Psychiatry Flashcards
1
Q
What is meant by ‘pharmacokinetics’?
A
What the body does to the drug
2
Q
What is meant by ‘pharmacodynamics’?
A
What the drug does to the body
3
Q
Name 4 key neurotransmitter systems
A
- Dopamine
- Serotonin
- Acetylcholine
- Glutamate
4
Q
Which dopamine pathway is important in the negative symptoms of schizophrenia? (e.g. blunting)
A
D1 Receptors in the mesocortical pathway
5
Q
Which dopamine pathway is important in the positive symptoms of schizophrenia? (e.g hallucinations)
A
D2 receptors in the mesolimbic pathway
6
Q
What are the functions of dopamine?
A
- Reward (motivation)
- Pleasure, euphoria
- Motor function (fine tuning)
- Compulsion
- Perseveration
7
Q
What is serotonin responsible for?
A
- Regulates fear and anxiety response
- Management of mood
- Circadian rhythm
- Memory
- Cognition
etc.
8
Q
Which amino acid is responsible for making serotonin?
A
Tryptophan
9
Q
Where is serotonin made?
A
Raphe area of the midbrain
10
Q
How would you treat a first episode of psychosis in schizophrenia?
A
Oral antipsychotic medication + Psychological interventions (family intervention and individual CBT)
11
Q
What is the hypothesis for the pathophysiology of schizophrenia?
A
Dopamine hypothesis
12
Q
Dopamine hypothesis for schizophrenia: What is responsible for ‘positive’ symptoms?
A
Overactivity of D2 receptors (mesolimbic)
13
Q
Dopamine hypothesis for schizophrenia: What is responsible for ‘negative’ symptoms?
A
Underactivity of D1 receptors (mesocortical)
14
Q
How does the neurodevelopmental theory explain schizophrenia?
A
D1 receptors aren’t underactive, there are just less of them
15
Q
Which are the main receptors targeted by antipsychotic medications?
A
Dopamine D2 receptor
and Serotonin 5HT2a receptor in atypical antipsychotics
16
Q
What is the main problem with ‘typical’ first generation antipsychotic (FGA) medication?
A
EPSEs (extra-pyramidal side effects)
17
Q
Antipsychotics: What are the 4 main EPSEs?
A
AdPAT
- Acute dystonic reaction (hours)
- Parkinsonism (days)
- Akasthisia (days-weeks)
- Tardive dyskinesia (months to years)
18
Q
Antipsychotics: What might you see in an acute dystonic reaction?
A
Muscle spasms, resulting in:
- Opisthotonic crisis (spasm of entire body - back arching, upper limb flexion, lower limb extension)
- Torticollis (twisting of the neck)
- Oculogyric crisis (rotated eyes/deviated gaze)
19
Q
How would you treat an acute dystonic reaction?
A
- ABCs
2. IV Anticholinergic drug (e.g. benztropine or procyclidine)
20
Q
Antipsychotics: Why do EPSEs occur?
A
The usual inhibition of cholinergic transmission in the nigostriatial pathways (caudate and putamen) by DA is blocked by antipsychotic drugs. This leads to a relative excess of cholinergic neurotransmission and may cause EPSEs.
21
Q
Antipsychotics: How do anticholinergic drugs prevent EPSEs?
A
They prevent cholinergic excess by blocking muscarinic M1 receptors
22
Q
Antipsychotic EPSEs. Give 2 features of Parkinsonism?
A
- Tremor
2. Bradykinesia
23
Q
Antipyschotic EPSEs. Give 2 features of Akasthisia?
A
‘Inner restlessness’
- Pacing and agitated
- Often intolerable - some patients kill themselves
24
Q
Antipsychotic EPSEs. Give 3 features of Tardive Dyskinesia?
A
Grimacing
Tongue protrusion
Lip smacking
25
Antipsychotic EPSEs. What causes Tardive Dyskinesia?
Blockage of D2 receptors in the nigrostriatal dopamine pathway causes them to upregulate, causing tardive dyskinesia
26
Name 4 'typical' (first generation) antipsychotics
Haloperidol
Chlorpromazine
Prochlorperazine
Pipothiazine
27
Name 4 'atypical' (second generation) antipsychotics
```
Olanzipine
Quetiapine
Clozapine
Risperidone
Amisulpride
```
28
What is the advantage of 'atypical' over 'typical' antipsychotics?
They antagonise 5-HT2A receptors as well as dopamine D2 receptors:
Reduced propensity for extrapyramidal side effects (EPSEs) i.e. fewer motor side effects
29
Against which receptors is the third generation antipsychotic (TGA) Aripiprazole effective?
```
Partial Agonist:
1) Dopamine D2
2) Serotonin 5-HT1A (weak)
Antagonist:
1) Serotonin 5-HT2A
```
30
What medication is used for treatment resistant schizophrenia?
Clozapine
31
What is a main risk of clozapine?
Agranulocytosis
| Also: myocarditis, weight gain, excessive salivation, neutropenia, arrhythmias, constipation)
32
What is agranulocytosis?
Severe lack of granulocytes (neutrophils, eosinophils, basophils) resulting in very high risk of infection due to suppressed immune system
33
Which are the key neurotransmitters implicated in depression?
