Psychiatry Flashcards
How long should antidepressants be continued after resolution of symptoms to minimise relapse possibility?
6 more months
How do you stop SSRIs?
Wean them by gradually reducing doses over 4 weeks
In what situation should you use sertraline over citalopram and fluoxetine
Post myocardial infarction (evidence it is safer).
Citalopram can cause prolonged QT
What is the medical name for delusional jealousy?
Othello Syndrome
What are the tricyclic antidepressants?
More Sedative
Amitriptyline
Clomipramine
Dosulepin
Trazodone*
Less sedative
Imipramine
Lofepramine
Nortriptyline
Tricyclic antidepressants side effects
Common side-effects
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval
How long after changing lithium dose should you check lithium levels?
1 week
What should you give if someone is on an SSRI and an NSAID?
PPI
Which is the most common endocrine disorder resulting from chronic lithium toxicity?
Hypothyroidism
What does use of SSRIs in the first semester increase the risk of?
Congenital heart defects
First line treatment for acute stress disorders
Trauma-focused cognitive-behavioural therapy (CBT)
What is an acute stress disorder?
Acute stress reaction that occurs within 4 weeks after a person has been exposed to a traumatic event
What is the first line treatement for alcohol withdrawl?
Long-acting benzodiazepines e.g. chlordiazepoxide or diazepam
What is a conversion disorder?
A psychiatric condition where psychological stress is unconsciously manifested as physical, neurological symptoms
What class of medication should be avoided when using SSRIs
Triptans- risk of serotonin syndrome
What electrolyte imbalance is caused by SSRIs?
Hyponatremia
What is the first line drug for GAD (Generalised Anxiety Disorder)
Sertraline
Which SSRI causes prolonged QT syndrome
Citalopram
What is circumstantiality?
Excessive detail when answering a question
What is tangientality?
When asked a questions changing topic without returning to answer the question
How long does mania last?
At least 7 days
How long does hypomania last?
Less than 7 days, typically 3-4 days
Over what period of time should an SSRI be stopped?
Gradually reduced over a 4 week period apart from fluoxetine which has a longer half life
Which SSRI should be used in children and adolescents?
Fluoxetine
Give some side effects of SSRIs?
GI Symptoms
GI Bleeding risk- prescribe PPI if also taking a NSAID
What type of drug is mirtazapine?
Noradrenergic and specific serotonergic antidepressant
What are two side effects of mirtazapine that make it useful for older people?
Fewer side effects than other antidepressants so used in older people however
Sedation
Increased appetite
Useful for insomnia and low appetite
What lifestyle factor can cause a rise in clozapine blood levels?
Smoking cessation. Starting smoking can reduce clozapine levels.
Alcohol binges can increase the levels
Give some side effects of atypical antipsychotics
Weight gain
Clozapine is associated with agranulocytosis
Hyperprolactinaemia
In elderly patients:
Increased risk of stroke
Increased risk of venous thromboembolism
Which of the atypical antipsychotics is the most tolerable?
Aripiprazole- good side effect profile particularly for prolactin elevation
Clozapine specific side effects?
- Agranulocytosis (1%), neutropaenia (3%)
*Reduced seizure threshold - can induce seizures in up to 3% of patients - Constipation
- Myocarditis: a baseline ECG should be taken before starting treatment
- Hypersalivation
What medication can be used for an acute episode of GAD?
Lorazepam (Benzodiazepines)
What are some alternative organic causes of anxiety?
Hyperthyroidism
Cardiac disease
Medication-induced anxiety
What is the first line SSRI for GAD?
Sertraline
What are Schneider’s first rank symptoms of schizophrenia?
Auditory hallucinations
Thought disorders
Passivity phenomena
Delusional perceptions
What drug can be used to stabalise mood in bipolar disorder?
Lithium
What is malingering?
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
What is factitious disorder?
The intentional production of physical or psychological symptom
What is conversion disorder?
Typically involves loss of motor or sensory function- not faking it or doing it for gain but no explanation
What is a somatisation disorder?
