Psych Flashcards
To be diagnosed with schizophrenia, the symptoms must have lasted..
One month or more
* with at least 1st rank symptoms or 2/more other symptoms
Hypercalcaemia can present with …
Psychosis
** as well as VIT b12/folate deficiency
Both typical and atypical psychotics are
Dopamine D2 receptor antagonists
Management of schizophrenia
- patient choice
if unsuccessful: change drug
if still unsuccessful: give clozapine
** can offer CBT if still a bit of symptoms despite being on clozapine OR family psychotherapy
Size effects of clozapine include
Weight gain, sedation, hypersalivation + neutropenia - too much = epilepsy
Side effects of 1st generation drug haloperidol….
EPSE + has a direct effect on the heart
symptoms of neuroleptic malignant syndrome
- pyrexia
- raised CK
- Tachy
- Deranged LFTs + increase WBC/neutrophils
- confusion
** potential if started new antipsychotic or rapid change in doses
Psychotic episode is diagnosed if it lasted
2 weeks or less
*symptom may vary over time
Schizoaffective disorder can be diagnosed if
- presence of affective symptoms (e.g. low mood/irritability) with schizophrenic symptoms
- Duration at least 2 weeks
Persistent delusion disorder is diagnosed if
Presence of delusional symptoms in the absence of hallucinations or thought disorder
** symptoms presents for either 1 or 3 months
To be diagnosed with depression you need to have
Core symptoms - low mood, lack of energy or anhedonia
Other symptoms - loss of libido, early morning awakening, loss of appetite, feelings of guilt or worthlessness
Classification of depression
Management of depression
For mild
- 1st line: CBT
- IPT (relationship problems)
- psychoeducation/ ask about social side e.g. housing
For mod-severe
- SSRI’s i.e. sertraline/citalopram
- Can give ECT with severe depression that has not responded to other treatments
Recurrence after a first episode of severe depression
80%
Anti-depressant withdrawal symptoms
- Restlessness/parathparaesthesiaing /insomnia dizziness
- Duration: few weeks to a year
Diagnosing bipolar disorder
At least 2 episodes of significant mood disturbance
- one of which must be mania or hypomania
- and the other depression
Difference between mania and hypomania
same symptoms but different duration and impairment
e.g. grandiosity/decreased need for sleep/ pressured speech/distractibility/ flight of ideas/ increased activity
- Hypomania lasts < 7 days + not cause functional impairment
- mania >7 days + causes functionol impairment
Long-term management for bipolar disorder
- 4 weeks after an acute episode has resolved: lithium (to prevent relapses)
- if lithium ineffective consider: Valprate, olanzipine or quetiapine
Management of acute manic or mixed episode
- offer antipsychotic e.g. olanzapine/risperidone
- Mood stabilizers e.g. lithium (2nd line)
- can consider benzodiazepines to aid sleep
What to do before you start someone on lithium
- U&E’s
- TFT’ss
- Pregnancy status
- Baseline ECG
Monitored closely for SE
Management of specific phobia
1st line: self-help - CBT online/booklet or website
2nd line: CBT - graded exposure focus
3rd line: can consider antidepressants/benzodiazepines or b blockers
How to diagnose specific phobia
- marked persistent fear/anxiety of a specific object/situation
- should last 6 months
- Avoids it but can tolerate it with pain
- immediate reaction with same response each time
Social/ anxiety phobia , its symptoms
A fear of social situations due to humiliation/criticism or embarrassment - individuals are usually self critical
- somatic symptoms e.g. blushing/trembling/palpitations
- with excessive fear
ICD-10 diagnostic criteria of GAD
- Anxiety symptoms lasting 6 months or more with at least one of autonomic arousal e.g. chest pain/discomfort
- anxiety symptoms e.g. excessive worry, concentration difficulties, restlessness, sleep disturbance
Management of GAD
- Self help
- CBT (low intensity - if fails, high)
- antidepressants - SSRI (1st line)
- Consider benzodiazepine or anti-histmiane e.g. promethazine
Diagnostic criteria for OCD
- obsession/compulsion present on most days
- originates from patients mind and carrying it out is not pleasureable but reduces anxiety levels
