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Psychiatry Flashcards

1
Q

What 3 statutory criteria must be met to section a patient?

A
  1. The patient has a mental disorder of a natural or degree that warrants detention in hospital for assessment or treatment
  2. The patient requires assessment or treatment of said mental disorder (treatment must be available)
  3. The admission of the patient is to protect themselves of others
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2
Q

What section is used for assessment of a patient?

A

Section 2

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3
Q

How long does a section 2 last?

Who can make the application?

A

28 days

An approved mental health professional on behalf of 2 doctors (of which 1 must be section 12 approved)

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4
Q

What is a section 3 used for?

How long does it last?

A

Admission of a patient for treatment

6 months

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5
Q

What additional requirements are needed for a patient to be treated with ECT under section 3?

A

Either consent from the patient or a specialist out of area doctor opinion.

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6
Q

How long can you treat a patient under a section 3 without consent?

A

3 months, then requires consent or a specialist out of area doctor opinion.

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7
Q

What is a section 4 used for?
How long does it last?
How can make the application?
What happens when it expires?

A

Emergency admission for assessment
72 hours
An approved mental health practitioner
1. Convert to section 2/3 2. Regrade to voluntary 3. Discharge

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8
Q

What is a section 5(2)?
How long does it last?
What can be done to patient under section 5(2)?

A

Detention of a patient already in hospital (Doctor’s holding power).
72 hours
Assessment then 1. convert to section 2/3, 2. Regrade to voluntary (informal) or 3. Discharge

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9
Q

What section can a mental health nurse apply for?

How long does it last?

A 
Section 5(3)
6 hours or until patient is assessed by doctor for S5(2) regardless of outcome.
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10
Q

What section powers do the police have?

A 
Section 136 (24 hours) - compulsory detention from public place
Section 135 - Allows police into someone's home and bring them to place of safety. Requires a warrant from magistrates court.
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11
Q

What are the differentials for someone presenting with low mood?

A 
Unipolar depression
Postpartum depression
Recurrent depressive episode
Bipolar affective disorder
Hypothyroidism
Cancer/Terminal illness diagnosis
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12
Q

Biological risk factors of depression

A

Genetic susceptibility
Monoamine theory
Female
Ventricular enlargement

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13
Q

What is the monoamine theory?

A

Depletion of monoamines eg serotonin (5-HT), noradrenaline and dopamine is the pathogenesis of depression

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14
Q

Psychological risk factors for depression

A

Neuroticism
Low self esteem
Childhood abuse

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15
Q

Social risk factors for depression

A

Disruption due to life events eg birth, death, job loss, illness
Alcohol/drug dependance
Stress
Social isolation

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16
Q

What might the presentation of depression be in the elderly?

A 
Global memory loss
Rapid onset
Early waking
Answering "don't know"
Decreased appetite
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17
Q

What are the core symptoms of depression?

A

Low mood
Anhedonia (loss of interest and pleasure)
Fatigue

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18
Q

What are the biological symptoms of depression?

A

Poor appetite - leads to weight loss
Disrupted sleep
Psychymotor retardation or agitation
Decreased libido

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19
Q

What are the psychological symptoms of depression?

A 
Worthlessness
Guilt
Decreased confidence
Hopelessness
Suicidal ideation
Decreased concentration
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20
Q

What is the 1st line treatment for mild depression?

A

Psychological intervention eg computerised CBT, group based therapy

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21
Q

What is the treatment for moderate depression?

A

Antidpressants eg SSRI + high intensity psycholigalc intervention eg 8-12 sessions of CBT

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22
Q

What are the indications for ECT?

A

Catatonia
Irretractable mania
Severe major depression

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23
Q

What are the side effects of SSRIs?

A 
N+V
Sexual dysfunction
Weight change
GI disturbance (diarrhoea)
Anxiety
Increased suicidal thoughts in first few weeks
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24
Q

What ECG change can be seen with citalopram?

