Psychiatry Flashcards
1
Q
What are the core symptoms of depressive disorder?
A
- Anhedonia- Lack of interests in things which were previously enjoyable to the patient
- Low Mood- Present for ≥2 wks
- Lack of Energy - AKA anergia
2
Q
What are the cognitive symptoms of depressive disorder?
A
- Lack of Concentration - ↓ Ability to think / concentrate
(Nearly everyday) - Negative Thoughts
Beck’s cognitive triad:
i. Negative views about oneself (Feels worthless)
ii. Negative views of the world (Unfair world)
iii. Negative views of the future (Hopeless future) - Excessive Guilt - Feeling of worthlessness / excessive or inappropriate guilt (Nearly everyday)
- Suicidal Ideation
Recurrent:
i. Thoughts of death
ii. Suicidal ideation without a specific plan
3
Q
What are the biological symptoms of depressive disorder?
A
- Diurnal Variation in Mood (DVM) - Low mood more pronounced during certain times of the day (Usually morning)
- Early Morning Wakening (EMW)- Wakening up to 2 hrs earlier than usual
* May have hypersomnia (Excessive sleep) in atypical depression - Loss of Libido - ↓ Sexual drive
- Psychomotor Retardation - Slow speech + Slow movement
- Weight Loss & Loss of Appetite-
i. Sig. weight lost (When not dieting)
/↓ Appetite nearly everydayii. In atypical depression; may have:
↑ Weight
↑ Appetite
4
Q
What are the psychotic symptoms of depressive disorder?
A
- Hallucinations - Usually second person auditory hallucinations
2. Delusions - Usually: o Hypochondrical o Guilt o Nihilistic o Persecutory
5
Q
What is the criteria to fulfil for positive diagnosis fo depressive disorder?
A
- Present for ≥2 wks and represent a change from normal
2. NOT secondary to: Effects of drug / alcohol misuse Medication Medical disorder Bereavement
- Significant distress and/or impairment of social, occupational or general functioning
6
Q
What is the ICD-10 classification of depression?
A
Mild depression = 2 core symptoms + 2 other symptoms
Moderate depression = 2 core symptoms + 3–4 other symptoms
Severe depression = 3 core symptoms + ≥4 other symptoms
Severe depression with psychosis = 3 core symptoms + ≥4 other symptoms + psychosis
7
Q
What is recurrent depressive disorder?
A
A recurrent depressive episode = When a patient has another depressive episode after their first
8
Q
What is seasonal affective disorder?
A
Characterized by depressive episodes recurring annually at the same time each year:
o Usually during the winter months!!!
9
Q
What is masked depression?
A
• A state in which depressed mood NOT particularly prominent
• But other features are prominent; eg:
o Sleep disturbance
o DVM
10
Q
What is dysthymia?
A
Depressive state for ≥2 yrs
+ BUT DOESN’T meet the criteria for:
Mild depressive disorder
/Moderate depressive disorder
/Severe depressive disorder
+ NOT the result of a partially treated depressive illness!!!
11
Q
What is cyclothymia?
A
Chronic mood fluctuation over ≥2 yrs
With episodes of elation & depression
BUT these episodes DON’T fulfill criteria of hypomanic / depressive disorder
12
Q
What are the differentials for depression?
A
- Other mood disorder - BPD
- secondary - Hypothyroidism , anaemia, diabetes (anergia)
- secondary to Substance abuse
- Secondary to psychiatric disorder
Recurrent depressive disorder
Masked depression
Dysthymia
13
Q
What is the broad approach for the management of depressive disoder?
A
A bio-psychosocial approach
14
Q
How is mild-moderate depression managed?
A
- Watchful waiting (reassess patient in 2wks)
- Self- help programs
- Computerised cognitive behavioural therapy (CBT)
- Physical activity programme
Antidepressants - not the 1st line for mild depression unless:
i. Depression has lasted a long time ii. Past Hx of moderate - severe depression iii. Failure of other interventions iv. Depression complicates care of other physical health problems
15
Q
What are the circumstances where antidepressants are prescribed in mild-moderate depression?
A
Antidepressants - not the 1st line for mild depression unless:
i. Depression has lasted a long time typically at least 2 years ii. Past Hx of moderate - severe depression iii. Failure of other interventions iv. Depression complicates care of other physical health problems
16
Q
How is moderate-severe depression managed?
A
• Suicide risk assessment (Performed on ALL patients)
• Psychiatry referral if: o High suicidal risk o /Severe depression o /Recurrent depression o /Unresponsive to initial Rx
• Antidepressants: o 1st line = SSRI (Eg: Citalopram) o Other choices include: TCAs SNRIs MAOIs (Only prescribed by specialist)
• Adjuvants; may be augmented with:
o Lithium
o /Antipsychotics
- Psychotherapy (CBT or IPT)
- Social support
- ECT
17
Q
How long do antidepressants need to taken for depression?
A
1st episode - Continue for 6mths after resolution
2nd episode - Continue for 2 yrs after resolution
Have had multiple severe episodes - Long term
18
Q
What are the indications for electro-convulsive therapy for depression?
A
o Acute Rx of severe depression which is life-threatening
o Rapid response required
o Depression + Psychotic features
o Severe psychomotor retardation / Stupor
o Failure of other Rx
19
Q
What is Cotard syndrome and what is it usually associated with?
A
• Affected patients believe that they (/Some parts of their body) is dead / non-existent
Associated with -
• Severe depression
• Psychotic disorders
20
Q
How is depression diagnosed?
A
Diagnostic questionnaires-
• PHQ-9
• HADS (Hospital Anxiety and Depression Scale)
• Beck’s depression inventory
21
Q
What tests are required to rule out secondary causes of depression?
A
Blood tests: o FBC (Anaemia?) o TFTs (Hypothyroidism?) o U&Es (Biochemical abnormalities?) o LFTs (Biochemical abnormalities?) o Ca2+ (Biochemical abnormalities?) o Glucose (Diabetes? – Can cause anergia)
Imaging:
MRI/Ct scan required when -
1. Atypical presentation or examination
2. Features suggest intracranial lesion - unexplained headache, personality change
22
Q
What are the diagnostic clinical features of mania and how is it diagnosed?
A
- Grandiosity (↑ Self-esteem)
- ↓ Sleep
- Pressure of speech
- Flight of ideas
- Distractibility
- Psychomotor agitation (Restlessness)
- Reckless behaviour (Eg: Spending sprees, reckless driving)
- Loss of social inhibitions (Hence inappropriate behaviour)
- ↑ Sexual energy
Mania / Hypomania requires presence of 3 out of 9 symptoms of above
23
Q
What is the criteria for hypomania?
A
- Mildly elevated mood / irritable mood for ≥4 d
- Symptoms of mania (BUT < severe)
- NO severe disruption of work & social life:
But may have considerable disruption - Partial insight may be preserved
24
Q
What is the criteria for mania without psychosis?
A
- Symptoms present for >1 wk
- Symptoms of mania (BUT > severe than hypomania)
- Complete disruption of work & social activities
- May have:
- Grandiose ideas (NOT delusion yet!)
