Psychiatry Flashcards
1
Q
Criteria for diagnosis of Generalised Anxiety Disorder
A
6+ months of excessive worry about everyday issues, disproportionate to any inherent risk, causing distress or impairment
Worry is not confined to features of another mental illness, caused by substance abuse or other medical condition
3+ of the following present most of the time: Restlessness or nervousness, Easily fatigued, Irritability, Muscle tension, Sleep disturbance
2
Q
Hypochondriasis
A
Obsessions and compulsions related to illness. Researching symptoms or checking if you have a condition.
3
Q
Simple phobia
A
Excessive or unreasonable psychological or autonomic response to a feared object or situation leading to avoidance.
5 subtypes are recognised: animals, aspects of natural environment, blood/injection/injury, situational (below), other.
4
Q
Social Phobia
A
Comorbid with low self esteem
Not secondary to delusional or obsessive thoughts and are restricted to particular social situations.
5
Q
Agoraphobia
A
Fear of going out. Anxiety related to places or situations where escape may be difficult or embarrassing. Leads to avoidance.
6
Q
Pathology of PTSD
A
Hyperactive amygdala
Hypoactive prefrontal cortex
7
Q
Panic Disorder
A
Extreme anxiety characterised by several severe attacks in one month. Experience fear of dying or losing control.
Physical symptoms e.g. nausea, abdominal pain, dizziness, paraesthesias, muscle shaking
8
Q
Differentials for Generalised Anxiety Disorder
A
Other anxiety disorder Depression Cardiac arrhythmia Hyperthyroidism Infections Substance misuse
9
Q
Management of Generalised Anxiety disorder
A
SSRIs e.g. Sertraline, escitalopram AND/OR CBT
Adjuncts: Benzodiazepines
Applied relaxation, Meditation training, Sleep hygiene education, Exercise, Self-help
10
Q
Management of Simple Phobia
A
CBT with graded exposure
+/- applied tension and benzodiazepines if vasovagal syncope
11
Q
Management of Acute Panic Attacks
A
Reassurance
Benzodiazepine
+/- Beta blockers
12
Q
Management of Panic Disorder
A
CBT +/- SSRIs
Reassurance, benzodiazepine +/- Beta blocker for acute episodes
13
Q
Obsessive Compulsive Disorder
A
Recurrent obsessional thoughts or compulsive acts functioning to prevent some objectively unlikely event.
14
Q
Obsessive thoughts
A
Ideas, images or impulses that enter the patient’s mind again and again in a stereotyped form
15
Q
Compulsive acts
A
Stereotyped behaviours that are repeated again and again
16
Q
Management of OCD
A
CBT +/- SSRIs
17
Q
Criteria for PTSD diagnosis
A
History of exposure to or threat of death, serious injury, sexual violence
- Reexperiencing: flashbacks, intrusive images, nightmares
- Avoidance symptoms: socially and of similar events
- Hyperarousal
- Emotional numbing - unable to laugh or feel the same about things as they did before the event
18
Q
Management of PTSD
A
Watchful waiting and follow up in 1 month OR
Trauma focused CBT +/- SSRIs (emotional stabilisation therapy may be necessary beforehand as difficulty engaging with CBT)
Eye movement desensitisation and reprocessing (EMDR) +/- SSRIs
19
Q
BPAD affects males more than females - true or false?
A
False - males and females are affected equally
20
Q
A patient with known BPAD has an elevated mood with difficulty sleeping and hypersexuality for 3 days. She continues going to work during this time.
Mania or hypomania?
A
Hypomania
21
Q
A patient with known BPAD has an elevated mood causing him to walk around naked in the street. He reports auditory hallucinations.
Mania or hypomania?
