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Pre-reg Exam 2021 > Mental Health Disorders > Flashcards

Mental Health Disorders Flashcards

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1
Q

What are the psychological symptoms of anxiety?

A 
Restlessness
Worry
Fear
Difficulty concentrating
Irritability
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2
Q

What are the physical symptoms of anxiety?

A 
Palpitations
Muscle aches and tension
Trembling or shaking 
Excessive sweating
Shortness of breath 
Insomnia
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3
Q

What class are benzodiazepines?

A

CD4 part 1

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4
Q

What are the benzodiazepines?

A 
Alprazolam
Clobazam
Chlordiazepoxide
Diazepam
Lorazepam
Oxazepam
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5
Q

What benzodiazepines are better for use in elderly?

A

Short acting

Lorazepam
Oxazepam

Greater risk of withdrawal symptoms

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6
Q

What beta blockers are used for palpitations in anxiety?

A

Propranolol

Oxprenolol

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7
Q

What is buspirone?

A

5HT1a agonist

Low potential for abuse and dependence
Takes two weeks to work

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8
Q

What is the mechanism of action of benzodiazepines?

A

Facilitates and enhances the binding of GABA to the GABAa receptor to cause widespread depressant effect on synaptic neurotransmission

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9
Q

What are benzodiazepines used for?

A

Short term (2-4 weeks) relief of anxiety that is severe, disabling or causing patient unacceptable distress

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10
Q

What are the side effects of benzodiazepines?

A

Paradoxical increase in hostility aggression

Overdose - ataxia, drowsiness, dysarthria, nystagmus, respiratory depression, coma

Sedation

Dependence

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11
Q

How do you withdraw benzodiazepines?

A

Gradually convert to equivalent diazepam dose ON

Reduce diazepam dose by 1-2mg every 2-4 weeks

Reduce further

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12
Q

What are the diazepam drug interactions that increase sedation and CNS depressant effects?

A 
Alcohol
Opioids
Antihistamines 
Antidepressants
Barbiturates 
Antipsychotics 
Z-drugs
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13
Q

What are the diazepam interactions that increase plasma concentrations?

A

Amiodarone
Diltiazem
Macrolides
Fluconazole

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14
Q

What are the symptoms of ADHD?

A

Hyperactivity
Impulsivity
Inattention

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15
Q

What is the treatment for ADHD in children 5 years + and young people?

A

Methylphenidate first line

Lisdexamfetamine second line

Atomoxetine/guanfacine alternative

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16
Q

What is the ADHD treatment in adults?

A

First line methylphenidate/lisdexamfetamine

Alternative atomoxetine

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17
Q

What is the mechanism of action of methylphenidate?

A

Potent CNS stimulant

Increases dopamine and noradrenaline levels in the brain

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18
Q

What are the side effects of methylphenidate?

A 
Appetite loss
Insomnia
Weight loss
Increased heart rate and blood pressure
Tics and Tourette’s 
Growth restriction
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19
Q

What needs to be monitored with methylphenidate?

A

Pulse
BP
Appetite
Weight and height

Psychiatric symptoms

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20
Q

What are the contraindications of methylphenidate?

A 
Cardiovascular disease
Hyperthyroidism
Hypertension
Uncontrolled bipolar
Severe depression

Prescribe by brand for MR

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21
Q

What is the mechanism of action of dexamfetamine and lisdexamfetamine?

A

Potent central nervous system stimulant

Increases dopamine and noradrenaline levels in the brain

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22
Q

What are the side effects of lisdexamfetamine and dexamfetamine?

A 
Appetite loss
Anorexia
Increased heart rate and blood pressure
Tics and Tourette’s 
Growth restriction in children
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23
Q

What are the signs of lisdexamfetamine overdose?

A 
Wakefulness
Hyperactivity 
Paranoia
Exhaustion 
Convulsions
Hyperthermia
Coma
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24
Q

What is the monitoring needed for lisdexamfetamine and dexamfetamine?

