PSYCHIATRY Flashcards
What are the 3 core symptoms of depressive disorder?
- Low mood
- for most of the day, every day, with little variation despite changes in time, circumstance or activity
- typically worse in morning - Anhedonia
- loss of interest/pleasure in daily life, especially in things they previously enjoyed - Fatigue
What are some other common symptoms of depressive disorder?
- Change to appetite (increased or decreased)
- Disturbed sleep - insomnia, early waking, naps in day
- Psychomotor retardation or agitation
- Decreased libido
- Poor concentration
- Feelings of worthlessness
- Inappropriate guilt
- Recurrent thoughts of death/suicide
When is it appropriate to refer someone with depressive disorder to psychiatry?
- Significant perceived risk of suicide, or harm to others, or of severe self-neglect
- If there are psychiatric symptoms
- Hx, or clinical suspicion of, bipolar disorder
- In all cases where a child/teen is presenting with major depression
What medical investigations should you perform in a patient presenting with suspected depressive disorder?
- Pulse, BP, BMI = baseline required as some ADs cause weight gain
- FBC, U+E, LFT, TFT, HbA1c = r/o metabolic causes of depression
- GGT level in alcoholics
- ECG = needed prior to starting ADs as some can cause QTc prolongation (escitalopram, citalopram, amitriptyline)
How do you manage mild depression?
Low intensity psychological interventions, focused on sleep hygiene, anxiety management + problem solving techniques
- individualized guided self-help e.g. books
- computerised CBT
- structured group based physical activity
ADs only required if symptoms progress beyond 8 weeks OR if there is a PMH of known depression
How do you manage moderate depression?
COMBINATION THERAPY:
- generic SSRI
- CBT: 8-12 sessions/interpersonal therapy
Should notice a response in about 12 weeks
What drugs are used to manage depressive disorders?
1st Line = SSRI
- Advise it may take 6-weeks to take effect + should be continued for at least 6 months after recovery
- if no response after 6 weeks, try another drug in same class
Fluoxetine = only one licensed for under 18s
Sertraline = best in IHD
Citalopram/escitalopram
Side effects include
- agitation (hence not given at night)
- nausea + GI upset
- sexual dysfunction
- prolonged QTc
- increased motivation initially
- low seizure threshold
- increased risk of bleeding
What mnemonic can be used to remember important Qs to ask in a depression history?
DEAD SWAMP
D – Depression = mood
E – Energy levels
A – Anhedonia
D – Death – thoughts about death and self harm – i.e. Risk Assessment!
S – Sleep pattern
W – Worthlessness, guilt
A – Appetite
M – Mentation – decreased ability to think and concentrate
P – psychomotor agitation and retardation
When do you consider hospitalization in a patient with severe depression?
- Significant suicidal ideation
- Intent + lack of protective factors
- Intent to hurt others
- Unable to care for themselves/adhere to treatment
- Have psychotic symptoms
- Uncontrolled agitation plus high risk of impulsive behaviour
When is ECT indicated to use in depression?
- Presence of psychotic features
- Active suicidal thoughts
- Unresponsive to ADs
What assessment tool should be used to monitor treatment in depression?
PHQ-9 assessment tool
What are some side effects of ECT?
- memory loss
- short-term retrograde amnesia
- confusion
- headaches
- clumsiness
What are the symptoms of psychotic depression?
- DELUSIONS
- mood congruent = guilt, persecution, punishment - HALLUCINATIONS
- auditory, visual, olfactory - AFFECT IS SAD - not flat
- severe anhedonia, loss of interest, psychomotor retardation
What is discontinuation syndrome? What are the symptoms?
Can occur when patients suddenly stop taking SSRIs
- GI upset
- neuro + flu-like symptoms
- sleep disturbance
In what conditions should you use SSRIs with caution?
- Epilepsy
- Peptic ulcer disease (risk of GI bleed)
- Young people - increased risk of self-harm + suicide
- Hepatic impairment - may require dose reduction
Why should SSRIs + MAO-B inhibitors not be prescribed together?
