Psychiatry Flashcards
1
Q
Another word for ‘mood’ disorders
A
Affective
2
Q
Rough prevalence of dementia in uk?
A
830,000
3
Q
Risk factors for alzheimer’s disease
A
Family hx Genetics Downs syndrome Vascular risk factors Low physical activity Low mental activity Depression Loneliness Smoking
4
Q
Gene often mutated in Alzheimer’s
A
Apolipoprotein E (ApoE)
5
Q
Define dementia
A
Progressive
Decline in cognitive function
Especially effecting memory
Usually global
6
Q
What are the 7 A’s of dementia? What do they mean?
A
Apathy - not initiating things
Aphasia - decreased language, both spoken and written
Agnosia - lack of recognition
Amnesia - lack of memory
Apraxia - lack of ability to coordinate movements despite understanding and adequate muscle strength
Altered perception - misinterpretation of events and visiospacial
Anosognosia - lack of insight
7
Q
What are the two core pathological hallmarks of Alzheimer’s disease. What is the effect on the cell signalling in the brain?
A
Deposition of extracellular beta amaloid
Formation of neurofibrillary tangles of tau proteins destabilising microtubules.
Results in cell apoptosis and low ACh, NA and 5HT
8
Q
What brain regions does alzheimers mainly effect. Where is usually effected later
A
Temporal, parietal and hipocampus
Later frontal
9
Q
How does alzheimers present on head imaging? What features of the scan suggest this?
A
Global atrophy +
Hippocampal atrophy +++
Suggested by increased ventricle size and sulci size
10
Q
Other than imaging, what other test may show a change associated with alzheimers?
A
CSF - raised tau proteins.
11
Q
What are the characteristics of vascular dementia?
A
Sudden onset
Stepped progression
Often memory and cognition but can effect where ever there are lesions
12
Q
4 main causes of dementia
7 minor ones
A
Alzheimers, vascular, lewy body, frontotemporal
Parkinsons, huntingtons, progressive supranuclear palsy, cjd, wilsons, ms, hiv
13
Q
What are the mental features of frontotemporal dementia?
A
Behaviour change
Language problems
Loss of world knowledge
14
Q
What is largely preserved in frontotemporal dementia?
A
Praxis
Episodic memory
Spatial skills
Perception
15
Q
What clinical signs may suggest frontotemporal dementia? (Group and specific)
A
Primitive reflexes
- grasp
- tap forehead and eyelids blink
- oral reflexes - sucking related
16
Q
What is the term for excessive blinking on tapping the forehead? What diseases is it related too?
A
Gabella tap
Frontotemporal dementia
Parkinsons
17
Q
What drugs are used in altzheimers
Example
Side effects
A
Acetylcholinesterase inhibitors
Donazepil
Bradycardia, constipation, nausea and vomiting
18
Q
What drug is useful in lewy body dementia to control behavioural issues?
A
Rivastigmine
19
Q
On what chromosome is the genetic change that is linked to frontotemporal dementia found?
A
9
19
Q
How is frontotemoral see on a CT?
A
Atrophy of the frontotemporal lobes only
19
Q
What reaction may occur in a patient with lewy body dementia who is given an antipsychotic?
A
Severe extrapyramidal side effects
20
Q
What specific imaging can be used in lewy body dementia? What is it? What other condition can it be used in?
A
DAT Scan - radioactive iodine with high affinity for presynaptic dopamine transporters
Parkinsons
21
Q
What should be checked for in cognitive impairment?
A
Fbc, u+e, bm, lfts, b12+folate, tfts, hiv, syphallis, serum copper,
Cxr, ct head
23
Q
What general pharmocological interventions may help in dementia and complications thereof?
A
Memantine
Depressed - SSRIs/mirtazapine
Agitation/aggression (if not manageable and no reversible cause) - lorazepam/haliperidol
24
What is the definition of psychosis? What are the four cardinal symptoms of psychosis?
```
Experiencing a different reality to the majority of people without insight.
Hallucinations
Delusions
Formal thought disorders
Disorders of the self
```
25
What are hallucinations?
Perception in the absence of stimuli
26
What is the definition of delusions?
A firm belief that is held despite a lack of evidence and contradictory evidence out of keeping with the individuals social and cultural norms.
27
Some types of delusion
```
Grandiose
Persecutory
Guilt
Reference
Hypochodriacal
```
28
Types of auditory hallucination
Second order - people speaking directly too the patient
| Third order - people speaking to other people often about the patient
29
How would a patient with formal thought disorder present?
Rapidly changing incoherent speech. One sentence/word does not necessarily follow the last
30
What are disorders of the self? Two examples?
Difficulty in distinguishing self from non-self.
Thought broadcast
Thought insertion
31
Give three functional causes of psychosis with they typical psychiatric abnormality
```
Schizophrenia (auditory hallucinations)
Severe depression (derisory hallucinations or delusions)
Mania (delusions of grandiose)
```
32
Some examples of organic causes of psychosis
```
Dementia
Delirium
Infections
SOL
Endocrine disease
Epilepsy
Drugs (stimulants, levodopa, cannabis)
Alcohol withdrawal
Nutritional deficiencies
Electrolyte imbalances
```
33
What are the core symptoms of depression?
Low mood for 2 or more weeks
Anhedonia
Lack of energy
34
What are somatic symptoms of depression?
Decreased appetite
Weight loss
Decreased libido
Early morning wakening
35
What are mental symptoms of depression?
```
Low self esteem
Guilt
Hopelessness
Diurnal variation in mood
Decreased attention
Hypochondriasis
Suicidal thoughts
```
36
What features can complicate depression and make diagnosis hard?
```
Psychosis
Cognitive impairment (depressive pseudodementia)
```
37
What are the criteria for the classification of depression as mild, moderate and severe?
Mild - 2 core symptoms and 2 other
Mod - 2 core and 3 other
Severe - 3 core and more than three other
38
What types of psycosis typically occur with depression?
Hallucinations - second person auditory - derisory and suggestions of suicide
Delusions - nihilsm (poverty and non-existence)
39
Risk factors for depression
```
Excessive alcohol
Female
Chronic illness
Social stress
Lack of support
```
40
What three categories can predisposing factors for mood disorders be divided into? Give some examples
Bio - genetics, physical health
Psycho - personality trait/disorder
Social - housing, relationships, finance
41
Biological treatments of depression?
