Psychiatry Flashcards
1
Q
What is an acute stress disorder?
A
Occurs up to 4 weeks post stressful event:
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
2
Q
What is PTSD?
A
Occurs post 4 weeks post stressful event:
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
3
Q
Management of acute stress reaction?
A
- trauma-focused cognitive-behavioural therapy (CBT)
- BZD
- should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation
4
Q
What is the mechanism of alcohol on the central nervous system ?
A
Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
5
Q
Mecdhanism of alcohol withdrawl?
A
Loss of GAB mediated controll from alcohol
Activation of glutamate receptors
6
Q
What is the onset of delirium tremens?
A
48 -72 hours post
MUST BE THIS TIME
7
Q
Features of alcohol withdrawl?
A
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
48 - Delirium tremens
8
Q
Features of delirium tremens?
A
coarse tremor
confusion
delusions
auditory and visual hallucinations
fever
tachycardia
9
Q
Management of alcohol withdrawl?
A
- Chlordiazepoxide or diazepam reducing protocol
10
Q
What BZD is preferable in alcohol withdrawl if there is liver disease ?
A
Lorazepam
11
Q
What are the features of anorexia nevosa?
A
reduced body mass index
bradycardia
hypotension
enlarged salivary glands
12
Q
Physiological changes in anorexia nervosa?
A
hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
13
Q
Mechanism of typical antipsycotics?
A
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
14
Q
Mechanism of atypical antipsycotics?
A
Act on a variety of receptors (D2, D3, D4, 5-HT)
15
Q
Adverse effectcs of typical antipsychoatics?
A
Extrapyramidal side-effects
Hyperprolactinaemia common
16
Q
Adverse effects of atypical antipsychotics?
A
Extrapyramidal side-effects
Hyperprolactinaemia less common
Metabolic effects
- increased risk of stroke
- increased risk of venous thromboembolism
17
Q
What are extrapyradmial side effects of antipsychotics?
A
Parkinsonism
Acute dystonia
Sustained muscle contraction (e.g. torticollis, oculogyric crisis)
Akathisia (severe restlessness)
Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
18
Q
Treatment of acute dystonia?
A
Procyclidine
19
Q
What antipsycotics reduce seizure threshold?
A
Atypicals
20
Q
Pyrexia + Muscle stiffness + Antipsychotic?
A
Neuroleptic malignsant syndrome
21
Q
Why do antipsychotics cause hyperprolactinaemia?
A
due to inhibition of the dopaminergic tuberoinfundibular pathway
22
Q
Examples of aytpical antipsycoatics?
A
clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation
23
Q
Atypical antipsychotic associated with agranulocytosis?
A
Clozapine
24
Q
Side effect of clozapine?
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
25
Mechanism of BZD?
inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.
Enhances the effect of GABA
26
Side effects of BZD?
sedation
hypnotic
anxiolytic
anticonvulsant
muscle relaxant
27
Mechanism of barabituates?
barbiturates increase the duration of chloride channel opening
28
How to wean BZD?
should be withdrawn in steps of about 1/8
switch patients to the equivalent 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
29
Features of BZD withdrawl syndrome?
insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
perspiration
perceptual disturbances
seizures
30
Diagnostic criteria for body dysmorphia?
1. Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive
2. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
3. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)
31
Diagnostic criteria of bulimia nervosa?
1. Recurrent episodes of binge eating - (eat more than normal people eat in one session)
2. lack of control over eating during the episode
3. recurrent inappropriate compensatory behaviour in order to prevent weight gain
- Errosion of teeth
- Russels signs
4. Binge eating and compensatory behaviours both occur, on average, at least once a week for three months.
5. self-evaluation is unduly influenced by body shape and weight.
32
Management of bulimia nervosa?
bulimia-nervosa-focused guided self-help for adults
ineffective after 4 weeks of treatment, NICE recommend that we consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking
33
What is Charles Bonnet syndrome?
characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness
background of visual impairment
Insight is usually preserved
34
Risk factors for charles bonnet syndrome?
