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Clinical Years / Progress Test > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What are the core symptoms for a diagnosis of depression?
what other symptoms can be present

A

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

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2
Q

what is the ICD10 criteria for diagnosis procedure of depression

A

2 of the core symptoms for at least 2 weeks plus at least 2 additional symptoms
4 total = mild
5-6 = moderate
7+ = severe

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3
Q

what is the DSMV criteria / diagnosis of major depressive disorder

A

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

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4
Q

what other mood is important to consider in diagnosing depression

A

any history of mania or hypomania which would change the diagnosis to bipolar mood disorder as opposed to depression

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5
Q

what initial investigations are necessary in someone presenting with depression

A

ECG
BMI
BP and pulse
FBC, U&E, LFT, TFT HBA1C

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6
Q

what is the advice for continuation of antidepressants after a depressive episode

A

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

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7
Q

what is the typical response rate of antidepressants
what change should be made if unsuccessful

A

about 67% respond
if not better to change class than change drug within class

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8
Q

side effects of Tricyclic Antidepressants

A

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

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9
Q

types of antidepressants and examples

A

TCAs; amitriptyline, imipramine, nortiptyline
MAOIs; phenelzine, selegeline
SSRIs; sertraline, fluoxetine, citalopram
SNRIs; venlafaxine, duloxetine

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10
Q

what is serotonin syndrome?
what are the symptoms

A

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

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11
Q

treatment of serotonin syndrome

A

discontinue causative medication
benzodiazepines
active cooling
if severe serotonin antagonist

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12
Q

SSRIs
side effect profile
is there discontinuation syndrome

A

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

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13
Q

Pros and cons of fluoxetine

A

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

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14
Q

Escitalopram pros and cons

A

Few drug drug interactions
More effective than citalopram is acute response
Good in epilepsy

Dose dependent QT prolongation
Nausea headache
Expensive drug

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15
Q

Citalopram pros and cons

A

Few drug drug interactions

Dose dependent QT prolongation
Can be sedating
GI side effects

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16
Q

Sertraline pros and cons

A

Short half life lower metabolic build up
Less sedating

Max absorption requires full stomach
Increased number of GI effects

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17
Q

Paroxetine pros and cons

A

Short half life
Sedating properties good at night

Sedation, weight gain, anticholinergic effects
Likely to cause discontinuation syndrome

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18
Q

Venlafaxine pros and cons

A

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

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19
Q

Duloxetine pros and cons

A

Some data to suggest helps physical depression symptoms
Less BP increase than venlafaxine

Inhibits CYP enzymes

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20
Q

What kind of drug is mirtazapine
Pros and cons

A

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

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21
Q

What actions do TCAs have

A

Blocks SERT
blocks NET
5HT2A antagonism - anxiolytic

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22
Q

What’s the difference between secondary and tertiary TCAs

A

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

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23
Q

What kind of drugs are MAOIs
When used
Side effects

A

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

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24
Q

How to switch between MAOI and SSRI or vice versa

A

Wait two weeks in between because of risk of serotonin syndrome
If fluoxetine wait 5 weeks because of long half life

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25
Q

What is the hierarchy to rule out diagnoses in psychiatry

A

In order to rule out
- organic
- drug and alcohol related
- psychosis
- mood disorders
- anxiety/ stress related (neuroses)
- personality/behavioural disorders

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26
Q

What is the management for mild generalised anxiety disorder

A

Watchful waiting
Internet based self help
Lifestyle advice

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27
Q

what drugs can be used as mood stabilisers
what conditions are they used in

A

atypical antipsychotics
lithium
anticonvulsants

indicated in bipolar disorder, schizophrenia, and lithium in unipolar depression

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28
Q

when is lithium prescribed

A

acute mania or hypomania, bipolar prophylaxis, depression prophylaxis
prescribed by brand
takes 1-2 weeks to work

