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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Give the sections you might ask about in a psychiatric history?

A

Presenting Complaint, Past Psychiatric History, Family History, Personal History, Past Medical History, Drug History, Forensic History

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2
Q

What types of assessment might you do during or after a psychiatric history?

A

Mental State Assessment
Physical Examination
Risk Assessment

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3
Q

What might you ask about in family history?

A

Any relatives had problems similar to this? Mental health problems? Seen psychiatrist? Are parents alive/any medical conditions? What is relationship with parents like?

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4
Q

What might you ask in personal history?

A 
Birth and early development
School - social and academic
Home environment - childhood and now
Qualifications
Relationships (including sexual experiences)
Children + family
Work
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5
Q

What might you ask about past medical history?

A 
Medical conditions
Admissions to hospital
Surgery
Trauma e.g. head injuries, road accidents, self harm
Side effects from medication
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6
Q

What might you ask about in drug history?

A

Current medication + compliance, side effects
Allergies
Illicit drug use - how much/long, what, when, how, why
Alcohol consumption - how much/long, often, dependency?

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7
Q

When would you do the Mental State Exam?

A

During history, but may need to ask specific questions afterwards to clarify

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8
Q

What are the components of the Mental State Exam?

A 
ASEPTIC
A = appearance and behaviour
S = speech
E = emotions/affect/mood
P = perceptions/hallucinations
T = thoughts/delusions
I = insight
C = cognition
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9
Q

What are you looking for in appearance as part of the MSE?

A 
eye contact
dress
psychomotor agitation/retardation
self-care
distractibility
cooperability
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10
Q

What are you looking for in their speech during MSE?

A

Speed
Volume
Language
Neologisms, punning, clanging

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11
Q

What is a neologism?

A

Inventing new words to describe something

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12
Q

What is clanging?

A

Changing thought pattern through rhyme

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13
Q

What is the difference between mood and affect?

A 
Mood = subjective/patient's own view
Affect = objective/professional's opinion
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14
Q

What do you assess for thoughts/delusions in MSE?

A

Content (obsession, preoccupation, delusion, over-valued idea)
Form (circumstantial, tangential, loosening of association)
Stream (poverty, racing, perseverative, thought insertion/withdrawal/broadcast)

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15
Q

What might you assess about perceptions in MSE?

A

5 senses: visual, auditory, olfactory, gustatory, tactile

If auditory - content, 2nd or 3rd person, command

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16
Q

How might you assess cognition?

A

Level of assessment guided by Hx and MSE
MMSE - but does not assess frontal
Formal cognitive assessment e.g. ACE-III

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17
Q

What different things might you look for in a general psychiatric risk assessment?

A 
Harm to self or others
Suicide risk
Vulnerability to exploitation
Risk to children
Self-neglect
For above: how likely? how soon? how bad?
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18
Q

What are the five Ps in formulation?

A

1) presenting problem
2) predisposing factors
3) precipitating factors
4) perpetuating factors
5) protective factors

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19
Q

What is the lifetime prevalence of mental illness?

A

1 in 4

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20
Q

What is the incidence of suicide in the UK? What is the proportion between men and women?

A

11.2 per 100 000. 75% men, 25% women

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21
Q

What is the point prevalence of mental illness?

A

1 in 6

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22
Q

What percentage of people with long term conditions in the UK have mental health problems?

A

30%

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23
Q

List the common affective disorders

A

Depression
Bipolar
Cyclothymia

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24
Q

What is the prevalence of depressive episodes?

A

2.6% (slightly higher in females than males)

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25
Q

What is the prevalence of mixed anxiety and depression?

A

11.4% (slightly higher in females than males)

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26
Q

What proportion still have depressive symptoms a year after first presenting?

A

50%

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27
Q

What proportion of people with depression have recurrent depression (another episode)?

A

50%

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28
Q

How much does depression increase mortality risk from physical illness?

A

50% increased risk (causes include CVD, cancer, metabolic, respiratory disease)

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29
Q

What are the 3 core symptoms of depression?

A
  1. Low Mood
  2. Low energy (anergia)
  3. Low pleasure/interest (anhedonia)
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30
Q

List non-core symptoms of depression

A

Change in appetite (decrease/increase)
Change in sleep (classically early morning waking)
Poor concentration
Change in libido
Diurnal mood variation (depression worse in morning)
Agitation
Guilt - past
Worthlessness/lack of confidence - present
Hopelessness - future
Suicidal ideation

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31
Q

Give diagnostic criteria for mild depression in first episode

A

at least 2 core symptoms + at least 2-3 other symptoms
No symptoms should be present to an intense degree
Minimum duration 2 weeks

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32
Q

Give diagnostic criteria for moderate depression in first episode

A

At least 2 core symptoms + at least 4 other symptoms
Functioning affected, symptoms to marked degree, but may be mild if wide range of symptoms
Minimum duration 2 weeks

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33
Q

Give the diagnostic criteria for severe depression in first episode

A

All 3 core symptoms + at least 4 other symptoms (usually several, some of which will be severe intensity)
Somatic syndrome almost always present
Marked loss of functioning, suicidal
Minimum duration 2 weeks (but if rapid onset and particularly severe, may diagnose earlier)

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34
Q

Give diagnostic criteria for severe depression with psychosis

A

Meets criteria for severe depression +
hallucinations, delusions or depressive stupor (psychomotor retardation can progress to stupor)

Classify psychotic symptoms as mood congruent or incongruent (typically congruent - nihilistic, guilty, derogatory)

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35
Q

Give incidence of post-natal depression in women after childbirth

A

13% (and is leading cause of mortality for women post-partum)

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36
Q

What is the difference between Bipolar I and Bipolar II and Rapid Cycling?

A

Bipolar I = both mania and depression (sometimes only mania)
Bipolar II = more episodes depression, only mild hypomania (often misdiagnosed as recurrent depression)
Rapid cycling - each episode only lasts few hours/days

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37
Q

What should you always screen for if someone presents with depressive history?

