Psych Flashcards
What are the different types of primary delusions?
Autochthonous delusions- appear out the blue
Delusional mood- feeling a sinister event is about to take place
Delusional perceptions- interpret normal stimulus with delusional meaning
Delusional memory- delusional interpretation of past event
In psych, Capgras syndrome
A type of misidentification delusion: someone close has been replaced by an identical looking imposter
In psych, Fregoli’s syndrome
A type of misidentification delusion:
strangers are actually familiar people in disguise
Different types of somatic hallucinations in psychosis
- Tactile- sensation of being touched or strangled
cocaine use = insects crawling under the skin - Kinaesthetic- limbs are being bent, muscles squeezed
- Visceral- internal organs being pulled/ electric shocks
What is the difference between hallucinations and pseudohallucinations?
Patient locates sensation within their own mind- ‘in my head’
May occur in borderline personality disorder, fatigue, bereavement
What are the organic causes of psychosis?
AIDs Brain- brain tumours, stroke Cocaine, LSD, ectasy Delirium, Dementia, Drugs (steroids, dopamine agonists) Epilepsy (temporal lobe)
What are the positive symptoms of schizophrenia?
- Hallucinations
- Delusion
- Ideas of reference- innocuous events believed to have great personal significance
What are the negative symptoms of schizophrenia?
Lack of activity and motivation
Lack of speech and emotional responsiveness
Few leisure interests
Social withdrawal and lack of convention
What tends to be different about the auditory hallucinations in schizophrenia compared to bipolar disorder
In schizophrenia- voices tend to discuss individual in 3rd person like a commentary ‘he/her’
In bipolar- tends to be in 2nd person ‘you’
2 of which symptoms needs to be present for most of a month in the DSM-V classification of schizophrenia?
- Delusions
- Hallucinations
- Disorganised speech
- Grossly disorganised or catatonic behaviour
- Negative symptoms
How long must continuous signs of disturbance be present for in the DSM-V classification of schizophrenia?
6 months
Which allele puts people at risk of schizophrenia if they smoke cannabis?
Valine at position 158 in COMT enzyme
COMT degrades dopamine
What neurochemical changes occur in schizophrenia?
- increased dopamine (mesolimbic + prefrontal cortex)
- decreased glutamate activity (GABA-Rs)
- increased 5-HT activity (decreased 5-HT 2aR in frontal cortex)
Antipsychotic medications are most effective against which aspects of schizophrenia?
Positive symptoms- delusions, illusions etc
How long do antipsychotics take to work in schizophrenia?
2-4 weeks
What is the difference between a primary and secondary delusion?
Primary- appears suddenly without any mental event leading up to them
Secondary- follows a change in mood, hallucination or another delusion
What is schizoaffective disorder?
Bipolar- delusions go away after two weeks of mood stabilising.
Schizoaffective- delusions/hallucinations continue once mania/depression has passed.
Other schizophrenic symptoms present.
What is the difference between schizophrenia and delusional disorder?
Delusional disorder = symptoms have lasted 1 month
Schizophrenia = symptoms have lasted 6 months
How long do brief psychotic disorders have to be to be classified as such?
more than 1 day, less than 1 month
with eventual return to normal functioning
Which types of hallucinations tend to suggest more of an organic cause than a psychiatric cause?
Elementary (simple) auditory hallucinations- noises
Visual hallucinations
Olfactory hallucinations
What two features characterise delirium?
Delusions/hallucinations
+
altered level of consciousness
What symptoms classify a mild depressive episode?
2 of: (mind, body, soul) mind- anhedonia body- reduced energy/activity soul- depressed mood
2 of:
mind- reduced concentration, pessimistic thoughts, ideas of self-harm
body- disturbed sleep, less appetite
soul- guilt/unworthiness, less self-esteem/confidence
NB count each , ___ , as one
How is a moderate depressive episode classified differently to a mild depressive episode?
mild- two A and two B symptoms
moderate- two A and three B symptoms
A= anhedonia, reduced energy/activity, depressed mood
B= pessamistic, self harm thoughts, reduced concentration
disrupted sleep, less appetite
low self-esteem, guilt/unworthiness
How is severe depressive episode classified?
all of type A + 4 of type B symptoms
A: anhedonia, low energy/activity, depressed mood
B: pessimism, ideas of self harm, low concentration
disrupted sleep, appetite
low self-esteem/confidence, guilt unworthiness
How long does depressed mood need to be present for to classify a mild, moderate or severe depressive episode?
2 weeks
What is Cotard’s syndrome in psychiatry?
In severe depression with psychosis, this is a rare syndrome where patient has a delusional belief that they are: dead or do no exist or are putrefying or have lost their blood/internal organs
What organic causes can prompt a depressive episode?
Glands:
Hypothyroidism
Cushing's (ACTH)
Hypoparathyroidism
SEs of steroids or antihypertensives
DementiaWho benefits from antidepressant medication?