A 
Pulse
BP
Appetite
Weight and height
Psychiatric symptoms
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25
What are the contraindications of lisdexamfetamine and dexamfetamine?
CVD Hyperthyroidism Hypertension Agitated states
26
What is the mechanism of action of atomoxetine?
Noradrenaline reuptake inhibitor causes increased levels of noradrenaline at synaptic cleft
27
What are the side effects of atomoxetine?
Suicidal ideation Hepatotoxicity QT prolongation
28
What are the side effect counselling points of atomoxetine?
Report suicidal thoughts, self harming behaviour Report signs of liver toxicity
29
What is the monitoring needed for atomoxetine?
``` Pulse BP Psychiatric symptoms Appetite Weight Height ```
30
What is bipolar disorder?
Characterised by extreme mood swings Bipolar episode can last several weeks or months
31
What are the two types of bipolar episodes?
Mania Depression
32
What do you give for acute mania and hypo mania?
Benzodiazepines - short term use, risk of dependence Antipsychotics - quetiapine, olanzapine, risperidone Lithium or valorous acid added if inadequate Asenapine in moderate-severe manic episodes
33
What do you use for prophylaxis of bipolar disorder?
Lithium salts Valproate Olanzapine Carbamazepine
34
What are the contraindications in bipolar disorder?
Do not give antidepressants in - rapid cycling bipolar disorder, recent history of hypo mania, manic episode, rapid mood fluctuations
35
What are the lithium salts used for?
Prophylaxis and treatment of mania, hypo mania and depression in bipolar disorder, resistant depression and aggressive or self harming behaviour
36
What is the therapeutic range for lithium?
0. 4 - 1 mmol/L - lower end for prophylactic/elderly | 0. 8 - 1 mmol/L - acute manic episodes
37
What is the monitoring needed for lithium?
12 hours post dose Monitored every 3 months Additional monitoring if significant inter current illness or significant changes to diet or water intake
38
Why should you avoid abrupt withdrawal of lithium?
Warn patients of higher risk of relapse
39
What are the signs and symptoms of lithium toxicity?
Revenge ``` Renal disturbances Extra pyramidal symptoms Visual disturbances Nervous system disturbances GI effects ``` > 2 mmol/L - renal failure, arrhythmias, seizures, BP changes, circulatory failure, coma, death
40
What are the side effects of lithium?
``` Thyroid disorders Renal impairment Benign intracranial hypertension QT prolongation Lowers seizure threshold ```
41
What are the counselling points for the side effects of lithium?
Report hypothyroidism symptoms Report renal dysfunction Report persistent headaches, visual disturbance
42
Does hyper or hyponatraemia predispose lithium toxicity?
Hyponatraemia
43
What are the counselling points for lithium?
Report signs and symptoms of lithium toxicity Maintain salt and water intake Lithium treatment pack Can cause drowsiness avoid alcohol OTC interactions - ibuprofen, soluble analgesics, antacids
44
Is lithium teratogenic?
Yes Need effective contraception Toxicity can occur in breast fed infants
45
What are the lithium interactions that increase risk of seizures?
Ciprofloxacin SSRIs Epilepsy
46
What are the lithium interactions that increase risk of arrhythmias due to QT prolongation?
``` Quinolones Citalopram Clarithromycin Amiodarone Antipsychotics Imipramine Theophylline Corticosteroids B2 agonists Loop/thiazide ```
47
What are the lithium interactions that increase risk of lithium toxicity due to reduced renal excretion?
ACEi ARB NSAIDs
48
What are the lithium interactions that increase risk of hyponatraemia and so predispose lithium toxicity?
Diuretics | Antidepressants
49
What are the lithium interactions that increase risk of extrapyramidal symptoms?
``` Haloperidol Clozapine Phenothiazines Parkinson’s disease Metoclopramide ```
50
What drugs used with lithium affect the salt balance?
Soluble analgesics | Sodium containing antacids
51
