Psychiatry Flashcards
what is cotards syndrome
A rare syndrome seen in severe depression - patient’s believe that they are dead, decaying, or do not really exist (also known as ‘walking corpse syndrome’).
withdrawal from which drug causes piloerection (hairs standing on end), rhinorrhea and hyperreflexia
opioid
which symptoms of alcohol withdrawal distinguish it from withdrawal from other drugs
hallucinations, tremors
describe symptoms of phencyclidine withdrawal
mood disturbances - anxiety and depression
flashback phenomenon’ (where patients experience the effects of taking phencyclidine long after the drug has exerted its effects on the body)
delayed reflexes
what is hypochondriasis aka illness anxiety disorder
persistent fear or belief that one has a serious medical illness, despite medical evaluation and reassurance to the contrary. The focus in hypochondriasis is on the fear or belief of having a medical illness, rather than the presence of medically unexplained symptoms.
what is somatisation disorder / somatic symptom disorder
multiple medically unexplained physical symptoms across multiple organ systems, with the symptoms causing significant distress and impairment
what is malingering
intentionally feigning or exaggerating symptoms for some external gain, such as financial compensation or avoiding legal consequences
what is conversion disorder
a psychiatric disorder characterised by symptoms affecting sensory or motor function eg paralysis / seizures.
These signs and symptoms are inconsistent with patterns of known neurologic diseases or other medical conditions.
what are slurred speech and coarse tremor symptoms of
lithium toxicity - requires urgent medical attention
likely diagnosis:
muscle rigidity and rhabdomyolysis followed by a fever and mental state changes
neuroleptic malignant syndrome
(life-threatening neurologic emergency associated with the use of antipsychotic (neuroleptic) agents)
what is neuroleptic malignant syndrome a complication of
anti psychotic use
mech of action of naloxone
opioid antagonist
which drug can be used to help relieve diarrhoea in opiate withdrawal
loperamide
which drug can be sued to help relieve agitation in opiate withdrawal
benzodiazepines
what is lofexidine used for
can be used as a form of symptomatic relief for opioid withdrawal
which medications can be used in detox programmes for opiate withdrawal (to help with detoxification and maintenance therapy to prevent further use)
methadone
buprenorphine
effects of LSD
Labile mood
Hallucinations
Increased blood pressure
Increased heart rate
Increased temperature
Sweating
Insomnia
Dry mouth
effects of cannabis
Drowsiness
Impaired memory
Slowed reflexes
Slowed motor skills
Conjunctival injection
Increased appetite
Paranoia and psychotic symptoms (contrast with cannabinoid associated schizophrenia, which has a more insidious onset, over many years)
Tachycardia
Dry mouth
which receptor does cocaine work at
dopamine receptors
which receptor does methamphetamine work at
TAAR1 (trace amine - associated receptor 1) receptors
which medication could be used to treat anxiety / agitation in patients with heroin withdrawal
benzodiazepine
contrast the pupils and management of heroin intoxication and heroin withdrawal
heroin intoxication = constricted pupils -> naloxone for OD
heroin withdrawal = dilated pupils -> supportive Tx, symptom relief -»> methadone, buprenorphine
management of stimulant (cocaine, methamphetamine, or MDMA (ecstasy)) intoxication
Deaths can occur due to hyperpyrexia and hypertension, so cooling, use of antihypertensives such as nitroprusside or GTN, and benzodiazepines, is the mainstay of management.
- nitroprusside
- GTN
- benzodiazepines
which condition causes personality / behaviour changes, seizures, short term memory impairment, altered conscious level, disorientation abruptly within days to weeks
limbic encephalitis
what should be confirmed before a lumbar puncture is performed
that there is no raised ICP
what is the order of investigations for a pt presenting with new seizures/confusion/memory impairment
- neurological exam
- MRI brain
- lumbar puncture (check for raised ICP before doing this)
what is Munchausen syndrome
patients fake illnesses to receive attention
what is la belle indifference
a syndrome where patients do not show any concern over the symptoms they are experiencing. An example is not worrying whether they cannot move a limb
what is wernickes syndrome caused by
thiamine deficiency in chronic alcoholism
what symptoms is wernickes encephalopathy characterised by
nystagmus
opthalmoplegia
confusion
ataxia
what is a nosocomial infection
infection originating in hospital
anterograde vs retrograde amnesia
Retrograde amnesia is when you can’t recall memories from your past.
Anterograde amnesia is when you can’t form new memories but can still remember things from before you developed this amnesia.
what is confabulation
a neuropsychiatric disorder wherein a patient generates a false memory without the intention of deceit
what is korsakoff’s syndrome
an irreversible progression of Wernicke’s encephalopathy.
