Psych Flashcards
Long-term lithium use can result in ________________ and resultant ________________
hyperparathyroidism and resultant hypercalcaemia
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)
Depression vs dementia
What is the most important test to perform when starting a patient on anti-psychotics?
FBC - agranulocytosis/neutropenia is a life-threatening side effect of clozapine
Antisocial personality disorder is associated with ______________ disorder
Conduct disorder
Schizoaffective vs mania
Mania: mood disturbances precede psychotic symptoms (low mood for a year and now presents with a manic episode + psychosis)
Schizoaffective: psychotic symptoms precede mood disturbances
Confusion
Ataxia
Ophthalmoplegia/nystagmus
Wernicke’s encephalopathy
Profound anterograde amnesia
Limited retrograde amnesia
Confabulation
Korsakoff’s syndrome
Retrograde: no past memories
Anterograde: no new memories
Which medication is used to treat Tardive dyskinesia?
Tetrabenazine = both begin with T
Have been TAking antipsychotics for several years -> give Tetrabenezine
Which medication is used to treat acute dystonia?
Acute dySTonia common when STarting antipsychotics -> give procyclidine
Which medication is used to calm a patient who is having a psychotic episode (among many other indications)?
Lorazepam
Which medication is used to treat akathisia?
Propranolol
Which medication is used as anti-depressant in children?
Fluoxetine
Give examples of typical antipsychotics
Haloperidol
Chlorpromazine
Blocks D2: Haloperidol and the “-zines”
Give examples of atypical antipsychotics
Clozapine
Risperidone
Olanzapine
Blocks 5HT2: “-idones”, “-apines” + Aripiprazole
Which drugs are normally avoided with SSRIs?
Aspirin
NSAIDs: if given co-prescribe PPI
Warfarin / heparin: consider mirtazapine
Triptans and MOAIs: serotonin syndrome
What are the preferred SSRIs?
Fluoxetine and Citalopram (risk of QT interval prolongation, avoid in congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval)
For patients who are on SSRIs and under the age of 25 years, there is an increased risk of _______ should be reviewed after _______
For patients who are on SSRIs and under the age of 25 years, there is an increased risk of suicide should be reviewed after 1 week
When stopping a SSRI the dose should be gradually reduced over a __ week period (this is not necessary with ___________). ___________ has a higher incidence of discontinuation symptoms
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms
Using SSRIs in the first trimester gives a small increased risk of..
Congenital heart defects
Using SSRIs in the third trimester can result in..
Persistent pulmonary hypertension of the newborn
The SSRI ____________ has an increased risk of congenital malformations, particularly in the first trimester
The SSRI Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after ________. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least ________ after remission as this reduces the risk of relapse
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse
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
Which PD is shown here?
Paranoid PD - Cluster A (Odd or eccentric)
Conspiracy theorist
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
Which PD is shown here?
Schizoid PD - Cluster A (Odd or eccentric)
Aloof virgin
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
Which PD is shown here?
Schizotypal PD - Cluster A (Odd or eccentric)
Rambler
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest
Deception
Impulsivenes
Irritability and aggressiveness - repeated physical fights or assaults;
Disregard for the safety of self or others;
Consistent irresponsibility
Lack of remorse
Which PD is shown here?
Antisocial PD - Cluster B (Dramatic, Emotional, or Erratic)
Liar, fighter, lazy
Avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealisation 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
Which PD is shown here?
Borderline PD - Cluster B (Dramatic, Emotional, or Erratic)
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
Which PD is shown here?
Histrionic PD - Cluster B (Dramatic, Emotional, or Erratic)
Attention seeking hoe
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
Which PD is shown here?
Narcissistic PD - Cluster B (Dramatic, Emotional, or Erratic)
Delulu and greedy
Details, rules, lists, order, organization, or agenda
Perfectionism that hampers with completing tasks
Elimination of spare time activities
Etiquettes of morality, ethics, or values
Dot 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
Which PD is shown here?
Obsessive-compulsive PD - Cluster C (Anxious and Fearful)
Literally just me tbh
Avoidance of occupational activities which involve 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
Which PD is shown here?
Avoidant PD: Cluster C (Anxious and Fearful)
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
Which PD is shown here?
Dependent PD: Cluster C (Anxious and Fearful)
Mx of PD
Dialectical behaviour therapy
Treatment of any coexisting psychiatric conditions
Timeline difference between Acute Stress Disorder vs PTSD
PTSD: 4 weeks
ASD: 2 weeks
PTSD has 4 letters so can only diagnose as PTSD 4 weeks after the event
Tx for acute stress disorder
CBT
Benzodiazepines for acute symptoms e.g. agitation, sleep disturbance. Addictive potential
Don’t do trauma-focused CBT in the first 4 weeks of an acute stress reaction as it can cause PTSD to develop
Side effects for Clozapine
Agranulocytosis, neutropenia, reduced seizure threshold, and myocarditis
All atypical antipsychotics can cause ________ and _____________
All atypical antipsychotics can cause weight gain and hyperprolactinemia
The atypical antipsychotic _________ has a good side effect profile and is less likely to increase prolactin levels or cause other side effects
Aripiprazole
Which atypical antipsychotic is used to a patient is underweight and cannot sleep?
Olanzapine
Which atypical antipsychotic has a notable side effect of postural hypotension?
Quetiapine
The atypical antipsychotic ____________ can increase the likelihood of developing extrapyramidal side effects, as well as cause postural hypotension and sexual dysfunction
Risperidone
What are the specific warnings when antipsychotics are used in elderly patients?
Increased risk of stroke
Increased risk of venous thromboembolism
What are the protective factors of GAD?
Aged 16 - 24
Being married or cohabiting
What are the risk factors of GAD?
Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent
Having a _________ disease or _________ may result in symptoms similar to GAD
Having a hyperthyroid disease or atrial fibrillation may result in symptoms similar to GAD
Mx of GAD
Mx of panic disorder
When checking lithium levels, the sample should be taken ________ post-dose
12 hours
After starting lithium, levels should be performed ________ and after each dose change until concentrations are stable. Once established, lithium blood level should ‘normally’ be checked every ________. After a change in dose, lithium levels should be taken a ________ later and ________ until the levels are stable
After starting lithium, levels should be performed weekly and after each dose change until concentrations are stable. Once established, lithium blood level should ‘normally’ be checked every 3 months. After a change in dose, lithium levels should be taken a week later and weekly until the levels are stable
After starting lithium, _________ and _________ function should be checked every 6 months
After starting lithium, thyroid and renal function should be checked every 6 months
What are the nephrotoxic effects of lithium?
