Psych Flashcards
what are 6 features of ADHD?
very short attention span
quick moving from one activity to another
quickly losing interest in a task and not being able to persist with challenging tasks
constant moving or fidgeting
impulsive behaviour
disruptive or rule breaking
must be consistent across various settings and adversely affect person for at least 6 months
what is the diagnostic criteria for ADHD?
A persistent pattern (e.g., at least 6 months) of inattention symptoms and/or a combination of hyperactivity and impulsivity symptoms that is outside the limits of normal variation expected for age and level of intellectual development
what is the management of ADHD?
conservative - diet and exercise, food diary (causative links), self management strategies and organisation, parent training program
Medication - central nervous stimulants - methylphenidate (ritalin) [1st line] or lisdexamfetamine, dexamfetamine, atomoxetine
what monitoring needs to be done for those on medication for ADHD?
height and weight measurements as reduces appetite (especially in children)
cardiovascular effects - BP and HR
what are 6 common side effects of methylphenidate?
Decreased Appetite + Growth retardation
Headache
mood disturbance - agression, irritability, anxious, tense, depressed
insomnia
dry mouth
What are the 5 Ps of formulation?
Presenting
Predisposing
Precipitating
Perpetuating
Protective
what is psychological formulation?
the dynamic framework through which the connection between our individual characteristic, experiences and behaviours can be understood
What are the 4 types of risk?
risk to self
risk to others
risk from others
risk to property
what is a delusion?
Fixed false belief that is outside of cultural or religious norms
what is an overvalued idea?
Delusional idea but held with less conviction when challenged than a delusion - the patient might accept there is a possibility that it is not real.
What is the name of the delusional belief and it’s syndrome where you believe that someone important is in love with you?
erotomania
de clerambault’s syndrome
What is the name of the delusion and its syndrome that there are bugs crawling on you skin all the time?
Paracitosis
Ekbom’s syndrome
what is the name for a delusion shared by multiple people?
Folie à deux (or trois)
what is the name for a delusions where you think that someone you know has been replaced by an imposter?
Capgras syndrome
what is the name for a delusion where you think multiple people are actually a single person in disguise?
Fregoli’s syndrome
what is the name for a delusion where you think you have special powers, wealth, a mission, intelligence or identity?
Grandiose delusions
what is the name of delusions where you think there is something wrong with part or all of your body?
somatic delusions
what is the name of delusions where you think that unrelated occurrences in the external world have special significance to you in particular?
delusion of reference
what are delusions where you falsely think someone is out to get you?
Persecutory delusions
what are delusions where you feel guilty for something you haven’t done?
delusions of guilt
what is a delusional perception?
a true perception that a patient attributes false meaning to
what is the name and syndrome of a delusion where you believe your partner is cheating on you?
Delusion of jealousy
Othello syndrome
what is the name of the delusion where you believe you are dead or don’t exist?
nihilistic delusions
delires de negation
Cotards syndrome
what is the name of the delusions where you believe your thoughts and actions are being controlled by an external force?
delusion of passivity/control
what is a hallucination?
a sensory perception in the absence of external stimuli
what is a somatic hallucination?
when you believe you can feel your internal organs moving or you heart beating out of chest
what is an extracampine hallucination?
one that is not possible due to geography
e.g. hearing the kings voice talking to you in sheffield from buckingham palace
what is a hallucination as you’re falling asleep called?
hypnogogic
NORMAL
what is a hallucination as you’re waking up called?
hyponopompic hallucinations
NORMAL
what are pseudohallucinations?
vivid mental images that though they sound like hallucinations are not EXTERNAL to the patient ie they’re coming from within the patient’s own head
what are illusions?
special perceptual experiences in which information arising from “real” external stimuli leads to an incorrect perception
eg monsters under bed is actually pile of washing
what is the old diagnostic criteria for schizophrenia?
schneider’s first rank symptoms
what are schneider’s first rank symptoms of schizophrenia?
A - Auditory hallucinations (3rd person)
B - Broadcasting thoughts
C - Control delusions - thoughts (withdrawal, insertion, interruption) and actions controlled by someone else (passivity phenomenon)
D - Delusional perceptions
what are 5 risk factors for schizophrenia?
FHx
Black Caribbean ethnicity
Migration
Urban environment
Cannabis
what are the 3 features of psychosis?
hallucinations
delusions
disorganised thinking and speech
What are 6 presentations of BPD?
Intense emotions/emotional instability
Impulsive/risky behaviour
Low self esteem
Difficulty maintaining relationships
Anger, violence and aggression
Self harm, suicide attempts
what are the 3 main categories of personality disorders?
Type A - Odd and eccentric
Type B - emotional and erratic
Type C - anxious and fearful
what is avoidant personality disorder?
severe anxiety about rejection or disapproval and avoidance of social situations due to this
what is dependent personality disorder?
heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach. Fear being left to care for selves
what is obsessive compulsive personality disorder?
unrealistic expectations of how things should be done by themselves and others, and catastrophising about what will happen is these expectations are not met
what is paranoid personality disorder?
