Psychiatry Flashcards
What are the key features of acute stress disorder?
occurs in first 4 weeks after a traumatic event
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
What is the management of acute stress disorder?
Trauma-focused CBT
Benzodiazepines
What are the features of alcohol withdrawal?
Symptoms start at 6-12 hours after cessation - tremor, sweating, tachycardia, anxiety
What are the features of delirium tremens?
Coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
When is the peak incidence of seizures following alcohol withdrawal?
36 hours
When is the peak incidence of delirium tremens?
48-72 hours
What is the management of delirium tremens?W
Admit to hospital for monitoring until withdrawals stabilized
Long-acting benzodiazepines (chlordiazepoxide, diazepam, lorazepam if hepatic failure)
What are the features of anorexia nervosa?
reduced body mass index
bradycardia
hypotension
enlarged salivary glands
What physiological abnormalities are present in anorexia nervosa?
hypokalaemia low FSH, LH, oestrogens and testosterone raised cortisol and growth hormone impaired glucose tolerance hypercholesterolaemia hypercarotinaemia low T3
What is the MOA of typical antipsychotics?
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
What is the MOA of atypical antipsychotics?
Act on a variety of receptors (D2, D3, D4, 5-HT)
What are the adverse side effects of typical antipsychotics?
Parkinsonism Acute dystonia (torticollis, oculogyric crisis) Akathisia Tardive dyskinesia Hyperprolactinemia Neuroleptic malignant syndrome Reduced seizure threshold Prolonged QT interval Anti-muscarinic
What is the management of acute dystonia?
Procyclidine
What are the features of 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
What does the use of antipsychotics increase the risk of in the elderly?
Stroke
VTE
What are the side effects of atypical antipsychotics?
Weight gain
Agranulocytosis
Hyperprolactinemia
Which atypical antipsychotic is associated with agranulocytosis?
Clozapine
Which atypical antipsychotic is associated with dyslipidemia and obesity?
Olanzapine
How should benzodiazepines be stopped?
Swtich to an equivalent dose of diazepam and reduce the dose every 2-3 weeks in steps of 2 or 2.5mg.
The time for withdrawal can vary from 4 weeks to a year or more.
What are the features of body dysmorphic disorder?
Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive
The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)
What are the criteria for bulimia nervosa?
Recurrent episodes of binge eating
Sense of lack of control over eating during the episode
Recurrent inappropriate compensatory behavior to prevent weight gain (vomiting, laxative abuse, diuretics, fasting, exercise, etc)
Binge eating and compensatory behaviors occur at least once a week for three months.
What is the management of bulimia nervosa?
Specialist care
CBT-ED
High dose fluoxetine
What are the risk factors for Charles-Bonnet syndrome?
Advanced age Peripheral visual impairment - age related macular degeneration, glaucoma, cataract Social isolation Sensory deprivation Early cognitive impairment
What is Charles-Bonnet syndrome?
persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness, usually with a background of visual impairment
What is Cotard syndrome?
The affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. It is usually associated with severe depression and psychotic disorders.
What is De Clerambault’s syndrome, also known as erotomania?
a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
What is delusional parasitosis?
A relatively rare condition where a patient has a fixed, false belief (delusion) that they are infested by ‘bugs’ e.g. worms, parasites, mites, bacteria, fungus. This may occur in conjunction with other psychiatric conditions or may present by itself, with patients often otherwise quite functional despite the delusion.
What are the side-effects of ECT?
headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia impaired memory
What is the only absolute contraindication for ECT?
Raised intracranial pressure
What is the indication for ECT?
Severe depression refractory to medication and with psychotic symptoms
Define anxiety.
excessive worry about a number of different events associated with heightened tension
What is the management of generalized anxiety disorder?
Education and active monitoring
Warn patients under 30 they are at increased risk of suicidal thinking and self-harm
Psychological intervention
MDT
Sertraline (second line SSRI or SNRI, third line pregabalin)
What is the management of panic disorder?
