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MRCPsych Paper B > General Adult Psychiatry > Flashcards

General Adult Psychiatry Flashcards

1
Q

DIS

A

Diagnostic Interview Schedule
1981 Robins
Structured diagnostic interview designed for use by lay interviewers

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2
Q

ECA programme

A

NIMH

Epidemiological Catchment Area Programme

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3
Q

CIDI

A

WHO Composite International Diagnostic Interview

Version of DIS that used ICD criteria

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4
Q

NCS

A

National Comorbidity Survey
First to use the CIDI. 1990-2.
8000 respondents
Reinterviewed between 2000-1 - called NCS-R
Found substantially higher prevalence results than the ECA
Most prevalent anxiety disorder was specific phobia.

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5
Q

Findings of ECA and NCS

A

Number of people with MH problems far outweighed resources available
Did not comment on severity therefore likely overstated demand

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6
Q

WMH-CIDI

A

Revised version of CIDI

Assesses severity and other aspects such as risk factors, socio-demographics and treatments

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7
Q

ECA study

A

Selected neighbourhoods in 5 US communities
1980-5
Each site - 3000 community residents and 500 residents in institutions were sampled (20,000 total)
2 interviews over a year using the DIS
DIS diagnosis of schizophrenia not congruent with psych classifications

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8
Q

ECA study - lifetime prevalences

A 
Any disorder 32.3%
Substance misuse disorder 16.4
Anxiety disorder 14.6
Affective disorder 8.3
Schizophrenia and schizophreniform 1.5
Somatization disorder 0.1
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9
Q

ECA study - anxiety disorder prevalence (1 month)

A 
Phobia 12.5%
Generalised anxiety and depression 8.5
OCD 2.5
Panic 1.6
Anxiety disorder were twice as common in women as they were in men
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10
Q

National Psychiatric morbidity survey 2000

A

1993-4
Conducted by OPCS (Office for Population Census and Surveys) using CIS (clinical Interview Schedule)
16-64 living in UK
10,000 interviews
Repeated in 2000 and upper age limit increased to 74

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11
Q

National Psychiatric Morbidity Survey - Findings

A

1 in 6 people in Britain have a neurotic disorder
• The most common neurotic/anxiety disorder was mixed anxiety and depression (88 cases per 1000), generalised anxiety was the next most common (44 cases per 1000)
• 5 per 1000 have a psychotic disorder
• Older people report less neurotic symptoms
• Prevalence rates were higher in women than men for all neurotics disorders except
panic (equal)

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12
Q

National Psychiatric Morbidity Survey - Findings (2)

A

44 per 1000 were classed as having a personality disorder, the prevalence being
slightly higher in men
• The most common personality disorder was anankastic (obsessive compulsive
personality disorder) (twice as common as all the others)
• The prevalence of alcohol dependence in the overall population was 74 per 1000
• 10% of people reported using illicit drugs in the year prior to interview, cannabis was
the most commonly used

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13
Q

World Mental Health Survey Initiative

A

Surveys in 28 countries
5000 interviews per country
Sample size >154,000
Interviews face to face by lay interviewers (trained)

Use the WMH-CIDI
The US has the highest prevalence of any disorder
Anxiety d most common followed by mood disorder

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14
Q

Male:Female ratios

A 
Reading disorder 3-4:1
ASD 4-5:1
Asperger's 5:1
Tourette's 2-5:1
ADHD children 2:1
ADHD adults 1.6:1
Major depression 1:2
BPAD1 1:1
Panic with agoraphobia 1:3
Panic without agoraphobia 1:2
GAD 1:2
OCS 1:1
Specific phobia 1:2
Conversion disorder 1:2-10
Anorexia 1:9
Bulimia 1:9
BOD 1:3
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15
Q

Bipolar disorder - epidemiology

A

lifetime prevalence 0.3-1.5%
6/12 month prevalence - same
mean age of onset - 17 (community), 21 (hospital studies)
Gender M=F
Comorbidity - substance misuse and anxiety disorder

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16
Q

Major depression - epidemiology

A

lifetime prevalence 4-30%
6/12 month prevalence - same
mean age of onset - 27
Gender M:F 1:2
Comorbidity - substance misuse and anxiety disorder
Most prevalent in 18-44 group
People born since 1945 in industrialised countries have higher lifetime risk and earlier age of onset
Higher rates in women become apparent at puberty
Higher rates in unemployed, divorced, lower socio-economic class, urban areas

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17
Q

Major Depression - genetics

A

Twin studies - risk in 1st degree relatives is about 3 fold
MZ concordance rate = 45%
DZ concordance rate = 20% Heritability = 37%
Polygenic inheritance
GWAS have yet to report any convincingly replicated loci in depression

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18
Q

Monamine theory of depression

A

suggests that allelic variation in genes coding for monoamine synthesis or metabolism or specific receptors may contribute to the risk of mood disorders

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19
Q

Serotonin transporter gene

A

a particular allele has been shown to increase the risk of a subsequent episode of major depression when exposed to childhood adversity (Caspi et al, 2003)

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20
Q

Sociotropy

A

A strong need for approval

a/w increased risk of depression after adverse life events

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21
Q

Neuroticism

A

Measured by EPQ

Predisposes to major depression

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22
Q

Parental deprivation and depression

A

Death of parent in childhood - does not increase risk

Parental separation - increases risk, particularly divorce - due to discord and diminished care

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23
Q

Relationship with parents and depression

A

Physical and seual abuse clear risk factors

Non-caring and overprotective parenting styles are a risk (non-melancholic depression)

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24
Q

Depression - precipitating factors

A

Recent life events - 6 fold excess of adverse life events in months before onset
Poor social support
Physical illness - source of stress but can also have organic mood disorder e.g. HIV, endocrine, brain disease

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25
Q

Psychoanalytic theories - Freud

A

Mourning and melancholia

Loss of an ‘object’

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26
Q

Psychoanalytic theories - Melanie Klein

A

Weaning represents a major symbolic loss for the infant
Leads to attempt at reparation and concern for others
Failure in this can result in depressive reactions in the face of future losses

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27
Q

Psychoanalytic theories - John Bowlby

A

Insecure attachment can increase the risk of depression

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28
Q

Cognitive theories - Beck

A

Cognitive distortions such as arbitrary inference, selective abstraction, overgeneralization and personalisation lead to persistence of negative automatic thoughts.
Believes that dysfunctional beliefs (schemas) precede and predispose to depression.

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29
Q

The monoamine hypothesis

A

depressive disorder is due to abnormality in a monoamine neurotransmitter at one or more brain sites
noradrenaline and dopamine are catecholamines

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30
Q

5-HT function

A

Plasma tryptophan levels are decreased in untreated depressed patients
Shown in CSF studies (impulsive suicide attempts), neuroendocrine tests (blunted 5-HT neuroendocrine responses), imaging studies (decreased brain 5-HT1a receptor binding (PET) and decreased brain 5-HT re-uptake sites (SPECT and PET))

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31
Q

Noradrenaline function

A

Increased brain noradrenaline elevates growth hormone. GH response is blunted in depressed patients
Catecholamine synthesis can be reduced with AMPT. AMPT leads to depressive relapse in those with a personal h/o depression

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32
Q

Dopamine function

A

CSF levels of HVA are consistently low in depressed patients

AMPT leads to clinical relapse

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33
Q

Amino acid neurotransmitters

A

Decreased levels of glutamate in the anterior brain regions in depressed patients

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34
Q

Endocrine abnormalities

A

50% of patients with Cushing’s syndrome suffer from major depression
Addison’s disease, hypothyroidism and hyperparathyroidism also associated

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35
Q

HPA axis

A

Plasma cortisol secretion is increased throughout the 24h cycle in 50% of those with mod-sev depression
A/w enlargement of the adrenal gland
Increased cortisol response to ACTH challenge

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36
Q

Thyroid function

A

levels of free T3 may be decreased

1/4 of depressed patients have a blunted TSH response to TRH (also in alcoholism and panic disorder)

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37
Q

Organic causes of depression

Medications

A 
Riserpine
Interferon alpha
Beta blockers
Levodopa
Digoxin
Anabolic steroids
H2 blockers
Oral Contraceptives
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38
Q

Organic causes of depression

Drug abuse

A

Alcohol
Amphetamine
Cocaine
Hypnotics

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39
Q

Organic causes of depression

Metabolic

A 
Hyperthyroidism
Hypothyroidism
Cushings
Addisons
Hypercalaemia (can be caused by Li or thiazide diuretics)
Hyponatraemia
DM
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40
Q

Organic causes of depression

Nutritional

A

Pellagra

Vit B12 def

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41
Q

Organic causes of depression

Neurological

A 
Stroke
MS
Brain tumour
PD
Huntington's
Epilepsy
Syphilis
Subdural haematoma
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42
Q

Organic causes of depression

Haematological

A

Anaemia

Leukaemia

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43
Q

Organic causes of depression

Other

A

Infection

Carcinoma

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44
Q

Revealed depression

A

Depressive symptoms present during acute psychotic episode but only become apparent as the positive symptoms resolve.

