Psychiatry Flashcards
1
Q
Unresponsive, moderate and severe depression Rx?
A
SSRI + High intensity psychological intervention
2
Q
High intensity psychological interventions?
A
- Individual CBT
- Interpersonal therapy (IPT)
- Behavioural activation
- Behavioural couples therapy
3
Q
How often do high intensity sessions usually happen?
A
16-20 sessions over 3-4 months
4
Q
People who decline the above?
A
- Counselling
- Short term psychodynamic psychotherapy
5
Q
Pt with poor oral compliance to antipsychotics?
A
Monthly IM depot injections
6
Q
Advantage of atypical antipsychotics (AAs)?
A
Significant reductions in EPSEs
7
Q
AA s/es?
A
- Weight gain
- Hyperprolactinaemia
- Clozapine associated with agranulocytosis
8
Q
AA warnings in elderly patients?
A
Increased risk of stroke and VTE
9
Q
Atypical antipsychotic examples?
A
AA CORQ
1. Aripiprazole
2. Amisulpride
3. Clozapine
4. Olanzapine (higher risk of dyslipidaemia and obesity)
5. Risperidone
6. Quetiapine
10
Q
When should clozapine be used?
A
If schizophrenia not controlled despite sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each at least 6-8 weeks
11
Q
Clozapine side effects?
A
- Agranulocytosis (1%), neutropenia (3%)
- Reduced seizure threshold (seizures in 3%)
- Constipation
- Myocarditis (need baseline ECG)
- Hypersalivation
12
Q
When is dose adjustment of clozapine required?
A
If smoking is started or stopped during treatment
13
Q
PTSD features?
A
For more than one month
1. Re-experiencing
2. Avoidance
3. Hyperarousal
4. Emotional numbing
14
Q
PTSD management?
A
- Watchful waiting for mild symptoms <4 weeks
- Trauma-focused CBT or EMDR therapy in more severe cases
- Drugs not first line, if needed then venlafaxine or SSRI, risperidone in severe cases
15
Q
Strongest RF for developing psychotic disorder?
A
FHx
16
Q
Familial of developing schizophrenia?
A
- Monozygotic twin = 50%
- Parent = 10-15%
- Sibling = 10%
- No relatives = 1%
17
Q
Selected RFs for psychotic disorders?
A
- Black Caribbean = RR 5.4
- Migration = RR 2.9
- Urban environment = RR 2.4
- Cannabis use = RR 1.4
18
Q
Mania features?
A
- At least 7 days, causing severe functional impairment in social and work setting
- May require hospitalisation due to risk of harm to self or others
- May present with psychotic symptoms
19
Q
Hypomania features?
A
- A lesser version of mania
- <7 days, typically 3-4 days, can be high functioning and does not impair functional capacity in social or work setting
- Unlikely to require hospitalisation
- No psychotic symptoms
20
Q
Increased risk of suicide factors?
A
- Male
- DSH
- Alcohol or druh misuse
- Hx of mental illness
- Hx of chronic disease
- Advancing age
- Unemployment or social isolation/living alone
- Being unmarried, divorced or widows
21
Q
What % of people with schizophrenia will commit suicide?
A
10%
22
Q
Increased risks of completed suicide at a later date after an attempt?
A
- Efforts to avoid discovery
- Planning
- Leaving a written note
- Final acts e.g. sorting out finances
- Violent method
23
Q
Protective factors for suicide?
A
- Family support
- Children at home
- Religious belief
24
Q
Somatisation disorder?
A
- Multiple physical symptoms present for at least 2 years
- Patient refuses to accept reassurance or negative test results
25
Illness anxiety (hypochondriasis)?
1. Persistent belief in the presence of an underlying disease e.g. cancer
2. Pt refused to accept reassurance or negative test results
26
Conversion disorder?
1. Typically involves loss of motor or sensory function
2. Pt doesnt consciously feign symptoms or seek material gain
3. La belle indifference
27
Dissociative disorder?
1. Separating off certain memories from normal consciousness
2. In contrast to conversion disorder, involves psychiatric symptoms e.g. amnesia, fugue, stupor
3. DID (dissociative identity disorder) is new term for multiple personality disorder as is the most severe form of dissociative disorder
28
Factitious disorder?
1. AKA Munchausen's
2. Intentional production of physical or psychological symptoms
29
Malingering?
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
30
Alcohol withdrawal mechanism?
1. Chronic alcohol consumption enhances GABA mediation inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
2. Alcohol withdrawal is though to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
31
Alcohol withdrawal features?
1. Sx start at 6-12 hours = tremor, sweating, tachycardia, anxiety
2. Peak incidence of seizures at 36 hours
3. Peak incidence of delirium tremens at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
32
Alcohol withdrawal management?
