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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

How long should antidepressants be continued after resolution of symptoms to minimise relapse possibility?

A

6 more months

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2
Q

How do you stop SSRIs?

A

Wean them by gradually reducing doses over 4 weeks

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3
Q

In what situation should you use sertraline over citalopram and fluoxetine

A

Post myocardial infarction (evidence it is safer).

Citalopram can cause prolonged QT

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4
Q

What is the medical name for delusional jealousy?

A

Othello Syndrome

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5
Q

What are the tricyclic antidepressants?

A

More Sedative
Amitriptyline
Clomipramine
Dosulepin
Trazodone*

Less sedative
Imipramine
Lofepramine
Nortriptyline

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6
Q

Tricyclic antidepressants side effects

A

Common side-effects
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval

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7
Q

How long after changing lithium dose should you check lithium levels?

A

1 week

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8
Q

What should you give if someone is on an SSRI and an NSAID?

A

PPI

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9
Q

Which is the most common endocrine disorder resulting from chronic lithium toxicity?

A

Hypothyroidism

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10
Q

What does use of SSRIs in the first semester increase the risk of?

A

Congenital heart defects

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11
Q

First line treatment for acute stress disorders

A

Trauma-focused cognitive-behavioural therapy (CBT)

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12
Q

What is an acute stress disorder?

A

Acute stress reaction that occurs within 4 weeks after a person has been exposed to a traumatic event

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13
Q

What is the first line treatement for alcohol withdrawl?

A

Long-acting benzodiazepines e.g. chlordiazepoxide or diazepam

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14
Q

What is a conversion disorder?

A

A psychiatric condition where psychological stress is unconsciously manifested as physical, neurological symptoms

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15
Q

What class of medication should be avoided when using SSRIs

A

Triptans- risk of serotonin syndrome

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16
Q

What electrolyte imbalance is caused by SSRIs?

A

Hyponatremia

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17
Q

What is the first line drug for GAD (Generalised Anxiety Disorder)

A

Sertraline

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18
Q

Which SSRI causes prolonged QT syndrome

A

Citalopram

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19
Q

What is circumstantiality?

A

Excessive detail when answering a question

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20
Q

What is tangientality?

A

When asked a questions changing topic without returning to answer the question

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21
Q

How long does mania last?

A

At least 7 days

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22
Q

How long does hypomania last?

A

Less than 7 days, typically 3-4 days

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23
Q

Over what period of time should an SSRI be stopped?

A

Gradually reduced over a 4 week period apart from fluoxetine which has a longer half life

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24
Q

Which SSRI should be used in children and adolescents?

A

Fluoxetine

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25
Q

Give some side effects of SSRIs?

A

GI Symptoms
GI Bleeding risk- prescribe PPI if also taking a NSAID

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26
Q

What type of drug is mirtazapine?

A

Noradrenergic and specific serotonergic antidepressant

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27
Q

What are two side effects of mirtazapine that make it useful for older people?

A

Fewer side effects than other antidepressants so used in older people however
Sedation
Increased appetite
Useful for insomnia and low appetite

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28
Q

What lifestyle factor can cause a rise in clozapine blood levels?

A

Smoking cessation. Starting smoking can reduce clozapine levels.

Alcohol binges can increase the levels

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29
Q

Give some side effects of atypical antipsychotics

A

Weight gain
Clozapine is associated with agranulocytosis
Hyperprolactinaemia

In elderly patients:
Increased risk of stroke
Increased risk of venous thromboembolism

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30
Q

Which of the atypical antipsychotics is the most tolerable?

A

Aripiprazole- good side effect profile particularly for prolactin elevation

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31
Q

Clozapine specific side effects?

A
  • 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
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32
Q

What medication can be used for an acute episode of GAD?

A

Lorazepam (Benzodiazepines)

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33
Q

What are some alternative organic causes of anxiety?

A

Hyperthyroidism
Cardiac disease
Medication-induced anxiety

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34
Q

What is the first line SSRI for GAD?

A

Sertraline

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35
Q

What are Schneider’s first rank symptoms of schizophrenia?

