Psychiatry Flashcards
Parts of a mental state examination?
Appearance Behaviour Speech Mood and affect Thought- form, content, possession (insertion, withdrawal, broadcasting) Perceptions- hallucinations and illusions Cognition- MMSE, orientation Insight
what is the difference between hallucinations and illusions?
hallucinations- false perception
illusions- misinterpreted perception
what is a biopsychosocial formation?
biological, psychological, social (X-axis)
predisposing (vulnerability), precipitating (triggers), prolonging (maintaining), protective (strengths) (Y-axis)
screening questions for depression?
1) During the last month, have you often been bothered by feeling down, depressed or hopeless?
2) During the last month, have you often been bothered by having little interest or pleasure in doing things?
screening tools for depression?
HAD scale
PHQ-9
DSM-IV criteria for depression?
SIG E CAPS
Sleep changes- insomnia or hypersomnia
Interest (loss)- in activities
Guilt (worthless)
Energy (fatigue)
Cognition/Concentration- both reduced
Appetite- weight loss
Psychomotor- agitation (anxiety) or retardation
Suicide thoughts
9th criteria- depressed mood most of the day, nearly every day
Mild depression- 5+ symptoms
moderate- between mild and severe
Severe- most symptoms, markedly interfere with functioning
tx of depression?
mild- sleep hygiene, self-help, computerised CBT, group-based CBT
pharmacological tx- SSRIs, SNRIs, TCAs, MAOIs, noradrenergic and specific serotonergic antidepressants
SSRIs: examples, SEs, CIs?
e.g. fluoxetine, sertraline, citalopram Need 3 weeks for peak effect, continue for 6 months after remission of symptoms, withdraw over 4 weeks CI- mania SEs- 4S's Stomach upset- GI disturbance Sexual disturbance Suicidal thoughts (increased anxiety) Serotonin syndrome
what is serotonin syndrome?
Cognitive impairment- confusion, agitation
Autonomic dysfunction- increased SNS
Neuromuscular hyperactivity- clonus, ataxia, hypertonia
tx= benzodiazepines or cryprohepatadine
examples of SNRIs and CI?
venlafaxine, duloxetine
CI-cardiac arrhythmia
examples and SEs of tricyclic antidepressants?
amitriptyline, clomipramine, lofepramine SEs- anticholinergic muscarinic receptor blockade Can't see- blurred vision, dry eyes Can't wee- urinary retention Can't spit- dry mouth Can't shit- constipation lengthening of QT interval
less commonly used due to side effects and toxicity in iverdose
MAOIs?
Monoamine oxidase inhibitors
e.g. phenelzine
SE- hypotension, anxiety, anticholinergic SEs, hypertensive crisis
CI- cheese and wine, adrenaline, amphetamines, L-DOPA
noradrenergic and specific serotonergic antidepressants?
e.g. mirtazapine
SE- increased appetite and weight gain, sedation at lower doses
CI- mania
mx of generalised anxiety disorder?
1- education and active monitoring
2- low intensity psychological intervention (self-help/groups)
3- high intensity psychological interventions (CBT) or drug treatment (SSRIs, buspirone, benzos)
4- high specialised input
risk of SSRIs in GAD?
Increased risk of suicidal thinking and self-harm if under 30
weekly follow-up is recommended for the first month
Mx of panic disorders?
1- recognition and diagnosis
2- primary care- CBT and SSRIs
3- review and consideration of alternative treatments
4- review and referral to specialist mental health services
5- care in specialist mental health services
features of PTSD?
Features most be present of >1 month:
- re-experiencing- flashbacks, nightmares etc
- avoidance
- hyperarousal- hypervigilance for threat, exaggerated startle response
- emotional numbing- lack of ability to experience feelings
mx of PTSD?
Watchful waiting for mild symptoms <4 weeks
Military have access to treatment provided by the armed forces
CBT or 1st line EMDR (eye movement desensitisation and reprocessing) therapy may be used in more severe cases
Drug tx- venlafaxine or SSRIs e.g. sertraline. Risperidone may be used in severe cases
what is mania vs hypomania?
