Psych Flashcards
what are the 5 As of dementia?
aphasia amnesia apraxia agnosia associated
how long must symptoms be present for to diagnose dementia?
6 months, must have no change in consciousness and symptoms must impair ADLs
what is BPSD
behavioural psychological symptoms of dementia
what are the areas of cognition?
only the prettiest people can actually make love continuously Orientation to Time Person Place Concentration Attention Memory Language Construction
what are contraindications to acetylcholinesterase inhibitors?
bradycardia
peptic ulcers
COPD/ asthma
if no response to acetylcholinesterase inhibitors what could you try?
NMDA receptor agonist- memantine (not in epilepsy, parkinsons medication)
what are the 5 pathological findings in Alzheimer’s?
neurofibrillary tangles Tau proteins B amyloid plaques reduced levels of ACh cerebral atrophy
what genetic condition increases your risk of Alzheimer’s?
Down’s
which medications are protective for Alzheimer’s?
statins, NSAIDs (long term), HRT
what is echolalia?
repeats what you are saying
what is palilalia?
repeats own words
what is perseveration?
patient continues to answer the same question despite a new question being asked
what is confabulation?
patient invents things without noticing
what is concrete thinking?
focusing on the facts, and the here and now
which assessment can be used to assess the areas of cognition?
primary care- GPCOP, 6-CIT
secondary care- MOCA, ACE III
what can be used to assess frontal lobe function?
luria hand test, tap test
other than medication what else should be considered in Alzheimer’s?
referral to memory team for cognitive rehabilitation/ training
emotional support
carer support
treat co-morbid anxiety/ depression
occupational therapy
social care (financial support, daycare, sitting, respite care, dementia cafe etc)
why should antipsychotics be avoided in BPSD?
increased risk of stroke, antidepressants especially mirtazapine
what are the non-core symptoms of lewy body dementia?
sleep REM disorder (acting out dreams)
severe neuroleptic sensitivity
SPECT (DaT) scan changes
what are the 3 core features of LBD?
fluctuations in cognition
spontaneous motor features of parkinsons
visual hallucinations
what are the Ninds-Airden criteria?
diagnosis if vascular dementia- presence of dementia, presence of cerebrovascular disease and relationship between the 2 inferred by; onset of dementia within 3 months following the stroke, abrupt or stepwise progression
Life expectancy of Alzheimers/ LBD/ Vascular dementia?
Alzheimer’s 6-8 years
LBD 6 years
Vascular 3-5 years
what type of dementia has the earliest onset?
frontotemporal, 45-60
what are the main differences between dementia and delirium?
speed of onset, no change in consciousness in dementia
for how long should a patient have symptoms of dependence for a diagnosis?
12 months
what are the 6 diagnostic criteria for dependence?
cravings withdrawal symptoms tolerance impaired ability to control use neglect of pleasures/ other interests in favour of alcohol persistent use despite evidence of harm
other than the CAGE questionnaire what other tools can be used to assess alcohol dependence?
CIWA, AUDIT
what are the withdrawal symptoms of alcohol?
6-12 hours: “shakes”, retching, insomnia
12-24 hours: hallucinations- tactile/ auditory
24-48 hours: DT- Delirium, seizures, persecutory delusions, coarse tremor, autonomic disturbances, insomnia
3-4 days: exhaustion and patchy amnesia
what is Wernicke’s?
caused by low thiamine, delirium, ataxia, nystagmus, ophthalmoplegia
what is korsakoff’s?
untreated Wernicke’s: hallucinations, amnesia, confabulation
treatment in acute alcohol withdrawal
thamine (pabrinex), chlordiazepoxide 20mg QDS to prevent seizures, lorazepam if seizing, motivational interview, counselling
treatment in chronic alcohol withdrawal
disulfram (antabuse)
acamprosate- must be continued for 6 months, reduces cravings
AA, CBT
how does alcohol affect the brain?
GABA agonist, depressant
what is a delusion?
a false unshakeable belief
despite evidence to the contrary
not shared by others in the same culture
held with intense personal conviction
what is a hallucination?
a perceptual experience without a stimulus but believed to be real (if know not real ie “in mind’s eye then is a pseudohallucination)
give an example of 1st person auditory hallucination
thought echo
what is 2nd person auditory hallucination?
someone talking to you eg command
what are 3rd person hallucinations?
talking about you eg running commentary
what are hallucinations as you fall asleep called?
hypnagogic hallucinations
how long must symptoms be present for a diagnosis of schizophrenia?
