Psychiatry Flashcards
Forms of delusion (5)
- reference
- control
- guilt
- grandiosity
- persecution
Somatisation disorder
Multiple physical symptoms and investigations with no physical cause.
Hypochondriasis
Persistent belief in the presence of an underlying serious disease
Refuses to accept reassurance or negative result
Munchausen/fictitious disorder
Intentional production/ falsification of psychological signs and symptoms to obtain medical attention and treatment
Malingering
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Conversion/ dissociative disorder
Loss of motor or sensory function without organic cause
La belle indifference
La belle indifference is defined as a paradoxical absence of psychological distress despite having a serious medical illness or symptoms related to a health condition.
Gander syndrome/ prison psychosis
Deliberately acts as if/she has physical or mental illness when they aren’t really sick
Cowards delusion / nihilistic delusion
Holds belief they are dead or do not exist
Or have lost their blood or internal organs
Capgras syndrome
Irrational belief someone they now has been replaced by an imposter
Fregoli delusion
Delusional belief the different people (>1) are in fact a single person that changes appearance / is in disguise
Acute alcohol withdrawal
- symptoms
- treatment
Sweating , agitation , tremors, altered mental ion
1 - Chlordiazepoxide
2- thiamine vit B1
If seizure of hallucination - delirium tremendous
- IV lorazepam or diazepam
Wenickes encephalopathy
Symptoms
treatment
CAS - confusion , ataxia, squint : ophthalmoplegia, nystagmus, diplopia
IV vitamin B1(thiamine), IV pabrinex or high potency Vit B complex
Medication to give alcoholic to serve as detergent when he takes alcohol
Disulfiram
Medication to help reduce withdrawal sx in alcoholics
Chlordiazepoxide
Acamprostate use
Reduces craving for alcohol
Chronic alcoholism liver fn
Raised MCV , GGT
Anorexia nervosa management
BMI <15
BMI 15-17.5
>17.5
BMI <15 ,+ rapid wt loss and evidence of system failure
= urgent referral to medical/pads ward
Severe electrolyte imbalance, Brady,hypoglycaemic
- acute medical ward regardless of BMI
15-17.5 + no system failure / complications =
Routine referral to eating disorder unit / local community mental health team
Severe self harm - high risk of suicide
- admit to an acute psychiatric ward
> 17.5 w/o complications - build trusting relationship and encourage self help books and food diary
Autism spectrum disorder
Features
Impaired language and communication “ social relationships Compulsive behaviour Collects things Decreased IQ in most children
Management of insomnia in ADHD patient
1st line - sleep hygiene
2nd - melatonin
Mania vs hypomania
Mania - > 7days , severe functional impairment, may have psychotic symptoms
Hypomania - < 7 day , function not impaired, no psychotic symptoms
Treatment of bipolar disorder
Mood stabilisers - lithium
Features of lithium toxicity
- coarse tremor (fine tremor at therapeutic level)
-muscular twitching - nausea & vomitng
- drowsiness, confusion
__
Hyperreflexia
Seizure - severe toxicity
Coma - severe toxicity
Blurred vision
Management of lithium toxicity
Serum lithium levels
Mild-moderate toxicity- normal resuscitation + normal saline
Haemodialysis - severe toxicity
Diuretic and NSAID effect on lithium
Increase renal absorption of lithium - leads to toxicity
Lithium and planning pregnancy
Teratogenic - ebstein anomaly, thyroid disease, floppy baby syndrome
If planning to get pregnant - reduce gradually & stop before pregnancy confirmed
Woman on lithium gets pregnant
What should be done?
Consider stopping it gradually over 4 weeks if she is well
Woman on lithium while pregnant
What. Should be done?
