Psych Flashcards
What are the questions into a past psychiatric history?
Past episodes/diagnoses Previous treatments Inter-episode functioning Previous admissions Atetmpted suicides Previous detentions under mental health legislation
What are the important personal history questions?
Developmental milestones Early life Schooling Occupational Relationships Financial Friendships, hobbies/interests
What is forensic history?
Anything relating to police/detention
Contact with police
Offences WITH sentences
Particular attention to violent or sexual crimes
What is pre-morbid personality?
Their personality before they became afflicted with mental health disorder
Ie - what would friends say they were like
What is the mental state examination?
Appearance Behaviour Mood Speech Thoughts Beliefs Percepts Suicide/homicide Cognitive function Insight
What should you comment on appearance?
Height/build
Clothing - appropriate? Kempt?
Personal hygiene
Make up, jewellery etc
What should you comment on for behaviour?
Greeting Non-verbal cues Gesturing - normal? Bizarre? Abnormal movements Cooperative, rapport?
What should you comment on for mood?
Eye contact
Affect - objective manifestation of mood
Mood rating - subjective, objective
Psychomotor function
What should you comment on for speech?
Spontaneity Volume Rate Rhythm Tone Dysarthria Dysphasia
What should you comment on for abnormal thoughts??
Phobias
Obesssions
Flight of ideas
Formal thought disorder
What are some examples of formal thought disorder?
Thought blocking Fusion Loosening Knight's move Derailment Loosening
What are the types of abnormal beliefs?
Preoccupations
Over valued ideas
Delusional beliefs
What are the types of abnormal perceptions?
Illusions (misinterpreted stimuli
Hallucinations
>Pseudo or true
What are te important questions in to suicide?
Suicidal thoughts Ideation Intent Plans - specific, vague, in motion? Also homicidal risk
How do you assess cognitive function?
Orientation in time, place, person
Attention/concentration
Short-term memory - 3 objects, name and address
Long term memory - personal history
What is insight?
Insight, hindsight and foresight into current condition
Are symptoms due to illness?
Is this a mental illness
Do you agree with treatment plan?
What are the types of delusions?
Grandiose Paranoid (persecutory) Hypochondrical Self referential Nhilistic
What is a thought disorder?
A pattern of interruption or disorganisation of thought processess
What is important past medical history for psychiatry?
Developmental problems Head injuries Endocrine abnormalities Liver damage, oesophgeal caricies, peptic ulcers >Tell you about alcohol Vascular risk factors Any medications?
What is a mood disorder?
A disorder of mental status and function
>Where altered mood is a core feature
Commonest group of mental disorders
Either primary problem or consequence of another disorder
Associated with anxiety symptoms/disorders
>Includes depression and mania
When does depression become abnormal?
Persistence of symptoms
Pervasiveness of symptoms
Degree of impairment
Presence of specific symptoms/signs
What are the three spheres of symptoms of depressive illness?
Psycological
Phsyical
Social
What is the psychological sphere?
Change in mood >Depression >Anxiety >Perplexity >Anhedonia Change in thought content >Guilt >Worthlesness >Ideas of refernece >Dellusions/hallucinations (if severe)
What is the physical sphere of depressive illness?
Change in bodily function >Low energy >Sleep disturbance >Appetite (either way) >libido ?Constipation Change in psychomotor functioning >Agitation >Retardation
What is the social sphere of depressive illness?
Loss of interests Irritability Apathy Withdrawl Loss of concentration/memory
What is stupor?
State of extreme retardation in which consciousness is intact
Patient stops moving, speaking, eating and drinking
On recovery has memory of events
What are the definition guidlines for depression?
Lasts at least 2 weeks No hypomanic or manic episodes in life Not attributable to substances/organic mental disorder With at least 2 general criteria And at least 4 from additional list
Moderate/severe need more criteria
What are the general criteria for depression?
Depressed mood that is abnormal for most of the day for last 2 weeks
Loss of interest or pelasure
Decreased energy/ increased fatigue
What is the additional criteria for depression?
Loss of confidence Unreasonable feelings of guilt recurrent thoughts of suicide Decreased concentration Agitation or retardation Change in appetite
What are the needs for mild/moderate/severe depression?
Mild - 2 general, 4 total
Moderate - 2 general, 6 total
Severe - all general, 8 total
What is postnatal depression?
Depression after giving birth
What are the differentials of depression?
SAD Dysthymia Cyclothymia Bipolar Stroke, tumour, dementia Hypothyroidism Infections
How do you treat depression?