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45
Q

Post-schizophrenic depression

A

Has met criteria for schizophrenia in last 12m
Some schizophrenic sx still present but not dominating
Depressive sx fulfill the criteria for a depressive episode and present for at least 2 weeks

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46
Q

Depression - clinical features

Core features

A

Low mood
anhedonia
anergia
lack of interest

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47
Q

Depression - clinical features

Negative cognitions

A

Worthlessness
Hopelessness
Helplessness
Guilt

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48
Q

Depression - clinical features

Biological symptoms

A 
Diminished sleep/insomnia
Reduced appetite/weight loss
Diurnal mood variation
Psychomotor agitation/retardation
Fatigue
Reduced libido
Constipation
Anhedonia
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49
Q

Depression - clinical features

Other features

A 
Suicidal ideation
Poor concentration
Self-neglect
Isolative behaviour
Anxiety/obsessional sx
Somatic complaints
Irritability
Depressive stupor
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50
Q

Atypical depression

A

Klein and Davis’ description 1969
Low mood with mood reactivity and reversal of features normally seen in depression
Hypersomnia, hyperphagia, weight gain and libidinal increases
Tend to respond best to MAOIs
Response to TCAs is poor, SSRIs in the middle
Not in ICD-10

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51
Q

Psychotic depression

A

Psychotic symptoms indicate severe depression and usually mood congruent around themes of worthlessness, guilt
Persecutory delusions also seen

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52
Q

Cotard delusion

A

Delusional belief that they are already dead, do not exist, are putrefying or have lost their blood or internal organs

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53
Q

Dysthymia

A

Low-grade depressive symptoms for at least 2 years (1 year in adolescence)
Often early onset
Lifetime prevelance 3.6% (3-6%) (US)

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54
Q

Dysthymia (DSM criteria)

A 
depressed mood for most of the day, for more days than not, as well as at least two of the following diagnostic symptoms:
• poor appetite or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self esteem
• poor concentration or difficulty making decisions
- hopelessness
- normal mood for no more than 2 months
- no episodes of major depression
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55
Q

Postnatal depression

A

Risk is 10%
Increased to 25% if there is a hx of depression
Increased to 50% if there is a hx of postpartum depression
Mod-sev depression = 3-5%
Risk is not influenced by obstetric factors (e.g. length of labour) or social class

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56
Q

Depression - treatment

A

First line - SSRI
Antidepressants are not 1st line for mild depression
Continue for at least 6 months after remission
If antidepressants are stopped immediately then 50% of patients experience a relapse within 3-6 months.
Continue for at least 2 years in pts with 2 prior episodes of depression
4 step approach

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57
Q

Depression - antidepressants

A 
First SSRI
Then another SSRI or newer gen
hen venlafaxine, TCA or MAOI
Augment with:
Lithium, antipsychotics or another antidepressant (mirtazapine)
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58
Q

Refractory depression

Definition and treatment

A

2 successive failed attempts at treatment despite good compliance and adequate doses

Add lithium
ECT
Add T3
Combined fluoxetine and olanzapine
Add quetiapine to SSRI or SNRI
Add risperidone
Add aripiprazole
Bupropion and SSRI
SSRI and venlafaxine, mirtazapine, or mianserin
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59
Q

Combining antidepressants

A

Irreversible MAOIs such as phenelzine and tranylcypromine are dangerous in combination with SSRIs - risk of serotonin syndrome

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60
Q

St John’s Wort

A

Effective in mild-mod depression but not recommended due to uncertainty about appropriate doses, variation in nature of preparations and potential serious reactions with other drugs
Can cause serotonin syndrome
Inducer of P450 system - decreases warfarin and ciclosporin, may also effect OCP

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61
Q

STAR*D Study

A

4 levels of treatment
Level 1 - citalopram for 14 weeks
Level 2 - swap to sertraline, bupropion or venlafaxine or augment with bupropion or buspirone. +/- cognitive psychotherapy
Level 3 - swap to mirtazapine or nortriptyline or adding on lithium or T3
Level 4 - swap to MAOI or ven + mirt
Outcome = remission

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62
Q

STAR*D Study - outcomes

A

Level 1 - 1/3 achieved remission, +10-15% responded
If levels 1 fails - 1 in 4 responded to switch, 1 in 3 responded to combination
50-85% who have a single episode will go on to have a second and 80-90% will have a third

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63
Q

Factors known to increase the risk of recurrence of depression

A 
Family hx of depression
• Recurrent dysthymia
• Concurrent non-affective psychiatric illness
• Female gender
• Long episode duration
• Chronic medical illness
• Lack of a confiding relationship
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64
Q

Bipolar disorder - prevalence

A

Bipolar 1 - 1%
Bipolar 2 - 0.4%
Lifetime risk 0.3-1.5%
Peak age of onset 15-19 yrs
Usually begins as depression, 1st manic episode 5yr later
Average length of manic episode is 6 months

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65
Q

Drugs that precipitate mania

A

Levodopa
Corticosteroids
Anabolic-androgenic steroids
Antidepressants (TCA and MAOi)

Weaker evidence for: Dopaminergic anti-parkinsonian drugs, thyroxine, iproniazid and isoniazid, chloroquine

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66
Q

Gerald Klerman subtypes of bipolar disorder

A

1981
Bipolar III - cyclothymic disorder
Bipolar IV: Hypomania or mania precipitated by antidepressant drugs
Bipolar V: Depressed patient with a family history of bipolar illness
Bipolar VI: Mania without depression (unipolar mania)

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67
Q

Bipolar depression is different from unipolar…

A

Episodes are more rapid in onset
Episodes are more frequent
Episodes are shorter
Likely to involve reverse neurovegetative sx such as hyperphagia and hypersomnia

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68
Q

Features suggestive of mania rather than hypomania

A 
Duration
Flight of ideas
Psychotic sx
Loss of social inhibitions
DSM - hypomania occurs without any marked social or occupational interference
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69
Q

Rapid cycling BPAD

A

10-20% of all patients with bipolar disorder
Tends to develop late in the course of the disorder and lasts less than 2 years in 50% of pts
Increased suicide risk
More common in women, earlier age at onset, greater illness burden, higher treatment resistance
More related to external factors such as life events, alcohol abuse, antidepressants and medical disorders rather than genetics

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70
Q

Medical disorders associated with rapid cycling

A 
hypothyroidism
Grave's disease
SAH
Stroke
MS
Head injury
Drugs (propranolol, levodopa, cyproheptadine)
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71
Q

BPAD depression - treatment - NICE

A

No drug treatment - fluox + olanz or quet. If no response consider lamotrigine on own
On lithium - check level etc. Add fluoxetine with olanz or quet, or lamotrigine if no resp
On valproate: Increase dose to max then add fluox + olanz or quet. If no resp consider lamotrigine.

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72
Q

BPAD depression - treatment - Maudsley

A

1st choice - quetiapine
2nd choice - lithium or valproate
3rd choice - lamotrigine
3th choice - antidepressant plus mood stabiliser or antipsychotic

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73
Q

BPAD Mania/hypomania - treatment

A

Stop antidepressant
Antipsychotic - haloperidol, olanzapine, quetiapine or risperidone
Check Li levels if taking
If antipsychotic ineffective try another, if still ineffective add lithium, if this is ineffective or unsuitable consider valproate.
Do not offer lamotrigine
Children and young people 13+ - aripiprazole
Short term benzos

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74
Q

Acceptability of antimanic medication

Cipriani 2011

A

Best overall were olanzapine, risperidone, quetiapine and quetiapine

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75
Q

Rapid cycling - treatment

A

Combine lithium and valproate as first line
Second line: lithium monotherapy
Stop antidepressants
Evaluate precipitants
Consider combining mood stabilisers. Quetiapine best choice based on limited evidence

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76
Q

BPAD - long-term management

A

Lithium as first line, long term
If lithium is ineffective, consider adding valproate
If lithium is poorly tolerated or not suitable, consider valproate or olanzapine instead, or if prev effective during episode, quetiapine
NICE recommend li, olanz, quet, valp

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77
Q

Sodium valproate - s/e

A

hepatic failure
pancreatitis
suicidal behaviour and ideation
thrombocytopenia

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78
Q

Carbamazepine s/e

A

marrow suppression
hyponatraemia and SIADH
skin reactions, inc TEN and SJS
suicidal behaviour and ideation

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79
Q

Lamotrigine s/e

A

skin reactions, TEN, SJS
suicidal behaviour and ideation
blood dyscrasias

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80
Q

Gabapentin s/e

A

DRESS/multiorgan hypersensitivity
anaphylaxis/angioedema
suicidal behaviour and ideation

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81
Q

Topiramate s/e

A

acute myopia and secondary angle closure glaucoma
oligohydrosis and hyperthermia
suicidal behaviour and ideation
kidney stones

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82
Q

Other uses of lithium

A

Aggressive and self mutilating behaviour
Steroid induced psychosis
To raise WCC in people using clozapine
Reduced completed suicide in patients with BPAD

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83
Q

Valproate - side effects

A 
Tiredness
Significant weight gain (affects 30-50%)
Tremor (25%)
Hair loss (5-10%)
Teratogenic effects
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84
Q

BPAD Mortality

A

8% of men and 5% of women hospitalised for BPAD died by suicide
Life expectancy is reduced by 13 years in men and 9 years in women

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85
Q

Schizophrenia - prevalence

A

1.4-4.6%

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86
Q

Schizophrenia - incidence

A

0.16 per 1000

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87
Q

Schizophrenia - gender

A

1:1

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88
Q

Schizophrenia

Increased risk/prevalence with…

A 
winter births (5-15% higher)
urbanicity
migration and ethnic minorities (AESOP)
lower socio-economic class
LD (3% vs 1%)
Family history
Obstetric complications (prenatal nutritional deprivation, prenatal brain injury, prenatal influenza)
no difference with race
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89
Q

Selection drift hypothesis

A

This suggests that people with schizophrenia tend to drift towards the lower class due to their inability to compete for good jobs etc

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90
Q

Schizophrenia and family history

Gottesman (1982)

Lifetime risk of developing schizophrenia

A 
Gen pop 1%
First cousin 2
Uncle/aunt 2
Nephew/niece 4
Grandchildren 5
Parents 6
Half sibling 6
Full sibling 9
Children 13
Fraternal twins 17
Off of dual matings 46
Identical twins 48
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91
Q

Schizophrenia and cannabis use

A

Overall, cannabis use appears to confer a two-fold risk of later schizophrenia or
schizophreniform disorder
People are 4.5 times more likely to be schizophrenic at 26 if they were regular cannabis smokers at 15, compared to 1.65 times for those who did not report
regular use until age 18
Lifetime risk of developing psychosis increased by 40% (odds ratio = 1.41) if a person had ever used cannabis (Moore, 2007)
Age at onset of psychosis for cannabis users was 2.70 years younger than for nonusers (Large, 2011).

