High Yield Psych Flashcards
What signs may be seen in a patient with anorexia nervosa?
reduced body mass index
bradycardia, hypotension
enlarged salivary glands
lanugo hair
failure to develop secondary sexual characteristics
yellow tinge to the skin (hypercarotinaemia)
What physiological abnormalities may be seen in a patient with anorexia nervosa?
hypokalaemia
low FSH, LH, oestrogens and testosterone
low T3
raised cortisol and growth hormone
hypercholesterolaemia
hypercarotinaemia
impaired glucose tolerance
Give two examples of typical antipsychotics
Haloperidol
Chlorpromazine
What is the mechanism of action of typical anti psychotics?
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
Give three examples of atypical antipsychotics
Clozapine
Risperidone
Olanzapine
What is the mechanism of action of atypical antipsychotics?
Act on a variety of receptors (D2, D3, D4, 5-HT)
What Extrapyramidal side-effects (EPSEs) may result from antipsychotic use?
Parkinsonism
acute dystonia
- sustained muscle contraction (e.g. torticollis, oculogyric crisis)
- may be managed with procyclidine
akathisia (severe restlessness)
tardive dyskinesia (involuntary movements of face and jaw, see image)
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
Increased risk of stroke and VTE
Atypical antipsychotics should now be used first-line in patients with schizophrenia. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.
What adverse effects may they present with?
weight gain
diabetes mellitus
hyperlipidaemia
hyperprolactinaemia
Qtc prolongation
clozapine is associated with agranulocytosis - monitor FBC if infection!!
What are the adverse effects of clozapine?
agranulocytosis, neutropaenia
reduced seizure threshold
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
constipation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment
The monitoring requires for patients taking antipsychotic medication are extensive. What does the BNF recommend?
FBC, U&Es, LFTs
Fasting blood glucose, prolactin, lipids
Weight
Blood pressure
(baseline, frequently during dose titration)
ECG (baseline)
Cardiovascular risk assessment (annually)
Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
What are the two types?
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression
Factors suggesting diagnosis of depression over dementia?
short history, rapid onset
global memory loss (dementia characteristically causes recent memory loss)
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
What is classified as ‘less severe’ depression?
a PHQ-9 score of < 16
What is classified as ‘more severe’ depression?
a PHQ-9 score of ≥ 16
Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia).
What are the potential side effects?
Short-term side-effects:
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
Long-term side-effects:
some patients report impaired memory
What is the absolute contraindication to ECT?
Raised ICP
Lithium is a mood stabilising drug used prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life.
What are its adverse effects?
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
weight gain
idiopathic intracranial hypertension
hyperparathyroidism and resultant hypercalcaemia
What may you see on FBC of someone on lithium?
leucocytosis
What ECG changes can lithium cause?
ECG: T wave flattening/inversion
When should lithium levels be checked?
the sample should be taken 12 hours post-dose
after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
once established, lithium blood level should ‘normally’ be checked every 3 months
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
What are the ‘Cluster A’ personality disorders?
‘Weird’
Paranoid
Schizoid
Schizotypal
What are the ‘Cluster B’ personality disorders?
‘Wild’
Antisocial
Borderline (Emotionally Unstable)
Histrionic
Narcissistic
What are the ‘Cluster C’ personality disorders?
‘Worriers’
Obsessive-Compulsive
Avoidant
Dependent
Indications for ECT?
indicated to achieve rapid improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:
catatonia
a prolonged or severe manic episode
severe depression that is life-threatening
Give some signs of lithium toxicity
coarse tremor
hyperreflexia
vision changes
ataxic gait
confusion
Give some examples of conditions in which psychosis may occur
schizophrenia: the most common psychotic disorder
depression (psychotic depression, more common in elderly patients)
bipolar disorder
puerperal psychosis
brief psychotic disorder: symptoms last less than a month
neurological conditions e.g. Parkinson’s disease, Huntington’s disease
prescribed drugs e.g. corticosteroids
certain illicit drugs e.g. cannabis, phencyclidine
Give some risk factors for developing a psychotic disorder
Fam hx - STRONGEST RISK FACTOR
Black Caribbean ethnicity
Migration
Urban environment
Cannabis use
What are the first rank symptoms of schizophrenia?
auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions
Give some negative features of schizophrenia
incongruity/blunting of affect
anhedonia (inability to derive pleasure)
alogia (poverty of speech)
avolition (poor motivation)
social withdrawal
Which is the best medication for managing negative sxs of schizophrenia?
clozapine
Give some factors associated with poor prognosis in schizophrenia
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
Which patients are specifically excluded from the mental health act?
Patients under the influence of alcohol or drugs
What is Section 2 of the mental health act used for?
admission for assessment for up to 28 days, not renewable
an Approved Mental Health Professional or rarely the nearest relative makes the application on the recommendation of 2 doctors
one of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)
treatment can be given against a patient’s wishes
What is section 3 of the MHA used for?
admission for treatment for up to 6 months, can be renewed
AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours
treatment can be given against a patient’s wishes
What are the preferred SSRIs for depression?
Citalopram and fluoxetine
What is the preferred SSRI post MI?
Sertraline
SSRIs should be used with caution in children and adolescents. What is the drug of choice if indicated?
Fluoxetine
ADRs of SSRIs?
GI symptoms are the most common
increased risk of gastrointestinal bleeding in patients taking SSRIs - a PPI should be prescribed if a patient is also taking a NSAID
risk of hyponatraemia
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
What drugs may SSRIs interact with?
NSAIDs
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine).
What discontinuation symptoms may be seen?
increased mood change
restlessness
difficulty sleeping
unsteadiness, dizziness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia, electric shock sensations
What are the risks of SSRIs during pregnancy?
Use during the first trimester gives a small increased risk of congenital heart defects
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Give 2 SNRIs
venlafaxine and duloxetine
Risk factors for suicide?
male sex
history of deliberate self-harm
alcohol or drug misuse
history of mental illness
depression
schizophrenia
history of chronic disease
advancing age
unemployment or social isolation/living alone
being unmarried, divorced or widowed
Risk factors for successful completion of suicide?
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method
Protective factors for suicide?
family support
having children at home
religious belief
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to ADRs and toxicity in overdose. They are used widely in the treatment of neuropathic pain, where smaller doses are required.
Give an example of a TCA.
What side effects may they cause?
Amitriptyline
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval
What can cause a sudden increase in clozapine blood levels?
Smoking cessation
