Psychiatry Flashcards
1
Q
Who is excluded from the Mental Health Act?
A
People under the influence of drugs or alcohol
2
Q
What are the cluster A personality types?
A
Schizoid
Schizotypal
Paranoid
3
Q
What are the cluster B personality types?
A
EUPD
Histrionic
Narcisstic
Antisocial
4
Q
What are the cluster C personality types?
A
OCPD
Dependant
Avoidant
5
Q
What are the essential diagnostic features of a personality disorder?
A
Impairments in:
Self and interpersonal functioning
Personality functioning
Consistent across time and situations
6
Q
What are the age requirements to be diagnosed with a personality disorder?
A
18.
OR under 18 with > 1 year symptoms. This does not apply for antisocial PD -> conductive disorder instead
7
Q
What is the treatment of choice for personality disorders?
A
Dialectical behaviour therapy
8
Q
Anhedonia
A
Reduced ability to experience pleasure
9
Q
Anergia
A
Lack of energy
10
Q
How can pseudodementia secondary to depression be differentiated from dementia?
A
Pseudodementia - idk
Dementia - confabulation
11
Q
What is the 1st line medication for depression?
A
SSRI
12
Q
How long is a depressive episode?
A
At least 2 weeks
13
Q
Lithium use in depression
A
Add if antidepressants do not work
Contraindicated in low oral intake
14
Q
Management of severe depressive episode which is life-threatening or requires a rapid response
A
ECT
15
Q
Management of mild depression
A
Monitor and follow up
16
Q
Indications for ECT in depression
A
Preference based on past experience
Rapid response needed
Other treatments unsuccessful
17
Q
Dysthymia
A
Low mood which does not meet threshold for depressive disorder
18
Q
Which SSRI is best for people who have had an MI?
A
Sertraline
19
Q
Which SSRI is best for children?
A
Fluoxetine
20
Q
What medication should be co-prescribed with SSRIs?
A
NSAIDs
21
Q
How long should SSRIs be continued for after remission of symptoms?
A
6 months
22
Q
Over how long of a period of time should SSRIs be weaned off?
A
4 weeks (except fluoxetine)
23
Q
If a patient feels that an SSRI is ineffective, how quickly should their medication be switched?
A
Wait at least 6 weeks from start of medication
24
Q
What medications can SSRIs interact with to cause serotonin syndrome?
A
TCAs
Triptans
Tramadol
St John’s Wort
Ecstacy
Amphetamines
Linezolid
MAOIs
25
Describe the symptoms of SSRI discontinuation syndrome.
Anxiety
Dizziness
Electric shock sensations
Diarrhoea
26
Which SSRI is most likely to cause SSRI discontinuation syndrome?
Paroxetine
27
What medications should not be prescribed if a patient is on an SSRI?
Heparin
Warfarin
Aspirin
28
What are the side effects of SSRIs?
Gastrointestinal upset
Hyponatraemia
Increased anxiety
29
Which SSRI is associated with congenital malformation?
Paroxetine
30
What is associated with the use of SSRIs during 1st trimester in pregnancy?
Congenital heart defects
31
What is associated with the use of SSRIs during 3rd trimester in pregnancy?
Persistent pulmonary hypertension of newborn
32
State an adverse effect of citalopram.
Lengthens QT inverval
33
Cyclothymia
Low and high mood which does not meet diagnosis for formal bipolar disorder
34
How many episodes of manic episodes are needed to diagnose bipolar disorder?
2 or more
35
What is the difference between type I and type II bipolar disorder?
Type I - mania
Type II - hypomonia
36
How should a manic episode be managed if a patient is on an antidepressant?
Stop antidepressant
Start antipsychotic e.g. olanzapine
37
State 2 mood stabilisers used in bipolar disorder.
Lithium
Valproate
Lamotrigine
Antipsychotics
38
Tests required when starting sodium valproate + frequency
LFTs
FBC
BMI
6 months after starting
Every 12 months thereafter
39
Side effects of sodium valproate
Weight gain
Dizziness
Hair loss
N&V
NTD in pregnancy
Tremor
40
State 4 side effects of lithium.
