Psych 2 Flashcards
Where can you see impairments in personality disorders?
- aspects of the self
- problems in interpersonal functioning
- impariemtns in self-functioning and/or interpersonal functioning
complete this FC from slides
Exclusion criteria for PD
- If organic causes
- developmentally appropriate
- can be primarily explained by social or cultural factors incl. socio-political conflict
Levels of PD
- mild
- moderate
- severe (global impairment of all social, cognitive and behavioural disturbance; likely to include self-harm or harm to others)
- Personality difficulty
What is personalty difficulty?
- poeple may have traits
- not a pervasive, chronic course like in PD
PD clusters
A - odd and eccentric
B - dramatic, emotional or erratic
C - fearful, avoidant
Paranoid PD features
- excessive sensitivity to setbacks
- suspicious
- can perceive others as hostile or contemptuous (misconstruing neutral or friendly actions)
- can easily feel rejected
- tend to hold grudges
- may have excessive self-importance
Schizoid PD
- cut off
- perceived emotionally as ‘cold’
- preference for fantasy, solitary activities and introspection
- limited capacity to express feelings and experience pleasure
- some overlap with ASD
Schizotypal PD
- cluster A PD
- inappropriate or constricted affects
- socially withdrawn
- bahevioue or appearance that is off, eccentric or peculiar
- odd beliefs, magical thinking
etc.
Classification of Schizotypal PD
- in ICD-10 used to be under schizophrenia
- in ICD-11 it is under Cluster A PD
Antisocial PD
- Cluster A
- persistent disregard for morals, social norms and the rights of others
- callous about the feelings of others
- low tolerance to frustration
- aggressive tendencies
- frequently offenders,
- impulsive
- lack of remorse, do not forgive
- behaviour that is not readily changed by adverse events
What is the difference between borderline PD and EUPD?
- EUPD can be classified into:
- borderline PD
- impulsive PD
Borderline PD
- difficulties managing emotions and behaviour
- impulsive without consideration of consequences
- unpredictable mood
- emotional instability
- very sensitive to rejection and criticism
- chronic feelings of emptiness
- intense and unstable interpersonal relationships
- really interrupted interpersonal relationships! difficult to have mutually satisfying relationships
- describe feeling numb/empty/worthless at times
- difficult internally - imagine your emotions being like that.
Histrionic PD
- shallow and labile affects
- self-dramatisation, theatricality, exaggerated expression of emotions
- seeking attention
add more info
Narcissistic PD
- grandiosity with expectations of superior treatment from other people
- fixation n fantasies pf power, success, intelligence, attractiveness
- self-perception of being unique, superior, and associated with high-status people and institutions
- constant need for admiration from others
Avoidant PD
- likely had difficulties with attachment when growing up
- want to fit in
- want to be liked
- sensitive to criticism and rejection
- feelings of tension and apprehension
- insecurity and inferiority
- tendency to avoid certain activities by habitual exaggeration of the potential dangers or risk in everyday situations
- restricted personal attachments
dependant PD
- pervasive passive reliance on others to make decisions
- great fear of abandonment
- constantly seeking reassurance
- a feeling of helplessness and incompetence
- passive compliance with the wishes of elders and others
- weak response to the demands of daily life
obsessive compulsive PD (anakastic PD)
- feelings of doubt
- perfectionism
- excessive conscientiousness
- checking and preoccupation with details
- stubbornness, caution and rigidity
- there may be insistent and unwelcome thoughts or impulses that do not attain the severity of an OCD (less intense in the PD; not as strict rituals etc)
Treatment of PD
- psychological therapy
- psychotropic medication
Psychological therapies for PD (especially cluster B)
- MBT
- CBT
- DBT
- dynamic psychotherapy
- cognitive analytical therapy
- therapeutic community
Which medications may be useful in personality disorders?
Nothing is licensed for PD!
- is the medication for the PD or for a co-morbid disorder?
