Psychiatry Flashcards
What is akathisia?
A feeling of inner restlessness and inability to stay still
What are the side effects of first generation antipsychotics? (4)
Sedation
Antimuscarinic effects
EPSEs
Hypotension
+ prolonged QT interval
Give examples of EPSEs (4)
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)
Overall, how do antipsychotics work?
Block post-synaptic dopamine D2 receptors
What drug class is Venlafaxine?
SNRI
How should you stop SSRIs eg citalopram, sertraline?
Gradually over 4 weeks
Why are lots of people put on Fluoxetine?
Longer half life so doesn’t matter if they forget to take it / stop taking it suddenly
Which antidepressant would you use in under 18s?
Fluoxetine
What happens 6-12 hours after alcohol withdrawal?
Symptoms - tremor, sweating, tachycardia, anxiety
When is the peak incidence of seizures following alcohol withdrawal?
36 hours
When is the peak incidence of delirium tremens following alcohol withdrawal?
48-72 hours
Describe the course of what happens following alcohol withdrawal
6 hours = symptoms
36 hours = seizures
72 hours = delirium tremens
What are the symptoms of alcohol withdrawal? (4)
Tremor
Sweating
Tachycardia
Anxiety
What are the features of delirium tremens? (6)
Coarse tremor Confusion Delusions Auditory / visual hallucinations Fever Tachycardia
Give the features of SSRI discontinuation syndrome (7)
Mood change Restlessness Difficulty sleeping Unsteadiness Sweating GI stuff - pain, cramps, diarrhoea, vomiting Paraesthesia
What are the risks of using SSRIs in the first trimester of pregnancy?
Congenital heart defects
What are the risks of using SSRI in the third trimester of pregnancy?
Pulmonary hypertension of the newborn
What is the first line management for a patient with delirium tremens?
+ route
Oral lorazepam
What would you do if the symptoms of delirium tremens persist in a patient treated with oral lorazepam
Parenteral lorazepam or haloperidol
What would you need to give to an alcoholic long term
Thiamine - Pabrinex
How do you treat alcohol withdrawal?
Benzodiazepines - reducing regime
Chlordiazepoxide
What are the adverse effects of antipsychotics in the elderly population?
Increased risk of stroke and VTE
What are the 2 features of conversion disorder?
Loss of motor or sensory function
Doesn’t consciously fake the symptoms
What are the risk factors for depression?
Separation / divorce
Adverse life event / loss
Shit childhood - sexual abuse, loss of parent, parental alcoholism
Physical illness
Personality traits - obsessive, impulsive, anxious
What are the core symptoms of depression?
Low mood
Anergia
Anhedonia
What are the non-core symptoms of depression? (other symptoms)
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
How do you make a diagnosis of mild depression?
2 core symptoms
2 other symptoms
Difficulty continuing with normal work + social functioning
How do you make a diagnosis of moderate depression?
2 core symptoms
3 other symptoms
Considerable difficulty in continuing with normal work, social functioning + domestic stuff
How do you make a diagnosis of severe depression?
3 core symptoms
4 other symptoms
With or without psychotic symptoms - different diagnoses
Very limited work / social functioning
How do you treat mild depression?
Psychological therapies
- CBT
- Interpersonal therapy
- Family / marital interventions
- Mindfulness based cognitive therapy
How would you treat moderate or severe depression, first-line?
Psychological therapy
+ SSRI
If there are psychotic symptoms + antipsychotic
What are the options for management of treatment-resistant depression?
Lithium / other antidepressant
ECT
Psych inpatient care
Crisis service
For which conditions is ECT used as a therapy?
Severe, treatment-resistant depression
Severe mania
Catatonia
Schizophrenia
What are the adverse effects of SSRIs?
GI upset GI bleeding (avoid NSAIDs) Appetite and weight changes Hyponatraemia QT prolongation Reduce seizure threshold
What groups of people would you avoid giving SSRIs to?
Peptic ulcers
Arrhythmias
Epilepsy
What is serotonin syndrome? (pathophysiology)
Caused by increased serotonin - overdose of SSRIs or use in combination with other antidepressants Triad - Autonomic hyperactivity - Altered mental state - Neuromuscular excitation
What are the symptoms associated with sudden withdrawal from SSRIs?
Sleep disturbance
GI upset
Neurological signs
Flu-like symptoms
What are tricyclic antidepressants used for?
Depression
Neuropathic pain
What are the side effects of tricyclic antidepressants?
- 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
What groups of people would you be cautious about giving tricyclic antidepressants to?
Elderly Epilepsy Suicidal Arrhythmias Constipation Raised intraocular pressure Prostatic hypertrophy
What are the symptoms associated with tricyclic antidepressant overdose?
Hypotension Arrhythmias Convulsions Coma Respiratory failure
What is bipolar affective disorder?
Depression + mania or hypomania
What are the types of bipolar affective disorder?
Bipolar I = multiple episodes of mania + mixed episodes or one or more episodes of depression
Bipolar II = multiple episodes of depression + hypomania
What is cyclothymia?
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
What are the risk factors for developing bipolar affective disorder?
