psychiatry_20231205142330 Flashcards
1
Q
What is bulimia?
A
An eating disorder marked by recurrent episodes of binge eaeting followed by compensatory behaviour such as self infuced vomiting or laxative abuse
2
Q
What population is bulimia most common in?
A
Women in their 20s and 30s
3
Q
What are the risk factors for bulimia?
A
Female sex Young age Perfectionism History of sexual abuse Personal history of depression or anxiety Family history of depression, anxiety or eating disorders
4
Q
What is the presentation of bulimia?
A
Recurrent episodes of binge eating Purging - self induced vomiting, laxative use Body image distortion Dental erosion Parotid gland swelling Russell’s sign
5
Q
What is Russell’s sign?
A
Scarring on the back of the hands or knuckles, by repeatedly inducing vomiting
6
Q
What blood abnormalities may be seen in bulimia?
A
Alkalosis from vomiting hydrochloric acid
Hypokalaemia
7
Q
What physical signs of bulimia may be seen?
A
Erosion of teeth Russell’s sign Parotid gland swelling GORD Mouth ulcers
8
Q
What are the differentials of bulimia?
A
Binge eating disorder Anorexia nervosa Rumination-regurgitation disorder Other psychiatric disorders
9
Q
What is the management of bulimia?
A
Referral to a specialist CBT Nutrition and meal support SSRIs
10
Q
What is a delusion?
A
Delusions are firmly held beliefs that persist, despite evidence to the contrary
11
Q
What conditions can delusions be a feature of?
A
Bipolar disorder Schizophrenia Psychosis
12
Q
What is a nihilistic delusion?
A
A negative delusion that fits with the patient’s depressed mood - patients may believe that they are dead, or that the world has ended (they believe that everything has come to an end)
13
Q
What is a grandiose delusion?
A
Patients believe that they exhibit extraordinary traits or powers
14
Q
What condition are grandiose delusions common in?
A
Bipolar disorder
15
Q
What condition are grandiose delusions common in?
A
Manic phases of bipolar disorder
16
Q
What is a delusion of control?
A
Where a patient experiences the sensation that an external entity is controlling their thoughts or actions
17
Q
What is a persecutory delusion?
A
A delusion where the patient believes they are being persecuted or conspired against
18
Q
What is a somatic delusion?
A
Where the patient believes that they have a medical, physical or biological problem despite no evidence to support the claim
19
Q
What are the differential diagnoses for patients with delusion?
A
Mood disorders with psychotic features
Neurocognitive disorders - dementia, parkinson’s
Substance induced psychosis
20
Q
What is a somatic delusion?
A
Where the patient believes that they have a medical, physical or biological problem despite no evidence to support the claim
21
Q
What is a personality disorder?
A
Maladaptive personality traits that interfere with daily life
22
Q
What are the classes of personality disorders?
A
Class A, B and C
23
Q
What types of personality disorder are there?
A
Anxious/fearfulSuspicious Emotional/impulsive
24
Q
What type of personality disorder are class A?
A
Suspicious
25
What type of personality disorder are class B?
Emotional/impulsive
26
What type of personality disorder are class C?
Anxious/fearful
27
What are the class C personality disorders?
Obsessive compulsive personality disorder Avoidant personality disorder Dependant personality disorder
28
What are the class B personality disorders?
Borderline personality disorder (emotionally unstable personality disorder)Antisocial personality disorderHistrionic personality disorder Narcissistic personality disorder
29
What are the class A personality disorders?
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
30
What are the features of obsessive compulsive personality disorder?
Occupied with details, rules, lists Perfectionism Unrealisitic expectations of themselves and others Catastrophising what will happen if expectations are not met Unwilling to pass tasks to othersIncapable of lettings things go
31
What are the features of avoidant personality disorder?
Avoidance of social situations and relationships Fear of rejection and disapproval Self-isolation despite longing for interactionViews self as inferior to othersHypersensitivity to criticism
32
What are the features of dependent personality disorder?
Excessive need to be taken care of
Lack of self confidence and initiative
Relies on others to make decisions
Difficulity in expressing disagreement with others
Extensive efforts to obtain support from others
33
What are the features of EUPD?
Unstable personal relationships which fluctuate between idealisation and devaluation Mood swings Unstable self imageTendency towards self harm and risky behaviours
34
What are the features of antisocial personality disorder?
Disregard for and violation of the rights of others Irritability and aggressivenessDeception Irresponsiblity Lack of remorse
35
What are the features of narcissistic personality disorder?
Grandiose sense of self importance
Taking advantage of others to sustain own needs
Feels that they are special and needs others to recognise this
Pre-occupied with personal fantasies and desires
Lack of empathy
36
What are the features of histrionic personality disorder?
The need to be at the centre of attention Inappropriate sexual behaviours Excessive displays of emotion Perceives relationships as being more intimate than they are
37
What are the features of histrionic personality disorder?
