Psychiatry Flashcards
What are the core symptoms for a diagnosis of depression?
what other symptoms can be present
core:
1. low mood
2. anhedonia
3. fatigue
others:
disturbed sleep
poor concentration or indecisiveness
low self confidence
poor or increased appetite
suicidal thoughts or acts
agitation or slowing of movement
guilt or self blame
what is the ICD10 criteria for diagnosis procedure of depression
2 of the core symptoms for at least 2 weeks plus at least 2 additional symptoms
4 total = mild
5-6 = moderate
7+ = severe
what is the DSMV criteria / diagnosis of major depressive disorder
5 or more over a 2 week period (must have one of )
depressed mood
markedly diminished interest or pleasure in all activities*
poor or increased appetite
insomnia or hypersomnia
psychomotor agitation or retardation
fatigue or loss of energy
feelings of worthlessness or inappropriate guilt
diminished ability to think or concentrate
recurrent thoughts of death or suicide
must impair functioning
what other mood is important to consider in diagnosing depression
any history of mania or hypomania which would change the diagnosis to bipolar mood disorder as opposed to depression
what initial investigations are necessary in someone presenting with depression
ECG
BMI
BP and pulse
FBC, U&E, LFT, TFT HBA1C
what is the advice for continuation of antidepressants after a depressive episode
assess risk of relapse including residual symptoms, previous episodes and severity, length and degree of treatment resistance in this episode
low risk - at least 6-9 months
if any risk factors - at least 1 year after symptoms resolve
high risk - 2 years after symptoms resolve
what is the typical response rate of antidepressants
what change should be made if unsuccessful
about 67% respond
if not better to change class than change drug within class
side effects of Tricyclic Antidepressants
cardio toxic
lower seizure threshold
anticholinergic effects - dry mouth, blurred vision, constipation, urinary retention
anti-adrenergic effects - postural hypotension, tachycardia, sexual dysfunction
antihistamine effects - weight gain, sedation
types of antidepressants and examples
TCAs; amitriptyline, imipramine, nortiptyline
MAOIs; phenelzine, selegeline
SSRIs; sertraline, fluoxetine, citalopram
SNRIs; venlafaxine, duloxetine
what is serotonin syndrome?
what are the symptoms
increased or excessive serotonin due to one drug or interactions
results in autonomic dysfunction, abdominal pain, myoclonus, delirium, CV shock, and death
symptoms; hyperthermia, hyperreflexia, hypertension, tachycardia, tremor, agitation, irritability, sweating diarrhoea, dilated pupils
treatment of serotonin syndrome
discontinue causative medication
benzodiazepines
active cooling
if severe serotonin antagonist
SSRIs
side effect profile
is there discontinuation syndrome
pretty safe drugs - not too cardio toxic in overdose
common side effects - GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia,
can develop discontinuation syndrome of agitation, nausea, and dysphoria
Pros and cons of fluoxetine
Long half life decreases discontinuation syndromes
Initially activating can give motivation
active metabolite can build up - not good in hepatic impairment
Lots of p450 interactions
Initial activation can increase anxiety and insomnia and more likely to induce mania
Escitalopram pros and cons
Few drug drug interactions
More effective than citalopram is acute response
Good in epilepsy
Dose dependent QT prolongation
Nausea headache
Expensive drug
Citalopram pros and cons
Few drug drug interactions
Dose dependent QT prolongation
Can be sedating
GI side effects
Sertraline pros and cons
Short half life lower metabolic build up
Less sedating
Max absorption requires full stomach
Increased number of GI effects
Paroxetine pros and cons
Short half life
Sedating properties good at night
Sedation, weight gain, anticholinergic effects
Likely to cause discontinuation syndrome
Venlafaxine pros and cons
Minimal interactions with almost no p450 activity
Can increase diastolic BP
significant nausea
Can cause bad discontinuation syndrome
Can cause QT prolongation
Sexual side effects
Note also indicated for post menopausal symptoms
Duloxetine pros and cons
Some data to suggest helps physical depression symptoms
Less BP increase than venlafaxine
Inhibits CYP enzymes
What kind of drug is mirtazapine
Pros and cons
Presynaptic alpha2 adrenoceptor antagonist increases central noradrenergic and serotonergic neurotransmission
15-30mg daily then increase up to 45 mg
Pros: can be used as a hypnotic at lower doses
Cons: increases cholesterol, sedating, weight gain
What actions do TCAs have
Blocks SERT
blocks NET
5HT2A antagonism - anxiolytic
What’s the difference between secondary and tertiary TCAs