A

Mania

Psychosis

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38
Q

Describe the features of cyclothymia

A

Persistent instability of mood with numerous episodes of depression and mild elation (neither severe enough to be bipolar affective disorder or recurrent depressive disorder)

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39
Q

Describe features of dysthymia

A

Chronic depression of mood often lasting several years, not sufficiently severe, or episodes not lasting long enough to be depressive disorder

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40
Q

Give the features of hypomania

A 
4+ days duration
Elevated mood (euphoric, dysphoric, angry)
Increased energy
Increased talkativeness
Poor concentration
Mild reckless behaviour
Sociability/overfamiliarity
Increased libido/sexual disinhibition
Increased confidence
Decreased need to sleep
Change in appetite
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41
Q

Give the features of mania

A 
>1 week
Extreme elation/uncontrollable
Over-activity
Pressure of speech
Impaired judgement
Extreme risk-taking
Social disinhibition
Inflated self-esteem, grandiosity
With psychotic symptoms - mood congruent/incongruent
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42
Q

List the common differentials for psychosis

A 
Schizophrenia
Delusional disorder
Schizotypal disorder
Depressive psychosis
Manic psychosis
Organic psychosis
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43
Q

What is the lifetime risk of having schizophrenia?

A

1%, equal male and female

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44
Q

When is the common age of onset for schizophrenia?

A

2nd-3rd decade with 2nd peak in late middle age

Men tend to get earlier, women get another peak post-menopausal

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45
Q

How does schizophrenia affect mortality?

A

Life expectancy 25 years less
Increased risk of suicide
Increased risk of CVD, resp, infection

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46
Q

What are the first rank symptoms of schizophrenia?

A

Thought alienation
Passivity phenomena
3rd person auditory hallucinations
Delusional perception

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47
Q

What are the second rank symptoms of schizophrenia?

A 
Delusions
2nd person auditory hallucinations
Hallucinations in any other modality
Thought disorder
Catatonic behaviour
Negative symptoms
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48
Q

Give some positive psychotic symptoms

A 
Hallucinations
Delusions
Passivity phenomena
Thought alienation
Lack of insight
Disturbance in mood
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49
Q

Give some negative psychotic symptoms

A 
Blunting of affect
Amotivation
Poverty of speech or thought
Poor non-verbal communication
Clear deterioration in functioning
Self-neglect
Lack of insight
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50
Q

How many first and second rank symptoms do you need to diagnose schizophrenia?

A

First rank = >1

Second rank = 2+

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51
Q

What is schizotypal disorder?

A

Eccentric behaviour, anomalies of thinking like schizohprenia but no definite schizophrenic anomalies
Symptoms only when stressors present
Cold or inappropriate affect
Anhedonia
Tendency to social withdrawal, paranoid or bizarre ideas (not true delusions), obsessive ruminations
Thought disorder
Transient quasi-psychotic episodes
Delusion-like ideas without external provocation
No definite onset/evolution, course like personality disorder

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52
Q

Give some examples of anxiety disorders

A 
Generalised anxiety disorder
Phobic disorders
Panic disorder
Mixed anxiety and depressive disorder
Obsessive compulsive disorder
Post traumatic stress disorder, acute stress reaction, adjustment disorder
Dissociative disorders
Somatoform disorders
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53
Q

Give some features of generalised anxiety disorder

A

Persistent and generalised anxiety, not restricted to certain circumstances
>6 months
Tiredness
Poor concentration
Irritability
Muscle tension, palpitations, epigastric discomfort
Disturbed sleep (usually insomnia rather than EMW)

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54
Q

Give some physical features of panic disorder

A 
Palpitations
Chest pain
Choking
Tachypnoea
Dry mouth
Urgency of micturition
Dizziness
Blurred vision
Paraesthesiae
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55
Q

Give some psychological features of panic disorder

A 
Feeling of impending doom
Fear of dying
Fear of losing control
Depersonalisation
Derealisation
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56
Q

What is depersonalisation?

A

Feeling outside of one self, observing thoughts and actions from a distance

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57
Q

What is derealisation?

A

Feeling like the world around you isn’t real or seems “foggy” or “lifeless”

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58
Q

Give some features of OCD

A

Obsessive/recurrent thoughts, images, compulsions
Often unpleasant, repetitive, intrusive, irrational
Recognised as patient’s own thoughts
Compulsive acts - stereotyped behaviours repeated, not pleasant, not to complete useful task, often to prevent unlikely harmful event
Patient often aware that acts are pointless, but does them to prevent anxiety - if resists acts, anxiety gets worse

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59
Q

Give some criteria to define personality

A 
Enduring pattern inner experience and behaviour
Deviates from cultural expectations
Pervasive and inflexible
Onset adolescence/early adult
Stable over time
Mode of relating to others
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60
Q

What about a personality makes it a personality disorder?

A

Leads to distress

Impairments in self and interpersonal functioning

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61
Q

Give the 3 different clusters for personality disorder types

A

Cluster A - “odd, eccentric”
Cluster B - “emotional, erratic”
Cluster C - “anxious/fearful”

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62
Q

What personality disorders fall under Cluster A?

A

Schizoid
Paranoid
Schizotypal

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63
Q

What personality disorders fall under Cluster B?

A

Emotionally unstable (borderline)
Histrionic
Dis-social/antisocial
Narcissistic

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64
Q

What personality disorders fall under Cluster C?

A

Obsessive-compulsive
Dependent
Avoidant

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65
Q

What is the most common personality disorder and what are its two sub-types?

A

Emotionally Unstable Personality Disorder (EUPD)

  1. Impulsive
  2. Borderline
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66
Q

What are the features of EUPD (impulsive)?

A

Unstable/capricious mood

Acts without thinking of consequences

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67
Q

What are the features of EUPD (borderline)?

A

Impulsive attributes (unstable mood, impulsive acts)
chronic feeling emptiness
Feelings of self-harm, suicide
Fears of abandonment
Intense/unstable relationships
Uncertainty regarding self-image, aims, preferences
Transient stress-related paranoia, dissociation, intense anger, PTSD

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68
Q

Give some reasons for self-harm in BPD

A

To relieve psychic pain, feel concrete pain, inflict punishment, reduce anxiety, feel in control, express anger, feel something when feeling numb, seek help, keep away bad memories

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69
Q

What is the management for EUPD?

A
  1. Psychotherapy - Dialectical Behavioural Therapy (DBT), therapeutic community approaches
  2. Medication for comorbidities if appropriate
  3. Structured Clinical Management - emphasis problem solving, crisis management
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70
Q

What is the prognosis for EUPD patients?

