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Phase 4 Question Knowledge > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Phenomenology

A

See other deck

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2
Q

Serotonin syndrome

A

increased serotonin in synapses

MAOIs, SNRIs, SSRIs, St John’s wort, MDMA, cocaine, LSD

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3
Q

SS Px

A

Sx onset <6hrs of taking drug

Autonomic hyperactivity
- HTN, high temp, tachycardia, sweaty, diarrhoea, mydriasis

Neuromuscular abnormality
- tremor, clonus, ocular clonus, hypertonicity, hyperreflexia

Mental status changes
- anxiety, agitation, confusion, coma

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4
Q

SS Ix

A
  • clinical dx
  • bloods, in FBC, U/E, CK, tox screen, culture, LFTs, ?CT head, ?LP
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5
Q

SS Mx

A
  • consider activated charcoal, IV fluids, benzos
  • cyproheptadine - serotonin antagonist
  • ICU / sedation + paralysis if severe
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6
Q

Neuroleptic malignant syndrome (NMS)

A
  • life-threatening reaction to antipsychotics
  • ?caused by D2 receptor blockade / dopamine depletion
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7
Q

NMS Px

A
  • <10d of starting med
  • severe rigidity
  • fever
  • altered mental state
  • autonomic dysfunction - tachycardia, BP up/down, tremor, incontinence, sweating, salivation
  • oculogyric crises, seizures, chorea
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8
Q

NMS Ix

A
  • bloods - eg FBC, U/E, Ca, ABG, LFTs, CK, coag, urinary drug screen
  • ?CT head, ?LP
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9
Q

NMS Mx

A
  • agitation - benzos
  • stop antipsychotic
  • bromocriptine / amantadine - DA agonists
  • dantrolene - muscle relaxant
  • consider ECT
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10
Q

Rapid tranquilisation

A

Idk see guidelines

Try oral first

IM / IV lorazepam

Consider haloperidol, promethazine….

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11
Q

Delirium

A

Acute reversible confusional state

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12
Q

Delirium causes

A

PINCH ME
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment

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13
Q

Delirium Px

A

Hyperactive - inappropriate behaviour, hallucinations, agitation, restlessness, wandering, aggression

Hypoactive - lethargy, reduced concentration and appetite, appear quiet + withdrawn

Mixed

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14
Q

Delirium Ix

A
  • Full examination, check for head injury
  • AMTS / MMSE / ACE-III
  • bloods - FBC, U/E, LFTs, coag, B12/folate, glucose, cultures, TFTs, bone profile
  • urinalysis if sx of UTI
  • CXR, CT head
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15
Q

Delirium Mx

A
  • tx cause
  • supportive mx
  • loraz / halo if agitated
  • STOPP-START criteria for medication review
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16
Q

Depression

A

low mood, loss of interest / pleasure

RFs
F>M, PMHx, significant physical illness, other mental health problems, psychosocial problems, bullying, homelessness etc

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17
Q

Depression Px

A

Core sx
- low mood
- anhedonia

Associated sx
- too much/little sleep
- change in appetite / weight
- fatigue, low energy
- agitation, slow movts
- poor conc, indecisiveness
- feel worthless / guilty
- suicidal thoughts / acts

Other sx
- headache, GI upset, loss of libido, catatonia, psychotic sx
- elderly - agitation, confusion, decline in normal function
- children - irritable, withdrawn, decline in school performance

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18
Q

Depression Dx

A
  • sx present >2wks
  • not secondary to alcohol, drugs, medication, bereavement
  • all must include low mood / anhedonia

sub-threshold - 2-5 sx
mild - 5 sx - minor functional impairment
moderate - >5sx - varying impairment
severe - >5 sx - marked impairment +/- psychosis

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19
Q

Depression Ix

A
  • Hx, MSE
  • PHQ-9, HADS, BDI-II
  • Bloods - FBC, U/E, LFTs, TFTs, B12/folate, ESR, glucose, bone profile, Mg
  • consider toxicology, thyroid ABs, ANA, dex suppression test, syphilis, LP, CT/MRI head
  • risk assessment
  • SAD PERSONS
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20
Q

