Psych Flashcards
EUPD description (3)
Problems in the functioning of aspects of self i.e. self-worth and direction
Intense interpersonal relationships that alternate between idealisation and devaluation
Associated with a history of recurrent self-harm
Histrionic PD description
Need to have attention and acting in a dramatic and narcissistic way to achieve this
Inappropriate sexual seductiveness
Paranoid PD description
Hypersensitivity and unforgiving if insulted
Question loyalty of those around them and are reluctant to confide in others
Anti-social
Schizoid PD description
Anti-social, aloof, indifferent and not complying to social norms
Lack of interest in sexual interactions
Schizotypal PD description
History of ‘magical thinking’ / odd beliefs and ideas of reference
Lack of close friends other than family members
- The ideas of reference are not firm enough to meet the criteria for delusional disorder or schizophrenia
Narcissistic PD
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success and power
Lack of empathy
Obsessive-compulsive / Anakastic PD
Unhelpful perfectionism - occupied with details, rules, lists
Rigid with respect to morals, ethics and values that everyone should follow
Unwilling to pass on tasks
Avoidant/anxious PD
Preoccupied with ideas that they are being criticised or rejected in social situations and therefore avoid interpersonal contact
Certainty of being liked is needed before becoming involved with people
Dependent PD
Difficulty making everyday decisions without excessive reassurance from others
Anti-social PD
Failure to conform to social norms
Repeatedly performing acts that are grounds for arrest
More common in men
Lack of remorse
Aggressiveness
Psychological therapy used for EUPD
Dialectical behaviour therapy (DBT)
medication should not be used unless comorbidities exist e.g. depression or psychosis
Factors favouring delirium over dementia
Acute onset
Impairment of consciousness
Fluctuation of symptoms: worse at nights, periods of normality
Abnormal perception (e.g. illusions and hallucinations)
Agitation, fear
Delusions
Monoamine Oxidase Inhibitor metabolise which neurotransmitters
serotonin and noradrenaline
2 examples of MAOIs drugs
- ine
Phenelzine
Tranylcypromine
Selegiline
Isocarboxazid
Rasagiline
Adverse effect of non-selective MAOI drugs
‘Cheese effect’:
Hypertensive reactions with tyramine-rich foods e.g. cheese, pickled herring, Bovril, OXO, marmite, broad beans
Prophylactic mood stabilisation in bipolar disorder 1st & 2nd line
1st line: Lithium (teratogenic)
2nd line: Sodium valproate (teratogenic)
3rd line: Olanzapine
Rapid cycling bipolar: Carbamazepine
Difference between hypomania and mania
Mania: severe functional impairment or PSYCHOTIC symptoms (e.g. delusions of grandeur) for 7 days or more
- Type 1
Hypomania: decreased or increased function for 4 days or more
- Type 2
Side effects of Lithium - name 5
Nausea/vomiting/diarrhoea
Hypothyroidism / Weight gain
Fine tremor
Polyuria and polydipsia secondary to nephrogenic DI (lithium = nephrotoxic)
Other:
Hyperparathyroidism and resultant hypercalcaemia (stones, bones, moans, groans)
Idiopathic intracranial hypertension
Leucocytosis
Lithium monitoring
Lithium levels:
taken 12 hours post-dose
After a dose change or after starting: weekly until levels are stable
Normally checked every 3 months
Thyroid and renal function (U&Es, eGRF) should be checked every 6 months
3 reasons lithium toxicity may be precipitated
Dehydration
Renal failure
Drugs: diuretics, ACE inhibitors, NSAIDs
Features of lithium toxicity - name 4
Coarse tremor (fine tremor seen in therapeutic)
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma
Management of assisted alcohol withdrawal
1st line: oral long acting benzo e.g. Lorazepam or Chlordiazepoxide
IV if symptoms persist
Features of alcohol withdrawal (timed stages)
6-12 hours: symptoms
36 hours: seizures
48-72 hours: delirium tremens
What is given during alcohol detoxification to replenish low B1 stores in delirium tremens
IV Pabrinex (thiamine, riboflavin etc.)
