Psychiatry Flashcards
What are the 3 core symptoms of depression
Low mood
Anhedonia
Low energy levels
Cognitive symptoms of depression
Low mood Feelings of guilt Feelings of uselessness Feelings of worthlessness Suicidal thoughts Poor concentration Mood congruent hallucinations and delusions
Functional symptoms of depression
Early morning waking - 2 hours before their normal time
Difficulty getting to sleep, waking up multiple times during the night
(Diurnal variation of symptoms - worse in early morning and late at night)
Weight loss - loss of appetite, nausea
Weight gain - comfort eating
Decreased libido
Slow thoughts/actions
Agitated/fidgety
Memory problems
Diagnostic criteria of depression
1 core symptoms + 3 others
3 others = mild
4-5 others = moderate
7+ others = severe
What does melancholia mean
Emotional numbness
Medications that increase the risk of depression
Steroids Beta blockers Statins Oral contraceptive Isotretinoin
Risk factors for depression
FH Female Stress/trauma Substance abuse Previous psychiatric diagnosis Chronic disease Unemployed Single Post-natal
Differentials for depression
Hypothyroidism
Bipolar disorder
Parkinson’s disease
Addison’s disease
Depression screening questionnaire
PHQ-9
What is bipolar I disorder
One or more manic episodes (lasting 1+ weeks) with or without major depressive episodes
What is bipolar II disorder
One episode of hypomania and one major depressive episode but no episodes of mania
What is rapid cycling in bipolar
4+ manic/hypomanic/major depressive episodes per year
What is cyclothymia
Persistent manic/depressive mood swings over the course of 2 years, which are not sufficiently severe to justify a diagnosis of bipolar disorder
How long do you have to allow before seeing beneficial effects of SSRIs
4-6 weeks
Common initial side effects of SSRIs
Dry mouth Mild nausea GI upset Sexual dysfunction Drowsiness
Side effects of tricyclic antidepressants
Dry mouth Blurred vision Constipation Urinary retention Sweating Dizziness Drowsiness
Venlafaxine and Duloxetine belong to which class of antidepressants
SNRIs
What are the 10 main symptoms of depression and how long do you need to have had symptoms for
At least 2 over a 2 week period
- Persistent low mood
- Anhedonia
- Fatigue/low energy
- Disturbed sleep
- Poor concentration/indecisiveness
- Low self-confidence
- Poor/increased appetite
- Suicidal thoughts or acts
- Agitation or slowing of movement
- Guilt or self-blame
What are the main differences between a manic and hypomanic episode
Manic lasts at least 1 week
Hypomanic lasts at least 4 days
Manic results in significant dysfunction (work/school), requires hospitalisation (risk to self or others), or has psychotic features. Whereas hypomanic doesnt result in significant dysfunction, hospitalisation or psychotic features
Features of mania and hypomania
Increased goal directed activity - sexually, work, socially
Psychomotor agitation
Increased talkativeness/pressure of speech
Flight of ideas or racing thoughts
Loss of social inhibition, socially inappropriate and reckless behaviour, aggressive/hostile
Decreased need for sleep
Overconfidence
Easily distracted
What is dysthymia
A chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate, or mild recurrent depressive disorder
Describe how acute stress reactions present
Often initial state of “daze” with lowered field of consciousness, narrowed attention, disorientation. Followed by either further withdrawal or agitation and over-activity (flight reaction). Signs of panic are commonly present. Symptoms usually appear within minutes of the impact of the stressful stimulus or event and disappear within 2-3 days (often within hours). Partial or complete amnesia may be present.
Typical symptoms of PTSD
Flashbacks Dreams/nightmares Persisting background sense of emotional blunting Social detachment Anhedonia Avoidance of triggers
What is the difference between somatoform/somatisation disorders and hyochondriacal disorder
Somatization disorder more general and changing symptoms whereas hypochondriacal disorder usually preoccupied with the possibility of having one or more serious and progressive disorders.
Describe how acute stress reactions present
Often initial state of “daze” with lowered field of consciousness, narrowed attention, disorientation. Followed by either further withdrawal or agitation and over-activity (flight reaction). Signs of panic are commonly present. Symptoms usually appear within minutes of the impact of the stressful stimulus or event and disappear within 2-3 days (often within hours). Partial or complete amnesia may be present.
Typical symptoms of PTSD
Flashbacks Dreams/nightmares Persisting background sense of emotional blunting Social detachment Anhedonia Avoidance of triggers
What is the difference between somatoform/somatisation disorders and hyochondriacal disorder
Somatization disorder more general and changing symptoms whereas hypochondriacal disorder usually preoccupied with the possibility of having one or more serious and progressive disorders.
