Psychiatry (P4) Flashcards
1
Q
Define an illusion.
A
Stimulus present but is misperceived.
2
Q
Define an hallucination.
A
Stimulus is not present but there is a perception.
3
Q
What are the terms for an hallucination just as you are going to sleep, and when waking up?
A
Hypnagogic (sleep)
Hypnopompic (waking)
4
Q
What is a reflex hallucination?
A
When a stimulus in one sensory modality triggers a perception in another modality e.g. hear a sound and see a ghost.
5
Q
What is an extracampine hallucination?
A
Perceiving something that is impossible e.g. hearing your deceased grandmother on mars.
6
Q
What is the difference between an over-valued idea and a delusion?
A
Over-valued ideas are firmly held false beliefs but one can be reasoned out of them.
A delusion is a fixed false belief which one cannot be reasoned out of.
7
Q
What is a Fregoli delusion?
A
Believing that various different people are the same person.
8
Q
What is delusional perception?
A
When a perception triggers a delusional belief e.g. the traffic light signal was a sign from MI6.
9
Q
Name three types of delusion/
A
Nihilistic Hypochondriacal Grandiose Fregoli Guilt Delusional perception
10
Q
Name two kinds of thought disorder.
A
Insertion: external agent putting thoughts in my head.
Broadcast: People can hear my thoughts.
Echo: Hear their own thoughts said back to them.
Block: Train of thought/speech suddenly stops.
11
Q
What is concrete thinking?
A
Rigid or literal thinking. Patients don’t grasp metaphor easily.
12
Q
What is Knight’s move thinking (aka loosening of association)?
A
Where there is no link between what someone is saying.
(vs. Flight of ideas where you can still see the links).
13
Q
What is circumstantiality?
A
When someone talks around a topic
14
Q
What is perseveration?
A
When someone gives the same answer repeatedly to multiple questions.
15
Q
In Schizophrenia what are Schneider’s 1st Rank symptoms?
A
[‘Have The Delusions Stopped’]
Hallucinations (typically auditory 3rd person)
Thought disorder e.g. insertion, broadcast etc.
Delusions e.g. delusional perception.
Somatic Passivity i.e. a sensation imposed by outside agent).
1+ for >1month = Dx
16
Q
Give two examples of negative symptoms
A
Catatonic behaviour
Social withdrawal
Blunt affect
Apathy
17
Q
Name a first generation antipsychotic. What receptors do they act on?
A
Haloperidol
Chlorpromazine
Block D2 receptors
18
Q
What kind of side effects do 1st generation antipsychotics produce? Give 2 examples.
A
Extrapyramidal Side Effects
Akathisia (Restless legs)
Parkinsonism
Dystonia (twisting repeating movements)
Tardive Dyskinesia (jaw/face jerks).
19
Q
What kind of patients should you avoid giving 1st generation antipsychotics to?
A
Patients with Parkinsons
Progressive Supranuclear Palsy
Lewy Body Dementia
CNS depression e.g. coma.
20
Q
Name two 2nd generation antipsychotics. What receptors do they act on?
A
Risperidone Clozapine Olanzapine Quetiapine Aripiprazole
D2 + 5-HT2a
21
Q
Give two side effects of 2nd generation antipsychotics
A
Weight gain [Olanzapine, Clozapine, Quetiapine].
Dyslipidemia [Olanzapine, Clozapine].
Hyperglycemia [Olanzapine, Clozapine]
Hyperprolactinemia [esp. Risperidone].
Agranulocytosis (reduction in granular leukocytes e.g. neutrophils). [esp. Clozapine]
22
Q
Which antipsychotic is reserved for treatment resistant schizophrenia?
A
Clozapine
23
Q
A patient presents with confusion, labile BP, hyperthermia, raised WCC and raised creatinine following treatment with antipsychotics. What is the most likely diagnosis? What is the treatment?
A
Neuroleptic Malignant Syndrome
Stop the antipsychotic
Supportive
24
Q
What are the 4 Ps of the biopsychosocial model?
A
Predisposing
Precipitating
Perpetuating
Protective
25
What is Dysthmia? What is the treatment?
Sustained low mood for >2 years.
Treatment is an SSRI e.g. Fluoxetine + CBT.
26
What is Cyclothymia? What is the treatment?
