Psychiatry Flashcards
1
Q
illusion
A
false perception of a detectable stimulus
2
Q
hallucination vs pseudo hallucination
A
- an experience involving the apparent perception of something not present
- pseudo - hallucination but they recognise it as being subjective and unreal
3
Q
over-values idea
A
exaggerated beliefs that a person sustains beyond reasons, but are not as unbelievable and are not as persistently held as delusions
4
Q
delusion
A
fixed beliefs that can’t be budged with evidence to the contrary, aren’t based of culturally accepted beliefs and are affecting interaction with reality
5
Q
concrete thinking
A
very literal interpretation of information, and can be tested by asking a patient to interpret proverbs
6
Q
loosening of association
A
a thought disturbance demonstrated by speech that is disconnected and fragmented, with the individual jumping from one idea to another unrelated or indirectly related idea
7
Q
circumstantiality
A
wandering away from the original idea, but eventually returning to it
8
Q
perseverance
A
uncontrollable repetition of a particular response or repeatedly returning to the same topic
9
Q
confabulation
A
confusion of imagination with memory
10
Q
somatic passivity
A
- Experience of bodily sensations (including actions, thoughts, or emotions) imposed by external agency
11
Q
pressure of speech
A
rapid and difficult to understand
12
Q
anhedonia
A
inability to experience pleasure
13
Q
incongruity of affect
A
facial expressions don’t match reported mood
14
Q
blunting of affect
A
decreased facial expressiveness
15
Q
belle indifference
A
lack of concern and felling of indifference
16
Q
depersonalisation
A
self doesn’t feel real
17
Q
thought insertion or withdrawal
A
believes that thought are being put/taken out of head
18
Q
thought echo
A
thoughts seem to be spoken just after being produced
19
Q
akathisia
A
subjective feeling of restlessness in the lower limbs that is related to abnormal activity in the extrapyramidal system in the brain, often due to antipsychotic medication
20
Q
catatonia and stupor
A
markedly disrupted physical reactivity to the environment, stupor is complete lack of reaction
21
Q
flight of ideas
A
excessive speech at a rapid rate that involves causal association between ideas, often rhymes/puns, mania
22
Q
formal thought disorder
A
disorganized way of thinking that leads to abnormal ways of expressing language when speaking and writing
23
Q
derealisation
A
sense surroundings aren’t fully real
24
Q
knights move thinking
A
complete loosening of associations where there is no logical link between one idea and the next
25
section 2
assessment
* 28 days (unrenewable)
* 2 doctors (1 s12 approved), AMHP
26
section 3
treatment
* 6 months (can be renewed)
* 2 doctors, AMHP
27
section 4
emergency order
* 72 hours
* Only when urgently required – waiting for another doctor etc.
* 1 doctor, 1 AMHP
28
section 5(4)
nurse can do to keep patient on ward until doctor can attend
6h
29
section 5(2)
stops patient leaving ward until section 2/3
72h
30
section 135
police, court order to remove patient from their home to a place of safety for further assessment
31
section 136
police, in a public place is suspected of having a mental disorder
32
formulation model
4p (predisposing, precipiytating, perpetuating, protective)
biopsychosocial approach
33
Features of MSE
- appearance
- behaviour
- speech
- mood/affect
- thoughts (possession/content/form)
- perceptions
- cognition
- insight
34
thought disorders
word salad
tangentiality (never go back to topic)
circumstantiality (does eventually get to point)
flight of ideas (abrupt topic change with discernable links)
derailment (no apparent links)
blocking
distractable speech
35
assessment of suicide attempt
before, attempt and future
36
psychosis
- group of symptoms - hallucinations and delusions associated with loss of connection to reality
37
hallucinations
- perception experienced without an external stimulus
- visual more common in organic disorders
- auditory more common in psychiatric disorders
38
what hallucination can cocaine cause
formication (insects crawling under skin)
39
psychiatric symptoms of types of dementia
* frontotemporal dementia – disinhibition, emotional blunting, language difficulty, paranoia, delusions
* Alzheimer’s disease – depression, apathy, withdrawal
* Lewy body dementia – visual hallucinations, illusions
40
