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Psychiatry Flashcards

1
Q

Which SSRI has the shortest half life and thus is associated with the severest discontinuation symptoms if you suddenly stop it?

A

Paroxetine

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2
Q

Which SSRI has the longest half life?

A

Fluoxetine

This means that discontinuation / withdrawal side effects are the least however it means that you need to taper down the dose and then leave a 4-7 day gap with no SSRI before switching to a different SSRI

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3
Q

How should you tackle switching between different SSRIs?

A

Switching from Citalopram, Escitalopram, Sertraline and Paroxetine -> can switch directly to the equivalent dose

Switching from fluoxetine (because it has such a long half life) - need to gradually reduce the dose, then leave 4-7 day pill free gap then start at a low dose of the new SSRI

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4
Q

What is a section 2 of the Mental Health Act

A

Applied for by an approved mental health practitioner (or rarely a relative) on the recommendation of 2x doctors, at least 1x of whom is ‘approved’ under section 2 ie normally a consultant psychiatrist

Enables admission against will for upto 28 days and treatment can be given under a section 2 against a patient’s wishes

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5
Q

What is a section 3 of the Mental Health Act?

A

Requires an AMHP + 2x doctors

Grants forced admission and treatment for upto 6 months, can then be renewed.

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6
Q

What is a section 4 of the Mental Health Act?

A

Requires a GP/doctor + an AMHP or nearest relative

An emergency assessment order you can use in the community when trying to get a patient into hospital. Gives you upto 72 hours to get the patient assessed.

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7
Q

What is a section 5.2 of the Mental Health Act?

A

Allows a doctor to detain a patient that is in hospital voluntarily but trying to leave for upto 72 hours

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8
Q

What is a section 5.4 of the Mental Health Act?

A

Allows a nurse to detain a voluntary inpatient for upto 6 hours

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9
Q

Which features are associated with a poor prognosis in schizophrenia?

A

Gradual onset and lack of obvious precipitant
Strong family history
Premorbid history of social withdrawal
Low IQ

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10
Q

Explain the PHQ-9 Questionaire

A

Screening tool for depression in the community

Max score is 27 (9 items which can then be scored 0-3)
Asks patients to assess their symptoms over the past 2 WEEKS (includes items asking about thoughts of self-harm)

Score < 5 no or minimal depression
5-15 - less severe depression
16+ more severe depression

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11
Q

What are the DSM-5 Criteria for Major Depressive Disorder?

A

Must meet 5x of the below criteria across the past 2 WEEKS most of the day nearly everyday , at least 1x of which must be either depressed mood or anhedonia/loss of pleasure

1) Depressed mood most of the day or nearly everyday
2) Loss of interest or pleasure in almost all activities of the day, nearly everyday
3) Significant increase or decrease in weight or appetite
4) Insomnia or hypersomnia
5) Psychomotor agitation or retardation
6) Fatigue, loss of energy
7) Feelings of worthlessness or excessive guilt
8) Diminuished concentration or decisiveness
9) Recurrent thoughts of death or suicidal ideation

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12
Q

What is the biochemical pathology behind schizophrenia?

A

Overproduction of dopamine in the midbrain - affecting both mesocortical and mesostriatal dopamine pathways.

Also dysregulation of acetychloline and glutamate

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13
Q

What are the DSM-5 diagnostic criteria for Schizophrenia?

A

A) 2 or more of the following criteria (at least one of 1,2 or 3 must be present) present for a significant amount of time during a 1 month period
1. Delusions
2. Hallucinations (usually auditory)
3. Disorganised speech
4. Grossly disorganised or catatonic behaviour
5. Negative symptoms (e.g avolition (lack of motivation), reduced emotional expression)

B) Impaired functioning
C) Duration of at least 6 months
D) Other disorders (e.g bipolar, schizo-affective) excluded
E) Other medical conditions / substance use excluded
F) Consider the impact of ASD (ASP patients 3x more likely to get schizophrenia)

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14
Q

What is the lifetime prevalence of schizophrenia in the background population?

