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Phase 3a Medicine Sheffield > Psychiatry > Flashcards

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.

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2
Q

What is the cause of Wernickes Encephalopthy?

A

Lack of B1 - seen in alcohol.

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3
Q

What are the symptoms of Wernicke’s Encephalopathy?

A
  1. Ataxia
  2. Ophthalmoplegia
  3. Confusion
  4. Nystagmus
  5. Altered GCS
  6. Peripheral sensory neuropathy
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4
Q

What investigations should you order in suspected Wernicke’s Encephalopathy?

A
  • Clinical history
  • Decreased Red cell transketolase
  • MRI scan
  • LFTs
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5
Q

How can you treat Wernicke’s Encephalopathy?

A
  • Reversed by IV Thiamine
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6
Q

If you fail to treat Wernicke’s Encephalopathy what may occur?

A

Korsakoff Syndrome

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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.

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8
Q

What is the cause of Korsakoff’s syndrome?

A

Often from untreated Wernicke’s/ chronic Thiamine deficiency

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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.

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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.

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11
Q

How can you treat Korsakoff’s syndrome?

A

IV Pabrinex (high potency B1 replacement) and chlordiazepoxide.

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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 `

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13
Q

What is Generalised Anxiety Disorder?

A

Anxiety not specific to environmental circumstance –> Excessive worry about everyday events/problems.

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14
Q

What are the risk factors for GAD?

A

Female, 35-54, Divorced/alone

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15
Q

What are the causes of GAD?

A

Genetic and Environmental factors

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16
Q

What are some diagnostic features of GAD?

A
  1. Anxiety is hard to control
  2. Excessive anxiety more days than not over 6 months (90 days at least)
  3. Adults 3 or more of the following, Children 1 or more of the following
  4. Impairment in daily life
  5. Not medication or drug abuse.
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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

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18
Q

What investigations should be carried out for GAD?

A

Rule out physical illness

  • Thyroid
  • B12/folate
  • Medication
  • Alcohol/bento use (withdrawal symptoms)
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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

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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

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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.

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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.
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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
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24
Q

What are two alcohol dependence assessments?

A
  • Audit

- CAGE

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25
Q

What is the cage assessment?

A

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?

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26
Q

What is Tweak (Alcohol dependence)?

A
  • 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

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27
Q

What investigations and results would you expect in an alcoholic patient?

A
  • Raised MCV - Macrocytic anaemia
  • Vitamin b12+ folate deficiency = with alcohol
  • Deranged LFTs – GGT, AST,ALT
  • Thrombocytopenia – reduced platelets
  • Breath test
  • Screening
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28
Q

What is the appropriate management of alcohol dependence?

A

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

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29
Q

When do symptoms usually start in alcohol withdrawal?

Symptoms
Seizures
Delirium

A

Symptoms 6-12 hours
seizures - peak at 36
Delirium Tremens - 48-72 hours.

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30
Q

What are some of the symptoms of alcohol withdrawal?

A
  • 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
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31
Q

What is the appropriate management of alcohol withdrawal?

A

Chlordiazepoxide – Benzodiazepine

IV Pabrinex – vitamin supplementation

Thiamine 100mg BD

Complex withdrawals should be admitted to hospital

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32
Q

Mental Health Act.

What are the 5 principles?

A
  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
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33
Q

Mental Health Act.

What can someone with capacity do?

A
  • Understand
  • Retain
  • Weigh up
  • Communicate decision
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34
Q

What is a mental disorder?

If someone is in A&E are they technically admitted?

A

Mental disorder – any disorder or disability of the mind – excluding alcohol and drug use.

No.

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35
Q

What are advanced statements?

A

Not legally binding, patient documents their wishes should they lack capacity in the future.

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36
Q

What are advanced decisions?

A

Legally binding document, made with capacity, may be refusing medical interventions.

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37
Q

What is the lasting power of attorney?

A

person to make decisions for them if they lack capacity in the future.

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38
Q

What is a court of protection?

A

make decisions if no lasting power of attorney.

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39
Q

What is a Deprivation of Liberty Guard?

A

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.

