Psychiatry Flashcards
1
Q
State the mechanism of action of SSRIs
A
Selective inhibition of serotonin reuptake. Increases availability of serotonin and enhances mood regulation.
2
Q
State indications of SSRIs
A
1st line for:
- Depression
- Generalised anxiety disorder (GAD)
- Panic disorder
- Obsessive - compulsive disorder (OCD)
- PTSD
3
Q
State cautions for SSRIs
A
- Omitted for mania
- Sertraline best for IHD patients
- Avoid in patients taking warfarin
4
Q
State common side effects of SSRIs
A
- GI upset
- Anxiety + agitation
- QT interval prolongation (especially with citalopram)
- Sexual dysfunction
- Hyponatraemia
- Gastric ulcer
5
Q
State common SSRIs
A
- Citalopram
- Fluoxetine
- Sertraline
- Paroxetine
- Escitalopram
6
Q
Describe important considerations for monitoring patients on SSRIs
A
- 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.
7
Q
Aetiology of serotonin syndrome
A
- SSRIs
- SNRIs
- MAOIs
- Tricyclic antidepressants
- MDMA and cocaine
8
Q
Sx of serotonin syndrome
A
- Anxiety
- Agitation
- Restlessness
- Hyperthermia
- Tachycardia
- Tremor
9
Q
Ddx of serotonin syndrome
A
- Neuroleptic Malignant Syndrome
- Same presentation but slower onset and longer duration
- Anticholinergic toxicity
- same presentation but decreased bowel sounds and urinary retention
10
Q
Management of serotonin syndrome
A
- Discontinuation of offending drug + supportive care
- Extreme case: Cyproheptadine
11
Q
State the mechanism of action of SNRIs
A
Increase serotonin and norepinephrine (adrenaline)
12
Q
State indications for use of SNRIs
A
- 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
13
Q
Side effects of SNRIs
A
- Nausea
- Insomnia
- Tachycardia
- Agitation
14
Q
State common SNRIs
A
- Duloxetine
- Venlafaxine
15
Q
Summarise Mirtazepine
A
- 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
16
Q
State the mechanism of action (Tricyclic Antidepressants) TCAs
A
- Block reuptake of serotonin and noradrenaline
- Also used as antimuscarinic
17
Q
State common TCAs
A
- Amitriptyline
- Clomipramine
- Imipramine
18
Q
State cautions for use of TCAs
A
- Previous heart disease
- Exacerbate schizophrenia
- Exacerbate long QT syndrome
- Urinary retention (avoid men with enlarged prostate)
19
Q
State side effects of TCAs
A
Anticholinergic activity:
- Urinary retention
- Drowsiness
- Blurred vision
- Constipation
- Dry mouth
20
Q
State signs of TCA toxicity
A
- Drowsiness
- Confusion
- Arrhythmias
- Seizures
- QT interval prolongation
21
Q
State mechanism of action for Monoamine Oxidase Inhibitors (MAO-IS)
A
- 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.
22
Q
State cautions for use of MAO-IS
A
- Cerebrovascular disease
- Manic phase of bipolar disorder
- Severe cardiovascular disease
23
Q
State side effects of MAO-IS
A
Hypertensive reactions: tyramine-containing foods to be avoided (cheese, marmite, salami, etc)
24
Q
State common MAO-IS
A
- Moclobemide
25
What are typical antipsychotics?
- 1st gen
- Acts as antagonist on:
- D2 receptor
- Cholinergic receptor
- Adrenergic receptor
- Histaminergic receptor
- Haloperidol
- Chlorpromazine
26
What are the D2 receptor blockade side effects
- Restlessness
- Parkinsonism: tremors, rigidity, bradykinesia
- Menstrual irregularities in women
- Gynaecomastia
- Sexual dysfunction
27
What are the H1 receptor blockade side effects?
Sedation
28
What are the adrenergic receptor blockade side effects?
Orthostatic hypotension: drop in BP from standing
29
What are the cholinergic receptor blockade side effects?
Anticholinergic effects
- Dry mouth
- Constipation
- Blurred vision
- Urinary retention
30
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
31
What are the serotonin (5-HT2A) receptor blockade side effects?
- Reduced risk of EPS
32
What are the other misc. side effects with atypicals?
- Mild H1 receptor blockade symptoms
- Mild adrenergic receptor symptoms
- Mild anticholinergic symptoms
33
What are the metabolic side effects of atypicals?
