Psychiatry Flashcards
What is the diagnosis for depression?
2+ weeks of low mood, low energy and anhedonia (loss of interest in things you’d normally enjoy)
Gender medicine: Who is at increased risk in depression (2)
females- getting it
males- being more suicidal when getting it
Characteristic of pseudodementia and how to differentiate with depression
depressive symptoms + difficulty with memory + cognition
‘i dont know answers’
normal MSE (over 25/30 is normal)
Risk factors for depression
chronic pain (bio)
abuse (psycho)
bereavement (social)
What are the symptoms of typical depression
SIGE CAPS
suicide/ selft harm
interest (reduced)
guilt/ worthlessness
energy (reduced)
concentration (reduced)
appetitie (reduced)
psychomotor retardation (slower speech, slower movement)
sleep (reduced)
What are the symptoms of atypical depression and tx for this
increased appetite
increased sleep
can have good mood on good occasians
catatonia (person is awake but don’t react/ respond)
very emotionally sensitive
Tx:
CBT
MAOI
2 ix for depression
- Questionnnaire PHQ 9 questionnaire, BDI-II, Edinburgh, HADS
- bloods: FBC (anaemia), U&E(electrolyte abnormality), TFT(hypothyroidism), B12/ folate (deficiency), prolactin
Tell me about the depression questionnaires
-> Patient Health Questionnaire 9: MC used in community
0-4= none, 5-9= mild, 10-14=mod, 15+= severe
-> Becks Depression Inventory-II: self reporting
-> EPDS: Edinburgh postnatal depression scale (11+ indicates depresssion/ anxiety)
-> HADS: hospital anxiety and depression scale: hospital use only
How is depression classified clinically into subclinical, mild, mod, severe and manangement for each
clincally= based on patient’s symptoms, not from questionnaire
subclinical= 4 or less SIGE CAPS
mild= 5+ SIGE CAPS and little functional impairment
-> psychotherapy and advice for 3/4 months (NICE says do not offer medication first line for mild depression unless it is patients request)
-> psychothereapy can be CBT or interpersonal therapy
-> then SSRI
mod= 5+ SIGE CAPS and marked functional impairment
-> SSRI and high intensity CBT
severe= 5+ SIGE CAPS and marker functional impairment (+/- psychosis)
-> SSRI and high intensity CBT
-> can consider electroconvulsive therapy
What are other forms of depression 2 and treatment
seasonal affective disorder: every winter
-> any form of psychotherapy (CBT, IPT), follow up in 2 weeks and mild SSRIs if needed
dysthymia: subclinical depression for 2+ years
-> low intensity CBT
what does NICE guidelines say about medical treatment of depression 2
- if severe depression, offer patient any treatment option first line
- always start with an SSRI first line when doing medical management
What are examples of self harm and rfx
eg: cutting, headbanging
rfx: female, depression, abuse
What are examples of suicide methods and rfx:
eg: overdose, jumping from height, hanging
rfx: SAD PERSONS
sex- male, age- old and teens, depression, phx suicide attempt, ethanol- alchohol, rational loss- ie psychotic, social support is low, organised plan, not married, sick- chronic illness
What indicates increased risk of suicide 4
- makes a conscious effort not be be found
- planing
- no regret after attempt
- sort out things in order and leaves a note
What can manage lower risks of suicide/ self harm
suicide: thinking about protective factors- family/ pets
self harm: rubber bands, calm harm app (DBT)
both: CBT
What SSRIs are preferred if breastfeeding 2
sertraline (first line for postnatal depression generally) or paroxetine
What are the types of bipolar disorder mean?
type 1: alternative mania and depression
type 2: alternating hypomania and depression
cyclomania: alternating hypomania and subclinical depression for 2+ years
-> to differentiate between hypomania and mania- mania has no insight, grandiosity and psychosis whereas hypomania you are still in touch with reality
What is rapid cycling with reference to bipolar
4+ manic episodes in a year
What can precipitate a manic episode 3
benzos
SSRI
alcohol
What is mania
7+ days of IDIG FAST sx (irritable, distractble, insomnia, grandiose delusions, flight of ideas, increased activity, increased speech, thoughtless behavior (increased risk taking))
-> can also have hallucinations/ psychosis
What is hypomania
4+ days of elevated mood, mild version of mania sx but no grandiose and no hallucinations
-> functional
How are referrals done for bipolar disorder?