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40
Q

What is an S12 doctor?

A

recognised under S12 of the MHA as having an expertise in diagnosing

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41
Q

Mental Health Act

What is a Section 2?

Duration:

Reason:

Approval:

Evidence:

A

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,

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42
Q

Mental Health Act

Section 3

Duration:

Reason:

Approval:

Evidence:

A

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.

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43
Q

Mental Health Act

Section 4

Duration:

Reason:

Approval:

Evidence:

A

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.

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44
Q

Mental Health Act

Section 5 (4)

Duration:

Reason:

Approval:

Evidence:

A

Duration: 6 Hours

Reason: Patient admitted but wanting to leave

Approved by: Nurse holding power

Evidence: Cannot be coercively treated whilst under section.

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45
Q

Mental Health Act

Section 5 (2)

Duration:

Reason:

Approval:

Evidence:

A

Duration: 72 Hours

Reason: Allows time for section 2 and 3

Approve by: Doctors holding power

Evidence: Cannot be coercively treated whilst under section

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46
Q

Mental Health Act

136

Duration:

Reason:

Approval:

Evidence:

A

Reason: Mental disorder in public – further assessment – section 2/3

Approved by Police sections

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47
Q

Mental Health Act

Section 135

Duration:

Reason:

Approval:

Evidence:

A

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

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48
Q

What is seretonin syndrome?

A

A syndrome where too much serotonin accumulates in the body.

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49
Q

What is the cause of seretonin syndrome?

A
  • SSRIs
  • MAO inhibitors
  • Ecstasy
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50
Q

What is Serotonin Syndrome?

A

A syndrome where too much serotonin accumulates in the body.

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51
Q

What are the symptoms of Serotonin syndrome?

A

Increased activity - agitation/restlessness

  • Clonus/myoclonus
  • Hyperreflexia
  • Confusion
  • Tremor
  • Diarrhoea
  • Muscle rigidity/loss of coordination
  • Dilated pupils
  • Autonomic dysfunction  tachy/high bp.
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52
Q

What are the signs of Seretonin Syndrome?

A
  • Elevated CK, WCC
  • Deranged LFTs
  • Metabolic acidosis

Like NMS

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53
Q

What is the treatment of serotonin syndrome?

A
  • Benzodiazepines

- Cyproheptadine – 5H2-a antagonist

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54
Q

What is the difference between serotonin syndrome and NMS?

A

Serotonin – increased activity + acute onset

Neuroleptic – reduced activity + insidious onset (4-11 days)

Similar signs - metabolic acidosis, CK, WCC, LFT

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55
Q

What is Neuroleptic malignant syndrome?

A

life threatening reaction that can occur in response to neuroleptic or antipsychotic medication.

10% mortality with atypical antibiotics.

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56
Q

What is the pathophysiology of NMS?

A

Unknown but dopamine blockade induced by antipsychotics triggers a massive glutamate release

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57
Q

What are the signs and symptoms of NMS?

A

Reduced activity

Fever, altered mental status, muscle rigidity and autonomic dysfunction

HTN, Tachycardia/pnoea

Biological - elevated CK, WCC and metabolic acidosis

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58
Q

What drugs can cause NMS?

A

Most frequently patients taking haloperidol and chlorpromazine

Can also occur with dopaminergic drugs e.g. levodopa when suddenly stopped or changed.

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59
Q

What is the treatment for NMS?

A

Bromocriptine – to reduce dopamine blockade (dopamine agonist)

Dantrolene – to reduce muscle spasms

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60
Q

What are the symptoms of opioid intoxication?

A
  • Drowsy
  • Mood change
  • Bradycardia
  • HTN
  • Pupil constriction
  • Resp depression
  • Decreased body temp
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61
Q

What are the symptoms of opioid withdrawal?

A
  • Muscle cramps
  • Low mood
  • Insomnia
  • Agitation
  • Diarrhoea
  • Shivering
  • Flu like symptoms
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62
Q

What are the complications of opioid misuse?

A

Infection due to sharing needles

VTE

Bacterial infection secondary to injection – IE, Septic arthritis, septicaemia and necrotising fasciitis.

