Psychiatry Flashcards
When to modify hx taking?
distressed, low cognition, no language, concerns about risk/safety, urgent issues, time, carer
What is phenomenolgy?
descriptive psychopathology (objectivity about abnormal states of mind); elicit, identify and interpret symptoms of psychiatric disorders; understand the mental experiences of the patient and try to be empathetic
5 Ps for helping with hx taking?
presenting problem, predisposing factors, precipitating factors, perpetuation factors and protective factors
Other questions to ask in hx other than the normal ones?
Mood, sleep, appetite, risks of harm to self or others
Questions to ask around drugs and alcohol?
what, injected?, which veins, what is meant by social drinking, what time start in morning, drink everyday
PMH questions?
med conditions, admissions, surgery, head injuries, deliberate self-harm, SEs from meds
FH questions?
mental health, suicides, drug/alcohol abuse, forensic encounters; if recent death and note reaction to this
Personal history (EE-OR)?
o Early life and development – pregnancy/birth complications, serious illnesses, bereavements, abuse (emotional, physical, sexual), childhood separation, describe childhood home environment, religion
o Educational history – school, academic achievements, friends/bullied?, school conduct/truancy
o Occupational history – job titles and duration, reasons for change (work satisfaction, relationships with colleagues, use longest job for indicator of normal before deterioration)
o Relationship history – duration, gender of partner, children, quality and abuse (communication, aggression, jealousy or infidelity), sex problems (menstruation, contraception, pregnancies)
Forensic hx?
arrests, imprisoned, juvenile crime, length of sentence, against person/property, prison experience
Premorbid personality questions?
how would you and friends describe you before; what do you enjoy; how do you cope
How common is mental health in the general population?
1 in 4
RFs?
inequalities in health (socioeconomic, refugees 5x more common), age, gender and sexual identity
Causes of RFs?
problems behind the illness, social determinants (poverty, isolation, migration unemployment, trauma, abuse, education, racism/discrimination, institutional care, homelessness)
Definition of primary prevention?
stop it in first place
Definition of secondary prevention?
intervene early when problem emerges
Definition of tertiary prevention?
manage ongoing problem and reduce its harm
Examples of primary prevention?
population wide campaigns, campaigns for at risk groups, screening questions to find at risk, physical exams, legislation, action to reduce harmful consequences
Mental state examination parts?
ABSolutely MAD PIC - appearance and behaviour, speech, mood and affect, disorders of thought content, perception, insight, cognition
Appearance and behaviour questions?
- General health and posture, tattoos, clothing, cuts, hygiene and tidiness
- Distinctive features
- Manner and report, hallucination response
- Motor activity high or low (tics, chorea, repeated movements)
- Antipsychotic side-effects (tremor, bradykinesia, akathisia [restlessness], tardive dyskinesia [rolling tongue/licking lips], dystonia [muscle spasm])
- Mannerisms
- Gait abnormalities
- Self-harm
Speech questions?
- Tone, rate and volume
- Look at PPS first lecture
- Circumstantiality
- Loosening of association – incoherent speech as lack of association of thoughts to speech (disorder of form of speech)
- Perseveration – inappropriate repetition
- Flight of ideas
- Pressure of speech – rapid and strays from topic
Mood and affect questions?
- Mood = self-explanatory (subjective view of mood from patient and objective is what you think)
- Affect = more to do with how mood is making the patient seem sometimes with reaction to certain cues (unreactive, labile, irritable etc)
Disorders of thought content questions?
• Negative thoughts
• Ruminations (preoccupations of the mind)
• Obsessions
• Depersonalisations (feel cut out from world) and derealisation (feel like world and people in it are lifeless and not real)
• Abnormal beliefs:
o Overvalued ideas
o Ideas of reference (thinking other people are talking about them but not at delusional intensity)
o Delusions – secondary can be explained by another morbid experience
• Concrete thinking – taking things literally
• Content (obsession, preoccupation, delusions), form (circumstantial, tangential, looseness of association) and stream (poverty, racing, perseverative, thought insertion/withdrawal/broadcast; disorders of continuity of thought or tempo)
• Think of main categories = disorders of tempo, continuity, possession (thought alienation and obsessions and compulsions)
• Disorder of memory – confabulation and dissociative amnesia (sudden from periods of trauma, lasts a few days)
• Disorder of emotion – anhedonia, apathy (lack of emotion), incongruity of affect (seen mood not related to actual emotion), blunting of affect, conversion (unconscious mechanism of symptom formation, in conversion hysteria, psych conflict into somatic symptom, motor or sensory), la belle indifference (lack of concern about their disability – not bothered about no legs)
Perception questions?