A

1 in 10 will commit suicide - worse if comorbidities and substance misuse
Impact and suicide risk greatest in early adulthood
Short-medium term outcome poor, longer term more positive

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71
Q

How is an illusion different from a hallucination

A

Illusion - misperception of an external stimulus

Hallucination - Perception without the presence of external stimulus

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72
Q

What type of hallucination is a first rank symptom of schizophrenia?

A

3rd person auditory hallucinations

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73
Q

What is the more common reason for visual hallucinations?

A

Organic episodes (often acute)

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74
Q

What causes are more common for olfactory, gustatory and tactile hallucinations?

A

Organic episodes
Olfactory and gustatory common as prodromal symptoms of temporal lobe epilepsy
Tactile sensations - more common in drug and alcohol withdrawal

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75
Q

What is a functional type of hallucination?

A

When a stimulus in one sensory modality triggers a hallucination in the same modality

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76
Q

What is a reflex type of hallucination?

A

Stimulus in one sensory modality triggers a hallucination in a different modality

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77
Q

What is an extracampine type of hallucination?

A

Hallucination outside of sensory field/physically impossible hallucination

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78
Q

What is a hypnagogic hallucination? Is it normal?

A

Hearing voices when falling asleep, normal and common - 1 in 3 people experience these

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79
Q

What is a hypapompic hallucination?

A

Hearing voices when waking up - less common than hypnagogic

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80
Q

What are the 4 sub-categories of thought disorders?

A

Disorders of Stream of Thought
Disorders of Possession of Thought
Disorders of Content of Thought
Disorders of Form of Thought

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81
Q

What is flight of ideas?

A

Thinking/speaking quickly, jumping from one point to another, but there is logical connectivity between points

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82
Q

What is circumstantiality?

A

Knows point to make, but goes round and round before getting to the point

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83
Q

What is tangentiality?

A

Goes off on a tangent in thought and does not make it to final point

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84
Q

What is perseveration?

A

Answering different questions with the same answer without it making sense

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85
Q

What is thought blocking?

A

Loses train of thought - which can be normal. May not be able to pick up line of thought once reminded

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86
Q

What is thought insertion?

A

Believes an external agency is placing thoughts in their head

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87
Q

What is thought withdrawal?

A

Believes external agency is taking thoughts out of their head

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88
Q

What is thought broadcast?

A

Believes their thoughts are being broadcasted to everyone

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89
Q

What is a delusion?

A

Firmly held thought/belief outside of social norm that is unshakeable, not deterred when provided evidence against it

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90
Q

What is an over-valued idea?

A

Firmly held belief, but is shakeable when given contrary evidence

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91
Q

Give 3 types of primary delusion

A
  1. Delusional Mood
  2. Delusional Perception
  3. Sudden delusional idea (autochthonous delusion)
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92
Q

What is a delusional mood?

A

Has strong conviction/feeling that something is not right, but cannot tell what it is, feeling comes out of nowhere

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93
Q

What is a delusional perception?

A

True perception of a stimulus evokes a delusional interpretation - adds new meaning often of personal significance to patient

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94
Q

What is a sudden delusional idea?

A

Sudden primary delusion with no stimulus/trigger. Also called autochthonous delusion

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95
Q

List some different types of delusion

A

Persecutory, Grandiose, Infidelity, Love, Religious, Guilt, Self-referential, Nihilistic, Poverty, Hypochondriacal, Misidentification

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96
Q

What is another name for infidelity delusion? What do they believe?

A

Othello’s delusion - believes partner is cheating

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97
Q

What is another name for love delusion? What do they believe?

A

Erotomania/De Clerembault - believes person that is unattainable is in love with them

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98
Q

What is a self-referential delusion?

A

Believes that actions/words/insinuations are aimed at them when they may not be

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99
Q

What is another name for nihilistic delusion? What does the delusion often involve? When might this delusion present? Prognosis?

A

Cotard’s syndrome - believes they are non-existent, dying, insides are rotting
Usually in severe depression
Prognosis usually good

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100
Q

Give 3 types of misidentification delusion and briefly describe what they involve

A

Capgras - believes someone they know has been replaced by imposter
Fregoli - believes different people are the same person in disguise
Intermetamorphosis - believes swapped bodies with someone else “Freaky Friday”

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101
Q

What is loosening of association?

A

No sense or association between points of thought/speech

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102
Q

What is dissociative amnesia?

A

Sudden memory loss during episodes of extreme trauma

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103
Q

What is confabulation? What cause is more common?

A

Short-term memory not good so fills in gaps with false stories that they believe are true
More common in organic pathology e.g. Korsakoff syndrome

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104
Q

What is anhedonia?

A

Inability to feel pleasure

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105
Q

What is apathy?

A

Lack of energy/motivation

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106
Q

What is incongruity of affect?

A

Affect/appearance of mood to others does not fall in line with thoughts or internal emotions

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107
Q

What is blunting of affect?

A

Reduced ability to express emotions

Can be due to meds, as well as disorders

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108
Q

What is conversion?

A

Type of somatic disorder involving central nervous system under voluntary control

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109
Q

What is somatic disorder?

A

Unconscious transposition of psychological conflict into somatic sensory or motor symptoms

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110
Q

What is Belle Indifference?

A

Lack of concern or feeling indifferent about a physical symptom - often associated with conversion

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111
Q

What is passivity phenomena? Give 3 examples

A

When the person does not feel in control of their own actions/feelings/drives.
E.g. somatic passivity, made act/feel/drive, catatonia

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112
Q

What is somatic passivity?

A

Feels as thought somebody has control over their body

113
Q

What is made act/feel/drive?

A

Made act - believes someone is in control of their actions
Made feel - believes someone is in control of their feelings
Made drive - believes someone is in control of their drives

114
Q

What is catatonia?

A

A state of excited or inhibited motor activity in the absence of a mood disorder or neurological disease

115
Q

What is waxy flexibility?

A

Patient’s limbs feel like wax or lead when moved and stay in same position they are left in. Found in catatonic schizophrenia and structural brain disease

116
Q

What is echolalia?

A

An automatic repetition of the words heard

117
Q

What is echopraxia?

A

An automatic repetition of the movements made by examiner/other person

118
Q

What is logoclonia?

