Psych Flashcards
A young woman takes a paracetamol overdose after splitting with her boyfriend. Two days later she is in a new relationship which is troubled by her repeated outbursts of anger. What personality disorder
Borderline personality disorder
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
Paranoid
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
Schizoid
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
Schizotypal
What is in cluster A personality disorders
Odd or eccentric
- paranoid
- schizoid
- schizotypal
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
Antisocial
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
Quasi psychotic thoughts
Borderline
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
Histrionic
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
Narcissistic
What is cluster B
dramatic, emotional, or erratic
- antisocial
- histrionic
- borderline
- narcissist
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
Obsessive compulsive personality disorder
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
Avoidant personality disorder
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
Dependant personality disorder
What is in cluster C personality disorders
Anxious and fearful
- avoidant
- obsessive compulsive
- dependant
Management of personality disorders
Dialectical behaviour therapy
What might you need to co-prescribe alongside SSRI
PPI such as omeprazole
If risks such as NSAID
Strongest risk factor for SZ
Family history
delusional jealously, usually believing their partner is unfaithful
Othello syndrome
Alcohol withdrawal symptom timeline
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Therapeutic range lithium
0.4-1.0 mmol/L
Adverse affects of lithium
Leukocytosis
Increased urination (insipidus)
Tremors (fine = SE, coarse = toxicity)
T wave flat/inverted
Hyperparathyroid –> hypercalcaemia
Hypothyroid (but enlarged thyroid)
Interactions (NSAIDs, ACEi, ARB, diuretics)
Upset stomach (diarrhoea, cramps, N+V)
Muscle weakness
Skin conditions (acne, psoriasis)
After a change in dose, how often should lithium levels be checked
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
When should thyroid and renal be checked when patients taking lithium
Every 6 months
Delusional belief that they (or in some cases just a part of their body) is either dead or non-existent.
Cotard syndrome
Cotard syndrome is associated with severe depression and psychotic disorders.
Factors that increase risk of completed suicide
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method
Protective factors suicide
family support
having children at home
religious belief
Factors increased risk of suicide
male sex (hazard ratio (HR) approximately 2.0)
history of deliberate self-harm (HR 1.7)
alcohol or drug misuse (HR 1.6)
history of mental illness
depression
schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
history of chronic disease
advancing age
unemployment or social isolation/living alone
being unmarried, divorced or widowed
Lithium and white cells
Lithium can ppt benign leukocytosis
Apart from drugs, what should be offered to all patients with Sz
CBT
Triad of PTSD
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing - lack of ability to experience feelings, feeling detached
A 21-year-old woman presents to her GP, seeking help for anxiety. She finds her office-based job stressful, especially the aspects involving discussions with colleagues and bosses, fearing criticism. Outside of work, she often finds herself worrying about what her friends think of her, and increasingly forgoes social interaction with them as a result. She mentions that she thinks quite lowly of herself and does not have much self-esteem.
Avoidant
Kosakoff syndrome features
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation
Illness anxiety disorder (hypochondriasis)
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Dissociative disorder
dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Factitious disorder
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
Somatisation
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
Perseveration
repeating the same words/answers
Echolalia
repeating exactly what someone has said.
Neologism
making up new words.
Word salad
disorganised speech, sentences that do not make sense.
Clozapine and smoking
Increase causes decrease and vice versa
Smoking cessation can cause a rise in clozapine blood levels
Delusional belief that a famous person is in love with them
Erotomania (De Clerambault’s syndrome)
Management traduce dyskinesia moderate/severe
Tetrabenazine
what screening tool is used for postnatal depression
Edinburgh scale
name 5 SSRIs
Sertraline
Citalopram
Escitalopram
Fluoxetine
Paroxetine
most common side effect ssris
GI disturbance
Complications of SSRIs
- QT prolongation / ventricular arrhythmias including torsade de pointes in citalopram
- Hyponatremia
- SSRI discontinuation syndrome
Interactions SSRIs
NSAIDs/aspirin: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
SSRI in first trimester can cause?
congenital heart defects
SSRI in third trimester can cause?
persistent pulmonary hypertension of the newborn
worst SSRI pregnancy
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
SSRIs of choice in breastfeeding women
Sertraline or paroxetine
SSRI of choice post MI
Sertraline
SSRI of choice children
fluoxetine
Name 2 SNRIs
Venlafaxine
Duloxetine
Side effects SNRIs
include nausea/vomiting, sweating, loss of appetite, dizziness, headache, increase in suicidal thoughts, and sexual dysfunction.
Complication SNRI
HTN
(Elevation of norepinephrine levels can sometimes cause anxiety, mildly elevated pulse, and elevated blood pressure. )(monitor before initiation and after titration)
Name 3 TCAs
Imipramine
Clomipramine
Amitriptyline
Mechanism TCAs
inhibit the reuptake of serotonin and noradrenaline.