A

Prolonged QT

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25
What are the short term side effects of ECT?
Headache Confusion Muscle ache Short term memory loss
26
Long term side effect of ECT?
Memory loss
27
What are the 2 different types of bipolar disorder?
Bipolar 1 Disorder: Depressive and Manic episodes in a ratio of 1:1. At least manic episode that has lasted a week. Bipolar 2 Disorder: Depression is more dominant, at least one episode of severe depression. More likely to experience hypomania.
28
Manic symptoms
``` Lasts >1 week Extreme elevation in mood Overactivity Pressure of speech Impaired judgement Extreme risk taking Social disinhibition Grandiosity Psychosis symptoms eg hallucination ```
29
Symptoms of hypomania
``` Lasts <4 days Elevated mood Increased energy Increased talkativeness Poor concentration Mild reckless behaviours eg excessive spending Sociability/overfamiliarity Increased confidence Increased libido Decreased need for sleep Change in appetite ```
30
Management of an acute manic episode
Atypical antipsychotic eg olanzapine, risperidone, quetiapine, clozapine
31
Benefit of using an atypical antipsychotic
Less extra-pyramidal side effects
32
What are the effects of haloperidol?
``` It is a typical antipsychotic. Extrapyramidal symptoms include: Acute dystonia Parkisonsim Tardive dyskinesia Akathisia ```
33
What are the side effects of olanzapine and other atypical antipsychotics?
``` Impaired glucose tolerance - increases risk of diabetes Weight gain Sexual dysfunction Sedation Cardiomyopathy Hyperprolactinaemia ```
34
What is the side effect of clozapine?
Agranulocytosis
35
Long term management of bipolar affective disorder
1st line: Lithium | 2nd line: Sodium Valproate, olanzapine
36
Side effects of lithium
``` Leukocytosis Insipidus (diabetes) Tremor (coarse) Hypothyroidism Increased Urine Metallic taste ``` +Teratogenic, sedation, lethargy, D+V, weight gain, oedema
37
Symptoms of lithium toxicity
``` Coarse tremor D+V Confusion Excessive sleeping Seizures Myoclonic jerks ```
38
What might cause lithium toxicity?
``` Dehydration Change in salt level Diuretics/NSAIDs Change in brand of lithium Reduced renal function Infection ```
39
What is the management of lithium toxicity?
Stop lithium Check levels Rehydrate
40
What is the dopamine hypothesis?
Dopamine theory of schizophrenia: Overactivity of the mesolimbic pathway due to increased expression of Dopamine 2 receptors. Antipsychotics block D2 receptor and improve symptoms
41
Name 4 types of schizophrenia
Paranoid schizophrenia Catatonic schizophrenia Disorganised schizophrenia (hebephrenic) Simple schizophrenia
42
What are the 1st rank symptoms of schizophrenia
``` Delusional perception eg "a red car drive past therefore I am going to be killed" Auditory hallucination (3rd person, running commentary) Thought alienation (withdrawal, insertion, broadcasting) Passivity phenomenon - delusion that one is not in control of ones own thoughts or feelings, they are being controlled by an external agent ```
43
What are the 2nd rank symptoms of schizophrnenia?
``` Delusions 2nd person auditory symptoms Thought disorder Catatonia Hallucinations of another modality Negative symptoms eg anhedonia, loss of motivation, apathy, decreased communication, self neglect, lack insight ```
44
What is the dopamine hypothesis?
In schizophrenia there is overactivity of the mesolithic pathway (dopaminergic pathway), there is increased expression of D2 receptors. Antipsychotics that block D2 receptors, improve symptoms.
45
What are the different types of dopamine receptors?
D1 | D2
46
What is the criteria for diagnosis of schizophrenia?
At least one 1st rank symptom for at least one month or at least two 2nd rank symptoms for at least one month
47
What is the stress vulnerability model?
Some people have an intrinsic vulnerability to mental illness due to genetic predisposition. When combined with stress/brain injury can lead to mental illness/relapse. Exacerbated with environmental factors, improved with protective factors.
48
When should clozapine be used in schizophrenia?
When at least 2 other antipsychotics have been tried first
49
What are the non-pharmacological treatments of schizophrenia?
Psychotherapy - for negative symptoms Structured weekly activities - to prevent social drift ECT - for catatonia
50
What are the 6 domains of cognitive function?
``` Learning and memory Language Executive function Complex attention Perceptual motor Social cognition ```
51
What is dementia?
Progressive global decline in cognitive function with no loss of consciousness.
52
Which type of dementia presents acutely with a step wise progression?
Vascular Dementia
53
Which type of dementia presents insidiously with progressive decline in memory loss being the most prominent symptom?
Alzheimer's Dementia
54