Hypothyroidism
Diabetes insipidus
Fine tremor
Weight gain
Intracranial HTN
Nephrotoxicity
Hyperparathyroidism
41
What congenital heart defect is associated with maternal lithium use?
Ebstein's anomaly
42
Management of lithium use in pregnancy
Gradually switch to antipsychotic
43
Tests required when starting lithium + frequency
TFTs
Calcium
Renal function
Every 6 months
44
Describe the frequency of monitoring lithium levels.
Every time a dose is changed - 1 week after
Otherwise every 3 months for 1 year
Then 6 monthly
45
How long post-dose should lithium levels be checked?
12 hours
46
How does lithium toxicity manifest?
Coarse tremor
Blurred vision
Ataxia
Oliguria
Seizures
Coma
47
How should lithium toxicity be managed?
Fluid resuscitation
Monitor renal function
- Renal dialysis if poor
Seizure control
48
What is the risk recurrence of post partum psychosis?
25-50%
49
How should post partum depression be managed?
CBT
Otherwise SSRI - sertraline or paroxetine
50
How is post partum psychosis managed?
Hospitalisation - mother and baby unit
Do not separate them
51
What is the lifetime risk of developing schizophrenia?
1%
52
What is the risk of recurrence of a psychotic episode in schizophrenia?
75%
53
What are the risk factors for schizophrenia in order?
Family history
Black Caribbean
Migration
Urban environment
Cannabis use
54
What are the first rank symptoms of schizophrenia?
Thought disorder (withdrawal, insertion, broadcast)
Passivity phenomenon
3rd person auditory hallucinations
Delusional perception
55
What are the second rank symptoms of schizophrenia?
Any other hallucinations/delusions
Negative symptoms
Breaks in thought fluency
Catatonic behaviour
Significant and consistent change in overall personal behaviour
56
Mitmachen
Motor symptom associated with schizophrenia - limb can be moved without resistance but returns to original position when released
57
What are the diagnostic criteria for schizophrenia?
1 1st rank or 2 2nd rank, for at least 1 month, evidence of disturbed functioning for 6 months
58
State 3 negative symptoms of schizophrenia
Blunting of affect
Amotivation
Poverty of speech
Lack of insight
Self-neglect
59
What features indicate a poor prognosis for schizophrenia?
Low IQ
Gradual onset
Male
Younger age at diagnosis
60
State 3 complications which can arise from schizophrenia.
Increased suicide
risk
Death 25 years earlier than general population
2x CVD death, 3x respiratory disease, 4x infection
61
Name 2 typical antipsychotics.
Haloperidol
Chlorpromazine
62
Name 4 atypical antipschotics.
Olazapine
Risperidone
Clozapine
Aripiprazole
Quetiapine
63
What is the mechanism of typical antipsychotics?
Dopamine D2 receptor antagonists
64
Which atypical antipsychotic has the best side effect profile?
Aripiprazole
65
Mechanism by which antipsychotics can cause infertility
Dopamine inhibits prolactin
Antipsychotics inhibit dopamine so prolactin increases
Prolactin inhibits GnRH
Reduced LH/FSH
66
Why is aripiprazole best for minimal side effects?
It is a partial agonist
67
Why should use of antipsychotics be cautioned in the elderly?
Increased risk of VTE, stroke
68
Starting clozapine
Dose must be titrated up to therapeutic dose
69
Clozapine + infection
Infection can precipitate toxicity of clozapine
Clozapine levels should be checked
70
State 2 side + adverse effects of clozapine
Constipation
Hypersalivation
Agranulocytosis
Reduced seizure threshold
Myocarditis
Arrhythmias
71
What is a contraindication to the use of haloperidol?
Parkinson's disease
72
Why is it important to keep an up to date social history from patients who are taking clozapine?
Smoking affects the efficiency of clozapine
73
What are the common side effects of typical antipsychotics?
Hyperprolactinaemia
Extrapyramidal side-effects
74
How should dystonia caused by antipsychotics be treated?
Procyclidine and benztropine
75
Treatment of tardive dyskinesia
Tetrabenazine
76
Why is it important for a baseline ECG to be carried out for patients on clozapine?
Increased risk of myocarditis
77
What kind of medication is mirtazapine?
