Pysch Flashcards
what is the diagnostic criteria of GAD?
>= 4 of, including at least 1 autonomic arousal symptom
- Autonomic arousal
- physical symptoms (SoB, choking, chest pain/discomfort)
- altered consciousness (dizzy, lightheaded, derealisation/depersonalisation, fear of passing out, dying or going crazy)
- tension (muscle, unable to relax)
- Exaggerated response to being startled
- concentration difficulty
DDx to consider with GAD
hyperthyroidism, phaeochromocytoma, hypoglycaemia
cardiac arrhythmia
substance abuse
depression, avoidant PD, psychosis
investigation with GAD
24 hour urine metanephrines and VMA
TFTs
ECG
blood glucose
UDS and blood EtOH, LFTs & GGT
‘initial help’ to offer in GAD
- advice and reassurance (with psychoeducation)
- Basic councilling (addressing ICE)
- problem-solving
- self-help (CBT books, computer programs, friends family and faith)
- Relaxation techniques and breathing exercises
psychological intervention with GAD
- CBT
- exposure therapy (best with phobias/triggers)
biological management of GAD
- SSRI - fluoxetine, paroxetine
- TCA - clomipramine, imipramine
- Busprione (s/e of dysphoria)
- BZDs for no more than 2-4 weeks while anticipating SSRI effect
- Beta-blocker - good if physical symptoms are central in the worry pattern
GAD prognosis
1/3 recover completely
1/3 improve partially
1/3 suffer considerable disability and poor QoL
OCD differentials to consider
- other anxiety disorder
- depression
- anakastic personality disorder (OCPD)
- Schizophrenia
- Organic causes (chorea)
management of OCD
Initial - psychoeducation
psychological - CBT and exposure therapy
Biological - SSRI or 2nd line clomipramine
PTSD management
psychological - CBT and eye movement desensitisation and reprocessing
biological - SSRIs
what alcohol dependence drug should not be used in pregnancy?
acamprosate - teratogenic
Biological management of alcoholism
detox, maintenance and WE
Detox - chlordiazepoxide (reducing regime) and thiamine, hydration and supportive care.
Inpatient (hx DT/seizures, lives alone, comorbid medical/psych illness, previous failed community detox) or outpatient (planned to start after a period of psychological preparation for upcoming change)
Maintenance - acamprosate (anti-craving) or disulfiram (Antabuse)
WE - IM Vitamin B1, slow IV saline 0.9%, oral glucose loading
alcoholic screening questions?
CAGE
C - ever felt you should cut down on your drinking?
A - have people annoyed you by criticizing?
G - have you felt guilty about your drinking?
E - have you ever had an eye-opener drink the very first thing in the morning?
>= 2 should prompt evaluation
investigations for alcohol abuse
FBC, LFTs, BBV screen, UDS
substance abuse history structure
- Current use (TRAP)
- Type of drug, route of administration, amount, pattern of use
- Current use - dependence and impact
- Past use
- Future use (do you think your drinking is a problem? What are you worried about if you keep drinking?)
Establish a diagnosis of dependence (tolerance, narrowing of rep, craving, withdrawal, use despite harm)
short term psychological management of self harm
Risk assessment & Coping strategies
Prevention
- Tablets/sharp objects hidden – prevent cues
- Avoid triggering images/situations
- Call friend/support line
- Avoid drugs and alcohol
- Breathing exercises/mindfulness
Alternatives to painful, damaging self-harm:
- Squeeze ice cubes
- Snap a rubber band around wrist
- Bite into something strongly flavoured e.g. ginger root, lemon
Alternatives to drawing blood:
- Put red food dye on dull side of knife and draw across skin
- Use a washable red pen
long term psychological management of self harm
CBT
Transference-focused psychotherapy
Family therapy
what scales/questionaires are useful in the assessment of a patient following a suicide attempt?
SAD PERSONS scale
Tool for assessment of suicide risk (TASR)
- multiple physical SYMPTOMS present for at least 2 years
- patient refuses to accept reassurance or negative test results
diagnosis?
somatisation disorder
- persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
- patient again refuses to accept reassurance or negative test results
diagnosis?
hypochondrial disorder
- typically involves loss of motor or sensory function
- the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
- patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
diagnosis?
conversion disorder
- a process of ‘separating off’ certain memories from normal consciousness
- in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
diagnosis?
dissociative disorder
the intentional production of physical or psychological symptoms
diagnosis?
Munchausen’s syndrome
fruaudelent simulation or exaggeration of symptoms with the intention of financial or other gain
what is this called?
Malingering
a psych patient takes an overdose of her TCAs with a view to ending her own life. In resus, cardiac monitoring reveals a tachyarrhythmia.
which antiarrhythmics are contraindicated?
1a (quinidine, procainamide);
1c (flecanide);
III (amiodarone, sotalol, dofletide)
what is the management of beta-blocker toxicity/poisoning?
IV atropine to increase HR
if resistant, IV glucagon
treatment of organophosphate poisoning
atropine, pralidoxime (?)
treatment for digoxin toxicity
digoxin-specific antibody fragments
lead antedote?
dimercaprol & calcium edetate
what are the 4 components of Schneider’s first rank symptoms?
