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Clinical Medicine > Psychiatry > Flashcards

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

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2
Q

Hypochondriasis

A

Obsessions and compulsions related to illness. Researching symptoms or checking if you have a condition.

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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.

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4
Q

Social Phobia

A

Comorbid with low self esteem

Not secondary to delusional or obsessive thoughts and are restricted to particular social situations.

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5
Q

Agoraphobia

A

Fear of going out. Anxiety related to places or situations where escape may be difficult or embarrassing. Leads to avoidance.

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6
Q

Pathology of PTSD

A

Hyperactive amygdala

Hypoactive prefrontal cortex

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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

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8
Q

Differentials for Generalised Anxiety Disorder

A 
Other anxiety disorder
Depression
Cardiac arrhythmia 
Hyperthyroidism 
Infections 
Substance misuse
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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

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10
Q

Management of Simple Phobia

A

CBT with graded exposure

+/- applied tension and benzodiazepines if vasovagal syncope

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11
Q

Management of Acute Panic Attacks

A

Reassurance
Benzodiazepine
+/- Beta blockers

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12
Q

Management of Panic Disorder

A

CBT +/- SSRIs

Reassurance, benzodiazepine +/- Beta blocker for acute episodes

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13
Q

Obsessive Compulsive Disorder

A

Recurrent obsessional thoughts or compulsive acts functioning to prevent some objectively unlikely event.

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14
Q

Obsessive thoughts

A

Ideas, images or impulses that enter the patient’s mind again and again in a stereotyped form

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15
Q

Compulsive acts

A

Stereotyped behaviours that are repeated again and again

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16
Q

Management of OCD

A

CBT +/- SSRIs

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17
Q

Criteria for PTSD diagnosis

A

History of exposure to or threat of death, serious injury, sexual violence

  1. Reexperiencing: flashbacks, intrusive images, nightmares
  2. Avoidance symptoms: socially and of similar events
  3. Hyperarousal
  4. Emotional numbing - unable to laugh or feel the same about things as they did before the event
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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

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19
Q

BPAD affects males more than females - true or false?

A

False - males and females are affected equally

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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

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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

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22
Q

Hypomania lasts for…

A

Around 4 days

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23
Q

Mania lasts for…

A

At least 7 days

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24
Q

Features of hypomania

A

Elevated mood
Increased energy/self esteem/libido/quantity of speech
Loss of concentration
Reduced sleep

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25
Q

Hypomania is seen in which form of BPAD

A

BPAD Type II

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26
Q

Mania is seen in which form of BPAD

A

BPAD Type I

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27
Q

Major depressive episodes are seen in which form of BPAD

A

BPAD Type II

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28
Q

Criteria for diagnosis of BPAD Type I

A

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

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29
Q

Criteria for diagnosis of BPAD Type II

A

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

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30
Q

Criteria for diagnosis of Cyclothymia

A

1+ hypomanic and depressive episode over 2 years or more.

Symptoms not severe enough to meet BPAD criteria

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31
Q

Physical health conditions associated with mania

A

Wilson’s disease

HIV

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32
Q

Screening required for initiation of lithium

A

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

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33
Q

Monitoring required in patients on Lithium treatment

A

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

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34
Q

ADRs of Lithium

A

Common: GI upset, N&V, weight gain, metallic taste in mouth

Notable: Hypothyroidism

Serious: Long QT syndrome

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35
Q

Signs and symptoms of Lithium toxicity

A 
GI upset 
Tremor 
Hyperreflexia 
Confusion
Seizure 
Coma
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36
Q

Separation anxiety

A

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.

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37
Q

Management of depression in children

A

CBT and family therapy are first line.

Fluoxetine is the only drug licensed in under 18s

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38
Q

Criteria for diagnosis of ADHD

A 
Inattention
Hyperactivity
Impulsivity 
Before 7 years old
Pervasive

MDT diagnosis - behaviours must be present at all times i.e. school and home

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39
Q

Management of ADHD

A

First line: Psychoeducation

+/- Behavioural treatment - parental training, effective timeouts, school plan

+/- Methylphenidate

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40
Q

MOA of Methylphenidate

A

Dopamine uptake and transport inhibitor

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41
Q

ADRs of Methylphenidate

A 
Poor appetite
Reduced growth
Insomnia 
Tics 
Headaches
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42
Q

Conditions associated with Autism Spectrum Disorder

A

Fragile X
Tuberous Sclerosis
Down’s syndrome

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43
Q

Criteria for diagnosis of ASD

A

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

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44
Q

Management of ASD

A

Family support
Treat comorbidities
Manage behaviour - Applied Behaviour Analysis used in children 2-3 years to reinforce behaviour and dissuade negative behaviour.

