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Phase 3A Revision > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

3 core symptoms of depression

A

Low mood
Anergia
Anhedonia

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2
Q

6 somatic/biological symptoms of depression

A
  1. Early morning wakening/sleep disturbance
  2. Loss of appetite + weight/change in appetite
  3. Diurnal variation of mood
  4. Change in libido/reduced libido
  5. Loss of emotional reactivity
  6. Psychomotor agitation/retardation
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3
Q

What is anhedonia?

A

Loss of enjoyment of formerly pleasurable activities

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4
Q

What is another name for obsessive compulsive personality disorder?

A

Anankastic personality disorder

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5
Q

What is the definition of depression?

A

Pervasive lowering of mood

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6
Q

Differential diagnosis of depression

A

Normal sadness
Dysthymia
Schizophrenia (blunting, unreactive affect)
Bipolar disorder
Alcohol/drug withdrawal

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7
Q

What drug, with specific anti-obsessional properties, is used in OCD?

A

Clomipramine (a tricyclic antidepressant)

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8
Q

First line pharmacological management of OCD

A

SSRIs

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9
Q

First line pharmacological management of PTSD

A

SSRIs e.g. sertraline

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10
Q

First line psychological therapy for PTSD

A

CBT

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11
Q

HARD features of PTSD

A

Hyperarousal
Avoidance
Reexperiencing
Distress

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12
Q

How long must core symptoms of depression be present for a diagnosis?

A

At least two weeks

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13
Q

In which patients would you be reluctant to prescribe benzodiazepines?

A

Patients with addiction problems/substance misuse

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14
Q

Main points of ICD-10 criteria for obsessive compulsive personality disorder

A
  1. General criteria of personality disorder must be met
  2. At least four of:
    - Feelings of excessive doubt and caution
    - Preoccupation with details, rules, lists, order organisation or schedule
    - Perfectionism that interferes with task completion
    - Excessive conscientiousness and scrupulousness
    - Undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships
    - Excessive pedantry and adherence to social conventions
    - Rigidity and stubbornness
    - Unreasonable insistence by the patient that others submit to exactly his or her way of doing things, or unreasonable reluctance to allow others to do things
    - Intrusion of insistent and unwelcome thoughts or impulses
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15
Q

Main points of ICD-10 criteria for OCD

A
  1. Obsessions, compulsions, or both, present on most days for >/= 2 weeks
  2. Obsessions or compulsions cause distress, or interfere with functioning
  3. Obsessions and compulsions share these features:
    - Acknowledged as originating in the mind of the patient
    - Repetitive and upleasant, with at least one acknowledged as excessive or unreasonable
    - Subject tries to resist them (at least one must be unsuccessfully resisted)
    - Carrying out the obsessive thought or compulsion is not in itself pleasurable
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16
Q

Main points of ICD-10 criteria for PTSD

A
  1. Exposure to stressful event or situation of an exceptionally threatening or catastropic nature, which is likely to cause distress in almost anyone
  2. Persistent remembering or reliving of the stressor; or, expriencing distress when exposed to circumstances similar to stressor
  3. Acutal or preferred avoidance of circumstances resembling or associated with the stressor, which was not present before exposure
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17
Q

Medical causes of depression

A

Hypothyroidism
Physical health problems/chronic disease
Medications
Childbirth (postnatal depression)

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18
Q

How is mild depression defined?

A

Core symptoms of depression + 2-3 others

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19
Q

How is moderatre depression defined?

A

Core symptoms of depression + 4 others + impact on daily functioning

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20
Q

Non-pharmacological treatments for depression

A

Self-help
CBT
Interpersonal therapy

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21
Q

Pharmacological treatment of PTSD (not SSRI)

A

Venlafaxine

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22
Q

Other, non-somatic, symptoms of depression (x5)

A

Loss of confidence
Loss of concentration
Guilt
Hopelessness
Suicidal ideation

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23
Q

Pharmacological management of anxiety symptoms in short-term of PTSD

A
  1. Benzodiazepines
  2. Beta-blockers
  3. Promethazine
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24
Q

Psychological therapy for OCD

A

CBT with exposure and response prevention

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25
Q

Psychological therapy specific to PTSD

A

Eye movement desensitising and reprocessing (EMDR) therapy

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26
Q

Psychotic symptoms are usually mood…

A

Congruent e.g.
Nihilistic and guilty delusions
3rd person derogatory auditory hallucinations

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27
Q

Risk factors for depression (x6)

A

Family history
History of abuse
Substance use
Low SES
Chronic disease
Traumatic life event

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28
Q

How is severe depression defined?

A

Core symptoms of depression + other symptoms + suicidal ideation/marked loss of functioning

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29
Q

Signs of depression on MSE

A

Possible weight loss
Psychomotor retardataion (movement, speech)
Decreased reactivity
Avoiding eye contact
Slow + quiet speech

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30
Q

Third line pharmacological management of OCD (resistant to SSRIs and clomipramine)

A

MAOIs e.g. phenelzine

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31
Q

5 Ps of Psychiatry

A 
Presenting problem
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors
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32
Q

What does ASEPTIC stand for in the MSE?

A 
Appearance and behaviour
Speech
Emotions - mood and affect
Perceptions
Thoughts
Insight
Cognition
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33
Q

Which medications may cause depression?

