James Bloomer Psych Flashcards

Question

Overdose and poisoning management: | Cyanide

Answer 1

Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate

Answer 2

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)

Answer 3

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

Answer 4

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

Answer 5

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

Answer 6

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 -

Answer 7

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 ```

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

The presence of psychotic symptoms differentiates mania from hypomania Psychotic symptoms: Delusions of grandeur Auditory hallucinations

Answer 13

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

Answer 14

``` 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

Answer 15

``` 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 ```

Answer 16

Parkinsonism Acute dystonia (torticollis, oculogyric crisis) Akathisia (severe restlessness) Tardive dyskinesia (chewing and pouting of jaw most common)

Answer 17

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)

Answer 18

``` Depression - 30% Schizophrenia - 3% Sydenham's chorea Tourette's Anorexia ```

Answer 19

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

Answer 20

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

Answer 21

``` drowsiness dry mouth blurred vision constipation urinary retention ```

Answer 22

The mini-mental state examination is widely used. A score of 24 or less out of 30 suggests dementia

Answer 23

``` 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

Answer 24

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)

Answer 25

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

Answer 26

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

Answer 27

Patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hrs

Answer 28

Similar to 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours

Answer 29

Supervised Community Treatment

Answer 30

Court order to allow the police to break into a property to remove a person from a Place of Safety

Answer 31

Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety

Answer 32

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

Answer 33

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.

Answer 34

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

Answer 35

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

Answer 36

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 ```

Answer 37

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

Answer 38

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 ```

Answer 39

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 ```

Answer 40

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 ```

Answer 41

Monozygotic twin has schizophrenia = 50% Parent has schizophrenia = 10-15% Sibling has schizophrenia = 10% No relatives with schizophrenia = 1%

Answer 42

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

Answer 43

Extreme restlessness Poor concentration Uncontrolled activity Impulsiveness

Answer 44

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

Answer 45

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

Answer 46

Canadian Club Whiskey Tastes Nicer Hammered ``` C - Compulsion C - Cut down W - Withdrawal T - Tolerance N - Neglect H - Harmful ```

Answer 47

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)