Random psych Flashcards
Organic causes of psychosis
Vascular -cerebrovascular accident
Infection- encephalitis, meningitis, neurosyphilis
Traumtic brain injury
Autoimmune encephalitis (anti-NMDA, anti-VGKC)
Metabolic- B12 deficiency, pellagra (vit B3 deficiency), acute intermittent porphrya, wilsons
Iatrogenic- steroids,
Neoplasms- brain tumor
Endocrine- thyrotoxicosis, cushings
Neurodegenerative disease- Alzheimers, Lewy-body, Parkinsons, huntingtons
what is schizoaffective disorder
schizophrina + bipolar disorder(mood disorder)
random episodes of psychosis within mood fluctuations
what prescribed medications can cause psychosis?
steroids
anticholinergics eg. TCAs
dopaminergics eg. bromocriptine
thyroxine
antimalarials
what illicit substances are most likely to cause psychosis
- high THC containing cannabinoids- esp synthetic weed (spice)
- amphatamines
- hallucinogens (LSD, PCP, psilocybin)
key question to ask with someone presenting with auditory hallucinations
do you hear the voices through your ear or inside your head?
(true psychotic pts will try to find an explanation for the auditory hallucinations and put them down to an external stimuli as to not sound as crazy. Pts who want to appear psychotic will say thet hear voices in their head)
according to ICD-11, how long does someone need to have symptoms to be diagnosed with schizoprenia?
1 month
what is the first line psychological treatment for borderline personality disorder
dialectal behavioural therapy (DBT)
remember its pretty much the only condition where CBT isnt the first line
What are the different personality disorders in cluster A personality type
Paranoid
schizoid
schizotypal
What are the different personality disorders in cluster B personality type
Antisocial
narcissistic
Histrionic
Borderline
Features of anorexia nervosa
- morbid fear of fatness (overvalued idea)
-BMI <17.5 - deliberate measures to lose weight eg. food restriction, excessive exercise
- endocrine disturbances eg. amenorrhoea in women,
Physical disturbances in anorexia nervosa
- low BMI <17.5
- bradycardia
- hypotension
- lenugo hair
- cold extremities
- hypothermia
- constipation
- amenorrhoea
- severe: long QTc
What is refeeding syndrome
Happens when there is a significant reintroduction of food after the person has had a substantial period of malnourishment
When glucose is reintroduced, there is a surge in insulin, which draws already depleted K, Mg and phosphate into cells leading to major hypokalaemia, hypomagnesmaeia and hypophosphataemia
clinical features:
nausea
muscle weakness
confusion/ coma
arrhythmias- torsades de pointes
ECG changes- T wave flattening and U waves
+thiamine deficiency –> wernickes encephalopathy
features of bulimia nervosa
- characterised by repeated bouts of binging, feeling of regret followed by purging
eg. vomiting, laxatives, diuretics - excessive preocupation of controlling body weight
- episodes must happen at least 1/week for 3 months to fit diagnostic criteria
may not be underwight like in anorexia
Physical/ clinical signs in bulimia nervosa
signs of excessive vomiting:
erosion of teeth
Russels sign- calluses on the knuckles due to self induced vomiting
swelling of parotid glands
hallitosis- bad breath
mallory weiss tear- haematemesis, pain
electrolyte disturbances- low Na, Cl, Mg, Phos and K
arrhythmias
metabolic alkalosis
dehydration
hypostnsion
tachycardia
what is the PHQ-9 questionnaire and what are the questions
assessment of the severity of depression
in the past 2 weeks how often…
1. have you had little interest or pleasure doing things
2. trouble sleeping or sleeping too much
3. loss of appetite or eating too much
4. feeling down, depressed or hopeless
5. lacked energy to do things
6. felt like youve let people around you down
7. trouble concentrating
8. changes in speech
9. had thoughts that youd be better off dead
how to interpret the PHQ-9 score
0-4: normal
5-9: mild depressiom
10-14: moderate
15-19: moderately severe
20-27: severe
management of acute mania
- risk assess and consider section 5(2)
- Urine drug screen
- monitor fluid status - if first presentation:
- short acting benzo (lorazepam)
- antipsychotic: olanzepine
- short acting benzo (lorazepam)
- if already on medication
- optimise dose
- check for any interactions
- consider adding antipsychotic - ECT if unresponsive to Rx
After:
-check compliance
- enquire for any trigger (eg. drugs, antidepressant)
- prev episodes of depression?
