Psychiatry Flashcards
What is the therapeutic range of lithium?
What can cause lithium toxicity?
What level is usually toxic?
0.4-1 mmol/l
Dehydration
Renal failure
Drugs - diuretics (esp thiazides), ACEI/ARB, NSAIDs, metronidazole
> 1.5 mol/l
Symptoms of lithium toxicity?
Rx?
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
Emergency detention:
- criteria?
- time?
- who?
- appeal?
- MHO informed?
- 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
Short term detention:
- criteria?
- time?
- who?
- appeal?
- MHO informed?
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
Compulsory treatment order:
- criteria?
- who?
- how is it decided?
- what does it allow?
- appeal?
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
Advanced statement:
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
Capacity assessment:
- who?
- What must pt be able to do?
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
Certificate of incapacity?
Confirms patient does not have capacity
Form found under section 47
Enables decision to be made by proxy or doctor
Power of attorney?
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
Guardianship order?
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
Intervention order?
Order that authorises a person to act and make a one off decision for an adult with incapacity
Childhood ages of capacity?
<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
Core symptoms of depression?
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
Medical differential for depression?
Hypothyroidism Cushing's Syphilis SLE Hypercalcaemia Drugs: steroids, retinoids, B blockers
What is dysthymia?
Chronic mild depression for 2 years in which episodes are either not long enough to not severe enough to meet criteria for depression
Depression: Mild? Mod? Severe? Mixed? Atypical?
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
Management of mild depression?
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
Management of mod-sev depression?
SSRI 1st line
Along with ‘high-intensity psychological therapy’ e.g.:
CBT
Interpersonal therapy
Behavioural couples therapy
When should someone be reviewed after starting an SSRI?
How long should they be stopped over?
2 weeks
Or 1 week if suicidal thoughts/behaviour
Stop over 4 weeks
Side effects of SSRI?
GI upset
Risk of GI bleeds - use PPI, esp with aspirin
Hyponatraemia
Increase in anxiety and suicidal ideation when starting
Citalopram - QT interval
Interactons with SSRIs?
NSAIDs - PPI
Warfarin/Heparin - consider mirtazapine
Triptans - avoid
Discontinuation symptoms of SSRI?
Increased mood changes Restlessness Difficulty sleeping Unsteadiness Sweating GI upset Paraethseia
Highest risk with paroxetine
Essentially like a come down
SE TCA’s?
What ones are least sedative?
Drowsy (affects ability to operate heavy machinery) Dry mouth Blurred vision Constipation Urinary retention QTc prolongation
Least sedative: imipramine, nortriptyline
What SSRI is safest after MI?
What one is preferred in adolescents?
Sertraline
Fluoxetine
SNRI examples?
SE?
Duloxetine, Venlafaxine
Basically same as SSRI
GI upset
Cardio: hypertension, palpitations, dizziness
NaSSA example?
SE?
Uses?
Mirtazapine
Weight gain
Sedation
Generally considered second line. Useful if weight loss or insomnia is an issue
MAOI examples?
SE?
Use?
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)
SARI example?
Use?
Trazodone
Useful as a non-addictive sedative
Can be used to augment SSRI/SNRI
Features of serotonin syndrome?
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
Mania vs hypomania?
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
Bipolar: - 1st and 2nd line mood stabilisers? - what else can be used? Management of: - mania? - hypomania? - depression?
- Lithium
- 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?)
Rapidly cycling bipolar?
Bipolar 1?
Bipolar 2?
4+ episodes of mood disorder in a year
1 - mania
2 - hypomania - depressive episodes tend to be worse and longer lasting
Why to try and avoid antidepressants in bipolar?
What are they normally used with/
Cause mania
Atypical antipsychotics
Lithium SE?
Fine tremor Metallic taste Dry mouth Weight gain Hypothyroidism (block peripheral conversion of T4 to T3) ECG: T wave flattening/inversion Hypercalcaemia Diabetes insipidus
Monitoring of lithium?
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
What these types of hallucinations suggest?
- auditory?
- visual?
- olfactory?
- gustatory?
- tactile?
Auditory - schiz
visual - drugs/delirium
Olfactory - seizures
Gustatory - seizures
tactile - delirium/alcohol withdrawal
Organic causes of psychosis?
