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
2
Q
What types of assessment might you do during or after a psychiatric history?
A
Mental State Assessment
Physical Examination
Risk Assessment
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?
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
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
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?
7
Q
When would you do the Mental State Exam?
A
During history, but may need to ask specific questions afterwards to clarify
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
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
10
Q
What are you looking for in their speech during MSE?
A
Speed
Volume
Language
Neologisms, punning, clanging
11
Q
What is a neologism?
A
Inventing new words to describe something
12
Q
What is clanging?
A
Changing thought pattern through rhyme
13
Q
What is the difference between mood and affect?
A
Mood = subjective/patient's own view Affect = objective/professional's opinion
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)
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
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
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?
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
19
Q
What is the lifetime prevalence of mental illness?
A
1 in 4
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
21
Q
What is the point prevalence of mental illness?
A
1 in 6
22
Q
What percentage of people with long term conditions in the UK have mental health problems?
A
30%
23
Q
List the common affective disorders
A
Depression
Bipolar
Cyclothymia
24
Q
What is the prevalence of depressive episodes?
A
2.6% (slightly higher in females than males)
25
What is the prevalence of mixed anxiety and depression?
11.4% (slightly higher in females than males)
26
What proportion still have depressive symptoms a year after first presenting?
50%
27
What proportion of people with depression have recurrent depression (another episode)?
50%
28
How much does depression increase mortality risk from physical illness?
50% increased risk (causes include CVD, cancer, metabolic, respiratory disease)
29
What are the 3 core symptoms of depression?
1. Low Mood
2. Low energy (anergia)
3. Low pleasure/interest (anhedonia)
30
List non-core symptoms of depression
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
31
Give diagnostic criteria for mild depression in first episode
at least 2 core symptoms + at least 2-3 other symptoms
No symptoms should be present to an intense degree
Minimum duration 2 weeks
32
Give diagnostic criteria for moderate depression in first episode
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
33
Give the diagnostic criteria for severe depression in first episode
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)
34
Give diagnostic criteria for severe depression with psychosis
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)
35
Give incidence of post-natal depression in women after childbirth
13% (and is leading cause of mortality for women post-partum)
36
What is the difference between Bipolar I and Bipolar II and Rapid Cycling?
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
37
What should you always screen for if someone presents with depressive history?
Mania
| Psychosis
38
Describe the features of cyclothymia
Persistent instability of mood with numerous episodes of depression and mild elation (neither severe enough to be bipolar affective disorder or recurrent depressive disorder)
39
Describe features of dysthymia
Chronic depression of mood often lasting several years, not sufficiently severe, or episodes not lasting long enough to be depressive disorder
40
Give the features of hypomania
```
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
```
41
Give the features of mania
```
>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
```
42
List the common differentials for psychosis
```
Schizophrenia
Delusional disorder
Schizotypal disorder
Depressive psychosis
Manic psychosis
Organic psychosis
```
43
What is the lifetime risk of having schizophrenia?
1%, equal male and female
44
When is the common age of onset for schizophrenia?
2nd-3rd decade with 2nd peak in late middle age
| Men tend to get earlier, women get another peak post-menopausal
45
How does schizophrenia affect mortality?
Life expectancy 25 years less
Increased risk of suicide
Increased risk of CVD, resp, infection
46
What are the first rank symptoms of schizophrenia?
Thought alienation
Passivity phenomena
3rd person auditory hallucinations
Delusional perception
47
What are the second rank symptoms of schizophrenia?
```
Delusions
2nd person auditory hallucinations
Hallucinations in any other modality
Thought disorder
Catatonic behaviour
Negative symptoms
```
48
Give some positive psychotic symptoms
```
Hallucinations
Delusions
Passivity phenomena
Thought alienation
Lack of insight
Disturbance in mood
```
49
Give some negative psychotic symptoms
```
Blunting of affect
Amotivation
Poverty of speech or thought
Poor non-verbal communication
Clear deterioration in functioning
Self-neglect
Lack of insight
```
50
How many first and second rank symptoms do you need to diagnose schizophrenia?
First rank = >1
| Second rank = 2+
51
What is schizotypal disorder?