mania= urgent community mental health team referral
hypomania= routine community mental health team referral
What is the management for bipolar disorder?
acute management of mania/hypomania
-> consider stopping antidepressant if the patient takes one
-> start antipsychotic therapy e.g. olanzapine or haloperidol
management of depression
talking therapies
fluoxetine
long term management
Mood stabiliser- Lithium
CBT
How is lithium monitored
monitor serum lithium 12 hours post dose then weekly until stable and then 3 monthly
also monitor FBC, UE, TFT, eGFR, BMI and ECG
TFTs, eGFR- checked every 6 months
BUT, if increasing/ decreasing dose and they are usually stable, then check in 1 week
lithium can cause isolated leukocytosis
What is the MoA of lithium and its interactions
CAMP inhibitor
interactions: NSAIDs (leads to AKI), diuretics (increases dehydration), ACEi (renal failure and dehydration)
what are the symptoms of lithium toxicity and side effects of lithium
LITHIUMS
levels of 1.5mmol/L +
increased urination
thirst/ tremor
hair loss/ hypothyroidism
impaired memory
upset stomach
muscle weakness
skin conditions (acne)
(guy has a handful of lithium tablets and urinates himself, then he’s super thirsty so he drinks lots of water and when he tips his head back to drink the water, his hair falls out in clumps. He wants to go to the barber but he can’t remember where their shop is anymore and decided to stay home because his stomach hurts. So stressed he gets acne)
Above are all side effects. These are sx of toxicity:
* seizures
* course tremor (fine is seen in therapeutic levels)
* acute confusion
mx of lithium toxicity 4
- ABCDE
- IV fluids
- measure serum lithium every 4 hours
- if above 3mmol then haemodialysis needed
LITH
L: Lithium toxicity starts with ABCDE
I:IV fluids to promote lithium excretion and prevent dehydration.
T:Track levels – Monitor serum lithium every 4 hours.
H: Haemodialysis if levels are above 3 mmol/L or in severe toxicity
What is an important thing to note about discontinuating lithium
months after stopping, can get neurological symptoms- SILENT (syndrome of irreversible lithium effectuated neurotoxicity)
sx: altered level consciousness, tremor, nystagmus, hyperreflexia
reduced conscious but everything else starts shaking
What type of index does lithium have and what are the values
narrow therapeutic index
0.4mmol/L - 1mmol/L
what are alternative mood stabilisers to lithium 2
carbimazapine
valproate
Define schizophrenia
dissociation from reality for 28+ days (not associated with substance abuse)
if less than 28 days then it is called transient psychosis
What lobe is mainly affected in schizophrenia
temporal
What are the symptoms of schizophrenia
First rank sx: ABCDE
Auditory hallucinations
Broadcasting/insertion of thoughts
Cognitive sx= memory + attention + executive function issues (these present the earliest)
Delusional perceptions
External person controlling you (passivity)
Second rank sx: NIPP
indifferent responses
non auditory hallucinations (visual/ tactile)
poorly organised delusions
poorly organised speech
How to dx schizophrenia
1+ first rank sx for 28+ days
OR
2+ second rank sx for 28+ days
Risk factors of schizophrenia 2
cannabis use in childhood
first degree fhx
What indicates poorer prognosis of schizophrenia 3
-> low IQ
-> strong fhx
-> continuing substance misuse
- What is simple schizophrenia
- What is paranoid schizophrenia
- What is disorganised schizophrenia
- schizophrenia characterised by 2nd rank symptoms
- schizophrenia characterised by prominent paranoid delusions and auditory hallucinations
- schizophrenia characterised by disordered thought or affect (delusions/ hallucinations are less prominent)- usually in young patients
What is delusional disorder and mx
- 3+ months of isolated delusion eg persecution
- no psychosis
- give CBT
What is late onsent schizophrenia and mx
- older than 45 y/o with schizo
- good prognosis with low dose antipsychotic
What is schizoaffective disorder and mx
schizophrenia + a mood disorder (eg depression/ bipolar)
mx- antipsch for schizo and treat mood disorder accordingly
What is management for schizophrenia
- 1st line: start atypical antipsychotic 6-8 weeks trial eg risperidone/ aripiprazole (trial two then go to clozapine if they both fail)
- offer CBT to all
If medication compliance is an issue for antipsychotics, what can be done?