Dementia Delirium Huntingtons SLE Syphilis Hyperthyroidism Hypoglycaemia Parkinson's HIV
Characteristics of psychosis?
Hallucinations
Delusions
Thought disorganisation:
- alogia: little information conveyed by speech
- tangentiality: answers diverge from topic
- clanging
- word salad: non-sensical
Causes of drug-induced psychosis?
Legal highs, amphetamines, cannabis
Levodopa, corticosteroids, antimalarials
Withdrawal: alcohol, bezos
Presents floridly, should resolve with cessation of use of causative drug
Schizoaffective disorder?
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
Pathophysiology of schizophrenia:
- neurochemical?
- histological?
- structural?
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
First rank symptoms of Schizophrenia? Other features (not negative symptoms)?
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
Negative symptoms of schizophrenia?
- incongruent/blunted affect
- anhedonia
- alogia (poverty of speech)
- avolition (poor motivation)
Features of catatonic schizophrenia?
Posturing
Negativism - resistance to command or attempts to be moved
Command automatism - will do whatever you ask them
Examples of typical antipsychotics?
MOA?
SE?
Haloperidol, chlorpromazine, prochlorperazine
D2 receptor blocker in mesolimbic system
EPSE Sedation Hyperprolactinaemia QT prolongation Increased appetite and weight gain
EPSE and how to manage each?
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)
Atypical antipsychotic examples?
MOA?
SE?
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
What causes weight gain with antipsychotics?
5HT2c receptor blockers
Most pronounced in clozapine and olanzapine
What atypical antipsychotics have highest risk of EPSE?
Rare: clozapine
Uncommon: aripiprazole
Higher doses: olanzapine, risperidone
4 main dopamine pathways?
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
Clozapine use?
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%)
Initiation of clozapine?
Monitoring of clozapine?
If missed dose?
If smoking?
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
Neuroleptic malignant syndrome:
- causes?
- presentation?
- Diagnosis?
- Management?
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
More sedating?
Olanzapine, Risperidone
Avoidance of weight gain - which antipsychotics?
Aripiprazole, Haloperidol
Depot antipsychotic?
Risperidone
What antipsychotic can be used for anxiety?
Olanzapine
Management of violent/aggressive patient if unknown Hx of antipsychotic exposure or cardiac disease?
If known significant exposure to typical antipsychotics (not just PRN)?
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
ApoE genes in Alzheimers? Presinilin genes in inherited? Macroscopic changes? Histological changes? Neurotransmitter changes?
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)
Presentation of alzheimer’s: memory, orientation, speech, behaviour, associated?
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
What functional deficits may be seen in vascular dementia?
Are mood/personality disorders prominent or not?
Insight?
What tests can be done?
Gait disturbance and urinary incontinence
Mood/personality disturbance - prominent
Insight preserved
SPECT - reduced attenuation throughout brain
Hackinski score
Lewy Body dementia:
- macroscopic changes?
Macro: degeneration of substantia nigra and cortex
Micro: levy body deposition in substantia nigra and cortex (a-synuclein inclusions)
Presentation of Lewy Body dementia?
Physical symptoms?
Can it present as psychosis?
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
Frontotemporal dementia presentation?
Insight?
Macro/microscopic changes?
Insight?
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
Huntington’s dementia:
- genetics?
- pathophysiology?
- features?
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
Mad cow disease features?
Only definitive diagnosis?
Caused by prion disease
Rapid onset dementia Ataxia Seizures Myoclonic jerk Reduced cognition
Posthalmous biopsy - proteinaceous B sheets
General tests for suspected dementia?
When to do LP?
Cognitive?
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
Cholinesterase inhibitors for dementia:
- 3 examples?
- use?
- SE?
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
NMDA antagonists for dementia:
- example?
- use?
- SE?
Memantine
Severe, or when cholinesterase inhibitors have failed to work in Alzheimers or Lewy body
SE: drowsiness, dizziness, consipation, balance
What drugs should be avoided in Lewy Body?
Antipsychotics
Can you use cholinesterase inhibitors or memantine in vascular dementia?
Only if co-existant alzheimers, lewy body or parkinson’s disease dementia
Treatment of depression in dementia?
Behavioural disturbance?
Depression - antidepressant
Behavioural - antidepressant, anticonvulsant or benzo
Appetitive system?