Multiple physical SYMPTOMS present for at least 2 years. Patient refuses to accept reassurance or negative test results.
What is illness anxiety disorder (hypochondriasis)
Persistent believe of an underlying DISEASE. Patient refuses to accept reassurance or negative test results.
What is the first line treatment for less severe depression?
Guided self help
What score is less severe depression on the PHQ-9 scale?
Less than 16
What score is more severe depression on the PHQ-9 scale?
16 or over
What type of drug is duloxetine?
SNRI
What type of drug is venlafaxine?
SNRI
How long post dose should lithium levels be checked?
12 hours
What is lithium’s therapeutic range?
0.4-1.0 mmol/L
What other organ functions should be checked in patient’s taking lithum?
Thyroid and renal function every 6 months
What side effects are seen when discontinuing an SSRI?
GI Symptoms- pain, cramping, diahorroea, vomiting
Increased mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
paraesthesia
What condition causes hallucinations, confusion and delusions in alcohol withdrawl?
Delirium tremens
What is the management for delirium tremens?
Long acting benzodiazepines- chlordiazepoxide or diazepam. Also lorazepam.
Replace B vitamins
What is cotard syndrome?
Mental disorder in which patients believe they or part of their body is dead and does not exist
What behaviours characterise EUPD
Borderline (emotionally unstable) personality disorder is associated with a history of recurrent self-harm and intense interpersonal relationships that alternate between idealization and devaluation
What treatment is good for personality disorders?
Dialectical behaviour therapy
What is another name for Knight’s move thinking?
Derailment
What is perseveration?
Giving the same answer repeatedly
What investigation should be considered in elderly patients with a new onset psychosis?
CT Head
How long after starting an SSRI should a patient under 25 be reviewed?
In 1 week
What are some poor prognostic indicators for schizophrenia?
Pre-morbid social withdrawal
Low IQ
FH Schizophrenia
Gradual onset symptoms
Lack of obvious precipitant
What is the triad for Wernicke’s encephalopathy?
Confusion
Ataxia (Broad based gate)
Oculomotor dysfunction (for example CN 6 palsies and nystagmus)
What is a complication of untreated Wernicke’s encephalopathy?
Korsakoff’s syndrome
What is the triad for Korsakoff’s syndrome?
Anterograde amnesia, retrograde amnesia and confabulation
What is the first line treatment for GAD?
Sertraline
What should happen to antidepressant medication before ECT is started?
Reduce the dose
If a patient with GAD cannot tolerate SSRIs or SNRIs what should be considered?
Pregabalin
What type of drug is risperidone?
Antipsychotic
What class of psychiatric medications can cause memory loss?
Benzodiazepines
Which class of psychiatric drugs cause hypertension?
SNRIs
NICE recommend that all patients have their blood pressure monitored at initiation and each dose titration of venlafaxine
Which class of psychiatric drugs may cause hyponatremia?
SSRIs
BNF observe all people taking antidepressants for signs of hyponatraemia. For people at high risk, measure the serum sodium level before starting treatment, 2–4 weeks after starting treatment and every 3 months thereafter
How long must depressive symptoms be to be classed as a depressive episode according to ICD-10?
2 weeks
Name the 3 criteria for diagnosing depression
Hospital Anxiety and Depression (HAD) scale
Patient Health Questionnaire (PHQ-9)
DSM-IV- used by NICE
What do you do if someone misses taking clozapine for 48 hours
Start them on it again slowly
What is Munchausen’s syndrome?
The intentional production of symptoms
Which antipsychotic has the most tolerable side effect profile?
Aripiprazole
What is one of the main differences between schizoid and avoidant personality disorder?
Schizoid don’t want and relations whereas avoidant do
What is the timeline for symptoms after alcohol withdrawl?
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
What are the features of anorexia?
Most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
What is first line for alcohol withdrawls?
Long acting benzodiazepines such as chlordiazepoxide or diazepam
What is the highest risk factor for schizophrenia?
Family history
Also:
Black Caribbean
Migration
Urban environment
Cannabis use
What are some examples of monoamine oxidase inhibitors?