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92
Q

Schizophrenia - macroscopic pathological features

A

Ventricular enlargement
Reduced brain vol (up to 5%)
Reduced left planum temporale gray matter, and reversed planum temporale surface area asymmetry (L larger than R in R-handed person)

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93
Q

Schizophrenia - microscopic findings

A

Reduction of the size of the dorsolateral prefrontal cortex

Reduction of the size of the hippocampus

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94
Q

AESOP study

A

Incidence of all psychoses was found to be higher in African-Caribbean (x9) and Black African (x6) populations compared to white british group.

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95
Q

Schizophrenia - Positive sx

A

Hallucinations
Delusions
Thought disorder

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96
Q

Schizophrenia - negative sx

A 
social withdrawal
apathy
lack of energy
poverty of speech (alogia)
flattening of affect
anhedonia
Amisulpride has the most evidence for treating negative sx
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97
Q

Psychogenic polydipsia

A

Fluid drinking that greatly surpasses physiological requirements
Results in hyponatraemia - vomiting, agitation, ataxia, seizures, coma
Manage by fluid restriction

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98
Q

PANSS

A

7 positive symptom items, 7 negative and 16 general psychopathology
Each item scored on 7 point severity scale

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99
Q

Schizophrenia subtypes (ICD-10)

A 
Paranoid
Hebephrenic (disorganised)
Catatonic
Undifferentiated (doesn't conform to any subtype)
Post-schizophrenic depression
Residual
Simple (predominate;y neg sx w/o being preceded by overtly psychotic sx
Other 
Unspecified
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100
Q

Bouffee delirante

A

Brief short lived psychosis that last less than 3 months

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101
Q

Schizophrenia subtypes (Crow)

A

Type 1 - positive symptoms - excess of dopamine D2 receptors - respond better to antipsychotics

Type 2 - negative sx - underlying/anatomical abnormality such as ventricular enlargement or cortical atrophy - respond poorly to tx, chronic course, poor outcome

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102
Q

Schizophrenia: DSM-5 vs ICD-10

A

ICD-10 - sx present for at least 1 month, DSM-V - 6 months with 1 mnth active sx

Less than 1m in ICD - acute and transient psychotic disorder and DSM - brief psychotic disorder. In DSM if between 1-6m then its schizophreniform disorder

DSM requires some impairment of social and occupational dysfunction - not in ICD

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103
Q

Early onset schizophrenia

A 
Affects 1 in 1000 children
EOS - 13-18yrs
VEOS - before 13yrs
Insidious onset
More severe premorbid neurodevelopmental abnormalities
More frequent terrifying visual hallucinations
Constant inappropriate of blunted affect
Higher rate of familial psychopathology
Minor response to tx
Poorer outcome
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104
Q

Antipsychotics in schizophrenia - minimum effective doses

A 
Chlorpromazine 200mg
Haloperidol 2mg
Sulpride 400mg
Amisulpride 400mg
Aripiprazole 10mg
Olanzapine 5mg
Quetiapine 150mg
Risperidone 2mg
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105
Q

Antipsychotics in schizophrenia - maximum doses

A 
Clozapine 900mg
Haloperidol 20mg
Olanzapine 20mg
Quetiapine 750mg
Risperidone 16mg
Aripiprazole 30mg
Flupentixol depot 400mg/week
Zuclopenthixol 600mg/week
Haloperidol depot 300mg 4 weekly
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106
Q

Antipsychotic Adverse Effects

A

Hypertension (mostly clozapine)
Reduction of the seizure threshold (esp clozapine)(haloperidol, sulpride and trifluperazine are good choices)
Sexual dysfunction (in order: risperidone, haloperidol, olanzapine, quetiapine, aripiprazole)
Weight gain

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107
Q

Antipsychotic weight gain - mechanisms

A

5-HT2c antagonism
H1 antagonism
Hyperprolactinaemia
Increased serum leptin (leading to desensitisation)

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108
Q

Antipsychotic weight gain - high risk

A

Clozapine

Olanzapine

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109
Q

Antipsychotic weight gain - medium risk

A 
Chlorpromazine
Quetiapine
Risperidone
Paliperidone
Zotepine
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110
Q

Antipsychotic weight gain - low risk

A 
Amisulpride
Asenapine
Aripiprazole
Haloperidol
Sulpride
Trifluoperazine
Ziprasidone
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111
Q

Tardive dyskinesia

A

Typically affects the face (75%), also limbs (50%) and trunk (25%)
Increasing dose of antipsychotic tends to lessen problem temporarily
Anticholinergics tend to worsen the movements. Believed to be due to postsynaptic D2 receptor hypersensitivity in the nigrostriatal pathway.
Develops over months to years

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112
Q

Risk factors for TD

A 
Advancing age
Females- not consistent finding
Ethnicity - higher in african americans
?higher in affective disorders
First gen antipsychotics
Mental retardation
Substance abuse
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113
Q

TD - treatment

A

Withdraw antipsych and switch to atypical e.g. clozapine or quetiapine
Discontinue anticholinergic
Tetrabenzine ( only licensed tx in UK - has depressogenic effects)
Benzos
Vit E (slows deterioration)
Ginkgo biloba
Propranolol

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114
Q

Schizophrenia - physical health monitoring

A 
FBC, U&E, LFT - baseline and yearly
lipids - baseline, 3m then yearly
weight - baseline, freq for 3m then yearly
glucose - baseline, 4-6m then yearly
ECG - baseline and after dose change
BP - baseline and freq during titration
prolactin - baseline, 6m then yearly
CPK - baseline, then if NMS suspected
TFT - yearly if on quetiapine
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115
Q

Depots

Suggested role in…

A

Zuclopenthixol decanoate (has slight advantage in terms of efficacy) - aggressive patients
Flupentixol - depressed patients
Haloperidol - prophylaxis of mania
Pipotiazine palmitate - when EPSEs are a problem

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116
Q

Chlorpromazine

A

1st drug used for psychosis

Photosensitivity reactions

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117
Q

Clozapine

A 
Reduced suicidality
30% would respond by 6wks
A further 20% by 3m
Additional 10-20% by 6m
30% do not respond (Meltzer 1992)
Need level of 350-450ng/ml before a pt is considered resistant
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118
Q

Clozapine resistance - augmentation

A 
Sulpride or amisulpride
Lamotrigine
Aripiprazole
Haloperidol
Risperidone
Avoid: Pimozide, olanzapine
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119
Q

Clozapine resistance - other options

A
  • Allopurinol + antipsychotic
  • Max dose amisulpride
  • Max dose aripiprazole
  • D-Alanine and D-Serine
  • ECT
  • High dose olanzapine (usually tried first, if failed then…
  • Olanzapine with various combinations
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120
Q

Lithium increases WCC - mechanism

A

?Stimulation of GM-CSF
?Demargination
No left shift

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121
Q

Clozapine levels (reference range)

A

350-500ug/L

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122
Q

Catatonia complications

A

Dehydration
DVT
PE
Pneumonia

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123
Q

Catatonia - treatment

A

Benzos (1st line)
ECT
Antipsychotics best avoided during acute phase

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124
Q

CATIE

A

Compared older vx newer antipsychotic meds
Phase 1 compared old and new antipsych
1400 participants
1 of 4 atypicals (OLZ, QTP, RIS, ZIP) or typical (perphenazine)
OLZ slightly better than others but weight gain significant
EPSEs not seen more with older drug

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125
Q

CATIE - Phase 2

A

Guidance on what to try next
If ineffective - tried clozapine
If intolerable - tried ziprasidone
Clozapine was much more effective than other atypicals

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126
Q

NCEP criteria for metabolic syndrome

A

• Central obesity: waist circumference 102 cm or 40 inches (male), 88 cm or 36
inches(female)
• Dyslipidaemia: TG 1.7 mmol/L (150 mg/dl)
• Dyslipidaemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female)
• Blood pressure 130/85 mmHg
• Fasting plasma glucose 6.1 mmol/L (110 mg/dl)

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127
Q

CATIE study - metabolic syndrome

A

The prevalence of MS at baseline in the CATIE group was 40.9%. By gender this was 51.6% in females and 36% in males. Male patients were twice as likely to have MS than matched controls, and female patients were three times as likely compared to matched controls.

