Psychiatry Flashcards
1
Q
Anti-psychotics side effects
A
Extra pyramidal side-effects Hyperprolactinaemia Metabolic Anticholinergic Seizures VTE and/in the elderly Neuroleptic malignant syndrome Arrhythmias bracket (haloperidol Prolonged QT interval)
2
Q
Typical versus atypical antipsychotics
A
Typical = Dopamine antagonists non-selective
Chlorpromazine, Haloperidol, Flupentixol Decanoate
- Cheap, effective
- EPSE’s greater and difficult to reverse
Typical equals more selective dopamine antagonists and other chemical messengers e.g. serotonin
Quetiapine, aripiprazole, Risperidone, Olanzapine, Amisulprimide
- Less EPSEs
- Greater metabolic side effects - but more reversible
3
Q
Effects of dopamine in schizophrenia
A
Excess dopamine in the Mesolimbic pathways equals positive symptoms
Reduced dopamine in the mesocortical pathways equals negative symptoms
4
Q
Clozapine side effects
Monitoring (bloods?)
A
Same as other antipsychotics but additionally Annulus psychosis granulocytosis Seizures Myocarditis Lacrimation Sedation Postural hypotension (when giving)
STOPPING SMOKING INCREASES CLOZAPINE LEVELS
Weekly for 18 weeks
Fortnightly for the rest of the year
Monthly
5
Q
Features of substance dependency
What is substance misuse
A
Tolerance Dependency Compulsions Salience Narrowing of repertoire Constant use despite home Difficult controlling use Reinstatement
Misuse = Pattern of use causing psychological/physical dame
6
Q
Alcohol units
A
10 in a bottle of wine
Three in a glass of wine
Three in a pint
40 in a bottle of spirits
7
Q
Delirium tremens presents
Management
A
72 HOURS INTO ABSTINENCE. DT = Day Three
= life threatening
[1] Mental - Tactile and visual hallucinations (typically feeling bugs crawling on skin and seeing young men) - Confusion - Disorientation - Paranoia [2] Neurological - Seizures - Cerebellar signs (DANISH: ataxia, decreased coordination etc) - Severe vomiting [3] Cardiovascular - Tachycardia (most sensitive sign) - Unstable blood pressure
Management Benzo (short acting) e.g. lorazepine reducine regime \+ Parenteral thiamine \+ Admit \+ Fluids + electrolytes
CIWA to assess severity of withdrawal symptoms
8
Q
Wernicke vs Korsakoff
A
Werknick's encephalopathy = COAT Confusion Opthalmoplgia Ataxia Thiamine required to REVERSE
Korsakoff syndrome = RACK Retrogrades amnesia Anterograde amnesia Confabulation Korsakoff IRREVERSIBLE
9
Q
Alcohol side effects
A
BIOLOGICAL
Liver: Hepatitis, cirrhosis –> ascites, hepatic encephalopathy
GI: Pancreatitis, oesophageal varices, peptic ulcers
Neuro: Peripheral neuropathy, seizures, dementia
Cancers: Bowel, breast, liver
CVS: HTN and cardiomyoptahy
Head injur: Risk of subdural haematoma
Fetal alcohol syndrome
PSYCHOLOGICAL
Depression, anxiety, self harm, suicide risk
Amnesia (blackouts)
Cognitive impairment (Korsakoff syndrome)
Alcoholic hallucinations
SOCIAL
Unemployment, poor performance/attendance at work
Domestic violence, separation, divorce
Children have increased risk of neglect/abuse/conduct disorder
10
Q
Investigations for alcohol
Management for alcohol (specifics)
A
AUDIT = dependency
CIWA-AR tool = dependency
FBC, LFTs, UDS, hepatitis screen (IVDU)
Referral to drugs and substance miss use clinic. Involve partner/family
- Assess and repair: motivation to change and motivational interviewing
- Detox
- Relapse prevention
- Rehabilitation
Detox
- Pabrinex (give in GP too)
- Long acting benzo (Chlordiazepoxide)
- In patient if : Dependent at home, previous failed, withdrawal fits, comorbid psych/medical illness
Relapse prevention
- Psychological = CBT, group therapy,
- Medical = Disulfiram (blocks aldehyde dehydrogenase); Acamprosate (Enhances GABA transmission –> reduces cravings); Naltrexone (Blocks Opiod receptors –> reduces cravings)
- Social = Alcoholics anonymous, day programmes, groups
11
Q
Opiates
Examples
Intoxication presentation
Withdraw presentation
A
Heroin (diamorphine, brown, smack, H), dihydrocodeine, morphine, pethidine, codeine
Act on receptors on brain and spinal cord that are normally acted on by endogenous endorphins (brains natural pain killers)
Intoxication = ARMED C Analgesia Respiratory + CNS depression --> seizures + death Miosis Euphoria Drowsy Constipation
Withdrawal = AFTER 6 HOURS of Abstinence
Everything runs: diarrhoea, nausea and vomiting, lacrimation, rhinorrhoea
Flu like symptoms: fever stomach cramps aching joints
Call turkey: Sweating Dilated Peoples, piloerection
Dysphoria, insomnia, agitation, yawning
12
Q
IV drug use complications
A
Local
- Abscess
- Cellulitis
- DVT
- Emboli
Systemic
- Septicaemia
- Infective endocarditis
- Blood borne infections
- Increased risk of overdose
13
Q
Opiates management
A
Overdose = NALOXONE
Referral to drugs and substance miss use clinic. Involve partner/family
- Assess and repair: motivation to change and motivational interviewing
- Detox
- Relapse prevention
- Rehabilitation
HARM REDUCTION - advise on needles, vaccination, testing for infection, free condoms, GUM clinic. FBC, LFTs, GUM.
