Psychiatry Flashcards
1
Q
Define autism?
A
A triad of communication impairment + impairment of social relationships + ritualistic behaviour
2
Q
A triad of communication impairment + impairment of social relationships + ritualistic behaviour would indicate what?
A
Autism
3
Q
What are the cluster A personality disorders?
A
Paranoid
Schizoid
Schizotypal
4
Q
What are the cluster B personality disorders?
A
Antisocial
Borderline (Emotionally unstable)
Histrionic
Narcissistic
5
Q
What are the cluster C personality disorders?
A
Obsessive-compulsive
Avoidant
Dependent
6
Q
What is ADHD?
A
A condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent.
7
Q
What would some features of inattention be?
A
Does not follow instructions
Reluctant to engage in mentally-intense tasks
Easily distracted
Finds it difficult to sustain tasks
Finds it difficult to organise tasks or activities
Often forgetful in daily activities
Often loses things necessary for tasks or activities
Often does not seem to listen when spoken to directly
8
Q
What would some features of hyperactivity be?
A
Unable to play quietly
Talks excessively
Does not wait their turn easily
Will spontaneously leave their seat when expected to sit
If often ‘on the go’
Often interruptive or intrusive to others
Will answer prematurely, before a question has been finished
Will run and climb in situations where it is not appropriate
9
Q
What is the first-line management for ADHD?
A
10 week period of ‘watch and wait’ to observe whether symptoms change or resolve
10
Q
What are the conditions of providing pharmacological therapy for patients with ADHD?
A
Used as a last resort, and is only available to those that are aged 5 and over.
11
Q
What is the first line pharmacological treatment for ADHD in children?
A
Methylphenidate on a 6 week trial basis
12
Q
What type of drug is methylphenidate?
A
It is a CNS stimulant which primarily acts as a dopamine/norepinephrine reuptake inhibitor
13
Q
What are some side effects of methylphenidate?
A
Abdominal pain, nausea and dyspepsia.
In children, weight and height should be monitored every 6 months
14
Q
What are the first line pharmacological agents for ADHD in adults?
A
Methylphenidate or lisdexamfetamine are first-line options.
Switch between drugs if the other fails
15
Q
What is the second line pharmacological agent for ADHD in children?
A
Lisdexamfetamine
16
Q
What is a third line pharmacological agent for ADHD in children?
A
Dexamfetamine - only in those who have benefited from lisdexamfetamine, but who can’t tolerate its side effects.
17
Q
What is a MAJOR side effect of methylphenidate and lisdexamfetamine?
A
Cardiotoxicity - Perform a baseline ECG before starting treatment, and refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity.
18
Q
Is ADHD more common in boys or girls?
A
Boys by a ratio of 4:1
19
Q
How many features must a 16 year old have if they are to be diagnosed with ADHD?
A
Up to 16 years old - 6 features must be present.
20
Q
How many features must a patient have if they are older than 17 years old, to be diagnosed with ADHD?
A
Over 17 years old - 5 features must be present.
21
Q
What is OCD?
A
Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both.
22
Q
Define obsession?
A
An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
23
Q
Define compulsion?
A
Compulsions are repetitive behaviours or mental acts that the person feels driven to perform.
A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.
24
Q
What would be defined as severe OCD?
A
Someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance
25
What would the management be for an individual with mild functional impairment for OCD?
Low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
If this is insufficient or can't engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)
26
What would the management be for an individual with moderate functional impairment for OCD?
Offer a choice of either a course of an SSRI or more intensive CBT (including ERP)
Consider clomipramine (as an alternative first-line drug treatment to an SSRI)
27
In what case would you specifically given fluoxetine for a moderate functional impairement of OCD?
Fluoxetine is specifically given for body dysmorphic disorder
28
In what case would you give clomipramide for a moderate functional impairment of OCD?
Can be considered as an alternative first-line drug treatment to SSRIs if the person has had a previous good response to it.
29
What would the management be for an individual with severe functional impairment for OCD?
Refer to secondary care mental health team for assessment.
Whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider Clomipramine
30
What is exposure and response prevention (ERP)?
ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
31
What timeframe would you review a patient who is starting a sertraline and is under the age of 30?
1 week
32
Define bipolar disorder?
Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
33
What are the two types of bipolar disorder?
Type 1 disorder - mania and depression (most common)
Type 2 disorder - hypomania and depression
34
What is the most common type of bipolar disorder?
