Module 3 Psychiatry notes Flashcards
First rank symptoms of Schizophrenia
3rd person auditory hallucinations Thought withdrawal, insertion and broadcast Delusional perceptions Delusions of control Somatic passivity
Schizophrenia positive symptoms
An excess or distortion of normal functioning Delusions, hallucinations and thought disorders Caused by overactivity of receptors in the mesolimbic pathway
Schizophrenia negative symptoms
Decrease or loss of functioning Blunting of affect, poverty of speech Caused by underactivity of receptors in the mesocortical pathway
Types of schizophrenia
Paranoid Catatonic Hebephrenic Residual Simple
Paranoid schizophrenia features
paranoid delusions, auditory hallucinations and perceptual disturbances
Catatonic schizophrenia features
hyperkinesis or negativism
Hebephrenic schizophrenia features
fluctuating affect
Residual schizophrenia features
long term negative symptoms
Simple schizophrenia features
negative symptoms without psychotic symptoms
First generation antipsychotics include/mechanism
Chlorpromazine, haloperidol, promazine, flupentixol and zuclopenthixol D2 antagonists, more potent than SGA due to increased occupancy of D2 receptors. Can worsen negative symptoms. Also block D2 receptors in nigrostriatal pathway causing extrapyramidal symptoms and in tuberoinfundibular pathway causing increased prolactin.
Second generation antipsychotics include/mechanism
ROCQAA- risperidone, olanzapine, clozapine, quetiapine, aripiprazole, amisulpride 5HT2A and D2 antagonists (dopamine, serotonin antagonists). High affinity for 5HT2A receptors than D2 receptors. Less extrapyramidal SE but more metabolic SE.
Third generation antipsychotics include/mechanism
Only licensed TGA is aripiprazole Dopamine partial agonists. Less SE but less efficacious.
Clozapine mechanism
SGA used in treatment resistant schizophrenia. Blocks D1 and D4 receptors, lower affinity for D2 receptors, also block 5HT2A receptors. Risk of agranulocytosis.
Significant Antipsychotic SEs
Pseudoparkinsonism Acute distonia Akathisia Tardive dyskinesia
Less significant antipsychotics SEs
Metabolic- weight gain, diabetes Anticholinergic- dry mouth, blurred vision, difficulty passing urine, urinary retention, constipation Anti-adrenergic- postural hypotension, tachycardia, sexual dysfunction Anti-histaminergic- sedation Cardiovascular (including prolonging the QT interval) Hormonal (including increasing plasma prolactin)
Acute dystonic reaction
Happens within a week or starting/increasing dose of antipsychotic Presentation: Mainly affects muscles of head and neck Torticollis, trismus, forceful protrusion of tongue, grimacing, oculogyric spasm, opisthotonos, blepharospasm Less commonly affects laryngeal/pharyngeal muscles- dyspshagia Management: Discontinue causative agent IM anticholinergic e.g. procyclidine
Neuroleptic Malignant Syndrome
Life threatening complication of antipsychotic medications. Presentation: hyperthermia (above 38°c), muscle rigidity, altered mental status, autonomic dysfunction (e.g. hypotension, incontinence) Elevated CK Management: ABCDE Stop causative agent IV benzos for agitation Cooling devices/antipyretics Treat rhabdomyolysis Sometimes bromocriptine and amantadine are used as muscle relaxants
ICD 10 classification of BPD
Two or more episodes in which the patient’s mood and activity levels are significantly disturbed At least one= hypomania (<4 days)/ mania (>7days)
DSM BPD types
Bipolar I- one or more manic episodes with or without a history of depressive episodes Bipolar II- one or more depressive episodes with at least one hypomanic episode
BPD mania symptoms
I DIG FAST Irritability/elevated mood Distractibility Inhibition loss Grandiosity Flight of ideas Activity increased Sleep not needed Talkative
Hypomania symptoms
Persistent mild elevation of mood Increased energy Marked feelings of well being Increased sociability Talkative Overfamiliar Increased sexual energy Hardly sleeping No impact on function
BPD treatments
Mood Stabilisers: Lithium Anticonvulsants: Valproate Lamotrigine +/- antipsychotics (haloperidol, olanzapine, quetiapine or risperidone) and antidepressants (fluoxetine) (Can try psychological treatment for depression)
Ebstein’s phenomenon
Ebstein’s anomaly is a congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart. In babies of mothers on lithium
Steven Johnson’s syndrome
Severe skin reaction to Lamotrigine
Valproate issue
Teratogenic
Lithium mechanism
Mechanism: inhibits cAMP production, cAMP inhibits monoamines so more monoamines available
Lithium safe level
Safe level: 0.6-1.0mmol/L
Lithium required monitoring
Li levels, U+E, TFTs, calcium
Lithium toxicity concentration