Depression Mx

A
  • CBT, IAPT
  • SSRIs - sertraline, fluoxetine, citalopram
  • Pregnancy - sert, cit
  • SNRIs - duloxetine, venlafaxine
  • TCA - sedating (amitriptyline, clomipramine), non-sedating (imipramine, lofepramine)
  • A2 antagonist - mirtazpine
  • MAOi - isocarboxazid, phenelzine sulfate - don’t eat tyramine food/drink (cheese, yoghurt, liver) -> HTN crisis
  • continue tx for 6mo after sx remission before gradual reduction
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21
Q

Dysthymic disorder

A
  • chronic >2yrs low grade depressive sx

Px - depressive sx

Mx - SSRI, TCA, CBT

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22
Q

Seasonal affective disorder

A
  • seasonal pattern to recurrent depressive episodes

Px - depressive sx during same time each year

Mx - light therapy, SSRIs

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23
Q

Bipolar affective disorder (BAD)

A

2+ episodes of disturbed mood (over months), with 1+ episode of hypomania / mania / mixed - with depression

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24
Q

BAD types

A

Type 1 - major depression + mania

Type 2 - major depression + hypomania

Cyclothymia - minor depression + hypomania (>2yrs)

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25
Q

BAD Px

A

Mania - abnormally + persistently elevated mood - >1wk, cause hospital admission, impair function
- elevated mood / self-esteem, take risks, over-familiar, increased energy, reduced attention
- thought disorder - pressure of thought / speech, flight of ideas, word salad
- Psychotic sx - delusions (eg grandiosity), hallucinations, violent behaviours, catatonia, loss of insight

Hypomania - mild form of mania
- mildly increased mood, no psychosis
- reduced sleep, sociable, more energy

Depressive phase
- low mood, low energy, anhedonia, negative thoughts, general depressive sx

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26
Q

BAD Ix

A
  • Hx, MSE
  • risk assessment
  • bloods
  • CT / MRI head
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27
Q

BAD Mx

A

Acute manic episode
- benzos - lorazepam
- antipsychotic - olanzapine / quetiapine (1st line), haloperidol / risperidone

Depressive episode
- SSRI - fluoxetine
- use antipsychotic also
- if manic, stop anti-depressant

Maintenance
- lithium
- also carbamazepine, lamotrigine, valproate
- ECT

Psychotherapy
- psychoeducation
- CBT
- IPT - interpersonal psychotherapy
- support groups

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28
Q

Lithium

A
  • mood stabiliser
  • therapeutic index 0.5-1.0mmol/L
  • takes ~3wks to reach max effect
  • take dose at night
  • usually 800-1200mg, 2g max dose
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29
Q

Lithium monitoring

A

Before - BMI, bloods (FBC - leucocytosis, U/E, TFTs, calcium, PTH, Mg) ECG, pregnancy, goitre

Monitor levels every 5d until stable dose (12hrs post dose)

Every 3mo - lithium levels, eGFR

Every 6mo - TFTs, BMI, S/E review

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30
Q

Lithium S/Es

A

Hypothyroidism
Teratogenic - Ebstein’s anomaly
Cardiac impairment
Renal impairment
Tremor, sedation, lethargy, hair loss, polyuria, polydipsia, wt gain, confusion

Passmed:
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia

CI
- pregnancy, breastfeeding
- renal drugs - diuretics, ACEi, ARBs, CCBs, NSAIDs

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31
Q

Lithium toxicity

A

Can be from OD, or reduced excretion - dehydration, low renal function, infections, drug interactions

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32
Q

Lithium toxicity Px

A
  • anorexia, N+V+D, drowsiness, restlessness, dysarthria, dizzy, ataxia, incoordination, twitching, tremor
  • excessive thirst / urination
  • hyperreflexia, convulsions, collapse, coma, seizures
  • renal failure, dehydration, circulatory collapse, hypokalaemia

Passmed:
coarse tremor (a fine tremor is seen in therapeutic levels)
hyperreflexia
acute confusion
polyuria
seizure
coma

