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Yr4 - Psych > Psychiatric Management > Flashcards

Psychiatric Management Flashcards

1
Q

Common receptor effects of adrenergic

A 
Sweating
Tremor
Headaches
Nausea
Dizziness
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2
Q

Common muscarinic (acetylcholine) receptor effects

A

Dry mouth, difficulty swallowing, thirst
Difficulty urinating, urinary retention
Hot flushed skin, dry skin

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3
Q

Common histamine receptor effects

A

Dry mouth
Drowsiness
Dizziness
N+V

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4
Q

Features of antidepressants

A 
Work on serotonin activity - increase activity at post synaptic receptors
Most of their effect in 2-3 weeks
Most commonly used = SSRIs
- SNRIs
- Mirtazapine
- Tricyclics
- MAOIs
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5
Q

Method of action of SSRIs

A

Selective Serotonin Reuptake Inhibitors

  • increase serotonin activity by reducing the presynaptic reuptake of serotonin after release
  • more serotonin sits in nerve junction
  • leads to down regulation of post-synaptic receptors
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6
Q

Side effects of SSRIs

A

Sense of restlessness and agitation on induction - countered by use of benzodiazepines
Nausea and GI disturbance
Headache
Weight change
Sexual dysfunction
Uncommon
- bleeding - due to serotonin receptors on GI tract and platelets
- suicidal ideation particularly teenagers and early 20s - due to increased motivation before increased optimism

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7
Q

Examples of SSRIs

A

Sertraline - safest in cardiac disease
Citalopram/Escitalopram - careful of QTc prolongation
Fluoxetine - watch out for serotonin syndrome when switching
Paroxetine - watch out for discontinuation syndrome

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8
Q

Method of action of SNRIs

A

Serotonin and Noradrenaline Reuptake Inhibitors
- bind to noradrenaline and serotonin reuptake inhibitors
- leads to down regulation of post-synaptic receptors
Evidence base for use in neuropathic pain also

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9
Q

Side effects for SNRIs

A

Sedation
Nausea
Sexual dysfunction

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10
Q

Types of SNRIs

A

Duloxetine - low dose range
Venlafaxine - more efficacious and can go to a higher dose
- caution with higher doses in heart disease

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11
Q

Method of action of Mirtazapine

A 
Acts as 5HT-2 and 5HT-3 serotonin receptor antagonist
Strong H1 (histamine) activity -> sedation
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12
Q

Side effects of mirtazapine

A

Sedation

Weight gain

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13
Q

Features of tricyclic antidepressants

A 
Reasonably effective - useful for those who do not responds to SSRIs
Newer tricyclics (lofepramine and nortriptyline) tolerated better than older tricyclics (amitriptyline)
Used at low doses for neuropathic pain
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14
Q

Side effects of tricyclic antidepressants

A

Muscarinic and histamine effects

Can be fatal in overdose - QTc prolongation and arrhythmias

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15
Q

Features of MAOIs

A

Monoamine Oxidase Inhibitors
- MAOI-A - work more on serotonin
- MAOI-B - work more on dopamine
Possibly more effective for atypical depression

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16
Q

Types of MAOIs

A 
Irreversible = more dangerous
- phenelzine
- isocarboxazid
Reversible = less dangerous
- moclobamide
- tranylcypromine
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17
Q

Considerations of MAOIs

A

Significant and dangerous interaction with other drugs
Potential for tyramine reaction leading to hypertensive crisis - avoid chees, pickled meats, wine
If changing to another antidepressant needs a washout period - up to 6 weeks

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18
Q

Features of vortioxetine

A

Serotonergic activity
Effective
Well tolerated - common side effect is nausea but less severe
Evidence for improvement in difficult to treat cognitive symptoms

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19
Q

Considerations when choosing an antidepressant

A

What has been used before
Was it effective/tolerated
Are there particular symptoms or co-morbidities to address
- weight loss and insomnia = mirtazapine
- neuropathic pain = SSRIs
In new cases start with an SSRI unless major weight loss and insomnia - consider mirtazapine

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20
Q

Considerations for increasing/switching antidepressant

A 
Don't need to wait 4 weeks to have idea about effectiveness
For depression
- if no benefit then switch
- if partial effect then increase dose
For anxiety
- consider increasing dose
If struggling with side effects
- may get better in couple of weeks
- switch is cannot stand
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21
Q

Define discontinuation syndrome

A

Group of symptoms occur when antidepressant stopped
- antidepressants not addictive
Influenced by half life - shorter half life = bigger problem

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22
Q

Features of discontinuation syndrome

A 
Sweating
Shakes
Agitation
Insomnia
Headaches
Irritability
Nausea
Vomiting
Paraesthesia
Clonus
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23
Q

