Psychiatry Flashcards

1
Q

What are the three core symptoms of depression?

A

Low mood
Anhedonia
Fatigue

At least two of the above must have been present for at least 2 weeks

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2
Q

What are the additional symptoms of depression?

A
Sleep disturbance
Change in appetite 
Low libido
Poor concentration
Low-self image
Poor perception of the future
Hopelessness / Worthlessness / Guilt
Suicidality
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3
Q

How is the severity of depression classified?

A
Mild = 4 symptoms (at least 2 core + 2 more)
Moderate = 5-6 symptoms (2 core + 3-4 more)
Severe = 7+ symptoms
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4
Q

What is dysthymia?

A

Chronic mild depression which doesn’t meet criteria for depressive episodes or recurrent depression

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5
Q

What type of delusion is most common in depression?

A

Nihilistic delusion

e.g. insides rotting, being eaten by insects/parasites

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6
Q

What investigations should be done in suspected depression?

A
HR, BP, BMI
FBC, U&E, LFT
TFT
HbA1c
ECG
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7
Q

What is the treatment algorithm for depression?

A

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

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8
Q

What are the side effects associated with tricyclic antidepressants?

A

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

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9
Q

What is the only SSRI licensed for under 18s?

A

Fluoxetine

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10
Q

What are the common side effects of SSRIs?

A
Dry mouth
Headaches
Nausea / dizziness
GI upset
Fatigue
Sexual dysfunction
Anxiety/restlessness
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11
Q

What are the withdrawal symptoms of SSRIs?

A
Agitation
Nausea / dizziness / vomiting
Anxiety
Fatigue
Flu-like symptoms
Tremors and muscle spasms
Insomnia
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12
Q

Which SSRI is first line in adult depression and anxiety?

A

Sertraline

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13
Q

Which SSRI is most associated with QTc prolongation?

A

Citalopram, escitalopram

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14
Q

What is the best antidepressant for people taking warfarin?

A

Mirtazapine

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15
Q

What is the main side effectsof mirtazapine?

A

Weight gain and increased cholesterol level
Can also be quite sedating
Agranulocytosis quoted in BNF but ? frequency

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16
Q

What are the symptoms of serotonin syndrome?

A
Hyperthermia, hypertension, hyper-reflexia
Tachycardia, Sweating
Tremor, agitation, irritability
Pupil dilation, diarrhoea
Myoclonus
Rigidity
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17
Q

How do you treat serotonin syndrome?

A

Diazepam

Cyproheptadine in severe symptoms (serotonin antagonist)

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18
Q

Over how long should you taper antidepressants before stopping/changing?

A

Minimum 4 weeks

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19
Q

How long should you have antidepressant therapy for?

A

Ideally 12 months after feeling well to reduce risk of relapse

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20
Q

What questionnaire is used to determine the severity of anxiety?

A

GAD-7

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21
Q

What is the management available for anxiety?

A

Watchful waiting, lifestyle advice, self-help
Symptomatic treatment: propranolol
1st line definitive treatment: SSRI
2nd line: Benzodiazepine e.g. diazepam

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22
Q

What is the management for panic disorder?

A

SSRIs + CBT most effective

Benzodiazepines can be considered if the above are not effective

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23
Q

What are the core principles of CBT?

A

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

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24
Q

What do CBT courses usually entail?

A

12 sessions, weekly-fortnightly
Hour-long and can be F2F or over telephone/online
Involves homework between sessions for reflection

