Psychiatry Flashcards
All deaths that occur while the patient is detained under the mental health act must be reported to the coroner regardless of mechanism of death - true or false?
True
What is section 4 of the mental health act?
Section 4 needs 1x doctor + 1 approved mental health professional / nearest relative without the opinion of a 2nd doctor. It provides a 72 hour window to bring the pt into hospital against their wishes for further assessment. YOU CANNOT GIVE TREATMENT AGAINST PATIENT WISHES UNDER A SECTION 4.
What is section 2 of the mental health act?
Section 2 allows you to detain and give treatment against a patient’s wishes for upto 28 days. Needs 2x doctors + an approved mental health professional / nearest relative. CANNOT BE RENEWED BUT PT CAN BE CONSIDERED FOR A SECTION 3 DURING THIS TIME IF NEED BE.
What is section 3 of the mental health act?
Section 3 allows you to detain and give treatment against a pt wishes for upto 6 months. Can be renewed for a further 6 months twice then in 12 month periods. Needs 2x doctors + a AMHP/NR.
What are the criteria to be eligible to sectioned?
- Must be a danger to yourself or others
- You need to be in hospital in order to receive the treatment you need
- The treatment you need is available
- You have a mental health disorder (being under the influence of drugs or alcohol doesn’t count!)
- You won’t voluntarily accept the admission
What is section 5 (2) of the mental health act?
Allows a single doctor to detain a patient already voluntarily an inpatient in hospital for 72 hours. A recommendation on why detainment is necessary should be submitted to hospital management.
What is section 5 (4) of the mental health act?
Allows a single nurse qualified in mental health / learning disabilities to detain a patient already voluntarily an inpatient in hospital for 6 hours until further assessment can be made.
What are the key factors associated with increased risk of suicide?
Male gender History of deliberate self harm Co-existent drug or alcohol abuse History of co-existent mental health disorder (schizophrenia carries upto a 10% risk of successful suicide) History of chronic illness Increasing age Unemployment Social isolation
True or false - mirtazapine is most sedative at lower doses than higher doses
True
What is the meaning of capgras syndrome?
a delusional belief where the patient thinks someone close to them has been replacement by an imposter
Which SSRI has the highest associated incidence of SSRI discontinuation syndrome on abruptly stopping?
Paroxetine (presents with sweating, headache and a needle-like sensation in the head)
True or false - tricyclic antidepressents such as amitriptyline can make alzheimer’s / dementia worse
True
What are the 2 presenting types of bipolar disease?
Type I (most common) = mania + depression Type II = hypomania + depression
What is the lifetime prevalence of bipolar disease and when does it typically first present?
Lifetime prevalence = 2%
Typically presents in the late teens
What is the difference between mania and hypomania?
Hypomania = elevated mood without the delusions/hallucinations/psychotic symptoms. May have reduced need for sleep, increased sexual energy etc. Typically lasts for shorter of periods of time as well than manic episodes. Mania = more extremely elevated mood/energy, doesn't have to be associated with psychotic symptoms but when it is typically associated with delusions of grandeur etc. Last for longer periods of time than hypomania.
How does NICE recommend you manage a patient presenting to the GP with mania/hypomania/suspected bipolar disease?
Hypomania - routine referral to community mental health
Mania or severe depression = urgent referral to community mental health
Scoring system to assess depression / anxiety
HAD (Hospital Anxiety and Depression Scale) -> can be used for anxiety and depression
PHQ-9 (Patient Health Questionnaire - 9) -> to assess depression
What are the Schneider’s First Rank Symptoms (strongly suggestive of a diagnosis of schizophrenia)?
Auditory hallucinations (hearing voices)
Thought broadcasting
Thought insertion/ withdrawal / interruption
Somatic hallucination
Delusional perception
What is the 1st line drug treatment for moderate to severe depression in under 18s
FLUOXETINE
What is the 1st line drug treatment for adults with moderate depression?
SSRI (fluoxetine, citalopram, sertraline)
What is the 2nd line drug treatment for moderate depression in adults?
