Psychiatry Flashcards
What is delirium?
acute confusional state. Fluctuating and impaired consciousness. Onset is over hours/days with a rapid deterioration in preexisting cognitive function
What are the features of delirium?
COGNITIVE - low concentration, confused, disorientated in time and space
PERCEPTION - visual and auditory hallucinations
PHYSICAL - reduced mobility and movement, restuless, agitated, appetite changed - fluctuation in behaviours
SOCIAL - reduced cooperation, withdrawal, delusions
name the 2 types of delirium
hyperactive and hypoactive
DD for delirium?
drug/alcohol withdrawal, mania, psychosis, anxiety
name some causes for delirium
SDH, meningitis, sepisis, stroke, encepalopathy, UE deranged, hypoxia, liver/kidney injury, thiamine/B12/folate deficiency
Ix for delirium?
Bloods - FBC, UE, LFT, blood glucose, blood gas, blood culture
urine culture
ECG
CT/CXR/LP
Mx for delirium
treat precipitating cause
optimise surroundings
1st line Mx = Haloperidol (monitor BP)
what is dementia?
progressive and global intellectual deterioration without impaired consciousness. 1st symptom = memory loss
features of dementia?
BEHAVIOUR - repetitive, restless, rigid and fixed routines
PERSONALITY - sexual disinhibition, shoplifting, blunting
SPEECH - dysphasia, mutism
THINKING - slow, muddled, reduced memory, confabulation, no insight
PERCEPTION - illusions, hallucinations
MOOD - irritable, depressed, crying
name the 4 As of alzheimers
amnesia, aphasia, agnosia, apraxia
irreversible causes of dementia
Alzheimers, vascular, lewy body, frontotemporal
Ix for a patient presenting with dementia symptoms?
fully history of function and decline/collateral Hx
BLOODS - FBC, UE, LFT, B12, folate, gGT, Ca, TSH, syphyllis, ESR, HIV
CT/MRI head - SD
cognitive examinations
Name some cognitive exams to do on a dementia investigation?
MMSE/AMSE MOCA addenbrooks AMT FAB
Name a medication and class that you can use in a patient with dementia to improve symptoms?
Rivastigmine - Acetylcholinesterase inhibitor
Memantine - NMDA receptor antagonist
what is ECT used for?
severe catatonic depression which is non-responsive to medication
what is schizoaffective disorder?
schizophrenia + mood disorder
what is section 2 of the MH law?
admission for assessment for <28 days. Requires 2 doctors (1 section 12 approved) and you can appeal within 14 days
what is section 3 of the MH law?
admission for treatment for <6 months. must have a diagnosis and appropriate management stated
what is section 4 of the MH law?
emergency treatment for <72 hours. Could be converted into a section 2 or a section 3.
What is a section 5(2) in the MH law?
detention of a patient already in hospital for <72 hours.
What is a section 5(4) in the MH law?
detention of a patient already in hospital by an authorized psych nurse for <6 hours.
what is somatisation disorder?
patient presents with multiple physical symptoms over 2 years. they refuse to accept reassurance from negative test results
what is anxiety?
maladaptive psych symptoms not due to organic cause, and precipitated by stress. can be a normal response but in anxiety disorder this response is exaggerated and lasts >3 weeks
symptoms of anxiety?
COGNITIVE - agitated, impending doom, reduced concentration, insomnia, repetitive thoughts, concern of self image
SOMATIC - tension, trembling, sense of collapse, butterfies, increased HR, headaches, sweating, palpitations
BEHAVIOURS - reassurance seeking, avoidance, dependance on a person
CHILDREN - thumb sucking, nail biting, bed wetting
how do you manage anxiety
GENERAL - listen and explain, exercise, meditation, breathing exercises, relaxation techniques
THERAPIES - CBT, hypnosis
MEDICATION - 1st line = SSRI
SYMPTOMATIC - B blocker
what are compulsions and obsessions?
COMPULSION - senseless repeated rituals
OBSESSIONS - purposeless ideas/words, perceived by the patient as intrusive (not like delusions.)
How do you manage OCD?
SSRI (e.g. fluoxetine)
What is a phobic disorder?
anxiety experienced in a well-defined situation that is not dangerous. This situation is avoided as it causes a lot of distress and impaired function
how do you manage a phobic disorder?
need to elicit the stimulus!
CBT + SSRI
what is PTSD?
develops after a stressful/life threatening situation
symptoms of PTSD?
re-experiencing the event - vivid nightmareds/flashbacks in which there is raised BP and HR sleep disturbance reduced concentration drug and alcohol misuse emotional numbing
Mx for PTSD?
eye movement desensitization and reprocessing
CBT
SSRI
What are the core symptoms of depression?
depressed mood, anhedonia, fatigue
more typical symptoms of depression?
reduced appetite, insomnia, reduced concentration, psychomotor retardation, reduced libido, feelings of worthlessness and guilt
How do you score Mild/Mod/Sev depression
Mild = 2 core + 2 typical Mod = 3 core + 2 typical Sev = 4 core + 3 typical
+/- psychosis/manic symptoms
name 2 screening tools for depression
HAD scale, PHQ9
How do you manage depression?
GENERAL - sleep hygeine, anxiety management, self help books, computorised CBT
IF MOD = CBT + SSRI
SEVERE = rapid MHA/ECT
how do you identify severe depression (SUICIDE)?
suicide plan/self harm unexplained guilt/worthlessness impaired function concentration impaired impaired appetite decreased sleep/early waking energy low
What is the order for antidepressant use in depression?
