Psychiatry Flashcards
Core symptoms of depression
Depressed mood for most of day, everyday for 2 weeks of more
Diurnal mood variation (worse in morning)
Anhedonia - don’t enjoy things they normally do
Fatigue
Typical symptoms of depression
Poor appetite, affecting weight Disrupted sleep Decreaesed libido Reduced concentration Feelings of worthlessness Recurrent thoughts of death, ideation or suicide attempts
Classification of depression
Subthreshold - <5 symptoms
Mild depression - few symptoms and minor functional impairment
Moderate - functional impairment between mild and severe
Severe - most symptoms, marked impairment of function. With or without psychotic symptoms
Management of mild to moderate depression
Antidepressants- SSRI
High intensity psychological intervention - CBT
Screening tools for depression
Patient health questionnaire 9 (PHQ-9)
— 9 iterm, self-administered scale
Hospital anxiety and depression scale (HADS)
— 14 questions, self-administered
Black depression inventory II (BD-II)
— 21 item
Key differences between mani and hypomania
Mania = psychotic symptoms (delusions of granduer or auditory hallucinations)
Management of bipolar
Psychological interventions specifically for bipolar
Anti-psychotic (acute)
Lithium- mood stabiliser of choice. Alternative is sodium vaporate semisodium
Can also add an anti-depressant
Hypomania - routine referral to community mental health team
Mania - urgent referral to CMHT
SSRI examples, side effects, monitoring
Flouxetine - children
Citalopram - adult
Sertraline
SE:
- GI low appetite, N+V (most common)
- increased risk of GI bleeding
- sexual dysfunction (5HT2a receptors)
- hyponatraemia
- serotonin syndrome (withdrawal?)
- weight gain (5HT3 receptors)
- increased suicide risk acutely
- citalopram - increased QT interval - Do ECG before starting
All:
Monitor FBC (anaemia GI bleeding)
U&E (hyponatraemia)
TCA examples, MoA, Side effects and monitoring
Used less commonly now due to SEs
Amitryptyline
Imipramine
Inhibit serotonin and NE reuptake
Non-selextive monoamine transporters inhibitors
FATAL IN OD (block sodium channels = arrhythmia) Drowsiness Dry mouth Blurred vision Constipation Urinary retention QT prolongation
Mirtazapine mechanism of action
Noradrenergic and selective serotonin blocker
Causes sedation and increases appetite
SNRI examples and SEs
Venaflaxine
Duloxetine
Tremors
Increased BP and HR
Anti-cholinergic effects
When is sertraline best used?
In ischaemic heart disease
Monoamine oxidase inhibitors examples, SEs
Serotonin and NE is metabolised by monoamine oxidase in presynaptic cell = increase these
Tranylcypromine
Phenelezine
Hypertensive reactions with tyrosine containing foods - cheese broad beans
Anticholinergic effects
Features of schizophrenia
First rank symptoms:
Auditory hallucinations, thought disorders, passivity phenomena, delusional perceptions
Auditory hallucinations- third person. Two or more voices discussion patient in third person. Thought echo,
Thought disorders - thought insertion, withdrawal, broadcasting
Passivity phenomena - bodily senses being controlled. Actions/feelings being imposed by others
Others - impaired insight, blunting of affect, decreased speech, neologism, catatonia
Negative symptoms - anhedonia, decreased speech, blunted emotional responses, apathy
Management of schizophrenia
Oral anti-psychotics first line
CBT should be offered
Modification of cardiovascular risk factors
Social support- social skills training, housing and benefits
Lifestyle- cardio, activity, diet, exercise
Tackle alcohol and drug addiction
Side effects of anti-psychotics
Common - anti-cholinergic. - blurry vision, dry mouth, urinary retentions, constipation
Weight gain
Sexual dysfunction
Galaxtorrhoea
Serious- tremors, muscle problems, reduced seizure threshold (citalopram), myocarditis
Sfarr investigation and monitoring of anti-psychotics
Baseline: Weight Waist circumference Pulse and BP Fasting glucose, lipid and prolactin levels ECG
Monitoring: Response to treatment Emergence of movement disorders FBC (nutrapenia), U+Es, LFT (annual) Lipids - weekly for 6 weeks, 3 months, yearly Prolactin, - start, 6 months, yearly
Examples of typical anti-psychotics, why they not used much?
