Psychiatry Flashcards
What can happen to newborns of pregnant women who take SSRIs during the 3rd trimester?
Pulmonary HTN in the newborn
What is Cotard syndrome?
When the patient believes they are dead. It is linked to severe depression.
What is pseudodementia?
Occurs in severe depression that gives a pattern of global memory loss
How and when does serotonin syndrome present?
Presents within minutes of elevated serotonin levels. Leads to confusion, restlessness, hyperthermia, hypertonia and clonus
What are the 7 parts of a Mental State Examination?
1) Appearance and behaviour
2) Speech
3) Mood (subjective and objective)
4) Thoughts: Form and Content
5) Perception
6) Cognitive function
7) Insight
When would you diagnose dysthymia?
When a patient has had persistent mild depression for at least 2 years
What is cyclothymia?
Mood swings between short periods of mild depression and hypomania
How long do symptoms have to be present for to diagnose depression?
For at least 2 weeks
How do you diagnose recurrent depressive disorder?
Over 2 episodes at least 2 months apart.
How would you diagnose hypomania?
Sustained elevated/irritable to a degree that is definitely abnormal for the individual 4 consecutive days.
How would you diagnose mania?
Sustained elevated/expansive/irritable mood for at least a week
What are the features of mania?
- Flight of ideas
- Constant changes in activity/plans
- Hardcore restlessness
- Loss of social inhibitions
- Grandiosity
Define bipolar affective disorder?
2 or more episodes of hypomania or mania, alternating with depression.
How long must symptoms of schizophrenia last for it to be diagnosed?
At least 1 month. Not due to organic cause of mood disorder.
When you diagnose delusional disorder?
When there is clear delusions, present for at least 3 months, clearly personal and not sub-cultural.
What can sections 2/3 be used for?
To arrest
What can sections 35/36/48/49 be used for?
To remand someone after being charged
What can sections 47/49 be used for?
For someone being held in custody after being found guilty
What can sections 37/38 be used for?
Sending someone to a psych hospital after being found guilty
What are the consequences of a restriction order?
The responsible clinician cannot give the patient leave without permission from the Ministry of Justice, and cannot discharge the patient
What types of memory decline with age?
Recall, episodic, processing, speed and divided attention
What is the pattern of symptoms in a patient with Lewy body dementia?
Memory problems early on then motor problems later on
What symptoms are characteristically seen in patients with frontotemporal dementias?
Younger pts, disinhibtion, don’t get memory problems
What is the pattern of symptoms in a patient with
PD dementia?
Motor symptoms first then memory loss
What intracellular changes are seen in someone with AD?
Neurofibrillary tangles and Tau
What extracellular changes are seen in someone with AD?
Neurotoxic amyloid plaques present
What pathological changes can you see in a patient with vascular dementia?
- Asymmetrical ventricle dilation
- Basal a atheroma
- Scattered infarctions, often 1-2 large infarcts
- Microinfarcts
- Most pathology in smaller vessels
- Enlarged perivascular spaces
What score is significant in 6 CIT?
Score of 8 or more is significant
What would you see on the MRI of someone with dementia?
Medial temporal atrophy and enlarged lateral ventricles
What is the criteria for diagnosing dementia?
Decline is at least 2 cognitive/behavioural areas, interferes w/ functional abilities, abnormal ADL
What is the criteria for diagnosing mild cognitive impairment?
Decline in at least 1 cognitive area, preservation of independence in functional abilities, normal ADL
What are the characteristic features of someone with Lewy body dementia?
Fluctuating cognition, recurrent visual hallucinations, spontaneous features of parkinsonism, REM sleep behaviour disorder, neuroleptic sensitivity
What are the 2 main classes of meds to treat dementia? List examples of each
Acetylcholinesterase inhibitors: Donepezil, Galantamine, Rivastigmine
NMDA receptor antagonists: Memantine
What symptoms occur in neuroleptic malignant syndrome?
Muscle rigidity, hyperthermia, renal failure, fluctuating consciousness, autonomic instability (e.g. tachycardia)
What are the treatments for neuroleptic malignant syndrome?
