Psychiatry 3 Flashcards
Describe some of the features seen in mania:
DIGFAST:
D - distractibility
I - Impulsivity - usually dangerously, including sexually
G - grandiosity
F - Flight of idea
A - Activity - usually starting up a business/ spend lots of money usually
S - Sleep - decreased need for sleep, typically not tired though (differentiated from depressive)
T -Talkativeness
> 7 days and significant impact on the persons life
unlike hypomania which is 4 days and doesn’t signicantly impact the persons well being or life
What is the criteria for a diagnosis of type I bipolar Affective disorder?
Symptoms of Mania which last for >7 days which causes impairment of function.
with depressive episode following.
or
Mania severe enough to require admission
or
Psychosis
Mania + depressive (with the mania lasting for at least 7 days)
Highlight the different types of bipolar affective disorders, and list some causes of mania:
Type I
- mania and depressive
Type II:
- hypomania + depressive
Cyclothymia
- subclinical features
Causes:
- Genetics (10x if family member)
- steroids
- illicit substances (cocaine)
- Infection
- stroke
- MS
What drug should you not give to a manic patient?
An SSRI
- this will push them into excessive mania
What is the diagnosis of type II bipolar affective disorder?
Hypomania + depressive episodes
Mania for >4 days <7 days
No evidence of psychosis
Does affect the person to the same degree as manic episode
How should Lithium be monitored?
Weekly - 12 hours after dose until levels stable for at least 4 weeks.
Then monthly for 6 months
Then 3 monthly following this.
Check:
- lithium levels
- TFTs - can induce hypothyroidism
- U&Es - can induce nephrogenic diabetes insipidus
What are the signs of lithium toxicity and how is treated?
Mild:
- Blurred vision
- altered taste
Moderate:
- blackouts
- fasciculations
Severe:
- coma
- seizures
- cerebellar signs (ataxia)
- ECG - AV block
Treatment:
- supportive
- IV fluids
- electrolyte balance +/- dialysis
What are some risks for suicide in those with bipolar disorder?
Previous suicide attempt
Family history of suicide
Rapid cycling
Alcohol/ drug abuse
What are the teratogenic effects of lithium?
Ebsteins anomaly
Floppy baby syndrome
Thyroid dysfunction
- if pregnancy try and avoid.
- if breast try and avoid
It is not absolutely contraindicated
Which drugs should be avoided with SSRIs and why?
Triptans
- due to risk of serotonin syndrome
Which anti-psychotic reduces seizure threshold?
Clozapine
Which of the personality disorders is most likely to transform into a psychotic disorder?
Schizotypal personality disorder
- these people think a lot about magical things, very eccentric, usually dresses weirdly
What is the disorder called which in which the person has the symptoms of schizophrenia but it has only been occurring for less than <6 months but more than 1 month?
Schizophreniform disorder
symptoms from 1-6 months.
How long must someone have psychotic symptoms for them to be diagnosed with schizophrenia?
> 6 months.
What are the different types of schizoaffective disorders and how are they differentiated?
Schizoaffective disorder, depressed type
Schizoaffective disorder, bipolar type
Major depressive disorder with psychotic features
Bipolar with psychotic features
*whatever syndrome came first and was sustained without other symptoms for 2 weeks is the primary condition.
What is it called when an individual with autism has a particularly interest in a subject becoming hyper focused on it, usually far surpassing normal knowledge/ ability in it?
Savants syndrome
Name some genetic conditions associated with autism:
Fragile X syndrome
Tuberous sclerosis
PKU
Highlight some key developmental restrictions in someone with autism:
Delayed speech
Lack of response to name
Reduced eye contact
Delayed and poor play with others
Regression of social milestones - especially language
Name some screening tools for autism:
Gilliam Autism scale rating
- used for pre-school
Social responsiveness scale
- for older children
What are the three main domains of symptoms of autism?
Social communication and reciprocal interaction
Global impairment of speech and language
Restricted behaviour/ interests/ activities
What advice should be given to a breast feeding woman taking lithium?
Do not breast feed
When is ECT indicated?
