Psychiatry Flashcards
1
Q
What is the name of a scoring system for anxiety & depression?
A
HADS - hospital anxiety and depression scale
2
Q
4 symptoms that distinguish mania from hypo mania?
A
- Symptoms for at least 7 days
- May require hospitalisation
- Psychotic features
- Causes severe functional impairment - work and social
3
Q
What is the time frame allowing a diagnosis of bulimia nervosa?
A
symptoms at least once a week for 3 months
4
Q
What is Russell’s sign?
A
calluses on the knuckles or back of the hand due to repeated self-induced vomiting
5
Q
What is the management of bulimia nervosa?
A
first line: referral for bulimia nervosa - focused guided self help
second line: individual eating disorder focused CBT
children: bulimia nervosa focused family therapy
6
Q
What are 5 risk factors for psychotic disorders?
A
- FH
- cannabis use
- migration
- urban living
- black caribbean ethnicity
7
Q
What are 3 things that may precipitate lithium toxicity?
A
- dehydration
- renal failure
- drugs - diuretics (thiazides), ACEi/ARBs, NSAIDs, metronidazole
8
Q
What are 5 drugs that may precipirate lithium toxicity?
A
- diuretics - especially thiazides
- ACE inhibitors
- Angiotensin II receptor blockers
- NSAIDs
- metronidazole
9
Q
What are 6 features of lithium toxicity?
A
- coarse tremor
- seizures
- polyuria
- confusion
- hyperreflexia
- coma
10
Q
At what levels of lithium does toxicity occur?
A
> 1.5 mmol/L (normal = 0.4 - 1.0)
11
Q
When should you re-review a patient with depression?
A
if not at increased risk of suicide:
* within 1 week if <30y and started on antidepressants
* within 2 weeks otherwise
12
Q
What is the management of lithium toxicity?
A
- normal saline for volume resuscitation if mild-moderate
- haemodialysis if severe
- sodium bicarbonate (limited evidence) - increases urine alkalinity to promote lithium excretion
13
Q
After what duration on an antidepressant should you consider increasing the dose or switching?
A
4 weeks (effects usually take 2-4 weeks)
14
Q
How should antidepressants be stopped?
A
reduce dose or frequency gradually over a 4 week period to minimise discontinuation symptoms
15
Q
What is section 2 MHA?
A
Admission for assessment up to 28 days, non renewable
Made by AMHP or NR on recommendation of 2 doctors (1 is approved under MHA 12(2) - usually psych cons)
16
Q
What is section 3 MHA?
A
Admission for treatment up to 6 months, can be renewed
AMHP along with 2 doctors, 1has seen patient in last 24h
17
Q
What is section 4 MHA?
A
72h assessment order - used when section 2 would cause unacceptable delay. GP + AMHP or NR
Often changed to s2 on arrival to hospital
18
Q
What is the first line treatment for mild-moderate Alzheimer’s?
A
Acetylcholinesterase inhibitors
* donepezil
* galantamine
* rivastigmine
19
Q
What is the second line treatment option for mild-moderate dementia?
A
NMDA receptor antagonist - memantine
20
Q
What are 3 situations when memantine is indicated?
A
- Moderate Alzheimer’s in patients intolerant or CI to acetylcholinesterase inhibtors
- Add on to acetylcholinesterase inhibitors in moderate to severe Alzheimer’s
- Monotherapy in severe Alzheimer’s
21
Q
What is a relative contraindication to acetylcholinesterase inhibitors E.g. donepezil
A
Resting bradycardia
22
Q
What is a side effect of acetylcholinesterase inhibitors such as donepezil and galantamine?
A
Insomnia
23
Q
What is the difference between somatisation and conversion disorder?
A
- somatisation - multiple somatic complaints, symptoms persist for several years (refuses to accept reassurance or negative test results)
- conversion - alteration or loss of a function suggestive of phsyical disorder, typically loss of motor or senosry function (La belle indifference)
24
Q
What is the ACE-3 and what does it detect?
A
Validated tool that is sensitive and specific for the detectionof dementia - >82 strongly suggests dementia
Tests 5 domains: memory, attention, fluency, language, visuospatial
25
What finding using the ACE-3 tool is suggestive of Alzheimer's dementia?
Global deficit in all 5 domains (memory, attention, fluency, language, visuospatial)
26
What will be seen in the ACE-3 with frontotemporal dementia?
deficits in domains Fluency and Language (due to frontal lobe damage, not memory/attention/visuospatial)
27
What will ACE-3 score show in vascular dementia?
no consistent pattern in ACE-3 examinations (depends on if previous stroke, and its location)
28
What ACE-3 score is suggestive of mild cognitive impairment?
