Psychiatry Flashcards
Tell me abit about ADHD
aetiology
when do sx start?
persistent inattention and/or hyperactivity/impulsivity.
in kids - developmental delay.
for kids - 6 of features present
17 + - 5 features
twice common in boys than girls.
genetic
pregnancy related - maternal smoking, premature birth, low birth weight
environmental factors
sx start in childhood. consistent across settings.
Diagnostic Features of ADHD
inattention
hyperactivity/impulsivity
inattention:
- doesnt follow instructions
- easily distracted
-finds it difficult to sustain tasks
- finds it difficult to organise tasks/activities
- loses things necessary for tasks or activities
- doesnt seem to listen when spoken directly
Hyperactivity:
- talks too much
- cant play quietly
- on the go
- interruptive/intrusive
- answer prematurely
- run and climb in situations where not appropriate
- doesnt wait their turn
screening tool for adult adhd
adult adhd self-report scale (ASRS)
How would you manage ADHD? kids
ten week watch and wait for a child.
refer to CAMHS.
drug last resort. only 5+
mild/moderate sx: parents attend education and training programmes.
then
methylphenidate 1st line in kids. - 6 week trial. cns stimulant acting on dopamine/norepinephrine reuptake inhibitor.
if dont work : switch to lisdexamfetamine.
dexamfetamine if benefit from lisdex but cant tolerate side effects
side effect of methylphenidate adhd - kids and also rules for taking
6 week trial initially
abdo pain
nausea
dyspepsia
weight and height to be monitored every 6 months
how would you manage adult adhd?
positive approach, routine, clear boundaries, physical activity, healthy diet
methylphenidate or lisdexamfetamine - 1st line.
switch between drugs if no benefit.
adhd treatment drugs main issue and what to do because of this?
cardiotoxic
do baseline ecg. before tx.
refer to cardiology if any pmh or fhx.
What is depression?
Pathophysiology of it
disorder of persistent feelings of low mood low energy and reduced enjoyment of activities.
disturbance in neurotransmitter activity in cns, particularly serotonin (5-ht). tx are serotonin booster essentially.
Causes of depression
life events ie loss of loved one.
genetic, psychological, biological and environmental factors.
physical health conditions like stroke mi ms parkinsons
What tools would you use to assess for depression?
hospital anxiety and depression - had
14 qus 7 for anxiety 7 for depression, each scored 0-3. total 21. 0-7 normal 8-10 borderline , 11+ cse.
answer quickly.
patient health questionaire (PHQ-9)
last 2 weeks, bothered by any of these problems?
9 items 0-3 scoring. thoughts of self harm.
less than 16 on phq-9 - less severe depression
score of 16 or more - severe depression
dsm-5 - criteria for diagnosing major depressive disorder.
tell me about dsm-5
major depressive disorder -5 or more of these during same 2 week period , at least 1 is either depressed mood or loss of interest or pleasure.
depressed mood most the day, nearly every day.
marked diminished interest or pleasure
significant weight loss /apetite
insomnia/hypersomnia
fatigue/loss of energy
feelings of worthlessness or guilt
cant think concentrate or decide
recurrent thoughts of death suicide
psychomotor agitation or retardation
all of these are nearly everyday
what 2 questions can i ask to screen for depresion
during last month have you been bothered by feeling down depressed or hopeless
during last month bothered by having little interest or pleasure in doing things?
presentation of depression
emotional
cognitive
physical
low mood
anhedonia - lack of pleasure or interest in activity
emotional:
- anxiety
-irritability
-low self esteem
-guilt
-hopelessness about future
cognitive:
- poor concentration
-slow thoughts
-poor memory
physical:
- low energy
-abnormal sleep
-poor apetite or overeating
-slow movements
when taking a depression history what factors should you ask about?
caring responsibilities
alcohol
drug use
forensic hx - violence/abuse
self neglect, self harm, harm to others, suicide
how would you manage depression?
phq less than 16 - less severe :
guided self help, cbt, group behavioural activation, group exercise, mindfullness, IPT, SSRIs, counselling, short term psychodynamic psychotherapy
more severe:
cbt and antidepressant (ssri or snri)
counselling
stpp
interpersonal psychotherapy - ipt
guided self help
group exercise
rules in switching antidepressants in depression tx
direct switch if you want for the following ssris: citalopram, sertraline, paroxetine, excitalopram
if fluoxetine to another ssri: stop leave 4-7 day gap then start low dose alternative ssri
ssri to tca: - cross tapering recommended.