endocrine causes of psychiatric disorders
* hypothyroidism - depression and poor cognition (myxoedema madness – mania and psychosis)
* hyperthyroidism - anxiety, irritability and in severe cases, psychosis
* Cushing disease – depression with psychotic features
* Adrenal insufficiency – psychotic disorder
* Hyperparathyroidism – cognitive slowing, memory impairment, depression
* Hypoparathyroidism – mood disorders
* Pheochromocytoma – nervousness, anxiety, panic attacks, depression
* Hyperprolactinaemia – depression, anxiety
41
nutritional deficiencies causing psychiatric symptoms
* Wernicke/Korsakoff syndrome – mental status change
* Zinc/vitamin D deficiency – depressive disorders, bipolar
42
ADHD
- types = innattentiveness, hyperactivity/impulsiveness, both (lasting >6m)
- associated with low dopamine/norepinephrine
- stimulants to slowly release neurotransmitter - amphetamines (methylphenidate hydrochloride 1st, dexamfetamine 2nd) – behavioural therapy
43
autism spectrum disorder
- difficulties in social interactions/communication, restricted/repetitive nature
- psychotherapy, behavioural therapy, educational programmes
44
tourette syndrome
* Tics – rapid, repeated, involuntary, often inappropriate movements/vocalisations, for >1y, starting before age 18
* Treatment: antipsychotics/epilepsy medications if severe, botox injections for face movements, CBT, habit reversal training
45
fragile X syndrome
- most common cause of inherited intellectual disability
- AR, Xlinked, decrease in FMR protein synthesis (normally high in brain and testes), anticipation
- diagnosis via DNA testing (prenatally at 12w)
46
signs of fragile x syndrome
* Intellectual disability, long face/large chin and ears, macroorchidism (large testes)
* Often have autism, ADHD, anxiety disorders, seizures, fragile X tremor/ataxia
47
generalised anxiety disorder
no identifiable cause, persistent and excessive worry about everyday issues, present for 6+ months
48
treatment of anxiety
* Identify co-morbidities and treat
* Psychoeducation
* CBT (systemic desensitisation for phobias)
* SSRI drugs
* Avoid benzodiazepines
49
PTSD symptoms
flashbacks, nightmares, severe anxiety, uncontrollable thoughts about the event, avoidance of triggers, has for at least 1 month
50
treatment of PTSD
- 1st line - psychoeducation, CBT, EMDR, group/family therapy
- 2nd line - SSRI/SNRI
51
OCD
* Pattern of unwanted thoughts and fears (obsessions) that lead to repetitive behaviours (compulsions)
52
treatment for OCD
* CBT – exposure and response prevention therapy (ERP)
* Antidepressants – clomipramine (tricyclic antidepressant) or SSRI’s
53
symptoms of anorexia nervosa
* Dieting, Denial, Dread of gaining weight, Disturbed beliefs about weight, Doesn’t want help, Disinterested/socially withdrawn
* Dual effect– dieting + over-exercise/diuretics, laxatives and self-induced vomiting
* Decline in weight = rapid
* Weight below 85% of predicted (adults <17.5)
54
investigations for anorexia nervosa
* Bloods – Cortisol ↑, Beta-carotene ↑, Potassium ↓, GH ↑, T3 ↓, Glucose ↓, Oestrogen ↓, Testosterone ↓, FSH ↓, LH ↓, Cholesterol ↑, Phosphate ↓
* ECG – Bradycardia, Prolonged QT (if severe anorexia), T wave changes (hypokalaemia)
* DXA: if underweight for a year (or if 2 years if adult)
55
features of bulimia nervosa
* recurrent binge eating
* lack of control during episode
* recurrent compensatory behaviour (vomiting, misuse of laxatives, diuretics, fasting, excessive exercise)
* once a week for 3 months
* self-evaluation is unduly influenced by body shape and weight
56
changes caused by recurrent vomiting
- metabolic alkalosis (cl loss)
- hypokalaemia on ECG
57
dopamine reward pathways
- mesocortical (cognition, memory, attention, emotional behaviour, learning)
- nigrostriatal (movement and sensory stimuli)
- mesolimbic (pleasure/reward seeking behaviours, addiction, emotion, perception
58
DSM IV criteria for addiction
3+ in 12m
* Tolerance
* Withdrawal
* Persistent desire/ unsuccessful attempt to stop
* Substance used for longer periods/larger amounts than intended
* Important vocational, social or recreational activities given up/reduced because of substance use
* Persistent use despite being aware substance is causing damage
59
stages of change model
1. Pre-contemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
6. Relapse
60
alcohol withdrawal
– decreases GABA and increases NMDA glutamate transmission
