Psychiatry Flashcards
1
Q
What is Wernicke’s Encephalopathy?
A
An acute neurological syndrome which is caused by a lack of thiamine presenting with a triad of symptoms.
2
Q
What is the cause of Wernickes Encephalopthy?
A
Lack of B1 - seen in alcohol.
3
Q
What are the symptoms of Wernicke’s Encephalopathy?
A
- Ataxia
- Ophthalmoplegia
- Confusion
- Nystagmus
- Altered GCS
- Peripheral sensory neuropathy
4
Q
What investigations should you order in suspected Wernicke’s Encephalopathy?
A
- Clinical history
- Decreased Red cell transketolase
- MRI scan
- LFTs
5
Q
How can you treat Wernicke’s Encephalopathy?
A
- Reversed by IV Thiamine
6
Q
If you fail to treat Wernicke’s Encephalopathy what may occur?
A
Korsakoff Syndrome
7
Q
What is Korsakoff’s syndrome?
What is the pathophysiology?
A
Thiamine deficiency causes damage and haemorrhage from mammillary bodies to the hypothalamus and medial thalamus, this often follows from untreated Wernicke’s Encephalopathy.
8
Q
What is the cause of Korsakoff’s syndrome?
A
Often from untreated Wernicke’s/ chronic Thiamine deficiency
9
Q
What are the symptoms of Korsakoff’s syndrome?
A
Anterograde Amnesia – inability to acquire new memories
Confabulation
Retrograde amnesia – inability to recall past events.
10
Q
How can you diagnose Korsakoff’s syndrome?
A
Clinical impression of symptoms
Basic blood and LFTs (measure Thiamine levels)
Confirmed by MRI – degeneration of Mammillary bodies.
11
Q
How can you treat Korsakoff’s syndrome?
A
IV Pabrinex (high potency B1 replacement) and chlordiazepoxide.
12
Q
Suicide risk assessment - What is SAD PERSONS?
A
SADPERSONS
Sex – Males > females
Age – <19 and >45
Depression
Previous attempts and severity of the means
Ethanol abuse – Alcohol
Rational thinking loss – schizophrenia
Support network loss
Organised plans – e.g. Note, alone, avoid detection, planned and impulsive.
No significant others
Sickness – physical disease
0-2 – no real problems, keep watch.
3-4 – send home, but check frequently
5-6 – consider hospitalisation, involuntary or voluntary
7-10 – Definitely hospitalise, involuntary or voluntary `
13
Q
What is Generalised Anxiety Disorder?
A
Anxiety not specific to environmental circumstance –> Excessive worry about everyday events/problems.
14
Q
What are the risk factors for GAD?
A
Female, 35-54, Divorced/alone
15
Q
What are the causes of GAD?
A
Genetic and Environmental factors
16
Q
What are some diagnostic features of GAD?
A
- Anxiety is hard to control
- Excessive anxiety more days than not over 6 months (90 days at least)
- Adults 3 or more of the following, Children 1 or more of the following
- Impairment in daily life
- Not medication or drug abuse.
17
Q
What are some of the clinical features of GAD?
A
- Restlessness/ on edge
- Easily fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
Clinical features can be put into 5 categories Autonomic, chest/abdo, general, mental state, non-specific
18
Q
What investigations should be carried out for GAD?
A
Rule out physical illness
- Thyroid
- B12/folate
- Medication
- Alcohol/bento use (withdrawal symptoms)
19
Q
What is the management of GAD?
A
Step 1 - educate, exercise, stop smoking/drinking
Step 2 - psychological support/groups
Step 3 - high intensity support CBT/ medication
20
Q
What medication could you prescribe for GAD?
A
Rapid response –> Benzodiazepine (longer acting preparations like diazepam, clonazepam)
Long term –> Sertraline/SSRIs/ Clomipramine
Busprione (5-H1TA partial agonist)
CBT
21
Q
What is Alcohol Dependence?
A
Dependence – Cluster of psychological, behavioural, and cognitive phenomena in which a substance takes on higher priority than other behaviours which once held greater value.
22
Q
What are the features of Alcohol dependence?
A
Compulsion to drink Tolerance Difficulties controlling consumption Physiological withdrawal Neglect of alternatives to drinking Persistent use of alcohol despite harm.
23
Q
What are some risk factors for alcohol dependence?
A
Male Unemployment + stress Peer pressure Younger age of usage/mental illness History of substance abuse Genetics
24
Q
What are two alcohol dependence assessments?
A
- Audit
- CAGE
25
What is the cage assessment?
C – Have you ever felt you should cut down on your drinking?
A – Have you ever become annoyed by criticisms of your drinking?
G – Have you ever felt guilty about your drinking?
E – Have you ever had a morning eye opener to get rid of a hangover?
26
What is Tweak (Alcohol dependence)?
- Tolerance (>6 drinks = 2 points)
- Worried (yes = 2 points)
- Eye opener = 1 point
- Amnesia = 1 point
- Cut down = 1 point
>3 points = problem with alcohol
27
What investigations and results would you expect in an alcoholic patient?
- Raised MCV - Macrocytic anaemia
- Vitamin b12+ folate deficiency = with alcohol
- Deranged LFTs – GGT, AST,ALT
- Thrombocytopenia – reduced platelets
- Breath test
- Screening
28
What is the appropriate management of alcohol dependence?
