Psychiatry Flashcards
Acute stress disorder vs PTSD
ACUTE stress discorder is defined as an acute stress reaction that occurs in the 4 weeks after a traumatic event, as opposed to PTSD which is diagnosed after 4 weeks
acute stress disorder features
Features include:
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
management of acute stress discordr
trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines
sometimes used for acute symptoms e.g. agitation, sleep disturbance
should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation
mechanism of alchool withdrawl
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
what happens first in Alchohol withdrawl
- 6-12 hours
- peak incidence of ____ at _____
what happens at 48-72 hours
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Treatment for alchohol withdrawl
1st line
what about people with hepatic failure
first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
lorazepam is often preferred in patients with liver cirrhosis
Physiological abnormalities
in Anorexia Nervosa
hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
Typical antipsychotics
Haloperidol
Chlorpromazine
Atypical antipsychotics
clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation
typical antipsychotics, ESPE
Parkinsonism
acute dystonia
sustained muscle contraction (e.g. torticollis, oculogyric crisis)
may be managed with procyclidine
akathisia (severe restlessness)
tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
acute dystonia
may be managed with
sustained muscle contraction (e.g. torticollis, oculogyric crisis)
mx
procyclidine
akathisia
akathisia (severe restlessness)
tardive dyskinesia
tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
neuroleptic malignant syndrome:
neuroleptic malignant syndrome: pyrexia, muscle stiffness
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Aphonia describes the inability to speak. Causes include:
recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy)
psychogenic
Adverse effects of atypical antipsychotics
weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia
Benzodiazepines
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.
The BNF gives advice on how to withdraw a benzodiazepine.
The BNF gives advice on how to withdraw a benzodiazepine. The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given
Russell’s SIGN
recurrent vomiting may lead to erosion of teeth and Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting
Charles-Bonnet syndrome
Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis).
CBS
The most common ophthalmological conditions associated with this syndrome are
The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.
De Clerambault’s syndrome
De Clerambault’s syndrome, also known as erotomania, is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
Depression in older people
Older patients are less likely to complain of depressed mood
Features
physical complaints (e.g. hypochondriasis)
agitation
insomnia
mX OF depresion in older people
SSRIs are first line (adverse side-effect profile of TCAs more of an issue in the elderly)
Depression vs. dementia
Factors suggesting diagnosis of depression over dementia
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
Short-term side-effects
for ECT
Short-term side-effects
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
Long-term side-effects
some patients report impaired memory
Management of generalised anxiety disorder (GAD)
step 1: education about GAD + active monitoring
step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
Management of generalised anxiety disorder (GAD)
DRUG
treatment
NICE suggest sertraline should be considered the first-line SSRI
if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI)
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
Management of panic disorder
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
Hypomania vs. mania
DURATION
hospitialzation
?psychotic sym
mania Lasts for at least 7 days - Causes severe functional impairment in social and work setting
May require hospitalization due to risk of harm to self or others
May present with psychotic symptoms
Hypomania
A lesser version of mania
Lasts for < 7 days, typically 3-4 days. Can be high functioning and does not impair functional capacity in social or work setting
Unlikely to require hospitalization
Does not exhibit any psychotic symptoms
Korsakoff’s syndrome
Overview
marked memory disorder often seen in alcoholics
thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
in often follows on from untreated Wernicke’s encephalopathy
Features:
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation
Adverse effects
of lithium
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
ECG chnages in lithium Adverse effects
ECG: T wave flattening/inversion
when checking lithium levels, the sample should be taken ______ hours post-dose
when checking lithium levels, the sample should be taken 12 hours post-dose
Guide on taking lithium
after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
once established, lithium blood level should ‘normally’ be checked every 3 months
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
thyroid and renal function should be checked every 6 months
Othello’s syndrome
Othello’s syndrome is pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.
PTSD Mx
following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
watchful waiting may be used for mild symptoms lasting less than 4 weeks
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used
then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried.
In severe cases, NICE recommends that risperidone may be used
Schizophrenia: management
oral atypical antipsychotics are first-line
cognitive behavioural therapy should be offered to all patients
‘Baby-blues’
timeframe
features
Typically seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
Postnatal depression
timeframe
features
tx
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe**
Puerperal psychosis
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Admission to hospital is usually required, ideally in a Mother & Baby Unit
Adverse effects
of SSRI
gastrointestinal symptoms are the most common side-effect
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
fluoxetine and paroxetine have a higher propensity for drug interactions
Schizophrenia: prognostic indicators
Factors associated with poor prognosis
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
Citalopram and the QT interval
associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
ssri interacttions
Interactions
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
Serotonin and noradrenaline reuptake inhibitors
Examples include venlafaxine and duloxetine. They are used to treat major depressive disorders, generalised anxiety disorder, social anxiety disorder and panic disorder and menopausal symptoms.
Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures
management
if troublesome clonazepam may be used
Whilst the evidence base is relatively weak, there are a number of factors shown to be associated with an increased risk of suicide
male sex (hazard ratio (HR) approximately 2.0)
history of deliberate self-harm (HR 1.7)
alcohol or drug misuse (HR 1.6)
history of mental illness
depression
schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
history of chronic disease
advancing age
unemployment or social isolation/living alone
being unmarried, divorced or widowed
There are, of course, factors which reduce the risk of a patient committing suicide. These include
family support
having 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 disorder (hypochondriasis)
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Functional neurological disorder (conversion disorder)
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
Dissociative disorder
dissociation is a process of ‘separating off’ certain memories from normal consciousness
Factitious disorder
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
