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Finals > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

When can involuntary admission be implemented?

A
  1. Patient has mental disorder
  2. Needs detention for assessment/treatment of it
  3. Admission is to protect themselves or others
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2
Q

What is section 2 of the mental health act

A
  • Admission for assessment for up to 28 days
  • 2 doctors and AMHP present
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3
Q

What is section 3 of mental health act

A
  • Admission for treatment for up to 6 months
  • Can be renewed indefinitely
  • Exact mental disorder stated and appropriate treatment available
  • Two doctors sign and find reason that community treatment is contraindicated
  • Treatment must be likely to benefit patient, prevent deterioration, necessary for health or safety of patient or protection of others
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4
Q

What is section 4 of the mental health act

A
  • Admission for emergency treatment for up to 72 hours
  • Admission must be urgent necessity
  • AMHP makes application after recommendation from one doctor
  • Patient must be seen within 72 hrs by doctor to decide whether to put section 2/3, voluntary admission or discharge
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5
Q

What is section 5(2) of mental health act

A
  • Detention of patient already in hospital for up to 72 hours
  • Doctors holding powers
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6
Q

Section 5(4) of mental health act

A
  • Nurse’s holding powers for up to 6 hours
  • Detain patient who is taking discharge against advice
  • During 6 hours nurse must find personnel to sign section 5(2) or allow discharge
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7
Q

Section 135 of mental health act

A
  • Allows police to force entry into someone’s premises to allow assessment under MHA to be made or bring them to place of safety
  • Warrant from Magistrates court required and accompanied by AMHP and/or doctor
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8
Q

Section 136 of mental health act

A
  • Allows police to arrest person ‘in a place to which public have access’ who they believe to be suffering from a mental disorder in order to convey them directly to a place of safety
  • Held under section 136 for up to 72 hrs during which they should be seen by doctor and AMHP to choose to complete MHA assessment, admit them informally or discharge them
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9
Q

Mental capacity act (2005)

A
  • Presumption of capacity
  • Individuals supported to make their own decisions
  • Unwise decisions
  • Best interests
  • Less restrictive option
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10
Q

What is a hallucination

A
  • Occur in any sensory modality without an external stimulus
  • Felt to occur in the external world along other objects, have the same qualities as everything else and cannot be consciously manipulated or stopped
  • To the person experiencing them, these experiences are real
  • Auditory = thoughts spoken aloud, second-person hallucinations, third-person hallucinations
  • Visual = More common in eye pathology and epilepsy than psychosis
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11
Q

What is a delusion

A

beliefs held unshakably, irrespective of counter-argument, that are unexpected and out of keeping with patient’s cultural background

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12
Q

Loosening of association

A

thought disturbance demonstrated by speech that is disconnected and fragmented with individual jumping from one idea to another unrelated or indirectly related idea

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13
Q

Circumstantiality

A

including a lot of unnecessary and insignificant details in your conversation or writing

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14
Q

Confabulation

A

production or creation of false or erroneous memories without intent to deceive. Or, falsification of memory by person who believes they are genuinely communicating truthful memories

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15
Q

Somatic passivity

A

experience of bodily sensations (including actions, thoughts or emotions) imposed by external agency
* E.g. voices commentating on one’s action
* E.g. voices describe patient’s activities as they occur

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16
Q

Anhedonia

A

inability to feel pleasure

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17
Q

Thought alienation

A

subjective experience of one’s own thoughts being under control of an outside agency
* Thought Insertion = foreign thoughts places into one’s mind
* Thought Withdrawal = thoughts suddenly disappearing (having been taken by external thought)
* Thought Broadcast = thoughts being transmitted to everyone around as though being played on a radio

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18
Q

Thought echo

A

form of auditory hallucination in which a patient hears their thoughts spoken aloud
* Associated with schizophrenia

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19
Q

Thought block

A

someone loses a train of thought for no apparent reason, which may cause them to suddenly stop speaking
* Can occur at any time due to tiredness or stress

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20
Q

Akathisia

A

inability to remain still
* Neuropsychiatric syndrome associated with psychomotor restlessness
* Experience intense sensation of unease or inner restlessness

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21
Q

Catatonia

A

group of symptoms that usually involve movement and communication
* Agitation, confusion, restlessness

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22
Q

Flight of ideas

A

Subjective quickening of thoughts so most are not carried to completion before being overtaken
* Meaningful connections between ideas are kept although often linked by distracting environmental cues or form words themselves spoken aloud
o E.g. puns, rhymes, clang associations
* Retardation of thinking is slowing of train of thought although is remains goal directed
* Opposite is pressure of speech

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23
Q

Dissociation

A

hysteria
* Amnesia
* Depersonalisation = feeling being detached from one’s body or ideas
* Dissociative identity disorder = patient has multiple personalities which interact in complex ways
* Fugue = inability to recall one’s past, loss of identity or formation of new identity

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24
Q

What is generalised anxiety disorder

A

Excessive state of anxiety across different situations that last >6m and interferes with daily life

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25
Q

Causes of GAD

A

Genetic predisposition
Stress = work, noise, hostile home
Events = losing/gaining spouse/job, moving house
Faulty learning or secondary gain

