James Bloomer Psych Flashcards
Unexplained symptoms:
Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
Unexplained symptoms:
Conversion disorder
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
Unexplained symptoms:
Hypochondrial disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Unexplained symptoms:
Dissociative disorder
dissociation is a process of ‘separating off’ certain memories from normal consciousness.
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
Unexplained symptoms:
Munchausen’s
also known as factitious disorder
the intentional production of physical or psychological symptoms
Unexplained symptoms:
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Typical Antipsychotic side-effects
Extrapyramidal side-effects
Parkinsonism
acute dystonia (e.g. torticollis, oculogyric crisis(upward deviation of the eyes))
akathisia (severe restlessness)
tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Other side-effects
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin: galactorrhoea, impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
Lithium
Mood stabilising drug used most commonly prophylatically 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 being excreted primarily by the kidneys.
Mechanism of action - not fully understood, two theories:
interferes with inositol triphosphate formation
interferes with cAMP formation
Adverse effects
nausea/vomiting, diarrhoea
fine tremor
polyuria (secondary to nephrogenic diabetes insipidus)
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
Monitoring of patients on lithium therapy
inadequate monitoring of patients taking lithium is common - NICE and the National Patient Safety Agency (NPSA) have issued guidance to try and address this. As a result it is often an exam hot topic
lithium blood level should ‘normally’ be checked every 3 months. Levels should be taken 12 hours post-dose
thyroid and renal function should be checked every 6 months
patients should be issued with an information booklet, alert card and record book
Overdose and poisoning management:
Paracetamol
Management
activated charcoal if ingested
Overdose and poisoning management:
Salicylate
Management
urinary alkalinization is now rarely used - it is contraindicated in cerebral and pulmonary oedema with most units now proceeding straight to haemodialysis in cases of severe poisoning
haemodialysis
Overdose and poisoning management:
Opioid/opiates
Naloxone
Overdose and poisoning management:
Benzodiazepines
Flumazenil
Overdose and poisoning management:
Tricyclic antidepressants
Management
IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias
dialysis is ineffective in removing tricyclics
Overdose and poisoning management:
Lithium
Management
mild-moderate toxicity may respond to volume resuscitation with normal saline
haemodialysis may be needed in severe toxicity
sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion
Overdose and poisoning management:
Warfarin
Vit K, prothrombin complex
Overdose and poisoning management:
Heparin
Protamine sulphate
Overdose and poisoning management:
Beta blockers
Management
if bradycardic then atropine
in resistant cases glucagon may be used
Overdose and poisoning management: Ethylene glycol (anti-freeze)
ethanol has been used for many years which works by competing with ethylene glycol for the enzyme alcohol dehydrogenase
this limits the formation of toxic metabolites (e.g. Glycoaldehyde and glycolic acid) which are responsible for the haemodynamic/metabolic features of poisoning.
Fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol.
Haemodialysis also has a role in refractory cases
Overdose and poisoning management:
Methanol poisoning
Fomepizole or ethanol
haemodialysis
Overdose and poisoning management:
Organophosphate insecticides
Atropine
the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit
Overdose and poisoning management:
Digoxin
Digoxin-specific antibody fragments
Overdose and poisoning management:
Iron
Desferrioxamine
Overdose and poisoning management:
Lead
Dimercapol, calcium edetate
Overdose and poisoning management:
Carbon monoxide
100% O2
Hyperbaric oxygen
Overdose and poisoning management:
Cyanide
Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate
Schneiders First-rank symptoms of schizophrenia
Auditory hallucinations of a specific type:
Two or more voices discussing the patient in the third person
Thought echo
Voices commenting on the patient’s behaviour
Thought disorder:
Thought insertion
Thought withdrawal
Thought broadcasting
Passivity phenomena
Delusional perceptions:
A two stage process where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
Other features of schizophrenia include
impaired insight
incongruity/blunting of affect (inappropriate emotion for circumstances)
decreased speech
neologisms: made-up words
catatonia
negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
Baby blues
Seen in around 60-70% of women
Typically seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
Mx: Reassurance and support, the health visitor has a key role
Postnatal depression
Affects around 10% of women
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
Mx: As with the baby blues reassurance and support are important
Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine (low milk/plasma ratio) may be used if symptoms are severe - whilst they are secreted in breast milk it is not thought to be harmful to the infant
Puerperal psychosis
Affects approximately 0.2% of women
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Mx: Admission to hospital is usually required
There is around a 20% risk of recurrence following future pregnancies
SSRI side effects?