Recognition and diagnosis
CBT
SSRI (second line imipramine or clomipramine)
Mental health services referral
What are atypical grief reactions?
delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
What is the key difference between mania and hypomania?
Mania has the presence of psychotic symptoms
What are the features of Korsakoff’s syndrome?
Follows on from untreated Wernicke’s encephalopathy
Anterograde amnesia
Retrograde amnesia
Confabulation
What is the MOA of lithium?
Interferes with cAMP formation
What are the adverse side effects of lithium?
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
What monitoring is required on lithium?
Check levels 12 hours post-dose
After starting, check levels weekly and after each dose change until levels are stable
Once stable, check lithium levels every 3 months for the first year and then 6 months thereafter
Check TFTs and U+Es every 6 months
What are the ADRs of MAOIs?
hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
anticholinergic effects
Define obsession.
An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
Define compulsion.
Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.
What is the management of OCD?
Mild functional impairment: CBT, exposure and response prevention
Moderate functional impairment: SSRI for at least 12 months after remission, more intense CBT/ERP
Severe functional impairment: SSRI + CBT (including ERP)
What is Othello syndrome?
Othello’s syndrome is pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.
What are cluster A personality disorders?
Cluster A: ‘Odd or Eccentric’
- Paranoid
- Schizoid
- Schizotypal
What are cluster B personality disorders?
Cluster B: ‘Dramatic, Emotional, or Erratic’
- Antisocial
- Borderline (Emotionally Unstable)
- Histrionic
- Narcissistic
What are cluster C personality disorders?
Cluster C: ‘Anxious and Fearful’
- Obsessive-Compulsive
- Avoidant
- Dependent
What are the characteristics of paranoid personality disorder?
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
What are the characteristics of schizoid personality disorder?
Indifference to praise and criticism Preference for solitary activities Lack of interest in sexual interactions Lack of desire for companionship Emotional coldness Few interests Few friends or confidants other than family
What are the characteristics of schizotypal personality disorder?
Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent
What are the characteristics of antisocial personality disorder?
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for the safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
What are the characteristics of borderline personality disorder?
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
What are the characteristics of histrionic personality disorder?
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
What are the characteristics of narcissistic personality disorder?
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
What are the characteristics of obsessive-compusive personality disorder?
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
What are the characteristics of avoidant personality disorder?
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
What are the characteristics of dependent personality disorder?
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
What are the features of post-concussion syndrome?
headache
fatigue
anxiety/depression
dizziness
What are the features of the baby blues?
Typically seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
What is the management of the baby blues?
Reassure and support
What are the features of postnatal depression?
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
What is the management of postnatal depression?
Reassure and support
CBT
SSRI - paroxetine, sertraline
What are the featuers of puerperal psychosis?
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
What is the management of puerperal psychosis?
Admission to hospital
What are the features of PTSD?
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing - lack of ability to experience feelings, feeling detached
What is the management of PTSD?
Watchful waiting for symptoms lasting less than 4 weeks
Trauma-focused CBT or eye movement desensitization and reprocessing therapy
Second line: venlafaxine, SSRI (sertraline)
What are the features of schizophrenia?
Auditory hallucinations - two or more voices discussing the patient, thought echo, voices commenting on behavior
Thought disorder: insertion, withdrawal, broadcasting
Passivity phenomena
Delusions
Impaired insight
Incongruity/blunting of affect (inappropriate emotion for circumstance)
Decreased speech
Neologisms
Catatonia
Negative symptoms: incongruity/blunting of affect, anhedonia, alogia, avoliton
What is the management of schizophrenia?
Oral atypical antipsychotics
CBT
What factors are associated with a poor prognosis in schizophrenia?
strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant
What is seasonal affective disorder?
depression which occurs predominately around the winter months
What is the management of seasonal affective disorder?
CBT
SSRI
Which SSRI is first line for depression?
Citalopram or fluoxetine
Which SSRI is first line post-myocardial infarction?