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29
Q

how is lithium monitored

A

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

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30
Q

lithium side effects and signs of toxicity

A

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

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31
Q

what are the complications, contraindications and interactions of lithium

A

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

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32
Q

important complications and contraindications of sodium valproate

A

can cause thrombocytopenia –> bruising, leucopenia, jaundice, dark urine
contraindicated in pregnancy, breastfeeding, personal or FH of hepatic impairment

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33
Q

when is lamotrigine prescribed? important side effect

A

type 2 bipolar (hypomania)
Steven johnson rash

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34
Q

what scale is used for post natal depression

A

Edinburgh post natal depression scale

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35
Q

what is panic disorder

A

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.

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36
Q

what features are panic attacks characterised by

A

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.

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37
Q

what is generalised anxiety disorder

A

‘several’ months with prominent tension, worry and feelings of apprehension, about every-day events and problems

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38
Q

what symptoms is GAD characterised by

A
  • autonomic arousal symptoms
  • chest and abdomen symptoms
  • brain and mind symptoms
  • tension symptoms
  • other non-specific; difficulty concentrating, irritability, difficulty getting to sleep
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39
Q

how is OCD characterised

A

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).

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40
Q

what are the features post traumatic stress disorder

A

flashbacks, hyper vigilance, avoidance and associated symptoms of anxiety and distress for one month or more following a traumatic or stressful event

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41
Q

what questionnaires can be used to measure severity of/ progress in anxiety and depression

A

GAD7 anxiety
PHQ9 depression

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42
Q

how do CBT sessions run

A

usually 8-12 1 hour sessions with homework to do in between
addresses thoughts, feelings, behaviours
uses interventions and activities to make changes

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43
Q

what to consider with CBT referral

A

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

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44
Q

perinatal mental health conditions

A

“baby blues”
postnatal depression
postpartum psychosis
pre-exisiting MH condition exacerbated by the perinatal period

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45
Q

baby blues

A

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

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46
Q

postnatal depression
- presentation
- management

A

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

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47
Q

postpartum psychosis
- presentation
- management

A

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

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48
Q

what other conditions need to be considered perinatally

A

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

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49
Q

basic rules of psychiatric prescribing in pregnancy

A
  • 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
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50
Q

antidepressants in perinatal period

A

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

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51
Q

antipsychotics in perinatal period

A

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)

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52
Q

sodium valproate in perinatal period

A

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

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53
Q

what SSRIs are indicated for PTSD

A

sertraline and paroxetine

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54
Q

what is acute stress disorder

A

PTSD like symptoms but within the 4 weeks immediately following a traumatic event including mental and physical symptoms

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55
Q

features of somatisation disorder

A

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

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56
Q

features of hypochondriasis

A

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

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57
Q

what other conditions are associated with medically unexplained symptoms

A

conversion disorder - nervous system symptoms due to underling psychological disorder
factitious disorder - feigning illness without a malingering motive
malingering - feigning illness for personal gain

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58
Q

what medications can be associated with depressive symptoms

A

beta blockers
statins
corticosteroids
benzos
alcohol
antipsychotics –> drowsiness

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59
Q

what treatments can be used for PTSD

A

EMDR - eye movement desensitisation and reprocessing
trauma focussed CBT
both recommended by NICE

can also consider medication

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60
Q

types of personality disorder

A

cluster A: paranoid, schizoid, schizotypal
cluster B: antisocial, emotionally unstable/borderline, histrionic, narcissistic
cluster C: obsessive compulsive, avoidant, dependant

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61
Q

management of OCD

A

exposure and response prevention therapy is first line if mild
if not responded or more severe then sertraline is indicated

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62
Q

SSRIs important interactions

A

triptans
warfarin/heparin
with NSAIDs try to avoid but if needed prescribe a PPI too
MAOIs - risk of serotonin syndrome

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63
Q

strongest risk factor for psychotic disorders

A

family history

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64
Q

examples of
- typical antipsychotics
- atypical antipsychotics

A

typical (1st gen) - haloperidol, chlorpromazine
atypical (2nd gen) - olanzapine, clozapine, risperidone