A

Repetition of the last syllable of a word

119
Q

What is negativism?

A

Motiveless resistance to movement

120
Q

What is palilalia?

A

Repetition of a word over and over with increasing frequency

121
Q

What is verbigeration?

A

Repetition of one or more sentences/strings of words, often in a monotonous tone

122
Q

What is concrete thinking?

A

Taking things literally

123
Q

What is a mental disorder?

A

Any disorder/disability of the mind excluding drug and alcohol use

124
Q

What is a S12 approved doctor?

A

A medically qualified doctor recognised under section 12 of the MHA with specific expertise in mental disorder and additional training in application of the Act

125
Q

What is an Approved Mental Health Professional (AMHP)?

A

From range of professions and authorised by local authority to carry out functions of MHA on their behalf e.g. sectioning

126
Q

Give some underlying principles of the Mental Health Act 1983

A 
Respect for patient's past and present wishes
Respect for diversity
Minimising restrictions on liberty
Involvement of patients in their own care
Avoidance of unlawful discrimination
Effectiveness of treatment
Parent/carer/relative's wishes
Patient wellbeing and safety
Public safety
127
Q

What is Section 2 of the MHA used for?

A

For Assessment!

treatment can be given without patient’s consent

128
Q

What is the duration of Section 2?

A

28 days, non-renewable

Patient can leave after 24 hours if section not approved by relevant professionals within this time

129
Q

Who is required to complete a Section 2 of MHA?

A 
2 doctors (at least one of which S12 approved)
1 AMHP
130
Q

What evidence is required for Section 2 of MHA?

A
  1. Patient suffering from mental disorder of nature/degree that warrants detention for hospital assessment
  2. Patient ought to be detained for his/her own safety OR protection of others
131
Q

What is the purpose of Section 3 of the MHA?

A

For treatment

132
Q

What is the duration of Section 3 of MHA?

A

6 months, renewable

133
Q

Who is required for Section 3 of MHA?

A

2 S12 doctors

1 AMHP

134
Q

What evidence is required for Section 3 of MHA?

A
  1. Patient has mental disorder of nature/degree that warrants hospital admission for treatment
  2. Treatment is in interests of his/her health/safety OR safety of others
  3. Appropriate treatment must be available for patient
135
Q

What is the purpose of Section 4 of MHA?

A

Only for “urgent necessity” when waiting for 2nd doctor would lead to undesirable delay - for patient not already admitted

136
Q

What is the duration of Section 4 of MHA?

A

72 hours

137
Q

Who is required for Section 4 of MHA?

A

1 doctor

1 AMHP

138
Q

What evidence is required for Section 4 of MHA?

A
  1. Patient has mental disorder of nature/degree that warrants hospital admission for assessment
  2. Detained for his/her own health and safety OR protection of others
  3. There is not enough time to wait for second doctor to attend
139
Q

What is the purpose of Section 5(2) of MHA?

A

To detain a patient ALREADY admitted in hospital (general or psychiatric) but wanting to leave. Allows time for Section 2 or 3, and if not able to coercively treat

140
Q

What is the duration of Section 5(2) MHA?

A

72 hours

141
Q

Who can carry out Section 5(2) of MHA?

A

Any registered medical practitioner (F2 or above), responsible for and knows the patient

142
Q

What is the purpose of Section 5(4) of MHA?

A

To detain a patient ALREADY admitted in hospital but wanting to leave, cannot be treated coercively, to allow time until doctor can attend

143
Q

What is the duration of Section 5(4) of MHA?

A

6 hours

144
Q

Who carries out Section 5(4) of MHA?

A

Nurses responsible for/know the patient

145
Q

What is the purpose of Section 135 of MHA?

A

To allow police to enter patient’s home and take them to a place of safety until further assessment by doctor and AMHP - requires warrant to enter home from magistrate/court

146
Q

What is the duration of Section 135 of MHA?

A

36 hours

147
Q

Who grants a Section 135 of MHA?

A

Magistrate - often requested by social worker, healthcare professional or police in emergency

148
Q

What is the purpose of Section 136 of MHA?

A

To remove a person from a public place and take them to a place of safety to await further assessment by doctor and AMHP

149
Q

What is the duration of Section 136 of MHA?

A

24 hours (but extendable up to another 12 hours for clinical reasons)

150
Q

Who grants a Section 136 of MHA?

A

Police

151
Q

Where can Sections 2, 3 and 4 be done?

A

anywhere except for prison

152
Q

What are the 4 components used in CBT?

A

Thoughts, Emotions, Bodily Sensations, Behaviours

153
Q

What is the purpose of section 37?

A

Hospital order - used in forensic psychiatry where crime is thought to be due to mental disorder, to move from prison to hospital for treatment

154
Q

Who orders a section 37?

A

Crown court

155
Q

What section may be given in forensic psychiatry as a restriction order?

A

Section 41 - Ministry of Justice controls movement

156
Q

What is section 35?

A

Crown court order for assessment of prisoners for mental disorder for 28 days

157
Q

Within what time frame must an appeal against Section 2 be made?

A

14 days

158
Q

What is Section 17?

A

Leave from hospital, with conditions placed by professionals, can be called back to hospital at any time

159
Q

What is a community treatment order?

A

Hospital leave under certain conditions, and will be called back or revoked if not taking medications/meeting conditions. Assigned care coordinator. If break conditions, may be detained for up to 72 hours while decision is made

160
Q

What’s an SOAD service?

A

Second Opinion Appointed Doctor service
Safeguards rights of patient under MHA, if patient lacks capacity to consent to treatment e.g. 3 months treatment without consent, but still not well enough to consent to further treatment

161
Q

Where is counselling usually done? What are typical features of counselling?

A

Usually in primary care
Short duration
Patient comes up with own answers

162
Q

What is cognitive analytical therapy a combination of?

A

CBT and psychoanalytical therapy

163
Q

What form of psychotherapy is often used in personality disorders?

A

Dialectical Behavioural Therapy (DBT) - for intense emotions, to help you understand and accept difficult feelings

164
Q

What are the 3 different types of family therapy?

A

Structural - how they interact
Systemic - therapist observes (unseen behind mirror), then comments
Strategic - therapist forms strategies with clear goals within family context

165
Q

What are some contraindications for psychotherapy?

