Psychiatry Flashcards
What drug class is Citalopram?
SSRI
What drug class is Mirtazapine?
Tetracyclic (NASSA)
What drug class is Venlafaxine?
SNRI (Selective Serotonin and Norepinephrine Reuptake Inhibitor)
Which drugs enhance the effect of gamma-aminobutyric acid?
Benzodiazepines
Stopping of voluntary movement or staying still in an unusual position is called?
Catatonia
How long can a nurse hold a patient under Section 5(4) of the Mental Health Act
6 hours
What is Section 4 of the Mental Health Act and what is the duration?
Emergency order - 72 hours
What is Section 3 of the Mental Health Act and what is the duration?
Treatment - 6 months
What is Section 2 of the Mental Health Act and what is the duration?
Assessment - 28 days
How long is a doctor’s holding power under Section 5(2) of the Mental Health Act?
72 hours
Name 3 models of psychotherapy
Psychodynamic / CBT / Counselling / Cognitive analytical therapy / Interpersonal therapy / Dialectic behavioural therapy / (family or marital therapy)
Syndrome of visual hallucinations in those with visual impairment
Charles Bonnet syndrome
Name an anti cholinesterase inhibitor
Rivastigmine / Donepezil / Galantamine / Pyridostigmine
Name the three core symptoms of Depression
Low mood, loss of energy, loss of pleasure (anhedonia)
Name three symptoms of depression (other than the three core ones)
Changes in sleep, appetite, libido, agitation, guilt, hopelessness
Name the symptoms of Bipolar Affective disorder (and what is Bipolar type 1 and type 2)
Depression + Hypomania OR Mania
Bipolar type 1: both depression + at least one episode of mania
Bipolar type 2: major depressive episode lasting at least two weeks and at least one hypomanic episode
What are some differences between mania and hypomania
Hypomania: elevated mood, increased energy and decreased concentration, reckless behaviour, increased libido and confidence
Mania: elation, over-activity, impaired judgement, risk-taking, social disinhibition
Name 3 first rank symptoms and 3 second rank symptoms of Schizophrenia
- First rank: Thought alienation, Passivity phenomena, 3rd person Auditory hallucination, Delusional perception
- Second rank: Delusions, thought disorder, Catatonia, 2nd person auditory hallucination, Increased frequency of hallucinations, negative symptoms (apathy etc.)
Name a psychological and a physical symptom of panic disorder
Physical: palpitations, CP, tachypnoea, dizziness, blurry vision, dry mouth
Psychological: impending doom, fear of dying/losing control
Name the symptoms of OCD
Obsessive thoughts + compulsive acts
What is a delusion?
False, unshakeable idea/belief with extraordinary conviction + subjective certainty
What is a delusional perception?
A delusional belief resulting from a perception
ie a true perception to which patient attaches a false meaning
Name the 5 types of thought alienation
Thought Insertion (not your own) Thought Withdrawal (stolen from mind) Though Broadcast (broadcast out loud) Thought Echo (hears them spoken aloud) Thought Block (interruption of train of thought)
What is a hallucination?
a perception occurring in absence of external physical stimulus
What is a perception occurring in absence of external physical stimulus called?
Hallucination
What is Catatonia?
A state of excited/inhibited motor activity in absence of mood disorder or neurological disease
SSRIs are associated with what electrolyte imbalance?
Hyponatraemia
SNRIs are associated with what complication?
Hypertension
Tricyclic antidepressants (eg. Amitriptyline) can cause what urinary problem
urinary retention
Involuntary pouting of the mouth is an example of what side-effect of antipsychotic medication?
Tardive Dyskinesia
Clozapine can reduce serum levels of what?
Agranulocytosis = lowering of the white blood cell count, primarily neutrophils
Which targeted therapy is used for depression or anxiety related conditions and which therapy is an effective treatment for borderline personality disorder?
Cognitive Behavioural Therapy (CBT) - depression or anxiety related conditions
Dialectical Behavioural Therapy (DBT) - Borderline personality disorder
ICD10 definition of hallucination
false sensory perception in the absence of an external stimulus. Maybe organic, drug-induced or associated with mental disorder.
What type of false sensory perception commonly occurs in people who are grieving
Pseudohallucination
A phenomenon which involves repetition of someone else’s speech including the questions being asked
Echolalia
Acute dystonia secondary to antipsychotics is usually managed with what medication?