Type 1 disorder - mania and depression (most common)
35
What is mania?
With mania, there is severe functional impairment or psychotic symptoms for 7 days or more
36
What is hypomania?
Hypomania describes decreased or increased function for 4 days or more
37
What is the difference between mania and hypomania?
The key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
38
What is the management for mood stabilisation in bipolar disorder?
Lithium remains the mood stabiliser of choice.
An alternative is sodium valproate (should not be used in women under 45 years old or men under 65 years old due to being tetrogenic and risk of infertility)
39
What psychotherapeutic drug should you consider stopping in mania/hypomania in bipolar disorder?
Consider stopping antidepressant if the patient takes one - manic switch
40
What is the management of mania/hypomania in bipolar disorder?
Antipsychotic therapy e.g. Olanzapine or haloperidol
41
What is the antidepressant of choice in bipolar disorder?
Fluoxetine
42
What is there an increased risk of in individuals with bipolar disorder?
There is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD
43
How would the types of referral differ for bipolar disorder presenting with mania or hypomania?
If symptoms suggest hypomania then routine referral.
If symptoms suggest mania or severe depression then urgent referral should be made.
44
What would the appropriate referral be for an individual with bipolar and in a hypomanic episode?
Routine referral to the community mental health team (CMHT)
45
What would the appropriate referral be for an individual with bipolar and in a manic or severely depressed episode?
Urgent referral to the community mental health team (CMHT)
46
Define anxiety?
Excessive worry about a number of different events associated with heightened tension.
47
List some medications that may trigger anxiety?
Salbutamol
Theophylline
Corticosteroids
Antidepression
Caffeine
48
What is step 1 of GAD management?
Education about GAD + active monitoring
49
What is step 2 of GAD management?
Low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
50
What is step 3 of GAD management?
High-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.
51
What is step 4 of GAD management?
Highly specialist input e.g. Multi agency teams
52
What is the first line pharmacological management of GAD?
Sertraline is first-line
53
What would second-line pharmacological management for GAD?
If sertraline is ineffective, an alternative SSRI or SNRI can be used.
Duloxetine or Venlafaxine (SNRI examples)
54
What would the pharmacological management be for an individual with GAD who cannot tolerate SSRIs or SNRIs?
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
55
What must you warn patients of who are under the age of 30, before commencing SSRIs and SNRIs?
For patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm.
Weekly follow-up is recommended for the first month
56
What is the first-line treatment of panic disorder in primary care?
Cognitive behavioural therapy or drug treatment
57
If there is no response to SSRIs for panic disorder in primary care, what can be offered?
If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
58
What are known to trigger mania or hypomania as a side effect in bipolar disorder?
Antidepressants - sometimes termed a manic 'switch' ie from depression to mania.
59
What antipsychotics medication could be used for a patient that has undergone a 'manic switch'?
Haloperidol
Olanzapine
Quetiapine
Risperidone
60
What is the third line treatment for a manic switch?
Lithium
61
What is the fourth line treatment for a manic switch?
Sodium valproate
62
How would you describe circumstantiality?
A circle comes back around eventually
63
How would you describe tangentiality?
A tangent goes off forever in another direction
64
How would you describe derailment?
A derailed train goes off the track after a little while and needs to be nudged back on
65
How would you describe pressured speech?
Pressured speech is as if there is a load of words behind a damn, then the damn breaks and it all comes flooding out
66
How would you describe incoherence?
Replying with nonsensical statements such as 'feelings like this different colour and rat poison'.
67
What is step 1 of panic disorder management?
Recognition and diagnosis
68
What is step 2 of panic disorder management?
Treatment in primary care
69
What is step 3 of panic disorder management?
Review and consideration of alternative treatments
70
What is step 4 of panic disorder management?
Review and referral to specialist mental health services
71
What are the risk factors of suicide?
Male sex (HR - 2.0)
History of deliberate self harm (HR - 1.7)
Alcohol or drug misuse (HR - 1.6)
History of mental illness
History of chronic disease
Advancing age
72
If an individual has attempted suicide, what are the factors associated with an increased risk of completed suicide at a future date?
Efforts to avoid discovery
Planning
Leaving a written note
Final acts such as sorting out finances
Voilent method
73
What are some protective factors which reduce the risk of a patient committing suicide?