change from oral to depot (injections)
What is generalised anxiety disorder and its symptoms
pervasive (means daily) persistant non specific anxiety for 6+ months (EGADS- excessive GAD for 6 months)
i’m MISERAble:
Muscle tension
Insomnia
Sweaty
Energy loss
Restlessness
Autonomic (palp, SOB, tremor)
What are the ix for GAD
- bloods: FBC, UE, TFT, urine tox (drugs)
- questionnaires
-> GAD 7: generalised anxiety disorder 5-9 mild, 10-14 mod, 15+ severe
-> HADS in hospital
What is mx for GAD 5
ladder management:
1. patient education
2. low intensity CBT
3. high intensity CBT + SSRI
4. refer to CMHT (comm MH team)
5. propanalol for muscle tension
What are phobias and what is their management
irrational extreme fear of particular things
eg spiders/ blood/ public speaking= social phobia
mx:
1. exposure and response prevention therapy (desentise)
2. consider SSRI
What is Panic disorder and sx
disorder for longer than a month with minimum of 4+ weekly panic attacks (that typically last up to 30 mins) of MISERAble sx + 3Cs: chills, chest pain, choking sensation
Investigations for panic disorder and mx
ix: panic disorder severity scale (PDSS) and PHQ- for panic disorder
mx:
1. CBT + SSRI
What is OCD and examples
at least 2 weeks where 4+ days/ week have obsessions that are only relieved by acting on these obsessions ie compulsions
(so obsession leads to compulsions which causes relief but then anxiety as obsessions build up again)
eg hand washing, cleaning
What is the ix and mx for OCD
ix: Yale Brown OCD scale
mx: exposure and response treatment therapy (ERP) in CBT
1st line med is SSRI (takes 3 months to start working- needs to take for this long AND take for a year after sx resolve)
2nd line is clomipramine TCA (clo mi pram mine)
What is PTSD and sx, who can get PTSD
28+ days of prolonged stress reaction to a traumatic event that happened in the past (after 4 weeks- before 4 weeks= acute stress reaction)
eg war veterans, rape victims
sx: HEAR
hypervigilance
emotional blunting
avoidance
reliving the experience (flashbacks, nightmares)
What is the ix and mx of PTSD
ix:
trauma screening questionnaire
mx:
* EMDR (eye movement desensitisation and reprocessing therapy)
* combat related trauma, in which case do truama focused CBT first line
Compare PTSD vs complex PTSD
Complex PTSD= PTSD plus
-feelings of worthlessness and guilt
-problems controlling emotions
-relationship problems/ struggling to connect to others
What are the 5 Ps of formulation and examples
predisposing (risk factors eg childhood abuse)
precipitating (just before episode eg grief)
presenting (what pt presents with eg depression)
perpetuating (things that keep the pts presentation ongoing eg distorted body image/ in an abusive relationship)
protective (things that keep pt grounded eg pets/ kids)
Explain the biopsychosocial model and examples
biological:
genetics, PMHx
psychological:
MHx conditions
social:
relationships, finances, stress, culture
How to do an MSE
ASEPTIC acronym
appearance + behavior (dress, eye contact)
speech (rate, rhythm, tone, volume)
emotion (mood- asked directly + affect- congruent with mood or not)
perception (delusions, hallucinations)
thought (forms and thought stream)
insight (awareness of reality)
cognition (up or down)
How to take a psychiatry history
Same medical history +
1. personal history (childhood to now)
2. suicide and self harm (history- how and when it was done, any regrets, any thoughts currently)
3. forensic hx (legal involvement)
When does ADHD present and what are its characteristics
6-12 year old
triad of hyperactivity, impulsivity and attention deficit in 2+ environments
(hyperactivity more likely to be in male, deficit in females)
What is the assessment for ADHD 2
- DIVA-5 questionnaire: diagnostic interview for ADHD in adults
- in kids= young DIVA 5 questionaire
What is the treatment for ADHD 4
- trial of watch and wait for 10 weeks
- methylphenidate (amphetamine- CNS stimulant)
- lisdexamfetamine
- monitor growth on charts 6 monthly as methylphenidate decreases appetite and basline ECG due to risk of RBBB