Hypersensitivity and an unforgiving attitude when insulted
difficulty in trusting or revealing personal information to others
what is schizoid personality disorder?
lack of interest or desire to form relationships with others and feelings that this is of no benefit to them
Few friends and like being alone
what is schizotypal personality disorder?
unusual beliefs thoughts and behaviours, as well as social anxiety that makes forming relationships difficult
what is borderline personality disorder?
fluctuating strong emotions and difficulties with identity and maintaining healthy relationships
what is histrionic personality disorder?
the need to be at the centre of attention and having to perform for others to maintain that attention
Rapidly shifting shallow emotions
what is narcissistic personality disorder?
feelings that they are special and need others to recognise this or else they get upset. They put themselves first.
what is antisocial personality disorder?
reckless and harmful behaviour with lack of concern for consequences or the impact of their behaviour on others
what are the 6 domains of personality disorder traits recognised in the ICD-11?
Negative affectivity
Detachment (from society)
Dissocialisation
Disinhibition
Anankastia - preoccupation with orderliness and control
Borderline pattern
What is the management for personality disorders?
Dialectic behavioural therapy (DBT) and CBT
No medical (though there may be other co-existing psychiatric problems that can be dealt with medically)
what are 6 risk factors for personality disorders?
Hx of abuse
FHx of schizophrenia
Negative parental interactions
emotional/disruptice disorder in childhood
ethnicity - White
other psychiatric diagnosis
what are 2 positive and 5 negative presentations of psychosis?
+ Hallucinations
+ Delusions
- Affect Flattening (lack of spontaneity or reactiveness)
- Avolition (lack of drive)
- Ahedonia
- Attention Deficit
- Impoverished speech or language
What is the prodromal period?
a period of subclinical signs and symptoms preceding the onset of psychosis that can last from a few days to around 18 months
what are 6 features of the prodromal period?
transient, low intensity psychotic symptoms
Reduced interest in daily activities
Problems with mood, sleep, memory, concentration, affect, motivation
Anxiety, irritability or depressive features
Incoherent or illogical speech
Positive family history
what are 8 risk factors for psychosis?
Genetics
Stressful life event
childhood adversity
Ethnicity - increase in south asian and african populations
Urban living
migration
cannabis and other substance use (including high dose corticosteroids)
Early life factors - maternal stress, nutritional deficiency, IUGR
what is the treatment for psychosis and schizophrenia?
Refer to early intervention in psychosis team/ crisis resolution team
Bio - Antipsychotics
psycho - CBT
Social - Family intervention, Care plan (crisis plan, advanced statement, key contacts), inform DVLA and don’t drive during episodes
Trial of 2x other antipsychotics for 6 weeks
Then Clozapine
What are 12 first generation antipsychotics?
Benperidol
Haloperidol
Chlorpromazine
Levomepromazine
Pericyazine
Perphenazine
Prochlorperazine
Promazine
Trifluperazine
Flupentixol
Zuclopenthixol
Pimozide
Sulpiride
what is the MOA of typical antipsychotics?
Dopamine D2 receptor antagonists
What are 7 2nd generation (atypical) antipsychotics?
Olanzapine
Quetiapine
Clozapine - when 2 other anti-psychotics have failed
Paliperidone
Risperidone
Amisulpride
Aripirazole
What are typical antipsychotic side effects?
Extrapyramidal - abnormal movements and pseudoparkinsonisms, restlessness, tardive dyskinesia
Increased risk of VTE and stroke
Antimuscarinic side effects - dry mouth, blurred vision, urinary retention, constipation
Sedation
Raised prolactin - galactorrhoea
Diabetic type effects - Weight Gain, dyslipidaemia, impaired glucose tolerance
Neurological -reduced seizure threshold neuroleptic malignant syndrome
Cardiac - QT prolongation (Haloperidol)
what antipsychotic side effect is most associated with atypicals?
Weight gain and metabolic syndrome
what typical antipsychotic can cause QT prolongation?
Haloperidol
What are the 3 core symptoms of autism ?
social interaction problems
communication problems
behavioural problems
what are 6 features of social interaction deficits in autism?
lack of eye contact
delay in smiling
avoids physical contact
unable to read non-verbal cues
difficulty establishing friendships
not displaying a desire to share attention
what are 4 features of communication deficits in autism?
Delay, absence or regression in language development
lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interests
Difficulty with imaginative or imitative behaviour
repetitive use of words or phrases
What are 6 behavioural deficit features in autism?
Greater interest in objects, numbers or patterns than people
Stereotypical repetitive movements - self stimulating repetitive movements to comfort self
Intensive and deep interests that are persistent and rigid
repetitive behaviours and fixed routines
Anxiety and distress with experiences that are outside their normal routine
Extremely restricted food preferences
What are 5 psychiatric emergencies?
Suicide, harm to self, harm to others
Substance intoxication and withdrawal
Overdose of psychoactive drug
Neuroleptic malignancy syndrome
Serotonin syndrome
what is neuroleptic malignant syndrome?
High fever, muscle stiffness, altered mental status and autonomic dysfunction (BP swings, excessive sweating, excessive salavating)
Caused by antipsychotics
what is seen on bloods in neuroleptic malignant syndrome?
