psychiatry Flashcards
hallucination?
perception in absence of external stimuli
depression auditory hallucination? Schizophrenia?
depression = 2nd person, usually persecutory “you are a bad person and deserve to die” schizophrenia = 3rd person
anhedonia? anergia? early morning wakening? psychomotor retardation? stupor?
anhedonia = loss of enjoyment
anergia = lack of energy
EMW = waking at least 2 hours before normal waking time
PR = slowing of thoughts/movement
Stupor = patient still, quiet, doesn’t respond
Depression ICD-10 criteria
Additional symptoms?
depressive episode should last at least 2 weeks
NO hypomanic/manic epidodes
General criteria
* depressed mood (to degree that is abnormal for individual) for at least 2 weeks
* anhedonia
* anergia
Additional symptoms
* low self-esteem
* guilt
* pseudodementia
* suicidal thoughts
* sleeping more/less
* eating more/less
severity of depression?
3 scales
* Hamilton (HAM-D)
* Montgomery-Asperg (MADRS)
* Beck (BDI)
ICD rates severity according to symptoms
* Moderate = 2 core symptoms + 4 additional symptoms (at least 6)
* severe = at least 8
depression + mania?
first episode of (hypo)mania with depression means it is bipolar
hypomania ICD-10
mood elevated to degree that is abnormal to individual for 4 days
at least 3 of following signs must be present
* increased activity or restlessness
* increased talkativeness
* decreased need for sleep
* difficulty concentrating
* increased libido
* mild spending sprees or reckless behaviour
manic episode ICD-10
abnormal mood/activity for at least 1 week (unless severe enough to require hospital admission)
at least 3 of following signs
* increased activity or restlessness
* increased talkativeness
* decreased need for sleep
* flight of ideas (racing thoughts)
* inappropriate behaviour (loss of social inhibition)
* grandiosity
* distractibility or constant change in activity/plans
* reckless behaviour
* marked sexual energy
psychotic symptoms bipolar?
grandiose delusions
onset bipolar?
usually late teens
FH results in earlier onset onset
>60 is rare and associated with worse outcomes
predictors of poor outcome bipolar?
* early-onset or very late onset
* low socioeconomic status
* long duration of illness
* rapid cycling
* psychosis
* comorbidities
* family history
bipolar I vs II?
bipolar I = mania + depression
bipolar 2 = hypomania + depression
substance misuse history
TRAPPED
Type
Route - injection/snort
Amount
Pattern - frequency of use and duration
Past abstinence - reason for relapse?
Effect on life
Dependency
mood vs affect?
mood - how you feel
effect - how patient appears (flattened, emotional labile)
thought disorders
thought insertion = belief that thoughts inserted into patients mind
thought withdrawal = thoughts removed (i.e. memories)
thought broadcasting = believe others can hear thoughts
how to assess cognition?
MMSE
MOCA
ACE-III
drugs that most effectively cross BB?
hydrophobic/lipophillic
depression pathophys?
where do they originate?
deficiency of monoamines - serotonin and noradrenaline
serotonin from rostral nucleus + caudal raphe
* rostral = mood, sleep, feeding behaviour
* caudal = analgesia
Noradrenaline from locus coeruleus + lateral tegmental area (pons)
monoamine oxidase inhibitors?
Side effects?
phenelzine (irreversible)
moclobemide (reversible)
S/E
* cheese reaction - hypertensive crisis
* insomnia
* postural hypotension
* peripheral oedema
* increases side effects of other drugs e.g. barbiturates
D - nausea
citalopram
tricyclic antidepressant examples?
mechanism?
side effects?
imapramine, dosulepin, amitryptyline, lofepramine
block reuptake of noradrenaline and 5-HT
Side effects
* anticholinergic - dry mouth, blurred vision, constipation, urinary retention
* sedation
* weight gain
* cardio - postural hypotension, tachycardia, arrhythmias
**** cardiotoxic in overdose!!
SSRI examples
mechanism?