Detox (12 wks in community or 4 in hospital)
- Methadone (full agonist) or Burepronorphine (partial agonist)
+ Adjuncts:
- Loperamide
- Metoclopramide
- Non-opiate pain killers
Relapse prevention
- Can use naltrexone (opiate antagonist)
Rehab
- SMART recovery, narcotics anonymous
14
Q
Opiate effects in pregnancy
A
Low birth weight IUGR Premature SIDS Neonatal abstinence syndrome Developmental delay
Management
- Methadone maintenance
15
Q
Sedatives
Examples
Uses
Intoxication + Withdrawal picture
A
Increase inhibitory Effect of GABA
Uses - Sedation - hypnotic - anxiolytic - anticonvulsants - muscle relaxant MAX 2-4 WEEKS
Intoxication
- Sedation
- Slurred speech
- Ataxia
- Stupor
- Coma
Withdrwal
- Just like alcohol.
- Withdraw by 1/8 every fortnight to prevent withdrawa syndrome = Insomnia, irritable, anxiety, tremor, loss off appetite, tinnitus, perspiration, perceptual disturbances, seizures
16
Q
UDS lengths it can detect drugs for
A
Heroine (2d) Amphetamine (2d) Cocaine (5-7d) Methadone (7d) Cannabis (up to 1month)
17
Q
Stimulants
MOA
Examples
Intoxication
Withdrawal
A
MOA: Potentiate effects of neurotransmitters DA, NA, 5HT
Cocaine, amphetamines, MDMA
Intoxication
- Euphoria, less sleep needed, risky behaviour
- Arrythmias, HTN, stroke
- Anxiety, panic, psychosis
Withdrawal
- Depression, lethargy
Rx: HARM REDUCTION - short term benzo for anxiety
Cocaine - formication
Ecstasy - chatty, empathy, closeness, withdrawal = lethargy
18
Q
Cocaine in pregnancy
A
Teratogenic IUGR PLACENTA abruption + vasa praevia Preterm Stillborn SIDS
19
Q
Cannabis
A
THC acts on receptors in the brain
Intoxication
- Relaxation, euphoria –> anxiety, paranoia, panic
- Perceptual disturbance (slows down time), hunger, N&V, dry mouth, tachy
Withdrawal
- Nothing specific
Complications
- Psychosis, schizophrenia
- Smoking, Ca if smoking
In pregnancy - IUGR, tobacco use
20
Q
Hx for substance use
A
TRAP
- Type
- Route
- Amount
- Pattern
Dependency symptoms
- Compulsions
- Tolerance
- Salience
- Withdrawal symptoms
- Narrowing of repertoire
- Re-instatement
- Use despite harm
Past use
- Current substance
- Other substances
Future use
- “what are you worried about”
21
Q
Frontotemporal dementia
A
Asymmetric frontal/anterior temporal lobe atrophy
40-60yos; sporadic; death in 5-10yrs
Disinhibition, inattention, antisocial, personality changes, apathy, akinesia, withdrawal, memory loss and disorientation
LOSE INSIGHT EARLY
3 types:
1) Frontotemporal dementia: Promnent disinhibition and personality change
2) Semantic dementia: progressive loss of understanding of verbal and visual meaning
3) progressive non-fluent aphasia: naming difficulties –> mutism
Picks disease = accumulation of Pick bodies (hyperphosphorylated Tau) in substantia nira
22
Q
HIV dementia
A
In 10% of HIV patients
Direct effect of virus on brain
Years after infection
- Cognitive function
- Energy and libido
- Incontinence and ataxia
MRI: Diagnostic - atrophy and diffuse white matter signal change
23
Q
Huntington’s disease
A
CAG repeat in huntington gene (Chr 4) depositis of Huntington protein, atrophy of basal ganglia and thalamus, mostly frontal (ATROPHY OF CAUDATE NUCLEUS)
Mid adulthood, AD, anticipation :(
Personality and behaviour changes Mood (depression, irritability, euphoria) Subcortical dementia (late onset) Chorea Wide based gait Seuzyres Insight maintained in early years
Dx: Clinical, MRI: caudate nucleus atrophy, EEG: flat, genetic testing
Supportive management, death within 15yrs
24
Q
Delerium
Risk factors
A
Acute and transient state of global brain dysfunction with clouding of consicousness
Sudden onset with fluctation throughout the day
Disorientated, poor attention and short term memorhy
Mood changes may dominate
Illusions/hallucinations common (visual usually)
Speech/sleep disturbance
Behavioural changes: Either hyperactive or hypoactive
Risk factors
- Old age
- Pre-existing physical/mental health illness (esp dementia)
- Subtance misuse
- Polypharmacy
Must check PAIN FLUID INTAKE CONSTIPATION URINARY RETENTION
25
Delirium aetiology
Investigations
```
Trauma (head)
Hypoxia
Infective
Metabolic
Endocrine (hypoglycaemia)
Nutritional (Wenickes)
CNS pathology
Drugs and alcohol
Medication e.g. anticholinergics, opiates
```
```
Physical exam.
