Psychiatry Flashcards
State the mechanism of action of SSRIs
Selective inhibition of serotonin reuptake. Increases availability of serotonin and enhances mood regulation.
State indications of SSRIs
1st line for:
- Depression
- Generalised anxiety disorder (GAD)
- Panic disorder
- Obsessive - compulsive disorder (OCD)
- PTSD
State cautions for SSRIs
- Omitted for mania
- Sertraline best for IHD patients
- Avoid in patients taking warfarin
State common side effects of SSRIs
- GI upset
- Anxiety + agitation
- QT interval prolongation (especially with citalopram)
- Sexual dysfunction
- Hyponatraemia
- Gastric ulcer
State common SSRIs
- Citalopram
- Fluoxetine
- Sertraline
- Paroxetine
- Escitalopram
Describe important considerations for monitoring patients on SSRIs
- Increased risk of impulsivity and suicide in people aged 18-25. Require review 1w post treatment commencement. With >25 can do 2-4w post.
- Continuation of antidepressants for at least 6m post remission to mitigate relapse risk.
Aetiology of serotonin syndrome
- SSRIs
- SNRIs
- MAOIs
- Tricyclic antidepressants
- MDMA and cocaine
Sx of serotonin syndrome
- Anxiety
- Agitation
- Restlessness
- Hyperthermia
- Tachycardia
- Tremor
Ddx of serotonin syndrome
- Neuroleptic Malignant Syndrome
- Same presentation but slower onset and longer duration
- Anticholinergic toxicity
- same presentation but decreased bowel sounds and urinary retention
Management of serotonin syndrome
- Discontinuation of offending drug + supportive care
- Extreme case: Cyproheptadine
State the mechanism of action of SNRIs
Increase serotonin and norepinephrine (adrenaline)
State indications for use of SNRIs
- First line for depression if SSRI not indicated or unsuccessful
- Licensed for use in GAD and panic disorder
- Contraindicated with history of heart disease and hypertension
Side effects of SNRIs
- Nausea
- Insomnia
- Tachycardia
- Agitation
State common SNRIs
- Duloxetine
- Venlafaxine
Summarise Mirtazepine
- Mirtazepine is 2nd line for management of depression.
- Preferred in cases with concern of weight loss and sleep
- Side effects include:
- Sedation
- Weight gain
- GI dysfunction
State the mechanism of action (Tricyclic Antidepressants) TCAs
- Block reuptake of serotonin and noradrenaline
- Also used as antimuscarinic
State common TCAs
- Amitriptyline
- Clomipramine
- Imipramine
State cautions for use of TCAs
- Previous heart disease
- Exacerbate schizophrenia
- Exacerbate long QT syndrome
- Urinary retention (avoid men with enlarged prostate)
State side effects of TCAs
Anticholinergic activity:
- Urinary retention
- Drowsiness
- Blurred vision
- Constipation
- Dry mouth
State signs of TCA toxicity
- Drowsiness
- Confusion
- Arrhythmias
- Seizures
- QT interval prolongation
State mechanism of action for Monoamine Oxidase Inhibitors (MAO-IS)
- Monoamine oxidase metabolises serotonin and noradrenaline.
- Inhibition -> elevation of serotonin
- Similar structure to amphetamines so also affects uptake and release of dopamine, noradrenaline and serotonin.
State cautions for use of MAO-IS
- Cerebrovascular disease
- Manic phase of bipolar disorder
- Severe cardiovascular disease
State side effects of MAO-IS
Hypertensive reactions: tyramine-containing foods to be avoided (cheese, marmite, salami, etc)
State common MAO-IS
- Moclobemide
What are typical antipsychotics?
- 1st gen
- Acts as antagonist on:
- D2 receptor
- Cholinergic receptor
- Adrenergic receptor
- Histaminergic receptor
- Haloperidol
- Chlorpromazine
What are the D2 receptor blockade side effects
- Restlessness
- Parkinsonism: tremors, rigidity, bradykinesia
- Menstrual irregularities in women
- Gynaecomastia
- Sexual dysfunction
What are the H1 receptor blockade side effects?
