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Finals Revision > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is the therapeutic range of lithium?
What can cause lithium toxicity?
What level is usually toxic?

A

0.4-1 mmol/l

Dehydration
Renal failure
Drugs - diuretics (esp thiazides), ACEI/ARB, NSAIDs, metronidazole

> 1.5 mol/l

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2
Q

Symptoms of lithium toxicity?

Rx?

A 
Coarse tremor (fine tremor seen in therapeutic level)
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma

If mild-mod dilution with saline can work
If severe, dialysis can be required
Sodium bicarbonate sometimes used to increase alkalinity of urine and promote excretion but no evidence

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3
Q

Emergency detention:

  • criteria?
  • time?
  • who?
  • appeal?
  • MHO informed?
A
  • likely the person has a mental disorder that is impairing decisions about their treatment
  • would be a risk to self or others without it
Up to 72 hours in hospital
Does not allow treatment
F2 or above
Cannot be appealed
MHO should be informed if possible but not mandatory
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4
Q

Short term detention:

  • criteria?
  • time?
  • who?
  • appeal?
  • MHO informed?
A

Patient has a metal disorder affecting their decision making, necessary to detain them to decide what treatment is required

28 days

Applied for by an approved medical practitioner (usually a psychiatrist)

Can be appealed

Requires consent of MHO

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5
Q

Compulsory treatment order:

  • criteria?
  • who?
  • how is it decided?
  • what does it allow?
  • appeal?
A

Patient has a mental health disorder and needs treatment to make this better. Harm to self or others without treatment

Applied for by MHO with supporting letters from 2 Dr’s, one of which must be psychiatrist treating pt

Heard in front of a tribunal, pt has right to legal representation

Imposes conditions of treatment and residence on pt for 6 months

Decision can be appealed at any time by pt or named person

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6
Q

Advanced statement:

A

Completed by pt with a mental health disorder when they are deemed to have capacity

Legal statement which a patient can outline what treatment they do not want to have in future should they become ill again and lose capacity

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7
Q

Capacity assessment:

  • who?
  • What must pt be able to do?
A

F2 or above

Pt must be able to:

  • understand treatment with respect to nature, purpose and requirements
  • understand benefits and risks
  • understand consequences of declining treatment
  • retain information long enough to use it, weigh it and come to a balanced decision
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8
Q

Certificate of incapacity?

A

Confirms patient does not have capacity

Form found under section 47

Enables decision to be made by proxy or doctor

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9
Q

Power of attorney?

A

Individual appointed by pt with capacity to have authority to make decision for them only when they are deemed to have lost capacity

Financial, property or personal welfare

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10
Q

Guardianship order?

A

When the court appoints an individual to act and make decisions on behalf of someone with incapacity

Same as power of attorney but appointee made by court

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11
Q

Intervention order?

A

Order that authorises a person to act and make a one off decision for an adult with incapacity

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12
Q

Childhood ages of capacity?

A

<13 - deemed not to have capacity

13-15 - may have capacity based on understanding

> 16 - assumed to have capacity

Parents cannot overrule decision of a child who is deemed to have capacity, but doctors can seek to overrule a decision made by parents for a child without capacity

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13
Q

Core symptoms of depression?

A

Core - 2 weeks of:

  • Low mood, usually worse in the morning
  • Anergia
  • Anhedonia

Biological:

  • loss of libido
  • reduced attention/concentration
  • reduced appetite and weight loss
  • loss of confidence and self-esteem
  • thought of DSH or suicide

Somatic:

  • fatigue
  • amenorrhoea
  • abdo pain, constipation, indigestion

Psychological (Beck’s triad):

  • Hopelessness
  • Worthlessness
  • Excessive guilt
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14
Q

Medical differential for depression?

A 
Hypothyroidism
Cushing's
Syphilis
SLE
Hypercalcaemia
Drugs: steroids, retinoids, B blockers
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15
Q

What is dysthymia?

A

Chronic mild depression for 2 years in which episodes are either not long enough to not severe enough to meet criteria for depression

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16
Q 
Depression:
Mild?
Mod?
Severe?
Mixed?
Atypical?
A

Mild: 2 core + 2 additional

Mod: 2 core + 4 additional - difficulty with ADL’s

Sev: 2 core + 4 additional. Hopelessness, suicidal ideation, somatic symptoms. Inability to carry out ADL’s

Mixed: depression with GAD

Atypical: biological symptoms are reversed - increased sleep, appetite and weight gain

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17
Q

Management of mild depression?