The need to be at the centre of attention Inappropriate sexual behaviours Excessive displays of emotion Perceives relationships as being more intimate than they are
38
What are the features of narcissistic personality disorder?
Grandiose sense of self importance Taking advantage of others to sustain own needsFeels that they are special and needs others to recognise this Pre-occupied with personal fantasies and desires Lack of empathy
39
What are the features of paranoid personality disorder?
Irrational suspicion and mistrust of others Hypersensitivity to insults, unwilling to forgive when insulted Reluctance to confide in others Preoccupied with unfounded beliefs about conspiracies against them
40
What are the features of schizoid personality disorder?
Restricted range of emotional expression Detachment from social relationships Indifference to praise and criticism Few friends and lack of desire for social companionship
41
What are the features of schizotypal personality disorder?
Odd or eccentric beliefs Social anxiety that makes forming relationships difficult More intact grasp on reality than in schizophrenia Inappropriate affect Ideas of reference
42
What is the management of personality disorders?
Psychotherapy
CBT
Medication for underlying psychiatric issues
43
What is bipolar affective disorder?
A psychiatric disorder characterised by periods of mania/hypomania and depression
44
When does bipolar disorder typically develop?
Late teens
45
What are the two types of bipolar disorder?
Type 1 - mania and depression Type 2 - hypomania and depression
46
Which type of bipolar disorder is most common?
Type 1 - mania and depression
47
What are the risk factors for bipolar disorder?
GeneticsPhysical illnessStressful life events Substance misuse
48
What is mania?
Severe functional impairment and psychotic symptoms for 7 or more days, with at least 3 associated symptoms
49
What is hypomania?
Less severe than mania - similar to mania but with no functional impairment, and no psychotic symptoms
50
What are the signs and symptoms of a depressive phase of bipolar?
TearfulnessAnhedonia Suicidal ideation or attempts Withdrawal Low mood Poor sleep
51
What are the signs and symptoms of a manic phase of bipolar?
Elevated moodIrritability Impulsivity Reduced need for sleep Flight of ideas Mood congruent delusions
52
What are the differential diagnoses of bipolar disorder?
Major depressive disorder Schizoaffective disorderGeneralised anxiety disorderSubstance induced mood disorder
53
What is the DSM-5 criteria for diagnosis of bipolar disorder?
Mania - 7 day episode of functional impairment and psychotic symptoms (3 associated symptoms needed)Hypomania - 4 day episode with features similar to mania (bit no functional impairment or psychotic symptoms)Depression - one episode of major depression lasting 2 weeks (with 4 associated symptoms)
54
What is the treatment of acute mania with agitation?
IM neuroleptic or benzodiazepine (olanzapine or haloperidol) Admission to secure unit
55
What is the treatment of acute mania without agitation?
Oral antipsychotic monotherapy (+ sedatives)
56
What is the treatment of acute depression in bipolar?
Mood stabiliser, antidepressant or atypical antipsychotic Psychosocial support
57
What is the long term management of bipolar disorder?
Mood stabilisers - lithium or valproateCBT, interpersonal therapy or family therapy
58
What are the side effects of litium?
Dry mouth Fine tremor GI disturbance Increased thirst Increased urination Drowsiness Thyroid dysfunction
59
What are the symptoms of lithium toxicity?
Coarse tremor Seizures Dysarthria Impaired coordination Cardiac arrhythmias Visual disturbance
60
What is the gold standard investigation for lithium toxicity?
Serum lithium levels
61
What other investigations can be performed to help diagnose lithium toxicity?
U&EsTFTsRenal function ECG
62
Which antipsychotics are most typically used in the treatment of mania?
Haloperidol Olanzapine Quetiapine Risperidone
63
What is the first line long term management of bipolar?
Lithium
64
What is the second line long term management of bipolar?
Add valproate/lamotrigine as an adjunct to lithium
65
What other medications can be used as mood stabilisers?
Carbamazepine Olanzapine
66
When should lithium levels be monitored after a change in dose?
1 week after dose change and then every week until levels are stable
67
What is section 2 of the mental health act for?
Admission for assessmentTreatment can be given against a patient's consent
68
How long does section 2 of the MHA last?
28 days (cannot be renewed)
69
What criteria must a patient fit to be treated under the MHA?
They must have a mental disorderThey must be a risk to the safety of themselves or others Their condition must be treatable
70
What are the 5 key principles of the mental capacity act?
A person is assumed to have capacity unless proven otherwise Steps must be taken to help a person have capacity An unwise decision does not mean the patient lacks capacityAny decisions taken under the MCA must be in a patient's best interests Any decisions made should be the least restrictive
71
What is an approved mental health professional AMHP?
A healthcare professional who receive and coordinate mental health assessment referrals
72
What is an S12 approved doctor?