What is the pathology of Alzheimer's dementia?
Accumulation of beta amyloid plaques and tangles of protein tau.
55
What is the inheritance pattern of early onset alzheimer's dementia?
Autosomal Dominant
56
What are the risk factors for alzheimer's disease?
``` Increased age Insulin resistance Past psychiatric history Down's syndrome Post-menopausal women ```
57
What are the symptoms of alzheimer's disease?
5 A's: Amnesia: Short term memory loss Apraxia: Difficulty in planning and performing tasks Agnosia: Inability to decipher sensory input Aphasia: Speech disorder Anomia: Inability to name things + Disorientation in time and place
58
What is the 1st line treatment in alzheimer's disease?
Acetylcholinesterase inhibitors eg donepazil, rivastigmine, galantamine
59
What is the 2nd line treatment of alzheimer's disease?
NMDA receptor antagonist eg memantine
60
What is the most common cause of death in alzheimer's disease?
Bronchopneumonia
61
Risk factors for vascular dementia
Smoking Diabetes Hypertension Past CVA
62
Symptoms of vascular dementia
``` Apraxia Difficulty following steps Poor concentration Slower speed of thought Disorientation in time and place ```
63
What is the management of vascular dementia?
Aspirin Antihypertensives Acetylcholinesterase inhibitors if there is a mixed aetiology
64
What is the pathology of lewy body dementia?
Aggregations of alpha synuclein protein (aka lewy bodies)
65
What are the symptoms of lewy body dementia?
``` Sleep disturbance - acting out dreams Depression Visual hallucinations Memory is spared until later Might have Parkinson's symptoms eg anosmia, incontinence, constipation ```
66
How do you treat levy body dementia?
Acetylcholinesterase inhibitors eg rivastigmine
67
What is seen on MRI for temporal dementia?
Knife blade appearance
68
What is the key symptom of temporal dementia which distinguishes from other causes of dementia?
Personality change
69
Symptoms of temporal dementia?
``` Personality change Poor visuospatial skills Hyperorality Emotional blunting Social disinhibition Repetitive, compulsive behaviour ```
70
How do you treat temporal dementia?
Acetylcholinesterase inhibitors eg rivastigmine
71
Risk factors for generalised anxiety disorder
``` Divorced/widowed Female Family history Substance misuse Self harm ```
72
Cognitive symptoms of anxiety
``` Agitation Feeling of impending doom Insomnia Excessive concern about self and bodily functions Repetitive thoughts and activities ```
73
Somatic symptoms of generalised anxiety disorder
``` Tension Trembling Sense of collapse Butterflies in stomach Hyperventilation Headaches Sweating Palpitations Nausea Lump in throat ```
74
How might anxiety present in children?
Thumb sucking Nail biting Bed wetting
75
What are the 6 categories of symptoms in the ICD-10 criteria for generalised anxiety disorder?
Autonomic - palpitations, tachycardia, sweating, dry mouth Physical - breathing difficulty, choking, chest pain, N+V Mental - Fearing of losing control, General - Hot flushes, numbness Tension - Muscle tension, restlessness Other - Decreased concentration, irritability
76
What are the management options for generalised anxiety disorder?
Psychological - CBT, relaxation techniques | Pharmacological - SSRIs are first line (SNRI eg duloxetine is an alternative)
77
How would you treat the autonomic symptoms of generalised anxiety disorder?
B blockers
78
What are the characteristic symptoms of OCD?
Obsessive thoughts - intrusive, irrational, repetitive and unpleasant thoughts Compulsive behaviour eg checking, counting, washing, symmetry and repetition
79
How does OCD differ to delusions?
The patient recognises that the symptoms are excessive and unreasonable and that they are of their own volition.
80
1st line and 2nd line pharmacological treatment for OCD
SSRIs | Clomipramine (TCA with anti-obsessional effects)
81
Non pharmacological management of OCD
CBT, psychotherapy | ECT, psychosurgery
82
Define panic attack
Period of intense fear associated with physical symptoms that develop rapidly, reach peak intensity in around 10 minutes and generally don't last longer than 20-30 minutes. They can be situation, spontaneous or nocturnal.
83
What is panic disorder?
Recurrent panic attacks which are not secondary to substance misuse, medical conditions ir other psychiatric conditions.
84
What physical symptoms can occur during a panic attack?
``` Palpitations Sweating Trembling/Shaking Shortness of breath feeling of choking/difficulty swelling (global hystericus) Chest pain Dizziness/light headedness/unsteadiness Derealisation/depersonalisation Fear of losing control Fear of dying Numbness/tingling Chills/hot flushes ```
85
Psychological management of panic disorder
CBT, psychodynamic psychotherapy
86
Pharmacological management of panic disorder
1st line: SSRIs | 2nd line: SNRI, TCA, benzo
87
4 features of PTSD
