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Finals Systems > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

A young woman takes a paracetamol overdose after splitting with her boyfriend. Two days later she is in a new relationship which is troubled by her repeated outbursts of anger. What personality disorder

A

Borderline personality disorder

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2
Q

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

A

Paranoid

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3
Q

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

A

Schizoid

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4
Q

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

A

Schizotypal

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5
Q

What is in cluster A personality disorders

A

Odd or eccentric
- paranoid
- schizoid
- schizotypal

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6
Q

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

A

Antisocial

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7
Q

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

A

Borderline

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8
Q

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

A

Histrionic

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9
Q

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

A

Narcissistic

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10
Q

What is cluster B

A

dramatic, emotional, or erratic

  • antisocial
  • histrionic
  • borderline
  • narcissist
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11
Q

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

A

Obsessive compulsive personality disorder

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12
Q

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

A

Avoidant personality disorder

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13
Q

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

A

Dependant personality disorder

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14
Q

What is in cluster C personality disorders

A

Anxious and fearful
- avoidant
- obsessive compulsive
- dependant

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15
Q

Management of personality disorders

A

Dialectical behaviour therapy

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16
Q

What might you need to co-prescribe alongside SSRI

A

PPI such as omeprazole

If risks such as NSAID

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17
Q

Strongest risk factor for SZ

A

Family history

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18
Q

delusional jealously, usually believing their partner is unfaithful

A

Othello syndrome

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19
Q

Alcohol withdrawal symptom timeline

A

symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety

peak incidence of seizures at 36 hours

peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

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20
Q

Therapeutic range lithium

A

0.4-1.0 mmol/L

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21
Q

Adverse affects of lithium

A

Leukocytosis
Increased urination (insipidus)
Tremors (fine = SE, coarse = toxicity)
T wave flat/inverted
Hyperparathyroid –> hypercalcaemia
Hypothyroid (but enlarged thyroid)
Interactions (NSAIDs, ACEi, ARB, diuretics)
Upset stomach (diarrhoea, cramps, N+V)
Muscle weakness
Skin conditions (acne, psoriasis)

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22
Q

After a change in dose, how often should lithium levels be checked

A

after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.

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23
Q

When should thyroid and renal be checked when patients taking lithium

A

Every 6 months

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24
Q

Delusional belief that they (or in some cases just a part of their body) is either dead or non-existent.

A

Cotard syndrome

Cotard syndrome is associated with severe depression and psychotic disorders.

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25
Q

Factors that increase risk of completed suicide

A

efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method

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26
Q

Protective factors suicide

A

family support
having children at home
religious belief

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27
Q

Factors increased risk of suicide

A

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

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28
Q

Lithium and white cells

A

Lithium can ppt benign leukocytosis

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29
Q

Apart from drugs, what should be offered to all patients with Sz

A

CBT

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30
Q

Triad of PTSD

A

re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images

avoidance: avoiding people, situations or circumstances resembling or associated with the event

hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating

emotional numbing - lack of ability to experience feelings, feeling detached

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31
Q

A 21-year-old woman presents to her GP, seeking help for anxiety. She finds her office-based job stressful, especially the aspects involving discussions with colleagues and bosses, fearing criticism. Outside of work, she often finds herself worrying about what her friends think of her, and increasingly forgoes social interaction with them as a result. She mentions that she thinks quite lowly of herself and does not have much self-esteem.

A

Avoidant

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32
Q

Kosakoff syndrome features

A

anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation

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33
Q

Illness anxiety disorder (hypochondriasis)

A

persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results

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34
Q

Dissociative disorder

A

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

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35
Q

Factitious disorder

A

also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms

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36
Q

Somatisation

A

multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results

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37
Q

Perseveration

A

repeating the same words/answers

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38
Q

Echolalia

A

repeating exactly what someone has said.

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39
Q

Neologism

A

making up new words.

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40
Q

Word salad

A

disorganised speech, sentences that do not make sense.