Polyuria, secondary to nephrogenic diabetes insipidus
What are the endocrinological effects of lithium?
Thyroid enlargement, may lead to hypothyroidism
hyperparathyroidism and resultant hypercalcaemia
What are the cardiological effects of lithium?
T wave flattening (red) or inversion (blue)
What are the side effects of tricyclics interacting with histamine receptors?
Drowsiness
What are the side effects of tricyclics interacting with muscarinic receptors?
Dry mouth
Blurred vision
Constipation
Urinary retention
What are the side effects of tricyclics interacting with adrenergic receptors?
Postural hypotension
T or F: Tricyclics cause shortening of QT interval
False, lengthening
Give examples of sedative tricyclics
Amitriptyline
Clomipramine
Dosulepin
Trazodone*
Give examples of less sedative tricyclics
Imipramine
Lofepramine
Nortriptyline
Mx of OCD
A patient diagnosed with OCD was prescribed with Setraline but has presented with no improvement after 6 weeks. What is the next course of action?
Increase dose, if no response after 12 weeks then:
Combined treatment with CBT (including ERP)
Switch to a different SSRI
Switch to clomipramine
First rank symptoms of SZ
TAPD:
- Thought disorder
- Auditory hallucinations
- Passivity phenomena
- Delusional perceptions/delusions
Distinguish between dementia and depression regarding memory loss
Depression: global memory loss
Dementia: short-term memory loss
What are the three core depressive symptoms?
Anhedonia, anergia or low mood
Atypical depression may include..
Increased appetite and hypersomnia
Outline somatic symptoms of depression
Loss of emotional reactivity
Diurnal mood variation
Anhedonia
Early morning waking
Psychomotor agitation or retardation
Loss of appetite and weight
Loss of libido
A personality disorder can only be diagnosed after..
The age of 18
The only exception is borderline PD which may be diagnosed before then provided there is sufficient evidence the patient has fully undergone the process of puberty
Two causes of unexplained symptoms
Somatisation = Symptoms
hypoChondria = Cancer
Differentiate between factitious disorder and malingering
Factitious: also known as Munchausen’s syndrome, consciously feign the symptoms
Malingering: seek material gain
Which symptoms of alcohol withdrawal starts at 6-12 hours?
Tremor
Sweating
Tachycardia
Anxiety
Which symptoms of alcohol withdrawal starts at 36 hours?
Seizures
Which symptoms of alcohol withdrawal starts at 48-72 hours?
Coarse tremor
Confusion
Delusions
Auditory and visual hallucinations
Fever
Tachycardia
Tx of alcohol withdrawal
Long-acting benzodiazepines e.g. chlordiazepoxide or diazepam
Lorazepam may be preferable in patients with hepatic failure
Carbamazepine also effective in treatment
Which scoring system is used to determine the severity of alcohol withdrawal?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale
What is Perseveration?
Repeating the same words/answers
What is Echolalia?
Repeating exactly what someone has said
What is Neologism?
Making up new words
What is Word salad?
Disorganised speech, sentences that do not make sense
Differentiate between circumstantiality and flight of ideas
Circumstantiality: excessive unnecessary details before eventually reaching the answer to the question
Flight of ideas: rapid shift in thoughts with loose connections between them, without ever answering the original question
Tx for PTSD
Watch and wait for mild symptoms <4 weeks
CBT or EMDR
If drug treatment is used then venlafaxine or SSRI, such as sertraline should be tried. In severe cases, risperidone may be used
____________ is a common finding associated with lithium
Benign leucocytosis is a common finding associated with lithium
When is carbamazepine used in the treatment of alcohol withdrawal?
Can help manage seizures associated with alcohol withdrawal as it is an anticonvulsant
Outline poor prognostic factors of SZ
Strong family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
Side effects of TCAs
‘TCAs’
Thrombocytopaenia
Cardiac (arrhythmias, MI, stroke, postural hypotension)
Anticholinergic (tachycardia, urinary retention, dry mouth, blurry vision, constipation) - Can’t see, can’t pee, can’t spit, can’t shit
Seizures
When performing a mini mental state examination on a patient with depression they will answer with __________ whereas patients with Alzheimer’s will try their best to answer your questions, but answer __________
When performing a mini mental state examination on a patient with depression they will answer with ‘I don’t know’, whereas patients with Alzheimer’s will try their best to answer your questions, but answer incorrectly
Which drug is used in treatment resistant schizophrenia?
Clozapine
Differentiate between borderline PD and bipolar disorder
EUPD - intense emotions, impulsivity, self-harm and unstable relationships
Bipolar - episodes of mania (elevated mood, increased activity, decreased need for sleep) interspersed with episodes of depression
The SSRI of choice in people with unstable angina or recent myocardial infarction is _________
Sertraline
Differentiate between mania and hypomania
Mania: severe functional impairment, psychotic symptoms, >7 days
Hypomania: high functioning and does not impair functional capacity, <7 days and no psychotic symptoms
Mx of bipolar disorder
Lithium is the mood stabiliser of choice (alt. valproate)
For mania/hypomania:
Consider stopping antidepressant if the patient takes one (antipsychotic therapy e.g. olanzapine or haloperidol
For depression:
Talking therapies and fluoxetine
Which co-morbidities exist with Lithium?
Diabetes, cardiovascular disease and COPD
What is ECT used for?
ECT
Euphoric - prolonged or severe mania
Catatonia
Tearful - severe depression
What is a C.I to ECT?
Raised intracranial pressure
What are the short-term side-effects to ECT?
Headache
Nausea
Short term memory impairment
Memory loss of events prior to ECT
Cardiac arrhythmia
What are the long-term side-effects to ECT?
Impaired memory
Hypertrophied dental gums is seen in which eating disorder?
Bulimia
What are the features of PTSD
HEART:
Hyperarousal
Emotional numbing
Avoidance of triggers
Re-experiencing
Time
Differentiate between OCD and psychosis
In OCD the patients normally have a good level of insight into their condition and understand that if they did not perform the acts their obsessive though would not come true. However, they still get the urge to perform them anyway, just to put their mind at ease
Which parameters are raised in anorexia nervosa?
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
What is Hoover’s sign?
Clinical tool to differentiate organic from non-organic leg paresis. In non-organic paresis, pressure is felt under the paretic leg when lifting the non-paretic leg against pressure, this is due to involuntary contralateral hip extension - conversion disorder
Hypercalcaemia sx
Stones, bones, abdominal moans, and psychic groans
Which foods are avoided with MOAi?
Tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
Psychotic episodes that last for less than a month are called..
Brief psychotic disorders
Which neurological conditions can cause psychotic symptoms?