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65
Q

when is ECT indicated

A

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

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66
Q

ECT side effects/contraindications

A

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

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67
Q

What electrolyte abnormality can long term lithium treatment cause

A

Hyperparathyroidism leading to hypercalcaemia
Presented with stones, bones, moans and groans

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68
Q

categories and examples of side effects of antipsychotics

A

metabolic - weight gain and diabetes
extrapyramidal - akathisia, dyskinesia, dystonia
cardiovascular - prolonged QT interval,
hormonal - hyperprolactinemia
other - inc unpleasant experiences

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69
Q

when should clozapine be used in schizophrenia

A

only after 2 other antipsychotics tried of at least one being an atypical antipsychotic

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70
Q

first episode psychosis treatment

A

oral antipsychotic
+
early intervention psychotherapy such as CBT

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71
Q

what tests should be done before starting an antipsychotic

A

ECG
Lipid levels
prolactin levels
BMI and physical measurements
movement assessment
assessment of nutrition
HBA1C
pulse and BP

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72
Q

what is schizophrenia
how are the symptoms of schizophrenia divided

A

schizophrenia is the most common psychotic disorder
symptoms are divided into positive and negative symptoms
positive - presence of hallucinations, delusions
negative - apathy, social withdrawal

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73
Q

what course does schizophrenia usually present with

A

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

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74
Q

typical/first gen antipsychotics

A

block D2 receptors in the brain
examples: haloperidol, chlorpromazine, prochlorperizine

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75
Q

atypical/2nd gen antipsychotics

A

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,

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76
Q

organic causes of psychosis

A

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

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77
Q

what conditions can psychotic symptoms occur in

A

schizophrenia
drug induced psychosis
manic phase of bipolar
severe depression
dementia

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78
Q

what is section 2 of the MHA

A

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

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79
Q

MHA section 3

A

up to 6 months (but reviewed after 3 and consent gained or a second opinion)
for treatment
2 doctors needed to approve

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80
Q

MHA section 4

A

up to 72 hours
any doctor
for emergency admission for treatment

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81
Q

MHA section 5(2)

A

up to 72 hours by doctor or clinician in charge
emergency holding when patient already in hospital for other reason

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82
Q

MHA section 5(4)

A

up to 6 hours by a registered nurse for emergency holding when pt already in hospital

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83
Q

MHA section 135

A

warrant to gain access to patient
can be used once
allows for further assessment but not treatment
one doctor, AMHP and police

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84
Q

MHA section 136

A

allows police to remove someone from public place to place of safety
can be used once
does not allow treatment

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85
Q

what is schizoaffective disorder

A

equal and simultaneous symptoms of a mood disorder and psychotic symptoms of schizophrenia

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86
Q

risperidone important side effects

A

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

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87
Q

giving olanzapine
+ important side effects

A

tablets or IM injection
weight gain predominant side effect
can cause lipid changes
increased prolactin but less than risperidone
transaminitis in 2%

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88
Q

giving quetiapine + important side effects

A

available only as tablet
some weight gain and lipid changes but less than olanzapine
transaminitis in 6%
can cause orthostatic hypotension
can prolong QTc

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89
Q

aripiprazole

A

available as IM depot
multiple indications
can be stimulating - caution in agitation
No QTc prolongation, low sedation

90
Q

clozapine important side effects

A

lower seizure threshold
agranulocytosis!!