Evidence suggests only the most severely depressed patients
What neurotransmitter in which area is thought to cause positive symptoms in schizophrenia
Brainstem to limbic system- too much dopamine might cause positive systems
Which neurotransmitter in which area is thought to cause negative symptoms in schizophrenia?
Brainstem to mesocortical system- too little dopamine might cause negative systems
Why are atypicals used first line instead of typical antipsychotics in schizophrenia?
Less severe side effects, not extra-pyramidal ones
Why do antipsychotics cause movement disorders in schizophrenia?
Brainstem to basal ganglia- blocking dopamine causes movement disorders leading to too much acetylcholine (so needs Anti-Ach)
Blocking dopamine receptors in the hypothalamus causes what side effects in antipsychotics?
Brainstem to hypothalamus- blocking dopamine leads to hyperprolactinaemia
Start an antipsychotic for schizophrenia but it doesn’t work, so switch drug. How long should you wait to see if response?
4-6 weeks
If two medications are tried and don’t help for a patient with schizophrenia, what is the next line?
For treatment resistant schizophrenia:
Clozapine
What is the risky side effect of high dose antipsychotics?
(May occur by giving dose above BNF recommendation or two combined drugs that work in the same way)
Why does this side effect arise?
Long QT syndrome- cardiac arrhythmia
Due to blocking K+ channels
What extrapyramidal SEs occur with schizophrenia medication- antipsychotics?
Dystonia- torticollis, occulo-gyral crisis
Tardive dyskinesia- irreversible
Akathisia- restless, moving around alot
How should dystonia SE be eased in a patient taking antipsychotics?
Procyclidine IM or IV if acute
(antimuscarinic)
Switch from typical drug to an atypical
What can be given to psychotic patients taking antipsychotics who have developed restlessness and are constantly shifting and fidgeting?
Propranolol- b blocker for AKATHISIA
extrapyramidal SE
What is the danger of antimuscarinics?
Patients can get addicted as it causes euphoria, may fabricate extrapyramidal SEs
watch out if previous substance misuse issues
CIs for anticholinergics?
Untreated urinary retention
Glaucoma
GI obstruction
(causes muscle relaxation)
Patient has fever, confusion and rigidity
PMH: schizophrenia
DHx: recent change in antipsychotic meds
Obs: HR 105
What might be occurring?
What blood test would give elevated result?
Rx?
Malignant Neuroleptic syndrome
Elevated creatinie kinase
Rehydrate
Ventilate
Sedate (benzodiazepines)
don’t Hesitate to withdraw antipsychotic
What antipsychotic medication might work well once someone has had neuroleptic syndrome?
One that can be washed out quickly:
Short half life
Doesn’t bind to dopamine receptors very tightly
eg.
What medical checks can be done to check for antipsychotic medication SEs?
Prolactin levels- hyperprolactinaemia Weight- weight gain Blood glucose- diabetes BP standing or sitting- postural hypotension ECG- CVS impact
Random drug screens- if think misuse problems
What is the big risk of clozapine?
What tests need to be preformed prior to treatment?
Tests during treatment?
Agranulocytosis
Before:
FBC- look at WBCs and RBCs
ECG- arrhythmia
During:
FBC- weekly then fortnightly for 18 weeks then monthly (after a year)
What are the CI for Clozapine antipsychotic?
Carbamazapine (epilepsy)
Cytotoxics
Carbimazole (hyperthroidism Rx)
as all increase risk of neutropenia
What is the risk of patient taking clozapine and smoking?
When someone stops smoking, it had previously been causing enzyme induction so loss of this causes reduced metabolism of clozapine and increased drug levels + toxicity.
Patient is having a violent psychosis. Have no background information on the patient. What to do temporarily?
Rapid tranquilization- Lorazepam
For a manic episode with no prior diagnosis what medications are considered?
If this doesn’t work?
Stop antidepressant
1st: antipsychotic
2nd: alternative antipsychotic
3rd: add lithium
4th: try valproate
For elderly patients taking lithium for Bipolar Disorder, how often do they need monitoring?
Every 3 months ish
Check renal function- GFR, creatinine, urea etc
What blood abnormality are patients taking valproate at risk of?
Thrombocytopenia
How does valpoate influence warfarin levels?
Causes increase in active drug level leading to raised INR because valproate displaces protein-bound Warfarin (that is inactive) to become free Warfarin (that is active).
For someone in a depressive phase of their bipolar disorder, what can be given?
SSRI- antidepressant
+ mood stabilizer- to prevent manic swing (like olanzapine or lamotragine)
What is the big side effect of lamotragine we worry about?
Rash- Stephen Johnson syndrome
Bipolar Disorder long term Rx?
once out the manic or depressive phase
1st: lithium
2nd: lithium + valproate
How long ideally should a mood stabiliser be tapered off for before stopping?
3 months ish
What is the risk of overdose in citalopram?
Long QT syndrome- citalopram is an SSRI
Patient switching between SSRIs for their depression. Has become restless and confused.
Notice there is a tremor present.
Why?