Parkinson’s disease, Huntington’s disease
Which prescribed drugs can cause psychotic symptoms?
Corticosteroids
Which illicit drugs can cause psychotic symptoms?
Cannabis, phencyclidine
Outline thought disorganisation features seen in psychosis
Alogia: little information conveyed by speech
Tangentiality
Clanging
Word salad
Symptoms you get when you FINISH taking SSRIs
Flu like symptoms
Insomnia
Nausea (& other GI side effects)
Imbalance
Sensory disturbances (paraesthesia)
Hyperarousal (restlessness, agitation)
Symptoms of anxiety and __________ often overlap
Hyperthyroidism
Clozapine is reserved for two cases. These are..
Treatment resistant schizophrenia - two antipsychotics have been trialled at their highest tolerated doses for adequate durations
Negative symptoms
What can improve concordance with SZ medication?
Switch to depot
Clozapine is contraindicated in those with a..
Chaotic lifestyle and/or poor adherence
When to stop SSRIs?
666 rule:
- Wait at least 6 weeks for it to take effect (before switching medication)
- Continue for 6 months to stabilise and avoid relapse
- Take at least 6 weeks for the washout period in order to avoid adverse effects
Differentiate between Knight’s move and flight of ideas
Knight’s move - illogical leaps from one idea to another
Flight of ideas - discernible links between ideas
________________ is the most common endocrine disorder developing as a result of chronic lithium toxicity
Hypothyroidism
Outline blood tests that are used as screening tests to look for other identifiable causes of confusion
TFTs, FBC, ESR, CRP, U&E, Ca, HbA1c, LFTs, serum B12 and folate
Mx for encephalitis
1st line: steroids and intravenous immunoglobulin +/- plasma exchange if not responding to meds
2nd line, if no response within two weeks: rituximab and cyclophosphamide + 1st line therapy
Anyone under the influence of _________ and ________ is specifically excluded from detainment under the Mental Health Act
Anyone under the influence of drugs and/or alcohol is specifically excluded from detainment under the Mental Health Act
What is the four criteria a patient needs to meet to demonstrate capacity to make a decision?
Understand the decision
Retain the information long enough to make the decision
Weigh up the pros and cons
Communicate their decision
What is Lasting power of attorney (LPA)? When does it come into effect?
When a person legally nominates a person of their choice to make decisions on their behalf if they lack mental capacity. LPA only comes into effect if the patient lacks the capacity to decide for themselves
Baby blues vs Post-partum depression vs Depression regarding time
Firs two weeks + resolves spontaneously - baby blues
First 12 months - postpartum depression
More than 2 weeks + not within first 12 months of birth - depression
2 weeks after - postpartum psychosis
Ix for CJD
Tissue biopsy, with tonsil or olfactory mucosal biopsy
EEG, MRI, and lumbar puncture
Change in personality. Often recognised by the patient’s friends and family, this can include changes in food preference or picking up new, often problematic hobbies like gambling. Memory remains intact until the later stages of the disease
Fronto-temporal lobe dementia
Triad of REM sleep disorder, a history of falls (secondary to motor problems), and hallucinations
Lewy body dementia
Which subtype of dementia has a stepwise decline in function?
Vascular
Tx for acute mania with agitation
IM therapy (neuroleptic or benzodiazepine) and potential secure unit admission
Tx for acute mania without agitation
Oral antipsychotic monotherapy, potential addition of sedatives or mood stabilisers
Tx for acute depression
Mood stabiliser, atypical antipsychotic, or antidepressant with psychosocial support
Alternative treatment for lithium
Valproate
Tx for treatment-resistant BPD
Atypical antipsychotics and anticonvulsants
Korsakoff’s syndrome is characterised by profound ____________ amnesia, limited ____________ amnesia, and confabulation
Korsakoff’s syndrome is characterised by profound anterograde amnesia, limited retrograde amnesia, and confabulation
What is Capgras delusion?
In which the patient believes that someone close to them has been replaced by a clone
What is Fregoli delusion?
Where a patient believes that everyone they meet is the same person but with different disguises
Which blood test should be performed when starting lithium?
Thyroid function tests
Urea and electrolytes (calcium and eGFR)
Mx for opiate relapse/craving reduction
Neltrexone
Mx for opiate overdose
Naloxone
Mx for opiate detox
Methadone and buprenorphine (the latter is a partial agonist of the opiate receptor, so can trigger withdrawal)
Mx for opiate withdrawal symptoms
Methadone
Lofexidine
Loperamide (for diarrhea)
Anti-emetics (for nausea)
Mx of lithium toxicity
Supportive + stopping lithium:
Maintaining electrolyte balance
Monitoring renal function (haemodialysis if poor)
Seizure control
IV fluid therapy and urine alkalisation, which enhance the excretion of the drug
Benzodiazepines may be used to treat agitation and seizures
Atrophy of the frontal lobes
Fronto-temporal dementia
Widespread cerebral atrophy
Alzheimer’s
Alpha-synuclein cytoplasmic inclusions
Lewy-Body dementia
Widespread infarcts
Vascular dementia
Prions causing encephalopathy
Creutzfeldt-Jakob disease
Always check a patient’s ______ before starting anti-cholinesterase inhibitors
ECG
Contra-indications include prolonged QT, second or third degree heart block in an unpaced patient and sinus bradycardia <50 bpm
In ________ syndrome, the patient believes they have been infested with parasites. The patient will complain of crawling sensations on the skin and can be due to a psychological or organic reason such as ____ deficiency
In Ekbom syndrome, the patient believes they have been infested with parasites. The patient will complain of crawling sensations on the skin and can be due to a psychological or organic reason such as B12 deficiency
___________ pupils are associated with opioid intoxication rather than withdrawal. In withdrawal, ___________ pupils are more commonly seen
Constricted pupils are associated with opioid intoxication rather than withdrawal. In withdrawal, dilated pupils are more commonly seen
Progressive cognitive decline, visual hallucinations, parkinsonism, fluctuating alertness, and falls
Dementia with Lewy bodies (DLB)
False belief that a close relative or partner has been replaced by an impostor
Clone = Capgras
Individual believes their partner is unfaithful, despite the absence of proof
Othello syndrome
False belief that the person themselves is dying or dead
Cotard’s syndrome
Belief that strangers are familiar to the individual and may even all be the same person
Fregoli = Familiars look the same
Differentiate between CAGE and AUDIT
CAGE - quickly screen for alcohol abuse/assess whether the patient needs further screening
AUDIT - assess whether there is a need for a specialist evaluation concerning alcohol consumption
Differentiate between malingering and munchausen’s syndrome
Malingering: patients fake or induce illness for secondary gain; e.g. drug seeking, disability benefits, avoiding work or prison time
Munchausen’s syndrome: intentionally faking signs and symptoms (i.e. adding blood to urine and complaining of pain) in order to gain attention and play “the patient role”
Low levels of which neurotransmitter are associated with the development of anxiety?