A

General advice: sleep hygiene, caffeine, alcohol, exercise
CBT
Structured exercise programme
Peer based support group

Over 8-12 weeks

Consider meds if:

  • previous severe depression
  • symptoms for 2 years or not responding to other therapy
  • chronic health condition and has developed mild depression
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18
Q

Management of mod-sev depression?

A

SSRI 1st line

Along with ‘high-intensity psychological therapy’ e.g.:
CBT
Interpersonal therapy
Behavioural couples therapy

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19
Q

When should someone be reviewed after starting an SSRI?

How long should they be stopped over?

A

2 weeks

Or 1 week if suicidal thoughts/behaviour

Stop over 4 weeks

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20
Q

Side effects of SSRI?

A

GI upset
Risk of GI bleeds - use PPI, esp with aspirin
Hyponatraemia
Increase in anxiety and suicidal ideation when starting

Citalopram - QT interval

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21
Q

Interactons with SSRIs?

A

NSAIDs - PPI
Warfarin/Heparin - consider mirtazapine
Triptans - avoid

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22
Q

Discontinuation symptoms of SSRI?

A 
Increased mood changes
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI upset
Paraethseia

Highest risk with paroxetine

Essentially like a come down

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23
Q

SE TCA’s?

What ones are least sedative?

A 
Drowsy (affects ability to operate heavy machinery)
Dry mouth
Blurred vision
Constipation
Urinary retention
QTc prolongation

Least sedative: imipramine, nortriptyline

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24
Q

What SSRI is safest after MI?

What one is preferred in adolescents?

A

Sertraline

Fluoxetine

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25
Q

SNRI examples?

SE?

A

Duloxetine, Venlafaxine

Basically same as SSRI
GI upset
Cardio: hypertension, palpitations, dizziness

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26
Q

NaSSA example?
SE?
Uses?

A

Mirtazapine

Weight gain
Sedation

Generally considered second line. Useful if weight loss or insomnia is an issue

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27
Q

MAOI examples?
SE?
Use?

A

Reversible: Moclobemide
Irreversible: Phenelzine

SE:

  • dizziness
  • postural hypotension
  • anticholinergic SE
  • cheese reaction

Good in atypical depression
Cannot be used with SSRI or TCA
Prevents tyramine breakdown so avoid cheese, red wine and soy (hypertensive reaction)

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28
Q

SARI example?

Use?

A

Trazodone

Useful as a non-addictive sedative
Can be used to augment SSRI/SNRI

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29
Q

Features of serotonin syndrome?

A 
Anxiety, agitation, hallucinations
Shivering, sweating
Hyperthermia
Tachycardia
Dilated pupils
Nausea, diarrhoea
Myoclonus
Rigidity
Hyper-reflexia
Management:
Stop causative drugs
Supportive
Cool patient
Benzos to reduce anxiety/sedate
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30
Q

Mania vs hypomania?

A

Mania:

  • at least 7 days
  • Psychotic symptoms (delusions of grandeur/auditory hallucinations)
  • May require hospitalisation

Hypomania:

  • lasts around 3-4 days
  • doesn’t normally impair functional capacity in social/work setting
  • no psychosis
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31
Q 
Bipolar:
- 1st and 2nd line mood stabilisers?
- what else can be used?
Management of:
- mania?
- hypomania?
- depression?
A
  1. Lithium
  2. Valproate
    Other anticonvulsants such as lamotrigine or carbamazepine
    Atypical antipsychotics

Mania:

  • urgent referral to CMHT
  • Stop antidepressants
  • Consider Olanzapine or Haloperidol

Hypomania:
- routine referral to CMHT

Depression:
- talking therapies
- Fluoxetine antidepressant of choice
(quetiapine?)

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32
Q

Rapidly cycling bipolar?
Bipolar 1?
Bipolar 2?

A

4+ episodes of mood disorder in a year

1 - mania

2 - hypomania - depressive episodes tend to be worse and longer lasting

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33
Q

Why to try and avoid antidepressants in bipolar?

What are they normally used with/

A

Cause mania

Atypical antipsychotics

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34
Q

Lithium SE?