A

Auditory hallucinations
Thought disorders
Passivity phenomena
Delusional perceptions

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36
Q

What drug can be used to stabalise mood in bipolar disorder?

A

Lithium

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37
Q

What is malingering?

A

Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

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38
Q

What is factitious disorder?

A

The intentional production of physical or psychological symptom

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39
Q

What is conversion disorder?

A

Typically involves loss of motor or sensory function- not faking it or doing it for gain but no explanation

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40
Q

What is a somatisation disorder?

A

Multiple physical SYMPTOMS present for at least 2 years. Patient refuses to accept reassurance or negative test results.

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41
Q

What is illness anxiety disorder (hypochondriasis)

A

Persistent believe of an underlying DISEASE. Patient refuses to accept reassurance or negative test results.

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42
Q

What is the first line treatment for less severe depression?

A

Guided self help

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43
Q

What score is less severe depression on the PHQ-9 scale?

A

Less than 16

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44
Q

What score is more severe depression on the PHQ-9 scale?

A

16 or over

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45
Q

What type of drug is duloxetine?

A

SNRI

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46
Q

What type of drug is venlafaxine?

A

SNRI

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47
Q

How long post dose should lithium levels be checked?

A

12 hours

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48
Q

What is lithium’s therapeutic range?

A

0.4-1.0 mmol/L

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49
Q

What other organ functions should be checked in patient’s taking lithum?

A

Thyroid and renal function every 6 months

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50
Q

What side effects are seen when discontinuing an SSRI?

A

GI Symptoms- pain, cramping, diahorroea, vomiting
Increased mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
paraesthesia

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51
Q

What condition causes hallucinations, confusion and delusions in alcohol withdrawl?

A

Delirium tremens

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52
Q

What is the management for delirium tremens?

A

Long acting benzodiazepines- chlordiazepoxide or diazepam. Also lorazepam.
Replace B vitamins

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53
Q

What is cotard syndrome?

A

Mental disorder in which patients believe they or part of their body is dead and does not exist

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54
Q

What behaviours characterise EUPD

A

Borderline (emotionally unstable) personality disorder is associated with a history of recurrent self-harm and intense interpersonal relationships that alternate between idealization and devaluation

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55
Q

What treatment is good for personality disorders?

A

Dialectical behaviour therapy

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56
Q

What is another name for Knight’s move thinking?

A

Derailment

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57
Q

What is perseveration?

A

Giving the same answer repeatedly

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58
Q

What investigation should be considered in elderly patients with a new onset psychosis?

A

CT Head

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59
Q

How long after starting an SSRI should a patient under 25 be reviewed?

A

In 1 week

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60
Q

What are some poor prognostic indicators for schizophrenia?

A

Pre-morbid social withdrawal
Low IQ
FH Schizophrenia
Gradual onset symptoms
Lack of obvious precipitant

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61
Q

What is the triad for Wernicke’s encephalopathy?

A

Confusion
Ataxia (Broad based gate)
Oculomotor dysfunction (for example CN 6 palsies and nystagmus)

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62
Q

What is a complication of untreated Wernicke’s encephalopathy?

A

Korsakoff’s syndrome

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63
Q

What is the triad for Korsakoff’s syndrome?

A

Anterograde amnesia, retrograde amnesia and confabulation

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64
Q

What is the first line treatment for GAD?

A

Sertraline

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65
Q

What should happen to antidepressant medication before ECT is started?

A

Reduce the dose

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66
Q

If a patient with GAD cannot tolerate SSRIs or SNRIs what should be considered?

A

Pregabalin

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67
Q

What type of drug is risperidone?

A

Antipsychotic

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68
Q

What class of psychiatric medications can cause memory loss?

A

Benzodiazepines

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69
Q

Which class of psychiatric drugs cause hypertension?

A

SNRIs

NICE recommend that all patients have their blood pressure monitored at initiation and each dose titration of venlafaxine

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70
Q

Which class of psychiatric drugs may cause hyponatremia?