Raised creatinine kinase
Raised WCC
what is serotonin syndrome and symptoms?
Neuromuscular excitation - Rigidity, hyperreflexia, myoclonus
Autonomic system excitation - increased HR + BP, hyperthermia, diaphoresis, dilated pupils, headache, diarrhoea and vomiting
Altered mental status and seizures
caused by too much serotonin => can lead to death
what is the MOA of alcohol?
stimulates GABA to have relaxing effect on brain.
Allso inhibits glutamate receptors causing further relaxation
Long term - GABA becomes down regulated and glutamate becomes upregulated
Units of alcohol =
(Volume (ml) X Percentage (%))/1000
what is classed as binge drinking?
> 6 units for women
> 8 units for men
in a single session
what are 9 complications of alcohol excess?
Alcohol related liver disease
Cirrhosis
Alcohol dependence and withdrawal
Wernicke-korsakoff syndrome
Pancreatitis
Alcoholic cardiomyopathy
Alcoholic myopathy - proximal muscle wasting and weakness
Increased risk of CVD
Increased risk of cancer - Breast, mouth, throat
What are 6 symptoms of alcohol withdrawal?
Tremors
sweating
tachycardia
GI disturbance
Anxiety and irritability
Headache
what may be seen on blood results with alcohol excess?
raised MCV
raised ALT and AST
AST:ALT ratio >1.5
raised GGT
what is alcohol detoxification treatment?
water
vitamins - B1 (IM if preventative or IV if symptomatic)
Food - high protein, high calorie
Benzos - chlordiazepoxide 5-20mg QDS
what medications are used for relapse prevention in alcoholics?
Disulphram - become unwell if drink
Naltrexone - opiate blocker that helps cravins
Acamprisate - helps with craving
what is the advise for an alcoholic if they want to cut down themselves?
safe to cut down 10%every day for 10 days
what are the serious side effects of alcohol withdrawal?
24-48 hours
Grandmal seizures
Wernicke’s encephalopathy
Delerium tremens
confusional state
what is the presentation of delirium tremens?
acute confusion
severe agitation
delusions and hallucinations
tremor
tachycardia
hypertension
hyperthermia
ataxia
arrhythmias
what causes Wernicke’s encephalopathy?
B1 (thiamine) deficiency
what are 4 symptoms of Wernicke’s encephalopathy?
Ataxia
Confusional state
Eye signs - palsy of lateral rectus or internuclear opthamloplegia, pupillary changes
What are 5 signs of opiate withdrawal?
running - eyes and nose
GI cramping and upset
Deep muscular pain into bones
Goosebumps
What are 2 opiate substitution options?
Methadone - green liquid, once a day
Buprenorphine - partial agonist
what is the antidote to opiates?
Naloxone
what medication can be used for relapse prevention in opiate addiction?
Naltrexone - take every day - if take normal dose of heroine then it’s blocked
what questionnaire can be used to screen for harmful alcohol use?
Alcohol use disorders identification test - AUDIT
What are the questions in the CAGE questionaire?
Ever thought of cutting back?
Annoyed when anyone else tells you to cut back?
Ever felt guilty abut drinking?
Eye opener?
what are the 7 different types of anxiety disorders?
Generalised anxiety disorder
Panic disorder
PTSD
OCD
Social anxiety
Phobia
Acute stress disorder
what is the diagnostic criteria for Generalised Anxiety Disorder?
Excessive anxiety and worry about a variety of topics, events or activities for >6 months
3 of the following:
- Edginess/restlessness
- Fatigue
- Impaired concentration/mind going black
- Irritability
- Difficulty sleeping
- Increased muscle aches or soreness
what is the diagnostic criteria for panic disorder?
presence of reoccurring unforeseen panic attacks followed by at least one month of persistent worry about having another panic attack and it’s consequences
Need to have at least 2 unexpected panic attacks
What is the management of generalised anxiety disorder?
1 - education and monitoring
2 - Self-help, psychoeducational groups
3 - CBT or SSRIs (1 - sertraline)
4 - refer to psychiatry
what are 4 medications that can induce anxiety?
Salbutamol
Theophylline
Beta blockers
St johns wart
what questionnaire can assess the severity of anxiety?
GAD-7 - Generalised anxiety disorder questionnaire
5-7 = mild anxiety
10-14 = moderate anxiety
15-21 = severe anxiety
what are the withdrawal symptoms from SSRIs?
Dizziness, numbness and tingling, GI disturbance, headache, sweating, anxiety and sleep disturbance
what is phobia?
intense fear of specific objects or situations
what are 3 risk factors for phobia?
somatisation disorder
anxiety disorders
mood disorders
what is the treatment for phobia?
Education, CBT, exposure therapy
What are 4 manifestations of PTSD?
Intrusion symptoms (flashbacks, reactivity, dreams)
Avoidance symptoms
Negative alterations in cognition and mood
Alterations in arousal and reactivity (hyper-vigilance, exaggerated startle response, irritability)
> 1 month of symptoms
what is the management of PTSD?