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128
Q

Antipsychotic non-compliance in psychotic patients

A 
25-75% - of these, 90% are intentional
Following d/c from hospital non-compliance is:
25% at ten days
50% at one year
75% at 2 years
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129
Q

DAI

A

Drug Attitude Inventory
Assess’ patient attitude to medication - to predict compliance

Other scales: ROMI, Beliefs about medication questionnaire, MARS

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130
Q

Schizophrenia - course and prognosis

A

Ram (1992) concluded that over a 2 year period, one-third of patients with schizophrenia showed a benign course, and two-thirds either relapsed or failed to recover.
2-3 fold increased risk of premature death
The risk of dying over the next year for people with schizophrenia is 2.6 times higher than for people without it. (SMR 2.6) - mainly due to CVD
SMR falls with age due to early peak of suicides and gradual rise of population mortality

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131
Q

Agoraphobia

A

Age at onset: 20s
Gender distribution: F>M
12m prevalence: 1.8%

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132
Q

Specific phobia

A

Age at onset: childhood
Gender distribution: F>M
12m prevalence: -

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133
Q

Social phobia

A

Age at onset: late teenage/early 20s
Gender distribution: F=M (more F in comm)
12m prevalence: 2.3%

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134
Q

OCD

A

Age at onset: 25-35 years
Gender distribution: F>M
12m prevalence: 0.7%

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135
Q

PTSD

A

Age at onset:
Gender distribution: F>M
12m prevalence: 1.1-2.9%

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136
Q

GAD - Epidemiology

A

Prevalence (12m) - 4.4%
Rates in women are twice as high as in men
A/w lower household income, unemployment, divorce and separation

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137
Q

GAD - Cognitive Theories

A

Looming cognitive style - increased attention to potentially threatening stimuli, overstimulation of environmental threat, enhances memory of threatening material

Lack of a sense of control of events and of personal effectiveness

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138
Q

GAD - Personality

A

Personality traits - neuroticism

Personality disorder - anxious-avoidant

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139
Q

GAD - Neurobiology

A
  • Amygdala and hippocampus implicated
  • Noradrenergic neurons that originate in the locus coeruleus have been shown to increase arousal and anxiety
  • GABA receptors are inhibitory and reduce anxiety, as fo the associated benzo-binding sites
  • Probably a role for corticotropin-releasing hormone
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140
Q

GAD - Diagnosis

A

6 months with prominent tension, worry and feelings of apprehension about every day events and problems

At least 4 of following (and at least 1 of 1st 4)
(1) Palpitations or pounding heart, or accelerated heart rate
(2) Sweating
(3) Trembling or shaking
(4) Dry mouth (not due to medication or dehydration)
(5) Difficulty breathing
(6) Feeling of choking
(7) Chest pain or discomfort
(8) Nausea or abdominal distress
(9) Feeling dizzy, unsteady, faint or light-headed
(10) Feelings that objects are unreal (derealization), or that one’s self is distant or ‘not
really here’ (depersonalization)
(11) Fear of losing control, going crazy, or passing out
(12) Fear of dying

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141
Q

GAD - Diagnosis (2)

A

(13) Hot flushes or cold chills
(14) Numbness or tingling sensations
(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax
(17) Feeling keyed up, or on edge, or of mental tension
(18) A sensation of a lump in the throat, or difficulty with swallowing
(19) Exaggerated response to minor surprises or being startled
(20) Difficulty in concentrating, or mind going blank, because of worrying or anxiety
(21) Persistent irritability
(22) Difficulty getting to sleep because of worrying

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142
Q

GAD Management - NICE

A 
Step 1 - mild - education and active monitoring
Step 2 - (no response to step 1) - low intensity psychological intervention
Step 3 - (no response to step 2 or marked impairment) - high intensity psychological intervention or drug treatment
Step 4 (no response to step 3 or marked impairment, comorbidity, risks) - complex drug/psychological treatment, input from MDT, crisis services, day hospital, inpatient care
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143
Q

GAD - Medication - NICE

A

Benzodiazepines should not be used beyond 2-4wks
1st line - SSRIs (sertraline) - warn of increased risk of suicidal thinking and self-harm if under 30 - weekly follow-up for 1m
If pt cannot tolerate SSRI or SNRI - offer pregabalin
Continue treatment for at least 1 year

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144
Q

Kava

A

Piper methysticum

Effective in reducing anxiety but a/w hepatotoxicity - not recommended

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145
Q

Specific phobia - epidemiology

A

Lifetime prevalence: men 7%, women 17%
Age of onset usually childhood
7 years for animals, 8 years for blood
Early twenties for most situational phobias

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146
Q

Specific phobia - Blood-infection-injury type

A

Bradycardia and hypotension often follow the initial tachycardia that is common to all phobias
Genetic link - may have particularly strong vasovagal reflex

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147
Q

Specific phobia - treatment

A

Behaviour therapy

Graded exposure

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148
Q

Social phobia - Epidemiology

A

Lifetime prevalence - 12%
Equally frequent in men and women who seek treatment, but more common in women in the community surveys
Associated with depression and alcoholism

149
Q

Social phobia - genetics

A

First-degree relatives of persons with social phobia are about three times more likely to be affected with social phobia

150
Q

Social phobia - clinical picture

A

Whereas breathlessness, dizziness, a sense of suffocation, and a fear of dying are common in panic disorder and agoraphobia, the symptoms associated with social phobia usually involve blushing, muscle twitching, and anxiety about scrutiny.

151
Q

Social phobia - treatment

A

Meds - antidepressants, anxiolytics, BB

Behaviour therapies - relaxation training and CBT

152
Q

Agoraphobia - Epidemiology

A

Prevalence considerably more in women (75%)
Age of onset early or middle 20s, with further peak in mid thirties
Typically starts with a panic attack

153
Q

Agoraphobia - Classical Conditioning Approach

A

a noxious stimulus (e.g., a panic attack) that occurs with a neutral stimulus (e.g., a bus ride) can result in the avoidance of the neutral stimulus.

154
Q

Agoraphobia - situations that provoke anxiety have 3 common themes

A

Distance from home
Crowding
Confinement

155
Q

Agoraphobia - treament

A

Medication - anxiolytics and antidepressants

Behaviour therapy, CBT

156
Q

Panic disorder - Epidemiology

A

20 years of age, highest in the 25-44 year age group. Rarely after 65yo
High comorbidity
Association with benign joint laxity (15 fold increase)

157
Q

Panic disorder - Panicogens

A

IV infusion of sodium lactate can induce panic

Others: carbon dioxide, bicarbonate, yohimbine, mCPP, flumazenil, cholecystokinin, caffeine

158
Q

Panic disorder - Cognitive theory

A

• Thoughts of imminent catastrophe have been identified as triggers of panic attacks
• Patients with panic disorder relative to healthy and patient controls have been shown to be:
⁃ 1. Characterized by strategic and automatic information processing (i.e., memory, attention) biases for physical threat cues;
⁃ 2. More accurate, in some instances, at detecting body sensations;
⁃ 3. More likely to report fear of somatic sensations and beliefs in their harmful
consequences

159
Q

Suffocation alarm theory of anxiety

A

States that some people have a hypersensitive central chemoreceptor leading to carbon dioxide sensitivity.

160
Q

Panic attacks in different disorders

A

SOB more common in panic attacks is agoraphobia
Blushing more common in social phobia
More dizziness, paraesthesia, shaking, chest pain in panic disorder

161
Q

Panic disorder - Management

A

1st line - SSRIs
2nd line - no response after 12 wk - imipramine or clomipramine
Sedating antihistamine, antipsychotics and benzos should not be used
Encourage CBT based self-help
Continue antidepressant for at least 6m after optimal dose reached

162
Q

OCD - Epidemiology

A

1-3% of population
Begins in early adulthood, mean age 20yrs (slightly earlier in men)
Very slightly higher prevalence in women
Lifetime prevalence for major depressive disorder is 67%, social phobia 25%

163
Q

OCD - Personality

A

Only about 15-35% of patients with OCD have had premorbid obsessional traits

164
Q

OCD - Psychodynamic theory

A

Disturbances in normal growth and development related to the anal-sadistic phase of development

Magical thinking - persons believe that merely by thinking about an event in the external world they can cause the event to occur without intermediate physical actions

165
Q

OCD - Biological causes

A

Historically associated with Encephalitis Lethargica

Increased glucose metabolism in the caudate nucleus and orbitofrontal cortex

166
Q

OCD - Neuroimaging

A

FDG-PET - increased glucose metabolism in the OFC, caudate, thalamus, prefrontal cortex and anterior cingulate

HMPAO-SPECT - increased and decreased blood flow to various brain regions including the OFC, caudate, various areas of the cortex and thalamus

167
Q

Obsessions

A

Recurrent intrusive thoughts, images, ruminations or impulses that a person recognises as his own, occurring against his will but he finds it difficult to resist it.

  • Most common is contamination, followed by washing
  • Obsessional sx occur in 20% of cases of severe depression
168
Q

Compulsions

A

Obsessional motor acts.

169
Q

OCD - Treatment

A

High dose SSRIs and clomipramine
8-16wks needed for maximal therapeutic benefit
Behaviour therapy (ERP) and CBT
ERP - habituation leads to eventual extinction of the response

170
Q

Hypochondriasis - Epidemiology

A

6m prevalence of 4-6%, but may be as high as 15%
M=F
20-30yo most commonly
80% have coexisting anxiety or depressive disorders

171
Q

Hypochondriasis - Psychodynamic theory

A

Aggressive and hostile wishes toward others are transferred (through repression and displacement) into physical complaints

172
Q

Hypochondriasis - common features

A

Avoidance
Bodily checking
Reassurance seeking

173
Q

Hypochondriasis - name in DSM V

A

Illness Anxiety Disorder

174
Q

Body dysmorphic disorder

A

Most common area perceived to be affected is the skin, followed by hair, nose, toes and then weight
Classified under hypochondriasis in ICD-10
Psychological therapy (CBT)

175
Q

Somatoform and Dissociative Disorders - differences in classification

A

• In DSM-5, somatoform disorders as a category has been replaced by somatic
symptom and related disorders. Somatisation disorder has been eliminated.
• A further confusion relates to the relationship between conversion disorder and
somatoform/dissociative disorders. In ICD-10, conversion is used synonymously with dissociation I.e. ‘Dissociative (conversion) disorders’. In DSM-4 and DSM-5, conversion is a subtype of somatoform/somatic symptom disorder. DSM-5 gives the alternative name of functional neurological symptom disorder.

