Psychiatry Flashcards
1
Q
Name endocrinological causes of dementia
A
- Hypothyroidism, Hyperparathyroidism, Cushing’s and Addisons
2
Q
Name vitamin deficiency that causes dementia
A
B12, folate and thiamine
3
Q
Metabolic causes of demenntia
A
- Hypoglycaemia, calcium, magnesium and electrolyte imbalance
4
Q
Clinical features of dementia
A
- Memory impairment
- Personality changes
- Fatigue
- Apathy
- Hallucinations and paranoid delusions
- Sundowner syndrome
- Seizures
- Catastrophic Reaction
- Pathological emotion
5
Q
Differentials of dementia
A
- Delirium
- Depression
- Learning Disability
- Normal ageing
6
Q
Investigations for Dementia
A
- FBC; LFT; U&E; glucose; erythrocyte sedimentation rate (ESR); thyroid-stimulating hormone (TSH); calcium; magnesium; phosphate; Venereal Disease Research Laboratory (VDRL) test for syphilis; HIV; vitamin B12 and folate; C-reactive protein; blood culture; LP; EEG; chest X-ray (CXR); ECG; CT (optima and axial protocol); MRI; SPECT
7
Q
Management of dementia
A
- Assessment
- Cognitive enhancement (Ach esterase inhibitors - rivastigmine), antioxidants (selegiline)
- Treat psychosis
- Treat depression
- Treat medical illness
- Psychological support to patient and care-givers
- Functional management: maximise mobility, encourage indépendance
- Social management
8
Q
What is catastrophic reaction
A
Happens when patients with dementia are asked to perform tasks that they are struggling with causing sudden anger, agitation and violence
9
Q
What characterises fronts-temporal dementia
A
- Frontal lobe so personality changes are early
2. Language impairment
10
Q
Onset of front-temporal dementia
A
Early-onset
11
Q
What would a CT show for fronts-temporal dementia
A
- Atrophy of fronto-temporal cortex
12
Q
What would a SPECT show for fronto-temporal dementia
A
fronto-temporal metabolism
13
Q
What part of the cortex does alzheimer’s affect
A
Posterior-parietal
14
Q
What characterises alzheimer’s
A
- Early memory and cognitive deficits
personality changes are later as frontal lobe starts to atrophy
15
Q
Most common cause of dementia
A
Alzheimer’s
16
Q
What can protect against Alzheimer’s
A
Smoking
Oestrogen
NSAIDs
17
Q
What causes Alzheimer’s
A
- Amyloid plaques (beta-amyloid deposits)
2. Neurofibrillary tangles
18
Q
Clinical symptoms of alzheimer’s (related to time)
A
Early symptoms: Memory problems, ADL issues, spatial dysfunction and changes to behaviour (e.g. irritability)
Middle: Intellectual and personality deterioration (aphasia, apraxia so struggling to dress) and agnosia (can’t recognise own body parts)
Impaired visuospatial skills
Late: Fully dependant with physical deterioration, incontinence, weight loss, primitive reflexes and extrapyramidal signs
19
Q
Psychiatric symptoms of alzheimer’s
A
- Paranoid Delusions, auditory and visual hallucinations, depression
20
Q
Factors for poor prognosis of alzheimer’s
A
- Sveerity of presentation
- Male
- <65
21
Q
What assessment is used for Alzheimer’s
A
IQCODE
22
Q
What imaging would be used for alzheimer’s
A
- CT: Cortical atrophy
- MRI: Atrophy of grey matter (hippocampus and amygdala)
- PET: 20-30% reduction in oxygen
23
Q
How often should patients be reviewed if they are put on treatment for alzheimer’s
A
Every 6 months
MMSE should be above 12 to continue treatment
24
Q
What drugs are given to patients with Alzheimer’s
A
- Donepezil or Rivastigmine
2. Memantine
25
Side-effect of AChEIs
GI bleeding
26
How does Memantine function
1. NMDA-receptor antagonist which protects over-excitation of neurons.
27
Clinical features of Lewy-Body Dementia
1. Dementia
2. Parkinsonism
3. Fluctuating cognitive performance
4. Complex Hallucinations
5. Depression
6. Transient episodes of consciousness disturbances (mute and unresponsive for several minutes)
28
How long does it take to rapidly deteriorate from lewy body
1-2 years
29
Name two of three core features that are needed to diagnose lewy body
1. Fluctuating cognition with variation in alertness and attention
2. Recurrent visual hallucinations
3. Spontaneous motor features of parkinsonism
30
When is Lewy Body less likely to be diagnosed
Presence of a stroke
31
Pathology of lewy body
1. Phosphorylated neurofilament proteins with ubiquitin and A-synuclein
These deposit in substantial nigra and hippocampus
32
Differentials of lewy body
1. Delirium
2. Mania, depressive disorder
3. Parkinson's
33
Investigations of lewy body
1. CT/MRI
| 2. SPECT
34
What is seen in CT/MRI in lewy body
deep white matter lesions and periventricular lucencies on MRI
Sparing of medial temporal lobes
35
How is Lewy Body treated
1. Antipsychotics, AChEIs
36
Core features of FTD
1. Gradual progression
2. EARLY decline in social interpersonal conduct
3. EARLY impairment in regulation of social conduct
4. EARLY emotional blunting
5. EARLY loss of insight
```
Supportive: Dietary changes (e.g. overeating, preferring sweet food)
Speech disturbances (e.g. mutism and echolalia)
```
Progressive symptoms: Primitive reflexes, Parkinsonism, MND
37
Investigations of FTD
1. EEG should be normal despite evident dementia
| 2. Brain imaging
38
Pathology of FTD
Macroscopic: 1. Bilateral atrophy of frontal and anterior temporal lobes
Microscopic: loss of cortical nerve cells and spongiform degeneration
Pick: loss of large cortical nerve cells, no spongiform change, swollen neurones, widespread gliosis
39
Three main features of vascular dementia
1. Cognitive deficits following a single stroke
2. Multi-infarct dementia (from multiple strokes)
3. Progressive small-vessel disease
40
Clinical Features of vascular dementia
1. EARLY emotional and personality changes followed by cognitive deficits that fluctuate
2. Depression and sundowner syndrome
3. Neurological impairments
41
Investigations of Vascular dementia
1. Routine screen
2. Serum Cholesterol, clotting and vasculitis screen (ESR, CRP and RF, Anti DsDNA, APL), syphillis if young
3. ECG, CXR, CT and MRI ESSENTIAL
42
Management of vascular
* Establish causative factors.
* Medical or surgical diseases that are contributory need to be treated early.
* Daily aspirin may delay course of disease.
* General health interventions include changing diet, stopping smoking, managing hypertension, optimizing diabetic control, and increasing exercise.
43
Pathology of neurosyphilis
1. Spirochaetes go for frontal and parietal lobes and presents as progressive frontal dementia
Symptoms: Grandiosity, euphoria and mania
Tremor, Ataxia and trombone tongue
44
Pathology of Huntington's
Triad repeat of CAG between 37 and 120 on chromosome 4
This decreases GABA neutrons in basal ganglia -> increased stimulation of thalamus and cortex of global pallid us.
