Selected Notes psych Flashcards
What is an illusion
Misenterpretation of an external stimulus
What is a hallucination
Perception without an external stimulus
What is a pseudo-hallucination?
Hallucination where the patient is aware it’s not real
What is an overvalued idea?
Solitary, abnormal belief that is not delusional or obsessional but preoccupying to the extent of dominating the persons life
What is a delusion?
Fixed, false belief maintained despite contrary evidence
What is delusional perception?
A true perception to which a patient attributes a false meaning.<br></br>E.g. traffic lights turning red means aliens are coming
What is concrete thinking?
Literal thinking focused on the physical world
What is meant by loosening of association?
AKA derailment, knight’s move thinking<br></br>No connection between topics
What is cirumstiantiality when describing thought patterns
Adds in irrelevent details but eventually returns to topic
What is meant by tangential thoughts?
Digress from subjecy with unrelated thoughts
What is thought blocking?
Sudden cessation of thought
What is meant by flight of ideas?
Pressured speech with shifts in topic with only a loose connection between ideas
What is perserveration?
Repitition of specific response despite removal of stimulus<br></br>
What are neologisms?
Made up words, unintelligible
What is meant by word salad?
Random string of words with no relation
What is meant by confabulation?
Generation of a fabricated memory without the intention of deceiving someone else
What is somatic passivity?
Experiene of one’s body or bodily sensations being controlled or influencfed by an external force
What is meant by pressure of speech?
Person speaks rapidly and continuously, often without pauses
What is anhedonia?
Inability to enjoy things/experience pleasure
What is incongruity of affect?
Mismatch between a person’s emotional expression and content of thoughts of speech
What is meant by blunting of affect?
Reduction in intensity and range of emotional expression<br></br>-Limited facial expressions, monotone speech etc
What is meant by the belle indifference?
Patient shows indifference/a lack of concern toward their symptoms depsite severity
What is meant by depersonalisation?
Detatched from own thoughts, feeling or body
What is thought alienation?<br></br>
Group of symptoms where patients feel thoughts are not their own. Includes:<br></br>1. Thought insertion<br></br>2. Thought withdrawal<br></br>3. Though broadcasting
Define thought insertion
Belief that thoughts are being placfed into one’s mind by an external source
What is thought withdrawal?
Belief that thoughts are being removed from one’s mind
What is thought broadcasting?
Belief that one’s thoughts are being broadcasted or shared with others
What is meant by thought echo?
Auditory hallucinations of their own thoughts being spoken aloud shortly after thinking them
What is akathisia?
Movement disorer characterised by intense restlessness and inability to stay still.<br></br>Side effect of antipsychotics
Define catatonia
Psychomotor disorder that can affect a person’s ability to move normally
What is stupor?
A symptom of catatonia in which the patient is unresponsive and unable to move, speak or react to external stimuli
What is psychomotor retardation?
Noticeable slowing down of thought processes and physical movements
What is flight of ideas?
Rapid and continuous speech with frequent shifts in topic with only a loose connection between ideas
What is a formal thought disorder?
Disruption in the organisation and expression of thought rather than the content
Define derealisation
Dissociative symptom where a person feels detached from their surroundings
What is a mannerism in psychiatry?
Habitual, often repetitive movement or gesture that appears to have some significance but may be out of context or exaggerated
What is stereotyped behaviour psychiatry?
Repetitive non functional motor movements, vocalisations or behaviours<br></br>-Often seen un individuals with developmental disorders like ASD
Define obsessions
Intrusive, unwnted thought, image or urge that repeatedly enters a person’s mind causing significant anxiety or distress
Define compulsion
Repetitive behaviour or mental act that a patient feels compelled to perform in response to an obsession or according to specific rules
What is the criteria for sectioning under the MHA?
<ul><li>Must have a MENTAL disorder</li><li>Must be a risk to their health/safety or the safety of others</li><li>Must be a treatment(including nursing/social care0</li></ul>
What is the one physial illness a patient could be sectioned and treated for?
Anorexia nervosa->re-feeding is allowed
Who carries out a mental health act assessment?
<ul><li>>=2 doctors, 1 of whom must be section 12(2) approved</li><li>1 approved mental health professional(AMHP)</li></ul>
Can a patient be considered for sectioning under the mental health act if under the influence of drugs/alcohol?