Alternate SSRI or TCA (Amitriptyline) or SNRI (venlefaxine, duloxetine)
Avoid SNRI or TCA if at higher risk of overdose.
If switching between anti-depressents you should cross-taper (slowly reduce the dose of one while increasing the other)
What are the typical blood tests in anorexia nervosa?
HIGH cholesterol, HIGH growth hormone, HIGH cortisol, HIGH blood glucose, HIGH carotin
LOW FSH +LH
Acute dystonia?
torticollis + oculogyric crisis
What is optimal management of PTSD
If mild + <4 wks - can watch + wait
if not:
1st line = Eye movement desensitisation and reprocessing (EMDR)
2nd line of above doesn’t work -> drug tx with eg Mirtazapine, Paroxetine (+ phenelzine, unlicensed, specialists only)
A score of what on the mini mental state exam is suggestive of dementia?
Score < 24
Symptoms of acute versus chronic schizophrenia?
Acute - POSITIVE symptoms -> Schneider’s first rank symptoms -> auditory / somatic hallucination, though disorders, delusional perceptions, passivity of feelings
Chronic - NEGATIVE symptoms -> depression, apathy, social withdrawal, loss of affect
what is the first line drug for schizophrenia?
Risperidone
Atypical antipsychotic
what is a agoraphobia?
fear of leaving home / being in public / crowded places
what are the different stages of detaining someone unde the mental health act England?
1) section 135 / section 136 is a warrant for the police to move a person from their home / the community respectively into a place of safety (POS) -> from then they have 24 hrs to get a Mental Health Act Assessment (2x doctors + approved mental health act practitioner)
->
Section 2 -> 28 days detained then needs re-assessment
->
Section 3 -> upto 6 months then needs re-assessment (pt needs a diagnosis for this)
IF PATIENT ALREADY IN HOSPITAL (either for a physical condition or in a psych hospital then wants to leave)
- > section 5 -> bides time for mental health act assessment.
- > section 5(4) - by nurses, lasts upto 6 hrs
- > section 5 (2)- by medics, lasts upto 72 hrs
what is echopraxia?
when someone involuntarily copies your movements/behaviour repetitively
What is the presentation of borderline / impulsive personality disorder?
Unstable, impulsive, fear of being abandoned
What is the presentation of dependent / asthenic personality disorder?
Inadequacy that leads to them to want to hand over responsibility over their lives to others
What is the presentation of histrionic / narcissistic personality disorder?
Attention seeking behaviour to maintain themselves as the centre of attention
What drugs should you avoid giving alongside lithium?
Low sodium increases the risk of lithium toxicity -> so should avoid DIURETICS alongside lithium -> especially thiazide diuretics
Which group of drugs are common culprits at causing NEUROLEPTIC MALIGNANT SYNDROME?
Neuroleptic malignant syndrome -> muscle rigidity + fever + autonomic dysfunction
More commonly occurs in the TYPICAL / 1ST GENERATION ANTIPSYCHOTICS.
Typical / 1st generation antipsychotics?
= more likely to cause neuroleptic malignant syndrome and extrapyramidal side effects
= promazine, chlorpromazine, prochlorperazine, haloperidol
Atypical / 2nd generation antipsychotic?
less likely to cause extrapyramidal side effects / NMS
BUT instead are associated with WEIGHT GAIN + GLUCOSE INTOLERANCE
=
Olanzapine, Quetiapine, Clozapine, Risperidone, Aripiprazole
CLOZAPINE = an atypical anti-psychotic used for RESISTENT schizophrenia -> needs regular monitoring as can cause NEUTROPENIA / AGRANULOCYTOSIS
1st line treatment for schizophrenia?
Should be started after the FIRST episode of psychosis because high risk of progression to future episodes.
Should NOT start antipsychotic in primary care UNLESS in liaison with a consultant psych.
1st line = oral antipsychotic (Risperidone) + psychological therapy (CBT)
Which SSRI must have a wash-out period before starting another anti-depressent?
FLUOXETINE
need to wait 4-7 days between weaning a patient off fluoxetine before starting a new type of anti-depressent due to it’s long half life
Main indications for electroconvulsive therapy?