A
Mania
22
Q
Hypomania lasts for…
A
Around 4 days
23
Q
Mania lasts for…
A
At least 7 days
24
Q
Features of hypomania
A
Elevated mood
Increased energy/self esteem/libido/quantity of speech
Loss of concentration
Reduced sleep
25
Hypomania is seen in which form of BPAD
BPAD Type II
26
Mania is seen in which form of BPAD
BPAD Type I
27
Major depressive episodes are seen in which form of BPAD
BPAD Type II
28
Criteria for diagnosis of BPAD Type I
Presence of 1+ manic episode:
For 7+ days
Features present most of the day, most days
Mania cannot be attributed to drug misuse or any other medical condition
29
Criteria for diagnosis of BPAD Type II
1+ hypomanic episode AND 1+ depressive episode
No psychosis (if psychosis is present, it must be mania)
Cannot be attributed to substance misuse or general medical condition
30
Criteria for diagnosis of Cyclothymia
1+ hypomanic and depressive episode over 2 years or more.
| Symptoms not severe enough to meet BPAD criteria
31
Physical health conditions associated with mania
Wilson's disease
| HIV
32
Screening required for initiation of lithium
FBC
U&Es - lithium is excreted from kidneys and can interfere with function
TFTs - for baseline as lithium can affect thyroid function (hyper OR hypo)
BhCG - lithium is contra’d in 1st trimester
ECG - rule out cardiac problems before treatment
33
Monitoring required in patients on Lithium treatment
Lithium level is checked 5 days after initiating
They are then measured weekly until they have been stable for 4 weeks
They are then measured 3 monthly
TFT, U&E and Ca2+ monitored 6 monthly
34
ADRs of Lithium
Common: GI upset, N&V, weight gain, metallic taste in mouth
Notable: Hypothyroidism
Serious: Long QT syndrome
35
Signs and symptoms of Lithium toxicity
```
GI upset
Tremor
Hyperreflexia
Confusion
Seizure
Coma
```
36
Separation anxiety
3-4% of 5-11 year olds. Often cling to the person and express fear of them being harmed or not returning. Often occurs after death of a loved one or family pet.
37
Management of depression in children
CBT and family therapy are first line.
Fluoxetine is the only drug licensed in under 18s
38
Criteria for diagnosis of ADHD
```
Inattention
Hyperactivity
Impulsivity
Before 7 years old
Pervasive
```
MDT diagnosis - behaviours must be present at all times i.e. school and home
39
Management of ADHD
First line: Psychoeducation
+/- Behavioural treatment - parental training, effective timeouts, school plan
+/- Methylphenidate
40
MOA of Methylphenidate
Dopamine uptake and transport inhibitor
41
ADRs of Methylphenidate
```
Poor appetite
Reduced growth
Insomnia
Tics
Headaches
```
42
Conditions associated with Autism Spectrum Disorder
Fragile X
Tuberous Sclerosis
Down's syndrome
43
Criteria for diagnosis of ASD
Reciprocal social interaction - playing alone
Difficulty with communication - language delay
Restricted, repetitive, stereotyped patterns of interest - repetitive language, habitual
Onset before 3 yrs
Pervasive
MDT assessment
44
Management of ASD
Family support
Treat comorbidities
Manage behaviour - Applied Behaviour Analysis used in children 2-3 years to reinforce behaviour and dissuade negative behaviour.
45
Secure attachment
Child values relationships and is confident in their own self-worth
46
Insecure avoidant attachment
Appears emotionally independent, does not value relationships.
47
Insecure anxious attachment
Self-worth depends on approval of others. Values relationships but finds them unreliable. Develops strategies for achieving attention.
48
Insecure ambivalent attachment
Values relationships but is insecure about their safety
49
Disorganised attachment
Neither self-sufficient nor able to use relationships
50
Patient complains of low mood for the last 3 months and being unable to enjoy her hobbies.
She is starting to lose concentration at work and has been waking up in the early hours of the morning
Mild depression
51
Patient complains of low mood for the last 2 months and feeling very tired, often unable to get out of bed.
He has lost weight as he doesn't think he has been eating much.
He is starting to feel guilty and hopeless about the future
Moderate depression
52
Patient complains of low mood for the last 3 months. She no longer enjoys her work and feels tired all the time.
