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The Panic Zone > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What is the mnemonic used for depression?

A

DEADSWAMPS

Depressed mood

Energy loss

Anhedonia

Death thoughts – suicide

Sleep disturbance

Worthlessness, guilty / Weight gain

Appetite loss

Memory / Mental decrease (concentration and thinking)

Psychomotor agitation / retardation

The first three are major symptoms

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2
Q

What is the definition of mild, moderate and severe depression?

A

Mild Depression:

At least two of the core symptoms plus other symptoms total is greater than or equal to 4

Moderate Depression:

At least two of the core symptoms plus other symptoms total is greater than or equal to 6

For mild or moderate you can subclassify with or without somatic syndrome.

Severe depression:

All three core symptoms plus other symptoms. Total is greater than or equal to 8

For severe depression you can subclasify as having/not having psychotic symptoms

More than one episode is a recurrent depressive disorder

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3
Q

What are the ICD 10 features of somatic syndrome?

A

Somatic Syndrome (ICD - 10):

Anhedonia

Apathy

  • waking 2 hrs before the normal time
  • Depression worse in the morning
  • Objective evidence of psychomotor agitation or retardation
  • Marked loss of appetite
  • Weight loss (5%+ of body weight in a month)
  • Marked loss of libido
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4
Q

What are example mesurement tools for depression?

A

Examples of measurement tools:

HADS (hospital anxiety and depression scale)

SCID (structured clinical interview for DSM disorders)

PHQ - 9 can determine the level of severity of depression, used in screening purposes, diagnosing purposes as well as monitoring. It incorporates the DSM depression criteria.

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5
Q

What is treatment for depression?

A

Mild depression: - Monitoring, self - help, cognitive behavioural therapy, exercise rather than medication

Moderate: antidepressant medication (SSRIs are first line), CBT

Severe without psychotic features:

antidepressant medication plus CBT

Severe with psychotic features: anti-depressant plus antipsychotic medication

Treatment refractory: switch anti-depressant or augment with lithium / antipsychotic.

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6
Q

What are the different types of anti-depressatns?

A

SSRIs

TCAs

Monamine oxidase inhibitors

Others

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7
Q

What psychological treatments are available for Depression?

A

Psychological treatments:

CBT

Behavioural activation (this is when patients take part in activities they have been avoiding).

TRAC - trigger response, alternate coping response - used to assess the effectiveness of coping strategies.

IPT - The aim of IPT is to help the patient to improve interpersonal and intrapersonal communication skills within relationships and to develop social support network with realistic expectations to deal with the crises precipitated in distress.

Motivational interviewing - It is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.

Individual dynamic psychotherapy

Family therapy

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8
Q

What is the advice when switching antidepressant medication?

A

Switching antidepressants: when switching

  • Initially switch to a different SSRI or a better tolerated newer generation antidepressant
  • Subsequently to another class that may be less well tolerated e.g. TCA, venlafaxine or MAOI (MAOI specialist initiated only)
  • Combining and augmentation: Using combinations should only normally be started in primary care in consultation with a psychiatrist
  • Consider combining or augmenting an antidepressant with lithium, an antipsychotic (e.g. quetiapine, aripriprazole etc) or another antidepressant such as mirtazapine

Stopping or reducing antidepressants

Advise re risk of discontinuation symptoms and gradually reduce the dose, normally over a 4 week period

SO basically:

  • Try a different SSRI
  • Try somehthing else
  • Combine or augment with the likes of anti-psychotics, lithium or another antidepressant sich as mirtazapine
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9
Q

What are physical treatments for depression

A

ECT

Psychosurgery

DBS (deep brain stimulation)

VNS (vagus nerve stimulation)

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10
Q

What is differential diagnosis for depression?

A
  • Normal reaction to life event
  • SAD
  • Dysthymia
  • Cyclothymia (this is essentially bipolar disorder)
  • Bipolar
  • Stroke, tumour, dementia
  • Hypothyroidism, Addison’s, Hyperparathyroidism
  • Infections – Influenza, infectious mononucleosis, hepatitis, HIV/AIDS
  • Drugs
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11
Q

What are negative associations of depression?

A

Employment

Financial independance

Stable marriage

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12
Q

What are risk factors for depression?

A

Lower educational attainment

Excess of adverse life events

Depression in first degree relatives

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13
Q

What are the features of mania?

A

Disinhibition

Grandiosity

Alteration of senses

Extravagant spending

Can be irritable rather than elated

Flight of ideas

HAS TO BE AT LEAST A WEEK LONG

MUST DISRUPT SOCIAL ACTIVITIES MORE OR LESS COMPLETELY

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14
Q

What are the different classifications of mania?

A

Hypomania

Mania without psychotic symptoms

Mania with psychotic symptoms

Other manic eposides

Manic episode unspecified

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15
Q

What are measuring tools for mania?

A

SCID

SCAN

Young mania rating scale

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16
Q

What is the definition of hypomania?

A

At least 4 of the following symptoms:

Duration of at least 4 days

Increased mood

Increased energy

Increased sociability

Increased talkativeness

Increased libido, overfamiliarity

Decreased sleep

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17
Q

What is the treatment for mania?

A

Antipsychotics

  • Olanzapine
  • Risperidone
  • Quetiapine

Mood Stabilisers

  • Sodium Valproate
  • Lamotrigene
  • Carbamazepine

Lithium

ECT

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18
Q

What are the tests required to carry out when someone is on lithium?

A

If patient is on lithium then there should be a 3 monthly lithium blood test. There should also be a 6 monthly thyroid/kidney function test.

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19
Q

What is the differential diagnosis for mania?

A

Differential DX:

Schizoaffective disorder

Schizophrenia

Cyclothymia

ADHD

Drugs and alcohol

Stroke

MS

Tumour

Epilepsy

AIDS

Neurosyphilis

Cushings

Hyperthyroidism

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20
Q

What is the diagnosis of bipolar disorder

A

ICD - 10

  • Bipolar Affective Disorder consists of repeated (2+) episodes of depression and mania or hypomania.
  • If no mania or hypomania then diagnosis is recurrent depression.
  • If no depression the diagnosis is hypomania or bipolar disorder
  • (In DSM-5 a single episode of mania is sufficient to diagnose bipolar disorder.)

Passmedicine says that there are two types of bipolar disorder:

type I disorder: mania and depression (most common)

type II disorder: hypomania and depression

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21
Q

What is the treatment for bipolar disorder?

A

Acute phase:

stop any antidepressants (this is to treat the mania)

start an antipsychotic (osmosis says that the antipsychotics should be atypical)

Consider adding a short-term benzodiazepine

If response is inadequate consider combining an antipsychotic with lithium/valproate.

Maintenance:

lithium/olanzapine/valproate, quetiepine for at least 2 years

Anti-depressants / cognitive behavioural therapy (CBT) for intercurrent episodes of depression, fluoxetine is the antidepressant of choice

Combine mood stabilisers for refractory / rapid cycling (at least 4 episodes in a year)

Mood stabilisers include lithium, anticonvulsants (valproic acid, carbemazepine, lamotrigine)

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22
Q

In wernicke’s - korsakoff syndrome, what do the two complonents mean?