Severe depression
Severe psychosis
Catatonia
Mania
What are RELATIVE and ABSOLUTE contraindications for electroconvulsive therapy?
ABSOLUTE - recent subdural or subarachnoid bleed
RELATIVE - recent MI or stroke
1st line treatment for OCD?
CBT with EXPOSURE + RESPONSE PREVENTION (exposing them to the thing that makes the anxious repeatedly)
If that fails or they have severe functional impairment -> SSRI + more intensive CBT
What severity of depression is associated with what PHQ9 score?
Mild depression - 5-9
Moderate - 10 -14
Moderately severe - 15-19
Severe - 20 or above
Which factors indicate a POOR prognosis in schizophrenia?
Male gender
Young age at onset
Predominantly negative symptoms
Insidious onset of initial symptoms
ALL indicate a poor prognosis
(if they’re older when they develop it this is a positive sign)
Bipolar I v Bipolar iI
Bipolar i -> MANIC episodes + SEVERE DEPRESSIVE EPISODES = MOST COMMON
Bipolar II -> hypomania + depressive episodes (less extreme, less common)
typical presentation of dyslexia?
boys more common
difficulty with phonemes / syllables
family component, linked to autism and ADHD
Screen for it using the GAPS test in 3-6 year olds
Oestrogen replacement therapy for postnatal depression?
evidence of SOME benefit
but should NOT be used if breast feeding
What is a pseudo-hallucination?
A hallucination that the patient is aware is not real life -> can sometimes lead into full blown psychosis but not always
What is dissociative identity disorder?
the new name for multiple personality disorder
what is a dissociative fugue?
often a response to trauma, you forget who you are, where you are from and everything about your past
typical presentation of amphetamine use?
Amphetamine = speed, whizz, uppers, billy, amp
Side effects –> mood swings, irritability, panic attacks, comedown
Patients that are dependent on alcohol are required by law to disclose to the DVLA - true or false?
TRUE
After psychological therapies, what drugs are recommended to maintain abstinence from alcohol?
1st line -> psychological therapy
2nd line -> Acamprosate or Naltrexone (reduce cravings) + Psychological therapy
Alternative options:
- Disulfiram -> produces an acute sensitivity if you drink on it
- Nalmefene -> reduces the high associated with alcohol in high risk drinkers that don’t need immediate detoxification
What is the typical presentation of cocaine withdrawal?
Ants crawling on the skin (fornication)
+ Paranoia
typical presentation of anti-depressant discontinuation reaction?
Higher risk with short acting anti-depressants like Venlafazine and Duloxetine
= VIVID DREAMS + LIMB NUMBNESS + GI UPSET
what is systemic therapy?
Systemic therapy = support for the whole family unit
= talking therapies with the whole family present but also individual sessions
what are examples of tests for frontal lobe function?
- Verbal fluency (how many words can you say that start with the letter ‘a’)
- Clock drawing
- Abstract thinking (What’s the link between a cat and dog)
- Response inhibition / motor perseveration (tap once when i tap twice)
- Estimating (how much do you think this weighs)
What is 1st line in the management of moderate ADHD in children?
Methylphenidate + psychotherapy
What duration of symptoms is needed to diagnosis a manic episode?
7 days + of manic symptoms
what duration of symptoms is needed to diagnose a hypomanic episode?
4 days + of hypomania
Which antipsychotic requires MONITORING EXCLUSIVELY IN SECONDARY CARE ?
Clozapine
due to the risk of neutropenia / agranulocytosis
What is the 1st line treatment for seasonal affective disorder?
Early morning light therapy
Medical management of Alzheimer’s dementia?
Moderate Alzheimer’s:
1st line = acetylcholinesterase inhibitor = Donepezil, Rivastigmine, Galantamine
2nd line -> if acetlycholinesterase inhibitor contraindicated = Memantine
Severe Alzheimer’s:
1st line = Memantine
Which dementia assessment tools take less than 5 mins and are suitable for use in the community?
GPCOG
6-item cognitive impairment test (6-CIT)
Abbreviated Mental Test Score (AMTS)