Check medications
UDS
Bloods: FBC, U&Es, glucose, LFTs, Ca
CVS/RS: SaO2, CXR, ECG
Septic screen
Consider imaging, blood cultures, CSF etc.
```
26
Delirium management
TREAT CAUSE
- Avoid constipation, urinary retention, dehydration and pain
Tell them who they are, who you are, where they are. Involve family/friends
Behavioural management
- Reorientate - clocks, calendars, lighting
- Sensory problems - glasses, hearing aids
- Minimise changes + calm environent
Involve family and friends, tell
Med
- Small nocturnal benzodiazepine MAY promote sleep and help correct sleep-wake cycle
- If distressed, a risk to others or self AND DE-ESCALATION NOT WORKED - short term <1 week) haloperidol
Consider referral to psych or old age
Prevention
- Good sleep, as above, minimal moves in hospital
Some pts never return to pre-morbid level - can take weeks/months
Higher mortality
Longer admissions
Higher re-admission rates
27
Dementia
General picture
Acquired, chronic progressive cognitive impairment impacting on ADLs
- normal consciousness
- > 6months!
```
Beginning - forgetful and anxiety/depressiom
Then disorientation in order
- Time
- Place
- Person
Towards the end
- Unable to carry out ADL
- Thinking and language impoverished
- Mood and personality severely affected
```
28
Dementia
Aetiology
Pathology
Acquired, chronic progressive cognitive impairment impacting on ADLs
- normal consciousness
- > 6months!
Aetiology
Age, female
Genetic mutations: PSEN 1/2 And APP and trisomy 21
Asking factors
Low IQ
Head injury: CTE (American football, boxing)
Pathology
- Widespread cortical atrophy
- beta-amyloid plaques
- Neurofibrillary tangles of town
- Cerebral amyloid angiopathy
- Loss of cholinergic neurons
29
Alzheimer's key features + management
Amnesia: recent memories first memories
Aphasia: word finding problems
Apraxia: difficulty with coordinating tasks e.g. dressing
Management
Memory clinic referral
ACh esterase inhibitors
– Donepazil: reversible
– Rivastigmine: Short half life of April as patch
– Galantamine: Like donepazil but extra actions
NMDAR inhibitors
– Memantine: Used for mod/severe Alzheimer;s
PSYCHO SOCIAL
HIPPOCAMPAL ATROPHY
30
Vascular dementia presentation
Management
Stepwise progression with each infarct
- Patchy if various patches e.g. personality/areas of cognition spared
- Neuro signs e.g. hemiparesis (contralateral motor cortex infarct) or aphasia (receptive - Wernicke's; expressive - Broca/s)
LACUNAR LESIONS
Death in 5yrs due to IHD/stroke
DO NOT USE DEMENTIA DRUGS
- Statins
- Anti-hypertensives
- Smoking + weight advise
- Aspirin
- Clopidogrel
- Warfarin
- Diabetes meds
PSYCHO SOCIAL
31
Lewy body dementia
Lewy bodies (composed on alpha synuclein and ubiquitin)
- In PD: In substantia nigra --> motor symptoms
- In LBD: In cyngulate gyrus and neocortes --> dementia
1) FLUCTUATING confusion with marked changes in alertness
- easy to confuse with delerium but cannot start haloperidol due to extreme neuroleptic sensitivity in LBD
2) Vivid visual hallucinations
3) Spontaneous parkinsonian signs
32
Anti-cholinesterase drugs side effects
Donepazil, Rivastimine if MMSE >12/30
```
SE:
S alivation
L acrimation
U rinary inc
D efacation
G I upset
E mesis
```
33
MS
Inflammation and demyelination at different sites/times within CNS white matter tracts
RELAPSING AND REMITTING
Triad
1) Scanning speech
2) Intention tremor/Incontinence/Internuclear opthalmoplegia
3) Nystagmus
50% have depression and mania is common
Treat as primary depression
34
Anxiety symptoms
```
Psychological
– Fears and worries
– poor concentration
– irritability
– insomnia
```
Motor symptoms
– restless and fidgety
– on edge
```
Neuromuscular
Headaches
– muscle aches
– trauma
– dizzy
– Tinnitus
```
```
GI
– dry mouth swallowing difficulty
– nausea
– butterflies
- Flatulence
– frequent or loose nations
```
CVS
– chest discomfort
– palpitations
Respiratory
– difficulty breathing
– tight chest
Genitourinary
– urinary frequency
– erectile dysfunction
– amenorrhoea
35
OCD diagnosis
>/= 1hr/day of symptoms
or
Interfering with life
Obsessions = Recurrent intrusive thoughts despite resistance. KNOWS irrational and their own
Compulsions = repeated, serotyped behaviour an seemingly purposeless
- May have no link to obsession
Do the Yale brown obsessive compulsive compulsive scale
36
Panic disorder diagnosis
Intermittent out of the blue
Sudden and extreme panic attacks. 4 or more of:
- Sweating
- Trembling
- Palpitations
- Chest pain
- SOB feeling
- Choking feeling
- Nausea or abdo distress
- Dizzy/lightheaded
- Fear of losing control or going crazy
- Fear of dying
- Numbness or tingling
- Chills or hot flushes
Dx:
Recurrent unexpected panic attacks
At least 1 attack followed by 1 month or more of of 1 or omore of:
- Persistent Worry about having another attack
– worry about the attack consequences
– significant change in behaviour related to the attacks
37
Agoraphobia
20-30yos
Core fear: Open spaces, away from 'safe space', fear of not being able to leave situations
MUST BE 2 situations. >/= 6 months
e. g.