- Seen/heard anything others can’t hear (5 senses = auditory, visual, tactile [usually in drug abuse], gustatory, olfactory); changes in intensity, quality, spatial form and distortion of experience of time (differentiate normal from abnormal)
- Illusions – misinterpretations of normal things
- Hallucinations
- Pseudo-hallucinations – internal perceptions with preserved insight (like a voice in head saying not doing good)
Insight questions?
- How patient sees their own condition
- Identifies abnormal mental phenomena
- Willing to seek help
- Appreciates risk of non-compliance, impact of illness on others
Cognition questions?
• Ability of pt to perform tasks • Memory – of list of objects etc • Orientations – in time, place, person • Attention and conc – count backwards • Dyspraxia – draw pentagons • Receptive dysphasia – follow a command • Expressive dysphasia – name object • Frontal lobe functioning tests: o Approximation (height of landmark) o Abstract reasoning (next shape in sequence) o Verbal fluency o Proverb interpretation
Main 3 classification categories for psych?
LD, PD and mental illness
Hierarchal classification categories for DSM-IV-TR?
o Personality disorders
o Anxiety disorders (GAD, panic, OCD, PTSD and adjustment disorder)
o Mood disorders (bipolar, affective disorder and psychotic depression)
o Psychotic disorders (schizophrenia)
o Organic disorders (delirium, dementia, drug abuse)
Overview of risk assessment in psych?
• Assess risk of self-harm and harm to others
o How likely is event to happen
o How bad will it be
o Collaborate with the pt and review plan
o Use past behaviour as a guide for future risk
o Any new risks let someone know
Suicide risk assessment questions?
method, belief in lethality, plan to avoid discovery, note and planning for death after (bank acc etc), how do they feel (anger it didn’t succeed and will they do it again) now, protective factors, risk factors
Questions and things to note with harm to others?
o Document any acts of violence of intimidation towards others o Any isolation put in place o Compliance with meds o Life events o Stressful incidents recently o Change in meds
Self-neglect and accidental harm questions?
o Malnutrition o No healthcare o Bad living conditions o Falls that can be prevented (frailty) o Wandering o Overdose o Vulnerability to crime
Psychosis definition?
misperception of thoughts and perceptions by the patient
Psychosis examples?
o Schizophrenia o Schizoaffective disorder o Delusional disorder o Brief psychotic episodes o Psychotic depression o Bipolar affective disorder o Drug-induced psychoses
Definition of schizophrenia?
more permanent than episodes of relapse of mania/psychosis
When does schizophrenia usually begin?
Adolescence/early 20s
Negative, positive and cognitive symptom examples of schizophrenia?
positive (hallucinations and delusions), negative (poor motivations, low speech, low function, socially withdrawn, self-neglect, blunted affect [same emotions but how they express this is less]) and cognitive
1st rank symptoms of schizophrenia?
o 3rd person auditory hallucinations (people talking about you, running commentary)
o Thought echo (hear own thoughts out loud)
o Thought block
o Delusional perception (real perception exaggerated to something else or jumping to conclusions from an unrelated thing e.g. a jumper means that someone is watching me)
o Thought insertion/withdrawal (thoughts interfered with e.g. like in big brother); all of these known as thought alientation
o Passivity (actions, feelings or impulses controlled by someone/something else) or somatic passivity (body movements controlled by someone else)
o Primary delusions – something they strongly believe in (an idea etc); mood, perception or sudden idea
2nd rank symptoms of schizophrenia?
o Other symptoms that can be present in schizophrenia but also other disorders
o Catatonic behaviour
o 2nd person auditory hallucinations (talking to you e.g. telling you that you’re the messiah)
o -ve symptoms
o Other hallucinations
o Thought disorder
Diagnosis for schizophrenia?
first rank symptom/persistent delusion/at least 2+ secondary symptoms; present for 6 months (using DSM-IV-TPR); no drug intoxication, withdrawal, overt brain disease, prominent affective symptoms
2 types of delusions?
o Persecutory (out to harm the person) o Delusions of reference (paranoia people or news is talking about them)
Thought disorder examples?