A doctor (usually a consultant psychiatrist) who is approved under section 12 of the mental health act
73
Who is needed for someone to be detained under section 2 of the MHA?
Two healthcare professionals - one S12 approved doctor
74
What evidence is needed to detain someone under section 2 of the MHA?
Patient is suffering from a mental health disorder of a degree that warrants detention for assessment The patient is at risk to themselves or to others
75
What is section 3 of the mental health act for?
Detention for treatment
76
How long does section 3 of the MHA last?
6 months (and can be renewed)
77
Who is needed for someone to be detained under section 3 of the MHA?
Two healthcare professionals - one S12 approved doctor
78
What evidence is needed to section someone under section 3 of the MHA?
Patient is suffering from a mental disorder of a degree which makes it appropriate for the patient to receive medical treatment in a hospitalTreatment is in the best interests of the patients and others safetyAppropriate treatment must be available for the patient
79
What is section 4 of the MHA used for?
An emergency 72 hour assessment order, used when a section 2 would cause too much delay
80
How many healthcare professionals are needed for a section 4?
Just one - it is used when waiting for a second doctor would be detrimental
81
What is section 5(2) of the MHA used for?
Section 5(2) is used by doctors for keeping a patient already admitted voluntary to hospital in hopsital
82
How long does section 5(2) of the MHA last for?
72 hours
83
What is section 5(4) of the MHA used for?
Section 5(4) is used by nurses for keeping a patient already admitted voluntarily to hospital, in hospital
84
What is section 135 of the MHA used for?
Section 135 is used by police - a court order is obtained to allow the police to break into a property in order to bring the patient to a place of safety for further assessment
85
What is section 136 of the MHA used for?
Section 136 is used by the police - a person found in a public place that has a suspected mental health disorder can be taken to a place of safety for further assessment
86
What conditions are thought disorders associated with?
Schizophrenia Psychosis
87
What is circumstantiality in thought disorders?
The patient moves onto different topics, in a way that can be followed, and eventually returns back to the original thought
88
What is circumstantiality in thought disorders?
The patient moves onto different topics, in a way that can be followed, and eventually returns back to the original thought
89
What is derailment (or flight of ideas) in thought disorders?
When the conversation moves randomly from topic to topic, that cannot be linked
90
What is poverty of speech?
A lack of spontaneous speech
91
What is perseveration in thought disorders?
The repetition of words or ideas when someone else attempts to change the topic
92
What is though blocking?
When a patient suddenly halts their thought process and cannot continue
93
What is echolalia?
When a person repeats someone else's speech, including the question that was asked
94
What are clang associations?
When ideas are related to each other only by the fact that they sound similar or rhyme
95
What is tangentiality?
Where a patient jumps from topic to topic, in a way that can be followed, but does not come back around to the original idea
96
What is tangentiality?
Where a patient jumps from topic to topic, in a way that can be followed, but does not come back around to the original idea
97
What is thought broadcasting?
Where a patient believes that others can hear their thoughts
98
What is Knight's move?
Where there are illogical leaps from one idea to another in conversation
99
What are Cotard delusions?
A delusion that the patient or a part of their body is dead or non-existent
100
What is a Capgras delusion?
A delusion that a person close to the patient has been replaced
101
What is a De Frogoli delusion?
Where a patient identified a familiar person in those around them and thinks that they are under disguise
102
What is a Ekbom delusion?
A delusion that the patient is infested with bugs
103
What is schizophrenia?
A relapsing and remitting form of psychosis characterised by positive features and negative features
104
What is the epidemiology of schizophrenia?
Typically develops in early adulthood (20s and 30s)Slightly more common in men
105
What is the strongest risk factor for schizophrenia?
Genetics
106
What is the risk of developing schizophrenia if a monozygotic twin or both parents have schizophrenia?
50%
107
What is the risk of developing schizophrenia if a parent or sibling has the condition?
10%
108
What are the environmental risk factors for developing schizophrenia?
Heavy cannabis use in childhood Childhood trauma Maternal health issues - rubella and CMV Birth trauma
109
What are Schneider's first rank symptoms of schizophrenia?
Auditory hallucinations
Thought disorders
Passivity phenomena
Delusional perceptions
110
What thought disorders are common in schizophrenia?
Thought withdrawal Thought insertion Thought broadcasting
111
What types of auditory hallucinations are seen in patients with schizophrenia?
Two or more voices discussing the patient in third person
Voices commenting on the patient's behaviour
Thought echo
112
What is thought echo?
A hallucination where the patient hears their own thoughts as if they were being spoken aloud
113
What is passivity phenomena?
The feeling that a patient's actions, thoughts, bodily sensations or feelings are being controlled by an external influence
114
What is a delusional perception?
A true perception, to which the patient attributes a false meaning
115
What are the negative features of schizophrenia?