It has the same symptoms, with the addition of antero- and retrograde amnesia and confabulation
how does lithium toxicity present
Toxicity may be precipitated by dehydration or illness.
The acute phase often presents with predominantly gastrointestinal symptoms and then neurological features of ataxia, tremor, confusion and nystagmus.
how does digoxin toxicity present
confusion
nausea
diarrhoea
visual symptoms
palpitations
if suspect a UTI in a pt over 65 yrs, what is the best investigation
urine culture
urine dips are unreliable in those > 65
gold standard Ix for lithium toxicity
serum lithium levels
what is used to treat agitation and seizures n drug overdose
benzodiazepines
how to manage lithium toxicity
discontinue lithium
supportive care
first line Tx for autoimmune encephalitis
steroids + IV Ig
Plasma exchange can also be used as an adjunctive treatment in those who are not fully responding to steroids or immunoglobulin; it is rarely used alone.
Second-line treatment, if patients are not responding within 2 weeks, includes immunosuppressant therapy with agents such as Rituximab and Cyclophosphamide. First line therapy should be continued during this time.
common complications of plasma exchange
infection
hypotension
electrolyte imbalances
in which cases would you give naloxone full dose instead of naloxone titrated to an opiate overdose pt
if they’re having any apnoeic episodes give naloxone full dose
first vs second generation antipsychotics
first generation (typical) = dopamine receptor antagonists eg haloperidol
second generation (atypical) = serotonin-dopamine antagonists eg risperiodone
what is acamprosate used for
maintaining alcohol abstinence
paranoid delusions
auditory hallucinations
agitation
diaphoresis
likely diagnosis ?
delirium tremens
first line Tx for delirium tremens
lorazepam
what is a reducing regime of chlordiazepoxide used for
acute alcohol withdrawal
what is IM olanzapine used to manage
agitation and disturbed behaviour in schizophrenia or mania
what does NICE specifically advise against doing fro opiate withdrawal and what should be done instead
dont prescribe opiates
instead do symptomatic management eg loperamide for diarrhoea, benzodiazepines for agitation
what is clozapine used to treat
treatment-resistant paranoid schizophrenia
first thing to do with a distressed patient who has delirium
use de-escalation techniques (verbal and non verbal)
Examples of de-escalation techniques include communicating and negotiating with the patient to resolve the situation in a non-confrontational manner, providing reassurance and reorientating the patient to time and place.
if de escalation techniques don’t work for distressed delirious pt what can u give
oral/IM (if refuse IM or pt poses risk to others) haloperidol/respiradone (antipsychotics)
or if they have parkisnons give benzodiazepines instead
for serum lithium levels above 3.5, what intervention is required
haemodialysis
somatoform disorder vs conversion disorder
somatoform = presence of PHYSICAL symptoms that cannot be explained by an underlying physical condition
eg abdo pain
conversion disorder = presence of NEUROLOGICAL symptoms that cannot be exlaplained by an underlying neurological condition
eg paralysis, loss of motor function
first line tx for delirium tremens
lorazepam
which medication is often used amongst student populations to increase concentration for revision, but can result in drug abuse
methylphenidate (‘ritalin’) - used to treat ADHD
which drugs cause hypertensive crisis, raised HR, raised body temp, anxiety and diarrhoea
stimulants eg cocaine, methamphetamine, or MDMA (ecstasy)
what is the key difference between alcohol and heroin withdrawal
presence of tremors and seizures in alcohol withdrawal.
Patients who withdraw from opiates also often have a runny nose and yawn.
methadone and buprenorphine are used to support detoxification from heorin. how do you decide which ten to use
if a patient has had a previous overdose on methadone, then buprenorphine should be given.
However, if both drugs are equally suitable, then methadone should be prescribed first line.
if a pt has delirium due to a UTI what is the tx
ABX!! eg trimethoprim
treat the underlying cause first
for medically unexplained symptoms should u offer psychological support or mediation/pain relief first
psychological support
how does delirium tremens and hepatic encephalopathy symptoms compare
hepatic encephalopothy is usually hypoactive - more drowsy and confused,
delirium tremens = agitated and anxious
train of symptoms of wernickes enceophalpathy
encephalopathy, oculomotor dysfunction and gait ataxia
lithium causes tremors. contrast the tremors caused by a therapeutic dose and an overdose
A fine tremor is a common side effect of therapeutic lithium medication. Importantly, a coarse tremor is seen in lithium toxicity.
