Psychiatry Flashcards
What is ADHD
Multifactorial (genetic, environmental, neurological factors) contributing to a triad of hyperactivity, inattention, impulsivity.
Presents in childhood and MAY continue to adulthood, but does not present as adult without childhood.
DSM-V criteria used. Symptoms must be persistent. 6 features <16, 5 features >16.
Twice as common as autism and affects boys more.
Diagnostic features of ADHD
Inattention
- Cant follow through instruction
- Reluctant to engage in mentally taxing tasks
- Difficult to sustain tasks
- Unorganised, forgetful in ADL
- Loses things
Hyperactivity/impulsivity
- Unable to sit still, or quietly
- Excessive talking
- Spontaneously leaves seat
- On the go
- Interrupts/intrusive
- Run and climb and answer questions before finishing question
Management of ADHD
Methylphenidate - first line in children (>5 only). 6 week trial, after considering non-pharm options.
- Lisdexamfetamine, followed by dexamfetamine.
Monitor child’s height, weight, blood pressure, ECG.
Side effects: Tachycardia, hypertension, abdo pain, nausea, dyspepsia. Reduced appetite can cause stunted growth
All drugs cardiotoxic.
Non pharm ADHD management
Healthy diet
Exercise
Parental and child education
School adjustments and interventions
Define Psychosis, Delusions and Hallucinations
Psychosis - Loss of contact with reality. Affects a person’s ability to distinguish what’s real and what’s not.
Delusions - Fixed false belief, held despite clear evidence to the contrary. Typically illogical, and not shared by those within person’s social or cultural group.
Hallucinations - Sensory perceptions that appear real but are not. Occur in absence of external stimuli
Types of delusion
- Persecutory delusions: Belief that one is being plotted against or harmed
- Grandiose delusions: Belief in having exceptional abilities, wealth, fame
- Delusions of reference: Belief that insignificant events or remarks are directed at the person
Types of hallucination
- Auditory (most common in psychosis)
- Visual hallucinations
- Tactile, olfactory, gustatory (less common)
Psychotic features
Hallucinations
Delusions
Thought disorganisation
- Alogia (little information conveyed)
- Tangentiality
- Clanging (rhyming or similar sounds)
- Word salad (Linking real wrods incoherently)
Associated features with psychosis
Agitation/aggression
Neurocognitive impairment (memory, attention, executive function)
Depression
Self harm thoughts
Give some conditions that may present with psychosis
- Schizophrenia (Most common)
- Depression
- BPD
- Puerperal psychosis
- Illicit drug use
- Neurological conditions (parkinson, huntington)
When does first episode psychosis normally occur
15-30 years
What is schizophrenia and whats its main risk factor
Severe long term mental health disorder characterised by psychosis. Presents most between 15-30. Earlier in men than women. Must have symptoms for >6 months to diagnose.
Family history
- 50% if twin
- 10-15% if parent
- 10% if sibling
Black caribbean have relative risk of 5.4
What are 2 other types of schizophrenia
Schizoaffective disorder combines symptoms of schizophrenia with bipolar. Psychosis + mania + depression
Schizofphreniform disorder - Lasts less than 6 months
First rank symptoms of schizophrenia
Auditory hallucinations
- Thoughts spoken aloud
- Voices referring to self
- Running commentary on life
Thought withdrawal, insertion, interruption
Thought broadcasting
Somatic hallucinations
Delusional perception
Experiencing actions as made or influenced by 3rd party
How does psychosis present
Psychosis normally preceded by prodrome phase. May have subtle memory loss, concentration, mood swings etc.
Key features of psychosis (positive symptoms)
- Delusions
- Hallucinations
- Thought disorder (Disorganised thoughts, causing abnormal speech and behaviour)
Lack of insight
How does schizophrenia present (positive symptoms)
Key positive symptoms
- Auditory hallucinations
- Somatic passivity (believing an external entity is controlling them)
- Thought broadcasting (believing others are overhearing their thoughts)
- Persecutory delusions (fasle belief people will harm them)
- Delusional perception (ordinary/unremarkable perception triggers delusion)
What are some negative symptoms of schizophrenia
4As
- Affective flattening (minimal emotional reactions to events)
- Alogia (Poverty of speech)
- Anhedonia (lack of interest in activities)
- Avolition (lack of motivation to complete goals)
Reduced functioning (social, productivity, selfcare) also important
What are patterns of schizophrenia
Continuous
Episodic (relapsing/remitting)
Single episode
Management of schizophrenia
Oral atypical antipsychotics first line
- Aripiprazole
- Olanzapine
- Risperidone
- Quetiapine
Offer CBT and WATCH for CVD risk factors, high rates of CVD in schizophrenia patients
Side effects of antipsychotics
Weight gain
Diabetes
Prolonged QT
Raised prolactin
Extrapyramidal
- Akathisia (psychomotor restlessness)
- Dystonia (abnormal muscle tone and postures)
- Pseudo-parkinsonism
- Tardive dyskinesia (abnormal movements)
Features associated with poor prognosis in schizophrenia
- Family history
- Gradual onset
- Low IQ
- Prodromal phase of social withdrawal
- Lack of obvious precipitant
What are typical antipsychotics
Dopamine D2 receptor antagonists, block dopaminergic transmission in mesolimbic pathways
- Haloperidol
- Chlorpromazine
Side effects of typical antipsychotics
Hyperprolactinaemia and Extrapyramidal symptoms
- Akathisia (psychomotor restlessness)
- Dystonia (abnormal muscle tone and postures)
- Pseudo-parkinsonism
- Tardive dyskinesia (abnormal, involuntary movements “chewing and pouting of jaw”, excessive blinking)
What are atypical antipsychotics
Atypical (Second gen) created due to extrapyramidal and prolactin side effects.