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33
Q

Lithium toxicity Ix

A
  • serum lithium levels
  • U/Es, renal function
  • ECG - T wave inversion, sinus node dysfunction, SA block, PR prolongation, QT prolongation, VT, STEMI, HB
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34
Q

Lithium toxicity Mx

A
  • stop lithium
  • stop diuretics
  • fluids
  • haemodialysis
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35
Q

Electroconvulsive therapy (ECT)

A
  • for catatonia, prolonged / severe mania, severe depression
  • CI - raised ICP
  • Short term S/Es - headache, nausea, short term memory impairment, memory loss, cardiac arrhythmias
  • Long-term S/Es - impaired memory
  • if on SSRI, reduce dose prior
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36
Q

Schizophrenia

A

Most common form of psychosis - splitting of thoughts / loss of contact with reality

  • underactivity of mesocortical pathway and relative overactivity of mesolimbic pathway (both dopaminergic systems)
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37
Q

Schizophrenia types

A

Paranoid - delusions / hallucinations
Hebephrenic - speech + behaviour
Simple - -ve sx
Residual - -ve sx after +ve
Catatonic - psychomotor features
Undifferentiated - no specific sx

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38
Q

Schizophrenia RFs

A
  • peaks 2-3rd decade and middle age
  • FHx
  • prem, urban areas, migration, trauma, abuse, cerebral injury, substance misuse
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39
Q

Schizophrenia Px

A

1st rank sx - need >1
- thought disorder (insertion, withdrawal, broadcast)
- passivity
- 3rd person auditory hallucinations
- delusional perceptions

2nd rank sx
- delusions
- 2nd person auditory hallucinations
- other hallucinations
- negative sx
- catatonia

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40
Q

Schizophrenia +ve/-ve sx

A

Positive sx
- auditory hallucinations
- delusions - fake, unshakeable belief
- catatonia
- thought disorder
- tangentiality, loosening of association
- speech disorder, eg pressured, word salad
- passivity

Negative sx
- avolition
- anhedonia
- asocial
- blunting / incongruity of affect
- low speech
- depression, self-neglect

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41
Q

Schizophrenia Ix

A
  • Hx / MSE
  • neuro exam
  • CT / MRI head
  • Bloods
  • Urine toxicology
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42
Q

Schizophrenia Mx

A
  • oral antipsychotics - risperidone / olanzapine
  • depot - slow release IM antipsychotic
  • Benzos for acute aggression
  • CBT, family therapy, art therapy, lifestyle changes
  • ECT
  • CVD risk modification
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43
Q

Schizoaffective disorder

A
  • mood disorder + schizophrenia

Manic - mania + psychosis
Depressive - depression + psychosis
Mixed - mania + depression + psychosis

Px
Combination of mania, depression, psychosis

Ix
- Hx/ MSE
- Bloods, imaging etc

Mx
- antipsychotics, antidepressants, CBT, social interventions

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44
Q

Psychotic depression

A
  • severe depression + delusions + hallucinations (false perception w/o external stimulus)

Mx
- CBT, antidepressants, antipsychotics

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45
Q

GAD Mx - NICE stepwise care model

A
  1. all dx, suspected GAD
    - education
    - monitor
  2. No improvement after 1.
    - low intensity CBT
    - individual / guided self-help groups
    - psychoeducational groups
  3. no response to 2. / marked functional impairment
    - high intensity CBT +/- sertraline / other SSRIs, SNRIs, pregabalin
  4. complex, refractory, self-neglect, self-harm
    - specialist
    - CBT + SSRI
  • propranolol - for autonomic sx
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45
Q

Generalised anxiety disorder (GAD)

A

Excessive worry / apprehension >6mo - leading to significant distress / functional impairment

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45
Q

GAD Px

A
  • Need >3 associated sx for dx

Mental
- apprehensive, nervous, frightened, rumination, depersonalisation, impaired conc, irritable…

Physical
- tach, palpitations, SOB, sweaty, N+V, dizzy, fatigue, diarrhoea, etc….