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41
Q

Clozapine and smoking

A

Increase causes decrease and vice versa

Smoking cessation can cause a rise in clozapine blood levels

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42
Q

Delusional belief that a famous person is in love with them

A

Erotomania (De Clerambault’s syndrome)

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43
Q

Management traduce dyskinesia moderate/severe

A

Tetrabenazine

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44
Q

what screening tool is used for postnatal depression

A

Edinburgh scale

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45
Q

name 5 SSRIs

A

Sertraline
Citalopram
Escitalopram
Fluoxetine
Paroxetine

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46
Q

most common side effect ssris

A

GI disturbance

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47
Q

Complications of SSRIs

A
  • QT prolongation / ventricular arrhythmias including torsade de pointes in citalopram
  • Hyponatremia
  • SSRI discontinuation syndrome
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48
Q

Interactions SSRIs

A

NSAIDs/aspirin: 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

triptans - increased risk of serotonin syndrome

monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

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49
Q

SSRI in first trimester can cause?

A

congenital heart defects

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50
Q

SSRI in third trimester can cause?

A

persistent pulmonary hypertension of the newborn

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51
Q

worst SSRI pregnancy

A

Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

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52
Q

SSRIs of choice in breastfeeding women

A

Sertraline or paroxetine

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53
Q

SSRI of choice post MI

A

Sertraline

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54
Q

SSRI of choice children

A

fluoxetine

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55
Q

Name 2 SNRIs

A

Venlafaxine
Duloxetine

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56
Q

Side effects SNRIs

A

include nausea/vomiting, sweating, loss of appetite, dizziness, headache, increase in suicidal thoughts, and sexual dysfunction.

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57
Q

Complication SNRI

A

HTN

(Elevation of norepinephrine levels can sometimes cause anxiety, mildly elevated pulse, and elevated blood pressure. )(monitor before initiation and after titration)

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58
Q

Name 3 TCAs

A

Imipramine
Clomipramine
Amitriptyline

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59
Q

Mechanism TCAs

A

inhibit the reuptake of serotonin and noradrenaline.

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60
Q

Side effects TCAs?

A

anticholinergic effects:
Can’t see (blurred vision)
Can’t pee (urinary retention)
Can’t spit (dry mouth)
Can’t shit (constipation)
Can’t sit for too long - postural hypotension

TCAs can cause overflow incontinence due to chronic urinary retention
Drowsiness
Postural hypotension

lengthening of QT interval

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61
Q

Name 1 NaSSA

A

Mirtazapine

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62
Q

Mechanism NaSSA

A

Blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters. Blocking α2-adrenergic autoreceptors and heteroreceptors, NaSSAs enhance adrenergic and serotonergic neurotransmission in the brain involved in mood regulation,[1] notably 5-HT1A-mediated transmission.

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63
Q

Side effects mirtazapine?

A

Sedative
Increases appetite

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64
Q

Name 3 MAOIs

A

Isocarboxazid
Phenelzine
Tranylcypromine

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65
Q

Complication MAOI

A

The tyramine cheese reaction is a classic side effect of MAOI (monoamine oxidase inhibitor) antidepressants, such as phenelzine. Consumption of foods high in tyramine (such as cheese) can result in a hypertensive crisis. Symptom: Throbbing headache at bottom of skull

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66
Q

Dizziness, electric shock sensations and anxiety

A

SSRI discontinuation syndrome

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67
Q

how to prevent SSRI discontinuation syndrome?

A

reduce gradually over 4 weeks

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68
Q

Neuromuscular excitation
- hyperreflexia
- myoclonus
- rigidity

autonomic nervous system excitation
- hyperthermia
- sweating

altered mental state
- Confusion

A

seretonin syndrome

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69
Q

management seretonin syndrome

A

supportive including IV fluids
benzodiazepines
more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine

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70
Q

acute management bipolar disorder

A

Consider stopping antidepressant and + antipsychotic therapy (e.g olanzapine or haloperidol)

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71
Q

long term management bipolar

A

Lithium
Valproate
Psychological interventions
Fluoxetine
Comorbidities

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72
Q

Flight of ideas

A

Jumping between ideas but with discernible links between topics

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73
Q

Knights move?

