Psychiatry Flashcards
What are the three core symptoms of depression?
Low mood
Anhedonia
Fatigue
At least two of the above must have been present for at least 2 weeks
What are the additional symptoms of depression?
Sleep disturbance Change in appetite Low libido Poor concentration Low-self image Poor perception of the future Hopelessness / Worthlessness / Guilt Suicidality
How is the severity of depression classified?
Mild = 4 symptoms (at least 2 core + 2 more) Moderate = 5-6 symptoms (2 core + 3-4 more) Severe = 7+ symptoms
What is dysthymia?
Chronic mild depression which doesn’t meet criteria for depressive episodes or recurrent depression
What type of delusion is most common in depression?
Nihilistic delusion
e.g. insides rotting, being eaten by insects/parasites
What investigations should be done in suspected depression?
HR, BP, BMI FBC, U&E, LFT TFT HbA1c ECG
What is the treatment algorithm for depression?
Mild: wait 2w and see, self-help therapies,
Moderate: CBT + counselling
Med-sev: SSRI + CBT
ECT gold standard in severe refractory depression - suicidal / catatonic patients who have not responded to any other therapies
What are the side effects associated with tricyclic antidepressants?
Lower seizure threshold
Prolonged QTc - ^ risk polymorphic VT (TdP)
Anticholinergic: dry mouth, blurred vision, constipation, retention, confusion, cognitive problems
Anti-adrenergic: postural hypotension, sexual dysfunction, tachycardia
What is the only SSRI licensed for under 18s?
Fluoxetine
What are the common side effects of SSRIs?
Dry mouth Headaches Nausea / dizziness GI upset Fatigue Sexual dysfunction Anxiety/restlessness
What are the withdrawal symptoms of SSRIs?
Agitation Nausea / dizziness / vomiting Anxiety Fatigue Flu-like symptoms Tremors and muscle spasms Insomnia
Which SSRI is first line in adult depression and anxiety?
Sertraline
Which SSRI is most associated with QTc prolongation?
Citalopram, escitalopram
What is the best antidepressant for people taking warfarin?
Mirtazapine
What is the main side effectsof mirtazapine?
Weight gain and increased cholesterol level
Can also be quite sedating
Agranulocytosis quoted in BNF but ? frequency
What are the symptoms of serotonin syndrome?
Hyperthermia, hypertension, hyper-reflexia Tachycardia, Sweating Tremor, agitation, irritability Pupil dilation, diarrhoea Myoclonus Rigidity
How do you treat serotonin syndrome?
Diazepam
Cyproheptadine in severe symptoms (serotonin antagonist)
Over how long should you taper antidepressants before stopping/changing?
Minimum 4 weeks
How long should you have antidepressant therapy for?
Ideally 12 months after feeling well to reduce risk of relapse
What questionnaire is used to determine the severity of anxiety?
GAD-7
What is the management available for anxiety?
Watchful waiting, lifestyle advice, self-help
Symptomatic treatment: propranolol
1st line definitive treatment: SSRI
2nd line: Benzodiazepine e.g. diazepam
What is the management for panic disorder?
SSRIs + CBT most effective
Benzodiazepines can be considered if the above are not effective
What are the core principles of CBT?
To understand problems
To reframe underlying beliefs driving the problem
Challenge irrational thoughts, core beliefs and thereby behaviour to be more positive and productive
Tailored to individual and problem
What do CBT courses usually entail?
12 sessions, weekly-fortnightly
Hour-long and can be F2F or over telephone/online
Involves homework between sessions for reflection
What is the difference between baby blues and post-natal depression?
Baby blues usually around 4d post-labour but PND usually after about 8-12w
Symptoms less severe in baby blues - tearfulness, irritability and restlessness
No treatment indicated for BB, just watchful waiting
How can you screen for post-natal depression?
Edinburgh PND scale
How is post-natal depression managed?
CBT and lifestyle advice
SSRIs
Admission to mother and baby unit if severe
What is postpartum psychosis?
Peak onset day 3-7 postpartum
Initially: irritable, poor sleep, fleeting anger, purposeless activity (similar to baby blues)
Quickly descends into florrid psychosis/ delusions/ hallucinations - often centred around baby
PSYCH EMERGENCY- need assessment within 4 hours and supervision
What are risk factors for postpartum psychosis?
Previous episodes
Bipolar disorder
-> if both present, 40% risk in subsequent pregnancies
How is postpartum psychosis managed?
Antipsychotic medication
What is the first line antidepressant in pregnancy?
Sertraline
What are the main risks of antipsychotics in pregnancy?
GDM / metabolic disturbance with olanzapine/quetiapine due to ^ cholesterol and glucose
Poor neonatal adaption syndorme
Agranulocytosis and seizures with clozapine
What congenital malformation is associated with lithium in pregnancy?
Ebstein’s cardiac abnormality
What is the therapeutic range for lithium?
