Psychiatry Flashcards
Mental state exam acronym?
ASEPTIC:
Appearance and behaviour
Speech
Emotion (mood and affect)
Perception
Thought (form and content)
Insight
Cognition
Screening tools for depression?
HAD scale
PHQ-9
Criteria for major (severe) depressive disorder?
≥ 5 depressive symptoms for ≥ 2 weeks
List core and additional features of depression?
Core = low mood, anhedonia, anergia
Insomnia
Weight change
Suicidal ideation
Psychosis
Conservative management options for depression?
Guided self-help
Mindfulness
Cognitive behavioural therapy (CBT)
Drug options for depression?
1st line = SSRI (fluoxetine preferred)
2nd line = different SSRI
3rd line = SNRI, mirtazapine, MAOI, TCA
How long should antidepressants be continued after symptoms improve for first episode vs recurrent?
First = 6 months (minimum)
Recurrent = 2 years (minimum)
When should patients < 25 be reviewed after starting an antidepressant?
1 week
Poor prognostic factors in suicide risk assessment?
PMH self-harm/previous attempts
Other mental health disorders
Alcohol or illicit drug abuse
Planned attempt e.g. left a note
Lack of social support network
SSRI examples and mechanism of action?
Examples = fluoxetine, sertraline, citalopram, escitalopram, paroxetine
Mechanism of action = inhibits 5-HT re-uptake in the pre-synaptic terminal
List some SSRI side effects?
GI upset
Dizziness
Loss of libido
Dry mouth/blurry vision
SIADH → hyponatraemia
Medications SSRIs should not be taken with and why?
NSAIDs, anticoagulants, antiplatelets = bleeding risk
Serotonergic agents e.g. triptans = serotonin syndrome
Withdrawal regime for SSRIs?
Gradually reduce dose over 4 weeks
SSRI with longest half-life?
Fluoxetine
Only SSRI licensed for children?
Fluoxetine
SSRI used in patients with CVD?
Sertraline
SSRIs with low plasma:milk ratio?
Paroxetine
Sertraline
SSRIs most strongly linked to QT prolongation?
Citalopram
Escitalopram
Are SSRIs safe in pregnancy?
Generally, yes
→ risk of heart defects (1st trimester) and PPHN (3rd trimester)
→ paroxetine linked to congenital malformations (1st trimester)
List features of serotonin syndrome.
Tachycardia/tachypnea
Hyperhydrosis
Mydriasis
Tremor
Hyperreflexia
Myoclonus/clonus
SNRI examples and mechanism of action?
Examples = venlafaxine, duloxetine
Mechanism of action = inhibits 5-HT and NA re-uptake in the pre-synaptic terminal
TCA examples and mechanism of action?
Examples = amitriptyline, clomipramine, imipramine
Mechanism of action = inhibits 5-HT and NA re-uptake in the pre-synaptic terminal
Tetracyclic antidepressant example and mechanism of action?
Example = mirtazapine
Mechanism of action = blocks post-synaptic 5-HT and NA receptors
MAOIs examples and mechanism of action?
Examples = selegiline, phenelzine, isocarboxazid
Mechanism of action = prevents monoamine breakdown by monoamine oxidases
Antidepressant used if sedation or weight gain is desired?
Mirtazapine
Antidepressant linked to hypertensive crisis with tyramine-containing food e.g. cheese?
MAOIs (e.g. phenelzine)
Antidepressant linked to hypertension?
SNRIs (e.g. venlafaxine)
Indications for ECT and only contraindication?
Severe depression (e.g. catatonia), severe mania and severe psychosis
Raised ICP
What is bipolar I and bipolar II?
I = mania + depression
II = hypomania + depression
Criteria for bipolar disorder?
≥ 2 episodes of depression or mania/hypomania lasting ≥ 2 weeks
→ 1 episode MUST be mania/hypomania
What is mania vs hypomania? Give features that distinguish them?
Mania = elevated mood/behaviour for ≥ 7 days
→ distinguished by psychotic symptoms and severe functional impairment
Hypomania = elevated mood/behaviour for ≥ 4 days
Acute management of mania vs bipolar depression?
Mania = oral or IM antipsychotic, IM BZD
Depression = fluoxetine + olanzapine or other antipsychotic monotherapy
Long-term drug options for bipolar disorder?
1st line = lithium
2nd line = sodium valproate
Lithium starting regime?
Bloods 12 hours post-dose
Aim for 0.4-1.0 mmol/L
Bloods every week until stable
→ every 3 months
→ every 6 months (after 1 year)
Side effects of lithium at therapeutic vs toxic dose?
Therapeutic = fine tremor, GI upset, polyuria/polydipsia, thyroid dysfunction
Toxic = coarse tremor, seizures, arrhythmias
Congenital cardiac abnormality associated with maternal lithium use?
Ebstein’s anomaly (tricuspid valve defect)
Extra screening requirements for lithium and why?
Weight = weight gain
U&Es = nephrotoxic
TFTs = hypothyroid
Ca2+ = hyperparathyroid
ECG = QT prolongation
Typical (1st gen) antipsychotic examples and mechanism of action?
