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MSRA > Mental Health > Flashcards

Mental Health Flashcards

1
Q

MHA: What is a section 2?

A
  • Admit for assessment for up to 28 days
  • Made by approved mental health professional on the recommendation of 2 doctors
  • Can give treatment against a patients wishes
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2
Q

MHA: What is a section 3?

A
  • Admit for treatment for up to 6 months
  • Can be renewed
  • Made my AHMP and 2 doctors who must have seen the pt within th elast 24h
  • Can give treatment against a patients wishes
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3
Q

MHA: What is a section 4?

A
  • 72h assessment order
  • Made me GP and AMHO or relative
  • Often changed to section 2 upon arrival at hospital
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4
Q

MHA: What is a section 5 (2)?

A
  • patient who is voluntarily in hospital can be legally detained by a doctor for 72 h
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5
Q

What is a section 5(4)?

A
  • patient who is voluntarily in hospital can be legally detained by a nurse for 6 h
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6
Q

What is a section 17a?

A
  • Supervised community treatment order
  • can be used to recall a patient to hospital if they do not comply with conditions of order in the community, eg, taking meds
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7
Q

What is a section 135 and 136?

A

135 is where I LIVE (from property)
- someone found in their property who appears to have a mental disorder can be taken by the police to a place of safety

136 stop the MIX
- someone found in a public space can be taken in

Both can only used for up to 24h

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8
Q

How is depression classified?

A

Patient health questionnaire (PHQ-9):
Less severe - PHQ-9 score <16
More severe 0 PHQ-9 score of 16 and over

Hospital anxiety and depression (HAD) scale:
11 + depression

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9
Q

What are the 1st line pharma options for depression and their MOA?

A

SSRI (citalopram, fluoxetine, sertraline, paroxetine)
OR
SNRI (venlafaxine)

SSRI - inhibit 5-HT uptake (selective)
SNRI - inhibit 5-HT and NA uptake

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10
Q

What is the antidepressant of choice in:
a) most patients?
b) children and adolescents?
c) post MI?

A

a) citalopram/fluoxetine
b) fluoxetine
c) sertraline

If some effect within 4 weeks, increase dose and review in 3 weeks. If no effect swap and try another SSRI

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11
Q

What are the risks of SSRIs?

A
  1. INTERACTIONS:
    NSAIDS > give PPI
    Warfarin/LMWH > mirtazapine instead
    Aspirin
    Triptans > increased risk serotonin syndrome
    MAOIs - increased risk serotonin sndrome
  2. CARDIO
    Citalopram prolongs QT
  3. MOOD
    Increased risk of suicidal ideation in first 1-2 weeks
  4. PREGNANCY
    - Use in 1st tri can cause congenital heart defects and in 3rd tri can cause pulmonary htn of the newborn. Generally will contninue SSRI except for paroxetine
    Paroxetine has increased risk of congenital malformation
  5. Hyponatremia
  6. GI side effects (most common)
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12
Q

How are SSRIs discontinued?

A
  • Continue for at least 6 months after remission
  • When stopping, gradually reduce over 4 weeks (apart from paroxetine) due to risk of discontinuation symptoms (restless, unsteady,s sweating, GI, electric shocks)
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13
Q

What is the MOA and common side effects of mirtazipine?

A

Blocks alpha2-adrenergic receptors which increases the release of neurotransmitters

  • Weight gain
  • Sedation (becomes less sedatory at higher doses?
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14
Q

What is the MOA and side effects of TCAs?

A

MOA:
- Inhibits 5-HT (serotonin) and noradrenaline
- Antagonises histamine receptors > drowsiness
- Antagonises muscarinic receptors > dry mouth, blurred vision, constipation, urinary retention
- Antagnosis adrenergic receptors > postural hypotension
- Lengthens QT

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15
Q

What is serotonin syndrome?

A

Triad of clinical features resulting from therapeutic use or overdose of serotonergic drugs:
1. Neuromusclar excitation
2. Autonomic effects
3. Altered mental status

Diagnosis with Hunter Serotonin Toxicity Criteria (HSTC) of which clonus is a diagnostic feature (+ agitaton, sweating, hypertonia, hyperreflexia AND pyrexia >38C)

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16
Q

Which drugs can cause serotonin syndrome?

A
  • Antidepressants (MAOIs, TCAs, SSRIs, SNRIs, trazodone, mirtazipine)
  • Opiates
  • CNS stimulants
  • Herbs (st johns wort, ginseng, nutmeg)
  • Other (valproate, lithium, linezolid, chlorpherniramine, risperidone, olanzapine, ondansetron, metoclopramide)
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17
Q

How is serotonin syndrome managed?