Mania- >7 days, severe functional impairment, may require hospitalisation, may present with psychotic symptoms
Hypomania- lasts <7 days, typically 3-4 days. Doesn’t impair functional capacity in social or work setting.Unlikely to require hospitalisation. No psychotic symptoms
mood is predominantly elevated, pressured speech, flight of ideas, poor attention, insomnia, loss of inhibitions, increased appetite
what are psychotic symptoms?
delusions of grandeur
auditory hallucinations
mx of mania or hypomania?
remove anti-depressants
mood stabilisers- lithium, lamotrigine, carbamazepine, sodium valproate
mechanism of lithium?
interferes with cAMP formation
why is lithium monitoring essential?
narrow therapeutic index
0.4-1.0mmol/L
long plasma half life
side effects of lithium?
Leukocytosis Insipidus (diabetes) Tremors Hypothyroidism IU increased urine Mum's beware (teratogenic)
monitoring of lithium?
lithium levels performed weekly and after each dose change until concentrations are stable
once established- lithium blood level should normally be checked every 3 months
thyroid and renal function should be checked every 6 months
level of lithium toxicity?
concentration >1.5mmol/L
precipitations of lithium toxicity?
dehydration
renal failure
drugs- diuretics, ACEi/ARBs, NSAIDs and metronidazole
features of lithium toxicity?
coarse tremor hyperreflexia acute confusion seizures coma
tx of lithium toxicity?
mild/moderate- may respond to volume resuscitation with normal saline
severe toxicity- haemodialysis
sodium bicarb is sometimes used
ICD-10 criteria for OCD?
- Obsessions or compulsions must be present for at least 2 successive weeks and area source of distress or interfere with the patient’s functioning
- They are acknowledged as coming from the patient’s own mind
- The obsessions are unpleasantly repetitive
- At least one thought or act is resisted unsuccessfully
- A compulsive act is not in itself pleasurable
tx of OCD?
mild/moderate- individual self-help group or group CBT
(with exposure response prevention)
moderate/severe- CBT
pharmacological therapy- SSRIs
what is a hallucination?
a perception without an external object
what is a delusion?
a strong belief which is fixed and unshakeable. Not explained by cultural, religious or educational belief
RFs for schizophrenia?
family history
black Caribbean ethnicity
cannabis use
features of schizophrenia?
- Auditory hallucinations of either:
- 2 or more voices discussing the patient in a 3rd person
- thought echo
- voices commenting on the patient’s behaviour - Thought disorder
- Passivity phenomena- bodily sensations being controlled by external influence or experiences whch are imposed on to the individual (actions, impulses, feelings)
- Delusional perceptions e.g. the traffic light is green therefore I am king
other features of schizophrenia?
impaired sight
neologisms (made up words)
catatonia- motor symptoms
Negative symptoms:
- Flat affect/ blunting
- Loss of motivation
- Anhedonia (lack of pleasure)
- Poverty of speech
- Social withdrawal
Ix to rule out physical causes of schizophrenia?
bloods drug and alcohol screen EEG fasting glucose MSU CT brain
1st line Mx of schizophrenia?
oral atypical anti-psychotics e.g. clozapine, olanzapine, risperidone, apiprazole
CBT
SEs of atypical antipsychotics?
weight gain
DM
hyperprolactinaemia- galactorrhoea and amenorrhoea in women, hypogonadism or ED in men
clozapine- risk of agranulocytosis (severe leukopenia)- FBC weekly monitoring is essential
- should only be used if 2 drugs fail
also risks of reduced seizure threshold, constipation, myocarditis (baseline ECG needed), hypersalivation
risks of typical and atypical antipsychotics for elderly people?
increased risk of stroke and VTE
How do typical antipsychotics work?
dopamine D2 receptor antagonists e.g. haloperidol, chlorpromazine, prochlorpromazine
SEs of typical antipsychotics?
extra pyramidal SEs- ADAPT
- Acute Dystonia (sustained muscle contractions)
- Akathisia (severe restlessness)
- Parkinsonism
- Tardive dyskinesia (chewing and pouting of jaw)
anti-muscarinc SEs sedation, weight gain raised prolactin- galactorrhoea, impaired glucose tolerance prolonged QT syndrome reduced seizure threshold neuroleptic malignant syndrome
what is neuroleptic malignant syndrome?
pyrexia, muscle stiffness, rigidity, tachycardia
Ix of neuroleptic malignant syndrome?
raised serum CK
increased WCC
metabolic acidosis
mx of neuroleptic malignant syndrome?
STOP antipsychotic
supportive- O2, IV fluids, cooling blankets
benzodiazepines (agitation)
IV dantrolene (malignant hypothermia)
monitoring of typical antipsychotics?