IV fluids, tepid sponging to drop temperature, Dantrolene (muscle relaxant), can use dopamine agonist.
Which side effect of taking typical antipsychotics will remain even after stopping treatment?
Tardive dyskinesia
What treatment can you give to a patient who is experiencing akathisia as a result of using typical anti-psychotics?
B blockers +/- benzos
What side effects can you get from Clozapine?
Sedation, anticholinergic, weight gain, decreased seizure threshold, hyper salivation, agranulomatosis (leukopenia)
What monitoring is required before starting Clozapine?
Check FBC
What monitoring is required once you have started Clozapine?
FBC weekly for 18 weeks, fortnightly until 1 year, every 4 weeks for as long as the patient is taking the drug.
What is the treatment for AD?
Donepezil (a selective reversible AChE inhibitor)
Name 3 medications used in alcohol abstinence
- Disulfiram
- Acamprosate
- Naltrexone
What is the mechanism of action of Acamprosate?
GABA analogue –> reduces cravings
What is the mechanism of action of Disulfiram?
An aldehyde dehydrogenase inhibitor –> unpleasant reaction if pt drinks
What is the mechanism of action of Naltrexone?
Partial opiate antagonist –> reduces cravings
What class is Venlafaxine and what must you monitor if you are on it?
It is an SNRI
Monitor BP and cardiac dysfunction
What class of meds is typically used for OCD?
High dose SSRIs.
What class of meds is typically used for OCD?
High dose SSRIs.
What 2 classes of meds can be used for Insomnia?
Benzos and Z hypnotics (zopiclone, zolpidem, zaleplon)
What is the medication Tryptophan used for?
It is a serotonin precursor that is used to treat depression (increases synthesis of serotonin)
How do the medications Mianserin and Mirtazapine work in depression?
They increase release of serotonin
Which class of antidepressants prevents breakdown of serotonin?
MAOIs
Name 3 classes of antidepressants that prevent re-uptake of serotonin
Most SSRIs, SNRIs, TCAs
Name the first 3 lines of antidepressant treatment in moderate/severe depression?
1st line: SSRIs
2nd line: Another SSRI
3rd line: Venlafaxine (SNRI), Mirtazapine (TCA)
Name 3 indications for ECT
Severe/resistant depression
Mania
Schizophrenia
Name a few things the increase Lithium levels in the blood
NSAIDS, ACEi, diuretics (esp thiazides), dehydration, low sodium
What monitoring must you do prior to starting lithium?
TFTs, eGFR, U&Es, pregnancy status, baseline ECG
What monitoring must you do once you have started lithium?
After 1 week: Check level (0.5 - 1.0 mmol/L)
When stable: Check level + TFTs + renal functioning every 3 months
Name the first 3 lines in the long-term treatment of bipolar depression
1st: Lithium
2nd: Sodium valproate
3rd: Olanzapine
What monitoring must occur for patients on antipsychotics?
BMI/ BP/ Lipids/ Glucose every 3 months for 1 year
What monitoring must occur for patients on lithium?
TFTs, U&Es and renal function every 6 months
Monitor lithium levels 12 hours following 1st dose, then weekly until therapeutic level 0.4-1.0 mmol/L has been stable for 4 weeks, once stable check levels every 3 months
What must you measure after 6 months for patients on sodium valproate?
FBC, LFTs, BMI
What must you measure after 6 months for patients on Carbamazepine?
FBC, renal function, LFTS, BMI, Levels
What is one clear difference between delirium and psychosis?
Delirium –> clouded consciousness
Psychosis –> clear consciousness
What is myxoedema madness?
Seen in hypothyroidism - delusions, paranoia, auditory hallucinations
Define somatisation. What age must it occur before to be diagnosed?
Patients with psych disorder consults with physical symptoms attributed to a physical cause by the patient.
Physical complaints begin before the age of 30.
How does Somatoform pain disorder present?
Persistent, severe and distressing pain in association with emotional conflict or psychosocial problems.