Alogia - decrease in the amount of words a person says Anhedonia Blunted affectAvolition - poor motivation Social withdrawal
116
What is blunted affect?
Decreased expression of emotion through facial expressions, tone and movement
117
What are the differentials of schizophrenia?
Substance induced psychosis Schizoaffective disorderDementia with psychosis Depression with psychosis Autoimmune encephalitis Metabolic disorders
118
What investigations are helpful in the diagnosis of schizophrenia?
Mostly a clinical diagnosis CT/MRI to rule out structural abnormalities Infectious screen TFTsU&EsDrug screening
119
What is the first line management of schizophrenia?
Atypical antipsychotics e.g risperidoneCBT
120
What is given first line for an acute episode of schizophrenia?
Oral benzodiazpine e.g lorazepam or haloperidol
121
What drug is considered if schizphrenia is resistant to other antipsychotics?
Clozapine
122
What is the major side effect of clozapine?
Agranulocytosis
123
What monitoring does clozapine require?
FBC before starting FBC weekly for 18 weeks then FBC fortnightly until 1 year then FBC monthly
124
What factors are associated with poor prognosis for schizophrenia?
Strong family history Gradual onset Low IQ Lack of obvious precipitant
125
What are the side effects of risperidone?
Weight gain
Poor glycaemic control
Dyslipidaemia
126
What are the side effects of haloperidol?
Dystonia (acute dystonic reaction)
Parkinsonism
Tardive dyskinesia
Akathisia
127
What are the side effects of all antipsychotics?
Sedation Hyperprolactinaemia Sexual dysfunction Cardiac arrhythmias Reduction of seizure threshold
128
What drug can be used to manage the extra pyramidal side effects of antipsychotics?
Procyclidine
129
What are the different types of schizophrenia?
CatatoicHebephrenic Simple Undifferentiated Paranoid
130
What is tardive dyskinesia?
Involuntary movements most commonly in the face, eyes and mouth
131
What is acute dystonia?
Sustained muscle contraction (commonly affects the head, face and neck, including the eyes)
132
What is generalised anxiety disorder?
GAD is a mental health condition that causes excessive worry that impacts a peron's day to day life
133
What screening tool can be used to diagnose generalised anxiety disorder?
GAD-7 questionnaire
134
What is the NICE recommended step-wise approach of anxiety treatment?
Step 1 - education and monitoring
Step 2 - low intensity psychological interventions (self help or groups)
Step 3 - high intensity psychological interventions (CBT) or drug treatment
Step 4 - specialist input
135
What is the first line drug treatment of GAD?
SSRIs or mirtazapine
136
What is the typical SSRI used to treat GAD?
Sertraline 50mg OD (can be increased to 200mg)
137
What is the second line drug treatment of GAD?
An alternative SSRI or an SNRI
138
Give 3 examples of SSRIs
Sertraline Citalopram Fluoxetine
139
Give 2 examples of SNRIs
Duloxetine Venlafaxine
140
What is the third line drug treatment of GAD?
Pregabalin
141
What are the side effects of SSRIs?
Agitation Nausea DizzinessDry mouth Suicidal thoughts
142
What monitoring is needed for patients on SSRIs?
Weekly follow up during the first month for increased risk of suicidal thoughts and self-harm
143
What are the key features of generalised anxiety disorder?
Feeling restlessEasily fatigued Poor concentration IrritabilityMuscle tension Sleep disturbance Feeling nervous or on edgeBeing unable to control worry Feeling as though something bad is going to happenGI symptoms
144
What other mental health disorders can cause anxiety?
Depression PTSDPanic disorder Social phobia Somatisation disorder Hypochondriasis
145
What medications can commonly cause anxiety?
Salbutamol Theophylline Herbal medicines CorticosteroidsAntidepressantsAlcohol Illicit drugs
146
What are the risk factors for generalised anxiety disorder?
Family history Physical and emotional stressHistory of physical, emotional or sexual trauma Other anxiety disorder Chronic health condition Female sex
147
How long must a person have had excessive worry to be diagnosed with GAD?
At least 6 months
148
What investigations can be performed to help rule out organic causes for GAD?
TFTsUrine drug screen 24 hour catecholamine urine test Pulmonary function ECG
149
What are the differentials of GAD?
Panic disorder Social anxiety disorder OCD PTSD Depression Substance related anxiety Situational anxiety HyperthyroidismAdjustment disorderWithdrawal from CNS depressantPhaeochromocytoma
150
What is panic disorder?
Unpredictable and recurrent episodes of severe anxiety not confined to any specific situation or circumstances
151
What is the epidemiology of panic disorder?
Bimodal distribution - peak incidence at ages 20 and 50 More common in females Concurrent agoraphobia in 30-50% of cases
152
What are the features of panic disorder?