methadone and buprenorphine can be used as opioid substitution therapy to assist in opioid dependence. which is more commonly used
methadone
effects of lithium on thyroid
hypothyroidism - raised TSH, low T3/4
which drug causes mood changes and hallucinations, as well as hypertension, tachycardia and hyperthermia
LSD
what do abscesses in a heroin user suggest
dependency - from where injected
“The abscess in this man’s antecubital fossa suggests that he continues to use heroin despite harmful physical side effects, one of the ICD-11 criteria for diagnosis of dependence syndrome”
which drug causes hypertension, tachycardia and hyperthermia, but no hallucinations
methamphetamine
which drug causes elevated mood, tachycardia and hyperthermia, but no hallucinations
ecstasy
false beliefs around the ownership of your thoughts. They can be subdivided into insertion, withdrawal, and broad-casting. They are classically seen in schizophrenia.
what type of delusion is this
delusion of thought possession
Patients believe they are being followed, spied on, or conspired against. This is classically seen in schizophrenia.
what type of delusion is this
delusion of persecution
exaggerated beliefs about one’s self-worth, power, or identity - for example, believing one is a king or queen. It is classically associated with mania.
what type of delusion is this
delusion of grandeur
the belief that one deserves to be punished. Usually, the ‘sin’ is an innocent error out of proportion to the guilt felt.
delusion of guilt
in which pts is venlefaxine / other SNRI’s contraindicated
pts with uncontrolled hypertension
what should be monitored in pts on venlefaxine / other SNRI’s
blood pressure - can cause hypertension
what medication is used for treatment resistant schizophrenia (failure of treatment of 2 other antipsychotic medications)
clozapine
side effects of clozapine
agranulocytosis, neutropenia, reduced seizure threshold, myocarditis, slurred speech (due to hypersalivation), constipation (most common cause of mortality when related to clozapine use).
what is carbamazepine used to treat
bipolar disorder
haloperidol side effects
neuroleptic malignant syndrome, QTc prolongation, extrapyramidal symptoms, tardive dyskinesia and antimuscarinic side effects.
which dementia is caused by multiple infarcts in the brain
vascular dementia - caused by multiple infarcts in the brain secondary to chronic cerebrovascular disease which disrupts the blood supply to the brain and affects cognitive function.
what does puerperal psychosis mean
postpartum psychosis
what is picks disease
frontotemporal dementia causing an accumulation of TAU proteins in neurones - usually identified post-mortem, and atrophy of the frontal and temporal lobes
what does lewy body dementia show on post mortem
alpha-synuclein cytoplasmic inclusions (Lewy Bodies)
early morning waking is pathognomonic of which condition
depression
contrast lewy body dementia and Parkinson’s disease dementia
Lewy body: cognitive impairments and parkisnonism present together
Parkinson’s disease dementia: presents with cognitive impairments years (or at least a year) after the development of the symptoms of Parkinson’s disease
pt who recently started anti psychotic medications that block dopamine, begins to experience hyperthermia, altered mental state, autonomic dysregulation, rigidity
diagnosis?
neuroleptic malignant syndrome
pt who recently started serotinergic medication begins to experience hyperthermia, autonomic dysregulation, and altered mental status.
diagnosis?
serotonin syndrome
what investigation is used for neurolpptic malignant syndrome
creatine kinase - CK will be elevated due to muscle rigidity
which specific questionnaire can be used for alcohol abuse
CAGE
(Cut down? Annoyed? Guilty? Eye opener?)
what is myalgic encephalomyelitis another word for
chronic fatigue syndrome
what is the AUDIT questionnaire used for
used to assess whether there is a need for a specialist evaluation concerning alcohol consumption. It is carried out by a skilled physician in the specialty.