- auditory hallucinations
- thought disorder
- passivity phenomena
- delusional perception
what is the target range for blood lithium levels?
when should a monitoring blood test be taken?
0.4-1.0 mmol/L
take levels 12 hours after the dose
what is the preferred SSRI in post-MI patients?
sertraline - best safety data
what is the clinical indication for initiating clozapine?
no improvement following sequential trails of alternative antipsychotics for at least 6-8 weeks each, with at least 1 being an atypical antipsychotic
what are the main risks of starting antipsychotic therapy in the elderly?
stroke and VTE risk increases
what are the common short-term side effects of ECT?
headache, nausea, short-term memory loss, retrograde amnesia for events prior to ECT, arrhythmia
what are the score thresholds for MMSE?
24-30 = no cognitive impairment
18-23 = mild cognitive impairment
<18 = severe cognitive impairement
what are the four main features of anorexia nervosa?
- Deliberate weight loss
- Distorted body image
- BMI <17.5
- Endocrine dysfunctions
what are the four features of bulimia nervosa?
- binge eating
- purging
- dysmorphic body image
- BMI >17..5 kg/m^2
what is the ED history screening tool?
SCOFF
- feeling Sick from too much food
- lose Control around food
- lost more than One stone/6.5 kg in 3 months
- feel Fat when others say you are thin
- feel that Food dominates your life
what are the signs for AN?
- general
- GI
- neuro
- CVS
- metabolic
- MSK
- general - lanugo hair, cold extremities, oedema, anaemia, hypothermia
- GI - tender abdo
- neuro - peripheral neuropathy
- CVS - orthostatic hypotension
- Metabolic - hypokalaemia, hyponatraemia, high GH < high cortisol, hypercholesteraemia, hypercarotaemia (yellowing of palms and soles)
- MSK - muscle wasting, fractures
what investigations are important in the management of eating disorders?
- BMI
- Squat test
- organic causes - ESR, TFTs
- consequences - FBC, U&E with CK , phosphate, albumin, LFTs, glucose
- ECG - bradycardia, arrhythmias, prolonged QT
which biological management is indicated in eating disorders and what is the purpose?
SSRIs in bulimia in order to help with impulse control
what is the daily calorie intake maximum that would suggest a possibility of refeeding syndrome?
400-600 kcal/day
what is the rate of weight loss that would suggests refeeding syndrome?
1 kg/week
what must be monitored before feeding in any patient at risk of refeeding syndrome?
ECG
what areas should you cover in a mania HPC?
(7)
mood, energy, sleep, concentration, libido, dangerous behaviour, psychosis
what areas should be specifically risk assessed in a mania history? (6)
work, gambling, money, sex, drugs, alcohol
what is the monitoring schedule for lithium?
‘level’ taken at 12 hours post dose (peak)
start medication, take level at 5 days
take level 1 weekly after until stable
take levels 3 monthly
monitor TFTs and U&E every 6 months (risk of renal failure and hypothyroidism)
what are the common side effects experienced by 75% of patients on lithium?
acne, weight gain, polyuria, polydipsia, fine tremor, GI disturbance, hair loss, oedema
what are the signs of lithium toxicity that must be advised to patients starting the medication and repeated at follow up visits?
coarse tremor, myoclonic jerks, restlessness, slurred speech, drowsiness, arrhythmia, seizures, visual disturbance
what are the definitions of the different types of bipolar affective disorder?
- Type I BPAD:
- Manic episodes interspersed with depressive episodes
- Type II BPAD
- Mainly recurrent depressive episodes, with less prominent hypomanic episodes
- Rapid cycling BPAD
- >=4 episodes per year
- More common in women
- May respond better to valproate
what are the GAD-2 screening questions?
- Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?
- Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?
‘Not at all’ scores 0;
‘Several days’ scores 1;
‘More than half the days’ scores 2;
‘Nearly every day’ scores 3.
NICE 2014
what are the domains of the presentaion of ADHD?
attention/concentration
hyperactivity
impulsivity and recklessness
what are some primary management options when assessing a child for ADHD?
questionnaire - Conner’s Rating scale
classroom observation with teacher feedback
educational psycholgist assessment
ADHD stimulant therapy - what are the drug options?
what are the side effects?
do they stop the child from growing properly?
methylphenidate (ritalin) or dexamphetamine
improves concentration and allows for better learning and maturation
S/e: appetite suppression, insomnia. NOT ADDICTIVE
with drug holidays (school breaks, not on weekends) this limits growth to 1 cm finally
what is the timeframe for alcohol withdrawal symptoms?
6-12 hours - any symptoms
36 hours - seizures
72 hours - delerium tremens
amitryptyline, clomipramine, dosulepin
are these sedative or non-sedative?
sedative
nortryptaline, imipramine, lofepramine
are these sedative or non-sedative?
non-sedative
which are the most dangerous TCAs to use because of toxicity/overdose?
amitryptaline and dosulepin
while on methylphenidate for ADHD, what should be monitored?
growth every 6 months
blood pressure and pulse rate every 6 months
which SSRI should be used in adolescents and children if needs be?
fluoxetine
what is the major side effect of SSRI?