Sedation
What are the adrenergic receptor blockade side effects?
Orthostatic hypotension: drop in BP from standing
What are the cholinergic receptor blockade side effects?
Anticholinergic effects
- Dry mouth
- Constipation
- Blurred vision
- Urinary retention
What are atypical antipsychotics?
- 2nd gen
- act as antagonist on:
- D2
- D3
- 5-HT2A
- As effective as typical antipsychotics
- More favourable side effect profile
- Reduced extrapyramidal effects
- Increased metabolic side effects
- 1st line for new-onset psychosis
- Risperidone
- Quetiapine
- Olanzapine
- Aripiprazole
- Clozapine
What are the serotonin (5-HT2A) receptor blockade side effects?
- Reduced risk of EPS
What are the other misc. side effects with atypicals?
- Mild H1 receptor blockade symptoms
- Mild adrenergic receptor symptoms
- Mild anticholinergic symptoms
What are the metabolic side effects of atypicals?
- Weight gain
- Dyslipidemia and glucose metabolism
- Prolactin elevation
- Seizures
- QT prolongation
- Increased risk of VTE in elderly
What monitoring should be undertaken when administering atypicals to a patient?
- Measure weight at start of therapy then weekly until week 6
- Then at week 12
- Then at year 1
- Then yearly
- Measure prolactin conc
- HbA1c
- ECG
- BP
When is clozapine indicated for treatment?
- Failure of treatment of 2 other antipsychotics (treatment resistant schizophrenia)
- Treats both +ve and -ve symptoms; more effective than other antipsychotics
- SE:
- Agranulocytosis
- Neutropenia
- Constipation
What are the important monitoring factors for clozapine?
- weekly FBC (for wbc check) for first 18w
- Blood lipids and weight every 3m
- Blood glucose after 1m
What is Neuroleptic Malignant Syndrome?
- Rare
- Life threatening
- Idiosyncratic reaction to antipsychotic medications
State the clinical features of NMS
- Hyperthermia
- Altered mental state - fluctuating levels of consciousness
- Autonomic dysregulation - flux in BP, tachycardia and diaphoresis (excessive sweating)
- Rigidity
Ddx for NMS
- Serotonin syndrome: same presentation but with serotoninergic medication
Ix for NMS
- FBC
- CK
- Renal function
- LFTs
Management of NMS
- Discontinuation + supportive care
- Benzodiazepines: manage agitation + rigidity
- Dantrolene: muscle relaxant for severe cases
State side effects of Lithium
LITHIuM pneumonic
- Leucocytosis
- Insipidus
- Tremor (fine)
- Hypothyroid
- Increased weight
- u
- Metallic taste
State the indications for lithium
- Bipolar disorder and mania
- Depression
- Mood stabiliser for aggressive/ self harming behaviour
State the clinical features of lithium toxicity
- Coarse tremor
- Seizures
- Cardiac arrhythmias
- Visual disturbances
State the Ddx of lithium toxicity
- Neuro conditions: Parkinson’s
- Cardiac conditions
- Substance intoxication or withdrawal: alcohol or benzos
State the Ix for lithium toxicity
- Serum lithium levels
- Electrolytes
- TFTs
- Renal function test
- ECG
State clinical features of Alzheimer’s
- Memory impairment
- Language impairment
- Executive dysfunction: impaired ability to plan, organise and carry out tasks
- Behavioural changes
- Psych symptoms
- Disorientation
- Loss of motor skills
State Ddx of Alzheimer’s
- Vascular dementia
- Sudden onset with history of cerebrovascular events
- Lewy body dementia
- visual hallucinations and fluctuating cognitive impairment
State Ix of Alzheimer’s
- History (cognitive screen)
- Examination (full Neuro exam)
- Blood tests (rule out reversible causes)
State the management of Alzheimer’s
