Psychiatry Passmed 1 Flashcards
What is acute stress disorder? How does it present?
an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc)
(PTSD occurs after 4 weeks)
Features include:
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
How can acute stress disorder be managed?
trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines
sometimes used for acute symptoms e.g. agitation, sleep disturbance
should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation
What is the mechanism behind alcohol withdrawal?
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal leads to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
How may alcohol withdrawal present?
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
How can alcohol withdrawal be managed?
patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until stabilised
first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam
Lorazepam may be preferable in patients with hepatic failure
carbamazepine also effective in treatment of alcohol withdrawal
Diagnosis of anorexia nervosa is now based on the DSM 5 criteria. What does this include?
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
What is the recommended management for children with anorexia nervosa?
NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. The second-line treatment is cognitive behavioural therapy.
What signs may be seen in a patient with anorexia nervosa?
reduced body mass index
bradycardia, hypotension
enlarged salivary glands
lanugo hair
failure to develop secondary sexual characteristics
yellow tinge to the skin (hypercarotinaemia)
What physiological abnormalities may be seen in a patient with anorexia nervosa?
hypokalaemia
low FSH, LH, oestrogens and testosterone
low T3
raised cortisol and growth hormone
hypercholesterolaemia
hypercarotinaemia
impaired glucose tolerance
Easy way to remember changes seen in anorexia?
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Give two examples of typical antipsychotics
Haloperidol
Chlorpromazine
What is the mechanism of action of typical anti psychotics?
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
Give three examples of atypical antipsychotics
Clozapine
Risperidone
Olanzapine
What is the mechanism of action of atypical antipsychotics?
Act on a variety of receptors (D2, D3, D4, 5-HT)
What Extrapyramidal side-effects (EPSEs) may result from antipsychotic use?
Parkinsonism
acute dystonia
- sustained muscle contraction (e.g. torticollis, oculogyric crisis)
- may be managed with procyclidine
akathisia (severe restlessness)
tardive dyskinesia (involuntary movements of face and jaw, see image)
What is tardive dyskinesia?
late onset of choreoathetoid movements (chorea = irregular contractions and athetosis = twisting and writhing)
abnormal, involuntary, may be irreversible
most common is chewing and pouting of jaw
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
Increased risk of stroke and VTE
Atypical antipsychotics should now be used first-line in patients with schizophrenia. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.
What adverse effects may they present with?
weight gain
hyperlipidaemia
diabetes mellitus
hyperprolactinaemia
Qtc prolongation
clozapine is associated with agranulocytosis - monitor FBC if infection!!
What should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks?
Clozapine
What are the adverse effects of clozapine?
agranulocytosis, neutropaenia
reduced seizure threshold
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
constipation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment
When should the following be monitored in patients taking antipsychotics:
FBC, U&Es, LFTs ?
at the start of therapy
annually
clozapine requires much more frequent monitoring of FBC (initially weekly)
The monitoring requires for patients taking antipsychotic medication are extensive. What does the BNF recommend?
FBC, U&Es, LFTs
Fasting blood glucose, prolactin, lipids
Weight
Blood pressure
(baseline, frequently during dose titration)
ECG (baseline)
Cardiovascular risk assessment (annually)
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.
They therefore are used for a variety of purposes including:
sedation
hypnotic
anxiolytic
anticonvulsant
muscle relaxant
Why should benzos be monitored closely?
Risk of developing tolerance or dependence
Only recommended to be prescribed 2-4 weeks at a time
If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, which is very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug.
Features include:
AAIITTSS
anxiety, loss of appetite
insomnia, irritability
tremor, tinnitus
sweating, seizures
perceptual disturbances
What is the difference in mechanism of action of benzodiazepines and barbiturates?
GABAA drugs
benzodiazipines increase the frequency of chloride channels
barbiturates increase the duration of chloride channel opening
(BarbiDurates increase Duration & Frendodiazepines increase Frequency)
Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
What are the two types?
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression
What is mania/hypomania?
both terms = abnormally elevated mood or irritability
with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
hypomania describes decreased or increased function for 4 days or more
the key differentiation in MCQs is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
What is the mood stabiliser of choice in bipolar disorder?
Lithium
Valproate is an alternative
How can mania/ hypo mania be managed?
consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
How can depressive episodes in bipolar disorder be managed?
Talking therapies and fluoxetine
When should patients with bipolar disorder be referred from primary care?
if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
if there are features of mania or severe depression then an urgent referral to the CMHT should be made
What is Bulimia nervosa ?
a type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising
What examinations findings might you see in bulimia nervosa?
recurrent vomiting may lead to erosion of teeth and Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting
How can bulimia nervosa be managed?
bulimia-nervosa-focused guided self-help for adults
If contraindicated or ineffective after 4 weeks of treatment, NICE recommend individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
children should be offered bulimia-nervosa-focused family therapy
high-dose fluoxetine
What is Charles-Bonnet syndrome (CBS)?
persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness.
This is generally against a background of visual impairment (age related macular degeneration)
What are the risk factors for Charles Bonnet syndrome?