unless fluoxetine stop way 4-7 days then low dose.
switch from citalopram,escitalopram,sert,parox to venlafaxine - be careful with paroxetine otherwise direct switch no problems
fluox to venlafaxine - stop that start venla at low dose 4-7 days later
how does depression differ from dementia?
favour depression over dementia :
short hx rapid onset
weight loss sleep disturbed
pt worried about memory
dont wanna ake tests dissapointed with results
mmse: variable
global memory loss - dementia is recent
name 3 specialist treatments for unresponsive or severe depression
antipsychotic meds : olanzapine or quetiapine
lithium
electroconvulsive therapy - twice weekly for 4 weeks . general anesthesia electrodes place on pt head , give electrical current, short generalised seizure trigged for 30 secs.
se: headache muscle ache short term memory loss
tell me the symptoms of psychotic depression
treatment
sx of psychosis:
delusions
hallucination
thought disorder - disorganised thoughts causing abnormal communication/behaviour
give antipsychotics olanzapine or quetiapine and antidepressants.
ect is an option too
What is autism spectrum disorder?
when sx start?
who can get it?
epidemiology
neurodevelopmental condition
spectrum of aspergers, autistic disorder, pervasive developmental disorder) - dsm def
qualitative impairment in social interaction and communication and repetitive stereotyped behaviour, interests and activities
sx in early childhood
association with any general intellectual learning ability
ranges from subtle understanding issue to impaired social function and severe disability.
no cure.
3-4* more likely in boys than girls. 50% of kids with it have intellectual disability
Clinical Features of Autism Spectrum Disorder
notice these things before 2-3 yrs old
Impaired Social Communication and interaction:
- kid plays alone, uninterested in being with other kids
- cant regulate social interaction by cues like eye gaze, facial expression, gestures
- cant form appropriate relationships, become socially isolated
- lack of eye contact,delay in smile
Repetitive behaviours,interests,activities:
- stereotyped and repetitive motor mannerisms, inflexible adherence to nonfunctional routines or rituals.
- certain way of going about activities.
intellectual impairement, language impairement.
adhd 35% association
epilepsy 18% association
higher head circumference to brain volume ratio.
How would you manage autism spectrum disorder?
no cure
start early , to increase functional independence and quality of life.
non pharm:
- applied behavioural analysis
- asd preschool programme
- treatment and education of autistic an communication related handicapped children/structured teaching method (TEACCH)
- early start denver model (ESDM)
- joint attention symbolic play engagement and regulation (JASPER)
Pharm: no evidence showing improves social communication
ssri: helps reduce sterotyped behaviour, anxiety, ,aggression
antipsychotics drug: reduces aggression, self-injury
methylphenidate: for adhd
family support: parental education
what communication delays are evident in autism pt?
language development
repetitive use of word/phrases
difficulty in imaginative or imitative behaviour
lack of appropriate nonverbal communication
what deficits in behaviour evident in autism?
greater interest in objects numbers or patterns than ppl
repetitive behaviour nd fixed routines
anxiety and distress with experiences outside of regular routine
strict food preferences
stereotypical movements - self-stimulating, hand-flapping or rocking
intense/deep interests persistent and rigid
What is bipolar?
types of it
chronic mental health recurrent episodes of depression and mania/hypomania.
usually start under 25 yrs. high rate of suicide.
manic episode: excessively elevated mood and energy, impact normal function like caring/working responsibilities. SEVERE FUNCTIONAL IMPAIREMENT OR PSYCHOTIC SX FOR 7 DAYS OR MORE
hypomanic: milder than manic without significant impact on their function. DECREASED/INCREASED FUNCTION FOR 4 DAYS OR MORE
mixed: mix of sx or rapid cycling between mania and depression
deprressive episodeS: low mood , anhedonia, low energy.
type 1 : mania and depression - MC
type 2: hypomania and depression
difference between hypomania and mania bipolar
delusions of grandeur or auditory hallucination - suggesting mania
how would you manage bipolar disorder?