How to prevent discontinuation syndrome

A

Go slow
- can alternate days of taking or snap tablets in half
Sometimes worth switching to Fluoxetine and reducing
Paroxetine and venlafaxine trickiest

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24
Q

Define serotonin syndrome

A

Symptoms caused by excess serotonin

- risk when starting another antidepressant after fluoxetine

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25
Q

Features of serotonin syndrome

A

Cognitive
- headaches, agitation, hypomania, confusions, coma
Autonomic
- shivering, sweating, hyperthermia, tachycardia, nausea and diarrhoea
Somatic
- myoclonus, hyper-reflexia and tremor

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26
Q

Treatment of serotonin syndrome

A

Supportive

  • fluids
  • monitoring
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27
Q

Method of action of antipsychotics

A

Reduce level of dopamine activity as D2 receptors antagonists

  • target pathways = mesocortical and mesolimbic
  • unwanted pathways = nigrostriatal (movement) and tuberoinfundibular (hypothalamic-pituitary-adrenal axis)
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28
Q

Classes of antipsychotics

A

Typical
- older
- more likely to cause extra-pyramidal side effects
- bind to more muscarinic and histaminic receptors
Atypical
- more serotonergic activity
- more likely to cause diabetes and dyslipidaemia

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29
Q

Examples of antipsychotics

A 
Typical
- haloperidol
- flupenthixol
- zuclopenthixol
- chlorpromazine
- sulpride
Atypical
- clozapine
- olanzapine
- risperidone
- quetiapine
- amisulpride
- aripirazole - partial D2 agonist
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30
Q

Side effects of antipsychotics

A 
Sedation
Weight gain
QTc prolongation
Typical
- extra-pyramidal
     - bradykinesia
     - muscle stiffness and tremor
     - tardive dyskinesia
     - akathisia
- dizziness
- sexual dysfunction
Atypical
- weight gain
- dyslipidaemia and diabetes
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31
Q

Monitoring required for antipsychotics

A 
Baseline
- FBC, lipids, LFTs, HbA1c, weight, ECG, BP and pulse
Weekly
- weight
Others at 3 months then yearly
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32
Q

Features of clozapine

A

D2 antagonist and 5HT-2 antagonist
Most efficacious antipsychotic
Improvements can continue for several months
Used in schizophrenia after at least 2 other antipsychotics failed
Dose titrated slowly upward over 2 weeks and vital signs monitored due to potential for autonomic dyregulation

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33
Q

Side effects of clozapine

A

Agranulocytosis
- close monitoring of FBC - weekly for first 18 weeks then fortnightly then monthly
Gastrointestinal hypomobility
- constipation and potentially fatal bowel obstruction
Hypersalivation
Urinary incontinence

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34
Q

Treatment of clozapine induced agranulocytosis

A

Stop clozapine
Stop other marrow supressing drugs - sodium valproate
Avoid other antipsychotics for a couple of weeks where possible - if needed aripiprazole
Contact consultant haematologist
Avoid sources of infection - consider broad spec abx
Lithium - increased WCC and neutrophil count
Granulocyte colony-stimulating factor - injection

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35
Q

Define neuroleptic malignant syndrome

A

Rare, life-threatening reaction to antipsychotics

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36
Q

Features of neuroleptic malignant syndrome

A 
Fever
Confusion
Muscle rigidity
Sweating
Autonomic instability
Death due to 
- rhabdomyolysis
- renal failure
- seizures
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37
Q

Risk factor for neuroleptic malignant syndrome

A

High potency dopamine antagonists (typical antipsychotics)
Antipsychotic naïve patients
High doses
Young men

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38
Q

Treatment for neuroleptic malignant syndrome

A

Emergency referral to A&E
Stop antipsychotics
Fluid resuscitation
Reduced temperature

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39
Q

Treatment for extra pyramidal side effects of antipsychotics

A

Anticholinergics

  • Ratio of dopamine: acetylcholine in nigrostriatal pathway more important than absolute quantities
  • If too much acetylcholine in relation to dopamine - reduce acetylcholine activity
  • not effective for tardive dyskinesia
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40
Q

Examples of anticholinergics

A

Procyclidine - potential for misuse
Benztropine
Trihexyphenidyl

41
Q

Define acute dystonia

A

Sustained, often painful, muscular spasms producing twisted abnormal postures

42
Q

Features of acute dystonia

A

Neck, tongue, jaw, oculogyric crisis (neck arched and eyes roles back)
50% cases in first 48 hours, 90% in first 5 days

43
Q

Treatment of acute dystonia

A 
Stop antipsychotic
Administer IM or IV anticholinergics 
- procyclidine
Continue for 1-2 days after dystonia
Consider long-term prophylactic
44
Q