Secondary act primarily on noradrenergic receptors
Generally less severe side effects as tertiary
E.g. nortriptyline
Tertiary act primarily on serotonin receptor
More side effects
E.g. amitriptyline, imipramine
What kind of drugs are MAOIs
When used
Side effects
Bind irreversibly to MAO preventing inactivation of amines such as dopamine, serotonin and noradrenaline
Very effective for depression
Side effects: orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction and sleep disturbance
Don’t take with tyramine rich foods
How to switch between MAOI and SSRI or vice versa
Wait two weeks in between because of risk of serotonin syndrome
If fluoxetine wait 5 weeks because of long half life
What is the hierarchy to rule out diagnoses in psychiatry
In order to rule out
- organic
- drug and alcohol related
- psychosis
- mood disorders
- anxiety/ stress related (neuroses)
- personality/behavioural disorders
What is the management for mild generalised anxiety disorder
Watchful waiting
Internet based self help
Lifestyle advice
what drugs can be used as mood stabilisers
what conditions are they used in
atypical antipsychotics
lithium
anticonvulsants
indicated in bipolar disorder, schizophrenia, and lithium in unipolar depression
when is lithium prescribed
acute mania or hypomania, bipolar prophylaxis, depression prophylaxis
prescribed by brand
takes 1-2 weeks to work
how is lithium monitored
check blood level: 12 hrs after first dose
after 5 days
weekly for first four weeks until stable
then every 3 months
also need urine dip (for protein), TFT, U&E
and calcium every 6 months - signs of lithium toxicity
lithium side effects and signs of toxicity
side effects: GI disturbance, metallic taste, fine tremor, urinary symptoms polydipsia, polyuria (excreted renally)
signs of toxicity:
GI - anorexia, diarrhoea, vomiting
Neuromuscular - twitch, tremor, dizziness, reduced coordination
drowsiness, restlessness, lack of interest
what are the complications, contraindications and interactions of lithium
complications: renal impairment, hypothyroidism, arrhythmias, nephrogenic diabetes insipidus, cognitive impairment
contraindications: 1st trimester, breastfeeding, cardiac conditions, significant renal impairment, addisons disease, untreated hypothyroidism
interactions: NSAIDs, SSRI, ACEi, thiazides
important complications and contraindications of sodium valproate
can cause thrombocytopenia –> bruising, leucopenia, jaundice, dark urine
contraindicated in pregnancy, breastfeeding, personal or FH of hepatic impairment
when is lamotrigine prescribed? important side effect
type 2 bipolar (hypomania)
Steven johnson rash
what scale is used for post natal depression
Edinburgh post natal depression scale
what is panic disorder
Recurrent panic attacks, that are not consistently associated with a specific situation or object,
and often occurring spontaneously. The panic attacks are not associated with marked exertion or with exposure to dangerous or life-threatening situations.
what features are panic attacks characterised by
discrete episode that starts abruptly with at least 4 symptoms of:
Autonomic arousal
* Palpitations, or accelerated heart rate.
* Sweating.
* Trembling or shaking.
* Dry mouth
Chest and abdomen
* Difficulty breathing.
* Feeling of choking.
* Chest pain or discomfort.
* Nausea or abdominal distress
Brain and mind
* Feeling dizzy, unsteady, faint or light-headed.
* Feelings that objects are unreal (derealisation), or that one’s self is distant or “not really here”
(depersonalisation).
* Fear of losing control, going crazy, or passing out.
* Fear of dying.
General symptoms
* Hot flushes or cold chills.
* Numbness or tingling sensations.
what is generalised anxiety disorder
‘several’ months with prominent tension, worry and feelings of apprehension, about every-day events and problems
what symptoms is GAD characterised by
- autonomic arousal symptoms
- chest and abdomen symptoms
- brain and mind symptoms
- tension symptoms
- other non-specific; difficulty concentrating, irritability, difficulty getting to sleep
how is OCD characterised
either obsessions or compulsions or both present most days for a period of 2 weeks causing functional impairment
Obsessions (thoughts, ideas or images) and compulsions (acts) share the following features,
* They are acknowledged as originating in the mind of the patient, and are not imposed by outside persons or influences (this differentiates it from psychosis)
* They are repetitive and unpleasant (egodystonic), acknowledged as excessive or unreasonable.
* Carrying out the obsessive thought or compulsive act is not in itself pleasurable. (This should be
distinguished from the temporary relief of tension or anxiety).