Key questions to ask in a history of a manic pt
why do they think they are here?
whats been going on?
MOOD: How do they feel in themselves
Have you ever had something like this before?
Have you ever had a period of time where you felt the complete opposite?
THOUGHT: probs will just come out
PERCEPTION: have you been hearing things when it seems like no one is around?
Do you hear through your ear or in your head
INSIGHT: Do you know why you are seeing a psychiatrist? Do you think there is a problem with your mental health
RISK: have you had any thoughts about harming/ killing yourself. Any thoughts of harming others
Do you feel safe?
been spending more money than usual?
what is the managament of adjustment disorders
- spectrum of reactions as a response to ill health
health psychology
antidepressents
commmunication
counselling
symptom control of medical issues
CBT
Medical emergencies related to psychiatric medication
neuroleptic malignant syndrome (anti psychotics)
serotonin syndrome (antidepressants)
long QTc –> torsades de pointes (citalopram)
psychiatric problems from medications
Roaccutane (acne) –> depression increased suicidality
steroids –> psychosis, delerium, mania, depression
max dose of lorazepam
4mg in 24 hrs
Tests to perform in a GP setting for addiction
urine drug screen
GABA-A targeting drugs
MOA of benzodiazepines
potentiates the affects of GABA which incrreases the flow of chloride ions and hence hyperpolarisation of post synaptic membrane –> reduced excitibility
Withdrawal features of benzos
anxiety, irritibility, restlessness, tremor, sweating, insomnia
toxicity features of benzos
drowsiness, ataxia, slurred speech, reduced conciousness
severe: hypotension, brady cardia
OD: respiratory depression
Antidote for benzo OD
Flumazenil
What drugs can be identified on the urinary drug screen
alcohol
amphetamines
barbiturates
benzodiazepines
cocaine
cannabis
methamphetamine
opioids
phencyclidine (PCP)
how long can cannabis be detected for on UDS after use?
casual use: 2-14 days
heavy use: 30 days
Criteria for dependence in ICD-10 (6 points)
meeting 3 or more = diagnosis
1. a strong desireor sence of compulsion to take
2. difficulties in controlling
3. physiological withdrawal Sx when stop taking
4. evidence of tolerance leading to increased doses to feel the same affect
5.
6.
what are the stages of change in the prohchaska and DiClemente’s model
pre-contemplation
contemplation
preparation
action
mainatainence
relapse
Screening tools for alcohol misuse
CAGE
FAST
AUDIT
Key questions to ask in alcohol/ substance misuse history
Type of drink and how much in units
when did it start
what time of day
alone or with people
social network
how much money are they spending on substances
pattern of drinking eg. binging/ steadily
any withdrawal sx
triggers
aware of the problem?
any period of abstinence and for how long?