Pharmacological - antidepressants
| ECT
42
Psychological treatments of depression
```
CBT
IPT (interpersonal psychotherapy)
```
43
Social treatments for depression
Helping sort finance, life etc!
| General coping strategies
44
What physical health conditions may cause depression?
Hypothyroid
Cushings
Hyperparathyroidism (hypercalcaemia)
Brain tumours
46
What 2 types of sleep disturbance are there?
Initiation
| Maintainance
47
What benzodiazapines are short acting?
Lorazepam, temazepam
48
What benzodiazapines are long acting?
Diazepam, nitrazepam
49
What is are issues with long term benzodiazepam use for insomnia?
Tolerance
Dependancy
withdrawal
50
What factors of benzodiazepams prescriptions would increase dependancy?
```
Short acting
Long prescription
Strong dose
Alcoholism
Drug dependancy
Personality disorders
```
51
Other than dependance what are the disadvantages of using hypnotics to aid sleeping?
```
Falls
Confusion
Psychosis
Day time drowsiness
Nightmares
Amnesia
Dizzyness
Depression
```
52
Definition of schizophrenia
A group of disorders causing distortion of thinking and perception with inappropriate or blunted affects.
54
What are the subtypes of schizophrenia?
Paranoid schizophrenia - large paranoid delusions
Catatonic schizophrenia - psychomotor disturbance both hyperkinesis and stupor
Hebephrenic schizophrenia - large affect changes and behaviour problems - disorganised speech, behaviour and emotions
Undifferentiated schizophrenia
55
Negative symptoms of schizophrenia
Apathy
Social withdrawal
Lack of motivation
56
None first rank positive schizophrenia symptoms
Other hallucination types
Behaviour disturbance
Secondary delusions
58
Prognosis of schizophrenia
1/3rd single psychotic episode
1/3rd multiple psychotic episodes
1/3rd multiple psychotic episodes with personality change
59
Treatments of schizophrenia
Bio - antipsychotics
Psycho - type a psychotherapy (opportunistic informal) and cbt
Social - family therapy, sheltered work, treatment adherence
60
What are the first rank symptoms of schizophrenia?
3rd person auditory hallucinations
Thought withdrawal, insertion or broadcast
Primary delusions
Delusional perception
Thoughs feelings or acts are controlled by others
61
What are schizotypal disorders?
Eccentric behaviour and anomalies of thinking like schizophrenia but not making the diagnosis
62
What are schizoaffective disorders?
Episodic affective and schizophrenic symptoms that do not justify a diagnosis of either schizophrenia or affective disorder (mania, depression, anxiety)
Essentially both schizophrenia and affective disorder together
63
What is a major theory of causation of depression?
| What is a major flaw with it?
Monoamine theory of depression
| Why do drugs eg. TCAs which rapidly raise NA and 5HT not rapidly resolve the depression
64
What is the proposed mechanism of ssris. How long can they take to have an effect? Why may this be?
Block serotonin reuptake
3-6 weeks
Increased cleft serotonin has negative feedback reducing serotonin release. With time presynaptic receptors desensitise and release returns to normal whilst serotonin still remains in cleft for longer
65
What percentage of patients respond to antidepressants?
70%
66
How long should antidepressants be continued past recovery from depression?
1 episode of depression in 5 years - 6 months
| >1 episode of depression in 5 years - 2 years
67
What advice should be given to someone about stopping antidepressants? Why? What features?
Slow discontinuation
Risk of discontinuation syndrome - dizzyness, headache, lethargy, extrapyramidal effects, mania. Rapid onset within days, rapid resolution when drug restarted.
68
What are side effects of SSRIs?
```
N+V
Diarrheoa and consitpation
Sexual dysfunction
Bleeding risk
Suicidal ideation
Hyponatraemia
Loss of appetite
```
69
Give four examples of TCAs
Amitriptyline
Imipramine
Nortriptyline
Dosulapin
70
How do TCAs effect NA?
Stimulate 5HT neurones which in turn stimulate NA neurones
| Desensitise alpha 2 receptors on presynaptic membrane
71
What unwanted receptors do TCAs effect? What side effects associated with each?
Muscurinic - blurred vision, dry mouth, constipation, urinary retention, st/svt
Alpha adrenoceptors - postural hypotension
Histamine receptors - confusion
Myocardial Na channels - decreased Na influx so prolongs QRS and arrhythmia
72
Which TCA is most cardiotoxic?
Dosulepin (dothiapin)
73
Examples of SNRIs
Venlafaxine
| Duloxetine
74
What differs in the side effect profile of SNRIs vs SSRIs - one positive and one negative.
Positive - less sexual dysfunction
| Negative - hypo or hypertension
75
How does mirtazapine work?
Blocks alpha 2 adrenoceptors increasing amount of NA and 5HT in synaptic cleft
76
Additional benefits of mirtazapine?
Increases appetite
| Sedative
77
Side effects of mirtazapine
```
Weight gain
Postural hypotension
Urinary retention
Dry mouth
Fatigue
Mania
Blood disorders
Hyponatremia
```
78
Other than mirtazapine what other antidepressant is involved in blocking receptors? Which does it block?
Trazodone
Blocks presynaptic 5HT and H1
Increases 5HT and NA
79
What can MAOIs interact with broadly?
Drugs - amine containing e.g. Cough mixtures or decongestants, other antidepressants
Drugs - also metabolised e.g. Opiates, barbiturates, alcohol
Foods - tyramine containing - e.g. Cheese, game, alcohol
80
Examples of MAOIs
Phenelzine
| Isocarboxazid
81
Why is tyramine dangerous in MOAIs?
Usually metabolised by MAOIs
Acts as an indirect sympathomimetic causing release of NA
Hypertensive crisis
82
Why is lithium used?
Mania
Bipolar
Recurrent depression
83
Side effects of lithium
```
Huge number
Arrhythmia, AV block, QT prolongation
Hypothyroidism
Intercranial hypertension
GI disturbance
Renal disturbance inc. polydipsia and polyuria
```
84
What is the proposed mechanism of action of lithium?
Interaction with second messanger system
85
What is the core mechanism of action of antipsychotics?