Overdose – respiratory depression

Crime/prostitution

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63
Q

What is the appropriate management of opioid overdose/misuse?

A

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

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64
Q

What is PTSD?

A

A mental health condition which is caused by a traumatic experience.

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65
Q

What clinical features would you find in PTSD?

A

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

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66
Q

How can you diagnose PTSD?

A

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

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67
Q

What is the management of PTSD?

A

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

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68
Q

What is the appropriate management of PTSD symptoms?

A

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

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69
Q

What is an Obsession?

A

Obsessions – unwanted intrusive thoughts, images or urges that repeatedly enter the person’s mind

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70
Q

What is a compulsion?

A

Compulsion – repetitive behaviours or mental acts that the person feels drive to perform

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71
Q

What are the causes of OCD?

A

Genetic

Psychological trauma

Paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS)

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72
Q

What are the symptoms of OCD?

A
  • Obsessions
  • Compulsions
  • Emotions – intense anxiety & distress.
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73
Q

What are some associated conditions with OCD?

A
  • Depression (30%)
  • Schizophrenia (3%)
  • Sydenham’s chorea
  • Tourettes Syndrome
  • Anorexia Nervosa
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74
Q

What is the management of OCD for:

Mild impairment

Moderate impairment

Severe impairment

A

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.

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75
Q

What are 4 examples of sleep disorders?

A
  • Narcolepsy
  • Sleep apnoea
  • Circadian rhythm disorder
  • Parasomnia
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76
Q

What is Narcolepsy?

A

Narcolepsy – always tired through the day that they cannot resist

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77
Q

What is sleep apnoea?

A

Sleep apnoea – repeated and intermittent upper air collapse during sleep

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78
Q

What is a Circadian Rhythm disorder?

A

Circadian rhythm disorder – mismatch between sleep-wake cycle and circadian rhythms (jet lag/shift work)

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79
Q

What is parasomnia?

A

Parasomnia – Restless leg syndrome, nightmares/tremors and sleepwalking/talking

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80
Q

What is some good sleep hygiene advice?

A
  • Limit – caffeine, alcohol and cigarettes
  • Less noise/lights/ screen use
  • Reduce sleep
  • Regular pattern
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81
Q

What are 3 core symptoms of depression?

A

3 core symptoms

  • Low mood
  • Low energy (anergia)
  • Loss of enjoyment (anhedonia)
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82
Q

What are the clinical features of depression - DEADSWAMP?

A

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
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83
Q

What tools can you use to assess depression?

A
  • PHQ-9

- HADs (Hospital Anxiety and Depression Scale)

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84
Q

What is the criteria for Diagnosing depression?

Mild
Moderate
Severe

A
  • Mild = 2 core 2 others
  • Moderate = 2 core and 3 others
  • Severe = 3 core and 4 others
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85
Q

What is the treatment of Depression?

Mild

Moderate

Severe?

A

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

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86
Q

What is the pharmacological management of depression?

A 
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

What is Delirium?

A

Acute sudden confusion.

88
Q

What are the causes of Delirium - PINCH ME?

A
  • Pain
  • Infection/intoxication
  • Nutrition – vit deficiency, thiamine, b12, folate
  • Constipation
  • Hypoxia, hydration
  • Medication/substance abuse (benzodiazepines, anticholinergics, opiates, anticonvulsants).
  • Environmental
89
Q

What are some features of Delirium?

A
  • Inattention
  • Disorientated
  • Visual hallucinations
  • Paranoia
90
Q

What are some ddx for delirium?

A

Dementia, Anxiety, Psychosis, Withdrawal, post ictal, normal pressure hydrocephalus, CJD, HD, Picks disease Wilsons, neurosyphilis

91
Q

What is the difference between a hypoactive and hyperactive state in delirium?

What do they commonly get misdiagnosed as?

A

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
Q

What is the lifestyle management/initial management of delirium?

A

Treat precipitating cause

  • Educate family and make the environment safe
  • Avoid sedation unless severely agitated
  • Regular follow ups
93
Q

What is the medication management of Delirium?