A

Jumping between ideas without discernible links

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74
Q

Difference between mania and hypomania

A

with mania, there is severe functional impairment or psychotic symptoms for 7 days or more

hypomania describes decreased or increased function for 4 days or more

from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania

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75
Q

referral from primary care ?bipolar

A

Hypomania → routine referral to CMHT
Mania → urgent referral to CMHT

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76
Q

what is baby blues? management?

A

60-70% women
3-7 days following birth, more common in primips
Anxious, tearful, irritable
Management : reassurance and support, health visitor

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77
Q

what is post natal depression? peak? management?

A

Affects around 10% women
Start within a month post birth and peak at 3 months
Features are similar to depression seen in other circumstances
Management: reassurance and support, CBT, sertraline or paroxetine if symptoms are severe

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78
Q

Management of PMDD

A

mild symptoms can be managed with lifestyle advice
- Specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates

moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
- Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)

severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
- this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)

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79
Q

How long should SSRI be continued after resolution of depression to prevent relapse

A

6 months

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80
Q

How long should SSRI be continued after resolution of anxiety state to prevent relapse

A

12 months

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81
Q

Define major depressive disorder

A

the presence of 5 symptoms in same 2 week period that represent a change from previous functioning

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82
Q

managment mild MDD

A
  1. Psychotherapy 1. Consider antidepressant
  2. alternative antidepressant
  3. St Johns wart
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83
Q

management moderate MDD

A
  1. Antidepressant + psychotherapy + immediate symptom management
  2. Alternative antidepressant
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84
Q

management severe MDD

A
  1. Psych rf +/- admisison + antidepressant or ECT
  2. switch to alternative
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85
Q

management treatment resistant MDD

A
  1. Reassess and switch antidepressants
  2. Consider augmentation (Li, aripiprazole, olanzapine) + psychotherapy
  3. MAOI
  4. ECT
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86
Q

what is GAD

A

Chronic excessive worry for at least 6 months that causes distress or impairment. The worry is disproportionate to any inherent risk. The worry is not confined to features of another mental health disorder, a result of substance misuse or relating only to a physical health condition.

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87
Q

diagnostic criteria GAD?

A

At least 3/6 req for diagnosis (DSM-5). ⅙ required in children:
Restlessness or nervousness
Easily fatigued
Poor concentration
Irritability
Muscle tension (achy neck/shoulders, tension headaches)
Sleep disturbance

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88
Q

Management of GAD?

A

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

If using drugs to treat GAD:
Sertraline
Alternative SSRI or SNRI
Pregabalin
Beta-blockers such as propranolol are good for treating the somatic symptoms of GAD

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89
Q

Management of obsessive compulsive disorder

A

Mild functional impairment
1. Low intensity : CBT including ERP
2. SSRI or high intensity CBT

Moderate functional impairment
1. SSRI or high intensity CBT including ERP

Severe functional impairment
1. SSRI AND high intensity CBT including ERP

ERP:
A psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

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90
Q

what is acute stress disorder

A

Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc). This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.

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91
Q

management acute stress disorder

A

trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line

benzodiazepines:
- sometimes used for acute symptoms e.g. agitation, sleep disturbance
- should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation

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92
Q

Management PTSD

A
  1. trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy
  2. venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried.
  3. In severe cases, NICE recommends that risperidone may be used
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93
Q

delusion: belief is or soon will be destitute

A

delusion of poverty

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94
Q

ekboms

A

Parasitosis (ekoms) : belief there are parasites/bugs under skin

95
Q

a feeling of some change in the self, feeling detached from one’s own body, actions feel mechanical and patient feels like an apathetic spectator of their own activities

A

Depersonalisation

96
Q

experiencing thoughts, actions and feelings as being foreign or manufactured against their will by a foreign influence

A

passivity

97
Q

delusional belief of body sensations from an external source

A

Somatic passivity

98
Q

actions feel controlled by an external influence

A

Made act passivity

99
Q

Thought alienation

A

Thought insertion
Thought withdrawal
Thought broadcasting

100
Q

delusion that a familiar person has been replaced by an imposter (a delusion of misidentification)