176
Q

Briquet’s syndrome (Somatisation disorder) - Epidemiology and Aetiology

A 
Lifetime prevalence 0.2%
More common in females (5:1)
Onset: childhood to early 30s
A/w childhood sexual abuse
Increased freq in 1st degree relatives
177
Q

Briquet’s syndrome (Somatisation disorder) - Presentation

A

Multiple, recurrent and frequently changing physical sx of at least 2 years duration
If short-lived or less striking sx - undifferentiated somatoform disorder

178
Q

Somatic symptom disorder

A

Excessive preoccupation and worry about somatic symptoms
Inversely related to social class (more common in low ed and low income)
More common in women
Sx may or may not be a/w med condition
Sx DO NOT need to be medically unexplained to qualify for diagnosis

179
Q

Somatoform autonomic dysfunction

A
  • Da Costa’s syndrome
  • Cardiac neurosis
  • Neurocirculatory asthenia
  • Dyspepsia
  • Pylorospasm
  • Irritable bowel syndrome
  • Psychogenic flatulence
  • Psychogenic cough
  • Hyperventilation
  • Psychogenic frequency
  • Dysuria
180
Q

Somatisation disorder - treatment

A

Communicate the diagnosis
Acknowledge symptom severity and experience of distress as real but emphasise negative investigations and lack of structural abnormality
Reassure patient of continuing care
Attempt to reframe symptoms as emotional
Assess for and treat psychiatric comorbidity
Reduce and stop unnecessary drugs

181
Q

Dissociative disorders

A

Complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.

Only disorders of physical functions normally under voluntary control and loss of
sensations are included here. Disorders involving pain and other complex physical
sensations mediated by the autonomic nervous system are classified under
somatization disorder (F45.0).
182
Q

Dissociative amnesia

A

Inability to recall important personal memories, usually of a stressful nature, too extensive for N forgetfulness

183
Q

Dissociative fugue

A

Rare. Loss of memory coupled with wandering away from the person’s usual surroundings. Some deny knowledge of personal identity.

184
Q

DID

A

Multiple personality disorder in ICD-10

Sudden alternations between 2 patterns of behaviour, each of which is forgotten by the pt when the other is present

185
Q

PD - Prevalence

A 
Any PD 4.4%
Paranoid 0.7
Schizoid 0.8
Schizotypal 0.06
Antisocial 0.6
Borderline 0.7
Avoidant 0.8
Dependent 0.1
Obsessive-compulsive (anankastic) 1.9
186
Q

PD - Prevalence by population

A
  • Community prevalence –2-3% (according to some studies, up to 10%)
  • GP attenders –20%
  • Psychiatric outpatients –40%
  • Psychiatric inpatients –50%
  • Male prisoners – 60%
187
Q

PD Screening - SAPAS

A 
Interview. 8 areas
2minutes to complete
Score between 0 and 8
Yes/no answers to 8 q
Score of 3 or more warrants further assessment
188
Q

PD Screening - FFMRF

A

Self reported
30 items
rated 1-5 for each item
Based on symptoms rather than diagnosis

189
Q

PD Screening - IPDE

A

Interview method, self reported
Semistructured clinical interview
Compatible with ICD-10 and DSM-IV
Includes patient questionnaire and an interview

190
Q

PD Screening - PDQ-R

A

Self reported
100 true/false questions
30 mins to complete
Based on DSM-IV criteria

191
Q

PD Screening - IPDS

A

Interview method
11 criteria
Takes less than 5 mins

192
Q

PD Screening - IIP-PD

A

Self reported
Contains 127 items
Items rated 0-4

193
Q

PD Classification - ICD-10

A
  1. Paranoid, Schizoid
  2. Dissocial, Emotionally Unstable (Impulsie, borderline), Histrionic
  3. Anankastic, Anxious (avoidant), Dependent
194
Q

PD Classification - DSM-V

A

Cluster A - Paranoid, Schizoid, Schizotypal
Cluster B - Antisocial, Borderline
Cluster C - Obsessive-compulsive, Avoidant, Dependent

195
Q

PD - Antisocial - male prisoners

A

47% of male prisoners

196
Q

Antisocial (dissocial) PD ICD-10

A

At least 3 of following:
• Callous unconcern for the feelings of others;
• Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
• Incapacity to maintain enduring relationships, though having no difficulty in
establishing them;
• Very low tolerance to frustration and a low threshold for discharge of aggression,
including violence;
• Incapacity to experience guilt or to profit from experience, particularly punishment;
• Markedly prone to blame others or to offer plausible rationalizations for the behaviour
that has brought the person into conflict with society.

197
Q

Antisocial (dissocial) PD DSM-V

A

Disregard for and violation of the rights of others, occurring since age 15, as indicated by three (or more) of:
⁃ Failure to conform to social norms with respect to lawful behaviours
⁃ Deceitfulness, as indicated by repeated lying or conning of others for personal
profit or pleasure
⁃ Impulsivity or failure to plan ahead
⁃ Irritability and aggressiveness, as indicated by repeated fights or assaults
⁃ Reckless disregard for safety of self or others
⁃ Consistent irresponsibility, as indicated by repeated failure to sustain work or honour financial obligations
⁃ Lack of remorse, as indicated by being indifferent or rationalising having hurt,
mistreated, or stolen from another
Must be evidence of conduct disorder before age 15.

198
Q

Avoidant PD - clinical features

A

• Avoidance of occupational activities which involve significant interpersonal contact
due to fears of criticism, or rejection.
• Unwillingness to be involved unless certain of being liked
• Preoccupied with ideas that they are being criticised or rejected in social situations
• Restraint in intimate relationships due to the fear of being ridiculed
• Reluctance to take personal risks doe to fears of embarrassment
• Views self as inept and inferior to others
• Social isolation accompanied by a craving for social contact

199
Q

Borderline PD - clinical features

A

• Efforts to avoid real or imagined abandonment
• Unstable interpersonal relationships which alternate between idealization and
devaluation
• Unstable self image
• Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
• Recurrent suicidal behaviour
• Affective instability
• Chronic feelings of emptiness
• Difficulty controlling temper
• Quasi psychotic thoughts

200
Q

BPD and abuse

A

• Up to 87% have suffered childhood trauma of some sort,
⁃ 40-71% have been sexually abused
⁃ 25-71% have been physically abused (Winston, 2000).

201
Q

Dependent PD - DSM-IV

A

At least 5 of:
• Difficulty making everyday decisions without excessive reassurance from others
• Need for others to assume responsibility for major areas of their life
• Difficulty in expressing disagreement with others due to fears of losing support
• Lack of initiative
• Unrealistic fears of being left to care for themselves
• Urgent search for another relationship as a source of care and support when a close
relationship ends
• Extensive efforts to obtain support from others
• Unrealistic feelings that they cannot care for themselves

202
Q

Dependent PD - ICD-10

A

At least 3 of following
• Encouraging or allowing others to make most of one’s important life decisions;
• Subordination of one’s own needs to those of others on whom one is dependent, and undue compliance with their wishes;
• Unwillingness to make even reasonable demands on the people one depends on;
• Feeling uncomfortable or helpless when alone, because of exaggerated fears of
inability to care for oneself;
• Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself;
• Limited capacity to make everyday decisions without an excessive amount of advice
and reassurance from others.

203
Q

Histrionic PD

A
  • Inappropriate sexual seductiveness
  • Need to be the centre of attention
  • Rapidly shifting and shallow expression of emotions
  • Suggestibility
  • Physical appearance used for attention seeking purposes
  • Impressionistic speech lacking detail
  • Self dramatization
  • Relationships considered to be more intimate than they are
204
Q

Narcissistic PD

A
  • Grandiose sense of self importance
  • Preoccupation with fantasies of unlimited success, power, or beauty
  • Sense of entitlement
  • Taking advantage of others to achieve own needs
  • Lack of empathy
  • Excessive need for admiration
  • Chronic envy
  • Arrogant and haughty attitude
205
Q

Obsessive-Compulsive PD

DSM-IV Criteria

A

4 of more of:
• Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
• Demonstrates perfectionism that hampers with completing tasks
• Is extremely dedicated to work and efficiency to the elimination of spare time
activities
• Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
• Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
• Is unwilling to pass on tasks or work with others except if they surrender to exactly
their way of doing things
• Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness

206
Q

Anankastic (Obsessive-Compulsive) PD

ICD-10 Criteria

A

At least 3 of:
• Feelings of excessive doubt and caution
• Preoccupation with details, rules, lists, order, organization or schedule
• Perfectionism that interferes with task completion
• Excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships
• Excessive pedantry and adherence to social conventions
• Rigidity and stubbornness
• Unreasonable insistence by the patient that others submit to exactly his or her way of
doing things, or unreasonable reluctance to allow others to do things
• Intrusion of insistent and unwelcome thoughts or impulses

207
Q

Paranoid PD

A
  • Hypersensitivity and an unforgiving attitude when insulted
  • Unwarranted tendency to questions the loyalty of friends
  • Reluctance to confide in others
  • Preoccupation with conspirational beliefs and hidden meaning
  • Unwarranted tendency to perceive attacks on their character
208
Q