ACUTE MANIC EPISODE:
antipsychotic meds - olanzapine,quetiapine, risperidone or haloperidol - 1st line
other options: lithium, sodium valproate
existing antidepressatn tapered and stopped
for acute depressive episode:
olanzapine+ fluoxetine
antipsycotic meds - olanzapine or quetiapine
lamotrigine
long term mx:
- lithium!! (alternative sodium valproate and olanzapine)
serum lithium levels monitered make sure dose is correct - take 12 hrs after most recent dose. target is 0.6-0.8 mmol/L. you can get lithium toxicity if levels are too high.
what potential adverse effects can you get with lithium? - long term bipolar tx
fine tremor
weight gain
ckd
hypothyroidism and goitre
hyperparathyroidism and hypercalcaemia
nephrogenic diabetes insipidus
ecg: t wave flattening/inversion
idiopathic intracranial hypertension
benign leucocytosis
what do i need to know about sodium valproate ? (bipolar tx)
teratogenic
neural tube defects
developmental delay if used in pregnancy.
VALPROATE PREGNANCY PREVENTION PROGRAMME - ensure effective contraception and annual risk acknowledgement form.
with bipolar what conditions are there an increased risk for? and by how much?
2-3 times increased risk
diabetes
cv disease
copd
tell me the spectrum of conditions for postpartum mental health issues
when is it seen?
baby blues - 1st week after birth - more common in primips
post natal depression - 3 months after months
puerperal psychosis - few weeks after birth
tell me the presentations of baby blues and why it might happen
tell me tx too.
when should it resolve
no tx
resolves within 2 weeks of delivery
sx: mild few days - mother anxious tearufl and irritable
- mood swings
-low mood
-anxiety
-irritability
-tearfulness
why it can happen:
- hormonal change
-recovery from birth
-fatigue, sleep deprivation
-establishing feeding
-responsibility of caring for neonate
how do you assess for postnatal depression?
edinburgh postnatal depression scale
10 item questionaire, max 30 score- asks how mother felt previous week. over 13 is depressive illness of varying severity. sensitivity and specificity over 90%. includes qu about self harm.
tell me about postnatal depression
10% of women
start within a month and peaks at 3 months.
similar to depressive features. triad: low mood, anhedonia,low energy
cbt
ssri - sertraline and paroxetine (good bc of low milk/plasma ratio) - if sx severe. secreted in breast ilk but not harmful to infant.
mild- self help
moderate - ssri and cbt
severe - specialist psych, rarely inpatient and mother and baby unit
tell me about puerperal psychosis
sx
tx
onset within first 2-3 weeks after birth.
severe swings in mood - similar to bipolar
and disordered perception - auditory hallucinations
admission to hospital - mother and baby unit
25-50% chance of recurrence
sx:
delusions
hallucination
depresion
mania
confusion
thought disorder
tx:
mother and baby unit
cbt
meds - antidepressants , antipsychotics, mood stabilisers
ECT
potential side effect of giving SSRI during pregnancy?
neonatal abstinence syndrome - withdrawal basically
few days after birth presents : irritability and poor feeding.
supportive management.
What is PTSD?
examples of traumatic events
mental health condition due to traumatic experiences with ongoing distressing symptoms
increases risk of depression anxiety substance misuse and suicide.
witnessing or experiencing:
- violence
- major car accidents
-major health events
-natural disasters
-military combat and war zone events
presentation of ptsd
re-experiencing : flashbacks, nightmares,repetitive and distressing intrusive images
avoiding: people, situations, circumstances resembling
hyperarousal: hypervigilance, exaggerated startle response, sleep issue, irritable, difficulty concentrting
emotional numbing - lack fo ability to experience feelings, feeling detached
derealisation - feeling the world isnt real
Diagnosis of PTSD - how?
screening tools
trauma screening questionaire - tsq
diagnosis based on the following criteria:
diagnostic and statistical manual of mental disorders (DSM-5)
International Classification of Diseases (ICD-11)
How would you manage PTSD?
watchful waiting - mild sx less than 4 weeks
trauma focused cbt or eye movement desensitisation and reprocessing (EMDR) therapy in severe cases.
drugs not 1st line .
if used : venlafaxine or ssri like sertraline.
in severe cases: risperidone
what is eye movement desensitisation and reprocessing (emdr)?
processing traumatic memories while performing specific eye movements.
basically reprocessing traumatic memories in a normal way so they dont cause negative emotion and distress.