Gamma-aminobutyric acid (GABA)
___________ and ___________ are common side effects of lithium
Hypothyrodism and nephrogenic diabetes insipidus
“I took the bus and the train, the problem is it rained yesterday so I was never very good at scrabble and I suppose my favourite food is lasagne because the neighbour’s dog kept me up all night”
Knight’s move thinking
Normal thought: a - b - c - d - e - f - g
Knights move: a - c - g - l
“Running lately people purpose purple”
Word salad
“I tied the rope soap the slope nope”
Clanging
“I like to play games because the river is flowing down a mountain.” (fast paced speech)
Flight of ideas
Normal thought: a - b - c - d - e - f - g
Flight of ideas: abcdefghijklmnop
T or F: Visual hallucinations is a first-rank symptom of schizophrenia
Visual hallucinations more associated with drug related problems
First rank symptoms:
A - Auditory hallucinations –> 2nd and 3rd person
B - Broadcasting of thoughts, withdrawal, insertion
C - Controlled emotions and actions, passive impulsivity phenomena
D - Delusional perceptions
Clozapine side effects
CLOZAPINE
C- Consitipation
Lo- Lowered Seizure Threshold
Z- Zzzzzz- sedation
A- Agranulocytosis
P- Phat- weight gain, dyslipidaemia, diabetogenic
I- Increased salivation
N- Neutropaenia
E- ECG- you need one when you start because it can cause cardiomyopathy
Which type of amnesia is seen as a side effect of ECT?
RECT
(R)etrograde amnesia in (ECT)
The tyramine cheese reaction is a classic side effect of…
MAOI (monoamine oxidase inhibitor)
_________ and _________ should never be combined as there is a risk of serotonin syndrome
SSRIs and MAOIs should never be combined as there is a risk of serotonin syndrome
Lithium blood level should ‘normally’ be checked every…
Lithium blood level should ‘normally’ be checked every 3 months
after a change in dose, lithium levels should be taken…
A week later and weekly until the levels are stable.
When on lithium, thyroid and renal function should be checked…
Every 6 months
Outline the 5 stages of grief
Denial
Anger
Bargaining
Depression
Acceptance
When does delayed grief occur?
Said to occur when more than 2 weeks passes before grieving begins
When does prolonged grief occur?
Difficult to define. Normal grief reactions may take up to and beyond 12 months
What does the following image show?
Acute dystonia - torticollis
What does the following image show?
Oculogyric crisis - involuntary upward deviation of both eyes due to spasms and increased tone in the extraocular muscles.
Define akathisia
Inability to remain still
Define tardive dyskinesia
Involuntary movements of the face and jaw
Tx for acute dystonia due to antipsychotics
Procyclidine
There are specific warnings when antipsychotics are used in elderly patients due to..
Increased risk of VTE and stroke
Which drug causes antimuscarinic side effects?
Typical antipsychotics
Why do typical antipsychotics cause raised prolactin?
Due to inhibition of the dopaminergic tuberoinfundibular pathway
Typical/atypical antipsychotic cause impaired glucose tolerance
Typical
Typical/atypical antipsychotic cause neuroleptic malignant syndrome
Typical
Typical/atypical antipsychotic cause reduced seizure threshold
Both (greater with atypicals)
Typical/atypical antipsychotic cause reduced seizure threshold
Prolonged QT interval (particularly haloperidol)
What is the function of the mesolimbic pathway?
Reward - transmits dopamine from the ventral tegmental area (VTA) to the ventral striatum
The ventral tegmental area is located in the _________ and the ventral striatum is located in the _________ and includes both the _________ _________ and _________ _________
The ventral tegmental area is located in the midbrain and the ventral striatum is located in the forebrain and includes both the nucleus accumbens and olfactory tubercle
What is the function of the mesocortical pathway?
Involved in cognition and emotion - transmits dopamine from the ventral tegmental area to the prefrontal cortex
What is the function of the nigrostriatal pathway?
Regulation of movement - transmits dopamine from the substantia nigra pars compacta to the caudate nucleus and putamen
The substantia nigra pars compacta (SNc) is located in the ________. The caudate nucleus and putamen are located in the ________ ________
The substantia nigra pars compacta (SNc) is located in the midbrain. The caudate nucleus and putamen are located in the dorsal striatum
What is the function of the tuberoinfundibular pathway?
Regulates secretion of pituitary gland hormones - transmits dopamine from the infundibular nucleus of the hypothalamus to the pituitary gland
Which dopamine pathway is involved in regulating prolactin?
Tuberoinfundibular pathway
Delusion that a famous person is in love with them, with the absence of other psychotic symptoms
De Clerambault’s syndrome
Delusion that a person closely related to the patient has been replaced by an impostor
Capgras syndrome
Delusion of identifying a familiar person in various people they encounter
De Frégoli syndrome
Delusion of sexual infidelity on the part of a sexual partner
Othello syndrome
Delusional parasitosis and describes the delusion of infestation
Ekbom syndrome
Which metabolic side effects are seen in antipsychotics?
Hyperlipidemia
Hypercholesterolemia
Hyperglycemia
Weight gain
Which SSRI is given with warfarin / heparin?
Avoidi SSRIs - consider mirtazapine aspirin
Which two drug classes can increase the risk of serotonin syndrome if combined with an SSRI?
Triptans
MOAIs
Give three protective factors against suicide
Family support
Having children at home
Religious belief
Tx for tardive dyskinesia
Tetrabenazine
Tx for akathisia
Propranolol
Mild symptoms of hypomania and depression for at least two years
Cyclothymia
Mood reactivity (mood brightens in response to positive events), increased appetite or weight gain, hypersomnia, leaden paralysis (heavy feeling in arms or legs), and a long-standing pattern of sensitivity to interpersonal rejection
Atypical depression
Disorganised speech in the form of ‘word salad’ is associated with…
Psychosis and mania
In OCD the patients normally have a good level of insight into their condition and understand that if they did not perform the acts their obsessive though would not come true. However, they still get the urge to perform them anyway, just to put their mind at ease.
This lack of insight into the condition she has may indicate that there is a delusional element to her symptoms and this may not be an obsessive-compulsive disorder and may have some form of psychosis.