> 1 month
what are Schneider’s 1st rank symptoms
thought echo thought insertion thought withdrawal thought broadcasting delusional perception delusions of control/ passivity (actions/ emotions/ somatic) 3rd person auditory hallucinations
what are positive symptoms of schizophrenia?
hallucinations
delusions
thought disorder
which part of the dopamine pathway is responsible for positive symptoms?
increased dopamine in mesolimbic
which part of the dopamine pathway is responsible for negative symptoms?
mesocortical (reduced dopamine)
which part of the dopamine pathway is responsible for EPSEs?
nigrostriatal pathway
which part of the dopamine pathway is responsible for hyperprolactinaemia?
tuberoinfundibular pathway
what are the negative symptoms of schizophrenia?
avolition (reduced motivation) anhedonia alogia (poverty of speech) asociality blunted affect
when can schizophrenia not be diagnosed?
if concurrent affective disorder (unless schizophrenia preceded this-> psychoaffective disorder)
during periods of intoxication/ withdrawal
not in presence of overt brain disease (eg epilepsy)
what are the medical treatments for schizophrenia?
antipshychotics
short term- hypnotics for sleep such as zopiclone, fluids/ TPN?
what non-medical treatments are there for schizophrenia?
educate- avoid alcohol, sleep deprivation, drugs CBT family therapy CRISIS team intervention first crisis plan for relapse supported employment drug counselling
poor prognosis factors for schizophrenia?
early age of onset male single drug use abnormal premorbid personality Family history delay in treatment
name some typical antipsychotics?
haloperidol
prochlorperazine
what are contraidications to typical antipsychotics?
elderly- increased risk of stroke
parkinsons
what do antipsychotics interact with?
QT prolonging drugs- SSRIs, quinines, macrolides
what are acute dystonic reactions?
Parkinsonian movements/ muscle spasms, treat with procyclisine
what is akithisia?
feeling of inner restlesness, treat with beta blockers
what is tardive dyskinesia?
pointless repetitive movements, may not stop on stopping antipsychotic. treat with procyclisine
what is neuroleptic malignant syndrome?
rare life-threatening response to antipsychotics. rigidity, confusion, autonomic dysregulation, pyrexia, increased risk in LBD
name some atypical antipsychotics?
quetiapine
olanzapine
risperidone
clozapine
which class of antipsychotics work better on negative symptoms?
atypical/ 2nd generation
What are some side effects of atypical antipsychotics?
if end in “-pine” metabolic SEs-> weight gain, DM, lipid changes
risperidone- hyperprolactinaemia-> breast symptoms and sexual dysfunction
all- prolonged QT
clozapine- agranulocytosis
which atypical antipsychotic is most effective?
clozapine, but reserved for resistant cases as can cause agranulocytosis
what is schizotypal disorder?
chronic (>2 years) odd beliefs but not delusions and no hallucinations, unconventional beliefs and asocialisation
what is chronic low mood that doesn’t fulfil the criteria for depression called?
dysthymia
how long must depressive symptoms be present for diagnosis?
> 2 weeks
what are the 3 core symptoms of depression?
anhedonia
low mood, ? worse in am
low energy
what are the classifications of depression?
mild 2 core + 2 other
moderate 2 core + 3 other
severe 3 core +4 other
what are non-core features of depression?
initial insomnia reduced appetite reduced concentration/ attention guilt/ hopelessness suicidal thoughts reduced libido
what are the core features of mania?
elevated mood gaiety/ irritability distractable/ impulsive reduced concentration flight of ideas/ pressured speech ideas of grandeour reduced need for sleep
what is hypomania?
present > 4days, some insight, no psychosis symptoms
what criteria should be met for a diagnosis of mania?
symptoms present >7 days, symptoms of psychosis, no insight, severe disruption of ADLs
treatments of mania/ hypomania?
hypomania-> IAPT, CBT, IPT
mania atypical antipsychotics.mood diary
what is a milder version of bipolar affective disorder known as?
cyclothymia
what are the classifications of bipolar affective disorder?
type 1; at least 1 episode depression + at least 1 episode mania lasting > 7 days
type 2; at least 1 episode depression + at least 1 episode hypomania lasting > 4 days
how is bipolar affective disorder treated?
mood stabilisers- Lithium, sodium valproate, carbamezapine
in depressive episode SSRI + antipsychotics (to prevent mania)
how long must symptoms be present for a diagnosis of generalised anxiety disorder?