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45
Q

GAD Ix

A
  • H/E
  • GAD-7 questionnaire
  • Exclude organic cause - eg thyroid, cardiac, meds
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46
Q

Panic disorder

A
  • recurrent, episodic, severe panic attacks

Px
- sx peak in 10 mins
- discrete episodes of intense fear
PANICS Disorder:
- Palpitations
- Abdominal distress
- Numbness / nausea
- Intense fear of death
- Choking / chest pain
- Sweating / shaking / SOB
- Depersonalisation / derealisation

Ix
- r/o organic, H/E, GAD-7 (r/o GAD)
- ECG

Mx
- CBT
- SSRI - sertraline
- If giving TCA - imipramine

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46
Q

Phobias

A
  • excessive / unreasonable sx of anxiety due to specific triggers
  • eg arachnophobia, social phobia, agorophobia

Mx
- exposure therapy
- CBT, psychoeducation, relaxation training
- Meds - SSRIs, SNRIs, benzos may help to engage pt in exposure

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47
Q

Obsessive compulsive disorder (OCD)

A
  • chronic condition of thoughts (obsessions) + acts (compulsions) -> significant distress / impairment

Obsessions - involuntary intense thoughts, recurrent, recognised as from own mind (active, whereas schizo is passive)

Compulsions - repetitive physical / mental acts in response to obsession, anxiety / stress if not performed

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48
Q

OCD Dx

A
  • presence of obsessions / compulsions / both
  • most days for >2wks
  • know it’s from pts mind
  • time consuming, causes significant distress / impairment
  • > 1 event of failure to resist obsession
  • obsession unpleasantly repetitive
49
Q

OCD Ix

A

Assess risk, impact on self

50
Q

OCD Mx

A
  • Exposure and Response prevention (ERP)
  • CBT, psychotherapy
  • SSRIs, clomipramine (TCA) 2nd line
  • antipsychotics
51
Q

Adjustment disorder

A
  • difficulty adapting to stressor
  • onset <1mo of stressor, resolves in 6mo
  • therapy / support
52
Q

Acute stress reaction

A
  • transient response to exceptional stress / trauma, <1hr of event, occurs in <4wks after event, sx resolve in 3d

Px
- initial daze, tunnel vision, fight/flight, panic, hyperarousal

Mx
- trauma-focused CBT
- maybe EMDR
- BBs for sx

53
Q

Post-traumatic stress disorder (PTSD)

A
  • severe psychological disturbance following traumatic stressor
  • sx develop >4wks, last >1mo, cause distress / impairment
  • cPTSD - more severe circumstances
54
Q

PTSD Px

A

Intrusion - eg flashbacks, nightmares
Avoidance - avoid triggers
Hyperarousal - hypervigilant, irritable, reckless
Mood - emotional numbing, feel estranged

  • depression, substance misuse, anger
55
Q

PTSD Ix

A
  • Hx, MSE
  • Trauma screening questionnaire (TSQ)
56
Q

PTSD Mx

A
  • trauma-focused CBT
  • Eye movt desensitisation and reprocessing (EMDR)
  • SSRI, venlafaxine, risperidone if severe
  • zopiclone for sleep
57
Q

Anorexia nervosa

A

low BMI, fear of fatness, extreme dieting

58
Q

Anorexia nervosa Px

A
  • low bodyweight, restrictive eating, over-exercise, diuretics, laxatives
  • amenorrhoea, constipation, dysphagia, fatigue, faint, puberty delay
  • brady, low BP, peripheral oedema, gaunt face
  • fail sit-up / squat test
59
Q

Anorexia nervosa Ix

A
  • Bloods
  • DEXA if <18yo
  • ECG, assess risk
  • MARSIPAN checklist
60
Q

Anorexia nervosa Mx

A
  • CBT-ED
  • MANTRA - Maudsley Anorexia Nervosa Tx for Adults
  • SSCM - specialist supportive clinical mx
  • Family therapy <18yo
  • admit if unwell, oral / IV supplements, bisphosphonates - use MARSIPAN
61
Q

Anorexia nervosa Cx

A
  • low K, P, Mg, Cl, BM, high cholesterol
  • high cortisol, GH, low T3/4, low sex hormones
  • pancreatitis, ECG changes, HF, low HR/BP
  • osteoporosis, renal stones, AKI, CKD
  • infertility, infections….
62
Q

