mental health end of block formative revision Flashcards
(65 cards)
1
Q
What are the positive symptoms of schizophrenia?
A
- Delusions e.g. passivity and persecutory
- Halluncinations (third person)
- Formal thought disorder
2
Q
What are the negative symptoms of schizophrenia?
A
- Loss of motivation
- Loss of awareness of socially appropriate behaviour
- Blunting of affect, flattening of mood and anhedonia
N.B. If schizophrenia is associated with high/low mood then is schizoaffective disorder
3
Q
What is the criteria for schizophrenia?
A
- One of the following:
- Thought echo, insertion, withdrawal or broadcasting
- Delusions of control/passivity
- Hallucinatory voices
- Persistent delusions of other kinds
- Or 2 of the following:
- Negative symptoms
- Persistent hallucinationswith fleeting delusions
- Catatonic behaviour
- Breaks in train of thought
- Significant and consistent change in overall uality of some aspects of personal behaviour
4
Q
what is emergency management of acute behavioural disturbance?
A
- If non-psychtoic then oral lorazepam
- If psychotic then oral lorazepam and oral anti-psychotic e.g. haloperidol
5
Q
Which drugs would you give in schizophrenia?
A
- First line is either:
- SGA (e.g. olanzapine, quetiapine, risperidone) and long-acting BDZ for non-acute anxiety/bheavioural disturbance e.g. diazepam (lorazepam is short acting)
- OR FGA e.g. chlorpromazine (has sedating effect at high doses)
- second line:
- Try another antipsychotics (at least one of the ones you have tried as either first or second line should be an SGA)
- Thrid line:
- Clozapine (after trying 2 one of which was an SGA)
6
Q
What are the criteria for a diagnosis of depression?
A
- At least 2 weeks of symptoms which aren’t secondary to drugs/alcohol/bereavement
- Symptoms must cause significant distress and/or impairment of social, occupational or general functining
- There must be at least 2 typical symptoms:
- Low mood
- Anhedonia
- Fatigue/lack of energy
- And at least 2 other core symptoms
- e.g. irritability, suicidal ideation, guilt, poor concentration/memory, indecisiveness, headache, stomach ache, psychomotor agitation/retardation, insomina/hypersomnia, eating/weight change, reduced libido
7
Q
What is mild depression and how is it treated?
A
- 2 core and 2 typical symptoms
- Treated with:
- Watchful waiting
- Guided self-help, computerised CBT or structured physcial activity programmes
- Although is patient has past history of moderate/severe depression or they had subthreshold symptoms for >2 years then consider antidepressants.
8
Q
What is moderate depression and how is it treated?
A
- 2 typical and 3 core symptoms
- Treated with combination of antidepressant and high-intensity psychological intervention e.g. CBT or IPT
9
Q
Severe depression (3 typical and 4+ core features) is treated in the same way as moderate depression. How is it treated differently if there is also psychosis?
A
- Antidpressant and antipsychotic use
- Start with the antipsychotic first to rule out that it is all due to psychosis:
- SGA or low dose FGA
10
Q
What are first and second line anitdepressants used in depression?
A
- First line: SSRIs (citalopram, fluoxetine or sertraline)
- If <18 then fluoxetine
- Second line:
- Alternative SSRI
- Venlafaxine
- Mirtazapine (can cause weight gain)
11
Q
What is the criteria for diagnosis of bipolar disorder?
A
- At least 2 episodes one of which must be hypomanic/mixed/manic wit recovery between.
- Criteria for manic:
- Abnormally + persistenly elevated, expansive or irritbale mood with 3 or more characteristic symptoms of mania
- At least one week duration
- Should be severe enough to impair occupation and social functioning and can be psychotic features
- (for hypomanic is same but lasts only 4 days and doesn’t impair social/occupational functioning or have psychotic features)
- Criteria for manic:
12
Q
What are the clinical features of mania?
