Psych notes Flashcards
mannerism vs stereotype vs tic
both are repeated movements
mannerisms are goal directed (e.g. sweeping hair out of face)
stereotypes are not goal directed (e.g. flicking fingers in air)
tics are like stereotypes in that they are purposeless actions but in this case they are involuntary
what system do you use to describe the cause of any psych problem
predisposing factors
precipitating factors
perpetuating factors
What is the psych version of:
conservative, medical, surgical
Social
Psychological
Biological
definition of delusion
a fixed, false belief that is held despite rational evidence to the contrary. it cannot be explained by religious or cultural background.
what are the two main features of psychosis
- delusion
2. hallucination
peak onset of schizophrenia/psychosis
15-25 in males
25-35 in females
lifetime risk of schizophrenia/psychosis
1%
theory for cause of schizophrenia positive and negative symptoms
\+ = excess dopamine in mesolithic tract - = too little dopamine in mesocortical tract
classic ‘voices’ in schizophrenia
2+ discussing or arguing about the patient
running commentary
thought echo
what are the positive and negative symptoms of schizophrenia
positive = first rank
- thought
- delusional perception
- auditory hallucination
- somatic perception
- passivity
negative
- apathy
- blunted affect
- anhedonia
- social withdrawal
what is the mechanism of typical and atypical antipsychotics
D2 receptor blockers
atypical also blocks 5HT (which is what helps take away prolactin and EPSEs)
name the most common typical and atypical antipsychotics
typical = chlorpromazine, haloperidol
atypical = the pines, the dones, 2 pips and a rip (clozapine is most common)
name the EPSEs
dystonia (hours)
akathisia (days)
parkinsonism (weeks)
tardive dyskinesia (months-years)
(remember hyperprolactinaemia as a SE of typical too)
main 2 SEs of clozapine
agranulocytosis
weight gain
what drug can be given to reduce the EPSEs
anticholinergic = procyclidine
monoamine hypothesis for depression
that there isn’t enough monoamine neurotransmitters that explains the Sx:
- dopamine
- noradrenaline
- serotonin
what is depressive stupor
when the psychomotor slowing with depression is so severe that the person just stops
is st johns wort effective for depression
yes, it’s as effective as SSRIs! but affects drug metabolism way more
SE of antidepressants
hyponatraemia sexual dysfunction lower seizure threshold citalopram can cause long QTc suicidality in first 3wks SSRIs
monitoring SSRIs?
ECG
UEs
FBC
what is mirtazapine
a noradrenaline and specific serotonergic antidepressant (NASSA)
it is 3rd line
which are the two SNRIs
venlafaxine and duloxetine
problem with TCAs in overdose
cardiotoxicity
main danger with MAO
hypertensive crisis after eating foods rich in tyramine like cheese. they are also dangerous to combine with any other type of antidepressants and have to withdraw and wait to weeks.
Sx of serotonin syndrome
sweating tremor confusion restlessness severe can be convulsions and death
how long do manic symptoms have to be around to call it mania
1 week (compared to 2 weeks of Sx for depression)
what is cyclothymic bipolar
subclinical depression + hypomania
type 1 vs type 2 bipolar
type 1 = mania + depression
type 2 = hypomania + depression
they often cycle so you have 2-3 episodes of each per year (>4 then its classed as rapid cycling BPAD)
5 investigations for mania
- collateral history
- examination
- FBC, TFT, CRP
- urine drug screen
- MRI/CT brain to rule out organic cause
what meds are used for bipolar in acute phase and to prevent another episode
acute = olanzapine
to prevent another = mood stabilisers
lithium
valproate
2nd line = carbamazepine
Main management point for acute phase of mania
STOP any antidepressants, steroids, DA agonists
GIVE olanzapine
what is the therapeutic window of lithium and at what point does toxicity start
0.6-1.0 mol/l = very narrow
toxicity starts at 1.2
Sx of lithium toxicity
coarse hand tremor + ataxia
D&V
polyuria/polydipsia (renal failure)
seizure, confusion, coma
common causes of lithium toxicity
- drugs interfering with excretion (NSAIDs, diuretics, ACEi)
- overdose
- dehydration, D&V
how do you monitor someone on lithium
check lithium levels weekly until desired dose is achieved
must monitor U/Es and TFTs every 3 months as it can damage kidneys and cause hypothyroidism
men are ?x more likely to die from suicide
3-4
most common method of successful suicide
hanging (overdose is most common method of attempt, esp in women)
structure of suicide history
BEFORE
ACT
AFTER
PDFs
- elicit RFs for ongoing risk to see whether they can go home
antidote for:
paracetamol
benzodiazepine
opioid
NAC
flumazenil
naloxone
when should you follow up an episode of self harm
if deemed safe to go home, follow up within a week
section 2
2 doctors can detain someone to assess then for up to 28d
section 3
2 doctors can detain someone for treatment for up to 6 months
section 5(2)
doctor can detain inpatient for MHA for up to 72 hours
section 5(4)
nurse can detain someone for assessment by a doctor for up to 6 hours
section 135
police can break into house and take them to a safe place
section 136
police can remove someone from public place and bring them to a safe place
section 17a
Community treatment order - can force an ex-inpatient to abide by a care coordinator’s treatment regime whilst in the community. If not readmit. This helps prevent readmission.
