Psychiatry Flashcards
What are the two core symptoms of depression?
Persistent sadness/low mood
Loss of interest or pleasure in most activities (anhedonia)
What are the other symptoms (not core symptoms) associated with depression?
Fatigue/loss of energy, worthlessness/excessive or inappropriate guilt, recurrent thoughts of death/suicidal ideation, diminished ability to think/concentrate, psychomotor agitation/retardation, changes in appetite or weight loss
How do you classify depression into less severe and more severe?
Less severe - PHQ-9 score <16
More severe - PHQ-9 score 16 and above
What are the risk factors for developing depression?
Female, past history of depression, other mental health problems, physical illness, psychosocial problems, hormonal imbalances
What is the first line management for someone with less severe depression>
CBT or other psychological intervention
Antidepressants are not recommended initially
What is the management of someone with more severe depression?
Offer psychological interventions and antidepressant therapy
What is the difference between type 1 and type 2 bipolar?
Type 1 = mania
Type 2 = hypomania
Both have major depressive episodes
What is cyclothymia?
Less severe version of bipolar in which there is hypomania and periods of low mood
What are the core features of mania?
Hyperactivity, elevated mood, irritability
What features are present in those with mania?
Irritability, euphoria, grandiose ideas, flight of ideas, poor concentration, lack of insight, rapid speech, decreased sleep, recklessness, delusions and hallucinations
What is required to diagnose someone with bipolar?
Needs to be at least two episodes in which a person’s mood and activity levels are signifiacntly disturbed (one of which has to be mania/hypomania)
What’s the difference between mania and hypomania?
In hypomania there are no psychotic symptoms, less associated dysfunction (compared to mania), hypomania lasts only 7-10 days
What medications are used during acute manic episodes?
If 1st episode = antipsychotics such as haloperidol, olanzapine are used
If already on antipsychotic then dose should be increased to maximum tolerated dose (+ another antipsychotic if required)
What medications can be used to prevent manic/depressive episodes in those with bipolar?
1st line = lithium (+valproate if ineffective)
What’s the difference between baby blues and post-partum depression?
In baby blues symptoms are usually mild and resolve within 2 weeks of delivery, no treatment is required
What are the risk factors for developing post-partum depression?
Previous history of mental health problems, psychological disturbance during pregnancy, poor social support, poor relationship with partner, recent major life event
How is post-partum depression managed for mild-to-moderate and moderate-to-severe?
Mild = facilitated self-help strategies
Mild (but previous history of severe depression) = consider SSRI - sertraline or paroxetine safest in breastfeeding)
Severe = consider high intensity CBT +/- antidepressant
What are the risk factors for developing post-partum psychosis?
Past history of postpartum psychosis, past history of bipolar disorder, family history of bipolar or postpartum psychosis
What are the features of post-partum psychosis?
Can be depressive or manic in nature, may be delusions, hallucinations and have beliefs about the baby
How is post-partum psychosis managed?
Admission onto a specialist mother and baby unit
Mood stabilising or antipsychotics drugs are usually used
What are the risk factors for developing schizophrenia?
Early use of cannabis, cocaine and amphetamines, family history, social isolation, abnormal family interactions
What are the 4 1st rank symptoms of schizphrenia?
Thought alienation (loss of sense that thoughts are their own)
Passivity phenomena (thoughts, actions or feeling as being manufactured against their will by someone else)
3rd person auditory hallucinations - someone is talking about them/thought echo
Delusional perception - delusional idea in response to a stimulus
What are the 2nd rank symptoms of schizophrenia?
Delusions, 2nd person auditory hallucinations (someone commanding you to do something), hallucinations in other modalities, thought disorder, catatonic behaviour
What is required to diagnose someone with schizophrenia?
Requires symptoms for around 6 months and symptoms to be present much of the time with marked impairment in functioning
1 1st rank symptom or 2 2nd rank symptoms
What medications can cause drug induced psychosis?
Muscle relaxants, antihistamines, antidepressants, parkinson medications, corticosteroids, stimulants
What investigations need to be done in someone presenting with schizophrenia symptoms?