Antidepressants >SSRIs >SNRIs >TCAs Psychological treatments >CBT Physical treatmetns >ECT
What is mania?
Term describing state of feeling/mood that can range from normal to a severe life threatening illness
Considered a pathological, inappropriate elevated mood
Rarely a symptom, often associated with grandiose ideas, disinhbition, loss of judgement
What is the definition of hypomania?
Lesser degree of mania with no psychosis
Mild elevation of mood for days on end
Increased energy and activity,
marked feeling of wellbeing
Increased sociability, talkativeness, overfamiliarity, increased sexual energy and decreased need for sleep
May be irritable
concentration reduced, new interests, overspending
What is mania?
1 week, severe enough to disrupt ordinary work and social activites Elevated mood, Increased energy and activity, marked feeling of wellbeing Disinhbition Grandiosity Aleration of senses Extravagant spending
What are the differentials of mania?
Mixed affective state Schizoaffective disorder Schizophrenia Cyclothymia ADHD Stroke Tumour Infections Cushings Hyperthyroidism
How do you treat mania?
Antipsychotics
Mood stabilisers
Lithium
ECT
How do you diagnose bipolar affective disorder?
2+ repeated episodes of depression and mania or hypomania
If only depression, than it is recurrent depression
If no depression then either hypomania or bipolar disorder
What is the epideminology of bipolar?
Male=female rate
Average age 21
Early onset usually related to family history
Prevelance increased with 1st relatives
What is the eipdemiology of depression?
Females 2x more likely than males Highest risk age 18-44 Mean age is 27 Associated with lower educational attainment Increased risk in 1st degree relatives
What are the affective disorders that can be treated with pyschological therapies?
Major depressive disorder
Generalised anxiety disorder
Panic disorder and phobic anxiety disorders
Obessive compulsive disorders
What is cognitive behavioural therapy?
Explores how thoughts relate to feelings/behaviours
Particularly good for depression, anxiety, phobias, OCD and PTSD
Focuses on here an now
Short term
Problem focussed
What is behavioral activation avoidance in depression?
Social withdrawl (avoiding friends/phone) Non-social avoidance (not taking challenges) Cognitive avoidance (not taking opportunities/thinking of future) Emotional avoidance (alcohol/substance abuse) Avoidance by distraction (games, comfort eating etc)
What is the aim of behavioral activation theory?
Analyse how actions have unintended consequences
Has a non-judgmental approach
Small changes building towards long term goal
Structred adgenda with review process
What is interpersonal psychotherapy?
Treatment for depression/anxiety 12-16 weeks Focused on present Analyses how affect and interpersonal event are related Given sick role Work towards a goal using focus area Non formal homework (unlike CBT)
What is motivational interviewing?
Talking with patient encouraging them to take up changes they have already been thinking about
Why do they find it helpful?
What donāt they like?
Effectively talk through their thoughts, and then offer support
Help through stages of change
How do you diagnose alcohol dependance?
3 or more of following for more than 1 month Cravings/compulsions to take Difficulty controlling use Primacy Increased tolerance Physiological widrawl on reduction Persistence despite harmful consequences
What is alcohol widrawl state?
Tremor Weakness Nausea Vomiting Anxiety Seizures Confusion Agitation Death
Usually 48-72 hours after alcohol stopped
What are the 4Ls of alcohol problems?
Liver
Love
Liveliehood
Legal
What is korsakoffās psychosis?
Prominent impairment of recent/remote memory Preservation of immediate recall No general cognitive impairment Impaired learning and disorientation Due to thiamine deficency
What are the screening tools for alcohol abuse?
CAGE
AUDIT
FAST
PAT
What is the medicla management of a patient presenting with alcohol abuse?
Prevent wernicke/karsakoff syndrome with thiamine
Benzodiazepine (chlordiazepoxide) for alcohol widrawl
Aversion/deterrent medication
Anti-craving medication
>Acanprosate
>Naltrexone
What is best practice in psychopharmacology?
Adjust dosage for optimum benefit and safety + compliance
Use adjunctive/combination therapies if needed
But strive for simplest regime
What are the indications for antidepressants?
Unipolar and bipolar depression Organic mood disorders Schizophrenic disorder Anxiety disorders >OCD >Panic >social phobia
What are the classifcations of antidepressants?
TCAs Monoamine oxidase inhibtors - MAOIs SSRIs SNRIs - serotonin/noradrenaline reuptake inhibs Novel antidepressants
What are the potential side effects of TCAs?