Rapid (within hours/days) fluctuations between depression and HYPOmania.
Treatment: CBT + mood stabilisers e.g. Lithium or lamotrigine.
27
What is the difference between Bipolar I and II?
Bipolar I = Mania + Depressive episodes.
Bipolar II = Depression without mania (may have hypomania).
28
What is the difference between mania and hypomania?
Mania: Typically longer than a week and cannot function socially (50% become psychotic).
Hypomania: Shorter duration and can still function.
29
Define psychosis
When a person loses touch with reality e.g. hallucinations or delusions.
30
What is the treatment for mania?
Antipsychotic
| Mood stabiliser e.g. carbamazepine or lithium
31
Can you take NSAIDs with Lithium?
Not advised. NSAIDs have been shown to reduce clearance of lithium which can potentiate its action.
32
Give an example of a Serotonin Noradrenaline Reuptake Inhibitor (SNRI)
Duloxetine
| Venlafaxine
33
Give an example of a Tricyclic Antidepressant (TCA)
Amitriptyline
| Nortriptyline
34
Name a monoamine oxidase inhibitor (MAOI)
Selegiline
(These are really only used as a last resort).
35
What kind of antidepressant is Mirtazapine?
Noradrenergic And Specific Serotonergic Antidepressant (NASSA)
36
Give two common side effects of antidepressants
```
Low libido
Erectile Dysfunction
Anxiety
Dry mouth
Insomnia
Addiction
```
37
TCAs can produce anticholinergic side-effects (pro sympathetic). Name two of these effects.
['Can't see, Can't pee, Can't spit, Can't shit']
Uveitis
Urinary retention
Dry mouth
Constipation
TCAs can also block alpha 1 adrenergic pathways and cause postural hypotension.
+block histamine pathways causing drowsiness.
38
Foods high in what amino acid can induce the "cheese effect" in patients talking SSRIs/MAOIs?
Tyramine
Strong cheese and cured meats.
39
A patient on SSRI switched to MAOI without stopping the SSRI and presents with confusion, hypertension, tremor, tachycardia, sweating and mydriasis (dilation). What is the likely diagnosis and treatment?
Serotonin Syndrome
Stop SSRI/MAOI
Cyproheptadine (5-HT2 antagonist).
Benzodiazepines.
40
Why are benzodiazepines such as diazepam (valium), lorazepam, and chlordiazepoxide not recommended for longer than 4 weeks?
Risk of addiction
41
What happens if you suddenly stop taking SSRIs?
Antidepressant Discontinuation Syndrome aka SSRI withdrawal.
Nausea, GI upset, Flu-like symptoms for up to 2 weeks.
42
What is a staggered overdose?
The cumulative effect of several overdoses over a short period of time which can be sufficient to kill the patient.
43
Name a mood stabiliser that is safe for pregnant women and one that is not safe
Safe: Carbamazepine or Lamotrigine.
Not Safe: Sodium Valproate (results in birth defects). Lithium can cause heart defects.
44
What does IAPT stand for?
| What is it for?
Improving Access to Psychological Therapy
[Self referral service for depression and anxiety]
45
What support service is available for mental health issues affecting those between 4-18 years of age?
Child and Adolescent Mental Health Services [CAMHS]
46
Define delirium.
Acute confusional state
| [Medical Emergency]
47
Name three things that can cause delirium
[PINCH ME]
```
Pain
Infection
Nutrition
Constipation
Hydration
```
Medical e.g. stroke/drugs
Environment
48
How do you treat delirium?
1st line: Verbal/non-verbal reorientation
2nd line: Low dose antipsychotic
NB: Benzos can make it worse! Only consider if patient is violent/uncontrollable.
49
What is paraphrenia?
Positive symptoms of schizophrenia (hallucination, thought disorder, delusions,, somatic passivity) without the negative. Mainly in older patients (>60yo).
50
How long can a person be detained under section 2 of the mental health act?
28 days maximum
[This cannot be renewed!]
[Sect 2 = ASSESSMENT]
NB: Treatment can still be administered under section 2.
51
What are the conditions that must be met for section 2 of the mental health act? (Who is required and what kind of patient?)
Patient must have a mental disorder which puts them or others at risk.
```
2 doctors (1 S12 approved).
+ Approved Mental Health Proffessional (AMHP).
```
52
How long can a patient be detained under section 3 of the mental health act?
