Psychiatry Flashcards
what is the definition of psychosis?
an individual is experiencing a reality different to everyone else (the individual does not realise they are psychotic)
name some symptoms of psychosis.
- hallucinations
- delusions
- formal thought disorder
- disorders of one self
what is a hallucinations?
the perception of an object in the absence of an external stimulus (in clear consciousness) that others cannot percieve
what type of hallucination is most common in psychosis?
auditory hallucination
what can olfactory halucination indicate?
frontal lobe pathology
what is pseudohallucination ?
‘hearing voice in my head’ - not psychosis!!
hallucinations are external, not internal
what is the likely diagnosis when someone is visually hallucinating?
delirium - usually a organic pathology
what is a delusion?
fixed, firmly held beleif that is false , that cannot be reasoned away, that is held despite evidence to the contrary is out of keeping with the persons sociiocultural norms
what are teh types of delusions?
persecutory (believe ppl coming after you)
grandiose (think your’e amazing)
reference (about urself)
erotomanic (think someones in love with you)
hypochrondriacal (health anxiety)
nihilistic (feeling you are dead)
bizarre (absolute not possible )
control (think someone/thing is controlling you)
what is formal thought disorder?
a problem of speech (+ flow of thought) which means each sentence doesnt follow on from the next
what is disorders of the self?
when an individual can no longer distinguish between themself and the world
icnludes:
- thought insertion
- thought broadcasting
- passivity phenomena
what organic disorders must you rule out in psychosis?
- delirium
- dementia
- infection
- endocrine disorders
- TLE
name the three types of functional psychosis?
- schizophrenic (bizarre, persecutory, 3rd person)
- manic (graniose, 2nd person)
- depressive (guilt, poverty, nihilism, 2nd person)
what is shcizophrenia?
a disorder or group of disorders charatcerised by psychotic episodes (positive symptoms) and negative symptoms
symptoms seen in schizophrenia (5 a’s)
Autism
flat Affect (or incongruous)
Ambivalence
loosening of Associations (thought disordeR)
Amotivation or Apathy
name schneiders first rank symptoms for schizophrenia
- hearing ones own thouhgts spoken alou d
- hallucinatory voices in form of statment + reply, pt hears voices speaking about them in 3rd person
- hallucinatory voices in running commentary
- thought broadcasting
- thought withdrawal , thought insertion
- influence of others on feelins, drive and volition of common events
- delusional perception
prevalence of schizophrenia in Uk?
1%
name some causes ??? of schizophrenia
- role of family/upbringing
- obstetrics complications (forcep delivery)
- winter births
- illicit drugs (amphetamines, cannabis)
- genetics (higher incidence in genetic twins)
how to know whether to treat a pt with schizophrenia informally or section them ?
- dependds on risk and insight
low or high risk
if they understand they have schizophrenia then more likely to take drugs
how to do a biopsychosocial assessment of schizophrenia??
bio: blood tests, drug tests, CT - rule out organic problem, check compliance
psycho: MSE, collateral Hx
social: carers and housing
biopsychosocial Tx of schizophrenia?
bio: antipsychotics
psycho: supportive counselling, family therapy
social: debts, benefits, housing, CPN, social worker
name the types of mood disorders
- depressive disorder
- bipoalr disorder
- persistant mood disorder
what are the core symptoms of depression?
- continuous low mood for at least 2 wks
- lack of energy
- lack of enjoyment/interest (anhedonia)
what are the somatic/biological symptoms of depression?
- sleep changes
- appetite and weight changes
- diurnal variation of mood (mornings are worst)
- psychomotor retardation/agitation (dont bother getting up)
- loss of libido
what are the cognititve symptoms of depression>
- low sefl esteem
- guilst/self blame
- hopelessness
- hypochondrical thoughts
- poor concentration/attention
- suicidal thoughts
diagnosis of depression (mild, moderate, severe, severe with psychotic symptoms)
mild - 2 core + 2 others (abel to function)
moderate - 2 core + 3/4 others
severe - 3 core + at least 4 others
severe with psychotic symptoms (auditory hallucinations, delusions)
what is the incidnece of PND?
10-15% within 1-2 months post partum
symptoms of hypomania?