Difficulty in breathing Chest discomfortPalpitations Hyperventilation Depersonalisation Sweating Shaking
153
What are the differentials of panic disorder?
Generalised anxiety disorder Agoraphobia Depression Alcohol or drug withdrawal Hyperthyroidism Hypoglycaemia
154
What is the first line pharmacological management of panic disorder?
SSRI
155
What is the first line treatment of panic disorder?
CBT
156
What is the second line pharmacological management of panic disorder?
Clomipramine
157
What is agoraphobia?
Fear of open spaces and associated features such as crowds, and difficulty of immediate escape
158
What are the characteristics of a panic attack?
Discrete episode of fear or intense discomfort Starts abruptly Reaches a crescendo in a few minutes At least one symptom of autonomic arousal
159
What are the criteria for a diagnosis of panic disorder?
Recurrent panic attacks
At least one panic attack that is followed by a month of worrying about the attacks
As well as maladaptive changes made because of the panic attack
160
What is agoraphobia?
Fear of public spaces or fear of entering a public space from which there would be difficulty escaping
161
What is the criteria for diagnosis of agoraphobia?
Fear of at least two of the following - crowds, public spaces, travelling alone, travelling away from home Symptoms of anxiety in the feared situations Significant emotional distress due to the anxiety or avoidance Recognised as excessive or unreasonable Symptoms restricted to feared situation
162
What is social phobia?
Fear of social situations which may lead to scrutiny by others, embarassment, humiliation or criticism
163
What is postpartum depression?
A depressive disorder that can develop up to a year after childbirth
164
What are the biological factors in the development of postpartum depression?
Sudden drops in oestrogen, progesterone and thyroid hormoneGenetic predispositions
165
What are the psychological factors in the development of postpartum depression?
History of mood or anxiety disorderPrevious episodes of postpartum depressionUnrealistic expectations of motherhood Psychological stress from becoming a new parent
166
What are the social factors in the development of postpartum depression?
Lack of social support Relationship issues Life stressors Low socioeconomic status
167
What are the symptoms of postpartum depression?
Persistent low mood Anhedonia Low energy levels Reduced appetiteDisturbed sleep patterns Concerns bonding with baby or caring for baby
168
What are the differentials of postpartum depression?
'Baby blues'Postpartum psychosis Adjustment disorderGeneralised anxiety disorder
169
What scale is used to help diagnose postpartum depression?
Edinburgh postnatal depression scale
170
What is the Edinburgh postnatal depression scale?
Evaluates how the mother has felt over the past 10 days - Covers anhedonia, anxiety, overwhelm, sleeping, low mood and thoughts of self harm
171
What score on the Edinburgh postnatal depression scale is indicative of postnatal depression?
A score of 13 (out of a maximum of 30) is indicative of postnatal depression
172
What is the first line management of postnatal depression?
Self help strategies CBT
173
What is the second line management of postnatal depression?
SSRIs - sertraline/paroxetine
174
What is the typical timeline of postnatal depression?
Symptoms typically start within a month of birth, and peak at 3 months
175
What are the clinical features of depression?
Depressed mood or irritabilityAnhedoniaWeight change or change in appetiteSleep alterationsActivity changesFatigueGuilt or feelings of worthlessnessCognitive issuesSuicidality
176
What are the criteria for a diagnosis of depression?
Need to have 5 out of the 9 symptoms for a minimum of 2 weeks, occuring almost every day
177
What are the differentials of depression?
Biopolar disorderAnxiety disordersAdjustment disorderPMDDGrief/bereavementDementia Substance induced mood disorder
178
What are the possible organic causes of depression?
Parkinson's Dementia Multiple sclerosisHypothyroidismHyperadrenalismSubstance misuseMedication side effectsCancersChronic conditions e.g diabetes
179
What investigations are carried out to rule out organic causes of depression?
FBCTFTU&ELFTGlucose B12/folate Cortisol levels Toxicology screenImaging of CNS
180
What clinical questionnaires are used in the diagnosis of depression?
Patient Health Questionnaire 2Patient Health Questionnaire 9
181
What is the first line management of depression?
Low intensity psychological intervention or CBT
182
What is the first line pharmacological management of depression?
SSRI such as sertraline
183
What are the treatment options for refractory depression?
Lithium ECT - electroconvulsive therapy
184
What is the first line management of moderate to severe depression?
CBT + pharmacological therapy
185
What is ECT for depression?
The brain is stimulated with short electric pulses to cause a seizure lasting less than 2 minutes
186
What are the side effects of ECT?
Memory lossHeadache Muscle achesConfusion NauseaCardiac arrhythmia
187
How long should antidepressant therapy be continued after remission of symptoms?
6 months
188
What is serotonin syndrome?
High levels of serotonin
189
What are the symptoms of serotonin syndrome?