As they can precipitate serotonin syndrome
What information do you need to tell patients before starting SSRIs?
- Symptoms should start to improve after 2 weeks
- discuss referral for CBT which may provide more long-term treatment
- Continue medication for at least 6 months after resolution of symptoms
- Do NOT stop taking suddenly (discontinuation syndrome)
- when time comes to stop treatment, it will be done gradually over 4 weeks
- discuss side effects
What drugs can cause serotonin syndrome?
- MAO-inhibitors (parkinson drug) => avoid ondansetron in PD
- SSRIs
- Ecstasy
- Amphetamines
What are the clinical features of serotonin syndrome?
- Neuromuscular excitation = hyperreflexia, myoclonus, rigidity
- Autonomic nervous system excitation e.g. hyperthermia
- Altered mental state
How do you manage serotonin syndrome?
- Supportive - including IV Fluids
- Benzodiazepines
- More severe cases are managed with serotonin antagonists e.g. cryoheptadine or chlorpromazine
How do you distinguish between mania and hypomania?
Hypomania might be used where patients still have some insight that they are unwell
and do not have full-blown delusions. Insight is completely lost and grandiose delusions
present in the more severe form- mania. In mania impairment must be severe enough to impair function.
True mania tends to last more than 7 days whilst hypomania usually 4-7 days with NO PSYCHOSIS
What is (i) Bipolar 1 (ii) Bipolar 2?
(i) underlying depression, interspersed with episodes of mania (tends to be 1:1)
(ii) depression tends to predominate, hypomania/less severe episodes tend to occur + less frequently.
Describe what you would expect in a MSE of a Bipolar patient.
- Appearance – bright coloured clothes, eccentric
- Behaviour – over friendly, perhaps inappropriate
- Speech – fast, and difficult to interrupt
- Mood – elated/irritable, euphoric, lability
- Thoughts – fast, sentences may be logical, but linked by puns and similar sounding words, and not by ideas, patient may be very self important and have grandiose ideas. Racing thoughts, flight of ideas, grandiosity
- Perception – Hallucinations – usually occur with elated mood
- Cognition – distractibility
What investigations should be performed in a patient with suspected Bipolar disorder?
- For depression = PHQ-9, PRIME-MD, PHQ-2 questionnaire
- For mania = mood disorder questionnaire (MDQ)
- R/O infection + drug use
- Perform CT, EEG, toxicology screen
- Enquire about personal + FHx of mental health
How do you treat an acute manic disorder?
1st Line = Atypical antipsychotic e.g. IM Olanzapine, risperidone, quetiapine, Clozapine (Be weary of Agranulocytosis!)
2nd Line = try Valproate, lamotrigine (anticonvulsants), or Lithium
What are the mood stabilisers used in Bipolar disorder ?
- Lithium
- Valproate
- Carbamazepine
What comorbidities are pts with Bipolar disorder at increased risk of?
- Diabetes
- COPD
- Cardiovascular disease
What are the side effects of Lithium use?
- Diarrhoea, N+V
- Weight gain
- Fine Tremor
- Hypothyroidism
- Thirst (polydipsia due to nephrogenic diabetes insipidus)
- Renal toxicity (excreted by kidneys, contraindicated in renal impairment)
- Idiopathic intracranial HTN
- Leucocytosis
- HyperPTH + subsequent raised calcium
What are the symptoms of lithium toxicity?
- Reduced vision
- Coarse tremor
- Hyperreflexia
- Confusion
- Polyuria
- Seizure
What can precipitate lithium toxicity?
- dehydration
- renal failure
- drugs e.g. thiazides, ACEi/ARBs, NSAIDs, metronidazole
What is the mainstay of treatment for lithium toxicity?
FLUIDS
What monitoring is required with Lithium treatment?
First test of lithium levels after 7 days of treatment + then weekly until stable. Once stable, do 3-monthly. Test should be done 12-hours post dose
- pt will be given info booklet, alert card + record book
Will also have TFTs, U+Es checked every 6 months
How long does it take for lithium to have an effect?
