Psychiatry Flashcards
1
Q
What are the SEs of antipsychotics?
A
Metabolic - weight loss and diabetes
EPS - akathisia, dyskinesia, dystonia
Cardio - long QT interval (especially in clozapine)
Hormonal - increase plasma prolactin as they are dopamine antagonist
2
Q
Key side effect of clozapine
A
Long QT interval
3
Q
What is treatment resistant schizophrenia?
A
Schizo does not respond to 2 different antipsychotics after trialing for 6-8 weeks each.
At least one drug should be non-clozapine second generation anti-psychotic.
Clozapine is treatment choice.
4
Q
What are Schneider’s first rank symptoms?
A
1) Auditory hallucinations
2) Thought disorders:
- –Thought interruption
- –Thought insertion
- –Thought withdrawal
3) Thought broadcasting
4) Somatic Hallucinations
5) Delusional perception (“I saw the green light and knew I was the king”)
6) Feelings or actions experienced as made or influenced by external agents
5
Q
What are the scoring systems for depression?
A
PHQ9
HAD scale
6
Q
Treatment for mild depression
A
BioPsychoSocial
Watch and wait for 2 weeks, self-help, lifestyle advice (sleep hygiene)
Group CBT or computerised CBT
7
Q
Treatment for moderate depression
A
BioPsychoSocial
Medication (review every 2 weeks for 3 months): SSRI first line (sertraline or citalopram)
High-intensity CBT: Individual CBT (16-20 session over 3-4 months) Interpersonal therapy (16-20 session over 3-4 months) IPT > CBT if depression due to death
8
Q
Examples of SSRIs used in adults
A
Sertraline or Citalopram
Peroxitine - for really bad depression, Fluoxetine - for kids
9
Q
Steps for medication in depression
A
1st line: SSRI (sertraline, citalopram, paroxetine, fluoxetine), 2 trials before 2nd line
2nd line: SNRI (duloxetine, venlafaxine)
3rd line: Antipsychotic, Lithium or other antidepressant eg.mirtazepine
4th line: ECT
10
Q
Treatment for severe depression
A
BioPsychoSocial
Medication → ECT if necessary (catatonia)
High-intensity CBT: Individual CBT (16-20 session over 3-4 months) Interpersonal therapy (16-20 session over 3-4 months) IPT > CBT if depression due to death
11
Q
What medication should be avoided with triptans?
A
SSRI
12
Q
What anti-depressants are cautioned with warfarin or heparin?
A
NICE guidelines recommend avoiding SSRIs and using mirtazapine instead
13
Q
What drug should NOT be prescribed with SSRIs and why?
A
Aspirin as can cause a haemorrhage
14
Q
What else need to be prescribed with an SSRI?
A
Omeprazole or lansaprazole
15
Q
A sick baby, with severe heart failure.
- Absent femoral pulses.
- Severe metabolic acidosis.
Suggestive of?
A
Duct dependant coarctation of the aorta
16
Q
Who are the “sickest of all neonates” and how do they present?
A
Hypoplastic left heart syndrome
- profound acidosis and cardiovascular collapse
- weakness or absence of all peripheral pulses
17
Q
Features of abnormal grief
A
Delayed
Lasting >6mths
Very intense
18
Q
What are some physical causes of depression?
A
Cushing’s syndrome Hypothyroidism Addison’s disease Dementia Head injury Stroke MS
19
Q
What are some of the biological symptoms of depression?
A
Sleep changes
Appetite changes
Weight changes
20
Q
What are some of the cognitive symptoms of depression?
A
Memory deficits
Concentration deficits
21
Q
List three classes of anti-depressants and give an example of each
A
SSRI – sertraline, citalopram, escitalopram, fluoxetine
SNRI – duloxetine, venlafaxine
NaSSA – mirtazapine
TCA – imipramine, amitriptyline
22
Q
How is psychosis in depression different from psychosis in schizophrenia?
A
Psychosis is mood congruent in psychotic depression
Psychosis tends not to be mood congruent in schizophrenia as patients have blunted affect
23
Q
What do you NOT give patients with lewy body dementia with visual hallucinations?
A
antipsychotics
24
Q
What is the difference between type I and type II bipolar?
A
Type I: mania + depression
Type II: hypomania + depression
25
What is the difference between psychosis and mania?
Mainly differentiated via mood - mania is associated with elevated mood
26
What should be excluded in hyper sexuality?
Mania, substance misuse, organic brain disorders eg frontal lobe syndrome
27
Investigations for erectile dysfunction
1. Full Hx (check for risk factors eg HTN, smoking, diabetes, Meds etc
2. Check sex hormone and testosterone levels (may see low testosterone or hyperprolactinaemia)
3. Check glucose
4. Check LFTS/TFTS
28
What are some examples of paraphilias?
