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CASC > General Adult Psychiatry > Flashcards

General Adult Psychiatry Flashcards

1
Q

Neuroleptic Malignant Syndrome - Explanation and Incidence

A
  • Suffering from Neuroleptic Malignant Syndrome - a rare but serious reaction usually in response to antipsychotic medication, sometimes others.
  • Affects around 1/500 patients. Medical emergency - mortality 5-10%.
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2
Q

Hyperprolactinaemia - Cause

A
  • Due to bloackaed of D2 receptors on pituitary
  • Common to FGAs and risperidone/amisulpride in SGAs, less common with others
  • Check no headache/visual changes, weakness numbness of limbs.
  • Check TFTs (rule out hypothyroid), IGF-1 (rule out acromegaly) and U+Es (exlude renal gailure), also rule out history of chronic alcohol misuse –> hepatic cirrhosis.
  • Consider CT/MRI and endocrinology referral (can consider OCP or DA agonists - amantadine, cabergoline, bromocriptine)
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3
Q

Explain Schizophrenia Diagnosis

A
  • A common mental health condition that affects how people think, feel and behave and causes them to have unusual experiences.
  • Affects around 1:100 at some point in their life, onset between 15-45, equally common in women and men but men’s onset tends to be earlier.
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4
Q

Bipolar Affective Disorder - Explanation

A
  • Bipolar is a common mental health disorder than affects, on average, 1/100 people.
  • It is called bipolar as there are two ‘poles’ of mood that people swing between: high mood = ‘mania’ and low mood = ‘depression’. These can last for weeks to months.
    • When a person is in a manic phase they often feel very good in mood, full of energy. This my be expressed by lots of activities and plans, reduced sleep and sometimes doing reckless things they might not usually. They may also find their thoughts coming very quickly and speak very quickly as a result.
    • When someone is in a depressive phase by contrast they will be persistently low in mood with decreased energy and interest in doing things. They may feel less confident and hopeless. There may also be difficulties with sleep and appetite. In extreme cases they may contemplate hurting themselves.
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5
Q

Treatment Resistant Depression - Definition

A
  • Defined as resistant to at least 2 antidepressants each for 6 weeks at BNF max or 1 antidepressant plus ECT
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6
Q

Depression After MI - Management

A
  • Best antidepressant choice is Sertraline (SADHEART study)
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7
Q

Depression After MI - Assessment

A
  • Core depression history + substances + DSH risk
  • Preceeding M.I. or developed after?
  • Affecting rehab/engagement with treatment?
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8
Q

Depression After MI - Risk

A
  • Chronic mental stress associated with ordinary life events most common precipitant of M.I. in patients with CAD
  • Type A behaviour - agression, impatience, hostility - associated with increased incidence of MI and death
  • 20% of people with an acute M.I. have a depressive disorder
  • Depression an independent risk factor - predicts mortality
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9
Q

Treatment Resistant Depression - Assessment

A
  • 4 As of treatment resistance - adequate dose, adherence, alcohol/drugs, Axis II/III disorders
  • Review diagnosis and MSE
  • Compliance
  • Comorbidity physical - do investigations to rule out physical issues - thyroid!
  • Comorbidity mental health - anxiety, PTSD, psychosis, drug and ETOH abuse
  • Optimise psychology and social interventions
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10
Q

Treatment Resistant Depression - Augmentation Options

A
  • Lithium
  • T3
  • Mirtazapine + SSRI/Venlfaxine
  • ECT
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11
Q

Neuroleptic Malignant Syndrome - Risk Factors

A
  • Rapid dose increases
  • High potency antipsychotics
  • Histor of NMS
  • Parkinsons
  • Lewy body
  • Dehydreation
  • Agitation and catatonia.
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12
Q

Neuroleptic Malignant Syndrome - Clinical Features

A
  • Main features are: raised temperature, muscle rigidity, confusion and changes in BP/HR (autonomic instability)
    *
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13
Q

Neuroleptic Malignant Syndrome - Biochemical Findings

A
  • Increased CK
  • Increased WCC
  • Deranged LFTs
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14
Q

Neuroleptic Malignant Syndrome - Immediate Management

A
  • Management is with: stopping offending drugs, ABC, transfer to medics (ICU) for O2, fluids, cooling (ice packs, blankets, antipyretics).
  • Medications - dantrolene and bromocriptine (limited evidence base)
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15
Q