A

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

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71
Q

How long must depressive symptoms be to be classed as a depressive episode according to ICD-10?

A

2 weeks

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72
Q

Name the 3 criteria for diagnosing depression

A

Hospital Anxiety and Depression (HAD) scale

Patient Health Questionnaire (PHQ-9)

DSM-IV- used by NICE

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73
Q

What do you do if someone misses taking clozapine for 48 hours

A

Start them on it again slowly

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74
Q

What is Munchausen’s syndrome?

A

The intentional production of symptoms

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75
Q

Which antipsychotic has the most tolerable side effect profile?

A

Aripiprazole

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76
Q

What is one of the main differences between schizoid and avoidant personality disorder?

A

Schizoid don’t want and relations whereas avoidant do

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77
Q

What is the timeline for symptoms after alcohol withdrawl?

A

Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours

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78
Q

What are the features of anorexia?

A

Most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia

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79
Q

What is first line for alcohol withdrawls?

A

Long acting benzodiazepines such as chlordiazepoxide or diazepam

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80
Q

What is the highest risk factor for schizophrenia?

A

Family history

Also:
Black Caribbean
Migration
Urban environment
Cannabis use

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81
Q

What are some examples of monoamine oxidase inhibitors?

A

Tranylcypromine

Phenelzine

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82
Q

What are monoamine oxidase inhibitors used for?

A

Atypical depression eg hyperphagia

Non frequently used due to side effects

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83
Q

Adverse reactions of monoamine oxidase inhibitors?

A

Hypertensive reactions with tyramine containing foods- cheese, picked herring, bovril

Anticholinergic effects

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83
Q

Features of alcohol withdrawl?

A

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

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83
Q

Alcohol withdrawl management?

A

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

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84
Q

What are the adverse effects of clozapine?

A

Agranulocytosis, neutropenia

Reduced seizure threshold

Constipation

Myocarditis- baseline ECG before starting treatment

Hypersalivation

Dose adjustment might be necessary if smoking started or stopped

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85
Q

Are pseudohallucinations a normal part of the grieving process?

A

Yes

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86
Q

What is a pseudohallucination?

A

False perception in the absence of external stimuli- affected is aware they are hallucinating

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87
Q

What to do for patients with more severe depression?

A

CBT and antidepressant

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88
Q

What score is less severe depression on PHQ-9?

A

A PHQ-9 score of < 16

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89
Q

What score is more severe depression on PHQ-9?

A

A PHQ-9 score of ≥ 16

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90
Q

Less severe depression management?

A

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)

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91
Q

More severe depression management?

A

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

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92
Q

First line drug treatment for PTSD?

A

Venlafaxine/ SSRI

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93
Q

SSRI interactions?

A

NSAIDs- need PPI

warfarin / heparin- consider mirtazapine instead

Aspirin

Triptans - increased risk of serotonin syndrome

Monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

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94
Q

When reviewed after starting antidepressants?

A

2 weeks

1 week if under 25 or increased suicide risk

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95
Q

Which SSRI has an increased risk of congenital malformations?

A

Paroxetine

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96
Q

What are the three clusters of personality disorders?

A

Cluster A: odd or eccentric

Cluster B: dramatic, emotional or erratic

Cluster C: Anxious and fearful

97
Q

What are the cluster A personality disorders?

A

Paranoid

Schizoid

Schizotypal

98
Q

What are the cluster B personality disorders?

A

Antisocial

Borderline (Emotionally Unstable)

Histrionic

Narcissistic

99
Q

What are the cluster C personality disorders?

A

Obsessive-Compulsive

Avoidant

Dependant

100
Q

What are the features of paranoid personality disorder?

A

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

101
Q

What are the schizoid personality disorder features?

A

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

102
Q

What are the schizotypal personality disorder features?

A

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

103
Q

What are the antisocial personality disorder features?

A

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

104
Q

What are the features of borderline personality disorder?

A

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

105
Q

What are the features of histrionic peronality disorder?

A

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

106
Q

What are the features of narcissistic personality disorder?