She rarely gets more than 4 hours sleep, has been pulled up at work for making mistakes and has started to consider suicide
Severe depression
53
Cotard's syndrome
Delusional belief that they are dead
54
Atypical depression
Increased sleep
Increased appetite
Phobic anxiety
55
Management of atypical depression
MAO-I > SSRIs
56
Investigations which may suggest an organic cause for depressive symptoms
```
FBC
TFTs
24 hr free cortisol
Vitamin B12
Folic acid
```
57
SAD PERSONS score
Determines suicide risk:
```
Sex: Male
Age <19 or >45
Depression or hopelessness
Previous attempt or psychiatric care
Excessive drinking or drugs
Rational thinking loss
Social isolation
Organised plan
No spouse
Sickness
```
58
Examples of TCA
Amitriptyline, Clomipramine
59
MOA of TCAs
5-HT and NA reuptake inhibition
60
TCAs with sedative effects
Amitriptyline, Clomipramine
61
TCAs without sedative effects
Imipramine, Nortriptyline
62
Common ADRs of TCAs
Cholinergic - dry mouth, constipation, blurred vision,
Alpha blockade: Dizziness, Hypotension
63
Serious ADRs of TCAs
long QT syndrome
64
Contraindications for TCAs
Arrhythmia
Mania
Medications: adrenergic vasoconstrictors, barbiturates, paracetamol
65
Preferred SSRI post-MI
Sertraline
66
Paroxetine is contraindicated in...
Pregnancy - caused congenital malformations
67
Common ADRs of SSRIs
GI upset
| Increased anxiety and agitation
68
Notable ADRs of SSRIs
Insomnia
Sexual dysfunction - anorgasmia, ED, low libido
Increased risk of bleeding - particularly GI bleeds
69
Serious ADRs of SSRIs
```
Suicidal ideation
Long QT syndrome
Hyponatraemia (SIADH)
Teratogenic
Discontinuation syndrome
Serotonin syndrome
```
70
SSRI most associated with Long QT syndrome
Citalopram
71
Hyponatraemia is most likely to occur in which patients taking SSRIs?
Women
> 80 yrs
Renal impairment
On medications which disrupt Na+
72
SSRIs disrupt metabolism of which drugs?
Codeine
benzoiazepines
Erythromycin
NSAIDs/Aspirin/Warfarin/Heparin - increased risk of bleeding
73
Examples of NRIs
Reboxetine
| Atomoxetine
74
Examples of SNRIs
Venlafaxine
| Duloxetine
75
Examples of MAOIs
Moclobemide
76
Common ADRs of MAOIs
Dry mouth
Drowsiness
Constipation
77
Notable ADRs of MAOIs
Hypotension
Weight gain
Insomnia
78
Serious ADRs of MAOIs
Hypertensive crisis when eating tyramine containing foods e.g. cheese, wine, marmite
Serotonin syndrome
79
Contraindications for MAOIs
CVD
Phaeochromocytoma
Thyrotoxicosis
BPAD
80
MOA of Bupropion
Inhibits dopamine and noradrenaline reuptake
81
Common ADRs of Bupropion
```
Headache
Dry mouth
Tachycardia
Palpitations
Mild HTN
```
82
Notable ADRs of Bupropion
Insomnia
| Weight loss
83
Serious ADRs of Bupropion
Reduces seizure threshold
| Depression, mania, psychosis, paranoia
84
Contraindications of Bupropion
Alcohol or benzodiazepine withdrawal (risk of seizures)
Epilepsy
BPAD
Liver cirrhosis
85
MOA of Mirtazapine
Alpha 2, 5HT2a and 5HT3 antagonist
86
Antidepressant with the lowest incidence of sexual side effects
Mirtazepine
87
Common ADRs of Mirtazepine
Increased appetite
Weight gain
Sedation (H1 antagonist)
Dry mouth
88
What percentage of patients taking antidepressants experience sexual side effects?
70%
89
What is ECT?
Patient is given a local anaesthetic and muscle relaxant in a safe environment. An electrical current is passed through the brain, inducing a small seizure.
90
Indications for ECT
```
Treatment resistant depression.
BPAD
Mania
Schizophrenia
Psychotic Depression
```
91
Side effects of ECT
Short term: headache, nausea, short term memory problems, cardiac arrhythmias
Long term: Memory problems
92
Contraindications for ECT
Raised ICP
93
Criteria for diagnosis with anorexia nervosa
Deliberate weight loss which is induced and sustained by patient
Overvalued ideas of dreading fat/flabbiness
Distorted body image & reliance on weight for self-esteem
BMI < 18
Amenorrhoea - 3 periods missed
94
Symptoms of anorexia
```
Sensitivity to cold
GI symptoms
Dizziness
Amenorrhoea
Poor sleep
```
95
Signs of anorexia
```
Emaciation
Cold extremities
Dry skin
Downy body hair
↓ secondary sexual features
Bradycardia
Postural hypotension
Arrhythmias
Peripheral oedema
Proximal myopathy
```
96
Hormone changes in anorexia nervosa
↓ LH, FSH, oestadiol and T3
| ↑ cortisol and GH
97
Electrolyte changes in anorexia nervosa
↓ K+, ↓ Na+ and met. alkalosis
98
FBC in anorexia nervosa
↓ WCC and platelets
99
Cholesterol in anorexia nervosa
Hypercholesterolaemia
100
Patient with BMI of 14 has a metabolic acidosis due to...