Suppression of the mesolimbic and mesocortical dopaminergic pathways by antagonising dopamine receptors
86
What unwanted pathways do antipsychotics effect? With what effects?
Nigrostriatal - EPSE - parkinsonism, acute dystonic reactions, akathisia, tardative dyskinesia
Tubero-infundibular - hyperprolactiemia, gynecomastia, galactorrhlea, menstrual irregularities, impotence
87
What other categories of side effects are there for antipsychotics other than effecting the dopamine pathways?
Autonomic
Neuroleptic malignant syndrome
QT prolongation
88
What side effects of antipsychotics occur due to blockage of the desired dopamine pathway?
Impaired performance
| Sedation
89
What autonomic receptors may be blocked by antipsychotics? What side effects do each cause?
Muscurinic - dry mouth, blurred vision, urinary retention, constipation
Alpha adrenoceptor blockade - postural hypotension, hypothermia
Histamine - sedation, weight gain, diabetes (unsure how on latter 2)
5HT - sedation
90
What is neuroleptic malignant syndrome?
A rare reaction to antipsychotics
Causes hyperthermia and muscle rigidity
Treat with cooling and dopaminergic agonists like bromocryptine
91
What are some examples of typical antipsychotics?
Haliperidol
| Chlorpromazine
92
What side effects predominate in typical antipsychotics?
EPSEs
93
What are the major side effects of chlorpromazine?
Sedation
Agranulocytosis
Haemolytic anaemia
94
What are the major side effects of haloperidol?
Movement disorders
| Prolonged qt
95
Examples (6) of atypical antipsychotics
```
Clozapine
Risperidone
Olanzapine
Quetiapine
Amisulpride
Aripriprazole
```
96
What atypical antipsychotic is especially useful in refractory patients? What are its major side effects? What side effects does it not tend to cause? Why?
Clozapine
Neutropenia, agranulocytosis, antimuscurinic
Low incidence of EPSE maybe due to 5HT blockage
97
Which antipsychotics are most likely to cause hyperprolactinaemia?
Typical
| Risperidone
98
Which antipsychotic doesnt cause hyperprolacinaemia? Why?
Aripriprazole
| Partial dopamine agonist
99
Which antipsychotics are most likely to prolong QT
Haloperidol
100
Which antipsychotics are most likely to cause weight gain and diabetes mellitus?
Clozapine and olanzapine
101
Which antipsychotics can be used in depot?
Haloperidol
| Risperidone
102
What are disadvantages of use of depot injections of antipsychotics?
Increased risk of movement disorders
| Cant stop quickly if side effects occur
103
What should be monitored in antipsychotic therapy GENERALLY?
```
FBC, U+Es, LFTs annually
ECG
Lipids and weight at 3 months then yearly.
BM at 6 months then yearly
Prolactin 6 months then yearly
```
104
Which antipsychotic requires more intensive monitoring?
Clozapine
105
What are the four extrapyramidal side effects?
Which is. Irreversible on. Withdrawal of drug
What is a possible treatment
```
Dystonia - abnormal contraction
Akatheisa - restlessness
Parkinsonism - tremor
Tarditive dyskinesia - rhythmic contraction - irriversible
Procyclidine
```
107
What teratogenic fetature results from lithium? What is it?
Ebsteins anomaly
| Tricuspid valve deplaced towards apex decreasing right ventricular size
108
Features of lithium toxicity
```
Tremor
Ataxia
Dysarthria
Coma
Convulsions
Death
```
109
What monitoring is required in a patient on lithium?
Litium levels
Tfts
Renal function
110
Other than lithium what other mood stabilisers are available?
Sodium valporate
Carbamezapine
Lamotragine
111
Psychiatric causes of anxiety as a mental health problem
```
Phobia
Generalised
Panic
OCD
PTSD
Secondary to depression, bipolar, shizophrenia
```
112
Physical causes of anxiety as a mental health problem
Tumour
Hormonal
Infections
113
Symptoms of a state of anxiety
Cognitive - constant worry, hyperarousal, difficulty sleeping, irritiability, hard to concentrate, rumination
Somatic - shaking, sweating, palpitations, hyperventilation (with paraesthesia and carpopedal spasm)
114
How do people with anxiety disorders try to cope?
Avoidance
| Self medication - e.g. Alcohol
115
What is a phobic anxiety
| Examples
Intense and irrational fear of a specific situation, event or thing
- social phobia
- specific phobias (agoraphobia, needles, spiders)
116
What subcategories of social phobia are there?
Generalised
| Specific (e.g. Public speaking)
117
What is a panic disorder?
Discrete episodes of intense fear accompanied by >4 anxiety symptoms more than twice a month with anxiety between attacks
Catastrophic misinterpretation of symptoms
118
What are the treatment options for phobic disorders?
SSRI
| CBT
119
Treatment options for panic disorders (long term)
SSRI
Group therapy
CBT
Imipramine (tca)
120
What is generalised anxiety disorder?
Primary anxiety symptoms most days for several weeks or months. Worry is out of proportion to risk and regards multiple stimuli.
121
Pharmocological treatments for GAD?
Ssris
Tcas
Pregabalin
122
Psycological treatment for gad
CBT
| Group therapy
123
Social treatment for gad
Self help
Exercise
Avoid caffine smoking and alcohol
124
What are the diagnositic criteria for OCD?
Repetitive and unpleasant obsessive or compulsive symptoms
Most days for >2 weeks
Has tried to stop and failed
Good insight
125
Treatment options for OCD
```
CBT
SSRI
Clomipramine (TCA)
MDT
Antipsychotic
```
126
Diagnostic criteria for ptsd
Delayed and protracted response
To exceptional threatening incident to self or loved one
Within 6 months
127
Signs and symptoms of ptsd
Reliving - nightmares, triggers, hypervigilance, startle reaction
Avoidance
Personality - blunting, anhedonia, detachment,
128
Treatment of ptsd
Bio - severe disease only - paroxetine, mirtazapine, amitriptyline
Psycho - trauma focussed CBT, EMDR (eye movement therapy)
Social - reduce alcohol, caffine, drug use etc.
129
Parts of the mental state exam?
```
Appearence/behaviour
Speech
Mood
Thoughts
Perceptions
Cognition
Insight
```
130
Parts of full cognition assessment?