Seratonin syndrome
For Rx resistant depression, not eating or drinking, what are the options?
Venlafaxine
SSRI + Mirtazepine
add lithium
add antipsychotic- if symptomatic
ECT
What symptoms do you get when you discontinue antidepressants?
Restlessness Mood change Sleep difficulty Unsteady Sweating GI effects
Risk factors for hyponaturaemia when taking antidepressants?
old age
female low birth weight
low baseline Na+
hypothyroidism
diabetes
concurrent medication
warm weather
Why would someone with Parkinson’s be more at risk of psychotic symptoms?
Reduced dopamine break down in the gut wall by dopa decarboxylase leads to increased dopamine agonism.
Why are elderly people more at risk of anti-cholinergic side effects and delirium?
Lower levels of ACh
Lower levels of acetyl transferase
Lower levels of post-synaptic ACh receptors
Definition of delirium?
An acute, transient, global, organic disorder of higher nervous system function involving altered consciousness and attention
What changes in mood may be associated with delirium?
Anxiety Depression Lability Irritability Aggression
Common infectious causes of delirium in the elderly?
Respiratory
Urinary
Cellulitis
CNS: encephalitis + meningitis
Commoner metabolic causes of delirium in elderly?
hypo/hyperglycaemia uraemia hepatic failure electrolyte disturbance hypoxia
Medications that may be causing delirium in elderly:
Anticholinergics (inc. digoxin, warfarin, cimetidine) psychotropic drugs steroids anticonvulsants overdose
What two criteria need to be met in IDC for delirium?
Acute onset/fluctuating course
Inattention- spell WORLD backwards or count down from 30
+1 of:
incoherent, illogical speech
or disorganised thinking
or altered level of consciousness
Rx options for delirium?
Rx to avoid? why?
antipsychotics- haloperidol/olanzipine
try to avoid benzodiazipines due to falls risk
What would you look for on an MRI to identify Alzheimers?
Bilateral hippocampal atrophy
Alzheimers patient with PMH bradycardiac. Rx?
Can’t give anti-cholinesterase
give Mimantine (glutamate blocker)
Term for when person fails to recognise relatives + friends etc
prosopagnosia
Which antipsychotic is used in lewy body dementia where they are having hallucinations?
Clozapine as it acts on D4 receptor rather than D2
Avoid most antipsychotics as they’re dopamine antagonists
If want to differentiate between lewy body dementia and alzheimers what test can be performed?
DaTscan
dopamine transporter scan
What are the beneficial side effects of mitazipine for old age depression?
Weight gain and sleep
for little old ladies who are having difficulty sleeping
What side effects does Olanzapine (Antipsychotic) cause?
Metabolic syndrome
What is the risk of giving a patient with dementia antipsychotics (especially in the long term)
Increased risk of stroke
What is the risk of giving delirious patients sleeping tablets to sedate them?
It causes drowsiness rather than sleep so will increase falls risk. Shouldn’t be given for walking around shouting, only give if actually hitting out (harm to themselves or others)
If hallucinations present, what conditions are less likely?
Neurosis- hypochondria, obsessive behaviour, depression, anxiety
Personality disorder
(Could be schizophrenia, affective disorder, organic disorder, paranoid state)
What are hypogogic and hypnopompic hallucinations?
Hallucinations that occur as someone wakes or falls asleep.
Doesn’t indicate pathology.
What type of hallucinations are more suggestive of an organic disorders?
Tactile and visual hallucinations
(Without auditory hallucinations)
Could be alcohol withdrawal or Charles Bonnet syndrome (failing vision in elderly)
Which condition are primary delusions associated with?
Schizophrenia
Delusion arrived fully formed with no events or experiences to account for it
What factors are most important in a risk assessment of risk towards self and others?
- Previous violence (PMH)
- Substance abuse (DHx)
- Lack of empathy (PC)
- Stress (SHx)
What characteristics of amnesia make it more likely to be due to dissociation rather than an organic cause?
Dissociative more likely: distant and near memories
Organic: short term memories impaired (holding 7 things in mind)
What diurnal variation in mode is typical of depression?
Low mood tends to be worse in the mornings
What categories can depression be classified with?
Mild, moderate, severe
± biological features
± delusions/hallucinations
± manic episodes (if bipolar)
What alterations of receptor distribution are found in the brains of whose who have committed suicide?
Excess 5-HT2 receptors in the frontal cortex
May suggest lack of 5-HT
What treatment may help in perimenopausal depression?
17b-estradiol, by exerting hormonal effects on neurone activity
What factors of depression suggest a good response to antidepressants?
Presence of biological features or stress
Which supplements may reduce suicidal behaviour?
Omega 3 supplements
What are the three P’s defining characteristics of personality disorders?
Pervasive- effects all types of relationships (work, home)
Problematic
Persistent- lasting more than a year, always a problem
What characteristics and personality types are found in Cluster A of personality disorders?
