Psychiatry Flashcards
What is somatic syndrome?
Depression with more physical symptoms
What is atypical depression?
Mood reactivity
Increase appetite and sleep
Leaden paralysis (heavy limbs)
What is psychotic depression?
Paranoid or hypochondriae or with nihilistic delusions
What are nihilistic delusions?
A nihilistic delusion of the nonexistence or dissolution of a body part; in extreme form, the delusion of being dead or nonexistent
Rate of suicidal thoughts/behaviour in depression?
25%
Onset age of bipolar disorder?
Late teens/early 20s
Bipolar disorder is a spectrum of..? (2 things)
Severity (mania vs hypomania)
Proportion (more depressed/manic)
Symptoms of hypomania + mania?
Elevated mood Restlessness Increased talkativeness (pressure of speech) Decreased need for sleep Increased sexual energy Difficulties concentrating
Symptoms of mania?
Flight of ideas
Loss of social inhibitions
Grandiosity
Reckless behaviour
Bipolar carries increased risk of … compared to other mental disorders
Suicide
Which kind of antidepressants are generally first line?
SSRIs
How long should antidepressants be used?
At least 6 months after remission
Treatment for bipolar in acute mania?
Anti-psychotics + Lithium
Benzodiazepines for symptom control
Hospitalisation if severe
Treatment of bipolar depressive phase?
Anti-depressant (SSRI- fluoxetine, lamotrigine)
+ Lithium
ECT if severe
What should be monitored in elderly people taking anti-depressants?
Sodium- risk of hyponatraemia
What do monoamine oxidase inhibitors (MAOIs) do?
Inhibit enzyme responsible for monoamine metabolism (less serotonin/noradrenaline metabolised)
Examples of MAOIs?
Moclobemide (reversible)
Phenelzine (irreversible)
When put fennel in food, it’s irreversible!
Side effects of MAOIs?
Postural hypotension Drowsiness Nausea Insomnia Constipation Peripheral Oedema
Depersonalisation?
Body not yours or disconnected from you
Derealisation?
Disconnected from world or “spaced out”
What are the dietary restrictions associated with MAOIs?
Tyramine foods (cheese, red wine, red meats etc)–> cause hypertensive crisis
How do tricyclic antidepressants work?
Block the reuptake of monoamines (5-HT and noradrenaline) at the presynaptic terminals
Examples of tricyclics?
amitriptyline, imipramine, dosulepin, lofepramine
When should tricyclics be avoided?
In suicidal patients
Side effects of triCyCliCs? (3Cs= clue)
Cardiovascular= postural hypotension, tachycardia, arrythmias Cognitive= impairment in elderly anti-Cholinergic= blurred vision, dry mouth, constipation, urinary retention
+ Weight gain, sedation
How do SSRIs work?
Selectively inhibit reuptake of serotonin
Examples of SSRIs?
Fluoxetine, citalopram, escitalopram, sertraline
Side effects of SSRIs?
N+V, headache, transient anxiety, agitation, sweating, sexual dysfunction, insomnia, HYPONATRAEMIA in elderly
Examples of dual reuptake inhibitors?
Venlafaxine, Duloxetine
Name an atypical anti-depressant and its use?
Mirtazapine
Supplement SSRIs to block serotonin side effects e.g. nausea
can cause weight gain, sedation
When is Reboxetine good to use?
In patients with reduced energy
won’t get tired with your Reeboks on
How is lithium monitored?
Lithium levels
U+Es
TFTs
ECG
Side effects of lithium?
GI upset, Tremor, HYPOTHYROIDISM, Weight gain, renal impairment, polydipsia, polyuria, sedation
Lithium toxicity signs include?
Vomiting, diarrhoea, ataxia, tremor, drowsiness, convulsions
What is sodium valproate?
Anti-convulsant- sometimes used in mania
Side effects of sodium valproate?
sedation, tremor, dizziness, GI upset, weight gain, TERATOGENIC
Features of addiction?
Strong desire Difficulties in control Psychological withdrawal Tolerance Neglect of alternative pleasures Persistence despite harm
CAGE questions for alcohol abuse?
