Psychiatry Flashcards
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
Borderline personality disorder
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
Paranoid
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
Schizoid
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
Schizotypal
What is in cluster A personality disorders
Odd or eccentric
- paranoid
- schizoid
- schizotypal
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
Antisocial
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
Borderline
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
Histrionic
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
Narcissistic
What is cluster B
dramatic, emotional, or erratic
- antisocial
- histrionic
- borderline
- narcissist
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
Obsessive compulsive personality disorder
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
Avoidant personality disorder
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
Dependant personality disorder
What is in cluster C personality disorders
Anxious and fearful
- avoidant
- obsessive compulsive
- dependant
Management of personality disorders
Dialectical behaviour therapy
What might you need to co-prescribe alongside SSRI
PPI such as omeprazole
If risks such as NSAID
Strongest risk factor for SZ
Family history
delusional jealously, usually believing their partner is unfaithful
Othello syndrome
Alcohol withdrawal symptom timeline
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
Therapeutic range lithium
0.4-1.0 mmol/L
Adverse affects of lithium
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)
After a change in dose, how often should lithium levels be checked
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
When should thyroid and renal be checked when patients taking lithium
Every 6 months
Delusional belief that they (or in some cases just a part of their body) is either dead or non-existent.
Cotard syndrome
Cotard syndrome is associated with severe depression and psychotic disorders.
Factors that increase risk of completed suicide
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method
Protective factors suicide
family support
having children at home
religious belief
Factors increased risk of suicide
male sex (hazard ratio (HR) approximately 2.0)
history of deliberate self-harm (HR 1.7)
alcohol or drug misuse (HR 1.6)
history of mental illness
depression
schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
history of chronic disease
advancing age
unemployment or social isolation/living alone
being unmarried, divorced or widowed
Lithium and white cells
Lithium can ppt benign leukocytosis
Apart from drugs, what should be offered to all patients with Sz
CBT
Triad of PTSD
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
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.
Avoidant
Kosakoff syndrome features
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation
Illness anxiety disorder (hypochondriasis)
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Dissociative disorder
dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Factitious disorder
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
Somatisation
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
Perseveration
repeating the same words/answers
Echolalia
repeating exactly what someone has said.
Neologism
making up new words.
Word salad
disorganised speech, sentences that do not make sense.
Clozapine and smoking
Increase causes decrease and vice versa
Smoking cessation can cause a rise in clozapine blood levels
Delusional belief that a famous person is in love with them
Erotomania (De Clerambault’s syndrome)
Management traduce dyskinesia moderate/severe
Tetrabenazine
what screening tool is used for postnatal depression
Edinburgh scale
name 5 SSRIs
Sertraline
Citalopram
Escitalopram
Fluoxetine
Paroxetine
most common side effect ssris
GI disturbance
Complications of SSRIs
- QT prolongation / ventricular arrhythmias including torsade de pointes in citalopram
- Hyponatremia
- SSRI discontinuation syndrome
Interactions SSRIs
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
SSRI in first trimester can cause?
congenital heart defects
SSRI in third trimester can cause?
persistent pulmonary hypertension of the newborn
worst SSRI pregnancy
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
SSRIs of choice in breastfeeding women
Sertraline or paroxetine
SSRI of choice post MI
Sertraline
SSRI of choice children
fluoxetine
Name 2 SNRIs
Venlafaxine
Duloxetine
Side effects SNRIs
include nausea/vomiting, sweating, loss of appetite, dizziness, headache, increase in suicidal thoughts, and sexual dysfunction.
Complication SNRI
HTN
(Elevation of norepinephrine levels can sometimes cause anxiety, mildly elevated pulse, and elevated blood pressure. )(monitor before initiation and after titration)
Name 3 TCAs
Imipramine
Clomipramine
Amitriptyline
Mechanism TCAs
inhibit the reuptake of serotonin and noradrenaline.
Side effects TCAs?
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
Name 1 NaSSA
Mirtazapine
Mechanism NaSSA
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.
Side effects mirtazapine?
Sedative
Increases appetite
Name 3 MAOIs
Isocarboxazid
Phenelzine
Tranylcypromine
Complication MAOI
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
Dizziness, electric shock sensations and anxiety
SSRI discontinuation syndrome
how to prevent SSRI discontinuation syndrome?
reduce gradually over 4 weeks
Neuromuscular excitation
- hyperreflexia
- myoclonus
- rigidity
autonomic nervous system excitation
- hyperthermia
- sweating
altered mental state
- Confusion
seretonin syndrome
management seretonin syndrome
supportive including IV fluids
benzodiazepines
more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
acute management bipolar disorder
Consider stopping antidepressant and + antipsychotic therapy (e.g olanzapine or haloperidol)
long term management bipolar
Lithium
Valproate
Psychological interventions
Fluoxetine
Comorbidities
Flight of ideas
Jumping between ideas but with discernible links between topics
Knights move?