Laxatives
101
Patient with BMI of 16 has a metabolic alkalosis due to...
Vomiting
102
SCOFF Questionnaire
Used to establish anorexia diagnosis.
```
Do you ever:
Make yourself sick?
Feel like you have lost control of your eating?
Lost one stone in 3 months?
Believed you are fat?
Feel like food dominates your life?
```
103
Investigations for low BMI, suspected eating disorder
FBC
U&E
Glu
LFT
TFT
Bone profile
Nutritional bloods +/- Glc, phosphate, K+, Mg2+
ABG: met acidosis associated with laxative use, met alkalosis associated with vomiting
Consider ECG if there are electrolyte abnormalities
104
Differentials for BMI < 18
Anorexia/Bulimia/EDNOS
Depression
OCD
```
T1DM
Hyperthyroidism
IBD
Neoplasm
Infection
```
105
Management of Anorexia Nervosa
First line: structured eating plan with oral nutrition + psychotherapy (1 year CBT, 50% success rate, family therapy used in children & adolescents) +/- potassium chloride supplementation
For medically unstable patients:
Inpatient admission +/- oral/enteral/parenteral nutrition
Fluid correction
Repletion of electrolytes
106
Complications of Anorexia Nervosa
Osteoporosis
Death from arrhythmias
Renal Failure
Refeeding syndrome
107
Pathology of refeeding syndrome
Sudden shift from catabolic to anabolic metabolism
108
Electrolyte abnormalities in refeeding syndrome
↓ Phosphate
↓ K+
↓ Mg2+
109
Mortality in Anorexia Nervosa
10-15% (⅔ physical complications, ⅓ suicide)
110
Prevention of refeeding syndrome
If a patient hasn’t eaten for > 5 days, refeed at no more than 50% of requirements for the first 2 days.
111
Criteria for Bulimia Nervosa
Recurrent episodes of overeating (2+/week over 3 months)
Persistent preoccupation with eating + strong desire/compulsion to eat
Attempts to counteract food by: Self-induced vomiting/purging, Alternating periods of starvation, Use of drugs e.g. appetite suppressants, thyroid preparations, diuretics, neglecting insulin if DM
Self perception of being too fat (dread fatness)
112
Russel's sign
Calluses on back of knuckles
113
Patient has a BMI of 16 and reports regular episodes of over eating followed by use of laxatives and self-induced vomiting.
What is the diagnosis?
Anorexia nervosa.
BMI < 18 is always Anorexia Nervosa, regardless of binging or purging.
114
Management of Bulimia Nervosa
5 months CBT, 70% will recover using this treatment
+/- Nutritional and meal support
+/- SSRI/SNRI
115
Electrolyte disturbance caused by self-induced vomiting
Hypokalaemia
116
Definition of learning disability
IQ < 70
| Onset before age of 18 yrs
117
Definition of Mild Learning Disability
IQ 50-69
Mental age 9-12
80% of LD population
118
Definition of Moderate Learning Disability
IQ 35-49
Mental Age 6-9
0.3% of LD population
119
Definition of severe Learning Disability
IQ 20-34
Mental age 3-6
7% of LD population
120
Definition of Profound Learning Disability
IQ < 20
Mental age < 3
1% of LD population
121
Prenatal factors associated with learning disability
Infections e.g. Congenital Syphilis and Rubella
Trauma
Anoxia
X-rays
Endocrine disorders (Hyperthyroid during pregnancy)
Teratogens
122
Perinatal factors associated with learning disability
Prematurity
Asphyxiation - prolonged labour, cord strangulation
Trauma e.g. forceps delivery
123
Postnatal factors associated with learning disability
```
Infection
Trauma - Head injury inc. shaken baby syndrome
Toxic agents
Nutrition
Sensory & social deprivation
Untreated conditions
```
124
Signs of Down's Syndrome at birth
```
Epicanthal folds
Upslanting, palpebral fissures
Brushfield spots of iris
Low-set, small ears
Single palmar crease
Wide space between 1st and 2nd toes
Hypotonia at birth
```
125
Chronic diseases associated with Down's Syndrome
Chronic diseases: Thyroid, DM, Epilepsy, Cardiovascular
| Psychiatric: Depression, Anxiety, OCD, ASD, Dementia (early - 40s, peak intellect at 12-13) - brain ages quicker.