side effects
fluoxetine, citalopram, sertraline, paroxetine
inhibit reuptake of serotonin
common side effects
* nausea
* headache
* worsened anxiety
* transient increase in self-harm/suicidal ideation <25 years
* sweating/vivid dreams
* HYPONATRAEMIA *(in elderly)
SNRI examples
mechnaism?
side effects
venlafaxine, duloxetine
block reuptake of serotonin and noradrenaline
side effects = same as SSRI but WITHOUT anticholinergic effects :)
atypical antidepressant drugs?
mechanism + side effects?
mirtazapine (blocks alpha receptors causing increased release of 5-HT and noradrenaline)
side effects
* weight gain!!! - increases appetite
*sedation
also bupropion which is a dopamine uptake inhibitor
ataxia
FALSE - renal metabolism
B - increase in lithium levels
lithium drug?
what is important when prescribing lithium?
lithium carbonate
requires monitoring
* 12 hours post dose
* target range is 0.4-1.0 mmol/l
Side effects lithium
toxic effects?
side effects
* dry mouth/strange taste
* polydipsia + polyuria
* tremor
* hypothyroidism
*reduced renal function
* nephrogenic diabetes inspidus
* weight gain
Toxic effects
vomiting, diarrhoea, ataxia/coarse tremor
drowsiness/unconscious
convulsions, coma
E - valproic acid (teratogenic)
anticonvulsant mood stabilisers?
side effects?
valproic acid, lamotrigine, carbamazepine
valproate + carbamazepine = induces liver enzymes, ataxia, drowsiness, arrhythmia
valproate is teratogenic (neural tube defects)
lamotrigine = small risk of SJS
antipsychotics as mood stabilisers
side effects?
quetiapine, apiprazole, olanzapine
side effects
* weight gain, sedation, metabolic syndrome (others covered in schizophrenia)
how long should you trial antidepressant?
is it stopped immediately after remission?
at least 4 weeks (6 weeks in the elderly)
no - continue for at least 6 months after full recovery without reducing dose
** if second episode - continue for at least a year after full recovery!!!
acute mania Tx?
1st line = antipsychotic (olanzapine, quetiapine, risperidone)
bipolar Tx?
what about bipolar depression?
1st line = lithium
2nd line = antipsychotics, anticonvulsants
antidepressants should NOT be prescribed without an antimanic drug
ECT complication?
memory problems - episodic memory
ability to learn new information is not affected
Anorexia nervosa ICD-10
BMI <17.5
self-induced weight loss (dieting, vomiting, excessive exercise)
body image isturbance
fear of fatness
amenorrhoea/sexual dysfunction in men
delaye dpuberty
physical assessment anorexia?
muscle wasting, hair loss
lanugo hair
cold, blue peripheries
dry skin
hypercarotenaemia (orange palms)
bradycardia, hypotension
bruising
high risk anorexia
BMI <13 or weight loss >1kg/week
prolonged QT, HR <40, systolic BP <80
core temp <34 C
unable to rise from squat without using arms
cognitive impairment
important to avoid when treating anorexia?
refeeding syndrome
patient given too many calories too quickly - fatal
Tx anorexia
co-morbidities?
CBT
dietician
family therapy
inpatient tx for high risk
co-morbs = depression, OCD, autism
bulimia nervosa ICD-10
persistent preoccupation with eating
irresistable craving for food
binges + attempts to counter effects of binges (starvation, laxatives, purging)
morbid dread of fatness
physical assessment bulimia?
Russel’s sign
parotid hypertrophy
dental caries
U + Es (hypokalaemia - can lead to seizures)
ketones - dehydration
cluster A personality disorders
cluster B personality disorders
cluster C personality disorders
Tx personality disorders?
pharmaoclogical treatment not recommended by NICE!!
For BPD, 1st line = DBT
rest = CBT, some req inpatient care
1st v 2nd v 3rd gen antipsychotics
1st = chlorpromazine, haloperidol, prochlorperazine
2nd = clozapine, olaznapine, quetiapine, risperidone
3rd = aripiprazole
Tx schizophrenia?