1-2 weeks
What is the definition of generalised anxiety disorder?
6 months or more of excessive worry about everyday issues that is disproportionate to any inherit risk, causing distress, and impairment
What are the clinical features of GAD? How many are needed for diagnosis?
- Muscle tension
- Sleep disturbance
- Fatigue
- Restless/sense of feeling on edge
- Irritability
- Poor concentration
Children may also have - thumb-sucking, nail biting, bed wetting
Need at least 3 key symptoms out of a possible 6 to diagnose. Only require 1 in children.
How do you manage patients with GAD?
- Educate about GAD + active monitoring
- Low intensity psychological interventions
- e.g. guided/non-guided self-help programmes or groups - High-intensity psychological interventions
- CBT and/or drug treatment
What drugs can be used in GAD?
- SSRI = sertraline 1st line
- Pregabalin
Propranolol can be used for somatic symptoms
What are some causes of psychosis? Think of both primary + secondary causes
PRIMARY
- schizophrenia, schizoaffective disorder
- brief psychotic disorder, bipolar, psychotic depression
- delusional disorder, puerperal psychosis
SEONDARY
- drugs/toxins = steroids, dopamine agonists, thyroid meds, cocaine, cannabis, alcohol etc.
- neuro disorders = epilepsy, MS, traumatic brain injury, dementia, tumour
- Infection = STDs, measles, mumps, rabies
- Delirium
- Vitamin deficiency = folate. b12, niacin, thiamine
- Endocrine = Cushing’s, thymoma, thyroid, hyperPTH
- Autoimmune = thyroid, coeliacs, malabsorption, PMR, Sjogren’s
- Metabolic = Wilson’s disease
- Chromosomal = Klinefelter’s, Prader-willi
What questions should you ask someone who reports auditory hallucinations?
- Hear noises/voices? Are they in your ears or mind?
- How many voices? Recognise them? What do they say?
- Do they tell you to do things? Do they comment on what you’re doing?
- Present all the time? Anything make them better or worse? Do you ever speak to them?
What questions should you ask to determine the type of thought disorder a patient is experiencing?
- INTERRUPTION = can you think clearly? Do your thoughts ever stop suddenly?
- WITHDRAWAL = anyone taking thoughts out of your own head?
- INSERTION = are your thoughts your own? Anyone/thing putting thoughts into your head?
- BROADCASTING = can anyone else every hear your thoughts? Ever hear thoughts echoed?
What q’s should you ask if you suspect a pt to have (i) delusional perception (ii) delusions of passivity?
(i) Every feel somebody is paying particular attention to what you are doing? Think TV/radio is referring to you?
(ii) Ever feel controlled by someone/thing? Someone forcing you to behave in this way?
How do you manage a pts first episode of psychosis?
Refer to early intervention in psychosis service
- needs secondary care assessment
1. Lifestyle modification = physical activity, diet, treatment of comorbidities
2. Oral antipsychotic medication - should only be started with input from psychiatrist
3. Psychological interventions = CBT + family interventions
What are the positive symptoms of shizophrenia?
- Auditory hallucinations (most common)
- Delusions
- Thought disorder = insertion, withdrawal, broadcasting
- Others = ideas of reference, bizarre behaviour, tangentiality, circumstantiality, pressured speech, word salad etc.
What are the negative symptoms associated with schizophrenia?
- Avolition = reduced ability/inability to initiate + persist with goal-directed behaviour
- Anhedonia = lack of capacity of enjoyment
- Asocial blunting
- Affective blunting = diminished/absent ability to express feelings
- Atolgia = decrease in speech
What criteria needs to be fufilled to diagnose schizophrenia?