- mildly elevated, expansive or irritable mood
- increased energy/activity
- increased self esteeem
- sociability, talkativeness over familiarity
- increased sex drive
- reduced need for sleep
- difficulty in focussing on one task alone
what is hypomania?
periods of over-active and excited behaviour that can have a significant impact on your day-to-day life. Hypomania is a milder version of mania that lasts for a short period
symptoms of mania?
- elevated/expansive/irritable mood (1 week)
- icnreased energy/activity
- gradiosity//increased self-esteem
- pressure of speech
- flights of ideas/racing thoughts
- distractibility
- reduced need to sleep
- increased libido
- psychotic symptoms (extreme)
what are teh two types of persistant mood disorder?
cyclothymia: mild periods of elation/depression, early onset, chronic cause (less severe bipolar disease)
dysthymia: chronic low mood not fulfilling the criteria of depression (less severe depression)
** both must be present for 2 yrs to make a diagnosis
what is mixed affective state?
characterised by either mixture or a rapid alternation of hypomanic, manic and depressive symptoms
what is the definition of bipolar I and bipolar II?
bipolar I: 1 or moe manic episodes or mixed episodes, +- 1 or more depressive episodes
bipolar II: 1 or more depressive episodes with at least 1 hypomanic episode
causes of mood disroders? (biopsychosocial)
bio: genetic, brain illnesses, physical illnesses,
psycho: childhood experiences, view of yourself and the world, personality traits
social: work, housing, finances, relationships, support etc
Tx of mood disorders?
bio: pharm , ECT (electroconvulsive tx) , rTMS (Repetitive transcranial magnetic stimulation), tDCS (Transcranial direct current stimulation)
psycho: psychoeducation, CBT, IPT, psychodynamic, mindfulness
social: family, housing, finance, employment, general coping strategies
what pharm tx is used in psychiatry
- antidepressants (e.g. SSRIs)
- mood stabilisers (lithium, valproate, carbamazepine, lamotrigine)
- antipsychotics
- anxiolytics
what are teh indications for ECT?
- severe depressive illness
- life threatening illness
- prolonged and severe manic episode
- catatonia
- high suicide risk
- stupor
- severe psychomotor retardation
what is ECT?
treatment that involves sending an electric current through the brain to trigger an epileptic seizure
occurs twice a week, max of 12 treatments
what are personality disorders?
conditions in which a idnividual differs significantly from an average person in terms of how they think, percieve, feel or relate to others
how many types of personality disorders are they?
10
what are the cluster A group of personality disorders?
paranoid: suspicious and mistrustful, misintepreting events as persecutory, bearing grudges, strong sense of personal rights
schizoid: detached, solitary, little interest in ppl or sex
schizotypal: eccentric, odd behaviour and thinking, unconventional beliefs
what are the cluster B group of personality disorder?
borderline: emotional instability, impulsivity, chronic feelings of emptiness, parasuicidal acts, intense and unstable relationships , fear of abandonment
narcissistic: present as grandiose, self-important, degrading others
antisocial: present wiht unconcern for the feelings of others, disregard rules, impulsivity, low tolerance to fustration, failure to take responsibility
historionic: present as theatrical, dramatic, exhibit superficial emotionality, seductiveness, suggestibility
what is in cluster C group of personality disorders?
obsessive compulsive: present as rigid, perfectionistic, preoccupied with rules, order and routine, higher snese of morality
dependent: present as needing others to make decisions for them, fear abandonment, unable to cope alone, need for resassurance
anxious-avoidant: present with persistent anxiety, sensitive to rejection, tend to avoid relationships unless acceptance is guarenteed
what is attachment theory?
the emotional bond between parent + child is crucial for childs survival
experience of consistent + responsive caregiver gives sense that world is safe and they are loved
helps brain develop and enables necessary wiring and chemical connection to allow regulation of feelings
Mx for personality disorders?
- harm minimisation (elastic bands or ice cubes on wrists)
- emotional management
- boundaries (explain expectations of the service user + be consistent and reliable)
Tx for personality disorders?
- psychotropic medication only to treat comorbidities
- group Tx/therapeutic community
- DBT (dialectical behaviourhal therapy)
- mentalisation base therapy
- transferance focused therapy
are children allowed to refuse life saving treatment?