A
  • Cyproheptadine
  • Chlorpromazine
  • Diazepam
  • Dantrolene

+ supporitve eg. cooling, correct blood sugars/electrolytes, bicarb if rhabdo

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18
Q

Name some A) TCAs B) SNRIs

A

a) Amitriptyline
Imipramine
Notriptyline
Dosulepin

b) Venlafazine
Duloxetine

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19
Q

How is generalised anxiety disorder managed?

A

Step 1: education + active monitoring
Step 2: low intensity psychological interventions
Step 3: high intensity psychological interventions or drug treatment
Step 4: highly specialist input

Drug treatment:
1st line - sertraline
2nd line - other SSRI/SNRI
3rd line - pregabalin

Follow up young pts weekly for the 1st month due to risk of suicide

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20
Q

How is panic disorder managed?

A

Diagnosis = symptoms present for at least 1 month

Step 1: recognition and diagnosis
Step 2: treatment in primary care (SSRI or CBT, imipramine/clomipramine 2nd line)
Step 3: review and consider alternative treatments
Step 4: review and referral to specialist mental health srevices
Step 5: care in specialist mental health services

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21
Q

What is agomelatine?

A

Melatonin agonist and 5HT antagonist - often given as an adjunct for sleep

Must monitor LFTs!

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22
Q

What is refractory depression and how is it treated?

A

Depression that doesn’t respond to 2 or more antidepressants

Treat with CBT, lithium, atypical antipsyschotics, phenlzine (TCA), MAOIs, ECT

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23
Q

What is bipolar disorder?

A
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24
Q

How is bipolar disorder managed?

A

Prophylaxis:
1. Mood stabiliser - lithium, valproate, lamotregine, carbamazepine
2. Antipsychotics (sometimes) - quetiapine, olanzapine
Do not give antidepressants - long term use increases risk of mania

Hypomania:
Mood stabilisers

Mania:
Antipsychotics

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25
Q

How does lithium work and how is it prescribed?

A

Mimics sodium - modulates dopaminergic, nodradrenergic and seratonergic transmission

Prescribe at night with BRAND NAME.

Don’t stop and start due to risk of rebound hypomania and increased risk of suicide

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26
Q

What are the contraindications for lithium therapy?

A

Addisons
Brugada syndrome
CVS disease
Pregnancy (risk of Epstein anomaly)
Breastfeeding

Interacts with thiazides, ACEis, NSAIDs

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27
Q

Describe the monitoring of lithium therapy

A

Before initiation: check renal function, thyroid function and ECG if CVS problems, pregnancy test

During initiation: 12-hour serum lithium after 5 days and then every 5-7 days after dose increment

Long-term: 12 hour serum lithium every 3/4 months, renal function every 6-12 months and TFTs every 12 months

Therapeutic level is between 0.6 and 1mmol/L

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27
Q

What are the signs of lithium toxicity and how is it managed?

A

Signs: severe GI upset, coarse tremor, ataxia, CV collapse, coma, seizures

Management:
- Stop therapy
- Fluids
- Monitor lithium, electrolytes, creatinine, eGFR, cardiac function

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28
Q

Name 3 typical/1st gen antipsychotics and their side effects

A

Haloperidol
Fluphenazine
Chlopromazine

Block D2 receptor (not selective) > cause extrapyramidal side effects, hyperprolactinaemia, sedation, metabolic effects, neuroleptic malignant syndrome, long QT, anticholinergic effects

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29
Q

Name 6 atypical/2nd gen antipsychotics and their side effects

A

Clozapine
Risperidone
Quetiapine
Olanzapine
Aripiprazole
Amisulpride

  • Block D2 and 5-HT2 receptors (more selective and fewer side effects) > metabolic
  • INCREASE RISK OF STROKE AND VTE IN ELDERLY
  • Risperidone is the only one of the above that can give EPSE
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30
Q

Which AP:
a) may give you EPSE?
b) less likely to cause weight gain?
c) more likely to cause postural hypotension?
D) may cause hyperprolactinaemia?
e) best for BPAD?

A

a) risperidone
b) aripiprazole, haloperidol
c) chlorpromazine, clozapine, quetiapine
d) amisulpride
e) quetiapine

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31
Q

When is clozapine prescribed?

A

Treatment resistant psychosis particularly schizophrenia - have to be on registry and need regular monitoring (weekly then 4 weekly) due to risk of neutropenia and agranulocytosis

32
Q

How are APs changed?

A
  • If no response in 4 weeks change medication
  • Avoid polypharmacy where possible
33
Q

What is the standard monitoring of antipsychotics?

A

FBC, U&Es, LFTs - at the start of therapy then annually

Lipids, weight - at the start of therapy, 3 months and then annually

Fasting blood glucose, prolactin - at the start of therapy, 6 months and then annually

Blood pressure - baseline, frequently during dose titration

ECG - baseline

CVS risk assessment - annually

34
Q

How are extrapyramidal side effects managed?

