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Placement > mental health end of block formative revision > Flashcards

mental health end of block formative revision Flashcards

1
Q

What are the positive symptoms of schizophrenia?

A
  • Delusions e.g. passivity and persecutory
  • Halluncinations (third person)
  • Formal thought disorder
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2
Q

What are the negative symptoms of schizophrenia?

A
  • Loss of motivation
  • Loss of awareness of socially appropriate behaviour
  • Blunting of affect, flattening of mood and anhedonia

N.B. If schizophrenia is associated with high/low mood then is schizoaffective disorder

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3
Q

What is the criteria for schizophrenia?

A
  • One of the following:
    • Thought echo, insertion, withdrawal or broadcasting
    • Delusions of control/passivity
    • Hallucinatory voices
    • Persistent delusions of other kinds
  • Or 2 of the following:
    • Negative symptoms
    • Persistent hallucinationswith fleeting delusions
    • Catatonic behaviour
    • Breaks in train of thought
    • Significant and consistent change in overall uality of some aspects of personal behaviour
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4
Q

what is emergency management of acute behavioural disturbance?

A
  • If non-psychtoic then oral lorazepam
  • If psychotic then oral lorazepam and oral anti-psychotic e.g. haloperidol
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5
Q

Which drugs would you give in schizophrenia?

A
  • First line is either:
    • SGA (e.g. olanzapine, quetiapine, risperidone) and long-acting BDZ for non-acute anxiety/bheavioural disturbance e.g. diazepam (lorazepam is short acting)
    • OR FGA e.g. chlorpromazine (has sedating effect at high doses)
  • second line:
    • Try another antipsychotics (at least one of the ones you have tried as either first or second line should be an SGA)
  • Thrid line:
    • Clozapine (after trying 2 one of which was an SGA)
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6
Q

What are the criteria for a diagnosis of depression?

A
  • At least 2 weeks of symptoms which aren’t secondary to drugs/alcohol/bereavement
  • Symptoms must cause significant distress and/or impairment of social, occupational or general functining
  • There must be at least 2 typical symptoms:
    • Low mood
    • Anhedonia
    • Fatigue/lack of energy
  • And at least 2 other core symptoms
    • e.g. irritability, suicidal ideation, guilt, poor concentration/memory, indecisiveness, headache, stomach ache, psychomotor agitation/retardation, insomina/hypersomnia, eating/weight change, reduced libido
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7
Q

What is mild depression and how is it treated?

A
  • 2 core and 2 typical symptoms
  • Treated with:
    • Watchful waiting
    • Guided self-help, computerised CBT or structured physcial activity programmes
  • Although is patient has past history of moderate/severe depression or they had subthreshold symptoms for >2 years then consider antidepressants.
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8
Q

What is moderate depression and how is it treated?

A
  • 2 typical and 3 core symptoms
  • Treated with combination of antidepressant and high-intensity psychological intervention e.g. CBT or IPT
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9
Q

Severe depression (3 typical and 4+ core features) is treated in the same way as moderate depression. How is it treated differently if there is also psychosis?

A
  • Antidpressant and antipsychotic use
  • Start with the antipsychotic first to rule out that it is all due to psychosis:
    • SGA or low dose FGA
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10
Q

What are first and second line anitdepressants used in depression?

A
  • First line: SSRIs (citalopram, fluoxetine or sertraline)
    • If <18 then fluoxetine
  • Second line:
    • Alternative SSRI
    • Venlafaxine
    • Mirtazapine (can cause weight gain)
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11
Q

What is the criteria for diagnosis of bipolar disorder?

A
  • At least 2 episodes one of which must be hypomanic/mixed/manic wit recovery between.
    • Criteria for manic:
      • Abnormally + persistenly elevated, expansive or irritbale mood with 3 or more characteristic symptoms of mania
      • At least one week duration
      • Should be severe enough to impair occupation and social functioning and can be psychotic features
      • (for hypomanic is same but lasts only 4 days and doesn’t impair social/occupational functioning or have psychotic features)
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12
Q

What are the clinical features of mania?

A
  • Elevated mood
  • Increased energy
  • Increased seld-esteem
  • Tendency to enage in behaviour with serious consequences
  • Irritability, aggresivenes or suspiciousnes
  • Psychotic symptoms e.g. delusions of grandiose, persecutory delusions, preoccupation with thoughts and schemes can lead to self-neglect, catatonic behaviour, total loss of insight
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13
Q

What is Bipolar I, II and rapid cycling?