- Have you ever felt you needed to Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
Why does neglect of other pleasures occur in addiction?
Relative lack of dopamine release
Why does tolerance occur in addiction?
Less dopamine released than in non-addicts (more needed for pleasure)
What is the role of the prefrontal cortex in addiction (3 roles)?
Helps intention guide behaviour + reward pathways + impulse control
Why is prefrontal cortex development relevant to addiction?
Last part of brain to develop- in early 20s
Shows lower activity in addicts
Craving in addictions is mediated by which parts of the brain?
Hippocampus
Striatum
Amygdala
What is heroin metabolised to?
Morphine
Effects of heroin?
Euphoria Analgesia Respiratory depression Constipation Contricted pupils Hypotension/bradycardia
Heroin withdrawal symptoms?
Dysphoria, agitation, tachycardia/hypertension, piloerection (hairs on end), diarrhoea, N+V, dilated pupils, joint pains
Complications of IV drug use?
Infection- cellulitis, abscess, endocarditis, HIV, Hep B/C
DVT
PE
Ischaemic limb
Treatment of heroin addiction?
OST- opiate substitution therapy
- replace short acting for long acting
- methadone
Why is opiate detoxification risky?
10% of completers dead after 4 months
Increased overdose- go back to previous dose
How to calculate number of units?
(% x volume)/10
What is high risk drinking?
> 35 units/week
Harmful effects of alcohol?
N+V, gastritis, mallory-weiss tears, ulcers, malnutrition, vitamin deficiency, hepatitis, arrythmias, dementia, cancer etc
Which LFT indicates liver injury? (in e.g. alcohol)
Gamma GT
What causes alcohol withdrawal?
Excess glutamate and less GABA activity
Symptoms of delirium tremens?
Confusion, agitation, disorientation, hypertension, fever, hallucinations (V+A), paranoia
Treatment of delirium tremens/alcohol withdrawal?
Benzodiazepines (e.g. chlordiazepoxide)
Vitamin supplementation
How does Antabuse work?
inhibits acetyldehyde dehydrogenase (cause unpleasant effects)
Drug name of antabuse?
Disulfiram
What is Acamprosate used for in alcohol relapse prevention?
Reduces cravings
First line for alcohol relapse prevention?
Naltrexone
Physical symptoms of anxiety?
Sweating, tremor, muscle tension, numbness, lightheadedness, dizzy, difficulty breathing, increase HR, nausea, chest pain etc
Behavioural symptoms of anxiety?
Avoidance, exaggerated response, sleep disturbance, restlessness, irritability, alcohol/drugs, checking behaviours
Cognitive symptoms of anxiety?
Feelings of losing control, on edge/tense, difficulty concentrating, derealisation, depersonalisation. hypervigilance, racing thoughts
2 definitions of anxiety disorder?
More extreme anxiety than normal
Anxiety is abnormal situations
Treatment of GAD?
CBT
SSRI/SNRI
Pregabalin
benzodiazepines (short-term)
Characteristics of panic disorder?
Unpredictable, recurrent attacks of severe anxiety with no pattern
What co-exists with panic disorder in 50-65%?
Agoraphobia
phobia of having panic attacks in public
Characteristics of phobia?
Irrational/Excessive fear
Marked and persistent
Avoidance and anticipatory anxiety
What is social anxiety disorder?
Persistent fear of social performance with unfamiliar people/scrutiny of others
Fear of embarrassment/humiliation
Obsessional thoughts associated with OCD?
Ideas/images/impulses
Patient’s own thoughts
Unpleasant + resisted thoughts
Compulsive acts associated with OCD?
Repeated rituals/stereotyped behaviour
No purpose- view as neutralising
Treatment of OCD?
CBT
SSRIs
Clomipramine (TCAD)
Definition of major incident?
Situation with multiple casualties due to natural/unnatural causes, that is beyond what normal emergency services can cope with
What is tonic immobility?
Involuntary state of profound motor inhibition due to fear
Main events leading to PTSD?
