Psychiatry Flashcards
1
Q
subtypes of schizophrenia?
A
Paranoid - Auditory/ visual hallucinations, flat affect
- Hebephrenic – disorganised type, thought disorder and flat
- Catatonic – immobile or agitated. Waxy.
- Undifferentiated
- Residual – chronic negative symptoms
- Simple – insidious and progressive negative symptoms, no Hx of psychotic symptoms
2
Q
what are schneiders first rank symptoms?
A
- Thought alienation: echo, insertion, broadcasting or withdrawal
- 3rd person auditory hallucinations (DDx; if pt has conversation to voices therefore trauma or ficticious)
- Delusional perception: Grandiose, Erotomanic, Paranoia, Cotards (belief they are dead), Othello (pathologic jealousy), Capgras (someone/something they know replaced by imposter), persecutory, somatic
- Passivity and somatic passivity
3
Q
what are the negative symptoms of shizophrenia?
A
blunted affect apathy social isolation withdrawal self-neglect poverty of speech
4
Q
diagnostic criteria of schizophrenia?
A
ICD-10 Dx: 1st rank symptoms or persistent delusions on most days for at least one month (delusional perception, passivity, delusions of thought interface, auditory hallucinations)
5
Q
management of schizophrenia?
A
1st line: Clozapine, Olanzipine, Risperidone - (usually second gen)
2nd line: Quetiapine, Aripirazole
3rd line: Haloperidol, chlopormazine (atpical first gen but last resort, req blood checks for agranulocytosis)
6
Q
subtypes of schizophrenia?
A
Paranoid - Auditory/ visual hallucinations, flat affect
- Hebephrenic – disorganised type, thought disorder and flat
- Catatonic – immobile or agitated. Waxy.
- Undifferentiated
- Residual – chronic negative symptoms
- Simple – insidious and progressive negative symptoms, no Hx of psychotic symptoms
7
Q
DDx for low mood?
A
hypothyroidism bipolar cancer DM anaemia, B12, folate vit D deficiency hypoglycaemia/electrolyte inbalances
8
Q
what are the symptoms of depression?
A
major- low mood, anergia, anhedonia
minor- cognition feeling of guilt, uselessness thoughts of suicide loss of conc low self esteem change in sleep weight loss loss of libido slow in thoughts or actions irritable
9
Q
diagnostic criteria of depression?
A
ICD-10:
Mild = 2/3 core + 2 others >2 weeks
Mod = 2/3 core + 3 others + functioning symps >2 weeks
Severe = 3/3 core + 4 others inc suicidal and decline in functioning ± psychotic symptoms (mood congruent)
10
Q
management of depression?
A
1st line: CBT, add SSRI (sertraline, fluoxetine, citalopram) if mod to severe.
2nd line: try second SSRI (then something different as 3rd)
3rd line: Serotonin Noradrenaline reuptake inhibitors (SNRI – Duloxetine/ venlafaxine), MAOI (phenelzine) , Tricyclic antidepressants (TCA - amitriptyline)
Continue for at least 6 months as relapse high before this time
11
Q
which antidepressant is recommended in children/teens?
A
fluoxetine
12
Q
how long does it take for SSRI’s to work?
A
4-6 weeks
13
Q
S/E of SSRI’s?
A
sexual dysfunction, weight gain, headache, erratic bowel movement, agitation, initial increase in suicidal ideation, hyponatraemia
14
Q
what is serotonin syndrome?
A
Serotonin syndrome is a drug induced syndrome characterised by a cluster of dose related adverse effects that are due to increased serotonin concentrations in the central nervous system.
15
Q
symptoms of serotonin syndrome?
A
- Mild- Mydriasis, Shivering, Sweating, Tachycardia
- Mod- Alt mental state: agitation, disorientation. Autonomic: rigidity, hyperthermia. Neuromuscular: tremor, clonus, hyperreflexia
- Life threatening- delirium, HTN, hyperthermia,
16
Q
management of serotonin syndrome?
A
Supportive, stop meds, Benzodiazepines
17
Q
what is malignant neuroleptic syndrome?
