Mental Health Flashcards
Assessment of capacity
- Understand information
- Retain information long enough to make a relevant decision
- Weigh information as part of the process of making a decision
- Communicate the decision (talking/sign language or other means)
Key Principles of Mental Capacity Act
A person must be assumed to have capacity unless it is established that he lacks capacity
A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
A person is not to be treated as unable to make a decision merely because he makes an unwise decision
An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
Features of Mental Health Act
- Presence of a mental disorder as defined by law (any disorder or disability of the mind)
- Disorder is of a certain nature or degree
- Significant risk to persons health and safety, safety of others or a risk of self neglect
- No alternative to hospital admission as a means of safeguarding that risk
Impairments in autistic spectrum disorder
TRIAD Social interaction - Difficulty with interpretation of sensory information - Can affect any sense -->Over/under sensitive - Sensory seeking/avoidance Communication - Problems in expressive and receptive language - Non-verbal communication problems - Literal understanding/humour - Visual learning - Problems with social communication; Worse when anxious Rigidity of thinking - Rituals and routines - Obsessions (not as in OCD) - Problems with imaginary play - Impaired theory of mind - Reduced empathy - Difficulty generalising
Management of autistic spectrum disorder
- Mainly educational
- Speech and language therapy
- Occupational therapy
- Behavioural management
- Medication (rarely used)
- Visual strategies – TEACHH, PECS
- Dietary – GF/CF, fish oils, additives
Problems associated with the autistic spectrum disorder
- Learning Difficulties
- Dyspraxia/ dyslexia
- Hyperactivity
- Special abilities
- Behavioural difficulties
- Anxiety
- Sleep and eating problems
Core features of ADHD
Poor attention and concentration
- Poorer than expect for age. Often seen when doing school work or ‘flitting’ from toy to toy. Cant watch whole tv programme. Poor academic achievement- reading often affected
Hyperactivity
- Significantly more active than expected for the age, therefore difficult to assess in very young children
- Running off, Fidgeting, appearing full of energy constantly, Difficulty in sleeping
Impulsivity
- Acting without considering the consequences.
- Interrupting conversations. Crossing the road without looking. Risk taking behaviour. - Aggression can be a consequence
Complications of ADHD
- difficulties in education
- risk of accidents
- low self-esteem
- rejection by peers
ICD - 10 classification of ADHD
Both are necessary for diagnosis:
- Impaired attention – manifested by a lack of persistent task involvement and tendency to move from one activity to another without completion
- Overactivity – characterised by restlessness, talkativeness, noisiness and fidgeting, particularly in situations requiring calm
Early onset – behavioural symptoms present prior to 6 years of age, and of long duration
Impairment must be present in two or more settings (e.g. home, classroom, clinic)
Diagnosis of anxiety disorders, mood affective disorders, pervasive developmental disorders and schizophrenia must be excluded.
Management of ADHD
Bio –> If severe
- Methylphenidate/ Atomoxetine/ Dexamfetamine
Psycho –>Parent education programmes/ interventions
• CBT
Social –> Social skills training
Actions and SE of drugs used for ADHD
Methylphenidate/Ritalin (short or long acting)
- Stimulant. Acts only in daytime
-About 2.3 of patients show significant improvement in their symptoms
-↑ Da and NAdr in synapse, as frontal lobe deficit – could cause personality changes.
- S.E – HTN, insomnia, headaches, weight loss/anorexia- ↓ appetite; tics; anxiety and dysphoria
-Abuse potential
Atomoxetine
- Acts on NAdr system–>Maintains NAdr levels and enhances frontal lobe
- 2 months to become effective.