A

Acute phase = wernicke’s encephalopathy

Korsakoff syndrome = chronic syndrome

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23
Q

What is the triad of symptoms in wernicke’s korsakoff syndrome?

A

Wernickes Encephalopathy:

Triad of symptoms:

Ophthalmoplegia (nystagmus and paralysis of the lateral rectus muscle)

Changes in mental state (confusion)

Unsteady stance and gait (ataxia)

Also may include:

Stupor

Low blood pressure

Tachycardia

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24
Q

What are the features of korsakoff syndrome?

A

Alcoholic korsakoff syndrome:

Severe memory impairment without any dysfunction in intellectual abilities

Variable presentation of retrograde amnesia

Anterograde amnesia

Aphasia

Apraxia

Agnosia

A defecit in executive functions

CONFABULATION

Key features used to make the clinical diagnosis:

  • Ataxia

Nystagmus

Anterograde and retrograde amnesia and confabulation

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25
Q

What is the treatment of wernickes korsakoff’s?

A

Thiamine administration

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26
Q

What are other causes of wernicke’s korsakoff syndrome?

A

Other causes include other reasons of gross malnourishment: Anorexia nervosa, stomach cancer and gastrectomy.

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27
Q

What are symptoms of alcohol withdrawal?

A

Withdrawal Symptoms

Agitation

Seizures (peak incidence is at 36 hours)

Delirium tremens (this appears 2-5 days after the last drink and is a life-threatening condition, consists of psychosis, confusion and autonomic hyperactivity, fever, tachycardia, visual hallucinations)

Tactile hallucinations - involves the sensation of bugs crawling on the skin

Tremor

Sweating

Tachycardia

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28
Q

What are screening tools for alcohol problems?

A

CAGE:

–Have you tried to Cut down?

–Have you felt Annoyed by people criticising your drinking?

–Have you felt Guilty about drinking?

–Have you felt the need to have an Eye-opener?

AUDIT (alcohol use disorders identification test)

FAST (4 questions)

PAT (paddington alcohol test)

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29
Q

What is diagnosis if harmful use of alcohol?

A

Pattern of use causing damage to physical or mental health. Use over 1 months or repeatedly over 12 months

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30
Q

What is the diagnosis of alcohol dependance?

A

3 or more of the following for > 1 month or repeatedly over 12 months:

Cravings / compulsions to take

Difficulty controlling use

Primacy (it is most important)

Increasing tolerance

Physiological withdrawal on reduction / cessation

Persistence despite harmful consequences

*think of pouring a bowl of krave, you are having difficulty controlling the amount of krave you are pouring. You are a primary school student and you are getting measured because you are getting taller (tolerance) you are getting withdrawn from school but you keep trying to get back in (persistence)

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31
Q

What are the non-pharmacological treatments available for alcohol misuse?

A

Support

CBT, group therapy

Social work inputs (benefits, housing, child protection)

Skills training

Community support

Inpatient or residential treatment

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32
Q

What are potential medical treatments for alcohol withdrawal?

A

Medication

Benzodiazepines (e.g chlordiazepoxide - typically given as a reducing dose protocol)

Carbemazepine is also an effective treatment of alcohol withdrawal (perhaps this will help with seizures and autonomic instability?)

Aversion / deterrant medication = disulfiram (antabuse)

Anti-craving medication (acamprosate, baclofen, naltrexone and nalmefene)

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33
Q

What is the mechanism of alcohol withdrawal?

A

Decreased inhibitory GABA

Increased NMDA glutamate transmission

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34
Q

What are the effects of cocaine on a developing fetus?

A

Intrauterine growth restriction

Pre-term labour

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35
Q

What is the mechanism of cocaine?

A

Blocks the uptake of noradrenaline, serotonin and dopamine

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36
Q

What are potential side effects of cocaine use?

A

Damage to nose and airways

Cardiac arrhythmias and MI

Paranoid psychosis

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37
Q

What are the effects of heroin?

A

Drowsiness

Euphoria

Respiratory depression

Bradycardia and hypotension

Pupillary constriction

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38
Q

What are potential complications of heroin use?

A

Side effects:

First time = nausea / vomiting and headache

Medium term:

phlebitis

Anorexia

Constipation

Longer term:

Tolerance

Withdrawal

Social and health problems

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39
Q

What are symptoms of heroin withdrawal?

A

Dilated pupils

Insomina

Increased salivary, nasal and lacrimal secretions

Piloerection

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40
Q

What are the effects of anabolic steroids?

A

Muscle hypertrophy

Acne, stretch marks, baldness

Gynaecomastia

Hypertension

Depression

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41
Q

What kind of things are encompassed by psychosis?

A

Hallucinations:

Full force and clarity of true perception

Located in external space

No external stimulus

Not willed or controlled

5 special senses:

Auditory or visual

Tactile

Olfactory and gustatory

Disordered thinking

Delusions:

(grandiosity, paranoid, hypochondrical, self referential)

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42
Q

What are necessary tests if you are on antipsychotics?

A

2nd generation anti-psychotics:

monitoring cardiovascular risk factors

1st generation anti-psychotics

  • monitoring ECG for QTC prolongation
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43
Q

What is a delusional beleif?

A

•“ a delusion is an unshakeable idea or belief which is out of keeping with the person’s social and cultural background; it is held with extraordinary conviction.”

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44
Q

Give examples of types of delusional beleifs

A

Examples

  • grandiose (characterized by fantastical beliefs that one is famous, omnipotent, wealthy, or otherwise very powerful)
  • paranoid (correctly persecutory)
  • hypochondriacal
  • self referential - this is the saem as ideas of reference (thinking a billboard sign is meant specifically for you)
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45
Q

What are risk factors for schizophrenia?

A

Other factors implicated in schizophrenia:

Obstetric complications

Maternal influenza

Malnutrition and famine

Winter birth

Substance misuse

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46
Q

What diseases is psychosis a feawture of?

A

Psychosis may be involved in the following conditions:

Schizophrenia

Delirium

A severe affective disorder such as a depressive episode with psychotic symptoms, manic episode with psychotic symptoms

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47
Q

What realms does schizophrenia affect?

A

Thinking

Emotion

Behaviour

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48
Q

What are the positive symptoms of schizophrenia?

A

Hallucinations

Delusions

Disordered thinking

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49
Q

What are the negative symptoms of schizophrenia?

A

Apathy

Lack of interest

Lack of emotions

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50
Q

What is the ICD 10 diagnoisis of schizophrenia?

A

For more than a month in the absence of organic or affective disorder:

At least one of the following:

  • a) Alienation of thought as thought echo, thought insertion or withdrawal, or thought broadcasting.
  • b) Delusions of control, influence or passivity, clearly referred to body or limb movements

actions, or sensations; delusional perception.

  • c) Hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing him between themselves, or other types of hallucinatory voices coming from some part of the body.
  • d) Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather).

