Psych Flashcards
Define the term ‘psychosis’
A mental state in which reality is greatly distorted
Name and define symptoms associated with psychosis
Delusions - a fixed, false belief firmly held despite evidence to the contrary, against normal social and cultural beliefs
Hallucinations - perception in the absence of external stimulus
Thought disorder - impaired ability to form thoughts from logically connected ideas
List some differentials for psychosis
Organic - drug induced, iatrogenic (levodopa, steroids), SLE, delirium, temporal lobe epilepsy, SOL, Lewy body dementia, cushing’s syndrome, vitamin B12 deficiency, syphillis
Functional - schizophrenia, schizotypal disorder, schizoaffective disorder, acute psychotic episode, mood disorder (+ psychosis), puerperal (post partum), delusional disorder
List different types of delusions
Grandiose Persecutory Reference Guilt Nihilistic Hypochondriacal Infestation De clérambault's syndrome (erotomania) Othello syndrome (jealousy, unfaithful) Capgras' syndrome (misidentification)
List different types of hallucinations
Visual (*organic brain disease/substance misuse)
Auditory (second/third/running commentary)
Olfactory
Gustatory
Somatic (bodily sensations)
List different types of thought disorder
Loosening of association (derailment, tangential, word salad
Neologisms
Describe how to undertake a psychiatric interview (history taking)
Sociodemographic details - name, age, gender, marital status, children, occupation, religious and ethnic background
HPC - onset, severity, duration, progression, precipitating events/aggravating/relieving factors, associated symptoms
PPH - diagnoses (date, duration), previous admissions (informal, MHA), treatments (medication, psychological, ECT) and response/side effects
PMH - head injury, cranial surgery, neurological conditions (epilepsy), endocrine abnormality (thyroid, cushing’s)
DH - medication (+ psychotropic), allergies
FH - +quality of family relationships
PH - early childhood (birth complications, milestones, childhood illness, family dynamics, home atmosphere, abuse), education (attendance, enjoyment, bullying, qualifications, higher education), employment (chronological list, duration, redundancy/choice, work environment), relationships (sexual orientation, major relationships, current relationships, children), forensics (offences, sentences, arrested)
SH - accommodation, social support, finances, hobbies, alcohol (units, type), illicit drugs (cannabis), smoking (pack years)
Premorbid personality (collateral)
Describe how to undertake a mental state examination (examination)
ASEPTIC:
Appearance and behaviour - physical state (unkempt, weight, EPSE, posture), clothing and accessories, personal hygiene, eye contact, facial expression, motor activity/abnormal movements, arousal, ability to build rapport, disinhibition
Speech - rate, rhythm, volume, content, quantity, tone, dysarthria
Emotion (mood and affect) - objective, subjective, labile
Perception (hallucination) - visual/auditory/olfactory/gustatory/somatic, pseudohallucination, depersonalisation, derealisation
Thought - content (delusion, overvalued idea, obsession, compulsion), form, stream, suicide and self harm/harming others
Insight - intact, partial, non existent
Cognition - mentation to time, place and person, tools (MMSE/AMT/ACE)
List Schneider’s first rank symptoms of schizophrenia
Delusional perception
Third person auditory hallucination
Thought interference
Passivity phenomenon
Define the terms ‘mood’, ‘affect’, ‘insight’
Mood - sustained, subjective, experienced emotion over a period of time
Affect - observe a patient’s posture, facial expression, emotional reactivity and speech
Insight - extent to which the patient understands the nature of the problem and if they are in agreement with treatment
Give an example of a MSE for a patient with paranoid schizophrenia
A&B - appropriate, normal, able to build rapport
S - normal rate, rhythm, tone, no formal thought disorder
E - subjectively good, objectively euthymic, appropriate affect
P - delusion, auditory third person hallucination (reacting to stimulus)
T - persecutory delusion
I - none - no presence of illness, no desire for treatment
C - orientated to TPP, cognition normal
List risk factors for depression
FAPS: Female Family history Alcohol Adverse events Past depression Physical comorbidities Low social support/socioeconomic background
List the core symptoms of depression
Low mood
Anergia
Anhedonia
>2 weeks
List cognitive symptoms of depression
Lack of concentration, negative thoughts, excessive guilt, suicidal ideation
List biological symptoms of depression
DVM, EMW, loss of libido, psychomotor retardation, weight loss, loss of appetite
Describe how you would classify severity of depression
Mild - 2 core, 2 other
Moderate - 2 core, 3-4 other
Severe - 3 core, >4 other
What is Beck’s triad of depression?