Acamprosate – reduces craving
Disulfiram – gives hangover SE if alcohol is consumed (alcohol intake inhibits acetaldehyde dehydrogenase)
Naltrexone reduces the pleasure alcohol brings
Support groups/CBT/motivational interviewing
29
When do symptoms usually start in alcohol withdrawal?
Symptoms
Seizures
Delirium
Symptoms 6-12 hours
seizures - peak at 36
Delirium Tremens - 48-72 hours.
30
What are some of the symptoms of alcohol withdrawal?
- Tremors
- Sweating
- N/V
- Sound sensitivity
- Insomnia /sleep disturbance
- Mood disturbance, e.g. anxiety, on edge, depression
- Autonomic hyperactivity – tachycardia, HTN, pyrexia, mydriasis
- Seizures – seen at 36 hours
- Delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
31
What is the appropriate management of alcohol withdrawal?
Chlordiazepoxide – Benzodiazepine
IV Pabrinex – vitamin supplementation
Thiamine 100mg BD
Complex withdrawals should be admitted to hospital
32
Mental Health Act.
What are the 5 principles?
1. Assume capacity
2. Individual supporterd to make their own decision
3. Unwise decisions do not mean lack of capacity
4. Best interests
5. Least restrictive practice
33
Mental Health Act.
What can someone with capacity do?
- Understand
- Retain
- Weigh up
- Communicate decision
34
What is a mental disorder?
If someone is in A&E are they technically admitted?
Mental disorder – any disorder or disability of the mind – excluding alcohol and drug use.
No.
35
What are advanced statements?
Not legally binding, patient documents their wishes should they lack capacity in the future.
36
What are advanced decisions?
Legally binding document, made with capacity, may be refusing medical interventions.
37
What is the lasting power of attorney?
person to make decisions for them if they lack capacity in the future.
38
What is a court of protection?
make decisions if no lasting power of attorney.
39
What is a Deprivation of Liberty Guard?
Allows deprivation of someone’s liberty who lacks capacity under legal framework in hospital or care environment if it’s in its patient best interest.
40
What is an S12 doctor?
recognised under S12 of the MHA as having an expertise in diagnosing
41
Mental Health Act
What is a Section 2?
Duration:
Reason:
Approval:
Evidence:
Duration: 28 days
Reason: Assessment
Approved by 2 Drs (1 S12) + 1 AMHP
Evidence: Patient suffers from disorder and detained for own and others safety,
42
Mental Health Act
Section 3
Duration:
Reason:
Approval:
Evidence:
Duration: 6 Months
Reason: Treatment
Approved by 2 Drs (1 S12) + 1AMHP
Evidence: Patient suffers from disorder and detained for own and others safety, can be renewed, appropriate treatment must be available, and burden of proof is much greater.
43
Mental Health Act
Section 4
Duration:
Reason:
Approval:
Evidence:
Duration: 72 hours
Reason: Emergency order – urgent when waiting for 2nd Dr would cause undesirable delay
Approved by 1 Dr and 1 AMHP
Evidence: Patient suffers from disorder and detained for own and others safety, not enough time for 2nd Dr.
44
Mental Health Act
Section 5 (4)
Duration:
Reason:
Approval:
Evidence:
Duration: 6 Hours
Reason: Patient admitted but wanting to leave
Approved by: Nurse holding power
Evidence: Cannot be coercively treated whilst under section.
45
Mental Health Act
Section 5 (2)
Duration:
Reason:
Approval:
Evidence:
Duration: 72 Hours
Reason: Allows time for section 2 and 3
Approve by: Doctors holding power
Evidence: Cannot be coercively treated whilst under section
46
Mental Health Act
136
Duration:
Reason:
Approval:
Evidence:
Reason: Mental disorder in public – further assessment – section 2/3
Approved by Police sections
47
Mental Health Act
Section 135
Duration:
Reason:
Approval:
Evidence:
Reason: Mental disorder at home – further assessment – section 2/3
Approved by: Police stations
Evidence: Needs court order to access patient home and remove them
48
What is seretonin syndrome?
A syndrome where too much serotonin accumulates in the body.
49
What is the cause of seretonin syndrome?
- SSRIs
- MAO inhibitors
- Ecstasy
50
What is Serotonin Syndrome?
A syndrome where too much serotonin accumulates in the body.
51
What are the symptoms of Serotonin syndrome?
Increased activity - agitation/restlessness
- Clonus/myoclonus
- Hyperreflexia
- Confusion
- Tremor
- Diarrhoea
- Muscle rigidity/loss of coordination
- Dilated pupils
- Autonomic dysfunction tachy/high bp.
52
What are the signs of Seretonin Syndrome?
- Elevated CK, WCC
- Deranged LFTs
- Metabolic acidosis
Like NMS
53
What is the treatment of serotonin syndrome?
- Benzodiazepines
| - Cyproheptadine – 5H2-a antagonist
54
What is the difference between serotonin syndrome and NMS?
Serotonin – increased activity + acute onset
Neuroleptic – reduced activity + insidious onset (4-11 days)
Similar signs - metabolic acidosis, CK, WCC, LFT
55
What is Neuroleptic malignant syndrome?
life threatening reaction that can occur in response to neuroleptic or antipsychotic medication.
10% mortality with atypical antibiotics.
56
What is the pathophysiology of NMS?