A
  • Bipolar I is severe mood episodes from mania to depressoin
  • Bipolar II is milder mood elevation alternating with severe depression
  • Rapid cycling is more than 4 mood swings in a 12 month period with no intervening asymptomatic periods.
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14
Q

In addition to psychoeducation, CBT, Interpersonal therapy, support groups etc. which pharmacological approaches can be used in long term management of bipolar?

A
  • Mood stabiliser
    • Lithium then carbamazepine​
  • Low dose antipsychotic
    • Aripiprazole or quetiapine
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15
Q

How is an acute manic episode managed in bipolar?

A
  • If severe/life threatening –> ECT
  • If not:
    • Stop antidepressants
    • Start antipsychotics:
      • First line: SGA
        • aripiprazole, risperidone, quetiapine
      • Second lineL
        • Lithium or valproic acid (mood stabilisers)- these take longer to work which is why SGA started first
  • BDZs can be used to help reduce dose of SGA needed for adequate sedation
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16
Q

Describe the management of an acute depressive episode in bipolar

A
  • SSRI and antipsychotic (SGA e.g. quetiapine) (to prevent mania)
  • Also mood stabiliser e.g. lithium or valproic acid
  • If severe/life threatening –> ECT
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17
Q

What is the criteria for panic disorder diagnosis?

A
  • Several attacks of autonomic anxiety in a period of 1 month:
    • in circumstances with no objective danger
    • Without being confined to known/predictable situations
    • With comparative freedom of anxiety between attacks.
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18
Q

Describe the management of panic disorder

A

No superior efficacy between the following:

  • SSRS- citalopram, escitalopram, paroxetine, sertraline
  • BDZs- Alprazolam or clonazepam (NOT recommended by NICE due to dependence)
  • TCAs- imipramine, clomipramine
  • MAOIs -phenelzine

Then also

  • CBT or psychodynamic therapy
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19
Q

What are the following?

  • Agoraphobia
  • Simple/specific phobia
  • Social phobia
A
  • Agoraphobia
    • Anxiety/panic with places/situations where escape may be difficult or embarassing
  • Simple/specific phobia
    • Recurring excessive pscyhological/autoimmune symptoms of anxiety in presence of a specific object or situation
  • Social phobia
    • Symptoms of incapacitating anxeity not secondary to delusional or obsessive thoughts. Restrcited to particular social situation –> desire for escape or avoidance
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20
Q

What is the management for agoraphobia, simple phobia and social phobia?

A
  • Agoraphobia:
    • Same as panic disorder
  • Simple phobia:
    • CBT
    • drugs not really used
  • Social phobia:
    • CBT and SSRIs/MAOIs
    • Can potentially add a BDZ e.g. clonazepam or alprazolam
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21
Q

What is GAD and how is it treated?

A
  • Generalised persistent anxeity and feelings of apprehension about everyday events/problems, with symptoms of muscle and psychic tension, causing significatn distress and functional impairment
  • Management should be directed towards predominant symptom:
    • Buspirone (anxiolytic)
    • Somatic symptoms- BDZs e.g. lorazepam
    • Depressive symptoms- trazodone (serotonin modulator), SSRIs (escitaloram or paroxetine) and SNRIs e.g. duloxetine or venlafaxine
    • CVS symptoms- B-blockers
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22
Q

What are adjustment disorders?

A
  • They lie between normal reaction and psychiatric diagnosis
  • They must occur within 1-3 months of a social stressor and not persist for more than 6 months after the stressor is removed
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23
Q

How are adjustment disorders managed?

A
  • Psychological
    • Practical help with the stressor
    • Allow patient to verbalise feelings
  • Pharmacological
    • Antidepressents or anxiolytics/hypnotics if symptoms persist or are distressing
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24
Q

Which symptoms suggest a grief reaction has become abnormal and how is this managed?

A
  • Abnormal grief reaction:
    • One which is v intense, prolonged, delayed (or absent), or where symptoms outside the normal range are seen e.g. feelings of worthlessness/guilt
  • Management:
    • Antidressents and support/counselling
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25
Q

What are typical symptoms associated with PTSD? How is it managed?

