Psychiatry Flashcards
How is depression diagnosed?
ICD-11 criteria
(international classification of diseases)
Depression is;
“…concurrent presence of at least five out of a list of ten symptoms, which must occur most of the day,
nearly every day, for at least 2 weeks.
What questionnaire can be used to aid a diagnosis of depression?
Patient Health Questionnaire (PHQ)-9
9 questions
Max score - 27 (severely depressed)
Min score - 0
Issues and Side effects of SSRI’s
Issues:
Bleeding risk (PPI?)
Interactions (SJW/Tramadol - Serotonin Syndrome)
Hypersensitivity
Side effects:
Minor sedation
Dizziness
Anxiety
Anti-muscurinic (diarrhoea/constipation)
GI
Sexual Dysfunction
Hyponatraemia (elderly - PPI causes hyponatraemia aswell)
Suicidal Ideation
Medication options for Depression
- Consider previously successful drugs
first. *
1st Line – SSRI
2nd Line – Alternative SSRI
3rd Line - Mirtazapine (stimulates appetite) or SNRI or
Trazodone/Tricyclic (both very sedative)
Tricyclic are a worry due to potential for overdose and cardiac arrythmias (cause irreversible cardiac damage and management for trycyclic overdose is purely supportive)
2 common questionaires to assess anxiety:
GAD-7 (General Anxiety Disorder-7)
Hospital Anxiety and Depression Scale (HADS)
Annual Health Check for adults and children aged ___ or above with learning disabilities.
14
When starting an anti-psychotic a Patient’s B.P, pulse rate, HbA1c level, serum cholesterol level and lipid profile should all be checked at ____ weeks, then at ____ and then annually thereafter.
Patient’s weight should be checked weekly for the first ____ weeks, then at ____ weeks, then at one year and then annually thereafter.
Waist circumference should be measured _____.
12
one year
6
12
annually
What is metabolic syndrome? Which class of medications are likely to cause this?
- Essential hypertension
- Truncal Obesity
- Insulin resistance
- Low glucose tolerance
- Dyslipidaemia/Hypercholesterolaemia
*2nd generation antipsychotics*
______ is caused by vitamin B3 (niacin) deficiency and is characterised by _____, _____ and ____.
Pellagra is caused by vitamin B3 (niacin) deficiency and is characterised by Dementia, Dermatitis and Diarrhoea. (3Ds)
Other features include hair loss, sunlight sensitivity and glossitis (“beefy tongue”). If left untreated, this can lead to Death. Alcoholism and Crohn’s disease are both risk factors for Pellagra due to malnutrition/malabsorption.
The first-line pharmacological therapy for moderate to severe Alzheimer’s disease is _____, which can cause ______.
Memantine (NMDA receptor antagonist)
Constipation
If nutritional intake is resumed too rapidly after a period of relatively low caloric intake, the patient is at high risk of _____. Rapidly increasing insulin levels lead to shifts of ____, _____ and from extracellular to intracellular spaces. This is potentially fatal if refeeding is too rapid.
refeeding syndrome
remember PIMP
Potassium Insulin Magnesium and Phosphate
Symptoms of refeeding syndrome may include ____ , ____ and ____. Blood tests initially show hypophosphataemia and it is treated with phosphate supplementation.
oedema
confusion
tachycardia
Because of the resulting malnutrition, those with Anorexia Nervosa are predisposed to cardiac arrhythmias.
An ECG should always be performed in those admitted to hospital with Anorexia Nervosa, in outpatient treatment or in those with symptoms such as dizziness, fainting or light-headedness.
In the body’s attempts to reduce energy expenditure with minimal calorie intake, _____ and _____ are commonly seen, as well as a ______ . This increases the risk of a fatal arrhythmia such as Ventricular Fibrillation.
bradycardia and hypotension
prolonged QT interval
Paranoid schizophrenia, as with any psychotic disorder, is treated first-line with atypical antipsychotics such as _____ .
Risperidone or Olanzapine (dopamine receptor antagonists)
NICE recommends ____ for children and young people whose schizophrenia has not responded to adequate doses of at least two different antipsychotics used sequentially for 6-8 weeks.
Clozapine (shown to be the most efficacious anti-psychotic and so used as last resort)
There are a number of conditions that can mimic schizophrenia:
1. Substance induced psychotic disorder (commonly drugs of abuse, but can be iatrogenic e.g. steroids)
2. Organic psychosis caused by infection, brain injury and CNS diseases such as Wilson’s disease
3. Metabolic disorder such as hyperthyroidism and hyperparathyroidism
4. Dementia and depression can also co-occur with psychosis
Description of dementia, which presents with progressive impairment of ____ , _____ and ____.
