Liaison/Gen Med Flashcards
What is another name for pathological crying or laughing?
Pseudobulbar affect
Which conditions may the pseudobulbar affect be seen in?
- Multiple Sclerosis (10% of patients)
- Post stroke (20%)
What’s the best treatment for pseudobulbar effect?
CITALOPRAM
but other TCAs and SSRIs work too
Which medication is to be avoided in HIV patients with mania as it interacts with antiretroviral agents and also carries the risk of neutropenia?
carbamazepine
What is the most appropriate antispychotic for individuals with HIV who require treatment for psychosis?
Risperidone
What is finding about depression in 1st degree relatives of people with MS?
rates of depression in 1st degree relatives of depressed patients with MS are much lower than rates of depression of in 1st degree relatives of people who do not have MS
What are some of the psychiatry manifestations of MS?
- fatigue
- DEPRESSION is most common
- anxiety
- mania
- pathological laughter and crying
In patients with suspected hypoparathyroidism what is an indicator of body stores of vitmin D?
25(OH)D3 is a reliable indicator of total body stores of vitamin D
What is the treatment of hypoparathyroidism?
combination of alfacalcidol and calcitriol
Chronic hypocalcaemia can cause?
- alopecia
- cataracts
- papilloedema
- tetany
- seizures
What is more common with endogenous Cushing: mania/depression?
Depression
What is more common with exogenous Cushing: mania/depression?
mania
Which is the most common neuropsychiatric condition that usually arises from Addison disease?
memory impairrment
Which scan is useful for diagnosing MS?
MRI
looks for focal white matter lesions
What’s the CSF finding for viral encephalomyelitis?
lymphocytosis with normal CSF/plasma glucose ratio
What are the clinical features of viral encephalomyelitis?
high fever, headaches, abrupt onset of confusion, change in personality and memory impairment, usually of acute onset.
Lyme disease overview
- caused by tick bites (borellia burgdorferi), usually lives on deers
- has 3 stages:
stage 1 - rash (red spot –> erythema migrans)
stage 2 - early neurological signs (15%) - meningitis,
radicular pain, facial palsy, perpheral neuropathies
stage 3 (7 years after diagnosis) - late neurological
signs - Bell’s palsy, dementia - neuropsych symptoms = poor memory, poor
concentration, fatigue, daytime hypersomnolence,
irritability, depression
Male to female rate for hypothyroidism
1:8 - 1:6
What are the features of MEN 1 syndrome?
- hyperparathyroidism
- pituitary adenoma
- pancreatic islet tumour
What are the features of uraemia?
Mental changes such as progressive torpor and drowsiness –> impaired memory, episodes of disorientation and confusion can occur, fascicular twitching, tremor, multi-focal myoclonus and muscle cramps
Rapid fluctuation between psychosis and normal periods have also been reported
Psychiatric abnormalities are present almost without exception in this disease. Difficulty with memory is a major feature. Other symptoms may include chronic physical exhaustion, emotional withdrawal, apathy, loss of motivation and sudden mood fluctuations. Loss of libido is common
Addisons
What can worsen Raynaud’s phenomena?
Beta blockers
Nicotine
Clonidine
Decongestants
What is the most likely site of the primary tumour which when metastatic could cause symptoms of peripheral neuropathy and memory loss?
Intestine
What is true about TCA use in HIV illness?
Lower doses of tricyclics can be used
What % of patients with SLE suffer with neuropsychiatric subtype?
50%
presents with one or more neuropsychiatric feature
What are the clinical criteria for PMDD as per DSMV?
- Most menstrual cycles during past year
- At least 5 of: depressed mood, marked anxiety, marked affective lability, marked anger or irritability, anhedonia, subjective sense of difficulty in concentrating, lethargy, marked change in appetite, hyper- or insomnia, sense of being overwhelmed or out of control, physical symptoms (breast tenderness, joint/muscle pain, bloating etc)
- Symptoms should begin to subside within a few days of menstruation and be absent the week after
What proportion of women are affected by PMS?
3-8% of women of reproductive age
What percentage of women with PMS have a comorbid mood disorder?
30-70%
How is severe PMDD treated?
Continuous or intermittent SSRIs (don’t just work as an antidepressant - other mechanism apparent as improvement noticed within one menstrual cycle)
What percentage of patients with CVD have comorbid depression?
20% (21% for heart failure)
What is the proposed mechanism by which SSRIs may be cardioprotective?