0.4-1.0
What is the gold-standard mood stabiliser?
Lithium
What baseline tests do you need to do before initiating lithium?
FBC, U&E, TFT, ECG, BMI
Rule out pregnancy
What monitoring is required with lithium treatment?
Levels weekly until stable, then 3 monthly for first year, then 6 monthly
Levels should be checked at least 12 hours after last dose.
6monthly: TFT, U&Es, BMI
What are the side effects of lithium treatment?
GI disturbance, tremor, polyuria, hair loss, acne
Chronic renal failure, thyroid dysfunction, diabetes insipidus, arrhythmia, reduced seizure threshold
What are the signs of lithium toxicity?
Tremor, tiredness, slurred speech, ataxia, dizziness
Blurred vision, convulsions, delirium, syncope, hypernatraemia, arrhythmia (prolonged QT)
Seizures, oliguria, renal failure, seizure, coma
What tests do you need before initiating sodium valproate?
FBC, LFT
LFTs also need to be monitored - don’t need to change unless transaminases TRIPLE
What is the most important side effect of lamotrigine?
SJS and TEN
What are the three main components of psychosis?
Hallucinations
Delusions
Thought disturbance
What are differentials for psychiatric causes of psychosis?
Schizophrenia Schizoaffective disorder Bipolar disorder Severe depression Dementia Drug-induced bipolar
What are differentials for organic causes of psychosis?
Encephalitis Delirium Drug intoxication Brain injury / tumour Temporal lobe epilepsy Neurosyphilis AIDs Huntington's disease
What measurements should be done before initiating antipsychotics?
Weight, waist circumference, BMI
HR BP
ECG
Fasting glucose, HbA1c, lipids and prolactin
Assess nutrition and any movement disorders
What is schizoaffective disorder?
Equal and simultaneous symptoms of schizophrenia and bipolar disorder
Can be predominantly manic / depressive / mixed
What are the positive symptoms of schizophrenia?
Delusions, illusions, thought disorder
Paranoia, persecutory delusions, agitation
Voices heard in 3rd person, running commentary
Thought block
Flight of ideas, overvalued ideas
What are the negative symptoms of schizophrenia?
Flattened affect, reduced speech
Anhedonia
Social withdrawal
Avolition: inability to initiate purposeful activity
Apathy
Loss of libido and interest in maintaining relationships
Catatonic behaviour
What is the management for catatonic behaviour?
Benzodiazepines first line
ECT gold standard
Which two antipsychotics are most associated with hypercholesterolaemia?
Olanzapine and Quetiapine
What are typical antipsychotics like haloperidol associated with?
Extrapyramidal side effects
Often used as single-use antipsychotics to control acute / violent behaviour rather than used in the long term
Why is risperidone less commonly used now?
Highest risk of pyramidal side effects and hyperprolactinaemia
What are the common side effects of olanzapine?
Weight gain
Sedation
Hypercholesterolaemia + hyperglycaemia
Hyperprolactinaemia
What are the common side effects of quetiapine?
Transaminitis Orthostatic hypotension Long QT Hyperlipidaemia/hyperglycaemia Weight gain
Why is aripirazole popular to use in practise?
Less sedating
No QTc prolongation
Low extrapyramidal effects
Available in short and long acting IM preparations
What are the side effects associated with clozapine use?
Agranulocytosis
Lowered seizure threshold - esp in combination with lithium
Sedation, weight gain, LFT derangement
Constipation, arrhythmia,
hyperprolactinaemia, hyperlipidaemia, hyperglycaemia
What precautions must be taken with clozapine use?
Weekly FBC for 6 monthly, fortnightly for 6m, then monthly thereafter
Shouldn’t suddenly stop smoking, causes bioavailability to increase
If stopped >48 hours, need to start titration again from the beginning
What are the symptoms of neuroleptic malignant syndrome?
Hyperthermia, confusion Hypertension Hyperreflexia (difference to serotonin synd) Muscle rigidity Tremor and agitation Sweating Seizures
How do you manage neuroleptic malignant syndrome?
Stop medication May need ICU Active cooling Benzodiazepine Dantrolene for rigidity IV rehydration + diuresis
What are signs of tardive dyskinesia?
Lip smacking, tongue protrusion
Hand movements
Pelvic thrusting
Managed by stopping anticholinergics and reducing antipsychotics
+ tetrabenzine, clonazepam and propranolol
What are the symptoms of hyperprolactinaemia?
Gynaecomastia Galactorrhoea Low libido Menstrual dysfunction Subfertility
What are the 5 key principles of the mental health act?
- Least restrictive option possible + maximised independence
- Empowerment and involvement of family and carers
- Respect and dignity
- Treatment purpose and effectiveness
- Efficiency and equity
What is section 2 of the MHA used for?
Assessment and treatment
28 days
Treatment can be given against will
Requires recommendation from 2 doctors- 1 independent
Discharge can be approved by responsible clinician, hospital manager or nearest relative
Either discharge or convert to section 3
What is section 3 of the MHA?