Act on variety of receptors (D2, D3, D4, 5-HT)
E.g.
- Clozapine (most effective - only indicated after all else tried)
- Risperidone
- Olanzapine
Which antipsychotic and which antidepressant is most likely to result in a long QT
Haloperidol
Citalopram
What are some other side effects of antipsychotics
Antimuscarinic - Dry mouth, blurred vision, urinary retention, constipation
- Sedation and weight gain
- Impaired glucose tolerance
- Reduced seizure threshold
- Neuroleptic malignant syndrome
What are some atypical antipsychotics and some side effects
- Clozapine
- Olanzapine (obesity and dyslipidaemia)
- Risperidone
- Aripiprazole (good side effect profile)
Weight gain
hyperprolactinaemia
Clozapine associated with agranulocytosis
Metabolic Syndrome!
What monitoring is required with antipsychotics
- FBC, U&E, LFT at start of therapy and annually
- Lipids and weight at start and 3 months
- Fasting blood glucose and prolactin: at start of therapy, 6 months and annually
- Baseline and frequently while titrating dose
- ECG baseline
- CVD risk assessment annually
ALCOHOL WITHDRAWAL SYMPTOMS and the hours at which they present
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Explain difference between circumstantiality, tangentiality and derailment
A circle comes back around eventually (Circumstantiality)
A Tangent goes off forever in another direction (Tangentiality)
A derailed train goes off the track after a little while and needs to be nudged back on (Derailment)
How is acute dystonia due to haloperidol treated
Procyclidine (prepare dose just in case)
What is bipolar
Chronic periods of depression + episodes of mania (type 1) or hypomania (type 2)
Typically develops in late teen/early 20s
What is the difference between hypomania and mania, and what are some features of mania
Both relate to abnormally elevated mood or irritability
- Hypo: Decreased/increased function >4 days, but less than 7
- Mania: Significant functional impairment or psychotic symptoms for at least 7 days
Features of mania:
- Abnormally elevated mood
- Significant irritability
- Increased energy
- Decreased sleep (sometimes going days without sleeping)
- Grandiosity, ambitious plans, excessive spending and risk-taking behaviours
- Disinhibition and sexually inappropriate behaviour
- Flight of ideas (rapidly generating and jumping between ideas)
- Pressured speech (rapid and unrelenting speech)
- Psychosis (delusions and hallucinations - more suggestive of mania)
How is bipolar diagnosed and what are cyclothymia and unipolar depression
By a specialist using DSM-5 criteria
Other differentials:
Cyclothymia involves milder symptoms of hypomania and low mood.
Unipolar depression is when the person has only 1 episode of depression +- mania
How is bipolar managed long term
Lithium
- Serum lithium levels have to be taken 12 hours after most recent dose, initial target range 0.6-0.8mmol/L. Lithium toxicity if gets too high!
Alternatives: Sodium valproate, olanzapine. Dont forget that valproates proper fuckin teratogenic
Depression - Talking therapies and SSRI (Fluoxetine antidepressant of choice)
Address comorbities (2-3x risk of Diabetes, CVD, COPD)
How should Bipolar primary care referrals be carried out
Hypomania - Routine referral to community mental health(CMHT)
Mania or severe depression - Urgent referral
Acute episode management in bipolar
Manic episode
- Antipsychotic (e.g. haloperidol)
- Lithium/sodium valproate
- Taper and stop existing antidepressants
Depressive episode
- Olanzapine + Fluoxetine
- Antipsychotic (olanzapine)
- Lamotrigine
What are some adverse effects of lithium
- Nausea/vomiting, diarrhoea
- Benign leucocytosis
- Fine tremor
- Nephrotoxicity (polyuria, secondary nephrogenic diabetes insipidus)
- Thyroid enlargement (Goitre) causing hypothyroidism
- ECG: T wave flattening/inversion
- Weight gain
- Idiopathic intracranial hypertension
- Hyperparathyroidism and hypercalcaemia!
How should patients on lithium be monitored
- Sample taken 12 hours post dose
- Lithium levels weekly and after each dose change until stable
- Once on stable dose, check every 3 months
- If dose change, check after 1 week, and weekly again until levels stable
- Thyroid and renal function every 6 months
What is lithium toxicity, and how is it normally precipitated
Lithium has narrow therapeutic range (0.4-1 mmol/L) and long plasma half-life, primarily excreted by kidneys. Toxicity normally occurs >1.5mmol/L
- Dehydration
- Renal failure
- Diuretics(thiazides), ACEi/ARB, NSAID, metronidazole
How does lithium toxicity present
- Coarse tremor (whatever the fuck that is)
- Hyperreflexia
- Confusion
- Polyuria
- Seizure
- Coma
How is lithium toxicity managed
Mild-Moderate: Fluid resuscitation with saline
Haemodialysis if severe
Sodium bicarbonate sometimes used, alkalinity of urine promotes lithium excretion
Give me the definitions of these thought disorders:
- Circumstantiality
- Tangentiality
- Neologisms
- Clang associations
- Word salad
- Knights move thinking
- Flight of ideas
- Perserveration
- Echolalia
- Circumstantiality: Inability to answer without excessive, unnecessary detail. Go on massive tangent BUT do return to original point.
