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Other Important Topics Flashcards

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1
Q

Timelines of PTSD and stress disorders

A
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2
Q

What is an acute stress disorder? How long must symptoms last for in order to warrant diagnosis?

A

Stress reaction that occurs in the first 4 weeks following a traumatic event. Symptoms must last for >3 days to warrant diagnosis

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3
Q

What is PTSD?

A

Stress reaction occurring for over 4 weeks following exposure to traumatic event

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4
Q

When does acute stress disorder become PTSD?

A

After 4 weeks

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5
Q

When does PTSD become chronic PTSD?

A

After a year

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6
Q

Core symptoms of PTSD

A

THINK: RAH(e) you have PTSD

Reexperiencing – flashbacks, nightmares, repetitive intrusive images

Avoidance – avoiding people/places/situations/associations with event

Hyperarousal – hypervigilance for threat, exaggerated startle response, sleep problems, difficulty concentrating

Emotional Numbing

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7
Q

What additional symptoms point towards a diagnosis of complex PTSD?

A

Emotion Dysregulation (hyperactivation, de-activation)
Negative Self-Concept (feeling diminished, defeated, worthless, guilt, despair)
Disturbed Relationships (difficulties in feeling close, little interest in relationships or social engagement)

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7
Q

What is required before a formal diagnosis of PTSD?

A

routine referral to the community health team

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7
Q

Give 3 differences between PTSD and acute stress disorder

A

PTSD defined by symptoms in clusters not necessarily totality

PTSD has dissociative subtype but depersonalisation/derealisation rare in ASD

PTSD feature non-fear based sx (e.g. risky behaviour) whereas ASD doesnt

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8
Q

Investigations for PTSD

A

Full and thorough history
TSQ – Trauma Screening Quesitonaire (10 qs)
CRIES8 – Child Revised Impacts of Events Scale; used for children
If ?PTSD – routine referral to CMHT for formal diagnosis
Rule out organic causes for depression

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9
Q

PACES: What screening tools can be used for PTSD? What’s the difference between them?

A

TSQ – Trauma Screening Quesitonaire (10 qs)
CRIES8 – Child Revised Impacts of Events Scale; used for children

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10
Q

What is the management of acute stress disorder?

A

Conservative management

NOTE: Arrange follow up after a month

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11
Q

Management of PTSD

A

Trauma-Focused CBT
Offered to all patients with PTSD symptoms lasting > 1 month

Eye Movement Desensitisation and Reprocessing (EMDR)
Offer to adults with a diagnosis of PTSD or clinical important symptoms who have presented > 3 months after non-combat related trauma

Group Therapy: meeting and speaking with other people with similar experiences.

Pharmacological Treatment
Consider SSRI (e.g. paroxetine and sertraline (licensed)) or venlafaxine for adults with PTSD. Consider antipsychotics (e.g. risperidone) in addition to psychological therapies if they have failed to respond to other drug treatment or have disabling symptoms/behaviours (e.g. hyperarousal)

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12
Q

Who is Trauma focussed CBT offered to? When?

A

Offered to all patients with PTSD symptoms lasting > 1 month

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13
Q

Who is Eye movement desensitisation and reprocessing offer to? When?

A

Offer to adults with a diagnosis of PTSD or clinical important symptoms who have presented > 3 months after non-combat related trauma

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14
Q

What pharmacological treatment is used in PTSD?

A

Consider SSRI (e.g. paroxetine and sertraline (licensed)) or venlafaxine for adults with PTSD.

NOTE: Consider antipsychotics (e.g. risperidone) in addition to psychological therapies if they have failed to respond to other drug treatment or have disabling symptoms/behaviours (e.g. hyperarousal)

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15
Q

What are 1st line medications in PTSD?

A

SSRI (e.g. paroxetine and sertraline (licensed)) or venlafaxine for adults with PTSD

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16
Q

When should antipsychotics be considered in patients with PTSD?

