psychiatry Flashcards
what neurotransmitter is deranged in depression
5HT (serotonin)
What PHQ-9 score correlates to what levels of depression
5-9 > mild depression
10-14 > moderate depression
15-19 > moderately severe depression
20-27 > severe depression
what is the incidence and timeline for postnatal mental health issues
Baby Blues > majority of women, first week
Postnatal depression > 1 in 10, 3 months after birth
Puerperal psychosis > 1 in 1000, a few weeks after birth
SSRI mechanisms and examples
block the re-uptake of serotonin by the presynaptic membrane on the axon terminal.
sertraline, citalopram, escitalopram, fluoxetine, paroxetine
SNRI mechanism and examples
block the reuptake of serotonin and noradrenaline by the presynaptic membrane.
duloxetine, venlafaxine
TCA mechanism and examples
block the reuptake of serotonin and noradrenaline by the presynaptic membrane. Also block acetylcholine and histamine receptors = anticholinergic and sedative side effects.
amitriptyline, nortriptyline
Mirtazipine mechanism
Mirtazapine is a presynaptic alpha2-adrenoreceptor antagonist which increases central noradrenergic and serotonergic neurotransmission.
how long do antidepressants take to work
2-4 weeks
how long should antidepressants be continued
at least 6 months
2 years for recurrent depression
when and how does antidepressant discontinuation syndrome present
2-3 days after stopping treatment
- flu-like symptoms
- electric-shock sensations
- irritability
- insomnia
- vivid dreams
Serotonins syndrome: presentation, severe presentation, management
- altered mental states
- autonomic nervous system hyperactivity
- neuromuscular hyperactivity
if severe: confusion, seizures, severe hyperthermia and respiratory failure
supportive care (eg sedation with benzodiazepines) & withdrawal from causative agent
What presenting features inc. risk of suicide
Previous suicidal attempts
Escalating self-harm
Impulsiveness
Hopelessness
Feelings of being a burden
Making plans
Writing a suicide note
what background factors increase risk of suicide
Mental health conditions
Physical health conditions
History of abuse or trauma
Family history of suicide
Financial difficulties or unemployment
Criminal problems (prisoners have a high rate of suicide)
Lack of social support (e.g., living alone)
Alcohol and drug use
Access to means (e.g., firearms
what are the protective factors to suicide
Social support and community
Sense of responsibility to others (e.g., children or family)
Resilience, coping and problem-solving skills
Access to mental health support
What substance can be used within one hour of overdoes
activated charcoal
what’s used to treat benzodiazepine overdose
flumazenil
whats used to treat beta blocker overdose
glucagon for heart failure or cardiogenic shock
atropine for symptomatic bradycardia
whats used to treat cocaine overdose
diazepam
whats used to treat cyanide overdose
dicobalt edetate
whats used to treat methanol or ethylene glycol poisoning
fomepizole or ethanol
whats used to treat carbon monoxide poisoning
100% oxygen
Treatment for mania in Bipolar Disorder
antipsychotic (e.g. olanazapine, quetiapine, risperidone or haloperidol)
lithium
sodium valproate
stop antidepressants
Treatment for acute depressive episode in Bipolar Disorder
olanzapine plus fluoxetine
antipsychotics (olanzapine or quetiapine)
Lamotrigine
Target range for Lithium
0.6-0.8mmol/L
Adverse effects of Lithium
fine tremor
weight gain
CKD
hypothyroidism and goitre
hyperparathyroidism and hypercalcaemia
nephrogenic diabetes insipidus
What GAD-7 score correlates to what levels of anxiety
5-9 > mild anxiety
10-14 > moderate anxiety
15-21 > severe anxiety
management of PTSD
eye movement desensitisation and reprocessing (EMDR)
medication (SSRI, venlafaxine, antipsychotics)
management of OCD
CBT
SSRI
Clomipramine (TCA)
what are the 3 clusters of personality disorders
Cluster A > Suspicious
Cluster B > Emotional or impulsive
Cluster C > Anxious
what is capgras syndrome
Capgras syndrome involves the false belief (delusion) that an identical duplicate has replaced someone close to them. This might be their spouse, family member or close friend. The person may be suspicious and aggressive towards the imposter.
Capgras syndrome is a delusional misidentification syndrome. It is most often seen in psychotic conditions, such as schizophrenia. It can also occur with dementia and other neurological conditions.
what is De Clérambault’s Syndrome
De Clérambault’s syndrome, also called erotomania, involves the false belief (delusion) that a famous or high-social-status individual is in love with the patient. This can lead to inappropriate harassment of the individual by the patient. The patient is most often a young, single woman. The patient usually has little or no contact with the individual and no objective evidence to support their belief. Frequently, it occurs without other psychiatric or neurological disease.
