Mental Health Flashcards
Monoamine Oxidase Inhibitors
Tryanylcypromine, phenelzine, moclobemide (reversible), and rasagiline
Used for atypical depression
SE’s of MAO-I’s
HTN with tyramine containing foods eg. Cheese, marmite, pickled herring etc.
Anticholinergic
Lithium Monitoring
Check lithium levels 12 hour post dose
After starting, check weekly until stable (resume weekly if dose changes- measure after 1 week)
When stable, every 3 months
Thyroid and renal function checked the every 6 months
Check for pregnancy
NB- give patient an info book, alert card, and record book, check levels during acute illness (dehydration can increase level)
Clozapine use
Treatment resistant schizophrenia/ schizophrenia not managed on 2 or more antipsychotic drugs for at least 6-8 weeks
NB- If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly
Clozapine SE’s
Agranulocytosis and neutropenia
Reduced seizure threshold
Constipation
Myocarditis
Hypersalivation
Weight gain and increased apetite
EPSE’s eg, Parkinsonism
Clozapine monitoring
Initial weekly FBC UE LFT for 18 weeks, then 2 weekly for a year, then monthly
Baseline ECG
lipids weight etc.
Antipsychotics monitoring
FBC UE LFT- start and annually
Lipids & weight- start, 3 months and annually
BM & prolactin- start, 6 months and annually (patients can present with polyuria and polydipsia, as antipsychotics can dysregulate glucose)
BP- start and during dose titration
ECG- baseline
CV risk- annually
NB- check not pregnant first
SSRI Interactions
NSAIDs- give PPI
Warfarin/ heparin- consider mirtazapine
Triptan and MAO-I: risk of serotonin syndrome
Tramadol- Serotonin syndrome
Citalopram and QT Interval
Citalopram and escitalopram are associated with dose-dependent QT interval prolongation
Shouldn’t be combined with drugs that do the same
NB- citalopram can also cause torsades de pointes
Drugs that lengthen the QT Interval
Amiodarone
Chlorpromazine
Citalopram/escitalopram
Clarithromycin/erythromycin
Flecanide
Haloperidol
Lithium
Methadone
Ondansetron
Risperidone
Venlafaxine
Atypical vs typical antipsychotics
Atypical are used now due to reduced incidence if EP SE’s eg. Parkinsonism, dyskinesia etc.
They still have SE’s though that the old typical drugs had eg. Galactorrhoea, weight gain, anti cholinergic etc.
Typical antipsychotics
Haloperidol
Chlopromazine
Atypical antipsychotics
Clozapine
Olanzapine
Aripiprazole
Risperidone
Quetiapine
Depression Investigations
FBC, UE, LFT, TFT, B12 and folate, HbA1c, cap glucose
NB- pregnancy test/ BMI/ lipids/ ECG (citalopram, escitalopram, amitriptyline) etc.
Depression Management
Refer to talking therapy (CBT), time off work, lifestyle changes
Moderate-severe: SSRI (if doesn’t work, add another one)
Psychiatry referral: SNRI (after 2 SSRI’s)
When to refer a depressed patient to secondary service (psychiatry)
Treatment has failed (non-response to two treatments)
Significant risk of suicide (harm to others/ severe self-neglect)
Psychotic symptoms
Bipolar affective disorder suspected
Child or adolescent presenting with major depression
Depression relapse prevention
First episode (without risk factors (see when to refer..): 6-9 months after remission (consider 1 year if risks)
High risk patients (>5 episodes or >2 in last few years): 2 years, consider life-long
Assess a patient’s cognition
AMT10
AMT10
Year
Time
Place
Age
DOB
20-1
WW1
Monarch
2 People
Address (1 min and 5 min)
Assess a delirious patient
4AT
4AT
Alertness- 4 if abnormal
AMT4 (Age, DOB, location, year)- 2 if 2 or more mistakes
Attention (Dec-Jan)- <7 (1), untestable (2)
Acute change/ fluctuating- 4
AMT 10 Outcome
> 6 normal
4-6 moderate impairment
<3 severe impairment
4AT Outcome
> 4 high chance of delirium
Delusions of grandeur
Special powers or importance
Ideas of reference
Normal events are of special importance to the patient (eg. News reporter)
Nihilistic delusions
They believe they are dead, decomposed, no organs, not human etc.
