Psychiatry Flashcards
Define obsessions
Obsessions are involuntary thoughts, images or impulses with the following characteristics:
1) Recurrent and intrusive, experienced as unpleasant/distressing
2) They enter the mind against conscious resistance - try to resist but they are unable to
3) Recognise that they are a product of their own mind - even though they are involuntary and repugnant - they have INSIGHT
Define compulsions
Compulsions are repetitive mental operations (counting/praying) or physical acts (hand washing/rituals/closing doors)
Patients feel compelled to perform them in response to their own obsessions
They are performed to reduce anxiety or to prevent dreaded event (counting before sleeping to prevent family dying)
What are the ICD diagnostic guidelines for Obsessive compulsive disorder
Obsessions or compulsions present for at least 2 weeks
Source of distress
Interfere with the patients functioning
Insight that they are coming from the patients own mind
Obsessions are unpleasantly repetitive
At least one has been resisted unsuccessfully
Compulsive act is not pleasurable (apart from relieving the anxiety)
How can OCD be treated?
CBT
SSRI’s
Define rumination
Rumination = repeatedly thinking about the causes and experience of previous distress & difficulties.
Voluntary
Not resisted
What are the differentials for obsessions and compulsions?
OCD - >2 weeks
Eating disorder - over valued idea of fatness, not recognised as unusual thoughts, not resisted (ego-syntonic)
Obsessive-complusive (anankastic) PD - enduring behaviour pattern of rigidity, doubt, perfectionism, ego syntonic - not true O / C
Explain the difference between a neurosis and a psychosis
Neurosis = mild mental illness with no organic cause - involves symptoms of stress with no loss of contact with reality. More inner struggles.
Anxiety, depression, phobias, OCD, eating disorders
Psychosis = involves a loss of contract with reality.
Major personality disorder with gross mental and emotional disturbances. Schizophrenia, bipolar,
What are the differences between positive and negative symptoms?
Positive symptoms are excessive or a distortion from normal functioning where as negative symptoms are a loss of normal functions
Give examples of positive and negative symptoms
Positive = hallucinations, delusions, disorganised speech, catatonic/bizarre behaviour.
Negative = Alogia (poverty of speech), Avolition (inability to do goal directed behaviour), Apathy, social withdrawal, flattening of affect, low interest, motivation and energy
What neurotransmitters do antipsychotics work on?
Primarily on dopamine
Serotonin, noradrenaline and acetylcholinesterase
What are the main side effects with clozapine?
Common: sexual dysfunction, weight gain, N+V, dry mouth, constipation
Agranulocytosis (can be fatal)
Metabolic disturbances (raised cholesterol and triglycerides) + DM
Cardio - myocarditis + cardiomyopathy
Which antipsychotics are associated with the most weight gain issues, raised lipid profile and high glucose?
Olanzapine and clozapine
Explain what extrapyramidal SE are
Extrapyramidal SE are due to low dopamine and are usually involving posture and muscle tone
What are the extrapyramidal SE of AP?
Akathisia Akinesia Tardive dyskinesia Dystonia Dyskinesia Demotivation
What are the non-extrapyramidal SE of AP? (non-dopamine)
Wight gain
Metabolic syndromes (insulin resistances and abnormal adipose deposit)
Sexual dysfunction
Anticholinergic effects (dry mouth, constipation)
Cardiovascular (long QT)
Sympathetic (sedation and low BP)
What baseline investigations should you do before commencing AP?
Wt, BMI Pulse, BP Fasting glucose/HbA1c Lipid profile ECG
What type of medication is haloperidol?
Give SE
High potency AP
SE:
EPSE = dystonia, Parkinsonism + akathisia
Anticholinergic (dry mouth, constipation, blurred vision)
Depression, low BP, dizziness and headaches
What is stupor?
Stupor is a state of near unconsciousness - that responds only to pain
Patient is immobile and mute but their eyes can follow external stimuli
Explain the following subtypes of formal though disorders
A) Tangentiality
B) De-railment
C) Incoherence
A) Tangentiality = replying to questions in an irrelevant manner
B) De-railment = speech moves from one topic to another mid-sentence
C) Incoherence = (word salad) unintelligible speech - real words that have randomly been put together
What is the difference between a mannerism and a stereotyped behaviour?
A mannerism is a normal goal directed behaviour (putting hand through hair) where as a steryotyped behaviour is a repeated movement of behaviour that is not goal directed (rocking)
What is a compulsion?
A compulsion is a repetitive and seemingly purposeless behaviour that is the action of an obsession - recognised by the patient as being from them selves
What are the differences between the positive and negative symptoms of schizophrenia?
+VE : Excess/distortion of normal function - delusions/hallucinations/disorganised speech/catatonic or bizarre behaviour
-VE: less than normal - Algolia (poverty of speech), Avolition (inability to do goal directed behaviour), flattening of affect, social withdrawl, low energy/interest/motivation
(taking away energy, emotions, enjoyment, motivation, speech, social skills)
A patient comes to see you as she suffered from 10 days of ‘chaos in her mind’ she was having hallucinations and could hear her neighbours talking about her. Before the symptoms came she had just had a near miss car accident. What could be the cause?
Acute and transient psychotic episode
Sudden onset <2weeks, changing/variable symptoms associated with acute stress
Recognised in ICD10 as being distinct from schizophrenia + affective psychosis
What is the most serious SE of clozapine?
Agranulocytosis (low wbc and risk of death)
Which antipsychotics are associated with the most gain and raised lipid profile and glucose?
Olanzapine and clozapine
What action do antipsycotics have?
D2 receptor antagonist - redcuing the dopamine action in the brain
What are the extra pyramidal SE from AP?
Akinesia (slow movements) Dyskinesia Akathisia (inner restlessnes) Dystonia Tardive dyskinesia Demotivation Hormonal changes - (raised prolactin)
What are the non-dopamine SE of AP?
Metabolic syndromes - DM, raised BM and lipids, raised
CVRF - Long QT
Increased weight
Anticholinergic - dry mouth and blurred vision
Sexual dysfunction - low libido and inability to maintain an erection
What is acute dystonic reaction?
Sustained painful muscle spasms that produce repetative twisting/abnormal postures following exposure to AP
A 20yr old M has just started with muscles spasms that has caused his arm to stay in an odd posture - he has just started an AP medication 2 hours ago. He has been diagnosed with acute dystonic reaction - how do you treat?
Acute dystonic reaction
Rx: IM anticholinergic (procyclidine)
A known schizopherenic presents to A&E with a fever, rigidity, they have a low GCS and have been incontinent. This has happened following an increase in their meds. Which is the most likely diagnosis? a) Neuoleptic malignant syndrome b) Acute dystonic reaction c) Serotonin syndrome D) Tardive dyskiesia
Neuoleptic malignant syndrome
What are the 4 characteristic features of neuroleptic malignant syndrome?
Delirium,
fever,
rigidity,
autonomic instability - pale, sweating, increased HR, RR, BP
How would you manage neuroleptic malignant syndrome?
ABC - medical emergency
Fluid and electrolyte balance (reduce risk of renal failure)
Cooling blankets, ventilatory support
Stop causeative agent/restart parkinson meds
Delirium - BDZ
Rigidity - Loarazepam
Rhabdomyolysis = IV sodium bicarbonate