o Loosening of associations
o Neologisms (new words or words used in special way – THINK OF SAM ABOUT TO DO SOMETHING DUMB)
o Concrete thinking (can’t deal with out of box thinking)
o Word salad (jumbled nonsense)
o Perseveration – keep persisting with a word/phrase and can’t help it
Subtypes of schizophrenia and what they consist of?
o Paranoid – delusions (persecution or grandeur) and hallucinations evident
o Catatonic – psychomotor disturbances, rigidity, posturing (strange posture), echolalia (LIKE IN ENGLISH LIT – copying speech), echopraxia (copying behaviours), waxy flexibility (limbs feel like wax – sustained abnormal position), logoclonia (repetition of last syllable of word), negativism (unreasonable resistance to movement and aversion), palilalia (repetition of word with increasing intensity), verbigeration (repetition of meaningless words/phrases)
o Hebephrenic – early onset and poor prognosis, irresponsible and unpredictable, disorganised/disordered, giggling and mannerisms, delusions and hallucinations
o Residual – negative and cognitive mainly and chronic
o Undifferentiated – negative
Main RFs for schizophrenia?
o Genetics and later age of parents
o Neurodevelopmental factors (winter births, obstetric complications, developmental delay, temporal lobe epilepsy, bad academia, smoking cannabis in adolescence, severe bullying/abuse)
o Life events and bad socio-economic factors
o Neurotransmitters – high dopamine/serotonin and low glutamate increase risk
Treatment and management of schizophrenia?
o Antipsychotics – atypical have fewer motor side effects than typical; lowest dose needed should be used; use clozapine if more than one anti-psychotic is ineffective
o Therapies – CBT, family therapy, art therapy and self-help forums and groups
o Social support – to maximise independence and get back working; always think of psychosocial factors (homelessness etc)
o Adjust diet, smoking
o If need to tranquilise then use benzodiazepine
Good prognostic factors for schizophrenia (FINDING PLANS)?
o Female o In relationship/s o No negative symptoms o aDheres to medications o Intelligence o No stress o Good premorbid personality o Paranoid subtype o Late onset o Acute onset o No substance misuse o Scan (CT head) normal
What is hypomania and S+Ss?
(4+ days) – elevated mood (euphoric, dysphoric, angry), increased energy, more talkative, poor conc, mild reckless, sociability, increased libido, increased confidence, decreased need to sleep, change in appetite
What is mania and S+Ss?
(more than 1 week) – extreme elation (uncontrollable), overactive, pressure of speech (can’t interrupt their flow but can in hypomania), impaired judgement, extreme risk taking/high libido, v grandiose ideas about self and strange (more normal in hypomania but still v self confident), social disinhibition, psychosis, mood congruent/incongruent
Types of bipolar affective disorder?
o Depressive o Manic (like schizophrenia) o Hypomanic (less severe and without psychosis – circumstantiality [take ages to get to point]) o Mixed (depressive and manic)
What is bipolar 1 disorder?
1+ episodes of manic/mixed episodes and 1+ major depressive episodes
What is bipolar 2 disorder?
recurrent major depressive and hypomania but not manic – easy to miss should treat with mood stabilisers not antidepressants
What is cyclothymic/persistent mood disorder?
not quite bipolar 2 but very close over 2 yearsish; more mild; mood swings and some periods of hypomania/depression; highs and lows for 6 months with only 2 months consecutive no symptoms
S+Ss of bipolar?
think of everything being high functioning and out of control mind and body-wise:
o High psychomotor
o Exaggerated optimism
o High self-esteem
o Low social inhibition (high libido, high spending, dangerous driving)
o High sensory awareness
o Rapid thinking and speech (fast and furious speech and thoughts)
o Manic symptoms can be 4 monthsish and depressive is longer
o Can be mixed with schizophrenia and the subtypes and ADHD or substance misuse
o Secondary delusions
RFs for developing bipolar?
o Genetics
o Small prefrontal and large amygdalas
o Childhood abuse
o Postpartum
Management and treatment of bipolar?
o Anti-manic drugs (also for prophylaxis) – lithium and valproate (like for epilepsy)
o Atypical anti-psychotics (also for prophylaxis) – orlanzapine, risperidone, aripiprazole, quetiapine
o Benzodiazepines for acute behavioural disturbance and lorazepam and antipsychotics for rapid tranquillisation
o Use antidepressants with anti-manics
o Electrocompulsive therapy (ECT) – stimulation to brain under anaesthesia
What is a personality disorder?
deeply engrained and long-lasting abnormal behaviour that can cause distress (similar to some mental illnesses but PDs not temporary and not treatable)
Cluster A PD?
