Psychiatry Flashcards
Define Bipolar disorder
A mood disorder characterised by episodes of depression and mania or hypomania
Aetiology of bipolar disorder?
Genetic factors: having a first degree relative affected with bipolar disorder increases an individual’s risk of developing bipolar and unipolar mood disorders, as well as schizoaffective disorder. It is a type of polygenic inheritance.
Environmental factors: environmental factors are not specific to this condition. Negative life events can trigger a manic or depressive episode
Neurobiological factors: increased dopamine activity may be important in the aetiology of mania.
Risk factors for bipolar disorder?
Genetic factors
Prenatal exposure to toxoplasma gondii
Premature birth <32 weeks gestation
Childhood maltreatment
Postpartum period
Cannabis use
What are the 2 main forms of bipolar disorder?
Bipolar I
Bipolar II
What is the difference between bipolar I and bipolar II?
Bipolar I: the person has experienced at least one episode of mania
Bipolar II: the person has experienced at least one episode of hypomania but not an episode of mania. They must also have experienced at least one episode
Describe the features of mania
ICD 10:
Elevated mood out of keeping with the patient’s circumstances
Elation accompanied by increasing energy resulting in overactivity, pressure of speech and a decreased need for sleep
Inability to maintain attention, often marked with distractibility
Self esteem which is often inflated with grandiosity and increased confidence
Loss of normal social inhibitions
The manic episode should last for at least 7 days and have a significant negative functional effect on work and social activities.
Describe the features of hypomania
Less severe than mania and is characterised by an elevation
Management of bipolar disorder?
Acute manic episode: atypical antipsychotic eg olanzapine or risperidone OR 2nd line try sodium valproate
Depressive episodes: avoid antidepressant as could cause rapidly cycling moods → try atypical antipsychotic eg olanzapine or quetiapine
General Maintenance:
1st line= lithium
Patients must not drive during an acute episode & must inform DVLA of diagnosis
CBT can be used as a psychological therapy
Define depression
Low mood lasting >2 weeks
Signs and symptoms of depression?
Core triad: low mood, anhedonia, anergia
Slow speech, withdrawn, sleep problems, change in appetite/libido, diurnal mood variation, agitation, guilt, hopelessness
Investigations for depression?
PHQ-9 Questionnaire
<4= none
5-9= mild
10-14= moderate
15-19= severe
>20= severe
Risk assessment: self harm and suicide
Bloods: rule out other causes of tiredness eg anaemia or hypothyroidism
Management of depression?
Mild: watch & weight w/ group CBT, individual self help etc
Moderate/Severe: SSRIs eg sertraline or citalopram if these are unsuccessful try SNRIs eg venlafaxine
Define GAD?
Excessive anxiety about a number of situations associated w/ heightened tension for >6 months
Define agoraphobia?
Fear of public spaces or fear of entering public spaces which immediate escape would not be possible. Marked avoidance of at least 2 of: crowds, public spaces, travelling alone, travelling away from home
Define social phobia?
Fear of social situations which may lead to embarrassment or humiliation or scrutiny or criticism from other people
Define panic disorder?
Acute attacks which are unpredictable in nature and not restricted to any particular circumstance or situation. Often first present to A&E
Symptoms of GAD?
Mental: restlessness, poor concentration, fatigue, irritability, nervousness, fear of losing control
Physical: increased muscle tension, light headedness, palpitations, tachycardia, GI disturbance, breathing difficulties, chest pain, sweating
Investigations for GAD?
GAD-7:
<4= normal
5-9= mild
10-14= moderate
15+= severe
Bloods/ECG= to rule out other causes
Management of GAD?
Psychoeducation and explaining GAD to the patient
Self help or psychoeducational groups
CBT
Medication:
SSRIs (sertraline or citalopram) or SNRIs (duloxetine)
Specialist input if cannot tolerate medication or medication/CBT not working
Define OCD?
Characterised by obsessive thoughts and compulsive acts that cause functional impairment and/or distress
What other conditions are associated with OCD?
Depression, schizophrenia, anorexia, tourette’s
Signs and symptoms of OCD?