How to take an anxiety history
Symptoms Episodic or continuous Drugs or alcohol Avoidance Timings trigger Effect on life Depression screen
what are the 3 anxiety conditions
GAD
PTSD
OCD
(also specific phobias e.g. agoraphobia is fear of masses of people)
how long must Sx be present to diagnose GAD
6m
difference between agoraphobia and social phobia
Agoraphobia hate massive crowds and open places
social phobia are ok in crowds but just don’t like small social groups where there is fear of being scrutinised
what triggers a panic in panic disorder
Nothing. Thats essential. If there is always one trigger (e..g crowds) then something like agoraphobia is more likely
what anxiety scale should we know
Beck anxiety inventory
prevalence of OCD
1%
word given for when a compulsion is resisted by patient
” when patient gives up to compulsion
egodystonic
egosyntonic
adjustment disorder vs PTSD
they are both reactions to adverse events. can involve dissociation, pseudohallucinations and strong mixed emotions
adjustment disorder = <1m
PTSD = >1m (but note that symptoms may not start for a couple months. usually starts within 6m)
what region of the brain is hyperactive in PTSD
amygdala (emotion)
and hippocampus (memory) is atrophied
is PTSD more common in men or women
women…
in an extreme trauma, 20% of women get PTSD compared to 8% of men
symptoms of PTSD
- re-experiencing (nightmares or flashbacks)
- hyperarousal (inability to relax, enhanced startle reflex, insomnia, poor concentration, irritability)
- avoidance
- other (anhedonia, crying)
SEs of benzos
IT IS A SEDATIVE!
sleepiness, unseatdiness, memory and concentration, agitation/aggression, addictive
safety concerns with benzos
not more than 4 weeks
avoid alcohol –> rest depression
addiction signs with benzos
can't sleep agitated dizzy blurred vision confused, hallucinations, fits
example of short and long acting benzo
short - lorazepam
long - diazepam
what are the Z-drugs and what are they used for
short term treatment of insomnia
zopiclone, zolpidem, zalepon
what is semantic memory
memory about things about the world e.g. paris is the capital of france
What are the areas of cognition that you need to ask about in a delirium/dementia history
Memory and learning Attention Personality Language and speech Executive function Visuospatial perception
investigations for ?dementia
MMSE, MOCA To rule out organic cause: - FBC, U/E, LFT, TFT, glucose, B12/folate, calcium, syphilis - CXR, cultures, MSU - CT/MRI head if unsure
Management of dementia
Conservative
- PT/OT to help with mobility and self-care
- Do they need carers?