Sad thoughts about self, World and the future
List investigations you would perform in a patient with suspected depression
Questionnaire - PHQ-9
Bloods - FBC, TFTs, calcium, glucose
Describe management of depression
Biological - antidepressants (SSRI, SNRI, TCA etc.), adjuvants, ECT
Psychological - psychotherapy, self help programmes, physical activity
Social - social support groups
List indications for ECT in depression
Life threatening severe depression Rapid response required Depression with psychotic features Severe psychomotor retardation/stupor Failure of other treatments
Give an example of a MSE for a patient with depression
A&B - unkempt, poor personal hygiene, difficulty establishing rapport, psychomotor retardation, poor eye contact, hunched position
S - slow rate, monotonous, no formal thought disorder
E - objectively and subjectively low, blunted affect
P - delusions of guilt, hallucinations
T - poverty of thought, suicidal ideation, self harm
I - good insight - accepts diagnosis and treatment
C - poor concentration
List symptoms of mania
I DIG FASTER: Irritability Distractibility, disinhibition (sexual, social, spending) Insight impaired, increased llbido Grandiose delusions Flight of ideas Activity/appetite increased Sleep decreased Talkative (pressured speech) Elevated mood, energy increased Reduced concentration, reckless, restless
List investigations you would perform in a patient with suspected bipolar disorder
Mood disorder questionnaire
Bloods - FBC, TFTs, U&E, LFT, glucose, calcium
Urine drug screen
CT head
Describe management of mania
Biological - mood stabiliser, benzodiazepine, antipsychotics, ECT
Psychological - psychoeducation, CBT
Social - social support groups, self help groups, calming activities
List ADRs of lithium
Polydipsia, polyuria (diabetes insipidus), metallic taste in mouth, fine tremor, weight gain, hypothyroidism, decreased renal function, oedema, teratogenic
*ECG - T wave flattening, widened QRS
List symptoms of lithium toxicity
Toxicity (1.5-2.0) - nausea, vomiting, coarse tremor, ataxia, muscles weakness Severe toxicity (>2.0) - nystagmus, dysarthria, hyperreflexia, oliguria, reduced consciousness, convulsions, coma, death
What investigations are required before commencing a patient on lithium therapy?
U&Es
TFTs
Pregnancy status
ECG
Give an example of a MSE for a patient with mania
A&B - flamboyantly dressed, psychomotor agitation
S - pressured speech, increased intonation, excessive punning, clang association, disinhibition
E - objectively and subjectively elated in mood, labile
P - no hallucinations, delusions of grandeur
T - delusion, loosening of association, thought acceleration
I - non existent insight
C - orientated to TPP, poor attention
List positive and negative symptoms of schizophrenia
Positive (Delusions Held Firmly Think Psychosis) - delusions, hallucinations, formal thought disorder, thought interference, passivity phenomena
Negative (As) - avolition, asocial behaviour, anhedonia, alogia (poverty of speech), affect blunted, attention deficits
Describe management of psychosis
Biological - antipsychotics, adjuvant, ECT
Psychological - CBT, family intervention, art therapy
Social - social skills training, support groups, peer support, supported employment programmes
What is anxiety?