No, they cannot
are children allowed to consent to procedures
yes they are - if they have capacity
what is the mental capacity act 2005
single test of capacity
principles of MCA 2005?
presumption of capacity at all times
a new legal right to support individuals in making their own decisions
pts have the right to make unwise decisions
if a pt is unconcsious and need an op, can you operate?
yes - if its in their best interest
- try and consult with next of kin
- try to regain pt consciousness beofre op
what is the two stage capacity test?
- is there an impairment of or disturbance in the functioning of a persons mind
- has it made the person unable to make a particular decision
what are the parts of capacity test to understand if a pt has capacity
- understand the information
- retain the information
- use or weigh up info
- communicate decision
what are advance decisions?
they are anticipatory refusals
only relate to medical tx
person must be >18 and have capacity when making AD
what are lasting power of attorney?
enables a mentally capable person to plan to incapacity
can extend to property, welfare, healthcare matters
still have to make decisions in pts best interest
what is deprivation of liberty safeguards (DOLS)?
for patients in hospital or care homes who lack capacity - allows pts who are not allowed to leave wards have some freedom e.g. supervised walks
MDT assessment
what is section 5(4) of the mental health act?
power granted to RMNs to detain an inpatient fro up to 6 hours for medical assessment where mental illness in suspected
(cannot be used in ED, need to be admitted to hosp)
what is section 5(2) of mental health act?
the consultant or nominated deputy can detain an inpatient for up to 72 hrs under MHA
-> to allow fuller assessment and MHA to be completed
(cannot be used in ED, need to be admitted to hosp)
what is section 2 of the MHA?
2 doctors (1 of whom shld be section 12(2) approved) & 1 AMHP
in community or inpatient (not prison) section for max 28 days for assessment + treatment of mental disorder
(pt can appeal within first 14 days)
what is section 3 of the MHA?
2 doctors (1 of whom shld be section 12(2) approved) & 1 AMHP
in community or inpatient (not prison) section for max 6 months for treatment of mental disorder
(pt can have 1 appeal)
what is section 136 of the MHA?
police power to remove to a place of safety from a public place for an assessment by an AMHP and 1 Dr
help up to 72 hrs to allow assessment
police to stay with person
what is section 17/117 of MHA?
section 17 - whilst detained in hopsital under S2 or S3 a pt may leave under S17 (go on walks, go home)
section 117 - anyone whos been under S3 is entitled to S117 aftercare from local authority
what is a community treatment order?
patient on S3 can be considered for a CTO
pt is well enough to leave hsopital but MUST take tx under supervision of nurses otherwise can be recalled to hospital
definiton of suicide
a fatal act of self-injury, udnertaken with more or less conscious self-destructive intent, however vague and ambiguous
definition of para-suicide?
similar to suicide - but for whatever reason the victim survived the attempt
defintion of deliberate self-harm?
an act of self-harm where the action was not the intention of death, but to cause harm
why are men more successful to die from suicide than women?
the way they choose to commit suicide is mroe aggressive therefore higher chance to be successful
why are people most likely to commit suicide in the 14 days post discharge from psychiatric hsopital?
- unplanned idscharge
- lack on continuity of care
- unemployment
- suicidal behaviour prior to admission
risk factors for suicide
- living alone
- Hx of mental illness/suicidal behaviour
- unemployment
- chronic physical illness
- alcohol abuse
- drug abuse
- FHx
- hopelessness
- certain professions e.g. vets, soldiers, farmers, doctors
what do you ask in a Hx of someone you as attempted suicide
- triggers
- preparation e.g. planning in advance, final acts
- circumstances e.g alone , precautions against discovery, alcohol, the acts itself, what did they think/want to happen?
- after the act e.g. didnt seek help, regret failure, intent
- psychiatric Hx + collateral Hx
- what do they think now? guilt? ongoing thoughts?
- MSE
which mental health illnesses have a higher associaition with homicide?
- DSPD
- alchohol drug/alcohol misuse
- schizophrenia (specific persecutory delusions or hallucinations, command auditory hallucinations)
what is anxiety?
feeling on unease, worrying, fear with physiological arousal
becomes a problem when someones brain is not able to dsitinuish between physical and psychological threat e.g. false alarm
what effect does anxiety have?
physiological arousal
racing thoughts
inability concentrate
cognitive bias - attentional focus
what are teh anxiety disorders?