Admission for treatment
< 6 months
Treatment can be enforced for the first 3 months, then consent required or review of enforcement
Needs 2 doctors to recommend
Discharge can be approved by responsible clinician, hospital manager or nearest relative
Can be renewed for further 6 months and then 12 monthly
Appeal after 6 months and annually thereafter
What is section 4 of the MHA?
Emergency detainment <72 hours for purposes of assessment
Application by AMHP, nearest relative and recommendation by 1 doctor
Treatment cannot be enforced
Often used while waiting to be assessed for section 2
Can’t renew
What is section 5(2) of the MHA?
Allows compulsory detention of an inpatient (not A&E) for < 72 hours
Recommendation from doctor or approved clinician (FY2 +)
Used to detain until senior able to assess patient
Can’t appeal
What is a section 5(4)?
Nursing staff able to detain patient for < 6 hours while waiting for a doctor to assess them
Must record time of detention on a specific form + state that patient was a danger to self/others and no doctor available to assess or do a 5(2)
What is a section 135?
Warrant to gain access to a premises and move a patient to a place of safety
No treatment allowed
Recommendation by 1 doctor, AMHP and police
What is a section 136?
Warrant to remove a patient from a public place to a place of safety
No treatment
Application by police power to bring patient in for assessment
What is a community treatment order?
Order stating that patients can be recalled to hospital or detained if not engaging with treatment in the community
What are the two main types of bipolar disorder?
Type 1: At least one episode of true mania
Type 2: At least one episode of hypomania + one major depressive episode
No history of TRUE mania
What are the features of mania?
Abnormally + persistently elevated mood with increased activity or energy
Lasts > 1 week
During this, 3+ of: increased self esteem, grandiosity, reduced sleep, flight of ideas, distractibility, goal-directed activity, psychomotor agitation, involvement in high risk activities
Can be with or without psychotic symptoms
How do you differentiate mania from hypomania?
Any psychotic symptoms = automatically mania
Hypomania generally less intense symptoms
Hypomania may lest for a shorter period of time
How do you manage bipolar affective disorder?
Following a manic episode, ensure to stop any antidepressant treatment. Can offer antipsychotic treatment + if ineffective consider adding lithium.
Mood stabilisers = first line
If already on lithium, consider checking levels to ensure they are within therapeutic range.
Psychological interventions
Supportive: limit external stimuli, limit access to driving/drugs/bank accounts/phones
What are examples of mood stabilisers?
Sodium valproate
Lamotrigine
Carbamazepine
Lithium
What are the 6 features of substance dependence?
Compulsion to take the substance
Impaired capacity to control substance-taking behaviour / unsuccessful efforts to stop/abstain
Physiological withdrawal state
Tolerance to substance
Salience: preoccupation with substance over normal tasks/activities
Continuation despite clear negative consequences
What can be used for opioid replacement and detoxification therapy?
Methadone
Buprenorphine
Lofexidine
Naltrexone can be used for relapse prevention
Which two medications are used to prevent alcoholism relapse?
Acamprosate
Disulfiram
What are symptoms of alcohol withdrawal?
8-24 hours: tremor, anxiety, insomnia, headache, GI disturbance, palpitations
24-72 hours: sweating, hypertension, tachycardia, tachypnoea, confusion, mild hyperthermia
> 72 hours: delirium tremens, disorientations, psychosis, seizures
What are the key features of Wernicke’s encephalopathy?
Confusion
Ataxia
Ophthalmoplegia
What are the features of Korsakoff’s syndrome?
Confusion
Anterograde and retrograde amnesia
Confabulation
Personality change
What assessments can be used to assess a patient’s cognition?
ACE-III: assessment of attention, memory, fluency, language and visuospatial ability
MoCA: mini version of ACE-III
MMSE
4AT test
What are the features of autism spectrum disorders?
Impaired communication and interaction- inability to form relationships, language delay, reduced ability to understand social etiquette, poor eye contact
Stereotypical patterns of behaviour- hand flapping, sensory behaviours, organisation, adverse response to loud sounds
May have intellectually impairment or excellence
How are autism spectrum disorders diagnosed?
Diagnostic interviews with child and parents
May wish to observe child in normal daily environments to assess behaviour
How are autism spectrum disorders managed?
Psychological interventions
Support at school
Respite care, carers
Low dose SSRIs can be used for restrictive behaviours
Risperidone first line for associated aggression
Melatonin can help with sleep
How is ADHD diagnosed?
Symptom profile
Quantitative Behaviour test
SNAP questionnaire
What treatments are available for ADHD?
Methylphenidate (ritalin) = first line treatment
Amphetamine/dextroamphetamine (adderall) second line
Psychoeducation, behavioural therapies and school support
What needs to be monitored in children having pharmacological treatment for ADHD?
Height, weight and B
