ICSM Year 5 Psychiatry Flashcards
What is the medical term for the state before falling asleep?
Hypnagogic
What is the medical term for the state before waking up?
Hypnopompic
What is an extracampine hallucination?
A sense of presence/ movement in the absence of a stimulus
What is an elemental hallucination?
Simple hallucinations eg. flashes of light/ noise
What is the term given to visual hallucinations in individuals who have lost their sight?
Charles de Bonnet syndrome
What are the 4 types of auditory hallucination?
- Thought echo (pt’s thoughts are projected out loud)
- 3rd person voices
- Running commentary
- Command
What is formication?
Tactile hallucinatory feeling of bugs crawling under your skin
What is the name given to the perception of meaningful images from a vague stimulus?
Pareidolic illusion
What is a delusion?
A fixed, false belief, held despite evidence to the contrary that is not explained by the patient’s background
What is a reference delusion?
Patient believes unsuspicious thing has reference to them, eg. TV programme dialogue refers to them
What is Ekbom’s syndrome?
The belief that one is infected with parasites
What is the difference between hypochondriasis and Munchausen/ factitious disorder?
Hypochondriasis is unconscious pretending to have a medical disorder
Munchausen is conscious
What is Othello syndrome?
False belief partner is being unfaithful
What are the names given to a delusionary disorder of excessive sexual desire (eg VIP is in love with them)?
Erotomania/ De Clerembault’s syndrome
What is capgras syndrome?
Belief that a close acquaintance has been replaced by an imposter
What is fregoli syndrome?
False belief that different people are in fact same person in multiple disguises
Fregoli was Italian actor - think one person acting as many
Recall the 3 types of thought disorder
Insertion, withdrawal + broadcasting
What is Cotard’s syndrome?
Nihilistic delusion in which pt believes they are rotting/ dead - can occur in severe depression
What is Knight’s move thinking?
Absence of clear links between successive thoughts
What is flight of ideas, and what psychiatric disorder is it a feature of?
Jumping of thoughts but, unlike Knight’s move, with a CLEAR LINK between ideas. A feature of mania but not of psychosis
What is the name given to when a person cannot answer a question without going into massive extra detail?
Circumstantiality
What is a neologsim?
The formation of new words, which may involve the combining of two words
When was the MHA made?
2007
Recall and differentiate between the 4 different non-emergency sections of the MHA under which a patient may be detained
S2: admission for assessment
S3: admission for tx
S5(2) Holding for a patient already on the ward
S136: Police order to remove someone who is mentally ill from a public place to a place of safety
What is the maximum duration of each of the non-emergency sections of the MHA?
S2: 28d
S3: 6m
S5(2): 72h
S136: 24-36h
What is the requirement for recommendation for detainment under each of the non-emergency sections on the MHA?
S2 + 3 = 2 DRs, with at least 1 being Section 12 approved
S5(2) = 1 DR
S136 = a police officer
Under what section of the MHA is emergency treatment undertaken, and who may apply for it?
S4: it only needs 1 DR because it’s an emergency + the DR MUST be S12 approved (a psychiatrist)
Who may apply for section 2/3 detainment under the MHA?
AMHP (approved mental health professional) or NR (nearest relative)
Who may apply for discharge from a section 2 MHA detention?
NR or Mental Health Review Tribunal (MHRT) within first 14d of detention
OR
At any time: by the responsible clinician
Recall the process for forcibly medicating someone under the MHA
Under S3 can be forcibly medicated for 3m, if then not consenting, need a SOAD assessment (second opinion appointed DR)
What qualification is required for someone to detain a patient under Section 4 of the MHA?
Must be a psychiatrist
What does section 5(4) of the MHA allow?
Detention of an inpatient by a nurse
What is the maximum duration of detention under section 5(4) of the MHA?
6h (detention by nurse)
What does section 17 of the MHA allow?
Allows leave from a current section, but is not permanent discharge
What does section 35 of the MHA permit?
Assesment of a patient accused of committing a crime
How long does assesment last under section 35?
28d
What are the appeal requirements to section 35 of the MHA?
You can’t appeal
What does section 37 of the MHA permit?
Tx of a convicted criminal - otherwise like section 3
What are the appeal requirements to section 37 of the MHA?
