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AKT > Psychiatry > Flashcards

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 < 25 or concerns re suicide risk
otherwise at 2 weeks post-starting

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

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

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.

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)

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!!

AKT (10 decks)

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