Pain has poor localisation and lack of conformity to nerve distribution. Persistent requests for investigations.
Define Hypochondriacal disorder
Pre-occupation with fears of having a serious disease based on misinterpretation of bodily symptoms, persists despite negative medical evaluation, not of delusional intensity, symptoms last for 6 months.
What is conversion disorder?
1 or more symptoms /deficits affecting voluntary motor or sensory function, symptoms not intentional or explicable by physical illness. Tends to be LOSS of sensations
What is the primary gain of conversion disorder?
To have their anxiety decreased.
What is “la belle indifference” and in which psych condition may it be seen?
A calm acceptance of their disability.
Seen in conversion disorder.
How does dissociative amnesia present?
1 or more episodes of inability to recall important personal info but memory otherwise intact
What is dissociative fugue?
Sudden unexpected travel away from home with inability to recall one’s past, confusion about identity.
What is dissociative identity disorder?
AKA Multiple personality disorder. Sudden change from 1 identity to another, initially linked with traumatic/stressful events.
What is another name for Factitious disorder, and what is it?
Munchhausen’s Syndrome = intentional production of symptoms, motivation is to resume the sick role, external incentives are absent.
It is a maladaptive habitual stress behaviour.
What is malingering?
Deliberate, conscious production of symptoms for external incentives e.g. obtaining illicit drugs - NOT a psych condition.
What is Journey syndrome?
Occurs when alcoholic patients regain awareness in strange places
Roughly what time period after stopping drinking will Delirium Tremens occur?
3 to 4 days
How long does Delirium Tremens tend to last?
3 to 5 days
What type of hallucinations are classically seen in Delirium Tremens?
Microscopic (leprachaun’s)
What is alcoholic hallucinosis, how long can it last for and when does it occur?
Auditory hallucinations, phonemes (running commentary), intermittent, NO clouding of consciousness
Can persist for years/months
Occurs if patient returns to drinking
How does Wernicke’s encephalopathy present?
Acute presentation of opthalmoplegia (CN VI palsy), clouding of consciousness & ataxia.
How does Korsakoff’s syndrome present?
Loss of short-term memory, confabulation of memories. NO altered consciousness.
What changes to the brain are seen with patients with alcoholic dementia?
Brain shrinkage due to loss of white matter, increase in ventricular size, decrease in corpus callosum
Why might carbamazepine be used in patients with alcohol dependence?
It reduces “kindling phenomenon” = when each withdrawal leads to more severe withdrawal symptoms than in previous episodes.
What treatments must be given to patients experiencing Delirium Tremens?
Benzos, vitamin supplements, rehydrate, sort out electrolytes
What non-pharmacological treatments should be offered to patients with alcohol dependence?
Brief interventions, motivational interviewing, CBT, AA
What does Pabrinex contain?
Vitamin B and C
What happens to MCV in heavy drinking?
It increases
What is carbohydrate deficient transferrin used for?
To detect heavy ethanol consumption
Biochemically, what is disulfiram? What is another name for it?
AKA antabuse
A aldehyde dehydrogenase inhibitor
What happens to the patient in the ‘antabuse’ reaction?
Flushing, N&V, dyspnoea, palpitations, decreased BP, dizziness, headache, may be life-threatening!
What advice should you give to a patient about ‘antabuse’ AKA disulfiram about drinking alongside taking it?
Don’t drink!! Blood levels of alcohol have to zero before disulfiram works. Patient needs to discontinue it for 5 days before drinking again.
What is Naltrexone biochemically? How does it work?
A pure opioid antagonist
It blocks opioid induced euphoria that alcohol is linked to
What is nalmefene biochemically?
An opioid antagonist with a long half-life.
How does Acamprosate work biochemically?
Acamprosate suppresses alcohol consumption
Reduces Ca2+ flux into neurones –> inhibits excitatory amino acids
When should you start Acamprosate after detoxification? How long should a patient stay on it? Does it interact with benzos or alcohol?
ASAP
Maintain patient on it for 1 year.
Does NOT interact with alcohol or benzos.