```
General (alertness)
Orientation
Attention
Concentration
Language
Calculation
Abstraction
Memory
Praxis (copying)
Gnosis (making sense of sensory information)
Right hemisphere function (visiospatial)
```
131
What is delirium?
Global impairment of cognition, disturbed attention and conscious level with abnormal psychomotor, affect and sleep patterns
132
What features are typical of delirium timing?
Acute onset
Fluctuating
Worse at night
133
What are the subtypes of delirium, how may they present?
Hyperactive - arousal, restless, irritable, wandering
| Hypoactive - quiet, sleepy, inactive, unmotivated
134
What are the core symptoms of delirium on top of the subtype behaviour?
Disturbed consciousness from alert to coma
Attention deficit
Visual hallucinations
Global cognitive impairment (orientation, speech, memory)
Labile mood
Disturbed sleep wake cycle
135
What are the features of delirium mediated hallucinations?
Fragmented or transient
| Illusionary (misinterpretation)
136
Causes of delirium?
Acute CNS insult - cva, trauma, infection, epilepsy
Acute systemic illness - sepsis, infection, MI,
Drugs - recreational, prescribed
Withdrawal - e.g. Alcohol, benzos
Hypoxia
137
What drugs raise delirium risk?
```
Diuretics
Sedatives
Opiates
Anticholinergics
Antidepressants
Antipsychotics
Antiparkinson
```
138
Risk factors for delirium? Inc specific condition with very high risk!
Age
Pre existing mental health problem
Severe illness
Hip fracture
139
How does delirium change patient outcome?
Worsens prognosis
Increases length of stay (3 fold!)
Increases mortality
Increases readmissions
140
Management ideas for delirium
Bio - antipsychotics (haloperidol or orlanzapine)
Psycho -
Social - food and drink, calm environment, moderate lighting, music, sensory aids, consistent staff, avoid intervention, promote sleep patterns (do they need 30min obs overnight!?)
141
What drugs to avoid prescribing to manage delirium?
Long acting benzos (e.g. Diazepam)
| Multiple side effects e.g. Chlorpromazine
142
What are the types of memory?
Short term
Long term
- explicit (episodic, semantic)
- implicit (procedural, priming)
143
What is the difference between implicit and explicit memory?
Explicit is conscious memory
| Implicit is unconscious memory
144
What are the types of explicit memory? What are they?
Episodic - knowledge of events that have happened to the individual
Semantic - general world knowledge
145
What are the types of implicit memory? What are they?
Priming - exposure to one stimulus effects response to another
Procedural - memory of an action
146
What is more common, anorexia or bulimia nervosa?
| What is the gender distribution?
Bulimia
| 10:1 f:m
147
How low does BMI need to be to make the diagnosis of anorexia nervosa?
17
148
What is the characteristic mindset of an anorexia nervosa patient?
Feels overweight despite being underweight
| Disturbed body image with fear of fatness
149
What are the two subtypes of anorexia nervosa? Which is most common?
Common - restrictive
| Rare - binge purge
150
How does binge purge anorexia differ from bulimia nervosa?
BP anorexia patients are underweight
151
What psychiatric comorbidites are common with anorexia nervosa?
Obsession
Withdrawal
Impaired concentration
152
What personality traits are common with anorexia nervosa?
-ve self evaluation
| Perfectionism
153
Do anorexia nervosa patients typically feel hungry or full? Why?
Full
| Gastroparesis occurs delaying stomach emptying
154
What physical complications commonly occur in anorexia nervosa?
```
Thiamine deficiency
Amenorrhoea and impotence
Osteoporosis
Gastroparesis
Bone marrow suppression
Brain shrinkage
```
155
What is the characteristic pattern of bulimia nervosa?
Binge at least once a week for 6 months followed by a compensation/purge.
156
What is a binge with respect to eating?
An abnormally large volume of food in an abnormally short period of time and feeling out of control.
157
How may a bulimia nervosa patient purge?
Vomit
Drugs - amphetamines, laxitives, thyroxine, orlostat.
Extreme exercise
158
What are psychiatric comorbidites associated with bulimia nervosa?
Depression
Anxiety
Impaired concentration
Substance misuse
159
What personality types are associated with bulimia nervosa?
-ve self evaluation
Perfectionism
Impulsivity
160
What physical complications are associated with bulimia nervosa?
Thiamine deficiency
Hypokalaemia (due to vomiting creating alkylosis thus k loss in kidney)
Hand callouses from putting hand in mouth
Hyponatraemia from laxatives
Bone marrow supression
Dental erosions
Mallory weiss tears
Parotid enlargement due to hyperstimulation
161
Physical treatments for eating disorders?
Multivitamins
| Paretal nutrition if gi dysfunction
162
Treatment of bulimia nervosa
Bio - ssri (large dose)
Psycho - CBT
Social - psychoeducation and self help
163
What therapy may be useful in treating a young anorexia patient?
Family therapy
164
What therapy may be useful in a bulimia nervosa patient with personality disorder?
Dialectical behavioural therapy
165
Which of anorexia nervosa and bulimia nervosa has the highest mortality? Which has the higher recovery rate?
Anorexia has higher mortality (6%)
| Both recover similarly (75%)
166
What are good prognostic factors for eating disorders?
Short duration
Adolescent onset
Family support
167
What decreases prognosis in eating disorders?
```
Duration
Severity
Psychiatric comorbidity
Admitted
Vomiting
```
168
Definition of bipolar
A severe effective disorder characterised by marked mood swings and a tendency to remiss and reoccur
170
What are the subclassifications of bipolar disorder?
Type 1 - =/>1 manic episode +/- depressive episodes
| Type 2 - =/>2 severe depressive episodes + hypomanic episodes
171
In what age rang does bipolar tend to present?
Late teens and early adult
172
Possible causes/risk factors of bipolar
Bio - genetic linkage, brain structure
Psycho -
Social - stressful experiences
173
What psychotic symptoms are associated with bipolar?
Mania - grandiose delusions
| Depression - persecutory delusions, hallucinations
174
What are the symptoms of mania?
```
Grandiose delusions
Happyness
Irritation with people who aren't as optimistic
Hallucinations
Lots of energy - very active
Hypersexual
Spur of moment decisions
Rash financial decisions / gambling
Less inhibited / overfamiliar
```
175
How long should mood stabilisers be continued after resolution of bipolar mood swings?
