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
What are the types of schizophrenia?
Paranoid Hebephrenic/disorganised Catatonic Simple Residual
Give the core symptoms of depressions
1) Low mood
2) Anhedonia
3) Low energy
then... Poor sleep/ concentration/libido Feelings of guilt Suicidal thoughts Weight changes
What questionnaire tool can use use for depression?
PHQ9 questionnaire
What are the differentials for depression?
Psych: Bipolar, GAD, OCD, schizzoaffective, borderline PD.
Neurological: PD, stroke, MS, dementia, huntingtons
Endocrine: Cushings, addisons, hyper/hypothyroidism
Medications: Antihypertensives, steroids, H2 blockers, sedatives
45 year old presents with fever, sweating, they are pale and acutely confused with myoclonic jerks. They have recently increased their antidepressant medications a) Neuoleptic malignant syndrome b) Acute dystonic reaction c) Serotonin syndrome D) Tardive dyskiesia
c) Serotonin syndrome
Explain how serotonin syndrome would present
Due to increased serotonergic meds, causes:
Psychiatric - confustion, agitation and coma
Neuromuscular - myoclonus, rigidity, tremors and ataxia
Autonomic - hyperthermia, GI upset (N+D),
The NV&D, and myoclonus suggests that it is SS compared to neuroleptic malignant syndrome
How do you treat serotonin syndrome?
BNZ: IV lorazepam (for agitation and clonus)
Serotonin receptor antagonists: cyproheptadine
IV sodium bicarbonate if rhabdomyolysis occurs
What are the SE of SSRIs?
SSRIs SE = 4S’s
Sickness (N, GI upset, headache and insomnia)
Sedation ( + dizziness)
Sexual dysfunction
Sodium low (SIADH in elderly and increased risk of bleeding)
Which does the following belong to? Mitazapine a) SSRIs b) SNRIs c) Alpha adrenoceptor antagonist d) MOAI e) TCA
Mitazapine = Alpha adrenoceptor antagonist
Which does the following belong to? Isocarboxazid a) SSRIs b) SNRIs c) Alpha adrenoceptor antagonist d) MOAI e) TCA
Isocarboxazid = MOAI
Which does the following belong to? Venlafaxine a) SSRIs b) SNRIs c) Alpha adrenoceptor antagonist d) MOAI e) TCA
Venlafaxine = SNRI
Which does the following belong to? Paroxetine a) SSRIs b) SNRIs c) Alpha adrenoceptor antagonist d) MOAI e) TCA
Paroxetine = SSRI
What advice would you give to someone starting on a MAOI?
Beware on tyramine containing foods - cheese, broad beans and avo
Increase BP - hypertensive reaction/crysis
Alcohol - can cause CNS depression
Insulin - Impaired glucose control
What order of preference would you give the antidepressants?
1 = SSRI 2 = another SSRI 3 = Mitazapine/venlaflaxin 4= TCA/MAOI/Lithium
Give an example of a low intensity psychological intervetion
Self guided CBT
Computerised CBT
What medication can you give for acute dystonic reaction
Procyclidine
What would you see in the blood test of an alcoholic?
Raised MCV (due to folate deficiency) Raised Gamma GT (gamma glutamyl transferase) Raised CDT (carbohydrate deficient transferrin)
What do you take for acute detox of alcohol and what drug type is it?
Chlordiazepoxide
LA Benzodiazepine
What are the regular health checks you need to do with someone who has bipolar?
Weight or BMI, diet, nutritional status and level of physical activity
cardiovascular status, including pulse and blood pressure
metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
liver function
SE of lithium?
Leucocytosis Insipidus Tremor Hypothyroidism Increased Urine Metalic taste, mums be aware
How can lithium toxicity present?
Initially: anorexia, diarrhoea, vomiting, blurred vision
More severe: coarse tremor, insteadiness, slurred speech, drowsiness and confusion,
Then: muscle twitching, more severe confusion, fits and LOC
Describe bipolar
Characterized by at least two episodes in which the patient’s mood and activity levels are significantly disturbed.
This disturbance consisting on some occasions of mania/ hypomania and on others depression.
Periods of recovery between episodes.
Depressive episodes tend to last longer (average 6 months).
What is dythymia?
Like depression but has less severe but longer symptoms.
Feels low in mood most days for 2 years.
What is cyclothymia?
Like bipolar affective disorder but does not meet the criteria for either mania/hypomania or depression.
Mood swings.
What is the difference between the baby blues and post-natal depression?
Baby blues occurs in the first 2 weeks and they are more tearful and emotional. Post natal depression occurs in the first few months and they have symptoms of depression as well as thoughts of being inadequate to care for their baby, not loving it and feeling no special bond towards it.
What are some of the autonomic symptoms of anxiety?
Palpitations Sweating/ shaking Dry mouth Difficulty breathing/ feeling of choking Chest pain/ discomfort Nausea or abdominal distress Dizziness
What are some of the symptoms of PTSD?
Flashbacks/vivid dreams
Hyperarousal and increased startle reflex
Hypervigilance
Avoidance of the situation
Blunting of emotions
Anxiety/depression/substance misuse is common
What are the 3 main symptoms that you get with Wernickes?
