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Psych Flashcards

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1
Q

What are the questions into a past psychiatric history?

A 
Past episodes/diagnoses
Previous treatments
Inter-episode functioning
Previous admissions
Atetmpted suicides
Previous detentions under mental health legislation
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2
Q

What are the important personal history questions?

A 
Developmental milestones
Early life
Schooling
Occupational
Relationships
Financial
Friendships, hobbies/interests
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3
Q

What is forensic history?

A

Anything relating to police/detention
Contact with police
Offences WITH sentences
Particular attention to violent or sexual crimes

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4
Q

What is pre-morbid personality?

A

Their personality before they became afflicted with mental health disorder
Ie - what would friends say they were like

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5
Q

What is the mental state examination?

A 
Appearance
Behaviour
Mood
Speech
Thoughts
Beliefs
Percepts
Suicide/homicide
Cognitive function
Insight
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6
Q

What should you comment on appearance?

A

Height/build
Clothing - appropriate? Kempt?
Personal hygiene
Make up, jewellery etc

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7
Q

What should you comment on for behaviour?

A 
Greeting
Non-verbal cues
Gesturing - normal? Bizarre?
Abnormal movements
Cooperative, rapport?
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8
Q

What should you comment on for mood?

A

Eye contact
Affect - objective manifestation of mood
Mood rating - subjective, objective
Psychomotor function

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9
Q

What should you comment on for speech?

A 
Spontaneity
Volume
Rate
Rhythm
Tone
Dysarthria
Dysphasia
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10
Q

What should you comment on for abnormal thoughts??

A

Phobias
Obesssions
Flight of ideas
Formal thought disorder

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11
Q

What are some examples of formal thought disorder?

A 
Thought blocking
Fusion
Loosening
Knight's move
Derailment
Loosening
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12
Q

What are the types of abnormal beliefs?

A

Preoccupations
Over valued ideas
Delusional beliefs

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13
Q

What are the types of abnormal perceptions?

A

Illusions (misinterpreted stimuli
Hallucinations
>Pseudo or true

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14
Q

What are te important questions in to suicide?

A 
Suicidal thoughts
Ideation
Intent
Plans - specific, vague,  in motion?
Also homicidal risk
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15
Q

How do you assess cognitive function?

A

Orientation in time, place, person
Attention/concentration
Short-term memory - 3 objects, name and address
Long term memory - personal history

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16
Q

What is insight?

A

Insight, hindsight and foresight into current condition
Are symptoms due to illness?
Is this a mental illness
Do you agree with treatment plan?

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17
Q

What are the types of delusions?

A 
Grandiose
Paranoid (persecutory)
Hypochondrical
Self referential
Nhilistic
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18
Q

What is a thought disorder?

A

A pattern of interruption or disorganisation of thought processess

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19
Q

What is important past medical history for psychiatry?

A 
Developmental problems
Head injuries
Endocrine abnormalities
Liver damage, oesophgeal caricies, peptic ulcers
>Tell you about alcohol
Vascular risk factors
Any medications?
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20
Q

What is a mood disorder?

A

A disorder of mental status and function
>Where altered mood is a core feature
Commonest group of mental disorders
Either primary problem or consequence of another disorder
Associated with anxiety symptoms/disorders
>Includes depression and mania

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21
Q

When does depression become abnormal?

A

Persistence of symptoms
Pervasiveness of symptoms
Degree of impairment
Presence of specific symptoms/signs

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22
Q

What are the three spheres of symptoms of depressive illness?

A

Psycological
Phsyical
Social

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23
Q

What is the psychological sphere?

A 
Change in mood
>Depression
>Anxiety
>Perplexity
>Anhedonia
Change in thought content
>Guilt
>Worthlesness
>Ideas of refernece
>Dellusions/hallucinations (if severe)
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24
Q

What is the physical sphere of depressive illness?

