Psychiatry Flashcards
What is Charles Bonnet syndrome?
Persistent or recurrent hallucinations, generally against a background of visual impairment. Insight is often preserved. (must be in absence of any other neuropsychiatric disturbance)
What are the protective factors against suicide?
- children at home
- family support
- religious beliefs
If someone has previously attempted suicide, what features increase risk of a further attempt?
- violent method
- making efforts to not be found out
- planning
- leaving a written note
- final acts e.g. sorting out finances
How to assess risk to self
- deliberate self harm, thoughts or carried out
- suicide risk
- ability to maintain health: substance abuse, concordance and neglect
What 3 risks should be assessed in psych review?
- risk to self
- risk to others: thoughts of harming others or hallucinations telling them to harm others
- risk from others
Features of Schizophrenia
- auditory hallucinations: voices discussing in 3rd person, voices commentating on behaviour, thought echo
- thought disorder: thought insertion/deletion/broadcast
- delusional perceptions: normal object is first perceived then delusional insight into the object’s meaning
- passivity phenomena
- other: impaired insight, negative symptoms, catatonia
What is the management of schizophrenia?
- anti-psychotics
- CBT
What are the factors associated with a poorer prognosis for schizophrenia?
- strong family onset
- prodrome of social withdrawal
- low IQ
- gradual onset
- lack of precipitating factor
What is the most common type of schizophrenia?
Paranoid schizophrenia
What are the positive symptoms of schizophrenia?
- thought echo (hearing thought out loud)
- thought broadcast
- thought insertion or withdrawal
- 3rd person auditory hallucination
- delusional perception
- passivity and somatic passivity
- thought disorder
- lack of insight
What are the negative symptoms of schizophrenia?
- blunted affect
- apathy
- social isolation
- poverty of speech
- poor self care
Investigations to rule out causes of schizophrenia/psychosis
- Baseline blood tests: including FBC, TFTs, U&Es, LFTs, CRP and a fasting glucose
- Urine culture: to rule out urinary tract infection causing delirium
- Urine drug screen: to rule out drug intoxication
- HIV testing if applicable
- syphilis serology
What is the management of acute psychosis?
- consider oral benzodiazepine
- refer to a specialist to start anti-psychotic
- family intervention/cbt
Name two typical antipsychotics
- haloperidol
- chlorpromazine
Name two atypical antipsychotics
- clozapine
- risperidone
- aripiprazole
What is anxiety-panic disorder
- panic attack: sudden onset of discrete period of severe anxiety in which at leat 4 of the following are experienced: palpitations, sweating, shaking, sensation of shortness of breath, feeling of choking, nausea dizziness, derealisation/depersonalisation, fear of losing control or dying or going crazy, paraesthesia, chills or hot flushes
- at least 3 panic attacks in 3 weeks: no objective danger, comparative freedom from anxiety symptoms between attacks, without being confined to known/predictable situations
What is the first line medication for generalised anxiety disorder?
Sertraline
At what point would you need to titrate clozapine slowly?
if doses have been missed for a period of over 48 hours
What is tangentiality?
wandering from a topic without returning to it
What is knights move?
severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.
What is Circumstantiality?
inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return to the original point.
What electrolyte imbalances can be seen with long term lithium use?
- hypercalcaemia
- hyperparathyroidism
What is the mechanism of benzodiazepines?
- Enhance effect of GABA (inhibitory neurotransmitter)
What is the difference between type 1 and type 2 bipolar disorder?
- type 1 associated with mania
- type 2 associated with hypomania
What is wernike’s encephalopathy?
- acute neurological disorder due to lack of b1
- Triad: ophthalmoplegia (often a lateral rectus palsy and/or horizontal nystagmus), confusion and ataxia (though any cerebellar signs can be present)
What is Korsakoff’s syndrome?
complication of Wernicke’s encephalopathy.
Its features include: anterograde amnesia, retrograde amnesia, and confabulation
What is conversion disorder?
psychiatric condition where psychological stress is unconsciously manifested as physical, neurological symptoms
What electrolyte imbalance can be caused by SSRIs?