45
Clinical features of huntington's
TRIAD:
1. Chorea (jerks, tics and involuntary movements of ALL parts of the body, grimacing, dysarthria and positive primitive reflexes, abnormal eye movement)
2. Dementia
3. History of HD
Psychiatric:
Anxiety and depression
Psychosis
Agression and violence
46
What does a CT/MRi show for huntington's
1. Atrophy of Basal Ganglia
47
Features of substance misuse dependance syndorme
1. Drug seeking behaviour
2. Increased tolerance to drug effects
3. Loss of control of consumption
4. Signs of withdrawal
5. Signs of withdrawal
6. Drug taking to avoid withdrawal symptoms
48
Stages of change
1. Pre-contemplation (user doesn't recognise problem)
2. Contemplation
3. Decision
4. Action
5. Maintenance
6. Relapse
49
How do we screen for alcohol problems
CAGE
| AUDIT and FAST assessment papers
50
Blood tests in heavy drinkers
MCV (raised)
GGT raised
CDT
51
Recommended units for men and female
1. 21 - Men
2. 14 - Female
Should be at least 2 days a week of non-drinking
52
Techniques of controlled drinking
1. Pricing
2. Motivational interview
3. Counselling families
53
What is uncomplicated alcohol withdrawal syndrome
How long does this last
1. Coarse tremor, sweating, insomnia, tachycardia and anxiety
2. Transient hallucination
3. Craving for alcohol
48Hours
54
When do withdrawal symptoms occur
4-12 hours after last drink
55
Onset of delirium tremens
1-7 days after drink, 48Hours usually
56
Clinical features of delirium trmeens
1. Uncomplicated withdrawal symptoms
2. Disorientation
3. Loss of conscious
4. Amnesia
5. Hallucinations
6. Paranoid delusions
57
Differentials of delirium
1. Hepatic encepholapath y
| 2. Head Injury
58
How is alcohol withdrawal managed
1. BDZ to manage tremor and anxiety
2. Antipsychotics
3. Dilsufiram (irreversible inhibition of Acetaldehyde Dehydrogenase which converts alcohol to water and co2)
4. Acamprosate (anticraving)
59
Name two types of alcohol-induced amnesia
1. En bloc - Well demarcated start and finish points
| 2. PartialL Episodes of island episodes which have been forgotten
60
Alcohol can cause Othello syndrome, what is this
Mono symptomatic Paranoid delusion disorder
61
What is Wernicke's encephalopathy
1. Acute onset of:
Acute confusional state
opthalmoplegia, nystagmus
ataxic gait
CAUSED: Thiamine deficiency
62
How is Wernicke's encephalopathy treated
1. IV Thiamine
| 2. ALL should have parenteral vitamins
63
How long can wernicke's last untreated
72 weeks
64
What is Korsakoff's syndrome
1. Retrograde amnesia
| 2. But has working memory
65
How is korsakoff's syndrome treated
1. Oral thiamine
2. Vitamin supplement
3. Treat psychiatric comorbidity
66
Medical complications of alcoholic misuse
1. ALD
2. Gastritis, Barrett's, Malloryy-weiss tears, peptic ulcers, chronic pancreatitis
3. HTN, Dilated cardiomyopathy, CVA
4. TB, Strep pneumonia
5. Central pontine myelinolysis, optic atrophy, ceberellar degeneration
6. Erectile problems, hypogonadism
7. Gout, osteoporosis, Foetal alcohol syndrome
67
How do you assess the drug user
1. Background
2. Reason for consult
3. Current drug use
4. Lifetime drug use
5. Complication
6. Precious treatment
7. Medical and psych history
8. Fam
9. Social
10. Forensic
11. Patient aims
12. MSE
13. Physical
14. Urine screening essential
68
Symptoms of opiate withdrawal
1. Sweating
2. Dilated pupils
3. Tachy cardia
4. Hypertension
5. Piloerection
VOMITING
6. Tremor and diarrhoea
69
What is given for opiate withdrawal
1. Lofexidine (alpha-adrenergic agonist)
| 2. Methadone or Buprenophine
70
Symptoms of BDZ withdrowal
1. Anxiety
2. Insomnia
3. Tremor
4. Agitation
5. Headache
6. Seizures
71
How are BDZ symptoms treated
Smallest dose of diazepam that stops symptoms
Then dose is reduced
72
How is Schizophrenia diagnosed
AT LEAST ONE OF THE FOLLOWING:
1. Thought echo, insertion, withdrawal or broadcasting
2. Delusions of control, influence or passivity; clearly referred to body and limb movements
3. Hallucinatory voices
4. Persistent delusions
AT LEAST TWO OF THE FOLLOWING:
1. Persistent hallucination
2. Catatonic behaviour
3. Negative symptoms
4. Consistent change in behaviour
More than a month
73
What substances can induce shizocphrenia type symptoms
1. Alcohol
2. Stimulants
3. Steroids
4. Antihistamines
74
What causes schizophrenia
1. Dopaminergic hyperactivity
2. Glutaminergic hyperactivity
3. Serotenergic overactivity
75
Why is there a 20% reduction in life expectancy with people having schizophrenia
Suicide
76
Which family members are most affected for schizophrenia
Twins
77
Investigations for schizo
1. Routine blood tests
2. CT or MRI if neurological deficits found
3. CXR if comorbid respiratory etc
4. Urine for drug screen
5. EEG if history of seizures
Special: 24-hr collection for cortisol
24hr catecholamine for phaeochromotocytoma
78
Stage of schizophrenia
1. Prodromal state (non-specific, negative symptoms)
2. First episode where there is a direct event related to their condition
3. Relapse and re-starting subsequent episodes
79
How is prodrome stage assessed
PACE
80
How is acute psychosis treated
1. Rispiridone
| 2. Long acting BDZ to control behavioural disturbances
81
Extra-pyramidal effects of antipsychotics
Typical and atypical both cause them but less so with atypical:
1. Dystonias
2. Parkinsonism
3. Akathisia
82
How is parkinsonism treated
Procyclidine
83
How should negative symptoms be treated
Mood medications
84
How can the effect of clozapine be enhanced
SSRI, lamotrigine or second antipsychotic
85
What is the first stage of discharge planning
1. CPA
86
What should be done if oral medications are refused
1. Depot injections
87
What types of psychological therapies can reduce relapse
Family therapy and psychoeducation
88
What assessments should be made at every schizo check up
1. MSE
2. Side-effects to drugs
3. Recent life stresses
89
What advice would I give to a schizo patient
1. Provide education on disease and treatment
2. Concerns adressed
3. Offer to meet family members
90
What type of injections are depots for antipsychotics
IM
91
Benefits of atypical psychotics
1. Less likely to cause extra pyramidal side effects
92
What receptor does rispiridone act on
5-HT2
93
To avoid sedation what drug should be given
1. High potency (haloperidol) or non-sedating (risperidone)
94
To avoid weight gain what drug should be given
1. Haloperidol or fluphenazine
95
What antipsychotics cause postural hypotension
Phenothiazides
96
EPSE examples
1. Acute dystonia (where contraction of muscle groups to maximal limit)
2. Parkinsonism (tremour, rigidity and bradykinesia)
3. Akathisia (restlessness of lower limbs)
4. Tardive dyskinesia (athetosis and chorea of mouth)
97
How is acute dystonia treated
Parenteral procyclidine
98
How is TD treated
VIT E helps deterioration
99
Anticholingeric sideeffects
1. Dry Mouth
2. Blurred vision
3. Urinary retention
4. Constipation
5. Glaucoma
100
Anti-adrenergic side-effects
1. Postural hypotension
2. tachycardia
3. Sexual dysfunction
101
Antihistaminic side effects
1. Sedation
| 2. Weight gain
102
Before considering treatment resistant schizo, what factors do we need to think about
1. Drug non compliance
| 2. Lack of adequate treatment or contraindications
103
How is TRS managed
1. Diagnosis clarified
2. See if comorbid substance misses is occurring
3. Psychoeducation for noncompliance
4. Clozapine or depot
104
When is clozapine prescribed to schizo patients
1. If patient with schizo has not adequately responded to treatment
105
Pharmacology of clozapine
1. Blocks D1 and D4 receptors
106
Side effect of lithium
Lowers threshold for seizures
107
Side-effects of clozapine
1. Constipation, fever, hyper salivation, hypertension, hypotension, nausea, agrunlocytosis, nocturnal enuresis, sedation, seizures, weight gain
108
Main two depot medications
1. Haloperidol and risiridone
109
What is post-injection syndrome
1. Immediate sedation, ESPEs, basically side effects after depot injection
110
What is schizoaffective disorder
• An uninterrupted period of illness during which there is a major depressive, manic, or mixed episode concurrent with symptoms that meet criterion A for schizophrenia.
111
How long before schizoaffective disorder can be diagnosed
2 weeks
112
What is Schizotypal disorder
1. CLUSTER A PD
Clinical features of achizo without delusions or hallucinations
e.g. Ideas of reference (you guys are talking about me), Social anxiety, odd beliefs and magical thinking , odd speech
113
Differential for schizotypal
1. Autism, asperger;s, PD cluster A
114
how is schizotypal disorder treated
1. Rispiridone
115
What is schizophreniform disorder
1. schizophrenia like psychosis that can't be classified as schizo
116
What is De Clerambault syndrome
1. Person believes that someone if in love with them
117
What is persecutory syndrome
1. Patients believe someone wants to harm them
118
Risk factors for schizophreniform
2. Social isolation
| 3. Low socio economic status
119
Definition of acute psychotic disorder
1. Sudden onset, variable presentation (including perplexity, inattention, formal thought disorder/disorganized speech, delusions or hallucinations, disorganized or catatonic behaviour), usually resolving within less than 1mth (DSM-5) or 3mths (ICD-10).
120
Differentials of acute psychotic disorder
1. organic disorders
2. BAD
3. Drugs and alcohol
121
What is folie a deux disorder
Shared delusions
122
What causes foil a deux disorders
1. Psychodynamic (where people feel like they will lose the other partner if they do not share beliefs)
2. Learning theory
3. . Social isolation
123
How is folly a deus managed
1. Separation
124
What is Capgras delusion
1. the patient believes others have been replaced by identical or near identical imposter
125
What is fregoli syndrome
1. an individual, most often unknown to the patient, is actually someone they know ‘in disguise’.
126
What is inter metamorphosis delusion
1. the patient believes they can see others change (usually temporarily) into someone else (both external appearance and internal personality).
127
What is subjective doubles delusion
the patient believes there is a double (‘dopplegänger’) who exists and functions independently.
128
What is autoscopic syndrome
the patient sees a double of themselves projected onto other people or objects nearby.
129
What is reverse fregoli syndrome
the patient believes others have completely misidentified them.