1st line = SSRI
2nd line = alternative SSRI
3rd line = NaSSA/SNRI
4th line = TCA
Give examples of SSRIs and their side effects
Citalopram/Sertriline/Fluoxetine
GI symptoms, hyponatraemia, increased anxiety when beginning, increased weight, sexual dysfunction
prolonged QT with citalopram
Give examples of NaSSA and their side effects
Mirtazipine
sedation, increased appetite
Give examples of SNRIs and their side effects
Venlaflaxine
nausea, dry mouth, drowsy, constipation, blurred vision
Give examples of TCA and their side effects
Amitryptilline
drowsy, dry mouth, blurred vision, constipation, urinary retention
what are the signs of mania?
MOOD - irritable, euphoric
COGNITION - grandiosity, distractable, flight of ideas, confusion, lack of insight
BEHAVIOUR - rapid speech, hyperactive, reduced sleep, hypersexuality
PSYCHOSIS - delusions, hallucinations
Name some causes of mania?
Meds - steroids, amphetamines, cocaine, SSRIs
PHYS - infection, stroke, neoplasm, bipolar
how do you assess someone who is acutely manic?
ASSESS - infections, drug use, CT head/EEG, screen toxins
EXAMINE - cycling speed, psychosis, suicide Rx
How do you manage acute mania?
Olanzipine
What medication do you use as prophylaxis of bipolar disease - what screening do you need to do before
Lithium carbonate
UE, T4, ECG
what is the therapeutic dose of lithium
0.6 - 1.0
causes of lithium toxicity?
dehydration, renal failure, thiazide diuretics, NSAIDS, metronidazole
features of lithium toxicity
coarse tremor, hyperreflexia, acute confusion, polyuria, seizure and coma
How do you manage lithium toxicity?
Mild - 0.9% normal saline
Severe - haemodialysis
how does cocaine act on the body?
blocks uptake of dopamine, noradrenaline and serotonin
effects of cocaine on the body?
CVS - MI, increased HR and BP, QT prolongation, aortic dissection
PSYCH - agitation, psychosis, hallucination
NEURO - seizure, mydriasis, hypertonia, hyperreflxive
Mx of cocaine toxicity?
benzodiazepene
what are the features of dependance on a substance?
strong compulsions/cravings
difficulty controlling substance levels of use
withdrawal
tolerance
neglect of other hobbies
persisting using despite harmful consequences
signs of opioid use?
rhinorrhea, needle tracks, pinpoint pupils, drowsy, yawning
complications of opioid addiction
HIV/Hep B and C infective endocarditis and sepsis DVT respiratory depression social - prostitution and crime
how can we reduce harm to opioid addicts?
needle exchange programmes
HIV and Hep B and C testing
Methodone and buprenorphine
how does Naloxone work?
opioid antagonist - blocks euphoria in relapse
How do you screen for alcohol overuse?
CAGE
- ever felt you should cut down?
- have people been annoyed by your drinking?
- ever felt guilty about drinking?
- ever had an eye opener drink?
signs of delerium tremens?
72 hours after stopping drinking alcohol
high heart rate, BP drops, tremor, fits, tactile or visual hallucinations
how do you manage delerium tremens?
monitor BP
give chlordiazepoxide
list support and 2 medications to help with alcohol abstinence?
treat coexisting depression refer to specialists AA Disulfiram - nasty reaction when relapse Naltrexone - reduces the pleasure when drinking (opioid antagonist)
Long term side effects of alcohol abuse?
LIVER - fatty liver, cirrhosis, hepatitis
CNS - memory and cognition, cerebellar atrophy, wernicke and korsakoff
GI - D&V, ulcers, varices, pancreatitis
CVS - arrhythmia, increased BP
what causes wernickes encepalopathy?
longstanding thiamine deficiency (B1)
triad of wernickes encepalopathy?
confusion, wide gait ataxia, ophtalmoplegia (nystagmus and conjugate gaze)
Mx for wernickes encepalopathy?
IM thiamine
what is Korsakoff syndrome?
hypothalamic damage and cerebral atrophy due to longstanding thiamine deficiency
features of korsakoff syndrome?
unable to form new memories (confabulation)
no insight and apathy
Name the first rank symptoms of schizophrenia
auditory hallucinations - thought echo, 3rd person, 2 people discussing in 3rd person
thought disorder - thought insertion/withdrawal/broadcast
passivity phenomena - body sensations externally controlled
delusional perception - object normal but leads to a delusion (traffic light green, therefore I am a god)
what is required for the diagnosis of schizophrenia?
a clear 1st rank symptom lasting >6 months, with all other causes ruled out
DD for schizophrenia?
head injury, tumour, bipolar, drugs, alcohol
Main RF for schizophrenia?
genetics
Name some psych interventions for patients with schizophrenia?
CBT - target hallucinations/delusions
Work with family
Social support
Early interventions service - supports people in their first psychotic episode (reduce time of untreated pschosis, quick effective care, increase return to education/employment, maintain life trajectory)
What advice/monitoring do you do before starting an antipsychotic?
Hx/Fam Hx of diabetes/HTN/CVD
advice on diet/exercise/weight control
MONITOR: BP/weight/BG/lipids/FBC/ECG for clozapine
how do first generation antipsychotics work? name a few and the side effects
D2 antagonists
e.g. Haloperidol
SE = EPSE - tremor, slurred speech, akathesia, dystonia, tardive dyskinesia
how do you manage dystonia and tardive dyskinesia?
Dystonia - Procyclidine
Tardive dyskinesia - tetrabenazine
How do second generation antipsychotics work? name a few and the SE
5HT2A and D2 antagonist
e.g. Risperidone/Olanzapine/Quetiapine
SE = hyperprolactinaemia, sexual dysfunction, increased weight, DM, CVS SE, daytime drowsiness
Name SE of clozapine - what additional baseline Ix are needed
Agranulocytosis and myocarditis
FBC and ECG
Different personality disorders - discuss the clusters and types
look in notes