Examples = haloperidol, chlorpromazine, prochloperazine
Mechanism of action = D2-receptor antagonists
Atypical (2nd gen) antipsychotic examples and mechanism of action?
Examples = olanzapine, clozapine, quetiapine, risperidone, aripiprazole
Mechanism of action = D2 and 5HT-receptor antagonists
What do typical antipsychotics have a higher risk of? Give some examples?
Extra-pyramidal side effects:
→ acute dystonia
→ parkinsonism
→ tardive dyskinesia
→ akathisia
Management of acute dystonia vs tardive dyskinesia?
Acute dystonia = procyclidine
Tardive dyskinesia = tetrabenazine
Major dopamine pathways and features of inhibition?
Mesolimbic = less hallucinations and delusions (desired therapeutic effect)
Mesocortical = low mood
Tuberoinfundibular = hyperprolactinaemia
Nigrostriatal = extra-pyramidal side effects
Antipsychotic side effects (other than extra-pyramidal)?
Weight gain
Sedation
QT prolongation
Anticholinergic e.g. dry eyes
Lower seizure threshold
Impaired glucose tolerance
Hyperprolactinaemia
Life-threatening complications of clozapine?
Neutropenia
Agranulocytosis
Reduced seizure threshold
Antipsychotics with highest risk of dyslipidaemia and obesity?
Olanzapine
Clozapine
Antipsychotic most requiring ECG monitoring for QT prolongation?
Haloperidol
Antipsychotic with highest and lowest risk of hyperprolactinaemia?
Highest = risperidone
Lowest = aripiprazole
Option for patients with poor antipsychotic compliance?
Depot injections
Risk of using antipsychotics in the elderly?
VTE and stroke
List core and additional features and management of schizophrenia?
Core = hallucinations (mainly 3rd person auditory), thought disorder, delusions, passivity phenomena
Blunted affect
Anhedonia
Social withdrawal
Management = CBT + antipsychotic
Poor prognostic factors for schizophrenia?
Family history
Low IQ
Gradual onset
Prodromal social withdrawal
Features and manegement of psychosis?
Hallucinations
Delusions
Thought disorders
Lack of insight
Management = CBT + antipsychotic
Delusion that own self or body part is dead, dying or non-existent?
Cotard’s syndrome
De Clerambault’s and Othello’s syndromes?
De Clerambault’s = delusion that famous person is in love with you
Othello’s = delusion partner is cheating on you without any evidence
Charles-Bonnet syndrome and major cause?
Complex hallucinations in a patient with no psychiatric distrubance/preserved insight
Visual impairment e.g. cataracts
Typical onset of puerperal psychosis and management?
Within 2 weeks of birth
Management = inpatient admission + antipsychotic/lithium/ECT
Typical onset of postpartum depression and management?
Up to 1 year after birth
Management = paroxetine or sertraline
Typical onset of baby blues and management?
3-7 days after birth
Management = support and reassurance
Criteria for GAD?
≥ 6 months of non-situational anxiety
Conservative management options for GAD and panic disorders?
Psychoeducation
CBT
Drug options for GAD?
1st line = SSRI (sertraline preferred)
2nd line = different SSRI or SNRI
3rd line = pregabalin
Beta blockers are also useful for somatic symptoms e.g. tremor, hyperhidrosis
Drug choices for panic disorders?
1st line = SSRI
2nd line = imipramine or clomipramine
Conservative management option for OCD?
CBT with exposure response therapy (ERT)
Drug options for OCD?
1st line = SSRI
2nd line = clomipramine
List features of PTSD?
HARD:
→ hyperarousal/hypervigilance
→ avoidance
→ re-living
→ dull/detached
Conservative management options for PTSD?
Trauma-focused CBT
Eye movement desensitisation and reprocessing (EMDR)
Drug options for PTSD?
1st line = SSRI or venlafaxine
2nd line = risperidone
Features and management of acute stress disorder?
PTSD-like symptoms presenting within 1 month of incident
1st line = trauma-focused CBT
2nd line = short-term BZD
Screening tool for eating disorders?
SCOFF
BMI criteria for malnourishment?
BMI < 18.5
Biochemical features of anorexia?
Most things low apart from 3 Gs & Cs:
Glucose
Growth hormone
Salivary glands
Cortisol
Cholesterol
Carotene
Outline the pathophysiology of re-feeding syndrome?
- Starvation causes insulin decrease and PO4, K and Mg movement out of cells into plasma
- Re-feeding causes rapid insulin increase and PO4, K and Mg movement back into cells leads to multi-organ complications
Typical onset of re-feeding syndrome and first biochemical sign?
48-72 hours after re-feeding begins
Hypophosphataemia
Re-feeding syndrome guidance?
If patient has not eaten for > 5 days, re-feed at no more than 50% of requirements for the first 2 days
Complications of vomiting and laxative abuse?
Vomiting = metabolic alkalosis from loss of H+ in stomach
Laxative abuse = metabolic acidosis from loss of HCO3 in diarrhoea
Initial management of eating disorders in children vs adults?
Children = family therapy
Adults = CBT-ED
SSRI used for co-morbid depression/OCD in eating disorders and when to avoid?