130
Core symptoms of depression
1. Depressed mood
2. Loss of interest
3. Weight change
4. Disturbed sleep
5. Psychomotor agitation
6. Fatigue
7. Loss of libido
8. diminished concentration
9. Recurrent thoughts of death
131
What is anhedonia
Loss interest in things
132
Biological symptoms of depression
1. Anhedonia
2. Loss of appetite
3. Loss of weight
4. Loss of libido
133
Psychotic symptoms
1. Delusions
2. hallucinations
Depressive stupor (lack of mental function)
134
What is non-melancholic depression
1. Irritable or hostile depression
2. Anxious depression (shy and withdrawn)
No somatic (biological) symptoms
135
What is melancholic depression
Has biological symptoms
136
Where is depression more common
```
Female, young
Marital status
Adverse life events
Physical illness
Low socio-economic status
```
137
Structural brain changes in depression
1. Ventricular enlargement
2. Sulcal prominence
3. Hypoperfusion in frontal, temporal and parietal areas.
138
Assessment of depression
1. HAM-D scale
2. Check co-morbidity of anxiety with HAM-A
3. MMSE
139
Investigations ofr depression
1. Blood tests
2. Urine
3. Breath
4. ABG
5. Thyroid antibodies
6. Antinuclear antibody
7. Ayphilis serology
8. Dexamthesone suppression test
9. Cosyntropin stimulation test (addison)
10. Lumbar puncture
140
Poor prognosis of depression
1. Lack of support social
| 2. Low self confidence
141
When should patients on antidepressants be followed up
1. 1-4 weeks
142
When should ECT for depression be considered
1. Severe biological symptoms
| 2. First line for depression with psychotic symptoms
143
How should SSRIs be discontinued
1. Gradually half the dose over months
144
First line treatment for psychotic depression
1. Olanzapine and fluoxetine
145
Problems with dual combination in psychotic depression
1. Antipsychotic can mask improvement on SSRI
| 2. Combination may worsen side-effects
146
Treatment resistant depression management
1. Is diagnosis correct, conduct more blood tests
2. Check compliance
3. Consider change in antidepressant
4. ECT?
TRYPTOPHAN
147
Atypical depressive features
1. Depressed but reactive to experiences
2. Hypersomnia
3. Hyperphagia
4. Leaden paralysis
5. Oversensitivity to rejection
6. Initial insomnia than early morning awakening
148
How is atypical depression treated
PHENELZINE (MAO inhibitor)
149
How is SAD treated
1. Light Therapy
| 2. SSRI
150
What is Dysthymic disorder
1. PD
151
Clinical features of dysthymic disorder
1. Depressed mood
2. Reduced appetite or increased
3. Changes in sleep
4. Low self esteem
5. Poor conc
6. Difficulties making decision
152
How does switching MAO medication differ from other drugs
MAO needs a washout period whereas cross-taper is usual for others.
153
Side-effects of MAOIs
1. Hypertensive crisis as intestinal MAO are inhibited
| 2. Dietary tyramine needs to be avoided
154
Side-effects of SSRIS
1. Agitation, GI upset, nausea, diarrhoea and headache as it affects 5-HT3 agonism
155
Side effects of SNRIs
1. Nausea, GI upset, constipation, loss of appetite, sweating, headache and sexual dysfunction
156
Name types of SNRIs
1. Vanlafaxine
| 2. Duloxetine
157
Sid effects of Tetracyclic antidepressants
1. GI issues
158
Name a Serotonin antagonist reuptake inhibitor
1. Trazodone
159
Mode of action of SARIs
* 5-HT1A/1C/2Aantagonism—sedating/anxiolytic, less sexual dysfunction;
* 5-HT agonism through the active metabolite (m-chlorophenylpiperazine)—antidepressant effect;
* α1 antagonism—orthostatic hypotension;
* H1antagonism—sedation and weight gain.
160
Side effect of mirtazepine
1. Increase in appetite
| 2. Weight gain
161
What type of antidepressant is mirtazapine
1. Noradrenergic and specific serotonergic antidepressant
162
Name a noradrenaline reuptak inhibitor
1. Reboxetine
163
What type of antidepressant is Bupropion
Noradrenergic and dopaminergic reuptake inhibitor
164
Indications for ECT
1. Depression, Treatment resistant psychosis and mania, catatonia, neuroleptic malignant syndrome, seizures
165
Side-effects of ECT
transient memory loss, seizures
Tonic contraction
Increase in cortisol
Raised ICP
```
Retrograde amnesia
Long-term emory loss
Confusion
Muscular aches
Clumsiness
```
166
Things to do before ECT is carried out
1. Patient fasts for 8 hours
2. establish IV access, oxygen mask, muscle relaxant
3. Hyperventilation
167
How is ECT carried out
1. Apply electrodes to scalp
2. Test for contact between electrodes and scalp
3. Monitor length of seizure
168
Types of ECT
Unilateral ECT and BECT
169
How often does ECt hav to be carried out
1. Twice a week
6-12 for depression
catatonic in 3-5
170
If ECT is causing prolonged seizures how is this treated
1. Administer IV diazemuls every 30s
171
Surgical methods for depression
Vagus nerve stimulation
| Deep brain stimulation
172
What medications can INDUCE mania
1. Anti-depressants
2. BDZ
3. Lithium
4. DIsulfiram
5. Anti-parkinsonian
6. Propanolol
7. Opioids
8. Steroids
173
Clinical features of mania
1. Elevated mood
2. Increased energy (either over activity or reduced need for sleep)
3. Though disorder (Pressured speech, flight of ideas, racing thoughts)
4. Increased self-esteem (grandiosity, reduced social inhibition, over familiarity)
5. Reduced attention
6. Behaviours which can cause serious consequences
Agression, irritability
174
Psychotic symptoms of mania
1. Grandios
2. Suspiciousness
3. Pressured speech to point where they can't communicate
4. Flight of ideas, proximity
5. Irritation and aggression
6. Catatonic features (Manic stupor)
7. Loss of insight
175
Differentials of mania
1. Anxiety
2. PTSD
3. ADHD
4. Schizophrenia
5. Alcohol misuse
176
How is mania managed
1. Risk assessment and ensure safety
2. Exclude other causes
3. Address any specific psychosocial stressors
177
Hypomania Clinical features
1. Mild elevation of mood
2. Increased energy
3. Increased self-esteem
4. Sociability
5. Talkativeness
6. Over-familiarity
7. Increased sex drive
8. Reduced need for sleep
9. Difficulty in focusing on one task alone
178
Differential diagnosis of hypomania
1. OCD
2. Substance misuse
3. Physical illness
179
Characteristic Clinical features of bipolar spectrum disorder
1. AT LEAST one depressive episode
2. No spontaneous hypomanic or manic episodes
The history will include some of the following:
* A family history of bipolar disorder in a first-degree relative.
* Antidepressant-induced mania or hypomania.
* Hyperthymic personality2 (at baseline, non-depressed state).
* Recurrent major depressive episodes (>3).
* Brief major depressive episodes (on average, <3mths).
* Atypical depressive symptoms (DSM-IV criteria).
* Psychotic major depressive episodes.
* Early age of onset of major depressive episode (
180
Treatment of bipolar disorder
1. Lithium/Valproate and SSRI
181
Why is SSRI not typically used for bipolar
1. Causes rapid cycling
182
Bipolar diagnostic threshold
1. AT least TWO episodes of mania and unipolar depression
183
What type bipolarism is associated with substance and medication use
1. Type 2
184
What type bipolarism is associated with other medical conditions
Type 2
185
Main differences between type 1 or 2
Type 2 is mainly hypomanic , more episodes of depression
Type 1 is mainly mania with or without depression
There is also mixed
186
Investigations for bipolari
As for depression; full physical and routine blood tests to exclude any treatable cause, including FBC, ESR/CRP, glucose, U&Es, Ca2+, TFTs, LFTs, drug screen. Less routine tests: urinary copper (to exclude Wilson’s disease [rare]), ANF (SLE), infection screen (VDRL, syphilis serology, HIV test). CT/MRI brain (to exclude tumour, infarction, haemorrhage, MS)—may show hyperintense subcortical structures (esp. temporal lobes), ventricular enlargement, and sulcal prominence; EEG (baseline and to rule out epilepsy). Other baseline tests prior to treatment should include ECG and creatinine clearance.
187
Poor prognosis of bipolar disorder
1. poor employment history; alcohol abuse; psychotic features; depressive features between periods of mania and depression; evidence of depression; male sex; treatment non-compliance.
188
Good prognosis of bipolar disorder
manic episodes of short duration; later age of onset; few thoughts of suicide; few psychotic symptoms; few comorbid physical problems, good treatment response and compliance.
189
How are catatonic symptoms (manic stupor) treated
1. ECT or BDZ with Lithium
190
How is acute mania treated
1. Lorazepam and haloperidol (low-dose antipsychotics)
191
If patient is already on prophylaxis for bipolarism, what do we need to do
1. Check serum levels
2. Exclude other problems
3. Consider adding SSRI to mood-stabiliser
4. OR if not already on antipsychotic, add quetiapine
192
If recent mood instability isn't helped by lithium what is 2nd line treatment
Lamotrigine
193
1st line for life threatening depressive episode
ECT
194
Non-medical interventions for bipolar
1. Psychoeducation
2. CBT
3. Family focused therapy
4. Interpersonal and social rhythm therapy
195
Cyclothymia clinical features
Rapid cycling, mood swings
196
Treatment of cyclothymia
1. Lithium low-dose, carbamazepine
| 2. At crisis, treat with low dose antipsychotic
197
How is Lithium monitored
1. Thyroid function
2. eGFR
3. Blood serum levels (FBC, U and E)
198
When should lithium levels be checked
5 Days after starting, 5 days after dose change
Then every 3 months
199
How is lithium stipped
Gradually reduced
200
Side-effects of lithium
1. Polyuria, Marked tremor, anorexia, nausea/vomiting, diarrhoea (sometimes bloody), with dehydration and lethargy.
2. Kindey interstitial fibrosis, Hypothyroidism, teratogenicity
3. T-waves change and QRS widens
201
When is valproateindicated
1. Acute mania
2. Acute depressive episode
3. Prophylaxis of bipolar affective disorder
202
Side-effects of valproate
1. Gi Upset, raised LFTs, tremor, sedation.
203
When is carbamazepine indicated
1. Acute mania
2. Acute depressive episode
3. Prophylaxis of bipolar
204
What is psychoeducation
1. Patients are given a theoretical and practical approach to understand their illness and the medication they are prescribed. Through understanding, patients can attain improved adherence to medication, recognize symptoms that might lead to decompensation, and recover occupational and social function.
