Psychiatry Flashcards
Give the key feature of panic attacks in panic disorder which distinguish it from phobias
Unpredictable/not in a particular situation/no objective danger present
Give physical symptoms that may occur during panic attacks
SOB/hyperventilation Chest pain/discomfort Palpitations Sweating Shaking/trembling Numbness/tingling Choking feeling/abnormal feeling at back of throat Nausea Churning stomach Dizzy/light headed/faint Chills/hot flushes Carpopedal spasm Dry mouth/difficulty swallowing
Excluding anxiety, give psychological symptoms that might occur as part of panic disorder
Derealisation Depersonalisation Fear of dying Fear of losing control or going crazy Need to escape from the situation Change in behaviour due to attacks /avoidance of places where attacks occurred Concern about having more attacks Agoraphobia/social withdrawal
Give lifestyle advice you could offer to try and reduce frequency of panic attacks
Reduce caffeine Reduce alcohol Reduce nicotine /smoking Improve sleep hygiene Address practical issues that may be increasing anxiety e.g. Housing, financial Regular exercise Avoid recreational drugs especially stimulants - amphetamines, cocaine, ecstasy Relaxation/anxiety management techniques
Following lifestyle advice, what is the recommended psychological intervention for panic disorder?
Cognitive behavioural therapy
In which social class groups is anorexia nervosa most common?
Middle and upper middle class families
What type of hair is seen on the body of patients with anorexia nervosa?
Lanugo hair
What are some predisposing factors for psychiatric problems?
Bio: Genetic Loading, Gender, Brain Injury/LD, Physical Illness, Substance Misuse, Previous Psychiatric Hx
Psycho: Personality factors, Parental modelling, Cognitive factors – low IQ, Beck’s triad, cognitive distortions, locus of control
Social: High expressed emotion, Parental discord, Poor socio-economic factors, Isolation, Debts
What are some precipitating factors for psychiatric problems?
Bio: Non-compliance, Substance misuse, Physical illness/trauma, Iatrogenic – drugs, Hormonal – Menopause
Psycho: Poor insight, Assault/conflict, Loss of loved object
Social: Significant life events, Isolation, Lack of support, Increasing stressors, Change of environment
What are some perpetuating factors for psychiatric problems?
Bio: Brain Injury, Non-compliance, Substance misuse, Physical illness, Genetic loading
Psycho: Personality factors, Cognitive factors, Poor insight, Anxiety, Reduced motivation
Social: Isolation, Poor socio-economic factors, High expressed emotion, Family discord
What are good prognostic features in psychiatric illness?
Acute Onset Family support Rapid de-escalation of symptoms/signs Older age group generally Good response to treatment Good insight & engagement with services Effective psycho-education
What are poor prognostic features in psychiatric illness?
Poor insight Physical illness Poor response to past/present treatment Substance misuse Younger age group generally Poor insight On-going substance use Disengagement with services Chronic psychiatric illnesses
What are important features of a generic anxiety history?
S ymptoms of Anxiety E pisodic or Continuous D epression / Drink / Drugs A voidance & Escape T iming + Triggers E ffect on Life
What is a definition of addiction?
Control - there are repeated attempts to cut back or control use, with episodes or loss of control in between
Compulsion - a person experiences a sense that they must use. Can be due to tolerance, withdrawal or psychological need
Consequences - substance use is continued despite significant negative consequences
What is personality disorder and what are the 3 Ps?
Pattern of relating to self, other and the world that deviates from cultural norm
Persistent – happens frequently
Pervasive – across different circumstances
Problematic – and cause problems for themselves and others
What are the traits of borderline personality disorder?
PRAISE
Paranoid ideas
Relationship instability
Affective instability/ Abandonment fears/ Angry outbursts
Impulsivity/ Identity disturbance
Suicidal behaviour/ Self-harming behaviour
Emptiness
What aspects of a personal history are important in a psych history?
