Psychiatry Flashcards
What is a delusion?
A firm, fixed belief, that is usually false, based on inadequate grounds, not amenable to a rational argument or evidence contrary and not in line with regional or cultural norms.
What is a hallucination?
Sensory perception without external stimulation of a sense, the patient believes its real.
Whats is a pseudo-hallucination?
Sensory perception without external stimulation of a sense, but the person is aware it is not real
What is an illusion?
Misinterpretation of an external stimulus
What is an emergency detention certificate?
To keep/bring someone into hospital for ASSESSMENT (you can NOT treat them)
Any Dr can do it, keeps them in for 72 hours
They can not appeal it
What is a short term detention certificate?
To keep/bring a patient in for assessment AND treatment
Can last 28 days
Must be approved by Drs and MHN
Patient has a right to appeal it
What is a Compulsory treatment orders (CTO)?
To keep/ bring a patient in for treatment or to continue treatment in the community
2 medical reports needed to be completed by approved medical practitioners
Heard by a tribunal *
6 months - 1 year
What is a panic disorder?
Recurrent unexpected panic attacks for a 1 month or more, + 1 of:
- Persistent worry about having panic attacks
- Worry about implications of an attack
- Physical sx - palpitations, tachycardia, sweating, SoB, trembling, feeling of chocking, chest pain, dizzy
What is Agoraphobia?
Marked fear or anxiety for more than 6 months about 2 or more of the following: Being in an enclosed space, using public transport, being in an open space, standing in line, in a crowd, leaving home alone
What is psychosis?
The inability to distinguish between subjective experiences and external reality
What is organic psychosis?
Abnormal brain function caused by a known physical or psychological abnormality
Substance misuse, infection, medications
What is schizophrenia?
A psychotic disorder where they have one or more of the following symptoms: Hallucinations, delusions, disorganised speech
What factors make someone more vulnerable to scizophrenia?
Biological - famiiilal risk, neurobiology, substance misuse, maternal infection, obstetric complications, hypoxia
Psychological - learning difficulty, attention and memeory disorders
Social - lower socioeconomic status, ACE, trauma, stressful life events
What gives a diagnosis of schizophrenia?
2 or more of the following with at least 1 being (*):
*Hallucination
*Delusions
*Disorgaised speech
Negative sx, catatonic behaviour, thought disorder
Ongoing for 6 months with at least 1 month of active sx not due to another cause
What medications can cause prolonged QTc?
tx - Mg
Haloperidol, clarithromycin, amiodarone, sotalol, ciprofloxacin, amitriptyline, fluoxetine, sumatriptan
What are the types of ADHD?
- Inattention
- Hyperactivity/ impulsive
- Both
How is ADHD managed?
- Behavioural psychotherapy
- Medication - Stimulants (methylphenidate)
non-stimulants (atomoxetine)
What are some Antidepressants?
SSRIs - fluoxetine, sertraline, citalopram
NaSSA - Mirtazapine
NaRI - Reboxetine
TCA - lofepramine, clomipramine, amytriptyline
SNRI - Venlafaxine
MOAI-A - Moclobemide
Give an examples of a NASSA (NA and selective 5HT antidepressant).
Mirtazapine
SE - MMMirtaZZZapine - MMM food - weight gain and ZZZ sedation
What are some side effects of SSRIs?
GI upset, QT prolongation, sexual dysfunction, hyponatraemia, weight and appetite changes
Why is it important to be careful when prescribing TCAs?
They are dangerous in OD, lots of side effects
Sedation, coma, arrhythmias, convulsions
Prolonged QT and QRS
What is an important SE to be aware of in MOAIs?
Tyramine reactions - Hypertensive crisis
Tyramine is broken down into NA and then NA is broken down by MOA and so - increased NA - sudden increased in bp - headache
(if they ingest tyramine - cheese, wine)
What dopamine pathways are in the brain?
Mesocortical (-ve sx)
Mesolimbic (+ve sx and reward)
Niagrostriatal (Extrapyramidal sx (movement))
Tubuloinfundibular (porlactin)
What are some examples of 1st generation/typical antipsyhoctics?
Chlorpromazine, haloperidol, prochlorperazine
Dopamine 2 receptor antagonists
What are some SE of typical antipsychotica?