1. Weight gain
2. Dyslipidemia and glucose metabolism
3. Prolactin elevation
4. Seizures
5. QT prolongation
6. Increased risk of VTE in elderly
34
What monitoring should be undertaken when administering atypicals to a patient?
1. Measure weight at start of therapy then weekly until week 6
- Then at week 12
- Then at year 1
- Then yearly
2. Measure prolactin conc
3. HbA1c
4. ECG
5. BP
35
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
36
What are the important monitoring factors for clozapine?
1. weekly FBC (for wbc check) for first 18w
2. Blood lipids and weight every 3m
3. Blood glucose after 1m
37
What is Neuroleptic Malignant Syndrome?
- Rare
- Life threatening
- Idiosyncratic reaction to antipsychotic medications
38
State the clinical features of NMS
1. Hyperthermia
2. Altered mental state - fluctuating levels of consciousness
3. Autonomic dysregulation - flux in BP, tachycardia and diaphoresis (excessive sweating)
4. Rigidity
39
Ddx for NMS
- Serotonin syndrome: same presentation but with serotoninergic medication
40
Ix for NMS
- FBC
- CK
- Renal function
- LFTs
41
Management of NMS
1. Discontinuation + supportive care
2. Benzodiazepines: manage agitation + rigidity
3. Dantrolene: muscle relaxant for severe cases
42
State side effects of Lithium
LITHIuM pneumonic
- Leucocytosis
- Insipidus
- Tremor (fine)
- Hypothyroid
- Increased weight
- u
- Metallic taste
43
State the indications for lithium
1. Bipolar disorder and mania
2. Depression
3. Mood stabiliser for aggressive/ self harming behaviour
44
State the clinical features of lithium toxicity
- Coarse tremor
- Seizures
- Cardiac arrhythmias
- Visual disturbances
45
State the Ddx of lithium toxicity
1. Neuro conditions: Parkinson’s
2. Cardiac conditions
3. Substance intoxication or withdrawal: alcohol or benzos
46
State the Ix for lithium toxicity
1. Serum lithium levels
2. Electrolytes
3. TFTs
4. Renal function test
5. ECG
47
State clinical features of Alzheimer’s
1. Memory impairment
2. Language impairment
3. Executive dysfunction: impaired ability to plan, organise and carry out tasks
4. Behavioural changes
5. Psych symptoms
6. Disorientation
7. Loss of motor skills
48
State Ddx of Alzheimer’s
1. Vascular dementia
- Sudden onset with history of cerebrovascular events
2. Lewy body dementia
- visual hallucinations and fluctuating cognitive impairment
49
State Ix of Alzheimer’s
1. History (cognitive screen)
2. Examination (full Neuro exam)
3. Blood tests (rule out reversible causes)
50
State the management of Alzheimer’s
1. Cognitive stimulation therapy
2. Cholineesterase inhibitors: Donepezil
3. NMDA receptor antagonists: Memantine
51
State the 5 types of anxiety disorders
1. Generalised Anxiety Disorder (GAD)
2. Specific phobias
3. Panic disorder
4. OCD
5. PTSD
52
State the clinical features of anxiety
1. Psychological: fears and worries
2. Motor symptoms: Restlessness
3. Neuromuscular: Tremor
4. GI: Dry mouth
5. Cardio: palpitations
6. GU: ED, amenorrhea
53
Management of GAD
1. SSRIs
2. CBT
3. Counselling
54
Define anorexia nervosa
- Extreme dietary restriction
- Intense fear of gaining weight
- Distorted body image
55
State clinical features of anorexia nervosa
1. History
- starvation via restricting intake, purging or excessive exercise
2. Examination
- BMI <17.5
- Hypotension
- Bradycardia
- Lanugo hair
- Amenorrhoea
56
State Ix for anorexia nervosa
Bloods
- deranged electrolytes
- Low sex hormone (FSH,LH, oestrogen, testosterone)
- Leukopenia
- Raised cortisol
- Hypercholesterolaemia
57
Management of Anorexia nervosa
1. CBT-ED
2. SSRIS
58
State possible complications of anorexia nervosa
1. Refeeding syndrome
2. Cardiac arrhythmias
3. Osteoporosis
59
State Sx of refeeding syndrome
1. Oedema
2. Confusion
3. Tachycardia
60
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
61
Describe preventative measures for refeeding syndrome
1. High dose vitamins before feeding commences
2. Replenish electrolytes early + daily bloods
3. Refeeding starts at no more than 50% of calorie requirement in Pt with little to no feed for >5d
62
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
63
What is hypomanic state and how do you differentiate it from a manic episode?