205
What is CBT
1. TIME-LIMITEd but focused education on condition and teach cognitive behavioural skills to cope with stressors
206
What is Interpersonal and social rhythm therapy
1. to reduce lability of mood by maintaining a regular pattern of daily activities, e.g. sleeping, eating, physical activity, and emotional stimulation.
207
What is family-focused therapy
usually brief, includes psychoeducation (of patient and family members) with specific aims: accepting the reality of the illness, identifying precipitating stresses and likely
208
Describe schizoid PD
1. Emotionally cold, detachment, lack of interest in others, excessive introspection and fantasy.
209
Describe Emotionally unstable–impulsive type
Inability to control anger, or plan with unpredictable behaviour
210
Describe Emotionally unstable–borderline type
Unclear identity, intense and unstable relationships, unpredictable affect, threats or acts of self-harm, impulsivity.
211
Describe Histrionic PD
Self-dramatization, shallow affect, egocentricity, craving attention and excitement, manipulative behaviour.
212
What are risk factors for Cluster B PDs
1. Substance Misuse
2. Easting Disorder
3. Somatoform disorders
4
213
Risk factors for cluster B PD
1. Eating Disorder
2. Neurotic disorder
3. Depression
214
How is PD assessed
SELF-REPORT QUESTIONNAIRE: PDQ-IV
INTERVIES: SCID-5-PD
215
How is OCD treated
SSRI
216
Psychotherapy for borderline
DBT
Or Cognitive analytic therapy
217
What is Hyperventilation Syndrome
1. Ventilation exceeds metabolic demands, leading to haemodynamic and chemical changes producing characteristic symptoms (dyspnoea, agitation, dizziness, atypical chest pain, tachypnoea, hyperpnoea, paraesthesias, and carpopedal spasm) usually in a young, otherwise healthy patient. HVS relatively common presentation; may be mistaken for panic disorder. Considerable overlap, hence inclusion here:
218
Clinical Features of HVS
1. Chest pain/angina
2. Tachypnoea, dyspnoea and wheeze
3. CNS (hypocapnia): Dizziness, weakness, paraesthesias, visual hallucinations
4. GI: Bloating, flats, epigastric pressure
219
Investigations for HVS
1. Routine blood tests
2. ABG
3. Pulse oximetry
4. PaCO2, HCO3 - low
5. CXR
220
How is HVS treated
1. Reassure patient
2. Use BDZ for severe anxiety
3. Establish normal breathing pattern
Education
Beta-blockers, BDZ prophylaxis
221
Define a panic attack
eriod of intense fear characterized by a constellation of symptoms (see Box 9.1) that develop rapidly, reach a peak of intensity in about 10min, and generally do not last longer than 20–30min (rarely over 1hr)
222
Define a panic disorder
Recurrent panic attacks, which are not 2° to substance misuse, medical conditions, or another psychiatric disorder.
223
Clinical features of panic attack
* Palpitations, pounding heart, or accelerated heart rate.
* Sweating.
* Trembling or shaking.
* Sense of shortness of breath or smothering.
* Feeling of choking or difficulties swallowing (globus hystericus).
* Chest pain or discomfort.
* Nausea or abdominal distress.
* Feeling dizzy, unsteady, light-headed, or faint.
* Derealization or depersonalization (feeling detached from oneself or one’s surroundings).
* Fear of losing control or going crazy.
* Fear of dying (angor animus).
* Numbness or tingling sensations (paraesthesia).
* Chills or hot flashes.
224
How are panic disorders managered
1. Citalopram
2. BDZs: Lorazepam
2nd line use BDZs
CBT
Psychodynamic psychotherapy
225
Define agoraphobia
Anxiety and panic symptoms associated with places or situations where escape may be difficult or embarrassing (e.g. of crowds, public places, travelling alone or away from home), leading to avoidance.
226
How are phobias managed
1. Exposure therapy
| 2. Severe: BDZs
227
Management of social anxiety
CBT and SSRI/beta blockers
228
Define GAD
‘Excessive worry’ (generalized free-floating persistent anxiety) and feelings of apprehension about everyday events/problems, with symptoms of muscle and psychic tension, causing significant distress/functional impairment.
229
How is GAD amanged
1. CBT but less affective in these cases
Psychotic symptoms: Busprione
Somatic: BDZz
Depressive: SSRI
CV: Beta blockers
WORST CASE: Psychosurgery
230
Define OCD
A common, chronic condition, often associated with marked anxiety and depression, characterized by ‘obsessions’ (see Anxiety and stress-related disorders [link]) and ‘compulsions’ (see Anxiety and stress-related disorders [link]).
231
Psychological management of OCD
1. CBT
| 2. Behavioural or cognitive therapy
232
If OCD becomes severe what must be considered
1. ECT, psychosurgery
DBS but not benefit established
233
Define hoarding disorder
Persistent difficulties in discarding or parting with possessions (including pets), regardless of their actual value, which leads to distress associated with discarding them and results in the accumulation of possessions that clutter active living areas.
234
Denis type 1 trauma
single, dangerous and overwhelming events comprising isolated (often rare) traumatic experiences of sudden, surprising, devastating nature, with limited duration.
235
Define type 2 trauma
due to sustained and repeated ordeal stressors
236
What is an acute stress reaction
1 .A transient disorder (lasting hours or days) that may occur in an individual as an immediate (within 1hr) response to exceptional stress
237
Clinical Features of acute stress reaction
1. Anger
2. Social withdrawal
3. Hopelessness
238
When does acute stress reaction begin to diminish under stress
1. 24 to 48 hours
239
Define acute stress disorder
Clear overlap with ‘acute stress reaction’ (symptoms of dissociation, anxiety, hyperarousal), but greater emphasis on dissociative symptoms, onset within 4wks, lasting 3 days to 4wks (after which diagnosis changes to PTSD).
240
What defines an adjustment disorder
Acute stress reaction with psychotic/depressive symptoms
Within 1 month but no more than 6 months of stressor being present
241
Define PTSD
Severe psychological disturbance following a traumatic event (see Anxiety and stress-related disorders [link]) characterized by involuntary re-experiencing of elements of the event, with symptoms of hyperarousal, avoidance, emotional numbing.
242
When is PTSD classified
Within 6 months of the traumatic event or present for at least 1 month
243
Clinical Features of PTSD
1. Recurrent recollections of the event
2. Nightmares
3. Flashbacks
4. Psychological distress when exposed to stressor
5. Avoidance behaviour
6. Inability to recall important aspect of trauma
244
Psychological therapy of PTSD
1. CBT
2. Eye movement desensitisation and reprocessing (oluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts and help process the emotions associated with traumatic experiences)
3. Hypnotherapy
2. Psychodynamic
245
How is sleep disturbance treated
1. Mirtazapine
246
How is hyperarousal treated
BDZs, SSRi or beta blockers
247
What is depersonalisation syndrome
A rare disorder, characterized by persistent or recurrent episodes of a distressing feeling of unreality or detachment.
248
How is depersonalisation syndrome assessed
1. Cambridge depersonalisation scale
249
How is depersonalisation syndrome managed
1. Exclude organic cause
2. SSRI
33. CBT
250
Onset of depersonalisation
Sudeen
251
How long does hypomania last
4 days
252
How long does mania last
More than a week
253
First rank symptoms of schizo
1. Thought alienation
2. Passivity phenomena
3. 3rd Person Auditory hallucination
4. Delusional perception
254
What secondary symptoms of schizo
1. Delusions
2. Hallucinations
3. catatonia
4. Negative symptoms
255
Clinical Features of postpartum depression
1. Anhyrdonia
2. Fatigue
3. Loss of appetite
4. Overwhelmed they are not bonding with baby
256
Onset of postpartum depression
Worsens and lastsover 2 weeks since having baby and
257
Postpartum depression vs postpartum blues
Postpartum blues only lasts two weeks and resolves.