A

Isoretinoin (roaccutane)
Beta-blockers

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34
Q

Main points of ICD-10 criteria for bipolar disorder

A

History of 2 mood episodes
At least one of:
- Hypomania (<4 days)
- Mania (>7 days)

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35
Q

DSM-IV criteria for bipolar disorder

A

One episode of mania (or mixed mood); or
One episode of hypomania plus a major depressive episode

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36
Q

Features of bipolar disorder on MSE: appearance + behaviour

A

Flamboyantly dressed
Self neglect (unkempt/dehydrated)
Overactivity
Difficult to interview

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37
Q

Features of bipolar disorder on MSE: Speech, mood + affect

A

Increased pressure of speech
Increased rate and amount of speech
Hard to interrupt
Usually elated

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38
Q

Features of bipolar disorder on MSE: thoughts

A

Content: inflated view of own importance, grandiose
Form: chance relationships, verbal associations, clang associations

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39
Q

Features of bipolar disorder on MSE: perception + insight

A

May have delusions of persecution or grandiose - usually mood congruent
Auditory hallucinations
Lacking insight

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40
Q

Differential diagnosis of bipolar disorder

A

Substance use (stimulants, hallucinogens, opiates)
Schizophrenia
Anxiety disorders/PTSD
ADHD or conduct disorder

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41
Q

Medications that may induce symptoms of hypomania/mania

A

Antidepressants
Benzodiazepines
Antipsychotics e.g. olanzapine, risperidone
Lithium (toxicity, or combined with TCAs)
Many others

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42
Q

Pharmacological management of bipolar disorder

A

Mood stabilisers:

  1. Lithium
  2. Anticonvulsants e.g. sodium valproate, carbamazepine, lamotrigine
  3. Anti-psychotics: used in acute mania e.g. olanzapine
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43
Q

Blood tests needed for a patient on lithium

A

Renal function (U+Es, Creatinine clearance): Li excreted by kidneys
TFTs (hypothyroidism)
Calcium

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44
Q

Side effects of Lithium

A

Leukocytosis
Insipidus (diabetes)
Tremor (fine)
Hypothyroidism
Increased Urine
Mums beware (teratogenic)

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45
Q

At what level is lithium toxic?

A

Upper therapeutic limit = 1.2mmol/L
>1.5mmol/L = some symptoms of toxicity
>2.0mmol/L = definite, life-threatening toxicity

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46
Q

What diuretics are most associated with lithium toxicity

A

Bendroflumethiazide

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47
Q

Effects of lithium toxicity

A

Blurred vision
Coarse tremor (fine tremor = early)
Muscle weakness
Ataxia
N+V
Hyperreflexia
Circulatory failure
Oliguria/polyuria
Seizures
Coma
Slurred speech

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48
Q

Example of selective serotonin re-uptake inhibitors (SSRI)

A

Sertraline
Citalopram
Fluoxetine

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49
Q

Side effects of SSRIs

A

Nausea + indigestion
Worsening of sexual dysfunction
Suicidal thoughts
Serotonin syndrome

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50
Q

Examples of serotonin-norepinephrine uptake inhibitors (SNRIs)

A

Venlafaxine

Duloxetine

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51
Q

Side effectts of SNRIs

A

Venlafaxine can raise BP + is c/i in heart disease

Similar to SSRIs

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52
Q

Examples of tricyclic antidepressants

A

Amitriptyline

Dosulepin

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53
Q

Side effects of TCAs

A

Anticholinergic effects
Dry mouth
Tachycardia
Constipation
Sleepiness
Weight gain
Urinary retention

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54
Q

Examples of monoamine oxidase inhibitors (MAOIs)

A

Phenelzine

Moclobemide

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55
Q

Side effects of MAOIs

A

Raised BP if taken with tyramine: aged cheese, cured meeats, broad beans

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56
Q

Example of atypical antidepressant

A

Mirtazepine

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57
Q

Action of mirtazapine

A

Alpha-2 antagonist

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58
Q

Side effects of mirtazapine

A

Drowsiness

Weight gain

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59
Q

What questionnaires can be useful in detecting/assessing severity of depression?

A

PHQ-9
HADS
BD-II

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60
Q

Management of first presentation of mild depression not wanting intervention, or subthreshold depressive symptoms

A

Active monitoring
Discuss problem + concerns
Arrange follow-up around 2 weeks time

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61
Q

Management of persistent subthreshold depressive symptoms, or mild-to-moderate depression

A

Low intensity psychological intervention e.g. IAPT
Group-based CBT if declining above
Consider antidepressants if:
- History of moderate or severe depression
- Subthreshold depressive symptoms lasting long period (2 years)
- Symptoms persisting after other interventions
- Mild depression complicating care of chronic physical health problem

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62
Q

Management of moderate or severe depression

A

Antidepressant

High-intensity psychological intervention

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63
Q

Important points when starting someone on an antidepressant

A

Consider suicide risk + toxicity in overdose
Symptoms of anxiety may initially worsen
May take time to work
Should be continued for at least 6 months following remission of symptoms, to prevent relapse

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64
Q

What is Section 2 under the Mental Health Act?

A

Assessment section (although treatment can be given)
Allows compulsory admission for up to 28 days
Cannot be renewed
Can occur anywhere except prison

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65
Q

What is Section 3 under the MHA?

A

Treatment section
Allows compulsory admission for up to 6 months
Can be renewed idefinitely

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66
Q

Who is required to enact a Section 2?