definition/criteria for chronic fatigue syndrome
- at least 4 months
- disabling fatigue
- affecting mental and physical function
- more than 50% of the time
- absence of other disease which may explain symptoms
symptoms of chronic fatigue syndrome
Persistent Disabling Fatigue → may be present for >6 months
Post-Exertional Fatigue –> Significant exhaustion and impairment following minimal physical or cognitive effort
PEM = Post exertion malaise)
Short-Term Memory or Concentration Impairment
Sore Throat
Arthralgia
Headache
Unrefreshing sleep
Flu-Like Symptoms (may preceed fatigue) → malaise, myalgia, feverness
Painful Lymph Nodes (NON PALPABLE)
screening tool for chronic fatigue syndrome
DePaul Symptom Questionnaire
management of chronic fatigue syndrome
Cognitive Behavioural Therapy → very effective
Graded Exercise Programme
Mindfulness, Sleep Hygeine, Occupational Therapy
Referral to a pain management clinic if pain is a predominant feature
describe pathology of alzheimers
degeneration of the cerebral cortex: cortical atrophy
hippocampal atrophy
reduction in acetylcholine production
build up of APP (due to beta and gamma secretase)
what is seen on neuroimaging in alzheimers
cortical atrophy
hippocampal atrophy
describe disease progression in alzheimers
slowly progressive,
episodic impairment of memory
describe pathology of vascular dementia
brain damage due to several incidents of cerebrovascular disease
what is seen on neuroimaging in vascular dementia
lacunar infarcts (white areas on MRI)
describe disease progression in vascular dementia
abrupt cognitive decline
stepwise deterioration
describe pathology of lewy body dementia
deposition of abnormal proteins (Lewy bodies) within the brain stem and neocortex
what form of neuroimaging is used in lewy body dementia
SPECT (DAT scan)
describe disease progression and features in lewy body dementia
steady decline,
fluctuating levels of consciousness,
visual hallucinations
parkinsonian motor disorders
which medications can cause irreversible Parkinsonism so should be avoided in Lewy body dementia
anti psychotics
describe pathology of frontotemporal dementia
specific degeneration of the frontal and temporal lobes caused by pick bodies
what is seen on neuroimaging in frontotemporal dementia
frontal and temporal lobe atrophy
describe disease progression and features in frontotemporal dementia
early changes in personality (eg. Impulsivity, aggressiveness)
metabolic disorders
Often has a family history
Starts slightly earlier than other dementias (50-60).
order of prevalence of the types of dementia
alzheimers
vascular
Lewy body
frontotemporal
depression in elderly vs dementia
depression has:
shorter history
rapid onset
biological symptoms (eg. sleep disturbance).
which test is used for dementia
MMSE
normal, mild and severe scores for MMSE
24-30 (no cognitive impairment)
18-23 (mild cognitive impairment)
0-17 (severe cognitive impairment)
what is done during dementia Ix to look for reversible causes
Neuroimaging: subdural haematoma
Blood screen
1st line / mild-moderate alzheimers Tx
acetylcholinesterase inhibitors (donepezil, rivastigmine)
- if hallucinations one of main symptoms, galantamine
in which pts are acetylcholinesterase inhibitors C/I for mild-moderate alzheimers
pts with prolonged QT
2nd Line / severe alzheimer’s Tx
memantine (NMDA receptor antagonist, leading to decreased glutamate induced excitotoxicity)
Non-Pharmacological Treatment for dementia
Cognitive Stimulation Therapy → improve memory and problem solving skills
Cognitive Rehabilitation
what is the aetiology behind depression
lack of monoamines (serotonin, noradrenaline, dopamine)
diagnosis of MDD
≥5/9 criteria met
⇒ Depressed Mood OR Anhedonia + 4 other symptoms of depression (for min. 2 weeks)
criteria: D SIGE CAPS
Depressed mood
Sleep disturbance
Interest diminished (anhedonia)
Guilt
Energy loss (fatigue)
Concentration difficulties
Appetite loss –> causes weight loss
Psychomotor retardation/agitation
Suicide ideation
2 depression questionnaires
Patient Health Questionnaire-9 (PHQ-9)
Hospital Anxiety and Depression (HAD) Scale
first line and alternative meds for depression
SSRIs (eg. citalopram or sertraline)
Alternatives include
SNRIs (venlafaxine, duloxetine),
MAO inhibitors,
TCAs (amitriptyline)
what type of med are venlafaxine / duloxetine
SNRIs
what type of med is amitryptiline
TCA
SSRIs side effects
GI side effects,
erectile dysfunction,
hyponatraemia (SIADH),
citalopram prolongs QT interval,
if used with NSAIDs have high risk of GI bleeding (co-prescribe PPI)
what should you coprescribe with SSRIs if they’re being used with NSAIDS, and why
co prescribe PPI, high risk of GI bleed
what is the SSRI of choice in children and adolescents for depression
Fluoxetine
what is the SSRI of choice post myocardial infarction, for depression
sertraline
describe how a patient should stop taking antidepressants when their symptoms are improved
Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of relapse.
