Psych Flashcards
Management of acute stress reaction in under 18s
If is a large shared trauma->group based CBT
If not can consider monitoring or individual CBT
Management of PTSD in under 18s
Individual trauma CBT
If after 3 months does not work use EMDR
NO MEDICATION
Management of PTSD in adults
Offer trauma focused CBT as first line but can use sertraline or venlafaxine if wants drug first
Second line paroxetine
When can use EMDR for PTSD
If 1-3 months after can consider if CBT not worked or has preference
If over 3 months then can offer EMDR alongside CBT
When use risperidone in PTSD
Psychotic symptoms present
Severe hyperarousal symptoms that have not responded to other treatments
Back pain and constipation, what psych medication may have caused
Lithium due to hyperparathyroidism
What is personality disorder when very strict moral code and ethics
Anankastic
Differentiating depression from dementia
In depression
- answer I dont know to questions in MMSE
- bothered about low MMSE score
- biological symptoms present
- short history
- global memory loss
What must do for psychosis in elderly
CT to rule out organic cause
Which amnesia get in ECT
Retrograde most commonly
Difference in malingering and muchausens
Malingering- exaggerate or simulate smyptoms
Muchausen- actualy inflict pain upon yourself
Which psych medication can cause renal stones
Lithium from hypercalcaemia
What is it when answer a question with excessive details
Circumstantiality
What do if patient develops a leukocytosis on lithium
Leave them alone just safety net
Causes of personality disorder
Genetic
Psychological
Environmental
If someone dependant on alcohol is admitted to hospital for elective procedure what do
Give chlordiazepoxide
NT associated with depression
Dopamine
How change from fluoxetine to another SSRI
Over 20mg- slowly taper over 2 weeks, 4-7 day washout then start again
Under 20mg- stop abruptly then 4-7 day washout
Which lymph nodes do the gynae cancers metasise to
Endometrial and ovarian- para-aortic
Cervical- pelvic
Vulval- inguinal and femoral
Do you admit patients after suicide attempts
Not always- if low risk then can arrange review by liason psych before discharge
What is atypical anorexia
When have all of the criteria for anorexia but is no weight loss
What defines underweight in children vs adults
Adults- under 18.5
Children- under 5th centile
Diagnostic criteria for anorexia DSMV
Restriction of weight
Intense fear of gaining weight
Disturbance of body image view
If someone escapes from care home, how long do emergency DOLS last
7 days
Hypotonia and non-blanching rash 2 days after birth
Group B streptococcus
If have test of cure for CIN2< and is negative when is recall
3 years regardless of age
How long does section 4 apply
72 hours
Features of paranoid personality type
Paranoid
Sense of self righteousness (doesnt like to be wrong)
Does not take criticism well
Possessive and jealous of partners
Conspiracy theories common
Which personality disorder most linked to schizophrenia
Schizotypal
MOA of procyclidine
Blocks cholinergic neurones
Diagnostic criteria for schizophrenia
2 psychotic symptoms (delusions, hallucinations or thought disorder) or 1 plus either catatonia or negative symptoms present for 1 month
Elemental illusion vs pareidiollic hallucination
Elemental- see flashing lights
Pareidiollic- see something within fire
Brief psychotic disorder vs acute psychotic disorder
Brief psychotic disorder DSM5
Acute psychotic disorder ICD-10
- brief psychotic lasts less than 1 month
- acute psychotic disorder under 3 months (onset within 2 weeks)
Anti-psychotics used for sedation
Haloperidol- risk of prolonged QT
Olanzapine
Management of NMS
Stop drug
Cooling devices
transfer to ITU
Fluids
Benzos- for agitation and to relax muscles
Bromocriptine
What antipsychotic use if prolonged QTC
Aripirazole
Zuclopenthixol
PET scan findings- schizophrenia vs OCD
Schizophrenia- hypoactivity in prefronatal cortex, enlarged ventricles
OCD- hyperactivity in prefrontal cortex
Questionnaire for psycopathy vs risk to others
