Psychiatry Passmed 2 Flashcards
Post-concussion syndrome is seen after even minor head trauma
Typical features include:
headache
fatigue
anxiety/depression
dizziness
Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse.
How long do symptoms have to have been present for a diagnosis to be made?
4 weeks
What features may PTSD present with?
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing - lack of ability to experience feelings, feeling detached
How can PTSD be managed?
watchful waiting may be used for mild symptoms lasting less than 4 weeks
military personnel have access to treatment provided by the armed forces
trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or an SSRI e.g. sertraline should be tried
What are hallucinations?
false sensory perception in the absence of an external stimulus.
organic, drug-induced or associated with mental disorder.
What are pseudohallucinations?
a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating
Examples : a hypnagogic hallucination (occurs when falling asleep), a hallucination as part of a grief reaction
Psychosis is a term used to describe a person experiencing things differently from those around them.
Psychotic features include:
hallucinations (e.g. auditory)
delusions
thought disorganisation
Give some examples of thought disorganisation
alogia: little information conveyed by speech
tangentiality: answers diverge from topic
clanging
word salad: linking real words incoherently → nonsensical content
What other features may be associated with psychosis?
agitation/aggression
neurocognitive impairment (e.g. in memory, attention or executive function)
depression
thoughts of self-harm
Give some examples of conditions in which psychosis may occur
schizophrenia: the most common psychotic disorder
depression (psychotic depression, more common in elderly patients)
bipolar disorder
puerperal psychosis
brief psychotic disorder: symptoms last less than a month
neurological conditions e.g. Parkinson’s disease, Huntington’s disease
prescribed drugs e.g. corticosteroids
certain illicit drugs e.g. cannabis, phencyclidine
What is the strongest risk factor for developing a psychotic disorder?
Family hx
an episode of psychosis lasting less than a month with a subsequent return to baseline functioning = ?
brief psychotic disorder
What is the risk of developing schizophrenia when :
monozygotic twin has schizophrenia?
parent has schizophrenia?
sibling has schizophrenia?
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
Give some risk factors for developing a psychotic disorder
Fam hx - STRONGEST RISK FACTOR
Black Caribbean ethnicity
Migration
Urban environment
Cannabis use
What are the first rank symptoms of schizophrenia?
auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions
Give some specific types of auditory hallucination that may be experienced in schizophrenia
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour
Give some examples of thought disorders seen in schizophrenia
thought insertion
thought withdrawal
thought broadcasting
What are passivity phenomena? ( can be experienced in schizophrenia)
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
What happens in delusional perception in schizophrenia?
a two stage process- where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
Give some negative features of schizophrenia
incongruity/blunting of affect
anhedonia (inability to derive pleasure)
alogia (poverty of speech)
avolition (poor motivation)
social withdrawal
Which is the best medication for managing negative sxs of schizophrenia?
clozapine
How should schizophrenia be managed?
oral atypical antipsychotics are first-line
CBT
close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
Give some factors associated with poor prognosis in schizophrenia
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
What is Seasonal affective disorder (SAD) ? How should it be managed?
depression which occurs predominately around the winter months
psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration
Don’t give sleeping tablets
Which patients are specifically excluded from the mental health act?
Patients under the influence of alcohol or drugs
What is Section 2 of the mental health act used for?
admission for assessment for up to 28 days, not renewable
an Approved Mental Health Professional or rarely the nearest relative makes the application on the recommendation of 2 doctors
one of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)
treatment can be given against a patient’s wishes
What is section 3 of the MHA used for?
admission for treatment for up to 6 months, can be renewed
AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours
treatment can be given against a patient’s wishes
What is section 4 of the MHA used for?
72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
a GP and an AMHP or NR
often changed to a section 2 upon arrival at hospital
What is section 5(2) of the MHA used for?
a patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
What is Section 17a of the MHA used for?
Supervised Community Treatment (Community Treatment Order)
can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication
What is section 135 of the MHA used for?
a court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety
“135, from inside”
What is section 136 of the MHA used for?
someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged
“136, from the sticks” (person outside / not at home)
What are the preferred SSRIs for depression?
Citalopram and fluoxetine
What is the preferred SSRI post MI?
Sertraline
SSRIs should be used with caution in children and adolescents. What is the drug of choice if indicated?
Fluoxetine
ADRs of SSRIs?
GI symptoms are the most common
increased risk of gastrointestinal bleeding in patients taking SSRIs - a PPI should be prescribed if a patient is also taking a NSAID
risk of hyponatraemia
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
Which SSRIs are more likely to cause drug drug interactions?
fluoxetine and paroxetine
What drugs may SSRIs interact with?
NSAIDs
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
When should patients who have been started on SSRIs be reviewed?
after 2 weeks
patients under the age of 25 years or at increased risk of suicide should be reviewed after 1 week
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine).
What discontinuation symptoms may be seen?
increased mood change
restlessness
difficulty sleeping
unsteadiness, dizziness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia, electric shock sensations
What are the risks of SSRIs during pregnancy?
Use during the first trimester gives a small increased risk of congenital heart defects
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Give 2 SNRIs
venlafaxine and duloxetine
What is sleep paralysis? How may it be managed ?
transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep
Features
paralysis - this occurs after waking up or shortly before falling asleep
hallucinations - images or speaking that appear during the paralysis
Management
if troublesome clonazepam may be used
Risk factors for suicide?
male sex
history of deliberate self-harm
alcohol or drug misuse
history of mental illness
depression
schizophrenia
history of chronic disease
advancing age
unemployment or social isolation/living alone
being unmarried, divorced or widowed
Risk factors for successful completion of suicide?
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method
Protective factors for suicide?
family support
having children at home
religious belief
What is circumstantiality?
the inability to answer a question without giving excessive, unnecessary detail
differs from tangentiality in that the person does eventually return to the original point
What is tangentiality?
wandering from a topic without returning to it
What are neologisms?
new word formations, which might include the combining of two words
What are clang associations?
when ideas are related to each other only by the fact they sound similar or rhyme
What is a word salad?
completely incoherent speech where real words are strung together into nonsense sentences
What is Knight’s move thinking?
a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another
It is a feature of schizophrenia.
What is flight of ideas?
a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them
What is perseveration?
the repetition of ideas or words despite an attempt to change the topic
What is echolalia?
the repetition of someone else’s speech, including the question that was asked
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to ADRs and toxicity in overdose. They are used widely in the treatment of neuropathic pain, where smaller doses are required.
Give an example of a TCA.
What side effects may they cause?
Amitriptyline
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval
What is somatisation disorder?
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
What is hypochondriasis?
Illness anxiety disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
What is conversion disorder?
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
What is Hoover’s sign?
a quick and useful clinical tool to differentiate organic from non-organic leg paresis (e.g. conversion syndrome)
In non-organic paresis, pressure is felt under the paretic leg when lifting the non-paretic leg against pressure, this is due to involuntary contralateral hip extension
What is dissociative disorder?
dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
What is factitious disorder?
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
What is malingering?
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
What can cause a sudden increase in clozapine blood levels?
Smoking cessation