*Extrapyramidal side effects - drug-indiced parkinsons, tardive dyskinesia (niagrostriatal), dystonia, akathasia
* Hyperprolactinaemia (tubuloinfundibular) - glacatorrhoea and breast tenderness in girls and impotence and reduced libido in men
Neuroleptic malignant syndrome, prolonged QT, erectile dysfunction
What are some examples of 2nd generation/atypical antipsyhoctics?
Quetiapine, Olanzapine, Risperidone, Clozapine, Aripirazole
What are some SE of atypical antipsychotics?
Metabolic symptoms (weight gain, hyperglycaemia, dyslipidaemia)
Antimuscarinic sx (like in typical) - dry mouth, constipation, blurred vision
Neuroleptic malignant syndrome
Less EPSx and Hyperprolactinaemia
What are some differences in typical and atypical antipsychotics?
Typical - Prominent EPsx and Hyperprolactinaemia
Atypical - more metabolic symptoms
Both - Antimuscarinic sx, neuroleptic malignant syndrome, torsades de pointe.
What Atypical antipsychotic is only used in sever cases?
If 2 antipsychotics have failed or are not tolerated, Clozapine can be started
SE - agranulocytosis*, myocarditis, seizures, sialorrhoea
When are antipsychotics indicated?
Psychomotor agitation
Schizophrenia (to help +ve symptoms)
Bipolar
What must you remember to do if prescribing atypical antipsychotics?
MONITORING - neutrophils, weight, glucose/HbA1c, Lipids, ECG (LFTs, U&Es, BP and pulse), smoking status, side effects
Wear sun cream
What is neuroleptic malignant syndrome and what are some symptoms?
Rare, but potentially serious or even fatal adverse effect of all antipsychotics
Fever, diaphoresis, rigidity, confusion, fluctuating
consciousness, fluctuating BP, tachycardia, elevated CK, leucocytosis, altered LFTs
What are some side effects of the mood stabiliser Lithium?
Lethargy Insipidus (diabetes) Tremor Hypothyroidism Insides (gastrointestinal) Urine (increased) Metallic taste
What are some signs of toxicity in Lithium?
Confusion, drowsiness, excessive thirst and urination, seizures, visual problems, difficulty with speech
What are some important considerations when taking lithium?
Pregnancy - Teratogenic - ebsteins anomaly
Lithium record book - records doses and blood tests -
6monthly bloods - U&Es, LFTs, Ca, TFTs**
3monthly lithium level*
Dont just stop and never take a double dose, if you miss one just take then next dose as normal
What is aversive therapy?
Used to reduce a desire for an addiction e.g. in alcoholics an averisve drug that makes you feel N&V is given so that you associated drinking with sickness, reducing your desire
Fluoxetine is usually used if an antidepressant is needed during pregnancy. What are some possible side effects from SSRIs in pregnancy?
PPHN
Neonatal withdrawl syndrome
Low birth weight, prematuirty
Paroxetine in 1st trimester can cause foetal heart defects
What is puerperal psychosis and what are some risk factors for it?
Severe mania/ psychosis precipitated by childbirth, usually occurs within first 2 weeks.
Risks - first pregnancy, obstetric complications, FHx, bipolar, discontinuing mood stabilisers, PMHx
What are some features of puerperal psychosis?
Rapid fluctuations in mood
Marked confusion
Fear, insomnia, restlessness
Delusions, hallucinations and disturbed behaviour
How would you manage a patient with high risk of puerperal psychosis?
Antipsychotics or
Mood stabiliser - Lithium - risks v benefit (may be on it during the pregnancy or start it immediately after delivery) or
ECT
Admission to mum and baby unit and monitoring of mum and baby
Lithium in pregnancy can cause an Ebsteins anomaly, what is this?
ECHO*
Downwards displacement of the tricuspid valve, with tricuspid incompetence means for a large RA and small RV. - poor pul perfusion - cyanosis once PDA closes.
There may also be an ASD and arrhythmia
Associated with Wolf Parkinson white
Presentation - HF (oedema), Poor feeding, cyanosis, tachypnoea, SoB, collapse
What other risks does lithium pose to a baby?
Floppy baby syndrome
Neonatal hypothyroidism
Prematurity
Do you need to change monitoring of lithium during pregnancy?
Yes - to monthly and by 36 weeks, weekly
When might the following conditions start after pregnancy?
Baby blues
Postnatal depression
Puerperal/postpartum psychosis
Baby blues - ~day 2-5 and last ~ 3 days
Depression - Weeks 6-8 and last weeks or months
Psychosis - usually in first 2 weeks, can last weeks or months
How might the following conditions be managed?
