Psychiatry Flashcards
What class of antipsychotic is Haloperidol and what is it’s MOA?
Typical Antipsychotic
Dopamine Receptor Antagonist (D2 Post-synaptic)
Name some common adverse effects of typical antipsychotics?
Extrapyramidal side effects; Tardive Dyskinesia(chewwing and pouting of jaw), Tremor, Stiffness, Involuntary Movements, Restlessness (Akathisia)
Hyperprolactinaemia
Name 2 Typical Antipsychotics
Haloperidol
Chlopromazine
Name 3 Atypical Antipsychotics
Clozapine
Risperidone
Olanzapine
What is neuroleptic malignant syndrome?
Life threatening neurological disorder associated with anti-psychotics
Give 3 medications that can cause neuroleptic malignant syndrome
Typical antipsychotics - Haloperidol (most common)
Atypical antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole)
Anti-emetics - Metoclopramide
Give 5 clinical features of neuroleptic malignant syndrome
Fever
Nausea and vomiting
Muscle rigidity
Autonomic instability
Mental status change (agitation, confusion, fluctuating consciousness)
When does neuroleptic malignant syndrome typically present?
Typically during the first 2 weeks of therapy.
But can develop years into treatment with no increase in dose.
Give 3 blood test findings that would be raised in neuroleptic malignant syndrome
Raised creatinine kinase
Raised LFTs (AST, ALT)
Raised leukocytes (leukocytosis)
Define illusion
An abnormal perception caused by a sensory misinterpretation of an actual stimulus
Define hallucination
An abnormal sensory experience that occurs in the absence of a direct external stimulus.
Perceived as real.
Define Pseudohallucination
An involuntary sensory experience that is similar to a hallucination but is recognised by the person experiencing it as subjective or unreal.
Perceived as unreal.
Define over-valued idea
A false or exaggerated and sustained belief that is maintained
Define delusion
A false, unshakable belief that’s out of keeping with the person’s cultural, intellectual and social background
Define delusional perception
A true perception to which a patient attributes a false meaning.
i.e a normal event such as traffic lights turning red is interpreted by the patient as meaning martians are about to land.
Define concrete thinking
Reasoning based on what you can see, hear, feel and experience here and now.
i.e if someone tells them to ‘break a leg’ they may wonder why they should snap their bone in two.
Define loosening of associations. What is it a feature of?
Aka derailment/knights move thinking.
Thought disorder describing a lack of connection between ideas.
Feature of schizophrenia
Define circumstantial speech
Aka fullness of detail
Describes when lots of unnecessary and insignificant details are used in conversation.
Patient returns to original point
Define tangential speech
Describes when the speaker wanders and drifts from the original topic, never returning to the original topic
Define confabulaiton
Describes the production or creation of false or erroneous memories without intent to deceive/lie
Define pressure of speech. What is it a sign of?
Describes a tendency to speak rapidly
Sign of mania/hypomania (linked to bipolar disorder)
Define anhedonia
Inability to enjoy things (common in depression/psychosis)
Define apathy
Complete lack of interest
Define incongruity of affect
Describes no link between the emotion their feeling and the story their telling.
I.e smiling when talking about their dog dying.
Define blunting of affect
No emotional response whatsoever to an emotional situation.
Define Belle indifference. What is it a feature of?
Describes lack of concern and/or feeling of indifference about medical symptoms they may have.
Feature of conversion symptoms/hysteria
Define conversion disorder
Disorder where a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by physical illness or injury
Define depersonalisation
Describes a feeling where the self is felt to be unreal or detached from reality
Define thought blocking
Describes when ones train of thought suddenly ceases
Define thought broadcasting
Describes an experience that ones thoughts are being transmitted from ones mind and broadcasted to everyone
Define thought disorder
Describes a disorder of the form of thought, where associations between ideas are lost or loosened
Describe thought echo
Describes where thoughts are heard as if they were spoken aloud
Describe thought insertion
The experience of alien thoughts being inserted into the mind
Describe thought withdrawal
The experience of thoughts being removed or extracted from ones mind
Define thought alienation
Describes when a patient feels their own thoughts are no longer in their control.
Define akathisia
Describes an inner feeling of excessive restlessness, provoking the patient to fidget or pace.
Define anterograde amnesia
Describes loss of memory subsequent to any cause e.g brain trauma
Define retrograde amnesia
Describes loss of memory for a period of time prior to any cause
Describe catatonia
A state where someone is awake but doesn’t seem to respond to other people and their environment.
