Liaison Psychiatry Flashcards
1
Q
What is Premenstrual syndrome (PMS)?
A
Collection of psychological and somatic sx occurring during the luteal phase of menstruation.
2
Q
How many patients with PMS suffer from severe PMS?
A
5%
3
Q
How many women suffer from severe PMS?
A
3-8%
4
Q
% of women with severe PMS who have a comorbid mood disorder?
A
30-70%
5
Q
What are women with PMDD at higher risk of?
A
Postnatal depression
6
Q
Where in ICD is Premenstrual tension syndrome?
A
Diseases of the Genitourinary tract
7
Q
Where was PMS classified in DSM IV?
A
Under depressive disorder not otherwise specific
8
Q
Where is PMS in DSM V?
A
As a diagnosis
9
Q
Which sx of PMS are not seen in depression?
A
Breast pain
Bloating
10
Q
At least 1 of which sx must be present for a diagnosis of PMDD for DSM V
A
Depressed mood
Marked anxiety
Marked affective lability
Marked anger or irritabiity
11
Q
Duration of sx for diagnosis of PMDD for DSM V
A
In most menstrual cycles during past year, at least 5 of the 11 sx including one of the first 4 should be present
12
Q
What are the other sx for PMDD under DSM V aside from the first 4
A
Anhedonia
Subjective sense of difficulity concentrating
Lethargy
Marked change in appetite or specific food craving
Hypersomnia/insomnia
Subjective sense of being overwhelmed/loss of control
Physical sx
13
Q
When must sx be present for PMDD diagnosis in DSM V
A
Must be present most of the time during lat week of luteal phase
Must begin to remit within few days of onset of menstrual flow
Must be absent in the week after menses
14
Q
Functional criteria for PMDD dx under DSM V
A
Sx must markedly interfere with work, school, social activities or relationships
15
Q
Exclusion criteria for PMDD
A
Sx cannot be an exacerbation of another disorder such as depression
16
Q
How must criteria be confirmed for PMDD under DSM V?
A
By prospective daily ratings for at least 2 consecutive menstrual cycles
17
Q
Pattern for symptoms in PMS
A
During each cycle, sx last for a few days to up to 2 weeks.
Peak is 2 days before menses.
18
Q
Hypothesis of pathology underlying PMS
A
Increased sensitivity to normal fluctuation of gonadal hormones.
19
Q
How do we know that serotonin has a role in PMS?
A
Serotonin-enhancing treatments reduce PMS symptoms.
Impairment in serotonin transmission provokes sx.
20
Q
What does imaging suggest re the pathology of PMS?
A
May be a role of GABA due to its interaction between progesterone metabolites and GABA-A receptors
21
Q
Treatment of mild PMS
A
Lifestyle changes
CBT
Exercise/diet
22
Q
Treatment for severe PMS
A
SSRIs
23
Q
SSRI response rate for PMS
A
60-90% compared with 30-40% with placebo
24
Q
Effective medications for PMS
A
Fluoxetine or Sertraline (best)
Citalopram
Escitalopram
Clomipramine
Venlfaxine
25
Which non-SSRIs can be used for PMS?
Clomipramine
Venlafaxine
26
Which SSRIs can be used for PMS?
Fluoxetine
Sertraline
Citalopram
Escitalopram
27
Impact of SSRIs on PMS?
Reduce mood and somatic sx
Improve QoL and social functioning
28
Most effective drug for PMS
Fluoxetine
29
What other dosing regime can be used for PMS?
Intermittent dosing during luteal phase; 2 weeks prior to menses.
30
Odds ratio of SSRI treatment for PMS
6.91 in favour of SSRIs compared with placebo
31
Difference in sx reduction between continuous and intermittent dosing for PMS?
No difference
32
Disadvantages of intermittent dosing for PMS?
Lower efficacy for somatic sx
33
Advantages of intermittent dosing for PMS
More effective than continuous
Cheaper
Less withdrawal due to SEs
34
When do SSRIs become effective for PMS?