What are the three core symptoms of depression?
anhedonia, anergia or low mood
An atypical symptom is one that is unusual in depressive patients and may include..
Increased appetite and hypersomnia
Which two questions screen for depression?
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
Which assessments tools are used to assess the degree of depression?
Hospital Anxiety and Depression (HAD) scale:
0-7 normal, 8-10 borderline, 11+ case
Patient Health Questionnaire (PHQ-9):
< 16:: less severe depression
≥ 16: severe depression
Major Depressive Disorder (MDD) DSM-5 Criteria
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Which scoring system is used to assess the severity of withdrawal?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale
Which medication causes nephrolithiasis?
Long-term lithium use
It is extremely important in patients who take clozapine to exclude __________ if they develop infections
Neutropaenia
Schizophrenia vs schizotypal personality disorder
Schizotypal = better connection with reality
Patients are more open to the idea that their perceptions are distorted. Their abnormal thoughts are generally less frequent, and less intense. Sperstitions or magical thinking, rather than fixed delusions
Another name for Hypochondriasis
Illness anxiety disorder
Factitious vs malingering
Factitious/Munchausen’s = Feign symptoms (to play patient)
Malingering = Material gain
OCD vs OCPD
OCD: Distressing to act
OCPD: Pleasurable to act
The only exception to diagnose a PD before the age of 18 is..
Borderline personality disorder IF there is evidence the patient has fully undergone puberty
List atypical antipsychotics
“Cats Often Roam Quietly, Awaiting Ameow”
Clozapine
Olanzapine
Risperidone
Quetiapine
Amisulpride
Aripiprazole
In OCD, if treatment with SSRI is effective then continue for at least ____________ to prevent relapse and allow time for improvemet
12 months
Tangentiality vs Derailment
Tangentiality: A tangent goes off forever in another direction
Derailment: A derailed train goes off the track after a little while and needs to be nudged back on
What does the following ECG show?
Hypokalaemia
What ABG finding would you expect in bulimia?
Metabolic alkalosis - may see low chloride due to loss of HCL from vomiting
A 17-year-old patient presents to A&E complaining of a tight feeling in their chest, shortness of breath and some tingling in their fingers and around their mouth. They have no significant past medical history and are not on any regular medication. An ABG is performed on the patient (who is not currently receiving any oxygen therapy)
An ABG is performed and reveals the following:
PaO2: 14 (11 – 13 kPa) || 105 mmHg (82.5 – 97.5 mmHg)
pH: 7.49 (7.35 – 7.45)
PaCO2: 3.6 (4.7 – 6.0 kPa) || 27 mmHg (35.2 – 45 mmHg)
HCO3–: 24 (22 – 26 mEq/L)
What is the diagnosis?
Respiratory alkalosis (no compensation cause HCO3 is not low) - due to panic attack/anxiety
What should be monitored when initiating an SNRI?
BP
If clozapine doses are missed for more than 48 hours, you will need to restart it..
Slowly
If clozapine doses are missed for more than 72 hours, you will need to restart it..
Slowly +may also require more frequent blood tests for a short period
If clozapine doses are missed for less than 48 hours, you will need to restart it..
Start again as soon as you remember
Unless it is almost time for your next dose, then go on as
before. Do not try to catch up by taking two or more doses at
once as you may get more side-effects
Benzodiazipines vs Barbiturates
Barbidurates increase duration of chloride channels & Frendodiazepines increase frequency of chloride channels
How to withdraw benzodiazepine?
Switch patients to the equivalent dose of diazepam
Reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
Time needed for withdrawal can vary from 4 weeks to a year or more
Which drug can cause anterograde amnesia?
Benzodiazepine
What is a contraindication for ECT?
Raised intracranial pressure
Antidepressants should be reduced/stopped/switched to another drug when a patient is about to commence ECT treatment
Reduced
Switching drugs or increasing dose makes it hard to know if the ECT is working or if a decrease in symptoms is due to the change in in medications
When is Clozapine initiated?
Two other antipsychotics must have been trialled before due to its large side effect profile
Mirtazapine belongs to the class of drugs known as ..
Noradrenergic and specific serotonergic antidepressants (NaSSAs)
Dizziness, electric shock sensations and anxiety are symptoms of..
SSRI discontinuation syndrome
Short term side-effects for ECT
“He Should Never Miss Cardio”
Headache
Short-term memory impairment
Nausea
Memory loss of events prior to ECT
Cardiac arrhythmia
Capgras vs Fregoli
“Capgras Creates Clones; Fregoli Fashions Familiar Faces”
Capgras - Delusional belief that a person or people have been replaced by identical impostors or duplicates
Fregoli - Delusional belief that different people are actually the same person in disguise
Schizoaffective VS Schizophrenia/Schizotypal disorders
Schizophrenia + bipolar characteristics (psychotic episodes, mania, or depression)
Factors associated with poor prognosis of SZ
“Fragile Grains Leave Pebbly Paths”
Family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant)
When checking lithium levels, the sample should be taken _________ post-dose
12 hours
After starting lithium, levels should be performed..
Weekly and after each dose change until concentrations are stable
After starting lithium, levels should be performed weekly and after each dose change until concentrations are stable. Once established, lithium blood level should ‘normally’ be checked every…
3 months
After a change in dose, lithium levels should be taken..
A week later and weekly until the levels are stable
When starting lithium, thyroid and renal function should be checked every..
6 months
_________ is the persistent belief in the presence of an underlying serious disease, e.g. cancer
Illness anxiety disorder (hypochondriasis)
Primary care referral if symptoms suggest hypomania
Routine referral to the community mental health team (CMHT)
Primary care referral if there are features of mania or severe depression
Urgent referral to the CMHT should be made
How often are lipids and weight monitored when starting antipsychotics?
At the start of therapy
At 3 months
Annually
How often are fasting blood glucose and prolactin monitored when starting antipsychotics?
At the start of therapy
At 6 months
Annually
Which class of drugs are Mirtazapine?
Noradrenergic and specific serotonergic antidepressants (NaSSAs)
666 rule for anti-depressants
Wait at least 6 weeks for it to take effect (before switching medication)
Continue for 6 months to stabilise and avoid relapse
Take at least 6 weeks for the washout period in order to avoid adverse effects
Antagonism of histamine receptors causes..
Drowsiness
Antagonism of adrenergic receptors causes..
Postural hypotension
Antagonism of muscarinic receptors causes..
Dry mouth
Blurred vision
Constipation
Urinary retention
Which tricyclic has a lower incidence of toxicity in overdose?
Lofepramine
Which tricyclics considered the most dangerous in overdose?