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26
Q

Clinical features of GAD

A

Psychological symptoms
* Unpleasant feeling of suspense
* Recurrent automatic thoughts about negative outcomes
* Reduced concentration
* Hypervigilance
Behavioural symptoms
* Avoidance of anxiogenic stimuli
* Restlessness/agitation
* Irritability
Physiological symptoms
* Palpitations
* Dyspnoea
* Muscle tension
* Disturbed sleep (initial insomnia)
* Fatigue
* Nausea
Children’s symptoms
* Thumb-sucking
* Nail biting
* Bed wetting

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27
Q

Signs of GAD

A

Tachycardia
Tachypnoea
Tremor
Sweating
Pallor
Pupil dilation

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28
Q

Severity scoring of GAD

A

GAD2 or GAD7

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29
Q

Management of GAD

A

Self-help based on CBT principles
Meditation and Progressive relaxation training
SSRI

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30
Q

What is panic disorder

A

Anxiety disorder associated with panic attacks

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31
Q

Presentation of panic disorder

A

Physical
* Palpitations
* Chest pain
* Choking
* Tachypnoea
* Dry mouth
* Urgency of micturition
* Dizziness
* Blurred visions
* Parasthesiae
Psychological
* Feeling of impending doom
* Fear of dying
* Fear of losing control
* Depersonalisation
* Derealisation

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32
Q

Management of panic disorder

A

Acute treatment = propranolol
1st line = CBT + SSRI (sertraline)
2nd line (no response after 12wks or CI) = imipramine or clomipramine
3rd line = pregabalin or clonazepam

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33
Q

What is obsessive-compulsive disorder

A

Compulsions = senseless, repeated rituals
Obsessions = stereotyped, purposeless words, ideas or phrases that come into mind

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34
Q

Presentation of OCD

A

Compulsions (ACTS)
* Usually a way to reduce stress from obsessions
* Often resisted by patient but if chronic patient may have given up resisting
* Repetitive behaviours
* Checking, washing, counting, symmetry, repeating certain words or phrases
Obsessive thoughts
* Unpleasant = death, sexual, blasphemous
* Intrusive
* Irrational
* Recognised as patient’s own thoughts
Presents with
* Derm, genital or anal, HIV/illness worries

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35
Q

Severity of OCD

A

Yale-Brown OC scale

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36
Q

Management of OCD

A

CBT = Exposure and response prevention
SSRIs = sertraline, fluoxetine
Clomipramine

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37
Q

What are phobic disorders

A

Group of disorders in which anxiety is experienced only or predominantly in certain well-defined situations that are not dangerous

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38
Q

Types of phobic disorders

A

Agoraphobia = fear of crowds, travel, events away from home
Social phobias = situations where closely observed
Simple phobia = e.g. dentists, spiders, clowns
Fear of fear

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39
Q

Presentation of phobic disorders

A

Situations are avoided or endured with dread
Become disorder when they cause marked distress and/or significantly impair ability to function
Can lead to panic attacks

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40
Q

Management of phobic disorders

A

Panic attacks
* CBT
* SSRI, TCA, pregabalin, clonazepam

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41
Q

What is PTSD

A

Develops after an exceptionally stressful, life-threatening or catastrophic event or situation and lasts for over 4 weeks

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42
Q

Presentation of PTSD

A

Re-experiencing event in vivid nightmares or flashbacks
* Any sensory modality: visual, smell, sound, touch
Precipitating anxiety or panic attacks
Avoidance of things that associated with event (place, person, thoughts)
Hypervigilance
Sleep disturbance
Poor concentration
Inability to recall key features of trauma
Overly negative thoughts and assumptions about oneself or the world
Exaggerated blame of self or other for causing trauma
Negative affect
Decreased interest in activities
Feeling isolated
Irritability or aggression
Risky or destructive behaviour
Heightened startle reaction
In children
* Re-enacting experience
* Repetitive play
* Frightening dreams without recognisable content

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43
Q

Associations of PTSD

A

Depression
Emotional numbing
Drug and alcohol misuse
Anger

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44
Q

Management of PTSD

A

Watchful waiting if <4wks = acute stress disorder
Trauma-focused treatments
* CBT
* Eye movement desensitisation and reprocessing (EMDR)
* Hypnotherapy
Stress management
Medication (2nd line to therapy)
* SSRIs or venlafaxine
* SGA
Treat comorbidity (depression)
No debrief or counselling

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45
Q

What is anorexia nervosa

A

Compulsive need to control eating and body shape

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46
Q

Epidemiology of anorexia nervosa

A

F>M
Men likely to be underdiagnosed
Typical age of onset mid-adolescence (16-17)

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46
Q

Risk factors for anorexia nervosa

A

Biological
* Genetics
* Serotonin dysregulation
Psychological
* Depression
* Anxiety
* Obsessive compulsive features
* Perfectionism
* Low self-esteem
* Absent sense of identity
Developmental
* Adverse life events and difficulties
* Dietary/feeding problems in early life
* Parents preoccupied with food
* Psychosexual immaturity
Sociocultural
* Substance abuse
* Negative body images due to media exposure
* Image-aware activities
* Past teasing or criticism for fatness
* Asexuality

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47
Q

Presentation of anorexia nervosa

A

Weight loss becomes over-valued idea
Marked distortion of body image
Males with anorexia tend to want high muscle mass rather than thinness
Ideal body shaped achieved by food refusal combined with over-exercising, induced vomiting, laxative abuse
Many have episodes of binge eating, followed by remorse, vomiting and concealment
Low self-worth
Comorbid depression/insomnia

