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EOY3 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

what medication can be used to treat sleep paralysis?

A

clonazepam

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2
Q

overdose antidotes

A 
paracetamol --> N-acetylcysteine
opiates --> naloxone 
benzodiazepines --> flumazenil 
warfarin --> vitamin K
beta-blockers --> glucagon 
TCAs --> sodium bicarbonate  
organophosphates --> atropine
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3
Q

pregabalin

A

used in GAD and neuropathic pain
is an anticonvulsant
ADR: dizziness, drowsiness, blurred vision, diplopia, confusion and vivid dreams

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4
Q

beta-blockers

A

e.g. propranolol
reduces somatic symptoms of GAD
CI in asthma

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5
Q

lamotrigine

A

anticonvulsant
used to treat BPAD as a mood stabilisers
less teratogenic than other mood stabilisers so used in women of child bearing age
ADR:
GI disturbance, rash, headache, tremor, patient must be informed to see doctor if signs of hypersensitivity reaction
avoid abrupt withdrawal

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6
Q

carbamazepine

A

used in epilepsy, neuropathic pain, alcohol withdrawal and BPAD unresponsive to lithium
blocks voltage dependent Na+ channels so prevents repetitive neuronal firing
ADR:
GI upset, dermatitis, dizziness, hyponatraemia, leukopenia and thrombocytopenia (monitor WCC after 1 week)
CI in pregnancy, AV conduction abnormalities and acute porphyria

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7
Q

sodium valproate

A

used to treat epilepsy (IV), BPAD (with lithium for rapidly cycling) and to prevent migraines
avoid in hepatic dysfunction, porphyria and pregnancy
ADR: “GI VALPROATE”
GI upset, very fat (weight gain), aggression, LFTs (increased), platelets (low - thrombocytopenia), reversible hair loss, oedema (peripheral), ataxia, tiredness/tremor/teratogenic, emesis

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8
Q

Lithium

A

1st line prophylaxis in BPAD, possible adjunct for depression
ADR: “GI LITHIUM”
GI upset, leucocytosis, impaired renal function, tremor (fine)/teratogenic/thirst (polydipsia), hypothyroidism/hair loss, increased weight and fluid retention, urine (polyuria), metallic taste
in TOXICITY
enhanced by DEHYDRATION, DRUGS (NSAIDS, ACEi), diuretics (thiazide), depletion of NA+
symptoms in toxicity “TOXIC” -
tremor (coarse), oliguric renal failure, ataxia, increased reflexes, convulsions/ coma/ consciousness reduced

normal therapeutic levels are 0.4-1.0mmol/l, toxic at 1.5 mmol/l - very narrow therapeutic window (must monitor levels 12hrs after first dose, then weekly until within range and stable for four weeks and then every three months)

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9
Q

antipsychotics

A

typical (e.g. haloperidol) more extra-pyramidal side effects, generally less tolerable, cause high prolactin

atypical (e.g. olanzapine, clozapine) are more likely to cause weight gain, T2DM, metabolic syndrome and stroke in the elderly.

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10
Q

haloperidol

A

typical antipsychotic
most ADRs, prolonged QTc (needs ECG monitoring)
available as a depot every 4 weeks
risk of neuroleptic malignant syndrome, extra-pyramidal side effects

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11
Q

sulpiride

A

typical antipsychotic
least ADRs, doesn’t really affect blood pressure
not available IM

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12
Q

chlorpromazine

A

typical antipsychotic
mainly used PO
risk of neuroleptic malignant syndrome

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13
Q

olanzapine

A 
atypical antipsychotic 
causes the most weight gain 
need a fasting glucose baseline, at 1 month and then every 4-6 months
an antidepressant at a low dose
available as a depot
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14
Q

clozapine

A

atypical antipsychotic
used in treatment resistant schizophrenia
need a fasting glucose baseline, at 1 month and then every 4-6 months
reduces seizure threshold, causes hypersalivation
good for negative symptoms
not available IM
causes neutropenia and agranulocytosis (need weekly WCC for 18 weeks, fortnightly for 1 year and then every 4-6 months)

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15
Q

risperidone

A

atypical antipsychotic
anti-manic at high dose (but increased risk of EPSE)
causes hyperprolactinaemia so avoid in women

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16
Q

aripiprazole

A

atypical antipsychotic

less ADRs, useful in the 1st episode of psychosis, doesn’t affect BP, available as a depot

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17
Q

quetiapine

A

atypical antipsychotic
used in BPAD during a depressive episode
not available IM

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18
Q

antipsychotics side effects

A

anti-dopaminergic (EPSE - more common in typical)
serotonergic (improves affective and negative symptoms, responsible for metabolic symptoms - mainly atypical)
anti-histaminergic (causes weight gain and sedation)
anti-adrenergic (postural hypotension, tachycardia, and ejaculation failure)
anti-cholinergic and anti-muscarinic (can’t pee, can’t see, can’t sit, can’t shit)

