Psychiatry Flashcards
What is Acute stress disorder ??
Acute stress reaction that occurs in 1st 4 wks after the exposure to a traumatic event
[PTSD is dx. after 4 wks]
Features & Rx. of Acute stress disorder ??
- Intrusive thoughts [eg. Flashbacks, nightmares]
- Dissociation [eg. Being in daze, time slowing]
- (-)ve mood, Avoidance,
- Arousal (Hypervigilance)
Rx. - Trauma Focused CBT
- BZPs (sometimes used for acute c/f)
Pathophysiology of Alcohol withdrawal ??
Chr. [-OH] intake => enhances GABA mediated inhibition in CNS (similar to BZPs) & (-) NMDA-type glutamate receptors
[-OH] withdrawal => decreased GABA inhibition & increased NMDA glutamate transmission
Alcohol withdrawal features ??
Symptoms start by 6- 12 hrs
- Tremors, Sweating, Tachycardia, Anxiety
Peak incidence of Seizures- 36 hrs
Delirium tremors at 48- 72 hrs
- COARSE tremors, confusion, Delusions, Auditory & Visual Hallucinations, fever, tachycardia
Rx. of Alcohol withdrawal ??
1st line: Long acting BZPs [eg. Chlordiazipoxide or Diazepam; Lorazepam is preferred in Hepatic failure, following Reducing dose protocol
Carbamazepine is also effective
DoC in [-OH] withdrawal with Hepatic failure ??
LORAZEPAM [Typically given as part of reducing dose protocol]
MoA of Typical Antipsychotics ??
DA-D2 receptor (-) => blocking dopaminergic transmission in MESOLIMBIC pathways
S/E
- EPS
- Hyperprolactinaemia
Eg.- Haloperidol, Chlorpromazine
MoA of Atypical Antipsychotics ??
Acts on DA- D2, D3, D4 & 5- HT receptors
S/E
- Metabolic effects
- EPS & Hyperprolactinaemia are less common
Eg.- Clozapine, Risperidone, Olanzapine, Quetiapine, Amisulpride, Aripiprazole
What are the EPS seen with the usage of Typical Antipsychotics ??
“ADAPT”
Acute Dystonia (hrs. to days)
- Sustained muscle contraction [eg.- Torticollis, Oculogyric crisis)
- Rx.- Procyclidine, Benztropine or Anticholinergics
Akathisia (Days to months)
- Severe restlessness)
- Rx.- Propranolol or Benzodiazepines
Parkinsonism (Wks to months)
- Akinesia, Bradykinesia
- Rx.- Amantadine, Benztropine or AntiCholinergics
Tardive Dyskinesia (Months to years)
- Abnormal Facial movt.
- LATE Onset
- Choreoathetoid movt., Abnormal, Involuntary)
- MC is Chewing & Pouting of Jaw, Lip smacking
- Rx.- Switch from Typical to Atypical to Clozapine; Add or treat with VMAT inhibitors (Valbenazine)
Other S/Es of Antipsychotics ??
- Increase risk of Stroke & VTE
- Antimuscarinic: Dry mouth, Blurred vision, Urine retention, Constipation
- Sedation, Wt. Gain, Impaired G T
- Raised Prolactin
- Neuroleptic M S (Pyrexia, muscle stiffness)
- Prolonged QT interval (particularly HALOPERIDOL)
Which Anti-psychotics are a/w the following features
- Reduced Seizure threshold
- Good- S/E profile for Prolactin elevation
- High risk of Dyslipidemia & Obesity
- ATYPICAL Anti-psychotics
- Aripiprazole
- Olanzapine
S/E of Atypical Anti-psychotics ??
WEIGHT Gain (particularly with Olanzapine)
Clozapine is a/w Agranulocytosis
Hyperprolactinaemia
What is Body Dysmorphic Disorder ??
aka Dysmorphophobia is a mental disorder where pts. have a significant distorted body image
DSM-IV criteria of Dysmorphophobia ??