Patient may stop voluntary movement or stay still in an unusual position
Define stupor
A state of near unconsciousness or insensibility
Define psychomotor retardation
Describes the slowing down or hampering of a persons mental or physical activities (i.e slowed speech, decreased movement ect)
Define flight of ideas. What condition is it commonly seen? (2)
Describes when thoughts become pressured and ideas may race from topic to topic, often guided by rhymes or puns.
Ideas are associated though, unlike thought disorder.
Seen in mania/hypomania
Define derealisation
An experience where a person perceives the world around them as unreal.
Linked to depersonalisation
Define cyclothymia
A variability of mood over days/weeks, cycling from positive to negative mood states.
Define compulsion
Describes the behavioural component of an obsession.
The individual feels the need to repeat a behaviour which has no immediate benefit beyond reducing the anxiety associated with the obsessional idea.
Define obsession (2)
Describes an unpleasant or nonsensical thought which intrudes into a person’s mind, despite a degree of resistance.
Patient recognises this thought as pointless or senseless.
Define stereotyped behaviour
Well-defined behavioural acts which are repeated over and over and seem to be aimless. (e.g pacing, body rocking
Define hypomania
An affective disorder characterised by elation, overactivity and insomnia
Lasts < 7 days
Doesn’t exhibit psychotic symptoms
Define mania
An affective disorder characterised by intense euphoria, overactivity and loss of insight
Lasts for at least 7 days
May present with psychotic symptoms (hallucinations/delusions of grandeur ect)
Define agnosia
Inability to organise sensory information to recognise objects (visual agnosia) or parts of the body (hemisomatoagnosia)
Define affect
Describes an individuals immediate emotional state which a person can recognise subjectively/objectively by others.
Describe asthenia
Abnormal physical weakness or lack of energy
Define passivity phenomena
When an individual feels some aspect of themselves is under the external control of another/others.
i.e made movements where they feel their arms and legs are under someone elses control, made thoughts (insertion/withdrawal) ect
What are Schneider’s First Rank Symptoms? (5)
Used in diagnosis of schizophrenia.
Auditory hallucinations
Thought disorders (insertion, withdrawal, echo, broadcasting)
Delusional perceptions
Somatic hallucinations
Passivity phenomena (when an individual feels some aspect of themselves is under the external control of another/others)
Give 5 positive (psychotic) symptoms seen in schizophrenia
Delusions
Hallucinations
Disorganised speech (hebephrenia)
Disorganised behaviour
Catatonic behaviour (decreased motor activity)
Give 5 negative symptoms of schizophrenia
Social withdrawal
Demotivation (Avolition)
Self-neglect
Alogia
Anhedonia
What age does schizophrenia tend to present?
Late teens to mid 30s
Describe the pathophysiology of schizophrenia
Thought to be due to;
- Increased activity in the mesolimbic neuronal pathway
and
-Decreased activity in the prefrontal cortical pathway
What are the 3 phases of schizophrenia?
Prodromal phase (withdrawal)
Active phase (positive symptoms)
Residual phase (cognitive symptoms)
Describe the prodromal phase (withdrawal) of schizophrenia. Give 4 features
Can precede active phase by 18 months
Features;
- Patients become withdrawn/socially isolated.
- Transient, low intensity psychotic symptoms
- Reduced interest in daily activities
- Anxiety, irritability or depressive features
Describe clinical features of the active phase (positive symptoms) of schizophrenia (5)
Follows the prodromal phase;
Delusions
Hallucinations
Disorganised speech (hebephrenia)
Disorganised behaviour
Catatonic behaviour (decreased motor activity)
Describe the residual phase (cognitive symptoms) of schizophrenia
Follows the active phase.
May display cognitive symptoms effecting;
Memory
Learning
Understanding
How is schizophrenia diagnosed?
Diagnosis requires at least 2 of the following ongoing for 6 months (with 1 month of active phase symptoms.
Delusions*
Hallucinations*
Disorganised speech*
Disorganised/catatonic behaviour
Negative symptoms.
Patients must have at least one of * for diagnosis.
Name 3 types of schizophrenia, which is most common?
Paranoid (most common - hallucinations/delusions are most prominent)
Hebephrenic (age of onset 15-25 years, poor prognosis)
Catatonic (stupor)
Describe schizoaffective disorder
Describes a combination of both schizophrenia and affective (mood) disorders (mania/depression)
Describe the management of schizophrenia
1st line - Oral atypical antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole ect)
2nd line - Clozapine
Clozapine offered to patients whom have not responded to sequential use of at least 2 different antipsychotics
What investigation should be performed before starting clozapine?
ECG (as can cause myocarditis)
What is the MOA of clozapine?
