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Phase 3a > Psychiatry > Flashcards

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
Q

What are the short term side effects of ECT?

A

Headache
Confusion
Muscle ache
Short term memory loss

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26
Q

Long term side effect of ECT?

A

Memory loss

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27
Q

What are the 2 different types of bipolar disorder?

A

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.

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28
Q

Manic symptoms

A 
Lasts >1 week
Extreme elevation in mood
Overactivity
Pressure of speech
Impaired judgement
Extreme risk taking
Social disinhibition
Grandiosity
Psychosis symptoms eg hallucination
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29
Q

Symptoms of hypomania

A 
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
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30
Q

Management of an acute manic episode

A

Atypical antipsychotic eg olanzapine, risperidone, quetiapine, clozapine

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31
Q

Benefit of using an atypical antipsychotic

A

Less extra-pyramidal side effects

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32
Q

What are the effects of haloperidol?

A 
It is a typical antipsychotic. Extrapyramidal symptoms include:
Acute dystonia
Parkisonsim
Tardive dyskinesia
Akathisia
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33
Q

What are the side effects of olanzapine and other atypical antipsychotics?

A 
Impaired glucose tolerance - increases risk of diabetes
Weight gain
Sexual dysfunction
Sedation
Cardiomyopathy
Hyperprolactinaemia
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34
Q

What is the side effect of clozapine?

A

Agranulocytosis

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35
Q

Long term management of bipolar affective disorder

A

1st line: Lithium

2nd line: Sodium Valproate, olanzapine

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36
Q

Side effects of lithium

A 
Leukocytosis
Insipidus (diabetes)
Tremor (coarse)
Hypothyroidism
Increased
Urine
Metallic taste

+Teratogenic, sedation, lethargy, D+V, weight gain, oedema

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37
Q

Symptoms of lithium toxicity

A 
Coarse tremor
D+V
Confusion
Excessive sleeping
Seizures
Myoclonic jerks
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38
Q

What might cause lithium toxicity?

A 
Dehydration
Change in salt level
Diuretics/NSAIDs
Change in brand of lithium
Reduced renal function
Infection
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39
Q

What is the management of lithium toxicity?

A

Stop lithium
Check levels
Rehydrate

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40
Q

What is the dopamine hypothesis?

A

Dopamine theory of schizophrenia:
Overactivity of the mesolimbic pathway due to increased expression of Dopamine 2 receptors.
Antipsychotics block D2 receptor and improve symptoms

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41
Q

Name 4 types of schizophrenia

A

Paranoid schizophrenia
Catatonic schizophrenia
Disorganised schizophrenia (hebephrenic)
Simple schizophrenia

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42
Q

What are the 1st rank symptoms of schizophrenia

A 
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
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43
Q

What are the 2nd rank symptoms of schizophrnenia?

A 
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
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44
Q

What is the dopamine hypothesis?

A

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.

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45
Q

What are the different types of dopamine receptors?

A

D1

D2

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46
Q

What is the criteria for diagnosis of schizophrenia?

A

At least one 1st rank symptom for at least one month or at least two 2nd rank symptoms for at least one month

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47
Q

What is the stress vulnerability model?

A

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.

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48
Q

When should clozapine be used in schizophrenia?

A

When at least 2 other antipsychotics have been tried first

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49
Q

What are the non-pharmacological treatments of schizophrenia?

A

Psychotherapy - for negative symptoms
Structured weekly activities - to prevent social drift
ECT - for catatonia

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50
Q

What are the 6 domains of cognitive function?

A 
Learning and memory
Language
Executive function
Complex attention
Perceptual motor
Social cognition
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51
Q

What is dementia?

A

Progressive global decline in cognitive function with no loss of consciousness.

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52
Q

Which type of dementia presents acutely with a step wise progression?

A

Vascular Dementia

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53
Q

Which type of dementia presents insidiously with progressive decline in memory loss being the most prominent symptom?

A

Alzheimer’s Dementia

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54
Q

What is the pathology of Alzheimer’s dementia?

A

Accumulation of beta amyloid plaques and tangles of protein tau.

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55
Q

What is the inheritance pattern of early onset alzheimer’s dementia?