6 months
[It can be renewed]
[Sect 3 = TREATMENT]
```
2 doctors (1 x S12 approved)
+ AMHP
```
53
What is section 4 used for under the mental health act?
| How long can a patient be detained under this?
Emergency assessment (out-patients). For max 72 hours (cant be renewed).
This is for a doctor to detain an outpatient while you wait for the criteria for Section 2 to be met.
54
What is the difference between Section 5(4) and 5(2) under the mental health act?
5(4) Nurses
6 hour detention for in patients.
5(2) Doctors
72 hour detention for in patients.
55
What is the difference between section 135 and 136 in the mental health act?
135 = Police detention from home. 24hrs. Requires a court order.
136 = Police detention from a public place. 24hrs.
56
What are the CAGE screening questions? Name another alcohol screening tool
Ever thought of Cutting down?
Ever get Angry when questioned about drinking?
Ever feel Guilty about your drinking?
Ever needed an Eye-opener in the morning?
AUDIT
MAST
JELLINEK
SADQ (severity)
57
What are the alcohol limits for blood and breath?
```
Blood = 80mg/100ml
Breath = 35ug/100ml
```
58
How many units of alcohol are recommended per week?
Max 14 units per week
| Spread over >3 days.
59
What is the technical definition of binge drinking?
>8U in a single session (Men)
>6U (Women)
60
How much is one unit of alcohol in ml and g?
10ml
| 8g
61
How do you calculate Units?
Units = [ABV% x Vol (ml)]
| 1000
62
Give two symptoms of alcohol withdrawal
```
Tremor
Tachycardia
Hypotension
Confusion
Hallucination (typically visual/tactile).
```
NB: Formication = visual hallucination seeing insects crawling on you.
63
What is the first line treatment for Delirium Tremens [medical emergency]?
Oral lorazepam
64
What drugs are used to treat alcohol dependence?
Relapse prevention:
1) Acamprosate Calcium
2) Naltrexone Hydrochloride
3) Disulfiram
Reduce consumption in high risk individuals
1) Nalmefene
65
What treatment should be given to all alcoholics to prevent encephalopathy?
Pabrinex
| [Vitamin C + Thiamine B1]
66
What are the signs of Wernicke's and Korsakoff's Encephalopathy?
Wernicke's: [CAN]
Confusion
Ataxia
Nystagmus (ophthalmoplegia)
Korsakoff's:
Amnesia (retro/anterograde)
67
Name a service that supports alcoholics
Change Grow Live (CGL)
68
What are the three Ps of personality disorders?
Persistent
Pervasive
Problematic
69
Name a personality disorder in Cluster A, B and C
A:
Paranoid
Schizoid
Schizotypal
```
B:
EUPD
Narcissistic
Histrionic
Antisocial
```
C:
Avoidant
Dependent
Obsessive Compulsive PD
70
What are the four diagnostic criteria for PTSD?
1) Exposure to stressful event
2) Persistent remembering e.g. flashbacks
3) Avoidance association
4) Either memory loss or hypersensitivity e.g. startle response (hyperarousal).
[All must occur in the 6 months following the stress/trauma]
71
What treatment is available for PTSD?
Eye Movement Desensitisation Reprocessing (EMDR)
Trauma focussed CBT
Antidepressants
72
What is the difference between PTSD and Adjustment disorder?
Adjustment disorder is a dysregulated response to minor stressors (no single big event).
73
What are the three diagnositc criteria for Anorexia Nervosa?
1) Body weight >15% below expected.
2) Weight loss self-induced e.g. dieting, purging, exercise.
3) Weight is an over-valued idea (body image distortion).
All three must be present
74
Give three signs of anorexia nervosa
```
Lanugo hair
Calloused knuckles
Enamel erosion
Prolonged QT
Hypokalaemia
```
75
How do you calculate BMI?
Weight (kg) / height (m) squared
76
What are the categories for BMI?
```
Underweight: <18.5
Normal: 18.5-25
Overweight: 25-30
Obese: 30-35
Morbid obesity: 35+
```
77
Which is more common Bulimia Nervosa or Anorexia Nervosa?
Bulimia Nervosa
78
What is binge eating?
Eating more than normal within a 2 hour period.
79
What are the three diagnostic criteria for Bulimia Nervosa?