Aversive system?
Appetitive - seeking and approach behaviours, controlled by dopamine
Aversive -promote survival in the event of threat, fear or pain, controlled by serotonin
GAD definition?
Management?
Follow up?
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:
- SSRI
- SNRI
- Pregabalin
Follow up: weekly for first month
(B blockers for symptoms)
What is seen in 2/3 of patients with panic disorder?
Agoraphobia
Management of acute panic attack?
- Reassure, encourage, slow breathing
- Benzo
Disorder: 1. Recognition 2. CBT 3. SSRI If no response after 12 weeks: 4. imipramine/clomipramine 5. Referral
Management of simple phobia?
- CBT - graded exposure
2. Benzo for short term e.g. flying
Management of agoraphobia?
- education and relaxation techniques
- CBT - graded exposure
- Fluoxetine
(combination of CBT and SSRI most effective)
Management of social phobia?
Education, CBT, social skills training
SSRI
Benzo MOA?
GABAa agonist, causing inhibitory effect
What is buspirone?
MOA?
Anxiolytic used for short term
5HT1a agonist
Anxiolytic effect but not sedative and addictive like Benzos
Does take several days-weeks to fully work
Management of OCD?
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
Specific SSRI for body dysmorphia?
Fluoxetine
Features of acute stress disorder?
Rection vs disorder?
When does it become PTSD?
Management of acute stress disorder?
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)
Management of PTSD?
If armed forces, right to access treatment from them:
- trauma focused CBT
- EMDR
Others:
EMDR
Drugs: don’t use 1st line
If needed:
1. Venlafaxine or Sertraline
If severe, Risperidone
What is adjustment disorder?
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
Cluster A personality disorders?
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
Cluster B personality disorders?
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
Cluster C personality disorders?
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.
Diagnosis of anorexia?
- restriction of energy intake leading to low weight
- Intense fear of gaining weight even though underweight
- Disturbance in way body is perceived (e.g. denial of low weight)
Features:
- low BMI
- bradycardia
- hypotension
- enlarged salivary glands
Physiological abnormalities in anorexia?
3 low:
- hypokalaemia
- hypothyroidism (low T3)
- hypogonadotrophins (FSH, LH, oestrogen, testosterone)
4 high:
- cortisol & aldosterone
- glucose (impaired tolerance)
- cholesterol
- hypercarotinaemia
Management of anorexia in adults?
In U18’s?
Adults:
- CBT
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- Specialists
Kids:
- anorexia-focussed family therapy
- CBT
Most and least common personality disorders?
Cluster C most common (avoidant, dependent, anokistic/OCD)
Cluster B least common (antisocial, borderline, histrionic, narcissistic)
Diagnosis of bulimia?
Management in kids and adults?
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
Most common eating disorder?
EDNOS - doesn’t fit neatly into bulimia or anorexia
Role of orbitofrontal cortex?
Prefrontal cortex?
How does addiction alter this?
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
Screening questions for alcoholism?
CAGE C - cut down? A - annoyed when folk comment? G - guilty? E - eye opener?
Questionnaire to assess alcoholism?
AUDIT
Mechanism of alcohol withdrawal?
Timeline
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
Management of acute alcohol withdrawal?
Pts with complex Hx of withdrawals should be admitted for monitoring
- Long acting benzo e.g. diazepam or chlordiazepoxide. Lorazepam if hepatic failure
Carbamazepine may be useful for seizures
Drugs for alcoholics?
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
Drugs for opioid withdrawal?
Methadone - opioid antagonist
Buprenorphine - partial agonist
Clonidine/Lofexidine - a-channel blocker
Somatisation?
Medically unexplained SYMPTOMS for at least 2 years, refusal to accept nothing wrong
Illness anxiety disorder/hypochondriasis?
Persistant belief they have a DISEASE
Conversion disorder?
Loss of motor and or sensory function at times of stress, but indifferent to symptoms (la belle indifference)
Dissociative disorder?
‘separating off’ certain memories from normal consciousness
Dissociative identity disorder = multiple personality, the most severe form
Factitious disorder?
Muschausen by proxy?
Causing symptoms of a disease in order to get medical attention
By proxy - doing it to others e.g. their kids
Othello syndrome?