WIthin a few days
35
Difference in side effects if SSRIs used for depression vs. PMS
In PMS lower frequency of sexual side effects and no reports of akathisia or increased suicidal ideation
36
Which other medications can be used (with caution) in PMS?
Alprazolam in premenstrual insomnia and anxiety
Hormonal treatment
37
How does hormonal treatment work in PMS?
Suppresses ovulation
38
Which hormonal treatments can be used for PMS?
Long-acting GnRH agonist, oestrogen
39
When should hormonal treatment be considered for PMS?
Only as last resort
40
Possible consequences of hormonal treatment for PMS
Introducing early menopause
41
Remission rates of PMS
Low on cessation of treatment
42
How many patients with coronary heart disease have comorbid depression?
20%
43
What type of interventions can reduce depression in patients with coronary artery disease?
Psychological & behavioural
44
Risk of patients with persistent depression who also have coronary artery disease?
Increased cardiac risk
45
Studies in patients with coronary artery disease and depression
Enhancing Recovery in Coronary Heart Disease (ENRICHD) for CBT
Myocardial Infarction and Depression Intervention Trial (MIND-IT)
Canadian Cardiac Randomization Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) for interpersonal therapy
COPES - problem-solving therapy trial
Women's Heart Study - CBT based stress management
46
What do ENRICHD and MIND-IT show?
CBT only has modest effects on depression and neither improve survival.
47
What is the largest randomised trial evaluating use of antidepressants on depressed patients with heart disease?
Sertraline Antidepressant Heart Attack Randomized Trial (SADHART)
48
Structure of SADHART
Compared Sertraline v placebo in 16 week trial
49
Results of SADHART
No difference in safety (LVEF, premature ventricular contractions, QTc prolongation)
Nonsignificant reduction in endpoint (MI or CHD death) in Sertraline group
50
What did SADHART show re impact of Sertraline on depression?
Little difference in depression status after 24 weeks treatment
Effect of Sertraline greater in patients with severe and recurrent depression
51
Prevalence of depression in CCF patients
21.5% (2-3 times higher than general population)
52
What is higher prevalence of depression in CCF associated with?
Females
Higher NYHA functional class
53
Relative risk of mortality in patients with CCF who are depressed
2:1 compared to risk in non-depressed CCF patients
54
What does severe depression in CCF increase rates of?
Clinical events
Rehospitalisation
General health care use
55
Psychiatric sx in hyperthyroidism
Generalised anxiety
Depression
Irritability
Hypomania
Cognitive dysfunction
Mania in severe thyrotoxicosis
56
M:F ratio of hypothyroidism
1:6
57
Psychiatric sx of hypothyroidism
Depression
Cognitive dysfunction
Psychosis in severe cases
58
What is subclinical hypothyroidism a risk factor for?
Depression
Rapid cycling in Bipolar
59
Sx at mild-moderate (10-14) hyperparathyroidism?
Depression
Apathy
Irritability
Lack of initiative
60
Sx at severe (>14) hyperparathyroidism
Delirious with psychosis
Catatonia
Lethargy progressing to coma
61
Sx in mild hypoparathyroidism
Anxiety
Paresthaesias
Irritability
Emotional Lability
62
Sx in severe hypoparathyroidism
Mania
Psychosis
Tetany
Seizures
63
Most common cause of Cushings Syndrome
Exogenous steroids
64
What causes Cushings disease?
ACH secretion from pituitary tumour
Corticosteroid secretion from adrenal adenoma
65
Physical sx of Cushings syndrome
Diabetes
Hypertension
Muscle weakness
Obesity
Osteopenia
66
Psychiatric sx of Cushings syndrome
Depression (most common)
Anxiety
Hypomania/mania
Psychosis
Cognitive dysfunction
67
Which type of steroid is more likely to produce mania?
Exogeneous
68
Psychiatric sx of Addisons
Apathy
Anhedonia
Fatigue
Depression
Anorexia
69
Which sx are present in Addisons but not in depression?
Nausea, vomiting
Skin changes 0 dark pigmentation
70
What causes Acromegaly?
Excess growth hormone
71
Psychiatric sx of Acromegaly
Mood lability
Personality change
Depression
72
How can Acromegaly cause psychosis?