258
What is postpartum psychosis
1. Occurs within 2 weeks of delivery
259
When is mirtazapine given in depression
When there is significant weight loss (it increased weight)s
260
Pharmacology of cocaine
1. Stimulator of sympathetic nervous system, by inhibiting dopamine reuptake
261
Complications of cocaine use
1. MI
2. Arrhythmia
3. Seizures
262
Symptoms of cocaine withdrawal
1. Vivid dream
2. Insomnia
3. Increased appetite
263
What structure does tryptylines effect
1. They are norephinerphinre and serotonin reuptake inhibitors that act on the LOCUS COERULEUS feels which release these into the cortex
264
Common clinical findings in Bulimia
1. Thickened skin of knuckles (russet sign) and decayed tooth enamel from forced vomiting, irregular menses
One thing that distinguishes anorexia from bullaemia is that weight is normal or over normal (above 85th percentile)
265
How is bulimia diagnosed
1. Binge eating at least once a week for three months
| 2. Coupled with weight controlling behaviours
266
How is acute autism presentation (aggression) treated
rispiridone as it is short-actiing
267
Prophylaxis in autism
SSRI
268
What is hypoactive sexual desire disorder
1. Lack of desire for sexual activity lasting over 6 months
Caused by physical illness, medications
269
How are wide QRS complexes in antidepressant side effects treated
Sodium bicarbonate
270
How is sleep-onset insomnia treated
Zolpidem helps people fall asleep
271
When do night terrors occur
Stage3 and 4 of sleep
272
What is alexithymia
Where a patient can't put their feelings into words (associated with somatisation and conversion disorder)
273
What co-morbidity is associated with autism
Epilepsy
274
What causes the complication of neuroleptic malignant syndrome
Antipsychotics
275
Signs of NMS
```
Increased body temperature >38 °C (>100.4 °F), or
Confused or altered consciousness
sweating
Rigid muscles
Autonomic imbalance
```
276
Risk factors of NMS
LEVADPOA
| Blocks d2 receptors
277
Define Mental Disorder
Any disorder or disability of the mind
278
How long does assessment for the MHA take
28 Days (section 2) - can't be renewed
279
What professionals are involved in MHA assessment
1. Two doctors - S12 and AMHP
280
What evidence is needed to assess a patient under the MHA
1. Pt is suffering from a mental disorder that warrants detention in hospital for assessment
2. The patient may be at risk of harming themselves or other people
281
How long is treatment (section 3) under the MHA
1. 6 months and can be renewed indefinitely (years)
282
What professionals are involved in treatment
1. 2 doctors and 1 AMHP
283
What evidence is needed for section 3
1. If the patient is suffering from a mental disorder or degree that makes it appropriate to be treated at hospital
2. The treatment is in his or her interest and safety to others
3. Appropriate treatment must be available
284
What is section 2 of MHA
1. Decide the patient needs further assessment and pt can be treated against consent under this act
285
What is section 4 of MHA
Emergency ORder
286
How long does sectioning under 4 of MHA last
72 Hours
287
Professionals required to order section 4
1 Doctor
| 1 AMHP
288
What evidence is required for an emergency order
1. Patient is suffering from a mental disorder of a nature that warrants hospital assessment
2. Patient ought to be detained for his or her own safety
3. There is not enough time for 2nd doctor to attend
289
What is Section 5(4)
1. For patient ALREADY admitted but wanting to leave
2. Nurses' holding power until doctor can attend
LASTS 6 hours
290
Can patients be treated under section 5(4)
No
291
What is Section 5(2)
1. For a patient ALREADY admitted but wanting leave
292
When is Section 5(2) applied
To allow time for S2 or 3 assessment
293
How long can pt be detained for section 5(2)
72 Hours
294
Can people be treated under section 5(2)
NO
295
What category are Section 135 and 136 of the mHA
1. Police Sections
296
What is S136
Person suspected of having mental disorder in a public place
297
What is S135
Needs court order to access patient's home and remove them to place of safety or further assessment
298
Onset of ADHD
12
299
Treatment of ADHD
Ritalin
300
What would be seen on an MRi of a patient with ADHD
1. Decreased frontal lobe volume
301
What are hypnogogic hallucinations
Hallucinations and paralysis occur when sleeping
302
How long does mania last
at least 7 days
Hypomania - less than 7 days
303
Characteristics of Cluster A
1. Odd or eccentric: Paranoid, Shizoid and schizotypal
304
Characteristics of Cluster B
Dramatic, emotional or erratic: Antisocial, histrionic, borderline, narcissistic
305
Characteristics of Cluster C
Anxious or fearful: Avoidant, dependant or OCD
306
How is GAD managed
1. Step 1: Active monitoring and education
Step 2: Low intensity psychological interventions (self help guides)
Step 3: High intensity (CBT) or drug treatments
Step 4: Highly specialist input
307
Side-effect of lorazepam
Anterograde amnesia
308
Side-effetcs of SSRIs
1. Hyponatraemia
2. GI bleeding
3. Citalopram can cause prolonged QT
309
What can SSRIs interact with
NSAIDs, warfarin/heparin, aspirin and triptans (avoid)
310
Symptoms of discontinuing SSRI
1. Restlessness
2. Difficulty sleeping
3. Sweating
4. GI symptoms (pain, cramp, diarrhoea)
311
Adverse effects of clozapine
1. Agrunlocytosis or neutropenia
2. Reduced seizure threshold
3. Constipation
312
Associations iwth OCD (other conditions)
1. Depression
2. Schizophrenia
3. Tourrette's
313
What class drug is Clomipramine
Tricyclcic antidepressent: Wieght gain, dry mouth.
314
Treatment of delirium tremens
Chlordiazepoxide
315
What scale can be used to assess alcohol withdrawal severity
Clinical Institute withdrawal assessment for Alcohol
316
Nam etwo screening tools toidentify patients who may have alcohol misuse issues
AUDIT
CAGE
317
What screening tool is used to assess the severity of achizophrenia
The positive and negative syndrome scale
318
Risk factors of insomnia
1. Female
2. Age
3. Unemployment
4. Divorce
319
Investigations for insomnia
1. Sleep diaries
| 2. Actigraphy
320
Advice given to people sufferingf rom insomnia
1. Do not drive if sleepy
2. Limi caffeine intake
3. No screens before bed
321
What drug is used to treat moderate/severe tardive dyskensia
Tetrabenazine
322
What is the tyramine cheese reaction
Hypertensive reactions to cheese/Marmite/ickled herring and broad beans
323
How do monoamine oxidase inhibitors work
Stops metabolism of serotonin and noradrenaline by monoamine oxidase.
324
When is clozapnie indicated for treatment resistant schziophrenia
Lack of clinical improvement after use of at least two antipsychotics for 6-8 weeks.
325
What psychotic should be used if the patient is suffering from prolactin elevation
Aripiprazole
326
Most common side effect of atypical antipsychotics
Weight gain
327
What tests should be done to monitor antipsyhoctics
1. Lipids, weight, fasting glucose, prolactin, BP, electrocardiogram.
328
Side effect of Tazadone
Sedating -used if person has insomnia
329
Side effect of venlafaxine
Raises BP
330
What is ideas of reference
When you can relate to things around you (people on TV talking about subject matter and you think they are talking about you)
331
What is a delusional perception
'there is a rainbow in the sky which means the world is going to end' - taken out of context
332
What is narrowed repertoire
Where someone cuts down on their drinking but frequency stays the same (goes from a bottle of wine and beer to just a beer)
333
How does inhibition from alcohol occur physiologically
GABA acts as an off switch for brain activity - ethanol is a GABA agonist and activates opioid receptors causing release of endorphins
Bind to nucleus accumbent and causes release of serotonin.
Blocks glutamate
334
Treatment for withdrawal
Disulfiram (deactivates acetaldehyde dehydrogenase causes hangover which deters from drinking further)
Calcium Acromposate (can be administered immediately to reestablish gaba pathways)
Naltrexone
Chlordizapeoxide
335
What is DoLS
Deprivation of liberty safeguarding: Taking civil rights of an individual because they have a lack of capacity
336
What is Lasting Power of Attorny
Allows you to appoint an attorney to manage finances.
337
Dementia vs Delirium
Global Amnesia vs Seletcive Amnesia
Acute vs Gradual
Impaired function of neutrons vs death of neurons
338
If a person is a risk to themselves and run out of the hospital; what should you do
Phone the police to section her for further assessment s(136)
339
Rapid tranquilisation
IM lorazepam and haloperidol
IM Promethizine - sedaing histamine
If that doesnt wokr, olanzapine or ariprizole (especially if CVD issues)
340
NMS can cause catatonia, what is used to treat this
Lorazepam
341
How is akathisia treated
Propranolol
342
Treatment of TR schizo
Arirprizaole and clozapine combo
343
Clinical features of serotonin syndrome
1. Neuromuscular abnormalities
2. Altered mental state
3. Autonomic dysfunction
4. Fever
5. Diarrhoea
Tremor
Agitation
CLONUS
SUDDEN ONSET
344
Treatment of serotonin syndrome
Cyproheptadine (5-HT@ antagonist)
345
Clinical Features of Psychosis
Positive Symptoms:
Hallucinations
Delusions
```
Negative:
Flattered affect
Cognitive difficulties
Poor motivation
Social Withdrawal
```
346
What pathway causes positive symptoms
Meso limbic pathways
347
What pathway causes negative symptoms
Mesocortiyal pathway
348
Side effect of olanzapine
Weight gain
349
What condition increases the risk of NMS
Lewy Body Dementia
350
Blood test results in NMS
Raised CK
351
Side effects of clozapnine
Agranulocytosis
Hyper salivation
Constipation
352
What elusions would you see in Depressive psychosis
Nihilistic delusions
353
Types of delusions in paranoid schizophrenia
1. Persecutory
2. Ideas of reference
3. Delusions of thought withdrawal
354
What antipsychotics are given to CAMHS or young women
Rispiridone
355
Safest antipsychotics with people with CVD
Aripiprazole
356
What antipsychotic is given for Parkinson's
Quetiapine or Clozapine
357
Side effects of clozapine
1. Induced bowel obstruction
| 2. Myocarditis
358
State some dynamic risk factors of suicide
Intent
Anxiety
Psychological Stress
Isolation
359
State some static risk factors of suicide
```
Age
Gender
Ethnic Group
Marital Status
Socioeconomic
```
360
What is the SADPERSONS criteria for suicide
S: Male sex → 1
A: Age 15-25 or 59+ years → 1
D: Depression or hopelessness → 2
P: Previous suicidal attempts or psychiatric care → 1
E: Excessive ethanol or drug use → 1
R: Rational thinking loss (psychotic or organic illness) → 2
S: Single, widowed or divorced → 1
O: Organized or serious attempt → 2
N: No social support → 1
S: Stated future intent (determined to repeat or ambivalent) → 2
361
Define hallucination
An experience involving an apparent perception of something not present
362
How is LD assessed
```
Information from staff and family
Obs
Symoblic understanding
Comprehension: Understanding phrases and words used in his nevironment
Expression: Naming objects
Choice making
Pragmatic profile.