A

Lack of motivation
Lack of psychological insight
Complex mental health needs or learning difficulties
Antisocial characteristics

166
Q

What is attachment theory?

A

A person needs stable relationship with at least one primary caregiver for successful social and emotional development + regulation of feelings

167
Q

How do MAO-Is work as anti-depressants?

A

Inhibit degradation enzyme (monoamine oxidase) from breaking down noradrenaline and dopamine. NAd and DA increase

168
Q

Why might dietary restrictions be put in place when taking MAO-Is for depression?

A

MAO breaks down tyramine in the gut, MAO-Is decrease MAO action, causing build up of tyramine. High tyramine levels can cause a spike in blood pressure requiring emergency treatment. Therefore should avoid eating foods rich in tyramine

169
Q

Give examples of foods high in tyramine

A 
Aged foods! - encourage fresh food instead
Over-ripe or dried fruits
Strong or aged cheese
Cured, smoked or processed meats
Pickled or fermented foods
Alcohol
Snow peas/broad beans/soybeans
Sauces - soysauce, teriyaki, shrimp sauce
Improperly stored/spoiled foods
170
Q

What monitoring might you do for a patient on MAO-Is?

A

Blood pressure - risk of postural hypotension or hypertensive responses

171
Q

How quickly should you withdraw MAO-I treatment?

A

Withdrawal symptoms may occur on cessation so withdraw slowly
Withdraw over 4 weeks (or longer if show withdrawal symptoms)
Withdraw over 6 months if on long-term maintenance treatment

172
Q

Give some examples of MAO-Is

A

Tranylcypromine
Phenelzine
Isocarboxazid

173
Q

What is the monoamine hypothesis?

A

Depression is caused by reduced monoamines (serotonin, norepinephrine, dopamine) in central nervous system

174
Q

What is the mechanims of action of tricyclic antidepressants?

A

Increase monoamines by blocking transporters 5HT.
Also agonises anti-cholinergic receptors and antihistaminergic receptors.
Antagonises a-1 adrenergic receptors

175
Q

Why are tricyclic antidepressants not first line treatments for depression anymore?

A

Higher risk if overdose taken (serotonin syndrome)
More side effects - e.g. postural hypotension, drowsiness, urinary retention, hallucinations, tachycardia, arrhythmias, blurred vision, dry mouth

176
Q

What is the mechanism of action for SSRIs?

A

Acts on 5HT receptors to reduce reuptake of serotonin, raising serotonin levels

177
Q

Give some side effects of SSRIs and why

A

Side effects due to other 5HT receptors in body being blocked e.g.
Nausea, vomiting, GI upset/bleeding
Also monoamines - Agitation, akathisia, anxiety, suicidal thoughts, worse depression
Sexual dysfunction
Insomnia
Hyponatraemia

178
Q

How long do SSRIs usually take to work?

A

2-4 weeks. Allow 6 weeks for initial side effects (worsening of depression, suicidal thoughts, anxiety) to wear off

179
Q

How long should SSRIs be given for?

A

6-9 months if first episode or uncomplicated

2 years if recurrent depression

180
Q

Give some contraindications for SSRIs

A

Caution - Bleeding disorders (especially GI bleeds)
Manic phase of bipolar disorder
Poorly controlled epilepsy
Prolonged QT interval or drugs that cause this
Severe hepatic impairment

181
Q

What drugs prescribed alongside SSRIs can increase risk of serotonin syndrome?

A 
Other SSRIs
SNRIs
MAO-Is!!!
Lithium
Opioids
St John's Wort
Triptans
Vortioxetine
182
Q

What are the symptoms of serotonin syndrome?

A

Fever
Tremors - neuromuscular
Diarrhoea - autonomic
Agitation - mental state

183
Q

What do SNRIs stand for? Give some examples of this medication

A

Serotonin and Noradrenaline Reuptake Inhibitors
Venlafaxine
Duloxetine

184
Q

What is the neuroplasticity hypothesis?

A

BDNF encourages neuronal plasticity
Stress increases cortisol which induces glutamate release that is neurotoxic and decreases plasticity
Antidepressants increase BDNF and decrease glutamate, improving neuroplasticity

185
Q

What is salience and how does it relate to psychosis?

A

Salience is choosing the importance of stimuli. Psychosis is the misdistribution of salience.

186
Q

What is the role of the nucleus accumbens?

A

Reward, pleasure centre, addictions

187
Q

What is the action of typical antipsychotics?

A

Block D2 dopaminergic receptors - blocks mesolimbic pathway which reduces positive symptoms of psychosis - but reduces ability to feel pleasure

188
Q

What is the action of atypical antipsychotics?

A

Lower affinity and occupancy of D2 receptors and high degree of occupancy on 5HT2A serotoninergic receptors

189
Q

What disorders may antipsychotics be used to treat?

A

Mainly schizophrenia
Bipolar disorder
Anxiety/Depression - if severe or difficult to treat

190
Q

Give some risk factors for neuroleptic malignant syndrome

A 
Use of neuroleptic drugs - new or increased dose
Genetic susceptibility
Patient agitation/catatonia
Withdrawal dopaminergic drugs (Parkinson's)
D2 receptor antagonists
Atypical antipsychotics
Increased temperature
Previous neuroleptic malignant syndrome
191
Q

Give some symptoms and signs of neuroleptic malignant syndrome

A

Usually within 10-21 days on changed medication - think Parkinson’s
Rigidity - muscle rigidity leading to Dyspnoea
Difficulty walking/shuffling gait
Tremor/involuntary movements
Seizures, chorea, oculogyric crisis, opisthotonos
Altered mental state
Raised temperature, high or low BP
Incontinence
Raised CK, WCC

192
Q

How would you manage neuroleptic malignant syndrome?

A

Protect airway if compromised
Physical restraint or IV benzodiazepines if agitated (only if necessary)
Discontinue neuroleptic agent
IV fluids for dehydration
Kidney management and dopaminergic medications if severe

193
Q

Give some ways that neuroleptic malignant syndrome might lead to death

A 
cardiovascular collapse
respiratory failure
myoglobinuric acute kidney injury
seizures
arrhythmias
194
Q

What is important to screen for if someone presents with self-harm/suicide attempt?