Toxicity: levels >1.5mmol/L
Lithium toxicity symptoms
Symptoms: tremor, anorexia, D+V, ataxia, dysarthria, delirium, fasciculations, hypotension, arrythmias, seizures, coma
Depression presentation
DEAD SWAMP Depressed mood Energy levels reduced Anhedonia Disturbed sleep Suicidal ideation Worthlessness Appetite reduced Mentation decreased (reduced concentration) Psychomotor retardation
Monoamine theory
Monoamine theory of depression where reduced monoamine function (5-HT, NA, DA) may cause depression. Precipitating factors: -Childhood trauma -Life events -Personality -Alcohol -Being female -Genetic -Illness
Depression severity categorisation
Mild Depression - 2 or 3 of the symptoms but can continue with day-to-day life Moderate Depression - 4+ of the symptoms and difficulty continuing with day-to-day life Severe Depression -Several symptoms are marked and distressing. Suicidal ideation common. Can be +/- psychosis
Depression screening tools
Hamilton Depression Rating Scale -21 assessed items, 17 total score, 18-21 assesses severity Beck Depression Inventory -18 is mild, 19-29 moderate and >30 severe Patient Health Questionnaire -PHQ2 screens and PHQ9 for diagnosis and monitoring symptom severity Major Depression Inventory -10 items, diagnosed using score of 1 or 0, severity using 0-5. Major depression if score >26
Depression management
Education Low intensity psychological interventions (sleep hygiene, computerised CBT self help, structured group physical activity programme), medication, referral or further assessment High intensity psychological interventions (CBT/IPT), medication, combined treatment, collaborative care, referral Inpatient care, input from MDT, ECT
Dysthymia
Chronic depressive mood lasting at least several years
Mental state symptoms of neuroses
depersonalisation/derealisation, fear of losing control, concentration difficulties
Low mood/depression symptoms
Depressed Mood Anhedonia Fatigability/Loss of energy Disturbed sleep Lack of concentration/indecisiveness Low self confidence Increased/decreased appetite Suicidal thoughts or actions Slowing of movement or speech Feelings of guilt, worthlessness or self-reproach
EUPD
Often result of insecure attachment/ domestic violence/ childhood sexual abuse etc. Low self esteem and intense feel of rejection, abandonment, being unloved Develops very intense feelings for people very quickly, but also one bad move can totally destroy their image of somebody Find it hard to control emotions they feel very intensely, emotional rollercoaster Often self-harm, overdose, engage in dangerous risky behaviour (eg. sex with randoms to feel better, desired) Often associated with depression, alcohol abuse etc. Finds it difficult to cope with life stresses, esp. friendship/relationship conflict
Delusion criteria
certainty (held with absolute conviction) incorrigibility (not changeable by compelling counterargument or proof to the contrary) impossibility or falsity of content (implausible, bizarre, or patently untrue)
Schizophrenia 2nd rank symptoms
Other delusions/hallucinations Breaks in thought fluency: incoherence, irrelevant speech, neologisms Catatonic behaviour: excitement, stupor, mutism, posturing, waxy flexibility, negativism Negative symptoms: apathy, paucity of speech, blunted emotions, social withdrawal: not due to depression or neuroleptic medication
Schizophrenia diagnosis
one 1st rank or two 2nd rank symptoms acutely for 1 month, with evidence of disturbance of functioning for 6 months.
Aripiprazole side effects
akathsia, decreased prolactin
Olanzipine SE
Anticholinergic symptons, diabetes, hyperlipidaemiam weight gain
Paliperidone
Acute parkinsonism, elevated prolactin, weight gain
Quetiapine
Diabetes, sedation, weight gain
Risperidone
Acute parkinsonism, elevated prolactin, weight gain
Ziprasidone
Prolonged QTc interval
GAD disgnosis
The patient must have a 6-month Hx of tension, worry and anxiety about everyday issues. 4 of the following Sx must be present: Autonomic Sx: palpitations, sweating, trembling, dry mouth Chest/Abdomen Sx: breathing difficulty, choking sensation, chest pain/discomfort, nausea Brain/Mind Sx: dizzy, unsteady, derealisation, depersonalization, fear of losing control or passing out, fear of dying Tension Sx: muscle tension, aches, restlessness, globus hystericus General Sx: tingling/numbness, hot flushes C) The criteria for panic disorder, hypochondriasis and OCD are not fulfilled: D) No physical medical condition or medication could be responsible for these symptoms
Compulsions
Senseless, repeated rituals
Obsessions
stereotyped, purposeless words, ideas or phrases that come into the mind (perceived as non-sensical – not delusions!)