And OR at least two of the following:

e) Persistent hallucinations in any modality, when occurring every day for at least one month.
f) Neologisms, breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech.
g) Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.
h) “Negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses.

There are subtypes including paranoid, catatonic,

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51
Q

What is pharmacological treatment of schizophrenia?

A

Pharmacological treatment:

Atypical antipsychotic (olanzapine, quetiapine - 6-8 week trial)

Treatment resistant schizophrenia = clozapine

Depot antipsychotic (intramuscular injection every 2-4 weeks if patient prefers/non-compliant. (clopixol)

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52
Q

What is the psychological therapy for schizophrenia?

A

Psycho-education and support for the family and carers

Cognitive behavioural therapy

Family interventions

Art therapy

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53
Q

What does the scottish recovery network define recovery of schizophrenia as?

A

Being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms

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54
Q

What is the pathophysiology of schizophrenia?

A

Pathogenesis = Neurotransmitters (e.g dopamine hypothesis including hyperactivity of dopaminergic transmission at D2 receptor)

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55
Q

What is the prognosis of schizophrenia?

A

After first episode 20 % never have recurrence, 50% have relapsing and remitting illness. 30% have ongoing symptoms. Suicide in 10% especially soon after diagnosis

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56
Q

What are good prognostic indicators for schizophrenia?

A

Good prognostic indicator:

Absence of family history

Good premorbid function - stable personality, stable relationships

Clear precipitant

Acute onset

Mood disturbance

Prompt treatment

Maintenance of initiative, motivation.

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57
Q

Whata re poor prognostic indicators for schizophrenia?

A

Poor prognostic indicators:

  • Slow, insidious onset and prominent negative symptoms (apathy, lack of interest and lack of emotions are associated with a worse outcomes)
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58
Q

What are the features of schizoid personality disorder?

A

Preference for solitary activities

Lack of interest in companionship/sexual interactions

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59
Q

What are the features of schizotypal personality disorder?

A

Odd speech

Eccentric behaviour

Paranoid ideation and suspiciousness

Lack of close friends (although they want friends unlike schizoid who would prefer to be alone)

Odd beleifs and magical thinking

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60
Q

What are the features of paranoid personality disorder?

A

Questioning of loyalty of friends

Reluctance to confide in others

Unwaranted tendancy to perceive attacks on their character

Psychological projection

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61
Q

What ar the features of antisocial personality disorder?

A

Little empathy

Disregard for social and societal norms

Impulsive

Willing to hurt others if it helps them

Aggressive and unlawful bnehaviour

Osmosis says that you have to be atleast 18 years old to be diagnosed with anti-social personality disorder

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62
Q

What are the features of narcissistic personality disorder?

A

Grandiose self image

Entitled

Fragile self-esteem that’s vulnerable to criticism

Lack empathy

Only get involved in situations that will benefit personal agenda

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63
Q

What are the features of borderline personality disorder?

A

Unstable self-image

Recurrent suicidal activity

Difficulty controlling temper

Unstable mood

Defence mechanism of splitting - (when an individual classes something as either completely good or completely bad)

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64
Q

What do cluster B personality disorders have a genetic link with?

A

Cluster B personality disorders have a genetic link with mood disorders such as depression and bipolar disorder. They also have a genetic link with substance abuse disorders.

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65
Q

What are the features of histrionic personality disorder?

A

Attention seeking

Superficial relationships

Excessive emotionality - manipulative to draw attention (inappropriately flirtatious, over dramatising stories)

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66
Q

What is avoidant personality disorder?

A

Avoid social risk - but they would want close relationships

Shy

Timid

Low self-esteem

Hypersensitive to rejection and negative feedback

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67
Q

What are the features of obsessive compulsive personalitydisorder?

A

Obsessed with orderliness, perfectionism, complete control, rules, details, schedules

Person is inflexible, easily stressed and has very rigid moral beleifs = they are perceived as being stubborn

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68
Q

What are the features of dependant personality disorder?

A

Overly indecisive

Excessive fear of separation / rejection

Overly dependant on others

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69
Q

What aer the features of attention deficit hyperactivity disorder?

A

Symptoms evident in more than one environment (e.g home, school and in clinic), before age 6 leading to moderate to severe psychological, social and/or educational or occupational impairment

Impaired attention

Overactivity

Associated features:

recklessness in potentially dangerous situations

impulsive flouting of social rules - difficulty waiting their turn, interrupting activities.

Co-morbidity is common (e.g conduct disorder, depressive disorder, autism)

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70
Q

What is the treatment for ADHD?

A

Parenting - training/education programme.

Schools to implement training programme

Group treatment (cognitive behavioural therapy/social skills training for child)

Pharmacological interventions such as methylphenidate or atomoxetine , guanfacine

(Meth, Finn, hydrate) (ALT-J, mexican, Tigne) (guacamole, face, shine)

Stimulant medication acts on DA and NAd systems. Atomoxetine is a non-stimulant and also acts on NAd systems, it is second line.

Treat co-morbidities.

Psychotherapy

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71
Q

What are the three dimensions in autism spectrum disorder?

A

Reciprocity

Language

Obsession

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72
Q

What are the abnormalities assocaited with autism spectrum disorder?

A

Impairment in reciprocal social interaction

Impairment in communication

Restricted repetitive and stereotyped patterns of behaviour, interests and activities.

Associated features include a lack of cognitive flexibility, altered seonsory sensitivity, sensory processing difficultes, emotional dysregulation

Emotional dysfunction

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73
Q

What is the managment of autism spectrum disorder?

A

Psychoeducation

Specialist education and behavioural programmes in mainstream or specialist school.

Treatment of co-morbidities.

Life-long condition. Many adults with autism require lifelong care.

Decrease the demands, reduce the stress, improve the coping

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74
Q

Who is more likely ot get affected by autism spectrm disorder?

A

Male to female ratio is 4:1

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75
Q

What genetic disorders are assocaited with autism spectrum disorder?

A

Neurofibromatosis

Tuberous sclerosis

ALso linked to down syndrome, fragile X

Maternal infection of rubella

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76
Q

What are the features of conduct disorders?

A

Repetitive and persistent patterns of antisocial, aggressive or defiant behaviours which violate age appropriate societal norms

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77
Q

What are outcomes of conduct disorders?

A

Outcomes:

Early death

Social exclusion

Poor school achievement

Long-term unemployment

Criminal activity

Adult mental health problems

Poor interpersonal relationships including those with their own children

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78
Q

What is the managment of conduct disorders?

A

Management:

Parent training programme (12 or younger) e.g. The Incredible Years

Modification of school environment eg behavioural support

Functional family therapy

Multi-systemic therapy

Child interventions: social skills, problem-solving, anger management, confidence building

Treat comorbidity

Address child protection concerns

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79
Q

What are the symptoms of anxiety?