126
Screening of newborns with Down's Syndrome
Echocardiogram recommended in all newborns with DS.
Hearing test
TFTs
Vision examination (4% are born with congenital cataracts)
127
Monitoring of patients with Down's syndrome
Annual Hb from 1 year old. Lower intake of iron compared to other children.
Dental examination at 2 yrs then every 6 months
128
GI pathology associated with Down's Syndrome
Coeliac
Duodenal stenosis or atresia
Anal stenosis or atresia
129
Testing for Down's syndrome at <14 weeks gestation
Combined test:
↑hCG
PAPP-A
Nuchal translucency
130
Testing for Down's syndrome at 14-20 weeks gestation
```
Quadruple test:
↓AFP
↑hCG
↓uE3
↑DIA
```
131
Most frequent form of inherited disability
1 in 4000
132
Genetic abnormality in fragile X
Unstable expansion of trinucleotide CGG
133
Physical abnormalities in Fragile X
```
Macrocephaly
Strabismus
Pale blue irises
Midface hypoplasia with sunken eyes
Arched palate
Mitral valve prolapse (seemingly benign)
Joint hyperlaxity
Hypotonia
Doughy skin over dorsum of hands
Flexible, flat feet
```
134
Fragile X affects males more than females: true or false?
True
135
Cognitive abnormalities in Fragile X
Developmental delay - delayed attainment of motor and language milestones
Intellectual disability
Learning disability
Decline in all skills after early childhood e.g. quantitative skills, verbal reasoning, visual/abstract abilities, short-term memory
136
Behavioural abnormalities seen in Fragile X syndrome
ADHD-like (inattentive, overactive, impulsive) symptoms which tend to decline with age
Avoidance of new things
Anxiety symptoms
137
Fragile X syndrome in females
In females, the phenotype is more variable as there is X chromosome inactivation. 50% will have normal intellect. The remaining 50% usually have milder features than boys.
138
Cerebral palsy
A diagnostic term, given to children with a static brain injury of varying aetiology. Associated with premature birth, hypoxic-ischaemic injury, meningitis, intracerebral haemorrhage.
Does NOT cause cognitive impairment, but is often associated with it.
139
MHA Section 2
2 doctors and 1 AMHP
Detained for 28 days
Used in new patients who are unwell in the community. Mainly for assessment
140
MHA Section 3
2 doctors and 1 AMHP
Detained for 6 months & can appeal once during this time.
Used in long term patients who are usually already under another section. Can be used for treatment of the condition.
141
MHA Section 4
1 doctor and 1 AMHP
Detained for 72 hours
Used in patients who are unwell in the community or in A&E. Used in emergencies when only one doctor is available. Not for treatment.
142
MHA Section 5(2)
1x doctor (F2+)
Detained for 72 hours
Patient must already be on the ward voluntarily
143
MHA Section 5(4)
1x nurse
Detained for 6 hours
Patient must already be on the ward voluntarily
144
MHA Section 117
Community Treatment Order - supervised community treatment. Used in patients sectioned under 2 or 3. Restrictions on where they can go may be put in place.
145
MHA Section 135
Allows the police to break into a property to remove a person to a Place of Safety
146
MHA Section 136
Allows the police to remove person from a public place and take to a Place of Safety
147
Deprivation of Liberty Safeguards
For treatment of a physical health condition in a general ward, in a patient who lacks capacity.
148
Dissociative/Conversion Disorder
Involuntary loss of a function with no secondary gain.
| Psychogenic.
149
Somatoform disorder
Repeated presentation of physical symptoms with persistent request for investigations
150
Somatisation
Convinced that something is wrong which requires investigation
151
Factitious Disorder
Persistent pattern of feigning symptoms, with no physical or mental disorder that could explain the symptoms.
No evidence for an external motivation.
