psychiatry Flashcards

1
Q

Section 2
Duration
Professionals
Evidence

A

Assessment
28 days (not renewable)
TWO doctors (one S12 approved)
ONE approved mental health professional (AMHP)
When a px is suffering a mental disorder of a nature that warrants detention in hx for assessment (+ they are not consenting)
When a px needs to be detained for their own/others safety

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2
Q

Section 3
Duration
Professionals
Evidence

A

Treatment
6 months (renewable)
TWO doctors (one S12 approved)
ONE approved mental health professional (AMHP)
When a px is suffering a mental disorder of a nature that makes it appropriate for them to receive tx in hx (+ they are not consenting)
Their tx is in the interests of theirs/others health + safety
There must be appropriate tx available

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3
Q

Section 4
Duration
Professionals
Evidence

A

Emergency order - urgent necessity to hold px until assessment by S12 doc
72 hrs
ONE doctor, ONE AMHP
There is not enough time for a second doctor to attend

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4
Q

Section 5 (4)
Duration
Professionals
Evidence

A

For a px already admitted (can be under psych or general hx) + is wanting to leave
6 hrs
NURSES holding power until a doctor can attend
Cannot be tx coercively whilst under this section

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5
Q

Section 5 (2)
Duration
Professionals
Evidence

A

For a px already admitted (can be under psych or general hx) + is wanting to leave
72 hrs
DOCTORS holding power
Allows time for a section 2/3 assessment

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6
Q

Section S136

A

Police section
Person suspected of having a mental disorder in a public place (A&E counts!)
24 hrs

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7
Q

Section S135

A

Police section
Needs court order to access px home + remove them
36 hrs

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8
Q

what are the factors assoc w poor prognosis in schizophrenia

A

strong FHx
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant

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9
Q

what are first rank sx

A

thought alienation
passivity phenomena
3rd person auditory hallucinations (he/she)
delusional perception

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10
Q

risk of developing schizophrenia if
monozygotic twin has it
parent
sibling
none

A

50%
10-15%
10%
1%

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11
Q

RFs for dev schizophrenia (in order of biggest to lowest)

A

FHx
Black caribbean
Migration
Urban environments
Cannabis use

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12
Q

risk factors for suicide

A

SAD PERSONS

Sex - male 2.0
Age - <19, >45
Depression

Prev attempt
Excess alcohol/substance use
Rational thinking loss
Social support lacking
Organised plan
No spouse
Sickness

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13
Q

depression sx

A

fatigue
low mood
anhedonia

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14
Q

mild depression

A

> 2 wks sx, 2/3 main sx, 5+ generalised sx

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15
Q

how to end SSRIs if gd response

A

continue for 6 months after remission to decrease relapse risk
then reduce dose over 4 wk period (don’t need to w fluoxetine)

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16
Q

when to avoid citalopram

A

if taking meds that cld prolong QT interval, check hx cardiac disease
will need to do ECG monitoring

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17
Q

what does paroxetine have increased incidence of

A

discontinuation sx

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18
Q

which SSRI to used post MI/unstable angina

A

sertraline

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19
Q

electrolyte abnormality to observe for w SSRIs

A

hyponatraemia
be careful in elderly especially

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20
Q

which SSRI to use in children

A

fluoxetine

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21
Q

what to check before starting SNRI

A

BP as can dev HTN

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22
Q

side effects of mirtazapine (SNRI)