Family support
Having children at home
Religious beliefs
74
What would the classic features of PTSD be?
Re-experiencing
Avoidance
Hyper-arousal
Emotional numbing
75
What secondary features may be present in a patient with PTSD?
Depression
Drug or alcohol misuse
Anger
Unexplained physical symptoms
76
How long do symptoms need to be present, for a diagnosis of PTSD?
At least one month
77
What would the management be for a patient with mild PTSD?
Watchful waiting may be used for mild symptoms lasting less than 4 weeks
78
What would the first-line management be for a patient with moderate / severe PTSD?
Trauma-focused cognitive behavioural therapy (CBT)
Eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
79
What are the rules surrounding pharmacological therapy in PTSD?
Drug treatments for PTSD should not be used as a routine first-line treatment for adults.
80
What are the pharmacological agents of choice in PTSD?
SNRI - Venlafaxine
SSRI - Sertraline
81
What pharmacological agent 'may' be used in severe PTSD?
In severe cases, NICE recommends that risperidone may be used
82
How are the cluster A personality disorders often described?
Odd or Eccentric
83
How are the cluster B personality disorders often described?
Dramatic, Emotional, or Erratic
84
Define acute stress disorder?
Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc).
85
What is the difference between acute stress disorder and PTSD?
Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event. This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.
86
What is the first line management of acute stress disorder?
Trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
87
What is the first line pharmacological management in acute stress disorder and what safety netting should be put in place?
Benzodiazepines.
Should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation
88
What 'may' some features of acute stress disorder include?
Intrusive thoughts e.g. flashbacks, nightmares
Dissociation e.g. 'being in a daze', time slowing
Negative mood
Avoidance
Arousal e.g. hypervigilance, sleep disturbance
89
List some factors that may indicate depression over dementia?
Short history and rapid onset
Biological symptoms e.g. weight loss and sleep disturbance
Patient is worried about their poor memory
They are reluctant to take tests / disappointed with the results
Global memory loss in depression / dementia characteristically causes recent memory loss
90
What would be less severe depression according to the PHQ-9 score?
A PHQ-9 score of < 16
91
What would be more severe depression according to the PHQ-9 score?
A PHQ-9 score of ≥ 16
92
A PHQ-9 score of < 16 would indicate what?
Less severe depression
93
A PHQ-9 score of ≥ 16 would indicate what?
More severe depression
94
List the treatment options for less severe depression in order of preference by NICE?
- Guided self-help
- Group cognitive behavioural therapy (CBT)
- Group behavioural activation (BA)
- Individual CBT
- Individual BA
- Group exercise
- Group mindfulness and meditation
- Interpersonal psychotherapy (IPT)
- Selective serotonin reuptake inhibitors (SSRIs)
- Counselling
- Short-term psychodynamic psychotherapy (STPP)
95
List the treatment options for more severe depression in order of preference by NICE?
- A combination of individual cognitive behavioural therapy (CBT) and an antidepressant
- Individual CBT
- Individual behavioural activation (BA)
- Antidepressant medication
- Selective serotonin reuptake inhibitor (SSRI), or
- Serotonin-norepinephrine reuptake inhibitor (SNRI), or
- Another antidepressant if indicated based on previous clinical and treatment history
- Individual problem-solving
- Counselling
- Short-term psychodynamic psychotherapy (STPP)
- Interpersonal psychotherapy (IPT)
- Guided self-help
- Group exercise
96
Define depression?
Five (or more) of the DSM-5 symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
97
In which antidepressants is a direct switch possible?
Citalopram
Escitalopram
Sertraline
Paroxetine
(only when to another SSRI)
98
What are the rules when switching from fluoxetine to another SSRI?
Withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low dose of the alternative SSRI
99
In which antidepressants is a direct switch to Venlafaxine possible?
Citalopram
Escitalopram
Sertraline
Paroxetine
100
What are the rules when switching from an SSRI to a tricyclic antidepressant?
Cross-tapering is recommended (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
101
List some SSRIs?
- Citalopram (Cipramil)
- Dapoxetine (Priligy)
- Escitalopram (Cipralex)
- Fluoxetine (Prozac or Oxactin)
- Fluvoxamine (Faverin)
- Paroxetine (Seroxat)
- Sertraline (Lustral)
- Vortioxetine (Brintellix)
102
List some SNRIs?
