Psych Flashcards
SE of Clozapine for Tx-resistant schizophrenia? (after trying >/=2 anti-psychotics for at least 6wks each)
Agranulocytosis/Neutropenia (**Monitor WCC often!)
weight gain, excessive salivation, neutropenia, myocarditis, arrhythmias
NB: if clozapine doses are missed for >48hrs - must restart dose by titrating it in again carefully (OTHERWISE WORSE SE WHEN RESTARTING)
General SE of atypical anti-psychotics?
METABOLIC SEs:
Weight gain (esp Olanzapine, Quetiapine)
Hyperprolactinaemia (Risperidone; D2 inhibits prolactin release)
Dyslipiadaemia (Risperidone)
+ sedation, reduced seizure thresholds
Risk of stroke and VTE in elderly
What can cause clozapine levels in blood to rise/fall?
Rises if: Smoking cessation, alcohol binges
Falls if: Start smoking/smoking more, alcohol cessation, omitting doses
SE of ECT?
Memory impairment (retrograde memory loss - event PRIOR to ECT) Drowsiness Confusion Headache Nausea Aching muscles Cardiac arrhythmia Appetite loss
Long term: apathy, anhedonia, diff concentrating, loss of emotional responses, difficulty learning new info
Difference between mania and hypomania?
The presence of psychotic symptoms (grandiose/auditory illusions etc) + mania lasts at least 7 days (hypomania 3-4days)
Hypomania indicates ROUTINE referral to CMHT
vs. URGENT referral in mania/severe depression
What differentiates between psychosis and OCD?
Higher level of insight present in OCD but not in psychosis (delusional)
OCD associated with depression (30%), also schizo, Sydenham’s chorea, Tourette’s, anorexia
Difference between flight of ideas and Knight’s move?
Discernible links between ideas in flight of ideas. However, Knight’s move has illogical leaps
Define the following thought disorders: Circumstantiality Tangentiality Neoligisms Clang associations Word salad Knight's move Flight of ideas Preservation Echolalia
Circumstantiality = excessive unnecessary detail when answering a q
Tangentiality = wandering from a topic and doesnt return to it
Neoligisms = new word formations (combining, etc)
Clang associations = relates ideas together because they sound similar/rhyme
Word salad = incoherent sentences (real words but nonsense sentences)
Knight’s move = unexpected illogical leaps from one idea to the next
Flight of ideas = leaps from topic to topic but logical (some link between them)
MANIA (Bipolar)
Preservation = repeats ideas/words despite trying to change topic
Echolalia = repeats someone’s words, including the q asked
What food should patients taking MAOIs (Monoamine oxidase inhibitors) avoid and why?
Cheese, bovril, Oxo, marmite, broad beans (contains tyramine)
Causes a hypertensive crisis
Factors associated with increased risk of suicide?
Male Hx of self harm Alcohol/drug misuse Hx of mental illness (depression, schizo - 10% commit suicide) MHx chronic disease Advancing age Unemployment/social isolation/living alone Unmarried/divorced/widowed
+ if previous attempt, then the following confer increased risk of another (completed) attempt:
efforts to avoid discovery, planning, written note, final acts (writing a will), violent method
Protective factors against suicide risk?
Family support, children at home, employment, religious belief
What are Schneider’s first rank symptoms?
Auditory hallucinations (>/= 2 voices, third person, thought echo, running commentary)
Thought disorder (insertion, withdrawal, broadcasting)
Passivity phenomena (controlled by external influence, actions/impulses/feelings imposed on them or influenced by others)
Delusional perceptions (2 stage - first perception of normal object then sudden intense delusional insight)
+ impaired eyesight, incongruity/blunting of affect, decreased speech, neologisms, catatonia, negative symptoms (blunting, anhedonia, alogia, avolition)
Features of PTSD?
Re-experiencing (flashbacks, nightmares), avoidance, hyperarousal (hypervigilance, sleep problems, exaggerated startling, irritability, diff concentrating), emotional numbing
To diagnose: PERSIST FOR OVER 1 MONTH (DSM IV criteria)
What is Othello syndrome?
Pathological jealousy (convinced partner has been unfaithful without proof)
Isolated event or secondary to schizo, personality disorder
Poor prognostic factor of schizophrenia?
Strong FHx, GRADUAL onset, low IQ, pre-morbid Hx of social withdrawal, lack of obvious precipitant
Examples of SNRIs and what are they used to treat?
