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