Check lithium levels monthly until 36 weeks
Then weekly until birth
How often should lithium levels be checked
1 week after starting
Every 3 months
- check lithium 12 hours after last dose (narrow therapeutic range)
LFT U&E -every 6 months
2 important tests to be done before initiating lithium
Thyroid & kidney function
Tests to be done before prescribing amiodarone
Serum U&E s
SSRI + lithium in bipolar patient
SSRI can worsen episodes of mania
Antidepressants precipitate manic episodes
Should be stopped if mania is worsened
Advice on stopping antidepressants
Continue for at least 6 months in total even if there is improvement
First line in depression - how long do they take to work
SSRIs - take 2-4 weeks to work
Depression management
Psychotherapy - CBT + SSRIs(fluoxetine, sertraline, citalopram)
No response 2- 4 weeks - check adherence to meds
If adherent and no response after 4 weeks - up the dose or change SSRI
Or shift to different class of antidepressants - mirtazapine
Best antidepressants in MI patients
SSRIs - sertraline
2nd line - citalopram
SSRIs
Citalopram
Fluoxetine - DOC when antidepressant indicated
Sertraline - post MI
Paroxetine
SNRIs
Venlafaxine , Duloxetine
Tricyclic antidepressants
Amitriptyline
Presynaptic alpha antagonist
Mirtazapine
^ atypical antidepressant
Postpartum blues
Features
Treatment
3-7 days following birth
Common in primi
Anxious tearful irritable , crying
T- reassurance
Postnatal depression
Features
Treatment
Peaks @ 3-4 weeks postpartum , can occur anytime in first 6 months
Occasional thoughts of harming baby
- feels she can’t look after baby properly or wont be a good mother
T - CBT , then SSRIs
If breastfeeding — sertraline
Puerperal psychosis.
Feature
Treatment
2-4 days postpartum, - peaks @ 2 weeks Can present anytime after delivery Severe mood swings + disordered perception Thought of harming baby Suicidal thoughts
t- ECT , mood stabilisers, antidepressant
Depressed person, no point in living
Refuses help/treatment
What should you do?
Compulsory admission under the mental health act
Hormone disturbance in Schizophrenia
Dopamine
Schizophrenia symptoms
Auditory hallucinations
Thought disorders - insertion, withdrawal, broadcast, blocking
Passivity phenomena - body sensation controlled externally
Delusional perceptions
Management of schizophrenia
Risperidone , Olanzapine
Quetiapine
Hypnagogic hallucination
Auditory hallucination while going to sleep
Hypnopompic hallucination
Auditory hallucination waking up
Management of panic attacks - long term
CBT
SSRIs - sertraline, fluoxetine
Acute episode - simple breathing exercise + reassurance
Panic disorder management
- before attack
- during
Before - b blocker
During - rebreathe into paper bag
Management of GAD
CBT
SSRI - sertraline
Othello syndrome
Over jealousy, suspecting unfaithful partner
Ekbom’s syndrome
Delusion of parasite infection
OCD
1st line of treatment
CBT
- exposure and response prevention (part of CBT)
PTSD
Features
Symptoms present for >1 month Re -experiencing Avoidance Hyperarousal Emotional numbing - depersonalisation Depression
PTSD treatment
1- CBT
2- SSRI
Watchful wait for mild symptoms <4weeks
Agoraphobia
Management
Fear of open spaces
- CBT + graded exposure
Opioid/heroin overdose
Low RR low HR low BP pinpoint pupils
Treatment
Naloxone
Opioid addict wants to quit, what will help combat withdrawal?
Methadone
Tourette’s
Age group
Repetitive tics - motor + vocal
6-13 yrs old
Asperger syndrome affects __
Social net reactions + behaviour
Rents syndrome
Normal development until 2-3 yrs old
Regression in motor social language and coordination skills after
Willis ekbom syndrome vs ekbom syndrome
WEs - restless leg syndrome, check ferritin
If low give iron , if normal give dopamine agonist
Ekbom - delusion of parasite infestation
Incongruent affect seen in
Bipolar disorder
Schizophrenia
Long term antipsychotic us + continuous involuntary movements
Management
Tardive dyskinesia
Depot injection of atypical antipsychotics- risperidone, olanzapine
Not oral!
