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Finals Revision > Psychiatry > Flashcards

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
Q

What is the difference between baby blues and post-natal depression?

A

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

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26
Q

How can you screen for post-natal depression?

A

Edinburgh PND scale

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27
Q

How is post-natal depression managed?

A

CBT and lifestyle advice
SSRIs
Admission to mother and baby unit if severe

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28
Q

What is postpartum psychosis?

A

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

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29
Q

What are risk factors for postpartum psychosis?

A

Previous episodes
Bipolar disorder

-> if both present, 40% risk in subsequent pregnancies

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30
Q

How is postpartum psychosis managed?

A

Antipsychotic medication

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31
Q

What is the first line antidepressant in pregnancy?

A

Sertraline

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32
Q

What are the main risks of antipsychotics in pregnancy?

A

GDM / metabolic disturbance with olanzapine/quetiapine due to ^ cholesterol and glucose
Poor neonatal adaption syndorme
Agranulocytosis and seizures with clozapine

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33
Q

What congenital malformation is associated with lithium in pregnancy?

A

Ebstein’s cardiac abnormality

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34
Q

What is the therapeutic range for lithium?

A

0.4-1.0

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35
Q

What is the gold-standard mood stabiliser?

A

Lithium

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36
Q

What baseline tests do you need to do before initiating lithium?

A

FBC, U&E, TFT, ECG, BMI

Rule out pregnancy

37
Q

What monitoring is required with lithium treatment?

A

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
Q

What are the side effects of lithium treatment?

A

GI disturbance, tremor, polyuria, hair loss, acne

Chronic renal failure, thyroid dysfunction, diabetes insipidus, arrhythmia, reduced seizure threshold

39
Q

What are the signs of lithium toxicity?

A

Tremor, tiredness, slurred speech, ataxia, dizziness
Blurred vision, convulsions, delirium, syncope, hypernatraemia, arrhythmia (prolonged QT)
Seizures, oliguria, renal failure, seizure, coma

40
Q

What tests do you need before initiating sodium valproate?

A

FBC, LFT

LFTs also need to be monitored - don’t need to change unless transaminases TRIPLE

41
Q

What is the most important side effect of lamotrigine?

A

SJS and TEN

42
Q

What are the three main components of psychosis?

A

Hallucinations

Delusions

Thought disturbance

43
Q

What are differentials for psychiatric causes of psychosis?

A 
Schizophrenia
Schizoaffective disorder
Bipolar disorder
Severe depression
Dementia
Drug-induced bipolar
44
Q

What are differentials for organic causes of psychosis?

A 
Encephalitis
Delirium
Drug intoxication
Brain injury / tumour
Temporal lobe epilepsy
Neurosyphilis
AIDs
Huntington's disease
45
Q

What measurements should be done before initiating antipsychotics?

A

Weight, waist circumference, BMI
HR BP
ECG
Fasting glucose, HbA1c, lipids and prolactin
Assess nutrition and any movement disorders

46
Q

What is schizoaffective disorder?

A

Equal and simultaneous symptoms of schizophrenia and bipolar disorder
Can be predominantly manic / depressive / mixed

47
Q

What are the positive symptoms of schizophrenia?

A

Delusions, illusions, thought disorder
Paranoia, persecutory delusions, agitation
Voices heard in 3rd person, running commentary
Thought block
Flight of ideas, overvalued ideas

48
Q

What are the negative symptoms of schizophrenia?

A

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
Q

What is the management for catatonic behaviour?

A

Benzodiazepines first line

ECT gold standard

50
Q

Which two antipsychotics are most associated with hypercholesterolaemia?

A

Olanzapine and Quetiapine

51
Q

What are typical antipsychotics like haloperidol associated with?

A

Extrapyramidal side effects

Often used as single-use antipsychotics to control acute / violent behaviour rather than used in the long term

52
Q

Why is risperidone less commonly used now?

A

Highest risk of pyramidal side effects and hyperprolactinaemia

53
Q

What are the common side effects of olanzapine?

A

Weight gain
Sedation
Hypercholesterolaemia + hyperglycaemia
Hyperprolactinaemia

54
Q

What are the common side effects of quetiapine?