- Cognitive stimulation therapy
- Cholineesterase inhibitors: Donepezil
- NMDA receptor antagonists: Memantine
State the 5 types of anxiety disorders
- Generalised Anxiety Disorder (GAD)
- Specific phobias
- Panic disorder
- OCD
- PTSD
State the clinical features of anxiety
- Psychological: fears and worries
- Motor symptoms: Restlessness
- Neuromuscular: Tremor
- GI: Dry mouth
- Cardio: palpitations
- GU: ED, amenorrhea
Management of GAD
- SSRIs
- CBT
- Counselling
Define anorexia nervosa
- Extreme dietary restriction
- Intense fear of gaining weight
- Distorted body image
State clinical features of anorexia nervosa
- History
- starvation via restricting intake, purging or excessive exercise
- Examination
- BMI <17.5
- Hypotension
- Bradycardia
- Lanugo hair
- Amenorrhoea
State Ix for anorexia nervosa
Bloods
- deranged electrolytes
- Low sex hormone (FSH,LH, oestrogen, testosterone)
- Leukopenia
- Raised cortisol
- Hypercholesterolaemia
Management of Anorexia nervosa
- CBT-ED
- SSRIS
State possible complications of anorexia nervosa
- Refeeding syndrome
- Cardiac arrhythmias
- Osteoporosis
State Sx of refeeding syndrome
- Oedema
- Confusion
- Tachycardia
What aspect of refeeding syndrome causes electrolyte imbalance?
- Rapid increase in insulin level -> shifts K+, Mg2+, phosphate from extracellular -> intracellular
- These electrolytes then need to be replenished
Describe preventative measures for refeeding syndrome
- High dose vitamins before feeding commences
- Replenish electrolytes early + daily bloods
- Refeeding starts at no more than 50% of calorie requirement in Pt with little to no feed for >5d
Define BPAD
At least 2 episodes including one hypomanic or manic episode
- BPAD Type 1: 1 or more manic episodes and one or more depressive episodes
- BPAD Type 2: recurrent major depressive episodes and hypomanic episodes
What is hypomanic state and how do you differentiate it from a manic episode?
- Mania: severe functional impairment with psychotic symptoms for at least 7d
- Increased/decreased function without psychotic symptoms for at least 4d
State Ix of BPAD
- Rule our organic causes from substances
- Rule out delirium from secondary causes such as: infection, thyroid, B12
State management of BPAD
- Hypomania -> routine CMHT
- Mania/severe depression -> urgent CMHT
- New diagnosis
- If SSRI recently started -> stop/taper
- Mania + agitation -> benzodiazepine
- Mania - agitation -> oral antipsychotic monotherapy (haloperidol). + lithium if unsuccessful
- Acute depression -> mood stabiliser
- Chronic
- 4w after resolution of acute episode
- Maintenance therapy with mood stabiliser (Li 1st line)
Define bulimia
- Eating disorder
- Recurrent binge eating with loss of control
- Followed by compensatory behaviours (vomiting, etc)
- Maintain normal/slightly above average BMI
Clinical presentation of bulimia
- Binge eating
- Purging
- Dental erosion (from vomiting)
- Parotid gland swelling
- Russell’s sign: scarring on hand from vomiting
- Amenorrhea
Ix for bulimia
Comprehensive history and examination
Management of bulimia
Bulimia focused guided self-help
Define delirium
- Acute and fluctuating disturbance in attention and cognition
- +/- change in consciousness
- Reversible
State the 3 types of delirium
- Hyperactive
- Increased psychomotor activity
- Restlessness
- Agitation
- Hallucinations
- Hypoactive
- Lethargy
- Reduced responsiveness
- Withdrawal
- Mixed
- Mixture of hyperactive and hypoactive
Aetiology of delirium
D: drugs and alcohol (anti-cholinergics, opiates, anti-convulsants)