No-under the influence excludes patients from detainment
What is section 2 of the MHA?
<ul><li>Compulsory detention for assessment</li></ul>
What is the citeria for detention under section 2 of the MHA?
<ul><li>Mental disorder AND risk to self/others</li></ul>
How long can you hold a patient for under Section 2 of the MHA?
Max 28 days
Is section 2 of the MHA renewable?
No
Which healthcare professionals are required to detain a patient under Section 2 of the MHA?
AMHP or NR+2 doctors(one S12 approved)
Section 3 of the MHA<br></br>What is it: {{c1::Compulsory detention for treatment}}<br></br>Criteria: {{c2::Mental disorder+risk to self/others+treatment available}}<br></br>Last for maximum: {{c2::6 months}}<br></br>Renewable yes/no: {{c2::Yes}}<br></br>Healthcare professionals required: {{c2::2 drs(one S12)++AMHP/NR+seen in last 24 hours}}<br></br><br></br>
Section 4 of the MHA<br></br>For: {{c1::admission for assessment in emergency}}<br></br>Last for max: {{c2::72 hours, then usually put on section 2}}<br></br>Healthcare professionals required: {{c3::Single doctor +AMHP/NR}}
What is section 5(2) of the MHA and how long does it last for?
<ul><li>Detainment of voluntary inpatient in hospital</li><li>Max 72 hours, only 1 dr needed</li></ul>
What is the difference between section 5(2) and 5(4) of the MHA?
<ul><li>Both detainment of voluntary inpatient in hospital</li><li>5(2) required dr, 5(4) requires registerend nurse and only lasts 6 hours</li></ul>
What is section 17 a of the MHA for?
<ul><li>Community treatment order-patient on section 3 can leave for treatment in the community</li></ul>
Who makes a section 17a of the MHA decision?
Responsible clinician and AMHP
When can a section 17a mof MHA be recalled and if recalled, how long can patients be held?
<ul><li>Recalled if non-compliant with treatment and missing appointments</li><li>If recalled, can be held for up to 72 hours for assessment</li></ul>
What is section 135 of the MHA for?
<ul><li>Police can enter proerpty to escort someone to a Place of Safety(police station or A&e)</li></ul>
What is section 136 of the MHA for?
<ul><li>Can take someone from ma public place to a Place of Safety</li></ul>
What is section 131 of the MHA?
<ul><li>Informal admission-voluntary</li></ul>
What is the criteria for a section 131 admission?
<ul><li>Must have capacity</li><li>Must consent to admission</li><li>Must not resist admissions</li></ul>
What are the key principles of the Mental capacity act?
<ol><li>Assumed to have capacity unless proven otherwise</li><li>Steps should be taken to help someone have capacity</li><li>Unwise decisions doesn'[t mean someone lacks capacity</li><li>Any decisions made under the MCA must be in the patient's best interests</li><li>Any decisions made must be the least restrictive to a patient's rights/freedom</li></ol>
How is mental capacity assessed?
<ol><li>Impairment of or isturbance of functioning of mind/;brain?</li><li>Are they unable to:</li></ol>
<ul><li>Understand relevant information</li><li>Retain relevant information</li><li>Weight up and reach a decision</li><li>Communicate that decison</li></ul>
<div><ol><li>How urgent is the clinical decision?</li><li>Do they have LPA, advanced directive/statement</li><li>Should a best interest meeting be held</li></ol></div>
What is a Deprivation of Liberty Safeguard(DoLS) and when is it used?
Used when necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment or care to keep them safe from harm<br></br><ul><li>Common in acute medical/geriatric wards</li></ul>
What criteria must be met before considering DoLS for a patient
<ul><li>>18yrs</li><li>Patient in hospital/care home with a mental disorder</li><li>Considered separately for detention under a MHA</li><li>Lacks capacity</li></ul>
Name some uses for antidepressants besides depression
<ul><li>AQnxiety</li><li>OCD</li><li>PTSD</li><li>Eating disorders</li><li>Menopause</li><li>Neuropathic pain</li><li>Fibro</li><li>Smoking cessation</li><li>Sleep</li><li>Parkinson's</li><li>Nocturnal enuresis</li></ul>
What does SSRI stand for?