A

capgras

101
Q

that a stranger is a familiar person in disguise (a delusion of misidentification

A

Fregoli delusion

102
Q

a sense of one’s surrounding lacking reality, often looking dull, grey, lifeless

A

Derealisation

103
Q

that unrelated occurrences in the external world have a special significance for the patient

A

Delusion of reference

104
Q

seeing lights, colours, geometric shapes, and indiscrete objects

A

Elementary visual hallucinations

105
Q

feeling that someone standing behind you

A

extracampine hallucination

106
Q

hallucinations when waking up

A

Hypnopompic

107
Q

hallucinations when going to sleep

A

Hypnagogic

108
Q

Circumstantiality

A

the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point.

109
Q

Tangentiality

A

refers to wandering from a topic without returning to it.

110
Q

ideas are related to each other only by the fact they sound similar or rhyme.

A

clang associations

111
Q

Perseveration

A

the repetition of ideas or words despite an attempt to change the topic

112
Q

Haloperidol

A

typical antipsychotic

113
Q

flupenthixol

A

typical antipsychotic

114
Q

chloropromazine

A

typical antipsychotic

115
Q

are EPSE more common with typical or atypical

A

typical

Typical antipsychotics are unselective in their blocking effect at the dopamine D2 receptor and so decrease positive symptoms and increase negative symptoms.

116
Q

What are the 4 types of EPSE

A

Parkinsonism

Acute dystonia

Akathisia

Tardive dyskinesia

117
Q

sustained muscle contraction (e.g. torticollis, oculogyric crisis)

diagnosis and manegemnt?

A

acute dystonia

procyclidine

118
Q

on antipsychotic

late onset of choreoathetoid movements, abnormal, involuntary, most common is chewing and pouting of jaw

diagnosis and management

A

tardive dyskinesia

tetrabenazine

119
Q

what typical antipsychotic is associated with long QT

A

haloperidol

120
Q

other side effects of typical antipsychotics other than EPSE

A

antimuscarinic: dry mouth, blurred vision, urinary retention, constipation

sedation, weight gain

raised prolactin
may result in galactorrhoea
due to inhibition of the dopaminergic tuberoinfundibular pathway

impaired glucose tolerance

neuroleptic malignant syndrome: pyrexia, muscle stiffness

reduced seizure threshold (greater with atypicals)

prolonged QT interval (particularly haloperidol)

121
Q

young patients with tachycardia and tachypnoea, hypertension, fever, muscle rigidity, hyporeflexia

diagnosis? invetsigation? management?

A

Neuroleptic malignant syndrome

Elevated CK

  1. immediate cessation of the dopamine antagonist (or restarting or continuing of the dopamine agonist)
  2. admission to medical ward
  3. IV fluids to prevent renal failure
  4. dantrolene may be useful in selected cases
    thought to work by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor, and decreasing the release of calcium from the sarcoplasmic reticulum
  5. bromocriptine, dopamine agonist, may also be used

A delay of at least 2 weeks in restarting antipsychotic treatment is advised following full resolution of NMS

122
Q

olanzapine

A

atypical antipsychotic

123
Q

risperidone

A

atypical antipsychotic

124
Q

quetiapine

A

atypical antipsychotic

125
Q

amisulpride

A

atypical antipsychotic

126
Q

aripiprazole

A

atypical antipsychotic

127
Q

clozapine

A

atypical antipsychotic

128
Q

Side effects of atypical antipsychotics

A

weight gain
clozapine is associated with agranulocytosis
Hyperprolactinaemia
Elderly : increased risk of stroke
Elderly : increased risk of venous thromboembolism

129
Q

Adverse effects 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
weight gain

130
Q

What do you need to monitor clozapine

A

FBC

131
Q

name 3 typcial antipsychotics

A

Haloperidol
Flupenthixol
Chlorpromazine

132
Q

Psychosis bad prognostic indicators

A

Gradual onset
History of social withdrawal
Strong family history
Lack of obvious precipitant eg trauma
low IQ