152
Munchausen's syndrome
Factitious disorder due to poisoning yourself
153
Munchausen's by proxy
Factitious disorder due to poisoning someone else
154
Features of postnatal blues
Onset within 2-5 days
Lasts a few days
Mood lability, irritation, tearfulness.
Self-limiting
155
Features of postnatal depression
Onset within a few days to 6 months
Last weeks-years
Features of depressive episode
156
Management of postnatal depression
Antidepressants and CBT
Often sertraline or paroxetine.
157
Features of Postpartum psychosis
Onset within 2 week
Lasts weeks to months
Rapidly progressive psychosis, mood change, perplexity and mania
158
Management of postpartum psychosis
Psychiatric emergency
Medication for symptoms - usually antipsychotics and antidepressants
Admission
ECT has a dramatic effect - low threshold for referral.
159
Postpartum psychosis is associated with which psychiatric condition?
BPAD
30% of type I, 10% of type II
160
Risk factors for postnatal depression
```
History of psychiatric disorder
Lacking in social support
Recent stressful life events
Sleep deprivation
Genetic susceptibility (FH)
Violence of partner during pregnancy
Discontinuation of antidepressants during 1st trimester
```
161
Pathology of postnatal depression
Postnatal change in sensitivity to dopaminergic system
162
Scoring system for postnatal depression
Edinburgh Postnatal Depression Score
163
Lithium is contraindicated in pregnancy: true or false?
Staying on lithium during pregnancy is considered reasonable after risk/benefit discussion.
164
Definition of personality disorder
Enduring (starting in childhood and continuing into adulthood), persistent and pervasive disorders of inner experience and behaviour that cause distress or significant impairment in social functioning.
165
Schizoid personality disorder
Indifferent to praise and criticism
| Solitary - uninterested in sexual interactions or companionship, few interests
166
Schizotypal PD
Ideas of reference
Odd beliefs and magical thinking
Odd speech
Unusual perceptual disturbance
167
Paranoid PD
Hypersensitive, unforgiving when insulted
Unwarranted questioning of loyalty of friends
Reluctant to confide in others
168
Antisocial PD
Fail to conform to social norms
Men > women
Irritable or aggressive - may be arrested
Lack of remorse
169
Borderline PD
```
Efforts to avoid abandonment
Unstable self image
Impulsivity
Suicidal behaviour
Temper control problems
Affective instability
```
170
Histrionic PD
Inappropriate sexual seductiveness
Needs to be centre of attention
Relationships considered more intimate than they are
171
Narcissistic PD
Grandiose sense of self importance
Excessive need for admiration
Lack of empathy
Takes advantage of others
172
Anakistic PD
OCD
Perfectionism
May hoard - unable to dispose of insignificant objects
Stingy spending style
173
Anxious/Avoidant PD
Fear of criticism or rejection
Avoids intimate relationships due to fear of being ridiculed
Feels inept and inferior
Social isolation with craving for social contact
174
Dependent PD
Requires reassurance before making decisions
Lack of initiative
Rarely disagrees with others
Quickly starts new relationship after one ends
175
Management of personality disorder
Drug management of comorbidities (depression, psychosis, mood lability)
Therapeutic community e.g. residential or day unit
DBT
176
Stages of DBT
Step 1: CBT-like, dealing with self-harm and other ‘therapy interfering’ behaviours
Step 2: processing previous trauma
Step 3: developing self-esteem and realistic future goals
177
Scheme
Core beliefs. Persistent, pervasive patterns of thinking, feeling & behaving.
178
CBT
Examining the link between the way you think and the things you do.
179
Uses of CBT
```
Depression
Anxiety disorders
Bipolar disorder
Psychosis
Stress
```
180
Systematic Desensitisation
Used in phobias.
Consists of a fear hierarchy (the spider vs a picture of a spider), relaxation techniques and reciprocal inhibition (i.e. exposure to phobia while relaxed)
181
Eye movement desensitisation
Side-to-side eye movements or other forms of bilateral stimulation (e.g. hand tapping), to aid patients’ processing of distressing memories and beliefs.