Reduction of platelet activation
What is the most common psychiatric symptom in hyperthyroidim?
Generalised anxiety
Patients can also present with depression, irritability, cognitive dysfunction, hypomania and mania (severe thyrotoxicosis)
What is myxoedema madness?
Psychosis secondary to severe hypothyroidism
What are the psychiatric symptoms of hypercalcaemia (hyperparathyroidism)?
Mild-moderate: depression, apathy, irritability
Severe: psychosis, catatonia, coma
What are the psychiatric symptoms of hypocalcaemia (hypoparathyroidism)?
Mild: anxiety, paraesthesia, emotional lability
Severe: mania, psychosis, tetany, seizures
What are the features of Cushing’s syndrome (excess cortisol)?
physical: diabetes, hypertension, obesity, osteopenia, muscle weakness
psychiatric: depression (most common), anxiety, hypomania/mania, psychosis
What are the features of Addison’s disease (depletion of cortisol)?
psychiatric: apathy, anhedonia, anorexia, fatigue, depressed mood
physical: nausea, vomiting, skin changes
What are the features of acromegaly (excess growth hormone)?
mood lability, personality change, depression
*psychosis secondary to treatment with dopamine agonists i.e. bromocriptine has been observed
What are the features of phaechomocytoma (excess catecholamines)?
physical: tachycardia, labile HTN, headache, sweating, palpitations (mimic panic attack)
psychiatric: IMPENDING DOOM
What is the best test for phaeochromocytoma?
plasma metanephrine level (urinary catecholamines can also be used)
How much more common is depression in diabetes?
2-3x
Which is more likely to cause cognitive dysfunction in diabetes patients - serial hypoglycaemia or hyperglycaemia?
hyperglycaemia
What is the prevalence of major depression in advanced cancer patients?
5-15%
What is the prevalence of delerium in patients with cancer?
44% - inpatients (rising to 62% shortly before death)
What adjustments should be made to antidepressants in renal failure?
Half dose of citalopram
Reduce dose of paroxetine
Avoid sertraline
What adjustments should be made to antipsychotics in renal failure?
Amisulpiride is contraindicated
Reduce dose of risperidone
What adjustments should be made to lithium in renal failure?
Avoid or lower dose
What adjustments should be made to benzodiazepines in renal failure?
Use with caution
Half lorazepam doses
When does uraemia occur?
eGFR <10
What are the psychiatric Sx of SLE?
depression, anxiety, pychosis (erarly)
What are the neuro CNS Sx of SLE?
peripheral neuropathy, seizures, chorea, severe headaches, b cell lymphoma, limbic encephalitis type picture
Which of the following drugs is most likely to precipitate porphyria?
Diazepam
The detection of what is needed to make a diagnosis of HIV?
P24 antigen
Mean age of onset of MS
The mean age of onset is between 20 and 40
Risk factors for SIADH
Being elderly
Being female
Being a smoker
Having medical co-morbidity
Polypharmacy
Low body weight
Low baseline sodium concentration
Reduced renal function
Warm weather
What is the most useful diagnostic indicator of depression in a patient with multiple sclerosis?
Suicidal ideation
Primary progressive multiple sclerosis constitutes what percentage of all cases of multiple sclerosis?
10%
*Steady progression with no remissions
Relapsing-remitting multiple sclerosis constitutes what percentage of all cases of multiple sclerosis?
20-30%
*Relapsing-remitting course but do not become seriously disabled
Secondary progressive multiple sclerosis constitutes what percentage of all cases of multiple sclerosis?
60%
*Course is initially relapsing-remitting but is then followed by phase of progressive deterioration
What are the lesions of MS?
multiple demylinating lesions with a predilection for the optic nerves, cerebellum, brainstem, and spinal cord
*predomnantly white matter disease
Ocular features of MS?
Optic neuritis (unilateral visual loss) Internuclear ophthalmoplegia (diplopia and/or nystagmus due to a problem arising from the midbrain) Ocular motor cranial neuropathy (e.g. sixth nerve palsy)
M:F MS
1:2
MS in relation to the equator
seen in greater frequency as the distance from the equator increases.
Risk factors for suicide in MS
Male gender Young age at onset of illness Current or previous history of depression Social isolation Substance misuse
Lifetime prevalence of depression in MS
40-50% (3x higher than general population)
Which medications are associated with priapism?