Dopamine receptor (D2) and Serotonin receptor (5HT3) antagonist
Give 3 side effects of clozapine
Metabolic side effects;
Weight gain
Hyperglycaemia (type 2 diabetes)
Dyslipidaemia
Agranulocytosis (decreased neutrophils)
Constipation/intestinal obstruction (common)
What can clozapine increase the risk of?
Seizures
As lowers seizure threshold
What side effects are associated with olanzapine?
Dyslipidaemia and weight gain
What side effects are associated with quetiapine?
Dyslipidaemia and weight gain
Also postural hypotension
What side effects are associated with risperidone?
Extrapyramidal side effects, postural hypotension and sexual dysfunction
Give 3 examples of acute dystonia
Torticollis (abnormal twisting of neck)
Oculogyric crisis (sustained upward deviation of both eyes)
Involuntary contractions of muscles in face, neck, abdomen or pelvis. Can lead to abnormal movement or postures
What is acute dystonia? Why can it occur?
Involuntary contractions of muscles in face, neck, abdomen or pelvis. Can lead to abnormal movements or postures.
Oculogyric crisis may occur (sustained upward deviation of both eyes)
Can occur 2nd to starting anti-psychotics
What is used to manage acute dystonia/parkinsonism following starting anti-psychotic treatment?
Procyclidine
What type of drug is procyclidine?
Anticholinergic
How is akathisia following starting antipsychotic treatment managed?
Propranolol +/- cyproheptadine
What is the moa of cyproheptadine?
Antihistamine + Anti serotonin
Used with propranolol for treatment of akathesia
What is a common symptom of high dose atypical antipsychotics (olanzapine, risperidone, ect)
Extrapyramidal side effects;
Tremor
Slurred speech
Akathesia (restlessness)
Dystonia (spasms/muscle contractions)
Describe Section 2 of the Mental Health Act
Section 2 - 28 day detainment
Act allows a patient to be detained in a hospital setting for assessment and treatment of a mental disorder.
Patients may be detained under section 2 if there is a risk to their own safety or the safety of others
Describe Section 3 of the Mental Health Act. What 2 medical recommendations are required?
Section 3 - 6 month detainment
2 medical recommendations are required;
- One from a psychiatrist approved under section 12
- One from a doctor who has a previous acquaintance with the patient (i.e GP)
Section 3 enables treatment to be restarted in a hospital setting.
Can patients appeal against their detention under Section 3?
Yes. This can be supported by an independent mental health advocate. A mental health is then conducted to review the patients detention.
Describe Section 5 (2) of the mental health act
Section 5(2) - 72 hour detention
Applies to patients whom are voluntary or whom are already a patient.
Patients under this section must be assessed by 2 doctors who decide whether they need more time in hospital. (then put under section 2/3)
Describe Section 135 of the Mental Health Act
Section 135 - Police detainment allowing entry into a property
Requires a warrant.
Patient can be kept in hospital for up to 24 hours.
Describe Section 136 of the Mental Health Act
Section 136- Police detainment from a public space (doesn’t require a warrant)
Give 2 core symptoms of Autism Spectrum Disorder
Persistent deficits in social communication and social interaction
Restricted, repetitive patterns of behaviour, interests or activities
When does ASD tend to present?
During childhood (before 2-3 years)
Give 5 clinical features of ASD
Impaired social communication and interaction
Repetitive behaviours, interests and activities (solitary play)
Impaired imagination
Ritualistic/insists on following routines in precise detail
Intellectual/language impairment
Give 2 conditions associated with ASD
ADHD
Epilepsy
Give 3 management strategies for ASD. Drugs (3)
Early intensive behavioural intervention (speech therapy, starting school at 3 can increase IQ)
Parent training
Drugs;
- Risperidone (reduces aggression)
- SSRIs (reduce repetitive behaviour)
- Melatonin (sleep)
What triad of symptoms is seen in ADHD?
Impulsivity
Hyperactivity
Inattention
Give 3 features of impulsivity that may be seen in a child with ADHD
Blurts out answers in class
Interrupts others
Cannot take turns
Give 3 features of hyperactivity that may be seen in a child with ADHD
Squirming/fidgeting
Talks constantly
Restless
Give 4 features of inattention that may be seen in a child with ADHD
Often unable to;
Listen/attend closely
Follow instructions
Organise tasks
Forgets/loses things
Between what ages are children commonly diagnosed with ADHD?
3-7 years old
What are the 1st and 2nd line non-pharmacological treatments for ADHD?
