Psychiatry Passmed 1 Flashcards
What is acute stress disorder? How does it present?
an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc)
(PTSD occurs after 4 weeks)
Features include:
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
How can acute stress disorder be managed?
trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines
sometimes used for acute symptoms e.g. agitation, sleep disturbance
should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation
What is the mechanism behind alcohol withdrawal?
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal leads to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
How may alcohol withdrawal present?
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
How can alcohol withdrawal be managed?
patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until stabilised
first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam
Lorazepam may be preferable in patients with hepatic failure
carbamazepine also effective in treatment of alcohol withdrawal
Diagnosis of anorexia nervosa is now based on the DSM 5 criteria. What does this include?
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
What is the recommended management for children with anorexia nervosa?
NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. The second-line treatment is cognitive behavioural therapy.
What signs may be seen in a patient with anorexia nervosa?
reduced body mass index
bradycardia, hypotension
enlarged salivary glands
lanugo hair
failure to develop secondary sexual characteristics
yellow tinge to the skin (hypercarotinaemia)
What physiological abnormalities may be seen in a patient with anorexia nervosa?
hypokalaemia
low FSH, LH, oestrogens and testosterone
low T3
raised cortisol and growth hormone
hypercholesterolaemia
hypercarotinaemia
impaired glucose tolerance
Easy way to remember changes seen in anorexia?
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Give two examples of typical antipsychotics
Haloperidol
Chlorpromazine
What is the mechanism of action of typical anti psychotics?
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
Give three examples of atypical antipsychotics
Clozapine
Risperidone
Olanzapine
What is the mechanism of action of atypical antipsychotics?
Act on a variety of receptors (D2, D3, D4, 5-HT)
What Extrapyramidal side-effects (EPSEs) may result from antipsychotic use?
Parkinsonism
acute dystonia
- sustained muscle contraction (e.g. torticollis, oculogyric crisis)
- may be managed with procyclidine
akathisia (severe restlessness)
tardive dyskinesia (involuntary movements of face and jaw, see image)
What is tardive dyskinesia?
late onset of choreoathetoid movements (chorea = irregular contractions and athetosis = twisting and writhing)
abnormal, involuntary, may be irreversible
most common is chewing and pouting of jaw
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
Increased risk of stroke and VTE
Atypical antipsychotics should now be used first-line in patients with schizophrenia. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.
What adverse effects may they present with?
weight gain
hyperlipidaemia
diabetes mellitus
hyperprolactinaemia
Qtc prolongation
clozapine is associated with agranulocytosis - monitor FBC if infection!!
What should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks?
Clozapine
What are the adverse effects of clozapine?
agranulocytosis, neutropaenia
reduced seizure threshold
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
constipation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment
When should the following be monitored in patients taking antipsychotics:
FBC, U&Es, LFTs ?
at the start of therapy
annually
clozapine requires much more frequent monitoring of FBC (initially weekly)
The monitoring requires for patients taking antipsychotic medication are extensive. What does the BNF recommend?
FBC, U&Es, LFTs
Fasting blood glucose, prolactin, lipids
Weight
Blood pressure
(baseline, frequently during dose titration)
ECG (baseline)
Cardiovascular risk assessment (annually)
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.
They therefore are used for a variety of purposes including:
sedation
hypnotic
anxiolytic
anticonvulsant
muscle relaxant
Why should benzos be monitored closely?
Risk of developing tolerance or dependence
Only recommended to be prescribed 2-4 weeks at a time
If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, which is very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug.
Features include:
AAIITTSS
anxiety, loss of appetite
insomnia, irritability
tremor, tinnitus
sweating, seizures
perceptual disturbances
What is the difference in mechanism of action of benzodiazepines and barbiturates?
GABAA drugs
benzodiazipines increase the frequency of chloride channels
barbiturates increase the duration of chloride channel opening
(BarbiDurates increase Duration & Frendodiazepines increase Frequency)
Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
What are the two types?
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression
What is mania/hypomania?
both terms = abnormally elevated mood or irritability
with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
hypomania describes decreased or increased function for 4 days or more
the key differentiation in MCQs is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
What is the mood stabiliser of choice in bipolar disorder?
Lithium
Valproate is an alternative
How can mania/ hypo mania be managed?
consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
How can depressive episodes in bipolar disorder be managed?
Talking therapies and fluoxetine
When should patients with bipolar disorder be referred from primary care?
if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
if there are features of mania or severe depression then an urgent referral to the CMHT should be made
What is Bulimia nervosa ?
a type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising
What examinations findings might you see in bulimia nervosa?
recurrent vomiting may lead to erosion of teeth and Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting
How can bulimia nervosa be managed?
bulimia-nervosa-focused guided self-help for adults
If contraindicated or ineffective after 4 weeks of treatment, NICE recommend individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
children should be offered bulimia-nervosa-focused family therapy
high-dose fluoxetine
What is Charles-Bonnet syndrome (CBS)?
persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness.
This is generally against a background of visual impairment (age related macular degeneration)
What are the risk factors for Charles Bonnet syndrome?
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
What is Cotard syndrome?
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
What is De Clerambault’s syndrome?
Also known as erotomania
a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
Factors suggesting diagnosis of depression over dementia?
short history, rapid onset
global memory loss (dementia characteristically causes recent memory loss)
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
What is classified as ‘less severe’ depression?
a PHQ-9 score of < 16
What is classified as ‘more severe’ depression?
a PHQ-9 score of ≥ 16
How should less severe depression be managed?
guided self-help
group / individual CBT
group / individual behavioural activation (BA)
group exercise, mindfulness and meditation
interpersonal psychotherapy (IPT)
SSRIs
counselling
short-term psychodynamic psychotherapy (STPP)