A

weight gain + sedation

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23
Q

SEs of tricyclic antidepressants

A

can’t pee, can’t see, can’t shit, can’t spit
weight gain
long QT

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24
Q

SNRI egs

A

mirtazapine
duloxetine
venlafaxine

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25
what to do if on SSRI + NSAID
take PPI as increased bleeding risk
26
tricyclic antidepressant (amitriptyline) OD
confusion seizure tachy hypotension dilated pupils metabolic acidosis long QT, wide QRS
27
tx tricyclic antidepressant (amitriptyline) OD
IV sodium bicarbonate
28
triad in wernicke's encephalopathy
nystagmus ophthalmoplegia ataxia
29
korsakoff's syndrome
untreated wernicke's encephalopathy - antero + retrograde amnesia confabulation
30
what is wernicke's encephalopathy
neuro dis caused by thiamine (v B1) deficiency most common in alcoholics
31
tx wernicke's encephalopathy
give thiamine (pabrinex)
32
what is Disulfiram
alcohol detox drug to Discourage give you unpleasant sx within 20-30 mins of drinking alcohol
33
what is alcomposate
alcohol detox drug enhancing GABA transmission anti-craving
34
what is naltrexone
alcohol detox drug, an opioid antagonist decreases cravings + pleasurable ex
35
6-12 hrs alcohol withdrawal
sweaty tremor tachy anxiety
36
peak incidence of seizures in alcohol withdrawal
36 hrs
37
what is delirium tremens
48-72 hrs after alcohol withdrawal coarse tremor confusion delusions auditory + visual hallucinations fever tachy
38
tx delirium tremens
long acting benzos - chlordiazepoxide
39
what is malingering
faking sx for material gain
40
what is munchausens / factitious disorder
self inflicted sx / fabricated illness you create sx can be by proxy
41
what is somatisation
multiple physical sx for 2+ yrs w no medical explanation px refuses to accept reassurance/-ve tests
42
what is hypochondriasis
persistent belief in presence of underlying serious disease (usually focuses on one body system / cancer) px refuses to accept reassurance/-ve tests
43
what is conversion disorder
loss of motor/sensory function with no neuro cause may be caused by stress Don't consciously feign/seek gain
44
what is akathisia
inner restlessness, inability to keep still
45
difference between depersonalisation + derealisation
depersonalisation is yourself derealisation is everything around you
46
what is hoover's sign
used to differentiate organic from non-organic leg paralysis If non-organic will feel oressure under paretic leg when lifting normal leg against pressure (invol contra hip extension)
47
PTSD sx + when is it dx
re-experiencing - flashbacks, nightmares avoidance hyperarousal - hyper vigilance, sleep probs 4 wks after event (b4 4 wks it is acute stress disorder) emotional detachment
48
PTSD tx
eye movement desensitisation + reprocessing therapy
49
acute stress disorder tx
trauma focused CBT
50
SEs clozapine
decreases seizure threshold agranulocytosis (need FBC monitoring) neutropenia constipation myocarditis (take baseline ECG b4 starting tx) hypersalvation
51
when to give clozapine in schizophrenia
if it does not respond to 2 consecutive trials of antipsychotics
52
what to do if clozapine doses missed for >48 hrs
re titrate again slowly
53
clozapine + smoking
smoking cessation can cause an increase in clozapine levels
54
when would you get an abnormal grief reaction
6+ months after
55
when do you have chronic insomnia
3+ months 3/7 nights a week
56
tx chronic insomnia
sleep hygiene hypnotics only if daytime impairment is severe - short acting benzos/nonbenzos - zopiclone lowest effective dose for shortest time review after 2 wks + consider CBT
57
features assoc w insomnia
Female gender Increased age Lower educational attainment Unemployment Economic inactivity Widowed, divorced, or separated status
58
RFs insomnia
Alcohol and substance abuse Stimulant usage Medications such as corticosteroids Poor sleep hygiene Chronic pain Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population. Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.
59
knights move
unexpected and illogical leaps from one idea to another w no logical assoc feature of schizophrenia
60
flight of ideas
leaps from one topic to another but with discernible links between them feature of mania
61
clang associations
when ideas are related to each other only by the fact they sound similar or rhyme
62
neologisms
new word formations, which might include the combining of two words
63
word salad
completely incoherent speech where real words are strung together into nonsense sentences