* 6-12 hours: tremor, nausea, anxiety, insomnia, increase BPM, BP, temp
* 7-48 hours: seizures
* 48-72: delirium tremens
61
delirium tremens
emergency, tremor, hallucinations (lilliputian- small animals), delusion, confusion, agitated
62
Wernicke's encephalopathy
* Ataxia, ophthalmoplegia, confusion – caused by cell death secondary to thiamine deficiency
* Can be fatal, need to avoid Korsakoff syndrome (inability to form/retain new memory)
* 500mg IV thiamine (pabrinex) for 3 days then IM
63
treatment of alcohol withdrawal
- Benzodiazepines – chlordiazepoxide (20-40mg QDS reducing to 0 over 7-10 days)
- long term can use acamprosate (anti-craving, neuroprotective), naltrexone (decreases reward from alcohol), disulfiram (hangover as soon as alcohol consumed)
64
opiate withdrawal
o Start at 6h, peak at 36-72h
o In order of onset - Anxiety, craving, yawn, sweat, abdo pain, dilated pupils, aches, nausea and vomiting, diarrhoea
o Unpleasant but generally not dangerous
65
opiate overdose symptoms and treatment
o Decreased consciousness, respiratory distress/arrest, pinpoint pupils
o Treat with naloxone – opiate antagonist, shorter half-life than opiates so need repeated doses or infusion
66
treatment for opiate withdrawal
- methadone (long acting opiate on reducing regime)
- buprenorphine (partial agonist)
- naltrexone (opiate antagonist to stop relapse)
67
benzodiazepine misuse
* Anxiolytic effect, resp depression
* Risk of seizures on withdrawal
* Gradual reduction over months
68
stimulant misuse (cocaine, amphetamines)
* Euphoria, increased energy, weight loss, exacerbates psychosis
* Not dangerous in withdrawal
* Lethargy/depression on withdrawal
69
cannabis misuse
- may cause/exacerbate psychosis
- not dangerous on withdrawal
- heavy long term use causes depression, anxiety, memory problems
70
solvent/inhalant misuse
- similar effect as alcohol
- Very risky – laryngospasm due to cold temp, brain damage, hypoxia
71
symptoms of depression
* Sustained low mood
* Reduced energy, motivation, anhedonia
* Poor concentration and memory, thoughts and speech slowed down
* Poor sleep – early morning waking
* Diurnal mood variation – feel worst on waking and gradually improve
* Cognitive distortions – worthlessness, hopelessness, guilt
* Suicidal ideation/attempt
* Psychotic symptoms – mood congruent, derogatory auditory hallucinations, delusions of guilt, nihilistic delusions (not existing any more), persecutory delusions
72
ICD10 classification of mild/moderate/severe depression
* Mild – 2/3 symptoms, managing most activities
* Moderate – 4+ symptoms, only managing essential activities
* Severe – with or without psychotic symptoms, multiple and marked symptoms, almost all activities impossible
73
treatment of depression
mild- counselling/CBT/exercise etc
moderate - CBT, SSRI/SNRI
severe with psychotic symptoms - antidepressant + atypical antipsychotic (olanzapine), ECT
74
Cotard's syndrome
- believes part/whole body is dead/non-existent
- severe depression and psychotic disorders
75
treatment of postnatal depression
psychotherapy, antidepressants (paroxetine or sertraline)
76
postnatal psychosis and treatment
- develops in first few weeks
- normally inpatient with meds (antipsychotics, mood stabilizers, benzodiazepines) – may need to stop breastfeeding, ECT
77
bipolar disorder
Periods of depression and mania – must have two discrete mood episodes, at least one of which must be manic or hypomanic
78
types of bipolar
* Type 1 (more common) - >7 days mania and depression
* Type 2 - >4 days hypomania and depression
79
mania
elated, irritable, increased energy, reduced need for sleep, distractible, pressured speech, grandiose, reckless, impacts functioning, poor insight
80
what psychotic symptoms are typical of mania
Grandiose delusions, Delusions of reference
Auditory hallucinations usually confirming grandiose beliefs
81
hypomania
- like mania but continues to function
- partial insight
- no psychotic symptoms
82
management of acute mania
atypical antipsychotic (olanzapine/quetiapine)
sodium valproate
+/- benzodiazepines
83
treatment of bipolar disorder
mood stabilisers (lithium, valproate, carbamazepine), atypical antipsychotic, CBT, psychoeducation
84
schizophrenia
- interpret reality abnormally – combination of hallucinations, delusions, and extremely disordered thinking and behaviour that impairs daily functioning.