2nd gen antipsychotic 6-8 weeks –> 1st/2nd gen 6-8 weeks –> check compliance + correct diagnosis
* if not compliant = depot haloperidol (3 months)
* if NONE of this has worked, try clozapine
** or higher dose OR combine 2 antipsychotics
antipsychotic mechanism?
dopamine (D2) antagonists
except clozapine - D4
side effects antipsychotics? + pathways
extrapyramidal (dystonia, parkinsonism, tardive dyskonesia) = nigrostriatal pathway
neuroleptic maligant syndrome = mesolimbic pathway
hyperprolactinaemia (lactation/gynaecomastia) = tubuloinfundibular pathway
Akathesia/restless legs = hypothalamospinal pathway
other side effects = anticholinergic, weight gain + sedation, postural hypotension, hepatoxicity, prolonged QT, photosensitivity
acute dystonia antipsychotics?
Tx?
onset in minutes
increased muscle tone
torticollis
oculogyric crisis
tongu eprotrusion
Tx = procyclidine (anticholingeric)
parkinsonism antipsychotic?
Tx?
bradykinesia
cogwheeling rigidity
shuffling gait
hypomimia
Tx = procyclidine
tardive dyskinesia antipsychotic?
Tx?
often permanent
involuntary repetative oro-facial movements e.g. pouting, lip-smacking
doesn’t reallt respond to procyclidine like acute dystonia or parkinsonism
when to suspect neuroleptic malignant syndrome?
Diagnostic test?
Treatment?
gradual onset 1-3 days - EMERGENCY, FATAL
increasing mucle tone, hyperpyrexia, changing pulse/BP
rhabdo > renal failure > death
Ix = raised CK
Tx = STOP ANTIPSYCHOTIC, dentroline (muscle relaxant), dopamine agonist, rapid cooling
effects of antipsychotic hyperprolactinaemia in women?
Men?
both?
Women = galactorrhoea, decresed libido, amenorrhoea
men = gynaecomastia, erectile dysfunction + oligospermia, decreased libido
both = osteoporosis
Akathesia symptoms?
Tx?
pacing
unable to sit/stand still
Tx = propanolol 1st line
2nd line = benzo
anticholingeric side effects?
5HT2?
anti-adrenergic?
anticholinergic = dry mouth, blurred vision, constipation, urinary retention
5HT2 = weight gain, metabolic syndrome (T2DM)
anti-adrenergic = postural hypotension
all seen in antipsychotic use
1st gen vs 2nd gen antipsychotic side effects?
1st gen = extra-pyramidal side effects (dystonia, parkinsonism, TD)
2nd gen = weight gain, sedation, diabetes
clozapine side effects
monitoring?
ANGRANULOCYTOSIS = neutropenic sepsis
myocarditis
constipation (bowel obstruction)
weight gain
sedation
sialorrhoea
weekly WBC count for first 6 months
age of onset depression?
bipolar?
personality disorders?
depression = 50% before 20
bipolar = approx 25
personality disorders = can only be diagnosed after 18
seperation anxiety disorder (SAD)?
Normal from age 7 months through preschool
- SAD distinguished by age inappropriate, excessive and disabling anxiety
- SAD and other anxiety disorders tend to lead to school refusal
Note marked increase in social anxiety and perfectionism during adolescence
delerium features?
Acute onset
Lasts for hours to weeks
Fluctuates (worst at night)
Attention decreased or hyperalert
Ax delirium?
I WATCH DEATH
I - infections
W - withdrawal from medications
Acute causes - electrolyte disturbance, dehydration
T - toxins, drugs
C - CNS pathology (strokes, tumours)
H - hypoxia
D - deficiencies, thiamine with alcohol abuse, B12
Endocrine - thyroid etc
A - acute vascular shock e.g. hypertensive encephalopathy
T - trauma
H - heavy metals e.g. lead, mercury, manganese poisoning
pseudodementia features?
Fluctuating loss of memory
Good insight into loss of memory
Prominent slowing of speech
Depressed mood
Not progressive
Responds to medication/ECT