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48
Q

Signs of anorexia nervosa

A

Most due to starvation and vomiting
Fatigue
Decreased cognition
Altered sleep cycle
Sensitivity to cold
Dizziness
Constipation
Fullness after eating
Psychosexual problems
Subfertility, Amenorrhoea
Decreased visuo-spatial ability
Decreased visual memory
Increased speed of information processing
Peripheral neuropathy
Caries
Dry skin
Brittle hair
Lanugo hair

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49
Q

Diagnostic criteria for anorexia nervosa

A

Weight <85% of predicted or BMI <17.5
Intense fear of gaining weight, becoming fat with persistent behaviour that interferes with weight gain
Feeling fat when thin
Endocrine change (Amenorrhoea, decreased libido)

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50
Q

Screening for anorexia nervosa

A

SCOFF questionnaire
* Sick (make yourself)
* Control (lost over eating)
* One stone lost in 3m
* Feel fat
* Food (dominates life)

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51
Q

Red flags for anorexia nervosa

A

BMI <13 or <2nd centile
Weight loss >1kg/wk
Temp <34.5
Hypotensive (BP <80/50)
Pulse <40
O2 sats <92%
Limbs blue and cold
Weakness in muscles = Unable to get up without using arms for leverage
Purpura
K+ <2.5
Na+ < 130
Phosphate <0.5
Long QT, flat T waves on ECG

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52
Q

Management of anorexia nervosa

A

Aim to restore nutritional balance
* Weight gain 0.5-1kg/wk
* 3500-7000 extra calories/wk
* Final BMI 20-25
Treat complications of starvation
Explore comorbidity
Involve family/carers (Family therapy = 1st line in children)
Address factors maintaining illness
Eating disorder CBT
Maudsley anorexia nervosa treatment for adults (MANTRA)
Specialist supportive clinical management (SSCM)

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53
Q

Complications of anorexia nervosa

A

Re-feeding syndrome
Cardiac
Amenorrhoea
Osteopenia

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54
Q

What is bulimia nervosa

A

Recurrent episodes of binge eating characterised by controlled overeating

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55
Q

Epidemiology of bulimia nervosa

A

F>M
Increased prevalence in developed countries
Young, Asian women increased risk

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56
Q

Risk factors for bulimia nervosa

A

Homosexuality/bisexuality in males
Urbanisation
Premorbid obesity
Female relatives of anorexics
Genetic contribution 54-83%

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57
Q

Presentation of bulimia nervosa

A

Preoccupation with control of body weight
Regular use of mechanisms to overcome fattening effects of binges (starvation, vomit-induction, laxatives, overexercise)
Fatigue
Lethargy
Feeling bloated
Constipation
Abdominal pain
Oesophagitis
Gastric dilation with risk of gastric rupture
Heart conduction abnormalities
Cardiomyopathy (if laxative use)
Tetany
Occasional swelling of hands and feet
Irregular menstruation
Erosion of dental enamel
Enlarged parotid glands
Calluses on back of hands (Russell’s sign) = from tooth marks during induction of vomiting
Oedema = use of laxatives and diuretics
Metabolic acidosis (if laxative use)

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58
Q

Diagnostic criteria for bulimia nervosa

A

Recurrent episodes of binge eating and feeling loss of control
Recurrent compensatory behaviour to prevent weight gain
Episodes occur at least once a week for 3m
Self-evaluation is influenced by body weight or shape
Disturbance does not occur exclusively during episodes of anorexia nervosa

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59
Q

Management of bulimia nervosa

A

Mild symptoms
* Support
* Self-help books
* Food diary
Referral to EDU if
* No response
* Moderate/severe symptoms
Refer to medical unit if medical complications
Antidepressants
* Decrease binges and purging
* First line = SSRIs (Fluoxetine)
CBT
Children = family therapy

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60
Q

What is refeeding syndrome

A

Metabolic abnormalities due to rapid initiation of food after >10 days of undernutrition

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61
Q

Presentation of refeeding syndrome

A

Rhabdomyolysis
Resp/cardiac failure
Low BP
Arrhythmias
Seizures

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62
Q

High risk of refeeding syndrome if

A

BMI <16
Unintentional weight loss >15% over 3-6m
Little nutritional intake >10 days
Hypokalaemia, hypophosphatemia or hypomagnesaemia prior to feeding
Hx of alcohol abuse, drug therapy including insulin, chemotherapy, diuretics, antacids

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63
Q

Management of refeeding syndrome

A

Slow refeeding
Thiamine and multivitamins
Monitor phosphate, potassium, glucose and magnesium levels

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64
Q

Complications of refeeding syndrome

A

Hypomagnesaemia = torsades de pointes
Abnormal fluid balance
Death

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65
Q

What is depression

A

Chronic feelings of low mood, low energy and loss of interest

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66
Q

Causes of depression

A

Biological
* Genetic susceptibility
* Decreased monoamine
* Structural brain change ventricular enlargement and raised sucal prominence
Psychological
* Personality traits neuroticism
* Low self-esteem
* Childhood experiences
Social
* Disruption due to life events
* Stress associated with poor social environment, social isolation
* Social drift to lower social class