A 
2 doctors (1 must be S12 approved)
AMHP
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67
Q

Evidence required for a Section 2

A

Should suspect a mental disorder

Risk to individual, or ris to other people

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68
Q

Who is required for a Section 3?

A

2 doctors

1 AMHP

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69
Q

Evidence required for a Section 3

A

Requires a diagnosis
Place of treatment must be identified
Treatment must be available
Treatment is in their best interests (and for other people)

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70
Q

What is Section 4 under the MHA?

A

Emergency order
Lasts 72 hours
Used when waiting for a second doctor would lead to an undesirable delay

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71
Q

Who is required for a Section 4?

A

1 doctor

1 AMHP

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72
Q

Requirements for a section 4?

A

Mental disorder suspected
Risk to self or others
Not enough time for a 2nd doctor to attend for the assessment

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73
Q

What is Section 5(4) under the MHA?

A

Nurses’ holding power
Patients in hospital (not A+E)
Lasts 6 hours (for until a doctor can attend)
Cannot be treated coercively

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74
Q

What is Section 5(2) under the MHA?

A 
Doctors' holding power
Patients in hospital (not A+E)
Lasts 72 hours
Cannot be done by FY1
Cannot be treated coercively
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75
Q

What is Section 136 under the MHA?

A

Police section

For a person suspected of having mental disorder in a public place (not someone’s home)

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76
Q

What is Section 135 under the MHA?

A

Police Section

Requires a court order to access a person’s home and remove them

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77
Q

What is the most common genetic cause of intellectual disability?

A

Trisomy 21 (Down’s syndrome)

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78
Q

What is the most common inherited intellectual disability?

A

Fragile X syndrome

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79
Q

Fragile X syndrome in females

A

Milder symptoms

Premature ovarian failure

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80
Q

Facial features of fragile X syndrome

A

Long, narrow face
Prominent jaw
Big ears

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81
Q

Body features of fragile X syndrome

A

Large hands and feet
Hyperextensible joints
Pes planus (flat foot)
Macroorchidism

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82
Q

Cardiac defect common in Fragile X syndrome

A

Mitral valve prolapse

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83
Q

Genetic testing for Fragile X syndrome

A

X-linked inheritance
>200 CGG repeats in FMR1 gene

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84
Q

What level of IQ is defined as a mild intellectual disability?

A

50-69

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85
Q

What level of IQ is defined as a moderate intellectual disability?

A

35-49

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86
Q

What level of IQ is defined as a severe intellectual disability?

A

20-34

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87
Q

What level of IQ is defined as a profound intellectual disability?

A

<20

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88
Q

Causes of intellectual disability?

A

Genetic abnormalities
Prenatal viruses
Birth complications e.g. prematurity, hypoxic brain injury, cerebral pasly
Childhood illness e.g. meningitis, brain injury, severe neglect

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89
Q

How is a personality disorder defined?

A

Lifelong, persistent, deeply ingrained maladaptive behaviour
Characterises an individual
Deviates markedly from expected or accepted ‘normal’
Onset in late childhood or early adolescence
Not explained by organic disease or other mental disorder

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90
Q

In what categories must a personality disorder deviate from normal?

A

More than one of:

  • Cognition
  • Affectivity
  • Occupational and social performance
  • Impulse control and need gratification
  • Interpersonal function
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91
Q

What are Cluster A personality disorders?

A

‘Odd/Eccentric’
Schizoid - socially withdrawn
Paranoid - delusional
Schizotypal - distorted reality

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92
Q

What are Cluster B personality disorders

A

‘Dramatic/Erratic’
EUPD
Histrionic
Narcissistic
Dissocial

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93
Q

What are Cluster C personality disorders?

A

‘Anxious/Fearful’
Obsessive compulsive personality disorder (Anankastic)
Dependant
Avoidant

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94
Q

Features of EUPD?

A 
Emotional instability
Lack of impulse control
Outbursts of violence or threatening behaviour are common - especially in response to criticism
Low self-esteem/self-image uncertaining
Feelings of emptiness
Intense and unstable relationships
Avoids abandonment
Self harm/suicide
Engage in dangerous, risky behaviour
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95
Q

First line psychological management of EUPD

A

DBT (dialectical behaviour therapy)

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96
Q

Common features in personal history of people with EUPD

A

Insecure attachment
Domestic violence
Childhood sexual abuse

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97
Q

Criteria for a delusion

A

Certainty held with absolute conviction
Incorrigibility
Impossibility or falseity of content

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98
Q

Ways of describing delusions

A

Mood congruent vs incongruent
Themes: persecutory, grandiose, erotomania, jealousy, poverty
Specific delusions e.g. delusions of reference (believing insignificant things have a personal meaning or significance)

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99
Q

Capgras syndrome

A

Form of delusional misidentification - person believes another person has been replaced by an exact double
Similar to:
- Intermetamorphosis (person transformed into different person)
- Fregoli syndrome (stranger is someone familiar)
- Syndrome of subjective doubles (another person been transferred into your own self)

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100
Q

Folie a deux

A

Where a delusional belief is transferred form a psychotic person to another inidividual, usually close to them
The associate is often socially, intellectually or physically deprived or disadvantaged

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101
Q

What is an obsession?

A

A recurrent thought, impulse or image that enters the subject’s mind despite resistance

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102
Q

What is formication?