Types of anxiolytics

A

Reduce anxiety

  • beta-blockers
  • benzodiazepines
  • pregabalin
  • antidepressants
45
Q

Method of action of beta-blockers

A

Reduce autonomic nervous system activation

- bio-psycho feedback

46
Q

Consideration for beta-blockers

A

Most commonly used = propranolol
Contraindicated in asthma
Limited effectiveness for enduring anxiety disorders

47
Q

Method of action of benzodiazepines

A

Bind to GABA receptors to potentiate effect of GABA

  • reduce excitability of neurones
  • positive allosteric modulators of GABA receptors
48
Q

Features of benzodiazepines

A 
Most commonly used
- diazepam - long half-life
- lorazepam - short half-life
Significant potential for
- tolerance
- dependence
- misuse
Use for no more than 6 weeks
Occasionally cause paradoxical disinhibition
49
Q

Method of action of pregabalin

A

Binds to voltage gated calcium channels in neurones
Increases extra-cellular amounts of enzyme responsible for synthesis of GABA
- increases GABA concentrations in brain
Reduces neuronal activity

50
Q

Features of pregabalin

A

Used in anxiety, neuropathic pain and epilepsy
Less potential for misuse and dependence than benzodiazepines
BNF says short term use
Causes sedation and weight gain

51
Q

Antidepressants for anxiety

A

Most commonly SSRIs

  • similar doses
  • doses for OCD higher
52
Q

Types of hypnotics (sleeping tablets)

A 
Benzodiazepines
- temazepam
- lormetazepam
- nitrazepam
Nonbenzodiazepines
- act in similar way - positive allosteric modulators
- zopiclone
- zolpidem
53
Q

Features of hypnotics

A

Significant potential for misuse, dependence and rebound insomnia
Use for only 2 weeks and take only 5 out of 7 days each week

54
Q

Features of mood stabilisers

A 
Used to treat bipolar mood disorder
Groups
- lithium
- anticonvulsants
- second generation (atypical) antipsychotics
55
Q

Features of lithium

A

Most effective mood stabiliser
MOA unknown
Narrow therapeutic window - 3 monthly serum lithium levels
Excreted by kidneys
Reduces suicide - licence for reduction of self-harm

56
Q

Side effects of lithium

A 
GI disturbance 
Metallic taste 
Dry mouth
Fine tremor
Polydipsia
Polyuria 
Weight gain
Long term effects 
- hypothyroidism - reversible
- renal impairment - irreversible
- need annual U&Es and LFTs
57
Q

Features of lithium toxicity

A 
Confusion
Coarse tremor
N+V
Ataxia
Seizures
58
Q

Treatment for lithium toxicity

A

Supportive - fluids

Dialysis if needed

59
Q

Risk factors for lithium toxicity

A 
Dehydration - advise to drink lots of water in hot climates
Drug interactions
- NSAIDs
- Loop diuretics
- ACE inhibitors
60
Q

Use of atypical antipsychotics in bipolar

A

Quetiapine - 1st line for bipolar

Doses and monitoring same for psychosis

61
Q

Use of anticonvulsants as mood stabilisers

A

Various modes of action - GABA receptors, calcium channels and sodium channels
Most common
- Sodium valproate - avoid in women in child bearing age due to teratogenicity, check LFTs before and soon after starting
- Carbamazepine
- Lamotrigine - potential for Stevens Johnson Syndrome
- Pregabalin

62
Q

Side effects of anticonvulsants

A

Sedation
Weight gain
Thrombocytopenia - check FBC

63
Q

Drugs used for cognitive symptoms in dementia

A

Do not prolong life or slow neurodegenerative changes
- improve cognitive and emotional/behavioural symptoms
Acetylcholinesterase inhibitors
Memantine

64
Q

Method of action of cholinesterase inhibitors

A

Inhibit breakdown of acetylcholine
- increase levels of acetylcholine in brain
Alzheimer’s associated with lower levels of activity in cholinergic system

65
Q

Uses of cholinesterase inhibitors in dementia

A

Used in Alzheimer’s for cognitive and neuropsychiatric symptoms
Indicated in mild to moderate dementia only

66
Q

Side effects of cholinesterase inhibitors

A 
Nausea
Diarrhoea
Vomiting
Insomnia
Muscle cramps
Anorexia
Muscle cramps
Anorexia
Bradaycardia
67
Q

Monitoring for cholinesterase inhibitors

A

Pulse check at every appointment

ECG before starting

68
Q

Examples of chonisterse inhibitors

A

Donepezil
Galantamine
Rivastigmine - given as patch - good for concordance and less GI side effect