A

0.5 - 1%

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15
Q

What are the 4 generations of antipsychotic medications?

A

The antipsychotics all have different receptor effects, but common feature is Dopamine 2 receptor (D2) ANTAGONISM

1st gen - Haloperidol, chlorpromazine
2nd gen - Olanzapine, Risperidone, Quetiapine
3rd gen - Aripiprazole, Brexpiprazole
Atypical - Clozapine (acts on D4 and M1 (muscarinic acetylcholine) receptors)

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16
Q

How long after starting an antidepressent in primary care should you review the patient?

A

After 1 week if aged 18-25 or concerns re suicide risk
otherwise at 2 weeks post-starting

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17
Q

What is the most common side effect of SSRIs?

A

GI symptoms

Note - ^ risk of GI bleeding with SSRIs, should be on PPI if taking an NSAID alongside

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18
Q

Common interactions with SSRIs that are important to know about?

A

NSAIDs - together with SSRIs ^ risk of GI bleeding, should avoid taking them together but if unavoidable then add in a PPI

Heparin / Warfarin - avoid SSRIs (^bleeding risk), consider Mirtazapine as an alternative

Triptans (for migraines) and MAO inihibtors - use alongside SSRIs increases the risk of serotonin syndrome

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19
Q

What are the 1st line treatment options for OCD and BDD (Body Dysmorphic Disorder) as per NICE guidelines?

A

If mild function impairment - 1st line is low intensity CBT (upto 10 hrs of therapist-> patient input) including ERP training (Exposure Response Prevention - a sub-type of CBT)

Moderate functional impairment - offer the choice of either an SSRI or more intensive CBT w/ ERP (both are comparably effective)

Severe functional impairment - give both an SSRI and more intensive CBT

For children and young people - guided-self help is first line followed by CBT w/ ERP involving family/careers if guided self help doesn’t work or if mod-severe functional impairment.

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20
Q

What scale is recommended by NICE for judging the severity of functional impairment in OCD?

A

The Y-BOCs scale (looks at the amount and type of obsessions and compulsions over the past week prior to the interview)

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21
Q

What is NICE guidance on recognising bipolar in primary care?

A

Ask patient’s presenting with depression symptoms about any previous episodes of hyperactivity / manic symptoms lasting 4 days or more. If present -> refer for specialist mental health assessment.

Refer the patient URGENTLY for a specialist mental health assessment if they have *mania *severe depression *Are a risk to themselves or others

You shouln’t use questionaires to screen for or diagnose bipolar in primary care!!

22
Q

How should bipolar disorder be managed in primary care?

A

Offer a choice of psychological intervention - inc CBT, interpersonal therapy or behavioural couples therapy.

Valproate should NOT be started in primary care
Lithium should NOT be started in primary care unless the patient has been on it before or it is under shared-care arrangements.

Pts with bipolar should have an annual physical health check inc weight/BMI, BP, metabolic status inc fasting glucose or HbA1C and cholesterol, LFTs. Pts on long term lithium need renal function, thyroid function and calcium level checking at least annually

If bipolar disorder is managed solely in primary care, re‑refer to secondary care if any one of the following applies:
* there is a poor or partial response to treatment
* the person’s functioning declines significantly
* poor treatment adherence
* the person develops intolerable or medically important side effects from medication
* comorbid alcohol or drug misuse is suspected
* the person is considering stopping any medication after a period of relatively stable mood
* a woman with bipolar disorder is pregnant or planning a pregnancy.

23
Q

How should you manage a patient presenting with mania / hypomania and is on an anti depressant?

A

Consider stopping the anti-depressant
Start one of the following anti-psychotics - Haloperidol, Risperidone, Olanzapine or Quetiapine

If initial anti-psychotic doesn’t work at max dose, then try another. If that doesn’t work then start Lithium. If lithium doesn’t work / is contraindicated then start Valproate.

24
Q

What is echolalia and in what condition can it be a feature?

