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5th year > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

MSE examination components?

A

A&B, SMT, PCI

Appearance & Behaviour

Speech

Affect & mood

Risk

Thought content

Perceptions

Cognition

Insight

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2
Q

MSE: Appearance & behaviour components

A 
Build
Dress
Kempt
Visible features (eg. tatoos)
Agitation/retardation/ EPSE
Strange behaviour
Eye contact
Rapport
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3
Q

Mood & Affect

A

Affect - at given time: euthymic/blunted/elated

Mood: Subjective/objective
–> Euthymic, depressed, elated

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4
Q

MSE: Thoughts

A 
Thought content
Formal thought disorder
Preoccupations
Obsessions
Overvalued ideas
Delusions (false belief)
Thought insertion/withdrawal/broadcast

Passivity phenomena

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5
Q

Types of delusions

A

Mood congruent (grandiose, poverty, guilt, nihilistic, worthless, hypochondriacal, Cotard’s syndrome)
Persecutory (conspiracy)
Reference (TV, radio, gestures)
Erotomanic (De Clerambault’s Syndrome)
Primary Delusion = autocthonous, out of blue, may be accompanied by delusional mood
Secondary delusion = delusional explanation for hallucination

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6
Q

Cotard’s ?

A

The Cotard delusion (also Cotard’s syndrome and walking corpse syndrome) is a rare mental illness in which an afflicted person holds the delusion that they are dead, either figuratively or literally

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7
Q

Illusion vs hallucination vs delusion

A

Delusion = false belief

Illusion = misinterpretation of normal stimulus

Hallucination = false perception in absence of stimulus

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8
Q

AMTS?

A

ATLAYRDYMB

Age

Time

Location

Adress

Current Year

Recognise 2

Date of birth

Years of WWII

Monarch

Backwards from 10-1

(address)

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9
Q

MMSE. Scores & why someone may perform badly

A

Normal = 30 – 26
Mild Dementia = 25– 20
Moderate Dementia = 19 – 10
Severe Dementia = 9 – 0

Inattention
Apathy
Pain
Hearing problems
Cultural or educational reasons
Dementia, delirium, psychosis, depression ro mania
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10
Q

General Psych management approach

A 
Biological:
Physical health care
Medication, eg, Antipsychotics, Antidepressants, Mood stabilisers
ECT	
Psychosurgery	
Psychological:
Cognitive behavioural therapy
Psychodynamic psychotherapy
Family interventions
Dual diagnosis i.e. substance abuse as well as mental health issues (motivational interviewing)
Relapse prevention

Social:
Occupational therapy and daily living skills
Work, education, leisure - structured, meaningful activities
Social support
Housing
Financial

Considerations
Risks
To self and others (relatives, children, strangers, professionals) – self-neglect, self-harm, violence
MHA (1983)

Setting
Inpatient vs. community
Patient’s wishes
Current and previous treatments, advance directives

Multidisciplinary team and multi-agency liaison
CMHT, Police, social services, GP

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11
Q

Depression Major + minor symtpoms

A

Major:

1) Low mood
2) Anhedonia
3) Reduced energy

Minor:

1) reduced conc
2) Guilt/worthlessness
3) Disturbed sleep/early waking
4) poor appetite
5) Pessimistic thoughts (Beck’s cognitive triad)
6) Reduced self esteem/confidence

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12
Q

Depression classification

A

Classification:
Mild depressive episode:
Depressed mood sustained for at least 2 weeks
At least 2 of A and 2 of B

Moderate depressive episode:
Depressed mood sustained for at least 2 weeks
At least 2 of A and 3 of B

Severe depressive episode
Depressed mood sustained for at least 2 weeks
All of A and at least 4 of B

Severe depression with psychosis

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13
Q

Depressive stupor?

A

Very severe depression - person stops speaking or moving (catatonia)

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14
Q

Depression Ddx?

A

1) Organic eg. hypothyroid, cushings, hypoparathyroidism, physical meds eg. antihypertensives/steroids
2) Dementia (depressive pseudodementia)
3) Substance misuse
4) personality disorder
5) Bipolar disorder

Mild depression
–> Ordinary unhappiness, bereavement/adjustment reactions, anxiety disorders

Severe depression:
- Schizophrenia/schizoaffective disorder

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15
Q

Depression Medication

A

1) TCAs: Amitriptyline, imipramine
2) MAOI: Phenelzine, moclobemide, selegiline
3) SSRIs: Fluoxetine, Sertraline, Citalopram, Paroxetine
4) SNRI: Venlafaxine
5) NaSSA: Mirtazapine

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16
Q

TCAs SEs

A 
Drowsiness
Anxiety
Emotional blunting (Apathy/anhedonia)
Restlessness
Dizziness (postural hypotension)
Akathisia 
Sexual dysfunction
N+V
Hypotension
Tachycardia
Rarely, arrythmias
Antimuscarinic (Dry mouth, dry nose, blurry vision, constipation, urinary retention)

Risk of OD/drug interactions –> metabolised by cyt p450

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17
Q

MAOI SEs

A

Reserved for last line due to SE/ food/drug interactions

Drowsiness
Dizziness
Low Bp
Sexual tension

Inhibit catabolism of dietry amines –> cheese effects with foods containing tyramine (sweating, tremor, tachycardia, raised BP)

IF foods containing tryptophan are consumed –> hyperserotonemia may result.

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18
Q

Foods that contain Tyramine

Tryptophan?

A

Tyramine: Pickled meats, smoked, fermented, marinated. Chocolate, alcoholic beverages, cheese, yoghurt, tofu, avocados, bananas nuts etc

Tryptophan: Red meat, dairy products, nuts, seeds, legumes, soybeans, soy products, tune, shellfish, turkey

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19
Q

SSRIs SE

A

N+V+D

Increased risk of Peptic ulcer/bleeding - especially in older people

Drowsiness/somnolence

Headache

Bruxism

Insomnia

Weight loss/gain

Increased risk of bone fractures

Changes in sexual behaviour

Autonomic dysfunction: orthostatic hypotension, increased/reduced sweating etc

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20
Q

What is Ribot’s law

A

Law for all pathological amnesias: ‘the new dies before the old’ (opposite of normal forgetting)

Occurs with ECT

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21
Q

NICE guidelines depression Mx:

A

Initially: Psychoeducation, self-help, mood diary

Persistant subthreshold depression or mild-moderate depression with inadequate response to initial interventions: SSRI or CPT or IAPT (interpersonal psychotherapy)

Moderate/severe: SSRI + CBT or IAPT

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22
Q

SSRI with highest incidence of discontinuation syndrome?

Lowest?

A

Highest = paroxetine

Lowest = fluoxetine (longest half life)

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23
Q

post-SSRI suicide monitoring?

