Psychiatry Flashcards
What is the strongest RF for schizophrenia
family history (monozygotic twins- 50%, parent- 10-15%)
RF for schizophrenia (5)
family history
black carribbean
migration
urban environment
cannabis use
two theories of the pathophysiology of schizophrenia
neurodevelopmental and neurotransmitter
factors that indicate a poor prognosis in schizophrenia (5)
strong Fhx
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
what are schnieder’s first rank symptoms for schizophrenia (4)
auditory hallucinations (3rd person narration)
thought disorder (insertion, withdrawal, broadcasting)
delusional perceptions
somatic passivity
what are the negative symptoms of schizophrenia (4)
anhedonia
alogia (poverty of speech)
avolition (poverty of motivation)
affective flattening
what are delusional perceptions
where someone experiences a normal perception which triggers a self related delusion
e.g. the traffic light is green so i am god
what are some examples of delusions
delusions of grandiosity
erotomatic delusions
cotard syndrome
What is circumstantiality
where someone answers a question by going of on a tangent but then returning to the point
what is tangentiality
where someone wanders from a topic but does not return to the original poin
What is neoligisms
where someone makes up a new word - sometimes from combining two words
what are clang associations
where someone speaks in a manner where ideas are related by rhyming
what is word salad
incoherent speech
What is knights move thinking
where someone makes illogical leaps between topics
what is flight of ideas
where someone leaps from one topic to another with discernable links
what is echolalia
repition of someone elses speech
what makes up DSM-5’s definition of schizophrenia
symptoms must be present for at least 6 months with features of the active phase being present for at least one month
what makes up ICD-10’s definition of schizophrenai
at least 2 symptoms present for one month where one of the symptoms is a core symptom:
- persistent delusions
- persistent hallucinations
- disorganised thinking
- experiences of influence, control, passivity
cannot be attributable to another illness or substance
what is the overall treatment of schizophrenia
antipsychotics and CBT
what type of antipsychotics are first lien
atypical antipsychotics
give some examples of atypical antipsychotics
risperidone
olanzapine
quetiapine
aripiprazole
which atypical antispychotic has the least SE
aripiprazole
what two types of antipsychotics are there
atypical and typical
give 2 examples of typical antipsychotics
haloperidol and chlopromazine
what is the criteria for prescribing clozapien
at least 2 antipsychotics need to have been tried for 6-8 weeks each
which type of antipsychotic is associated with extrapyramidal side effects
typical (e.g. chlorpromazine)
give examples of extrapyramidal SE
parkinsonisms
acute dystonia
akasthisia
tardive dyskinesia
how can acute dystonia be treated
procyclidine
SE of typical antipsychotics
extrapyramidal SE
hyperprolactinoma
SE of atypical antipsychotics
metabolic effects
impaired glucose tolerance
weight gain
reduced stroke threshold
which antipsychotic can cause prolonged QT
haloperidol
SE of clozapine
agranulocytosis
reduced seizure threshold
constipation
myocarditis
hypersalivation
what lifestyle factor can effect clozapine
smoking
what is bipolar disorder
a psychiatric condition characterised by recurrent episodes of depression and mania/hypomania
what is mania
episodes of excessively elevated mood and energy with significant impact on normal functions-
- episodes last at least one week
- epsiodes have severe impacts on social or occupational functioning
- psychotic features (e.g. delusions of grandiosity, flight of ideas, pressured speech)
what is hypomania
episodes of elevated mood and energy, milder than manic episodes
- last at least 4 days
- do not have psychotic features or have significant impacts on normal functions
what are some symptoms of mania
increased mood
irritability
increased energy
decreased sleep
grandiosity
increased risk taking behaviour
disinhibition and sexually inappropriate behaviour
flight of ideas
pressured speech
psychosis
increased libido
what is cyclothymia
mild symptoms of low mood and hypomania
how is mania acutely managed (2)
stop current antidepressants
start antipsychotics- e.g. olanzapine, haloperidol
can use sodium valproate or lithium
how is depression in bipolar treated
olanzapine plus fluoxetine
can do antipsychotics or lamotrigine
what is the first line long term mood stabiliser in bipolar
lithium
what are side effects of lithium (10)
nausea and vomiting
fine tremor
weight gain
chronic kidney disease (renally excreted)
hypothyroidism
hyperparathyroidism and hypercalcaemia
nephrogenic diabetes insipidus
idiopathic intracranial HTN
T wave flattening on ECG
lithium toxicity
at what level does lithium toxicity often present
above 1.5 mmol/l
what can precipitate lithium toxicity
dehydration
renal failure
drugs (NSAIDs, thiazides, ACEi)
how does lithium toxicity present?