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
What is Cotard syndrome?
rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent
What is De Clerambault’s syndrome?
Also known as erotomania
a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
Factors suggesting diagnosis of depression over dementia?
short history, rapid onset
global memory loss (dementia characteristically causes recent memory loss)
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
What is classified as ‘less severe’ depression?
a PHQ-9 score of < 16
What is classified as ‘more severe’ depression?
a PHQ-9 score of ≥ 16
How should less severe depression be managed?
guided self-help
group / individual CBT
group / individual behavioural activation (BA)
group exercise, mindfulness and meditation
interpersonal psychotherapy (IPT)
SSRIs
counselling
short-term psychodynamic psychotherapy (STPP)
How should more severe depression be managed?
a combination of individual cognitive behavioural therapy (CBT) and an antidepressant first line
citalopram and sertraline are the SSRIs of choice
For how long should antidepressants be continued after remission of symptoms?
6 months to reduce risk of relapse
Which two questions can be used to screen for depression?
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
What tools can be used to assess the degree of depression?
Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9)
What symptoms may depression present with?
SIGECAPS
Sleep (difficult) Interest ( lack of) , Guilt, Energy ( low) Concentration (poor) and Appetite, Psychomotor retardation , and Suicidal ideation
Anhedonia - lack of pleasure in activities
What is the guidance for switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI?
the first SSRI should be withdrawn before the alternative SSRI is started
What is the guidance on switching from fluoxetine to another SSRI?
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
What is the guidance for switching from a SSRI to a tricyclic antidepressant (TCA)?
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- an exception is fluoxetine which should be withdrawn prior to TCAs being started
Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia).
What are the potential side effects?
Short-term side-effects:
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
Long-term side-effects:
some patients report impaired memory
Indications for ECT?
indicated to achieve rapid improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:
catatonia
a prolonged or severe manic episode
severe depression that is life-threatening
What is the absolute contraindication to ECT?
Raised ICP
What differentials are important to consider for GAD?
hyperthyroidism, cardiac disease and medication-induced anxiety
Medications that may trigger anxiety include : salbutamol, theophylline, corticosteroids, antidepressants and caffeine
Give some key risk factors and protective factors for GAD
Risk factors for the development of GAD include;
Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent
Protective factors include;
Aged 16 - 24
Being married or cohabiting
What is the stepwise approach to tx of GAD?
step 1: education about GAD + active monitoring
step 2: low-intensity psychological interventions (individual self-help, psychoeducational groups)
step 3: high-intensity psychological interventions (CBT) or drug treatment
step 4: highly specialist input e.g. Multi agency teams
What drug tx is available for GAD?
Sertraline first line SSRI
if sertraline is ineffective, offer an alternative SSRI or SNRI
examples of SNRIs include duloxetine and venlafaxine
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
What is the mx of panic disorder?
CBT or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
What are the 5 stages of grief?
Denial: feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
Anger
Bargaining
Depression
Acceptance
What are the risk factors for atypical grief reactions?
more likely to occur in women
Sudden unexpected death
Problematic relationship before death
Little social support
Features of atypical grief reactions include:
delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
How may speech and thought present in mania ?
pressured
flight of ideas: characterised by rapid speech with frequent changes in topic based on associations, distractions or word play
poor attention
How may behaviour change in mania?
insomnia
loss of inhibitions: sexual promiscuity, overspending, risk-taking
increased appetite
What is chronic insomnia ?
diagnosed if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer
How may patients with insomnia present?
decreased daytime functioning
decreased periods of sleep (delayed sleep onset or awakening in the night)
increased accidents due to poor concentration
Give some risk factors for insomnia
Female gender
Increased age
Lower educational attainment
Unemployment
Economic inactivity
Widowed, divorced, or separated status
Alcohol and substance abuse
Stimulant usage
Poor sleep hygiene
Anxiety and depression
How is insomnia investigated?
Diagnosis is primarily made through patient interview
Sleep diaries and actigraphy may aid diagnosis
(Actigraphy is a non-invasive method for monitoring motor activity)
Polysomnography is not routinely indicated
How should insomnia be managed?
Identify any potential causes e.g. mental/ physical health issues or poor sleep hygiene
Advise the person not to drive while sleepy
Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc
ONLY consider use of hypnotics if daytime impairment is severe.
What is Korsakoff’s syndrome?
marked memory disorder often seen in alcoholics
thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
in often follows on from untreated Wernicke’s encephalopathy
What features does Korsakoff’s present with?
anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation
Lithium is a mood stabilising drug used prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life.
What are its adverse effects?
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
Give some signs of lithium toxicity
ataxic gait
vision changes
confusion
What is the most common endocrine disorder developing as a result of chronic lithium toxicity?
hypothyroidism
What ECG changes can lithium cause?
ECG: T wave flattening/inversion
When should lithium levels be checked?
the sample should be taken 12 hours post-dose
after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
once established, lithium blood level should ‘normally’ be checked every 3 months
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
What is the mechanism of action of mirtazipine? Which patients is it particularly useful in?
antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters
fewer side effects and interactions than many other antidepressants and so is useful in older people
Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite
When should mirtazipine be taken?
