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James' Phase 3A Medicine > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Psychiatric assessment: what is modification?

A

Recognising when a process needs to be modified and how to modify e.g. distressed patient, reduced cognitive capacity, non-native speaker.

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2
Q

What is a forensic history?

A

Asking the patient about past juvenile crime, court appearances or convictions.

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3
Q

What 7 things are you assessing throughout a mental state examination?

A
  1. Appearance and behaviour
  2. Speech
  3. Mood and affect
  4. Thoughts
  5. Perception
  6. Insight and Judgement
  7. Risk
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4
Q

Psychiatric assessment: what is a risk assessment?

A

Consideration of how likely an event will occur, when it will occur and how bad will it be. E.g. harm to self, harm to others, suicide, self-neglect.

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5
Q

Formulation: what are the 5 P’s?

A
  1. Presenting problem.
  2. Predisposing factors.
  3. Precipitating factors.
  4. Perpetuation factors.
  5. Protective factors.
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6
Q

What is psychopathology?

A

The study of abnormal experience, cognition and behaviour.

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7
Q

What are the 2 essential components of psychopathology?

A
  1. Observation of behaviour.

2. Empathic assessment of subjective experience.

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8
Q

What is a concrete concept?

A

Real objects or situations e.g. tremor.

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9
Q

What is a defined concept?

A

Classes of concept e.g. delusions.

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10
Q

What are concept systems?

A

Sets of related concepts e.g. schizophrenia.

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11
Q

Give 3 examples of perceptual symptoms.

A
  1. Illusion.
  2. Hallucination.
  3. Pseudo-hallucination.
  4. Delusion.
  5. Over-valued idea.
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12
Q

Define illusion.

A

A misperception of real external stimuli.

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13
Q

What is a hallucination?

A

Perceptions occurring in the absence of an external physical stimulus. Can be auditory, visual or olfactory.

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14
Q

Define pseudo-hallucination?

A

Pseudo-hallucinations appear to arise in the subjective inner space of the mind, not through one of the external sensory organs - this is how they differ from hallucinations.

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15
Q

What is meant be the term ‘over-valued idea’?

A

An over-valued idea is a false or exaggerated belief sustained beyond logic or reason e.g. I am the best employee ever.

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16
Q

Define delusion.

A

A false, unshakable idea which is out of keeping with the patients educational, cultural and social background; it is held with extraordinary conviction and certainty.

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17
Q

Give 5 examples of different types of delusion.

A
  1. Persecutory.
  2. Grandiose.
  3. Self-referential.
  4. Nihilistic (Cotard’s syndrome).
  5. Misidentification.
  6. Religious.
  7. Hypochondriacal.
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18
Q

What is the Capgras delusion?

A

The idea that someone has been replaced by an impostor.

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19
Q

What is the Fregoli delusion?

A

The idea that various people are in fact the same person.

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20
Q

Thoughts are a common psychiatric sign. Name 5 types of thoughts patients may report/describe.

A
  1. Thought insertion.
  2. Thought withdrawal.
  3. Thought broadcast.
  4. Thought echo.
  5. Thought block.
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21
Q

What is concrete thinking?

A

A lack of abstract thinking, in adults this may be due to organic disease or schizophrenia.

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22
Q

Define loosening of association.

A

A lack of logical association between succeeding thoughts, often leads to incoherent speech. It is impossible to follow the patients train of thought.

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23
Q

Define circumstantiality.

A

Irrelevant wandering in conversation.

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24
Q

What is perseveration?

A

Repetition of a word, theme or action.

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25
Q

What is confabulation?

A

Giving a false account to fill a gap in memory. This is often seen in dementia patients.

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26
Q

Define somatic passivity.

A

The delusional belief that one is a passive recipient of bodily sensations from an external agency.

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27
Q

Define catatonia.

A

Excited or inhibited motor activity in the absence of a mood disorder or neurological disease.

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28
Q

What is psychomotor retardation and in what conditions would it be present?

A

Slowing of thoughts and movements.

It can be seen in depression, Parkinson’s disease etc.

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29
Q

Presentation: describe incongruity of affect.

A

Emotional responses that seem grossly out of tune with the situation or subject being discussed.

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30
Q

Presentation: what is blunting of affect?

A

An absence of normal emotional responses.

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31
Q

Presentation: what is depersonalisation?