what are the features post traumatic stress disorder
flashbacks, hyper vigilance, avoidance and associated symptoms of anxiety and distress for one month or more following a traumatic or stressful event
what questionnaires can be used to measure severity of/ progress in anxiety and depression
GAD7 anxiety
PHQ9 depression
how do CBT sessions run
usually 8-12 1 hour sessions with homework to do in between
addresses thoughts, feelings, behaviours
uses interventions and activities to make changes
what to consider with CBT referral
patient needs to be able to engage with sessions and homework
pt expectations important and beliefs about psychotherapy
more pressing issues may need addressing first
wider issues such as alcohol/substances
perinatal mental health conditions
“baby blues”
postnatal depression
postpartum psychosis
pre-exisiting MH condition exacerbated by the perinatal period
baby blues
poorly defined condition present in up to 70% of mothers and characterised by tearfulness, irritability, low mood and restlessness
symptoms peak at 4 days postpartum and should resolve
management is watchful waiting
postnatal depression
- presentation
- management
present in 10% mothers
same diagnostic criteria as depression can be used but need to also consider baby bond, feelings as a mother and specific feelings about self or baby - ask about risk to self or others
most prevalent 8-12 weeks post partum
management includes lifestyle advice, CBT, antidepressants (SSRI) and if severe CMHT or hospital admission preferably a mother and baby unit
postpartum psychosis
- presentation
- management
1 in 1000 mothers
strong genetic component to risk
strong risk if existing bipolar affective disorder or previous psyhchosis
peak onset day 3-7; subtle symptoms at first of irritability, low mood and change in behaviour but quickly progress to severe psychotic symptoms
needs urgent senior input, admission under mental health act and antipsychotic treatment which is mainly effective
what other conditions need to be considered perinatally
bipolar affective disorder and schizophrenic patients should be referred to perinatal team for management relating to medications and risks of relapse
note maternal OCD - obsessive intrusive thoughts in perinatal period
basic rules of psychiatric prescribing in pregnancy
- don’t stop medications suddenly
- plan ahead; high risk period; need alternative management if stopping
- most medications require risk v benefit discussions
- consider reduction or avoidance in first trimester
- low doses but not sub therapeutic
- avoid polypharmacy
- consider personal or family history of medication responses
antidepressants in perinatal period
generally quite safe - not teratogenic
paroxetine - risk of cardiac malformations
venlafaxine - increased risk of miscarriage
sertraline recommended in pregnancy and breast feeding first line
latterly in pregnancy all ADs associated with risk of persistent pulmonary hypertension in the newborn
antipsychotics in perinatal period
not thought to be teratogenic in themselves but can cause other problems;
- hyperprolactinemia leading to sub fertility
- metabolic disturbance and gestational diabetes
- monitoring required in breastfeeding
- clozapine in breastfeeding can lead to agranulocytosis and seizures in the newborn
- Poor Neonatal Adaption Syndrome (self limiting withdrawal)
sodium valproate in perinatal period
10% risk of significant congenital malformation if taken at conception and first trimester
child bearing age women should NOT be prescribed unless absolutely necessary and only with long term contraception
what SSRIs are indicated for PTSD
sertraline and paroxetine
what is acute stress disorder
PTSD like symptoms but within the 4 weeks immediately following a traumatic event including mental and physical symptoms
features of somatisation disorder
repeated presentation to healthcare with medically unexplained symptoms on a background of extensive and chronic investigations. usually representative of underlying psychology
usually presents less than 40 years and 5:1 female to male
can be associated with childhood abuse/neglect or illness and with parental preoccupation with illness
can be linked to EUPD and depressive disorders
features of hypochondriasis
rumination on bodily abnormalities, normal variants and minor ailments as signs of disease
unmeasured by investigation findings
1:1 female to male
associated with GAD, OCD, panic disorders and depression
associated with childhood illness, abuse or neglect, parental preoccupation with illness and neglect
what other conditions are associated with medically unexplained symptoms
conversion disorder - nervous system symptoms due to underling psychological disorder
factitious disorder - feigning illness without a malingering motive
malingering - feigning illness for personal gain
what medications can be associated with depressive symptoms
beta blockers
statins
corticosteroids
benzos
alcohol
antipsychotics –> drowsiness
what treatments can be used for PTSD
EMDR - eye movement desensitisation and reprocessing
trauma focussed CBT
both recommended by NICE
can also consider medication
types of personality disorder
cluster A: paranoid, schizoid, schizotypal
cluster B: antisocial, emotionally unstable/borderline, histrionic, narcissistic
cluster C: obsessive compulsive, avoidant, dependant
management of OCD
exposure and response prevention therapy is first line if mild
if not responded or more severe then sertraline is indicated
SSRIs important interactions
triptans
warfarin/heparin
with NSAIDs try to avoid but if needed prescribe a PPI too
MAOIs - risk of serotonin syndrome
strongest risk factor for psychotic disorders
family history
examples of
- typical antipsychotics
- atypical antipsychotics
typical (1st gen) - haloperidol, chlorpromazine
atypical (2nd gen) - olanzapine, clozapine, risperidone
when is ECT indicated
catatonia
a prolonged or severe manic episode
severe depression that is life-threatening
only when rapid and short term relief is needed and other avenues have been tried/ the condition is imminently life threatening
ECT side effects/contraindications
Short-term side-effects
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
Long-term side-effects
some patients report impaired memory
only absolute contraindication is raised ICP
What electrolyte abnormality can long term lithium treatment cause
Hyperparathyroidism leading to hypercalcaemia
Presented with stones, bones, moans and groans
categories and examples of side effects of antipsychotics
metabolic - weight gain and diabetes
extrapyramidal - akathisia, dyskinesia, dystonia
cardiovascular - prolonged QT interval,
hormonal - hyperprolactinemia
other - inc unpleasant experiences
when should clozapine be used in schizophrenia
only after 2 other antipsychotics tried of at least one being an atypical antipsychotic
first episode psychosis treatment
oral antipsychotic
+
early intervention psychotherapy such as CBT
what tests should be done before starting an antipsychotic
ECG
Lipid levels
prolactin levels
BMI and physical measurements
movement assessment
assessment of nutrition
HBA1C
pulse and BP
what is schizophrenia
how are the symptoms of schizophrenia divided
schizophrenia is the most common psychotic disorder
symptoms are divided into positive and negative symptoms
positive - presence of hallucinations, delusions
negative - apathy, social withdrawal
what course does schizophrenia usually present with
a prodromal period of a change in behaviour, deterioration in personal functioning and emergence of negative symptoms - few days to 18 months
followed by an acute phase of psychosis marked by positive symptoms
typical/first gen antipsychotics
block D2 receptors in the brain
examples: haloperidol, chlorpromazine, prochlorperizine
atypical/2nd gen antipsychotics
work on 5HT and DA receptors in 4 pathways throughout the brain - serotonin dopamine 2 antagonists
lower rates of extrapyramidal/movement side effects
more associated with weight gain and impaired glucose tolerance
examples: clozapine, olanzapine, risperidone,
organic causes of psychosis
acute confusion
dementia
brain tumour - usually accompanied by physical issues
temporal lobe epilepsy
CNS infections e.g. in AIDS, encephalitis, neurosyphilis
brain injury
huntingtons
metabolic or endocrine disorders
medication side effects e.g. with high dose steroids
autoimmune e.g. lupus
what conditions can psychotic symptoms occur in
schizophrenia
drug induced psychosis
manic phase of bipolar
severe depression
dementia
what is section 2 of the MHA
allows detention for up to 28 days for assessment where the person is suffering from a mental disorder of a nature or degree which warrants their detention in hospital for assessment (or for assessment followed by treatment) for at least a limited period, and the person ought to be so detained in the interests of their own health or safety or with a view to the protection of others.