6 months- excessive worrying more days than not
what are the non-pharmacological treatments of anxiety?
self-help/ psycho-education groups
CBT
applied relaxation
what are the pharmacological treatments of anxiety?
SSRI
BB for peripheral symptoms?
not benzos
criteria for diagnosis of panic disorder?
> 1 month of attacks of severe anxiety, + fear of attacks + behavioural changes as a result
what advice can you give in a panic attack?
try to focus on objects around you
breathe in for 5 and out for 5
focus on senses eg touch something soft
stomp on the spot
how is panic disorder treated?
CBT
SSRI (can often increase frequency of attacks first)
avoid caffeine/ alcohol/ substance abuse
increase exercise
what is agoraphobia?
anxiety provoked by large, open spaces
what is social phobia?
fear of crowded places
What 2 criteria define OCD?
obsessional thoughts- recurrently enter a patients mind, knows own thoughts but can’t dismiss them
compulsive acts- repetitive behaviours, give no pleasure and recognised as pointless, often done to avoid an unlikely event
what are the treatments for OCD?
combined pharmacological and non-pharmacological works best
CBT/ exposure and response prevention, repeated graded exposure
SSRI esp fluoxetine/ sertraline/ TCA
what is an acute stress reaction?
emotional reaction to severe physical/ mental stress,
appears minutes- hours after event and lasts 2-3 days
may have amnesia, disorientation
when does the onset of PTSD occur?
months- years after the event (usually <6months)
name some symptoms of PTSD
re-experiencing of events through "day-dreams"/ dreams flashbacks avoidance of activities rumination increased startle reaction numbness and emotional blunting
what is the treatment for PTSD?
psycho- trauma focussed CBT, eye movement desensitision + reprocessing (EMDR), relaxation therapy
bio- SSRI or mirtazipine if co-morbid depression
how long should “normal” grief last?
< 2 years (would expect <6 months)
what are the stages of grief?
shock denial anger (self-blame?) bargaining depression testing acceptance
what is an abnormal grief reaction?
delayed onset
prolonged
delay at 1 stage for a long time
what are risk factors for an abnormal grief reaction?
sudden death
having to put on a brave face eg if has kids
ambivalent relationship
what is conversion disorder?
anxiety causing medically unexplained neuro symptoms eg amnesia, pseudoseizures, paralysis
what is munchausen/ facticious syndrome?
invents symptoms to be cared for
what is somatisation disorder?
medically unexplainable symptoms
what is malingering?
invention of symptoms for secondary personal gain such as avoiding prosecution
how does hypochodrial disorder differ from somatisation?
somatisation= unexplainable symptoms hypochondria= patient thinks they have disease
what are common types of purging?
diet pills laxatives diuretics exercise vomiting
what is the definition of anorexia?
weight <15% expected/ BMI <17.5
+ secondary endocrine/ metabolic disturances
what are complications of anorexia?
amenorrhoea loss of libido myopathy bradycardia hypotension electrolyte imbalances-> arrhythmias osteoporosis renal failure pancreatitis/ hepatitis seizures peripheral neuropathy
what guidelines should be consulted in the management of someone with anorexia nervosa?
MARSIPAN guidelines
which SSRI is most effective in bulimia?
fluoxetine
borderline personality disorder
instability in interpersonal relationships, self-image, affect. impulsivity
antisocial personality disorder
disregard for/ violation of the rights of others
histrionic personality disorder
excessive emotion, attention seeking
narcissistic personality disorder
grandiosity, need for admiration
avoidant personality disorder
social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation
dependent personality disorder
clingy behaviour
schizoid personality disorder
detachment from social relationships, reduced emotional expression
paranoid personality disorder
distrust and suspiciousness
obsessive-compulsive personality disorder
preoccupied with orderliness, perfectionism and control
schizotypal personality disorder
acute discomfort in close relationships, cognitive or perceptual distortions, eccentric behaviour
what are contraindications to SSRIs?
peptic ulcers, epilepsy, previous mania (can increase recurrence)
what are side effects of SSRIs?
GI upset
headaches and drowsiness
increased suicide risk
withdrawal symptoms if stopped suddenly (insomnia, hyperarousal)
which drugs do SSRIs interact with?
NSAIDs (increased risk of GI bleed)
QT prolonging drugs
MAOI (risk of serotonin syndrome)
what is serotonin syndrome?
autonomic hyperactivity (fever) + altered MS + muscular excitation-> tremor seizures
give an example of an SNRI
venlafaxine
what should venlafaxine be avoided in?