- Travelling
- Supermarkets
- Large crowds
- Parks
38
Social phobia
Late teens. Male=Female
Core fear: Scrutiny by others and embarrassed in public.
Large crowds usually ok but not small events e.g. dinner parties
Sometimes specific problems e.g. eating/ fear of embarrassing symptoms
39
PTSD
Management
Hyperarousal - can't relax, hypervigilant, insomnia, poor conc
Re-experiencing - flashbacks, nightmares, intrusive mems
Avoidance - Avoiding reminders of the event
Decreased interests and powerful emotions
Co-morbidities
- Depression and anxiety
- Alcohol use
Active monitoring for 1 month
Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended
40
Depression
Aetiology
Core symptoms:
Low mood
Anhedonia
Anergia
At least 2 for 2 weeks
Becks model of depression:
- worthless, helpless, hopeless
- Self, world, future
Cognitive symptoms
- Guilt, pessimistic
- Poor concentration and memory
- Thinking may feel slowed
Biological symptoms
- Sleep altered: insomnia, early waking (2h before)
- Appetite for food and sex suppressed --> weight loss and relationship strain
- Physical symptoms of constipation, aches, pains may occur
Psychotic symptoms (if severe)
- Auditory hallucinations (derogatory) or rarely visual
- Nihilistic delusions - rotting, guilt themes etc.
- Guilt can progress to delusion, believing they have committed a crime
41
Depression
Aetiology
Hypothesis
Physical illness: Cushings, hypothyroid, MS, hyperPTH
Medications: beta blockers, anti-HTN, cocaine, steroids
FH of depression or BPAD
Adverse childhood events
Life events
- Death of close relative, divorce/separation, jail term
Vulnerability factors
- Unemployment, lack of confiding relationships, lower socioeconomic status and social isolation
Monamine hypothesis = Depression is deficiency in brain monamine neurotransmitters:
- Serotonin: Sleep, Appetite, Mood, Memory
- Noradrenaline: Mood, Energy
- Dopamine: Psychomotor activity
42
Depression prevalence
Lifetime risk ~ 15%
Point prevalence ~ 8%
Female 2 x risk
Age of onset
- F: 40
- M: 60-70s
43
Subtypes of depression
SAD:
Lower mood in winter. Usually reserved symptoms of overeating and sleeping
Atypical depression:
Reserved biological symptoms and may retain mood reactivity
Agitated depression:
Depression with psychomotor agitation instead of retardation e.g. restlessness, pacing, hand wringing
Depressive stupor:
Psychomotor retardation so profound that person grinds to a halt
Masked depression:
Doesn't present with low mood; maintain a cheerful exterior
Somatic syndrome:
>/= 4 biological symptoms of depression
Pseudo-dementia:
Depression affecting memory so badly that patient appears to have dementia
- NB dementia itself can begin with affective change
44
Depression investigations
Screening questions - in last 2 weeks:
1) Feeling down, depressed or hopeless?
2) Little interest or pleasure in doing things?
```
Collateral hx
Physical examination
Depression screening tools: PHQ9, HADS
Bloods: TFTs, FBC, Glucose or HbA1c
Rating scaled to measure severity or monitor response: BDI
```
CT/MRI ONLY if cerebral pathology suspected
45
SSRIs
Side effects
Length of treatment
Fluoxetine, Sertraline, Paroxetine, Fluvoxamine, Citalopram, Escitalopram
Initial Side effects:
- Nausea, Vomiting
- Appetite and weight change
- Anxiety and agitation
Persistent side effects:
- Blurred vision
- Insomnia, tremor, dizziness
- Headache
- Sweating
- Lower seizure threshold
- Hyponatraemia
- Some degree of sexual dysfunction
1st choice in depression generally.