A

Main

  • Haloperidol
  • Olanzapine

Other benzo

  • Risperidone
  • Quetiapine

Benzodiazepines – only chlordiazepoxide to be used in alcohol withdrawal or else it’ll worsen the delirium.

94
Q

What are the differences between Dementia and Delirium?

A

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
Q

What is Anorexia Nervosa?

A

Anorexia is a serious mental disorder where people try and keep their weight as low as possible.

96
Q

What is the epidemiology of anorexia nerovsa?

A

90% female and predominately young teenagers to young adults

0.5-1% prevalence in general population

97
Q

What is the diagnostic criteria of Anorexia Nervosa?

A

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
Q

What are some red flags for anorexia nervosa in terms of prognosis?

A
  • 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
Q

What is the SCOFF questionnaire and what is it used for?

A

Screening tool for eating disorders.

Sick (make yourself)
Control (lost overeating)
One stone lost in 3 months
Feel fat 
Food (dominates life)
100
Q

What is the general management of Anorexia Nervosa?

A
  • Restore nutritional balance
  • Involve carers
  • Psychological therapies
101
Q

What is the management of anorexia nervosa for adults?

A

One of:

Eating disorder focused CBT – ED-CBT

Maudsley anorexia nervosa treatment for adults (MANTRA)

Specialist supportive clinical management (SSCM)

102
Q

What is the management of Anorexia Nervosa for Children?

A

First line – anorexia focused family therapy

Second line – CBT-ED

103
Q

What is Bulimia Nervosa?

A

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
Q

What is the DSM 5 diagnostic criteria for Bulimia Nervosa?

A

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
Q

What are some signs of Bulimia Nervosa?

A

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
Q

What Metabolic disturbance can Bulimia Nervosa induce?

A

Vomiting can cause metabolic alkalosis = hypokalaemia/hypochloraemia

Laxative abuse can cause metabolic acidosis

107
Q

What is the appropriate management of Bulimia Nervosa?

A

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
Q

What is Bipolar Disorder?

A

Chronic mental health disorder characterised by periods of mania & hypomania along with periods of depression.

109
Q

What is the epidemiology of Bipolar Disorder?

A

Typically develops in teen years and lifetime prevalence is 2%

110
Q

What are the types of Bipolar Disorder?

A

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
Q

What are the causes of Bipolar Disorder?

A
  • Post-partum female
  • Substance misuse
  • Chronic illness
  • Past trauma/mental health problems
112
Q

What is the diagnostic criteria for Bipolar disorder?

A

Requires at least two episodes, one of which must be mania/hypomania for a diagnosis

113
Q

What are signs of Mania and how long does it usually last?

A

Over one week.

Uncontrollable elation
Over activity
Pressure of speech
Impaired judgement/risk taking
Social Disinhibition
Grandiosity
Psychotic symptoms
114
Q

What are the signs of Hypomania and how long does it usually last?

A

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
Q

What is the management of Bipolar Disorder?

A

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
Q

What is Agoraphobia?

A

Anxiety/panic over public places that are difficult to escape

117
Q

What is the management of Agoraphobia?

A

Short term – BDZ
SSRIs
Relaxation and exposure training/techniques

118
Q

What is refeeding syndrome and what is the pathophysiology of it?

A

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
Q

What are some metabolic consequences of refeeding syndrome?

A

Hypophosphatemia

Hypokalaemia

Hypomagnesaemia – may predispose to torsades de pointes (deadly heart rhythm)

Abnormal fluid balance

120
Q

What are some signs of refeeding syndrome?

A

Drop in phosphate due to rapid initiation of food after >10 days of undernutrition

Rhabdomyolysis
Resp/cardiac failure 
Low bp 
Arrhythmias 
Seizures
121
Q

Who would be considered high risk of Refeeding syndrome?

A

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
Q

What is the management of Refeeding syndrome?

A

Slow refeeding
Thiamine/vit Ba and multivitamins

Monitor for:

  • Low phosphate
  • Low potassium
  • High glucose
  • High magnesium
123
Q

What is Schizophrenia?

A

A type of psychosis. A severe and long-term mental health condition.

