Psych Flashcards
Depression: definition and grading (NICE)
Persistent low mood, anhedonia and fatigue, associated with biological, cognitive and emotional symptoms.
NICE grades it, using DSM IV -
1. Less severe depression - subthreshold & mild
2. Severe depression - mild & moderate
Grading systems?
DIfferentials?
PHQ-9 and HAD
Dx
Dementia
Bipolar disorder type II
Hypothyroidism
Depression - 1st-3rd line management: less severe and severe
Other opt
Less severe:
1. guided self-help
2. group CBT/BA
3. individual
Severe:
1. Antidepressant + individual CBT/BA
2. One of the 2 options / BA
Counselling, interpersonal psychotherapy, STPP
What causes serotinergic syndrome?
What two types of antidepressants should never be prescribed together? and how does it present?
Overuse of serotinergic drugs: overactivation of 5HT1-a and 5HT2-a receptors.
MAO-I and SSRIs : dangerous levels of serotonin
Sx -
- change in mental state (anxiety, agitiation)
- autonomic hyperactivity (tachycardia, tachypnoea, hyperthermia)
- muscular hyperactivity (tremors, rigitdity, akithesia)
What are the potential AEs of ECT (reserved for sevre L-T depression/ when a rapid response is required or other treatments have failed)
Initial: haedache, confusion,
SHort term: mouth damage due to jaw muscle contraction
Long term: Anterograde and retrograde amnesia, personality change, loss of certain skills
Define bipolar - types 1 and 2
Bipolar disorder = 1+ episode of mania/hypomania usually WITH 1+ episode of depression
Type 1:Mania +/- depression
Type 2:Hypomania +/- depression.
Not episodes of mania themselves are not diagnostic. The depression is most often major/severe.
Distinguish mania from hypomania
Mania - persistent elevated mood/irritability for >=1week (+ 3 of typical sx - decreased fatiguability, increased spending/reckless behaviour, sexual inhibition, psychosis, primary delusions)
Hypomania - elevated mood/irritabilty for >=4 consecutive days (typical sx…increased energy/activity without delusions or hallucinations.
Note - mania most often includes psychosis (grandiose/persecutory delusions or auditory hallucinations) but it doesn’t HAVE to.
Physical problems that could cause mania?
Syphillis, HIV, thyroid disease, epilepsy
Management - bipolar type 1 (referral process and treatment options)
referral process: urgent to CMHT if mania/severe depression, routine if hypomania
Talking therapies: bipolar psychological intervention
Mania: Antipsychotic + Valproate/Lithium (mood stabiliser)
depression: Talking therapies. If already on an antidepressant (stop it; usually doesn’t help) and consider mood stabiliser.
Define Melancholia
Severe depression where biological symptoms are prominent
List 6 causes of psychosis
- Schizophrenia
- Schizoaffective disorder
- Bipolar affective disorder (type 1)
- Brief psychotic disorder
- Persistent delusional disorder
- Drug induced
Define psychosis
- Disorder of thought form or content (delusions) and/or perception (hallucinations)
- causing loss of contact with reality
- personality change
- and deterioation of normal social function
Characterise schizophrenia - (3)
DIsorder of thought processing
Loss of contact with reality
Loss of emotional responsiveness
- Definition
- +ve and -ve sx
- Schneider’s first rank symptoms
Schizophrenia is a chronic disorder characterised by positive, negative and cognitive symptoms, that lead to a loss of contact with external reality and deterioration in social function.
Positive - hallucinations (typically auditory third person and running commentrary), delusions (paranoia, persecutory).
Negative - alogia, anhedonia, anergia, avolition, blunted affect.
First rank symptoms:
1. Auditory hallucinations
2. Thought disroders- insertion/withdrwawal/broadcasting
3. Passivity phenomena - bodily sensations controlled by external influence.
4. Delusional perception - the traffic light is green therefore I am king.
Features of PTSD and duration according to DSM-V
- Re-experiencing: flashbacks/nightmares
- Hyperarrousal: anger, insomina, hypervigilance etc
- Emotional numbing
- Avoidance; of things/people that remind them
For > 1 month
Side effects of tricyclic antidepressants (and name 3)
“Drycyclics” - blurred vision, urinary retention (or overflow incontience), constipation, dry mouth, drowsiness, and lengthening of QT interval (A drug).
