Psychiatry Flashcards
What disorder of medically unexplained symptoms includes:
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results.
Somatisation disorder.
Symptoms - somatisation.
Eg back pain, headaches that have no organic explanation. However when the tests all come back negative their belief remains.
What disorder of medically unexplained symptoms includes:
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient refuses to accept reassurance or negative test results
Hypochondriacal disorder.
Disease - hypochonDriacal
What disorder of medically unexplained symptoms includes:
Loss of sensory or motor function
Not consciously invented
Conversion disorder
What disorder of medically unexplained symptoms includes:
Conscious inventing of symptoms
For MATERIAL gain
Malingering
What disorder of medically unexplained symptoms includes:
Conscious inventing of symptoms
For PSYCHOLOGICAL gain
Factitious disorder
(Munchausen’s)
Assuming the sick role provides an internal reward
In hypochondriacal disorder and somatisation disorder, what form do the thoughts take?
Overvalued ideas.
Not delusions or obsessions
What is the differential for low mood and medically unexplained symptoms? How would you differentiate them?
Depression
Somatisation disorder
Treat the low mood and see if somatic symptoms resolve. If so it was depression.
What questions should you specifically ask a patient with medically unexplained symptoms?
- Check it is an overvalued idea and not an obsession. (Do they agree it is irrational)
Do you find it hard to trust doctors if they tell you there is nothing physically wrong?
How do you feel about the idea of a psychological cause for your problems? - Check it is not a delusion
The xray came back negative - do you think it is possible there is no physical cause for your symptoms?
What is the difference between an overvalued idea, a delusion and an obsession?
Overvalued idea - egosyntonic (patient doesn’t think it is irrational)
Obsession - egodystonic (patient acknowledges irrational)
Delusion - Implausible and unshakeable.
What are Schneider’s first rank symptoms of schizophrenia?
Highly suggestive of diagnosis except 20% never have them and 10% bipolar do.
Third person auditory hallucinations Thought echo (hear own thoughts)
Delusional perceptions (real things have special meaning) Thought withdrawal/broadcast/insertion (thoughts interfered with) Passivity (someone else controlling you)
Describe the dopamine hypothesis of schizophrenia.
Increased dopamine in the mesolimbic dopaminergic pathway.
What are the functions of each of the dopaminergic pathways in the brain?
Mesolimbic - reward
Mesocortical - cognitive control of behaviour/restraint
Nigrostriatal - motor control - think parkinsons
Tuberoinfundibular - pathway between hypothalamus and pituitary in prolactin axis.
Give some risk factors for schizophrenia.
Bio - dopamine, FHx
Psycho - family high expressed emotion
Social - persistent cannabis use, migration
Give some factors which improve prognosis for schizophrenia.
Bio - Female, Late onset, Acute onset, adherence
Psycho - Sociable premorbid personality, intelligent, no negative symptoms
Social - No substance misuse, social support
Give some symptoms of schizophrenia other than delusions an hallucinations.
Negative symptoms - blunted affect, social withdrawal, poverty of speech etc
Neologisms - made up words
Catatonia
What questions should you ask a patient with psychosis?
Disclaimer - I need to ask you a few questions that may seem a little strange but they are routine and they should help me understand a bit better what has been going on.
Delusions:
Schizoid
1. Do you have any enemies? Do you feel anyone is out to get you?
2. Are your thoughts ever interfered with? Put in/removed?
3. Are you being controlled by anyone else?
Bipolar
4. Do you have any particular talents?
5. Are you religious? What is your relationship with God like?
6. Try to shake delusion.
Hallucinations:
- Do you hear people talking that other people can’t hear?
- Do you ever see things that other people can’t?
What diagnoses are associated with visual hallucinations?
NOT usually schizophrenia
Delirium Dementia Epilepsy Alcohol withdrawal Drugs - especially LSD
What diagnosis is associated with olfactory hallucinations?
Temporal lobe lesion/epilepsy
How is capacity assessed?
- For what decision?
- Do they understand information?
- Do they retain the information long enough to make a decision?
- Do they weigh and balance the information?
- Can they communicate their decision to you?
If no, is the impairment temporary? If so, can the decision wait until capacity returns.
What should be done about a decision if the patient does not have capacity?
Best interests decision, taking into account views of either a nearest relative or IMCA.
Does a sectioned patient have capacity?
Depends on what decision.
They might have the capacity to decide what to eat fro lunch but perhaps not to refuse medication.
What is a section 2?
28 days for assessment and treatment
Requires 2 drs (1 section 12 approved) and an AMHP
What is a section 3?
6 months for treatment
Requires 2 drs (1 section 12 approved) and an AMHP
What is a CTO?
Patient who has been on section 3 or 37
Treatment enforced in the community
What is a section 5(2)?
