Psychiatry Flashcards
What is the pharmacological management of GAD?
step 1 - offer SSRI sertaline
step 2 - if sertraline is not effective - offer alternative SSRI such as paroxetine or escitalopram, or SNRI such as duloxetine or venlafaxine
if unable to tolerate SSRI or SNRI consider pregabalin
what are the risks for pregnant women taking SNRI or SSRI?
first trimester - risk of congenital heart defects
at 20 weeks - risk of persistent pulmonary hypertension of the newborn and can lead to neonatal withdrawal - advised of these risks
what are some of the risk associated with clozapine?
agranulocytosis and neutropenia - most major
also causes hypersalivation
constipation - risk of bowel obstruction
myocarditis
reduced seizure threshold
what are the categories of depression based on the PHQ-9 scoring?
PHQ 9 < 16 = less severe depression
PHQ 9 > 16 = more severe depression
what treatment options are first line for less severe depression?
consider talking therapy/lifestyle first line if the patient is open for other options
self guided therapy
CBT etc
can consider antidepressants if it is the patients wishes
what are schneiders first rank symptoms?
auditory hallucinations
thought disorder
passivity phenomena
delusional perceptions
what are three different types of thought disorder?
thought wtihdrawal
thought insertion
thought broadcasting
what is passivity phenomena?
bodily sensations that are being controlled by external influences
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
what are delusional perceptions?
a two stage process whereby first a normal object is perceived, and then secondly there is a sudden intense delusional insight into the objects meaning for a patient - i.e. the traffic light is green therefore I am a king
what are the negative features of schizophrenia?
blutning of affect
anhedonia
alogia - poverty of speech
poor motivation
social withdrawal
catatonia
how should clozapine be initiated?
slowly, at lowest dose and titrated upwards
what should be done if clozapine dose is missed for 48 hours?
re-titrated upwards again slowly - under the direction of psychiatry team
how often are blood tests done for patients taking clozapine?
initially weekly for 18 weeks, then can be reduced as appropriate for the patient
what SE can happen if clozapine is re-titrated too quickly?
Side effects can include postural hypotension,
myocarditis, arrhythmias and tachycardia - can be LIFE THREATENING
how often are lipids + weight monitored for antipyschotics?
at the start of therapy
at 3 months
then annually
how often are fasting blood glucose and prolactin monitored for antipyschotic therapy?
at the start of therapy
at 6 months
annually
how often is ECG done when taking antipsychotics?
at start
how often is FBC/LFT/U+E monitored for antipyschotics?
at the start of therapy
annually
clozapine requires much more frequent monitoring of FBC
which sign is used to evaluate for functional neurological disorder?
hoovers sign
what are the features of PTSD?
re-experiencing e.g. flashbacks, nightmares
avoidance e.g. avoiding people or situations
hyperarousal e.g.hypervigilance, sleep problems
what is the treatment for PTSD?
can watch and wait for 4 weeks
trauma focussed CBT or EMDR can be used in severe cases
drug treatments - should not routine. If required - venlafaxine or SSRI’s should be used.
what are examples of SSRI’s?
sertraline
paroxetine
escitalopram
citalopram
fluoxetine
vortioxetine
what are common SE of SSRI’s?
GI SE are most common
increased risk of GI bleeds
serotonin syndrome
period of increased risk of symptoms worsening/suicide/self harm in first 2 weeks after starting
which 5 medications do SSRI’s interact with?
NSAID’s - increase risk of bleeding, prescribe PPI if starting
warfarin/heparin - advised to avoid
aspirin
triptans - increased risk of serotonin syndrome
MOAI’s - increased risk of serotoniin syndrome
which is the SSRI of choice if starting antidepressants after MI?
sertraline - considered safest immediately after MI
how long should SSRI’s be continued before withdrawing if symptoms improve?
6 months - this reduces the risk of a relapse
how should SSRI’s be stopped?
gradually reduced over 4 weeks
which SSRI has the highest risk of withdrawal symptoms when stopping?
paroxetine
what are some common withdrawal symptoms when stopping SSRI’s?
mood change
restlessness
difficulty sleeping
unsteadiness
sweating
GI symptoms
parasthesia
what are some examples of SNRI’s?
duloxetine
venlafaxine
what are some common examples of SE with SNRI’s?
nausea
dizziness
insomnia or drowsiness
sexual dysfunction
HTN
what are two more common SE of venlafaxine?
hypertension
prolonged Qt
what are 4 medications that SNRI’s interact with?