A
- Elevated mood
- Increased energy
- Increased seld-esteem
- Tendency to enage in behaviour with serious consequences
- Irritability, aggresivenes or suspiciousnes
- Psychotic symptoms e.g. delusions of grandiose, persecutory delusions, preoccupation with thoughts and schemes can lead to self-neglect, catatonic behaviour, total loss of insight
13
Q
What is Bipolar I, II and rapid cycling?
A
- Bipolar I is severe mood episodes from mania to depressoin
- Bipolar II is milder mood elevation alternating with severe depression
- Rapid cycling is more than 4 mood swings in a 12 month period with no intervening asymptomatic periods.
14
Q
In addition to psychoeducation, CBT, Interpersonal therapy, support groups etc. which pharmacological approaches can be used in long term management of bipolar?
A
- Mood stabiliser
- Lithium then carbamazepine
- Low dose antipsychotic
- Aripiprazole or quetiapine
15
Q
How is an acute manic episode managed in bipolar?
A
- If severe/life threatening –> ECT
- If not:
- Stop antidepressants
- Start antipsychotics:
- First line: SGA
- aripiprazole, risperidone, quetiapine
- Second lineL
- Lithium or valproic acid (mood stabilisers)- these take longer to work which is why SGA started first
- First line: SGA
- BDZs can be used to help reduce dose of SGA needed for adequate sedation
16
Q
Describe the management of an acute depressive episode in bipolar
A
- SSRI and antipsychotic (SGA e.g. quetiapine) (to prevent mania)
- Also mood stabiliser e.g. lithium or valproic acid
- If severe/life threatening –> ECT
17
Q
What is the criteria for panic disorder diagnosis?
A
- Several attacks of autonomic anxiety in a period of 1 month:
- in circumstances with no objective danger
- Without being confined to known/predictable situations
- With comparative freedom of anxiety between attacks.
18
Q
Describe the management of panic disorder
A
No superior efficacy between the following:
- SSRS- citalopram, escitalopram, paroxetine, sertraline
- BDZs- Alprazolam or clonazepam (NOT recommended by NICE due to dependence)
- TCAs- imipramine, clomipramine
- MAOIs -phenelzine
Then also
- CBT or psychodynamic therapy
19
Q
What are the following?
- Agoraphobia
- Simple/specific phobia
- Social phobia
A
- Agoraphobia
- Anxiety/panic with places/situations where escape may be difficult or embarassing
- Simple/specific phobia
- Recurring excessive pscyhological/autoimmune symptoms of anxiety in presence of a specific object or situation
- Social phobia
- Symptoms of incapacitating anxeity not secondary to delusional or obsessive thoughts. Restrcited to particular social situation –> desire for escape or avoidance
20
Q
What is the management for agoraphobia, simple phobia and social phobia?
A
- Agoraphobia:
- Same as panic disorder
- Simple phobia:
- CBT
- drugs not really used
- Social phobia:
- CBT and SSRIs/MAOIs
- Can potentially add a BDZ e.g. clonazepam or alprazolam
21
Q
What is GAD and how is it treated?
A
- Generalised persistent anxeity and feelings of apprehension about everyday events/problems, with symptoms of muscle and psychic tension, causing significatn distress and functional impairment
- Management should be directed towards predominant symptom:
- Buspirone (anxiolytic)
- Somatic symptoms- BDZs e.g. lorazepam
- Depressive symptoms- trazodone (serotonin modulator), SSRIs (escitaloram or paroxetine) and SNRIs e.g. duloxetine or venlafaxine
- CVS symptoms- B-blockers
22
Q
What are adjustment disorders?
A
- They lie between normal reaction and psychiatric diagnosis
- They must occur within 1-3 months of a social stressor and not persist for more than 6 months after the stressor is removed
23
Q
How are adjustment disorders managed?
A
- Psychological
- Practical help with the stressor
- Allow patient to verbalise feelings
- Pharmacological
- Antidepressents or anxiolytics/hypnotics if symptoms persist or are distressing
24
Q
Which symptoms suggest a grief reaction has become abnormal and how is this managed?
A
- Abnormal grief reaction:
- One which is v intense, prolonged, delayed (or absent), or where symptoms outside the normal range are seen e.g. feelings of worthlessness/guilt
- Management:
- Antidressents and support/counselling
25
What are typical symptoms associated with PTSD? How is it managed?