- some benefit of antidepressants
- low dose antipsychotics can help with impulse control
- mood stabilisers
- sedatives (short term use, can dampen arousal and high level of stress they are feeeling)
psychodynamic psychotherapy
- long term therapy
- looks at relationship between the patient and the therapist
- looks at early childhood and relationships and how these relationships are now showing themselves
Therapeutic community therapy
lots of people with similar illness come together, speak about it and do activities together
probably mostly used in addiction etc
can be useful to speak to ex-patients etc.
What is the HCR-20?
used to assess violence
used in forensic psychiatry
What tool do you use to assess psychopathic traits?
PCL-R
How do you assess if someone is fit to plead?
Pritchard’s criteria for fitness to plead
(1. understanding the charge/charges)
2. deciding whether to plead guilty / not
3. exercising the right to challenge juniors
4. instructing solicitors to counsel
5.
)
“Not guilty by reason of insanity”
- rare
M’naughten rules 1843
1. a defect to reason
2. due to a disease of mind
3 leading to loss of appreciation of nature and quality of an act
4. so the accused did not realise what he was doing was not
usually results with a hospital order
What medication is good at treating negative sx of schizophrenia?
clozapine
Splitting
- a primitive way of dealing with ambiguity
- objects and/or the self are either wholly good or wholly bad
‘black and white’
Projection
- intolerable feelings/aspects of self are externalised to reduce anxiety (e.g. I’m not angry, you’re angry)
Severities of ID
- mild
- moderate
- severe
-profound
How is ID diagnosed?
- formal diagnosis
- clinical assessment
prevalence of mild ID
2-3/100
no specific cause
prevalence of severe ID
3/1000
causes of severe ID
usually specific cause e.g. brain damage
What are people with Down syndrome at higher risk of?
Poeple with Down syndrome are at higher risk of developing dementia (sometimes in their 30s)
What physical condition are people with ID at higher risk of?
Epilepsy
(higher rate of brain damage is linked to higher rate of seizures?)
What psychiatric conditions are more prevanent in people with ID?
Schizophrenia prevalence 3% (compared to 1% gen pop)
Mood disorders and anxiety (4x more likely)
autism (75% have learning disability)
Core domains in ASD
- reciprocal social interaction
- restricted and repetitive behaviours or interests
- verbal and nonverbal communication
Prevalence of ASD
1%
Heritability of ASD
HIGH
80-90%
Diagnosis of ASD
- usually involves MDT
- autism diagnostic inventory - revised (ADI-R)
- autism diagnostic observatory schedule (ADOS)
Diagnosis of ASD
- usually involves MDT
- autism diagnostic inventory - revised (ADI-R)
- autism diagnostic observatory schedule (ADOS)
Are pharmacological approaches used in ASD?
only used for comorbid conditions such as anxiety
dopamine antagonists often help stereotypical behaviour (motor)
irritability can be treated with low dose risperidone or aripiprazole
IQ in mild ID
50-69 (mental age from 9-12yo)
moderate ID IQ and mental age
35-49
mental age from 6-9
need support to live and work
severe ID IQ and mental age
20-34
mental age 3-6 yo
likely to result in continuous need of support
Profound ID IQ and mental age
below 20
under 3yo
Patient with LD presenting for psych review - what do you have to assess?
- current situation
- pre-morbid situation
- Risk assessment
- detailed developmental hx
- physical health (rule out physical illness)
- triggers
- what is going into a hospital environment going to do with QoL
Alzheimer’s disease
- insidious onset
- slowly getting worse over time
Vacsular demenita
- rapid onset
- fluctuant (can have good or bad days)
AF is a RF
Dementia with Lewy Bodies
- Lewy Bodies – alpha synuclein and ubiquitin positive inclusions
- In Parkinson’s Lewy Bodies are confined to the substantia nigra, in DLB they are more widespread and also involve cortical regions
- Often thought of hybrid of PD and AD
- Visual hallucinations
- REM behavioural sleep disorder
- Autonomic dysfunction (postural hypotension) - Neuroleptic sensitivity
MRI – similar to AD
SPECT – may show disproportionately severe occipital hypoperfusion
DatSCAN – to differentiate AD from PD (shows reduction in dopamine transportation in PD)
What are Lewy bodies?
alpha synuclein and ubiquitin positive inclusions
DDx for dementa
Delirium
Depression
more?