oral thiamine is used to replenish low B1 stores when not in DE
Risk factors for delirium
PINCHME
Pain
Infection (think UTI)
Nutrition
Constipation
Hydration
Medication
Environment
Hypoxia (type 1 resp failure i.e. low O2 with normal CO2)
Causes of serotonin syndrome (2)
- Antidepressants e.g. MAOIs + SSRIs e.g. rasagiline + Citalopram, or SSRI-drug interactions e.g. St John’s wort / Tramadol
- Illicit substances e.g. Ecstasy + Amphetamines
3 features of serotonin syndrome (triad)
think: excess 5-HT to neuromuscular and central synapses (brain + spinal cord)
Neuromuscular excitation: Hyperreflexia, Myoclonus, Rigidity
Autonomic nervous system excitation:
Hyperthermia, Sweating 😓
Altered mental state:
Confusion
Favouring features for neuroleptic malignant syndrome compared with serotonin syndrome
Caused by antipsychotics
Slower onset (days to weeks vs 24h)
Hyporeflexia, normal pupils
Neuroleptic malignant syndrome investigation results
Raised creatine kinase (due to muscle rigidity) - rhabdomyolysis
Raised white cell count (leukocytosis)
Acute renal failure = abnormal U&Es
Deranged LFTs
Metabolic acidosis - low pH, low HCO3
Neuroleptic malignant syndrome tetrad
think: neurotransmitter overload:
1. Autonomic instability - hypertension, tachycardia, tachypnoea
2. Altered mental status - delirium with confusion
3. Hyperthermia (pyrexia)
think: dopamine overload i.e. Parkinsonism rigidity:
4. Muscle rigidity
Definition of severe depression
triad (low mood for at least 2 weeks, anhedonia, anergia)
PLUS most other symptoms e.g. weight change, sleep change, psychomotor, worthlessness, inability to think, suicidal ideation - all of which markedly interfere with functioning
PHQ-9 > 16
3 core symptoms of depression
Low mood for at least 2 weeks
Anhedonia
Anergia
ICD-10 criteria for delirium (5)
- Impairment of consciousness and attention
- Global disturbance in cognition
- Psychomotor disturbance
- Disturbance of sleep-wake cycle
- Emotional disturbances
Name 4 medical problems associated with Down’s syndrome
Heart defects (ToF, AV/V/A septal defects)
Hearing loss
Visual disturbance (cataracts, strabismus)
GI problems (oesoph/duodenal atresia, Hirschsprung’s)
Hypothyroidism
Haematological malignancies (AML, ALL)
Alzheimer’s risk increase
Describe 4 physical appearance features in Down’s syndrome
Face:
Upslanting palpebral fissures
Epicanthic folds
Brushfield spots in iris
Protruding tongue
Small low set ears
Round/flat face
Flat occiput
Single palmar crease
NICE first line for mild depression
Watch and wait (review in 2 weeks) and consider referral to IAPT for low intensity psychological interventions
NICE first line for severe depression
Combination of individual CBT + an antidepressant
First line antidepressant for less severe depression
SSRI
What kind of antidepressant is amitriptyline
Tricyclic antidepressant
NICE recommends avoiding TCAs in history or risk of overdose due to toxicity
What kind of antidepressant is duloxetine
SNRI
What kind of antidepressant is isocarboxazid
MAOI
GAD definition
Syndrome of ongoing, uncontrollable, widespread worry about many events that the patient recognises as excessive - must be present on most days for at least 6 months
Agoraphobia definition
Fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack
First and second line drug for GAD
- SSRI e.g. sertraline
- another SSRI or an SNRI e.g. duloxetine and venlafaxine
Examples of stimulant drugs
Cocaine
Meth
MDMA
Khat
Nicotine
4 main dopaminergic pathways
Mesolimbic
Mesocortical
Nigrostriatal
Tuberohypophyseal
4 common indications for the prescription of a benzodiazepine
Alcohol withdrawal
Seizures
Severe anxiety
Severe insomnia
Benzos should not be used for more than 2-4 weeks due to addiction / side effects (drowsiness)
4 extrapyramidal side effects of typical antipsychotics
Parkinsonism
Acute dystonia - sustained muscle contraction such as torticollis or oculogyric crisis
Akathisia (severe restlessness)
Tardive dyskinisea (chewing and pouting of jaw or excessive blinking)
How is acute dystonia secondary to antipsychotics managed
Procyclidine
anti-cholinergic which corrects cholinergic neurotransmission
what 2 complications can antipsychotics cause in the elderly
Stroke
VTE
Non-EPSE side effects of typical antipsychotics
Antimuscarinic - dry mouth, blurred vision, urinary retention, constipation
Sedation
Dyslipidaemia/Weight gain
Hyperprolactinaemia - may result in galactorrhoea
Dysglycaemia/diabetes Mellitus
