Psychiatry Flashcards by Andrea Jayawardena

Acute stress disorder
- when does it occur?

occurs in first 4 weeks post exposure to traumatic event

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Acute stress disorder
- 1st line management

1st Line = CBT

Benzodiazepines may be given
- for acute symptoms
- agitation, sleep disturbance

BEWARE of giving benzo’s due to addictive potential

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Diagnosis of Anorexia Nervosa used what criteria?

DSM 5

Restriction of energy intake, leading too:
- low body weight
- physical health impacts
Intense fear of gaining weight even though underweight
Disturbance in ways bodyshape is experienced

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Anorexia Nervosa

NICE management for Adults

individual eating-disorder focused cognitive behavioural therapy
MANTRA
- maudsley anorexia nervosa treatment for adults
SSCM
- specialist supportive clinical management

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Anorexia Nervosa

Management in children and young people

1st Line
- anorexia focused family therapy

2nd Line
- CBT

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Anorexia Nervosa

What might happen when nutritional intake is resumed too rapidly after period of low caloric intake?

Describe pathophy behind this?

Refeeding Syndrome

Rapidly increasing insulin level leads to shift of potassium, magnesium and phosphate
from extracellular to intracellular spaces

Blood tests will show
- hypophosphataemia

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Refeeding syndrome

Symptoms?

Treatment?

Symptoms
- oedema
- confusion
- tachycardia

Treatment
- phosphate supplementation

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What is Alzheimer’s disease?

common cause of dementia
chronic and progressive form of dementia
characterised by neuropathological features
1. amyloid plaques
2. Tau proteins

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What causes Alzheimer’s disease?

Caused by build up of
- amyloid protein deposits around brain cells

tau protein tangles within brain cells

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How might severe Alzheimer’s disease be managed?

1st Line

Memantine
- glutamate receptor antagonist
(side effect: constipation)

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What is autoimmune encephalitis?

non-infectious neuroinflammation

increasingly recognised cause of acute/ subacute progressive mental status change with variety of clinical phenotypes

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Describe some clinical features associated with autoimmune encephalitis?

-wide range of symptoms:
- confusion
- seizures
- movement disorders
- behavioural changes
- emotional lability
- psychosis
- cognitive impairment
- reduced conscious level

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Autoimmune encephalitis

Investigations

Full neurological examination
Blood tests:
- Low sodium is associated with LG1 encephalitis
- Antibodies: LGI1, NMDA receptor, CASPR2

3.MRI

4.Lumbar puncture (will show increased levels of lymphocytes in the cerebrospinal fluid (‘lymphocytic pleocytosis’))

EEG is sensitive but not specific

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Autoimmune encephalitis

Treatment

1ST LINE

steroids + IV immunoglobulin
plasma exchange as adjunctive treatment if not fully responding to steroids or immunoglobulin

2ND LINE

alongside 1st line
immunosuppressant therapy with agents such as Rituximab and Cyclophosphamide

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Describe side effects associated with first generation antipsychotics?

Higher risk of EXTRAPYRAMIDAL SIDE EFFECTS

Akathisia (severe restlessness)
Dystonia (muscle spasm and contractions)
Parkinsonism
Tardive dyskinesia (irregular uncontrollable movements in face or body)

Example: HALOPERIDOL

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Main side effects of second generation antipsychotics?

Examples
- Ariprazole
- Risperidone
- Quetiapine
- Olanzapine
- Clozapine

weight gain
worsening glycaemia control
dyslipidaemia

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What condition is Clozapine use associated with?

HIGH RISK AGRANULOCYTOSIS

needs regular FBC monitoring and close follow up

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Bipolar disorder is characterised by:

periods of depression
periods of elevated mood (mania)

Mania
- distinct period of abnormally and persistently elevated, expansive or irritable mood

each episode must last at-least a week

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What are the two types of bipolar disorder?

Type 1
- mania and depression
- most common

Type 2
- hypomania and depression

Chronic management of bipolar disorder

careful follow up
ongoing maintenance
treatment
GOLD STANDARD
- LITHIUM (mood stabiliser)
2nd Line
- Valproate
Psychological therapies
- CBT, interpersonal therapy
- couples family therapy

What are clinical features of Bulimia Nervosa?

Characterised by
- episodes of binging and purging (induced vomiting)
- pt usually has normal or low BMI

Physical features
- Dental erosion
- Parotid gland swelling
- Russell’s sign (scarring on fingers from induced vomiting)

Describe Class A personality disorders and examples?

Described as ‘odd, eccentric disorders’

Paranoid personality disorder
Schizoid personality disorder
Schizotypical personality disorder

Describe differences between Schizoid and Schizotypal personality disorder?