Psychopathy- PCL-R
Risk to others- HCR-20
Organic causes of psychosis- infective, nutritional, endocrine
Infective- toxoplasmosis, enceph/meningitis, neurosyphylis
Nutritional- pellagra, B12, B1
Endocrine- cushings, thyroid
When measure FBC in clozapine
Weekly for first 18 weeks
18 weeks- 1 year- fortnightly
Beyond 1 year- monthly
How does FBC testing in clozapine classify patients
Red, amber, green
Red- stop immediately
Amber- measure twice weekly until green
Green- continue
What is used to detect/screen delirium
Confusion assessment method
Which antipsychotic particularly associated with weight gain and DM
Olanzapine
If someone has history of DM and HTN what antipsychotic use
Haloperidol or any other typical anti-psychotic
First step in management of neuroleptic malignancy
Cooling and fluids
What other than antipsychotics can cause NMS
Missed dopamine agonist dose
What typically precipitates NMS
Abruptly withholding a dopamine agonist or anti-psychotic
How manage if have long QT evidence on ECG
Discuss with cardiology- do not immediately cessate
What is couvade syndrome
Where mimic pregnant womans
What is particularly associated with ekbom syndrome
B12 deficiency
How does clozapine toxicity present
Confusion
Drowsiness
Ataxia
Tachycardia
Often precipiated by infetions
What do for someone with an at risk mental state with a first degree relative who has schizophrenia
Refer immediately for CBT
What is difference between thought withdrawal and blocking
In both patients randomly stop talking
Withdrawal- stop talking then begin talking about same thing
Blocking- stop talking then start talking about different topic
What do the different antidepressants target
SSRI- presynaptic serotonin uptake channel
TCA- blockade of noradrenaline, serotonin and to lesser extent dopamine reuptake channels- also blocks muscarinic and histaminergic
MOA- non selective and irreversible inhibition of MOA A and B
SNRI- presynaptic blockade of both noradrenaline and serotonin (high doses dopamine)
NaSSA- blocks alpha 2 which increases noradrenaline and seorotonin
Serotonin syndrome presentation
Physiologically too much serotonin in synapses in brain
Autonomic dysfunction- tachycardia, HTN, diaphoresis, mydriasis
Altered mental state- agitation, confusion
NMJ hyperactivity- tremor, hyperreflexia, myoclo
Management of acute phase mania
Trial oral antipsychotic choosing from
- haloperidol
- olanzapine
- quetiapine
- risperidone
If not tolerated then add another from list
If second line not effective lithium may be added, if thats not successful then valproate added unless pre-menopausal woman
MOA of lithium, sodium valproate and carbamezapine
Inhibits recycling of neuronal membrane phosphoinositides
Most important thing to monitor- sodium valproate vs carbamezepine
Sodium valproate- LFT
Carbamezepine- FBC
Side effects of lithium
Weight gain
Tremor
Muscle weakness
GI
Metallic taste
Nephrogenic DI (renal impairment)
T wave inversion
Leucocytosis which is benign
Hypothyrodism and hyperparathyroidism
Management of lithium toxicity
Stop drug
Measure levels
Fluids
Osmotic or forced alkaline diuresis may be required
Haemodialysis may be used if severe
- Renal failure and levels over 2.5
- Severe signs- nystagum etc
- Lithium over 4
How are lithium levels checked
Every week when increasing the dose
Every 3 months should have levels measured if dose stable
Every 6 momnths BMI, U&Es, calcium, TFTs and eGFR measured
Side effects of lamotrigine
Most common is maculopapular rash where must withdraw drug immediately
GI
Headache
Diplopia
Which antidepressants has high chance of death from overdose so avoid in case of suicide risk
Venlafaxine
TCAS except lofepramine
How long should someone be on a SSRI for depression before changing dose/drug
4 weeks
6 weeks if elderly
Side effects of carbamezapine and how to remember
CABRA MEAN
Confusion
Ataxia
Rashes
Blurred vision
Aplastic anaemia
Marrow suppression
Eosinophilia
ADH release
Neutropenia
Secondary causes of mania
Steroids
Levo dopa
Hyperthyroid
Illicit drugs