Odd/eccentric:
Paranoid
Schizoid (solitary, indifferent, aloof)
Schizotypal (isolated, odd beliefs)
Main difference between schizoid and schizotypal personality disorder?
Schizoid don’t form relationships because no desire to, whereas schizotypal fear interactions and so don’t.
Both cluster A (odd/eccentric behaviour)
What characteristics and types of personality disorder are associated with cluster B?
Dramatic or emotional behaviour:
Antisocial (psychopathic)
Borderline (Impulsive, unstable extremes of emotion)
Histrionic (attention seeking, lively, flirtatious)
Narcissistic (self-important, vanity)
What characteristics and personality disorders come under cluster 3?
Anxious or avoidant behaviour:
Avoidant (feel inadequate, shy, hypersensitive)
Dependent (reliant on others for emotional/physical needs)
Obsessive-compulsive (perfectionism)
What’s the difference between OCD and obsessive-compulsive personality disorder?
OCD is an anxiety, behaviours are unwanted and thoughts seen as involuntary.
OC personality disorder sees behaviours as rational and desirable
What management options can be used to help people with Dangerous and Severe Personality Disorder?
CBT
Anti-libidinal drugs (SSRIs or anti-androgens)
Risks of anti-androgens (Cyproterone acetate)?
Liver damage Breast growth Hot flushes Depression Reduced bone density
GnRH analogues may be better.
How can benzodiazepines be used to reduce the chance of benzodiazepine withdrawal syndrome occurring?
Use on alternate nights
Short term use
What happens in benzodiazepine withdrawal syndrome?
After 1 week: anxiety or psychosis Then months of gradually reducing (HIPA): hyperactivity insomnia panic agrophobia depression
What can benzodiazepine withdrawal be confused with?
Multiple Sclerosis due to:
Diplopia, parasthaesia, fasciculation, ataxia
What helps patients give up benzodiazepines?
3 things
- Switch to long-acting benzos (diazepam)
- Communicate:
advantages
A contract to say if weekly supply is used up early, no further supply
Likely effects of withdrawal - Withdraw 2mg/week
How much should diazepam be reduced by when weaning off benzodiazepines?
2mg per week
What SSRI can help with withdrawing someone from antidepressants?
Why?
Fluoxetine
Has a long half life so stable level
If sudden peak and trough, then body tries to compensate for deficit by taking pill again
What is discontinuation syndrome?
When does it occur?
Occurs about 5 days after a patient stops taking antidepressants.
Thought to be due to temporary deficit of neurotransmitter in the brain.
What symptoms are associated with MAOi discontinuation syndrome?
MAOi= increased levels of seratonin, melatonin, adrenaline, noradrenaline
Head: Agitation, irritation, reduced cognition, pressured speech
Shoulders: movement disorders
Knees + toes: ataxia
Eyes: insomnia (reduced melatonin)
Symptoms associated with tricylics discontinuation syndrome?
Awake:
Flu symptoms
Arrhythmia (rare)
Asleep:
Insomnia
Increased dreaming
Symptoms associated with SSRI discontinuation
Dizzy
Headaches
Flu-like symptoms
Tears/fury/irritability
Insomnia
Dreaming increased
Which SSRI is most troublesome to discontinue?
Paroxetine
Due to short half life (fluoxetine has long half life)
Which tricyclics are most troublesome in causing discontinuation syndrome?
Imipramine
Amitriptyline
Which class of antidepressants can’t be co-administrated with others if swapping drug?
MAOi
Especially tranylcypromine
After stopping a MAOi how long should you wait before starting a new antidepressant?
2 weeks
(The time taken for Monoamine Oxidase to be replenished)
Or 24 hours if moclobemide
Clomipramine (TCA) can’t be co-administered with which other class of antidepressant?
Why?
SSRIs or Venlafaxine (SNRI)
Risk of seratonin syndrome, excess seratonin causes restlessness, sweating, myoclonus, confusion
What happens in serotonin syndrome?
Restless Diaphoresis- sweating Tremor, myoclonus, shivering Confusion Convulsion Death
For how long after stopping Fluoxetine might you get interactions?
5 weeks, due to long half life
What behavioural therapies may be used for phobias?
Flooding (in vivo)/Implosion (imagined): exposure to stimulus until habituation
Systematic desensitisation: exposure with relaxation techniques in a graded fashion
What behavioural techniques may be used for anxiety?
Relaxation training Response prevention (dirty cup, stop patient cleaning it)
What behavioural therapies may be used for sexually deviant behaviours?
Thought stopping- use sudden intrusion like elastic band on wrist to interrupt thoughts
Aversion therapy/covert sensitisation- unpleasant stimulus with exposure
Group therapy
What symptom in severe depression may make CBT less likely to work?
Poor concentration
What situations does group psychotherapy tend to help with?
Addictions (including drug and alcohol)
Personality disorders
Major medical illnesses
Victims of childhood sexual abuse
Which psychological disorder benefits most from intensive group cognitive therapy?
Social phobia
What is intensive group cognitive therapy?