Tranylcypromine
Phenelzine
What are monoamine oxidase inhibitors used for?
Atypical depression eg hyperphagia
Non frequently used due to side effects
Adverse reactions of monoamine oxidase inhibitors?
Hypertensive reactions with tyramine containing foods- cheese, picked herring, bovril
Anticholinergic effects
Features of alcohol withdrawl?
Symptoms start 6-12 hours- tremor, sweating, tachycardia, anxiety
Peak incidence of seizures at 36 hours
Peak incidence of delerium tremens at 48-72 hours- coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Alcohol withdrawl management?
Patients with complex history admitted until withdrawls stabilised
1st- long acting benzodiazepines- chlordiazepoxide or diazepam.
Lorazepam may be preffered in hepatic failure
Carbamazepine also effective
Phenytoin not as effective
What are the adverse effects of clozapine?
Agranulocytosis, neutropenia
Reduced seizure threshold
Constipation
Myocarditis- baseline ECG before starting treatment
Hypersalivation
Dose adjustment might be necessary if smoking started or stopped
Are pseudohallucinations a normal part of the grieving process?
Yes
What is a pseudohallucination?
False perception in the absence of external stimuli- affected is aware they are hallucinating
What to do for patients with more severe depression?
CBT and antidepressant
What score is less severe depression on PHQ-9?
A PHQ-9 score of < 16
What score is more severe depression on PHQ-9?
A PHQ-9 score of ≥ 16
Less severe depression management?
Antidepressant not first line unless person’s preference
guided self-help
group cognitive behavioural therapy (CBT)
group behavioural activation (BA)
individual CBT
individual BA
group exercise
group mindfulness and meditation
interpersonal psychotherapy (IPT)
selective serotonin reuptake inhibitors (SSRIs)
counselling
short-term psychodynamic psychotherapy (STPP)
More severe depression management?
a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
individual CBT
individual behavioural activation (BA)
antidepressant medication
selective serotonin reuptake inhibitor (SSRI), or
serotonin-norepinephrine reuptake inhibitor (SNRI), or
another antidepressant if indicated based on previous clinical and treatment history
individual problem-solving
counselling
short-term psychodynamic psychotherapy (STPP)
interpersonal psychotherapy (IPT)
guided self-help
group exercise
First line drug treatment for PTSD?
Venlafaxine/ SSRI
SSRI interactions?
NSAIDs- need PPI
warfarin / heparin- consider mirtazapine instead
Aspirin
Triptans - increased risk of serotonin syndrome
Monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
When reviewed after starting antidepressants?
2 weeks
1 week if under 25 or increased suicide risk
Which SSRI has an increased risk of congenital malformations?
Paroxetine
What are the three clusters of personality disorders?
Cluster A: odd or eccentric
Cluster B: dramatic, emotional or erratic
Cluster C: Anxious and fearful
What are the cluster A personality disorders?
Paranoid
Schizoid
Schizotypal
What are the cluster B personality disorders?
Antisocial
Borderline (Emotionally Unstable)
Histrionic
Narcissistic
What are the cluster C personality disorders?
Obsessive-Compulsive
Avoidant
Dependant
What are the features of paranoid personality disorder?
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
What are the schizoid personality disorder features?
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
What are the schizotypal personality disorder features?
Ideas of reference (differ from delusions in that some insight is retained)
Odd beliefs and magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent
What are the antisocial personality disorder features?
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
What are the features of borderline personality disorder?
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
What are the features of histrionic peronality disorder?
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
What are the features of narcissistic personality disorder?
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
What are the features of the obsessive compulsive personality type?
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
What are the features of avoidant personaity disorder?
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
What are the features of dependant personality disorder?
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
How to manage personality disorders?
Difficult to treat
Psychological therapies- dialectical behaviour therapy
Treat coexisting psychiatric conditions
Adverse effects/ example of typical antipsychotics?
Extrapyramidal side effects and hyperprolacinaemia
Examples:
Haloperidol
Chorpromazine
Atypical antipsychotics examples and side effects?