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
52
Give some examples of anxiety disorders
```
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
```
53
Give some features of generalised anxiety disorder
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)
54
Give some physical features of panic disorder
```
Palpitations
Chest pain
Choking
Tachypnoea
Dry mouth
Urgency of micturition
Dizziness
Blurred vision
Paraesthesiae
```
55
Give some psychological features of panic disorder
```
Feeling of impending doom
Fear of dying
Fear of losing control
Depersonalisation
Derealisation
```
56
What is depersonalisation?
Feeling outside of one self, observing thoughts and actions from a distance
57
What is derealisation?
Feeling like the world around you isn't real or seems "foggy" or "lifeless"
58
Give some features of OCD
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
59
Give some criteria to define personality
```
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
```
60
What about a personality makes it a personality disorder?
Leads to distress
| Impairments in self and interpersonal functioning
61
Give the 3 different clusters for personality disorder types
Cluster A - "odd, eccentric"
Cluster B - "emotional, erratic"
Cluster C - "anxious/fearful"
62
What personality disorders fall under Cluster A?
Schizoid
Paranoid
Schizotypal
63
What personality disorders fall under Cluster B?
Emotionally unstable (borderline)
Histrionic
Dis-social/antisocial
Narcissistic
64
What personality disorders fall under Cluster C?
Obsessive-compulsive
Dependent
Avoidant
65
What is the most common personality disorder and what are its two sub-types?
Emotionally Unstable Personality Disorder (EUPD)
1. Impulsive
2. Borderline
66
What are the features of EUPD (impulsive)?
Unstable/capricious mood
| Acts without thinking of consequences
67
What are the features of EUPD (borderline)?
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
68
Give some reasons for self-harm in BPD
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
69
What is the management for EUPD?
1. Psychotherapy - Dialectical Behavioural Therapy (DBT), therapeutic community approaches
2. Medication for comorbidities if appropriate
3. Structured Clinical Management - emphasis problem solving, crisis management
70
What is the prognosis for EUPD patients?
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
71
How is an illusion different from a hallucination
Illusion - misperception of an external stimulus
| Hallucination - Perception without the presence of external stimulus
72
What type of hallucination is a first rank symptom of schizophrenia?
3rd person auditory hallucinations
73
What is the more common reason for visual hallucinations?
Organic episodes (often acute)
74
What causes are more common for olfactory, gustatory and tactile hallucinations?
Organic episodes
Olfactory and gustatory common as prodromal symptoms of temporal lobe epilepsy
Tactile sensations - more common in drug and alcohol withdrawal
75
What is a functional type of hallucination?
When a stimulus in one sensory modality triggers a hallucination in the same modality
76
What is a reflex type of hallucination?
Stimulus in one sensory modality triggers a hallucination in a different modality
77
What is an extracampine type of hallucination?
Hallucination outside of sensory field/physically impossible hallucination
78
What is a hypnagogic hallucination? Is it normal?
Hearing voices when falling asleep, normal and common - 1 in 3 people experience these
79
What is a hypapompic hallucination?
Hearing voices when waking up - less common than hypnagogic
80
What are the 4 sub-categories of thought disorders?
Disorders of Stream of Thought
Disorders of Possession of Thought
Disorders of Content of Thought
Disorders of Form of Thought
81
What is flight of ideas?
Thinking/speaking quickly, jumping from one point to another, but there is logical connectivity between points
82
What is circumstantiality?
Knows point to make, but goes round and round before getting to the point
83
What is tangentiality?
Goes off on a tangent in thought and does not make it to final point
84
What is perseveration?
Answering different questions with the same answer without it making sense
85
What is thought blocking?
Loses train of thought - which can be normal. May not be able to pick up line of thought once reminded
86
What is thought insertion?
Believes an external agency is placing thoughts in their head
87
What is thought withdrawal?
Believes external agency is taking thoughts out of their head
88
What is thought broadcast?
Believes their thoughts are being broadcasted to everyone
89
What is a delusion?
Firmly held thought/belief outside of social norm that is unshakeable, not deterred when provided evidence against it
90
What is an over-valued idea?
Firmly held belief, but is shakeable when given contrary evidence
91
Give 3 types of primary delusion
1. Delusional Mood
2. Delusional Perception
3. Sudden delusional idea (autochthonous delusion)
92
What is a delusional mood?
Has strong conviction/feeling that something is not right, but cannot tell what it is, feeling comes out of nowhere
93
What is a delusional perception?
True perception of a stimulus evokes a delusional interpretation - adds new meaning often of personal significance to patient
94
What is a sudden delusional idea?
