Psychiatry Flashcards
Antipsychotics: Indications?
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)
Antipsychotics: MOA?
• 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)
Anti-psychotics: Main drug groups & examples?
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)
Tardive Dyskinesia: Major SE of antipsychotics.
Give Features, cause & Rx?
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
Neuroleptics malignant syndrome (NMS): features, Ix & RX?
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
Other SE of antipsychotics?
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.
How to manage: Dystonia, akathisia, bradykinesia, tardive dyskinesias & parkinsonism?
Procyclidine
If prolactin levels are elevated, which antipsychotic is chosen?
Aripiprazole
Antidepressant medication types & examples?
• Types:
o SSRIs Fluoxetine, citalopram, sertraline
o SNRIs Venlafaxine
o TCAs Amitriptyline
o NaSSA (noradrenergic + specific serotonin antidepressant) Mirtazapine
SE of SSRI?
Anxiety + suicide in first 2wk GI (most com) ↑ risk GI bleeding Anorgasmia/↓libido/erectile dysfunction Sedation Hyponatraemia – likely due to SIADH
ECT: Indications, procedure, post-procedure & SE’s?
• 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
Sections?
Sections -NB: Patient’s can be discharged from any section at any time by professionals
- SECTION 2:
a. Assessment for 28d, CANNOT be renewed
b. Treatment CAN be given against patient’s will - SECTION 3:
a. Treatment for 6mo, CAN be renewed
b. Treatment IS given, even against patient’s will - 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 - 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 - 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 - 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
Depression: Risks?
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)
Features of depression?
: DEAD SWAMP (depression, energy, anhedonia, death [suicide], sleep, worthlessness, appetite, mentation, psychomotor agitation/pessimistic)
Major depressive disorder criterias:
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
Depression: IX & MX?
o R/O organic cause FBC, B12 (anaemia) Calcium TFT (hypothyroid) SynACTHen test (Addison’s
PHQ-9 questionnaire
General examination
Mx: CBT + SSRI
Bipolar disorder:
Types?
o Bipolar I Mania (psychosis or delusions present) + depression
o Bipolar II Hypomania (psychosis and delusions ABSENT) + depression (more common)
Criteria for hypomania & mania?
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.
Features of bipolar?
• 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.
Bipolar Ix?
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)
Bipolar acute Mx?
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
Schizophrenia: Features?
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
Schizophrenia IX & MX?
Collateral Hx & MSE
Neurological Exam
Ix: Urine toxicity screen
Bloods
MX:
o Conservative: CBT (all patients should be offered!)
o Medication: Atypical antipsychotics
Delusional disorder: Features, Types, Mx?
• 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
Anxiety disorders: Definition & types?
• 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
Features of anxiety disorders?
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
Anxiety: panic disorder:
Definition, features, Ix?
• 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)
Mx of panic disorder?
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)
GAD: Definition, features, Ix & MX?
• 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
OCD: Definition & MX?
• 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
Phobias: Definition, Common types & Mx?
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
PTSD: Definition, Features Mx?
• 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)
Somatoform: Somatization/Somatisation Disorder: Definition, criteria & Mx?
• 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)
Somatoform: Conversion Disorder: Definition & Mx?
• 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)
Somatoform: Hypochondriasis: Definition & Mx?
• 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)
Munchausen’s/Factitious Disorder: Definition?
• 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
Malingering: Definition?
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
Anorexia Nervosa: Common ways to lose weight? Epidemiology?
• 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
AN: Types & features?
• 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)
AN: Mx?
o First: Correct physiology (re-feed)
NB: Monitor for re-feeding syndrome
o Second: Psychotherapy (CBT
Bulimia Nervosa:
Definition, Features & types, Mx?
• 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
Personality disorders:
Clusters types & A features of each?
• 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
PD- Cluster B types & features?
• 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)
Cluster C: types & features?
• 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
