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MRCP > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

obsession v compulsion

A

· Obsession = intrusive unpleasant and unwanted thought/image/urge
Compulsion = repetitive senseless action taken to reduce the anxiety caused by the obsession

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2
Q

syndrome of person believing they are dead or non-existent

A

cotard syndrome

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3
Q

lithium SE

A

• N/V/D
• fine tremor
• nephrotox: polyuria, secondary to nephrogenic diabetes insipidus
• thyroid enlargement, can&raquo_space; hypothyroidism
• ECG: T wave flattening/inversion
• weight gain
• idiopathic intracranial hypertension
• leucocytosis
hyperparathyroidism and resultant hypercalcaemia

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4
Q

lithium monitoring

  • how to and when to
  • what else needs monitoring
A

Monitoring

- inadequate monitoring is common - an exam hot topic
- when checking lithium levels: sample 12 hours post-dose
- after starting lithium: levels weekly + after each dose change until concentrations are stable
- once established, lithium should 'normally' be checked every 3 months
- after a change in dose: level should be taken a week later and weekly until the levels are stable.
- TFTs and renal function: every 6 months
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5
Q

lithium therapeutic range

A

0.4-1

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6
Q

which ssri to use when

A

Pref SSRIs: fluoxetine, citalopram
- Children/teens: fluoxetine (caution w SSRIs generally)
- Post-MI: sertraline
Caution w citalopram RE QT interval

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7
Q

SE of SSRI

A

SE: GI syms most common. Increased risk of GI bleed.

low Na

After starting can be more anxious/agitated

Citalopram/escitalopram: dose-dep QT interval prolongation. (max dose 40mg in adults, 20 in >65y old or hepatic impairment)

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8
Q

interactions of SSRIs

A
  • Fluoxetine/paroxetine have higher propensity for drug interactions
    • NSAIDs/aspirin: ‘do not normally offer SSRIs’, but if given co-prescribe a PPI
    • warfarin/heparin: avoid SSRIs and consider mirtazapine
    • Triptans/MAOIs increased risk of serotonin syndrome

if on triptans avoid SSRI

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9
Q

if good response how long to conitnue on SSRI

A

If good response: continue on tx for at least 6 months after remission as this reduces the risk of relapse.

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10
Q

discontinuation symptoms
how to prevent
what ssri causes these syms most

A

When stopping: reduce dose gradually over 4 weeks

- (don’t need to w fluoxetine). 
- Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms
	• increased mood change
	• restlessness
	• difficulty sleeping
	• unsteadiness
	• sweating
	• GI syms: pain, cramping, diarrhoea, vomiting
Paraesthesia
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11
Q

ssris in pregnancy - safe?

A

SSRIs and pregnancy
• Use in first trimester: small increased risk of congenital heart defects
• Use in third trimester can > persistent pulmonary hypertension of the newborn
• Paroxetine: increased risk of congenital malformations, esp in first trimester

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12
Q

delusion that a famous is in love with them, with the absence of other psychotic symptoms

A

de clerambault’s syndrome

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13
Q

believe a relative/friend has been replaced by an identical imposter

A

capras syndrome

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14
Q

pt believes different people are the same person in disguise

A

fregoli delusion

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15
Q

delusion of sexual infidelity on part of a sexual partner

A

othello syndrome

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16
Q

mx of PTSD

A

• Mild syms <4wks: watchful waiting may be used
• More severe: trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) therapy
• drug treatments should not be routine first-line treatment for adults.
○ venlafaxine or SSRI, such as sertraline should be tried
Severe: risperidone may be used

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17
Q

conversion disorder
somatisation
hypochondriasis

A

Conversion disorder: usually involves loss of motor or sensory function. May be caused by stress

Somatisation: multiple physical symptoms for >2y

Hypochondriasis: persistent belied in presence of an underlying serious disease

18
Q

couvade syndrome

A

fathers suffer somatic features of pregnancy

19
Q

atypical antipsychotics

  • used for?
  • why are they better than older ones?
  • SE (5)
  • EG of them
A

Examples of atypical antipsychotics
• clozapine
• olanzapine: higher risk of dyslipidemia and obesity
• risperidone
• quetiapine
• amisulpride
• aripiprazole: generally good SE profile, esp for prolactin elevation

Use: 1st line for schizophrenia
Adv: sig reduction in EPSE

SE

- Weight gain
- Hyperprolactinaemia
- Clozapine: agranulocytosis
- In elderly: increased risk of stroke and VTE
20
Q

clozapine

  • when to use
  • SE
  • when might you need to change dose
A
  • Only use if schizophrenia is not controlled despite the sequential use of two or more antipsychoticss (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.

SE of clozapine
• agranulocytosis (1%), neutropaenia (3%)
• reduced seizure threshold - can induce seizures in 3% of pts
• constipation
• myocarditis: baseline ECG should be taken before starting tx
• Hypersalivation

Dose adjustment might be necessary if smoking is started or stopped during tx

21
Q

RF for suicide (8)
RF of a previous attempt that increases risk in future (5)
protective factors (3)

A 
RF:
	• Male
	• history of deliberate self-harm 
	• alcohol or drug misuse 
	• history of mental illness: depression, schizophrenia (10% w schizo will complete suicide)
	• history of chronic disease
	• advancing age
	• unemployment or social isolation/living alone
	• being unmarried, divorced or widowed

If has attempted suicide, factors ass w an increased risk of completed suicide at a future date:
• efforts to avoid discovery
• planning
• leaving a written note
• final acts such as sorting out finances
• violent method

Protective factors
• family support
• having children at home
religious belief

22
Q

diff between mania and hypomania

A

Mania:

- >7ds
- severe functional impairment in social or work setting
- Psychotic symptoms
- Might need hospitalisation due to risk of harm to self or others