Noradrenaline and Serotonin
34
Give 3 monoamine neurotransmitters
Dopamine
Noradrenaline
Serotonin
35
Antipsychotics. What is a potentially fatal side effect of the atypical antipsychotic Aripiprazole?
Neuroleptic malignant syndrome
36
Antipsychotics: How do most typical antipsychotics work?
By antagonising Dopamine D2 receptors in the mesolimbic dopamine pathway
37
Antipsychotics: What is the most common risk associated with olanzipine (and other SGAs)?
METABOLIC SYNDROME - patients can put on a lot of weight, resulting in a high risk of obesity, diabetes, hypertension and dyslipidaemia
38
Give 8 different classes of antidepressants
1. Tricyclic Antidepressants (TCAs)
2. Selective Serotonin Reuptake Inhibitors (SSRIs)
3. Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs)
4. Monoamine Oxidase Inhibitor (MAOI)
5. Reversible Inhibitor of Monoamine Oxidase A (RIMA)
6. Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)
7. Selective Noradrenaline Reuptake Inhibitor (NARI)
8. Serotonin 2A Antagonist/Serotonin Reuptake Inhibitor (SARI)
9. Others: tetracyclic antidepressats, dopaminergic and noradrenergic antidepressants
39
What is the general aim of antidepressants?
1) Elevate levels of monoamine neurotransmitters in synaptic cleft
2) Activate 2nd messenger systems, e.g. to increase expression of BDNF (brain-derived neurotrophic factor)
40
Why should abrupt withdrawal of an antidepressant be avoided?
May cause discontinuation syndrome
41
What is the model used to explain the pathogenesis of depression?
Biopsychosocial model
42
Give an example of a Tricyclic Antidepressant (TCA)
Amitryptilline
Imipramine
Lofepramine
43
Antidepressants: Give an example of an SSRI
Fluoxetine
Paroxetine
Sertraline
Citalopram
44
Antidepressants: What are the advantages of SSRIs over TCAs?
Less sedating
| Low cardiotoxicity
45
What are some of the common side effects of SSRIs?
```
GI disturbance (increased bowel motility)
Anxiety/agitation
Altered appetite/weight
Insomnia
Sweating
Sexual dysfunction/anorgasmia
```
46
Why should MAOIs not be prescribed with other antidepressants?
They can cause serotonin syndrome
47
What might you see in someone with serotonin syndrome?
Tremor
Hyperthermia
Cardiovascular symptoms
48
Antidepressants: What dietary caution should be given with MAOIs?
```
Do not eat:
Beer
Red wine
Aged cheese
Smoked meat/fish
```
49
Antidepressants: Why should foods such as smoked meat and aged cheese be avoided in patients on MAOIs?
They contain tyramine (monoamine) - a potent vasoconstrictor.
MAOIs prevent the breakdown of tyramine leading to a HYPERTENSIVE CRISIS
50
Antidepressants: How do tricyclic antidepressants (TCAs) work?
Inhibit reuptake of serotonin and noradrenaline at pre-synaptic terminals
51
Antidepressants: Side effects of TCAs
```
Cardiotoxicity
Weight gain
Epileptic fits
Tremor and sweating
Postural hypotension (due to alpha blockade)
```
52
Antidepressants: Give an example of a MAOI
Phenelzine
53
Antidepressants: What class of antidepressant is Venlafaxine?
SNRI (serotonin-noradrenaline reuptake inhibitor)
54
If someone is experiencing general anxiety and depression, what antidepressant would you be likely to prescribe?
A SNRI like venlafaxine
55
Antidepressants: Give an example of a Reversible inhibitor of monoamine oxidase A (RIMA)
Moclobemide
56
Antidepressants: Give an example of a Noradrenergic and specific serotonergic antidepressant (NaSSA)
Mirtazepine
57
Mood Stabilisers: Give some examples of drugs used in bipolar affective disorder
```
Lithium
Sodium Valproate
Carbamazepine
Lamotrigine
Gabapentin
```
58
Mood Stabilisers: How does lithium work?
Inhibits cAMP production (cAMP inhibits monoamines)
59
Lithium has a narrow therapeutic window. Why is this significant?
It quickly becomes toxic as levels increase
60
What are some unwanted SEs of lithium?
```
LITHIUM
Leukocytosis
Insipidus
Tremors (and other CNS effects - ataxia, dysarthria)
Hypothyroidism
Increased thirst
Under-active memory
Mothers (teratogenic)
```
61
Mood Stabilisers: Important drug interactions with lithium?
Diuretics, ACEis, NSAIDs: reduced lithium excretion; may cause toxicity
Antipsychotics: increased risk of EPSEs
62
Phenomenology: Define illusion
Misperception of real external stimuli
63
Phenomenology: Define hallucination
Perceptions occurring in the absence of external physical stimulus (can be in any sensory modality: auditory, visual, olfactory, gustatory, tactile, somatic)
64
Hallucinations: What is a hypnopompic hallucination?
Hallucination as waking up (non-pathological
65
Hallucinations: What is a hypnagogic hallucination?
Hallucination as falling to sleep (non-pathological)
66
What medication may cause hypnopompic and hypnagogic hallucination?
Tricyclic antidepressants
67
Hallucinations: What is a reflex hallucination?
Stimulus detected in one modality and experienced in another
68
Hallucinations: What is an extracampine hallucination?
Something out of the realms of feasibility
69
Hallucinations: If someone is hearing voices saying "You are going to do X", what type of hallucination is this?