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25
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
26
How can you screen for post-natal depression?
Edinburgh PND scale
27
How is post-natal depression managed?
CBT and lifestyle advice SSRIs Admission to mother and baby unit if severe
28
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
29
What are risk factors for postpartum psychosis?
Previous episodes Bipolar disorder -> if both present, 40% risk in subsequent pregnancies
30
How is postpartum psychosis managed?
Antipsychotic medication
31
What is the first line antidepressant in pregnancy?
Sertraline
32
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
33
What congenital malformation is associated with lithium in pregnancy?
Ebstein's cardiac abnormality
34
What is the therapeutic range for lithium?
0.4-1.0
35
What is the gold-standard mood stabiliser?
Lithium
36
What baseline tests do you need to do before initiating lithium?
FBC, U&E, TFT, ECG, BMI | Rule out pregnancy
37
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
38
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
39
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
40
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
41
What is the most important side effect of lamotrigine?
SJS and TEN
42
What are the three main components of psychosis?
Hallucinations Delusions Thought disturbance
43
What are differentials for psychiatric causes of psychosis?
``` Schizophrenia Schizoaffective disorder Bipolar disorder Severe depression Dementia Drug-induced bipolar ```
44
What are differentials for organic causes of psychosis?
``` Encephalitis Delirium Drug intoxication Brain injury / tumour Temporal lobe epilepsy Neurosyphilis AIDs Huntington's disease ```
45
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
46
What is schizoaffective disorder?
Equal and simultaneous symptoms of schizophrenia and bipolar disorder Can be predominantly manic / depressive / mixed
47
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
48
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
49
What is the management for catatonic behaviour?
Benzodiazepines first line | ECT gold standard
50
Which two antipsychotics are most associated with hypercholesterolaemia?
Olanzapine and Quetiapine
51
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
52
Why is risperidone less commonly used now?
Highest risk of pyramidal side effects and hyperprolactinaemia
53
What are the common side effects of olanzapine?
Weight gain Sedation Hypercholesterolaemia + hyperglycaemia Hyperprolactinaemia
54
What are the common side effects of quetiapine?
``` Transaminitis Orthostatic hypotension Long QT Hyperlipidaemia/hyperglycaemia Weight gain ```
55
Why is aripirazole popular to use in practise?
Less sedating No QTc prolongation Low extrapyramidal effects Available in short and long acting IM preparations
56
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
57
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
58
What are the symptoms of neuroleptic malignant syndrome?
``` Hyperthermia, confusion Hypertension Hyperreflexia (difference to serotonin synd) Muscle rigidity Tremor and agitation Sweating Seizures ```
59
How do you manage neuroleptic malignant syndrome?
``` Stop medication May need ICU Active cooling Benzodiazepine Dantrolene for rigidity IV rehydration + diuresis ```
60
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
61
What are the symptoms of hyperprolactinaemia?
``` Gynaecomastia Galactorrhoea Low libido Menstrual dysfunction Subfertility ```
62
What are the 5 key principles of the mental health act?
1. Least restrictive option possible + maximised independence 2. Empowerment and involvement of family and carers 3. Respect and dignity 4. Treatment purpose and effectiveness 5. Efficiency and equity
63
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
64
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
65
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
66
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
67
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)
68
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
69
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
70
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
71
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
72
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
73
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
74
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
75
What are examples of mood stabilisers?
Sodium valproate Lamotrigine Carbamazepine Lithium
76
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
77
What can be used for opioid replacement and detoxification therapy?
Methadone Buprenorphine Lofexidine Naltrexone can be used for relapse prevention
78
Which two medications are used to prevent alcoholism relapse?
Acamprosate | Disulfiram
79
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
80
What are the key features of Wernicke's encephalopathy?
Confusion Ataxia Ophthalmoplegia
81
What are the features of Korsakoff's syndrome?
Confusion Anterograde and retrograde amnesia Confabulation Personality change
82
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
83
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
84
How are autism spectrum disorders diagnosed?
Diagnostic interviews with child and parents | May wish to observe child in normal daily environments to assess behaviour
85
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
86
How is ADHD diagnosed?
Symptom profile Quantitative Behaviour test SNAP questionnaire
87
What treatments are available for ADHD?
Methylphenidate (ritalin) = first line treatment Amphetamine/dextroamphetamine (adderall) second line Psychoeducation, behavioural therapies and school support
88
What needs to be monitored in children having pharmacological treatment for ADHD?
Height, weight and B