Psychiatry Flashcards
Mental State Examination parts
Appearance and behaviour Speech- RTV Mood and affect Thoughts Perceptions Insight Cognition Suicidal ideation
What is a delusion?
Firm, fixed false belief in something that is not in-keeping with cultural or societal views
What is an illusion
Real stimulus but false perception
Can be normal
Types of thoughts in MSE
Tangential Circumstantial Knight's move Clanging/ punning Blocking Perseveration Disorganised Neologism Loosened associations
Things to comment about appearance in MSE
Unkempt Clothing Behaviour- eye contact, expressions Motor symptoms- akathisia, depressive Body habitus Distracted
Types of hallucination
Auditory Visual Gustatory Olfactory Somatic Tactile
One unit of alcohol in grams
8g of absolute alcohol
Alcohol detoxification withdrawal symptoms/signs
Seizures after around 37 hours
Delirium tremens after around 72 hours
1-4 days Nausea and vomiting Tremor Sweats Anxiety Disturbed sleep Hypertension Tachycardia
2+ days Confusion Extreme agitation Dehydration Delirium tremens
Symptoms/signs of delirium tremens
Severe confusion Agitated behaviour Extreme hyperactivity Global dysfunction LOC Hallucinations Sleep disturbance Fever HTN Tachycardia Hyperhidrosis Dehydration
Scoring system used in alcohol withdrawal
CIWA-Ar
10 or more then diazepam
Three scores less than 10- stop diazepam
ICD-10 definition of dependence syndrome
Compulsion to take it and difficulty controlling this
Physiological withdrawal state
Evidence of tolerance
Neglect of alternative pleasures
Continuation of substances despite harming consequences
Drugs for alcohol withdrawal
Disulfiram- causes acute insensitivity reaction to ethanol- inhibits acetaldehyde dehydrogenase
Naltrexone- opioid receptor antagonist, reduces cravings and euphoria
Acamprosate- GABA analogue, good for maintenance of alcohol abstinence
Adverse effects of lithium
Nausea and vomiting
Diarrhoea
Fine tremor
Nephrotoxic- diabetes insipidus and secondary polyuria
Hypothyroid secondary to thyroid enlargement
IIH
Weight gain
Leucocytosis
Hyperparathyroidism and secondary hypercalcaemia
When should lithium levels be monitored?
12 hours post-dose
Weekly after starting or changing dose, until stable levels
Checked every 3 months
Thyroid and renal function assessed every 6 months
Features of lithium toxicity
Coarse tremor Hyperreflexia Acute confusion Polyuria Seizure Coma
Lithium toxicity may be precipitated by
Dehydration
Renal failure
Diuretics, ACE-i, ARBs, NSAIDs and metronidazole
Lithium toxicity management
If low levels then alkalisation of urine may help to excrete more
Fluid resuscitation
If extreme then haemodialysis may be indicated
Side effect of Mirtazapine
Increase in appetite
Conversion disorder
Typically motor or sensory options
Patient doesn’t consciously feign symptoms or seek material gain
Second generation anti-psychotics
Clozapine Olanzapine Risperidone Quetiapine Amisulpride Aripiprazole
Monitoring of what with clozapine use is extremely important
FBC
Risk of agranulocytosis/ neutropenia
Should only be used in patients resistant to other treatment
Dose adjustment if starting or stopping smoking
What is bulimia nervosa?
Characterised by episodes of uncontrollable binge eating followed by purgative behaviours to prevent weight gain (such as self-induced vomiting, laxative use, diuretics, exercise)
First generation antipsychotics and their side effects
Haloperidol, chlorpromazine
Extrapyramidal side effects and hyperprolactinaemia are common
Examples of typical antipsychotic extra-pyramidal side effects
Parkinsonism
Acute dystonia- sustained muscle contraction (managed with procyclidine)
Akathisia
Tardive dyskinesia
Best SSRI post-MI
Sertraline
Which SSRI is most likely to cause a prolonged QT?