- Preoccupation with an imagined defective appearance; if slight physical anomaly seen, they are excessively concerned
- Preoccupation causes- clinically significant distress/ impairment in social, occupational or other important areas of functioning
- Preoccupations are not better accounted for by other mental disorder (eg. dissatisfied body shape & size in A Nervosa)
What is Cotard Syndrome ??
Pts. believe that their body or a part of body is either dead or non-existent
- It is very difficult to treat as the pts. stop eating & drinking as they feel its unnecessary
- a/w severe depression & psychotic disorders
What is De Clerembault’s Synd. ??
aka Erotomania
- Paranoid delusion with amorous quality
- Pt. is often a Single Woman, believes that a famous person is in love with her
What is Delusional Parasitosis ??
Pt. has a fixed, false belief (Delusion) that they are Infested by ‘Bugs’- eg.- Worms, Parasites, Mites, Bacteria, Fungus
- Can be a/w other psychiatric conditions/ may present by itself, with the pts. often otherwise functional despite delisions
What is Bulimia Nervosa ??
Eating disorder charecterized by Binge eating episodes followed by Vomiting or other purgative behaviours- eg. use of Laxatives/ Diuretics or Exercising
DSM 5 criteria for Dx. of Bulimia Nervosa ??
- Recurrent episode of binge eating
- Sense of Lack of Control over eating during the episode
- Recurrent inappropriate compensatory behaviour- to prevent wt. gain (vomiting, medicines, fasting, excessive exercise)
- Binge eating + Compensatory behaviour occur at least- 1x /wk for 3 months
- Self evaluation unduly influenced by body shape & wt.
- The disturbance do not occur during Anorexia N episode
Rx. of Bulimia Nervosa ??
Referral to specialist care
- Adults: B-N-focused guided self-help
- Eating-disorder-focused CBT: If 1st line is unacceptable/ CI/ Ineffective after 4 wks of Rx.
- Children: B-N-focused Family Therapy
Trial of High-dose FLUOXETINE is licensed
SERTRALINE is a/w increased risk of Suicide in teenagers during 1st few wks
Features of Anorexia Nervosa ??
- Reduced BMI
- BRADYCARDIA, - Hypotension
- ENLARGED Salivary gland
- Low K+, FSH, LH, Osetrogen, Testosterone, T3
- Impaired G T
- Hypercholesterolaemia
- HyperCarotinaemia
Rx. of Depression in Older people ??
Older pts. are less likely to complain of depressed mood
- Insomnia, Agitation
- Physical Complaints (eg. Hypochondriasis)
1st line: SSRIs (TCAs have more s/e in elderly)
What is Charles Bonnet Syndrome [CBS] ??
Persistent or recurrent COMPLEX Hallucinations (usually Visual or Auditory) occurring in Clear Consciousness
- Generally against a background of Visual impairment (but NOT mandatory for Dx.)
- INSIGHT preserved
- There should be no other Neuro-psychiatric disorder
MC condition a/w Charles-Bonnet synd. are ??
ARMD (most common cause)
Glaucoma & Cataract
RF- Advanced age, Peripheral visual impairment, Social isolation, Sensory deprivation, Early cognitive impairment
What are the factors that suggests a Dx. of depression over dementia ??
- Short Hx., Rapid onset
- Biological symptoms eg.- Wt. loss, sleep disturbance
- Pt. WORRIED about poor memory
- Reluctant to take tests, disappointed with results
- MMSE is variable
- GLOBAL Memory loss (Dementia typically cause RECENT memory loss)
What is GAD ??
‘Excessive worry about a no. of different events a/w heightened tension’
- Always look for a potential physical cause before dx. - Hyperthyroidism, Cardiac disease, Medication-induced (Salbutamol, Theophylline, Corticosteroids, Antidepressants, Caffeine)
Steps of Rx. in GAD ??
- Step 1: Educate about GAD + active monitoring
- Step 2: Low-intensity psychological interventions (Self-help grps.)
- Step 3: High-intensity psychological interventions (CBT or Applied Relaxation) OR Drug Rx
- Step 4: Highly Specialist input (eg. Multi agency team)
Drugs used in GAD ??