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45
Q

Secure attachment

A

Child values relationships and is confident in their own self-worth

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46
Q

Insecure avoidant attachment

A

Appears emotionally independent, does not value relationships.

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47
Q

Insecure anxious attachment

A

Self-worth depends on approval of others. Values relationships but finds them unreliable. Develops strategies for achieving attention.

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48
Q

Insecure ambivalent attachment

A

Values relationships but is insecure about their safety

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49
Q

Disorganised attachment

A

Neither self-sufficient nor able to use relationships

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50
Q

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

A

Mild depression

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51
Q

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

A

Moderate depression

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52
Q

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

A

Severe depression

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53
Q

Cotard’s syndrome

A

Delusional belief that they are dead

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54
Q

Atypical depression

A

Increased sleep
Increased appetite
Phobic anxiety

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55
Q

Management of atypical depression

A

MAO-I > SSRIs

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56
Q

Investigations which may suggest an organic cause for depressive symptoms

A 
FBC
TFTs
24 hr free cortisol
Vitamin B12
Folic acid
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57
Q

SAD PERSONS score

A

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
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58
Q

Examples of TCA

A

Amitriptyline, Clomipramine

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59
Q

MOA of TCAs

A

5-HT and NA reuptake inhibition

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60
Q

TCAs with sedative effects

A

Amitriptyline, Clomipramine

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61
Q

TCAs without sedative effects

A

Imipramine, Nortriptyline

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62
Q

Common ADRs of TCAs

A

Cholinergic - dry mouth, constipation, blurred vision,

Alpha blockade: Dizziness, Hypotension

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63
Q

Serious ADRs of TCAs

A

long QT syndrome

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64
Q

Contraindications for TCAs

A

Arrhythmia
Mania
Medications: adrenergic vasoconstrictors, barbiturates, paracetamol

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65
Q

Preferred SSRI post-MI

A

Sertraline

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66
Q

Paroxetine is contraindicated in…

A

Pregnancy - caused congenital malformations

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67
Q

Common ADRs of SSRIs

A

GI upset

Increased anxiety and agitation

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68
Q

Notable ADRs of SSRIs

A

Insomnia
Sexual dysfunction - anorgasmia, ED, low libido
Increased risk of bleeding - particularly GI bleeds

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69
Q

Serious ADRs of SSRIs

A 
Suicidal ideation
Long QT syndrome 
Hyponatraemia (SIADH)
Teratogenic 
Discontinuation syndrome 
Serotonin syndrome
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70
Q

SSRI most associated with Long QT syndrome

A

Citalopram

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71
Q

Hyponatraemia is most likely to occur in which patients taking SSRIs?

A

Women
> 80 yrs
Renal impairment
On medications which disrupt Na+

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72
Q

SSRIs disrupt metabolism of which drugs?

A

Codeine
benzoiazepines
Erythromycin
NSAIDs/Aspirin/Warfarin/Heparin - increased risk of bleeding

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73
Q

Examples of NRIs

A

Reboxetine

Atomoxetine

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74
Q

Examples of SNRIs

A

Venlafaxine

Duloxetine

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75
Q

Examples of MAOIs

A

Moclobemide

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76
Q

Common ADRs of MAOIs

A

Dry mouth
Drowsiness
Constipation

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77
Q

Notable ADRs of MAOIs

A

Hypotension
Weight gain
Insomnia

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78
Q

Serious ADRs of MAOIs

A

Hypertensive crisis when eating tyramine containing foods e.g. cheese, wine, marmite

Serotonin syndrome

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79
Q

Contraindications for MAOIs

A

CVD
Phaeochromocytoma
Thyrotoxicosis
BPAD

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80
Q

MOA of Bupropion

A

Inhibits dopamine and noradrenaline reuptake

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81
Q

Common ADRs of Bupropion

A 
Headache
Dry mouth
Tachycardia
Palpitations 
Mild HTN
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82
Q

Notable ADRs of Bupropion

A

Insomnia

Weight loss

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83
Q

Serious ADRs of Bupropion

A

Reduces seizure threshold

Depression, mania, psychosis, paranoia

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84
Q

Contraindications of Bupropion

A

Alcohol or benzodiazepine withdrawal (risk of seizures)
Epilepsy
BPAD
Liver cirrhosis

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85
Q

MOA of Mirtazapine

A

Alpha 2, 5HT2a and 5HT3 antagonist

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86
Q

Antidepressant with the lowest incidence of sexual side effects

A

Mirtazepine

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87
Q

Common ADRs of Mirtazepine

A

Increased appetite
Weight gain
Sedation (H1 antagonist)
Dry mouth

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88
Q

What percentage of patients taking antidepressants experience sexual side effects?