A

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

107
Q

What are the features of the obsessive compulsive personality type?

A

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

108
Q

What are the features of avoidant personaity disorder?

A

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

109
Q

What are the features of dependant personality disorder?

A

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

110
Q

How to manage personality disorders?

A

Difficult to treat

Psychological therapies- dialectical behaviour therapy

Treat coexisting psychiatric conditions

111
Q

Adverse effects/ example of typical antipsychotics?

A

Extrapyramidal side effects and hyperprolacinaemia

Examples:
Haloperidol
Chorpromazine

112
Q

Atypical antipsychotics examples and side effects?

A

Metabolic effects

Clozapine
Risperidone
Olanzapine

113
Q

Extrapyramidal side effects examples?

A

Parkinsonism

Acute dystonia- sustained muscle contraction managed by procyclidine

Akathesia- severe restlessness

Tardive dyskinesia

114
Q

Risk of typical antipsychotics in elderly patients?

A

Increaed risk of stroke

Increased risk VTE

115
Q

Other side effects typical antispychotics?

A

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)

116
Q

Features of alcohol withdrawl?

A

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

117
Q

Management of alcohol withdrawl?

A

History of complex withdrawls- admitted to hosptial

Long acting benzos- chordiazepoxide or diazepam. Lorazepam in hepatic failure

Carbamazepine effective

Phenytoin not

118
Q

What is an obsession?

A

Unwanted intrusive thought, image or urge that repeatedly enters the person’s mind

119
Q

What is a compulsion?

A

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

120
Q

Risk factors for OCD?

A

FH
Age- peak onset is 10-20
Pregnancy/postnatal period
History of abuse, neglect, bullying

121
Q

Management of mild OCD?

A

Mild functional impairment- CBT and exposure and response prevention (ERP)

If this is insufficient course of SSRI or more intensive CBT

122
Q

Mangement of moderate OCD?

A

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

123
Q

Management of severe OCD?

A

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

124
Q

How long to carry on OCD treatment if effective?

A

At least 12 months

Compared to depression SSRI usually requires a higher dose and longer treatment duration (at least 12 weeks) for initial response

125
Q

What should be used first line for schizophrenia?

A

Atypical antipsychotics- main advantage is the reduction in extrapyramidal side effects

126
Q

Adverse effects of atypical antipsychotics?

A

Weight gain

Clozapine causes agranulocytosis

Hyperprolactinemia

Increased risk stroke/VTE in elderley patient

127
Q

Examples of atypical antipsychotics?

A

Clozapine

Olanzapine- higher risk obesity

Risperidone

Quetiapine

Amisulpride

Aripriprazole- good side effect profile, particualrly for prolactin elevation

128
Q

What should be monitored when using clozapine?

A

Bloods for agranulocytosis

Only used when resistant to other antipsychotics

129
Q

When should clozapine be used?

A

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.

130
Q

Adverse effects clozapine?

A

Agranulocytosis, neutropenia

Reduced seizure threshold

Constipation

Myocarditis- baseline ECG before starting

Hypersalivation

Dose adjustment may be needed if smoking started or stopped during treatment

131
Q

How to remember clozapine side effects?

A

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

132
Q

What physical causes are important to exclude in anxiety?

A

Hyperthyroidism, cardiac disease and medication induced anxiety

Medications that may induce anxiety- salbutamol, theophylline, corticosteroids, antidepressants and caffeine

133
Q

Management GAD?

A

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

134
Q

Drug treatment for GAD?

A

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

135
Q

Management panic disorder?

A

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

136
Q

Adverse effects of lithium?

A

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

137
Q

Monitoring of patients on lithium?

A

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

138
Q

What is somatisation disorder?

A

Multiple physical SYMPTOMS present for at least 2 years

Patient refuses to accept reassurance or negative test results

139
Q

What is illness anxiety disorder (hypochondriasis)?

A

Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer

Patient again refuses to accept reassurance or negative test results

140
Q

What is facticious disorder?

A

Also known as Munchausen’s syndrome

The intentional production of physical or psychological symptoms

141
Q

What is dissociative disorder?