- panic disorder
- social anxiety disorder
- specific phobias
- health anxiety
- OCD/BDD
- PTSD
- GAD
definition of specific phobias?
marked fear of specific object or situation e.g. spiders
marked avoidance of such object or situations
what is panic disorder?
a fear of you own physiological and psychological reactions
impending collapse, insanity or death
symptoms of panic disorder?
- sense of dread
- shaky
- feel faint
- choking
- rapid heart beat
- wobbly legs
what is GAD?
specific content of (type 1) worries varies
included “worries about worries” (type 2 worries)
usually accompanied with low level physical symptoms ( insomnia, msucel tension, GI problems, headahce)
often maintained by the belief that worry is useful (e.g. motivation, prepares for problems)
definition of social anxiety disorder (social phobia)?
fear of negative evaluation by others
can lead to avoidance of feared situations, use of safety behaviours, with unhelpful ‘port mortems’ following social encounters
definition of OCD?
unwanted recurring distressing intrusive thoughts or images (=obsessions)
e.g. being contaminated, causing harm, aggression impulses, sexual imagery
to manage the stress cuased by intrusiosn the pt conducts neutralising behaviours (= compulsions) e.g. washing, checking, praying, counting, repeating words
definition of BDD?
characterised by preoccupation with an imagined defect in apperance
-> conusuming behviours e.g. mirror gazing, comparing to others
definition of PTSD
caused by exposure to event of situation of exceptionally threatening or catastrophic nature which would be likely to cause pervasive distress in almost anyone
e.g. warfare, car crash, terrorism
3 mian features of PTSD?
- re-experiencing
- avoidance
- hyperarousal - scan for threats, jumpy
common PTSD cormorbities?
substance misuse
depression
other anxiety disorder
problems associated with anxiety disorders?
- icnreased autonomic arousal
- alcohol and drug dependence
- impaired sleep pattern
- avoidance
- worry
- time consuming anxiety reducing behaviours
- procrastination
- reduced concentration
- impact on functioning - work, social, health
differentional diagnsis ofr anxiety
- adjustment disorders or bereavement
- other functional psychiatric illnesses
- organic cuases: endocrine (thyroid), drug induced (steroids, antihypertensiveS) , neurological (MS, dementia, lupus), alcohol and illicit drug misuse, infection, anaemia,
first line Tx of anxiety
CBT - graded expsoure/systematic desensitisation
(SSRIs cna be given first line if the pt wants it)
side effects of adrenergics (adrenaline e.g.)
- sweating
- tremor
- headaches
- nausea
- dizziness
commone side effects of muscarinics (acetycholine e.g.)
- dry mouth
- difficulty urinatin, urinary retention
- difficulty swallowing
- thirst
- hot and flushed skin
- dry skin
common side effects of histamine?
- dry mouth
- drowsiness
- dizziness
- N+V
name the types of anti-depressants?
- SSRIs (most common as fewer SE)
- NSRIs
- mirtazapine
- tricyclics
- MAOIs
name some SSRIs
sertraline (first line)
citalopram
fluoxetine
paroxetine
vortioxetine
commen SE of SSRIs
- restlessness, agitation on initiation
- nausea, GI disturbance
- headache
- weights changes
- sexual dysfunction
(- bleeding, suicidal ideation)
what is the main SE of citalopram?
QTc prolongation
what is serotonin syndrom ?
when switching from fluoxetine to another SSRI can get serotonin syndrome (increased serotonin) as fluoxetine has a very long half life
headaches
agitation
hypomania
confusions
coma
shiverin g
sweating
hyperthermia
tachycardia
hyperreflexia
tremor
what is discontinuation syndrome?
caused when antidepressants are stopped too quickly (go slow!)