A

A form of haptic or tactile hallucination where the person feels insects crawling in, on, or underneath the skin.
Associated with intoxication or withdrawal from alcohol and drugs (particularly cocaine)
Can also occur in psychosis

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103
Q

What is an overvalued idea?

A

A belief not held quite as strongly as a delusion, and is typically more understandable

104
Q

What is passivity?

A

Feeling as if they are being taken over/not in control of own thoughts and actions

105
Q

Examples of thought interference

A

Insertion
Withdrawal
Broadcasting

106
Q

Circumstantial speech/thought

A

Irrelevant details and digressions overwhelm the direction of the thought process
Cannot provide an answer without excess, unnecessary detail
Question will still be answered in the end
Seen in mania and anankastic personality disorder

107
Q

Tangenital speech

A

Patient goes off on a tangent and will not answer the question

108
Q

Perseveration speech

A

Repeating ideas or words despite an attempt to change the topic

109
Q

Clanging speech

A

Speech pattern where sounds rather than meaning govern the use of words
May occur during flight of ideas

110
Q

Neologisms

A

Use of made up words

111
Q

Echolalia

A

Repetition of someone else’s speech, including the question that was asked
Occurs in schizophrenia and intellectual disabilities

112
Q

Flight of ideas

A

Patients leap from one topic to another with minimal links between them
Ideas may be linked by puns, rhymes etc.
Seen in hypomania/mania

113
Q

Loosening of associations

A

Lack of connection between ideas

Seen in schizophrenia

114
Q

Word Salad

A

Complete jumble of words

115
Q

Verbigeration

A

Sounds/words repeated in a senseless way

116
Q

Knights move thinking

A

Unexpected and complete illogical leaps from one topic to another

117
Q

Thought block

A

Abrupt and complete interruption in stream of thought
Seen in schizophrenia
Often accompanies thought withdrawal

118
Q

Derealisation

A

The feeling of unreality or detachment with respect to surroundings or external world

119
Q

Depersonalisation

A

Subjective feeling of altered reality of the self
Alteration in the perception or experience of the self so that one feels detached from and as if one is an outside observer of one’s mental procceses or body

120
Q

Akathisia

A

Subjective sense of an uncomfortable desire to move, relieved by repeated movement of the affected part (typically legs)
Side-effect of neuroleptic drugs

121
Q

Autochthonous delusion

A

A primary delusion which appears to arise fully formed in a patient’s mind without explanation

122
Q

Automatism

A

Behaviour which is apparently conscious in nature that appears in the absence of full consciousness e.g. in a seizure

123
Q

Blunting of affect

A

Loss of the normal degree of emotional sensitivity and sense of the appropriate emotional response to events
Negative symptoms of schizophrenia

124
Q

Belle indifference

A

Surprising lack of concern for, or denial of, apparently severe functional disability

125
Q

Catatonia

A

Increased resting muscle tone which is not present on active or passive movement
Motor symptom of schizophrenia

126
Q

Clouding of consciousness

A

Level between full consciousness and coma

127
Q

Confabulation

A

Process of describing plausibly false memories for a period for which the patient has amnesia
Seen in Korsakoff psychosis and dementia

128
Q

Conversion

A

Development of features suggestive of a physical illness which are instead attributed to psychiatric illness or emotional disturbance

129
Q

Cotard syndrome

A

Psychotic depressive illness seen in eldery people in particular
Severely depressed mood with nihilistic delusions and/or hypochondriacal delusions

130
Q

Cyclothymia

A

Personality characteristic of cyclical mood variation to a lesser degree than bipolar disorder

131
Q

Dissociation

A

Separation of unpleasant emotions and memories from consciousness awareness with subsequent disruption to the normal integrated function of consciousness and memory

132
Q

What are the first rank symptoms of schizophrenia?

A

Auditory hallucinations :
- Third person auditory hallucinations
- Thought echo
- Running commentary
Delusions of thought interference:
- Thought insertion
- Thought withdrawal
- Thought broadcasting
Delusions of control
- Passivity of affect
- Passivity of impulse
- Passivity of volitions
- Somatic passivity
Delusional perception: a primary delusion of any content that is reported by the patient as having arisen following the experience of a normal perception

133
Q

Somatic passivity

A

Experience of bodily sensations being imposed by external agency

134
Q

Flattening of affect

A

Dimunition of the normal range of emotional experience

Negative symptom of schizophrenia

135
Q

Formal thought disorder

A

Used to refer to three different groups of psychiatric symptoms:

  • All pathological disturbances in the form of thought
  • Synonym for schizophrenic thought disorder
  • The group of first-rank symptoms which are delusions regarding thought interference (insertions, withdrawal, and broadcasting)
136
Q

Concrete thinking

A

Loss of ability to understand abstract concepts and metaphorical ideas leading to a strictly literal form of speech and inability to comprehend allusive language
Seen in schizophrenia and dementing illness

137
Q

Hallucination

A

An internal perception without a corresponding external object

138
Q

Pseudo-hallucination

A

Lacks one or all of the characteristics of a true hallucination:

  • Perceived in external space
  • Distinct from imagined images
  • Outside concious control
  • Possessing relative permanence
139
Q

Delusional perception

A

A primary delusion which is recalled as having arisen as a result of a perception
Percept is a real, external object, and not a result of hallucination

140
Q

Illusion

A

A type of false perception in which the perception of a real world object is combined with internal imagery to produce a false internal percept