coarse tremor (usually fine tremor at the therapeutic dose)
hyperreflexia
confusion
polyuria
seizure
coma
how is lithium toxicity managed
IV isotonic saline
may need haemodialysis
sometimes sodium bicarbonate is used
how soon after a dose change should lithium levels be checked
1 weeks
how long after a dose of lithium should levels be checked?
12 hours
generally how often should lithium levels be checked
every 3 months
what are alternatives to lithium in the long term management of bipoalr
sodium valproate and olanzapine
two theories of how lithium works
interferes with inositol triphosphate formation
interferes with cAMP formation
what is generalised anxiety disorder
excessive worrying and disproportional anxiety about a number of events that negatively impacts the persons everyday life
RF for GAD
female
family histord
childhoof adversity
history of sexual or emotional trauma
secondary causes of anxiety that need to be excluded (5)
substance use (e.g. caffeine, cortiocsteroids)
substance withdrawal (e.g. alcohol, benzos)
hyperthyroidism
phaeochromocytoma
cushings disease
What can the symptoms of anxiety be split into?
emotional and cognitive symptoms
physical symptoms
emotional and cognitive symptoms of anxiety
excessive worrying
restlessness
difficulty relaxing
difficulty concentrating
unable to control worrying
easily tired
physical symptoms of anxiety
muscle tension
tremor
palpitations
sweating
insomnia
GI symptoms
headaches
how long should symptoms of anxiety occur for for a diagnosis
most days for at least 6 months
What can be used to quantify the severity of anxiety
the generalised anxiety disorder questionnaire (GAD-7)h
interpretation of the GAD-7 results
5-9 = mild anxiety
10-14= moderate anxiety
15-21= severe anxiety
stepwise management of GAD
1- education and active monitoring
2- low intensity psychological intervention (e.g. non guided self-help, guided self-help, psychoeducations groups)
3- high intensity psychological interventions (e.g. CBT)
or drug therapy
4- specialisy inputfi
first line drug treatment in GAD
sertraline
stepwise management of drug treatment of anxiety
1- sertraline
2- other SSRI or SNRI (venlafaxine or duloxetine)
3- pregabaline
what characterises depression
a disorder of low mood, low energy and reduced enjoyment of activities
pathophysiology of depression
thought to be due to neurotransitter disturbance in the CNS - particularly serotonin
what might contribuite to causing depression
relationship breakdowns
grief
housing situations
occupational stress
financial stress
three types of symptoms associated with depression
emotional
cognitive
physical
emotional symptoms of depression
anxiety, low mood, irritability, low self-esteem, guilt, hopelessness
cognitive symptoms of depression
poor concentration, slow thoughts, poor memory
physical symptoms of depression
low energy
abnormal sleep (Early awakening)
poor appetite
slow movmements
what features of depression need to be risk assessed in assessment
self-neglect
self harm
harm to others (including neglect)
suicide
what physical conditions can cause depression?
stroke
MI
MS
parkinsons
What questionnaire can assess the severity of depression and how does it work?