- Excessive spending (Lead to debts)
- Sexual disinhibition
- ↓ Sleep (Exhaustion)
25
What is the criteria for mania with psychosis?
1. Severely elevated / Suspicious mood
+ Psychotic features; eg:
o Grandiose delusion
o Persecutory delusion
o Auditory hallucinations (Mood congruent)
2. May have signs of aggression
26
What is the criteria for diagnosing bipolar affective disorder?
To diagnose bipolar affective disorder:
≥2 Episodes of a person’s mood disorder (Depressive / Mania / Hypomania)
+
One of the episode MUST be mania / Hypomania
27
What is Bipolar I ?
Involves periods of severe mood episode from mania to depression
Mania
+
Depression
28
What is Bipolar II ?
Milder form of mood elevation
Involves milder episodes of hypomania that alternate with periods of severe depression
Hypomania
+
Severe Depression
29
What is Rapid cycling?
>4 mood swings in 12mth period (With NO intervening asymptomatic period)
Poor prognosis
30
What are the differentials for BPAD?
1. Mood disorders: hypomania, mania, mixed episode, cyclothymia.
2. Psychotic disorders: schizophrenia, schizoaffective disorder.
3. Secondary to medical condition: hyper/hypothyroidism, Cushing’s disease, cerebral tumour (e.g. frontal lobe lesion with disinhibition), stroke.
4. Drug related: illicit drug ingestion (e.g. amphetamines, cocaine), acute drug withdrawal, side effect of corticosteroid use.
5. Personality disorders: histrionic, emotionally unstable
31
What are the tests done for Mania/BPAD?
• Self-rating scales (Eg: Mood Disorder Questionnaire)
Blood Tests
• FBC (Routine)
• TFTs:
o Hyper/hypothyroidism
• U&Es (Baseline renal Fx with view to starting Li)
• LFTs (Baseline hepatic Fx with view to starting mood stabilizers)
• Glucose
• Ca2+ (Biochemical disturbances can cause mood symptoms)
* Urine drug test (Illicit drugs can cause manic symptoms)
* CT Head (To rule out SOL that may cause manic symptoms eg: Disinhibitions)
32
What does the management of BPAD other than drugs and pshysocial mx involve?
• Full risk assessment:
Suicidal ideation
Risk to self (Eg: Financial ruin from overspending)
• Driving:
o DVLA has clear guideliens abt driving when manic / hypomanic / severely depressed
• Mental Health Act; needed if:
o Patient is violent
o /Pose a risk to self
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• Hospitalization will be required if:
o Reckless behaviour causing risk to patient or others
o Sig. psychotic symptoms
o Impaired judgement
o Psychomotor agitation
```
33
What is the management of acute manic episode/ mixed episode
• Consider stopping Antidepressants + Offer antipsychotics
```
• 1st line = An antipsychotic; eg:
o Olanzapine
o Risperidone
o Quetiapine
(Haloperidol also effective)
```
Offer 2nd antipsychotic if the 1st one:
NOT effective
/Poorly tolerated
Antipsychotics have rapid onset of action (Compared to mood stabilizers): - So used in severe mania
```
• If 2nd antipsychotic doesn’t work: Add Mood stabilizer (2nd line):
o Lithium (Preferred)
o If Li not suitable = Valproate
```
• ECT (For severe mania that doesn’t respond to other Rx)
Benzodiazepines may be required to:
Aid sleep and ↓ Agitation
• Rapid transquilization may be required with:
o Haloperidol
+//Lorazepam
DONT OFFER LAMOTRIGINE!
34
When are lithium levels to be measured in BPAD pateints?
Sample should be taken 12hrs post dose, after that weekly for 4 weeks
once level established, lithium blood level should 'normally' be checked every 3 months
35
What are the features of psychosis?
Reality is distorted with:
1. Delusions
2. Hallucinations
3. Thought disorder
36
What are the non-organic causes of psychosis?
1. Schizophrenia
2. Schizotypal disorder
3. Schizoaffective disorder
4. Acute psychotic episode
5. Mood disorders with psychosis
6. Drug-induced psychosis
7. Delusional disorder
8. Induced delusional disorder
9. Puerperal psychosis
37
What are the non-organic causes of psychosis?
1. Drug-induced psychosis -Alcohol, cocaine, amphetamine, methamphetamine, MDMA, mephedrone, cannabis, LSD, psilocybins (e.g. magic mushrooms), ketamine
2. Iatrogenic (medication) -levodopa, methyldopa, steroids, antimalarials.
3. Complex partial epilepsy
4. Delirium
5. Dementia
6. Huntington’s disease
7. Systemic lupus erythematosus
8. Syphilis
9. Endocrine disturbance, e.g. Cushing’s syndrome Metabolic disorders including vitamin B12 deficiency and porphyria
38
What is the most common type of schizophrenia?
Paranoid schizophrenia
39
What are the 5 positive symptoms (the acute syndrome) of schizophrenia?
1. Delusions - persecutory, grandiose, nihilistic, reference, or religious
2. Hallucination - Third person running commentary
3. Formal thought disorder
4. Thought interference - thought insertion, withdrawal and broadcast
5. Passivity phenomenon - action and feeling influenced by external force
Mnemonic: Delusions Held Firmly Think Psychosis
40
What are Schnieder's first rank symptoms of schizophrenia?
1. Delusional perception - A new delusion that forms in response to a real perception without any logical sense, e.g. ‘the traffic light turned red so I am the chosen one.’
2. Third person auditory hallucinations: usually a running commentary.
3. Thought interference - thought insertion, withdrawal and broadcast
4. Passivity phenomenon
If one or more are present, are strongly suggestive of schizophrenia
41
What are the negative symptoms (the chronic syndrome) of schizophrenia?
1. Avolition (↓ motivation): Reduced ability (or inability) to initiate and persist in goal-directed behaviour.
2. Asocial behaviour: Loss of drive for any social engagements.
3. Anhedonia: Lack of pleasure in activities that were previously enjoyable to the patient.
4. Alogia (poverty of speech): A quantitative and qualitative decrease in speech.
5. Affect blunted: Diminished or absent capacity to express feelings.
6. Attention (cognitive) deficits: May experience problems with attention, language, memory
42
How is schizophrenia diagnosed according to ICD10?
Group A:
A. Thought echo/insertion/withdrawal/ broadcast.
B. Delusions of control, influence or passivity phenomenon.
C. Running commentary auditory hallucinations.
D. Bizarre persistent delusions.
Group B:
E. Hallucinations in other modalities that are persistent.
F. Thought disorganization (loosening of associations, neologisms, incoherence).
G. Catatonic symptoms.
H. Negative symptoms.
At least one very clear symptom from Group A (A–D) or two or more from Group B (E–H) for at least 1 month or more
43
What are the investigations to perform for schizophrenia?