133
Q

management psychosis

A

atypical antipsychotic

134
Q

Schneider’s first rank symptoms

A

Acronym WASBID

Withdrawal (thought)
Auditory hallucinations
Somatic passivity/control
Broadcasting (thought)
Insertion (thought)
Delusional perception

135
Q

Paranoid Sz

A

Most common type of Sz
Relatively stable, often paranoid, delusions, usually accompanied by hallucinations and perceptual disturbances
Uncommon : disturbances of affect, volition, speech, catatonia
Episodic or chronic

136
Q

Hebephrenic Sz

A

Prominent affective changes
Mood inappropriate and accompanied by: giggling or self-satisfied, self-absorbed smiling, grimaces, mannerisms, pranks, hypochondriac complaints and reiterated phrases
Disorganised thought and speech
Delusions and hallucinations are fleeting and fragmentary
Adolescence/young adult onset
Poor prognosis due to rapid development of negative symptoms

137
Q

DSM IV diagnostic criteria for Sz

A

2 of 5 main symptoms present for a significant number of time in 1 month, present for 6 months
Delusions
Hallucinations
Disorganised speech
Movement
Negative symptoms

138
Q

Management of Sz

A
  1. Antipsychotic 1
  2. Antipsychotic 2
  3. Clozapine (Sz that does not respond to two consecutive trials of antipsychotics (TRSz) should be given clozapine)
139
Q

Presentation and management of peurperal psychosis

A

Onset usually within the first 2-3 weeks following birth

Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

Admission to hospital is usually required, ideally in a Mother & Baby Unit

140
Q

What is schizoaffective disorder

A

Schizoaffective disorder is characterised by abnormal thought processes and an unstable mood. This diagnosis is made when the person has symptoms of both schizophrenia (usually psychosis) and a mood disorder: either bipolar disorder or depression.

The main criterion for a diagnosis of schizoaffective disorder is the presence of psychotic symptoms for at least two weeks without any mood symptoms present.

On a ranking scale of symptom progression of mental health issues relating to the schizophrenic spectrum, a mood disorder would be the first diagnosis; as symptoms progress it would then be diagnosed as schizoaffective disorder, and if symptoms progress even more it would then be diagnosed as schizophrenia, with other disorders included on the ranking as well depending on symptoms.

141
Q

What is dementia

A

Progressive IMPairment of Intellect, Memory and Personality resulting in impairment in the activities of daily living

142
Q

MMSE scoring

A

20-26 = mild cognitive impairment
10-20 = moderate impairment
less than 10 indicates severe impairment.

MMSE <25 supports dementia. 25-27 is borderline.

143
Q

Investigations for dementia

A

MMSE
(confusion screen)
FBC
Metabolic panel
TSH
B12, folate
Urine drug screen
Structural imaging is recommended at least once during the work-up

144
Q

insidious onset, Loss of ability to learn, process and retain new info, memory loss especially for names and recent events, language deficits, rapid forgetting, normal gait and neuro exam early

A

alzhimers

145
Q

Alzhimers on imaging

A

generalised atrophy (esp medial temporal and parietal later), beta amyloid plaques amyloid plaques and neurofibrillary (tangles tau protein tangles within brain cells)

146
Q

Management of alzhimers

A
  1. Supportive treatment, environmental control measures
  2. Acetylcholinesterase inhibitors such as donepezil (can slow progression), galantamine and rivastigmine. SE diarrhoea

Manage depression (sertraline) manage dementia-related psychosis (risperidone) manage insomnia (trazodone)

  1. Memantine (an N-methyl-D-aspartate antagonist). SE constipation
147
Q

Name 3 Anticholinesterase inhibitors

A

donepezil

galantamine

rivastigmine

148
Q

What can anticholinesterase inhibiors cause? need to check before?

A

Unsafe if have QT prolongation, third degree heart block, sinus bradycardia - always check ECG before prescribing

149
Q

Side effects of anticholinesterase inhibitors

A

cholinergic side effects such as diarrhoea, nausea and vomiting, bradycardia, increased salivary production and urinary incontinence.