DDx for dementa
Depression
Delirium
What is BPSD?
behavioural and psychological symptoms in dementia
What medications can be used in Alzheimer’s dementia?
Donepezil, Galantamine and Rivastigmine (reversible AChE inhibitors, cause ~50% reduction)
Memantine
(Non-competitive Glutamate receptor and antagonist; recommended for moderate AD unresponsive to AChEi or with CI to AChEi or severe AD).
signs and symptoms of delirium tremens
- coarse tremor
- sweating
- insomnia
- tachycardia
- visual and auditory (lilliputian) hallucinations
- N&V
- psychomotor agitation
- marked alteration in severity hour by hour, usually worse at night
Why would you chose mirtazapine first line in some people with depression:
it helps with biological symptoms
helps with sleep and with appetite and weight gain
SSRIs and bleeding
serotonin inhibits platelet aggregation, increases the risk of bleedng
What are the 6 ICD-10 diagnostic criteria for dependence syndrome?
- string desire or sense of compulsion to take the substance
- difficulties in controlling substance taking behaviour: onset, termination, levels of use
- Physiological withdrawal state when substance use has been ceased or reduced
- evidence of tolerance, such as increased doses of the psychoactive substance are required in order to achieve effects originally produced by low doses
- progressive neglect of alternative pleasures or interests because of psychoactive substance use increased amount of time necessary to obtain or take the substance or to recover from its effects
- persisting with substance use despite clear evidence of overly harmful consequences, such as harm to the liver through excessive drinking, depressive m mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning
you need 3 or 4 of these 6 to diagnose the dependence
Screeing tests for alcohol use
- FAST
- AUDIT
- CAGE
- MAST
- SADQ
Questions to ask in alcohol history
How do you calculate units of alcohol?
ABV x Volume (in liters)
or ABV x Volume (in ml) / 1000
What medication can you give to people if they want to stay abstinent from alcohol?
disulfiram
naltrexone
acamprosate
(nalfamene)
What medication do you give in alcohol withdrawal?
chlordiazepoxide
What is pabrinex?
- used for Wernicke’s prophylaxis
- Vitamin B and C
Do you give IV dextrose to a heavy drinker?
not before giving pabrinex
(glucose loading can precipitate wernicke’s in thiamine deficient patients)
How do you decide if you treat alcohol dependence/withdrawal in IP/OP setting?
- ?
- poly drugs users
- severity of dependence
- social support
- previous experiences with detox
What questionnaire can you use to determine the management of alcohol withdrawal?
CIWA-Ar
Risk factors
- co-existing infection
- previous DT
- precious hx of alcohol withdrawal seizures
- pancreatitis/hepatitis
- recent higher than normal alcohol intake
- older age
- abnormal liver function
- more severe withdrawal symptoms on presentation
What causes Wernicke’s and Korsakoff? which one is reversible?
arise from thiamine (B1) deficiency
Wernicke’s is reversible, but without thiamine supplementation in will develop into Korsakoff psychosis
What causes Wernicke’s and Korsakoff? which one is reversible?
arise from thiamine (B1) deficiency
Wernicke’s is reversible, but without thiamine supplementation in will develop into Korsakoff psychosis
Wernicke’s encephalopathy triad
confusion (80%)
ophthalmoplegia - nystagmus or 6th cranial nerve palsy usually (30%)
ataxia (25%)
May not have all three!
What is methadone?
an opioid
How do you manage opioid overdose?