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67
Q

Diagnosis of depression

A

Symptoms present every or nearly every day without significant changes throughout day for over 2 weeks and represent change from normal personality without alcohol/drugs, medical disorders or bereavement
2 Core symptoms
* Low mood
* Loss of interest or pleasure (Anhedonia)
* Loss of energy
2 or more typical symptoms
* Change in appetite (marked with weight loss without dieting)
* Change in sleep = initial insomnia or early waking
* Psychomotor retardation or agitation
* Change in libido
* Reduced ability to concentrate
* Loss of confidence
* Feelings of worthlessness, inappropriate guilt, self-reproach, hopelessness
* Recurrent thoughts of death, suicide ideation or suicide attempts
* Diurnal mood variation

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68
Q

Severity of depession

A

ICD-10
Mild = 4 symptoms
Moderate = 5-6 symptoms + functioning affected
Severe = 7+ symptoms + suicidal + loss of functioning
Severe with psychotic Sx = Nihilistic, guilty delusions, derogatory voices

69
Q

Investigations for depression

A

PHQ9 0-27

70
Q

Management of mild depression

A
  • Low-intensity psychological interventions
  • Sleep hygiene
  • Anxiety management (mindfulness)
  • Problem-solving techniques
  • Computerised CBT
  • Structured group-based physical activity
71
Q

Management of moderate depression

A
  • SSRI
  • CBT or interpersonal therapy
72
Q

Management of severe depression

A
  • Rapid specialist mental health assessment
  • Inpatient admission
  • ECT
73
Q

Antidepressants for depression

A

1st line = fluoxetine, citalopram, sertraline
2nd line = different of first line
3rd line = mirtazapine, venlafaxine
4th line = try any other = lithium, tricyclics, monoamine oxidase inhibitors, serotonin agonist and reuptake inhibitor

74
Q

Epidemiology of suicide

A

Most common cause of death in men <35
M > F
Elderly
Widow > divorced > single > married
Unemployed and retired
Seasonal variation = higher in spring, summer

75
Q

Risk factors for suicide

A

Bipolar disorder
Depression
Borderline personality disorder
Anorexia
Substance abuse
Past self-harm
Past suicide attempts

76
Q

Assessment of suicide risk

A

Circumstances of act
* What happened that day?
* How they feel about it?
* Feeling and events leading up
Background of act
* How things over last few months?
* Previous attempts
* Plans in place
Relevant family and personal history
Intention lying behind act
* Present feelings and intentions
* Try again?
* Wish it had been successful?

77
Q

SAD persons score

A

Sex: male
Age: <19, >45
Depression
Previous suicide attempt
Ethanol (or other substance abuse)
Rational thinking loss (psychosis, psychotic depression)
Single/separated
Organised
No social support
Sickness (chronic illness)

78
Q

Prevention of suicide

A
  • Promote access to help
  • Limit access to lethal means
  • Shift position from unstable to stable
  • Social support
79
Q

What is self harm

A

Self-poisoning or injury, irrespective of apparent purpose of act
Expression of personal distress not an illness

80
Q

Methods of self harm

A

Overdose
Laceration

81
Q

Reasons for self harm

A

Communicating a message
Gaining power by escalating conflict often after argument with partner
Emotional immaturity
Inability to cope with stress
Weak religious ties
Availability of drugs
Offers release from psychological pain

82
Q

Risk factors for self harm

A

Witness deliberate self-harm
* FHx of DSH
* Learned behaviour from friends/ celebrities
* Exacerbated by social media
Biological
* Reduced endorphin response to emotional arousal (traumatic brain damage)
* Abnormalities in serotonin release
Developmental
* Poor early care
* Physical, Emotional, Sexual abuse
* Parental separation
Peer relations
* Conflicts
* Bullying
* Poor interpersonal skills
Psychological
* Identity problems
* Low self-esteem
Antisocial behaviour
* Conduct disorder
* Impulsivity
* Substance misuse

83
Q

Management of self harm

A

Prioritise treating physical effects of DSH
Psychiatric assessment
* Initial risk management (suicide risk, admission)
* On-going risks with subsequent DSH
* Relevant psychiatric, medical, social issues

84
Q

Types of bipolar disorder

A

Bipolar I = mania and depression (sometimes only mania)
Bipolar II = more episodes of depression, only mild hypomania
Rapid cycling = episodes only last few hours or days
Cyclothymia = highs and lows milder and don’t meet criteria for bipolar

85
Q

Causes of bipolar disorder

A

Medication
* Steroids
* Illicit substances (cocaine, amphetamines)
* Antidepressants
Physical
* Infection
* Stroke
* Neoplasm
* Epilepsy
* MS
* Metabolic disturbances (hyperthyroidism)

86
Q

Presentation of a manic episode

A

(>1wk)
* Mood = irritability, euphoria, lability
* Grandiosity
* Distractibility/poor concentration
* Fight of ideas/racing thoughts
* Confusion
* Lack of insight
* Rapid speech
* Hyperactivity
* Decreased need for sleep
* Change in appetite
* Hypersexuality (increased libido/sexual disinhibition)
* Inflated self-esteem
* Reckless/ extreme risk-taking behaviour
* Extravagance (manic overspending)
* Social disinhibition
* Delusions
* Hallucinations
* Impairment severe enough to limit function

87
Q

Presentation of hypomania

A
  • No psychotic symptoms
  • No impairment of daily functioning or need for inpatient treatment
  • Sociability/overfamiliarity
  • Lasts less than a week (4 days)
88
Q

Management of bipolar disorder

A

Treatment of manic episode  Stop antidepressant and start antipsychotic (olanzapine)
Risk assessment
Mood stabiliser for longer term control = lithium or valproate