1. Admission
2. Long acting benzodiazepines e.g. chlordiazepoxide or diazepam as part of reducing dose protocol (lorazepam preferable in pts with hepatic failure)
3. Carbamazepine also effective
33
Who is excluded from sectioning under the MHA?
Pts under influence of alcohol or drugs
34
Section 2 mushkies?
1.Admission for assessment up to 28 days, not renewable
2. AMHP or NR makes the application on the recommendation of 2 doctors
3. One of the doctors should be 'approved' under Section 12(2) of the MHS (usually consultant)
4. Treatment can be given against a patient's wishes
35
Section 3 mushkies?
1. Admission for treatment up to 6 months, can be renewed
2. AMHP along with 2 doctors, both of which must have seen the pt with the past 24 hours
3. Treatment can be given against a pt's wishes
36
Section 4 mushkies?
1. 72 hour assessment order
2. Used as an emergency, when a Section 2 would involve an unacceptable delay
3. a GP and an AMHP or NR
4. Often changed to a Section 2 upon arrival at hospital
37
Section 5(2) mushkies?
A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
38
Section 5(4)?
Similar to 5(2), allows nurse to detain a pt who is voluntarily in hospital for 6 hours
39
Section 17a?
1. Supervised Community Treatment (Community Treatment Order)
2. Can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication
40
Section 135?
A court order can be obtained to allow pt to break into a property to remove a person to a place of safety
41
Section 136?
Someone found in a public place who appears to have a mental disorder can be taken by the police to a place of safety, can only be used for up to 24 hours whilst a MHA is arranged
42
When is a second opinion sought for a section 3?
After 3 months, if a pt still does not consent to treatment, from an impartial psychiatrist
43
Agranulocytosis definition?
Absolute neutrophil count <500 cells/mm^3
44
When are antidepressants recommended?
1. Moderate-severe depression
2. Subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years).
3. Subthreshold symptoms or mild depression that persists after other interventions.
4. Mild depression that is complicating the care of a chronic physical health problem
45
4 SSRIs?
1. Sertraline
2. Fluoxetine
3. Citalopram
4. Paroxetine
46
Lithium uses?
1. Prophylactically in bipolar disorder
2. Adjunct in refractory depression
47
Lithium therapeutic range?
0.4-1.0mmol/L
48
Lithium excretion?
Kidneys, has long plasma half life
49
Lithium MOA?
Not fully understood, two theories
1. Interferes with inositol triphosphate formation
2. Interferes with cAMP formation
50
Lithium adverse effects?
1. N&V&D
2. Fine tremor
3. Nephrotoxicity, nephrogenic DI
4. Thyroid enlargement, hypothyroidism
5. Weight gain, IIH
6. Leukocytosis
7. Hyperparathyrodism and hypercalcaemia
51
Lithium ECG?
T wave flattening/inversion
52
Lithium monitoring?
1. 12 hours post-dose
2. Weekly after commencement and after each dose change until concentrations are stable
3. Once established, every 3m
4. Thyroid and renal function every 6m
5. Pt should have information booklet, alert card and record book
53
Mirtazapine s/e?
Sedation and weight gain
54
Olanzapine s/e?
Dyskinetic tremore
55
Sertraline s/e?
Altered sleep-wake cycles, weight gain, sexual dysfunction, tremor
56
Flight of ideas?
Rapid speech with requent changes in topic based on associations, distractions or word play
57
Knights move thinking?
No apparent link between topics
58
Tangentiality?
Veers off topic
59
Circumstantiality?
Similar to tangentiality but patient, after giving excessive details, eventually returns to the topic
60
SAD?
Treat as per NICE guidelines for NICE depression (begin with psychological therapies and f/up in 2w to ensure no deterioration, following this an SSRI can be given if needed)
61
What should you not give in SAD?
Sleeping tablets as can make symptoms worse
62
Typical antipsychotic MOA?
D2 receptor antagonist, blocking transmission in mesolimbic pathways
63
Typical antipsychotic adverse effects?
EPSEs and hyperprolactinaemia commona
64
Typical antipsychotic examples?
Haloperidol, chlopromazine
65
EPSEs?
DAPT
1. Dystonia = torticollis, oculogyric crisis
2. Akathisia = severe restlessness
3. Parkinsonism
4. Tardive dyskinesia = 40% with typical, may be irreversible, most commonly chewing and pouting of jaw
66
Acute dystonia management?
Procyclidine
67
Typical antipsychotic s/e?
