: F = 3: 1)
  • Occupation (Doctor, Police, Vet)
  • Live alone
  • Mental illness (>90% have a mental illness (i.e. depression))
  • Substance abuse
  • Lower social class
  • Unmarried
  • Widowed/divorced
148
Q

What are the protective factors against suicide?

A
  • Married
  • Lithium medication
  • Faith in a religion
  • No substance abuses
  • Rural environment
149
Q

What are indicators of suicide intent following deliberate self-harm?

A
  • Preplanning
  • Attempts at concealment
  • Stated wish to die
  • Lack of help-seeking following the act
  • On-going suicidal intent
  • Actions in anticipation of death (a will, suicide note)
  • Belief the act would be fatal (even if medically, it wouldn’t be)
  • Sorrow/anger at failure
150
Q

What agent/medication is used to reverse BDZ overdose?

A

Flumazenil

  • A selective GABA A receptor antagonist
151
Q

What agent/medication is used to reverse opiate overdose?

A

Naloxone

152
Q

What agent/medication is used to reverse Z-drug overdose?

A

Flumazenil

  • A selective GABA A receptor antagonist
153
Q

What agent/medication is used to reverse paracetamol overdose?

A

N-acetylcysteine

154
Q

How would a delirium diagnosis be made using the DSM-V?

A

A. Disturbance in attention and awareness

B. Develops over a short period of time (hours to days), represents a change from baseline attention and awareness and tends to fluctuate in severity during the course of the day

C. Additional disturbance in cognition

D. Disturbances in Criteria A and C are not better explained by another condition

E. Evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal

155
Q

Name some causes of delirium.

A
  • Infection
  • Change in environment
  • Medication/Drugs
  • Alcohol withdrawal
  • Surgery
  • Pain
  • Liver/renal impairment
  • Hypoxia
  • Hyponatraemia
  • Stroke
  • Encephalitis
  • Constipation
  • Urine retention
  • Dehydration
156
Q

How would a delirium diagnosis be made using the Confusion Assessment Method (CAM)?

A
  • Delirium requires1, 2 and 3 or 4
  • Always use CAM to evaluate delirium
157
Q

What is the management of delirium?

A
  • Exclusion of alternative diagnoses
  • Modify risk factors if possible
  • Treat the causes
  • Single, well lit room with visible clock
  • Familiar staff/family
  • Medication:
    • PO antipsychotics (short-term in dementia with infection)
    • Alpha-agonists (not a lot of evidence but growing)
      • Avoid anticholinergics
158
Q

What is the prognosis of delirium?

A
  • 37% die within 6 months
  • 43% have reversible cognitive impairment
  • 25% had clinically recovery in important ADLs
159
Q

What medications are used for rapid tranquilisation?

A

Use lorazepam if unsure or known cardiac disease

160
Q

How long should be left after initial administration of rapid tranquilisation? If the first dose is ineffective what should be done?

A
161
Q

Describe the grid framework of the bio-psycho-social model.

A
162
Q

What are the predisposing factor for an elderly widow who suffered from a fall according to the bio-psycho-social model?

A
  • Bio = anaemia, renal, etc
  • Psycho = lonely, depressed etc
  • Social = on here own, cant maintain house etc
163
Q

How intensively should a person under 30 presenting with psychosis be treated?

A

Very intensive iput/treatment

  • evidence suggest that this provides better short and long term outcomes
164
Q

How does an illusion differ from hallucinations?

A 
Illusion = external stimulus + distorted perception
Hallucination = NO external stimulus + perception
165
Q

What is the Rule of 1/3 in schizophrenia?

A
  • 1/3 will never have another episode/respond well to treatment
  • 1/3 will have chronic relapsing and remitting illness
  • 1/3 will be chronically unwell and suffer badly
166
Q

What is the peak incidence of depression in men and women? Why are these ages?

A
  • Men = 60-70s
  • Female = 40-50s
    • Empty nest syndrome - traditionally men may not have released this until retiring before releasing empty nest
167
Q

What is the suicide rates of men and women and why is the difference present?

A

7% in men and 1% in females

  • Women more likely to take pills (harder to do/more time to think) than men who use more violence
    • Only makes up part of the reason but is important
168
Q

How common is postnatal depression?

A

10%

169
Q

How common is postpartum psychosis?

A

1 in 500

170
Q

What time in the day is delirium worst?

A
  • Evening
    • Sundowning delirium = ward structure disappears as well as sun drive for circadian rhythm
171
Q

What are the key features of psychodynamic therapy?

A
  • The unconcious
  • Transference countertransference
  • Free association within reliable setting
172
Q

What is the unconcious in terms of psychodynamic therapy?

A
  • Parts of the brain that you have NO direct access to
    • Dreams, mistakes, slips of the tongue, repetitive patterns
173
Q

What is transference in terms of psychodynamic therapy?