With treatment of Bromocriptine - dopamine agonist
73
Cause of Phaechromocytoma?
Catecholamine-secreting tumour
74
Physical sx of Phaechromocytoma>
Tachycardia
Labile hypertension
Headache/sweating
Episodic palpitations
75
How is Pheochromoctyoma screened?
Urinary catecholamines - Vanillyl mandelic acid, metanephrines
76
Best diagnostic test for Pheochromoctyoma?
Plasma metanephrine level
77
Rates of depression in patients with Diabetes
2-3 times more common compared to general population
78
Correlation between Depression and Diabetes
Poorer glycaemic control
Increased diabetic complication
79
Which psychiatric disorders have increased prevalence of TII DM?
Bipolar
Schizophrenia (2-4 times higher)
Severe depression
80
How can Diabetes lead to cognitive dysfunction?
Frequent hyperglycaemic episodes result in cerebral micro and macrovascular damage
81
Prevalence of depression in those with advanced cancer
5-15%
82
Which sx are not useful in diagnosing depression in those with advanced cancer?
Somatic sx
83
What is a useful criterion for depression in those with advanced cancer?
Pervasive global anhedonia
84
Drug treatments for depression in palliative care
SSRI
Low dose Amitriptyline
Lofepramine
Rapid-acting psychostimulants e.g. Dexamphetamine/methylphenidate
85
When should Amitriptyline be avoided in palliative care?
High risk of delirium
86
When is Amitriptyline helpful in palliative care?
Neuropathic pain
87
Prevalence of delirium in cancer in-patients?
44%
88
Prevalence of delirium in patients shortly before death
62%
89
Impact of diazepam use in end stage renal disease?
The metabolite desmethyldiazepam may accumulate, causing excessive sediation
90
Impact of Lorazepam in end stage renal disease
Half life increased from 8-25 hours to 32-65 hours.
91
By how much should lorazepam dose be reduced in low level of renal function?
By 50%
92
Which antidepressants can be used at normal dose in renal impairment?
Imipramine
Amitriptyline
Fluoxetine
Fluvoxamine
93
Which antidepressant should not be used in renal impairment?
Sertraline
94
Which medications should be reduced in renal impairment and the elderly?
Half dose of Citalopram
Reduced dose in Paroxetine
95
Which antipsychotic should be avoided in renal impairment?
Amisulpride
96
Which antipsychotic does not require dose reduction in renal impairment?
Haloperidol - unless excessive sedation or hypotension occur
97
Dosing of Amisulpride in renal failure if no other option
Alternate day dosing or dose reduction
98
Impact of Risperidone in renal impairment
Active metabolite 9-hydroxy-risperidone is excreted in urine so eliminatino half life is prolonged
99
When does uraemic encephalopathy occur?
When eGFR falls to 10% of normal
100
Sx of uraemic encephalopathy
Cognitive dysfunction
Psychomotor activity
Change in personality
Vomiting
Restlessness
Myoclonus
Coma
101
What is dialysis disequilibrium syndrome?
Temporary clinical disorder that may occur during first few days of dialysis.
102
Who is dialysis disequilibrium syndrome more common in?
Younger patients
Pre-existing neurological problems
103
Sx of dialysis disequilibrium syndrome?
Headache
Restlessness
Nausea/vomiting
HTN
Tremor
Disorientation
Seizures
104
What are most of the sx of dialysis disequilibrium syndrome a result of?
Cerebral Oedema
105
What causes Lyme disease?
Borrelia burgdorgeri transmitted via wooden tick bite which lives on deers.
106
Signs of Lyme disease
Red spot develops around location, and develop a central clearing called erythema migrans within 4 weeks.
107
How many patients with erythema migrans develop neuroborreliases?
15%
108
What is neuoborreliases?
Lyme disease where CNS is affected
109
Sx of Lyme disease
Back pain worse at night
Facial numbness
Facial palsy
110
Where is Lyme disease common?
