Psych conditions Flashcards
Causes of cognitive decline
Dementia Depression Wilson's Disease Hypothyroidism Alcoholic dementia Brain injury
Alzheimer’s presentation
Struggle to remember recent events
Gradual deterioration in global cognitive function - memory loss goes back in time
Amyloid plaques and tau protein
Life expectancy for Alzheimer’s
7 years after diagnosis
Treatment for Alzheimer’s
Donepezil (acetylcholinesterase inhibitor)
Memantine (NMDA receptor antagonist)
Presentation of vascular dementia
Stepwise progression in memory loss, previous stroke, difficulty in concentration, seizures, speech disturbance
Treatment for vascular dementia
Treat risk factors e.g. hypertension, AF. Only use AChE inhibitors if have co-existing Alzheimer’s
Lewy body dementia presentation
Progressive cognitive impairment, early attention impairment, fluctuating cognition, visual hallucinations, parkinsonism
Treatment of Lewy body dementia
Acetylcholinesterase inhibitors (donepezil, rivastigime) and memantine (NDMA inhibitor) can be used.
What medication should be avoided in Lewy body dementia
Antipsychotics can lead to irreversible parkisonism.
What are features of frontotemporal dementia (Pick’s disease)
Onset before 65 Insidious onset Relatively preserved memory Personality change and social conduct problems Disinhibition Increased appetite
Management of frontotemporal dementia
AChE inhibitors (donepezil) or memantine
What are some rarer causes of dementia
Huntington's CJD HIV B12 deficiency Syphilis
Treatment for anxiety
Cognitive behavioural therapy, phobias - systematic desensitisation
SSRIs (sertraline)
AVOID BENZODIAZEPINES
may use proranolol etc to treat tremor
Treatment for OCD
CBT, clomipramine (tricyclic antidepressant) or SSRIs
Core depression symptoms
- Persistent sadness or low mood
- Loss of interest/pleasure
- Fatigue or low energy
Diagnostic criteria for depression
At least 1 core symptom most days, most of the time for at least 2 weeks
Associated depression symptoms
Disturbed sleeo Poor concentrtion or indecisiveness Low self-confidence Poor or increased appetite Suicidal thoughts Agitation or slowing of movements Guilt or self-blame
What would be classed as mild depression
Four symptoms (at least one core symptom)
What is moderate depression
Five to six symptoms
What is severe depression
Seven or more symptoms +/- psychotic symptoms
Two questionnaires to screen for depression
Hospital Anxiety and depression scale
PHQ-9
Depression treatment
CBT, sleep hygiene, SSRI, TCA
Examples of SSRI
Sertraline, citalopram, fluoxetine, paroxetine
General side effects of SSRIs
GI symptomas, agitation, hyponatraemia
Side effects specific to citalopram
Prolonged QT interval, don’t use in those with long QT syndrome
Which SSRI would be used post myocardial infarction
Sertraline
Which SSRI would be used in children
Fluoxetine
How should an SSRI be stopped
Dose gradually reduced over a 4 week period (not fluoxetine)
SSRI discontinuation symptoms
Increased mood change Restlessness Difficulty sleeping Unsteadiness Sweating GI symptoms Paraesthesia
SSRIs and pregnancy
Weigh up risks and benefits. Small increased risk of congenital heart defects in first trimester.
Can cause persistent pulmonary hypertension of newborn in third trimester.