A

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The person finds it difficult to control the worry

C. The anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months).

  • Restlessness or feeling keyed up or on edge
  • Being easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Other symptoms include:

Autonomic arousal - swallowing difficulties, dyspepsia, nausea, wind, tight chest, palpitations, dizziness, sweating

Hyperventilation - breathlessness, hypocapnia

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80
Q

What is a potential screening tool for anxiety?

A

GAD-7

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81
Q

What co-morbid issues may need therapy before treatment of GAD?

A

Depression

Substance misuse

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82
Q

What are the low intensity nd high intensity psychological interventions for GAD?

A

Low intensity =

  • Individual faciliitated self-help
  • Indivdual guided self-help
  • Psychoeducational groups

High intensity =

  • CBT - one to one sessions
  • Applied relaxation
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83
Q

What are pharmacological therapies for GAD?

A

Drug therapy for generalised anxiety disorder at step 3:

Offer SSRI first line eg sertraline (off label but most cost effective) / fluoxetine

If ineffective then swap to a different SSRI or an SNRI (venlaxafine / duloxetine)

If ineffective then consider using pregabalin

Do not use benzodiazepines except for short-term measures during a crisis

Do not offer antipsychotics for anxiety disorder in primary care

Review patients regularly

Continue therapy for at least 12 m after initiation to reduce the risk of relapse

If patient fails to respond to adequate drug treatment or to high-intensity psychological therapies, offer the alternative treatment.

84
Q

What are the reasons to refer someone with GAD to a specialist?

A

Severe anxiety disorder with marked functional impairment and:

  • risk of self-harm or suicide

Significant comorbidity (substance misuse, personality disorder, complex physical health problems)

Self-neglect

Failure to respond to step 3 interventions

Step 4 will develop comprehensive care plan, may offer combined drug and psychological intervetnsions, augmentation of antidepressaants or combinations of antidepressants

85
Q

What is the prognosis of GAD?

A

60% is improved at 5 years

High co-morbidity with alcohol

10% severe impairment

86
Q

What might affect the development, course and the severity of the anxiety state?

A

The following may affect the development, course and severity of anxiety state:

Other anxiety disorder

Depression

Substance misuse

Physical health problems (complex physical health problems is listed as a reason to refer to specialist care)

History of mental health problems

Past experience and response to treatments.

87
Q

What are differentials for GAD?

A

Differential diagnosis:

Psychiatric Conditions

  • Depression
  • Schizophrenia
  • Dementia
  • Substance Misuse

Physical Conditions

  • Thyrotoxicosis
  • Phaeochromoctoma
  • Hypoglycaemia
  • Asthma and or Arrhythmias
88
Q

What is the presentation of phobic anxiety disorders?

A

Same core features as GAD, only in specific circumstances, person behaves to avoid these circumstances.

Anticipatory anxiety - thinking of the actual thing they are afraid of

89
Q

Good screening questions for phobic anxiety disorders

A

Do you find yourself avoiding social situations or activities?

Are you fearful or embarassed in social situations?

90
Q

What are the three specifically important types of phobic anxiety disorder?

A

Agoraphobia

Social phobia (inappropriate anxiety where a person feels observed or could be criticised - restaurants, queues, public speaking) - symptoms are the same as GAD however blushing and tremor predominate. He or she believe that they will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating. The person realises that the fear is unreasonable and excessive. The fear or avoidance is not due to direct physiological effects of a substance (e.g drugs, medications) or a general medical condition not better accounted for by another mental disorder.

Specific phobias

91
Q

What are the therapies available for social anxiety disorder?

A

For social anxiety disorder

1st line = CBT

2nd line = medication (sertraline or escitalopram). Continue for 6 months of treatment once treatment has become effective

92
Q

What is the presentation of obsessive compulsive disorder?

A

Combination of obsession and compulsions

Obsessions: repetitive thoughts, images or impulses, unsuccessfully resisted, recognised as the patient’s own. These are unwilled and occur repeatedly. They are unpleasant and distressing. Anxiety symptoms arise

Compulsions: non-enjoyable repeated rituals or stereotyped behaviours that the patient believes may prevent harm to self or others. Patient recognizes as pointless or ineffective and tries to resist.

Compulsions can include things like locking doors and washing hands.

93
Q

What is the diagnosis of obsessive compulsive disorder?

A

Obsessions and/or compulsions must be present on most days for at least two successive weeks, causing distress or interference with daily activities

Differentials include: depressive disorder, obsessive compulsive personality disorder, part of tourettes syndrome or schizophrenia.

MSE to exclude treatable depressive illness.

94
Q

What is the therapy for obsessive compulsive disorder?

A

1st line therapy = CBT including exposure and response prevention (asking people to resist their urges / compulsions)

2nd Line: Medication; SSRIs (sertraline/citalopram/fluoxetine/paroxetine) - often required at higher doses for longer duration - up to 12 weeks to see a response

3rd line: Medication; clomipramine (most SSRI like of tricyclics)

95
Q

What are the features of post traumatic stree disorder?

A

Three key elements to reaction

Hyperarousal

Re-experiencing phenomena

Avoidance of reminders

Hyper-arousal = persistent anxiety, irritability, insomnia, poor concentration

Re-experiencing phenomena = intense intrusive images, flashbacks when awake, nightmares during sleep

Avoidance = emotional numbness, cue avoidance, recall difficulties, diminishes interests, anhedonia?

96
Q

What is a pre=requisite for the diagnosis of post traumatic stress disorder?

A

Onset is within 6 months of the event

97
Q

What is the treatment for post traumatic stress disorder?

A

Psychological interventions:

Survivors of disasters are screened after one month.

trauma focused CBT has the best evidence base

EMDR (eye movement desensitisation and reprocessing)

Pharmacological interventions: paroxetine (SSRI) or mirtazapine

98
Q

What things might cause an onset of post traumatic stress?

A

Combat

Rape

Natural or human disaster

Assult

torture

Witnessing any of the above

99
Q

What are vulnerability factors for PTSD?

A

Mood disorders

Previous trauma especially as a child

Lack of social support

Female

100
Q

What are protective factors?

A

Higher eduactional group

Social group

Good parental relationship

101
Q

What are comorbidities assocaited with PTSD?

A

Depression

Suicidality

Self-harm

Substance misuse

102
Q

What is the key feature of dementia?

A

6 months or more decline in memory and thinking including impairment of activities of daily living

There must be a clear conscious (i.e not delirium)

103
Q

What are the features of alzheimers dementia?

A

Alzheimer’s

Early stages - memory impairment, executive dysfunction (impaired reasoning, concentratino, impaired visuospatial skills, anosognosia, slee disturbance)

Intermediate stages - behaviour and psychological symptoms (apathy, social disengagement, wandering), dyspraxia, word finding difficulties

Advanced - complete bilitatinon, dependance on others, urinary/fecal incontinence

104
Q

What are the findings of dementia on head CT?

A

Diffuse cortical atrophy (especially on the hippocampus)

Gyri narrowing

Sulci wideneing

Ventricle enlargement

105
Q

What are the potential mental satus clinical asessments available for alzheimers?