Wernicke’s encephalopathy
Ocular disturbances (ophthalmoplegia)
Changes in mental state (confusion)
Unsteady stance andgait (ataxia)
What are the antidotes for OD of the following?
a) Paracetamol
b) Opiates
c) Benzodiazepines
d) Lithium
Paracetamol – N-acetyl Cysteine (Parvolex)
Opiates – Naloxone (Narcan)
Benzodiazepines – Flumazenil
Lithium – Haemodialysis
What personality disorders occur in cluster A?
‘Mad’
Paranoid: characterized by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent
Schizoid: lack of interest and detachment from social relationships, apathy, and restricted emotional expression
Schizotypal: a pattern of extreme discomfort interacting socially, and distorted cognitions and perceptions
What personality disorders occur in cluster B?
‘Bad’
Anti-social: a disregard for the rights of others, lack of empathy, increased self-image, manipulative and impulsive behaviour.
Borderline: mood swings, instability in relationships, self-image/identity, behaviour and affect, often leading to self-harm and impulsivity.
Histronic: attention seekingbehaviour and excessive emotions.
Narcissistic: grandiosity, need for admiration and a perceived lack of empathy.
What personality disorders occur in cluster C?
‘Sad’
Avoidant: social inhibition and inadequacy, extreme sensitivity to negative evaluation.
Dependent: a pervasive psychological need to be cared for by other people.
Obsessive-compulsive: rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendship
You have a patient who you think is experiencing delirium tremens.
What investigation work up do you need to do for them?
Bloods: FBC, U&E, Cr, LTFs
ABG, Amylase, CK
ECG
You have a 66 yr old woman who is a known alcoholic in A&E. She is acutely confused, is walking very unsteadily and has odd eye movements (ophthalmoplegia).
You suspect that she has Wernicke’s Encephalopathy but what would your differentials be?
Hepatic encephalopathy Alcoholic ketoacidosis Delirium tremens Dementia Drug abuse
Explain the pathophysiology behind hepatic encephalopathy
Gut derived toxins (ammonia) accumulate due to the failed hepatic detoxification. Ammonia can pass the BBB where it is metabolised while converting glutamate to glutamine. Glutamine causes osmotic stress in the astrocytes causing them to swell and change.
Ammonia has a number of effects on cellular and neurotransmitter functions
Give all the neuro complications of chronic alcoholism
Cerebral cortex - atrophy, impaired memory
Limbic system - memory and emotional problems
Cerebellum - uncoordinated movements + balance issues
- Delirium tremens
- Wernickes encephalopathy
- Korsakoff’s syndrome
- Hepatic encephalopathy
Give the CV complications of chronic alcoholism
HTN
Arrhythmias
Cardiomyopathy
CVA/Stroke
Describe the mental health act section 2
2 = Assessment 28 days - 2drs and AMHP (approved mental health professional) - MH disorder - Detained for their own/others safety
Describe the mental health act section 3
3 = Treatment 6m - 2Drs and AMHP - MH that needs hospital treatment - Treatment is in their best interests - Acceptable treatment is available
Describe the mental health act section 4
4 = Emergency section when a 2nd Dr is not available
- 72hrs
- 1Dr and AMHP
- MH
- Best interest/safety
Should be done only when waiting for the 2nd Dr would be too much risk (lead to an undesirable delay)
Describe the mental health act section 5 (2)
5 (2) = Dr’s holding power
- 72hrs
For a patient already admitted but wanting to leave - it allows time for a section 2/3 to occur
- X treatment
Describe the mental health act section 5 (4)
5 (4) = Nurses holding power
- 6 hrs
For a patient already admitted but wanting to leave - allows time for a Dr to arrive
- X treatment
Describe the mental health act section 135
135 = police section
A court order which allows the police to break into someone’s house to take them to a place of safety
Describe the mental health act section 136
136 = police section
Allows the police to take someone suffering from a MH disorder in a public place
What are the main presentations of anorexia nervosa?
Neuro - peripheral neuropathy, cerebral atrophy Oral - dental caries GI - constipation Skin - Dry skin and brittle hair Cardiac - bradycardia, hypotension, arrhythmias, Long QT, cardiomyopathy Gynae - Amenorrhoea and infertility Endocrine - low K+, Na, delayed puberty MSK - Osteoporosis
What is the diagnostic criteria of anorexia nervosa?
1) Low body weight (BMI <17.5)
2) Self induced weight loss
3) Body image distortion
4) Endocrine disorders (TSH and inuslin)
Cognitive analytical therapy can be used as a psychological therapy for anorexia nervosa.
How does it work?
Cognitive analytical therapy
3 stages
1) Reformulation - looking into the past to explain why the unhealthy patterns have arisen
2) Recognition - helping people to see how these patterns are contributing
3) Revision - trying to change
Cognative analytical therapy is one psychological method to help patients with anorexia nervosa.
Give 3 more
1) CBT
2) Inter-personal therapy
3) Focal psychodynamic therapy
4) Family interventions
What are the physical signs of Bulimia nervosa?
- Arrhythmias, cardiac failure
- Electrolyte disturbances - low K+, metabolic acidosis if using laxatives
- Oesophageal erosions/perforations
- Gastric/duodenal ulcers
- Pancreatitis, constipation/steatorrhoea
Define personality disorders
PD = severe disturbances in the character and behaviour of the individual involving several areas of personality with considerable personal and social disruption
What are the diagnostic criteria of personality disorders?
- Impairment/traits that started <18 (long standing)
- Stable across time and consistent across situations
- Impairment in self and intrapersonal functioning