- fetishism
- paedophilia
- masochism
- sadism
29
Treatment for disorders of sexual identify
- hormone replacement therapy
| - gender reassignment surgery
30
What does acamprosate do?
Enhances GABA transmission to reduce craving for alcohol (given after detoxification)
31
Uses of BDZs
```
Sedative
Anxiolytic
Muscle relaxant
Hypnotic
AnticonvulsAnt
```
32
Risks of using BDZ
Short: drowsiness, reduction in concentration
Long term: cog impairment, anxiety and depression, sleep disruption and dependence
33
Signs of BDZ use
Calm and mild euphoria
Slurred speech
Ataxia
Stupor
34
Signs of BDZ overdose
Respiratory depression (give IV flumazenil)
- low GCS
- low BP
- mydriasis
- hyporeflexia
35
Symptoms of withdrawal from BDZs
- ANXIETY
- insomnia
- irritability
- tachypnoea/cardia
- ataxia
- tremor, tinnitus, sweating
- hyperreflexia, seizures,
- palpitations, delusions, depressions
- derealisation, depersonalisation
- anterograde amnesia
36
What is naltrexone?
Antagonist of endorphins release from Etoh to reduce the high
37
What is disulfiram?
Second line for chronic management of alcoholism - irreversible inhibitor of acetaldehyde dehydrogenase - gives a really bad hangover
38
What are some features of lithium toxicity?
```
GI disturbance (diarrhoea and vomiting)
Sluggishness + muscle weakness
Ataxia
Mild/gross tremor
Fits
Renal failure
```
39
What are some side-effects of anti-psychotics?
```
Extra-pyramidal: dystonia, akathisia, parkinsonism, tardive dyskinesia
Hyperprolactinaemia (galactorrhoea)
Weight gain
Sedation
Dyslipidaemia
```
40
What are Schneider’s First-Rank Symptoms?
Delusional perception
Passivity (they think someone else is controlling their actions)
Delusions of thought interference (insertion, withdrawal, broadcasting eg i think other people can hear what i'm thinking)
Auditory hallucinations (thought echo, 3rd person voices, running commentary)
41
What is a schizoid personality disorder?
Lack of interest in social or intimate relationships, difficulty with expressing emotions, and preferring a solitary lifestyle
42
Features of mania
Elevated mood/energy
Can get thought disorder (insertion, withdrawal broadcasting)
Delusions of grandeur
Flight of ideas
Cog symptoms: poor concentration and memory
In PACES: won't be able to stop them talking
43
What are some features of lithium toxicity?
```
GI disturbance (diarrhoea and vomiting)
Sluggishness
Giddiness
Ataxia
Gross tremor
Fits
Renal failure
```
44
What are the side effects of Amitriptyline?
Constipation
Dry eyes and mouth
Headaches
45
What is the most common childhood ASD?
PDD-NOS - persuasive developmental disorder, not otherwise specified
46
What is dysthymia?
Persistent sub-threshold depression for at least 2years (between 2-5 symptoms, no functional impairment)
47
What are the subtypes of depression?
- SAD
- Atypical depression
- Anxiety-induced insomnia
- Agitated depression
- Depressive stupor
48
What are some risk factors for depression?
Biological:
- Genetics
- Neurochemical eg MA hypothesis
- Endocrine eg cortisol
- Illness eg cushings/hypothyroidism etc or indirect eg cancer
- Medication
Psychosocial
- Childhood experiences
- Vulnerability
- Life events
- Substance abuse
49
What is beck's triad in depression?
Worthlessness
Hopelessness
Helplessness
50
What are the different types of BPAD and what is the diagnosis criteria?
BPAD 1: depressive + manic episodes
BPAD 2: more depressive episodes + some episodes of hypomania
Mixed cycling: mix of >4 episodes per year (respond to valproate well)
Mania: >3 characteristics (ICD-10), lasting at least 7 days, impairs social/occupational functioning, may have psychosis
51
SEs of valproate
Hair loss
Weight gain
Nausea
52
What are the teratogenic manifestations of mood stabilisers?
Lithium - Ebsteins anomaly
| Valproate + Carbamazepine - spina bifida
53
Ddx for anorexia nervosa
```
Medical causes of weight loss
Depression
Bulimia nervosa
Psychosis
Eating disorder not otherwise specified (EDNOS)
Body dysmorphic disorder (BDD)
```
54
What is the danger of food replacement in anorexia nervosa? What are the hallmarks of it?