1st line: Sertraline (SSRIs)
2nd line: SNRIs (Duloxetine, Venlafaxine)
3rd line: Pregabalin (when both SSRIs & SNRIs are not tolerated)
< 30yrs old + increased risk of suicide => WEEKLY follow up for the 1st month
Steps involved in the Rx. of Panic disorder ??
Step 1: Recognition + Dx.
Step 2: Rx. in Primary care
Step 3: Review & consideration of alternative Rx.
Step 4: Review & referral to specialist mental health services
Step 5: Care in Specialist mental health services
Rx. of Panic disorder ??
CBT or Drug therapy
- SSRIs are 1st line
- Imipramine or Clomipramine : If SSRIs are CI or No response after 12 wks.
What is Korsakoff’s syndrome ??
Memory disorder in ALCOHOLICS
- Thiamine deficiency => damage & haemorrhage to Mammillary bodies of Hypothalamus & Medial Thalamus
Untreated Wernicke’s Encephalopathy + Amnesia (Antero-/ Retro- grade) + Confabulations
What is Wernicke’s Encephalopathy ??
Global Confusion
Ophthalmoplegia & Nystagmus
Ataxia
What is the absolute CI for Electroconvulsive Therapy ??
Raised ICP
What is Othello’s Synd. ??
- Pathological JEALOUSY where a person is convinced their partener is cheating on them without any real proof.
- Associated by socially unacceptable behaviour linked to this claims.
What are the stages of Grief Reaction ??
- Denial: may include feeling numb, Pseudo-hallucinations of the deceased (Auditory & Visual); focus on physical objects that reminds them, talk to them
- Anger : directed against other family member & medical professionals
- Bargaining
- Depression
- Acceptance
NOT all pts. go through all these 5 stage
What are Atypical Grief Reactions ??
DELAYED Grief: More than 2 wks. passes before grieving begins
PROLONGED Grief: Normal Grief reaction may take >= 12 months
Difference b/w Mania & Hypomania
Mania: >= 7 days
- Severe functional impairment
- Hospitalization [if Self harm or harming others is seen]
- Psychotic symptoms
Hypomania: < 7 days; ie. 3-4 days
- Does’t impair Functional capacity
- Do not require hospitalization
- NO psychotic symptoms
S/E of Monoamine oxidase inhibitors ??
- HTN reaction with Tyramine containing food (Cheese, pickled herring, bovril, oxo, marmite, broad beans.)
- Anti-Cholinergic effect
[Serotonin & NE is normally metabolised by MAO in Presynaptic cell]
Eg. of Non selective MAO inhibitors ??
Tranylcypromine, Phenelzine
- Used in the Rx. of Atypical depression (eg.- Hyperphagia) & other psychotic disorders
What is OCD ??
Obsession : Unwanted intrusive thoughts, image or urge that repeatedly enters the person’s mind
Compulsion : Repetitive behaviours or mental acts that the person feels drive to perform. It can be covert (mental act) or observable by others
What are the causes & associations of OCD ??
Multifactorial
- Genetic. - Psychological Trauma
- Paediatric autoimmune Neuro-psychiatry: a disorder a/w Strep. infection [PANDAS]
Associations
- DEPRESSION (30%)
- Schizophrenia (3%)
- Sydenham’s Chorea
- Tourette’s Synd. - Anorexia N
Rx. of OCD ??
Mild Functional Impairment
- 1st line: CBT + Exposure & Response Prevention (ERP)
- 2nd line: SSRIs or More intensive CBT + ERP
Moderate Functional Impairment
- SSRIs or More Intensive CBT + ERP
Severe Functional Impairment
- SSRIs + [CBT-ERP Therapy]
If SSRI effective, continue Rx. for 12m.
If SSRIs ineffective/ not tolerated, try other SSRIs
Drug of choice for Body dysmorphic disorder ??
FLUOXETINE
What is Personality Disorder & how is it Treated ??