A

70%

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89
Q

What is ECT?

A

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.

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90
Q

Indications for ECT

A 
Treatment resistant depression. 
BPAD
Mania
Schizophrenia 
Psychotic Depression
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91
Q

Side effects of ECT

A

Short term: headache, nausea, short term memory problems, cardiac arrhythmias

Long term: Memory problems

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92
Q

Contraindications for ECT

A

Raised ICP

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93
Q

Criteria for diagnosis with anorexia nervosa

A

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
Q

Symptoms of anorexia

A 
Sensitivity to cold
GI symptoms 
Dizziness
Amenorrhoea 
Poor sleep
95
Q

Signs of anorexia

A 
Emaciation
Cold extremities 
Dry skin
Downy body hair 
↓ secondary sexual features
Bradycardia
Postural hypotension
Arrhythmias 
Peripheral oedema 
Proximal myopathy
96
Q

Hormone changes in anorexia nervosa

A

↓ LH, FSH, oestadiol and T3

↑ cortisol and GH

97
Q

Electrolyte changes in anorexia nervosa

A

↓ K+, ↓ Na+ and met. alkalosis

98
Q

FBC in anorexia nervosa

A

↓ WCC and platelets

99
Q

Cholesterol in anorexia nervosa

A

Hypercholesterolaemia

100
Q

Patient with BMI of 14 has a metabolic acidosis due to…

A

Laxatives

101
Q

Patient with BMI of 16 has a metabolic alkalosis due to…

A

Vomiting

102
Q

SCOFF Questionnaire

A

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
Q

Investigations for low BMI, suspected eating disorder

A

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
Q

Differentials for BMI < 18

A

Anorexia/Bulimia/EDNOS
Depression
OCD

T1DM
Hyperthyroidism
IBD
Neoplasm
Infection
105
Q

Management of Anorexia Nervosa

A

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
Q

Complications of Anorexia Nervosa

A

Osteoporosis
Death from arrhythmias
Renal Failure
Refeeding syndrome

107
Q

Pathology of refeeding syndrome

A

Sudden shift from catabolic to anabolic metabolism

108
Q

Electrolyte abnormalities in refeeding syndrome

A

↓ Phosphate
↓ K+
↓ Mg2+

109
Q

Mortality in Anorexia Nervosa

A

10-15% (⅔ physical complications, ⅓ suicide)

110
Q

Prevention of refeeding syndrome

A

If a patient hasn’t eaten for > 5 days, refeed at no more than 50% of requirements for the first 2 days.

111
Q

Criteria for Bulimia Nervosa

A

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
Q

Russel’s sign

A

Calluses on back of knuckles

113
Q

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?

A

Anorexia nervosa.

BMI < 18 is always Anorexia Nervosa, regardless of binging or purging.

114
Q

Management of Bulimia Nervosa

A

5 months CBT, 70% will recover using this treatment
+/- Nutritional and meal support
+/- SSRI/SNRI

115
Q

Electrolyte disturbance caused by self-induced vomiting

A

Hypokalaemia

116
Q

Definition of learning disability

A

IQ < 70

Onset before age of 18 yrs

117
Q

Definition of Mild Learning Disability

A

IQ 50-69
Mental age 9-12
80% of LD population

118
Q

Definition of Moderate Learning Disability

A

IQ 35-49
Mental Age 6-9
0.3% of LD population

119
Q

Definition of severe Learning Disability

A

IQ 20-34
Mental age 3-6
7% of LD population

120
Q

Definition of Profound Learning Disability

A

IQ < 20
Mental age < 3
1% of LD population

121
Q

Prenatal factors associated with learning disability

A

Infections e.g. Congenital Syphilis and Rubella
Trauma
Anoxia
X-rays
Endocrine disorders (Hyperthyroid during pregnancy)
Teratogens