Refeeding syndrome

A
  • metabolic cx of refeeding after prolonged starvation
  • when starved - body turns from carb to fat/protein metabolism - drop in circulating insulin (low carb), decrease in IC electrolytes (phosphate)
  • when refeeding - carb levels rise, insulin increases, phosphate cellular uptake increases
  • low serum phosphate
  • low thiamine (co-enzyme in carb metabolism)
  • salt + water retention
63
Q

Refeeding syndrome Px

A
  • low K, Mg, phosp
  • high BM, encephalopathy (Wernicke-Korsakoff)
  • arrhythmias, HF, PO, rhabdo, seizures, death
64
Q

Refeeding syndrome Mx

A
  • prevention - high-dose pabrinex, refeed slowly
  • dietician involvement
  • correct electrolytes
  • phosphate supplementation
65
Q

Bulimia nervosa

A

Eating disorder characterised by binges + wt loss behaviours

66
Q

Bulimia Px

A
  • binge eating
  • vomiting / laxatives, fasting, excessive exercise
  • irregular periods
  • bloating, lethargy, reflux, abdo pain, sore throat
  • swollen salivary glands
  • dental erosion
  • Russel’s sign - calluses on back of hand
67
Q

Bulimia Ix

A
  • bloods - low K (check U/E)
68
Q

Bulimia Mx

A
  • CBT-ED
  • family therapy (bulimia focused)
69
Q

Personality disorders

A
  • series of maladaptive personality traits that interfere with normal function in life
  • Dx >18yo

Cluster A - weird
- paranoid
- schizotypal
- schizoid

Cluster B - wild
- antisocial
- EUPD / BPD
- histrionic
- narcissistic

Cluster C - worried
- avoidant / anxious
- obsessive-compulsive (anankastic)
- dependant

Ix
- Hx, MSE
- personality diagnostic questionnaire (PDQ-IV)
- Minnesota multiphasic personality inventory
- consider CT / MRI head
- risk assessment

Mx
- Tx sx - antidepressants, mood stabilisers
- Dialectical behavioural therapy (DBT)
- Mentalisation-based therapy
- CBT / psychodynamic therapy

70
Q

Paranoid

A

paranoid, doubts loyalty, relationships suffer, hypersensitive, perceives attacks

71
Q

Schizoid

A

cold, detached, doesn’t want close relationships, loner, reduced sex drive, few interests

72
Q

Schizotypal

A

odd beliefs, ideas of reference, paranoid, eccentric, lack of close friends, odd speech, magical thinking, inappropriate affect

73
Q

Antisocial

A

cold, rule-breaker, non-conformer to social rules, deceptive, aggressive, can’t maintain relationships

74
Q

EUPD

A

unstable, intense emotions, insecure, self-damaging, impulsive, suicidal

75
Q

Histrionic

A

centre of attention, inappropriate sexual seductiveness, shallow, egocentric, dramatic, manipulative

76
Q

Narcissistic

A

cold, arrogant, self-centred, takes advantage, egotistical, power-seeking, lack of empathy

77
Q

Obsessive-compulsive

A

Obsessive, meticulous, unwilling to delegate, pedantic, perfectionist, inflexible

78
Q

Avoidant

A

Anxious, timid, socially withdrawn (but crave interaction), insecure, fear of rejection

79
Q

Dependant

A

fear of abandonment, lack of self-confidence, clingy, needs others to take responsibility, lack of initiative, can’t disagree

80
Q

Autism spectrum disorder (ASD)

A

Developmental disorder of:
- impairments in social interaction / communication
- restricted interests / rigid behaviours

association with epilepsy, ADHD, LDs

Multifactorial causes

81
Q

ASD Px

A
  • sx emerge 1-2yo, initially - language delay, lack of response to name, limited eye contact

A - antisocial
- lack of eye contact, delay smiling, can’t read non-verbal cues, not playing