A

Feelings of detachment from one’s own body; the patient feels like a spectator of his own activities.

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32
Q

Presentation: describe derealisation.

A

A sense of one’s surroundings lacking reality, surroundings may appear dull, grey, lifeless.

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33
Q

Presentation: describe dissociation.

A

When a person feels disconnected from his/herself and/or their surroundings.

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34
Q

Psychiatric signs: what is obsession?

A

A recurrent persistent thought, image or impulse; it remains despite efforts to resist.

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35
Q

Psychiatric signs: what is compulsion?

A

Repetitive, purposeful behaviour accompanied by a subjective sense that it must be carried out despite the recognition of its senselessness and resistance.

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36
Q

Psychiatric signs: what is akathisia?

A

Motor restlessness, ranging from anxiety to the inability to lie/sit still.

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37
Q

Phenomenology: what is projection?

A

What is emotionally unacceptable in the self is unconsciously rejected and projected to others e.g. mother projects her anxiety onto her children claiming they are anxious instead.

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38
Q

Give 3 signs/symptoms of mania.

A
  1. Pressured speech.
  2. Lots of projects/things going on.
  3. Delusions.
  4. Increased energy/activity.
  5. Overfamiliarity.
  6. Impulsivity.
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39
Q

Give 2 examples of affective disorders.

A
  1. Depression.

2. Bipolar disorder.

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40
Q

Give 3 symptoms of depression.

A
  1. Low mood.
  2. Lacking energy.
  3. Loss of pleasure.
  4. Sleep disturbance.
  5. Appetite change.
  6. Feelings of guilt, hopelessness.
  7. Suicidal thoughts.
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41
Q

Give 3 symptoms often seen in bipolar disorder.

A
  1. Increased energy.
  2. Pressured speech.
  3. Recklessness.
  4. Impaired judgement.
  5. Inflated self-esteem.
  6. Elevated mood.
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42
Q

When is the onset of schizophrenia most typical?

A

In the 2nd or 3rd decade.

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43
Q

Give a characteristic sign of schizophrenia.

A

Characteristic splitting of thoughts or a loss of contact with reality. Thoughts, perceptions, mood, personality, speech can all be affected.

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44
Q

Give 3 first rank symptoms of schizophrenia.

A
  1. Thought alienation.
  2. Passivity phenomena.
  3. 3rd person auditory hallucinations.
  4. Delusional perception.
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45
Q

Give 3 second rank symptoms of schizophrenia.

A
  1. Delusions.
  2. 2nd person auditory hallucinations.
  3. Thought disorder.
  4. Negative symptoms.
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46
Q

Name 3 types of psychoses.

A
  1. Schizophrenia.
  2. Delusional disorder.
  3. Schizotypal disorder.
  4. Depressive psychosis.
  5. Manic psychosis.
  6. Organic psychosis.
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47
Q

Give 3 physical signs and 3 psychological signs of panic disorder.

A 
Physical:
1. Palpitations.
2. Chest pain.
3. Tachypnoea.
4. Dry mouth.
5. Dizziness.
Psychological:
1. Feeling of impending doom.
2. Fear of dying.
3. Fear of losing control.
4. Derealisation.
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48
Q

Give 3 positive signs/symptoms.

A
  1. Hallucinations.
  2. Delusions.
  3. Passivity phenomena.
  4. Thought alienation.
  5. Lack of insight.
  6. Mood disturbance.
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49
Q

Give 3 negative signs/symptoms.

A
  1. Blunting of affect.
  2. Amotivation.
  3. Poverty of speech and/or thought.
  4. Self-neglect.
  5. Lack of insight.
  6. Poor non-verbal communication.
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50
Q

What 2 classification systems are used for psychiatric conditions?

A
  1. DSM5.

2. ICD10.

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51
Q

Give 2 pros and 2 cons of using classification systems for psychiatric conditions.

A 
Pros:
1. Allows for population study and health planning.
2. Aids education.
Cons:
1. Over generalised.
2. Ignores individual characteristics. 
3. Diagnostic labels may lead to stigma.
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52
Q

Define personality disorder.

A

Long-lasting, rigid patterns of thought and behaviour. Behaviour that differs from ‘normal’. Present in a range of situations and causes considerable distress. Tends to begin in adolescence.