Prolonged QT interval (particularly haloperidol)
Adverse effects of atypical antipsychotics
Weight gain
Hyperprolactinaemia
+ Clozapine is associated with agranulocytosis
Examples of atypical antipsychotics
Clozapine
Olanzapine
Risperidone
Quetiapine
Amisulpride
Aripiprazole
Atypical antipsychotic that increases risk of dyslipidemia and obesity
Olanzapine
Atypical antipsychotic with good side effect profile
Aripiprazole
Why is FBC monitoring essential during clozapine treatment
Significant risk of agranulocytosis
When is clozapine indicated in schizophrenia
Sequential use of two or more antipsychotic drugs (one of which should be a second generation anti-psychotic drug) each for at least 6-8 weeks
What activity can cause a rise in clozapine blood levels
Smoking
Adverse effects of clozapine (5)
Agranulocytosis, neutropaenia
Reduced seizure threshold
Constipation
Myocarditis
Hypersalivation
Management of depressive episode in bipolar disorder
Fluoxetine + atypical antipsychotic e.g. olanzapine
Talking therapies
Management of manic episode in bipolar disorder
Consider stopping antidepressant (SSRIs and TCAs especially venlafaxine increase risk of ‘switch’)
Atypical antipsychotic therapy e.g. olanzapine
Midazolam
RAPID acting benzo
Indications: status epilepticus
ICD-10 criteria for agoraphobia
- fear and avoidance of 2 of: crowds, public spaces, travelling alone, travelling away from home
- symptoms of anxiety in feared situation with autonomic arousal
- significant emotional distress due to avoidance or anxiety symptoms
- recognised as excessive or unreasonable
- symptoms restricted to feared situation
Panic disorder definition
Recurrent, episodic, severe panic attacks which are unpredictable and not restricted to any particular situation or circumstance
Not associated with marked exertion or with exposure to dangerous or life-threatening situations
ICD-10 criteria of panic disorder (5)
- discrete episodes of intense fear or discomfort
- starts abruptly
- reaches a crescendo within a few minutes and lasts at least some minutes
- at least 1 symptom of autonomic arousal
- other symptoms of anxiety
Schizophrenia Schneider’s first rank symptoms (4)
auditory hallucinations
delusional perceptions
thought disorders
passivity phenomena
Auditory hallucinations in schizophrenia (3)
thought echo
two or more voices discussing the patient in the third person
voices commenting on the patient’s behaviour
Thought disorders in schizophrenia (3)
thought insertion
thought withdrawal
thought broadcasting
Passivity phenomena seen in schizophrenia definition
bodily sensations being controlled by external influence
Delusional perceptions in schizophrenia definition
two stage process:
first a normal object is perceived
secondly there is a sudden intense delusional insight into the objects meaning for the patient
e.g. ‘The traffic light is green therefore I am the King’
this can include persecutory delusions
Name 4 negative symptoms of schizophrenia
incongruity/blunting of affect
anhedonia (inability to derive pleasure)
alogia (poverty of speech)
avolition (poor motivation)
social withdrawal
Schizophrenia prognostic indicators
strong family history
gradual onset
pre-morbid low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
Strongest risk factor for developing a psychotic disorder
Family history
Risk factors associated with an increased risk of future completed suicide after an attempted suicide (5)
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method
Suicide risk factors
static:
male sex
history of deliberate self-harm
history of mental illness
depression
schizophrenia (10%)
history of chronic disease
advancing age
dynamic:
alcohol or drug misuse
unemployment or social isolation/living alone
financial problems
being unmarried, divorced or widowed
Flumazenil
reverses the sedative effects of benzodiazepines (particularly in benzodiazepine overdose)
Indication for the use of EMDR in PTSD
recommended in patients who have presented between 1 and 3 months after a non-combat related trauma who specifically prefer EMDR > trauma-focussed CBT
Indication for the use of trauma-focused CBT in PTSD
1st line for patients
1st line medical management of PTSD (2)
SSRIs e.g. sertraline or venlafaxine (SNRI)
4 types of thought disorganisation seen in psychosis
alogia e.g. … (poverty of speech)
tangentiality e.g. ‘How was your week?’ ‘The sky is blue’
clanging e.g. Where are the keys knees freeze breeze?