Paranoid, schizoid, schizotypal
Cluster B PD?
Borderline/EUPD, histrionic, narcissistic, antisocial
Paranoid PD S+Ss?
cold sensitive, distrust and suspicious (friends and spouse), won’t confide, bears grudges, takes everything negatively, grandiose sense of personal rights; cold and calculating; meds not recommended
Schizoid S+Ss?
(sad and withdrawn): socially withdrawn, low emotional range, low pleasure, won’t confide, not bothered about praise or criticism, insensitive to social norms; daydream; no meds
Schizotypal S+Ss?
(hallucinations and inappropriate dot joining): struggles socially and interpersonally, ideas of reference, magical thinking, unusual perceptions, tangential and circumstantial thinking, suspicious, socially anxious, eccentric; hallucinations 2 weeks before mood; schizophrenia symptoms with mood disorder; antipsychotics and SSRIs and lithium for bipolar types
Borderline S+Ss?
(both schizophrenic and bipolar): self-damaging impulsivity, unstable mood and intense interpersonal relationships/attachment issues, identity confusion, anhedonia (won’t feel pleasure in things meant to feel pleasure), recurrent suicidal/self-harm behaviour to relieve psychic pain, tries to avoid real life, transient paranoid ideation (feelings of grandeur and persecution and sometimes paranoia of others); emotional insensitivity and chronic feelings of emptiness; sometimes uncontrollable anger; most likely to have other co-morbidities like anxiety, depression, PTSD, substance misuse and past trauma
Self injury causes (prevalent) – feel something when numb, reduce anxiety, feel in control, express anger, keep away bad memories
Histrionic S+Ss?
(blonde, dumb valley girl): shallow and excessive emotions, attention-seeker, suggestable, immature, inappropriate sexual seductiveness, narcissism, grandiosity, exploitable actions
Narcissistic S+Ss?
grandiose, lack of empathy, need for praise
Antisocial PD S+Ss?
(like a young ADHD kid – most likely to be in secure psychiatric units): disregard for rights/safety of others, irresponsible, can’t maintain relationships, irritable, low threshold for frustration and aggression, no guilt, deceitful, impulsive, no personal safety, blames others
Cluster C PD?
avoidant, dependent, anankastic/OCD
Avoidant S+Ss?
feeling tense/anxious, socially inhibited, won’t join in unless know is liked by others, restricts lifestyle to keep physical security; antidepressants
Dependent S+Ss?
needs taken care of, fear of separation, too much advice to make decisions, won’t disagree in case argument, won’t express opinion first as low self-confidence, lengths to gain support from others, always thinking about being left alone; CBT
Anankastic/obsessive compulsive PD?
(perfectionist and stickler for the rules): excessive doubt, rigid and stubborn, must stick to rules, perfectionism, always must be productive and takes over life, must be socially norm, obsessional thoughts and impulses
Treatment for PDs?
some mood stabilisers for symptomatic but CBT and DBT (dialectical behavioural therapy) is usually more helpful; medium-term outcome = bad but long-term is better
Adjustment disorder characteristics and treatment?
lasts less than 6 months few weeks after change in life; symptoms (depression, anxiety, autonomic arousal); support (vent feelings, CBT, problem solving; some SSRI and SNRI)
Abnormal grief reaction S+Ss?
delayed onset of grief, prolonged and higher intensity; with difficult relationship with deceased, sudden death or constraints to grieving
Normal grief stages?
shock and disbelief, anger, guilt and self-blame, sadness and despair, acceptance
Examples of exceptional stress?
PTSD and acute stress reactions?
PTSD S+Ss and treatment?
over 1 month symptoms from weeks to months after event; autonomic system and hypothalamic-pituitary-adrenal axis and noradrenaline; symptoms = intrusive thoughts and reimagining, avoidance, detachment, high arousal and heightened senses; treatment = trauma-focussed CBT, EMDR (eye movement desensitisation reprogramming – asked to recall upsetting moments and then directed to do eye movements and exercises to reprogram how feel about event), antidepressants, PIES (proximity, immediacy, expectancy and simplicity)
Acute stress reaction S+Ss and treatment?
starts within minutes to hour and last less than 3 days; symptoms = dazed, confused, intense anxiety, autonomic arousal, intense sadness or depression and heightened senses; reorientate and brief CBT
Pathophysiology of anxiety disorders?