Amitryptiline, Imipramine, Clomipramine.
Used less for depression and more for neuropathic pain.
Define the syndromes (disorders of thought)
* Capgras
* Fregoli
* Othello
* De Clerambault (Erotomania - specific form of delusion disorder)
* Folies e deux
* Cotard
- belief that someone in their life has been replaced by an imposter
- belief that people are **following **them and changing appearance
- belief that partner is cheating on them (Keaton)
- belief that person is in love with them, normally a famous person
- between 2 people - identical disorder with shared delusions
- belief they are dead/non-existent
When should Lithium levels be checked?
12 hours after dose, every 3 months.
ALso check thyroid and renal function.
Self-harm hx - 5 key questions (the cut drips….)
-
Before, during, after the episode
Death wish? - what was their intention
Relief - on being found?
Influence - did it have an effect on someone else?
Punishment - to themselves for what reason?
Seeking help - did you tell anyone afterwards/seek medical attention? How has mindset changed now?
+ suicide screen - intentions, methods, future plans
+ PMHx of suicide/self-harm
+ risk factors and protective factors
+ risk assess (self, to others, from others)
3 key aspects of screening for mental illness
- Depression /anxiety- persistent low mood / worries
- Psychosis - delusions & hallucinations
- Alcohol dependence - CAGE questionnaire
MUS can be split into conscious (malingering, factitious) and unconscious (somatoform, conversion, dissociative, functional syndromes). Name the 4 main times of somatoform disorders?
PUS(B)H(B)y
* Persistant somatoform pain disorder / autonomic disfunction
* Undifferentiated
* Somatisation disorder (Briquet’s)
* Hypochondriacal (inc. Body dysmorphia)
What is the difference between somatisation disorders, dissociativ, conversion disorders and functional syndromes?
- Somatisatio- physical symptoms as a manifestation of psychological distress.
- Dissociative - act of dissociating a memory/event from consciousness; involves psychiatric symptoms (fugue, amensia, stupor)
- Conversion - conversion of distressing events into physical symptoms, typically CNS dysfunction - paralysis or blindness
- Functional syndrome - persistent complaints unexplained by pathology (IBD, CFE, non-epileptic seizures)
Schizophrenia - define (3 aspects)
A severe mental illness, characterised by
1. disorders of thought and/or perception (+ve sx)
2. lack of emotional responsiveness (-ve sx)
3. loss of contact with external reality
Schneider’s first rank symptoms of schizophrenia (4)
- Auditory hallucinations
- Passivity phenomena
- Thought disorder (insertion, withdrawal, broadcasting)
- Delusional perception (roses are red therefore i am god)
5 As of Negative symptoms in schizophrenia
Anhedonia
Avolition
Alogia
Anergia
Flat Affect
Theories behind schizophrenia involve defective glutaminergic, serotinergic and dopaminergic mechanisms. What is the the premise for the dominergic theory behind schizophrenia?
- Lack of dopamine in mesocortical sysytem = negative sx (associated with emotion and cognition)
- Excess of dopamine in mesolimbic sysytem = postiive sx (associated with reward & reinforcement)
Prognosis for people with schizophrenia, suicide risk and reduced life span?
1/3 recover, 1/3 have recurrent episodes, 1/3 chronic.
10% suicide risk.
10 Yr reduced life span - note high risk of CVS disease (antipsychotic medication & high smoking rates)
Generalised anxiety disorder (ICD11) and 2 main presentations:
Anxiety that persists for at least several months for more days than not.
1. “Free-floating anxiety” - not circumstantial
2. “Apprehensive expectation” - excessive worry
GAD definition
Diffs
Excessive worries occuring more days than not for 6 months, with associated biological, cognitive and emtoional symptoms.