GAD management
Step 1: Active monitoring Step 2: Individualised non-facilitated self help Step 3: CBT OR SSRI (sertraline is preferred, if not consider SNRI/pregabalin) Step 4: Psych referral for specialist care
PTSD symptoms
Emotional numbing Avoidance Inability to recall Re-experiencing Hyperarousal
How long should PTSD victims experience symptoms before diagnosis
1 month
Depression diagnosis time
2 weeks
Bulimia diagnosis time
3 months
PTSD first line
TF-CBT or eye movement desensitisation and reprocessing (EMDR) therapy
What 2 drugs may be used 2nd line in PTSD?
Duloxetine or venlafaxine
Anorexia nervosa symptoms
8 Ds Dieting Denial Dread of gaining weight Disturbed beliefs about weight Doesn’t want help Dual effect– dieting + over-exercise/diuretics, laxatives and self-induced vomiting Disinterested/socially withdrawn Decline in weight = rapid
Anorexia nervosa physical signs
Physical signs Dry skin Hypercarotenemia Lanugo body hair Acrocyanosis Breast atrophy Swelling of the parotid and submandibular glands Thinning hair
Anorexia emergency management name
MARSIPAN
Anorexia emergency signs
BMI under 13/ rare of weight loss Pulse <40 SBP <90 DBP <70 Postural BP drop of 10< T <35C Bloods: Drop in Na, K, Mg, P. albumin and glucose. Rise in urea, Creatine, transaminases ECG: Prolonged QTc T-wave changes Bradycardia Squat test - cannot stand from sitting/lying with using arms for balance or leverage
AN first line in adults
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) specialist supportive clinical management (SSCM).
AN management child
ANOREXIA BASED FAMILY THERAPY CBT = 2nd line
Bulimia nervosa features
Metabolic alkalosis on ECG Low chloride suggests cause is from loss of Cl- from stomach The ECG shows hypokalaemia recurrent binge eating lack of control during episode recurrent compensatory behaviour (vomiting, misuse of laxatives, diuretics, fasting, excessive exercise) once a week for 3 months self-evaluation is unduly influenced by body shape and weight
OCD characteristics
present on most days at least 2 weeks acknowledge that they originate in the mind tries to resist them but is unsuccessful doing the act itself is not pleasurable interferes with functioning
OCD Treatment
Based on function impact Mild: CBT and ERT or group CBT. SSRI if cannot engage Moderate: high intensity CBT and ERP - can chose SSRI instead Severe: High intensity CBT and ERP, SSRI in combination
Opiate overdose signs
Acute presentation = drowsiness Resp depression 🡪 resp acidosis (retaining CO2) Hypotension Tachycardia are possible. Pin point pupils Chronic = constipation
Opiate overdose management
ABCDE obviously Give naloxone intravenously (IV) if coma or respiratory depression is present (IM if crappy veins) Oral activated charcoal if have ingested a load
Serotonin syndrome symptoms
Cognitive: headaches, agitation, hallucinations, coma Autonomic: sweating, shivering, tachycardia, hypertension, nausea, diarrhoea. Somatic: myoclonus, hyperreflexia (clonus), tremor.
SS treatment
Remove causative agent Support - cooling, fluids, benzodiazepine Serotonin antagonist - cyproheptadine, if persistent.
NMS - caused by
Antipsychotics Usually within 10 days of treatment
NMS features
CNS- fluctuating consciousness, stupor Autonomic- hyperreflexia, unstable BP, bradycardia, excessive sweating, salivation, urinary incontinence Motor- muscular rigidity, dysphasia, dysponea Lab results- Raised WBC, raised CPK Complications- Pneumonia, cardiovascular collapse, thromboembolism, renal failure
NMS management
Stop drug Maintain fluid balance Diazepam for muscle rigidity Dantrolene for malignant hyperthermia Bromocriptine to get rid of dopamine blockade
MHA section 2
28 days, can’t be renewed. 2 doctors
MHA section 3
6 months can be renewed. 2 docs, treatment and inv etc
MHA section 4
Emergency - 72 hr 1 doc, can change to a 2
MHA section 5
Detention within hospital, only stops leaving until reviewed under a 2 or 3
MHA section 135
Police can take you from a private place to a safe place
MHA section 136
like a 135 but from public place
Difference between pyramidal and extra-pyramidal