Venlafaxine, Duloxetine
Treats: Major depressive episodes, GAD, social anxiety disorder, panic disorder, menopausal symptoms
If patient is on aspirin and you are prescribing SSRI, what precautions do you need to take?
Co-prescribe a PPI to prevent GI bleeding (e.g. Lansoprazole)
First choice SSRI in a pt with Hx of cardiovasc disease?
Sertraline (esp post-MI)
Whereas Citalopram and escitalopram are associated with dose-dependent QT interval prolongation (So DONT use in congenital long QT syn or pre-existing QR prolongation)
When do you prescribe Mirtazapine instead of a SSRI?
when the pt is on warfarin/heparin
When do you prescribe Mirtazapine (NaSSA) instead of a SSRI?
When the pt is on warfarin/heparin
Usually given to older people as it stimulates appetite and is sedative (taken in evenings)
Define the following disorders regarding unexplained symptoms: Somatisation Hypochondrial Conversion Dissociative Factitious Malingering
SomatiSation (Symptoms) = OVER 2 YRS, refuses to accept negative test results
HypoChondrial (Cancer) = persistent belief of a serious underlying disease, also refuses to believe negative test results
Conversion = loss of motor/sensory function due to stress
Dissociative = ‘separating off’ certain memories from normal consciousness (+ psychiatric symptoms - amnesia, fugue, stupor) –> can develop into dissociative identity disorder
Factitious = Intentionally producing physial/psych symtoms (Munchausen’s syndrome)
Malingering = faking/exaggerating symptoms for monetary gain
Key difference between severe depression and dementia in elderly?
Severe depression - GLOBAL memory loss + RAPID onset (<6mnths) + biological symptoms + RELUCTANT to take tests/disappointed with results (variable MMSE scores)
Dementia - SHORT-TERM memory loss, GRADUAL onset
Is the use of SSRIs safe in pregnancy and why/why not?
NO - esp Paroxetine
Risk of congenital malformations (T1 - Heart defects, T3- persistent pulmonary HTN)
Features of anorexia? (what is low, high etc)
MOSTLY ALL LOW
EXCEPT Gs & Cs (GH, salivary glands, glucose, cortisol, cholesterol, carotinaemia)
Extra-pyramidal side-effects (EPSEs) of antipsychotics (+ Tx for each of them)?
Parkinsonism (CHANGE DRUG/DOSE)
acute dystonia (torticollis, oculogyric crisis –> PROCYCLIDINE)
akathisia (severe restlessness –> CHANGE DRUG/DOSE, PROPANOLOL, BENZOS)
tardive dyskinesia (late onset choreoathetoid movements - involuntary, may be irrev - chewing/pouting of jaw –> TETRABENAZINE)
NB: Do NOT give Procyclidine in tardive dyskinesia as it makes it worse!!
Risk of using anti-psychotics in elderly?
Incr risk of stroke, VTE
SE of anti-psychotics + which atypical anti-psychotic has the best SE profile?
Extra-pyramidal SE, anti-muscarinic (dry mouth, blurry vision, urinary retention, constipation), sedation, weight gain, hyperprolactinaemia, impaired glucose tolerance, neuroleptic malignant syndrome (pyrexia, muscle stiffness), reduced threshold (greater w/ atypicals), prolonged QT int (esp Haloperidol)
Aripripazole (esp good to reduce prolactin lebels)
Features of and scoring tool to assess alcohol withdrawal severity?
Features:
6-12hrs: fine tremors, sweating, tachy, anxiety
36hrs: seizures (peak incidence)
48-72hrs: coarse tremors, confusion, delirium, auditory and visual hallucinations, fever, tachy
CIWA-Ar (Clinical Institute Withdrawal Assessment for alcohol)
Scoring tool to assess severity of schizophrenia?
PANSS (Positive and Negative Syndrome scale)
Tx for alcohol withdrawal?
1st line: Benzodiazepines (Chlordiazepoxide OR in hepatic failure pts - Lorazepam)
Anti-convulsant (Carbamazepine )
Risk factors for GAD?
35-54 years,divorced/separated, living alone, being a lone parent
Protective factors for GAD?
16-24yrs, married/co-habiting
Key difference between acute and chronic insomnia?
Acute = usually related to a life event, self-resolving (no Tx needed)
Chronic = >3 months, trouble falling/staying asleep for at least 3 nights/week
RFs for insomnia?