A
  • Difficulty falling/staying asleep
  • Nightmares
  • Flashbacks
  • Irritability/outbursts of anger
  • Difficulty concentrating
  • Hypervigilence
  • Exaggerated startle response
  • distress when exposed to circumstances resembling stressor
  • Inability to recall some important aspects of period around stressor
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26
Q

How is PTSD managed?

A
  • Trauma- focussed CBT or EMDR (eye movement desensitisation and reprocessing)
  • Psychodynamic therapy
  • Stress management
  • Drugs:
    • SSRIs- paroxetine or sertraline
    • Sleep disturbance- mirtazapine or zopiclone
    • Anxiety/hyperarousal- BDZs
    • Intrusive thoughts- mood stabilisers- carbamazepines, valproate, lithium
    • Pyshcotic symptoms- olanzapine, risperidone, quetiapine, clozapine
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27
Q

Which drugs can lower the seizure threshold and so should be used in caution in epilepsy?

A
  • Antidepressants
    • TCAs
  • Antipsychotics
    • esp. SGAs
    • Lowest risk is haloperidol
  • Mood stabilisers
    • lithium (but only in OD)
  • Others:
    • Disulfiram
    • Anticholinesterase inhibitors (except galantamine)
28
Q

How does conduct disorder present?

A
  • With aggression, cruelty to others/animals
  • Destruction of property
  • Deceitfulness
  • Theft
  • Fire-setting
  • Truancy
  • Running

Management is through parent training, family therapy, child interventions (e.g. anger management, problem solving, social skills) etc.

29
Q

How is depression in children treated?

A
  • CBT, interpersonal therapy and family therapy for at least 3 months
  • If unresponsive then consider additional psychological therapy and pharmacology (reluctance to use pharmacology though)
  • Drugs:
    • Fluoxetine
    • (if unresponsive can try sertraline or citalopram)
30
Q
A
  • Start with CBT and other therapies and then only consider drugs if you absolutely must.
  • Drugs can be considered for:
    • GAD, OCD, panic disorder/agoraphobia and social phobia
    • Not really used in simple phobia, PTSD or separation anxiety
31
Q

What is ADHD characterised by? How is it managed?

A
  • Hyperactivity, inattention and impulsiveness
  • Psychoeducation then medication:
    • Methylphenidate
      • Can cause growth supression and so monitor growth. Can give drug holidays if growth supression is a worry.
    • Atomoxetine
    • Dexamfetamine (if the others don’t work)
32
Q

What is the difference between anorexia and bulimia?

A
  • Anorexia is marked distortion of body image with pathological desire for thinness and self-induced weight loss by a variety of methods
  • Bulimia is recurrent episodes on binge eating with compensatory behaviour and overvalued ideas about ‘ideal’ body shape and weight
33
Q

Describe the management of anorexia and bulimia

A
  • Fluoxetine in both
  • In anorexia can do family therapy (esp. if early onset) or individual therapy eg. CBT. and nutritional education
  • In bulimia can do CBT also.
34
Q

What is the difference between delirium and dementia?

A
  • Dementia has slower onset, is progressive, lasts longer and doesn’t alter consciousness
  • Delirium is acute, fluctuating, shorter duration and impairs conciousness
35
Q
  • Delirium is managed through reassurance and supportive measures. What are the management options for dementia?
A
  • For vascular can modify cardiovascula risk factors to stop progression
  • For Alzheimer’s can give:
    • AChEi e.g. donepezile and rivastigmine
      • Side effects include D+V, cramps, incontinence, headache, dizziness, insomnia, raised LFTs, arrhtyhmias, peptic ulcers and hallucinationa
      • Contraindications are: peptic ulcers, arrhythmias, COPD (lots of elderly will have these)
36
Q

What are common side effects of SSRIs?

A
  • Nausea and GI upset
  • Headache
  • Restlessness
  • Insomnia
37
Q

What are cautions and contraindications for the use of SSRIs?

A
  • Cautions:
    • can effect CYP450 enzymes so caution with drugs undergoing hepatic metabolism
  • Contraindications:
    • Manic episode
    • Use of MAOIs
38
Q

How long after starting SSRIs do you follow patients up for increased suicidal ideation?

A
  • If low risk then after 2 weeks
  • If high risk of <30 then after 1 week
39
Q

What is serotonin syndrome?