A

Low risk: after 2/52, then every 2-4 weeks for 1st 3/12, longer intervals after if good response

Higher risk/

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24
Q

Serotonin syndrome?

A

Increased risk with cross-tapering antidepressants + other concurrent medicines eg. tramadol

Sx: Restlessness, tremor, sweating, shivering

Myoclonus

Changes in BP

Confusion/delirium - Altered mental state

Convulsions/death

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25
Q

Mirtazapine SE

A

Often used 2nd life after SSRI

SE:
Drowsiness (can help sleep)

Weight gain

Rare cases of neutropenia

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26
Q

Venlafaxine - careful in which pts?

A

Often used 2nd/3rd line agent / treatment resistant depression

Care in pts with CVS problems -

Increased BP at higher doses + may exacerbate cardiac arrhythmias

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27
Q

Anti-depressant advice for risk of relapse?

A

Advise people with depression to continue antidepressants for atleast 2 years.

Maintain the level of medication at which acute treatment was effective (unless there is a good reason to reduce dose, eg. unacceptable adverse effects)

–> lithium should not be used as a sole agent to prevent recurrence

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28
Q

Anti-depressants discontinuation symptoms

A 
Increased mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
Abdominal symptoms
Altered sensations

Appears 1-14 days after cessation, last 7-14 days

–> When stopping, gradually reduce dose, normally over atleast a 4 week period

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29
Q

Hyponatraemia and antidepressants/

A

Most antidepressants cause this
Risk factors – old age, female LBW, low baseline Na, concurrent medication, hypothyroidism, diabetes, warm weather
May need to be clinically managed
SSRIs are more likely to cause it
Lofepramine, reboxetine and moclobemide are less likely.

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30
Q

Bipolar disorder: Sx

A

Mood: Irritable, euphoria, lability

Cognition: grandiosity, flight of ideas, racing thoughts, distractibility, confusion, lack of insight

Behaviour: rapid speech, hyperactivity, lack of sleep, hypersexuality, extravagance

Psychotic symptoms: delusions, hallucinations, hypomania

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31
Q

Hypomania Dx

A

Elevated/irritable mood sustained for atleast 4 days

Atleast 3 of following, leading to some interference with personal function:

Increased activity or restlessness
Increased talkativeness
Distractibility
Decreased need for sleep
Increased sexual energy
Mild reckless or irresponsible behaviour
Increased sociability
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32
Q

Mania Dx

A

Predominately elevated or irritable mood sustained for atleast 1/52. Atleast 3 of the following - leading to severe interference with personal function:

  • increased activity/restlessness
  • Increased talkativeness
  • Flight of ideas
  • Loss of normal social inhibitions
  • Decreased need for sleep
  • Inflated self-esteem or gradiosity
  • Distractibility or constant changes in activity
  • Behaviour that is foolhardy or reckless
  • Marked sexual energy or sexual indiscretions
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33
Q

What is cyclothymia

A

Hx or mild hypomania interspersed with periods of depression that do not meet the criteria for major depressive episodes.

low grade cycling of mood, which appears to the observer as a personality trait, and interferes with functioning

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34
Q

Define bipolar disorder

A

A major affective disorder marked by severe mood swings (manic or major depressive episodes) and a tendency to remission and recurrence.

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35
Q

Mania/hypomania/bipolar Tx Acute episode

A 
Mania/hypomania
Lithium
Valproate
Atypical antipsychotic (olanzapine, risperidone)
Combinations
Bipolar depression
Valproate
Quetiapine
Lamotrigine
Olanzapine
SSRIs
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36
Q

Bipolar - maintenance treatment

A 
Lithium - first line (NICE Guidelines September 2014)
Valproate
Olanzapine
Lamotrigine
Risperidone
Aripiprazole
Quetiapine
Combinations
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37
Q

Lithium: mechanism?

A

Not fully understood

Alters Na+ transport across cell membranes

Alters metabolism of neurotransmitters including catecholamines and serotonin

Reduces PKC activity, possibly affecting genomic expression associated with neurotransmission

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38
Q

Lithium SE

A

Levels 0.4-1mmol/L

Abdominal Pain
Nausea
Metallic taste in mouth
Fine tremor
Thirst
Polyuria
Weight gain
Oedema
Leukocytosis - Advice to seek medical attentino if they develop D/V or become acutely ill for any reason

Long term effects:

  • hypothyroidism
  • Hyperparathyridism
  • hypercalcaemia
  • Renal failure
  • Nephrogenic diabetes insipidus

‘Fine tremor is fine, coarse tremor is not (Toxicity)’

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39
Q

Lithium toxicity Sx

A

Levels >1.5mmol

Anorexia
D+V
drowsiness
Apathy
Restlessness
Dysarthria
Ataxia
Muscle twiches
Coarse tremor
Blackouts/coma
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40
Q

Lithium Drug monitoring

A

Pre-lithium work up:
ECG, TFTs, U+Es, Renal function tests

Monitoring:

  • Start at 400mg once daily (200mg in elderly)
  • -> Plasma level after 5-7 days
  • Then every 5-7 days until required level reached (0.6-1mmol/L)

–> Toxicity occurs at > 1.5mmol/L)

  • Bloods taken at 12 hours post dose (trough)
  • Once stable - levels every 3 months, U+Es and TFTs every 6 months
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41
Q

Valproate SE

A 
Abnormal eye movements
blood/marrow problems
confusion
deafness
EPSE
agitation
N+D
hair loss
headaches
liver problems...
Paraesthesiae
Osteoporosis

Basically a Fuck tonne

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42
Q

Valproate CI/ work up/ monitoring

A

CI: Women of child bearing potential - teratogenic.

Work-up - TFTs, FBC, RFTs, BM, LFTs, Lipid profile, Weight + height, ECG

Monitoring: FBC, LFTs, Weight + height every 6/12

Dose monitoring - only useful to ensure adequate dosing and compliance

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43
Q

Olanzapine SE

A

Very common:
- Postural hypotension, abnormal gait, appetite gain, falls, metabolic syndrome, sedation, lethargy, weight gain, worsening of parkinson’s

Common: Constipation, decreased libido, dry mouth, erectile dysfunction, joint pain

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44
Q

Non-pharmacological approaches to bipolar

A

Psychoeducation - sleep hygiene, identifying relapsing markers, managing stress, mood monitoring

CBT - some evidence in reduction in severity of symptoms, but only early on in course of illness

  • Psychopharmacology remains mainstay of treatment
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45
Q

Bipolar I vs II

A

Bipolar I - mania has occurred on atleast one occasion

Bipolar II - hypomania has occurred on atleast one occasion

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46
Q

Antipsychotic Tx monitoring

A

Pretreatment, measure and record:

  • Weight/BMI
  • Pulse, BP
  • Fasting bloods, HbA1c
  • Blood lipid profile
  • offer ECG if known cardiovascular risk, FH

Monitoring

  • HR + BP after each dose change
  • Weight/BMI weekly for first 6 weeks, then at 12 weeks
  • Blood glucose, HbA1c and lipid profile at 12 weeks
  • Response to treatment including changes in symptoms and behaviour
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47
Q

Stopping Lithium

A

Reduce dose gradually over at least 4 weeks, preferably up to 3 months

during dose reduction + 3 months after, monitor closely for signs of mania/depression

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48
Q

Situations that may increase lithium levels

A

Decreased Na+ intake/increased sodium excretion (low Na+ diet, diuretics, ACEis, AR2b, excessive sweating, D+V)

Decreased water intake/increased water excretion (dehydrating, diuretics, fever, illness)

Renal disease

  • Renal dysfunction
  • NSAIDs
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49
Q

Moderate/severe bipolar depression Mx

A

Fluoxetine + Olanzapine

OR

Quietiapine

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50
Q

Lamotrigine serious SE?