Tetracyclic antidepressant
NASSA (noradrenergic and specific serotonergic antidepressant)
78
What is the mechanism of mirtazapine?
Blocks alpha 2 adrenergic receptors
79
Tyramine cheese reaction
MAOIs + cheese
80
What side effects are associated with mirtazapine?
Increases appetite
81
Give 3 examples of MAOIs.
Rasagiline
Isocarboxazid
Phenelzine
Selegiline
Tranylcypromine
82
What foods/drugs can MAOIs interact with?
Cheese
Cured meats
Soy products
Draft beer
83
Name 3 tricyclic antidepressants.
Amitriptyline
Clomipramine
Dosulepin
Trazodone
Nortriptyline
Imipramine
Lofepramine
84
State 3 side effects of TCAs.
Drowsiness
Anticholinergic effects - dry mouth, eyes etc.
Lengthens QT interval
85
How should TCA overdose be managed?
Activated charcoal within 2-4 hours
IV sodium bicarbonate for arrhythmias
86
How does TCA overdose present?
Metabolic acidosis
Seizures
Coma
Arrhythmias
87
How should a missed dose of clozapine be managed?
Take ASAP if just 1 - unless almost time for 2nd dose then miss 1st dose
88
How should two missed doses of clozapine be managed?
Re-titrate doses slowly
Never take more than 1 dose at once!
89
Clozapine monitoring
FBC monitored
Weekly for 18 weeks
Fortnightly 20-52 weeks
Then monthly
90
Antipsychotic monitoring
Monitor glucose and HbA1C
0, 3 months then annuallly
For olanzapine + clozapine, monitor at 0, 1 month and then every year
91
Antipsychotic monitoring prolactin levels
All typical antipsychotics + risperidone
6 months then every 12 months
92
State 4 extrapyramidal side effects of antipsychotics.
Acute dystonia
Tardive dyskinesia
Parkinsonism
Akathisia
93
What is the mortality rate of neuroleptic malignant syndrome?
10%
94
Describe the presentation of neuroleptic malignant syndrome.
Lead pipe rigidity
Fever, tachycardia, hypertension
95
Describe the onset of neuroleptic malignant syndrome.
Gradual onset
96
Describe the investigation results of neuroleptic malignant syndrome.
Increased CK
Increased WBC
97
What can cause neuroleptic malignant syndrome?
Antipsychotics - atypical
Dopaminergic drugs - when dose is changed/drug is started
98
How should neuroleptic malignant syndrome be managed?
Stop antipsychotic
IV fluids
Diazepam - rigidity
DA agonist- Bromocroptine
Dantrolene - malignant hyperthermia
99
What complication can arise as a result of neuroleptic malignant syndrome?
AKI secondary to rhabdomyolysis
100
What is the pathophysiology of serotonin syndrome?
Excess serotonin in CNS
101
Describe the onset of serotonin syndrome.
Sudden onset
102
Describe the presentation of serotonin syndrome.
Clonus (hyperreflexia)
Diarrhoea
Mydriasis
Fever, tachycardia, hypertension
103
How should serotonin syndrome be managed?
IV fluids
Benzodiazepines
Severe: serotonin antagonists (cyproheptadine, chlorpromazine)
104
What is generalised anxiety disorder?
Excessive anxiety across different situations without a specific associated person or event > 6 months
105
What are the 3 core symptoms of GAD?
Apprehension
Motor tension
Autonomic overactivity
106
Which part of the brain is responsible for the activation of the 'fight or flight' response?
Amygdala
107
State 3 risk factors for developing GAD.
Divorcee
Living alone
Lone parent
Aged 35-54
108
What is the first-line medication offered for GAD?
Sertraline
109
What is the second-line medication offered for GAD?
Alternative SSRI or SNRI to sertraline
110
Describe the psychological symptoms of panic disorder.
Feeling of impending doom
Depersonalisation
Derealisation
Fear of dying
111
1st line management for panic disorder
CBT
112
What medications are offered for panic disorder?
1: SSRI e.g. escitalopram
2: TCA e.g. Imipramine or clomipramine
113
How long should SSRIs be trialled for panic disorder before switching to a new medication?