Hyponatraemia
Risperidone
Atypical antipsychotic
Clomipramine
Tricyclic
Haloperidol
Typical antipsychotic
Escitalopram
SSRI
What are the SSRI discontinuation symptoms?
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
- paraesthesia
When should lithium levels be checked?
12 hours post dose
What is the management of acute dystonia secondary to antipsychotics?
Procyclidine
Venlafaxine
SNRI
What antidepressant can cause urinary retention?
Tricyclic antidepressants e.g. amitriptyline
What is the most effective antipsychotic in dealing with negative symptoms?
Clozapine
Akathisia
Restlessness and inability to sit still
What are the risk factors for depression?
- female
- strong family history of depression/anxiety
- teen to age 40
- ACE or childhood abuse
- substance misuse
- Issues with physical health
- poor socio-economic group
- separated/divorced
What are the clinical features of depression?
Lasting at least 2 weeks, impairing daily life or causing distress, no organic or substance cause
Typical core symptoms:
- low mood
- anhedonia
- lack of energy
Other core:
- weight change
- disturbed sleep
- psychomotor retardation or restlessness
- reduced libido
- guilt/worthlessness
- decreased concentration
- thoughts of death/suicide/self harm
What are the organic causes of depression?
- hypothyroidism
- Cushing’s
- B12 deficiency
Mild depression
2 core + 2 other
Moderate depression
2 core + 3 other
Severe depression
all 3 typical + at least 4 others
Recurrent depressive disorder
2+ episodes
Investigations for depression
- PHQ-9
- TFTs
- FBC
- B12
What are the peaks of bipolar presentation?
-15-24
- 45-54
Risk factors for bipolar
- genetic
- prenatal toxoplasma gondii infection
- born premature <32 weeks
- childhood maltreatment
- post partum period
- cannabis use
What is the difference between type 1 and 2 bipolar?
Type 1= mania, type 2= hypomania
Mania symptoms
- elevated mood outwith circumstances
- elation leading to increased energy, decreased need for sleep, pressure of speech
- inability to maintain attention
- grandiosity and increased confidence
- loss of social inhibition
- lasting at least 7 days with severe negative impact on social functioning
- may have psychotic symptoms (mood-congruent)
Hypomania symptoms
- persistent, mild elevation of mood
- increased energy and activity
- increased sociability, talkativeness, libido and over familiarity
- decreased need for sleep
- irritability
- absence of psychotic symptoms
- at least 4 days, some functional impairment but not as severe as mania
Investigations for bipolar
- FBC, UEs, LFTs, CRP, B12, Foalte, Vit D, Ferritin
- HIV
- Toxicology
- neurological exam
- CT head
Differentials for bipolar
- Schizophrenia
- Frontal lobe pathology
- Drug use
- Recurrent depression
- Emotionally unstable personality or borderline personality disorder
- cyclothymia
What is the management for bipolar?
- Referral to specialist mental health team for diagnosis
- for acute mania: haloperidol/risperidone/olanzapine
- for depressive episode: Fluoxetine + olanzapine
- long term: lithium, if not working add sodium valproate
Symptoms of generalised anxiety
- several months, more days than not, resulting in significant impairment and not a manifestation of another condition or substance
- subjective nervousness
- difficulty maintaining concentration
- muscular tension or motor restlessness
- sympathetic autonomic over-activity
- irritability
- sleep disturbance
Agoraphobia
Fear of crowds, public places, leaving home
Social phobia
low self esteem, fear of criticism
Panic disorder symptoms
- recurrent, unpredictable episodes of severe, acute anxiety not restricted to stimuli/situations
- crescendo of anxiety resulting in exit
- somatic symptoms
- secondary fear of dying or losing control
first line drug for generalised anxiety
SSRI
Features of PTSD
- hyperarousal
- Avoidance
- Re-experiencing
- Distress
Management of PTSD
- trauma focused CBT
- eye movement desensitisation and reprocessing
- SSRI or venlafaxine
What is an obsession?