A 
Change in bodily function
>Low energy
>Sleep disturbance
>Appetite (either way)
>libido
?Constipation
Change in psychomotor functioning
>Agitation
>Retardation
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25
What is the social sphere of depressive illness?
``` Loss of interests Irritability Apathy Withdrawl Loss of concentration/memory ```
26
What is stupor?
State of extreme retardation in which consciousness is intact Patient stops moving, speaking, eating and drinking On recovery has memory of events
27
What are the definition guidlines for depression?
``` Lasts at least 2 weeks No hypomanic or manic episodes in life Not attributable to substances/organic mental disorder With at least 2 general criteria And at least 4 from additional list ``` Moderate/severe need more criteria
28
What are the general criteria for depression?
Depressed mood that is abnormal for most of the day for last 2 weeks Loss of interest or pelasure Decreased energy/ increased fatigue
29
What is the additional criteria for depression?
``` Loss of confidence Unreasonable feelings of guilt recurrent thoughts of suicide Decreased concentration Agitation or retardation Change in appetite ```
30
What are the needs for mild/moderate/severe depression?
Mild - 2 general, 4 total Moderate - 2 general, 6 total Severe - all general, 8 total
31
What is postnatal depression?
Depression after giving birth
32
What are the differentials of depression?
``` SAD Dysthymia Cyclothymia Bipolar Stroke, tumour, dementia Hypothyroidism Infections ```
33
How do you treat depression?
``` Antidepressants >SSRIs >SNRIs >TCAs Psychological treatments >CBT Physical treatmetns >ECT ```
34
What is mania?
Term describing state of feeling/mood that can range from normal to a severe life threatening illness Considered a pathological, inappropriate elevated mood Rarely a symptom, often associated with grandiose ideas, disinhbition, loss of judgement
35
What is the definition of hypomania?
Lesser degree of mania with no psychosis Mild elevation of mood for days on end Increased energy and activity, marked feeling of wellbeing Increased sociability, talkativeness, overfamiliarity, increased sexual energy and decreased need for sleep May be irritable concentration reduced, new interests, overspending
36
What is mania?
``` 1 week, severe enough to disrupt ordinary work and social activites Elevated mood, Increased energy and activity, marked feeling of wellbeing Disinhbition Grandiosity Aleration of senses Extravagant spending ```
37
What are the differentials of mania?
``` Mixed affective state Schizoaffective disorder Schizophrenia Cyclothymia ADHD Stroke Tumour Infections Cushings Hyperthyroidism ```
38
How do you treat mania?
Antipsychotics Mood stabilisers Lithium ECT
39
How do you diagnose bipolar affective disorder?
2+ repeated episodes of depression and mania or hypomania If only depression, than it is recurrent depression If no depression then either hypomania or bipolar disorder
40
What is the epideminology of bipolar?
Male=female rate Average age 21 Early onset usually related to family history Prevelance increased with 1st relatives
41
What is the eipdemiology of depression?
``` Females 2x more likely than males Highest risk age 18-44 Mean age is 27 Associated with lower educational attainment Increased risk in 1st degree relatives ```
42
What are the affective disorders that can be treated with pyschological therapies?
Major depressive disorder Generalised anxiety disorder Panic disorder and phobic anxiety disorders Obessive compulsive disorders
43
What is cognitive behavioural therapy?
Explores how thoughts relate to feelings/behaviours Particularly good for depression, anxiety, phobias, OCD and PTSD Focuses on here an now Short term Problem focussed
44
What is behavioral activation avoidance in depression?
``` Social withdrawl (avoiding friends/phone) Non-social avoidance (not taking challenges) Cognitive avoidance (not taking opportunities/thinking of future) Emotional avoidance (alcohol/substance abuse) Avoidance by distraction (games, comfort eating etc) ```
45
What is the aim of behavioral activation theory?
Analyse how actions have unintended consequences Has a non-judgmental approach Small changes building towards long term goal Structred adgenda with review process
46
What is interpersonal psychotherapy?
``` Treatment for depression/anxiety 12-16 weeks Focused on present Analyses how affect and interpersonal event are related Given sick role Work towards a goal using focus area Non formal homework (unlike CBT) ```
47
What is motivational interviewing?
Talking with patient encouraging them to take up changes they have already been thinking about Why do they find it helpful? What don't they like? Effectively talk through their thoughts, and then offer support Help through stages of change
48
How do you diagnose alcohol dependance?
``` 3 or more of following for more than 1 month Cravings/compulsions to take Difficulty controlling use Primacy Increased tolerance Physiological widrawl on reduction Persistence despite harmful consequences ```
49
What is alcohol widrawl state?
