Psychiatry Flashcards
state 3 risk factors for depression
Family history
Significant life event
Physical health conditions
What are the 2 core symptoms of depression?
Low mood
Anhedonia (a lack of pleasure or interest in activities)
What are some emotional symptoms of depression?
Anxiety
Irritability
Low self-esteem
Guilt
Hopelessness about the future
What are some cognitive symptoms of depression?
Poor concentration
Slow thoughts
Poor memory
What are some physical symptoms of depression?
Low energy (tired all the time)
Abnormal sleep (particularly early morning waking)
Poor appetite or overeating
Slow movements
What environmental factors can contribute to depression?
Potential triggers (e.g. stress, grief or relationship breakdown)
Home environment (e.g., housing situation, who they live with and their neighbourhood)
Relationships with family, friends, partners, colleagues and others
Work (e.g., work-related stress or unemployment)
Financial difficulties (e.g., poverty and debt)
Safeguarding issues (e.g., abuse)
Every patient with depression should be asked about what risks?
Self-neglect
Self-harm
Harm to others (including neglect)
Suicide
What are some essential factors to cover in a depression history?
Caring responsibilities (e.g., children or vulnerable adults)
Social support
Drug use
Alcohol use
Forensic history (e.g., violence or abuse)
What questionnaire can be used to assess the severity of depression? what do the scores mean?
PHQ-9 questionnaire
ask over the past 2 weeks
5-9 indicates mild depression
10-14 indicates moderate depression
15-19 indicates moderately severe depression
20-27 indicates severe depression
What are the management options for depression?
Active monitoring and self-help
Address lifestyle factors (exercise, diet, stress and alcohol)
Therapy (e.g., cognitive behavioural therapy, counselling or psychotherapy)
Antidepressants (selective serotonin reuptake inhibitors are first-line)
What are the additional specialist treatments for unresponsive or severe depression?
Antipsychotic medications (e.g., olanzapine or quetiapine)
Lithium
Electroconvulsive therapy
State 3 side effects of ECT
headache, muscle aches and short-term memory loss
What are the 3 key symptoms of psychosis?
Delusions
Hallucinations
Thought disorder
What scale can be used to asses postnatal depression?
Edinburgh postnatal depression scale
How long after birth does postnatal depression usually peak?
around three months after birth
How long after birth does puerperal psychosis usually present?
starting a few weeks after birth
What are the 3 main classes of antidepressants?
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Tricyclic antidepressants (TCAs)
What is the mechanism of action of SSRIs?
blocking the reuptake of serotonin by the presynaptic membrane on the axon terminal
What is the mechanism of action of SNRIs?
blocking the reuptake of serotonin and noradrenaline by the presynaptic membrane
Name 4 examples of SSRIs
sertraline, citalopram, escitalopram, fluoxetine, paroxetine
What SSRI is considered safest in heart disease?
Sertraline
What is the key side effect of Citalopram?
can prolong the QT interval
what is the usual first line antidepressant in children and adolescents?
Fluoxetine
What are the key side effects of SSRIs?
Gastrointestinal symptoms (e.g., nausea and diarrhoea)
Headaches
Sexual dysfunction, such as loss of libido, erectile dysfunction and difficulty achieving an organism
Hyponatraemia (due to SIADH)
Anxiety or agitation, typically in the first few weeks of use
Increased suicidal thoughts, suicide risk and self-harm (this applies to all antidepressants)
Increased risk of bleeding (e.g., gastrointestinal bleeding, intracranial haemorrhage and postpartum haemorrhage)
Name 2 examples of SNRIs?
Duloxetine
Venlafaxine
what condition are SNRIs contraindicated in?
uncontrolled hypertension
What is duloxetine used to treat?
neuropathic pain, particularly diabetic neuropathy
what are the key issues with venlafaxine?
more likely to cause discontinuation symptoms when stopped
It has an increased risk of death from overdose
What are the side effects of TCA ?
arrhythmias, including tachycardia, prolonged QT interval and bundle branch block
very dangerous in overdose, with a high risk of death
anticholinergic side effects, such as dry mouth, constipation, urinary retention, blurred vision and cognitive impairment
What are the key side effects of Mirtazapine?
sedation, increased appetite and weight gain
When should you arrange a follow up when starting antidepressants?
review within two weeks of starting an antidepressant (one week in patients aged 18-25 due to the increased risk of suicide)
By what time period is there usually a noticeable response to treatment with antidepressants?
within 2-4 weeks of treatment
When do you need to cross-taper antidepressants?