1 - trauma focused CBT
1 - eye movement desensitisation and reprocessing
2 - other psychological therapy
2 - pharmacological management (SSRIs or venlafaxine)
what is a screening tool that can be used for PTSD?
Trauma screening questionnaire
what is the presentation of OCD?
Obsessive themes
- contamination fears
- harm related obsessions
- unwanted sexual thoughts
- religious/moral obsessions
- perfectionism/symmetry
Compulsive behaviours
- cleaning/washing
- checking rituals
- counting/repeating rituals
- ordering/arranging behaviours
- mental neutralising strategies
what scale can be used to grade OCD severity?
Yale-Brown obsessive compulsive scale
what is the management of OCD?
1 - CBT, exposure and response prevention
2 - Pharmacotherapy - 1 - SSRIs or 2 - clomipramine
combine if severe
what is somatisation disorder?
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
what conditions can ECT treat?
severe depression - if:
Preferred by patients
Need rapid response
Refractory to medication
Severe/long lasting mania
Catatonia
what is ECT?
electroconvulsive therapy
what is an abosolute contraindication to ECT?
Raised ICP
what are 5 short term side effects of ECT?
Headache
Nausea
Short term memory impairment
Cardiac arrhythmia
what is 1 long term side effect of ECT?
Reports of impaired memory
what are hypnotics?
medications used to treat insomnia
what medications are hypnotics?
benzodiazepines
zolpidem and zopiclone - non-benzo hypnotics
Clomethiazole
antihistamines
which hypnotic benzos have a hangover effect that can cause drowsiness the next day?
nitrazepam
flurazepam
which 3 hypnotic benzos are shorter acting so cause no hangover?
Loprazolam
lormetazepam
temazepam
what is bipolar I?
manic episode of abnormal persistent, elevated, expansive or irritable mood with abnormally and persistently increased energy or activity lasting for at least one week.
Also depression
what is bipolar II?
current or past hypomanic episode and current or past major depressive episode.
Hypomania presents similarly to mania but causes less impairment and lasts at least 4 days
what is the management of acute mania in bipolar?
Antipsychotics - olanzapine, quetiapine, risperidone, haloperidol
Lithium, sodium valproate
what is the management of an acute depressive episode in bipolar?
Olanzapine PLUS fluoxetine
antipsychotics - olanzapine or quetiapine
lamotrigine
What is the chronic treatment of Bipolar?
1 - mood stabiliser (lithium) or antipsychotic (halporidol, olanzapine, quetiapine, risperidone, valporate***)
*not women of childbearing age
what are the monitoring requirements for lithium and range?
has narrow therapeutic index so levels must be monitored regularly (3-6 monthly) - should be between 0.4-1mmol/L
what are 2 screening questions for depression?
during the last month have you often been bothered by feeling down, depressed or hopeless?
Do you have little interest or pleasure in doing things?
what are 2 core symptoms of depression?
Persistent Low mood
Anergia (low energy)
Anhedonia (loss of enjoyment)
for 2 weeks+
what are 7 cognitive symptoms of depression?
Processing
- reduced concentration
- reduced memory
- reduced processing speed
Thought
- self confidence reduced
- ideas of guilt and worthlessness
- thinking it will never get better
- Suicidal ideation
what are 5 biological symptoms of depression?
sleep disturbance
changes in appetite and weight
loss of libido
Slow/fast movements - psychomotor agitation/retardation
loss of energy
what is the criteria for a diagnosis of depression?
1 core symptom + 4 other symptoms
> 2 weeks
+ clinically significant distress and not attributable to substances or other conditions
what are 4 medical conditions that are differentials for depression?
Hypothyroidism
Neurological disorders - parkinsons, MS
Nutritional deficiencies - B12, folate, vitamin D
Endocrine disorders - Cushings, Addisons
what are 4 psychiatric differentials for depression?
Bipolar
Dysthymia - persistent depressive disorder
Adjustment disorder with depressed mood
Anxiety
what are 3 medications that can cause depression?
Beta blockers
Corticosteroids
isotretinoin
what are 6 symptoms of antidepressant withdrawal?
Unsteadiness, vertigo, dizziness
Altered sensations
Restlessness/agitation
Problems sleeping
Abdo symptoms
Palpitations, tiredness, Headaches, muscle and joint aches, sweating
what is the management of less severe depression? 11
PHQ-9 <16
Guided self help
Group CBT
Group behavioural activation
Individual CBT/BA
group exercise
group mindfulness and meditation
Interpersonal psychotherapy
SSRIs
counseling
short term psychodynamic psychotherapy (STPP)
what is the management of severe depression?
PHQ-9 >16 inclusive
1 - CBT + SSRIs/SNRIs
individual behavioural activation
individual problem solving
counseling
Short term psychodynamic therapy
guided self help
group exercise
what is the last line medication for depression?
vortioxetine - used if 2 prev antidepressants have not been responded to
what is the 1st line SSRI in children?
Fluoxetine 10-20g OD
what antidepressants should be avoided in warfarin use and what is the alternative?
SSRIs
Mirtazapine is alternative
what is the max dose of citalopram in adults?
40mg
what monitoring is needed with SSRIs?