Procyclidine
What drug class is Fluoxetine?
SSRI
What drug class is Amitriptyline?
Tricyclic antidepressant
What is a persecutory delusion?
They are being mistreated or someone intends to harm them
What is a grandiose delusion?
Over-inflated sense of worth, power, knowledge or identity
What is a self-referential delusion?
Believing innocuous events to have strong personal significance
What is a nihilistic delusion?
Believing themselves to be dead or the world to no longer exist
What is a misidentification delusion?
Somebody has been replaced with an imposter
What is perseveration?
Repetition of a particular response
- Associated with brain injury or organic disease
Somatic passivity
Sensations imposed upon the body by an outside force
Belle indifference
Patient unconcerned with symptoms of conversion disorder
Paracetamol overdose management
ABCDE
- IV fluids
- Treat acidosis
- Treat hypoglycaemia
N-acetylcysteine - Dose dependent on paracetamol level @ 4 hours
Arrange psych review
Schizophrenia organic causes
Neuro
- Injury
- Infection
- Tumour
Recreational drugs and alcohol; Steroid-induced
Hypernatraemia
Hypocalcaemia
Hyperthyroidism
Cushing’s
Schizophrenia diagnostic criteria
1 month of symptoms
+ 1 first rank symptom
Serotonin syndrome cognitive features
Agitated Confused Euphoric Manic Hallucinating
Serotonin syndrome autonomic features
Tachycardia Tachypnoea Hypertension Fever Sweating Mydriasis Arrhythmias
Serotonin syndrome neurological features
Tremor Ataxia Incoordination Clonus Hyper-reflexive
Serotonin syndrome causes
SAME OA
SSRI
Amphetamines
MAOIs
Ecstasy
Opioids
Antipsychotics
- Lithium
- Olanzapine
- Risperidone
Generalised anxiety disorder diagnostic criteria
Anxiety
+ 3 or more symptoms for 6 months
PTSD diagnostic criteria
Within 6 months of event
Interferes with ADLs
+ TRIAD
- Can’t recall some of the event
- Avoids circumstances associated with the event
- Constantly relives the experience
PTSD symptoms
Hyper…
- Vigilant
- Arousal
- Exaggerated startle response
Physical NEGATIVES
- Decreased concentration
- Decreased sleep
Mood
- Guilt
- Depression
- Anger
- Emotional outbursts
PTSD management
Watchful waiting
< 3 months
- CBT
- Medication for sleep disturbance
> 3 months
- Eye Movement Desensitising and Processing
- SSRI - Paroxetine
- NaSSA - Mirtazapine
What is panic disorder
Frequent panic attacks present for 1 month
Period of intense fear…
- Rapid onset
- Peaks at 10 minutes
- Spontaneous or situational
Panic disorder physical symptoms
Tachycardia
Palpitations
Chest pain
Dizziness
Blurred vision
Paraesthesia
Dry mouth
Abdo pain
Choking sensation
Sweating
Trembling
Panic disorder psychological symptoms
Feeling of impending doom
Fear of dying
Fear of losing control
Depersonalisation
Derealisation
Panic disorder management
CBT
SSRI
Review in 12 weeks
TCA - Clomipramine
Refer
MSE sections
- Appearance and behaviour
- Speech – rate, tone, volume
- Mood and affect:
Current mood +/- variation
Congruent/incongruent affect - Thoughts:
Content – delusions, obsessions, compulsions
Form – loosening of association, thought block - Perception – hallucinations
- Orientation – date, place, time
- Insight
Depression core symptoms
- Persistently depressed mood and anhedonia (somatic) – must have at least 1 of these
- Weight change, psychomotor agitation/retardation and fatigue/anergia
- Feelings of worthlessness or excessive/inappropriate guilt
- Inability to concentrate
- Suicidal thoughts/acts
How many symptoms for mild, moderate and severe depression?
- Mild depression: 5 core symptoms + minor social/occupational impairment
- Moderate depression: ≥5 core symptoms + variable degree of social/occupational impairment
- Severe depression: ≥5 core symptoms + significant social/occupational impairment - can occur with or without psychotic symptoms.