Unknown but dopamine blockade induced by antipsychotics triggers a massive glutamate release
57
What are the signs and symptoms of NMS?
Reduced activity
Fever, altered mental status, muscle rigidity and autonomic dysfunction
HTN, Tachycardia/pnoea
Biological - elevated CK, WCC and metabolic acidosis
58
What drugs can cause NMS?
Most frequently patients taking haloperidol and chlorpromazine
Can also occur with dopaminergic drugs e.g. levodopa when suddenly stopped or changed.
59
What is the treatment for NMS?
Bromocriptine – to reduce dopamine blockade (dopamine agonist)
Dantrolene – to reduce muscle spasms
60
What are the symptoms of opioid intoxication?
- Drowsy
- Mood change
- Bradycardia
- HTN
- Pupil constriction
- Resp depression
- Decreased body temp
61
What are the symptoms of opioid withdrawal?
- Muscle cramps
- Low mood
- Insomnia
- Agitation
- Diarrhoea
- Shivering
- Flu like symptoms
62
What are the complications of opioid misuse?
Infection due to sharing needles
VTE
Bacterial infection secondary to injection – IE, Septic arthritis, septicaemia and necrotising fasciitis.
Overdose – respiratory depression
Crime/prostitution
63
What is the appropriate management of opioid overdose/misuse?
EMERGENCY - IV Naloxone – rapid onset + short
Opioid dependence – detoxification (last up to 4 weeks in residential, 12 in community)
Methadone
Buprenorphine
Harm reduction – needle exchange and offering testing for hiv, hep B&C
64
What is PTSD?
A mental health condition which is caused by a traumatic experience.
65
What clinical features would you find in PTSD?
Re-experiencing (flashbacks, nightmares)
Avoidance – avoiding people or circumstances resembling the traumatic event
Hyper arousal – exaggerates responses to small threats
Emotional numbing – feeling detached
May also manifest as depression, drug or alcohol misuse, anger, and unexplained physical symptoms
66
How can you diagnose PTSD?
Clinical diagnosis + criteria met.
Diagnosis - PTSD -ICD10
Symptoms arise within 6 months of a traumatic event
Symptoms present for at least 1 month with significant distress/impairment in daily functioning
67
What is the management of PTSD?
Watchful waiting may be used for mild symptoms less than 4 weeks.
1st – CBT and EMDR (eye movement desensitisation and reprocessing)
2nd – Venlafaxine or a SSRI (sertraline) --> Risperidone in severe cases
68
What is the appropriate management of PTSD symptoms?
Tx of anxiety symptoms - BDZ, Antidepressants and Propranolol
Treatment of intrusive thoughts/impulsiveness - Carbamazepine, valproate, lithium
Treatment of psychotic symptoms - antipsychotics
Treatment of sleep disturbance - Mirtazapine
69
What is an Obsession?
Obsessions – unwanted intrusive thoughts, images or urges that repeatedly enter the person’s mind
70
What is a compulsion?
Compulsion – repetitive behaviours or mental acts that the person feels drive to perform
71
What are the causes of OCD?
Genetic
Psychological trauma
Paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS)
72
What are the symptoms of OCD?
- Obsessions
- Compulsions
- Emotions – intense anxiety & distress.
73
What are some associated conditions with OCD?
- Depression (30%)
- Schizophrenia (3%)
- Sydenham’s chorea
- Tourettes Syndrome
- Anorexia Nervosa
74
What is the management of OCD for:
Mild impairment
Moderate impairment
Severe impairment
If functional impairment is mild
Low intensity treatment – CBT including exposure and response prevention (ERP)
If this is insufficient/they can’t engage – offer a course of SSRI or more intense CBT+ERP
If moderate functional impairment
Offer a course of either SSRI (any for OCD but fluoxetine for Body dysmorphia) or more intense CBT + ERP
If severe functional impairment
Offer a combined treatment with SSRI and CBT with ERP.
75
What are 4 examples of sleep disorders?
- Narcolepsy
- Sleep apnoea
- Circadian rhythm disorder
- Parasomnia
76
What is Narcolepsy?
Narcolepsy – always tired through the day that they cannot resist
77
What is sleep apnoea?
Sleep apnoea – repeated and intermittent upper air collapse during sleep
78
What is a Circadian Rhythm disorder?
Circadian rhythm disorder – mismatch between sleep-wake cycle and circadian rhythms (jet lag/shift work)
79
What is parasomnia?
Parasomnia – Restless leg syndrome, nightmares/tremors and sleepwalking/talking
80
What is some good sleep hygiene advice?
- Limit – caffeine, alcohol and cigarettes
- Less noise/lights/ screen use
- Reduce sleep
- Regular pattern
81
What are 3 core symptoms of depression?
3 core symptoms
- Low mood
- Low energy (anergia)
- Loss of enjoyment (anhedonia)
82
What are the clinical features of depression - DEADSWAMP?
Depressed mood most of the day
Energy low
Anhedonia
Death thoughts – suicide
```
Sleep disturbance (insomnia/hypersomnia)
Worthlessness/guilt/hopelessness
Appetite/weight change
Mentation decreased – lack of concentration
Psychomotor agitation /retardation
```
83
What tools can you use to assess depression?
- PHQ-9
| - HADs (Hospital Anxiety and Depression Scale)
84
What is the criteria for Diagnosing depression?