A

MoCA

MMSE

106
Q

The presence of what two structural defects is assocaited with alzheimers?

A

Neurofibriallry tangles - happen as a result of tua proteins

Beta amyloid plaques - happen as a result of amyloid precursor protein

107
Q

What gene increases the chance of getting sporadic alzheimers?

A

e4 allele of apolipoprotein E

108
Q

What genes are responsible for the familial alzheimers?

A

mutations in PSEN1 (chromosome 14) and PSEN2 (chromosome 1) genes

(these code for presenilin 1 and presenilin 2 (these code for subunits of gamma secretase that is needed to chop up amyloid precursor protein)

109
Q

Why are people with down’s syndrome more liklely to get alzheimers?

A

Gene responsible for producing APP is found on chromosome 21 - extra expression of APP and therefore there is a potential for more amyloid plaque build up

110
Q

What is non-pharmacological therapy for alzheimers?

A

NICE recommend offering ‘a range of activities to promote wellbeing that are tailored to the person’s preference’

NICE recommend offering group cognitive stimulation therapy for patients with mild and moderate dementia

other options to consider include group reminiscence therapy and cognitive rehabilitation

(So basically give them activities to do, give them cognitive stimulation therapy, group remniscience therapy and cognitive rehabilitation)

111
Q

What are potential drugs you can give for alzheimers?

A

Antichilinesterase inhibitors: rivastigmine, galantamine, donepezil

Memantine

112
Q

What type of drug is memantime?

A

NMDA receptor antagonist

113
Q

When should we use memantine?

A

→ moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors

→ as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s

→ monotherapy in severe Alzheimer’s

114
Q

When should antipsychotics be given to somone with dementia?

A

antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress

115
Q

What is the mean survival of someone with dementia?

A

7-10 years

116
Q

What is the purpose of cholinesterase inhibitors?

A

Cholinesterase inhibitors = improve cognitive function, slow decline, improve non-cognitive symptoms (ADL, longer at home, reduce carer stress)

117
Q

What are the side effects of cholinesterase inhibitors?

A

Nausea, vomiting, diarrhoea

Fatigue

Insomnia

Muscle cramps

Headaches, dizziness

Syncope

Breathing problems

118
Q

What is the most common reason for admission to hospital with dementia?

A

Pneumonia

UTI

119
Q

What is the pattern of progression in vascular dementia?

A

Step wise progression

120
Q

What are risk factors for vascular dementia?

A

History of stroke or transient ischaemic attack (TIA)

Atrial fibrillation

Hypertension

Diabetes mellitus

Hyperlipidaemia

Smoking

Obesity

Coronary heart disease

A family history of stroke or cardiovascular

121
Q

What are the causes of vascular dementia?

A

Cerebral artery atherosclerosis

Carotid artery/heat embolisation

Chronic hypertension - cerebral arterioles sclerosis

Vasculitis

122
Q

What are the signs and symptoms of vascular dementia?

A

Depends on the cortical area affected:

  • Frontal = executive dysfunction
  • Left parietal = aphasia, agnosia, apraxia
  • Right parietal = hemineglect, confusion, agitation, visuospatial
  • Temporal = anterograde amnesia
  • Subcortical infarcts = Focal motor signs, gait disturbance, personality / mood change
123
Q

How is the diagnosis of vascular dementia made?

A

MRI/CT scan - would show cortical/subcortical infarcts

After the infarcts are identified you would want to do further testing to assess the etiology:

  • Carotid doppler - reveal carotid plaques
  • Echocardiogram - reveal cardiogenic emboli
124
Q

What is the pharmacological treatment for vascular dementia?

A

There is no specific pharmacological treatment approved for cognitive symptoms

Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies³.

125
Q

What is the presentation of dementia with lewy bodies?

A

Amnesia not present

PARKINSONISM AND VISUAL HALLUCINATIONS

Two = probable, One = possible

fluctuation - marked, important feature

Visual hallucinations

parkinsonism

Deficits of attention, frontal executive, visuospatial

Supported by falls, syncope, loss of consciousness, other psychiatric problems, autonomic dysfunction, scans, sleep disturbance and sleep walking

126
Q

What scan can be used to detect lewy body dementia?

A

Abnormal DAT scan

Normal patient will show normal reuptake of the dopamine transporter in the caudate nucleus and putamen in the shape of a comma, whereas in DLB, re-uptake in the putamen is reduced, leading to the full-stop sign.

127
Q

What causes lewy body dementia?

A

Alpha synuclein protein aggregation in the neurones (particularly in the neurones and the substantia nigra) forming lewy bodies

128
Q

What is the treatment for dementia with lew bodies?

A

Acetylecholinesterase inhibitors

Dopamine anologues (for motor symptoms)

Atypical neuroleptic agents (persistent disabling hallucinations, psychotic features, used very cautiosuly)

129
Q

What is the presentation of fronto-temporal dementia?

A

Behaviour change

(loss of social inhibition, aggression, apathy and ritualized behaviours, imuplsive behaviours)

Early emotional blunting

Speech disorder - altered output, stereotypy, echolalia, persevation, mutism

Preservation of memory and visuospatial function

130
Q

What is a screening tool for an eating disorder?

A

If patient scores two or more then an eating disorder is likely

Questions include:

Do you make yourself sick because you feel uncomfortably full?

Do you worry you have lost control over how much you eat?

Have you recently lost more than one stone of weight 6.35 kg in a three month period?

Do you believe yourself to be fat when others say that you are too thin?

Would you say that food dominates your life?

131
Q

What are the features of enorexia nervosa?

A

Weight loss: self-induced by dieting/vomiting/purging, excessive exercise, use of appetite suppressants / diuretics, insulin

Overactivity - obsessive housework, fidgeting, twitching, never sitting down, fetching one item at a time, carrying heavy loads

Cooling - inadequate dress, open windows etc

Body image distortions: fear of fatness as over-valued idea.

Endocrine disorder: for females this includes amenorrhoea, for males it includes reduced libido/potency

If onset is pubertal then puberty is delayed or arrested.

Cold intolerance

Blue hands and feet

Constipation

Bloating

Delayed puberty

Primary or secondary amenorrhea

Dry skin

Fainting

Hypotension

Lanugo hair

Scalp hair loss

Early satiety

Weakness, fatigue

Short stature

Osteopenia & osteoporosis

132
Q

What is the diagnostic criteria for anorexia nervosa?

A

Body weight at least 15 percent below of that expected, or BMI index 17.5 or below because of fear of eating

133
Q

What are the differentials for anorexia nervosa?

A

Differentials include depressive disorder, obsessive compulsive disorder, personality disorder.

Somatic causes of weight loss include chronic debilitating diseases, neoplasia, intestinal diseases such as crohn’s disease or a malabsorption syndrome

134
Q

What is therapy for anorexia?

A

Psychological interventions: cognitive analytical therapy, CBT, interpersonal psychotherapy and family interventions - focussed specifically on eating disorders.

Little evidence for pharmacological interventions.