1st line - 10 week wait (observe symptoms)
2nd line - If symptoms persist, refer to secondary care > CAHMS referral
What are the 1st, 2nd and 3rd line drug therapies for ADHD? From what age can they be given?
Only given to children >5
1st line - Methylphenidate (ritalin)
2nd line - Lisdexamfetamine
3rd line - Dexafetamine
For how long is methylphenidate initially given to children with ADHD?
Initially given on a 6 week trial
What is the MOA of Methylphenidate (ritalin) (ADHD)
Dopamine/norepinephrine reuptake inhibitor
Give 3 side effects of Methylphenidate (ritalin) (ADHD)
Abdominal pain
Nausea
Dyspepsia
What should be monitored in children on Methylphenidate (ritalin)?
Height and Weight every 6 months
What investigation should be performed before starting ADHD drugs? Why?
ECG
As they’re cardiotoxic
What is required for ADHD diagnosis? (6)
> 6 Inattentive symptoms
> 6 Hyperactive/impulsive symptoms
Other conditions;
- Several symptoms occur before age of 12
- Symptoms must be present in 2 or more settings (home, school, work ect)
- Symptoms cannot be explained by another mental disorder
- There is clear evidence that symptoms interfere with school, social or work functioning.
What can long term lithium treatment cause?
Hyperparathyroidism and resultant hypercalcaemia.
Also hypothyroidism
Symptoms;
‘Stones, bones, abdominal moans and psychic groans’
What is the 1st line pharmaceutical for generalised anxiety disorder?
Sertraline
What is the SSRI of choice in children/adolescents?
Fluoxetine
Give 2 common side effects of SSRIs
Gastrointestinal symptoms (most common)
GI bleeding
What side effect is Citalopram associated with? Who is it contraindicated in?
Dose Dependent QT interval prolongation (torsades de points)
Contraindicated in;
Congenital Long QT syndrome
In patients on warfarin/heparin, what should be given instead of an SSRI?
Mirtazapine
How do NICE define generalised anxiety disorder?
A feeling of excessive worry about a number of different events associated with heightened tension
Give 3 alternative causes of generalised anxiety disorder
Hyperthyroidism
Cardiac disease
Medication-induced anxiety
Give 5 medications that may trigger anxiety
Salbutamol
Theophylline
Corticosteroids
Antidepressants
Caffeine
How is generalised anxiety disorder managed? (4)
Stepwise approach
Step 1 - Education about GAD + active monitoring
Step 2 - Low intensity psychological interventions (self guided/non-facilitated help)
Step 3 - High intensity psychological interventions (CBT) or drug treatment
Step 4 - Highly specialised input (multi agency teams)
Give 4 risk factors for GAD
Aged between 35-54
Being divorced or separated
Living alone
Being a lone parent
Give 2 protective factors against GAD
Being aged 16-24
Being married or cohabiting
Describe the drug treatment for generalised anxiety disorder (1st, 2nd and 3rd line)
1st line - Sertraline (SSRI)
2nd line - Duloxetine or Venlafaxine (Serotonin-noradrenaline reuptake inhibitor)
3rd line - Pregabalin
In whom may pregabalin be contrandicated?
Diabetes (can cause weight gain)
Renal impairment
Respiratory depression
Define panic disorder
A disorder of recurrent, unexpected panic attacks and persistent concern about having panic attacks
Define panic attack
A state of extreme acute, intensity anxiety and unreasoning fear accompanied by disorganization of personality function
Give 5 symptoms of a panic attack
Feeling of impending doom
Dyspnoea
Dizziness
Loss of balance or faintness
Palpitations, sweating, nausea
What is agoraphobia?
Fear of being in situations where escape may be difficult or that help wont be available if things go wrong.
How is panic disorder managed? What are the 1st and 2nd line drug treatments?
CBT or Drug treatment
1st line - SSRI
2nd line/no response after 12 weeks - Imipramine or clomipramine (tricyclic antidepressant)
What is the MOA of cocaine?
Blocks uptake of dopamine, noradrenaline and serotonin
Give 5 cardiovascular effects of cocaine
Coronary artery spasm > MI/ischemia
Tachy/Bradycardia
Hypertension
QRS widening and QT prolongation
Aortic dissection
Give 4 neurological effects of cocaine
Seizures
Mydriasis (dilated pupils)
Hypertonia
Hyperreflexia
Give 4 additional adverse effects of cocaine abuse
Ischemic colitis (abdominal pain/rectal bleeding)
Hyperthermia
Metabolic acidosis
Rhabdomyolysis
How is cocaine toxicity managed? (chest pain + hypertension)
Benzodiazepines are 1st line
Chest pain : Benzodiazepines + Glyceryl trinitrate
Hypertension: Benzodiazepines + Sodium nitroprusside
How is paracetamol overdose managed? (2)
If presenting within 1 hour - Activated charcoal
Acetylcysteine (infused over 1 hour)
What is the MOA of acetylcysteine?