A

Consider antipsychotics (e.g. risperidone) in addition to psychological therapies if they have failed to respond to other drug treatment or have disabling symptoms/behaviours (e.g. hyperarousal)

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17
Q

Difference between personality traits and disorders

A

Patient have no insight in a personality disorder, and they cause significant distress and/or impaired function

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18
Q

Examples of personality traits

A

Positive traits: Kind, Confident, Generous
Negative traits: Lazy, Rude, Violent

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19
Q

3 clusters of personality disorders

A

Cluster A - Weird
Cluster B - Wild
Cluster C - Wacky

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20
Q

What personality disorders fall within cluster A (Weird)?

A

Paranoid
Schizoid
Schizotypal

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21
Q

Features of paranoid disorder

A

Deep-seated distrust of others, including friends and family
Guarded, suspicious, struggles to build close relationships
Hallmark is Projection – immature defence mechanism aimed at attributing unacceptable thoughts to others

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22
Q

Hallmark of paranoid disorder

A

Projection – immature defence mechanism aimed at attributing unacceptable thoughts to others

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23
Q

Example of paranoid disorder

A

Patient accuses doctor of being judgemental and suspicious

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24
Q

guarded, suspicious, struggles to build close relationships

A

Paranoid disorder

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25
Q

Features of schizoid personality disorder

A

Likes to be alone
Voluntary social isolation/withdrawal
More comfortable in that way
Does not enjoy close relationships
Little/no interest in sexual experiences
Few/no pleasure activities (hobbies)
Lacks close friends, detachment, limited emotional expression

NOTE: Think of school: we all knew kids who were reclusive and did not spend time with friends

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26
Q

What personality disorder should schizoid NOT be confused with? How to differentiate?

A

DO NOT CONFUSE WITH AVOIDANT –> want to make relationships, but afraid of doing so as afraid of rejection

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27
Q

Features of schizotypal

A

Fear of social interactions and few close friends
Classic feature: odd beliefs and/or magical thinking e.g. superstitious, believes in telepathy, sixth sense etc.
Not psychotic and no hallucinations, just weird and strange beliefs
Ideas of reference: often believe that events happening are somehow related to them
No delusions: a key feature is that they are open to challenges to their beliefs, they may reconsider their superstitions when confronted

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28
Q

Classic feature of schizotypal

A

odd beliefs and/or magical thinking e.g. superstitious, believes in telepathy, sixth sense etc.

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29
Q

Difference between schizotypal and psychosis

A

No delusions: a key feature is that they are open to challenges to their beliefs, they may reconsider their superstitions when confronted

NOTE: In schizotypal they are open to confrontation/challenges about their thoughts

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30
Q

What personality disorders are in cluster B (Wild)?

A

Antisocial
Borderline
Histrionic
Narcissistic

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31
Q

Features of Antisocial personality disorder

A

Aka Sociopathy
Lots of the people in jail
More common in men
Disregard for rights of others, often breaks the law
Impulsive, lacks remorse
If it occurs in a child < 18yo, named conduct disorder (CD)

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32
Q

What is antisocial personality disorder called if it occurs in a child?

A

If it occurs in a child < 18yo, named conduct disorder (CD)

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33
Q

What does diagnosis of antisocial personality disorder require?

A

Diagnosis requires to be at least 18yo and have evidence of CD before the age of 15 - not necessarily diagnosed, a hx is sufficient e.g. violence, killing animals, cruelty

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34
Q

Difference between schizoid, antisocial and avoidant personality disorder

A

Schizotypal  no interest in friends
Antisocial  no friends due to their actions being so antisocial e.g. violent
Avoidant  trying to make friends, but no success due to deep rooted fear

35
Q

Borderline personality disorder AKA

A

Emotionally unstable personality disorder (EUPD)

36
Q

Features of EUPD

A

Unstable personal relationships
They have great friends and the second day, they hate them – “All people are either very good or very bad”
Stormy relationships, common to them in on/off patterns
Fear of abandonment
Impulsivity: spending sprees, sex with strangers, reckless driving
Self-mutilation: cutting, burning
Suicide gestures/attempts: rarely follow through
Splitting is a major ego defence mechanism -black-and-white thinking, cannot hold opposing view

37
Q

How is EUPD treated?