- S.E - upset stomach, ↓ appetite, n&v, dizziness, tiredness and mood swings
Dexamphetamine
- sympathomimetic amine with central stimulant and anorectic activity (also used in narcolepsy)
SE - restlessness, headache, reduced appetite
Complications ADHD can cause in adulthood
- Increased criminality
- Decreased academic performance
- Increased substance abuse
- Increased aggression
- Poor relationships
- Poor employment record
- Girls have increased pregnancy and STD rates
Core symptoms of Depression
- Continuous low mood for at least 2 weeks
- Anhedonia
- lack of energy
Other and somatic symptoms of Depression
Other:
- reduced self-esteem/confidence
- guilt and self-blame
- hopelessness
- hypochondrical thoughts
- poor concentration/ attendence
- suicidal thoughts/ self-harm
- irritably
Somatic:
- loss of libudo
- psychomotor agitation
- Early morning wakening
- weight loss/ anorexia
ICD 10 classification of depression
Mild - 2 core symptoms and 2 others
Moderate 2/3 core and 3/4 others
Severe 3 core and 4+ others (or some very severe)
Severe with psychotic symptoms
- hallucinations (2nd person auditory)
- delusions (hypocondrical guilt, nilhilistic, persecutary)
Treatment of depression
Mild - reassess in 2 weeks –> exercise/ lifestyle and self-help/ CBT
Moderate - CBT/ Antidepressants
Severe - CBT and Antidepressants +- ECT
- Fluoxetine is antidepressant of choice
Psych–> psycho-education (about illness, relapse signatures meds), CBT (stop patterns of negative thinking), IPT, peer support and supportive counselling
Social –> family, housing, education, finance, employment, general coping strategies, assess physical needs
ICD-10 classification of Bipolar
at least 2 episodes in which a patients mood and activity are significantly disturbed
1) 1+ manic/mixed +/- 1+ depression
2) 1+ depression + 1 Hypomania
Criteria and Symptoms of mania
Elevated/expansive/irritable mood (1 week) and 3+ or more other symptoms
• ↑ energy/activity (including agitation)
• Grandiosity/ ↑ self-esteem
• Flight of ideas/racing thoughts; Pressure of speech; Distractible (poor concentration)
• Reduced need for sleep; ↑ libido
• Social inhibitions lost- sexual indiscretion (and reckless behaviour e.g overspending)
• Psychotic symptoms (of mood congruent nature) - hallucinations, grandiose delusions
• Psychomotor agitation - risk of self-injury, dehydration
• Thoughts of self-harming self or others
Criteria and symptoms of hypomania
3 or more characteristic symptoms for at least 4 days, not severe enough to interfere with social or occupational functioning
• Mildly elevated, expansible or irritable mood; ↑ energy/activity (can still function)
• ↑ self-esteem; Difficulty focussing on one task alone
• Sociability; talkativeness; over familiarity
• ↑ sex drive (out of character); Reduced need for sleep
Management for bipolar
Biological:
• Mood Stabilisers: Lithium
• Atypical anti-psychotics e.g. risperidone, olanzapine, quetiapine
Psychological- CBT, psychoeducation (about illness, relapse, medication, supportive psychotherapy)
Social- targeted interventions (family, housing, finance, employment, general coping strategies)
Environmental risk factors for ADHD
- Premature birth
- prenatal tobacco exposure
- single-parent household
- maternal depression
- lower social class
Pre-disposing factors for depression
- genetics
- abuse in childhood
- personality traits
- family support
Precipitating factors for depression
- brain illness
- physical illness
- iatrogenic
- family relationships
- increased workload
- life events
- substance use
- change in routine
Perpetuating factors for depression
- substance use
- difficult relationship
- financial difficulty
- work
- housing
Indications for ECT
- severe depressive illness, where other treatments haven’t been effective
- life-threatening illness