the PHQ-9 questionnaire
enquires about how often someone has experienced certain symptoms over the past 2 weeks
interpretation of the scores of the PHQ-9
5-9 mild
9-14 moderate
15-19 moderate- severe
20-27 severe
NICE recommends that >16 is more severe depression and <16 is less severe
features of the ICD-10 definition of depression
at least one core symptom (low mood, anhedonia, low energy) on most days for the past 2 weeks
management of less severe depression
- guided self help and active monitoring
- therapy- group CBT, group behavioural activation, individual CBT, individual BA, group exercise, group meditation and mindfulness
- antidepressants (not 1st line)
first line treatment of more severe depression
CBT and SSRI (sertraline)
examples of SSRI’s
sertraline
citalopram
fluoxetine
paroxetine
escitalopram
how do SSRI’s work?
they block the reuptake of serotonin from the neuromuscular junction
which two groups of patients would likely have sertraline first line
those with anxiety symptoms
those who have had MI’s or cardiac disease
specific SE of citalopram
prolonged QT interval - can cause Torsades de pointes
why is fluoxetine preferred in children
it has a longer half life so is less likely to cause discontinuation syndrome (stays in body for longer)
SE of SSRIs
GI upset (diarrhoea- particularly sertraline) , headaches, sexual dysfunction (ED, low libido), hyponatraemia (SIADH), anxiety, increases suicide risk in first few weeks, increased bleeding (particularly if on NSAIDs, anticoagulants)
what is a complication that can occur with SSRIs (increased)
serotonin syndrome
what can trigger serotonin syndrome
St Johns wart, triptans, MAO-B’s
pathophysiology of serotonin syndrome
too much serotonin stimulation
how does serotonin syndrome present
altered mental state- confusion
autonomic system hyperactivity- hyperthermia, sweating
neuromuscular hyperactivity- rigidity, hyperreflexia, myoclonus
how is serotonin syndrome managed?
IV fluids
benzodiazepiens
serotonin antagonists- chlorpromazine
What is discontinuation syndrome and why does it occur
occurs when antidepressants aren’t slowly tappered down
how does discontinuation syndrome present?
increased mood changes
restlessness
difficulty sleeping
parasthesia
GI upset
sweating
unsteadiness
which antidepressants are at an increased likelihood of discontinuation syndrome
paroxetine and venlafaxine
which antidepressant does not cause discontinuation syndrome
fluoxetine
which patients would not be prescribed SNRI’s
those with uncontrolled HTN as can cause increased BP
2 examples of SNRIs
venlafaxine and duloxetine
action of TCA’s
blocks the reuptake of serotonin and noradrenaline
SE of TCAs
anticholinergic effects- dry mouth, blurred vision, constipation , urinary retention
drowsiness
postural HTN
arrhythmias - tachycardia, prolonged QT
Who might be prescribed mitrazapine (2)
those with low appetite
those with insomnia
what is OCD
a mental disorder characterised by recurrent obsessions, compulsions or both which causes significant functional impairment and or distress
what is an obsession
an unwanted intrusive thought, image or urge that repeatedly enters the persons mind
what is a compulsion
a repetitive behaviour or ritual including mental acts that the person may be driven to perform by their obsession
RF for OCD
female
family history
pregnancy and postpartum
history of abuse
common obsessions
contamination with dirt
fear of harm
forbidden thoughs
common compulsions
repetitive hand washig
checking
ordering and arranging
how can the severity of OCD be determined?
