Mental Health Flashcards
What is the therapeutic range for Lithium?
0.4-1.0 mmol/L
Indication of lithium
Bipolar disorder
When do the lithium levels need to be checked when dose changed?
1 week
What are the common features of PTSD?
1) Re-experiencing
2) Avoidance
3) Hyperarousal
4) emotional numbing
What ECG changes does Citalopram cause?
QT prolongation and Torsades de pointes
What are the examples of SSRI?
Citalopram
sertraline
Fluoxetine
Side effect of lorazepam
Anterograde amnesia
What should be monitored when initiating and titrating venlafaxine?
Blood pressure (HTN)
What is 2nd line option for depression?
SNRI - venlafaxine
What signs should be monitored when taking antidepressants?
Hyponatraemia
What is life-threatening side-effect of clozapine?
Agranulocystosis/Neutropenia
What is agranulocystosis?
Decreased WCC, primarily neutrophils
What is the 1st line medication for GAD?
SSRI - specifically Sertraline
What are the side effects of typical antipsychotics?
- Acute dystonia (e.g. torticollis, oculgyric crisis)
- Parkinsonism
- Akathisia (severe restlessness)
- Tardive dyskinesia
- Neuroleptic malignant syndrome
What is torticollis?
- Unilateral pain and deviation of the neck with pain on palpation and restricted range of motion
What is neuroleptic malignant syndrome?
- Altered MSE
- Generalised rigidity
- Fever
- Fluctuating blood pressure
What is tardive dyskinesia?
- uncontrolled facial movements such as lip-smacking
What are examples of typical antipsychotics?
- Haleperidol
- Chlopromazine
What are examples of atypical antipsychotics?
- Clozapine
- Risperidone
- Olanzapine
Why was atypical antipsychotics developed?
Due to problematic extrapyramidal side-effects
What is ESPEs?
- Parkinsonism
- Acute dystonia (sustained muscle contraction)
- akathisia (severe restlessness)
- tardive dyskinesia
MOA of venlafazine
Serotonin and noradrenaline reuptake inhibitor
What are the first rank symptoms of schizophrenia?
1) Auditory hallucinations
2) Thought disorder
3) Passivity phenomena
4) Delusional perceptions
For a diagnosis of PTSD, how long should symptoms be present for?
4 weeks
What is the key difference between mania and hypomania?
Psychotic symptoms
What are the symptoms associated with depression?
DSM-5
5/9 symptoms required for diagnosis (everyday for at least 2 week):
Core symptoms:
- Low mood
- Anhedonia
Associated symptoms:
- Disturbed sleep
- Decreased or increased appetite
- Fatigue /loss of energy
- Agitation or slowing of movements
- Poor concentration
- Feelings of worthlessness
- Suicidal thoughts
What tools can be used to assess the degree of depression?
HAD scale
PHQ-9
What investigations should be carried out for depression?
- Bloods to eliminate other causes
What is seasonal affective disorder?
Depression which occurs predominately around the winter months.
What is dsythmic disorder?
- Chronic depressive state (2 years or more)
- Persistent low mood not meeting depression diagnostic criteria
- Not the consequence of a partly resolved major depression
Define bipolar disorder
Chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
What are the types of bipolar disorder?
- type I disorder:
mania and depression (most common) - type II disorder:
hypomania and depression
Difference between mania & hypomania
- Hypomania:
• Mild elevation of mood and increased energy / activity
• 4 days of manic symptoms
• Does NOT disrupt life
2. Mania: • Mood change (7 days of persistently high, expansive, or irritable mood) AND 3 manic symptoms: --> Increased activity level --> Talkativeness --> Racing thoughts --> Distractibility --> Reduced need for sleep --> Inflated self esteem --> Faulty judgement
Referral criteria for bipolar disorder?
- if symptoms suggest hypomania = routine referral to the community mental health team (CMHT)
- if there are features of mania or severe depression then an urgent referral to the CMHT should be made
Define obesity
BMI 25-29.9 kg/m2
What is the criteria for anorexia?
A. Restriction of energy intake relative to requirements, leading to a significantly low weight in the context of age, sex, developmental trajectory, and physical health
B. Intense fear of gaining weight or persistent behaviour that interferes with weight gain
C. Disturbance in body image.
What are the physical clinical features for anorexia?
- BMI <85% predicted (<17.5 adults). Often rapid loss
- Amenorrhea 3/12 or longer
- Delayed puberty
- Fatigue, fainting, dizziness
- Intolerance to cold
- GI: constipation, abdo pain
- Appearance: wearing baggy clothes
What are the psychological clinical features of anorexia?
- fear/ dread gaining weight
- Distorted body image
- Social withdrawal
- Denial of problem/ resistance to treatment
What is the mechanism behind alcohol withdrawal?
- chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) + inhibits NMDA-type glutamate receptors
- alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
What are the features of alcohol withdrawal?