- prolonged/severe manic episode
- catatonia- high suicide risk
- stupor
- severe psychomotor retardation
Components of Mental State Examination
Appearance/Behaviour Speech Emotion (mood and affect) Perception - hallucinations Thought - content, form Insight Cognition
Features of a cognitive assessment
General - alert/ conscious Orientation Attention and Concentration Language Calculation R hemisphere function Abstraction Memory Praxis
Sections in the MHA
136 - police can move to a place of safety from public place - 72h
5 (4) - nurse can detain inpatient for up to 6h for medical assessment
5(2) - consultant can detain inpatient for up to 72h
2 - 2 doctors and MH practiioner - section for assessment (+/- treatment IM) for 28d
- can appeal within 14d
3- 2 doctors and 1MHP can section up to 6m for treatment
17 - leave when on section 2/3
ICD-10 classification of OCD
Obsessions and compulsions present for at least 2 weeks on most days and are a source of distress
- Obsessions - involuntary and unwanted thoughts, images or compulsions - often intrusive, distressing and repeptitive
- compulsions - repetitive mental operations/physical acts - feel compelled to perform to help reduce anxiety - not pleasurable
Acknowledges as coming from patients own mind - patient knows irrational
Management of OCD
- CBT - exposure and response prevention
- SSRI - fluoxetine. 2nd line - clomipramine
- help with work, peer support group
ICD-10 definition of PTSD
Presents for at least 1m, <6m from stressor
A) exposure to a stressful event or situation of exceptionally threatening or catastrophic nature
B) Persistent remembering or ‘reliving’ the stressor by intrusive flashbacks, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor
C) Avoidance of circumstances resembling/ associated with the stressor
D) 1- inability to recall some important aspects of the period of exposure to the stressor
2- persistent symptoms of increased physiological sensivity and arousal - 2 of:
> difficulty in falling/ staying asleep
> irritability
> difficulty concentrating
> hypervigilence
> exaggerated startle response
Predisposing factors for developing PTSD
- personality traits
- previous hx of neurotic illness
- childhood trauma
- poor social support
Management of PTSD
- trauma focused CBT or EMDR
- psychoeducation
- short term hypnotics
- mirtazepine, paroxetine, amitriptylline
ICD 10 classification of schizophrenia
FOR AT LEAST 1M
1) At least 1 of the following:
a - thought echo, insertion, withdrawal or broadcasting
b - delusions of control, influence or passivity
c - hallucinatory voices
d - persistent delusions
OR 2) At least 2 of the following a - persistent hallucinations b- breaks in train of thought c - catatonic behaviour d- -ve symptoms (apathy) e - significant and consistent change in overall quality of personal beaviour
Classifications of schizophrenia
Paranoid - delusions and hallucinations
Disorganised - disorganised speech, behaviour and flat/inappropriate affect
Catatonic - psychomotor disturbance
Simple - no delusions or hallucinations
Management of schizophrenia
- CBT - reality testing
- Olanzapine/ Haloperidol
- Psychoeducation
- Family interventions
Differentials of mania
- normal fluctuation in mood
- drug intoxication
- PD
- Thyrotoxicosis
- PTSD
- Dementia
ICD-10 definition of dependence
3+ at the same time in the preceeding year
- strong desire to take the chemical
- ↑ tolerance
- difficulties controlling use
- continue to use despite clear evidence of harm
Presentation of alcohol intoxication
- slurred speech
- ataxoc
- dishevelled
- tremulous
- sweating
Management of alcohol dependence
- In patient detox (if delirium tremens, seizers, cognitive impairment etc)
- disulfarim (acetaldehyde dehydrogenase I)
- Acamprosate (prevents cravings - SE - GI)
- Chlordiazepoxide (prevent seizures)