A

Echolalia is the repeating of someone else’s words e.g the last word of a question they were asked

It can be seen in schizophrenia

25
Q

What are the 3 clusters of personality disorders ?

A

Cluster 1 - Odd / Eccentric:
Paranoid
Schizoid
Schizotypal

Cluster 2 - Dramatic / Emotional
Borderline / Emotionally Unstable
Histrionic
Narcissistic
Antisocial

Cluster 3 - Anxious & Fearful
Obsessive Compulsive
Avoidant
Dependant

26
Q

What are the features of paranoid personality disorder?

A

Hypersensitive, very unforgiving when insulted, unwarranted perceival of attacks on their character
Paroid and question loyalty of friends

27
Q

What are the features of schizoid personality disorder?

A

Very isolated, not interested in companionship or sexual relationships, emotionally cold, some crossover with autistic traits

28
Q

What are the features of schizotypal personality disorder?

A

Odd, eccentric behaviour with beliefs in odd concepts and magical thinking , characterised by ideas of reference (different from delusions in that some insight is retained), inappropriate affect, odd speech, not a lot of social contacts other than immediate family

29
Q

What are the rules on driving / informing the DVLA for bipolar patients who present with manic symptoms?

A

They must inform the DVLA and stop driving for at least 3 months if stable disease or at least 6 months if unstable disease (4 or more significant mood swings in the past 12 months)

30
Q

What are the 2 types of bipolar disorder?

A

Type I - (most common) - mania and depression
Type 2 - hypomania and depression

31
Q

What is the difference between mania and hypomania

A

Both involve abnormally elevated mood or irritability

Mania = presence of severe functional impairment or psychotic symptoms (delusions of grandeur or auditory hallucinations) for 7 days or more

Hypomania = decreased or increased function for 4 days or more

Note - if psychotic symptoms present then by definition is mania!!

32
Q

What parameter is important to monitor when starting or up-titrating Venlafaxine and other SNRIs?

A

Blood pressure
Venlafaxine and SNRIs can cause hypertension and so BP should be monitored before starting and uptitrating

33
Q

What is the guidance for switching from fluoxetine to another antidepressent?

A

Have to be cautious as Fluoxetine has a long half life and so risk of toxicity. Normally have to stop the fluoxetine and wait 4-7 days washout period before starting the new medication.

Switching from fluoxetine to: Method
A TCA (except clomipramine) Stop fluoxetine, start TCA at a low dose 4–7 days later and increase dose very slowly
SSRIs: citalopram, escitalopram, sertraline, or paroxetine Stop fluoxetine, start SSRI at a low dose 4–7 days later
SNRIs: duloxetine, venlafaxine Stop fluoxetine, start SNRI at a low dose 4–7 days later
Mirtazapine Cross-taper cautiously
Reboxetine Cross-taper cautiously
Trazodone Cross-taper cautiously

34
Q

What are the major adverse effects of Clozapine?

A

Agranulocytosis (drop in granulocyte white cells leading to vulnerability to infection) - 1%
Neutropenia - 3%
Reduced seizure threshold
Constipation
Myocarditis - need to do an ECG before starting treatment
Hypersalivation

Stopping or starting smoking while on Clozapine can change Clozapine levels so may need dose titration

35
Q

What is the required monitoring requirements for patients on Lithium?

A

You need to check Lithium levels 1 week after first starting or after a dose change, and then weekly thereafter until concentrations are stable.

Lithium levels should be taken 12 hours after the last dose

Once lithium dose is stable, lithium levels should be checked every 3 months and renal & thyroid function should be checked every 6 months (Lithium is renally excreted)

36
Q

What are the main adverse effects associated with lithium to look out for?

A

Nephrogenic diabetes insipidus (kidneys don’t respond to ADH, leading to polyuria - lots of dilute urine) and hypernatraemia)
Hypothyroidism with enlarged thyroid
Fine tremor
Idiopathic intracranial hypertension
Hyperparathyroidism and subsequent hypercalcaemia

37
Q

How does the NICE 2022 guideline define ‘less severe’ and ‘more severe’ depression?

