Psychiatry Flashcards
What is the function of the amygdala?
Processes info about potential threats before we know we have seen it
What is the function of the hippocampus?
Regulates memories in the right time, place and context
What is Cotards syndrome?
Seen in severe depression
Delusional belief that they are dead or non-existent
Indications for ECT in depression
Severe depression refractory to medication
Catatonia
Psychotic symptoms
Schizophrenia management steps
2nd gen antipsychotic - Risperidone (other than clozapine or olanzapine)
if not responding - try other 2nd gen
if still not responding - clozapine
Management of generalized anxiety disorder
SSRI/SNRI
Atypical antidepressant (e.g. mirtazepine)
Pregabalin
Must stay on for at least 18m (if responding)
Timeline classification of PTSD
< 48hrs = acute stress reaction
< 4wks = acute stress disorder
< 3m = acute PTSD
> 3m = chronic PTSD
Management of PTSD
if <4 wks = wathcful waiting
Trauma focused CBT
EMDR
Drug tx = paroxetine or mirtazepine
Difference between mania and hypo mania
Hypomania
- must be sustained for at least 4 days
- milder symptoms than mania
Mania -
- must be sustained for at least 1 weeks
Management of acute mania
1 - aripiprazole or olanzapine
2 - haloperidol, lorazepam
Management of chronic bipolar
Lithium carbonate (therapeutic range 0.4 - 1 mmol/L)
2nd line = sodium valproate or carbamazepine
Physiological abnormalities in anorexia
Decreased K Decreased LH, FSH, oestrogen + testosterone Increased cortisol + GH Impaired glucose tolerance Hypercholesterolaemia Low T3
Metabolic abnormalities in re-feeding syndrome
(abrupt change from catabolic - carb metabolism)
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia (may predispose to torsades)
Abnormal fluid balance
How to prevent re-feeding syndrome?
If not eaten in > 5 days - aim to refeed < 50% of requirements for first 2 days
Classification of personality disorders
Cluster A = “Weird” (odd + eccentric)
- Schizoid (“aloof”)
- Schizotypal (“awkward”)
- Paranoid (“accusatory”)
Cluster B = Wild (“dramatic + emotional”)
- Antisocial (“bad”)
- Borderline (“borderline”)
- Histrionic (“bullshit”)
Cluster C = Worried (anxious + avoidant”)
- Avoidant (“coward”)
- Dependent (“clingy”)
- Ankastic (“compulsive”)
Features of borderline PD
Unstable + intense interpersonal relationships Recurrent suidical behaviour Impulsivity Identity disturbance Chronic emptiness
Features of histrionic PD
Needs to be centre of attention Always sexually seductive Uses physical appearance to get attention Self dramatisation Suggestable
Symptoms of alcohol withdrawal
6-12 hrs = 1st symptoms (tachycardia, HTN)
24-48 hrs = peak
36 hrs = generalised seizures
72 hrs = delirium tremens
Features of delirium tremens
Hallucinations Agitation Paranoid ideation Fever Disorientation/confusion
What are the features of thiamine deficiency (Wernickes encephalopathy?
- confusion
- ataxia
- opthalmoplegia
if left untreated - Korsakoffs syndrome (amnesia, confabulation)
How to prevent alcohol withdrawal?
Start before withdrawal symptoms
- BZD’s
- Pabrinex (IV thiamine)
- Hydration
Drugs for alcohol replase prevention
Naltrexone (opiod antagonist)
Acamprostate (decrease cravings)
Disulfram (horrible reaction to alcohol)
Signs of opiod intoxication
Constricted pupils Euphoria Altered mental status Resp depression Agitation
Treatment of BZD overdose
Flumazenil
Detoxification for BZD misuse
Transfer onto equivalent dose of diazepam/chlordiazepoxide
Decrease dose every 2-3wks in steps of 2-2.5mg
Classification of learning difficulties
Borderline = 70-84 Mild = 50-69 Moderate = 35-49 Severe = 20-34 Profound = <20
Investigation before ADHD treatment
ECG (methyphenydate, lisdexamfotmine, dexamfetamin can all be cardiotoxic)
How long does Nurses Holding Power last?
6 hours
What is emergency detention?
FY2 or above
Lasts 72 hours
Doesn’t authorise treatment
No right of appeal
What is short term detention order?
By approved medical practitioner Lasts for 28 days Requires MHO approval Authorises treatment Right of appeal (<14 days)
What is compulsory treatment order?
Needs either 2AMPs or AMP + GP
Requires a tribunal
Lasts up to 6m
MOA of typical anti-psychotics
Block dopamine D2 receptors on mesolimbic pathway
Side effects of typical anti-psychotics
Dopamine blockade in nigrostriatial pathway = EPSEs
Dopamine blockade in the tubero-infundibular pathway = hyperprolactinaemia
What are EPSEs?
Acute dystonic reaction (hrs - days) = muscle spasm
Parkinsonism (days-months) = rigidity, bradykinesia, tremor
Akathisia (months) = restlessness
Tardive dyskinesia (years) = repetitive involuntary purposeless movements
MOA of atypical anti-psychotics
5-HT2 antagonism + dopamine blockade
Side effects of atypical anti-psychotics
Weight gain (mostly olanzapine) Metabolic syndrome (mostly clozapine)
General S/E of anti-psychotics
Anti-muscarinic
Sedation
Weight gain
Reduced seizure threshold (more so in atypicals)
Increased risk of VTE/Stroke (esp in elderly)
Neuroleptic malignant syndrome (just started tx - pyrexia + muscle stiffness)
How is clozapine monitored?
Weekly for 1st 6 months
Fortnightly for 2nd 6 months
Monthly thereafter
One month after sedation
Side effects of clozapine
Agranulocytosis
Reduced seizure threshold
Constipation Myocarditisi
Hypersalivation
How is lithium monitored?
Weekly when starting + after each dose change
Once stable - 3 monthly (take level 12hrs post dose)
Also monitor
- Thyroid - 6 mths
- Renal - 6 mths
Side effects of lithium
N + V Diarrhoea Dry mouth Metallic taste Hypothyroidism Worsening of psoriasis Weight gain Idiopathic intracranial HTN Nephrotoxicity Fine tremor Hair loss T wave flattening
Side effects of carbamazepine
N + V Confusion Unsteadiness Double vision Headache
Lamotrigine side effects
Rash (SJS)
Caution during pregnancy/breastfeeding
Side effects of sodium valproate
Tetratogenic p450 inhibitor GI upset Alopecia Pancreatitis Thrombocytopenia Hyponatraemia
Anti-depressant used post-MI
Sertraline
Anti-depressant 1st line in children/adolescents
Fluoxetine
Side effects of SSRI’s
GI upset
Increased risk of GI bleed
QT prolongation (citalopram)
Hyponatraemia
How to stop SSRIs?
Gradual reducing dose over 4 weeks
SSRI discontinuation symptoms
Increased mood
Restlessness
Difficulty sleeping Sweating GI symptoms
Paraesthesia
Side effects of MAO inhibitors
(Not routinely used because of S/E)
Hypertensive reactions with tyramine containing foods (e.g. broad beans, cheese)
Anti-cholinergic effects
Side effects of TCA’s
Anti-cholinergic (drowsiness, dry mouth, blurred vision, constipation, urinary retention)
QT prolongation