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53
Q

What are the essential diagnostic features of a personality disorder?

A
  1. Impairments in self and interpersonal functioning.
  2. Impairments in personality functioning.
  3. Impairments are relatively stable across time and consistent across situations.
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54
Q

What daily life tasks might someone with a personality disorder struggle with?

A
  1. Forming/maintaining friendships and work relationships.
  2. Struggle to control feelings and behaviours.
  3. Struggle to trust others.
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55
Q

What is the main type of personality disorder?

A

Emotionally unstable personality disorder.

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56
Q

Give 3 symptoms of a borderline type personality disorder.

A
  1. Emotional instability.
  2. Difficult, intense relationships.
  3. Feelings of emptiness.
  4. Impulsive.
  5. Self injurious behaviour.
  6. Fear of abandonment/rejection.
57
Q

Why might someone with a borderline personality disorder self-harm?

A
  • Relieve psychic pain.
  • Express anger.
  • Reduce anxiety.
  • Feel in control.
  • Feel something when numb.
  • Communicate how they feel.
58
Q

How would you treat/manage someone with a personality disorder?

A
  1. Psychological therapies - dialectical behavioural therapy.
  2. Structured clinical management.

Medication is not mainstay.

59
Q

What principles underly the Mental Health Act?

A
  1. Respect for patients’ wishes and feelings.
  2. Minimise restrictions on liberty.
  3. Public safety.
  4. Patient well-being and safety,
  5. Involving patients in planning, developing and delivering care.
60
Q

Describe Section 2 of the MHA - purpose, duration, professionals involved.

A
  1. Purpose: assessment, treatment can be given without consent.
  2. Duration: 28 days.
  3. Professionals involved: 2 doctors, AMHP.
61
Q

Describe Section 3 of the MHA - purpose, duration, professionals involved.

A
  1. Purpose: treatment.
  2. Duration: 6 months.
  3. Professionals involved: 2 doctors, AMHP.
62
Q

Describe Section 4 of the MHA - purpose, duration, professionals involved.

A
  1. Purpose: emergency order.
  2. Duration: 72 hours.
  3. Professionals involved: 1 Dr and 1 AMHP.
63
Q

Lithium is an effective treatment for many psychiatric conditions including mania, bipolar disorder, depression etc. Why should it be used with care?

A

Lithium has a narrow therapeutic range which can lead to renal failure.

64
Q

What is dementia?

A

A progressive neurological disorder impacting cognition which causes functional impairment.

65
Q

Name 3 types of Dementia.

A
  1. Alzheimer’s.
  2. Vascular.
  3. Lewy Body.
66
Q

Give 3 differential diagnoses for dementia.

A
  1. Old age.
  2. Depression.
  3. Physical health problems e.g. DM, hypothyroid, vitamin deficiencies.
67
Q

What is the main investigative screening tool used for dementia?

A

ACE-III/ Addenbrooke’s screening tool.

68
Q

Dementia: what 5 cognitive domains does the ACE-III screening tool assess?

A
  1. Attention.
  2. Memory.
  3. Fluency.
  4. Language.
  5. Visiospatial.
69
Q

What drugs can be used in the treatment of dementia?

A
  1. Acetylcholinesterase inhibitors e.g. Donepezil, Rivastigimine.
  2. NMDA antagonist e.g. Memantine.
  3. RF reduction in vascular dementia is important too.
70
Q

What is pseudo-dementia?

A

Cognitive impairments secondary to a mental illness e.g. depression/anxiety.

71
Q

Give one way that you could distinguish between pseudo-dementia and dementia.

A

Patients with pseudo-dementia will use ‘don’t know’ answers whereas those with dementia will make up answers - confabulation.

72
Q

What is delirium?

A

Delirium is an acute confusional state often with changes in consciousness. It is a medical emergency but is often reversible.

73
Q

Give 3 causes of delirium.

A
  1. Infection e.g. UTI.
  2. Dehydration.
  3. Iatrogenic e.g. medication changes or surgery.
  4. Constipation.
  5. Urinary retention.
74
Q

Patients with what psychiatric disorder may be more prone to delirium?

A

Patients with dementia - bidirectional relationship.

75
Q

How can you treat delirium?

A

Treat the underlying cause and consider environmental support. Antipsychotics can be used in extreme cases if the patient is suffering from hallucinations.