- Tangentiality: Wander from topic without ever returning to point.
- Neologisms: New word formations, maybe combining 2 words
- Clang associations: Ideas related to each other only because they sound the same or rhyme
- Word salad: Completely incoherent speech made up of real words that make no sense together
- Knights move thinking: Severe loosening of associations. Unexpected and illogical leaps from one idea to another.
- Flight of ideas: Feature of mania, leaps from one idea to another, but with discernable links between the 2. Super fast.
- Perseveration: repetition of ideas or words, despite attempting to change subject
- Echolalia: repeating someone else’s speech, including asked question
Symptoms common to both hypomania and mania
The following symptoms are common to both hypomania and mania
Mood
- predominately elevated
- irritable
Speech and thought
- pressured
- flight of ideas: characterised by rapid speech with frequent changes in topic based on associations, distractions or word play
- poor attention
Behaviour
- insomnia
- loss of inhibitions: sexual promiscuity, overspending, risk-taking
- increased appetite
Hypomania vs mania
Mania >7 days, psychotic symptoms, severe impairment in social or work setting, may need admission
Hypomania <7 days, 3-4 days usually, high functioning - no significant impairment, unlikely to require hospital, no psychosis
What is Generalised anxiety disorder, and what are some non GAD causes of anxiety
Excessive worry about a number of events associated with heightened tension, that significantly impact patients life. Symptoms persist most days for at least 6 months, with no other cause.
- Hyperthyroidism
- Cardiac disease
- Medication (salbutamol, theophylline, corticosteroids, antidepressants, caffeine)
- Phaeochromocytoma
- Alcohol, benzodiazepine withdrawal
How does GAD present
Emotionally:
- Excessive, uncontrollable worrying
- Restlessness
- Difficulty relaxing and concentrating
- Easily/Hard to be tired
Physical (sympathetic nervous system overactivity):
- Muscle tension
- Palpitations
- GI symptoms
- Headaches
- Sleep disturbance
- Sweating/tremor
How is anxiety diagnosed
Clinical diagnosis (GAD-7 can help)
- 5-9 mild
- 10-14 moderate
- 15-21 severe
What are panic attacks and how do they present
Sudden onset physical/emotion symptoms of anxiety that come on quickly for a short while then gradually fade. Can be isolated events or panic disorder (diagnosed symptoms present for a month)
Physical:
- Tension
- Palpitations
- Tremor
- Sweating
- Dry mouth
- Chest pain/SOB
- Dizziness/Nausea
Emotional:
- Panic
- Fear/danger
- Depersonalisation (detached)
- Loss of control
What are risk factors for panic disorder
Living alone
Early parental loss
History of abuse
Poor educational history
Urban living
Family history
How is anxiety managed
Step-wise
1 - Education + monitoring
2 - Self referral to low intensity psych intervention
3 - High intensity intervention (CBT, applied relaxation) or drugs
- Sertraline (SSRI) first line
- Then, alternative SSRI or SNRI (duloxetine/venlafexine)
- Pregabalin if cant manage SSRI/SNRI
- If under 30, advise increased risk of suicide/self harm ideation!
How is panic disorder managed
Stepwise again, common sense pathway really.
Then:
- CBT
- Drugs (SSRI first line, imipramine or clomipramine if not!)
What do benzodiazepines do and what are their side effects
Enhance inhibitory GABA by increasing frequency of chloride channels. Range of effects:
- Sedation, hypnosis, anxiolytic, anticonvulsant, muscle relaxant
Side effects:
- Tolerance/dependance - only prescribe for short time (2-4 weeks)
- Withdrawals, up to 3 weeks after stopping, if they come off abruptly.
- Withdrawal symptoms: insomnia, irritability, anxiety, tremors, tinnitus, perceptual disturbance, seizures
How are beta blockers used in anxiety
non selective beta blocker reduces sympathetic nervous system effects, treating physical symptoms. (Tremors, palpitations, sweating etc). Contraindication is asthma (bronchoconstriction/bronchospasms)
What is OCD
Obsessions - unwanted intrusive thought, image, urge, repeatedly entering persons mind
Compulsions - repetitive behaviours or mental acts that person feels driven to perform. Can be overt (checking a door is closed) or covert (mentally repeating a phrase)
Usually a combination of both
Risk factors for OCD
- Family history
- Age 10-20 at onset
- Pregnancy/postnatal
- History of abuse, bullying, neglect
What is the OCD cycle
Obsessions
Anxiety
Compulsion
Temporary relief
Becomes more ingrained each cycle
How is OCD diagnosed and how is symptom severity scored
DSM-5 and/or ICD 11 scoring
Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is used to assess severity of symptoms
Management of OCD
Mild:
- Low intensity psych treatments (CBT including exposure and response prevention (ERP))
Moderate or mild ineffective:
- SSRI (Any fine but fluoxetine specifically for body dysmorphic disorder) or more intense CBT with ERP
- Clomipramine (TCA) if SSRI not wanted
Severe
- Secondary care referral with SSRI and CBT with ERP in meantime.