Sexual assault Burns Combat veterans RTAs Intensive care
Symptoms of PTSD?
Intrusive thoughts
Avoidance behaviours (reminders, amnesia, detachment)
Hyperarousal- sleep disturbance, anger, low conc
Dissociation
Survivor guilt
Neurobiological features of PTSD?
Hippocampal atrophy
Increase amygdala activity
Low cortisol
Treatment of PTSD?
Trauma focused CBT
EMDR
Exposure therapy
Meds: paroxetine, mirtazapine
Reasons for deliberate self harm?
Die
Escape situation/anguish
Display desperation
Influence others
What do brain scans show in recent self-harmers?
Decreased frontal lobe activity
What are the most common methods of suicide in UK?
Hanging/poisoning
What pathology causes Alzheimer’s disease?
Amyloid plaques and neuro-fibrillary tangles
At what age is Alzheimer’s disease considered early onset?
<60 years
How do benzodiazepines work?
Enhancing action of GABA- open Cl channels- less APs produced
Examples of benzodiazepines?
Lorazepam, diazepam, chlordiazepoxide
What do benzodiazepines do?
Reduce anxiety, aggression
Sedation
Muscle relaxation
Anti-convulsant
What can benzodiazepines cause with alcohol?
Respiratory depression
Symptoms of benzodiazepine withdrawal?
Confusion, tachycardia, psychosis, sweating, hypertension, tremor, agitation, abdo cramps
What is a functional disorder?
Cannot easily associate symptoms with classically identifiable organic disease
(like a ‘software’ problem- no obvious cause)
Common functional symptoms?
Pain, altered sensation, dizziness, movement disorder, weakness, seizures (non-epileptic attacks), cognitive symptoms
Important history for functional symptoms?
Timeline of symptoms Disability PMH ICE Psychiatric/mood history
Should you exam functional symptoms?
ALWAYS EXAMINE
inconsistent findings common
Management of functional disorders?
Reassure
CBT
Tricyclic antidepressants
Classic symptoms of psychosis?
Hallucinations, delusions, disorder of form of thoughts
Impaired communication/relating to others
Unable to recognise reality
What are neologisms?
Assuming you understand strange words they’re using
Differential of psychosis?
Schizophrenia Substance abuse (drug induced) Mania with psychosis Depressive psychosis Dementia Delirium
Positive symptoms of schizophrenia?
Hallucinations (often 3rd person auditory)
Delusions
Passivity of thought
Thought interference
Passivity (outside control of affect, impulses etc.)
Negative symptoms of schizophrenia?
Reduced speech BLUNTED affect Reduced motivation Reduced interest Reduced social interaction
Causes of schizophrenia?
Multifactorial GENETIC (often seen in same families)
Risk factors for schizophrenia?
Obstetric problems (pre-eclampsia, fetal hypoxia, prolonged labour) Childhood viral CNS infection Drug use (esp. cannabis) Urban dwelling Social adversity/deprivation
Neurological findings in schizophrenia?
Reduced frontal lobes volume + grey matter
Enlarged ventricles
Altered dopamine signalling (overactivity)
Prognosis of schizophrenia?
Some have relapsing/remitting, some have progressively worse
10-15% commit suicide
Which anti-psychotics are first line?
Atypicals (2nd generation- newer)
Which type of anti-psychotic can be used if compliance is an issue?
Depot
Name some mood stabilisers?
Lithium
Sodium Valproate
Carbamazepine
Lamotrigine
How do typical anti-psychotics work?
Block D2 receptors
Examples of typical anti-psychotics?
Chlorpromazine Thioridazine Fluphenazine Haloperidol Zuclopentixol
Side effects of typical anti-psychotics?
Acute dystonic reaction (muscle spasms)
Parkinsonism
Tardive dyskinesia (repetitive involuntary purposeless movements + inner restlessness)
Hyperprolactinaemia (due to lack of prolactin inhibition by dopamine)
Treatment of acute dystonic reactions?
Anti-cholinergics
What is akathisia?
Inner restlessness
Symptoms of hyperprolactinaemia in antipsychotics?