Life threatening depressive disorder order or Catatonia or Severe mania
What age can a personality disorder be diagnosed?
> 18 years old. when their personality is fully formed
What are the core features of PTSD?
Re-experiencing the ordeal - flashbacks
Avoidance - people, places
Hyperarousal - hypervigilant, sleep disorder
Emotional blunting
What is it called when then there is loss of function or strange sensations felt and no organic feature can be felt:
Conversion disorder
- this is a NEUROLOGICAL sensation of disorders. i.e. things that would mimic MS or a stroke (loss of sensory, motor function)
*this differs to somatisation disorder which multiple PHYSCIAL symptoms for least 2 years
List some specific mental health illnesses which are associated with increased risk of suicide:
Depression Bipolar disorder Borderline personality disorder Substance abuse Anorexia
If clozapine is missed on more than 2 days (48 hours) what is the management:
Restart the titration dose. if you start back at the dose previously on it may cause BP abnormalities
What are the treatment options for OCD?
Mild:
- CBT and exposure therapy
Moderate:
- SSRI
or
- Intense CBT + exposure therpay
Severe:
- SSRI + CBT + exposure therapy
*clomipramine is can be used which is a TCA
What is the most common type of memory loss occurs in ECT?
Retrograde memory loss
- usually improves following months
*they can have both though, retrograde and antegrade
What are some of the side effects of mirtazapine?
Weight gain
- increased appetite
Sleep disturbance
*a noradrenaline specific specific serotonin anti-depressant
When diagnosing a generalised anxiety disorder, what organic causes should be ruled out?
Hyperthyroidism
Cardiovascular disease - arrhythmias
Medication induced
Medications:
- salbutamol
- corticosteroids
Define a phobia:
Anxiety induced by a well defined situation that are not dangerous and should not provoke the level of anxiety experienced.
What is the management of generalised anxiety disorder?
Low:
- Self education
Medium:
- Low intensity psychotherapy - self help
High:
- CBT
+
- Medication
Medications:
1st line: SSRI
+/- Beta blockers
2nd line: SRNI
3rd line: Pregabalin
**Benzodiazepines can be used for acute severe anxiety episodes for short term
**propranolol
What are the key features of PTSD:
Re-experiencing
- flashbacks
- nightmares
Avoidance
- people
- situations/ areas which remind
Hyperarousal
- Sleep disturbance
- startle response
- poor concentration
Emotional numbing
How long must symptoms of PTSD be present for in order for it to be classified as PTSD?
> 1 month.
Prior to this it adjustment disorder
What is the treatment for PTSD?
1st line:
- CBT
- eye movement desensitization and reprocessing / EMDR
2nd line:
- SSRI - paroxetine most effective
- TCAs - amitriptyline
What is mirtazapine?
Noreadrenaline Selective Serotonin Receptor Antidepressant
- NaSSA
- used for depression
- can increase appetite
What is the drug of choice to treat acute dystonia?
Procyclidine
- an anti- cholinergic
What are the negative symptoms of schizophrenia?
Apathy
Poverty of thought and speech
Blunting
Social withdrawing
Lack of motivation
What are the different types of auditory hallucinations?
1st person:
- own thoughts spoken out aloud or ehco
2nd person:
- voice speaks to them
3rd person:
- voices talking - usually about them
What are the types of delusions that can occur?
Delusion of perception *1st rank symptoms
- seeing something and believing it has a meaning *i.e. a cloud in the sky meaning God is speaking to them
- this can be primary (spontaneous) or secondary (usually related to mood and the interviewer can rationalise why they think that i.e. a depressed person believing they are responsible for something terrible that has happened)
Persecutory
Grandiose
Delusion of reference (believing the news lady is talking to them)
Nihilistic
Erotomania
Contrast circumstantial thinking and Tangential thinking:
Circumstantial thinking:
- goes off topic but eventually returns
Tangential thinking:
- diverts from topic and doesn’t return to answer question
What symptoms must be present for a diagnosis of schizophrenia?
