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Medicine > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Antipsychotics: Indications?

A

o Schizophrenia
o Other psychotic disorders: Brief psychotic disorder, schizophreniform, delusional disorder, etc
o Mood disorder (w/ agitation and/or psychosis; e.g. depression or mania w/ psychosis)

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2
Q

Antipsychotics: MOA?

A

• Mechanism: Dopamine antagonists
o Cortical areas and effects:
1- Mesolimbic + Mesocortical: ↓psychosis
2- Nigrostriatal: Worsen/create movement disorders (Parkinsonism)
3- Tuberoinfundibular: ↑prolactin (by inhib dopamine)

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3
Q

Anti-psychotics: Main drug groups & examples?

A

o Typicals:
 Haloperidol (prolonged QT interval)

o Atypicals:
 Clozapine (old atyp; seizures + agranulocytosis)
• Best efficacy, but use 2 atypicals first

 Olanzapine (wt gain)

 Quetiapine (sedation)

 Aripiprazole (akathisia)

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4
Q

Tardive Dyskinesia: Major SE of antipsychotics.

Give Features, cause & Rx?

A

o Tardive dyskinesia
 Features: Choreoathetosis/involuntary movement
• Writhing fingers (progressing to whole of limb)
• Tongue protrusion
• Lip smacking
• Chewing + pouting of jaw

 Cause: IRREVERSIBLE dopamine hypersensitivity caused by chronic blockage (i.e. this is an effect when NOT on the antipsychotic, or after long time on same dose) [upregulation of DA receptors], same pathophys as alcoholic seizures

 Rx: No treatment

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5
Q

Neuroleptics malignant syndrome (NMS): features, Ix & RX?

A

 Features:
• Antipsychotics use in last 1-4wk (often last 10d)
• Hyperthermia (>38)
• Muscular rigidity/cramps
• Autonomic problems (Tachycardia, Hypo/HTN, tremor, incont, sweating…)
• Delirium/fluctuating consciousness

 Ix: Urinalysis (myoglobin), Bloods (CK can cause AKI) , Drug screen (?amphetamines), raised WCC

	Rx: Life threatening (even though it is rare)
•	Discontinue antipsychotic
•	Dantrolene (muscle relaxant)
-Bromocriptine 
-IV fluids
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6
Q

Other SE of antipsychotics?

A

Acute Dystonia→ involuntary painful muscle spasms.

Torticollis: Neck twists to 1 side.

Oculogyric crisis: eye twists up.

Parkinsonism→ Resting tremor, rigidity, bradykinesia, shuffling gait.

Akathisia→ severe restlessness

Anticholinergic/antiadrenergic effects: dry mouth, constipation, blurred vision, urinary retention, tachycardia.

↑ Prolactin Secretion from Pituitary: Galactorrhoea, amenorrhoea, sexual dysfunction and ↑ risk of osteoporosis.

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7
Q

How to manage: Dystonia, akathisia, bradykinesia, tardive dyskinesias & parkinsonism?

A

Procyclidine

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8
Q

If prolactin levels are elevated, which antipsychotic is chosen?

A

Aripiprazole

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9
Q

Antidepressant medication types & examples?

A

• Types:
o SSRIs  Fluoxetine, citalopram, sertraline
o SNRIs  Venlafaxine
o TCAs  Amitriptyline
o NaSSA (noradrenergic + specific serotonin antidepressant)  Mirtazapine

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10
Q

SE of SSRI?

A 
	Anxiety + suicide in first 2wk
	GI (most com)  ↑ risk GI bleeding
	Anorgasmia/↓libido/erectile dysfunction
	Sedation
	Hyponatraemia – likely due to SIADH
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11
Q

ECT: Indications, procedure, post-procedure & SE’s?

A

• Indications:
o Major depressive episode and…:
 In patients who have positively responded to ECT in the past
 Patients with contraindications to antidepressant medication
 Non-responsive to antidepressants or mood stabilizers (two agents, adeq dose/time)
 High risk of immediate suicide, or death by other means (e.g. starvation, dehydration)

  • Procedure: General anaesthetic, 2 sessions per week for 6-12 total sessions
  • Post-procedure: Continue medical Rx (as relapse rates are high otherwise)

• S/Es:
o Immediate:
 Anaesthetic complications
 Status epilepticus

o Long term  Memory loss

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12
Q

Sections?