12 weeks
114
Follow up of pharmacological management of panic disorder / GAD
2, 4, 8, 12 week follow up
If continued, arrange 8-12 week follow ups
115
What is the abortive treatment for panic disorder?
Benzodiazepines
116
State 3 features of GAD according to ICD-10 criteria.
Apprehension
Motor tension
Autonomic overactivity
117
State 3 features of panic disorder according to ICD-10 criteria.
Recurrent attacks of severe anxiety
Secondary fears of dying, losing control or going mad
Attacks last for minutes, with crescendo of fear and autonomic symptoms
Comparative freedom from anxiety symptoms between attacks
118
What is the preferred treatment of panic disorder?
CBT
119
What are the 1st and 2nd line medications given for panic disorder?
1st: SSRI
2nd: TCA e.g. Imipramine, clomipramine
120
How long must symptoms be present to diagnose PTSD?
4 weeks
121
What are 5 key manifestations of PTSD?
Re-experiencing
Avoidance
Hyperarousal
Emotional numbing
Inability to recall
122
What is the 1st line treatment for PTSD?
Trauma-focused CBT
OR
EDMR therapy
123
What are the 1st, 2nd and 3rd line medications used for PTSD?
1st: Venlafaxine
2nd: SSRI
3rd: Risperidone
124
What is the mechanism of venlafaxine?
SNRI - serotonin and noradrenergic reuptake inhibitor
125
What is the difference between PTSD and acute stress disorder?
Acute stress disorder < 4 weeks of symptoms
126
What is the preferred treatment of acute stress disorder?
Trauma-focused CBT
127
What is the 2nd line treatment for acute stress disorder?
Benzodiazepines
128
Define compulsion.
Repetitive behaviours or mental acts that a person feels required to perform
129
Define obsession.
Unwanted, intrusive thoughts, images or urges entering the mind
130
How long must OCD symptoms be present for to make a diagnosis?
2 weeks
131
Describe the epidemiology of OCD.
1-2% population
132
How is mild impairment OCD managed?
1st: CBT including exposure and response prevention
2nd: SSRI
133
How is moderate impairment OCD managed?
SSRI
134
How is severe impairment OCD managed?
Combined SSRI + CBT
135
Difference between overt and covert impulsions.
Overt – observable, covert – mental act
136
What is emotional splitting?
Perceiving something as "all good" or "all bad"
137
De Clerambault syndrome
Erotomania
Delusional belief that another individual is infatuated with them
138
Charles Bonnet syndrome
Significant visual loss + vivid visual hallucinations
139
Cotard syndrome
Delusion that they are/part of their body is dead
Associated with severe depression/psychotic disorders
140
Munchausen’s syndrome/Factitious disorder
Factitious disorder
Intentional production of symptoms
Can be by proxy
141
Illness anxiety disorder
Hypochondriasis
Persistent belief of underlying SERIOUS disease
Patient refuses reassurance or negative results
142
Somatisation disorder
Multiple physical symptoms present over 2 years
Patient refuses to accept reassurance or negative test results
143
Dissociative disorder
Process of separating off certain memories from normal consciousness
DID (dissociative identity disorder) = multiple personality disorder - severe form of dissociative disorder
144
Conversion disorder
Loss of motor or sensory function
May be caused by stress e.g. exams/competition
145
La Belle indifference
Lack of concern over symptoms
Associated with conversion disorder
146
De Frégoli syndrome
Delusion of identifying a familiar person in various people they encounter
147
Delusional parasitosis
Belief that they are infested with bugs
148
Ekbom syndrome
Belief that they are infested with bugs (same as parasitosis)
149
Oppositional defiant disorder
Precedes conduct disorder
Younger children, problems with anger
150
Conduct disorder
< 18 years old, behavioural disorder
Aggression, violence towards animals
151
Folie a deux
Shared hallucinations/delusions between individuals
152
Othello syndrome
Delusional jealousy, usually believing partner is unfaithful
153
What is Hoover’s sign?
Identifies non-organic paresis – pressure under paretic leg when lifting non-paretic leg against pressure - involuntary contralateral hip extension
154
3 indications for ECT
E uphoria
C atatonia
T earful (severe treatment resistant depression)
155
State a contraindication to ECT.
Raised ICP
156
How should antidepressants be managed before ECT?