A

Skin rash including SJS or Toxic epidermal necrolysis

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51
Q

Long term pharm treatment of bipolar?

A

Offer lithium 1st line –> Most effective long term tx

If ineffective/poorly tolerate, consider valproate or olanzapine

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52
Q

Attempted suicide assessment

A

Inner ring:
Circumstances of the attempt
What happened that day?
Were things normal to begin with?
Were there any preparations made e.g. making a will or giving things away?
Was there a last act (e.g. suicide note)?
What happened after the attempt?

Middle ring:
	Background to the event
	How have things been over the preceding months?
	Has the patient thought about attempting suicide in the last few months?
	What relationships were important over this time?

Outer ring:
Family and personal history
What was the intention behind the attempt?
What are the present feelings and intentions?
If the patient was to leave hospital today how would they cope?

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53
Q

Suicide attempt Mx

A

Agree a contract offering help by negotiation
Discuss confidentiality and then talk with family
Anti-depressants
Problem solving therapy
Follow up with preventative strategies

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54
Q

Anxiety Sx

A

anxiety, depression, fatigue, insomnia, irritability, worry, obsessions, compulsions, somatisation, agitation, feelings of impending doom, trembling, sense of collapse, insomnia, poor concentration, goose flesh, butterflies in the stomach, hyperventilation, headaches, sweating, palpitations, poor appetite, nausea, lump in the throat (globus hystericus), difficulty getting to sleep, excessive concern, repetitive thoughts and activities

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55
Q

Generalised anxiety disorder Dx?

A

Anxiety + 3 somatic symptoms; present for > 6 months

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56
Q

Anxiety disorder types:

A 
GAD
Panic disorder
Phobia
PTSD
Social anxiety disorder
Obsessive compulsive disorder
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57
Q

Anxiety disorder management

A

Symptom control: reassurance, listening

Regular exercise

meditation

CBT

Meds:

  • Benzo eg.diazepam
  • SSRI eg. paroxetine
  • Antihistamines eg. hydroxyzine
  • B-blockers
  • others: pregabalin, venlafaxine

Progressive relaxation training

Hypnosis

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58
Q

Phobic disorders?

A

Anxiety in specific situations – leads to avoidance

Elicit the exact phobic stimulus

Mx: CBT; paroxetine

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59
Q

OCD?

A

Compulsions: senseless, repeated rituals

Obsessions: stereotyped, purposeless words, ideas or phrases that come into the mind

Perceived by the patient as nonsensical and originating from themselves
E.g. rambler who cannot do a long walk because every few paces they wonder if they have really locked the car and has to return repeatedly to ensure this has been done; repetitive cleaning, counting and dressing rituals

Pathophysiology: orbitofrontal and caudate nucleus

Mx: behavioural or cognitive therapy; clomipramine or fluoxetine

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60
Q

Acute stress symptoms

A

Fearful, horrifeid, dazed, helpless, numb, detached, decreased emotional responsiveness, intrusive thoughts, hypervigilance, depersonalisation, dissociative amnesia, reliving of events, autonomic arousal , headaches, abdo pain

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61
Q

PTSD

A

DSM-IV: symptoms have been present for more than one month:

  • Re-living: flashbacks, nightmares, repetitive and distressing intrusive images
  • hyperarousal (hypervigilance, exaggerated startle, sleep problems, irritability, difficulty concentrating)
  • Avoidance
  • Emotional numbing
from other people:
- Depression
- Druh or alcohol misuse
Anger
- Unexplained physical symptoms
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62
Q

PTSD Mx

A
  • watchful waiting for mild symptoms
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63
Q

Anorexia nervosa definition

A

Compulsive need to control eating

Low self-worth

Weight loss becomes an over-valued idea - achieved by over-exercising, induced vomiting, laxative abuse, diuretics or appetite suppressants.

May also have episodes of binge following by remorse, vomiting and concealment

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64
Q

Anorexia Nervosa features

A

Reduced BMI

Bradycardia

Hypotension

Enlarged salivary glands

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65
Q

Anorexia Physiological abnormalities

A

Hypokalaemia

Low FSH, LH, oestrogens and testosterone

Impaired glucose tolerance

Low T3

Raised cortisol/growth hormone

Hypercholesterolaemia

Hypercarotinaemia

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66
Q

Eating disorders screening questionnaire?

A

SCOFF

Do you ever make yourself SICK because you feel too full?
Do you worry you’ve lost CONTROL over eating
Have you recently lost more than ONE stone in 3 months?
Do you believe you are FAT when others say you are thin?
Does FOOD dominate your life?

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67
Q

Anorexia Mx

A

Restore nutritional balance
Treat complications of starvation

Severe anorexia:
- BMI 17.5
Encourage use of self help books and a food diary
- If no response within 8 weeks, consider referral to secondary care

Therapy: cognitive, analytic, interpersonal, supportive or family therapy

Meds: Fluoextine, olanzapine

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68
Q

What is refeeding syndrome?

A

Complication of metabolic disturbances that occur when reintroducing normal calorific intake to pts who have been severe starved/malnutritioned for a prolonged period:

Signs:
rhabdo, resp/cardiac failure, decreased BP, arrhytmias, seizures, comas and sudden death
- Acute gastric dilatation if poorly nourished pt binges
- Monitor PO3-, glucose, potassium and magnesium

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69
Q

Bulima. What is it and Mx

A

Recurrent episodes of binge eating characterised by uncontrolled overeating
Preoccupation with control of body weight
Regular use of starvation, vomit-induction, laxatives or overexercise to overcome effects of binges
BMI >17.5

Mx:
Mild: support, self-help books, food diary
Moderate/severe: refer to community mental health team or eating disorder unit
Medication: antidepressants e.g. fluoxetine
Cognitive therapy

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70
Q

Delirium features

A

Acute confusional state with disorientation in time, place or person.