141
Q

Incongruity of affect

A

Objective impression that the displayed affect is not consistent with the current thoguths or actions
Occurs in schizophrenia

142
Q

Mannerism

A

Abnormal and occasionally bizarre performance of a voluntary, goal-directed activity

143
Q

Positive symptoms of schizophrenia

A

Delusions
Hallucinations
Passivity phenomena
Thought alienation
Lack of insight
Disturbance of mood

144
Q

Negative symptoms of schizophrenia

A

Blunting of affect
Amotivation
Poverty of speech + thought
Poor non-verbal communication
Deterioration in functioning
Self-neglect
lack of insight

145
Q

Second rank symptoms of schizophrenia

A

Other delusions/hallucinations
Breaks in thought fluency: incoherence, irrelevant speech, neologisms
Catatonic behaviour e.g. excitement, stupor, mutism, posturing, wavy flexibility, negativism
Negative symptoms

146
Q

Number of first/second rank symptoms for diagnosis of schizophrenia

A

One 1st rank symptom, or two 2nd rank, acutely for 1 month

With evidence of disturbance of functioning for 6 months

147
Q

Side effects of aripiprazole

A

Akathisia

Decreased prolactin

148
Q

Side effects of olanzapine

A

Anticholinergic symptoms
Diabetes/dysglycaemia
Hyperlipidaemia/hypercholesterolaemia
Orthostasis
Sedation
Weight gain

149
Q

Side effects of paliperidone

A

Acute parkinsonism
Elevated prolactin
Weight gain

150
Q

Side effects of quetiapine

A

Diabetes
Orthostasis
Sedation
Weight gain

151
Q

Side effects of risperidone

A

Acute parkinsonism
Elevated prolactin
Weight gain

152
Q

Side effects of ziprasidone

A

Prolonged QTc interval

153
Q

Hypnogogic hallucinations

A

Occur when an individual is falling asleep

Mostly auditory

154
Q

Hypnopompic hallucinations

A

Occurs as a person awakes

Experience continues once the individual’s eyes open from sleep

155
Q

Action + side effects of mirtazapine

A

Noradrenergic and specific serotonergic antidepressant
Sedation
Weight gain

156
Q

Torticollis

A

Cervical dystonia - an acute dystonic reaction

Commonly caused by antipsychotic medications

157
Q

Indications for hospital admission in patients with anorexia nervosa

A

Low weight: 85% or less of expected weight and/or less than 3rd percentile for BMI
Lack of any weight gain
Significant oedema
Physiological decompensation e.g.
- Severe electrolyte imbalance
- Cardiac disturbances
- Altered mental status
- Orthostatic differential > 30/min
Temperature less than 36 degrees
Pulse <45 bpm
Psychosis or high risk of suicide
Symptoms refractory to outpatient treatment

158
Q

Signs + symptoms of a TCA overdose

A 
Tachycardia
Drowsiness
Dry mouth
N+V
Urinary retention
Confusion
Agitation
Headache
Hypotension
Hyperreflecia
Dilated pupils
Hyperthermia
159
Q

Russell’s sign

A

Calluses on knuckles, causing by being scraped across teeth

Seen in bulimia nervosa

160
Q

What is refeeding syndrome

A

The potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding

161
Q

Main biochemical feature of refeeding syndrome

A

Hypophosphataemia

162
Q

Features of refeeding syndrome

A 
Low phosphate
Abnormal sodium
Abnormal fluid balance
Changes in glucose, fat and protein metabolism 
Thiamine deficiency 
Low potassium 
Low magnesium
163
Q

Conditions predisposing to refeeding syndrome

A

Eating disorders
Chronic alcoholism
Malabsorption conditions e.g. IBD
Chronic malnutrition
Poorly contrólele diabetes
Oncological conditions
Post-operative state

164
Q

Mechanism of refeeding syndrome

A

Glycaemia leads to increased insulin, decreased glucagon
—> glycogen, protein and fat synthesis which requires phosphate, magnesium and thiamine
Insulin —> absorption of potassium into cells
Magnesium and phosphate also taken up into cells
Water follows by osmosis

165
Q

Complications of thiamine deficiency

A

Wernicke’s encephalopathy

Korsakoff’s syndrome

166
Q

Mechanism of changes in sodium and fluid metabolism in refeeding syndrome

A

Introduction of CHO into diet —> decreased renal sodium and water excretion
If fluid depletion instituted —> fluid overload
—> congestive cardiac failure, pulmonary oedema, cardiac arrhythmia

167
Q

Complications of refeeding syndrome

A

Potassium: arrhythmias, cardiac arrest
Magnesium: cardiac dysfunction, neuromuscular complications
Glucose: excess glucose, fatty liver, increased CO2, hypercapnoea, respiratory failure
Thiamine deficiency
Heart failure
Pulmonary oedema
Arrhythmia

168
Q

How long must food intake be decreased for to be at risk of refeeding syndrome?