Organic damage to right side of brain in elderly
Serotonin syndrome management
Stop meds
Supportive- cooling and fluids
Benzos for muscle rigidity
Can use cyproheptadine which is a serotonin antagonist
Management of mania if already on lithium or sodium valproate
If on lithium- check levels, optimise treatment and consider adding antipsychotic depending on preference and previous response
If on sodium valproate- increase dose, if no improvement then add antipsychotic
Depression management in BPAD if not on drug
If not on drug- offer olanzapine/quetiapine and fluoxetine or just olanzapine or lamotrigine
If no response use lamotrigine
Depression management in BPAD if on lithium or valproate
Optimise dose of lithium
If unsuccessful then add olanzapine/quetapine with fluoxetine or olanzapine if prefers
If unsuccessful use lamotrigine
Management of mania in children
If under 14 refer to CAMHS
14 or older refer to EIP or CAMHS centre with expertise in psychosis
Can start aripiprazole if over 13 in severe cases
Maanagement of BPAD depression in children
First line - CBT for 3 months
How stop lithium or valproate
Slowly stop over 4 weeks
Best antipsychotic if want to not put on weight
Quetiapine
Which drugs can cause depression
Beta blockers, methylopda, CCB
H2 anti-histamine
Chemo
Oestrogen
Psychiatric conditions
Low versus high intensity psych interventions for depression
Low
- Self-help
- Group physical activity
- Computerised CBT
- Group CBT
High
- CBT
- behaviorual activation
- interpersonal therapy
What is done before ECT
Examination
Bloods- FBC, U&Es, LFTs
ECG- over 50 or medical indication
CXR- over 55 or medical indication
NBM for 8 hours
How are patients assessed after ECT
Assess congnition and rating scale
Cognition- MMSE
Rating scale- montgomery asberg depression rating scale (MADRS)
ECG effects of TCAs
QT prolongation
ST elevation
What is important diagnostic criteria for depression or mania with psychosis
That psychosis not present when euthymic
How do you switch between SSRI and SNRIs (not from fluoxetine)
Direct switch
How do you switch from fluoxetine to a TCA, SSRI or SNRI
Reduce dose of fluoxetine then start next drug 1 week later
How do you switch from TCA to fluoxetine
Halve the TCA then add fluoxetine
Slowly withdraw TCA
How to switch from TCA to SNRI or non-fluoxetine SSRI
Slowly reduce dose by 25mg then start new one
Remove TCA over next week
What are trazodone and dosulepin
TCA
Who need to use venlafaxine with caution in
HTN
What use as second line to lithium if sodium valproate CI for BPAD
Olanzapine
Medication for GAD
1st line: sertraline
2nd line: citalopram/ paroxetine or venlafaxine
Criteria for OCD
Intrusive obsessions and compulsions prsent for 1 hour a day
How is mild, moderate and severe OCD managed
Mild- refer for CBT with ERP
Moderate- 1 of CBT with ERP or SSRI (if unsuccessful after 12 weeks change SSRI or to clomipramine)
Severe- refer to specialist with CBT with ERP plus SSRI
Withdrawal from benzos
Insomnia
Anxiety
Loss of appetite
Tremor
Weight loss
Sweating
Tinnitus
Which benzos give for insomina
Tamezapam
How to withdraw a benzoQ
Reduce the dose by 1/8th every forntight
Can consider switching to longer term from short term
What is management of a panic disorder
Rule out
- thyroid
- alcohol- ECG
Then management
CBT/relaxation techniques
Can use SSRI/venlafaxine
What is flumenazil
A GABA antagonist
Used for benzo OD
What tool is used to screen for social phobia
SPIN
Social phobia inventory
What is it called when start repeating actions of a dead person
Identification
What is fear of
- heights
- pain
Pain= algophobia
Heights= acrophobia
What is technique used in psychotherapy for dissociative disorders
Abreaction
Used as part of psychotherapy
Medications used for agoraphobia
1st line- Sertraline
2nd line- venlafaxine
If either of these are CI then use pregabalin
What is sexual side effect of trazodone and chlorpromazine
Priapism- anti histamines have this effect
Which NT most associated with anxiety
GABA
What is it when binge eat and then period of long sleep