Fluoxetine due to long half life
Others need to be cross-tapered over several weeks (e.g., switching between an SSRI and mirtazapine), gradually reducing the dose of the existing drug while increasing the dose of the new one.
how long should antidepressants be continued for once started?
continued for at least six months before stopping (or two years in recurrent depression)
What are discontinuation symptoms of antidepressants?
typically start within 2-3 days of stopping treatment and resolve within 1-2 weeks. Possible symptoms include:
Flu-like symptoms
Electric shock-like sensations
Irritability
Insomnia
Vivid dreams
What are the 3 categories of symptoms in serotonin syndrome?
Altered mental state (e.g., anxiety and agitation)
Autonomic nervous system hyperactivity (e.g., tachycardia, hypertension and hyperthermia)
Neuromuscular hyperactivity (e.g., hyperreflexia, tremor and rigidity)
What symptoms can severe serotonin syndrome cause?
confusion, seizures, severe hyperthermia (over 40°C) and respiratory failure
What is the management of serotonin syndrome?
supportive care (e.g., sedation with benzodiazepines) and withdrawal of the causative medications
What is the definition of self-harm?
intentional self-injury without suicidal intent
What groups of people are more at risk of suicide?
three times more common in men and most common around the age of 50 years. It also increases in older age.
What are the steps in the cycle of self-harm ?
Emotional suffering
Emotional overload
Panic
Self-harming
Temporary relief
Shame and guilt
what are some presenting features that increase the risk of suicide?
Previous suicidal attempts
Escalating self-harm
Impulsiveness
Hopelessness
Feelings of being a burden
Making plans
Writing a suicide note
What background factors may increase the risk of suicide?
Mental health conditions
Physical health conditions
History of abuse or trauma
Family history of suicide
Financial difficulties or unemployment
Criminal problems (prisoners have a high rate of suicide)
Lack of social support (e.g., living alone)
Alcohol and drug use
Access to means (e.g., firearms)
What are some protective factors that may help reduce the risk of suicide?
Social support and community
Sense of responsibility to others (e.g., children or family)
Resilience, coping and problem-solving skills
Access to mental health support
when can activated charcoal be given?
may be given within one hour of overdose of various substances to reduce the absorption
what is the treatment for opioid overdose?
Naloxone
What is the treatment of benzodiazepine overdose?
Flumazenil
What is the treatment for overdose with beta blockers?
Glucagon for heart failure or cardiogenic shock
Atropine for symptomatic bradycardia
What is the treatment of overdose of calcium channel blockers?
Calcium chloride or calcium gluconate
What is the treatment for cocaine overdose?
Diazepam
What is the management of carbon monoxide toxicity?
100% oxygen
What are the features of mania?
Abnormally elevated mood
Significant irritability
Increased energy
Decreased sleep
Grandiosity, ambitious plans, excessive spending and risk-taking behaviours
Disinhibition and sexually inappropriate behaviour
Flight of ideas
Pressured speech
Psychosis
what is diagnosis of bipolar disorder based on?
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
What does bipolar I disorder involve?
at least one episode of mania
What does bipolar II disorder involve?
at least one episode of major depression and at least one episode of hypomania
What is Cyclothymia?
milder symptoms of hypomania and low mood. The symptoms are not severe enough to significantly impair their function
What are the treatment options for an acute manic episode?
Antipsychotic medications (e.g., olanzapine, quetiapine, risperidone or haloperidol) are first-line
Other options are lithium and sodium valproate
Existing antidepressants are tapered and stopped
What are the treatment options for an acute depressive episode in bipolar disorder?
Olanzapine plus fluoxetine
Antipsychotic medications (e.g., olanzapine or quetiapine)
Lamotrigine
What is used for the long-term management of bipolar disorder?