Mental health comorbidity
Diet
any mixing of substances
How is it affecting their life
forensic history, getting into trouble on substances or to get substances
how to calculate units of alcohol
(total vol of drink (mls) x ABV%) /1000
features of alcohol dependence syndrome
Management options for someone with alcohol dependence
psycho:
- motovational interview and discuss evidence for concern eg. deranges LFTs
- discussion of a plan and warn not to go cold turkey
- referral to specialist alcohol services
social:
- notify the DVLA
- drink diary
Bio:
- thiamine replacement
alcohol effects on the CNS
complex interplay between excitatory and inhibitory systems
physical and psychological symptoms of alcohol usage
medication to help with cravings
Naltrexone - reduces the pleasure feelings of alcohol
acampostate - reduces hyperglutamatergic state. Anticraving drug
symptoms of alcohol withdrawal
tremors
sweating
N+V
anxiety
hypertension, tachycardia, dilated pupils
24-48hrs after last drink : seizures (tonic clonic)
24-72hrs after last drink: delerium tremens
Management of alcohol withdrawal
alcohol detox: clinical institute assessment for alcohol withdrawal
benzos: long acting eg. chlordiazepoxide
pabrinex
dextrose: NEVER GIVE BEFORE PABRINEX as dextrose can potentiate wernikes in thamine depleted pts
risk factors for developing delerium tremens
previous DT
co-infeciton
pancreatitis, hepatitis
older age
abnormal liver function
What is wernickes encephalopathy
vitamin B1 (thiamine) deficiency
confusion
opthalmoplesia (eg. nystagus or CN6 palsy)
ataxia
mechanism for thiamine deficiency in AD
- poor diet due to alcohol
- damage to gut from alcohol so poor absorption
what is korsakoffs psychosis
irreversible complication of wernickes
antegrade and retrograde amnesia
change in personality (frontal lobe dysfunction) eg. childlike behaviour confabulation
psychotic symptoms
clinical features of opiate OD
reduced GCS
pinpoint pupils
hypotension
respiratory depression
hypotonia
hyporeflexia
opioid substitution therapy
methadone:
- reduces euphoria
- more SEs: resp distress, long QTc, constipation, dry mouth
buprenorphine
- less sedation, less euphoria, less SEs but more unpleasant feelings
differentials for depression
organic- anaemia, low vitamin D, thyroid, cushings
cognitive- dementia
adjustment disorder
insomnia
differentials for mania
organic- thyrotoxicosis, steroids, antimalarials
acute psychosis
delusional disorder, grandiosity
differentials for psychosis
organic- porphyrias, pellegra, brain tumour, autoimmune encephalitis, thyrotoxicosis, steroids, antimalarials
delirium
mania
drug induced psychosis/ currently high
depression with psychosis
differentials for confusion
organic- delerium/ infection, low glucose
dementia
What questionnaire is used in the investigations for OCD and what are the questions
Yale-Brown obsessive compulsicve scale
5qus for each obsession and compulsion and each qu scored out of 5 (5most severe)
Time, interference, distress, resistance, control
- how much time is spent on the obsessions or compulsions
- how much do these thoughts/ actions interfere with life
- how much distress is it causing you
- how much do you try to resist the obsessions/ compulsions
- how much control do youe obsessions/ compulsions have over you
what are some example themes of typical obsessions
agressive obsessions
sexual obsessions
contamination obsessions
hoarding obsessions
religious obsessions
obsession for symmetry
somatic obsessions
what are some example themes of typical compulsions
checking compulsions
cleaning/ washing compulsions
repeating rituals
counting
ordering/ arranging
sorting compulsions
what effects do smoking and alcohol have on clozapine levels
smoking cessation - levels will rise
starting smoking/ smoking more will reduce levels
alcohol binging - increase levels
stopping drinking- reduces levels
features of PTSD
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
factors associated with poor prognosis of schizophrenia
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
different classess of medically unexplained symptoms
somatisation - physical SYMPTOMS being present. Not reassured by negative test results
hypoChondriasis - believing they have a severe medical condition despite reassurance eg. Cancer
conversion disorder - loss of sensory or motor function usually in leg. common for over worked athletes
dissociative disorder - separating off certain memories from reality eg. amnesia
factitious disorder/ muchaussen syndrome - purposefully causing symptoms eg. causing a hypo by taking insulin
malignering - fraudulent exaggeration or making up of symptoms with the intention of gains eg. financial, opioid medication
what features support a diagnosis of depression over dementia
short history, rapid onset
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
global memory loss (dementia characteristically causes recent memory loss)
quick and useful clinical tool to differentiate organic from non-organic leg paresis
Hoovers sign
get pr to raise unaffected leg and put hand under the heel of the affected leg. In a non-organic causes you will feel pressure under the heel due to involuntary contralateral hip extension
what is Cotard syndrome
Cotard syndrome is a 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. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.