Review after 2 weeks or 1 week if <30 years
continue treatment for at least 6 months post remission
what are 2 beneficial associated features of mirtazapine?
Drowsiness
Increased appetite
what antidepressant is 1st line post MI?
Sertraline - 50mg OD
what are the 2 2nd line antidepressants in children?
Sertraline
Citalopram
what is the 1st line management of moderate-severe depression in childre?
CBT, non-directive supportive therapy, interpersonal therapy and family therapy
what is cyclothymia?
A persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify other diagnosis
what are 5 medications that interact with SSRIs?
NSAIDs - gastroprotection needed
Warfarin/heparin
Aspirin
Triptans
Monoamine oxidase inhibitors - risk of serotonin syndrome
what antidepressant has highest risk of antidepressant discontinuation syndrome?
paroxetine
what are 2 SSRIs that causes long Q-T?
Citalopram and escitalopram
what are 2 of the most common causes of general cognitive impairement?
Down’s syndrome
Foetal Alcohol syndrome
what are 6 specific learning difficulties without generalised cognitive impairement?
Dyslexia
Dyscalculia
ADHD
Specific language impairment
Central auditory processing disorder
Dyspraxia
What are 11 genetic disorders that can cause cognitive impairment?
Down’s syndrome
Fragile X
Prader-willi syndrome
Angelman’s syndrome
15q11 duplication syndromes
William’s syndrome
Rett’s syndrome
Turner’s syndrome
Tuberous sclerosis
DiGeorge syndrome
16p11.2 deletion syndrome
what are 5 intra-uterine infections or drugs that can cause cognitive impairement?
Cytomegalovirus
Toxoplasmosis
Rubella
Foetal alcohol syndrome
Teratogenic drugs
What are 2 perinatal events that can cause cognitive impairmenent?
Extreme prematurity
Perinatal hypoxia
What are 6 CNS disorders that can cause cognitive impairment?
Bacteria meningitis
encephalitis
tumour
trauma
hypoxia
Seizures
what is the definition of a cognitive impairment?
IQ <70
what is schizoaffective disorder?
a combination of mood and psychotic symptoms lasting at least one month. Bipolar type has manic symptoms and can also have depressive ones. Depressive type has psychosis and depressive symptoms only.
what section of the mental health act allows police to enter private property and take someone to a place of safety for assessment?
section 135
what section of the mental health act allows police to pick someone up of the street and take them to a place of safety for assessment?
section 136
only for 24 hours before mental health act assessment is needed
How long can you detain someone under section 135/6 of the MHA?
25 hours (up to 36 if still waiting for assessment)
what sections of the MHA allow doctors or nurses to detain a patient?
section 5 (2) - doctors for 72 hours
Section 5 (4) - nurses for 6 hours
How long can you detain someone for under section 2 of the MHA?
28 days
How long can you detain someone for under section 3 of the MHA?
6 months with further renewals
AMHP with 2 doctors
what section of the mental health act allows patients to go on leave?
section 17
what are the 5 core principles of the mental capacity act?
1 - assume capacity until proven otherwise
2 - Use all means necessary to allow people to make their own decisions
3 - people are allowed to make unwise decisions
4 - all actions must be in the patients best interest
5 - treat in the least restrictive way possible
What is CBT?
focuses on what you believe and how you think and tests you on these behaviours in order to develop the ability to self test thoughts and change behaviours
what are 7 risk factors for suicide?
Prev Hx of suicide/mental illness
Chronic illness
criminal/legal/financial problems
Substance use
impulsive/aggressive tendencies
Fhx
isolation
what is anorexia nervosa?
an eating disorder characterised by restriction of calorific intake leading to low body weight, an intense fear of gaining weight and body image disturbances
what are 6 features of anorexia nervosa?
Weight loss
Amenorrhoea
Lanugo hair
Hypotension
Hypothermia
Mood changes - anxiety and depression
what are 3 cardiac complications of anorexia nervosa?
Arrythmia
Cardiac atrophy
sudden cardiac death
what electrolyte deficiencies does prolonged starvation cause?
hypokalaemia - especially intracellular
Hypophosphatemia
Hypomagnesaemia
what is the management of anorexia nervosa?
CBT-ED
Anorexia focused family therapy in children
Slow refeeding
magnesium, potassium, phosphate and glucose monitoring
Fluid balance monitoring
ECG monitoring
supplementation - B vitamins, thiamine
what is classed as mild, moderate, severe and extreme anorexia nervosa by BMI?
mild >17
moderate 16-17
severe 15-16
extreme <15
what are the 2 types of schizoaffective disorder?
depressive type - more common in older patients
bipolar type - more common in younger people
what are the 2 types of schizoaffective disorder?
depressive type - more common in older patients
bipolar type - more common in younger people
what questionnaire can be used to screen for eating disorders?
SOFF
Sick - every make self sick because feel uncomfortably full
Control - wory lost control over how much eaten
One stone - more than 1 stone loss in a month
Fat - do you think you are fat
Food - would you say food dominates your life
what are the 7 most common physical signs of bulimia nervosa?