5 screening questions for eating disorders
Sick? - do you make yourself sick after meals Control? - do you feel you've lost control over how much you eat One stone (in 3 months)? Fat? - do you believe yourself to be fat when others say you are thin Food? - would you say food dominates your life
Differentials for eating disorders
Anxiety/depression/stress Malignancy Addison's disease Chronic infection Malabsorption syndrome Drug/alcohol dependency
Physical effects of an eating disorder
Tooth damage due to acid Cold Bradycardic Think hair Think skin Amenorrheic
Differentials for anxiety
OCD Hyperthyroidism Psychotic illness Substance abuse Substance withdrawal Phaeochromocytoma
What are Schneider’s first rank symptoms of schizophrenia
Thought echo Thought insertion/withdrawal Thought broadcasting 3rd person auditory hallucinations Delusional perceptions Passivity/somatic passivity - belief that movements/emotions/thoughts are being controlled
What are the positive symptoms of schizophrenia
Delusions
Hallucinations
Thought disorders
Schneider’s first rank symptoms
What are the negative symptoms of schizophrenia
Decline in normal function Affective blunting - lack of facial expression, flat voice, lack of eye contact Social isolation/withdrawal Anhedonia Poverty of speech Avolition - lack of motivation Apathy Poor self-care
What are delusions
Fixed beliefs that are not reality based and cannot be explained as part of the patients cultural background
Types of delusions
Persecution Reference Grandeur Control - includes thought broadcasting, insertion, withdrawal Nihilistic
What is the difference between thought disorders and delusions
Formal thought disorder refers to an impaired capacity to sustain coherent discourse, and occurs in the patient’s written or spoken language. Whereas delusions reflect abnormal thought content, formal thought disorder indicates a disturbance of the organization and expression of thought
Types of auditory hallucinations
Commands
Derogatory
Conversing
Running commentry
Drug-induced psychosis usually causes which type of hallucination
Tactile
Types of formal thought disorder
Tangentiality/flight of thought Derailment/knights move thinking Word salad - no connection between words Incongruent affect Circumstantiality Pressured speech Distractible speech - cant maintain attention, distracted by irrelevant things Perseveration Neologisms - new word or new meaning to an existing word that is only apparent to them
Describe the prodromal period before schizophrenia
Before disease develops tendency as a child to be withdrawn, have loss of interest, self-neglect, depression.anxiety, brief psychotic episodes
Periods of stress/intense emotion/significant event can trigger schizophrenia in a susceptible individual
What drug class is used to treat schizophrenia
Dopamine (D2) receptor antagonists
Examples of typical antipsychotics
Haloperidol Chlorpromazine Promethazine Flupenthixol Decanoate (IM)
Side effects of typical antipsychotics
Extrapyramidal - parkinsonism, akathisia, dytonia, dyskinesia
Hyperprolactinaemia - sexual dysfunction, osteoprosis, amenorrhea, galactorrhea, gynaecomastia, hypogonadism
Metabolic - weight gain, T2DM risk, hyperlipidaemia, metabolic syndrome
Anticholinergic - tachycardia, blurred vision, dry mouth, constipation, urinary retention
Neuro - seizures, neuroleptic malignant syndrome
Increased QT interval
Examples of atypical antipsychotics
Clozapine Olanzapine Quetiapine Risperidone Amisulpride
Life threatening potential side effect of Clozapine
Agranulocytosis
Organic causes of psychosis
Dementia Temporal lobe epilepsy Infection - encephalitis, AIDS Brain injury Brain tumour Huntington's disease Low B12 Cushings High dose steroids SLE Thyroid disease
What are the 5 main differentials of psychosis
Schizophrenia
Drug induced/withdrawal
Severe depression (psychosis would be mood congruent)
Manic phase of bipolar disorder (psychosis would be mood congruent)
Dementia
Describe section 2 of the mental health act
Allows for assessment +/- treatment
Lasts 28 days
AMHP (approved mental health practitioner) activates it
2 doctors need to approve it, one of whom needs to be section 12 approved
Describe section 4 of the mental health act
Allows emergency admission for assessment
Lasts 72 hours