Neuroleptic Malignant Syndrome - Prognosis and Restarting Antipsychotics

A
  • Course - 5-7 days after oral antipsychotics, up to 21 if depot.
  • May consider cautiously restarting antipsychotic 1-2 weeks after symptoms fully resolved.
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16
Q

Hyperprolactinaemia - Management

A
  • Management - chenge to prolactin sparing antipsychotic (quetiapine, olanzapine or aripiprazole)
  • Augment with low dose aripiprazole
17
Q

Hyperprolactinaemia - Clinical Features

A
  • Clinical features: gynaecomastia, galactorrhea
  • Erectile dysfunction, loss of libido, hypogonadism in men
  • Oligo/amennhorea, infertility, loss of libido, acne, hirsutism, increased risk of osteoporosis in women (also increased risk of breask cancer)
18
Q

Hyperprolactinaemia - Assessment

A
  • Check no headache/visual changes, weakness numbness of limbs.
  • Check TFTs (rule out hypothyroid), IGF-1 (rule out acromegaly) and U+Es (exlude renal gailure), also rule out history of chronic alcohol misuse –> hepatic cirrhosis.
  • Consider CT/MRI and endocrinology referral (can consider OCP or DA agonists - amantadine, cabergoline, bromocriptine)
19
Q

BPAD - Psychological Treatment

A
  • CBT treatment valuable - education about illness and regarding early warning signs, monitoring mood, coping strategies. 16 x 1 hour sessions over 6-9 months.
20
Q

BPAD - Medication Mania/Depression

A
  • Mania - treated with Lithium, Sodium Valproate or antipsychotics acutely
  • Depression - can consider antidepressant with a mood stabiliser, alternatively quetiapine also an option. Also Lamotrigine in BPAD 2. CBT.
21
Q

BPAD - Medication Prophylaxis

A
  • Prophylaxis - considered when people have two or more episodes or a single severe manic episode.
  • Best evidence is for Lithium (30-40% overall reduction in relapses), also consider Sodium Valproate or Olanzapine.
  • Second line combination of Li and Valproate.
  • Third line Carbamazepine.
22
Q

BPAD - Cause

A
  • We are not sure what causes it - seems to run in families 10-15% of people will have a close relative with the condition. Stressful life circumstances and drugs may provoke an episode in someone predisposed.
23
Q

BPAD - Definition and Incidence

A
  • The incidence of BPAD is similar between men and women. Its onset is usually before the age of 30.
  • BPAD 1 = at least 1 full manic episode >1 week, BPAD 2 - hypomania and depression. Rapid cycling = 4 or more highs or lows a year (risk factors = female, thyroid problems, LD, MS).
24
Q

Schizophrenia - Prognosis

A
  • About 2/10 will not have another episode, of the remainder about 50% will relapse within 2 years - some have waxing and waning symptoms, some chronic severe symptoms.
25
Q

Schizophrenia Explanation - Symptoms

A

Three main groups of symptoms:

  • Positive symptoms - where people have sensory experiences of things that aren’t there (hallucinations) and believe things that aren’t true (delusions)
  • Negative symptoms - where people lose normal functions such as decreased motivation, less emotional expression, less speech
  • Disorganised thinking and behaviour
26
Q

Schizophrenia - Aetiology/Causes

A
  • ​Causes - usually due to a combination of factors in the environment and genes:
    • We know that it runs in families
    • Some times adverse things that happen around pregnancy (e.g. infection, birth problems)
    • Also aspects of the environments including living in the city, stress, drugs can cause
  • Our main hypothesis is that it is often driven by imbalances in dopamine within the brain - too much causes positive symptoms, too little causes negative
27
Q

Schizophrenia - Common Questions - Will he be violent? Is it my fault? How long do they need treatment for?