Hospitalisation: minority of patients will require hospital admission with a structured symptom focused weight-restoration programme, with careful monitoring during re-feeding, combined with psychosocial interventions.

135
Q

What are predisopsing factors for anorexia nervosa?

A

OCD

Anxiety disorders

Perfectionism

Trauma

136
Q

What are the health implications assocaited with anorexia?

A

Mental implication: depression, anxiety, loss of concentration

Starvation: reduced immunity, subfertility, anaemia, bone loss, heart damage (arrhythmias, seizures)

137
Q

What is the prognosis of anorexia?

A

Recovery is only in one third

Anorexia nervosa is associated with a mortality of 5-20 percent

Sufferers withdraw from friendships and lose interest in sexual relationships

138
Q

What are the features of bulimia nervosa?

A

Persistent preoccupation with eating.

Irresistable cravings leading to binges

Attempts to counteract fattening foods by self-induced vomiting, purgative abuse, alternating periods of starvation, use of appetite suppressants, thyroid preparations, or diuretics, neglect of insulin treatment in diabetics.

Morbid dread of fatness, sets self sharply defined weight threshold, well below optimal and pre-morbid weight.

Mouth sores

Pharyngeal trauma

Dental caries (tooth decay or cavities)

Heartburn, chest pain

Esophageal rupture

Impulsivity:

  • Stealing
  • Alcohol abuse
  • Drugs/tobacco

Muscle cramps

Weakness

Bloody diarrhoea

Irregular periods

Fainting

Swollen parotid glands

hypotension

Russell’s sign

139
Q

What is the diagnostic criteria for bulimia nervosa?

A

Binges and the resulting compensatory behaviour must occur a minimum of two times per week for three months

140
Q

What is the differential diagnosis of bulimia nervosa?

A

Differential diagnosis = Upper GI disorder, depressive disorder, personality disorder (where the eating disorder may coexist with alcohol dependance and petty offences such as shoplifting)

141
Q

What is the treatment for bulimia nervosa?

A

Evidence based self-help programme

Cognitive behavioural therapy for bulimia nervosa

Anti-depressants (SSRI’s specifically fluoxetine)

Involve family members in treatment - psycho eduction/behavioural management/communication.

142
Q

What are the risk factors for bulimia nervosa?

A

Risk factors for bulimia:

Obesity

Mood disorder

Sexual or physical abuse

Parental obesity

Substance misuse

Low self-esteem

143
Q

What is binge eating disorder?

A

Similar to binge eating disorder but without the purging behaviour

144
Q

What are the features of delirium?

A

ACUTE ONSET
FLUCTUATING

·Impaired attention/concentration

·Anterograde memory impairment

·Disorientation in time, place or person

·Fluctuating levels of consciousness (often nocturnal exacerbations)

·Disordered sleep/wake cycle

·Increased/decreased psychomotor activity

·Disorganised thinking as indicated by rambling, irrelevant or incoherent speech

·Perceptual distortions, leading to misidentification, illusions, and hallucinations

·Changes in mood such as anxiety, depression and lability

145
Q

What can cause delirium?

A

Infection (but not always a UTI!)

Dehydration

Biochemical disturbance

Pain

Drugs

Constipation/Urinary retention

Hypoxia

Alcohol/drug withdrawal

Sleep disturbance

Brain injury

Stroke/tumour/bleed etc

Changes in environment

146
Q

What are the features of amnesic syndrome?

A

Preserved global intellectual abilities

Anterograde amnesia

Retrograde amnesia (temporal gradient)

Preserved registration/working memory (digit span)

Preserved procedural (implicit memory)

147
Q

What are causes of amnesic syndrome?

A

Causes of Amnesic Syndrome:

Hippocampal damage:

·Herpes simplex virus encephalitis

·Anoxia

·Surgical removal of temporal lobes

·Bilateral posterior cerebral artery occlusion

·Closed head injury

·Early Alzheimer’s disease

Diencephalc Damage:

·Korsakoff’s syndrome (alcoholic and non-alcoholic)

·3rd ventricle tumours and cysts

·Bilateral thalamic infarction

·Post subarachnoid haemorrhage, especially from anterior communicating artery aneurysms

148
Q

What are common conditions assocaited with learning difficulties?

A

Epilepsy – increased incidence and complexity with severity of learning disability (10-50%)

Sensory impairments – hearing (40 %) and vision (20%), earwax

Obesity – predisposes to other health problems

Gastrointestinal – swallowing problems, reflux oesophagitis, Helicobacter pylorii, constipation

Respiratory problems – chest infections, aspiration pneumonia

Cerebral palsy – especially with severe learning disability

Orthopaedic problems – joint contractures, osteoporosis

Dermatological and Dental problems- 33% unhealthy gums, for Down’s Syndrome, 80%

Psychiatric disorders as well.

149
Q

What psychiatric conditions are more common in people with learning difficulties?

A

Schizophrenia

Psychosis

Mood disorders

OCD

Autism

Overactivity syndromes

150
Q

What mannerisms are more common in learning disability?

A

Head banging

Rocking

151
Q

What are areas for assessment in leaning disability?

A

Aetiliogy

Assocaited biomechanical conditions

Severity of LD

Psychiatric disorders, their cause and consequences

(so what caused them, how basd they are, anything else going on?)

152
Q

What is the ICD 10 diagnosis of learning disability?

A

‘A condition of arrested or incomplete development of the mind, which is especially characterised by impairment of skills manifested during the developmental period, which contribute to the overall level of intelligence i.e. cognitive, language, motor and social abilities’

SO basically this is an underdeveloped brain, a deficit in skills which contribute to their level of intelligence

153
Q

What is the diagnostic criteria for learning disability?

A

Criteria:

  1. Intellectual impairment (IQ < 70) (Wechsler)
  2. Social or adaptive dysfunction (Vineland Scale)

Deficits/Impairments in 2 or more of following adaptive skills: communication, self-care, home living, social skills, community use, self direction, health and safety, functional academics, leisure & work

3.Onset in the developmental period (age 18)

154
Q

IQ classification

A

Classification: IQ is used to classify

Mild learning disability 50 to 69

Moderate learning disability 35 to 49

Severe learning disability 20 to 34

Profound learning disability <20

155
Q

What are key points for managment of a learning disability?

A

Take time and have patience.

Value what is being communicated.

Recognise non-verbal cues.

Find out about the person’s alternative communication strategies if verbal communication is difficult (e.g. their typical non-verbal cues, use symbols, sign language).

Explain things clearly in an appropriate way (verbally & with pictures etc). Simple, short, jargon free language

Be prepared to meet the person several times to build up rapport & trust.

Use the knowledge and support of people’s carers

Books beyond words - this helps communication with people with learning difficulties

156
Q

Aetiology of learning disability?

A

Aetiology

●Genetic: e.g.