Mild
Moderate
Severe
- Mild = 2 core 2 others
- Moderate = 2 core and 3 others
- Severe = 3 core and 4 others
85
What is the treatment of Depression?
Mild
Moderate
Severe?
Mild depression
Lifestyle modification – sleep hygiene, manage anxiety, physical activity, CBT
Avoid use of Antidepressants but consider those with a history of moderate/severe depression.
Management of moderate depression
Lifestyle
Antidepressants
High intensity psychological therapies e.g., CBT via IAPT
Management of Severe depression
Rapid specialist mental health assessment with inpatient admission consideration
86
What is the pharmacological management of depression?
```
1st – SSRI – Citalopram, fluoxetine, paroxetine, or sertraline (QT prolongated in citalopram)
2nd – Alternative SSRI
3rd – NaSSA – Mirtazapine
4th – TCA (Amitriptyline)
5th – MAO - Moclobemide
```
*Sertraline is a good one for those with chronic conditions as fewer s/e
87
What is Delirium?
Acute sudden confusion.
88
What are the causes of Delirium - PINCH ME?
- Pain
- Infection/intoxication
- Nutrition – vit deficiency, thiamine, b12, folate
- Constipation
- Hypoxia, hydration
- Medication/substance abuse (benzodiazepines, anticholinergics, opiates, anticonvulsants).
- Environmental
89
What are some features of Delirium?
- Inattention
- Disorientated
- Visual hallucinations
- Paranoia
90
What are some ddx for delirium?
Dementia, Anxiety, Psychosis, Withdrawal, post ictal, normal pressure hydrocephalus, CJD, HD, Picks disease Wilsons, neurosyphilis
91
What is the difference between a hypoactive and hyperactive state in delirium?
What do they commonly get misdiagnosed as?
Hyperactive
Agitation
Lack of cooperation/disorientation
Delusions
Confused with schizophrenia
Hypoactive
Apathy
Withdrawal
Quiet confusion
Easily missed – diagnosed as depression.
THE PRESENTATION MAY BE MIXED.
92
What is the lifestyle management/initial management of delirium?
Treat precipitating cause
- Educate family and make the environment safe
- Avoid sedation unless severely agitated
- Regular follow ups
93
What is the medication management of Delirium?
Main
- Haloperidol
- Olanzapine
Other benzo
- Risperidone
- Quetiapine
Benzodiazepines – only chlordiazepoxide to be used in alcohol withdrawal or else it’ll worsen the delirium.
94
What are the differences between Dementia and Delirium?
Delirium
```
Acute
Outside of brain pathology
Can improve
Inattention
Impaired consciousness
Treatable
Fluctuates significantly
```
Dementia
```
Gradual
Brain pathology
Can’t improve
Still alert
Conscious
Untreatable
Normally has a good part of the day and a bad part of the day
```
95
What is Anorexia Nervosa?
Anorexia is a serious mental disorder where people try and keep their weight as low as possible.
96
What is the epidemiology of anorexia nerovsa?
90% female and predominately young teenagers to young adults
0.5-1% prevalence in general population
97
What is the diagnostic criteria of Anorexia Nervosa?
Restriction of energy intake relative to requirements leading to significantly low Body weight
Intense fear of gaining wait or becoming fat even though underweight
Disturbance in the way which one’s body weight or shape is experienced or denial of seriousness of low body weight.
98
What are some red flags for anorexia nervosa in terms of prognosis?
- BMI <13 or below 2nd centile or a weight loss of over 1kg/week
- Temp <34.5
- Hypotensive - <80/50
- SaO2 <92%
- Long QT, flat T waves
- Weakness in muscles
99
What is the SCOFF questionnaire and what is it used for?
Screening tool for eating disorders.
```
Sick (make yourself)
Control (lost overeating)
One stone lost in 3 months
Feel fat
Food (dominates life)
```
100
What is the general management of Anorexia Nervosa?
- Restore nutritional balance
- Involve carers
- Psychological therapies
101
What is the management of anorexia nervosa for adults?
One of:
Eating disorder focused CBT – ED-CBT
Maudsley anorexia nervosa treatment for adults (MANTRA)
Specialist supportive clinical management (SSCM)
102
What is the management of Anorexia Nervosa for Children?
First line – anorexia focused family therapy
| Second line – CBT-ED
103
What is Bulimia Nervosa?
A type of eating disorders characterised by episodes of binge eating following by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercise.
104
What is the DSM 5 diagnostic criteria for Bulimia Nervosa?
Recurrent episodes of binge eating and a feeling of loss of control
Recurrent compensatory behaviour to prevent weight gain
Episodes occur at least once a week for 3 months
Self-evaluation is influenced by body weight or shape
Disturbance does not occur exclusively during episodes of anorexia nervosa
105
What are some signs of Bulimia Nervosa?
Oesophagitis
Russell’s sign (callouses on back of hands)
Oedema
Cardiomyopathy (laxatives)
Metabolic disturbance
Vomiting can cause metabolic alkalosis = hypokalaemia/hypochloraemia
Laxative abuse can cause metabolic acidosis
106
What Metabolic disturbance can Bulimia Nervosa induce?
Vomiting can cause metabolic alkalosis = hypokalaemia/hypochloraemia
Laxative abuse can cause metabolic acidosis
107
What is the appropriate management of Bulimia Nervosa?
Referral to specialist in all cases is appropriate.