Antihisteminic >Weight gain >Sedation Anticholinergic >Dry mouth >Constipation Antiadrenergic >orthostatic hypotension >Sedation >Sexual dysfunction Very lethal in overdose Can cause QT lengthening
What are tertiary TCAs?
Have tertiary amine side chains
>These cross react with other receptors which gives the side effects (more than secondary)
Act on serotonin receptors
Also used for chornic pain
How affective are antidepressants?
70% response rate
40% placebo response
What are the examples of tertiary TCAs?
Imipramine
Amitrptyline
Doxepin
Clomipramine
What are secondary TCAs?
Often metabolites of tertiary TCAs
Side effects same as tertiary, just more severe
Block noradrenaline
What are the examples of secondary TCAs?
Desipramine
Notrtriptyline
What is the MOA of monoamine oxidase inhibitors?
They bind to monoamine oxidase
Prevent inactivation of amines like noradrenaline, dopamine and serotonin
Leads to increased synaptic levels
Very effective for depression
What are the side effects of monoamine oxidase?
Orthostatic hypotension Weight gain Dry mouth Sedation Sleep disturbance Sexual disfunction
!!! Hypertensive crisis if taken with tyramine-rich foods - like cheese or wine!!!
!!!serotonin syndrome!!!
What is serotonin syndrome?
If MAOI taken with meds that increase serotonin/sympathetic actions Leads to Abdominal pain Diarrhoea Sweats Tachycardia Hypertension Myoclonus Can lead to cardiovascular shock and death
How do you prevent serotonin syndrome?
Wait 2 weeks before switching from SSRI to MAOI
>Fluoxetine needs 5 weeks
How do SSRIs work?
Block presynaptic serotonin reuptake
Treat symptoms of both anxiety and depression
What are the side effects of SSRIs?
GI upset Sexual dysfunction Anxiety Restlessness Nervousness Insomnia Fatigue Sedation Dizziness
What are the common SSRIs?
Paroxetine
>Short half life
>Significant CYP2D6
Sertraline
>very weak P450 interactions
>Short half life
>Needs full stomach
Flucoetine
>Long half life - less discontinuation syndrome
>But may build up
>Significant P450 interactions
Citalopram
>Low P450 inhibition with immediate half life
>Dose-dependant QT interval prolongation
Escitalopram
>Low inhibition of P450
>More effective than citalopram in acute response
>Dose dependant QT interval prolongation
Fluvoxamine
>Shortest half life
>Strong inhibitor of CYP1A2 and CYP2C19
What are SNRIs?
Inhibit both serotonin and noradrenergic reuptake
Without antihistamine, antiadrenergic or anticholinergic side effects that TCAs have
Used for depression, anxiety and neuropathic pain
What are teh different SNRIs?
Venlafaxine >Minimal drug interactions >Short half life >Can cause rise in BP >QT prolongation
Duloxetine
>Less BP increase compared to venlafaxine
>CYP2D6 and CYP1A2 inhibitor
>Not stable in stomach, needs capsule
What are teh novel antidepressants?
Mirtazapine 5HT2/3 receptors antagonist
>increaes cholesterol/triglycerides
Buporoprion
How do you treat resistant depression?
Combination therapy
Adjunctive treatment with lithium
Adjunctive with atypical antipsychotics
ECT
What is lithium useful for?
Long term prophylaxis of mania
And depressive episodes
Reduces suicide rate
How should lithium be prescribed?
Before starting - baseline U&Es + TSH
>Pregnancy test
Monitor - steady state achieved after 5 days, check 12 hours after last dose
Check every 3 months for TSH + creatinine
Looking for blood level between 0.6-1.2
What are the side effects of lithium?
GI distress Reduced appetite Nausea/vomiting Thyroid abnormalities Nonsignificant leukocytosis Polyuria/polydipsia secondary to ADH antagonism Hair loss Acne Cognitive slowing Intention tremor
What are the symptoms of lithium toxicity?
Mild - moviting, diarrhoea, atacia, slurred speach, dizziness, nystagmus
Moderate - symptoms of mild + blurred vision, clonic limb movements delerium
Severe = convulsions, oliguria, renal failure
What indicates a positive response for valproic acid?
Rapid cycling patients
Comorbid substance issues
Mixed patients
Patients with comorbid anxiety disorders
What is valproic acid good for?
As goo as lithium for mania prophylaxis
Not as effective in depression prophylaxis
What tests need to be done before starting valproic acid, what other consideration needs to be taken into account?