Continue at least 6 months after no longer depressed
- reduces relapse
- not associated with addiction
Explain onset delayed and outline major side effects
2 YEARS IF RECURRENT DEPRESSION
46
When to avoid antidepressants
Hypomania or mania
DON'T DRINK
Don't kneed to avoid but be cautious in epilepsy
47
Choice of antidepressant in patients with cardiac conditions
Sertraline post MI
Citalopram/Escitalopram prolong the QT interval so shouldn't be used in those with
- long QT
- Know pre-existing QT prolongation
- Other meds that in combination prolong the QT
48
Antidepressant choice for children
Fluoxetine is the drug of choice
49
Anti-depressant interactions
NSAIDs (asparin)
- Don't give together if avoid but if needed offer PPI (omeprazole)
Warfarin/Heparin
- AVOID SSRIs
- Give Mirtazapine
Triptans
- Avoid SSRIs
MAOIs
- Avoid as risk of serotonin syndrome
50
Anti-depressants in pregnancy
Weigh up risks and benefits
1st trimester use
- Small risk of congenital heart defects esp paroxetine
3rd trimester use
- Risk of persistent pulmonary hypertension of the neborn esp fluoxetine
51
What type of drug is Venlaflaxine
Others in category
MOA
+ Side effects
SNRI = Serotonin and Noradrenaline reuptake inhibitor
Venlafaxine and Duloxetine
Side effects
- Constipation
- Hypertension
- Cholesterol
```
Other side effects same as SSRIs:
Initial Side effects:
- Nausea, Vomiting
- Appetite and weight change
- Anxiety and agitation
```
Persistent side effects:
- Blurred vision
- Insomnia, tremor, dizziness
- Headache
- Sweating
- Lower seizure threshold
- Hyponatraemia
- Some degree of sexual dysfunction
52
Mirtazapine type of drug
Side effects
NASSA: Noradrenergic and specific serotonin reuptake inhibitor
Side effects
- Sedation
- Increased appetite/weight
- Oedema
Drug of choice if on warfarin/heparin
53
TCAs examples
Side effects
```
Amitriptyline
Clomipramine
Imipramine
Lofepramine
Dosulepin
```
SIDE EFFECTS
Anti-cholinergic
- Drowsy, tachycardia, dry mouth, urinary retention, constipation, blurred vision
Alpha-adrenergic receptor blocking
- Postural hypotension
Histamine receptor blockade
- Sedation and weight gain
Cardiotoxic
- Tachycardia, arrhythmia, ST elevation, QT prolongation
Choosing TCA
- Amitriptyline is used for neuropathic pain and headache prophylaxis
- Lofepramine has a lower incidence of toxicity in overdose
Amitryptiline and dosulepin considered most dangerous in overdose
54
Reviewing antidepressants
After 2 weeks for all
If increased risk of suicide or <30yo: 1 week
After 6 months review need for continued medication
55
What is serotonin syndrome
Too much antidepressant
Psychiatric:
Agitation, Excitation, Confusion, Restless, Decresed co-ordination
Neuromuscular:
Tremor, clonus, myoclonus, hyperreflexia
Autonomic
Fever, Tachycardia, Tachypnoea, D&V, HTN
56
Swapping antidepressant from fluoxetine
To other SSRI/TCA
- Taper and stop. Wait 4-7 days
To SNRI
- Taper, stop and then start new drug
To MAO
- Taper, stop, Wait 5-6 weeks
57
Swapping antidepressant from SSRI
| not fluoxetine
To fluoxetine:
- Taper, stop. Then start
To other SSRI
- Cross tapering
To TCA
- Cross tapering
58
Swapping antidepressant from MAOI
Taper and stop then wait 2 weeks
- Wait 3 weeks for TCAs
- Wait 5 weeks for fluoxetine
59
Stopping antidepressants suddenly can give rise to what
Discontinuation syndrome
FLUI LIKE
'Electric shock' sensations
Headaches
Vertigo/Unstable
Irritability, Difficulty sleeping, mood changes
GI symptoms: Cramps, diarrhoea, pain, vom
To avoid: Withdraw over a few weeks esp short acting ones (Paroxetine)
To treat: Benzodiazepines, fluids, cryoprecipitate, fluoxetine (due to it's long half life)
60
What is treatment resistant depression
Management
REFRACTORY DEPRESSION
Failure to respond to 2 adequate trials of different antidepressants at adequate dose and for 6-8 weeks
- Up to 30% may be treatment resistant
Check compliance!!! and re-examine diagnosis
- Can try changing dose, drug, class of drug
Specialists can try augmentation strategies
- Lithium
- T3 or T4
- Buspirone (anxiolytic) No antidepressant effect alone but may have synergistic effect when combined with SSRI
61
ECT
Indication
GA, small electrical current passed through brain and stimulates a seizure that affects the whole brain including parts that control mood, appetite or sleep
Indications
- Refractory depression
- When rapid response is required
- When life threatening
Short term side effects
- Headache
- Memory loss (can be long term)