*ERP = Exposing patient to anxiety provoking situation without allowing compulsion.
2 considerations when prescribing SSRIs in OCD
- Requires longer than depression (at least 12 weeks) for initial response
- If effective, continue for at least 12 months to prevent relapse
What is PTSD
Mental health condition resulting from traumatic experiences. Affects any age, and increases risk of depression, anxiety, substance misuse, and suicide. Symptoms last longer than 1 month (DSM-5)
Can arise from witnessing or experiencing:
- Violence (domestic, sexual, abuse or physical attacks)
- Major car accidents
- Major health events
- War
- Natural disasters
How does PTSD present
Re-experiencing: flashbacks, nightmares, repetitive and disturbing intrusive thoughts/images.
Avoidance: avoiding people, situations, circumstances associated with the event
Hyperarousal: Hypervigilance for threat, exaggerated startle response, sleep problems, irritability, difficulty concentrating
Emotional numbing - lack of feeling, feeling detached, derealisation (world isnt real)
Also:
- Substance misuse
- Anger
- Depression
- Unexplained physical symptoms
- Negative beliefs and emotions
How is PTSD Diagnosed
Trauma Screening Questionnaire
Diagnosis based off:
- ICD-11 or
- DSM-5
Management of PTSD
Following a traumatic event, single session intervention probably not great.
Watchful waiting if mild/less than 4 weeks
Trauma focused CBT or eye movement desensitisation and reprocessing (EMDR)
Drug treatment SSRI or venlafaxine, but definitely not first line.
Army offers services to military personnel
What is acute stress disorder
Acute stress reaction in first 4 weeks following a traumatic event. (PTSD is >4 weeks)
- Intrusive thoughts (flashback, nightmare)
- Dissociation
- Negative mood
- Avoidance
- Arousal
Managed with CBT and Benzodiazepines sometimes used (addictive!!)
What is mirtazapine, its MoA, use case and side effects
An antidepressant that works to block alpha2-adrenergic receptors, increasing release of neurotransmitters. NaSSA (Noradrenergic and Specific Serotonergic Antidepressant)
Fewer side effects and interactions, so good in old people, who may be on lots of meds
Two main side effects: Sedation and increased appetite, good for old people who are skinny and cant sleep.
Take in evening to sleep
What are the 4 criteria of capacity
Understanding: Patient must understand the information relevant to the decision
Retention: Retain the info long enough to make the decision
Weighing: Weight up the information, consider both risks and benefits
Communicating: Communicate their decision back, verbally or non verbally.
Explain the decision, assess their understanding, check their retention sometime later, and assess their ability to weigh it up. If they can communicate all this clearly, respect their decision
What are the main points of a mental state examination
- Appearance/Behaviour
- Speech
- Emotion - Mood/affect
- Perception
- Thought
- Insight/Judgement
- Cognition
How can overdose to various drugs be treated acutely? (single drug for lots of substances)
Activated charcoal - within an hour of various substances to reduce absorption
What can you give for overdose of these drugs:
- Paracetamol
- Opiods
- Benzodiazepines
- Beta blockers
- CCB
- Cocaine
- Cyanide
- Methanol/ethylene (solvents or fuels/antifreeze)
- Carbon monoxide
- Paracetamol: N-Acetylcysteine
- Opiods: Naloxone
- Benzodiazepines: Flumazenil
- Beta blockers: Glucagon (heart failure/cardiogenic shock) or atropine for bradycardia
- CCB: Calcium chloride or gluconate
- Cocaine: Diazepam
- Cyanide: Dicobalt edetate
- Methanol/ethylene (solvents or fuels/antifreeze): Fomepizole or Ethanol (alcohol)
- Carbon monoxide: 100% Oxygen
What is a personality disorder
Maladaptive personality traits that cause significant psychosocial distress and interfere with functioning.
Patterns of thought behaviour and emotion that inhibit normal relationships, QOL and physical health.
Genetic and environmental causes, including history of childhood trauma and difficult circumstances
What are the 3 clusters of personality disorder
DSM-5
A - Suspicious
B - Emotional/impulsive
C - Anxious
Give the types of Suspicious (or Odd/Eccentric) Personality Disorder
DSM-5
Paranoid - Difficulty trusting or revealing personal info. Hypersensitive and unforgiving.
Schizoid - Lack of interest or desire to form relationships, with the belief that this is of no benefit to them. Prefer solitary activities.
Schizotypal - Unusual beliefs, thoughts and behaviours and social anxiety that makes forming relationships hard. Odd speech, eccentric behaviour, magical thinking.
Give the types of Emotional/Impulsive personality disorders
Antisocial - Reckless, harmful behaviour. Lack of concern for the consequences or impact of their behaviour. Aggression. Criminal. Men>women
Borderline - Fluctuating strong emotions and difficulty with identity and maintaining relationships. Recurrent suicidal behaviours. Chronic emptiness etc
Histrionic - Needs to be centre of attention and performing for others to maintain this. Sexual seductiveness, rapidly shifting, shallow emotions, self dramatisation.
Narcissistic - Feelings that they are special and need this to be recognised, or they get upset. Put self first. Entitled, lack empathy, chronic envy. Arrogant
Give types of anxious personality disorders
Avoidant - Severe anxiety about rejection or disapproval, causing avoidance of social situations or relationships. Constantly think theyre being criticised or rejected.