Auditory, second person
70
Hallucinations: If someone is hearing voices discussing things/commenting, what type of hallucination are they experiencing?
Auditory, third person
71
Phenomenology: Define over-valued idea
A false or exaggerated belief sustained beyond logic or reason, but with less rigidity than a delusion, being less patently unbelievable
72
Phenomenology: Define delusion
False, unshakeable belief which is out of keeping with the patient's educational, cultural and social background.
73
Delusions: What is a persecutory delusion?
Personal harm
74
Delusions: What is a grandiose delusion?
Inflated importance/self esteem
75
Delusions: What is a self-referential delusion?
Belief things are referencing you, e.g. on TV
76
Delusions: What is a nihilistic delusion?
the belief that oneself, a part of one's body, or the real world does not exist or has been destroyed.
Bowels rotted, already dead, etc.
77
Delusions: Give 3 examples of misidentification delusions?
1. Capgras: someone replaced by an imposter
2. Fregoli: various people are the same person
3. Subjective doubles: doppelganger
78
What is a delusional perception?
A delusional belief resulting from a perception, e.g. "The traffic light has turned red, therefore MI5 are following me"
79
Give 3 types of hallucinations
1. Auditory (second or third person)
2. Visual
3. Olfactory
4. Gustatory
5. Tactile
6. Somatic
7. Normal (hypnopompic, hypnagogic)
8. Reflex
9. Extracampine
80
Give 3 types of delusions
1. Persecutory
2. Grandiose
3. Self-referential
4. Nihilistic
5. Misidentification
81
If someone believes that their mother has been replaced by an exact double, what are they experiencing?
Delusional misidentification (specifically, Capgras syndrome)
82
If someone believes that one person is impersonating lots of familiar people, what are they experiencing?
Delusional misidentification (specifically, Fregoli syndrome)
83
What are the four broad characteristics of conventional thought processes?
1. Thought stream (speed, quality, quantity of thinking)
2. Thought content (what is being thought about)
3. Thought form (how thoughts are linked)
4. Thought possession (are they considered to be their own thoughts)
84
Thoughts: Give 3 examples of disorders of thought stream
Flight of ideas
Retardation of thinking
Pressure of speech
85
Thoughts: Give 2 examples of disorders of thought content
Delusions
| Over-valued ideas
86
Thoughts: Give some examples of disorders of thought form
```
Derailment (aka asyndesis, loosening of association)
Omission
Fusion
Substitution
Block
etc.
```
87
Thoughts: Give some examples of disorders of thought possession
```
Obsession
Thought alienation (insertion, withdrawal, broadcast)
```
88
What are the two main classification systems for mental health conditions?
ICD-10 (International Classification of Diseases)
| DSM-5 (Diagnostic and Statistical Manual for Mental Disorders)
89
Thoughts: What is concrete thinking?
Can't understand abstract concepts
90
Thoughts: What is loosening of association? (aka 'derailment', 'asyndesis')
Lack of logical association between succeeding thoughts; gives rise to incoherent speech
91
Thoughts: What is circumstantiality?
Citing excessively minute details which distract from the central theme of a conversation.
e.g. When asked about a bruise on her arm, the patient recounts everything else that happened that same day before explaining how she was injured.
92
Thoughts: What is perseveration?
Repetition of a word, theme or action beyond the point in which it was relevant and appropriate
93
Thoughts: What is confabulation?
Giving a false accounts to fill a gap in memory (seen in Wernicke-Korsakoff, Alzheimer's, Schizophrenia)
94
Phenomenology: What is somatic passivity?
Delusion that one is a passive recipient of an external entity producing a somatic movement
95
Phenomenology: What is meant by made acts/feelings/drives?
Person believes they are being made to act/feel/being driven by another entity
96
Phenomenology: Define anhedonia
Loss of enjoyment in something one would usually engage with
97
Phenomenology: Define apathetic
Loss of engagement in something one would usually engage with
98
Phenomenology: What is incongruity of affect?
Emotional response which seems grossly out of tune with the situation or subject being discussed
99
Phenomenology: What is blunting of affect?
Objective absence of emotional response, with no evidence of depression or psychomotor retardation
100
Phenomenology: What is 'Belle Indifference'?
Lack of concern and/or feeling of indifference about a disability or symptoms
101
Phenomenology: What is depersonalisation?
Feeling of detachment from self physically; lack of feeling of control (may see in anxiety and personality disorders)
102
Phenomenology: What is derealisation?
World outside seems unreal
103
Phenomenology: What is dissociation?
Feeling of removing yourself from a situation; often a defence mechanism
104
Phenomenology: What is conversion?
Disorder in which physical symptoms, e.g. paralysis or blindness, occur without apparent physical cause and instead appear to result from psychological conflict or need
105
Phenomenology: What is stereotyped behaviour?
Uniform, repetitive, non-goal-directed actions
106
Phenomenology: What is gender dysphoria?
Feeling of being a different gender to how one was born
107
Phenomenology: What is gender identity?
Person's inner conviction of being a particular gender
108
Phenomenology: What is transvestism?
Sexual pleasure derived from dressing as the opposite gender
109
Phenomenology: What is a phobia?
Irrational, intense fear
110
Phenomenology: What is meant by projection?