AMHP or nearest relative can activate it
One doctor needed to approve it
Describe section 3 of the mental health act
Allows treatment for up to 6 months
Treatment for 1st 3 months then need consent or 2nd opinion application by AMHP or NR, needs 2drs approval
Describe section 5 (4) of the mental health act
Can hold a patient for up to 6 hours in an emergency
Can be done by a registered nurse
Describe section 5 (2) of the mental health act
Can hold a patient for up to 72 hours in an emergency
Can be done by a doctor or approved clinician in charge of the patients care
Describe section 135 of the mental health act
Can be used once to remove a patient from their home
Describe section 136 of the mental health act
Can be used once to remove a patient from a public place
Clinical features of Alzheimers dementia
Progressive memory loss
Struggling with ADLs
Reduced executive function - planning, organising
Nominal dysphasia - word finding, names, objects, paraphrasing
Disorientation to time and place - misplacing objects, getting lost
Visuo-spatial deficits
Behaviour/personality/affect - aggression, apathy, sleep more, disinhibition, paranoia, delusions, hallucinations, depression
Prospopagnosia - cant recognise familiar faces
In later stages - incontinence, effects of institutionalisation, loss of spontaneous speech, poor self-care, confusion
Does alzheimer’s dementia affect men or women more commonly
Women
Patho of alzheimers dementia
Deposits of senile plaques, beta amyloid plaques and neurofibrillary tangles
Neuronal loss
Cortical atrophy
Medications used to slow progression of cognitive impairment in alzheimers dementia
Cholinesterase inhibitors - Donepezil
NMDA receptor antagonists - Memantine
Rivastigmine - inhibits acetylcholinesterase and butyrylcholinesterase
Donepezil (cholinesterase inhibitor) slows progression of alzheimers dementia by how long for what % of patients
6-12 month delay for 50% of patients
Contraindications to use of Donepezil
Bradycardia
LBBB
Long QTc interval
Need to do an ECG before initiating treatment
Side effects of Memantine
Headache
Confusion
Dizziness
Risk of acute renal failure - need to do U+Es before initiating treatment
Management of BPSDs (behavioural and psychological symptoms of dementia)
Non pharm – CBT, routine, programmed activities, orientation (large clocks, easy to read calendars), music therapy, aromatherapy, exercise
SSRIs for depression
Carbamazepine for aggression/agitation
Risk factors for vascular dementia
Smoking
DM
Hyperlipidaemia/hypercholesterolaemia
Obesity
Describe the typical presentation of vascular dementia
Acute/subacute onset of cognitive impairment
Stepwise history - varies between periods of stability followed by acute declines
Functional deficits before memory loss
Mood changes and emotional lability are common
May have psychosis, delusions, hallucinations, paranoia
Describe the typical presentation of lewy-body dementia
Age >50
Hallucinations
Parkinsonism
Fluctuations in cognitive ability
Multitasking and cognitive tasks more affected than memory at presentation
Sleep disorders common
Rapidly progression (death usually within 7 years)
Frontotemporal dementia tends to affect people under how old?
<65
What are the 3 main presentations of frontotemporal dementia
Behavioural (most common)
Semantic
Non-fluent
Features of behavioural predominant frontotemporal dementia
Apathy Disinhibition Impulsivity Decline in interpersonal skills Change in preferences e.g. food Childlike amusements Obsessions/rituals
Features of semantic predominant frontotermporal dementia
Progressive decline in understanding of word meanings
Speech may be fluent but difficulty in name retrieval and use of less precise terms
Unable to determine meaning of common words
Loss of ability to recognise objects or familiar faces
Features of non-fluent predominant frontotemporal dementia
Speech takes effort Not fluent Apraxia - poor articulation Disorders of speech sound Impaired sentence comprehension
Types of dementia in order of how common they are
Alzheimers (60%)
Vascular (25%)
Lewy body (15%)
Frontotemporal
Organic diseases you need to rule out before dementia diagnosis
Delirium Depression/pseudodementia Stroke SOL B12 deficiency Hypothyroidism Substance abuse Metabolic - e.g. Calcium HIV