When stopping antidepressants, doses should be reduced gradually over a four week period
pt has triad of gait disturbance, dementia and urinary incontinence
diagnosis?
normal pressure hydrocephalus (NPH)
(NPH is a rare condition characterised by excessive fluid building up in the ventricles of the brain)
(“Wet, Wobbly, Weird”)
which SSRIs are preferred in breastfeeding
paroxetine and sertraline
baby blues vs post natal depression
baby blues = few days after giving birth due to fall in hormone levels
post natal depression = presents a couple months after giving birth has more symptoms of classic depression eg. guilt, anhedonia, and lasts for 2 weeks at least
what kind of medication is paroxetine
SSRI
treatment for baby blues
reassurance and observation.
what should patients be monitored for when starting antidepressants or having a change of dose of their current antidepressant
suicidal thoughts
(All antidepressants, including sertraline, have been associated with an increase in suicidal thoughts in adolescents and young adults, as well as in those with a history of suicidal behaviour)
main symptoms of vascular dementia
focal neurological deficits, such as weakness or paralysis, rather than the gradual cognitive decline seen in Alzheimer’s disease
what is the maximum number of months after birth in which depression is classed as post part depression
within the first 12 months
Tx for transient global amnesia
no action needed
treatment for recurrent depression
antidepressant + lithium
treatment for severe depression and poor oral intake/psychosis/stupor(almost unconscious)
ECT - Electroconvulsive therapy
Tx for pts with persistent subthreshold depressive symptoms or mild-to-moderate depression
psychological therapy
side effect of memantine
constipation
what are the 6S side effects of SSRIs
Stomach ulcers
Sexual dysfunction
Sodium low
Sleep disturbance
Suidical ideations
serotonin syndrome
what does agnosia mean
inability to recognise people, objects or places that were once known to a person
what does apraxia mean
inability to carry out skilled motor function, despite normal motor function
what does abolition mean
loss of motivation
side effect of ECT (electroconvulsive therapy)
memory loss
woman has been on galantamine max dose for a year and her depression is not getting better
which medication should it be changed to, added with
add memantine
Donepezil, galantamine and rivastigmine are in the same class of drugs. There is no evidence that galantamine is not tolerated or ineffective in this woman. Hence, there is no indication to change the current drug to another drug in the same class. Offering memantine in addition to galantamine is the most appropriate management option for disease progression.
what kind of antidepressant is venlafaxine
SNRI (serotonin and noradrenaline reuptake inhibitor)
what are SNRIs C/I in
controlled HTN - can cause increased bp
1st 2nd and 3rd line medications for depression
- SSRIs
- NaSSA eg mirtazapine
SNRI eg venlafaxine - MAOI eg moclobemide
TCA (Clomipramine)
which medications should SSRIs not be prescribed with
anticoagulants, esp among elderly - increases the risk bleeding
NSAIDS - increases risk of GI bleed, co prescribe PPI
which SSRIs can be used whilst breastfeeding
sertraline
paroxetine
why should TCAs be avoided in pts with coronary heart disease
can cause arrhythmias
what kind of antidepressant is clomipramine
TCA
what kind of antidepressant is imipramine
TCA
which part of brain does flight or fight response
amygdala
normal AMTS
8 and above = normal cognitive function
pt on haloperidol begins to feel restless feeling of tension, low mood and suicidal ideation
what is the problem
akathisia
This man most likely has akathisia secondary to the antipsychotic haloperidol. Akathisia is characterised by the feeling of inner restlessness and tension, an urge to constantly move parts of the body, especially the legs, and difficulty maintaining a posture for a few minutes.
Due to its distressing nature, akathisia is associated with aggression, low mood and suicidal ideations
which factor increases risk of a pt going on to complete suicide
previous PLANNED suicide attempts
(not unplanned - that just shows impulsivity)
how does panic disorder affect calcium levels
causes hypocalcaemia
A sudden feeling of intense anxiety can cause hyperventilation, which in turn reduces arterial CO2 and increases blood pH. Alkalosis promotes calcium binding to albumin, reducing the levels of free calcium and thus causing hypocalcaemia.
hypocalcaemia causes numbness and tingling
what is tardive dyskinesia
repetitive movements often affecting the face and jaw, but can also affect the limbs too
(side effect of typical first generation antipsychotics)
what is the effect of hypo and hyperthyroidism on periods
Hyperthyroid - Amenorrhoea
Hypothyroid - Menorrhagia
A 60-year-old patient presents with behavioural changes, social disinhibition, and loss of empathy.