What is FRAMES? What does each letter stand for?
A type of brief intervention for alcohol dependent patients
F: Feedback (personal risks) R: Responsibility for change A: Advice (cut down!) M: Menu (alternative options) E: Empathetic interviewing S: Self-efficacy
What is the main treatment for opioid dependency? What is it biochemically? How does it work?
Methadone. Full opioid Mu receptor agonist. It reduces cravings and prevents euphoria if patient abuses opiates.
When does methadone’s effects peak? How long does it last for?
Peaks at 2 - 4 hours
Lasts for 24 - 36 hours
A woman who is a heroin addict discovers that she is pregnant - what should you do in terms of detox?
Detox should only be done in middle trimester, if not then stabilise the woman until after birth.
What is Buprenorphine used for? What is it biochemically?
It is a partial agonist of the opioid mu receptor that is used in people who are addicted to heroin.
How does Buprenorphine compare with methadone? What is the maximum dose? How long does it lasts for?
As it is a partial agonist, it causes less euphoria and less of a sedating effect. It’s max dose is 32mg. It lasts 48-72 hours.
Roughly how long after birth do ‘baby blues’ appear?
3rd - 5th day after birth
What is the prognosis of someone with ‘baby blues’?
Usually self-limiting within 10 days of delivery, no treatment.
Roughly how long after birth does postnatal depression appear? How long must symptoms last for it to be diagnosed?
4 - 6 weeks after childbirth. Symptoms must be present for at least 2 weeks before it is diagnosed.
What is the onset of post-partum psychosis?
Severe and sudden onset in the first few weeks.
What is tokophobia?
A significant fear of childbirth
What treatment options are available for pregnant women with SEVERE bipolar? In what trimester should you avoid prescribing psychotropic meds?
Antipsychotics or Lithium. Avoid prescribing psychotropic meds in 1st trimester.
Name 4 side effects that can occur as a result of using SSRIs during pregnancy?
- Small birth weight
- Heart and lung malformations
- Persistent pulmonary hypertension in newborn
- Newborns may experience withdrawal symptoms (irritability, convulsions)
If a pregnant woman does take lithium, what is the well-known side effect if could have on the fetus?
Ebstein’s anomaly
What monitoring should you do if a pregnant woman is on Lithium?
Monitor maternal serum levels, fetal US and ECHO @ 6 and 18 weeks of gestation.
What may happen if a pregnant woman takes benzos in their 3rd trimester? How does this present?
Floppy baby syndrome (poor muscle tone and feeding)
What does alexia mean? What does agnosia mean? What does prosopagnosia mean? Which brain lobe would be damaged to see these symptoms?
Alexia = cant read
Agnosia = Can’t recognise objects
Prosopagnosia = Can’t recognise faces
Seen in occipital lobe damage.
What are the typical ages of onset for Huntington’s disease?
10% start in childhood
Rest start 30 - 40 years old.
How does Huntington’s disease present? Which sort of symptoms tend to occur first?
Gradual clumsiness, fidgety, chorea, psych symptoms often prior.
What psych symptoms may Huntington’s disease present with?
Irritability, mood changes, depression, cognitive impairment
How does Creutzfeldt-Jakob disease (CJD) present?
50-70 year olds
Early onset dementia, personality change, anxiety, depression, movement disorders, upgaze paralysis
How does new variant CJD present? What is the cause of it linked to?
Onset in 30s. Psych symptoms.
Linked to beef infected with BSE
What criteria is needed to diagnose Tourette’s?
Multiple motor + 1 or more vocal ticks over 1 year. Onset before 18 years old and not due to another condition/substance.
What class of medication can be offered to patients with Tourette’s?
Low-dose antipsychotics (risperidone, clonidine)
When does the onset of Freudreich’s ataxia occur?
In teens
When does Wilson’s disease become apparent?
In childhood
Is Wilson’s disease recessive or dominant?
Recessive
What are the psych symptoms that Wilson’s disease may present with?
Mood disorder, psychosis, personality change, epilepsy, eventual dementia
At what age must symptoms of autism be apparent by for it to be diagnosed?