- for a period of at least 2 weeks which causes distreess
Management of OCD
- Guided self help or computerized CBT (mild)
- SSRI (mod)
- SSRI + CBT with ERP (severe)
symptoms of PTSD
- reliving situation
- avoidance
- hyperarousal
- emotional numbing e.g negative thoughts about oneself, feelings of detachment
diagnosis of ptsd
Note: if same symptoms lasts less than a month then consider acute stress reaction as diagnosis
Treatment of PTSD
- Trauma-focused CBT
- Eye-movement desensitization reprocessing (EMDR)
- narrative exposure therapy
- can consider antidepressants SSRI/SNRI or short term sleep treatment (zopiclone)
Difference between adjustment disorder and PTSD
PTSD usually catastrophic event and lasts >6 months but AD is non-catast. and last < 6months
What antidepressants can you offer pregnant women
1st line is Setraline (as it is only secreted in 10% of breast milk and so can be continued after birth)
* needs to be avoided in 1st trimester
*avoid benzidiazepines
* can give promethazine low dose to help with sleep
Abortion is legal upto
12 weeks
Post natal depression usually presents
8-12 weeks post delivery (at worse 4-6 weeks)
Body mass indes
weight/H2
Diagnosis of anorexia nervosa
FEED
- Fear of gaining weight
- Endocrine disorder e.g. amenorrhea/loss of sexual interest
- Emaciated (abnormally low body weight): >15% below expected weight (or BMI <17.5)
- Distorted body image
***symptoms must be present for a_t least 3 months_ + in the absence of recurrent episodes of binge eating or preoccupation with eating/craving to eat
Other symptoms include
- Physical (fatigue/hypothermia/bradycardia/hair loss/ palpitations)
- Dieting/ diet pills/ self-induced vomiting/ use of laxatives
- socially isolated + sexually feared
- Symptoms of depression and obsessions
Anorexia has the highest x rate out of all psych disorders
Death
Investigations to do if investigating eating disorders
Blood results of someone with refeeding syndrome
Low phosphate, magnesium and potassium - due to a surge in insulin
Management of AN
- if BMI <14 then consider hospitalization -
- Correct electrolyte abnormality
- Aim of treatment as an inpatient is for a weight gain of 0.5–1 kg/week and as an outpatient of 0.5 kg/week
- Psycho-education about nutrition
- CBT/ cognitive analytical therapy/ IPT
- Consider SSRI if depressed
Treatment of paracetamol over dose
Intravenous N-acetylcysteine (NAC)
MHA
2 types of bulimia nervosa - what are they
- Purging type - self induced vomiting + laxatives
- non-purging type - excessive exercise + fasting/dieting
ICD-10 criteria for BN
- Compensatory behaviours to prevent weight gain
- pre-occupation with eating
- fear of fattness
- overeating
- other features include: normal/overweight/depression/ signs of dehydration
Management of BN
- Risk assess
- Guided self -help + nutritional advise
- if unsuccessful after 4 week: do CBT- ED
Diagnostic criteria for binge eating disorder
- Recurrent episodes of binge eating - associated with 3 (or more of the following)
- Eating very fast during a binge
- Eating until you feel uncomfortably full
- Eating when not hungry
- Eating alone or secretly because of feeling embaressed
- Feeling depressed, guilty, ashamed or disgusted after binge eating
- Binge eating occurs, at least once a week for 3 months
- Other physical Features: Tiredness, Difficulty sleeping, Weight gain, Bloating, Constipation + Stomach pain
Dementia diagnosis
Methods of testing cognition in dementia
- MMSE
- Glasgow coma scale
- 4AMT
What investigation would you do if you suspect dementia/delirium
- urine - rule outUTI
- blood test - hypercalaemia/ anaemia/ hypoglycaemia/ vit b12or folate deficiency
Managment of dementia
- non-pharmaco include: social support, info and communication, CBT for depression/anxiety
- Pharamco - Acetylcholinesterase inhibitors (AChE)
e.g. Donepezil, galantamine and rivastigmine. (alternative: memantine)
***cognitive enhancement and slows progression on MMSE per year and adds 6 months to placement in a home.
- Can consider antipsychotics if agitation is uncontrollable or anti-depressants for low mood
Common features of Lewy body dementia?