Obsessive thoughts: patient’s own thoughts. Unpleasant, repetitive, intrusive and irrational thoughts that are regarding sexual or blasphemous subjects or surrounding death.
Compulsions: Repetitive behaviours or mental acts that the patient cannot resist performing and may be overt or covert → washing, checking, contamination, fears, doubts, symmetrical insistence, aggressive thoughts
Diagnostic criteria for OCD?
- obsession and/or compulsion
- time consuming
- causes distress or the patient knows it is unreasonable
Management of OCD?
Mild: low intensity psychological intervention eg CBT or ERP, may consider SSRI
Moderate: SSRI & high intensity psychological intervention.
Severe: refer to specialist and combine SSRI with ERP & CBT
Define PTSD?
Heightened state of stress occurring after a traumatic event or lots of little traumatic events and must occur over >4 weeks
Signs and symptoms of PTSD?
HEAR:
Hyperarousal, emotional numbing, avoidance, intrusive recollections
others may notice depression, drug/alcohol misuse, anger issues
Management of PTSD?
<4 weeks: acute stress reaction- watch & wait
1st line: (1 month after trauma) trauma focused CBT
1st line (3 months after trauma or 2nd line): EMDR
Define schizophrenia?
Splitting of thoughts or loss of contact with reality, affecting thoughts, perceptions (sight, smell, taste, touch, sounds), mood, personality, speech etc
Epidemiology of schizophrenia?
onset typically 2nd-3rd decade and second peak in middle age
Risk factors for schizophrenia?
family hx, black Caribbean ethnicity, migrated, live in urban environment, cannabis use
1st rank schizophrenia symptoms?
Auditory hallucinations: talking about the patient, thought echo or commenting on the patient’s behaviour
Thought disorders: thought insertion, thought withdrawal, thought broadcasting
Passivity phenomena: bodily sensations controlled by something else, actions, impulses or feelings controlled by others
Delusional perception: normal object perceived and then intense delusional insight into the object’s meaning
2nd rank schizophrenia symptoms?
Auditory hallucinations: 2nd person hallucinations, hallucinations in any other modality
Negative symptoms: incongruity, blunting of affect, amotivation, poverty of speech, poverty of thought, self neglect, lack of insight, anhedonia
Delusions: delusions of reference, paranoid or accusatory delusions
Investigations and diagnosis of schizophrenia?
Bloods- rule out other causes & ECG
Diagnosis: 1x first rank symptoms and 2x 2nd rank symptoms for >1 month
Management of schizophrenia?
1st line: atypical antipsychotics eg olanzapine, quetiapine
CBT: to modify CVD risk factors due to behaviours like smoking and links with antipsychotic medication
DVLA: must inform DVLA and must not drive until symptoms have been resolved for 3 months + letter from psychiatrist
Definition of personality disorders?
Life long, ingrained, maladaptive behaviours that characterises an individual and deviates markedly from cultural or accepted norm with onset in early childhood or late adolescence
What are the type A personality disorders?
(Mad)
Paranoid
Schizoid
Schizo-typal
What are the type B personality disorders?
(Bad)
Antisocial personality disorder
Borderline/EUPD
Histrionic
Narcissistic
What are the type C personality disorders?
(Sad/Anxious)
Avoidant
Dependant
OCPD (anankastic)
Describe EUPD/Borderline personality disorder?
Instability in relationships
Instability in self image
Impulsivity- sex, money, eating
Repetitive suicide/self harm
Frantic efforts to avoid abandonment
Describe typical/1st gen antipsychotics?
Principally antagonise dopamine D2 receptors, having an immediate quietening effect and have a good effect on positive symptoms
Haloperidol, Chlorpromazine
Describe atypical/2nd gen antipsychotics?
Have lower D2 receptor affinity but also cause an additional block of 5-HT receptors so better at controlling positive and negative symptoms
Side effects more typical of 1st gen/typical antipsychotics?
