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MRCPsych Part B > General Adult Psychiatry > Flashcards

General Adult Psychiatry Flashcards

1
Q

Prognostic factors in schizophrenia

Poor

A

Early age onset
Negative symptoms
Insidious onset
No precipitating factors
Single, divorced, widowed
Family history (weak)
Poor social network, family highly expressed emotion
Poor compliance
Neurological signs and symptoms
Hx of perinatal trauma; anoxia, low birth weight, pregnancy induced hypertension, premature rupture of membrane
Many relapses
History of violence
No remission in 3 years

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2
Q

Prognostic factors in schizophrenia

Good

A

Late onset
Obvious precipitating factors
Acute onset
Good premorbid adjustment
Affective symptoms (esp depression)
Married
Good social support
FH of affective disorders
Positive symptoms only
Good initial response to treatment

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3
Q

Median episode of treated depression

A

3 months

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4
Q

Median episode of untreated depression

A

6-13 months

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5
Q

Types of Bilpoar Affective Disorder

A

1 - Mania (+-/ depression)
2 - Hypomania and depression
3 - recurrent depression plus hypomania occurring solely in association with AD or other somatotherapy
4. Depression superimposed on a hyperthymic tempermant

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6
Q

Acute manic episode treatment - new

A
  1. Antipsychotics - olanazapine, quetiapine, haloperidol, risperidone
    - rapid anti-manic effect.
  2. If on anti-depressant therapy, consider
    stopping.
  3. Adjunctive benzodiazepine e.g. clonazpeam
    Not advised as monotherapy
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7
Q

Acute manic relapse in known BPAD

A
  1. Increase the dose of mood stabiliser
  2. Check the serum lithium levels
    • optimised Li levels
    • consider adding in an antipsychotic
  3. Antipsychotic medication for those on
    valproate
  4. ECT - treatment resistant, severely manic, in
    pregnancy
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8
Q

Bipolar depression - no medication

A

1st line - high intensity psychological therapy for
all

Moderate/severe
1st line - can consider olanzapine and
fluoxetine; quetiapine as monotherapy
(300-600 mg)
2nd line - lamotrigine

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9
Q

Long term lithium indications

A
  1. Manic episode involved significant risk or
    adverse consequences
  2. Bipolar 1 with 2 or more acute episodes
  3. Biploar 2 with significant functional
    impairment or risk of adversities

1st line Lithium (anti- manic and depressive effect, probably more anti-manic)

2nd line: olanzapine, valproate, carbamazapine, lamotrigine

Those who respond well to lithium

  • euphoric mania
  • no rapid cycling
  • full remission between episodes
  • no co-morbidity
  • no psychosis
  • fewer lifetime episodes
  • mania-depression-euthymia course
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10
Q

Median time to recover from a manic episode

A

4-5 weeks

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11
Q

Antidepressant most likely to precipitate mood switch from depression to mania

A

Tricyclics

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12
Q

1st line primary care antidepressants

A

Mirtazpine and paroxetine

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13
Q

Acute stress reaction

A

Follows a sudden severe stressor and symptoms resolve in 2-3 days. Rapid onset.

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14
Q

Dyssomnia

A

Primary sleep disorder affecting getting off to sleep, remaining asleep of excessive sleepiness during the day.

Primary insomnia
Primary hypersonic
Circadian sleep disorder
Narcolepsy
Breathing related sleep disorder
Sleep state misinterpretation

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15
Q

Parasomnia

A

A disorder which intrudes the sleep process

Arousal disorder - confusion arousal, sleep walking, sleep terrors

Sleep wake transition (sleep starts, sleep talking)

Rem sleep - REM behavioural disorder, nightmare, sleep paralysis

Non-REM - sleep terror, sleep walking

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16
Q

Schizotypal PS

A

Cold affect
Eccentric behaviour
Social withdrawal
Odd beliefs, magical thinking
Paranoid ideas
Obsessive ruminations without inner resistance
Illusions, dépersonnalisation, derealisation
Vague and circumstantial speech
Transient quasi-psychotic episodes

3/4 typical features in 2 years; never met criteria for schizophrenia

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17
Q

DIGFAST - bipolar criteria

A

D - distractibility
I - impulsivity
G - grandiose
F - Flight of ideas
A - goal-directed activity increased, psychomotor
agitation
S - sleep - decreased need for sleep
T - talkative

18
Q

First episode psychosis

A
  • 4/5 people show some response to treatment
    in the first year
  • 1/5 have no further psychotic episodes in next
    5 years
  • 15% symptoms which are unresponsive 2 years
    after the acute episode
19
Q