Alkalosis on blood gas
Hypokalaemia
Parotid hypertrophy
dental erosion
Russell’s sign - scaring on dorsum of hands from teeth scraping when inserted into mouth
Mouth ulcers
GORD
What is the management of bulimia nervosa?
1st line - Bulimia focused self help (4 weeks)
2nd - Individual CBT-ED
Children - Bulimia focused family therapy
3 - SSRIs (fluoxetine 20mg OD)
What are the 3 things necessary for capacity?
ability to understand relevant information
ability to retain information
ability to weigh up information and communicate a decision
What is the therapeutic range of lithium?
0.4-1.0 mmol/L
what is dysthymia?
A chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate, or mild recurrent depressive disorder
what is hypomania?
persistent mild elevation of mood, increased energy and activity but does not affect function and no psychotic symptoms
4-7 days
what is mania?
elevated mood with increased energy, overactivity, pressure of speech and decreased need to sleep. Attention cannot be sustained, grandiosity, loss of normal social inhibitions and alteration of function
lasting 1 week+
may have psychotic symptoms
what is delirium?
disturbance of attention, orientation and awareness that develops within a short period of time typically presenting as significant confusion or global neurocognitive impairment with transient symptoms that may fluctuate
what are the causes of delerium? (mneumonic)
PINCH ME
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment
what is classed as a mild learning disability?
IQ 50-69
Some learning difficulties at school but can generally work and function independently
what is classed as a moderate learning disability?
IQ 35-49
marked developmental delays in childhood but can learn some level of independence will probably need support in the community
what is classed as a severe learning disability?
IQ 20-34
likely to need continuous support in all things
What is classed as a profound learning disability?
IQ <20
severe limitation in self-care, continence, communication and mobility
what is the 4 essential diagnostic criteria for schizophrenia?
At least one of :
- persistent delusions
- persistent hallucinations
- disorganised thinking or speech
- Experiences of influence, passivity or control
must be experienced for at least a month
what is the 3 none essential diagnostic criteria of schizophrenia?
Negative symptoms
Grossly disorganised behaviour
Psychomotor disturbances
what are 5 negative symptoms of schizophrenia?
affect flattening
alogia (poverty of speech)
avolition (lack of motivation)
anhedonia
social withdrawal
what are 5 poor prognostic factors for schizophrenia?
strong FHx
Gradual onset
low IQ
prodromal phase
lack of obvious precipitant
what scale can be used for depression questionnaire in elderly?
Geriatric depression scale questionnaire
where in the body are the most serotonin receptors?
GI tract
what depression scale can be used in patients with dementia?
cornell depression scale
what electrolyte disturbance can SSRIs cause?
hyponatraemia
what is the second line management of panic disorder?
if SSRIs/SNRIs ineffective after 12 weeks try imipramine or clomipramine
what questionnaire can be used in depression?
PHQ-9
what is a less severe depression score on PHQ-9?
<16
what is a more severe depression score on PHQ-9?
> 16 inclusive
what are 6 biological features of anorexia nervosa?
Most things low but
Gs and Cs raised
Growth hormone
Glucose
Salivary Glands
Cortisol
Cholesterol
Carotinaemia (oranging of skin)
when do alcohol withdraw symptoms start?
6-12 hours after last drink
when can hallucinations start in alcohol withdrawal?
12-24 hours
when is the peak incidence of seizure in alcohol withdrawal?
36 hours
when is the peak incidence of delirium tremens?
48-72 hours
What are the symptoms of delirium tremens?
coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
what medication is given first line in management of alcohol withdrawal?
1- Chlordiazepoxide
2 - lorazepam in liver cirrhosis as chlordiazepoxide in oxidised in liver
what medication is given to prevent wernikes in people with alcohol withdrawl?
Thiamine - Vitamin B1 => Pabrinex
what are 5 side effects of ECT?
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
what is a contraindication to ECT?
raised ICP
what is an obsession?
an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind
what is a compulsion?
repetitive behaviours or mental acts that the person feels driven to perform
which SSRI has a long half life?
fluoxetine
fully withdraw fluoxetine and wait a few days when switching antidepressants
when is gastroprotection needed with SSRI?
if use NSAIDs - add PPI
what medications when taken with SSRIs increase risk of serotonin syndrome?
Triptans
St john’s wart
Monoamine oxidase inhibitors
amphetamines and ecstasy
what is the management of serotonin syndrome?
Supportive
Benzodiazepines
If severe - Serotonin antagonists – cyproheptadine, chlorpromazine
what is the management of neuroleptic malignant syndrome?
supportive
Dantrolene in severe cases
what are 9 side effects of lithium?
Nausea, vomiting, diarrhoea
Fine tremor
Nephrotoxicity secondary to diabetes insipidus
Thyroid enlargement => hypothyroidism
ECG - T wave flattening/inversion
weight gain and idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism => raised calcium - bones, stones, groans, moans
when should lithium levels be taken?
12 hours post dose
how often should lithium levels be monitored?
weekly until at stable dose
then 3 monthly once stable
what 2 bloods should be done every 6 months in patients on lithium?