the section also allows treatment if needed
needs at least 2 doctors and application made by an AMHP or nearest relative
MHA section 3
up to 6 months (but reviewed after 3 and consent gained or a second opinion)
for treatment
2 doctors needed to approve
MHA section 4
up to 72 hours
any doctor
for emergency admission for treatment
MHA section 5(2)
up to 72 hours by doctor or clinician in charge
emergency holding when patient already in hospital for other reason
MHA section 5(4)
up to 6 hours by a registered nurse for emergency holding when pt already in hospital
MHA section 135
warrant to gain access to patient
can be used once
allows for further assessment but not treatment
one doctor, AMHP and police
MHA section 136
allows police to remove someone from public place to place of safety
can be used once
does not allow treatment
what is schizoaffective disorder
equal and simultaneous symptoms of a mood disorder and psychotic symptoms of schizophrenia
risperidone important side effects
dose dependent extrapyramidal
high prolactin
dose dependent weight gain
acts more like a typical antipsychotic at doses > 6mg
can be given tablet or IM depot
giving olanzapine
+ important side effects
tablets or IM injection
weight gain predominant side effect
can cause lipid changes
increased prolactin but less than risperidone
transaminitis in 2%
giving quetiapine + important side effects
available only as tablet
some weight gain and lipid changes but less than olanzapine
transaminitis in 6%
can cause orthostatic hypotension
can prolong QTc
aripiprazole
available as IM depot
multiple indications
can be stimulating - caution in agitation
No QTc prolongation, low sedation
clozapine important side effects
lower seizure threshold
agranulocytosis!!
what is neuroleptic malignant syndrome
syndrome of autonomic dysfunction
- hyperthermia
-hypertension
-hyperreflexia
- elevated CK due to muscle break down
can be fatal
discontinue antipsychotic and transfer to medical ward
What is akathisia
A sense of inner restlessness and inability to keep still
Usually due to anti psychotic use
What is acute dystonia
Management
Acute sustained muscle contraction
Can be managed with procyclidine
What is tardive dyskinesia
Abnormal, involuntary choraethoid movement
Usually late onset in antipsychotic treatment
May be irreversible
Commonly lip smacking and jaw pouting
What are the risks of antipsychotics in elderly patients
Increased risk of stroke and VTE
Management of mania in bipolar disorder
Stop any antidepressants
Start an antipsychotic
Continue or start a mood stabiliser
4 types of extrapyramidal side effects caused by antipsychotics (predominantly typical)
Parkinsonism
Akathisia
Acute dystonia
Tardive dyskinesia
What is the antidepressant of choice in children and adolescents
Fluoxetine
Symptoms of mania
DIGFAST
Distractability
Irresponsibility
Grandiose delusions
Flight of ideas
Activity increase
Sleep deficit
Talkative
Types of bipolar
Type 1 - depression and mani
Type 2 - depression and hypo mania
structure of MSE
ASEPTIC
Appearance and behaviour - clothing, cleanliness, alertness, intoxication, abnormal movements, rapport, eye contact
Speech - rate, tone, volume, spontaneity
Emotion/mood - nature of mood and affect. objective and subjective
Perception - hallucinations, other abnormal experiences
Thoughts - Form; flight, blocking, loosening of associations. Content; obsessions, delusions, thought interference. suicidal thoughts, plans, actions or thoughts to harm others
Insight - awareness of illness and need for treatment
Cognition - orientation, attention, memory, language, praxis, planning, judgement and personality
structure of psychiatric history
Presenting Complaint
HOPC
Past psychiatric history
Past medical history
Medications
Illicit drugs and alcohol
Family History
Personal History; gestation and birth, milestones, early childhood, school, employment, relationships
Present social circumstances
Forensic history
Pre-morbid personality
MSE
Physical examination
Formulation of plan
Criteria for substance dependence syndrome diagnosis
3 of the symptoms present together at some point during the last year or constantly for 1 month
- strong desire or compulsion to take the substance
- difficulties controlling taking behaviour including onset, termination or levels of use
- evidence of tolerance
- psychological withdrawal state when reduced or ceased
- progressive neglect of alternative pleasure of interests and or more time spent obtaining, taking and recovering
- persistence of use despite clear evidence of harmful consequences
What is disulifram?