1. Mania: severe functional impairment with psychotic symptoms for at least 7d
2. Increased/decreased function without psychotic symptoms for at least 4d
64
State Ix of BPAD
- Rule our organic causes from substances
- Rule out delirium from secondary causes such as: infection, thyroid, B12
65
State management of BPAD
1. Hypomania -> routine CMHT
2. Mania/severe depression -> urgent CMHT
3. New diagnosis
- If SSRI recently started -> stop/taper
- Mania + agitation -> benzodiazepine
- Mania - agitation -> oral antipsychotic monotherapy (haloperidol). + lithium if unsuccessful
- Acute depression -> mood stabiliser
4. Chronic
- 4w after resolution of acute episode
- Maintenance therapy with mood stabiliser (Li 1st line)
65
Define bulimia
1. Eating disorder
2. Recurrent binge eating with loss of control
3. Followed by compensatory behaviours (vomiting, etc)
4. Maintain normal/slightly above average BMI
65
Clinical presentation of bulimia
1. Binge eating
2. Purging
3. Dental erosion (from vomiting)
4. Parotid gland swelling
5. Russell's sign: scarring on hand from vomiting
6. Amenorrhea
65
Ix for bulimia
Comprehensive history and examination
66
Management of bulimia
Bulimia focused guided self-help
67
Define delirium
1. Acute and fluctuating disturbance in attention and cognition
2. +/- change in consciousness
3. Reversible
68
State the 3 types of delirium
1. Hyperactive
- Increased psychomotor activity
- Restlessness
- Agitation
- Hallucinations
2. Hypoactive
- Lethargy
- Reduced responsiveness
- Withdrawal
3. Mixed
- Mixture of hyperactive and hypoactive
69
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
70
Sx of delirium
1. Disorientation
2. Hallucinations
3. Inattention
4. Memory problems
5. Change in mood or personality (sundowning: worsening as EoD approaches)
6. Disturbed sleep
71
Ddx for delirium
1. Dementia (gradual onset)
2. Psychosis (preserved orientation and memory)
3. Depression (stable consciousness level)
4. Stroke (abrupt onset + neuro signs)
72
Ix for delirium
1. 4AT and CAM (tools)
2. Bedside
- Bladder scan
- ECG
3. Bloods
- FBC
- U+E
- LFTs
- TFTs
- Blood cultures
4. Imaging
- CXR
73
Management of delirium
1. Treat underlying cause
2. Comfortable environment for pt
3. Haloperidol if severely agitated
74
Define delirium tremens (DT)
1. Alcohol withdrawal
2. 72h after alcohol cessation
3. Immediate medical attention
75
Sx of DT
1. Confusion + disorientation
2. Hallucinations (visual or tactile; sensation of crawling insects under skin)
3. Autonomic hyperactivity
4. Seizures
76
Management for DT
1. Lorazepam (1st line)
2. Maintenance
- Chlordiazepoxide
- Hydration
- Anti-emetics
- Pabrinex (vitamins)
77
Define delusions
1. Fixed false beliefs
2. Maintained despite contradictory evidence
3. Bizarre (very strange or highly unusual) or non-bizarre (plausible but incorrect)
78
Sx of delusions
1. Nihilistic delusions
2. Grandiose delusions
3. Delusion of control (external entity controlling thoughts/action)
4. Persecutory delusions (being conspired against)
5. Somatic delusion (convinced they have physical, medical or biological problem despite no medical evidence)
6. Delusional perceptions (arise from real perception leading to delusion)
7. Delusions of reference (mundane things meaning something special and directed at pt)
79
Management of delusions
1. Pharmacological
- antipsychotics
2. Psychotherapy
- CBT
80
Define dementia
1. Chronic syndrome
2. Impairment of multiple higher cortical functions
3. MMSE of 24/30 or less = dementia
81
Sx of dementia
1. Gradual, progressive, impairment of higher cortical function
2. Memory loss
3. Difficulty with familiar tasks
4. language problems
5. Disorientation
6. Poor judgement
82
State the 4 common types of dementia
1. Alzheimer’s
2. Vascular
3. Lewy body
4. Fronto-temporal
83
Define alzheimer's
1. Most common cause
2. Neuropathological features: amyloid plaques and tau proteins
84
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)
85