Memory disturbances

Difficulty concentration

Agitated/withdrawn

Mood change

Visual hallucination

Disturbed sleep cycle

Poor attention

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71
Q

Delirium causes

A

1) Infection
2) Metabolic: U+Es, glucose, decreased PaO2, Increased PaC02
3) Drugs: Benzodiazepines, opiates, anticonvulsants, digoxin, L-DOPA), Alcohol / withdrawal
4) Trauma
5) Surgery

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72
Q

Surgical Sieve

A

MEDIC HAT PINE

Metabolic
Endocrine
Degenerative
Inflammatory
Congenital
Haematological
Autoimmune
Trauma
Psychological/Neurological
Iatrogenic
Neoplastic
Enviromental
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73
Q

Delirium Mx

A

Treat cause

Calm patient - place in quiet sideroom , music, muscle relaxation and massage. If does not work, try haloperidol/ risperidone

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74
Q

Dementia symptoms

A

Behaviour: restless, repetitive, no initiative, purposelessness activity, sexual disinhibition, social gaffes, shoplifting, rigid routines

Speech: syntax errors, dysphasia, mutism

Thinking: slow, muddled, delusions, poor memory, no insight

Perception: illusions, hallucinations

Mood: irritable, depressed, blunted affect, emotional incontinence

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75
Q

Dementia initial Ix

A

Bloods: FBC, b12, folate, ESR, U+E, LFT, yGT, Ca2+ , TSH

Serology: Syphilis, HIV

CT/MRI: excludes tumours, hydrocephalus, subdural haematoma, stroke

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76
Q

Alzheimer’s 3 stages

A

Stage I: amnesia and spatial disorientation
Stage II: personality disintegration (aggression, psychosis, agitation, depression) and focal parietal signs (dysphasia, apraxia, agnosia and acalculia); parkinsonism
Stage III: neurovegetative changes with apathy, akathisia, wasting, immobility, seizures and spasticity

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77
Q

Alzheimer’s meds

A

Anti-AchE: Donepezil, rivastigmine, galantamine

NMDA Antagonists: Memantine

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78
Q

Delirium tremens signs?

A

increased HR, decreased BP, tremor, fits, visual or tactile hallucinations

Admit and monitor vital signs

Give diazepam or chlordiazepoxide for 1st three days

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79
Q

Alcohol abuse Mx

A

Explore whether patient wants to change – abstinence or controlled intake

Treat co-existing depression

Self-help/group therapy/12-step programme

Disulfiram	
Naltrexone – reduces pleasure that alcohol brings
Acamprosate – can increase abstinence rates
80
Q

Personality disorder Cluster A?

A

Odd or eccentric behaviour:

  • -> Paranoid
  • –> Schizoid
  • -> Schizotypal
81
Q

Personality disorder Cluster B

A

Dramatic or emotional behaviour:

  • Antisocial (Psychopathic)
  • Borderline
  • Histrionic
  • Narcissistic
82
Q

Borderline personality disorder?

A

Unstable affect regulation, poor impulse control, poor interpersonal relationships/self-image, repeated self-injury, suicidality and difficult life course trajectory
Tendency to form intese relationships and rapid fluctuations in mood, with impulsivity, unstable relationships

Associated with ADHD and learning difficulties

Mx: dialectical behaviour therapy, inpatient hospital programmes and medication

83
Q

Personality disorder: Cluster C?

A

Anxious or avoidant behaviour

  • -> Avoidant
  • -> dependent
  • -> Obsessive-compulsive
84
Q

Histrionic personality?

A

The self-centred, sexually provocative (but frigid) person who enjoys (but does not feel) angry scenes; can maintain relationships; episodic outbursts of rage; less impulseve

Schizoid personality: Cold, aloof, introspective, misanthropic

85
Q

Delusions of persecution?

A

Belief that someone or something is interfering with the person in a
Malicious or destructive way
Examples:
Someone (or an organisation e.g. MI5) is trying to kill or harm them
The neighbours are harassing them
People are monitoring their movements or following them
Asking about delusions of persecution:
Are there times when you worry that people are against you/ trying to harm you?
Do you have any concerns for your safety?

86
Q

Grandiose delusions

A

Belief of being famous, having supernatural powers, having enormous wealth
Suggestions for interview: “Do you have any exceptional abilities or talents?”

87
Q

Delusions of reference

A

Belief that actions of other people, events, media etc. are either directly referring to the person or are communicating a message
Suggestions for interview:
Have there been times when you have overheard people talking about you?
Do you ever see things on the TV or hear things on the radio which you think are about you?

88
Q

Delusions of misidentification

A

Capgras syndrome: someone close has been replaced by an identical looking impostor

Fregoli’s syndrome: belief that strangers are actually familiar people in disguise

89
Q

Delusions of control

A

“Passivity phenomena”: made actions, feelings or impulses
The boundaries between self and the world are broken
Thoughts, actions or feelings are subject to outside influences
Thought insertion, withdrawal, broadcasting
Often accompanied by delusional explanations
Asking about delusions of control:
Thought interference: Have you ever felt that your thoughts were being directly interfered with or controlled by another person?
Was this just because people were distracting you or being persuasive, or did it come about in a way many people would find hard to believe, for instance through telepathy?
Passivity: Have you ever felt that another person was able to control what you did directly, as if they were pulling the strings of a puppet?

90
Q

Somatic delusions

A

Beliefs about body
Including:
Illnesses (hypochondriacal delusions)
Infestations (Ekbom’s syndrome)

91
Q

Disturbances in form of thought

A

In flight of ideas, there are links between phrases but they are clang associations.

Clang associations are associations of words similar in sound but not in meaning.
Links may be rhymes or puns
This occurs in mania and hypomania and usually with pressure of speech.
“You come in here swinging your stethoscope…….telling me about my horoscope”
In loosening of association there is no link between phrases.

Knight’s move thinking is a type of loosening of association where there is an abrupt jump from one idea to another midway through the first thought e.g. “Inferior schools! Inferior schools! Preferably Dr Sims? Your tablets have been a miserable failure. I have had to sit with these mad surgeries. With regard to these tablets it will depend what the lord wants. With these women it is certainly destiny humph” In word salad, there is no link between words e.g. “blue does runs shaky lovely very

92
Q

Circumstantiality?