A

5 days

169
Q

Features of histrionic personality disorder

A

Distinguished by a pattern of exaggerated emotionality and attention-seeking behaviours
Shallow affect
Egocentricity
Craving attention and excitement
Manipulative behaviour
Seductive or provocative behaviour
Easily influenced
Preoccupied with physical attractiveness

170
Q

Management of histrionic personality disorder

A

Psychodynamic/CBT/Group therapy

171
Q

Features of schizoid personality disorder

A

Emotionally cold/flattened affect
Detachment
Lack of interest in others
Excessive introspection and fantasy
Solitary
Little interest in sexual experiences
Indifferent to praise or criticism

172
Q

Management of schizoid personality disorder

A

Psychodynamic and/or group therapy

173
Q

Features of paranoid personality disorder

A

Sensitive
Suspicious
Consipiratorial explanations
Self-referential attitude
Distrust of others
Holds grudges

174
Q

Features of schizotypal personality disorder

A

Interpersonal discomfort
Magical thinking/peculiar ideas
Unusual perceptions
Odd appearance and behaviour
Inappropriate affect
Vague + circumstantial
Delusions of reference (but may be persuadeable)

175
Q

Features of acute confusional state/delirium

A

Impaired level of consciousness
Impairment of cognition - disorientation, recent memory + abstract thinking
Disturbance in sleep - nocturnal worsening of symptons
Psychomotor agitation
Emotional lability
Perceptual abnormalities - typically visual
Speech disorder - rambling, incoherent + thought disordered
Paranoid delusions
Rapid onset with fluctuations in severity

176
Q

Management principles of acute confusional state/delirium

A

Treat precipitating cause + exacerbating factors
Environmental + supportive measures e.g. reduce noise, incude clock, correct sensory impairments
Avoid sedation unless absolutely necessary
Regular clinical review + follow-up

177
Q

Treatment for an acute manic episode in Bipolar affective disorder

A

Atypical antipsychotic e.g. olanzapine, quetiapine, risperidone, clozapine
Then valproate, lamotrigine or lithium

178
Q

Treatment of depressive episode in bipolar affective disorder

A

Psychological interventiom
Avoid antidepressants alone - can cause rapid cycling of mood
Atypical antipsychotic e.g. quetiapine or olanzapine +/- fluoxetine
Add anticonvulsant lamotrigine, or lithium adjunct

179
Q

Maintenance therapy in bipolar disorder

A

First line = lithium
If ineffective, add valproate
Avoid in women of chidbearing age where possible

180
Q

Management of acute alcohol withdrawal

A

Benzodiazepine (likely chlordiazepoxide) or Carbamazepine
Alternative = clomethiazole
Give thiamine to replenish low B1 stores

181
Q

Maintenance of alcohol detoxification

A

Acamprosate
Disulfiram
Started 6-12 months after abstinence, to prevent relapse

182
Q

Disulfram

A

Aversive drug in maintenance of alcohol abstinence
Causes flushing, headache, N+V and tachycardia
Inhibits conversion of alcohol to CO2 and water –> build up of acetaldehyde
S/E = halitosis and headache

183
Q

Acamprosate

A

Anti-craving drug in maintenance of alcohol abstinence

S/E = GI upset, pruritiss, rash, altered libido

184
Q

Delirium tremens

A

Acute confusional state secondary to alcohol withdrawal
Onset 1-7 days after last drink (peak at 48-72 hours)
Clouding of consciousness, disorientation, amnesia, psychomotor agitation, hallucinations, terror-stricken face
Tachycardia, sweating etc.
Tremor

185
Q

Management of delirium tremens

A

High dose benzodiazepine e.g. chlordiazepoxide (lorazepam also used)
May also give IV Pabrinex (high dose vitamin B1)
Fluid replacement
Dextrose

186
Q

Triad of serotonin syndrome

A

Neuromuscular excitability
Autonomic dysfunction (hypo or hypertension)
Altered mental state

187
Q

Common features of serotonin syndrome

A

Autonomic effects: hyper/hypotension, tachycardia, fever, diarrhoea
Psychiatric effects: agitation, confusion, hypomania, seizures
Muscle/peripheral neurological effects: increased tone, tremor, shaking, hyperreflexia, clonus

188
Q

Possible blood test findings in serotonin syndrome

A

Increased WCC
Increased CK

Increased CK

189
Q

Management of serotonin syndrome

A

Stop causative medications
Manage complications
Oral cyproheptadine - serotonin-antagnostic effects

190
Q

Complications of serotonin syndrome

A

Hyperthermia
Rhabdomyolysis
ARDS
DIC
Hypertension
Seizures
Renal failure

191
Q

Agoraphobia

A

Fear of public spaces/fear of entering a public space from which immediate escape would be difficult int he event of a panic attack
Fear in, or avoidance of at least 2 of: crowds, public spaces, travelling alone, travelling away from home
Symptoms of anxiety

192
Q

Features of anxious (avoidant) personality disorder

A

Tense
Self-conscious
Fear of negative evaluation by others
Timid
Insecure
Avoidance of social or occupational activities

193
Q

Management of anxious (avoidant) personality disorder

A

Psychodynamic/CBT/group therapy

Social skills training

194
Q

Panic disorder

A

Recurrent panic attacks not consistently associated with a specific situation or object, often spontaenous
>4 attacks in one month
Sudden onset with somatic symptoms, and cognitive deficits
Often believe some large misfortune is about to happen e.g. heart attack
Sweating, tachycardia, palpitations, tremor, hyperventiliation
Minutes-hours

195
Q

Management of panic disorder

A

Psychoeducation
Breathing/relaxation techniques
CBT
SSRIs may reduce frequency and severity of attacks e.g. citalopram