ABC approach (incl. airway management and IV fluids)
naloxone
Name opioids
illicit (heroin)
methadone/buprenorphine
codeine
oxycodone
tramadol
morphine
fentanyl
clinical features of opioid OD
- reduced GCS
- resp Depression
- hypotension (accompanied by tachycardia)
- pin poin pupils (miosis)
- hypotonic/hyporeflexic coma
What medications do you use for OST (opiate substitution therapy)?
methadone (long acting, half life 24h; less euphoria than heroid;)
Buprenorphine (partial agonist, long half life, OD)
Suboxone (combination of buprenorphone, naloxone - NO LONGER USED)
SE of methadone as OST
- lethargy
- resp depression at high disease
- constipation
- reduced saline (contributes to poor dental hygiene)
Buprenorphine as OST
- partial agonist, long half life
- attenuates the effects of opiates (timing in initiation is important to avoid precipitated withdrawals)
How can death occur in opioid withdrawal?
dehydration due to diarrhoea and vomiting
is opiate withdrawal lethal?
not lethal
Negative symptoms of schizophrenia
impaired motivation
lack of drive and initiative
social withdrawal and loss of interest in other people
emotional bluntness and reduced reactivity
poverty of speech
self neglect
Are patients with PDs more likely to experience psychotic mental illness?
yes
Physical causes of psychosis
any cause of delirium
head injury or other intracranial pathology
degenerating dementias
epilepsy
acute intermittent porphyria
hyperthyroidism
What is the MoA of typical and atypical antipsychotics?
typical: inhibit D2 receptors
atypical: inhibit D2 and 5HT receptors
What SE are atypical antipsychotics likely to cause?
- HTN
- central obesity
- raised fasting glucose
- weight gain
- dyslipidaemia
How do you manage the metabolic SE caused by SGAs?
- decerase or change drug
- diet, exercise
- anti-HTN drugs, statins, hypoglycaemic,
- add metformin to aripiprazole to help weight loss
What measurements should you do before starting an antipsychotic?
weight (plotted on a chart)
waist circumference
pulse and blood pressure
fasting blood glucose or glycosylated haemoglobin (HbA1c)
blood lipid profile and prolactin levels
assessment of any movement disorders
assessment of nutritional status, diet and level of physical activity.
+/- ECG
[NICE https://www.nice.org.uk/guidance/cg178/chapter/recommendations#choice-of-antipsychotic-medication 1.3.6.1]
‘rapid neuroleptisation’
Which of the ESPEs is an indication to stop the antipsychotic right away and why?
tardive dyskinesia (rhythmic, involuntary movements)
because it can be irreversible
What should you warm patients about when prescribing chlorpromazine?
If prescribing chlorpromazine, warn of its potential to cause skin photosensitivity. Advise using sunscreen if necessary.
Examples of depot antipsychotics
first generation
- flupentixol decanoate
- fluphenazine decanoate
- haloperidol decanoate
- zuclopenthixol decanoate
When is it recommended to give depot antipsychotics?
if…
- you find it difficult to swallow medication
- you find it difficult remembering to take medication regularly
- you prefer not to have to think about taking medication every day.
Examples of typical antipsychotics
haloperidol
chlorpromazine
sulpiride
zuclopenthixol
trifluopenalzine
Examples of atypical antipsychotics
olanzapine
aripiprazole
risperidone
quetiapine
amisulpride
lurasidone
clozapine
How common is agranulocytosis in clozapine use?
0.7% patients experience it
Summarise all side effects associated with antispsychotics and which antipsychotics are likely to cause them
- ESPEs (akathisia, dystonia, Parkinsonism, tardive dyskinesia) - FGAs; risperidone for dystonia, aripiprazole for akathisia;
- hyper-PRL - FGAs; amisulrpride; risperidone;
- metabolic SE (weight gain, central obesity, increased fasting glucose, dyslipidaemia) - SGAs [clozapine > olanzapine > risperidone > quetiapine - CORQ)
- sedation - chlorpromazine, clozapine, olanzapine, quetiapine
- anticholinergic effects -trifluoperazine, clozapine (clozapine can cause hypersalivation rather than dry mouth which can be associated with an increased risk of aspiration pneumonia)
- increased QTc on ECG - haloperidol, quetiapine
- decreased seizure threshold - clozapine
- neuroleptic malignant syndrome - FGAs
Which SGAs are more likely to cause metabolic SEs than others?