> 1 or more of the following:
- Thought disorder (insertion, withdrawal, broadcast)
- Delusions of perception (traffic light is green therefore I am king)
- Hallucinations (usually auditory or tactile)
- Passivity phenonium (feeling they are being controlled)
OR
> 2 or more of the following:
- Other hallucinations + fleeting delusions
- Though disorganisation (loosening of association, incoherence)
- Catatonic symptoms
- Negative symptoms
- Change in personal behaviour
When is clozapine used?
Failure of at least 2 anti-psychotic for 6-8 weeks
What are anti-psychotics good at treating and what are they not good at treating?
Good at treating positive symptoms but poor at negative symptoms
What are some of the issues with the monoamine hypothesis?
Lag in time when the medication starts to work
Massive increase in monoamines with the medications yet sometimes no improvement
Outline the management of a patient with bipolar disorder during a manic phase and the management when in a depressive stage:
Manic:
- consider admission - may need detention
+
- stop all SSRIs
+
- 2nd line Anti-psychotic medication or increase dose
- Risperidone
- Quetiapine
- olanzapine
(sodium valproate can be added if not working)
Depressive:
- Antidepressants
+
- Anti-psychotic
**Quetiapine is a good medication for both
**discontinue anti-depressants once depression is in remission for 8 weeks
What are the indications for lithium?
- manic episode with severe adverse/ risks
- manic episode following another disordered mood
- repeated hypomania or depressive episodes with significant dysfunction
What is the minimal amount of time should be patient be on lithium for?
2 years
What drugs should be avoided with lithium and what is the ECG effect seen with lithium?
Lithium is renally excreted therefore drugs affecting renal functions should be discontinued.
- diuretics
- ACE inhibitors
- NSAIDs
ECG:
- flattening of the T waves or inversion
What is the criteria for dependence?
3 or more of the following:
- strong compulsion/ desire to take the substance
- difficult controlling substance taking behaviour (level of use, when to stop)
- Physiological withdrawal symptoms
- Tolerance to substance
- Neglect of alternative pleasures/ duties (usually due to time spent)
- Persistence despite known it is harmful
What is the definition of harmful substance use:
A quantity of pattern use of a substance causes adverse consequences in the following:
- Love
- Livelihood
- Liver
- Law
What types of delusions are usually seen in delirium tremens and what is the most common cause of death in these patients?
Paranoid delusions
- usually with intense fear
Cardiovascular collapse
Hypo/ hyperthermia
Infection
What are the signs and symptoms of delirium tremens and how is it treated?
Usually occurs 48 after withdrawal but can occur in 1-7 days.
- Altered consciousness and cognitive ability
- Hallucinations (typically tactile and visual)
- Paranoid delusions
- Hyperthermia
- tachycardic
- Hypotensive
- Seizures
Treatment: - Admit - get medical opinion - Benzodiazepines (chlordiazepoxide) - Pabrinex - IV \+/- - Haloperidol (lower's seizure threshold so careful management is needed)
What are the treatment options for alcohol dependence?
Psychosocial interventions:
- motivation interviewing
- CBT
- group therapy
Medications:
- Disulfiram (blocks aldehyde dehydrogenase)
- Acamprosate (Enhances GABA, reducing cravings)
- disulfiram and Acamprosate are contraindicated in pregnancy
- Naltrexone (Blocks opioid receptors reducing the enjoyment of alcohol)
What are the symptoms of depression in order for there to be a diagnosis and how do these relate to severity?
2 week history of: >2 or more - Low mood - Anhedonia - Reduced energy/ fatigue
+
> 2 or more:
- reduced concentration and attention
- Diminished appetite
- Disturbed sleep
- Ideas of guilt and worthlessness
Mild:
- 4 symptoms
- minimal affect on completing daily tasks
Moderate:
- 5 symptoms
- difficulty completing normal tasks
Severe:
- 7 symptoms
- inability to complete normal tasks
Severe with psychotic symptoms
- hallucinations
- delusions
List some times when Haloperidol can not be used as sedative medication:
Lewy body dementia/ Parkinson’s disease
- any of the Parkinsonism diseases
QT prolongation
- other medications
- congenital
- if no baseline ECG
History of torsade de pointes
Comatose
What are the genetics linked to Alzheimer’s? and what are the medications that are used?