Self-help resources for adults and CBT – ED if self-help is ineffective or unacceptable
Children should be offered bulimia nervosa family therapy
High dose fluoxetine is currently licensed but lacks long term data.
108
What is Bipolar Disorder?
Chronic mental health disorder characterised by periods of mania & hypomania along with periods of depression.
109
What is the epidemiology of Bipolar Disorder?
Typically develops in teen years and lifetime prevalence is 2%
110
What are the types of Bipolar Disorder?
Type 1 disorder – mania and depression (most common)
Type 2 disorder – hypomania and depression
Cyclothymia – subclinical depression and hypomania, not meeting the criteria of bipolar.
111
What are the causes of Bipolar Disorder?
- Post-partum female
- Substance misuse
- Chronic illness
- Past trauma/mental health problems
112
What is the diagnostic criteria for Bipolar disorder?
Requires at least two episodes, one of which must be mania/hypomania for a diagnosis
113
What are signs of Mania and how long does it usually last?
Over one week.
```
Uncontrollable elation
Over activity
Pressure of speech
Impaired judgement/risk taking
Social Disinhibition
Grandiosity
Psychotic symptoms
```
114
What are the signs of Hypomania and how long does it usually last?
Over 4 days
```
Elevated mood – angry/irritable usually
Increased energy and talking
Poor concentration
Mild reckless behaviour
Overfamiliarity
Increased libido + confidence
Decreased need for sleep + eating.
```
115
What is the management of Bipolar Disorder?
Psychological therapies specifically designed for bipolar disorder
Address comorbidities – 2/3x risk of diabetes, CVD and COPD.
Mania
Lithium to stabilise mood (up to two weeks) w/ antipsychotics/bdz due to delayed effect
- Includes haloperidol, olanzapine and risperidone – If patient is on AP consider stopping
- If on long term lithium check TSH, U&E and hydration every 6 months.
- 2nd line - Valproate/lamotrigine if lithium is not tolerated, CBT+ECT can be helpful in severe mania
Management of depression - talking therapies or fluoxetine is the antidepressant of choice.
116
What is Agoraphobia?
Anxiety/panic over public places that are difficult to escape
117
What is the management of Agoraphobia?
Short term – BDZ
SSRIs
Relaxation and exposure training/techniques
118
What is refeeding syndrome and what is the pathophysiology of it?
Refers to metabolic abnormalities that occur on feeding a patient following a period of starvation.
Occurs when an extended period of catabolism ends abruptly switching to carbohydrate metabolism
119
What are some metabolic consequences of refeeding syndrome?
Hypophosphatemia
Hypokalaemia
Hypomagnesaemia – may predispose to torsades de pointes (deadly heart rhythm)
Abnormal fluid balance
120
What are some signs of refeeding syndrome?
Drop in phosphate due to rapid initiation of food after >10 days of undernutrition
```
Rhabdomyolysis
Resp/cardiac failure
Low bp
Arrhythmias
Seizures
```
121
Who would be considered high risk of Refeeding syndrome?
Patients are considered high-risk if one or more of the following:
* BMI < 16 kg/m2
* unintentional weight loss >15% over 3-6 months
* little nutritional intake > 10 days
* hypokalaemia, hypophosphatemia or hypomagnesaemia prior to feeding (unless high.
Patients are high risk If two or more of the following:
* BMI < 18.5 kg/m2
* unintentional weight loss > 10% over 3-6 months
* little nutritional intake > 5 days
* History of alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
122
What is the management of Refeeding syndrome?
Slow refeeding
Thiamine/vit Ba and multivitamins
Monitor for:
- Low phosphate
- Low potassium
- High glucose
- High magnesium
123
What is Schizophrenia?
A type of psychosis. A severe and long-term mental health condition.
124
What are some risk factors for schizophrenia?
Family history is said to be the strongest, stressful life event and drug use also linked.
125
What are some subtypes of schizophrenia?
Paranoid, Hebephrenic/disorganised, Catatonic, Undifferentiated, Residual – low intensity, Simple (progressive)
Hebephrenic schizophrenia – predominated by thought disorders with poor prognosis
Paranoid schizophrenia – lots of positive symptoms
Simple schizophrenia – mainly negative symptoms with a history of psychosis
126
What is the cause of Schizophrenia?
Excess dopamine production
Overactivity of the neurones = Mesolimbic = hallucinations/disorders (positive symptom)
Under activity of the neurones = Mesocortical = blunted, anhedonia, apathy (neg symptom)
127
What are some first rank symptoms of schizophrenia?
Passivity phenomena
Thought disorders – withdrawal, insertion, broadcasting
Hallucinations – 3rd person auditory
Delusional perception – delusions of passivity, influence or control
128
What are some second rank symptoms for schizophrenia?
```
Any hallucination
Catatonic behaviour
Negative symptoms (no talking, acting incorrectly, no pleasure/motivation)
Breaks in train of thought
Neologisms
Impaired insight
Change in behaviour
```
129
What is the ICD-10 Diagnostic criteria for schizophrenia?
* One or more of any first rank symptom
| * Or two or more of the second rank symptoms
130
What are some appropriate investigations to carry out on someone who is a suspected schizophrenic?
- Rule out drugs – urine screen
- Rule out alcohol – LFTs, FBC, Macrocytosis, Thrombocytopenia
- Rule out syphilis = sero test
- Rule out brain lesion – CT head
131
What is the management of Schizophrenia?