Sudden primary delusion with no stimulus/trigger. Also called autochthonous delusion
95
List some different types of delusion
Persecutory, Grandiose, Infidelity, Love, Religious, Guilt, Self-referential, Nihilistic, Poverty, Hypochondriacal, Misidentification
96
What is another name for infidelity delusion? What do they believe?
Othello's delusion - believes partner is cheating
97
What is another name for love delusion? What do they believe?
Erotomania/De Clerembault - believes person that is unattainable is in love with them
98
What is a self-referential delusion?
Believes that actions/words/insinuations are aimed at them when they may not be
99
What is another name for nihilistic delusion? What does the delusion often involve? When might this delusion present? Prognosis?
Cotard's syndrome - believes they are non-existent, dying, insides are rotting
Usually in severe depression
Prognosis usually good
100
Give 3 types of misidentification delusion and briefly describe what they involve
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"
101
What is loosening of association?
No sense or association between points of thought/speech
102
What is dissociative amnesia?
Sudden memory loss during episodes of extreme trauma
103
What is confabulation? What cause is more common?
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
104
What is anhedonia?
Inability to feel pleasure
105
What is apathy?
Lack of energy/motivation
106
What is incongruity of affect?
Affect/appearance of mood to others does not fall in line with thoughts or internal emotions
107
What is blunting of affect?
Reduced ability to express emotions
| Can be due to meds, as well as disorders
108
What is conversion?
Type of somatic disorder involving central nervous system under voluntary control
109
What is somatic disorder?
Unconscious transposition of psychological conflict into somatic sensory or motor symptoms
110
What is Belle Indifference?
Lack of concern or feeling indifferent about a physical symptom - often associated with conversion
111
What is passivity phenomena? Give 3 examples
When the person does not feel in control of their own actions/feelings/drives.
E.g. somatic passivity, made act/feel/drive, catatonia
112
What is somatic passivity?
Feels as thought somebody has control over their body
113
What is made act/feel/drive?
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
What is catatonia?
A state of excited or inhibited motor activity in the absence of a mood disorder or neurological disease
115
What is waxy flexibility?
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
What is echolalia?
An automatic repetition of the words heard
117
What is echopraxia?
An automatic repetition of the movements made by examiner/other person
118
What is logoclonia?
Repetition of the last syllable of a word
119
What is negativism?
Motiveless resistance to movement
120
What is palilalia?
Repetition of a word over and over with increasing frequency
121
What is verbigeration?
Repetition of one or more sentences/strings of words, often in a monotonous tone
122
What is concrete thinking?
Taking things literally
123
What is a mental disorder?
Any disorder/disability of the mind excluding drug and alcohol use
124
What is a S12 approved doctor?
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
What is an Approved Mental Health Professional (AMHP)?
From range of professions and authorised by local authority to carry out functions of MHA on their behalf e.g. sectioning
126
Give some underlying principles of the Mental Health Act 1983
```
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
What is Section 2 of the MHA used for?
For Assessment!
| treatment can be given without patient's consent
128
What is the duration of Section 2?
28 days, non-renewable
| Patient can leave after 24 hours if section not approved by relevant professionals within this time
129
Who is required to complete a Section 2 of MHA?
```
2 doctors (at least one of which S12 approved)
1 AMHP
```
130
What evidence is required for Section 2 of MHA?
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
What is the purpose of Section 3 of the MHA?
For treatment
132
What is the duration of Section 3 of MHA?
6 months, renewable
133
Who is required for Section 3 of MHA?
2 S12 doctors
| 1 AMHP
134
What evidence is required for Section 3 of MHA?
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
What is the purpose of Section 4 of MHA?
Only for "urgent necessity" when waiting for 2nd doctor would lead to undesirable delay - for patient not already admitted
136
What is the duration of Section 4 of MHA?
72 hours
137
Who is required for Section 4 of MHA?
1 doctor
| 1 AMHP
138
What evidence is required for Section 4 of MHA?
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
What is the purpose of Section 5(2) of MHA?
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
What is the duration of Section 5(2) MHA?
72 hours
141
Who can carry out Section 5(2) of MHA?
Any registered medical practitioner (F2 or above), responsible for and knows the patient
142
What is the purpose of Section 5(4) of MHA?
