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Psychiatry Flashcards

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1
Q

What are the three core symptoms of depression?

A

Low mood

Anhedonia

Reduced energy

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2
Q

What are other cognitive symptoms of depression?

A

Reduced concentration

Feelings of guilt

Impaired memory

Nihilism

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3
Q

What are physical symptoms of depression?

A

Reduced appetite
Reduced libido
Early morning wakening
Constipation

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4
Q

What is the ICD-10 criteria for mild depression?

A

2 core symptoms and at least 2 cognitive symptoms

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5
Q

What is the ICD-10 criteria for moderate depression?

A

2 core symptoms and 3-4 cognitive symptoms

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6
Q

What is the ICD-10 criteria for severe depression?

A

3 core symptoms and at least 5 cognitive symptoms

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7
Q

What is the management of mild depression?

A

Low intensity psychosocial intervention e.g.
individual guided self help
Computerised CBT
Group based CBT

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8
Q

When should antidepressants be prescribed for mild depression?

A

If there is a history of moderate/severe depression

If symptoms persist after other interventions

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9
Q

How is moderate to severe depression managed?

A

Combination of SSRI + high intensity psychosocial intervention e.g. interpersonal therapy, behavioural activation, behavioural couples therapy

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10
Q

What are the preferred SSRIs to prescribe first?

A

Citalopram or fluoxetine

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11
Q

Which SSRI is safe to use post myocardial infarction?

A

Sertraline

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12
Q

Which SSRI is safe in children?

A

Fluoxetine

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13
Q

Which SSRI is associated with QT prolongation?

A

Citalopram

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14
Q

How long after prescribing an SSRI should you review the patient?

A

After 2 weeks

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15
Q

What are adverse effects of SSRIs?

A

GI symptoms

Increased risk of GI bleeding

Sexual dysfunction

Hyponatraemia

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16
Q

Which drugs interact with SSRIs?

A

NSAIDs/aspirin - co-prescribe PPI

Warfarin/heparin - consider mirtazapine instead

Triptans - increased risk of serotonin syndrome

Caution with other drugs that can cause hyponatraemia

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17
Q

Over how long should you taper SSRIs when discontinuing?

A

Over 4 weeks

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18
Q

What are symptoms of SSRI discontinuation syndrome?

A

GI upset

Restlessness

Difficulty sleeping

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19
Q

Which SSRI has an increased risk of congenital malformations when used in pregnancy?

A

Paroxetine

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20
Q

What are side effects of mirtazapine?

A

Sedation

Increased appetite

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21
Q

Which foods do monoamine oxidase inhibitors react with?

A

Cheese

Broad beans

Oxo

Marmite

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22
Q

What are side effects of tricyclic antidepressants?

A 
Drowsiness 
Dry mouth
Urinary retention 
Constipation 
Blurred vision
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23
Q

How does serotonin syndrome present?

A

Increased reflexes

Myoclonus

Rigidity

Hyperthermia

Confusion/agitation

Dilated pupils

Tremor

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24
Q

Which drug most commonly causes serotonin syndrome?