82-88
29
Which domains in the ACE-3 will people with Parkinson's dementia show deficits?
visualspatial, memory, attention (less fluency and language)
30
What is Capgras syndrome?
delusion that a friend or partner has been replaced by an identical-looking imposter
31
What is Othello syndrome?
irrational belief that your partner is having an affair with no objective evidence
32
What is de Clerambault syndrome?
delusional idea that a person whom they onsider to be of **higher social and/or professional standing** is **in love** with them
33
What is Cotard syndrome?
delusional idea that one is dead
34
What is Fregoli syndrome?
delusional idea that the various people that the patient meets are in fact the same person
35
What is the mechanism of action of typical antipsychotics?
dopamin D2 receptor antagonists - block dopaminergic transmission in mesolimbin pathways
36
What is the mechanism of action of atypical antipsychotics?
act on variety of receptors - D2, D3, D4, 5-HT
37
What are 4 key side effects of typical antipsychotics?
EPSEs
1. acute dystonias - e.g. torticollis, ocylogyric crisis
2. Parkinsonism
3. akathisia - severe restlessness
4. tardive dyskinesia - choreoathetoid movements, chewing + pouting of jaw
38
What is the treatment of acute dystonias?
procyclidine
39
What are 2 specific risks of antipsychotics (typical and atypical) in elderly patients?
1. stroke
2. VTE
40
In addition to EPSEs what are 8 other side effects of typical antipsychotics?
1. antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
2. sedation
3. weight gain
4. raised prolactin (galactorrhoea)
5. impaired glucose tolerance
6. neuroleptic malignant syndrome
7. reduced seizure threshold
8. prolonged QT interval (haloperidol)
41
What are 5 factors assocaited with poor prognosis in schizophrenia?
1. strong family history
2. gradual onset
3. low IQ
4. prodromal phase of social withdrawal
5. lack of obvious precipitant
42
What condition is the impulse urge to pick at one's own skin, often to the extent that damage is called?
dermatillomania
43
What is the only absolute contraindication to electroconvulsive therapy?
raised intracranial pressure
44
What are the indications for electroconvulsive therapy?
life-threatening major depressive disorder where catatonia is present or psychotic symptoms
45
What are 5 short-term side effects of ECT?
1. headache
2. nausea
3. short-term memory impairment
4. memory loss of events prior to ECT
5. cardiac arrhythmia
46
What is a long term side effect of ECT?
impaired memory
47
What drugs can cause neuroleptic malignant syndrome?
* antipsychotics - typically typical
* dopaminergic drugs e.g. levodopa
48
What is thought to be a possible mechanism for neuroleptic malignant syndrome?
the dopamine blockade induced by antipsychotics triggers massive glutamate release and subsequent neurotoxicity & muscle damage
49
How quickly does neuroleptic malignant syndrome occur?
within hours to days of starting an antipsychotic
50
What may blood tests show in neuroleptic malignant syndrome?
* raised creatine kinase
* raised leukocytes
* AKI may develop secondary to rhabdomyolysis
51
What are 4 aspects of the management of neuroleptic malignant syndrome?
1. stop antipsychotic
2. transfer to medical ward - usually ITU
3. **IV fluids**
4. **dantrolene**
5. bromocriptine may also be used
52
How does dantrolene work to treat neuroleptic malignant syndrome?
decreasing excitation-contraction coupling in skeletal muscle by binding to the **ryanodine receptor**, decreasing release of **calcium** from the **sarcoplasmic reticulum**
53
What are 7 findings on examination in patients with neuroleptic malignant syndrome?
1. hyporeflexia
2. lead pipe rigidity
3. normal pupils
4. tachycardia
5. hypertension
6. pyrexia
7. diaphoresis
54
What are 3 differences between neuroleptic malignant syndrome and serotonergic syndrome?
1. hyperreflexia in SS, hyporeflexia in NMS
2. SS has faster onset (hours) than NMS (hours to days)
3. dilated pupils in SS, normal pupils in NMS
55
What are 8 risk factors for a patient to attempt suicide?
1. male sex
2. history of DSH
3. alcohol or drug abuse
4. history of mental illness (schizophrenia, depression)
5. chronic disease
6. advancing age
7. unemployment / social isolation
8. unmarried, divorced or widowed
56
What are 5 risk factors for successful suicide attempt in someone who has already attempted suicide unsuccessfully?
1. efforts to avoid discovery
2. planning
3. leaving written note
4. sorting finances
5. violent method
57
What are 3 protective factors which reduce the risk of a patient committing suicide?
1. family support
2. children at home
3. religious belief
58
What is the primary mechanism via which TCAs exert their antidepressant effect?
inhibition of reuptake of neurotransmitters - serotonin and noradrenaline (increase synaptic cleft concentration)
59
What other receptors do TCAs interact at (as well at 5-HT and noradrenaline), and what side effects does this lead to?