- sweating
- shakes
- agitation
- insomnia
- headaches
- irritability
- n + v
- paraesthesia
- clonus
most commonly in paroxetine and venlafaxine
name some NSRIs
- duloxetine
- venlafaxine
SE of NSRIs?
similar to SSRIs, but greater potential for sedation, nausea and sexual dysfunction
SE of mirtazapine?
major SE are sedation and weight gain
name some tricyclics?
lofepramine
nortriptyline
amitriptyline
SE of tricyclics?
muscurinic and histamine SE
+ can cuase QTc prolongatio n and arrythmias
name the mian interaction of MAOIs
tyramine reaction = hypertensive crisis
therefore avoid foods like cheese, pickled meats, wine
SE of antipsychotics?
- sedation
- extrapyramidal side effects
- weight gain
- acute dystonia
- oculogyric crisis
atypical antipsychotic SE?
weight gain
dyslipidaemia and diabetes
typical antipsychotics SE?
extra-pyramidal SE
dizziness
sexual dysfunction
name some typical antipsychotics
haloperidol
flupenthixol
zuclopenthixol
chlorpromazine
name some atypical antipsychotics?
clozapine (common!)
olanzapine
risperidone
quetiapine
name the extrapyramidal SE
bradykinesia
muscle stiffness
tremor
tardive dyskinesia
akathisia
(parkinsons symptoms basically)
what monitoring is needed for antipsychotics?
at beginning: FBC, lipids, LFT, HbA1C, weight, ECG, BP, pulse
weekly: weight (they cuase weight gain and diabetes!)
three months; FBC, LFT, HbA1C, weight, ECG, BP, pulse
yearly:FBC, lipids, HbA1C, weight, ECG, BP, pulse
what is the monitoring for ppl on clozapine due to the major SE?
significant potential for agranulocytosis (severe leukopenia)
therefore need monitoring of FBC weekly for first 18 weeks
major clozapine SEs?
agranulocytosis
GI hypomobility = constipation = potentially fatal bowel obstruction
hypersalivation
urinary incontinence
indication fro clozapine
used in schizophrenia after two antipsychotics have been prescribed (because of major SEs)
what is neuroleptic malignant syndrome?
rare life threatening reaction to antipsychotics
characterised by fever, confusion, muscle rigidity, sweating, autonomic instability
death occurs by rhabdomyolysis, renal failure, seizures
risk factors for neuroleptic malignant syndrome?
high potency typical antipsychotics in ppl who have never taken antipsychotics
high doses
young men
what is the tx for neuroleptic malignant syndrome?
- emergency referral to A+E,
- stop antipsychotics
- fluid resus
- reduce temp
what can be used to treat extra pyramidal side effects in use of antipsychotics?
anticholinergics e.g.
- procyclidine (most commonly useD)
- benzatropine
- trihexphenidyl
name the anxiolytic drugs.
beta blockers
benzodiazepines
pregabalin
antidepressants
most commonly used beta blocker in anxiety ?
propanolol (contraindicated in asthma !!)
not very effective in long term anxiety disorder (not used v often in secondary care, more often in priamry care)
why do benzodiazepines have to be used cautiously?
significant potential for misuse, tolerance and dependence
use for no more than six wks at once
occasionally cause paradoxical disinhibition
why is pregabalin being used more in anxiety?
as less potential for misuse and dependence than benzodiazepines
(still can be misused - should only be used fro max 6 wks)
first line meds for OCD?
high dose antidepressants
what drugs are hypnotics (used as sleeping tablets)?
- benzodiazepines (temazepam, lormatazepam nitrazepam)
- non benzodiazepines (zopiclone, zolpidem)
how are hypnotics given to reduce misuse?
signigficant potential for misuse, dependence, rebound insomnia
threefore use for only 2 weeks, take for 5/7 days each week to reduce potential for tolerance
what are mood stabiliser drugs?
- lithium
- anticonvulsants
- second generation (atypical) antipsychotics
what is common mental illness that mood stabilisers treat?
bipolar mood disorder
SE of lithium?
- GI disurbance
- metallic taste and /or dry mouth
- fine tremor
- polydipsia
- polyuria
- weight gain
- hypothyroidism
- renal impairment
monitoring on lithium?
U+Es and TFTs
because of renal impairments and hypothyroidism
symptoms of lithium toxicity?
confusion
coarse tremor
n+v
ataxia
seizures
**ensure pts are well hydrated to reduce lithium toxicity
what is the first line tx for bipolar mood disorder?
quetiapine (a second generation antipsychotic)
name some anticonvulsants that can be used as mood stabilisers?