Lithium
other: sodium valproate, olanzapine
When should serum lithium levels be taken?
12 hours after the most recent dose
What is the initial target range for lithium?
0.6–0.8 mmol/L
what are some potential adverse effects of lithium?
Fine tremor
Weight gain
Chronic kidney disease
Hypothyroidism and goitre
Hyperparathyroidism and hypercalcaemia
Nephrogenic diabetes insipidus
How long do symptoms need to be persistent for in generalised anxiety disorder?
occurring most days for at least six months, and not caused by substance use or another condition
State 3 secondary causes of anxiety
Substance use (e.g., caffeine, stimulants, bronchodilators and cocaine)
Substance withdrawal (e.g., alcohol or benzodiazepine withdrawal)
Hyperthyroidism
Phaeochromocytoma
Cushing’s disease
What are some emotional and cognitive symptoms of generalised anxiety disorder?
Excessive worrying
Unable to control the worrying
Restlessness
Difficulty relaxing
Easily tired
Difficulty concentrating
What are some physical symptoms of generalised anxiety disorder?
Muscle tension
Palpitations
Sweating
Tremor
Gastrointestinal symptoms (e.g., abdominal pain and diarrhoea)
Headaches
Sleep disturbance
What are some physical symptoms of a panic attack?
tension, palpitations, tremors, sweating, dry mouth, chest pain, shortness of breath, dizziness and nausea
What are some emotional symptoms of a panic attack?
feelings of panic, fear, danger, depersonalisation (feeling separated or detached) and loss of control
What questionnaire can help assess the severity of generalised anxiety disorder?
Generalised Anxiety Disorder Questionnaire (GAD-7)
5-9 indicates mild anxiety
10-14 indicates moderate anxiety
15-21 indicates severe anxiety
How can mild anxiety be managed?
active monitoring and advice about self-help strategies (e.g., meditation), sleep, diet, exercise and avoiding alcohol, caffeine and drugs
What are the management options for moderate to severe anxiety?
CBT
SSRIs (sertraline)
propranolol (physical symptoms)
Benzodiazepines
others: SNRIs, pregabalin
what are the key symptoms of PTSD?
Intrusive thoughts relating to the event
Re-experiencing (experiencing flashbacks, images, sensations and nightmares of the event)
Hyperarousal (feeling on edge, irritable and easily startled)
Avoidance of triggers that remind them of the event
Negative emotions
Negative beliefs (e.g., the world is dangerous)
Difficulty with sleep
Depersonalisation (feeling separated or detached)
Derealisation (feeling the world around them is not real)
Emotional numbing (unable to experience feelings)
What can be used to screen for PTSD?
Trauma Screening Questionnaire (TSQ)
What are the management options for PTSD?
Psychological therapy (e.g., trauma-focused CBT)
Eye movement desensitisation and reprocessing (EMDR)
Medication (e.g., SSRIs, venlafaxine or antipsychotics)
What is an obsession?
unwanted and uncontrolled thoughts and intrusive images that the person finds very difficult to ignore
What are compulsions?
repetitive actions the person feels they must do, generating anxiety if they are not done
What are the stages in the cycle of OCD?
Obsessions
Anxiety
Compulsion
Temporary relief
What criteria is a diagnosis of OCD base on?
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
International Classification of Diseases (ICD-11)
What can be used to assess the severity of OCD?
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
What are the management options for OCD?
Cognitive behavioural therapy (CBT) with exposure and response prevention (ERP)
SSRIs
Clomipramine (a tricyclic antidepressant)
What are some symptoms of someone with borderline personality disorder?
Strong and intense emotions
Emotional instability
Difficulty managing emotions
Difficulty maintaining relationships
Poor sense of identity
Feelings of emptiness
Fear of abandonment
Impulsive and risky behaviour
Recurrent self-harm
Recurrent suicidal behaviours
What are the cluster A personality disorders?
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
What is Schizoid personality disorder?
a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them.
What are the cluster B personality disorders?
Antisocial
Borderline
Histrionic
Narcissistic
What is histrionic personality disorder?
involves the need to be the centre of attention and performing for others to maintain that attention
What are the cluster C personality disorders?