Metabolic effects
Clozapine
Risperidone
Olanzapine
Extrapyramidal side effects examples?
Parkinsonism
Acute dystonia- sustained muscle contraction managed by procyclidine
Akathesia- severe restlessness
Tardive dyskinesia
Risk of typical antipsychotics in elderly patients?
Increaed risk of stroke
Increased risk VTE
Other side effects typical antispychotics?
Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
Raised prolactin
Impaired glucose tolerance
Neuroleptic malignant syndrome: pyrexia, muscle stiffness
Reduced seizure threshold (greater with atypicals)
Prolonged QT interval (particularly haloperidol)
Features of alcohol withdrawl?
Symptoms start at 6-12 hours- tremor, sweating, tachycardia, anxiety
Peak incidence seizures at 36 hours
Peak incidence delirium tremens at 48-72 hours- coarse tremor, confusion, delusions, auditory and visual halluciations, fever, tachycardia
Management of alcohol withdrawl?
History of complex withdrawls- admitted to hosptial
Long acting benzos- chordiazepoxide or diazepam. Lorazepam in hepatic failure
Carbamazepine effective
Phenytoin not
What is an obsession?
Unwanted intrusive thought, image or urge that repeatedly enters the person’s mind
What is a compulsion?
Repetitive behaviours or mental acts that the person feels driven to perform
Can be external and observable overt
or internal such as repeating a phrase covert
Risk factors for OCD?
FH
Age- peak onset is 10-20
Pregnancy/postnatal period
History of abuse, neglect, bullying
Management of mild OCD?
Mild functional impairment- CBT and exposure and response prevention (ERP)
If this is insufficient course of SSRI or more intensive CBT
Mangement of moderate OCD?
Choice of SSRI (any SSRI but fluoxetine for body dysmorphic disorder) or more intensive CBT
Consider clomipramine as alternative first line, patient preference or if SSRI contraindicated
Management of severe OCD?
OCD taking >3 hours a day
Refer to secondary care mental health team for assessment
Whilst awaiting assessment offer combined SSRI and CBT
or clomipramine as alternative
How long to carry on OCD treatment if effective?
At least 12 months
Compared to depression SSRI usually requires a higher dose and longer treatment duration (at least 12 weeks) for initial response
What should be used first line for schizophrenia?
Atypical antipsychotics- main advantage is the reduction in extrapyramidal side effects
Adverse effects of atypical antipsychotics?
Weight gain
Clozapine causes agranulocytosis
Hyperprolactinemia
Increased risk stroke/VTE in elderley patient
Examples of atypical antipsychotics?
Clozapine
Olanzapine- higher risk obesity
Risperidone
Quetiapine
Amisulpride
Aripriprazole- good side effect profile, particualrly for prolactin elevation
What should be monitored when using clozapine?
Bloods for agranulocytosis
Only used when resistant to other antipsychotics
When should clozapine be used?
Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
Adverse effects clozapine?
Agranulocytosis, neutropenia
Reduced seizure threshold
Constipation
Myocarditis- baseline ECG before starting
Hypersalivation
Dose adjustment may be needed if smoking started or stopped during treatment
How to remember clozapine side effects?
Clozapine S/E
C - constipation
Lo - lower seizure threshold
Z - zzz sedation
A - agranulocytosis
P - phat weight gain
I - increased salivation
N - neutropenia
E - ECG changes
What physical causes are important to exclude in anxiety?
Hyperthyroidism, cardiac disease and medication induced anxiety
Medications that may induce anxiety- salbutamol, theophylline, corticosteroids, antidepressants and caffeine
Management GAD?
1- education and active monitoring
2- Low intensity psychological interventions (individual guided self help)
3- High intensity psychological interventions- CBT or drug interventions
4- Highly specialised input
Drug treatment for GAD?
1st sertraline
If sertraline ineffective offer alternative SSRI or SNRI (duloxetine/venlafaxine)
If not SSRI/SNRI offer pregabalin
Weekly follow up for month in patients unde r30 as increased risk suicide and self harm
Management panic disorder?