A series of maladaptive personality traits that interfere with normal function in life
Rx.
- Psycho-Therapy: DIALECTICAL Behaviour Therapy
- Rx. of any co-existing psychiatric condition
Name the Personality Clusters
Cluster A: Odd/ Eccentric
- Paranoid.
- Schizoid
- Schizotypical
Cluster B: Dramatic, Emotional or Erratic
- Antisocial
- Borderline (Emotionally Unstable)
- Histrionic
- Narcissistic
Cluster C: Anxious & Fearful
- Obsessive- Compulsive
- Avoidant
- Dependent
What is PTSD ??
Can develop in people of any age following a Traumatic event (eg. major disaster or childhood sexual abuse. It encompasses what became known as ‘Shell Shock’ after 1st world war
Rx. of PTSD ??
- Mild C/F: Watchful wait if symptoms last for < 4 wks
- Severe cases: Trauma focused CBT or Eye Movt. Desensitization & Reprocessing [EMDR]
Drug Rx. - Not used as 1st line
- VENLAFAXINE or other SSRIs (Sertraline)
- Risperidone in Severe cases
Difference b/w PTSD & Acute Stress Disorder ??
PTSD: Seen after > 4 wks
ASD: Seen before < 4 wks
What are the Postpartum Mental Health Problems ??
Baby-blues (60 - 70% woman)
Postnatal Depression (10% woman)
Puerperal Psychosis (0.2% of woman)
What is Baby-blues ??
- Typically seen 3- 7 days after birth
- MC among Primi’s : Anxious, Tearful & Irritable, low mood, low confidence
Rx. - Reassurance & Support
- Health Visitor has a key role
What is Postnatal depression ??
- Starts within 1 month & typically peaks at 3 months
- Features similar to Depression- low mood persists, early morn. awakens, decreased appetite
Rx. - CBT
- SSRIs: Sertraline & Paroxetine-[ recommended by SIGN cause of low milk/ plasma ratio] may be used if severe symptoms. They are secreted in breast milk but is not harmful to the infant
What is Puerperal Psychosis ??
- Starts at first 2- 3 wks after birth
- Mood swings (similar to Bipolar), disordered perception (eg. Auditory hallucinations)
Rx. - Admission in Mother & Baby Unit
- 25 to 50% risk of recurrence in further pregnancies
What is the strongest factor for developing a psychotic disorder (including Schizophrenia) ??
Family Hx.
Epidemiology of Schizophrenia ??
Risk of developing-
- Monozygotic twins has S : 50%
- Parent has S : 10 to 15%
- Sibling has S : 10%
- No relatives with S : 1%
Other RF for Psychotic disorders-
- Black Caribbean race : RR- 5.4
- Migration : RR- 2.9
- Urban environment : RR- 2.4
- Cannabis use : RR-1.4
Features of Schizophrenia ??
SCHNEIDER’s 1st Rank symptoms are divided into
AUDITORY Hallucinations
- 3rd party hallucinations
- Thought echo
- Voices commenting pt.’s behaviour
DELUSIONAL Perceptions
- 2 stage process: 1) Normal object is perceived, then 2) sudden intense delusional insight into the objects meaning for the pt. (eg. Traffic light is green, so, I am the King
PASSIVITY phenomenon (Body sensations controlled by external influence
THOUGHT disorder
- Thought Insertion, Withdrawal, Broadcasting
What are the Negative symptoms of Schizophrenia ??
- Incongruity/ Blunting effect
- Anhedonia (inability to derive pleasure)
- Alogia (Poverty of speech)
- Avolition (poor motivation)
Rx. of Schizophrenia ??
1st line: Oral Atypical Antipsychotics
CBT to all pts.
Close attention should be paid to CVS risk factor
Poor prognostic indicators of Schizophrenia ??
- Strong FHx.
- Gradual onset
- Prodrome of Social Withdrawal
- Low IQ
- Lack of Obvious Precipitants
What is Seasonal Affective Disorder (SAD) ??