B - behaviour
- rituals, stereotyped behaviour, fixed routines, restricted food

C - communication
- delay in language development, lack of non-verbal cues

82
Q

ASD Ix

A
  • ASD tools - eg CHAT, ADI-R, DISCO
  • Dx after 2-3yo
  • refer to ASD team
  • full developmental assessment, hearing tests, karyotyping
83
Q

ASD Mx

A

Bio - tx co-existing conditions, melatonin, antipsychotics

Psycho - education, CBT, SSRIs

Social - educational interventions, play-based tx, behaviour modifications

84
Q

Attention deficit hyperactivity disorder (ADHD)

A

Inattention / hyperactivity / impulsivity that interferes with functioning / development

85
Q

ADHD Px

A

Inattentive - not paying attention, easily distracted

Hyperactive/impulsive - fidgets, leaves seat, blurts out etc

Can be inattentive / hyperactive / combined

86
Q

ADHD DSM-5 Dx

A
  • sx <12yo
  • present in 2+ settings, eg school + home
  • interfere with functioning
  • no schizo / psychosis
87
Q

ADHD Ix

A
  • by specialist psychiatrist / paediatrician
  • clinical / psychosocial assessment
  • rating scales, determine impact of sx on life
  • TFTs
88
Q

ADHD Mx

A
  • ADHD-focused support, diet + exercise
  • CBT
  • 10 week watch and wait

Drug therapy seen as last resort and only in those over 5 years old
- Methylphenidate (ritalin) - S/Es abdo pain, nausea, dyspepsia- in children weight and height every 6 months
- 2nd line - lisdexamfetamine, dexamfetamine- in those who can’t tolerate lis side effects
- All drugs - cardiotoxic (rpt ECGs), monitor height/weight every 6mo

89
Q

Alcohol misuse

A
  • drinking out of control
  • recommended levels <14units/wk
  • 1 unit = %ABV x volume (L)
90
Q

Alcohol misuse Ix

A

CAGE - yes to 2 - excessive drinking
- felt like you should cut down?
- people annoyed?
- feel bad / guilty?
- eye opener - drink in morning?

AUDIT - Alcohol Use Disorders Identification Test

FAST - Fast Alcohol Screening Test

SADQ - Severity of Alcohol Dependence Questionnaire

  • examination - ?withdrawal, hepatomegaly, ascites, ascites, Wernicke-Korsakoff syndrome
  • Bloods - FBC, clotting, U/E, LFTs, alcohol level
91
Q

Alcohol misuse Mx

A
  • CBT, behavioural therapies, motivational interviewing
  • Acamprosate - reduces cravings
  • Naltrexone - reduces pleasurable effects of alcohol
  • Disulfiram - causes unpleasant sx when drinking
  • Nalmefene - reduce alcohol consumption
92
Q

Acute alcohol withdrawal

A
  • after not drinking
  • mild sx 6-8hrs after, moderate/severe ~48hrs later
  • thought to be from low inhibitory GABA, increased NMDA glutamate transmission
93
Q

Alcohol withdrawal Px

A
  • insomnia, fatigue, anorexia
  • tremor, anxiety, N+V, headache, sweating, palpitations
  • hallucinations - after 12-24hrs
  • seizures - after 24-48hrs
  • delirium tremens - after 48-72hrs
94
Q

Alcohol withdrawal Ix

A
  • Hx
  • CIWA-Ar score - Clinical Institute withdrawal Assessment for Alcohol scale (revised) - >10 = benzos
  • Bloods - FBC, U/E, LFTs, coag, bone profile, Mg, phosph, BM
95
Q

Alcohol withdrawal Mx

A

Benzos
- reducing dose chlordiazepoxide over 5-7d
- diazepam
- Lorazepam preferred in patients with liver cirrosis/hepatic failure

  • pabrinex - thiamine
  • IV fluids
  • antiemetics
  • refer to alcohol liaison team
96
Q

Delirium tremens

A
  • Acute confusional state - hyperadrenergic

Px
- 24-72hrs after last drink
- hallucinations, confusion, delusions, severe agitation, seizures
- tachy, increased RR, hyperthermia, sweaty, tremor, mydriasis