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Primary care: CBT or drug treatment
SSRI first line, if contraindicated or no response after 12 weeks then imipramine or clomipramine
Adverse effects of lithium?
Nausea/vomiting, diarrhoea
Fine tremor
Nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
Thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
Weight gain
Idiopathic intracranial hypertension
Leucocytosis
Hyperparathyroidism and resultant hypercalcaemia
Monitoring of patients on lithium?
When checking levels done 12 hours post dose
After starting lithium levels taken weekly and after each dose change until concentrations are stable
Once established, blood level checked every 3 months
After change in dose levels taken week later and weekly until stable
Thyroid and renal function every 6 months
Patients provided with information booklet, alert card and record book
What is somatisation disorder?
Multiple physical SYMPTOMS present for at least 2 years
Patient refuses to accept reassurance or negative test results
What is illness anxiety disorder (hypochondriasis)?
Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
Patient again refuses to accept reassurance or negative test results
What is facticious disorder?
Also known as Munchausen’s syndrome
The intentional production of physical or psychological symptoms
What is dissociative disorder?
Dissociation is a process of ‘separating off’ certain memories from normal consciousness
In contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
Dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
What are the two types of bipolar disorder?
Type 1- mania and depression
Type 2- hypomania and depression
What is one way to differentiate mania/hypomania?
Mania has psychotic symptoms (delusions of grandeur or auditory hallucinations
Management of bipolar disorder?
Psychological interventions for bipolar
Lithium. alternative is valproate
Management of mania/hypomania- consider stopping antidepressant, antipsychotic therapy- olanzapine or haloperidol
Managment of depression- fluoxetine, talking therpaies
Address co morbities- increaed risk with DM, CVD and COPD
How do benzos work?
Enhance the effect of GABA
How long should benzodiazepines be used for?
2-4 weeks
How to withdraw benzodiazepines?
Withdraw approximately 1/8 of the dose every fortnight
If being difficult
Switch patients to equivelant dose of diazepam
Reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
Time needed for withdrawal can vary from 4 weeks to a year or more
Features of benzodiazepine withdrawl syndrome?
May occur up to 3 weeks after stopping
Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Perspiration
Perceptual disturbances
Seizures
How to remember GABA drugs function?
Benzodiazipines increase the frequency of chloride channels
Barbiturates increase the duration of chloride channel opening
What are the factors suggesting a diagnosis of depression over dementia?
Short history, rapid onset
Biological symptoms- weight loss, sleep disturbance
Patient worried about poor memory
Reluctant to take tests, disappointed with results
Mini mental test score variable
Global memory loss- dementia characteristically causes recent memory loss
What is the most common electrolyte disturbance in anorexia nervosa?
Hypokalaemia
What are the features of anorexia nervosa?
Reduced body mass index
Bradycardia
Hypotension
Enlarged salivary glands
(Failure secondary sexual characteristics, cold intolerance, yellow skin)
Physiological abnormalities of anorexia nervosa?
Hypokalaemia
Low FSH, LH, oestrogens and testosterone
Raised cortisol and growth hormone
Impaired glucose tolerance
Hypercholesterolaemia
Hypercaritonemia- yellow tinge on skin
Low T3
What are the features of sleep paralysis?
Paralysis- occurs after waking up or before falling asleep
Hallucinations- images or speaking that occur during the paralysis
Management of sleep paralysis?
If troublesome clonazepam may be used
Pneumonic for PTSD?
HEART:
Hyperarousal
Emotional numbing
Avoidance of triggers
Re-experiencing
Time
Features of PTSD?
Re-experiencing- flashbacks, nightmares, repetitive and distressing intrusive images
Avoidance- avoiding people, situations or circumstances resembling or associated with the event
Hyperarousal- hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
Emotional numbing- lack of ability to experience feelings, feeling detached
Depression
Drug/alcohol misuse
Anger
Unexplained physical symptoms
How long do symptoms have to be present for a diagnosis of PTSD?