word salad e.g. soggy blankets and red tomatoes
5 conditions where psychosis is a symptom
Schizophrenia (most common)
Depression (psychotic depression seen in elderly patients)
Bipolar disorder
Parkinson’s disease
Corticosteroid induced
Illicit drugs e.g. cannabis
Knight’s move thinking
phenomenon where a patient’s thoughts move from one topic to another
differential from flight of ideas: knight’s move has no logical connection between them
Flight of ideas
increased rate of thought with at least some logical links between the frequent changes of topics that a patient is talking about
commonly a feature of mania/hypomania
Circumstantiality
patient gives an excessive amount of detail that is irrelevant to the question but there is a logical progression of thought + normal rate
Perseveration
repetition of a certain word/phrase/thought
Features of opioid misuse
rhinorrhoea
needle track marks
pinpoint pupils
drowsiness
watering eyes
yawning
emergency management of opioid overdose
IV or IM naloxone
1st line treatment for opioid detoxification
methadone or buprenorphine
lithium in pregnancy
teratogenic
risk of Ebstein’s anomaly (congenital heart defect characterised by enlarged right atrium, shrunken right ventricle, pansystolic murmur by defective tricuspid valve)
Clomipramine
tricyclic antidepressant used 2nd line in OCD
4 features of a capacity assessment
WURC
The ability to…
weigh-up
understand
retain
communicate
…the decision made
How does a person need to communicate their decision for a capacity assessment
A person can communicate their decision verbally or by other means such as in writing or via sign language, the assessor must take into account the patients’ primary communication method
Egodystonic vs egosyntonic in OCD thoughts
Obsessive thoughts are usually egodystonic (very different to the patient’s normal beliefs and values) rather than egosyntonic (in keeping with ones beliefs and values)
Cognitive function test used in primary care settings
Six Item Cognitive Impairment Test (6-CIT)
Medications associated with delirium
PROF
Propranolol
Ranitidine (H2 blocker)
Chlorphenamine (H1 blocker)
Oxybutynin - causes constipation (PINCH ME)
Furosemide (diuretic)
Blood test monitoring clozapine
first 18 weeks: minimum of 1 blood test per week
until 1 year: fortnightly
after 1 year: monthly (as long as there are no abnormalities)
Confusion screen (4)
Infection screen
Chest X-ray
C-Reactive Protein
Full Blood Count, B12/folate, TFTs, glucose, calcium
Urinalysis
Depression over Dementia features
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
GAD risk factors (4)
Aged 35-54
Being divorced or seperated
Being a lone parent
Living alone
How long should a patient continue with treatment once they have reached remission with antidepressant therapy
6 months (to reduce the risk of relapse)
Over what period of time should SSRIs be reduced when stopping them
4 weeks
Section 5 (4)
Holding power for nurses for up to 6 hours
Section 5 (2)
Holding power for doctors for up to 72 hours
key differential when elderly patient experiences drowsiness, confusion, or convulsions while taking an SSRI
Hyponatraemia
Disulfiram
Deterrent drug which increases serum acetaldehyde if alcohol is consumed which causes diaphoresis, palpitations, facial flushing, nausea etc.