What are the lithium interactions that increase risk of neurotoxicity?
Phenytoin Carbamazepine Antipsychotics Amitriptyline
52
What are the lithium interactions that increase risk of serotonin syndrome?
``` Sumatriptan Citalopram Granisetron MAOIs Amfetamines St Johns Wort Tramadol ```
53
What are the psychological symptoms of depression?
Low self esteem Worry and anxiety Suicidal thoughts
54
What are the physical symptoms of depression?
Lack of energy Changes in weight/appetite Insomnia
55
How do antidepressants work?
Depression is thought to be caused by under activity of monoamine neurotransmitters Antidepressants increase monoamine levels at synapse
56
What are the tricyclic antidepressants?
Raises 5HT, NA ``` Amitriptyline Clomipramine Dosulepin Imipramine Nortriptyline ```
57
What are the tricyclic related antidepressants?
Mianserin | Trazodone
58
What are the selective serotonin reuptake inhibitors?
Raises 5HT ``` Citalopram (QT prolongation) Escitalopram (QT prolongation) Fluoxetine (only antidepressant given in children) Fluvoxamine Paroxetine Sertraline - safe to use after MI ```
59
What are the irreversible monoamine oxidase inhibitors?
Raise 5HT, NA, DA Phenelzine Isocarboxazid Tranylcypromine
60
What are the reversible monoamine oxidase inhibitors?
Moclobemide
61
What are antidepressants used for?
Moderate to severe depression
62
What are the first line antidepressants?
SSRIs Better tolerated and safer in overdose Less sedating, antimuscarinic, epileptogenic, cardiotoxicity than TCAs MAOIs rarely used
63
How long does it take for antidepressants to work?
At least two weeks Initially feel worse, increased agitation, anxiety, suicidal ideation Review every 1-2 weeks Wait at least 4 weeks
64
How long should you take antidepressants for?
At least six months after remission 12 months in generalised anxiety 2 years in recurrent depression
65
What is the second line depression treatment?
Increase SSRI dose Different SSRI Mirtazapine
66
What are the alternative antidepressant treatments?
Lofepramine Reboxetine Moclobemide Other TCAs Venlafaxine Irreversible MAOIs
67
What are the side effects of antidepressants?
Hyponatraemia - drowsiness, confusion, convulsion Suicidal ideation and behaviour Serotonin syndrome
68
What are the symptoms of serotonin syndrome?
Neuromuscular hyperactivity - tremors, myoclonus, muscle rigidity Altered mental state - agitation, confusion, mania Autonomic dysfunction - labile blood pressure, urination, diarrhoea, hyperthermia, tachycardia, pallor, sweating, shivering
69
How do you switch between different antidepressants?
Washout period required when antidepressant is stopped before switching to different antidepressant class, avoid serotonin syndrome
70
What is the washout period for MAOIs?
Wait 2 weeks before switching Except meclobomide which doesn’t need a washout period
71
What is the washout period for SSRIs?
Wait 1 week before switching 2 weeks if sertraline 5 weeks if fluoxetine
72
What is the washout period for TCAs?
Wait 1-2 weeks before switching 3 weeks if imipramine or clomipramine
73
Why do you need to avoid abrupt withdrawal for antidepressants?
Withdrawal reactions occur within 5 days of stopping Risk of withdrawal reactions is increased if antidepressant stopped suddenly after taking for 8 weeks or more Reduce dose gradually over 4 weeks
74
What antidepressants have a higher risk of withdrawal reaction?
Paroxetine | Venlafaxine
75
What is the mechanism of action of SSRIs?
Selectively inhibit the reuptake of 5HT from synaptic cleft
76
What are the side effects of the SSRIs?
GASH GI Appetite or weight disturbances Serotonin syndrome Hypersensitivity reactions Bleeding risk increased QT interval prolongation with citalopram/escitalopram Seizure threshold lowered Movement disorders and dyskinesia
77
Which SSRI is used in children?
Fluoxetine
78
Which SSRI is used in MI/unstable angina?
Sertraline
79
Which SSRIs cause QT prolongation?