A
The most widely accepted mechanism by which antipsychotics cause neuroleptic malignant syndrome is that of dopamine D2 receptor antagonism. In this model, central D2 receptor blockade in the hypothalamus, nigrostriatal pathways, and spinal cord leads to increased muscle rigidity and tremor via extrapyramidal pathway
Life threatening reaction of taking neuroleptic/ increased antipsychotic medication dose <2wks of first dose
18
Q
symptoms of malignant neurolpetic syndrome?
A
High fever
Autonomic instability ( increased HR, sweating)
Stiffness/ rigidity of muscles (leadpipe), hyporeflexia
Seizures, Coma
Confusion, mutism, stupor
Extrapyramidal symptoms
Fast CARS
Fever, confusion, autonomic, rhabdo, seizure
gradual onset and slowly resolving
19
Q
complications of malignant neuroleptic syndrome?
A
rhabdomyolysis (rapid breakdown of skeletal muscles), hyperkalaemia, kidney failure, seizures, pneumonia and thromboembolism
20
Q
investigations of malignant neuroleptic syndrome?
A
ABG: metabolic acidosis, increased creatinine kinase, leucocytosis, prolonged QT
21
Q
management of neurloeptic malignant syndrome?
A
supportive, fluids, stop drug
Dantrolene (prevents the release of calcium leading to muscle relaxation and treatment of pyrexia)
Alternatives:
Bromocriptine (dop agonist)
Lorazepam (Benzo for rigidity)
22
Q
symptoms of abruptly discontinuing SSRI’s?
A
Increased mood change
Restlessness
Difficulty sleeping
GI: diarrhea, cramping
23
Q
S/Eof tricyclics?
A
Anticholinergic (Blocks muscarinic receptors) dry mouth, blurred vision, urinary retention (leads to overflow incon), constipation
CNS: drowsiness, dizziness, sleep difficulties, confusion
Cardiotoxic: arrhythmias, heart block
Pyrexia
respiratory depression
Withdrawal can occur
Lowers seizure threshold
24
Q
which questionnaires are used to screen for depression?
A
PHq-9
HAD
beck depression inventory
25
important questions to ask someone who has had a suicide attempt?
Wanted to die?
Wrote a note or will
Amount of planning/ method/ ability to act on plans
Still wants to die?
26
diagnostic criteria of bipolar disorder?
ICD-10
| At least 2 episodes, including 1 manic/ hypomanic episode
27
what are the different types of bipolar disorder?
Bipolar I – underlying depression + episodes of mania interspersed (1:1)
Bipolar II – predominant depression + 1 hypomania (5:1) – can be easy to miss mania
Rapid Cycling - ?> 4 episodes/ year of mania + depression. Lasts days
Cyclomania: chronic mood fluctuations over > 2 yrs, with episodes of depression + hypomania
28
DDx for bipolar disorder?
```
Depression
Emotionally unstable personality disorder
Cylothymia
Cocaine use
Hypomania
```
29
features of mania?
- Euphoria/ elated modd
- Irritable mood/ aggressive
- Feeling of increased self-worth (grandiose, overconfidence)
- Inappropriate social behaviour (sexual disinhibiton, compulsive actions, gambling, spending lots of money)
- Delusions of reference, grandiose delusions, auditory
- Jumping from project to project, not always finishing them
- Flight of ideas (discernible links between ideas) vs Knights move (illogical leaps between ideas)
- Increase in activity
- Lack of sleep due to reduced ‘need’ of sleep
- Pressure of speech/ difficult to interrupt
- Psychoses congruent with current mood
30
management of manic episode?
1st line: acute anti-psychotic (olanzapine, risperidone, quetiapine) & mood stabiliser (lithium – inhibits cAMP formation).
Slowly ween off anti-psychotics after episode
2nd line: different mood stabiliser: valporate (s/e. birth defects therefore not for <50yo women/ reproductive age), lamotragine (use in pregnancy - s/e. steven-johnson syndrome)
31
management of depressive episode in bipolar disorder?
SSRI only. Stop during manic episodes. Caution of inducing mania or rapid-cycling. (Clozapine/ carbamazapine for rapid cycling)
32
maintenance treatment of bipolar disorder?
lithium
33
S/E of lithium?