Amitriptyline and dosulepin (dothiepin)
Consider ________________- with initial onset of psychosis in the elderly to rule out organic causes (e.g. ________________)
Consider brain imaging (CT or even an MRI) with initial onset of psychosis in the elderly to rule out organic causes (e.g. a brain tumour, stroke or CNS infection)
Persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved
Charles-Bonnet syndrome
Sudden changes in his behaviour. Agitated, restless, confused, sweaty and not orientated to time, person or place
Widespread muscle rigidity, hyperreflexia, dilated pupils and flushed skin
Serotonin syndrome
Which prescribed medications can cause psychotic symptoms?
Corticosteroids
Which illicit drugs can cause psychotic symptoms?
Cannabis, phencyclidine
Factors associated with poor prognosis of SZ
Strong family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
A 45-year-old female complains of lower back pain, constipation, headaches, low mood, and difficulty concentrating.
Her presentation is likely due to which of the following medications?
Lithium = hyperparathyroidism and resultant hypercalcaemia
“Stones, bones, abdominal moans, and psychic groans”
When is clozapine started?
After trying two antipsychotics
Which anti-psychotic is most effective for dealing with negative symptoms of SZ?
Clozapine
Negative symptoms of SZ
Incongruity/blunting of affect
Anhedonia (inability to derive pleasure)
Alogia (poverty of speech)
Avolition (poor motivation)
Social withdrawal
Clozapine can present with symptoms of..
Infection: check FBC
First line investigation for patients who present of a new onset of palpitations with no clear cause?
24 or 48 hour holter monitor ECG
Memory for recent events is worsening. Struggling to manage her finances, remember words, and recognise objects
Amyloid plaques
Prevention and treatment of alcohol withdrawal is with..
Short acting benzodiazepines such as chlordiazepoxide (Librium) and oxazepam (latter if there is evidence of liver injury)
SSRI of choice in GAD
Setraline
GAD
Salbutamol
Theophylline
Corticosteroids
Antidepressants
Caffeine
Naloxone vs Neltrexone use
Naloxone =NoOverdone
Neltrexone = relapse
Lesions in mamillary bodies
Wernicke’s encephalopathy
Interactions between lithium, and __________ can cause renal impairment
Ibuprofen
Lithium should be stopped in the first/second/third trimester
First - due to risk of Ebstein’s abnormality
Give examples of TCAs
Amitriptyline, clomipramine and imipramine
A 50-year-old patient with a history of bipolar disorder presents with confusion, ataxia, and tremors. They have been on lithium therapy for the last 10 years.
What is the most appropriate initial management of this patient?
Discontinuation of lithium and supportive care
Enlarged ventricles and absent sulci seen on CT brain scan
Normal pressure hydrocephalus
Prominent U waves
Hypokalaemia - refeeding syndrome
Hyperintense temporal lobe lesions + increased lymphocytes in LP
Viral encephalitis
Symptoms of encephalitis but normal MRI
Autoimmune encephalitis
Tx for autoimmune encephalitis
Steroids and intravenous immunoglobulin
+/- Plasma exchange if not fully responding to above treatment
If no response within two weeks, immunosuppressant therapy with agents such as Rituximab and Cyclophosphamide
Agitation: second-generation antipsychotics eg Risperidone
Recurrent episodes of sudden onset anxiety. Shortness of breath, palpitations, and intense feelings of something bad about to happen (e.g. fear of dying). Patient feels well between episodes
Panic disorder
SSRIs licensed to treat panic disorder include..
Escitalopram, sertraline, citalopram, paroxetine and venlafaxine
Sudden onset anterograde amnesia, with repetitive questioning and a preserved level of consciousness
Transient global amnesia
Ix for TGA
CT or MRI to exclude stroke/brain abnormalities
EEG
Neuropsychological tests
Blood tests to exclude metabolic causes such as hypoglycemia or electrolyte imbalance
Ix for encephalitis
Full neurological examination
Bloods (low sodium)
CT and/or MRI
LP
Side effects of carbamazepine
CARBA MEAN
Confusion
Ataxia
Rashes
Blurred vision
Aplastic anaemia
Marrow (bone marrow) suppression
Eosinophilia
ADH release
Neutropenia
Grief reaction >6 months with impact on important areas of functioning, for example, taking care for oneself
Prolonged grief disorder
Positive symptoms of SZ
ABCD
Auditory Hallucinations
Broadcasting of Thoughts
Control Issues
Delusional Perception
Negative symptoms of SZ
Overlap with features of depressive disorders
Alogia
Anhedonia
Affective incongruity or blunting
Avolition
Acute tx for mania with agitation
Intramuscular neuroleptic or benzodiazepine, potential psychiatric admission
Acute tx for mania without agitation
Oral antipsychotic monotherapy (haloperidol, olanzapine, quetiapine, or risperidone). If one is unsuccessful an alternative should be tried
Lithium
ECT
Maintenance Tx for chronic BPD
Lithium (first line) or Valproate (second line), and psychotherapy
Side effect of memantine
Constipation
What are the most appropriate SSRI in breastfeeding?
Sertraline and paroxetine
Which medication is most likely to cause sexual dysfunction and constipation?
SSRI
The antipsychotics most commonly used in the treatment of manic episodes or mixed episodes in bipolar affective disorder..
Quetiapine, olanzapine, risperidone and haloperidol
Which electrolyte abnormality is associated with panic disorders?
Hypocalcaemia
Which electrolyte abnormality is associated with refeeding syndrome?
Low serum, magnesium and potassium
Tangentiality, loose associations, and neologisms
Formal thought disorder
Which parameter should be checked when started on Venlafaxine?
BP
Confusion, polyuria, polydipsia, coarse tremor, hyperreflexia
Lithium toxicity
Fatigue, constipation, weight gain, menorrhagia, bradycardia and hyporeflexia
Hypothyroidism
Drugs that cause lithium toxicity
NSAIDs, furosemide, thiazide diuretics, ACE inhibitors and some antidepressants
Metabolic alkalosis/acidosis is seen in anorexia
Acidosis
Who can take consent?
Every clinician - but they must be able to fully explain the
procedure and ideally should be able to carry it out
themselves (e.g. the FY1 on neurosurgery is NOT best
placed to take consent for endovascular aneurysm
repair)
Criteria for assessing capacity
- Understand information given
- Weigh risks and benefits of the specific decision
- Communicate their decision
- Retain the decision that they have made and communicated
- Apply that decision or be aware of how this may be applied
Which legal frameworks are used when assessing capacity?
Adults with Incapacity
MHS
Advanced statements
Guardianship requires assessment carried out by..