A

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

142
Q

What are the two types of bipolar disorder?

A

Type 1- mania and depression

Type 2- hypomania and depression

143
Q

What is one way to differentiate mania/hypomania?

A

Mania has psychotic symptoms (delusions of grandeur or auditory hallucinations

144
Q

Management of bipolar disorder?

A

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

145
Q

How do benzos work?

A

Enhance the effect of GABA

146
Q

How long should benzodiazepines be used for?

A

2-4 weeks

147
Q

How to withdraw benzodiazepines?

A

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

148
Q

Features of benzodiazepine withdrawl syndrome?

A

May occur up to 3 weeks after stopping

Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Perspiration
Perceptual disturbances
Seizures

149
Q

How to remember GABA drugs function?

A

Benzodiazipines increase the frequency of chloride channels

Barbiturates increase the duration of chloride channel opening

150
Q

What are the factors suggesting a diagnosis of depression over dementia?

A

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

151
Q

What is the most common electrolyte disturbance in anorexia nervosa?

A

Hypokalaemia

152
Q

What are the features of anorexia nervosa?

A

Reduced body mass index

Bradycardia

Hypotension

Enlarged salivary glands

(Failure secondary sexual characteristics, cold intolerance, yellow skin)

152
Q

Physiological abnormalities of anorexia nervosa?

A

Hypokalaemia

Low FSH, LH, oestrogens and testosterone

Raised cortisol and growth hormone

Impaired glucose tolerance

Hypercholesterolaemia

Hypercaritonemia- yellow tinge on skin

Low T3

153
Q

What are the features of sleep paralysis?

A

Paralysis- occurs after waking up or before falling asleep

Hallucinations- images or speaking that occur during the paralysis

154
Q

Management of sleep paralysis?

A

If troublesome clonazepam may be used

155
Q

Pneumonic for PTSD?

A

HEART:
Hyperarousal
Emotional numbing
Avoidance of triggers
Re-experiencing
Time

156
Q

Features of PTSD?

A

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

157
Q

How long do symptoms have to be present for a diagnosis of PTSD?

A

4 weeks

158
Q

PTSD management?

A

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

159
Q

What are the types of acute dystonia from antipsychotics?

A

General muscle freezing

Torticollis

Oculogyric crisis

Managed with procyclidine

160
Q

What are some suicide risk factors?

A

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

160
Q

Increased risk of successful suicide factors?

A

Efforts to avoid discovery
Planning
Leaving a written note
Final acts such as sorting out finances
Violent method

161
Q

Suicide protective factors?

A

Family support

Having children at home

Religious belief

162
Q

What are the features of schizophrenia?

A

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’.

163
Q

What type of amnesia does ECT cause?

A

Retrograde amnesia

164
Q

ECT contraindication?

A

Raised ICP

165
Q

What are the short term side effects of ECT?

A

Headache
Nausea
Short term memory impairment
Memory loss of events prior to ECT
Cardiac arrhythmia

166
Q

Schizophrenia management?

A

Oral atypical antispychotics are first line
CBT offered to all patients
High risk of CVD in schizophrenia patients so check RFs

167
Q

What is a the condition where patient feel like they are infested with bugs?

A

Delusional parasitosis

168
Q

What electrolyte disturbance can bulimia nervosa cause?

A

Hypokalaemia

169
Q

What is De Clerambault’s syndrome (erotomania)?

A

Delution with an amourous quality. Believing a famous actor in love with you

170
Q

Metabolic side effects of antipsychotics?

A

Dysglycaemia, dyslipidemia and DM

171
Q

Which antipsychotics are bad for the extrapyramidal side effects?

A

Typical antipsychotics

Extrapyramidal side effects:
Parkinsonism
Acute dystonia- managed with procyclidine
Akathesia
Tardive dyskinesia

Haloperidol
Chorpromazine

172
Q

What are the atypical antipsychotics?

A

CORQA

Clozapine
Olanzapine
Risperidone
Quetiapine
Arripriprazole

173
Q

What are the typical antipsychotics?