Examples of SNRIs
Venlafaxine, duloxetine, mirtazapine
Examples of tricyclic antidepressants
Amitriptyline, clomipramine, imipramine
Side effects of tricylclic antidepressants
Drowsiness
Dry mouth
Blurred vision
Constipation
Difference between manic episode and bipolar disorder
Two manic episodes = bipolar disorder
What is mania
7 DAYS OR MORE Elated/irritable mood Overactive, increased energy, reduced need for sleep Poor concentration Pressured speech Grandiose, overconfident Socially/sexually dis inhibited Psychotic symptoms (grandiose delusions, delusions of reference, auditory hallucinations)
What is hypomania
4 DAYS OR MORE Elated, overactive, social/sexual disinhibition, poor sleep Continues to function Partial insight retained NO PSYCHOTIC SYMPTOMS
Management of acute mania
Atypical antipsychotics (quetiapine, olanzapine)
Sodium valproate
Benzodiazepines
Urgent referral to CMHT
Long term mood stabilisation for bipolar
Lithium, sodium valproate, carbamazepine
Atypical antipsychotics - quetiapine, olanzapine
For depressive episodes - fluoxetine (must stop in mania)
Side effects of lithium
Nausea/vomiting Fine tremor Nephrotoxicity, polyuria Thyroid enlargement/hypothyroidism T wave flattening Weight gain Idiopathic intracranial hypertension Leucocytosis
How is lithium monitored
12 hours post dose.
After starting chek weekly and then every three months once stabled.
Thyroid and renal functioned check 6 monthly
What can precipitate lithium toxicity
Dehydration
Renal failure
Diuretics, NSAIDs, metronidazole
Features of lithium toxicity
Coarse tremor Hyperreflexia Acute confusion Polyuria Seizure Coma
How is lithium toxicity managed
Fluid resuscitation, haemodialysis if severe
Risk factors for completed suicide
Male, young, divorced, mental illness, chronic illness, substance misuse, previous attempt, note, attempts to not be found, violent methods
What is the physiological cause of psychosis
Excess dopamine in the mesolimbic pathyway
What are the first rank symptoms in schizophrenia
Auditory hallucinations, somatic hallucinations, thought withdrawal, thought insertion, thought broadcasting, delusional perceptions, passivity
What are the positive symptoms of schizophrenia
Hallucinations, delusions, passivity phenomena, thought alienation, lack of insight, disturbance in mood
What are the negative symptoms of schizophrenia
Blunting of affect, amotivation, poverty of speech, poverty of thought, deterioration in functioning, lack of insight
Other features of schizophrenia
Incongruity/blunting of affect, neologisms, catatonia
What is catatonia
Adopts strange poses (rigid) and inability to speak. Waxy flexibility (maintain position after being placed in it)
Typical antipsychotics
Haloperidol, chlorpromazine
Commonly cause parkinsonian side effects
Atypical antipsychotics
Olanzepine, quetiapine, risperidone, clozapine
Less likely to cause parkinsonism but cause metabolic side effects like weight gain
What is clozapine
Atypical antipsychotic, ONLY used for treatment resistant.
Risk of fatal agranulocytosis
Reduced seizure threshold
What is neuroleptic malignant syndrome
Rare condition seen in patients taking antipsychotics. May also occur with dopaminargic drugs such as levodopa (usually when stopped or reduced in dose).
Occurs within days of staring antipsychotic
Features of neuroleptic malignant syndrome
Pyrexia Muscle rigidity hypertension, tachycardia Delirium with confusion raised creatinine - rhabdomyolysis causing AKI
What are some extrapyramidal side effects of antipsychotics
Akathisia, dyskinesia, dystonia
What are some cautions on the use of antipsychotics in the elderly
Increased risk of stroke and VTE
What is Akathisia
Feeling of restlessnness and the inability to sit still. Usually legs are most affected.
Treatment of akathisia
Remove cause e.g. antipsychotic.