Side effects TCAs?
anticholinergic effects:
Can’t see (blurred vision)
Can’t pee (urinary retention)
Can’t spit (dry mouth)
Can’t shit (constipation)
Can’t sit for too long - postural hypotension
TCAs can cause overflow incontinence due to chronic urinary retention
Drowsiness
Postural hypotension
lengthening of QT interval
Name 1 NaSSA
Mirtazapine
Mechanism NaSSA
Blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters. Blocking α2-adrenergic autoreceptors and heteroreceptors, NaSSAs enhance adrenergic and serotonergic neurotransmission in the brain involved in mood regulation,[1] notably 5-HT1A-mediated transmission.
Side effects mirtazapine?
Sedative
Increases appetite
Name 3 MAOIs
Isocarboxazid
Phenelzine
Tranylcypromine
Complication MAOI
The tyramine cheese reaction is a classic side effect of MAOI (monoamine oxidase inhibitor) antidepressants, such as phenelzine. Consumption of foods high in tyramine (such as cheese) can result in a hypertensive crisis. Symptom: Throbbing headache at bottom of skull
Dizziness, electric shock sensations and anxiety
SSRI discontinuation syndrome
how to prevent SSRI discontinuation syndrome?
reduce gradually over 4 weeks
Neuromuscular excitation
- hyperreflexia
- myoclonus
- rigidity
autonomic nervous system excitation
- hyperthermia
- sweating
altered mental state
- Confusion
seretonin syndrome
management seretonin syndrome
supportive including IV fluids
benzodiazepines
more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
acute management bipolar disorder
Consider stopping antidepressant and + antipsychotic therapy (e.g olanzapine or haloperidol)
long term management bipolar
Lithium
Valproate
Psychological interventions
Fluoxetine
Comorbidities
Flight of ideas
Jumping between ideas but with discernible links between topics
Knights move?
Jumping between ideas without discernible links
Difference between mania and hypomania
with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
hypomania describes decreased or increased function for 4 days or more
from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
referral from primary care ?bipolar
Hypomania → routine referral to CMHT
Mania → urgent referral to CMHT
what is baby blues? management?
60-70% women
3-7 days following birth, more common in primips
Anxious, tearful, irritable
Management : reassurance and support, health visitor
what is post natal depression? peak? management?
Affects around 10% women
Start within a month post birth and peak at 3 months
Features are similar to depression seen in other circumstances
Management: reassurance and support, CBT, sertraline or paroxetine if symptoms are severe
Management of PMDD
mild symptoms can be managed with lifestyle advice
- Specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
- Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
- this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
How long should SSRI be continued after resolution of depression to prevent relapse
6 months
How long should SSRI be continued after resolution of anxiety state to prevent relapse
12 months
Define major depressive disorder
the presence of 5 symptoms in same 2 week period that represent a change from previous functioning
managment mild MDD
- Psychotherapy 1. Consider antidepressant
- alternative antidepressant
- St Johns wart
management moderate MDD
- Antidepressant + psychotherapy + immediate symptom management
- Alternative antidepressant
management severe MDD
- Psych rf +/- admisison + antidepressant or ECT
- switch to alternative
management treatment resistant MDD
- Reassess and switch antidepressants
- Consider augmentation (Li, aripiprazole, olanzapine) + psychotherapy
- MAOI
- ECT
what is GAD
Chronic excessive worry for at least 6 months that causes distress or impairment. The worry is disproportionate to any inherent risk. The worry is not confined to features of another mental health disorder, a result of substance misuse or relating only to a physical health condition.
diagnostic criteria GAD?
At least 3/6 req for diagnosis (DSM-5). ⅙ required in children:
Restlessness or nervousness
Easily fatigued
Poor concentration
Irritability
Muscle tension (achy neck/shoulders, tension headaches)
Sleep disturbance
Management of GAD?
step 1: education about GAD + active monitoring
step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
If using drugs to treat GAD:
Sertraline
Alternative SSRI or SNRI
Pregabalin
Beta-blockers such as propranolol are good for treating the somatic symptoms of GAD
Management of obsessive compulsive disorder
Mild functional impairment
1. Low intensity : CBT including ERP
2. SSRI or high intensity CBT
Moderate functional impairment
1. SSRI or high intensity CBT including ERP
Severe functional impairment
1. SSRI AND high intensity CBT including ERP
ERP:
A psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
what is acute stress disorder
Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc). This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.
management acute stress disorder
trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines:
- sometimes used for acute symptoms e.g. agitation, sleep disturbance
- should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation
Management PTSD
- trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy
- venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried.
- In severe cases, NICE recommends that risperidone may be used
delusion: belief is or soon will be destitute
delusion of poverty