LFTs and FBC to rule out alcohol abuse
Serological tests for syphilis
Urine screen for signs of drug abuse
What is the management of someone with schizophrenia?
Antipsychotics continued for 1-2 years after initial event before gradually reducing dose with plan to stop
Atypical antipsychotics are 1st line
What is schizoaffective disorder?
Features of schizophrenia + mood disorder such as depression or bipolar
What is the management of someone with schizoaffective disorder?
Antipsychotics, mood stabilisers used if bipolar type, psychological treatments
What are the risk factors for anxiety?
Genetic, stress, life events, 34-54, being divorced, living alone, single parent
What is required to diagnose anxiety?
Excessive anxiety any worry occurring more days than not for at least 6 months, difficult to control the worry
+ associated with fatigue, restlessness, difficulty concentrating, irritability, muscle tension
+ physical symptoms
How is anxiety managed?
Sleep hygiene, regular exercise, meditation, CBT, SSRIs
1: self help
2: CBT or SSRI
3: refer for specialist assessment
In those who cannot tolerate SSRIs venlafaxine or pregabalin can be considered
What is a panic disorder?
Panic attacks associated with >1 month duration of anxiety about recurrence or attacks/consequences of attacks
Often co-exists with agoraphobia or social anxiety
What is the management for panic disorders?
Avoid anxiety producing substances like caffeine, exclude alcohol or drug misuse, CBT, SSRIs
What is a complex phobia?
Develop during adulthood, associated with deep-rooted fear or anxiety about a particular situation/circumstance
Common examples: social phobia and agoraphobia
What is the management for complex phobias?
Counselling, psychotherapy, CBT
Sometimes SSRIs or beta blockers can be prescribed to help people cope
What are obsessions and compulsions?
Obsession = unwanted intrusive thought, image or urge that repeatedly enters the person’s mind
Compulsions = repetitive behaviours or mental acts that the person feels driven to perform
What is the diagnostic criteria for OCD?
Either obsession or compulsions present on most days for a period of at least 2 weeks - repetitive and unpleasant, cause distress, unable to resist them, interfere with functioning
What is the management for OCD?
1st line = CBT including exposure and response prevention
2nd line = SSRI
If severe they get both
Clomipramine (TCA) is also used as alternative to SSRI
How is PTSD diagnosed?
Symptoms need to persist for 4 weeks after event (if not it is acute stress disorder)
What are the risk factors for PTSD?
Life threatening events, asylum seekers, first responders, military, previous psychiatric disorders, female
What are the symptoms of PTSD?
Re-experiencing (recurrent and intrusive)
Avoidance and overthinking relating to the event
Hyperarousal (being concerned about imminent danger) or emotional numbing
Chronic stress reactions
What is the management for severe PTSD?
1st line = Trauma focused CBT should be offered including EMDR
2nd line = SSRI/SNRI
What is somatisation disorder?
Multiple physical symptoms present for at least 2 years e.g. headaches, tiredness, chest pain
What is hypochondirasis?
Persistent belief in presence of an underlying serious disease e.g. thinking they have cancer
What is conversion disorder?
Loss of motor or sensory function which suggest serious neurological disease
Usually develops quickly in response to a stressful situation
What is factitious disorder? (also known as Munchausen’s)
The intentional production of physical or psychological symptoms
What is malingering?
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
What are protective factors against suicide?
Strong religious faith, family support, having children at home, sense of responsibility, problem solving skills
What is the management of someone who has suicidal ideation?
Urgent referral to psychiatry team
What are the symptoms of paranoid personality disorder?
Find it hard to confide in people, find ti difficult to trust others, think people are taking advantage of you, cannot relax, find danger in everyday situations
What are the symptoms of schizoid personality disorder?
Find it hard to form close relationships, live alone, do not experience pleasure, little interest in sex
What are the symptoms of schizotypal personality disorder?
Find making relationships hard, express themselves in a way that others find odd, believe they have special powers, feel anxious and paranoid in social situations
What are the symptoms of antisocial personality disorder?
Put themselves in dangerous situations without thinking about consequences, criminal record, behave in a way that is unpleasant for others, aggressive, problems with empathy
What are the symptoms of histrionic personality disorder?