Dependent - Heavy reliance on others to make decisions, very passive, cant take responsibility for own life. Need constant support and reassurance
Obsessive-Compulsive - Unrealistic expectations of how things should be done, catastrophising about what will happen if needs not met. Stingy spending, meticulous, rigid morals, ethics. Hoarding.
Define these terms (according to ICD11)
Negative affectivity
Detachment
Dissociality
Disinhibition
Anankastia
Borderline Pattern
With trait domains
Negative affectivity
- Wide range of negative emotions, prone to mood swings, insecurity, emotional lability
Detachment
- Avoidance of interactions, relationships, emotional withdrawal. Limited pleasure
Dissociality
- Disregard for rights/feelings of others. Lack empathy, impulsive and manipulative
Disinhibition
- Impulsive, risk taking, difficulty controlling self. Struggle with planning and foresight; reckless and irresponsible
Anankastia
- Orderliness, control, perfectionism. Rigid and stubborn
Borderline pattern
- Additional qualifier for those with emotional instability, intense and unstable interpersonal relationships, fluctuating sense of identity, impulsivity.
How is severity classified in personality disorder
Mild
- Some impairment, limited. Symptoms noticable, but do not cause pervasive distress. Still maintains relationships.
Moderate
- More significant impairments in multiple areas of life. Struggle with maintaining relationships, but can manage day to day
Severe
- Impairments to all aspects of life. Pervasive difficulties in interpersonal relationships, significant effect on QOL, dysfunction and distress.
- Intense and long term therapeutic intervention may be required
Management of Personality disorders
CBT
Risk management (self harm, suicide, harm to others - MDT approach)
Medication not recommended long term, but may help in crisis.
Treat coexisting mental health issues
Give me the ages and genders most likely to self harm and commit suicide
Self harm
- 15-24 and females (but males use more lethal methods)
Suicide
- Middle aged men highest (40-49)
- Men 3-4x more likely to die by suicide, but women attempt more, just less lethal methods usually.
Repeating steps in the cycle of self harm
1 Emotional suffering
2 Emotional overload
3 Panic
4 Self harm
5 Temporary relief
6 Shame and guilt
What are some factors protective from suicide
- Social support/community
- Sense of responsibility to others
- Resilience, coping, problem solving skills
- Access to mental health support
What is the Mental Capacity Act and what are its 5 key principles
MCA 2005 applies to adults over 16 and sets out who can make decisions if they become incapacitated
- A person must be assumed to have capacity unless it is established that he lacks capacity
- A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
- A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
- An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
- Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
What should be considered when assessing whats in someones best interests, and whether to make a best interest decision
- Whether the person is likely to regain capacity and can the decision wait
- How to encourage and optimise the participation of the person in the decision
- The past and present wishes, feelings, beliefs, values of the person and any other relevant factors
- Views of other relevant people
How does an advance decision on refusing life saving treatment need to be made
Written, signed, witnessed.
Other advance decisions to deny treatments can be made verbally.
What decisions can someone with lasting power of attorney make
- Property/financial affairs
- Health and welfare decisions
- Life-sustaining decision authority must be pre specified.
- LPA must be registered with the Office of the Public Guardian
Whats the Mental Health Act 1983
Provides legal framework for keeping patients in hospital against their will (detaining/sectioning)
If patient agrees, its called an voluntary or informal admission, doesnt involve mental health act
What is a mental health act assessment and who can initiate it
Detailed evaluation into whether or not to detain someone under MHA.
Approved Mental Health Professional (AMHP) is primary person making application and organising admission. Nearest relative can do this too.
Decision needs to be recognised by 2 doctors;
- A section 12 doc (Qualified doctor who can undertake MHA assessments (usually Psych))
- Another doctor
Can result in compulsory admission under Section 2 or 3
What are section 2 and 3 of the MHA
2: Compulsory admission for assessment, maximum period of 28 days. Non renewable, must discharge or go onto:
Section 3: Compulsory admission for treatment. Max period 6 months, the Responsible Clinician can renew.
What are Section 4, Section 5(2), Section 5(4) and section 136 of the MHA
4 - detain patients for up to 72 hrs in urgent scenarios. Requires AMHP and a doctor.
5(2) - Used in emergency to detain patient voluntarily in hospital. Up to 72 hours, requires 1 doctor.
5(4) - Same as 5(2) but lasts 6 hours and only needs a nurse
135 - can break into a house to remove someone to Place of Safety
136 - used by police to remove someone that has a mental health disorder from public place to safe place for assessment. Lasts up to 24 hours.
ALL are followed by a Mental Health Act Assessment
How do you calculate units of alcohol
Volume (ml) x Alcohol Content (%) ÷ 1000 = Units of Alcohol
What is the MoA of alcohol on the brain
Stimulates GABA (inhibitory) receptors, having a relaxing effect on the brain. Also inhibits NMDA receptors (usually binded by glutamate - excitatory neurotransmitter), causing further relaxing effect.
Chronic alcohol results in GABA system becoming down regulated and glutamate system becoming upregulated. Patient must continue drinking or suffer severe withdrawal symptoms
What is the recommended level of alcohol consumption in the UK, what counts as binge drinking
<14 units/week
<5 units/day
> 6 units for women, or >8 units for men, in a single session classify as binge drinking.