IMPairment:
Intellect
Memory
Personality
What is the key distinguishing feature between Anorexia nervosa and bulimia nervosa?
BMI
with most guidelines using a BMI of 17.5 as a diagnostic feature of anorexia nervosa.
Most individuals with bulimia nervosa are in the normal weight range (BMI: 18.5 - 30).
Calluses on the back of the hand as a result of repetitive tooth induction from induced vomiting can be a feature of both bullimia nervosa and anorexia nervosa and is called ____ sign.
Russell’s
Common symptoms of opiate intoxication include:
Drowsiness
Confusion
Decreased respiratory rate
Decreased heart rate
Constricted pupils
Clozapine needs careful blood monitoring with:
Baseline:
FBC
CRP
Troponin-T level
(CRP and Troponin-T to be checked weekly for first six weeks).
Weekly FBC for
- first 18 weeks
- then fortnightly up to one year of treatment
- then four-weekly thereafter.
What is the most notable side effect to be aware of in patients taking anti-psychotics?
Which medication can be used as an alternative if this happens?
Antipsychotic medications commonly also produce ____ symptoms as side effects.
Hyperprolactinaemia
Aripiprazole (also a useful alternative if patient is putting on weight with other antipsychotics)
extrapyramidal
Antipsychotics can cause hyperprolactinaemia. Prolactin production can be stimulated by dopamine receptor antagonists such as Risperidone and many other antipsychotic medications. Hyperprolactinaemia in men can present with gynaecomastia, galactorrhoea, reduced libido and erectile dysfunction. Hyperprolactinaemia in women can present with galactorrhoea and menstrual dysfunction.
Treatment with the responsible antipsychotic should be stopped and alternative medications or adjuncts considered. Aripiprazole is one of the antipsychotics that does not raise prolactin as much as others, so is often a good alternative or adjunct.
The extrapyramidal symptoms include acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome.
If a patient is voluntarily in hospital and needs to be sectioned under the mental health act a section ____ can be issued by the doctor. This permits detainment for ____ hours for further assessment.
5(2)
72 hours
Sectioning under the Mental Health Act (MHA) is used for those over ____ years of age who will not be admitted voluntarily.
16 years
Common causes of delirium can be remembered using the mnemonic ______ :
DELIRIUMS
D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
E - Eyes, ears and emotional (reduced input)
L - Low Output state (MI, ARDS, PE, CHF, COPD)
I - Infection
R - Retention (of urine or stool)
I - Ictal
U - Under-hydration/Under-nutrition
M - Metabolic (Electrolyte imbalance, thyroid, wernickes
(S) - Subdural, Sleep deprivation
_____ is not disturbed in the early stages of dementia (in comparison with delirium which can cause cognitive decline in the context of fluctuating or altered ____ )
Consciousness X2
Patients with anorexia nervosa exhibit which bichemical abnormality?
Hypercholesterolaemia
The pathophysiology is unclear, however it is thought to be due to alterations in the metabolic pathway.
Tricyclic anti-depressants are a ____ line medication for depression. They are strongly associated with anti-cholinergic activity. Consequently, the common side effects include:
Second
Urinary retention
Drowsiness
Blurred vision
Constipation
Dry mouth
_____ is a rare but potentially fatal adverse effect of Clozapine.
Agranulocytosis
Agranulocytosis occurs in about 1% of patients taking clozapine. Neutropenia is seen in about 3%
____ is the antidepressant of choice in breastfeeding mothers.
Sertaline
_____ otherwise known as erotomania, is a delusional disorder in which the patient has a specific, fixed, false belief that someone else is in love with them.
De Clerambault’s syndrome
The patient is usually a woman and the person they are fixated upon is usually of a higher social status, despite only a brief or non-existent acquaintance. This is not normally any unusual behaviour or hallucinations accompanying the delusion.
Re-feeding is permitted under the ____ as if a physical problem is a result of a mental disorder - Anorexia Nervosa
MHA
A diagnosis of PTSD requires that symptoms are present for longer than ____ . The shorter duration and strong dissociative symptoms this patient describes are more in keeping with a diagnosis of .
a month
acute stress reaction
_____ such as _____ are first-line in the pharmacological treatment of adults who present with an episode of acute mania.