Reliving the situation eg flashbacks/nightmares Avoidance eg inability to recall event Hyperarousal eg hypervigilence, irritability Emotional numbing eg feeling of detachment
88
ICD-10 criteria for PTSD
Exposure to extremely stressful event Reliving the situation Avoidance of similar situation Inability to recall OR increased psychological sensitivity Traumatic event occurred in the last 6 months
89
What is the management for PTSD if the symptoms have been present for <3 months?
Watchful waiting Trauma-focussed CBT Pharmacological management for sleep disturbance eg zopiclone
90
What psychological therapy is specifically used in PTSD?
Eye-movement desensitisation and reprocessing
91
What is the definition of personality disorder?
A deeply ingrained and enduring pattern of inner experience and behaviour that: - Deviates from the expectations of an individuals culture - Is pervasive and inflexible - Has an onset in adolescence or early adulthood - Is stable over time - Leads to distress or impairment.
92
Risk factors for personality disorders
``` Abuse Foster care Being bullied in school Chronic illness in family and self Bereavement ```
93
What features of a someone's behaviour might lead them to be diagnosed with a personality disorder?
``` Self harm/suicide attempt Police involvement Eating disorder Substance misuse Difficulty maintaining relationships/jobs No long term friendships Impulsivity ```
94
What personality disorders are in cluster A?
WEIRD - Paranoid - Schizoid - Schizotypical
95
What is the difference between a cluster A personality disorder and schizophrenia?
Personality disorders do not have hallucinations and delusions
96
What is the difference between schizoid and schizotypal personality disorders?
Schizoid: No emotion, decreased sexual drive, no friends, detached, indifferent to praise and criticism Schizotypal: Eccentrial, saying weird stuff, odd thoughts
97
What personality disorders are in cluster B?
WILD - Borderline - Anti-social - Histrionic
98
What are the features of histrionic personality disorder?
``` Shallow Overly concerned about physical attractiveness Egocentric Provocative behaviour Attention seeking Seductive Exaggerated emotions ```
99
What are the features of anti-social personality disorder?
``` Violence Temper Blames other Reckless Lack of remorse Impulsive Deceitful ```
100
What are the features of borderline personality disorder?
``` Unstable relationships Impulsivity Self harm Abandonment fears Mood instability Poor control of emotions Intense relationships Disturbed sense of self Emptiness ```
101
What personality disorders are in cluster C?
WORRIERS - Dependant - Anxious - Obsessional
102
What are the features of anxious (avoidant) personality disorder?
Requires certainty of being liked Restricted lifestyle to maintain security Feels inadequate Embarrassment potential prevents involvement in new activities Social inhibition
103
What are the features of obsessive personality disorder?
``` Perfectionism Unable to complete a task unless perfect Workaholic at expense of leisure Preoccupation for detail (meticulous) Inflexible and rigid ```
104
What are the features of dependant personality disorder?
``` Reassurance required Initiating projects is difficult Lack of self confidence Companionship sought Needs others to assume responsibility Exaggerated fears ```
105
What is the management of personality disorder?
There is no licensed medication for personality disorders. Identify and treat any co-existing mental disorder Depression/Anxiety = SSRI Mood stabilisers Benzodiazepines
106
What psychological therapies can be used in personalty disorders?
Dialectical Behavioural Therapy | CBT
107
What is the attachment theory?
An infant needs to develop a relationship with at least one primary care giver for the child's social and emotional development, in particular how to regulate feelings.
108
Why are personality disorders no usually diagnosed in children?
Their personalities are still developing
109
What is toxic stress?
Prolonged activation of stress response systems in childhood eg due to abuse, can disrupt the development of the brain architecture and other organ systems, increasing the risk of stress related disease and cognitive impairment eg heart disease (women), cancer, COPD
110
What is the ICD-10 criteria for anorexia nervosa?
Fear of weight gain Endocrine disturbance eg amenorrhoea Emaciated (>15% below what is expected or BMI<17.5) Deliberate weight loss Distorted body image These features must be present for at least 3 months with absence of binge eating and absence of preoccupation with eating/craving to eat.
111
Physical symptoms of anorexia nervosa
``` Fatigue Hypothermia Bradycardia Arrythmias Peripheral oedema Headaches Lanugo hair ```
112
Why might patients with anorexia nervosa have peripheral oedema?