Single gene: Fragile X, PKU, Retts Syndrome

Microdeletion/duplication: DiGeorge Syndrome, Prader-Willi, Angelman syndrome

Chromosomal abnormality: Down Syndrome

●Infective :

ante-natal e.g. rubella;

post-natal e.g. meningitis, encephalitis

●Toxic: e.g. foetal alcohol syndrome

●Trauma: e.g. birth asphyxia, head injury

●Unknown: for most individuals, the cause of their LD is unknown

157
Q

Note for learning disability

A

Beware of ‘diagnostic overshadowing’

Presenting symptoms are put down to their learning disability, rather than seeking another potentially treatable cause:

Social cause - change in carers, lack of support, lack of social activities

Psychological issues - bereavement, abuse

Physical problems - pain or discomfort, e.g. from ear infection, toothache, constipation, reflux oesophagitis, deterioration in vision or hearing.

Psychiatric cause - depression, anxiety, psychosis, dementia

158
Q

What are panic attacks?

A

Panic attacks are described as intense fear or physical discomfort reaching its peak within a few minutes. 4 of the following symptoms are present:

  • Palpitations, pounding heart, tachycardia
  • Sweating
  • Muscle trembling, shaking
  • Shortness of breath, sensations of smothering
  • Choking sensations
  • Chest pain or discomfort
  • Nausea, abdominal distress
  • Dizzy, lightheaded, instability, feeling faint
  • Derealization, depersonalization
  • Fears of losing control or going crazy
  • Fear of dying
  • Numbness, tingling sensations
  • Chills, hot flushes.
159
Q

Note on panic disorder

A

‘Recurring unforeseen panic attacks, followed by at least a month of persistent worry about having another attack and concern about its consequences OR a significant change in behaviour related to the panic attacks.’

So you have persistnat panic attacks

You are worried about having another

You are concerned about the consequences of a panic attack or a significant change in behaviour related to the panic attack.

160
Q

What is the treatment of panic disorder?

A

Mild-moderate =

Self help

Moderate - severe =

Psychological therapy

Drug treatment

Self-help = offer bibliotherapy based on CBT principles, offer information on support groups, discuss the benefits of exercise as part of good health. Review progress appropriately based on individual circumstances (often every 4-8 weeks)

Psychological interventions:

CBT

Drug treatment:

SSRI for panic disorder (citalopram, sertraline, paroxetine, escitalopram but NOT fluoxetine

If there is no response in 12 weeks / unable to use the SSRI then consider imipramine or clomipramine - both of these are dangerous in overdose.

Avoid benzodiazepines / sedating antihistamines / antipsychotics

If one therapy (CBT, drugs, self-help) fails to give adequate response, try an alternative from the list; if no response, refer for specialist input (CMHT)

161
Q

What is the presentation of grief?

A
  • Feelings of disbelief and difficulty comprehending the reality of the loss.
  • Bitterness/anger/guilt/blame.
  • Impaired functioning: within the family, socially, ability to work/go to school.
  • Intense yearning and sadness, and emotional and physical pain. There may be physical symptoms of anxiety.
  • Mental fogginess, difficulty concentrating, forgetfulness.
  • Loss of sense of self or sense of purpose in life.
  • Feeling disconnected from other people and ongoing life.
  • Difficulty engaging in activities or making plans for the future.
162
Q

What are the key differences between normal grief and depression?

A

Differentiating grief from depression

  • Grief includes longing/yearning for the loved one
  • positive emotions can still be experienced
  • symptoms worst when thinking about the deceased person.
  • people often want to be with others, whereas people with depression tend to want to be alone.
163
Q

What is the length of time recquired for prolonged grief disorder?

A

Presence of distress and disability for more than 6 months after bereavement

164
Q

What are treatment options for prolonged grief disorder?

A

Treatment options:

Counselling eg Cruse

Antidepressants for co-morbid depression

Behavioural /cognitive/exposure therapies

Refer if significant impairment in functioning

165
Q

What are things covered in sleep hygiene?

A
  • Avoid stimulating activities before bed
  • Avoiding alcohol/caffeine/smoking before bed
  • Avoid heavy meals or strenuous exercise before bed
  • Regular day time exercise
  • Same bedtime each day
  • Ensure bedroom environment promotes sleep
  • Relaxation
166
Q

What is the therapy for insomnia?

A

CBT - 1

Medications not routinely advised

Melatonin licensed if over 55 years for short term insomnia <13 weeks use

Hypnotics: Z drugs (zolipidem/zopiclone) / temazepam - only in severe disabling insomnia causing marked distress

Addictive potential, may interfere with next day tasks, avoid driving / operating machinery 8 hrs after use

Reduces time to fall asleep by 22 minutes

167
Q

What are causes of insomina?

A

Anxiety / depression

Physical health problems (pain, dyspnoea)

Obstructive sleep apnoea (risk increased if BMI is 30 or over or neck circumference is 40 cm or greater)

Excess alcohol or illicit drugs

Parasomnias (restless legs, sleep walking/talking/sleep terrors/teeth grinding (bruxism etc)

Circadian rhythm disorder (especially shift workers)

168
Q

What are side effects of TCAs?

A

Antihistaminic (sedation and weight gain)

Antiadrenergic (orthostatic hypotension, sedation, sexual dysfunction)

Anticholinergic (dry mouth, dry eyes, constipation, memory deficits and potentially delirium)

Lethal in overdose

Can cause QT lengthening

Side effects of secondary TCAs are the same as tertiary TCAs but are generally less severe

169
Q

Give an example of a monamine oxidase inhibitor

A

Phenelezine

170
Q

What are side effects of monamine oxidase inhibitors?

A

Anti-adrinergic and anti-muscarinic?

Orthostatic hypotension

Sexual dysfunction

Sedation

Dry mouth

Sleep disturbance

Hypertensive crisis can develop when MAOI’s are taken with tyramine rich foods or sympathomimetics (cheese reaction)

171
Q

What is the main risk attached to monamine oxidase inhibitors?

A

Serotonin syndrome can happen as a result of taking MAOIs as well as meds that increase the levels of serotonin as well as drugs with sympathomimetic actions.

172
Q

What are the symptoms of serotonin syndrome?

A

Serotonin Sy:

Abdominal pain

Diarrhoea

Sweats

Tachycardia

Myoclonus

HTN

Can lead to hyper-pyrexia, cardiovascular shock and death

173
Q

How do you avoid serotonin syndrome?

A

TO AVOID SEROTONIN SYNDROME - wait two weeks before switching from an SSRI to an MAOI. Fluoxetine = 5 weeks because of the long half-life.

174
Q

Give examples of SSRI

A

Paroxetine - short half-life, sedating - bad discontinuation syndrome - can be given during pregnancy?

Sertaline - short half-life, less sedating, requires full stomach for max absorption

Fluoxetine - long-half life (this means there is less incidence of discontinuation syndrome, good if issues with compliance). More likely to induce mania than some other SSRI’s.

Citalopram - low inhibition of P450 enzymes so fewer drug-drug interactions. Increases QT interval. GI side effects.

175
Q

What are side effects of sertraline?

A

GI upset

Sexual dysfunction

Anxiety

Restlessness

Nervousness

Insomnia

Fatigue

Sedation

Dizziness

176
Q

What are symtoms of discontinuation syndrome?