FBC, U&E, LFT- at start of therapy, annually, clozapine more frequently needed
lipids, weight- at start, 3 months, annually
fasting BG, prolactin- at start, 3 months, annually
BP- baseline, frequently during dose titration
ECG- baseline
CV risk assessment- annually
what is bipolar disorder?
chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression
types of bipolar disorder?
Type I disorder-> mania and depression
Type II disorder-> hypomania and depression
mx of bipolar disorder?
psychological interventions
mood stabilisers- lithium
if mania -> antipsychotic e.g. olanzapine or haloperidol
if depression -> talking therapies, fluoxetine
address co-morbidities- DM risk, CV disease risk
when should GPs refer to if symptoms of hypomania? or mania/depression in bipolar?
hypomania- community mental health team (CMHT)
mania/depression- urgent referral
DSM 5 criteria of anorexia nervosa?
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age/sex
- Intense fear of gaining weight or becoming fat
- Disturbance in the way they feel about their body weight
features of anorexia nervosa?
reduced BMI bradycardia hypotension enlarged salivary glands G's and C's raised- cortisol, GH, cholesterol, carotin, glucose low- hypokalaemia, low FSH/LH, low T3
mx of anorexia nervosa?
CBT- eating disorder
MANTRA
SSCM- specialist supportive clinical management
mx of anorexia nervosa in children and young people?
anorexia focused family therapy (1st line)
CBT
what is bulimia?
episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising
mx of bulimia?
1st line- bulimia nervosa focused self help for adults
2nd line- CBT-ED
Children- family based therapy
features of borderline personality disorder?
efforts to avoid real or imagined abandonment
unstable interpersonal relationships
impulsivity, temper, recurrent suicidal behaviour
features of schizoid personality disorder?
preference to praise and criticism, lack of interest in sexual interactions, lack of desire for companionship
features of schizotypal PD?
ideas of reference, odd beliefs and magical thinking, unusual perceptual disturbances
mechanism of alcohol withdrawal?
chronic alcohol consumption enhances GABA mediated inhibition in the CNS
alcohol withdrawal does the opposite
features of alcohol withdrawal?
symptoms start at 6-12 hours: tremors, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens at 72 hours- coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
mx of alcohol withdrawal?
patients admitted if withdrawal unstable
1st line- benzodiazepines e.g. chlordiazepoxide
lorazepam preferable if hepatic failure
reducing dose protocol
2nd line- carbamazepine
others- disulfram- promotes abstinence by producing severe symptoms -> N&V, hypotension, facial flushing, headache
Acamprosate- reduces cravings
Thiamine (pabrinex)
blood signs of alcohol withdrawal?
LFTS- GGT, AST FBC- high MCV, low Hb low BG high uric acid CDT- detects alcohol consumption
features of alcohol dependence?
- strong desire/compulsion to drink
- difficulty controlling drinking
- physiological withdrawal state
- tolerance
- neglect
- persisting with drinking over other activities
- narrowing of drinking repertoire
- reinstatement after abstinence
what is wernicke’s encephalopathy?
a neuropsychiatric disorder caused by thiamine
triad of wernicke’s encephalopathy?
opthalmoplegia, confusion, ataxia
Ix of wernicke’s encephalopathy?
decrease in red cell transketolase
MRI
Tx of wernicke’s encephalopathy?
urgen replacement of thiamine
if untreated -> Korsakoff’s syndrome-> amnesia, confabulation
examples of opioids?
morphine, buprenorphine, methadone
features of opioid misuse?
rhinorrhoea needle track marks pinpoint pupils drowsiness watery eyes yawning
complications of opioid misuse?
viral infection secondary to sharing needles- HIV, HEP B&C
bacterial infection- IE, septic arthritis, septicaemia, necrotising fasciitis
VTE
Psychological problems
Social problems- crime, prostitution, homelessness
emergency management of opioid dependence?
IV or IM naloxone
mx of opioid dependence?
1st line- buprenorphine or methadone
Compliance is monitored using urinalysis
Detoxification should last up to 4 weeks as an impatient and 12 weeks in the community
what is a risk assessment for suicide?
Sex-male
Age <19, >45
Depression- present
Previous suicide attempt Ethanol Rational thinking loss e.g psychosis Single or separated Organised No social support Sickness (chronic)