Female
Younger - average age of onset 21 years
Family history - of bipolar and schizophrenia
How long do symptoms have to be present for someone to have hypomania?
4+ days
How long do symptoms have to be present for someone to have mania?
7+ days
What are the features of hypomania?
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
What are the features of mania?
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
How would you treat a bipolar patient presenting with an acute manic episode?
Give an atypical antipsychotic - haloperidol, olanzapine, risperidone, quetiapine
- -> switch to another
- -> add Lithium
- -> add valproate
- -> ECT
+ STOP ANTIDEPRESSANT (if taking one)
How would you initially treat a bipolar patient presenting with an acute depressive episode?
Psychological therapy
After psychological therapy, what medications would you use in a bipolar patient presenting with a depressive episode?
Check lithium / valproate levels if on this and increase
Then (or if not on treatment):
Fluoxetine + olanzapine
OR quetiapine alone
If a bipolar patient who is on long-term therapy presents with a depressive episode, what would your first-line management be?
If lithium or valproate - check levels and increase to maximum tolerated dose
How would you treat someone with bipolar disease long-term (BEFORE MEDICATION)
Education
Structured psychological interventions
Individualised assessment, help with problem-solving and monitoring thoughts and behaviour
What medical treatments are used for bipolar affective disorder?
Lithium = most effective
Sodium valproate or olanzapine if Lithium not tolerated or unsuitable
What are good prognostic features for bipolar disorder?
Short manic episodes Late onset Fewer suicidal thoughts Few psychotic symptoms Good response to treatment
What are bad prognostic features for bipolar disorder?
Rapid cycling Depressive episodes Alcohol abuse Male sex Non-compliance with treatment
What is the therapeutic range for Lithium plasma concentration?
0.6-1.2mmol/L
When should you measure plasma concentrations of Lithium?
12 hours after last dose
If new dose –> 1 week after they have been on that dose
What are the short term side effects of Lithium use?
Dry mouth Metallic taste Nausea Fine tremor Polydipsia
What are the long term side effects of Lithium use?
Diabetes insipidus Ataxia Weight gain Hypothyroidism Hypokalaemia --> arrhythmias Teratogenicity
If a lady with bipolar disorder becomes pregnant, which medication would you put her on?
Lithium + sodium valproate are both teratogenic
But Lithium less so –> put her on this but make sure to check levels etc more regularly
What baseline tests would you do in someone on Lithium treatment + how often?
General physical including weight U&E LFTs TFTs Pregnancy test Calcium ECG
Every 3 months
(more often if pregnant / on diuretic)
What are the signs of Lithium toxicity?
D&V Visual disturbance Hypokalaemia Ataxia Severe tremor Dysarthria Coma
What level of Lithium would be classed as toxic?
Over 1.5mmol/L
What are the side effects of sodium valproate use?
Valproate (mnemonic) Appetite increase Liver failure Pancreatitis Regrowth of hair curly Oedema Ataxia Teratogenicity / tremor / thrombocytopaenia Encephalopathy
What is a paranoid personality type?
Suspicious
What is a Schizoid personality type?
Cold, emotionless, stays by themselves with no friends, not bothered by criticism or praise
What is an emotionally unstable personality type?
Borderline = attention seeking, in the worst possible way aka pretend to be suicidal, clingy in relationships Impulsive = unpredictable
What is a schizotypal personality disorder?
Schizophrenia basically - ideas of reference, odd beliefs, eccentric, inappropriate affect
What is a dissocial personality disorder?
Needs an ABSO basically
Gets into fights, doesn’t turn up to work, doesn’t pay bills, general dickhead
What is a histrionic personality disorder?
Manic
Inappropriate sexually, wants to be centre of attention, self dramatic, considers relationships to be more intimate than they are
What is a narcissistic personality disorder?
Grandiose, crave compliments, high self importance, manipulative
What is an anankastic personality disorder?
OCD
What is an anxious personality disorder?
Anxious person
What is a dependent personality disorder?
Reckon they are dependent on everyone, can’t do anything by themselves, always need to be in a relationship, can’t make decisions alone
What is an avoidant personality disorder?
Avoid things because they can’t take criticism / think everyone doesn’t like them
Crave social situations but don’t go to them
What are the first rank symptoms (major symptoms) of Schizophrenia?
Thought alienation
Delusions of control or passivity
3rd person auditory hallucinations
Delusional perception
What are the minor symptoms of Schizophrenia?
Other hallucinations ie 2nd person auditory Other delusions Thought disorganisation Catatonia Negative symptoms
How do you make a diagnosis of Schizophrenia?
1 or more major symptoms or 2 or more minor symptoms
Present for most of the time for at least 1 month
How long do symptoms have to be present to make a diagnosis of Schizophrenia?
1 month
How would you treat a first episode of psychosis?
Antipsychotic medication
Psychological intervention - CBT / family therapy
How would you pharmacologically manage someone with psychosis / Schizophrenia?
SGA
Another SGA
FGA
(so 2 non-Clozapine antipsychotics, at least 1 being SGA)
Then Clozapine
What must be taken into consideration when deciding what antipsychotic medication to put someone on?