- Cardiac arrhythmias
- Nausea
Contraindications
- Raised ICP
62
Benzodiazepine indications
1. Short-term relief (two to four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness.
2. Use to treat short-term ‘mild’ anxiety is inappropriate.
3. Used to treat insomnia only when it is severe, disabling, or causing the patient extreme distress.
63
EPSEs
Management
Dystonia
= Involuntary painful sustained muscle spasm
- Rx: Anticholinergic e.g. procyclidine
Akathisia
= Unpleasant subjective feeling of restlessness, need to jiggle legs etc
- Rx: Decrease dose/change antipsychotic. Add propanolol or benzos
Parkinsonism
= Resting tremor, bradykinesia, rigidity
- Rx: Decrease dose/change antipsychotic. Try anticholinergic e.g. procyclidine but review frrequently and don't prescribe prophylactically
Tardive dyskinesia
= Rhythmic involuntary movements of mouth, face, limbs
- Stop antipsychotic or reduce dose if able (may worsen initially). Switch to atypical or clozapine. Often irreversible
:(
- Can try Tetrabenazine if severe
64
Neuroleptic malignant syndrome
Management
Rare but life threatening after new/change in antipsychotic
```
Fever
Encephalopathy
Vital signs: Labile BP, tachycardia
Elevated enzymes (WCC, CK)
Rigidity and muscle stiffness
```
Management
- STOP antipsychotic
+ Urgent treatment - dantrolene, D2 agonists e.g. bromocriptine
Can lead to death from a range of causes e.g. AKI from rhabdomyolysis
65
Antipsychotic in pregnancy
OK ones are
Haloperidol
Olanzapine
Quetiapine
66
What happens to neonate of an opiate dependent mother
Neonatal abstinence syndrome = withdrawal symptoms in neonate of an opiate-dependent mother
- Within hrs of birth
- Lasts several weeks
- Rx: paediatric preparations, anti-convulsants, supportive measures
67
Term for delusional jealously, usually believing their partner is unfaithful
Othello syndrome
Isolated delusion
Secondary to affective state or schizophrenia or PD
68
Mania vs hypomania
PSYCHOTIC SYMPTOMS
- Delusions of grandeur
- Auditory hallucinations
Lasts 7 days or more or severe functional impairment
Other symptoms in common:
Mood
- predominately elevated
- irritable
Speech and thought
- pressured
- flight of ideas
- poor attention
Behaviour
- insomnia
- loss of inhibitions: sexual promiscuity, overspending, risk-taking
- increased appetite
69
Alcohol withdrawal symptoms
Start at 6-12 hours: tremor, sweating, tachycardia, anxiety
Peak incidence of seizures at 36 hours
Peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
70
Management of subthreshold depressive symptoms or mild depression
General measures
sleep hygiene
active monitoring for people who do want an intervention
LOW INTENSITY PSYCHOSOCIAL interventions
- Individual CBT (8-9 sessions weekly)
- Computerised CBT (9-12 weeks)
- Group physical activity programme
- Group based CBT
Drug treatment
Do not use antidepressants routinely but consider them for people with:
- Hx of moderate or severe depression
-Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)
- Subthreshold depressive symptoms or mild depression that persist(s) after other interventions
- If chronic physical health problem and mild depression complicates the care of the physical health problem
71
Poor prognosis indicators in schizophrenia
```
strong family history
gradual onset
low IQ
premorbid history of social withdrawal
lack of obvious precipitant
```
72
What are psuedohallucinations
False sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating
e.g. hypnogogic (from wake to sleep)
Common in grieving patients
Management is reassurance - doesn't mean they will develop a mental illness
73
Schizophrenia presentation
Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient's behaviour
Thought disorder*:
thought insertion
thought withdrawal
thought broadcasting
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'.
Other features of schizophrenia include
impaired insight
incongruity/blunting of affect (inappropriate emotion for circumstances)
decreased speech
neologisms: made-up words
catatonia
negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
74
Antipsychotic with best side effect profile
Aripiprazole
| - particularly if prolactin elevation is an issue
75
How to manage hypomania in primary care (in terms of referral)
vs
Mania
Routine referral to CMHT
Mania:
- Urgent referral to CMHT
Stop antidepressants if on them for either
76
Schizophrenia diagnosis
Two diagnostic criteria have to be met over much of the time of a period of at least one month, with a significant impact on social or occupational functioning for at least six months.
77
ACEi side effects on U&Es
Hyperkalaemia
78
Features of post concussion syndrome
headache
fatigue
anxiety/depression
dizziness
79
Type of personality disorder
Occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Obsessive compulsive
Cluster C
Other features
- Perfectionism that hampers with completing tasks
- Extremely dedicated to work and efficiency to the elimination of spare time activities
- Meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
- Not capable of disposing worn out or insignificant things even when they have no sentimental meaning
- Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
- Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
80
Type of personality disorder
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Avoidant
Cluster C
Other features
- Unwillingness to be involved unless certain of being liked
- Preoccupied with ideas that they are being criticised or rejected in social situations
- Restraint in intimate relationships (fear of being ridiculed)
- Reluctance to take personal risks doe to fears of embarrassment
- Views self as inept and inferior to others
- Social isolation accompanied by a craving for social contact
81
Type of personality disorder
Difficulty making everyday decisions without excessive reassurance from others
- Need for others to assume responsibility for major areas of their life
- Difficulty in expressing disagreement with others due to fears of losing support
- Lack of initiative
- Unrealistic fears of being left to care for themselves
- Urgent search for another relationship as a source of care and support when a close relationship ends
- Extensive efforts to obtain support from others
- Unrealistic feelings that they cannot care for themselves
82
Bullemia diagnosis
Bloods
Management
Recurrent episodes of binging and purging
Lack of control during episodes
At least once a week for 3 months
Self evaluation unduly influenced by body shape and weight
Bloods: Hypochloraemia, hypokalaemia, alkalosis
Specialist referral for all
Adults: self guided help for 4 weeks, if unsuccessful - CBT- ED
Children: FT-BN
Psychosocial: BEAT charity
Can consider fluoxetine (specialist)
83
Most sedative TCA
Amitriptyline
Clomipramine
Dosulepin
Trazodone*
Less sedative
Nortriptyline
Imipramine
Lofepramine
84
Type of personality disorder
Repetitive unlawful behaviour - no regrets
Antisocial
Class B
MORE COMMON IN MEN
Other features
- Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
- Impulsiveness or failure to plan ahead;
- Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
- Reckless disregard for safety of self or others;
- Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
- Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
85
Insomnia
Difficulty initiating or maintaining sleep, or early-morning awakening
+ leads to dissatisfaction with sleep quantity or quality
+ Despite adequate time and opportunity for sleep
+ Results in impaired daytime functioning.
Acute: Typically related to a life event and resolves spontaneously
Chronic: If a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer.
86
Missed clozapine dose rules
If doses are missed for > 48 hours
- Restart their clozapine slowly (like when they first started on it). This restart of treatment needs to be under the direction of a Psychiatrist. This is because when you start Clozapine after a break of >48 hours, it can make side effects worse, such as blood pressure changes, drowsiness and dizziness.
If there is a gap in treatment of 3 days (72 hours) then you may also require more frequent blood tests for a short period.