- thiamine
- Motivational interviewing/ AA
Symptoms and mx of alcohol withdrawal
- restlessness
- tachycardia
- sweating
- tremor
- anxiety
- n+v
- loss of appetite
- insomnia
- HTN
- Delirium tremens
- Seizures
Mx - IV diazepam; fluids; manage electrolytes
Features of delirium tremens
- hallucinations
- confusion
- disorientation
- seizures
- paranoid ideation
- ↑ HR and RR
- fever
- ataxia
- risk of suicide
Features of Wernicke’s encephalopathy
- nystagmus
- ataxia
- opthamoplegia
+/- altered consciousness, com, fever, consusion, ptosis
Features of Korsakoff’s
- irreversible
- impaired recent and remote memory
- disordered time sense
- cant learn new things +/- confabulation
What causes Wernicke’s and Korsakoffs
Thiamine (B1) deficiency
- glucose oxidation requires it so deficiency inhibits cell metabolism
- always give glucose after Pabrinex injection
- early features are poor memory, irritability and sleep disturbance
Define and give features of psychosis
A state of impaired reality
1) perception - illusions and hallucinations
2) thought - delusions/flight of ideas
3) -ve symptoms - apathy, poverty of thought & speech, blunting of afect
4) psychomotor function - catatonia
Define illusions and hallucinations
illusion - misperception of a real stimuli
hallucinations - perception in absence of external stimuli
Define delusion and give different types
a belief that is incorrect, incorrigible and incompatible with social/cultural norms
- persecutory (being harmed/threatened)
- grandiose
- of refernce
- religious
- erotomonia
- infedility
- misidentigiation
- nilhilistic
- somatic
- infestation
- though control - insertion/withdrawal/ broadcasting
Differentials of psychosis
- substance misuse (alcohol, amphetamine, cocaine)
- depression with psychotic symptoms
- dementia/ delirium
- brief psychotic episode (<1m)
- PTSD, OCD
- PD
- Encephalitis, tumour
- Thyroid/ cushings
Examples of disorganised thinking in psychosis
- circumstantial speech
- tangential thinking
- flight of ideas
- loosening of association
- neologisms
- thought blocking
- palialia /echalalia
- irrelevant answers
Features, types, Ix and Rx of frontotemporal dementia
- insidious onset and gradual profression
- early decline in social interpersonal and personal conduct (disinhibition)
- early emotional blunting and loss of insight
3 types
1) behavioural - changes in personality/behaviour/emotions and judgement
2) non-fluent aphasia - early changes in language
3) semantic - lose understanding of what objects are
IX - bilateral atropy of frontal and anterio temporal lobes on CT
Rx - SSRI and language therapy
Define dementia and give ICD-10 definition
global impairment of cognitive function and personality without impairment of consciousness
ICD-10 - 6m+ of:
- a decline in memory
- a decline in other cognitive abilities (memory, language, visuospatial and exectutive function)
- preserved awareness of the environment
- a decline in emotional control/ motivation/ changes in social behaviour (aggression/ anxiety/ hallucination/ delusions)
Reversible causes of dementia
- chronic alcohol abuse
- vit b12/thiamine/t2 def
- normal pressure hydrocephalus
- infection
- frontal lobe tumour
Risk factors for dementia
- ApoE4 allele
- smoking
- alcohol
- obesity
- raised total cholesterol and diet high in sat fat
- BP
- DM
- CVD and cerebrovasc disease
- lower education
- poor social network
- depression
Factors protective for dementia
- diet, vit e+C, Mediterranean diet
- increased exercise
- mental activity e.g. musci/reading
- complex mental activity
Features of AD
- gradual onset with progressive cognitive decline - beta=amyloid plaques and tau tangles
EARLY
- amnesia and disorientation
- spatial dysfunction
- changes in behaviour (wandering, irritable)
Moderate
- significant memory loss (orientaion and global aphasia)