What is the most likely diagnosis?
front-temporal dementia
what is the first investigation to do for a pt on antipsychotics who presents with amenorrhoea or oligomenorrhoea, decreased libido, galactorrhoea, infertility and osteoporosis
prolactin (most antipsychotics increase prolactin)
what is the triad of confusion, ataxia and ophthalmoplegia
wernickes syndrome
what needs to be given to a pt with wernickes syndrome to prevent it becoming Korsakoff’s syndrome
vit B1
what is confabulation
making up things
what features does korsakoffs syndrome consist of
disorientation, anterograde and retrograde amnesia and confabulation
which dementia presents as a stepwise deterioration
vascular
main TCA side effects
dry mouth
urinary retention
Tx for normal pressure hydrocephalus (wet, wobbly, weird)
first line investigation/treatment would be a lumbar puncture and if relieving the pressure resolves the symptoms a ventriculoperitoneal shunt would be inserted
what type of dementia is semantic dementia
a form of frontotemporal dementia
what is semantic dementia
defect in semantic memory (the ability to associate meaning to objects presented via visual or auditory modalities) –> is a type of frontotemporal dementia
what kind of medication is quetiapine
antipsychotic - can be used to treat postpartum psychosis
lines of treatment for anxiety
- psychoeducation
- self help eg online workbooks
- CBT
- pharmacological therapies –> SSRIs (sertraline)
- another SSRI / SNRI (duloxetine or venlafaxine) / pregabalin
what are lesions in mamillary bodies a sign of
wernickes encephalopathy - due to thiamine deficiency
what does apathetic mean
showing or feeling no interest, enthusiasm, or concern
likely cause for sudden onset memory loss
transient global amnesia
what type of dementia can affect hippocampus
alzheimers
(affects cerebral cortex and hippocampus)
first symptoms of alzheimers
amnesia for recent memories
(amnesia for childhood memories and procedural memory loss are more later stage Alzheimer’s)
most significant side effects of antipsychotics
stroke (cause weight gain and abnormal lipid profiles)
what blood test is most appropriate to do in a pt presenting with depressive symptoms
TFT
how long after delivery does postpartum psychosis present
2 weeks after delivery
intellectual disability, macrodactyly, macro-orchidism, long face and large ears, autism
likely diagnosis
fragile X syndrome (caused by a trinucleotide repeat in the Fragile X Mental Retardation 1 (FMR1) gene)
pathology of parkisnons
caused by build up of alpha-synuclein, starting in the substantia nigra and then progressing often to include the majority of the cerebral cortex
which genetic condition causes early onset alzheimers
down syndrome
which condition causes protruding tongue, prominent epicanthal folds and a single transverse palmar crease
Down syndrome
what is risperidone
antipsychotic used for schizophrenia
which medication can be used to manage tremor and akathisia, the extra pyramidal side effects of antipsychotics
procyclidine
which medication can be used to manage the parkinsonsonian and dystonic side effects of antipsychotics
benztropine
which medication can be used to treat the metabolic and prolactin elevation side effects of antipsychotics
metformin
which dementia can present with history of falls, sleep walking and talking to pets which are dead
lewy body dementia
triad of REM sleep disorder, a history of falls (secondary to motor problems- Parkinsonism), and hallucinations. The hallucinations are often of small, non-threatening people and animals (Lilliputian hallucinations).
what kind of medication is citalopram
SSRI
which medications can be used to manage the somatic symptoms vs the cognitive aspect of anxiety
somatic symptoms eg tremors, sweating = beta blockers - PROPANOLOL (not bisoprolol)
cognitive aspect = SSRIs
first line management for pt with dementia and Qt prolongation
cognitive stimulation therapy
what should you check for on ECG before starting as pt on Acetylcholinesterae inhibitors
prolonged QT,
second or third degree heart block in an unpaced patient
sinus bradycardia <50 bpm
–> all of these are contraindications for Acetylcholinesterae inhibitors
how long can uncomplicated grief persist, after which it could be prolonged grief disorder depression
no longer than 6 months
what is the initial questionnaire for alcohol intake, and then the further questionnaire done after this to assess if there’s need for specialist evaluation
initial = CAGE
further questionnaire = AUDIT
pt on antipsychotic medication presents with hypertonia, hyperthermia, autonomic instability and mental state change
likely diagnosis and investigation required?
neuroleptic malignant syndrome (NMS)
measure creatinine kinase - will be very high
first lien investigation for new onset palpitations that are exercise induced or pt has history of syncope/near syncope
48 hour Holter monitor ECG
INITIAL screening for confusion / memory loss
TFTs/bloods
cognitive questionnaires
THEN can begin neuroimaging eg MRI
what is Creutzfeldt–Jakob disease (CJD) caused by
prions (misfolded proteins)
management of behavioural and psychological symptoms of FTD
behavioural interventions and lifestyle modifications
- if these don’t work can use atypical antipsychotics, but are generally not recommended as first-line treatment due to their side effect profile and the increased risk of mortality in elderly patients with dementia.
preferred TCAs for breastfeeding women
Imipramine and nortriptyline
what is pseudodementia caused by
severe depression can lead to psycho-motor slowing, memory impairment and difficulties in concentration similar to dementia in appearance
haloperidol ecg changes
prolonged QT interval
serious side effect of clozapine
agranulocytosis
common side effect of clozapine
constipation
what is clozapine used to treat
treatment resistant schizophrenia
speech disturbance, vertical gaze dysfunction, dementia
diagnosis?
progressive supra nuclear palsy
psychosis, extrapyramidal symptoms, jaundice, Kayser-fleischer rings, dementia, young age onset
diagnosis ?