122
Q

Perinatal factors associated with learning disability

A

Prematurity
Asphyxiation - prolonged labour, cord strangulation
Trauma e.g. forceps delivery

123
Q

Postnatal factors associated with learning disability

A 
Infection 
Trauma - Head injury inc. shaken baby syndrome 
Toxic agents 
Nutrition
Sensory &amp; social deprivation
Untreated conditions
124
Q

Signs of Down’s Syndrome at birth

A 
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
Q

Chronic diseases associated with Down’s Syndrome

A

Chronic diseases: Thyroid, DM, Epilepsy, Cardiovascular

Psychiatric: Depression, Anxiety, OCD, ASD, Dementia (early - 40s, peak intellect at 12-13) - brain ages quicker.

126
Q

Screening of newborns with Down’s Syndrome

A

Echocardiogram recommended in all newborns with DS.
Hearing test
TFTs
Vision examination (4% are born with congenital cataracts)

127
Q

Monitoring of patients with Down’s syndrome

A

Annual Hb from 1 year old. Lower intake of iron compared to other children.
Dental examination at 2 yrs then every 6 months

128
Q

GI pathology associated with Down’s Syndrome

A

Coeliac
Duodenal stenosis or atresia
Anal stenosis or atresia

129
Q

Testing for Down’s syndrome at <14 weeks gestation

A

Combined test:
↑hCG
PAPP-A
Nuchal translucency

130
Q

Testing for Down’s syndrome at 14-20 weeks gestation

A 
Quadruple test:
↓AFP
↑hCG
↓uE3
↑DIA
131
Q

Most frequent form of inherited disability

A

1 in 4000

132
Q

Genetic abnormality in fragile X

A

Unstable expansion of trinucleotide CGG

133
Q

Physical abnormalities in Fragile X

A 
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
Q

Fragile X affects males more than females: true or false?

A

True

135
Q

Cognitive abnormalities in Fragile X

A

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
Q

Behavioural abnormalities seen in Fragile X syndrome

A

ADHD-like (inattentive, overactive, impulsive) symptoms which tend to decline with age
Avoidance of new things
Anxiety symptoms

137
Q

Fragile X syndrome in females

A

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
Q

Cerebral palsy

A

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
Q

MHA Section 2

A

2 doctors and 1 AMHP

Detained for 28 days

Used in new patients who are unwell in the community. Mainly for assessment

140
Q

MHA Section 3

A

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
Q

MHA Section 4

A

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
Q

MHA Section 5(2)

A

1x doctor (F2+)

Detained for 72 hours

Patient must already be on the ward voluntarily

143
Q

MHA Section 5(4)

A

1x nurse

Detained for 6 hours

Patient must already be on the ward voluntarily

144
Q

MHA Section 117

A

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
Q

MHA Section 135

A

Allows the police to break into a property to remove a person to a Place of Safety

146
Q

MHA Section 136

A

Allows the police to remove person from a public place and take to a Place of Safety

147
Q

Deprivation of Liberty Safeguards

A

For treatment of a physical health condition in a general ward, in a patient who lacks capacity.

148
Q

Dissociative/Conversion Disorder

A

Involuntary loss of a function with no secondary gain.

Psychogenic.

149
Q

Somatoform disorder

A

Repeated presentation of physical symptoms with persistent request for investigations

150
Q

Somatisation

A

Convinced that something is wrong which requires investigation

151
Q

Factitious Disorder

A

Persistent pattern of feigning symptoms, with no physical or mental disorder that could explain the symptoms.

No evidence for an external motivation.

152
Q

Munchausen’s syndrome

A

Factitious disorder due to poisoning yourself

153
Q

Munchausen’s by proxy

A

Factitious disorder due to poisoning someone else

154
Q

Features of postnatal blues

A

Onset within 2-5 days
Lasts a few days
Mood lability, irritation, tearfulness.
Self-limiting

155
Q

Features of postnatal depression

A

Onset within a few days to 6 months
Last weeks-years
Features of depressive episode

156
Q

Management of postnatal depression

A

Antidepressants and CBT

Often sertraline or paroxetine.

157
Q

Features of Postpartum psychosis

A

Onset within 2 week
Lasts weeks to months
Rapidly progressive psychosis, mood change, perplexity and mania

158
Q

Management of postpartum psychosis

A

Psychiatric emergency
Medication for symptoms - usually antipsychotics and antidepressants
Admission

ECT has a dramatic effect - low threshold for referral.

159
Q

Postpartum psychosis is associated with which psychiatric condition?