Main points of diagnosing Alzheimer’s dementia
Insidious onset
Decline in at least 2 cognitive domains
Impaired ADLs
No other cause
Classic triad of normal pressure hydrocephalus features
Gait disturbance
Memory problems/dementia
Urinary incontinence
What are the associated functions of the frontal lobe
Problem solving/reasoning/planning Emotion/personality Primary motor cortex Brocas area (motor aspects of speech, usually left) Inhibitory functions
What are the associated functions of the temporal lobe
Perception/recognition of sound
Memory
Speech
Wernicke’s area - formulation/understanding of speech
What are the associated functions of the parietal lobe
Recognition
Movement
Orientation
Primary sensory cortex
What are the associated functions of the cerebellum
Posture
Balance
Co-ordination of movement
What tool/questionnaire can be used to screen for dementia
Mini mental state examination
What are the 4 defining features common to all personality disorders
Distorted thinking patterns
Problematic emotional responses
Over/under regulated impulse control
Interpersonal difficulties
Describe the Cluster A personality disorders
Odd/eccentric
Dominated by distorted thinking with common features of social awkwardness and withdrawal
3 subtypes of Cluster A personality disorders
Paranoid PD
Schizoid PD
Schizotypal PD
Describe the Cluster B personality disorders
Dramatic, emotional, erratic
Problems with impulse control and emotional regulation
4 subtypes of Cluster B personality disorders
Borderline PD
Narcissistic PD
Histrionic PD
Antisocial PD
Describe the Cluster C personality disorders
Anxious/fearful
3 subtypes of Cluster C personality disorders
Avoidant PD
Dependent/Asthenic PD
Obsessive-compulsive PD
What’s the difference between CBT and psychodynamic approach
CBT is shorter than PA
CBT looks at how we think and feel affects our behaviour and how changing patterns of thinking can change emotion
Whereas PA looks at how the past has shaped the present
What is a ‘care programme approach’
A package of care for people with mental health problems
Care plan is written down + sets out what support the patient will get day to day and who’ll give it to you – meds, money problems, housing, support at home, help to get out of the house, risks, what should happen in an emergency/crisis, problems with drugs/alcohol.
Patients get given a CPA care-coordinator (usually a nurse, social worker or OT) to manage care plan and review it at least annually.
Dependency syndrome criteria (7)
Craving
Increased tolerance
Substance use prioritised
Feel like they’ve lost control
Withdrawal symptoms
Reinstatement after a period of abstinence despite knowing its harmful
Narrowing repertoire (usually to cheapest available)
What is the national recommended alcohol limit for men and women
<14 units per week
<3 units per day
How do you calculate alcohol units
Volume (L) X % alcohol
OR
(Volume mL X % alcohol) / 1000
Health problems caused by excessive alcohol intake
Depression/anxiety HTN Arrhythmias Alcoholic cardiomyopathy Hypoglycaemia Liver cirrhosis Oesophageal varices Hepatitis Altered medication breakdown Gastritis Pancreatitis Thiamine deficiency - peripheral neuropathy Symptoms of withdrawal Sleep disturbances and memory impairment Oral/oesophageal/hepatic cancer risk increased
Medications used to treat alcoholism by causing bad side effects
Acetaldehyde dehydrogenase inhibitors
Disulfiram
Metronidazole
Chlorporamide
Medication used for alcohol withdrawal
Benzos - Chlordiazepoxide or Diazepam. Reduce dose gradually over 7-10 days
Clonidine
Which medication can be used to reduce alcohol cravings
Acamprosate
What are the 5 stages of addiction
Pre-contemplation - not thinking about it Contemplation - thinking about it Preparation - planning Action - tries Maintenance
Early symptoms of alcohol withdrawal
Autonomic overactivity: Tremor Nausea Sweating Agitation Tachycardia Palpitations Raised BP
Late symptoms of alcohol withdrawal
Delusions Confusion Diarrhoea Convulsions Auditory hallucinations
When do the late symptoms of alcohol withdrawal peak
24-48 hours
What is delirium tremens
Rapid onset of confusion caused by withdrawal from alcohol. When it occurs, it is often three days into the withdrawal symptoms and lasts for two to three days.