Schizoid personality disorder

characterised by lack of interest in others
apathy
lack of emotional breadth
tend to have few friends
do not form relationships
preferring solitary activities

Schizotypal personality disorder

characterised by pattern of extreme difficulty interacting socially
bizzare or magical thinking and distorted perceptions
inappropriate behaviour
strange speech and affect
better grasp on reality than schizophrenics

Describe Class B personality disorders?

Dramatic, emotional or erratic disorders

Antisocial
Borderline personality
Histrionic
- attention seeking behaviours
- relationships perceived more intimate than actually are
Narcissistic

What is the name to a condition which is characterised by the following? - Persistent or recurrent complex hallucinations (visual or auditory) - insight usually preserved - must occur in the absence of any other significant neuropsychiatric disturbance

Charles-Bonnet syndrome

Type of Delusion - This relates to body function, sensations. The patient will be convinced something is wrong with them.

Somatic delusion

When does Delerium tremens usually develop?

Definition - rapid onset of confusion - precipitated by alcohol withdrawal Usually develops at around 48-72 hours after ceasing alcohol intake. Symptoms - confusion - hallucination - formication (sensation of crawling insects under skin) - sweating - hypertension

How might acute delerium tremens be managed?

NICE guidelines state in people with acute delirium tremens - offer oral lorazepam as first-line treatment. - If symptoms persist or oral medication is declined: - offer parenteral lorazepam or haloperidol.

What might be seen on imaging in a patient with Alzheimer's disease?

Widespread cerebral atrophy

Agnosia definition

recognition problems

Lewy Body dementia is characterised by:

Abnormal protein deposits called Lewy Bodies. Cause cognitive decline associated with parkinsonism - rigidity - tremor - bradykinesia - fluctuating cognition - parkinsonism - visual hallucinations

How might fronto-temporal dementia present and why?

1. cognitive impairment 2. personality change 3. disinhibition atrophy of frontal and temporal lobes is seen

Describe vascular dementia?

- may result from multiple infarcts in brain - tends to present with sudden onset cognitive decline - stepwise deterioration in someone with previous cardiovascular illness or events

What is THE TETRAD Wernicke's encephalopathy associated with?

Classic tetrad 1. Ataxia 2. Opthalmoplegia 3. Nystagmus 4. Acute confusional state associated with lesions in mamillary bodies

How many features of the DSM-5 criteria need to be seen and for how long to make a diagnosis of depression?

5/9 features present nearly every day for 2 weeks or longer

What is the cut of for more severe and less severe depression?

Less severe - PHQ-9 score of < 16 More severe - PHQ-9 score of > 16

Patients who have benefited from antidepressants should be continued on these for how long to reduce risk of relapse?

at least 6 months after remission

Describe some features of opiate withdrawal?

Clinical features - sweating - watering eyes - rhinorrhoea - yawning - GI upset - anxiety - Irritability - general aches and pains Withdrawal from heroin can begin as early as 6 hours since last dose. Symptoms peak at 36-72 hours Unpleasant but not as dangerous as alcohol withdrawal.

How would you manage opiate withdrawal?

NICE GUIDELINES DO NOT PRESCRIBE OPIATES IN WITHDRAWAL GIVE EITHER - Lofexidine (an alpha 2 receptor agonist) - Benzodiazepines (for agitation) - Loperamide / Anti-emetics for GI symptoms

Describe differences between hypomania and mania

HYPOMANIA - < 7 days - typically 3-4 days - does not impair functional capacity in social or work setting - does not exhibit any psychotic symptoms MANIA - atleast 7 days - 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

What is Korsakoff syndrome?

If Wernicke's encephalopathy left untreated may progress to Korsakoff syndrome Korsakoff syndrome - targets the LIMBIC system **Severe memory impairment** 1. Anterograde amnesia - inability to create new memories 2. Retrograde amnesia - inability to recall previous memories Confabulation - creates stories to fill in the gaps in their memory

What is thought to the the pathophysiology behind Korsakoff's syndrome?

Thought to occur AAR of degeneration of mammillary bodies. Mammillary bodies are part of the circuit of papez - plays a role in memory formation

Give some symptoms of Lithium toxicity?

- tremor (becomes more coarse) - slurred speech - confusion - drowsiness - vomiting - declining renal function - convulsions

What medications can increase lithium levels in a patient on lithium?

- NSAID - ACEi / ARB - thiazide like diuretics

Define postpartum psychosis aka puperal psychosis?

- usually develop in first 2 weeks post birth - rare but severe

How would you treat schizophrenia?

1st Line --> atypical antipsychotics --> RISPERIDONE Sedative drugs --> Lorazepam Children and young people --> CLOZAPINE (if not responded to two different anti-psychotics used sequentially for 6-8 weeks)