Kleine-levin syndrome
Diagnostic criteria for bulimia nervosa
Binge eating episodes with compensatory behaviour to prevent weight gain at least once a week for 3 months
Feel as if have no control over episodes
Physical signs may be present
Management of bulimia nervosa
Refer immediately to eating disorder specialist
First line is BN focused guided self help for 4 weeks
If ineffective then ED-CBT
Can cosider high dose fluoxetine
MOA of naltrexone and disulfiram
Acamprosate- Modulates NMDA to reduce glutamergic transmission
Naltrexone- Mixed opiod antagonist with high affinity for u-opiod receptor
Disulfiram- Acetaldehyde inhibitor
How can spice use present
Psychosis
Confusion
Aggression
Vomiting
How is benzo withdrawal managed
Contact addiction services
Convert to diazepam equivalent dose
Slowly reduce by 10% every 2 weeks
Talking therapies
How manage OST in acute hospital care
Check with GP/drug service the drug and date of last collection
Rating scale for opiate withdrawal
Clinical opiate withdrawal scale
Difference between withdrawal syndrome and complex withdrawal
Withdrawal includes typical symptoms expected
Complicated involves delirium, seizures or psychosis
What questionnaire for severity of dependance
SADQ- severity of alcohol dependance questionnaire
Management based on AUDIT and SADQ outcome
Over 20 on AUDIT- refer to alcohol services
Over 30 on SADQ- refer for inpatient withdrawal
Principles of managing opiate withdrawal
Test for blood borne viruses and offer vaccinations
Detoxification regime- methadone or buprenorphine (will lessen symptoms of withdrawal)
Treat symptomatically
Refer to drugs and alcohol services
- key worker
- talking therapies
What do you assume are units in a pint, glass of wine and a shot
Pint- 2
Glass of wine- 1.5
Shot- 1
How are cocaine induced myocardial infarctions managed
Benzos
What murmur can be heard in anorexia
Mid systolic murmur with a click due to mitral valve prolapse from loss of cardiac muscle
When is lofexidine indicated in opiate withdrawal
Want to avoid methadone and buprenorphone
Want to do it quickly
What do excoriation marks after an overdose suggest
Opiods as relesaes histamine
What drug can be given to help with anorexia nervosa treatment
Olanzapine as can reduce obsessions with food as well as increase appetite
First clinical signs of refeeding
Tachycardia
Oedema
Confusion
Drugs for dementia
Anticholinesterase inhibitor- rivastigmine, donepezil, galamantine
NMDA antagonist- memantine
Which antipsychotics do women respond better to
Typical
Best antidepressants in pregnancy
Sertraline is first line
Second line- TCAs
- amitryptylline
- imipramine
- nortriptylline
Bipolar management if get pregnant
Slowly reduce lithium and switch to antipsychotic
Can remain on lithium but must have levels monitored every 4 weeks
If pregnant what is advised for depression in BPAD
Olanzapine and fluoxetine
First line for LBD
Donepezil or rivastigmine
What drugs are contraindicated in LBD
Levodopa
Antipsychotics
Management of post natal depression
Assess with PHQ9 or edinburgh post natal depression tool
If mild/moderate
- facilitated self help
- if history of severe depression still give medication
If moderate/severe
- offer CBT or antidepressant if does not want CBT and understands risk
- sertraline/paroxetine first line then TCA
Management of post natal depression
Assess with PHQ9 or edinburgh post natal depression tool
If mild/moderate
- facilitated self help
- if history of severe depression still give medication
If moderate/severe
- offer CBT or antidepressant if does not want CBT and understands risk
- sertraline first line then TCA
Imaging findings of fronto-temporal dementia
CT normal
PET or SPECT (single photon emission computerised topography) will show hypometabolism in frontal lobe
When do you use memantine
Contraindication/ intolerance to acetylcholinesterase inhibitor in mild/moderate dementia
Can add to acetylcholinesterase inhibitor in moderate dementia
Severe dementia first line
How are behavioural and psychiatric disorders in dementia screened for