A
  • Characterised by:
    • Altered mental state, agitation, tremor, shivering, diarrhoea, hyperreflexia, ataxia, hyperthermia
  • May need gastric lavage or activated charcoal of serotonin antagonists e.g. chlorpromazine
40
Q

Give examples of TCAs. What are their common side effects?

A
  • Amitriptyline, comipramine, dosulepin, imipramine, nortripyline
  • Side effects:
    • Anticholinergic e.g. dry mouth, blurred vision, constipation, urinary retention, drowsiness, confusion, palpitations
    • Anti-adrenergic e.g. drowsiness, postural hypotension, sexual dysfunction
    • Serotonin antagonsim –> anxiolytic, sedation
    • Antihistaminergic e.g. drowsiness and weight gain
41
Q

Give examples of MAOIs (used in treatment resistant and atypical depression/anxeity). What are possible side effects?

A
  • Isocarboxazid, phenelzine, tranylcypromine
  • Most common side effect is postural hypotension BUT can also cause hypertensive crisis (due to MAO inhibition in intestines- need to avoid food with tyramine and also certain medications)
42
Q

What class of drugs are venlafaxine and duloxetine? What are common side effects and what moniotring is needed?

A
  • SNRIs
  • Common side effects:
    • Nausea, GI upset, constipation, loss of appetite, dry mouth, dizziness, agitation, insomnia, sexual dysfunction, headache, sweating, shaking
  • Dose-dependent monitoring needed.
43
Q

What class of drug is mirtazapine? What are common side effect? What monitoring is required?

A
  • NaSSA (noradrenergic and specific serotinergic antidepressants)
  • Common side effects:
    • Sedation (more at lower doses)
    • Increased appetite
    • Weight gain
  • Can rarely cause agranulocytosis
    • Need to look for sore throat, fever, stomatitis, signs of infection. If seen then stop medication immediately and do blood test to check for neutropenia.
44
Q

Give examples of FGAs. What are the possible EPSEs that can occur with FGAs?

A
  • Haloperidol, Chlorpromazine, zuclopenthixol, flupenthixol
  • EPSEs:
    • Rigidity
    • Bradykinesia
    • Dystonia
    • Tremor
    • Askathisia
    • Parkinsonism
    • Tardive dyskinesia
45
Q

Antipsychotics can also cause neuroleptic malignant syndrome. What is this?

A
  • Life threatening reaction to antipsychotic drugs
  • Causes fever, altered mental status, muscle rigidity and autonomic dysfunction
  • Transfer to ITU, dantrolene can help
46
Q

What monitoring is required on any antipsychotic?

A
  • Prolactin levels should be checked before starting and then every 6 months after.
47
Q

Give examples of SGAs. Rather than EPSEs what are they more likely to cause?

A
  • Olanzapine, risperidone, paliperidone, quetiapine, clozapine, aripiprzole, amisulpride
  • More likely to cause metabolic syndrome –> high TGAs, cholesterol, diabetes, weight gain
48
Q

As well as ESPEs, hyperprolactinaemia and metabolic syndrome, what are other side effects of antipsychotics?

A
  • Anticholinergic effects e.g. dry mouth, blurred vision, difficuly passing urine, urinary retention, constipation
  • Anti-adrenergic e.g. hypotension, tachycardia, sexual dysfunction
    *
49
Q

Which antipsychotics should you give if the patient has the following:

  • Sedation
  • Weight gain
  • ESPEs
  • Postural hypotension
A
  • Sedation –> haloperidol or non-sedating SGA (risperidone or amisulpride)
  • Weight gain –> haloperidol or fluphenazine
  • ESPEs –> SGAs
  • Postural hypotension –> haloperidol, amisulprde, trifluoperazine
50
Q

What is post-injection syndrome?

A
  • Occurs after depot of olanzapine –> sedation, acute confusion, agression, EPSEs, dysarthria, ataxia, seizure
51
Q

What are the common side effects of clozapine?

A
  • Anticholinergic- constipation, dry mouth (but also causes hypersalivation), blurred vision
  • Anti-adrenergic –> hypotension, sexual dysfunctio
  • Sedation
  • Nausea and vomiting
  • Weight gain
  • ECG changes
  • Headache
  • Fatigue
  • Hypertension
  • Tachycardia
  • Drowsiness
  • Seizures
52
Q

What are potentially life-threatening side effects of clozapine?