E: Eyes, ears, emotional disturbance
L: Low output state (MI, PE, COPD)
I: Infection
R: Retention (urine/stool)
I: Ictal (seizure)
U: Under (hydration/nutrition)
M: Metabolic disorders
S: Subdural hematoma, sleep deprivation
Sx of delirium
- Disorientation
- Hallucinations
- Inattention
- Memory problems
- Change in mood or personality (sundowning: worsening as EoD approaches)
- Disturbed sleep
Ddx for delirium
- Dementia (gradual onset)
- Psychosis (preserved orientation and memory)
- Depression (stable consciousness level)
- Stroke (abrupt onset + neuro signs)
Ix for delirium
- 4AT and CAM (tools)
- Bedside
- Bladder scan
- ECG
- Bloods
- FBC
- U+E
- LFTs
- TFTs
- Blood cultures
- Imaging
- CXR
Management of delirium
- Treat underlying cause
- Comfortable environment for pt
- Haloperidol if severely agitated
Define delirium tremens (DT)
- Alcohol withdrawal
- 72h after alcohol cessation
- Immediate medical attention
Sx of DT
- Confusion + disorientation
- Hallucinations (visual or tactile; sensation of crawling insects under skin)
- Autonomic hyperactivity
- Seizures
Management for DT
- Lorazepam (1st line)
- Maintenance
- Chlordiazepoxide
- Hydration
- Anti-emetics
- Pabrinex (vitamins)
Define delusions
- Fixed false beliefs
- Maintained despite contradictory evidence
- Bizarre (very strange or highly unusual) or non-bizarre (plausible but incorrect)
Sx of delusions
- Nihilistic delusions
- Grandiose delusions
- Delusion of control (external entity controlling thoughts/action)
- Persecutory delusions (being conspired against)
- Somatic delusion (convinced they have physical, medical or biological problem despite no medical evidence)
- Delusional perceptions (arise from real perception leading to delusion)
- Delusions of reference (mundane things meaning something special and directed at pt)
Management of delusions
- Pharmacological
- antipsychotics
- Psychotherapy
- CBT
Define dementia
- Chronic syndrome
- Impairment of multiple higher cortical functions
- MMSE of 24/30 or less = dementia
Sx of dementia
- Gradual, progressive, impairment of higher cortical function
- Memory loss
- Difficulty with familiar tasks
- language problems
- Disorientation
- Poor judgement
State the 4 common types of dementia
- Alzheimer’s
- Vascular
- Lewy body
- Fronto-temporal
Define alzheimer’s
- Most common cause
- Neuropathological features: amyloid plaques and tau proteins
Sx of Alzheimer’s
4 A’s
1. Amnesia (recent memories lost first)
2. Aphasia (muddled speech)
3. Agnosia (recognition problems)
4. Apraxia (inability to carry out skilled tasks)
Management of Alzheimer’s
- Cholinesterase inhibitors
- Galantamine
- NMDA inhibitor (severe)
- Memantine
Summarise vascular dementia
- 2nd most common cause
- Impaired blood flow to brain
- Step-wise progression (due to progressive infarcts)
- Clinical Dx
- Tx = manage underlying vascular condition
Summarise lewy body dementia
- 3rd most common
- Abnormal protein deposits (lewy bodies) -> cognitive decline
- Sx
- Parkinsonism (rigidity, tremor, bradykinesia)
- Visual hallucinations (small creatures/children/figures; lilliputian bodies)
State management difficulties with lewy body dementia
- Neuroleptics
- Manage agitation/hallucination but trigger rigidity and parkinsonism
- Dopaminergic agents
- Manage rigidity but worsen hallucinations
Sx of fronto-temporal dementia
- Cognitive impairment
- Personality change
- Repetitive checking behaviour
- Disinhibition
- Construction apraxia (failure to draw interlocking pentagons)