4 weeks
PTSD management?
Traumatic event single session interventions
Watchful waiting for symptoms less than 4 weeks
Trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) in more severe cases
Drug treatment not first line but if required- venlafaxine or SSRI such as sertraline. In severe cases risperidone may be used
What are the types of acute dystonia from antipsychotics?
General muscle freezing
Torticollis
Oculogyric crisis
Managed with procyclidine
What are some suicide risk factors?
Male sex (hazard ratio (HR) approximately 2.0)
History of deliberate self-harm (HR 1.7)
Alcohol or drug misuse (HR 1.6)
History of mental illness
depression
Schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
History of chronic disease
Advancing age
Unemployment or social isolation/living alone
being unmarried, divorced or widowed
Increased risk of successful suicide factors?
Efforts to avoid discovery
Planning
Leaving a written note
Final acts such as sorting out finances
Violent method
Suicide protective factors?
Family support
Having children at home
Religious belief
What are the features of schizophrenia?
Auditory hallucinations of a specific type:
two or more voices Discussing the patient in the third person
Thought echo
Voices commenting on the patient’s behaviour
Thought disorders
thought insertion
thought withdrawal
thought broadcasting
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
What type of amnesia does ECT cause?
Retrograde amnesia
ECT contraindication?
Raised ICP
What are the short term side effects of ECT?
Headache
Nausea
Short term memory impairment
Memory loss of events prior to ECT
Cardiac arrhythmia
Schizophrenia management?
Oral atypical antispychotics are first line
CBT offered to all patients
High risk of CVD in schizophrenia patients so check RFs
What is a the condition where patient feel like they are infested with bugs?
Delusional parasitosis
What electrolyte disturbance can bulimia nervosa cause?
Hypokalaemia
What is De Clerambault’s syndrome (erotomania)?
Delution with an amourous quality. Believing a famous actor in love with you
Metabolic side effects of antipsychotics?
Dysglycaemia, dyslipidemia and DM
Which antipsychotics are bad for the extrapyramidal side effects?
Typical antipsychotics
Extrapyramidal side effects:
Parkinsonism
Acute dystonia- managed with procyclidine
Akathesia
Tardive dyskinesia
Haloperidol
Chorpromazine
What are the atypical antipsychotics?
CORQA
Clozapine
Olanzapine
Risperidone
Quetiapine
Arripriprazole
What are the typical antipsychotics?
Haloperidol
Cholpromazine
Risk factors for GAD?
Aged 35-54
Being divorced or separated
Living alone
Being a lone parent
Protective
16-24
Married or cohabiting
What is seasonal affective disorder?
Depression around winter
Parkinson’s unilateral or bilateral?
Unilateral more likely to be Parkinson’s disease
Bilateral more likely to be drug induced Parkinsonism
When to prescribe clozapine?
Treatment resistant schizophrenia- not responded to two different antipsychotics including one atypical
Treatment of persistent negative symptoms- efficacy in reducing negative symptoms
Difference between serotonin syndrome and neuroleptic malignant syndome?
Serotonin syndrome
Faster onset
Reflexes- clonus, dilated pupils
Mx- cyprohepatadine, chlorpromazine
Neuroleptic malignant syndrome
Slower onset
Reflexes- lead pipe rigidity
Mx- dantrolene
What electrolyte disturbances can long term lithium use cause?
Hyperparathyroidism which causes hypercalcemia
Which medication is a deterrant that makes you ill if you drink alcohol?
Disulfiram
What medication is anti craving for alcohol?
Acamprosate
Which medications can be used as opiate replacement therapy?
Methadone- commonest
Buprenorphine- sublingual tablet less sedating than methadone
What is the difference between the two types of bipolar disorder?
Type I disorder: mania and depression (most common)
Type II disorder: hypomania and depression
What is the management for schizophrenics with poor medication compliance?
Give IM depot antispychotic injections
Canvernous sinus syndrome vs posterior communicating artery aneurysm?