- Desvenlafaxine (Pristiq, Khedezla)
- Duloxetine (Cymbalta, Irenka)
- Levomilnacipran (Fetzima)
- Milnacipran (Savella)
- Venlafaxine (Effexor XR)
103
What are some risk factors for developing GAD?
Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent
104
What are some protective factors against GAD?
Aged 16 - 24
Being married or cohabiting
105
Define pseudodementia?
Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss - this is called pseudodementia
106
What is normal pressure hydrocephalus? What is it thought to be caused by?
Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. It is thought to be secondary to reduced CSF absorption at the arachnoid villi.
107
What is the classic triad of features seen in normal pressure hydrocephalus?
Urinary incontinence
Dementia and bradyphrenia
Gait abnormality (may be similar to Parkinson's disease)
108
What would the triad of urinary incontinence, dementia and bradyphrenia, gait abnormality (may be similar to Parkinson's disease) suggest?
Normal pressure hydrocephalus
109
What would normal pressure hydrocephalus present with on imaging?
Hydrocephalus with ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement
110
Ventriculomegaly without sulcal enlargement on imaging of the brain would indicate what?
Normal pressure hydrocephalus
111
What is the management of normal pressure hydrocephalus?
Ventriculoperitoneal shunting
112
What are the complications of ventriculoperitoneal shunting?
Around 10% of patients who have shunts experience significant complications such as seizures, infection and intracerebral haemorrhages
113
What are some non-pharmacological managements of Alzheimer's disease?
A range of activities to promote wellbeing that are tailored to the person's preference
Group cognitive stimulation therapy for patients with mild and moderate dementia
Group reminiscence therapy and cognitive rehabilitation
114
What types of drugs are donepezil, galantamine and rivastigmine?
Acetylcholinesterase inhibitors
115
What pharmacological management can be given for mild to moderate Alzheimer's disease?
Donepezil, Galantamine and Rivastigmine
116
What second line pharmacological management can be given for Alzheimer's disease?
Memantine
117
What type of drug is memantine?
NMDA receptor antagonist
118
Under what conditions can the second line pharmacological management be used for Alzheimer's disease?
- For moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors.
- As an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's.
- Monotherapy in severe Alzheimer's
119
What feature would contraindicate use of donepezil?
Bradycardia
120
What is an adverse effect of donepezil?
Insomnia
121
What is the characteristic pathological feature of lewy-body dementia?
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
122
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas would suggest what?
Lewy-body dementia
123
What are the features of lewy-body dementia?
Progressive cognitive impairment which typically occurs before parkinsonism, but usually both features occur within a year of each other.
Cognition may be fluctuating (different to other dementias)
Parkinsonism
Visual hallucinations + dementia = lewy -body dementia
124
Visual hallucinations + dementia would indicate what?
Lewy body dementia
125
What pharmacological management can be given for mild to moderate lewy body dementia?
Donepezil and Rivastigmine
126
What second line pharmacological management can be given for Lewy body dementia?
Memantine
127
What class of drugs should be avoided in lewy body dementia and why?
Antipsychotics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism.
E.g, Risperidone and Haloperidol.
128
What is the classic triad of Wernicke's encephalopathy?
Confusion
Ataxia
Nystagmus/ophthalmoplegia
129
What is Wernicke's encephalopathy?
Wernicke's encephalopathy is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics
130
What is the classic pentad of Korsakoff syndrome?
Confusion
Ataxia
Nystagmus/ophthalmoplegia
Amnesia (retrograde and anterograde)
Confabulation
131
What is a confabulation?
A neuropsychiatric condition that occurs when someone creates a false memory without intending to deceive
132
What is the management for Wernicke's encephalopathy?
Pabrinex (IV B/C vitamins)
Replacement of thiamine
133
What is anterograde amnesia?
Anterograde amnesia is a type of memory loss that occurs when you can't form new memories.
134
What is retrograde amnesia?
Retrograde amnesia is when you can't recall memories from your past.
135
What are the risk factors for charles-bonnet syndrome?
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
136
What is charles-bonnet syndrome?
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness.
137
Which ophthalmological pathology is associated with charles-bonnet syndrome?
Age-related macular degeneration
138
What is frontotemporal lobular degeneration?
Frontotemporal lobar degeneration (FTLD) is the third most common type of cortical dementia after Alzheimer's and Lewy body dementia.
139
What are the three recognised types of FTLD?