Late onset AD:
- Apo E
Early onset:
- Presenilin -1
- Preselin - 2
- Trisomy 211 (3 copies of Amyloid precursor protein)
Medication:
- Donezepil (cholinesterase inhibitor)
- Memantine (MNDA receptor agonist)
What is the drug management for Lewy body dementia and what drugs should be avoided?
Rivastigmine (Cholinesterase inhibitor)
Avoid:
- Anti-psychotics especially haloperidol. makes things much worse.
What are some associations with Schizophrenia?
Genetics
- twin with it may increase likely hood
Winter births
Pre-eclampsia
Low birth weight
Urbanisation
What is meant by a primary delusion and what is meant by a secondary delusion?
Primary
- it is spontaneous.
- person wakes up and believes the delusion without a triggering factor. I.e. Traffic lights are green therefore I am king
Secondary
- something has happened but its misinterpreted or it is in keeping with their mood . i.e. depressed person believes they are reasonable for a car accident that they were involved in
What are some poor prognostic factors for schizophrenia?
Long standing illness
Early onset
Recurrent episodes
- each time there is an episode more neural damage occurs
Poor response to medication
Prodromal social withdrawal
Long time in diagnosis
Which 3 people are present for a tribunal for a compulsory treatment order?
Psychiatrist
Lawyer
Lay person with personal association of mental health
What are the two types of Emergancy detention and how long do they last for?
Emergancy Detention Certificate
- by a doctor >FY2
- 72 hours
- to assess patient, legally no treatment must be given
Detention by a nurse
- detained for 3 hours to allow a doctor to review
What are some red flags relating to alcohol use?
Driving
Children
Vulnerable children at home
Which alcohol withdrawal patients get lorazepam and who gets diazepam?
lorazepam is used for those with liver disease.
it has a lower half life thus toxic metabolites don’t stick around as long.
Negative is that it doesn’t give as much coverage due to its short half life.
Outline the general managements for alcohol dependent treatment:
Psycho:
- Motivation interviewing
- CBT
Social:
- Social support
- Peer support
Biological:
- Disulfiram - Acetlyaldheye dehydrogenase inhibitor
- Acamprosate - Reduces gravings (GABA)
- Naltrexone - opioid antagonist reducing pleasant sensation
What are the schizophrenia first rank symptoms?
1 of more of the following:
- Delusions of control, influence (passivity phenonium)
- Auditory hallucinations
- Delusions of perception (traffic lights are green so I am king)
- Thought disturbance (Echo, withdrawal, insertion)
What is the criteria for anorexia nervosa?
Overvalued idea of body image
BMI <17.5 or <15% less than expected
Deliberate weight loss
*cut from criteria now are:
Endocrine disturbance
- amenorrhoea
- lack of libido
What important things must you rule out when diagnosing anorexia nervosa?
Rule out other causes of weight loss:
- G.I pathology = Crohn’s
- diabetes
- Addison’s disease
- Hypo-pituitary
What blood investigations should be done into anorexia nervosa?
and what is the general management?
FBC
Coagulation
Bone profile
Mg2+ levels
Refeeding (even if NG)
Psychotherapy
- family therapy
- ED - CBT (eating disorder)
*highest mortality in mental health
How is refeeding syndrome managed?
In addition to hypophostamia, what important electrolyte must you consider and why?
Dietician involvement
Smaller portions given and built up usually starting at 1/4 portions
Parbinex
Daily bloods (electrolytes) - if abnormal cannot progress forward Monitor: - Glucose - Phosphate - K+ - Mg+ - Ca2+
**K+ needs to be monitored due to insulin driving K+ into cells when food is reintroduced.
Daily ECG
What drugs may be used in the treatment of borderline personality disorder?
Quetiapine
- antidepressant + anxiety
Mood stabilisers
- Lamotrigine
- Lithium