MAOI’s
triptans
antihypertensive
warfarin/anticoagulants
which section allows admission for assessment to hospital under MHA for 28 days?
section 2 - admission for assessment for 28 days - 2 independent doctors , one has to be approved under section 12(2)
which section allows hospital stay for up to 6 months under MHA?
section 3 -
admission for treatment for up to 6 months, can be renewed
can section 2 be renewed?
no - has to either be converted to a section 3 or patient discharged
what is a section 4?
72 hour assessment order
used in an emergency where section 2 would involve unacceptable delay
can be done by GP or AMHP or nurse
often changed to section 2 on arrival to hospital
which section is used to allow a nurse to detain a patient who is voluntarily in hospital for 6 hours?
section 5(4)
which section is used to allow a doctor to detain a patient for 72 hours who is already voluntarily in hospital?
section5(2)
what is a section 17a?
community treatment order
can be used to recall a patient to hospital for treatment if they do not comply with the conditions of the order in the community i.e. if they stop taking their medication
what section is used by the police to break into a property to take a person to a place of safety?
section 135
what section is used by the police to take someone from a public space into a place of safety for 24 hours?
section 136
what is the therapeutic window for lithium?
0.4-1 mmol
where is lithium excreted?
renal
what are some common SE of lithium?
fine tremor
GI disturbance
weight gain
idiopathic intracranial hypertension
hypothyroidism
nephrotoxicity
which organs are affected by lithium?
kidneys - renally excreted, can cause nephrotoxicity and nephrogenic diabetes insipidus
thyroid - causes enlargement, leading to hypothyroidism
heart - T wave flattening/inversion
brain - idiopathic intracranial hypertension
how long after lithium dose should monitoring blood test be taken?
12 hours post dose
how often should lithium monitoring levels be taken?
initially every week after starting until stable, then every 3 months
what blood tests are done for lithium monitoring?
lithium levels weekly until stable then 3 monthly
TFT + renal + calcium - 6 monthly
what are the physiological abnormalities in anorexia nervosa?
LOW K
LOW FSH/LH/testosterone/oestrogen
LOW T3
G’s and C’s HIGH - growth hormone, cholesterol, cortisol
how do you switch from fluoxetine to another SSRI??
gradually reduce fluoxetine, then leave a gap of 4-7 days, then start the new antidepressant
how do you switch from citalopram/escitalopram/sertraline or paroxetine to venlafaxine?
direct switch (caution if paroxetine)
which is the antidepressant of choice in teenagers and children
fluoxetine - started in secondary care
how does tardive dyskinesia present?
chewing
jaw pouting
excessive blinking
what is tardive dyskinesia?
extra pyramidal SE of long term antipyschotic use - presents as repetitive facial movements
what are some examples of the extrapyramidal SE patients can experience with long term antipyschotic use?
parkinsonism
acute dystonia
akathisia
tardive dyskinesia
what are the atypical antipsychotics?
clozapine
risperidone
olanzapine
what are the typical antipyschotics?
haloperidol
chlorpromazine
what are the risks of taking antipyshcotics in the elderly population?
increased risk of stroke + VTE
what are some antimuscarinic SE of antipsychotics?
dry mouth
blurred vision
urinary retention
constipation
what are the SE of antipyschotics generally?
antimuscarinic - dry mouth, blurred vision, retention, constipation
sedation
weight gain
impaired glucose tolerance
raised prolactin
do antipsychotics reduce the seizure threshold?
yes
what effect do antipyschotics have on the QT interval?
prolong
what scale is used to classify the symptoms of OCD?
Y-BOCS scale
what is the treatment of mild OCD?
if functional impairment is mild - low intensity posychological treatments such as CBT or ERP (exposure and response prevention)
if this is insufficient - consider SSRI or more CBT
what is the treamtnet of moderate OCD?
offer choice of SSRI or more intensive CBT
clomipramine is alternative to SSRI
what is the treatment of severe OCD?
refer to secondary services
SSRI + CBT whilst waiting appt
which antidepressant is recommended for body dysmorphia?
fluoxetine
how should benzodiazepines be withdrawn?
in steps of 1/8th of the daily dose every fortnight
how long must a patient stop driving for if stable bipolar and then develops manic episode?
3 months
how long must a patient stop driving for if they have bipolar and are unstable, then develop a mani episode?
6 months
how do you classify unstable bipolar disorder for the DVLA?
if 4 or more episodes of mood disturbance in 12 months
what is the first line management of panic disorder?
SSRI
what is somatisation disorder?
presenting with multiple physical symptoms over 2 years, pt refuses to accept any reassurance or negative test results
what is hypochondriasis?
persistent belief that there is a serious underlying disease
which antidepressant is contraindicated in breast feeding?
citalopram
which antidepressant is the ONLY medication licensed for PTSD?
sertraline
others can be used, but only sertraline is licensed
what is the most common type of abuse?
coercion
which questionnaire can be used to screen for eating disorders?