76
Q

Give 5 potential causes of depression.

A
  1. Drugs e.g. beta-blockers, opioids.
  2. Metabolic e.g. anaemia, B12/folate def, cancer.
  3. Infective e.g. post-viral, UTI.
  4. Inflammatory e.g. temporal arteritis.
  5. Intracranial e.g. post-stroke, Parkinson’s, Delirium, Dementia.
77
Q

Give 3 treatment/management strategies for depression.

A
  1. Antidepressants e.g. SSRI’s.
  2. Talking therapies.
  3. Social inclusion and community support.
  4. ECT.
78
Q

What type of depression often responds poorly to antidepressants?

A

Vascular depression.

79
Q

What is Charles Bonnet Syndrome?

A

A condition characterised by visual hallucinations.

80
Q

What is the recovery model?

A

A non-pharmacological, psychosocial approach to treatment e.g. supporting housing, living, money, social inclusion, therapy, counselling, family work.

81
Q

What is formulation?

A

A meaningful narrative - summarising a patients condition.

The 5 P’s demonstrates a good formulation model.

82
Q

Give examples of psychosocial therapies.

A
  1. Psychotherapy.
  2. CBT.
  3. Counselling.
  4. Cognitive analytic therapy.
  5. Interpersonal therapy.
  6. Dialectic behaviour therapy.
  7. Family therapy.
83
Q

What questions should you ask when taking a developmental history.

A
  1. Pre and post-natal: maternal substance use, birth, milestones.
  2. Who was the main carer?
  3. Life events and early childhood adverse experiences.
  4. Teenage years: drug/alcohol use, changes in academic level, bullying.
84
Q

What is attachment disorder?

A

When a child is unable to develop relationships with parents/carers.

85
Q

What do you need to monitor for when treating a patient with Lithium?

A

Kidney function and Thyroid function.

86
Q

Give examples of the following anti-depressants:

  • SNRI.
  • MAOI.
  • SSRI.
  • Tri-cyclic.
  • Tetra-cyclic.
A
  1. SNRI: Duloxetine.
  2. MAOI: Isocarboxazid, Phenelzine.
  3. SSRI: Sertraline, Citalopram, Fluoxetine.
  4. Tri-cyclic: amitriptyline, imipramine
  5. Tetra-cyclic: Mirtazapine.
87
Q

What type of anti-depressant is associated with a hypertensive crisis if too much cheese/wine is consumed? Give an example of one of these drugs.

A

MAOI e.g. Isocarboxazid, Phenelzine.

Hypertensive crisis related to tyrosine.

88
Q

A 27 year old man has a long history of interpersonal difficulties. He has feelings of doubt and caution, is preoccupied with detail and is pedantic. These features cause him considerable distress and dysfunction.
Which personality disorders best describes this man?

A

Anankastic Personality Disorder (Obsessive).

89
Q

Who can release someone from their section?

A
  1. RMO.
  2. Consultant psychiatrist.
  3. MH Tribunal.
90
Q

What is another name for RAPD?

A

Marcus Gunn pupil.

91
Q

In what conditions might you see RAPD?

A
  1. MS.
  2. Glaucoma.
  3. Severe retinal disease.
  4. Optic nerve lesion.
92
Q

Describe the treatment for bipolar disorder

A

Mood stabilisers e.g. Lithium, sodium valporate or aripiprazole.
Psychological therapies e.g. CBT

93
Q

What tool is used to screen for eating disorders?

A

SCOFF
● Do you make yourself Sick because you feel uncomfortably full?
● Do you worry you have lost Control over how much you eat?
● Have you recently lost more than One stone (14 lb or 7.7 kg) in a three month period?
● Do you believe yourself to be Fat when others say you are thin?
● Would you say that Food dominates your life?

2 or more yes answers warrants further assessment

Bulimia Nervosa specific:
1. Are you satisfied with your eating patterns?
2. Do you ever eat in secret?

94
Q

What is the diagnostic criteria for anorexia nervosa?

A

Actual body weight at least 15% below expected weight, or body mass index 17.5 or less (in adults).

Weight loss is caused by the avoidance of high-calorie foods and at least one of the following:

Self-induced vomiting

Self-induced purging

Excessive exercise

Use of appetite suppressants and/or diuretics

Distorted body image as a specific psychological disorder

Endocrine disorder, manifests in the female as amenorrhea and in the male as a loss of libido

95
Q

What is the risk if anorexia nervosa onset if prepubertal?