Leukocytosis
Insipidius - Nephrogenic DI: lacks aquaporin channels
Tremors = fine, Tremors = coarse in Toxicity
deHydration - Dry mouth, diarrhoea, thirsty - must drink
Increased - GI, Skin (psoriasis, acne), memory problems
Under active thyroid (decreased TSH)
Metallic taste, Mums pregnancy = Ebsteins anomaly (Congenital tricuspid valve defect), Myopathy
(LITHIUM)
34
treatment range of lithium?
Level - 0.4 to 1.0 mmol/L,
35
S/E of sodium valproate?
```
Valproate s/e:
Appetite
Liver failure
Pancreatitis
Reversible hair loss
Oedema
Ataxia
Teratogenicity
Encephalopathy
```
36
features of dependence syndrome?
1. Tolerance
2. Withdrawal
3. Persistent desire/ unsuccessful attempt to stop
4. substance used for longer periods than intended
5. Important social or recreational activities given up/ reduced due to substance abuse
6. Much time spent in seeking/ recovering from effects of substance
7. Persistence use despite being aware substance is causing damage
37
complications of alcohol dependence?
delirium tremens
| wernickes encephalopathy
38
screening tools for alcohol dependence?
CAGE questionnaire
AUDIT tool
FAST questoinnaire
39
features of alcohol dependence syndrome?
```
CANT SSTOP
•Compulsion to drink
•Aware of harms, but persists
•Neglecting other activities
•Tolerance of alcohol
```
* Stopping causes withdrawal
* Stereotyped pattern
* Time pre-occupied by alcohol
40
timeline of symptoms for alcohol withdrawal once someone has stopped drinking?
>6-12hrs: Tremor, nausea, vomiting, anxiety, insomnia, raised pulse, temp and BP
36hrs: peak incidence of Seizures, risk of status epilepticus
48-72hrs: peak incidence of Delirium tremens: hallucinations (auditory & visual), delusions (persecutory), confusion, agitation, coarse tremor, fever
41
features of delirium tremens?
```
coarse tremor
delusions
hallucinations- small insects
fever
tachycardia
ataxia
panic attacks
autonomic hyperactivity
death
```
42
management of acute withdrawal?
diazepam
chlordizapoxide
pabrinex
43
features of wernickes encephalopathy?
- Ataxia (loss of voluntary control of movements)
- Ophthalmoplegia
- Nystagmus
- Confusion
44
cause of wernickes encepahtlopathy?
cell death secondary to thiamine B1 deficiency
45
mangement of wernickes encephalopathy?
pabrinex
46
management of alcohol dependence (not acute)?
disulfuram - inhibits acetaldehyde dehydrogenase- causes hangover
acamproste- inhibits glutamate
Naltrexone- opiate antagonist - reduces positive rewards of alcohol
Pabrinex
47
what is the pathophysiology of alzhiemers?
atrophy of brain tissue due to accumulation of amyloid protein plaques and neurofibrillary tangles (tau protein)
48
features of alzhiemers?
4A's:
Amnesia- recent memory, disorientation of time and space
Apraxia- clothes, appropriate clothing
Agnosia- recognising parts of body
Aphasia- mixture of receptive and expressive
49
management of alzheimers?
anticholinesterase- donepazil, galantamine, rivastigmine
NMDA receptor antagonost- memantine
50
features of lewy body dementia?
1) fluctuating cognitive
impiarement and alertness
2) visual hallucinations
3) feautres of parkinsons- cog-wheel rigidy, tremor, bradykinesia, postural instability
51
Pathophysiology of lewy body dementia?
accumulation of lewy bodies (deposits of alpha synuclein) in brain-stem and neo-cortex
52
pathophysiology of front-temporal dementia (picks)?
atrophy of fronto-temporal area of brain without the protein deposits seen in Alzheimers
53
feautres of fronto-temporal dementia?
```
apathy
dis-inhibition
emotional blunting
loss of empathy
aphasia
language changes
intellectual functioning
memory impairment - may occur later but not the main feature
```
54
investigations of dementia?
FBC anaemia, Ca2+, ESR/CRP, U+E, blood glucose, LFT, TFT (hypothyroidism- can cause memory deficits), B12/folate, syphilis
MSU
CXR
ECG
MRI- shrinkage of hippocampus, cerebellar cortex, enlarged ventricles
55
what are some tools used for screening for dementia?