Citalopram
SSRI side effects
Most common is GI
Increased risk of GI bleed (PPI if also on NSAID)
Hyponatraemia
Management of Generalised Anxiety Disorder
Education about GAD and active monitoring
Low intensity psychological interventions- self help or psychoeducational groups
CBT or drug treatment
Specialist input
PTSD management (symptoms for 4 weeks)
Watchful waiting if <4 weeks
Trauma-focused CBT or Eye Movement Desensitisation and Reprocessing
Venlafaxine or SSRI if pharmacological is necessary
Anti-muscarinic side effects of TCAs
Blurred vision Dry mouth Drowsiness Constipation Urinary retention QT lengthening
Schneider’s first rank symptoms of Schizophrenia
Auditory hallucinations- thought echo, two or more voices discussing in the third person, voices commenting on patients behaviour (running commentary)
Thought disorder- Insertion, withdrawal, broadcasting
Passivity phenomena- body activities being controlled externally, experiences are imposed on the individual- eg actions, impulses or feelings
Delusional perceptions- a two stage process- delusional insight from a normal stimulus
How long should SSRIs be prescribed for minimum
6 months- prevents relapse into depression
Indications for ECT
Severe depression, catatonic schizophrenia and severe mania
Side effects of ECT
Headache, nausea, memory impairment and arrhythmias
Very few long term effects noted
Definition of hypomania
Decreased or increased function for 4 days
Elevated mood or irritability
Definition of mania
Severe functional impairment or psychotic symptoms (delusions of grandeur or hallucinations) for 7 days or more
Definition of chronic insomnia
Trouble falling asleep or staying asleep at least 3 nights a week for at least 3 months
What should be measured and observed in people starting an SSRI?
U&Es- risk of hyponatraemia
Indications for ECT
Treatment resistant depression
Manic episodes
Catatonia (life threatening)
Episode of moderate depression known to respond to ECT in the past
Somatisation disorder
Unexplained symptoms persisting for at least 2 years, refusal to accept negative results
Erotomania
Delusional disorder that involves the belief that a famous person is in love with you, absence of any other psychotic features
Diagnosis of anorexia nervosa
Restriction of energy intake relative to requirements leading to a low body weight
Intense fear of gaining weight, getting fat, even though underweight
Disturbance in the way one’s body shape or weight is experienced, denial of the seriousness of underweight, undue influence of body weight on self-image
Management of anorexia nervosa
Anorexia focused family therapy first line in children and young people
CBT 2nd line
Side effects of ECT
Immediate- drowsiness, confusion, headache, nausea, aching muscles, anorexia, cardiac arrhythmia, retrograde memory loss, short term memory impairment
Long term- apathy, anhedonia, difficulty concentrating, loss of emotional responses, difficulty learning new information
Factors associated with a poorer prognosis in schizophrenia
Low IQ Strong FH Social withdrawal prodrome Gradual onset Lack of obvious precipitant
What is an oculogyric crisis?
Spasmodic movements of eyeballs into fixed positions, typically upward deviation
Core features of major depressive episode and other features
Depressed mood, anhedonia and/or anergia Weight loss or gain Anorexia or increase in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue Feelings of worthlessness or guilt Loss of concentration Suicidal ideation
Main features of a manic episode
Mood- inappropriate, elevated, excited, irritable
Motor activity/ volition- productive, increased energy, reduced sleep, poor concentration, increased libido
Increased cognition- rapid speech, flight of thoughts, clang associations, rhyming, grandiose ideas
Bipolar type 1
At least one manic episode for at least one week
Significant impairment of functioning
Bipolar type 2
Milder episode of hypomania
No severe impairment
Duration of 4 days
Management of bipolar affective disorder
Admission
Antipsychotic drugs and lithium
Prophylactic mood stabilisers- lithium, anticonvulsants, atypical anti-psychotics
Psychosocial support
Average number of ECT shocks to achieve remission
8
Contraindications of ECT
Brain tumour
Increased ICP
Recent MI
Brain aneurysm
Memory loss from ECT
Uncommon to have autobiographical memory loss
Increased cognitive testing 4-14 days post-test
Metanalysis shows no cumulative cognitive deficits from successive treatment
What is psychosis
‘Loss of contact with reality’
Inability to pick out salient information
What is a delusion
Fixed, firm, unshakeable belief in something that is held against the evidence and the social and cultural norms
Environmental factors that increase likelihood of developing schizophrenia
Though FH- genetic is greatest risk!
Fetal infection and malnutrition Chronic cannabis consumption Urbanicity Social class Social isolation Immigrant status
What is the PANSS scoring system?