A

Haloperidol

Cholpromazine

174
Q

Risk factors for GAD?

A

Aged 35-54
Being divorced or separated
Living alone
Being a lone parent

Protective
16-24
Married or cohabiting

175
Q

What is seasonal affective disorder?

A

Depression around winter

176
Q

Parkinson’s unilateral or bilateral?

A

Unilateral more likely to be Parkinson’s disease

Bilateral more likely to be drug induced Parkinsonism

177
Q

When to prescribe clozapine?

A

Treatment resistant schizophrenia- not responded to two different antipsychotics including one atypical

Treatment of persistent negative symptoms- efficacy in reducing negative symptoms

178
Q

Difference between serotonin syndrome and neuroleptic malignant syndome?

A

Serotonin syndrome
Faster onset
Reflexes- clonus, dilated pupils
Mx- cyprohepatadine, chlorpromazine

Neuroleptic malignant syndrome
Slower onset
Reflexes- lead pipe rigidity
Mx- dantrolene

179
Q

What electrolyte disturbances can long term lithium use cause?

A

Hyperparathyroidism which causes hypercalcemia

180
Q

Which medication is a deterrant that makes you ill if you drink alcohol?

A

Disulfiram

181
Q

What medication is anti craving for alcohol?

A

Acamprosate

182
Q

Which medications can be used as opiate replacement therapy?

A

Methadone- commonest

Buprenorphine- sublingual tablet less sedating than methadone

183
Q

What is the difference between the two types of bipolar disorder?

A

Type I disorder: mania and depression (most common)

Type II disorder: hypomania and depression

184
Q

What is the management for schizophrenics with poor medication compliance?

A

Give IM depot antispychotic injections

185
Q

Canvernous sinus syndrome vs posterior communicating artery aneurysm?

A

Posterior communicating artery aneurysm (pupil dilated)
= Think: 3rd nerve palsy = ptosis + dilated pupil

Cavernous sinus thrombosis
= absent corneal reflex + proptosis

186
Q

Wernicke’s and Korsakoff’s help? Remember can have it when drinking (smelling of alcohol)

A

COAT (Wernicke’s encephalopathy), RACK (Korsakoff’s syndrome)

Confusion
Ophthalmoplegia (nystagmus)
Ataxia
Thiamine deficiency

Retrograde amnesia
Anterograde amnesia
Confabulation
Korsakoff’s syndrome

187
Q

Can raised ICP cause dilated pupil?

A

Yes something like haematoma can give 3rd nerve palsy signs

188
Q

What are the basic investigations for infertility?

A

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)

189
Q

What should you give for tardive dyskinesia vs acute dystonia?

A

Tardive dyskinesia occurs after long term antipsychotic use

Tardive dyskinesia- terabenezine- both begin with T

Acute dystonia- procyclidine

Propanolol can be used for akathesia

190
Q

Is hyperprolactinemia more common with typical or atypical antipsychotics?

A

Typical

191
Q

What is tardive dyskinesia?

A

Face or body sudden movements you can’t control- chewing or pouting of the jaw

192
Q

Way to remember first rank symptoms of schizophrenia?

A

A - Auditory hallucinations –> 2nd and 3rd person

B - Broadcasting of thoughts, withdrawal, insertion

C - Controlled emotions and actions, passive impulsivity phenomena

D - Delusional perceptions

193
Q

What are Schneider’s first rank symptoms for schizophrenia?

A

Auditory hallucinations

Thought disorders

Passivity phenomena

Delusional perceptions

194
Q

How long does a normal grief reaction last?

A

Under 6 months

(another place says up to 12 months)

195
Q

What are the five stages of grief?

A

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

196
Q

What are the features of atypical grief reactions?

A

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

197
Q

What are the factors assocaited with a poor prognosis for schizophrenia?

A

Strong family history

Gradual onset

Low IQ

Prodromal phase of social withdrawal

Lack of obvious precipitant

198
Q

Does smoking cessation raise or reduce clozapine levels?