Seelctive serotonin reuptake inhibitors
What is the MOA of SSRI’s?
Inhibit serotonin reuptake to increase availabilty and improve mood regulation
What conditions are SRIS’s typically used to treat?
1st line for:<br></br><ul><li>Depression</li><li>GAD</li><li>OCD</li><li>PTSD</li><li>Panic disorder and phobias</li></ul>
Give some exampples of SSRIS
<ul><li>Sertraline</li><li>Fluoxetine</li><li>Citalopram</li><li>Paroxetine</li></ul>
Which SSRI is mostly only used for PTSD?
Paroxetine
Name some side effects of SSRIs
<ul><li>GI upset</li><li>Anxiety</li><li>Insomnia</li><li>Weight gain</li><li>Palpitations</li><li>HYPOnatraemia</li><li>QT prolongation(citalopram)</li><li>GI bleed(anti-platelet affect)</li></ul>
What is a key side effect of citaloparm?
QT prolongation
What is the most important mthing to wathc out for in patients on SSRI’s?
Serotonin syndrome
What should you be cautious of when prescribing SSRIs?
<ul><li>Shouldn't be used in mania</li><li>Fine for patients with IHD</li><li>In aptients aged 18-25: increased risk of suicide->follow up after 1 week</li></ul>
What do SNRI’s stand for?
Serotonin and noradrenaline reuptake inhibitors
Describe the MOA of SNRI?
<ul><li>Increase serotonin and noradrenaline levels, improve mood and reduce anxiety</li></ul>
When are SNRI’s commonly used?
2nd line after truing SSRIs for depression<br></br>Also used for GAD and panic disorder
Name some examples of SNRI’s
<ul><li>Duloxetine</li><li>Venlafaxine</li></ul>
Name some side effects of SNRI’s
<ul><li>Nausea</li><li>Insomnia</li><li>Agitation</li><li>Tachycardia</li></ul>
What should you be cautious about when prescribing SNRI’s?
CI in patints with a history of heart disease and hypertension
Descirbe the MOA of TCA’s
<ul><li>Block reuptake of serotonin and noradrenaline(anti-muscarinic)</li></ul>
When might TCA’s be used as a treatment?
Another 2nd line choice ofr depression/anxiety
Give some examples of TCAs
<ul><li>Amitryptaline</li><li>Clomipramine</li><li>Imipramine</li></ul>
What are the side effects of TCA’s?
Anti-cholinergic<br></br>Can’t see, pee, shit or spit<br></br><ul><li>Urinary retention</li><li>Blurred vision</li><li>Constipation</li><li>Dry mouth</li><li>Dizziness</li></ul><div><br></br></div><div>TCA TOXICITY*****</div>
When are TCA’s contraindicated?
Patients with heart disease, diabetes, urinary retention, long QT syndrome, liver damage, CP450 medications
When should TCA’s be prescirbed with caution?
<ul><li>In the elderly-risk of falls</li></ul>
What are MAO-I’s and what is their mechanism of action?
Monoamine Oxidase Inhibitors<br></br><ul><li>Inhibit monoamines which are responsible for metabolism of serotoning and noradrenaline in the presynaptic cleft-> increae serotonin and noradrenaline</li></ul>
When are MAO-Is used?
Sometimes sued to treat depression-not first line
Give some examples of MAO-I’s?
Moclobemide<br></br>Phenelzine
Name some side effects of MAO-I’s?
<ul><li>Hypertensive reaction with tyramine-containing foods</li></ul>
<div>Marmite, cheese, salami etc</div>
When are MAO-Is contraindicated?
<ul><li>Cerebrovascular disease</li><li>Mania in bipolar</li><li>Phaeochromocytoma</li><li>CVR disease</li></ul>
What drug class does mitrazapine belong to?
Noradrenergic and specific seretonergic antidepressant(NaSSA’s)<br></br><br></br><ul><li>Modulate serotonin and nordrenaline levels in the brain</li></ul>
What are the indications for using mirtazapine as a treatment?