16 group sessions in 3 weeks
Which personality disorders don’t tend to gain benefit from group therapy?
Extreme schizoid (aloof, cold)
Narcissistic (self-admiring)
Paranoid
What are the indications for counselling?
What disorders won’t be suitable for it?
- Current problems and stressors (acute psychological distress in response to life events)
- Brief anxiety disorders
NOT personality disorders (too deep-rooted)
What medications may affect sexual function?
SSAAPP
SSRIs Alcohol Antihypertensives- b blockers Phenothiazines (typical antipsychotics) Pill, finasteride (some anti-androgen effects)
In premature ejaculation, when a partner is about to ejaculate, what can the partner do?
Squeeze the penis at the frenulum (the attaching bit of skin by the bell of the penis)
Traits of high expressed emotion
Hostility
Emotional over-involvement
Critical comments
Contact time
What are the main signs of depression in children and adolescents?
(ERSATZ)
Existential hopelessness Relationship issues Sexual issues Anger in the face of conflicting adult values Tearfulness when it all goes wrong overZealous attachment to false gods
Medication for adolescent with major depression?
Fluoxetine 10mg/d
Escitalopram 10mg/d
But not first line Rx by NICE
Which antidepressants should be avoided for under 18s?
SSRIs of:
Citalopram
Sertraline
Paroxetine
Tricyclics
Venlafaxine (SNRI)
Charles Bonnet syndrome?
Failing vision in the elderly leads to complex visual hallucinations- often faces
In olfactory hallucinations, which investigations should be considered?
MRI/CT head
Likely organic cause
What can cause day time sleepiness in children/adolescents?
Reduced sleep at night Sleep apnoea Depression Narcolepsy Encephalitis lethargicans (rare, + extrapyramidal effects, mood change)
What is the pathogenesis of narcolepsy?
Which HLA is associated?
Autoimmune destruction of hypocretin (orexins)-containing neurones in the hypothalamus.
Orexin is an excitatory neuropeptide involved in maintaining wakefulness
HLA DR2 +ve
4 features of narcolepsy
Daytime sleepiness
Attacks of sleep ± hallucinations at sleep onset
Cataplexy (sudden atonia)
Sleep paralysis
Encephalitis lethargicans is characterised by sleepiness combined with which features?
Sleepy + EPSEs: caused by flu, measles etc
dystonia, myoclonus, oculogyric crisis
mood change, obsessions, inversion of diurnal rhythm
Clearly defined parasomnias in children are a risk factor for what later in life?
Tonic clinic nocturnal epileptic seizures
parasomnia = abnormal behaviours, emotions, perceptions around or during sleep
Autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) occurs due to a mutation in which gene?
NACh receptor alpha 1 subunit
A father and his two sons all have violent behaviour in their sleep, with sudden awakening, and dystonic movements. The father is believed to have nocturnal epilepsy, what rare heritable disease might they all share?
Autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE)
Related to nAChR mutation
For those with parasomnias, what medications can be tried?
Clonazepam (GABA-a binder, benzo)
Amitriptyline (TCA)
Carbamazepine (GABA agonist + Na channel inactivator)
What physiological changes occur during REM sleep?
Breathing is irregular
BP rises
Decreased muscle tone
Antidepressants may suppress which phase of sleep
REM
What serious conditions are associated with REM sleep behaviour disorders?
(Violent movements rather than atonia)
Parkinson’s
Dementia
Alcohol or drug withdrawal
What treatment can be offered for REM sleep behaviour disorder?
Moving during REM phase, when normally atonic:
Mattress on the floor, sleep alone
Clonazepam 0.5mg at bedtime (enhances GABAergic inhibition)
What three features characterise autism spectrum disorders?
- Impaired reciprocal social interaction
- Impaired imagination (abnormal communication)
- Restricted activities and interests
Severity of autism correlates with what during pregnancy?
Testosterone level in the amniotic fluid
Which other neurological problem do 30% of those with autism suffer from?
Epilepsy
These comments might be typically describing an infant with which condition before age 2:
He doesn’t respond to his own name, he hates change in routine, is not interested in toys.
Autism
What is dyslexia characterised as?
Reading ability doesn’t match IQ level- a ‘specific learning difficulty’
Aside from reading what other difficulties might someone with dyslexia have?
(Large scale to small)
Left/right muddle Jumbling of text Telling if words rhyme Verbal short term memory- eg phone numbers Telling number of syllables
Which chromosomes have genes linking to dyslexia on them?
1, 2, 6, 15
6 = association with autoimmune disease as near the HLA complex
Why are autoimmune diseases thought to be associated with dyslexia?
Possible dyslexia -related genes found near HLA complex on chromosome 6
What is a possible cause for dyslexia on a gross neuro anatomical level?
Weak connectivity between anterior and posterior language regions in the brain and the angular gyrus
(PET scanning shows less activation of language areas when given short-term verbal memory tasks)
What 2 changes were introduced in the 2007 Mental Health Act?