Infancy and Childhood: Mother’s pregnancy, Neuro-developmental milestones – birth, walking, talking, sitting and socializing age, Childhood separation or emotional problems, Home and school environment (Bullying, school refusal, shyness,
conduct disorders), Schooling and academic achievements
Adolescence: onset of puberty, early sexual experience, peer relationship
Adulthood: education, military experiences, employment, social life, sexual history, marriage, children, forensic history and substance misuse
What aspects of a social history are important in a psych history?
Profession and employment record, Current employment
Financial situation, Current and past debt problems, spending
Marital status – single, married, divorced, widowed
Children – ages if dependent, parental responsibility
Housing situation, past and present-living alone
Stressors
Social supports
Typical day
What aspects of a forensic history are important in a psychiatric history?
Past and present charges, penalties, arrests and convictions (Violence/Anger, sexual offences)
Pending court cases
Unrecorded offences
Relationship to symptoms and substance misuse
What aspects of pre morbid personality are important in a psychiatric history?
Life long persistent characteristics prior to illness
Moral and religious beliefs
Leisure activities and hobbies
How would others e.g. relatives/friends describe them
What are the elements of the mental state examination?
Appearance and behaviour
Speech: Rate, volume, tone, Formal Thought Disorder
Mood: Subjectively, Objectively
Affect
Thoughts : Content and Form, Abnormal ideas and beliefs, Delusions and ideas of reference, Negative Thoughts about past, present and future / self Passivity phenomena (inc thought insertion & withdrawal), Symptoms of severe anxiety, esp obsessions and compulsions, SUICIDAL THOUGHTS, INTENTIONS and PLANS
Perceptions : Hallucinations (modality, person, content), Illusions
Cognitive Functions: Attention and Concentration, Orientation (T, P and P), Memory: Immediate, Short-term, Long Term
Insight: Recognise nature and severity of condition, Willingness to accept appropriate help
RISK: Self, Others , Health and Self-neglect
What might be things that you notice/comment on about a psychiatric patient’s appearance and behaviour in a mental state examination?
Body language Appropriateness of dress Evidence of self neglect Under or over psychomotor activity – excitation or retardation Facial expression – dilated pupils, rigidity Abnormal movements or posture Rapport and eye contact Distractibility Disinhibition Preoccupation
What might be things that you notice/comment on about a psychiatric patient’s speech in a mental state examination?
Rate, tone and volume
Rate: slow in depression; pressured in mania
Quantity: poverty in depression and chronic schizophrenia
Form
What’s the difference between mood and affect?
Mood - a person’s sustained emotional state
Affect – outward manifestation of a person’s feelings, tone, or mood, the way the patient shows feelings- variability, intensity, appropriateness
What might you notice about a psychiatric patient’s mood in a mental state examination?
Subjective description-Sad, happy, top of the world, worried, up and down
Objective
Range: depression – euthymic – euphoria
Inability to enjoy activities (anhedonia)
Inability to describe one’s emotion (alexithymia)
What might you notice about a psychiatric patient’s thought form and process in a mental state examination?
Stream of Thought Goal directness/continuity Process Connectivity/Organisation Circumstantiality Tangentiality Loose Association Word Salad Echolalia Neologisms Perseveration Thought blocking
What might you notice about a psychiatric patient’s thought content in a mental state examination?
Delusions: persecution, infidelity, grandiose, hypochondriacal, love, guilt, nihilistic, poverty, reference, infestation Obsessions Negative Cognitions Overvalued Ideas Primary and secondary delusions
What might you notice about a psychiatric patient’s perception in a mental state examination?
Illusions
Hallucinations: Auditory (2nd, 3rd) visual gustatory, olfactory (organic, TLE), tactile (cocaine addiction, drug withdrawals)
Pseudo-hallucinations
Hypnopompic/hypnogogic hallucinations
Derealisation and depersonalization
First rank symptoms
Thought insertion, withdrawal, broadcast
Voices- echo, running commentary and 3rd Person auditory hallucinations
Passivity affect, action and impulses
How might you assess cognitive function in a mental state examination of a psychiatric patient?