Paranoid delusions
Exaggerated distrust of others and suspicious of motives
Delusions of Erotomania
Other individuals are in love with them
Persecutory delusions
Patient insists they are being cheated on, contoured against, or harassed
Somatic delusions
Experience bodily functions or sensations when none are present
Loose associations (Knights move/ derailment)
Incoherent thinking, expressed as illogical, sudden, frequent changes of topic
NB- Knight’s move thinking there are illogical leaps from one idea to another, flight of ideas there are discernible links between ideas
Word salad
Incoherent thinking expressed as a sequence of words without a logical connection
Tangential speech
Nonlinear thought expressed as a gradual deviation from a focused idea or question
Neologisms
Creation of new words
Echolalia
Repetition of others words or sentences
Flight of ideas
Quick succession of thoughts usually demonstrated in a continuous flow of rapid speech and abrupt changes in topic (although discernible links between ideas)
Clang association
Using rhyming words rather than words of meaning
Circumstantial speech
Non linear thought expressed as a long winded manner of explanation, with many deviations from central topic, before finally expressing the central idea
Thought blocking
Objective observation of an abrupt ending in a thought process, expressed as sudden interruption in speech
Pressured speech
Accelerated thoughts expressed as rapid, loud, voluminous speech (often in absence of social stimulation)
Schizophrenia
A severe psychiatric disorder characterised by chronic or recurrent psychosis
Psychosis
Distorted perception of reality characterised by delusions, hallucinations, and or disorganised thoughts
Non organic causes of psychosis
Schizophrenia
Mania
Depression
Medication induced
Substance induced
Poisoning eg. Heavy metals/ insecticides etc.
Medications that can induce psychosis
Opiates
Levodopa
Antiepileptics
Corticosteroids
Substances that can induce psychosis
Alcohol
Cannabis
Cocaine
LSD
Glue
Amphetamines
Investigations for first psychotic episode
Bedside- ECG, urine drug screen, urine pregnancy test
Bloods- FBC UE LFT TFT CRP B12 Folate lipids blood glucose (HIV syphilis
serology potentially)
Imaging- MRI head (exclude dementia/ brain injury or disease)
NB- if person is a known schizophrenia/ bipolar, may want to do plasma drug level monitoring (are they compliant with medication eg. lithium levels in a BP patient)
Initial Management of Schizophrenia/ Psychosis
Urgent input from CRT
Section under MHA
Admit to acute psychiatry ward
Oral typical antipsychotic (not clozapine or olanzapine- big SE profile so reserved for more resistant disease) eg. Quetiapine, aripriprazole or risperidone
If necessary IM, or may need IM benzo
Ongoing management of schizophrenia/ psychosis
CMHT, EIT, CRT (crisis) give them access to these services when they need it (tell to make family and friends aware), organise care co-ordinator
Family therapy
Treat co-morbid conditions
Regular health check up’s (lipids, BP, prolactin, etc.)
Advice on lifestyle factors (help with above risk factors)
NB- address co-morbidities (AP therapy is high risk of CV disease)
Psychosis in mood disorders
Mood congruent ie. they fit with the mood
Depression- nihilistic, guilty of a major crime etc.
Bipolar (manic episode)- they have special powers
Schizoaffective disorder
affective disorder (manic and depressive episodes), with psychosis
Antipsychotic use in the elderly
increased risk of VTE and stroke
Causes of neuroleptic malignant syndrome
Antipsychotics
Sudden stopping of PD drugs (either due to lack of absorption (illness/ vomiting/ obstruction (constipation)) or not giving them at the correct time
Management of acute bipolar
Anyone in community with mania- urgent referral to CMHT and CRT
Psychosocial intervention (family therapy)
Medications- lithium is mood stabiliser of choice (also anticonvulsants like valproate or AP like quetiapine). Stop antidepressant during acute mania
Give AP if presenting with acute mania/hypomania
Can also give an antidepressant once mood stabiliser commenced (SSRI eg. citalopram)
NB- address co-morbidities (AP therapy is high risk of CV disease)
Antidepressants and BAD
Antidepressants should not be used before initiating therapy with mood stabilizers because antidepressants can precipitate a manic episode
eg. Stop someone’s mirtazapine/citalopram first
NB- antidepressants can cause a manic shift in undiagnosed BAD patients (follow up in depression is essential- make sure they don’t develop mania)
Features of a manic episode (DIGFAST)
Distractibility
Irresponsibility (sex, money)
Grandiosity (psychotic symptoms)
Flight of ideas
Activity increase
Sleep deficit
Talkativeness
NB- lasts for at least a 7 days
Difference between mania and psychosis
Patients psychotic due to schizophrenia may not be as restless and hyper agitated as manic patients
Illness course is different- patient will be less sick less often in mania (BAD) and will have depressive episodes. Schizophrenic/psychotic patients are constantly I’ll until treated
In mania there is no thought interference, 3rd person auditory hallucinations, running commentary etc.)