used to deter patient from drinking alcohol
what are the main classes of drugs used in dementia + examples
acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine
glutamate receptor antagonist e.g memantine
when are AChE inhibitors used
early on in treatment
mild symptoms of Alzheimers present
which AChE inhibitor is licensed in lewy body and Parkinson’s dementia
rivastigmine
when is memantine the drug of choice
in moderate to severe alzheimers disease
what is the cognitive deterioration in Alzheimers thought to result from
loss of cholinergic neurons and decreasing levels of acetylcholine in the brain
how is donzepezil given
once daily - reaches a steady state in 2-3 weeks and has a long half life
started at 5mg then can be increased up to 10mg after a month
how is rivastigmine given
orally twice daily or by patch once daily
very short half life
how does memantine improve symptoms of AD
inhibits the excessive neuronal excitation that occurs in glutamate pathways thought to cause neurotoxicity
how are memantine and donzepezil metabolised
through the liver - so subject to serum levels altered by enzymes
not the case with rivastigmine
main side effects of AChE inhibitors
anticholinergic side effects
- nausea, vomiting, diarrhoea
- urinary incontinence
- insomnia, dizziness
may cause bradycardia
rivastigmine is most safe with other drugs
which is the most comprehensive cognitive function test?
what other ones are there
ACE III - Addenbrook’s cognitive examination; assesses Memory, Attention, Fluency, Visuospatial Skills and Language. score out of 100. A score below 82 is highly suggestive of possible dementia but the test is NOT a diagnostic test as dementia is a clinical diagnosis.
others; MOCA or MMSE
what is dysexecutive syndrome
dysfunction in the frontal part of the brain which can present with cognitive, behavioural and emotional symptoms caused by several things; neurodegeneration (dementias), stroke, brain tumour, and functional disorders such as schizophrenia or ADHD
what is the frontal assessment battery
a 10 minute bedside test of questions and actions to assess the function of the frontal lobe
scored out of 80
good for differentiating between frontotemproal dementia and early stage alzheimers
what tools can assess the functional, psychological and care giver strain in dementia
Functional: ADL questionnaire, functional activities questionnaire, bristol funcitonal assessment
Psychological: neuropsychiatric inventory
Care giver strain: MBRC instrument
what other action does rivastigmine have
also an inhibitor of butyl cholinesterase as well as AChE
what are the non-cognitive symptoms of dementia
behavioural and psychological symptoms including hallucinations, delusions, anxiety, marked agitation and associated aggressive behaviour, wandering, hoarding, sexual disinhibition, apathy and disruptive vocal activity
What investigations need to be completed prior to starting cholinesterase inhibitors or NMDA receptor antagonist?
ECG – Assess heart rate, presence of conduction abnormalities and QTc interval
Cholinesterase inhibitors are contraindicated for patients with bradykinesia, Left Bundle Branch Block and a prolonged QTc interval
U&E – Memantine can cause acute renal failure
when are AChE inhibitors cautioned
in patients with a history of gastric ulcers and seizures
what psyhcolocial can be used in dementia
Cognitive stimulation therapy
CBT
Reminiscence therapy
Aromatherapy
Sensory stimulation
Music therapy
what is essential for a diagnosis of dementia
history taking and a cognitive assessment
other useful aspects include neuropsychological assessment and brain imaging
cortical vs subcortical types of dementia
cortical; alzheimers, Lewy body, frontotemporal
subcortical; vascular, huntingtons, alcohol, HIV/AIDS related
what symptoms result from temporal lobe degeneration
prospagnosia- recognising celebrity faces
difficulty understanding words
short term and semantic memory affected
visuospacial neglect
can recognise music
inability to categorise
what symptoms result from parietal lobe degeneration
difficulty writing and drawing
L-R disorientation
dyscalculia
apraxia
visuospatial neglect
what symptoms result from frontal lobe degeneration
affects sequencing, spontaneity, cognitive flexibility, conceptualisation, concentration, impulse control, problem solving
what lobe does alzhimers tend to affect first
temporal lobe symptoms first and hippocampal
what are the dementia screening bloods
BC, U&E, CRP, LFT’s, TFT’s, B12, and Folate, HIV, syphillis
what symptoms are common in Lewy body dementia
hallucinations often of children or small animals
acting out in dreams
associated parkinsonian symptoms
memory problems
early loss of facial expression
fluctuating cognitive impairment
more common in men (unlike AD)
what drugs are used in Lewy body dementia
levodopa for motor symptoms
rivastigmine (usually 4.6mg/24hr patch) or similar for cognitive symptoms
antispychitoics such as quetiapine can be considered for hallucinations
what is REM sleep behaviour disorder what is the treatment
disorder where patient acts out during sleep
clonazepam
main clozapine side effects
weight gain
excessive salivation
agranulocytosis
neutropenia
myocarditis
arrhythmias
what symptoms suggest pseudo dementia secondary to depression
sleep disrutbance
presence of stressors
normal mini mental state examination with global memory loss
not attempting questions or answering I don’t know
short onset
what endocrine disorder is associated with chronic lithium toxicity
hypothyroidism
list of thought disorders
cricumstantialty
tangentiality
clang associations
neologisms
word salad
knights move thinking
flight of ideas
perseveration
echolalia
what needs monitoring with SNRIs?