A 
Fine tremor
Metallic taste
Dry mouth
Weight gain
Hypothyroidism (block peripheral conversion of T4 to T3)
ECG: T wave flattening/inversion
Hypercalcaemia
Diabetes insipidus
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35
Q

Monitoring of lithium?

A

Therapeutic 0.4-1
Toxic >1.5

Avoid in 1st trimester preganncy

Check weekly when starting until stable
Once stable check 3 monthly
Change in dose - check weekly again until stable

TFT and renal function 6 monthly

Check levels 12 hours after dose

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36
Q

What these types of hallucinations suggest?

  • auditory?
  • visual?
  • olfactory?
  • gustatory?
  • tactile?
A

Auditory - schiz

visual - drugs/delirium

Olfactory - seizures

Gustatory - seizures

tactile - delirium/alcohol withdrawal

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37
Q

Organic causes of psychosis?

A 
Dementia
Delirium
Huntingtons
SLE
Syphilis
Hyperthyroidism
Hypoglycaemia
Parkinson's
HIV
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38
Q

Characteristics of psychosis?

A

Hallucinations
Delusions
Thought disorganisation:
- alogia: little information conveyed by speech
- tangentiality: answers diverge from topic
- clanging
- word salad: non-sensical

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39
Q

Causes of drug-induced psychosis?

A

Legal highs, amphetamines, cannabis

Levodopa, corticosteroids, antimalarials

Withdrawal: alcohol, bezos

Presents floridly, should resolve with cessation of use of causative drug

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40
Q

Schizoaffective disorder?

A

Schizophrenia and bipolar - psychosis and mood symptoms in equal measure

Psychosis is mood congruent (in all cases, not just for this)
Mania - delusions of grandeur
Depression - delusions of worthlessness, guilt, nihilism. Auditory hallucinations that are derogatory

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41
Q

Pathophysiology of schizophrenia:

  • neurochemical?
  • histological?
  • structural?
A

Neurochem:
- changes of dopamine signalling, increased and decreased in different parts of the brain

Hist:
- lack of gliosis

Structural:

  • ventricular enlargement
  • loss of healthy white matter (cognitive decline)
  • decrease in grey matter volume
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42
Q 
First rank symptoms of Schizophrenia?
Other features (not negative symptoms)?
A

Auditory hallucinations

Thought: insertion, broadcasting or removal

Passivity: external force controlling thoughts, emotions or actions

Delusions: e.g. the traffic light is green therefore I am King

Others:

  • Lack of insight
  • Neologisms
  • Catatonia
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43
Q

Negative symptoms of schizophrenia?

A
  • incongruent/blunted affect
  • anhedonia
  • alogia (poverty of speech)
  • avolition (poor motivation)
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44
Q

Features of catatonic schizophrenia?

A

Posturing

Negativism - resistance to command or attempts to be moved

Command automatism - will do whatever you ask them

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45
Q

Examples of typical antipsychotics?
MOA?
SE?

A

Haloperidol, chlorpromazine, prochlorperazine

D2 receptor blocker in mesolimbic system

EPSE
Sedation
Hyperprolactinaemia
QT prolongation
Increased appetite and weight gain
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46
Q

EPSE and how to manage each?

A

Acute dystonia:

  • painful, sustained contraction, usually within a few hours of starting treatment
  • Procyclidine

Akathisia:

  • Restlessness or constant need to wander
  • Rx: Propanolol

Parkinsonism:

  • usually symmetrical shuffling gait, tremor, reduced facial expressions
  • Antimuscarinics e.g. procyclidine

Tardive dyskinesia:

  • repetitive, uncontrollable, involuntary contraction of facial muscles
  • seen in long-term use, typically irreversible
  • Rx: tetrabenazine (not curative)
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47
Q

Atypical antipsychotic examples?
MOA?
SE?

A

Olanzapine, quetiapine, aripiprazole, risperidone, amisulpride

Block D2 receptors but work on other D receptors 1-5 and other receptors depending on the drug

SE:

  • drowsiness
  • weight gain and increased appetite (metabolic syndrome)
  • hyperprolactinaemia
  • sexual dysfunction
  • increased risk of seizures
  • elderly: increased risk of stroke
  • low risk of EPSE
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48
Q

What causes weight gain with antipsychotics?

A

5HT2c receptor blockers

Most pronounced in clozapine and olanzapine

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49
Q

What atypical antipsychotics have highest risk of EPSE?