Wilsons disease
low levels of which neurotransmitter are associated with developing anxiety
GABA
(GABA is inhibitory so low levels of it allow neurones to activate at an increased rate)
in which dementia is haloperidol C/I
Lewy body
- shouldn’t give antipsychotics as can worsen parkinsonism and cause fall
first line managment of post partum depression
CBT
- if mother/babys safety is at risk, admit to baby and mother unit
in which type of antipsychotics are extrapyramidal symptoms seen
typical antipsychotics - in particular dopamine receptor blockers
in which type of antipsychotics is weight gain a very common side effect
atypical antipsychotics
pt is taking SSRI, amphetamines and has restlessness, diaphoresis, clonus, hyperthermia, rigidity, hyperreflexia
diagnosis?
serotonin syndrome
pt is taking antipsychotic olanzapine and has altered mental state, diaphoresis, tachycardia, rigidity and hyperthermia, normal pupils, hyporeflexia and does not have clonus
diagnosis?
Neuroleptic malignant syndrome (NMS)
NMS vs serotonin syndrome
NMS:
antipsychotics
altered mental state, diaphoresis, tachycardia, rigidity and hyperthermia
HYPOreflexia
NORMAL pupils
serotonin syndrome:
SSRIs / amphetamines
restlessness, diaphoresis, clonus, hyperthermia, rigidity
HYPERreflexia
DILATED pupils
olanzapine common side effect
weight gain
which antidepressants can cause blurred vision
TCAs eg imipramine
what type of antidepressant is imipramine
TCA
TCA side effects
Urinary retention
Drowsiness
Blurred vision
Constipation
Dry mouth
A 52-year-old man with a history of chronic alcoholism presents with ataxia and confusion. He has nystagmus, ophthalmoplegia and short-term memory loss on examination.
What is the most likely diagnosis?
Wernicke’s encephalopathy
(Korsakoffs syndromen is a chronic memory disorder often seen in patients with chronic alcoholism, following Wernicke’s encephalopathy - MEMORY LOSS AND CONFABULTION)
first line pharmacological Tx for panic disorder
SSRis: escitalopram, sertraline, citalopram and paroxetine
and Venlafaxine (a serotonin and noradrenaline reuptake inhibitor)
risk factors for opiate overdose
mental health conditions,
alcoholics,
renal impairment (can’t excrete drug)
what kind of drug is fentanyl
opiate
what kind of drug is loperamide
opiate
features of opiate overdose
bilateral miosis (’pinpoint pupils’),
respiratory depression (bradypnoea),
altered mental status,
constipation,
needle track marks,
Rhinorrhoea
Ix for opiate overdose
- Toxicology Screen
- Opiate
→ therapeutic trial of naloxone.
May show reversal of overdose signs.
management of opiate overdose
Airway Management + Oxygen
IV Naloxone
max dose of paracetamol
2x 500mg tablets, 4x in 24 hours
2 types of paracetamol overdose
acute overdose or staggered overdose
(staggered is worse than acute)
risk factors for developing hepatotoxicity due to paracetamol overdose
chronic alcohol use,
HIV,
p450 inducers
malnourished patients (eg. anorexia)
most important prognostic factor for paracetamol overdose
arterial pH (<7.30)
features of paracetamol overdose
nausea & vomiting,
RUQ pain,
jaundice (may signify acute liver failure),
hepatomegaly,
altered conscious level
Ix for paracetamol overdose
serum paracetamol concentration (whether treated or not based on nomogram),
LFTs (ALT may be elevated),
PT (may be prolonged).
pH (<7.30 is bad).
management of paracetamol overdose based on type of overdose and hours
not staggered < 1hr
= activated charcoal
not staggered < 4hrs
= wait till 4 hrs, take level, treat with Nacetylcysteine based on level
not staggered 4-15 hrs
= take level, treat with Nacetylcysteine based on level
staggered > 1hr / not staggered > 15 hrs / timing uncertainty
= IV Nacetylcysteine
which medication has been overdose in salicylate toxicity
aspirin
ABG results of salicylate toxicity
mixed respiratory alkalosis
(due to hyperventilation)
raised anion gap metabolic acidosis
(due to toxicity + acute renal failure)
features of salicylate toxicity
tinnitus,
N&V,
lethargy,
tachypnoea (hyperventilation),
diaphoresis,
hyperthermia,
agitation,
seizures,
Coma
Ix and classification for salicylate overdose
ABG (mixed respiratory alkalosis and metabolic acidosis),
Salicylate Levels (repeat every 2 hours until peak level).