Dopamine agonists - pramipexole, ropinirole
Benzodiazepines
What is dyskinesia
Involuntary muscle movements similar to tics or tremor. Includes abnormal face and lip movements e.g. lip smacking and pouting
What is tardive dyskinesia
Chronic dyskinesia due to long term antipsychotic treatment e.g. haloperidol
What is dystonia
Repetitive muscle contractions result in twisting of limbs or abnormal fixed postures
What is cyclothymia
Rapid cycling between depressive and hypomanic states
What is thought echo
A patient hears aloud their thoughts shortly after thinking them
What is loosening of association
Speech that is fragmented jumping from one topic to the next unrelated idea
What is circumstantiality
Patient talks a lot and goes of topic before coming to answer
What is perseveration
Repetition of same response regardless of question
What is confabulation
Fabricated memories
What is psychomotor retardation
Slowed speech, movement and impaired cognitive functioning
What is thought disorder
Disruption in the structure of thought, disordganised speech. Includes pressure of speech, poverty of speech, thought blocking
What is flattening of affect
No expression or emotion
What is blunting of affect
Reduced expression or emotion
What is incongruity of affect
Wrong emotion for situation
What is Belle indifference
Associated with conversion disorder, they are not bothered by paralysis
What is depersonalisation
Feel outside their body
What is derealisation
Surroundings dont feel real
What are some classes of hypnotics
Benzodiazepines, Z-drugs, antihistamines, clomethiazole, melatonin, barbiturates
Name benzos used for hypnotics
Nitrazepam, may have residual effects the following day, GABA agonists
Name Z-drug hypnotics
Zoiclone, zolpidem tartrate, act on benzodiazepine receptor, GABA agonists
What are barbiturates
Severe insomnia, avoided in elderly. Phenobarbital. GABA agonist
What is dialectic behavioural therapy
Type of talking therapy for those who feel emotions very strongly (EUPD)
What is psychoanalytic psychotherapy
Classic psychiatry - talks about whats on your mind and the unconscious feelings behind it
Treatment of catatonia
Benzodiazepines
What can precipitate seortonin syndrome
SSRIs, TCAs, SNRI, MAOI, MDMA, St. John’s wort. Change in dose
Symptoms of serotonin syndrome
Three categories - neuromuscular hyperactivity (tremor, hyperreflexia, clonus) autonomic dysfunction (tachy cardia, hypertension, hyperthermia, diarrhoea) altered mental state (confusion, agitation, mania)
Treatment of serotonin syndrome
Benzodiazepines, cyproheptadine (blocks serotonin production) IV fluids. Medicine withdrawal
Treatment of neuroleptic malignant syndrome
Bromocriptine mesylate - a dopamine agonist
When can you restrain a patient
If they are putting themselves or others at risk, if restraining them is proportionate to risk, and if you have tried the least restrictive option first
What is the most important thing about restraint and de-escalation
LEAST RESTRICTIVE OPTION FIRST
Process of rapid tranquilisation
IM lorazepam or haloperidol combined with IM promethazine (antihistamine)
Stats of delirium
30% of elderly patients admitted to hospital >65 background of dementia frailty or multimorbidity polypharmacy
Precipitating events for delirium
Infection - UTI Hypercalcaemia/hypoglycaemia/dehydration/other metabolic causes Change of environment Severe pain Alcohol withdrawal Constiption
Features of delirium
Memory disturbance (short term) Agitated/withdrawn Disorientation Mood change Visual hallucinations Disturbed sleep cycle Poor attention
Management of delirium
Treat underlying cause, modify environment.
