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Year 4 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

ICD-10 Criteria to diagnose schizophrenia

A

Duration of symptoms >1 month

At least one of:

  • Thought echo, insertion, withdrawal or broadcasting
  • Delusions of control, influence or passivity (clearly referred to body or limb movements or specific thoughts, actions or sensations- controlled by external influence, imposed on individual), and delusional perception
  • Hallucinatory voices giving running commentary on patient’s behaviour or discussing them between themselves, or other types of hallucinatory voices coming from some part of the body
  • Persistent delusions of other kinds that are culturally inappropriate or implausible

OR At least 2 of:

  • Persistent hallucinations in any modality
  • Neologisms- made up words
  • Catatonic behaviour- rigidity, posturing, negativism, waxy flexibility, excitement, stupor
  • Negative symptoms such as: marked apathy, poverty of speech, poverty of thought, blunting of affect, social isolation, poor self-care, and incongruity of emotional responses
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2
Q

Positive and negative symptoms of schizophrenia

A

Positive:

  • Perceptual disturbances- hallucinations
  • Delusions
  • Formal thought disorder (flgiht of ideas, neologisms, knight’s move thinking, thought blocking, circumstantial and tangential thinking…)

Negative:

  • Marked apathy
  • Poverty of speech
  • Poverty of thought
  • Blunting affect
  • Social isolation
  • Poor self-care
  • Incongruity of emotional response
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3
Q

Types of schizophrenia

A

Paranoid

  • Most common type
  • Dominated by presence of delusions and hallucinations
  • Absense of negative and catatonic symptoms, thought disorganisation not prominent
  • Better prognosis, later age of onset

Hebephrenic (disorganised)

  • Promient thought disorder, disturbed behaviour and speech, flat/incongruent affect
  • Delusions and hallucinations are short lasting/fleeting
  • Poorer prognosis than paranoid, earlier age of onset

Catatonic

  • Presence of one or more catatonic symptoms
  • Hallucinations and delusions less obvious

Simple

  • Insidious development of odd behaviour, social withdrawal, declining performance at work/academic
  • Clear symptoms are absent, difficult to identify reliably
  • Diagnosis of last resort after exclusion of other treatable conditions

Residual

  • One year of predominantly chronic negative symptoms, must be preceeded by at least one clear psychotic episode in the past
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4
Q

Treatment teams involved in schizophrenia

A

Depends on stage of the illness

  • First episode of psychosis or at risk of developing first episode- Early Intervention in Psychosis Team, for 14-65 y/o, duration of follow up is up to 3 years
  • Chronic psychotic illness- transferred to local Community Mental Health Team
  • Early stage or relapse- Crisis Resolution and Home Treatment (short term only)
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5
Q

Biological management of schizoprehnia

A

Antipsychotics

  • 1st line- Olanzapine (atypical/2nd gen). preferably oral
  • 2nd line- review diagnosis, check concordance with medication… try another 2nd gen: risperidone, quetiapine, clozapine, ariprazole. Can consider depot if patient adamant they dont want oral

Benzodiazepines

Short-term use only to manage acutely disturbed behaviour, no more than 4 weeks to avoid risk of dependence. more common in inpatient setting

  • Lorazepam, Clonazepam, Diazepam
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6
Q

Definition of treatment resistent schizophrenia and management

A

Failure to respond to adequate trial (at least 6 weeks) of at least 2 antipsychotics, at least one being 2nd gen

  • Review diagnosis
  • Check patient’s concordance with medication
  • Consider clozapine- only antipsychotic shown to be more efficacious than all others
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7
Q

Types of depot injections if patients refuse oral antipsychotics

A

Patient’s willingness to accept any oral medication prior to starting depot has an impact on which choice of depot for them

Those with poor oral compliance should be considered for once monthly IM anti-psychotic depot injection

Two types:

  • Those that require a test dose- Clopixol (zulcopenthizol deconate) and Depixol (flupenthixol decanoate). These are 1st generation depot antipsychotics. Dose is needed to determine sensitivity of patient to extrapyramidal side effects
  • Those that require initial loading with the oral equivalent- aripiprazole depot, risperidone depot. Do not give clozapine as a depot
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8
Q