2 years
| 5 years if frequent, psychotic, substance misuse, continued stress
176
What therapies are useful in bipolar?
Psychoeducation
| CBT if depression occurs or threatens
177
When should an ssri not be considered in a bipolar depressed patient? If they are prescribed when should they be stopped?
Recent manic episode
Rapid cycling disease
Slowly tailor off 8 weeks after effect
178
What management could be considered in a manic episode of bipolar?
Bio - stop antidepressants, consider mood stabilisers and antipsychotics
Social - try to avoid mania precipitating situations such as parties when manic
179
Management of bipolar between episodes
Bio - mood stabilisers
Psycho - psychoeducation
Social - exercise, support network of friends and family, decrease stress,
180
How is lithium metabolised and excreted? What does this mean for monitoring?
Renal
Must monitor renal function to check both for damage from lithium and deteriorating function that could increase lithium levels
181
What two terms can define different elements of bipolar disorder in terms of number and severity of episodes?
Rapid cycling - >4 mood swings in 12 months
| Cyclothymia - mood swings not as severe as bipolar but can be longer
182
What are the criteria for implementing the mental health act?
Must have a mental health disorder or disability of the mind
Significant risk of danger to self or other
No alternative to mitigate that risk
183
In implementing the mental health act - what can 'danger to self' refer too?
Physical harm
Neglect
Deteriorating mental health
184
What sections should i know of the mental health act?
```
5(4)
5(2)
2
3
136
17
117
```
185
What is mha section 5(4)
Mental health nurse
Detain inpatients not in A+E
For up to 6 hours
Where mental illness is suspected
186
What is mha section 5(2)
Approved consultant or deputy as in policy
For inpatients
For up to 72 hours
For assessment of mental health condition
187
What is mha section 2
Anywhere but prison
2 drs (at least one approved) and a mental health practitioner who isnt a dr
For 28 days
For assessment and treatment of mental disorder
188
What is the right of appeal on MHA section 2
Can appeal in first 14 days with hearing in 7 days from appeal
189
What is S3 of MHA?
Anywhere but prison
By 2 drs (one approved) and non dr mental health practitioner
For up to 6 months
For treatment of known mental health condition
190
What is s136 of mental health act?
Police detain in public place to remove to place of safety
| Held for up to 72 hours for assessment by dr and approved mental health practitioner
191
What is section 17 of the mha?
For someone under s2 or s3 allowing leave
192
What is section 117 of the mha?
Anyone under s3 gets this
| Aftercare from local authority is provided free of charge
193
What is the right of appeal for s3 mha?
Appeal once per renewal of section to a tribunal
Apply to mha manager for discharge
Ask for help of independant advocate
Patient rights leaflet
194
How long can someone under s3 of the mha be treated against there will until further measures must be taken? What are the measures?
3 months
| Second opinion appointed dr
195
What are the different theories of addiction?
```
Genetic
Neurobiological
Social
Behavioural
Attachment
```
196
What is the attachment theory of addiction?
Care increases opiate stimulated areas in the brain thus neglected or abused patients may turn to drugs to replace these
197
What is the social theory of addiction?
All drugs start with a social element - it is a bad indicator when abuse occurs alone
198
What is the concept of reinforcement as applied to drug use?
Classical conditioning model - use of drug produces a good experience or removal of bad so drug is associated with this experience
199
What property make drugs more reinforcing? Why?
Faster onset time - greater classical conditioning association
200
What is tolerance as applied to illicit drugs? Why does it occur?
Need for higher dose for same effect
Down regulation of receptors
Upregulation of liver enzymes
201
What is drug dependance?
The presence of a withdrawal reaction if a drug is stopped due to increased tolerance
202
What is withdrawal in elicit drugs?
Reverse of tolerance
| If drug is stopped downregulated receptors and increased enzymes result in a below baseline state.
203
What are the basic principles of treatment in drug abuse?
Harm minimisation
Psychological
Reduce craving
Treat complications
204
What is the principle of harm minimisation in drug use?
Accepts people use drugs, seeks to make it safer then try and reduce use.
205
What is one unit of alcohol?
| How many units in 1 litre of 40%
I0 ml of alcohol in a unit
| 40 units
206
What is the recommended weekly allowance of alcohol for males and females?
M
207
What classifies an individual at being an:
At risk drinker
Heavy drinker
Problem drinker?
At risk - M >21 F>14
Heavy - M >50 F>35
Problem - damage to health
208
Why do alcoholics become thiamine deficient?
Most calories from alcohol so generally nutritionally deficient
Alcohol destroys thiamine pump in intestine
209
What is the short term effect of alcoholic thiamine deficiency? How does it present?
Wernicke's encephalopathy
Eye signs - nystagmus, lateral rectus nerve palsy, fixed pupils Encephalitis - confusion, vomiting
Ataxia - with broad based gait, cerebellar signs
210
What is the progress of wernicke's encephalopathy?
Can be stopped with thiamine administration but is irreversible.
211
What occurs following repeated episodes of wernicke's encephalopathy? How does it present?
Korsekoffs sydrome
Dementia like
Inability to form new memories
Confabulation
212
How should wernicke's encephalopathy be treated?
Iv thiamine
213
Why might we prescribe in substance abuse?
```
Harm minimisation
Reduce reinforcement
Ability to escape harmful social circles
Decrease criminalisation
Decrease cost to society
```
214
What are risks of prescribing in substance abuse?
OD
Selling it on
Dependancy on prescription
Encourages external locus of control
215
What would need to be checked prior to prescribing in suspected substance abuse? How?
Ensure dependancy
- two urine checks
- attend in withdrawal
216
What drugs can be used to help opiate addiction?
Methadone
Buprenorphine
Naltrexone
217
What are objective withdrawal symptoms of opiate withdrawal?
```
Sweating
Yawning
Lacrimation
Coughing
Diarrhoea
Tachycardia
```
218
What are the pharmocological characteristics of buprenorphine? What does thais mean for the drugs mechanism and safety? What is the disadvantage of it?
Partial opiate agonist that tightly binds to receptor
Hard to OD and heroin taken on top has no effect as some blocking properties and not displaced
Negative is if given when not in withdrawal percipitates an acute withdrawal reactoin
219
What drugs are useful during alcohol withdrawal?