SCOFF questionnaire
what is the SCOFF questionnaire made up of?
Do you ever make yourself SICK because you feel uncomfortably full?’
‘Do you worry that you have lost CONTROL over how much you eat?’
‘Have you recently lost more than ONCE stone in a 3-month period?’
‘Do you believe yourself to be FAT when others say you are too thin?’
‘Would you say that FOOD dominates your life?’
what are feeding disorders?
disorders involving behavioural disturbances but not association to body weight or body image/shape concerns
what are examples of feeding disorders?
PICA
avoidant restrictive food disorder
rumination regurgitation disorder
which antidepressant has lowest risk of bleeding?
mirtazapine
which medications are used in bipolar disorder?
sodium valproate
lamotrigine
lithium
olanzapine
which antidepressant is chosen if the patient has co-current alcohol abuse?
mirtazapine
SSRI’s not found to be particularly helpful
at how many hours foes the incidence of alcohol withdrawal seziures peak?
24-48 hours post withdrawal
at how many hours does delirium tremens typically occur after alcohol withdrawal?
72 hours
how many hours after alcohol withdrawal do the symptoms start usually?
6-12 hours
what is given for prophylaxis of alcohol withdrawl seizures?
diazepam or chlordiazepoxide (long acting benzos)
lorazepam in liver failure
what are the symptoms of delirium tremens?
coarse tremor
confusion
delusions
auditory hallucinations
visual hallucinations
fever
tachycardia
what should be monitored before starting SNRI?
BP - as increases the risk of HTN
what should be monitored before starting citalopram?
ECG - increased risk of QT prolongation in patients with previous heart issues, so ECG should be done for high risk groups
what is the management of acute dystonic reaction?
procyclidine
how long are antidepressants recommended to be taken for GAD if symptoms have improved?
12 months
what type of medication should be avoided when taking lithium, as it increases the risk of lithium toxicity?
NSAIDS - they reduce the excretion of lithium and increase the risk of toxicity
what is the criteria for bulimia nervosa?
binge eating once a week for at least three months with compensatory behaviour (vomiting and excessive exercise) to prevent weight gain, and psychological features such as loss of control of his binge eating
what are the two types of medications used to treat dementia?
cholinesterase inhibitors - donepazil, rivastigmine, galantamine
glutamate receptor antagonist - memantine
what are the most common type of SE due to dementia medications?
GI upset
which blood tests should be done for monitoring of sodium valproate annually?
FBC
LFT
when is postnatal depression most likely to occur?
0-5 weeks post natally
what are the three options for smoking cessation treatment?
NRT
varenicline
bupropion
how long should the prescription for NRT/varencline/bupropion be for?
sufficient to last only until 2 weeks past set expected quit date
if someone is unsuccessful in stopping smoking with NRT/varencicline/bupropion - how quickly can they repeat the prescription?”
must be after 6 months
what are examples of NRT?
patches
lozenges
gum
nasal spray
can NRT be offered in combination?
yes - can offer combination of patches , lozenges, gum and nasal spray if single treatment was unsuccessful
how does varenicline work?
nicotine receptor partial agonist
when should varenicline be started?
should be started 1 week before the patients due stop date
how do you take varenicline?
pill taken twice a day
which is more effective - varenicline or bupropion?
varenicline
how long do you take varenicline for?
12 week course
what is the risks associated with varenicline?
should be used with caution for patient with history of self harm or depression - can increase the risk
when is varenicline contraindicated?
pregnancy and breast feeding
how does bupropion work?
a norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
when should buproprion started?
1 to 2 weeks before patients due stop smoking date
what is the risk of taking bupropion?
small risk of seziure
when is bupropion contraindicated?
epilepsy
pregnancy
breastfeeding
eating disorder - relative contraindication
are women who are smoking tested during pregnancy
yes - using carbon monoxide detectors , if CO reading of 7ppm or above - refer to NHS stop smoking services
what measures can be used to stop smoking in pregnancy?
first line - CBT, motivational interviewing, or structured self help and support from NHS stop smoking services
NRT if above fails
how long can you not drive for while dependent on benzodiazepines?
3 years - must notify the DVLA, who will revoke license for minimum of 3 years which must be free of misuse or dependence
what are contraindications for disulfuram?
cardiac failure
coronary aretery disease
CVA
HTN
psychosis
suicide risk
what are contraindications for acamprosate?
hepatic impairement, renal impairement and pregnancy
when can amphetamine users have their license back?
when abstinent for > 6 months
how long should patients with alcohol addiction be abstinent for before they can have a group 1 licenes?
12 months
how long should patients with alcohol addiction be abstinent for before they can have a group 2 license?
3 years