blood pressure - can lead to hypertension
monitor before and every dose titration
what needs to be monitored with valproate drugs
LFTs before and at 6 months - can cause liver dysfunction
what are the four As in diagnosing dementia
Amnesia
Agnosia - not recognising people or objects
Aphasia
Apraxia
Alzheimers presentation
gradual onset cortical decline evidenced by the 4 As
memory problems and decreased motivation/drive
slow progression
what are BPSD
behavioural and psychological symptoms of dementia
vascular dementia presentation
stepwise progression
usually vascular risk factors - biggest one smoking also hypertension, previous strokes, high cholesterol, obesity, diabetes
multi infarct shows multiple areas of brain affected evidenced in presentation
single infarct can affect a localised area of the brain
subcortical vessel disease can affect personality, affective symptoms and executive skills
management specific to VD
manage vascular risk factors and treat with aspirin and a statin
what is mild cognitive impairment
a disorder in cognitive function lasting at least two weeks but not affecting ability to carry out day to day life
what is dementia as an umbrella term
decline in cognitive function including memory and other cognitive domains with functional impairment for at least 6 months and without reduced consciousness
what are the three types of frontotemporal dementia
Picks disease- behaviour predominant
Semantic
progressive non-fluent aphasia - language predominant
risk assessment in dementia
Suicide, self-neglect, susceptibility to illness
Abuse, aggression
Wandering
Falls, fire
Exploitation
Non-compliance with medication
Driving, drugs and alcohol
taking a history in cognitive impairment
- onset, duration, progression
- cognitive domains; memory, orientation, recognition, speech/word finding, ADLs/apraxia, executive functioning
- mood
- behaviour and personality
- relevant medical, personal and family history
- Risk assessment
- MSE
short term side effects of ECT
headache, nausea, memory impairment and arrhythmias
long term very few - some patients describe long term memory loss
what electrolyte abnormality are SSRIs associated with
hyponatrameia
How can Schneider’s first rank symptoms be divided and what are they
Auditory hallucinations of a specific type
- voices commenting on behaviour
- 2 or mor voices discussing the pt
- thought echo
Thought disorder - insertion, withdrawal or broadcasting
Passivity phenomena
- bodily sensations controlled by external influence
- actions/impulses/feelings imposed by an external force
Somatic hallucinations
Delusional perceptions
what three features must be present for a diagnosis of autism to be made?
Global impairment of language &
communication
Impairment of social
relationships
Ritualistic & compulsive phenomena
- Stimming; repetitive behaviour
(e.g. tapping pencil)
- Meltdowns; complete loss of control over behaviour
how does social interaction and communication present in autism?
- poor eye contact
- inability to recognise emotion in themselves and others
- late talking and sometimes non verbal
- may not respond to own name
- difficulties with non verbal communication
- often limited interests with repetitive play and behaviour
what conditions can be linked with autism
- Anxiety
- Depression
- OCD
- sleep disturbance
- gender dysphoria
taking an autism history
Behavioural history - home, school, etc - temper, meltdowns, obsessions, fears, phobias
Birth history - alcohol, drugs, smoking, illness, delivery, post natal period
Developmental history -gross motor/fine motor, hearing, speech and language, social interaction
Family history
Social circumstances
making friends, eye contact, interests
imaginative play, mannerisms
Sensory features - seeking, avoiding
specific tools for Assessment and examination in autism
interactive assessment / observation of social skills, communication and behaviour
Schedule of growing skills or Griffith Mental Development scales
ADOS: autism diagnostic observation schedule - standardised assessment tool that uses play and interview
DISCO (Diagnostic Interview for Social & Communication Disorders) - Interview with parent/carer of patient to gain holistic understanding
ADI-R: autism diagnostic interview revisited
physical examination including coordination, self injuries or abuse
MSE
what is the definition of autism
a lifelong developmental disability that affects how a person communicates with and relates to others and experiences the world around them
what is the so called triad of autism
social interaction
social communication
social understanding
general principles of diagnosing autism
Diagnosis of autism covers a broad spectrum
Diagnosis takes a few appointments
MDT approach - psychiatrist, paediatrician, SALT, psychologist
Involve the school
Try to map to ICD-10 or DSMV criteria
management of autism (biopsychosocial)
bio/medication; SSRIs, 2nd Gen antipsychotics, melatonin for sleep
psycho; psychotherapy for patient and parents including CBT, behaviour management, communication and educational psychology
social; led by a functional assessment and focuses on peers, school, carers and respite care
core symptoms of ADHD
inattention
impulsivity
hyperactivity
diagnostic criteria of ADHD
- symptoms appeared before aged 6-7 and persist for at least 6 months and evident in 2 places i.e. school and home
- cause functional impairment
- not better accounted for by another mental disorder
management of ADHD
- psychoeducation to child, family, school
- control of hyperactive behaviours
- behavioural management strategies
- first line stimulant medication such as methylphenidate. start low dose
- non-stimulant as 2nd line drug
what obstetric infection has been associated with autism
congenital rubella infections particularly in the first trimester
what physical brain differences is there evidence for in ASD compared to the rest of the population
structural brain differences - increased brain size with early growth and reduced number of purkinje cells in the cerebellum
1/3 of autistic people have increased serotonin in the brain and Social withdrawal and stereotypic behaviour has been associated with high concentrations of homovanillic acid in cerebrospinal fluid in some children with autism.