- psychological support e.g. reminiscence therapy
- AChEi/memantine
- antidepressants if co-existing
What are the 4 A’s of Alzheimer’s presentation
Amnesia - recent memory problem
Agnosia - recognising things
Apraxia - doing skilled tasks
Aphasia - finding words for things
progression/presentation of vascular dementia vs AD
stepwise with sudden onset due to infarcts in cortex from arteriolosclerosis being the cause
ALSO
there is relative preservations of personality and insight. instead, there is PATCHY COGNITION
what is the picture with DLB
fluctuating confusion
Parkinsonism
Vivid visual hallucinations
most affected area with DLB
circulate gyrus (the strip above the corpus callosum below the cortex)
can you give antipsychotics to DLB
No, they have a sensitivity to them
FTD presentation
changes in persoanlity, emotion, mood
later motor and expressive language deficits (Broca’s)
most common type of FTD
Pick’s disease
presentation of Huntington’s
Middle age prodrome = irritability, depression, incoordination
Later = chorea, dementia, fits/death
what is HIV dementia
10% of patients with HIV get early dementia –> apathy and withdrawal with subcritical features such as tremor, ataxia, myoclonus
triad for normal pressure hydrocephalus
wet = incontinent wobbly = ataxia weird = confused/dementia
definition of delirium
acute confusional state that affects all areas of cognition and is fluctuating in nature
types of delerium
hyperactive
hypoactive (under diagnosed)
mixed
causes of delirium
PINCHME - Pain, Infection, Nutrition, Constipation, Hydration/hypoxia/hypothermia, Medication (TCAs, anticholinergics), environment
investigations for delirium
CT head for stroke
AND
full septic screen (incl. CXR/urine dip) and bloods
first line sedative for delirium
haloperidol (or olanzapine)
beware benzos make delirium worse
what is pseudodementia
the memory problems associated with severe depression. in contact to true dementia, onset is rapid (<1-2m) and answers are ‘i don’t know’ instead of trying and getting answer wrong in true dememtia. also pseudos struggle/fatigue with cognitive tasks.
drug for bad sleep and depression in elderly
mirtazapine good sedative effect if sleep is a problem
substance misuse history structure. example alcohol.
ASDM (for alcohol)
Alcohol use
- now, before, future:
- present use
- past use/attempts to stop
- desire about future use
Social effects
- self, work, friends, family, finances, police, driving
Dependence
- 6 criteria (compulsions, lack of control, tolerance, withdrawal, neglect, persistence)
Mood
- screen for depression
- assess risk
Rest of history
what is operant conditioning
behaviours that are rewarded are repeated
key dopaminergic pathway in addiction?
mesolimbic pathway
current alcohol guidelines
14 units a week spread evenly over at least 3 days, with as least some alcohol free days
alcohol abuse vs addiction
abuse = harm to persons work or social life
addiction = signs of addiction like compulsion, tolerance, withdrawal, narrowing of repertoire etc
onset and duration of delirium tremens
48-72 hours into abstinence. lasts 3-4 days if not fatal
Tx of delirium tremens
benzo (chlordiazepoxide or diazepam)
IM thiamine
Wernicke’s syndrome cause
B1 deficiency
Wernicke’s triad
confusion
ataxia
ophthalmoplegia
what does wernickes progress to if left untreated
Korsakoff’s syndrome
Korsakoff’s syndrome presentation
permanent anterograde amnesia - patient confabulates to fill gaps
what is acampraste
an anti-craving drug used to prevent relapses in alcohol misuse
what is antabuse a.k.a. disulfram
blocks an enzyme and mimics flush reaction making the consumption of alcohol unpleasant
what receptor do opioids work on
mu opioid receptor (normally for endogenous endorphin hormone)
withdrawal symptoms of opioids
opposite of effect itself (because you get a NA storm where its been suppressed for so long):
- tachycardia
- restlessness
- dilated pupils
- (and a flu like ache)
how do you treat withdrawal of opioids
lofexifine (or clonidine), which is an alpha2 adrenergic agonist
what can we use as substitute drugs for opioid abuse and why are they helpful
blocks euphoric effects of herion whilst preventing withdrawal Sx
- methadone (long acting full agonist)
- buprenorphine (partial agonist)
how is methadone given and when is it weaned
daily OBSERVED drinking of the fluid. weaned after 12 weeks or so
compliance is measured using urinalysis
management of acute opioid overdose
IM naloxone
what is naltrexone