* antagonist of histamine: drowsiness
* antagonist of muscarinic: dry mouth, blurred vision, constipation, urinary retention
* antagonist of adrenergic: postural hypotension
* prolonged QT
60
Which TCA has a lower incidence of toxicity in overdose?
lofepramine
61
Which 2 TCAs are most dangerous in overdose?
1. amitriptyline
2. dosulepin
62
Which 4 TCAs are more sedative?
1. amitriptyline
2. clompramine
3. dosulepin
4. trazodone
63
Which 3 TCAs are less sedative?
1. imipramine
2. lofepramine
3. notriptyline
64
If a patient is under the MCA and MHA, regains capacity and refuses treatment, what is the appropriate course of action?
if treatment is for mental disorders & patient admitted to hospital already - MHA overrides MCA so can give patient treatment against their will even if they have capacity
65
What is the main benefit of atypical antipsychotics over typical antipsychotics?
reduction in extra-pyramidal side-effects
66
What are 4 key adverse effects of atypical antipsychotics?
1. weight gain
2. clozapine - agranulocytosis
3. hyperprolactinaemia
4. reduced seizure threshold
67
What are 6 examples of atypical antipsychotics?
1. clozapine
2. olanzapine
3. amisupride
4. risperidone
5. quetiapine
6. aripiprazole
68
Which atypical antipsychotic has a higher risk of dyslipidaemia and obesity?
olanzapine
69
Which atypical antipsychotic has a lower risk of prolactin elevation?
aripiprazole
70
What are the 4 steps for the management of generalised anxiety disorder?
1. education / active monitoring
2. low intensity psych interventions (self help, psychoed groups)
3. high intensity psych interventiosn (CBT, applied relaxation)
4. higly specialist input e.g. multi-agency teams
drug treatment - SSRI first line
71
What are 3 steps in the approach for medication in GAD?
* SSRI - sertraline firts line
* alternative SSRI or SNRI second line
* if can't tolerate SSRI/SNRI - pregabalin
72
What treatment is offered for panic disorder in primary care?
either CBT OR drug treatment (SSRI first-line)
73
What is recommended if there is no response to SSRIs used first-line in panic disorder?
if no response after 12 weeks - imipramine or clomipramine should be offered
74
What should be done if a patient is responding well to mirtazapine but suffering with daytime somnolence?
increase the dose - mirtazapine is more sedating at lower doses (e.g. 15mg) than higher (e.g. 45mg)
75
What are 3 main subtypes of vascular dementia?
1. stroke-related: multi-infarct or single-infarct dementia
2. subcortical: small vessel disease
3. mixed: vascular and Alzheimer's dementia present
76
How does NICE recommend a diagnosis of vascular dementia is made?
NINDS-AIREN criteria for probable vascular dementia
77
What are 4 physical features of anorexia nervosa?
1. reduced BMI
2. bradycardia
3. hypotension
4. enlarged salivary glands
78
What are 11 physiological abnormalities seen in anorexia nervosa?
1. hypokalaemia
2. low FSH
3. low LH
4. low oestrogens
5. low testosterone
6. impaired glucose tolerance (high glucose)
7. hypercholesterolaemia
8. hypercarotinaemia
9. low T3
10. raised cortisol
11. raised growth hormone
| everything low apart from Gs and Cs
79
What is thought to cause sleep paralysis?
part of rapid eye movement sleep - transient paralysis of skeletal muscles when awakening or while falling asleep
80
What are 2 key features of sleep paralysis?
1. paralysis - after waking or shortly before falling asleep
2. hallucinations - images or speaking during paralysis
81
What is a treatment option for sleep paralysis?
if troublesome - **clonazepam**
82
What is the diagnostic criteria for ADHD?
* persistent inattention and/or hyperactivity / impulsivity
* for children up to age 16 y - 6 features present
* > 17 years - 5 features
| see table
83
What is the gender ratio of ADHD?
M:F 4:1
84
What does NICE suggest as the initial management of ADHD?
* 10 week watch and wait period to observe
* if persistent symptoms - refer to paediatrician with special interest in behavioural disorders or CAMHS
* education and training programmes for parents
* drug therapy last resort, only for age > 5years
85
What is the first line drug for ADHD in children?
methylphenidate - 6 week trial basis
86
What is the mechanism of action of methylphenidate?
dopamine/noradrenaline reuptake inhibitor
87
What are 3 side effects of methylphenidate?
1. abdominal pain
2. nausea
3. dyspepsia
88
If a child with ADHD shows inadequate response to methylphenidate which drug shouhld be tried?
lisdexamfetamine
89
What can be tried for ADHD in those who have benefited from lisdexamfetamine but can't toelrate the side effects?
dexamfetamine
90
What are the 2 first line options for ADHD in adults?
methylphenidate or lisdexamfetamine (switch between if no benefit after initial trial)
91
What baseline investigation should be done before starting methylphenidate or lisdexamfetamine?