Re-feeding syndrome - insulin release in response to food drives ions into cells leading to (low phosphate is the hallmark)
- hypokalaemia
- hypophosphataemia
- low Mg
- low thiamine
- salt and water retention
Symptoms: fatigue, weakness, confusion, high blood pressure, seizures, arrhythmia, heart failure
55
What are the 5 different types of schizophrenia?
1. Paranoid
2. Catatonic
3. Hebephrenic
4. Simple
5. Residual
56
Basic management of Schizophrenia
1st line: atypical antipsychotic for 6 weeks eg low dose aripriprazole, high dose olanzapine, quetiapine, risperidone
2nd line: typical antipsychotic
3rd line: Clozapine (ie if treatment resistant
If non-compliant: once monthly depot injection
Psychological therapies:
1. CBT
2. fam therapy
3. Concordance therapy
Social help: skill based, care based, fam etc
57
SEs of (atypical) antipsychotics
EPSEs:
1. Dystonia
2. Akathisia
3. Parkinsonism
4. Tardive dyskinesia
Other:
Prolactinaemia: amenorrhoea, gynaecomastia, hypogonadism, galactorrhoea
- weight gain (olanzapine&clozapine)
- anti-cholinergic symptoms: dry mouth, blurred vision, urinary retention, constipation, tachycardia
- sedation
- dyslipidaemia
- increased risk of diabetes (olanzapine)
- arrythmias
- seizures
- neuroleptic malignant syndrome
58
Investigations for schizophrenia
1) Hx and collateral Hx
2) Physical and OT assessment
3) urine MSU and toxicology screen
4) Bloods: FBC, TFTs, LFTs, Lipid, FG, CRP, U&Es
5) Consider HIV or syphilis screening
6) EEG? CT/MRI?
7) Social assessment
8) Screening of symptoms: Brief psychiatric rating scale
59
Differentials for schizophrenia
1) Organic: substance misuse, delirium, dementia, epilepsy, steroids, tumours
2) Acute/transient psychotic episode
3) Mood disorder
4) Schizoaffective disorder
5) Persistent delusional disorder
6) Schizotypal disorder
60
What are the 3 phases of schizophrenia?
1. ARM: at risk mental state (or prodrome)
- reclusive, disinterest in activities
2. Active
- thought disorder, delusions, hallucinations, passivity phenomena
3. Passive
- negative symptoms: anhedonia, anergia, paucity of thought/speech, non-reactivity of mood, blunted affect, social withdrawal
61
What are Schneiders first rank symptoms?
```
(1) Delusions (false and fixed beliefs)
(2) Passivity (delusions of control)
(3) Thought disorder:
• Thought insertion
• Thought withdrawal
• Thought broadcasting
(4) Auditory disorder:
• Thought echo
• 3rd person voice
• Running commentary
```
62
What is intoxication?
Transient state of emotional and behavioural change following drug use. Dependant on dose and time limited.
63
What is Harmful use?
Pattern of use likely to cause physical or psychological harm
64
What is drug dependency?
A cluster of physiological, behavioural and cognitive symptoms in which the use of substance takes on greater priority than other behaviours that once had greater value.
65
What 3 drugs does physical withdrawal occur from?
1) Etoh
2) BDZ
3) Opiates
66
What is withdrawal?
A transient state occuring while re-adjusting to lower levels of the drug in the body
67
What is a psychotic disorder?
Psychotic symptoms occurring during or immediately after use of a psychoactive substance, characterised by vivid hallucinations, abnormal effect, psychomotor disturbances, persecutory delusions and delusions of reference
68
What is amnesic disorder?
Memory and other cognitive impairments due to substance use eg Wernicke's
69
What are residual and late onset psychotic disorders?
effects on behaviour, affect, personality or cognition lasting beyond the period during the which the direct effect of the psychoactive substance might be expected
70
What are the different types of dementia?
```
Most (75%) AD
Vascular
Lewy-body
Fronto-temporal
Mixed
```
71
What are lewy bodies made from?
alpha-synuclein with ubiquitin
72
What should you not do to manage a patient who is delirious?
Don't sedate with BDZ or haloperidol
| Don't anti-cholinergic
73
What is prosopagnosia?
Difficulty in recognising faces (seen in AD)
74
What are some signs of frontal lobe damage? (Organic psych)
```
Poor judgement/planning
Change in personality/mood/actions eg disinhibited behaviour
Change in executive function
Broca's aphasia + telegraphic speech
Contralateral spastic hemiparesis
Primitive reflexes reemerge
```
75
What are some signs of temporal lobe damage? (Organic psych)
Auditory impairment/agnosia
Wernicke's aphasia
Auditory, olfactory, gustatory hallucinations
Lability
76
What are some signs of parietal lobe damage? (Organic psych)
```
Contralateral sensory impairment
Apraxias
Agnosias
Contralateral sensory neglect
Dyscalculia
```
77
What are some signs of occipital lobe damage? (Organic psych)
Contralateral visual deficits
Visual blindness
Visual agnosia
78
What condition affects the HTT gene?