Sedation needs Patient choice, taking into account: - EPSEs - Metabolic effects eg weight gain - Other side effects
What do the early intervention team aim to do?
Reduce duration of untreated psychosis
Provide the most effective intervention at an early stage
Increase likelihood of re-integration into school / work
Reduce death
How do you make a diagnosis of Schizoaffective disorder?
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
How do you classify Schizoaffective disorder?
Manic type = Prominent elevation of mood + 1 or 2 Schizophrenic symptoms
Depressive type = 2 classical depressive symptoms + 1 or 2 Schizophrenic symptoms
How do you treat Schizoaffective disorder?
As you treat depression / mania / Schizophrenia
What is persistent delusional disorder?
Persistent non-bizarre (not typical schizophrenic) for >3 months
What are the risk factors for developing persistent delusional disorder?
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
What types of delusions would be experienced by a patient with persistent delusional disorder?
Grandiose Persecutory Hypochondriacal Jealousy Erotomanic Somatic
How would you treat someone with persistent delusional disorder?
Psychological therapy
Medication - antipsychotics + SSRI (overlaps with depression)
Separation from focus / source of delusional ideas
What is acute and transient psychosis?
Short-term psychosis - resolves in a few days / weeks / months
Can occur in the context of an acute stressor eg bereavement, marriage, accident, childbirth
What are the risk factors for developing acute and transient psychosis?
Acute stressors - bereavement, marriage, accident, childbirth
Social isolation - so more in developing countries
Certain personality disorders - paranoid, borderline, histrionic
What are the subtypes of acute and transient psychosis?
Broadly with or without the symptoms of schizophrenia
How would you manage a patient with acute and transient psychosis?
Short term admission
Medication - antipsychotics / benzodiazepines / antidepressants
Address specific social issues - supportive psychotherapy
What is generalised anxiety disorder?
Anxiety that is generalised and persistent but not restricted to, or strongly predominating in, any particular environmental circumstances (ie is free-floating anxiety)
What are the symptoms associated with generalised anxiety disorder?
(how do you make a diagnosis)
- 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
What are the physical signs of anxiety (related to generalised anxiety disorder)
Tachycardia
Dyspnoea
Trembling
Exaggerated startle responses
How would you assess a patient with generalised anxiety?
GAD-2 or GAD-7 questionnaires
What are the risk factors associated with a diagnosis of generalised anxiety disorder?
- 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)
How would you treat someone with generalised anxiety disorder?
Manage co-morbidities
Address environmental stressors
Education
CBT or SSRI / SNRI
What is dementia?
Irreversible global cognitive decline that can’t be attributed to a different cause
What is the most common cause of dementia in older people?
Alzheimer’s dementia
What are the symptoms of Alzheimer’s dementia?
4 A's Amnesia Apraxia Agnosia Aphasia
What are the pathophysiological features of Alzheimer’s dementia?
Neurofibrillary tangles
Amyloid plaques
What are the pharmacological treatments for Alzheimer’s dementia?
Acetylcholinesterase inhibitors - Donepizil, Rivastigmine
Antiglutaminergics - Memantine
What are the risk factors for developing Alzheimer’s disease?
Down's syndrome Parkinson's disease Increased age Previous head injury Family history Family history of Down's syndrome or Parkinson's
What are the features of Vascular dementia?
Acute onset
Stepwise deterioration
What would you look for in a patient with vascular dementia (risk factors)?
Hypertension Previous strokes or MI Diabetes + peripheral vascular disease Hypercholesterolaemia Focal CNS signs
What are the features of Lewy body dementia?
Fluctuating in nature Rapid cognitive decline Hallucinations - often visual, of small animals and children REM sleep disorders Frequent falls Later --> parkinsonism
What are the features of fronto-temporal dementia?
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
What are the reversible causes of dementia?
B12 deficiency Pellagra - B3 deficiency Hypothyroidism Thiamine deficiency - alcoholics Syphilis Tumours Normal pressure hydrocephalus Whipple's disease
How would you manage challenging behaviour in a patient with dementia?
Rule out infection / pain as a cause
Trazodone (at night) or Lorazepam
How do you generally treat a patient with dementia?
Advance care planning Monitor physical + mental health Cognitive stimulation Life history etc Routines Pharmacological - for Alzheimer's / vascular Occupational therapy Physiotherapy Social activity / inclusion
What is delirium?
Acute confusional state
What are the features of delirium?
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
What are the causes of delirium?
Infection - UTI, pneumonia, meningitis Metabolic - anaemia, uraemia, electrolyte disturbance Intracranial - head injury, tumour Substance intoxication / withdrawal Hypoxia
How would you assess a patient with delirium?
CAM - confusion assessment method
MOCA
MMSE
Bloods for causes
ECG
EEG?
CXR
Urinalysis
How would you treat a patient with delirium?
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
How would you treat a delirious patient who is severely agitated?
Haloperidol
Lorazepam if they are really bad
What are the complications of delirium?
Infections Pressure sores Falls Functional impairment Continence problems Over-sedation - also leads to falls
What are the features of Wernicke’s encephalopathy?
Confusion
Ataxia
Ophthalmoplegia - nystagmus, 6th nerve
