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?
Hyponopompic
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?
The 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, whereas 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Belief that a close acquaintance has been replaced by an imposter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 and 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
Section 2: admission for assessment
Section 3: admission for treatment
Section 5(2) Holding for a patient already on the ward
Sectrion 136: 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?
Section 2: 28 days
Section 3: 6 months
Section 5(2): 72 hours
Section 136: 24-36 hours
What is the requirement for recommendation for detainment under each of the non-emergency sections on the MHA?
Sections 2 and 3 = 2 doctors, with at least one being Section 12 approved
Section 5(2) = 1 doctor
Section 136 = a police officer
Under what section of the MHA is emergency treatment undertaken, and who may apply for it?
Section 4 - it only needs ONE doctor because it’s an emergency and the doctor 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 14 days of detention
OR
At any time: by the responsible clinician
Recall the process for forcibly medicating someone under the MHA
Under Section 3 can be forcibly medicated for 3 months, if then not consenting, need a SOAD assesment (second opinion appointed doctor)
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?
6 hours (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?
28 days
What are the appeal requirements to section 35 of the MHA?
You can’t appeal
What does section 37 of the MHA permit?
Treatment of a convicted criminal - otherwise like section 3
What are the appeal requirements to section 37 of the MHA?
Within 21 days to court, after 6 months to the MHRT (mental health review tribunal)
What section of the MHA is applied for by the Crown Court?
Section 41 - a restriction order
Under which section of the MHA can a serving prisoner be transferred to hospital?
Section 47 - when restriction is added = section 49
What is a community treatment order?
Discharge from a previous section providing certain conditions are met - requires renewal every 6 months
Describe the role of the Approved Mental Health Professional
95% are social workers, and are responsible for coordinating the assessment and 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 and 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 but Clozapine blocks D1 and 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 and 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 and VTE
Describe how the dosage of clozapine is controlled
Start low and titrate up slowly, if >48 hours missed medication, need to start again
Recall one caution of using clozapine
If patient stops smoking suddenly, the clozapine levels will suddenly go up
Recall 2 examples of typical antipsychotics
Haloperidol, chlorpromazine
Recall 4 examples of atypical antipsychotics
Clozapine, risperidone, apiprazole, 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 side effect of antipsychotics characterised by fever, altered mental status, muscle rigidity, and autonomic dysfunction
What is akathisia?
An unpleasant subjective feeling of restlessness
What is tardive dyskinesia?
Rhythmic involuntary movements of the mouth, face, limbs and trunk
Describe the monitoring process for patients who take antipsychotic medications
Basic obs + bloods (more frequent for clozapine) + assessment of movement disorders, nutritional status and physical activity + ECG if CVD risk factors 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 symptoms
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 and 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 and QT prolongation - but still the antidepressant of choice following an MI (this was asked in a PPQ so nb)
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 4-6 weeks to work
How long should SSRI medications be continued for?
6 months after remission of first episode, 2 years after remission if it’s a recurrence - gradually stop over 4 weeks
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 2 weeks before starting another SSRI
If fluoxetine, wait 4-7 days 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 but also constipation, HTN + raised cholesterol
What is the mechanism of action of TCAs?
Block serotonin and NA reuptake
What can TCAs be used for at low vs high doses?
Low dose: blocks H1 and 5HT and aids sleep
Higher doses: blocks all receptors and is 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 is 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 and 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 and 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?
2-4 weeks
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?
BARB increases duration of receptor opening, BDZ increases frequency of opening
barbidurate
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, whereas hypnotic will induce sleep
Give 2 examples of short-acting BDZs and recall their main clinical use
Teazepam, 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 and 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 2 weeks: reduce by 5mg every 2 weeks until 20mg/day, then reduce by 2mg every 2 weeks until 10mg/day, then reduce by 1mg every 2 weeks until 5mg/day, then reduce by 0.5mg every 2 weeks 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 and 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 some 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 disturbance/ urinary symptoms
Seizures
AKI
What regular monitoring should be done in lithium prescription?
Every 3 months: lithium levels, every 6 months: UandEs and 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 and (autonomically) unstable
In what time frame does the NMS develop?
4-11 days after starting any antipsychotic medication
What investigations should be done to identify NMS?
FBC (to show leucocytosis), UandEs (show high CK and AKI)
How should the NMS be managed?
- ABC
- AandE/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 and autonomic instability (so very similar to NMS but abrupt onset rather than gradual)
What symptom is likely to present in the serotonin syndrome but not the NMS?
Diarrhoea and Vomiting
How does management differ in the serotonin syndrome compared to the NMS?