Addenbrooks cognitive examination
MMSE
Abbreviated Mental Test (AMT)
56
what are the differences between delirium and dementia?
delirium- acute onset, fluctuating, impaired attention, reduced consciousness, reversible
dementia- gradual onset, non-fluctuating, consciousness preserved, irritable
57
management of delirium?
try talking the patient down
offer oral lorazepam
give IM lorazepam
treat underlying cause
58
causes of delirium?
```
Drugs
Electrolyte imbalances
Lack of drugs
Infection
Reduced sesnory inout
Intracranial
Urinary retention/fecal impaction
Myocardial
```
59
what are the types of personality disorder?
Cluster A – ‘eccentric’: paranoid, schizoid, schizotypal
Cluster B – ‘dramatic’: antisocial, emotionally unstable, narcissistic, histrionic
Cluster C – ‘anxious’: avoidant, dependent, obsessive compulsive
60
what is the definition of GAD?
Generalised persistent and excessive anxiety or worry about a number of events that individuals find difficult to control for at least 3 months
61
features of GAD?
```
persistent anxiety- out of proportion with life events
Apprehension
Motor tension- muscle stiffness, tension headaches, tremor
tachycardia
tachypnoea
sweating
palpitations
diarrhoea
hypervigilance
panic attack
```
62
management of GAD?
first line- CBT
second line- SSRI (sertraline)
pregabalin for physical symptoms
short course of benzodiazepines if acutely anxious
63
definition of panic disorder?
recurring panic attacks for more than 4 months
64
features of panic disorder?
at least 1 of the attacks is followed by a month of:
persistent worry about future attacks
avoidance behaviours
hypervigilance
65
what are panic attacks?
brief intensive periods of episodes of extreme fear and anxiety
66
features of panic attacks?
physical- sweating, palpitations, dizziness, SOB, chest pain, hyperventilation, blurred vision
psychological- feeling of impending doom, derelisation , depersonalization, fear of losing control, fear of dying
67
management of panic disorder?
CBT
SSRI
benzodiazepines for acute treatment
68
definition of OCD?
obsessive thoughts and compulsive acts that are present for most days for more than 2 weeks and are distressing and interfere with activities.
69
what is an obsession?
a preoccupying idea (often unpleasent, repetitive, and intrusive- recognised as patients own thoughts)
Recurrent/ persistent, intrusive thoughts, or urges that cause anxiety or distress
Accompanied by attempts to suppress these thoughts/ urges
70
what is a compulsion?
An irresistible urge to behave a certain way
Repetitive behaviours or thoughts that the individual feels forced to perform by the obsession
Intensions to prevent or reduce anxiety, distress or a dreaded event. Behaviours are excessive
71
examples of obsessions in OCD?
```
fear of being contaminated by germs
fear of losing control
worrying about catching HIV
intrusive violent thoughts
worrying about causing an accident
```
72
what are some examples of compulsions in OCD?
```
excessive washing of hands or body
excessive cleaning of clothes
checking items are arranged just right and constantly adjusting
mental rituals
checking light switches
```
73
what is PTSD?
Triad of intrusive flashbacks, hyper arousal and avoidance following a stressful event of an unexpected and catastrophic nature
74
management of OCD?
first line- CBT
| second line- SSRI
75
features of maternal baby blues?
```
transient condition lasts up to 2 weeks after birth
mood lability
difficulty sleeping
disconnection with baby
anxiety
tearful
depressive symptoms
```
76
management of maternal baby blues?
not appropriate to give antidepressants
| support and reassurance
77
what is the difference between post-natal depression and baby blues?
post-natal depression does not tend to appear until later (usually 6 weeks after birth, but can be up to a year) and lasts 2 weeks or longer
baby blue usually peaks 5 days after birth and does not last longer than 2 weeks
78
RF for post-natal depression?
```
baby blues
px mental health issues
unplanned pregnancy
no support network
unemployed
abuse
```
79
what scale is used to grade severity of post-natal depression?
Edinburgh post-natal depression scale
80
management of post-natal depression?
psychological therapy
| SSRI's
81
when does post-natal psychosis present?
within 2 weeks of birth
82
features of post-natal psychosis?