A

BPAD

30% of type I, 10% of type II

160
Q

Risk factors for postnatal depression

A 
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
Q

Pathology of postnatal depression

A

Postnatal change in sensitivity to dopaminergic system

162
Q

Scoring system for postnatal depression

A

Edinburgh Postnatal Depression Score

163
Q

Lithium is contraindicated in pregnancy: true or false?

A

Staying on lithium during pregnancy is considered reasonable after risk/benefit discussion.

164
Q

Definition of personality disorder

A

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
Q

Schizoid personality disorder

A

Indifferent to praise and criticism

Solitary - uninterested in sexual interactions or companionship, few interests

166
Q

Schizotypal PD

A

Ideas of reference
Odd beliefs and magical thinking
Odd speech
Unusual perceptual disturbance

167
Q

Paranoid PD

A

Hypersensitive, unforgiving when insulted
Unwarranted questioning of loyalty of friends
Reluctant to confide in others

168
Q

Antisocial PD

A

Fail to conform to social norms
Men > women
Irritable or aggressive - may be arrested
Lack of remorse

169
Q

Borderline PD

A 
Efforts to avoid abandonment 
Unstable self image
Impulsivity 
Suicidal behaviour 
Temper control problems 
Affective instability
170
Q

Histrionic PD

A

Inappropriate sexual seductiveness
Needs to be centre of attention
Relationships considered more intimate than they are

171
Q

Narcissistic PD

A

Grandiose sense of self importance
Excessive need for admiration
Lack of empathy
Takes advantage of others

172
Q

Anakistic PD

A

OCD
Perfectionism
May hoard - unable to dispose of insignificant objects
Stingy spending style

173
Q

Anxious/Avoidant PD

A

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
Q

Dependent PD

A

Requires reassurance before making decisions
Lack of initiative
Rarely disagrees with others
Quickly starts new relationship after one ends

175
Q

Management of personality disorder

A

Drug management of comorbidities (depression, psychosis, mood lability)
Therapeutic community e.g. residential or day unit
DBT

176
Q

Stages of DBT

A

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
Q

Scheme

A

Core beliefs. Persistent, pervasive patterns of thinking, feeling & behaving.

178
Q

CBT

A

Examining the link between the way you think and the things you do.

179
Q

Uses of CBT

A 
Depression 
Anxiety disorders 
Bipolar disorder
Psychosis 
Stress
180
Q

Systematic Desensitisation

A

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
Q

Eye movement desensitisation

A

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
Q

Uses of Eye Movement Desensitisation

A

PTSD

183
Q

Psychodynamic therapy

A

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
Q

Uses of psychodynamic therapy

A

PD

185
Q

Sociodemographics for Schizophrenia

A

Males > females
18-25yrs in males and 25-35yrs in females
Higher incidence in migrant populations

186
Q

Risk Factors for Schizophrenia

A 
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
Q

Pathophysiology of Schizophrenia

A

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
Q

Criteria for Schizophrenia

A

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
Q

Auditory hallucinations seen in Schizophrenia

A

Thought echo - hears their own thoughts
3rd person voices
Running commentary - hears a narration of their actions/intentions

190
Q

Negative symptoms seen in schizophrenia

A 
Affective flattening
Avolition
Anhedonia
Attention deficit
Impoverishment of speech and language
191
Q

First line antipsychotics

A

Second Generation (Olanzapine, Quetiapine, Paliperidone, risperidone, Ziprasidone)

192
Q

Management of schizophrenia

A

Antipsychotics (Second generation is first line)

CBT, FT, sometimes ECT

Suicide prevention

Social support

Monitoring of physical health - especially BMI and waist circumference

193
Q

Antipsychotics used in pregnancy

A

First > Second generation

194
Q

MOA of first generation antipsychotics

A

Dopamine receptor antagonists

195
Q

MOA of second generation antipsychotics

A

5HT2A receptor antagonism and D2 receptor antagonism

196
Q

Examples of first generation antipsychotics

A

Haloperidol (more antipsychotic effect, less sedative)
Fluphenazine
Chlorpromazine (less antipsychotic, more sedative)

197
Q

Examples of second generation antipsychotics

A 
Clozapine
Olanzapine 
Risperidone 
Quetiapine 
Amisulpride
Ziprasidone 
Aripiprazole
198
Q