* Difficulty falling/staying asleep
* Nightmares
* Flashbacks
* Irritability/outbursts of anger
* Difficulty concentrating
* Hypervigilence
* Exaggerated startle response
* distress when exposed to circumstances resembling stressor
* Inability to recall some important aspects of period around stressor
26
How is PTSD managed?
* Trauma- focussed CBT or EMDR (eye movement desensitisation and reprocessing)
* Psychodynamic therapy
* Stress management
* Drugs:
* SSRIs- paroxetine or sertraline
* Sleep disturbance- mirtazapine or zopiclone
* Anxiety/hyperarousal- BDZs
* Intrusive thoughts- mood stabilisers- carbamazepines, valproate, lithium
* Pyshcotic symptoms- olanzapine, risperidone, quetiapine, clozapine
27
Which drugs can lower the seizure threshold and so should be used in caution in epilepsy?
* Antidepressants
* TCAs
* Antipsychotics
* esp. SGAs
* Lowest risk is haloperidol
* Mood stabilisers
* lithium (but only in OD)
* Others:
* Disulfiram
* Anticholinesterase inhibitors (except galantamine)
28
How does conduct disorder present?
* With aggression, cruelty to others/animals
* Destruction of property
* Deceitfulness
* Theft
* Fire-setting
* Truancy
* Running
Management is through parent training, family therapy, child interventions (e.g. anger management, problem solving, social skills) etc.
29
How is depression in children treated?
* CBT, interpersonal therapy and family therapy for at least 3 months
* If unresponsive then consider additional psychological therapy and pharmacology (reluctance to use pharmacology though)
* Drugs:
* Fluoxetine
* (if unresponsive can try sertraline or citalopram)
30
* Start with CBT and other therapies and then only consider drugs if you absolutely must.
* Drugs can be considered for:
* GAD, OCD, panic disorder/agoraphobia and social phobia
* Not really used in simple phobia, PTSD or separation anxiety
31
What is ADHD characterised by? How is it managed?
* Hyperactivity, inattention and impulsiveness
* Psychoeducation then medication:
* Methylphenidate
* Can cause growth supression and so monitor growth. Can give drug holidays if growth supression is a worry.
* Atomoxetine
* Dexamfetamine (if the others don't work)
32
What is the difference between anorexia and bulimia?
* Anorexia is marked distortion of body image with pathological desire for thinness and self-induced weight loss by a variety of methods
* Bulimia is recurrent episodes on binge eating with compensatory behaviour and overvalued ideas about 'ideal' body shape and weight
33
Describe the management of anorexia and bulimia
* Fluoxetine in both
* In anorexia can do family therapy (esp. if early onset) or individual therapy eg. CBT. and nutritional education
* In bulimia can do CBT also.
34
What is the difference between delirium and dementia?
* Dementia has slower onset, is progressive, lasts longer and doesn't alter consciousness
* Delirium is acute, fluctuating, shorter duration and impairs conciousness
35
* Delirium is managed through reassurance and supportive measures. What are the management options for dementia?
* For vascular can modify cardiovascula risk factors to stop progression
* For Alzheimer's can give:
* AChEi e.g. donepezile and rivastigmine
* Side effects include D+V, cramps, incontinence, headache, dizziness, insomnia, raised LFTs, arrhtyhmias, peptic ulcers and hallucinationa
* Contraindications are: peptic ulcers, arrhythmias, COPD (lots of elderly will have these)
36
What are common side effects of SSRIs?
* Nausea and GI upset
* Headache
* Restlessness
* Insomnia
37
What are cautions and contraindications for the use of SSRIs?
* Cautions:
* can effect CYP450 enzymes so caution with drugs undergoing hepatic metabolism
* Contraindications:
* Manic episode
* Use of MAOIs
38
How long after starting SSRIs do you follow patients up for increased suicidal ideation?
* If low risk then after 2 weeks
* If high risk of \<30 then after 1 week
39
What is serotonin syndrome?