Replenishes body stores of glutathione (needed to detoxify toxic intermediary product of paracetamol metabolism - NAPQI)
What is a common adverse reaction of acetylcysteine use? How is it managed?
Anaphylactoid reaction (non IgE mediated mast cell release)
Managed by stopping infusion and restarting at a slower rate
When is a paracetamol overdose considered as staggered?
When all tablets are not taken within an hour
What is the King’s Collage Hospital criteria for liver transplantation (paracetamol liver failure)
Arterial pH <7.3, 24 hours after ingestion
or all of the following;
PT time >100 seconds
Creatinine >300 umol/L
Grade III or IV encephalopathy
Give 4 early features of tricyclic antidepressant (Amitriptyline + Imipramine) overdose (antimuscarinics)
Dry mouth
Dilated pupils/Blurred vision
Agitation
Sinus tachycardia
Give 4 severe symptoms of tricyclic antidepressant overdose
Arrhythmias
Seizures
Metabolic acidosis
Coma
Give 3 ECG changes seen in tricyclic antidepressant overdose
Sinus tachycardia
Widening of QRS complex
QT prolongation
How is tricyclic antidepressant overdose managed?
IV bicarbonate (1st line for hypotension or arrhythmias)
How is beta blocker overdose managed?
Bradycardia - Atropine
If resistant - Glucagon
How does salicylate overdose (i.e aspirin) manifest?
As mixed respiratory alkalosis and metabolic acidosis
Give 5 features of salicylate overdose
Hyperventilation
Tinitus
Lethargy
Sweating, pyrexia, nausea and vomiting
Seizures
Hyperglycemia and hypoglycemia
How is salicylate overdose managed?
ABC + Charcoal
IV sodium bicarbonate (increases aspirin elimination in urine)
Haemodialysis
Give 5 indications for haemodialysis use in salicylate overdose
Serum concentration >700mg/L
Metabolic acidosis resistant to treatment
Acute renal failure
Pulmonary oedema
Seizures/coma
Describe the emergency management of opioid overdose
IV or IM naloxone (rapid onset)
What medications are used in the management of opioid dependence?
Methadone or Buprenorphine (sublingual tablet - alternative to methadone)
Define tolerance
Refers to the way someone has become physically dependent on a substance (alcohol or heroine) no longer responds to it the same way.
Leads to increasing the dose in order to feel the same effects
Define withdrawal
Describes onset of symptoms, both physical and mental, when a substance is reduced or not given to the body.
What is the recommended number of alcohol units per week
14 per week
If you do drink 14, spread over 3 days or more
How long does it take the kidney to eliminate one unit of alcohol?
1 hour
How is the number of units in a drink calculated?
Multiply the number of millilitres by the ABV and divide by 1000.
i.e 1 pint of 5% beer
1 pint = 568ml
(568*5)/1000 = 2.8 units
Describe the pathophysiology of chronic alcohol consumption
Enhances GABA mediated inhibition of CNS
Inhibits NMDA type glutamate receptors
Give 4 features of alcohol withdrawal
Symptoms start 6-12 hours after stopping;
Tremor
Sweating
Tachycardia
Anxiety
When is the peak incidence of seizures in alcohol withdrawal?
36 hours
When is the peak incidence of delirium tremens in alcohol withdrawal? How may it present? (5)
48-72 hours
Presents with;
Coarse tremor
Confusion
Delusions
Auditory/visual hallucinations
Fever + Tachycardia
How is alcohol withdrawal managed?
Hospital admission (if experiencing delerium tremens, seizures or blackouts)
1st line - Long acting Benzodiazepines (chlordizepoxide or diazepam)
2nd line - Lorazepam (in hepatic patients)
What medication is used as a deterrent to prevent alcohol relapse?
Disulfiram (acetaldehyde dehydrogenase inhibitor)
Causes severe vomiting after alcohol consumption
What medication is seen as an ‘anti-craving’ medication for preventing alcohol relapse?
Acamprosate
Define alcoholic ketoacidosis
Describes a non-diabetic euglycaemic form of ketoacidosis, occurring in people who regularly drink large amounts of alcohol.
Occurs due to malnourishment 2nd to not eating/vomiting from alcohol consumption
Give 4 features of alcoholic ketoacidosis
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose
How is alcoholic ketoacidosis managed?