A

Raise

199
Q

When can chronic insomnia be diagnosed?

A

Diagnosed after 3 months, need to have trouble falling or staying asleep at least 3 nights per week

200
Q

What features are associated with insomnia?

A

Female gender
Increased age
Lower educational attainment
Unemployment
Economic inactivity
Widowed, divorced, or separated status

201
Q

Other risk factors for insomnia?

A

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

202
Q

Type 1 bipolar?

A

Mania and depression

203
Q

Type 2 bipolar?

A

Hypomania and depression

204
Q

Do antipsychotics cause dysregulation of glucose and DM?

A

Yes

205
Q

Electric shock sensations are seen in what type of withdrawl?

A

SSRI

206
Q

What are the symptoms of discontinuation syndrome?

A

(SSRIs)
Discontinuation Syndrome (FIRM STOP)
Flu like Sx
Insomnia
Restlessness
Mood swings
Sweating
Tummy problems (pain, cramps, D+V)
Off balance
Parasthaesia

207
Q

What is Charles-Bonnet syndrome?

A

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

208
Q

What to do for phimosis?

A

In children under 2 is normal and will resolve with time- may be bulging when they wee

209
Q

Lithium after dose change?

A

One week after dose change then weekly until stable

Once stable checked every three months

210
Q

Other antipsychotic side effects?

A

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)

211
Q

What is brief psychotic disorder?

A

Psychosis lasting less than a month with a subsequent return to baseline

212
Q

Clozapine blood monitoring?

A

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

213
Q

Can corticosteroids such as prednisolone cause psychosis?

A

Yes

214
Q

Perseveration

A

repeating the same words/answers

215
Q

Word salad

A

disorganised speech, sentences that do not make sense

216
Q

Neologism

A

making up new words

217
Q

Echolalia

A

repeating exactly what someone has said

218
Q

Circumstantiality

A

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.

219
Q

Tangentiality

A

refers to wandering from a topic without returning to it

220
Q

Clang associations

A

when ideas are related to each other only by the fact they sound similar or rhyme

221
Q

Knight’s move thinking

A

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

222
Q

Flight of ideas

A

a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them

223
Q

Sections of the mental state examination

A

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)

224
Q

Mechanism of each drug?

A

hfhd

225
Q

When can a patient be detained?

A

They have a mental disorder that poses significant
risk to themselves or others, and treatment in the
community is not possible because of this

226
Q

MH act powers?

A

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

227
Q

MH act holding powers?

A
  • 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

228
Q

MH act assessment powers?

A

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

229
Q

MH act police powers?

A

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

230
Q

What are the negative symptoms of schizophrenia?

A

Negative symptoms suggestive of schizophrenia include:

Incongruity/blunting of affect

Anhedonia (inability to derive pleasure)

Alogia (poverty of speech)

Avolition (poor motivation)

Social withdrawal

231
Q

Neuroleptic malignant syndrome treatment?

A

Bromocriptine or Dantrolene

232
Q

Weird side effect of lamotrigine?

A

Steven-Johnson syndrome

233
Q

How long to be a depressive episode?

A

2 weeks

234
Q

SSRI side effect?

A

Hyponatraemia

GI upset
Anxiety and agitation after starting

235
Q

Only absolute contraindication for ECT?

A

Raised ICP

236
Q

Serotonin syndrome treatment?

A

Supportive- IV fluids

Benzodiazepines

Severe cases managed with- cyproheptadine or chlorpromazine

237
Q

Causes of serotonin syndrome?

A

Causes

Monoamine oxidase inhibitors

SSRIs
St John’s Wort
Tramadol may also interact with SSRIs

Ecstasy

Amphetamines

238
Q

Features of serotonin syndrome?

A

Features

Neuromuscular excitation
hyperreflexia
myoclonus
rigidity

Autonomic nervous system excitation
hyperthermia
sweating

Altered mental state
confusion

239
Q

Does lithium cause hypothyroidism?

A

Yes

240
Q

What are the 3 P’s in Psychiatry formulation?

A

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

Phase 3a (17 decks)

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