Define metabolic syndrome

A

Risk of metabolic syndrome with 2nd generation antipsychotics

  • Essential hypertension
  • Truncal obesity
  • Insulin resistance (hyper-insulinaemia)
  • Low glucose tolerance
  • Dyslipidaemia
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9
Q

Monitoring antipsychotics in general and dates

A

Before starting, check: weight, waist circumference, BP, pulse, ECG, HbA1c, cholesterol levels, lipid profile, serum prolactin

For weight- weekly for first 6 weeks, then at 12 weeks (3 months), 1 year, then annually

BP, pulse, HbA1c, cholesterol, lipids- 12 weeks (3 month), 1 year, then annually

Waist circumference- annually

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10
Q

Monitoring clozapine

A

Baseline- FBC, CRP, Troponin-T levels

FBC- weekly for first 18 months, then fortnightly up to 1 year, then 4 weekly. risk of agranulocytosis

CRP and troponin-T- weekly for first 6 weeks. risk of myocarditis

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11
Q

Side effects of clozapine

A
  • Agranulocytosis
  • Sedation- split up dose so larger one at night, smaller in morning
  • Hypersalivation- antimuscarinic medication e.g. hyoscine hydrobromide 1st line, pirenzepine 2nd line
  • Constipation- stool softeners, movicol/doscusate/sennna
  • Increased appetite- difficult to manage
  • Reduced seizure threshold
  • Myocarditis
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12
Q

Explain who is needed in a Mental Health Act assessment

A
  • Approved Mental Health Professional (AMHP)
  • Psychiatrist on-call (consultant or SpR)- they will be Section 12(2) approved
  • Section 12(2) doctor (usually independent of the mental health trust, can be patient’s GP)

At least one of the two doctors involved in the Mental Health Act assessment must be approved under Section 12(2) of the Mental Health Act 1983

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13
Q

Explain Section 12, Section 3, Section 136 of the Mental Health Act 1938

A

Section 12- assessment section (up to 28 days). Used when person is not previously known to mental health services and requires assessment of mental state in hospital

Section 3- treatment section (up to 6 months, then can be renewed for up to another 6 months- then every 12 months thereafter). Person has established mental disorder

Section 136- police detaining power, valid for up to 24 hours. Allows police officer to remove individual from public place to place of safety for assessment due to concerns about their mental state and risk to self and/or others/from others.

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14
Q

Explain what a community treatment order is

A

Used when necessary for the patient’s health or safety or for the protection of others to continue to receive treatment after their discharge from the hospital

Seeks to prevent patients with mental disorder becoming “revolving door” patients

Conditions are attached to it e.g. agree to take one’s prescribed psychotropic meds in the community, agree to engage with one’s care-coordinator on a regular basis in the community, and make oneself available for medical examination with the community responsible clinician as and when required

CTO lasts up to 6 months initially, then extended for further 6 months, and every 12 months thereafter

Any patient on CTO may be recalled to hospital for up to 72 hours if they fail to adhere to any of their stated conditions and evidence of deterioration in their mental state

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15
Q

Clinical features of unipolar depression

A

Symptoms present for at least 2 weeks (for diagnosis)

3 core features: low mood, anhedonia, anergia

Other features:

  • Sleep disturbance
  • Anorexia
  • Emotional unreactivity
  • Somatic symptoms- e.g. early morning waking, changes in appetite and weight
  • Suicidal thoughts
  • Memory problems
  • Loss of self-confidence
  • Thoughts of self harm
  • Loss of libido
  • Reduced concentration and attention
  • Feelings of guilt, hopelessness, worthlessness, helplessness
  • Psychotic symptoms (only in severe depressive episodes)
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16
Q