A

Rare: clozapine

Uncommon: aripiprazole

Higher doses: olanzapine, risperidone

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50
Q

4 main dopamine pathways?

A

Mesolimbic: reward and aggression (positive schizophrenia symptoms)

Mesocortical: emotions, affect, executive functioning (negative schizophrenia symptoms)

Nigrostriatal: substantia nigra to striatum - EPSE

Tubuloinfundibular: hypothalamus to anterior pituitary - PRL

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51
Q

Clozapine use?

A

Schizophrenia which doesn’t respond to 2 separate 6 week trials of other antipsychotics

SE:

  • weight gain
  • hypersalivation (hyoscine)
  • myocarditis
  • reduced seizure threshold (3%)
  • agranulocytosis (1%)
  • neutropenia (3%)
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52
Q

Initiation of clozapine?
Monitoring of clozapine?
If missed dose?
If smoking?

A

Initiation - baseline ECG and titrate dose up

Regular FBC testing

Must re-titrate to therapeutic dose if 2 missed doses

Smoking reduces clozapine levels - so need to alter dose if starting/stopping
Stopping smoking can dramatically increase level

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53
Q

Neuroleptic malignant syndrome:

  • causes?
  • presentation?
  • Diagnosis?
  • Management?
A

Any antipsychotic but especially typicals e.g. haloperidol
Others: parkinson’s medication, metoclopramide, lithium

Presentation:

  • hyperthermia
  • muscle rigidity and bradykinesia
  • altered mental state: stupor, agitation, confusion
  • autonomic dysfunction: tachycardia, tachypnoea, dilated pupils, sweating

Dx:
- Raised WCC and CK

Manegemtn:

  • withdraw drugs
  • cool pt
  • supportive (fluids etc)
  • Benzos and Dantrolene if necessary
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54
Q

More sedating?

A

Olanzapine, Risperidone

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55
Q

Avoidance of weight gain - which antipsychotics?

A

Aripiprazole, Haloperidol

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56
Q

Depot antipsychotic?

A

Risperidone

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57
Q

What antipsychotic can be used for anxiety?

A

Olanzapine

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58
Q

Management of violent/aggressive patient if unknown Hx of antipsychotic exposure or cardiac disease?
If known significant exposure to typical antipsychotics (not just PRN)?

A

1st line - distraction, seclusion

Unknown:
Try for oral Lorazepam
If too aggressive IM
If no response in 30 mins - IM lorazepam

Known:
Haloperidol +/- Lorazepam
Try for oral, IM if not
If no response in 30 mins - IM lorazepam

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59
Q 
ApoE genes in Alzheimers?
Presinilin genes in inherited?
Macroscopic changes?
Histological changes?
Neurotransmitter changes?
A

ApoE4 - predisposes disease
ApoE2 - protective, assoc with longevity in disease

Presenilin 1 - Chr14
Presenilin 2 - Chr21 (hence early onset in Down’s)
These code for amyloid precursors

Macroscopic:

  • cortical atrophy thinning of sulci and gyri
  • Occipital lobe SPARED
  • Compensatory ventricular enlargement

Histological:

  • Extracellular and perivascular deposition of B amyloid plaques - stain green with congo red
  • Intracytoplasmic neurofibrillary tangles of hyperphosphorylated tau proteins

NT: reduced acetylcholine in nucleus basilis of meynert (this is where disease starts)

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60
Q

Presentation of alzheimer’s: memory, orientation, speech, behaviour, associated?

A

Progressive memory loss. short term then long term
Disorientation, especially somewhere new
Speech: trouble getting words out and understanding
Behaviour: wandering, restlessness, aggressive outbursts
Associated: low mood, lability of mood, poor sleep

61
Q

What functional deficits may be seen in vascular dementia?
Are mood/personality disorders prominent or not?
Insight?
What tests can be done?

A

Gait disturbance and urinary incontinence

Mood/personality disturbance - prominent

Insight preserved

SPECT - reduced attenuation throughout brain
Hackinski score

62
Q

Lewy Body dementia:

- macroscopic changes?

A

Macro: degeneration of substantia nigra and cortex

Micro: levy body deposition in substantia nigra and cortex (a-synuclein inclusions)

63
Q

Presentation of Lewy Body dementia?
Physical symptoms?
Can it present as psychosis?