Sexual dysfunction, galactorrhoea, gynaecomastia, amennorhea, infertility
How do atypical anti-psychotics work?
Transient block D2 receptors, and block 5HT2 receptors too
Examples of atypical anti-psychotics?
Olanzapine
Risperidone
Quetiapine
Clozapine
Side effects of atypical anti-psychotics?
MUSCARINIC BLOCKADE (blurred vision, dry eyes, dry mouth, constipation, urinary retention) Metabolic syndrome (high CV risk) Sedation Increased appetite Postural hypotension
Major side effects of clozapine?
Agranulocytosis (fever, sore throat)
Myocarditis
Monitoring for clozapine?
FBC
ECG + BP
Psychiatric illness is 3 times as common in people with LD. How can it be managed?
Improve skills + relaxation CBT Antidepressants Physical e.g. headgear, guards Aid communication
Define violence?
Intentional use of physical force or power, threatened or actual against self or others
Results in injury, psychological harm or deprivation
Predictors of violent behaviour?
Severe mental illness
Substance abuse
History of violence
Define aggression?
Intentionally hurting or gaining advantage over another
What can be used as rapid tranquillisation in aggression?
oral Lorazepam or Haloperidol
Then IM injection
What are personality disorders and when are they diagnosed?
Enduring pattern of inner experience + behaviour that deviates markedly from the expectations of an individuals culture
Diagnosed >18 years
Manifestations of personality disorders? (4)
- Cognition (perceptions)
- Affectivity (range/ intensity of emotion)
- Interpersonal functioning
- Impulse control
Which personality disorder is most inheritable?
Obsessive compulsive personality
How many people are affected by personality disorders?
10%
Which personality disorders are until Cluster A: odd and eccentric?
Paranoid
Schizoid
Schizotypical
Which personality disorders are until Cluster B: dramatic, emotional, erratic?
Antisocial
Borderline
Histrionic
Narcissistic
Which personality disorders are until Cluster C: anxious and fearful?
Avoidant
Dependent
Obsessive-Compulsive
Features of paranoid PD?
Distrust and suspicion of others that motives are malevolent
Doubts of loyalty and partner fidelity
Bears grudges
No confiding in others
Features of schizoid PD?
Detachment from social relationships and restricted range of emotion No close relationships Solitary Detachment/emotional coldness Aloof/fantasy world
Features of antisocial PD?
Disregard for rights of others Deceitful No conform to laws Impulsivity, aggression Disregard for safety Irresponsible Lack of REMORSE
Features of borderline PD?
Instability of interpersonal relationships, self-image, affect + impulsivity (money, sex, driving etc.) Avoid abandonment Unstable/intense relationships Extreme moods Suicidal/DSH
Features of histrionic PD?
Excessive emotionality + attention seeking Centre of attention Provocative behaviour Self-dramatisation Suggestible
Features of avoidant PD?
Social inhibition, feeling inadequate, hypersensitive to negative evaluation
Avoid activities leading to criticism
Reluctant for new activities- embarrassment
Features of dependent PD?
Excessive need to be taken care of Submissive/clingy behaviour Fear of separation Seeking advice/reassurance Uncomfortable alone Seeks new relationships when others end
Features of obsessive-compulsive PD?
Preoccupation with orderliness, perfectionism at expense of flexibility and efficiency Details, rules, lists, order, schedules Devoted to work Overconscientious Rigid
Treatments of PD?
Antidepressant (borderline)
DBT- dialectical behavioural therapy
Mindfulness
Topiramate for aggression
What causes Karsakoff’s amnesia?
Severe thiamine (vit B1) deficiency In chronic alcoholism
How long do dementia symptoms last for a diagnosis?
At least 6 months
What must be considered when interpreting cognition score?
Pre-morbid cognition (e.g. doctor, lawyer etc. may have higher scores)
Symptoms of Alzheimer’s disease?
Memory loss (esp. short term)
Dysphasia
Dyspraxia
Agnosia (cannot recognise objects)
Neuropathology of Alzheimer’s disease?
