Psych Flashcards
What’s the top risk for suicide?
Previous suicide attempt or eating disorder and other mental ils
What is the difference between suicide and self harm
Intention to die = suicide. Self-harm is a coping mechanism with strong emotional distress.
What are the 4 Components of the suicide risk assessment
Risk, protective factors, suicidal ideation, level of risk + safety plan
When to do a suicide risk assessment?
1 st visit
Suicidal behaviour
Clinical chance
Inpatient before increasing Privileges or discharge
What is the threshold for considering hospitalization for sad persons score?
5+ (although no evidence for this threshold)
What does the acronym SAD PERSONS stand for?
male Sex
Age
Depression
Psychiatric disturbance / previous attempt EtOH Rational thinking loss Social isolation Organized plan No spouse Sickness
What information should you collect regarding past or recent attempts?
Circumstances, timing, plan (esp if escalation in means), intent, consequences (feelings, reactions)
Past attempts, prior care plan, length of time since previous attempt. Triggers?
How do you come up with a safety plan?
Keep safety plan in a place you can easily access. What activities that calm them down? Who they can call?
Crisis line, 911 if needed.
What language should you use in terms of suicide?
Use direct language. Avoid commit vs attempt & complete.
Do not imply that “good/great” if patient denies suicide
What are risks of violence due to the environment?
Long wait times, overcrowding, discomfort, distressing situations, evening / overnight
What are the patient-related risk factors for violence
Altered mental status: dementia, delirium, substance use or decompensated mental illness
What is agitation?
Behavioural emergency! repetitive motor symptoms, vocalizations, irritability & response to stimuli.
How do you assess violence with the DASA?
1) Negative attitude
2) impulsivity
3) irritability
4) verbal theats
5) sensitivity to percieved provocation
6) easily angered when requests denied
7) Unwillingness to follow directions
high risk is >3, must act if 1+
How do you manage agitation?
Help patient manage emotions and regain control of behaviour. Focus on safety of patient and care team.
Respectful, non-coercive.
How do you use SBAR to communicate about potentially violent situation?
Situation: what’s going on with patient
Background: clinical context
Assessment: What do I think the problem is?
Recommendation: what do I think we need to do?
What is Miller’s Law?
To understand what another person is saying, you must assume that it is true and try to imagine what it could be true of?
How do you set limits with DESC for a patient?
Describe situation to your pt.
Explain your concerns: state your concerns twice
Suggest alternatives: you want to help patient but need to feel not threatened
Consequences: be prepared to follow through with these so make sure they are realistic
What are the 2 concepts that must be present to hold a form 1.
Current risk of dangerous behaviour (self, others or lack of self care) DUE TO evidence of mental illness (not diagnosis, just evidence - mental status findings)
What timeline is allowed between seeing the patient and completing a form 1?
7 days - you can send form later if risk changes
How does the future test work on Form 1
Must link back to past/present test
Page 2
Evidence of mental illness (MSE) MUST be filled in
What is box B on a form 1?
When you know your patient really well - needs to be completed by a psychiatrist - many ANDS.
What are the 3 signatures required by the form 1? When does the 72 hrs start ticking?
Examining physician first
Then 2 sigs from the hospital
then letting the patient know with the form 42. Keep a copy on the chart.
What happens if the Form 1 is invalid?
Cannot contest form 1, but Form 3 will get thrown out if challenged at capacity / consent board.
Does the form 1 require an assessment by a psychiatrist?
No - it is not necessary, just requires an MD to do a psychiatric assessment?
What happens if the patient leaves the ED?
ED doc cannot complete form 1 if they haven’t eyeballed the patient.
What other forms allow continued involuntary detention in a psychiatric facility after the form 1 expires?
Form 3 = 14 days, requires separate MD
Form 4 = 1st lasts a month, 2nd last 2 months, 3rd lasts 3 months
Can cancel with a form 5
How do you declare someone incapable of consent to treatment?
Form 33: consent to treatment
What is the benefit of CBT beyond medication?
reduced rates of relapse after d/c treatment out to 2 years
What is the key question to answer for formulation?
Why does this patient, have this problem at this time?
Why might you want to not automatically offer a kleenex when you have a patient that is crying
It’s a boundary crossing but also it sends a message that “pull yourself together” “this is not the place to cry”
What is the benefit of CBT beyond medication?
reduced rates of relapse after d/c treatment out to 2 years
What is the key question to answer for formulation?
Why does this patient, have this problem at this time? Make a hypothesis
Why might you want to not automatically offer a kleenex when you have a patient that is crying
It’s a boundary crossing but also it sends a message that “pull yourself together” “this is not the place to cry”
What is the supportive / expressive continuum
Supportive / friendly chat (low anxiety, increasing defenses)
Expressive -> change occurs on this side, defenses go down and anxiety goes up
What is transference and counter-transference?