CORQ
clozapine > olanzapine > risperidone > quetiapine
Symptoms of neuroleptic malignant syndrome?
confusion
drowsiness
diaphoresis
rigidity
pyrexia
tachycardia
tachypnoea
high BP
What could you see on blood findings in a patient with neuroleptic malignant syndrome?
- high CK
- raised WCC
Management of neuroleptic malignant syndrome
STOP antipsychotic
supportive care (may need ICU, cooling, fluid resuscitation)
dantrolene, amantadine,bromocriptine
careful: can develop rhabdomyolysis which can cause AKI
once well try a different SGA if antipsychotic still needed
What can cause neuroleptic malignant syndrome?
new antipsychotic / increased dose
mainly FGA
Which brain haematoma presents with a lucid interval?
extradural haematoma
Features of TCA overdose
- confusion
- seizure
- tachycardia
- hypotension
- mydriasis (dilated pupils)
- metabolic acidosis
- QRS prolonged
- QTc prolongation
Name of the delusions when someone thinks that someone of higher status (e.g. celebrity/politician) is in love with them?
erotomanic
What is echopraxia?
In echopraxia, the patient involuntarily imitates another person’s movements. This is a rare feature of schizophrenia.
In schizophrenia, if the patient is involuntarily mimicking another person’s movements, what is this called?
Echopraxia
Logoclonia
Logoclonia describes a phenomenon in Parkinson’s Disease where the patient gets ‘stuck’ on a particular word of a sentence and repeats it.
What is la belle indifference?
La belle indifference is a syndrome where patients do not show any concern over the symptoms they are experiencing. An example is not worrying whether they cannot move a limb. This is associated with conversion disorder.
Common side effects of SSRIs
- headache
- GI disturbance (nausea, diarrhoea/constipation)
- sleep disturbance/vivid dreams
- sexual dysfunction
Risk of suicidality in the first 2 weeks
Which SSRI is used in children?
fluoxetine
What are contraindications to SSRIs?
- GI bleeding
- hyponatraemia
Duration of treatment with SSRIs?
once well, same dose for 6-12 months
if there is a high risk of relapse continue for 2 years
review initially 2-weekly, then regularly
What are the symptoms of SSRI overdose?
What are the side effects of TCAs?
anti-cholinergic/muscarinic SE:
- dry mouth
- blurred vision
- constipation
- urinary retention
Cardiotoxic:
- QT prolongation
- AV block
- ST elevation
Anti-histaminergic
- sedation
- postural hypotension
- weight gain
What are the dangers/disadvantages of SSRIs
- discontinuation syndrome
- can be lethal in overdose
- act on more receptors than e.g. SSRIs -> more SE (including higher cardiotoxicity)
Venaflaxine / Duloxetine drug class
SNRI
(patients require monitoring of BP)
Which class of antidepressants requires patients to each a diet low in tyramine?
MOAIs
What is the cheese reaction?