Haloperidol, chlorpromazine
Greater association with extrapyramidial movement disorders
Adverse effects of clozapine
Agranulocytosis Nutrapenia Reduced seizure threshold Constipation Myocarditis Hypersalivarion
What is borderline personality disorder?
Condition that affects how you think, feel and interact with others
Efforts to avoid real or imagined abandonment Unstable interpersonal relationships Unstable self image Impulsivity Chronic feelings of emptiness
Obsessive compulsive disorder management
Mild functional impairment- low intensive CBT, ERP, if not work = SSRI
Moderate - more intensive CBT or SSRI
Severe - combined treatment
ERP = exposure response prevention
- exposing to trigger and stopping their usual response
Management of PTSD
Watch and wait for mild symptoms <4 weeks
Trauma-fpcused CBT or eye movement desensitisation reprocessing therapy
Drug treatments if unsuccessful - veneflaxine or SSRI
Features of alcohol withdrawal
Symptoms start 6-12 hours - tremor, sweating, tachycardia, anxiety Seizures at 36 hours Delirium tremens 48-72 hours -tremor -confusion -delusions -visual and auditory hallucinations (crawling under skin, insects) -fever -tachycardia
Management of alcohol withdrawal
Admit if history of complex withdrawal
First line pharm - long acting benzodiazepines (chlordiazepoxide, diazepam)
Carbmazepine also effective
When should lithium levels be measured?
12 hours post dose, then every 3 months
Checked weekly after each dose change until concentrations stable
Side effects of lithium
GI - nausea, vomiting, diarrhoea Fine tremor Nephrotoxicity - polyuria Hypothyroidism ECG - T wave inversion / flattening Weight gain IIH Leucocytosis
What should be monitored in patients taking lithium?
Iithium levels (every 3 months after level stabilisation)
Thyroid and renal function every 6 months
Monitor weight and eGFR
Assess renal, thyroid and cardiac function before commencement
Examples of extra-pyramidial side effects of anti-psychotics
Parkinsonism
Acute dystonia (sustained muscle contraction)
Akathisia (severe restlessness)
Tardive dyskinesia (abnormal, involuntary, repetitive movements) - chewing of jaw, excessive blinking
SSRI discontinuation symptoms
Diarhoea Increased mood change Restlessness Unsteadiness Sweating GI - pain, cramping, vomiting, diarrhoea
Indication and side effects of electroconvulsive therapy
Contraindications
Severe depression refractory to medications (catatonia) those with psychotic symptoms
SEs:
- headache
- nausea
- short term memory loss
- cardiax arrhythmia
CI:
Raised ICP
Recent MI
Brain aneurysm
How should benzo’s be withdrawn
1/8 of daily dose every 2 weeks
Switch patients to equivalent dose of diazepam
Reduce dose in steps of 2-2.5 mg every 2-3 weeks
Management of an acute dystonia
Procyclidine
Features of anorexia neevosa
Main:
Persistant restriction of energy intake leading to significant low body weight
Intense fear of gaining weight
Disturbance in the way the body shape or weight is experienced
Also:
bradycardia
Hypotension
Enlarged salivary glands
Physiological abnormalities: Hypokalaemia Low FSH, LH, oestrogen and testosterone Raised cortisol and GH Hypercholestrolaemia Low T3
Most low, G’s and C’s high
Management of anorexia nervosa
One of - individualised eating disorser focused CBT
Specialist supportive clinical management
Maudsley anorexia nervous treatment
Children- family focused therapy
Dietary advice - dietician, supplements, structured earing plan
Other - electrolyte correction, potassium repletion, fluids
Bone health - risk of osteoporosis (bisphosphates)
Symptoms of mania what should you do?
Refer urgently to CMHT
How do anti-psychotics work?
Inhibit dopaminergic transmission (overactivation of mesolimbic pathway associated with schiz)
What is an acute dystonia, what is it associated with?
Involuntary contractions of muscles of extremities, face, neck, pelvis - either sustained or intermittent pattern leading to abnormal movements or postures
What medications are associated with increased risk of VTE and stroke in the elderly?
antipsychotics
What is a tardive dyskinesia?