91
Q

what is neuroleptic malignant syndrome

A

syndrome of autonomic dysfunction
- hyperthermia
-hypertension
-hyperreflexia
- elevated CK due to muscle break down
can be fatal
discontinue antipsychotic and transfer to medical ward

92
Q

What is akathisia

A

A sense of inner restlessness and inability to keep still
Usually due to anti psychotic use

93
Q

What is acute dystonia
Management

A

Acute sustained muscle contraction
Can be managed with procyclidine

94
Q

What is tardive dyskinesia

A

Abnormal, involuntary choraethoid movement
Usually late onset in antipsychotic treatment
May be irreversible
Commonly lip smacking and jaw pouting

95
Q

What are the risks of antipsychotics in elderly patients

A

Increased risk of stroke and VTE

96
Q

Management of mania in bipolar disorder

A

Stop any antidepressants
Start an antipsychotic
Continue or start a mood stabiliser

97
Q

4 types of extrapyramidal side effects caused by antipsychotics (predominantly typical)

A

Parkinsonism
Akathisia
Acute dystonia
Tardive dyskinesia

98
Q

What is the antidepressant of choice in children and adolescents

A

Fluoxetine

99
Q

Symptoms of mania

A

DIGFAST

Distractability
Irresponsibility
Grandiose delusions
Flight of ideas
Activity increase
Sleep deficit
Talkative

100
Q

Types of bipolar

A

Type 1 - depression and mani
Type 2 - depression and hypo mania

101
Q

structure of MSE

A

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

102
Q

structure of psychiatric history

A

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

103
Q

Criteria for substance dependence syndrome diagnosis

A

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

104
Q

What is disulifram?

A

used to deter patient from drinking alcohol

105
Q

what are the main classes of drugs used in dementia + examples

A

acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine

glutamate receptor antagonist e.g memantine

106
Q

when are AChE inhibitors used

A

early on in treatment
mild symptoms of Alzheimers present

107
Q

which AChE inhibitor is licensed in lewy body and Parkinson’s dementia

A

rivastigmine

108
Q

when is memantine the drug of choice

A

in moderate to severe alzheimers disease

109
Q

what is the cognitive deterioration in Alzheimers thought to result from

A

loss of cholinergic neurons and decreasing levels of acetylcholine in the brain

110
Q

how is donzepezil given

A

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

111
Q

how is rivastigmine given

A

orally twice daily or by patch once daily
very short half life

112
Q

how does memantine improve symptoms of AD

A

inhibits the excessive neuronal excitation that occurs in glutamate pathways thought to cause neurotoxicity

113
Q

how are memantine and donzepezil metabolised

A

through the liver - so subject to serum levels altered by enzymes
not the case with rivastigmine

114
Q

main side effects of AChE inhibitors

A

anticholinergic side effects
- nausea, vomiting, diarrhoea
- urinary incontinence
- insomnia, dizziness
may cause bradycardia

rivastigmine is most safe with other drugs

115
Q

which is the most comprehensive cognitive function test?
what other ones are there

A

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

116
Q

what is dysexecutive syndrome

A

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

117
Q

what is the frontal assessment battery

A

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

118
Q

what tools can assess the functional, psychological and care giver strain in dementia

A

Functional: ADL questionnaire, functional activities questionnaire, bristol funcitonal assessment
Psychological: neuropsychiatric inventory
Care giver strain: MBRC instrument

119
Q

what other action does rivastigmine have

A

also an inhibitor of butyl cholinesterase as well as AChE

120
Q

what are the non-cognitive symptoms of dementia

A

behavioural and psychological symptoms including hallucinations, delusions, anxiety, marked agitation and associated aggressive behaviour, wandering, hoarding, sexual disinhibition, apathy and disruptive vocal activity

121
Q

What investigations need to be completed prior to starting cholinesterase inhibitors or NMDA receptor antagonist?