Low levels of GABA and remodelling of amygdala (heightened stimulation) and frontal cortex
What can worsen anxiety?
alcohol and benzodiazepines
Define panic disorder?
o Episodic severe panic attacks can happen whenever (last a few mins)
o >4 panic attacks in a >4 week period
S+Ss panic attack?
palpitations, tachycardia, choking feeling, chest pain, nausea, dizziness, paraesthesia, dry mouth, chills and hot flushes, derealisation and depersonalisation, fear of losing control, feeling of impending doom
Treatment for panic disorder?
SSRIs, CBT, tricyclics, NOT BENZODIAZEPINES
What is generalised anxiety disorder?
o Last 6 months or longer; generalised, persistent and excessive worry
GAD S+Ss?
subjective apprehension, high vigilance, restless, insomnia (difficulty falling asleep), motor tension, autonomic hyperactivity
GAD treatment and management?
CBT and SSRIs and benzodiazepines for no longer than 4 weeks; also SNRIs, buspirone and pregabalin; psychotherapy
3 elements of phobic disorder?
phobia, avoidance of anxiety situations and severe anxiety
Treatment for rare phobias?
Benzodiazepines
What is agoraphobia
fear and avoidance of places cannot escape from easily
What is an obsession?
thoughts, images, impulses, ruminations (continuous pondering) or doubts and infiltrate everything think about; unpleasant, irrational, intrusive, thought as own thoughts
What are compulsions?
repetitive and purposeful physical/mental behaviours in response to an obsession (neutralise discomfort), need to be differentiated from superstitions and rituals; patient realises behaviour is unreasonable
Examples of compulsions?
o Hand-washing o Counting and checking o Touching and rearranging o Hoarding o Arthimomania (counting) o Onamatomania (say a forbidden word) o Folie du pourquoi (asking questions to facts that don’t need to be asked)
OCD S+Ss?
concerned with contamination, concerned with harm (leaving gas on), obsessions without overt compulsive acts, hoarding; More than an hour per day of obsessions/compulsions; Avoidance of stimuli is common and sometimes resistance
RFs for OCD?
conditioning as a child by parents; defence from cruel and aggressive fantasies in mind; traumatic event where had a disease as a child (PANDAS – paediatric autoimmune neuropsychiatric disorders associated with streptococci)
What is body dysmorphic disorder/dysmorphophobia
(BDD) and S+Ss?
o Imagined defect in appearance
o Time consuming behaviours: mirror gazing, comparing features to others, excessive camouflaging of area, skin picking, seeking reassurance, surgery request
BDD treatment and management?
psychoeducation so understand their disorder; CBT with medication and patient told to try and avoid compulsion in CBT when exposed to it; SSRIs or clomipramine; sometimes psychosurgery and deep brain stimulation
S+Ss of anankastic PD?
obsessive-compulsive personality disorder; rigidity of thinking, perfectionism, preoccupation with the rules, excessive cleanliness and order, emotional coldness
Atypical antipsychotic examples?
o Amisulpride o Aripiprazole o Clozapine o Lurasidone o Olanzapine o Paliperidone o Quetiapine o Risperidone
Clozapine SEs?
side effect of agranulocytosis, seizures and weight gain; most effective; offered only when 2+ treatments tried, in treatment resistance
Olanzapine SEs?
weight gain
Risperidone SEs?
galactorrhoea SE; only one indicated in older people with dementia and behavioural disturbance (lower stroke risk and glycaemic loss of control)
General SEs of atypical antipsychotics?
Parkinsonism (e.g. rest tremor, postural tremor)
Akathisia (severe restlessness)
Acute dystonia (sustained muscle contractions – laryngeal, oculogyric crisis, buccolingual and scoliosis [basically mainly in top of body])
Tardive dyskinesia (involuntary movements of the tongue, lips, face, trunk, and extremities)
o Other side-effects
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin may result in galactorrhoea due to inhibition of the dopaminergic tuberoinfundibular pathway
impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
Physiology of antipsychotics?
Most antipsychotics work by blocking dopamine D2/3 receptors to reduce input it is thought; can be taken orally but some as depot injections like risperidone; low meso-cortical pathway and overactive mesolimbic (reward/pleasure centre) in psychosis
When are antipsychotics used?