Investigations for anxiety
ECG, physical exam, observations
Bloods- FBC UE LFT bone profile TFT magnesium
Imaging- if phaechromocytoma suspected (CT abdomen)
Management of GAD
Lifestyle management- sleep hygiene, substance misuse education, diet, exercise
Psychological support- low intensity CBT (high intensity if moderate to severe)
Medical- if moderate to severe, try SSRI (sertraline), then SNRI, then pregabalin
Panic disorder
Recurrent spontaneous and unexpected panic attacks that often occur without a known trigger
NB- GAD= constant, doesn’t dissipate
Social anxiety disorder
Pronounced anxiety lasting longer than 6 months of social situations that might involve scrutiny by others
Anticipatory anxiety and drinking
Avoiding social situations
OCD Symptoms
Intrusive thoughts (ego dystonic)
Compulsions and rituals that cause relief
Time consuming and distressing
Investigations for a dementia screen
ECG, ACE-III, BM, top to toe physical exam, urinalysis (no infection)
Bloods- FBC, UE, LFT, TFT, CRP, ESR, B12, folate, bone profile
Imaging- MRI brain
Factors favouring delirium over dementia
Impaired consciousness
Fluctuating symptoms (worse at night/periods of normality)
Abnormal perceptions (hallucinations)
Agitation, fear
Delusions
Factors suggesting depression over dementia
Short history, rapid onset
Biological symptoms eg. Weight loss, sleep disturbance
Patient worried about their memory
Reluctant to take tests, disappointed with results
Global memory loss (dementia- characteristically recent memory loss)
Medications to be careful with in PDD or DLB
Neuroleptics eg. Antipsychotics
Can cause akinetic crises/NMS (also caused by withdrawal of levodopa meds). Don’t always have to treat the psychosis and if we do, quetiapine is best tolerated
What types of dementia can medications be used for?
AD and LBD
NB- there is no direct treatment for vascular dementia
Levodopa
Be careful in DLB as this can exacerbate neuropsychiatric and cognitive symptoms
Management of acute stress disorder
CBT
Benzo’s (short term)
Management of an eating disorder
Treat co morbidities/nutritional supplementation
Eating disorder focused CBT
Management of panic disorder
CBT
SSRI (if not working, then imipramine)
Charles Bonnet syndrome
Persistent complex hallucinations occurring in clear consciousness (no neuropsychiatric disturbance). May have visual impairment
Cotard syndrome
Patient believes that they (or a part of their body) is dead. May not eat or drink for this reason
De Clerembaults syndrome
AKA erotomania (a form of delusional disorder)
Delusional belief that a person is in love with the patient
NB- delusional disorder can be a disorder on its own
Delusional parasitosis
Delusional belief that they are filled with worms/bugs/fungus etc.
When is ECT used
Severe depression refractory to medication (Catatonia) or with severe psychotic symptoms
NB- Antidepressant medication should be reduced but not stopped when a patient is about to commence ECT treatment
Side effects of ECT
Headache
Nausea
Cardiac arrhythmia
Short term memory loss (some people report these memory problems long term but they are usually transient)
Othello syndrome
Pathological jealousy that a partner is cheating on someone without proof
SAD
Treat normal as you would with depression
No sleeping tablets
Light therapy not routinely recommended
Section 17a (CTO)
Used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as medication compliance
Capgras delusion
Family have been replaced by an identical imposter
Formication
Parasthesia- feels like insects are crawling on the skin
Managing BAD in primary care- Symptoms of mania/ severe depression
Urgent referral to CMHT
Routine referral- hypomania or non severe depression
The CMHT can then decide if they need to section them
NB- this is for BAD, wouldn’t refer everyone with severe depression to CMHT
Antisocial PD
Failure to conform to social norms with respect to lawful behaviour
More common in men
Deception and lying
Impulsiveness
Aggressiveness (fights)
Disregard for safety
Irresponsibility
Lack of remorse
Avoidant PD
Avoidance of activities which involve interpersonal contact
Preoccupied with ideas that they are being criticised or rejected in social scenarios
Restraint in intimate relationships
Reluctance to take risks due to fear of embarrassment
Inferior view of self
Self isolation but craving for social contact
Borderline (Emotionally unstable) personality disorder
Efforts to avoid abandonment
Unstable interpersonal relationships which alternate between idealisation and devaluation
Unstable self image
Impulsivity in damaging areas eg. Sex and substances
Recurrent suicidal behaviour
Affective instability
Difficulty controlling temper
Chronic feelings of emptiness
Dependent personality disorder
Difficulty making everyday decisions without help from others
Need others to assume responsibility for major areas of their life
Difficulty in expression disagreement for fear of losing support
Lack of initiative
Unrealistic care of being left to care for themselves
Urgent search for relationships
Extensive efforts to obtain support from others
Histrionic personality disorder
Inappropriate sexual seductiveness
Centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used to seek attention
Self dramatisation
Relationships considered more intimate than they are
Narcissistic personality disorder
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power, or beauty
Sense of entitlement
Taking advantage of others
Lack of empathy
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
Obsessive compulsive personality disorder
Occupied with details, rules, lists, order, organisation
Perfectionism that hampers tasks
Dedicated to work and efficiency to the elimination of spare time activities
Rigid about etiquette of morals, ethics, etc.