Schizoid PD

A
  • Indifference to praise and criticism
  • Preference for solitary activities
  • Lack of interest in sexual interactions
  • Lack of desire for companionship
  • Emotional coldness
  • Few interests
  • Few friends or confidants other than family
209
Q

Schizotypal PD

A
  • Ideas of reference (differ from delusions in that some insight is retained)
  • Odd beliefs and magical thinking
  • Unusual perceptual disturbances
  • Paranoid ideation and suspiciousness
  • Odd, eccentric behaviour
  • Lack of close friends other than family members
  • Inappropriate affect
  • Odd speech without being incoherent
210
Q

Treatment for PD - Meds

A
  • Low dose neuroleptics in cluster B and schizotypal disorders
  • Carbamazepine for behavioural dyscontrol in borderline PD
  • Lithium for aggressive behaviour
  • SSRIs in impulsive behaviour
  • MAOIs or imipramine in comorbid atypical depression in histrionic and borderline PD
  • Comorbid PD and depression may benefit from ECT (good initial response)
211
Q

Psychotherapy for BPD

A 
DBT
MBT
SFT
TFP
STEPPS
CAT (Ryle)
Some evidence for IPT
Therapeutic communities - milieu therapy
212
Q

Acute Stress Reaction

A

• There is an initial stage of a daze, followed by symptoms of disorientation, inattention, and inability to comprehend external stimuli.
• This is then usually followed by a rapidly changing picture of symptoms which might
include flight reactions, panic, autonomic hyperarousal, anger, or despair.
• Symptoms usually diminish within 24-48 hours and should be minimal after 3 days.

213
Q

PTSD - epidemiology

A

Female preponderance
Lifetime incidence - 9-15%
Lifetime prevalence - 8% of general population

214
Q

PTSD - aetiology

A
  • Ambient cortisol levels lower than normal due to chronic adrenal exhaustion from inhibition of the HPA axis by persistent severe anxiety.
  • Decreased hippocampal volume
  • Amygdala - mediates unconscious memories
  • Hippocampus - mediates conscious memories
  • Neuroimaging studies - decreased activity in medial prefrontal and anterior cingulate, increased activity in amygdale.
215
Q

Moderate impact traumas

A

Precede PTSD in 5-20%
e.g. diagnosis of life threatening illness in self or loved one, sudden death of a loved one, witnessing death
or serious injury of another person, direct involvement in a serious accident and
involvement in fires, floods or small scale natural disaster

216
Q

High impact traumas

A

Precede PTSD in >20%
e.g. muggings, threats with a
weapon, serious domestic violence, rape, childhood sexual abuse, war/combat,
kidnap, torture, large-scale or man-made disasters.

217
Q

PTSD - ICD-10 criteria

A

• Exposure to a traumatic event which would be likely to cause pervasive distress in
almost anyone.
• The event must be persistently remembered or relived, as evidenced by flashbacks, vivid memories, or nightmares.
• The patient must actively avoid situations which remind them of the event.
Plus 1 of:
• Partial amnesia for part of the event
• Persistent symptoms of psychological arousal such as, poor sleep, poor concentration, hypervigilance, exaggerated startle response, irritability.
Above must occur within 6m of event

218
Q

PTSD - Treatment - Children and Young people

A

Do not offer psychological debriefing

  • Sx for >1m - individual trauma-focused CBT intervention
  • Consider EMDR for children 7-17 with sx >3m with no response to CBT
  • Do not offer drug tx
219
Q

PTSD - Treatment - Adults

A
  • Do not offer psychological debriefing
  • 1st line - Individual trauma-focused CBT or EMDR (non-combat related only and if pt prefers) or supported trauma-focussed computerised CBT
  • Do not offer drug treatments to prevent PTSD
  • Venlafaxine or SSRI (not 1st line)
  • Antipsychotics if severe hyperarousal or psychotic sx
220
Q

EMDR

A

Francine Shapiro in 1980s

221
Q

Grief - John Bowlby

A
  1. Shock and protest including disbelief (few days)
  2. Preoccupation - involves yearning and anger (few weeks)
  3. Disorganisation - includes despair and acceptance of loss (several months)
  4. Resolution (1-2 years)
222
Q

Grief - Kubler-Ross 1969

A 
Stage 1 - Denial
Stage 2 - Anger
Stage 3 - Bargaining
Stage 4 - Depression
Stage 5 - Acceptance
223
Q

Abnormal grief - Inhibited

A

Absence of expected grief sx at any stage

224
Q

Abnormal grief - Delayed

A

Avoidance of painful sx within 2 weeks of loss

225
Q

Abnormal grief - chronic/prolonged

A

Continued significant grief related sx 6m after loss

226
Q

Features that distinguish normal grief from depression

A

Generalised guilt
Thoughts of death (except in relation to the deceased)
Feeling worthless
Psychomotor retardation
Prolonged functional impairment
Hallucinations (except in relation to the deceased)

227
Q

Dyssomnias

A

Intrinsic sleep disorder
Extrinsic sleep disorders
Circadian rhythm disorders

228
Q

Parasomnias

A
  • Arousal disorders - sleepwalking, sleep terrors
  • Sleep wake transition disorders - RMD, sleep talking, nocturnal leg cramps
  • Parasomnias a/w REM sleep - nightmare, sleep paralysis
229
Q

Intrinsic sleep disorder

A 
Narcolepsy
Psychopsycholical insomnia
Idiopathic hypersomnia
RLS
Periodic Limb Movement disorder
OSA
230
Q

Extrinsic Sleep disorders

A

Inadequate sleep hygiene

Alcohol dependent Sleep disorder

231
Q

Circadian Rhythm Disorders

A 
Jet lag syndrome
Shift work sleep disorder
Irregular sleep wake pattern
Delayed sleep phase syndrome
Advanced sleep phase disorder
232
Q

Cataplexy

A

Sudden loss of bilateral muscle tone provoked by strong emotion
Seen in Narcolepsy
Few sec to few mins
Treat with TCA such as protriptyline or imipramine

233
Q

Narcolepsy

A

Commonly begins in 2nd decade
Peak incidence around 14yo
Repeated episodes of sleep of short duration

234
Q

Modafinil

A

Enhances wakefulness, attention and vigilance
Not addictive, lacks euphoric effect, does not tend to precipitate psychosis
Used in narcolepsy, OSA, chronic shift work, depression

235
Q

Periodic Limb Movement Disorder

A

Repetitive and highly stereotyped limb movements during sleep
A/w partial arousal or awakening

236
Q

Restless Leg Syndrome

A

Disagreeable leg sensations that usually occur prior to sleep onset causing irresistible urge to move the legs - partial or complete relief when legs moved

237
Q

RLS - risk factors

A
  • Older age
  • Female sex
  • Pregnancy
  • Iron deficiency and anemia
  • Renal failure
  • Hypothyroidism
  • Diabetes
  • B12 deficiency
238
Q

Jet leg syndrome

A

Sx typically last longer following eastward flights

239
Q

Shift work sleep disorder

A

Sleep length reduced by 1-4 hours and mainly affects REM and stage 2 sleep

240
Q

Non 24hr sleep wake syndrome

A

Chronic steady pattern comprising one to two hour daily delays in sleep onset and wake times

241
Q

Sleepwalking

A

During slow-wave sleep - therefore 1st 1/3 of the night or following sleep deprivation
Peak between 4-8yo
Lithium can exacerbate or induce it

242
Q

Sleep terrors

A

sudden arousal from slow wave sleep with a piercing
scream or cry, accompanied by autonomic and behavioural manifestations of intense
fear.
May have micturition
Amnesia for episode

243
Q

Rhythmic Movement Disorder

A

Stereotyped, repetitive movements

involving large muscles, usually of the head and neck

244
Q

Sleep starts

A

sudden, brief contractions of the legs, sometimes also involving the arms
and head, that occur at sleep onset

245
Q

Nocturnal leg cramps

A

Painful sensations of muscular tightness or tension, usually in calf
Few seconds up to 30min
One or two episodes nightly several times a week

246
Q

Nightmares

A

Usually awaken the sleeper from REM sleep

Long dreamlike feature differentiates it from sleep terrors

247
Q

Sleep paralysis

A

Transient paralysis of skeletal muscles which occurs when awakening from sleep or when falling asleep
Hallucinations
Clonazepam may be used

248
Q

Insomnia - short term

A

Hypnotic drug e.g. temazepam or z drug only if daytime impairment is severe
Max 2 weeks

249
Q

Insomnia - long-term

A

CBT
Meds for up to 4 weeks
If over 55 - melatonin - 3w, if response then cont for 10w

250
Q

Neurasthenia (F48)

A

Excessive fatigue following mental or physical effort

251
Q

Neurasthenia - ICD-10

A
  • Either persistent and distressing complaints of increased fatigue after mental effort, or bodily weakness and exhaustion after minimal effort
  • At least two of the following: muscular aches, dizziness, tension headaches, sleep disturbance, inability to relax, irritability, dyspepsia
  • Inability to recover through rest, relaxation or enjoyment
  • Duration exceeds 6 months
  • Does not occur in the presence of organic mental disorders, affective disorders or panic or GAD
252
Q

Somatisation disorder

A
  • multiple physical SYMPTOMS present for at least 2 years

* patient refuses to accept reassurance or negative test results

253
Q

Hypochondrial disorder

A
  • persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
  • patient again refuses to accept reassurance or negative test results
254
Q

Conversion disorder

A

• typically involves loss of motor or sensory function
• the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
• patients may be indifferent to their apparent disorder - la belle indifference - although
this has not been backed up by some studies

255
Q

Dissociative disorder

A
  • in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
  • dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
256
Q

Munchausen’s syndrome

A
  • also known as factitious disorder

* the intentional production of physical or psychological symptoms

257
Q

Malingering

A

• fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

258
Q

BDD - Epidemiology

A

• Equal sex incidence
• Less than 1% prevalence but markedly over-represented in some groups (e.g. plastic
surgery - 10% - and dermatology)
• 10% incidence in first-degree family members

259
Q

BDD - Treatment

A
  • SSRI - fluoxetine 20mg increasing to 60mg
  • If ineffective try Clomipramine up to 250mg
  • Antipsychotic if delusional features
  • Psychological - CBT, with ERP
260
Q

Premenstrual tension syndrome (ICD-10)

A

Known as Premenstrual dysphoric disorder in DSM-V
- mood lability, irritability, dysphoria, and anxiety
symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around
the onset of the menses.