A

Fluctuating cognition with lucid periods. Main issue is with executive functions - multi-tasking and complex tasks are a problem. Memory loss is late

Parkinsonism
REM sleep disorders

First time psychosis - SPECT - low dopamine uptake in basal ganglia

64
Q

Frontotemporal dementia presentation?
Insight?
Macro/microscopic changes?
Insight?

A

Behavioural change, altered emotions, disinhibition
Decline interpersonal skills
Decline in understanding in words and ability to produce speech

Insight is lost quickly - memory preserved until late

Macro: Extreme atrophy of frontal and temporal lobes

Micro: swollen neurones and intracytoplasmic filamentous inclusions

65
Q

Huntington’s dementia:

  • genetics?
  • pathophysiology?
  • features?
A

AD
Trinucleotide CAG repeat on Chr4
Genetic anticipation - starts younger in each generation

Degeneration of GABA and cholinergic neurones in striatum

At 35 y/o:

  • choreiform movements
  • personality change
  • intellectual impairment
  • dystonia
  • saccadic eye movements
66
Q

Mad cow disease features?

Only definitive diagnosis?

A

Caused by prion disease

Rapid onset dementia
Ataxia
Seizures
Myoclonic jerk
Reduced cognition

Posthalmous biopsy - proteinaceous B sheets

67
Q

General tests for suspected dementia?
When to do LP?
Cognitive?

A

ECG
FBC, U&E, LFT, TFT, B12, folate, Ca
CXR, CT brain

LP if suspect CJD, syphilis, normal pressure hydrocephalus

Cognitive - MMSE
MOCE or ACEIII (addenbrooks) in depth

68
Q

Cholinesterase inhibitors for dementia:

  • 3 examples?
  • use?
  • SE?
A

Rivastigmine, Donepezil, Galantamine

Alzheimers, can also be used in Lewy Body

Drug of choice in mild-mod

SE: GI, hyper salivation, vivid dreams, sleeplessness, urinary incontinence

69
Q

NMDA antagonists for dementia:

  • example?
  • use?
  • SE?
A

Memantine

Severe, or when cholinesterase inhibitors have failed to work in Alzheimers or Lewy body

SE: drowsiness, dizziness, consipation, balance

70
Q

What drugs should be avoided in Lewy Body?

A

Antipsychotics

71
Q

Can you use cholinesterase inhibitors or memantine in vascular dementia?

A

Only if co-existant alzheimers, lewy body or parkinson’s disease dementia

72
Q

Treatment of depression in dementia?

Behavioural disturbance?

A

Depression - antidepressant

Behavioural - antidepressant, anticonvulsant or benzo

73
Q

Appetitive system?

Aversive system?

A

Appetitive - seeking and approach behaviours, controlled by dopamine

Aversive -promote survival in the event of threat, fear or pain, controlled by serotonin

74
Q

GAD definition?
Management?
Follow up?

A

Excessive, persistent worry that is not restricted to particular circumstances, present most of the day for at least 6 months

Management:
- CBT, selg help, relaxation, meditation, exercise

Meds:

  1. SSRI
  2. SNRI
  3. Pregabalin

Follow up: weekly for first month

(B blockers for symptoms)

75
Q

What is seen in 2/3 of patients with panic disorder?

A

Agoraphobia

76
Q

Management of acute panic attack?

A
  1. Reassure, encourage, slow breathing
  2. Benzo
Disorder:
1. Recognition
2. CBT
3. SSRI
If no response after 12 weeks:
4. imipramine/clomipramine
5. Referral
77
Q

Management of simple phobia?

A
  1. CBT - graded exposure

2. Benzo for short term e.g. flying

78
Q

Management of agoraphobia?

A
  1. education and relaxation techniques
  2. CBT - graded exposure
  3. Fluoxetine
    (combination of CBT and SSRI most effective)
79
Q

Management of social phobia?

A

Education, CBT, social skills training

SSRI

80
Q

Benzo MOA?

A

GABAa agonist, causing inhibitory effect

81
Q

What is buspirone?

MOA?

A

Anxiolytic used for short term
5HT1a agonist
Anxiolytic effect but not sedative and addictive like Benzos
Does take several days-weeks to fully work

82
Q

Management of OCD?

A

If mild:

  • CBT with exposure response prevention
  • SSRI if no response

Mod-sev:
SSRI with intensive CBT

If SSRI effective continue for at least 12 months to prevent relapse

83
Q

Specific SSRI for body dysmorphia?