Posterior communicating artery aneurysm (pupil dilated)
= Think: 3rd nerve palsy = ptosis + dilated pupil
Cavernous sinus thrombosis
= absent corneal reflex + proptosis
Wernicke’s and Korsakoff’s help? Remember can have it when drinking (smelling of alcohol)
COAT (Wernicke’s encephalopathy), RACK (Korsakoff’s syndrome)
Confusion
Ophthalmoplegia (nystagmus)
Ataxia
Thiamine deficiency
Retrograde amnesia
Anterograde amnesia
Confabulation
Korsakoff’s syndrome
Can raised ICP cause dilated pupil?
Yes something like haematoma can give 3rd nerve palsy signs
What are the basic investigations for infertility?
Semen analysis
Serum progesterone 7 days prior to expected next period. For typical cycle this is day 21, but could be different if longer cycle.
Follicular phase of menstrual cycle variable, the luteal phase after ovulation is constant at 14 days- (progesterone peaks 7 days after ovulation occurs)
What should you give for tardive dyskinesia vs acute dystonia?
Tardive dyskinesia occurs after long term antipsychotic use
Tardive dyskinesia- terabenezine- both begin with T
Acute dystonia- procyclidine
Propanolol can be used for akathesia
Is hyperprolactinemia more common with typical or atypical antipsychotics?
Typical
What is tardive dyskinesia?
Face or body sudden movements you can’t control- chewing or pouting of the jaw
Way to remember first rank symptoms of schizophrenia?
A - Auditory hallucinations –> 2nd and 3rd person
B - Broadcasting of thoughts, withdrawal, insertion
C - Controlled emotions and actions, passive impulsivity phenomena
D - Delusional perceptions
What are Schneider’s first rank symptoms for schizophrenia?
Auditory hallucinations
Thought disorders
Passivity phenomena
Delusional perceptions
How long does a normal grief reaction last?
Under 6 months
(another place says up to 12 months)
What are the five stages of grief?
Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
Anger: this is commonly directed against other family members and medical professionals
Bargaining
Depression
Acceptance
What are the features of atypical grief reactions?
Delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
Prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
What are the factors assocaited with a poor prognosis for schizophrenia?
Strong family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
Does smoking cessation raise or reduce clozapine levels?
Raise
When can chronic insomnia be diagnosed?
Diagnosed after 3 months, need to have trouble falling or staying asleep at least 3 nights per week
What features are associated with insomnia?
Female gender
Increased age
Lower educational attainment
Unemployment
Economic inactivity
Widowed, divorced, or separated status
Other risk factors for insomnia?
Alcohol and substance abuse
Stimulant usage
Medications such as corticosteroids
Poor sleep hygiene
Chronic pain
Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population.
Psychiatric illness: anxiety and depression are highly correlated with insomnia.
People with manic episodes or PTSD will also complain of extended periods of sleeplessness
Type 1 bipolar?
Mania and depression
Type 2 bipolar?
Hypomania and depression
Do antipsychotics cause dysregulation of glucose and DM?
Yes
Electric shock sensations are seen in what type of withdrawl?
SSRI
What are the symptoms of discontinuation syndrome?
(SSRIs)
Discontinuation Syndrome (FIRM STOP)
Flu like Sx
Insomnia
Restlessness
Mood swings
Sweating
Tummy problems (pain, cramps, D+V)
Off balance
Parasthaesia
What is Charles-Bonnet syndrome?
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness
Usually associated with visual impairment
Insight preserved
Must be in the absence of any other significant neuropsychiatric disturbance
RFs:
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
What to do for phimosis?
In children under 2 is normal and will resolve with time- may be bulging when they wee
Lithium after dose change?
One week after dose change then weekly until stable
Once stable checked every three months
Other antipsychotic side effects?
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin
may result in galactorrhoea
due to inhibition of the dopaminergic tuberoinfundibular pathway
impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
What is brief psychotic disorder?
Psychosis lasting less than a month with a subsequent return to baseline
Clozapine blood monitoring?
Monitor leucocyte and differential blood counts. Clozapine requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly as part of the clozapine patient monitoring service
Can corticosteroids such as prednisolone cause psychosis?
