Psychiatry Flashcards
Difference between acute stress disorder over PTSD
Mx acute stress disorder (2)
<4 weeks acute stress disorder
>4 weeks PTSD
CBT
Benzos
What is agoraphobia?
Fear of open spaces e.g presence of crowds
Peak incidence of:
symptoms
seizures
Delirium tremons
with ETOH withdrawal
6-12 hours
36 hours
48-72 hours
DSM 5 criteria for anorexia (3)
- Restriction of energy intake
- Intense fear of gaining weight even though underweight
- Disturbance in body weight/ shape experience
Anorexia mx (3)
In children and young people mx (1)
- CBT
- MANTRA Maudsley Anorexia Nervosa Treatment for Adults
- SSCM specialist supportive clinical management
Anorexia focused family therapy first line
Features anorexia (4)
Reduced BMI
Bradycardia
Hypotension
Enlarged salivary glands
Physiological abnormalities in anorexia
K+
FSH, LH, oesetrogen, testosterone
Cortisol
GH
Glucose tolerance
T3
K+ - low
FSH, LH, oesetrogen, testosterone low
Cortisol - high
GH - high
Glucose tolerance - impaired
T3 - low
Typical antipsychotics (2)
Atypical antipsychotics (3)
Haloperidol
Chlopromazine
Clozapine
Risperidone
Olanzapine
Extrapyramidal side effects (4)
Parkinsonism
Acute dystonia
Akathisia
Tardive dyskinesia
Acute dystonia mx
Procyclidine
Antipsychotics monitoring
FBC,U+E, LFT
Lipids, weight
Fasting blood glucose + prolactin
FBC, U+E, LFT at the start of therapy and annually
Lipids, weight at the start, 3 months and then on annually
Fasting blood glucose + prolactin start, 6 months, then annually
Antipsychotic monitoring
BP
ECG
CVD assessment
BP baseline, frequently during titration
ECG baseline
CVD assessment annually
How long should benzos be prescribed for?
How do you withdraw?
2-4 weeks
Withdrawn in steps of 1/8 of the daily dose every fortnight
Switch to diazepam
Reduced dose of diazepam by 2 or 2.5mg every 2-3 weeks
Benzos veruss barbiturates MOA
Increase frequency of chloride channels - benzos
Barbiturates - increase duration of opening
Bipolar types
I + II
I mania and depression
II hypomania and depression
Bipolar
Mania management (2)
Depression
Hypomania versus mania for referral
Olanzapine or haloperidol
Fluoxetine
Routine referral to CMHT
Mania urgent referral
What is Charles Bonnet syndrome? (4)
- Persistent or recurrent complex hallucinations (visual or auditory)
- Occurring in clear consciousness
- BG of visual impairment (not mandatory)
- Insight preserved
RF for Charles Bonnet syndrome (5)
- Advancing age
- Peripheral visual impairment
- Social isolation
- Sensory deprivement
- Early cognitive impairment
What is Cotard syndrome?
Patient believes they are dead or non existent
Associated with severe depression
What is De Clerambault’s syndrome?
AKA erotomania
Single woman often believes a famous person is in love with her
What is delusional parasitosis?
Delusion that they are infested by bugs/ worms/ parasites
Mx subthreshold depression symptoms (4)
Individual guided CBT
Computerised CBT
Group physical activity programme
Group based CBT
Mx moderate and severe depression
High intensity psychological interventions (3)
- Individual CBT
- Behavioural activation
- Behavioural couples therapy
What is the Hospital Anxiety and Depression scale
14 questions
7 for anxiety, 7 depression
Each a score is given 0-3
0-7 normal
8-10 borderline
11+ abnormal
PHQ-9 explained
Over the last two weeks:
9 items 0-3 score
0-4 none
5-9 mild depression
10-14 moderate
15-19 moderately severe
20-27 severe
DSM IV criteria for depression (9)
- Depressed mood
- Diminished interest/ pleasure
- Weight loss/ gain
- Insomnia/ hypersomnia
- Psychomotor agitation
- Fatigue
- Worthlessness
- Reduced concentration
- Suicidal ideation
Switching antidepressants
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
Direct switch
Switching antidepressants
From fluoxetine to another SSRI
Withdraw then leave a gap of 4-7 days before starting low dose alternative SSRI
Switching from SSRI to TCA
Cross tapering (except fluoxetine which should be withdrawn before TCAs starting)
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
Cross taper cautiously
Switching from fluoxetine to venlafaxine
withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly
What is somatisation disorder?
Multiple physical symptoms present for at least 2 years
What is illness anxiety disorder?
Persistent belief in presence of an underlying serious disease e.g cancer
Hypochondriasis
What is conversion disorder?
Loss of motor or sensory function
Patient doesn’t consciously feign the symptoms
La belle indifference may be present
What is dissociative disorder?
Separating off certain memories from normal consciousness - involves psychiatric symptoms
What is dissociative identity disorder?
Multiple personality disorder & is most severe form of dissociative disorder
What is factitious disorder?
AKA Munchausen’s syndrome
Intentional production of physical or psychological symptoms
What is malingering?
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
What is circumstantiality?