***& Fronto-temporal lobe
- Visual Hallucinations
- Parkinsonism
**personality changes
Delerium/confusion screening test
- Sqid
- 4AT
- CAM
Test used in the detection of mild cognitive impairment and Alzheimer’s disease
MOCA (Montreal cognitive assessment)
*other Addenbrookes (ACE-II)
there are 2 types of EUPD
- Impulsive type - lack of impulse control/anger control + outbursts of violence and threatening behaviour
- Borderline type -
- Unclear identity
- Series of suicidal threats or acts of self harm
- Unclear identity, intense and unstable relationships including sexuality
Treatment for EUPD
- Dialectical behavioural therapy
- CBT
* can consider short-term management of insomnia e.g. zopiclone
Diagnosis of EUPD - what to remember
NICE emphasises that ‘borderline personality disorder’ should not be diagnosed under the age of 18, although characteristic personality traits can be detected at an earlier age.
Diagnostic criteria for antisocial PD
At least 3 of the following
- Callous unconcern for the feelings of others.
- Frequent encounter with police
- Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations.
- Incapacity to maintain enduring relationships, although having no difficulty to establish them.
- Very low tolerance to frustration and a low threshold for discharge of aggression, including violence.
- Incapacity to experience guilt, or to profit from adverse experience, particularly punishment.
- Marked proneness to blame others, or to offer plausible rationalizations for the behavior bringing the subject into conflict with
Treatment of antisocial PD
- non-pharmacological
- psychotherapy e.g. group psychotherapy or CBT
ICD-10 definition of LD
ICD- 10 definition: Life long condition of arrested or incomplete development of the mind.
It is characterized by
- A significant global impairment of intelligence
- A significant impairment of social or adaptive functioning
- Originating in the developmental period (or before age of 18)
People with Ld are more prone to
- psychiatric illnessess e.g. schizophrenia, anxiety, depression
- Physical illnessess e.g. cancer , CVD, epilepsy
- hearing and speech difficulties
- more sensitive to side effects of drugs
Name the IQ test
WAIS
test to check for behaviour
Adaptive Behaviour Assessment System (ABAS-II)
Vineland Adaptive Behaviour Scales, (Vineland-II)
IQ ranges
Most common cause of LD
- Downs syndrome - chromosome 21 trisomy
- Fragile X syndrome - X linked dominant condition
Autism diagnostic criteria
- Carry Autism spectrum coefficient AQ-10 - 6 or more = possible autism
- others: DISCO, AAA
Features of autism
Management of autism
- Treat any co-morbodities
- non-pharma
- psychological e.g.
- CBT
- Early intensive behavioral intervention (EIBI) programs
- Communication intervention e.g. speech and language therapy
- Occupational therapy/ music therapy
- Other: Routines are helpful, Visual aids can facilitate communication, Look at changes to their environment to help (e.g. reduction in noise)
How to tell if someone is dependent on recreational drugs
DRUG PROBLEMS WILL CONTINUE TO HARM - 3 or more of
- strong desire to consume substance
- pre-occupation with substance use
- withdrawal state when substance withdrawn
- impaired ability to control substance-taking behaviour
- persisting of use with use, despite clear evidence of harmful effects
Side effects of opioids e.g. morphine/codeine
respiratory depression, hypoxia, pupillary constriction
Management of substance abuse
- motivational interviewing
- Methadone (first line) or buprenorphine for detox and maintenance
Anti-dote opioid overdose
IV naloxone
One unit of alcohol is defined as
10ml (8g) of pure ethanol
- can be worked out % x ml
- divided by 1000
Clinical features of alcohol intoxication
- slurred speech
- impaired judgement
- labile affect (excessive display of emotion)
- poor coordination
Features of alcohol dependence
- Subjective awareness of compulsion to drink.