Blood tests:
1. FBC (anaemia, infection)
2. TFTs (thyroid dysfunction can present with psychosis)
3. Glucose or HbA1c (as atypical antipsychotics can cause metabolic syndrome)
4. Serum calcium (hypercalcaemia can present with psychosis)
5. U&Es and LFTs (assess renal and liver function before giving antipsychotics)
6. Cholesterol (as atypical antipsychotics cause metabolic syndrome)
7. Vitamin B12 and folate (deficiencies can cause psychosis).
Urine drug test: Illicit drugs can cause and exacerbate psychosis
ECG: Antipsychotics cause prolonged QT interval
CT scan: To rule out organic causes such as space-occupying lesions
EEG: To rule out temporal lobe epilepsy as possible cause of psychosis
44
How is schizophrenia managed biologically ?
1st line : Second generation/ atypical antipsychotics - Risperidone or Olanzapine
Interchange drug if not tolerated or effective after 2-3 weeks of assessing
2nd line : If not effective - Clozapine - treatment resistant schizo
Compliance issues - use depot formulations (1st or 2nd line)
Adjuvants:
1. Benzodiazepines can provide short-term relief of behavioural disturbance, insomnia, aggression and agitation.
2. Antidepressants and lithium can be used to augment antipsychotics.
ECT - patients who are resistant to pharmacological agents. Effective for catatonic schizophrenia.
45
How is schizophrenia managed phycologically and socially ?
Psychologically:
1. CBT
2. Family intervention - to reduce high levels of expressed emotions
3. Art therapy
4. Social skill training
Socially:
1. National support groups - Rethink and SANE - rehabilitation back into the community.
2. Peer support - peer support worker -recovered from psychosis or schizo
3. Supported employment programmes
46
What is schizotypal disorder?
Also known as latent schizophrenia
it is characterized by eccentric behaviour, suspiciousness, unusual speech and deviations of thinking and affect that is similar to those suffering from schizophrenia.
These individuals however, do not suffer from hallucinations or delusions.
There is an increased risk of schizotypal disorder in those who have first-degree relatives with schizophrenia.
47
What is acute and transient psychotic disorders?
A psychotic episode presenting very similarly to schizophrenia but lasting <1 month and so not meeting the criteria for schizophrenia.
48
What is schizoaffective disorder?
1. Characterized by both symptoms of schizophrenia and a mood disorder (depression or mania) in the same episode of illness
2. The mood symptoms should meet the criteria for either a depressive illness or a manic episode together with one or two typical symptoms of schizophrenia.
Schizophrenia + depression/mania
49
What is persistent delusional disorder?
The development of a single or set of delusions for a period of
at least 3 months in which the delusion is the only, or the most prominent, symptom with other areas of thinking and functioning well preserved, unlike in schizophrenia
The content of the delusion is often persecutory, grandiose or hypochondriacal in nature. The onset and content of the delusion is often related to the patient’s life situation.
Symptoms often respond well to antipsychotics.
50
How do you manage an acute case of schizophrenia?
Non-pharmacological de-escalation therapy
IM/Oral lorazapam
51
What is the diagnostic criteria for general anxiety disorder?
A. A period of atleast 6mths with prominent tension, worry and feelings of apprehension about everyday events and problems
B. Atleast four of the following symptoms with at aleast one symptoms of autonomic arousal: palpitation, sweating, shaking/tremor, dry mouth
Other symptoms: tension in muscles, tremors, concentration difficulty, headache, energy loss, restlessness, startled easily, sleep disturbances
52
What is the management of general anxiety disorder involve?
NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.
step 4: highly specialist input e.g. Multi agency teams
53
Which step is drug intervention used in general anxiety disorder and what drugs are used?
Step 3: high intensity psychological interventions (CBT/ applied relaxation) or drug treatment
1st line - SSRI (sertaline)
2nd line - SNRI (venflexine or duloxetine) - if sertaline ineffective
3rd line - Pregabalin - if SSRI or SNRI are ineffective or not tolerated
54
What are the questionnaries used for GAD?
GAD-2, GAD7, Beck's anxiety inventory, hospital anxiety and depression scale
55
What is agoraphobia?
A fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack.
56
What is the diagnostic criteria for agoraphobia?
A. Marked and consistently manifest fear in, or avoidance of, at least two of the following:
1. Crowds
2. Public spaces
3. Travelling alone
4. Travelling away from home
B. Symptoms of anxiety in the feared situation with at least two symptoms present together (and at least one symptom of autonomic arousal).
C. Significant emotional distress due to the avoidance, or anxiety symptoms. Recognized as excessive or unreasonable.
D. Symptoms restricted to (or predominate in) feared situation.
57
What is the diagnostic criteria for social phobia?
A. Marked fear (or marked avoidance) of being the focus of attention, or fear of acting in a way that will be embarrassing or humiliating.
```
B. At least two symptoms of anxiety in the feared situation plus one of the following:
1. Blushing
2. Fear of vomiting
3. Urgency or fear of
micturition/defecation
```
C. Significant emotional distress due to the avoidance or anxiety symptoms.
D. Recognized as excessive or unreasonable.
E. Symptoms restricted to (or predominate in) feared situation.
58
What is the diagnostic criteria for specific phobia?
A. Marked fear (or avoidance) of a specific object or situation that is not agoraphobia or social phobia.
B. Symptoms of anxiety in the feared situation
C. Significant emotional distress due to the avoidance or anxiety symptoms. Recognised as excessive or unreasonable
D. Symptoms restricted to the feared situation.
59
What is the management of agoraphobia?
* CBT - graduated exposure and desensitization. Graduated exposure techniques such as walking increased distances from home day by day
* SSRIs are the first-line .
60
What is the management of social phobia?
CBT (individual or group) specifically designed for social phobia - graduated exposure to feared situations
Pharmacological interventions - SSRIs (escitalopram, sertaline), SNRIs (venlafaxine) or MAOI (moclobemide)
Psychodynamic psychotherapy - for those who decline CBT or medication
61
What is the management of specific phobia?
* The mainstay of treatment is exposure either using self-help methods or more formally through CBT.
* Benzodiazepines may be used as anxiolytics in the short term (due to risk of dependence) for instance if a patient needs an urgent CT scan and they are claustrophobic.
62
What are the causes of panic disorder?
Mostly inherited
Neurochemical - post synaptic hypersensitivity to serotonin and adrenaline
Sympathetic nervous system (SNS) - fear or worry stimulates the SNS --> increased cardiac output which can lead to further anxiety
63
What questionnaires are used for phobic anxiety disorder?
Social Phobia Inventory and Liebowitz Social Anxiety Scale.
64
What is the important clinical feature of panic disorder and what is the diagnostic criteria?
Panic symptoms usually peak within 10 minutes and rarely persist beyond an hour
Diagnostic criteria:
A. Recurrent panic attacks that are not consistently associated with a specific situation or object and often occur spontaneously.
B. Characterised by:
1. Discrete episode of intense fear or discomfort
2. Starts abruptly
3. Reaches a cresendo within a few minutes and atleast some minutes
4. At least one symptoms of autonomic arousal
5. Other symptoms of GAD
65
What are the differentials for panic disorder?
1. Psychiatry - other anxiety disorders - GAD, phobic anxiety disorder, dissociative disorder, BPAD, depression, schizophrenia
2. Organic - pheochromocytoma, hyperthyroidism, hypoglycaemia, carcinoid syndorme, alcohol/substance withdrawal
66
What is the management of panic disorder?
step 1: recognition and diagnosis
step 2: treatment in primary care - CBT and SSRI, then TCA
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
67
What are the drugs used in the management of panic disorder?