A

Fluoxetine

84
Q

Features of acute stress disorder?
Rection vs disorder?
When does it become PTSD?
Management of acute stress disorder?

A

After serious incident:

  • flashbacks
  • dissociation
  • negative mood
  • avoidance
  • hyper vigilance
Reaction = 2 days
Disorder = 2 days - 4 weeks
PTSD = >4 weeks

Management:
Can use watchful waiting. If not:
1. trauma focused CBT
2. Benzo (with caution)

85
Q

Management of PTSD?

A

If armed forces, right to access treatment from them:

  1. trauma focused CBT
  2. EMDR

Others:
EMDR

Drugs: don’t use 1st line
If needed:
1. Venlafaxine or Sertraline
If severe, Risperidone

86
Q

What is adjustment disorder?

A

Failure to adapt to new life circumstances, often following a traumatic event
Must develop within 3 months and resolve within 6 months

Presentation:

  • depression, anxiety
  • panic attacks, poor concentration
  • preoccupation with event

Management:
- education and self help
2. SSRI
Short course of bentos

87
Q

Cluster A personality disorders?

A

MAD

Paranoid: distrust and suspicious of others, hypersensitivity and unforgiving when insulted, reluctance to confide in others

Schizoid: socially withdrawn, asexual, emotional coldness, few interests

Schizotypal: ideas of reference (but insight preserved), odd beliefs and magical thinking, odd eccentric behaviour

88
Q

Cluster B personality disorders?

A

BAD

Antisocial: usually young men, disregard for others, aggressiveness, failure to conform to social norms

Borderline: Usually young women, impulsivity and emotional lability, unstable relationships, recurrent suicidal behaviour, difficulty controlling temper

Histrionic: excessively emotional and attention seeking, inappropriate sexual seduction, need to be the centre of attention, rapidly shifting and shallow emotions, consider relationships more than they are

Narcissistic: preoccupied with power, prestige and vanity, grandiose sense of self importance, sense of entitlement, take advantage of others, chronic envy

89
Q

Cluster C personality disorders?

A

SAD

Avoidant/anxious: avoidance of occupational activities for fear of criticism, unwilling to be involved unless certain of being liked, restraint from intimate relationships for fear of being ridiculed

Dependent: Difficulty making everyday decisions, need excessive reassurance from others, difficulty expressing disagreement for fear nobody will support, feel they cannot take care of themselves

Obsessive compulsive/anakistic: order, control, inflexible, perfectionist. Rigid about ethics, values. Extremely dedicated to work at expense of social life.

90
Q

Diagnosis of anorexia?

A
  1. restriction of energy intake leading to low weight
  2. Intense fear of gaining weight even though underweight
  3. Disturbance in way body is perceived (e.g. denial of low weight)

Features:

  • low BMI
  • bradycardia
  • hypotension
  • enlarged salivary glands
91
Q

Physiological abnormalities in anorexia?

A

3 low:

  • hypokalaemia
  • hypothyroidism (low T3)
  • hypogonadotrophins (FSH, LH, oestrogen, testosterone)

4 high:

  • cortisol & aldosterone
  • glucose (impaired tolerance)
  • cholesterol
  • hypercarotinaemia
92
Q

Management of anorexia in adults?

In U18’s?

A

Adults:

  • CBT
  • Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
  • Specialists

Kids:

  1. anorexia-focussed family therapy
  2. CBT
93
Q

Most and least common personality disorders?

A

Cluster C most common (avoidant, dependent, anokistic/OCD)

Cluster B least common (antisocial, borderline, histrionic, narcissistic)

94
Q

Diagnosis of bulimia?

Management in kids and adults?

A

Recurrent binges with a sense of lack of control over these binges, followed by inappropriate compensatory behaviour to prevent weight gain (exercise, laxatives, vomiting, diuretics)

Management:
Refer to a specialist in all cases
1. self help for adults
2. CBT

Kids: family therapy

95
Q

Most common eating disorder?

A

EDNOS - doesn’t fit neatly into bulimia or anorexia

96
Q

Role of orbitofrontal cortex?
Prefrontal cortex?
How does addiction alter this?

A

Orbitofrontal - producing motivation to act

Prefrontal - inhibitory control

Addiction increases dopamine in reward pathway which increases activity of orbitofrontal cortex and reduces it in prefrontal cortex. Tolerance develops with down regulation of D2 receptors in reward pathway

97
Q

Screening questions for alcoholism?