A

Sections -NB: Patient’s can be discharged from any section at any time by professionals

  1. SECTION 2:
    a. Assessment for 28d, CANNOT be renewed
    b. Treatment CAN be given against patient’s will
  2. SECTION 3:
    a. Treatment for 6mo, CAN be renewed
    b. Treatment IS given, even against patient’s will
  3. SECTION 4:
    a. Emergency order for 72hr, CANNOT be renewed but CAN be converted to Section 2
    b. For GPs
    c. Treatment CANNOT be given against patient’s will until psychiatrist reviews and converts to Section 2
  4. SECTION 5:
    a. Compulsory detention for patients who show up to hospital and then try to leave
    b. 5(2)  By doctor, up to 72hr
    c. 5(4)  By nurse, up to 6hr
    d. Treatment CANNOT be given against patient’s will
  5. SECTION 135:
    a. Police can ENTER + REMOVE patient from their premises and take to “safe place” for 72hr, but can ONLY be used if a warrant is obtained
    b. Treatment CANNOT be given against patient’s will
  6. SECTION 136:
    a. Police take someone from PUBLIC SPACE (hence warrant not needed) to “safe place” for 72hr
    b. Treatment CANNOT be given against patient’s will
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13
Q

Depression: Risks?

A

SAD PERSONS – much of this will come out in general medical history!
o Sex (male) – more likely for suicide
o Age (Elderly or young 20-30)
o Depression
o Previous suicide attempts/FH of suicide attempts
o Ethanol abuse
o Rational thinking lost
o Social support lacking
o Organised suicidal plan (e.g. avoid discover, notes, closing accounts)
o No spouse/kids/friends/job
o Sickness (chronic illness)

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14
Q

Features of depression?

A

: DEAD SWAMP (depression, energy, anhedonia, death [suicide], sleep, worthlessness, appetite, mentation, psychomotor agitation/pessimistic)

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15
Q

Major depressive disorder criterias:

A

 Major criteria  2 of 3:
• Depressed mood
• Anhedonia (absence of pleasure)
• Low energy

	Minor criteria:
•	↓concentration/attention
•	↓sleep
•	↓appetite/↓weight
•	Psychomotor agitation (restless)/retardation (slow movement)
•	Hopeless, helpless, worthless, guilt
•	Pessimistic view of future
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16
Q

Depression: IX & MX?

A 
o	R/O organic cause
	FBC, B12 (anaemia)
	Calcium
	TFT (hypothyroid)
	SynACTHen test (Addison’s

PHQ-9 questionnaire

General examination

Mx: CBT + SSRI

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17
Q

Bipolar disorder:

Types?

A

o Bipolar I  Mania (psychosis or delusions present) + depression
o Bipolar II  Hypomania (psychosis and delusions ABSENT) + depression (more common)

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18
Q

Criteria for hypomania & mania?

A

Hypomania: mild elevated mood (>/= 4days), milder form of mania symptoms (they interfere with work & social life but no severe disruption), partial insight.

Mania w/ or w/o psychosis: Symptoms >1 week, complete disruption of work & social activities.

19
Q

Features of bipolar?

A

• Features of mania OR hypomania: 3 of the following (GST PAID)
o Grandiosity/inflated self-esteem (grandeur = PSYCHOTIC)
o Sleep decreased
o Talkative

o Pressured speech (excessive spending, flirtacious)
o Always on the go/attention lacking
o Ideas, flight of ideas
o Distractibility

o Psychosis (e.g. hallucinations [auditory], delusions [grandiose, persecutory])  always Bipolar I

NB: Patients experience normality of mood in between episodes – this is characteristic of bipolar.

20
Q

Bipolar Ix?

A 
MSE
Collateral Hx
Full examination
=
Blood Test: FBC, TFT (hypo/hyper thryoidism), U&E (baseline renal function to view starting lithium), LFT (baseline hepatic function to start mood stabilizers), glucose, Ca

Urine drug test: illicit drugs

CT-head: space-occupying lesion (can cause disinhibition)

21
Q

Bipolar acute Mx?

A

Biological:
1-Antipsychotics: Olanzipine or risperidone, quetiapine, haloperidol

2-Mood stabiliser: lithium, sodium valproate (after 4w)

3-Benzodiazepine: aid in sleep & reduce agitation (e.g. lorazepam, clonazepam)

Psychiatry: CBT, psychoeducation

Social: Social group support, self-help groups, key worker in community

22
Q

Schizophrenia: Features?