Management of Alzheimer's
1. Cholinesterase inhibitors
- Galantamine
2. NMDA inhibitor (severe)
- Memantine
86
Summarise vascular dementia
1. 2nd most common cause
2. Impaired blood flow to brain
3. Step-wise progression (due to progressive infarcts)
4. Clinical Dx
5. Tx = manage underlying vascular condition
87
Summarise lewy body dementia
1. 3rd most common
2. Abnormal protein deposits (lewy bodies) -> cognitive decline
3. Sx
- Parkinsonism (rigidity, tremor, bradykinesia)
- Visual hallucinations (small creatures/children/figures; lilliputian bodies)
88
State management difficulties with lewy body dementia
1. Neuroleptics
- Manage agitation/hallucination but trigger rigidity and parkinsonism
2. Dopaminergic agents
- Manage rigidity but worsen hallucinations
89
Sx of fronto-temporal dementia
1. Cognitive impairment
2. Personality change
3. Repetitive checking behaviour
4. Disinhibition
5. Construction apraxia (failure to draw interlocking pentagons)
6. Memory loss = LATE FEATURE
7. Presents at young age)
90
What are the 3 main variants in fronto-temporal dementia
1. Behavioural variant (60%)
- Loss of social skills
- Disinhibition
2. Semantic dementia (20%)
- Inability to remember words for things
3. Progressive non fluent aphasia (20%)
- Unable to verbalise
91
Define depression
1. 5/9 Sx for at least 2w
- Low mood
- Anhedonia (unable pleasure)
- Weight change
- Sleep and activity changes
- Fatigue
- Guilt
- Poor concentration
- Suicidality
92
Ix for depression
1. FBC
2. TFTs
3. U+E
4 LFT
5. Glucose
6. B12
7. Tox screen
93
Management of depression
1. Mild to moderate
- CBT
2. Moderate to severe
- SSRI
3. Severe
- ECT
94
Define Wernicke's encephalopathy
1. Thiamine (B1) deficiency
2. Commonly from chronic alcohol abuse
95
Sx of Wernicke's encephalopathy
Classic triad of:
- Confusion
- Ataxia
- Opthalmoplegia/nystagmus (paralysis of eye muscle)
96
Sx of Korsakoff's syndrome
1. Profound anterograde amnesia (creating new memories)
2. Limited retrograde amnesia (recall memories before injury)
3. Confabulation (fabricate memories to mask lack of)
97
State Ddx for Wernicke's encephalopathy
1. Alcohol withdrawal syndrome (includes tremors, agitation, nausea)
2. Hepatic encephalopathy (changes in consciousness, asterixis)
3. Stroke
4. Cerebellar disorders (lacks confusion or opthalmoplegia)
98
Ix for Wernicke's encephalopathy
1. Thiamine level
2. Full bloods
3. MRI (mamillary body atrophy in Korsakoff's syndrome)
99
Management of Wernicke's encephalopathy
1. Thiamine supplementation
2. Address underlying condition
100
Management of Korsakoff's syndrome
1. Ongoing thiamine supplementation
2. Cognitive rehab
3. Treat underlying causes
101
Define OCD
1. Recurrent obsessional thoughts or compulsive acts
2. Cause significant functional impairment
3. Time consuming
102
Management of OCD
1. Mild
- CBT
2. Moderate
- CBT
- SSRI
3. Severe
- CBT AND SSRI
103
State the different types of PCM OD
1. Acute
- Excessive amounts in <1h
2. Staggered
- Excessive amount over >1h
3. Therapeutic
- Excess with intent to treat pain or fever (no self harm intent)
104
Sx of PCM OD
1. N+V
2. Loin pain
3. Haematuria & proteinuria
4. Jaundice
5. Abdo pain
105
Ix for PCM OD
1. Usual bloods
2. Clotting screen
3. VBG
4. NOMOGRAM (plots pcm levels)
106
Management of PCM OD
1. <1h + dose >150mg/kg
- Activated charcoal
2. <4h
- Wait until 4h to take level and treat with N-acetylcysteine
3. 4-24h + dose >150mg/kg
- N-acetylcysteine immediately
107
What is the criteria for immediate liver transfer with PCM OD
1. Arterial pH <7.3
or ALL of:
1. Serum creatinine > 3.4mg/dL
2. Prothrombin time > 100s
3. Grade III or IV encephalopathy
108
Define postpartum depression
1. Depressive disorder
2. Develop up to one year following childbirth
3. Interferes with daily functioning
109
Sx of postpartum depression
1. Low mood
2. Low energy
3. Biological symptoms of depression
- poor appetite
- Disturbed sleep pattern
4. Concerns about baby bonding
110
Ix of postpartum depression