For schizophrenia, psychoses, acute mania and sometimes violent or agitated behaviour with benzodiazepine; if have negative symptoms then can have neuroleptic dysphoria/neuroleptic malignant syndrome (tremor, muscle cramps, fever, autonomic instability, delirium, raised CK, give DA agonists bromocriptine) when give dopamine agonist; Low dose for tourette’s
Antipsychotic length taken?
Taper over 2-3 weeks; usually continue meds for 5 years to prevent relapse
Typical antipsychotic examples?
o Haloperidol o Trifluperazine o Chlorpromazine o Pericyazine o Levomepromazine o Flupentixol
Antimanic/mood stabilising drug examples?
Lithium, lamotrigine, valproic acid and carbamazepine
What is lithium used for?
acute mania, control aggression, schizoaffective disorder, prophylaxis in recurrent affective disorder, resistant depression
How does lithium work?
affects all systems associated with electrolytes, 5HT, dopamine, acetylcholine and noradrenaline
Checks done when on lithium?
thyroid and renal before and every 6 months checked and serum lithium as well
Lithium CIs?
avoided in renal, cardiac, thyroid and Addison’s; dehydration and diuretics = toxicity; also NSAIDs, CCBs and some antibiotics
When to stop lithium?
toxicity and OD stop it and fluid therapy (normal bad SEs incl tremor and muscle twitching)
What is lamotrigine for?
bipolar depression
Valproic acid and carbamazapine SEs?
nausea, drowsiness, gastric irritation, diarrhoea, dizziness
What to check when taking valproic acid and carbamazapine?
check bloods every 6 months as could be agranulocytosis
Give types of hypnotics and anxiolytics?
Benzodiazepines, zopiclone, zolpidem, quinazoliones; Some antidepressants (mirtazapine), antihistamines and some antipsychotics (clozapine) used as hypnotics; H1 antihistamines as anxiolytics
What are benzodiazepines for?
– flumazenil given (for muscle relaxants, anticonvulsants, insomnia, alcohol withdrawal)
Withdrawal S+Ss from benzos?
Resp depression, tremors, seizures, anxiety
Benzo SEs?
drowsiness, ataxia, amnesia, dependence, disinhibition
Benzo physiology?
GABA agonist
Benzo examples?
Midazolam
Diazepam – long-acting
Lorazepam – short-acting
Chlordiazepoxide – long-acting
What are zopiclone and zolpidem?
Hypnotics
What are zopiclone and zolpidem used for?
Sleep and sedatives
Example of a quinazolinone?
chloroqualone
What is a quinazolinone?
hypnotic
Examples of H1 antihistamines?
hydroxyzine, chlorpheniramine, diphenhydramine
What are H1 antihistamines used for?
anxiolytics for GAD
Examples of stimulants?
o Methylphenidate and atomoxetine
What are stimulants used for?
ADHD and narcolepsy
Stimulant SEs?
low appetite and weight loss, anxiety, agitation, insomnia
Types of antidementia drugs?
Cholinesterase inhibitors, glutamate receptor antagonist
Cholinesterase inhibitor examples?
donepezil, rivastigmine galantamine
Glutamate receptor antagonist example?
memantine
SEs from antidementia drugs?
GI disturbance, dizziness, drowsiness, cramps, incontinence, dyspnoea and syncope
What is serotonin discontinuation syndrome and what are the S+Ss?
stop taking them: increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
SEs from SSRIs?
gastro SEs mainly with bleeding (especially with aspirin) and hyponatraemia in older; sexual dysfunction, headaches, anorexia, nausea, indigestion, anxiety
Why shouldn’t you give SSRIs with triptans/MAOIs?
serotonin syndrome (neuromuscular abnormalities, altered mental state, autonomic dysfunction – use cyproheptadine)
Examples of SSRIs?
o Fluoxetine o Zimeldine o Citalopram o Sertraline o Paroxetine
Physiology of SNRIs?
block pre-synaptic alpha-2 receptors, increasing monoamine output
Examples of SNRIs?
o Mirtazapine and mianserin, venlafaxine and duolxetine
SEs and physiology of tricyclics?
dry mouth, tremor, tachycardia, constipation, fatigue and weight gain; anticholinergic effects, alpha-1 adrenergic antagonism, antihistaminergic
Examples of tricyclics?
o Imipramine
o Amitriptyline
o Dothiepin
o Lofepramine
What are norepinerphine reuptake inhibitors for and some examples?