- degenerative (need lifelong treatment)
85
pathophysiology of schizophrenia
* Increased dopamine in mesolimbic pathway produces psychotic positive symptoms
* Decreased dopamine affects in mesocortical pathway produces negative symptoms
86
first rank symptoms of schizophrenia
- auditory hallucinations (third person, thought echo, commentary voices)
- thought disorder
- passivity phenomena
- delusional perceptions
87
second rank symptoms of schizophrenia
- other delusions/hallucinations
- breaks in thought fluency
- catatonic behaviour
- negative symptoms (apathy, blunted emotions, social withdrawal)
88
Diagnostic criteria for schizophrenia
- 1 1st rank or 2 2nd rank symptoms acutely for 1m with evidence of disturbed functioning for 6m
89
bio/psycho/social treatment of schizophrenia
BIO - antipsychotics (block dopamine)
PSYCHO - CBT/DBT/psychoeducation/familt therapy
SOCIAL - housing/employment/social activities
90
what is schizoaffective disorder
disorder with combination of schizophrenia and mood disorder symptoms
91
types of schizoaffective disorder
- bipolar type - includes episodes of mania and depression
- depressive type - only major depressive episodes
92
what is somatisation disorder and the treatment
- extreme focus on symptom which is causing significant distress and problems functioning
- CBT/psychotherapy
93
stages of attachment
1. pre-attachment (<3m)
2. indiscriminate (6w-7m)
3. discriminant (7-11m)
4. multiple (>9m)
94
4 patterns of attachment
- ambivalent attachment (result of poor parental availability)
- avoidant attachment (abuse/neglect from carer)
- disorganised attachment (inconsistent carer behaviour)
- secure attachment
95
cluster A personality disorders
- paranoid PD (excessive distrust)
- schizoid PD (blunted emotions, preferes being alone)
- schizotypal PD (unusual/magical thinking, self-centred)
96
cluster B personality disorders
- antisocial (outwardly normal, hidden hostility, 'psychopath')
- borderline/EUPD (unstable mood, fear of abandonment, self-destructive impulses)
- histrionic PD (attention seeking, maipulative, shallow, tantrums)
- narcissistic (grandiose, arrogant, lacks empathy, exploits others)
97
cluster C personality disorders
- avoidant (shy, social inhibition, hypersensitive to rejection)
- obsessive compulsive (happy being way they are)
- dependant
98
typical/first generation antipsychotics
- Block D2 receptors – only treat high dopamine (positive symptoms)
- Extrapyramidal side effects (parkinsonism)
- Haloperdol (5-20mg), Zuclopentixol (20-50mg) and chlorpromazine (75-300mg)
99
atypical/second generation antipsychotics
- Block D2 receptors and serotonin (5HT2a) receptors in nigrostriatal pathway (increases dopamine in that pathway so treats positive and negative symptoms)
- Metabolic SE such as weight gain
- Olanzapine, Quetiapine, Aripiprazole (dopamine partial agonist- least side effects but only works in mild cases)
- Clozapine: Only licensed for treatment resistant schizophrenia
100
clozapine
- only licenced for treatment resistant schizophrenia
- risk of fatal agranulocytosis - regular blood monitoring (before, 1 weekly for 18w then every 2w)
- probably most effective but can't be given as depot
101
neuroleptic malignant syndrome
- emergency
- acute onset of symptoms usually within 10d of antipsychotic treatment
102
features of neuroleptic malignant syndrome
o CNS- fluctuating consciousness, stupor
o Autonomic- hyperreflexia, unstable BP, bradycardia, excessive sweating, salivation, urinary incontinence
o Motor- muscular rigidity, dysphasia, dyspnoea
o Lab results- Raised WBC, raised CPK
o Complications- Pneumonia, cardiovascular collapse, thromboembolism, renal failure
103
management of neuroleptic malignant syndrome
o Stop drug
o Maintain fluid balance
o Diazepam for muscle rigidity
o Dantrolene for malignant hyperthermia – muscle relaxant
o Bromocriptine (dopamine agonist)
104
acute dystonic reaction
- can be caused by antipsychotics (mostly typicals)
- oculogyric crisis (up and out eyes), torticollis (head held to one side), opisthotonos (painful forced extension of neck, possibly back arch too), macroglossia, trunk spasticity
- can cause laryngospasm