SSRIs are first-line but if they are not suitable, or there is no improvement after 12 weeks
TCA, e.g. imipramine or clomipramine - need to be considered
* Benzodiazepines should not be prescribed!
68
What is PTSD? What are the causes or situations that can lead to it?
Post-traumatic stress disorder (PTSD): Is an intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event.
Genetic vulnerability has been suggested.
```
traumatic events -
Severe assault
Major natural disaster
Observer/survivor of civilian disaster
Involvement in wars
Freak
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69
What is abnormal bereavement
Loss of a loved one
Delayed onset, is more intense and prolonged (>6 mths). the impact of their loss overwhelms the individual's coping capacity
70
What is acute stress reaction ?
Exposure to an exceptional physical or mental stressor - phsycial assault or RTA
followed by an immediate onset of symptoms - within an hour
Symptoms - anxiety symptoms, narrowing of attention, apparent disorientation, anger or verbal aggression, despair or hopelessness, uncontrollable or excessive grief.
Symptoms begin to diminish within 8hrs or 48hrs
71
What is adjustment disorder?
Identifiable (non-catastrophic) psychosocial stressor (e.g. redundancy, divorce) within one month of onset of symptoms.
The symptoms must be present for less than 6 months.
72
What is the clinical features of PTSD?
PTSD symptoms must occur within 6 months of the event and can be divided into four categories:
1. Reliving the situation - Persistent, intrusive, involuntary - flashbacks, vivid memories, nightmares, distress when exposed to similar circumstances as the stressors
2. Avoidance - Avoiding reminders of trauma - excessive rumination about the trauma, inability to recall aspects of the trauma
3. Hyperarousal - irritability or outbursts, difficulty with concentration, sleep, hyper vigilance, exaggerated startle response
4. Emotional numbing - negative thoughts about oneself, difficulty experiencing emotions
73
What is the diagnostic criteria for PTSD?
A. Exposure to a stressful event or situation of extremely threatening or catastrophic nature (would likely cause distress in almost anyone).
B. Persistent remembering (‘reliving’) of the stressful situation.
C. Actual or preferred avoidance of similar situations resembling or associated with the stressor.
D. Either (1) or (2)
1. Inability to recall some important aspects of the period of exposure to the stressor.
2. Persistent symptoms of increased psychological sensitivity and arousal.
E. Criteria B, C & D all occur within 6 months of the stressful event, or the end of a period of stress.
74
What are the questionnaries used for PTSD?
Trauma Screening Questionnaire
| (TSQ), Post-traumatic diagnostic scale.
75
How is PTSD within 3mths of trauma managed?
* Watchful waiting may be used for mild symptoms lasting <4 weeks.
* Military personnel have access to treatment provided by the armed forces.
* Trauma-focused CBT should be given at least once a week for 8–12 sessions.
* Short-term drug treatment may be considered in the acute phase for management of sleep disturbance (e.g. zopiclone - GABA agonist).
* Risk assessment is important to assess risk for neglect or suicide.
76
How is PTSD after 3mths of trauma managed?
Course on trauma-focused psychological intervention
Psychological interventions - CBT and eye movement desensitisation and reprocessing (EMDR)
Drug treatment - 1. little benefit from psychological therapy, 2. patient preference not to engage in psychological therapy 3. Co-morbid depression or severe hyperarousal
Paroxetine, mirtazapine, amitriptyline and phenelzine - Paroxetine is the weakest
77
What are obsessions?
Unwanted intrusive thoughts, images or urges that repeatedly enter the individual’s mind. They are distressing for the individual who attempts to resist them and recognizes them as absurd (egodystonic) and a product of their own mind.
78
What are compulsions?
Repetitive, stereotyped behaviours or mental acts that a person feels driven into performing. They are overt (observable by others) or covert (mental acts not observable).
79
What the causes of OCD?
1. Biological - reduced serotonin in the frontal cortex and basal ganglia.
2. Genetic contribution - paediatric onset
3. Childhood group A beta-haemolytic streptococcal infection - role in causing OCD symptoms
4. Psychoanalytic - filling the mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness
5. Behavioural - compulsive behaviour is learned and maintained by operant conditioning.
Strong association with - depression, schizophrenia, syndenham's chorea, Tourette's syndrome and anorexia nervosa
80
What is the criteria for the diagnosis of OCD?
A. Either obsessions or compulsions (or both) present on most days for a period of at least 2 weeks.
B. Obsessions (thoughts, ideas or images) or compulsions (acts) share a number of features
ALL of which must be present: (FORD Car)
1. Failure to resist - at least one obsession or compulsion is present which is unsucessfully resisted
2. Originate from the patient's mind - acknowledges that the obsessions are all from their own mind and not imposed by outside persons or influences
3. Repetitive and Distressing - at least one obsession or compulsion must be preset which is acknowledged by the patient as excessive or unreasonable
4. Carrying out the obsessive thoughts/act is not in itself pleasurable but reduces anxiety levels
C. The obsessions or compulsions cause distress or interfere with the subject’s social or individual functioning, usually by wasting time.
NOTE: The diagnosis can be specified as ‘predominantly obsessional thoughts or ruminations’, ‘predominantly compulsive acts’, or ‘mixed obsessional thoughts and acts’.
81
What are some of the common obsessions in OCD?
1. Contamination - dirt, virus, germs
2. Fear of harm - door locks not safe
3. Excessive concern with order
82
what is the quesstionaire used to look for severity of OCD?
Yale- Brown obsessive-compulsive scale
83
How is mild OCD managed?
Low intensity psychological intervention (<10 hrs of therapist input per patient)
84
How is moderate OCD managed?
SSRI - Fluoxetine, Fluvoxamine, paroxetine
Alternate therapy - Clomipramine (TCA)
OCD responds to much higher doses of SSRI
OR
High intensity psychological intervention
85
How is severe OCD managed?
SSRI + CBT (with ERP - exposure and response prevention)
SSRI - Fluoxetine, Fluvoxamine, paroxetine if insufficient :
Citalopram + Clomipramine (TCA)
SSRI/ clomipramine + antipsychotic
86
What are somatoform disorders?
• Somatoform disorders = A group of disorders whose:
o Symptoms are suggestive of / take the form of a physical disorder
o BUT in the absence of a physiological illness
(Leads to the presumption that they are caused by psychological factors)
o Sufferers repeatedly seek medical attention (Even when it has constantly failed to benefit them)
‘I think I have a serious illness and need to go to hospital for more tests!’
87
What is dissociative conversion disorder?
Characterized by symptoms which:
o Cannot be explained by a medical disorder
o Convincing associations in time btwn symptoms & stressful events / problems / needs
The unpleasant stressful events / problems are ‘converted’ into symptoms!!!
‘Ever since I lost my job, I’ve been feeling so unwell!’
88
What is the management of somatoform disorders?