what is Charles Bonnet syndrome
is a psychophysical visual disorder where patients with significant vision loss have vivid, often recurrent visual hallucinations. These hallucinations can be simple (i.e. shapes, patterns) or complex (i.e. detailed objects, people) but patients almost always have insight into the fact that they are not real and do not suffer from any other forms of hallucinations (e.g. auditory) or delusions.
what is the mechanism of hypocalcaemia in someone who is hyperventilating
hyperventilation leads to low CO2 ad respiratory alkalosis
alkalosis promotes albumin binding to calcium in the blood and therefore causes reduces free Ca
Sx: tingling or numbness in hands and feet and around the mouth, funny turns
particular autoantibody associations with autoimmune encephalitis and paraneoplastic conditions
Anti-Hu: Small cell lung cancer
NMDA receptor antibodies: Ovarian teratoma
Anti-Yo: breast and ovarian tumours
management of paracetamol overdose
if injested <1hr ago - activated charcoal
if injested <4hrs ago- wait til 4hrs to take blood sample
if dose >150mg/kg- start N-acetylcysteine
if staggered dose takene- start N- acetylecystein immediately
if injested >24hrs ago - start NAC immediately
calculation of paracetamol treatment level done using the NOMOGRAM
- blood paracetamol level vs time after injestion. If above line then commence Rx
pathophysiology of paracetamol OD and antidote
Paracetamol is metabolised by CyP450 into NAPQI which is toxic
glutothione binds to NAPQI into a non toxic conjugate
in paracetamol OD the gutathione stores become depleated so you get toxic build up of NAPQI which is hepato and nephrotoxic
NAC provides cystine for glutathione synthesis to help remove toxic build up
which is the preferred SSRI in breastfeeding women
paroxetine
contraindications oto Ach inhibitors in dementia
pre-existing QT prolongation
schneiders first rank symptoms
auditory hallucinations:
hearing thoughts spoken aloud
hearing voices referring to himself / herself, made in the third person
auditory hallucinations in the form of a commentary
thought withdrawal, insertion and interruption
thought broadcasting
somatic hallucinations
delusional perception
feelings or actions experienced as made or influenced by external agents
definition of learning disability
significant or resuced ability to understand new or complex information or skills
reduce ability to cope independently
present from before adulthood with persistent effect
tools used to help diagnose LD
weshcler adult intellegence scale to determine IQ
Adaptive/Social functioning established via clinical interview
and ABAS II (Adaptive Behaviour Assessment System)
• Presence in childhood established using clinical interview and
school reports
values for mild moderate and severe LD in terms of IQ
mild 50-69
moderate 35-49
severe 20-34
profound <20
common causes of LD
most common is genetic
hypoxia
infection
genetic diseases with LD
Downs syndrome
fragile X
prader will/ angelmans
lesch nyan syndrome
congenital hypothyroidism
phenylketouria
diGeorge
what physical illnesses are common in people with LD
epilepsy
obestiy, DM, HPTN- due to poorer lifestyles
hearing impairment
what psychiatric conditions are common in people with LD
autism
schizophrenia
mood disorders
vulnerability factors in people with LD
rejections/ neglect/ abuse
poorer coping stratergies
sexual/ emotional vulnerability
low self esteem
bereavement/ adjustment issues
what might challenging behaviour be as result of in someone with LD
physical problems- eg. pain, discomfort, dererium
psychological- eg. anxiety, depression, psychosis, dementia
social- eg. change in routine, carers, bereavement, ABUSE!!!
principles of management of someone with LD
BIO- regular physical health checks at GP
treat any co-morbidities
PSYCHO- counseling, support groups, CBT, behavioural therapy, family therapy
SOCIAL- RISK assessment especially abuse, educational support, support with life skills etc..