72 hours
Dr sections from inpatient (not a and e)
What is a section 5(4)?
6 hours
RMN sections from inpatient (not a and e)
What is a section 135?
Police section from home (with magistrate’s warrant) and take to place of safety
What is a section 136?
Police section from public and take to place of safety
What is a section 35/36?
Remand to hospital before sentencing
What is a section 37?
Hospital instead of prison straight from court.
Psychiatrist discretion when to discharge.
What is a section 37/41?
Hospital instead of prison straight from court.
Home office must allow discharge/ approve section 17
What are the indications for ECT?
Refractory depression
Uncontrolled mania
Catatonia
What are the contraindications for ECT?
Increased intracranial pressure
Recent stroke or MI
Crescendo angina
What are the risks associated with ECT?
Acute cognitive impairment - retrograde and anterograde amnesia
Dysrhythmias eg WPW
Anaesthetic associated risks - malignant hyperthermia, anaphylaxis, nausea and vomiting
What EEG trace would you expect to see in a good ECT treatment?
- High frequency low amplitude
- Increasing amplitude and lower frequency
- Flat line post ictal phase
What are the symptoms of malignant hyperthermia?
Pyrexia
Muscle rigidity
What drugs can cause malignant hyperthermia?
Suxamethonium (in ECT anaesthesia)
Antipsychotics (neuroleptic malignant syndrome)
Halothane
What is the aetiology of malignant hyperthermia?
Excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
associated with defects in a gene on chromosome 19 encoding the ryanodine receptor.
Which SSRI is particularly appropriate for adolescents?
Fluoxetine
Which SSRI is particularly appropriate post MI?
Sertraline
Which SSRI is particularly appropriate when breastfeeding or pregnant?
Paroxetine
Which psychiatric drugs are associated with long QT?
Haloperidol
Citalopram
What are the side effects of SSRIs?
GI Anxiety Mania Suicidal ideation Sexual dysfunction Hyponatraemia (in the elderly)
Serotonin syndrome
What are the symptoms of serotonin syndrome?
Myoclonic jerks - distinguishing feature Hyperthermia Hyperreflexia Rigidity Delirium
What drugs can cause serotonin syndrome?
MAOIs
SSRIs
Ecstasy
Amphetamines
Which drugs might interact with SSRIs?
- Bleeding risk:
Anticoagulants
NSAIDs - add a PPI - Triptans
What is the halflife of fluoxetine? Why is this significant?
Long 1-3 days
No need to taper off
Avoid in pregnancy/ breastfeeding
Leave a week before switching to a different SSRI
What happens if you stop an SSRI abruptly? What is the exception to this rule?
Discontinuation symptoms:
Mood decreases Restless/insomnia Dizziness Parasthesia Diarrhoea
Except fluoxetine
What is the mechanism of action of venlafaxine?
Low dose - SSRI
High dose - SNRI
What are the side effects of venlafaxine?
SSRI related
Plus NA related - hypertension, dry mouth
Which receptor do TCAs act on?
Tricyclic antidepressants
Block alpha 1, Ach, NA
What receptor does mirtazapine act on?
Alpha 2
What are the side effects of TCAs?
Sedation Dry mouth Postural hypotension Seizures Easy to overdose Urinary retention
What are the side effects of mirtazapine?
Weight gain
Sedation
Dry mouth
Why might mirtazapine be your antidepressant of choice?
Physically ill patient (eg cancer) who could benefit from weight gain and sedation
When you want to mix with SSRI and not risk serotonin syndrome
What is the main mechanism of action of antipsychotics?
D2 and D3 dopamine receptor antagonism
Give 3 differences between typical and atypical antipsychotics.
- Typical have higher affinity for D2/D3
- Typical have more dopaminergic side effects (atypical more metabolic)
- Atypical also antagonise 5HT receptors
Which antipsychotic is the most effective at removing psychotic symptoms?
Clozapine
All the rest are much the same
What are the specific side effects of olanzapine?
Weight gain
Stroke/VTE in elderly
What are the specific side effects of rispiridone?
Hyperprolactinaemia - galactorrhoea
Stroke/VTE in elderly
What are the specific side effects of clozapine?
Agranulocytosis and neutropenia
Myocarditis
Arrhythmias
Why does aripiprazole theoretically have the fewest side effects?
Partial D2 agonist
Doesn’t affect D3 receptors
And partial agonism rather than antagonism means less potent
What are the symptoms of neuroleptic malignant syndrome?
(Like malignant hyperthermia) Pyrexia Labile BP Rigidity Confusion Increased creatine kinase - rhabdomyolysis Can lead to renal failure
Who presents with neuroleptic malignant syndrome?
Young male
Recently started treatment
How is neuroleptic malignant syndrome managed?