Benzodiazepines such as chlordiazepoxide
220
What drugs are useful in preventing alcohol withdrawal?
Disulfarim
| Acamprosate
221
How does disulfarim it work? Whats the biggest issue?
Disulfiram
Prevents breakdown of acetylaldehyde causing hangover symptoms if patient drinks
If you drink though the hangover can get a fatal build up of acetylaldehyde
222
How does acamprosate work?
Reduces alcohol craving
223
What drugs could be considered propsychotic?
Cannabis
| Stimulants
224
Why may mh problems result in increased substance abuse?
Used as anxiolytics (e.g. Alcohol)
Used to mitigate side effects of meds (stimulants over antipsychotics)
Social vulnerability
225
What is the hallmark interview technique in motivational interviewing? How does it work?
Reflection
| Rephrasing what the patient has just said leading them to expand on it.
226
What are the broad classifications of drug types?
Stimulants
Hallucinogens
Depressants
227
Examples of stimulant drugs
Cocaine
Amphetamine
Nicotine
228
Examples of hallucinogen drugs
LSD
Psilocybin
Cannabis
229
Examples of general depressant illicit drugs
Opioids
Benzos
Alcohol
230
What is cocaine that can be smoked called? Which is faster onset, smoked snorted or injected? Why?
Crack cocaine
Smoked
Because it has a faster onset so is more reinforcing
231
What are the 'positive' effects of cocaine?
Euphoria, excitement
232
What are the cardiovascular complications of cocaine
Blood vessel constriction
Increased heart rate
Thus hypertension and risk of MI
233
Roughly how does cocaine work to produce its euphoric effects?
Blocks the reuptake of NA 5HT and dopamine from synapses
234
How does cocaine produce its cardiovascular effects?
Blocks reuptake of catacholamines at synaptic nerve terminals
235
Roughly how do amphetamines work?
They resemble NA, 5HT and dopamine
Very fat soluble so easily enter the brain
Compete for reuptake
Displace neurotransmitters from vesicles
236
By what mechanisms are amphetamines toxic?
Overhydration - causes swelling of the brain
| Rhabdomyolysis - results from dehydration and exercise
237
What effect do stimulants have on appetite?
Reduce it
238
What are the different effects of methamphetamine over amphetamine?
More stimulatory on cns with potential for psycosis
| Less peripheral effects
239
How does nicotine achieve its physiological effect?
Stimulation of nicotinic ach receptors!
240
What does nicotine do to the cvs? What is the effect on someone with CAD?
Increases hr, co and bp
| No vasodilation possible so angina to mi
241
How does activation of nicotinic ach receptors cause effects on mood?
Nic ach receptors on presynaptic terminals of dopamine and serotonin
242
What are hallucinogens?
Conpounds that can induce visual or auditory hallucinations and alter perception.
243
What common medically used drugs are hallucinogens?
Atropine
Ketamine
Levodopa
244
How is lsd thought to work?
Effects serotonin receptors in the raphe nuclei in the reticular activating system - the part of the brain that filters sensory inputs for stimuli that are irrelevant, unimportant or commpnplace
245
What psychological effects can lsd have on an individual?
Mood changes - either euphoric or depressive/paranoid with related behavioural changes
Synesthesia
Illusions and hallucinations
Time distortion
246
What are big risks with lsd?
Panic attacks
Suicidal ideation
Feeling of invulnerability
Flashbacks
247
Why may a 2 hour trip when taking lsd be such a harrowing experience time wise?
Lsd distorts time perception so two hours could feel like days
248
How could a bad lsd trip be treated?
Quiet environment
Reassurance
Diazepam
249
What is the active ingedient in magic mushrooms?
Psilocibin
250
What physical symptoms occur with lsd intoxication?
```
Tachycardia
Mydriasis (large pupils)
Htn
Sweating
Hyperthermia
```
251
What is the active substances in cannabis? What do they do?
THC - euphoria, hallucinations/illusions, hypnosis
| CBD - antipsychotic
252
What is a risk of the newer preparations of cannabis?
Decreased cbd to thc ratio thus more psychotic
253
What does the active ingredient in cannabis bind too? Where are these receptors found?
Thc receptors
Frontal cortex
Hippocampus
Cerebellum
254
What signs show cannabis use?
Injected sclera
| Tachycardia
255
Differentiate opiode, opiate,
Opioid - all agonists with morphine like activity
| Opiate - any opioid derived from a poppy
256
What are the opiate receptor subtypes?
Mu
Kappa
Delta
257
Where are mu opioid receptors found? What effects do the different regions have when opioids are taken
Spinal cord and cerebral cortex - pain relief, euphoria
Brain stem - respiratory depression and nausea
Nucleus accumbens - compulsion and dependance
258
What pysiological effects do opioids have on kappa receptors
Analgesia
Disorientation
Dysphoria
Depersonalisation of feeling
259
What effect do opioids have on delta receptors?
Analgeisa
| Emotional response
260
What is the t1/2 of heroin?
4-6 hours
261
Give an example of an opioid that has an agonist effect at kappa and an antagonist effect at mu receptors
Pentazicine
262
What happens chemically in opiate withdrawal?
No stimulation of opioid receptors
Dompamine release and reduction of dynophine in nucleus acumbens
Release of NA (inhibited during opioid addiction) in nucleus accumbens and hippocampus causing NA storm
263
What happens symptomatically in opioid withdrawal?
Symptoms
Abdo pains, anxiety, depression, irritability, craving, inisomnia
Signs
Vomiting, increased resp rate, fever, diarrhoea
264
Where do benzodiazepines act?
GABAa receptors on the post synaptic membrane
265
What are the clinical effects of benzodiazepines on GABA in different regions
Increase chlorine conductance so post synaptic inhibition causing:
Alleviation of anxiety - amygadala
Mental confusion and amnesia - cerebral cortex
Muscle relaxation - spinal cord, cerebellum, brain stem
Psychological dependancy - nuculus accumbens
266
Withdrawal effects of benzos?
```
Anxiety
Insomnia
Agitation
Irritability
Psychosis
Seizures
```
267
Why is diazepam one of the least addictive benzos?
