Psychiatry 4 Flashcards
What aspects of care are in a care programme approach?
Social workers
Community psychiatry nurse
Home care assessment
OT to help get the patient back into community
What is the main management of lithium overdose?
Organ support
- IV fluids to flush the lithium
- continual monitoring
- dialysis may be needed
Give some differentials for depression:
Adjustment disorder
Grief reaction
Cyclothymia
Organic causes
- hypothyroidism
Schizophrenia
- negative symptoms
What is the mnemonic for organic symptoms of depression?
CALS
- concentration
- Appetite
- Libido
- Sleep
What cognitive functions can be tested in delirium?
Orientation
Recall and delayed recall
Language - Naming objects
What diagnosis would you think if someone is suffering from recurrent panic attacks when out in public places?
Panic disorder with agoraphobia
What advice would you give when prescribing SSRIs to patients?
They can take 2-6 weeks to work and may increase suicide idealisation at first
*bring back <30’s in one week
How should changing an fluoxetine to another SSRI be done?
withdraw and leave a gap of 4-7 days before starting the new SSRI
- due to the long half life of the fluoxetine
What is the management of switching from an SSRI to TCA?
Cross coverage
- slowly reduce the SSRI which slowly increasing the dose of the TCA
Which antidepressant causes an increase in QTc?
citalopram
How should switching from fluoxetine I to an SNRI be managed and name an SNRI:
Withdrawal the SSRI and start the SNRI immediately, building up slowly
Venlafaxine is the most commonly used SNRI
How long should a patient be kept on anti-depressants for following recovery?
6 months
2 years if relapsing
1 year if anxiety
What blood tests should be conducted for those on SSRIs?
FBC
- for G.I Bleeding
U&Es
- hyponatraemia
ECG
- QTc prolongation
What is the medication options for anti-depressants?
1st line:
- SSRI
- ensure adequate dose before moving
2nd line:
- change SSRI
3rd line:
- SNRI
or
- NaSSA
4th line:
- TCA
- lithium
How should switching from an SSRI to an SNRI be managed and name an SNRI:
cross coverage
What are the classification of severity of depression?
Mild:
Core symptoms + 2 symptoms
Moderate:
Core symptoms + 4 symptoms
Severe:
Core symptoms +>4 symptoms
or
Psychotic features
What are the additional symptoms of depression?
Early morning wakening
Decreased appetite
Low libido
Psychomotor retardation (slow movement, reduce movement)
Poor concentration
Suicidal idealisation
Feelings of guilt
When starting antidepressants, how long after starting should individuals be followed up?
<25 years old: weekly to begin with and following any increases in dose
> 25 years old: 2 weekly to begin with and following any increase in dose
What drug is good in a depressed patient if they have poor sleep and/or appetite?
mirtazapine
What are the indications for ECT?
Catatonic patients
Life threatening depression
- not eating drinking
Severe mania
How often is ECT given? and what are some side effects?
Typically:
- twice weekly for 6-12 weeks
*>2 treatment tend to see improvement
Side effects:
- short term memory loss - retrograde
- episodic memory loss of previous memories
- complications from GA
*reduce prior antidepressants
How does the dosage of SSRIs vary between anxiety and depression?
Anxiety a lower dose is started first
Depression higher dosage is started first
What is the syndrome in which some believes their partner/ lover is having an affair and what is a risk with it?
Othello syndrome
- risk of violence
What is called when a person mimics your behaviour?
Echoprexia
- falls under appearance and behaviour.
typic of cationic behaviour
What test can be done quickly to screen for delirium?
4AT
- Alertness
- Orientation - marks for making mistakes
- Attention - months backwards
- noticed change or fluctuation
List some factors which suggest a suicide attempt is more serious:
Method of attempt Precautions to be avoided Not seeking help before or after faield attempt Planning of attempt Notes
What is the BMI equation?
Weight / (height)2
Weight Kg / Height, meters. squared
What investgiations should you do when you are presented with someone with anorexia nervosa?
Bloods:
- FBC/ MCV
- B12/ Folate
- U&Es (electrolyte abnormalities)
- Glucose
- Bone profile
- Amylase
- TFTs
ECG:
- bradycardia
- prolonged QT
- Hypokalaemia
What clinical signs may you see with anorexia nervosa?
Low BMI Bradycardia/ hypotension Lanugo hair Brittle nails/ dry hair Hyothermia Russels sign Parotid enlargement
Why must lithium not be stopped abruptly?
It can induce severe mania.
What is the upper limit of time benzodiazepines can be used for to treat generalised anxiety? and how are they withdrawn off?