Biological - antidepressants - underlying mood disorder - SSRI
Physical exercise - enhances self-esteem - particularly helpful in dysmorphophobia
Psychological - CBT(short course) - mainstay of Rx
Social:
1. Stress-relieving activities - meditation, long walks
2. Interventions reduce secific causes of stress
3. Interview/involve family
89
What is malingering?
Intentionally produced physical/psychologial symptoms to seek advantageous consequences of being Dx with a medication
eg:
1. Evading criminal prosecution
2. Receiving government benefits - secondary gain
‘If I go to the hospital, I may receive compensation.’
90
What is a facticious disorder (Manchausen's syndrome)
• The individual wishes to adopt the ‘sick role’ to receive the care of a patient for internal emotional gain (Primary gain)
‘I want to go to the hospital to be looked after.’
91
What is the diagnostic criteria for anorexia nevorsa?
FEEDD
1. Fear of weight gain
2. Endocrine disturbance resulting in amenorrhoea in females and loss of sexual interest and potency in males
3. Emacitated - abnormally low body weight >15% below expected weight or BMI <17.5kg/m2
4. Deliberate weight loss - reduced food intake or increased exercise
5. Distorted body image
NOTE: The above features must be present for at least 3 months and there must be the ABSENCE of (1) recurrent episodes of binge eating; (2) preoccupation with eating/craving to eat.
92
How do you differentiate anorexia from bulimia nervosa?
ANOREXIA
1. Significantly underweight
2. more likely to have endocrine abnormalities
3. do not have any strong cravings for food
4. do not bingr eat
5. may have compensatory weight loss behaviours - excluding purging
BULIMIA
1. Are usually normal weight/overweight
2. Are less likely to have endocrine abnormalities
3. Have strong cravings for food
4. Gave recurrent episodes of binge eating
5. Have compensatory weight loss behaviours
93
What are the metabolic complications of anorexia nervosa?
Hypokalemia (depletion)
Hypercholestrolaemia (possibly due to the increased HDL)
Hypoglycaemia (Not often, but if hypo admit)
Increased urea and creatinine (If dehydrated)
Low phosphate, magnesium, albumin and choloride
94
What are the endocrine complications of anorexia nervosa?
```
High cortisol (Stress related)
High Growth hormone
Low T3 and T4
Low LH and FSH
Low Oestrogens and progestrogens leading to amenorrhoea --> Osteoporosis
Low testosterone in men
```
95
What is binge eating disorder?
Recurrent episodes of binge eating without compensatory behaviour such as vomiting, fasting, or excessive exercise.
96
When should a patient with anorexia be admitted?
1. Rapid/Excessive weight loss
2. Failure of outpatient Rx
3. Severe electrolyte imbalance; eg:
Hypokalaemia
Hyponatraemia
4. Serious physiological complications; eg:
Temp. <36oc
Fainting; due to:
Bradycardia (PR <40bpm)
/Marked postural drop in BP
Cardiac complications
Sig. ↑ LFTs
5. Marked chg in mental status due to:
Severe malnutrition
Psychosis
6. Sig. risk of suicide
97
What does the management of anorexia nervosa involve?
Psychological treatment - at least 6mths
1. Psycho-education about nutrition
2. Cognitive behavioural therapy
3. Interpersonal pyschotherapy
4. Family therapy
Biological-
SSRI - co-morbid depression or OCD
Risk assessment for suicide and medical complications
98
What are the complications of feeding in anorexia nervosa? How does it present and how is it managed?
Refeeding syndrome
Fasting Main source - fatty acid and amino acids --> reduced insulin secretion and increased glucagon secretion --> food and liquid consumed during initial period of refeeding --> triggers insulin secretion due to increased blood sugar --> triggers synthesis of glycogen, fat and protein --> decreased serum concentration of K+, Mg and Phosphorus
Complications - Cardiac complications - HF and arrhythmias, renal impairment, Liver function abnormalities
Treatment - Measure serum electrolytes prior to feeding and monitor refeeding bloods
daily, start at 1200 kcal/day and gradually increase every 5 days, monitor for signs such as
tachycardia and oedema.
99
How do you differentiate knight's move thinking and flight of ideas in schizophrenia?
Differentiating between Knight's move and flight of ideas - Knight's move thinking there are illogical leaps from one idea to another, flight of ideas there are discernible links between ideas
Normal thought: a - b - c - d - e - f - g
Knights move: a - c - g - l
The patient may be aware of the 'letters in-between' but they race ahead. So the association isn't necessarily apparent to whoever is listening.
Flight of ideas: abcdefghijklmnop...
Thoughts with a more discernible link than knights move but its the *rapid interchange* that is the key. They don't dwell on a topic, and move on to another (linked) topic. Basically: more topics per minute.
100
What are the diagnostic criteria for bulimia nervosa?
mnemonic: Bulimia Patients Fear Obesity
1. Behaviours to prevent weight gain (compensatory) - self induced vomiting, alternating periods of starvation, drugs (laxatives, diuretics, appetite suppressants) and excessive exercise
2. Preoccupation with eating - sense of compulsion - craving to eat which leads to bingeing. Shame/regret after an episode
3. Fear of fatness - self-perfection
4. Overeating - two episodes per week over a period of 3mth
101
What is an important life -threatening complication of bulimia nervosa?
A potentially life-threatening complication of excessive vomiting.
• Low potassium (<3.5 mmol/L) can result in muscle weakness, cardiac arrhythmias and renal
damage.
• Mild hypokalaemia requires oral replacement with potassium-rich foods (e.g. bananas)
and/or oral supplements (Sando-K).
• Severe hypokalaemia requires hospitalization and intravenous potassium replacement.
metabolic alkalosis - due to loss of acid and K+
102
What is the management of bulimia nervosa?
Biological - trial of antidepressants and reduced frequency of binge eating - Fluoxetine
Psychoeducation about nutrition, CBT for bulimia. Interpersonal physchotherapy
Social - food diary, techniques to avoid bingeing (eating in company, distractions), small, regular meals
103
What is the criteria for substance dependence?
Mnemonic: Drug Problems Will Continue To Harm
≥3 of the following manifestations must have occurred over 1 month:
1. Strong Desire (compulsion) to consume substance
2. Preoccupation with substance use
3. Withdrawal state when substance ingestion is reduced or stopped
4. Impaired ability to control substance taking behaviour (onset, termination or level of use)
5. Tolerance to substance, requiring more consumption for desired effect
6. Persisting with use, despite evidence to the Harmful effects
104
What are the important tests to perform for substance ause?
Bloods:
1. HIV screen, Hep B, Hep C and tuberculosis testing --> risk of blood borne infections (needle sharing)
2. U&E - to check renal function
3. LFT and clotting - check hepatic function
4. Drug levels
Urinalysis - drug metabolites (cannabis, opioids) an be detected in urine
ECG - for arrhythmias, ECho if endocarditis suspected
105
What is the management of substance abuse?
1. Hep.B immunisation - considered for those at risk
2. Motivational interviewing (substance misuse) and CBT (for co-morbid depression or anxiety)
3. Contingency management - changing specified behaviours by offering incentives (financial) for positive behaviour
4. Supportive help - housing, finance, employment
5. Self help groups - Narcotic anonymous, cocaine anonymous
106
How do you manage opioid dependence?