Within 21d to court
After 6m to the MHRT (mental health review tribunal)
What section of the MHA is applied for by the Crown Court?
S41: a restriction order
Under which section of the MHA can a serving prisoner be transferred to hospital?
S47
When restrictions are added: S49
What is a community treatment order?
Discharge from a previous section providing certain conditions are met
Requires renewal every 6m
Describe the role of the Approved Mental Health Professional
95% are social workers
Responsible for coordinating assessment + admission of a patient to hospital if needed
Describe the role of the Independent Mental Health Advocate
Advocate trained to help the patient find out their rights under the MHA + provide support - you can’t have one under sections 4, 5, 135 or 136
What does DoLS stand for?
Deprivation of Liberty Safeguards (within MCA 2005) - which can be within a carehome or hospital
What is the mechanism of action of most antipsychotic drugs vs clozapine?
Dopamine receptor antagonists: most block D2
Clozapine blocks D1 + D4
Recall some common side effects of anti-psychotics
Extrapyramidal - dystonia/ akathisia/ parkinsonisms/ tardive dyskinesias (more common in typicals)
Hyperprolactinaemia (galacorrhoea, amenorrhoea, gynaecomastia)
Weight gain
Why do atypical antipsychotic drugs have fewer side effects than typicals?
More selective (just antagonise D2 + 5-HT2 receptors)
What class of drug is the first line treatment in schizophrenia?
Atypical antipsychotic
What class of drug is the first line treatment in relapsed schizophrenia?
Typical antipsychotic
In the elderly, what extra risk do antipsychotic drugs carry?
Increased risk of stroke + VTE
Describe how the dosage of clozapine is controlled
Start low + titrate up slowly
If >48h missed medication, need to start again
Recall one caution of using clozapine
If patient stops smoking suddenly, clozapine levels will suddenly rise
Recall 2 examples of typical antipsychotics
Haloperidol
Chlorpromazine
Recall 4 examples of atypical antipsychotics
Clozapine
Risperidone
Aripiprazole
Olanzapine
Quetiapine
Recall one significant side effect to remember of clozapine
Agranulocytosis (1%)
Recall one drug interaction of clozapine
Lithium
What is neuroleptic malignant syndrome?
A major SE of antipsychotics characterised by:
Fever
Altered mental status
Muscle rigidity
Autonomic dysfunction
What is akathisia?
An unpleasant subjective feeling of restlessness
What is tardive dyskinesia?
Rhythmic involuntary movements of the mouth, face, limbs + trunk
Describe the monitoring process for patients who take antipsychotic medications
Basic obs + bloods (more frequent for clozapine)
Assessment of movement disorders, nutritional status + physical activity
ECG if CVD RFs present
When should an FBC be done in a patient taking clozapine?
At frequent intervals for monitoring + every time there’s an infection as need to check there’s no agranulocytosis
Recall the symptoms of suddenly stopping antidepressant medication
FIRM STOP
Flu-like Sx
Insomnia
Restlesness
Mood swings
Sweating
Tummy problems
Off-balance (ataxia)
Paraesthesia
Recall 4 examples of SSRIs
For Sadness, Panic, Compulsion:
Fluoxetine
Sertraline
Paroxetine
Citalopram
For approx how long do SSRIs make someone feel worse before they feel better?
1-2 weeks
Recall one important risk of SSRIs
May increase suicidal thoughts/ self-harm risk
Depression can stop people performing ADLs due to extreme lethargy/ apathy: when antidepressant begins to work + enable people to do things again, they are also more able to act on thoughts of self-harm
Recall one important interaction of SSRIs
Triptans
Interaction can cause serotonin syndrome, so ask about migraines
Recall one important side effect of citalopram
QT prolongation
Recall one important side effect of sertraline
Can cause arrhythmias + QT prolongation
But still the antidepressant of choice following an MI
Recall the main side effects of all SSRIs
The 5 ‘S’s:
Suicidal idealisation
Stomach (weight gain, DNV)
Sexual dysfunction
Sleep (insomnia)
Serotonin syndrome
When prescribing an SSRI for anxiety, how long should you advise the patient it may take to work?
Anxiety may initially worsen, will need 4-6w to work
How long should SSRI medications be continued for?