Complications of alcohol excess
Alcoholic liver disease, cirrhosis, HCC, varices
Alcohol dependence/withdrawal
Wernicke-Korsakoff
Pancreatitis
Alcoholic Myopathy/cardiomyopathy
Pregnancy:
SGA
Miscarriage
Preterm delivery
Fetal alcohol syndrome
What 2 questionnaires can be used to identify harmful alcohol use?
AUDIT - WHO. 10 MCQs, >8=harmful use.
CAGE
Cut down - Do you ever think you should?
Annoyed - Do you get annoyed at others commenting on your drinking?
Guilty - Do you ever feel guilty about drinking?
Eye opener - Do you ever drink in the morning to help hangover or nerves?
Findings on examinations and blood results of alcoholism
Examination
- Smelling of it
- Slurred speech
- Bloodshot eyes
- Dilated capillaries on face (telangactasia)
- Tremor
Bloods
- Raised MCV
- Raised AST and ALT (AST:ALT >1.5 in particular)
- Raised GGT
How do alcohol withdrawal symptoms present
6-12 hours: Tremor, sweating, headache, cravings, anxiety
12-24 hours: Hallucinosis (aware not real)
~36 hours: Seizures
48-72 hours: Delirium tremens
What is delirium tremens (Pathophys)
Medical emergency with high untreated mortality, associated with alcohol withdrawal.
Long term alcohol down regulates GABA and upregulates Glutamate systems. When removed, GABA underfunctions and glutamate overfunctions, causing extreme excitability and excessive adrenergic activity.
How does delirium tremens present
- Acute confusion
- Coarse tremor
- Delusions
- Tachycardia, Hypertension, Hyperthermia
- Ataxia
How is alcohol withdrawal managed
CIWA-Ar tool to score symptoms and guide treatment
Benzodiazepine - Chlordiazepoxide or Diazepam as a reducing dose protocol, over ~7 days.*
High dose vitamin B followed by long term Thiamine (B1) to prevent Wernicke Korsakoff
*In liver disease use Lorazepam, as chlordiazepoxide is excreted through CYP450 pathway, which is impaired in cirrhosis, increasing risk of accumulation and toxicity.
Naltrexone or disulfiram or acamprosate for long term prevention of relapse
What is Wernicke’s encephalopathy
Thiamine (vitamin B1) deficiency, commonly seen in alcohol excess.
Thiamine deficiency causes Wernicke’s and eventually leads to Korsakoff syndrome.
Petechial haemorrhages occur in variety of brain structures including mamillary bodies and ventricle walls.
Features of Wernicke’s encephalopathy
Oculomotor dysfunction
- Nystagmus (most common)
- Ophthalmoplegia
Gait ataxia
Confusion
Disorientation
Peripheral sensory neuropathy
Triad is:
- Ophthalmoplegia and nystagmus
- Ataxia
- Encephalopathy
Investigations and management of Wernicke’s
- Decreased red cecll transketolase
- MRI
Managed with thiamine replacement
What can Wernicke’s lead to if untreated
Korsakoff syndrome, caused by continued haemorrhage and damage to mamillary bodies in hypothalamus.
Features of wernickes with added retro and anterograde amnesia, and confabulation (false memory making). Can be irreversible.
Define tolerance and dependence
T - Need for increasing drug dosage to achieve same effect over time
D - Physical and psychological need to use a drug regularly to avoid withdrawals
What is the main neurotransmitter associated with psychological addiction?
Dopamine, released by brain’s mesolimbic reward system
Withdrawal symptoms from benzodiazepines
Anxiety
Tremor
Insomnia
Seizure
What is Charles Bonnet syndrome
Persistent or recurrent complex hallucinations in clear consciousness. Must occur in absence of any other neuropsychiatric disturbance.
Associated with age related macular degeneration, glaucoma and cataracts
What is Somatisation disorder
When multiple physical symptoms have existed for at least 2 years, with no organic cause and patient refuses to accept reassurance or negative results
What is functional neurological disorder
AKA Conversion disorder
Sensory and motor symptoms unexplained by neurological disorders
- Gait disturbance
- Weakness
- Seizures
- Sensory loss
- Visual disturbance
Symptoms not under patients control, they are not faking nor seeking material gain
What is hypochondriasis
Persistent belief in the presence of a serious underlying disease, with no accepting reassurance or negative results
What is Factitious disorder
AKA Munchausen’s. Intentional production of physical or psychological symptoms
What is malingering
Fraudulent simulation or exaggeration of symptoms for financial or other gain
What is delusional parasitosis
Delusional belief of parasitic infection (bugs, worms, parasites, mites, bacteria, fungi)
What is Cotard delusion
Delusion that they are dead or dying. Most often caused by psychiatric conditions (schizophrenia, depression) but can be due to neurological conditions, such as tumours or migraines.
What is Capgras syndrome
False belief that a duplicate has replaced someone close to them, possibly causing suspicion or aggression towards them
AKA Delusional misidentification syndrome
Whats De Clerambaults
AKA Erotomania
Delusion that high status or famous person is in love with them. Can lead to harassment or stalking. Usually has little/no contact with person
Whats Todd Disorder
AKA Alice in Wonderland syndrome
Incorrectly perceiving size of body parts (too big/small). Also associated with changes to perception of time and symptoms of migraine (e.g. aura and headache).