261
Q

Premenstrual tension syndrome - treatment

A

SSRIs
Gonadotrophin releasing hormone analogues
?Vit B6
?Bright light therapy
For mastalgia - Danazol, evening primrose oil
Progesterone has no effect

262
Q

Drugs affecting contraception

A

Carbamazepine
Phenytoin
Topiramate

263
Q

Valproate and carbamazepine in pregnancy

A

Increase risk of neural tube defect (1-2% and 0.5-1% resp)

264
Q

Lithium in pregnancy

A

Ebstein’s anomaly (relative risk 10-20 times that of control, absolute risk 1:1000)

265
Q

Benzos in pregnancy

A

Oral clefts in newborns and floppy baby syndrome

266
Q

Antipsychotics in pregnancy

A

Olanzapine is recommended choice

267
Q

Paroxetine in pregnancy

A

More commonly a/w neonatal withdrawal, increased risk of cong malformations (particularly heart defects)

268
Q

Pregnancy

A

spontaneous abortion 10-20%
Major malformations 2-3% (1 in 40)
Drugs account for 5% of all abnormalities

269
Q

Antidepressants recommended in pregnancy

A

Fluoxetine, sertraline, amitriptyline, imipramine

270
Q

Antidepressants recommended in breastfeeding

A

Sertraline

271
Q

Antipsychotics rec in pregnancy

A

Olanzapine, quetiapine, haloperidol, clozapine, chlorpromazine

272
Q

Antipsychotics rec in breastfeeding

A

Olanzapine

273
Q

Mood stabilisers in pregnancy

A

Avoid if possible

274
Q

Mood stabilisers in breastfeeding

A

Avoid if possible

Valproate if essential

275
Q

Sedatives in preg

A

Promethazine (little data)

Benzos (avoid in late preg)

276
Q

Sedatives in breastfeeding

A

For anxiety - lorazepam

For insomnia - zolpidem

277
Q

Baby blues

A

30-75%
transient mood disturbance characterised by emotional lability, sadness, and tearfulness. This usually clears up by 2 weeks
Onset 3-5 days following birth

278
Q

Postpartum depression

A

10-15%
Similar to major depression
Risk increased to 25% with h/o depression and 50% with h/o postpartum depression
3-5% will be mod-sev

279
Q

Postpartum psychosis

A

1-2 per 1000
Approx 50% have FH of mood disorder
Usually begins within 1st 2wk following birth (2-14d)

280
Q

HIV and CD4 count

A

Most individuals are asymptomatic when their CD4 counts are >500 x 10^6/l. They are at greatest risk when this count falls below 200 x 10^6/l.

281
Q

Non-nucleoside reverse-transcriptase inhibitors

A

Efavirenz - can cause psychosis, suicide, mania

Nevirapine

282
Q

Nucleoside reverse-transcriptase inhibitors

A

Abacavir

Didanosine

283
Q

Protease inhibitors

A

Retinovir

Indinavir

284
Q

Others (HIV drugs)

A

Enfuvirtide

285
Q

Psychosis in HIV

A

Atypicals

Risperidone widely used

286
Q

Delirium in HIV

A

Atypicals and low-dose short acting benzos

287
Q

Depression in HIV

A

SSRIs, esp citalopram. Also SNRIs, mirtazapine and bupropion

288
Q

Bipolar in HIV

A

Valproate, lamotrigine
Lithium ok but poorly tolerated
Avoid carbamazepine
Atypicals

289
Q

MS - primary progressive

A

5-10%

Steady progression no remissions

290
Q

MS - relapsing-remitting

A

20-30%

Relapsing-remitting course

291
Q

MS - secondary progressive

A

60%

Initially relapsing-remitting but followed by phase of progressive deterioration

292
Q

Depression in MS

A

Lifetime prevalence of 25-50%
Somatic sx not good discriminators in MS
SSRIs 1st line
Interferon-beta - start on antidepressant prophylaxis if there is h/o depression

293
Q

Risk factors for suicide in MS

A
  • Male gender
  • Young age at onset of illness
  • Current or previous history of depression
  • Social isolation
  • Substance misuse
294
Q

Mania in MS

A

More common

Mood stabilisers recommended in preference to lithium due to tolerance issues

295
Q

Pathological laughing/crying

A

uncontrollable laughing and/or crying but
without the associated affect and is a common feature of Multiple sclerosis
Use amitriptyline or fluoxetine 10% in MS

296
Q

Emotional lability in MS

A

Amitriptyline and SSRIs recommended

297
Q

Porphyria - drugs that precipitate

A
  • Barbiturates
  • Benzodiazepines
  • Sulpiride
  • Certain mood stabilizers
298
Q

Porphyria - symptoms

A
  • Abdominal pain
  • Mental state changes
  • Constipation
  • Vomiting
  • Muscle weakness
299
Q

Post-concussion syndrome - symptoms

A
  • headache
  • fatigue
  • anxiety/depression
  • dizziness
300
Q

Wilson’s disease - inheritance

A

Autosomal recessive inheritance

301
Q

Wilson’s disease - cause

A

Mutation in Wilson disease protein (ATP7B) gene

Low levels of ceruloplasmin and total serum copper, high levels of copper in liver and brain

302
Q

Wilson’s disease - presentation

A

movement disorders such as dystonia, parkinsonian tremor, and rigidity combined with behavioural problems and a degree of dementia is often seen.
Kayser-Fleischer ring is the term given to the brown ring seen around the iris in people with Wilson’s disease.

303
Q

Suicide - Epidemiology

A

M:F = 4:1 in western countries, 2:1 in asian countries, higher in women in China. GENERAL 3:1
Average suicide rate = 1 per 10,000 in gen pop
Most common in 40-44 age group

304
Q

Suicide - most popular methods in desc order

A
  • Hanging/strangulation
  • Self-poisoning
  • Jumping and multiple injuries (mainly jumping from a height or being struck by a train)
  • CO poisoning and drowning (these occur at approximately the same rate)
  • Cutting and stabbing
305
Q

Patient suicides

A

28% of gen population suicides
10% of patient suicides occurred as inpatients
Suicide is rate is 1 in 1000 (x10 higher than gen pop)
1st 3m after discharge is high risk

306
Q

Risk factors for completed suicide

A 
⁃ Male
⁃ Elderly age.
⁃ Single, divorced, or widowed
⁃ Living alone
⁃ Poor social support
⁃ Unemployed
⁃ Low socio-economic class
⁃ Previous self harm
⁃ Any mental disorder 
⁃ Dependence on substances
⁃ Recent inpatient treatment
⁃ Concurrent physical disorder
⁃ Bereavement in recent past
307
Q

Suicide - protective factors

A
  • Children in the home
  • Sense of responsibility to family
  • Pregnancy
  • Religiosity
  • Life satisfaction
  • Reality testing ability
  • Positive coping skills
  • Positive problem-solving skills
  • Positive social support
  • Positive therapeutic relationship
308
Q

Self-harm

A

Annual prevalence 0.5%
16% of pt repeat within 1yr
3-12 session of psychological intervention for self-harm
Do not offer drug treatment specifically for self-harm

309
Q

SCOFF questionnaire

A

• Do you ever make yourself Sick because you feel uncomfortably full?
• Do you ever worry that you have lost Control over how much you eat?
• Have you recently lost more than One stone in a three month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say Food dominates you life?
Score 2 or more indicated AN or bulimia
84.6% sensitivity and 98.6% specificity, NPV 99.3%

310
Q

AN - DSM-V

A

• Restriction of energy intake relative to requirements, leading to a significantly low
body weight (generally speaking a BMI < 18.5)
• Intense fear of gaining weight or of becoming fat, or persistent behaviour that
interferes with weight gain, even though at a significantly low weight
• Disturbance in the way in which one’s body weight or shape is experienced,

311
Q

AN - DSM-V (severity)

A
  • Mild = BMI > 17
  • Moderate = BMI 16 – 16.99
  • Severe = BMI 15 – 15.99
  • Extreme = BMI < 15
312
Q

AN - cardiac complications

A

bradycardia, hypotension, arrhythmia, prolonged QT, ventricular tachy, peripheral oedema, sudden death

313
Q

AN - skeletal complications

A

osteoporosis

314
Q

AN - haematologic complication

A

anaemia, leukopenia, thrombocytopenia

315
Q

AN - reproductive complications

A

amenorrhea, low levels of LH and FSH, premature births

316
Q

AN - metabolic complications

A

Hypothyroidism, hypothermia, dehydration, hypoglycaemia, hypokalaemia, hypomagnesia, metabolic alkalosis