6m after remission of 1st episode
2y after remission if it’s a recurrence
Gradually stop over 4w
Recall 3 drugs that should be avoided in suicide risk, and 2 that are particualrly useful when there is a suicide risk
Avoid: TCAs, MAOIs, Venlafaxine - lethal in OD
Use: SSRIs (despite INITIAL suicide risk) or mirtazapine
How should different SSRI medications be switched?
Reduce dose over 2w before starting another SSRI
If fluoxetine, wait 4-7d after before starting new SSRI, due to long half life
What does SNRI stand for?
Serotonin-noradrenaline reuptake inhibitor
What is the main side effect of SNRIs?
Headache
Recall 2 examples of SNRIs
Venlaxafine
Duloxetine
Describe the side effects of SNRIs
Same ‘5S’ as SSRIs +
Constipation
HTN
Raised cholesterol
What is the mechanism of action of TCAs?
Block serotonin + NA re-uptake
What can TCAs be used for at low vs high doses?
Low dose: blocks H1 + 5HT + aids sleep
Higher doses: blocks all receptors- used in depression
Why are TCAs not given if there is risk of suicide?
Can be fatal in OD
What is one key contraindication for TCAs?
If patient also taking a monoamine oxidase inhibitor
Recall the side effects of TCAs
TCA:
Thrombocytopaenia
Cardiac (QT prolongation, ST elevation, heart block, arrhythmias)
Anticholinergic (urinary retention, dry mouth, blurry vision, constipation)
Also:
Weight gain + sedation from histaminergic receptor blockade
Postural hypotension from alpha-adrenergic receptor blockade
What are the anticholinergic side effects that are possible with all types of antidepressant?
“Can’t see, can’t pee, can’t spit, can’t shit”
Give 2 examples of TCAs
Amitriptyline
Clomipramine
What type of antidepressant is mirtazapine?
noradrenergic + specific serotonin antidepressant (NaSsA)
What is the most common side effect of mirtazapine?
Weight gain
When is mirtazapine indicated?
Triad of depression + insomnia + loss of appetite
Give 2 examples of MAOI antidepressants
Phenelzine
Selegiline
What does MAOI stand for?
MonoAmine Oxidase Inhibitor
What is the main risk of MAOI use?
Hypertensive cheese reaction
What type of antidepressant is moclobemide?
Reversible Inhibitor of Monoamine oxidase A (RIMA)
What is the max length of prescription for a BDZ drug?
2-4w
What is the mechanism of action of BDZs and BARBs?
Enhance GABA transmission at GABA-A receptor
How does the mechanism of action of BDZs and BARBs differ?
BDZ increases duration of receptor opening
BARB increases frequency of opening
Why are barbiturates more dangerous than BDZs?
Less selective so more excitatory transmission
Give 3 examples of long-acting benzodiazepene medications, and what these are useful for
Diazepam, lorazepam, chlordiazepoxide
Useful as an anxiolytic, in delirium tremens/ acute alcohol withdrawal
What is the difference between a sedative and a hypnotic drug?
Sedative reduces physical + mental activity without producing a loss of consciousness
Hypnotic: induces sleep
Give 2 examples of short-acting BDZs and recall their main clinical use
Temazepam
Oxazepam
Used as sedatives
What is a Z drug used to treat?
Treats insomnia (similar to a BDZ)
Give an example of a Z drug
Zopiclone
When should Z drugs be used?
Only when insomnia is severe + disabling
What is a key side effect of zopiclone?
Increased risk of falls
Describe the withdrawal process from zopiclone
1/8th the daily dose every 2w: reduce by 5mg every 2w until 20mg/d
Then reduce by 2mg every 2w until 10mg/d
Then reduce by 1mg every 2w until 5mg/d
Then reduce by 0.5mg every 2w until completely stopped
What is the antidote to zopiclone, and its mechanism of action?
Flumenazil (BDZ antagonist)
Why should zopiclone not be used in pregnancy?
Can cause a cleft lip
What are stimulants used to treat?
ADHD
Narcolepsy
Give 2 examples of stimulant drugs used to treat ADHD
Methylphenidate (Ritalin)
Dexaphetamine
What is the mechanism of action of stimulant drugs used in ADHD?