89
Q

Psychosocial interventions for bipolar disorder

A

Emotional consequences of cycling disorder with periods of acute illness, stigma, fear of recurrence
Psychoeducation
CBT
Support groups

90
Q

Complications of bipolar disorder

A

Mood swings increase risk of suicide
* Previous suicide attempt
* FHx of suicide
* Early onset of bipolar disorder
* Extent of depressive symptoms
* Increasing bad affective signs
* Mixed affective states
* Rapid cycling
* Abuse of alcohol or drugs

91
Q

Risk factors for substance misuse

A

Individual factors  Age, Gender, Family
External factors  Culture, Price, Availability, Advertising
Being a novelty seeker
Impulsive
Inherited vulnerability

92
Q

Presentation of substance misuse

A

Acute intoxication  Administration of psychoactive substances resulting in disturbances of level of consciousness, cognition, perception, affect, behaviour
Harmful use  Pattern of psychoactive substance use causing damage to mental/physical health or social functioning
Dependence syndrome
* Strong desire or send of compulsion to take substance (craving)
* Difficulty in controlling substance use
* Physiological withdrawal state when reducing or ceasing substance use
* Tolerance = increased doses required to produce original effect
* Progressive neglect of alternative pleasures or interests
* Persisting use despite clear evidence of harmful consequences

93
Q

Associations of substance misuse

A

Arrests for theft (to buy drugs)
Odd transient behaviour (visual hallucinations, elation, mania)
Unexplained nasal discharge (cocaine sniffing/ opiate withdrawal)
Withdrawal symptoms (red eyes, shaking)
Injection stigmata (marked veins, abscesses, hepatitis, HIV)
Repeated requests for analgesics, only opiates acceptable, sedatives

94
Q

Management of substance misuse

A

Opiate detoxification
Methadone maintenance (transition to abstinence)
* Free (no crime)
* Safer (no injecting)
* Still an addiction
* Daily observed dosing
Naltrexone = opioid antagonist
Psychological support
* Counselling
* Motivational therapy
* Cognitive therapy
* Counsel on HIV and Hep C risk, needle exchange, safe sex

95
Q

Relapse prevention of substance misuse

A

Barbiturate withdrawal may cause seizures (+-death) so admit as inpatient
Anti-craving drugs (unvalidated approach)

96
Q

Opioid withdrawal presentation

A

Intoxication
* Drowsy
* Mood change
* Bradycardia
* HTN
* Pupil constriction
* Resp depression
* Decreased body temp
Withdrawal
* Muscle cramps
* Low mood
* Insomnia
* Agitation
* Diarrhoea
* Shivering
* Flu like Sx

97
Q

Management of opioid withdrawal

A

IV naloxone = rapid onset and short
Opioid detoxification
Methadone
Buprenorphine
Needle exchange
Testing for HIV, Hep B and C

98
Q

Complications of opioid misuse

A

Infection (sharing needles) = IE, septic arthritis, septicaemia, necrotising fascitis
VTE
Overdose = resp distress
Crime/prostitution

99
Q

Risk factors for alcohol dependence

A

Male
Unemployment and stress
Peer pressure
Younger age of usage/mental illness
History of substance abuse
Genetics

100
Q

Presentation of alcohol dependence

A

Increased tolerance to alcohol
Narrowing of drinking repertoire
Difficulty or failure of abstinence
Withdrawal = sweats, nausea, tremor
Priority to maintain alcohol intake
Often aware of compulsion to drink
Gradual deterioration in function
Alcohol dependence overtakes work, relationships, financial stability, health
Patient’s drinking habits excessive within their own social context

101
Q

Screening for alcohol dependence

A

CAGE questionnaire
* Have you ever felt you should CUT down on your drinking?
* Have you ever become ANNOYED by criticisms of your drinking?
* Have you ever felt GUILTY about your drinking?
* Have you ever had a morning EYE opener to get rid of a hangover?

TWEAK questionnaire
* Tolerance (2)
* Worried (2)
* Eye opener (1)
* Amnesia (1)
* Cut down (1)
* >3 points indicates problem with alcohol

102
Q

Management of alcohol dependence

A

Immediate management
* Water
* Vitamins (B1, B6, B12)
* Food (calories and protein)
* Benzo (Diazepam, chlordiazepoxide)
Treat co-existing depression
Refer to specialists
Self-help/group therapy
Disulfiram (drugs that produce nasty reaction if alcohol taken)
Naltrexone (reduce pleasure alcohol brings and cravings on withdrawal)
Acamprosate (improve abstinence rates by reducing cravings)

103
Q

Complications of alcohol dependence

A

Liver = fatty liver, cirrhosis
CNS = Poor memory/cognition, Cortical/cerebellar atrophy, Retrobulbar neuropathy, Fits, Falls, Neuropathy
Gut = Vomiting and diarrhoea, Peptic ulcer, Erosions, Varices, Pancreatitis
Heart = Arrhythmias, Increased BP, Cardiomyopathy
Increased osteoporosis risk
Sperm = Decreased fertility, Decreased sperm motility
GI and breast cancer
Marrow = Decreased Hb, Increased MVC
Violent crime
Suicide

104
Q

Stages of alcohol withdrawal

A

6-12 hrs – symptoms
12-24 hrs = hallucinations
24-48 hours = seizures
48-72 hours = delirium tremens