Ask them to repeat 3 words i.e. Velvet, Daisy, Red (or address), inform them to remember them
Orientation to Time , Place and Persons
Concentration / Immediate Memory (Numbers or Letters)
Serial 7s or WORLD forwards and backwards or Months of the Year or Days of the Week backwards
Past Memory
General Knowledge / Intelligence
Recall ( 3 words or address )
Separate poor concentration from memory problems
What are the aspects of the mini mental state examination?
Year, month, Day of week, date, season Place, Floor, city, county, country 3 Objects to remember WORLD backwards or serial 7’s Recall 3 objects Pen, watch – naming Repeat phrase ‘No ifs ands or buts’ 3 stage command Read and follow instruction Write sentence (verb and noun) Interlocking pentagons
What are bedside measures you can use to assess frontal lobe executive functioning?
Luria Motor Test: alternate hand movements; fist, cut; slap.
Word Fluency Test: “You have a minute Could you tell me as many words as you can starting with the letter “A”
Similarities: ability to apply abstract concepts
Proverb interpretation: conceptual thinking ability
Clock Drawing: “This circle represents a clock face. Please put the numbers, so that it looks like a clock and then set the time to 10 minutes past 11” (parietal and frontal lobes involved)
What is insight and how can you assess it in a mental state examination?
Awareness of abnormal state of mind
Insight rests on a continuum from complete lack of insight to being partially insightful to having insight
Ask the patient if they think they are ill, Mentally or physically
Ask the patient if they are willing to accept help
Ask the patient if they will take treatment
What criteria are required for diagnosis of somatisation disorder?
Four different pain sites or functions
Two GI symptoms other than pain
One sexual or reproductive symptom other than pain
One pseudoneurological symptom
Under what law is a patient held in A and E who has taken a large paracetamol overdose and suicidal ideation? Who needs to be involved?
Held under common law until appropriate time to take blood sample (4 hours after ingestion)
Medically stabilise - N acetylcysteine treatment etc
Then psych team advice
What is a section 5(2) of the mental health act? Where can this not be done?
Used for patients who are already admitted to hospital who have a mental illness to allow compulsory detention for up to 72 hours for assessment
Cannot be done in A and E
What is the PHQ9 used for?
Assess severity of depression symptoms
What is the GAD7 score used for?
Screening tool and severity measure for generalised anxiety disorder
What is a SCOFF score used for?
Detect eating disorders and aid treatment
What are the guiding principles of the mental health act?
PuRPLE Purpose Respect Participation Least restriction Effectiveness, efficiency and equity
What is Munchausens syndrome?
Intentional production of symptoms for example self poisoning
Factitious disorder
What is somatisation disorder?
Patient concerned about persistent unexplained symptoms for at least 2 years
Refuse to accept reassurance or negative test results
What is hypochondrial disorder?
Patient persistently concerned about an underlying diagnosis such as cancer
Refuse to accept reassurance or negative test results
What is conversion disorder?
Loss of motor or sensory function not consistent with well established organic cause which causes significant stress and can be traced back to a psychological trigger
What is la belle indifference?
Person unconcerned with symptoms caused by a conversion disorder
What is malingering?
Fraudulent simulation or exaggeration of symptoms with intention of financial or other gain
What are Schneiders first rank symptoms of schizophrenia?
Auditory hallucinations: 3rd person, thought echo, commentary
Thought disorder: insertion, withdrawal, broadcasting
Passivity phenomena: control by external influence
Delusional perception: normal object perceived, then intense delusional insight into objects meaning for patient
What are the negative symptoms of schizophrenia?
Blunting of affect
Anhedonia
Alogia
Avolition
What are the features required for a diagnosis of autism to be made?
Global impairment of language and communication
Impairment of social relationships
Ritualistic and compulsive phenomena
Usually before age of 3
Which conditions are associated with autism?