Can’t throw away insignificant things
Inability to delegate work
Stingy spending habits
Paranoid personality disorder
Hypersensitivity
Unforgiving attitude when insulted
Questions loyalty of friends
Reluctance to confide in others
Preoccupation with conspiracy beliefs and hidden meaning
Perceives attacks on character
Schizoid personality disorder
Indifference to praise or criticism
Preference for solitary activities
Lack of interest in sexual relationships
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
NB- negative symptoms of schizophrenia
Schizotypal personality disorder
Ideas of reference (but some insight retained) eg. TV talks to them
Odd beliefs and magical thinking
Unusual perceptive disturbances
Paranoid ideation and suspiciousness
Odd eccentric behaviour
Lack of close friends other than family
In appropriate affect
Odd speech without being coherent
NB- positive symptoms of schizophrenia
Management of personality disorders
Dialectical behavioural therapy
NB- can’t diagnose until out of teens
Pseudodementia
Another psychiatric disorder presenting as dementia eg. Depression, anxiety
MRI Head Alzheimer’s
Can be normal, or may show cortical atrophy
NB- early changes in Alzheimer’s: temporal lobe deficits
EPSE’s
Parkinsonism
Acute dystonia (sustained muscle contraction eg. Torticollis (twisted neck), oculogyric crisis (eye deviation)- procyclidine
Akathisia/(severe restlessness)
Tardive dyskinesia (abnormal involuntary movements eg. Chewing, jaw pouting)
NB- torticollis is also known as cervical dystonia
SSRI Interactions
NSAID (give PPI if together)
Warfarin and heparin (give mirtazapine instead)
Triptans
MAO-I
Review period after starting an SSRI
2 weeks
Under 25 or high risk, 1 week
Length of SSRI treatment
6 months after symptoms abate
Stopping an SSRI
Over a 4 week period (not fluoextine)
Discontinuation symptoms
Mood changes eg. anxiety
Restlessness
Difficulty sleeping
Unsteadiness and dizziness
Sweating
GI symptoms
Parasthesia eg. electric shock sensations
NB- treatment= give old dose of SSRI
TCA Side effects
Anti cholinergic eg.
Drowsiness
Dry mouth
Blurred vision
Constipation
Urinary retention
QTc lengthening
Lithium SE’s (different to toxicity)
N v diarrhoea
Fine tremor
Polyuria, nephrogenic DI
Hypothyroidism
Weight gain
T wave flattening, inversion
Intracranial hypertension
Leukocytosis
Hyperparathyroidism and hypercalcaemia
NB- benign leukocytosis
Mirtazapine
Good if 2 SSRI’s can’t be taken (warfarin),p or not tolerated
SE- weight gain and sedation
Class- Noradrenergic and specific serotonergic antidepressants
Antidepressants and addiction
Antidepressants are not addictive but when stopped suddenly they can cause discontinuation syndrome
Antipsychotics known for increasing prolactin
Typical- zuclopenthixol, haloperidol
Atypical- amisulpride, risperidone
Antipsychotics not typically associated with increasing prolactin
-pine
Olanzapine
Clozapine
Quetiapine
NB- aripiprazole has one of the better side effect profiles
Combining antidepressants
Not typically done, but may see venlafaxine + mirtazapine (increased risk of serotonin syndrome and antidepressant SE’s)
Factors likely to be in a VD history
TIA/stroke
Can almost pinpoint when things started to change (rather than AD- insidious onset)
Emotional lability
Support for people with dementia at home
Occupational therapists- safe around the home/blister packs
Carers- personal care
Physiotherapists- stairs
Fire brigade- gas (stove)
Social services- LPA
Pharmacological management of BPSD’s (Behavioural and Psychological Symptoms of Dementia)
Carbamazepine
AD
AP
Severe cases- benzodiazepines
Pseudohallucinations
They are part of the normal grieving process
Extrapyramidal side effects
Symptoms associated with the extrapyramidal system of the cerebral cortex (involuntary movement). They include;
Dystonia (continuous and sustained contraction eg. oculogyric crisis, torcillosis)
Akathisia (inner restlessness and inability to sit still)
Parkinsonism
Tardive dyskinesia- irregular jerky movements, typically of face and neck (lip smacking)
Alternative to methadone
Buprenorphine is a mixed opioid agonist/antagonist. It is typically given as a sublingual tablet
Causes of altered clozapine levels
Smoking cessation can cause a significant rise in clozapine levels, and so it should be discussed with a psychiatrist before stopping smoking. Starting smoking, or smoking more, can reduce clozapine levels. Stopping drinking can also reduce levels, as alcohol binges can increase the level. Omitting doses will cause a reduction in clozapine levels, and stress and weight gain won’t have significant effects on the level.