Feel uncomfortable if not centre of attention, flirt with people to remain centre of attention, dramatic, overemotional, easily influenced by others
What are the symptoms of narcissitic personality disorder?
Special reasons that make them different/better, fragile self-esteem, put own needs above other people, selfish/unaware of others needs, get upset if people don’t get them what they think they deserve
What are the symptoms of avoidant personality disorder?
Avoid social activities, expect disapproval and criticism, worry about being rejected, reluctant to try new things due to fear
What are the symptoms of obsessive compulsive personality disorder?
Need to keep everything in order/under control, set high standards of yourself and others, your way is the best way, anxious if things aren’t perfect (do not get obsessions or compulsions)
How long should antidepressants be continued following remission of symptoms?
6 months before tapering down for 4 weeks
Whats the difference between normal grief reaction and depression?
Normal grief reaction under 6 months whereas depression can last longer
Bot have similar symptoms including pseduohallucinations about lost person being with them
What are the two types of EUPD?
Borderline type - chronic feelings of emptiness, thoughts of self harm, fear of abandonment, unstable and intense relationships
Impulsive type - emotional instability and lack of impulse control
What are the presenting features of EUPD?
Inability to maintain relationships, intense and unstable relationships, adverse childhood experiences e.g. abuse, neglect, recurrent self-harm, threats of suicide, emotional instability, impulsivity, transient psychotic episodes
What is the gold standard management for EUPD?
Dialectical behaviour therapy - twice weekly sessions for over 3 months
What symptoms are present in mild alcohol withdrawal (6-12 hours)?
Headache, insomnia, anxiety, hand tremor, palpitations
What symptoms are present in moderate alcohol withdrawal (12-48 hours)?
Increased heart rate and BP, confusion, mild hyperthermia, rapid abnormal breathing
What symptoms are present in delirium tremens (48-72 hours)?
Visual/tactile/auditory hallucinations, seizures, impaired attention, agitation
What is the management of delirium tremens?
1st line = oral lorazepam
2nd line = haloperidol
What are the symptoms of Wernicke’s encepahlopathy?
Ophthalmoplegia, confusion, ataxia
What are the symptoms of Korsakoff syndrome
Anterograde amnesia, retrograde amnesia, confabulation
How is Wernicke-Korsakoff syndrome prevented?
IM/IV Pabrinex for 3-5 days followed by long term thiamine replacement
What is the standard treatment for alcohol withdrawal
Chlordiazepoxide reducing regime over 7-10 days
Diazepam is alternative
What is the action of disulfiram in terms of it preventing alcohol consumption?
Results in violent vomiting if taken with alcohol, irreversible inhibitor of acetaldehyde dehydrogenase
What is acamprosate?
Medication taken 3 times a day and has shown to be effective in preventing alcohol relapse along with psychological support
What symptoms are associated with acute withdrawal of opioids?
Sweating, watering eyes/nose, anorexia, N+V, tremors, dilated pupils, insomnia, restlessness
What are the symptoms of opioid overdose?
Loss of tone (limp), very slow respiratory rate, altered mental status, pinpoint pupils
What is anorexia nervosa and what are the symptoms?
Maintained body weight of at least <15% below that expected = BMI <17.5
Distorted body image, weight loss by voluntary avoidance of food (+use of laxatives/excessive exercise), amenorrhoea >3 months in girls, fear of gaining weight, lanugo body hair
What is bulimia nervosa and what are the symptoms?
Episodes of overeating large amounts of food followed by compensatory behaviour in order to prevent weight gain e.g. laxatives, excessive exercise, induced vomiting
May have calluses on hand, sore throat and dental erosion
When is a person at risk of refeeding syndrome?
When a malnourished person begins feeding after a period of starvation or limited intake
What electrolyte abnormalities are found in some with refeeding syndrome?
Low phosphate, low magnesium, low potassium, hyperglycaemia
What are the symptoms of neuroleptic malignant syndrome?
Onset over days to weeks = tremor, muscle cramps, fever, autonomic instability, delirium
What complications can occur due to neuroleptic malignant syndrome?
Cardiac arrest, rhabdomyolysis, AKI, seizures, respiratory failure, liver failure
How is neuroleptic malignant syndrome managed?