2nd line for depression<br></br>Especially helpful in patients with sleep and low weight problems
Name some side effects of mirtazapine
<ul><li>Sedation</li><li>Increased appetite</li><li>Weight gain</li><li>Constipation/diarrhoea</li></ul>
What are antipsychotics used to treat?
<ul><li>Bipolar</li><li>Depression</li><li>Delirium</li><li>Personality disorders</li><li>Eating disorders</li><li>Huntington's</li><li>Tic disorders</li><li>Intractable hiccups</li><li>Nausea and hyperemesis</li></ul>
How do typical/1st gen antipsychotics work?
Antagonists to D2 receptors on cholinergic, adrenergic and histaminergic receptors
Give some examples of 1st gen/typical antipsychotics
<ul><li>Haloperidol</li><li>Chlorpromazine</li><li>Flupentixol</li></ul>
What kind of symptoms to typical/1st gen antipsychotics cause?
Extra-pyramidal
Side effects of 1st gen/typical antipsychotics:<br></br>Dopamine 2 receptor blockade:<br></br><ol><li>{{c1::Acute dystonia}}->spasms/involuntary movements</li><li>{{c2::Akathisia->}}restlessness and inability to sit still</li><li>{{c3::Parkinsonism}}->Tremors, rigidity, bradykinesia</li><li>{{c4::Tardive dyskinesia}}->involuntary,repetitive movements particulary of face lip smackin etc</li></ol>
What is acute dystonia?
Involuntary muscle contractions/spasms
What is tardive dyskinesia?
Involuntary repetitive movements, particulary of face<br></br>Lip smacking, tongue movements etc
What is a side effect of antipsychotics with regards to the histamine 1 receptor blockade?
Sedation->drowsiness/sleepiness
What is a side effect of antipsychotics with regards to the alpha 1-adrenergic receptor blockade?
Orthostatic hypotension
What is a side effect of antipsychotics with regards to the muscarinic receptor blockade?
Anticholinergic effect:<br></br>Can’t pee, see,shit or spit<br></br><ul><li>Dry mouth</li><li>Constipation</li><li>Blurre vision</li><li>Urinary retention</li></ul>
What is 1st line for psychosis?
2nd gen/atypical antipsychotics
Why are 2nd gen antipsychotics now preferred to 1st gen?
Fewer extrapyramidal side effects
What is a disadvantage of using 2nd gen antipsychotics compared to 1st gen
Increased metabolic side effects
How do 2nd gen/atypical antipsychotics work?
D2, D3, D5 and HT2A antagonists
Give some examples of 2nd gen/atypical antipsychotics
<ul><li>Risperidone</li><li>Quetiapine</li><li>Olanzapine</li><li>Aripiprazole</li><li>Clozapine</li></ul>
What are some of the metabolic side effects of 2nd gen/atypical antipsychotics?
<ul><li>Weight gain</li><li>Impaired glucose metabolism/diabetes</li><li>Increase levels of lipids</li><li>Increased levels of prolactin</li></ul>
What are some general side effects of 2nd generation/atypical antipsychotics?
<ul><li>Seizures</li><li>QT prolongation</li><li>Increase VTE and stroke risk in elderly</li></ul>
What monitoring should be done in patients on 2nd gen/atypical antispychotics?
<ul><li>Weight</li><li>Blood glucose</li><li>HbA1c</li><li>Lipids</li><li>BP</li><li>ECG</li></ul>
When is clozapine used as a treatment?
<ul><li>Treatment resistant schizophrenia once 2 others have failed-treats both positive and negative symptoms</li></ul>
What are the side effects of clozapine?
AGRANULOCYTOSIS<br></br><ul><li>Neutropenia</li><li>Decreased seizure threshold</li><li>Myocarditis</li><li>Slurred speech</li><li>Constipation</li></ul>
What monitoring should be done for patients on clozapine?
<ul><li>Weekly FBC looking at WCC for first 18 weeks, then fortnightly</li><li>Bloods</li><li>Lipids</li><li>Weight</li><li>Fasting blood glucose</li></ul>
Name some common mood stabilisers
<ul><li>Lithium</li><li>Sodium valproate</li><li>Carbamazepine</li><li>Lamotrigine</li></ul>
What is lithium used to treat?