Hypoalbuminaemia
113
What non-physical symptoms are there in anorexia nervosa?
``` Preoccupation with food Socially isolated Sexuality feared Depression Distorted body image ```
114
What endocrine complications are there in anorexia nervosa?
``` Increased cortisol Increased growth hormone Decreased thyroid hormones (T3 and T4) Decreased LH, FSH, oestrogen and progesterone - amenorrhoea Decreased testosterone (in men) ```
115
What metabolic consequences are there in anorexia nervosa?
``` Decreased K, Mg, Cl, PO4, albumin Hypoglycaemia Hypercholesterolemia Increased urea and creatinine Deranged LFTs ```
116
What are the GI complications of anorexia nervosa?
Enlarged salivary glands Peptic ulcers Contipation Pancreatitis
117
What are the CV complications of anorexia nervosa?
``` Cardiac failure ECG changes Decreased BP Bradycardia Peripheral oedema ```
118
What are the haematological complications of anorexia nervosa?
Iron deficiency anaemia Thrombocytopaenia Leukpenia
119
What are the neurological complications of anorexia nervosa?
Seizures Peripheral neuropathy Autonomic dysfunction
120
What are the MSK complications of anorexia nervosa?
Proximal myopathy | Osteoporosis
121
What is the management of anorexia nervosa?
SSRIs if there is depression | Family therapy/interpersonal therapy/CBT
122
What are the electrolyte disturbances seen in refeeding syndrome?
Phosphate Magnesium Potassium
123
What causes the disruption of electrolytes in refeeding syndrome?
Surge of insulin - Causes intracellular movement of electrolytes - Leads to increased glycogen, fat and protein production from already depleted stores
124
How do you prevent refeeding syndrome?
``` Monitor electrolytes daily Start dietary intake at 1200 and increase every 5 days Electrolyte supplementation (PO/IV) ```
125
What metabolic disturbance is seen in bulimia nervosa?
Metabolic acidosis
126
What is the ICD-10 criteria for bulimia nervosa?
Behaviours to prevent weight gain eg self-induced vomiting, starvation, drugs, excessive exercise Preoccupation with eating - compulsion to eat followed by shame and binging Fear of fatness Overeating - 2 episodes per week over 3 months
127
What is the 4 step cycle in bulimia nervosa?
1. Compulsion to eat 2. Binge eating 3. Fear of fatness 4. Compensatory weight loss behaviour
128
Risk factors for bulimia nervosa
``` Female Family history Early onset of puberty T1DM Childhood obesity ```
129
Physical features of someone with bulimia nervosa that you might see on investigation?
``` Dry mucous membranes Decreased cap refill Decreased skin turgor Sunken eyes Russel's sign Normal weight ```
130
Difference in presentation between neuroleptic malignant syndrome and serotonin syndrome?
Serotonin syndrome onset is rapid (<24hrs) where as NMS takes days to weeks to present. Same with resolution, SS tased <24hrs, NMS takes days to weeks There is diffuse rigidity in NMS and tremor and myoclonus in SS. Hyperreflexia in SS, hyporeflexia in NMS
131
How do you treat neuroleptic malignant syndrome?
Stop Antipsychotic medication | Bromocriptine + Benzos eg IV lorazepam
132
How do you treat serotonin syndrome?
Stop serotonergic drug | Benzodiazepines
133
What are the side effects of sodium valproate?
``` V Appetite (increased - weight gain) Liver failure Pancreatitis Reversible hair loss Oedema Ataxia Teretogenic Encephalopathy ``` +Abdo pain, drowsiness, tremor
134
What monitoring is needed for sodium valproate and why?
6 monthly LFTs as can cause blood dyscriasis
135
What monitoring is needed for lithium?
6 monthly FBC, TFTs, Ca and renal function Serum lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable, then every 3 months thereafter
136
What type of side effects do patients get on TCAs?
Antimuscarinic side effects
137
What are the antimuscarinic side effects?
Can't see: blurred vision, dry eyes Can't wee: urinary retention Can't spit: dry mouth Can't shit: constipation + postura hypotension
138
Why are TCAs contraindicated in the elderly?
Increases risk of stroke
139
Define learning difficulty
Any learning or emotional problem that affects a person's ability to learn, get along with others and follow convention
140
Define learning disability
``` A significant lifelong condition that starts before adulthood, affects development and learning. Additional helps required to: - understand information - learn skills - cope independently IQ<70 ```
141
Define hallucinations
Perceptions in the absence of physical stimulus
142
Define delusions
A false, unshakable idea or belief which is out of keeping with the person's eduction, cultural and social background
143
Causes of psychosis other than bipolar disorder and schizophrenia
``` Post-partum psychosis Drug-induced psychosis Persistant delusional disorder Schizotypal disorder Paraphrenia ```

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