A

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

122
Q

when are AChE inhibitors cautioned

A

in patients with a history of gastric ulcers and seizures

123
Q

what psyhcolocial can be used in dementia

A

Cognitive stimulation therapy
CBT
Reminiscence therapy
Aromatherapy
Sensory stimulation
Music therapy

124
Q

what is essential for a diagnosis of dementia

A

history taking and a cognitive assessment
other useful aspects include neuropsychological assessment and brain imaging

125
Q

cortical vs subcortical types of dementia

A

cortical; alzheimers, Lewy body, frontotemporal
subcortical; vascular, huntingtons, alcohol, HIV/AIDS related

126
Q

what symptoms result from temporal lobe degeneration

A

prospagnosia- recognising celebrity faces
difficulty understanding words
short term and semantic memory affected
visuospacial neglect
can recognise music
inability to categorise

127
Q

what symptoms result from parietal lobe degeneration

A

difficulty writing and drawing
L-R disorientation
dyscalculia
apraxia
visuospatial neglect

127
Q

what symptoms result from frontal lobe degeneration

A

affects sequencing, spontaneity, cognitive flexibility, conceptualisation, concentration, impulse control, problem solving

128
Q

what lobe does alzhimers tend to affect first

A

temporal lobe symptoms first and hippocampal

129
Q

what are the dementia screening bloods

A

BC, U&E, CRP, LFT’s, TFT’s, B12, and Folate, HIV, syphillis

130
Q

what symptoms are common in Lewy body dementia

A

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)

131
Q

what drugs are used in Lewy body dementia

A

levodopa for motor symptoms
rivastigmine (usually 4.6mg/24hr patch) or similar for cognitive symptoms
antispychitoics such as quetiapine can be considered for hallucinations

132
Q

what is REM sleep behaviour disorder what is the treatment

A

disorder where patient acts out during sleep
clonazepam

133
Q

main clozapine side effects

A

weight gain
excessive salivation
agranulocytosis
neutropenia
myocarditis
arrhythmias

134
Q

what symptoms suggest pseudo dementia secondary to depression

A

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

135
Q

what endocrine disorder is associated with chronic lithium toxicity

A

hypothyroidism

136
Q

list of thought disorders

A

cricumstantialty
tangentiality
clang associations
neologisms
word salad
knights move thinking
flight of ideas
perseveration
echolalia

137
Q

what needs monitoring with SNRIs?

A

blood pressure - can lead to hypertension
monitor before and every dose titration

138
Q

what needs to be monitored with valproate drugs

A

LFTs before and at 6 months - can cause liver dysfunction

139
Q

what are the four As in diagnosing dementia

A

Amnesia
Agnosia - not recognising people or objects
Aphasia
Apraxia

140
Q

Alzheimers presentation

A

gradual onset cortical decline evidenced by the 4 As
memory problems and decreased motivation/drive
slow progression

141
Q

what are BPSD

A

behavioural and psychological symptoms of dementia

142
Q

vascular dementia presentation

A

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

143
Q

management specific to VD

A

manage vascular risk factors and treat with aspirin and a statin

144
Q

what is mild cognitive impairment

A

a disorder in cognitive function lasting at least two weeks but not affecting ability to carry out day to day life

145
Q

what is dementia as an umbrella term

A

decline in cognitive function including memory and other cognitive domains with functional impairment for at least 6 months and without reduced consciousness

146
Q

what are the three types of frontotemporal dementia

A

Picks disease- behaviour predominant

Semantic

progressive non-fluent aphasia - language predominant

147
Q

risk assessment in dementia

A

Suicide, self-neglect, susceptibility to illness
Abuse, aggression
Wandering
Falls, fire
Exploitation
Non-compliance with medication
Driving, drugs and alcohol

148
Q

taking a history in cognitive impairment

A
  • 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
149
Q

short term side effects of ECT

A

headache, nausea, memory impairment and arrhythmias
long term very few - some patients describe long term memory loss

150
Q

what electrolyte abnormality are SSRIs associated with

A

hyponatrameia

151
Q

How can Schneider’s first rank symptoms be divided and what are they

A

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

152
Q

what three features must be present for a diagnosis of autism to be made?

A

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

153
Q

how does social interaction and communication present in autism?