Female, incr age, lower educational attainment, unemployment, economic inactivity, widowed/divorced/separated
(+ alcohol/drug absue, stimulant usage, corticosteroids, poor sleep hygiene, chronic pain/illness ( DM, CAD, HTN, HF, BPH, COPD, psych illness)
Tx of insomnia?
Identify any cause
Driving advice (dont drive if sleepy)
Advice on good sleep hygiene
ONLY consider hypnotics if severe daytime impairment (short-acting benzo or non-benzos e.g. Z drugs) –> lowest dose for shortest time possible; NO repeat prescriptions an review after 2 weeks + consider CBT referral
ECG features associated with bulimia?
Excessive vomitting –> Hypokalaemia (first degree HB, tall P waves, flattened T waves)
Monitoring schedule of the following during anti-psychotic use:
FBC, U&Es, LFTs
Lipids, weight
Fasting BG, Prolactlin
BP
ECG
Cardiovasc risk assessment
FBC, U&Es, LFTs: at start, annually
[EXCEPTION: Clozapine - weekly initially]
Lipids, weight: at start, 3mths, annually
Fasting BG, Prolactlin: at start, 6mnths, annually
BP: baseline, during dose titration
ECG: baseline
Cardiovasc risk assessment: annually
Ddx for GAD?
Hyperthyroidism, cardiac disease, medication-induced (salbutamol, theophylline, corticosteroids, anti-depressants, caffeine)
Tx for GAD?
Step-wise approach:
- Education, active monitoring
- low intensity psych interventions (self-help/guided self-help or psychoeducational groups)
- high intensity (CBT or applied relaxation) OR meds - SERTRALINE (warn of incr suicide risk in <30yrs + weekly follow up for 1mnth)
[[+ Buspirone (5-HT1A partial agonist), beta-blockers, benzodiazepines (diazepam, clonazepam)]]
- MDT input
Tx for panic disorder?
Stepwise:
- recognition, diagnosis
- Tx in primary care (CBT, SSRIs - if contraindic/no response after 12wks, imipramine or clomipramine offeerd)
- review and consider alternative tx
- review, refer to specialist MH services
- care in specialist MH services
Define catatonia?
** (seen in Schizo)
Stopping of voluntary movement/staying in an unusual position
SE of TCAs?
Drowsiness, dry mouth, blurred vision, constipation, urinary retention, lengthening of QT int
Which TCAs are most dangerous in overdose?
Amitriptyline (for neuropathic pain, prophylaxis), Dosulepin/dothiepin
(both have sedative effects too)
Lofepramine = LOWEST risk of toxicity
Which drugs to be avoided during SSRI use + why?
Triptans, MAOIs
Incr risk of serotonin syndrome
What occurs in metabolic syndrome from Tx with anti-psychotics?
Hyperlipidaemia, hypercholesterolaemia, hyperglycaemia, weight gain
Diagnostic criteria for depression and classification?
Core symptoms: Anhedonia, Anergia, Low mood
+ reduced concentration/attention, low self-esteem/confidence, guilt/unworthy, bleak/pessimistic views of future, ideas/acts of self harm or suicide, disturbed sleep, low appetite/weight loss, low libido, psychomotor agitation/retardation
[FOR ALL >2 weeks of symptoms]
Mild - 2 core AND at least 2 extra symp, high functioning (although distressed)
Mod - 2 core AND 3/4 extra symp, difficulty living a normal life
Severe - ALL 3 core + at least 4 other SEVERE symp, psychotic symp w/ severe depressive episodes, severe distress and/or agitation
When do lithium levels need to be checked after a dose change?
A week after and 12hrs after last dose
ONCE STABLE –> every 3 months
Which endocrine disorder occurs due to chronic lithium toxicity?
Hypothryroidism
+ Hyperparathyroidism —> Hypercalcaemia
When do the following occur after alcohol withdrawal:
symptoms
seizures
delirium tremens
symptoms: 6-12 hours (tremor, sweating, tachycardia, anxiety)
seizures: 36 hours
delirium tremens: 72 hours (coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia)
Ix for Neuroleptic Malignant syndrome (after starting/changing dose of anti-psychotics)?
High CK
High WCC
deranged LFTs
deranged U&Es
Tx for Neuroleptic Malignant syndrome?
STOP ANTI-PSYCHOTICS TREAT SYMPTOMS (cooling blankets, bromocriptine, dantrolone - muscle rigidity, benzos for agitation, AKI treatment)