Huntington's - trinucleotide expansion disorder
79
Symptoms of Huntington's disease
Movement: chorea, speech/swallowing, stumbling/clumsiness
Cognitive: organising tasks, flexibility, impulse control, learning new information
Psych: suicide risk, depression, irritability/mood swings
80
Triad of normal pressure hydrocephalus
Subcortical dementia
Urinary incontinence
Unsteady gait
Treat with ventriculo-atrial shunt
81
Causes of normal pressure hydrocephalus
Meningitis
Head injury
Idiopathic
82
What are prion diseases?
Progressive spongiform encephalopathies -> normal prion protein change to abnormal, insoluble form: accumulation leads to spongiform and amyloid changes
Most common = sporadic CJD
83
How may prion diseases present?
```
Loss of intellect and memory
Changes in personality
Loss of balance and coordination
Slurred speech
Progressive loss of motility/cognitive function
```
84
What are causes of amnesic syndrome?
Korsakoff syndrome: most common form
Hypoxia
Encephalitis
CO poisoning
85
What are the symptoms of amnesic syndrome?
Procedural memory is intact -> remember how to do things but ANTEROGRADE memory is lost ie patients can't retain new information
Some patients may CONFABULATE to fill in the memory gaps
86
How may a patient with transient global amnesia present?
They remember their identity but may be bewildered as to where they are or have difficulty with anterograde memory - conciousness and cognition should be normal
- usually lasts only 1-24 hours and may be caused by emotional/physical stress or may be due to transient ischaemia of memory structure
87
How does executive dysfunction manifest?
1) Poor planning/decision making
2) Poor judgement
3) Poor reasoning/problem solving
88
What are the 3 cardinal features of frontal lobe syndrome?
1) Executive dysfunction
2) Social behaviour and personality change
3) Apathy
89
What are the two types of head injury?
1. Open: penetration of skull causing direct damage to cerebrum
2. Closed: no penetration = results from shearing forces/acceleration or deceleration
90
What is the triad of extrapyramidal symptoms?
1) Tremor (pill-rolling)
2) Rigidity (stiffness)
3) Bradykinesia
91
What is bradyphrenia?
Slowness of thought
92
What psych condition are 80% of parkinson's cases associated with?
Dementia - but in PD the PD comes first, then dementia.
In LBD the dementia comes first then Parkinsonism symptoms.
Can treat with acetylcholinesterase inhibitors.
(NB: 40% of patients can also experience psychotic symptoms)
93
What are some secondary causes of Parkinson's?
1) Drug-induced eg antipsychotics
2) Repeated infarcts/ischaemia
3) Repeated head injury eg chronic traumatic encephalopathy
4) Parkinsons plus syndrome eg PSP, CBGD, MSA, DLB
94
What psychiatric symptoms/problems may be seen in multiple sclerosis patients?
- Depression (50%)
| - Cognitive impairment (60%) -> especially if late stages
95
What psychiatric problems may epileptic patients face?
1) Depression/suicide risk (4x higher than general population)
2) Cognitive impairment/ psychotic symptoms/ learning disabilities
96
Boy with conduct disorder is most likely to get what personality disorder when older?
Antisocial personality disorder
97
Guy presents with itching but no cause. In the past has presented with tingling and other symptoms. What type of disorder?
Somatisation disorder
98
Deficiency of what vitamin is causing visual disturbances, ataxia and confusion?
Thiamine (B1)
99
What drug is most likely to cause neuroleptic malignant syndrome?
Haloperidol
100
What do nihilistic delusions include?
Beliefs that the patient is dead/ has no future/ parts of body are dead or don't exist
101
What is Knight's move thinking?
Derailment of thought
102
What is schizoaffective disorder?
Group of disorders in which both schizophrenic (psychotic) and affective symptoms are present and develop at the same time (can be manic type or depressive type depending on which episodes are predominant)
NB: symptoms for either don't justify a full diagnosis
DSM-V requires 2 episodes of psychosis, one has to occur for greater than 2wks without concurrent affective symptoms, and one with overlap of psychotic and affective symptoms
103
What is the most important test for a patient on clozapine?
FBC
104
A patient was recently started on antipsychotic and experiences stiffness, fever and tachycardia and seems a bit confused - what test would you do?