what is the typical course of ASD
starts before age 3 and is a lifelong condition
can be associated with learning disabilities and concurrent mental health conditions particularly depression
some people with autism require long term residential care
what indicates good prognosis for a person with ASD
Communicative speech 6 years old and above
Higher IQ (>50)
Skills that can be used to secure employmen
Autism Diagnostic Interview Revisited
93 question interview of a parent of caregiver done by an experienced professional
effective at differentiating ASD from other conditions
focuses on
Language and Communication
Reciprocal Social Interactions
Restricted, Repetitive and Stereotyped Behaviours and Interests
Diagnostic Interview for Social and Communication Disorders (DISCO)
comprised of 300 questions and used to get a global idea of the autistic spectrum of the patient and their specific needs
ADOS-2
This is a semi-structured, standardised assessment tool that uses play and interview to examine communication, social interaction, imagination and restricted and repetitive behaviours.
has 5 modules to select from
Toddler Module – for children between 12 and 30 months of age who do not consistently use phrase speech.
Module 1 – for children 31 months and older who do not consistently use phrase speech.
Module 2 – for children of any age who use phrase speech but are not verbally fluent.
Module 3 – for verbally fluent children and young adolescents.
Module 4 – for verbally fluent older adolescents and adults.
what is the Connor’s questionnaire
assesses people for ADHD
What medication is licensed to treat challenging aggressive behaviour in autistic children?
Risperidone
what is emotionally unstable personality disorder
disorder of significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour. pattern of fluctuation from periods of confidence to despair, with fear of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm. Transient psychotic symptoms, including brief delusions and hallucinations, may also be present.
subtypes of EUPD; impulsive type and borderline type
what is DBT and its use in BPD
Dialectical behavior therapy (DBT) is a comprehensive treatment program that includes many aspects of other cognitive-behavioral approaches but also some unique elements
- 5 functions of treatment
- biosocial therapy and focusing on emotions
- dialectical philosophy
- acceptance and mindfulness
what are trait theories
what are the five central traits
what happens with these traits in personality disorder
personalities are seen as a complex mix of traits
traits are habitual patterns of behaviour, thoughts and emotions
openness, conscientiousness, extroversion, agreeableness, neuroticism
abnormality of personality traits present causing distress to the patient or people around them
aetiology of personality disorders
mixed nature and nurture with epigenetic influence
genetic predisposition and this can also lead parents to show behaviours that may influence the development of PD e.g. substance misuse, marital discord, abuse
3/4 of cases have prolonged abuse in childhood
neglect often present
possible brain injury/cognitive decline
treatment of personality disorder
biopsychosocial approach
bio - treat comorbidites (medication not used for PD itself but treat anxiety, depression etc)
psycho - DBT, group support for patients and carers
social - support, structure, crisis management
balling groups - reflection for healthcare professionals
what are the types of ego defences and examples
- Primitive e.g. denial, regression, acting out, projection, splitting (seeing things/people as extreme good or bad), identification (assimilating an admired other),
- Less primitive (intellectualisation, rationalisation, undoing)
- Mature (sublimation, compensation, assertiveness)
important to identify them and address in psychotherapy
what are the types of ego defences and examples
- Primitive e.g. denial, regression, acting out, projection, splitting (seeing things/people as extreme good or bad), identification (assimilating an admired other),
- Less primitive (intellectualisation, rationalisation, undoing)
- Mature (sublimation, compensation, assertiveness)
important to identify them and address in psychotherapy
what is the diagnosis similar to ADHD made as an adult
hyperkinetic disorder
taking a history ADHD
school and home
can the child:
- sit still
- concentrate
- follow instructions
- aware of dangers
- behave out of the house .g. supermarket
- maintain focus
- fussy at mealtimes
- able to sleep
what is conduct disorder
repetitive and persistent pattern of dis social, aggressive or defiant conduct
2 main types:
- oppositional defiant disorder (young children or less severe)
- conduct disorder
what is the SNAP questionnaire
questionnaire completed by parents and teachers in diagnosing ADHD
each item scored 0-3
score is calculated by sum of the scores /number of total questions
what is a Qb test
used in assessment of ADHD
Quantitative behaviour test
an objective measure of inattention, hyperactivity and impulsivity
a Q score between -1 and 1 is normal
what are the mainstay medications for ADHD
psychostimulant medications
3 major groups
Ritalin group (Methylphenidate) -first line NICE either short or long acting. try for 6 weeks then switch to a dexamphetamine
Adderal group (mixed amphetamine salts)
Dexedrine group (dextroamphetamine)
Increase levels of dopamine and noradrenaline in the brain
non stimulant medications are also sometimes used - help by decreasing overactive portions of the brain but less effective than stimulants
side effects of stimulant ADHD medications
- poor appetite and weight loss
- sleep troubles
- stomach aches and headaches
how is ADHD medication reviewed/monitored
review annually for efficacy
this can be done by treatment holidays - coming off for a few days and comparing Childs behaviour
what is mutlisystemic therapy
3-4 months intensive therapy programme used for patients and family’s with conduct disorder
what is Charles-bonnet syndrome
characterised by visual hallucinations associated with eye disease
occurs more in increasing age
what are the triads of Wernicke’s and Korsakoff’s and what is the relationship between them
Wernicke’s: ophthalmoplegia, nystagmus, ataxia
Korsakoff’s: retrograde amnesia, anterograde amnesia, confabulation
if left untreated wernickes can progress to korsakoffs which is irreversible
Wernicke’s is treated with thiamine
what things are low/raised in anorexia nervosa?