Jumping between ideas without discernible links
Difference between mania and hypomania
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
referral from primary care ?bipolar
Hypomania → routine referral to CMHT
Mania → urgent referral to CMHT
what is baby blues? management?
60-70% women
3-7 days following birth, more common in primips
Anxious, tearful, irritable
Management : reassurance and support, health visitor
what is post natal depression? peak? management?
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
Management of PMDD
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)
How long should SSRI be continued after resolution of depression to prevent relapse
6 months
How long should SSRI be continued after resolution of anxiety state to prevent relapse
12 months
Define major depressive disorder
the presence of 5 symptoms in same 2 week period that represent a change from previous functioning
managment mild MDD
- Psychotherapy 1. Consider antidepressant
- alternative antidepressant
- St Johns wart
management moderate MDD
- Antidepressant + psychotherapy + immediate symptom management
- Alternative antidepressant
management severe MDD
- Psych rf +/- admisison + antidepressant or ECT
- switch to alternative
management treatment resistant MDD
- Reassess and switch antidepressants
- Consider augmentation (Li, aripiprazole, olanzapine) + psychotherapy
- MAOI
- ECT
what is GAD
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.
diagnostic criteria GAD?
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
Management of GAD?
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
Management of obsessive compulsive disorder
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
what is acute stress disorder
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.
management acute stress disorder
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
Management PTSD
- trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy
- venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried.
- In severe cases, NICE recommends that risperidone may be used
delusion: belief is or soon will be destitute
delusion of poverty
ekboms
Parasitosis (ekoms) : belief there are parasites/bugs under skin
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
Depersonalisation
experiencing thoughts, actions and feelings as being foreign or manufactured against their will by a foreign influence
passivity
delusional belief of body sensations from an external source
Somatic passivity
actions feel controlled by an external influence
Made act passivity
Thought alienation
Thought insertion
Thought withdrawal
Thought broadcasting
delusion that a familiar person has been replaced by an imposter (a delusion of misidentification)
capgras
that a stranger is a familiar person in disguise (a delusion of misidentification
Fregoli delusion
a sense of one’s surrounding lacking reality, often looking dull, grey, lifeless
Derealisation
that unrelated occurrences in the external world have a special significance for the patient
Delusion of reference
seeing lights, colours, geometric shapes, and indiscrete objects
Elementary visual hallucinations
feeling that someone standing behind you
extracampine hallucination
hallucinations when waking up
Hypnopompic
hallucinations when going to sleep
Hypnagogic
Circumstantiality
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.
Tangentiality
refers to wandering from a topic without returning to it.
ideas are related to each other only by the fact they sound similar or rhyme.
clang associations
Perseveration
the repetition of ideas or words despite an attempt to change the topic
Haloperidol
typical antipsychotic
flupenthixol
typical antipsychotic
chloropromazine
typical antipsychotic
are EPSE more common with typical or atypical
typical
Typical antipsychotics are unselective in their blocking effect at the dopamine D2 receptor and so decrease positive symptoms and increase negative symptoms.
What are the 4 types of EPSE
Parkinsonism
Acute dystonia
Akathisia
Tardive dyskinesia
sustained muscle contraction (e.g. torticollis, oculogyric crisis)
diagnosis and manegemnt?
acute dystonia
procyclidine
on antipsychotic
late onset of choreoathetoid movements, abnormal, involuntary, most common is chewing and pouting of jaw
diagnosis and management
tardive dyskinesia
tetrabenazine
what typical antipsychotic is associated with long QT
haloperidol
other side effects of typical antipsychotics other than EPSE
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)
young patients with tachycardia and tachypnoea, hypertension, fever, muscle rigidity, hyporeflexia
diagnosis? invetsigation? management?