GI symptoms are the most common side-effect
Increased risk of GI bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
Patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
Fluoxetine and paroxetine have a higher propensity for drug interactions
Prolonged QT interval -
PTSD symptoms
Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
Avoidance: avoiding people, situations or circumstances resembling or associated with the event
Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
Others: emotional numbing - lack of ability to experience feelings, feeling detached from other people depression drug or alcohol misuse anger unexplained physical symptoms
PTSD management
Debriefing is not recommended
Watchful waiting may be used for mild symptoms lasting less than 4 weeks
Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
Drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended
Alzheimers NICE treatment
NICE recommend the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
Memantine (a NMDA receptor antagonist) is reserved for patients with moderate - severe Alzheimer’s
Alzheimers pathological changes
Macroscopic: widespread cerebral atrophy, particularly involving the cortex and hippocampus
Microscopic: cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
Biochemical: there is a deficit of acetylecholine from damage to an ascending forebrain projection
Sleep paralysis
Features
Paralysis - this occurs after waking up or shortly before falling asleep
Hallucinations - images or speaking that appear during the paralysis
Management
If troublesome clonazepam may be used
Difference between mania and hypomania?
The presence of psychotic symptoms differentiates mania from hypomania
Psychotic symptoms:
Delusions of grandeur
Auditory hallucinations
Clozapine
One of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason clozapine should only be used in patients resistant to other antipsychotic medication
Adverse effects of clozapine
agranulocytosis (1%), neutropaenia (3%)
reduced seizure threshold - can induce seizures in up to 3% of patients
Atypical antipsychotics
Clozapine Olanzapine Risperidone Quetiapine Amisulpride
Adverse effects of atypical antipsychotics
weight gain
clozapine is associated with agranulocytosis
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke (especially olanzapine and risperidone)
increased risk of venous thromboembolism
Suicide risk factors (7)
Male sex Advancing age Unemployment or social Isolation Divorced or widowed History of mental illness (depression, schizophrenia) History of deliberate self harm Alcohol or drug misuse
Extra pyramidal side-effects of antipsychotics?
Parkinsonism
Acute dystonia (torticollis, oculogyric crisis)
Akathisia (severe restlessness)
Tardive dyskinesia (chewing and pouting of jaw most common)
Other side-effects of antipsychotics?
Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
Sedation, weight gain
Raised prolactin: galactorrhoea, impaired glucose tolerance
Neuroleptic malignant syndrome: pyrexia, muscle stiffness
Reduced seizure threshold (greater with atypicals)
Prolonged QT interval (particularly haloperidol)
OCD associations
Depression - 30% Schizophrenia - 3% Sydenham's chorea Tourette's Anorexia
St John’s Wort
Shown to be as effective as tricyclic antidepressants in the treatment of mild-moderate depression
Mechanism: thought to be similar to SSRIs (although noradrenaline uptake inhibition has also been demonstrated)
NICE advise ‘may be of benefit in mild or moderate depression, but its use should not be prescribed or advised because of uncertainty about appropriate doses, variation in the nature of preparations, and potential serious interactions with other drugs’
Adverse effects
Can cause serotonin syndrome
Inducer of P450 system, therefore decreased levels of drugs such as warfarin, ciclosporin. The effectiveness of the combined oral contraceptive pill may also be reduced
Tricyclic antidepressants
Used less commonly now for depression due to their side-effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.
low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
lofepramine has a lower incidence of toxicity in overdose
amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose
Tricyclic antidepressants side effects
drowsiness dry mouth blurred vision constipation urinary retention
Dementia
The mini-mental state examination is widely used. A score of 24 or less out of 30 suggests dementia
Anorexia nervosa physiological abnormalities?
Hypokalaemia Low FSH, LH, oestrogens and testosterone Raised cortisol and growth hormone Impaired glucose tolerance Hypercholesterolaemia Hypercarotinaemia Low T3
Most things low
G’s and C’s raised: Growth hormone, Glucose, salivary Glands, Cortisol, Cholesterol, Carotinaemia
Mental Health Act
Section 2
Admission for assessment for up to 28 days, not renewable
Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) 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)
Mental Health Act
Section 3
Admission for treatment for up to 6 months, can be renewed.
If known to mental health services or following a section 2.
AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours
Mental Health Act
Section 4
72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
A GP and an AMHP or NR
Often changed to a section 2 upon arrival at hospital
Mental Health Act Section 5(2)
Patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hrs
Mental Health Act Section 5(4)
Similar to 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours
Mental Health Act
Section 17a
Supervised Community Treatment
Mental Health Act
Section 135
Court order to allow the police to break into a property to remove a person from a Place of Safety
Mental Health Act
Section 136
Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
Neuroleptic malignant syndrome
Typically seen in patients who have just commenced treatment.
More common in young male patients
Onset usually in first 10 days of treatment or after increasing dose
Pyrexia
Rigidity
Tachycardia
A raised creatine kinase is present in most cases. A leukocytosis may also be seen
Management:
Stop antipsychotic
IV fluids to prevent renal failure
Dantrolene may be useful in selected cases
Bromocriptine, dopamine agonist, may also be used
Depression
NICE guidelines - things to consider
Manage suicide risk (this may include voluntary/compulsory admission)
Manage any safeguarding concerns for children or vulnerable adults in their care
Manage any co-morbid condition associated with depression (for example, alcohol or substance abuse)
Psychotic symptoms seek expert advice
Eating disorders seek expert advice
Dementia treat the underlying depression.
