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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is akathisia?

A

A feeling of inner restlessness and inability to stay still

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2
Q

What are the side effects of first generation antipsychotics? (4)

A

Sedation
Antimuscarinic effects
EPSEs
Hypotension

+ prolonged QT interval

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3
Q

Give examples of EPSEs (4)

A

Acute dystonic reactions (involuntary Parkinsonian movements / muscle spasms)
Akathisia
Neuroleptic malignant syndrome (rigidity, confusion, autonomic dysregulation - life threatening)

After a long time
Tardive dyskinesia (pointless, involuntary, repetitive movements eg lip smacking)
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4
Q

Overall, how do antipsychotics work?

A

Block post-synaptic dopamine D2 receptors

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5
Q

What drug class is Venlafaxine?

A

SNRI

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6
Q

How should you stop SSRIs eg citalopram, sertraline?

A

Gradually over 4 weeks

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7
Q

Why are lots of people put on Fluoxetine?

A

Longer half life so doesn’t matter if they forget to take it / stop taking it suddenly

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8
Q

Which antidepressant would you use in under 18s?

A

Fluoxetine

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9
Q

What happens 6-12 hours after alcohol withdrawal?

A

Symptoms - tremor, sweating, tachycardia, anxiety

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10
Q

When is the peak incidence of seizures following alcohol withdrawal?

A

36 hours

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11
Q

When is the peak incidence of delirium tremens following alcohol withdrawal?

A

48-72 hours

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12
Q

Describe the course of what happens following alcohol withdrawal

A

6 hours = symptoms
36 hours = seizures
72 hours = delirium tremens

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13
Q

What are the symptoms of alcohol withdrawal? (4)

A

Tremor
Sweating
Tachycardia
Anxiety

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14
Q

What are the features of delirium tremens? (6)

A 
Coarse tremor
Confusion
Delusions
Auditory / visual hallucinations
Fever
Tachycardia
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15
Q

Give the features of SSRI discontinuation syndrome (7)

A 
Mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI stuff - pain, cramps, diarrhoea, vomiting
Paraesthesia
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16
Q

What are the risks of using SSRIs in the first trimester of pregnancy?

A

Congenital heart defects

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17
Q

What are the risks of using SSRI in the third trimester of pregnancy?

A

Pulmonary hypertension of the newborn

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18
Q

What is the first line management for a patient with delirium tremens?
+ route

A

Oral lorazepam

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19
Q

What would you do if the symptoms of delirium tremens persist in a patient treated with oral lorazepam

A

Parenteral lorazepam or haloperidol

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20
Q

What would you need to give to an alcoholic long term

A

Thiamine - Pabrinex

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21
Q

How do you treat alcohol withdrawal?

A

Benzodiazepines - reducing regime

Chlordiazepoxide

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22
Q

What are the adverse effects of antipsychotics in the elderly population?

A

Increased risk of stroke and VTE

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23
Q

What are the 2 features of conversion disorder?

A

Loss of motor or sensory function

Doesn’t consciously fake the symptoms

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24
Q

What are the risk factors for depression?

A

Separation / divorce
Adverse life event / loss
Shit childhood - sexual abuse, loss of parent, parental alcoholism
Physical illness
Personality traits - obsessive, impulsive, anxious

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25
Q

What are the core symptoms of depression?

A

Low mood
Anergia
Anhedonia

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26
Q

What are the non-core symptoms of depression? (other symptoms)

A 
Change in appetite
Change in sleep - early waking, slow to get to sleep
Decreased concentration
Suicidal ideation
Loss of libido
Diurnal mood variation
Loss of confidence
Feeling guilty
Hopelessness
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27
Q

How do you make a diagnosis of mild depression?

A

2 core symptoms
2 other symptoms

Difficulty continuing with normal work + social functioning

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28
Q

How do you make a diagnosis of moderate depression?

A

2 core symptoms
3 other symptoms

Considerable difficulty in continuing with normal work, social functioning + domestic stuff

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29
Q

How do you make a diagnosis of severe depression?

A

3 core symptoms
4 other symptoms

With or without psychotic symptoms - different diagnoses
Very limited work / social functioning

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30
Q

How do you treat mild depression?

A

Psychological therapies

  • CBT
  • Interpersonal therapy
  • Family / marital interventions
  • Mindfulness based cognitive therapy
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31
Q

How would you treat moderate or severe depression, first-line?