Discontinue offending drug, benzodiazepines for agitation, bromocriptine reverses changes
What drugs can cause serotonin syndrome?
SSRIs, SNRIs, herbal remedies, MAO-I, illicit drugs
What are the features of serotonin syndrome?
Onset within 24 hours = hypertension, hyperthermia, tachycardia, sweating, dilated pupils, tremor, clonus, hyperreflexia, altered mental state
What medication can be given in serotonin syndrome?
Benzodiazepines, cyproheptadine
How long does it take for antidepressants to work?
2-4 weeks
What are the common side effects of SSRIs?
Decreased sexual dysfunction, GI upset, headache, insomnia, anticholinergic side effects
What side effect is associated with citalopram?
QT prolongation - need ECG before starting
What are you concerned about if someone on a SSRI presents with new onset confusion?
Hyponatraemia
Why would you need to prescribe PPI with SSRI?
Increases risk of GI bleeding give PPI if SSRI is prescribed with another drug that increases risk e.g. NSAIDs
What is the 1st line SSRI for adults and those under 18?
Adults = sertraline
Under 18 = fluoxetine
What are some examples of tricyclic antidepressants?
Amitriptyline, clomipramine, imipramine
What side effects are associated with TCA?
Anticholinergic (dry mouth, blurred vision, confusion)
Adrenergic (drowsiness, postural hypotension)
Anti-histamine (drowsiness, weight gain)
What are some examples of MAO-I and what are their indications?
Isocarboxazid, moclobemide
Used in treatment resistant depression or anxiety
What are some examples of SNRI and what are their indications?
Venlafaxine and duloxetine
Used in major depression and GAD
Need to monitor BP in those taking SNRI
When is mirtazapine used and what side effects are common with mirtazapine use ?
Depression with insomnia
Sedation, weight gain due to increased appetite, tremor, myoclonus
What is the therapeutic window for lithium?
0.4-1.0mmol/L
How often does lithium monitoring need to occur once stabilised on dose?
Every 3 months, 12 hour after last lithium dose
What blood tests need to be monitored every 6 months in those taking lithium?
Renal function, thyroid function and calcium
What are the symptoms of lithium toxicity?
Coarse tremor, N+V, involuntary movements, blurred vision, muscle weakness
What is the management of lithium toxicity?
Stop lithium, rehydrate, consider haemodialysis
When is sodium valproate indicated as a mood stabiliser?
When rapid mood stabilisation is required as takes shorter period of time to work
What are the side effects of sodium valproate?
Teratogenic, GI upset, confusion, hair loss, weight gain, agitation
What are some examples of typical/1st generation antipsychotics?
Chlorpromazine, flupentixol, zuclopenthixol, haloperidol
What are some examples of atypical/2nd generation antipsychotics?
Olanzapine, quetiapine, arpiprazole, clozapine
What side effects are associated with typical antipsychotics?
Extra pyramidal side effects
What side effects are associated with atypical antipsychotics?
Diabetes, dyslipidaemia, osteoporosis, weight gain
What is acute dystonia and what medication can be prescribed to prevent it?
Involuntary contraction of a muscle group e.g. neck, tongue, eye
Procyclidine
What symptoms are associated with Parkinsonism side effects?
Tremor, rigidity, bradykinesia
What is akathisia and how can it be treated?
Restlessness usually of lower limbs
Treat with propranolol or benzodiazepines
What is tardive dyskinesia and how can it be treated?
Continuous slow movements e.g. lip smacking, chewing, winking
Tetrabenazine can help
Which antipsychotic is usual 1st line?
Quetiapine due to fewest cardiac side effects
What antipsychotic is used if patient has had side effects from other ones?
Aripiprazole
When can clozapine be prescribed?
Only if 2 other antipsychotics have been tried and failed due to risk of agranulocytosis
When is ECT indicated?
Severe symptoms of depressive disorder after adequate trial of other treatment options of condition is life threatening e.g. catatonia
What are the side effects of ECT?
Short term memory loss, retrograde amnesia, headache, confusion
How do you treat amitriptyline overdose? (if they have broadened QRS)
Sodium bicarbonate