A

Autosomal Dominant

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56
Q

What are the risk factors for alzheimer’s disease?

A 
Increased age
Insulin resistance
Past psychiatric history
Down's syndrome
Post-menopausal women
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57
Q

What are the symptoms of alzheimer’s disease?

A

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

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58
Q

What is the 1st line treatment in alzheimer’s disease?

A

Acetylcholinesterase inhibitors eg donepazil, rivastigmine, galantamine

59
Q

What is the 2nd line treatment of alzheimer’s disease?

A

NMDA receptor antagonist eg memantine

60
Q

What is the most common cause of death in alzheimer’s disease?

A

Bronchopneumonia

61
Q

Risk factors for vascular dementia

A

Smoking
Diabetes
Hypertension
Past CVA

62
Q

Symptoms of vascular dementia

A 
Apraxia
Difficulty following steps
Poor concentration
Slower speed of thought
Disorientation in time and place
63
Q

What is the management of vascular dementia?

A

Aspirin
Antihypertensives
Acetylcholinesterase inhibitors if there is a mixed aetiology

64
Q

What is the pathology of lewy body dementia?

A

Aggregations of alpha synuclein protein (aka lewy bodies)

65
Q

What are the symptoms of lewy body dementia?

A 
Sleep disturbance - acting out dreams
Depression
Visual hallucinations 
Memory is spared until later
Might have Parkinson's symptoms eg anosmia, incontinence, constipation
66
Q

How do you treat levy body dementia?

A

Acetylcholinesterase inhibitors eg rivastigmine

67
Q

What is seen on MRI for temporal dementia?

A

Knife blade appearance

68
Q

What is the key symptom of temporal dementia which distinguishes from other causes of dementia?

A

Personality change

69
Q

Symptoms of temporal dementia?

A 
Personality change
Poor visuospatial skills
Hyperorality
Emotional blunting
Social disinhibition
Repetitive, compulsive behaviour
70
Q

How do you treat temporal dementia?

A

Acetylcholinesterase inhibitors eg rivastigmine

71
Q

Risk factors for generalised anxiety disorder

A 
Divorced/widowed
Female
Family history
Substance misuse
Self harm
72
Q

Cognitive symptoms of anxiety

A 
Agitation
Feeling of impending doom
Insomnia
Excessive concern about self and bodily functions
Repetitive thoughts and activities
73
Q

Somatic symptoms of generalised anxiety disorder

A 
Tension
Trembling
Sense of collapse
Butterflies in stomach
Hyperventilation
Headaches
Sweating
Palpitations
Nausea
Lump in throat
74
Q

How might anxiety present in children?

A

Thumb sucking
Nail biting
Bed wetting

75
Q

What are the 6 categories of symptoms in the ICD-10 criteria for generalised anxiety disorder?

A

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
Q

What are the management options for generalised anxiety disorder?

A

Psychological - CBT, relaxation techniques

Pharmacological - SSRIs are first line (SNRI eg duloxetine is an alternative)

77
Q

How would you treat the autonomic symptoms of generalised anxiety disorder?

A

B blockers

78
Q

What are the characteristic symptoms of OCD?

A

Obsessive thoughts - intrusive, irrational, repetitive and unpleasant thoughts
Compulsive behaviour eg checking, counting, washing, symmetry and repetition

79
Q

How does OCD differ to delusions?

A

The patient recognises that the symptoms are excessive and unreasonable and that they are of their own volition.

80
Q

1st line and 2nd line pharmacological treatment for OCD

A

SSRIs

Clomipramine (TCA with anti-obsessional effects)

81
Q

Non pharmacological management of OCD

A

CBT, psychotherapy

ECT, psychosurgery

82
Q

Define panic attack

A

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
Q

What is panic disorder?

A

Recurrent panic attacks which are not secondary to substance misuse, medical conditions ir other psychiatric conditions.

84
Q

What physical symptoms can occur during a panic attack?