Frontotemporal dementia (Pick's disease)
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
Semantic dementia
140
What are the common features of FTLD?
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
141
What are the most common features of Frontotemporal dementia (Pick's disease)?
Characterised by personality change and impaired social conduct.
142
What axillary features 'may' be present in Frontotemporal dementia (Pick's disease)?
Hyperorality
Disinhibition
Increased appetite
Perseveration behaviours
143
What would you see on imaging for frontotemporal dementia (Pick's disease)?
Focal gyral atrophy with a knife-blade appearance.
Macroscopic - Atrophy of the frontal and temporal lobes
Microscopic: Pick bodies - spherical aggregations of tau protein (silver-staining)
Gliosis
Neurofibrillary tangles
Senile plaques
144
What is the most common feature of chronic progressive aphasia (CPA)?
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
145
What is the most common feature of semantic dementia?
A fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer's memory is better for recent rather than remote events.
146
What classes of drugs can causes serotonin syndrome?
Monoamine oxidase inhibitors
SSRIs
Ecstacy
Amphetamines
147
What two drugs can interact with SSRIs and cause serotonin syndrome?
St John's Wort
Tramadol
148
What neuromuscular features are associated with serotonin syndrome?
Hyper-reflexia
Myoclonus
Rigidity
149
What autonomic nervous system features are associated with serotonin syndrome?
Hyperthermia
Sweating
150
What mental state features are associated with serotonin syndrome?
Confusion
151
What is the management for serotonin syndrome?
Supportive management including fluids.
Benzodiazepines
152
What is the management for severe serotonin syndrome?
More severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
153
What classes of drugs are cyproheptadine and chlorpromazine?
Serotonin antagonists
154
Define hallucination?
False sensory perception in the absence of an external stimulus
155
What is a pseudohallucination?
False sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.
156
Define Alzheimer's disease?
Alzheimer's disease (AD) is a progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK
157
What are the risk factors for Alzheimer's disease?
Increasing age
Family history
Inherited autosomal trait
Apoprotein E allele E4
Caucasian ethnicity
Down syndrome
158
What autosomal dominant traits are associated with an increased risk of Alzheimer's disease?
Mutations in:
- The amyloid precursor protein (chromosome 21)
- Presenilin 1 (chromosome 14)
- Presenilin 2 (chromosome 1) genes
159
What genetic condition is associated with an increased risk of Alzheimer's disease?
Down syndrome
160
What macroscopic pathological changes are seen in Alzheimer's disease?
Widespread cerebral atrophy, particularly involving the cortex and hippocampus
161
What microscopic pathological changes are seen in Alzheimer's disease?
Cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
Hyperphosphorylation of the tau protein has been linked to AD
162
What biochemical pathological changes are seen in Alzheimer's disease?
There is a deficit of acetylcholine from damage to an ascending forebrain projection
163
What is Cotard's syndrome?
Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent.
164
What mnemonic can be used for features of Wernicke's encephalopathy?
A useful mnemonic to remember the features of Wernicke's encephalopathy is CAN OPEN
Confusion
Ataxia
Nystagmus
Ophthamoplegia
PEripheral
Neuropathy
165
What is the difference between Parkinson's disease dementia and Lewy-body dementia?
Motor symptoms will be present before dementia symptoms for PDD.
PDD is diagnosed if a patient had a Parkinson's disease diagnosis for at least 1 year.
166
What is Creutzfeldt-Jakob disease?
Creutzfeldt-Jakob disease (CJD) is rapidly progressive neurological condition caused by prion proteins.
167
What is the pathophysiology of Creutzfeldt-Jakob disease?
Prion proteins induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases.
168
What are the features of Creutzfeld-Jakob disease?
Dementia with rapid onset
Myoclonus
169
What would you see on imaging with an individual with Creutzfeldt-Jakob disease?
MRI - hyperintense signals in the basal ganglia and thalamus.
170
Hyperintense signals in the basal ganglia and thalamus of an MRI would indicate what?
Creutzfeldt-Jakob disease
171
What does Schneider's first rank symptoms mean?
Schneider's first-rank symptoms (FRS) are a set of symptoms that are associated with schizophrenia
172
What are the divisions of Schneider's first rank symptoms?
Auditory hallucinations of a specific type
Thought disorders
Passivity phenomena
Delusional perceptions
173
List types of auditory hallucinations of a specific type?