Infusion of saline and thiamine
Thiamine required to avoid Wernicke encephalopathy or Korsakoff psychosis
Give 5 features of opioid misuse
Rhinorrhoea
Needle track marks
Pinpoint pupils
Drowsiness
Watering eyes
A patient misses > 2 days of their clozapine dose, how should this be managed?
Re-titrate clozapine doses again slowly
Give 3 features of SSRI discontinuation syndrome
Occurs when SSIRs are suddenly stopped/reduced.
Features;
Dizziness
Electric shock sensations
Anxiety
GI side effects (diarrhoea)
How may Bulimia nervosa present in an emergency setting?
May present with features of Hypokalemia;
ECG (features of hypokalaemia);
Tall P waves
Flattened T waves
First degree heart block
ABG
Metabolic alkalosis
Hypochloremia (due to loss of HCL in stomach from vomiting)
What metabolic disturbance is seen in anxiety?
Respiratory alkalosis (due to hyperventilation)
Describe the process of grief (5)
Denial - Numbness and pseudohallucinations of deceased (auditory/visual)
Anger - Directed against family members and medical professionals
Bargaining
Depression
Acceptance
Give 2 questionnaires used to screen for depression
Hospital Anxiety and Depression (HAD) scale
Patient Health Questionnaire (PHQ-9)
What 2 ‘depression identification’ questions are asked to a patient presenting with depression?
During the last month, have you often been bothered by feeling down, depressed, or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
How is depression diagnosed?
Depressive symptoms present most days, most of the time for at least 2 weeks.
Patients must have at least 2 core symptoms and 2 or more typical symptoms
What are the core symptoms of depression? (3)
Depressed mood for most of the day, nearly every day
Anhedonia (loss of interest/pleasure in daily life)
Fatigue (lack of energy which goes beyond poor sleep)
What are the typical symptoms of depression? (7)
Poor appetite with marked weight loss (>5%) or Rarely increased appetite
Disrupted sleep (early waking/initial insomnia)
Psychomotor retardation or agitation
Decreased libido
Reduced ability to concentrate
Feeling of worthlessness/excessive guilt
Recurrent thoughts of death, suicide ideation or suicide attempts.
Describe the criteria for depression severity
Mild - 2 typical + 2 core symptoms
Moderate - 2 typical symptoms + 3+ core symptoms
Severe - 3 typical symptoms + 4+ core symptoms
What is the 1st line for mild depression?
Guided self-help.
Do not routinely offer antidepressants unless the person wishes to start drug treatment, then offer SSRI.
What antidepressants should be avoided in depression, and why?
Tricyclic antidepressants (except lofepramine)
Venlafaxine (SNRI)
Due to risk of death from overdose.
What are the preferred 1st line antidepressants for patient with chronic physical conditions?
Sertraline or Citalopram (SSRI)
When should an initial review be conducted in an 18-25 year old starting antidepressant medication?
1 week after starting medication
What antidepressants should be avoided in a patient taking NSAIDs for a chronic physical condition? What is suitable instead?
SSRIs and SNRIs (due to increased risk of GI bleeding)
Mirtazapine (atypical antidepressant) may be given instead
What antidepressants should be avoided in patients taking Warfarin/Heparin? What may be offered instead?
Warfarin - Tricyclic antidepressants, SSRIs or SNRIs
Heparin - SSRIs and SNRIs
Mirtazapine may be offered instead
What is the 1st line antidepressant for patients on anti-epileptic drugs?
SSRIs - Sertraline/Citalopram
What antidepressants should be avoided in patients taking anti-epileptic drugs? Why?
Tricyclic antidepressants - Amitriptyline ect
As they lower the seizure threshold
What antidepressant should be avoided in patients on Clozapine or Theophylline? What can be given instead?
Fluvoxamine (SSRI)
Give Sertraline/Citalopram instead
What kind of electrolyte imbalance can SSRIs cause?
Hyponatremia
What are the 1st, 2nd and 3rd line medications for treatment of depression?
1st line - SSRI (Fluoxetine, Sertraline, Citalopram)
2nd line - Alternative SSRI
3rd line - Mirtazapine (NaSSA) or Venlafaxine (SNRI)
Give 2 side effects of mirtazapine
Increased appetite > weight gain
Increased fatigue
Mmmmm - Makes you hungry
Zzzzz - Makes you tired
Name 2 MAOIs - Monoamine oxidase inhibitors (anti-depressants)
Moclobemide and Phenelzine
Describe the process of swapping from an MAOI to another anti-depressant (2)
Withdraw drug and wait 2 weeks.