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
age-related macular degeneration, followed by glaucoma and cataract.
35
What is cotard syndrome?
believes that they (or in some cases just a part of their body) is either dead or non-existent
associated with severe depression and psychotic disorders.
36
What is De Clerambault syndrome?
paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
37
What is delusional parastiosis?
fixed, false belief (delusion) that they are infested by 'bugs' e.g. worms, parasites, mites, bacteria, fungus.
38
Features of depression in elderly?.
physical complaints (e.g. hypochondriasis)
agitation
insomnia
39
Management of depression in elderly?
SSRIs are first line (adverse side-effect profile of TCAs more of an issue in the elderly)
40
Features of depression over dementia?
short history, rapid onset
biological symptoms e.g. 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)
41
What are the screening questions for depression?
'During the last month, have you often been bothered by feeling down, depressed or hopeless?'
'During the last month, have you often been bothered by having little interest or pleasure in doing things?'
42
How should depression be tested?
Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).
43
HAD scale scores?
severity: 0-7 normal, 8-10 borderline, 11+ case
44
Patient Health Questionnaire (PHQ-9) scores?
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
45
Criteria for depression diagnosis?
1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
3. Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
8. Diminished ability to think or concentrate, or indecisiveness nearly every day
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
46
Indication for ECT ?
severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms
47
Side effects of ECT?
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
Long-term side-effects
some patients report impaired memory
48
Management of generalised anxiety disorder?
step 1: education about GAD + active monitoring
step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
49
Drug management in generaliosed anxiety disorder?
NICE suggest sertraline should be considered the first-line SSRI
If ineffecitve then SNRI:
duloxetine and venlafaxine
If cannot have SSRI or SNRI:
Pregablin
50
Management of 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
51
Drug management in panic disorder?
1. SSRI
2. No improvement in 12 weeks:
- Imipramine
- Clomipramine
52
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
53
Grief cycle?
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
54
Features of mania?
Lasts for at least 7 days - Causes severe functional impairment in social and work setting
May require hospitalization due to risk of harm to self or others
May present with psychotic symptoms
55
Features of hypomania?
A lesser version of mania
Lasts for < 7 days, typically 3-4 days. Can be high functioning and does not impair functional capacity in social or work setting
Unlikely to require hospitalization
Does not exhibit any psychotic symptoms
56
Pathophysiology of korsakoff's syndrome?
marked memory disorder often seen in alcoholics
thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
in often follows on from untreated Wernicke's encephalopathy
57
Features of korsakoff's syndrome?
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation
58
Features of wernicke encephalopathy?
Nystamus
Ophtalmoplegia
Ataxia
59
Mechanism of lithium?
interferes with inositol triphosphate formation
interferes with cAMP formation
60
Adverse side 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
61
When should a lithium level be taken?
12 hours post dose
62
What is the therapeutic range of lithium?
0.4 -1
63
How often should lithium levels be checked?
Every 3 months
64
Mehcnaims of MAOI ?
serotonin and noradrenaline are metabolised by monoamine oxidase in the presynaptic cell
65
Examples of non-selective MAOI?
e.g. tranylcypromine, phenelzine
66
Inidications for MAOI?
reatment of atypical depression (e.g. hyperphagia) and other psychiatric disorder
67
Adverse effects of MAOI?
hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
anticholinergic effects
68
Definition of an obsession?
An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind.
69
Definition of compulsion?
Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one's mind.
70
Treatment ofr mild OCD?
low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
If fails:
1. SSRI
2. More intensive therapy (ERP)
71
Treatment for moderate OCD?
offer a choice of either a course of an SSRI + ERP
consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
72
What SSRI should be used in body dysmorphia?
Fluoxetine
73
What is Othello's syndrome?
pathological jealousy where a person is convinced their partner is cheating
74
Cluster A personality disorders?