Depression questionnaires
Patient Health Questionnaire-9 (PHQ-9)
Hospital Anxiety & Depression Scale (HADS)
Becks Depression Inventory-2 (BDI-II)
Dysthymic disorder features + Mx
- Chronic (>2yrs), low-grade depressive symptoms
- Clinical features similar to depression
- Epidemiology: 1:2 M:F, usually early age onset (<20yrs)
- Course: less severe, more chronic
Management - SSRI/TCA, CBT may be useful
Seasonal affective disorder features + Mx
- Clear seasonal pattern to recurrent depressive episodes
- Usually January/February (‘winter depression’)
- Low self- esteem, hypersomnia, fatigue, increased appetite/weight gain
- Decreased social and occupational functioning
- Symptoms mild-moderate
Management
- Light therapy, then SSRI
How long postpartum to be classified as Post-Natal Depression?
Significant depressive episode related to childbirth (<6month post-partum)
Criteria for GAD Dx
- Excessive anxiety and worry about everyday events/activities and difficulty controlling the worry on most days for 6 months
- Should cause clinically significant distress/impairment in social, occupational or other important areas of functioning
- At least 3 associated symptoms
Associated symptoms
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or ‘mind going blank’
- Irritability
- Muscle tension
- Sleep disturbance
Panic disorder features (PANICSD mnemonic)
P – Palpitations A – Abdominal distress N – Numbness/nausea I – Intense fear of death C – Choking/chest pain S – Sweating/shaking/SOB D – depersonalization/derealization
Assessment + Mx of panic disorder
Assessment
- Psychiatric Hx + MSE
- Bloods: FBC, TFTs and glucose
- ECG: sinus tachycardia
- Rule out GAD with GAD-7
Treatment
- SSRIs (e.g., sertraline) > TCA (e.g. imipramine)
- Don’t give BDZ!
- CBT and self-help methods
Mx of phobic anxiety
- Behavioural therapy i.e., graded exposure therapy
- Education/anxiety management
Classic quadrad of PTSD
- Reliving the situation
- Avoidance
- Hyperarousal
- Emotional numbing
PTSD - features present how long after event and last how long?
Exposure to traumatic event, above features present within 6 months of event, features last > 1 month.
Assessment + Mx of PTSD
Assessment
- Psychiatric history + MSE
- Trauma Screening Questionnaire (TSQ)
Treatment
- First-line: Trauma-focused CBT + Eye movement desensitization and reprocessing (EMDR)
- Sertraline/venlafaxine
- Zopiclone
Obsession vs Compulsion
- Obsession: an idea, image or impulse recognised by patient as their own, but which is experienced as repetitive, intrusive and distressing
(E.g., Aggressive impulses, contamination, need for order, repeated doubts, sexual imagery etc.) - Compulsion: behaviour or action recognised by patient as unnecessary and purposeless but which they cannot resist performing repeatedly
(E.g., Checking, cleaning (overt), mental acts (covert), ordering etc.)
Mx of OCD
- CBT + exposure and response prevention (ERP)
- Behavioural therapy/psychotherapy (supportive)
- Pharmacological approach: SSRI (first-line), clomipramine (second-line)
Mania vs Hypomania
Mania:
- Elevated, expansive, euphoric, or irritable mood with ≥3 characteristic symptoms of mania on most days for 1 week
- Increased energy
- Pressure of thought, flight of ideas, pressure of speech and word salad
- Increased self-esteem and reduced attention
- Tendency to engage in risky behaviour
- Other: excitement, irritability, aggressiveness and suspiciousness
- Marked disruption of work, social activities and family life
Hypomania: ≥3 characteristic symptoms lasting ≥4 days and be present most of the day, almost every day
- Shares mania symptoms
- Symptoms evident to lesser degree
- Not severe enough to interfere with social or occupational functioning
- Does not result in hospital admission
- No psychotic features
Bipolar disorder psychotic symptoms
- Occur in up to 75% of manic episodes
- Grandiose delusions e.g., special powers
- Persecutory delusions may develop from suspiciousness