A

Puberty is delayed

96
Q

What is bulimia nervosa?

A

Episodes of overeating a large amount of food in a discrete period of time (binges) where an individual feels that they cannot stop eating or control how much they are eating.
Recurrent compensatory behaviour in order to prevent weight gain, such as induced vomiting, misuse of laxatives, diuretics, appetite suppressants, enemas, fasting or excessive exercise

Disturbance in the perception of body image with a morbid “fear of fatness”

Body image/self-esteem unduly influenced by weight and shape.

97
Q

What could you find from a history and examination of a patient with an eating disorder?

A

Amenorrhea, Constipation, Headaches, Fainting, Dizziness
* Fatigue / Lethargy
* Palpitations, cold intolerance
* Dry Skin, Hair Loss, Bloating, Fullness
* Gastroesophageal Reflux Disease
* Abdominal Pain, Polyuria (diuresis), Polydipsia (increased thirst)
* Sore throat (from vomiting), Dental Enamel Erosion
* Lanugo (fine body Hair)

98
Q

What co-morbidities are associated with eating disorders?

A

Type 2 diabetes, Hypertension, Cardiovascular disease, Osteoarthritis, Dyslipidaemia, Sleep apnoea

99
Q

What investigations would you order for someone with an eating disorder?

A

Blood Pressure, Temperature, Respiration
Sit up–Squat–Stand (SUSS) test - assessing muscle power
FBC, U&E
Ca, Mg, P, K
Serum proteins
LFT
Urinalysis
ECG

100
Q

What investigation findings are specific to bulimia nervosa?

A

Calluses on the dorsum of the dominant hand, Dental Enamel Erosion, Salivary Gland Enlargement, cardiomegaly

101
Q

What are the risks of untreated anorexia nervosa?

A

Death from health complications
Refeeding syndrome
Anemia
Seizure
Thyroid problems
Low potassium levels in the blood
Decrease in white blood cells
Abnormally low blood pressure and heart rate, which can lead to heart failure
Kidney problems
Suicide
Osteoporosis

102
Q

What is re-feeding syndrome?

A

A severe electrolyte disturbance and metabolic abnormalities in undernourished patients undergoing refeeding by any route

103
Q

What are the consequences of re-feeding syndrome?

A

Congestive cardiac failure and cardiac arrhythmias are the most common.
Liver dysfunction, respiratory failure and CNS abnormalities have also been reported

104
Q

How is re-feeding syndrome prevented?

A

Identify at-risk patients
Oral Thiamine 200-300mg + Vitamin B
Prescribed Menu Plan of 20Kcals/Kg that is slowly increased

105
Q

Who are at-risk of re-feeding syndrome?

A

Patients with protein-energy malnutrition, alcohol abuse, anorexia nervosa, prolonged fasting, no nutritional intake for seven days or more, and significant weight loss

106
Q

What is the impact of anorexia nervosa on cognition?

A

Anorexia nervosa (AN) is associated with adverse effects on cognitive functioning in the domains of attention, processing speed, visual and verbal memory, and visuospatial construction

107
Q

What are the difficulties when assessing the capacity of a patient with an eating disorder?

A

Some patients with anorexia nervosa – who might have the intellectual capacity to understand the nature, purpose and likely effect of treatment – may be unable to give valid consent, perhaps because their capacity to consent is compromised by fears of obesity or by denial of the consequences of their actions

108
Q

What are signs of semistarvation/ over exercising?

A

Loss of subcutaneous fat tissue, orthostatic hypotension, bradycardia, impaired menstrual function, hair loss, and hypothermia

109
Q

What is somatisation disorder?

A

A disorder that is characterised by an extreme focus on physical symptoms — such as pain or fatigue — that causes major emotional distress and problems functioning.

110
Q

What is Munchausen syndrome?

A

Factitious disorder imposed on self. The person lies about their own health.

111
Q

What is Munchausen syndrome by proxy?

A

Factitious disorder imposed on another. The person lies about someone else’s health. The victim is typically a child or other person who can’t take care of themselves

112
Q

Why might a patient make up/ lie about symptoms?