Unpleasant emotional state involving subjective fear and somatic symptoms
List different anxiety disorders
Phobic - agoraphobia, social phobia, specific phobia
Other anxiety - panic, generalised, mixed anxiety and depressive
Obsessive compulsive
Reactional - acute stress reaction, PTDS, adjustment disorder
List common symptoms of anxiety disorders
Psychological - anticipatory fear of impending doom, worrying thoughts, exaggerated startle response, restlessness, poor concentration/attention, irritability, depersonalisation/derealisation
Cardiovascular - palpitations, chest pain
Respiratory - hyperventilation, chest tightness
GI - abdo pain (butterflies), loose stools, nausea, vomiting, dysphagia, dry mouth
Genitourinary - increased micturition, failure of erection, menstrual discomfort
Neuromuscular - tremor, myalgia, headache, paraesthesia, tinnitus
Describe how you would assess a patient’s cognitive function
GOAL CRAM(P):
General - consciousness, alertness
Orientation - awareness of surroundings (time, place, personal identity)
Attention & Concentration - focus, distractible
Language - fluency, naming, comprehension, repetition
Calculation - simple arithmetics
Right hemisphere function - hand-eye coordination (clock drawing)
Abstraction - proverb interpretation
Memory - short term (10 mins), long term (1 week)
–> MMSE, AMTS, CAMCog
What is the purpose of the mental health act (MHA)?
Allows detention and treatment of patients in the least restrictive way to minimise the undesirable effects of mental illness
Can only be used to treat mental illness
Define sections 2, 3, 5(2), 5(4), 17, 117, 135, 136
2 - detain for up to 28 days for a period of assessment and/or treatment, seen by two doctors (at least one S12 approved) and 1 AMHP, can be carried out in community/hospital *NOT prison, right to appeal within first 14 days, tribunal in 7 days
3 - detain for up to 6 months for treatment of a known mental illness, right to appeal to tribunal and hospital managers
5(2) - doctor can hold an inpatient for up to 72hrs, patient cannot appeal, can only sedate, no treatment
5(4) - MH nurse can detain inpatient for up to 6hrs for medical assessment
17 - whilst detained in hospital a patient may have leave
117 - entitled to care from the state
135 - police power to remove someone from their home to a place of safety
136 - police power to remove someone from a public place for up to 72h for an assessment by an AMHP and 1 doctor
What is capacity?
Ability to make a decision
What is the purpose of the mental capacity act (MCA)?
A right to make unwise decisions
Treatment should be least restrictive of a person’s freedom of action and their rights and must be done in their best interests
Assessment is time and decision specific
If in doubt, second opinion, ultimate referral is to the high courts
How is capacity assessed?
- The person has a disorder of brain function
- Does the person understand the information needed to make a decision
- Can they retain the information given to them
- Can they weigh up pros and cons of the information given to them
- Can they communicate their decisions by any means
- -> if a person cannot do any of 2-5, they do not have capacity
What are DOLS?
Deprivation of liberty safeguards - for patients in hospital or care homes who lack capacity and are unlikely to recover capacity e.g. dementia
List examples and ADRs of SSRIs
Fluoxetine (long half life, safe in children), sertraline (most cardioprotective), paroxetine (short half life), citalopram (long QTc/toursades)
ADRs - suicidal ideation, nausea, loss of appetite, dyspepsia, bloating, diarrhoea, constipation, hyponatraemia, headache, insomnia, fatigue, sweating, sexual dysfunction, increased risk of bleeding (aspirin, NSAIDs)
List examples and ADRs of SNRIs
Venlafaxine, duloxetine
ADRs - sleep disturbance, nausea, dry mouth, headache, dizziness, sexual dysfunction, hypotension, tachycardia
List examples and ADRs of TCAs
Amitriptiline, imipramine, clomipramine (OCD)
ADRs - dry mouth, blurred vision, urinary retention, constipation, worsening glaucoma, drowsiness, weight gain, prolonged QTc, fine tremor, *dangerous in overdoes (sudden cardiac death)