A

Procyclidine

35
Q

What is neuroleptic malignant syndrome?

A

A life threatening reaction to antipsychotic drugs characterised by fever, altered mental status, muscle rigidity and autonomic dysfunction

Bloods show markedly elevated CK and altered LFTs

Often seen after initiation/dose change/addition of SSRI with AP

36
Q

How is NMS managed?

A
  1. Withdraw meds for at least 5 days
  2. Monitor observations
  3. IM lorazepam
  4. Fluids
  5. Dantrolene if needed (muscle relaxant)
37
Q

What are the symptoms of mania vs hypomania?

A

Mania:
> 7 days
May require hospitalization
May present with psychotic symptoms (eg. grandeur, hallucinations)

Hypomania
Typically 3-4 days
Often high functioning and not requiring hospitalization

37
Q

What are the features of psychosis?

A
  1. Auditory hallucinations
  2. Delusions
  3. Thought disorganisation
    - Alogia; little information conveyed by speech
    - Tangengiality
    - Clanging; rhyming words
    - World salad; linking real words incoherently
    - Neologisms; new word formation
    - Knight’s move; loosening of associations
    - Flight of ideas
    - Perserveration
    - Echolalia
38
Q

How is psychosis managed?

A
  • Antipsychotics
  • Offer CBT if subsequent episodes
39
Q

What is the strongest risk factor for developing a psychotic disorder (including schizophrenia)?

A

Family history - having a parent leads to a relative risk of 7.5

40
Q

What are Schneider’s first rank symptoms of schizophrenia?

A

ABDS VV

A - auditory hallucinations (3rd person)
B - broadcasting thoughts + insertion/withdrawal
D - delusional perception
S - somatic passivity (bodily sensations that are imposed on the individual)

V - volition absent
V - voices speaking/arguing

41
Q

How is schizophrenia managed?

A

1st line - oral atypical antipsychotics + CBT

42
Q

Which factors are associated with poor prognosis in schizophrenia?

A
  • Strong family history
  • Gradual onset
  • Low IQ
  • Prodromal phase of social withdrawal
  • Lack of obvious precipitant
43
Q

What are the categories of personality disorder?

A

Cluster A ‘Odd or Eccentric’:
- Paranoid
- Schizoid
- Schizotypal

Cluster B ‘Dramatic, Emotional or Erratic’:
- Antisocial
- Borderline (EUPD)
- Histrionic
- Narcissistic

Cluster C ‘Anxious and Fearful’:
- Obsessive- Compulsive
- Avoidant
- Dependant

44
Q

What are the characteristics of paranoid PD?

A
  • 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
45
Q

What are the characteristics of schizoid PD?

A
  • Indifference to praise and criticism
  • Preference for solitary activities
  • Lack of interest in sexual interactions
  • Lack of desire for companionship
  • Emotional coldness
  • Few interest or friends
46
Q

What are the characteristics of schizotypal PD?

A
  • 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
47
Q

What are the characterisits of antisocial PD?

A
  • Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
  • More common in men;
  • Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
  • Impulsiveness or failure to plan ahead;
  • Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
  • Reckless disregard for the safety of self or others;
  • Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
  • Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
48
Q

What are the characteristics of borderline/EUPD?

A
  • Efforts to avoid real or imagined abandonment
  • Unstable interpersonal relationships which alternate between idealization and devaluation
  • Unstable self image
    Impulsivity in potentially self damaging area (e.g.
    Spending, sex, substance abuse)
  • Recurrent suicidal behaviour
  • Affective instability
  • Chronic feelings of emptiness
  • Difficulty controlling temper
49
Q

What are the characteristics of histrionic PD?

A
  • Inappropriate sexual seductiveness
  • Need to be centre of attention
  • Rapidly shifting and shallow expression of emotions
  • Suggestibility
  • Physical appearance used for attention seeking purposes
  • Impressionistic speech lacking details
  • Self dramatization
  • Relationships considered to be more intimate than they are
50
Q

What are the features of narcissistic PD?

A
  • 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
51
Q

What are the features of obsessive-compulsive PD?

A
  • Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
  • Demonstrates perfectionism that hampers with completing tasks
  • Is extremely dedicated to work and efficiency to the elimination of spare time activities
  • Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
  • Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
  • Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
  • Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
52
Q

What are the features of avoidant PD?

A
  • 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
  • Preoccupied with ideas that they are being criticised or rejected in social situations
  • Restraint in intimate relationships due to the fear of being ridiculed
  • Reluctance to take personal risks due to fears of embarrassment
  • Views self as inept and inferior to others
  • Social isolation accompanied by a craving for social contact
53
Q

What are the features of dependent PD?