Two Medical professionals (usually GP and a senior psychiatrist) and a Mental Health Officer
T or F: Guardianship can be used to place an adult in a hospital or treatment facility against their will
False - if an adult does not comply with the decisions of their appointed Guardian, a Sheriff can issue a compliance order to enforce welfare decisions
Who can approve an emergency detention certificate? How long does it last?
Any doctor more senior than FY1. Where possible, a mental health officer should also agree to it. BUT can only be removed by a senior psychiatrist
Lasts for 72 hours
Who can approve a short term detention certificate? How long does it last?
Senior psychiatrist AND Mental Health Officer
Lasts up to 28 days
Who can approve a compulsory treatment order? How long does it last?
Senior psychiatrist and an MHO with the approval of a
special tribunal hearing
Reports from 2 independent doctors (2 AMPs or AMP+GP), a care plan and MHO report
Lasts for 6 months initially but can be applied for a year at a time if needed longer term
What is an advanced statement?
Written up by individuals while well and able to make capacitous decisions - outlines wishes and beliefs about treatment they may need
Who should sign off on an advanced statement?
By the individual and a health or social care worker if possible.
Recommended to be reviewed every 6-12 months
T or F: In British law, the patient’s biological mother can always provide consent. If parents are not married and the father is not named on the birth certificate then the father cannot consent
True
In order to have capacity, the person being examined must be able to demonstrate the following four abilities. What are they?
Understand, retain, use, and communicate the information/decision
With regards to the provision of contraceptives to patients under 16 years of age the Fraser Guidelines state that all the requirements should be fulfilled. What are they?
Some doctors use the term ___________ competency when referring to contraception and ___________ competency when referring to general issues of consent in children
Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children
Nurse holding power is only held up for…
Up to 3 hours
Policing powers is only held up for…
Up to 24 hours
T or F: An Emergency Detention does not authorise treatment
True
Gender incongruence of adolescence or adulthood cannot be assigned prior to…
Onset of puberty
Gender incongruence of adolescence or adulthood can be assigned after…
2 years
Masculinising hormone options
Injectables (weekly or bi-weekly)
Patches
Topical gels
Pellet
Undecanoate
Masculinising option for atrophy?
Estrogen vaginal cream
Masculinising option for clitoral enlargement?
Test. cream/DHT cream
Masculinising option for cessation of menses?
Progesterone - IUD, Nexplanaon, Depo
Risks of testosterone therapy
Feminising hormonal options
Oral
Injectables
Patches
Anti-androgens: Spironolactone
Risks of oestrogen therapy
Risks of spironolactone therapy
Increased urinary frequency
Hyperkalamia
Hypotension
Dehydration + renal insufficiency
Gendered health calculator/ equation
eGFR (15% reduction applied to ‘female’)
QT interval (longer if assigned female at birth or taking oestrogen)
CHA2DS2VASc (extra point applied to ‘female’)
Initia management in suspected ADHD
Watch and wait for ten weeks then refer
Drug treatment of ADHD in children
Only aged 5 years and above:
1st line: Methylphenidate (weight and height should be monitored every 6 months)
2nd line: Lisdexamfetamine
3rd line: Dexamfetamine if can’t tolerate side effects for Lisdexamfetamine
Drug treatment of ADHD in adults
1st line: Methylphenidate or lisdexamfetamine
Switch between these drugs if no benefit is seen after a trial of the other
All ADHD drugs are _________ and require __________
Cardiotoxic
Perform a baseline ECG before starting treatment, and refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity
Which medications reduce the risk of refeeding?
Thiamine and Forceval
Which medications correct electrolyte abnormalities during refeeding syndrome?
Oral supplementation using sandok, phosphate sandox and magnesium glycerophosphate
Which pharmacologic interventions are used in ASD?
SSRIs: repetitive stereotyped behaviour, anxiety, and aggression
Antipsychotics: reduce aggression and self-injury
Methylphenidate: ADHD
_________ (35%) and _________ (18%) are also commonly seen in children with ASD
ADHD and epilepsy
ASD is also associated with..
A higher head circumference to the brain volume ratio
Long, narrow face
Large ears
Large testicles after puberty
Hypermobile joints (particularly in the hands)
Fragile X syndrome
Fragile X syndrome is caused by a mutation in the..
FMR1
Mode of inheritance in fragile X
X-linked (unclear whether dominant or recessive)
Males are always affected
In females, if the mother is phenotypically normal, the affected child may have inherited the X chromosome from their mother, or it may result from a de novo (random) mutation
Elevated mood, hypertension, tachycardia and hyperthermia
Cocaine/ Methamphetamine/ Ecstasy
Elevated mood, hypertension, tachycardia and hyperthermia + hallucinations
LSD
Descreased HR and RR
Constricted pupil
Opioids - heroine
Drowsiness
Impaired memory
Slowed reflexes
Slowed motor skills
Conjunctival injection
Increased appetite
Paranoia and psychotic symptoms
Tachycardia
Dry mouth
Cannabis
Ix for BN
Urea & electrolytes - hypokalaemia
What is considered as severe AZ?
Less than 10 is scored on MMSE
Which medication can cause insomnia?
Corticosteroids
Ix for insomnia
Patient interview
Sleep diaries + actigraphy
When is Polysomnography indicated in insomnia?
OSA
Periodic limb movement disorder
When insomnia is poorly responsive to conventional treatment
Tx for insomnia
Sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc
Hypnotics if daytime impairment is severe (zopiclone, zolpidem and zaleplon): daytime sedation, poor motor coordination, cognitive impairment and related concerns about accidents and injuries
Diazepam is not recommended but can be useful if the insomnia is linked to daytime anxiety
Guidance on Tx for insomnia
Use the lowest effective dose for the shortest period possible
If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given
It is important to review after 2 weeks and consider referral for CBT
Electric shock sensation + restlessness
Discontinuation syndrome - SSRI
Circadian rhythm disturbance is a feature of ____________
Schizophrenia
Fluctuating cognitive decline
Dementia with Lewy bodies
Tangentiality, loose associations, and neologisms
Formal thought disorder
In lithium toxicity, regardless of whether they are symptomatic or not, levels of >4 would indicate..
Haemodialysis
Precipitated by dehydration or illness. The acute phase often presents with predominantly gastrointestinal symptoms and then neurological features of ataxia, tremor, confusion and nystagmus
Lithium toxicity
The reason for delayed presentation in a subdural haematoma is because it is lower/higher in pressure than the system that an extradural haematoma occurs in
The reason for delayed presentation in a subdural haematoma is because it is lower in pressure than the system that an extradural haematoma occurs in (low-pressure veins bleed more slowly than high-pressure arteries!)