Neuropsychiatry inventory questionnaire (NPI-Q)
Management of depression/anxiety in dementia
Same as normal person
Only use SSRI if severe
What drugs used for severe agitation or hallucinations in dementia
Haloperidol
Risperidone- preferred and what use in lecture
How is bipolar depression treated in elderly
Quetiapine or lamotrigine
Management of anxiety in elderly
SSRI/CBT first line
Second line- venlafaxine or mirtazapine second line
In elderly what is most common psychotic disorder diagnosis
Delusional disorder
What must be done before starting an anti-cholinesterase
ECG to rule out long QT or bradycardia
What Edinburgh post natal score suggests a depressive illness
13
What antidepressant should be used if on MAOi
Mirtazapine
As increased risk of serotonin syndrome
Anxiety disorders seen in different ages
Under 3
- separation
3-6
- phobias
- monsters
6-12
- performance
12-18
- social
Mild depression management in children
Can offer 2 weeks watchful waiting
or
3 months low intensity psychological therapy, digital CBT, group CBT
Moderate- severe depression management in children
Reviewed by CAMHS
3 months of higher intensity psychological therapy- family therapy, individual therapy, brief psychosocial intervention
2nd line- switch psychological therapy or add fluoxetine
Management of anxiety in a child
1st line- psychoeducation, Group CBT
Second line- fluoxetine or sertaline if OCD
Liaise with school if pertinent to presentation
When is only time use sertraline in a child
OCD
Management principles of behaviour disorders
- Rule out physiological cause
- Behavioural therapy based around conditioning and positive behaviour rewards
- eg if sleeping disorder look at sleep environment and hygiene, if encopresis look at using toilet after meals - Last line medication like melatonin for sleep and desmopressin for enuresis
Imaging findings in ADHD
Pathology behind ADHD= hypoactivity of frontal cortex
Frontal cortex atrophy
Reduced blood flow fMRI
Management of ADHD
Refer to specialist to make diagnosis
First line is family education and training
Second line methyphenidate if symptoms still severe
Third line if does not work- lisdexamfetamine
Fourth line if does not work- dexamfetamine
Can also consider Atmoxetine
If medication unsuccessful use CBT
MLD
When admit for CAMHS depression
High risk to self
Poor home supervision
Intensive assessment required
What tests can you use to test prefrontal cortex in ADHD
Wisonsin card sorting
Stroop
- colours written out but colour of text different
How is intellectual impairment measured
Wechsler adult intelligence scale
How is adaptive/social functioning assessed
Adaptive behaviour assessment system II (ABAS) in a clinical interview
How is learning diability assessed in children
Clinical interview
School reports
How is autism diagnosed
Autism diagnostic inventory
How is irritability managed in autism pharmacologically
Risperidone and aripiprazole
How are obsessional behaviours treated pharmacologically in autism
SSRIs
How are stereotypical motor behaviours treated in autism
Risperidone
Management of tourettes
If mild
- Self help- education about them and identifying triggers
If debilitating
- risperidone
- exposure with response prevention
How does methylphenidate OD present
HTN
Tachycardic
High fever
Restless
Cant sleep
What do if develop tics on methylphenidate
Switch medications
What are techniques used in psychodynamic therapy
Free association- Ask patient just to say everything that comes to mind
Transferance- Where one applies all emotions and thoughts they have for someone else to the psychiatrist
Recognising resistance- Demonstrating to patient things they are doing which is preventing the therapy from carrying on
What is jamais vu
When experience something have many times but think is new
What is derailment
Thought disorder where no meaningful connections between what talking about
What is it when repeat last syllable of a word over and over
Logoclonia
What you like arranging objects in a particular order
Punding