- Avoidance or relief of withdrawal symptoms by further drinking (also known as relief drinking).
- Withdrawal symptoms
- Drink-seeking behaviour predominates
- Reinstatement of drinking after attempted abstinence.
- Increased tolerance to alcohol.
- Narrowing of drinking repertoire i.e. fixed time for drinking
An alcoholic patient presenting with delirium, nystagmus, ophthalmoplegia, and ataxia. What is this?
Wernickes encephalopathy and is due to thiamine deficiency
Treatment fo alcohol abuse
- Thiamine if patient deficient
- For dependence long term: Disulfiram, Acamprosate (reduces craving) and Naltrexone (opioid antagonist that reduce pleasurable effects of alcohol)
- Psychological
CBT, Motivational interviewing
- Social e.g. alcoholics anonymous
What to give somone for alcohol withdrawal ?
BDZ e.g. chlordiazepoxide
Delirum tremens
- Occurs within 3 days of abstinence or decreased drinking
- global confusion with hallucinations, seizures
Amitriptyline is a tricyclic antidepressant that should be avoided in
patients with suicidal ideation
- MOA: inhibits reuptake of serotonin and NA and act on cholinergic receptors and histamine
- SE: dry mouth, constipation, thirst
SSRI is prescribed for
And when should it be avoided
- Moderate to severe depression
- Avoided in those taking blood-thinning meds
Most common side effects of SSRI
Gi symptoms, csn also give tremor, rashes, sweating
SSRI MOA
Prevents the reuptake of serotonin from the synaptic cleft therefore increasing their concentration
Examples of SNRI’s
Venlafexine (second or third line in treatment of anxiety/depression)
MOA: prevents reuptake of NA and serotonin but do not block cholinergic receptors
SE: nausea/dry mouth and headaches
NASSA (noradrenaline serotonin specific antidepressants) example + MOA
Mirtazapine (often 2nd line in depression)
MOA: alpha 1 and 2 blocker
SE: increases appetite and is sedative
Prolonged QT is a particular concern in which antipsychotic
Haleperidol
Typical
Atypical antipsychotics
- Haleperidol and chlorpromazine
- Olanzepine, clonazepine
EPSE is most common in
Typical antipsychotics
- Examples include Parkinsonism, akathisia (unpleasant feeling of restlessness), dystonia (painful spasms), tardive dyskinesia
Mood stabilizers
Lithium (1st line) , sodium valproate and lamotrigine
Sodium valproate
MOA?
Avoid in?
- inhibit catabolism of GABA
- Pregnancy
- SE: GI disturbance, weight gain, ataxia, increase in agression
Lithium is first line in
Bipolar affective disorder
Side effects of lithium
Presentation of lithium toxicity
LITHIUM
- leucocytosis, impaired renal function, fine tremor, hypothyroidism, metallic taste
- Course tremor, renal failure, ataxia, convulsions/seizures and increased reflexes
Management of lithium toxicity
If signs of toxicity are identified,
- lithium should be stopped immediately
- give a high intake of fluid should be given
- IV sodium chloride therapy, to stimulate osmotic diuresis.
- In the most severe cases, renal dialysis may be needed.
Anxiolytics e.g. BDZ, busiprone or B-blockers are used as
Sedatives
- BDZ (first line)
- Can be used in anxiety, insomnia, delirium tremens and alcohol detox or violent behaviour
Examples of long-acting and short acting BDZ
- Long acting >24 hrs: Diazepam/chlordiazepoxide/clonazepam
- Short-acting <24hr: Lorazepam
BDZ MOA
- increases the inhibitory effect of GABA
What is promethazine
- antihistamine sometimes used as a sleeping pill.
- Can be given to pregnant women but for shortest period of time
Side effects of BDZ
Lighti headedness, drowsiness, confusion
Features of BDZ overdose
+ management
ataxia, nystagmus, coma, resp depression
- IV flumazenil
When to expect a lack of capactiy
CARD
- cognitive impairment
- abnormal behaviour
- refusing treatment
- delirium
CAMHS
MHA
HTT
PICU
EIP
CRT