Citalopram | Escitalopram
80
What are the symptoms of SSRI overdose?
``` Nausea Vomiting Agitation Tremors Nystagmus Drowsiness Sinus tachycardia Convulsions ```
81
What drugs cause an increased plasma concentration when used with SSRIs?
Grapefruit juice
82
What drugs cause an increased risk of bleeding when used with SSRIs?
NSAIDs/aspirin Anticoagulants Antiplatelets
83
What drugs cause an increased risk of QT prolongation when used with SSRIs?
``` Erythromycin TCAs Sotalol Amiodarone Chloroquine Mefloquine Lithium Quinine Antipsychotics Theophylline Beta 2 agonists Loop/thiazide diuretics Corticosteroids ``` Hypokalaemia increases risk of torsade de pointes
84
What drugs cause an increased risk of hyponatraemia?
Diuretics Desmopressin Carbamazepine NSAIDs
85
What drugs cause an increased risk of serotonergic effects/serotonin syndrome when used with SSRIs?
``` St Johns Wort Amfetamines Sumatriptan Selegiline Tramadol TCA MAOI Ondansetron ```
86
What is the mechanism of action of TCAs?
Inhibits reuptake of 5HT and NA | Also blocks a wide array of receptors M, H1, a1/2, D2
87
What is the dose of TCAs?
Once daily at night
88
Which TCAs are sedating?
``` Amitriptyline Clomipramine Dosulepin Doxepin Trimipramine ``` Mianserin Trazodone
89
What TCAs are less sedating?
Imipramine Lofepramine Nortriptyline
90
What are the side effects of TCAs?
More sedating, more epileptogenic, more cardiotoxicity, more antimuscarinic than SSRIs Toxic Cardiac effects Antimuscarinics Seizures ``` Hallucinations Mania Hypotension Sexual dysfunction Breast changes EPS ```
91
What are the drugs that reduce plasma concentrations when used with TCAs?
Carbamazepine
92
What are the drugs that increase plasma concentrations when used with TCAs?
Cimetidine
93
What are the drugs that increase the risk of hyponatraemia when used with TCAs?
Diuretics Desmopressin Carbamazepine
94
What are the drugs that increase risk of QT interval prolongation when used with TCAs?
``` Amiodarone Sotalol Antipsychotics Citalopram Escitalopram Loop diuretics B2 agonists Corticosteroids Theophylline ```
95
What are the drugs that increase the risk of hypotension when used with TCAs?
``` Alpha blockers Beta blockers ACEi CCBs Antipsychotics Levodopa/dopaminergic as NSAIDs SGLT2 inhibitor Diuretics Phosphodiesterase type 5 inhibitor ```
96
What are the drugs that increase antimuscarinic effects when used with TCAs?
Antimuscarinics Antihistamines Atropine Antipsychotics
97
What are the drugs that increase the risk of serotonin syndrome when used with TCAs?
``` MAOIs/selegiline Tramadol Amfetamines 5HT1a agonists (sumatriptan) Ondansetron Lithium ```
98
What is the mechanism of action of the MAOIs?
Blocks monoamine oxidase enzymes which leads to accumulation of monoamines - DA, NA, 5HT
99
What are the MAOIs used for?
Rarely used due to significant food/drug interactions
100
What are the irreversible MAO-A and MAO-B inhibitors?
Phenelzine Isocarboxazid Tranylcypromine
101
Which MAOIs have a high risk of hepatotoxicity?
Phenelzine | Isocarboxazid
102
Which MAOI has the greatest stimulant action?
Tranylcypromine
103
What are the reversible MAO-A inhibitors?
Moclobemide
104
What are the side effects of MAOIs?
Hepatotoxicity Postural hypotension/hypertensive responses Hypertensive crises
105
What are the interactions with MAOIs that cause hypertensive crises?
``` Pseudoephedrine Adrenaline Noradrenaline Levodopa DRAs MAO-B inhibitors TCAs ```
106
What are the counselling points for MAOIs?
Avoid food containing tyramine - cheese, marmite, cured meat Eat only fresh food Avoid alcohol Interactions 2 weeks after stopping an irreversible MAOIs
107
What are the negative symptoms of schizophrenia?
Under activity in mesocorticol pathway Social withdrawal Poor hygiene Apathy Catatonia
108
What are the positive symptoms of schizophrenia?
Overactivity of mesolimbic pathway Hallucinations Delusions Disorganised speech/thoughts
109