Reduce dose
157
What are the short term side effects of ECT?
Headache
Nausea
Short-term memory impairment
Cardiac arrhythmia
158
What are the long term side effects of ECT?
Impaired memory
159
Circumstantiality
Inability to answer a question without giving excessive, unnecessary detail
Does eventually answer the question
160
Tangentiality
Wandering from a topic without returning to it
161
Neoligisms
New word formations
162
Clang associations
Ideas are related to each other only by the fact they sound similar or rhyme
163
Word salad
Incoherent speech comprised of nonsense sentences with real words
164
Knight's move thinking
Unexpected and illogical leaps from one idea to another
Featured in schizophrenia
165
Flight of ideas
Discernible links between ideas
Featured in mania
Does not answer question
166
Perseveration
Repetition of ideas or words despite an attempt to change the topic
167
Echolalia
Repetition of someone else's speech, including the question that was asked
168
Echopraxia
Repetition of someone else's movements
169
Incongruity of affect
Emotional responses grossly out of tune with the situation
170
Blunting of affect
Absence of normal emotional response
171
Passivity phenomenon
Someone is controlling your actions or feelings
172
Thought Insertion
Someone put the thought there
173
Thought Withdrawal
Someone taking thoughts out of head
174
Thought Broadcast
Belief that people know what you are thinking
175
Alcohol effect on GABA and glutamate activity
Increases GABA
Decreases glutamate
176
At what stage of alcohol withdrawal does delirium tremens occur?
2-3 days without alcohol
177
What symptoms are present in delirium tremens?
Confusion
Lack of orientation
Delusional parasitosis
Lilliputian hallucinations
178
How should delirium tremens be managed? What is 1st line?
1st line: Benzodiazepines e.g. diazepam/chlordiazepoxide
IV pabrinex
179
State the difference between the presentation of delirium tremens and alcoholic hallucinosis.
DT: 48-72 hours, orientation not intact
AH: 12-48 hours, orientation intact
180
Name 4 stimulant drugs.
Ecstasy
Cocaine
Nicotine
Methamphetamine
181
Name a hallucinogen.
LSD
Ecstasy
182
What is Marchiafava-Bignami disease?
Complication of chronic alcohol intake
Neuropsychiatric symptoms due to corpus callosum degeneration
183
Disulfiram mechanism and trade name
Antabuse
Inhibits acetaldehyde dehydrogenase - leads to build up of acetaldehyde
Causes unpleasant symptoms if alcohol is consumed
184
Acamprosate mechanism and trade name
Campral
Anti-craving, mechanism unknown
Safe with alcohol, minimal side effects
185
State 3 symptoms of opioid intoxication.
Pin-prick pupils
Euphoria
Constipation
Respiratory depression
186
State 3 symptoms of opioid withdrawal.
Yawning
Dilated pupils
Lacrimation
Sweating
N+V+D
187
Mechanism of methadone and form
Opioid mu receptor agonist
Liquid form
1st line for detox
188
How often must heroin be used in heroin dependency to avoid withdrawal?
8 hourly
189
What can be offered in primary care for a newly presenting drug user?
Health check
Screen for blood borne viruses
Contraception, smear
Sexual health advice
Check immunisation and Hep A/B
Signpost to additional help
Information on local drug services
190
Management of missed doses of methadone/buprenorphine
1, 2, 3 days - carry on as normal
4 days - reduce dose
5 days of more - urgent assessment
191
Mechanism of naltrexone and indication
Opioid receptor antagonist
Used in overdose / relapse prevention
192
Mechanism of buprenorphine and form
Mixed opioid agonist/antagonist
Sublingual tablet
193
Caution of opioid antagonist use
Can make co-codamol ineffective
194
Opiate overdose management
Naloxone - works for 5 minutes
May need to be readministered to maintain effects
195
What is the most important investigation to carry out before starting substitute medication for opioid dependence?
