Psych Flashcards
5 stages of grief?
Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
Anger: this is commonly directed against other family members and medical professionals
Bargaining
Depression
Acceptance
When are abnormal grief reactions more common?
Women
If the death is sudden / unexpected
Anorexia nervosa features?
Physiological abnormalities
most things low reduced body mass index bradycardia hypotension enlarged salivary glands
Physiological abnormalities hypokalaemia low FSH, LH, oestrogens and testosterone raised cortisol and growth hormone impaired glucose tolerance hypercholesterolaemia hypercarotinaemia low T3
[Most things are low but
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia]
Usual use of tricyclics? Why are they less commonly used for depression?
neuropathic pain
Side effects and toxicity in overdose
Common tricyclic side effects?
drowsiness Dry mouth Blurred vision Constipation Urinary retention
Which tricyclic is usually used for management of neuropathic pain and prophylaxis of headaches?
low dose amitriptyline
Which tricyclics are most dangerous in overdose?
Least?
Dosulepin / amitriptyline
Lofepramine
Sedative tricyclic? Less sedative?
Sedative - amitriptyline
les - Imipramine / Lofepramine
How do benzodiazepines work?
Enhance effects of GABA by increasing the frequency of chloride channels
Uses of Benzos
Sedation hypnotic Anxiolytic Anticonvulsant Muscle relaxant
How long is recommended for length of time with benzo prescription?
2-4 weeks
How long does withdrawal from Benzos take? Side effects if withdraw too fast?
4 weeks - over 1yr
Insomnia, irritability, anxiety, trmor, loss of appetite, perspiration, seizures, tinitus
Way of remembering how Barbiturates work?
Frequently Bend - During Barbeque
benzodiazipines increase the frequency of chloride channels
barbiturates increase the duration of chloride channel opening
When would you use clozapine?
tried 2 antipsychotics (at least 1 atypical) for 6-8 weeks
Side effects of clozapine
weight gain excessive salivation agranulocytosis neutropenia myocarditis arrhythmias
Key Mx aspects of Schitz with first diagnosis
Offer atypical antipsychotic first line
CBT should be offered to ALL
Pay attention to CVD risk factor modification due to high rates of CVD
-Due to antipsychotics and smoking
Which are the most preferred SSRIs
Fluoxetine and Citalopram (Remember QT interval)
Most useful SSRI post MI?
Sertraline
Which SSRI in children / adolescents?
fluoxetine
Most common side effects with SSRIs ?
GI sx
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs.
When would you prescribe a PPI?
If also taking a NSAID Eg aspirin
Which SSRI affects QT interval? When should it not be used?
citalopram
congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
Key interactions with SSRIs ?
Warfarin / heparin -
Avoid SSRIs and consider mirtazapine
Triptans - avoid SSRIs
How often should you review after initiation of SSRIs ? If increased risk of suicide? Under 30?
2 weeks
1 week
1 week
How long should you stay on SSRIs after Sx improvement.?
How do you reduce?
Discontinuation Sx?
6 months
gradually over 4 weeks
Discontinuation symptoms increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
Divide up the first rank sx of schitz
auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:
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 behavior
Thought disorder*:
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’.
You are called by the husband of a 45-year-old patient who is registered at your practice. Her only history of note is type 2 diabetes mellitus treated with metformin. For the past three days he states that she has been ‘talking nonsense’ and starting to hallucinate. An Approved Mental Health Professional is contacted and makes her way to the patient’s house. On arrival you find a thin, unkempt lady who is sat on the pavement outside her house, threatening to ‘kick your head in’. What is the most appropriate action?
Call the police
Alice, an 80-year-old recently widowed woman, attends your GP practice with her daughter, who is worried about her mother’s memory. For the past few months, she’s been forgetting appointments and conversations that they had only a few days ago, needing prompting often to remember recent events. After talking to Alice she tells you she doesn’t have much of an appetite nowadays is waking up earlier than she used to. She denies any hallucinations or movement problems.