Biological - tachycardia, nausea, palpitations, fatigue
Cognitive- concentration problems
Emotional - distress –> impaired functioning.
Generalised - the worries can be about any event, and are not linked to a particular trigger.
Medican inducced anxiety, hyperthryoidism, angina.
Stepwise management for GAD (1-4)
- Education and active monitoring
- Low intensity psych intervention (self-help or groups)
- High intensity “ (CBT, applied relaxation) or drug treatment (Sertraline 1st line)
- Specialty - psychiatrist input
Personality - ICD 11 definition
An individual’s characteristic way of behaving, experiencing life, perceiving and interpreting themselves/other people/events/situations
Classification of personality disorder (according to ICD 11)
- Severity of impaired interpersonal functioning (mild/moderate/severe)
- trait domain specifiers, or, borderline pattern
Trait domain specifiers include negative affectivity, detachment, dis-sociality, disinhibition and anankastia.
Management of personality disorders
Dialectical behavioural therapy
(long-term, similar to CBT, involves mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness)
SSRIs - risks in first and 3rd trimester pregnancy
1 - congenital heart defects
3 - persistent pulmonary hypertension of ewborn
Diagnostic criteria for intellectual disability
- IQ <70 (Wechsler Adult Intelligence Scale)
- Significant adaptive/social impairments (ABAS II)
- Onset <18 yrs
Most common cause of LD
Fragile X syndrome
Distinguish mild/moderate/severe/profound based on IQ score
Mild 50-69
Moderate 35-49
Severe 20-34
Profound <20
Tourette’s can involve motor and vocal sx - describe these?
Motor - echopraxia and copropraxia
Vocal - coprolalia and echolalia
Tourette’s - management
Behavioural management
Topiramate (anticonvulsant) - if severe
Classify sleeping problems into 2 categories.
Insomnia includes …
Dysomnia- problems with quality and quantity (insomnia, hypersomnia, narcolepsy)
Parasomnia - abnormalities during sleep (night terrors, sleep paralysis)
* 2ndary insomnia - due to other cause, e.g. OSA, pain, COPD/CF, diabetes, medications
Definition and management (2) of primary insomnia.
If >55 what treatment would you consider?
Difficulty initiating/maintaing sleep, either acute (<1 month) or chronic (>3 months).
Management:
* Sleep hygeine methods
* Relaxation therapy, CBT
* Medical management= BDZ, antidepressants or Z drugs
* >55 - melatonin
Narcolepsy - diagnosis and mangement
- daytime sleepiness, >3x/wk, > 3mo
- and 1 of cateplexy, hypocretin deficiency or short REM sleep
- SSRIs
Cateplexy - collapse after strong emotions
Restless leg syndrome - describe presentation, investigation and management
- Strong urge to move legs while resting, unpleasant sensations (burning, tingling, itching).
- Nerve conduction studies, polysomnogram, needle electromyogram
- Dopamine agonists/BDZ/Gabapentin/Iron replacement
Child psych - what are the 4 classes of attatchment disorder (A-D)
Insecure avoidant
Secure
Insecure ambivalent
Disorganised
Between 6 and 36 months - Ainsworth Strange Situation Procedure
Autism is a neurodevelopmental disorder diangosed before the age of 3. What are the 3 typical symptom clusters?
And what is mindblindness
- Communication (note ehcolalia and neologisms, fail to regulate with non-verbal cues)
- Social interraction (note mindblindness)
- Restricted interests & ritualistic behaviours (routines, repetitive actions, inflexibility_
Mindblindness - inability to have an awareness of what others are thinki
Psychosocial support for children with autism (4)
* ABA - Applied behavioural analysis: positive reinforcement; ABC (antecedent, behaviour and consequence)
* TEACHH - Treatment and education of autistic and communication related handicapped children
* JASPER - joint attention symbolic play engagment and regulation
* ESDM - early start Denver Model
+ parental education / family support/ counselling
+ ASD preschool programme
+ antipsychotics for aggression/self-injury
What psychiatric/neuro conditions are also common with autism?