A

Psychological therapy
+ SSRI
If there are psychotic symptoms + antipsychotic

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32
Q

What are the options for management of treatment-resistant depression?

A

Lithium / other antidepressant
ECT
Psych inpatient care
Crisis service

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33
Q

For which conditions is ECT used as a therapy?

A

Severe, treatment-resistant depression
Severe mania
Catatonia
Schizophrenia

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34
Q

What are the adverse effects of SSRIs?

A 
GI upset
GI bleeding (avoid NSAIDs)
Appetite and weight changes
Hyponatraemia
QT prolongation
Reduce seizure threshold
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35
Q

What groups of people would you avoid giving SSRIs to?

A

Peptic ulcers
Arrhythmias
Epilepsy

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36
Q

What is serotonin syndrome? (pathophysiology)

A 
Caused by increased serotonin - overdose of SSRIs or use in combination with other antidepressants
Triad
- Autonomic hyperactivity
- Altered mental state
- Neuromuscular excitation
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37
Q

What are the symptoms associated with sudden withdrawal from SSRIs?

A

Sleep disturbance
GI upset
Neurological signs
Flu-like symptoms

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38
Q

What are tricyclic antidepressants used for?

A

Depression

Neuropathic pain

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39
Q

What are the side effects of tricyclic antidepressants?

A
  • Dry mouth
  • Constipation
  • Urinary retention
  • Blurred vision
  • Sedation - so give at night
  • Hypotension - falls in the elderly
    + arrhythmias and ECG changes - prolonged QT and QRS
    + can cause convulsions, hallucinations, mania
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40
Q

What groups of people would you be cautious about giving tricyclic antidepressants to?

A 
Elderly
Epilepsy
Suicidal 
Arrhythmias
Constipation
Raised intraocular pressure
Prostatic hypertrophy
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41
Q

What are the symptoms associated with tricyclic antidepressant overdose?

A 
Hypotension
Arrhythmias
Convulsions
Coma
Respiratory failure
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42
Q

What is bipolar affective disorder?

A

Depression + mania or hypomania

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43
Q

What are the types of bipolar affective disorder?

A

Bipolar I = multiple episodes of mania + mixed episodes or one or more episodes of depression

Bipolar II = multiple episodes of depression + hypomania

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44
Q

What is cyclothymia?

A

Persistent instability of mood - numerous periods of mild depression and mild elation, not sufficiently severe or prolonged to fulfil the criteria for bipolar affective disorder or recurrent depressive disorder

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45
Q

What are the risk factors for developing bipolar affective disorder?

A

Female
Younger - average age of onset 21 years
Family history - of bipolar and schizophrenia

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46
Q

How long do symptoms have to be present for someone to have hypomania?

A

4+ days

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47
Q

How long do symptoms have to be present for someone to have mania?

A

7+ days

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48
Q

What are the features of hypomania?

A 
Decreased concentration
Hyperactivity / increased energy
Elevated mood
Increased self-confidence / ideas of self-worth (confidence)
Spending more money
Sexual disinhibition
Sociability
Talkativeness
Reduced sleep
Reduced appetite
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49
Q

What are the features of mania?

A 
Extreme elation
Hyperactivity
Flight of ideas / pressure of speech
Grandiosity
Social disinhibition
Inappropriate sexual encounters
Overfamiliarity
Very reduced sleep
Decreased concentration
Extreme risk taking / reckless behaviour
Hyperacusis

Can have psychotic symptoms

Marked effects on work + life

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50
Q

How would you treat a bipolar patient presenting with an acute manic episode?

A

Give an atypical antipsychotic - haloperidol, olanzapine, risperidone, quetiapine

  • -> switch to another
  • -> add Lithium
  • -> add valproate
  • -> ECT

+ STOP ANTIDEPRESSANT (if taking one)

51
Q

How would you initially treat a bipolar patient presenting with an acute depressive episode?

A

Psychological therapy

52
Q

After psychological therapy, what medications would you use in a bipolar patient presenting with a depressive episode?

A

Check lithium / valproate levels if on this and increase

Then (or if not on treatment):
Fluoxetine + olanzapine
OR quetiapine alone

53
Q

If a bipolar patient who is on long-term therapy presents with a depressive episode, what would your first-line management be?