<ul><li>Bipolar disorder and mania</li><li>Depression</li><li>Aggression/self harm</li></ul>
When is lithium contraindicated?
<ul><li>Addison's disease</li><li>Arrhythmias</li><li>Brugada</li><li>Hypothryoidism</li></ul>
Side effects of lithium:<br></br><ul><li>L-{{c1::leukocytosis}}</li><li>I-{{c2::Insipidus(diabetes)}}</li><li>T{{c3::-tremor(fine)}}</li><li>H-{{c4::hypothryoidism}}</li><li>I-{{c5::Increased weight}}</li><li>M-{{c6::Metallic taste}}</li></ul>
What should be given to women of childearing age who are on lithium and why?
<ul><li>Contraception</li><li>Causes cardiac malformations in the 1st trimester</li></ul>
Monitoring for patients on lithium<br></br><br></br>At the start:<br></br><ol><li>{{c1::U&E’s}}</li><li>{{c1::ECG}}</li><li>{{c1::TFT’s}}</li><li>{{c1::BMI}}</li><li>{{c1::FBC}}</li></ol><div>Throughout:</div><div><ol><li>{{c2::}}Electroytes</li><li>{{c2::eGFR}}</li><li>{{c2::TFT’s}}</li><li>{{c2::BMI}}</li></ol></div>
Name some side effects of sodium valproate
<ul><li>Nausea</li><li>Gastric irritation</li><li>Diarrhoea</li><li>Weight gain</li></ul>
What are carbamazepine and sodium valproate used for in psychiatry?
Mood stabilisers:<br></br><ul><li>Both used for bipolar disorder prophylaxis</li></ul>
What is lamotrigine used for in psychiatry?
Mood stabiliser<br></br><ul><li>Useful in preventing depressive episodes</li></ul>
Name some side effects of lamotrigine
<ul><li>Steven Johnson syndrome</li><li>Dizziness</li><li>Rashes</li></ul>
What is important to remember about prescribing mood stabilisers to women of child bearing age?
Teratogenic
<b>Lithium toxicity:</b><br></br>Therapeutic dose symptoms: {{c1::fine tremor, dry mouth, GI disturbance, Increased thirst and urination}}<br></br><br></br>Toxicity symptoms{{c2::: Coarse tremor, CNS dysfunction(seizures, impaired co-ordination, dysarthria), arrhythmias, visual disturbance}}<br></br><br></br>Investigations: <br></br><ul><li>For diagnosis:{{c3::Serum lithium levels}}</li><li>For assessment: {{c4::electrolyes, LFT’s U&Es, ECG}}</li></ul><div>Treatment:</div><div><ul><li>{{c5::</li><li>Supportive</li><li>Maintain electrolytes, monitor renal function, IV fluids</li>}}<br></br></ul></div>
Describe some symptoms of TCA toxicity
<ul><li>Drowsiness</li><li>Confusion</li><li>Arrhythmia</li><li>Seizures</li><li>Vomiting</li><li>Headache</li><li>Flushing</li><li>Dilated pupils</li></ul>
What investigations should be done to diagnose and assess TCA toxicity?
<ul><li>FBC</li><li>U&E</li><li>CRP</li><li>LFT'S</li><li>VBG</li><li>ECG-QT prolongation</li></ul>
How is TCA toxicity treated
<ul><li>Generally supportive care and management</li><li>Consider activated charcoal withint 2-4 hours of OD and intensive care review if severe</li></ul>
<br></br>
What is neuroloeptic malignant syndrome?
<ul><li>Rare, life threatening reaction to antipsychotics</li></ul>
When does neuroleptic malignant condition occur?
After the introduction of or increase in neuroleptic medications (antipsychotics)
How do patients with neuroleptic malignany syndrome present?
<ul><li>Hyperthermia</li><li>Altered mental state</li><li>'Lead pipe rigidity' </li><li>Autonomic dysregulation</li></ul>
Name some differentials for neuroleptic malignant syndrome
<ul><li>Malignant hyperthermia</li><li>Serotonin syndrome</li></ul>
What are some investigations to investigate neuroleptic malignant syndrome?
<ul><li>Creatine kinase!</li><li>FBC</li><li>Renal and liver function</li></ul>
What is the treatment for neuroleptic malignant syndrome?