Inability to answer a question without giving excessive, unnecessary detail, the person does eventually return to the original point.
What is tangentiality?
Refers to wandering from a topic without returning to it.
What is neologisms?
What are clang associations?
What is word salad?
Formation of new words
Ideas are related to each other only by the fact that they sound similar or rhyme
Word salad - completely incoherent speech
What is echolalia?
Repetition of someone else’s speech including the question
What is perseveration?
Repetition of ideas or words despite an attempt to change the topic
What is Knight’s move?
Severe type of loosening associations, unexpected and illogical leaps from one idea to another
Common SE of SSRIs (3)
GI symptoms
GI bleeding (must take PPI if taking NSAID)
Hyponatraemia
Which two SSRIs have increased drug interactions
Fluoxetine
Paroxetine
Citalopram and escitalopram
Investigation to do prior to starting
Max dose adults
Max dose >65yo
Hepatic impairment
ECG
Adults 40mg
65yo > 20mg
Hepatic impairment 20mg
Interactions of SSRI
NSAIDS
Warfarin/heparin
Triptans
NSAIDS - co-prescribe PPI, but normally do not offer SSRI
Warfarin/ heparin - consider mirtazapine instead of SSRI
Triptans avoid SSRI
How to stop an SSRI?
Gradually reduce over a four week period
Sleep paralysis mx (1)
Clonazepam
Children and adolescents SSRI of choice
Fluoxetine
SSRIs in pregnancy: Risks during:
First trimester
Third trimester
Use during first trimester - small increased risk of congenital heart defects
Third trimester - can results in persistent pulmonary hypertension of the newborn
Paroxetine in pregnancy risk
Increased risk of congenital malformations in first trimester
Section 2
Section 3
Section 5(2)
Section 136
28 days assessment
6 months treatment
72 hours in hospital doctor
Police pt found in public place 24 hours
Section 2 AMHP OR nearest relative + x2 doctors
Section 3 AMPH + x2 doctors seen pt within last 24 hours
Section 135
Police can break into property to remove a person to a Place of Safety
Section 5(4)
Nurse to detain a voluntary pt for 6 hours
What is section 17a
Community Treatment Order
Can recall a patient to hospital for treatment if they do not comply with conditions of the order in the community
What is section 4?
72 hour assessment order
GP + AMHP/NR
Schneider’s first rank symptoms classification (4)
Auditory hallucinations
Thought disorder
Passivity phenomena (belief that thoughts or actions are influenced or controlled by an external agent)
Delusional perceptions
Mx schizophrenia
First line (2)
Atypical antipsychotics
CBT
Schizophrenia poor prognostic factors (5)
FH
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
Absolute contraindication to ECT
Raised intracranial pressure
Medications that can trigger anxiety (5)
Salbutamol
Theophylinne
Steroids
Antidepressants
Caffeine
GAD mx (4)
HINT: step wise approach, not specifics
- Education
- Low intensity psychological interventions
- High intensity psychological interventions +/- drug treatment
- Specialist input
GAD drug treatment:
(2)
If not tolerated then give
- SSRI
- SNRI e.g duloxetine, venlafaxine
If they cannot tolerate above then pregabalin
GAD FU if <30yo
Weekly FU for the first month as increased risk of suicidal ideation and self harm
Mx of panic disorder (2)
If no response after how long switch to (2)
- CBT
- SSRIs
If no response after 12 weeks then imipramine or clomipramine
Grief reaction stages (5)
Denial
Anger
Bargaining
Depression
Acceptance
Difference between mania and hypomania
Length of time
Mania versus Hypomania
>7 days <7 days
Lithium
Adverse effects (6)
GI effects
Fine tremor
Nephrotoxicity
T wave flattening
Hypothyroidism
IIH
Lithium monitoring explained
What blood tests should be checked and how often?
12 hour post dose
Lithium levels should be performed weekly when starting and after each dose change until concentrations are stable
TFT + U+E every 6 months
OCD Mx
Which SSRI is best for body dysmorphic disorder?
- Low/high intensity psychological treatments
- SSRI for at least 12 months
Fluoxetine
What is Othello’s syndrome?
pathological jealousy where a person is convinced their partner is cheating on them without any real proof
Personality disorders
Cluster A
Cluster B
Cluster C
A - odd/ eccentric
B - dramatic, emotional, erratic
C - anxious and fearful
Cluster A personality traits (3)
Paranoid
Schizoid
Schizotypal
Cluster B personality traits (4)
Antisocial
Borderline
Histrionic
Narcissistic
Cluster C personality traits (3)
Obsessive compulsive
Avoidant
Dependent
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power, or beauty
Sense of entitlement
Taking advantage of others to achieve own needs
Lack of empathy
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
=
Narcissistic
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
=
Histrionic
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
Emotionally unstable/ borderline
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for the safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
=
Antisocial
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
=
Dependent
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
=
Avoidant
Peak age of first episode psychosis
15-30yo
PTSD
Mx (2)
Drug treatment (2)
- Watchful waiting for mild symptoms lasting <4 weeks
- CBT/ EMDR
Venlafaxine or SSRI