- Auditory and visual hallucinations
- Catatonia i.e., manic stupor
- Total loss of insight
Bipolar I vs Bipolar II
Bipolar I disorder: characterised by episodes of depression, mania or mixed states separated by periods of normal mood
Bipolar II disorder:do not experience mania but have periods of hypomania, depression or mixed states
Lithium adverse effects
weight gain, subclinical/clinical hypothyroidism, renal impairment and teratogenic
Pharmacological Tx of Bipolar
- Manic episode: lithium ± benzodiazepine (e.g., clonazepam or lorazepam)
- Depressive episode: SSRI
- Maintenance: Lithium
Schizophrenia risk factors
- Bimodal age distribution
- Family history of schizophrenia
- Pre-morbid schizoid personality
- Abuse
- Delayed developmental milestones
- Obstetric risk factors
- Substance abuse
- Significant life event
- Cerebral injury
- Acute psychosis
Antipsychotics + SE’s
Antipsychotics (PO or depot):
Atypical: Risperidone, Quetiapine, Aripiprazole, Olanzapine, Clozapine
Typical: Haloperidol, Chlorpromazine
Side effects:
Extra-pyramidal – akathisia, tardive dyskinesia, dystonia, NMS
Metabolic – weight gain, diabetes, liver dysfunction
General – dry mouth, constipation, sexual dysfunction, ECG changes
Specific:
Risperidone – hyperprolactinaemia
Clozapine – agranulocytosis, cardiomyopathy
Monitoring – FBC, prolactin, U&E, LFT, ECG, HbA1c, weight measurement
Section 2 (Duration, Purpose + Professionals)
- Duration: 28 days
- Non-renewable
- Purpose – assessment and treatment
- Professionals: TWO doctors (ONE S12) + ONE approved mental health professional (AMHP)
- Evidence: Patient is suffering from mental disorder
- Being detained for their own health/safety or others protection
Section 3 (Duration, Purpose + Professionals)
- Duration: 6 months
- Renewable
- Purpose – long term treatment
- Professionals: TWO doctors (ONE S12) + 1 AMHP
- Evidence: Section 2 rationale
- Appropriate treatment is available
Section 4 (Duration, Purpose + Professionals)
- Duration – 72 hours, non-renewable
- Purpose – to hold patient until assessment by S12 doctor
- Professionals: ONE doctor + ONE AMHP
- Evidence – Section 2 rationale
Section 5(2) + 5(4) (Duration, Purpose + Professionals)
Purpose – patient is in hospital but wants to leave, cannot be treated coercively
5(4): - Duration - 6 hours - Initiated by nurse 5(2): - 72 hours - Initiated by doctor in charge of patient’s care
Section 135 + 136 (Duration, Purpose + Professionals)
135:
- Duration – 36 hours
- Purpose - police allowed to enter patient’s home to move to a place of safety
136:
- Duration – 24 hours
- Purpose – police can move patient with mental disorder in a public place to place of safety
Neuroleptic Malignant Syndrome features, Ix + Mx
- Adverse reaction to dopamine receptor agonists (anti-psychotics)
- Abrupt withdrawal of dopaminergic medication
- Altered mental state
- Hypertonia
- Autonomic dysfunction
- Hyperthermia
Ix - Bloods – FBC, CK, U and Es / Imaging – CT/MRI head / Infection screen - urine/blood culture, LP
Mx - Withdraw anti-psychotic medication / Supportive treatment
Serotonin Syndrome features + Mx
- Caused by antidepressants – SSRI and SNRI
- OR opioid analgesics, MAOI, lithium
- Altered mental state
- Neuromuscular dysfunction
- Autonomic dysregulation (hyperactive bowels, tachy, excessive sweating, tremor, HT)
Mx: Withdraw offending medication / Supportive treatment / If recent overdose – activated charcoal
Paranoid vs Schizoid vs Schizotypal
- Paranoid = sensitive, suspicious, unforgiving, jealous, distrust, preoccupied with conspiratorial explanations and self-referential
- Schizoid = Emotionally cold, detached affect, lack of interest in others, indifferent to praise/criticism, tasks done alone, sexual drive low
- Schizotypal = Interpersonal discomfort with peculiar ideas, perceptions, appearance, eccentric behaviour, speech and beliefs are odd, inability to maintain friendships, lack of companionship
(Schizotypal are more eccentric!)