Transference = pt transfers emotions to therapist
What are the 2 types of counter-transference?
Counter-transference = provider transfers emotions or associations to the patient -> subjective (specific to you) vs objective (most people would respond the same way)
What is the unconscious?
Things that we are not aware of that are driving our behaviour
Name some primitive defenses
Denial, projection, acting out, splitting
Name some mature defenses
Humour, sublimation, suppression, altruism
What are the 4 domains of interpersonal therapy? What is the indication?
Loss, conflict/disputes, role transition, deficits. For depression
What is the cognitive model
Thoughts affect feelings and behaviours
“Thoughts are just ideas, just because you think it doesn’t mean it’s true”
What is Beck’s triad?
Negative thoughts about self, others/world and future
What is the timeline for improvement on general antidepressants?
Physical symptoms improve between 1-3 weeks. Emotional symptoms 4-6 weeks.
What is the relationship between antidepressants and suicidE?
Adults = NO increase in completed suicide. May be theoretical risk of increased suicidal ideation.
Adolescents (<24) = NO increase in completed suicide. Increased self-harm and suicidal ideation on antidepressants
What antidepressants are contraindicated in adolescents? Why?
Paroxetine and Venlafaxine.
Restlestness is common side-effect -> increased self-harm
When can you stop antidepressants?
1st episode = 6 months, 2nd episode = 12months, 3rd episode 2+ years
What must also be there if you are using antidepressants with bipolar
Need a mood stabilizer (this is the person that comes back on day 3 of antidepressant in mania)
How do you stop antidepressants?
Minimum 1 month to develop withdrawal. Antidepressant withdrawal is NOT lifethreatening.
Which 2 antidepressant has no withdrawal?
Prozac (fluoxetine). It’s self-tapering. Wellbutrin (bupropion)
What does SSRI withdrawal look like?
Feel like they’re being electrocuted from the top of the head to toes -> sudden decrease in serotonin. Anxious, can’t sleep, GI symptoms. 2 weeks
What is the rule of 3rds for antidepressants.
1/3 -> remission
1/3 -> significant improvement
1/3 -> partial / no response
What are drug interactions that occur with antidepressants?
Serotonin syndrome if MAOI + SSRI
Watch out for CYP-450 inhibition
What is the biochemical basis of depression
Low serotonin, norepi, or dopa
Why does it take a long time for emotions to normalize on antidepressants?
need to downregulate presynaptic receptors of serotonin back to normal levels -> they’re supersensitive to the serotonin and they’re telling the presynaptic release to shut off.
What are common side-effects of SSRIs
Sexual dysfunction (anorgasmia, delayed ejaculation), nausea, activating or sleepiness (sertraline vs paroxetine). Minor increase in bleeding risk. Sweating, tremor, brief uptick in anxiety.
What is the difference between SSRI and TCA in terms of overdose?
SSRI - no danger
TCA - Coma, Convulsions, Cardiac
TCA side effects?
Sleepy, dizzy, weight gain, anticholinergic effects
Wellbutrin - what are the indications?
Anergia, Anhedonia, sleepiness etc. esp for geriatrics
Good for suppressing cigrette and alcohol cravings. Not good for anxiety
When would you use mirtazepine?
Tea & toast diet, nervous, depressed etc.
What are the three core mood stabilizers? What other drugs have mood-stabilizing effects?
Lithium, divalproex (valproic acid), carbamazepine.
Atypical antipsychotics
What are the key side effects for lithium?
Polyuria, polydipsia, fine tremor, stomach upset, skin issues (acne), hypothyroidism. Bad for overdose
Carbamazepine - key side effects?
P450 induction, agranulocytosis, stevens johnson (rash! Canker sores!), anticholinergic side effects.
What are benzos used for?
Sleep, anxiety, seizures, muscle relaxant
What are the key issues for benzos?
Withdrawal (1+ months), memory loss (ultra-short), addiction
What are the difference categories for benzos?
Ultra-short = midazolam
Short = lorazepam
Long = diazepam
Clonazepam better for addiction because it’s slow acting
How do you talk about antipsychotics?
Neuroleptics: help you feel calm, help you organize your thoughts, help stop things that you hear and see that other people don’t see, and help with the fears and thoughts that brought you to hospital
15 minutes IM, 30 minutes oral for agitation
1-2 weeks for mood stabilization and schizophrenia
What are the differences between low and high potency typical antipsychotics?
Low potency = Sedation, dizziness, weight gain, anticholinergic effects. good for refractory sleep
Loxapine and perphrenazine -> mid potency
High potency = haloperidol, schizo EPS prolactin tardive symptoms with long term use
Atypical antipsychotics side effects?
may make obsessive behaviour worse. Metabolic effects esp clozapine and olanzapine.