* Characterised by:
* Altered mental state, agitation, tremor, shivering, diarrhoea, hyperreflexia, ataxia, hyperthermia
* May need gastric lavage or activated charcoal of serotonin antagonists e.g. chlorpromazine
40
Give examples of TCAs. What are their common side effects?
* Amitriptyline, comipramine, dosulepin, imipramine, nortripyline
* Side effects:
* Anticholinergic e.g. dry mouth, blurred vision, constipation, urinary retention, drowsiness, confusion, palpitations
* Anti-adrenergic e.g. drowsiness, postural hypotension, sexual dysfunction
* Serotonin antagonsim --\> anxiolytic, sedation
* Antihistaminergic e.g. drowsiness and weight gain
41
Give examples of MAOIs (used in treatment resistant and atypical depression/anxeity). What are possible side effects?
* Isocarboxazid, phenelzine, tranylcypromine
* Most common side effect is postural hypotension BUT can also cause hypertensive crisis (due to MAO inhibition in intestines- need to avoid food with tyramine and also certain medications)
42
What class of drugs are venlafaxine and duloxetine? What are common side effects and what moniotring is needed?
* SNRIs
* Common side effects:
* Nausea, GI upset, constipation, loss of appetite, dry mouth, dizziness, agitation, insomnia, sexual dysfunction, headache, sweating, shaking
* Dose-dependent monitoring needed.
43
What class of drug is mirtazapine? What are common side effect? What monitoring is required?
* NaSSA (noradrenergic and specific serotinergic antidepressants)
* Common side effects:
* Sedation (more at lower doses)
* Increased appetite
* Weight gain
* Can rarely cause agranulocytosis
* Need to look for sore throat, fever, stomatitis, signs of infection. If seen then stop medication immediately and do blood test to check for neutropenia.
44
Give examples of FGAs. What are the possible EPSEs that can occur with FGAs?
* Haloperidol, Chlorpromazine, zuclopenthixol, flupenthixol
* EPSEs:
* Rigidity
* Bradykinesia
* Dystonia
* Tremor
* Askathisia
* Parkinsonism
* Tardive dyskinesia
45
Antipsychotics can also cause neuroleptic malignant syndrome. What is this?
* Life threatening reaction to antipsychotic drugs
* Causes fever, altered mental status, muscle rigidity and autonomic dysfunction
* Transfer to ITU, dantrolene can help
46
What monitoring is required on any antipsychotic?
* Prolactin levels should be checked before starting and then every 6 months after.
47
Give examples of SGAs. Rather than EPSEs what are they more likely to cause?
* Olanzapine, risperidone, paliperidone, quetiapine, clozapine, aripiprzole, amisulpride
* More likely to cause metabolic syndrome --\> high TGAs, cholesterol, diabetes, weight gain
48
As well as ESPEs, hyperprolactinaemia and metabolic syndrome, what are other side effects of antipsychotics?
* Anticholinergic effects e.g. dry mouth, blurred vision, difficuly passing urine, urinary retention, constipation
* Anti-adrenergic e.g. hypotension, tachycardia, sexual dysfunction
*
49
Which antipsychotics should you give if the patient has the following:
* Sedation
* Weight gain
* ESPEs
* Postural hypotension
* Sedation --\> haloperidol or non-sedating SGA (risperidone or amisulpride)
* Weight gain --\> haloperidol or fluphenazine
* ESPEs --\> SGAs
* Postural hypotension --\> haloperidol, amisulprde, trifluoperazine
50
What is post-injection syndrome?
* Occurs after depot of olanzapine --\> sedation, acute confusion, agression, EPSEs, dysarthria, ataxia, seizure
51
What are the common side effects of clozapine?
* Anticholinergic- constipation, dry mouth (but also causes hypersalivation), blurred vision
* Anti-adrenergic --\> hypotension, sexual dysfunctio
* Sedation
* Nausea and vomiting
* Weight gain
* ECG changes
* Headache
* Fatigue
* Hypertension
* Tachycardia
* Drowsiness
* Seizures
52
What are potentially life-threatening side effects of clozapine?