Categorisation of mild, moderate and severe depression

A

Mild- 2 core symptoms + 2 other

Moderate- 2 core + 4 other

Severe- 3 core + 5+ other symptoms

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17
Q

Biological management of depression

A
  • 1st- Start with SSRI antidepressant- typically sertraline, fluoxetine, citalopram
    • Assess within 2 weeks , increase dose if no response after 3-4 weeks (check concordance)
    • If no response, try alternative SSRI
  • 2nd- Use SNRI if no response to first- venlafaxine, duloxetine
    • If no response, refer to secondary care for specialist opinion
    • Could try mirtazapine- helps with sleep disturbance (causes drowsiness) and appetite disturbance (is an appetite stimulant so causes weight gain)
    • Then combination: Venlafaxine + Mirtazapine OR SSRI + Mitrazapine
    • Lithium carbonate can be added in- helps reduce suicidality
  • Augment antidepressant with an antipsychotic (quetiapine, risperidone or aripiprazole)
  • Avoid MAO inhibitors (tyramine-containing foods can provoke hypertensive crisis)
  • Avoid tricyclic antidepressants (cardiotoxic in overdose and poorly tolerated)
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18
Q

Role and indications of electroconvulsive therapy

A

Indications:

  • 1st line in psychotic depression
  • Catatonia
  • Schizophrenia
  • Prolonged or severe manic epiosde
  • Difficult to treat depression
19
Q

Reviewing patients on antidepressants, and duration of treatment

A

For those considered to be at increased risk of suicide:

  • Initial review
    • Within 1 week for those <30 who have been started on antidepressant
    • Within 2 weeks for anyone >30
  • Subsequent reviews every 2-4 weeks for first 3 months, and if response is good, longer review intervals can be considered

Duration of treatment:

  • Continue antidepressants for at least 6 months after resolution of symptoms/single depressive episode
    • Cannot discontinue abruptly
    • Symptoms can worse in initial 2 weeks
  • Continue for 2 years- for those with recurrent depressive episode
20
Q

Risk factors and protective factors for suicide

A

Risk factors for suicide:

  • Male
  • Age > 45 years
  • Unemployed
  • Divorced, widowed or single
  • Physical illness
  • Mental disorder present
  • Substance misuse
  • Previous suicide attempt
  • Family history of mental disorder
  • Family history of suicide attempt

Protective factors:

  • Positive social support
  • Spirituality/religion
  • Sense of responsibility to family
  • Children in home or pregnant spouse
  • Life satisfaction
  • Reality testing ability
  • Positive problem solving skills
  • Positive coping skills
  • Positive therapeutic relationship
21
Q

Management of a suicidal patient

A

Through history, evidence of illicit substance use or alcohol abuse, MSE and formulate risk assessment

4 management options:

  • Discharge with advice to be reviewed by the GP within 2 weeks
  • Discharge with referral made to local CMHT to monitor patient’s mental health
  • Discharge with follow-up from crisis team (can visit daily if required). May refer to the CMHT for ongoing follow-up
  • Admission to psychiatric inpatient unit- either voluntarily or detained under the Mental Health Act 1983 (usually section 2- not previously known to mental health services and no established mental health diagnosis)
22
Q

Definition of bipolar affective disorder (manic depression)

A

Periods of profound depression alternate with periods of mania (excessively elevated and/or irritable mood) or hypomania (milder form of mania)

23
Q

Characterising between mania and hypomania

A
  • Mania- disturbance affects occupational and social functioning, or symptoms for 7 days or less if hospital admission is necessary. can have psychotic symptoms (delusions of grandeur, hallucinations)
  • Hypomania- last at least 4 days, not severe enough to interfere with social/occupational functioning, require hospital admission. shares symptoms with mania, but evident to lesser degree
24
Q

Clinical feautres of mania

A

Mood:

  • Elevated mood, irritable

Speech and thought

  • Pressured speech “flight of ideas”
  • Racing thoughts
  • Poor attention

Behaviour

  • Insomnia
  • Loss of inhibitions: sexual promiscuity, overspending, risk-taking
  • Increased appetite
  • Increased self-esteem- gradiosity, overfamiliarity
  • Disruption of work, usual social activities and family life
25
Q