Hypomania: <7ds (usually 3-4ds), no impairment of function, no psychotic syms, unlikely to need admission

23
Q

EPSE - types and mx

A
  • parkinsonism
  • akathisia (severe restlessness)
    • tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, 40% pts, may be irreversible, most common is chewing and pouting of jaw)
    • acute dystonia: sustained muscle contraction (e.g. torticollis, oculogyric crisis) - mx procyclidine
24
Q

se of typical antipsychotics (apart from epse)

A

Elderly: increased risk of VTE and stroke

Other side-effects
- antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
- sedation, weight gain
- raised prolactin - can > galactorrhoea
○ due to inhibition of the dopaminergic tuberoinfundibular pathway
- impaired glucose tolerance
- neuroleptic malignant syndrome: pyrexia, muscle stiffness
- reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)

25
Q

typical v atypical antipsychotics

  • action
  • SE
A

typical: Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
- EPSE and high prolactin common
- haloperidol, chlorpromazine

atypicals 
Act on a variety of receptors (D2, D3, D4, 5-HT)
EPSE and high prolacitn less common
metabolic effects
Clozapine
Risperidone
Olanzapine
26
Q

whats the strongest RF for psychotic disorders

A

FHx

27
Q

TCAs

  • SE
  • which 2 are most dangerous in OD
  • which is least dangerous
A 
Common side-effects
	• drowsiness
	• dry mouth
	• blurred vision
	• constipation
	• urinary retention
	• lengthening of QT interval

Choice of tricyclic
• low-dose amitriptyline: neuropathic pain and prophylaxis of headache ( tension or migraine)
• Lofepramine: lower incidence of toxicity in overdose
amitriptyline and dosulepin (dothiepin): most dangerous in OD

28
Q

physical and medication causes of anxiety to r/o

A
  • Hyperthyroidism
    • cardiac disease
    • medication-induced anxiety: salbutamol, theophylline, corticosteroids, antidepressants and caffeine
29
Q

GAD mx

A
  • 1: education about GAD + active monitoring
    • 2: low-intensity psych interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
    • 3: high-intensity psychological interventions (CBT or applied relaxation) or drug treatment.
    • 4: highly specialist input e.g. Multi agency teams

Drug treatment
• 1st line: sertraline
• ineffective, offer an alternative SSRI or a SNRI (EG duloxetine and venlafaxine)
• If can’t SSRIs or SNRIs: offer pregabalin
<30y old: warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up for the first month

30
Q

panic disorder mx

A

• 1: recognition and diagnosis
• 2: treatment in primary care: CBT or drugs
○ 1st line SSRI
○ If CI or no response by 12wkL imipramine or clomipramine
• 3: review and consideration of alternative treatments
• 4: review and referral to specialist mental health services
5: care in specialist mental health services

31
Q

bulimiia mx

- whats the only med licensed?

A

• referral for specialist care
• Adults: bulimia-nervosa-focused guided self-help
• If unacceptable, CI, or ineffective after 4 weeks: individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
• Children: bulimia-nervosa-focused family therapy (FT-BN)
Pharm tx have limited role - a trial of high-dose fluoxetine is currently licensed for bulimia

32
Q 
ECT
- tx for?
- absolute CI (1)
- short term SE (5)
long term SE 1
A

Tx: severe depression refractory to medication with psychotic symptoms

Absolute CI: raised ICP

Short term SE:

- Short-term memory impairment
- Headache
- Nausea
- Memory loss of events prior to ECT
- Cardiac arrhythmia

Long term SE: some report impaired memory

33
Q

benzodiazepine

  • pharm action?
  • how to withdraw
  • withdrawal fts
A

Enhance the effect of GABA (main inh neurotransmitter) by increasing frequency of chloride channels

On how to withdraw a benzodiazepine.
- withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight.
- A suggested protocol for patients experiencing difficulty is given:
○ switch patients to the equivalent dose of diazepam
○ reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
○ time needed for withdrawal can vary from 4 weeks to a year or more

If patients withdraw too quickly:
	- may occur up to 3 weeks after stopping a long-acting drug. 
	· insomnia
	• irritability
	• anxiety
	• tremor
	• loss of appetite
	• tinnitus
	• perspiration
	• perceptual disturbances
Seizures
34
Q

Alcohol withdrawal peak incidence of
- Symptoms
- Seizures
DT

A
  • Symptoms 6-12h
    • Seizures 36h
      DT 72h
35
Q

poor prognostic indicators for schizophrenia

A
  • Strong FHx
    • Gradual onset
    • Low IQ
    • prodromal phase of social withdrawal
    • Lack of obvious trigger
36
Q

diabetic neuropathy 1st line

A

duloxetine

37
Q

atypical antipsychotic pharm action

A
  • Block serotonin receptors (esp 5-HT2) + D2 dopamine recs
38
Q

when stopping SSRI how do you do it?

which one is an exception

A

When stopping, gradually reduce dose over 4wk (except fluoxetine: longer half life so don’t need to)

39
Q

anorexia

  • fts
  • blood abns
A 
Features
	• reduced body mass index
	• bradycardia
	• hypotension
	• enlarged salivary glands
Physiological abnormalities
	- hypokalaemia
	- low FSH, LH, oestrogens and testosterone
	- raised cortisol and growth hormone
	- impaired glucose tolerance
	- hypercholesterolaemia
	- hypercarotinaemia
low T3
40
Q

fts to suggest depression over dementia

A
  • short history, rapid onset
    • biological syms e.g. weight loss, sleep disturbance
    • patient worried about poor memory
    • reluctant to take tests, disappointed with results
    • mini-mental test score: variable
    • global memory loss (dementia characteristically causes recent memory loss)

MRCP (16 decks)

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