Neuroleptic malignant syndrome
Elevated CK
- immediate cessation of the dopamine antagonist (or restarting or continuing of the dopamine agonist)
- admission to medical ward
- IV fluids to prevent renal failure
- 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 - 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
olanzapine
atypical antipsychotic
risperidone
atypical antipsychotic
quetiapine
atypical antipsychotic
amisulpride
atypical antipsychotic
aripiprazole
atypical antipsychotic
clozapine
atypical antipsychotic
Side effects of atypical antipsychotics
weight gain
clozapine is associated with agranulocytosis
Hyperprolactinaemia
Elderly : increased risk of stroke
Elderly : increased risk of venous thromboembolism
Adverse effects of clozapine
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
What do you need to monitor clozapine
FBC
name 3 typcial antipsychotics
Haloperidol
Flupenthixol
Chlorpromazine
Psychosis bad prognostic indicators
Gradual onset
History of social withdrawal
Strong family history
Lack of obvious precipitant eg trauma
low IQ
management psychosis
atypical antipsychotic
Schneider’s first rank symptoms
Acronym WASBID
Withdrawal (thought)
Auditory hallucinations
Somatic passivity/control
Broadcasting (thought)
Insertion (thought)
Delusional perception
Paranoid Sz
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
Hebephrenic Sz
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
DSM IV diagnostic criteria for Sz
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
Management of Sz
- Antipsychotic 1
- Antipsychotic 2
- Clozapine (Sz that does not respond to two consecutive trials of antipsychotics (TRSz) should be given clozapine)
Presentation and management of peurperal psychosis
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
What is schizoaffective disorder
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.
What is dementia
Progressive IMPairment of Intellect, Memory and Personality resulting in impairment in the activities of daily living
MMSE scoring
20-26 = mild cognitive impairment
10-20 = moderate impairment
less than 10 indicates severe impairment.
MMSE <25 supports dementia. 25-27 is borderline.
Investigations for dementia
MMSE
(confusion screen)
FBC
Metabolic panel
TSH
B12, folate
Urine drug screen
Structural imaging is recommended at least once during the work-up
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
alzhimers
Alzhimers on imaging
generalised atrophy (esp medial temporal and parietal later), beta amyloid plaques amyloid plaques and neurofibrillary (tangles tau protein tangles within brain cells)
Management of alzhimers
- Supportive treatment, environmental control measures
- Acetylcholinesterase inhibitors such as donepezil (can slow progression), galantamine and rivastigmine. SE diarrhoea
Manage depression (sertraline) manage dementia-related psychosis (risperidone) manage insomnia (trazodone)
- Memantine (an N-methyl-D-aspartate antagonist). SE constipation
Name 3 Anticholinesterase inhibitors
donepezil
galantamine
rivastigmine
What can anticholinesterase inhibiors cause? need to check before?
Unsafe if have QT prolongation, third degree heart block, sinus bradycardia - always check ECG before prescribing
Side effects of anticholinesterase inhibitors
cholinergic side effects such as diarrhoea, nausea and vomiting, bradycardia, increased salivary production and urinary incontinence.
what type of drug is memantine? SE?
N-methyl-D-aspartate antagonist
SE constipation
donepezil SE
insomnia
abrupt or gradual onset, focal neurological signs, stepwise deterioration in someone with previous cardiovascular illness or events.
vascular dementia
imaging vascular dementia
strokes, lunacar infarcts, white matter lesions, vulnerable to CVS events
Brain MRI would show old infarcts and TIAs
Management of vascualr dementia
Antiplatelet therapy (aspirin, clopidogrel)
Carotid angioplasty/stenting etc
BP control, glycaemic control, statins
Scan for vascuar dementia
MRI
insidious onset, progressive with fluctuations, fluctuating cognition, visual hallucinations, neuroleptic sensitivity, shuffling gait, increased tone, tremors, falls.
LBD
Scans LBD
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
Scan for LBD
SPECT or PET
Manageemnt LBD
- anticholinesterase inhibitors or NMDA
AVOID neuroleptics
Insidious onset, 50-60yo, rapid progression, sibinhibition, socially inappropriate, poor judgement, apathy, poor executive function, impulsivity. No movement abnormalities
Frontotemporal dementia/Picks
Imaging frontotemporal dementia
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
Most common frontotemporal dementia
Picks disease
Presentation picks disease
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.
Management frontotemporal dementia
supportive care, benzos, antipsychotics
don’t use acetylcholinesterase inhibitors or memantine
Dementia, Dermatitis, Diarrhoea
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).
Wet, wobbly and weird
normal pressure hydrocephalus
Investigation for normal pressure hydrocephalus?
lumbar puncture, if relieving pressure resolves symptoms then a ventriculoperitoneal shunt would be inserted
Imagine normal pressure hydrocephalus
On CT, enlarged ventricles and absent sulci. Pressure normal as sulci are absent to compensate. No raised intracranial pressure.