1st line CBT offered to all and oral atypical antipsychotics are first line
2nd line – typical antipsychotics
3rd line – clozapine for treatment resistant schizophrenia
CV disease to be monitored as increased incidence in schizo patients linked to AP medication
132
What is Psychosis?
An acute condition where people lose contact with reality which usually includes hallucinations and delusions.
Peak at 15-30.
133
What conditions is psychosis seen in?
```
Schizophrenia
Psychotic depression
Bipolar
Puerperal psychosis
Brief psychotic disorder – symptoms less than one month
Neurological conditions e.g. PD and HD.
Prescribed drugs – corticosteroids
Illicit drugs – Cannabis, phencyclidine (PCP)
```
134
What are some causes of psychosis?
Alcohol and drug misuse/withdrawal
Too much dopamine
Psychological causes - Schizophrenia, Bipolar, severe stress/anxiety, severe depression, lack of sleep.
Medical conditions – Brain tumour, HIV/AIDS, malaria, syphilis, Alzheimer’s, PD, hypoglycaemia, lupus, MS
135
What are two positive symptoms of psychosis?
Hallucinations
| Delusions
136
What are some negative symptoms of psychosis
Flattened affect
Cognitive difficulties
Poor motivation
Social withdrawal
137
What are some associated features with psychosis?
- Agitation and aggression
- Neurocognitive impairment
- Depression & thoughts of self-harm
138
What is Puerperal psychosis?
Postnatal psychosis (puerperal psychosis)
A severe form of post-natal depression with the same symptoms as normal psychosis but can also have changes in mood - mania/hypomania.
139
What investigations should you do for psychosis?
Psychiatric evaluation
Investigate any indication of underlying pathology that can cause psychosis.
140
What is the appropriate management of psychosis?
Refer to psychiatry - emergency.
Offer antipsychotic with psychological interventions --> Family intervention and CBT.
Review medication and agree a time within a month to reassess situation.
Clozapine can be given in psychosis + schizophrenia if treatment has failed x2.
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What is Panic Disorder?
Period of intense fear characterised by a group of symptoms that develop rapidly, reach the peak at 10 mins and generally don’t last longer than 20-30 mins.
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What are some risk factors for Panic Disorder?
- Loneliness
- Living in a city
- Poor education
- Early parental loss
- Sexual/physical abuse
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What are the symptoms of Panic Disorder?
```
Anxiety
Tachy, feeling faint, sweating and nauseous
Chest pain, sob
Hot flushes and chills
Trembling/shaking/numbness/pins and needles
Dry mouth/choking sensation
Ring in ears
Churning stomach / need to go the toilet
```
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What is the management for Panic Disorder?
- CBT and talking therapies
- Referral to specialist if nothing works
Pharmacological management
1st – SSRIs (sertraline) if not suitable use a TCA (Clomipramine)
2nd – pregabalin or clonazepam
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What is the difference between an illusion and a hallucination?
Illusion – Misperception of a real external stimulus (affect driven)
Hallucination – a disorder of perception in the absence of external stimuli
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What type of hallucinations are there?
Auditory
Visual
Olfactory
Gustatory = taste
Tactile
Hypnogogic – on falling asleep
Hypnopompic – on waking up
Autoscopic – seeing oneself
Reflex – stimulation in one modality causes a hallucination in the other
Extracampine – hallucinations outside of sensory fields
Charles bonnet – visual associated with eye disease
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What is a Delusion?
A belief that is:
- Firmly held.
- Not affected by rational argument/evidence
- Not a conventional belief
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What is the difference between a primary and secondary delusion?
Primary delusions - A new meaning arises in connection with some other psychological event.
Secondary delusions - Can be understood as arising from some other morbid experience.
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What are 5 types of Delusions?
Persecutory – thinking someone is going to hurt them.
Grandiose – inflated self-importance
Delusions of reference – events/actions take on special significance to a patient.
Nihilistic – delusion of almost nothingness – not existing, being dead, insides rotting etc.
Hypochondrial – firm belief that they have a disease.
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What is psychosis?
severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality
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What is Neurosis?
mild mental illness involving symptoms of stress but not a radical loss of touch with reality.
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What is a passivity phenomena?
controlled by someone else
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What is meant by blunting of affect?
an objective absence of normal emotional responses, without evidence of depression or psychomotor retardation.
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What is meant by incongruity of affect?
Emotional responses which seem grossly out of tune with the situation or subject being discussed.
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What is meant by catatonia?
significantly excited/inhibited motor activity
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What is psychomotor retardation?
slowing of thoughts/movements.
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What is meant by concrete thinking?
lack of abstract thinking = Asperger’s
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What is meant by confabulation?
give false account to fill in a gap in memory (Korsakoff = most common)
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What is meant by neologism?
new word formation – it seems right to them.
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What is meant by Anhedonia?
inability to experience pleasure.
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What is meant by Akathisia?
inner restlessness and always in motion (rocking)
162
What is meant by:
Pharmacokinetics
Pharmacodynamics
Pharmacokinetics – what a body does to a drug (Absorption, distribution, metabolism, elimination) ADME
Pharmacodynamics – what the drug does the body (receptor sensitivity, agonism/antagonism)
163
What is meant by a flat effect?