Baby blues
Postnatal depression
Puerperal/postpartum psychosis
Baby blues - reassurance and support
Postnatal depression - CBT, Antidepressants
Puerperal/postpartum psychosis - Urgent assessment, admission to mum and baby unit?
What are the 2 broad treatment medications in ADHD?
1st line - stimulants (methylphenidate, dexamfetamine)
2nd line - non-stimulants (atomoxetine)
What are the differences between stimulants and non-stimulants in ADHD management?
need 6 monthly review of Bp and HR
Stimulants - Work on people who don’t have ADHD (diversion likely (malingering - pretending)), immediate acting, a controlled drug
Non-stimulants - Slower onset, doesn’t work on those without ADHD, Preferred in anxiety, tourettes and psychosis, not a controlled drug
What is first line treatment in ADHD?
Stimulants - Methylphenidate - DA and NA reuptake inhibitor
Immediate (Ritalin) and slow release (concerta) preparations
Then Dexamfetamine - DA and NA release and a reuptake inhibitor - more likely to be abused/ diversion
What is the 2nd line option for ADHD if stimulants are ineffective or not tolerated?
Non-stimulant - Atomoxetine - NA reuptake inhibitor
- Acute liver failure and suicidality rare
What are some side effects of stimulant medications in ADHD?
Tics, seizures, reduced appetite, insomnia, headache, tachycardia, irritable
What are some side effects of non-stimulant medications in ADHD?
Dizzy, sexual dysfunction, seizures, constipation, insomnia, sweating
Avoid in Pheochromocytoma
What is the core triad of symptoms in Autism?
Develops before 3 years
1. Abnormal reciprocal social interaction
(difficulty making and maintaining friends, minimal shared enjoyment, attachement to objects, aloof/awkward)
2. Communication and language impairment
(prolonged or absent eye contact, talk at you, delayed or absent speech, minimal body language)
3. Restricted and repetitive interests
(obsessive fixed interests, motor mannerisms (hand flapping or body rocking), OCD, fixed routine or route to school, change is unsettling, preference for sameness)
What is the difference between autism and aspergers?
Aspergers has NO global developmental delay (in language or cognition), they usually have normal intelligence
What is a conduct disorder?
A behaviour disorder of antisocial behaviour
- Aggressive conduct (bullying, intimidating, physical fights, cruelty, forcing sexual activity)
- Deceitful conduct (lying, theft, shoplifting)
- Destructive conduct (intentionally destroying property)
- Violation of rules (skipping school, running away, pranks)
Childhood onset < 10y
What is the range of affective/mood disorders?
Mania with psychosis - mania - hypomania - elation - normal - dysthymia - mild depression - mod dep - severe dep - severe depression with psyhosis
What is the difference between mania and hypomania?
Mania - no insight, >=3 sx for .=7 days, extreme interference with ADL
Hypomania - partial insight, >=4sx for 3d, slightly interfers with ADL
*How it interfers with ADL
What is bipolar affective disorder?
2 or more episodes where the patient has significantly disturbed mood and activity levels
Bipolar 1 - Mania + depression
Bipolar 2 - Hypomania + depression
How would you manage bipolar affective disorder?
Antipsychotics (acute and continue for 4 wks)
Mood stabilisers (continue life long)
Psychological - CBT, psychotherapy
Social - Support groups, relaxation
How might you manage schizophrenia?
Assess risk, general physical health and co-morbidities
2nd generation/ Atypical antipsychotic (Dopamine antagonists) - quetiapine, olanazpine
- Regular review of SE
- SE - weight gain, antimuscarinic affects (dry mouth, constipation, urinary retention), neuroleptic malignanct syndrom, torsades de pointe
Whats the difference between schizophrenia and schizoaffective disorder?
Schizophrenia is a disturbance in behaviour, thought, emotions and cognition
Schizoaffective disorder is that PLUS a MOOD disorder
What is a phobia?
An irrational intense fear that the patient realises as excessive
Causes avoidance of situations that cause anxiety
(generalised anxiety disorder is not pinned to certain circumstances and so they cannot avoid the ‘situation’)
What medication could you give in GAD after education and psychological intervention have failed?
1st - Sertraline
2nd - try another SSRI
3rd - SNRI - Venlafaxine, duloxetine
4th - pregbalin