What is autism spectrum disorder (ASD) and what age and gender does it roughly manifest
spectrum of impaired communication and social interactions
more males, less than 3 years old
What is the difference between ADHD and autism presentation
Autistic individuals fail to recognise social cues but individuals with ADHD can
What are the symptoms of ASD 7
decreased speech S
decreased empathy E
isolation and decreased interest in shared play I
concrete thinking T (literal thinking eg think outside the box and they’d look for a box)
specific knowledge K
ritualistic behavior (repetitive, inflexible routine) R
decreased response to emotional cues
3E TRIKES (3 ASD boys sitting on trikes)
What is the assessment for ASD 1
M-CHAT: modified checklist for autism in toddlers
What is the management for ASD 3
supportive management
eg special needs teaching in school and
applied behavioral analysis therapy (ABA)
What are causes of learning disabilities 4
- ASD
- genetic: downs and fragile x syndrome
- TORCH
What is the classification of learning disability
IQ over 100 is normal
50-70 is mild
35-49 moderate
20-34 severe
<20 profound
What are the two types of tics and examples of them
simple: non goal oriented movement eg nose wrinkling/ moving head to side
complex:
echolalie-echoing others coprolalie-verbal swearing
how is tourettes syndrome diagnosed
2+ motor tics AND 1+ vocal tic for 1 year minimum
What is PANDAs
When a kid gets OCD/ TICS after a strep A infection
What is insomnia and mx
3+ days a week struggling to sleep
mx: zopiclone
What is the criteria for gender dysphoria dx
2+ of the following for 6+ months:
* strong desire to be opposite gender
* strong desire to have opposite gender’s genitals
* strong desire to be treated like opposite gender
* has feelings like opposite gender
* do not like how their physical appearance is
How should antidepressants be taken 3
- takes 4-6 weeks to start working
- baseline monitor then weekly for 4 weekly (esp SSRIs increase suicidaility risk for under 30 Y/O) and then every fortnight
- need to take for 6 months after sx have improved and wean over 4 weeks to prevent serotonin syndrome
What is something important to consider when prescribing antidepressants under 30 years old 1
initially increases suicidality risk
What are the 5 types of antidepressants
SSRI
SNRI
MAOI
TCA
mirtazipine
What is the MoA of SSRI, examples and where relevant its uses and SEs
5-HT presynaptic reuptake inhibitor
* sertraline
* fluoxetine- prescribed in CAMHS
* paroxetine- safe for breastfeeding but has severe discontinuation side effects and causes severe congenital defects if taken during pregnancy 2/3rd tri
* citalopram- SE of QT interval prolongation >480ms (not short cutie, long cutie)
What are the general SE of SSRIs 5
Stomach issues (n/v/pain)
Serotonin syndrome
Reduced sex drive/ ability to have an erection (libido/ erectile dysfunction)
Interactions: increases risk of GI bleed if in conjunction with NSAIDs (co-prescribe PPI!), lowers seizure threshold, decreases efficacy of triptans (RST)
Ssodium low (hyponatraemia)
What are the risks of SSRIs when pregnant and which in particular increases risk of defects
1st trimester- congenital heart defect, cleft palate
2/3rd trimester- persistant pulmonary HTN of newborn (PPHN)
paroxetine has the highest association with congenital defects
What is the MoA of SNRI, examples
noradrenaline and 5-HT reuptake inhibitor presynaptically
eg venlafaxine or duloxetine
What are the SE of SNRIs
Nausea/ vomiting
No drooling (dry mouth)
No muscle (rhabdomyolysis)
No sodium (SIADH)
4Ns
also can cause HTN so baseline BP check needed
What is the MoA of MAO inhibitors and examples
monoamine oxidase inhibitor (prevents noradrenaline, 5-HT and Adrenaline breakdown in CNS)
eg phenelzine sulfate, isocarboxazid, selegilline
(i saw car (in a) box as is(d))
What
What are SE of MAOIs
SE:
* cause hypertensive crisis with foods high in tyramine eg (cheese and 2+ glasses alcohol)
* cause serotonin syndrome if co-prescribed with an SSRI