No emotional expression
164
What is a mannerism?
repeated involuntary movements
165
What is Belle indifference?
lack of concern for implications of symptoms
166
What are the 5 types of Thought Alienation?
Thought insertion
Thought withdrawal – someone removing their thoughts
Thought broadcast
Thought echo
Thought block – can’t continue idea
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What is meant by splitting?
Believing that people are either all good or all bad at different times due to intolerance of ambiguity. It is commonly seen in borderline personality disorder.
168
What is idealisation?
Expressing extremely positive thoughts of self and others while ignoring negative thoughts
169
What is meant by identification?
the unconscious assumption of the characteristics, qualities, or traits of another person
170
What is meant by projection?
Attributing an unacceptable internal impulse to an external source (vs displacement)
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What does fixation mean?
Partially remaining at a more childish level of development e.g. when a surgeon throws a tantrum in the theatre because the last case ran late (vs regression)
172
Lilliputian and formication are two hallucinations. What are they?
Lilliputian – visual hallucinations of small animals
Formication – insects crawling on the skin
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What is meant by:
Egosystonic?
Egodystonic?
Egosystonic – behaviour is consistent with ones ideal self image (does like their own thoughts/behaviours)
Egodystonic = conflict with ones ideal self-image (does not like their own thoughts/behaviours)
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What are some types of antidepressants?
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin Noradrenaline Reuptake Inhibitors (SNRIs)
Monoamines Oxidase Inhibitors (MAO Inhibitor)
Tricyclics
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What are some types of Selective serotonin reuptake inhibitors and what are some common side effects?
Sertraline
Citalopram
Fluoxetine
Paroxetine
Side effects - Headache, Nausea, Insomnia
176
What are some types of Serotonin Noradrenaline Reuptake Inhibitors and what are some common side effects?
Venlafaxine
Duloxetine
Mirtazapine
Side effects - constipation, tiredness, insomnia, loss of appetite, loss of libido.
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What are some types of Monoamine Oxidase Inhibitors and what should you avoid when taking them?
- Rasagiline
- Selegiline
- Isocarboxazid
- Phenelzine
Avoid high fat diet (+cheese) as contains tyramine hypertensive crisis
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What are some examples of Tricyclic Antidepressants and what are some side effects?
Amitriptyline
Clomipramine
Side effects - Tachycardia, dry mouth, blurred vision, anticholinergic/muscarinic effects, postural hypotension, sedation, weight gain.
179
What are some short acting benzodiazapines?
- Clorazepate
- Midazolam
- Triazolam
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What are some non-benzo hypnotic agents?
[psychoactive drugs which are used to induce sleep]
- Zopiclone
- Zaleplon
- Zolpidem
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What can antipsychotic treatment cause?
Extra pyramidal side effects.
182
What are some examples of EPSE?
EPSE of antipsychotics
Hours = dystonic reaction – muscle spasms
4 weeks = parkinsonism (tremor, bradykinesia)
6-60 days = Akathisia (inner restlessness)
Long term use = tardive dyskinesia – stiff jerky movements of your face and body.
183
How can you treat EPSE?
- Procyclidine
- Propranolol +/- cyproheptadine
- Tetrabenazine
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EPSE treatments
Procyclidine - what does it treat?
Propranolol/cyproheptadine - what does it treat?
Tetrabenazine - what does it treat?
Procyclidine – treatment of EPSE - Acute dystonia/parkinsonism
Propranolol/cyproheptadine -Treatment of Akathesia
Tetrabenazine - Treatment of EPSE Tardive Dyskinesia although its generally reversible.
185
What are some side effects of anti-cholinergics/muscarinic drugs?
- Tachycardia
- Dry mouth
- Blurred vision
- Constipation
- Urinary retention
- Drowsiness
186
What are some side effects of hyperprolactinaemia?
Can be induced by dopamine antagonists as dopamine causes a negative feedback mechanism to prolactin.
- Galactorrhoea
- Amenorrhoea
- Infertility
- Sexual dysfunctional (vaginal dryness)
- Long term = osteoporosis
187
What is the mesolimbic pathway?
Mesolimbic pathway – reward pathway – dopaminergic pathway in the brain. Blocking this reduces the positive symptoms of psychosis.
188
What severe side effect can clozapine cause and when should it only be used?
Clozapine can cause agranulocytosis so should be used only in treatment resistant schizophrenia/psychosis.
- Can also cause constipation + hypersalivation.
189
Why are EPSE more common in typical antipsychotics?
EPSEs are more common in typical antipsychotics whereas atypical antipsychotics have less activity at the D2 receptor so less activity.
190
What are 4 key Neurotransmitters?
- Dopamine
- Serotonin
- Acetylcholine
- Glutamate
191
Where does the following pathways begin?
Dopamine pathway
Serotonin Pathway?
Dopamine pathway begins in substiantia nigra
| Serotonin pathway begins in the raphe nuclei
192
What does issues in the following pathways cause?
Tuberoinfundibular pathway
Nigrostriatal pathway
Tuberoinfundibular pathway – causes excess prolactin
Nigrostriatal pathway causes movement disorders
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What are some side effects of clozapine?
- Agranulocytosis
- Reduced seizure threshold
- Sedating
- Postural hypotension
- Toxic megacolon 1 in 1800
- Cardiomyopathy 1 in 2500
- Extreme salivating
194
What is lithium used to treat and how does it work?