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19
Q

extrapyramidal side effects

A
  • parkinsonism; bradykinesia, increased rigidity, coarse tremor, masked facies, shuffling gait, takes weeks-months to develop
  • akathisia: unpleasant feeling of restlessness, occurs in the first months of treatment, reduce dose and give propranolol temporarily
  • dystonia: acute painful spasms of the neck muscles, jaw and eyes (oculogyric crisis), can occur within days
  • tardive dyskinesia: late onset (years) in 40% of patients, may be irreversible - choreoathetoid movements: abnormal, involuntary movements, most commonly presents as chewing or pouting
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20
Q

neuroleptic malignant syndrome

A

a rare, life-threatening condition seen in patients taking antipsychotics in first 10 days or after increasing the dose
10% mortality
pyrexia, muscle rigidity, confusion, fluctuating consciousness and autonomic instability +/- delirium
Ix: increased creatinine kinase, leucocytosis, deranged LFTs
Rx: stop drug, monitor, IVF, cooling, dantrolene (muscle relaxant), bromocriptine (dopamine agonist), benzodiazepine
complications: PE, renal failure, shock

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21
Q

the “z” drugs

A

zolpidem, zopiclone (used in insomnia), zaleplon
have reduced psychomotor and hangover effects compared to benzos
enhance GABA transmission, but mainly used as sedatives

22
Q

classes of antidepressants

A 
SSRIs
SNRIs
NASSAs
NARIs
SARIs
TCAs
MAOIs
23
Q

selective serotonin reuptake inhibitors

A

increase the concentration of serotonin in the synaptic cleft
safe in overdose
generally well tolerated
work quickly (effects from 1 week, clinically detectable benefits by 4-6 weeks)
low risk of mania
must reduce the dose gradually over 4 weeks to prevent discontinuation syndrome

ADR: GI upset and “STRESS”
sweating, tremor, rashes, EPSE, sexual dysfunction, somnolence

CI in mania, and if on warfarin/heparin, co-prescribe a PPI if on a NSAIDs

24
Q

citalopram

A

1st line in depression, also used in OCD
dose dependant QT elongation
hepatotoxic at high dose

25
Q

fluoxetine

A

safest in pregnancy and breast feeding
preferred choice in adolescents
used in OCD and bulimia
longest half life so less withdrawal risk but a greater risk of serotonin syndrome

26
Q

sertraline

A

safest if there is cardiac disease
safe in pregnancy
increases motivation for suicide (so must review after 1 week)
used for PTSD and OCD

27
Q

paroxetine

A

increased risk of drug interactions, increased risk of discontinuation symptoms
used in PTSD, GAD, OCD, social phobia

28
Q

escitalopram

A

used in OCD, panic disorder, social phobia, depression and long QTc

29
Q

serotonin and noradrenaline reuptake inhibitors

A

are not used if high risk of cardiac arrhythmias or if there is uncontrolled HTN
ADR include nausea, dry mouth, headache, dizziness and sexual dysfunction
are second/third line for depression and anxiety

duloxetine 
venlafaxine (long QTc and blood pressure problems, take BP monitoring)
30
Q

noradrenaline serotonin specific antidepressants

A

mirtazapine - 2nd line in depression for those who need to gain weight and have insomnia
ADR: postural hypotension (caution if frail), increased appetite and weight gain, sedative

31
Q

noradrenaline reuptake inhibitors

A

reboxetine - 2nd/3rd line for major depression
caution in CVD, prostatic hypertrophy, pregnancy and urinary retention
ADR: hypokalaemia in the elderly, nausea, tachycardia, palpitations, postural hypotension, impotence
avoid abrupt withdrawal

32
Q

serotonin antagonist and reuptake inhibitors

A

trazodone - used in depression where sedation is required or in dementia/anxiety with agitation or insomnia
ADR: minimal anticholinergic SE and relatively low cardiotoxicity compared with TCAs, may cause dizziness, sedation and GI upset

33
Q

tricyclic antidepressants

A

amitriptyline - used for chronic neuropathic pain and headache & migraine prophylaxis
ADR:
anticholinergic (dry mouth, constipation, urinary retention, confusion and blurred vision)
hypersensitivity reactions (urticarial, photosensitivity)
CVS (arrhythmias, postural hypotension, tachycardia, syncope)
psychiatric (hypomania/mania, confusion, delirium)
metabolic (increased appetite and weight gain, changes in blood glucose)
endocrine (testicular enlargement, gynaecomastia, galactorrhoea)
neurological (convulsions, dyskinesia, dysarthria, paraesthesia, taste disturbance)