A 
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
Q

Psychological management of panic disorder

A

CBT, psychodynamic psychotherapy

86
Q

Pharmacological management of panic disorder

A

1st line: SSRIs

2nd line: SNRI, TCA, benzo

87
Q

4 features of PTSD

A

Reliving the situation eg flashbacks/nightmares
Avoidance eg inability to recall event
Hyperarousal eg hypervigilence, irritability
Emotional numbing eg feeling of detachment

88
Q

ICD-10 criteria for PTSD

A

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
Q

What is the management for PTSD if the symptoms have been present for <3 months?

A

Watchful waiting
Trauma-focussed CBT
Pharmacological management for sleep disturbance eg zopiclone

90
Q

What psychological therapy is specifically used in PTSD?

A

Eye-movement desensitisation and reprocessing

91
Q

What is the definition of personality disorder?

A

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
Q

Risk factors for personality disorders

A 
Abuse
Foster care
Being bullied in school
Chronic illness in family and self
Bereavement
93
Q

What features of a someone’s behaviour might lead them to be diagnosed with a personality disorder?

A 
Self harm/suicide attempt
Police involvement 
Eating disorder
Substance misuse
Difficulty maintaining relationships/jobs
No long term friendships
Impulsivity
94
Q

What personality disorders are in cluster A?

A

WEIRD

  • Paranoid
  • Schizoid
  • Schizotypical
95
Q

What is the difference between a cluster A personality disorder and schizophrenia?

A

Personality disorders do not have hallucinations and delusions

96
Q

What is the difference between schizoid and schizotypal personality disorders?

A

Schizoid: No emotion, decreased sexual drive, no friends, detached, indifferent to praise and criticism
Schizotypal: Eccentrial, saying weird stuff, odd thoughts

97
Q

What personality disorders are in cluster B?

A

WILD

  • Borderline
  • Anti-social
  • Histrionic
98
Q

What are the features of histrionic personality disorder?

A 
Shallow
Overly concerned about physical attractiveness
Egocentric
Provocative behaviour
Attention seeking
Seductive
Exaggerated emotions
99
Q

What are the features of anti-social personality disorder?

A 
Violence
Temper
Blames other
Reckless
Lack of remorse
Impulsive
Deceitful
100
Q

What are the features of borderline personality disorder?

A 
Unstable relationships
Impulsivity 
Self harm
Abandonment fears
Mood instability 
Poor control of emotions
Intense relationships
Disturbed sense of self
Emptiness
101
Q

What personality disorders are in cluster C?

A

WORRIERS

  • Dependant
  • Anxious
  • Obsessional
102
Q

What are the features of anxious (avoidant) personality disorder?

A

Requires certainty of being liked
Restricted lifestyle to maintain security
Feels inadequate
Embarrassment potential prevents involvement in new activities
Social inhibition

103
Q

What are the features of obsessive personality disorder?

A 
Perfectionism
Unable to complete a task unless perfect
Workaholic at expense of leisure
Preoccupation for detail (meticulous) 
Inflexible and rigid
104
Q

What are the features of dependant personality disorder?

A 
Reassurance required
Initiating projects is difficult
Lack of self confidence
Companionship sought
Needs others to assume responsibility 
Exaggerated fears
105
Q

What is the management of personality disorder?

A

There is no licensed medication for personality disorders.
Identify and treat any co-existing mental disorder
Depression/Anxiety = SSRI
Mood stabilisers
Benzodiazepines

106
Q

What psychological therapies can be used in personalty disorders?

A

Dialectical Behavioural Therapy

CBT

107
Q

What is the attachment theory?

A

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
Q

Why are personality disorders no usually diagnosed in children?

A

Their personalities are still developing

109
Q

What is toxic stress?

A

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
Q

What is the ICD-10 criteria for anorexia nervosa?

A

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
Q

Physical symptoms of anorexia nervosa

A 
Fatigue
Hypothermia
Bradycardia
Arrythmias
Peripheral oedema
Headaches
Lanugo hair
112
Q

Why might patients with anorexia nervosa have peripheral oedema?

A

Hypoalbuminaemia

113
Q

What non-physical symptoms are there in anorexia nervosa?

A 
Preoccupation with food
Socially isolated
Sexuality feared
Depression
Distorted body image
114
Q

What endocrine complications are there in anorexia nervosa?