Urine toxicology screen to confirm dependence and identify other substances used - in case of potential interactions
196
Methamphetamine mechanism
Stimulates release of monoamines
197
Methamphetamine intoxication
Pupil dilation
Euphoria
Tactile hallucinations
Agitation
Alertness
198
Methamphetamine withdrawal
Sleepiness
Hunger
Depression
199
Cocaine intoxication
Pupil dilation
Euphoria
Agitation
Alertness
200
Cocaine withdrawal
Sleepiness
Hunger
Depression
201
Cocaine mechanism
Blocks reuptake of monoamines
202
Cannabis intoxication
Calm
Munchies
203
Cannabis withdrawal
Decreased appetite
Insomnia
Irritable
204
Cannabinoid hyperemesis syndrome
Profuse vomiting
Better with heat
205
Cannabis mechanism
Stimulates (endocannabinoid) CB1 and CB2 receptors
206
Benzodiazepine mechanism
Enhances effect of inhibitory neurotransmitter GABA
Increases frequency of chloride channel opening
207
Mechanism by which GABA causes neuronal inhibition
Enhanced flow of chloride ions
Neuron hyperpolarised
Neuronal inhibition
208
Benzodiazepine intoxication symptoms + treatment of overdose
Ataxia
Somnolence
Mild respiratory depression
Flumazenil
209
Benzodiazepine withdrawal
Insomnia
Anxiety
Seizures (later)
210
3 indications for use of benzodiazepines as treatment.
Severe insomnia
Mania
Epilepsy
Alcohol withdrawal
Severe anxiety
Acute back pain
211
Phencyclidine mechanism
NMDA receptor antagonist
212
Phencyclidine intoxication
Violence
Analgesia
Psychosis
213
Phencyclidine withdrawal
Insomnia
Mood disturbance
214
Phencyclidine associations
Rotary nystagmus
Flashback phenomenon
215
MDMA intoxication
Euphoria
Disinhibition
Altered sensation
216
MDMA withdrawal
Anxiety
Depression
Difficulty concentrating
217
MDMA mechanism
Blocks reuptake of dopamine and serotonin
218
Chronic insomnia diagnosis
> 3 months
At least 3 nights a week
219
Narcolepsy
Hypersomnolence
Associated with sleep paralysis, vivid hallucination on going to sleep/waking up, cataplexy
220
HLA narcolepsy
HLA DR2
221
Narcolepsy EEG
Multiple sleep latency
222
Narcolepsy management
Daytime stimulant e.g. modafinil
Night-time sodium oxybate
223
Cataplexy
Sudden muscle weakness occurring while person is awake caused by strong emotion
224
Nearest relative
Having sausages for breakfast:
- Husband, wife or civil partner (including cohabitee for more than 6 months).
- Son or daughter
- Father or mother (an unmarried father must have parental responsibility in order to be nearest relative)
- Brother or sister
- Grandparent
- Grandchild
- Uncle or aunt
- Nephew or niece
225
Anorexia nervosa mortality
10%
226
Investigations in anorexia nervosa
ECG
Blood glucose
U&Es
227
Anorexia nervosa diagnostic criteria
BMI < 18.5
SCOFF screening
Fear of fatness
228
SCOFF screening questions
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone in a 3 month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say that Food dominates your life?
229
SUSS test
Sit up squat test
Assess muscle wasting in anorexia nervosa
230
Anorexia nervosa BMI categories
≥ 17: mild
16 – 17: moderate
15 – 16: severe
14 – 15: extreme
231
Lab test results for anorexia nervosa
Increase cortisol, cholesterol, beta-carotene, GH
Decrease GnRH oestrogen, testosterone, FSH, LH, T3, glucose, WCC, Hb, potassium
232
Preventing refeeding syndrome
If not eaten for > 5 days, refeed < 50% for first 2 days
1200 calories, increase by 200 each day
233
Refeeding syndrome investigation results
Hypophosphatemia
Hypokalaemia
Abnormal fluid balance
Hypomagnesaemia
234
Refeeding syndrome treatment
Phosphate replacement
235
Bulimia nervosa clinical manifestations
Erosion of teeth
Russell's sign - calluses on knuckles
Recurrent binge eating
236
Paracetamol overdose: paracetamol levels for N-acetyl-cysteine treatment
100 at 4 hours and 15 at 15 hours
Or
Staggered dose - 1st and last tablets taken an hour apart
237
Paracetamol overdose: Indication for liver transplant
> 24 hours and ph < 7.3