87
What is word salad
Indicative of?
a confused or unintelligible mixture of seemingly random words and phrases - nonsensical
Indicative of advanced schizophrenia.
88
What is perseveration?
Indicative of?
Stuck, repetition of answers
Organic brain disorders
89
Tangential speech
Indicative of what condition/s
Normal speed & number
- Don't get to answer what is asked
- Logical flow of thoughts but veer away from goal
- Stays within general topic unlike flight of ideas
Schizophrenia, Obsessive personality traits
90
What are
Neoligsms
Clang associations
Punning
Neologsms
- Made up words
Clang associations
- Rhyming connections
Punning
- Playing on words with the same sound but different meanings
91
What is thought block
Indicative of what condition
Stops suddenly, last sec-min, pt cannot remember what they are trying to say
Schizophrenia
92
What is echolalia
Pt repeats what is said to them
93
Mood descriptions
Labile
- V changeable mood
- Dementia, frontal lobe disease, extreme stress, hypomania, intoxication, mixed affective states
Flat/blunted
- Schizophrenia, Depression, Parkinson's, hypothyroid
Reactive
- Shifts appropriately with conversation
Inappropriate affect
- Conversion disorer, intoxication, Frontal dementia, Parkinsonism, Hebephrenic schizoprenia
Incongruent
- Schizophrenia, antisocial PD, hypomania
94
What is folie a deux
When 2 people v close and share a delusion
95
Types of delusion
Grandiose
Persecutory
Nihilistic (Cotard's syndrome)
Of reference
Of control: Passivity, delusions of thought interference
Of Jealousy (Othello's syndrome)
Amorous (Erotomanic)
Of guilt
Of worthlessness
Hypochondrial (belief they have an illness)
Infestation (Capgras syndrome): Thinks object/person not real but has been replaced
Fregoli : Single persecutor impersonates several people familiar to the pt
96
Mental health act
Purpose of, who needed to do it and how long it lasts
Sections 2,3, 4
Section 2
- For assessment
- 2 Drs (1 being section 12 approved) + AMHP/NR
- Lasts 28 days
Section 3
- For treatment
- 2 Drs (1 being section 12 approved) + AMHP/NR
- 6 months
Section 4
- For emergency
- Any Dr + AMHP/NR
- 72 hours
Sections 2 and 3 require an application from an Approved Mental Health Professional (AMHP, formerly an Approved Social Worker), or, rarely, the person's nearest relative, and recommendations from two doctors; one of whom is section 12-approved (usually a psychiatrist) and one who has previous acquaintance with the person (usually the person's GP if at all practicable).
97
Mental health act
```
Purpose of, who needed to do it and how long it lasts
Sections 5(2), 5 (4), 135, 136
```
5(2)
- Detention of an INPATIENT. Holding power for MHAA
- Dr in charge of pt care only 1 + NURSE
- Doesn't authorise medical treatement
- 72h
5(4)
- Detention of an inpatient
- Done by a nurse
- 6 h
135
- Police right to enter home, Need magistrate
- No medics needed
- 72h
136
- Admission by police from public place
- No medic/court needed
- 24h
98
What is Anorexia nervosa
Need for hospital admission
1) Restriction of energy intake --> low body weight
2) Intense fear of gaining weight or becoming fat even though under weight
3) Disturbance in body view, high priority in selve evaluation or denial of current body weight
Typically BMI <17.5 (or 15% less than affected) - <2.4 on centile charts for kifs
Endocrine dysfunction
Physical signs, such as cachexia, acrocyanosis (hands or feet are red or purple in colour), dry skin, hair loss, bradycardia, orthostatic hypotension, hypothermia, loss of muscle mass and subcutaneous fat, oedema, and lanugo hair (downy hair on the upper part of the body and face).
Hospital admission to be considered urgently
- BMI <15
- Risk of suicide/ self harm
- Home environment not suitable
- Severe deterioration
- Medical complications
```
Bloods
hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
```
99
Bulimia nervosa diagnsosis
Management
Present for 3 months, at least 1 episode per week
Binge eating - with lack of control
Purging - e.g. laxative, vomiting, diuretics, excess exercise
BMI >17.5
Body image distortion
Management
Psychological treatments are usually offered first line
- Treat medical complications
- Treat co-morbid psych illness
- CBT
- Fluoxetine (trial can be done, not by GP for kids)
100
Eating disorders investigations
BMI (centile if <18)
Full physical examination
- Lanugo hair, Russel's sign, lack of 2ndary sexual characteristics, Enamel erosions on teeth, Osteoporosis, Cardiac arrhythmias, Renal impairment
Squat test for proximal myopathy
Bloods: Glucose, FBC, U&Es, LFTs, phosphate, albumin, CK + TFTs, ESR
ECG
DEXA scan (if indicated)
101
Complications of anorexia nervosa
```
Osteoporosis
Fatty liver
Bradycardia
Collapse
Arrhytmia
Cognitive
Nutriional deficiencies
```
In EDs in general (actually AN)
- General - anaemia, leukopenia, thrombocytopenia, infections
- CV - 80% of AN have problems, bradycardia, postural drop, arrhythmias, secondary to hypokalaemia
GI: Constipation, abdo pain, ulcers, oespophagea tears
Reproductive - amenorrhoea, infertility, loss of libido
MSK - osteoporosis, prox myopathy
Neurological - peripheral neuropathy, delirium, convulsions
102
In which psyh condition is this blood panel present
```
Rapid reduction in
- Phosphate
- Potassium
- Magnesium
Water dysregulation
Altered glucose
```
What is the risk
Refeeding syndrome in ED - risk of arrhythmia
103
Somatisation definition
Somatisation disorder