Management of episode of acute mania

A
  • Stop antidepressant
  • Start oral antispsychotic- Olanzapine, Quetiapine, Risperidone. consider depot if patient wont accept oral
  • Start benzodiazepine e.g. Diazepam 5mg TDS if patient is agitated and distressed
  • Consider hypontic e.g. Zopiclone to ensure good quality sleep
  • Once episode treated consider initation of oral mood stabiliser e.g. Lithium Carbonate or possibly Carbamazepine
26
Q

Most effective treatment for bipolar depressive episodes

A
  • Olanzapine + fluoxetine
  • Lithium carbonate also effective- mood stabiliser
27
Q

Prophylaxis in bipolar affective disorder

A

Consider the initiation of mood stabiliser after remission of manic episode

  • 1st line for mood stabilisation- Lithium carbonate or Depakote (must not be used in women of childbearing potential)
  • 2nd line- Carbamezapine
  • Lamotrigine- in those more prone to bipolar depressive episodes rather than manic/hypomanic episodes
28
Q

Side effects of lithium, and signs and symptoms of lithium toxcicity

A

Side effects:

  • Polydipsia
  • Polyuria
  • Weight gain
  • Peripheral oedema
  • Fine resting tremor
  • Worsening or precipitation of skin complaints

Signs and symptoms of lithium toxicity:

  • Level of 1.5-2.0 mmol/L: N+V, apathy, coarse tremor, ataxia, muscle weakness
  • Level >2.0mmol/L: nystagmus, dysarthria, impaired consciousness, hyperactive tendon reflexes, oliguria, hypotension, convulsions, coma
29
Q

Treatment of acute lithium toxcicity

A

Supportive management only

Stop Lithium Carbonate abruptly

Ensure adequate hydration with IV fluids if necessary

Monitor renal function and electrolyte balance

Haemodialysis may be required if pt goes into acute renal failure

30
Q

Things that precipitate lithium toxcicity

A
  • Drugs: NSAIDs, Diuretics (especially thiazide), ACE-inhibitors
  • Dehydration
  • Renal failure
31
Q

Monitoring lithium levels

A
  • It has a narrow therapeutic range of 0.4-1.0mmol/L
  • Check serum levels 12 hours post-dose
  • Monitor levels weekly and everytime the dose has changed, until it has stabilised
  • Once established, check every 3 months
  • Check thyroid and renal fucntion every 6 months
32
Q

What are the Cluster A “Odd or Eccentric” personality disorders

A
  • Paranoid
    • Overly sensitive
    • Questions loyalty of those around them
    • Reluctant to confide in others
    • Thinks others are exploiting, harming or deceiving them
  • Schizoid (avoid)
    • Emotionally cold
    • Indifferent to praise or criticism
    • Prefers to be alone, doesnt like relationships
    • Few interests, low libido
  • Schizotypal (atypical)
    • Ideas of reference
    • Odd beilefs or magical thinking
    • Perceptual disturbances
    • Lack of close friends
    • Odd speech
33
Q

What are the Cluster B “Dramatic, Emotional, Erratic” personality disorders

A
  • Antisocial/Dissocial
    • Repeated unlawful or aggressive behaviour
    • Lack or remorse
    • Doesn’t feel guilt
    • Reckless irresponsibility, deceitful
  • Bordeline (Emotionally Unstable)
    • Unstable, intense interpersonal relationships
    • Unstable self image
    • Recurrent suicidal behaviour
    • Impulsivity in potentially self damaging area
    • Difficulty in controlling temper
    • Quasi (transient) psychotic symptoms- occur when individual is highly distessed and/or in a state of crisis. include paranoia, voice hearing, visual hallucinations
  • Histrionic
    • Inappropriate sexual seductiveness
    • Need to be centre of attention
    • Shallow expression of emotions
  • Narcissistic
    • Grandiose sense of self-importance
    • Need for admiration
    • Fantasies of unlimited success, power or beauty
    • Lack of empathy
34
Q