North America
111
Sx of late-stage Lyme disease
Memory impairment
Word-finding problems
Visual/spatial processing impairment
Slowed processing of information
Psychosis
Seizures
Violent behaviour
112
Psychiatric sx of SLE
Depression
Anxiety
Psychosis (Rare)
113
Physical sx of SLE
Chronic, remitting-relapsing course of febrile illness, butterfly rash, inflammation of joints, kidney and serosa
114
In which patients with SLE is butterfly rash common?
Middle-aged women
115
What characterises SLE?
Anti-nuclear antibodies
116
CNS manifestations of SLE
Peripheral neuropathy
Grand mal seizures
Chorea and choreoathetosis
Cognitive impairment
Severe headaches
Stroke
B Cell Lymphoma
Limbic-encephalitis type picture
117
Sx of Insulinoma
Recurrent headache
Lethargy
Diplopia/blurred vision - with exercise/fasting
Psychosis/depression
118
What is Neurosarcoidosis?
Idiopathic granulomas in various tissue - mainly lungs and mediastinal node.
May affect CNS - mainly CN.
119
Sx of neurosarcoidosis
Bilateral facial palsy
Depression - 20%
Psychosis
Erythema nodosium
120
Blood test results in Neurosarcoidosis
Raised ACE levels due to macrophage activity
121
Treatment of Neurosarcoidosis
Immunosuppression
122
What happens in Metachromatic Leucodystrophy (MLD)?
Impairment of development of myelin sheath.
123
Cause of MLD
Genetic defecs of enzyme arylsulfatase A.
124
Forms of MLD
Late infantile
Juvenile
Adult
125
What is the most common form of MLD?
Late infantile
126
Signs of late infantile MLD?
Children have difficulting walking after first year of life
Muscle wasting/weakness
Muscle rigidity
Developmental delays
Progressive loss of vision leading to blindness
Convulsions
Impaired swallowing
Paralysis
Dementia
127
Outcome of late infantile MLD
Most children die by age of 5
128
Onset of juvenile MLD
3-10 years of age
129
Sx of juvenile MLD
Impaired school performance
Mental deterioration
Dementia
Slower progression of sx of late infantile MLD
130
When does adult form of MLD begin?
>16 years of age
131
Sx of adult form of MLD
Progressive dementia or psychiatric disorder
Mental deterioration
Depression
132
How many patients with adolscent-onset MLD have schizophrenia-like psychosis?
60%
133
What is Neuroacanthocytosis?
Genetically heterogenous neurologic disorder characterised with acanthocytosis.
134
Sx of Neuroacanthocytosis?
Movement disorders/ataxia
Personality changes
Cognitive deterioration
Axonal neuropathy
Seizures -tonic-clonic
Subcortial dementia
135
What is acanthocytosis?
10-30% of patients erythrocytes having a star-like appearance with projections.
136
Gait of those with neuroacanthocytosis?
Lurching with long strides
Quick, involunary knee flexion
137
Age of onset of MS
20-40
138
Lifetime risk of MS in the UK
1:8000
139
Gender disparity in MS
Twice as common in women
140
Geographical distribution of MS
Greater frequency as distance from equator increases
141
Pathology of MS
Multiple demyelinating lesions with predilection for optic nerves, cerebellum, brainstem and spinal cord.
142
How many people with MS have a steady progression of disability with no remission?
5-10%
143
How many patients with MS have a relapsing-remitting course?
20-30%
144
How many patients with MS have a progressive deterioration following a number of relapses and remissions?
60%
145
Treatment for MS
Steroids
Glatiramer acetate
146
How does Glatiramer acetate work for MS?
Neuroprotective
Immunomodulator
147
When is Glatiramer acetate used in MS?
Reduces frequency of relapses in relapsing-remitting MS
148
Trade name of Clatiramer acetate?
Copaxone
149
Dose of Glatiramer acetate?
20mg OD s/c
150
Lifetime prevalence of depressive sx in MS
40-50% - 3x higher than general population
151
What is depression in MS linked with?
Poorer cognitive function
Poor compliance with treatment
Lower QoL
152
What can cause drug-induced low mood in MS?
Steroids
Baclofen
Dantrolene
Tizanidine
153
Brain abnormalities between MS and depression?
