Psychiatry Flashcards
What is the diagnosis: fever, muscle rigidity, altered mental status and autonomic dysfunction
Neuroleptic malignant syndrome (NMS)
What is Serotonin syndrome?
Syndrome caused by initiation or dose increase of a serotonergic agent characterised by:
- altered mental state, agitation, tremor, shivering, diarrhoea, hyperreflexia, myoclonus, ataxia, hyperthermia
What is the diagnosis?
- rapid onset and progression of hyperreflexia, agitation/restlessness, altered mental state, myoclonus, sweating
Serotonin Syndrome (SS)
How do Serotonin syndrome and Neuroleptic malignant syndrome differ in presentation:
NMS - ass. with antipsychotics, slow onset and progression, severe ‘lead pipe’ rigidity, bradykinesia
SS - ass. with serotonergic agents, rapid onset and progression, less severe muscle rigidity, hyperkinesia
What is Neuroleptic Malignant Syndrome (NMS)?
A rare and life threatening idiosyncratic reaction to anti-psychotics (and other meds) characterised by:
- fever
- muscular rigidity
- altered mental status
- autonomic dysfunction
What is the ICD-10 definition of harmful usage of a substance?
A pattern of psychoactive substance use that is causing damage to health. The damage may be physical or mental
What factors constitute dependence according to ICD-10?
- a strong desire to take the drug
- difficulties controlling its use
- persisting in its use despite harmful consequences
- a higher priority given to drug use rather than other activities/obligations
- increased tolerance
- sometimes a physical withdrawal state
What is used for Maintenance for opiate dependence?
Methadone
Buprenorphine
What is the ICD-10 definition of harmful usage of a substance?
A pattern of psychoactive substance use that is causing damage to health. The damage may be physical or mental
What factors constitute dependence according to ICD-10?
- a strong desire to take the drug
- difficulties controlling its use
- persisting in its use despite harmful consequences
- a higher priority given to drug use rather than other activities/obligations
- increased tolerance
- sometimes a physical withdrawal state
What is used for Maintenance for opiate dependence?
Methadone
Buprenorphine
What are the main characteristics of Wernicke Encephalopathy?
Acute confusional state
Opthalmoplegia
Ataxic gait
(Nystagmus)
What is the cause of Wernickes encephalopathy?
Thiamine (B1) deficiency
Part of a larger group of diseases due to thiamine deficiency called Beriberi
What drug is used to treat an overdose of benzodiazipines?
Flumazenil
What is somatisation disorder?
Multiple physical symptoms present for at least two years
Patient refuses to accept reassurance or negative test results
What is the disorder?
Multiple physical symptoms for two years with no organic cause found with patient refusing to accept the negative results
Somatisation Disorder
What is Hypochondrial disorder?
Persistent belief in the presence of an underlying serious disease eg cancer
Patient refuses to accept reassurance or negative test results
What is the diagnosis?
Patient persistently believes they have cancer despite negative test results
Hypochondrial Disorder
What is 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)
What is malingering?
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
What is Factitious disorder?
Aka Munchausen’s
The intentional production of physical or psychological symptoms
What is Dissociative Disorder?
Process of separating off certain memories from normal consciousness
Psychiatric symptoms eg amnesia, fugue, stupor
What is Fugue?
A loss of awareness of one’s identity, often coupled with flight from one’s usual environment, associated with certain forms of hysteria and epilepsy
What is given in an overdose of tricyclics?
IV bicarbonate
What does a severe overdose of tricyclics cause?
Seizures and arrhythmias
What are the four types of first rank symptoms of schizophrenia?
Auditory hallucinations (3rd person, echo, running commentary) Thought disorder (insertion, withdrawal, broadcasting) Passivity phenomena Delusional perceptions (two stage process)
What is Passivity Phenomena?
Bodily sensations being controlled by external force
Actions/impulses/feelings imposed on the individual
What is the most useful screening tool for detecting Post-natal depression?
Edinburgh scale
What is the diagnosis?
A patient experiencing increased anxiety, sweating, headache and a needle like sensation in his head having recently suddenly stopped his Paroxetine
Selective serotonin reuptake inhibitor discontinuation syndrome
What are the main features of PTSD?
Re-experiencing (flashbacks, nightmares etc)
Avoidance
Hyperarousal (hyper vigilant, exaggerated startled response, sleep problems, irritability and difficulty concentrating)
Emotional numbing
What are the main drugs for Alzheimer’s?
Mild to mod - donepezil, galantamine or rivastigmine (acetylcholinesterase inhibitors)
Mod to severe - memantine (NMDA receptor antagonist)
What differentiates mania from hypomania?