Describe serotonin syndrome
Too much serotonin from antidepressants, tramadol, amitriptyline - restlessness, excess sweating, tremor, shivering, myoclonus, confusion, convulsions, death
List examples and ADRs of typical antipsychotics
Haloperidol - sedative, EPSE
Chlorpromazine - sedative, anticholinergic side effects, EPSE
Sulpiride - less EPSE
ADRs - parkinsonism, akathisia, dystonia (*give procyclidine), tardive dyskinesia
List examples and ADRs of atypical antipsychotics
Olanzapine, quetiapine, amisulpiride, risperidone, clozapine
ADRs - hyperprolactinaemia, amenorrhoea, galactorrhea, gynaecomastia, sexual dysfunction, osteoporosis, sedation, postural hypotension, prolonged QTc interval (sudden cardiac death)
List monitoring required for antipsychotic therapy
Metabolic - weight, BMI, waist circumference, BP, glucose, lipids
ECG
*clozapine - FBC, clozapine levels
Describe neuroleptic malignant syndrome (NMS)
Rare idiosyncratic response to antipsychotics
Medical emergency
EPSE - rigidity, akinetic mutism, stupor
Autonomic dysfunction - hyperpyrexia, tachycardia, unstable blood pressure, excessive sweating, salivation, urinary incontinence
CK increased
Complications - renal failure, pneumonia, thromboembolism
List examples and ADRs of drugs used in dementia
Mild/moderate - acetylcholinesterase inhibitors - donepezil, rivastigmine, galantamine
ADRs - nausea, vomiting, anorexia, diarrhoea, fatigue, insomnia, headaches, muscle cramps, bradycardia, syncope *regular HR monitoring
Moderate/severe - NMDA antagonist - memantine
ADRs - contipation, dyspnoea, headache, dizziness, drowsiness
List different types of dementia
Alzheimer’s disease
Vascular
Lewy body
CJD, AIDS
Define the term ‘delirium’
Acute confusional state, decreased consciousness/cognitive function
Can be hypoactive/hyperactive/mixed agitation
List risk factors for delirium
Age (>65) Pre existing dementia/cognitive impairment Comorbidities AKI/CKD Male Current hip fracture Sensory impairment
List causes of delirium
Hypoxia Infection Drugs (steroids, benzodiazepines) Dehydration Pain Constipation/urinary retention
List indications for ECT
Severe depressive illness
Uncontrolled mania
Catatonia
List side effects of ECT
From anaesthesia - MI, arrhythmias, aspiration pneumonia, prolonged apnoea, nausea, adrenocortical suppression (with etomidate), malignant hyperthermia, muscle aches, death
From ECT - confusion, headache, status epileptics, stroke, arrhythmias, bleeding from ulcers, PE, raised intraocular pressures, broken teeth
List contraindications of ECT
Raised ICP, cerebral aneurysm, recent cerebrovascular event
MI within 3 months, unstable angina, DVT, potassium imbalance, uncontrolled HR/BP
Acute respiratory infection, other respiratory conditions
Recent food/fluids/chewing gum/cigarettes/sweets
Cochlear implants, phaeochromocytoma, unstable fractures, bariatric patients
*consider with pregnancy, controlled epilepsy, pacemakers
What is an intellectual disability?
A significant developmental intellectual impairment
Concurrent deficits in social functioning or adaptive behaviours
The condition is manifest before the age of 18
IQ = 0-70
Define the term ‘phobia’ and list different types
An intense, irrational fear of an object, situation, place or person that is recognised as excessive or unreasonable e.g. agoraphobia, social phobia, specific phobia
Describe panic disorder
Recurrent panic attacks not consistently associated with a specific situation or object
Describe clinical features and management of PTSD
An intense, prolonged, delayed reaction following an exceptionally traumatic event (<6 months)
1. Reliving - flashbacks, vivid memories, nightmares
2. Avoidance - avoiding reminders, ruminating, inability to recall aspects of trauma
3. Hyperarousal - irritability, loss of concentration, exaggerated startle response
4. Emotional numbing - negative thoughts, detachment
Mx - trauma focused psychological intervention (CBT/EMDR), zopiclone, paroxetine/mirtazapine/amitriptyline/phenelzine
Describe clinical features and management of OCD
Obsessional thoughts +/- compulsive acts for most days for >2 weeks.