CI in recent MI, arrhythmias (particularly heart block), mania, agranulocytosis)

34
Q

monoamine oxidase inhibitors

A

phenelzine and Isocarboxide - irreversible
moclobemide - reversible

ADR: get a hypertensive reaction with tyramine containing foods - cheese, pickled herring, liver, Bovril, oxo, marmite, and some red wines

CI in acute confusional states, pheochromocytoma

35
Q

serotonin syndrome

A

a rare but life-threatening complication of increased serotonin activity, usually rapid - occurring within minutes of taking the medication
most commonly caused by SSRIs but can also be caused by TCAs and lithium
- cognitive effects (headache, agitation, hypomania, confusion, hallucinations, coma)
- autonomic effects (shivering, sweating, hyperthermia, HTN, tachycardia)
- somatic effects (myoclonus, hyperreflexia and tremor)

management - stop the offending drug and use supportive measures

36
Q

benzodiazepines

A 
long acting (>24hrs); diazepam, chlordiazepoxide 
short acting (<12hrs): lorazepam 
used for delirium tremens and status epilepticus 
ADR: amnesia, confusion and ataxia, dependence and respiratory depression
OD = ataxia, dysarthria, nystagmus, coma and respiratory depression --> IV flumazenil
37
Q

buspirone

A

non-sedating anxiolytic used for GAD
no dependence
ADR: nausea, headaches, light-headedness and dizziness

38
Q

causes of delirium

A 
"I WATCH DEATH"
infection 
withdrawal
acute metabolic
trauma
CNS pathology
hypoxia
deficiencies - B1, B3, B9, B12
endocrinopathies 
acute vascular
toxins/ drugs 
heavy metals

25% hyperactive, 20% hypoactive, 35% mixed
management - treat cause +/- low dose haloperidol/ olanzapine

39
Q

schizophrenia

A

symptoms must be present for >1 month
precipitators - cannabis, adverse life events, poor coping strategies
perpetuating - substance abuse, poor compliance, adverse life events, reduced social support

clinical features - positive and negative symptoms

40
Q

Schneider’s first rank symptoms

A
  • delusional perception
  • third person auditory hallucinations
  • thought interference
  • passivity phenomenon
41
Q

schizophrenia positive symptoms

A 
delusions
hallucinations (3rd person, auditory) 
formal thought disorder
thought interference (insertion/ withdrawal/ broadcast) 
passivity phenomenon
42
Q

schizophrenia negative symptoms

A 
avolition (reduced motivation) 
asocial behaviour
anhedonia (reduced pleasure)
alogia (poverty of speech)
affect blunted
attention deficits
43
Q

types of schizophrenia

A

paranoid (positive symptoms)
post-schizophrenic depression
hebephrenic (thought disorganisation dominant)
catatonic schizophrenia (unresponsive)
simple (negative symptoms, no psychosis)
undifferentiated
residual (psychotic episode then 1 year of negative symptoms)

44
Q

differentials of schizophrenia

A 
drug induced psychosis 
schizoaffective disorder
delirium 
dementia
vitamin B12 deficiency 
porphyria
45
Q

treatment of schizophrenia

A

risperidone/ olanzapine

46
Q

depressive disorder symptoms

A

affective mood disorder characterised by persistent low mood, loss of pleasure +/- lack of energy
accompanied by emotional, cognitive and biological symptoms
depressed mood for > 2 weeks

early morning wakening, weight loss, psychomotor retardation

47
Q

treatment of depression

A

CBT, exercise, social support
SSRIs
suicide risk assessment

48
Q

bipolar affective disorder

A

chronic episodic mood disorder characterised by mania followed by mania/ depression
ALL cases of mania will eventually develop a depressive episode
bipolar I is the most severe, bipolar II is milder
rapid cycling - >4 mood swings in 1 year with no asymptomatic phases - poor prognosis

49
Q

differentials of depression

A

bipolar
hypothyroidism
secondary to other psychiatric disorders or substance abuse
normal bereavement

50
Q

symptoms of mania

A 
"I DIG FASTER"
irritability 
distractibility/ disinhibited 
impaired insight/ increased libido
grandiose delusions
flight of ideas
activity/ appetite increased 
sleep reduced 
talkative - pressure of speech
elevated mood/ energy increased
reduced concentration/ reckless behaviour and spending
51
Q

differentials for mania

A

must do a CT head to rule out a SoL (can cause disinhibition), frontal lobe tumour
schizoaffective disorder
EUPD

52
Q

treatment of mania

A 
"CALMER"
CBT/ consider hospitalisation 
atypical antipsychotics - olanzapine 
mood stabilisers - lithium 
ECT
risk assessment

EOY3 (20 decks)

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