At least 1 positive symptom + 1 other symptom present for most of the time during a 1-month period in addition to a degree of symptoms being present for at least 6 months
What investigations are required before a diagnosis of schizophrenia is made? (To r/o other causes of psychosis)
- urine drug screen
- FBC to r/o anaemia
- plasma drug level monitoring
- serum HIV ELISA r/o syphilis
- serum plasma rapid regain test
- MRI/CT head: r/o CNS conditions
- LFT r/o Wilson’s
- Toxicology screen
How do you manage the chronic symptoms of schizophrenia?
1st Line:
- 2nd gen antipsychotic = risperidone, olanzapine, quetiapine
- psychosocial = suicide prevention, CBT, supported employment, psychoeducation
- health maintenance = managing extrapyramidal SEs + metabolic syndrome
What is schizoaffective disorder?
Schizophrenia symptoms plus mood symptoms (depression or mania)
What baseline investigations are required before commencing antipsychotics?
- weight + waist circumference
- pulse + BP
- ECG
- fasting BMs, HbA1c, lipids, prolactin
- assess any mood disorders
- assess nutritional status + activity levels
What monitoring is required for patients on antipsychotics?
- Response to treatment (symptoms + behaviour)
- Side effects of treatment
- Emergency of any mood disorders e.g. Parkinsons
- Weight= weekly for 1st 6 weeks then at 12 weeks then to yearly
- Waist circumference, pulse + BP
- Fasting glucose, HbA1c, blood lipids
- Adherence
- Overall physical health
NOTE: clozapine requires intensive monitoring due to risk of agranulocytosis = weekly FBC for 18 weeks
What are the adverse effects of atypical antipsychotics (2nd generation)?
- sedation
- extrapyramidal side effects (but less than 1st gen)
- metabolic disturbances = weight gain, DM, lipid increase
- prolonged QTc interval
- risperidone can cause breast symptoms + sexual dysfunction
- clozapine can cause agranulocytosis + myocarditis
What is dystonia? How is it treated?
Muscle spasms e.g. torticolis, dysarthria
- managed with procyclidine, anticholinergics
What is akathasia? How is it treated?
Inner restlessness
- treat with reducing antipsychotic + switching to 2nd gen
- propranolol
What is pseudo-parkinsonism? How do you treat it?
Tremor, rigidity, bradykinesia
- treat with procyclidine, anticholinergics, propranolol
What is tardive dyskinesia? How is it managed?
Lip smacking, tongue protrusion, choreiform hand movements, pelvic thrusting
- treat by stopping anticholinergics, decrease antipsychotic + tetrabenazine
What are the clinical features of neuroleptic malignant syndrome?
Occurs within hours to days of starting antipsychotics
- pyrexia
- muscle rigidity
- autonomic lability = HTN, tachypnoea, tachycardia
- agitated delirium with confusion
What investigations should be performed in neuroleptic malignant syndrome? What will the results be?
- CK raised + AKI present due to rhabdomyolysis
2. FBC = leucocytosis
How do you manage pts with neuroleptic malignant syndrome?
- STOP antipsychotic
- Transfer to medical ward
- IV fluids to prevent renal failure
- Dantrolene
- Bromocriptine may be used
What management is typically used in pts with personality disorders?
Dialectual behaviour therapy (DBT)
= individual + group therapy using mindfulness, CBT + eastern therapy
Medication plays NO part in treatment
What is the ICD-10 criteria for dependence? (HINT there’s 7 points)
- craving for substance
- Loss of control when taking substance
- Physiological withdrawal
- Tolerance
- Salience over needs + responsibilities
- Persistent use despite harmful consequences
- Narrowing of repertoire
What are the 4 questions of the CAGE screening questionnaire?
- Ever felt you should CUT DOWN on your drinking?
- Have people ANNOYED you by commenting on drinking
- Ever felt bad or GUILTY about drinking?
- Ever had a drink first thing in morning to steady nerves/rid hangover? EYE OPENER
2 or more is considered significant
If someones CAGE score is significant, what other questionnaire would you do?
AUDIT questionnaire
15 or more requires specialist advice
How do you manage detoxification regimes both in the community + as an inpatient?