- personality deterioration
- apraxia, agnosia, amnomia
Late
- physical deterioration - incontinence, falls, seizures
- extra-pyramidal signs
- dysphasia
- paranoid delusions, auditory and visual hallucinations
- depression
- personality changes
- behavioural disturbances - aggression/ sexual disinhibition. restlessness
Ix and Rx of AD
Ix - SPECT - generalised atrophy
Rx
prevention - modify risk factors, identify mild cognitive impairment
meds - donepezil, rivastigmine, galantamine
- memantine (mod-severe)
cognition training
SE of AD drugs
Donepezil, Rivastigmine, Galantamine
- do baseline ECG
- n,v,d, anorexia, bradycardia, syncope, insomnia, muscle cramps
Memantine
- constipation, dyspnoea, headache, dizzy, drowsy
CI - renal impairment
- effect level procyclidine
Features, diagnosis and mx of vascular dementia
- Acute onset
- stepwise deterioration in cognitive function (especially planning)
- emotional and personality changes (aggressive +/- hallucinations and delusions) - fluctuating
Also: visual/ sensory/ motor deficits (rigidity, akinesia, brisk reflexes); difficulties with attention; gait disturbance; seizures
Diagnosis - dementia, proven CVD, onset dementia <3/12 stroke and abrupt decline in cognitive function
Ix - SPECT - small vessel ischaemic changes +/ micro-haemotthages
- PREVENTION IS KEY - modify CVD
- ramipril, statin, apixaban, control DM
Pathogenesis of vascular dementia
- reduced cerebral blood flow - oxidative stress - damaged endothelial cells - chronic hypoperfusion
May follow single/ multiple strokes or progressive small vessel disease
Features and mx of LBD
A) fluctuating cognition
B) visual hallucinations
C) parkinsonism
+/- falls, sycope, LOC
Ix - DAT = reduced dopamine
A-synuclein and ubiquitin –> substania nigra and cortex seen on DAT scan
Mx - AchEI + Levodopa
- avoid anti-psycotics
Features of delirium
- acute confusional state
- impaired consciousness and attention
- global impairment of cognition (impaired short term memory, diorientated, language abnormalities, perception disturbance)
- psychomotor disturbance (hypo/hyper)
- sleep-wake cycle disturbance
- emotional disturbance
Predisposing factors for delirium
- old
- male
- dementia
- visual/hearing impairment
- depression
- malnutrition
- previous stroke
- PD
- funcitonal impairment
Precipitating factors for delirium
- medication
- infection
- hypoxia
- ↑/ ↓ - glucose, calcium, sodium
- shock
- hepatic/renal failure
- hypoperfusion
- thyrotoxicosis/myxoedema coma
- anaemia
- sleep depreivation
- pain
- surgery/anaesthesia
- neurological (tumour locally compresses)
Management of delirium
- treat underlying cause
- environmental and supportive measure
> educate those who interact with patient
>remove catheter
>avoid transfer
>consistent nursing staff
> calm environment, large clocks, easily readable notes, induce healthy sleep-wake cycle
> correct sensory deficit
> reality orientation - review meds
- refer to geriatrician +/- psych
- avoid sedation
SE of haloperidol
EPSE ADAPT Acute Dystonia Akathisia Parkinsonism Tardive dyskinesia
Torsades
ICD-10 classification of generalised anxiety disorder
- present for most days for at least 6m -
- symptoms of autonomic arousal
+ 3 of: - physical symptoms - SOB, chest, pain, nausea
- mental state symptoms - dizzy, derealisation, fear of losing control
- general symptoms - hot flushes/cold chills, numbness/ tingling
- symptoms of tension - muscle/mental, lump in throat
- other - exaggerated startle response, concentration difficulties, persistent irritability, difficulty getting to sleep
Management of GAD
- CBT
- Applied relaxation
- SSRI
Social anxiety disorder features and Mx
symptoms of incapacitating anxiety, not secondary to delusional/obsessive thoughts and are restricted to a particular social situation
- leading to a desire to escape/avoidance