On mini mental state exam Alice scores 23, you notice she’s not properly concentrating on your questions, answering many of the questions with ‘i don’t know’.
What is the most likely diagnosis?
Depression
Only absolute CI to ECT?
Raised ICP
ECT short term side effects ? Long term?
headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia
Some report impaired memory
Features of an atypical grief reaction?
Delayed - >2 weeks pass before grieving
Prolonged - Usually over 12 months
Diagnostic criteria for Mild, moderate and severe depression?
Mild Depressive Episode:
At least 2 of the main 3 symptoms of depression, and at least two of the other symptoms, should be present for a definite diagnosis. None of the symptoms should be present to an intense degree
Minimum duration of the whole episode is about 2 weeks
Individuals may be distressed by symptoms, but should be able to continue work and social functioning
Moderate Depressive Episode:
At least 2 of the main 3 symptoms of depression, and at least three (and preferably four) of the other symptoms, should be present for a definite diagnosis
Minimum duration of the whole episode is about 2 weeks
Individuals will usually have considerable difficulty continuing with normal work and social functioning
Severe Depressive Episode:
All three of the typical symptoms should be present, plus at least four other symptoms, some of which should be of severe intensity
The minimum duration of the whole episode should last at least 2 weeks, but if the symptoms are particularly severe then it may be appropriate to make an early diagnosis
Can also experience psychotic symptoms with severe depressive episodes
Individuals show severe distress and/or agitation
2 questions used to screen for depression ?
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
2 tools for assessing depression?
Hospital anxiety and depression (HAD) scale
PHQ-9
A 16-year-old girl is brought for review by her father. She is talented violinist and is due to start music college in a few weeks time. Her parents are concerned she has had a stroke as she is reporting weakness on her right side. Neurological examination is inconsistent and you suspect a non-organic cause for her symptoms. Despite reassurance about the normal examination findings the girl remains unable to move her right arm. What is the most appropriate term for this behaviour?
Features of this?
Conversion disorder
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
What is 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
A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure you decide she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action?
Start sertraline + lansoprazol
2 features of sleep paralysis?
Mx?
Features
paralysis - this occurs after waking up or shortly before falling asleep
hallucinations - images or speaking that appear during the paralysis
Management
if troublesome clonazepam may be used
Timing for Parts of alcohol withdrawal?
Mx of alcohol withdrawal?
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hour
Management
first-line: benzodiazepines e.g. chlordiazepoxide. Typically given as part of a reducing dose protocol
carbamazepine also effective in treatment of alcohol withdrawal
Hypokalaemia on ECG?
first-degree heart block, tall P-waves and flattened T-waves
Mx of bulimia?
Refer for specialist care
1st line - CBT
Mechanism for alcohol withdrawal?
Chronic alcohol consumption - Enhances GABA and inhibits NMDA-type glutamate receptors
Withdrawal -> opposite
Criteria for diagnosis of body dysmorphic disorder
Preoccupation with an imagined defect in appearance / excessive concern over slight anomaly
Leads to significant distress / impairment in social, occupational or functioning
Cannot be accounted for another disorder Eg body shape and anorexia
Step wise Mx of GAD
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
Drug treatment
sertraline should be considered the first-line SSRI
[interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month]
Steps Mx of panic disorder
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Primary care treatment
CBT or drugs
-SSRIs are first-line.
If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
Which psychotic Sx differentiate mania and hypomania?
Sx in both (categories)
delusions of grandeur
auditory hallucinations
Mood
predominately elevated
irritable
Speech and thought
pressured
flight of ideas
poor attention
Behaviour
insomnia
loss of inhibitions: sexual promiscuity, overspending, risk-taking
increased appetite
Mx of PTSD Should you use single session debriefing? When would you watchfully wait? Which therapy? Drugs?
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
military personnel have access to treatment provided by the armed forces
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
Why can fluoxetine be stopped quicker than other SSRIs
Longer half life