- Community treatment orders to allow compulsory treatment
- Patients with severe antisocial personality disorder may be detained prior to committing a crime if deemed a significant enough danger to themselves or others.
How long does a community treatment order last?
6 months, then may be renewed
What aspects relating to capacity are included in the 2007 Mental Health Act?
(Name 2)
- No ECT can be given in capacitous refusal except in an emergency where life-saving treatment or prevention of serious deterioration is required
- 16 and 17 year olds capacitous refusal of treatment cannot be overridden by parental authority
How long does a Section 2 detention of the Mental Health Act last for? What is it’s purpose?
28 days
Assessment and initial treatment
How long does a Section 3 of the Mental Health Act last? Why is it given?
What is the length of renewals?
6 months
Care and treatment for the therapeutic benefit of the patient.
May be renewed twice to give 6 month extensions, then 1 year extensions after that.
What extent of force is legally justified in community treatment orders to ensure a patient takes compulsory medication?
Force proportionate to the likelihood of serious harm to the patient
What conditions are required for detention of a patient under the 1983 mental health act?
Needs to have a mental disorder
That needs to be treated
Or detention needed to protect patient or others
If patient is detained under Section 2 of the MHA 1983, if patient wishes to appeal, how soon should the appeal be sent to a tribunal?
Within 14 days
A Mental Health Tribunal that assesses a patient’s appeal against detention under mental health act is composed of which three types of people?
- a doctor
- a lay person
- a lawyer
What aspects of diagnosis are necessary for a Section 3 of the Mental Health Act to be used to detain a patient?
The exact mental disorder must be stated
How long does detention under Section 4 of the Mental Health Act last? What is it for?
72 hours
Emergency treatment
One doctor may recommend it and social worker or family member makes application of the section
Which would a section 4 (72 hours) be given rather than a section 2 (28 days) in the mental health act?
Section 2 requires:
social worker/nearest relative + 2 doctors from different hospitals (one who is psych consultant or senior registrar)
Section 4 requires:
Social worker/nearest relative + 1 doctor
So used in emergency where need to have no delay
Often converted to a section 2 in hospital
Under what circumstances can Section 5(2) of the mental health act apply?
How long does it last?
If patient it already in hospital- in a ward not A&E
Lasts 72 hours
In a section 5(2) of the mental health act, who administers it?
The clinician in charge, not necessarily any psych specialism.
Lasts 72 hours for patients currently in hospital already
Which section can psychiatric nurses detain under?
How long does it last?
Section 5(4) Lasts 6 hours
Which section allows police to detain a person in a public place if suffering from a mental disorder?
Section 136
Lasts 72 hours
Which 3 sections under the mental health act allow for detention of a patient for up to 72 hours?
Where are these applicable, who issues it?
Section 4- urgent treatment (one doctor) Section 5(2)- on a ward (one doctor) Section 136- from public place (police)
Which section is needed to retrieve an at risk mental health patient from private property?
Who else needs to be present?
Section 135
Requires medical practitioner/approved social worker + police
Name three examples of treatments that don’t just require patient consent but also a second opinion (under Section 57 of the MHA)
For treatments deemed very restrictive that involve:
- Destruction of brain tissue
- Impaired functioning afterwards
- Implanting hormones to reduce male sex drive
When someone is detained under section for mental health, how long can they be given medication without their consent before an independent doctor must decide if it is necessary?
3 months
Which sections of the mental health act do not allow for administering medication without consent?
Those for emergency detention:
Section 4
Section 5 (nurses and already on ward)
Section 136 (police holding)
Who decides if you have a 14 year old child with capacity and their parent making different decisions about treatment?
Child’s view trumps parent if they have capacity
For patients with suspected seasonal affective disorder, presence of which symptoms suggests light therapy is more likely to be useful?
Winter symptoms of:
Hypersomnia
Carbohydrate craving
Weight gain
Where is the most important site of retinal cells found that projects to the suprachiasmatic nucleus (hypothalamus) to control circadian rhythms?
Nasal retinal cells, important for light exposure in SAD
Which antidepressants used 1st line for seasonal affective disorder?
SSRIs
Newer ones: AGOMELATINE resynchronises circadian rhythm
For seasonal affective disorder, what is the advantage of newer antidepressant argomelatine over SSRIs?
Less sexual dysfunction
How long does post-natal depression normally take to resolve?
6 months post birth
Which antidepressants tend to be safe for breastfeeding with?
SSRIs- Fluoxetine
TCAs
What other treatments may help with postnatal depression if severe?
Lithium
ECT
What is the normal upper limit of a QT interval?
470ms in female
440ms in males
Over 500ms is worrying, think about stopping antipsychotics depending on risk benefit analysis
What dangerous side effect of starting Clozapine could a leukocytosis indicate?
What investigations would exclude this?
Myocarditis
Check Troponin, baseline echo
Symptoms of delirium tremens
Hallucinations (auditory, tactile, visual), agitated, confused
Obs: increased HR and BP, Temperature
Which scale can be used to quantify amount of Chlordiazepoxide for alcohol withdrawal?