3 years old
Name 3 differences between Asperger’s syndrome and Autism
1) No delay in language or cognitive development
2) Above average IQs
3) Doesn’t restrict progress/ potential
By what age must symptoms of hyperkinetic disorder be present at for it to be diagnosed?
How long must symptoms last for?
In how many situations must they have occurred?
Symptoms must have started before 6 years old and persisted for at least 6 months. Symptoms need to occur in more than 1 situation.
What are the 2 treatments available for those with hyperkinetic disorders?
Behavioural approaches and stimulants (e.g.methylphenidate or dexamphetamine)
What type of schizophrenia is diagnosed more commonly in young adults?
How may this present?
How long must symptoms be present for?
Hebephrenic schizophrenia
Affective changes with less prominent delusional beliefs/ abnormal perceptions
Symptoms must be present for at least 1 month and not be attributed to brain disease of substance misuse.
Define functional enuresis
Repeated involuntary voiding of urine after an age at which continence is usual and in absence of any physical disorder.
What 2 types of haemorrhage are associated with child abuse in particular?
Subdural/ retinal haemorrhage
What does part III of the Mental Health Act 1983 refer to?
Detention and treatment of mentally disordered offenders.
What 3 criteria must be met for a patient to have the Mental Health Act 1983 applied to them?
1) Must have a mental disorder
2) Be a risk to their health or safety, or others
3) Warrant treatment in hospital
Someone with suspected mental health problems get arrested by the police. Whom should they be seen by and what can this person do?
Can be seen by a Forensic Medical Examiner who can request a MHA assessment
What does Section 136 of MHA 1983 say?
A person can be apprehended by a police in a public place and taken to a place of safety.
A woman is running around a high street naked and screaming - what Section be used by the police to take her to a place of safety?
Section 136
If someone who has been arrested with a suspected mental health illness is then later not charged or given bail, which 2 Sections can be used so that a MHA assessment can be arranged?
Section 2/3 of MHA 1983
While in custody, what section can be used for someone who should be remanded in hospital for a psych report?
Section 35
While in custody, what section can be used for someone who should be remanded in hospital for assessment and treatment?
Section 36
While in custody, what section can be used for someone who should be remanded in hospital for treatment? Which section is it often used with and why?
Section 48
Often used with Section 49 which restricts them to hospital
At sentencing, which Section can be used as an “Interim Hospital order”? What exactly will this allow for?
Section 38: allows for admission for a maximum of 1 year to decide whether person is suffering from a treatable mental disorder.
What is Section 37?
A Hospital Order for someone with a mental health disorder at sentencing
What is Section 41? Which section is it commonly used with? When is it used? Who imposes it?
A Restriction Order (used in combo with section 37).
Used for someone at sentencing if the offence was serious and person remains a serious risk to public.
It is imposed by Judge of Crown Court.
Which section is used to transfer a sentenced prisoner to hospital?
Section 47.
Define erotomania
Not in a relationship with victim but they think they are
What criteria regarding weight has to be met for a diagnosis of anorexia to be made (ICD-10)?
Body weight maintained below at least 15% of expected or BMI <17.5
What happens to the following in Anorexia…
GH
Cortisol
T3
GH and cortisol is high
Low T3
Pick which of these are physical complications of anorexia…
a) Decreased or increased plasma amylase
b) Shortened or prolonged QTi
c) Small or large ovaries
d) Low or high testosterone
e) Metabolic alkalosis or acidosis
a) Increased plasma amylase
b) Prolonged QTi
c) Small ovaries
d) Low testosterone
e) Metabolic alkalosis
What weight gain should you aim for someone with Anorexia to put on per week?
A weight gain of 1kg/ week
Name 3 effects of vomiting in Bulimia
1) Hypokalaemia
2) Erosion of enamel
3) Parotid gland swollen
Which SSRI may be used in bulimia and at what dose relative to the dose that is used in depression?
Fluoxetine - used at a higher dose than that used in depression. It decreases binge frequency.