- Intellectual disability (50%)
- Depression & Anxiety (40%)
- Dyspraxia (70%)
- ADHD (35%)
- Eplepsy (18%)
What is required for a diagnosis of ADHD?
Persistent impairment in attention and/or hyperactivity/impulsitivity.
If <16 = 6 features to be present from DSM-V table.
(If 17+, 5)
Management for ADHD:
When to refer?
1st line drug for children?
2nd line for chhildren?
Adults?
Note which toxicity?
- Watch & Wait (10-week) before referral to paeds/CAMHS.
- Methylphenidate (>5yrs only) - dopamine and noradrenaline reuptake inhibitor.
- Lisdexamfetamine
- Either of the 2.
- Cardiotoxicity (baseline ECG reqd).
What is conduct disorder?
- repetitive and persistent antisocial/aggressive or defiant behaviour (ICD 10: >6 mo).
- the most common type of behavioural disorder in adults and children
- treated with CBT (children, 7 yrs+), parental training
Distinguish anorexia nervosa from bulimia nervosa
-
Anorexia is an eating disorder characterised by intentional weight loss, distorted body image (body dysmorphia) + associated endocrine disturbance (F - amenorrhoea, M - lack of libido)
* Bulimia is an eating disorder assoicated with repeated binges followed by compensatory behaviours (excessive exercise/laxative use). Purging vs non purging types.
Binge-eating disorder - frequent binges w/o episodes of purging, associated
Eating disorders, F:M (10:1)
Taking a hx for anorexia: questionnaire
SCOFF
- sick from feeling full
- worry of loss of control on eating habits
- > **one ** stone in 3 months
- believing to be fat despite what others say
- does food dominate your life
2+ indicates likely anorexia/bulimia nervosa
Diagnostic criteria for weight loss in anorexia
> 15% below expected
or BMI <17.5kg/m2
Describe refeeding syndrome and the typical electolyte findings
After a period of starvation (2-4wks) refeeding too quickly can result in a dramatic rise in insulin (in attempt to move glucose into cells) –> increased cellular uptake of electrolytes.
This causes reduced serum PO4, K+, Mg, glucose, H20 -
1**. Reduced phosphate **- seizures, paraesthesia, rhabdo, cardiomyopathy
**2. Reduced potassium **- muscle cramps, weakness, fatigue, arrhythmia
3. Reduced magnesium - oedema, arrythmia, hypotension
4. Reduced glucose and water - dehydration
What metabolic side effects are associated with antipsychotics (typically atypical)?
Hyper:
* - cholesterolaemia
* - lipidemia
* - glycaemia
+ weight gain.
Metabolic syndrome
* obesity
* diabetes
* htn
Presentation of SSRI discontinuation syndrome
GI, psych & neuro sx
and hence need to taper down SSRI dose if wish to come off it
- Dizziness
- Electric shock sensation (paraesthesia)
- Anxiety/restlessness
What happens to GABA/NMDA in alcohol withdrawal?
Decreased GABA (reduced CNS inhibition) and increased NMDA (increased excitatory mechanisms).
Progression of alcohol withdrawal at 6-12hr, 36, 72 hr
- 6-12hr: sx (sympathetic overactivity)
- -36 - seizures
- 48-72 delirium tremens - tremor, confusion, hallucination/delusion
- onwards - Wernicke-korsikoff syndrome
Management - acute alcohol withdrawal
Chlordiazepoxide (long-acting BZD) or Diazepam
+ admit to hospital for monitoring
Indications for ECT:
1. T-R D
2. L-T C
3. Man-
4. Mod-
- Treatment resistant depression
- Life-threatening catatonia
- Manic episodes
- Moderate depression previously treated with ECT in past (with good response)
Antipsychotics in the elderly increase the risk of (2)
STROKE and VTE
3 scoring systems to assess alcohol-related disorders
- SADQ (Severity of alcohol dependence)
- AUDIT (alcohol use disorders identification test)
- CAGE(initially screening during hx)
Maintenance treatments for alcohol abuse - describe class/MOA?