To detain a patient ALREADY admitted in hospital but wanting to leave, cannot be treated coercively, to allow time until doctor can attend
143
What is the duration of Section 5(4) of MHA?
6 hours
144
Who carries out Section 5(4) of MHA?
Nurses responsible for/know the patient
145
What is the purpose of Section 135 of MHA?
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
What is the duration of Section 135 of MHA?
36 hours
147
Who grants a Section 135 of MHA?
Magistrate - often requested by social worker, healthcare professional or police in emergency
148
What is the purpose of Section 136 of MHA?
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
What is the duration of Section 136 of MHA?
24 hours (but extendable up to another 12 hours for clinical reasons)
150
Who grants a Section 136 of MHA?
Police
151
Where can Sections 2, 3 and 4 be done?
anywhere except for prison
152
What are the 4 components used in CBT?
Thoughts, Emotions, Bodily Sensations, Behaviours
153
What is the purpose of section 37?
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
Who orders a section 37?
Crown court
155
What section may be given in forensic psychiatry as a restriction order?
Section 41 - Ministry of Justice controls movement
156
What is section 35?
Crown court order for assessment of prisoners for mental disorder for 28 days
157
Within what time frame must an appeal against Section 2 be made?
14 days
158
What is Section 17?
Leave from hospital, with conditions placed by professionals, can be called back to hospital at any time
159
What is a community treatment order?
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
What's an SOAD service?
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
Where is counselling usually done? What are typical features of counselling?
Usually in primary care
Short duration
Patient comes up with own answers
162
What is cognitive analytical therapy a combination of?
CBT and psychoanalytical therapy
163
What form of psychotherapy is often used in personality disorders?
Dialectical Behavioural Therapy (DBT) - for intense emotions, to help you understand and accept difficult feelings
164
What are the 3 different types of family therapy?
Structural - how they interact
Systemic - therapist observes (unseen behind mirror), then comments
Strategic - therapist forms strategies with clear goals within family context
165
What are some contraindications for psychotherapy?
Lack of motivation
Lack of psychological insight
Complex mental health needs or learning difficulties
Antisocial characteristics
166
What is attachment theory?
A person needs stable relationship with at least one primary caregiver for successful social and emotional development + regulation of feelings
167
How do MAO-Is work as anti-depressants?
Inhibit degradation enzyme (monoamine oxidase) from breaking down noradrenaline and dopamine. NAd and DA increase
168
Why might dietary restrictions be put in place when taking MAO-Is for depression?
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
Give examples of foods high in tyramine
```
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
What monitoring might you do for a patient on MAO-Is?
Blood pressure - risk of postural hypotension or hypertensive responses
171
How quickly should you withdraw MAO-I treatment?
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
Give some examples of MAO-Is
Tranylcypromine
Phenelzine
Isocarboxazid
173
What is the monoamine hypothesis?
Depression is caused by reduced monoamines (serotonin, norepinephrine, dopamine) in central nervous system
174
What is the mechanims of action of tricyclic antidepressants?
Increase monoamines by blocking transporters 5HT.
Also agonises anti-cholinergic receptors and antihistaminergic receptors.
Antagonises a-1 adrenergic receptors
175
Why are tricyclic antidepressants not first line treatments for depression anymore?
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
What is the mechanism of action for SSRIs?
Acts on 5HT receptors to reduce reuptake of serotonin, raising serotonin levels
177
Give some side effects of SSRIs and why
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
How long do SSRIs usually take to work?
2-4 weeks. Allow 6 weeks for initial side effects (worsening of depression, suicidal thoughts, anxiety) to wear off
179
How long should SSRIs be given for?
6-9 months if first episode or uncomplicated
| 2 years if recurrent depression
180
Give some contraindications for SSRIs
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
What drugs prescribed alongside SSRIs can increase risk of serotonin syndrome?
```
Other SSRIs
SNRIs
MAO-Is!!!
Lithium
Opioids
St John's Wort
Triptans
Vortioxetine
```
182
What are the symptoms of serotonin syndrome?
Fever
Tremors - neuromuscular
Diarrhoea - autonomic
Agitation - mental state
183
What do SNRIs stand for? Give some examples of this medication
Serotonin and Noradrenaline Reuptake Inhibitors
Venlafaxine
Duloxetine
184
What is the neuroplasticity hypothesis?
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
What is salience and how does it relate to psychosis?
Salience is choosing the importance of stimuli. Psychosis is the misdistribution of salience.