What does the CALMER acronym mean in the management of a patient with bipolar?
Consider hospitalisation/ CBT Atypical antipsychotics Lorazepam Mood stabilisers (Li) ECT Risk assessment
What happens to the following in refeeding syndrome... - Potassium - Magnesium - Phosphate Name 2 other effects
- Decreased Potassium
- Decreased Magnesium
- Decreased Phosphate
Fluid balance abnormalities and abnormal glucose metabolism
What can you do to prevent refeeding syndrome?
Measure serum electrolytes prior to refeeding and monitor refeeding bloods daily.
Start at 200kcal/day - gradually increase every 5 days
Monitor for signs e.g. tachycardia and oedema
List some side effects of SSRIs
Gastro: nausea, dyspepsia, bloating, flatulence, diarrhoea, constipation
S: sweating T: tremor R: rashes E: extrapyramidal SEs S: sexual dysfunction S: somnolence S: 'stopping SSRI' symptoms AKA discontinuation syndromes
What are the symptoms you can get from discontinuing SSRIs?
GI symptoms, chills, insomnia, hypomania, anxiety and restlessness
When should you review patients after you have started them on an SSRI? When would this change?
Review patients after 2 weeks of prescribing or after 1 week if they are under 30 y/o or at increased risk of suicide.
What class is Venlafaxine? List some of their side effects
SNRI
SEs = nausea, dry mouth, headache, dizziness, sexual dysfunction, hypertension
What are the 2 contraindications for starting someone on Venlafaxine?
Patients with cardiac disease and uncontrolled HTN
How do tricyclic antidepressants work? Name one example
Inhibit the reuptake of adrenaline and serotonin in the synaptic cleft.
E.g. Amitriptylline
List some side effects of tricyclic antidepressants.
- Anticholinergic: dry mouth, constipation etc
- Cardia: arrhythmias, postural hypotension etc
- Urticaria
- Hypo/mania
- WEIGHT GAIN
- Gynaecomastia
- Movement disorders
List 5 CIs of tricyclic antidepressants
1) Recent MI
2) Arrhythmias
3) Mania
4) Severe liver disease
5) Agranulocytosis
What class is phenelzine, isocarboxide, moclobemide apart of?
MAOIs (Monoamine oxidase inhibitors)
How do MAOIs work?
They inactivate enzymes that oxidase dopamine, noradrenaline, serotonin and tyramine.
Name some side effects of MAOIs
- Postural hypotension
- Arrhythmias
- Drowsy
- WEIGHT GAIN
- Increased LFTs
- Hypertensive reactions with tyramine containing foods
Which SSRI would you suggest if insomnia is present or weight gain is desired?
Mirtazapine
Which is the safest anti-depressant to prescribe to a patient post-MI?
Sertraline
Which class of antidepressants should you avoid prescribing in patients on warfarin/ heparin/ other anticoagulants and NSAIDs?
SSRIs
Which 2 antidepressants are safest to use during pregnancy?
Sertraline and fluoxetine (both SSRIs)
Which 2 antidepressants are 1st line to use during breastfeeding?
Sertraline and paroxetine (both SSRIs)
Which antidepressant is the SSRI of choice for children and teenagers?
Fluoxetine
Roughly how long after taking meds does Serotonin syndrome start? Which medication causes this most commonly?
Usually rapidly occurring within minutes.
Most commonly caused by SSRIs.
Classify the symptoms of Serotonin syndrome into 3 categories and give examples of each
- Cognitive: headache, agitation, confusion, hallucinations, coma
- Autonomic: shivering, sweaty, hyperthermia, hypertension, tachycardia
- Somatic: Myoclonus, hyperreflexia, tremor, stop drug!
Is Haloperidol a typical or atypical antipsychotic?
Typical
Is Olanzapine a typical or atypical antipsychotic?
Atypical
Is Risperidone a typical or atypical antipsychotic?
Atypical
Is Chlorpromazine a typical or atypical antipsychotic?
Typical
Is Aripiprazole a typical or atypical antipsychotic?