A

Overinclusion of details and parenthetical remarks

Takes a long time to get to the desired point

93
Q

Tangentiality

A

Inability to have goal-directed associations of thought

Never gets from desired point to desired goal

94
Q

Echolalia

A

Repeating of words or phrases of another person

Can occur in schizophrenia, mental retardation or dementia

95
Q

Perseveration

A

Persisting response to a prior stimulus after the new stimulus has been presented

96
Q

Thought block

A

Abrupt interruption in train of thinking before a thought or idea is finished
After a brief pause the person indicates no recall of what was being said or what was going to be said
May be explained by the patient as thought withdrawal

97
Q

Pseudohallucinations

A

They do not appear to the patient to be real and instead located in the mind (i.e. in subjective inner space) e.g. visual pseudohallucinations - seen by ‘inner eye’ and auditory pseudohallucinations - ‘voice in my head’
Or they seem to occur in the outside world but patient views it as unreal.
They may occur in, for example, borderline personality disorder, fatigue, bereavement

98
Q

Delirium definition

A

Generalized impairment of cognitive functions (perception, thinking, memory, orientation), emotion, psychomotor activity and sleep-wake cycle

99
Q

Psychosis : Causes

A

Organic:

  • Infection (sepsis, encephalitis)
  • Cerebral neoplasm, trauma, stroke
  • Neurological disorderss: parkinson’s, epilepsy
  • Psychoactive drug use
  • Alcohol: withdrawl, intoxication, hallucinosis

Psychiatric:

  • Schizophrenia spectrum disorders
  • Mood disorders (bipolar/depression
100
Q

Hallucinations: Trends?

A 
Elementary hallucinations (noises)
Visual or olfactory hallucinations = ?organic conditions (LBD)
Episodic delusions and hallucinations = ?epilepsy, substance abuse	
Delusions / hallucinations + altered level of consciousness = delirium
Bizarre delusions and hallucinations = ? Schizophrenia spectrum disorders
Mood congruent delusions and hallucinations = ? Mood disorders
101
Q

Schizophrenia first rank symptoms (highly suggestive if present)

A
  • Auditory hallucinations
  • Thought withdrawal, insertion & broadcast
  • Somatic hallucinations
  • Delusional perception
  • feelings or actions experienced as made or influenced by external agents (passivity phenomena)
102
Q

ICD-10 Schizophrenia Dx

A

Atleast 1 of:

  • Thought echo, insertion, withdrawal, broadcast
  • Delusions of control, influence, passivity, clearly referred to body or limb movements or thoughts, actions and sensations
  • Voices giving a running commentary or discussing
  • Persistent delusions

or atleast 2 of:

  • Other hallucinations which occur every day for weeks on end
  • Thought disorder
  • Catatonic behaviour eg. excitement, posturing, wavy flexibility, negativism, mutism, echopraxia
  • Negative symptoms
  • Significant and consistent change in behaviour

FOR atleast 1 month, in absence of intoxication, brain disease or extensive manic/depressive symptoms.

Symptoms have to be present for 6 months for diagnosis of schizophrenia to be made

103
Q

Schizophrenia positive symptoms

A

Hallucinations

Delusions

Ideas of reference

104
Q

Schizophrenia negative symptoms

A

Under activity

Anhedonia

Apathy

Sexual problems

Lethargy

Social withdrawal

  • Reduced speech
  • Reduced motivation
  • Reduced responsiveness (flat affect)
105
Q

Schizophrenia sybtypes

A

Paranoid schizophrenia - stable delusions, usually + hallucinations

Hebephrenic schizophrenia - fleeting delusions & hallucinations Behaviour & thought disorganized

Residual schizophrenia – after a period of positive symptoms, negative symptoms predominate

Simple schizophrenia – negative symptoms, no initial positive symptoms (rare)

Catatonic schizophrenia
Rare
Disturbances of voluntary motor activity including
		Stupor
		Periods of over-activity
		Rigidity
		Posturing
		 “Waxy flexibility” (maintenance of limbs and body in externally imposed positions)
106
Q

Schizophrenia radiological changes

A

Volume of lateral ventricles is increased

Volume of brain decreased
– Especially Temporal lobe, Amygdala / hippocampal complex

Same changes found in newly diagnosed patients as chronic schizophrenics

Appear to be non-progressive

Neuropathological changes suggestive of neuronal degeneration

107
Q

Males with schizophrenia?

A

Volume of lateral ventricles is increased
Volume of brain decreased
– Especially Temporal lobe, Amygdala / hippocampal complex
Same changes found in newly diagnosed patients as chronic schizophrenics
Appear to be non-progressive
Neuropathological changes suggestive of neuronal degeneration

108
Q

Schizophrenia neurotransmitter changes

A

Increased dopamine

Reduced glutamate activity

Increased 5-HT activity

109
Q

Schizophrenia poor cognitive factors

A 
Male
Insidious onset
Long duration of untreated psychosis
Drug use
Family environment
Non-compliance
Neuro-cognitive deficits
110
Q

Schizoaffective disorder?

A

Both affective and psychotic symptoms are prominent within illness episode, simultaneously or within a few days of each other
Therefore criteria for schizophrenia and depressive/ manic episode not met
Usually less impairment between episodes and social impairment than for schizophrenia (but more than in bipolar affective disorder)

111
Q

Schizophrenia Mx

A 
Risk assessment 
Care Programme approach:
- Assess health & social needs
- Agreed carer plan
- Named Care Co-ordinator
Regular monitoring and review meetings
- Interagency and MDT working
- Early intervention in psychosis services

These are being set up in many areas
Specialist teams who treat people experiencing their first episode of psychosis (aged 18-35)
Aim to reduce the Duration of Untreated Psychosis, because shorter time to treatment associated with better outcome
Therefore focus on early detection and treatment and maintaining contact to try to prevent relapse

Anti-psychotic medicine

CBT for psychosis

112
Q

Antipsychotics for schizo?

A

Typical antipsychotics: chlorpromazine, haloperidol

Atypical antipsychotics: risperidone, olanzapine, quetiapine, amisulpiride, aripiprazole, clozapine
Antipsychotic medication are started at low dose and increased gradually

They take affect after 1-6 weeks
They should be continued for a minimum of a year after a person is asymptomatic. There is probably benefit in continuing for up to 5 years, but many people are reluctant to do so.
Adherence to medication is key

1st episode Schizophrenia

Start agreed antipsychotic

Titrate if necessary
1st onset of antipsychotic action – 2/52

Assess at optimum dosage over 4-6 weeks.
If successful, continue for at least 1-2 years. If withdrawal, undertake gradually.

After withdrawal monitor for at least two years

If not, change to another antipsychotic & as above.

