Psychiatry Flashcards
Acute stress disorder is defined as an acute stress reaction that occurs ……
in the first4 weeks after a person has been exposed to a traumatic event
Treatment of Acute stress disorder
- trauma-focused cognitive-behavioural therapy (CBT)is usually used first-line
- benzodiazepines ( sometimes used for acute symptoms e.g. agitation, sleep disturbance)
chronic alcohol consumption
- enhances ……..
- inhibits
- enhances GABA mediated inhibition in the CNS (similar to benzodiazepines)
- inhibits NMDA-type glutamate receptors
alcohol withdrawal
- decreased inhibitory……..
- increased …..
- decreased inhibitory GABA
- increased NMDA glutamate transmission)
In alcohol withdrawal
- tremor, sweating, tachycardia, anxiety start at … hours
- peak incidence of seizures at ….. hours
- peak incidence ofdelirium tremens is at ….. hours
- 6-12 hours
- at 36 hours
- at 48-72 hours
Management of alcohol withdrawal
- patients with Hx of complex withdrawals from alcohol should be admitted for monitoring until withdrawals stabilised
- first-line:long-acting benzodiazepinese.g.chlordiazepoxide or diazepam.
Treatment of alcohol withdrawal in patients with hepatic failure.
Lorazepam is preferable
Anorexia nervosa is associated with Physiological abnormalities
- hypercholesterolaemia
- hypercarotinaemia
- impaired glucose tolerance
- raised cortisol and growth hormone
- low T3, FSH, LH, oestrogens and testosterone
- hypokalaemia
Features of Anorexia nervosa
reduced body mass index
bradycardia
hypotension
enlarged salivary glands
Causes of aphonia
- recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy)
- psychogenic aphonia
mental disorder where patients have a significantly distorted body image
Body dysmorphic disorder
mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent.
Cotard syndrome
Cotard syndrome is associated with
severe depression and psychotic disorders
form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
De Clerambault’s syndrome, also known as erotomania
condition where a patient has a fixed, false belief (delusion) that they are infested by ‘bugs’e.g. worms, parasites, mites, bacteria, fungus.
Delusional parasitosis
Depression in older people
- Features
- Treatment
- Features
- physical complaints (e.g. hypochondriasis)
- agitation
- insomnia - SSRIs first line
Factors suggesting diagnosis of depression over dementia
- short history, rapid onset
- biological symptoms e.g. weight loss,sleep disturbance
- patient worried about poor memory
- mini-mental test score: variable
- global memory loss (dementia characteristically causes recent memory loss)
Electroconvulsive therapy
The only absolute contraindications is
raised intracranial pressure.
Short-term side-effects of Electroconvulsive therapy
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
Long-term side-effects of Electroconvulsive therapy
some patients report impaired memory
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation
Features of……?
Korsakoff’s syndrome
pathological jealousy where a person is convinced their partner is cheating on them without any real proof.
Othello’s syndrome
Features of Post-concussion syndrome
headache
fatigue
anxiety/depression
dizziness
transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep.
Sleep paralysis
Managment of Sleep paralysis
if troublesome clonazepam may be used
depression which occurs predominately around the winter months.
Seasonal affective disorder
Treatment of Seasonal affective disorder
- for mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration.
- Following this an SSRI can be given if needed.
In seasonal affective disorder, you should not give the patient ……… as this can make the symptoms worse.
sleeping tablets
What is Somatisation disorder
multiple physical SYMPTOMSpresent for at least 2 years
patient refuses to accept reassurance or negative test results
Illness anxiety disorder (hypochondriasis )
persistent belief in the presence of an underlyingserious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Malingering
Factitious disorder
(Munchausen’s syndrome)
the intentional production of physical or psychological symptoms
dissociation is a process of ‘separating off’ certain memories from normal consciousness
Dissociative disorder
Functional neurological disorder (conversion disorder)
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
Examples of Serotonin and noradrenaline reuptake inhibitor (SNRI’s)
venlafaxine
duloxetine
Treatment of Post-traumatic stress disorder
- watchful waiting may be used for mild symptoms lasting less than 4 weeks
- trauma-focused cognitive behavioural therapy(CBT) or eye movement desensitisation and reprocessing (EMDR) therapy
- drug treatments should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or SSRI.
eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising.