105
Q

Presentation of alcohol withdrawal

A

Tachycardia
Hypotensive
Tremor
Fits/seizures (generalised tonic clonic) = seen at 36 hrs
Visual or tactile hallucinations
Diarrhoea and vomiting, nausea
Shaking
Sweaty
Anxiety
Insomnia/sleep disturbance
Mood disturbance

106
Q

Management of alcohol withdrawal

A

Water
Vitamins = thiamine, IV pabrinex
Food
Chlordiazepoxide 5-7 days
Complex withdrawals may need admission to hospital

107
Q

Presentation of delerium tremens

A
  • Confusion state
  • Hallucinations (tactile or visual)
  • Vomiting
  • Extreme paranoia
  • Coarse tremor
  • Delusions
  • Fever
  • Tachycardia
108
Q

What is wernicke’s encephalopathy

A

Thiamine (B1) deficiency related to alcohol abuse

109
Q

Causes of wenicke;s encephalopathy

A

Chronic alcohol consumption
Brain tumour
Malabsorption
Prolonged vomiting
Hyperemesis gravidarum
Chemotherapy

110
Q

Presentation of wernicke’s encephalopathy

A

Triad = confusion, wide-based gait ataxia, ophthalmoplegia (nystagmus, conjugate gaze, bilateral lateral rectus palsies)
peripheral neuropathy
Clouding of consciousness
memory disturbance
hypotension
hypothermia
ptosis

111
Q

Management of wernicke’s encephalopathy

A

MEDICAL EMERGENCY
High dose IV/IM thiamine over 1 wk
Oral supplementation until no longer at risk
Give before glucose if hypoglycaemic

112
Q

What is Korsakoff’s syndrome

A

Hypothalamic damage and cerebral atrophy due to thiamine deficiency

113
Q

Presentation of korsakoff’s syndrome

A

Anterograde amnesia = inability to acquire new memories
Confabulation
Retrograde amnesia
Lack of insight
Apathy

114
Q

Management of Korsakoff’s syndrome

A

IV pabrinex + chlordiazepoxide

115
Q

Classification of personality disorders

A
  • Cluster A = odd or eccentric
  • Cluster B = dramatic, emotional, erratic
  • Cluster C = anxious and fearful
116
Q

Paranoid personality disorder

A
  • Suspicious, preoccupied with conspiratorial explanations, distrusts others, holds grudges
  • Hypersensitivity and unforgiving attitude when insulted
  • Unwarranted tendency to question loyalty of friends
  • Reluctance to confide in others
  • Preoccupation with conspirational beliefs and hidden meaning
  • Unwarranted tendency to perceive attacks on character
117
Q

Schizoid personality disorder

A
  • Emotionally ‘cold’, lacks interests in others, rich fantasy world, excessive introspection
  • Indifference to praise and criticism
  • Preference for solitary activities
  • Lack of interest in sexual interactions
  • Lack of desire for companionship
  • Few interests or friends other than family
118
Q

Schizotypal personality disorder

A
  • Ideas of reference
  • Odd beliefs and magical thinking
  • Unusual perceptual disturbances
  • Paranoid ideation and suspiciousness
  • Odd, eccentric behaviour
  • Lack of close friends
  • Inappropriate affect
  • Odd speech without being incoherent
119
Q

Antisocial personality disorder

A
  • Aggressive, easily frustrated, callous lack of concern for others, irresponsible, impulsive, unable to maintain relationships, criminal activity, lack of guilt, conduct disorder
  • Failure to conform to social norms
  • Deception, repeatedly lying, conning others for personal profit or pleasure
  • Impulsiveness or failure to plan ahead
  • Irritability and aggressiveness
  • Reckless disregard for safety of self or others
  • Consistent irresponsibility
  • Lack of remorse
120
Q

Emotionnally unstable personality disorder

A
  • Feeling of emptiness, unclear identity, intense and unstable relationships, unpredictable affect, threats or acts of self-harm, impulsivity, pseudohallucinations
  • Inability to control anger or plan, unpredictable affect and behaviour
  • Quasi psychotic thoughts
  • Efforts to avoid real or imagined abandonment
121
Q

Histrionic personality disorder

A
  • Over-dramatise, self-centred, shallow affect, labile mood, seeks attention and excitement, manipulative behaviour,
  • Inappropriate sexual seductiveness
  • Need to be centre of attention
  • Rapidly shifting and shallow expression of emotions
  • Suggestibility
  • Physical appearance used to attention seeking purposes
  • Impressionistic speech lacking detail
  • Relationships considered more intimate than they are
122
Q

Narcissistic personality disorder

A
  • High self-importance, lacks empathy, grandiose, needs admiration
  • Preoccupation with fantasies of unlimited success, power, beauty
  • Sense of entitlement
  • takes advantage of others to achieve own needs
  • Chronic envy
  • Arrogant and haughty attitude
123
Q

Obsessive-compulsive personality disorder

A
  • Worries and doubts, orderliness and control, perfectionism, sensitive to criticism, rigidity, indecisiveness, pedantry, judgemental
  • Stingy spending style towards self and others
  • Meticulous, scrupulous, rigid about etiquettes of morality, ethics or values
124
Q

Anxious avoidant personality disorder

A
  • Extremely anxious and tense, self-conscious, insecure, fearful of negative evaluation by others, timid, desires to be liked
  • Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism or rejection
  • Unwillingness to be involved unless certain of being liked
  • Preoccupied with ideas of being criticised or rejected in social situations
125
Q