Long t1/2 so less severe withdrawal
268
What neurotransmitters are effected by alcohol?
| To what end?
Decrease ACh release and NMDA antagonist - confusion/amnesia
| Dopamine release increases
269
Where is alcohol excreted?
5% unchanged lungs
| 95% metabolised and converted to CO2 and water
270
What are the stages of alcohol metabolism?
Alcohol - acetylaldehyde - acetic acid - CO2 + water
271
What is the half life of methadone. What are issues with this?
13-50hrs
Large interperson variability
[ ] will increase over days of admministration untill 5 half lives passed thus a safe dose on day one may not be by day 3
272
What are risks for od when initiating methadone treatment? 2 non-modifiable and 3 modifiable
```
Low opioid tolerance
Long half life in patient
Use of other cns depressants like alcohol
Too high initial dose
Increase dose to fast
```
273
What are risky behaviours with buprenorphine precipitated by the patient?
Injecting or snorting it
| Using with alcohol or benzos
274
Why may buprenorphine and naloxone be combined in a tablet form for treatment of opioid addiction?
Naloxone has low oral bioavailability so does not effect the dose when taken properly. If user injects or snorts the tablet then the naloxone will stop it having an effect.
275
How should methadone be dosed for opiate withdrawal on the first day?
What would alter this dose?
10-30mg od
Decrease with low tolerance or uncertain tolerance
Decrease with liver or kidney failure
Decrease with low body weight
Add further 10mg bolus if objective withdrawal signs shown
276
How fast can methadone be increased?
5-10mg a day
| No more than 30mg a week
277
What is the standard buprenorphine dose
4-8mg
278
When should buprenorphine be given? Why?
During withdrawal as it causes a withdrawal reacting if given when opioids still in system
279
How should buprenorphine be increased?
Quite rapidly, can go up from 8 to 32 mg in days
280
If users are still using heroin despite replacement what action can be taken?
Dose adjustment
Change regime (e.g. Back to maintenance if on reducing)
Increase interventions such as counselling, supervised consumption, urine testing
Withdraw/suspend if pt at risk and mdt agree - following warning!
281
When should methadone maintainance change to detoxification?
Committed and informed patient
Stable social situation with support
Plans for continued support in place
282
What drugs can be used in opiate withdrawal for symptomatic treatment?
```
Lofexadine - alpha adrenergic agonist
Loperimide for diarrhoea
Metoclopramide for nausea
Mebevarine for stomach cramps
Diazepam for insomnia
```
283
What is the role of naltrexone in opiate addiciton
Relapse prevention
284
How should hypnotics be detoxed? Why?
Convert to diazepam and slowly reduce dose
| Diaz is long t1/2, has variable tablet strengths, can be give OD
285
What is the definition of a learning disability?
Condition that effects a persons ability to learn and function independently
Starts before the age of 18
Associated with a low IQ
and a deficite in >1 of communication, self care, home living, interpersonal skills, academic skills, safety
286
How can the causes of learning disability be subdivided?
Pre-natal
Birth
Post natal
287
Prenatal causes of learning difficulties
Downs syndrome
| Fragile X syndrome
288
Perinatal causes of learning difficulty
Cerebral palsy
Spina bifida
Premature birth
Infection in utero
289
Post natal causes of learning difficulty
```
Malnutrition
Epilepsy
Drugs/alcohol
Head injury
Lead poisoning
Infection e.g. Meningitis
```
290
What are phenotypic features of fragile x?
High forehead
Long face
Large ears
Hyperextendible jaw
291
Define mild learning difficulty
| Level of functioning
IQ 50-69
| Normal but delayed speech, reasonable comprehension, may live independently, able to do simple work, normal mobility
292
Define moderate learning difficulty
| Level of function
IQ 35-49
Speaks in simple phrases, low comprehension, needs supported living, delayed development of mobility, little social development
293
Define severe learning difficulty
| Level of function
IQ 20-34
| Speaks few words, very low comprehension,needs full time supervision
294
Define profound learning difficulty
| Level of function
IQ
295
What are risks with ld patients?
```
Aggression and violence
Neglect (to and from)
Abuse (to and from)
DSH
Suicide
```
296
What form dose dsh tend to take in ld patients?
Hitting walls
| Banging head
297
What physical problems are commonly associated with ld patients?
```
Constipation
Dental
Epilepsy
GORD
Infections (ears)
Obesity
Mobility problems
Sensory impairment
Swallowing problems
```
298
Why are psychiatric disorders more common in ld patients?
```
Language and sensation difficulties
Epilepsy
Mobility problems and physical ill health
Limited coping strategies
Limited social networks and choices
Adverse life events like bullying
```
299
What is autism?
Neurodevelopmental disorder causing social problems, communication problems and restricted activities and imagination
300
What are the three axis of autistic problems
Social
Activities
Communication
301
How prevelant is the autistic spectrum amongst ld patients?
33%
302
What differentiates autistic compulsions from ocd?
Autistic patients enjoy their compulsions
303
What is the difference in sensitivites in autistic patients?
Hyper or hypo sensitivity
| Can lead to sensitivity overload
304
What things help autisitic patients?l
Safeguarding
| Structure and routine
305
How does paediatric psychiatry differ from adult in means of presentation and overall case view?
Presented by, and involves, family
306
How do anxiety disorders in children often present?
Physically e.g. Ibs
307
At what age do children begin to understand death?
10
308
What is a caviat for basically all child and adolecent mental health disorders (autism, adhd etc.)
Must occur in multiple environments
309
At what age can adhd be diagnosed?
Above 6
310
What are the symptoms of adhd?
Poor concentration
Overactivity
Impulsivity
311
Treatment options for adhd?
Parenting or school intervention
Stimulants - methylphenidate, atomoxetine
Treat comorbidites
312
What comorbidities occur with adhd and autism commonly?
Anxiety
313
Why are eating disorders in pre adolecence very seious?
Delayed puberty and growth
| Worse prognosis
314
How common are mental health problems in childhood?
At any one time 1 in 10 meet the criteria cor psychiatric disorder!
315
What are the two types of conduct disorders?
| Which is worse
Socialised
| Unsocialised - worse
316
What are risk factors for conduct disorders?