Atypical
Is Clozapine a typical or atypical antipsychotic?
Atypical
When should Clozapine be prescribed?
Should only be prescribed after failing to respond to 2 other antipsychotics (i.e. treatment-resistant schizophrenia)
How do typical antipsychotics work?
Block dopamine receptors
How do atypical antipsychotics work?
They have specific dopaminergic action (Block D2 receptor) and serotonergic effects
Which metabolic side effects are associated with atypical antipsychotic use?
Why do these side effects not occur in those on typical antipsychotics?
Metabolic side effects: Weight gain, increased risk of type 2 diabetes, increased risk of stroke
Occurs as Atypical antipsychotics block serotonergic effects too whilst typical antipsychotics only block dopamine receptors
List 4 other receptors that antipsychotics have an affinity for other than dopamine and serotonin receptors
1) Muscarinic
2) 5 HT
3) Histaminergic
4) Adrenergic receptors
Name 4 examples of EPSEs
- Parkinsonism
- Akathisia
- Dystonia
- Tardive dyskinesia
List 4 side effects based on antimuscarinic actions
- Blurred vision (can’t see)
- Urinary retention (can’t wee)
- Dry mouth (can’t spit)
- Constipation (can’t shit)
Name 2 anti-histaminergic side effects of antipsychotics
Sedation and weight gain
Name 3 adrenergic side effects of antipsychotics
Postural hypotension, tachycardia, ejaculatory failure
Name 5 side effects of antipsychotics that arise due to increase in prolactin that they cause
- Sexual dysfunction
- Decreased bone mineral density
- Menstrual disturbances
- Breast enlargement
- Galactorrhoea
Which typical antipsychotic is associated with a prolonged QT interval? Why is this important?
Haloperidol - risk of Torsades de pointes
When does the onset of neuroleptic malignant syndrome occur?
Onset usually in first 10 days of treatment/ after an increase in dose
Name 1 major side effect of Clozapine and 1 minor one
Major side effect = agranulocytosis
Minor side effect = hypersalivation
What monitoring is needed in a patient on Clozapine?
WBC monitored weekly for 18 weeks, then fortnightly for up to 1 year then monthly
How often are depot antipsychotics given? What are their 2 advantages?
Given IM every 1 - 4 weeks
Bypasses 1st pass metabolism and improves adherence
Name some side effects of lithium
GI disturbances
L: Leucocytosis I: Impaired renal function T: Tremor/ teratogenic/ thirst H: Hypothyroidism/ hair loss I: Increased weight and fluid retention U: Urine increased M: Metallic taste
What are the normal therapeutic levels of lithium?
0.5 - 1.0 mmol/L
Name some symptoms of lithium toxicity
T: tremor O: oliguric renal failure X: ataxia I: increased reflexes C: convulsions C: coma C: reduced consciousness
What are the treatments for lithium toxicity?
Stop lithium immediately
Give lots of fluid
IV NaCl (stimulates osmotic diuresis)
Renal dialysis
What is a toxic level of lithium?
> 1.5 mmol/L
What are the side effects of sodium valproate?
V: very fat (increased weight) A: aggression L: LFTs raised P: Platelets low (thrombocytopenia) R: reversible hair loss O: oedema A: ataxia T: tremor/ tiredness/ teratogenic E: Emesis
Name 3 classes of anxiolytics. What do they generally do?
Benzos
Low dose amitriptyline
Z drugs: zopliclone, zolpidem, zalephon
Which benzo is used in DT and alcohol detoxification?
What should you do in terms of dosing?
Chlordiazepoxide
Reduce the dose over roughly 1 week
What should be given in a benzodiazepine overdose?
IV flumazenil
What is the maximum time that benzodiazepines should be prescribed for and what is a complication you have to watch out for?
Should not be prescribed for more than 2-4 weeks
Watch out for withdrawal syndrome
What does ECT induce? How long does this last?
A modified epileptic seizure lasting for at least 30 seconds
What medication is given prior to ECT?
A muscle relaxant to limit motor activity
How does bilateral ECT differ to unilateral ECT?