A

o “First-rank”/Positive symptoms:
presence of even one is suggestive of schizophrenia
 Auditory Hallucinations
• Two people discussing patient in THIRD PERSON
• Running commentary in THIRD PERSON (one or two people talking)

 Delusions (mainly persecutory, also grandiose, reference- mostly bizarre)

 Though disorder (insertion, withdrawal, broadcasting)

 Passivity  Bodily sensations or motions being controlled be external influence

23
Q

Schizophrenia IX & MX?

A

Collateral Hx & MSE

Neurological Exam

Ix: Urine toxicity screen

Bloods

MX:
o Conservative: CBT (all patients should be offered!)
o Medication: Atypical antipsychotics

24
Q

Delusional disorder: Features, Types, Mx?

A

• Delusional Disorder-
o Features: Believable/non-bizarre delusions for >1mo and NO hallucinations without a significant impact on the patient’s life

o Types:
 Erotomania  High-status stranger (e.g. celebrity) is in love with them
 Jealous
 Grandiose  They are the CEO of a large multinational company
 Persecutory etc.

o Rx: OP treatment
 First: CBT + atypical antipsychotics
• NB: POOR evidence for antipsychotics, so worth a trial but stop if no effect

25
Q

Anxiety disorders: Definition & types?

A

• Definition: A syndrome of over-worry which manifests with psychological and physiological components, and which significantly impacts on one’s life

• Types:
o Panic: No specific trigger
o Phobic: Specific trigger(s) and response occurs in predictable fashion (e.g. spider)
o GAD: Anxious nearly all the time to most stimuli
o OCD: Intrusive thoughts, anxiety relieved by performing certain meaningless actions
o PTSD: A traumatizing event in past with flooding of memories, avoidance + hyperarousal

26
Q

Features of anxiety disorders?

A 
o	Psychological
	Worrying
	Fear of dying/impending doom
	Restlessness
	Concentration decreased
	Sleep decreased

o Physiological:
↑↑sympathetic drive/adrenaline
 Chest pain (mimicking MI – radiation to arm, jaw)
 Palpitations + ↑HR
 SOB/hyperventilation + tingling in peripheries (hyperventilation phenomenon)
 Tremor, sweating, dry mouth

27
Q

Anxiety: panic disorder:

Definition, features, Ix?

A

• Definition of Panic Attack: A very large burst of anxiety lasting often <30min, often in young patient

• Features:
o Very significant and short burst anxiety which occurs out of the blue
o Feeling of impending doom/death

• Types:
o Panic disorder with agoraphobia (25%)
o Panic disorder without agoraphobia (75%)

• Ix: Do not extensively investigate – consider only relevant things (e.g. ECG, but not Ix for pheo)

28
Q

Mx of panic disorder?

A

o Active ATTACK: Explain
 Will subside spontaneously
 Breath slow but not deep + distract yourself + stay in situation (unless unsafe)
 Don’t use alcohol; DO NOT prescribe benzo’s

o Chronic DISORDER:
 Non-Pharm:
• Lifestyle  ↓stress, ↓alcohol, ↓coffee, ↑exercise
• Psychotherapy  CBT

 Pharm: SSRI (best)

29
Q

GAD: Definition, features, Ix & MX?

A 
•	Definition/Features: 
o	Anxiety (psych + physio) in a abnormally large number of normal life circumstances lasting >6mo
	3 of 6 on most days for >6mo:
•	On edge
•	Easily fatigued
•	Irritability
•	Muscle tension
•	Poor concentration
•	Sleep disturbances

• Ix:
o GAD-7 (screening questionnaire)
o Consider TFTs, urine free catecholamines, tox screen

• Rx:
o Non-Pharm: CBT (MOST important)

o Pharm: SSRI

30
Q

OCD: Definition & MX?

A

• Definition: Egodystonic disease (patient does NOT like that they have disorder and have to do rituals)

o Obsession (thoughts)  Anxiety-provoking intrusive thoughts which are constant, repetitive and senseless

o Compulsion (motor)  Odd but seemingly purposeful behaviour which is time-consuming but pt is compelled to perform and decreased anxiety by performing

• Rx:
o Non-Pharm: CBT, Exposure + Response Prevention (ERP; e.g. make dirty, do not allow to wash)

o Pharm: SSRI

31
Q

Phobias: Definition, Common types & Mx?