What is the MoA of TCAs, examples
5-HT and NAd reuptake inhibitor
eg amitryptilline (sedating), eg imipramine (non sedating)
What are side effects of TCAs 4
can’t see (blurred vision)
can’t pee (urinary retention)
can’t spit (dry mouth)
can’t sh-t (constipation)
What are the signs of TCA overdose, Ix and Tx
confusion
cardiotoxicity
colossal pupils (dilated pupils)
cracked skin (dry and hot)
Ix:
24 hour ECG:
wide QRS >100 and QT prolongation >480
Tx: IV sodium bicarbonate (if cardiac signs)
What is the MoA of mirtazipine, SE
NASSA: noradrenergic and specific serotonergic antidepressant
SE: weight gain + sedation
When does NICE recommend using mirtazipine? 2
- first line as an antidepressant if patient on warfarin/ LMWH (dalteparin)
- use in very skinny patients who struggle with sleeping
compare serotonin syndrome and neuroleptic malignant syndrome (onset, cause, features)
SS: over hours
NMS: over days/ weeks
SS: antidepressants, opioids, illicit drugs
NMS: anti-psychotics and sudden stop of dopaminergic agents eg levodopa
SS: hyperreflexia, clonus, tremor, dilated pupils, diarrhoea, autonomic features (HTN, tachycardia)
NMS: hyporreflexia, lead-pipe rigidity, no eye or bowel signs, autonomic features (HTN, tachycardia)
compare management of serotonin syndrome and neuroleptic malignant syndrome
SS:
1. stop SSRI
2. ABCDE
3. give chlorpromazine (typical antipsychotic which blocks 5HT receptors)
NMS:
1. stop antipsychotic
2. ABCDE
3. start dantrolene and bromocriptine
What is the pathophysiology of addicative behaviors
mesolimbic reward pathway involving dopamine
What sx define dependance
- use substance to avoid withdrawl from it eg drinking first thing in the morning to avoid withdrawl symptoms
- tolerance (reduced reaction to a drug followign its repeated use)
- craving
- loss of control
- rapid reinforcement (quick return to old level after stopping)
- continous use despite harm
- primacy (additions takes precendance over basic human needs)
We Took Crazy Risks Playing Cards
What defines alcohol dependance and according to what criteria
ICD 10
12 months history with 3+ dependance sx
What is the effect of alcohol on the brain 1and body 4
GABAergic CNS retardant (slows things down)
increased cortisol
increased adipose mass
decreased resp rate
decreased co-ordination
What are the symtoms of chronic and excessive alcohol overuse 4
confusion (AMS change)
opthalmoplegsia
ataxia
thiamine (wernickes)
COAT
What are the symptoms and timeframes of alcohol withdrawl
6-12 hours: anxiety and fine tremor
36 hours: seizures
72 hours: delirium tremens (course tremor, AMS, change in GCS, tacile hallucinations eg skin crawling)
What is the illegal limit of alcohol for driving
0.08 + BAC (blood alcohol content)
What are the investigations for alcohol abuse 3
- bloods (high GGT, high CDT- carbohydrate defecient transferrin for long term alcohol, high ALP)
- screening questionnaires CAGE (2/4+) and Audit (8/10+)
- once stable, CIWA questionnaire for assessing severity of alcohol withdrawal
What is the treatment for acute and long term withdrawal of alcohol
acute: IV chlordiazepoxide
long term:
* naltrexone (opioid inh) to decrease pleasure
* acamprosate (NDMA inh) to decrease cravings
* disulfiram (AAD inh) to induce angover symptoms with alcohol- CI in pregnancy and alcohol use (can cause severe SE)
What are the symptoms of opioid overdose 5
pain relief
constipation
euphoria
pinpoint pupils
respiratory depression
What are the symptoms of opioid withdrawl 5
dilated pupils
yawning
rhinorrhoea
lacrimation
hot and cold flushes
(sick and ill person in bed)
what is the management for opioid overdose 2
acute: IV 400mg naloxone
long term: oral methadone
State the difference between substance misuse and substance abuse
misuse: substances that are taken for a purpose that is not consistent with medical guidelines/ taken for a secondary purpose eg alchol to help them go to sleep or reduce anxiety/ taking too many prescription opioid meds for pain
abuse: drugs including alcohol are used to get high/ inflict self harm excessively