150
Q

what type of drug is memantine? SE?

A

N-methyl-D-aspartate antagonist

SE constipation

151
Q

donepezil SE

A

insomnia

152
Q

abrupt or gradual onset, focal neurological signs, stepwise deterioration in someone with previous cardiovascular illness or events.

A

vascular dementia

153
Q

imaging vascular dementia

A

strokes, lunacar infarcts, white matter lesions, vulnerable to CVS events

Brain MRI would show old infarcts and TIAs

154
Q

Management of vascualr dementia

A

Antiplatelet therapy (aspirin, clopidogrel)

Carotid angioplasty/stenting etc

BP control, glycaemic control, statins

155
Q

Scan for vascuar dementia

A

MRI

156
Q

insidious onset, progressive with fluctuations, fluctuating cognition, visual hallucinations, neuroleptic sensitivity, shuffling gait, increased tone, tremors, falls.

A

LBD

157
Q

Scans LBD

A

generalised atrophy, lewy bodies in cortex and midbrain.

single-photon emission CT (SPECT) or positron emission tomography (PET) shows reduced dopamine transporter uptake in basal ganglia

158
Q

Scan for LBD

A

SPECT or PET

159
Q

Manageemnt LBD

A
  1. anticholinesterase inhibitors or NMDA

AVOID neuroleptics

160
Q

Insidious onset, 50-60yo, rapid progression, sibinhibition, socially inappropriate, poor judgement, apathy, poor executive function, impulsivity. No movement abnormalities

A

Frontotemporal dementia/Picks

161
Q

Imaging frontotemporal dementia

A

MRI shows significant atrophy of the frontal and temporal lobes. Pick cells and pick bodies in cortex

Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease

162
Q

Most common frontotemporal dementia

A

Picks disease

163
Q

Presentation picks disease

A

This is the most common type and is characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.

164
Q

Management frontotemporal dementia

A

supportive care, benzos, antipsychotics

don’t use acetylcholinesterase inhibitors or memantine

165
Q

Dementia, Dermatitis, Diarrhoea

A

Pellagra

Caused by vitamin B3 (niacin) deficiency

Alcoholism and chron’s are risk factors for pellagra due to malnutrition/malabsorption. Pellagra may occur as a consequence of isoniazid therapy (isoniazid inhibits the conversion of tryptophan to niacin).

166
Q

Wet, wobbly and weird

A

normal pressure hydrocephalus

167
Q

Investigation for normal pressure hydrocephalus?

A

lumbar puncture, if relieving pressure resolves symptoms then a ventriculoperitoneal shunt would be inserted

168
Q

Imagine normal pressure hydrocephalus

A

On CT, enlarged ventricles and absent sulci. Pressure normal as sulci are absent to compensate. No raised intracranial pressure.

169
Q

Presentation and management wernikes

A

ataxia, ophthalmoplegia, nystagmus and acute confusional state

Treatment is with urgent replacement of thiamine (vitamin B1)

170
Q

side effects of ECT

A

retrograde amnesia

171
Q

features korsakoffs

A

anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation

172
Q

factors suggesting depression over delirium

A

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)

answering ‘I dont know”

173
Q

Causes delirium

A

PINCH ME
Pain
Infection (particualrly UTI)
Nutrition

Constipation (think post surgery, think constpating meds eg codeine, ondansetron)

Hydration + electrolytes
Medication
Environement

174
Q

features delirium

A

memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention

175
Q

Management delirium

A
  1. treat underlying cause and modification of environement
  2. haloperidol 0.5 mg or olanzapine

If parkinsons, use benzo or atypical (last resort)

176
Q

A form of frontotemporal dementia (FTD). Peak age onset 55-65. The ability to associate meaning to objects presented via the visual or auditory modalities.