``` Tremor Weakness Nausea Vomiting Anxiety Seizures Confusion Agitation Death ``` Usually 48-72 hours after alcohol stopped
50
What are the 4Ls of alcohol problems?
Liver Love Liveliehood Legal
51
What is korsakoff's psychosis?
``` Prominent impairment of recent/remote memory Preservation of immediate recall No general cognitive impairment Impaired learning and disorientation Due to thiamine deficency ```
52
What are the screening tools for alcohol abuse?
CAGE AUDIT FAST PAT
53
What is the medicla management of a patient presenting with alcohol abuse?
Prevent wernicke/karsakoff syndrome with thiamine Benzodiazepine (chlordiazepoxide) for alcohol widrawl Aversion/deterrent medication Anti-craving medication >Acanprosate >Naltrexone
54
What is best practice in psychopharmacology?
Adjust dosage for optimum benefit and safety + compliance Use adjunctive/combination therapies if needed But strive for simplest regime
55
What are the indications for antidepressants?
``` Unipolar and bipolar depression Organic mood disorders Schizophrenic disorder Anxiety disorders >OCD >Panic >social phobia ```
56
What are the classifcations of antidepressants?
``` TCAs Monoamine oxidase inhibtors - MAOIs SSRIs SNRIs - serotonin/noradrenaline reuptake inhibs Novel antidepressants ```
57
What are the potential side effects of TCAs?
``` Antihisteminic >Weight gain >Sedation Anticholinergic >Dry mouth >Constipation Antiadrenergic >orthostatic hypotension >Sedation >Sexual dysfunction Very lethal in overdose Can cause QT lengthening ```
58
What are tertiary TCAs?
Have tertiary amine side chains >These cross react with other receptors which gives the side effects (more than secondary) Act on serotonin receptors Also used for chornic pain
59
How affective are antidepressants?
70% response rate | 40% placebo response
60
What are the examples of tertiary TCAs?
Imipramine Amitrptyline Doxepin Clomipramine
61
What are secondary TCAs?
Often metabolites of tertiary TCAs Side effects same as tertiary, just more severe Block noradrenaline
62
What are the examples of secondary TCAs?
Desipramine | Notrtriptyline
63
What is the MOA of monoamine oxidase inhibitors?
They bind to monoamine oxidase Prevent inactivation of amines like noradrenaline, dopamine and serotonin Leads to increased synaptic levels Very effective for depression
64
What are the side effects of monoamine oxidase?
``` Orthostatic hypotension Weight gain Dry mouth Sedation Sleep disturbance Sexual disfunction ``` !!! Hypertensive crisis if taken with tyramine-rich foods - like cheese or wine!!! !!!serotonin syndrome!!!
65
What is serotonin syndrome?
``` If MAOI taken with meds that increase serotonin/sympathetic actions Leads to Abdominal pain Diarrhoea Sweats Tachycardia Hypertension Myoclonus Can lead to cardiovascular shock and death ```
66
How do you prevent serotonin syndrome?
Wait 2 weeks before switching from SSRI to MAOI | >Fluoxetine needs 5 weeks
67
How do SSRIs work?
Block presynaptic serotonin reuptake | Treat symptoms of both anxiety and depression
68
What are the side effects of SSRIs?
``` GI upset Sexual dysfunction Anxiety Restlessness Nervousness Insomnia Fatigue Sedation Dizziness ```
69
What are the common SSRIs?
Paroxetine >Short half life >Significant CYP2D6 Sertraline >very weak P450 interactions >Short half life >Needs full stomach Flucoetine >Long half life - less discontinuation syndrome >But may build up >Significant P450 interactions Citalopram >Low P450 inhibition with immediate half life >Dose-dependant QT interval prolongation Escitalopram >Low inhibition of P450 >More effective than citalopram in acute response >Dose dependant QT interval prolongation Fluvoxamine >Shortest half life >Strong inhibitor of CYP1A2 and CYP2C19
70
What are SNRIs?
Inhibit both serotonin and noradrenergic reuptake Without antihistamine, antiadrenergic or anticholinergic side effects that TCAs have Used for depression, anxiety and neuropathic pain
71
What are teh different SNRIs?
``` Venlafaxine >Minimal drug interactions >Short half life >Can cause rise in BP >QT prolongation ``` Duloxetine >Less BP increase compared to venlafaxine >CYP2D6 and CYP1A2 inhibitor >Not stable in stomach, needs capsule
72
What are teh novel antidepressants?
Mirtazapine 5HT2/3 receptors antagonist >increaes cholesterol/triglycerides Buporoprion
73
How do you treat resistant depression?
Combination therapy Adjunctive treatment with lithium Adjunctive with atypical antipsychotics ECT
74
What is lithium useful for?
Long term prophylaxis of mania And depressive episodes Reduces suicide rate
75
How should lithium be prescribed?
Before starting - baseline U&Es + TSH >Pregnancy test Monitor - steady state achieved after 5 days, check 12 hours after last dose Check every 3 months for TSH + creatinine Looking for blood level between 0.6-1.2
76
What are the side effects of lithium?
``` GI distress Reduced appetite Nausea/vomiting Thyroid abnormalities Nonsignificant leukocytosis Polyuria/polydipsia secondary to ADH antagonism Hair loss Acne Cognitive slowing Intention tremor ```
77
What are the symptoms of lithium toxicity?