124
Q

What are some risk factors for schizophrenia?

A

Family history is said to be the strongest, stressful life event and drug use also linked.

125
Q

What are some subtypes of schizophrenia?

A

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
Q

What is the cause of Schizophrenia?

A

Excess dopamine production

Overactivity of the neurones = Mesolimbic = hallucinations/disorders (positive symptom)

Under activity of the neurones = Mesocortical = blunted, anhedonia, apathy (neg symptom)

127
Q

What are some first rank symptoms of schizophrenia?

A

Passivity phenomena

Thought disorders – withdrawal, insertion, broadcasting

Hallucinations – 3rd person auditory

Delusional perception – delusions of passivity, influence or control

128
Q

What are some second rank symptoms for schizophrenia?

A 
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
Q

What is the ICD-10 Diagnostic criteria for schizophrenia?

A
  • One or more of any first rank symptom

* Or two or more of the second rank symptoms

130
Q

What are some appropriate investigations to carry out on someone who is a suspected schizophrenic?

A
  • Rule out drugs – urine screen
  • Rule out alcohol – LFTs, FBC, Macrocytosis, Thrombocytopenia
  • Rule out syphilis = sero test
  • Rule out brain lesion – CT head
131
Q

What is the management of Schizophrenia?

A

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
Q

What is Psychosis?

A

An acute condition where people lose contact with reality which usually includes hallucinations and delusions.

Peak at 15-30.

133
Q

What conditions is psychosis seen in?

A 
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
Q

What are some causes of psychosis?

A

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
Q

What are two positive symptoms of psychosis?

A

Hallucinations

Delusions

136
Q

What are some negative symptoms of psychosis

A

Flattened affect
Cognitive difficulties
Poor motivation
Social withdrawal

137
Q

What are some associated features with psychosis?

A
  • Agitation and aggression
  • Neurocognitive impairment
  • Depression & thoughts of self-harm
138
Q

What is Puerperal psychosis?

A

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
Q

What investigations should you do for psychosis?

A

Psychiatric evaluation

Investigate any indication of underlying pathology that can cause psychosis.

140
Q

What is the appropriate management of psychosis?

A

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.

141
Q

What is Panic Disorder?

A

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.

142
Q

What are some risk factors for Panic Disorder?

A
  • Loneliness
  • Living in a city
  • Poor education
  • Early parental loss
  • Sexual/physical abuse
143
Q

What are the symptoms of Panic Disorder?

A 
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
144
Q

What is the management for Panic Disorder?

A
  • 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

145
Q

What is the difference between an illusion and a hallucination?

A

Illusion – Misperception of a real external stimulus (affect driven)

Hallucination – a disorder of perception in the absence of external stimuli

146
Q

What type of hallucinations are there?

A

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

147
Q

What is a Delusion?

A

A belief that is:

  • Firmly held.
  • Not affected by rational argument/evidence
  • Not a conventional belief
148
Q

What is the difference between a primary and secondary delusion?

A

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.

149
Q

What are 5 types of Delusions?

A

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.

150
Q

What is psychosis?

A

severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality

151
Q

What is Neurosis?

A

mild mental illness involving symptoms of stress but not a radical loss of touch with reality.

152
Q

What is a passivity phenomena?

A

controlled by someone else

153
Q

What is meant by blunting of affect?

A

an objective absence of normal emotional responses, without evidence of depression or psychomotor retardation.

154
Q

What is meant by incongruity of affect?

A

Emotional responses which seem grossly out of tune with the situation or subject being discussed.

155
Q

What is meant by catatonia?

A

significantly excited/inhibited motor activity

156
Q

What is psychomotor retardation?

A

slowing of thoughts/movements.

157
Q

What is meant by concrete thinking?

A

lack of abstract thinking = Asperger’s

158
Q

What is meant by confabulation?

A

give false account to fill in a gap in memory (Korsakoff = most common)

159
Q

What is meant by neologism?

A

new word formation – it seems right to them.

160
Q

What is meant by Anhedonia?

A

inability to experience pleasure.

161
Q

What is meant by Akathisia?