For moclobemide wait 24 hours
How should antidepressant medication be stopped?
Advise slowly tapering dose in steps over time
Define serotonin syndrome
Describes a life threatening condition caused by serotonergic overactivity
Give 4 causes of serotonin syndrome
SSRIs taken with St John’s wort
Monoamine oxidase inhibitors
Ecstasy
Amphetamines
Give 3 clinical features of serotonin syndrome
Acute onset - Hours
Tremor, myoclonus, rigidity, hyperreflexia
Hyperthermia, sweating, restlessness
Confusion/Convulsions
How is serotonin syndrome managed?
Mild/moderate - IV fluids + Benzodiazepines (sedation)
Severe - Cyproheptadine (serotonin receptor antagonist) +/- Chlorpromazine
Define bipolar disorder
Describes psychiatric condition characterised by episodes of mania (or hypomania) and major depression, separated by periods of normal mood and functioning.
Define mania and describe how an episode of mania may present? (5)
Describes functional impairment/psychotic symptoms for >7 days
Elevated mood
Talkativeness (pressured speech)
Racing thoughts (flight of ideas)
Psychosis (impaired perception of reality - delusions (grandiose) /hallucinations)
Decreased need for sleep
Define hypomania
Describes decreased of increased function for 4 days or more. Similar to mania but without psychotic symptoms.
Name 2 types of bipolar and state how they are defined
Type 1 Bipolar disorder - Defined by at least one episode of mania
Type 2 Bipolar Disorder - Defined by at least 1 episode of hypomania AND one major depressive episode (no previous episodes of mania)
How may a manic episode present in children? (3)
Sleeping only for a few hours and not feeling tired
Difficulty staying focused in school
Increased interest in risky activities (dangerous sports without proper training(
How may a depressive episode present in children? (3)
Sleeping more than usual (>12 hours several days in a row)
Lack of interest in activities they previously enjoyed
Feelings of doing everything wrong
How is an acute episode of mania treated in secondary care? (1st, 2nd and 3rd line)
1st - Trial oral antipsychotic (Haloperidol, Olanzapine, Quetiapine or Risperidone)
2nd - Trial alternative antipsychotic (list above)
3rd - Lithium +/- Sodium valproate (if lithium not suitable)
How is mania/hypomania managed in patients taking antidepressants?
Stop antidepressant and start antipsychotic therapy (i.e olanzapine)
How is depression treated in an acute bipolar episode? (4)
Quetiapine alone, or
Fluoxetine + olanzapine, or
Olanzapine alone, or
Lamotrigine alone.
To prevent further relapses of acute bipolar episodes, what may a patient be offered?
To continue current treatment for mania, or
Start long term Lithium (to prevent relapses), or
If Lithium is ineffective, add Sodium Valoprate, or
If Lithium is poorly tolerated, Valporate alone or Olanzapine may be considered
How should treatment with lithium be monitored? (3)
Check serum Lithium levels weekly (12 hours post dose).
Once level is constant, check blood levels every 3 months
Also check thyroid and renal function every 6 months
After increasing a dose of lithium, when should a patients blood levels be re-checked?
1 week later
What should be suspected if lithium levels are slowly rising (in weekly checks)?
Nephrotoxicity (polyuria, DI)
Give 4 adverse effects of lithium use
Nausea/vomiting/Diarrhoea
Fine tremor
Hypothyroidism
Weight gain
Lithium toxicity occurs in concentrations above?
> 1.5mmol/L
What may lithium toxicity be precipitated by? (3)
Dehydration
Renal failure
Drugs: diuretics (thiazides), ACEi/ARBs, NSAIDs, Metronidazole
Give 5 clinical features of lithium toxicity
Coarse tremor
Hyperreflexia
Polyuria
Acute confusion
Seizure/coma
How is lithium toxicity managed? (3)
Mild/moderate - IV fluids (volume resuscitation)
Severe - Haemodialysis
Adjunct - Sodium bicarbonate (increasing alkalinity of urine promotes lithium excretion)
What medication can cause iatrogenic mania in patients taking Lithium?
Tricyclic antidepressants
Define dissociative identity disorder
Describes when a patient has multiple personalities.
Define fugue
Describes an inability to recall ones past +/- loss of identity or formation of a new identity.
Define delirium
Acute confusion state (ACS).