Dependent personality disorder

A
  • Passive, clingy, submissive, excess need for care, feels helpless when not in relationship, feels hopeless and incompetent
  • Difficulty making everyday decisions without excessive reassurance from others
  • Need for others to assume responsibility for major areas of life
  • Difficulty in expressing disagreement with others due to fears of losing support
  • Lack of initiative
  • Unrealistic fears of being left to care for themselves
  • Urgent search for another relationship as source of care and support when close relationship ends
126
Q

Management of EUPD

A

No evidence for medication
Psychological therapies
* Dialectical behaviour therapy = self-soothing, distraction techniques, radical acceptance, wise mind vs emotional mind
* Therapeutic communities
* Cognitive analytic therapy
* Mentalisation based therapy

127
Q

Risk factors for post-partum depression

A

History of postpartum depression
Unipolar/bipolar depression
Unplanned pregnancy
Lack of support
Marital problems
Social circumstances
Sleep deprivation
Hormonal changes

128
Q

Screening for post-partum depression

A

Edinburgh postnatal depression scale
- Low threashold for referring to MDT in mother and baby units

129
Q

Management of post-partum depression

A

Involve partners/ other parent of child
Short-term antidepressants  Stop breastfeeding as antidepressants can end up in breast milk
CBT
ECT (if severe, stop eating/drinking, suicidal)

130
Q

Complications of post-partum depression

A

Impairs infants cognitive and social skills
Suicide is leading cause of maternal death postpartum

131
Q

Risk factors for post-partum psychosis

A

Previous postpartum psychosis
Single parenthood
Reduced social support
Previous mental illness

132
Q

Presentation of post-partum psychosis

A

Psychotic episode usually peaks 2w post-partum
Prominent affective symptoms (depression or mania)
Rapidly fluctuating symptoms
Mood lability
Insomnia
Disorientation

133
Q

Prevention of post-partum psychosis

A

High-risk patients need individualised care plan with antenatal specialist perinatal mental health input
Early detection essential

134
Q

Management of post-partum psychosis

A

Medication to target affective symptoms
* Mood stabiliser
* Antidepressant
* ECT
Medication to target psychotic symptoms
* SGA
* Long-acting benzodiazepine
Therapy
Reassurance
Emotional support
Refer to local mental health services and health visitors at discharge

135
Q

Causes of lithium toxicity

A

Dehydration
Renal failure
Drugs
* Diuretics (thiazides)
* ACE inhibitors/angiotensin II receptor blockers
* NSAIDs
* Metronidazole

136
Q

Presentation of lithium toxicity

A

Coarse tremor
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma

137
Q

Management of lithium toxicity

A

Mild-moderate  Volume resuscitation with normal saline
Severe  Haemodialysis

138
Q

What is neuroleptic malignant syndrome

A

Neurotoxicity and muscle damage from antipsychotics

139
Q

Presentation of neuroleptic malignant syndrome

A

Occurs within hrs to days of starting antipsychotic
Fever
Muscle rigidity
Autonomic dysfunction
* Hypertension
* Tachycardia
* Tachypnoea
Agitated delirium with confusion
Decreased reflexes

140
Q

Investigations in NMS

A

Raised creatine kinase
AKI (secondary to rhabdomyolysis)
Leucocytosis

141
Q

Management of NMS

A

Stop antipsychotic
Transfer to medical ward
IV fluids (prevent renal failure)
Dantrolene (benzos)
Bromocriptine, dopamine agonist

142
Q

Causes of serotonin syndrome

A

SSRIs and SNRIs
MAO-I
Ecstasy
Amphetamines
Drug interactions with
* St Johns Wort
* Triptans
* TCAs
* Linezolid

143
Q

Presentation of serotonin syndrome

A

Neuromuscular abnormalities = myoclonus, tremor, hyperreflexia, ataxia, incoordination, seizures
Altered mental state = agitation, confusion, euphoria, hallucinations, LOC
Autonomic dysfunction = tachycardia, HTN, fever, diaphoresis, arrhythmias, tachypnoea, sweating, shivering, diarrhoea
Rapidly onsets after increased dose of serotonin boosting drug

144
Q

Management of serotonin syndrome

A

Benzos
S blocking drug = cyproheptadine (5-HT2 antagonst)
Stop SSRI/SNRI
Monitor

145
Q

types of psychoses

A
  • Schizophrenia
  • Delusional disorder
  • Schizotypal disorder
  • Depressive psychosis
  • Manic psychosis
  • Organic psychosis = head injury, drug induced
146
Q

Positive psychotic symptoms

A
  • Thought insertion, thought broadcasting, thought withdrawal, repeating thoughts, thought alienation
  • Persistent delusions (culturally inappropriate and completely impossible)
  • Persistent hallucinations
  • Passivity phenomena
  • Disturbance in mood = Sudden excitement, posturing, waxy flexibility, negativism, echopraxia
147
Q

Negative psychotic symptoms

A
  • Reduced speech
  • Loss of motivation
  • Self-neglect
  • Social withdrawal
  • Apathy, blunting or incongruity of affect
  • Poverty of thought
  • Poor non-verbal communication
  • Clear deterioration in functioning
  • Lack of insight
148
Q