182
Uses of Eye Movement Desensitisation
PTSD
183
Psychodynamic therapy
Analysis of dreams
Transference: the person projects to the analyst, the characteristics that are unconsciously associated with important people in their life. This experience, repeated, helps the person to reveal their repressed feelings and neurotic symptoms disappear gradually
Free association: person is encouraged to say whatever comes to their head without editing or censorship, to be interpreted by the analyst
184
Uses of psychodynamic therapy
PD
185
Sociodemographics for Schizophrenia
Males > females
18-25yrs in males and 25-35yrs in females
Higher incidence in migrant populations
186
Risk Factors for Schizophrenia
```
Early use of cannabis
Exposure to prejudice (high rates among Black Caribbean residents of less ethnically diverse areas of London) - reduced incidence once an ethnic group reaches 25% of local population
Unemployment
Housing issues
Poor education
```
187
Pathophysiology of Schizophrenia
Most likely hyperactivity of dopaminergic neurons in mesolimbic tract. May also be associated with excessive stimulation of glutamate neurons at hippocampus, leading to toxicity and eventual degeneration.
188
Criteria for Schizophrenia
1 first rank symptom or 2+ other symptoms:
First rank:
- Thought insertion/withdrawl/broadcast
- Delusions of passivity
- Delusional perception
- Auditory hallucination
Other:
- Disorganised speech
- Disorganised/catatonic behaviour
- Negative symptoms
189
Auditory hallucinations seen in Schizophrenia
Thought echo - hears their own thoughts
3rd person voices
Running commentary - hears a narration of their actions/intentions
190
Negative symptoms seen in schizophrenia
```
Affective flattening
Avolition
Anhedonia
Attention deficit
Impoverishment of speech and language
```
191
First line antipsychotics
Second Generation (Olanzapine, Quetiapine, Paliperidone, risperidone, Ziprasidone)
192
Management of schizophrenia
Antipsychotics (Second generation is first line)
CBT, FT, sometimes ECT
Suicide prevention
Social support
Monitoring of physical health - especially BMI and waist circumference
193
Antipsychotics used in pregnancy
First > Second generation
194
MOA of first generation antipsychotics
Dopamine receptor antagonists
195
MOA of second generation antipsychotics
5HT2A receptor antagonism and D2 receptor antagonism
196
Examples of first generation antipsychotics
Haloperidol (more antipsychotic effect, less sedative)
Fluphenazine
Chlorpromazine (less antipsychotic, more sedative)
197
Examples of second generation antipsychotics
```
Clozapine
Olanzapine
Risperidone
Quetiapine
Amisulpride
Ziprasidone
Aripiprazole
```
198
Common side effects of first generation antipsychotics
```
Cholinergic: Dry mouth, dizziness
N&V
Rash
Tremor
Sedation
```
199
Notable side effects of first generation antipsychotics
Extrapyramidal Side effects
Hyperprolactinaemia - gynaecomastia, galactorrhoea, erectile dysfunction
Metabolic syndrome
200
Serious side effects of first generation antipsychotics
Long QT syndrome
201
Extrapyramidal side effects
Acute Dystonia
Parkinsonism
Akathisia
Tardive dyskinesia
202
Acute dystonia
Painful and lasting muscle spasms
203
Akathisia
Restlessness
204
Tardive dyskinesia
Choreic movements, may be irreversible
205
Management of extrapyramidal side effects
Procyclidine
206
Common ADRs of 2nd generation antipsychotics
Sedation
Increased appetite
Weight gain
Hyperglycaemia
207
Notable ADRs of 2nd generation antipsychotics
Hyperprolactinaemia
Metabolic syndrome - 1/3 develop diabetes after 5 yrs of treatment
Extrapyramidal side effects - rare
208
Serious ADRs of 2nd generation antipsychotics
Agranulocytosis seen with clozapine
209
Smoking cessation guidance with Olanzapine
Should only stop smoking under medical guidance.
Smoking cessation can lead to Olanzapine-induced Parkinsonism.
Heavy smoking affects cytochrome p450, stimulating drug metabolism
210
Common side effects of clozapine
```
Weight gain
Constipation
Hypersalivation
Malaise
Speech disorder
Urinary incontinence
```
211
Serious side effects of clozapine
Agranulocytosis
Thromboembolism (20x risk)
Cardiomyopathy and myocarditis
Intestinal obstruction
212
Monitoring requirements for all antipsychotics (except clozapine)
Blood lipids and weight at baseline, at 3 months and then yearly
Fasting blood glucose at baseline, 4-6 months and then yearly
213
Monitoring requirements with clozapine
FBC - weekly for first 6 months, 2-weekly for next 6 months, then 4-weekly.