<ul><li>Stop causative agent</li><li>Cooling blankets and IV fluids to prevent renal failure and hyperthermia</li><li>Benzodiazepines for muscle rigidity</li><li>Dantrolene in severe cases</li><li>Intensive monitoring</li></ul>
What is serotonin syndrome?
<ul><li>Life threatening emergency characterised by an increase in serotonergic activity in the CNS</li></ul>
When does serotonin syndrome occur?
Typically first few months after starting an SSRI/increasing the dose<br></br><ul><li>Can also happen with SNRI’s, MAO-I’s, TCA’s, MDMA/cocaine</li></ul>
Describe the presentation of a patient with serotonin syndrome
<ul><li>Hyperthermia</li><li>Altered mental state</li><li>Neuromuscular hyperactivity-> tremors, clonus, hyperreflexia</li><li>NOT rigidity</li></ul>
Name some differentials for serotonin syndrome
<ul><li>Neuroleptic malignant syndrome</li><li>Malignant hyperthermia</li><li>Anti-cholinergic toxicity->decreased bowel sounds, urinary retention</li></ul>
How can serotonin syndrome and neuroleptic malignant syndrome be differentiated?
<ul><li>Neuroleptic malignant syndrome: slower onset, longer duration</li></ul>
How is serotonin syndrome diagnosed?
<ul><li>Mostly based on clinical exam and history</li><li>Bloods to monitor organ function</li></ul>
How is serotonin syndrome managed?
<ul><li>Stop causative agent</li><li>Supportive care and symptom management</li><li>In severe cases: antidotes like cypropheptadine</li></ul>
What are the features of addiction?
<ul><li>Tolerance</li><li>Withdrawal</li><li>Persistent desire/unsuccessful attempts to stop</li><li>Substance taken in large amounts/used for longer periods then intended</li><li>Vocational/social/recreational activities given up or reduced because of substance us</li><li>More time spent seeking/recovering from meffects of substance</li><li>Repeated use despite awareness of damage from substance</li></ul>
Which pathway is addiction medicated by?
Dopamine reward pathway
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Descirbe the general management of addiction
<ul><li>Maintainence vs abstinence</li><li>Treat co-morbidities(mental and physical)</li><li>Psychological interventions(CBT, motivational interviewing, AA)</li><li>Pharmacological intervention(manage detox, maintainence etc)</li><li>Social intervention(work, housing, family)</li></ul>
Descirbe the symptoms of acute alcohol intoxication
<ul><li>Ataxia</li><li>Nausea and vomiting</li><li>Decreased GCS</li><li>Respiraotyr depression</li><li>Impaired judgement</li><li>Anterograde amnesia</li><li>Dysarthria</li></ul>
When does alcohol withdrawal typically occur?
12 hours after the last drink
What scoring system is used to monitor signs of alcohol withdrawal and guide treatment?
CIWA score<br></br>Clinical institute withdrawal assessment
<b>Symptoms of alcohol withdrawal:</b><br></br><ul><li>>6 hours: {{c1::tremor, nausea, sweating, vomiting, anxiety, insomnia, tachycardia, hypertension, pyrexia}}</li><li>7-48 hours: {{c2::Seizures, risk of status epilepticus}}</li><li>48-72 hours: {{c3::Tremor, hallucintations, delusions, confusion, agitation}}</li></ul>
How many hours after the last drink is a patient going through alcohol withdrawal most at risk of seizures or status epilepticus?
7-48 hours
Descirbe the pharmacological management of alcohol withdrawal
<ul><li>Short acting benzodiazepines</li></ul>
<div>Chlordiazepoxide reducing regine (20-40mg qds reducing to 0 over 1 week)</div>
<div><br></br></div>
<div><ul><li>Pabrinex-prevent Wernicke-Korsakoff's syndrome</li></ul></div>
<div><br></br></div>
<div><ul><li>Oxazepam if evidence of liver injury</li></ul></div>
Describe the supportive management of alcohol withdrawal
<ul><li>Fluids</li><li>Anti-emetics</li><li>Referral to local drug and alcohol liasion teams</li></ul>
What is delirium tremens?