fear of negative evaulation by others and low self-esteem
- more likely to have substance/addiction problems
Mx - psychodynamic psychotherapy
Agoraphorba features and Mx
Anxiety in 2 situations
- leads to avoidance
- CBT - systematic desensitisation
Panic disorder features
- recurrent attacks of severe anxiety - spontaneous/ situational
- symptoms develop rapidly, reach a peak of intensity in about 10 min and generally font last longer than 20-30 mins
- usually persistant worry about having another attack/ consequences of attack
Mx of panic disorder
- CBT - non-phobic focus
- family therapy
- SSRI/ TCA - citaoplam (takes up to 12wk to work) +/- diazepam short term
- beta blocker for autonomic arousal
Symptoms of anxiety
PHYSIOLOGICAL
- dry mouth
- shaking
- sweating
- light- headedness
- nausea
- SOB/ increased RR
- fatigue
- muscular tension
- diarrhoea
- urinary urgency
COGNITIVE
- fear of dying
- fear of losing control
- catastrophising
- anticipatory anxiety
- presence of obsessional thoughts
- increased alertness
- irritability
Differentials of anxiety
- Phobia
- psychosis
- depression
- Pheo/ hypoglycaemia/ cushings/ anaemia/ AF
- drugs - anti-hypertensives/arrthmics, anti-cholinergics, withdrawal from benzos
Features of personality disorder
- presence since adolescence
- stable over time despite fluctuations in mood
- manifest in different environments
- recognised by friends and acquaintances
- deeply ingrained maladaptive traits
Clusters of personality disorder
A
- paranoid -suspicious, jealous, self-important
- schizoid - emotionally cold, lack of enjoyment, +/- hallucinations
B
- dissocial - neglect, abuse, violence
- emotionally unstable - anger, emotional dysregualtion- hx abuse
- histrionic - attention seeking
C
- anakastic - obessional
- anxious avoidant - overcome with feelings of worry
- dependent - look for other people to make decisions
Management of personality disorders
- CBT
- Group therpay
- EUPD –> quetiapine, and dialectical behaviour therapy +/- therapeutic community
- dissocial - stop and think group
Complications of personality disorder
- distress
- adverse effects on society
- substance abuse
- suicide
- violent behaviour
Borderling personality disorder features
- frantic effort to avoid abandonment
- unstable/intense relationships
- disturbed sense of self
- impulsive/ suicide threats
- inappropriate intense anger
- can hallucinate
ICD-10 classification of anorexia nervosa
All of the following
- low body weight (BMI<17.5)
- self-induced weight loss
- overvalued idea (dread gaining weight)
- endocrine disturbance (amennorhoea >3m)
+/- body shape disturbance and undue influence of weight and shape on self-evaluation
ICD-10 classification of Bulimia Nervosa
All of the following
- binge eating (at least 2 x week over 3m)
- compensatory behaviours (purging - lax/vom or non-purging- exercise)
- cravings and preoccupation with eating
- self-perception of being too fat
Predisposition to anorexia
- low self-esteem
- perfectionism
- geentics
- NT/ predisposition to stress
complications of anorexia
- amenorrhoea
- infertility
- constipation and abdo pain
- cold intolerance
- bradycardia, low BP, arrhythmia’s
- peripheral oedema
- osteoporosis
- seizures
- depression
due to vom
- erosion of dental enameal
- enlargement of salivary glands
- calluses
- oesophageal tears
- ↓- K+ and Na+
- raised amylase
- hypochloraemic alkalosis
GI
- GI perf/ upper GI bleed
- reflux oesophagitis
- acute pancreatitis
- bowel obstruction
- delayed gastric emptying (AN)
- loss of gag reflex (BN)
Reduced grey and white matter
Thiamine deficiency
Pathophysiology of refeeding syndrome
- starvation reduces insulin - drives phosphate and potassium out of the cell and depletes stores
- when introduce CHO insulin rapidly increases - this drives K/P into cells and rapidly drops the serum levels