A
  • Will he be violent? No most patients with SZ are not violent, slightly higher risk but this is greatly exaggerated, more likely to be a victim of violents.
  • Is it my fault? No multifactoral, even with a genetic element many genes responsible
  • How long does he need to be on medication? Usually we recommend continuing 1-2 years after FEP, if multiple episodes then continued indefinitely. Stoppeing to soon increases risk and severity of relapse. Will evaluate the risks/benefits of stopping.
28
Q

Schizophrenia - Psychosocial Treatment

A
  • Psychological treatments are also important - CBT can help people come with their experiences, family therapy can help the family deal with the impact of the illness
  • Social support important - we’ll look at accomodation, finances, support with education/employment, day centres and voluntary support groups.
  • You’ll have a care coordinator who will get to know you and see you frequently, and have regular MDT reviews.
29
Q

Schizophrenia Explanation - Medication

A
  • Biologically we know that antipsychotics are often very effective in controlling positive symptoms - help around 80% of patients. Work by blocking excess dopamine in the brain. They do have side effects however.
  • Muscular - pain, stiffness, tremor, restlessness, involunatry movements
  • Sleepiness and weight gain - long term can cause obesity, diabetes
  • Sexual function, dizziness - adrenergic
  • Dry mouth, blurry vision, urinary retention, constipation - anticholinergic
30
Q

Antidepressant Induced Sexual Dysfunction - Assessment

A
  • Assess current state of depression/mood
  • Problems with:
    • Interest in sex?
    • Arousal or erection?
    • Ejaculation?
  • How were things before you commenced on the antidepressant?
  • Do you have any physical health problems? Do you take any other medications?
  • How are things otherwise in your relationship?
  • How is the problem impacting you’re sexual relationship?
31
Q

Antidepressant Induced Sexual Dysfunction - Management

A
  • If responding in terms of depressive symptoms should continue - could try drug holidays over the weekend to see if symptoms improve
  • Could consider switch to antidepressant with less sexual SEs - Duloxetine, Mirtazapine, Reboxetine
  • Could consider Viagra if cardiovascular system fine
  • Psychological therapies such as couples-based counselling
32
Q

QTC Prolongation - Management

A

Mild (440-500ms men, 470-500ms women)

  • Repeat ECG
  • Review current medications and potentially offending agents - consider dose reductions

Significant (>500ms)

  • Stop offending drugs
  • Switch to an alternative non-QTC affecting drug
    • SSRIs - Sertraline (basically just not Citalopram)
    • Antipsychotics - Aripiprazole, Olanzapine, Sulpride, Risperidone
  • Refer to cardiologist
33
Q

Sertotonin Syndrome - Explanation

A
34
Q

Serotonin Syndrome - Management

A
  • Clinical assessment
  • Stop serotoninergic medication
  • Liase with medics and consider transfer to hospital
  • Medical interventions:
    • Hydration
    • Cooling blankets
    • Vital signs monitoring
    • Anticonvulsants
    • Clonzepam for myoclonus
    • Nifedipine for increased BP
    • May need ventilation in extreme cases
35
Q

Delerium Tremens - Definition and Course

A
  • Delirium tremens is a toxic confusional state that occurs when alcohol withdrawal symptoms are severe.
  • Onset is usually within 2 days of the last drink and it usually lasts about 5 days.
36
Q

Delerium Tremens - Symptoms (Core)

A
  • Clouding of consciousness
  • Disorientation
  • Amnesia for recent events
  • Marked psychomotor agitation
  • Visual, auditory and tactile hallucinations
    • Classically Lilliputian - small people/animals
  • Fluctuations hour by hour, worse at night
37
Q

Delerium Tremens - Severe Symptoms

A
  • Heavy sweating
  • Fear, agitation
  • Paranoid delusions
  • Suggestibility
  • Raised temperature
  • Sudden cardiovascular collapse
    • Mortality 5-10%
38
Q

Delerium Tremens - Management

A
  • Medical emergency - needs medical admission
  • Regular monitoring
  • Nursed in a quiet room, regular reorientation, familiar nursing staff
  • Sedation
  • Fluid and electrolyte replacement
  • IV thiamine
  • Oral Lorazepam first line treatment according to NICE
    • IV if unable to take orally
  • Haloperidol can be considered as an adjunct if agitated and aggressive
  • Monitor for withdrawal seizures or Wernicke’s encephalopathy
39
Q

Temporal Lobe Epilepsy - Assessment

A
  • Onset, link with anything? Sleep deprivation, stress, strobe lighting
  • -Aura – GI? Smell?
  • Decreased responsiveness to environment
  • Panoramic, dream-like, déjà vu, emotional change – fear/anxiety, automatic movements e.g. lips, hand rubbing.
  • Violence?
  • Generalisation to full seizure? Biting tongue, loss of continence, physical injury. Limb movements.

CASC (9 decks)

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