A

Less severe - PHQ-9 < 16 - choice discussed with the patient of guided self-help / low intensity psychological intervention +/- SSRI depending on preference.
More severe - PHQ-9 score of 16 or more - recommend medication and high intensity psychological intervention

38
Q

What is the required frequency of FBC testing when first starting a patient on Clozapine?

A

Weekly for 18 weeks, then fortnights for upto a year then monthly for the long term

39
Q

What is Othello syndrome as seen in psychiatry?

A

Othello’s syndrome is pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.

40
Q

What are the 4 groups of symptoms associated with PTSD?

A
  1. Emotional numbing - feeling detached from others, finding it hard to relate
  2. Intrusive thoughts in the form of re-experiencing / pseudohallucinations, nightmares, flashbacks
  3. Avoidance behaviours - avoiding places / people that remind of the traumatic event
  4. Hyerarousal / hypervigilance

Symptoms must be present for at least 1 month to meet criteria for PTSD

41
Q

True or false - triptans should not be co-prescribed with SSRIs?

A

TRUE
Triptans also have an effect on serotonin receptors and taken together with SSRIs increase the risk serotonin syndrome (hyperthermia, autonomic instability, mental confusion, hyperactivity)

42
Q

What is an acute stress disorder?

A

Acute stress disorder is a condition that may occur WITHIN A MONTH of a traumatic event - symptoms may last between 3 days - 1 month.
Once significant symptoms present for > 1 month then consider PTSD diagnosis.

Must have 9 or more symptoms from any of the 5 categories of symptoms (Dissociation, intrusive thoughts, avoidance symptoms, low mood, arousal symptoms)

43
Q

What does NICE guidelines on PTSD recommend for prevention of PTSD.

A

Psychologically-focused debriefing is NOT recommended for immediately after a traumatic event.

For those with an acute stress reaction or high risk of developing PTSD, active monitoring or individual trauma-focused CBT can be considered within the first month after the traumatic event. (for children, group trauma-focused CBT can be considered)

44
Q

What does the NICE PTSD guidelines recommended for treatment of PTSD for children < 18 yrs?

A

For children < 18 yrs:
Individual trauma-focused CBT is first line
EMDR can be considered second line if at least 3 months since the traumatic event and not responded to trauma-focused CBT

Drug therapy is NOT recommended for PTSD for those < 18

45
Q

What does the NICE PTSD guidelines recommended for treatment of PTSD for adults?

A

Either individual trauma-focused CBT or EMDR can be offered to adults with PTSD depending on their preference (EMDR has to have been at least 3 months since the trauma and shouldn’t be used for combat related PTSD)

1st line medication for PTSD in adults is either Venlafaxine or an SSRI

You should normally treat the PTSD first in patients presenting with significant depressive symptoms, UNLESS they are at high risk of harming themselves or will be unable to comply with treatment without treating depression first.

46
Q

What are the different types of extrapyramidal side effects associated with antipsychotics (especially the typical ones)?

A
  1. Tardive dyskinesias - involuntary, choreoathetoid movements, most commonly pouting of the lips and chewing - can be irreversible
  2. Akathisia - severe restlessness
  3. Acute dystonias - SUSTAINED muscle contractions e.g torticollis, oculogyric crisis - treat with PROCYCLIDINE
  4. Parkinsonism symptoms
47
Q

What are side effects experienced in SSRI discontinuation syndrome (ie if they stop their SSRI too quickly)?

A

GI side effects - D&V, abdo cramps
Irritability
Poor sleep
Paresthesias
Sweating

48
Q

What are the risks of SSRI use in pregnancy?

A

SSRI use in pregnancy - advice is to individually weigh the pros and cons for each pt

1st trimester- small increased risk of congenital heart defects

3rd trimester - risk of persistent pulmonary hypertension of the newborn

49
Q

When should lithium levels be taken?

A

12 hours post-dose

50
Q

What organisation should be informed (with the patient’s consent) when they are started on a methadone programme?

A

The National Drug Treatment Monitoring System

51
Q
A

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