```
Main: Informayion, comprehennsion and prgamatic profiel
363
Intervention for LD
Adjusting verbal communication
Strategies for developing language
Makaton: signing system to support spoken language
364
LD severities
50-70 = mild
35-49 = moderate
20-34 = severe
20 or less = profound
365
LD vs learning difficulty
Difficulty doe snot affect general intelligence while LD is overall cognitive impairment
366
What receptors generally do antipsychotics act on
D2
367
Signs and symptoms of lithium toxicity
```
Tremour
Nystagmus
Retrograde amnesia
Ataxia
Vomiting and diraahoea
Brugadda syndrome
Nephrogenic DI
Weight Gain
Change in mental state
```
368
SSRI and st john's wart can cause serotonin syndrome
N/a
369
Side-effect of SSRI
Can cause hyponatraemia and then SIADH
| Constipation/Diarrhoea/vomiting
370
Signs and symptoms of lithium toxicity
```
Tremour
Nystagmus
Retrograde amnesia
Ataxia
Vomiting and diraahoea
Brugadda syndrome
```
371
Side-effect of SSRI
Can cause hyponatraemia and then SIADH
372
Risk factors for delirium
1. Male
2. Drugs and drug-dependance
3. Alcohol dependence
4. Dementia
373
Treatment of Delirium Tremens
1. Alcohol
2. BDZ (Chlordiazepoxide)
Complication of DT is status epilepticus
374
What else can cause korsakoff's syndrome (lack of thiamine)
1. Eating disorders
| 2. Malnutrition
375
Clinical features of delirium
1. Inattention
2. Memory impairment
3. Disorientation
4. Disordered thinking
5. SLEEP DISTURBANCES
6. Mood lability
376
Huntington's psychiatric symptoms
1. Impulsivity
| 2. Psychosis
377
Effects of long term atypical antipsychotics on the body
Glucose dysregulation and diabetes: Polyuria and polydipsia.
378
What are the five stages of bereavement
DABDA:
```
Denial
Anger
Bargaining
Depression
Acceptance
```
379
When checking lithium levels, when should the sample be taken
12 hours after the first dose.
380
Treatment for tardy dyskinesia
Tetrabenazine
381
What is acute dystonia
Acute contraction of a group of muscles.
382
ECG findings in citalopram overuse
QT prolongation and Torsades de pointes.,
383
What is hoover's sign
Pressure if felt under the paretic leg when lifting the non-paretic left against pressure - used to differentiate between organic and non-organic causes of leg paresis.
384
Treatment of tricyclic antidepressant overdose/side effects
Acetylcholine esterase inhibitors (physostigmine)
385
What is the most potent benzodiazepine
Clonazepam
386
What is Stevens-Johnson syndrome
This is an Upper respiratory tract Infection which progresses to the non pruritic burning rash onto face and upper torso, can also cause inflamed oral mucosa
387
What psychiatric drug can trigger Stevens-johnson syndrome
Lamotrigine.
388
First line treatment for nephrogenic diabetes insipidus
Hydrochlorothiazide
389
What drug can cause nephrogenic diabetes inspires
Lithium
390
The immediate treatment of a paracetamol overdose
Oral activated charcoal
N-Acetylcysteine is only used a few ours after when serum levels are checked.
391
What is prosoopagnosia
Unable to identify faces due to lesions in the occipital or temporal regions
Appreceptive: Cannot perceive if the two faces are the same or different
Associative: Canot associate a face with memories but can differentiate the,.
392
Anticholinergic syndrome: Red as a beet, dry as a bone, blind as a bat, mad as a hatter and hot as a hare.
N/a
393
What is the impact of SSRIs on an ECG
Qt Elongation.
394
Pneumonic for serotonin syndrome
HARMED:
```
Hyperthermia
Autonomic Instability
Rigidity
Myoclonus
Encephalopathy
Diaphoresis
```
395
What is late neurosyphilis
This happens after 10+ years of undiagnosed neurosyphilis:
TABES DORSALIS
This Ataxia comes from generation of the dorsal roots and columns of the spinal cord, with associated back pain from this.
They lack positional sense so will life their legs really high.
396
What is blunted affect
Difficulties expressing emotions.
397
What is la belle indifference
Lack of concern shown by patients towards their symptoms
398
What are SSRIs commonly co prescribed with
PPIs.
399
How long should SSRIs be continued for
6 months
400
How is Buprenorphine given for opiate withdrawal
Sublingual.
401
What is perseveration
Repeating the same words/answers.
402
What is neologism
Making up new words.
403
Signs of Factitious Hypoglycaemia
Usually results from Patient's overuse of insulin secretagegogues (e.g., Sulfonylureas)
remember, C-Peptide -> Proinsulin -> Insulin
C-Peptide is equivalent to the amount of ENDOGENOUS insulin produced. As the patient is injecting EXOGENOUS sources for insulin, endogenous insulin and C-Peptide will be lower.
404
What is Asterixis
Flapping Tremor - Caused in hepatic failure
405
What is Kluver Bucy Syndrome
Bilateral lesions of the temporal lobes (a manifestation of meningoencephalitis)
406
Signs of Kluver Bucy Syndrome
Disease of the HYPER:
1. Hyperphagia
2. Hypersexuality
3. Hyperorality
4. Hyperdocility
Visual agnosia, aphasia and disinhibition
407
What can cause Kluver Bucy Syndrome
HSV - remember, meningoencephalitis
408
What is Torsades de Pointes
A type of tachycardia arrhythmia -> ventricular fibrillation and sudden cardiac death
409
Treatment of Torsades de Pointes
IV Magnesium Sulfate
410
How do we reverse a Benzo overdose
Flumazenil
411
How to treat tricyclic antidepressant overdose
IV Sodium Bicarbonate
412
First Line Treatment of alcohol withdrawal
Benzodiazepines or Carbamazapine
413
What is Creutzfeldt-Jakob Disease
TRIAD:
Dementia
Myoclonus
Personality Changes
414
What causes Creutzfeldt-Jakob Disease
A prion disease (incorrectly folded proteins that causes misfiling of other proteins) - Mad Cow Disease
415
Signs of Neonatal Abstinence Syndrome
```
High-pitched cry
Irritability
Hypertonia
Feeding Difficulties
Failure to Thrive
```
416
What substance usually causes neonatal abstinence syndrome
Opioids
417
What protein is found in Creutzfeldt-Jakob Disease
14-3-3
418
What medication may treat a Parkinson's patient with Parkinsonism and psychosis
Clozapine - It Is the only antipsychotic that does not affect the nigrostriatal dopaminergic system: the only one that improves parkinsonian symptoms
419
What is psychogenic polydipsia
Excessive fluid intake, causes polydipsia and polyuria. Followed by hyponatraemia
1. Increased water surpasses ADh secretion = Excess water excretion and dilute urine
2. Hyponatraemia as water intake overcomes the capacity to excrete urine
420
Pharmacology of Zolpidem and other sleeping medications
GABA receptor agonist
421
How long does it take for an SSRI to fully work
Allow up to 2 weeks, about 6 weeks to reach its optimum and take full affect.