Depression occurring more common in Winter months
- Treated in the same as depression
- Mild: CBT & follow up in 2 wks to ensure there is no deterioration
- SSRIs can be given after this
- Do NOT give Sleeping Pills as they can worsen their symptoms
What is Sleep Paralysis ??
Transient paralysis of Skeletal muscles which occurs when waking up or less often while falling asleep
- Related to the paralysis that occurs as a natural part of REM sleep
Paralysis & Hallucinations (images or speaking that occurs during paralysis)
Rx. - CLONAZEPAM
What is Somatization disorder ??
Multiple physical SYMPTOMS present for at least 2 yrs.
- Pt. refuses to accept Reassurance or (-)ve results
What is Illness Anxiety disorder ??
aka Hypochondriasis
- Persistent belief in the presence of an underlying serious DISEASE eg. Ca
- Pt. refuses to accept Reassurance or (-)ve test result
What is Conversion Disorder ??
Loss of Motor & Sensory function (Typical)
- Pt. does NOT consciously feign the symptoms (Factitious) or seek material gain (Malingering)
- Involves psychiatric C/F eg. Amnesia, Fugue, Stupor
- La Belle Indifference: Indifferent to their apparent disorder
What is Dissociative disorder ??
- It is a process of ‘Separating off’ certain memories from normal consciousness
What is the most severe form of Dissociative Disorder ??
Dissociative Identity Disorder (DID)
What is
- Factitious disorder ??
- Malingering ??
- aka Munchausen’s syndrome; involves Intentional production (feigning) of physical or psychological symptoms
- Fraudulent simulation / Exaggeration of symptoms with the intention of financial or other gain
Which TCA has a
- lower incidence of toxicity in a overdose ??
- Most dangerous toxicity in a overdose ??
- Lofepramine
- Amitriptyline & Dosulepin (Dothiepin)
Name the More & Less sedative TCAs ??
MORE Sedative
- Amitriptyline
- Clomipramine
- Dosulepin
- Trazadone (is a Tricyclic related antidepressant
LESS Sedative
- Imipramine
- Lofepramine
- Nortriptyline
S/E of TCAs ??
- Dry mouth, Constipation, Urine retention, Drowsiness
- Blurred vision
- Prolonged QT interval
Factors a/w increase in risk of Suicide ??
- Male sex
- H/o deliberate self harm
- Alcohol or Drug misuse
- H/o Mental illness: Depression, Schizophrenia (10% people will COMPLETE Suicide)
- H/o Chr. disease
- Advancing Age
- Unemployment/ Social isolation/ Living alone
- Unmarried, Divorced, Widowed
- Victim or Perpetrator of violence
- Sense of hopelessness
- Criminal Record
Name the factors a/w increased risk of Completed suicide at a further date, who, now has attempted suicide
- Efforts to avoid discovery
- Planning
- Leaving a Written letter
- Final acts (eg. sorting out Finances)
- Violent methods
- Impulsive & aggressive tendencies
What are the protective factors in Suicides ??
- Family support
- Having Children at home
- Religious Belief
Which is the 1st line Rx. in Depression ??
SSRIs: Citalopram & Fluoxetine
- Sertraline: 1st line in Post-MI case
- Fluoxetine: DoC in Children & Adolescents
- Mirtazapine: In pts. on Warfarin/ Heparin
S/E of SSRIs ??
MC is Gastrointestinal s/e
- increased risk of GI bleed (so a PPI is prescribed if the pt. is on NSAIDs)
- Counsel the pt. to be vigilant for INCREASED Anxiety & Agitation after starting SSRIs
- Fluoxetine & Paroxetine have a higher propensity for drug interactions
Important S/E of Citalopram ??
Citalopram & Escitalopram are a/w Dose dependent QT interval prolongation
- CI in Congenital long QT syndrome; pre-existing QT interval prolongation
- Max. dose: 40mg in adults; 20mg in > 65yrs & in Hepatic impairment
Drug interactions of SSRIs ??