ECG (can be cardiotoxic)
92
What is the characteristic pathological feature of lewy body dementia?
alpha-synuclein cytoplasmic inclusions (Lewy bodies) in substantia nigra, paralimbic and neocortical areas
93
What differentiates Lewy body dementia from parkinson's disease dementia?
progressive cognitive impairment occurs before motor symptoms
| visual hallucinations seen and fluctuating cognition
94
How is a diagnosis of Lewy body dementia made?
* usually clinical
* SPECT increasingly used (123-I FP-CIT used as radioisotope)
95
What is the management of Lewy body dementia?
* acetylcholinesterase inhibitors e.g. donepezil, rivastigmine
* memantine
| avoid neuroleptics
96
What are 3 types of frontotemporal lobar degeneration?
1. Frontotemporal dementia (Picks disease)
2. Progressive non-fluent aphasia (chronic progressive aphasia, CPA)
3. semantic dementia
97
What are 4 common features of frontotemporal lobar degeneration?
1. onset < 65 y
2. insidious
3. preserved memory and visuospatial skills
4. personality change and social conduct problems
98
What pathological change in anatomy is characteristic of Pick's disease?
focal gyral atrophy with knife-blade appearance
99
What are 4 microscopic changes in frontotemporal dementia?
1. Pick bodies - spherical aggregations of tau protein (silver-staining)
2. Gliosis
3. Neurofibrillary tangles
4. Senile plaques
100
What do NICE recommend about management of frontotemporal dementia?
do NOT recommend AChE inhibitors or memantine
101
What are the key features of chronic progressive aphasia?
non fluent speech - short utterances that are agrammatic. Comprehension relatively preserved.
102
What characterises semantic dementia?
fluent progressive aphasia. speech fluent but empty and conveys little meaning. memory is **better** for **recent** rather than remote events.
103
When should clozapine be used?
only if not controlled despite 2 or more antipsychotics tried (at least one second generation drug) for 6-8 weeks
104
What are 5 adverse effects of clozapine?
1. agranulocytosis / neutropenia
2. reduced seizure threshold
3. constiptaion
4. myocarditis
5. hypersalivation
105
What might cause the dose of clozapine to need adjusting during treatment?
smoking stopped or started
106
What are 2 assessment tools for dementia recommended by NICE for the non-specialist setting ?
1. 10-point cognitive screener (10-CS)
2. 6 item cognitive impairment test (6CIT)
107
What is a section 17a?
* Supervised Community Treatment (Community Treatment Order)
* can be used to recall a patient ot hospital for treatment if don't comply with conditions of the order in community, e.g. complying with medication
108
What is section 5(2) MHA?
patient who is voluntary patient in hospital can be legally detained by a doctor for 72h
109
What is section 5(4) MHA?
allows nurse to detain a patient who is voluntarily in hospital for 6 hours
110
What is section 135?
allow the police to break into a property to remove a person to a Place of Safety (13fiv - where I live)
111
What is section 136?
someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
112
How long does a section 136 last for?
up to 24h - whilst MHA assessment arranged
113
What are the 3 clusters of personality disorders?
1. cluster A: odd/eccentric - **paranoid, schizoid, schizotypal**
2. cluster B: dramatic/emotional/erratic: **antisocial, borderline (EUPD), histrionic, narcissistic**
3. cluster C: anxious/fearful: **obsessive-compulsive (anankastic), avoidant, dependent**
114
What is another name for anankastic personality disorder?
obsessive compulsive personality disorder
115
How is obsessive compulstive personality disorder (OCPD) different from OCD?
* in OCD, thoughts and behaviours are seen as unwanted/unhealthy + product of anxiety-inducing and involuntary thoughts
* OCPD thoughts are egosyntonic i.e. perceived as being rational and desirable
116
What are the features of paranoid personality disorder?
* **Hypersensitivity** and an **unforgiving** attitude when insulted
* tendency to **question loyalty** of friends
* Reluctance to **confide** in others
* Preoccupation with **conspirational beliefs** and hidden meaning
* tendency to perceive **attacks on their character**
117
What are the key 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
118
What are the key features of schizotypal personality disorder?
* I**deas 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
119
What are the key 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
120
What are the key features of borderline personality disorder (EUPD)?
* 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
121
What are the key features of histrionic personaliy 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
122
What are the key 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
123
What are the features of obsessive-compulsive peresonality 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
124
What are the key 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
125
What are the key 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
126
What are the key 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
127
What are 2 key things which help in the treatment of personality disorders?
1. Psychological therapies: dialectical behaviour therapy
2. treatment of co-existing psychiatric conditions
128
What type of thyroid derangement picture is caused by Riedel's thyroiditis?
hypothyroidism
129
What type of thyroid derangement picture is caused by toxic multinodular goitre?
hyperthyroidism