A
  • New edition of earlier relationship
    • Suggests that early interactions with care givers (often parents) will be replicated to care givers late on in life
  • Usually infantile
174
Q

What is countertransference in terms of psychodynamic therapy?

A
  • Response a doctor transfers on to the patient]
    • Nervous energy of a doctor transferring on to a patient
175
Q

What is free association within reliable setting in terms of psychodynamic therapy?

A
  • Patient can say anything and can begin where they wish
  • Only structure is time, place and duration
    • Setting is very well planned/organised/rationale
176
Q

What is formulation in terms of psychodynamic therapy?

A
  • Hypothesis to test with patient
    • Core internal scenes - give meaning to patients issue
    • Use symptoms as solution to current life situation
    • Accounts of early life - relationships with key figures; core scenes
      • Does anything in earlier life account for current situation
    • Relationship with doctor
      • Does anything overlap with the past - anything influencing current situation
177
Q

How should a doctor act in a consultation to gain trust and the best outcome for patients?

A
  • Doctor should use analytic ‘neutrality’
    • Blank canvas allows patient to project their true feelings with being influenced by doctor relationship
  • Does anything overlap with the past - anything influencing current situation
178
Q

What sorts of negative automatic thoughts are there?

A
  • Mental filters – only noticing stuff you filter to notice – i.e. filter out positive
  • Judgements – making judgements about events
  • Prediction – believing you know what will happen in the future
  • Emotional reasoning – “I feel anxious – so, I must be in danger”
  • Mind-reading – believe you know what people are thinking
  • Mountains and molehills – exaggerating the risks/negatives of danger
  • Compare & despair – comparing to the ‘image’ others portray on social media
  • Catastrophising – imaging only the worst will happen
  • Black and white thinking – i.e. things can only be good OR bad
  • “Should” and “must” – thinking ‘I must’ puts undue pressure on oneself
  • Memories – events trigger bad memories making us think that ‘bad’ thing is here right now
179
Q

What work-up must be done before ECT?

A
  • Full physical examination
  • Investigations – Bloods, ECG if over 50 (looking for arrythmia), CXR if over 55
  • Medication review
    • Increase seizure threshold = benzodiazepines, mood stabilisers
    • Reduce seizure threshold = anti-psychotics, TCAs, lithium
180
Q

Which anti-psychotic is licensed as a mood stabiliser/for BPAD?

A

Olanzapine

  • For both acute mania and prophylaxis
181
Q

What are the 4 types of EPSE?

A
  • Parkinsonism
  • Dystonia
  • Dyskinesia
  • Akathisia
182
Q

What are the features of Parkinsonism?

A
  • Tremor
  • Rigidity
  • Bradykinesia
183
Q

How is Parkinsonism treated if a consequence of anti-psychotic medication?

A
  • Anti-cholinergic (procyclidine)
  • Reduce antipsychotic dose or change antipsychotic (especially typical to atypical)
184
Q

Define Dystonia.

A

Sustained or repetitive muscle contractions resulting in twisting and repetitive movements and posture

185
Q

What are the features of Dystonia?

A
  • Often shortly after administration
  • Happens in young/antipsychotic naive
  • Can be life threatening if the right muscle (laryngeal)
186
Q

How is Dystonia treated if a consequence of anti-psychotic medication?

A
  • Anti-cholinergic (procyclidine)
  • Reduce antipsychotic dose or change antipsychotic (especially typical to atypical)
187
Q

Define Dyskinesia.

A

Repetitive and stereotypical jerking movements of the face

188
Q

What are the features of Dyskinesia?

A
  • Idiosyncratic reaction
  • Choreo-athetoid movements
  • Can be irreversible
  • Made worse by anticholinergics
189
Q

How is Dyskinesia treated if a consequence of anti-psychotic medication?

A
  • Careful reduction in the dose of antipsychotic
190
Q

Define Akathisia.

A

Subjective feeling of restlessness, it can be mental and/or physical

191
Q

How is Akathisia treated if a consequence of anti-psychotic medication?

A
  • Reduce antipsychotic dose or change antipsychotic (especially typical to atypical)
  • Short-term benzodiazepine or beta-blockers (both of these are rarely used),
192
Q

Define QTc prolongation in men and women.

A
  • Men = >440ms
  • Women = >470ms
193
Q

What is the risk of a prolonged QTc?

A
  • Torsades de Pointes
  • Other arrhythmias
194
Q

What are the risk factors for Neuroleptic malignant syndrome?

A
  • High dose
  • Rapid increase in dose
  • Withdrawing anticholinergics
  • Depot
  • Male (2:1)
  • Past Hx of NMS
  • Dehydrated
195
Q

What is the starting dose for SSRI’s for Depression, Anxiety, OCD and Bulimia Nervosa?

A
  • Depression = 20mg
  • Anxiety = 40mg
  • OCD, Bulimia Nervosa = 60mg or 80mg

Y5 Psychiatry (11 decks)

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