```
gross mood swings
suicidal ideation
delusions
mutism
confusion
mixed features of psychosis and mania
```
83
management of post-natal psychosis?
admittance to mother and baby unit
neuroleptics
lithium
84
features of anorexia?
```
obsessive fear of weight gain
secondary amenorrhoea
poor insight
very low BMI
lanugo hair disturbed
concentration and memory
hypokalaemia, bradycardia, hypotension
secondary osteoporosis
```
85
investigations of anorexia?
Growth Hormone - ↑due to reduced carb intake
FSH, LH – maybe reduced
Prolactin - ↓at night
Impaired glucose tolerance
TFTs – do not treat hypothyroidism as secondary to amenorrhea. T3 low
Cortisol - high/ normal
most things low
G+C's raised- growth hormone, glucose, glands, cortisol, cholesterol
86
management of anorexia?
psychotherapies: CBT, interpersonal therapy, pscyhodynamic
admit to hospital and antidepressants if needed
encourage weight gain
87
complication of anorexia?
re-feeding syndrome
88
what is re-feeding syndrome?
massive insulin release after rapid food intake causes extracellular to intracellular displacement of Mg, K, PO3-
89
what are the electrolyte results of re-feeding syndrome?
hypophosphataemia
hypoK+
hypoMg+
thiamine deficiency
90
hwo to avoid refeeding syndrome?
feed at no more than 50% of requirements for 2 days
91
what is bulimia?
Cycles of binging followed by compensatory measures to counteract weight gain (usually via self-induced vomiting or starving) - does not lead to severe weight loss
92
features of bulimia?
```
body image concern
urge to overeat
isolated binges
depressed mood
social withdrawal
self-induced vomiting
impaired conc.
```
93
what are the physical features of bulimia?
```
oesophagitis
erosion of dental enamel
dry skin
brittle nails
swollen salivary glands
knuckle collapses
```
94
what is seen on blood gas for bulimia?
hypokalaemia, metabolic alkalosis
95
management of bulimia?
CBT
fluoxetines
thiamine and vit B supplements
96
management of ADHD + S/E of each drug?
Methphenidate (Ritalin)
- s/e: appetite suppression
Atomoxetine
- s/e liver dysfunction, suicidality
97
what is section 2 of the MHA, how long does it last and what are the requirements?
Assessment period
Lasts 28 days - cannot be renewed
People required:
AMP + 2 doctors (one S12 approved, one >F2)
Evidence required:
-pt suffering of mental health disorder that warrants hospital admission
-pt has to be detained for safety of themselves or others
98
what is section 3 of the MHA, how long does it last and what is required?
Treatment section
lasts up to 6 months, can be renewed
people required: AMP, 2 docs (one S12 approved, one >F2)
evidence required:
- pt suffering from mental health condition that requires tx in hospital
- tx is in their best interests
- tx is required for safety of patient and others
- tx is available to the patient in the hospital
99
what is section 4, how long does it last and who can put on in place?
emergency order - gives time to find another doctor to convert to section 2
lasts 72 hours
AMP + one doctor of any stage
100
what are the two parts of section 5, how long does it last and who can put it in place?
5: 2- doctors holding power, detain anyone admitted to hospital consensually for 72 hours - holds patient for assessment, cannot be treated
5: 4- nurses holding power, same as above but only 6 hours
101
what is a section 135?
police order- able to enter patients premises and remove them to a place of safety
social worker must be present
unable to treat patient under this order
102
what is a section 136?
police order- able to remove person from public place and detain them in a place of safety - no warrant needed
103
what is a community treatment order?
patient must turn up to appointments and take their treatment or they will be returned to hospital for 72 hours or S2/3 for treamtent
104
what is the MCA act?
Provides legal framework to make decisions for those who lack capacity to do so themselves.
Protects people who lack capacity.
105
what are the 5 statutory principles of the MCA?
* Assume capacity until proven otherwise.
* Supported to make their own decisions
* Retain right to make poor/ unwise decisions
* Act in patients best interests
* Least restrictive intervention
106
what is the criteria for deciding if someone has capacity?
1) is patient able to understand information
2) are they able to retain the information for long enough to make a decision
3) are they able to weigh up the pros and cons of the decision
4) are they able to communicate their decision