Patient believes their partner is cheating despite being no evidence for this
Cotard’s syndrome?
Patient is convinced that they are, orpart of their body is dead/decaying. severe depression.
Capgras syndrome?
Patient believes that a person has been replaced by an exact clone who is a replica
De Clerambaults Syndrome?
Patient (usually female) believes that someone (usually a celeb) is madly in love with them and can’t live life without them
Do NF and Tuberous sclerosis cause learning difficulties>
Yes
Fragile X?
2 features?
Most common cause of chromosomal LD, usually seen in males
Huge balls
Mitral valve prolapse
Prader wili?
Paternal chromosome 15 - obesity, compulsive over eating, self injurious behaviour
Angelman?
Maternal chromosome 15 - ataxia, puppet like movement, paroxysms of laughter, obsessed with water
Di George?
CATCH 22
Cardiac Abnormal facies Thymic hypoplasia Cleft palate Hypocalcaemia 22q11 deletion
Cri du chat?
Chr 5
Microcephaly, cry like a cat
Lesch Nyhan?
X linked condition of purine metabolism
Gout, renal stones, self-injurious behaviour (usually biting fingers)
Charles bonnet syndrome?
Visual/auditory hallucinations in someone who is blind - retain insight
Only absolute CI for ECT?
Short term SE?
Long term?
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
Normal grief reaction?
Atypical grief?
Prolonged grief?
- Denial - numbness, pseudohallucinations, focussing on objects that remind them of person
- Anger - usually at loved ones/medical professionals
- Bargaining
- Depression
- Acceptance
Atypical: takes >2 weeks for grieving to begin
Prolonged: difficult to define, often takes up to 12 months
When is insomnia classed as acute and chronic?
<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
How to the Z drugs work?
act on a2-GABA receptors - similar to benzos but different structure
High addictive/toletance potential
Risk of falls in elderly
Management of seasonal affective disorder?
CBT - follow up after 2 weeks
SSRI if needed
Do not give sleeping tablets, can make things worse
Knights move thinking?
Severe loosening of associations, leaping from one idea to another illogically - schizophrenia
Circumstantiality?
Inability to answer a question without giving excess unnecessary detail, but returns to original point eventually
Tangentiality?
Wandering from the topic
Clang associations?
Ideas that are related to each other only by the fact they sound similar
Word salad?
Complete incoherent, non-sensical speech using real words
Flight of ideas?
Mania - rapid leads from one idea to another but with a discernible connection between them
Perseveration?
Repetition of ideas or words in an attempt to change the topic
Echolalia?
Repetition of one’s speech, including the question that was asked
Why might patients on quetiapine have polyuria and polydipsia?
Dysglycaemia
When doing MMSE, what can help differentiate between depression and alzheimer’s?
Pts with depression will often answer “I don’t know” where as patients with Alzheimer’s will try to answer your question, just incorrectly
Monitoring of antipsychotics:
- baseline?
- FBC, LFT, U&E?
- lipids and weight?
- glucose and prolactin?
- BP?
- Cardiovascular risk assessment?
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
Why do most schizophrenia patients have insomnia?
Disturbance of circadian rhythm
Pt on clozapine, has been suffering malaise for a few days, and presents to A&E with chest pain looking sweaty and uncomfortable - cause?
Myocarditis
Which antipsychotic has the best side effect profile, esp when it comes to prolactin?
Aripiprazole
Antihistamine effect of TCA effect on weight?
Weight gain
Scoring system to assess the severity of alcohol withdrawal?
CIWA-Ar (clinical institute withdrawal assessment)
Symptoms of post-concussion syndrome?
How long does it last?
Does it have to be a high impact head injury?
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
Patient has sudden onset psychosis after a course of prednisolone for asthma flare up?
Steroid-induced psychosis
What should you do with a patient’s antidepressants prior to commencing ECT?
Reduce the dose
but don’t stop due to risk of withdrawal effects
Difference between GAD and panic disorder?
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
What can SSRI use in pregnancy cause?
1st trimester - congenital heart defects
3rd trimester - PPH
1st line management for borderline personality disorder?
Dialectical behavioural therapy
What non-standard things might suggest OCD?
How long must is last for?
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
Raised WCC with no other symptoms whilst taking lithium?
Benign leucocytosis