186
What is the role of the nucleus accumbens?
Reward, pleasure centre, addictions
187
What is the action of typical antipsychotics?
Block D2 dopaminergic receptors - blocks mesolimbic pathway which reduces positive symptoms of psychosis - but reduces ability to feel pleasure
188
What is the action of atypical antipsychotics?
Lower affinity and occupancy of D2 receptors and high degree of occupancy on 5HT2A serotoninergic receptors
189
What disorders may antipsychotics be used to treat?
Mainly schizophrenia
Bipolar disorder
Anxiety/Depression - if severe or difficult to treat
190
Give some risk factors for neuroleptic malignant syndrome
```
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
Give some symptoms and signs of neuroleptic malignant syndrome
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
How would you manage neuroleptic malignant syndrome?
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
Give some ways that neuroleptic malignant syndrome might lead to death
```
cardiovascular collapse
respiratory failure
myoglobinuric acute kidney injury
seizures
arrhythmias
```
194
What is important to screen for if someone presents with self-harm/suicide attempt?
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
What are possible organic causes of anxiety?
Hyperthyroidism
Pheochromocytoma - increases serum catecholamines, do 24hr urine test with vanillylmandelic acid
Brain tumour
Delirium due to infection, pain, trauma, medications
196
How would you manage EUPD?
No meds recommended unless to treat comorbidities - can give clozapine/quetiapine to numb emotions
DBT
MBT - mentalisation-based treatment
Therapeutic communities
197
How might you distinguish between OCD and OCPD?
```
OCPD = pervasive, childhood, ego-syntonic but unhappy
OCD = not pervasive, ego-dystonic, unhappy
```
198
How might you manage OCPD?
Life advice - eat healthy, exercise, mindfulness, reduce workload (if appropriate)
Therapy - CBT or community, IAPT
Anxiety medication - propanolol, benzodiazepines, SSRIs
199
What are 3 ways of thinking about harm when doing risk assessment in relation to others
1. Risk of self-harm/suicide
2. Risk of harm to others
3. Risk of others causing patient harm
200
What conditions might have psychotic symptoms?
1. Paranoid schizophrenia/schizotypal disorder
2. Depressive psychosis
3. Manic psychosis
4. Drug/alcohol-induced psychosis
201
What can negative psychotic symptoms suggest?
Depressive psychosis
Bipolar, depressive phase leading to psychosis
Schizophrenia prodrome! - appear before schizophrenic episode
202
Give the full name and an example of a NASSA. When might these be used?
Noradrenergic and selective Serotonin Antidepressant (aka tetracyclics)
Mirtazapine
Used when people can't take SSRIs, less sexual symptoms, but may cause drowsiness
203
What is the mechanism of action of mirtazapine?
| Give some side effects
It is a pre-synaptic alpha-2 adrenergic receptor antagonist - increases noradrenaline and serotonin
SE: weight gain, sedation
204
If someone is being treated for depression and presents with manic or psychotic symptoms, what should you do?
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
What is the management for mild depression?
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
How would you manage mild-moderate depression or persistent sub-threshold symptoms?
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
How would you manage moderate-severe depression?
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
What might you need to discuss with a patient starting antidepressants?
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
What antidepressants are first line?
SSRIs - sertraline, citalopram, fluoxetine, paroxetine..
210
Why might you avoid prescribing tricyclics or venlafaxine?
High risk of toxicity or overdose
211
If treating recurrent depression, what might you consider in selecting antidepressant?
- choose one that responded to previously
| - avoid ones that failed to respond to previously
212
If chronic health problem, which antidepressant should you consider?
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
Name 3 screening questionnaires for depression
Patient Health Questionnaire-9, PHQ-9
Hospital Anxiety and Depression Score, HADS
BDI-II, Back Depression Inventory-II
214
Describe the scoring system for PHQ-9
```
9 symptoms, rated 0 (not at all) to 3 (nearly everyday)
Total Score = 27
Mild = 5
Moderate = 10
Moderately Severe = 15
Severe = 20
```
215
Describe scoring system for HADS
```
14 questions (7 depression, 7 anxiety), total score 21
8-10 = mild
11-14 = moderate
15-21 = severe
```
216
How would you manage PTSD?
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
How would you manage mania or mixed episodes in bipolar disorder?
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
How would you manage depression within bipolar disorder?