Life threatening emergency characterised by extreme autonomic hyperactivity and neuropsychiatric symptoms
How long after alcohol cessation is delirium tremens most likely to set in?
About 72 hours
What are the triggers for developing delirium tremens
<ul><li>Cessation of alcohol</li><li>Cna be precipitated by infeciton, trauma or illness</li></ul>
Describe the symptoms of delirium tremens
<ul><li>Confusion and disorientation</li><li>Hallucinations (visual or tactile, formication)</li><li>Autonomic hyperactivity-> sweating, hypertension</li><li>Rarely seizures</li></ul>
When do symptoms of delirium tremens typically peak?
<ul><li>Between 4th and 5th day post withdrawal</li></ul>
Give some differentials for delirium tremens
<ul><li>Alcohol withdrawal(no hallucinations)</li><li>Wernicke-korsakoff(no autonomic instability)</li><li>Encephalitis/meningitis(no focal neurological signs)</li></ul>
Describe the management of delirium tremens
<ul><li>1st line: lorazepam</li><li>If symptoms persist: parenteral lorazepam or haloperidol</li><li>Maintainence therapy of alcohol withdrawal</li></ul>
What is Wernicke’s encephalopathy?
<ul><li>Acute neurological syndrome from a thiamina(B1) deficiency</li></ul>
Name some causes of Wernicke’s encephalopathy
<ul><li>Most common: chornic alcohol abuse</li><li>Malabsorption, eating disorders</li></ul>
What are the 3 core symptoms of Wernicke’s encephalopathy?
<ul><li>Confusion</li><li>Ataxia</li><li>Ophthalmoplegia/nystagmus</li></ul>
<div>Don;t need all 3 to make a diagnosis</div>
How is Wernicke’s encephalopathy investigated?
<ul><li>Thiamine level testing</li><li>Bloods-FBC's, U&E's, liver and bone profile, magensium, clotting</li><li>Neuroimaging->MRI</li></ul>
How is Wernicke’s encephalopathy managed?
<ul><li>Treat underlying cause</li><li>Thiamine supplementation->pabrinex</li></ul>
What is Korsakoff’s syndrome?
<ul><li>Chronic memory disorder that arises as a late complication og untreated Wernicke's</li></ul>
What is the main complication of Wernicke’s encephalopathy?
<ul><li>Korsakoff's syndrome(becomes permanent)</li><li>Also coma, death</li></ul>
What is the aetiology of Korsakoff’s syndrome?
<ul><li>Degeneration of mamillary bodies(part of circuit of papez involved in memory formation) due to thiamine deficiency</li></ul>
What are the symptoms of a patient with Korsakoff’s syndrome?
<ul><li>Profoound anterograde amnesia</li><li>Limited retrograde amnesia</li><li>Confabulation(fabricate memories to mask deficit)</li></ul>
How is Korsakoff’s syndrome treated?
<ul><li>Ongoing thiamine supplementation</li><li>Cognitive rehabilitation</li><li>Treat underlying cause(like alcoholism)</li></ul>
What are some symptoms of opiate intoxication?
<ul><li>Drowsiness</li><li>Confusion</li><li>Constricted pupils</li><li>Bradypnoea</li><li>Bradycardia</li></ul>
How many hours after the last dose might opiate withdrawal symptoms begin, and when does it peak?
<ul><li>Can begin as early as 6 hours after last dose</li><li>Symptoms peak at 36-72 hours</li></ul>
Is opiate withdrawal typically life threatening?
No
Describe the symptoms of opiate withdrawal
<ul><li>Agitation</li><li>Chills</li><li>Cramps</li><li>Sweating</li><li>Increased salivation</li><li>Insomnia</li><li>GI disturbance</li><li>Dilated pupils</li><li>Piloerection</li><li>Tachycardia and hypertension</li></ul>
How is opiate withdrawal managed acutely?
<ul><li>Methadone(can cause prolonged QT syndrome)</li><li>Lofexedine(alpha 2 receptor agonist)</li><li>Loperamide(for diarrhoea)</li><li>Anti-emetics(nausea)</li><li>Benzodiazepines(only for agitation, should be avoided)</li></ul>
What is used in opiate detox programmes?
<ul><li>Methadone and bupernorphine</li></ul>