64
Tangentiality
wandering from a topic without returning to it
65
Circumstantiality
excessive, unnecessary detail but the person does eventually return to the original point
66
derailment
series of unrelated ideas
67
Perseveration
repetition of ideas or words despite an attempt to change the topic
68
Echolalia
repetition of someone else's speech, including the question that was asked
69
lithium therapeutic range
0.4-1.0 mmol/L
70
lithium SEs
N&V, diarrhoea fine tremor nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus thyroid enlargement, may lead to hypothyroidism ECG: T wave flattening/inversion weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia
71
lithium monitoring requirements
when checking lithium levels, the sample should be taken 12 HOURS POST DOSE after starting lithium LEVELS should be performed WEEKLY and after each dose CHANGE until concentrations are STABLE once established, lithium blood LEVEL should be checked EVERY 3 MONTHS after a CHANGE in dose, lithium LEVELS should be taken a WEEK later and WEEKLY until the levels are stable. THYROID AND RENAL FUNCTION should be checked every 6 MONTHS patients should be issued with an information booklet, alert card and record book
72
what can precipitate lithium toxicity
dehydration renal failure drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
73
features of lithium toxicity
coarse tremor (a fine tremor is seen in therapeutic levels) hyperreflexia acute confusion polyuria seizure coma
74
mx lithium toxicity
mild-moderate toxicity may respond to volume resuscitation with normal saline haemodialysis may be needed in severe toxicity sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion
75
what can lithium cause in preg
Ebstein's abnormality (where tricuspid valve is in the wrong position) so stop in 1st trim
76
when would you use ECT
severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms
77
absolute CI to ECT
raised intracranial pressure
78
SEs ECT
short term: headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia long term: impaired memory
79
tx for acute dystonia 2ndary to antipsychotics
procyclidine
80
what is acute dystonia
sustained muscle contraction (e.g. torticollis, oculogyric crisis) example of a extrapyramidal SEs of antipsychotics
81
what is tardive dyskinesia
late onset of choreoathetoid movements, abnormal, involuntary most common is chewing and pouting of jaw
82
tardive dyskinesia tx
tetrabenazine
83
mechanism of action of typical antipsychotics
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways (can get prolactinaemia as SE)
84
mechanism of action of atypical antipsychotics
Act on a variety of receptors (D2, D3, D4, 5-HT)
85
warnings when antipsychotics are used in elderly patients
increased risk of stroke increased risk of venous thromboembolism
86
SEs typical antipsychotics eg Haloperidol Chlopromazine
Extrapyramidal side-effects (EPSEs) 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)
87
Extrapyramidal side-effects (EPSEs)
Parkinsonism Acute dystonia Akathisia (severe restlessness) Tardive dyskinesia
88
SEs atypical antipsychotics
weight gain clozapine is associated with agranulocytosis (see below) hyperprolactinaemia
89
Examples of atypical antipsychotics
clozapine olanzapine: higher risk of dyslipidemia and obesity risperidone quetiapine amisulpride aripiprazole: generally good side-effect profile, particularly for prolactin elevation
90
palilalia
automatic repetition of own words / phrases
91
echopraxia
meaningless repetition/imitation of movements of others
92
othello syndrome
pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.
93
Delusional parasitosis
fixed, false belief (delusion) that they are infested by 'bugs'
94
Cotard syndrome
patient believes that they (or in some cases just a part of their body) is either dead or non-existent
95
De Clerambault's syndrome / erotomania
a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
96
capgras syndrome
delusional/misidentification syndrome px believes someone significant in their life has been replaced by an identical imposter
97
fregoli syndrome
px believes multiple ppl are the same person
98
charles bonnet syndrome
px w vision loss have hallucinations these px have insight
99
ekbom syndrome
px believes they are infested w parasites sx B12 def?
100
anorexia physiological abnormalities
hypokalaemia low FSH, LH, oestrogens and testosterone raised cortisol and growth hormone impaired glucose tolerance hypercholesterolaemia hypercarotinaemia low T3
101
anorexia features