not an anti-craving drug - used for alcohol abstinence
Naltrexone use in alcohol abuse recovery
Naltrexone blocks opioids from releasing endorphins (associations of alcohol with endorphin rush are diminished) = undermines the reinforcement/reward system with drinking alcohol
3 drugs used for alcohol addiction rehabilitation
Naltrexone
Disulfiram
Acamprosate
Normal pressure hydrocephalus
Reversible cause of dementia thought to be secondary to reduced CSF absorption at the arachnoid villi
these changes may be secondary to head injury, sub arachnoid, meningitis
Normal hydrocephalus features triad
Urinary incontinence
Dementia and bradyphrenia
Gait abnormality
Neuroimaging of normal pressure hydrocephalus
Ventriculomegaly in the absence of sulcal enlargement
Management normal pressure hydrocephalus
Ventriculoperitoneal shunting
Medications that can trigger anxiety (5)
Salbutamol
Theophylline
Corticosteroids
Antidepressants
Caffeine
Alternative causes of anxiety disorders
Hypothyroidism - TFTs
Cardiac disease - ECG
Medication induced anxiety
Anaemia (palpitations + fatigue) - FBC
Phaeochromocytoma - 24 hour urinary metanephrines
Management of serotonin syndrome
IV fluids + Benzodiazepines
More severe cases: serotonin antagonists i.e. cyproheptadine and chlorpromazine
1st line management step after someone presents with depression in a primary care setting for the first time
PHQ-9 questionnaire
Acamprosate mechanism of action
Reduces alcohol cravings by increasing GABA transmission
Indication for the use of mertazapine as an antidepressant
the 2 side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite
what is the 1 absolute contradiction for ECT
Raised intracranial pressure
Causes of drug induced psychosis
Illicit substances
Alcohol
Anti-malarial
Bromocriptine
Levodopa
Steroids
Edwards and Gross criteria for alcohol dependence
- Narrowing of repertoire
- Salience of drink-seeking behaviour
- Increased tolerance to alcohol
- Repeated withdrawal symptoms
- Relief or avoidance of withdrawal symptoms by further drinking
- Subjective awareness of compulsion to drink
- Reinstatement after abstinence
Schizoaffective disorder
Schizophrenia along with another disorder e.g. depression or bipolar
What age does autism normally present by
3 years old
Features of autism
- Impaired social communication and interaction
- Repetitive behaviours, interests, and activities
Often associated with intellectual impairment or language impairment
ASD has a co-occurrence of 35%
3 management options in autism
Early educational and behavioural interventions e.g. applied behavioural analysis
SSRIs for anxiety symptoms
Family support and counselling
Risk factors for OCD
Family history
Age: peak onset 10-20 years
Pregnancy/post natal period
History of abuse, bullying, neglect
Severe OCD features
> 3 hours a day on their obsessions/compulsions
Severe interference/distress
Very little control/resistance
Mild functional impairment OCD management
1st: low-intensity CBT including exposure response prevention
2nd: SSRI or more intensive CBT with ERP
Moderate functional impairment OCD management
1st: Intensive CBT with ERP +/- SSRI for at least 12 weeks
2nd: Different SSRI or Clomipramine (1st if the person prefers it, has had a good previous response, or if SSRI is C/I)
Severe functional impairment OCD management
Refer to the secondary care mental health team for assessment and whilst waiting offer SSRI and CBT with ERP (or clomipramine as alternative)
SSRI for body dysmorphia
Fluoxetine
OCD SSRI dose vs depression
Higher dose and longer duration of treatment before an initial response (at least 12 weeks)
Somatatisation disorder definition
Multiple physical symptoms present for at least 2 years
Patient refuses to accept reassurance or negative test results
Illness anxiety disorder (hypochondriasis)
Persistence belief in the presence of an underlying serious disease e.g. cancer
Patient refuses to accept reassurance of negative test results
Conversion disorder