- Memory loss = LATE FEATURE
- Presents at young age)
What are the 3 main variants in fronto-temporal dementia
- Behavioural variant (60%)
- Loss of social skills
- Disinhibition
- Semantic dementia (20%)
- Inability to remember words for things
- Progressive non fluent aphasia (20%)
- Unable to verbalise
Define depression
- 5/9 Sx for at least 2w
- Low mood
- Anhedonia (unable pleasure)
- Weight change
- Sleep and activity changes
- Fatigue
- Guilt
- Poor concentration
- Suicidality
Ix for depression
- FBC
- TFTs
- U+E
4 LFT - Glucose
- B12
- Tox screen
Management of depression
- Mild to moderate
- CBT
- Moderate to severe
- SSRI
- Severe
- ECT
Define Wernicke’s encephalopathy
- Thiamine (B1) deficiency
- Commonly from chronic alcohol abuse
Sx of Wernicke’s encephalopathy
Classic triad of:
- Confusion
- Ataxia
- Opthalmoplegia/nystagmus (paralysis of eye muscle)
Sx of Korsakoff’s syndrome
- Profound anterograde amnesia (creating new memories)
- Limited retrograde amnesia (recall memories before injury)
- Confabulation (fabricate memories to mask lack of)
State Ddx for Wernicke’s encephalopathy
- Alcohol withdrawal syndrome (includes tremors, agitation, nausea)
- Hepatic encephalopathy (changes in consciousness, asterixis)
- Stroke
- Cerebellar disorders (lacks confusion or opthalmoplegia)
Ix for Wernicke’s encephalopathy
- Thiamine level
- Full bloods
- MRI (mamillary body atrophy in Korsakoff’s syndrome)
Management of Wernicke’s encephalopathy
- Thiamine supplementation
- Address underlying condition
Management of Korsakoff’s syndrome
- Ongoing thiamine supplementation
- Cognitive rehab
- Treat underlying causes
Define OCD
- Recurrent obsessional thoughts or compulsive acts
- Cause significant functional impairment
- Time consuming
Management of OCD
- Mild
- CBT
- Moderate
- CBT
- SSRI
- Severe
- CBT AND SSRI
State the different types of PCM OD
- Acute
- Excessive amounts in <1h
- Staggered
- Excessive amount over >1h
- Therapeutic
- Excess with intent to treat pain or fever (no self harm intent)
Sx of PCM OD
- N+V
- Loin pain
- Haematuria & proteinuria
- Jaundice
- Abdo pain
Ix for PCM OD
- Usual bloods
- Clotting screen
- VBG
- NOMOGRAM (plots pcm levels)
Management of PCM OD
- <1h + dose >150mg/kg
- Activated charcoal
- <4h
- Wait until 4h to take level and treat with N-acetylcysteine
- 4-24h + dose >150mg/kg
- N-acetylcysteine immediately
What is the criteria for immediate liver transfer with PCM OD
- Arterial pH <7.3
or ALL of: - Serum creatinine > 3.4mg/dL
- Prothrombin time > 100s
- Grade III or IV encephalopathy
Define postpartum depression
- Depressive disorder
- Develop up to one year following childbirth
- Interferes with daily functioning
Sx of postpartum depression
- Low mood
- Low energy
- Biological symptoms of depression
- poor appetite
- Disturbed sleep pattern
- Concerns about baby bonding
Ix of postpartum depression
- Edinburgh Postnatal Depression Scale (EPDS)
- Screening tool
Management of postpartum depression
- Self help + CBT
- Paroextine and sertraline (best with breastfeeding)
Define postpartum psychosis
- Psychiatric disorder
- First 2w after childbirth
Sx of postpartum psychosis
- Paranoia
- Delusions
- Capgras delusions: misidentification syndrome where belief close person replaced by imposter
- Hallucinations
- Manic episodes
- Depressive episodes
- Confusion
Management of postpartum psychosis
- Olanzapine & quetiapine (safe with breastfeeding)
- Li
Define schizophrenia
- Chronic or relapsing/remitting form of psychosis