how long do symptoms of schizophrenia need to be present for diagnosis
6 months
typical and atypical antipsychotics examples
typical
- chlorpromazine
- haloperidol
atypical
- quetiapine
- aripiprazole
- olanazapine
- risperidone
depot antipsychotics (how often and examples)
2wks - 3mnths
- aripiprazole
- flupentixol
- paliperidone
- risperidone
Clozapine complications
Agranulocytosis (severely low neutrophil count)
myocarditis or cardiomyopathy
constipation (Intestinal obstruction)
seizures
excessive salivation
Monitoring requirements for antipsychotics
before & during
- weight and waist circumference
- BP and HR
- Bloods > HbA1c, lipids, prolactin
- ECG
Side effects of antipsychotics
weight gain
diabetes
prolonged QT interval
raised prolactin
extrapyramidal symptoms
extrapyramidal side effects of antipsychotics
akathisia > restlessness
dystonia > abnormal muscle tone, leading to abnormal postures
pseudo-parkinsonism > tremor, rigidity
tardive dyskinesia > abnormal movements, particularly the face
Neuroleptic Malignant Syndrome : presentation, investigation findings, management
presentation
- muscle rigidity
- hyperthermia
- altered consciousness
- autonomic dysfunction
blood test findings
- raised creatinine kinase
- raised white cell count
management
- stop causative meds
- supportive care (IV fluids and sedation with benzodiazepine)
- if severe treat with bromocriptine (a dopamine agonist) or dantrolene (muscle relaxant)
what is the mechanism of alcohol
Alcohol is a depressant. It stimulates GABA receptors, which have a relaxing effect on the brain. It inhibits glutamate receptors (also known as NMDA receptors), causing a further relaxing effect on the electrical activity of the brain.
Long-term alcohol use results in GABA system becoming down-regulated and the glutamate system becoming up-regulated to balance the effects of alcohol. The patient must continue drinking alcohol, or they will experience unpleasant, uncomfortable and potentially dangerous withdrawal symptoms.
calculation for alcohol units
volume (ml) * alcohol content (%) = units of alcohol
recommended alcohol consumption
no more than 14 units a week
spread evenly over 3 or more days
no more than 5 units in a single day
CAGE questions for alcohol consumption
C – CUT DOWN? Do you ever think you should cut down?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Do you ever feel guilty about drinking?
E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?
blood results in alcoholics
Raised mean corpuscular volume (MCV)
Raised alanine transaminase (ALT) and aspartate transferase (AST)
AST:ALT ratio above 1.5 particularly suggests alcohol-related liver disease
Raised gamma-glutamyl transferase (gamma-GT) (particularly notable with alcohol-related liver disease)
alcohol withdrawal timeline
6-12 hrs > tremor, sweating headache, craving, anxiety
12-14 hrs > hallucinations
24-48hrs > seizures
24-72hrs > delirium tremens
delirium tremens : presentation, mortality rate
presentation:
- acute confusion
- severe agitation
- delusions and hallucinations
- tremor
- tachycardia
- hypertension
- hyperthermia
- ataxia
- arrhythmias
mortality rate 35%
management of alcohol withdrawal
- CIWA-Ar tool
- Chlordiazepoxide (Librium) a benzodiazepine, Diazepam is an alternative. Given orally as a reducing regime over 5-7 days.
- High-dose B vitamins (Pabrinex) given IM or IV followed by long-term oral Thiamine. To prevent Wernicke-Korsakoff Syndrome
what medications can be given to help maintain abstinence
acamprosate > tablets that diminsh cravings
naltrexone > blocks opiod receptors so prevents people feeling good when drinking
disulfiram > produces unpleasant side effects if you drink alcohol (headache, vomiting etc)
wernicke-korsakoff syndrome
due to thiamine (B1) deficiency. Thiamine poorly absorbed in presence of alcohol.
Wernicke’s encephalopathy (reversible)
- confusion
- oculomotor disturbances
- ataxia
Korsakoff syndrome (irreversible)
- memory impairment
- behavioural changes
do you replace B12 or thiamine first
B12
medications used in opiod dependence (and MOA)
methadone > binds to opioid receptors
buprenorphine > binds to opioid receptors
Naltrexone > helps prevent relapse
refeeding syndrome mechanism
during prolonged starvation intracellular Potassium, Phosphate and Magnesium are depleted. Electrolytes are moved from inside cell to the blood to maintain normal levels in absence of dietary intake. Cell metabolism redice to conerve energy resultin gin loss of intracellular electrolytes.
During refeeding, Magnesium, Potassium and Phosphate are shifted out of the blood and Sodium is shifted into the blood. Carbohydrates cause increase in Insulin which further drives glucose, potassium and phosphate into cells. Insulin also causes extra sodium resorption in the kidneys.
Blood findings in refeeding syndrome
hypomagnesaemia
hypokalaemia
hypophosphataemia
fluid overload ( due to water following extra sodium into extracellular space)
management of refeeding syndrome
slowly reintroduicing food
magnesium, potassium, phosphate and glucose monitoring
fluid balance monitoring
ECG monitoring in severe cases
supplementation with electrolytes and vitamins (particularly B vitamins and Thiamine)
pathophysiology of alzheimers dementia
brain atrophy
amyloid plaques
reduced cholinergic activity
neuroinflammation
associated symptoms of Dementia with Lewy Bodies
visual hallucinations
delusions
REM sleep disorders
Fluctuating consciousness.
Frontotemperal dementia : symptoms and age of onset
abnormalities in behaviour, speech and language
Onset 40-60 yrs, can be familial
initial blood tests in suspected dementia (for exclusion)
Full blood count
Urea and electrolytes
Liver function tests
Inflammatory markers (e.g., CRP and ESR)
Thyroid profile
Calcium
HbA1c
B12 and folate
Mid-stream urine (MSU) if infection is suspected
Chest x-ray (if lung cancer is suspected)
Specialist investigations will include imaging (e.g., MRI brain) to exclude structural pathology.
five domains of ACE-III
Attention
Memory
Language
Visuospatial function
Verbal fluency
medications for alzheimers dementia
Acetylcholinesterase inhibitors (e.g., donepezil, rivastigmine or galantamine)
Memantine, which works by blocking N-methyl-D-aspartic acid (NMDA) receptors
first-line antipsychotics in dementia
Risperidone