Potentiate the effect of monoamine neurotransmitters (DA, NA, 5HT)
Recall 6 side effects of stimulant drug use
Cardiac pathology
Drug-induced psychosis
Appetite suppression
“Risky” behaviour
Insomnia
Impulsivity
What are mood stabilising drugs used to treat?
BPAD
Schizoaffective disorder
What are the 4 main mood stabilising drugs?
Lithium (1st line)
Valporate (2nd line)
Carbamazapine
Lamotrigine
Recall 4 key side effects of lithium
Mild tremor
Hypothyroidism
Eyebrow hair loss
Nephrogenic DI
How does a lithium OD present?
Tremor
Ataxia
GI / urinary Sx
Seizures
AKI
What regular monitoring should be done in lithium prescription?
Every 3m: lithium levels
Every 6m: U+Es + TFTs
Why should lithium not be used in pregnancy?
Causes Ebstein’s abnormality (heart defect)
Recall 2 key side effects of valporate
Hair loss + weight gain
What is the main risk of using valporate in pregnancy?
Spina bifida
Do NOT prescribe to a woman of child-bearing age unless a pregnancy prevention programme is in place
What is the main risk of using carbamazipine in pregnancy?
Spina bifida
What is the key side effect of lamotrigene use?
Severe skin rash - SJS
What is the most likely drug to cause the neuroleptic malignant syndrome?
Haloperidol
Recall the symptoms of the NMS
Gradual onset triad of:
Mental status change (catatonia)
Muscular rigidity
Autonomic instability (hyperthermia + labile BP)
“MMA” fighters are muscular, mental + (autonomically) unstable
In what time frame does the NMS develop?
4-11d after starting any antipsychotic medication
What investigations should be done to identify NMS?
FBC (to show leucocytosis)
U+Es (show high CK + AKI)
How should the NMS be managed?
- ABC
- A+E/ ITU admission
- Stop antipsychotics
- Supportive (fluids, dialysis etc to deal with AKI)
- Dantrolene, bromocriptine
Recall the symptoms of the serotonin syndrome
ABRUPT onset triad of:
Mental state change
Neuromuscular changes
Autonomic instability (very similar to NMS but ABRUPT rather than gradual)
What symptom is likely to present in the serotonin syndrome but not the NMS?
D+V
How does management differ in the serotonin syndrome compared to the NMS?
The same except the drug used is a BDZ (clonazepam) rather than dantrolene + bromocriptine
How does ECT work?
Induces a generalised tonic-clonic seizure under general anaesthetic
What are the indications for ECT?
ECT:
Euphoric (manic episodes)
Catatonia (not moving in an unusual position)
Tearful (severe depression that is life-threatening)
What is an absolute contraindication for ECT?
Raised intracranial pressure
What are 5 short term side effects of ECT?
Headaches
Nausea
Muscle aches
Cardiac arrhythmia
Retrograde amnesia (loss of memories before the ECT)
What is the main target of CBT?
So-called ‘Negative Automatic Thoughts’
What is Beck’s negative cognitive triad
Self-perpetuating triad of:
- Negative self-view
- Negative future view
- Negative world view
Describe the negative cycle that CBT aims to tackle
Thoughts (eg “She didn’t smile at me when she walked past”)
–> emotions (“I’m such a nobody, no one acknowledges me”
–> behaviours (“I’m going to avoid everyone + not waste their time”)
Recall the name of 2 CBT methods used to tackle negative thought patterns
Longitudinal format/ hot-cross bun methods
Describe the longitudinal format of CBT
- Get a detailed hx from early life to present: identify early experiences, critical incidents etc
- How do these early experiences affect core beliefs? (Beck’s triad)
- Identify NATs: eg mental filters/ predictions/ mountains + molehills
What is the theoretical basis of psychodynamic psychotherapy?
Problems are shaped by childhood experiences
–> causes conflict between conscious + unconscious mind
Therapy reveals unconscious mind
What is the difference between psychoanalytics and psychodynamics?
Psychoanalytics = internal conflicts
Psychodynamics = interpersonal conflicts
How does the aim of psychodynamic psychotherapy differ from CBT primarily?
Aims to change personality + emotional development, rather than aiming to understand thoughts + see how that impacts the individual
Recall 4 protective factors against suicide
Married
Lithium medication
Faith
No substance abuse
What is the reversing agent for overdose on a BDZ?