Positive and negative syndrome scale
Positive symptoms of schizophrenia
Symptoms of psychosis
Delusional perception
Hallucinations (auditory most common)
Negative symptoms of schizophrenia
Blunted affect Alogia Avolition Anhedonia Asociality
Management of schizophrenia
Biopsychosocial approach
Anti-psychotic medication- assess which will be best
Initial benzodiazepines acutely
Psychological- psychoeducation, CBT and/or family therapy
Social- housing and benefits, substance misuse, occupation and employment, lifestyle- smoking, exercise, diet
Tests to perform before beginning anti-psychotic medication
Weight and waist circumference
Pulse and BP
Fasting blood glucose, HbA1c, lipid profile and prolactin levels
Assessment of any mood disorders
Nutritional status, diet and level of physical activity
Treatment resistant schizophrenia and management
Attempted two different antipsychotics at an adequate dose for an adequate amount of time (6-8 weeks), one has to be a second generation antipsychotic
Clozapine
Side effects of clozapine
AGRANULOCYTOSIS
Anti-dopaminergic- tardive dyskinesia, tremor, movement disorders, apathic facial expressions
Anti-cholinergic- constipation, dry mouth
Anti-histamine- weight gain, dizziness, drowsines
Anti-adrenergic- hypotension
Neuroleptic malignant syndrome
Withdrawal
Seizures
Section 135
Police can enter your home and remove an individual to a place of safety for assessment by approved mental health care professionals
Section 136
Police can detain individuals in a safe place from a public place (usually kept in station or hospital)
Section 5(2)
Doctors have the ability to detain an inpatient for up to 72 hours but CAN’T force treatment
Section 5(4)
Nurses can detain inpatients for up to 6 hours
Section 2 of the mental health act
Assessment of mental health disorder Up to 28 days Require 2 senior doctors and another health or social worker (AMP) Can treat Can be appealed after 14 days
Section 3 of the mental health act
Long term section for treatment
Up to 6 months with various appeal processes
What class is Mirtazipine?
NaSSA
Noradrenaline and specific serotonin antidepressant
Risk assessment of a failed suicide
4Ps to assess degree of intent and seriousness Planning vs impulsivity Precautions to remain hidden Preparations prior to act Public/ in isolation
Regret Future planning Current MSE Past Hx and background Coping mechanisms Protective factors
Schizoid personality
Introspective, asociality, emotionally cold, asexual, lack of close relationships
Paranoid personality
Bears grudges, possessive, suspicious, combative, excessive self importance
Schizotypal personality
Ideas of reference , strange beliefs and thinking, abnormal perceptual experiences, paranoia and social anxiety, inappropriate affect, strange behaviour or appearance
Antisocial personality
Impulsive, aggressive, irritable, tendency or violence and aggression, short lived relationships
Emotionally unstable personality
Intense unstable relationships, boredom/emptiness, uncertain about identity, fear of abandonment, unstable mood, impulsive
Histrionic personality
Dramatic, excessive, exaggerated, shallow, centre of attention, inappropriate, manipulative
Narcissistic personality
Need to be admired, egocentric, entitled, lack of empathy, grandiosity
Anankastic/ obsessive- compulsive personality
Rigid, requires order, adherence to rules, perfectionist, exclusion of pleasure, intrusive thoughts
Anxious personality
Social withdrawal, fear of rejection, low self esteem, inferiority, embarrassment
Dependent personality
Requires reassurance, fear of abandonment, insecure, clingy, indecisive
Clinical features of ADHD
Inattention
Over activity
Impulsivity
Management of ADHD
Bio- medication- methylphenidate or dexamphetamine
Psych- Parenting training programmes, CBT/behavioural therapy
Social- Structure and routine, educational support/ school liaison
Side effects of methylphenidate/ dexamphetamine
Headaches, insomnia, anorexia, dizziness, anxiety
Growth suppression
Autism spectrum disorder clinical features
Triad of
Social impairment
Communication impairment
Restrictive/ repetitive behaviours and interests
Management of autism
Bio- risperidone, SSRI
Psych- SALT, social skills training, behavioural modification programmes, parental training courses
Social- appropriate educational setting
What is a learning disability?
Significant sub-average intellectual functioning
Deficits in adaptive or social functioning
Onset within developmental period
Investigating confusion in the elderly
Bloods and blood culture ABG CXR MMSE/AMT Urine and culture ECG CT head/ LP/EEG if indicated
Puerperal psychosis recovery time
Usually 6-8 weeks
Management of puerperal psychosis
As per condition outside pregnancy
Bio- benzos, antipsychotics, mood stabilisers, antidepressants, ECT
Psych- CBT, family therapy, psychoeducation
Social- Support for the family, housing, employment, protection of the children
Suicide risk assessment questions
Current episode BEFORE Precipitant Planned or impulsive Precautions against discovery Alcohol DURING Method, alone, where, what was going through their mind, did they mean to end their life, what did they do straight after AFTER Who were they found by, how did they feel when help arrived, do they regret it, current mood, still feeling suicidal, what would they do if they went home today
Specific questions to ask about overdose
What medication(s) did they take? Where did they get it How much of them? What did they take it with? How long had they been planning and what made them decide? What did they do after? How did they get here?