Two or more voices discussing the patient in the third person
Thought echo
Voices commenting on the patient's behaviour
174
List types of though disorders?
Thought insertion
Thought withdrawal
Thought broadcasting
175
What is thought insertion?
The experience of the insertion of alien thoughts
176
What is thought withdrawal?
The experience of having thoughts taken out of one's mind
177
What is thought broadcast?
Thoughts are transmitted to others.
178
List types of passivity phenomena?
Bodily sensations being controlled by external influence
Actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
179
What is a delusional perception?
A two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient
180
What are some other features of schizophrenia aside from Schneider's first rank symptoms?
Impaired insight
Negative symptoms
Neologisms - made up words
Catatonia
181
What are some negative symptoms associated with schizophrenia?
Incongruity / blunting of affect
Anhedonia - inability to derive pleasure
Alogia - Poverty of speech
Avolition - Poor motivation
Social withdrawal
182
What factors are associated with a poor prognosis of schizophrenia?
Strong family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
183
What is catatonia?
Stopping of voluntary movement or staying still in an unusual position
184
What is delusional parasitosis?
Where a patient has a fixed, false belief (delusion) that they are infested by 'bugs' e.g. worms, parasites, mites, bacteria, fungus.
185
What is Fregoli syndrome?
Where the patient believes that multiple people are in fact all the same person, who is constantly changing their appearance.
186
What is Capgras syndrome?
This is a delusional misidentification syndrome whereby the patient believes that someone significant in their life, such as a spouse or a friend, has been replaced by an identical imposter.
187
What is a neologism?
Making up new words
188
What is echolalia?
Repeating exactly what someone has said
189
What is word preservation?
Repeating the same words/answers.
190
What is word salad?
Disorganised speech, sentences that do not make sense.
191
What is the management for schizophrenia?
Oral atypical antipsychotics are first-line
Cognitive behavioural therapy should be offered to all patients
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What are clang associations?
When ideas are related to each other only by the fact they sound similar or rhyme.
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What is Knight's move thinking?
A severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.
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Define psychosis?
Psychosis is a term used to describe a person experiencing things differently from those around them.
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What is brief psychotic disorder?
Where symptoms of psychosis last less than a month
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What is neuroleptic malignant syndrome?
A life-threatening reaction to antipsychotic medications.
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What is the mechanism of action of antipsychotic medications?
Work by inhibiting dopamine receptors, specifically D2 receptors
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What class of drugs work by inhibiting dopamine receptors, specifically D2 receptors
Antipsychotic medications
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What are the two typical (first generation) oral antipsychotics?
Chlorpromazine
Haloperidol
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What are the six atypical (second generation) oral antipsychotics?
Clozapine
Quetiapine
Aripiprazole - generally good side-effect profile, particularly for prolactin elevation
Olanzapine - higher risk of dyslipidemia and obesity
Risperidone
Amisulpride
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What are some examples of depot antipsychotics?
Aripiprazole
Flupentixol
Paliperidone
Risperidone
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Why may depot antipsychotics be given?
Given as an intramuscular injection every 2 weeks – 3 months. This can be helpful where adherence may be an issue.
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What antipsychotic is used when other treatments do not control symptoms of schizophrenia?
Clozapine
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What parameters should be monitored before and during antipsychotic medication initiation?
Weight and waist circumference
Blood pressure and pulse rate
Bloods, including HbA1c, lipid profile and prolactin
ECG
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What are some extra-pyramidal side effects of antipsychotic medications?
Akathisia
Dystonia
Pseudo-parkinsonism
Tardive drive dyskinesia
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What are the key features of neuroleptic malignant syndrome
Muscle rigidity
Hyperthermia
Altered consciousness
Autonomic dysfunction (e.g., fluctuating blood pressure and tachycardia)
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Muscle rigidity, hyperthermia, altered consciousness, autonomic dysfunction (e.g., fluctuating blood pressure and tachycardia) would indicate what?
Neuroleptic malignant syndrome
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What are the key blood findings for neuroleptic malignant syndrome?
Raised creatine kinase
Raised white cell count (leukocytosis)
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What is the management for neuroleptic malignant syndrome?
Stopping the causative medications and supportive care (e.g., IV fluids and sedation with benzodiazepines)
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What would the management be for severe neuroleptic malignant syndrome?