A 
Increased cortisol
Increased growth hormone
Decreased thyroid hormones (T3 and T4)
Decreased LH, FSH, oestrogen and progesterone - amenorrhoea
Decreased testosterone (in men)
115
Q

What metabolic consequences are there in anorexia nervosa?

A 
Decreased K, Mg, Cl, PO4, albumin 
Hypoglycaemia
Hypercholesterolemia
Increased urea and creatinine
Deranged LFTs
116
Q

What are the GI complications of anorexia nervosa?

A

Enlarged salivary glands
Peptic ulcers
Contipation
Pancreatitis

117
Q

What are the CV complications of anorexia nervosa?

A 
Cardiac failure
ECG changes
Decreased BP
Bradycardia
Peripheral oedema
118
Q

What are the haematological complications of anorexia nervosa?

A

Iron deficiency anaemia
Thrombocytopaenia
Leukpenia

119
Q

What are the neurological complications of anorexia nervosa?

A

Seizures
Peripheral neuropathy
Autonomic dysfunction

120
Q

What are the MSK complications of anorexia nervosa?

A

Proximal myopathy

Osteoporosis

121
Q

What is the management of anorexia nervosa?

A

SSRIs if there is depression

Family therapy/interpersonal therapy/CBT

122
Q

What are the electrolyte disturbances seen in refeeding syndrome?

A

Phosphate
Magnesium
Potassium

123
Q

What causes the disruption of electrolytes in refeeding syndrome?

A

Surge of insulin

  • Causes intracellular movement of electrolytes
  • Leads to increased glycogen, fat and protein production from already depleted stores
124
Q

How do you prevent refeeding syndrome?

A 
Monitor electrolytes daily
Start dietary intake at 1200 and increase every 5 days
Electrolyte supplementation (PO/IV)
125
Q

What metabolic disturbance is seen in bulimia nervosa?

A

Metabolic acidosis

126
Q

What is the ICD-10 criteria for bulimia nervosa?

A

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
Q

What is the 4 step cycle in bulimia nervosa?

A
  1. Compulsion to eat
  2. Binge eating
  3. Fear of fatness
  4. Compensatory weight loss behaviour
128
Q

Risk factors for bulimia nervosa

A 
Female
Family history
Early onset of puberty
T1DM
Childhood obesity
129
Q

Physical features of someone with bulimia nervosa that you might see on investigation?

A 
Dry mucous membranes
Decreased cap refill
Decreased skin turgor
Sunken eyes
Russel's sign 
Normal weight
130
Q

Difference in presentation between neuroleptic malignant syndrome and serotonin syndrome?

A

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
Q

How do you treat neuroleptic malignant syndrome?

A

Stop Antipsychotic medication

Bromocriptine + Benzos eg IV lorazepam

132
Q

How do you treat serotonin syndrome?

A

Stop serotonergic drug

Benzodiazepines

133
Q

What are the side effects of sodium valproate?

A 
V
Appetite (increased - weight gain)
Liver failure
Pancreatitis
Reversible hair loss
Oedema
Ataxia
Teretogenic
Encephalopathy

+Abdo pain, drowsiness, tremor

134
Q

What monitoring is needed for sodium valproate and why?

A

6 monthly LFTs as can cause blood dyscriasis

135
Q

What monitoring is needed for lithium?

A

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
Q

What type of side effects do patients get on TCAs?

A

Antimuscarinic side effects

137
Q

What are the antimuscarinic side effects?

A

Can’t see: blurred vision, dry eyes
Can’t wee: urinary retention
Can’t spit: dry mouth
Can’t shit: constipation

+ postura hypotension

138
Q

Why are TCAs contraindicated in the elderly?

A

Increases risk of stroke

139
Q

Define learning difficulty

A

Any learning or emotional problem that affects a person’s ability to learn, get along with others and follow convention

140
Q

Define learning disability

A 
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
Q

Define hallucinations

A

Perceptions in the absence of physical stimulus

142
Q

Define delusions

A

A false, unshakable idea or belief which is out of keeping with the person’s eduction, cultural and social background

143
Q

Causes of psychosis other than bipolar disorder and schizophrenia

A 
Post-partum psychosis
Drug-induced psychosis 
Persistant delusional disorder
Schizotypal disorder
Paraphrenia

Phase 3a (5 decks)

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