- this can cause oxidative phosphorylation to uncouple - arrythmias, HF, cardaic arrest
Management of anorexia
Fluoxetine (to reduce binging and purging) CBT Psychoeducation Guided self-help IPT Education on risks/treatment
Reasons for hospitalisation in anorexia
- BMI <13.5
- Rapid weight loss
- Electrolyte disturbance
- Suicide risk
Ix for anorexia
Bloods - ↑ urea, abnormal LFT, ↓ T3, ↓ glucose, ↑ amylase, ↓ zinc, ↑ cholesterol , ↓ vitb12, ↓ mg, ↓ folate, ↓ CK, ↓ thiamin
- ↑GH, ↓FSH &LH, Leucopenia
- dexamethosone suppression test - ↑ cortisol
- ECG
- DEXA bone scan
SSRI - names and SE
Fluoxetine, citalopram
-n,v,d, agitation, erectile dysfunction, reduced libido, anorexia ↓ NA, temor
cit - prolongs QT
Ci - lithium
symptoms of 5HT toxicity
- altered mental state (agitated/excited)
- tremor, clonus hyper-reflexia
- autonomic hypersensitivity (↑ BP, HT, RR, fever)
NaSSa - name,SE and CI
Mirtazipine
- weak NAdr reuptake I, anti-hitamine, A1+2
- ↑ appetite, weight gain, dry mouth, sedation, confusion, postural hypotension
CI - renal/hepatic impairment, jaundice, pregnancy
Classification of anti-psychotics and SE
Typical - Holoperidol and chlorpromazine
SE - EPSE - ADAPT
Acute - Dystonia Akanthesia Parkinsonism (rigidity, trmor, fenestrating gait) Tardive Dyskinesia
- Neuroleptic malignancy syndrome - rigidity, hyperthermia, ↑CK, flucuating consciuness, autonomic disturbance
- weight gain
Atypical - Olanzapine, risperodone, clozapine
- Fewer EPSE
- excessive weight gain (o)
- amenorrhoea, glactorrhoea (r)
- agranulocytosis and myocarditis (c)
- ↑QTc
SNRI - name and SE
Duloxetine and venlafaxine
SE - n,v,d, agitation, erectile dysfunction, reduced libido, anorexia ↓ NA, temor
- sleep disturbance, dry mouth, hyponatraiea, fluctuating BP, sexual dysfunction
TCA - name, SE and CI
Amitriptyline, lofepramine, clomipramine
Blocks reuptake 5HT and Nadr at pre-synaptic membrane
SE _ sedation, dry mouth, eye accomodation block, tachycaria, post hypotension, arrthymias, constipation, weight gain
- in overdose - VF, hypotension, resp dep, twitching, hallucinations, pyrexia
CI - agranulocytosis, liver damage, glaucoma, BPH
SE of Sodium Valproate
V,n Appetite increase Liver failure Pancreatitis Reversible hair loss Oedema Ataxia Teratogen/tremor/ thrombocytopenia Encephalopathy
Action, SE and CI carbamazepine
V-g sodium ch blocker (reduce glutamase release)
Cyp inducer Ataxia Rash/SJS BM suppression (neuropenia + leukopenia) Affects vision (diplopia) Motor disturbance Anaesthesia Z - N&V Excreted breast milk Parasthesia dIzzy Na - low Edema
CI - AVN abnormality; hx BM depression; acute intermittent porphyria
SE of lithium
- therapeutic dose
- toxicity symptoms and Rx
- CI
0.4-1mmol/L
SE Leucocytosis Insipidus (diabetes) - polyuria and dipsia Tremor (fine), teratogen -ebsteins anomaly Hair loss/ hypothyroid Increased weight U (V ) + N Metallic taste and memory problems \+ ECG changes; AKI drowsy,
TOXICITY - coarse tremor, ataxia, dysathria, reduced consciousness, v+d, slurred speech, coma, death, restless
Rx - IV fluids +/- haemodialysis and bowel irrigation + anti-convulsants
CI - Low Na diet (competes Na at glomerulus), untreated hypothyroid (can damage thyroid). cardiac rhythm disorder, excreted in breast milk
Name and SE of anxiolytics
Benzodiazepines - diazepain - GABAa R
SE - dependence, tolerance, drowsy, ataxia, resp depression (flumazenil)
Pregabalin (I Glutamate, NAdr and Substance P)
SE - dizzy, drowsy, blurred vision, confusion
Zopicone - insomnia
Features of brain lesions in different lobes
Parietal lobe lesions
- sensory inattention
- apraxias
- astereognosis (tactile agnosia)
- inferior homonymous quadrantanopia
- Gerstmann’s syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left disorientation
Occipital lobe lesions