1. Antimuscarinic = dry mouth, blurred vision, urinary retention, constipation
2. Sedation, weight gain, impaired glucose tolerance
3. Raised prolactin = may galactorrhoea, due to inhibition of dopaminergic tuberoinfundibular pathway
4. NMS = pyrexia, muscle stiffness
5. Reduced seizure threshold (greater with atypicals)
6. Prolonged QT interval (particularly haloperidol)
68
Which are preferred SSRIs?
Citalopram and Fluoxetine
69
What SSRI is useful post-MI?
Sertraline
70
Antidepressant for children?
Fluoxetine
71
SSRI S/e?
1. GI
2. Increased risk of bleeding, PPI if taking NSAID
3. Pt to stay vigilant for anxiety and angitation
72
SSRIs with higher propensity for drug interactions?
Fluoxetine and paroxetine
73
Which SSRI elongates QT interval?
Citalopram, dose dependent
74
Citalopram maximum daily doses?
1. 40mg for adults
2. 20mg for >65 y/o and hepatic impairment
75
SSRI interactions?
1. NSAIDs (plz prescribe PPI)
2. Warfarin
3. Aspirin
4. Triptans
5. MAOis
76
Alternative to SSRI if on warfarin?
Mirtazapine
77
SSRI + Triptan?
Increased risk of serotonin syndrome
78
SSRI + MAOi?
Increased risk of serotonin syndrome
79
F/up after initiating antidepressant?
1. Review after 2 weeks
2. If <30 y/o / increased risk of suicide after 1 weeks
80
How long antidepressant continued after remission?
6 months, reduces risk of relapse
81
How to stop SSRI?
Dose gradually reduced over 4 week period
82
Which SSRI has higher incidence of discontinuation symptoms?
Paroxetine
83
Which SSRI can be stopped suddenly?
Fluoxetine
84
SSRI discontinuation symptoms?
1. Increased mood change
2. Restlessness, difficulty sleeping
3. Unsteadiness, sweating
4. GI = pain, cramping, D&V
5. Paraesthesia
85
SSRIs in pregnancy?
1. 1st trimester = increased risk CHD
2. 3rd trimester = PPH of newborn
3. Paroxetine has increased risk of congenital malformations, esp. in 1st trimester
86
Main use of TCAs?
Neuropathic pain
87
TCA s/e?
1. Drowsiness
2. Dry mouth, blurred vision, constipation, urinary retention
3. QT prolongation
88
Amitryptiline uses?
1. Neuropathic pain
2. Headache prophylaxis (tension and migraine)
89
More sedative TCAs?
1. Amitryptiline
2. Clomipramine
3. Dosulepin
4. Trazodone
90
Less sedative TCAs?
1. Imipramine
2. Lofepramine
3. Nortryptiline
91
Benzodiazepine MOA?
Enhance effect of inhibitory GABA by increasing the frequency of chloride channels
92
Benzodiazepine uses?
1. Sedation
2. Hypnotic
3. Anxiolytic
4. Anticonvulsant
5. Muscle relaxant
93
How long show BZDs be prescribed for?
2-4 weeks
94
How to withdraw BZDs?
1. Switch pt to equivalent dose of diazepam
2. Reduce diazepam every 2-3 weeks in steps of 2-2.5mg
3. Time needed for withdrawal can vary from 4 weeks to a year or more
4. (Dose should be withdrawn in steps of about 1/8 of the daily dose every fortnight)
95
Benzodiazepine withdrawal syndrome symptoms?
1. Insomnia
2. Irritability
3. Anxiety
4. Tremor
5. Loss of appetite
6. Tinnitus
7. Perspiration
8. Perceptual disturbance
9. Seizures
96
How long after stopping long acting BZDs can withdrawal occur?
Up to 3 weeks
97
Barbiturate MOA?
Increase duration of chloride channel opening (Barbidurates increase duration, frenzodiazepines increase frequency)
98
Personality disorder definition?
Series of maladaptive personality traits that interfere with normal function in life
99
Personality disorder prevalence?
1 in 20
100
Personality disorder clusters?
1. Cluster A = Weird
2. Cluster B = Wild
3. Cluster C = Worried
101
Cluster A personality disorder types?
1. Paranoid = Accusatory
2. Schizoid = Aloof
3. Schizotypal = Awkward
102
Cluster B personality disorder types?
1. Antisocial
2. Borderline
3. Histrionic
4. Narcissistic
103
Cluster C personality disorder types?
1. Avoidant = cowardly
2. Obsessive-compulsive = compulsive
3. Dependent = clingy
104
Personality disorder Rx?
1. DBT
2. Treatment of coexistent psychiatric conditions
105
Schizophrenia poor prognosis indicators?