Methadone - first line
Buprenorphine - detoxification and maintenance
Naltrexone - recommended for those who were formerly opioid dependent but have stopped and are motivated to continue abstinence
IV naloxone - opioid antagonist - antidote for opioid overdose
107
What is the criteria for alcohol dependence
SAW DRINk
• Subjective awareness of compulsion to drink.
• Avoidance or relief of withdrawal symptoms by further drinking (also known as relief drinking).
• Withdrawal symptoms.
• Drink-seeking behaviour predominates.
• Reinstatement of drinking after attempted
abstinence.
• Increased tolerance to alcohol.
• Narrowing of drinking repertoire
(i.e. a stereotyped pattern of drinking – individuals have fixed as opposed to variable times for drinking, with reduced influence from environmental cues).
108
What are the features of alcohol withdrawal?
Malaise, tremor, nausea, transient hallucinations and autonomic hyperactivity - 6-12hrs after abstinence
The severe end of the spectrum of withdrawal - delirium tremens and the peak incidence is at 72hrs
Dehydration and electrolytic disturbances are a feature.
• It is characterized by:
• Cognitive impairment
• Vivid perceptual abnormalities (hallucinations and/or illusions)
• Paranoid delusions
• Marked tremor
• Autonomic arousal (e.g. tachycardia, fever, pupillary dilatation and increased sweating).
109
How is alcohol withdrawal treated?
Large doses of bezodiazepines - chlordiazepoxide
Haloperidol - psychotic features
Intravenous Pabrinex
110
What are the tests to use to assess alcohol dependence?
```
Bloods:
FBC - anaemia
U&E - dehydration, decreased urea
LFT - included gamma GT (may be increased)
Blood alcohol concentration
MCV - macrocytosis
Vitamin B12/folate/TFTs (alternate causes of increased MCV)
Amylase - pancreatitis
hepatitis serology
glucose
```
Alcohol questionnaire: Alcohol use disorders identification test (AUDIT) , Severity of alcohol dependence questionnarie (SADQ), FAST screening tool
CT head
ECG
111
What is the neuropyschiatric complications of alcohol dependence?
Wernicke’s encephalopathy: An acute encephalopathy due to thiamine deficiency, presenting with delirium, nystagmus, ophthalmoplegia, hypothermia and ataxia. Requires urgent treatment and may progress to Korsakoff’s psychosis (AKA amnesic syndrome). Treated with parenteral thiamine.
• Korsakoff’s psychosis: Profound, irreversible short-term memory loss with confabulation (the unconscious filling of gaps in memory with imaginary events) and disorientation
to time.
112
What is the long term management of alcohol dependence?
1. Disulfiram - build up of acetaldehyde on consumption of alcohol - causing unpleasant symptoms eg. anxiety, flushing and headache
2. Acomprasate - reduces craving by enhancing GABA transmission
3. Naltrexone - Blocks opioid receptors - antagonists in the body, thus reducing the pleasurable effects of alcohol
113
What are the different clusters of personality disorders?
Cluster A - WEIRD (paranoid, schizoid, schizotypal)
Cluster B - WILD (Emotionally unstable, dissocial, histrionic)
Cluster C - WORRIES (dependent, avoidant and anankastic)
114
What are the features of paranoid PD?
MNEMONIC: SUSPECTS
* Suspicious of others
* Unforgiving (bears grudges)
* Spouse fidelity questioned
* Perceives attack
* Envious (jealous)
* Criticism not liked/Cold affect
* Trust in others reduced • Self-reference
115
What are the features of schizoid PD?
MNEMONIC: DISTANT
* Detached (flattened) affect
* Indifferent to praise or criticism
* Sexual drive reduced
* Tasks done alone
* Absence of close friends -Voluntary
* No emotion (cold)
* Takes pleasure in few activities
116
What are the features of schizotypal PD?
* Magical thinking
* Odd and eccentric behavior
* Excessive social anxiety
* Ideas of reference
* Unusual perceptual experiences
* Constricted affect
* Preference for social isolation because of paranoia and suspicion of others
* Lack of close friends other than family members - although they want to have relationships - cannot maintain
117
What are the features of emotionally unstable/borderline PD?
MNEMONIC: AM SUICIDE
```
• Abandonment feared
• Mood instability
• Suicidal behaviour
• Unstable relationships
• Intense relationships
• Control of anger poor
• Impulsivity
• Disturbed sense of self
(identity)
• Emptiness (chronic)
```
118
What are the features of dissocial/antisocial PD?
MNEMONIC: CORRUPT
* Callous - insensitive
* Others blamed
* Reckless disregard for safety
* Remorseless (lack of guilt)
* Underhanded (deceitful)
* Poor planning (impulsive)
* Temper/Tendency to violence
119
What are the features of histrionic PD?
MNEMONIC: PRAISE
* Provocative behaviour
* Real concern for physical attractiveness
* Attention seeking
* Influenced easily
* Shallow/Seductive inappropriately
* Egocentric (vain)/ Exaggerated emotions
120
What are the features of Narcissistic PD?
* Grandiose sense of self importance
* Preoccupation with fantasies of unlimited success, power, or beauty
* Sense of entitlement
* Taking advantage of others to achieve own needs
* Lack of empathy
* Excessive need for admiration
* Chronic envy
* Arrogant and haughty attitude
121
What are the features of Dependent PD?
MNEMONIC: RELIANCE
* Reassurance required
* Expressing disagreement is difficult
* Lack of self-confidence
* Initiating projects is difficult
* Abandonment feared
* Needs others to assume responsibility
* Companionship sought
* Exaggerated fears
122
What are the features of ananakastic/ obsesessive-compulsive PD?
MNEMONIC: LAW FIRMS
* Loses point of activity (due to preoccupation with detail)
* Ability to complete tasks compromised (due to perfectionism)
* Workaholic at the expense of leisure
* Fussy (excessively concerned with minor details)
* Inflexible
* Rigidity
* Meticulous attention to detail
* Stubborn
123
How do you differentiate between OCD and anankastic PD/obsessive complusive PD?
OCD - Anxiety disorder which causes ritualistic actions
Ego-dystonic conditions - They wish they could stop
OCPD - Ego-syntonic - happy with how they are and dont want to change
124
How do you differentiate between social phobias and Avoidant/anxious PD?
Social phobias - anxiety of specific situations - public situations
Avoidant PD- general situations
125
What are the investigation used to diagnose personality disorder?
* Questionnaires: e.g. Personality Diagnostic Questionnaire, Eysenck Personality Questionnaire.
* Psychological testing: Minnesota Multiphasic Personality Inventory (MMPI).
* CT head/MRI: to rule out organic causes of personality change such as frontal lobe tumours and intracranial bleeds.
126
What are the important steps other than medication to consider when treating someone with depression?
Manage suicide risk (this may include voluntary/compulsory admission)
Manage any safeguarding concerns for children or vulnerable adults in their care
Manage any co-morbid condition associated with depression (for example, alcohol or substance abuse)
Psychotic symptoms seek expert advice
Eating disorders seek expert advice
Dementia treat the underlying depression.