CK - could be neuroleptic malignant syndrome
105
A 56-year-old woman presents to your GP practice complaining of pain. She has attended your clinic multiple this year with the same complaint, however all of her investigations are normal. She describes the pain as all over her body. It is worse on some days and better on others, although there doesn't seem to be a pattern to it. The pain is also associated with fatigue and low mood.
The patient has a past medical history of anxiety, depression, migraines and hypothyroidism for which she takes phenelzine, levothyroxine and propranolol. She smokes 20 cigarettes a day and works as a business manager. You suspect fibromyalgia and consider prescribing a selective serotonin reuptake inhibitor (SSRI).
Why shouldn't you prescribe an SSRI in this patient?
Phenelzine is a MAOI - can't prescribe SSRI with MAOI as increased risk of serotonin syndrome
106
What are the preferred SSRIs?
Citalopram or fluoxetine (eps flux. in kids)
107
What is the preferred SSRI after a MI?
Sertraline (improved safety data compared to the others)
108
What drugs should not be used in patients with congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval?
Citalopram or escitalopram (SSRIs)
109
If a patient is on NSAIDs and needs an SSRI, what other drug should be given?
PPI
110
Should an SSRI be given to a patient on warfarin / heparin?
Avoid, give something like mirtazapine instead
111
What does prescribing SSRIs with a triptan increase the risk of?
Serotonin syndrome
112
Should SSRIs be used in pregnancy?
Balance risks vs rewards
First trimester: small risk of CHDs
Third: persistent pulmonary HTN of newborn
Paroxetine has highest risk of congenital malformations, esp in first trimester
113
What are discontinuation symptoms and what can they include?
Symptoms that occur after stopping an SSRI (NB: they should normally be tapered down over 4wk period apart from fluoxetine. Paroxetine has higher risk of discontinuation symptoms)
- Mood changes
- Restlessness, unsteadiness
- Difficulty sleeping
- Sweating
- GI symptoms: pain, cramping, diarrhoea, vomiting
- Paraesthesia
114
What are the 3 types of cluster A personality disorders?
WEIRD
Paranoid - accusatory/distrustful
Schizoid - avoidant
Schizotypal - awkward
115
What are the cluster B personality disorders?
```
WILD
Antisocial
Borderline
Histrionic
Narcissistic
```
116
What are the cluster C personality disorders?
WORRIED
Avoidant
Dependant
Obsessive compulsive
117
SEs of Lithium carbonate
AKI/NEPHROTOXICITY (can get diabetes insipidus also)
- Teratogenic
- Hypothyroidism
- Tremor
- Ataxia/muscle weakness/blurred vision
- Tinnitus
- GI: Nausea and diarrhoea
118
What is the REPORT criteria used for?
ICD-10 criteria for personality disorders
119
SEs of steroids / Prednisolone
Psychosis
Insomnia/sleep disturbance
Can precipitate manic/depressive episode in BPAD
120
Why might hep C patients be prescribed an antidepressant?
If given Peg-IFN-alpha for treatment then high risk of depression (50% of pts)
121
What do you need to warn a parkinson's patient about if put on ropinirole?
Dopamine agonist that increases risk of disinhibition
122
SEs of Lithium carbonate
AKI/NEPHROTOXICITY (can get diabetes insipidus also)
- Teratogenic
- Hypothyroidism
- Tremor
123
SEs of Clozapine
```
Agranulocytosis
Seizures
Long QT syndrome
Sudden cardiac death
Metabolic syndrome (DM, weight gain, CVS problems)
```
124
When is rapid tranquilisation required?
Non-pharm deescalation techniques have failed
- Pt harm to themselves or others
- Use to reduce psychological stress of pt
125
What is a dissociation disorder?
Disorder of physical functions under voluntary control and loss of sensation
- may include conversion disorder where an internal conflict is converted into physical (often neuro) symptoms
126
What is a somatisation disorder?
disorders involving pain or autonomically controlled sensations - officially 'multiple, recurrent and frequently changing physical symptoms of >2yrs'
127
What hormone can be raised after a seizure?
Prolactin
128
Management of chronic fatigue syndrome
Graded exercise +/- CBT
129
Management of medically unexplained symptoms
1) Therapeutic assessment (Physical examination + MSE) but avoid over-investigation
2) Reattribution/reassure/avoid reinforcing beliefs regarding physical symptoms
3) Emotional support +/- fam support
4) Treat any co-morbidities (med/psych)
5) Consider CBT
130
Two big tests in a pt on lithium, how often performed and why
Every 3mths need U&Es and TFTS -> risk of nephrotoxicity and hypothyroidism
131
What is charles bonnet syndrome?