Unwanted, intrusive thought, image or urge
What is a compulsion?
Repetitive behaviour or act a person feels driven to act upon
management of OCD
- Mild: CBT including exposure and response prevention
- moderate: SSRI
- severe : (>3 hours of compulsions), referral to secondary mental health team for assessment
What is ADHD?
Persistent features relating to inattention and/or hyperactivity/impulsivity
What are the inattention symptoms of ADHD?
- Forgetful
- loses things
- easily distracted
- doesn’t seem to listen
- doesn’t follow through on instructions
What are the hyperactivity/impulsivity symptoms of ADHD?
- unable to play quietly
- talks excessively
- often ‘on the go’
- often interruptive or intrusive
- answers prematurely
What is the management of ADHD?
- 10 week watch and wait period for children, if the symptoms persist them referral to secondary care
- consider methylphenidate in children over the age of 5 and adults
What must you do before prescribing methylphenidate?
ECG as it is cardiotoxic
What are the risk factors for ASD?
- male
- genetic variants e.g. PTEN
- chromosomal abnormalities
- strong family history
What are the clinical features of ASD?
- Social interaction: inability to interpret social cues or form social attachments, lack of response to emotion
- Communication: delayed/minimally expressive speech, impairment in make believe or fantasy play, lack of social gestures, one way conversation skills
- Resisted, repetitive behaviour: resist change with a rigid daily routine, pre-occupations with specific interests, inability to adapt to new environments
What is the management of ASD?
- specialist education
- clinical psychiatry
- occupational therapy
- speech therapist
- sleep hygiene
DSM diagnosis of anorexia nervosa
- Restriction of energy intake relative to requirements leading to significantly low body weight
- intense fear of gaining weight/becoming fat, even though underweight
- undue influence of body weight on self-evaluation, or denial of the seriousness of the current low body weight
What is the management of anorexia nervosa?
- CBT-ED
- In children: anorexia focused family therapy
anorexia signs
- bradycardia
- hypotension
- enlarged salivary glands
- hypokalaemia
- impaired glucose tolerance
- low oestrogen, testosterone, FSH, and LH
- raised cortisol and growth hormone
- hypercholesterolaemia
- low T3
What is bulimia nervosa?
Recurrent episodes of binge eating associated with a lack of control over eating, with purging behaviour to prevent weight gain
What are the symptoms of bulimia nervosa?
- recurrent episodes of binge eating
- loss of control over eaitng during these episodes
- recurrent inappropriate compensatory behaviours to prevent weight gain e.g. self induced vomiting
- binge and compensatory behaviours both occur on average once a week for 3 months
- self evaluation is unduly influenced by body shape/weight
- disturbance does not exclusively occur during episodes of anorexia nervosa
What is the management of bulimia nervosa?
- Referral to mental health
- bulimia-nervosa focused guided self help for adults
Target of typical antipsychotics
Dopamine D2 antagonists
Target of atypical antipsychotics
Variety of receptors: D2, D3, D4, 5HT3
What are the typical antipsychotics?
- Haloperidol
- Chlorpromazine
What are the atypical antipsychotics
- Risperidone
- Clozapine
- Olanzipine
What is the difference in the side effect profiles of the antipsychotics?
Typical are more likely to have extrapyramidal side effects and hyperprolactinaemia, atypical less commonly have extrapyramidal and prolactinaemia, but have metabolic effects
What are the extra pyramidal side effects?
- Parkinsonism
- Acute dystonia
- Tardive dyskinesia (chewing, pouting)
- Akanthisia (severe restlessness)
What are the side effects of antipsychotics?
- Anti muscarinic
- sedation, weight gain
- raised prolactin
- impaired glucose tolerance
- neuroleptic malignant syndrome
- reduced seizure threshold
- prolonged QT (particularly haloperidol)
What do antipsychotics increase the risk of (especially in elderly)
- VTE
- Stroke
What is akathisia?
Severe restlessness
What is tardive dyskinesia?