Amyloid plaques and neurofibrillary tangles
Temporal lobe atrophy
Posterior Frontal Atrophy is a type of Alzheimer’s disease. What are its special features?
Visual/ visuo-spatial symptoms
Symptoms of vascular dementia?
Dysphasia Dyscalculia (number difficulties) Frontal lobe symptoms Apathy Decreased processing speed Focal neurology
Progression of vascular dementia?
Step-wise decline
What does a CT/MRI show in vascular dementia?
Small vessel disease or multiple lacunar infarcts
Symptoms of frontotemporal dementia?
Behaviour changes Executive functioning Disinhibition +Impulsivity Decreased social skills PRIMARY PROGRESSIVE APHASIA- lack of words, impaired understanding of words
What does a CT/MRI show in frontotemporal dementia?
Frontotemporal atrophy
Features of Lewy-Body Dementia?
Cognitive impairment + parkinsonism
Triad of FALLS, VISUAL HALLUCINATIONS + FLUCTUATING COGNITIVE IMPAIRMENT
REM sleep disorders
Features of dementia with Parkinson’s?
Parkinsonism for >1 year BEFORE dementia onset
How is all Alzheimer’s, Lewy Body and Parkinson’s Dementia treated?
Cholinesterase Inhibitors
Examples of Cholinesterase Inhibitors?
Donepezil, Rivastigmine, Galantamine
How do Cholinesterase Inhibitors work?
Increase cholinergic transmission
SLOWS PROGRESSION
Side effects of Cholinesterase Inhibitors?
N+V, diarrhoea, headache, muscle cramps, bradycardia, worsen COPD/asthma
Contraindications of Cholinesterase Inhibitors?
Active peptic ulcer
Asthma
COPD
Apart from Cholinesterase Inhibitors, what else is commonly prescribed in Alzheimer’s, and how does it work?
Memantine
Blocks NMDA-type glutamate receptors
What is Memantine used for?
Slows progression + prevent “challenging behaviour” (hallucinations/delusions, insomnia, anxiety/depression, aggression, disinhibition)
Side effects of Memantine?
Hypertension, dizziness, sedation, headache, constipation, insomnia
What are all people diagnosed with dementia and their families offered?
Post-diagnosis support (information, advance planning, advice, counselling)
Who else needs to know about a diagnosis of dementia?
DVLA
What is more common in ASD?
Gender dysphoria
Core features of ASD?
Difficulties in Social Communication, Social Interaction and Social Imagination
+ Repetitive behaviours
+ sensory problems
Causes of ASD?
Rubella is pregnant mother Tuberous sclerosis Fragile X Encephalitis Untreated PKU Birth injury/foetal distress
Neuropathological changes in ASD?
Large amygdala + cerebellum pathology
Diagnostic tools for ASD?
ADOS- autism diagnostic observation schedule
Common co-morbidities in ASD?
Anxiety/depression Eating disorders Learning disability OCD Tourette's Self harm etc
What can be used to manage aggression and self-injury in ASD?
Risperidone
Triad of ADHD?
Inattention
Hyperactivity
Impulsivity
What is the typical feature of adult ADHD?
Inattention or “inner restlessness”
Impact of ADHD on children?
Parenting difficulties Home stress Reckless behaviour Emotional dysregulation Barrier to learning Impaired decision making
Impact of ADHD on adults?
Increased psychiatric problems
Criminality
Antisocial behaviour
Substance misuse
Causes of ADHD?
Genetics (increases through generations)
Alcohol + smoking in pregnancy
Prematurity
Psychosocial adversity (economic class, crime, parent martial status, trauma)
Neuropathological changes in ADHD?
Frontal lobe underactivity
Decreased noradrenaline, serotonin and dopamine
Prognosis of ADHD?
Some will ‘grow out of it’
Some have symptoms persistent into adulthood
First line medication in ADHD?
Methylphenidate (block dopamine transport)
or
Dexamphetamine
Other second line treatments of ADHD?