Blood lipids and weight - at baseline, then every 3 months for first year, then annually.
Fasting blood glucose - at baseline, at 1 month, then 4-6 monthly
214
Pathology of neuroleptic malignant syndrome
Central D2 receptor blockade in nigrostriatal pathway
215
Features of neuroleptic malignant syndrome
```
Altered mental state
Increased muscle tone
Abnormal autonomic neurology
Hyperactivity
Hyperthermia
```
216
Management of neuroleptic malignant syndrome
Discontinue antipsychotic
Supportive measures
Dantrolene (ryanodine receptor antagonist) or Benzodiazepines
217
What effect does Dantrolene have in Neuroleptic Malignant Syndrome?
Ryanodine Receptor Antagonist. Prevents release of Ca2+ from sarcoplasmic reticulum of striated muscle. Therefore, causes muscle relaxation.
218
Risk of suicide in patients who self harm
3 in 100
50x more likely than the rest of the population
219
Dependence
Prolonged, regular use of substances which can lead to addiction and withdrawal.
Drug is now needed to feel normal, rather than euphoric.
Emotional - feeling like you need the drug
Physical - experiencing negative symptoms without it.
220
Tolerance
Having to increase intake to get the same feeling.
When the brain is constantly overstimulated with dopamine, dopamine receptors are shut down. Therefore, the same level of ‘high’ will have a reduced effect.
221
Withdrawal
Feeling depressed and anxious and experiencing physical symptoms when substance is removed after a period of prolonged intake.
When the substance is removed, dopamine is reduced and the body isn’t producing it.
222
CAGE questionnaire
Have you ever felt like you should CUT down your drinking?
Have people ever ANNOYED you by criticising your drinking?
Have you ever felt GUILTY about your drinking?
Have you ever had an EYE-opener i.e. drinking in the morning?
223
Management of problematic alcohol use and mild dependence
Physician advice and brief intervention
224
Management of moderate to severe dependence
Psychosocial - CBT, counselling strategies and referral to self-help groups (AA)
Pharmacotherapy e.g. Opioid antagonists (Nalmefene 1-2hrs before drinking and Naltrexone daily PO or monthly IM) - reduces the pleasant effects of alcohol, may cause opiate withdrawal symptoms in opiate-drug users
225
Alcohol withdrawal symptoms occur at what time after last drink?
4-12 hours
226
Delirium tremens
Hallucinations & delusions, seizures, coarse tremor, dehydration, autonomic disturbance (sweating, fever, tachy, HTN) 24-48 hours after last drink.
227
Management of delirium tremens
Benzodiazepines
Supportive care
Vitamin supplementation (IV thiamine reduces risk of Wernicke’s encephalopathy and Korsakoff’s +/- folic acid +/- MgSO4)
228
Features of opiate intoxication
```
Euphoria
Analgesia
Drowsy
Respiratory depression
Cough reflex suppression
↓HR & ↓BP
↓ temperature
Pupillary constriction
Constipation
```
229
Features of opiate withdrawal
```
AKA ‘Cold turkey’
Craving
Restlessness & insomnia
Myalgia
Sweating
Abdo pain, D&V
Dilated pupils
Tachycardia
Yawning
‘Goosebumps’
```
230
Opiate detoxification
First line: Maintenance therapy Buprenorphine OR Methadone +/- IM or Nasal Naloxone
Supportive therapy inc. monitoring physical health, self-help groups e.g. Narcotic Anonymous, psychosocial services
Needle risk reduction (needle exchange service)
NB Methadone is preferred in very high-dose opioid addiction.
Second line: Naltrexone
Takes 2-5 years
231
Features of opiate overdose
```
Key diagnostic factors:
Miosis = constricted pupils
Bradypnoea i.e. respiratory depression
Altered mental status i.e. drowsy and sleep
Dramatic response to naloxone
```
Common factors:
Fresh needle marks
Drug paraphernalia nearby
Decreased GI motility
232
Management of opiate overdose
Ventilatory support - maintain 94-98% O2 to reduce risk of ARDS
Naloxone 0.4mg IV/IM/SC every 2-3 mins OR 2-4 mg intranasally every 203 mins (alternating nostrils)