A

semantic dementia

177
Q

Features of lithium toxicity

A

Levels >1
Increased reflexes
Tremor coarse
Hypotension
Increased tone
Upset stomach (N+V)
Myoclonus
Seizures

Oligogyric renal failure
Ataxia

178
Q

Features of autism

A
  • impaired social communication and interaction
  • repetitive behaviours, interests and activities
  • unusual/delayed language
179
Q

features of ADHD

A

Very short attention span
Quickly moving from one activity to another
Quickly losing interest in a task and not being able to persist with challenging tasks
Constantly moving or fidgeting
Impulsive behaviour
Disruptive or rule breaking

180
Q

Management ADHD

A
  1. 10 week watch and wait
  2. Referral to secondary care
  3. Methylphenidate (“Ritalin“) >5 years old, 6 week trial
  4. lisdexamfetamine
  5. Dexamfetamine if can’t tolerate SE of lisdexamdetamine
181
Q

Management ASD

A

Early educational and behavioural interventions

Family support and counselling

Severe:
SSRIs: helpful to reduce symptoms like repetitive stereotyped behaviour, anxiety, and aggression
Antipsychotic drugs: useful to reduce symptoms like aggression, self-injury

182
Q

Pharamcology methylphenidate

A

CNS stimulant which primarily acts as a dopamine/norepinephrine reuptake inhibitor

183
Q

Side effects and monitoring ADHD drugs

A

SE:
- stunted growth (In children, weight and height should be monitored every 6 months)
- cardiotoxic (baseline ECG)
- abdominal pain, nausea and dyspepsia

184
Q

Opiod drugs - withdrawal, treatment etc

A

Methodone - transition from use to abstience
Buprono - safer and used when not taking
Naltrexone - prevent relapse as it makes it shit
Lofexidine - reduce withdrawal symptoms
Naloxone - for overdose

185
Q

Alcohol drugs for getting off it

A

Disulfiram - if you take alcohol you’ll be sick so its a deterrent
Acamprosate - reduces craving
Naltrexone - prevent relapse coz makes it not pleasurable

186
Q

Smoking drugs for cessation

A

varenciline/champix- reduces craving - think V
bupropion- reduces pleasure - think p
NRT -

187
Q

SE disulfiram

A

halitosis (bad breath), short of breath, consuming alcohol could be fatal

188
Q

mechanism disulfiram

A

irreversible inhibitor of acetyl dehydrogenase

189
Q

mechanism acamprosate

A

blocks the effect of glutamate and boosts GABA

190
Q

Alcohol effect

A

depressant

191
Q

amphetamine effect

A

(speed)
stimulant

192
Q

methamphetamine effect

A

(meth, mdma/ecstacy)
stimulant

193
Q

buprenorphine effect

A

opiods
depressant

194
Q

cannibis stimulant or depressent

A

depressant

195
Q

cocaine effect

A

stimulant

196
Q

ketamine effect

A

depressant/hallicinogen

197
Q

Are barbituates stimulant or depressant

A

depressant

198
Q

benzo effect

A

depressent

199
Q

benzo effect

A

depressent

200
Q

LSD effect

A

hallucinogen

201
Q

Management LSD intoxication

A
  1. Benzos if agitated
  2. May use antipsychotic if psychosis has been induced
202
Q

What drugs cause mydriasis

A

cocaine
LSD
MDMA

203
Q

Missed doses of clozapine

A

If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly

204
Q

Mechanism benzodiazepines?

A

enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.

205
Q

Side effects/risks benzodiazepines

A

anterograde amnesia
Highly addictive
Withdrawal and overdose risks

206
Q

Short acting benzos

A

Temazepam
Lorazepam

207
Q

Long acting benzos

A

Chlordiazepoxide
Diazepam

208
Q

depression vs dementia

A

depression:
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)

209
Q

genetic risk sz

A

monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%

210
Q

invgn if elderly person 1st presentation psychosis

A

A CT head scan

211
Q

SSI choice for OCD with body dysmorphic disorder

A

fluoxetine

212
Q

Physiological changes anorexia nervosa

A

Most things low
BMI
Bradycardia
Hypotension
Potassium
FSH, LH
Oestrogen and testosterone

G&C raised
Growth hormone
Glucose
Salivary Glands
Cortisol
Cholesterol
Carotenemia

213
Q

Management anorexia

A

For adults with anorexia nervosa, NICE recommend we consider one of:
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
specialist supportive clinical management (SSCM).