A

inner restlessness and always in motion (rocking)

162
Q

What is meant by:

Pharmacokinetics
Pharmacodynamics

A

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
Q

What is meant by a flat effect?

A

No emotional expression

164
Q

What is a mannerism?

A

repeated involuntary movements

165
Q

What is Belle indifference?

A

lack of concern for implications of symptoms

166
Q

What are the 5 types of Thought Alienation?

A

Thought insertion

Thought withdrawal – someone removing their thoughts

Thought broadcast

Thought echo

Thought block – can’t continue idea

167
Q

What is meant by splitting?

A

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
Q

What is idealisation?

A

Expressing extremely positive thoughts of self and others while ignoring negative thoughts

169
Q

What is meant by identification?

A

the unconscious assumption of the characteristics, qualities, or traits of another person

170
Q

What is meant by projection?

A

Attributing an unacceptable internal impulse to an external source (vs displacement)

171
Q

What does fixation mean?

A

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
Q

Lilliputian and formication are two hallucinations. What are they?

A

Lilliputian – visual hallucinations of small animals

Formication – insects crawling on the skin

173
Q

What is meant by:

Egosystonic?

Egodystonic?

A

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)

174
Q

What are some types of antidepressants?

A

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin Noradrenaline Reuptake Inhibitors (SNRIs)

Monoamines Oxidase Inhibitors (MAO Inhibitor)

Tricyclics

175
Q

What are some types of Selective serotonin reuptake inhibitors and what are some common side effects?

A

Sertraline
Citalopram
Fluoxetine
Paroxetine

Side effects - Headache, Nausea, Insomnia

176
Q

What are some types of Serotonin Noradrenaline Reuptake Inhibitors and what are some common side effects?

A

Venlafaxine
Duloxetine
Mirtazapine

Side effects - constipation, tiredness, insomnia, loss of appetite, loss of libido.

177
Q

What are some types of Monoamine Oxidase Inhibitors and what should you avoid when taking them?

A
  • Rasagiline
  • Selegiline
  • Isocarboxazid
  • Phenelzine

Avoid high fat diet (+cheese) as contains tyramine  hypertensive crisis

178
Q

What are some examples of Tricyclic Antidepressants and what are some side effects?

A

Amitriptyline
Clomipramine

Side effects - Tachycardia, dry mouth, blurred vision, anticholinergic/muscarinic effects, postural hypotension, sedation, weight gain.

179
Q

What are some short acting benzodiazapines?

A
  • Clorazepate
  • Midazolam
  • Triazolam
180
Q

What are some non-benzo hypnotic agents?

[psychoactive drugs which are used to induce sleep]

A
  • Zopiclone
  • Zaleplon
  • Zolpidem
181
Q

What can antipsychotic treatment cause?

A

Extra pyramidal side effects.

182
Q

What are some examples of EPSE?

A

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
Q

How can you treat EPSE?

A
  • Procyclidine
  • Propranolol +/- cyproheptadine
  • Tetrabenazine
184
Q

EPSE treatments

Procyclidine - what does it treat?

Propranolol/cyproheptadine - what does it treat?

Tetrabenazine - what does it treat?

A

Procyclidine – treatment of EPSE - Acute dystonia/parkinsonism

Propranolol/cyproheptadine -Treatment of Akathesia

Tetrabenazine - Treatment of EPSE Tardive Dyskinesia although its generally reversible.

185
Q

What are some side effects of anti-cholinergics/muscarinic drugs?

A
  • Tachycardia
  • Dry mouth
  • Blurred vision
  • Constipation
  • Urinary retention
  • Drowsiness
186
Q

What are some side effects of hyperprolactinaemia?

A

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
Q

What is the mesolimbic pathway?

A

Mesolimbic pathway – reward pathway – dopaminergic pathway in the brain. Blocking this reduces the positive symptoms of psychosis.

188
Q

What severe side effect can clozapine cause and when should it only be used?

A

Clozapine can cause agranulocytosis so should be used only in treatment resistant schizophrenia/psychosis.

  • Can also cause constipation + hypersalivation.
189
Q

Why are EPSE more common in typical antipsychotics?