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
What is obsessive-compulsive personality disorder?
unrealistic expectations of how things should be done by themselves and others and catastrophising about what will happen if these expectations are not met
What are the management options for personality disorders?
Risk management
CBT, DBT
sedative medications may be used short term
What are the 3 types of dissociative disorder?
Depersonalisation-derealisation disorder
Dissociative amnesia
Dissociative identity disorder
What is catatonia?
abnormal movement, communication and behaviour. It can present in a variety of ways. Patients are awake but not behaving normally.
What are the 2 most common causes of catatonia?
severe depression
bipolar disorder
What is reactive attachment disorder?
results from severe neglect and trauma in early childhood. It results in emotional withdrawal and inhibition, sadness, fearfulness, irritability and impaired cognition. They struggle to form close relationships or attachments and do not respond well to affection or discipline.
What is factitious disorder?
also known as Munchausen Syndrome, involves a conscious effort to fake illness and seek medical attention for personal gain
What is alien hand syndrome?
involves the patient losing control of one of their hands. The hand acts independently, with a mind of its own. It may perform spontaneous actions, such as touching body parts or grabbing objects. It is usually the result of an underlying brain lesion, such as brain tumours, injuries, aneurysms, or following brain surgery.
What is a Cotard delusion?
false belief (delusion) that they are dead or actively dying
What is Capgras syndrome?
false belief (delusion) that an identical duplicate has replaced someone close to them
What is De Clerambault’s syndrome?
false belief (delusion) that a famous or high-social-status individual is in love with the patient
What is Alice in Wonderland syndrome?
also known as Todd syndrome, involves incorrectly perceiving the sizes of body parts or objects
What is Koro syndrome?
alse belief (delusion) that the sex organs (particularly the penis) are retracting or shrinking and will ultimately disappear
What is body integrity dysphoria?
involves a strong feeling that part of the body, for example, one or both of the legs, does not belong to them
What is functional neurological disorder?
involves sensory and motor symptoms that are not explained by any neurological disease and may be caused by underlying psychosocial factors
How long must symptoms be present for schizophrenia to be diagnosed?
6 months
What is schizoaffective disorder?
combines the symptoms of schizophrenia with bipolar disorder. Patients have psychosis and symptoms of depression and mania
What is Schizophreniform disorder?
presents with the same features as schizophrenia but lasts less than six months
What are the 3 key features of psychosis?
Delusions (beliefs that are strongly held and clearly untrue)
Hallucinations (perceiving things that are not real)
Thought disorder (disorganised thoughts causing abnormal speech and behaviour)
What are the key positive symptoms of schizophrenia?
Auditory hallucinations
Somatic passivity
Thought insertion or withdrawal
Though broadcasting
Persecutory delusions
Ideas of reference
delusional perceptions
What are the 4 key negative symptoms of schizophrenia?
Affective flattening (minimal emotional reaction to emotive subjects or events)
Alogia (“poverty of speech” – reduced speech)
Anhedonia (lack of interest in activities)
Avolition (lack of motivation in working towards goals or completing tasks)
What are the management options for schizophrenia ?
Early intervention in psychosis
community mental health team
Antipsychotics
CBT
What is the mechanism of action of antipsychotics?
inhibiting dopamine receptors, specifically D2 receptors.
Name 2 typical antipsychotics
Chlorpromazine
Haloperidol
Name 3 atypical antipsychotics
Quetiapine
Aripiprazole
Olanzapine
Risperidone
What are the key complications of Clozapine?
Agranulocytosis, with a severely low neutrophil count (predisposing to severe infections)
Myocarditis or cardiomyopathy, which can be fatal
Constipation (rarely to the point of intestinal obstruction)
Seizures
Excessive salivation
What are the monitoring requirements before starting and during antipsychotic treatment?
Weight and waist circumference
Blood pressure and pulse rate
Bloods, including HbA1c, lipid profile and prolactin
ECG
What are some side effects of antipsychotic drugs?