What is somatisation disorder vs somatoform disorder
when individuals have an extreme focus on physical symptoms to the point where it affects their daily functioning and mental health- linked with hypochondriasis
also called illness anxiety
somatoform- medically unexplained symptoms (encompasses conversion disorder)
What are differential diagnoses for psychosis 4
-drug induced (cocaine, meth, steroids)
-schizophrenia/ schizoaffective
-depression (/post partum)
-Huntingtons
What are personality disorders
chronic unwavering behavior pattern OVER age of 18+ years
What are the subcategories of personality disorders
class A= mad
class B= bad (bad people to be around)
class C=sad
Name and describe the class A personality disorders
- paranoid: sensitive, unforgiving, takes attacks on character seriously, persecutary delusions: Elsa
- schizotypal: inappropriate affect, magical thinking, odd behavior, ideas of reference: Willy Wonka
- schizoid: cold, solitude, decreased libido, thinks world is uncaring (think batman)
Name and describe the class B personality disorders
- narcassistic: beleive lifes a competition, grandiose, entitled: Donald Trump
- histrionic: crave centre of attention, flirtacious, consider relationships closer than they are: Harley Quinn
- EUPD: crave sympathy, impulsive acts eg self harm, poor relationship hx: Pick Me
- antisocial: repeated unlawful violent acts eg arson, animal cruelty, no remorse (psycho- law involved, socio- no law involved): Scar from the lion king
Name and describe the class C personality disorders
- anankastic (OCPD obsessive compulsive personality disorder): strict time regulation, inflexible, refuses to delegate, perfectionist: Sheldon Cooper
- avoidant: craves companionship and intimacy but fear of rejection
- dependant: wants others to make big decision with, submissive: Daphne Scooby Doo
What are the investigations and management for personality disorders
Ix: Minnessota multiple personality inventory (MMPI)
Tx: CBT- DBT for EUPD to change thought perception
Behavioral Action therapy
What is catatonia and what is it associated with 2
abrupt ceases in speech or movement
associated with mania and schizophrenia
What is ECT, how is it done and what are the indications 3 and SE 2
electrode guided current to brain parenchyma
under general anaesthesia which causes a seizure
indicated in:
-severe life threatening or last resort depression
-resistant mania
-catatonic schizophrenai
SE: amnesia/ confusion
What are the types of talking therapy 4 and explain how each works
CBT: changes negative thoughts by breaking them down into STEAP (situation/ thoughts/ emotions/ actions/ physical feelings)
DBT: changes negative thoughts and positively promotes acceptance, focuses on more emotional and social aspects of life than CBT
IPT: resolves relationship problems
couple/ family therapy: promotes communication, teaches how to support pt and modified dysfunctional behavior
What is the function of hypnotics, examples and moa
hypnotics: drugs used to induce sleep + maintain good sleep (for short term use in insomia)
MoA: GAGA agonist- zopiclone (nonbenzodiazipine), lorazepam (benzodiazepine)
What are the two psych emergencies regarding chronic alcohol overuse
wernickes encephalopathy
korsakoffs pyschosis
What is wernickes encephalopathy caused by, is it reversible, what areas of the brain does it affect, symptoms, investigation with results, and treatment
B1 thiamin deficiency due to chronic alcoholism (alcohol reduced thiamin absorption in body)
reversible
thalamus + hypothalamus
sx: nystagmus, ataxia, altered mental state, opthalmoplegia (any eye muscle palsy) (two As and 2 eyes)
MRI: reversible cytotoxic odema
Tx: ABCDE then on suspicion IV pabrinex 500mg TDS 3 days then 250mg for 5 days (pabrinex given immediately on suspicion of condition)
question example:
A 35-year-old man is brought to the emergency department by police after being found intoxicated in public. He appears unkempt and confused and has a bottle of vodka that he has been drinking over the last hour.