Altered mental state Autonomic nervous system overactivity Neuromuscular excitability
190
How should antidepressants be changed before starting ECT?
Antidepressant doses should be reduced but not stopped before ECT
191
What are the three core symptoms of depression?
Low moodAnhedonia Anergia
192
What is PTSD?
A condition that may develop following a traumatic event. It can be immediate or delayed
193
What are the four groups of symptoms in PTSD?
Intrusion symptoms Avoidance Negative alterations in cognition and mood Alterations in arousal and reactivity
194
How long must symptoms have been present for in PTSD?
1 month - they must also cause a functional impairment
195
What are examples of intrusion symptoms?
Flashbacks
Nightmares
Repetitive intrusive images
196
What are examples of avoidance symptoms?
Avoiding people, situation or circumstances resembling or associated with the event
197
What are examples of hyper arousal symptoms?
Hyper-vigilance for threat Sleep problems Irritability Exaggerated startle responseDifficulty concentrating
198
What are the risk factors for PTSD?
Exposure to extreme traumatic stressors - Acts of violence - Physical or sexual abuse - Military action - Accidents - DisasterPeople who have experienced a threat to their own life in medical careLow social support History of mental health problems History or drug or alcohol abuse
199
What conditions are frequently comorbid with PTSD?
AnxietyDepression Drug and alcohol misuse
200
What scales are used in the diagnosis of PTSD?
PTSD checklist (DSM-5)
Trauma screening questionnaire
Posttraumatic diagnostic scale
International trauma questionnaire
201
What are the differentials of PTSD?
Depression Anxiety Specific phobias Panic disorder Adjustment disorderDissociative disordersOCD Psychosis
202
What is the first line management of PTSD?
For cases under 4 weeks - watchful waiting For cases over 4 weeks - Trauma focused CBT
203
What other form of therapy may be used first line in PTSD?
Eye movement desensitisation and reprocessing
204
What is eye movement desensitisation and reprocessing?
A therapy that uses eye movements to change the way that the memory is stored in the brain, reducing problematic symptoms
205
What is the first line pharmacological management of PTSD?
Venlafaxine or an SSRI such as sertraline
206
What are the risk factors for suicide?
Male sexPrevious deliberate self-harmPrevious suicide attemptsAlcohol or drug misuseHistory of mental illnessHistory of chronic diseaseAdvancing ageUnemployment Being unmarried, divorced or widowed
207
What are protective factors from suicide?
Social support
Having children at home
Religious beliefs
208
In someone who has previously attempted, what factors put them at increased risk of a future completed suicide?
Efforts to avoid discoveryPlanning Leaving a written note Final acts e.g sorting out financesViolent method of attempt
209
What is psychosis?
Psychosis is where people experience things around them differently to normal
210
What are the features of psychosis?
Hallucinations Delusions Thought disorganisation Agitation/aggression Neurocognitive impairment Depression Thoughts of self harm
211
What is brief psychotic disorder?
An episode of psychosis lasting less than a month with a return to baseline functioning
212
What disorders might psychosis be seen in?
Schizophrenia Depression Bipolar disorderPuerperal psychosisNeurological conditions - Parkinson's, Huntington's
213
What is OCD?
A mental disorder characterised by persistent obsessions and compulsions
214
What are obsessions?
Uncontrolled thoughts and intrusive images that the patient finds it difficult to ignore
215
What are compulsions?
Repetitive actions that the patient feels they must doIt generates anxiety if they are not done
216
What other mental health disorders is OCD associated with?
Depression Anxiety ASDPhobias Eating disorders
217
What are the risk factors for OCD?
History of abuse, bullying or neglect
Age (teens)
Family history of OCD
Postnatal period
218
When does OCD typically develop?
Peak incidence of OCD is between 10 and 20 years
219
What scale is used to determine the severity of OCD?
Y-BCOS (yale brown obsessive compulsive scale)
220
What are the differentials of OCD?
Obsessive compulsive personality disorder Hypochondriasis Body dysmorphic disorderSomatic symptom disorderSevere social phobia Panic disorder Delusional disorder
221
What is the first line management of mild OCD?
CBTExposure and response therapy
222
What is exposure and response therapy?
It aims to prevent responses to obsessive thoughts by exposing patients to anxiety inducing situations and prolonging compulsions as long as possible
223
What is the first line pharmacological management of OCD?
SSRI (any SSRI is suitable in OCD)Fluoxetine should be given for body dysmorphic disorder
224
What is the alternative drug to SSRI in OCD?
Clomipramine
225
What should be done in cases of severe OCD?
Refer to secondary care mental health team for assessment Offer SSRI and CBT
226
When does postpartum psychosis typically occur?
Within 2-3 weeks postpartum
227
What are the features of postpartum psychosis?