Taking one's own emotions and projecting them onto someone else
111
Phenomenology: What is transference?
Unconscious redirection of feelings from one person to another. e.g. patient may be angry with therapist because he has a beard, and when they were younger they had a bad experience with someone who had a beard
112
Schizophrenia: What is it?
'Splitting of thoughts'
A common chronic relapsing condition often presenting in early adulthood with psychotic symptoms , disorganisation symptoms, negative symptoms and cognitive impairment.
113
Schizophrenia: Give 2 examples of psychotic symtoms
Hallucinations
| Delusions
114
Schizophrenia: Give 2 examples of disorganisation symptoms
Incongruous mood
| Abnormal speech and thought
115
Schizophrenia: Give 5 examples of negative symptoms
```
Apathy
Decreased motivation
Withdrawal
Self-neglect
Blunted mood
```
116
Schizophrenia: Prevalence?
1%
117
Schizophrenia: What is the typical age of onset?
1. Typically 2nd-3rd decade (more men than women)
| 2. Second (smaller) peak incidence in late middle age (more women than men)
118
Mood Stabilisers: Why is it important to drink lots of water when on lithium?
It can compete with sodium
119
Schizophrenia: What is the change in life expectancy in someone with schizophrenia?
25 years shorter than the general population
120
Schizophrenia: What are the 4 First Rank Symptoms (FRS)?
1. Thought interference(insertion/withdrawal/broadcasting)
2. Passivity phenomena/delusions of control
3. 3rd person auditory hallucinations
4. Delusional perceptions
(and 5. Thought echo)
121
Schizophrenia: What are the secondary symptoms?
Delusions
2nd person auditory hallucinations
Hallucinations in any modality
Thought disorder
122
Schizophrenia: Give 6 positive symptoms
```
Hallucinations
Delusions
Passivity phenomena
Thought alienation
Disturbance in mood
Disorganised speech
Disorganised behaviour
Catatonic behaviour
```
123
Schizophrenia: Give negative symptoms
```
Blunting of affect
Amotivation
Poverty of speech (Alogia)
Poverty of thought
Poor non-verbal communication
Clear deterioration in functioning
Self-neglect
Lack of insight
Avolition
Catatonia
```
124
Schizophrenia: According to the ICD-10 criteria, what is required for diagnosis?
For >6 months, they must have experienced :
1 of the following (if clear-cut):
1. Hallucinations
2. Thought disorder (echo, insertion/withdrawal, broadcasting)
3. Delusions (control, influence, passivity, etc)
4. Persistent delusions of other kinds (e.g. political identity, superhuman powers/abilities)
Or any 2 of the following:
1. Persistent hallucinations
2. Thought disorder (e.g. breaks/interpolations/invented words)
3. Catatonic behaviour (excitement, posturing, waxy flexibility, negativism, mutism, stupor)
4. Negative symptoms (e.g. marked apathy, reduced speech, etc - NOT due to depression/antipsychotic medication)
125
Schizophrenia: Give 2 risk factors
```
FHx of schizophrenia
Increasing paternal age
Obstetric complications
Cannabis use
Being brought up in cities
Migrant groups (Asians/Afro-Caribbeans)
```
126
Schizophrenia: Differential diagnoses?
1. Severe affective (mood) disorders with psychotic symptoms, e.g. severe depression or bipolar disorder
2. Substance-induced psychosis (cannabis, corticosteroids, opioids, cocaine, amphetamines)
3. Underlying medical condition (e.g. CVD, cerebral tumours, temporal lobe epilepsy, sepsis)
4. PTSD (distinguished by existence of traumatic event and characteristic features such as re-living/re-enacting the event)
5. OCD
6. Autism spectrum disorder (distinguished by deficits in social interaction with repetitive and restricted behaviours)
127
Schizophrenia: How would you assess someone with psychotic symptoms?
1. Medical assessment to look for underlying cause of symptoms
2. Psychiatric assessment
3. Detailed assessment of psychotic symptoms
128
Schizophrenia: What underlying medical cause for psychotic symptoms might you look for on assessment?
1. Prescribed drugs (anticonvulsants, corticosteroids, levodopa and dopamine agonists, opioids)
2. Illicit drugs (amphetamines, cocaine)
3. Temporal lobe epilepsy
4. Cerebrovascular disease
129
Schizophrenia: How is it managed?
1. Therapeutic trial of an oral antipsychotic
+/-
-Family intervention for relatives
-Individual CBT
-Arts therapies
2. Care plan (including a crisis plan, advance statement, and clinical contacts in case of emergency)
3. Regular reviews
130
Schizophrenia: If concordance to medication is an issue, what may be used?
A depot (long-lasting injection)
131
Antipsychotics: Give 8 common side effects of antipsychotic medication
1. EPSEs (FGAs)
2. Hyperprolactinaemia
3. Sexual dysfunction (all SGAs)
4. Weight gain
5. Diabetes mellitus
6. Cardiovascular effects
7. Daytime drowsiness
8. Decreased seizure threshold
132
Depression: Give 5 biological (somatic) symptoms of depression
1. Early morning wakening (3+ hours earlier than usual)
2. Depression worse in the morning
3. Poor appetite, weight loss
4. Psychomotor retardation or agitation
5. Loss of libido
133
Depression: Give 5 cognitive symptoms
1. Reduced concentration and memory
2. Poor self-esteem
3. Guilt
4. Hopelessness
5. Suicidal ideation or self-harm
134
Depression: What is the ICD-10 criteria for a depressive episode?