If a patient is complaining about their SSRI before then, reassure and ask them to wait
422
What Co-morbidity is usually associated with ADHD
Oppositional Defiant Disorder
423
Key lab findings in Psychogenic Polydipsia
Normal Serum Electrolyte values and an a negative water deprivation test (osmolality increases over time)
424
What waves are visible on an EEG for nocturnal Eneuresis in children
Delta Waves - N3
425
What is characteristic about frontotemporal dementia
SUDDEN change in personality and no changes in visuospatial skills (unlike Alzheimer's)
426
What is the major side effect of Chlorpromazine
Severe Sunburns and causes blue pigmentation as if the patient is cyanotic
427
What medication is given for Narcolepsy management
Pitolisant
428
Name three typical antipsychotics
1. Haloperidol
2. Chlorpromazine
3. Anything ending in -zine.
429
Name four atypical antipsychotics
1. Clozapine
2. Olanzapine
3. Quetiapine
4. Any psychotics ending in -pine, -zole (e.g., aripiprazole) and -done.
430
How do typical antipsychotics work
Bind to D2 receptors in the mesolimbic region - REDUCING positive symptoms
Blocks D2 receptors in the mesocortical region - WORSENING negative symptoms
431
What are some positive side-effects to typical antipsychotics
1. Blocks Dopamine receptors in the chemoreceptor trigger zone - DECREASES vomiting
2. Blocks H1 Receptors - Antipruritic and Sedative
432
What are the adverse effects seen in both typical and atypical antipsychotics by binding to the tuberoinfundibulnar zone
Oligomenorrhoea
Gynecomastia
Galactorrhoea
433
How do atypical antipsychotics work
1. Blocks D2 receptors in the mesolimbic regions - REDUCING positive symptoms
2. Blocks 5-HT2 receptors in mesocortiyal system - REDUCING negative symptoms
434
What atypical antipsychotic has the least impact on weight gain
Aripiprazole
435
What are side-effects specific to atypical antipsychotics
METABOLIC SYNDROME: CV risk, Dyslipidaemia, Weight Gain, Diabetes (Polydipsia, Polyuria)
Seizures
Agronulocytosis (usually in Clozapine)
436
What is the purpose of a Section 2
Admission for Assessment: Can be medicated against your will
437
What section allows a sectioned patient to leave
A 'Section 17' leave
438
Why is a Section 4 used
It keeps the patient in hospital for 72 hours, to allow a second doctor to come and confirm if you need to be kept in - if they say yes, you will removed to a section 2 or 3 for further assessment
439
Can a patient be medicated on Section 4 against their will
No, you have the right to refuse medication
440
What is the difference between a section 2 and 3
Section 2: If the diagnoses is unclear and we don't know how to treat them
Section 3: Diagnoses is clear (pre-existing) and treatment is readily available.
441
What score on the SADPERSONS scale would indicate hospital admission
>8
6-8 = Psychiatric consultation
442
What is the difference between the pars compact and pars reticulate
Pars Compacta: Projection into the basal ganglia (supplies striatum with dopamine)
Pars Reticulata: Conveys signs from the basal ganglia to other brain structures (has GABA neurones rather than dopamine)
443
What symptoms does bitermporal lesions cause
1, Deafness
2. Apathy
3. Impaired learning and memory
4. Amnesia, Korsakoff Syndrome and Kluver-Bucy Syndrome
444
What disease causes bilateral temporal atrophy
1. Frontotemporal Dementia (Pick's)
2. HSV (meningoencephalitis) -> causes similar symptoms
3. Neurosyphilis
All result in memory loss/agnosia
445
What part of the lobe is responsible for memory
Medial Temporal Lobe (home to the hippocampus)
446
Signs of Brugada Syndrome
Caused in Lithium Toxicity:
ST-Elevation
Right Bundle Branch Block (Right ventricle depolarising normally).
447
What psyhictaric symptoms can threadworm cause
Hair-pulling disorder and pica (a compulsive need to eat non-nutritious food like ice, hair and dirt).
Pica and trichotolomania (hair pulling) is caused by iron-deficiency anaemia (if they're hypo chromic, microcytic anaemia is present, think PICA rather than OCD)
448
What PHQ score indicates Severe depression
20+
449
Onset of NMS vs Serotonin Syndrome
NMS happens over a few weeks
Serotonin Syndrome happens within hours of administration
450
Why are bentos absolutely contraindicated with opioid use
They both cause muscle relaxation = respiratory failure.
451
What causes respiratory alkalosis
Tachypnoea as CO2 is blown off, causing hypocapnia
As CO2 levels drop, there is less inhibition on albumin carrying H+ ions which release these. Albumin has free space which binds to calcium ions instead, causing hypocalcaemia.
452
What medication should women on bipolar disorder be switched to, during the course of their pregnancy
Lamotrigine
453
Name two medications that reduce prolactin levels (as opposed to raising them)
Clozapine and Olanzapine
454
What medication can cause a rise in Lithium levels
NSAIDs - DO not give for pain relief in bipolar
Give Aspirin instead
455
Sign of Carbamazepine toxicity
Ataxia
456
Treatment od Delirium (medication)
Physostigmine
457
Signs of Cocaine intoxication
REMEMBER: Hyperstimulation of the sympathetic nervous system 9ismonia, vivid dreams, tachycardia, mydriasis, HTN and sweating)
Also, Hyper-alertness and aggression
And 'COCAINE BUGS', when patients think that bugs are crawling over them
458
A main side-effect of Fluoxetine
Tremours
459
How do SSRIs affect sleep cycles
They cause REM disruption (so treatment-caused insomnia)
460
What kind of therapy is used to treat PD, behavioural problems and Schizophrenic patients
Milieu Therapy
461
What distinguishes Schizophreniform disorder over Schizophrenia
Schizophreniform disorder is basically the same, except it lasts between 1-6 months (think of it as a precursor for Schizophrenia -> most people get diagnosed with this later)
462
What antidepressant has the lowest sexual side effect (does not have a loss of libido)
Buproprion
463
Define Copropaxia
Involuntary performing of obscene or forbidden or inappropriate touching
464
Define Echopraxia
Meaningless repetition or imitation of movements
465
Describe Palilalia
Automatic repetition of one's own words, phrases or sentences
466
Define De Fregoli Syndrome
Delusion of identifying a familiar person in various people they encounter
467
Define Ekborn Syndrome
Delusion of infestation
468
GAD vs Panic Disorder
GAD has a background of persistent anxiety vs Panic Disorder which is more associated with random panic attacks on a background of no anxiety
469
What medication can precipitate serotonin syndrome from SSRIs
Rasagiline (MAO-Is)
470
Metabolic consequences of Lithium
Hyperparathyroidism (hypercalciuria, hpophosphataemia)
Hypothyroidism.
Nephrogenic Diabetes Insipidus
T wave inversion
471
When are the biological/somatic symptoms of Depression
1. Diurnal mood variation
2. Anhedonia
3. Early Morning Waking
4. Psychomotor agitation or retardation
5. Loss of appetite and weight
6. Loss of Libido
472
What is the first line management for addictions
Motivational Therapy
473
What is the first line management of an acute psychotic episode
Non-Therapeutic de-escalation
Then oral lorazepam
Then IM Lorazepam/Haloperidol + Promethazine
474
What is the first Line intervention used for someone with heart palpitations
Even in suspected anxiety, a new onset of palpitation with no real cause should be given a 48 hour ECG
475
What type of dementia has a rapid progression from mild memory loss to myoclonus, speech and language impairment
CJD
476
What are the first line medications given for mild Alzheimer's
Donepezil
| Rivastigmine
477
Side effect of Alzheimer medications donepezil and rivatstigmine
Diarrhoea
478
What is the first line intervention for acute manic episdoes
ORAL BDZs or atypical antipsychotics (not haloperidol)
479
What is characteristic about vascular dementia
Sudden deterioration and then the symptoms plateu. Then deteriorate again
480
Knight's Move vs Flight of Ideas
Knight's Move - illogical leaps between ideas
Flight of Ideas - Meaningful links, just hard to catch on to what they say
481
Describe the levels of management used for depression
If less than 5 core symptoms (NICE):
First Line: Low Intensity psychological interventions / group-based CBT
Otherwise:
Second Line: Sertraline OR CBT
482
First line management of paracetamol overdose
Activated Charcoal: Only if the patient presents <1 hour since ingestion
Otherwise, N-AcetylCysteine if taken many hours before (it has already reached the stomache)
483
What is the first investigation that should be done in a patient with gradual forgetfullness
FBC: As this rules out any reversible causes of dementia
Think simple before CT Head
484
What is Pellagra
B3 Deficiency: Dementia, Dermatitis and Diarrhoea
And a big old tongue
485
What would a lumbar puncture show for autoimmune encephalitis
Increased lymphocytes in the CSF
486
First line management of autoimmune encephalitis
IV methylprednisolone
IV Ivg
Second Line: Rituximab
487
What structure atrophies in Alzheimer's
Hippocampus
488
Sign of corticobasal degeneration
Apraxia on one side of the body - alien limb
Where the patient thinks their limb is floating about their body independently
489
First line treatment of panic disorders
CBT
490
Causes of Delirium
```
D - Drugs or Alcohol
E - Eyes, Ears, Emotional
L - Low Output states (MI, PE)
I - Infections
R - Retention (urinary)
I - Ictal
U - Underhydration/nutrition
M - Metabolic (thyroid, wernicke's, electrolyte imbalance)
```
491
Define Derailment
The conversation moves quickly from one topic to another
492
What is the first line management of opioid withdrawal
Symptomatic management only
493
What is the first line treatment of an Alzheimer's patient, experiencing QT prolongation
REMEMBER, QT elongation makes anti-cholineesterase inhibitors unsafe (so no donepezil or rivastigmine)
First Line: Cognitive Stimulation Therapy
494
What are other contraindications to anti-cholinesterase therapy in Alxheimer's
Prolonged QT
Bradycardia (<50)
Second or Third degree heart block
495
What is characteristic of Alzheimer's over all the other dementias
Early deterioration in memory (if memory is the main symptom or first symptom in the exam - think Alzheimer's)