A

If lithium or valproate - check levels and increase to maximum tolerated dose

54
Q

How would you treat someone with bipolar disease long-term (BEFORE MEDICATION)

A

Education
Structured psychological interventions
Individualised assessment, help with problem-solving and monitoring thoughts and behaviour

55
Q

What medical treatments are used for bipolar affective disorder?

A

Lithium = most effective

Sodium valproate or olanzapine if Lithium not tolerated or unsuitable

56
Q

What are good prognostic features for bipolar disorder?

A 
Short manic episodes
Late onset
Fewer suicidal thoughts
Few psychotic symptoms
Good response to treatment
57
Q

What are bad prognostic features for bipolar disorder?

A 
Rapid cycling
Depressive episodes
Alcohol abuse
Male sex
Non-compliance with treatment
58
Q

What is the therapeutic range for Lithium plasma concentration?

A

0.6-1.2mmol/L

59
Q

When should you measure plasma concentrations of Lithium?

A

12 hours after last dose

If new dose –> 1 week after they have been on that dose

60
Q

What are the short term side effects of Lithium use?

A 
Dry mouth
Metallic taste
Nausea
Fine tremor
Polydipsia
61
Q

What are the long term side effects of Lithium use?

A 
Diabetes insipidus
Ataxia
Weight gain
Hypothyroidism
Hypokalaemia --> arrhythmias
Teratogenicity
62
Q

If a lady with bipolar disorder becomes pregnant, which medication would you put her on?

A

Lithium + sodium valproate are both teratogenic

But Lithium less so –> put her on this but make sure to check levels etc more regularly

63
Q

What baseline tests would you do in someone on Lithium treatment + how often?

A 
General physical including weight
U&E
LFTs
TFTs
Pregnancy test
Calcium
ECG

Every 3 months
(more often if pregnant / on diuretic)

64
Q

What are the signs of Lithium toxicity?

A 
D&V
Visual disturbance
Hypokalaemia
Ataxia
Severe tremor
Dysarthria
Coma
65
Q

What level of Lithium would be classed as toxic?

A

Over 1.5mmol/L

66
Q

What are the side effects of sodium valproate use?

A 
Valproate (mnemonic)
Appetite increase
Liver failure
Pancreatitis
Regrowth of hair curly
Oedema
Ataxia
Teratogenicity / tremor / thrombocytopaenia
Encephalopathy
67
Q

What is a paranoid personality type?

A

Suspicious

68
Q

What is a Schizoid personality type?

A

Cold, emotionless, stays by themselves with no friends, not bothered by criticism or praise

69
Q

What is an emotionally unstable personality type?

A 
Borderline = attention seeking, in the worst possible way aka pretend to be suicidal, clingy in relationships
Impulsive = unpredictable
70
Q

What is a schizotypal personality disorder?

A

Schizophrenia basically - ideas of reference, odd beliefs, eccentric, inappropriate affect

71
Q

What is a dissocial personality disorder?

A

Needs an ABSO basically

Gets into fights, doesn’t turn up to work, doesn’t pay bills, general dickhead

72
Q

What is a histrionic personality disorder?

A

Manic
Inappropriate sexually, wants to be centre of attention, self dramatic, considers relationships to be more intimate than they are

73
Q

What is a narcissistic personality disorder?

A

Grandiose, crave compliments, high self importance, manipulative

74
Q

What is an anankastic personality disorder?

A

OCD

75
Q

What is an anxious personality disorder?

A

Anxious person

76
Q

What is a dependent personality disorder?

A

Reckon they are dependent on everyone, can’t do anything by themselves, always need to be in a relationship, can’t make decisions alone

77
Q

What is an avoidant personality disorder?

A

Avoid things because they can’t take criticism / think everyone doesn’t like them
Crave social situations but don’t go to them

78
Q

What are the first rank symptoms (major symptoms) of Schizophrenia?

A

Thought alienation
Delusions of control or passivity
3rd person auditory hallucinations
Delusional perception

79
Q

What are the minor symptoms of Schizophrenia?

A 
Other hallucinations ie 2nd person auditory
Other delusions
Thought disorganisation
Catatonia
Negative symptoms
80
Q

How do you make a diagnosis of Schizophrenia?

A

1 or more major symptoms or 2 or more minor symptoms

Present for most of the time for at least 1 month

81
Q

How long do symptoms have to be present to make a diagnosis of Schizophrenia?