In children and young people, NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. The second-line treatment is cognitive behavioural therapy.

214
Q

Metabolic consequences re-feeding syndrome

A

KPMg

Hypophosphatemia
Hypokalaemia
Hypomagnesaemia
Abnormal fluid balance

215
Q

Management/prevention re-feeding

A

Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days
Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements
Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)

216
Q

Management opiod overdose

A

IV or IM naloxone :

rapid onset and short half life so need more than one dose often
Initially 400 micrograms, then 800 micrograms for up to 2 doses at 1-minute intervals if no response to preceding dose, then increased to 2 mg for 1 dose if still no response (4 mg dose may be required in seriously poisoned patients)

217
Q

criteria for liver transplant following paracetamol overdose

A

Arterial pH < 7.3, 24 hours after ingestion

or all of the following:
prothrombin time > 100 seconds
creatinine > 300 µmol/l
grade III or IV encephalopathy

218
Q

Management paracetamol overdose

A

if presented within 1 hour: activated charcoal

if present after: IV Acetylcysteine is now infused over 1 hour

219
Q

Reaction to acetylcystine management?

A

Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release).

Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.

220
Q

TCA overdose

A

Clinical features of TCA overdose include confusion, seizure, tachycardia, hypotension and dilated pupils (mydriasis). In addition, TCA overdose can cause ECG changes (eg. prolonged QRS duration and QTc interval) and metabolic acidosis.

221
Q

ecg refeeding syndrome

A

prominent u waves due to hypokalaemia

222
Q

Electrolytes in re-feeding

A

Low KPMg

K - potassium
P - phosphate
Mg - magnesium

223
Q

Management re-feeding

A

electrolytes and vitamin B/thiamine

224
Q

How does heroin withdrawal present?

A

Withdrawal from opioids presents in a flu-like manner with gastrointestinal upset (abdominal pain, diarrhoea), sympathetic hyperactivity (tachycardia and hypertension) and central nervous system (CNS) stimulation.

Agitation
Anxiety
Muscle aches or cramps
Chills
Runny eyes
Runny nose
Sweating
Yawning
Insomnia
Gastrointestinal disturbance such as abdominal cramps, nausea, diarrhoea and vomiting
Dilated pupils
‘Goose bump’ skin
Increased heart rate and blood pressure
Symptoms usually occur within 12 hours of stopping the drug. The withdrawal syndrome is unpleasant but not life-threatening.

225
Q

features of cannibis intoxication

A

drowsiness, impaired memory, slowed reflexes and motor skills, bloodshot eyes, increased appetite, dry mouth, increased heart rate and paranoia.

226
Q

what is AUDIT score

A

Alcohol use disorders identification test (AUDIT)

AUDIT is a comprehensive 10 question alcohol harm screening tool. It was developed
by the World Health Organisation (WHO) and modified for use in the UK and has been
used in a variety of health and social care settings

0 to 7 indicates low risk
● 8 to 15 indicates increasing risk
● 16 to 19 indicates higher risk,
● 20 or more indicates possible dependence

227
Q

triad LBD

A

REM sleep disorder, a history of falls (secondary to motor problems), and hallucinations.

228
Q

blood tests before lithium

A

tft
u&e

229
Q

risk factors charles bonnet

A

Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment

230
Q

management panic disorder

A

NICE recommend either cognitive behavioural therapy or drug treatment

SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

231
Q

indications ECT

A

treatment resistant severe depression
manic episodes
an episode of moderate depression know to respond to ECT in the past
life threatening catatonia

232
Q

what type of drug is bupronorphine

A

opioid agonist/antagonist

given sublingual

233
Q

Monitoring clozapine

A

Monitor leucocyte and differential blood counts. Clozapine requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly as part of the clozapine patient monitoring service.

Blood clozapine concentration should be monitored in certain clinical situations—consult product literature.

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