Ix
- Bloods
- CT head
- CXR

Mx
- A-E
- Sedation - benzos
- pabrinex

97
Q

Wernicke-Korsakoff syndrome

A
  • thiamine (B1) deficiency
  • Triad - confusion + ataxia + ophthalmoplegia
  • Wernicke encephalopathy untreated -> Korsakoff syndrome

Px
- Double vision, eye movt abnormalities, eyelid drooping, unsteady walking, loss of memory, hallucinations
- abnormal reflexes, polyneuropathy, nystagmus, BP low, low temp, tachycardic
- confabulation, memory loss
- encephalopathy - 2/4 of thiamine deficiency, oculomotor abnormalities, cerebellar dysfunction, altered mental state

Ix
- Bloods, CT head, LP

Mx
- IV pabrinex - Wernicke’s
- PO thiamine + multivitamins for 2yrs - Korsakoff’s syndrome

98
Q

Opioid misuse

A

Sx of withdrawal
- 6-24hrs after last dose, lasts 5-7d
- sweaty, dilated pupils, increased HR, high BP, watering eyes/nose, abdo pain, N+V, tremor, cramps

OD Mx
- naloxone

Dependence Mx
- methadone / buprenorphine as detox - monitor compliance with urinalysis
- lofexidine - sx relief in withdrawal
- naltrexone - aids abstinence

99
Q

Mental health act

A

Legislation that defines how patients who won’t be admitted voluntarily may be detained (sectioned) for tx
- must not be under influence of drugs / alcohol
- need to have mental disorder - disorder / disability of mind

100
Q

Section 2

A
  • assessment
  • 28d, unrenewable
  • 2 Drs (one S12), 1 AMHP (approved mental health professional)
101
Q

Section 3

A
  • treatment
  • 6mo, renewable
  • 2 Drs, 1 AMHP
102
Q

Section 4

A
  • emergency order
  • 72hrs
  • only in urgent necessity where wait for S2 is too long
  • 1 Dr, 1 AMHP
103
Q

Section 5(2)

A
  • pt admitted but trying to leave
  • Drs holding power
  • 72hrs - allow time for section 2/3 assessment
  • can be coercively treated
104
Q

Section 5(4)

A
  • pt already admitted, wanting to leave
  • Nurses’ holding power
  • 6hrs
  • cannot be coercively treated
105
Q

Section 135/136

A
  • police sections
  • S135 - police remove person from home - need court order
  • S136 - police remove from public place
  • 24hrs, MHA assessment needed
  • take to place of safety - psych ward / police cell
106
Q

SSRIs

A
  • block serotonin transporters
  • sertraline, citalopram, fluoxetine, paroxetine

Indications
- depression, GAD, PTSD, ED, OCD

  • sertraline fewest drug interactions
  • Fluoxetine - for adolescents
  • sertraline post-MI
  • once started, review after 2wks / 1wk if <30 or high suicide risk
  • continue for >6mo after sx resolve
107
Q

SSRIs Adverse Effects

A
  • long QT (citalopram)
  • GI sx - N+V+D
  • GI bleed - if taking NSAID + SSRI, add PPI
  • sexual dysfunction
  • SIADH -> hyponatraemia
  • irritable, insomnia, anxiety, increased suicide risk
108
Q

SSRIs drug interactions

A
  • NSAIDs - give PPI
  • Warfarin / heparin / aspirin - avoid SSRI, consider mirtazapine
  • Triptans - avoid - SS risk
  • MAOIs - SS risk
109
Q

SSRI stopping

A
  • gradually reduce over 4wks (not necessary with fluoxetine)

Discontinuation sx
- mood change, restless, difficulty sleeping, unsteady, sweaty, abdo pain, D+V, paraesthesia

110
Q

SSRIs in pregnancy

A
  • risk vs benefit
  • congenital heart defect risk in 1st trim
  • pulm HTN risk in 3rd trim
  • paroxetine - risk of congenital malformations
111
Q

SNRIs

A
  • duloxetine, venlafaxine
  • block serotonin + noradrenaline reuptake inhibitors

Indications
- major depressive disorder, GAD, social anxiety disorder, panic disorder….