Low-pressure veins bleed more slowly than high-pressure arteries!
Lesions in mamillary bodies
Wernicke’s encephalopathy
Which is the best investigation to confirm the diagnosis of bulimia nervosa?
Urea and electrolytes (U&Es)
Prolonged PR interval, widespread ST depression and T-wave flattening or inversion and prominent U waves
Hypokalaemia - bulimia nervosa
An overdose of which medication can cause prolonged QRS duration and QTc interval) and metabolic acidosis?
Tricyclic antidepressant (TCA)
Confusion, agitation, sweating, hypertension, tachycardia, myoclonus, hyperreflexia and clonus
Selective serotonin reuptake inhibitor (SSRI)
Nausea and vomiting, abdominal pain and fulminant hepatic failure
Paracetamol
pH: 7.48 (7.35-7.45)
PaO2: 15.4KPa (>10)
PaCO2: 2.9KPa (4.7-6.0)
HCO3: 22mmol/L (22-26)
Acute respiratory alkalosis secondary to hyperventilation
Panic attack
In patients with subdural haematoma, surgery is needed if there is..
Any focal neurology
If the patient is deteriorating
if there is a large haematoma
Raised intracranial pressure
Midline shift
What can be used to treat the somatic symptoms of generalised anxiety disorder?
Propranolol
Feelings of anxiety are short-lived and unrelated to long-standing worries
Panic disorder
Feelings of anxiety are constant, usually about multiple things
Generalised anxiety disorder (GAD)
Which type of delusion is seen in mania?
Grandiose delusions
Which type of delusion is seen in psychosis?
Persecutory/somatic delusions
Which type of delusion is seen in depression?
Nihilistic delusions
Which medication is most commonly associated with reducing the seizure threshold?
Ciprofloxacin and other quinolones (levofloxacin, ofloxacin, moxifloxacin, gatifloxacin and nalidixic acid)
Meds that lower seizure threshold
Antibiotics: Imipenem, penicillins, cephalosporins, metronidazole, isoniazid
Antipsychotics
Antidepressents: Bupropion, Tricyclics, Venlafaxine
Tramadol
Fentanyl
Ketamine
Lidocaine
Lithium
Antihistamines
What is Naltrexone used for?
Opiod antagonist for relapse prevention
What is Diazepam used for in alcohol detox?
Anxiolytic but can also be used in reducing regime in drug detox
Side effects of clozapine
Weight gain
Excessive salivation
Agranulocytosis
Neutropenia
Myocarditis
Arrhythmias
Lithium toxicity may be precipitated by..
Dehydration
Renal failure
Drugs: diuretics (especially thiazides), ACEi/ARBs, NSAIDs and metronidazole
Non-selective monoamine oxidase inhibitors
Tranylcypromine, phenelzine
When are non-selective monoamine oxidase inhibitors used?
Atypical depression (e.g. hyperphagia) and other psychiatric disorder
Adverse effects of non-selective monoamine oxidase inhibitors
Hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
Anticholinergic effects
Cotard syndrome is associated with…
Severe depression
Muscular rigidity, fever, altered mental status, and autonomic dysfunction (such as tachycardia and hypertension)
NMS
Seizures, arrhythmias, muscle twitching, and shivering
Serotonin syndrome
Tx Bulimia nervosa
Bulimia-nervosa-focused guided self-help for adults
Unacceptable, contraindicated, or ineffective after 4 weeks: CBT-ED
Children: FT-BN
Schizophrenic psychotic features are…
Persecutory delusions and auditory hallucinations
Carbamazepine is known to exhibit ___________, hence when patients start carbamazepine they may see a return of seizures after 3-4 weeks of treatment
Autoinduction
Adverse effects of Carbamazepine
P450 enzyme inducer
Dizziness and ataxia
Drowsiness
Headache
Visual disturbances (especially diplopia)
Steven-Johnson syndrome
Leucopenia and agranulocytosis
Hyponatraemia secondary to syndrome of inappropriate ADH secretion
Petechial rash overlying chest
Fat embolism
Coarse tremor
Central nervous system disturbance, which may include seizures, impaired coordination, and dysarthria
Cardiac arrhythmias
Visual disturbance
Lithium toxicity
Long-term atypical antipsychotics can lead to the development of…
Glucose dysregulation and diabetes
Not a first-rank symptom of schizophrenia
Visual hallucinations
Sodium valproate associated with…
Neural tube defects
_____________ often considered the least teratogenic of the older antiepileptics
Carbamazepine
___________ associated with cleft palate
Phenytoin
___________ dose may need to be increased in pregnancy
Lamotrigine
______ requires urea and electrolyte monitoring
SSRI
Patients will reach conclusions that do not logically follow on from the previous statement or argument; they are also known as non-sequiturs or faulty inferences
Illogicality
Words are inappropriately substituted; e.g. ‘I baked the cake in the dustbin, then I put the butter back in the dog’
Semantic paraphasia
Medical management of ADHD
Methylphenidate or amphetamine
These medicines have some activity in the frontal lobe, thus increasing executive function, attention, and reducing impulsivity
__________ is a common withdrawal symptom of mirtazapine
Headache
Drugs that cause SJS
Phenytoin
Carbamazepine
Salicylates
Sertraline
Imidazole antifungal agents
Nevirapine
Side effects of sodium valproate
V - VALPROATE:
A - Appetite increase –> weight gain
L - Liver failure
P - Pancreatitis
R - Reversible hair loss (alopecia)
O - Oedema
A - Ataxia
T - Teratogenic, tremor, thrombocytopaenia
E - Enzyme inhibitor (p450), encephalopathy (due to high ammonia)
Rigidity, hyperthermia, autonomic instability (hypotension, tachycardia) and altered mental status (confusion)
Neuroleptic malignant syndrome
Starting smoking, or smoking more, can reduce/increase clozapine levels
Stopping drinking can increase/reduce levels
Starting smoking, or smoking more, can reduce clozapine levels
Stopping drinking can also reduce levels
If a patient has had a previous overdose on methadone, then _______________ should be given. However, if both drugs are equally suitable, then _______________ should be prescribed first line
If a patient has had a previous overdose on methadone, then buprenorphine should be given. However, if both drugs are equally suitable, then methadone should be prescribed first line
Overdose + apnoeic = naloxone full dose/titrated
Overdose + NOT apnoeic = naloxone full dose/titrated
Overdose + apnoeic - naloxone full dose
Overdose + NOT apnoeic - naloxone titrated
Refeeding syndrome
Potassium
Magnesium
Phosphate