Weight gain
Diabetes
Prolonged QT interval
Raised prolactin
Extrapyramidal symptoms
what are some extrapyramidal side effects of antipsychotics?
Akathisia (psychomotor restlessness, with an inability to stay still)
Dystonia (abnormal muscle tone, leading to abnormal postures)
Pseudo-parkinsonism (tremor and rigidity, similar to Parkinson’s disease)
Tardive dyskinesia (abnormal movements, particularly affecting the face)
What are they key features of neuroleptic malignant syndrome?
Muscle rigidity
Hyperthermia (raised body temperature)
Altered consciousness
Autonomic dysfunction (e.g., fluctuating blood pressure and tachycardia)
What are the blood test findings in neuroleptic malignant syndrome?
Raised creatine kinase
Raised white cell count (leukocytosis)
What is the management of neuroleptic malignant syndrome ?
Stopping causative medications
Supportive care
sever: bromocriptine or dantrolene
What are the aspects of a mental state examination?
Appearance and behaviour
Speech
Mood and affect
Thought
Perception
Cognition
Insight
Judgement
What should be included in a mental state examination risk assessment ?
self-harm, suicide and harm to others
What is Knight’s move thinking?
jumping from one thought to another without a logical association or flow
Who is required to apply and carry out a mental health act assessment?
The Approved Mental Health Professional (AMHP) is the primary person making the application and organising the admission. The Nearest Relative can also make the application.
The decision needs to be recommended by two registered medical practitioners (doctors):
A Section 12 doctor
Another doctor (e.g., their GP)
What is a section 2
compulsory admission for assessment following a Mental Health Act assessment, with a maximum period of 28 days
What is section 3
compulsory admission for treatment. The maximum period is six months, after which the Responsible Clinician can arrange to renew it for further treatment
What is a section 4
used to detain patients for up to 72 hours in urgent scenarios where other procedures cannot be arranged in time. It requires an AMHP and one doctor
What is a section 5(2)
used in an emergency to detain patients who are already in hospital voluntarily. It lasts up to 72 hours and requires only one doctor
what is a section 5(4)
used in an emergency to detain patients who are already in hospital voluntarily. It lasts up to 6 hours and requires only one nurse
What is a section 136
used by the police to remove someone that appears to have a mental health disorder from a public place and take them to a place of safety where they can be assessed. It lasts up to 24 hours.
How do you calculate alcohol units?
Volume (ml) x Alcohol Content (%) ÷ 1000 = Units of Alcohol
What is the recommended level of alcohol consumption?
Not more than 14 units per week
Spread evenly over 3 or more days
Not more than 5 units in a single day
How is binge drinking defined?
6 or more units for women
8 or more units for men
What are some complications of alcohol excess?
Alcohol-related liver disease
Cirrhosis and its complications
Alcohol dependence and withdrawal
Wernicke-Korsakoff syndrome (WKS)
Pancreatitis
Alcoholic cardiomyopathy
Alcoholic myopathy, with proximal muscle wasting and weakness
Increased risk of cardiovascular disease
Increased risk of cancer, particularly breast, mouth and throat cancer
name 2 questionnaires used to screen for harmful alcohol use
AUDIT
CAGE
What are the CAGE questions?
C – CUT DOWN? Do you ever think you should cut down?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Do you ever feel guilty about drinking?
E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?
What blood results can occur with alcohol excess?
Raised mean corpuscular volume (MCV)
Raised alanine transaminase (ALT) and aspartate transferase (AST)
AST:ALT ratio above 1.5 particularly suggests alcohol-related liver disease
Raised gamma-glutamyl transferase (gamma-GT)
What is the timeline of alcohol withdrawal symptoms?
6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: delirium tremens
What is the mortality rate of delirium tremens?
35%
What are the presenting features of delirium tremens ?
Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hypertension
Hyperthermia
Ataxia (difficulties with coordinated movements)
Arrhythmias
What tool can be used to score the patient on withdrawal symptoms?
CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised)
What is the management of alcohol withdrawal?
Chlordiazepoxide (Librium)
High-dose B vitamins (Pabrinex)
What medications are used for opioid dependence?