Presentation and management wernikes
ataxia, ophthalmoplegia, nystagmus and acute confusional state
Treatment is with urgent replacement of thiamine (vitamin B1)
side effects of ECT
retrograde amnesia
features korsakoffs
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation
factors suggesting depression over delirium
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”
Causes delirium
PINCH ME
Pain
Infection (particualrly UTI)
Nutrition
Constipation (think post surgery, think constpating meds eg codeine, ondansetron)
Hydration + electrolytes
Medication
Environement
features delirium
memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention
Management delirium
- treat underlying cause and modification of environement
- haloperidol 0.5 mg or olanzapine
If parkinsons, use benzo or atypical (last resort)
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.
semantic dementia
Features of lithium toxicity
Levels >1
Increased reflexes
Tremor coarse
Hypotension
Increased tone
Upset stomach (N+V)
Myoclonus
Seizures
Oligogyric renal failure
Ataxia
Features of autism
- impaired social communication and interaction
- repetitive behaviours, interests and activities
- unusual/delayed language
features of ADHD
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
Management ADHD
- 10 week watch and wait
- Referral to secondary care
- Methylphenidate (“Ritalin“) >5 years old, 6 week trial
- lisdexamfetamine
- Dexamfetamine if can’t tolerate SE of lisdexamdetamine
Management ASD
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
Pharamcology methylphenidate
CNS stimulant which primarily acts as a dopamine/norepinephrine reuptake inhibitor
Side effects and monitoring ADHD drugs
SE:
- stunted growth (In children, weight and height should be monitored every 6 months)
- cardiotoxic (baseline ECG)
- abdominal pain, nausea and dyspepsia
Opiod drugs - withdrawal, treatment etc
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
Alcohol drugs for getting off it
Disulfiram - if you take alcohol you’ll be sick so its a deterrent
Acamprosate - reduces craving
Naltrexone - prevent relapse coz makes it not pleasurable
Smoking drugs for cessation
varenciline/champix- reduces craving - think V
bupropion- reduces pleasure - think p
NRT -
SE disulfiram
halitosis (bad breath), short of breath, consuming alcohol could be fatal
mechanism disulfiram
irreversible inhibitor of acetyl dehydrogenase
mechanism acamprosate
blocks the effect of glutamate and boosts GABA
Alcohol effect
depressant
amphetamine effect
(speed)
stimulant
methamphetamine effect
(meth, mdma/ecstacy)
stimulant
buprenorphine effect
opiods
depressant
cannibis stimulant or depressent
depressant
cocaine effect
stimulant
ketamine effect
depressant/hallicinogen
Are barbituates stimulant or depressant
depressant
benzo effect
depressent
benzo effect
depressent
LSD effect
hallucinogen
Management LSD intoxication
- Benzos if agitated
- May use antipsychotic if psychosis has been induced
What drugs cause mydriasis
cocaine
LSD
MDMA
Missed doses of clozapine
If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly
Mechanism benzodiazepines?
enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.
Side effects/risks benzodiazepines
anterograde amnesia
Highly addictive
Withdrawal and overdose risks
Short acting benzos
Temazepam
Lorazepam
Long acting benzos
Chlordiazepoxide
Diazepam
depression vs dementia
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)
genetic risk sz
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%
invgn if elderly person 1st presentation psychosis
A CT head scan
SSI choice for OCD with body dysmorphic disorder
fluoxetine
Physiological changes anorexia nervosa
Most things low
BMI
Bradycardia
Hypotension
Potassium
FSH, LH
Oestrogen and testosterone
G&C raised
Growth hormone
Glucose
Salivary Glands
Cortisol
Cholesterol
Carotenemia
Management anorexia
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.
Metabolic consequences re-feeding syndrome
KPMg
Hypophosphatemia
Hypokalaemia
Hypomagnesaemia
Abnormal fluid balance
Management/prevention re-feeding
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)
Management opiod overdose
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)
criteria for liver transplant following paracetamol overdose
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
Management paracetamol overdose
if presented within 1 hour: activated charcoal
if present after: IV Acetylcysteine is now infused over 1 hour
Reaction to acetylcystine management?
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.
TCA overdose
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.
ecg refeeding syndrome
prominent u waves due to hypokalaemia
Electrolytes in re-feeding
Low KPMg
K - potassium
P - phosphate
Mg - magnesium
Management re-feeding
electrolytes and vitamin B/thiamine
How does heroin withdrawal present?
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.
features of cannibis intoxication
drowsiness, impaired memory, slowed reflexes and motor skills, bloodshot eyes, increased appetite, dry mouth, increased heart rate and paranoia.
what is AUDIT score
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
triad LBD
REM sleep disorder, a history of falls (secondary to motor problems), and hallucinations.
blood tests before lithium
tft
u&e
risk factors charles bonnet
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
management panic disorder
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
indications ECT
treatment resistant severe depression
manic episodes
an episode of moderate depression know to respond to ECT in the past
life threatening catatonia
what type of drug is bupronorphine
opioid agonist/antagonist
given sublingual
Monitoring clozapine
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.