A

agitation, nausea, disequilibrium and dysphoria

177
Q

What antidepressant is preferred in patients with anorexia?

(to treat depression not anorexia)

A

Mirtazapine is an antidepressant preferred in patients with anorexia nervosa as it also elevates the appetite and produces weight gain.

178
Q

What are examples of SNRI’s?

A

Venlaxafine

Duloxetine

179
Q

How do SNRI’s work?

A

Inhibit both serotinin and noradrenergic reuptake like the TCAs but without the antihistamine, antiadrenergic or anticholinergic side effects

180
Q

What are your examples of novel antidepressants?

A

Mirtazapine (5HT2 and 5HT3 receptor antagonist)

Buproprion - this is contraindicated in bulimia

181
Q

What are the uses of mood stabilisers?

A

Bipolar diosrder

Cyclothymia

Schizoaffective disorder

182
Q

What are the side effects of lithium?

A

GI - nausea, vomiting, diarrhoea

Fine tremor

Noprhotoxicity - polyuria secondary to nephrogenic diabetes insipidus

Thyroid enlargement - may lead to hypothyroidism

ECG - t wave flattening/inversion

Weight gain

IIH

183
Q

What is the presentation of lithum toxicity?

A

Lithium toxicity:

Mild = vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus

Moderate = nausea, vomiting, blurred vision, clonic limb movements, convulsions, delirium, syncope

Severe = generalised convulsions, oliguria and renal failure

184
Q

What tests are necessary before starting someone on lithium?

A

Baseline U and E and TSH

Check for pregnancy (avoiding ebsteins anomaly)

185
Q

What is the treatment of lithum toxicity?

A

mild-moderate toxicity may respond to volume resuscitation with normal saline

haemodialysis may be needed in severe toxicity

sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion

186
Q

What are the side effects of valproic acid?

A

Thrombocytopenia and platelet dysfunction

Nausea, vomiting, weight gain, sedation

Increased risk of neural tube defects in general population secondary to reduction in folic acid

187
Q

What drug is first line for mania prophylaxis?

A

Carbamzepine

188
Q

What are the side effects of carbamazepine?

A

Rash is the most common SE seen

Nausea, vomiting, sedation

Aplastic anaemia and agranulocytosis

Hyponatraemia - SiADH

189
Q

What is a side effect of lamotrigine?

A

TENS

Stevens Johnson’s syndrome

Blood dyscrasias

190
Q

What are examples of typical antipsychotics?

A

Fluphenazine

Haloperidol

Pimozide

191
Q

What are side effects of antipsychotics?

A

Extrapyramidal side effects:

  • Parkinsonism

Acute dystonia (torticollois and oculogyric crisis)

Antipsychotics = stroke and VTE risk

Antimuscarinic (dry mouth, blurred vision, urinary retention, constipation)

Sedation

Weight gain

Raised prolactin (reduced inhibition from dopamine)

Neuroleptic malignant syndrome

Reduced seizure threshold

Prolonged QT (especially haloperidol)

192
Q

Give examples of atypical antipsychotics

A

olanzapine

risperidone

Quetiapine

CLozapine

193
Q

What is the main risk attached to clozapine?

A

Agranulocytosis - requires weekly blood draws for 6 months, then every two weeks for 6 months

Clozapine is used for treatment resistant schizophreia becuase of the side effect profile

194
Q

What are side effects of benzodiazepines?

A

Solomnence

Cognitive deficits

Amnesia

Disinhibition

Tolerance

Dependance

195
Q

What are indications for anxiolytics?

A

Panic disorders

GAD
substance related disorders and their withdrawal

Insomnias

Parasomnias

196
Q

Which act allows people to be detained for treatment?

A

Mental Health (and care) act 2003

197
Q

What are the differnt lengths of time someone can be detained for under the mental health (care and treatment) act 2003?

A

Emergency detention certificate = 72 hours

Short-term detention certificate = 28 days

Compulsory treatment order = 6 months

Nurses holding power = 3 hours

198
Q

Who can dish out the likes of emergency detention ccertificates, short term detention certificates and compulsory treatment orders?

A

Emergency detention certifiicate = Before granting the certificate, the doctor must consult a mental health officer and get his/her agreement, unless it is not possible for this consultation to take place.

Short term detention certificate = Before granting the certificate, the doctor must consult a mental health officer (MHO) and get his/her agreement. Before deciding whether to agree to the certificate, the MHO should see you and discuss matters with you, unless there is a good reason why they cannot do this.

Compulsory treatment order = Mental health officer sends an application to mental health tribunal, also recquires reports from GP and approved medical practitioner or 2 approved medical practitioners

199
Q

What are the reasons for using an emergency detention certificate?

A

Must consider it likely that:

  • Patient has a mental disorder
  • Becasue of their mental disorder their decision making ability is impaired

Must also be satisfied that:

  • Detaiment is needed in order to decide medical treatment
  • Risk to themselves or the others if not detained
  • Granting short-term detention certificate would involve undesirable delay
200
Q

What are the reasons that a short-term detention certificate or a compulsory treatment order be used?

A

Must consider it likely that:

  • Patient has a mental disorder
  • Becasue of their mental disorder their decision making ability is impaired

Must also be satisfied that:

  • Detaiment is needed in order to decide medical treatment (CTO - medical treatment is available and would likely prevent deterioration or allevaite symptoms)
  • Risk to themselves or the others if not detained
  • It is necessary
201
Q

What are the potential powers, allowing decisions to be made on behalf of the patient?

A

Powers (these are the people who make decisions for the person)

Intervention order (one off power is required and there is an application to the court, so I think this means that thye court makes a decision for the patient)

Guardianship order. Somone else is appointed to make decisions on behalf of the adult (financial or welfare or both)

202
Q

What act is this:

The person (criminal) can be removed from a public place if they appear to be in immediate need of care. They can be detained for up to 24 hours in order to allow for assessment and make arrangements for their care and treatment.

A

Mentally disordered offenders provisions - Criminal procedures act 1995

203
Q

When can someone be acquitted from the wrong doing of a crime?

A

Criminal Responsibility - part of criminal justice and licensing act

Says a person can be acquitted from a criminal act if they were unable to appreciate the wrongful nature of an act as a resul tof a mental disorder. This does not include aggressive and irresponsible disorders of personality.

204
Q

Which act allows the following:

Unfitness for trial:

They can be classified as unfit for a trial if a mental or physical condition stops them from participating effectively in the trial.

A

Criminal justice and licensing act (scotland 2010)

205
Q

When can murder be rebranded as culpable homocide?

A

Diminished responsibility:

A person with abnormality of the mind at the time of the offence can be charged of culpable homocide instead of murder. Abnormality of mind includes mental disorder. Being on drugs or alcohol doesn’t constitute abnormality of mind.

206
Q

What are the foresnsice sections?

A

Compulsion order

Restriction order

Assessment order

Treeatment order

207
Q
A

The Panic Zone (15 decks)

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