2 weeks.
if been on for a long time - reduce dose 1/8th every 2 weeks
Which Anti-depressant/ anti-anxiety medication should be avoided in pregnancy?
Paroxetine
- congenital malformations
Benzodiazepines
- causes cleft lip abnormalities in first semester
List two risk factors for post-partum depression:
Previous history of depression
Family history of depression
What is the most common cause of death during pregnancy and 1year after pregnancy?
Suicide
Is lithium contraindicated in pregnancy and breast feeding?
Yes
- high concentrations enter pass through both
What are the differences in MMSE scores?
> 27 normal
24- 27: mild cognitive impairment
21- 23: Mild dementia
10-20: moderate
<10: severe dementia
What are some poor prognostic factors for schizophrenia?
Late onset
Drug use
Drug resistant
Negative symptoms - have a poorer prognosis
List several blood tests you would do in order to try and establish a reversible cause for dementia:
FBC - macrocytosis? U&Es - electrolyte abnormaliteis Bone profile - Ca2+? LFTs - alcohol, encephalopathy? Thyroid function Glucose B12
What would be some differentials for first presentation of schizophrenia?
Illicit drug abuse
Delirium
Personality disorder
Temporal lobe epilepsy
What is the definition of dementia?
An acquired loss of higher cerebral functioning in >2 more domains which include:
- episodic memory
- executive function
- visuospatial function
- Language
- aprexia/ agnosia (poor recognition)
It must be severe enough to have a significant impact on the individual and be in the absence of reduced consciousness (separating it from delirium)
What imaging may be conducted into dementia and why?
Head CT
- rule out neoplasms
- rule out hydrocephalus
- rule out sub-durals
CT angiogram
- assess for vascular status of the brain
Brain MRI
- establish specific atrophy patterns
Amyloid Radio-nuclear scan
- picks up amyloid deposits
What are some of the causes of dementia?
Degenerative:
- Alzheimer’s
- Lewy body
- Fronto-temporal
- Huntington’s
- vCJD
Vascular
Metabolic:
- Uricemia
- Liver failure
Toxic:
- heavy metal poisoning
Endocrine:
- Hypothyroidism
- Hypoparathyroidism
Infections:
- HIV
- Syphilis
- TB
Trauma:
- subdural
List some investigations you could conduct in a patient with dementia to try and establish the cause:
Bloods:
- U&Es (renal)
- LFTs
- TFTs
- Bone profile (Ca2+)
- Vitamin B12
- HIV serology
- Syphilis serology
Imaging
<65 years old:
- Genetic studies for AD genes and Huntington genes
- EEG
Why are those with Down’s syndrome at increased risk of Alzheimer’s disease?
They have increased copies of Amyloid precursor protein
- APP is found on chromosome 21 therefore they have 3 copies.
What are some risk factors for Alzheimer’s disease?
1st degree relative with AD
Down’s syndrome
- 3 copies of APP
Homozygosity for ApoE E4 allele
Head injuries
Smoking
Which two types of dementias should NOT receive acetylcholinesterase inhibitors?
Fronto-temporal
Vascular
What are some poor prognostic factors for schizophrenia?
Pre-dromal social withdrawing
Prolonged illness
Gradual onset
Family history
Medication resistant
How often are Depot injections given and list a type of anti-psychotic medication typically used for it:
IM injection
- once monthly
Risperidone
Are pseudo-hallucinations part of a normal grief reaction?
Yes
- even seeing the loved one can be normal
If a patient is going for ECT what should occur to their current anti-depressant medication?
Dose should be reduced
Which antidepressant should be avoided in early pregnancy and why, and list some complications of SSRI use in late pregnancy:
Paroxetine
- congenital abnormalites
Third trimester
- resistant pulmonary hypertension
Highlight some areas where children differ from adults with regard to their presentation of depression:
Difficulty dealing with criticism
- low self esteem which is easily damaged
Mood variability
- periods of crying
- anger out bursts
- irritability
Behavioural issues
- can often be mistaken for ADHD
- poor school work
Somatic symptoms
- headaches
- stomach aches
Self harm
- more likely to self harm which may be due to immaturity in dealing with emotions
What is the genetic defect in Huntington’s disease and list some features seen with it:
Tri-nucleotide repeat of CAG (>39)
- Genetic anticipation is seen
- AD inheritance
Features:
- early dementia
- Chorea
- dystonic movements
- changes in personality
In anorexia nervosa what does the Growth hormone and cortisol levels look like?
Raised.
What are some of the genes linked to ADHD and list some risk factors:
DRD4
DRD5
*dopamine receptors
Risk factors:
- family history
- Low social economic status
- Head injury
- Brain injury - HIE, meningitis
- Spina-bifida