Discuss practical solutions to stresses contributing to depression.
127
What is the most worrying side effect of clozapine? And the other side effects
Agranulocytosis --> neutropenia
1. Reduced seizure threshold - can induce seizures in up to 3% of patients
2. constipation
3. myocarditis: a baseline ECG should be taken before starting treatment
4. hypersalivation
128
Which antipsychotic is most sensitive to smoking?
Clozapine - levels to need to be adjusted according to change in smoking levels
129
What antipsychotic is used if prolactin levels are generally high and lead to breast pain?
Ariprapazole
130
What are the common side effects of antipsychotics?
Weight gain
High prolactin levels
parkinsonism - due to D2 blockers
Increased risk of stroke and VTE in the elderly
131
Which drug is used to treat tardive dyskinesia?
Tetrabenezine
132
Which drug is used to treat acute dystonia?
procyclidine - also used in Extrapyramidal symptoms (but not tardive dyskinesia) in parkinsonism
133
Which SSRI is shown to be effective post-MI?
Sertaline
134
What are the adverse reactions of SSRI use?
GI bleeding - with SSRI use - add PPI in case also taking NSAIDs
Hyponatraemia
Patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
Fluoxetine and paroxetine have a higher propensity for drug interactions
135
What are the adverse effects of citalopram use?
Citalopram and escitalopram are associated with dose-dependent QT interval prolongation
136
What are the drug interactions of SSRIs?
1. NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding 2. SSRIs and considering mirtazapine
3. aspirin: see above
4. triptans - increased risk of serotonin syndrome
5. monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
137
How are antidepressants prescribed?
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks.
For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week.
If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
138
How are antidepressants weaned off?
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
139
What are the discontinuation symptoms of SSRI?
```
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
```
140
What are the complications of SSRI use during 1st trimester?
Small increased risk of congenital heart defects
141
What are the complications of SSRI use during 3rd trimester?
Persistent pulmonary hypertension of the newborn
142
What is the risk of using Paroxetine in the 1st trimester?
Congenital cardiac malformations
143
what are the indications for the use of MAO? Give some examples of MAO?
Used in atypical depression (hyperphagia, weight gain and hypersomnia)
Examples of Non-selective monoamine oxidase inhibitors - tranylcypromine, phenelzine
144
What are the adverse effects of MAO?
1. hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
2. anticholinergic effects
145
How do you differentiate circumstantiality from echolochia?
Circumstantiality is when the patient doesn't answer the question directly and talks about things surrounding the topic but yet will not answer the question specifically. In this case, the patient may start talking about other people's moods, or things surrounding her mood, but not directly answering the question about her mood. However, in circumstantiality, the patient will return to the original point and answer the original question eventually.
Echolochia - patient repeating the doctor's questions and repeating their phrasing, instead of simply answering the question.
146
How is lithium monitored after a change in dose?
Lithium levels should be taken a week later and weekly until the levels are stable.
thyroid and renal function should be checked every 6 months
147
What are the side effects of lithium?
1. nausea/vomiting, diarrhoea
2. fine tremor
3. nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
4. thyroid enlargement, may lead to hypothyroidism
5. ECG: T wave flattening/inversion
6. weight gain
7. idiopathic intracranial hypertension
8. leucocytosis - benign
9. hyperparathyroidism and resultant hypercalcaemia -lower back pain, constipation, headaches, low mood, and difficulty concentrating.
148
How do you differentiate somatisation disorder from Hypochondrial disorder?
Somatisation - symptoms with no identificable cause present for at least 2 years; patient refuses to accept reassurance or negative test results
Hypochondrial - believe they have cancer or a disease; patient again refuses to accept reassurance or negative test results
149
How do you differentiate antisocial PD and borderline PD?
The features of the two can often overlap with both having impulsivity as a key feature.
The important features of borderline personality disorder are an unstable affect with fluctuating self image and recurrent suicidal ideation and self harm.
The more important features of antisocial personality disorder are repeated failure to conform to social norms or rules and reckless disregard for their own safety as well as others with a lack of sense of remorse when these actions are discussed
BUPD - common in female ; antisocial PD- more common in male
150
What type of drug is mirtazapine and what are its specific side effects?
Serotonin-Noradrenaline reuptake inhibitor
Some of the most potent side effects of mirtazapine are a large increase in appetite (and subsequent weight gain) and drowsiness. These side effects are so pronounced that mirtazapine has been known to be used as an appetite stimulant and sleep aid off-formulary.
Mirtazzzzzzzzapine
151
How do you switch from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
the first SSRI should be withdrawn gradually before the alternative SSRI is started
152
How do you switch from fluoxetine to another SSRI
Withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
153
How do you switch from SSRI to a tricyclic antidepressant (TCA)
Cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
an exceptions is fluoxetine which should be withdrawn prior to TCAs being started (gap of 4-7 days before new drug)
154
How do you switch from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
Cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly
155
How do you switch from fluoxetine to venlafaxine
Withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly
156
What are the factors which are associated with increased risk of suicide in those who attempt?
```
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method
```
157
What are the stages of grief reaction?
Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
Anger: this is commonly directed against other family members and medical professionals
Bargaining
Depression
Acceptance
158
what are the short term side effects of ECT?
```
headache
nausea
short term memory impairment - retrograde amnesia
memory loss of events prior to ECT
cardiac arrhythmia
```
159
what are the long term side effects of ECT?
```
Apathy
Anhedonia
Difficulty concentrating
Loss of emotional responses
Difficulty learning new information
```
160
What are the poor prognostic factors of schizophrenia?
```
strong family history
gradual onset
low IQ
premorbid history of social withdrawal
lack of obvious precipitant
```
161
What is the MMSE scoring thresholds
24-30- no cognitive impairment
18-23- mild cognitive impairment
0-17- Severe cognitive impairment
162
How do alzhiemers patients differ from depression pts?
As a rule of thumb, when performing a mini mental state examination on a patient with depression they will answer with 'I don't know', whereas patients with Alzheimer's will try their best to answer your questions, but answer incorrectly.
1. short history, rapid onset
2. biological symptoms e.g. weight loss, sleep disturbance
3. patient worried about poor memory
4. reluctant to take tests, disappointed with results
5. mini-mental test score: variable
6. global memory loss (dementia characteristically causes recent memory loss)
163
What are the stages of alcohol withdrawal?
1. symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
2. peak incidence of seizures at 36 hours
3. peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
164
What are the side effects of antipsychotics?
Extrapyramidal side-effects (EPSEs):
1. Parkinsonism
2. Acute dystonia: sustained muscle contraction (e.g. torticollis, oculogyric crisis)
3. Akathisia (severe restlessness)
4. Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
EPSEs may be managed with procyclidine
165
What is the preferred psychological therapy for EUPD?
Dialectical behaviour therapy (DBT) -this is a targeted therapy that is based CBT, but has been adapted to help people who experience emotions very intensely.
emphasis placed on developing coping strategies to improve impulse control and reduce self-harm in emotionally unstable PD.
166
What is the preferred psychological therapy for OCD?
Exposure and response prevention therapy (ERP)
167
What is the preferred psychological therapy for PTSD?