Psychological stress converted to loss of motor or sensory function
Doesn’t consciously feign the symptoms (factitious) or seek material gain (malingering)
La belle indifference = indifferent to their apparent disorder
Factitious disorder
Also known as Münchausen’s syndrome
Intentional production of physical or psychological symptoms
Malingering disorder definition
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Concordance rate for schizophrenia in monozygotic twins
50%
Mental Health Act: Section 2
Admission for assessment for up to 28 days
Not renewable
2 doctors (usually 1 consultant psychiatrist) + AMHP
Treatment can be given against a patient’s wishes
Mental Health Act: Section 3
Admission for treatment for up to 6 months
Renewable
2 doctors + AMHP (all must have seen patient within past 24 hours)
Treatment can be given against a patient’s wishes
How long can a section 136 be used for
24 hours (whilst a MHA assessment is arranged)
What should be offered to all schizophrenia patients after medication
Cognitive behavioural therapy
Differential diagnoses in depression
Bipolar disorder
psychotic disorders
premenstrual syndrome
substance misuse
Anaemia
Hypothyroidism
3 screening tools for depression
PHQ-9
HADS
BDI-II
What should be co-prescribed with an SSRI if they are already taking an NSAID
PPI
Patient under 25 time until review after initiating SSRIs
1 week
Acute stress disorder definition
Acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event
(PTSD is diagnosed after 4 weeks)
1st line for acute stress reaction
1st line: Trauma focused CBT
Benzodiazepines can sometimes be used for acute symptoms e.g. sleep disturbance - but should be used with caution due to addictive potential
4 antipsychotics used in a manic episode
Haloperidol
Olanzapine
Quetiapine
Risperidone
2 typical antipsychotics
Chlorpromazine
Haloperidol
3 features of PTSD
Re-experiencing e.g. flashbacks, nightmares
Avoidance e.g. avoiding people or situations
Hyperarousal e.g. hyper vigilance, sleep problems
Most effective antipsychotic for dealing with negative symptoms
Clozapine
Catatonia definition
Stopping of voluntary movement or staying in an unusual position arising from disturbed mental state
Most likely SSRI to cause QT prolongation and torsades de points
Citalopram
Most useful SSRI post-myocardial infarction
Sertraline
SSRI discontinuation symptoms
Increased mood change
restlessness
Difficulty sleeping
Sweating
GI symptoms: pain, cramping, diarrhoea
Dizziness
electric shock sensations
Anxiety
Use of SSRIs in pregnancy (3)
1st trimester: small risk congenital heart defects
3rd trimester: small risk pulmonary hypertension of new born
Paroxetine increases risk of congenital malformations (particularly in 1st)
SSRI drug-drug interactions
NSAIDs (co-prescribe PPI)
Warfarin/Heparin (prescribe mirtazapine instead)
Aspirin
Triptans (increased risk of SS)
MAOIs (increased risk of SS)
Recommended monitoring before initiating treatment of SNRI
Blood pressure
Signs of cocaine use
Dilated pupils
Hyperreflexia
Chronic insomnia definition
Difficulty with falling or staying asleep at least 3 nights per week for at least 3 months
TCA side effect profile
Histamine receptors: drowsiness
Muscarinic receptors: dry mouth, blurred vision, constipation, urinary retention/overflow incontinence
Flight of ideas vs knights move thinking
Flight of ideas = discernible links, seen in bipolar
Knight’s move = no discernible links, seen in schizophrenia
Where would a patient with hypomania be referred to from primary care
Community mental health team
When might dose adjustment of clozapine be necessary
If smoking is started (increase) or stopped (reduce)
Charles-Bonnet syndrome
Persistent complex hallucinations occurring in clear consciousness with a background of visual impairment (age related macular degeneration is the most common)
Patients usually have insight that the hallucinations are not real
anorexia bloods
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
