Psychiatry Flashcards
What congenital defect can Lithium cause?
Ebstein’s anomaly of the heart
What congenital defect can Sodium Valproate cause?
Neural tube defects
What congenital defect can Carbamazepine cause?
Neural tube defects
What is Torticollis and what causes it?
Type of acute dystonic reaction.
Abnormal spasm of the neck muscles, it is a key side effect of antipsychotics.
What are the symptoms of Serotonin syndrome?
DASH
Diarrhoea
Ataxia
Shivering
Hyperreflexia
What are the symptoms of Neuroleptic malignant syndrome?
Dysphagia Obtundation (less than full alertness) Fever Confusion Autonomic instability
What are the clinical features of Lithium toxicity?
Anorexia, diarrhoea, vomiting Drowsiness, restlessness Dysarthria Dizziness, ataxia, incoordination, muscle twitching, coarse tremor Hyperreflexia, convulsions Acute renal failure Collapse, coma, death
What is Charles Bonnet syndrome
Recurring hallucinations in those with impaired vision.
The classic triad is:
- Intact cognition
- Ocular pathology
- Visual hallucination
What are some side effects of tricyclic antidepressants?
Can’t see, can’t pee, can’t spit, can’t shit
What differentiates Mania from hypomania
Mania has psychotic symptoms
What is SSRI discontinuation syndrome
Can present with a wide variety of symptoms including diarrhoea, vomiting, abdo pain, restlessness, paraesthesia and insomnia.
Side effects of antipsychotics
Extrapyramidal side effects:
- Parkinsonism
- Acute dystonia (e.g. torticollis, oculogyric crisis)
- Akathisia (severe restlessness)
- Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
Other side effects:
- Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
- Sedation, weight gain
- Raised prolactin
- Neuroleptic malignant syndrome: pyrexia, muscle stiffness
- Reduced seizure threshold
- Prolonged QT interval
What is the minimum duration of a depressive episode?
2 weeks
Definition of Autism
Difficulty with social and emotional, language and communication and flexibility of thought
What things may an Autistic person find challenging?
- Friendships
- Managing unstructured parts of the day
- Working in a team
- Processing and retaining verbal information
- Jokes and sarcasm
- Social use of language
- Body language, facial expression and gesture
- Coping with changes in routine
- Empathy
- Generalization
How to explain Autism?
It’s as if your child’s brain has been wired up in a different way to usual. They struggle to communicate and relate to other people.
There are positives though, they do things that make you look at things differently. As you get older you are conditioned to think you should do things this way or that but they do things in a refreshingly different way. All children do this but especially autistic children.
Diagnostic criteria for ADHD
- Onset before 7 years
- Persists for at least 6 months
- Present in more than one setting
- Has caused significant functional impairment
- Not better accounted for by other mental disorders: ASD, depression, anxiety, schizophrenia
What is the main treatment for ADHD?
Behavioural management strategies are the first line
Stimulant medication is also possible e.g. Methylphenidate (Ritalin) - start at a low dose, titrate dose against behaviour and school work
What is the DISCO tool?
Diagnostic interview for social communication disorders - used to elicit a broad picture of an individual’s behaviours and needs - more than 300 questions organised into 8 parts
What is the ADOS-2 tool?
Autism diagnostic observation schedule - semi-structured assessment tool using play and interview to examine communication, social interaction, imagination, restricted and repetitive behaviours. The score is given which puts the patient into one of three categories:
- Autism
- Autism spectrum
- Non-spectrum
What is the theory of mind?
People’s ability to understand that other people have mental states - beliefs, desires, intentions and perspectives which differ from our own
Have obstetric complications been shown to be associated with Autism?
No
What is Connor’s questionnaire used for?
To assess patients with ADHD
What is the only licensed pharmacological treatment in Autism and what is it indicated for?
Risperidone
For aggressive behaviour in children, psychosocial interventions should be tried first and a physical cause should be ruled out/treated first
What are some useful tools in ASD diagnosis?
DISCO
ADOS-2
ADI
What is the biggest risk factor for self-harm?
Previous self-harm
What is a delusion
Fixed, false idea which is totally out of keeping with someone’s social/religious background
What is an illusion
Misinterpretation of sensory input e.g. mistaking a shadow for a spider
What is a hallucination
No sensory input, comes from something
What is the most common cause of Dementia?
Alzheimer’s Disease (2/3 of patients with Dementia)
What is used to treat Alzheimer’s Disease?
- Cholinesterase inhibitors – donepezil, galantamine
- Butyrylcholinesterase and acetylcholinesterase inhibitors – rivastigmine
- NMDA receptor blockers – memantine
Before starting the medications used to treat Alzheimer’s disease what must be checked?
ECG to assess HR and to screen for any conduction abnormalities
U+Es
Memantine can cause acute renal failure
Cholinesterase inhibitors are contraindicated for patients with bradykinesia, left bundle branch block and a prolonged QTc interval
How are the anti AD drugs metabolised?
Donepezil and Galantamine - Liver enzymes
Rivastigmine - site of action (little interactions)
Memantine - non hepatic metabolism and is eliminated by the kidneys
What is Dementia?
A chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning
Exclusion criteria for AD
- Absence of delirium
- Symptoms present for at least 6 months
- Should be irreversible
What genetic pattern does early onset AD have?
Autosomal dominant inheritance pattern
What allele is associated with AD?