Pellagra
Dermatitis, diarrhoea, dementia/delusions, leading to death (vitamin B3 deficiency)
Conversion disorder
Typically involves loss of motor or sensory function. May be caused by stress
Features of PTSD
Symptoms often present later after the event, and have to be present for a month
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
emotional numbing - lack of ability to experience feelings, feeling detached from other people
depression
drug or alcohol misuse
anger
unexplained physical symptoms
Management of PTSD
Conservative- watchful waiting may be used for mild symptoms lasting less than 4 weeks, or trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases/after 4 weeks
Medical- if CBT hasn’t worked- venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used
Risk factors for PTSD
Exposure to trauma or combat, refugee/asylum seeker status, first responder occupation, combat specific (duration of exposure, low morale, poor social support, lower rank, unmarried, low educational attainment, childhood adversity), previous psychiatric disorders.
Management of a patient who has attempted suicide
If they say they would do it again -admit to a psychiatric hospital for assessment (section 5(2) as a junior doctor- hold for 72 hours, if they are unwilling)
If not- refer to CMHT, take a bio/psycho/social approach eg. talking therapy, address any social concerns, may require medication eg. for concomitant depression
Pharmacological management of Alzheimer’s
First line- acetylcholinesterase inhibitor (donepezil, galantamine, rivastigmine)
Second line- memantine (NMDA receptor antagonist)
NB- don’t use donepezil if bradycardia, and it can cause insomnia
Schniders first rank symptoms
3rd person/ running commentary/ heading thoughts out loud auditory hallucinations
Thought with drawl/insertion
Thought broadcasting
Somatic hallucinations
Delusional perceptions
Causes of serotonin syndrome
monoamine oxidase inhibitors
SSRIs- St John’s Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome
ecstasy
amphetamines
tramadol
Features of serotonin syndrome
neuromuscular excitation
-hyperreflexia
-myoclonus
-rigidity
autonomic nervous system excitation
-hyperthermia
-sweating
altered mental state
-confusion
Treatment of serotonin syndrome
supportive including IV fluids
benzodiazepines
more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
Features of neuroleptic malignant syndrome
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion
raised creatine kinase
Acute kidney injury (secondary to rhabdomyolysis) leukocytosis
Management of neuroleptic malignant syndrome
stop antipsychotic
patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units
IV fluids to prevent renal failure
dantrolene may be useful in selected cases
bromocriptine, dopamine agonist, may also be used
SS vs NMS
SS- faster onset, hyperreflexia, myoclonus (muscle jerks, rather than rigidity), dilated pupils
NMS- slower onset, hyporeflexia, lead pipe rigidity, normal pupils
SSRI SE’s
-gastrointestinal symptoms are the most common side-effect
-reduced libido and sexual performance
-there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
hyponatraemia (duodenal ulcers)
-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
NB- may initially worsen symptoms (why people are reviewed soon after)
SSRI and pregnancy
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
OCD Management
Mild- cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
Severe- admit to a secondary service and treat whilst waiting referral, SSRI and CBT (including ERP)
Somatisation Disorder
multiple physical SYMPTOMS (S for S) present for at least 2 years
patient refuses to accept reassurance or negative test results
Illness anxiety disorder (hypochondriasis)
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer (C in cancer and hypochondriasis)
patient again refuses to accept reassurance or negative test results
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
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
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
Factitious Disorder
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain (ie. they want something out of it)
Brief psychotic disorder
This describes an episode of psychosis lasting less than a month with a subsequent return to baseline functioning.