A

Psychosis - hallucinations/delusions/intrusive thoughts/voices
Depression - low mood, anergia, anhedonia
If depression, screen for mania (4+ days increased activity, disinhibition)
Anorexia
Alcohol or illicit drug use
Recent change in medication e.g. SSRIs

195
Q

What are possible organic causes of anxiety?

A

Hyperthyroidism
Pheochromocytoma - increases serum catecholamines, do 24hr urine test with vanillylmandelic acid
Brain tumour
Delirium due to infection, pain, trauma, medications

196
Q

How would you manage EUPD?

A

No meds recommended unless to treat comorbidities - can give clozapine/quetiapine to numb emotions
DBT
MBT - mentalisation-based treatment
Therapeutic communities

197
Q

How might you distinguish between OCD and OCPD?

A 
OCPD = pervasive, childhood, ego-syntonic but unhappy
OCD = not pervasive, ego-dystonic, unhappy
198
Q

How might you manage OCPD?

A

Life advice - eat healthy, exercise, mindfulness, reduce workload (if appropriate)
Therapy - CBT or community, IAPT
Anxiety medication - propanolol, benzodiazepines, SSRIs

199
Q

What are 3 ways of thinking about harm when doing risk assessment in relation to others

A
  1. Risk of self-harm/suicide
  2. Risk of harm to others
  3. Risk of others causing patient harm
200
Q

What conditions might have psychotic symptoms?

A
  1. Paranoid schizophrenia/schizotypal disorder
  2. Depressive psychosis
  3. Manic psychosis
  4. Drug/alcohol-induced psychosis
201
Q

What can negative psychotic symptoms suggest?

A

Depressive psychosis
Bipolar, depressive phase leading to psychosis
Schizophrenia prodrome! - appear before schizophrenic episode

202
Q

Give the full name and an example of a NASSA. When might these be used?

A

Noradrenergic and selective Serotonin Antidepressant (aka tetracyclics)
Mirtazapine
Used when people can’t take SSRIs, less sexual symptoms, but may cause drowsiness

203
Q

What is the mechanism of action of mirtazapine?

Give some side effects

A

It is a pre-synaptic alpha-2 adrenergic receptor antagonist - increases noradrenaline and serotonin
SE: weight gain, sedation

204
Q

If someone is being treated for depression and presents with manic or psychotic symptoms, what should you do?

A

History and MSE, risk assessment
Wean off antidepressant (SSRI, NASSA, SNRI) as could be causing mania
1st line = trial antipsychotic + psychotherapy (cognitive analytical, CBT, interpersonal social rhythm therapy)
2nd line = add lithium or sodium valproate

205
Q

What is the management for mild depression?

A

Risk assessment, biopscychosocial formulation, 5Ps
Manage comorbid issues: mania, anxiety, psychosis, alcohol/substance abuse, eating disorders, dementia
2 week follow-up if sub-threshold symptoms

206
Q

How would you manage mild-moderate depression or persistent sub-threshold symptoms?

A

Low intensity psychosocial interventions e.g. IAPT. Group CBT if refuse IAPT
Consider antidepressant if:
- subthreshold symptoms persist despite intervention or been present for at least 2 years
- past history moderate-severe depression
- complicating chronic physical health problems

207
Q

How would you manage moderate-severe depression?

A

Offer anti-depressant
High intensity psychosocial intervention
Treat comorbidities e.g. sleep hygiene
Follow up within 2 weeks if low suicide risk, if high risk suicide or under 30yrs review within 1 week - crisis team signposting

208
Q

What might you need to discuss with a patient starting antidepressants?

A

Be vigilant for worsening depression or suicidal ideas, signpost to seek help
Takes 2-4wks for symptoms to improve
Antidepressants should be taken for at least 6 months after symptoms improve/remission
Risk of discontinuation symptoms but not addictive, should be withdrawn slowly
May have sedating effects - affect driving ability in first few weeks
Not to use St John’s Wort

209
Q

What antidepressants are first line?

A

SSRIs - sertraline, citalopram, fluoxetine, paroxetine..

210
Q

Why might you avoid prescribing tricyclics or venlafaxine?

A

High risk of toxicity or overdose

211
Q

If treating recurrent depression, what might you consider in selecting antidepressant?

A
  • choose one that responded to previously

- avoid ones that failed to respond to previously

212
Q

If chronic health problem, which antidepressant should you consider?

A

Sertraline has lower risk drug reactions
If bleeding problem/anticoagulation - avoid SSRIs, use mirtazapine as alternative
If SSRI prescribed, but take aspirin/NSAID - consider PPI in older people

213
Q

Name 3 screening questionnaires for depression

A

Patient Health Questionnaire-9, PHQ-9
Hospital Anxiety and Depression Score, HADS
BDI-II, Back Depression Inventory-II

214
Q

Describe the scoring system for PHQ-9

A 
9 symptoms, rated 0 (not at all) to 3 (nearly everyday)
Total Score = 27
Mild = 5
Moderate = 10
Moderately Severe = 15
Severe = 20
215
Q

Describe scoring system for HADS

A 
14 questions (7 depression, 7 anxiety), total score 21
8-10 = mild
11-14 = moderate
15-21 = severe
216
Q

How would you manage PTSD?

A

Self-help advice
Trauma-focused CBT, narrative exposure therapy, prolonged exposure therapy
Eye Movement Desensitisation and Reprocessing (EMDR)
Venlafaxine or SSRI (fluoxetine)
Benzodiazepine for crisis moments
If persists or disabling - add antipsychotic (risperidone)

217
Q

How would you manage mania or mixed episodes in bipolar disorder?

A

Risk assessment - drugs? anti-depressants?
Mania - oral antipsychotic (haloperidol, olanzapine, quetiapine, risperidone)
Try 2nd line antipsychotic if 1st doesn’t work
Add in lithium or sodium valproate
Taper any antidepressant medication

218
Q

How would you manage depression within bipolar disorder?