```
Lack of boundaries
Rejection
Conflict
Abuse
Temperament
Comorbidities
```
317
What are piaget's stages of intellectual development? What happens in each?
Sensory motor phase (birth - 2)
-motor skills, understanding of world, body schemata
Concrete preoperational phase (2 - 6)
-mental representation of objects and actions, egocentric
Concrete operational phase (7 - 11)
Logical thinking in concrete terms, collecting
Formal operational phase >12
Abstract thinking, hypothesis testing
318
List different theories in the development of child mental health problems
Biological theories e.g. Genetics
Family theories e.g. Dysfunctional families result in issues
Behavioural social learning theories e.g. Conditioning, attachment
Psychodynamic theories e.g. Freudian - repression, projection,
Cognitive development theories e.g. Piaget's
Psychosocial theories e.g. Bullying
319
If a child is presented with a single symptom or problem that falls short of a psychiatric diagnosis what should be considered?
```
Frequency and severity
Other symptoms
Impact on development and academic performance
Impact on family and friends
Level of distress
```
320
What are the five axis that can be used for describing a child mental health problem
```
Psychiatric disorder (diagnosis by icd 10)
Specific developmental delay
Global developmental delay
Physical disorders
Social factors
```
321
A child presents with psychosis? What are likely differentials?
```
Drug use
Deleirium
Affective disorder with psychosis
Neurodegenitve disorder (rare)
Functional schizophrenia (rare)
```
322
What factors influence the development of psychological factors in physical illness
```
Chronic
Life threatening
Poor past experience
Lack of support
Poor understanding
Individual coping mechanisms
Issues with communication and attachment
```
323
What are therapy options in child mental health?
Individual therapy - addresses child's thoughts
Behavioural therapy - reward and punishment
Cognitive therapy - challenges dysfunctional assumptions
CBT - combines above
Family therapy
Group therapy
324
What medication could be used in a child with learning difficulties and behavioural problems as a last resort?
Risperidone
325
Which ssri is licences for young people?
Fluoxetine
326
What could be used for children with sleep disorders?
Melatonin
327
What issues do marital problems have for child mental health?
Inconsistant parenting
Parents playing off one and other
Child playing parents off one and other
Failure of parents to support child
328
Chemical name and side effects of ritilin
Methylphenidate
| Low appetite, anxiety, insomnia, headaches, tachycardia
329
What are the variable prognosis for ADHD
Some improve
Some continue but can be managed symptomatically
Some have secondary problems e.g. Conduct disorder, criminality
330
What behavioural techniques can help patients with ADHD
Stopping and thinking before acting
Breaking tasks up into smaller ones
Prompting
Consistency in management
331
What technique can be used to manage aggression in autism?
Redirecting it with reward
332
Behavioural techniques to manage paeditric anorexia
Parental management of mealtimes
Increase calorific intake
Reward for eating
Setting targets
333
How could obsessive compulsive disorder be managed in a child with learning difficulties?
Phased withdrawal - stopping behaviour for increasing periods of time
334
What is a personality disorder?
Conditions in which individuals differ significantly from the average person in the way the think, perceive, feel or relate to others
Of their culture
Across multiple environments
Causing maladaptive behaviour
335
What are the three p's of personality disorder?
Persistent
Pervasive
Problematic
336
How are personality disorders subdivided?
Cluster A - mad
Cluster B - bad
Cluster C - sad
337
What are the cluster A personality disorders?
Paranoid - lack of trust, misinterpreting, sensitive, strong sense of rights
Schizoid - detached, aloof, little interest in people, solitary
Schizotypal - eccentric, odd, unconventional
338
What are the cluster B personality disorders?
EUPD - impulsive, parasuicidal acts, unstable self image, dsh
Narcissistic - grandiose, arrogant, denigrating others
Antisocial - crime, problems with authority, disregard of rules, lack of empathy
Histrionic - theatrical, dramatic, seductive, suggestible, overreacts
339
What are cluster C personality disorders?
Anankastic - rigid, stubborn, perfectionistic, order, rules, moral
Dependant - needs others to function, fear of abandonment
Obsessive compulsive
Anxious - persistent fear, sensitive to rejection
340
Treatment options for personality disorder
Group therapy
Therapeutic community
Dialectical behavioural therapy
Transference focused therapy
341
What is dialectical behavioural therapy?
Approved therapy for self harm to allow patients to 'ground' self
342
Depressive symptom checklist
```
Mood
Diurnal variation
Anhedonia
Exhaustion
Early morning wakening
Attention
Appetite
Weight
Hopelessness
Future
Libido
```
343
Anxiety symptom checklist
```
Provoking factors
Avoidance
Trigger in past
Panic
Sleep
Nightmares
Concentration
Appetite
Self medication
```
344
Psychosis symptom checklist
```
Hallucinations
Special talents
Persecuted
Paranoid
Thought insertion
Control
Thought withdrawal
```
345
Mania symptom checklist
```
Mood
Sleep
Spending
Regretted actions
Speed of thought
Criminality
```
346
What mental health conditions do the dvla need to know about?
```
Severe anxiety/depression with memory/concentration/agitation/suicidal thoughts.
Mania
Psychosis
Schizophrenia
Personality disorder
```
347
What may suggest a patient has depression with cognitive impairment rather than dementia with depression?
Faster onset rather than chronic deterioration
Younger age rather than almost exclusively elderly
Concern about memory loss rather than apathy
Constant rather than fluctuant depression
Responds to treatment rather than deteriorates
348
Someone presents with paranoid delusions and hallucinations but no negative symptoms of schizophrenia. Possible diagnosis?
Paraphrenia
349
Someone has an isolated delusion which isnt effecting their life or associated with other symptoms. What is this termed?
Encapsulated delusion
350
Neuropathological features of altzheimers
Amyloid plaques
Neurofibrillary tangles
Loss of synapses
Atrophy
351
Causes of acute confusion
```
Seizure
Trauma
Bleed
Hypoglycaemia
Delerium
Hypothermia
Electrolyte disturbance
```
352
Causes of chronic confusion
```
Dementia
Depression
Mild cognitive impairment
Tumour
Parkinsons
Nutritional deficiencies (wernicke korsikoffs)
```
353
What is cam?
Confusion assessment method
Acute onset with fluctuation AND
Inattention AND
Disorganised thinking OR altered consciousness