a hypertensive crisis as a results of ingestion of tyramine rich foods and MAOIs
Patients taking MAOIs should have a diet low in tyramine
Cheese is tyramine rich
If people on MAOIs eat a lot of tyramine containing foods,
Mirtazapine drug class
NsSSA
Symptoms of discontinuation syndrome with antidepressants
- headache
- dizziness
- GI-symptoms
- anxiety
- double sleeping
- flu-like symptoms
- electric shocks
Risk factors for serotonin syndrome
- antidepressant use (esp higher dose),
- combination antidepressants
- overdose of antidepressants
-lithium - ECT
- opiates, antiemetics (metoclopramide, odansetron), illicit drugs
Complications of serotonin syndrome
o DIC,
o Rhabdomyolysis,
o renal failure/Metabolic
acidosis
o seizures
Management of serotonin syndrome
➢ Management of severe cases in the general hospital
➢ Stop the offending medications
➢ Supportive measures (ABCDE)- airway management, renal care, IV fluids, temp control
➢ ?Cyproheptadine (antihistamine and also serotonin antagonist)
What drugs belong to mood stabilisers
- lithium
- anti-epileptics
- atypical antipsychotics
Adverse effects of lithium
Common
- fine tremor
- mild GI upset
- metallic taste
- sedation
Persistent
- renal disease (polyuria, polydipsia CKD)
- hypothyroidism
- lethargy
- weight gain
- persistent tremor
- T-wave flattening on ECG
- mild cognitive impairment
- change in hair texture
- leukocytosis
Adverse effects of lithium
Common
- fine tremor
- mild GI upset
- metallic taste
- sedation
Persistent
- renal disease (polyuria, polydipsia CKD)
- hypothyroidism
- lethargy
- weight gain
- persistent tremor
- T-wave flattening on ECG
- mild cognitive impairment
- change in hair texture
- leukocytosis
symptoms of lithium toxicity
- coarse tremor
- marked GI upset
- ataxia
- dysarthria
- impaired conciousness
- epileptic seizures
- nystagmus
- renal failure
Lithium toxicity if potentially fatal
SE of sodium valproate
GI upset (nausea, vomiting, dyspepsia, diarrhoea), tremor, sedation, weight gain, curly/loss hair, ankle swelling FBC abnormalities (leucopenia, thrombocytopenia), abnormal LFTS
which anticonvulsants can be used as mood stabilisers?
carbamazepine (used for prophylaxis but not really mentioned in NICE guidelines)
lamotrigine (for prophylaxis and in bipolar depression)
SE of carbamazepine
Nausea and vomiting, blurred vision, ataxia/, fatigue, hepatic failure, antidiuretic effect
(hyponatraemia), FBC abnormalities (leucopenia, thrombocytopenia), skin rashes, abnormal LFTS
SE of lamotrigine
Nausea and vomiting, rash, headache, sedation, insomnia, aggression
can rarely cause Steven Johnson syndrome
Which antipsychotics can you give in mania?
HORQ
haloperidol
olanzapine
risperidone
quetiapine
negative symptoms of schizophrenaia
5 As
blunted Affect (little or no emotion)
Alogia (speech lacks content)
Anhedonia (lack of pleasure)
Asociality (lack of desire for social interaction and relationships)
Avolition (lack of motivation)
Cognitive sx of schizophrenai
- low attention
- poor decision making
- lack of problem solving abilities
good predictor of day to day functioning
often first symptoms to appear
Cognitive sx of schizophrenai
- low attention
- poor decision making
- lack of problem solving abilities
good predictor of day to day functioning
often first symptoms to appear
What is the prodromal phase in schizophrenia?
- gradual cognitive and negative symptoms then followed by the first episode of psychosis
this is followed by a residual phase where they come back to baseline (then they can have another decline)
DSM V criteria for schizophrenia
at least 2 of the 5 (1 must be 1-3)
- delusions
- hallucinations
- disorganised speech
- disorganised/catatonic behaviour
- negative symptoms
must have been present for most of the time for at least 1 month
significant impairment for 6 months
not as a result of substance abuse or medical conditions
What are the most consistent MRI findings can be seen in patients with Schizophrenia
- Lateral cerebral ventricles enlargement (up to 30% larger than normal)
- decreased cortical volume
The specific reason for ventricular enlargement is not known, but it seems to stem from diffusely decreased cortical volume and shrinkage of the thalamus and putamen.
When can ventricle enlargement on MRI be seen?
- schizophrenia (esp if younger Age, here the ventricles tend to enlarge at a more rapid rate)
- Alzheimer’s disease
- normal pressure hydrocephalus
- ageing
Can you give sleeping pills in SAD?
No
makes Sx worse