A 
Psychotherapy
Quetiapine
Olanzapine
Fluoxetine and Olanzapine combined
Lamotrigine
219
Q

Give examples of atypical antipsycotics

A 
Clozapine
Olanzapine
Risperidone
Aripiprazole
Quetiapine
220
Q

Which type of antipsychotics cause metabolic syndrome? Give some features of this

A 
ATYPICAL antipsychotics
Weight gain
Hypertriglyceridaemia
Increased insulin + glucose
increased LDL cholesterol
Clozapine - risk of cardiomyopathy
221
Q

Which type of antipsychotics are more likely to cause extra-pyramidal effects. Give examples of these side effects

A 
TYPICAL antipsychotics
Dystonias
Akathisias
Seizures
Parkinson-like symptoms - rigid, tremor, shuffle
Neuroleptic malignant syndrome
222
Q

Give examples of typical antipsychotics

A

Haloperidol
Chlorpromazine
Loxapine
Perphenazine…

223
Q

Give 2 examples of Z drugs for sleep/hypnotic effects. What is their mechanism of action?

A

Zopiclone, Zolpidem
Bind to GABA-A receptors which mediate inhibitory neurotransmission
(same action as benzodiazepines)

224
Q

Give examples of hypnotics

A

Benzodiazepines (e.g. lorazepam, chlordiazepoxide)
Z drugs (zopiclone, zolpidem)
melatonin

225
Q

Give some side effects of clozapine? When is clozapine often used?

A

Side effects: weight gain, neutropenia, cardiac myopathy

Used for resistant psychosis not responsive to other antipsychotics

226
Q

Give diagnostic criteria for anorexia nervosa

A

Actual body weight <15% expected for height
BMI<17.5 (adults)
Females - amenorrhoea >3 months
Men - loss sexual interest and impotence
Weight loss self-induced: avoidance, excessive exercise, purging, appetite suppressants, laxatives, diuretics
Distorted self-image - persistent over-valued idea of fatness

227
Q

What must you exclude when considering diagnosing eating disorders in someone with change in weight?

A

Unintended or organic cause of weight loss or weight gain - infections, diarrhoea, vomiting, cancer, poor sleep, hyper/hypothyroidism
Psychosis

228
Q

Give some features you may find on physical examination in a patient with anorexia nervosa

A 
Dry skin, thin hair
Lollipop head
Lanugo - fine body hair
Dental marks on fingers/calluses (Russell's sign)
Cardiomegaly
High temperature
Salivary gland enlargement
Muscle weakness (sit-up-stand-up-squat test)
Angular stomatitis
229
Q

Give a mnemonic that screens for eating disorders and expand

A 
SCOFF
S = sick because full?
C = control lost over eating
O = one stone or more lost in last 3 months
F = fat when others think thin
F = food dominates life
230
Q

What investigations might you do in a patient with anorexia nervosa?

A

FBC
U+Es - Na, Cl imbalance due to water intake/purging
Calcium
Magnesium
Phosphate
Serum proteins
LFTs - raised liver enzymes due to hypovolaemia
Potassium - hypokalaemia
Urinalysis - diabetes?
ECG - arrhythmias? T wave inversion, bradycardia, high take off, prolonged QT

231
Q

What are the health risks of anorexia nervosa?

A 
Cardiac arrest/heart failure (breakdown cardiac myocytes and hypokalaemia)
Respiratory arrest
Gastroparesis
Constipation - decreased intake, muscle weakness, laxative-dependency
Oesophageal rupture (Mallory-Weiss tear)
Pancreatitis
Amenorrhoea/Infertility
Increased fracture risk/falls risk
Hypothyroidism
Increased cholesterol
Renal failure - prolonged dehydration
Anaemia
Infection
232
Q

What is the mortality in anorexia nervosa compared to general population?

A

6 times higher

233
Q

What might be immediate management for a patient with anorexia nervosa?

A

Ask consent to admit, if decline - section
IV fluids + K, offer food/Forsips
If decline, consider NG tube or parenteral

234
Q

What would be long-term management for a patient with anorexia nervosa?

A 
Psychoeducation
Monitor physical weight
CBT (family therapy if child)
Diet plan
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
235
Q

What is refeeding syndrome?

A

Feeding after period of starvation
Body switches from fat to carb metabolism, increases insulin
Causes electrolytes to enter cells

236
Q

How might you treat refeeding syndrome?

A

IV thiamine, magnesium, phosphate

237
Q

What deficiency causes Wernicke’s encephalopathy? What are the triad of symptoms you might see?

A

Thiamine deficiency

Triad = confusion, ataxia, ophthalmoplegia

238
Q

What is difference between hypochondriasis and somatisation?

A

Hypochondriacal delusions - focused on illness

Somatisation - focus on symptom

239
Q

Which antidepressant can help with neuropathic pain?

A

Duloxetine

240
Q

What must you rule out in a patient presenting with confusion before diagnosing dementia?

A

Organic causes of confusion - delirium

241
Q

What investigations might you do to rule out organic causes of confusion?

A 
CHECK MEDICATIONS
FBC - WCC + Hb
U+E - Na, K, eGFR
Calcium
LFT
Clotting factors
TFT
Vitamin D/Vit B12/Folate
Mandatory - CT head or MRI with contrast!!
CXR
24 hr ECG
Cognitive test - MoCA, AMT, GPCOG, 6CIT, MMSE, ACE-III
242
Q

What criteria must be met for dementia?

A

Decline in lots of types of cognition
Duration at least 6 months
Sufficient impairment

243
Q

What is the definition of delirium? What is its management?

A

Acute confusional state
Mx: treat underlying cause, improve environment, DoLs if appropriate
Sedatives if aggressive

244
Q

Would you use DoLS or LPS on a mental health ward?

A

No, would use Mental Health Act instead. LPS only applies to other hospital wards

245
Q

What are the characteristic features of vascular dementia?

A

Step-wise decline in cognition
Previous CVD events - TIAs
Decline in affect first
Vascular RFs - HTN, cholesterol, smoking, DM, previous MI/stroke, AF

246
Q

How would you manage vascular dementia?

A

Manage vascular risk factors

Supportive - OT, PT, SLT, memory cafe, cognitive stimulation therapy, aromatherapy, play therapy, art therapy

247
Q

What are the characteristic features of Lewy Body Dementia?

A

Parkinsonian features AFTER cognitive decline (rigidity, shuffling, bradykinesia, tremor, dysphagia)
FLUCTUATING COGNITION
Vivid psychotic symptoms

248
Q

How would you manage Lewy body dementia?

A 
1st line = Rivastigmine
Supportive care (can't use anti-psychotics unless minimm dose quetiapine/olanzapine)
249
Q

What are the characteristic features of Alzheimer’s disease?