He is afebrile, observations are normal, and he is not agitated. However, his gait is ataxic and his eyes move involuntarily and rhythmically in the lateral direction (opthalmoplegia). There is no sweating or tremor and his blood glucose is normal.
COAT
What is korsakoff psychosis caused by, is it reversible, symptoms, investigation with results, and treatment
progression of wernickes encephalopathy
irreversible brain damage
wernicke’s symptoms plus confabulation
MRI: mammilary body and thalamic atrophy
Tx: oral pabrinex for 2 years
What are the different types of delusions and explain each one 9
- nihallistic (belief that life has no meaning)
- persecutory (belief someone is trying to harm them)
- grandiose (mania sx where pt believes they have made important discover/ have great undiscovered talent)
- othello (believes partner is cheating)
- capgras (close relative replaced with an imposter)
- fregoli (everyone is 1 person with masks)
- de cleraumbault (high status person in love with them)
- cotard (beleif they are dead and rotting)
- ekrom (creepy crawly, restless leg syndrome- mx propapalol and check for iron deficiency)
What does the mental health act 1983 entail
principles for individuals: least restriction to ensure pt safety and wellbeing and give the most effective treatment
for detaining: evidence of mental health incident, risk to society, whether they will benefit from admission and if there is availability of treatment
Explain the difference between mental health act 1983 and mental capacity act 2005
MHA are the rights for individuals with MH problems that are sectioned under the act
MCA applied to individuals with a MH problem which assesses capacity to make decisions
The MHA can override the MCA and pts can be detained even if they have capacity
Explain sections 2 and 3 in the mental health act 1983 and where is this relevant
2) section for 28 days for investigations for section 12, required by 2 drs and a social worker (AMHP). Non renewable
3) section for 6 months for Tx, required by 2 drs and a social worker (AMHP). Renewable 6 monthly
for community
Explain section 5 in the mental health act 1983 and where is this relevant
5.2) 72 hour dr has holding power to wait for section 12 and AMHP
5.4) 6 hour hold nurse has to wait for doctor
inpatient
Explain section 135 and 136 in the mental health act 1983 and where is this relevant
135) Police have 24-36 hour pt admission to access home
136) Police have 24-36 hour pt admission with suspected mental health incident in public place
police in community
What is the MoA of antipsychotics and how do they work
dopamine 2 receptor antagonist which affect mesolimbic pathway and therefore reduce positive symptoms
What are two important things to note with taking antipsychotics: reviews and stopping
- have 12 monthly review of FBC, U/E, Hba1c, LFT, prolactin and BMI
- to stop, there needs to be a gradual reduction over a period of 3+ months to prevent relapse
Give examples of typical antipsychotics, what generation and what are they associated with
haloperidol and chlorpromazine
1st generation (older)
extrapyramidal side effects (due to their effect inhibiting the nigrostriatal pathway)
What are the extrapyramidal symptoms of typical antipsychotics 4 and their treatments
Parkinsonisms (bradykinesia, rigidity, resting tremor)
mx: levodopa
acute dystonia (inv contractions of muscles of extremities)
mx: IV/IMprocyclidine (anti Ach) and switch to 2nd gen antipsychotic
akathisia (severe restlessness)
mx: oral propanalol
tardive dyskinesia (inv movements of the face and jaw- occur years after)
mx: oral tetrabenazine (VMAT2 inh) and switch to 2nd gen antipsychotic if on one currently
Give examples of atypical antipsychotics, what generation and what are they associated with
risperidone, olanzapine, aripiprazole, clozapine
2nd generation (newer)
metabolic syndromes: (cushings/T2DM/ hyperprolactinaemia) and weight gain