The presence of psychotic symptoms:
- delusions of grandeur
- auditory hallucinations
When should blood samples for therapeutic monitoring of lithium levels be taken?
12 hours after the last dose
Name some examples of atypical antipsychotics
Clozapine Olanzapine Risperidone Quetiapine Amisulpride
What are the adverse effects of Clozapine?
Agranulocytosis, neutropaenia
Reduced seizure threshold
Weight gain (like most atypicals)
What do anti-psychotics increase the risk of in elderly patients?
Stroke and VTE
What are the main extrapyramidal side-effects of antipsychotics?
Parkinsonism
Acute Dystonia
Akathisia (severe restlessness)
Tardive dyskinesia
What combination of side effects is most likely to be seen in a patient taking imipramine?
Blurred vision and dry mouth
What are the eight tests recommended by NICE for primary care to rule out reversible causes of dementia?
FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels.
(NB in secondary care neuro imaging is also performed)
What are the main features of anorexia nervosa?
Most things low (hypokalaemia, low FSH, LH, oestrogen so, testosterone, low T3)
G’s and Cs raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
What is the first line treatment for PTSD lasting longer than four weeks?
CBT and EMDR (eye movement desensitisation and reprocessing therapy)
What is a section 136?
Someone found in a public place who appears to have a mental disorder can be taken by the police to a place of safety
What is a section 135?
A court order can be obtained to allow the police to break into a property to remove a person to a place of safety
What is a Section 5(2)?
A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
What is a section 4?
A 72 hour assessment order
Used as an emergency when a section 2 would involve an unacceptable delay
Often changed to a section 2 on arrival at hospital
What is a Section 3?
Admission for treatment for up to 6 months which can be renewed
What is a Section 2?
Admission for assessment for up to 28 days, not renewable
What are the main adverse effects of St Johns Wort?
Profile in trials similar to placebo
Can cause serotonin syndrome
Inducer of P450 system
What are the main features of NMS?
Pyrexia, rigidity, tachycardia
Raised CK also seen in most cases, occ. a leukocytosis also seen
Nb. More common in young males, onset usually in first 10 days of treatment or after increasing dose
What is the management for NMS?
Stop antipsychotic
IV fluids to prevent renal failure
Dantrolene may be useful
Bromocriptine may also be used
What is Akathisia?
Severe restlessness
What is Tardive dyskinesia?
Slow/belated onset of involuntary, repetitive body movements most commonly chewing or pouting of the jaw
Name some symptoms of SSRI discontinuation syndrome
Increased mood change, restlessness, difficulty sleeping, unsteadiness, sweating, paraesthesia
GI symptoms: pain, cramping, diarrhoea, vomiting
What treatment should be given to reverse the antipsychotic side effect of acute Dystonia?
Anticholinergics such as Procyclidine
How is Lithium metabolised and interaction with what common drug can lead to toxicity?
Excreted by the kidneys
NSAIDs such as indometacin can reduce excretion of lithium leading to toxicity.
Which common drugs increase excretion of lithium, lowering serum levels?
Antacids eg lansoprazole
Theophylline
What are the main side effects of Olanzapine?
Dyslipaemia and obesity
What are the main side effects with long term use of lithium?
Hypothyroidism and deranged kidney function
What is the recommended first line treatment for depression in adolescents? And what is second?
1st - Fluoxetine
2nd - Citalopram
What is the ‘Cheese reaction’?
Ingestion of tyramine containing food (eg cheese) while taking MAOIs resulting in a hypertensive crisis (headaches, papilloedema, dyspnoea and arrhythmia)
What is the first line treatment for ADHD?
Methylphenidate
What is the mechanism of methylphenidate?
Acts on dopamine and noradrenaline transporters to inhibit their reuptake, increasing concentration and attention
What is the mechanism for antipsychotics?
Antagonistic effect on D2 and D4 receptors resulting in depression if hyperactivity
What is the main underlying mechanism of benzodiazipines?
Enhancement of GABA transmission to reduce neuronal firing and induce a calming effect
Which drugs use the following mechanism?
Enhancement if GABA transmission to reduce neuronal firing and induce a calming effect
Benzodiazipines
What drug is thought to use the following mechanism of action?
Acts on dopamine and noradrenaline transporters to inhibit their reuptake, increasing concentration and attention
Methylphenidate
What class of drugs uses the following mechanism?
Antagonistic activity on D2 and D4 receptors resulting in suppression of activity
Antipsychotics
What class of drugs uses the following mechanism of action?
Inhibition of serotonin and noradrenaline reuptake leading to decreased impulsivity
SNRI - serotonin-noradrenaline reuptake inhibitor
Eg venlafaxine