A

Anxiety: Phobias

• Definition: Irrational fear and avoidance of stimuli/objects/situations which results in a panic-like reaction/anxiety when in contact with particular stimuli and predicted response occurs

• Common types:
o Social phobia  Fear of humiliations or embarrassment in general or specific social situations

o Specific phobias

• Rx:
o For all: CBT, systematic de-sensitization for specific phobias

32
Q

PTSD: Definition, Features Mx?

A

• Definition: Anxiety/fear/horror following a severe/threatening/catastrophic event (war, rape, etc)

• Features:
o Re-experiencing/flooding of memories: Nightmares, intrusive flashbacks

o Avoidance of stimuli associated with the trauma (people, similar circumstances)

o Hyperarousal: ↑anxiety, waking from sleep, hypervigilance for threat, poor concentration

o Emotional numbing: Indifferent to stimuli, feeling detached

• Rx:
o Non-Pharm: MOST IMPORTANT
 CBT
 Eye movement desensitization and reprocessing (EMDR)
• Ask to remember flashback + emotion + centre it (e.g. “some people feel it in chest, in abdo”)
• Ask pt to follow object side-to-side min 20x
o Some pt may not be able to continue, this is okay
• Repeat over course of weeks until pt does not outpour when confronted

o Pharm: SSRI (less important)

33
Q

Somatoform: Somatization/Somatisation Disorder: Definition, criteria & Mx?

A

• Definition: Multiple symptoms affecting multiple organs without a medical explanation after investigation, and patient often does not accept professional reassurance (can go on for years with pt seeking advice)
o Criteria  Must have complained of:
 4+ pain symptoms
 2+ GI symptoms
 1+ sexual symptoms
 1+ neurological symptom
Often should be >2yr with no conclusive diagnosis, but pt does not accept this

• Rx: Psychotherapy (e.g. CBT)

34
Q

Somatoform: Conversion Disorder: Definition & Mx?

A

• Definition: One or more neurological symptoms (often sensory or motor) which cannot be explained medically and are always precipitated by a life stressor
o Patients also experience “la belle indifference” – lack of concern for neuro deficit (as opposed to anxiety in other conditions)
• Rx:
o Psychotherapy (e.g. CBT)

35
Q

Somatoform: Hypochondriasis: Definition & Mx?

A

• Definition: Consistently thinking one has a health issue (e.g. a diagnosis like cancer; NOT symptoms) due to a misinterpretation of symptoms (e.g. “I’m tired = cancer”) + despite regular professional reassurance
o Pre-occupations with their health issues
o Level of functioning affected
o >6mo

• Rx: Psychotherapy (e.g. CBT)

36
Q

Munchausen’s/Factitious Disorder: Definition?

A

• Definition: Consciously faking symptoms to attain attention/nurturing from healthcare staff WITHOUT motivation from secondary gain
o More common in men, and healthcare workers
o Methods to fake may seem atrocious to us, but patients will do ANYTHING sometimes
o Demand treatment in hospital
o Angry when confronted/about to be confronted, then leave

37
Q

Malingering: Definition?

A

Malingering (NOT a psych disorder)
• Definition: Consciously faking symptoms due to motivation for a secondary gain (e.g. avoid school, work)

o E.g. faking symptoms, coming into A+E for morphine

38
Q

Anorexia Nervosa: Common ways to lose weight? Epidemiology?

A 
•	Common ways to lose weight:
o	Diet
o	Exercise
o	Laxatives
o	Diuretics
o	Fasting
o	Purging

• Epidemiology:
o 90% are female, 10% male
o Age 15 (but up to 30)
o Most common cause for admission to child psychiatric wards

39
Q

AN: Types & features?

A

• Types:
o Restricting: Limiting food, no vomiting
o Binge-eating/purging: Regularly binge on food and vomit afterwards

• Features: Triad for anorexia
o BMI <17.5
o Body image distortion (check mirror/scale often; deny thin appearance)
o Amenorrhea x3 consecutive cycles (almost ALWAYS occurs with BMI <17.5)
 Occurs due to HYPOTHALAMIC dysfunction (LOW GnRH)

40
Q

AN: Mx?