CIWA scale
Lorazepam and Olanzepine together for rapid tranquilization puts patients at risk of what?
Hypertension
Which medications can precipitate psychosis?
Steroids
Chemotherapy
Antibiotics
What medication is given for alcohol withdrawal?
Chlordiazepoxide
Gentleman in hospital 3 days ago requires sectioning, which can be used?
Section 5(2).
What are first rank symptoms in schizophrenia?
(Tend to be distinctive of schizophrenia)
Auditory hallucinations- 3rd person, echo, running commentary
Passivity phenomena- feel emotions, thoughts and actions are being controlled
Thought insertion, withdrawal, broadcasting
Delusional perception- normal stimulus (red light) linked to delusion
What is the differential of schizophrenia?
Organic: Epilepsy- especially temporal lobe CNS infections, tumours, strokes Other CNS disease- Huntinton's, Wilson's, leukodystrophy, SLE, autoimmune encephalitis Drug induced psychosis
Psych
Affective disorder
Delusional disorder (transient psychosis)
Personality disorder
Features of temporal lobe epilepsy (commonest localised partial seizure type)
Series of old memories resurface
Familiar things may appear strange
Hallucinations
What do the terms ‘flight of ideas’ and ‘loosening of associations’ tend to point towards?
Flight of ideas- mania
(Links between ideas remain)
Loosening of associations- schizophrenia
(knight’s move thinking, fragmented thinking)
Treatment for catatonic state?
High dose benzodiazepines (IV Lorazepam)
Despite it being a sedative
Which psych condition is associated with post-partum psychosis?
Bipolar disorder
What is the risk of re-occurrence in a mum who gets post-partum psychosis with next pregnancy?
50%
Iatrogenic hypomania/mania is characterised as what category of bipolar?
Bipolar III
How long does high mood need to last for it to be considered an episode?
1 week
How long does a hypomanic episode need to last for it to be considered an episode?
4 days
What is rapid-cycling bipolar disorder? which medication is less effective for it?
4 mood-extreme episodes within a year
Lithium
Worse prognosis.
Which antipsychotics are useful in bipolar disorder
Olanzapine- sedative effect is useful in acute manic phase
Quitiapine- better for bipolar II (cyclothermia)
What is the average age of onset for depression?
28
What is binge drinking defined as?
Double the recommended limit in one session
>6 units in women, >8 units in men
How do you work out units of alcohol?
10ml of pure (100%) alcohol
How many units is there in a 12% 750ml bottle of wine?
12% of 1000ml = 100 x 10ml in 1 litre so 100 x0.12 = 12 units
12% of 750ml = 9 units
Bipolar disorder Rx
How does Rx change if predominantly a depressive episode or manic episode?
For prevention of depressive episodes?
Acute mania: antipsychotic + stop SSRI
Acute depression: SSRI + antipsychotic
Long term: lithium +/- anticonvulsant
What Rx acts as a preventative for depressive episodes in Bipolar disorder?
Lamotrigine
OCD Rx?
1st line: CBT
2nd: SSRIs
Higher dose than depression
Which atypical has least effect on appetite and weight gain?
Aripiprazole
Difference between atypical and typical antipsychotics in terms of mechanism?
Typical- D2 antagonists
Atypical- 5-HT2, D4 and weak D2 antagonists
Difference between typical and atypical antipsychotic side effects?
Strong D2 antagonism in typical antipsychotics leads to extra-pyramidal side effects and hyperprolactinaemia
Less of a problem in atypical antipsychotics
How do atypical and typical antipsychotics differ in how they address positive and negative symptoms of schizophrenia?
Typical- positive symptoms
Atypical- positive and negative symptoms
Triad of symptoms for Wernicke’s (from alcohol abuse)
- Ataxia
- Nystagmus
- Opthalmaplegia
what does dementia mean?
Chronic persistent disorder of cognitive deficit in one or more domains affecting daily functioning
(Domain could be memory, language, orientation etc)
Common side effects of ssri’s?
Nausea (5-ht released by stomach)
Gi upset
Restlessness
Insomnia
Common side effects of tricyclic antidepressants
Anticholinergics
Dry mouth, blurred vision
Confusion, memory loss (in elderly)
What vision do you need to be allowed to drive?
So long as one eye is 6/12
And visual fields of sixty degrees round each side
Reflexes are not assessed
Girl aged 5, normal development until age 2 but now has epilepsy and episodes of limb spasticity, hand wringing and hand flapping. She has irritability and now severe learning disabilities
Rett’s- x linked dominant
What is the difference between genetic cause of angelman and prader-willi syndrome?
Both involve chromosome 15 deletions
Angelman: maternal chromosome
Prader-willi: paternal chromosome
Child with jerky movements (unable to walk) and hand flapping, severe epilepsy and learning difficulties.
Ehx- prominant jaw
Angelman syndrome
When do women normally present with postpartum psychosis?