A form of psychosis where the patient has hallucinations with a clear conciousness: usually theres a background of visual impairment
132
Core symptoms of GAD
- restlessness/nervousness
- poor concentration
- sleep disturbance
- muscle tension
- being easily fatigued
- irritability
need at least 3, present all the time, for at least 6mths
133
What drug class should be avoided in GAD?
BDZ
134
What always needs to be identified in agoraphobia (in terms of manifestation of symptoms)?
Is it WITH or WITHOUT a panic disorder
135
What is the only anxiety disorder that affects genders equally?
Social phobia
136
How can social phobia be differentiated from agoraphobia?
Agoraphobia - avoid crowds/public situations
| Social phobia - tolerate anonymous crowds but may get anxious in small groups
137
Investigations for GAD
GAD-7 scale (5 = mild, 10=mod, 15=severe)
HADS
Beck's anxiety scale
138
If a patient who recently stopped an antidepressant describes feeling 'electric shocks' and flu like what is wrong with them?
Discontinuation syndrome
139
Ideal SSRI for panic disorder
Citalopram
140
Ideal SSRI for OCD
Fluoxetine
141
4 phases of CBT for OCD
Relabel, reattribute, refocus, revalue
142
Symptoms of opiate intoxication
- euphoria "warm feeling" - sedation and bradycardia
- low dose ie non IV users: constipation, anorexia, decreased libido
+/- overdose symptoms
143
Presentation of opiate overdose
- Miosis
| - low RR
144
Presentation of opiate withdrawal
May begin 6hrs after injection, peak 36-48hr, last 5-7 days
Rarely life-threatening:
- Craving, nausea, insomnia, agitation
- Flu like symptoms, feverish, abdo cramps, aches
- RUNS - diarrhoea, lacrimation, rhinorrhoea
- Mydriasis
- Goose-flesh: pilomotor unit erection, yawning
145
What drug may be offered for a rapid opiate detox?
Lofexidine (alpha 2 agonist)
146
What do you need to look out for after administering naloxone?
Signs of withdrawal
147
What drugs can be given to a patient in opiate withdrawal?
- Lofexidine or clonidine
- Metoclopramide (anti-emetic)
- Loperamide (anti-diarrhoea)
148
Symptoms of cannabis withdrawal
Only very mild and can occur in long term users eg insomnia, anxiety, irritability
149
Complications of cannabis use
Short term - anxiety, paranoia, panic attacks (can be associated with dangerous driving eg accidents due to slow reaction time)
150
Chronic complications of cannabis use
Can potentially induce schizophrenia, dysthymia, anxiety/depressive illness, amotivational syndrome
151
What are the four types of hallucinogens and what are they associated with?
LSD- affects DA + 5HT transmitter systems
Phencyclidine = angel dust, violent outbursts or ongoing psychosis
Ketamine = cortical anaesthetic effect, smaller doses = dissociation, larger doses = hallucinations and synaesthesia
Magic mushrooms = small doses cause euphoria, larger hallucinations
152
What are the signs and symptoms of hallucinogenics?
Hallucinations and altered perception
Depersonalisation and derealisation
Synaesthesia
Behavioural toxicity
153
What abnormalities can be noted on an ECG in a patient on TCAs?
- T wave flattening
- QT prolongation
- ST elevation/depression
- AV block
154
Stimulant drug classes
- cocAine
- crack cocaine
- amphetamine
- khat
- ecstasy
155
What is the key difference between mania and hypomania?
Degree of functional impairment (also diagnostically hypomania is for <4 days whereas mania is for 7 but this is not always the case)
156
What is the difference between flight of ideas and knight's move thinking?
Flight of ideas: pt speaks quickly and jumps between ideas, associated with mania - there are DISCERNIBLE links
Knights move thinking: seen in schizophrenia, NO links -> loosening of association, pt jumps from topics of conversation
157
If a patient who recently stopped an antidepressant describes feeling 'electric shocks' what is wrong with them?
Discontinuation syndrome
158
Whats the biggest thing to warn TCA users about?
Cheese effect or tyramine interaction - potentially lethal
159
A patient on an antidepressant presents with a black tongue - what is the most likely cause?
TCA eg imipramine
160
What is the triad of serotonin syndrome?
1) Altered mental state
2) Neuromuscular changes: hallmark feature is myoclonus
3) Autonomic dysfunction
161
What complication is associated with MAOIs?
Hypertensive crisis (cheese effect)
162
What are the different types of delusion disorder?
```
Erotomaniac
Fregoli
Otholelli
Folie e deux
Factitious disorder
```
163
What are factors associated with suicide?