1) Bingeing
2) Self induced weight loss (vomiting, starvation, exercise)
3) Morbid fear of being fat.
80
What is the key difference between Anorexia and Bulimia?
Anorexia = underweight
| Bulimia are often normal/overweight.
81
What is the treatment for Bulimia?
Nutritional counselling
Psychotherapy/CBT
SSRI
NB: Mirtazapine (NASSA) is useful as it can cause weight gain.
82
What is the SCOFF questionnaire?
1) Ever make yourself Sick because of eating too much?
2) Do you worry you have lost Control of your eating?
3) Have you recently lost more than One stone (last 3 months).
4) Do you think you are Fat when others don't?
5) Does Food dominate your life?
83
What scoring tool is used to assess patients for malnutrition?
Malnutrition Universal Screening Tool [MUST]
1) BMI
2) % Weight loss (3-6 months)
3) Acute disease
Scores:
0 = low risk
1 = moderate risk (monitor)
2+ = high risk (ref dietician)
84
What are the three categories of deficit for ADHD? (Provide one example for each category).
Hyperactivity: fidgets, talks a lot, can't play quietly.
Impulsivity: Interrupts, can't take turns, speaks without thinking.
Inattention: Loses things, can't focus, lacks structure.
85
What are the diagnostic criteria for ADHD?
6 signs of (Hyperactivity + Impulsivity)
OR
6 signs of inattentiveness.
Signs must be present before the age of 12 and must last for >6 months.
86
What is the treatment for ADHD?
Methylphenidate (Ritalin)
Or Amphetamines.
NB: Must be over 5 years old to take this.
87
What investigations can be done to determine a diagnosis of ADHD?
Clinical interview (parents/teachers).
Clinical History
Quantitative Behavioural Test [QB Test].
88
What are the diagnostic criteria for autism?
Difficulties with social interaction
Difficulties with social communication
Strereotyped behaviours / resistance to change.
[Should be present from childhood, must limit everyday function, must not be explainable by intellectual disability].
89
Describe three signs of autism spectrum disorder?
```
Not smiling by 9 months
Not sharing by 3-4 years
Repetitive movements/sounds
Obsessive interests
Avoidance of eye contact
No words by 16 months
```
90
What is the difference between Asperger's and Autism?
Both are on the autism spectrum disorder (ASD).
However, Asperger's is high functioning with no speech delay during development.
Asperger's are normal/above average intellenge but tend to be obsessive/narrowly focussed and don't grasp the nurances of language/communication such as humour, irony or listening to others. Their tone/speech pattern tends to be atypical i.e. monotone, broken, higher pitch.
91
Define dementia
Progressive global decline in cognitive function
92
What are the hallmark pathological changes in the brain with Alzheimer's disease?
Beta amyloid plaques
Neurofibrillary Tau tangles
Atrophy (hipocampus)
93
Name three clinical investigations would you do in a patient with Alzheimer's
FBC, U&E, ESR, Calcium, HbA1c, LFT, Thyroid, Serum B12 [+HIV, CXR, ECG if indicated]
MRI or CT to rule out other causes.
94
What are the four domains of the mental capacity assessment?
Understand
Retain
Weight up
Communicate
95
Name three cognitive assessment tools
```
Mini Mental State Exam
MOCA
Mini Cog
GPCOG
Memory Impairment Screener (MIS)
10 point cognitive screen (10CS)
6 item cognitive impairment test (6-CIT)
Test your memory (TYM)
ACE-III
Abreviated Mental Test (AMT)
```
96
What is an IMCA?
An Independent Mental Capacity Advocate. They support those patients without capacity who are under Deprivation of Liberty (DoLs) to ensure they are being detained appropriately.
97
Where do you commonly see atrophy of the brain in Alzheimer's patients?
Temporal lobe atrophy
| Esp. hippocampus
98
What is the typical early presentation specific to Alzheimer's?
Visuospatial deficits - tend to get lost easily.
Loss of episodic memory - forget recent events, repeat the same questions
Cognitive impairment - struggle to learn new things.
99
What is the typical early presentation of vascular dementia?
Step-wise progressive loss
- Attention
- Personality change
- Focal deficit e.g. paralysis
100
What is the typical presentaiton of Fronto-Temporal Dementia aka Pick's disease?
Personality change e.g. social or sexual disinhibition.