Assessment + Mx of substance (drug) abuse
Assessment
- Psychiatric Hx + MSE
- Physical exam: weight, dentition, signs of IVDU
- Signs of withdrawal
- Bloods: FBC, U&Es, LFTs, clotting profile, drug level and screen for blood-borne infections
- Urinalysis: toxicology
- ECG, echocardiogram and CXR
Mx
- Self-help groups/Motivational interviewing/CBT
- Pharmacological: opioid dependence
- Substitute prescribing/detoxification: Methadone, buprenorphine or dihydrocodeine
- Withdrawal symptom relief: Lofexidine
- Relapse prevention: Naltrexone
- Overdose: Naloxone
Alcohol dependence (SAWDRINK mnemonic)
S – Subjective awareness of compulsion to drink
A – avoidance or relief of withdrawal by further drinking
W – Withdrawal symptoms
D – Drink-seeking behaviour
R – Reinstatement of drinking after attempted abstinence
I – Increased tolerance
N – Narrowing of drinking repertoire
Alcohol withdrawal after 12, 36 and 72 hours
- Symptoms appear 6-12hrs after last drink
(Malaise, tremor, nausea, insomnia, transient hallucination and autonomic hypersensitivity) - At 36 hours: Seizures
- At 72 hours: Delirium tremens
Delirium Tremens features
- Dehydration ± electrolyte disturbances
- Cognitive impairment
- Hallucinations/illusions
- Paranoid delusions
- Marked tremor
- Autonomic arousal
Wernicke’s vs Korsakoff’s features
Wernicke’s encephalopathy
- Thiamine deficiency
- Ataxia
- Delirium
- Hypothermia
- Nystagmus
- Ophthalmoplegia
- IV Pabrinex (thiamine)
Korsakoff’s syndrome
- Inability to lay down new memories
- Working memory impaired with confabulation
- Ante/retrograde amnesia
- Disorientation to time
Alcohol withdrawal first-line vs relapse prevention
- First-line: Chlordiazepoxide + IV Thiamine
- Maintenance and relapse prevention: Acamprosate, naltrexone or disulfiram
Dementia risk factors
- Age
- Family history
- Genetics
- Down’s syndrome
- Cerebrovascular disease
- Hyperlipidaemia
- Lifestyle – smoking, obesity, high fat diet, alcohol
- Poor education
Alzheimer’s vs Lewy body vs Vascular Dementia
Alzheimer’s: - Gradual onset + progressive - No insight to condition Vascular: - Stepwise progression - Insight into condition Lewy body: - Hallucinations common - Parkinsonian signs
3 common screening tools for Dementia
MMSE
ACE III
MoCA
Pharmacological + Non-pharmacological Mx of Dementia
Pharmacological:
- Acetylcholinesterase inhibitors:
- Donepezil
- Galantamine
- Rivastigmine
- Other psychiatric disturbances – antipsychotics/antidepressants/anxiolytic
Non-pharmacological:
- Lifestyle changes - diet, exercise, maintain social contacts
- Cognitive rehabilitation/occupational therapy
3 types of delirium
- Hyperactive – restlessness, agitation, delusion/hallucination
- Hypoactive – lethargy, sedation, slow to respond
- Mixed – hyperactive + hypoactive
Drugs that cause Agranulocytosis
- Antithyroid medications, such as carbimazole and methimazole (Tapazole)
- Anti-inflammatory medications, such as sulfasalazine (Azulfidine), dipyrone (Metamizole), and nonsteroidal anti- - NSAIDs
- Antipsychotics, such as clozapine (Clozaril)
- Antimalarials, such as quinine
Agranulocytosis features
- sudden fever
- chills
- sore throat
- weakness in your limbs
- sore mouth and gums
- mouth ulcers
- bleeding gums
How often should lithium levels be checked after being prescribed?
12 hours post-dose + 1 week after
Anorexia features (3G’s 3C’s)
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
How does Haloperidol work?
Dopamine antagonist
Four DSM-V criteria for ADHD
- ) Answers questions prematurely
- ) Always on the go, spontaneously moving around
- ) Losing important things, Forgetful
- ) Cannot play quietly
Three clusters of personality types
- Cluster A patients are likely to appear ‘odd’ or eccentric (paranoid, schizoid, schizotypal)
- Cluster B includes patients often appear dramatic, emotional or erratic (antisocial, EUPD, Histrionic, Narcissistic)
- Cluster C patient tend to appear anxious or fearful (Avoidant, Dependant, OCD)