Akathisia
Long term antipsychotic use + continuous sensation of restlessness
Brocas aphasia
Broken speech
Know and understand what they are saying
Wernickes aphasia
Difficulty with speech comprehension
Fluent speech that doesn’t are sense
Normal grief reaction
Stages
<6 months after major life event Denial & isolation Anger Depression Bargaining Acceptance
Adjustment disorder
<6 months after major life event
Crying hopeless withdrawn
Normal grief = subtype of adjustment disorder
Acute stress reaction
Duration < 4 weeks
Starts few mins or hrs after stressful event
Antisocial personality disorder
Features
M>F
Criminal act
Lack of remorse
Aggressive
Borderline personality disorder
Features
Unstable interpersonal relationships Marked impulsivity , inability to control anger Mood swings Self harm attempts Dramatic attention seekers
Side effects of SSRIs
Avoid use w/
GI symptoms - most common
- increased risk of GI bleed
SIADH
Avoid w/- NSAIDs, aspirin, warfarin, triptans
Fluoxetine - anorgasmia (delayed ejaculation)
Side effect haloperidol
Sexual dysfunction
Gynecomastia
Rapid tranquillisation in acute psychosis
Lorazepam > haloperidol > olanazapine
Acute episode - halo is drug of choice, esp in elderly
Contraindication of haloperidol
Parkinson’s
Alzheimer’s
Erotomania
Delusional belief that someone oh higher social status falls in love with them and makes amorous advances
Delusion of love
Folic a deux/ shared psychosis
Shared delusional disorder
Serotonin syndrome
Overdose of SSRI Neuromuscular excitation - hyperreflexia, myoclonus, rigidity ANS excitation - hyperthermia Altered mental state Nause, diarrhoea
Neuroleptic malignant syndrome vs SSRI syndrome
Similar features in both
1 with SSRI use
NMS - dopamine antagonist overdose (metoclopramide) or potent antipsychotic - clozapine , risperidone
LSD overdose (5)
Mydriasis - dilated pupils Flushing sweating Tremors Hyperreflexia Delusions + hallucinations** - smelling colours , seeing sounds
Ecstasy overdose
Nausea, flushing , hyperthermia , tachycardia, tachypnea , thirst
Seeing spots of colour when eyes OPEN
LSD - colours when eyes closed
Paracetamol overdose
- investigations
On admission - FBC UE LFT INR blood gases glucose
Serum paracetamol 4 hours after ingestion**
When IV n-acetylcysteine should be given (6)
Staggered paracetamol overdose - tablets not takenWithin 1 hr
Doubt over the time of ingestion
patient presents >8hr after ingestion
Jaundice or liver tenderness
Unconscious pt w/ suspected overdose
4 hr post ingestion plasma conc - on or above treatment line
Critical dose of paracetamol
150 mg/kg in 24 hrs - approx 24 tablets
Activated charcoal use in paracetamol overdose
If presents within 1 hr - give activated charcoal 1g/kg = max 50g
+ paracetamol ingested >=150mg/kg or 24 tabs
Liver transplant referral in paracetamol over dose
When?
Arterial pH <7.3, 24 hrs after ingestion OR all of the following : PT >100 s Creatinine > 300 umol/l Grade 3 or 4 encephalopathy
Delirium tremens vs alcohol hallucinosis
DT - hallucinations begin > 48 hrs after alcohol intake in chronic alcoholic
AH- few hrs after acute alcohol intake
AUDIT questionnaire (7)
Wake up drinking
Remorse/guilt
> = 8 units on single occasion male / female >= 6
No memory of wha happened night before being drunk
Self injury or injury to others
Cants stop once they start
Health professional is concerned
Important association/ side effect of citalopram
Associated with a cute angle closure glaucoma
Depressed patient on warfarin / heparin
Med to be given?
Mirtazapine (may cause INR to rise slightly )
Don’t give SSRI
Drug of choice in psychotic depression
TCA - amitriptyline
Continue 6-9 months after symptom resolution
Drug induced Parkinson’s
Treatment
2ry to antipsychotic meds - dopamine deficiency
Stop or lower dose
If not suitable - give anticholinergic - procyclidine
Acute stress reaction
Features
Management
Few mins or hrs after stressful stimulus
Can last up to 4 weeks
Characterised by :
Flashbacks + avoidant + hyperarousal
Mgmt - reassure
If severe and affects daily functions - trauma focused CBT
*PTSD if >4 weeks
Risk factors of suicide
Previous attempts= greatest risk ;or self harm Depression and other mental illness Alcohol and drug abuse Low SE status Divorce
Most appropriate treatment of psychotic depression
ECT
Refer to CBT afterwards