- sodium valproate (becareful in child bearing age females)
- carbamazepine
- lamotrigine
- pregabalin
what drugs are used for cognitive symptoms of dementia?
- acetylcholinesterase inhibitors (donepezil, rivastigmine)
- memantine (NMDA receptor antagonist)
what drugs are used to treat ADD and ADHD ?
- methylphenidate (aka ritalin)
- dextroamphetamine
- atomexetine
what are personality disorders?
A personality disorder is a condition that affects how you think, feel, behave or relate to other people
what is dissocial personality disorder?
characterized by disregard for social obligations, and callous unconcern for the feelings of others, can become violent + tendancy to blame others
amoral
antisocial
asocial
psychopathic
sociopathic
what is emotionally unstable personality disorder? (also known as borderline personality disorder)
tendency to act impulsively and without consideration of the consequences
aggressive
borderline
explosive
Tx for personality disorders?
CPA (care programme approach)
psychotherapy
dialectal behaviour therapy
only treat iwrth drugs ifthere are co-morbidities (e.g. anxiety, depression)
what is autism spectrum disorder?
- persistent deficits to initiate and sustain social interaction and communication
- restricted, repetitive and inflexible patterns of behaviour
+/- interests that are atypical or excessive for the individual’s age and sociocultural context
+/- Sensory differences
name some comorbidities with ASD?
- epilepsy
- visual or hearign impairment
- mental health (depression, anxiety, OCD)
- learnign disability
- sleep disorders
Mx of autism?
bio: meds for comorbidities
psycho: early intensive behavioural intervention (EIBI)
- interventions for behaviour that challenges
- positive behavioural support (PBS)
- family therapy
- communications interventions (SALT)
- OT (sensory integration therapy)
(- music therapy)
(- advise from dietician)
social: social worker to work w family, school challenges, do they need to go to placements?
name some important variables when assessing a patients risk (dynamic and static)
static: gender, personality disorders, genetics, previous history of self harm, adverse childhood event
dynamic risk factor - mental disorder, substance misuse, bereavement, unemployment, no social contact, comorbid physical conditions, age, marital status
what sedative would you give to a patient who has delirium and de escalation methods havent worked
IM haloperidol
what sedative would you give to a patient (with parkinsons or lewy body dementia) who has delirium and de escalation methods havent worked
IM lorazepam
as IM haloperidol can cause extrapyramidal SE
what are teh highest causes of mortality due to alcohol?
- fights and falls
- lvier failure
- pancreatitis
- overdose
- withdrawal
- wernikes encephalopathy
symptoms of alcohol toxicity?
head injury
confusion
shaking/seizures
hallucinations
vomit blood or coffee grounds
severe abdo pain
sudden yellow
signs of early alcohol withdrawal?
- tremor
- sweating
- nausea
- anxiety
- tachycardia
signs of late alcohol withdrawal
- delirium tremens
- disorientation
- hallucination -tremor
- BP, pulse, fever, motor incoordination
signs nd symptoms of wernickes encephalopathy?
- ataxia
- nystagmus
- opthalmoplegia
- altered consiousness
- fever
- hypothermia
- ptosis
- abnormal pupillary reflexes
cause fo wernickes encephalopathy?
deficiecny of vitamin B1
treatment of wernickes encephalopathy?
parenteral thiamine
what is korasakoffs syndrome?
caused from long term thiamine deficiency (long term wernickes encephalopathy)
signs are same as wernickes plus short term memory loss - nroamlly need to go into care/need carer
sign of opiate overdose?
- pinpoint pupils
- decreasing consciousness
- slow breathing
- death
Tx of opiate overdose?
naloxone IM
signs of opiate withdrawal?
- sweting
- rhinorrhea
- tachycardia
- restlessness
- dilated pupils
- lacrimation
- goosebumps
later:
- N+V
- diarrhoea
- insomnia
- abdo cramps
- muscle pains
tx for opiate withdrawal ?
- methadone
what is the tx for benzo withdrawl?
diazepam - as it is long acting
which two antidepressants are used preferred for patients who are breastfeeding?
sertraline and paroxetine