What are the extrapyrimidal symptoms of schizophrenia?
D2 antagonism in nigrostriatal pathway ``` Parkinsonism Tardive dyskinesia Akathisia Dystonia Dyskinesia ```
110
What are the hyperprolactinaemia symptoms of schizophrenia?
D2 antagonism in tuberofundibular pathway Menstrual disturbances Galactorrhoea Breast enlargement Sexual dysfunction
111
Is the dose of antipsychotics higher or lower in the BNF compared to the Royal college of psychiatrists?
Lower
112
What needs to be considered in antipsychotic prescribing?
Consider alternatives Be aware of risk factors Drug interactions ECG Increase dose slowly and once weekly Regular pulse, blood pressure and temperature checks High dose for limited period, stop if no improvement after 3 months
113
How do you administer antipsychotics in an emergency?
Via IM IM dose lower than oral dose Prescription should specify dose for each route Review dose of antipsychotic at least daily
114
What needs to be considered when prescribing antipsychotics in the elderly?
In elderly patients with dementia there’s an increased risk of death and stroke Susceptible to postural hypotension and hyper/hypothermia Do not treat mild-moderate psychotic symptoms Initial dose is half adult dose Review regularly
115
What needs to be considered for prescribing antipsychotics in patients with learning disabilities?
If patient is not experiencing psychotic symptoms Reduce dose or stop long term treatment Review condition Refer to psychiatrist Annual documentation of reasons for continuing antipsychotic
116
What is the mechanism of action of 1st generation antipsychotics?
Blocks post synaptic dopamine D2 receptors in the brain
117
What are the phenothiazines?
Group 1 Chlorpromazine Levomepromazine Promazine Group 2 Pericyazine ``` Group 3 Fluphenazine Perphenazine Prochlorperazine Trifluoperazine ```
118
Which phenothiazines are the most sedative?
Group 1
119
Which phenothiazines have the least extrapyramidal symptoms?
Group 2
120
Which phenothiazines have the most extrapyramidal symptoms?
Group 3
121
What are the butyrophenones?
Haloperidol - high extrapyramidal symptoms and QT interval prolongation
122
What are the thioxanthenes?
Flupentixol - not in evening | Zuclopenthixol
123
What are the other 1st generation antipsychotics?
Pimozide Sulpiride Loxapine
124
What is the mechanism of action of the second generation antipsychotics?
Blocks post synaptic dopamine D1-D4 receptors and act on wide range of other receptors
125
What are the second generation antipsychotics?
``` Amisulpride Aripiprazole Clozapine Lurasidone Olanzapine Paliperidone Quetiapine Risperidone ```
126
Which second generation antipsychotics cause the most hyperprolactinaemia?
Amisulpride | Risperidone
127
Which second generation antipsychotics cause weight gain and diabetes?
Clozapine | Olanzapine
128
What is clozapine?
Second generation antipsychotic and is the most effective
129
What is clozapine used for?
Licensed for resistant schizophrenia Try for at least 8-10 weeks, if symptoms don’t respond to optimised dose measure plasma levels before augmenting with second antipsychotic
130
What do you do for a missed dose of clozapine?
> 2 missed doses re-initiate by specialist
131
What are the interactions of clozapine that cause an increased risk of agranulocytosis (blood dyscrasias)?
Aminosalicylates | Immunosuppressants
132
What are the side effects of clozapine?
MAG Myocarditis and cardiomyopathy- stop permanently Agranulocytosis and neutropenia - report flu like illness GI obstruction - constipation can be fatal
133
How often is clozapine monitored?
Leukocyte and differential blood count Every 18 weeks, then every 2 weeks for a year, then monthly onwards
134
What is the MHRA warning for clozapine?
Reminder of potential,y fatal risk of intestinal, obstruction, faecal impaction, paralytic ileus Report constipation before taking next dose
135
How often are antipsychotic depot preparations administered?