```
Symptoms should be present for >2 weeks.
>2 of the following core symptoms:
1) Depressed mood
2) Loss of interest and enjoyment
3) Reduced energy/ increased fatiguability
```
```
AND >2 of the following:
Reduced concentration and attention
Reduced self-esteem and self-confidence
Ideas of guilt and unworthiness
Bleak and pessimistic views of the future
Ideas/acts of self-harm or suicide
Disturbed sleep
Diminished appetite
```
135
Depression. Give two biological factors that may predispose someone to depression.
1. Genetics
2. Monoamine theory of depression (reduced monoamine (5-HT, NA, DA) function may cause depression)
3. Endocrinology (dexamethasone test abnormal in 1/3)
4. Structural brain change (ventricular enlargement and raised sucal prominence)
136
Schizophrenia. Give three factors that are associated with poor prognosis.
1) Strong FHx
2) Gradual onset
3) Low IQ
4) Premorbid Hx of social withdrawal
5) Lack of obvious precipitant
137
Depression. What are the 3 core symptoms of depression?
Low mood
Anhedonia
Anergia
138
Depression. What 2 tools may be used to assess degree of depression?
1) Patient Health Questionnaire (PHQ-9)
| 2) Hospital Anxiety and Depression (HAD) scale
139
Antipsychotics. Give some antimuscarinic side-effects of antipsychotics.
Dry mouth
Blurred vision
Urinary retention
Constipation
140
Antipsychotics. How can antipsychotics (haloperidol in particular) affect the heart?
Prolonged QT interval
141
Antipsychotics. How can they affect seizure threshold?
They can reduce seizure threshold
142
Antipsychotics. Give 2 conditions that elderly patients are at greater risk of when on antipsychotics.
1) Stroke
| 2) Venous thromboembolism
143
Antipsychotics. Why should a patient on antipsychotics have regular ECGs?
They can cause prolonged QT interval
144
Antipsychotics. Why can galactorrhea be a side effect?
Dopamine has an inhibitory effect on the secretion of prolactin; inhibition of DA relieves this inhibition, resulting in increased prolactin secretion
145
Suicide. Give 3 factors associated with increased risk of suicide.
```
Male sex
Hx self-harm
Alcohol/drugs
Hx mental illness
Hx chronic disease
Older age
Unemployment/social isolation
Unmarried, divorced, widowed
```
146
Suicide. Give 3 factors associated with increased risk of completed suicide at a later date, following an attempt.
```
Efforts to avoid discovery
Planning
Leaving a note
Sorting out finances, etc
Violent method
```
147
Suicide. Give 3 factors that reduce the risk of a patient committing suicide.
Family support
Having children at home
Religious belief
148
Antidepressants. What is a possible consequence of abruptly stopping an SSRI (eg paroxetine)?
Discontinuation syndrome
149
Antidepressants. Which SSRI has the greatest propensity for causing discontinuation syndrome?
Paroxetine
150
Antidepressants. What are the symptoms of discontinuation syndrome following abruptly stopping an antidepressant?
```
FINISH
Flu-like symptoms
Imbalance (vertigo, ataxia)
Nausea and vomiting
Insomnia
Sweating
H...
(there are lots of possible symptoms)
```
151
Antidepressants. Why is paroxetine more likely to cause discontinuation syndrome when stopped abruptly than another SSRI like fluoxetine?
It has a shorter half-life
152
Depression. Give 2 psychological factors that may predispose someone to depression.
1) Low self-esteem
| 2) Childhood experiences
153
Depression. Give 2 social factors that may predispose someone to depression.
1) Disruption to life events (births, job loss, divorce, illness)
2) Stress associated with poor social environment and social isolation
3) Social drift to lower social class
154
Depression. If someone presented with 2 core + 2/3 other symptoms, what severity of depression would they be classed as having?
Mild
155
Depression. If someone presented with 2 core + 4 other symptoms + functioning affected, what severity of depression would they be classed as having?
Moderate
156
Depression. In severe depression without psychotic symptoms, what would be seen?
Multiplicity of symptoms + suicidal ideation
157
Depression. In severe depression with psychotic symptoms, what would be seen?
Multiplicity of symptoms + mood congruent (nihilistic and guilty delusions, derogatory voices)
158
Depression. How is mild depression managed?
1) Psychosocial interventions: CBT, physical activity programme, etc.
2) Psychological interventions
3) Medication
159
Depression. How is moderate-severe depression managed?
1) Medication
2) Psychological intervention
3) Combined treatments
160
Depression. How is severe depression managed?
1) Medication
2) Psychological interventions
3) Electroconvulsive therapy (ECT)
4) Crisis service
5) Combined treatments
6) MDT
7) Inpatient care
161
According to NICE Guidelines, what are the 3 indications for electroconvulsive therapy (ECT)?
1) Severe Depression
2) Mania (prolonged period)
3) Catatonia
162
Depression. Give 3 risk factors
```
Genetic susceptibility
Alcohol/drug dependence
Abuse (particularly in childhood)
Unemployment
Previous psychiatric diagnosis
Chronic disease
Lack of confiding relationship
Urban population
Post natal
```
163
Depression. Give 3 differentials for 'low mood'
```
Hypothyroidism
Hypopituitarism
Early dementia
Bipolar disorder, Cyclothymia, SAD, etc.