Antipsychotics
Olanzapine
Antipsychotics with mood-stabilising properties are used and alternatives include Haloperidol, Risperidone or Quetiapine.
Hyperprolactinaemia is a side effect seen in some patients prescribed antipsychotics, as they act as _____, stimulating the production of prolactin If the patient complains of clinical features of hyperprolactinaemia and blood results support this, it is necessary to stop the responsible agent (in this case Risperidone) and change to an alternative antipsychotic. _____ is one antipsychotic with a much lower risk of inducing hyperprolactinaemia.
dopamine receptor antagonists
Aripiprazole
______ such as Donepezil, _____ and ____ are recommended by NICE guidelines as options for managing mild to moderate Alzheimer’s disease.
Remember in Alzheimer’s there is a progressive loss of _____ neurons.
Acetylcholinesterase inhibitors
Galantamine
Rivastigmine
Cholinergic
NICE specifically advises against prescribing opiates in withdrawal, favouring either ____ or ____ management.
lofexidine
symptomatic
Parkinson’s disease is caused by build up of ____ starting in the substantia nigra and then progressing often to include the majority of the cerebral cortex.
alpha-synuclein
alpha-synuclein aggregates to form “lewy bodies” and so the pathophysiology is very similar in lewy body dementia.
NB - To distinguish between and parkinsons LBD - Determine the time bewtween dementia and movement symptoms. If they are within 12 months of eachother it is more likely a diagnosis of LBD.
Alzheimer’s disease is caused by an accumulation of ____ , and the ____ is also implicated.
Down Syndrome is caused by Trisomy 21, and the ____ is found on chromosome 21. The extra copy of APP leads to early onset beta-amyloid plaques.
Amyloid plaques
Tau protein
Amyloid precursor protein
_____ is used in the treatment of neuroleptic malignant syndrome; a complication of anti-psychotic use which presents with ______ and ______ .
Dantrolene (muscle relanxant)
Pyrexia
Rhabdomyolysis
Dantrolen mechanism of action: Depresses excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor 1, and decreasing intracellular calcium concentration. Ryanodine receptors mediate the release of calcium from the sarcoplasmic reticulum, an essential step in muscle contraction.
Clinical features of lithium toxicity
Coarse tremor
CNS disturbance including seizures, impaired co-ordination, dysarthria
Arrhythmias
Visual disturbance
____ is a rapid onset of confusion precipitated by alcohol withdrawal. It usually develops at around ____ after ceasing alcohol intake, and can last for several days.
Delirium tremens
72 hours
Clinical features
Symptoms usually peak on day 4-5. Symptoms include confusion, hallucinations (particularly visual hallucinations and tactile hallucinations (such as formication - the sensation of crawling insects on or under the skin), sweating, hypertension and (rarely) seizures.
Step 1 for all known presentations of Generalised Anxiety Disorder is to provide _____ and ______.
Psychoeducation and active monitoring
______ or ____ can be used as pharmacological support in the detoxification from opiates
Methadone
Buprenorphine
______ is a first generation H1 antagonist that also has ____ activity. It is able to cross the blood brain barrier and can lead to anti-depressant/anxiety effects.
In the elderly however, there is a high risk of inducing ____ or other anti-cholinergic actions such as ____ and ____ .
Chlorphenamine
anticholinergic
dry mouth
urinary retention
Unlike anorexia nervosa, sufferers of bulimia nervosa may have a normal _____.
BMI.
What is the first line pharmacological therapy of mild to moderate Alzheimer’s disease?
Acetylcholinesterase Inhibitors
Donepezil
Galantamine
Rivastigmine
When taken as an overdose, the metabolism of paracetamol results in a buildup of a toxic substance called _____.
NAPQI (N-acetyl-p-benzoquinone-imine).
NAPQI is inactivated by glutathione. In an overdose, glutathione stores are rapidly depleted, and NAPQI is left un-metabolised. It can cause liver and kidney damage.
Management of Paracetamol overdose:
If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoal
If ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level using** nomogram**
If ingestion 4-15 hours ago: Take immediate level and treat based on level
If staggered overdose or ingestion >15 hours ago: Start N-acetylcysteine immediately
Obtain following bloods:
FBC
Urea and Electrolytes
INR
Venous gas
Consider need for transfer to liver unit if blood tests are worsening
Symptoms of dementia?
Remember the 4 a’s for cognitive decline:
Amnesia
Anosmia
Apraxia
Aphasia
Non-cognitive:
Behavioral and psychological
Functional/Activities of daily living:
Bills cooking shopping etc.