Caused by migraine epilepsy brain tumours
What is Koro syndrome
Belief that sex organs are retracting or shrinking and will disappear, killing the patient. Causes anxiety and panic attacks.
Mostly seen in asia, especially china and india
What is body integrity dysphoria
Apotemnophilia involves a strong feeling that a body part doesn’t belong to them, causing them distress, and wanting to remove it. May have desire to be disabled.
No associations
What is Binge eating disorder
Episodes where patient overeats often as an expression of distress. Typically feels a loss of control, not restrictive like anorexia or bullimia, patients likely to be overweight
- Planned binge involving binge foods, eating quickly, unrelated to hunger, becoming uncomfortably full and eating in dazed state
How do bloods present in Binge Eating Disorder
- Anaemia
- Leucopenia
- Thrombocytopenia
- Hypokalaemia
(low Hb, WCC, platelets, potassium)
Reduced bone marrow activity causes normocytic normochromic anaemia, leukopenia and thrombocytopenia
What is refeeding syndrome
Occurs when someone with an extended severe nutritional deficit resumes eating. The lower the BMI, and the longer the period of malnutrition, the higher the risk.
Pathophys of refeeding syndrome
During starvation, intracellular potassium, phosphate, magnesium depleted. These electrolytes move from inside cells to blood to maintain serum levels
Cell metabolism reduces to conserve energy, causing a loss of intracellular electrolytes.
During refeeding, potassium, phosphate and sodium shift into blood. Carbs cause increase in insulin which drives glucose, potassium, phosphate into cells.
Na+/K+ pump pumps K+ into cells and Na+ out. Insulin causes sodium reabsorption from kidneys.
Overall metabolic effects of refeeding syndrome on bloods
- Hypomagnesaemia
- Hypokalaemia
- Hypophosphataemia
- Fluid overload
Clinical features of refeeding syndrome
Hypophosphataemia
- Main cause of symptoms
- Muscle weakness (including cardiac and diaphragm) -> heart and respiratory failure
Hypomagnesaemia may cause torsades de pointes
Clinical consequences of hypophosphataemia (as in refeeding)
- Cardiac dysfunction
- Respiratory failure
- Confusion, seizures, coma
- Tissue hypoxia and haemolysis
- Rhabdomyolysis
How is refeeding syndrome prevented
If patient hasnt eaten, or high risk, for more than 5 days, aim to refeed at no more than 50% of requirements for first 2 days.
High risk if
- BMI <16
- Unintentional weight loss >15% over 3-6 months
- Little nutritional intake 10+ days
- Derranged electrolytes prior to feeding
If 2 or more of:
- BMI <18.5
- Weight loss >10%
- Little intake >5days
- History of alcohol abuse, drugs, chemotherapy, diuretics, antacids, insulin
What is metabolic syndrome
- Hypercholesterolaemia
- Hypertension
- Impaired glucose tolerance
- Central obesity
Caused more often by atypical antipsychotics (aripiprazole less so, has less side effects)
When can u use ECT
Severe, medication resistant or psychotic depression. Course of treatments.
Involves triggering a short generalised seizure under anaesthaesia.
Side effects: Headache, muscle ache, short term memory loss
How do SSRIs, SNRIs and TCAs work
SSRI - Block reuptake of serotonin by presynaptic membrane on axon terminal. Hence, more serotonin in synapses throughout CNS, boosting communication between neurones
SNRI - Blocks reuptake of serotonin and noradrenaline by presynaptic membrane
TCA - Block serotonin reuptake and noradrenaline by presynaptic membrane. Also block ACh and histamine receptors, giving them anticholinergic and sedative effects
What are anticholinergic side effects
Anticholinergics block Ach, which is involved in bodily secretions, having a drying effect around the body.
Results in:
- Dry mouth
- Constipation
- Blurred vision
- Dizziness
- Cognitive impairment
“cant see pee or climb a tree”
Blurred vision, urinary retention and muscle pain/impaired coordination and balance
Side effects of SSRIs
- Sertraline - usually safe but associated with diarrhoea
- Citalopram - Can prolong QT, which can lead to torsades de pointes. Least safe SSRI in patients with heart disease
- Fluoxetine - Long half life (4-7 days) first line in children
- Paroxetine causes weight gain
Other side effects:
- GI symptoms
- Headaches
- Sexual dysfunction (loss of libido, ED, orgasm difficulty)
- Increased risk of bleeding (esp when taken with NSAID, anticoagulant)
- SIADH causing hyponatraemia!
SNRI side effects
Similar to SSRIs. Can increase BP so contraindicated in uncontrolled HTN.
Venlafaxine - more likely to cause discontinuation symptoms when stopped. Increased risk of death by OD
Duloxetine - Treats neuropathic pain, especially diabetic neuropathy
TCA side effects
Amitriptyline - used at low dose to treat neuropathic pain
TCA - cardiotoxic!! Cause arrhythmia -> tachycardia, long QT, Bundle branch block. Dose dependent. Very dangerous in overdose, so not used in depression
Also have anticholinergic side effects.
Vortioxetine. Tell me about it
Serotonin reuptake inhibitor. 3rd line after inadequate response from 2 others.
Stimulates and blocks other serotonin receptors. Good for anti-anxiety. Not many side effects, safe in heart disease.