Bilateral ECT is more effective but has more cognitive side effects
What happen to the following during ECT…
- Pulse
- BP
- Cerebral blood flow
All increase
What is a typical regimen of ECT?
Typically require 6-12 treatment sessions, twice a week
What type of consent is needed for ECT?
Written, informed consent
What are the 3 indications for ECT?
- Prolonged or severe mania
- Catatonia
- Severe depression: TX resistant depression, suicidal ideation, life-threatening depression (e.g. refusing to eat and drink)
Name as many short-term side effects of ECT as you can
- Peripheral nerve palsies
- Cardiac arrhythmias
- Confusion
- Dental and oral trauma
- Anaesthetic risks
- Muscular aches
- Headaches
- Short-term memory impairment
- Status epilepticus
Name 2 long-term side effects of ECT
Anterograde and retrograde amnesia
List 6 contraindications to ECT
- MI (<3 months ago)
- Cerebral aneurysm
- Raised ICP
- Stroke <1 month ago
- Hx of status epilepticus
- Severe anaesthetic risk
What are the 3 criteria needed to diagnose someone with a learning disability?
1) Anyone of any age with an IQ of 70 or below
2) A significant impairment of social or adaptive functioning
3) Onset in childhood or developmental delay
What is a borderline learning disability IQ score?
71 - 79
What is a mild learning disability IQ score?
50 - 70
What is a moderate learning disability IQ score?
35 - 49
What is a severe learning disability IQ score?
20 - 34
What is a profound learning disability IQ score?
< 20
How would you describe someone with borderline learning difficulty?
Independent in the community, capable of accessing open employment in adult life
What is the most common severity of learning difficulty?
Mild
In which severity is a cause of learning difficulty often identified by?
Moderate learning difficulty onwards
Which severity of learning difficulty can function but with some supervision?
Moderate learning difficulty
Mandy has limited communication and can’t function very well by herself, requiring constant help. She is also not very mobile. How severe would you class her learning difficulty?
Severe learning difficulty
What is the main genetic problem that causes Down’s?
Trisomy 21 due to non-dysfunction
What 3 psychiatric presentations is someone with Down’s more likely to present with?
Depression, OCD, Conduct disorder
What is the genetic cause of Fragile X Syndrome?
XS number of trinucleotide repeats on abnormal area of X chromosome.
How does Fragile X Syndrome present?
Large head and ears
Long face
“Cluttered speech”
Hyperactivity
How does Phenylketonuria present?
How is it diagnosed?
Microencephaly, autistic behaviour, epilepsy, cognitive impairment Guthine test (a blood test) on newborn babies to Dx
What is the genetic cause of Prader-Willi Syndrome?
Lack of part of chromosome 15 from father.
Short, hyperphagia (overeats), congenital dislocation of hips, hypogonadism, outbursts of temper, OCD, skin picking, mood swings.
Name 3 classes of causes of intrauterine causes of learning difficulty
1) Toxins from mum (e.g. alcohol, nicotine)
2) Infection (toxoplasmosis, rubella)
3) Trauma/ hypoxia
Name 2 perinatal causes of learning difficulty
Hypoxia during birth and trauma
Name 4 postnatal causes of learning difficulty
Meningitis
Measles
Head injury
Vaccinations/meds received via breast milk
Name 5 things that increase lithium levels
NSAIDs ACEi Diuretics (especially thiazides) Dehydration Low sodium
Why should you look out for a rash in someone who is on an anticonvulsant mood stabiliser?
These patients can develop Stevens-Johnson syndrome
What are 2 side effect so associated with Aripiprazole? Which side effect that is typical of atypical antipsychotics is not as big of an issue with Aripiprazole?
Can cause akathisia and anxiety but decreases the risk of metabolic side effects
What 2 medications should a patient experiencing bipolar depression be started on? List one alternative option
Fluoxetine + olanzapine OR quetiapine
Which antipsychotic is associated with high prolactin levels? When should prolactin monitoring occur?
Risperidone - must monitor prolactin levels big they are symptomatic