homonymous hemianopia (with macula sparing)
cortical blindness
visual agnosia
Temporal lobe lesion
Wernicke’s aphasia: this area ‘forms’ the speech before ‘sending it’ to Brocas area. Lesions result in word substituion, neologisms but speech remains fluent
superior homonymous quadrantanopia
auditory agnosia
prosopagnosia (difficulty recognising faces)
Frontal lobes lesions expressive (Broca's) aphasia: located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus. Speech is non-fluent, laboured, and halting disinhibition perseveration anosmia inability to generate a list
Cerebellum lesions
midline lesions: gait and truncal ataxia
hemisphere lesions: intention tremor, past pointing, dysdiadokinesis, nystagmus
Features of parkinsons disease
Resting tremor
bradykinesia
rigidity (cogwheel/ lead pipe)
Other:
TRAPPS PD
Tremor
Rigidity
Akinesia (monotone voice, micrographia, mask-like face)
Postural instability/ Bradykinesia (stooped, festination, pedistool turn, reduced arm swing)
Postural hypotention and autonomic dysfunction (constipation, hypersalvia, urgency
Sleep disorder - REM
Psychosis (visual hallucinations)
Depression/ Dementia
+ve glabellar tap
Pathophysiology and RF for PD
- degeneration of dopaminergic pathway of substantia nigra in basal ganglia
RF - male, age, FH, pesticide exposure
Ix and Mx of PD
Ix - DAT scan and CT/MRI to exclude other causes
Mx - MDT, PT, screen for depression, inform DVLA
- Young and fit –> 1) Ropinirole (SE - gambling, complusive behaviour)
2) MOA - BI (Rasagiline)
3) Co-careldopa - Frail + co-morbidities –> 1) Co-Careldopa 2) MOAB-I
SE of Levodopa
levodopa - DOPAMINE Dyskinesia (involuntary writhing movements) On-off' effect Psychosis Anorexia Mouth dry, postural hypotension and palpitations Insomnia N&V Excessive daytime sleepiness/ drowsiness
Differentials for parkinsons disease
Parkinsonism - Multiple system atrophy; progressive supranuclear palsy; corticobasilar degeneration; LBD
Infection - syphilis, CJD, HIV
Vascular - multiple infarcts in SN
Drugs- metoclopramide, chlorpromazine, haloperidol
Trauma - dementia puglisitca
Inherited - wilsons
Delirium v Dementia
Delirium
- acute onset (hr/d)
- lasts hours - weeks
- fluctuates in intensity
- impaired consciousness
- perceptual disturbance
- disrupted sleep-wake cycle
Dementia
- gradual onset
- lasts m-year
- progressive deterioration
- normal consciousness
- perceptual disturbance in later stages
- normal sleep-wake cycle
Causes of delirium
DELIRIUM
- Drugs - opioids, sedative, L-DOPA
- Eyes, Ears, Sensory deficit
- Low or (MI, Stroke, PE)
- Infection
- Retention (urine/stools)
- Ictal
- Under hydration/ nutrition
- Metabolic - DM, POst-op, Na, uraemia
- Subdural haemorrhage
Criteria for alcohol dependence
Drink >14 units/weel
- craving
- withdrawal
- tolerance
- impairment to control use
- neglect of pleasure
- persistent use despite evidence of harm
Mx and stages of herion withdrawal
Withdrawal - 72 hours cold turkey
- Grade 0 –> craving/ anxiety
- Grade 1 - Yawning, sweating, restless sleep
- grade 2 - dilated pupil, gooseflesh, muscle twitching, shivering
- Grade 3 - insomnia, fever, increased HR, RR< BP, cramps, N,v,d
CI for ECT
Raised ICP Cerebral aneursym Recent cerebrovascular event Cochlear implant Mi <3m Resp infection DVT Potassium imbalance Pheochromocytoma
SE of ECT
Anaesthetic - MI/arrhythmia, aspiration, malignant hyperthermia
- confusion/ memory loss
- headaches
- status epilepticus
- stoke/ arrhythmia
- broken teeth
Stages of bereavement
Denial Anger Bargaining Depression Acceptance
SE of lamotrigine
- dizzy
- ataxia
- nausea
- SJS
Se of phenytoin
P450 inhibitor Hirsutism Enlarged gums (gingival hyperplasia) Nstagmus/ nervous sYndrome - cerebellar Teratogen/ Tremor Osteomalacia Interfers folic acid absorption (anaemia) Neuropathy - peripheral sensory, vertigo, headache