Acute dystonia- sustained muscle contraction
Akathisia- severe restlessness
Tardive dyskinesia- abnormal & involuntary. Has late onset and involves chewing/pouting jaw
Parkinsonism- tremor & bradykinesia
Mx of s/e: Valbenazine/Tetrabenazine
General treatment: procyclidine (anticholinergic)
Side effects more typical of 2nd gen/atypical antipsychotics?
Reduced seizure threshold
Metabolic syndrome- weight gain and poor glucose control/diabetes
Olanzapine gives most weight gain
Risperidone gives most hyper-prolactinaemia
Side effects of both types of antipsychotics?
ACh block- dry mouth, diplopia, blurred vision
Sedation
Prolongation of QT interval
Increased prolactin due to D2 block → gives galactorrhoea and amenorrhoea
SIADH
Postural hypotension
Describe paranoid personality disorder
Excessive sensitivity to insults, unforgiving of insults, perceiving neutral or friendly actions as hostile, recurrent suspicions without justification, often regarding sexuality of spouse or infidelity, often obsessive self reference and self obsession
Describe schizoid personality disorder
Characterised by withdrawal from social and affectionate company, preferring own company, fantasies and solitary introspection. Limited capacity to express feelings or experience pleasure.
Describe dissocial personality disorder
Characterised by disregard for social norms, social obligations and others’ feelings. Disparity between behaviour and social norms. Behaviour is not easy to change, even by punishment. Low tolerance for frustration & quick to anger, especially to violence. Tendency to blame others
Describe emotionally unstable personality disorder
Characterised by tendency to act impulsively and without thought of consequences. Incapacity to control emotions or behavioural outbursts.
Impulsive type- emotional instability & impulsivity.
Borderline type- disturbances in self image, aims and and internal preferences. Intense and unstable relationships. Frequent suicide attempts & gestures.
Describe histrionic personality disorder
Characterised by shallow and labile affectivity, self-dramatization, theatricality, exaggerated expressions of emotions, suggestibility, self indulgence, need to be centre of attention, constant searching for excitement and attention
Describe anankastic personality disorder
(OCPD)
Characterised by perfectionism, feelings of doubt, excessive conscientiousness, checking and preoccupation with details, stubbornness, rigidity, & caution.
Describe anxious/avoidant personality disorder
Characterised by feelings of tension, apprehension, insecurity and inferiority. Continuous yearning to be liked and accepted, a hypersensitivity to rejection or criticism. A tendency to avoid certain activities by habitual exaggeration of the dangers
Describe dependent personality disorder
Characterised by passive reliance on other people to make their minor and major life decisions. Great fear of abandonment, feelings of helplessness and incompetence, passive compliance with the wishes of elders and others and a weak response to daily life and demands.
Signs and symptoms of opioid overdose/misuse?
Rhinorrhoea, needle track marks, pinpoint pupils, respiratory depression, drowsiness, watering eyes, yawning
Management of opioid misuse/overdose?
Acute overdose: IV/IM naloxone
Opioid withdrawal: methadone, buprenorphine
Relieve withdrawals: iofexidine
Prevent relapse: naltrexone
Define delirium tremens?
Up-regulation of NMDA receptors and down regulation of GABA receptors → leading to CNS hyperexcitability
Signs and symptoms of delirium tremens?
Cognitive impairment, Lilliputian hallucinations (little people), paranoid delusion, tremor, fever, tachycardia, sweating, dehydration
Management of delirium tremens?
Acute:
1st line= IV Pabrinex, long acting BZDs eg chlordiazepoxide, lorazepam in hepatic failure & IM haloperidol if psychotic features
Nil acute:
Disulfiram- gives bad sx when drinking
acamprosate- reduces cravings
naltrexone- reduces pleasure
CBT, motivational meetings, AA, family support
Therapeutic/ toxic range of lithium?
Normal therapeutic range: 0.4-1.0mmol/L and is excreted renally
Toxicity is >1.5mmol/L
Risk factors for lithium toxicity?
Dehydration, renal failure, drugs - ACEi, ARBs, metronidazole, especially thiazides.
Signs and symptoms of lithium toxicity?
TOXICC
Tremor
Oliguric renal failure
Ataxia
Increased reflexes
Convulsions
Coma
Consciousness reduced
Management of lithium toxicity?