Cancer/terminal diagnosis
```
164
Depression. For the diagnosis of depression, over what time period must the patient have experienced at least 2 of the core symptoms?
2 weeks
165
Depression. What are the key features to ask about in a history?
```
DEAD SWAMP
Depression
Energy levels
Anhedonia
Death (thoughts about death and self harm)
Sleep pattern
Worthlessness
Appetite
Mentation (decreased ability to think and concentrate)
Psychomotor agitation and retardation
```
166
ECT. What are some possible side effects?
```
Memory loss (retrograde and anterograde amnesia)
Confusion
Manic switch
```
167
Bipolar. What are the 3 types?
1) Bipolar 1 disorder
2) Bipolar 2 disorder
3) Rapid cycling bipolar
168
Bipolar. What is Bipolar 1 disorder?
Underlying depression with episodes of mania (1:1 ratio)
169
Bipolar. What is Bipolar 2 disorder?
Depression more predominant; ratio of 5:1 depression to mania
170
What are the main parts of a Mental State Examination?
Appearance (clothes, scars, tattoos)
Behaviour (engagement and rapport, eye contact, psychomotor, general)
Speech (rate, rhythm, tone, answering questions)
Affect (subjective, objective)
Thoughts (form, content (interference or passivity phenomenon, preoccupying thoughts, delusions, obsessions, overvalued ideas)
Perceptions (hallucinations, illusions, depersonalisation)
Cognition (orientation in time, place, person)
Insight
171
Bipolar. What is 'Rapid cycling bipolar'?
>4 episodes/year of mania + depression
172
What is the term for cyclical mood swings with subclinical features?
Cyclothymia
173
Mania. What 3 changes may you see in mood?
Irritability
Euphoria
Lability
174
Mania. What 3 changes might you see in cognition?
```
Grandiosity
Distractibility/poor concentration
Confusion
Flight of ideas
Lack of insight
```
175
Mania. What 3 changes might you see in behaviour?
```
Rapid speech
Hyperactivity
Hypersexuality
Extravagance
Lack of sleep
```
176
Mania. What psychotic symptoms might you see?
Delusions
| Hallucinations (usually second person auditory hallucinations)
177
Mania. How long must the elated mood last in order to be termed mania?
>1 week (or shorter, but requiring admission)
| AND other symptoms must be present
178
Mania. Give 3 types of medications that may cause mania
Steroids
Illicit substances (amphetamines, cocaine)
Antidepressants
179
Mania. Give 3 physical/biological causes of mania
```
Infection
Stroke
Neoplasm
Epilepsy
Multiple sclerosis
Metabolic (hyperthyroidism, adrenal, pituitary)
```
180
Mania. Give 3 things you would ask about in the history
Infections
Drug use
Past/FHx psychiatric disorders
181
Mania. Give 3 investigations you would carry out
CT head
EEG
Screen for drugs/toxins
182
Bipolar. How would you manage an acute manic episode?
First line: atypical antipsychotic (olanzapine, risperidone, quetiapine, clozapine)
Second line: Valproate semisodium (Depakote), lamotrigine, or lithium
183
Bipolar. How would you manage a depressive episode?
AVOID ANTIDEPRESSANTS (can cause rapid cycling mood)
1) Clozapine (useful in rapid cycling)
2) Atypical antipsychotics, anticonvulsants, possible lithium adjunct
3) SSRI may be suitable
184
Bipolar. What is the first line treatment for longer-term control?
Lithium (mood stabiliser)
185
Bipolar. Which gene has been identified as being associated with rapid cycling bipolar disorder?
COMT gene
186
Bipolar. Give 3 risks in mania
Reckless behaviour
Aggression
Promiscuous sex (STIs, pregnancy)
Self-neglect (especially important in e.g. diabetes)
187
Anxiety. What is the definition of neurosis?
Maladaptive psychological symptoms not due to organic causes or psychosis, and usually precipitated by stress
188
Anxiety. Give 6 cognitive symptoms
1) Agitation
2) Feelings of impending doom
3) Poor concentration
4) Insomnia (difficulty getting to sleep)
5) Excessive concern about self and bodily functions
6) Repetitive thoughts and activities
189
Anxiety. Give 3 somatic symptoms
1) Tension
2) Trembling
3) Sense of collapse
4) Hyperventilation (so tinnitus, tetany, tingling)
5) Headaches
6) Sweating
7) Palpitations
8) Nausea
9) Globus hystericus
190
Anxiety. What is 'Globus Hystericus'?
'Lump in throat' unrelated to swallowing
191
Anxiety. What behaviours might you see?
1) Reassurance seeking
2) Avoidance
3) Dependence on person/object
192
Anxiety. What symptoms might you see in a child?
1) Thumb-sucking
2) Nail-biting
3) Bed-wetting
193
Anxiety. Give 7 ways it can be managed
1) Exercise
2) Meditation
3) Progressive relaxation training (deep breathing)
4) CBT and relaxation
5) Behavioural therapy with graded exposure to anxiety-provoking stimuli
6) Hypnosis
7) Medication (SSRI = first line)
194
Anxiety. What appears to be the most effective treatment?
CBT and relaxation
195
Anxiety. What medications may be used to treat anxiety?