LFTs
Pregnancy test
FBC
>In women, need to start folic acid supplement
How do you monitor valproic acid?
Steady state after 4-5 days
12 hrs after last dose check LFTs
Target between 50-125
What are the side effects of valproic acid?
Thrombocytopenia = platelet dysfunction Nausea, vomiting, weight gain Sedation Tremor Hair loss Increased risk of neural tube defects due to reduced folic acid
When is Carbamazepine indicated?
Acute mania
Prophylaxis of mania that is resistant to lithium
What tests need to be carried out before carbamazepine is started?
LFTs
FBC
ECG
How do you monitor carbamazepine?
Steady state after 5 days
12 hours after last dose check levels + lfts
Target is 4-12 mcg/ml
Recheck after a month and adjust due to inducing own metabolism
What are the side effects of carbamazepine?
Rash Nausea, vomiting, diarrhoea Sedation, dizziness, ataxia, confusion AV conduction delays Aplastic anaemia Water retention Lots of drug-drug interactions
What are the side effects of lamotrigine?
Nausea/vomiting Sedation, dizziness, ataxia, confusion TEN/SJS >If any tash develops discontinue! Blood dyscrasias
What is the mesocortical dopamine pathway#?
Projects from brain stem (ventral tegmentum) to cerebral cortex
Where negative symptoms /cognitive disorders are thought to arise
Too little dopamine
What is the mesolimbic dopamine pathway?
Projects from dopaminergic cell bodies in brain stem (ventral tegmentum) to limbic system
Pathway for positive symptoms
Too much dopamine
What is the nigrostriatal dopamine pathway?
Projects from dopaminergic cell bodies in substantia nigra to basal ganglia
Movement regulation
Too little dopamine can cause parkinsonian movements due to suppression of ACh
What is the Tuberoinfundibular dopamine pathway?
From hypothalamus to anterior pituitary
Dopamine inhibits prolactin release
Hyperprolactinaemia in low dopamine
What are D2 dopamine receptor antagonists?
High potency antipsychotic
High affinity for Dā dopamine receptors
>HIgh risk of extrapyramidal side effects
What are some examples of D2 dopamine receptor antagonists?
Fluphenazine,
Haloperidol,
Pimozide.
What are the effects of low potency typical anti-psychotics?
Less affinity for D2 receptors
Tend to interact with non-dopaminergic receptors
>Results in cardiotoxic and anticholinergic adverse effects
> Includes sedation and hypotension
What are the examples of low potency typical anti-psychotics?
chlorpromazine
Thioridazine
What are atypical antipsychotics?
Serotonin-dopamine 2 antagonists
Atypical because affect both dopamine and serotonin in the 4 dopamine pathways
What is risperidone?
Atypical antipsychotic that can act like a typical at higher doses
Increased extrapyramidial side effects
Weight gain
Sedation
Very likely to induce hyperprolactinaemia
What are the side effects of olazapine?
Weight gain Hypertriglyceridemia Hyperglycaemia Abnormal LFTs Hyperprolactaemia
What are the side effects of quetiapine?
Same as olazapine although lesser extent
Although causes orthostatic hypotension
What is Aripiprazole + side effects?
D2 partial agonist
No weight gain
No QT prolongation, low sedation
However, CYP2D6 interactions
When is clozapine indicated?
Treatment resistant patients
>Due to side effects. However high effiacy
What are the side effects of clozapine?
Agranylocytosis >Requires weekly bloods for a month Increased risk of seizures Sedation weight gain + abnormal LFTs Increased hypertrigylcerideaemia, hypercholesterolaemia and hyperglycaemia
What are the adverse effects of antiphyschotics in general?
Tardive dyskinesia
>involuntary muscle movements
Neuroleptic malignant syndrome
Extrapyramisial side effects
What is neuroleptic syndrome?
severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK and lfts. Potentially fatal
What drugs can help with extrapyramidial symptoms?
Anticholinergics
Dopamine facilitators
Betablockers
What are the common anxiolytics?
Buspirone
Benzodiazipines
What is buspirone?
No sedation
Works independant of endogenous serotonin
Takes 2 weeks to kick in
Will not help if benzos have been used before
When are benzodiazapines used?
Insommnia
Parasomnias
Anxiety disorders
Also CNS depressant withdrawal protocols (eg alcohol)
What are the side effects of benzodiazipines?
Somnolence Cognitive deficits Amnesia Disinhibition Tolerance Dependence