Symptoms start at 6-12 hours:
- tremor
- sweating
- tachycardia
- anxiety
As a result of alcohol withdrawal, when is it most likely for seizures and delirium to occur?
- peak incidence of seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours:
- coarse tremor
- confusion
- delusions
- auditory and visual hallucinations
- fever
- tachycardia
What is staggered overdose?
if all the medication is not taken within 1 hour
What medication should be give if patient presents within 1 hours of paracetamol overdose?
activated charcoal
What the management of paracetamol overdose?
Acetylcysteine if:
- staggered overdose or doubt of ingestion time
- the plasma conc is on or above single line of 100mg/l at 4 hours and 15 mg/L at 15 hours
How is acetylcysteine given?
IV over 1 hour
What is the criteria for liver transplantation due to paracetamol liver failure?
Aterial pH < 7.3 + 24 hours after ingestion
or all of the following:
- prothrombin time > 100 seconds
- creatinine > 300 µmol/l
- grade III or IV encephalopathy
Example of natural opiates
morphine
Example of synthetic opioid
- buprenorphine
- Methadone
Features of opioid misuse
- rhinorrhoea
- needle track marks
- pinpoint pupils
- drowsiness
- watering eyes
- yawning
What is Bulimia Nervosa?
- Type of eating disorder characterised by:
1. episodes of binge eating followed by
2. intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising.
What is the diagnostic criteria for Bulimia Nervosa?
A. Recurrent episodes of binge eating, character sited by BOTH:
• Eating objectively large amount of food (larger than most would in a similar time period, and circumstances) in a discrete period of time (e.g. 2 hours)
• Loss of control overeating during episode
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain – e.g. vomiting, using laxatives/ diuretics/enemas/ other meds
C. Binge Eating and inappropriately compensatory behaviors both occur, on average at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight
E. Disturbance does not occur exclusively during episodes of anorexia nervosa.
What are some clinical features you may see with Bulimia Nervosa?
- Weight fluctuation
- Low mood
- Low self esteem
- Body image concerns
- Dental erosion
- Parotid hypertrophy
- Arrhythmias
What is acute stress disorder?
- Acute stress reaction that occurs first 4 week after a person has exposed to a traumatic event
What are the features in acute stress disorder?
- intrusive thoughts e.g. flashbacks, nightmares
- dissociation e.g. ‘being in a daze’, time slowing
- negative mood
- avoidance
- arousal e.g. hypervigilance, sleep disturbance
What is bereavement?
A period of mourning or loss
What are the stages of grief?
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
What are some types of elder/child abuse?
- Neglect
- Sexual
- Physical
What are some features of abuse?
- story inconsistent with injuries
- repeated attendances at A&E departments
- late presentation
- child with a frightened, withdrawn appearance - ‘frozen watchfulness’
What are some physical symptoms of abuse?
- bruising
- fractures: particularly metaphyseal, posterior rib fractures or multiple fractures at different stages of healing
- torn frenulum: e.g. from forcing a bottle into a child’s mouth
- burns or scalds
- failure to thrive
- sexually transmitted infections e.g. Chlamydia, Gonorrhoea, Trichomonas
What is domestic violence?
Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence, or abuse between people aged 16 years or over who are, or have been, intimate partners or are family members regardless of gender or sexuality
What are the types of domestic violence?
- Psychological
- Physical
- Sexual
- Emotional
- financial
What does ADHD stand for?
Attention Deficit Hyperactivity Disorder
What is the definition of ADHD?
DSM 5: Condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent.
What are the diagnostic features for ADHD?
For children up to the age of 16 years, 6 of these features have to be present; in those > 17 y/o the threshold is 5 features:
Inattention:
- Does not follow through on instructions
- Reluctant to engage in mentally-intense tasks
- Easily distracted
- Finds it difficult to sustain tasks
- Finds it difficult to organise tasks or activities
- Often forgetful in daily activities
- Often loses things necessary for tasks or activities
- Often does not seem to listen when spoken to directly
Hyperactivity/Impulsivity:
- Unable to play quietly
- Talks excessively
- Does not wait their turn easily
- Will spontaneously leave their seat when expected to sit
- Is often ‘on the go’
- Often interruptive or intrusive to others
- Will answer prematurely, before a question has been finished
- Will run and climb in situations where it is not appropriate
How is ADHD diagnosed?
Clinical diagnosis
What is schizophrenia?
Fundamental and characteristic distortion of thinking and perception and affects that are blunted or inappropriate.
What are the types of symptoms in schizophrenia?
- Auditory hallucinations
- Thought disorder:
- thought insertion
- thought withdrawal
- thought broadcasting - Passivity phenomena:
- bodily sensations being controlled by external influence
- actions/impulses/feelings - experiences which are imposed on the individual or influenced by others - 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’.
How is schizophrenia diagnosed?