APOE4
When does deprivation of liberty occur?
The person is under continuous supervision and control and is not free to leave, and the person lacks the capacity to consent to these arrangements.
What type of Dementia are Pick bodies found in?
Frontotemporal dementia
What pharmacological treatments are there available for frontotemporal dementia?
There aren’t any
What is the role of antipsychotics in Dementia
Only offer antipsychotics for people living with dementia who are either:
- at risk of harming themselves or others or
- experiencing agitation, hallucinations or delusions that are causing them severe distress
What is mild cognitive impairment?
Some people have problems with their memory which may not significantly affect the person’s everyday life and are not severe enough to be called dementia.
What genes are linked to frontotemporal dementia?
MAPT
GRN
C90RF72
What is thought to pathologically accumulate in Lewy Body Dementia
Alpha-synuclein (this gets misfolded and aggregates to form Lewy bodies)
What is Lexical Anomia
When a patient knows how to use an object and can correctly select the target object from a group of objects but cannot provide the name of the object
What medication is used to treat REM sleep behavioural disorder
Clonazepam
DSM-5 criteria for conduct disorder?
- Aggression to people or animals
- Destruction of property
- Deceit and Theft
- Serious violation of rules
What is conduct disorder?
When a child’s behaviour is bad enough to affect their development
What is the first line treatment for EUPD?
Dialectical behavioural therapy
What is projection?
The misattribution of a person’s undesired thoughts, feelings or impulses onto another person who does not have those thoughts, feelings or impulses
What is splitting?
When a person is unable to tolerate that there are both positive and negative aspects of themselves or others. Tend to think in extremes (i.e., an individual’s actions and motivations are all good or all bad with no middle ground).
What is sublimation?
Channelling of unacceptable impulses, thoughts and emotions into more acceptable ones e.g. sport, humour
What bloods should be taken for the first episode of psychosis
FBC, LFT, TFT, Bone, U+E
Before starting antipsychotic medication the following baseline investigations should be performed
- weight (plotted on a chart)
- waist circumference
- pulse and blood pressure
- fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile and prolactin levels
- assessment of any movement disorders
- assessment of nutritional status, diet and level of physical activity.
- ECG (under certain specific circumstances, see guidance)
What is section 135 of the MHA for?
Can be used to gain access to premises to remove patient to a place of safety
What is section 136 of the MHA for?
Allows police to remove a person from public place to place of safety
What is section 5(2) and 5(4) of the MHA for?
5(2) is for 72 hours - done by doctor
5(4) is for 6 hours - done by nurse
Both are emergency holding orders
What are the negative symptoms of Schizophrenia?
- Blunted mood
- Reduced speech
- Poor self-care
- Loss of volition
Deprivation of liberty
Is the person subject to continuous supervision and control?
Is the person free to leave?
If both of these criteria are met then a person is defined as having their liberty deprived
When is grief considered pathological?
If it continues for longer than 6 months
What antidepressants are associated with prolonging the QT interval?
Citalopram
Escitalopram
Amitriptyline
What is CBT?
- Talking therapy that can help you manage your problems by changing the way you think and behave
- Based on the concept that thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feeling can trap you in a vicious cycle
- It cannot cure the physical symptoms of the conditions, but it can help people cope better with them
- Session once a week or once every 2 weeks. The course lasts between 5-20 sessions with each session lasting 30-60 minutes.
What is the only SSRI that can be prescribed for under 18s?
Fluoxetine (and only with specialist input)
Suicide risk assessment
- What precipitated the attempt?
- Why did they choose that time and place?
- Was it planned or impulsive?
- Did they leave a suicide note?
- Were they intoxicated (drugs/alcohol)?
- Did they take any precautions against discovery (e.g. was he expecting his wife to be out of the house at that time? Did they tell work in advance that they wouldn’t be in that day?)
- Have they made previous attempts at suicide or self-harm by any methods?
- How does he feel about the episode now? (e.g. regrets the attempt? wishes he had succeeded?)
- Questions to assess his current severity of depression, including ongoing suicidal thoughts. Completing the PHQ-9 with him may be a helpful first step.
- If he goes home, what supports – and stresses – will he have there?
- Does he have thoughts to harm/kill anyone else as well as himself? Are there young children at home? Does he have unsupervised responsibility for them? Are they potentially at risk?
- What does he think about the future?
What to check for with an anxiety history?
Take full Hx and check for caffeine or other stimulant use
ECG and troponin levels in a patient with chest pain
TSH and Thyroid levels
GAD-7 useful to measure anxiety
Where is the major site of production of Noradrenaline?
Locus Ceruleus
Where is the major site of production of Serotonin?
Raphe nuclei
Step wise treatment of depression?
- SSRI e.g. Sertraline or Citalopram
- Venlafaxine, Mirtazapine or Escitalopram
- Add an augmenting agent e.g. a second-generation antipsychotic such as quetiapine (5-HT2AR) then Lithium
- TCA e.g. Amitriptyline or Clomipramine
- MAOIs
Which antidepressants are withdrawal symptoms most commonly seen in?
Venlafaxine and Paroxetine
Before starting Lithium what do you need to check?
Get baseline U&Es, TFTs and FBC, Weight + BMI, ECG
• Check for pregnancy:
– Teratogenic during the first trimester, don’t breastfeed on it either
– Associated with Ebstein’s anomaly 1/1000 (20X greater risk than the general population)