A

1 month

82
Q

How would you treat a first episode of psychosis?

A

Antipsychotic medication

Psychological intervention - CBT / family therapy

83
Q

How would you pharmacologically manage someone with psychosis / Schizophrenia?

A

SGA
Another SGA
FGA
(so 2 non-Clozapine antipsychotics, at least 1 being SGA)

Then Clozapine

84
Q

What must be taken into consideration when deciding what antipsychotic medication to put someone on?

A 
Sedation needs
Patient choice, taking into account:
- EPSEs
- Metabolic effects eg weight gain
- Other side effects
85
Q

What do the early intervention team aim to do?

A

Reduce duration of untreated psychosis
Provide the most effective intervention at an early stage
Increase likelihood of re-integration into school / work
Reduce death

86
Q

How do you make a diagnosis of Schizoaffective disorder?

A

Symptoms of an affective disorder and Schizophrenia in about equal proportions - meet criteria for manic / depressive episode, and 1 or more symptoms of Schizophrenia
In the same episode of illness - not separate episodes
Episodes not in the context of substance abuse or another mental health disorder

87
Q

How do you classify Schizoaffective disorder?

A

Manic type = Prominent elevation of mood + 1 or 2 Schizophrenic symptoms
Depressive type = 2 classical depressive symptoms + 1 or 2 Schizophrenic symptoms

88
Q

How do you treat Schizoaffective disorder?

A

As you treat depression / mania / Schizophrenia

89
Q

What is persistent delusional disorder?

A

Persistent non-bizarre (not typical schizophrenic) for >3 months

90
Q

What are the risk factors for developing persistent delusional disorder?

A 
Advanced age
Low socioeconomic status
Premobid personality disorder
Sensory impairment, especially deafness
Recent immigration
Family history
History of head injury
History of substance abuse 
Social situations:
- Jealousy
- Distrust
- Isolation
- Low self-esteem

Acutely = stress

91
Q

What types of delusions would be experienced by a patient with persistent delusional disorder?

A 
Grandiose
Persecutory
Hypochondriacal
Jealousy
Erotomanic
Somatic
92
Q

How would you treat someone with persistent delusional disorder?

A

Psychological therapy
Medication - antipsychotics + SSRI (overlaps with depression)
Separation from focus / source of delusional ideas

93
Q

What is acute and transient psychosis?

A

Short-term psychosis - resolves in a few days / weeks / months
Can occur in the context of an acute stressor eg bereavement, marriage, accident, childbirth

94
Q

What are the risk factors for developing acute and transient psychosis?

A

Acute stressors - bereavement, marriage, accident, childbirth
Social isolation - so more in developing countries
Certain personality disorders - paranoid, borderline, histrionic

95
Q

What are the subtypes of acute and transient psychosis?

A

Broadly with or without the symptoms of schizophrenia

96
Q

How would you manage a patient with acute and transient psychosis?

A

Short term admission
Medication - antipsychotics / benzodiazepines / antidepressants
Address specific social issues - supportive psychotherapy

97
Q

What is generalised anxiety disorder?

A

Anxiety that is generalised and persistent but not restricted to, or strongly predominating in, any particular environmental circumstances (ie is free-floating anxiety)

98
Q

What are the symptoms associated with generalised anxiety disorder?
(how do you make a diagnosis)

A
  • Persistent nervousness
    • Trembling
    • Muscular tensions
    • Sweating
    • Lightheadedness
    • Palpitations
    • Dizziness
    • Epigastric discomfort (and other physical manifestations eg headaches –> so is important to check for this if the patient has chronic pain of any sort that they are repeatedly presenting to primary care for)
      + often express fears that the patient or a relative will shortly become ill or have an accident

apprehensive on most days for 6 months

99
Q

What are the physical signs of anxiety (related to generalised anxiety disorder)

A

Tachycardia
Dyspnoea
Trembling
Exaggerated startle responses

100
Q

How would you assess a patient with generalised anxiety?

A

GAD-2 or GAD-7 questionnaires

101
Q

What are the risk factors associated with a diagnosis of generalised anxiety disorder?