Involuntary neurological movement disorder that results in repetitive body movements e.g. sticking out the tongue
What is acute dystonia?
I
What is bulimia neevosa?
Recurrent episodes of binge eating
- eating in a specific period of time (e.g. within a 2 hour period) an amount of food that is too large to be normal + feeling lack of self control
Recurring compensatory behaviour to prevent weight gain - self-induced vomiting, misuse of laxatives, diuretics etc.
BMI IS HEALTHY OR ABOVE NORMAL
What is the BMI like in bulimia?
Normal or above normal
Management of bulimia
Refer to specialist care
Bulimia-nervosa-focused guided self-help for adults
If ineffective - eating-disorder-focused CBT
Plus nutritional and meal support
Adjuvant SSRI and SNRI
- fluoxetine is licenced in bulimia
Management of generalised anxiety disorder
Look for a potential cause - hyperthyroidism, cardiac disease, drugs
- educate GAD and active monitoring
- low-intensity psychological interventions
- high-intensity psychological intervention (CBT) OR DRUG TREATMENT
Drug treatment:
- serialise as first-line SSRI
- If ineffective - another SSRI or SNRI
- if cannot tolerate these - try pregabalin
Management of severe OCD
SSRI and CBT (exposure and response prevention)
What should be monitored at initiation and during SNRIs such as venlafaxine?
Blood pressure
Theyre associated with HTN
What should be done at commencement of sertraline?
ECG (for long QT)
Initial therapy for OCD
Exposure and response prevention therapy
Common features of PTSD
Re-experiencing - flashbacks, nightmares
Avoidance - avoiding people of situations
Hyperarousal - hypervigilance, sleep problems
Also, emotional detachment
When can lithium be measured 3 monthly?
When levels have stabilised (measured weekly until then) - also 12 hours after initiation and dose changes
Whats measured 6 monthly in patients on lithium?
TFTs and U&Es
What should you rule out before a diagnosis of GAD is made?
Hyperthyroidism
What is malingering?
Fraudualtn simulation or exaggeration of symptoms with the intention of financial or other gain
What is somatisation disorder?
Multiple physical symptoms for at least 2 years
Patient refuses to except reassurance or negative test results
What is conversion disorder?
Loss of motor or sensory function
They don’t consciously feign symptoms or seek gain
What is Munchausen’s syndrome?
Also called fictitious disorder, intentional production of symptoms
What is cotard syndrome?
Patient believes they are dead or non-existant
Associated with severe depression and psychotic disorders
Long-term complications of antipsychotics
Diabetes
Features of Neuroleptic Malignant syndrome
Confusion, fever, rigidity
Dysautonomia (autonomic instability)
- tachycardia
- liable BP
- profuse BP
- sweating
- arrhythmia
What is the major risk factor for neuroleptic malignant syndrome
Antipsychotic use
Management of neurleptic malignant syndrome
Supportive care - stop anti-psychotic - cardiac monitoring - IV fluids Treat specific complications - electrolyte imbalance - AKI - Rhabdomyolysis Severe disease may need organ support - intubation - ventilation - haemofiltration Medical therapy - dantrolene - causes skeletal relaxation (helps with hyperthermia and rigidity) - bromocriptine - dopamine agonist (antipsychotics block dopamine)
Features of serotonin syndrome
Altered mental status
Autonomic hyperactivity
Neuromuscular abnormalities - rigidity, clonus, hyperreflexia
Also - fever, sweating, vomiting, dilated pupils
What medications cause serotonin syndrome?
SSRIs - most commonly MOAIs Amphetamines Ecstasy Cocaine SNRIs TCAs Lithium
Management of serotonin syndrome
Largely supportive
- managing complications
- providing organ support
- stopping serotoniergic therapy
- cardiac monitoring
Medical therapy
- benzos- help improve agitation
- cyproheptadine - histamine receptor antagonist
What does section 2 of the mental health act mean?
Admission for assessment for up to 28 days, not renewable
Treatment can be given against a patients wishes
What does section 3 of the mental health act mean
Admission for treatment for up to 6 months, can be renewed
Section 5(2) mental health act
A patient who is voluntarily in hospital can be detained for 72 hours
Section 136 mental health
Someone in a public place who appears to have a mental health disorder can be taken by police to a place of safety
Can only be used for up to 24 hours