"Weird"
Paranoid
Schizoid
Schizotypal
75
Cluster B personality disorders?
"Wacky"
Antisocial
Borderline (Emotionally Unstable)
Histrionic
Narcissistic
76
Cluster C personality disorders?
*Anxious*
Obsessive-Compulsive
Avoidant
Dependent
77
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
78
Features of a schizoid personality disorder?
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
79
Features of schizotypical personality disorder?
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
80
Features of antisocial personality disorder?
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
81
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
82
Features of Histronic personality 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
83
Features of narcicisstic 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
84
Features of obsessive compulsive personality disorder?
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
85
Features of avoidant personality 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
86
Features of dependent 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
87
Post concussive syndrome?
headache
fatigue
anxiety/depression
dizziness
88
Management of PTSD?
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
venlafaxine or a selective serotonin reuptake inhibitor (SSRI),
89
How to assess post natal depression?
Edinburgh Postnatal Depression Scale may be used to screen for depression:
10-item questionnaire, with a maximum score of 30
indicates how the mother has felt over the previous week
score > 13 indicates a 'depressive illness of varying severity'
sensitivity and specificity > 90%
includes a question about self-harm
90
Strongest risk factor for schizophrenia?
Family history
91
First rank symptoms?
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'.
impaired insight
incongruity/blunting of affect (inappropriate emotion for circumstances)
decreased speech
neologisms: made-up words
catatonia
negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
92
Management of schizophrenia?
1. oral atypical antipsychotics are first-line
+
cognitive behavioural therapy should be offered to all patients
close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
93
Factors associated with poor prognsis in schizophrenia?
Factors associated with poor prognosis
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
94
Features of seasonal affective disorder?
Treat as depression
95
SSRI + Post MI?
Sertraline
96
Side effect of SSRI?
gastrointestinal symptoms are the most common side-effect
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
fluoxetine and paroxetine have a higher propensity for drug interactions
97
Side effect citalopram?
QT prolongation
98
Interactions of SSRI's?
NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: see above
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
99
How should an SSRI be stopped
Over 4 weeks
100
What SSRI has a high incidence of discontinuation symptoms?
Paroxetine
101
Features of discontinuation symptoms?
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
102
Pathophyusilogy of sleep paralysis?
paralysis that occurs as a natural part of REM (rapid eye movement) sleep.
103
Management of sleep paralysis?
if troublesome clonazepam may be used
104
Electrolyte distrbance from SSRI?
Hyponatraemia
105
High risk suicide?
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
106
Side effects of tricyclic antidepressants?
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval
107
More sedating Tricyclics?
Amitriptyline
Clomipramine
Dosulepin
Trazodone*
108
Less sedating tricyclics?
Imipramine
Lofepramine
Nortriptyline
109
Features of somatisiation disorder?
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
110
Features of illness anxiety disorder?
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
111
Features of conversion disorder?
typically involves loss of motor or sensory function
the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
112
Features of 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
113
Features of factitious disorder?
also known as Munchausen's syndrome
the intentional production of physical or psychological symptoms
114
Features of malingering disorder?
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
115
Baby blue duration?
5-7 days post
116
When is post natal depresisn most common?
Onset 1 months
Peak 3 months
117
What is couvade syndrome?
‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
118
?What is capragas?
characterised by a person believing their friend or relative had been replaced by an exact double.
119
Management of oculogyric crisis?
Procyclidine
120
Features of somatisation disorder?
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
121
Safest tic for overdose?
Lofepramine - the safest TCA in overdosage
122
Most dangerous TCI in overdose?
Dosulepin - avoid as dangerous in overdose
123
Atypical antipsychotic with highest risk of hyperlipidaemia?
Olanzopine
124
What drug should be avoided with SSRI?
Triptans
125
What receptors does atypical antipsyoctic block?
D2
Serotonin HT2
126
Excessive blinking
Tardive dyskinesia