Bulimia nervosa
Management of bulimia nervosa
- NICE recommend bulimia-nervosa-focused guided self-help for adults
- eating-disorder-focused cognitive behavioural therapy
- high-dose fluoxetine
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the ………
the frequencyof chloride channels
benzodiazipines increase the….1…..of chloride channels
barbiturates increase the…..2….of chloride channel opening
- frequency
- duration
age-related macular degeneration, followed by glaucoma and cataract associated with ….
Charles-Bonnet syndrome
Factors associated with poor prognosis of Schizophrenia
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
The strongest risk factor for developing a psychotic disorder is ……….
Family history
management of schizophrenia
- oral atypical antipsychotics are first-line
- cognitive behavioural therapy should be offered to all patients
- close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
Adverse effects of atypical antipsychotics
- Weight gain
- Hyperprolactinemia
- clozapine is associated with agranulocytosis
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Which one of atypical antipsychotics has higher risk of dyslipidemia and obesity?
olanzapine
Examples of atypical antipsychotics
- clozapine
- olanzapine
- risperidone
- quetiapine
- amisulpride
- aripiprazole
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Paranoid
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
Schizoid
Ideas of reference (differ from delusions in that some insight is retained)
Odd beliefsand magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent
Schizotypal
4 Side effects of SSRIs
- gastrointestinal symptoms are the most common side-effect
- increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
- Hyponatremia
- increased anxiety and agitation after starting a SSRI
citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with
- congenital long QT syndrome.
- known pre-existing QT interval prolongation.
- in combination with other medicines that prolong the QT interval
7 Discontinuation symptoms of SSRI
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
When stopping a SSRI the dose should be gradually reduced over ……. period
4 week
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering …..
mirtazapine
triptans & SSRI increase risk of….
serotonin syndrome
monoamine oxidase inhibitors (MAOIs) & SSRI increase risk of….
serotonin syndrome
Which one of SSRI has a higher incidence of discontinuation symptoms?
Paroxetine
antidepressant therapy they should continue on treatment for at least………. after remission as this reduces the risk of relapse.
6 months
SSRIs and pregnancy
1. Use during the first trimester gives a small increased risk of …
- Use during the third trimester can result in……
- Paroxetine has an increased risk of ………, particularly in the first trimester
- congenital heart defects
- persistent pulmonary hypertension of the newborn
- congenital malformations
Which one of SSRI is useful post myocardial infarctionas there is more evidence for its safe use in this situation than other antidepressants
sertraline
9 Adverse effects of lithium
- nausea/vomiting, diarrhoea
- Fine tremor
- nephrogenic diabetes insipidus
- thyroid enlargement, may lead to hypothyroidism
- ECG: T wave flattening/inversion
- Weight gain
- idiopathic intracranial hypertension
- leucocytosis
- hyperparathyroidism and resultant hypercalcaemia
Monitoring of patients on lithium therapy
1. lithium blood level should ‘normally’ be checked every…..
- thyroid and renal function should be checked every …..