Causes nausea for first few weeks
Considerations when prescribing antidepressants
Can be initial period of agitation, anxiety, suicidal ideation, acts of suicide.
Review all patients within 2 weeks of starting (1 week in 18-25 due to high suicide risk)
Noticable response 2-4 weeks after starting.
Some can be directly switched, others need to be crosstapered. Most SSRI and SNRI are safe to switch between except fluoxetine due to long half life
Advice for stopping antidepressants
- continue for at least 6 months (2 years in recurrent) before stopping
- Reduce slowly over 4 weeks to prevent discontinuation symptoms
Discontinuation symtpoms
- Flu like
- Electric shock sensations
- Insomnia
- Irritability
- Vivid dreams
What drugs interact with SSRIs
- NSAIDs (prescribe with PPI)
- Warfarin/heparin (consider mirtazapine instead)
- Aspirin
- Triptans and MAOIs - increased risk of serotonin syndrome!
SSRI risks in pregnancy
1st trimester - Small risk of congenital heart defects
3rd trimester - persistent pulmonary HTN of the baby
Paroxetine has risk of congenital malformations!
Clozapine Side effects
One of the earliest atypical agents, carries risk of agranulocytosis. FBC monitoring ESSENTIAL!
- Agranulocytosis, neutropenia
- Constipation
- Myocarditis
- Hypersalivation
Dose adjustment if start/stop smoking
What food cant you eat with a MAOI
Cheese because it contains tyramine whatever the fuck that is
What is serotonin syndrome
Serotonin syndrome is a potentially life threatening drug reaction. Typically results from the use of serotonergic drugs.
Caused by:
- MOAI
- SSRIs (St John’s Wort and tramadol interact with SSRIs to cause serotonin syndrome)
- Ecstasy
- Amphetamines (ADHD Meds - Lisdex)
- Triptans
Usually due to interactions, doses that are too high, or a new drug is added without sufficient time to affect levels.
Features of serotonin syndrome
Neuromuscular excitation
- Hyperreflexia
- Myoclonus
- Rigidity
Autonomic Nervous System excitation
- Hyperthermia
- Sweating
Altered mental state
- Confusion
Management of serotonin syndrome
How is serotonin syndrome managed
- IV fluids
- Benzodiazepines
- Serotonin antagonists, cyproheptadine, chlorpromazine if severe
What is Neuroleptic Malignant syndrome (NMS)
Condition caused by a sudden dopamine deficiency usually caused by overdoing
Gradual 1-3 days after starting or increasing an antipsychotic
Symptoms of NMS
MAIN 4:
- Fever
- Muscle rigidity
- Autonomic lability: typical features include HTN, tachycardia, tachypnoea.
- Agitated delirium/confusion.
FALTER:
Fever,
Autonomic instability,
Leukocytosis,
Tremor,
Elevated enzymes (creatine kinase, transaminases), and
Rigor
Investigations of NMS
- Raised Creatinine Kinase
- AKI Secondary to Rhabdomyolysis
- Leucocytosis
Management of NMS
Stop antipsychotics
- IV Fluids
- Benzodiazepines
Severe cases -Dantrolene
Serotonin syndrome vs NMS
SS
- Caused by SSRI, MAOI, ecstasy, novel psychoactive stimulants
- Faster onset (hours)
- Hyperreflexia, clonus, dilated pupils
- Severe treatment: Cyproheptadine, Chlorpromazine
NMS
- Caused by antipsychotics
- Slower onset (hours-days)
- Reduced reflexes, lead pipe rigidity, normal pupils
- Severe treatment: Dantrolene
How is acute personality disorder crisis management
Acute short term antipsychotic (quetiapine), mood stabiliser (valproate/lamotrigine) if severe
How do MAOIs work, give an example or 2
Serotonin and noradrenaline are metabolised by monoamine oxidase in the presynaptic cell
MAOI = Monoamine oxidase inhibitor
- Tranylcypromine, phenelzine
Adverse effects of MOAIs
- Hypertensive reactions with tyramine containing foods (cheese, pickled herring, Bovril, Oxo, Marmite, broad beans)
Anticholinergic effects
- Dry mouth
- Blurred vision
- Constipation
- Urinary retention
- Confusion
- Tachycardia
How should SSRIs be stopped, what can happen if not done right
Stop gradually over 4 weeks
Discontinuation symptoms (especially with Paroxetine, Fluoxetine can be stopped whenever)
- Increased mood change
- Restlessness
- Difficulty sleeping
- Electric shock sensations
- Unsteadiness/dizziness
- GI sx - pain, cramping, diarrhoea, vomiting
- Paraesthesia
What is treatment resistant psychosis and how is it treated. What are some considerations of treatment
Uncontrolled psychosis following 2 antipsychotic drugs (right dose and timeframe)
Treated with clozapine.
48 hr rule: if missed for 48 hrs, must be retitrated.
Side effects:
- Myocarditis
- Constipation (cholinergic receptor block)
- Smoking cessation increases levels (smoking increases cytochromic b450 levels in liver)
- Increased salivation
What medication can be given as a deterrent from alcohol and why
Disulfiram - causes vomiting, nausea, facial flushing
What is an anti-craving medication from alcohol
Acamprostate
Opioid addiction drug - alternative to methadone
Buprenephorine
What is low and what is high in anorexia nervosa
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Most other things low