What are the Cluster C “Anxious and Fearful” personality disorders

A
  • Obsessive-Compulsive
    • Occupied with details, rules, lists
    • Extremely dedicated to work and efficiency
    • Perfectionism and control
    • Overly cautious
    • Rigid about etiquettes of morality, ethics, or values
  • Avoidant
    • Avoidance of activities due to fears of criticism or rejection
    • Fearful of ridicule, inadequancy
    • Sees themselves as inept and inferior to others
  • Dependent
    • Excessive need to be cared for
    • Lack of initiative
    • Submissive, clingy, fear of separation
35
Q

Pharmacological management of EUPD

A

No psychotropic medication is licensed for use in EUPD

Psychotropic medication should be used to treat comorbid mental disorders like depression, anxiety..

Benzodiazepines- used short term (no longer than a week) if patient is in crisis

36
Q

Psychological therapy options for EUPD

A
  • Dialectical behavioural therapy (DBT)- uses combination of cognitive and behavioural therapies
  • Mentalisation-based therpay (MBT)- focuses on allowing individual to better understand what is going on in their mind and in minds of others
  • Therapeutic community (TC)- residential form of therapy, where individual stays for weeks or months. community is run as a “democracy”
37
Q

Guidelines on starting antipsychotic/psychotropic medication in patients with challenging behaviour

A

Start if:

  • Psychological or other interventions do not produce change in agreed time
  • Treatment for co-existing mental or physical illness has not led to reduction in behaviour or
  • Risk to person or others is very severe .e.g violence, aggression, or self-injury

Should only offer in combination with psychological or other interventions

Risperidone- used more frequently up ot 6 weeks in children with severe aggression and autism

Chlorpromazine and trifluoperazine- licensed for short-term use, not often used in practice

38
Q

Principes of Positive Behavioural Support (PBS)

A

This is the preferred approach for preventing and supporting challenging behaviours

Principles include:

Use of person-centred, values-based approach

Helps to ensure person is living the best life they possibly can

Helping people achieve meaningful outcomes- better health, relationships, integration

Helps reduce use of physical interventions and restrictive practices

39
Q

Examples of typical (1st generation) antipsychotics, including side effects

A

Block D2 receptors, not selective for any of the 2 dopamine pathways

Haloperidol, Chlopromazine

Extrapyramidal side effects:

  • Parkinsonism
  • Acute dystonia- sustained muscle contraction- totyicollis, oculogyric crisis (prolonged involuntary upward deviation of the eyes)
  • Akathisia- severe restlessness
  • Tardive dyskinesia- can present as chewing, jaw pouting or excessive blinking
40
Q

Examples of atypical (2nd generation) antipsychotics, including side effects

A

Block both D2 and 5-HT2A receptors (serotonin receptors)- serotonin inhibits dopamine release

Clozapine, olanzapine, risperidone, quetiapine, aripiprazole (most tolerable side effect profile)

Side effects- metabolic side effects:

  • Weight gain, hyperglycaemia, diabetes mellitus, hyperlipidiemia, hypercholesterolaemia
  • Extrapyramidal side-effects and hyperprolactinaemia less common
  • Clozapine is only atypical that can cause agranulocytosis
41
Q

Examples of SSRIs, their side effects, and discontinuation symptoms

A

Sertraline, citalopram (likely to lengthen QT interval), fluoxetine

Side effects:

  • GI symptoms
  • Increased risk of GI bleeding, PPI should be precribed if also taking NSIADs
  • Hyponatraemia (rare)

Discontinuation symptoms:

  • GI symptoms- pain, cramping, diarhoea, vomiting
  • Restlessness, difficulty sleeping
  • Increased mood change
42
Q

Describe serotonin syndrome

A

Symptoms seen within 24 hours of starting/changing therapy and resolves after few days of treatment

Causes are serotonergic agents e.g. SSRIs, ecstasy, amphetamines

Features:

  • Hyperreflexia, myoclonus, rigidity
  • Hypertemia, sweating, confusion
43
Q

Examples of SNRIs (serotonin and noradrenaline reuptake inhibitors)

A

Venflaxaine

Duloxetine

Year 4 (9 decks)

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