They may be otherwise congitively normal.
101
What is the typical presentation of Lewy Body or Parkinson's dementia? What is the difference between them?
Falls, delusions, hallucinations. Acute sensitivity to antipsychotics.
Parkinson's = Motor then dementia
Lewy Body = Dementia then motor.
102
Define mild cognitive impairment (MCI). What proportion go on to develop dementia?
Decline in cognitive function which does not affect daily activities.
50% go on to develop dementia
103
What is sundowning? How can it be managed?
An associated phenomenon of dementia where the symptoms get worse at night. Believed to be related to circadian rhythm dysregulation.
- Boost natural light in day
- Provide structure
- Avoid caffeine/alcohol late in the day
104
Name two reversible causes of dementia
```
Hypothyroidism
Delirium
Tumours
Depression
Vit B/Folate deficiency
Neurosyphilis
```
105
What four main drugs are used to treat dementia? Which types of dementia are they effective in?
Acetylcholinesterase inhibitors
- Donepezil
- Rivastigmine
- Galantamine
NMDA receptor antagonist
- Memantine
Lewy Body, Alzheimer's. Parkinson's [LAP] respond.
106
What are the three cardinal symptoms of depression?
Anhedonia
Anenergia
Low mood
(early morning waking, suicidal ideation, tearful, loss of libido, low self esteem etc)
[more than 2 weeks]
107
How is Generalised Anxiety Disorder (GAD) diagnosed?
>6 months of chronic, excessive worry that is disproportionate to their experience/environment.
108
What screening tool is used to assess anxiety?
GAD-7
| HADS
109
Name a screening tool for depression
Patient Health Questionnaire-9 [PHQ9]
Beck Depression Inventory [BDI]
Hospital Anxiety & Depression Score [HADS]
ICD-10 Depression Inventory
110
Give two differential diagnoses for generalised anxiety disorder
```
Hyperthyroidism
Phaeochromocytoma
PTSD
Adjustment disorder
Panic disorder
Social phobia
Cardiac arrhythmias
```
111
What is the difference between OCD and OC personality disorder?
OCD is typically less disruptive to life/personal relationships as it involves a specific recurring behaviour e.g. hand washing.
However, OCPD is generalised perfectionism which does impair life/relationships.
112
What is the difference between an obsession and a compulsion?
Obsession is a recurring, intrusive thought or idea.
Compulsion is a recurring actions/behaviours.
113
What is the treatment for OCD?
CBT
| SSRIs
114
What is the treatment for anxiety?
CBT
| SSRIs
115
Are SSRIs safe in pregnancy?
Not advised during the first trimester as increase the chance of birth defects (especially heart defects).
116
What is clanging?
Rhyming words e.g. "I heard a bell, tell, sell, well, spell..."
117
What are made acts/feelings/drives?
The belief that acts, feelings or drives are caused by an external agent.
118
What is a neologism?
Forming new words
119
What is the difference between a mood and affect?
Mood is an individual's subjective emotional state.
| Affect is the objective expression of emotion.
120
What is the difference between blunt and flat affect?
```
Blunt = significantly reduced
Flat = no emotional expression
```
121
What is incongruity of affect?
Mismatch between reported mood and displayed affect.
122
What is conversion?
Where psychological trauma results in physical symptoms e.g. loss of vision or motor function.
123
What is Belle Indiference?
Psychological conversion which the patient doesn't recognise as a problem e.g. loss of function of left arm is normal to them.
124
What is derealisation?
Belief that the world is not real (external disconnect)
125
What is depersonalisation?
An internal disconnect between mind and body.
126
What is Charles Bonnet Syndrome?
Visual hallucination (shapes, patterns, colours) in patients with visual impairment.
127
What is erotomania?
The delusion that someone is in love with them.
128
What is an elementary hallucination?
A simple, unstructured sound e.g. buzzing, whistling.
129
How long do SSRIs take to work?
4-6 weeks
130
Give three risk factors for suicide
```
Male
Young
Substance abuse
FHx
Recent antidepressants
Prior attempts
Physical illness
Access to means
Severe depression
Lack of social relationships
```
131
True or false Wernicke's encephalopathy is reversible?
True
[Korsakoff's is not]
132
What is another name for an Advanced Statement? Is it legally binding?