Explain hyperplactiniaemia sx as a SE of atypical antipsych
Hyperprolactinaemia
Sx: lactation
decreased libido
infertility
What is unique about aripiprazole
only forms a partial dopamine blockade so has reduced side effects
What is the indication for clozapine and how is it monitored
last line, after trialling 2 different antipsychotics for treatment resistant schizophrenia
med reviews + monitoring:
* first 18 weeks, weekly
* then 16 weeks, every fortnight
* then monthly
* FBC, BP, BMI, checking for SE
what are the SE of clozapine
what are the requirements for taking clozapine
agranulocutosis: sore throat, fever, mouth ulcers
general SE: CLOzapine
constipation, lots of saliva, overweight
need to retitrate if dose missed for over 48 hours or if smoking status changes (smoking increases metabolism which decreases bioavailability of clozapine)
What is the only antipsychotic that has proven to treat negative symptoms and where does it act
clozapine
mesocortical pathway
what is a hallucination vs illusion
hallucination= unreal interpretation of an unreal stimuli
illusion= unreal intepretation of a real stimuli
What is a delusion
fixed false unsahkeable belief that is outside social norms and cannot be challenged
What is flight of ideas speech
rapid stream of speech where there are jumps between topics but connections between topics
what is a knights move in speech
illogical jumps between topics, no connections
what is tangeltiality vs circumstantiality in speech
tan: deviating from a point and not returning
circ: deviating from a point and the returning
What is munchenhausen
fabrication signs and symptoms to play a sick role
what is maungering
fabricating MH for secondary gain eg avoid jail time
(your honour, he is maungering his way out!!)
What is hypochondriasis
mental preoccusations (convinced) that pt has severe illness/ cancer depsite multiple negative tests
compare depersonalisationa dn derealisation
depersonal: they think they are not real (nihilistic delusion)
dereal: thinks the world around them isnt real
What is conversion disorder
neurolgical sx eg weakness with no physcial pathology so it is put down to psychological causes
What are ideas of reference?
eg thinks messages on TV news are directed at self
What is word salad
mixture of words in a sentance that is difficult to understand eg spiders bubles flew blue
What is anorexia nervosa
under 17.5 BMI with body dysmorphia and using excessive methods to ensure no weight gained eg laxatives/ induced vomiting
What are symptoms of A nervosa
amenorrhea (hypogonadotrophic hypogonadism)
parotitis
lanugo hair (soft fine hair across body)
dry skin
hypotension
mood issues: depresssion/ anxiety
What are investigations for anorexia and results
- general bloods: FBC, UE, Hba1c, growth hormone, cortisol
- BP (will be low)
- ECG (potential arrythmias due to low K+ and bradycardia)
- can do MUST score calculation
everythign in bloods low and growth hormone and cortisol high
What is mx for a nervosa in children and adults
children:
anorexia focussed family therapy then CBT
adults:
individual eating disroder focsued CBT
consider inpatient and fluoxetine in severe cases
comp of anorexia 3
- refeeding syndrome (need to monitor electrolytes as intracellular shift- particularly low phosphate)
- osteoporosis
- rhabdomyelysis
define bulimia nervosa
3 months consisting of 2+ episodes in a week of binging and purging with a normal BMI
what are clincial signs of bulimia nervosa
russels sign (calluses on knuckles from repeated attempts to induce vomiting)
dental caries
parotitis (inflammation of parotid glands)
what are the ix for bulimia
Venous blood gas= hypokalemiac hypochloric metabolic alkalosis (low K low Cl)
mx for bulimia in children and adults
chlidren:
bulimia nervosa focused family therapy
adults:
bulimia focused self help for 4 weeks
eating disorder focused CBT