69
Q

Features of Memantine

A

Glutamine (NMDA) receptor antagonist -> lower neuronal excitability
Used in moderate to severe Alzheimer’s
- agitated/challenging behaviour
Generally well tolerated if initiated slowly
No specific monitoring needed

70
Q

Side effects of memantine

A

Headache
Drowsiness
Insomnia
Nausea

71
Q

Drugs used in ADD and ADHD

A

Most treatments are CNS stimulants
- potential for misuse and dependency
- monitor weight, height and pulse in children
- Methylphenidate
- most commonly prescribed
- given as combination of immediate and sustained release
- Dextroamphetamine
Atomoxetine
- noradrenaline re-uptake inhibitor
- used according to patient preference, unable to tolerate stimulants or previous drug dependence

72
Q

Framework of psychological therapies

A

Type A - psychological treatment as integral part of mental health care
Type B - eclectic psychological therapy and counselling
Type C - formal psychotherapies

73
Q

Types of formal psychotherapies available

A

CBT - cognitive-behaviour therapy
Psychoanalytic/psychodynamic therapies
Systemic and family therapy

74
Q

Define transference

A

Unconscious transfer of feeling and attitudes from the past into the therapist
- being seen through eyes of the past

75
Q

Uses of psychodynamic therapy

A 
Recurrent and chronic inter-personal difficulties
Contribute to management of
- personality disorders
- depression
- eating disorders
- anxiety
76
Q

Uses of CBT

A 
Depression
Anxiety states - phobias, OCD, GAD, panic, PTSD
Eating disorders
Sexual dysfunction
Insomnia
77
Q

Features of CBT

A

Based on learning theory
Thoughts, feelings, actions and physical symptoms all connected - changing one can affect others
Unhelpful thinking leads to unhelpful behaviours

78
Q

Five areas model of CBT

A 
Life situation, relationships and practical problems
Altered thinking
Altered emotions
Altered physical feelings/symptoms
Altered behaviour or activity levels
79
Q

Features of psychodynamic psychotherapy

A

Evolution of conscious understanding primarily by interpreting what the patient does and says during a session
Addresses issues of transference and psychological defence mechanisms

80
Q

What is psychotherapy

A

Systematic use of a relationship between a patient and therapist to produce changes in feelings, cognition and behaviour

81
Q

Uses of psychodynamic psychotherapy

A

Recurrent and chronic inter-personal difficulties
Psychological conflict or alienation
Contribute to management of
- personality disorders, depression, eating disorders

82
Q

Use of interpersonal therapy

A

Depression

83
Q

Features of interpersonal therapy

A

Uses link between onset of depressive symptoms and current interpersonal problems as a focus for treatment

84
Q

Features of family/systemic therapeis

A

Target system that generates problematic behaviour

- suggestion, emphasising positive values

85
Q

Uses of family therapies

A

Intervention for children
Eating disorders
Adjunctive treatment in schizophrenia

86
Q

Aim of CBT

A

Help individuals to identify and challenge their automatic negative thoughts and then modify any abnormal underlying core beliefs

87
Q

Define selective abstraction

A

Focusing on one minor aspect rather than the bigger picture

88
Q

Define all or nothing

A

Thinking of things in all or nothing terms

89
Q

Define magnification/minimization

A

Over or under estimating the importance of an event

90
Q

Define catastrophic thinking

A

Anticipating the worst possible outcome of an event

91
Q

Define overgeneralisation

A

Anticipating the worst possible outcome of an event

92
Q

Define arbitrary interference

A

Coming to a conclusion in the absence of any evidence to support it

93
Q

Features of relaxation training

A

Stress-related and anxiety disorders
Patient is asked to use muscle relaxation during times of stress or anxiety
Patient learns to put themselves in situations where they feel relaxed

94
Q

Features of systemic desensitisation

A

Phobic anxiety disorders

Individual gradually exposed to hierarchy of anxiety-producing situations

95
Q

Features of flooding

A

Patient rapidly being exposed to phobic object

96
Q

Exposure and response prevention features

A

Anxiety disorders - OCD and phobias
Patient repeatedly exposed to the situation that causes them anxiety and prevented from performing their compulsive actions

97
Q

Features of behavioural activation

A

Depressive illness
Patient avoid doing certain things as they feel they will not enjoy them or fear of failure
Involves making realistic and achievable plans to carry out activities and then gradually increased amount of activity

98
Q

Indications of psychodynamic therapy

A 
Dissociative disorders
Somatoform disorders
Psychosexual disorders
Certain personality disorders
Chronic dysthymia
Recurrent depression
99
Q

Rationale of psychodynamic therapy

A

Childhood experiences, past unresolved conflicts and relationships significantly influence individuals current situation

Yr4 - Psych (13 decks)

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