Fragile x
Retts syndrome
What are diagnostic criteria for body dysmorphic disorder?
Preoccupation with imaginary defect in appearance. If slight anomaly present - markedly excessive concern
Preoccupation causes clinically significant distress or impairment in social, occupational or other areas of functioning
Preoccupation not better accounted for by another mental disorder (e.g. Anorexia nervosa)
Which screening tool is used to screen for post natal depression?
Edinburgh postnatal depression scale
10 item questionnaire, max 30 points
How mum has felt over previous week
Score >13 indicates depressive illness
Over what time period should SSRIs be stopped? Why?
Gradually reduced over 4 weeks
Discontinuation symptoms: mood change, restlessness, difficulty sleeping, sweating, GI symptoms
After how long of starting on an antidepressant should a patient be reviewed by a doctor?
2 weeks
If under 30 or increased risk of suicide - 1 week
How long should a patient remain on antidepressants if they make a good response?
At least 6 months after remission to reduce risk of relapse
Which drugs interact with SSRIs?
NSAIDs
Warfarin/heparin
Aspirin
Triptans
In which patients should citalopram not be used?
Congenital long QT syndrome
Known existing QT prolongation
In combination with other medicines that prolong QT
What are adverse effects of SSRIs?
GI upset
GI bleeding - may need PPI
Increased anxiety and agitation
What are features of post traumatic stress disorder?
Re experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
Avoidance: people, situations, circumstances associated with the event
Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability, difficulty concentrating
Emotional numbing: lack of ability to experience feelings, detachment
Depression
Drug or alcohol misuse
Anger
Unexplained physical symptoms
What is the management for post traumatic stress disorder?
Watchful waiting if mild lasting less than 4 weeks
Trauma focussed CBT
Eye movement desensitisation and reprocessing
Paroxetine or mirtazepine
Which score is used to calculate risk of suicide if a patient reveals suicidal intent?
SADPERSONs score
Which questions can be used to screen for depression?
During the last month have you been bothered by feeling down, depressed or hopeless?
During the last month have you often been bothered by having little interest or pleasure in doing things?
What is the hospital anxiety and depression scale?
14 questions, 7 anxiety 7 depression Each item score 0-3 Score out of 21 for each 0-7 normal 8-10 borderline 11+ case Encourage patients to answer quickly
What is the patient health questionnaire 9?
9 items scored 0-3 Includes thoughts of self harm Grades severity of depression 0-4 none 5-9 mild 10-14 moderate 15-19 moderately severe 20-27 severe
How is depression graded?
Mild: few symptoms in excess of 5 required for diagnosis, minor functional impairment
Moderate: functional impairment between mild and severe
Severe: most symptoms, markedly interfere with functioning
What is the management guidelines for Alzheimer’s?
Acetylcholinesterase inhibitors: donepezil, galantamine, rivastigmine used in mild to moderate
NMDA antagonist: memantine in moderate to severe
What are features of sleep paralysis? How is it managed?
Paralysis: after waking or before falling asleep
Hallucinations: images or speaking present during paralysis
If troublesom, can be managed with clonazepam
What is the main feature that differentiates mania from hypomania?
Presence of psychotic symptoms: delusions of grandeur, auditory hallucinations
When should blood samples be taken for therapeutic monitoring of lithium levels?
12 hours post dose
In a patient on clozapine presenting as generally unwell and tired, what is the most important test?
FBC - check for agranulocytosis
What are some risk factors for suicide?
Male Age 35-49 Mental illness Treatment and care received after suicide attempt Physically disabling or painful illness Alcohol and drug misuse Loss of a job Debt Living alone - socially excluded or isolated Bereavement Family breakdown including divorce and family mental health problems Imprisonment
What factors are associated with risk of suicide following an episode of deliberate self harm?
Efforts to avoid discovery Planning Leaving a written note Final acts such as sorting out finances Violent method
For which conditions is ECT considered effective?