- Trazodone
- Chlorpromazine
- Thioridazine
What is the treatment for priapism?
alpha-adrenergic agonists - either as tablets or by injecting them into the penis!
Drugs that can cause renal stones?
Zonisamide
Topiramate
Drugs associated with prominent visual side effects?
Topiramate (closed angle glaucoma)
Vibagatrin (visual fields defects)
What is most likely drug associated with gum bleeding?
Carbamezepine
Which is the most appropriate treatment in a man who develops depression following a myocardial infarction?
Sertraline (SADHART study)
Drugs that can precipitate mania
Levodopa
Corticosteroids
Anabolic-androgenic steroids
Antidepressants (tricyclic and monoamine oxidase inhibitor classes)
Less evidence for these: Dopaminergic anti-Parkinsonian drugs Thyroxine Iproniazid and isoniazid Chloroquine
Which antidepressant has minimal interaction with Tamoxifen?
Venlafaxine
Which drugs for sedation are recommended in patients with liver failure?
Lorazepam, Oxazepam and Temazepam (short half lives and no active metabolites)
A 52 year old woman on sodium valproate is complaining of severe abdominal pain. What is the most likely cause for this presentation?
pancreatitis
Clozapine must be used with caution in conditions where anticholinergic effects can produce significant adverse reactions such as?
Glaucoma
BPH
Which antipsychotic medication can cause hypothyroidism?
Quetiapine
What is a common side effect of treatment with Carbamazepine?
Hyponatreamia is a common side effect, seen on treatment with Carbamazepine
Among Cholinesterase inhibitors whch is the safest to prescribe for patients with pre-existing cardiac problems mainly due to its lack of interaction with cardiac drugs?
Rivastigmine
Antidepressant with anti nausea properties?
Mirtazapine
Which antidepressants should be avoided with Tamoxifen?
Fluoxetine
Paroxetine
Duloxetine
Amitriptyline
Which antidepressants are low risk for GI bleeding?
Mirtazapine
Bupropion
Nortriptyline
Desipramine
Moderate risk: amitriptyline, venlafaxine
High risk: Sertraline, Paroxetine, fluoxetine, clomipramine
Which antipsychotic is most likely to cause orthostatic hypotension?
Risperidone
Proportion of people who take lithium that develop hypothyroidism?
10%
When is amisulpride contraindicated?
In renal failure
Which medication can increase the likelihood of neurotoxicity when prescribed with lithium?
Haloperidol
What is the age of onset of MS?
20-40
What is the lifetime risk of MS?
1 in 8000
What medications can be used in the management of MS?
Steroids Glatiramer acetate (Copaxone) - neuroprotective agent + immunomodulator (reduces relapse frequency)
What percentage of patients with MS die by suicide according to studies?
3% (over a 6 year period)
What percentage of people experience post-stroke depression and how long does it last?
35%
Mean duration = 34 weeks
What treatment is recommended for post-stroke depression?
Fluoxetine or Citalopram
What is the prevalence of post-stroke anxiety?
25%
Are mania and psychosis more common in MS or post stroke?
MS (rare post stroke)
How common is depression in patient with epilepsy?
30-50% (more common in temporal lobe epilepsy)
What is the suicide risk in patients with epilepsy?
10-15%
What is the management of depression?
SSRIs (but these may reduce seizure threshold, as does lithium)
How common is panic disorder in patients with epilepsy?
20%
Which AEDs may cause psychosis?
Vigabatrin
What are the risk factors for and features of pseudoseizures?
- Past psych hx
- Somatization
- Social stressors i.e. childhood abuse
- More likely to happen in daytime and when others are present
- Eyes kept tightly shut
- More likely to maintain body tone
- Alertness/orientation is regained quickly
- Crying or emotional displays may be seen
- Ability to recall events
- Incontinence has no diagnostic value
How common is Transient Global Amnesia?
5-10 per 100,000 pey year
What is the diagnostic criteria for TGA?
- Attacks must be witnessed
- Clear cut anterograde amnesia
- Absence of clouding of consciousness
- No focal neurology
- No features of epilepsy
- Attack must resolve within 24h
- No recent head injury
What is Fahr’s Disease?
Idiopathic progressive calcium deposition in basal ganglia
How does age of onset affect the presentation of Fahr’s disease?