(for ADHD):
o Atomoxetine
o Methylphenidate
reboxetine
Antidepressants physiology?
increase NA and 5-HT function; stress neurotoxic as causes glutamate release and affects neuronal neuroplasticity; depressed have more BDNF
MAO-A reversible inhibitor example?
Moclobemide
MAO-i examples?
phenelzine and tranylcypromine and iproniazid
MAOi physiology?
inhibit breakdown of serotonin by MAO-A
MAOi CIs?
don’t take with high tyramine foods (cheese, red wine) as can cause hypertension or headaches
Other non-category antidepressants?
agomelatine, trazadone, maprotiline, nefazodone; St John’s Wort (acts like MAO inhibitor but herbal)
When are antidepressants taken?
• Moderate or severe episode of depression; take at least 4 weeks to work; phobic disorder, panic disorder, PTSD, generalised anxiety, bulimia and OCD
What is ECT?
• ELECTROCONVULSIVE THERAPY (ECT) – modified cerebral seizure
What is ECT used for?
severe depressive illnesses, prolonged/severe mania, catatonia, moderate resistant depression; depressive and/or psychomotor retardation most likely to respond; when all other treatment options failed (for fast and short-term improvement when sitch is life threatening)
What is involved in the process of ECT?
= patient fasts for 4 hours then anaesthesia, muscle relaxant and preoxygenation then place electrodes then seizure for 20-60 seconds and EEG then monitor
ECT CIs?
raised ICP, stroke, MI and angina
ECT SEs?
mainly memory and cognition = orientation problems, new learning, retrograde amnesia, anaesthetic complications, dysrhythmias, confusion, headaches
What is transcranial magnetic stimulation?
prefrontal cortex stimulation using magnetic field; daily 30 min session or 2-4 weeks
When is transcranial magnetic stimulation used?
severe depression
When is deep brain stimulation used?
PD
What is deep brain stimulation?
thin electrode into brain
What types of neurosurgery are there?
bilateral anterior capsulotomy, anterior cingulotomy for severe treatment-resistant depression and OCD
What is malingering?
give fake reasons for symptoms for monetary gain (secondary gain)
What is conversion disorder?
pt not bothered by symptoms
What is somatic symptom disorder?
experience real but unidentifiable symptoms in somatic pathway (bit like fibromyalgia)
What is Munchausen disorder?
patient complains of symptoms for primary gain (medical attention and attention from loved ones); often those with severe PD; sometimes can be by proxy
What is hypochondriasis?
patient worried about disease even though don’t have one; must have lasted over 6 months and can be associated with other psych
What is dysmorphophobia?
patient worried about something wrong with morphology of self and causes social anxiety
What is Korsakoff’s syndrome?
like more acute version of wernicke’s encephalopathy; symptoms = anterograde amnesia (can’t make new memories), retrograde amnesia (can’t remember past) and confabulation (making up new memories)
What is delusional misidentification syndrome?
Capgras’ = delusional belief that person known to them has been replaced with a imposter of them, Fregoli’s = delusion that strangers the person meets are the patient’s persecutors in disguise
What is delusional parasitosis/Ekbom’s syndrome?
think insects colonising body (esp under skin and eyes)
What is Folie a deux?
delusional belief shared by two or more people but only one has psychotic illness but is more dominating and intelligent over the others who aren’t
What is De Clerambault’s syndrome/erotomania?
delusional belief that someone is in love with them and makes inappropriate advances and can get angry when rejected
What is Othello syndrome?
morbid/pathological jealousy, patient usually convinced partner is unfaithful and always trying to find evidence; can sometimes occur from Parkinson’s disease dopamine agonists
What is Cotard’s syndrome?
nihilistic delusions where pt thinks parts of body rotting/decaying or stopped existing, also that they are dead or eternally alive
What is Couvade’s syndrome?
pregnant symptoms (abdo swelling, spasms, nausea and vomiting etc) in expectant fathers
What is Ganser’s syndrome?
approximate, absurd and inconsistent answers to simple questions (colour of snow = green); clouding of consciousness, somatic symptoms, true/pseudo-hallucinations
What is Somatoform disorder?
pain severe enough to disrupt patient’s life (like somatic symptom disorder)
What is a reflex hallucination?
normal sensory stimulus causes a hallucination
What is an extracampine hallucination?
hallucination outside limits of sensory field
What is a hypnagopic and hypnopompic hallucination?
occur when the subject is falling asleep or waking up respectively
What is an autoscopic hallucination?
see self in a hallucination externally
What is first person auditory hallucination?
hear own thoughts out loud
What is a haptic hallucination?
tactile feel
What is an elementary hallucination?
simple, unstructured sounds
What is a gustatory hallucination?
in mouth in absence of food/drink
What is functional vs organic?
organic is something that can be physically seen and functional is the symptom/sign
Give the different types of delusions?