Severe cases may require treatment with bromocriptine (a dopamine agonist) or dantrolene (a muscle relaxant).
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What is the strongest risk factor for developing schizophrenia?
The strongest risk factor for developing a psychotic disorder (including schizophrenia) is family history.
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What is the risk of developing schizophrenia if a monozygotic twin has schizophrenia?
50%
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What is the risk of developing schizophrenia if a parent has schizophrenia?
10-15%
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What is the risk of developing schizophrenia if a sibling has schizophrenia?
10%
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In what condition would ECT be indicated?
Depressive disorder which is resistant to medication.
Catatonia
Manic phase of bipolar diorder
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What is the difference between schizophrenia and schizoaffective disorder?
In schizophrenia, the psychotic symptoms are almost always present, but the mood symptoms come and go or disappear altogether. In schizoaffective disorder, the psychotic symptoms and mood symptoms come and go together, with the mood symptoms being present the majority of the time alongside the psychotic symptoms
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What are the classic features of paranoid personality disorder?
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
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What are the classic features of schizoid personality disorder?
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
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What are the classical features of schizotypal personality disorder?
Ideas of reference (differ from delusions in that some insight is retained)
Odd beliefs and magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent
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What are the classical features of antisocial personality disorder?
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for the safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
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What are the classical features of borderline personality disorder?
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
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What are the classical features of historonic personality disorder?
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
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What are the classical features of narcissistic personality disorder?
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power, or beauty
Sense of entitlement
Taking advantage of others to achieve own needs
Lack of empathy
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
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What are the classical features of obsessive-compulsive personality disorder?
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
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What are the classical features of avoidant personality disorder?
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
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What are the classical features of dependent personality disorder?
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
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What is the management for personality disorders?
Dialectical behaviour therapy
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What are specific warnings against antipsychotics in elderly patients?
Increased risk of stroke
Increased risk of venous thromboembolism
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What is Akathisia?
Subjective feeling of restlessness, often with an inability to sit still.
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What is acute dystonia?
A sudden onset involuntary muscle contractions that cause abnormal movements and postures. These can include oculogyric crisis (involuntary upward eye movement), torticollis (twisting of the neck muscles) and trismus (lockjaw).
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What is tardive dyskinesia?
Repetitive, involuntary movements such as lip smacking or puckering, grimacing, tongue protrusion and rapid blinking.
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What is the mechanism of action of benzodiazepines?
They enhance the activity of the inhibitory neurotransmitter GABA in the CNS.
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What are the common benzodiazepines?
Diazepam (Valium) and Lorazepam, and Alprazolam (Xanax)
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What is the overdose management for benzodiazepines?
Flumazenil IV
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What is the mechanism of action of barbiturates?
Barbiturates act on GABA-A receptors by increasing the amount of time the chloride ion channel is opened, which increases the affinity of the receptor for GABA.
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What are the common barbiturates?
Pentobarbitone and Phenobarbitone
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What is the mechanism of action of opioids?
Opioids work via the endogenous opioid system by acting as a potent agonist to the μ receptor. This results in a complex cascade of intracellular signals resulting in dopamine release, blockade of pain signals, and a resulting sensation of euphoria.
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What is the triad of an opioid overdose?
Pinpoint pupils
Respiratory depression
Decreased level of consciousness
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What is the immediate management of an opioid overdose?
IV or IM Naloxone
Activated charcoal can be given in 3 hour window instead of 1 hour due to slowing of gastric motility by opiates
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What is the mechanism of action of naloxone?
Naloxone is a competitive opioid receptor antagonist
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What is the mechanism of action of amphetamines?
Amphetamines increase neurotransmission of dopamine (DA), serotonin (5-HT), and norepinephrine (NE) by entering neurons via the 5-HT and DA transporters and displacing storage vesicles.
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What is the overdose management for amphetamines?
Benzodiazepines for sedation and to control seizures
Activated charcoal if within 1 hour of amphetamine ingestion
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What is the overdose management for cocaine?
Benzodiazepines - These are CNS depressants and thus will counteract the effects of cocaine
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What is the overdose management of paracetamol?
N-acetylcysteine
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What is the overdose management for tri-cyclic antidepressants?
Sodium bicarbonate
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What is the overdose management for organophosphates?
Atropine
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What is the management for opioid detoxification?
Methadone or buprenorphine
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Outline section 2 of the mental health act?