A 
CAGE
C - cut down?
A - annoyed when folk comment?
G - guilty?
E - eye opener?
98
Q

Questionnaire to assess alcoholism?

A

AUDIT

99
Q

Mechanism of alcohol withdrawal?

Timeline

A

Alcohol chronically enhances GABA inhibition of CNS and inhibits NMDA glutamate receptors. Alcohol withdrawal leads to the opposite

Timeline:
6-12 hours: tremor, sweating, tachycardia, anxiety

36 hours: seizure

48-72 hours: DT - coarse tremor, confusion, delusions, auditory & visual hallucinations, fever, tachycardia

100
Q

Management of acute alcohol withdrawal?

A

Pts with complex Hx of withdrawals should be admitted for monitoring

  1. Long acting benzo e.g. diazepam or chlordiazepoxide. Lorazepam if hepatic failure

Carbamazepine may be useful for seizures

101
Q

Drugs for alcoholics?

A

Disulfram - inhibits acetaldehyde dehydrogenase (promotes abstinence). Even small amounts of alcohol (e.g. in mouthwash, perfume) may cause severe vomiting etc

Acamprosate - Weak antagonist of NMDA, reduces cravings

102
Q

Drugs for opioid withdrawal?

A

Methadone - opioid antagonist

Buprenorphine - partial agonist

Clonidine/Lofexidine - a-channel blocker

103
Q

Somatisation?

A

Medically unexplained SYMPTOMS for at least 2 years, refusal to accept nothing wrong

104
Q

Illness anxiety disorder/hypochondriasis?

A

Persistant belief they have a DISEASE

105
Q

Conversion disorder?

A

Loss of motor and or sensory function at times of stress, but indifferent to symptoms (la belle indifference)

106
Q

Dissociative disorder?

A

‘separating off’ certain memories from normal consciousness

Dissociative identity disorder = multiple personality, the most severe form

107
Q

Factitious disorder?

Muschausen by proxy?

A

Causing symptoms of a disease in order to get medical attention

By proxy - doing it to others e.g. their kids

108
Q

Othello syndrome?

A

Patient believes their partner is cheating despite being no evidence for this

109
Q

Cotard’s syndrome?

A

Patient is convinced that they are, orpart of their body is dead/decaying. severe depression.

110
Q

Capgras syndrome?

A

Patient believes that a person has been replaced by an exact clone who is a replica

111
Q

De Clerambaults Syndrome?

A

Patient (usually female) believes that someone (usually a celeb) is madly in love with them and can’t live life without them

112
Q

Do NF and Tuberous sclerosis cause learning difficulties>

A

Yes

113
Q

Fragile X?

2 features?

A

Most common cause of chromosomal LD, usually seen in males

Huge balls
Mitral valve prolapse

114
Q

Prader wili?

A

Paternal chromosome 15 - obesity, compulsive over eating, self injurious behaviour

115
Q

Angelman?

A

Maternal chromosome 15 - ataxia, puppet like movement, paroxysms of laughter, obsessed with water

116
Q

Di George?

A

CATCH 22

Cardiac 
Abnormal facies
Thymic hypoplasia
Cleft palate
Hypocalcaemia
22q11 deletion
117
Q

Cri du chat?

A

Chr 5

Microcephaly, cry like a cat

118
Q

Lesch Nyhan?

A

X linked condition of purine metabolism

Gout, renal stones, self-injurious behaviour (usually biting fingers)

119
Q

Charles bonnet syndrome?

A

Visual/auditory hallucinations in someone who is blind - retain insight

120
Q

Only absolute CI for ECT?
Short term SE?
Long term?

A

CI - raised ICP

Short term:

  • headache
  • nausea
  • short term memory loss (retrograde amnesia)
  • cardiac arrhythmia
  • aching muscles

Long term:

  • difficulty learning new information
  • apathy and anhedonia
  • difficulty concentrating
  • decreased emotional response
121
Q

Normal grief reaction?
Atypical grief?
Prolonged grief?

A
  1. Denial - numbness, pseudohallucinations, focussing on objects that remind them of person
  2. Anger - usually at loved ones/medical professionals
  3. Bargaining
  4. Depression
  5. Acceptance

Atypical: takes >2 weeks for grieving to begin

Prolonged: difficult to define, often takes up to 12 months

122
Q

When is insomnia classed as acute and chronic?