Atomoxetine (SNRI)
Clonidine (alpha agonist)
What is one of the biggest predictors for serious antisocial behaviour, criminality and substance misuse?
Oppositional Defiant Disorder (<12s) Conduct Disorder (>12s)
How is separation anxiety recognised?
Age appropriate, excessive and disabling anxiety
6 features of anorexia?
- BMI <17.5
- Self-induced weight loss
- Fear of fatness
- Body image disturbance
- Delayed puberty/amonorrhea
- Sexual dysfunction (men)
Physical symptoms of anorexia?
Muscle wasting Hair loss Lanugo hair Dry skin Hypotension Cold, blue peripheries Bradycardia Bruising Hypercarotenaemia (orange skin)
High risk anorexia?
BMI <13, >1kg loss/week, HR <40, Prolonged QT, sBP<80, temp <34
Unable to rise from squat without help
Confusion
Specific investigations of anorexia?
LFTs- show liver damage (catabolism of liver for calories)
FBC- anaemia
ECG
DEXA- osteopenia/porosis
What causes re-feeding syndrome?
Due to depletion of already inadequate nutrient stores (quickly used up when body starts repairing)
How to prevent re-feeding syndrome?
Slow pace initial feeding
Frequent bloods
5 features of bulimia?
- Preoccupation with food
- Irresistible craving for food
- Bingers
- Counter effects of binges (starvation, vomiting, laxatives)
- Morbid dread of fatness
Physical symptoms of bulimia?
Calluses of knuckles (Russell’s sign)
Parotid hypertrophy
Dental caries
Abnormal U+Es
Complications of bulimia?
Oesophageal reflux/tears/rupture
Hypokalaemia
Subconjunctival haemorrhage
What MMSE scores could suggest dementia?
21-26 = mild 10-20= moderate <10= severe dementia
Features of puerperal psychosis and when does it occur?
Sudden psychotic/manic symptoms, disinhibition, confusion
2-4 weeks post-birth
Risk factors for puerperal psychosis?
Mental illness Thyroid disorder FH First pregnancy C-section Perinatal death
Risk factors of post-natal depression and when does it occur?
Hx of depression/anxiety Complicated pregnancy Traumatic birth Domestic violence Trauma/abuse Financial difficulties
2-6 week post-birth
When is urgent referral needed in perinatal mental health? (3)
Significant change in mental state/new symptoms
Thoughts/acts of violent self-harm
Incompetency as mother/estrangement from baby
Risk factors for perinatal mental health problems?
Young Single Domestic issues Lack of support Substance abuse Unplanned pregnancy Pre-existing MH condition
How many people with bipolar will relapse during pregnancy?
50%
Management of puerperal psychosis?
EMERGENCY admission to mother + baby unit Antidepressants Antipsychotics Mood stabilisers ECT
What is the recurrence rate of puerperal psychosis?
80% in 10 years
25% will develop bipolar
3 general prescribing principles in pregnancy mental health?
- Low risk medication + low dose monotherapy
- Beware altered pharmacokinetics e.g. lithium
- Encourage breastfeeding- relatively less that exposure in-utero
Which 2 anti-depressives to avoid in pregnancy?
Paroxetine (heart defects)
Citalopram
Can benzodiazepines be used in pregnancy?
NO
Increase malformations + floppy baby syndrome
Which anti-psychotics are safe to use in pregnancy?
Typicals better
AVOID clozapine (agranulocytosis) + olanzapine (diabetes, weight gain)
Can lithium be used during pregnancy?
Yes
Monitor serum levels closely (toxicity can mimic pre-eclampsia)
Can lithium be used during breastfeeding?
NO
concentrated to baby
Is sodium valproate safe in breastfeeding?
Yes
Is tetracycline safe in breastfeeding?
No
absorbed by breastmilk- can discolour infant teeth permanently
Is carbamazepine safe in pregnancy?
No
Neural tube + facial defects
Is lamotrigine safe in pregnancy?
No
Oral cleft + stevens-johnson syndrome
Management of illicit drug misuse in pregnancy?
Methadone Child protection/social work Early IV access Vitamins Contraception!