Eye movement desensitisation and reprocessing therapy (EMDR)
168
What are the side effects of TCA?
1. Drowsiness
2. Dry mouth
3. Blurred vision
4. Constipation
5. Urinary retention
6. Lengthening of QT interval
anticholinergic side effects and anti-histaminic (weight gain)
169
What are the different choices of TCA and how are they different?
1. Low-dose amitriptyline is commonly used in the
2. Management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
3. Lofepramine has a lower incidence of toxicity in overdose
4. Amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose
170
Examples of TCA
Amitriptyline
Clomipramine
Dosulepin
Trazodone*
Imipramine
Lofepramine
Nortriptyline
171
What is the tx for delerium tremens?
Benzodiazepine - Chlordiazepoxide
172
What is oculogyric crisis a feature of?
Acute dystonia
173
What is charles bonnett syndrome and what are its risk factors?
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness
Risk factors include:
1. Advanced age
2. Peripheral visual impairment
3. Social isolation
4. Sensory deprivation
5. Early cognitive impairment
174
What are the features of post-concussion syndrome?
headache
fatigue
anxiety/depression
dizziness
175
What are the z drugs and how do they work?
Imidazopyridines: e.g. zolpidem
Cyclopyrrolones: e.g. zopiclone
Pyrazolopyrimidines: e.g. zaleplon
They act on the α2-subunit of the GABA receptor. - GABA agonist
176
What are the features of sleep paralysis?
1. Paralysis - this occurs after waking up or shortly before falling asleep
2. Hallucinations - images or speaking that appear during the paralysis
Management- if troublesome clonazepam may be used
177
What are the poor prognostic factors for schizophrenia?
- Strong family history
- Gradual onset
- Low IQ
- Prodromal phase of social withdrawal
- Lack of obvious precipitant
178
What drug is CI in lewy body dementia?
antipsychotics can make the parkisons disease worse
179
Which antidepressants can be used during breastfeeding?
Sertaline and paroxetine
180
What antidepressants are CI for those after a heart attack?
Tricyclic antidepressants and SNRI
181
What do patients with aspirin overdose present as?
Anxious and hyperventilating patient
Aspirin overdose initially presents with a respiratory alkalosis due to hyperventilation, progressing to a metabolic acidosis. Patients may also experience tinnitus, vomiting and severe dehydration.
182
What is the first line pharmacological mx for alzhiemers disease?
Mild- moderate - acetylcholinesterase inhibitors (donepezil, galantine and rivastigmine)
Severe disease, CI to acetylcholinesterase inhibitors and add on to acetylocholinesterase inhibitors in moderate - severe disease - NMDA receptor antagonist - Memantine
183
When is donepezil contraindicated?
- Relatively contraindicated in patients with bradycardia
| - Adverse effects include insomnia
184
What are the common side effects of SSRI?
```
GI upset
Anxiety and agitation
QT interval prolongation (especially associated with citalopram)
Sexual dysfunction
Hyponatreamia
Gastric Ulcer
```
185
What are the common side effects of TCA?
They are strongly associated with anti-cholinergic activity.
```
Urinary retention
Drowsiness
Blurred vision
Constipation
Dry mouth
```
186
What are features of opiate overdose?
Drowsiness, confusion, decreased respiratory rate, decreased heart rate and constricted pupils.
If the substance, such as heroin, has been injected, there may be evidence of needle marks (often referred to as 'track marks'), abscesses or vein collapse at injection sites. Opiates such as heroin act at opioid receptors.
187
What are features of cannabis intoxication?
Drowsiness, impaired memory, slowed reflexes and motor skills, bloodshot eyes, increased appetite, dry mouth, increased heart rate and paranoia.
188
What are the features of stimulants such as cocaine or methamphetamine intoxication?
Euphoria, increased blood pressure, increased heart rate and increased temperature. Stimulants such as cocaine or methamphetamine can, in low doses, produce a feeling of increased concentration and focus.
Cocaine acts at dopamine receptors. Methamphetamine acts at TAAR1 (Trace Amine-Associated Receptor 1) receptors. Both increase the available amount of dopamine in the brain, producing the associated pleasurable effects of the drugs.
189
What are the features of barbiturates and benzo intoxication?
Sedation, slurred speech and impaired judgements
| They have anxiolytic effects
190
What drugs are used for postnatal depression?
After CBT
Paroxetine and sertaline can be used while breastfeeding
Avoid fluoxetine - due to a long half-life
191
What is the criteria for drug induced psychosis?
Onset of psychotic symptoms within 2 weeks of substance use.
| Must persist for more than 48 hours.
192
What are the side effects of lithium use?
MNEMONIC - GI disturbance + LITHIUM
```
Leucocytosis
Impaired renal function
Tremor (fine)/ teratogenic/ thirst
Hypothyroidism/hair loss
Increased weight and fluid retention
urine - increased (Polyuria)
Metallic taste
```
193
What are the features of lithium toxicity?
MNEMONIC - TOXIC
```
T - Tremor (coarse)
O - Oliguric renal failure
X - ataXia
I - Increased reflexes
C- Convulsions/Coma/Consciousness ↓
```
194
What are the factors that can precipitate lithium toxicity?
4 D’s: Dehydration, Drugs (ACE inhibitors, NSAIDs),
| Diuretics (thiazide), Depletion of sodium.
195
What are the side effects of ECT?
Peripheral nerve palsies
Cardiac arrhythmias, Confusion
Dental and oral trauma
Anaesthetic risks → laryngospasm, sore throat, N+V
Muscular aches and headaches
Short-term memory impairment, Status epilepticus
196
What are the indications for ECT?
‘ECT’ (Euphoric Catatonic Tearful):
1. Prolonged or severe mania (Euphoric).
2. Catatonia(Catatonic).
3. Severe depression (Tearful):
• Treatment-resistant depression.
• Suicidal ideation or serious risk to others.
• Life-threatening depression, e.g. when the patient refuses to eat or drink.
197
What are the CI for ECT?
MARS
• MI (<3 months ago), Major unstable fracture.
• Aneurysm (cerebral).
• Raised ICP, e.g. intracranial bleed, space-occupying lesion (the only absolute contraindication).
• Stroke <1 month ago, a history of Status epilepticus, Severe anaesthetic risk (e.g. severe cardiovascular or respiratory disease).
198
What is the mnemonic for the management of bipolar manic episode?
CALMER
* Consider hospitalization/CBT
* Antipsychotics (Atypical)
* Lorazepam
* Mood stabilizers (e.g. lithium)
* Electroconvulsive therapy
* Risk assessment
199
How and when is long term treatment of BPAD started?
* 4 weeks after an acute episode has resolved, lithium should be offered first-line to prevent relapses.
* If lithium is ineffective consider adding valproate. Olanzapine or quetiapine are alternative options.
200
How is bipolar depressive episode managed?
1. Atypical antipsychotics are effective in bipolar depression. Options include olanzapine (combined with fluoxetine), olanzapine alone or quetiapine alone.
2. Mood stabilizer option is lamotrigine. Lithium is also effective.
3. Antidepressants alone are usually avoided