Haloperidol first line sedative
Types of delirium
Hypoactive (most common)
Hyperactive (most recognised)
Mixed
Anorexia criteria
BMI below 18.5 (this may now be excluded)
- Restriction of energy intake to lose weight
- Intense fear or gaining weight even though underweight
- Disturbance in perception of body
Symptoms of anorexia
Low BMI, rapid weight loss, dieting that worries family, social withdrawal, disproportionate concern about weight, menstrual changes, dizziness, palpitations
Treatment for anorexia
Family therapy <18, CBT. Fluoxetine
Signs of anorexia
Bradycardia, hypoension, enlarged salivary glands, hypokalaemia, low FSH, LH, impaired glucose tolerance, low T3
Bulimia criteria
Recurrent episodes of binge eating with a sense of lack of control
Compensatory purging (laxative, fasting, exercise, vomiting)
Distorted view of body image
Treatment for bulimia
Family therapy <18, CBT, fluoxetine
what is anankastic personality disorder
another name for OCD
What is phenelzine
Monoamine oxidase inhibitor. Avoid in ECT therapy, avoid tyramine rich food (cheese, salami, marmite) as can cause life-threatening hypertensive crisis
What would be used as a mood stabiliser second line to lithium in bipolar
sodium valproate
what is the treatment for delirium tremens
pabrinex+high dose benzo
which vitamin is thiamine
B1
Name the 5 ICD-10 criteria for delirium
impairment of consciousness global disturbance in cognition psychomotor disturbance disturbance of sleep-wake cycle emotional disturbances
name some ICD10 criteria for agoraphobia
fear of: crowds public spaces travelling alone travelling away from home \+ 1 symptom of autonomic arousal
What blood results would you find in neuroleptic malignant syndrome
raised creatinine kinase raised WCC deranged LFTs acute renal failure metabolic acidosis
Which drug can treat and prevent extra-pyramidal side effects of antipsychotics
procyclidine (anti-cholinergic)
What can be used to reverse the sedative effects of benzos
flumazenil
What is the first-line treatmet for PTSD
Trauma-focused CBT, EMDR is used more specifically
What is knights move thinking
Anther term for loosening of association!
How long should an SSRI be triad for in OCD
12 weeks
Name some drugs that are known to induce delerium
Furosemide
oxybutinin
propranolol
ranitidine
When do you do blood tests for clozapine
once a week for 18 weeks then fortnightly for a year, then monthly
symptoms of GAD
excessive worry distress and functional impairment restlessness easily fatigued poor concentration irritability muscle tension trembling sweating dry mouth palpitations dizziness
mnemonic for remembering delirium triggers
Pain Infection Nutrition Constipation Hydration Medications Electrolyte disturbance
how is acetlycysteine infusion fiven
within eight hours of ingestion if levels are above the treatment line.
Given in three infusions, the first over an hour
when can activated charcoal be given for overdose
within one hour of ingestion
what can be used other than chlorodiazepoxide for alcohol withdrawal
lorezepam - remember its just a fancy name for a benzo
first line management for borderline personality disorder
dialectical behavioural therapy
withdrawal symptoms within 24 hours of high cocaine use
anxiety increased hunger fatigue irritability lack of motivation
Which antidepressants have the strongest association with hyponatraemia
SSRIs,
consider hyponatraemia in those presenting with drowsiness, confusion and convulaions
What can be used as an alcohol deterrent
disulfiram - causes diaphoresis, palpitation, flushing, nausea and headache if alcohol is ingested
why would morphine, oxycodone and oxybutinin cause delirium
all cause constipation
what blood tests should be monitored on lithium
TFT, U&Es, eGFR
what tests should be done to exclude an organic cause for anxiety
24-hour urine metanephrines (phaeochromocytoma) (causes panick attacks due to high adrenaline)
ECG
FBC + iron
TFTs
what is lillliputain
seeing lots of small people - typically seen in selirium tremens
what combination of drugs is most likely to cause serotonin syndrome
SSRI + MAOI
mechanism of disulfiram
nuild up of acetaldehyde to cause flushing and headache on consumption of alcohol
side effects of mirtazapine
SNRI, drowsiness, weight gain
absolute contraindication for ECT
raised ICP (only absolute)
poor prognostic factors for schizophrenia
gradual onset, low IQ, family history, premorbid social withdrawal, no obvious precipitant
examples of drugs that can induce psychosis
anti malarial bromocriptine levodopa steroids alcohol cocaine amphetamine MDMA ket
which tool is used to screen for post natal depression
Edinburgh scale
methylphenidate drug reacctions
carbamazepine
isocarboxazid (MAOI)
linezolid (antibiotic)
risperidone (atypical antipsychotic)