What type of mental illness does it come under?
Within 7 days, after before day 3
Bipolar disorder
What psych medications should you avoid breastfeeding with?
Clozapine
Depots
Lithium
Carbamazepine
Young person with suicidal depression started on an SSRI, how regularly would you want to see them after starting the drug?
Every week to assess risk, SSRI increases risk
1st line Rx for generalised anxiety disorder?
CBT
Which drugs raise lithium levels?
ACE inhibitors
Thiazide diuretics
NSAIDs
Due to affects on kidneys
Metabolic abnormality associated with refeeding syndrome?
Physiological problems?
Low phosphate
Confusion, seizures, arrhythmias
10 year old has a temper, argues with parents alot, defiant, shifts blame and gets angry easily. Name that disorder
Oppositional defiant disorder
What is the difference between oppositional defiant disorder and conduct disorder?
Oppositional defiant disorder is a subcategory of conduct disorder, but lacks the serious violation of other people’s rights.
Rx for behavioural disorders?
Parent training programmes- for under 12s
Older children- cognitive therapy
Multi-systems therapy
Four features of conduct disorder?
Behaviour that is: Aggressive- violates rights of others, or animals Destructive- vandalism etc Deceitful- theft, lying Defiant- rule breaking, truancy
What is mertazipine used for?
Depression where inability to sleep is a problem
Commonest cause of genetic learning difficulties?
Downs syndrome
Cause of fragile X?
CGG repeat in non-coding region of the long arm of X chromosome
Commonest inherited form of learning disability?
Fragile X
Inherited, Downs is genetic but most people with Down’s have infertility so not inherited
How does depression present differently to anxiety in someone with learning difficulties?
Anxiety- more sympathetic symptoms, tremor, hyperventilation, self-harm, drinking more water (dry mouth)
Depression- tearful, irritable, sleep disturbance etc
Essentially the biological symptoms of both
What are the triad of features in autism?
Communication problems
Social problems
Narrowed range of interests and hobbies
Organic mimics of anxiety disorder?
Phaeochromocytoma Hyperthyroidism Mitral valve prolapse Arrhythmias Hypoglycaemia
Questions to ask about if someone has PTSD to check for co-morbidity?
Rx?
Depression
Substance abuse
Rx: SSRIs, benzos
Trauma focused CBT, eye movement desensitisation disorder
What is the difference between ICD and DSM criteria for bipolar affective disorder?
ICD- need two manic or hypomanic episodes
DSM- one episode
Type 1 = manic episode
Type 2 = hypomanic episode
Main differences between mania and hypomania?
Mania- lasts 1 week, severe interference
Hypomania- lasts 4 days, some interference with function
What is the difference between bereavement and adjustment disorder?
Both last 6 months
Adjustment is depression triggered by a major event that isn’t a death
What are the boundaries for mild moderate and severe learning difficulties?
All below 70 IQ Mild: 50-70 Moderate: 35-50 Severe: 20-35 Profound:
What are the 3 main features of learning disabilities?
Onset during development period (18 months)
Intellectual disabilities
Difficulty adapting
What proportion of learning disability are due to features pre-birth?
60%
What are the physical health problems someone with fragile X might get?
Epilepsy
Mitral valve prolapse
Ear- Otitis media
What behavioural/mental disorders are those with fragile X at risk of?
Autism 50%
Low IQ
Social anxiety, shyness, ADHD
What is the SCOFF questionnaire to ask when suspecting an eating disorder?
Ever make yourself SICK because you feel too full?
Worry that you’ve lost CONTROL over eating?
Recently lost ONE stone in 3 months?
Believe you are FAT when others say you are thin?
Does FOOD dominate your life?
What happens to the FBC in someone with anorexia?
Low WCC, low platelets, low Hb
Red flag observations for anorexia?
Including BMI
BMI
Red flag U+E and ECG results for anorexia?
K+
What is the definition and management of moderate anorexia?
BMI 15-17.5, no systemic failure
Routine referral to community mental health team
Which electrolyte is it most important to monitor on re-feeding in anorexia?
Phosphate (becomes very low)
Also low K+, high Mg2+ and high glucose may occur
What is the Kleine Levin syndrome?
Lethargy, excessively sleepy, overeating, hypersexuality occurring for week long periods every so often for decades.
Often follows a viral infection
Medical Rx for moderate-severe bulimia?
Fluoxetine
In someone with a positive syphilis-specific test result, why ask about travel history?
Other syphilis treponemes can give a +ve result
What is early and late latent syphilis defined as?
Early 2 years of primary infection
Before what age do symptoms need to be present for a diagnosis of ADHD?
Age 7
How long do symptoms need to be present for to get a diagnosis of ADHD?
6 months
+ pervasive (at home, at school)
+ severe disruption of function
How does treatment change if you have ADHD and a tic?
Methylphenidate (Ritalin) no longer first line Rx as it makes tic’s worse
Atomoxetine (SNRI) is 2nd line