COMMUNITY:
- daily supervision to detect complications
- Pabrinex to prevent Wernicke’s
- Chlordiazepoxide to prevent withdrawals
- continuing support = community alcohol team
INPATIENT CARE FOR:
- those at risk of suicide
- without social support
- with hx of severe withdrawal reactions
What are the symptoms of delirium tremens?
- tachycardia
- drop in BP
- tremor
- fits
- visual/tactile hallucinations
What are the symptoms of Wernicke’s encephalopathy? (Thiamine B1 deficiency)
Triad of:
- Confusion
- Wide based gait ataxia
- Ophthalmoplegia = nystagmus, conjugate gaze, B/L rectus palsies
Also clouding of consciousness, memory disturbance, peripheral neuropathy, hypotension, hypothermia, ptosis
If patient has Wernicke’s + co-existing hypoglycaemia, in what order should you treat?
Give high-dose IV thiamine before glucose
What is given to treat acute opioid intoxication?
Naloxone
What are the 4 features of the confusion assessment method?
- Acute onset + fluctuating course
- Inattention - cannot count backwards or observed inattention
- Disorganized thinking
- Altered level of consciousness - hyperalert, hypoalert, or both
CAM +ve = 1+2+(3 or 4)
- if +ve then pt has delirium
What are the 8 signs of delirium? (HINT DELIRIUM)
- D - disordered thinking
- E - euphoric, fearful, depressed, angry
- L - language impaired
- I - illusions/delusions/hallucinations
- R - reversal of sleep wake cycle
- I - inattention
- U - unaware/disoriented
- M - memory deficits
What are some causes of delirium? (HINT DIMES)
D - drugs e.g. opiates, anticonvulsants, levodopa, sedatives, recreational, post-GA, alcohol, withdrawal
I - infection e.g. UTI, pneumonia, encephalitis, meningitis
M - metabolic e.g. uraemia, liver failure, sodium or glucose changes, low Hb, malnutrition (thiamine or B12 deficiency)
E - environmental e.g. head injury
S - structural e.g. stroke, MI, epilepsy, brain SOL
What investigations should be done in a patient with suspected delirium?
- FBC
- U+E
- LFT
- Blood glucose
- ABG
- Septic screen = urine dip, blood cultures, CXR
- ECG
- Malaria films
- CT/MRI/LP
- EEG
- Review prescription
What is the pathophysiology of alzheimer’s disease?
Beta-amyloid protein deposition causing amyloid plaques and neurofibrillary tangles
What cognitive testing tools can be used to diagnose dementia?
ACE3
MoCA
MMSE
- the mental state exam may reveal anxiety, depression, or hallucinations
What is involved in a confusion screen?
- Vital signs
- CT head r/o structural pathology
- FBC - infection/anaemia/malignancy
- U+Es - high or low sodium
- LFTs - liver failure with 2ndary encephalopathy
- Coagulation/INR
- TFTs - hypothyroid
- Calcium - raised?
- B12 + folate/haematinics
- Glucose
- Blood cultures
- CXR - r/p pneumonia
- urine dipstick (note a positive dip without any other clinical signs is not enough to diagnose urosepsis)
What management is involved in treating dementia? (think biopsychosocial)
- COGNITIVE + WELLBEING PROMOTION
- cognitive stimulation therapy
- CBT
- reminiscence therapy
- aromatherapy + muscle therapy - NON-COGNITIVE SYMPTOM MANAGEMENT
- explore reasons for distress
- assess pain, delirium, inappropriate care - MEDICATIONS - only for LD + AD
(i) anticholinesterase drugs e.g. donepezil, galantamine, rivastigmine
(ii) NMDA receptor blockers e.g. memantine
r/v treatment every 6 months
What are the side effects of anticholinesterase drugs?
- anorexia
- abdominal pain
- insomnia
- vomiting
- nausea
- headache
- diarrhoea
What will LFTs show in liver disease associated with alcohol? (alcoholic hepatitis)
AST:ALT ratio over 2.5
Raised GGT