1. Strong FHx
2. Gradual onset
3. Low IQ
4. Prodromal phase of social withdrawal
5. Lack of obvious precipitant
106
TCA OD Rx?
1. Hypertonic sodium bicarbonate
2. Acidosis correction, hypoxia, electrolyte imbalance correction
107
Procyclidine MOA?
Anticholinergic
108
Contraindication to ECT?
Raised ICP
109
ECT short term side effects?
1. Headache
2. Nausea
3. Short term memory impairment
4. Memory loss of events prior to ECT
5. Cardiac arryhthmia
110
Long term side effects of ECT?
Impaired memory
111
Schizophrenia management?
1. Oral atypical antipsychotic
2. CBT to all pts
3. Close attention paid to CVS risk (linked to antipsychotic medication and high smoking rates)
112
Dizziness, electric shock sensations and anxiety?
SSRI discontinuation syndrome (esp. paroxetine)
113
TCA causes what type of urinary incontinence?
Overflow incontinence due to anticholinergic effect
114
Sleep paralysis definition?
Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures
115
Sleep paralysis features?
1. Paralysis = short before falling asleep or after waking up
2. Hallucinations
116
Sleep paralysis management?
If troublesome clonazepam may be used
117
Death under MHA?
Referral to coroner
118
What to do instead of prolonged manual restraint (>10mins)?
Rapid tranquilisation or seclusion
119
Psychosis definition?
A person experiencing things differently from those around them
120
Psychotic features?
1. Hallucinations
2. Delusions
3. Thought disorganisation (alogia, tangentiality, clanging, word salad)
121
Peak age of first episode of psychosis?
15-30 years
122
Hoover's sign?
In non-organic paresis, pressure is felt under the paretic leg when lifting the non-paretic leg against pressure, this is due to involuntary contralateral hip extension
123
What kind of amnesia can BZDs cause?
Anterograde
124
Rapid tranquilisation medication of acutely disturbed pts?
1. IM Lorazepam
2. IM haloperidol + IM promethazine
125
Anorexia nervosa features?
1. Reduced BMI
2. Bradycardia
3. Hypotension
4. Enlarged salivary glands
126
Anorexia nervosa bloods?
Most things low, Gs and Cs raised
1. Low = hypokalaemia, FSH, LH, oestrogens, testosterone, T3
2. High = GH, glucose, (glands (salivary), cortisol, cholesterol, carotinaemia
127
Antipsychotic monitoring?
1. FBC, U&E, LFT = start, annual
2. Lipids, weight = start, 3m, annual
3. Fasting glucose, prolactin = start, 6m, annual
4. BP = start, during dose titration
5. ECG = baseline
6. CVS = annual
128
Section 17a AKA?
Community Treatment Order (CTO)
129
SSRI sodium levels?
Hyponatraemia
130
Schneider's first rank symptoms?
1. Delusional perception
2. Auditory hallucinations
3. Passivity
4. Thought disorders
131
Negative schizophrenia symptoms?
1. Affect blunting
2. Anhedonia
3. Alogia
4. Avolition
132
Perfectionism at the expense of completing tasks?
Obsessive-compulsive personality (anankastic personality disorder)
133
Anxiety central feature?
Excessive worry about a number of different events associated with heightened tension
134
GAD management?
1. Education + active monitoring
2. Low intensity psychological intervention
3. High intensity psychological intervention (CBT or drug treatment)
4. Highly specialist input e.g. multi agency teams
135
GAD medications?
1. Sertraline 1st line
2. If ineffective another SSRI or SNRI (duloxetine/venlafaxine)
3. If cannot tolerate SSRI/SNRI, then pregabalin
4. Weekly f/up for 1st month
136
Panic disorder management?
1. Recognition and diagnosis
2. Treatment in primary care (CBT or drugs)
3. Review and consideration of alternative treatment
4. Review and referral to specialist mental health services
5. Care in specialist mental health services
137
Panic disorder in primary care?
1. CBT or drug treatment
2. SSRIs 1st line, if contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
138
Section 136 duration?
24 hours
139
Depression assessment tools?
1. HAD
2. PHQ-9
3. DSM-IV
140
HAD scale?
1. 14 questions, 7 for anxiety and 7 for depression
2. Each scored 0-3
3. Produces score out of 21 for each
4. Severity: 0-7 normal, 8-10 borderline, 11+ case
5. Encourage pt to answer questions quickly
141
PHQ-9 scale?
1. Over last 2 weeks, how often bothered by the following problems?
2. 9 items scored 0-3
3. Depression severity: 0-4 = none, 5-9 mild, 10-14 moderate, 15-19 moderatley severe, 20-27 severe