Dantrolene
Like malignant hyperthermia
What are the dopaminergic side effects of antipsychotics?
Acute dystonia - increased muscle tone, torticollis, oculogyric crisis
Tardive dyskinesia
Hyperprolactinaemia
Sexual dysfunction
What are the cholinergic side effects of antipsychotics?
Dry mouth
Constipation
What are the metabolic side effects of antipsychotics?
Dyslipidaemia
Diabetes
Weight gain
Thyroid dysfunction
What are the metabolic side effects of antipsychotics?
Dyslipidaemia
Diabetes
Weight gain
Thyroid dysfunction
What are the side effects of Lithium?
Fine tremor GI and weight gain Oedema Polydipsia, polyuria Diabetes insipidus Skin exacerbation - psoriasis and acne
What are the signs and symptoms of Lithium toxicity?
Coarse tremor Slurred speech Ataxia Drowsiness/confusion Diarrhoea and vomiting
Nephrotoxicity (U and Es)
What is the therapeutic range for Lithium?
0.4-1 mmol/l
What is the monitoring required for Lithium?
Baseline TFTs and U and Es
Then every 6 months
Lithium levels weekly until stable
Then every 12weeks, 12 hours after last dose
What receptor do benzodiazepines act on?
GABA
Which is one of the most addictive benzos?
Temazepam
How strong is chlordiazepoxide? What is it prescribed for?
40% Diazepam
Alocohol withdrawal
How strong is Lorazepam?
10 time Diazepam
What are the side effects of benzos?
Dependence
Respiratory depression
Crosses the placenta
What are the signs of benzo OD?
Respiratory depression
Ataxia
Dysarthria
Drowsy
What is the antidote to benzos? How is it used?
Flumazenil
Can’t use in OD when someone is addicted because it will push them into withdrawal and seizure. Only prescribe with expert advice.
What are the signs of benzo withdrawal?
Anxiety Cramps Increased dreaming/hallucinations Delusions Seizure
Describe the ICD 10 criteria for depression.
low mood
anhedonia
fatigue
at least one of these, most days, most of the time for at least 2 weeks
associated symptoms:
disturbed sleep poor concentration or indecisiveness low self-confidence poor or increased appetite suicidal thoughts or acts agitation or slowing of movements guilt or self-blame
not depressed (fewer than 4 symptoms) mild depression (4 symptoms) moderate depression (5-6 symptoms) severe depression (7+ with or without psychotic symptoms for a month)
Describe the ICD 10 criteria for schizophrenia
At least 1 of:
Auditory hallucinations
Delusions
Thought disorder
Or at least 2 of:
Other hallucinations
Neologisms/speech disturbance
Negative symptoms
For at least one month most days.
Describe the ICD 10 criteria for anorexia
Body weight 15% expected or below BMI 17.5
Self induced by food restriction and or purging
Overvalued idea of dread of fatness
Endocrine disorder - amenorrhoea
Describe the ICD 10 criteria for bulimia
Overvalued idea of dread of fatness
Binging
Purging
What hormone changes do you expect to see in anorexia?
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
low T3
What electrolyte changes do you expect to see in anorexia and bulimia?
hypokalaemia
impaired glucose tolerance
hypercholesterolaemia
Which antipsychotic has some anxiolytic qualities?
Quetiapine
What SSRI is recommended by NICE for anxiety, particularly OCD?
Sertraline
What is the workup for potential dementia?
Check for reversible causes (delirium)
FBC - infection U&E - electrolyte imbalance eg hyponatraemia LFTs - hepatitis/cirrhosis calcium glucose - hypo TFTs, vitamin B12 and folate
CXR
CT head - normal pressure hydrocephalus
What are some common causes of delirium?
Infection - UTI, pneumonia Chronic disease - lung, cirrhosis Electrolyte imbalance - hypoNa, hypercalcaemia Thyroid Hypoglycaemia
What is the differential for a confused older person?
Delirium
Dementia
Depression
Describe the main symptoms of delirium.
Clouding of consciousness Delusions Hallucinations (can be visual) Reversal of sleep cycle Disorientation
What are the 3 most common type of dementia?
Alzheimers
Vascular
Lewy Body
How is the MMSE scored?
18-23/30 mild dementia
10-18/30 - moderate
Below 10 - severe
Which genes are associated with Alzheimers?
ApoE
Describe the macroscopic changes found in Alzheimers.
widespread cerebral atrophy, particularly involving the cortex and hippocampus
Describe the microscopic changes found in Alzheimers.
- Type A-Beta-amyloid cortical plaques
- Intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein, because they are excessively phosphorylated
What is the treatment for Alzheimers?
- acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine)
- memantine (a NMDA receptor antagonist) for moderate/severe
What are the symptoms of Lewy body dementia?