○ Classified according to peak salicylate levels
mild (<300 mg/L),
moderate (300-700 mg/L),
severe (>700 mg/L)
management for for salicylate overdose
Activated Charcoal → can be used within an hour of opiate overdose
Sodium Bicarbonate → alkalizes urine, hence increasing elimination of aspirin in urine
Haemodialysis → indicated if pulmonary oedema and severe metabolic acidosis
indications for haemodialysis in salicylate toxicity
pulmonary oedema
severe metabolic acidosis
features of TCA overdose
blurred vision,
dilated pupils,
dry mouth/skin
convulsions
agitation,
ECG: broad QRS, prolonged QT (arrhythmias)
ECG changes in TCA overdose
broad QRS, prolonged QT (arrhythmias)
Tx for TCA overdose
IV sodium bicarbonate
time frame needed for anxiety diagnosis
Excessive worry for at least 6 months
6 core symptoms of anxiety, and how many are needed for diagnosis
(at least 3 for diagnosis)
muscle tension, sleep disturbance, fatigue, restlessness, irritability, poor concentration
what must be ruled out with a blood test if a pt presents with anxiety symptoms
must rule out hyperthyroidism with TFTs
3 steps of anxiety management
Step 1 (education + monitoring)
Step 2 (low-intensity psychological intervention)
Step 3 (CBT or Pharmacology)
pharmacology 1st line = SSRI sertraline
- If ineffective, try another SSRI or an SNRI (duloxetine or venlafaxine).
- If can’t tolerate SSRIs and SNRIs, offer pregabalin.
main causes of delirium
metabolic causes
(hypercalcaemia, hypoglycaemia, hyponatraemia, dehydration),
infections
(UTIs, pneumonia),
how long after alcohol cessation does delirium tremens develop
72 hours after ceasing alcohol intake
Tx for delirium tremens
chlordiazeproxide, pabrinex, lorazepam, diazepam
main factor which differentiates delirium and dementia
Impairment of consciousness: consciousness is affected in delirium not dementia
2 types of delirium and which is more common
May be hypoactive (25% - decreased psychomotor activity) or hyperactive (75% - increased psychomotor activity)
(Hypoactive ⇒ withdrawn, lethargic, slow to respond)
how do severity of symptoms of delirium change through the day and when is it worse
severity of symptoms fluctuates throughout the day and worsens in the evening
delirium vs dementia: onset
sudden vs insidious
delirium vs dementia: course
rapid and fluctuating vs slowly progressive deterioration
delirium vs dementia: consciousness and attention
decreased/fluctuating vs intact
delirium vs dementia: memory
recent memory loss only vs recent then remote memory loss
delirium vs dementia: hallucinations
present vs present in advanced disease
delirium vs dementia: psychomotor activity
increased/decreased vs normal
delirium vs dementia: EEG
abnormal vs normal
delirium vs dementia: reversibility
reversible vs irreversible
Ix for delirium
Confusion Screen
- TFTs (Hypothyroidism),
B12,
Folate,
Glucose (Hypoglycaemia),
Bone Profile (Hypercalcaemia)
Look for underlying cause
- urinalysis (UTI),
chest x-ray (infection),
CRP/WCC,
serum glucose (hypoglycaemia),
bladder scan (urinary retention),
Electrolytes
Cognitive Impairment Screening
- AMTS or MMSE or MoCA
AMTS (6 or less suggests delirium or dementia)
AMTS score which indicates delirium/dementia
6 or less
management of delirium and more specifically hyperactive delirium
treat underlying cause
patient comfort and symptom control
Reducing Confusion → reorient patient to time, place and person a few times a day
Treatment of Agitation (Hyperactive Delirium)
→ 1st line antipsychotics (haloperidol/respiradone)
Antipsychotics contraindicated in parkinson’s as they worsen symptoms → Lorazepam (benzodiazepine) may be used instead
Offer oral initially, if refused and patient poses immediate physical risk to other patient, IM route is justified.