A

o First: Correct physiology (re-feed)
 NB: Monitor for re-feeding syndrome

o Second: Psychotherapy (CBT

41
Q

Bulimia Nervosa:

Definition, Features & types, Mx?

A

• Definition: Frequent binge eating and purging, and a self-image that is heavily influenced by weight with a NORMAL BMI

• Types + Features:
o Restricting: Fasting and/or exercise, but no purging
o Purging: Self-induced vomiting, use of laxatives/diuretics/enemas

o Pre-occupation with weight
o Prefer to eat alone + when others not around
 If forced to eat with others will serve less food/hide rest
o Poor dentition + Russell’s sign (calluses on back of hand from repeated self-induced vomiting)

• Rx: OP treatment: SSRI (fluoxetine)
o Second: Psychotherapy (CBT) with focus on eating disorders

42
Q

Personality disorders:

Clusters types & A features of each?

A 
•	Cluster A: Odd and Eccentric
o	Paranoid:
	Features: (like Gollum from LoTR)
•	Distrust + suspiciousness of others
•	Secretive + isolated
•	“Odd” personality
•	NO psychotic symptoms

o Schizoid:
 Features: (more like depressive + seclusion)
• Detachment from society/interpersonal relationships (e.g. restaurant/vacation/movies by self) NOT due to rejection
o I.e. disinterested in other people
• Anhedonia
• Indifferent to praise or criticism

o Schizotypal:
 Features: (more like seclusion + schizo)
• Uncomfortable w/ social relationships even if familiar, prefers social isolation
• Odd pre-occupations with specific things; believe these things are “special”
• Odd speech + affect
• Delusional, but only for limited period or type (unlike schizophrenia – extended bouts of psychosis)
o Reference
o Persecution/paranoid

43
Q

PD- Cluster B types & features?

A

• Cluster B: Dramatic and Emotional
o Histrionic: Centre of attention
 Features:
• Dresses colorfully, has exaggerated behaviours  become centre of attention
o Easily excitable – everything is dramatic/exciting
• Uses physical appearance to draw attention + sexually seductive
• Uncomfortable in situations where she (more common in women) is not the centre of attention

o Borderline: Emotions easily swing to extremes
 Features:
• Unstable affect, rapid mood swings (inc inappropriate anger)
• Recurrent “suicidal behaviour”  feel relieved when cut themselves/see blood, i.e. not trying to kill self (hence may be many “suicide attempts” in past)
• Unstable + intense relationships, boredom
o Can throw away long-term relationship no problem
o Can also do everything possible to avoid abandonment
• Impulsivity (substance abuse, physical violence, promiscuity)
• Splitting (black-and-white or all-or-nothing thinking; e.g. something is either good OR bad, not in the middle)

o Antisocial: Does not follow social rules/norms
 Features:
• Does not follow rules, breaks law, lies frequently
• Disregards rights of others, does not feel remorse for acts
• Acts on impulse (even if risks own safety), not responsible

• MUST have occurred since <15 and individual MUST be >18 to diagnose
o NB: If <18, “conduct disorder”

o Narcissistic: “Inflated ideas of self-importance”, fantasies of success
 Features:
• Inflated sense of self-importance, borderline grandiosity even
• Pre-occupation with fantasies of success/being better than others (NB: may sometimes break law in order to get ahead)
• Believes he/she is special, requiring admiration
• Reacts with rage when criticized, lacks empathy, envious of others
• Exploitive of others (uses people via their charisma/charm)

44
Q

Cluster C: types & features?

A

• Cluster C: Anxious and Fearful
o Avoidant: Can’t stand criticism
 Features:
• Social avoidance due to feelings of inadequacy or hypersensitivity to criticism
• Shy away from relationships because of fear of feeling inadequate
• Feel lonely and sub-par, pre-occupied with rejection

o Dependent: Can’t be alone
 Features:
• Neglect their needs and wellbeing for the needs and wellbeing of others
• Unable to make decisions, seek constant advice + reassurance
• Anxiety on being alone/left alone

o Obsessive Compulsive Personality: Can’t let others take control
 Features:
• Pre-occupied with orderliness, perfectionism, control
• Inflexible with pre-occupations, hesitant to delegate tasks
• Consumed by details, lose sense of overall goals

• DO NOT FEEL ANXIETY AND INNER UNREST as per OCD

Medicine (11 decks)

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