Dementia
Fluctuating
Visual hallucinations
Recurrent falls
+ Parkinsons (bradykinesia, tremor, rigidity) therefore sensitivity to antipsychotics
What are the indications for clozapine?
Tried 2 other antipsychotics
Psychosis in parkinsons
In which type of dementia are antipsychotics contraindicated?
Lewy body
May lead to irreversible parkinsons
How do you differentiate between alzheimers and vascular dementia?
Global versus patchy cognitive deficits
Steady versus stepwise decline
Focal neurology in vascular
Onset following stroke in vascular
What are the differences between delirium and dementia?
Delirium is acute
Delirium is reversible
Dementia does not include clouding of consciousness
Dementia does not usually include sleep wake disruption
Dementia presents much later with hallucinations
What is Delirium tremens? When does it kick in?
Delirium following alcohol withdrawal.
Usually kicks in after 72hours
Following a psychiatric history, what questions should you ask to complete the mental state examination?
How are you feeling today? Have you been having any of your symptoms today? Some odd questions, routine Name? Where are we? What is the date? Insight Attitude to treatment Risk
Why do you have to be careful with prescribing drugs in the elderly?
Decreased egfr Increased percentage body fat (lipid soluble) Decreased plasma albumin Decreased hepatic metabolism Comorbidities
What is the mechanism of action of Donepezil?
Ach esterase inhibitor. Inhibits the breakdown of ach at the synapse. Therefore slows down the progression of early alzheimers
What are the common side effects of donepezil?
Increased parasympathetic:
Bradycardia
SLUDGE
Salivation
Lacrimation
Urination: relaxation of the internal sphincter muscle of urethra, and contraction of the detrusor muscles
Diaphoresis: stimulation of the sweat glands
GI - diarrhoea
Emesis
Which alzheimers patients may not be suitable for donepezil?
COPD - increased ach - parasympathetic smooth muscle contraction
On beta blockers - bradycardia
What is the mechanism of action of memantine?
NMDA (glutamate) receptor antagonist
How might you differentiate between depression, dementia and delirium in an elderly person?
Depression more likely if:
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, “I don’t know”
disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
What is the non psychiatric differential for a person presenting with low mood?
Endocrine:
Cushings
Hypothyroid
PCOS
Electrolytes:
Hypercalcaemia
Hyponatraemia
Malignancy:
Pancreatic
Small cell lung (ACTH-cushings)
Vitamin D deficiency
Thiamine deficiency
SLE
Chronic pain
Parkinsons
MS
Huntingtons
Heptatitis
Renal failure
Syphillis
Drug side effect
Describe the workup for a patient presenting with low mood.
Fbc - anaemia, infection, MCV (alcohol) U&E - renal LFT - hepatitis, alcohol Thyroid Calcium B12 and folate
What is psychosis?
Loss of touch with reality characterised by hallucinations and delusions
What is an obsession?
Obsession
- recurrent, intrusive thought
- unpleasant/distressing
- recognised from own mind
- resisted
- egodystonic (patient acknowledges irrational)
What is a delusion?
Delusion - Fixed firm belief that is unshakeable, and implausible taking into account cultural norms.
What is an overvalued idea?
Overvalued idea
- recurrent thought
- plausible
- preoccupied to an unreasonable extent (causes distress to themselves or others)
- egosyntonic (patient doesn’t think it is irrational)
What is a hallucination?
Perception occuring in the absence of an external physical stimulus. Can occur in any of the 5 sensory modalities.
Give some poor prognostic factors for anorexia.
Very low weight Late onset Long duration PD Poor social adjustment Poor family relationship Bulimic symptoms
What is the pharmacological approach to eating disorders?
Bulimia - high dose fluoxetine
anorexia - weight gain plus an ssri
What is the management of PTSD?
EMDR
CBT
What are the diagnostic criteria for ADHD?
Short attention span
Distractibility
Overactivity
Impulsivity
Present for 6 months
Affecting functioning
What negative outcomes are associated with untreated ADHD?
Conduct disorder
Clumsiness
Dyslexia
Future substance misuse
What is the treatment for ADHD?
Methylphenidate
Atomoxetine
What are the side effects of methylphenidate for ADHD?
Stimulant: Tachycardia/palpitations Hypertension Dry mouth Insomnia Psychosis Stunted growth
Describe the 3 conduct disorders
Oppositional defiant - under 10, persistent, aggressive and angry outbursts. No serious violent acts. Good prognosis.
Socialised conduct disorder - Behaviours are viewed as normal amongst peers eg gangs.
Unsocialised - behaviours are solitary with peer rejection. Most likely to develop into antisocial personality disorder.
What are the risk factors for a child to develop a psychiatric illness?
Family history Perinatal hypoxia Abuse Harsh, violent, inconsistent parenting Poverty