Fluoxetine
Electrolyte imbalance and bradycardia
Weekly weight gain goal for anorexia nervosa?
0.5kg/week
Core features of ADHD?
Hyperactivity
Inattention
Impulsivity
Drug options for ADHD?
Only available for children > 5
→ 1st line = methylphenidate
→ 2nd line = lisdexamfetamine
Monitoring of children on ADHD medication?
Prior = ECG
6 monthly = height and weight
Features of ASD?
Impaired communication
Impaired social interaction
Repetitive behaviours
Intense focus on interests
Management of ASD?
Educational support
Behavioural therapy
Family counselling
Medical therapy
Cluster A, B and C personality disorders?
A = odd or eccentric
B = dramatic, emotional or erratic
C = anxious and fearful
Suspicious of others, hypersensitive, bears grudges?
Paranoid PD
Apathetic, solitary, few interests?
Schizoid PD
Odd and eccentric behaviour, lack of friends, suspicious of others?
Schizotypal PD
Irresponsible, dangerous, shows no remorse?
Antisocial PD
Unpredictable, unstable relationships, emotional outbursts?
Borderline PD
Shallow, dramatic, sexually suggestive?
Histrionic PD
Self-absorbed, arrogant, uses people?
Narcissistic PD
Perfectionist, stubborn, inflexible?
Obsessive-compulsive PD
Fears rejection, low self-worth, socially isolated?
Avoidant PD
Needy, submissive, lacks initiative?
Dependent PD
Management of personality disorders?
Dialectical behaviour therapy
Emergency detention (Section 5(4)) timescale, who is involved and can you provide treatment?
Up to 72 hours
FY2 or above +/- MHO
Can’t provide treatment unless emergency (form T4 required)
Short-term detention (Section 2) timescale, who is involved and can you provide treatment?
Up to 28 days
Psych reg/consultant + MHO
Can provide treatment (care plan not required)
CTO (Section 3) timescale, who is involved and can you provide treatment?
Up to 6 months
Psych reg/consultant + MHO
Can provide treatment (only medications on care plan)
Screening tools for alcohol dependency?
AUDIT
FAST
Pharmacology of alcohol withdrawal and list features?
Decreased GABA (inhibitory) and increased glutamate (excitatory) activity:
Tachycardia/tachypnea
Hyperhydrosis
Mydriasis
Seizures
Psychological disturbance
When do symptoms of alcohol withdrawal begin, peak incidence of seizures and delirium tremens?
Begin 6-12 hours after last drink
Seizures peak at 12-48 hours
Delirium tremens 48-72 hours
Acute drug options for stable vs unstable alcohol withdrawal?
Stable = chlordiazepoxide + pabrinex (thiamine)
DT or seizure = short-acting BZD e.g. lorazepam
Long-term management of alcohol addiction?
1st line = CBT
2nd line = acamprosate, naltrexone, disulfiram
Main role of thiamine?
Co-enzyme in glucose metabolism
How does alcoholism reduce thiamine levels?
- Inhibits conversion to active form (thiamine pyrophosphate)
- Reduces duodenal absorption
- Cirrhosis affects storage
Wernicke’s encephalopathy and Korsakoff syndrome triads?
Wernicke’s = altered mental state, ophthalmoplegia, nystagmus and ataxia
Korsakoff = anterograde amnesia, retrograde amnesia and confabulation
BZD examples and mechanism of action?
Examples = diazepam, lorazepam, midazolam
Mechanism of action = increases GABA-A receptor affinity for GABA
Examples of a short and long-acting BZDs?
Short = midazolam, lorazepam
Long = diazepam, chlordiazepoxide
BZDs not metabolised by the liver?
Out The Liver:
→ oxazepam
→ temazepam
→ lorazepam
BZD maximum duration of treatment?
2-4 weeks
BZD withdrawal regime?
Switch to equivalent dose of diazepam
→ reduce by 1/8th of the daily dose every fortnight
Opiate vs opioid and give examples?
Opiate = natural compound derived from poppies
→ opium, morphine, codeine
Opioid = semi or fully synthetic subset of opiates
→ heroin, methadone, oxycodone
Drug options for opioid replacement?
1st line = methadone, buprenorphine, suboxone (buprenorphine + naloxone)
2nd line = lofexidine
Criteria for insomnia?
Trouble falling asleep for ≥ 3 nights/week for > 3 months
Advice for drug management of insomnia and options?
Only if daytime impairment is severe
Use lowest dose for shortest time
1st line = short-acting BZD or Z-drug
Z-drug examples and mechanism of action?
Examples = zopiclone, zolpidem and zaleplon
Mechanism of action = increases GABA-A affinity for GABA
Multiple physical symptoms present for > 2 years with no organic cause found?
Somatisation disorder
Persistent belief of having a certain disease e.g. cancer?
Hypochondriasis (illness anxiety disorder)
Loss of motor or sensory function with no organic cause found?
Conversion disorder
IQ cut offs for mild, moderate, severe and profound learning disability?
Mild = less than 70
Moderate = 35-50
Severe = 20-34
Profound = less than 20