A

Dialectical Behaviour Therapy (form of CBT) designed to treat chronic suicidality is now the gold standard

38
Q

Which personality disorder is the only one with treatment? What is it?

A

Borderline, with DBT

39
Q

Features of histrionic personality disorder

A

Wants to be the centre of attention
The kind of people you see at a party who talk loudly, tell wild stores, use grandiose hand gestures  anything to get everyone to look at them
More common in women
Inappropriate sexually provocative behaviour
Often wears provocative clothing, touching others frequently
Concerned with physical appearance to draw attention – exotic outfits, hats, shoes etc.

NOTE: Think centre of attention

40
Q

Features of narcissistic personality disorder

A

Grandiosity, inflated sense of self
Brags and thinks everything they do is great
Lacks empathy and views other people as competitors – does not point out when someone else is doing something good
Wants to hear that they are great all the time
Overreacts to criticism with anger/rage

NOTE: Usually lack empathy, sleep with best mates girlfriend and don’t understand what they did wrong

41
Q

What personality disorders are in cluster C (Wacky)?

A

Avoidant
Obsessive Compulsive
Dependent

42
Q

Features of avoidant personality disorder

A

Avoids social interactions and “displays social inhibition”
Reason is that they feel inadequate – hypersensitive to rejection
Afraid people won’t like them and of embarrassment
Struggles with intimate relationships

43
Q

Features of obsessive compulsive personality disorder

A

Preoccupied with order and control
Loves ”to-do” lists, always needs a plan
Inflexible at work or in relationships because they want things done a certain way
The behaviours they engage in help them achieve their goals – in contrast to OCD where the behaviours are barriers

44
Q

How does OCD differ from OCPD?

A

In OCPD the behaviours they engage in help them achieve their goals (ego syntonic)

In contrast to OCD where the behaviours are barriers (ego dystonic)

45
Q

Features of dependent personality disorder

A

Clingy, low self-confidence
Struggle to care for themselves
Depend on others excessively
Rarely alone, often in a relationship
Hard to make decisions on their own, need someone to tell them what to do
Difficulty expressing opinions
Often involved in abusive relationships because they’re afraid to walk away

46
Q

What are people with depdendent personality disorder at risk of?

A

Abusive relationships

47
Q

What is Neuroleptic Malignant Syndrome? When does it occur?

A

Rare life-threatening psychiatric emergency
Occurs if suddenly stopping or changing dose of antipsychotic or dopaminergic drugs e.g. Levodopa (Parkinson’s Disease)

48
Q

What is Seretonin Syndrome? When does it occur?

A

Overstimulation of serotonin receptors
More commonly occurs from a drug combinations but can occur singularly:

49
Q

What drugs can cause seretonin syndrome?

A

SSRIs
MOA
TCAs
Amphetamines+ Ecstasy

50
Q

How does the onset of neuroleptic malignant syndrome and seretonin syndrome vary?

A

NMS - hours to days
Seretonin syndrome - <12 hours, usually in a few hours

51
Q

Signs and symptoms that appear in both of NMS/Seretonin syndrome

A

Autonomic dysfunction: High fever (> 40°C), shivering, excessive sweating (diaphoresis), tachycardia, palpitations
Headache
Abdominal pain
Nausea, vomiting, diarrhoea
Altered mental state
Coma 🡪 NMS stupor

52
Q

Specific signs and symptoms for NMS

A

Muscle deactivation – stiffness, rigidity, hyporeflexia
Dysphagia
Incontinence

53
Q

Specific signs and symptoms for seretonin syndrome

A

Muscle activation - tremor, myoclonus, clonus, hyperreflexia
Oculogyric crisis: EOM spasms leading up upward gaze
Dilated pupils