Sertraline
Which SSRI is first line for children?
Fluoxetine
What ADRs are associated with SSRIs?
GI Increased risk of GI bleeding Increased anxiety and agitation Prolonged QT interval (citalopram) Hyponatremia
What drugs do SSRIs interact with?
NSAIDs (need PPI co-prescribed)
Warfarin/heparin
Aspirin
Triptans (increased risk of serotonin syndrome)
MAOIs (increased risk of serotonin syndrome)
What are the features of SSRI discontinuation?
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
What is the risk of using SSRIs in pregnancy?
Avoid paroxetine
First trimester: congenital heart defects
Third trimester: persistent pulmonary hypertension of the newborn
What is the management of sleep paralysis?
Clonazepam
What risk factors assocaited iwth an increased risk of suicide?
Male History of self-harm Alcohol or drug misuse History of mental illness History of chronic disease Advancing age Unemployment or social isolation Unmarried/divorced/widowed
What risk factors are associated with an increased risk of completed suicide?
efforts to avoid discovery planning leaving a written note final acts such as sorting out finances violent method
What are protective factors in suicide?
family support
having children at home
religious belief
What are common side effects of TCAs?
drowsiness dry mouth blurred vision constipation urinary retention lengthening of QT interval
What is somatization disorder?
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
What are the features of illness anxiety disorder (hypochondriasis)?
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
What are the features of conversion disorder?
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
What are the features of dissociative disorder?
dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
What are the features of factitious disorder?
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
What are the features of malingering?
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
What are indications for ECT in depression?
Stupor or catatonia Psychotic depression Refusal of food and drink Dangerously suicidal patient Delay in effect of antidepressants will cause serious health risk
When do night terrors and sleepwalking most commonly occur?
NREM 3
What are the key features of alcohol depedence syndrome?
Strong desire/compulsion to drink; difficulty controlling levels of drinking
Physiological withdrawal symptoms
Evidence of tolerance
Progressive neglect of other pleasures/interests (salience)
Persistent drinking despite clear evidence of harmful effects
Narrowing of the drinking repertoire
Reinstatement of drinking after periods of abstinence
What are the features of Ganser syndrome?
Approximate answers Somatic conversion Pseudohallucination Subsequent amnesia Apparent clouding of consciousness
What is undoing?
Performance of an activity that symbolically reverses some previous behavior or thought
What is compensation?
Unconscious defence mechanism by which one attempts to make up for real or imagined deficiences
What is cyclothymia?
Cyclical mood swings from mild depression to hypomania
What is dysthymia?
Persistent (moer than 2 years) of chronic low grade depression without periods of elevated mood
What is the management of bipolar disorder?
1st line: lithium
2nd line: sodium valproate
What are the 4 phases of grief (Parkes and Bowlby)
1) Numbness
2) Pining
3) Disorganization and despair
4) Reorganization and repair
Define delusion.
Strongly held false belief that is not typical of the patient’s cultural or religious background and will be held despite evidence to the contrary
What is the classification of learning disability by IQ?
50-69: mild
35-49: moderate
20-34: severe
<20: profound
What are the symptoms of serotonin syndrome?
Pyrexia, tremor, hyper-reflexia anxiety, agitation, autonomic dysfunction, increased tone
What is the management of serotonin syndrome?
Removing the causative drug, providing supportive care, and cyproheptadine
What is the narcoleptic tetrad?
Cataplexy
Hypnagogic hallucinations
Daytime sleepiness
Sleep paralysis
Define illusion.
False perception of a real external stimulus
Define countertransference.
Therapist’s own feelings, emotions, and attitude
Define transference.
Unconscious process in which the patient transfers feelings and emotions to the therapist
Define resistance.
Words and actions of a patient that act to obstruct them from gaining access to their unconscious.
Define acting out.
Expression of unconscious emotional conflicts directly into actions without the patient being consciously aware of their meaning
What is the management of ADHD?
Methylphenidate