Obessions - unwanted intrusive thoughts, images or urges, egodystonic
Compulsions - repetitive, stereotyped behaviours/mental acts, overt/covert
Obsession –> anxiety –> compulsion –> relief
FORD CAr - failure to resist, originate from patient, repetitive, distressing, carrying out thought is not pleasurable
Mx - CBT (exposure and response prevention), SSRIs, clomipramine, antipsychotic
Describe clinical features of anorexia nervosa
FEED >3 months
Fear of weight gain, Endocrine disturbance (amenorrhoea, impotence), Emaciated (BMI <17.5), Deliberate weight loss, Distorted body image
Amenorrhoea, No friends (social isolation), Obvious weight loss, Restriction of food intake, Emaciated, Xerostomia, Irrational fear of fatness, Abnormal hair growth (lanugo)
Describe clinical features of bulimia nervosa
Bulimia Patients Fear Obesity
Behaviours to prevent weight gain (vomit, starvation, drugs, excess exercise), Preoccupation with eating (compulsion –> binging +/- regret/shame), Fear of fatness, Overeating (>2 episodes per week for 3 months)
Binge eating, Use of drugs, Low potassium, Irregular periods, Mood disturbance, Irrational fear of fatness, Alternating periods of starvation
List symptoms and management of alcohol dependence
Subjective awareness of compulsion, relief drinking, withdrawal symptoms, drink seeking behaviour, reinstatement, increased tolerance, narrowing of drinking repertoire
Mx - high dose benzodiazepines (chlordiazepoxide), thiamine
List symptoms and management of alcohol withdrawal
6-12h - malaise, tremor, insomnia
36h - seizures
72h - delirium tremens
Mx - disulfiram, acamprosate, naltrexone, motivational interviewing, CBT
Describe features of delirium tremens
Cognitive impairment Vivid perceptual abnormalities Paranoid delusions Marked tremor Autonomic arousal
Describe the three different types of personality disorders
Cluster A (weird) - paranoid, schizoid Cluster B (wild) - emotionally unstable, dissocial, histrionic Cluster C (worriers) - dependent, anxious, anankastic
What are the antidotes for overdose of paracetamol, opiates, benzodiazepines, warfarin, beta blockers, TCAs and organophosphates
*activated charcoal within 1hr Paracetamol - NAC Opiates - naloxone Benzodiazepines - flumazenil Warfarin - vitamin K B-blockers - glucagon TCAs - sodium bicarbonate Organophosphates - atropine
List clinical features of delirium
DELIRIUM
Disordered thinking - slowed, irrational, incoherent thoughts
Euphoric, fearful, depressed, angry
Language impaired - rambling speech, repetitive
Illusions, delusions, hallucinations
Reversal of sleep/wake pattern
Inattention - inability to focus, clouding of consciousness
Unaware/disoriented - disorientated to time, place or person
Memory deficits
Define autism and describe the clinical features
Pervasive developmental disorder characterised by a triad of impairment in social interaction, impairment in communication and restricted, stereotyped interests and behaviours, onset before the age of 3
Asocial, Behaviour restricted, Communication impaired
List clinical features and management of hyperkinetic disorder (ADHD)
Inattention
Hyperactivity
Impulsivity
Age of onset 3-7, duration of at least 6 months
Mx - psychoeducation, CBT, methylphenidate (Ritalin) for school age, atomoxetine, dexamfetamine
List the triad of symptoms for intellectual disability
Low intellectual performance (IQ <70)
Onset at birth/during early childhood
Wide range of functional impairment (social handicap, lack of ADLs)
Define criteria for severity of LD
Mild = 50-70 (mental age 9-12) Moderate = 35-49 (mental age 6-9) Severe = 20-34 (mental age 3-6) Profound = <20 (mental age <3 years)
Describe specific congenital conditions associated with LD
Down’s syndrome - genetic disorder (trisomy 21), LD, dysmorphic facial features, multiple structural abnormalities
Fragile X syndrome - sex linked
Prader-Willi - deletion on chromosome 15, obesity, hypogonadism, behavioural problems (compulsive eating, disruptive behaviour)
Cri du chat - partial deletion of chromosome 5, high pitched cry (like a cat), low birth weight, feeding difficulties
DiGeorges - CATCH22, psychosis