GI symptoms of nausea, diarrhoea and GORD
if on NSAID, should be prescribed PPI as well
what should be offered instead of SSRI when a patient is on warfarin/heparin?
mirtazapine
what are the side effects of mirtazapine?
apetite stimulant (so put on weight)
drowsiness
what are the 4 features of autism?
- poor social interaction
- poor communication skills
- poor imaginaiton: restricted play/behaviours
- onset before age 3
what congenital diseases can present with features of autism?
Downs
neurofibromatosis
tuberosclerosis
phenylketonuria
fragile X syndrome
what are some symptoms of social impairment in autism?
- Interacting with others; plays alone/prefer own company
- Eye contact (gaze avoidance)
- Attachment impoverished, lack mutuality or warmth
- cannot read emotional states
what are some symptoms of communication impairment in autism?
- poor use of nonverbal behaviours; gestures/pointing/ facial expression
- Speech delays?, reduced variation in words or tone
- Struggles with sarcasm
- Echoes questions, repeats instructions, refers to self as ‘you’
what are some symptoms of imagination impairment in autism?
- routines & rituals
- violence if these are not adhered to
- stereotypical movements
- hand flapping and tip toe walking
- poverty of imagination in play and with activities
- peculiar interests/obsessions
what comorbidities should you screen for in ASD?
special learning difficulties
epilepsy
what is the prognosis for children with autism?
what factor affect the prognosis?
only 10-15% function independently in adult life
about 15-20% function well with support
IQ >70; supportive family/home environment; good language skills at age 5-7 are positive prognostic factors
along with AChE-I, is aspirin indicated in the management for Alzheimer?
what is the medication for moderate-severe Alzheimer?
no
memantine (NMDA antagonist)
when stopping SSRI, what is the reducing schedule?
taper down over 4 weeks
NOT NECESSARY with fluoxetine
what is the review after starting SSRI?
normally follow up in 2 weeks to check how they’re getting on. reassure that anxiety will imrpove and check compliance
if under 30 with increased risk of suicide, follow up in 1 week
is imipramine better or worse than other TCAs for side effects?
has the worst profile for anti-muscarinic s/e’s
what are the symptoms of BZD withdrawal? How long does this last without management?
insomnia, irritability, tinnitus, perceptual disturbance, nausea & anorexia, tremor, anxiety, sweating
seizures
up to 3 weeks
which TCA is most dangerous in overdose?
dosulepin - so don’t prescribe it
what is the monitoring schedule for clozapine?
weekly for 18 weeks, 2 weekly thereafter up to a year from starting
then monthly thereafter
what medication is useful in the treatment of tardive diskineasia?
anticholinergic meds - procyclidine
what is the time frame for diagnosing schizophrenia?
symptoms >=1 month
what is the absolute and relative contraindications for ECT?
absolute - raised ICP
relative - high anaesthetic risk, cerebral aneurysm
what is the calculation for units of alcohol?
[volume (mL) * ABV (%)]/1000
what are two positive and 6 negative prognostic factors for depression?
positive - young age, acute onset
negative - old age, insidious onset, low self esteem, poor social support, comorbidity, neurotic depression
when do you start to give mood stabilisers in the treatment of BPAD?
only if they have had an episode of mania before
coming out of manic episode first time managed with antipsychotics (i.e. olanzapine)
what drugs are a risk factor for depression? (6)
opiates, NSAIDs, steroids, BZDs, beta-blockers, anticonvulsants
what are the police sections of the mental health act?
135 - go into someone’s home if they are at risk of hurting themselves/neglect
136 - take someone off the street who is acting crazy and bring them to a place of safety (jail, A&E or 136 suite in mental health hospital)
can ECT be used for NMS?
yes
can ECT be used for dementia?
no
how do you tell the difference betwen dementia and pseudodementia on MMSE?
patient with pseudodementia has memory loss/cognitive decline mainly becuase of their loss of motivation
the answer to questions will be “don’t know”
in dementia, the patient will confabulate and give an answer with no meaning
hebephrenic schizophrenia
disorganized speech and behaviour
&
flat or inapprorptiate affect
paranoid schizophrenia
most common and best outcome
prominent hallucinations and positive symptoms, increased risk of suicide
simple schizophrenia
only ever negative symptoms
chronic schizophrenia
negative symptoms persistent 1 year beyond the resolution of positive symptoms
what is the time frame for transient pyschotic episode?
cresciendo to maximum in 2 weeks and resolution in 3 months
what is the incidence in the population for suicide?
what is the incidence for completed suicide 1 year following a suicide attempt?
1 in 10,000 (0.01%)
1 in 100 (1%) - 100 times greater than the general public
what are the actelycholinesterase inhibitors?
what is the next step up from this for more severe alzheimer treatment?
donepezil, rivastigmine, galantamine
memantine