A 
Transaminitis
Orthostatic hypotension
Long QT
Hyperlipidaemia/hyperglycaemia
Weight gain
55
Q

Why is aripirazole popular to use in practise?

A

Less sedating
No QTc prolongation
Low extrapyramidal effects
Available in short and long acting IM preparations

56
Q

What are the side effects associated with clozapine use?

A

Agranulocytosis
Lowered seizure threshold - esp in combination with lithium
Sedation, weight gain, LFT derangement
Constipation, arrhythmia,
hyperprolactinaemia, hyperlipidaemia, hyperglycaemia

57
Q

What precautions must be taken with clozapine use?

A

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
Q

What are the symptoms of neuroleptic malignant syndrome?

A 
Hyperthermia, confusion
Hypertension
Hyperreflexia (difference to serotonin synd)
Muscle rigidity
Tremor and agitation
Sweating
Seizures
59
Q

How do you manage neuroleptic malignant syndrome?

A 
Stop medication
May need ICU
Active cooling
Benzodiazepine 
Dantrolene for rigidity
IV rehydration + diuresis
60
Q

What are signs of tardive dyskinesia?

A

Lip smacking, tongue protrusion
Hand movements
Pelvic thrusting

Managed by stopping anticholinergics and reducing antipsychotics
+ tetrabenzine, clonazepam and propranolol

61
Q

What are the symptoms of hyperprolactinaemia?

A 
Gynaecomastia
Galactorrhoea
Low libido
Menstrual dysfunction
Subfertility
62
Q

What are the 5 key principles of the mental health act?

A
  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
Q

What is section 2 of the MHA used for?

A

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
Q

What is section 3 of the MHA?

A

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
Q

What is section 4 of the MHA?

A

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
Q

What is section 5(2) of the MHA?

A

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
Q

What is a section 5(4)?

A

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
Q

What is a section 135?

A

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
Q

What is a section 136?

A

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
Q

What is a community treatment order?

A

Order stating that patients can be recalled to hospital or detained if not engaging with treatment in the community

71
Q

What are the two main types of bipolar disorder?

A

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
Q

What are the features of mania?

A

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
Q

How do you differentiate mania from hypomania?

A

Any psychotic symptoms = automatically mania
Hypomania generally less intense symptoms
Hypomania may lest for a shorter period of time

74
Q

How do you manage bipolar affective disorder?

A

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
Q

What are examples of mood stabilisers?

A

Sodium valproate
Lamotrigine
Carbamazepine
Lithium

76
Q

What are the 6 features of substance dependence?

A

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
Q

What can be used for opioid replacement and detoxification therapy?

A

Methadone
Buprenorphine
Lofexidine

Naltrexone can be used for relapse prevention

78
Q

Which two medications are used to prevent alcoholism relapse?

A

Acamprosate

Disulfiram

79
Q

What are symptoms of alcohol withdrawal?

A

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
Q

What are the key features of Wernicke’s encephalopathy?

A

Confusion
Ataxia
Ophthalmoplegia

81
Q

What are the features of Korsakoff’s syndrome?

A

Confusion
Anterograde and retrograde amnesia
Confabulation
Personality change

82
Q

What assessments can be used to assess a patient’s cognition?

A

ACE-III: assessment of attention, memory, fluency, language and visuospatial ability

MoCA: mini version of ACE-III

MMSE

4AT test

83
Q

What are the features of autism spectrum disorders?

A

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
Q

How are autism spectrum disorders diagnosed?

A

Diagnostic interviews with child and parents

May wish to observe child in normal daily environments to assess behaviour

85
Q

How are autism spectrum disorders managed?

A

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
Q

How is ADHD diagnosed?

A

Symptom profile
Quantitative Behaviour test
SNAP questionnaire

87
Q

What treatments are available for ADHD?

A

Methylphenidate (ritalin) = first line treatment
Amphetamine/dextroamphetamine (adderall) second line

Psychoeducation, behavioural therapies and school support

88
Q

What needs to be monitored in children having pharmacological treatment for ADHD?

A

Height, weight and B

Finals Revision (23 decks)

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