Y-BOCS scale
what would classify severe OCD
> 3 hours a day are taken up by compulsions or obsessions
there is significant distress
there is little self control
features of the ICD-10 definition of OCD
present on most days for 2 weeks
- thoughts or impulses are recognised as individuals own
- must be at least one thought that is resisted unsuccessfully
- the though of carrying out the act is not itself pleasurable
- the thoughts and impulses must be unpleasantly repetitve
first line treatment of mild OCD
CBT and exposure and response prevention
first line drug treatment of severe OCD
SSRI
2nd line drug treatment of severe OCD
clomipramine
drug treatment of body dysmorphic disorder
fluoxetine
what is PTSD
a mental condition that results from traumatic experiences with ongoing distressing symptoms and impaired function
what are the 4 key symptoms of PTSD
re-experiencing: flashbacks, nightmares, repetivite and disturbing images
avoidance- of places, people, situations that remind them of event
Hyperarousal- hypervigilance to threat, exaggerated startle resposnse, sleep problems
emotional numbing- lack of ability to experience emotions, feeling detached
first line treatment for PTSD
trauma focused CBT or eye movement desensitisation and reprocessing
what drugs may be used to treat PTSD
venlafaxine or sertraline
how long do PTSD symptoms need to have lasted for
4 weeks
difference between PTSD and acute stress reaction
acute stress reaction is present for less than 4 weeks, PTSD is over 4 weeks
What is somatisation disorder
a disorder where a patient presents with multiple physical symptoms that have been present for over 2 years but have no apparent organic cause
Symptoms may include cardiac (chest pain), GI (diarrhoea, vomiting), MSK and neuro (headache, dizziness)
The patient will refuse to accept negative tests
What is hypochondriasis
illness anxiety disorder
where a patient has persistent belief that they have an underlying condition (e.g. cancer)
patient will refuse to accept negative tests
what is conversion disorder
a condition where a patient presents with symptoms of a disease of the brain and nerves
- may include vision loss, weakness, paralysis
- the patient is not consciously feigning symptoms and often expresses la belle indifference
What is la belle indifference
where there is absence of psychological distress when a patient presents with symptoms of a serious medical illness
what is factitious disorder
intentional production of physical or psychological symptoms
also called munchausens
What is malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial gain
what is delirium
an acute and fluctuating change in mental status with inattention, disorganised thinking and altered levels of consciousness
RF for delirium
old age
dementia
visual or hearing impairment
functional impairment
immobility
past history of delirium
decreased oral intake
polypharmacy
coexisting medical conditions
frailty
surgery
predisposing factors for delirium
drugs (sedatives, opiates, TCA’s, stimulants, alcohol)
primary neurological injury (stroke, haemorrhage)
acute illness (infection- pneumonia, UTI)
metabolic disturbance
surgery
iatrogenic events
pain
prolonged sleep deprivation
drug withdrawal
3 types of delirium
hypoactive- lethargy, decreased motor activity, incoherent speech
hyperactive - restlessness, agitation, hallucinations, inappropriate behaviour
mixed
what features would suggest delirium over dementia ?
acute onset
agitation or fear
impairment of consciousness
delusions
fluctuating symptoms (worse at night)
abnormal perceptions (illusions and hallucinations)
what quick test can be used to screen for delirium and what are its components
the 4A’s test
Alertness
a short test of orientation
attention
acute and fluctuating changes
what drug treatment may be used for delirium
haloperidol first line
What are three types of phobia disorders
specific phobia
social phobia
agoraphobia
what is specific phobia and give some examples
intense anxiety triggered by a specific object or situation leading to avoidance behaviour
common examples include animals, heights, thunder, flying, blood exposure
what is social phobia
fear of scrutiny by others in relatively small groups leading to the avoidance of social situations- can be specific to things such as public speaking or can be generalised
What is agoraphobia
fear of open spaces and associated factors like the presence of crowds or perceived difficulty of immediate easy escape to a safe place
first line management of phobias
CBT
first line drug treatment is SSRIs
What 3 features make up the DSM-5 criteria for anorexia nervosa
- restriction of energy intake relative to requirement leading to a significantly lower body weight in the context of age, sex, developmental trajectory and physical health
- intense fear of gaining weight or becoming fat despite being underweight
- disturbance in the way in which ones body weight or shape is experienced, undue influence of body weight or shape on self-evaluation or denial of the seriousness of the current low body weight.