- 3 months
- 6 months
serotonin and noradrenaline are metabolised by ……… in the presynaptic cell
monoamine oxidase
Drug treatment of generalised anxiety disorder
- sertraline should be considered the first-line SSRI
- if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI)
- If cannot tolerate SSRIs or SNRIs, consider offering pregabalin
Management of panic disorder
- either cognitive behavioural therapy or drug treatment
- SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
Mechanism of action of Typical antipsychotics
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
Examples of Typical antipsychotics
Haloperidol
Chlorpromazine
Examples of Atypical antipsychotics
Clozapine
Risperidone
Olanzapine
Mechanism of action of Atypical antipsychotics
Act on a variety of receptors (D2, D3, D4, 5-HT
Extrapyramidal side-effects of Antipsychotics
- Parkinsonism
- acute dystonia
- akathisia (severe restlessness)
- tardive dyskinesia
8 side-effects of sSRI
- antimuscarinic:dry mouth,blurred vision,urinary retention,constipation
- sedation
- weight gain
- Hyperprolactinemia
- impaired glucose tolerance
- neuroleptic malignant syndrome
- reduced seizure threshold
- prolonged QT interval
The primary mechanism by which TCAs exert their antidepressant effects is through the inhibition of the reuptake of neurotransmitters
- Serotonin (5-HT)
- Noradrenaline (NA)
Side effects of TCA
- lengthening of QT interval
- postural hypotension
- drowsiness
- Dry mouth
- Blurry vision
- Constipation
- Urinary retention
What is the safest TCA in overdosage
Lofepramine
Which TCA is the most dangerous in overdose ?
amitriptyline and dosulepin
Less sedative preparations of TCA
- Nortriptyline
- Imipramine
- Lofepramine
- NIL
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Dependent
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Avoidant
Risk factors of Obsessive-compulsive disorder
family history
age: peak onset is between 10-20 years
pregnancy/postnatal period
history of abuse, bullying, neglect
Management of Obsessive-compulsive disorder
Iffunctional impairment is mild
- cognitive behavioural therapy
- If this is insufficient or can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT
Management of Obsessive-compulsive disorder
Iffunctional impairment is moderat
- either a course of anSSRI(any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
- considerclomipramine(as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
Management of Obsessive-compulsive disorder
Iffunctional impairment is severe
refer to the secondary care mental health team for assessment
whilst awaiting assessment - offer combined treatment with anSSRIand CBT (including ERP) or consider clomipramine as an alternative as above
What is a classic somatic symptom of depression and often develops earlier than general insomnia.
Early morning waking
Which personality disorder is characterised by inappropriate sexual seductiveness, suggestibility and intense relationships
Histrionic personality disorder
Which personality disorder is associated with impulsivity, feelings of emptiness, fear of abandonment and unstable self image?
Borderline personality disorder
Hyperprolactinaemia is uncommon with certain ….. antipsychotics -
atypical
What is the first-line pharmacological therapy for generalised anxiety disorder
SSRIs
What is characterised by a person believing their friend or relative had been replaced by an exact double.
Capgras syndrome
monoamine oxidase inhibitors, hypertensive reactions with tyramine containing foods e.g.
cheese,
pickled herring,
Bovril,
Oxo,
Marmite,
broad beans
Which drug is used in the management of extrapyramidal symptoms caused by antipsychotics.
Procyclidine, an anticholinergic drug
Risk of developing schizophrenia
monozygotic twin has schizophrenia = ……%
parent has schizophrenia = ……%
sibling has schizophrenia = ……%
no relatives with schizophrenia = … %
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%
Generalizad anxiety disorder
Excessive worry about a number of different events
Avoid places or situations make you feel trapped or helpless or embarrassed
Agoraphobia
Monozygotic twin has risk of development of schizophrenia……%
50 %
risk of development of schizophrenia
If
1. parents has schizophrenia …….
2. sibling has schizophrenia……….
3. no relatives with schizophrenia…….
- 10-15 %
- 10 %
- 1 %
risk of development of schizophrenia
If
1. parents has schizophrenia …….
2. sibling has schizophrenia……….
3. no relatives with schizophrenia…….
- 10-15 %
- 10 %
- 1 %
Poor prognosis of schizophrenia
- Strong FH
- Gradual onset
- Low IQ
- Social withdrawal
- Lack of obvious precipitant
Prodromal schizophrenia
Social withdrawal
Behavioral changes
Which infection has role in Obsessive compulsive disorder
Group A beta hemolytic streptococcus
Which infection has role in Obsessive compulsive disorder
Group A beta hemolytic streptococcus