If not successful, consider clozapine

113
Q

CBT for psychosis

A

Recommended by NICE as a treatment in addition to medication for people with persistent positive symptoms of psychosis
Typically, around 50-65% of people who receive therapy benefit in some way

Identify a client’s main difficulties, how they arose, and what they understand about them.
The aim is not necessarily to get rid of symptoms, but to alleviate distress and disability, by helping them find:

New ways to reframe their experiences

New strategies to cope with their symptoms

114
Q

Anti-psychotics informed consent

A

If possible, including:
Provide information and discuss the likely benefits and possible side effects of each medicine including:
Metabolic (including weight gain and diabetes)
EPSEs (including akathisia, dyskinesia and dystonia) cardiovascular (including prolonging the QT interval)
Hormonal (including increasing plasma prolactin)
Other (including unpleasant subjective experiences)

115
Q

Antipsychotics monitoring

A

Before starting:

  • weight, waist circumference
  • Pulse and BP
  • Fasting BM, HbA1c, blood lipid profile and proclactin
  • Assessment of any movement disorders
  • ECG if CVS riskMonitor and record the following throughout treatment:
  • Response to treatment, including changes in symptoms and behaviour
  • Side effects of treatment, taking into account overlap between certain side effects and symptoms e.g. the overlap between akathisia and agitation or anxiety, and impact on functioning
  • Emergence of SEs- EPSEs, anticholinergic SEs
    Weight, waist circumference, pulse and blood pressure, fasting blood glucose, HbA1c and blood lipid levels
    Hyperprolactinaemia, drowsiness, postural hypotension
116
Q

EPSEs?

A

Dystonia:
- Sustained involuntary muscle contractions, twisting of neck, limbs, trunk or face. Acute form more likely in younger

Parkinsonian:
- Rigidity, coarse tremor (no pill rolling), akinesia

Akathisia:

  • Uncontrolled restlessness with feelings of inability to sit still
  • -> Consider propanoll

Tardive dyskinesia:

  • Involuntary hyperkinesia, increases with anxiety and relieved with sleep.
  • Symptoms include tics, choreas and dystonias.
  • Repetitive involuntary purposeless movements of jaw, neck and tongue.

–> Switch onto atypicals or consider procyclidine IM/IV for acute episode

117
Q

Anti-muscarinic side effects

A
  • Dry Mouth
  • Blurred vision
  • GI disturbance - Constip.
  • Urinary retention
  • Tachycardia
  • Mental confusion
118
Q

Neuroleptic malignant syndrome?

A

Rigidity, fever, confusion, fluctuating BP, tachycardia

Elevated creatine kinase

? Dopamine deficiency

Risk factors including high potency drugs, rapid dose changes, agitation, dehydration, abrupt withdrawal of anticholinergics, concurrent lithium

Treatment

  • Life threatening
  • Withdraw antipsychotic immediately
  • Monitor TPR
  • May need to be admitted to A&E
  • Rehydrate, artificial ventilation
  • Sedate with benzodiazepines
  • Dantrolene – muscle relaxant
  • Bromocriptine – dopamine agonist
  • ECT for psychosis

No antipsychotics for at least 5 days.
Wait for symptoms to resolve including CPK.
Use small doses of an unrelated antipsychotic, preferably not a long acting one and one with low dopamine affinity. Monitor for symptoms of NMS –TPR, CPK

119
Q

Clozapine SE?

A
  • indicated for treatment resistance.
  • Reversible neuropenia (3%)
  • Agranulocytosis (0.8%)
  • -> Higher risk in elder and those with lower WBC counts
  • Myocarditis
  • Reduce seizure threshold

Blood tests during tx

  • -> weekly for 18 weeks
  • -> fornightly for 52 weeks
  • -> Monthly ever after
Sore throat, fever
Hypersalivation – must be treated.
Constipation – must be treated.
Seizures – must be treated.
Urinary incontinence
Drowsiness
Hypotension
Tachycardia – investigate and treat if necessary.
Weight gain – potential long term problems
	Raised glucose and cholesterol levels
	Pulmonary embolism
	Myocarditis
	Cardiomyopathy
120
Q

Clozapine important interactions

A
  • Carbamazepine and various meds which cause neutropenia are CI
  • Fluovoxamine may increase clozapine levels
  • Smoking
121
Q

Drugs used in rapid tranquilisation?

A

Antipsychotic: haloperidol PO/IM, atypical antipsychotics, aripiprazole IM

Promethazine PO/IM

Benzodiazepines: lorazepam PO/IM

Combination
Some evidence that this works synergistically
Also can mean giving less of more toxic antipsychotics

122
Q

Adverse effects of long term benzo use

A 
Drugs of abuse
Tolerance
Hangover effect		
Disinhibition, Confusion
Resp. depression
Do not discharge with this unless longterm
123
Q

Types of Behaviour therapy

A

Exposure/flooding/implosion therapy (phobias - pt stays with anxiety provoking stimuli until habituation/ avoidance response extinguished)

Relaxation training

Systematic desensitisation

Response Prevention –> obsessions.

Thought stopping

Aversion therapy

Social skills training

Token economy

CBT

124
Q

CBT

A

Helps change how pt thinks and feels by consideration interaction between our thoughts, feelings in a particular situation and the action taken.
CBT lets use see how thoughts and feelings interact.

BY changing thoughts, the cycle is broken or turned into a virtuous cycle

Indication
General:
The patient prefers to use psychological interventions, either alone or in addition to medication.
The target problems for CBT (extreme, unhelpful thinking; reduced activity; avoidant or unhelpful behaviours) are present.
No improvement or only partial improvement has occurred on medication.
Side effects prevent a sufficient dose of medication from being taken over an adequate period.
Significant psychosocial problems (e.g. relationship problems, difficulties at work or unhelpful behaviours such as self-cutting or alcohol misuse) are present that will not be adequately addressed by medication alone.

125
Q

Types of cognitive distortions?

A

Arbitrary inference—conclusions drawn with little or no evidence to support them

Selective abstraction—dwelling on insignificant (negative) detail while ignoring more important features or stimuli

Overgeneralization—drawing global conclusions about worth/ability/performance on the basis of single facts
Magnification/minimization—Gross errors of evaluation with small bad events magnified and large good events minimized.

126
Q

Group Psychoterapy

A

Patient can be confronted by the effect his behaviour and beliefs have on others and be protected during his first attempts to change

Specific:
Personality disorders
Addictions: drug and alcohol dependence
Victims of childhood sexual abuse
People with difficulties in socialisation
Major medical illnesses e.g. breast cancer

127
Q

What is psychodynamic psychotherapy?

A

Individual dynamic psychotherapy is based on the premise that a person’s behaviour is influenced by unconscious factors (thoughts, feelings, fantasies).

128
Q

MHA 1959?

A

Aimed to provide a legal framework for detention of people suffering from mental disorders against their will

129
Q

MHA 1983?

A

To ensure that people with serious mental disorders which threaten their health or safety or the safety of the public can be treated irrespective of their consent where it is necessary to prevent them from harming themselves or others
Details the circumstances in which a person with a mental disorder can be detained for treatment with or without his or her consent
Outlines the processes that must be followed
Introduces new safeguards for patients
Aims to ensure that patients are not inappropriately detained or treated without consent

130
Q

Can physical illness be treated under MHA?