TFTs
U+E
what are 2 monoamine oxidase inhibitors?
tranylcypromine
phenelzine
what can’t monoamine oxidase inhibitors be taken with?
tyramine containing foods
cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
can cause hypertensive reaction
what is the management of acute mania?
antipsychotics - olanzapine, haloperidol
what are 5 side effects of clozapine?
Agranulocytosis
Reduced seizure threshold
Constipation
Myocarditis
Hypersalivation
which antipsychotic is most likely to cause dyslipidaemia and obesity?
olanzapine
what antipsychotics are most likely to cause extra pyramidal side effects?
1st generation antipsychtics - haloperidol, chlorpromazine etc
what are extrapyramidal side effects of antipsychotics?
Parkinsonism
Acute dystonia
Sustained muscle contraction
Akathisia – severe restlessness
Tardive dyskinesia - Choreoathetoid abnormal, involuntary movements
what is the management of sustained muscle contraction due to antipsychotics (acute dystonia)?
procyclidine
what is acute dystonia?
involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures due to medications usually antipsychotics
which non-antipsychotic can cause acute dystonia?
metoclopramide - antiemetic
what is the management for acute dystonia?
IV anticholinergics - benzotropine
IV Benzodiazepines
at what level does lithium toxicity usually occur?
> 1.5 mmol/L
what are 3 things that may precipitate lithium toxicity?
dehydration
renal failure
drugs - diuretics (thiazides), ACEI/ARBS, NSAIDS, metronidazole
what are 5 side effects of lithium toxicity?
COARSE tremor (fine is side effect of normal lithium level)
hyperreflexia
acute confusion
seizure
polyuria
coma
what is the management of lithium toxicity?
IV fluids until euvolaemic
Monitor serum sodium closely
haemodialysis if severe
what is the diagnostic criteria for delirium? (5)
1.) Impairment of consciousness and attention
2.) Global disturbance in cognition
3.) Psychomotor disturbance
4.) Disturbance of sleep-wake cycle
5.) Emotional disturbances
what is the MOA of benzodiazepines?
They facilitate and enhance the binding of GABA to the GABAA receptors
what is the MOA of antipsychotics?
block the postsynaptic dopamine D2 receptors
what are 4 blood results for neuroleptic malignant syndrome?
Raised CK (creatine kinase) –> due to muscle rigidity
Raised white cell count
Deranged LFT’s
Acute renal failure –> abnormal U&E’s
Metabolic acidosis –> low pH, low HCO3
what are the hallucinations like in schizophrenia?
3rd person auditory
external to patient
thought echo
running commentary
multiple voices talking about the patients amongst themselves
what is Illness anxiety disorder (hypochondriasis)?
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
what is conversion disorder?
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
what is factitious disorder?
aka Muchausen’s syndrome - intentional production of physical or psychological symptoms
what is malingering?
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
How often is monitoring for clozapine?
weekly for 18 weeks then fortnightly till one year then every month
what is the name for severe restlessness in antipsychotic use?
akathisia
what is acute stress reaction?
Phycological condition following exposure to severe stress or traumatic events lasting up to a month
what are 5 risk factors for acute stress reaction?
Genetics + neurobiological factors
Prior psych Hx
Trauma/precipitating event
Lower socioeconomic status
Lack of coping mechanisms and social support
what are 3 cognitive symptoms of acute stress reaction?
Confusion and disorientation
Intrusive thoughts - memories, dreams, flashbacks
Derealisation and depersonalisation
what are 2 behavioural symptoms of acute stress reaction?
Avoidance behaviour - avoid thoughts, conversations, activities, places or people
Hyper-vigilance
what are 2 physiological symptoms of acute stress reaction?
tachycardia and hypertension
Sweating and trembling
what is the management of acute stress reaction?
1 - Trauma focused CBT
Mindfulness
can consider short term use of benzodiazepines
what is self harm?
intentional self injury without suicidal intent
Cutting is most common
what are the 6 steps in the cycle of self harm?
Emotional suffering
Emotional overload
Panic
Self-harm
Temporary relief
Shame and guilt
what are 7 presenting features that increase risk of suicide?
Previous attempts
Escalating self harm
impulsiveness
hopelessness
feelings of being a burden
making plans
Writing a note
what are 9 background factors that increase risk of suicide?
Mental health conditions
physical health conditions
Hx of abuse/trauma
FHx
Financial difficulties/unemployment
Criminal problems
Lack of social support
Alcohol and drugs
Access to means
what are 4 protective factors for suicide?
Social support and community
sense of responsibility over others
resilience, coping and problem solving skills
access to mental health support
what are 4 examples of self harm?
Cutting
hitting self
burning own skin
applying tight ligatures to skin
What are the baby blues?
transient mood disturbance in the 1st week post partum
crying, fatigue, sensitivity, anxiety, irritability, helplessness, low mood and mood swings
Managed with reassurance and support
What is postnatal depression?
low mood, anhedonia and low energy typically affecting mothers around 3 months post natally
what is the management of postnatal depression?
Mild - reassurance, support, self help, follow up
Moderate - SSRIs - sertraline, paroxetine, CBT
Severe - referral to psychiatry, impatient care on mother and baby unit
what scoring system is used for post natal depression?