- NSAIDs: do not offer; if given, co-prescribe a PPI
- Warfarin/ Heparin: avoid SSRIs & consider MIRTAZAPINE
- Triptans & MAOIs : increased risk of SEROTONIN Synd.
Follow up interval in pts on SSRIs for depression ??
Following initiation
- FU in 2 wks in all pts.
- FU in 1 wk: < 30yrs old & Risk of Suicide
- Good response to Rx.- Continue for 6 months after remission as this reduces the relapse rates.
- Stopping SSRIs: Gradually over 4 wks. PAROXETINE has a higher incidence of discontinuation symptoms
Which SSRI can be stopped without gradual weaning in Depression ??
FLUOXETINE
What are the discontinuation C/F seen in SSRIs ??
- Increased mood changes
- Restlessness, Unsteadyness
- Difficulty sleeping
- Sweating
- GI symptoms: N & V, Pain, Cramps, Diarrhoea
- Paraesthesia
S/E of SSRIs in Pregnancy ??
1st trimester: CHD
3rd trimester: Persistent Pulm. HTN of Newborn
Use of Paroxetine in 1st trimester has a increased risk of Congenital Malformations
MoA of SNRIs ??
Relatively new class of antidepressant
- Inhibits Serotonin & NE re-uptake at pre-synaptic cells => increased conc. of S & NE at synaptic cleft
- Venlafaxine & Duloxetine: used in Rx. of Maj. Depressive disorder, GAD, Social Anxiety disorder, Panic disorder, Menopausal symptoms
MoA of Lithium ??
Used in the Prophylaxis of Bipolar disorder & as an Adjunct in Refractory Depression
- Interferes with Inositol Triphosphate (ITP) & cAMP formation
Excreted primarily by KIDNEY
Long plasma half life
S/E of Lithium ??
- N & V, Diarrhoea, Wt. gain
- Fine tremors
- Nephrotoxicity: Polyuria, secondary to induced nephrogenic DI
- Thyroid enlargement: causing Hypothyroidism
- Hyperparathyroidism => Ca2+ rise
- ECG: T wave flattening/ inversion
- Idiopathic ICH
- LEUCOCYTOSIS
Mention the ECG changes seen with
- Citalopram & Escitalopram ??
- Lithium ??
- Clozapine ??
- Digoxin ??
- Azithromycin ??
- QT prolongation
- T wave inversion/ flattening
- Myocarditis
- Down sloping ST depression (Reverse Tick Sign), Short QT interval, T wave inversion/ flattening
- QT prolongation
Which is the 1st Atypical antipsychotics to be developed ??
Clozapine
- Should be used in pts. resistant (after use of 2 drugs; 1 of which must be from 2nd generation) to other antipsychotic medication (due to risk of Agranulocytosis)
S/E
- Agranulocytosis, Neutropenia
- Reduced seizure threshold
- Constipation
- Myocarditis (baseline ECG before Rx
- Hypersalivation
- Dose adjustment in Smokers
BZPs MoA ??
By increasing the Frequency of Cl- channels, it enhance inhibitory effects of inhibitory neurotransmitter GABA
- Pts. commonly develop a Tolerance & Dependence to BZPs => should be prescribed for a short duration (2-4 wks)
How are BZPs withdrawn ??
In steps of 1/8 (range 1/10 to 1/4) of daily dose every FORTNIGHT
- Diazepam dose is reduced every 2-3 wks in steps of 2 to 2.5 mg
- Time needed for withdrawal: 4 wks to 1 year.
- If withdrawn abruptly, it will lead to BZP withdrawal syndrome
What are the features of BZP Withdrawal synd. ??
This can occur upto 3 wks after stopping a long-acting drug
- Irritable, Anxiety
- Insomnia, Loss of appetite
- Tinnitus, Tremors, Perspiration
- Perceptual disturbance, Seizures
What is the difference in the MoA of BZPs & Barbiturates ??
BZPs: Increase FREQUENCY of Cl- channels
Barbiturates: Increase the DURATION of Cl- channel opening
‘FREQuently BENd-DURing BARBeque’