All the same except the drug used is a BDZ (clonazepam) rather than dantrolene and 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 the short term side effects of ECT?
Headaches and 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 and 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 history 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 and molehills
What is the theoretical basis of psychodynamic psychotherapy?
Problems are shaped by childhood experiences –> causes conflict between conscious and 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 and emotional development, rather than aiming to understand thoughts and 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 and constipation but there are SO MANY causes, look for many and don’t be satisfied with one
How is delirium diagnosed?
Confusion Assesment Method
How is delirium managed?
Modify risk factors, exclude diagnosed dementia, treat the causes
What is the medical management of delirium?
PO antipsychotics, AVOID anticholinergics
What is the prognosis for delirium?
37% die within 6 months, 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 24 hours, and 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 AND promethazine (acronym = Lots Of Hallucinations and 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 30 mins for a response
If response only partial - repeat IM lorazepam dose
If no response: WAIT until >1hr since lorazepam, then give IM olanzapine OR IM haloperidol with promethazine
(note - 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 (think - makes sense that last thing on rapid tranq ladder (L–>O –> P+H) is for patients who are known and definitely do not have cardiac disease) -
Wait 30 mins for response and 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 30 mins for response OR olanzapine (repeat if partial response)
- If no response: wait 1 hour, then give lorazepam/ olanzapine
Recall the dosing for oral rapid tranquilisation medications
Lorazepam: 1-2mg (max in 24 hours = 4mg)
Olanzapine: 5-10mg (max in 24 hours = 20mg)
Haloperidol: 5-10mg (max in 24 hours = 20mg)
Promethazine: 25-50mg (max in 24 hours = 100mg)
Recall the dosing for IM rapid tranquilisation medications
Lorazepam: 1-2mg (max in 24 hours = 4mg)
Olanzapine: 5-10mg (max in 24 hours = 20mg)
Haloperidol: 2.5-5mg (max in 24 hours = 12mg)
Promethazine: 25-50mg (max in 24 hours = 100mg)
Describe how rapid tranquilisation should be monitored
Ensure baseline is taken
For oral PRN: monitor hourly for minimum one hour on NEWS form
For IM monitor every 15 mins for minimum 1 hour 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?
Subthreshold depression (2-5 symptoms) of depression for at least 2 years
What is atypical depression?
Just somatic symtpoms (weight gain, hypersomnia)
What can improve the symptoms of anxiety-induced insomnia?
Mood is increased by increased sleep and 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 history and collateral history, physical exam and MSE, bloods to check for anaemia, hypothyroidism and diabetes, and a rating scale (Eg PHQ9, CDI (children), EPDS (pregnancy)
Describe the MSE
Appearance
Behaviour
Speech (rate, tone, volume)
Emotion (mood subjective and objective, affect)
Thought (formal thought disorder? Content? (delusions)
Perception (illusion and hallucination)
Cognition (orientation to time/ place/ person), AMTS/MOCA score
Insight (into both diagnosis and treatment)
How is depression treated in children and young people?
If mild, watchful waiting, self-help and lifestyle advice
If moderate-severe:
- 5-11 y/os = family therapy, IPT/ individual CBT, referral made through CAMHS
- 12-18 y/os = psychological intervention, probably individual CBT, if really bad + fluoxetine
Must try and avoid medication if at all possible
Intensive psychological therapy thorugh CAMHS if completely unresponsive to treatment
How is depression treated in adults?
Check suicide risk
Step one: if initial suspected depression / subthreshold symptoms –> watchful waiting, with follow up in 2 weeks, education about sleep/ mind.co.uk etc
Step two: if persistent subthreshold/ mild symptoms: group/ computerised CBT/ guided self-help - only give medication if subthreshold symptoms last longer than 2 years
Step three: moderate symtoms/ persistent subthreshold refractory to step 2: individual CBT/IAPT + medications with regular review every 2 weeks for 3 months (or every week if suicidal )
Step four: 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 treatment, you can’t augment treatment 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 symptoms of insomnia and appetite reduction are evident and debilitating
Describe the side effect profile of sertraline
Smallest side-effect profile, so a good one to give to people with comorbid 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 trimester may cause congenital heart defects, in 3rd trimester 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 around 4 months, depression lasts around 6 months, there is complete recovery between 2 episodes
How can a manic episode be identified?
It’s more associated with irritability than elevated mood - they may have grandiose delusions, flight of ideas, over-optism OR suicidal ideas
How is mania diagnosed?
Need at least 3 characteristcs of mania on the MSE, lasting at least 7 days and causing an impaired occupational/ social functioning +/- psychosis
What is hypomania?
> 3 characteristics of mania lasting at least 4 days, 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?
More than 4 episodes per year