Stop lithium immediately
High fluid & IV NaCl
Can use sodium bicarb
If severe- dialysis
When should lithium levels be measured?
12 hours after the dose
Define serotonin syndrome
High synaptic concentration of serotonin
Causes of serotonin syndrome?
Normally when a serotonergic medication is given to a patient and they are already taking one, can rarely occur if patient is switching medications and don’t have a long enough ‘wash out’ period. Or seen in accidental child drug overdosing.
SSRIs
SNRIs
Opioids
MAOi
Lithium
TCAs
St John’s wort
Stimulants eg amphetamines
Signs and symptoms of serotonin syndrome?
Neuromuscular excitation- hyperreflexia, myoclonus & rigidity.
Autonomic NS excitation- hyperthermia & sweating
Altered mental state- confusion, hallucinations
Management of serotonin syndrome?
Stop medications responsible
Supportive treatments- IV fluids & BZDs
Severe cases- serotonin antagonist eg chlorpromazine or cyproheptadine
SSRI overdose- activated charcoal
Differential diagnosis for serotonin syndrome?
Neuroleptic malignant syndrome - WCC will be ↑ in this but normal in serotonin syndrome
How long does a section 2 last?
28 days
What is the purpose of a section 2?
to assess and treat a patient (without their consent)
Which professionals are involved in a section 2?
2x doctor & AMHP
What are the requirements for a section 2?
Patient must be suffering from a mental disorder that requires them to be detained in hospital for assessment and they must be detained for their own health and safety and/or that of others
How long does a section 3 last?
6 months (can be renewed)
What is the purpose of a section 3
For treatment
Which professionals are involved in enacting a section 3?
2x doctors and an AMHP
What is the purpose of a section 3?
Patient must be suffering from a disorder that requires them to be in hospital and the treatment is in their best interest for their health and safety and the protection of others AND appropriate treatment must be available
How long does a section 4 last?
72 hours
What is the purpose of a section 4?
It is an emergency order where waiting for a second doctor would lead to undesirable delay
Which professionals are involved in a section 4?
1x dr and 1x AMHP
What are the requirements for a section 4?
Patient must be suffering from a disorder that requires them to be in hospital for assessment and patient must be detained for their own safety and that of others and there is not enough time for a second doctor to attend
How long does a section 5(4) last?
6 hours
What is a section 5(4)?
For a patient already admitted in either a general or psychiatric hospital but wants to leave- allows nurses to keep patient in hospital until doctor can attend BUT cannot be treated coercively under this power.
How long does a section 5(2) last?
72 hours
What is a section 5(2)?
Doctors’ holding power. Allows doctors to detain a patient in hospital (must already be admitted) in order to allow enough time for a section 2 or 3 assessment. Cannot be treated coercively under this section.
What is a section 136?
Police section lasting 24 hours for a person suspected of having a mental disorder in a public place.
What is a section 135?
A police section lasting 36 hours needing a court order to remove a patient to either a place of safety (police cell/psychiatric unit) or for further assessment (section 2 or 3)
Side effects of MAOIs?
Cheese- react with tyramine rich foods eg cheese causing a hypotensive tension
Extensive drug interactions
Side effects of tricyclic antidepressants?
Anticholinergic effects
Overdose can lead to seizures
Side effects of SSRIs?
GI upset- N&V
Agitation, anxiety, akathisia
Sexual dysfunction
Insomnia
Hyponatraemia
Signs and symptoms of neuroleptic malignant syndrome?
Tremor, muscle cramps, fever, autonomic instability, delirium
Key investigation finding in neuroleptic malignant syndrome?
Creatinine kinase will always be raised- if not raised, is not NMS
Side effects of clozapine?
Agranulocytosis (monitoring needed), hypersalivation and constipation
Side effects of atypical antipsychotics?
QT prolongation
Weight gain
Reduced seizure threshold 0
Orthostatic hypotension
Sexual dysfunction
Difference between atypical and typical psychotics?
Both very similar and no difference in efficacy
Typical have a smaller therapeutic window
Atypical have a larger therapeutic window