ParanoiaDelusionsHallucinations Manic episodesDepressive episodesConfusion
228
What is the pharmacological management of postpartum psychosis?
Antipsychotic medications Mood stabilisers
229
What management option may be necessary for women with postpartum psychosis?
Admission to mother and baby unit/ referral to perinatal mental health team
230
Why does alcohol withdrawal occur?
Decreased inhibitory GABA and increased NMDA glutamate transmission
231
When do symptoms of alcohol withdrawal start?
6-12 hours after last drink
232
What are the first symptoms of alcohol withdrawal?
Tremor Anxiety Sweating Tachycardia
233
When is the peak incidence of seizures after alcohol withdrawal?
36 hours
234
When does delirium tremens occur after alcohol withdrawal?
48-72 hours after last drink
235
What is delriuim tremens?
The rapid onset of confusion precipitated by alcohol withdrawal
236
What are the symptoms of delirium tremens?
Confusion and disorientation Hallucinations Sweating Tachycardia Hypertension Seizures (rarely)
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What is the first line management of delirium tremens?
Oral lorazepam
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What is the second line management of delirium tremens?
Pareneteral lorazepam or haloperidol
239
What questionnaires can be used to assess alcoholism?
AUDIT questionnaire SADQ questionnaire
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What are the indications for inpatient withdrawal from alcohol?
Drinking > 30 units per day Scoring over 30 on the SADQ questionnaire High risk of alcohol withdrawal seizuresConcurrent withdrawal from benzodiazepines Significant medical or psychiatric comorbidity Patients under 18 Vulnerable patients
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What is the medical management of alcoholism?
Assisted withdrawal with chlordiazepoxide
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What other medical options are available for alcoholism?
Acamprosate Naltrexone
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What is acamprosate used for?
Acamprosate is used to help maintain abstinence from alcohol
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What is the first line psychological management for alcoholism and withdrawal?
CBT
245
What are the features of opiate intoxication?
Drowsiness Confusion Decreased respiratory rateBradycardia Constricted pupils Track marks
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What are the features of opiate withdrawal?
Agitation and anxiety Chills Runny eyes and nose Sweating Tachycardia High blood pressureDilated pupils Muscle cramps Insomnia Vomiting
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When does withdrawal from heroin begin?
6 hours after last dose
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When do symptoms of heroin withdrawal peak?
36-72 hours
249
What is the first line management of opiate dependence?
Methadone or buprenorphine
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What drug can be used to prevent relapse of opiate addiction?
Neltrexone
251
What is the treatment of opiate overdose?
Naloxone
252
What are the features of cannabis intoxication?
Drowsiness Impaired memory Slowed reflexes and motor skillsConjuntival injection Increased appetite Paranoia Tachycardia
253
What are the features of LSD intoxication?
Hypertension
Tachycardia
Increased temperature
Labile mood
Hallucinations
Sweating
Insomnia
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What are the features of stimulant intoxication?
Euphoria Hypertensive crisisSeizures Agitation Psychosis Excessive thirst Ischaemic events
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What is the action of MDMA?
Induces rapid serotonin and dopamine release by binding to the 5HT2 receptor
256
What is the action of cocaine?
Increases free levels of serotonin and dopamine by decreasing uptake of dopamine, serotonin and noradrenaline
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What is the action of methamphetamines?
Acts at the sigma receptors which increase release of dopamine
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What is the action of LSD?
Acts at the dopamine receptors to increase release of dopamine
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What are the complications of opioid misuse?
HIVHepatitis B and CInfective endocarditis Sepsis VTE Respiratory depression Social problems - homelessness, crime
260
How long does opioid detox last for?
4 weeks in an inpatient setting 12 weeks in the community
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How is opioid dependence treatment compliance monitored?
Urinalysis
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Which drugs are stimulants?
Cocaine Methamphetamine Khat Nicotine MDMA
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Which drugs are hallucinogens?
Ketamine LSD
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What type of drug is cannabis and what type of effects can it have?
Cannabinoid - can have hallucinogenic, depressive and stimulant effects
265
What is neonatal abstinence syndrome?
A condition caused by withdrawal from substances that a mother has taken during pregnancy
266
What is the treatment for neonatal withdrawal of opiates?
Morphine
267
What is the treatment for neonatal withdrawal of cocaine?
Phenobarbital
268
What is Wernicke's encephalopathy?
A syndrome of low vitamin B1 that is associated with chronic alcohol consumption
269
What are the features of Wernicke's encephalopathy?
Confustion Ataxia Ophthalmoplegia Nystagmus
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What is Korsakoff's syndrome?
An irreversible manifestion of untreated Wernicke's encephalopathy
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What are the features of Korsakoff's syndrome?
Retrograde amnesia Anterograde amnesia Confabulation
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What is the treatment of Wernicke's encephalopathy?
IV pabrinex
273
What foods should be avoided in patients on MAO inhibitors?