- chewing
- pouting
involuntary movements
Signs of neuroleptic malignant syndrome
- fever
- muscle rigidity
- tachycardia/tachypnoea
Name 3 SSRIs
- citalopram
- fluoxetine
- sertraline
What are the side effects of SSRIs?
- GI effects
- increased risk of GI bleeding
- Increased anxiety and agitation
- Citalopram can increased QT interval
- hyponatraemia
What are the interactions of SSRIs?
- NSAIDs, if used prescribe proton pump inhibitor
- Triptans - increased risk serotonin syndrome
- Monoamine Oxidase inhibitors, increased risk of serotonin syndrome
- aspirin
- warfarin/heparin
What period of time should you stop SSRIs over?
4 weeks
What are the discontinuation symptoms of SSRIs?
- increased mood changes
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- GI symtpoms- pain, cramping, diarrhoea
- paraesthesia
What are the risks of SSRIs in pregnancy?
- increased risk of congential heart defects if used in 1st trimester
- increased risk of persistent pulmonary hypertension if used in 3rd trimester
- paroxetine increases risk of congenital malformation
When should you review someone after starting them on an anti-depressant?
- Review in 2 weeks
- Review in 1 week if under 25 years or if they have an increased suicide risk
Mechanism of tricyclic antidepressants
- inhibit uptake of noradrenaline and serotonin
- also affect histamine, muscarinic and adrenergic receptors
What are the side effects of tricyclic antidepressants?
- drowsiness
- anti -muscarinic effects: dry mouth, blurred vision, constipation, urinary retention
- postural hypotension
- lengthens QT interval
Name 4 tricyclics, 2 more sedative, 2 less sedative
More sedative: amitriptyline, clomipramine
less: imipramine, lofepramine
What are the serotonin syndrome symptoms?
- neuromuscular excitation
- hyperreflexia
- myoclonus
- rigidity
- autonomic nervous system:
- excitation
- hyperthermia
- sweating
- altered mental state
- confusion
What is the management of serotonin syndrome?
- benzodiazipines
- IV fluids
- more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
Name 3 MAO inhibitors
- Moclobemide ( depression_
- selegiline, rasagiline (parkinsons)
What are the side effects of MAO- inhibitors?
- anti-cholinergic effects
- Avoid tyramine containing foods: cheese, marmite, broad beans
What are the uses of benzodiazepines?
- sedation
- hypnotic
- anxiolytic
- anti-convulsant
- muscle relaxant
Why should you only prescribe a benzodiazepine for a short time
Because you can easily develop a tolerance
What are the symptoms of benzodiazepine withdrawal?
- insomnia
- irritability
- anxiety
- tremor
- perspiration
- seizure
Where is lithium excreted?
Kidneys
What are the adverse effects of lithium?
- nausea, vomiting, diarrhoea
- nephrotoxicity -> polyuria secondary to nephrogenic diabetes
- fine tremor
- weight gain
- thyroid enlargement -> hypothyroidism
- leucocytosis
- hyperparathyroidism
- hypercalcaemia
Describe the monitoring of lithium doses
- sample should be taken 12 hours post dose
- when starting dose or changing the dose, check the levels weekly until stable
- once levels are stable check once every 3 months
- check thyroid and renal function every 6 months
what can precipitate lithium toxicity
- dehydration
- renal failure
- diuretics
- ACEi
- ARBs
- NSAIDs
- metronidazole
what are the features of lithium toxicity?
- coarse tremor
- hyperreflexia
- acute confusion
- polyuria
- seizure
- coma
What is the management of lithium toxicity?
- normal saline fluid resuscitation if mild/moderate
- haemodialysis if severe
What is the mechanism of alcohol withdrawal?
chronic alcohol consumption enhances GABA mediated inhibition in the CNS and inhibits NMDA-type glutamate receptors, withdrawal is the opposite
What are the features of alcohol withdrawal?
- symptoms at 6-12 hours: tremor, sweating, tachycardia, anxiety
- peak incidence of seizure is at 36 hours
- delirium tremens at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
What is the management of alcohol withdrawal?