In the evening as it is sedative
Give some risk factors for OCD
family history
age: peak onset is between 10-20 years
pregnancy/postnatal period
history of abuse, bullying, neglect
How can OCD be classified?
NICE recommend classifying impairment into mild, moderate or severe
Y-BOCS scale
an example of ‘severe’ OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control
How should OCD be managed If functional impairment is mild?
low-intensity psychological treatments: CBT / ERP
If this is insufficient or can’t engage in psychological therapy, then offer a either an SSRI or more intensive CBT
How should OCD be managed if
moderate functional impairment?
SSRI (fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
consider clomipramine (as an alternative first-line drug treatment to an SSRI if contraindicated)
How should OCD with severe functional impairment be managed?
refer to the secondary care mental health team for assessment
whilst awaiting assessment - offer combined treatment with an SSRI and CBT
What is ERP?
Exposure response prevention
psychological method which involves exposing a patient to an anxiety provoking situation and then stopping them engaging in their usual safety behaviour
This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
How does SSRI tx for OCD compare to that of depression?
compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response
In OCD, if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
What is Othello’s syndrome?
pathological jealousy where a person is convinced their partner is cheating on them without any real proof
This is accompanied by socially unacceptable behaviour linked to these claims.
What are personality disorders?
series of maladaptive personality traits that interfere with normal function in life
What are the ‘Cluster A’ personality disorders?
‘Weird’
Paranoid
Schizoid
Schizotypal
What are the ‘Cluster B’ personality disorders?
‘Wild’
Antisocial
Borderline (Emotionally Unstable)
Histrionic
Narcissistic
What are the ‘Cluster C’ personality disorders?
‘Worriers’
Obsessive-Compulsive
Avoidant
Dependent
How does paranoid personality disorder present?
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to question the loyalty of friends and to perceive attacks on their character
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
How does schizoid personality disorder present?
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
How does schizotypal personality disorder present?
Ideas of reference (differ from delusions in that some insight is retained)
Odd beliefs and magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent
How does antisocial personality disorder present?
More common in men
Failure to conform to social norms with respect to lawful behaviours
Deception (repeatedly lying, use of aliases)
Impulsiveness or failure to plan ahead
Irritability and aggressiveness (physical fights or assaults)
Reckless disregard for the safety of self or others
Consistent irresponsibility
Lack of remorse
How does Borderline - also known as Emotionally Unstable - Personality disorder present?
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
How does histrionic personality disorder present?
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
How does obsessive compulsive personality disorder present?
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that interferes with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to delegate
Takes on a stingy spending style , stiffness and stubbornness
How does avoidant personality disorder present?
Avoidance of significant interpersonal contact due to fears of criticism or rejection
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
How does dependent personality disorder present?
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
Spot diagnosis : A young woman comes for relationship advice. She is constantly questioning the loyalty of her partner and regularly accuses him of having affairs for no reason. She also regularly falls out with her female friends as she thinks they are belittling her .
paranoid personality disorder
Spot diagnosis : A man asks for help with social anxiety. He prefers to be alone and doesn’t like to share his beliefs, which other people think are odd. He has a strong interest in the paranormal and talks in an high-pitched voice when talking about his ‘spirit-guide’
schizotypal personality disorder
Spot diagnosis : A young man is arrested after crashing his car into a pedestrian. He shows little remorse and repeatedly lies to try and avoid prosecution. He is known to police after being involved in repeated fights
antisocial personality disorder
Spot diagnosis : A young woman takes a paracetamol overdose after splitting with her boyfriend. Two days later she is in a new relationship which is troubled by her repeated outbursts of anger
borderline personality disorder
Spot diagnosis : A woman presents to her male family doctor wearing a low-cut top and a short skirt. She tries to flirt with the doctor. The consultation is filled with drama and she becomes annoyed with the centre of attention shifts from her
- histrionic personality disorder
Spot diagnosis : A middle-aged male manager comes in for review after having trouble at work. His colleagues find him arrogant, ‘cut-throat’ and lacking empathy. He seems to exaggerate his own importance to the company and seems preoccupied with success
- narcissistic personality disorder
Spot diagnosis : A female librarian comes for advice. Her colleagues find her inflexible in her approach to her work. She easily becomes annoyed if her ‘systems’ are interfered with and generally likes to work by herself, using lists and rules to structure her day
obsessive-compulsive personality disorder
Spot diagnosis : A young woman complains of feeling lonely. She has stopped seeing her old friends as she is worried about not being liked or criticised
- avoidant personality disorder
Spot diagnosis : A middle-aged woman asks for help after splitting up with her partner, who apparently felt she was too ‘needy’. She describes him as ‘my world’ and thinks she won’t be able to cope by herself and wants your advice on how to find a new partner quickly
- dependent personality disorder
How can personality disorders be managed?
psychological therapies: dialectical behaviour therapy
treatment of any coexisting psychiatric conditions