- Male sex
- Spring/summer season
- Social class V
- Recent event eg divorce
- Age >40
164
What should be performed before a patient is put on clozapine?
ECG - can cause QT prolongation and tachyarrhythmias
165
What should be prescribed in a patient with acute psychosis with Hx of ischaemic heart disease or dementia?
Typical antipsychotic (avoid the atypical antipsychotics due to risk of cerebrovascular disease)
166
At what time after given should the lithium dose be checked?
8-12hrs
167
What needs regular assessment in patients on long term antipsychotics?
- waist circumference and BMI
| - if suspected DM then check fasting blood glucose levels
168
What are the aetiological factors for schizophrenia?
- Family history
- Genetics
- Cannabis use
- Winter births
- Perinatal trauma
- Paternal age
169
If a patient is depressed but is on an NSAID or aspirin, what drugs should be commenced?
SSRI + NSAID = bleeding risk so GIVE A PPI eg sertraline + lanosprozole
Or avoid SSRI
170
What antidepressant should be prescribed in a patient with a history of ischaemic heart disease?
Sertraline
171
What pathway in the brain is affected in schizophrenic patients who may neglect themselves, struggle with planning, apathy and inattention?
Mesocortical
172
What medication should be avoided with a prescription of SSRIs?
MAOIs eg rasagiline due to risk of serotonin syndrome
173
What are the normal QTc time? What is the risk of prolongation?
<440m/s in men, <470ms in women
Risk of sudden cardiac death and torsades des pointes
174
What is the protocol for managing a patient on lithium?
When starting take the levels 12hrs post dose
Then check weekly until stable level reached
Then check every 3mths
If change in dose - check weekly until levels are stable
Also check TFTS and renal function every 6mths
NB: pt should also be given information booklet, alert card and record book
175
What is Munchausen’s syndrome?
Fictitious disorder
176
What is zopiclone used for?
Sedative used to treat sleeping difficulties
177
What is the strongest risk factor for psychotic disorders?
Family history
178
What SSRI is most likely to lead to QT prolongation and torsades de pointes?
Citalopram
179
What is re-feeding syndrome?
Defined mainly by the low phosphate -> intracellular shift of already low ions due to insulin release upon refeeding
- low phosphate
- low Mg
- low K
- low nitrate
- low thiamine
- low salt and water retention
180
What two factors can affect clozapine levels?
Smoking - quitting can cause a RISE in levels, starting or increasing amount can cause a DROP
Alcohol - stopping drinking can REDUCE the levels whereas alcohol binges can INCREASE the levels
181
What are the warnings of using atypical antipsychotics in the elderly?
Increased stroke and VTE risk
182
What antibodies are found in 90% of cases of primary biliary cirrhosis?
Anti-mitochondrial Abs
183
What is PBC? Which sex does it predominantly affect? What is seen on the bloods, USS and histology?
Autoimmune destruction of medium sized intrahepatic bile ducts and cholestasis + eventually HCC
184
What is late syphilis characterised by?
Dominated by arthritis
185
What abnormalities can be noted on an ECG in a patient on TCAs?
- QT prolongation
- ST elevation
- AV block
186
What is the shortest acting BDZ?
Lorazepam
187
What is the mode of action of barbituates and benzodiazepines?
Both affect GABA transmission: enhance it at GABA-A receptor
Benzos: increased freq of opening
Barbituates: increased duration of opening
188
What impairments is carbamazepine known to cause?
Renal and hepatic impairment
Blood dyscrasias
Bone marrow suppression
189
What mood stabiliser is associated with eye defects eg cortical lens opacities and conjunctivitis?
Carbamazepine
190
What is the MOA of TCAs?
Inhibit uptake of NA and 5HT
191
A patient on an antidepressant presents with a black tongue - what is the most likely cause?
TCA
192
What effect can TCAs have on the blood ie levels of different blood cells?
Leukopenia
Agranulocytosis
Eosinophilia
Thrombocytopenia
193
Side effects of ECT
Headache
Confusion
Memory loss
194
What are the main contraindications for ECT?
Cardiac disease
Respiratory disease
Raised ICP
195
What is the drug of choice in an acutely psychotic pregnant women?
Olanzapine
196
Whats the likely timeframe for post-natal depression?
2-6wks post partum
197
What cardiac abnormalities can be seen on an ECG in anorexia?
```
ST depression
T wave flattening
T wave inversion
Prolonged QT interval
QT slope enhancement
```
198
What is wavy flexibility?
Can be seen in schizophrenia
| Individual's body results in feeling of plastic resistance then subsequent preservation of final posture
199
What are some metabolic and additional causes of delirium?