most things low; potassium, LH, FSH, oestrogen/testosterone, HR, BP, BMI
G’s and C’s raised; growth hormone, glucose, glands (salivary), cortisol, cholesterol, carotinemia
how should antidepressants be managed when ECT commences
reduce dose but don’t stop
alcohol withdrawal; when are the peak incidences of
symptoms
seizures
delirium tremens
how is it treated
symptoms 6-12 hrs
seizures 36 hrs
delirium tremens 72 hrs
treat with long acting bento such as chlordiazepoxide or diazepam
Acute stress disorder management
Trauma focussed CBT
Benzodiazepines sometimes for acute symptoms but use with caution for dependence
side effects of cholinesterase inhibitors
Diarrhoea, dizziness, anorexia, weightless, nausea, vomiting and insomnia
how long does a DoL last
12 months then must be reviewed to be reissued
REM sleep behaviour disorder
treatment
pt has vivid dreams in which they may act out what is happening
alert once woken
clonazepam
what is the preferred anti-psychotic for treating behavioural and psychological dementia symptoms in Lewy body dementia or PD dementia
Quetiapine (low dose; increased sensitivity to neuroleptics in these conditions)
what hormone initiates the fear response
cortisol
Tests that may be done for conditions mimicking depression
FBC - infective causes, anaemia
U+Es- electrolyte abnormality
Endocrine tests
Urine drug screen
Neurological conditions - bloods, imaging
Psychiatric examination for other mental disorder that may better explain symptoms
what can happen when tyramine rich foods are consumed with MAO-Inhibitors
a hypertensive crisis can occur
management of acute dystonia
procyclidine
also consider anti-cholinergic drugs
antipsychotics; what monitoring tests needed and how frequently
FBC, U+Es, LFTs; at start, then annually (except clozapine much more frequent)
Lipids and weight; at start, 3 months, annually
Fasting blood glucose and prolactin; start, 6 months, annually
BP; frequently during dose titration
CV risk assessment annually
Cotard syndrome
delusion associated with severe depression and psychosis in which the pt believes that them or a part of their body is dead or non-existent
switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
the first should be gradually withdrawn before the new one is started
switching from fluoxetine to a new SSRI
leave a gap of 4-7 days before starting the new SSRI
switching from an SSRI to a TCA
cross-taper
(except fluoxetine-stop first)
switching from an SSRI to venlafaxine
most of them cross-taper cautiously
fluoxetine completely stop first
panic disorder treatment
CBT or drug therapy; SSRI for 12 weeks if ineffective switch to imipramine or clomipramine
post concussion syndrome
can be seen after even minor head trauma
- headahce
- fatigue
- anxiety/depression
- dizziness
important neurological side effect of both clozapine and lithium
lower seizure threshold
what is the pathophysiology of positive and negative symptoms in schizophrenia
positive - too much dopamine in the mesolimbic pathways
negative - too little dopamine in the mesocortical pathways
action on what dopamine pathways leads to side effects seen with antipsychotic use
dopamine blocking activity in the nigrostriatal pathways causes the movement disorder (extrapyramidal) side effects
dopamine blocking activity in the tuberoinfundibular pathway leads to hyperprolactinemia
what drugs can be used in management of akathisia and tar dive dyskinesia
if possible reduce dose of antipsychotic
clonazepam
propranolol
NSAIDs with lithium
avoid
NSAIDs cause an unpredictable increase in lithium levels and a high risk of toxicity
aspirin and paracetamol are safe
what are acamprosate and naltrexone used for in relation to alcohol
to reduce cravings
lithium in pregnancy
teratogenic in first trimester
signs of severe lithium toxicity (>2.5mmol/l)
generalised convulsions
renal failure
+ from moderate; nausea, clonic limb movements, delirium, syncope
how can carbamazepine be used in bipolar disorder
- acute mania mono therapy (not first line)
- mania prophylaxis monotherapy
- augmentation of antipsychotics in mania
get baseline FBC, LFTs and ECG
carbamazepine side effects
rash - most common
nausea, vomiting, dizziness, diarrhoea, sedation
AV conduciton delays
agranulocytosis and aplastic anaemia
water retention
drug drug interactions
when is lamotrigine indicated in bipolar disorder
type 2 bipolar (hypomania)
get baseline LFTs before