196
Q

Mechanism of benzodiazepines

A

Facilitate and enhance binding of GABA to GABA-A receptors

197
Q

Mechanism of typical antipsychotics

A

Block postsynaptic dopamine D2 receptors –> blocks dopaminergic pathways of CNS

198
Q

Blood test results in neuroleptic malignant syndrome

A 
Raised CK due to muscle rigidity
Raised WCC
Deranged LFTs
Acute renal failure --> abnormal U+Es
Metabolic acidosis --> low pH, low HCO3
199
Q

Neuroleptic malignant syndrome

A

Adverse reaction to antipsychotic (and other) medication e.g. anti-parkinsonian agents (often withdrawal), anti-depressants and others

200
Q

Features of neuroleptic malignant syndrome

A

Rigidity
Hyperthermia
Delirium
Fluctuating BP
Tachycardia
Sweating
Extrapyramidal side effects

201
Q

Management of neuroleptic malignant syndrome

A

Stop drug/restart anti-parkinsonian if relevant
Treat hyperthermia aggressively
Circulatory +ventilatory support where necessary
Benzos to control agitation

202
Q

Early symptoms of alcohol withdrawal

A

Autonomic overactivity due to withdrawal of alcohol’s inhibition
Tremor
Nausea
Sweating
Agitation
Tachycardia/palpitations
Raised BP
Often features early in the morning, where a drink will relieve the symptoms

203
Q

Later symptoms of alcohol withdrawal (24-48 hours)

A

Delusions
COnfusion
Diarrhoea
Epileptic seizures/convulsions (peak incidence at 36 hours)
Auditory hallucinations
After 48-72 hours –> delirium tremens

204
Q

Action of alcohol on nervous system

A

GABA agonist
GABA neurones are inhibitory
–> alcohol suppresses brain activity

205
Q

Formication

A

A hallucination of the feeling of insects crawling in, on, or under your skin
Seen in many conditions, but associated with alcohol withdrawal/delirium tremens

206
Q

Features of Wernicke’s encephalopathy

A

Altered mental status
Ataxic gait
Ophthalmoplegia (often abducens nerve)
Nystagmus

Nausea
Occurs in any type of thiamine deficiency e.g. diet, gastric carcinoma, pernicious anaemia

207
Q

Features of Korsakoff’s syndrome

A

Anterograde memory disorder - old memories can be accessed, but new memories cannot be consolidated
Distorted sense of time
Confabulation
No clouding of consciousness
Peripheral neuropathy

208
Q

Management of wernicke’s encephalopathy

A

Thiamine! Usally in conjunction with other B vitamins. Given IV or IM
Sedation if necessary
Fluid/electrolytes

209
Q

Management of Korsakoff’s

A

Life-long chronic illness
Thiamine supplements may have some role

210
Q

Side effects of electroconvulsive therapy

A

Memory loss = most important
- Retrograde amnesia is more common
Immediate:
- Drowsiness
- Confusion
- Headache
- Nausea
- Aching muscles
- Loss of appetite
Long-term:
- Apathy
- Anhedonia
- Difficulty concentrating
- Loss of emotional responses
- Difficulty learning new info

211
Q

Taking which medications alongside SSRIs increase the risk of serotonin syndrome

A

Triptans
MAOIs
TCAs
SNRIs
Carbamazepine
Many types of analgesia e.g. opiod medications
Lithium

212
Q

Specific warnings for use of antipsychotics in elderly patients

A

Increased risk of stroke
Increased risk of VTE

213
Q

SSRIs and pregnancy

A

Weigh up benefits + risk
Use during first trimester gives small increased risk of congenital heart defects (paroxetine especially)
Use during third trimester can result in persistent pulmonary hypertension of the newborn

214
Q

Possible cardiac issue/s associated with citalopram/escitalopram

A

QT prolongation
and/or ventricular arrhythmias including torsade de pointes
–> take an ECG in patients with history of cardiac disease

215
Q

What should be measured when starting someone on an SSRI

A

U+Es to look for hyponatraemia
High risk: measure level before starting treatment, 2-4 weeks after starting treatment and every 3 months after

216
Q

Lithium monitoring

A

Weekly after initiation, and after each dose change
Done until concentrations are stables –> then in 3 months time, then every 3 months for the first year –> then can go to every 6 months in low-risk patients, or continue on 3 months indefinitely
TFTs should be monitored 6-monlty

217
Q

Management of a patient taking an antidepressant as a monotherapy who has developed mania or hypomania

A

Consider stopping the antidepressant
Offer an antipsychotic regardless:
- Haloperidol
- Olanzapine
- Quetiapine
- Risperidone
If one of these fails at top dose/not tolerated –> try an alternative from the list
3rd line = lithium
4th line = sodium valproate

218
Q

Features of somatisation disorder

A

Multiple physical SYMPTOMS
Present for at least 2 years
Patient refuses to accept reasurrance or negative test results

219
Q

Features of illness anxiety disorder/hypochondriasis

A

Persistent belief in presence of underlying serious DISEASE e.g. cancer
Patient refuses to accept reassurance or negative test results

220
Q

Step 1 in management of GAD

A

Education about GAD + active monitoring

221
Q

Step 2 in management of GAD

A

Low-intensity psychological interventions e.g. individual non-facilitated self-help, or individual guided self-help, or psychoeducational groups

222
Q

Step 3 in management of GAD

A

High-intensity psychological interventions eg. CBT or applied relaxation
And/or drug treatment