Schizophrenia prognosis explained

A

In 5 people with schizophrenia:

1/5 will get better within 5 years

3/5 relapse and remitting

1/5 difficult symptoms for a long period of time

20
Q

Acute and transient psychotic disorders

A

Onset 2 weeks = acute
Onset 48 hours = abrupt

Complete recovery in 2-3 months

Acute polymorphic form = hallucinations and delusions changing in type and intensity from day to day, or same day

21
Q

Schizoaffective

A

DSM V-

distinct period of just psychotic symptoms > 2 weeks
Features of schizophrenia and mood disorder in equal intensity
Meets criteria of moderate-severe mood disorder

Depressive, bipolar

ICD 10:
Definife schizophrenic and mood symptoms, equally prominent and simultaneously, or within a few days of each other

-depressive, manic, mixed

Mood-incongruent delusions are suggestive

22
Q

Depression episode length

A

Most short, minority chronic (>2 years)
-10-20% chronic course, without remission

Untreated depression: 6-13 months
Treated depression: 3 months

23
Q

Depression recurrence

A

Recurrence typical of mood disorders
20 episodes over 5-6 years

50% of people who have an episode of depression will then have a recurrence within 5 years.

75% probability of recurrence after 2 years

Risk of relapse or recurrence is higher in people with residual symptoms

24
Q

Treatment length of depression first episode

A

6-9 months after resolution of symptoms

25
Q

Treatment length for patients >2 episodes in recent past, or residual impairment

A

Continue for 2 years

26
Q

Medication discontinuation FEP

A

74% of patients discontinued antipsychotic medication before 18 months in CATIE

82% Quetiapine
79% ziprasidone
75% perphenazine
74% risperidone
64% olanzapine

27
Q

Late-onset schizophrenia

A

Develops over 40 yo
Insidious in presentation
Auditory hallucinations most common
In 20% only delusions are seen

28
Q

BPAD and breast feeding

A

Should avoid carbamazepine, clozapine and lithium
Antipsychotics, avoid depot preparations, except when hx of non-compliance or responded well in past
Does not advise against lamotrigine, advises frequent levels

29
Q

Treatment acute mania with antipsychotic

A

6 months

30
Q

Treatment acute mania with antipsychotic

A

6 months

31
Q

Schneider’s first rank symptoms

A

Delusional perception
3rd person, running commentary
Thought insertion, withdrawal, broadcast
Somatic hallucinations
Made affect, impulse or volition

32
Q

Cognitive aspects of schizophrenia

A

All domains, disproportionate involvement of semantic memory, working memory and attention.

Executive function and attention appear to be core deficits.

Marked impairment in theory of mind.

33
Q

Environmental risk factors and relative risk

A

Life events 3.2
Immigrant 2.9
Childhood trauma/adversity 2.8
Tobacco 2.2
Cannabis 2
Maternal/birth complications 2
Urban birth 1.9
Winter birth 1.1

34
Q

Brain changes and imaging in schizophrenia

A

Decreased brain and intracranial volume
Enlarged lateral and third ventricles
Reduced hippocampus and thalamus
Thinner cortical grey matter
Altered white matter pathway (temporal and frontal lobe)

Decreased perfusion in frontal cortex vs posterior
Bold signal on fMRI - decreased frontal cortex activity

35
Q

Antipsychotics best to use in hepatic impairment

A

Haloperidol
Amisulpride/sulpride (avoid in renal impairment)

36
Q

Antidepressant in hepatic impairment

A

Imipramine; 25 mg & slow titrate
Paroxetine, citalopram. (Avoid sertraline)

37
Q

Antipsychotics safest in renal impairment

A

Haloperidol 2-6 mg OD
Olanzapine 5 mg OD

Contraindicated; clozapine, amisulpride, sulpride

38
Q

Stopping antidepressants

A

Mean time to onset; 2 days and normal resolution 5-8 days.
Most short and self-limiting, however for some they can last longer.

Serotonergic symptoms; flu-like, pins and needles, electric shock, dizzy, GI, lethargy, headache, sleep disturbance, mood change

MAOI; worsening anxiety/depression, confusion, psychosis

39
Q

Highest risk of relapse after stopping antidepressants

A

1st 6 months
Consider life events

40
Q

Tapering antidepressant

A

Minimum over 4 weeks
Can be several months if longer term prophylaxis

41
Q

Psychotic depression

A

No known optimum duration of treatment with combination of AD and AP. Some evidence suggests continue both, no consensus.

Some evidence stopping antipsychotic can worsen the outcome.

MRCPsych Part B (13 decks)

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