Psych 4 Flashcards
What is charles-Bonnet syndrome?
= persistent/recurrent complex visual (/auditory) hallucinations occurring in clear consciousness, usually on a background of visual impairment
- in absence of significant neuropsych disturbance
- 1/3 find the hallucinations unpleasant/disturbing; insight usually preserved; usually transient for a few years
RFs for charles-bonnet syndrome?
commonest ophthalmological ass conditions?
- advancing age
- peripheral visual impairment
- social isolation
- sensory deprivation
- early cognitive impairment
- AMD commonest, also glaucoma & cataract common
Failure to conform to social norms with respect to lawful behaviours - repeating acts that are grounds for arrest;
Deception - repeatedly lying, use of aliases, or conning for personal profit/pleasure;
Impulsiveness or failure to plan ahead;
Irritability & aggressiveness - repeated physical fights/assaults;
Reckless disregard for safety of self/others;
Consistent irresponsibility - repeated failure to sustain consistent work behavior or honour financial obligations;
Lack of remorse - indifferent to or rationalizing having hurt, mistreated, or stolen from another
Antisocial PD
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism/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
Avoidant PD
Efforts to avoid real/imagined abandonment
Unstable interpersonal relationships which alternate between idealization & 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
Borderline PD
Difficulty making everyday decisions without XS 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 & support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
Dependent PD
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting & 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
Histrionic PD
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
Narcissistic
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not 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
Obsessive-compulsive PD
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
Paranoid PD
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
Schizoid PD
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
Schizotypal PD
MoA of benzodiazepines?
what can they be used for?
Enhance effect of inhibitory GABA by increasing frequency of chloride channels
- sedation
- hypnotic
- anxiolytic
- anticonvulsant
- muscle relaxant
How long should benzodiazepines be prescribed for?
Why ?
How should they be withdrawn?
What if they’re having difficulty?
- only prescribe for short period 2-4weeks
- can develop tolerance & dependence quickly
Withdraw in steps of about 1/8 daily dose every fortnight
If difficulty:
- switch to equivalent diazepam dose
- reduce dose every 2-3wks in steps of 2-2.5mg
- time needed for withdrawal can vary from 4wks-1yr+
Features of benzodiazepine withdrawal syndrome?
- can occur unto 3 wks after stopping a long-acting drug
- insomnia, irritability, anxiety
- tremor, tinnitus, perspiration
- loss of appetite, perceptual disturbances, seizures
Indications for electroconvulsive Rx?
Absolute C/I?
Short & long-term side-effects?
- severe refractory depression
- psychosis
- raised ICP absolute C/I
- nausea, headache
- short-term memory impairment, memory loss of events prior to ECT
- cardiac arrhythmia
long term some report impaired memory
- multiple physical Sx for at least 2yrs
- pt refuses to accept reassurance or negative test results
Somatisation disorder
- persistent belief in presence of underlying serious disease e.g. cancer
- pt refuses to accept reassurance/negative test results
Hypochondrial disorder
- Pt has Sx that involve loss of motor/sensory function
- they may be indifferent e.g. la belle indifference
Conversion disorder
- separating off certain memories from normal consciousness
- psychiatric Sx
Dissociative disorder
- if multiple personality disorder, is terms dissociative identity disorder (most severe form)
factitious disorder with the intentional production of physical/psychological Sx
Munchausen’s syndrome
fraudulent simulation/exaggeration of Sx with the intention of financial or other gain
Malingering
Features of anorexia nervosa?
- reduced BMI
- bradycardia
- hypotension
- enlarged salivary glands
Physiological abnormalities in anorexia nervosa?
- G & Cs are raised: GH, Glucose, salivary Glands, cortisol, cholesterol, carotinaemia
- low K
- low T3
- low FSH, LH, oestrogens & testosterone
Causes of aphonia?
Can’t speak
- recurrent laryngeal nerve palsy
- psychogenic
Preoccupation with an imagined 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 & size in Anorexia Nervosa)
Body dysmorphic disorder/dysmorphophobia
Post-partum in 2/3 of women typically seen 3-7 days after birth, more common in primips
- anxious, tearful, irritable
- Rx?
Baby blues
Reassurance, health visitor support
Screening for depression postpartum?
Edinburgh Postnatal Depression Scale
Post-partum in 10% with features of depression, usually start within a month & typically peaks at 3months?
Rx?
Postnatal depression
Support etc
- CBT
- some SSRIs can help if severe e.g. paroxetine & sertraline (but secreted in breast milk)
Post-partum in 0.2% with onset within first 2-3wks after birth
- severe mood swings & disordered perception?
Rx?