Psychotic terms

A

Knights move = no links
Flight of ideas = flight from one place to another
Circumstantiality = comes back round
Perseverance = same point
Tangentiality = off on tangent, never returns
Echolalia = repeat same word/phrase
Clanging/clang associations
Word salad
Othello = delusional jealousy
Fregoli = stranger is family in disguise
Capgras = family member has evil twin
Cotard = nihilistic, dead body
Charles bonnet = hallucinations due to sight loss

149
Q

Management of psychoses

A

Oral antipsychotic
Psychological interventions = CBT, family therapy

150
Q

What is schizophrenia

A

Common chronic relapsing condition with psychotic symptoms, disorganisation symptoms, negative symptoms and sometimes cognitive impairment

151
Q

Risk factors for schizophrenia

A

Early use of cannabis
Genetic susceptibility (Family history)
Brought up in cities
Migrant groups (Asians, African-Caribbeans)

152
Q

Presentation of schizoprenia

A

First rank symptoms (>1)
* Thought alienation
* Passivity phenomena
* 3rd person auditory hallucinations
* Delusional perception
Second rank symptoms (2+)
* Delusions
* 2nd person auditory hallucinations
* Hallucinations in any other modality
* Thought disorder
* Catatonic behaviour
* Negative symptoms

153
Q

Prodromal symptoms in schizoprenia

A
  • Precedes most first episodes of psychosis by up to 18m
  • Gradual deterioration in functioning
  • Transient and/or attenuated psychotic symptoms
  • Odd thoughts, beliefs and behaviours
  • Concentration problems
  • Altered affect
  • Social withdrawal
  • Reduced interest in daily activities
154
Q

Management of schizoprenia

A

Anti-psychotics (started ASAP)
Psychosocial interventions
* CBT
* Treating substance misuse
* Addressing housing, benefits, social skills training
* Supported employment
Support for family
* Family therapy
* Support groups
Referral to Early Intervention Service

155
Q

Schizoprenia prognosis better if

A
  • Sudden onset
  • No negative symptoms
  • Supportive home
  • Female (better social integration)
  • Later onset of illness
  • No CNS ventricular enlargement
  • No family history
156
Q

Schizoprenia prognosis worse if

A
  • Strong family history
  • Gradual onset
  • Low IQ
  • Prodromal phase of social withdrawal
  • Lack of obvious precipitant
157
Q

Somatisation disorder

A
  • Multiple physical symptoms present for at least 2 years
  • Patient refuses to accept reassurance or negative test results
158
Q

Illness anxiety disorder

A
  • Persistent belief in presence of underlying serious disease
  • Patient refuses to accept reassurance or negative test results
159
Q

Conversion disorder

A
  • Loss of motor or sensory function
  • Patient doesn’t consciously feign symptoms or seek material gain
  • individual experiences neurological or physical symptoms that cannot be explained by neurological or medical causes
160
Q

Dissociative disorder

A
  • Separating off certain memories from normal consciousness
  • Psychiatric symptoms = amnesia, fugue, stupor
161
Q

indications for ECT

A

o Prolonged or severe manic episode
o Severe depression
o Catatonia

162
Q

Cautions for ECT

A

o Recent subdural/subarachnoid haemorrhage bleed
o Stroke
o MI
o Arrhythmia
o CNS vascular anomalies

163
Q

Side effects of ECT

A

o Memory loss
o Short term retrograde amnesia
o Confusion
o Headaches
o Clumsiness
o Common anaesthetic S/E

164
Q

Withdrawal symptoms of benzos

A

o Insomnia
o Irritability
o Anxiety
o Tremor
o Loss of appetite
o Tinnitus
o Perspiration
o Perceptual disturbances
o Seizures

165
Q

Side effects of SSRIs

A

o headache, nausea, insomnia
o Indigestion, stomach aches, diarrhoea, constipation
o Loss of appetite
o Dizziness
o Loss of libido
o Erectile dysfunction
o increased risk of GI bleeding = PPI if taking NSAID
o Hyponatraemia
o Increased anxiety and agitation
o Fluoxetine and paroxetine higher risk of drug interactions
o Citalopram  QT interval prolongation

166
Q

Contraindications to SSRIs

A

o Do not use with warfarin/heparin = switch to mirtazapine
o Avoid triptans
o In first trimester = congenital heart defects (particularly paroxetine)
o In third trimester = persistant pulmonary hypertension of newborn

167
Q

Side effects of TCA

A

o tachycardia,
o dry mouth
o blurred vision
o Constipation
o Problems passing urine
o anticholinergic/muscarinic effects,
o postural hypotension
o sedation
o weight gain
o Excessive sweating (especially at night)
o Arrhythmias, palpitations, tachycardia

168
Q

side effects of first generation antipsychotics

A

o Extrapyramidal: parkinsonism, acute dystonia (sustained muscle contraction), akathisia (severe restlessness), tardive dyskinesia (movements)
o Hyperprolactinaemia
o Increased risk of stroke and VTE in elderly
o Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
o Sedation and weight gain
o Neuroleptic malignant syndrome
o Reduced seizure threshold
o Prolonged QT (haloperidol)
o Olucogyric crisis

169
Q

Side effects of second generation antipsychotics

A

o Metabolic effects
o Weight gain
o Hyperprolactinaemia
o Hypercholesterolaemia

170
Q

Side effects of clozapine

A

agranylocytosis, constipation, hypersalivation, reduced seizure threshold, sedating, postural hypotension, toxic megacolon, cardiomyopathy

Finals (23 decks)

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