First line: SSRI
Benzodiazepines were widely used but can lead to dependence problems.
Buspirone
Beta blocker
196
Anxiolytics. How do benzodiazepines work?
Bind to receptors and increase the amount of GABA released.
197
OCD. What is a compulsion?
Compulsions are thoughts or actions that you feel you must do or repeat. Usually the compulsive act is in response to an obsession. A compulsion is a way of trying to deal with the distress or anxiety caused by an obsession.
198
OCD. What is an obsession?
Obsessions are unpleasant thoughts, images or urges that keep coming into your mind.
199
OCD. How do obsessions in OCD differ from delusional beliefs?
Perceived by the patient as intrusive and non-sensical
200
OCD. How do obsessions in OCD differ from hallucinations or thought insertion?
The patient knows they originate from themselves
201
OCD. What % of people experience OCD in their lifetime?
2-3%
202
OCD. Treatments?
1) CBT (including ERP)
| 2) SSRI, or Clomipramine (a TCA)
203
What is a phobia?
Type of anxiety disorder provoked in certain situations
204
Phobias. Agoraphobia is a common phobia. What is it?
Fear of unfamiliar surroundings (being a long way from home, going to shops, in crowds)
205
Phobias. How can you manage panic attacks?
1) CBT
| 2) SSRI, TCA, pregabalin, clonazepam
206
PTSD. What triggers it?
A particularly stressful event (eg war, assault, rape)
207
PTSD. Give 4 key symptoms
1) Flashbacks (intrusive)
2) Nightmares and sleep disturbance
3) Hypervigilance (overly alert, 'jumpy' and anxious)
4) Poor concentration
Also common: Depression, emotional numbing, substance misuse and anger
208
PTSD. What is avoidance behaviour?
Patients alter their behaviour to avoid triggers of flashbacks, e.g. avoiding visiting parks
209
PTSD. What are the 2 main (first line) treatments?
1) Trauma-focused CBT
| 2) EMDR (eye movement desensitisation and reprocessing)
210
PTSD. What does EMDR stand for?
Eye movement desensitisation and reprocessing
211
PTSD. What does EMDRinvolve?
Pattern of voluntary eye movements, whilst attempting to recall the memory. Sometimes, hand-tapping or another small motor movement is used rather than eye movement
212
PTSD. For patients who are not responding to/are too distressed to use psychological therapy (CBT, EMDR), what is the next step in treatment?
Medication
1) SSRI (paroxetine)
2) TCAs (amitryptiline)
3) Mirtazapine
4) MAOIs (phenelzine)
5) Second generation antipsychotics
213
PTSD. Give 2 factors that contribute to a good prognosis
1) Lack of maladaptive coping strategy (eg denial)
2) Single traumatic event
3) No on-going secondary problems (disfigurement, legal action, acquired disability)
214
Antipsychotics. What are 4 key symptoms of neuroleptic malignant syndrome?
1) Fever
2) Muscle rigidity
3) Delirium
4) Autonomic instability
215
What are the 3 forms of delirium?
1) Hyperactive (agitated and upset)
2) Hypoactive (drowsy and withdrawn)
3) Mixed
216
Delirium. What changes might be seen in cognitive function?
1) Worsened concentration
2) Slow responses
3) Confusion
4) Disorientation in time
217
Delirium. What changes might be seen in perception?
Hallucinations (visual or auditory)
218
Delirium. What changes might be seen in physical function?
1) Reduced mobility
2) Reduced movement
3) Restlessness
4) Agitation
5) Changes in appetite
6) Sleep disturbnce
219
Delirium. What changes might be seen in social behaviour?
1) Lack of cooperation
2) Withdrawal
3) Altered communication/mood/attitude
220
Give 6 differential diagnoses for delirium
1) Withdrawal (alcohol/drugs)
2) Mania
3) Post-ictal
4) Psychosis
5) Anxiety
6) Dementia
221
Delirium. Give 3 investigations you would order
```
U&Es
FBC
Haematinics (B12, folate)
ABG, VBG
Glucose
Cultures (blood, MSU)
LFT
ECG
CXR
LP
```
222
Delirium. Give 3 CNS causes
1) Cerebral tumour/abscess
2) Subdural haematoma
3) Epilepsy
4) Acute post-trauma psychosis
223
Delirium. Give 3 infective causes
1) Meningoencephalitis
2) Septicaemia
3) Cerebral malaria
4) Trypanosomiasis
224
Delirium. Give 3 vascular causes
1) Stroke (/TIA)
2) Hypertensive encephalopathy
3) SLE
225
Delirium. Give 3 metabolic causes
1) Deranged U&Es
2) Hypoxia
3) Liver/kidney failure
4) Cancer (non-metastatic)
5) Porphyria
6) Alcohol withdrawal
226
Delirium. Give 3 endocrine causes
1) Addisonian or hyperthyroid crisis
2) Diabetic pre-coma
3) Hypoglycaemia
4) Hypo/erparathyroidism
227
Delirium. Give 3 toxic causes
1) Alcohol
2) Drugs
3) Arsenic
4) Lead
5) Mercury
228
Delirium. Give 3 deficiencies that can cause delirium
1) Thiamine
2) B12
3) Folate
4) Nicotinic acid
229
Delirium. Give some causes of delirium (using the PINCH ME mnemonic)
```
Pain
INfection
Constipation
Hypoxia and hydration
Medications
Environment/electrolytes
```
230
What is delirium?