Flumenazil
What is the reversing agent for overdose on a Z drug?
Flumenazil
What is the reversing agent for overdose on an opiate?
Naloxone
What is the reversing agent for overdose on paracetamol?
N-acetylcysteine
What is delirium?
Disturbance of attention/ awareness that develops over a short period of time that is a change from baseline - that can’t be better explained by another condition
What are the most important differentials to consider in delirium?
Infection
Medication
Constipation
SO MANY causes, look for many + don’t be satisfied with 1
What assessment tools are used for delirium diagnosis?
Confusion Assesment Method
4AT
Describe the conservative management of delirium
Re-orientation techniques
Treat precipitants
De-escalation techniques for distress + agitation
What is the medical management of delirium?
Haloperidol
Lorazepam (if parkinsons)
Chlordiazepoxide (if alcohol withdrawal)
What is the prognosis for delirium?
37% die within 6m
Only 25% have a clinically important recovery in ADLs
What drug can be used IM to rapidly tranquilise if the individual refuses PO medications?
IM lorazepam
Recall 3 things that are important to consider before the administration of rapid tranquilisation
- Is there an advance decision in place?
- What is the therapeutic goal (ie. desired level of sedation)?
- What medicines have they had in the past 24h + how did they respond?
How should the INITIAL method of rapid tranquilisation differ between an unknown/ neuroleptic naïve patient, and a patient with a confirmed history of antipsychotic use?
PO medication (not IM)
Unknown/naïve pt: lorazepam
Known/ confirmed antipsychotic use: lorazepam/ olanzapine/ haloperidol + promethazine (acronym = Lots Of Hallucinations + Panic)
How long should be left to assess a patient’s response to oral tranquilisation?
1 hour at least
What is the convention for IM tranquilisation in an unknown/ neuroleptic naïve patient?
IM Lorazepam: wait 30m for a response
If response only partial: repeat IM lorazepam dose
If no response: WAIT until >1h since lorazepam, then give IM olanzapine OR IM haloperidol + promethazine
(check there is no cardiac disease with ECG)
Acronym for orders of anti-psychotics = Lots Of Hallucinations AND Panic (Lorzaepam, Olanzapine, Haloperidol AND promethazine)
What is the most important factor to guide use of IM medication for rapid tranq in a known patient/ patient with a confirmed history of antipsychotic use?
Presence/ absence of cardiac disease
What is the convention for administering IM tranquilisation in a known patient with NO cardiac disease?
Start with haloperidol with promethazine (Last thing on rapid tranq ladder (L–>O –> P+H) is for patients who are known + definitely do not have cardiac disease)
Wait 30m for response + repeat if response only partial
If no response: lorazepam (if not already used) or olanzapine
What is the convention for administering IM tranquilisation in a known patient WITH cardiac disease?
- Lorazepam: wait 30m for response OR olanzapine (repeat if partial response)
- If no response: wait 1h, then give lorazepam/ olanzapine
Recall the dosing for oral rapid tranquilisation medications
Lorazepam: 1-2mg (max in 24h = 4mg)
Olanzapine: 5-10mg (max in 24h = 20mg)
Haloperidol: 5-10mg (max in 24h = 20mg)
Promethazine: 25-50mg (max in 24h = 100mg)
Recall the dosing for IM rapid tranquilisation medications
Lorazepam: 1-2mg (max in 24h = 4mg)
Olanzapine: 5-10mg (max in 24h = 20mg)
Haloperidol: 2.5-5mg (max in 24h = 12mg)
Promethazine: 25-50mg (max in 24h = 100mg)
Describe how rapid tranquilisation should be monitored
Ensure baseline is taken
For oral PRN: monitor hourly for minimum 1h on NEWS form
For IM monitor every 15m for minimum 1h on rapid tranquilisation monitoring form
What are the 2 core symptoms of depression?
Low mood + anhedonia
What are the adjunct symtpoms of depression?
Fatigue
Insomnia
Concentration problems
Appetite change
Suicidal thoughts/ acts
Agitation/ slowing of movements
Guilt
Recall 3 medications that may cause depression
Steroids
COCP
Propranalol
What is dysthymia?
Sub-threshold depression (2-5 Sx) of depression for at least 2y
What is atypical depression?