Clinical diagnosis
What is the management of schizophrenia?
1st line = Atypical antipsychotics e.g. Respirdone
Acute setting = haliperidol (aggressive)
CBT should be offered to all pts.
What is delusional disorder?
False beliefs which are sustained despite contrary evidence
What are the types of delusional disorder?
- Grandiose
- persecutory
- mixed
- erotomanic
- jealousy
- somatic
- not classified
What are some symptoms of delusional disorder?
- Jealousy/paranoia
- Aggression
- Abnormal behaviours
- Feeling of persecution
- Disordered thinking
What investigations should be carried out in delusional disorder?
- Bloods
o To rule out organic causes like anaemia, electrolyte abnormalities - X-ray Imaging
o CT or MRI brain - Special Tests
o Urine toxicology
What is shizoaffective disorder?
Symptoms of schizophrenia and a mood disorder (depressed or manic) are equally prominent
What questionnaire is used for diagnosis of PTSD?
Trauma Screening Questionnaire
What is the 2nd line medication for GAD?
SNRI : Duloxetine
What advice should be given when starting medication for GAD?
- Warn patients of the increased risk of suicidal thinking & self-harm
What is the follow-up after starting medication in GAD?
Weekly follow-up for the 1st month
What is the diagnostic requirement for GAD?
DSM-5: core symptoms of excessive widespread worry for more days than not for at least 6 months
What are some symptoms in GAD?
- Restlessness
- Easily fatigued
- Poor concentration
- Irritably
- Muscle tension
- Sleep disturbance
What are some types of phobia?
- Agoraphobia
- Social phobia
- Simple phobia
What are the symptoms of panic disorder?
A panic attack is defined as a discrete episode of intense subjective fear, where at least four of the characteristic symptoms: • Palpitation • Sweating • Trembling or shaking • Dry mouth • SOB • Chest pain or discomfort • Dizziness
What are personality disorders?
Series of maladaptive personality traits that interfere with normal function in life.
What are the clusters of personality disorder?
Cluster 1: Odd or eccentric
- Paranoid
- Schizoid
- Schizotypal
Cluster 2: Dramatic, emotional or erratic
- Antisocial
- Borderline (Emotionally Unstable)
- Histrionic
- Narcissistic
Cluster 3: Anxious & Fearful
- Obsessive-Compulsive
- Avoidant
- Dependent
What are characteristics of paranoid?
- Hypersensitivity and an unforgiving attitude when insulted
- Unwarranted tendency to questions the loyalty of friends
- Reluctance to confide in others
- Preoccupation with conspirational beliefs and hidden meaning
- Unwarranted tendency to perceive attacks on their character
Shizoid features
- Indifference to praise and criticism
- Preference for solitary activities
- Lack of interest in sexual interactions
- Lack of desire for companionship
- Emotional coldness
- Few interests
- Few friends or confidants other than family
Shizotypal features
- Ideas of reference (differ from delusions in that some insight is retained)
- Odd beliefs and magical thinking
- Unusual perceptual disturbances
- Paranoid ideation and suspiciousness
- Odd, eccentric behaviour
- Lack of close friends other than family members
- Inappropriate affect
- Odd speech without being incoherent
Anti-social features
- Deception
- Impulsiveness
- Irritability
- Reckless
- Consistent irresponsibly
- Lack of remorse
Bordeline (Emotionally unstable) features
- Efforts to avoid real or imagined abandonment
- Unstable interpersonal relationships
- Unstable self image
- Impulsivity in potentially self damaging area
- Recurrent suicidal behaviour
- Affective instability
- Chronic feelings of emptiness
- Difficulty controlling temper
- Quasi psychotic thoughts
Histrionic features
- Inappropriate sexual seductiveness
- Need to be the centre of attention
- Rapidly shifting and shallow expression of emotions
- Suggestibility
- Physical appearance used for attention seeking purposes
- Impressionistic speech lacking detail
- Self dramatization
- Relationships considered to be more intimate than they are
Narcissitc Features
- Grandiose sense of self importance
- Preoccupation with fantasies of unlimited success, power, or beauty
- Sense of entitlement
- Taking advantage of others to achieve own needs
- Lack of empathy
- Excessive need for admiration
- Chronic envy
- Arrogant and haughty attitude
Obsessive- compulsive features
- Is occupied with details
- perfectionism
- Is extremely dedicated to work
- Is meticulous, scrupulous, and rigid about etiquettes
- Is not capable of disposing worn out or insignificant things
- Is unwilling to pass on tasks or work with others
- Takes on a stingy spending style
Avoidant features
- Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
- Unwillingness to be involved unless certain of being liked
- Views self as inept and inferior to others
- Social isolation accompanied by a craving for social contact
What is somatisation disorder?
- multiple physical SYMPTOMS present for at least 2 years
2. patient refuses to accept reassurance or negative test results