CVD
what class of antidepressant is mirtazipine in?
NaSSa
What are 2 advantages of mirtazipine?
increased appetite
sedative effect
what are some side effects of TCAs?
antimuscarinic (dry mouth, constipation, urinary retention, blurred vision) sedation and weight gain, prolonged QT and heart block
when should TCAs be avoided?
recent MI/ CVD
severe liver disease
epilepsy
recent suicide attempt (TCAs toxic in OD)
what foods should be avoided with MAOIs?
tyramine rich foods; cheese, red wine, smoked fish
also decongestants
cause a hypertensive crisis
what is DBT used for (dialectical behavioural therapy)
personality disorders
how long is a course of ECT?
2x a week for 12 weeks
what is the response rate for ECT?
70-80%
what are side effects of ECT?
Nausea,
headache
amnesia around time of ECT
how long post-recovery should antidepressants be continued for?
6 months
what level of Li is toxic?
> 1.5mmol/L (TI is 0.5-1)
how often should Li levels be checked?
initially after 5 days
then weekly until stable for 4 weeks
then every 3 months
what other bloods should be checked regularly if on Li?
check renal function before starting
6 monthly TFT, U&Es, Ca
pregnancy test? avoid in pregnancy
Side effects of Lithium
GI metallic taste fine tremor thirst, polyuria, oedema/ weight gain long term- hypothyroidism, renal tox, diabetes insipidus
symptoms of Li toxicity?
coarse tremor, Vomiting, dysarthria, dizziness, ataxia, delirium, fits
interactions of Li
avoid with NSAIDs and ACEIs/ thiazides as impair excretion
suicidal assessment, what do you want to know about the lead-up to the event?
- precipitant eg argument with spouse
- was it planned
- final acts- note, will, cancel direct debits eg gas
- precaution against discovery
suicidal assessment, what would you like to know about the event?
- method, including where procured weapon/ medication
- alcohol involved
- what was their intention
suicidal assessment, what would you like to know about after the event?
- did they call anyone
- how did they feel when help arrived
- current mood/ intention
- protective factors
in a suicidal assessment how would you screen for other mental health disorders?
depression: anhedonia, low mood, fatigue
psychosis: “are the thoughts to hurt yourself ever not your own?”, hear voices
alcohol dependency
anorexia
what investigations if suscpecting dementia?
Bloods: FBC, U+E, LFT, ESR/CRP, B12/ folate, Ca to look for reversible causes
CT head
AMTS questions
- Year
- Time
- Age
- DOB
- where are we
- give address
- count 20-1
- ww2 date
- current monarch
- name 2 people
what symptoms should you warn someone of if starting them on galantamine/ rivastigmine/ donepazil?
initially GI disturbance, sleep disturbance and muscle cramps, Should settle in <3 weeks
What imaging would you do if suspecting frontotemporal dementia and what would it show?
MRI, frontotemporal atrophy
mnemonic for assessing risk
DR SONEC: Driving Self Others Neglect Exploitation Children
how would you treat an abnormal bereavement reaction?
bereavement counselling, CBT, monitor suicide risk
pseudodementia
cognitive impairment arising from depression
first line treatment for mild depression?
CCBT/ self help
sleep hygiene
activity programmes
social e.g- citizens advice bureau for financial issues
when are first line treatments for mild depression not appropriate?
when symptoms have been present >/= 2 years or PMHx of moderate/ severe depression
Non-pharmacological treatment of moderate depression?
CBT
IPT
Behavioural activation
psychodynamic therapy
which side effect of SSRIs is it important to make men aware of?
erectile dysfunction (other side effects include muscarinic, and hyponatraemia)
what is a section 2?
allows section for 28 days
must be signed by 2 doctors and ASW (one should know patient, ASW= Approved social worker)
cannot be renewed
for assessment
what is a section 3?
for treatment, last 6 months
can be renewed
ASW must seek approval of relatives
What is a Section 4?
admission for emergency
lasts 72 hours
must be signed by 1 doctor and ASW
can be converted to section 2 after review by another doctor
What is a section 135?
police enter patients house and remove to place of safety for 72 hours
what is a section 136?
police pick up a patient from public place and take to place of safety
investigations pre starting an antipsychotic?
ECG and HR Prolactin, lipids, cholesterol HbA1c FBC, U+E, LFT weight and BP