Puerperal psychosis
- hospital admission
- 20% recurrence in future pregnancies
Schneider’s 1st rank Sx for schizophrenia?
- Auditory hallucinations - 3rd person, echo etc
- Thought disorder - insertion/withdrawal/broadcasting
- Delusional perceptions - 2stage
- Passivity phenomena - external influence on bodily sensations, actions/impulses/feeling imposed/influenced by others
Features other than 1st rank Sx, of schizophrenia?
impaired insight blunted affect/incongruity decreased speech neologisms negative Sx inc alogia, anhedonia, avolition, affect blunted catatonia
Rx options of generalised anxiety disorder
CBT
- SSRIs 1st line e.g. sertraline; other SSRI/SNRI if not tolerated
- buspirone (5-HT1A partial agonist)
- beta-blockers
- benzodiazepines (longer-acting)
4 features & duration of Sx for Dx of PTSD?
What else can occur as a result?
- Sx > 1month of:
1. Hyper-arousal - hypervigilance, exaggerated startle response, sleep problems, irritable, difficulty
2. Re-experience - flashbacks, nightmares, repetitive & distressing intrusive images
3. Avoidance - of people, situations or circumstances resembling/ass with the event
4. Emotional numbing - lack of ability to experience feelings, feeling detached from others - anger
- depression
- etoh/substance misuse
- unexplained physical Sx
Rx for PTSD?
If drug required?
- military personnel have access to Rx by the armed forces
- if mild Sx <4wks then watchful waiting
- trauma-focused CBT or EMDR: eye movement desensitisation & reprocessing therapy if more severe
- IF drug recommended then Paroxetine/Mirtazapine recommended
Associations with OCD?
- depression 30%
- schizophrenia 3%
- Sydenham’s chorea
- Tourette’s syndrome
- anorexia nervosa
- childhood group A beta-haemolytic streptococcal infection
OCD 1st line Rx?
CBT/ERP: exposure-response prevention therapy
5 factors ass with poor prognosis with schizophrenia?
- strong FHx
- gradual onset
- low IQ
- premorbid Hx of social withdrawal
- lack of obvious precipitant
Where a patient cannot use abstraction to understand the meaning of a sentence - more common in schizophrenia ?
Concrete thinking
Main advantage of atypical over typical antipsychotics?
Examples of atypicals?
Significant reduction in extra-pyramidal side-effects
- clozapine, olanzapine, risperidone, quetiapine, amisulpride, aripiprazole
Adverse effects of atypical antipsychotics?
What about esp if used in the elderly?
- weight gain
- clozapine: ass with agranulocytosis
Elderly:
- increased risk stroke (esp olanzapine & risperidone)
- increased risk VTE
Use & monitoring of Clozapine?
What are the adverse effects?
- only use in pts resistant to other atypical antipsychotics due to significant risk of agranulocytosis
- FBC monitoring essential
Adverse effects: - agranulocytosis 1%
- neutropenia 3%
- reduced seizure threshold (can induce seizures in unto 3%)
A form of paranoid delusion with amorous quality - when someone believes a famous person is in love with them (often a single woman)
De Clerambault’s syndrome
Acute disorder in which hallucinations, delusions or perceptual disturbances are obvious but markedly variable, changing from day to day or even hour to hour
Bouffee delirante
The mistaken belief that there is a stranger present in the (deluded) person’s environment disguised as a familiar person to them
Fregoli delusion
The mistaken belief that others have been replaced by imposters, robots or aliens etc?
Capgras delusion
Common but poorly understood phenomenon whereby the expectant father experiences somatic Sx during pregnancy for which there is no recognised physiological basis
Couvade syndrome
What are the 2 preferred SSRIs, used 1st line in depression?
Citalopram & Sertraline
Which SSRI is most useful for depression after an MI?
Sertraline
Which SSRI is the drug of choice if an antidepressant is indicated in children/adolescents?
Fluoxetine
Commonest side effect of SSRIs?
What is there an increased risk of?
- GI Sx most common side effect
- increased risk of GI bleed!! - ALWAYS prescribe a PPI if they’re also taking an NSAID
- warn of increased anxiety & agitation
What is a specific risk to citalopram & escitalopram?
DOSE-dependent QT interval prolongation
- do not use if congenital LQTS, know pre-existing prolonged QT or in combo with other medicines the prolong it
- max daily dose 40mg adults, 20mg if >65yrs or if with hepatic impairment
4 Interactions of SSRIs?
- NSAIDs - inc risk GI bleed - give PPI always
- warfarin/heparin - avoid SSRIs - consider mirtazapine
- aspirin - avoid, give PPI
- triptans - avoid SSRIs
How gradually should an SSRI be stopped?