* Fatal myocarditis or cardiomyopathy
* PE
* Neuroleptic malignant syndrome
* Agranulocytosis
* Leukopnia, eosinophilia and leukocytosis
* Must do bloods before starting then every week for 18 weeks, every fortnight for one year then monthly
* Stop the clozapine and admit to hospital
53
What can haapen when stopping clozapine quickly?
* Return of psychosis
* Rebound:
* Sweating, headache, nausea, vomiting, diarrhoea
54
What do you worry about in OD of the following? What do you give in OD? What about in dependency?
* Opiates
* BDZs
* Opiates
* Resp. depression
* Give naloxone in OD
* Give methodone or buprenorphine in dependency
* BDZs:
* Resp. depression
* Give flumazenil
* In dependency give diazepam (also give diazepam in alcohol dependency)
55
Describe the CAGE screening tool for alcohol use
* C- have you ever felt you should cut down on drinking
* A- has anyone ever annoyed you be criticising your drinking
* G- have you ever felt guilty about your drinking?
* E- have you ever had a drink early in the morning as an eye-opener?
56
What do you give for alcohol withdrawal? What can you give for maintenance?
* Give:
* BDZs (diazepam)- acts as anticonvulsant and antipsychotic as well (although can also add haloperidol)
* Supplementary vitamins
* Maintenance:
* Support, counseling, residential abstinence
* Also:
* Disulfiram (aversive drug)
* Acomprostate and naltrexone (anti-craving)
57
For lots of anxeity disorders you tend to give SSRIs but for GAD can give buspirone. what are common side effects?
* dizziness, excitement, headache, nausea, nervousness
58
What are the common side effects of diazepam?
* Amnesia
* Ataxia (esp. in elderly)
* Confusion (esp. in elderly)
* Dependence
* Drowsiness and lightheadedness the next day
* Muscle weakness
* Paradoxical increase in aggresion
59
Normal side effects of lithium?
* polyuria and polydipsia
* oedema and weight gain
* Conigtive problems e.g. impaired memory and concentration
* Tremor (fine tremor)
* Impaired co-ordination
* GI upset e.g. nausea, vomiting, diarrhoea
* Hair loss
* Acne
60
Chronic side effects of lithium
* Renal function decrease
* Monitor creatinine and urea levels
* Hypothyroidism
* Monitor TFTs
* Teratogenic
* Esp. in first trimester --\> Ebstein's abnormality increased risk (tricuspid valve defect)
61
What levels should lithium be kept between? What are early and late signs of lithium toxicity?
* 0.6-1mmol/L
* Ealy:
* Coarse tremor, anorexia, nausea/vomiting, diarrhoea (can be bloody), dehydration and lethargy
* Late:
* Severe neurological complications --\> fasciculations, hypertonicity, resltessness
* Hypotension and cardiac arrhythmias then circulatory collapse with seizures, stupor and eventual coma
62
What does Li interact with?
* ACEi
* ARBs
* NSAIDs
* SSRIs
* Antihypertensive
* Haloperidol
* All increase the conc.
63
What are CIs to lithium use?
Heart failure and sick sinus syndrome
64
What are early and late side effects of ECT?
* Early:
* Loss of short term memory
* Retrograde amnesia
* Headache
* Temporary confusion
* Nausea/vomiting
* Clumsiness
* Musclear aches
* Late:
* Loss of long term and past memories
65
What do the following sections allow?
* Section 2
* Section 3
* Section 4
* Section 5(2)
* Section 5(4)
* Section 2
* For assessment. For 28 days. Needs 2 medical recommendations.
* Section 3
* For treatment. For 6 months. Can be renewed for another 6 and then 12 thereafter.
* Section 4
* Emergency admission of those not yet admitted e.g. in A&E, outpatients, day hospitals.
* 72h
* Section 5(2)
* Emergency detention of informal patient (on pschiatric of non-psych ward)
* 72h
* Section 5(4)
* Same as 5(2) but for nurses and is only for 6h
