Psychiatry Flashcards
Acute stress disorder
- when does it occur?
occurs in first 4 weeks post exposure to traumatic event
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
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
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
Anorexia Nervosa
Management in children and young people
1st Line
- anorexia focused family therapy
2nd Line
- CBT
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
Refeeding syndrome
Symptoms?
Treatment?
Symptoms
- oedema
- confusion
- tachycardia
Treatment
- phosphate supplementation
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
What causes Alzheimer’s disease?
Caused by build up of
- amyloid protein deposits around brain cells
- tau protein tangles within brain cells
How might severe Alzheimer’s disease be managed?
1st Line
Memantine
- glutamate receptor antagonist
(side effect: constipation)
What is autoimmune encephalitis?
non-infectious neuroinflammation
increasingly recognised cause of acute/ subacute progressive mental status change with variety of clinical phenotypes
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
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
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
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
Main side effects of second generation antipsychotics?
Examples
- Ariprazole
- Risperidone
- Quetiapine
- Olanzapine
- Clozapine
- weight gain
- worsening glycaemia control
- dyslipidaemia
What condition is Clozapine use associated with?
HIGH RISK AGRANULOCYTOSIS
- needs regular FBC monitoring and close follow up
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
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?
- cognitive impairment
- personality change
- 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
- Ataxia
- Opthalmoplegia
- Nystagmus
- 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
- 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)