Which drug has a higher incidence of discontinuation Sx?
What are the discontinuation Sx?
- gradually reduce over 4wks
- Paroxetine has a higher incidence
Sx: - increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- paraesthesia
- GI Sx: pain, cramping, diarrhoea, vomiting
SSRIs during pregnancy
- risk during 1st trimester
- risk during 3rd trimester
- 1st: small inc risk congenital heart defects
- 3rd: persistent pulmonary HTN of the newborn
- weight up benefits/risks
- paroxetine has an increased risk of congenital malformations
A rare mental disorder where the affected patient believes that they (or a part of their body) is either dead or non-existent
Cotard syndrome
- delusion often difficult to treat and can result in significant problems due to patients stopping eating/drinking as they deem it not necessary
- ass with severe depression & psychotic disorders
A person believing their friend or relative had been replaced by an exact double.
Capgras syndrome
‘sympathetic pregnancy’
It affects fathers, particularly during the 1st & 3rd trimesters of pregnancy, who suffer the somatic features of it
Couvade syndrome
When pt believes their partner is cheating on them. They may be threatening/stalk their partner & v jealous
- seems to affect males > females
Othello syndrome
Mechanism of chronic ETOH consumption?
- chronic etoh consumption enhances GABA-mediated inhibition of the CNS (similar to benzodiazepines) & inhibits NMDA-type glutamate receptors
Mechanism of ETOH withdrawal?
- decreased inhibitory GABA
- increased NMDA glutamate transmission
(opposite to chronic ETOH consumption)
Features of ETOH withdrawal?
- Sx start at 6-12h: tremor, sweating, tachycardia, anxiety
- 36h: peak incidence of seizures
- 48-72h: peak incidence delirium tremens
Features of delirium tremens?
- coarse treor
- confusion
- delusions
- auditory & visual hallucinations
- fever, tachycardia
Rx of ETOH withdrawal?
- 1st: benzodiazepines e.g. chlordiazepoxide typicaly reducing dose
- carbamazepine also effective
- phenytoin not as effective in Rx of etch-withdrawal seizures
Features of hypo/mania?
Difference between hypomania & mania?
Mood: elevated, irritable
Speech & thought: pressured, flight of ideas, poor attention
Behaviour: insomnia, increased appetite, loss of inhibitions: sexual promiscuity, overspending, risk-taking
Mania has presence of psychotic Sx:
- delusions of grandeur
- auditory hallucinations
A fear of open spaces but also includes related aspects, e.g. the presence of crowds or the difficulty of escaping to a safe place?
1st line Rx?
Agoraphobia
- Sertraline
What is Korsakoff’s syndrome?
- marked memory disorder often seen in alcoholics
- thiamine deficiency causes damage & haemorrhage to mammillary bodies of hypothalamus & medial thalamus
- often follows on from untreated Wernicke’s encephalopathy
Features of Korsakoff’s syndrome?
- anterograde amnesia: inability to acquire new memories
- retrograde amnesia
- confabulation
Features of Wernicke’s encephalopathy?
- nystagmus
- ophthalmoplegia
- ataxia
Risk of developing schizophrenia if: monozygotic twin has it? parent? sibling? no relatives?
monozygotic twin = 50%
parent = 10-15%
sibling = 10%
no relatives = 1%
RFs for schizophrenia/psychotic disorders?
FHx is stronges RF, parent with it has RR 7.5 Black caribbean ethnicity RR 5.4 Migration RR 2.9 Urban environment RR 2.4 Cannabis use RR 1.4
Schizophrenia Rx?
Cons: offer CBT to all, CVD RF modification (linked to antipsychotics & high smoking rates)
Med: oral atypical antipsychotics
Lithium uses?
Therapeutic range?
Excretion?
MoA?
- prophylactic mood stabiliser in BPAD
- adjunct in refractory depression
- v narrow: 0.4-1.0
- long plasma half-life, excreted by kidneys
2 theories:
- interferes with inositol triphosphate formation
- interferes with cAMP formation
Monitoring of pts on lithium Rx?
- weekly lithium levels after starting or dose changes, until concentrations are stable
- check/3months once established
- levels 12h post-dose
- check TFTs & U&Es every 6months
- info booklet, alert card, record book etc
Adverse effects of lithium Rx?
- nausea, vomiting, diarrhoea, weight gain
- fine tremor
- idiopathic intracranial hypertension
- nephrotoxic: polyuria, 2ry to nephrogenic diabetes insipidus
- thyroid enlargement: may lead to hypothyroid
- ECG: T wave flattening/inversion