496
What is the first line treatment of schizophrenia
Rispiridone (remember, atypical always preferred to typical like haloperidol)
497
What is the first line investigation for elderly patients, exhibiting signs of dementia, incontinence, mood swings
Urine Cultures - rule out UTIs over anything else
498
Name a first generation antihistamine
CHlorphenamine
499
What is the first line management of Lithium Toxicity
Fluid Resuscitation (remember, can cause nephrogenic DI)
500
How is methadone given
Orally
501
What organic disorders can mimic schizophrenia
Hyperparathyroidism
Hyperthyroidism
Infections, brain disease and CNS
Steroids
502
What is interpersonal therapy
Primarily focuses on the way our relationships affect us (great for postpartum depression)
503
What are the clinical signs for referring syndrome
Confusion
Tachycardia (Hypokalaemia)
Oedema (loss of phosphates)
504
What blood level is Lithium considered severe
2.0
505
What is found in Pcik's disease at post-mortem
TAU proteins that stain silver
506
What are the three core symptoms of GAD
Apprehension
Motor Tension
Autonomic Overactivity
507
What is formal thought disorder
The inability to express thoughts in an organised way
508
What antidepressant is contraindicated in heart disease
Tricyclic Antidepressants
509
Side effect of memantine
Can Cause Seizures
510
What hormone contributes to referring syndrome
A rise in insulin
511
What is the first line pharmacological treatment of a manic episode
ORAL Antipsychotics with mood stabilising properties: Quetiapine, Haloperidol, Rispiridone, Olanzapine, Aripiprazole
+ Psychological interventions
512
What drug classes cause delirium in the elderly
1. BDZs
2. Opitates
3. Antiparkinsonian agents
4. Tricyclic antidepressants
5. Digoxin
6. Beta blockers
7. Steroids
8. Antihistamines
513
What is DBT
To recognise extreme emotions by letting patients experience, recognise and accept them
514
What is comorbid PTSD
PTSD + another disorder (usually alcohol use disorder)
515
If someone is presenting with bipolar depression and refusing to take lithium, what should be given
Offer fluoxetine + Olanzapine
Or Quetiapine on it's own
Or Second line lamotrigine, Sodium Valproate
This is because quetiapine and olanzapine are mood stabilising antipsychotics
516
If Lithium is at maximum level for bipolar disorder, what should be done
Add Olanzapine + Fluoxetine
Or Quetiapine on it's own
OR second line, lamotrigine, valproate etc
517
How often does someone's lithium levels have to be observed
Every 3 months for the first year
Every 6 months after that
518
A characteristic of olanzapine
Sedating
519
Why is Haloperidol given as second line rapid tranquillisation
Given alongside IM Promethazine
Because Haloperidol can be given both as oral and IM
Rispiridone is only found as oral
ONLY DONE IF ORAL IS NOT POSSIBLE
520
In what form are Quetiapine and Clozapine given
PO
521
Barbituates vs BDZ
BarbiDURATES increase duration + FREndodizapines increase frequency of chloride channel opening
522
How does Acromposate reduce craving
Enhances GABA transmission, reducing craving
523
Pharmacology of Naltrexone
Opioid antagonist - reduces pleasurable affect of alcohol
524
Pharmacology of Disulfiram
Causes build up of acetaldehyde - causing hangovers
525
What is an absolute contraindication to ECT
Raised Intracranial Pressure
526
How do SSRIs affect BDZs
They enhance the concentration of BDZs
527
What is the first line treatment of Delirium
PO Haloperidol 0.5mg
528
What is the first line management of PTSD
CBT
Then EMDR
529
How often should thyroid and renal function be checked on Lithium
Every 6 months
530
What PHQ score is normal
0-4
531
What PHQ score is mild
5-9
532
What PHQ score is moderate
10-14
533
What PHQ score is Moderate - Severe
15-19
Severe = 20+
534
What is the first line management of assisted withdrawal from alcohol
Chlordiazepxide
Delivered either:
Inpatients: >30 units a day, comorbidities or 15-30 minutes gap between drinks
Community if these do not apply
535
What are extracampine hallucinations
Hallucinations beyond realm of possibility
536
What are lilliputian hallucinations
Seen in delirium tremens - seeing lots of small people
537
What is the significance of an AUDIt score, why is it used
To determine if a patient should be hospitalised or be kept and treated in the community
538
In what people is lithium contraindicated or avoided in
1. History of brugadda syndrome and DI
2. Cardiac disease associated rhythm disorders
3. Elderly (reduce dose)
4. Epilepsy (causes seizures)
5. Receiving ECT (causes seizures)
6. Breastfeeding
7. Those who refuse regular blood tests
539
What is the initial adverse effects of Lithium
1. FINE tremours
2. Polyuria and Polydipsia
3. Nausea, diarrhoea, vertigo
4. Feeling dazed
In long term, fine tremors become COARSE tremors
540
What drugs can interact with Lithium
1. Diuretics
2. NSAIDs
3. Haloperidol
4. Carbamazepine
5. Antidepressants
6. ACEi
7. Drugs that prolong QT-interval
541
How often does Clozapine need to be monitored for
Every week for 18 weeks
542
What Questionnaire is used to check for Autism
AQ-10
543
Criteria for ADHD
1. Meet the diagnostic criteria of ICD-10
| 2. Occur in 2 or more important settings
544
Do people with ADHD have to tell the DVLA
Yes
545
At what age are medications for ADHD recommended
>5 Years
546
What should be done in an individual with ADHD, suffering from an acute manic episode
Stop any medication for ADHD
547
How often should height be measured in people with ADHD
Every 6 months
548
Other than height, what other things need to be monitored in children with ADHD
Weight every 3 months <10 years
549
Name some side effects of ADHD stimulants
1. Cardiotoxicity
2. Height restriction and Weight loss
3. TICS
4. Sexual Dysfunction
5. Seizures
6. Sleep problems
550
What is second line treatment of Bipolar disorder
Sodium Valproate -> Then Lamotrigine (especially for women)
551
How long is haloperidol given for delirium
Usually about one week
552
What is the first line management for bullaemia nervosa in adults
Focused self-guided programmes
Then CBT-ED, but doesn't usually have an impact on body weight
553
What is the first line management of bullaemia for children
Bullaemia-nervosa focused family therapy
554
First line management of anorexia nervosa in adults
1. CBT-ED
2. Maudsley Anorexia Treatment for Adults
3. Specialist Supportive Clinical Management
555
First Line management of anorexia in children
Family Focused Therapy
556
First line treatment for children with a first episode of psychosis
1. Oral antipsychotic medication + psychological interventions (CBT + Family Therapy or Arts Therapy)
This is the same for recurrent episodes
557
When is Arts Therapy indicated for schizophrenia or psychosis
Helps to alleviate negative symptoms
558
First Line intervention for a first episode of psychosis in adults
NO antipsychotics unless inpatient
559
If Clozapine is not working in schizophrenia, what should be done
Add a second antipsychotic to augment the treatment (should not compound the common side effects of clozapine)
560
First Line SSRI to give if on Warfarin/Heparin
Mirtazapine or Venlafaxine
561
Complication of using Lithium + NSAIDs
Kidney Damage
562
Complication of using Lithium + Diuretics
Dehydration
563
Are seizures common in delirium tremens?
No, they do not form the criteria for delirium tremens - this happens in the first 24-48 hours after stopping drinking
564
What are indications for in-patient medical detoxification
1. Severe withdrawal symptoms
2. Older age
3. High Severity of Dependance
4. Abnormal LFTs
5. Previous BDZ use as they may be develop tolerance
565
Give an example of a 12-step programme for substance management
Alcoholics Anonymous
566
What SSRI is used in the management for alcohol induced depression as part of the nicotine replacement therapies
Buproprion
567
What defines severe cognitive function on a MMSE
<10
568
What is moderate cognitive decline on an MMSE
10-20
569
When does Memantine become the first line drug treatment for Alzheimer's
Severe Alzheimer's (MMSE <10)
570
What psychiatric disorders are most commonly associated with epilepsy
Depression and Anxiety
571
What is Anterograde memory loss
Loss of memory from head injury to resumption of normal memory
572
What part of the MMSE is used to check for semantic memory loss
Using dates for WW2
573
How do we test attention in MMSE
Spell WORLD backwards
574
What antipsychotics increase the risk of Strokes and Falls in the elderly
Second generation antipsychotics
575
When is agitation of delirium worse
AT night
576
What co-morbidities are found in ADHD
1. BPD
2. OCD
3. Substance misuse disorders
4. Depression
577
What is Anankastic Personality Disorder
An An OCD-type personality disorder with excessive doubt + caution and preoccupation to details
578
What is the problem of smoking when being given antipsychotics
They increase the metabolism of antipsychotics (e.g., Clozapine), making them sub-therapeutic
579
How is life expectancy affects din psychotic disorders
Reduced by 15-20 years
580
What is the first line management of clozapine induced DM in Schixophrenia
Metformin
581
What kind of obesity is seen in atypical antipsychotic use
Central, must measure waist circumference
582
What complication of DM is seen in Schizophrenic patients
DKAs
583
Medical indications for admitting someone with anorexia
1. BMI <13
2. Syncope
3. Postural myopathy
4. Electrolyte imbalances
5. Hypoglycaemia
6. Petechial Rash + Low platelets
584
What symptoms is commonly seen in chronic fatigue syndrome
Post-Exertion fatigue
585
What receptors are involved in causing tremours
Dopaminergic receptors
586
What interacts with Lithium
NSAIDs
ACEi
These increase Lithium levels and cause toxicity
587
What receptors cause GI upset with SSRIs
5-HT3 stimulation
588
What is psychoanalysis and psychodynamic psychotherapy
These focus on an individual's maladaptive functioning in the present that may have developed from early life experiences
589
Define displacement
Constant frustration in X, is expressed as aggression or agitation towards Y