Aged cheese Smoked fish and meats Red wines, ales and beers Other fermented foodsAvocado
274
Why should these foods be avoided in patients on MAO inhibitors?
Tyramine can build up leading to hypertension
275
What is neuroleptic malignant syndrome?
A life-threatening reaction to antipsychotic drugs (dopamine antagonists)
276
What are the symptoms of neuroleptic malignant syndrome?
FeverAltered mental status Muscle rigidity Autonomic dysfunction
277
What blood test results would be seen in neuroleptic malignant syndrome?
Raised creatinine kinaseRaised white blood cells Deranged LFTsMetabolic acidosis Renal failure
278
What is the treatment of neuroleptic malignant syndrome?
Stop dopamine antagonist + supportive therapy - Rehydration - Cooling
279
What is the action of benzodiazepines?
Target the GABAA receptor to increase the inhibitory effect of GABA on the nervous system
280
What are the side effects of lithium?
Hypothyroidism Hyperparathyroidism and hypercalcaemia Fine tremor Nausea/vomiting Weight gain Idiopathic intracranial hypertension Leukocytosis
281
What monitoring is needed for patients on lithium?
Serum lithium TFTs Renal functionU&Es
282
When should patients be followed up after starting an SSRI?
1 week for patients aged 18-252-4 weeks for patients over 25
283
What medication might be helpful in patients with acute dystonia?
Benzatropine
284
What medication might be useful for patients with tardive dyskinesia?
Tetrabenazine
285
What medication might be helpful for patients with akathisia?
Atenolol
286
What is schizoaffective disorder?
A condition that combines both 'psychotic' symptoms and 'bipolar' type symptoms
287
What are the types of schizoaffective disorder?
Schizoaffective manic type Schizoaffective depression type Schizoaffective mixed type
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What psychotic symptoms are experienced by people with schizoaffective disorder?
Hallucinations Delusions Thought disorder
289
What manic symptoms are experienced by people with schizoaffective disorder?
Elevated mood Lack of sleep IrritabilityFlight of ideas Incomprehensible speech Excessive energyRisky behvaiours
290
What depressive symptoms are experienced by people with schizoaffective disorder?
Low mood Anhedonia Low energy Lack of concentration Suicidal thoughts Sleep disturbance
291
What is the treatment of an acute episode of schizoaffective disorder?
Antipsychotics - Risperidone - Olanzapine - Quetiapine
292
What is the treatment of depressive symptoms in schizoaffective disorder?
Antidepressants - SSRI - sertraline, citalopram
293
What is the treatment of manic symptoms in schizoaffective disorder?
Lithium
294
What is neuroleptic malignant syndrome?
A life-threatening emergency associated with the use of antipsychotics
295
What type of drugs can neuroleptic malignant syndrome occur with?
Typical antipsychotics Atypical antipsychotics Withdrawal of dopaminergic drugs (levodopa)
296
What are the symptoms of neuroleptic malignant syndrome?
Pyrexia Muscle rigidityHypertension TachycardiaTachypnoea Altered mental state Tremor
297
What results might be seen on blood tests in neuroleptic malignant syndrome?
Raised creatinine kinase AKI LeukocytosisDeranged LFTsMetabolic acidosis
298
What is the management of neuroleptic malignant syndrome?
Stop antipsychotic IV fluids AntipyreticsMuscle relaxant - dantrolene, bromocriptine
299
What are the risk factors for neuroleptic malignant syndrome?
Use of antipsychotics
Withdrawal of parkinsons medication
Depot medication
High dose antipsychotics
Previous episode of NMS
300
What are the symptoms of a paracetamol overdose?
NauseaVomiting Loin pain Haematuria Proteinuria Jaundice Coma Severe metabolic acidosis
301
What investigations should be performed in a paracetamol overdose?
FBC U&E Clotting screenLFTs VBG Serum paracetamol level
302
What is the definition of a staggered paracetamol overdose?
If all the paracetamol tablets are not taken within 1 hour
303
What can be given if a patient presents withina n hour of overdose?
Activated charcoal
304
What is the main treatment of paracetamol overdose?
N-acetylcysteine
305
What parameters are used to predict mortality in paracetamol overdose?
Arterial pH < 7.3Serum creatinine > 300PT time > 100 seconds Bilirubin > 18 INR > 6.5
306
What are the features of tricyclic overdose?
Dry mouth Blurred vision DIlated pupils Agitation Seizures Vomiting
307
What ECG changed are common in tricylic overdose?
Sinus tachycardiaWidening of QRS QT prolongation
308
What investigations are performed in tricyclic overdose?
FBC U&ECRPLFTsVBG ECG
309
What is the management of tricylic overdose?
IV sodium bicarbonate Activated charcoal within 2-4 hours of overdoseIV fluids Invasive ventilation