- stop med and give slow IV anticholinergic benztropine
105
SSRIs
-Block serotonin reuptake receptors (5HT)
-Citalopram (risk of QT prolongation), escitalopram, fluoxetine, fluvoxamine, paroxetine (increases risk of congenital malformation during pregnancy) and sertraline (safe post-MI)
- need PPI if taking SSRI and NSAID
106
SNRIs
- Inhibit presynaptic reuptake of both serotonin and norepinephrine
- Venlafaxine and duloxetine
107
tricyclic antidepressants
- Inhibit presynaptic reuptake of both serotonin and norepinephrine
- Competitive antagonists of post-synaptic alpha cholinergic (alpha1 and alpha2), muscarinic, and histaminergic receptors (H1)
- amitriptyline, nortriptyline
- SE - cant see, pee, spit, shit (seizures in overdose)
108
monoamine oxidase inhibitors
- inhibit MAO enzyme (metabolised neurotransmitters when renters presynaptic neuron)
- old antidepressant not really used
- strict dietary restrictions and drug interactions
109
serotonin syndrome
- excess serotonin in CNS
- often precipitated by the use of serotoneric drugs (often two or more): SSRIs, SNRIs, MAOIs, TCAs, amphetamines, tramadol, cocaine, MDMA
110
symptoms of serotonin syndrome
o Cognitive: headaches, agitation, hallucinations, coma
o Autonomic: sweating, shivering, tachycardia, hypertension, nausea, diarrhoea.
o Somatic: myoclonus, hyperreflexia (clonus), tremor
111
treatment of serotonin syndrome
- remove causative agent
- supportive (fluids, benzo etc)
- cyproheptadine (serotonin antagonist) if severe
112
comparison between serotonin syndrome and neuroleptic malignant syndrome
113
benzodiazepines
Safe for short-term use but long-term use causes tolerance, dependence and adverse effects
114
mechanism of benzodiazepines
increase GABA in CNS – open GABA-activated chloride channels – negative charge in neurons make them more resistant to excitation – decreases neuron activity causing sedative/anxiolytic effect
115
4 types of drugs used as anxiolytics
*all habit forming and addictive*
- benzos
- barbiturates (stronger than benzos)
- non-benzo drugs (also target GABA, zopiclone)
- beta blockers (relive symptoms, propranolol not addictive)
116
lithium for mood stabilisation
- most effective (treats both mania/depression)
- fine tremor, sedation, lethargy, GI, weight gain, hypothyroidism
- regular blood tests (U&E, TFT, Ca every 6m, serum level after 1w then every 3m)
117
lithium toxicity
- levels >1.5mmol/L
- Nausea, vomiting, diarrhoea, confusion, excessive sleeping, seizures, myoclonic jerks and coarse tremor
- causes: dehydration (hot weather), changes in salt, reduced renal function, meds)
- STOP lithium, rehydrate, consider haemodialysis
118
anti-convulsants for mood stabilisation
- sodium valproate (both mania/depression)
- carbamazepine (not licenced)
- lamotrigine (only depressive symptoms)
- blood tests FBC, LFT every 6m
119
HYPNOTICS
- zopiclone 7.5mg at night for up to 4w
- addictive
- agonist at GABA receptors
120
stimulants used medically
- for ADHD and narcolepsy
- increases dopamine and norepinephrine
- not habit forming in the small doses used
- amphetamines etc
121
rapid tranquilisation steps
1. Verbal de-escalation
2. Offer oral lorazepam 1-2mg
3. Lorazepam 1-2mg IM (takes 30 mins to work) – half dose in adolescent/elderly
4. Repeat every 30-60minutes
5. Be-aware benzo induced respiratory depression (Flumazenil)
122
ELECTROCONVULSIVE THERAPY
- under short acting GA
- triggers brief seizure that changes chemistry in brain
- highly effective after full course (2/3x weekly for 3/4w)
- mostly for severe depression and bipolar disorder
123
CBT
Identify troubling situations or conditions - thoughts, emotions and beliefs about these problems - identify negative or inaccurate thinking - reshape negative or inaccurate thinking
- 1st wave – behaviour therapy
- 2nd wave – cognitive therapy
- 3rd wave – mindfulness and acceptance/coping techniques
124
cognitive analytical therapy
depression and emotional disorders
coping mechanisms
125
eye movement desensitisation and reprocessing
- PTSD
- series of bilateral (side-to-side) eye movements as you recall traumatic or triggering experiences in small segments, until those memories no longer cause distress