1st line treatment of anorexia in children and adolescents
anorexia family focused therapy
second line treatment of anorexia in children
CBT
treatment options for anorexia in adults
individual eating disorder CBT
maudsley anorexia nervosa treatment for adults
specialist support clinical management
what electrolyte abnormalities are present in refeeding syndrome?
hypophosphataemia
hypokalaemia
hypomagnesaemia
What physiological abnormalities might be present in anorexia (7)
hypokalaemia
low FSH,LH, oestrogen and testosterone
increased growth hormone and cortisol
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
What receptors do opioids bind to?
opioid receptors
Features of opioid misuse
rhinorrhoea
needle track marks
pinpoint pupils
drowsiness
watering eyes
yawning
complications of opioid misuse
viral infections from sharing needles- HIV, Hep B and C
bacterial infections - Infective endocarditis, septic arthritis
VTE
overdose- resp depression
psychosocial problems
How is opioid overdose managed?
IV or IM naloxone
What two drugs can be used in the management of opioid dependence?
methadone or bupenorphine
What additional benefit does bupenorphine have and why?
it can reduce the effect of other opioids injected- it has a high affinity for the receptors so means other opioids cannot bind and exert their effects
Action of cocaine
blocks the reuptake of dopamine, noradrenaline and serotonin from the presynaptic membrane
What can cocaine misuse cause?
- coronary artery vasospasm (MI)
- hypertension
- aortic dissection
- seizures
- mydriasis
- hypertonia and hyperreflexia
- agitation
- hallucinations
- ischaemic colitis
- rhabdomyolisis
How is cocaine toxicity treated?
benzodiazepines
- if chest pain may add GTN
- if HTN may had sodium nitroprusside
Action of ecstasy
stimulates the release of serotonin and blocks its reuptake
how does ecstasy toxicity present?
agitation
confusion
tachycardia
hypertension
rhabdomyolisis
hyponatraemia (from SIADH or excessive water intake)
hyperthermia
what may be used to treat hyperthermia in ecstasy toxicity
dantrolene
Action of LSD
stimulation of the serotonin receptors
Action of benzodiazepines
stimulation of the GABA receptors
action of cannabis
stimulation of the cannabinoid receptors
management of paracetamol overdose
if within 1 hour= activated charcoal to reduce absorption
if over an hour- acetylcysteine infusion over one hour (if concentration is above treatment line)
when might a liver transplant be indicated in paracetamol overdose?
if arterial pH is <7.3 24 hours after ingestion
If PTT > 100 seconds
IF creatinine > 300
If the is grade III of IV encephalopathy
antedote to methanol overdose?
fomepizole or ethanol
antidote to TCA overdose
IV bicarbonate
Antidote for calcium channel blocker overdose?
calcium chloride or calcium gluconate
what is antifreeze known as ?
ethylene glycol
management of antifreeze ingestion
fomepizole or ethanol
How can paracetamol overdose present?
nausea and vomiting
right subcostal pain and tenderness
reduced conciousness
hypoglycaemia
respiratory depression
How might TCA overdose present?
dry mouth
seizures
coma
arrhythmias
hypothermia
how might beta blocker overdose present
bradycardia
hypotension
syncope
heart failure
drowsiness and confusion
antidote of benzodiazepine overdose
flumazenil
Who can be treated using ECT?
- severe treatment resistant depression (catatonia)
- prolonged and severe manic episodes
- may be used in schizophrenia however evidence negates this from being recommended
what is an absolute contraindication to ECT ?
increased intracranial pressure
- need to be careful in those with increased risk of a cardiovascular even
What are some side effects of ECT?
headache
nausea
short term memory loss
cardiac arrhythmias
How many sessions of ECT are usually used?