A
  • 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
154
Q

what conditions can be linked with autism

A
  • Anxiety
  • Depression
  • OCD
  • sleep disturbance
  • gender dysphoria
155
Q

taking an autism history

A

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

156
Q

specific tools for Assessment and examination in autism

A

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

157
Q

what is the definition of autism

A

a lifelong developmental disability that affects how a person communicates with and relates to others and experiences the world around them

158
Q

what is the so called triad of autism

A

social interaction
social communication
social understanding

159
Q

general principles of diagnosing autism

A

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

160
Q

management of autism (biopsychosocial)

A

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

161
Q

core symptoms of ADHD

A

inattention
impulsivity
hyperactivity

162
Q

diagnostic criteria of ADHD

A
  • 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
163
Q

management of ADHD

A
  • 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
164
Q

what obstetric infection has been associated with autism

A

congenital rubella infections particularly in the first trimester

165
Q

what physical brain differences is there evidence for in ASD compared to the rest of the population

A

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.

166
Q

what is the typical course of ASD

A

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

167
Q

what indicates good prognosis for a person with ASD

A

Communicative speech 6 years old and above
Higher IQ (>50)
Skills that can be used to secure employmen

168
Q

Autism Diagnostic Interview Revisited

A

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

169
Q

Diagnostic Interview for Social and Communication Disorders (DISCO)

A

comprised of 300 questions and used to get a global idea of the autistic spectrum of the patient and their specific needs

170
Q

ADOS-2

A

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.

171
Q

what is the Connor’s questionnaire

A

assesses people for ADHD

172
Q

What medication is licensed to treat challenging aggressive behaviour in autistic children?

A

Risperidone

173
Q

what is emotionally unstable personality disorder

A

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

174
Q

what is DBT and its use in BPD

A

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

175
Q

what are trait theories

what are the five central traits

what happens with these traits in personality disorder

A

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

176
Q

aetiology of personality disorders

A

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

177
Q

treatment of personality disorder

A

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

178
Q

what are the types of ego defences and examples

A
  1. Primitive e.g. denial, regression, acting out, projection, splitting (seeing things/people as extreme good or bad), identification (assimilating an admired other),
  2. Less primitive (intellectualisation, rationalisation, undoing)
  3. Mature (sublimation, compensation, assertiveness)

important to identify them and address in psychotherapy

178
Q

what are the types of ego defences and examples

A
  1. Primitive e.g. denial, regression, acting out, projection, splitting (seeing things/people as extreme good or bad), identification (assimilating an admired other),
  2. Less primitive (intellectualisation, rationalisation, undoing)
  3. Mature (sublimation, compensation, assertiveness)

important to identify them and address in psychotherapy

179
Q

what is the diagnosis similar to ADHD made as an adult

A

hyperkinetic disorder

180
Q

taking a history ADHD

A

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

181
Q

what is conduct disorder

A

repetitive and persistent pattern of dis social, aggressive or defiant conduct

2 main types:
- oppositional defiant disorder (young children or less severe)
- conduct disorder

182
Q

what is the SNAP questionnaire

A

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

183
Q

what is a Qb test

A

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

184
Q

what are the mainstay medications for ADHD

A

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

185
Q

side effects of stimulant ADHD medications

A
  • poor appetite and weight loss
  • sleep troubles
  • stomach aches and headaches
186
Q

how is ADHD medication reviewed/monitored

A

review annually for efficacy

this can be done by treatment holidays - coming off for a few days and comparing Childs behaviour

187
Q

what is mutlisystemic therapy

A

3-4 months intensive therapy programme used for patients and family’s with conduct disorder

188
Q

what is Charles-bonnet syndrome

A

characterised by visual hallucinations associated with eye disease
occurs more in increasing age

189
Q

what are the triads of Wernicke’s and Korsakoff’s and what is the relationship between them

A

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

190
Q

what things are low/raised in anorexia nervosa?