a long acting version of naloxone that is given IM and is sometimes used instead of methadone/buprenorphine (which are 1st line)
how addictive are stimulants
not PHYSICALLY as addictvive as opioid or benzos
relationship between psychosis and cannabis
early use can precipitate psychosis in the short term and schizophrenia in the long term
what is somatisation
unconscious expression of psychological distress as physical symptoms
unconscious and unintentional
what is hypochondriasis
worrying about a specific illness (often cancer). stuff like that must be going on for >6m
unconscious and unintentional
factitious disorder
Munchausens = inventing Sx to get treatment because they like it
conscious and intentional
malingering
inventing symptoms for financial or some other benefit (e.g. to sell on drugs)
conscious and intentional
conversion disorder
following a stress or conflict, people genuinely believe that they can’t do something physical e.g. move, see, hear, remember
unconscious and unintentional
SCOFF questionnaire
do you make yourself sick when you eat
have you lost control over your eating
have you lost more than one stone in weight recently
do you think you’re fat
does food dominate your life
cutoff BMI for anorexia
<17.5
Symptoms of anorexia
General
- leathery
- fatigue
- cold
- infections
GI
- constipation
- bloating/abdo pain
reproductive
- amenorrhea
- libido/impotence
red flags for anorexia --> admit straight away BMI weight loss rate temp BP HR Sats ECG
bmi <13 >1kg/week loss T <34.5 BP <80/50 HR <40 Sats <92% or limbs blue and cold purpura long QT and flat T (hypoK) on ECG biochemical anomalies
organic causes to rule out of weight loss
hyperthyroidism coeliac IBD Addison's chronic infection
investigations for anorexia OSCE ting
blood test (TFT, coeliac screen, FBC, LFT, U/Es, albumin) ECG
3 scales of treatment plan based onseverity
mild = try 8 weeks of community based treatment
moderate = refer to eating disorders clinic now
severe = admit
mortality with anorexia nervisa
5-10% (a lot is suicide)
referring syndrome cause
during refeeding ,phosphate becomes low
Sx of refeeding syndrome
rhabdomyolysis resp failure cardiac failure hypotension seizures
Mx of refeeding syndrome
stop refeeding and introduce food more slowly this time over 4-7 days, monitoring for phosphate. give additional thiamine and vitamin B
key feature of bulimia
purging behaviour AND BMI>17.5
purging behaviour in bulimia
vomiting
exercising
diuretics
laxative
SSRIs in eating disorders?
in bulimia yes
in anorexia no
but CBT and therapy in both
presentation of ADHD (with timeline cutoff)
IN 2 OR MORE SETTINGS FOR >6 months
- inattention
- hyperactivity
- impulsivity
think of 6 questions for inattention and 6 for hyperactiivty
INATTENTION
o Fails to give close attention to detail or makes careless mistakes in schoolwork or other activities
o Difficulty sustaining attention in tasks or play activities
o Does not seem to listen when spoken to directly
o Does not follow through on instructions
o Difficulty organising tasks and activities
o Avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
o Loses things
o Distracted by extraneous stimuli o Forgetful in daily activities
HYPERACTIVITY o Fidgets and squirms o Leaves seat in classroom o Runs about or climbs excessively o Difficulty playing quietly o ‘On the go’ or acts as if ‘driven by a motor’ o Talks excessively o Blurts out answers o Difficulty in waiting turn o Interrupts or intrudes on others
screening tool for ADHD
connors questionnaire
investigations for ADHD
- conors
- parent interview
- school observation
1st line Mx for ADHD
parent training/education programmes
+/- methyphenidate
ASD triad
- social awkwardness
- repetitive behaviours
- SALT difficulty
investigations for child with ?ASD
hearing test!
SALT assessment
cutoff IQ for learning disability
<70
causes of learning difficulty
prenatal - chromosomal, infection, intraventribular haemorrhage, alcohol abuse perinatal - stroke, HIE, infection, kernicterus postnatal - meningitis, encephalitis, head injury
6 factors for dependence (e.g. alcohol)
- compulsion to drink
- lack of control
- tolerance
- neglect of alternative pleasures
- withdrawal symptoms
- persistence despite negative impact
–> note that narrowing of repertoire is an extra one but isn’t part of the crucial 6 questions
Clozapine monitoring
weekly for 18w
two-weekly for rest of year
monthly thereafter
What can cause lithium toxicity (5)
ACEi dehydration NSAIDs diuretics (especially thiazide) metronidazole