A
  • Female sex
  • Family history of anxiety
  • Current physical or emotional stress
  • History of physical or emotional trauma
  • History of other anxiety disorders eg panic disorder, social phobia or specific phobias
  • Chronic pain or physical illness (eg arthritis, cancer, coronary heart disease, cerebrovascular accident, COPD) - History of substance abuse
  • Repeated visits with the same physical symptoms which do not respond to treatment (eg insomnia, headache, fatigue)
102
Q

How would you treat someone with generalised anxiety disorder?

A

Manage co-morbidities
Address environmental stressors
Education
CBT or SSRI / SNRI

103
Q

What is dementia?

A

Irreversible global cognitive decline that can’t be attributed to a different cause

104
Q

What is the most common cause of dementia in older people?

A

Alzheimer’s dementia

105
Q

What are the symptoms of Alzheimer’s dementia?

A 
4 A's
Amnesia
Apraxia
Agnosia
Aphasia
106
Q

What are the pathophysiological features of Alzheimer’s dementia?

A

Neurofibrillary tangles

Amyloid plaques

107
Q

What are the pharmacological treatments for Alzheimer’s dementia?

A

Acetylcholinesterase inhibitors - Donepizil, Rivastigmine

Antiglutaminergics - Memantine

108
Q

What are the risk factors for developing Alzheimer’s disease?

A 
Down's syndrome
Parkinson's disease
Increased age
Previous head injury
Family history
Family history of Down's syndrome or Parkinson's
109
Q

What are the features of Vascular dementia?

A

Acute onset

Stepwise deterioration

110
Q

What would you look for in a patient with vascular dementia (risk factors)?

A 
Hypertension
Previous strokes or MI
Diabetes + peripheral vascular disease
Hypercholesterolaemia
Focal CNS signs
111
Q

What are the features of Lewy body dementia?

A 
Fluctuating in nature
Rapid cognitive decline
Hallucinations - often visual, of small animals and children
REM sleep disorders
Frequent falls
Later --> parkinsonism
112
Q

What are the features of fronto-temporal dementia?

A

Personality change - apathy, disinhibition, emotional blunting, coarsening of sociability
Language changes
Intellectual functioning
Initially memory stuff / orientation preserved - distinguishing feature from Alzheimer’s, but can be lost later

113
Q

What are the reversible causes of dementia?

A 
B12 deficiency
Pellagra - B3 deficiency
Hypothyroidism
Thiamine deficiency - alcoholics
Syphilis
Tumours
Normal pressure hydrocephalus
Whipple's disease
114
Q

How would you manage challenging behaviour in a patient with dementia?

A

Rule out infection / pain as a cause

Trazodone (at night) or Lorazepam

115
Q

How do you generally treat a patient with dementia?

A 
Advance care planning
Monitor physical + mental health
Cognitive stimulation
Life history etc
Routines
Pharmacological - for Alzheimer's / vascular
Occupational therapy
Physiotherapy
Social activity / inclusion
116
Q

What is delirium?

A

Acute confusional state

117
Q

What are the features of delirium?

A 
Impaired consciousness
Impaired cognitive function
- Short term memory and recent memory loss
- Relative preservation of remote memory
- Disorientated to time and place 
- Language abnormalities eg rambling, incoherent speech, impaired ability to understand
Perceptual and thought disturbance
Sleep-wake cycle disturbance
Mood disturbance
118
Q

What are the causes of delirium?

A 
Infection - UTI, pneumonia, meningitis
Metabolic - anaemia, uraemia, electrolyte disturbance
Intracranial - head injury, tumour
Substance intoxication / withdrawal
Hypoxia
119
Q

How would you assess a patient with delirium?

A

CAM - confusion assessment method
MOCA
MMSE

Bloods for causes

ECG
EEG?
CXR
Urinalysis

120
Q

How would you treat a patient with delirium?

A

Identify / treat the cause and precipitating factors
Make the environment safe
Optimise stimulation - lighting, reduce noise, mobilise, hearing aid, glasses
Orientation techniques - same staff, big clock, newspapers with the date on

121
Q

How would you treat a delirious patient who is severely agitated?

A

Haloperidol

Lorazepam if they are really bad

122
Q

What are the complications of delirium?

A 
Infections
Pressure sores
Falls
Functional impairment
Continence problems
Over-sedation - also leads to falls
123
Q

What are the features of Wernicke’s encephalopathy?

A

Confusion
Ataxia
Ophthalmoplegia - nystagmus, 6th nerve

Phase 3a (11 decks)

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