Major depression
Catatonic schizophrenia
Prolonged/severe mania
What are some side effects associated with olanzapine?
Akathisia Agranulocytosis Hyperprolactinaemia Hyperglycaemia Depression Anxiety
What is the first line treatment for mild depression?
Psychological therapies usually via an IAPT referral
Which is the preferred antidepressant following a myocardial infarction?
Sertraline
When should clozapine be used to treat schizophrenia?
Lack of clinical improvement following sequential use of at least 2 antipsychotics for 6-8 weeks with at least 1 from the atypical class
What are side effects of clozapine?
Weight gain Excessive salivation Agranulocytosis Neutropenia Myocarditis Arrhythmias
What do antipsychotics increase the risk of in elderly patients?
Stroke and VTE
What differentiates a normal grief reaction from depression?
Normal grief reaction lasts under 6 months
What are the 5 stages of grief?
Denial: numbness, pseudohallucinations of the deceased Anger Bargaining Depression Acceptance
In which patients are atypical grief reactions more likely to occur?
Women
If death is sudden and unexpected
Problematic relationship before death
Lack of social support
What are features of atypical grief reactions?
Delayed grief: more than 2 weeks passes before grieving begins
Prolonged grief
Which is the SSRI of choice in children and adolescents?
Fluoxetine
What are long term management options in a patient addicted to benzodiazepines?
Drug addiction counselling
Self help groups
Slow withdrawal under cover of propranolol/antidepressant
Psychiatric referral for withdrawal
What are withdrawal symptoms of benzos?
Rebound anxiety
Insomnia
Depression
What are the features of ADHD?
Extreme restlessness
Poor concentration
Uncontrolled activity
Impulsiveness
What are favourable prognostic indicators in schizophrenia?
Premorbid stable personality Acute onset Higher social class Female Later age of onset
When is a grief reaction said to be delayed?
If it commences 2 weeks after bereavement
A 30 year old schizophrenic female attacks her mother believing that aliens have replaced her with an exact double. What is the diagnosis?
Capgras syndrome
What is another term for delusional jealousy?
Othello syndrome
What is Gansers syndrome?
Prisoner tries to feign insanity
In a patient who has bulimia nervosa that has failed CBT and psychotherapy, what is the next line treatment?
Fluoxetine
In a patient with Parkinson’s disease who develops paranoid ideation and auditory hallucinations, which antipsychotic would be useful?
Atypical like Olanzapine
Less likely to exacerbate PD than chlorpromazine
Which contraceptive is a well recognised cause of severe depression?
Depo provera
Which anxiolytic drug cab cause vivid dreams?
Propranolol
Which antimalarial can cause neuropsychiatric disturbances?
Mefloquine (lariam)
What is the commonest side effect of antipsychotics and one of the most common reasons stated for non compliance of medication?
Impaired sexual performance
What are common organic causes of anxiety?
Hypoglycaemia Alcohol withdrawal Drug intoxication or withdrawal Thyroxine Paroxysmal SVT
What are features of anorexia nervosa?
Phobic avoidance of normal weight Relentless dieting Self induced vomiting Laxative use Excessive exercise Amenorrhoea Lanugo hair Hypotension Denial Concealment Over perception of body image Enmeshed families
What are possible serious side effects of chlorpromazine?
Hyperprolactinaemia
Hypogonadism
Neuroleptic malignant syndrome
What are the unusual pharmacodynamic properties of venlafaxine?
Acts at different receptors depending on dose given
Low strengths: acts only at serotonin receptors
Moderate: acts on serotonin and noradrenaline
High doses: also has dopaminergic activity
What is the mechanism of action of venlafaxine?
SNRI
Increased serotonergic neurotrasmission to improve mood and depressive symptoms
Increased noradrenaline increases drive, memory, learning and energy levels
What is a problem of coprescribing SSRI with Tramadol?
Seizures: Particularly if elderly, drug or alcohol withdrawal, head injury
Serotonin syndrome