reduced body mass index bradycardia (long QT) hypotension enlarged salivary glands
102
metabolic consequences of refeeding syndrome
hypophosphataemia hypokalaemia hypomagnesaemia: may predispose to torsades de pointes abnormal fluid balance
103
who is high risk of refeeding syndrome
ONE + of: BMI < 16 kg/m2 unintentional weight loss >15% over 3-6 months little nutritional intake > 10 days hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high) TWO + of: BMI < 18.5 kg/m2 unintentional weight loss > 10% over 3-6 months little nutritional intake > 5 days history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
104
Russell's sign
calluses on the knuckles or back of the hand due to repeated self-induced vomiting
105
acid base in bulimia
hypokalaemic metabolic alkalosis
106
MOAs with tyramine containing foods (cheese, pickled herring, bov + marmite, oxo, broad beans)
causes hypertensive reactions
107
tx heroin withdrawal
lofexidine (alpha 2 receptor agonist) sx mx - benzos, antiemetics, loperamide (immodium)
108
Semantic dementia
form of fronto temporal dementia 55-65 yrs px has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer's memory is better for recent rather than remote events.
109
pick's disease
type of fronto temporal dementia characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.
110
Pick's disease ix
Focal gyral atrophy with a knife-blade appearance Macroscopic changes:- Atrophy of the frontal and temporal lobes Microscopic changes:- Pick bodies - spherical aggregations of tau protein (silver-staining) Gliosis Neurofibrillary tangles Senile plaques
111
what is creutzfeldt-Jakob disease (CJD)
rapidly progressive neurological condition caused by prion proteins causes misfolded proteins leading to cell death
112
features CJD
rapidly progressive dementia myoclonus
113
CJD ix
CSF is usually normal EEG: biphasic, high amplitude sharp waves (only in sporadic CJD) MRI: hyperintense signals in the basal ganglia and thalamus
114
stages of AI encephalitis
early sx: fever headaches diarrhoea URTIs 2nd stage: confusion paranoid word finding later: seizures rigid temp dysreg
115
causes of serotonin syndrome
monoamine oxidase inhibitors SSRIs - St John's Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome - tramadol may also interact with SSRIs ecstasy amphetamines multiple antidepressants
116
features serotonin syndrome
neuromuscular excitation - hyperreflexia - myoclonus - rigidity autonomic nervous system excitation - hyperthermia - sweating altered mental state - confusion presents in hrs
117
what is neuroleptic malignant syndrome
are but dangerous condition seen in patients taking antipsychotic medication. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson's disease, usually when the drug is suddenly stopped or the dose reduced. dopamine blockade induced by antipsychotics triggers massive glutamate release and subsequent neurotoxicity and muscle damage
118
features of neuroleptic malignant syndrome
within hours to days of starting an antipsychotic and the typical features are: pyrexia muscle rigidity autonomic lability: typical features include hypertension, tachycardia and tachypnoea agitated delirium with confusion RAISED CREATININE KINASE AKI if severe leukocytosis
119
pxs at an increased risk of developing hepatotoxicity following a paracetamol overdose
patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John's Wort) malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days
120
paracetamol OD tx
<1hr ago + does >150mg/kg = activated charcoal staggered OD/ ingestion >15 hrs ago = n-acetylcysiene asap ongestion <4hrs ago = wait 4 hrs to take a level + tx w n-acetylcysiene based on level ingestion 4-5 hrs ago = immediate level based on nonogram + tx
121
n-acetylcysiene adverse effects
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 infused over 1 hour
122
what is semantic paraphasia
words are inappropriately substituted; e.g. 'I baked the cake in the dustbin, then I put the butter back in the dog'
123
SSRI discontinuation symptoms
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
124
overview of refeeding syndrome + how it happens
- sudden introduction of glucose after prolonged starvation - causes insulin to be released which pushes glucose into cells - causing demand for phosphate, potassium, magnesium - leading to them all being low
125
Clinical Consequences of Hypophosphatemia:
Cardiac Dysfunction Respiratory Failure - due to muscle weakness as needed for ATP prod Neurological Complications Haematological Effects - hypoxia + haemolysis Rhabdomyolysis