- +ve Sx
- hallucinations
- delusions
- thought disorders
- -ve Sx
- Alogia (decreased speech)
- Anhedonia (decreased joy)
- Avolition (decreased motivation)
State the subtypes of psychosis
- Paranoid
- delusions
- hallucinations
- persecutory theme
- Catatonic
- motor disturbance
- Waxy flexibility
- Hebephrenic
- disorganised thinking, emotion and behaviour
- Residual
- residual Sx post major episode
- Simple
- Gradual decline in functioning without prominent +ve Sx
Sx of schizophrenia
+ve Sx (ABCD)
- Auditory hallucinations
1. Broadcasting of thoughts
2. Control issues
3. Delusional perception
-ve Sx
1. Alogia
2. Anhedonia
3. Avolition
4. Blunting
Ix for schizophrenia
- Clinical diagnosis
- Excluding Ddx tests
- Brain imaging
- Bloods to exclude infectious or metabolic causes
- Drug screen
Management of schizophrenia
- Acute episode
- Lorazepam (sedative)
- Haloperidol (manage dangerous behaviour)
- Atypicals
- Risperidone
- Resistant schizophrenia
- Clozapine
- CBT
Sx of opiate intoxication
- Drowsiness
- Confusion
- Decreased RR and HR
- Constricted pupils
Sx of opiate withdrawal
- Agitation
- Anxiety + irritability
- Muscle aches
- Chills
- Runny nose
- Sweating
Management of opiate use
WITHDRAWAL
1. Methadone (QTc prolongation)
2. Lofexidine (Alpha 2 receptor agonist)
3. Loperamide (for diarrhoea)
4. Anti-emetics
5. Benzos (for agitation)
DETOX
1. Methadone and buprenorphine
RELAPSE
1. Neltrexone post detox
OVERDOSE
1. Naloxone
State the 5 key principles of the MCA
- Capacity unless proven otherwise
- Steps must be taken to help a person have capacity
- An unwise decision does not mean a person lacks capacity
- Any decision under MCA must be under patient’s best interests
- Decisions must be least restrictive to person’s rights and freedoms
How is capacity assessed?
- Is there an impairment of or disturbance in the functioning of mind or brain?
- If yes:
- Understand relevant info
- Retain relevant info
- Weigh up relevant info
- Communicate a decision
Summarise DoLS
- Deprivation of pt liberty due to lack of capacity
- Common in acute/geris
State the conditions that must be met for DoLS to be applied
- > 18
- Mental disorder
- Patient in hospital or care home
- Lack capacity
- Proposed restrictions would deprive liberty
- Proposed restrictions in best interest
- Consider MHA
- No valid advance decision to refuse treatment or support that would contradict DoLS
State the criteria for the MHA
- Must have mental disorder
- Risk to self or others
- Must be a treatment (including nursing care)
- Applies only to mental health disorders
- Does not cover physical illness except anorexia for refeeding
Describe the MHA assessment
- requires to 2 doctors ( at least 1 section 12(2) approved) + 1 approved AMHP
Summarise Section 2
- Allows admission for mental health assessment and treatment
- 28 days
- Non-renewable
Summarise Section 3
- Admission for treatment for upto 6m
- Renewable
Summarise Section 4
- For emergencies when Section 2 would cause delay
- Recommendation of single doctor or AMHP or nearest relative
- 72h followed by Section 2
Summarise Section 5(2)
- Holding power for voluntary patient
- 72h
Summarise Section 5(4)
- Same as Section 5(2) but by nurses
- 6h
Summarise Section 17a
Supervised community treatment (Community Treatment Order CTO)
Summarise Section 135
Enables police to enter a property to escort a person to safety
Summarise Section 136
Provides police authority to take mental disorder individual from public place to place of safety