53
Q

Management of NMS and seretonin syndrome

A

Conservative
Stop causative drug: resolves once medicines have been discontinued
Stabilise e.g. IV crystalloid fluids – prevents renal failure esp. in NMS

Medication
Muscle relaxants: benzodiazepines & bromocriptine 🡪 IV dantrolene (after senior review
SS: IM chlorpromazine (antipyretic + sedative).
IV Paracetamol

54
Q

Investigations for NMS and seretonin syndrome

A

Vital signs: either hypertensive crisis or shock
ECG: 12 lead syndrome
Bloods:
FBC / CRP / blood cultures: rule out sepsis
U&Es: AKI (NMS) and rule out electrolyte imbalances
CK: hyperthermia causes rhabdomyolysis (NMS)
LFTs
ABG (metabolic acidosis)
Clotting screen
TFTs: rule out thyrotoxicosis
Urinalysis: drug screen (rule out overdose), myoglobulin
CT head: rule out CNS infections, brain tumours (malignant hyperthermia), normal pressue hydrocephalus
Consider Lumbar Puncture to rule out meningitis and encephalitis

55
Q

What medication may be used in the management of NMS or seretonin syndrome?

A

Muscle relaxants: benzodiazepines & bromocriptine 🡪 IV dantrolene (after senior review)

IV Paracetemol

56
Q

What specific medication may be used for seretonin syndrome?

A

IM chlorpromazine (antipyretic + sedative).

57
Q

What is gender dysphoria defined as?

A

incongruence between a person’s experienced and expressed gender, and their primary and secondary sexual characteristics.

58
Q

How is gender dysphoria managed conservatively?

A

supporting a person to live the way that they want to, in their preferred gender identity or as non-binary and treatment of any concurrent MH disorders

59
Q

When to consider medical or surgical options in gender dysphoria?

A

After a year

60
Q

Medical options for gender dysphoria

A

GnRH analogues to block puberty

Hormonal treatment
Oestrogen +/- androgen suppression
Androgens

61
Q

Surgical options for gender dysphoria

A

Re-assignment surgery
Mammoplasty
Hair removal

62
Q

PACES: What information to be given to people over 16 who want gender-affirming hormones?

A

side-effects include infertility, blood clots and weight gain.

63
Q

How many dopamine pathways are there in the brain? What are they?

A

Mesolimibic pathway (positive symptoms) -limbs – fast/positive

Mesocortical (negative symptoms) – cortical – clever - depressed

Nigrostriatal (Extrapyramidal side effects) – striatal – striving for (extrapyramidal) side effects

Tuberoinfundibular (hyperprolactinaemia) – tubero – sounds like hyperpro -… lactinaema

64
Q

What dopaminergic pathway is involved in positive symptoms?

A

Mesolimibic pathway (positive symptoms) -limbs – fast/positive

65
Q

What dopaminergic pathway is involved in negative symptoms?

A

Mesocortical (negative symptoms) – cortical – clever - depressed

66
Q

What dopaminergic pathway is involved in extrapyramidal side effects?

A

Nigrostriatal (Extrapyramidal side effects) – striatal – striving for (extrapyramidal) side effects

67
Q

What dopaminergic pathway is involved in hyperprolactinaemia?

A

Tuberoinfundibular (hyperprolactinaemia) – tubero – sounds like hyperpro -… lactinaema

68
Q

What do typical antipsychotics act on? What are they AKA? Give some examples

A

Typical antipsychotics –widely acting on D2 dopamine receptors

Also known as First Generation Antipsychotics (FGAs)

Examples – Chlorpromazine, Haloperidol

69
Q

What do atypical antipsychotics act on? What is it AKA? Give examples

A

less affinity for dopamine, more on serotonin and 5-HT2A

Also known as Second Generation Antipsychotics (SGAs)