Name the types of learning disabilities
dyslexia - specific difficulty in reading, writing, spelling
dysgraphia - specific difficulty in writing
dyspraxia - developmental co-ordination disorder.
auditory processing disorder
non-verbal learning disability - difficulty processing it, such as body language facial expressions.
profound and multiple learning disability - severe difficulties across multiple areas, need help daily life.
how to classify learning disabilities?
iq :
55-70 mild
40-55 moderate
25-40 severe
under 25 - profound
causes of learning disability
fhx.
environmentals - abuse neglect psychological trauma and toxins.
certain conditions:
- genetic disorders such as downs
- autism
-epilepsy
- problems in early childhood eg meningitis
- antenatal problems eg - fetal alcohol syndrome and maternal chickenpox
- problems at birth eg prematurity and hypoxic ischaemic encephalopathy
mdt involved in managing learning disability
health visitor
social worker
school
educational psychologist
paediatrician gp nurses
OT
speech and language therapist
to have capacity pt must demonstrate the ability to ?
understand - decision needs to be made
retain - information long enough to make decision
weight up - options and implications
communicate- decision
what is psychosis?
features of psychosis?
person experiencing things different from those around them
hallucinations - auditory
delusions
thought disorganisation
- alogia - little info conveyed by speech
- tangentiality - answers diverge from topic
- clanging - rhyming
- word salad: link words incoherently - nonsensical content
give some associated features of psychosis
agitation and aggression and depression and thought of self harm
neurocognitive impairment - memory attention and executive function
what conditions can psychotic symptoms occur in?
schizophrenia - MC
depression
bipolar
puerperal psychosis
brief psychotic disorder - sx last less than 1 month
neuro: parkinsons, huntingtons
prescribed drugs: corticosteroids
certain ilicit drugs: cannabis phencyclidine
what is the peak age for first episode psychosis?
15-30
Typical Antipsychotics
MoA
Adverse Effects
Examples
moa : dopamine d2 receptor antagonists - block dopaminergic transmission in mesolimbic pathways.
effects: extrapyramidal and hyperprolactinaemia common
eg: haloperidol , chlorpromazine
atypical antipsychotics
moa
adverse effects
examples
moa: act on variety of receptors - d2,d3,d4,5-ht
effects: extrapyramidal and hyperprolactinaemia less common.
metabolic effects
eg: clozapine
risperidone
olanzapine
what are the extrapyramidal side effects (antipsychotics)
parkinsonisms
acute dystonia: sustained muscle contraction (torticollis, oculogyric crisis). can manage with procyclidine
akathisia - severe restlessness
tardive dyskinesia - late onset choreoathetoid movements, abnormal, involuntary, 40% pts, irreversible, mc is chewing and pouting jaw. excessive blinking
in elderly pts what are the risks for antipsychotics - normal and atypical
increased risk of
stroke
vte
what general side effects can you get from antipsychotics?
raised prolactin - galactorrhoea, due to inhibition of dopaminergic tuberoinfundibular pathway.
impaired glucose tolerance
sedation, weight gain
antimuscarinic: dry mouth blurred vision urinary retention constipation
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold - greater with atypicals
prolonged QT interval - particularly haloperidol
what atypical antipsychotic is associated with agranulocytosis?
and tell me some other side effects of this drug
clozapine - very low neutrophil count.
myocarditis/cardiomyopathy - fatal
constipation
seizures
excessive salivation
general adverse effects of atypical antipsychotics
examples
weight gain and hyperprolactinaemia
clozapine - agranulocytosis
clozapine
olanzapine - higher risk of dyslipidemia and obesity.
risperidone
quetiapine
amisulpride
aripiprazole : good side effect profile, esp for prolactin elevation
what tests would you have to do on a pt you have given antipsychotics to?
fbc,u+e, lft - start of therapy, annually, clozapine do weekly initially
lipids, weight - start, 3 months, annually
fasting bg, prolactin - start , at 6 months, annually
bp - baseline - frequent during dose titration
electrocardiogram - baseline
cv risk assessment - annually
Risk factors for schizophrenia
fhx. - parents has relative risk of 7.5
risk of gettin git:
monozygotic twin has it = 50%
parent has it = 10-15%
sibling has it = 10%
no relatives = 1%
black carribean ethnicity - RR 5.4
Migration - RR 2.9
Urban Environment RR 2.4
Cannabis Use RR 1.4
environmental
poor prognostic factors of schizophrenia
strong fhx
gradual onset
low iq
prodomal phase of social withdrawal
lack of obvious precipitant
how do you manage schizophrenia?
oral atypical antipsychotics - 1st line
cbt
crisis resolution
early intervention
acute hospital admission
comm mental health team
check for cv risk factor modification due to high rates of cv disease in schizophrenic pts - linked to antipsychotic medication and high smoking rates
features of schizophrenia
auditory hallucination
thought disorder
passivity phenomena
delusional perceptions
others
PRODOME PHASE : BEFORE FULL SX : poor memory, reduced conc, mood swings, suspicion of others, loss of apetite, difficulty sleeping, social withdrawal and decreased motivation.