Describes a state of fluctuating, impaired consciousness with onset over hours or days, or a rapid deterioration in pre-existing cognitive function
Name 4 behavioural changes seen in delirium
Cognitive function - Worsened concentration, slow responses, confusion and disorientation in time
Perception - Visual/auditory hallucinations
Physical function (fluctuating) - Reduced mobility/movement, restlessness, agitation
Social behaviour - Lack of cooperation, withdrawal, mood changes, poorly developed delusions.
Give 6 common causes of delirium
Infection
Drugs (benzodiazepines, opiates, digoxin, L-dopa)
Hypoglycemia
AKI
Alcohol withdrawal
Trauma/surgery
How is delirium managed?
Remove precipitating cause
Optimize supportive surroundings and nursing care
Avoid sedation unless extreme agitation (Haloperidol/Olanzapine - as benzodiazepines can precipitate delirium).
What medications should be avoided in patients taking SSRIs?
Triptans
NSAIDs
How may OCD present to primary care? (3)
Dermatological symptoms (excessive hand washing)
Genital or anal symptoms (Excessive checking/washing)
General stress (losing job/interpersonal relationships)
Give 5 common obsessions seen in OCD
Contamination from dirt, germs of viruses
Fear of harm
Excessive concern with order or symmetry
Superstition (bad umbers, magical thinking)
Forbidden thoughts (such as being a paedophile, blasphemy, harming others ect)
Give 5 common compulsions
Repetitive hand washing (fear of contamination)
Checking (doors are locked, electrical items unplugged)
Ordering, arranging and/or repeating
Mental compulsions (prayers, asking for forgiveness, counting)
Memory checking
What scale is used to measure severity of OCD?
Yale-Brown Obsessive-Compulsive Scale
How is OCD managed in adults with mild functional impairment?
Low intensity CBT including exposure and response prevention (ERP)
10 hours per person
How is OCD managed in adults with moderate functional impairment
Offer choice of CBT including ERP or SSRI
Consider clomipramine as 2nd line is SSRI is contraindicated or if they had a good response to it in the past
How is OCD with severe functional impairment managed?
Combined therapy of CBT (inc ERP) with SSRI
2nd line - Clomipramine
What SSRIs are used in OCD? (5)
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
SSRIs after 20 weeks pregnancy increase the risk of what?
Persistent pulmonary hypertension of the newborn and/or neonatal withdrawal
SSRIs after 20 weeks pregnancy increase the risk of what?
Persistent pulmonary hypertension of the newborn and/or neonatal withdrawal
What type of drug is clomipramine?
Tricyclic antidepressant
Give 4 clinical features of autism spectrum disorder
Impaired social communication and interaction
Impaired imagination
Poor range of activities and interests
Intellectual impairment, ADHD or epilepsy
Give 2 protective factors against GAD
Being aged 16-24
Being married or cohabiting
Define copropraxia
Involuntary performing of obscene or forbidden gestures/ inappropriate touching
Define echopraxia
Meaningless repetition or imitation of movements of others
Define neologism
Made up word
Define palilalia
Automatic repetition of one’s own words, phrases or sentences
Define Cotard Delusion/Syndrome. What is it a feature of?
Patients believe they are dead or non-existent
Feature of severe depression
Define De Clerambault Delusion/Syndrome (erotomania). What is it a feature of?
Delusional idea what someone of higher social/professional standing is in love with them.
Feature of major depressive disorder
Describe Othello Syndrome. What is it a feature of?
Paranoid delusion of jealousy, characterised by false absolute certainty of the infidelity of a partner.
Feature of Paranoid Schizophrenia
Describe Capgras delusion. What is it a feature of?
Delusional misidentification syndrome. Characterised by a false belief that an identical duplicate has replaced someone significant to the patient.
Feature of dementia
What is the MOA of benzodiazepines?
Enhances effect of GABA (gamma-aminobutyric acid)
By increasing the frequency of chloride channels
What is the MOA of duloxetine?
Serotonin Noradrenaline Reuptake Inhibitor (SNRI)
What additional medication should be offered to patients on a combination of SSRI and NSAID?
PPI - To lower risk of GI bleeding
What scoring system is used to assess alcohol withdrawal severity?
Clinical institute withdrawal assessment (CIWA-Ar)
What should be monitored at initiation and dose titration of Venlaflaxine?
Blood pressure
SNRIs are associated with hypertension
Give 4 factors associated with a poor prognosis in schizophrenia
Strong family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
How is sexual aversion disorder characterised?
By disgust at the thought of sex
How is female sexual arousal disorder characterised?
Patients lack the desire to have sex and also experience vaginal dryness when trying to have sex
How is hypoactive sexual desire disorder characterised
Typically follows starting antidepressant (SSRI).
Patient show reduced libido following starting SSRI/depression