  • Increased NAd -> HTN, CV sx
112
Q

TCAs

A
  • sedative - amitriptyline, clomipramine, dosulepin, trazodone
  • less sedative - imipramine, lofepramine, nortriptyline

TCA choice
- low dose amitriptyline - neuropathic pain, tension/migraine prophylaxis
- lofepramine - lower risk of toxicity in OD
- amitriptyline / dosulepin - most dangerous in OD

S/Es
- anticholinergic - blurred vision, urinary retention, dry mouth, constipation
- A1 adrenergic antagonism - orthostatic hypotension
- Antihistamine (H1) - sedation
- OD, seizures
- QT prolongation

113
Q

MAOIs - monoamine oxidase inhibitors

A
  • phenelzine, isocarboxazid (A+B), selegiline (B)
  • serotonin + NAd are metabolised by monoamine oxidase in presynaptic cell
  • Type A - prevent serotonin breakdown
  • Type B - prevent dopamine breakdown (good for Parkinson’s)

Adverse effects
- SS risk if used with another antidepressant
- Food interaction - avoid tyramine foods (cheese, pickled herring, Bovril, Oxo, marmite, broad beans) - leads to hypertensive crisis (headache, tremor, HTN)
- Anticholinergic

114
Q

Atypical antidepressants

A
  • mirtazapine, bupropion
  • mirtazapine - blocks A2 adrenergic receptors - increases appetite, causes sedation (take in evening) - fewer S/Es - good for older pts
115
Q

1st gen antipsychotics (typical)

A
  • haloperidol, chlorpromazine
  • antagonise D2 receptors

S/Es
- hyperprolactinaemia, long QT, EPSEs

116
Q

2nd gen antipsychotics (atypical)

A
  • clozapine, olanzapine, risperidone, quetiapine, aripiprazole
  • antagonise D2 + serotonin receptors - lower EPSEs / prolactin - but wider S/E profile
  • aripiprazole - most tolerable S/Es
  • clozapine - for tx-resistant schizophrenia - agranulocytosis - weekly FBCs for 18wks, then monthly bloods, myocarditis risk - regular ECGs, reduced seizure threshold, smoking reduces efficacy (smokers need higher dose)
  • also wt gain, high lipids, sedation, orthostatic hypotension, long QT
117
Q

General S/Es antipsychotics

A
  • stroke / VTE risk in elderly
  • antimuscarinic - can’t pee…
  • galactorrhoea
  • reduced seizure threshold
  • long QT
  • NMS
118
Q

Antipsychotics monitoring

A
  • FBC, U/E, LFTs annually (clozapine weekly FBC to start)
  • lipids, weight gain, fasting BM, prolactin, BP, ECG, CV risk assessment
119
Q

Pseudoparkinsonism

A
  • parkinson-like sx - stooped posture, shuffling gait, rigidity, bradykinesia, tremors at rest, pill-rolling motion

Mx
- procyclidine / amantadine - anticholinergics

120
Q

Acute dystonia

A
  • abnormal involuntary muscle tone - spasms, twisting / repetitive movts, cramps
  • facial grimacing
  • oculogyric crisis
  • muscle spasms of tongue, face, neck, back

Mx
- procyclidine
- oculogyric crisis - clonazepam (BZD) second line

121
Q

Akasthisia

A
  • restlessness, affects voluntary movt
  • trouble standing still, pace floor, rocking back and forth

Mx
- Beta blocker

122
Q

Tardive dyskinesia

A
  • slower onset, continuous smooth involuntary movts
  • choreoathetoid movts - sucking, smacking movts of lips, chewing motions
  • involuntary movts of body / extremities

Mx
- tetrabenazine - anti-chorea

123
Q

Benzos

A
  • enhance GABA - increase frequency / duration of chloride channels
  • sedation, hypnotic, anxiolytic
  • withdrawal - insomnia, irritable, anxiety, tremor
  • flumazenil - benzo reversal, but seizure risk
124
Q

Z-drugs

A
  • non-benzo hypnotics
  • zopiclone
  • increased falls risk in elderly
125
Q

Barbituates

A
  • eg phenobarbitol
  • sedative hypnotics

Phase 4 Question Knowledge (30 decks)

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