Psychosis:
auditory hallucinations:
- 2 or more voices discussing pt in 3rd person
-thought echo
-voices commenting on pt behaviour
thought disorder
- thought insertion
-thought withdrawal
-thought broadcasting
passivity phenomena
- bodily sensations being controlled by external influence
- actions/impulses/feelings - experiences imposed on individual or influenced by others
delusional perceptions
- 2 stage - 1st normal object percieved , 2nd sudden intense delusional insight into objects for pt: traffic light is green therefore im king
impaired insight
catatonia - abnormal movements
neologisms - made up words
persecutory delusions
negative sx:
- alogia - poverty of speech
-avolition - poor motivation
-social withdrawal
-anhedonia - inability to derive pleasure
-incongruity - blunting of affect to emotive subjects or events
what is schizophrenia?
how long sx present before diagnosis?
severe long term psychosis.
between 15-30 . earlier in men than women.
at least 6 months
what is schizoaffective disorder?
schizophrenia + bipolar.
psychosis and sx of depression and mania
what is schizophreniform disorder
same features as schizophrenia but lasts less than 6 months.
patterns of behaviour in schizophrenia
active sx can be:
continuos
episodic - relapsing and rmeitting
single episode only
how would you make a diagnosis of schizophrenia?
DSM-5
sx including prodome phase must be present min 6 months with sx of active phase (delusions, hallucinations, thought disorder) at least 1 month (or less if tx successful)
key features of neuroleptic malignant syndrome (complication of antipsychotics)
blood findings
treatment
muscle rigidity
hyperthermia
altered conciousness
autonomic dysfunction - fluctuating bp and tachy
blood findings:
raised creatine kinase
raised wcc - leukocytosis
AKI 2 to rhabdomyolysis
stop causative meds and supportive care - iv fluids and sedation with benzodiazepines.
severe may need bromocriptine - dopamine agonist or dantrolene - muscle relaxant
as an antipsychotic when would you give clozapine?
when other tx dont control sx.
if adherence was an issue for antipsychotics what would you do?
give depot antipsychotics im injection every 2 weeks-3 months.
eg:
aripiprazole
flupentixol
paliperidone
risperidone
what is somatisation disorder?
tx
also known as briquets syndrome
multiple recurrent clinically significant somatic complaints that cant be fully explained by any underlying medical conditions.
pt get wide range of physical sx - cause distress and impairement in daily function
tx: cbt
tell me about the mental health act
law for hospital pts against wish inside hospital.
if pt has capacity, its voluntary/informal admission. - doesnt involve MHA ./
section 131 of mha - pts can be admitting without MHA.
how would be involved with MHA? - mental health act
approved mental health professional - organise mha assessments
section 12 doc - does mha assessments
responsible clinician - overall responsibility of pt care.
nearest relative - pts interests relative.
independent mha advocate - independent. - support persion help understand situation
a mha admission needs to be recommended by which 2 ppl?
section 12 doc
another doc - like their gp
tell me about the different sections in mha
section 2 - compulsory admission for assessment - max 28 days. cant be renewed. ends in discharge or further detention under section 3
section 3 - compulsory admission for tx. max 6 months. requires MHA. if mental health service under section 3 straight from community. otherwise following section 2 .
section 4 - detain pts upto 72 hrs in urgent scenarios where other procedures cant be arranged in time. need AMHP+ doc.
section 5(2) - emergency to detain pt already voluntarily in hospital. upto 72 hrs. 1 doc . after mha assessment
section 5 (4) - emergency detain and voluntary. 6 hours max. requires 1 nurse.
section 17 a - supervised community treatment. can recall a pt to hospital for tx if they dont comply with conditions of order in community ie medication adherence.
section 135 - court order to allow police to break into property to remove a person to place of safety
section 136 - police to remove someone which mental health disorder from public place and take to place of safety to be assessed. last up to 24 hours.
what is self harm?
cycle of self harm?
self injury without suicidal intent. cutting mainly. more in females under 25. pt under emotional distress and try to copy.
- emotional suffering
- emotional overload
- panic
- self harm
- temporary relief
- shame and guilt