Yes
Perseveration
repeating the same words/answers
Word salad
disorganised speech, sentences that do not make sense
Neologism
making up new words
Echolalia
repeating exactly what someone has said
Circumstantiality
the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return to the original point.
Tangentiality
refers to wandering from a topic without returning to it
Clang associations
when ideas are related to each other only by the fact they sound similar or rhyme
Knight’s move thinking
a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia
Flight of ideas
a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them
Sections of the mental state examination
ASEPTIC
● Appearance and behaviour
● Speech - rate, tone, volume, quantity, flow
● Emotion (Mood and Affect)
● Perception
● Thoughts - form, content, possession
● Insight
● Cognition (Orientation to time, place, person)
Mechanism of each drug?
hfhd
When can a patient be detained?
They have a mental disorder that poses significant
risk to themselves or others, and treatment in the
community is not possible because of this
MH act powers?
Holding Powers - to stop patient leaving a ward, no MHA needed
* Section 5(4): MH Nurse HP: can stop psychiatric patient leaving a ward up to 6hrs
to allow for assessment by a doctor
* Section 5(2): Doctor HP: can stop a patient leaving any ward up to 72hrs to allow
for MHA to be organised
Require MHA Assessment - 1 AHMP + 2 Section 12 Approved doctors
* Section 2: 28 days ; for assessment (can treat)
* Section 3: 6 months ; for treatment
* Patient has right to appeal via tribunal
Police Powers
* Section 136: to take an individual to a place of safety - from a public place
* Section 135: to enter someone’s property and take them to a place of safety,
needs magistrate approval
MH act holding powers?
- Section 5(4): MH Nurse HP: can stop psychiatric patient leaving a ward up to 6hrs
to allow for assessment by a doctor - Section 5(2): Doctor HP: can stop a patient leaving any ward up to 72hrs to allow
for MHA to be organised
Section 17a
Supervised Community Treatment (Community Treatment Order)
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
MH act assessment powers?
Require MHA Assessment - 1 AHMP + 2 Section 12 Approved doctors
* Section 2: 28 days ; for assessment (can treat)
* Section 3: 6 months ; for treatment
* Patient has right to appeal via tribunal
Section 4
72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
a GP and an AMHP
often changed to a section 2 upon arrival at hospital
MH act police powers?
Police Powers
* Section 136: to take an individual to a place of safety - from a public place
* Section 135: to enter someone’s property and take them to a place of safety,
needs magistrate approval
What are the negative symptoms of schizophrenia?
Negative symptoms suggestive of schizophrenia include:
Incongruity/blunting of affect
Anhedonia (inability to derive pleasure)
Alogia (poverty of speech)
Avolition (poor motivation)
Social withdrawal
Neuroleptic malignant syndrome treatment?
Bromocriptine or Dantrolene
Weird side effect of lamotrigine?
Steven-Johnson syndrome
How long to be a depressive episode?
2 weeks
SSRI side effect?
Hyponatraemia
GI upset
Anxiety and agitation after starting
Only absolute contraindication for ECT?
Raised ICP
Serotonin syndrome treatment?
Supportive- IV fluids
Benzodiazepines
Severe cases managed with- cyproheptadine or chlorpromazine
Causes of serotonin syndrome?
Causes
Monoamine oxidase inhibitors
SSRIs
St John’s Wort
Tramadol may also interact with SSRIs
Ecstasy
Amphetamines
Features of serotonin syndrome?
Features
Neuromuscular excitation
hyperreflexia
myoclonus
rigidity
Autonomic nervous system excitation
hyperthermia
sweating
Altered mental state
confusion
Does lithium cause hypothyroidism?
Yes
What are the 3 P’s in Psychiatry formulation?
3 P’s:
Pre-disposing factors
Precipitating factors
Perpetuating factors
Explain briefly what these mean and give examples:
Predisposing = family history of a mental disorder
Precipitating = traumatic life event
Perpetuating = lack of support/stable social situation