Just somatic Sx (weight gain, hypersomnia)
What can improve the symptoms of anxiety-induced insomnia?
Mood is increased by increased sleep + eating
What is a depressive stupor?
Such extreme psychomotor retardation that the individual grinds to a halt
Recall the roles of the different monoamines, which are reduced in depression
Noradrenaline (mood, energy)
5-HT/serotonin (sleep, appetite, memory, mood)
Dopamine (psychomotor activity, reward)
How would you go about investigating for depression?
Full hx + collateral hx
Physical exam + MSE
Bloods to check for anaemia, hypothyroidism + diabetes
Rating scale (Eg PHQ9, CDI (children), EPDS (pregnancy)
Describe the MSE
Appearance
Behaviour
Speech (rate, tone, volume)
Emotion (mood subjective + objective, affect)
Thought (formal thought disorder? Content? (delusions)
Perception (illusion + hallucination)
Cognition (orientation to time/ place/ person), AMTS/ MOCA score
Insight (into both dx + tx)
How is depression treated in children and young people?
If mild, watchful waiting, self-help + lifestyle advice
If moderate-severe:
5-11y = family therapy, IPT/ individual CBT, referral made through CAMHS
12-18y = psychological intervention, probably individual CBT, if really bad + fluoxetine
Must try to avoid medication if at all possible
Intensive psychological therapy thorugh CAMHS if completely unresponsive to tx
How is depression treated in adults?
Check suicide risk
- Initial suspected depression / sub-threshold Sx: watchful waiting, with follow up in 2w, education about sleep/ mind.co.uk etc
- Persistent sub-threshold/ mild Sx: group/ computerised CBT/ guided self-help - only give medication if sub-threshold Sx last > 2y
- Moderate Sx/ persistent sub-threshold refractory to 2: individual CBT/IAPT + medications with regular review every 2w for 3m (or every week if suicidal )
- Severe depression/ risk to life/ neglect: high-intensity psychsocial interventions, section if necessary, medications, ECT if necessary
What is the first line antidepressant medication?
SSRIs (sertraline, citalopram, fluoxetine, paroxetine)
When should a second line antidepressant be tried?
After trying 2 different SSRIs
What is the second line antidepressant medication?
SNRIs (venlaxafine, duloxetine)
Recall the stepped increase of dose of venlaxafine
37.5mg BD –> 75mg BD –> 75mg morning, 150mg evening
What is the indication for 3rd line antidepressant treatment?
If they are resistant to tx, you can’t augment tx with further medication
What are the 3rd line treatment options for depression medication?
Antipsychotic (eg quetiapine), lithium, or other antidepressant eg mirtazapine
What is the ideal blood level of lithium?
0.6-1.0 (toxicity at >2.0)
In which scenario is mirtazapine most useful?
When Sx of insomnia + appetite reduction are evident + debilitating
Describe the side effect profile of sertraline
Smallest SE profile, so good to give to people with co-morbid IHD
What is the best antidepressant to give to children?
Fluoxetine
What is the most common use of paroxetine?
For major depressive episodes
When should paroxetine not be used and why?
Pregnancy:
In 1st trim may cause congenital heart defects
In 3rd trim may cause persistent pulmonary HTN
How can you differentiate between psychotic depression and schizophrenia in the history?
“He wants to kill me”, “Why is that?”, “the world is better off without me” = depression
“I have no idea, but I got the message “ = schizophrenia
How is BPAD defined in the ICD-10?
> /= 2 episodes
1 must be manic
Mania lasts ~4m
Depression lasts ~6m
Complete recovery between 2 episodes
How can a manic episode be identified?
It’s more associated with irritability than elevated mood
May have grandiose delusions, flight of ideas, over-optism OR suicidal ideas
How is mania diagnosed?
Need >,3 characteristics of mania on the MSE, lasting at least 7d + causing an impaired occupational/ social functioning +/- psychosis
What is hypomania?
> 3 characteristics of mania lasting >,4d
No impairment of functioning
No delusions/ psychosis
What is the difference between type 1 and type 2 BPAD?
Type 1 has proper manic episodes
Type 2 has recurrent depressive episodes with less prominent hypomanic episodes
What is rapid cycling BPAD?
> 4 episodes per year