317
Q

AN - Gastrointestinal complications

A

Delayed gastric emptying, constipation, pancreatitis

318
Q

AN - CNS complications

A

Cerebral atrophy, depression, cognitive impairment

319
Q

AN - Dermatological complications

A

Lanugo, hypercarotanaemia, acrocyanosis, hypertrichiosis

320
Q

AN - Treatment

A

CAT, CBT, IPT, focal psychodynamic therapy and family interventions
Aim 0.5-1kg/wk weight gain inpatient, or 0.5kg outpatient
No medication for sole or primary tx for AN but olanzapine can effect weight restoration

321
Q

MARSIPAN - high risk items for AN

A 
BMI <13
Pulse <40bpm
SUSS test <2
Sodium <130mmol/L
Potassium <3 mmol/L
Serum glucose <3mmol/L
QTc >450ms
322
Q

AN f/u over 29yr period

A

50% recovered completely
1/3 had partial recovery
20% had chronic eating disorder
5% died

323
Q

Factors for poor prognosis with anorexia

A 
Patients with a long duration of hospital care
Psychiatric co-morbidity
Being adopted
Growing up in a 1 parent household
Having a young mother
Lower minimum weight
Poor family relationships
Failed treatment
Late age of onset
Social problems
324
Q

Bulimia Nervosa - Prevalence

A 
Prevalence 2-3%
F:M = 10:1
Depression more prominent than in AN
Alcohol abuse occurs in 15%
13% have co-morbid BPD
325
Q

BN - aetiology

Risk factors

A

?decreased CCK levels

Childhood sexual abuse
Male homosexuality
Having an occupation that focuses on weight
Low self-esteem
Female gender
326
Q

BN - DSM-IV

A
  • Recurrent episodes of binge eating (large amount of food with lack of control)
  • Recurrent inappropriate compensatory behaviour in order to prevent weight gain
  • Above occur at least twice a week for 3 months
  • Self-evaluation is unduly influenced by body shape and weight
  • Disturbance does not occur exclusively during episodes of AN
  • Can be over or underweight
327
Q

Ipecac

A

Produces vomiting within 15-30min
A/w serious cardiac toxicity, including cardiomyopathy and left ventricular dysfunction
Causes elevated serum amylase levels

328
Q

BN - Physical Complications

A
  • Hypokalemia
  • Hypochloremia
  • Hyperphosphatemia (note in anorexia a low phosphate level is usually seen)
  • Metabolic alkalosis (if induced vomiting is main method)
  • Metabolic acidosis (if purging is main method)
  • Parotid gland enlargement (sialadenosis)
  • Dental erosion
  • Gastric and oesophageal rupture
  • Seizure
329
Q

BN - treatment

A
  • 1st line - evidence-based self-help program or/plus antidepressant - SSRI (fluoxetine 60mg OD)
  • CBT-BN 16-20 sessions
  • IPT but takes 8-12m
330
Q

BN - Outcome

A

Standardised Mortality Rate 1.3

BN is preceded by AN in about 25% of cases or AN-like state

331
Q

Metabolic complications in eating disorders - Electrolytes

A
  • Hypokalemia
  • Hypomagnesemia
  • Hypocalcemia
  • Hypophosphatemia (note in bulimia a high phosphate level is generally seen)
332
Q

Metabolic complications in eating disorders - Endocrine

A
  • Low estradiol
  • Low luteinizing hormone (LH)
  • Low follicular stimulating hormone (FSH)
  • Low T3 (low T3 syndrome/ sick euthyroid syndrome), TSH and T4 are usually normal
  • Hypercortisolism
  • Hypoglycemia
  • Elevated growth hormone
333
Q

Metabolic complications in eating disorders - other

A
  • Hypercarotenemia
  • Hypercholesterolemia
  • Urea and creatinine low
334
Q

Complications of purging - vomiting

A

Na high, low or N
K low
Chloride low
pH high

335
Q

Complications of purging

- laxatives

A

Na high or N
K low
Chloride high or low
pH high or low

336
Q

Complications of purging - diuretics

A

Na low or N
K low
Chloride low
pH high

337
Q

Transsexualism

A

Desire to live and be accepted as a member of the opposite sex
Feelings persistent for 2yrs

338
Q

Dual-role transvestism

A

Wearing of clothes of the opposite sex in order to enjoy the temporary membership of opposite sex w/o desire for permanent change.
No sexual excitement

339
Q

Gender identity disorder of childhood

A

Persistent intense distress about assigned sex, together with desire to be other sex, manifests before puberty.
M>F

340
Q

Risk factors for QTc prolongation

A 
Long QT prolongation
Bradycardia
IHD
Myocarditis
MI
LVH
Hypokalaemia
Hypomagnesia
Hypocalcaemia
Extreme
Extreme physical exertion
Stress or shock
AN
Extremes of age
Female gender
341
Q

Drugs causing prolonged QTc (non-psych)

A

Ampicillin, Erythromycin
Amiodarone, sotalol
Chloroquine, quinine
Methadone, tamoxifen, amantadine

342
Q

Priapism

A

Persistent and painful erection
Caused by alpha blockade, ?also by serotonin
Drugs that cause: trazodone, chlorpromazine
Treatment: Alpha-adrenergic agonists

343
Q

Drugs that raise ALT

A 
clozapine
haloperidol
olanzapine
quetiapine
chlorpromazine
mirtazapine
moclobemide
SSRIs
Carbamazepine
lamotrigine
valproate
344
Q

Drugs that lower ALT

A

vigabatrin

345
Q

Drugs that raise ALP

A 
haloperidol
clozapine
olanzapine
duloxetine
sertraline
carbamazepine
346
Q

Drugs that raise AST

A

clozapine
olanzapine
valproate
methadone

347
Q

Drugs that lower AST

A

trifluperazine

348
Q

Drugs that raise TSH

A

aripiprazole
carbamazepine
lithium

349
Q

drugs that lower TSH

A

moclobemide

350
Q

Drugs that raise thyroxine

A

dexamfetamine

moclobemide

351
Q

Drugs that raise thyroxine

A

lithium
aripiprazole (rare)
quetiapine (rare)

352
Q

Sedatives in liver impairment

A

lorazepam
oxazepam
temazepam
zopiclone

353
Q

Serotonin syndrome

A

⁃ neuromuscular abnormalities (myoclonus, and clonus, hyperreflexia, muscular rigidity),
⁃ altered mental state
⁃ autonomic dysfunction.
Onset usually after 1 or 2 doses of the medication
Most frequently due to co-administration of MAOI and SSRI
Mild cases: benzos and fluids
Severe: ITU

354
Q

NMS

A
  • result of dopamine blockade at the hypothalamus which messes up the thermo-regulatory system and hence results in hyperthermia
  • also suggested that the use of antipsychotics (neuroleptics) causes calcium uptake
    into muscles resulting in muscle rigidity, then rhabdomyolysis and elevated CPK
  • Caused by antipsychotics, also antidepressants and lithium
  • Onset - within 2w of initial treatment usually
  • Management: removal of drug, control of fever, benzos, sometimes ECT, bromocriptine, dantrolene
  • Mortality up to 20%
355
Q

Risk factors for NMS

A 
Younger age
Make
Physical exhaustion
Dehydration or electrolyte imbalance
Previous and FH of NMS
Organic mental disorders
Low serum iron levels
Raised CK levels
Comorbid substance misuse
Higher loading dose
Faster rate of loading
High potency
Sudden withdrawal
356
Q

NMS vs serotonin syndrome

A

SS has acute onset, NMS more insidious

357
Q

SADHART study

A

Found sertraline to be a safe treatment for depression post-myocardial
infarction.

358
Q

Hyponatraemia a/w antidepressant use

A

Recurs upon rechallenge, even if a different antidepressant is rx
Sx: n&v, confusion, lethargy, irritability, muscular spasm and cramp, seizures

359
Q

SIADH

A

Drug induced hyponatraemia (due to excessive secretion of ADH)
Fluid overload
Antidepressants and antipsychotics
Risk factors: elderly, female, smokers, med co-morbidity, polypharmacy, low body weight, reduced renal function, warm weather
Normally develops within a few weeks of starting the new drug

360
Q

Antidepressants a/w SIADH

A 
SSRIs
TCAs
Trazodone
Phenelzine
Tranylcypromine
Venlafaxine
361
Q

Antipsychotics a/w SIADH

A 
Chlorpromazine
Fluphenazine
Trifluoperazine
Thioridazine
Thiothizene
Haloperidol
Clozapine
362
Q

Treatment of SIADH

A

Fluid restriction
Sometimes demeclocycline
Consider switching to noradrenergic drug such as nortriptyline and lofepramine or an MAOI such as moclobemide

363
Q

Tamoxifen (SERM)

A

Metabolised by CYP2D6 - some antidepressants inhibit this therefore decrease the anticancer effect.
Paroxetine, fluoxetine, bupropion, duloxetine interact (strong).
Sertraline, escitalopram, doxepin are moderate inhibitors.
Venlafaxine is a weak inhibitor.

364
Q

Teratogens - valproic acid

A

Spina bifida (1-2% vs 0.2-0.5% background risk), hypospadias

365
Q

Teratogens - Lithium

A

Ebstein’s anomaly

366
Q

Teratogens - alcohol

A

Fetal alcohol syndrome

367
Q

Teratogens - phenytoin

A

Craniofacial defects, limb defects, cerebrovascular defect, mental retardation

368
Q

Teratogens - carbamazepine

A

Fingernail hypoplasia, craniofacial defects

369
Q

Teratogens - diazepam

A

Cleft lip/palate

MRCPsych Paper B (3 decks)

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