A

EPSEs are more common in typical antipsychotics whereas atypical antipsychotics have less activity at the D2 receptor so less activity.

190
Q

What are 4 key Neurotransmitters?

A
  • Dopamine
  • Serotonin
  • Acetylcholine
  • Glutamate
191
Q

Where does the following pathways begin?

Dopamine pathway
Serotonin Pathway?

A

Dopamine pathway begins in substiantia nigra

Serotonin pathway begins in the raphe nuclei

192
Q

What does issues in the following pathways cause?

Tuberoinfundibular pathway
Nigrostriatal pathway

A

Tuberoinfundibular pathway – causes excess prolactin

Nigrostriatal pathway causes movement disorders

193
Q

What are some side effects of clozapine?

A
  • Agranulocytosis
  • Reduced seizure threshold
  • Sedating
  • Postural hypotension
  • Toxic megacolon 1 in 1800
  • Cardiomyopathy 1 in 2500
  • Extreme salivating
194
Q

What is lithium used to treat and how does it work?

A

Use - acute treatment of mania

Works by inhibiting cAMP production (cAMP inhibits monoamines)

195
Q

What are some S/E of lithium?

A
  • Fine tremor
  • Impaired renal function
  • Nephrogenic DI
  • Weight gain
  • Oedema
  • Hypothyroidism
  • Cardiac – t wave flattening/inversion
  • Leucocytosis
  • Teratogenic!
196
Q

What are some signs of lithium toxicity?

A

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
Q

What is a common s/e seen in the use of atypical antipsychotics?

A

Side effect of weight gain is seen in All atypical antipsychotics

  • Most with olanzapine/clozapine
  • Lowest with apriprazole
198
Q

Give an example of an NaSSA and its side effects

Mirtazapine

sedation and weight gain.

A

Give an example of a NaSSA and its side effects

  • Mirtazapine
  • Sedation, weight gain
199
Q

What are the types of personality disorder?

A

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
Q

What is Emotionally unstable personality disorder?

A

Borderline Personality Disorder – 0.5-2% incidence, not lifelong and psychosocial treatment may promote long term recovery

201
Q

What are the causes of EUPD?

A

Genetics, Trauma and Attachment problems

202
Q

What are some clinical features of Emotionally Unstable Personality Disorder?

A

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
Q

Why would somebody with Emotionally unstable personality disorder self harm?

A

Self-harm likely not with suicidal intent but for punishment, to feel in control, reduce anxiety, feel something, seek help etc.

204
Q

What are some differential diagnoses of EUPD?

A

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
Q

What is the treatment of EUPD?

A

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
Q

What is the management of EUPD?

A

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
Q

What are two types of Therapy in EUPD?

A

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
Q

What is the definition of the following therapies

Dialectical Behavioural Therapy?

Mentalization based therapy?

A

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
Q

What is the difference between Schizoid and avoidant personality disorders?

A

Schizoid – voluntarily withdraw

Avoidant – desires companionship but too afraid of rejection

210
Q

What is the difference between OCD and OCPD?

A

Obsessive compulsive personality disorder = they are okay with how they are

OCD = do not like the obsessions/compulsions = Egodystonic

211
Q

What are some types of therapies?

A
  • Counselling
  • Behavioural therapy
  • Cognitive therapy
  • Psychodynamic therapy
  • Electroconvulsive therapy
212
Q

What are the contraindications of convulsive therapy?

A
  • Raised ICP
  • Arrhythmias
  • Headache
  • Nausea
213
Q

What is Schizoaffective disorders?

A

Mixture of schizophrenia and mood disorders

Symptoms of both mania and depression in small time frame

Treatment – mood stabilisers and anti-psychotics.

214
Q

How can you diagnose personality disorders?

A

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
Q

What are some risk factors for personality disorders?

A

Past abuse, bullying, childhood trauma, expelled, self-harm.

216
Q

What are the four core features of PTSD?

A

4 core features of PTSD

Hyperarousal
Emotional numbing
Avoidance
Re-experiencing

Phase 3a Medicine Sheffield (2 decks)

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