A

Insurance fraud or other form of financial gain
To get time off work
To get prescriptions for controlled medications
Reducing work obligations
An attempt to avoid a custodial sentence

113
Q

What must be checked before commencing a patient on anti-cholinesterase inhibitors?

A

ECG - prolonged QT interval contraindicates

114
Q

What is anticholinergic syndrome?

A

Competitive antagonism of acetylcholine at central and peripheral muscarinic receptors which can lead to an agitated delirum, as well as dry eyes, dizziness, dilated pupils, absent bowel sounds and tachycardia.

115
Q

What medications can cause anticholinergic syndrome?

A

Tricyclic antidepressants, Anti-parkinson’s drugs, antihistamines

116
Q

What are the signs of lithium toxicity?

A

Toxicity may be precipitated by dehydration or illness. The acute phase often presents with predominantly gastrointestinal symptoms and then neurological features of ataxia, coarse tremor, confusion and nystagmus. The patient may also present with polyuria, polydipsia, hyperreflexia

117
Q

What are the dangerous potential side effects of lithium?

A

Lithium Toxicity, Thyroid Toxicity, Agranulocytosis

118
Q

What are the clinical features of a tricyclic antidepressant overdose?

A

Confusion, seizure, tachycardia, hypotension and dilated pupils. ECG changes can also be present (Prolonged QRS and QT)

119
Q

Why are SSRIs contraindicated in the eldery and what might you prescribe instead?

A

SSRIs are associated with an increased risk of bleeding when prescribed with anticoagulants. A noradrenergic and specific serotonergic antidepressant (NaSSA) e.g. mirtazapine can be used alternatively.

120
Q

What is histronic personality disorder?

A

Histrionic personality disorder is characterised by excessive displays of emotions and attention seeking behaviours. They can be sexually inappropriate, and may consider relationships more intimate than they really are

121
Q

How do you treat delirium tremes in alcohol withdrawal?

A

Benzodiazepines to manage symptoms of alcohol withdrawal and supportive care including hydration, electrolyte management, and nutritional support.

122
Q

What is the mechanism of action of the most commonly used antidepressant classes?

A

Inhibition of the reuptake of monoamine neurotransmitters

123
Q

What are some common side effects of SSRIs?

A

Sexual dysfunction and gastrointestinal side effects, such as constipation

124
Q

What is used to treat opiate overdose?

A

Naloxone

125
Q

What is used to treat Benzodiazapine overdose?

A

Flumanezil

126
Q

What is used to treat TCA overdose?

A

Activated charcoal/ sodium bicarbonate

127
Q

What is used to treat alcohol withdrawal?

A

Treat with Chlordiazepoxide regimen for 5 -7 days + 3 days IM Pabrinex (IV if medical ward)

Thiamine supplementation x 3 months

128
Q

What psychiatric medication can cause acute dystonia?

A

Increasing or withdrawing of antipsychotic medication

129
Q

How is acute dystonia managed?

A

Stop offending drug
Establish Airway
IM Procyclidine

130
Q

What is serotonin syndrome?

A

Too much serotonin the the body. It presents as the 3A’s :

Activity : Clonus, hyperreflexia, hypertonia, tremors, seizures

Autonomic instability

Altered mental state

131
Q

How do you manage a patient with serotonin syndrome?

A

ABCDE
Stop offending medications
Cyproheptadine

132
Q

What is Neuroleptic Malignant Syndrome (NMA)?

A

A life-threatening neurologic emergency associated with the use of antipsychotic medications. Symptoms include: Fever, encephalopathy, muscle pain – due to
rhabdomyolysis, dyspnoea, dysphagia, shuffling gait

133
Q

How do you manage a patient with NMA?

A

ABC

Stop offending drug

Urgent medical transfer for largely supportive management

IV fluid rush to prevent AKI

Administer Dantrolene sodium

134
Q

What is clozapine?

A

An atypical anti-psychotic that is very effective in treating resistant schizoprenia

135
Q

Why does clozapine require regular blood monitoring?

A

Risk of agranulocytosis

136
Q

What are some dangerous side effects of clozapine?

A

Agranulocytosis, Myocarditis, Constipation

137
Q

What risk assessment should be completed for someone with an eating disorder?

A

MEED risk assessment

138
Q

How do you manage bulimia nervosa?

A

High dose fluoxetine + CBT

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