A living will
Sets out preferences of care.
Not legally binding.
133
What are the two types of lasting power of attorney? Where are they registered?
Health & Welfare
Property & Finance
Registered at the Office of the public guardian (OPG).
134
What is the CIWA score used for?
Clinical Institute Withdrawal Assessment for Alcohol
To assess whether treatment is needed for alcohol withdrawal.
135
When would you use Lorazepam vs [Diazepam or chlordiazepoxide] in patients with alcohol withdrawl?
Lorazepam is indicated if the liver is impaired.
| If the liver is fine you can give diazepam or chlordiazepoxide.
136
What is the treatment for acute dystonia e.g. resulting from Extra Pyramidal Side effects of antipsychotics, antidepressants or metoclopramide?
Procyclidine IM
137
Give two signs of acute dystonic reaction?
Mout open
Dysarthria
Upward eye gaze
Neck spasms
[Tends to occur in younger men & cocaine users who are on antipsychotics, antidepressants or metoclopramide]
138
What medications are used to rapidly tranquilise a psychotic or aggressive patient who cannot be calmed?
Lorazepam (IM)
or
Haloperidol + Promethazine (IM)
139
Give three side effects of 2nd generation antipsychotics
- Metabolic disorder: weight gain, hyperlipidemia, DM
- Agranulocytosis (neutropenia) [Clozapine]
- Hyperprolactinaemia + Gynaecomastia [Risperidone]
- QT prolongation
- Sexual dysfunction
- Constipation [Clozapine]
- Hypersalivation [Clozapine]
Clozapine needs frequent monitoring!
140
What is the difference in presentation between neuroleptic malignant syndrome and Serotonergic syndrome?
Both exhibit:
- Autonomic instability
- Fever
- Altered mental state e.g. confusion
```
NMS = Neuromuscular HYPOactivity (hypotonia, rigidity)
SS = Neuromuscular HYPERactivity (twitching, brisk reflexes etc.)
```
141
Can Section 5 of the mental health act be used in A&E?
No. Section 5 [5(4) and 5(2)] Can only be used for in patients. Patient's in A&E have not been admitted.
Section 2/3 or 4 would be more appropriate.
142
Give 2 extrapyramidal side effects of antipsychotics
Acute dystonia [
Akathisia [Switch to 2nd gen]
Parkinsonism (without tremor) [Switch to 2nd gen]
Tardive dyskinesia [No treatment]
143
What receptor do most 1st generation antipsychotics work on?
D2 receptors
144
True or false, Creatine Kinase and WCC are elevated in neuroleptic malignant syndrome and Serotonin syndrome?
True. CK is particularly high in NMS. This can result in renal failure! WCC is raised in both.
145
Give two common side effects of Lithium
```
Nausea
Metallic taste in mouth
Dry mouth
Tremor (mild)
Thirst
Diarrhoea
```
[Lithium has a narrow therapeutic index so it becomes toxic very easily]
146
True or false, Lithium is safe during pregnancy
False. It can cause foetal abnormalities.
147
Give two signs of Lithium toxicity. What should a patient be advised to avoid toxicity?
```
Nausea
Polyuria
Tremor
Twitching
Incontinence
Drowsiness
```
```
Avoid dehydration (e.g. travel/sport)
Avoid rapid drop in sodium (diet)
Caution with diuretics
```
148
True or false, a woman of childbearing age who is sexually active and wishes to take sodium valproate must be on contraceptives?
True.
149
What mood stabiliser is safe in pregnancy?
Lamotrigine is a safe option
[Sodium valproate and Lithium are not safe!]
150
How long can a patient be detained under a section 5(4) and 5(2)?
5(4) - 6 hours
| 5(2) - 72 hours
151
What rights does a patient have under the Mental Health Act?
- Told why they have been detained
- Allowed legal advice
- Ask police/hospital to inform someone where they are
- To get treatment for their mental health condition
152
Can any treatment be given without consent to a patient who is under the mental health act?
No. Only treatment can be given to a patient to treat their mental health condition. With eating disorders, this may include food and drink.
If you want to give other treatment without their consent this needs to be under the Mental Capacity Act i.e. they must lack capacity.
153
What is waxy flexibility?
When you move a person they adopt the new position.
| It is a sign of catatonia
154
What is negativism?
When a person does the opposite of what is asked of them