A

Linear cognitive decline
Physical health preserved
Decreased learning ability and new memory formation first

250
Q

How would you manage Alzheimer’s disease?

A

1st line = Donepezil
2nd line = Memantine
Supportive

251
Q

What are the risk factors of Alzheimer’s disease?

A

family history, genes, age, vascular disease, head injury

252
Q

What are the characteristic features of Parkinson’s Disease Dementia?

A

Parkinsonian features BEFORE dementia
Fluctuating cognition
Visual and auditory hallucinations

253
Q

How might you manage Parkinson’s Disease Dementia?

A

Rivastigmine

Supportive

254
Q

What are the characteristic features of FrontoTemporal Dementia?

A

Personality and behaviour changes
Disregard for others, apathy
Social disinhibition

255
Q

How would you manage frontotemporal dementia?

A

Supportive

May use SSRIs to control impulsions and compulsive behaviours, or antipsychotics (rare) if SSRIs not working

256
Q

If suspect or have diagnosed dementia, what investigations might you do?

A

SPECT - to detect hypoperfusion

DaT - Parkinson’s, LBD?

257
Q

Give the 5 principles of the Mental Capacity Act

A
  1. Assume capacity until proven otherwise
  2. Support to make own decision
  3. Unwise decisions do not mean lack of capacity
  4. Act in best interests of patient
  5. Least restrictive option preferred
258
Q

What is the 2-stage test for assessing capacity?

A
  1. Does person have impairment of mind or brain?

2. Does that impairment make them unable to make a specific decision at this time?

259
Q

What are the 4 stages to assess if a person is able to make a decision when assessing capacity?

A
  1. Can they UNDERSTAND?
  2. Can they RETAIN?
  3. Can they WEIGH UP information?
  4. Can they COMMUNICATE back to you?
260
Q

What is the mechanism of action of Donepezil?

A

Binds reversibly to acetylcholinesterase to inhibit hydrolysis of acetylcholine. Acetylcholine transmission increases

261
Q

What is the mechanism of action of Galantamine?

A

Reversible competitive inhibitor of acetylcholinesterase

262
Q

What is the mechanism of action of Rivastigmine?

A

Inhibits acetylcholinesterase and butrylcholinesterase to increase cholinergic transmission

263
Q

What is the mechanism of action of Memantine?

A

NMDA receptor antagonist, blocking effect of glutamate which causes neuronal excitement and excessive stimulation in Alzheimer’s disease

264
Q

What are important things to ask about in someone presenting with generalised anxiety disorder?

A

Comorbid depression
Other anxiety disorders - OCD, PTSD, phobias
Physical health problems
Substance abuse
Environmental stressors
Suicide risk (if comorbidities or severe)

265
Q

What would be first interventions offered for people with anxiety without marked functional impairment?

A

Psychoeducation + Active monitoring

Low intensity psychological intervention: Self-help, guided self-help, psychoeducational groups

266
Q

What would be interventions for GAD with marked functional impairments or no improvement from Step 1 interventions?

A

Inform that response to psychological interventions is not immediate and encourage continuing
High intensity individual psychological - CBT /applied relaxation
Or drug treatment - SSRI or SNRI alternative
Pregabalins if SSRI or SNRI not tolerated

267
Q

When might benzodiazepines be used in treatment of anxiety? Why might they not be used?

A

Used for short-term anxiolytic effect
Not to be used in GAD unless for crises - long-term use can lead to dependency and withdrawal symptoms (including anxiety)

268
Q

What might you refer to specialist treatment for GAD?

A

Not responded to Step 3 interventions (drug treatments, CBT)
Or risk of self harm/suicide/self-neglect
Or significant comorbidity

269
Q

What self-care advice could you give to someone with GAD?

A

Sleep hygiene - regular bedtime, no alcohol after 6pm, no caffeine after 3pm
Regular exercise helps mental health

270
Q

Describe the scoring system that helps to screen for GAD.

A 
GAD-7
7 questions, each with score 0-3 based on frequency of symptoms in last 2wks, total score = 21
Mild = 5
Moderate = 10
Severe = 15
271
Q

Give some differential diagnoses of anxiety/GAD?

A 
Situational anxiety
Adjustment disorder
Panic disorder
Social phobia
OCD
PTSD
Somatoform
Anorexia nervosa
Medication-induced anxiety
Cardiac disease, hyperthyroidism, pulmonary disease, anaemia, infection, IBS, phaechromocytoma
272
Q

Give features and test for phaeochromocytoma

A

Anxiety with hypertension and tachycardia

24 hr vanillylmandelic urine and metanephrines to diagnose

273
Q

How might you manage PTSD at different levels?

A

subclinical - active monitoring, follow up within 1mnth
If event occurred in last month - refer for psychotherapy and drug treatment
If symptoms for over a month - refer specialist mental health service

274
Q

When might you consider drug treatment for PTSD? What drugs would you choose?

A

Patient preference, declines psychotherapy, referral delayed
Venlafaxine or SSRI
Hypnotic if sleep problems

275
Q

What psychotherapy would be offered to someone with PTSD?

A

Trauma-focused CBT
Exposure therapy
EMDR

276
Q

How might you manage OCD?

A

Psychotherapy - CBT, Exposure and Response Prevention Therapy (ERPT)
OR
Drug treatment - SSRI
Clomipramine if SSRI not tolerated, preferred
Combine drug and psychotherapy if severe

277
Q

What scale might be used to assess severity of OCD?

A

Y-BOCS (Yale Brown Obsessive Compulsive Scale)
How much of day have thoughts/act on compulsions?
How much interfere with life?
How much distress?
How much effort to resist?
How much control over thoughts do you have?

278
Q

Give features of lithium toxicity and management

A

Tremor, hypereflexia, ataxia, chorea, muscle weakness, diarrhoea, vomiting, renal impairment, altered consciousness
Management: Stop lithium and supportive care (fluids + electrolytes)

279
Q

Give features of delirium tremens and management

A

Tremor, confusion/delirium, sweating, tachycardia. Severe - coma, convulsions
Oral lorazepam or parenteral lorazepam/haloperidol
Treat for WE - IV Pabrinex

Phase 3a (8 decks)

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