Examples – Clozapine, Olanzapine, Quetiapine, Risperidone

70
Q

Example of a partial agonist

A

Apiprazole

71
Q

Difference between typical and atypical antipsychotics

A

Newer atypicals are associated with a lower risk of extrapyramidal side effects
Atypicals all act as antagonists at the 5HT-2A serotonin receptor

72
Q

Gold standard drug for psychosis that is used in treatment resistant schizophrenia

A

Clozapine

73
Q

Clozapine specific side effects

A

Neutropenia/leucopenia/agranulocytosis – requires regular FBC blood test monitoring

74
Q

What do patients on Clozapine require regular monitoring for? Why?

A

Patients require regular FBC monitoring due to the risk of neutropenia/leucopenia/agranulocytosis (approximately 1% of patients)

75
Q

Rules of dosage for clozapine

A

Clozapie must be started at a low dose and titrated slowly due to the risk of cardiovascular instability
Clozapine must be re-titrated if stopped for more than 48 hours

76
Q

What type of medication might be beneficial for patients with poor oral compliance?

A

Depot injections

77
Q

Management of hyperprolactinaemia as a SE of anti-psychotics

A

Switch to a prolactin sparing agent ( quetiapine, and ziprasidone)
add in aripiprazole (partial dopamine agonist),
dopamine agonists are generally avoided (e.g. carbergoline, bromocriptine)

78
Q

Symptoms of hyperprolactinaemia

A

Women – Reduced libido, amenorrhoea, galactorrhoea, osteoporosis
?increased risk of breast cancer
Men – Reduced libido, erectile dysfunction, gynaecomastia, galactorrhoea

79
Q

What dopaminergic pathway is suppressed by hyperprolactinaemia?

A

Release is supressed by dopamine as part of the tuberoinfundibular pathway

80
Q

What is the classic parkinsonism symptom tetrad that may be seen in drug induced parkinsonism?

A

Core features - Bradykinesia, rigidity, pill rolling tremor (4-6 Hz), postural instability

Additional features – Hypomimia (mask face), festinating gait with reduced arm swing

81
Q

How does drug induced parkinsonism present differently to parkinson’s?

A

Generally is bilateral, which is in contrast to Parkinson’s Disease which typically starts asymmetrically

82
Q

Management of drug induced parkinsonism

A

Management – Switch medication, add in a regular antimuscarinic (e.g. procyclidine 5mg)

83
Q

What is tardive dyskinesia? How to manage?

A

An involuntary orofacial dyskinesia associated with long term antipsychotic use
Typically seen as continuous mouth and tongue movements, classic “lip smacking”
presentation. May also involve eye closing, jaw clenching and may affect the trunk/extremities
Develops after months or years of treatment

Management – May be permanent even if medication is stopped. Stop causative agent. Consider Tetrabenazine 25mg

84
Q

What is dystonia? How to manage?

A

Involuntary muscle spasm/contractions

Develops acutely, within hours of starting antipsychotics

Can affect any part of the body. Specific names are given to certain forms
Oculogyric crisis (eyes rolling upward)
Torticollis (head and neck twisted to one side)
Laryngeal dystonia (can compromise airway and be life threatening)

Management – Anticholingerics (e.g. procyclidine 5-10mg PO or IM)

85
Q

What is akathisia? When does it occur? How is it managed?

A

A sense of internal restlessness. The patient feels compelled to constantly move, rock, fidget or pace around. Very unpleasant! And associated with an increased risk of suicide.

Occurs within days to weeks of starting/increasing an antipsychotic

Diphenhydramine (sedating antihistamine), Propranolol, low dose benzodiazepines

86
Q

What is metabolic syndrome? How to manage?

A

Triad of weight gain, dyslipidaemia and insulin insensitivity

Monitor weight, blood pressure, lipid profile and HbA1C
Treat any complications on their merits (e.g. statins, anti-glycaemics, anti-hypertensives)
Promote healthy eating and exercise

Psych (11 decks)

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