Every 1-4 weeks by IM injection Test dose Oral antipsychotic whilst stabilising
136
What is the safety information needed for antipsychotic depot preparations?
Do not confused with other preparations IM haloperidol decanoate for maintenance IM haloperidol rapid control
137
In patients with schizophrenia what needs to be monitored?
Physical health annually
138
What are the extrapyramidal symptoms associated with antipsychotics?
``` Parkinsonism Dystonia Dyskinesia Akathisia Tardive dyskinesia - stop at first sign of fine vermicular movements of tongue ``` Occurs most frequently with group 3 phenothiazines, butyrophenones, 1st generation depot preparations
139
What are the hyperprolactinaemia symptoms associated with risperidone, amisulpride and 1st generation antipsychotics?
Breast symptoms Reduced bone mineral density Menstrual irregularities Sexual dysfunction Aripirazole is the only antipsychotic without this side effect as it is a partial dopamine agonist
140
What monitoring is needed for hyperprolactinaemia in antipsychotics?
Prolactin levels at start, 6 months and then yearly Endocrine function in children - weight, height, sexual maturation, menstrual function
141
What are the metabolic side effects more commonly associated with second generation antipsychotics?
Hyperglycaemia and sometimes diabetes - ciroq (clozapine, risperidone, olanzapine, quetiapine) Weight gain Lipid changes
142
What are the antipsychotics that most commonly cause sexual dysfunction?
Haloperidol | Risperidone
143
What is the mechanism of action of antipsychotics that cause hyperprolactinaemia and low libido?
Block D receptors
144
What is the mechanism of action of antipsychotics that cause arousal disorders?
Block M receptors
145
What is the mechanism of action of antipsychotics that cause erectile dysfunction and ejaculatory problems?
Block a1 receptors
146
What are the cardiovascular effects of antipsychotics?
Tachycardia Arrhythmias Hypotension QT interval prolongation - pimozide, haloperidol
147
What antipsychotics are most likely to cause hypotension and interference with temperature regulation?
Elderly especially at risk of falls, hypothermia, hyperthermia Clozapine Chlorpromazine Lurasidone Quetiapine
148
Is neuroleptic malignant syndrome fatal?
Yes Discontinue antipsychotic drug immediately Bromocriptine or dantrolene Lasts 5-7 days after stopping but longer with depot preparation
149
What are the other side effects of antipsychotics?
``` Antimuscarinic side effects Blood dyscrasias Photosensitivity Jaundice Sedation ```
150
What is the warning with chlorpromazine?
Contact sensitisation, avoid direct contact
151
What are the warnings for pimozide?
Prolongs QT interval, cases of sudden death If QT interval prolonged stop or reduce dose Do not give concomitant drugs that prolong QT interval Do not give concomitant drugs that cause electrolyte imbalance
152
What are the side effects of phenothiazines?
Hepatotoxicity | Acute dystonic reactions
153
What is the monitoring needed for antipsychotics?
``` FBC Urea Electrolytes LFT Blood lipids Weight Fasting blood glucose ECG Blood pressure before starting and frequently during dose titration ```
154
What are the antipsychotic interactions that cause QT interval prolongation?
Amiodarone Ciprofloxacin Macrolides Quinine SSRIs
155
What are the antipsychotic interactions that increase the risk of extrapyramidal symptoms?
Metoclopramide | Parkinson’s disease
156
What are the interactions with antipsychotics that increase the risk of sedation and CNS depressant effects?
Hypnotics Benzodiazepines Opioids Antiepileptics
157
What are the interactions with antipsychotics that increase the risk of hypotension?
Antihypertensives Diuretics Nitrates
158
What are the interactions with antipsychotics that increase the risk of antimuscarinic effects?
TCA Antihistamines Antimuscarinics

Pre-reg Exam 2021 (79 decks)

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