A

<3 months = acute
>3 months = chronic

Short term management:

  • advice on sleep hygiene
  • don’t drive if sleepy
  • Only use hypnotics/benzos at lowest dose possible if daytime functioning severely impaired
123
Q

How to the Z drugs work?

A

act on a2-GABA receptors - similar to benzos but different structure

High addictive/toletance potential

Risk of falls in elderly

124
Q

Management of seasonal affective disorder?

A

CBT - follow up after 2 weeks

SSRI if needed

Do not give sleeping tablets, can make things worse

125
Q

Knights move thinking?

A

Severe loosening of associations, leaping from one idea to another illogically - schizophrenia

126
Q

Circumstantiality?

A

Inability to answer a question without giving excess unnecessary detail, but returns to original point eventually

127
Q

Tangentiality?

A

Wandering from the topic

128
Q

Clang associations?

A

Ideas that are related to each other only by the fact they sound similar

129
Q

Word salad?

A

Complete incoherent, non-sensical speech using real words

130
Q

Flight of ideas?

A

Mania - rapid leads from one idea to another but with a discernible connection between them

131
Q

Perseveration?

A

Repetition of ideas or words in an attempt to change the topic

132
Q

Echolalia?

A

Repetition of one’s speech, including the question that was asked

133
Q

Why might patients on quetiapine have polyuria and polydipsia?

A

Dysglycaemia

134
Q

When doing MMSE, what can help differentiate between depression and alzheimer’s?

A

Pts with depression will often answer “I don’t know” where as patients with Alzheimer’s will try to answer your question, just incorrectly

135
Q

Monitoring of antipsychotics:

  • baseline?
  • FBC, LFT, U&E?
  • lipids and weight?
  • glucose and prolactin?
  • BP?
  • Cardiovascular risk assessment?
A

Baseline: FBC, U&E, LFT, lipids, weight, glucose, prolactin, BP, ECG

FBC, LFT, U&E checked weekly at the start of clozapine, then annually

Lipids and weight: 3 months after start then annually

Glucose and prolactin: 6 months after start then annually

BP checked frequently during dose titration

Cardiovascular risk assessment annually

136
Q

Why do most schizophrenia patients have insomnia?

A

Disturbance of circadian rhythm

137
Q

Pt on clozapine, has been suffering malaise for a few days, and presents to A&E with chest pain looking sweaty and uncomfortable - cause?

A

Myocarditis

138
Q

Which antipsychotic has the best side effect profile, esp when it comes to prolactin?

A

Aripiprazole

139
Q

Antihistamine effect of TCA effect on weight?

A

Weight gain

140
Q

Scoring system to assess the severity of alcohol withdrawal?

A

CIWA-Ar (clinical institute withdrawal assessment)

141
Q

Symptoms of post-concussion syndrome?
How long does it last?
Does it have to be a high impact head injury?

A

Headache (generalised, there for most of the day, most days)
Fatigue
Anxiety/depression
Dizziness

Usually 7-10 days, but often lasts weeks-months, sometimes up to a year

No, can be after several small impacts that the patient might not have even taken notice of, e.g. if they play rugby

142
Q

Patient has sudden onset psychosis after a course of prednisolone for asthma flare up?

A

Steroid-induced psychosis

143
Q

What should you do with a patient’s antidepressants prior to commencing ECT?

A

Reduce the dose

but don’t stop due to risk of withdrawal effects

144
Q

Difference between GAD and panic disorder?

A

GAD can have moments of almost like panic attacks feeling very short of breath and heart beating out of chest, on a background of nearly constant anxiety with no particular trigger

Panic disorder has panic attacks but people have no background anxiety usually

145
Q

What can SSRI use in pregnancy cause?

A

1st trimester - congenital heart defects

3rd trimester - PPH

146
Q

1st line management for borderline personality disorder?

A

Dialectical behavioural therapy

147
Q

What non-standard things might suggest OCD?

How long must is last for?

A

Repeating phrases e.g. “today will be a good day” when going into work
Intrusive thoughts, which can be suicidal, with no trigger for them
50% drink to try and get rid of these

At least 2 weeks

148
Q

Raised WCC with no other symptoms whilst taking lithium?

A

Benign leucocytosis

Finals Revision (29 decks)

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