A
  • Fatal myocarditis or cardiomyopathy
  • PE
  • Neuroleptic malignant syndrome
  • Agranulocytosis
    • Leukopnia, eosinophilia and leukocytosis
    • Must do bloods before starting then every week for 18 weeks, every fortnight for one year then monthly
    • Stop the clozapine and admit to hospital
53
Q

What can haapen when stopping clozapine quickly?

A
  • Return of psychosis
  • Rebound:
    • Sweating, headache, nausea, vomiting, diarrhoea
54
Q

What do you worry about in OD of the following? What do you give in OD? What about in dependency?

  • Opiates
  • BDZs
A
  • Opiates
    • Resp. depression
    • Give naloxone in OD
    • Give methodone or buprenorphine in dependency
  • BDZs:
    • Resp. depression
    • Give flumazenil
    • In dependency give diazepam (also give diazepam in alcohol dependency)
55
Q

Describe the CAGE screening tool for alcohol use

A
  • C- have you ever felt you should cut down on drinking
  • A- has anyone ever annoyed you be criticising your drinking
  • G- have you ever felt guilty about your drinking?
  • E- have you ever had a drink early in the morning as an eye-opener?
56
Q

What do you give for alcohol withdrawal? What can you give for maintenance?

A
  • Give:
    • BDZs (diazepam)- acts as anticonvulsant and antipsychotic as well (although can also add haloperidol)
  • Supplementary vitamins
  • Maintenance:
    • Support, counseling, residential abstinence
      • Also:
        • Disulfiram (aversive drug)
        • Acomprostate and naltrexone (anti-craving)
57
Q

For lots of anxeity disorders you tend to give SSRIs but for GAD can give buspirone. what are common side effects?

A
  • dizziness, excitement, headache, nausea, nervousness
58
Q

What are the common side effects of diazepam?

A
  • Amnesia
  • Ataxia (esp. in elderly)
  • Confusion (esp. in elderly)
  • Dependence
  • Drowsiness and lightheadedness the next day
  • Muscle weakness
  • Paradoxical increase in aggresion
59
Q

Normal side effects of lithium?

A
  • polyuria and polydipsia
  • oedema and weight gain
  • Conigtive problems e.g. impaired memory and concentration
  • Tremor (fine tremor)
  • Impaired co-ordination
  • GI upset e.g. nausea, vomiting, diarrhoea
  • Hair loss
  • Acne
60
Q

Chronic side effects of lithium

A
  • Renal function decrease
    • Monitor creatinine and urea levels
  • Hypothyroidism
    • Monitor TFTs
  • Teratogenic
    • Esp. in first trimester –> Ebstein’s abnormality increased risk (tricuspid valve defect)
61
Q

What levels should lithium be kept between? What are early and late signs of lithium toxicity?

A
  • 0.6-1mmol/L
  • Ealy:
    • Coarse tremor, anorexia, nausea/vomiting, diarrhoea (can be bloody), dehydration and lethargy
  • Late:
    • Severe neurological complications –> fasciculations, hypertonicity, resltessness
    • Hypotension and cardiac arrhythmias then circulatory collapse with seizures, stupor and eventual coma
62
Q

What does Li interact with?

A
  • ACEi
  • ARBs
  • NSAIDs
  • SSRIs
  • Antihypertensive
  • Haloperidol
  • All increase the conc.
63
Q

What are CIs to lithium use?

A

Heart failure and sick sinus syndrome

64
Q

What are early and late side effects of ECT?

A
  • Early:
    • Loss of short term memory
    • Retrograde amnesia
    • Headache
    • Temporary confusion
    • Nausea/vomiting
    • Clumsiness
    • Musclear aches
  • Late:
    • Loss of long term and past memories
65
Q

What do the following sections allow?

  • Section 2
  • Section 3
  • Section 4
  • Section 5(2)
  • Section 5(4)
A
  • Section 2
    • For assessment. For 28 days. Needs 2 medical recommendations.
  • Section 3
    • For treatment. For 6 months. Can be renewed for another 6 and then 12 thereafter.
  • Section 4
    • Emergency admission of those not yet admitted e.g. in A&E, outpatients, day hospitals.
    • 72h
  • Section 5(2)
    • Emergency detention of informal patient (on pschiatric of non-psych ward)
    • 72h
  • Section 5(4)
    • Same as 5(2) but for nurses and is only for 6h

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