Psychiatry Flashcards
Unresponsive, moderate and severe depression Rx?
SSRI + High intensity psychological intervention
High intensity psychological interventions?
- Individual CBT
- Interpersonal therapy (IPT)
- Behavioural activation
- Behavioural couples therapy
- Eye Movement Desensitization and Reprocessing (EMDR): Specifically designed for PTSD
- Dialectical Behavior Therapy (DBT): A form of CBT designed for borderline personality disorder (BPD) and emotional dysregulation.
- Psychodynamic Therapy
- Schema therapy
How often do high intensity sessions usually happen?
16-20 sessions over 3-4 months
People who decline the above?
- Counselling
- Short term psychodynamic psychotherapy
Pt with poor oral compliance to antipsychotics?
Monthly IM depot injections
Advantage of atypical antipsychotics (AAs)?
Significant reductions in EPSEs
AA s/es?
- Weight gain
- Hyperprolactinaemia
- Clozapine associated with agranulocytosis
AA warnings in elderly patients?
Increased risk of stroke and VTE
Atypical antipsychotic examples?
AA CORQ
1. Aripiprazole
2. Amisulpride
3. Clozapine
4. Olanzapine (higher risk of dyslipidaemia and obesity)
5. Risperidone
6. Quetiapine
When should clozapine be used?
If schizophrenia not controlled despite sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each at least 6-8 weeks
Clozapine side effects?
- Agranulocytosis (1%), neutropenia (3%)
- Reduced seizure threshold (seizures in 3%)
- Constipation
- Myocarditis (need baseline ECG)
- Hypersalivation
When is dose adjustment of clozapine required?
If smoking is started or stopped during treatment
PTSD features?
For more than one month
1. Re-experiencing
2. Avoidance
3. Hyperarousal
4. Emotional numbing
PTSD management?
- Watchful waiting for mild symptoms <4 weeks
- Trauma-focused CBT or EMDR therapy in more severe cases
- Drugs not first line, if needed then venlafaxine or SSRI, risperidone in severe cases
Strongest RF for developing psychotic disorder?
FHx
Familial of developing schizophrenia?
- Monozygotic twin = 50%
- Parent = 10-15%
- Sibling = 10%
- No relatives = 1%
Selected RFs for psychotic disorders?
- Black Caribbean = RR 5.4
- Migration = RR 2.9
- Urban environment = RR 2.4
- Cannabis use = RR 1.4
Mania features?
- At least 7 days, causing severe functional impairment in social and work setting
- May require hospitalisation due to risk of harm to self or others
- May present with psychotic symptoms
Hypomania features?
- A lesser version of mania
- <7 days, typically 3-4 days, can be high functioning and does not impair functional capacity in social or work setting
- Unlikely to require hospitalisation
- No psychotic symptoms
Increased risk of suicide factors?
- Male
- DSH
- Alcohol or druh misuse
- Hx of mental illness
- Hx of chronic disease
- Advancing age
- Unemployment or social isolation/living alone
- Being unmarried, divorced or widows
What % of people with schizophrenia will commit suicide?
10%
Increased risks of completed suicide at a later date after an attempt?
- Efforts to avoid discovery
- Planning
- Leaving a written note
- Final acts e.g. sorting out finances
- Violent method
Protective factors for suicide?
- Family support
- Children at home
- Religious belief
Somatisation disorder?
- Multiple physical symptoms present for at least 2 years
- Patient refuses to accept reassurance or negative test results
Illness anxiety (hypochondriasis)?
- Persistent belief in the presence of an underlying disease e.g. cancer
- Pt refused to accept reassurance or negative test results
Conversion disorder?
- Typically involves loss of motor or sensory function
- Pt doesnt consciously feign symptoms or seek material gain
- La belle indifference
Dissociative disorder?
- Separating off certain memories from normal consciousness
- In contrast to conversion disorder, involves psychiatric symptoms e.g. amnesia, fugue, stupor
- DID (dissociative identity disorder) is new term for multiple personality disorder as is the most severe form of dissociative disorder
Factitious disorder?
- AKA Munchausen’s
- Intentional production of physical or psychological symptoms
Malingering?
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Alcohol withdrawal mechanism?
- Chronic alcohol consumption enhances GABA mediation inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
- Alcohol withdrawal is though to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
Alcohol withdrawal features?
- Sx start at 6-12 hours = tremor, sweating, tachycardia, anxiety
- Peak incidence of seizures at 36 hours
- Peak incidence of delirium tremens at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Alcohol withdrawal management?
- Admission
- Long acting benzodiazepines e.g. chlordiazepoxide or diazepam as part of reducing dose protocol (lorazepam preferable in pts with hepatic failure)
- Carbamazepine also effective
Who is excluded from sectioning under the MHA?
Pts under influence of alcohol or drugs
Section 2 mushkies?
1.Admission for assessment up to 28 days, not renewable
2. AMHP or NR makes the application on the recommendation of 2 doctors
3. One of the doctors should be ‘approved’ under Section 12(2) of the MHS (usually consultant)
4. Treatment can be given against a patient’s wishes
Section 3 mushkies?
- Admission for treatment up to 6 months, can be renewed
- AMHP along with 2 doctors, both of which must have seen the pt with the past 24 hours
- Treatment can be given against a pt’s wishes
Section 4 mushkies?
- 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
Section 5(2) mushkies?
A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
Section 5(4)?
Similar to 5(2), allows nurse to detain a pt who is voluntarily in hospital for 6 hours
Section 17a?
- 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
Section 135?
A court order can be obtained to allow pt to break into a property to remove a person to a place of safety
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, can only be used for up to 24 hours whilst a MHA is arranged
When is a second opinion sought for a section 3?
After 3 months, if a pt still does not consent to treatment, from an impartial psychiatrist
Agranulocytosis definition?
Absolute neutrophil count <500 cells/mm^3
When are antidepressants recommended?
- Moderate-severe depression
- Subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years).
- Subthreshold symptoms or mild depression that persists after other interventions.
- Mild depression that is complicating the care of a chronic physical health problem
4 SSRIs?
- Sertraline
- Fluoxetine
- Citalopram
- Paroxetine
Lithium uses?
- Prophylactically in bipolar disorder
- Adjunct in refractory depression
Lithium therapeutic range?
0.4-1.0mmol/L
Lithium excretion?
Kidneys, has long plasma half life
Lithium MOA?
Not fully understood, two theories
1. Interferes with inositol triphosphate formation
2. Interferes with cAMP formation
Lithium adverse effects?
- N&V&D
- Fine tremor
- Nephrotoxicity, nephrogenic DI
- Thyroid enlargement, hypothyroidism
- Weight gain, IIH
- Leukocytosis
- Hyperparathyrodism and hypercalcaemia
Lithium ECG?
T wave flattening/inversion
Lithium monitoring?
- 12 hours post-dose
- Weekly after commencement and after each dose change until concentrations are stable
- Once established, every 3m
- Thyroid and renal function every 6m
- Pt should have information booklet, alert card and record book
Mirtazapine s/e?
Sedation and weight gain
Olanzapine s/e?
Dyskinetic tremore
Sertraline s/e?
Altered sleep-wake cycles, weight gain, sexual dysfunction, tremor
Flight of ideas?
Rapid speech with requent changes in topic based on associations, distractions or word play