Edinburgh postnatal depression scale
What is pueperal psychosis?
typically onset 2-3 weeks postnatal with mother experiencing psychotic symptoms (delusions, hallucinations, depression, mania, confusion, thought disorder)
what is the treatment for puerperal psychosis?
admission to mother and baby unit
CBT
medications - antidepressants, antipsychotics, mood stabilisers
electroconvulsive therapy
25-50% recurrence rate in future pregnancies
what is charles-bonnet syndrome?
persistent or recurrent complex hallucinations - usually visual - predominantly against a background of visual impairment. Insight is preserved and there is absence of other neuropsychiatric disturbance
what are 5 risk factors for charles bonnet syndrome?
Older age
peripheral visual impairment
Social isolation
sensory deprivation
early cognitive impairment
what are 3 types of dissociative disorders?
Depersonalisation-derealisation disorder
Dissociative amnesia
Dissociative identity disorder
what is Depersonalisation-derealisation disorder ?
feeling of being separated/outside body and feeling that the world is not real
what is Dissociative amnesia?
forgetting autobiographical information typically following trauma
what is Dissociative identity disorder?
AKA multiple personality disorder - lack of clear individual identity, with multiple separate identities
what is catatonia?
abnormal movement, communication and behaviour presenting in a variety of ways
what is reactive attachment disorder?
from severe neglect and trauma in childhood
emotional withdrawal and inhibition, sadness, fearfulness, irritability, impaired cognition
what is alien hand syndrome?
patient loses control of one of their hands which then acts independently
can occur after brain tumour, injury surgery
what is alice in wonderland syndrome?
AKA todd syndrome
incorrectly perceiving size of objects or body parts
May be caused by migraine, epilepsy, brain tumour
what is Koro syndrome?
delusion that sex organs are retracting or shrinking and will one day disappear
what is body integrity dysphoria?
delusion the part of body does not belong to them and they want to remove it
what is binge eating disorder?
characterised by episodes where a person excessively overeats and feels as though they have lost control - likely to be overweight
binges may involve eating very quickly, unrelated to feelings of hunger, being uncomfortably full, eating in dazed state, feelings of guilt/disgust
marked distress regarding binges
at least once a week for 3 months
what is tolerance?
loss of effect when taking the same dose - person may have to increase dose to get same effect
what is dependence?
psychological and psychosocial need to keep using a drug
may occur due to physiological changes and psychological factors
what are benzos withdrawal symptoms?
Anxiety, irritability, tremmors, insomnia, seizures
due to reduced natural production of GABA (inhibitory neurotransmitter)
what pathway of the brain is involved in psychological addiction?
mesolimbic pathway
involves ventral tegmental area, nucleus accumbens, amygdala and prefrontal cortex
what is the mechanism of psychological addiction?
substances lead to dopamine release within mesolimbic pathway leading to pleasurable reward. Repeat dopamine exposure reduces number and sensitivity of dopamine receptors leading to a need for increasingly stronger stimuli to produce same reward
what is the MOA of cocaine?
Blocks reuptake of dopamine by presynaptic membrane
what is the MOA of MDMA?
stimulates release of serotonin and blocks reuptake
what is the MOA of methamphatamines?
Stimulates release of dopamine and blocks reuptake
what is the MOA of alcohol and benzos?
stimulate GABA receptors
what is the MOA of hallucinogens?
stimulate serotonin receptors, particularly 5-HT2A receptors
what are the rules surrounding driving and alcoholsim?
must inform DVLA - licence revoked until extended period of abstinence
what is the management of alcoholic ketoacidosis?
infusion of saline and thiamine
what is the diagnostic criteria for alcoholism?
3+ of
Compulsion to drink
difficulties controlling alcohol consumption
physiological withdrawal
tolerance
neglect of alternative activities to drinking
persistent use of alcohol despite evidence of harm
what is phenomenology is psychiatry?
the scientific study of subjective experiences
what is insomnia?
difficulty initiating or maintaining sleep or early morning waking that leads to dissatisfaction with sleep quantity or quality
what is classed as chronic insomnia?
difficulty sleeping at least 3 nights per week for >3 months
what are 6 risk factors for insomnia?
female
increased age
lower educational attainment
unemployment
economic inactivity
widowed, divorced, separated status
alcohol and substance abuse, corticosteroids, poor sleep hygiene, chronic pain or illness
what is the MOA of benzodiazepines?
enhace effect of inhibitory neurotransmitter GABA by increasing frequency of chloride channels
how long should benzos be given for?
no more than 2-4 weeks
what are 3 examples of z-drugs?
zopiclone
zolpidem
zaleplon
what are 3 concerning side effects of hypnotics?
daytime sedation
poor motor coordination
cognitive impairment
what monitoring is needed for antipsychotics?
FBC, U+E, LFT - initiation, annually - clozapine FBC initially weekly
Lipids, weight - initiation, 3 months, annually
Fasting blood glucose, prolactin - initiation, 6 mon, anual
BP - Initiation, dose titration
ECG - baseline
CVD risk - annually