An acute confusional state characterised by the rapid onset of a global but fluctuating dysfunction of the CNS, due to an underlying cause
231
Delirium. Give two risks in a hospital patient with delirium
Increased mortality
| Longer hospital stay
232
Delirium. What are the 4 criteria of the Confusion Assessment Method?
1. Acute onset and fluctuating course
2. Inattention
3. Disorganised thinking
4. Altered levels of consciousness
(1 + 2 must be present, with 3 +/or 4)
233
OCD. What is ERP?
Exposure and Response Prevention. Part of CBT: exposes the patient to a situation and prevents repetitive actions
234
What is an acute stress reaction?
Sudden reaction (typically due to an unexpected life crisis) with anxiety, low mood, irritability and other symptoms. It usually settles quickly.
235
What is adjustment disorder?
Anxiety/depression symptoms develop days/weeks after stressful situation, and last a few months
236
What is somatisation?
When physical symptoms are caused by mental or emotional factors
237
Whatare somatoform disorders?
Severe form of somatisation, where symptoms cause distress long-term.
238
Somatoform disorders. Give some examples
1. Somatisation disorder
2. Hypochondriasis
3. Conversion disorder
4. Body dysmorphic disorder
5. Pain disorder
239
Somatoform disorders. What is conversion disorder?
Patient has Sx suggestive of neurological disease
240
Somatoform disorders. How might a patient with conversion disorder present?
1. Total loss of vision
2. Deafness
3. Weakness, paralysis, numbness of arms/legs
241
Antidepressants. For how long after symptoms have eased should a patient continue on an antidepressant?
6 months
242
What are the 3 types of dissociative disorders?
1. Dissociative identity disorder
2. Dissociative amnesia
3. Depersonalisation/Derealisation disorder
243
Mental Health Act. For how long can someone be admitted under Section 2?
28 days (non-renewable)
244
Mental Health Act. For how long can someone be admitted under Section 3?
6 months (can be renewed)
245
What are some key differentials for neuroleptic malignant syndrome?
Serotonin syndrome
Malignant hyperthermia
Recreational drug toxicity (especially cocaine, MDMA)
246
Give 3 causes of neuroleptic malignant syndrome?
1. Use of neuroleptic drugs
2. Withdrawal of anti-Parkinsonian medication
3. Previous episode of NMS
247
Mental Health Act. What is an AMHP?
Approved Mental Health Professional: mental health professionals approved by local social services authority to carry out certain duties under the Mental Health Act
248
Mental Health Act. What is a Section 12 approved doctor?
A doctor trained and qualified in the use of the Mental Health Act 1983, usually a psychiatrist. They may also be a responsible clinician, if the responsible clinician is a doctor.
249
Mental Health Act 1983. What is the purpose of Section 2?
Assessment
250
Mental Health Act. Why would you detain someone under Section 2?
1. They have a mental disorder
| 2. They are a potential danger to themselves or others
251
Mental Health Act. Who do you need to enforce a Section 2?
2 doctors (only one needs to be S12 approved) and 1 AMHP
252
Mental Health Act. Who do you need to enforce a Section 3?
2 doctors (only one needs to be S12 approved) and 1 AMHP
253
Mental Health Act. What additional evidence do you need to enforce a Section 3?
Same as Section 2 plus:
1. Treatment must be in interest of patient's health or safety, or the protection of others
2. Appropriate treatment must be available for the patient
254
Mental Health Act. Who do you need to enforce a Section 4?
1 doctor and 1 AMHP
255
Mental Health Act. How long may someone be detained under Section 4?
72 hours
256
Mental Health Act. What are the criteria for enforcing a Section 4?
Same as section 2
| + not enough time for 2nd doctor to attend (high risk)
257
Mental Health Act. In what setting is a Section 4 often used?
In A&E - it is an emergency order
258
Mental Health Act. How long can you treat someone for without their consent under Section 3?
3 months, then need opinion from second doctor
259
Mental Health Act. How long may someone be detained under Section 5(2)?
72 hours
260
Mental Health Act. Who do you need to enforce a Section 5(2)?
1 doctor
261
Mental Health Act. Who may be sectioned under a Section 5(2)?
Someone who is already admitted
262
Mental Health Act. What is the purpose of a Section 5(2)?
To allow time for Section 2/3 assessment
263
Mental Health Act. How long may someone be detained under Section 5(4)?
6 hours
264
Mental Health Act. Who do you need to enforce a Section 5(4)?
A nurse
265
Mental Health Act. What is the difference between Section 135 and Section 136?
Section 135: in own home
Section 136: in public location
They both allow someone to be held for up to 23 hours
266
Mental Health Act. Who is responsible for sectioning someone under Section 135 or 136?
Police
267
Mental Capacity Act 2005. What is meant by DoLS?
Deprivation of Liberty Safeguards
268
Mental Capacity Act. What are the 3 key elements of DoLS?
1. Best interests
2. Unavoidable
3. Can only be used in care home or hospital; can't be used to take someone out of their own home
269
DOLS. What are the 6 assessment criteria that must be met for a DOLS?
1. Age 18 or over
2. Mental health
3. Capacity
4. Best interests
5. Eligibility
6. No-refusals