Onset at 20-40y = schizophreniform psychosis and catatonia
Onset at 40-60y = dementia and chreoatheosis
What percentage of patients with Fahr’s Disease have psychiatric Sx?
50%
What is the difference between Fahr’s Syndrome and Fahr’s Disease?
Syndrome = known cause of calcium deposition i.e. hypoparathyroidism Disease = idiopathic
What is the presentation of Herpes Simplex Encephalitis?
- Abrupt onset of confusion, memory impairment and seizures
- Psychiatric Sx present in 70% (depression, psychosis, confusion)
What are the CSF findings in HSV Encephalitis?
Lymphocytosis and raised protein
CSF PCR positive for herpes virus
What is the mortality rate of HSV Encephalitis?
70% (untreated)
20-30% (treated)
What is the treatment of HSV Encephalitis?
IV Aciclovir (14 days minimum)
What are the features of Kluver-Bucy syndrome?
Bilateral temporal lobe damage (most commonly caused by HSV Encephalitis) leading to:
- Emotional blunting
- Hyperphagia
- Visual agnosia
- Inappropriate sexual behaviour
What is the management of Kluver-Bucy syndrome?
Carbamazepine (symptom control)
What is Meige Syndrome?
An idiopathic orofacial dystonia characterised by repetitive blinking and chin thrusting +/- lip pursing, tongue movements and shoulder movement
F>M
When is the peak incidence of head injury?
15-24y
What is concussion?
Transient coma (hours) followed by complete clinical recovery
What are the mechanism of TBI?
Axonal and neuronal damage from
- Shearing and rotational stresses
- Damage from direct trauma
- Brain oedema and raised ICP
- Brain hypoxia and ischaemia
What are the negative prognostic factors for TBI (re psychiatric morbidity)?
- duration of LOC
- long post traumatic amnesia
- elderly
- chronic ETOH use
- new onset of seizures
- lower GCS at 24h post injury
How is the severity of TBI classified?
Duration of post traumatic amnesia is used as proxy
- Mild = PTA < 60mins, may return to work within <1 month
- Moderate = PTA 1-24h, may RTW in 2m
- Severe = PTA 1-7d, may RTW in 4 months
- Very severe = PTA >7d, may require more than 1 year before RTW possible
What are the neuropsychiatric sequalae of TBI?
- cognitive impairment
- personality changes
- depression (most common)
- schizophrenia-like psychosis
- schizophrenia
- post-traumatic epilepsy (5% of closed TBI, 30% of open)
What is post-concussion syndrome?
Follows mild/moderate brain injury, controversial
Sx include: headache, dizziness, fatigue, poor memory/concentration, irritability/restlessness, depression, sleep disturbance, blurred vision, photophobia, nausea, tinnitus,
How are neuropsychiatric disorders in HIV classified?
Primary (directly due to CNS damage) i.e. HIV dementia
Secondary (due to drugs or opportunistic infections)
Reactive i.e. HIV associated acute stress reaction
What is the lifetime prevalence of mental disorders in HIV+ve patients?
38-73%
What is HIV associated acute stress reaction?
Follows diagnosis (minutes - hours) and remits within 2-3 days. May be followed by adjustment disorder (5-20% of patients).
What is the prevalence of anxiety in HIV+ve patients?
11-25%
What is the prevalence of depression in HIV+ve patients?
40% (common risk factors and symptoms)
How should depression in patients with HIV be treated?
SSRIs
TCAs (lower dose)
IPT - particularly useful
What is the most common reason for a HIV+ve patient to be admitted to inpatient psychiatric unit?
Mania (due to illicit drug use, antiretrovirals, steroids)
What are the psychiatric effects of zidovudine?
Confusion, agitation, insomnia, mania, depression
What are the psychiatric effects of stavudine, didanosine and zalcitabine?
Peripheral neuropathy, mania
What are the psychiatric effects of efavirenz?
Depression and psychosis (46% of patients)
What secondary organic brain diseases are associated with HIV?
- Progressive multifocal leucoencephalopathy (parvovirus)
- Cerebral toxoplasmosis (protozoa) - ring like lesions
treatment -> pyrimethamine, sulphadiazine - Cryptococcal meningitis (yeast-like fungus)
treatment -> amphotericin B IV, fluconazole, 5 flucytosine - Primary CNS lymphoma (EBV)
Which brain cells are least likely to be directly affected by HIV?
Neurons
The risk of HIV infection of health care workers after a needlestick accident
1/300