A

MHA 1983 does not provide legal framework for assessment or treatment of physical illness
Can only treat concurrent physical illness if:
Patient consents
Patient lacks capacity to consent/refuse to treatment for physical illness (under MCA)

MHA allows treatment to alleviate or prevent a worsening of a mental disorder (or one or more of its symptoms or manifestations)
This includes “treatment of physical health problems only to the extent that such treatment is part of, or ancillary to treatment for mental disorder (e.g. treating wounds self-inflicted as a result of mental disorder)”

131
Q

Anorexia nervosa - which law for re-feeding?

A

Anorexia nervosa is classed as mental illness: re-feeding allowed under MHA

132
Q

Learning difficulties and MHA?

A

A person with LD shall not be considered by reason of that disability to be:
Suffering from a mental disorder for purposes of the Act
Requiring treatment in hospital for mental disorder
Unless that disability is associated with abnormally aggressive or seriously irresponsible conduct by that person

133
Q

MHA 2007 changes?

A

New definitions
“Mental disorder” refers to any disorder or disability of the mind

Omitted definitions from MHA 1983	
Severe mental impairment
Mental impairment		
Mentally impaired	
Psychopathic disorder

Exclusions
MHA 1983: a person cannot be deemed to be suffering from a mental disorder “by reason only of promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs”
MHA 2007: alcohol/drug dependency retained; promiscuity etc. removed

Appropriate treatment test
Is appropriate treatment for this patient’s mental disorder going to be available to them when they are detained?

134
Q

MHA assessment requirements?

A

This is used for someone over the age of 16 years who will not be admitted voluntarily. Patients who are under the influence of alcohol or drugs are specifically excluded

Can take place anywhere

Approved Mental Health Professional (AMHP)

2 x Section 12 Approved Doctors

Sometimes Psychiatrist and GP joint assessment

--------
Patient is suffering from a mental disorder that is of a NATURE and DEGREE to merit detention
Risks:
Patient’s health and safety
Risk to self	
Protection of others
Refuses to go to hospital
No alternative to hospital admission
Medical Recommendation Form completed and given to AMHP
Patient is transported to hospital
135
Q

Section 2?

A

Admission for assessment for up to 28 days, not renewable

An Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors

One of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)

136
Q

Section 3?

A

Admission for treatment up to 6 months, can be renewed for 1 month at a time.

AMHP, along with 2 doctors, both of which must have seen the pt within the past 24hrs

  • Cannot be detained under section 3 if NR objects
  • Most Tx can be given, including psychotropic meds
  • -> Safeguards for ECT
137
Q

Community treatment order? (Section 17a)

A

For pts on section 3 (or 37)
–> Enforce treatment in community

Power to bring pt back to hospital if does not comply with treatment plan

  • Allows them to go home under supervision of senior psych
138
Q

Section 4?

A

72 hour assessment order

Used as an emergency, when a section 3 would involve an unacceptable delay

A GP and an AMHP or NR

139
Q

Section 5(2)

A

A pt who is a voluntary pt in hospital can be legally detained by a doctor for 72 hours

When an informal inpt tries to leave:
Any registered doctor		
Any ward (can't be used in A&E)

Further assessment must occur within 72 hrs: can be released from 5(2) by senior psych

  • Discharge if not detainable, or detention under S2 or S3
140
Q

Section 5(4)

A

Same as 5(2) - Allows a nurse to detain a pt voluntarily in hospital for 6 hours

141
Q

Section 135?

A

A court order can be obtained to break into a property to remove a person to a place of safety

MAgistrate’s order - Applied for by AMHP where person refusing to allow mental health professionals into residence

142
Q

Section 136

A

Someone found in a public place who appears to have a mental disorder can be taken by the police to a place of safety

Assessment by duty psych

  • -> Discharge
  • -> Admit under S2 or S3, or discharge if not detainable
143
Q

Mental health review tribunal?

A

Appeals against detention under the Act
Members appointed by Lord Chancellor
Members include an independent doctor, a lawyer and a lay person
Detained person has right to be represented by a solicitor
2007 Act introduces one MHRT for the whole of England

144
Q

Capacity assessment?

A

Understand information relevant to decision

Retain information

Weigh up information

Communicate decision

145
Q

What is the Bournewood Gap

A

Arose following a case involving DOL of a man with severe autism and LD

People with who lack capacity with mental disorders/disabilities may need to be deprived of liberty for treatment or care

Not necessarily detainable under MHA

Human rights act demands people who lack capacity and are Deprived of Liberty in “best interests” have safeguards in place, as with MHA

Not detainable under MHA
No acute deterioration – do not fulfil ‘degree’ criteria
Deprivation necessary to reside in an institution to receive care, not assessment / treatment
People with dementia living in long-stay institutions
Learning disability not a detainable disorder under MHA

146
Q

MCA 2005 - DOL safeguards?

A

Provides legal safeguards for mentally ill patients deprived of liberty when MHA not applicable

Who is covered by DoLS?
Adults (18+) in hospitals or care homes,
Mental disorder/disability not covered by MHA
Lack capacity to make decision on care/placements
Deprivation of Liberty is necessary to provide appropriate care (in their best interests)

At times during care, liberty may need to be restricted in for clinical reasons in individual’s best interests
For people who lack capacity this is done under the Mental Capacity Act.
When does restriction of liberty become deprivation of liberty? (Requiring DoL Safeguards)
What constitutes “Deprivation” of liberty?

147
Q

DOLs process

A

DoLS process
Patient identified as needing restraint to receive care
Authority for DoL requested from Supervisory Body (usually PCT)
6 DoLS assessments (≥2 different trained assessors)
Patient representative appointed
Review process
DoL last for 12 months.
Review at 3 months to check detention still in patient’s best interests.
Elements of care that could introduce more ‘liberty’

148
Q

MHA vs MCA

A

MHA:

  • Mental health disorders only
  • 3 professionals’ decision
  • Formalised and standard application procedure
  • Appeal to MHRT after decision made
  • Not related to capacity

MCA:

  • Applies to any decision
  • Trumped by MHA
  • Assessment procedure depends on complexity of decision
  • Also depends on how restrictive the treatment is
149
Q

Tx of choice in postnatal depression?

A

1) Reassurance.support
2) CBT
3) certain SSRIs, Paroxetine preferred due to low milk/plasma ratio, but also sertaline

150
Q

Atypical risk in elderly?

A

Increased risk of stroke (especially olanzapine and risperidone)

Increased risk of VTE

151
Q

Somatisation disorder

A

Multiple physical SYMPTOMS present for atleast 2 years

Pt refuses to accept reassurance or negative test results

152
Q

Hypochondrial disorder

A

Persistent belief in the presence of an underlying serious DISEASE eg. CANCER

PT refuses to accept reassurance or -ve test results

153
Q

Conversion disorder

A

Typically involves LOSS OF MOTOR OR SENSORY FUNCTION

Pt doesn’t consciously fign the symptoms (Factitious disorder) or seek material gain (malingering)

Pt may be indifferent to their apparent disorder - le belle indifference

154
Q

Dissociative disorder

A

Dissociation - a process of separating off certain memories from normal consciousness

  • In contrast to conversion disorder, involves psychiatric symptoms eg. amnesia, fugue, stupor

DID - new term for multiple personality disorder

155
Q

Munchausen’s

A

Factitious disorder

- The intentional production of physical or psychological symptoms

156
Q

Malingering

A

Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

157
Q

Preferred antidepressant in IHD?

