Psych Flashcards
Somatisation disorder
- Multiple physical SYMPTOMS present for at least 2 years
- Patient refuses to accept reassurance or negative test results
Hypochondrial disorder
Persistent belief in the presence of an underlying serious DISEASE, e.g. Cancer
* Patient again refuses to accept reassurance or negative test results
Conversion disorder
Typically involve loss of motor or sensory function
* Some patients may experience secondary gain from loss of function
* Patients may be indifferent to their apparent disorder
* Psychogenic aphonia is a form of conversion disorder: not speaking after a shocking event.
Dissociative disorder
- Dissociation is a process of ‘separating off’ certain memories from normal consciousness
- In contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
- Dissociative identity disorder (DID) is the new term for multiple personality disorder as is the
most severe form of dissociative disorder
Body dysmorphic disorder
Diagnostic and Statistical Manual (DSM) IV criteria:
* Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive
* The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
* The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)
Post-traumatic stress disorder (PTSD) features
- Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
- Avoidance: avoiding people, situations or circumstances resembling or associated with the
event - Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems,
irritability and difficulty concentrating - Emotional numbing - lack of ability to experience feelings, feeling detached from other people
- Depression
- Drug or alcohol misuse
- Anger
- Unexplained physical symptoms
Post-traumatic stress disorder (PTSD) treatment
Management
* Following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
* Watchful waiting may be used for mild symptoms lasting less than 4 weeks
* Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and
reprocessing (EMDR) therapy may be used in more severe cases
* Drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug
treatment is used then paroxetine or mirtazapine are recommended
Post-concussion syndrome
Typical features include
* Headache
* Fatigue
* Anxiety/depression * Dizziness
‘Baby-blues’
Seen in around 60-70% of women
Typically 3-7 days following birth and more common in primips
Mothers: characteristically anxious, tearful and irritable
Postnatal depression
Affects around 10% of women
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
Puerperal psychosi
Affects approximately 0.2% of women
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Schizophrenia:
Auditory hallucinations of a specific type:
* Two or more voices discussing the patient in the third person
* Thought echo
* Voices commenting on the patient’s behaviour
Thought disorder (occasionally referred to as thought alienation):
* Thought insertion
* Thought withdrawal
* Thought broadcasting
Passivity phenomena:
* Bodily sensations being controlled by external influence
* Actions/impulses/feelings - experiences which are imposed on the individual or influenced by
others
Delusional perceptions
* A two stage process: where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘the traffic light is green therefore i am the king’.
SCZ Factors associated with poor prognosis
Strong family history
* Gradual onset
* LowIQ
* Premorbid history of social withdrawal
* Lack of obvious precipitant
SCZ Risk of developing schizophrenia
Monozygotic twin has schizophrenia = 50%
* Parent has schizophrenia = 10-15%
* Sibling has schizophrenia = 10%
* No relatives with schizophrenia = 1%
Alcohol withdrawal
time frame
- Symptoms: 6-12 hours
- Seizures: 36 hours
- Delirium tremens: 72 hours
Alcohol withdrawal mechanism
Mechanism
* Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
* Alcohol withdrawal is thought to lead to the opposite (↓ inhibitory GABA and ↑ NMDA glutamate transmission)
Bulimia nervosa management
Management
* Referral for specialist care is appropriate in all cases
* Cognitive behaviour therapy (CBT) is currently consider first-line treatment
* Interpersonal psychotherapy is also used but takes much longer than CBT
* Pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently
licensed for bulimia but long-term data is lacking
Anorexia features
Most things low
* G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinemia
Hospitalized patients with AN and NGT feeding are at risk of
f refeeding syndrome, which can
lead to profound hypophosphatemia
actors associated with risk of suicide following an episode of deliberate self harm:
Efforts to avoid discovery * Planning
* Leaving a written note
* Final acts such as sorting out finances * Violent method
Serotonin Syndrome features
Features
* Agitation
* Hyperthermia
* Tachycardia
* Labile BP
* Hyperreflexia and ↑ tone
Serotonin Syndrome drugs
SSRI
* MAOI (e.g. Moclobemide)
Restless legs syndrome (RLS)
- Uncontrollable urge to move legs (akathisia). Symptoms initially occur at night but as condition progresses may occur during the day. Symptoms are worse at rest
- Paraesthesias e.g. ‘Crawling’ or ‘throbbing’ sensations
- Movements during sleep may be noted by the partner - periodic limb movements of sleeps
(PLMS)
RLS Causes and associations
- There is a positive family history in 50% of patients with idiopathic RLS
- Iron deficiency anaemia
- Uraemia
- Diabetes mellitus
- Pregnancy
RLS managment
Management
* Simple measures: walking, stretching, massaging affected limbs
* Treat any iron deficiency
* Dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole)
* Benzodiazepines
* Gabapentin
antipsychotics - Extrapyramidal side-effects
Extrapyramidal side-effects
* Parkinsonism
* Acute dystonia (e.g. Torticollis, oculogyric crisis)
* Akathisia (severe restlessness)
* Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur
in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
antipsychotics other side-effects/features
ther side-effects/features
* Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
* Sedation, weight gain
* Raised prolactin: galactorrhoea
* Neuroleptic malignant syndrome: pyrexia, muscle stiffness
* ↓ seizure threshold (greater with atypicals)
* Antipsychotics are not addictive
Olanzapine, like other atypical antipsychotics,
is known to block serotonin receptors
(especially 5-HT2 subtype) as well as D2 dopamine receptors
Adverse effects of atypical antipsychotics
- Weight gain
- ↑ risk of venous thromboembolism
- Olanzapine and risperidone are associated with an ↑ risk of stroke in elderly patients
- Clozapine is associated with agranulocytosis (see below)
Adverse effects of clozapine
- Agranulocytosis (1%), neutropaenia (3%)
- ↓ seizure threshold - can induce seizures in up to 3% of patients
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression:
how to pick
Citalopram and fluoxetine are currently the preferred ssris
* Citalopram is useful for elderly patients as it is associated with lower risks of drug interactions
* Sertraline is useful post myocardial infarction as there is more evidence for its safe use in this
situation than other antidepressants
* SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice
when an antidepressant is indicated
Adverse effects SSRIs
Gastrointestinal symptoms are the most common side-effect
* There is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump
inhibitor should be prescribed if a patient is also taking a NSAID
* Patients should be counselled to be vigilant for increased anxiety and agitation after starting a
SSRI
* Fluoxetine and paroxetine have a higher propensity for drug interactions
* Citalopram and sertraline and more suitable for patients with chronic physical health problems
as they have a lower propensity for drug interactions.
Interactions SSRIs
NSAIDs: NICE advised ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
* Warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
* Aspirin: see above
* Triptans: avoid SSRIs
Discontinuation symptoms SSRI
Increased mood change
* Restlessness
* Difficulty sleeping
* Unsteadiness
* Sweating
* Gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
* Paraesthesia
Tricyclic antidepressants Common side-effects:
- Drowsiness * Constipation * Blurred vision
- Dry mouth * Urinary retention
Choice of tricyclic
Low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
* Lofepramine has a lower incidence of toxicity in overdose
* Amitriptyline and dosulepin (dothiepin) and considered the most dangerous in overdose
Neuroleptic Malignant Syndrome
Features
* More common in young ♂ patients
* Onset usually in first 10 days of treatment or after increasing dose
* Pyrexia
* Rigidity
* Tachycardia
A raised creatine kinase is present in most cases. A leukocytosis may also be seen