Unconscious expression of psychological distress through physical symptoms
Somatisation disorder
- Multiple medically unexplained symptoms
- Lasting 2 years
- Difficult to treat
104
Chronic fatigue syndrome presentation
Management
Extreme fatigue, after mild exertion
Often with aches and pains
Can follow viral infection or be spontaneous
Management
- Graded exercise
- Pacing of activity with realistic goals
- CBT
105
Hyponchondrias
Patient believes they have a specific illness (rather than inexplicable symptoms)
- Refusal to be reassured with -ve results
106
Malingering
vs
Factitious disorder (other name)
Malingering
- Feigning symptoms to obtain SECONDARY REWARD
- Not a psychological disorder
Factitious disorder aka Munchausen's syndrome
- Feigning symptoms to receive medical treatment
- Motivation is a pathological need for the sick role
- Medical disorder
107
What are onversion disorders
```
Internal conflict converted to NEURO symptoms
May have la belle indifference despite concerning symptoms
- Blindness
- Paralysis
- Seizures
- Aphonia
- Psychogenic amnesia
- Fugue - loss of entire memory
```
Management
- Exclude organic causes
- reassure
- Encourage return to normal activities
- Address triggering factors
BETTER OUTCOME THAN MUS
108
Management of paracetamol overdose
< 1h - give activated charcoal, check paracetamol levels at 4h and tx according to nomogram
1-8h - check paracetamol levels and tx according to nomogram
>8h - give N-acetylecysteine if blood paracetamol levels >75mg/kg and treat according to nomogram
109
Type of personality disorder
- Odd beliefs and magical thinking
- Lack of close friends other than family members
Other symptoms
Schizotypal = ALL ALONE
Type A
Ideas of reference (differ from delusions in that some insight is retained)
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Inappropriate affect
Odd speech without being incoherent
110
Management of GAD - stepwise
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
Medication options
- SSRI anti-depressants
- buspirone (5-HT1A partial agonist)
- beta-blockers
- benzodiazepines: use longer acting preparations e.g. diazepam, clonazepam
- cognitive behaviour therapy
111
Management of panic disorder
| - Stepwise approach
Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Treatment in primary care
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
112
Type of personality disorder
Indifference to praise and criticism
Few interests
Few friends or confidants other than family
Other symptoms
Schizoid
Group A
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
113
Type of personality disorder
Efforts to avoid real or imagined abandonment
Recurrent suicidal behaviour
Other symptoms
Borderline personality disorder
Group B
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
114
What is dissociative disorder?
Dissociation is a process of 'separating off' certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
115
Withdrawing SSRI time frame
4 weeks
116
What is Charles Bonnet syndrome
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.
```
Risk factors include:
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
```
117
Mania differentials
Investigations
Organic - drug induced (cocaine, dementia, delirium, frontal lobe disease, Myxoedema
Schizophrenia/Schizotypal
Cyclothymia
Puerperal disorders
Investigations
- FBC, TFTs, CRP
- MSU, UDS
118
CBT explanation
Stands for cognitive behaviour therapy
– type of talking therapy
– don't want to one basis one-to-one basis
– with a trained therapist
– usually 8 to 12 sessions once a week
– Takes a practical approach
– based on the fact that thoughts can affect how we feel
– encourages different ways of thinking
– uses looks of practical effects and problem and uses problem-solving
–Make get task to do at home between sessions
– alongside any medication you may be taking
119
Indications for detox in hospital for alcohol
hx of withdrawal fits
Comorbid medical/psychological illness
Previous detox Failure
Vulnerable people/children at home
120
MOA of the alcohol relapse prevention medications
Disulfiram
– Blocks aldehyde dehydrogenase
– Mimics flush, anxiety, headaches, nausea and vomiting
– contra indicated in: cardiovascular disease and respiratory patients
Acamprosate
– Enhances GABA transmission
– Reduces relapse by reducing cravings
Naltrexone
– Blocks opioid receptors
– reduces cravings
121
Lithium toxicity picture
Levels + Cause
Management
1.2 mmol/L and – triggered by salt balance changes due to D&V, dehydration and drugs (NSAIDs, ACEi, diuretics)
GI
- N&V
- Anorexia
CNS
- Drowsy
- ATAXIA
- Coarse tremor
- Confusion
- Muscle weakness
- Slurred speech
Management
- STOP lithium
- Check levels + U&Es, eGFR
122
Symptoms of mild lithium toxicity (side effects really)
Test to do before starting
Explanation for pts
```
Fine hand tremor
Metallic taste in mouth
Polyuria, polydipsia
Hypothyroid
Weight gain
GI effect (N&V)
```
Test to do before starting
- BMI, U&Es, Ca, TFTs, FBC, PREGNANCY TEST
- ECG if CVD risk
Is a mood stabiliser. Tends to be needed lifelong I need to be reviewed regularly
Initially blood levels weekly until they are stable and then every three months. You'll also need other blood tests every six months (U&Es, TFTs, Ca)
– Because the medication can affect kidney function and thyroid function.
IF PREGNANT/ planning talk to your doctor immediately, seek attention if acutely ill or D&V, don't take over the counter NSAIDs