A

Sertaline following MI as more evidence for its safe use than other antidepressants

158
Q

SSRI Interactions

A

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: see above
triptans: avoid SSRIs

159
Q

ECT absolute CI?

A

Raised ICP

160
Q

Depression vs Dementia?

A

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)
Next question

161
Q

Mx of GAD

A

NICE suggest a step-wise approach:
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

Drug treatment
NICE suggest sertraline should be considered the first-line SSRI
interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

162
Q

Mx of Panic disorder

A

Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services

Treatment in primary care
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

163
Q

Which TCA has the most common anti-muscarinic SE?

A

Imipramine

164
Q

Anorexia metabolic imbalances pneumonic?

A

Most things low

G’s and C’s raised: Growth hormone, Glucose, salivary Glands, Cortisol, Cholesterol, Carotinaemia

165
Q

St John’s wort inducer or inhibitor?

A

Inducer of P450 system - therefore decreased levels of drugs such as warfarin, ciclosporin and COCP.

166
Q

NMS features

A

Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking antipsychotic medication. It carries a mortality of up to 10% and can also occur with atypical antipsychotics. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson’s disease, usually when the drug is suddenly stopped or the dose reduced.

Features
more common in young male patients
onset usually in first 10 days of treatment or after increasing dose
pyrexia
rigidity
tachycardia

A raised creatine kinase is present in most cases. A leukocytosis may also be seen

Management
stop antipsychotic
IV fluids to prevent renal failure
dantrolene* may be useful in selected cases
bromocriptine, dopamiqne agonist, may also be used

167
Q

LBD characteristic pathological feature?

A

Alpha-synuclein cytoplasmic inclusions (lewy bodies) in the substantia nigra, paralimbic and neocortical areas

168
Q

What set of drugs should be avoided in LBD and why?

A

Neuroleptics as LBD pts are extremely sensitive and may develop irreversible parkinsonism

169
Q

LBD triad?

A

Progressive cognitive impairment

Parkinsonism

Visual hallucinations

Autonomic dysfunction

Dx with SPECT/DAT scan

170
Q

Drug induced parkinsonism differences?

A

1) motor symptoms generally rapid onset/ bilateral

2) Rigidity/rest tremor uncommon

171
Q

Switching antidepressants

A

Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
the first SSRI should be withdrawn* before the alternative SSRI is started

Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI

Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- an exceptions is fluoxetine which should be withdrawn prior to TCAs being started

Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly

Switching from fluoxetine to venlafaxine
withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly

*gradually reduce dose then stop

172
Q

Schizophrenia risk

Monozygotic twin

Parent

Sibling

No relatives

A

Risk of developing schizophrenia
monozygotic twin has schizophrenia = 50%

parent has schizophrenia = 10-15%

sibling has schizophrenia = 10%

no relatives with schizophrenia = 1%

173
Q

Benzodiazepine withdrawal regime

A

Dose should be withdrawn in steps of about 1/8 of the daily dose every fornight. A suggested protocal is:

  • switch patients to the equivalent dose of diazepam
  • reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
  • time needed for withdrawal can vary from 4 weeks to a year or more
174
Q

Benzodiazepine withdrawal syndrome

A

If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include:

insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
perspiration
perceptual disturbances
seizures
175
Q

Alcohol withdrawal timings:

A

Symptoms: 6-12 hrs

Seizures: 36 hrs

Delirium tremens: 72 hrs

176
Q

Alcohol withdrawal mechanism

A

Mechanism
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors

alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Mx:

  • Benzos
  • Carbemazepine also effective
177
Q

Most dangerous tricyclic in OD?

A

Dosulepin

Amitryptaline

178
Q

Anti-depressants in acute psychotic episode?

A

NICE guidelines advice to consider stopping antidepressant (As some evidence SSRI may precipitate acute psychotic episode) before starting anti-psychotic

179
Q

Clozapine drug monitoring

A

Don’t do normally, only do it if suspecting toxicity or sub-therapeutic levels

–> trough levels - 12 hrs after last dose

180
Q

NMS vs Serotonin syndrome

A

Serotonin: Altered mental state. NM problems and autonomic nervous system excitiation (SEE SLIDES) . Risk factors: SSRI, MAOs, REcreational drugs, ecstacy and amphetamines

NMS: Presents similar to SS. Associated with antipsychotic use and dopaminergic drugs. Classically found in young men. A raised CK and leukocytosis (as well as Dhx) are best way to differentiate from SS

nb. Malignnant hyperthermia: Associated with anaesthetic agents

Cocaine toxicity: chest pain, convulsions, psychosis

GBH: stiffness, stiff muscles, collapse

181
Q

Couvade syndrome

A

a man thinks he’s pregnant

182
Q

De Clerambault’s syndrome

A

Erotomania - Delusion that a person of high-standing is in love with them.

183
Q

Ekbom’s

A

Infestations

184
Q

Fregoli

A

belief that strangers are actually familiar people in disguise

185
Q

Othello’s syndrome

A

Morbid jealous obsession their partner is cheating

Associated with alcoholism

186
Q

Folie a deux

A

A shared delusion between two family members

187
Q

Capgras

A

someone close has been replaced by an identical looking impostor

188
Q

Fregoli

A

Fregoli’s syndrome: belief that strangers are actually familiar people in disguise

189
Q

Alcohol withdrawal management:

A

OP: Oral thiamine + reducing dose chlordiazepoxide

Inpatient:
IV pabrinex bags 1+2 (NOT ORAL THIAMINE), oral chlordiazepoxide

  • If high risk of seizures, cover with diazepam (quicker onset of action than chlordiazepoxide)
190
Q

Alcohol limits?

A

men: 14 units, over atleast 3 days

Binge = 8 units for a man, 6 for awomen

  • Hazardous drinking = exceeding recommendations

Harmful drinking = physical or mental harm caused by exceeding recommendations

191
Q

Sublimination ?

A

Modifying unacceptable desires to become acceptable

192
Q

Projection

A

internal issues becomes external

193
Q

Acting out

A

Unacceptable behaviours in response to conflict (eg. self harm following conflict)

194
Q

Reaction formation

A

Having the opposite reaction to your true feelings

195
Q

Transference

A

Patients attitude towards their therapist eg. pt thinks their psychiatrist is their father they don’t like

196
Q

Counter-transference

A

dfsadfasdf

197
Q

Splitting

A

People are either all good or all bad

5th year (14 decks)

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