Methadone (binds to opioid receptors)
Buprenorphine (binds to opioid receptors)
Naltrexone (helps prevent relapse)
Autistic spectrum disorder included a range of impairments in what 3 areas?
social interaction, communication and behaviour
What are some deficits in social interaction in ASD?
Lack of eye contact
Delay in smiling
Avoiding physical contact
Unable to read non-verbal cues
Difficulty establishing friendships
Not displaying a desire to share attention (e.g., not playing with others)
What deficits in communication may be present in ASD?
Delay, absence or regression in language development
Lack of appropriate non-verbal communication (e.g., smiling, eye contact, responding to others and sharing interest)
Difficulty with imaginative or imitative behaviour
Repetitive use of words or phrases
What deficits in behaviour may be present in ASD?
Greater interest in objects, numbers or patterns than people
Stereotypical repetitive movements
Intense and deep interests that are persistent and rigid
Repetitive behaviour and fixed routines
Anxiety and distress with experiences outside their regular routine
Extremely restricted food preferences
What are some symptoms of ADHD?
Short attention span
Easily distracted
Quickly moving from one activity to another
Quickly losing interest in a task
Inability to persist with and complete tasks
Constantly moving or fidgeting
Impulsive behaviour
Disruptive behaviour
Difficulty managing time
What can be used as a screening test for ADHD?
Adult ADHD Self-Report Scale (ASRS)
What are some medications used to treat ADHD?
Methylphenidate
Lisdexamfetamine
Dexamfetamine
Atomoxetine
What are some features of anorexia nervosa?
Weight loss (e.g., 15% below expected or BMI less than 17.5)
Amenorrhoea
Lanugo hair
Hypotension
Hypothermia
Mood changes, including anxiety and depression
What are some features of bulimia nervosa?
Erosion of teeth
Swollen salivary glands
Mouth ulcers
Gastro-oesophageal reflux
Calluses on the knuckles where they have been scraped across the teeth (called Russell’s sign)
What are possible blood test findings in restrictive eating disorders?
Anaemia (low haemoglobin)
Leucopenia (low white cell count)
Thrombocytopenia (low platelets)
Hypokalaemia (low potassium – due to vomiting or excessive laxatives)
What are the overall effects of refeeding syndrome?
Hypomagnesaemia
Hypokalaemia
Hypophosphataemia
Fluid overload
What is the management of refeeding syndrome?
Slowly reintroducing food with limited calories
Magnesium, potassium, phosphate and glucose monitoring
Fluid balance monitoring
ECG monitoring in severe cases
Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine
What classifies dementia as early onset?
when the symptoms start before aged 65
What is the most common type of dementia?
Alzheimers dementia
what is the underlying pathophysiology of Alzheimers?
brain atrophy, amyloid plaques, reduced cholinergic activity and neuroinflammation
What is the second most common type of dementia?
Vascular dementia
What are some features of advanced dementia?
Inability to speak or understand speech (aphasia)
Swallowing difficulties (dysphagia), which can lead to aspiration and pneumonia
Appetite and weight loss
Incontinence
What are some memory screening tests for dementia?
Six Item Cognitive Impairment Test (6CIT)
10-point Cognitive Screener (10-CS)
Mini-Cog
General Practitioner Assessment of Cognition (GPCOG)
Montreal Cognition Assessment (MoCA)
What investigations are required to exclude a physical cause of memory loss?
Full blood count
Urea and electrolytes
Liver function tests
Inflammatory markers (e.g., CRP and ESR)
Thyroid profile
Calcium
HbA1c
B12 and folate
What 5 domains are tested in the Addenbrooke’s Cognitive Examination-III (ACE-III)
Attention
Memory
Language
Visuospatial function
Verbal fluency
What drug options are available for Alzheimer’s dementia?
Acetylcholinesterase inhibitors (e.g., donepezil, rivastigmine or galantamine)
Memantine, which works by blocking N-methyl-D-aspartic acid (NMDA) receptors
What are the behavioural and psychological symptoms of dementia
Depression
Anxiety
Agitation
Aggression
Disinhibition (e.g., sexually inappropriate behaviour)
Hallucinations
Delusions
Sleep disturbance