None
154
Treatment used for depression in MS?
Desipramine
SSRI
ECT
155
Risk of ECT use in MS
20% risk of triggering relapse of MS
156
What must be done before ECT is used for depression in MS?
MRI to look for presence of active brain lesions - risk factor for MS relapse
157
Suicide rates of people with MS
3% over 6 year period
15% over 16 years
158
Drug-induced mania causes in MS
Steroids
Baclofen
Dantrolene
Tizanidine
159
What is Tizanidine?
Central muscle relaxant
160
How many patients with MS on steroids develop mild to moderate mania?
33%
161
Which patients with MS on steroids are more likely to develop hypomania?
FHx of affective disorder/alcoholism
Premorbid history of affective disorder/alcoholism
162
Link between Psychosis and MS
Patients with psychosis and mania who have MS have plaques distributed in bilateral temporal horn areas
163
Psychiatric sx of MS
Depression
Psychosis
Mania
Pathological laughing and crying syndrome/pseudobulbar affect
Cognitive Impairment
164
Treatment for pathological crying/laughing in MS
75mg Amitroptyline OD
Amantadine
Levodopa
Fluoxetine
Sertraline
Citalopram
165
Impact of Amitriptyline on pathological crying/laughing in MS?
66% of patients had improvement in sx
166
What type of cognitive impairment is seen in MS?
Subcortical pattern
167
Is MMSE useful to identify cognitive impairment in MS?
No
168
Treatment for cognitive impairment in MS?
Donepezil
169
Prevalence of post-stroke depression?
35%
170
Which type of stroke has higher incidence of depression?
Subcortial
Infarcts of basal ganglia - especially left hemisphere.
171
What type of stroke has high incidence of anxiety?
Cortical
172
Prevalence of post-stroke anxiety?
25%
173
Prevalence of apathy without depression in stroke?
20%
174
Prevalence of emotional incontinence in stroke?
20%
175
Prevalence of catastrophic reaction in stroke?
20%
176
Mean duration of post-stroke depression?
34 weeks
177
Screening guidelines for depression and anxiety in stroke
Screen in first month after stroke.
Confirm emotionalism by simple questions.
If one mood disorder is present, assess for others
178
Treatment for mild-moderate post-stroke depression
Increase social interaction
Exercise
Psychosocial intervention
179
Treatment for severe post-stroke depression
Antidepressants
Monitor effectiveness
180
How long should antidepressants be used for post-stroke depression if good initial effect
At least 4 months
181
Which antidepressants have good evidence for post-stroke depression?
Fluoxetine
Citalopram
182
Frequency of depression in epilepsy
30-50%
183
Frequency of panic disorder in epilepsy
20%
184
Frequency of psychosis in epilepsy
3-7%
185
Which type of epilepsy is depression most common in?
TLE
186
Risk of suicide in patients with epilepsy
10-15%
187
Mortality rate if epilepsy and depressed
25x higher than general population
188
First line treatment of depression in epilepsy
SSRIs - may reduce seizure threshold
189
Which type of epilepsy is psychosis more common in
Partial epilepsies
190
Risk factors of psychosis in epilepsy
Role of mesial temporal and extratemporal damage
191
When is episodic psychosis most common in epilepsy?
Post-ictal
192
What is more common in post-ictal psychosis than in functional psychosis?
Visual hallucinations
193
Which psychotropic can cause psychosis?
Vigabatrin
194
Which antipsychotics are less epileptogenic?
Sulpride
Haloperidol
195
What are pseudoseizures linked with?
Past psychiatric hx
Somatisation
Social stressors
Childhood abuse
196
Prolactin levels in seizures
Increased after epileptic seizures but should be taken within 15 mins of seizure
197
Prevalence of depression in Parkinsons
40-50%
198
Prevalence of hypomania/euphoria in Parkinsons
2%/10%
199
Prevalence of anxiety in Parkinsons
50-65%
200
Prevalence of Psychosis in Parkinsons
40% - drug-related
201
Prevalence of cognitive impairment in Parkinsons
19% if no dementia
25-40% if dementia