Admission for assessment for up to 28 days, not renewable
Via an Approved Mental Health Professional (AMHP)
Treatment can be given against a patient's wishes
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Outline section 3 of the mental health act?
Admission for treatment for up to 6 months, can be renewed
AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours
Treatment can be given against a patient's wishes
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Outline section 4 of the mental health act?
72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
a GP and an AMHP or NR
Often changed to a section 2 upon arrival at hospital
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Outline section 5(2) of the mental health act?
A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
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Outline section 5(4) of the mental health act?
Similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours
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Outline section 17a of the mental health act?
Supervised Community Treatment (Community Treatment Order)
Can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication
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Outline section 135 of the mental health act?
A court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety
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Outline section 136 of the mental health act?
Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
Can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged
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What are the features of lithium toxicity?
Coarse tremor (fine tremor seen in therapeutic levels)
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma
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What may lithium toxicity be precipitated by?
Dehydration
Renal failure
Drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
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What is the management of mild-moderate lithium toxicity?
Volume resuscitation with normal saline
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What is the management of severe lithium toxicity?
Haemodialysis may be needed in severe toxicity
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When should lithium levels be checked?
12 hours post-dose
When starting - performed weekly after each dose until concentrations are stable
Once established they are checked every 3 months
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What pharmacological agent can be used to manage acute dystonia due to typical antipsychotics?
Procyclidine and benztropine
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What are the short-term side effects of ECT?
Headache
Nausea
Short term memory impairment
Memory loss of events prior to ECT
Cardiac arrhythmia
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What pharmacological agent can be used to manage tardive dyskinesia due to typical antipsychotics?
Tetrabenazine
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What pharmacological agent can be used to manage akathisia due to typical antipsychotics?
Propranolol
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What is vascular dementia?
It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease.
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What is the second most common form of dementia?
Vascular dementia
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What are the subtypes of vascular dementia?
Stroke-related VD
Subcortical VD
Mixed dementia
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What is stroke-related VD?
Vascular dementia caused by a multi-infarct or single-infarct dementia
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What is subcortical VD?
Vascular dementia caused by small vessel disease.
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What is mixed dementia?
The presence of both VD and Alzheimer's disease
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What are the risk factors for vascular dementia?
History of stroke or transient ischaemic attack (TIA)
Atrial fibrillation
Hypertension
Diabetes mellitus
Hyperlipidaemia
Smoking
Obesity
Coronary heart disease
A family history of stroke or cardiovascular
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In what disease would vascular dementia be inherited?
CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopath)
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What is the typical presentation of vascular dementia?
Several months or several years of a history of a sudden or STEPWISE DETERIORATION of cognitive function.
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What may some features of vascualr dementia be?
Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
The difficulty with attention and concentration
Seizures
Memory disturbance
Gait disturbance
Speech disturbance
Emotional disturbance
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What criteria is used to diagnose vascular dementia?
NINDS-AIREN criteria
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The NINDS-AIREN criteria is used for what?
For a diagnosis of vascular dementia
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Outline the NINDS-AIREN criteria?
Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event
Cerebrovascular disease defined by neurological signs and/or brain imaging
A relationship between the above two disorders inferred by:
- The onset of dementia within three months following a recognised stroke
- An abrupt deterioration in cognitive functions
fluctuating, stepwise
- Progression of cognitive deficits
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What is the management for for vascular dementia?
Include: cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy
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What score is used to assess postpartum mental health problems in pregnancy?
The Edinburgh Postnatal Depression Scale may be used to screen for depression
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What score in the Edinburgh Postnatal Depression Scale would indicate a 'depressive illness of varying severity'
Score of > 13
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A score of > 13 in the the Edinburgh Postnatal Depression Scale would indicate what?
A 'depressive illness of varying severity'
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When is 'baby-blues' most likely to occur?
Typically seen 3-7 days following birth
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When is post-natal depression most likely to occur?
Most cases start within a month and typically peaks at 3 months
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When is puerperal psychosis most likely to occur?
Onset usually within the first 2-3 weeks following birth
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What is the management for 'baby blues'?
Reassurance and support, the health visitor has a key role
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What is the management for postnatal depression?
Reassurance and support are important
CBT may be beneficial
Paroxetine SSRI may be used if severe
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What is the management for puerperal psychosis?
Admission to hospital is usually required, ideally in a Mother & Baby Unit