A
  • Difficulty making everyday decisions without excessive reassurance from others
  • Need for others to assume responsibility for major areas of their life
  • Difficulty in expressing disagreement with others due to fears of losing support
  • Lack of initiative
  • Unrealistic fears of being left to care for themselves
  • Urgent search for another relationship as a source of care and support when a close relationship ends
  • Extensive efforts to obtain support from others
  • Unrealistic feelings that they cannot care for themselves
54
Q

How are personality disorders managed?

A

Psychological therapies: dialectical behaviour therapy
Treatment of any coexisting psychiatric conditions

54
Q

What is acute stress disorder?

A

An acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event

Involves:
- intrusive thoughts
- negative mood
- avoidance
- arousal

55
Q

How is acute stress disorder managed?

A

1st line - trauma focused CBT

Benzos sometimes used

56
Q

What is post-traumatic stress disorder?

A

A cluster of symptoms which have been present for 4 weeks or MORE after a traumatic event

Involving:
- Re-experiencing
- Avoidance
- Hyperarousal
- Emotional numbing

57
Q

How is PTSD managed?

A

1st line - trauma based CBT
or eye movement desensitization and reprocessing therapy (EMDR)

Drug treatments should not be used routinely - if necessary given venlafaxine or SSRI, risperidone if SEVERE

58
Q

What is Cotard syndrome?

A

A rare disorder in which the patient believes that they or part of their body is dead

59
Q

What is somatisation disorder?

A

Multiple physical symptoms present for at least 2 years
Patient refuses to accept reassurance or negative test results

60
Q

What is illness anxiety disorder (eg. hypochondriasis)?

A

Persistent belief in the presence of an underlying serious disease eg. cancer
Patient refuses to accept reassurance or negative test results

61
Q

What is conversion disorder?

A

Typically involves loss of motor or sensory function in which the patient doesn’t consciously feign the symptoms or seek material gain

Patients may be indifferent to their apparent disorder

62
Q

What is dissociative disorder?

A

Dissociation is a process of seperating off certain memories from normal consciousness - also involves PSYCHIATRIC symptoms

63
Q

What is factitious disorder?

A

AKA Munchausen’s syndrome - the intentional production of physical and psychological symptoms

64
Q

What is malingering?

A

Fraudulent simulation of exaggeration of symptoms with the intention of financial or other gain

65
Q

What is sleep paralysis ?

A

Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures

Can treat with clonazepam

66
Q

How do benzos work and how are they prescribed?

A

Increase the frequency of chloride channels on inhibitory GABA

High chance of tolerance so only prescribe for 2-4 weeks

67
Q

How are benzos discontinued?

A

Withdraw in steps of about 1/8 of the daily dose every fortnight - if difficult, switch to equivalent dose of diazepam and reduce every 2-3 weeks in steps of 2 or 2.5mg

Acute withdrawal causes insomnia, irritability, anxiety, tremor, loss of appetite, tinnitus, perspiration, perceptual disturbances, seizures

68
Q

What are the signs and symptoms of anorexia nervosa?

A

Features:
- reduced body mass index
- bradycardia
- hypotension
- enlarged salivary glands

Physiological abnormalities:
- hypokalaemia
- low FSH, LH, oestrogens and testosterone
- raised cortisol and growth hormone
- impaired glucose tolerance
- hypercholesterolaemia
- hypercarotinaemia
- low T3

69
Q

How is anorexia managed?

A

1st line - CBT-ED and family based therapy
Nutritional rehabilitation
No medications licensed - consider SSRI if co-morbid depression
Severe cases require hospitalization

70
Q

What are the diagnostic criteria for bulimia nervosa?

A
  • Recurrent episodes of binge eating
  • A sense of lack of control over eating during the episode
  • Recurrent compensatory behaviour to prevent weight gain such as purging/laxatives/diuretics
  • Occurs at least once weekly for 3 months
  • Self-evluation is unduly influenced by body shape and weight
  • Disturbance does not occur exclusively during episodes of anorexia nervosa
71
Q

How is bulimia nervosa managed?

A
  • Refer for specialist care is appropriate
  • Bulimia nervosa focused guided self help
  • CBT-ED if refractory
  • No medications licensed
72
Q

What is De Clerambault’s syndrome?

A
  • aka erotomania
  • Delusion of being loved by someone of superior social status
73
Q

What is Fregoli syndrome?

A
  • Condition in which patient falsely identifies a loved one in strangers
74
Q

What is Capgras syndrome?

A
  • Opposite to Fregoli
  • Condition in which a patient believes their loved one has been replaced by a stranger
75
Q

What is Othello syndrome?

A
  • Delusion of infidelity of a spouse or partner
76
Q

What is Ekbom’s syndrome?

A
  • Delusion of infestation with insects

MSRA (24 decks)

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