- admit if complex history from alcohol withdrawal
- long acting benzodiazepine e.g. chlordiazepoxide or diazepam
ICD-10 alcohol excess
3 or more:
- compulsion to drink
- difficulties controlling alcohol consumption
- physiological withdrawal
- tolerance to alcohol
- neglect of alternative activities to drinking
- persistent use of alcohol despite evidence of harm
Management of alcohol excess
- oral thiamine
- benzodiazepines for acute withdrawal
- disulfram: causes severe reaction from alcohol intake
- acamprostate reduces the craving
Cluster A personality disorders
Odd or eccentric:
- paranoid
- schizoid
- schizotypal
Cluster B personality disorders
Dramatic, emotional, or erratic
- antisocial
- borderline
- histrionic
- narcissistic
cluster c personality disorder
anxious and fearful
- obsessive compulsive
- avoidant
- dependent
Paranoid personality disorder
- hypersensitivity and unforgiving attitude
- unwarranted tendency to question loyalty of friends
- reluctance to confide in others
- conspirational beliefs
- perceive attacks on their character
Schizoid personality disorder
- 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
schizotypal personality disorder
- odd beliefs and magical thinking
- unusual perceptual disturbances
- paranoid ideation and suspiciousness
- odd, eccentric behaviour
- lack of close friends
- inappropriate affect
- odd speech but still coherent
antisocial personality disorder
- more common in men
- failure to conform to social norms e.g. breaking law
- deception e.g. lying, conning people
- impulsive
- irritable and aggressive
- disregard for safety of others
- irresponsibility e.g. cant keep consistent work
- lack of remorse
Borderline personality disorder
also known as emotionally unstable
- efforts to avoid abandonment
- unstable interpersonal relationships which alternate between idealization and devaluation
- unstable self image
- impulsivity
- recurrent suicidal behaviour
- affective instability
- chronic feelings of emptiness
- difficulty controlling temper
obsessive compulsive perosnality
- 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 rigid about 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
Management of personality disorders
dialectical behaviour therapy
What is conversion disorder?
- loss of motor or sensory function
- patient doesn’t consciously feign the symptoms
Hypochrondrial disorder
- persistent belief in the presence of an underlying serious disease e.g. cancer
- patient refuses to accept reassurance or negative test results
What is somatisation disorder?
Presence of multiple, recurrent and clinically significant somatic complaints
- pain is most common symptom including migraine like or tension type headaches, abdominal pain
Section 2 mental health act
- admission for assessment for up to 28 days, not renewable
- an approved mental health professional makes the application on recommendation of 2 doctors, one of which shoul dbe approved under section 12(2) of the mental health act (usually consultant psychiatrist)
- treatment can be given against a patients wishes
How many days section 2 MHA
28, not renewable
Section 3 mental health act
- admission for treatment for up to 6 months, can be renewed
- AMHP along with 2 doctors who must have seen the patient within the past 24 hours
- treatment can be given against a patient’s wishes
section 4 MHA
- 72 hour assessment order
- used when section 2 would involve an unacceptable delay
- a GP and AMHP/Nearest relative
- often then changed to a section 2 on arrival at hospital
section 5 (2) MHA
a patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
section 17a MHA
- supervised community treatment
- can be used to recall a patient to hospital for treatment if they dont comply with conditions of the order in the community such as complying with medication
section 135 MHA
Court order can be obtained to allow the police to break into a property to remove a person to a place of safety
section 136 MHA
- someone in a public place who appears to have a mental disorder can be taken by the police to a place of safety
- can only be used for up to 24 hours
What are the adverse effects of clozapine?
- agranulocytosis and neutropaenia
- reduced seizure threshold
- constipation
- myocarditis
- hypersalivation
When should you use clozapine for schizophrenia
if not controlled despite the sequential use of two or more antipsychotic drugs, each for at last 6-8 weeks
What should be checked when starting venlafaxine?
blood pressure