```
Psychotherapy
Quetiapine
Olanzapine
Fluoxetine and Olanzapine combined
Lamotrigine
```
219
Give examples of atypical antipsycotics
```
Clozapine
Olanzapine
Risperidone
Aripiprazole
Quetiapine
```
220
Which type of antipsychotics cause metabolic syndrome? Give some features of this
```
ATYPICAL antipsychotics
Weight gain
Hypertriglyceridaemia
Increased insulin + glucose
increased LDL cholesterol
Clozapine - risk of cardiomyopathy
```
221
Which type of antipsychotics are more likely to cause extra-pyramidal effects. Give examples of these side effects
```
TYPICAL antipsychotics
Dystonias
Akathisias
Seizures
Parkinson-like symptoms - rigid, tremor, shuffle
Neuroleptic malignant syndrome
```
222
Give examples of typical antipsychotics
Haloperidol
Chlorpromazine
Loxapine
Perphenazine...
223
Give 2 examples of Z drugs for sleep/hypnotic effects. What is their mechanism of action?
Zopiclone, Zolpidem
Bind to GABA-A receptors which mediate inhibitory neurotransmission
(same action as benzodiazepines)
224
Give examples of hypnotics
Benzodiazepines (e.g. lorazepam, chlordiazepoxide)
Z drugs (zopiclone, zolpidem)
melatonin
225
Give some side effects of clozapine? When is clozapine often used?
Side effects: weight gain, neutropenia, cardiac myopathy
| Used for resistant psychosis not responsive to other antipsychotics
226
Give diagnostic criteria for anorexia nervosa
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
What must you exclude when considering diagnosing eating disorders in someone with change in weight?
Unintended or organic cause of weight loss or weight gain - infections, diarrhoea, vomiting, cancer, poor sleep, hyper/hypothyroidism
Psychosis
228
Give some features you may find on physical examination in a patient with anorexia nervosa
```
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
Give a mnemonic that screens for eating disorders and expand
```
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
What investigations might you do in a patient with anorexia nervosa?
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
What are the health risks of anorexia nervosa?
```
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
What is the mortality in anorexia nervosa compared to general population?
6 times higher
233
What might be immediate management for a patient with anorexia nervosa?
Ask consent to admit, if decline - section
IV fluids + K, offer food/Forsips
If decline, consider NG tube or parenteral
234
What would be long-term management for a patient with anorexia nervosa?
```
Psychoeducation
Monitor physical weight
CBT (family therapy if child)
Diet plan
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
```
235
What is refeeding syndrome?
Feeding after period of starvation
Body switches from fat to carb metabolism, increases insulin
Causes electrolytes to enter cells
236
How might you treat refeeding syndrome?
IV thiamine, magnesium, phosphate
237
What deficiency causes Wernicke's encephalopathy? What are the triad of symptoms you might see?
Thiamine deficiency
| Triad = confusion, ataxia, ophthalmoplegia
238
What is difference between hypochondriasis and somatisation?
Hypochondriacal delusions - focused on illness
| Somatisation - focus on symptom
239
Which antidepressant can help with neuropathic pain?
Duloxetine
240
What must you rule out in a patient presenting with confusion before diagnosing dementia?
Organic causes of confusion - delirium
241
What investigations might you do to rule out organic causes of confusion?
```
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
What criteria must be met for dementia?
Decline in lots of types of cognition
Duration at least 6 months
Sufficient impairment
243
What is the definition of delirium? What is its management?
Acute confusional state
Mx: treat underlying cause, improve environment, DoLs if appropriate
Sedatives if aggressive
244
Would you use DoLS or LPS on a mental health ward?
No, would use Mental Health Act instead. LPS only applies to other hospital wards
245
What are the characteristic features of vascular dementia?
Step-wise decline in cognition
Previous CVD events - TIAs
Decline in affect first
Vascular RFs - HTN, cholesterol, smoking, DM, previous MI/stroke, AF
246
How would you manage vascular dementia?
Manage vascular risk factors
| Supportive - OT, PT, SLT, memory cafe, cognitive stimulation therapy, aromatherapy, play therapy, art therapy
247
What are the characteristic features of Lewy Body Dementia?
Parkinsonian features AFTER cognitive decline (rigidity, shuffling, bradykinesia, tremor, dysphagia)
FLUCTUATING COGNITION
Vivid psychotic symptoms
248
How would you manage Lewy body dementia?