Mild - moviting, diarrhoea, atacia, slurred speach, dizziness, nystagmus Moderate - symptoms of mild + blurred vision, clonic limb movements delerium Severe = convulsions, oliguria, renal failure
78
What indicates a positive response for valproic acid?
Rapid cycling patients Comorbid substance issues Mixed patients Patients with comorbid anxiety disorders
79
What is valproic acid good for?
As goo as lithium for mania prophylaxis | Not as effective in depression prophylaxis
80
What tests need to be done before starting valproic acid, what other consideration needs to be taken into account?
LFTs Pregnancy test FBC >In women, need to start folic acid supplement
81
How do you monitor valproic acid?
Steady state after 4-5 days 12 hrs after last dose check LFTs Target between 50-125
82
What are the side effects of valproic acid?
``` Thrombocytopenia = platelet dysfunction Nausea, vomiting, weight gain Sedation Tremor Hair loss Increased risk of neural tube defects due to reduced folic acid ```
83
When is Carbamazepine indicated?
Acute mania | Prophylaxis of mania that is resistant to lithium
84
What tests need to be carried out before carbamazepine is started?
LFTs FBC ECG
85
How do you monitor carbamazepine?
Steady state after 5 days 12 hours after last dose check levels + lfts Target is 4-12 mcg/ml Recheck after a month and adjust due to inducing own metabolism
86
What are the side effects of carbamazepine?
``` Rash Nausea, vomiting, diarrhoea Sedation, dizziness, ataxia, confusion AV conduction delays Aplastic anaemia Water retention Lots of drug-drug interactions ```
87
What are the side effects of lamotrigine?
``` Nausea/vomiting Sedation, dizziness, ataxia, confusion TEN/SJS >If any tash develops discontinue! Blood dyscrasias ```
88
What is the mesocortical dopamine pathway#?
Projects from brain stem (ventral tegmentum) to cerebral cortex Where negative symptoms /cognitive disorders are thought to arise Too little dopamine
89
What is the mesolimbic dopamine pathway?
Projects from dopaminergic cell bodies in brain stem (ventral tegmentum) to limbic system Pathway for positive symptoms Too much dopamine
90
What is the nigrostriatal dopamine pathway?
Projects from dopaminergic cell bodies in substantia nigra to basal ganglia Movement regulation Too little dopamine can cause parkinsonian movements due to suppression of ACh
91
What is the Tuberoinfundibular dopamine pathway?
From hypothalamus to anterior pituitary Dopamine inhibits prolactin release Hyperprolactinaemia in low dopamine
92
What are D2 dopamine receptor antagonists?
High potency antipsychotic High affinity for D" dopamine receptors >HIgh risk of extrapyramidal side effects
93
What are some examples of D2 dopamine receptor antagonists?
Fluphenazine, Haloperidol, Pimozide.
94
What are the effects of low potency typical anti-psychotics?
Less affinity for D2 receptors Tend to interact with non-dopaminergic receptors >Results in cardiotoxic and anticholinergic adverse effects >Includes sedation and hypotension
95
What are the examples of low potency typical anti-psychotics?
chlorpromazine | Thioridazine
96
What are atypical antipsychotics?
Serotonin-dopamine 2 antagonists | Atypical because affect both dopamine and serotonin in the 4 dopamine pathways
97
What is risperidone?
Atypical antipsychotic that can act like a typical at higher doses Increased extrapyramidial side effects Weight gain Sedation Very likely to induce hyperprolactinaemia
98
What are the side effects of olazapine?
``` Weight gain Hypertriglyceridemia Hyperglycaemia Abnormal LFTs Hyperprolactaemia ```
99
What are the side effects of quetiapine?
Same as olazapine although lesser extent | Although causes orthostatic hypotension
100
What is Aripiprazole + side effects?
D2 partial agonist No weight gain No QT prolongation, low sedation However, CYP2D6 interactions
101
When is clozapine indicated?
Treatment resistant patients | >Due to side effects. However high effiacy
102
What are the side effects of clozapine?
``` Agranylocytosis >Requires weekly bloods for a month Increased risk of seizures Sedation weight gain + abnormal LFTs Increased hypertrigylcerideaemia, hypercholesterolaemia and hyperglycaemia ```
103
What are the adverse effects of antiphyschotics in general?
Tardive dyskinesia >involuntary muscle movements Neuroleptic malignant syndrome Extrapyramisial side effects
104
What is neuroleptic syndrome?
``` severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK and lfts. Potentially fatal ```
105
What drugs can help with extrapyramidial symptoms?
Anticholinergics Dopamine facilitators Betablockers
106
What are the common anxiolytics?
Buspirone | Benzodiazipines
107
What is buspirone?
No sedation Works independant of endogenous serotonin Takes 2 weeks to kick in Will not help if benzos have been used before
108
When are benzodiazapines used?
Insommnia Parasomnias Anxiety disorders Also CNS depressant withdrawal protocols (eg alcohol)
109
What are the side effects of benzodiazipines?
``` Somnolence Cognitive deficits Amnesia Disinhibition Tolerance Dependence ```

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