A

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

191
Q

how should antidepressants be managed when ECT commences

A

reduce dose but don’t stop

192
Q

alcohol withdrawal; when are the peak incidences of
symptoms
seizures
delirium tremens

how is it treated

A

symptoms 6-12 hrs
seizures 36 hrs
delirium tremens 72 hrs

treat with long acting bento such as chlordiazepoxide or diazepam

193
Q

Acute stress disorder management

A

Trauma focussed CBT

Benzodiazepines sometimes for acute symptoms but use with caution for dependence

194
Q

side effects of cholinesterase inhibitors

A

Diarrhoea, dizziness, anorexia, weightless, nausea, vomiting and insomnia

195
Q

how long does a DoL last

A

12 months then must be reviewed to be reissued

196
Q

REM sleep behaviour disorder

treatment

A

pt has vivid dreams in which they may act out what is happening
alert once woken

clonazepam

197
Q

what is the preferred anti-psychotic for treating behavioural and psychological dementia symptoms in Lewy body dementia or PD dementia

A

Quetiapine (low dose; increased sensitivity to neuroleptics in these conditions)

198
Q

what hormone initiates the fear response

A

cortisol

199
Q

Tests that may be done for conditions mimicking depression

A

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

200
Q

what can happen when tyramine rich foods are consumed with MAO-Inhibitors

A

a hypertensive crisis can occur

201
Q

management of acute dystonia

A

procyclidine

also consider anti-cholinergic drugs

202
Q

antipsychotics; what monitoring tests needed and how frequently

A

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

203
Q

Cotard syndrome

A

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

204
Q

switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI

A

the first should be gradually withdrawn before the new one is started

205
Q

switching from fluoxetine to a new SSRI

A

leave a gap of 4-7 days before starting the new SSRI

206
Q

switching from an SSRI to a TCA

A

cross-taper
(except fluoxetine-stop first)

207
Q

switching from an SSRI to venlafaxine

A

most of them cross-taper cautiously

fluoxetine completely stop first

208
Q

panic disorder treatment

A

CBT or drug therapy; SSRI for 12 weeks if ineffective switch to imipramine or clomipramine

209
Q

post concussion syndrome

A

can be seen after even minor head trauma
- headahce
- fatigue
- anxiety/depression
- dizziness

210
Q

important neurological side effect of both clozapine and lithium

A

lower seizure threshold

211
Q

what is the pathophysiology of positive and negative symptoms in schizophrenia

A

positive - too much dopamine in the mesolimbic pathways
negative - too little dopamine in the mesocortical pathways

212
Q

action on what dopamine pathways leads to side effects seen with antipsychotic use

A

dopamine blocking activity in the nigrostriatal pathways causes the movement disorder (extrapyramidal) side effects

dopamine blocking activity in the tuberoinfundibular pathway leads to hyperprolactinemia

213
Q

what drugs can be used in management of akathisia and tar dive dyskinesia

A

if possible reduce dose of antipsychotic

clonazepam
propranolol

214
Q

NSAIDs with lithium

A

avoid
NSAIDs cause an unpredictable increase in lithium levels and a high risk of toxicity

aspirin and paracetamol are safe

215
Q

what are acamprosate and naltrexone used for in relation to alcohol

A

to reduce cravings

216
Q

lithium in pregnancy

A

teratogenic in first trimester

217
Q

signs of severe lithium toxicity (>2.5mmol/l)

A

generalised convulsions
renal failure

+ from moderate; nausea, clonic limb movements, delirium, syncope

218
Q

how can carbamazepine be used in bipolar disorder

A
  • acute mania mono therapy (not first line)
  • mania prophylaxis monotherapy
  • augmentation of antipsychotics in mania

get baseline FBC, LFTs and ECG

219
Q

carbamazepine side effects

A

rash - most common

nausea, vomiting, dizziness, diarrhoea, sedation

AV conduciton delays

agranulocytosis and aplastic anaemia

water retention

drug drug interactions

220
Q

when is lamotrigine indicated in bipolar disorder

A

type 2 bipolar (hypomania)
get baseline LFTs before

Clinical Years / Progress Test (24 decks)

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