Discuss practical solutions to stresses contributing to depression.
Depression
NICE guidelines - treatment
Moderate - severe depression
Offer an antidepressant and a high-intensity psychological intervention
First episode:
Prescribing a generic selective serotonin reuptake inhibitor (SSRI), such as citalopram, fluoxetine, paroxetine, or sertraline.
Recuurent episode:
Prescribing an antidepressant that the person has had a good response to previously.
Avoiding antidepressants that the person has previously failed to respond to or could not tolerate.
Chronic physical health problem:
Sertraline due to lower drug interactions
Depression
NICE guidelines - treatment
Subthreshold or mild-moderate depression
General measures -
Sleep hygiene
Active monitoring for people who do want an intervention
Consider a psychological intervention. This is accessed by referral or self-referral to IAPT (Improving Access to Psychological Therapies).
Avoid the routine use of antidepressants, but consider this for people with a history of moderate or severe depression, subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years) or mild depression that is complicating the care of a chronic physical health problem.
The following ‘low-intensity psychosocial interventions’ may be useful:
Computerised CBT
Structured group physical activity programme
Group-based CBT
SSRI discontinuation syndrome
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms: Increased mood change Restlessness Difficulty sleeping Unsteadiness Sweating Gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting Paraesthesia
Bulimia nervosa
Management:
Referral for specialist care is appropriate in all cases
Cognitive behaviour therapy (CBT) is currently consider first-line treatment
Interpersonal psychotherapy is also used but takes much longer than CBT
Pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking
Diagnostic criteria for mild depressive episodes
At least 2 of the main 3 symptoms (anergia, anhedonia, depressed mood) of depression and at least 2 of the other symptoms should be present for a definitive diagnosis
Minimum duration of the whole episode is about 2 weeks
Other symptoms: Reduced concentration and attention Decreased self-esteem and confidence Feelings of guilt and unworthiness Bleak and pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep Diminished appetite and weight loss Psychomotor agitation or retardation Marked loss of libido
Diagnostic criteria for moderate depressive episodes
At least 2 of the main 3 symptoms (anergia, anhedonia, depressed mood) of depression and at least 3 (preferably 4) of the other symptoms should be present for a definitive diagnosis
Minimum duration of the whole episode is about 2 weeks
Individuals will usually have considerable difficulty continuing with normal work and social functioning
Other symptoms: Reduced concentration and attention Decreased self-esteem and confidence Feelings of guilt and unworthiness Bleak and pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep Diminished appetite and weight loss Psychomotor agitation or retardation Marked loss of libido
Diagnostic criteria for severe depressive episodes
All three of the typical symptoms should be present (anergia, anhedonia, depressed mood), plus at least four other symptoms, some of which should be of severe intensity
The minimum duration of the whole episode should last at least 2 weeks, but if the symptoms are particularly severe then it may be appropriate to make an early diagnosis
Can also experience psychotic symptoms with severe depressive episodes
Individuals show severe distress and/or agitation
Other symptoms: Reduced concentration and attention Decreased self-esteem and confidence Feelings of guilt and unworthiness Bleak and pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep Diminished appetite and weight loss Psychomotor agitation or retardation Marked loss of libido
Risk of developing schizophrenia?
Monozygotic twin has schizophrenia = 50%
Parent has schizophrenia = 10-15%
Sibling has schizophrenia = 10%
No relatives with schizophrenia = 1%
Dementia
Dementia is thought to affect over 700,000 people in the UK and accounts for a large amount of health and social care spending. The most common cause of dementia in the UK is Alzheimer’s disease followed by vascular and Lewy body dementia. These conditions may coexist.
Mx
In primary care a blood screen is usually sent to exclude reversible causes (e.g. Hypothyroidism). NICE recommend the following tests: FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels. Patients are now commonly referred on to old-age psychiatrists (sometimes working in ‘memory clinics’).
In secondary care neuroimaging is performed* to exclude other reversible conditions (e.g. Subdural haematoma, normal pressure hydrocephalus) and help provide information on aetiology to guide prognosis and management
ADHD characterised by?
Extreme restlessness
Poor concentration
Uncontrolled activity
Impulsiveness
Management of GAD
NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
Drug treatment
NICE suggest sertraline should be considered the first-line SSRI
interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
Management of panic disorder
NICE recommend a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Treatment in primary care
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
Signs of dependence
Canadian Club Whiskey Tastes Nicer Hammered
C - Compulsion C - Cut down W - Withdrawal T - Tolerance N - Neglect H - Harmful
Management of schizophrenia
NICE published guidelines on the management of schizophrenia in 2009.
Key points:
oral atypical antipsychotics are first-line
cognitive behavioural therapy should be offered to all patients
close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