Hepatic, renal, cardiac and respiratory failure
| Deficiency of B12, Folate, Nicotinic acid, Thiamine (b1)
200
Very common side effect of atypical antipsychotics?
Weight gain (also hyperprolactinaemia)
201
Olazanapine has a higher risk of what two things compared to the other atypical antipsychotics?
Dislipidaemia and obesity
202
Adverse effects of clozapine?
agranulocytosis (1%), neutropaenia (3%)
reduced seizure threshold - can induce seizures in up to 3% of patients
constipation
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
203
What are some side effects of ECT?
Cardiac arrhythmias
Memory loss (short term)
Headache and nausea
204
How may acute dystonia manifest itself?
Torticollis
| Oculogyric crisis
205
What antidepressant may be of advantage to use in older patients?
Mirtazepine - less poly pharmacy and other drug interactions. Also increased appetite and sedation which can be helpful in older patients
206
What is the difference between acute stress disorder and PTSD?
Acute stress reaction/disorder is within 4 weeks of a traumatic event whereas ptsd is after 4 weeks
207
What are the aetiological factors for schizophrenia?
- Genetics
- Cannabis use
- Winter births
- Perinatal trauma
- Paternal age
208
What is the most effective antipsychotic?
Clozapine
209
Excess activity in what dopamine based pathway causes psychosis?
Mesolimbic
210
What pathway in the brain is affected in schizophrenic patients who may neglect themselves, struggle with concentration and inattention?
Mesocortical
211
What drug can you give for akathisia?
Short term benzodiapines
212
What are the normal QTc time?
<440m/s in men, <470ms in women
213
What is a hallmark of neuroleptic malignant syndrome?
Lead pipe rigidity
214
What drug might you give to a patient in an acute manic episode?
Olanzapine (has mood stabilising properties as well as antipsychotic)
215
What is the difference between delirium and psychosis?
Delirium: disorientated, cognition impaired, clouding of consciousness, transient changes, INATTENTION - test via asking them to count backwards, likely to be sick as well
Psychosis: orientated, fairly steady and constant changes in thought, not necessarily visual hallucinations
216
What is korsakoff syndrome?
impairment of recent memory with preservation of immediate recall
217
Defining features of temporal lobe damage?
Alexia
Agraphia
Sensory aphasia
218
What lesions can cause hyperalgesia?
Thalamic
219
Following a placement under section 2 of MHA how long do patients have to appeal?
14 days
220
Immediate treatment of BDZ overdose?
IV flumezanil (GABAA antagonist)
221
Metallic taste in mouth is linked to which psychiatric drug
Lithium
222
What is the key difference between mania and hypomania?
Mania: can exhibit psychotic symptoms
223
What are the first line management of acute stress reaction?
Trauma focused CBT
| +/- BDZ
224
Examples of SNRIs
Venlafaxine
| Duloxetine
225
What are the most potent side effects of mirtazapine?
Weight gain
| Drowsiness
226
What drug is an irreversible inhibitor of acetaldehyde dehydrogenase and used in alcohol withdrawal?
Disulfiram
227
Lithium exposure is associated with which cardiac congenital defect?
Ebstein's anomaly
228
What are the 3 key components of atherosclerotic plaques?
Cells
ECM
Lipids
229
What are the two negative key features of ischaemic heart disease?
Less nutrients
| Less waste removal
230
What are the three possible acute events of an atherosclerotic plaque?
Rupture
Erosion
Haemorrhage
231
What is a SE of TCAs that affects the waterworks?
Urinary retention - its a type of anticholinergic effect. Others may include:
- Dry Mouth
- Tachycardia
- Mydriasis
232
What drug may be given in functional enuparesis?
TCA eg imipramine
233
Why is the risk of AD significantly higher in downs syndrome?
The gene for amyloid precursor protein is found on chromosome 21
234
In a older patient with urinary incontinence, frequent falls, balance issues and possible memory problems, what should be considered?
Normal pressure hydrocephalus
235
When should activated charcoal be offered to overdose patients?
Within first hour of OD
236
At what time should paracetamol and salicylate levels be checked post-overdose?
4 hours - they reach max plasma concentration
237
How is one unit of alcohol defined?
Amount of ethanol the body can metabolise in 1 hr which equates to 8g pure ethanol or 10ml
238
A lady feels insects running along her skin, what is the term used to describe this type of hallucination?
Formication - type of tactile hallucination
239
Drugs for opiate withdrawal
Buprenorphine
Methadone
Lofexidine
240
A patient describes their limbs as rotting and they feel they are already dead. What is this phenomena called?
Cotards