Massive autonomic overactivity
An emergency
What causes Wernickes encephalopathy
Thiamine deficiency
Features of Wernickes encephalopathy
Nystagmus
Ophthalmoplegia
Ataxic gait - wide based, small steps
Confusion
What is the difference between Wernickes and Korsakoffs
Both cause by thiamine deficiency
Wernickes is acute and reversible
Korsakoffs is chronic and irreversible
Features of Korsakoffs syndrome
Confabulation (fabricate memories to fill in the gaps) Anterograde > retrograde amnesia Personality changes Disorientation Hallucinations
What is anterograde amnesia
Loss of the ability to create new memories after the event that caused amnesia, leading to a partial or complete inability to recall the recent past, while long-term memories from before the event may remain intact
In Wernickes encephalopathy, do you give glucose or thiamine first and why
Thiamine first
Because glucose increases thiamine demand and will worsen encephalopathy, IV glucose infusions must be administered after thiamine
Structure of a mental health history
PC HPC PMH and past psych history DH, Alcohol/illicit drugs FH Personal hx - birth, milstones, childhood, school, employment, relationships, forensic Present SH - home, financial, work, education, dependents Pre-morbid personality
What things need to be considered/explored as part of a post-suicide attempt risk assessment
Were they along How far away was help/intervention Precautions against discovery - none/passive/active Did they get help during or after Final acts - will, insurance, gifts Any active preparation Suicide notes Overt communication of intent Purpose of attempt Expectation of fatality Seriousness of attempt to end life Attitude towards dying - didnt want to/not sure/wanted to Conception of medical rescuability Degree of premeditation Reaction to attempt - regret/accepts/wishes it was successful Number of previous attempts Whether or not they took drugs/alcohol to facilitate the attempt
Components of the mental state examination (9)
Appearance Behaviour Speech Mood and Affect Thought form Thought content Perceptions Cognition Insight/Judgement
How can you describe a persons appearance in the MSE
Age Build Clothing Hygiene Grooming Clues about quality of self-care Appropriateness for weather and consultation
How can you describe someones behaviour in the MSE
Facial expression Eye contact Body language Response to the consultation Rapport/social engagement Level of arousal (calm/agitated) Anxious/aggressive Hyper/hypoactive Unusual movements - tremors, slowed, repetitive, involuntary
How can you describe a persons affect
Range - restricted, blunted, flat, expansive
Appropriateness - appropriate, inappropriate, incongruous
Stability - stable, labile
How can you describe a persons speech in the MSE
Rate - normal, slow, rapid, pressured, reduced
Volume - loud, normal, soft
Flow - spontaneous, hesitant, slurred, stuttering, mute
Tone - monotonous, tremulous, hostile
Quantity - minimal, excessive
Ease of conversation
How can you describe a persons cognition in the MSE
Level of consciousness - alert, drowsy, intoxicated Orientation to time/place/person Memory functioning Attention/concentration MMSE
How can you describe a persons perception in MSE
Dissociative symptoms - derealisation, depersonalisation
Illusions
Hallucinations - visual, olfactory, tactile, gustatory, somatic, auditory
How can you assess insight and judgement in the MSE
Insight - do they acknowledge a possible mental health problem, do they understand treatment options, will they comply with treatment, can they identify hallucinations and suicidal impulses
What do they attribute their symptoms to?
Judgement - problem solving
How can you describe someones thought content
Negative - self worth, helpless, guilt, suicidal
Positive - inflated self worth, grand plans, overplanning, risk taking, sexual
Anxieties - worries, preoccupations
Overvalued ideas
Delusions - grandiose, persecutory, referential, bizarre, nihilistic, somatic
Passivity - thought insertion/withdrawal/broadcast/echo, feelings, body actions/impulses/urges
How can you describe someones thought form
Circumstantiality Tangential, loose associations Derailment/knights move thinking Flight of ideas Word salads Metonyms - word approximations e.g. paper holder for book Neologism - new word or known word used in a new/unrecognised way Perseveration Thought racing or blocking
What questions can you ask about someones auditory hallucinations
Internal vs external Single or multiple voices 2nd or 3rd person Is it a voice they recognise Is the voice positive/negative/neither Running commentary Commanding
Name some mood stabilisers
Lithium
Gabapentin
Valproate
Carbamazepine
Symptoms of lithium toxicity
Coarse tremor Diarrhoea, nausea, abdo pain, vomiting Dizzy/drowsy/confused Agitated Slurred speech Ataxia Nystagmus Seizures
Lithium toxicity occurs when serum levels are ?
> 1.5 mmol/L
Name some extrapyramidal side effects of typical antipsychotics
Acute dystonia
Akathisia
Tardive dyskinesia
What is neuroleptic malignant syndrome
Life threatening reaction to antipsychotics
Usually within 2 weeks of the first dose
Confusion and EPS
High fever, tachycardia, tachypnea, diaphoresis
What does FALTER stand for in relation to the clinical features of neuroleptic malignant syndrome
Fever Autonomic instability Leukocytosis Tremor Elevated enzymes - CK, transaminases Rigor
Side effects of tricyclic antidepressants
Orthostatic hypotension Sedation, delirium, condusion Arrhythmias, tachycardias Long QT - risk for torsade-de-pointes Constipation Urinary retention
Features of serotonin syndrome
Fever, sweating HTN, tachycardia Agitation, anxiety Hyperreflexia Tremor Ataxia