Use - acute treatment of mania
Works by inhibiting cAMP production (cAMP inhibits monoamines)
195
What are some S/E of lithium?
- Fine tremor
- Impaired renal function
- Nephrogenic DI
- Weight gain
- Oedema
- Hypothyroidism
- Cardiac – t wave flattening/inversion
- Leucocytosis
- Teratogenic!
196
What are some signs of lithium toxicity?
Levels above >1.0mmol/L - onset is sudden – course tremor, ataxia, weakness, N&V
Levels above >2.0mmol/L - nystagmus, dysarthria, impaired consciousness, hyperactive tendon reflexes, oliguria, hypotension, convulsions, tremor, fasciculations, renal failure, death
197
What is a common s/e seen in the use of atypical antipsychotics?
Side effect of weight gain is seen in All atypical antipsychotics
- Most with olanzapine/clozapine
- Lowest with apriprazole
198
Give an example of an NaSSA and its side effects
Mirtazapine
sedation and weight gain.
Give an example of a NaSSA and its side effects
- Mirtazapine
- Sedation, weight gain
199
What are the types of personality disorder?
Simple overview of cluster A
Paranoid – delusional, jealousy, conspiracy
Schizotypal – Weird and magical, circumstantial, bizarre and peculiar
Schizoid – Voluntarily withdraw from social interaction
Simple overview of Cluster B
Antisocial – impulsive, lack of guilt, low anger tolerance
Borderline – act without regard of consequences, unstable affect, mood swings.
Histrionic – dramatic, shallow, extrovert, sexually inappropriate.
Narcissistic – grandiosity, egotistical
Simple overview of Cluster C
Avoidant – tense and apprehensive
Dependant – need to be cared for, cant make own decisions
Anankastic – stubborn, perfectionism, Egosystonic, inflexibility, OCPD
200
What is Emotionally unstable personality disorder?
Borderline Personality Disorder – 0.5-2% incidence, not lifelong and psychosocial treatment may promote long term recovery
201
What are the causes of EUPD?
Genetics, Trauma and Attachment problems
202
What are some clinical features of Emotionally Unstable Personality Disorder?
Impulsivity – Acts without thinking of consequence - substance issue, sexual behaviours, risky behaviour, overspending, disordered eating etc
Intense unstable relationship
Fear of and attempts to avoid abandonment
Unstable mood
Chronic feelings of emptiness
Thoughts of self-harm/suicide
Uncertainty around self-image, aims and preferences
Can also include transient stress induced paranoia, and dissociation (can include hearing voices)
Patient is impaired in their daily functioning, high levels of anxiety, distress and stress.
203
Why would somebody with Emotionally unstable personality disorder self harm?
Self-harm likely not with suicidal intent but for punishment, to feel in control, reduce anxiety, feel something, seek help etc.
204
What are some differential diagnoses of EUPD?
Bipolar affective disorder more episodic mood changes, longer mood changes
Neurodevelopmental disorders – autism (esp in women), ADHD
Psychosis - Schizophrenia, schizoaffective disorder (voices and paranoid common)
Complex PTSD – may overlap in patients with a history of trauma
205
What is the treatment of EUPD?
Nonpharmacological best = gold standard. Benzos can be given short term.
Dialectical behavioural therapy – especially in cluster b personalities
Other psychological therapies – therapeutic communities, mentalization based therapy
206
What is the management of EUPD?
Short term management – brief crisis admission, crisis house, home treatment
Medium term – CMHT Support, community nursing, support worker, structured clinical approach
Longer term – psychotherapeutic approaches and occupational therapy input.
207
What are two types of Therapy in EUPD?
Dialectic behavioural therapy – Self soothing, distraction techniques, radical acceptance and group with individual support.
Mentalization based therapy – Through therapy experience of being understood by another and learn to do so independently
208
What is the definition of the following therapies
Dialectical Behavioural Therapy?
Mentalization based therapy?
Dialectic behavioural therapy – Self soothing, distraction techniques, radical acceptance and group with individual support.
Mentalization based therapy – Through therapy experience of being understood by another and learn to do so independently
209
What is the difference between Schizoid and avoidant personality disorders?
Schizoid – voluntarily withdraw
Avoidant – desires companionship but too afraid of rejection
210
What is the difference between OCD and OCPD?
Obsessive compulsive personality disorder = they are okay with how they are
OCD = do not like the obsessions/compulsions = Egodystonic
211
What are some types of therapies?
- Counselling
- Behavioural therapy
- Cognitive therapy
- Psychodynamic therapy
- Electroconvulsive therapy
212
What are the contraindications of convulsive therapy?
- Raised ICP
- Arrhythmias
- Headache
- Nausea
213
What is Schizoaffective disorders?
Mixture of schizophrenia and mood disorders
Symptoms of both mania and depression in small time frame
Treatment – mood stabilisers and anti-psychotics.
214
How can you diagnose personality disorders?
Requires inhibition of self and social functioning
One or more pathological personality traits
Impairments are stable across most situations
Impairments cannot be explained as normal for the individual’s developmental stage or socio-cultural environment.
215
What are some risk factors for personality disorders?
Past abuse, bullying, childhood trauma, expelled, self-harm.
216
What are the four core features of PTSD?
4 core features of PTSD
Hyperarousal
Emotional numbing
Avoidance
Re-experiencing