What do you use for schizophrenia? What is the problem?
Clozapine - no movement disorders! no TD! antisuicidal. Worse for diabetes and weight gain. Agranulocytosis (very strict monitoring). Myocarditis, low risk, bad anticholinergic side effects.
What is the difference in mechanism of action between typical vs atypical antipsychotics?
D2 + 5HT2a blockade in atypicals undoes the dopamine blockade in some areas.
What causes TD? What does it look like?
Oversignalling of dopamine (countering haloperidol blockade). Cheek puffing, lip smacking, tongue movement, writhing extremities
What is neuroleptic malignant syndrome
Too much blockade of dopamine.
What is the general rule for personality disorder? What is the minimum age to diagnose a personality disorder?
They tend to improve even without treatment. Especially cluster B traits.
Early 20s - bc personality is still developing. Do not put the label on a minor.
What are the cluster A personality disorders?
A -
Schizoid:
Schizotypal:
Paranoid:
What is schizoid personality disorder?
Aloof, loners, no interest with interpersonal relationships.
What is schizotypal personality disorder?
Aloof, keep to themselves, bizarre ideas, but not true schizophrenia
What is the definition of true paranoia?
Fixed, false belief.
What is paranoid personality disorder?
Paranoid = not trusting, endorsing thinking that other people are after them.
What is the treatment for personality disorder?
CBT / therapy.
Prevalence of cluster A?
Tends more male > female
Prevalence is 1-2%
What are the cluster B personality disorders?
B for Bad Borderline Narcissistic Antisocial Histrionic
What are the criteria for borderline PD?
Impulsive & self-damaging behaviors Emotionally unstable Angry Empty/Adrift Chronic elevated risk of Self harm / suicide Want to get help but reject it Unstable and intense relationships; splitting. Fear of abandonment
What is the prevalence of BPD?
2-3%, more F > m
What is the biggest environmental factor that contributes to the development of BPD?
Trauma of any kind
What is the goal of hospital admissions for BPD?
Try to keep it short and focused on immediate stabilization and then discharge to community.
What type of therapy is first line for BPD?
Dialectical behavioral therapy.
What is narcissistic personality disorder?
++self centered, fragile ego, very envious, having trouble with relationship / life.
Tends to have comorbid anxiety/depression later in life.
Tends more M>F
What is antisocial personality disorder
DO NOT DIAGNOSE UNDER 18
It is conduct disorder under 18
Complete disregard for rules / authority.
Tends to be male
What is histrionic personality disorder?
Tends to use theatricality or appearance to attract attention. ++emotional.
They don’t know they are histrionic often.
more F>M
What are the cluster C personality disorders?
Avoidant
Dependent
Obsessive Compulsive Personality Disorder
What is dependent personality disorder?
Rely on others to make decisions, seek out romantic relationships, depend on others to do things
What is avoidant personality disorder?
Low self esteem; fear of judgement. Avoid interpersonal function.
What is obsessive compulsive personality disorder? How do you differentiate between OCD and it?
Very exact, tend to abide by rules, stingy with money, perfectionistic.
Pattern of excessive deference to people in authority and disregard those “beneath” them.
Like structure/rigidity, so psychodynamic therapy often helpful.
NOT OCD.
What are the common comorbidities of personality disorders?
Mood disorders, anxiety, depression, substance use, other personality disorders.
Cluster A esp. associated with schizophrenia or schizotypal.
What is a rumination disorder?
When people regurgitate food in the absence of nausea, disgust or reflux
How do you distinguish between conversion disorder and illness anxiety disorder?
One + symptoms of voluntary motor / sensory origin incompatible with known disease
Illness anxiety ppl focused on having serious illness despite diagnostic evidence to the contrary
What is the key difference that makes speech sound disorder?
Early developmental onset: patients usually normalize by age 8
When you have regression in an infant and deceleration in head circumference growth from 3 months, what syndrome and what mutation is suspected?
Rhett syndrome MECP2
What are the recommendations for treatment of conversation disorder?
CBT & physio
What additional symptoms most commonly associated with major depression with seasonality
Carb craving, weight gain, hypersomnia, low energy, typical pattern is worse in fall/winter and better in summer
What are the key criteria for diagnosis of intellectual disability?
Impaired adaptive skills (social, cognitive etc) + intellectual impairment
What is the orbitofrontal cortex responsible for?
Impulse control
How many times should you repeat the words for registration on the MoCA?
As many times as needed to reliably repeat them.
What is first line for restless leg?
Check ferritin first! If low iron, + oral
What drugs are used for restless leg
Gabapentin, dopamine agonists (pramiprexole)
What class of drugs is gabapentin?
Alpha-2-delta calcium agonist
What medication is indicated to treat somatic symptoms disorder
None / CBT