Common side effects of first generation antipsychotics

A 
Cholinergic: Dry mouth, dizziness
N&amp;V
Rash
Tremor 
Sedation
199
Q

Notable side effects of first generation antipsychotics

A

Extrapyramidal Side effects
Hyperprolactinaemia - gynaecomastia, galactorrhoea, erectile dysfunction
Metabolic syndrome

200
Q

Serious side effects of first generation antipsychotics

A

Long QT syndrome

201
Q

Extrapyramidal side effects

A

Acute Dystonia
Parkinsonism
Akathisia
Tardive dyskinesia

202
Q

Acute dystonia

A

Painful and lasting muscle spasms

203
Q

Akathisia

A

Restlessness

204
Q

Tardive dyskinesia

A

Choreic movements, may be irreversible

205
Q

Management of extrapyramidal side effects

A

Procyclidine

206
Q

Common ADRs of 2nd generation antipsychotics

A

Sedation
Increased appetite
Weight gain
Hyperglycaemia

207
Q

Notable ADRs of 2nd generation antipsychotics

A

Hyperprolactinaemia
Metabolic syndrome - 1/3 develop diabetes after 5 yrs of treatment
Extrapyramidal side effects - rare

208
Q

Serious ADRs of 2nd generation antipsychotics

A

Agranulocytosis seen with clozapine

209
Q

Smoking cessation guidance with Olanzapine

A

Should only stop smoking under medical guidance.
Smoking cessation can lead to Olanzapine-induced Parkinsonism.
Heavy smoking affects cytochrome p450, stimulating drug metabolism

210
Q

Common side effects of clozapine

A 
Weight gain 
Constipation
Hypersalivation 
Malaise 
Speech disorder 
Urinary incontinence
211
Q

Serious side effects of clozapine

A

Agranulocytosis
Thromboembolism (20x risk)
Cardiomyopathy and myocarditis
Intestinal obstruction

212
Q

Monitoring requirements for all antipsychotics (except clozapine)

A

Blood lipids and weight at baseline, at 3 months and then yearly
Fasting blood glucose at baseline, 4-6 months and then yearly

213
Q

Monitoring requirements with clozapine

A

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
Q

Pathology of neuroleptic malignant syndrome

A

Central D2 receptor blockade in nigrostriatal pathway

215
Q

Features of neuroleptic malignant syndrome

A 
Altered mental state 
Increased muscle tone 
Abnormal autonomic neurology 
Hyperactivity 
Hyperthermia
216
Q

Management of neuroleptic malignant syndrome

A

Discontinue antipsychotic
Supportive measures

Dantrolene (ryanodine receptor antagonist) or Benzodiazepines

217
Q

What effect does Dantrolene have in Neuroleptic Malignant Syndrome?

A

Ryanodine Receptor Antagonist. Prevents release of Ca2+ from sarcoplasmic reticulum of striated muscle. Therefore, causes muscle relaxation.

218
Q

Risk of suicide in patients who self harm

A

3 in 100

50x more likely than the rest of the population

219
Q

Dependence

A

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
Q

Tolerance

A

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
Q

Withdrawal

A

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
Q

CAGE questionnaire

A

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
Q

Management of problematic alcohol use and mild dependence

A

Physician advice and brief intervention

224
Q

Management of moderate to severe dependence

A

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
Q

Alcohol withdrawal symptoms occur at what time after last drink?

A

4-12 hours

226
Q

Delirium tremens

A

Hallucinations & delusions, seizures, coarse tremor, dehydration, autonomic disturbance (sweating, fever, tachy, HTN) 24-48 hours after last drink.

227
Q

Management of delirium tremens

A

Benzodiazepines
Supportive care
Vitamin supplementation (IV thiamine reduces risk of Wernicke’s encephalopathy and Korsakoff’s +/- folic acid +/- MgSO4)

228
Q

Features of opiate intoxication

A 
Euphoria 
Analgesia
Drowsy
Respiratory depression
Cough reflex suppression
↓HR &amp; ↓BP
↓ temperature 
Pupillary constriction 
Constipation
229
Q

Features of opiate withdrawal

A 
AKA ‘Cold turkey’
Craving
Restlessness &amp; insomnia 
Myalgia 
Sweating
Abdo pain, D&amp;V
Dilated pupils 
Tachycardia
Yawning 
‘Goosebumps’
230
Q

Opiate detoxification

A

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
Q

Features of opiate overdose

A 
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
Q

Management of opiate overdose

A

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)

Clinical Medicine (9 decks)

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