```
1st line = Rivastigmine
Supportive care (can't use anti-psychotics unless minimm dose quetiapine/olanzapine)
```
249
What are the characteristic features of Alzheimer's disease?
Linear cognitive decline
Physical health preserved
Decreased learning ability and new memory formation first
250
How would you manage Alzheimer's disease?
1st line = Donepezil
2nd line = Memantine
Supportive
251
What are the risk factors of Alzheimer's disease?
family history, genes, age, vascular disease, head injury
252
What are the characteristic features of Parkinson's Disease Dementia?
Parkinsonian features BEFORE dementia
Fluctuating cognition
Visual and auditory hallucinations
253
How might you manage Parkinson's Disease Dementia?
Rivastigmine
| Supportive
254
What are the characteristic features of FrontoTemporal Dementia?
Personality and behaviour changes
Disregard for others, apathy
Social disinhibition
255
How would you manage frontotemporal dementia?
Supportive
| May use SSRIs to control impulsions and compulsive behaviours, or antipsychotics (rare) if SSRIs not working
256
If suspect or have diagnosed dementia, what investigations might you do?
SPECT - to detect hypoperfusion
| DaT - Parkinson's, LBD?
257
Give the 5 principles of the Mental Capacity Act
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
What is the 2-stage test for assessing capacity?
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
What are the 4 stages to assess if a person is able to make a decision when assessing capacity?
1. Can they UNDERSTAND?
2. Can they RETAIN?
3. Can they WEIGH UP information?
4. Can they COMMUNICATE back to you?
260
What is the mechanism of action of Donepezil?
Binds reversibly to acetylcholinesterase to inhibit hydrolysis of acetylcholine. Acetylcholine transmission increases
261
What is the mechanism of action of Galantamine?
Reversible competitive inhibitor of acetylcholinesterase
262
What is the mechanism of action of Rivastigmine?
Inhibits acetylcholinesterase and butrylcholinesterase to increase cholinergic transmission
263
What is the mechanism of action of Memantine?
NMDA receptor antagonist, blocking effect of glutamate which causes neuronal excitement and excessive stimulation in Alzheimer's disease
264
What are important things to ask about in someone presenting with generalised anxiety disorder?
Comorbid depression
Other anxiety disorders - OCD, PTSD, phobias
Physical health problems
Substance abuse
Environmental stressors
Suicide risk (if comorbidities or severe)
265
What would be first interventions offered for people with anxiety without marked functional impairment?
Psychoeducation + Active monitoring
| Low intensity psychological intervention: Self-help, guided self-help, psychoeducational groups
266
What would be interventions for GAD with marked functional impairments or no improvement from Step 1 interventions?
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
When might benzodiazepines be used in treatment of anxiety? Why might they not be used?
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
What might you refer to specialist treatment for GAD?
Not responded to Step 3 interventions (drug treatments, CBT)
Or risk of self harm/suicide/self-neglect
Or significant comorbidity
269
What self-care advice could you give to someone with GAD?
Sleep hygiene - regular bedtime, no alcohol after 6pm, no caffeine after 3pm
Regular exercise helps mental health
270
Describe the scoring system that helps to screen for GAD.
```
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
Give some differential diagnoses of anxiety/GAD?
```
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
Give features and test for phaeochromocytoma
Anxiety with hypertension and tachycardia
| 24 hr vanillylmandelic urine and metanephrines to diagnose
273
How might you manage PTSD at different levels?
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
When might you consider drug treatment for PTSD? What drugs would you choose?
Patient preference, declines psychotherapy, referral delayed
Venlafaxine or SSRI
Hypnotic if sleep problems
275
What psychotherapy would be offered to someone with PTSD?
Trauma-focused CBT
Exposure therapy
EMDR
276
How might you manage OCD?
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
What scale might be used to assess severity of OCD?
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
Give features of lithium toxicity and management
Tremor, hypereflexia, ataxia, chorea, muscle weakness, diarrhoea, vomiting, renal impairment, altered consciousness
Management: Stop lithium and supportive care (fluids + electrolytes)
279
Give features of delirium tremens and management
Tremor, confusion/delirium, sweating, tachycardia. Severe - coma, convulsions
Oral lorazepam or parenteral lorazepam/haloperidol
Treat for WE - IV Pabrinex