- Persecutory – person feels persecuted even though lack of evidence of it
- Grandiose
- Self-referential
- Love
- Infidelity
- Nihilistic – pt denies existence of their body
- Poverty
- Misidentification
- Religious
- Hypochondriacal
- Guilt
What is idealisation?
dealing with emotional conflict by attributing overly positive attributes to others
What is reaction formation?
intrapsychic conflict dealt with by thoughts and behaviours that are opposite to their own
What is projecting?
blames other people for their own wrongdoings etc
What is rationalising?
reassures self why things that are wrong are ok to happen
What is sublimation?
channelling potentially threatening and bad feelings and impulses into a socially acceptable outlet (bit like fighting in arguments out on the street after having been in prison like in the Louie Theroux doc)
S+Ss oppositional defiant disorders (ODD)?
6 months+; rebellious and won’t listen to authority
Conduct disorder S+Ss?
like ODD but also violent to people and animals; worse prognosis if younger diagnosis
What is antisocial PD?
socio/psychopath label; hurts others; 18+ years old; low moral values and societal norms; low empathy and impulse control
What is intermittent explosive disorder?
intense anger in brief and spontaneous and out of proportion bursts; 6+ age; twice per week for 3 months
What is impulse control disorder?
difference between this and like it is that these urges are compulsion
Two types and descriptions of impulse control disorders?
o Pyromania – fire compulsion (not arsonist)
o Kleptomania – stealing compulsion
Treatment of conduct disorders and disruptive impulse control?
CBT, social skills training, anger management, parent management training (for parents of the children)
What is depersonalisation and derealisation defined?
• Depersonalisation (feeling of detachment)/derealisation (world around isn’t real) disorders – emotionally and physically numb; weak sense of self; deadpan speech; relationship trouble; altered sense of time
What is dissociative amnesia?
localised (traumatic event); generalised (not remember any of past, comes in attacks); continuous (only remember present moment)
What is dissociative identity disorder?
(multiple personality disorder) – covert (sudden ways in which they perceive and think about themselves; think are a different person but can be aware of this afterwards; when different identity bit like being trapped in that body [bit like being trans]); overt (acts like different person; takes over mind and often not aware/blackout periods; more than 2 distinct identities)
What is bruxism and S+Ss?
• Clenching jaw – tooth fracture; tongue deformation; temporomandibular joint disorder
o Nocturnal – grinding and clicking, gets better through day and worse at start
o Diurnal – no waking pain and increases through day; no grinding or clicking; stress and chewing
Bruxism complications?
• Improperly aligned teeth, stress, dehydration, meds and MDMA can cause
Bruxism treatment and management?
behaviour modification, mouth guards, dental plates, muscle relaxants, avoid stimulants and depressants, avoid chewing, do stress-relieving activities
Social complications from LD?
- More vulnerable (easy to abuse) and lower intellectual ability (IQ<70) and struggles with ADLs
- Impairment to social/adaptive functioning (can’t cope with new sitch’s and info easily); lower life expectancy
RFs for LD?
development in womb/genetic problems
Examples of learning difficulties?
o Auditory processing disorder o Dyscalculia o Dysgraphia o Dyslexia o Language processing disorder o Non-verbal learning disabilities o Visual perceptual/motor deficit o ADHD o Dyspraxia executive functioning (higher brain functioning = organisation and planning etc) o Cognition/memory
LD S+Ss?
poor task performance/cognition; congenital syndromes and challenging behaviour (aggression and self-aggression, withdrawal and destructive behaviour); can have other associated physical/psychological problems (psych problems, epilepsy, incontinence, visual/hearing impairment)
LD management?
• GP – should have annual physical and mental health check and check meds (Cardiff health check used)
Down’s syndrome outlined?
o Multiple malformations, medical conditions and cognitive impairment
o Different severities
o Trisomy 21 – risk factors = FH and maternal age
o 1/1000 affected