6-12 sessions given twice weekly
how does ECT work>
electrodes are placed on a persons scalp and electrical activity is passed through the brain
this induced a generalised seizure
the patient is under general anaesthetic and muscle relaxants
the theory is that it changes the post-synaptic response to CNS neurotransmitters
what are hypnotics
medications that induce sleep and treat insomnia
- most commonly benzodiazepines
what are anxiolytics
medications that are used in the treatment of acute anxiety
- most commonly benzodiazepines
what are some benzodiazepines that my be used as hypnotics
nitrazepam
flurazepam
which type of benzodiazepines are more likely to cause behaviour disinhibition?
short acting.
pathway of ADHD medication in children
1- methylphenidate
2- lisdexamphetamine
3- dexamphetamine (if positive response to 2 but SE)
What three clusters of personality disorders are there?
cluster A- odd or eccentric
cluster B- Dramatic, Emotional or Erratic
cluster C- anxious and fearful
what personality disorders make up cluster A
paranoids
schizoid
schizotypal
what personality disorders make up cluster B
antisocial
borderline (emotionally unstable)
histrionic
narcissistic
what personality disorders make up cluster c
obsessive-compulsive
avoidant
dependent
describe paranoid personality disorder
-hypersensitivity and unforgiving attitude when insulted
-unwarranted tendency to question the loyalty of friends
-reluctance to confide in others
-preoccupation with conspirational beliefs and hidden meaning
describe schizoid personality disorder
- indifference to praise and criticism
- preference for solitary activities
- lack of interest in sexual interactions
- few friends
- emotional coldness
describe schizotypal personality disorder
-ideas of reference (differ from delusions as some insight is retained)
- odds 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
What makes up DSM 5’s definition of ADHD?
A disorder that incorporates features of inattention and or hyperactivity/impulsivity that are persistent.
If <16 then 6 features are required
If >17 then 5 features are required
Features:
inattention:
- doesn’t follow instructions
- reluctant to engage in mentally intense tasks
- easily distracted
- finds it difficult to sustain tasks
- finds it difficult to organise tasks
- often forgetful in daily tasts
- often looses things needed for tasks
- often does not seem to listen when spoken to
hyperactivity/impulsivity:
- unable to play quietly
- often talks excessively
- doesnt want to wait their turn
- will spontaneously leave their seat
- ‘on the go’
- interruptive or intrusive to others
- answers questions prematurely
- runs and climbs when not appropriate
What are the key features of ICD-11s definition of personality disorders
persistent pattern - the persons patterns of behaviour are stable over time and span across various personal and social situations
Impairment- the devision results in significant problems or dysfunctions in the persons life
Duration- the characteristics are stable over time and are not transient
Distress or dysfunction= the impairment may result in distress or the individual or others
what three clusters of personality disorders are there?
Cluster A- odd or eccentric
Cluster B- dramatic, emotional or erratic
Cluster C- anxious and fearful
what personality disorders are including in cluster a?
paranoid
schizoid
schizotypal
what personality disorders are included in cluster B
antisocial
borderline
histrionic
narcissistic
what personality disorders are included in cluster c
obsessive-complusive
avoidant
dependent
describe the features of paranoid personality disorder
hypersensitivity and an unforgiving attitude when insulted
unwanted tendency to question the loyalty of friends
reluctance to confide in others
preoccupation with conspirational beliefs and hidden meaning
unwarranted tendency to perceive attacks on their character
describe features of schizoid personality disorder
indifference to praise or criticisms
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
describe schizotypal personality disorder
ideas of reference
odd beliefs and magical thinking
unusual perceptual disturbance
paranoid ideation and suspiciousness
odd eccentric behaviour
lack of close friends other than family members
inappropriate affect
odd speech without being incoherent
describe antisocial personality disorder
failure to conform to social norms with respect to the law
more common in men
deception
impulsiveness
irritability and aggressiveness
reckless disregard for safety of self or others
consistent irresponsibility - failure to sustain work
lack of remorse
Describe histrionic personality disorder
inappropriate sexual seductiveness
need to be the centre of attention
rapidly shifting and shallow expression of emotions
suggestibility
physical appearance to seen attention from others
describe narcissistic personality disorder
grandiose sense of self importance
preoccupation with fantasies of unlimited sucess
sense of entitlement
taking advantage of others
lack of empathy
chronic envy
describe avoidant personality disorder
avoidance of occupational activities which involve significant interpesonal contact due to fears of criticism or rejection
preocccupied with ideas that they are being criticised or rejected in social situations