Acomprosate
Disulfiram
Naloxone
+ oral thiamine
Acomprosate - GABA agonist (reduces craving)
Disulfiram - aldehyde dehydrogenase inhibitor (promotes abstinence by causing a severe reaction to alcohol)
Naltrexone - opioid antagonist (reduces pleasure)
Thiamine - vitamin B1 if diet is deificient
psychological mngmnt for alcohol abuse
motivational interviewing - breaking the habit cycle
Schizophrenia risk factors
- Male sex
- FHX - genetic component (polygenic - multigple genes)
- Age (30-40)
- Substance abuse such as cannabis
- Antenatal complications
- Social - stressful life events
- Structural brain abnormalities - enlarged ventricles
Schizophrenia risk factors
- Male sex
- FHX - genetic component (polygenic - multigple genes)
- Age (30-40)
- Substance abuse such as cannabis
- Antenatal complications
- Social - stressful life events
- Structural brain abnormalities - enlarged ventricles
Acute stress reaction
Adjustment disorder
Complicated grief (abnormal grief reaction)
Acute reaction to a stressful event (<72 hrs, or within a few weeks).
Adjustment disorder - 3-6mo from tigger.
The event causing the acute stress reaction is normally more traumatic.
Grief - denial, anger, bargaining, depression, acceptance.
Delayed - (more than 2 weeks before grieving begins). or prolonged (cannot define exactly).
Complicated - more than 6 months; difficult to define.
Acute stress reaction - management
Trauma-focused CBT
OCD
Management
- Mild
- Moderate
- Severe
Mild:
CBT + ERP
Moderate:
CBT + ERP + SSRI
Severe:
Above + referral to specialsit
Specific SSRI for body dysmorphia
Fluoxetine
Alternative SSRI for OCD
Tricyclic = Clomipramine
What does ERP involve?
Exposure and Response Prevention - patients are deliberately exposed to anxiety-provoking situation, and then stopped from engaging in their safety mechanism. With the aim of confronting anxiety and habituation –> extinction of response
Risk of Lithium
Alters calcium homeostasis.
Hyperparathyroidism –> hypercalcaemia –> moans, groans, stones, bones:
abdo pain
psychosis
back pain
kidney stones
Stopping SSRIs: key points (2)
- Continue for 6 months past point of “resolution” - prevent relapse
- Wean for 4 weeks to reduce risk of discontinuation syndrome
Typical antispychotics:
Examples (2)
MOA:
Side effects:
Haloperidol and Chlorpromazine
Antagonist at D2 receptors in mesolimbic pathways.
Extrapyramidal sx (parkinsonism, dystonias) and hyperprolactinaemia (breast pain, lactation)
Atypical antipychotics:
Examples (3)
MOA:
Side effects:
Risperidone, Olanzapine, Clozapine.
Antagonist at dopamine, histamine & serotinergic receptors (D2, D3, D4, 5-HT, H2)
Metabolic effects: weight gain, QT prolongation, hyperprolactinaemia but less common
Management of acute dystonias (oculogyric crisis, oromandibular dystonia, torticollosis)
Procyclidine (anticholinergic)
Distinguish Knight’s move thinking from flight of ideas
KM: illogical leaps from one idea to the next (schizophrenia)
FOI: discernible links between ideas (associated with rapid and pressured speech; mania)
Side effects: CLozapine
weight gain
excessive salivation
agranulocytosis
neutropenia
myocarditis
arrhythmias
reduces seizure threshold
What psychotropic drug can cause a benign leucocytosis
Lithium
Safetynet and conitnue monitoring as normal - no need to treat if no symptoms of infection
Best antipsychotic for negative symptoms of schizophrenia
Clozapine (atypical)
Treatment for tardive dyskinesia
Tetrabenazine