1. Edinburgh Postnatal Depression Scale (EPDS)
- Screening tool
111
Management of postpartum depression
1. Self help + CBT
2. Paroextine and sertraline (best with breastfeeding)
112
Define postpartum psychosis
1. Psychiatric disorder
2. First 2w after childbirth
113
Sx of postpartum psychosis
1. Paranoia
2. Delusions
- Capgras delusions: misidentification syndrome where belief close person replaced by imposter
3. Hallucinations
4. Manic episodes
5. Depressive episodes
6. Confusion
114
Management of postpartum psychosis
1. Olanzapine & quetiapine (safe with breastfeeding)
2. Li
115
Define schizophrenia
1. Chronic or relapsing/remitting form of psychosis
2. +ve Sx
- hallucinations
- delusions
- thought disorders
3. -ve Sx
- Alogia (decreased speech)
- Anhedonia (decreased joy)
- Avolition (decreased motivation)
116
State the subtypes of psychosis
1. Paranoid
- delusions
- hallucinations
- persecutory theme
2. Catatonic
- motor disturbance
- Waxy flexibility
3. Hebephrenic
- disorganised thinking, emotion and behaviour
4. Residual
- residual Sx post major episode
5. Simple
- Gradual decline in functioning without prominent +ve Sx
117
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
118
Ix for schizophrenia
1. Clinical diagnosis
2. Excluding Ddx tests
- Brain imaging
- Bloods to exclude infectious or metabolic causes
- Drug screen
119
Management of schizophrenia
1. Acute episode
- Lorazepam (sedative)
- Haloperidol (manage dangerous behaviour)
2. Atypicals
- Risperidone
3. Resistant schizophrenia
- Clozapine
4. CBT
120
Sx of opiate intoxication
1. Drowsiness
2. Confusion
3. Decreased RR and HR
4. Constricted pupils
121
Sx of opiate withdrawal
1. Agitation
2. Anxiety + irritability
3. Muscle aches
4. Chills
5. Runny nose
6. Sweating
122
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
123
State the 5 key principles of the MCA
1. Capacity unless proven otherwise
2. Steps must be taken to help a person have capacity
3. An unwise decision does not mean a person lacks capacity
4. Any decision under MCA must be under patient's best interests
5. Decisions must be least restrictive to person's rights and freedoms
124
How is capacity assessed?
1. Is there an impairment of or disturbance in the functioning of mind or brain?
2. If yes:
- Understand relevant info
- Retain relevant info
- Weigh up relevant info
- Communicate a decision
125
Summarise DoLS
1. Deprivation of pt liberty due to lack of capacity
2. Common in acute/geris
126
State the conditions that must be met for DoLS to be applied
1. >18
2. Mental disorder
3. Patient in hospital or care home
4. Lack capacity
5. Proposed restrictions would deprive liberty
6. Proposed restrictions in best interest
7. Consider MHA
8. No valid advance decision to refuse treatment or support that would contradict DoLS
127
State the criteria for the MHA
1. Must have mental disorder
2. Risk to self or others
3. Must be a treatment (including nursing care)
4. Applies only to mental health disorders
- Does not cover physical illness except anorexia for refeeding
128
Describe the MHA assessment
1. requires to 2 doctors ( at least 1 section 12(2) approved) + 1 approved AMHP
129
Summarise Section 2
1. Allows admission for mental health assessment and treatment
2. 28 days
3. Non-renewable
130
Summarise Section 3
1. Admission for treatment for upto 6m
2. Renewable
131
Summarise Section 4
1. For emergencies when Section 2 would cause delay
2. Recommendation of single doctor or AMHP or nearest relative
3. 72h followed by Section 2
132
Summarise Section 5(2)
1. Holding power for voluntary patient
2. 72h
133
Summarise Section 5(4)
1. Same as Section 5(2) but by nurses
2. 6h
134
Summarise Section 17a
Supervised community treatment (Community Treatment Order CTO)
135
Summarise Section 135
Enables police to enter a property to escort a person to safety
136
Summarise Section 136
Provides police authority to take mental disorder individual from public place to place of safety