223
Q

Step 4 in management of GAD

A

Highly specialist input e.g. mutli-agency teams

224
Q

Drug treatment of GAD

A

Sertraline as first-line SSRI
If sertraline ineffective, offer an alternative SSRI or SNRI
If these are not tolerated, consider offering pregabalin

225
Q

How long must symptoms be present for in order to make a diagnosis of PTSD

A

Minimum 4 weeks/1 month
Less than this time = acute stress reaction

226
Q

Management of acute dystonia

A

Procyclidine

227
Q

Catatonia

A

Stopping of voluntary movement or staying still in an unusual position

228
Q

Which antipsychotic should be used in someone with symptoms of hyperprolactinaemia

A

Aripiprazole

229
Q

Choice of SSRI in children + adolescents

A

Fluoxetine

230
Q

Discontinuation of an SSRI

A

Dose should be gradually reduced over a 4 week period (not necessary for fluoxetine)

231
Q

Symptoms of discontinuation of SSRIs

A

FIRM STOP

Flu like sx
Insomnia
Restlessness
Mood swings

Sweating
Tummy problems (pain, cramps, D+V)
Off balance
Paraesthesia

232
Q

Factors associated with poor prognosis in schizophrenia

A

Strong family history
Gradual onset of symptoms
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
Younger age at diagnosis
Predominant negative symptoms

233
Q

Medication used to treat EPSEs with antipsychotics

A

Anti-cholinergic medication e.g. procyclidine
In tardive dyskineisa, given tetrabenazine instead

234
Q

Medication used to reverse sedative effects of benzodiazepines

A

Flumazenil

235
Q

Pharmacological intervention in opioid detoxification

A

1st line = methadone, or buprenorphine
May consider lofexidine

236
Q

Scoring of PHQ-9

A

Ranges from 0-27
5-9 = mild
10-14 = moderate
15-19 = moderately severe
20+ = severe depression

237
Q

Scoring of GAD-7

A

Ranges from 021
0-4 = minimal anxiety
5-9 = mild anxiety
10-14 = moderate anxiety
15+ = severe anxiety

238
Q

Typical features of obsessive thoughts

A

Typically egodystonic i.e. very different to patient’s normal beliefs and values
Sexual content is relatively common
Usually resisted
Usually intrusive + repetitive
Can occur in depressive disorders as well as obsessive disorders

239
Q

Strongest risk factor for psychotic disorders

A

Family History

240
Q

What physiological elements are raised in anorexia nervosa

A

Gs and Cs
Growth hormone
Glucose
salivary Glands
Cortisol
Cholesterol
Carotinaemia

241
Q

What physiological elements are low in anorexia nervosa

A

Hypokalaemia
FSH, LH, oestrogen + testosterone
T3

242
Q

Metabolic consequence of long-term lithium use

A

Hyperparathyroidism –> hypercalcaemia
‘Stones, bones, abdominal moans + psychic groans’

243
Q

Which anti-psychotic medication may make seizures more likely?

A

Clozapine - reduces seizure threshold

244
Q

Risk of taking NSAIDs in a patient on an SSRI

A

GI bleeding risk –> give PPI protection

245
Q

Adverse effects of atypical antipsychotics

A

Weight gain
Hyperprolactinaemia
Increased risk of stroke/VTE in the elderly

246
Q

Preferred choice of antidepressant following an MI

A

Sertraline

247
Q

Antipsychotic to use in patients who have symptoms of prolactin elevation

A

Aripiprazole - most tolerable side effect profile of atypical antipsychotics

248
Q

What is tardive dyskinesia

A

EPSE of typical antipsychotics
Late onset of abnormal, involuntary choreoathetoid movements in patients
Often irreversible
Can involve chewing, pouting or ecessive blinking

249
Q

Indications for electroconvulsive therapy

A

Treatment resistant severe depression
Manic episodes
An episode of moderate depression known to respond to ECT in the past
Life threatening catatonia

250
Q

Contraindication to ECT

A

Raised intracranial pressure

251
Q

Risk factors for GAD

A

Aged 35-54
Being divorced or separated
Living alone
Being a lone parent

252
Q

Protective factors for GAD

A

Aged 16-24
Being marred or cohabiting

253
Q

Management of paracetamol overdose

A

Within 1 hour of ingestion: activated charcoal
Within 8 hours of ingestion, above treatment line: N-acetylcysteine. Total dose divided into 3 consecutive IV infusions. First infusion done over an hour

254
Q

Cocaine withdrawal

A

First 24 hours after a period of high-intensity use (first phase) =
- Increased hunger + cravings
- Anxiety
- Fatigue
- Irritability
- Lack of motivation
Second phase lasts up to 10 weeks
Final phase shows decrease in most withdrawal symptoms, but low mood can persist (up to 6 months)

255
Q

COAT RACK mnemonic for Wernicke-Korsakoff’s

A

Wernicke’s (acute phase) –>
- Confusion
- Ophthalmoplegia
- Ataxia
- Thiamine treatment
Korsakoff’s (chronic phase) –>
- Retrograde amnesia
- Anterograde amnesia
- Confabulation
- Korsakoff’s psychosis

256
Q

Typical hallucinations seen in delirium tremens

A

Liliputian i.e. seeing lots of small people

257
Q

What are extracampine hallucinations

A

Hallucinations outside the realm of physical possibility
Seen in schizophrenia and other psychotic illnesses

Phase 3A Revision (12 decks)

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