A

MAOIs

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25
How is serotonin syndrome managed?
Remove causative medication IV fluids Benzodiazepines
26
What are features of generalised anxiety disorder?
Depersonalisation Derealisation ``` Palpitations Dizziness Dry mouth Headache Nausea ``` ``` Sleep disturbance Fatigue Irritability Muscle tension Poor concentration ```
27
How is generalised anxiety disorder managed?
1. Patient education 2. Low intensity psychological interventions – self-help, group sessions 3. Choice of high intensity CBT or drug treatment 4. CBT + drug treatment Marked functional impairment --> straight to step 3 Very marked function impairment/self-neglect/risk of self-harm --> straight to step 4 Drug treatment 1st line = SSRI 2nd line = alternative SSRI/SNRI Other options Pregabalin Propranolol
28
What are differential diagnoses for GAD?
Psychiatric: Panic disorder Social anxiety Agoraphobia Depression Physical: Hyperthyroidism Cardiac disease Substance misuse Medication induced anxiety - salbutamol, theophylline, steroids, caffeine
29
What is panic disorder?
Acute unprovoked periods of intense fear and discomfort
30
How does panic disorder present?
``` Breathing difficulties Hyperventilation Chest discomfort Palpitations Dizziness/shaking Agoraphobia ``` Tingling around mouth or in peripheries
31
What is the first line management for panic disorder?
CBT
32
What are other management options for panic disorder?
Can also prescribe an SSRI but second line after CBT
33
How long do symptoms have to be present to be classed as PTSD?
1 month
34
What are features of PTSD? (4)
1. Re-experiencing - flashbacks, nightmares, intrusive thoughts 2. Avoidance - avoiding people/situations which resemble the event 3. Hyperarousal - exaggerated startle response, hyper vigilant to threat 4. Emotional numbing
35
How is PTSD managed?
Trauma focused CBT EMDR (eye movement desensitisation and reprocessing)
36
What is acute stress reaction?
Occurs in the first 4 weeks after a traumatic event
37
How is acute stress reaction managed?
Trauma focused CBT
38
What is the strongest risk factor for schizophrenia?
Family history
39
What are first rank symptoms for schizophrenia?
Auditory hallucinations - usually third person Thought disorder - insertion, withdrawal, broadcasting Passivity phenomena - belief that bodily sensations are being controlled by an external influence Delusional perception - the traffic light is green which means I am the king
40
What features of schizophrenia indicate a poor prognosis?
Gradual onset Low IQ Prodromal phase of social withdrawal
41
What negative symptoms are seen in schizophrenia?
``` Catatonia Anhedonia Poverty of speech Poverty of thought Blunting of affect ```
42
What is the first line treatment for schizophrenia?
Oral atypical antipsychotic e.g. olanzapine/risperidone
43
What are examples of a typical antipsychotic?
Haloperidol and Chlopromazine
44
What are extra pyramidal side effects seen in typical antipsychotics?
Parkinsonism Acute dystonic reaction - sustained muscle contraction such as twisted neck or fixed position of eyeballs Akathisia (severe restlessness) Tardive dyskinesia - abnormal involuntary movements such as chewing or pouting of jaw
45
How is an acute dystonic reaction managed?
Procyclidine
46
What are other side effects of typical antipsychotics? (not extra-pyramidal)
Dry mouth, blurred vision, urinary retention, constipation Raised prolactin (causes galactorrhea) - however this is more in atypical Impaired glucose tolerance Reduced seizure threshold Prolonged QT interval Neuroleptic malignant syndrome
47
What are examples of atypical antipsychotics?
Olanzapine Risperidone Clozapine Quietiapine
48
What are adverse effects of atypical antipsychotics?
Weight gain Hyperprolactinaemia -> Galactorrhoea
49
What side effects are clozapine associated with?
Clozapine = 2nd gen (atypical) antipsychotic Agranulocytosis and neutropaenia Reduced seizure threshold Constipation Myocarditis
50
What is neuroleptic malignant syndrome?
Life threatening condition that occurs in those taking antipsychotics
51
How does neuroleptic malignant syndrome present?
Slow onset - usually within 1 to 2 weeks after starting or changing dose ``` Fever Altered mental state Muscle rigidity Reduced reflexes Hypertension Tachycardia Tachypnoea Delirium/confusion ```
52
What lab results are seen in neuroleptic malignant syndrome?
Raised creatinine kinase Raised white cell count May be AKI
53
How is neuroleptic malignant syndrome managed?
Stop antipsychotic IV fluids to prevent renal failure
54
What is schizoaffective disorder?
Presence of both a mood disorder and schizophrenic symptoms at the same time
55
What are the three types of schizoaffective disorder?
Manic Depressive Mixed
56
How is schizoaffective disorder managed?
Manic type - antipsychotics, mood stabiliser Depressive type - antidepressants
57
What is Charles Bonnet Syndrome?
Presence of recurrent complex hallucinations in those with visual impairment
58
What is type 1 bipolar disorder?
Mania and depression
59
What is type 2 bipolar disorder?
Hypomania and depression
60
What is the difference between mania and hypomania?
Duration: Mania lasts for at least 7 days, hypomania is 3-4 days Functional impairment: seen in mania Psychotic symptoms: may be seen in mania
61
What features are seen in mania/hypomania?
``` Elevated mood Risk taking behaviour Sexual promiscuity Insomnia Flight of ideas Pressured speech ```
62
What is used for the long-term management of bipolar disorder?
Psychological intervention e.g. CBT First line pharmacological management = Lithium If Lithium is not tolerated or inappropriate (e.g. unwilling to have routine bloods) -> Sodium Valproate
63
Which antidepressant can be used in bipolar disorder by itself?
Fluoxetine
64
What is the therapeutic level of lithium?
Between 0.5 and 1.0
65
What adverse effects can lithium cause at the therapeutic level?
Fine tremor Diarrhoea Hypothyroidism Increased thirst + Increased urination (can cause nephrogenic diabetic insipidus) Hyperparathyroidism (hypercalcaemia) Nephrotoxicity Weight gain Idiopathic intracranial hypertension Leukocytosis
66
How often should lithium levels be monitored?
Weekly until stable for 4 weeks then every 3 months
67
What other levels are monitored whilst taking lithium? And how often ?
Renal function and thyroid function, every 6 months
68
What medications can precipitate lithium toxicity?
NSAIDs Loop diuretics Thiazide diuretics ACEi/ARBs Methotrexate
69
How does lithium toxicity present?
Coarse tremor Increased reflexes Confusion Seizure Coma
70
How is lithium toxicity managed?
If mild/moderate - normal saline If severe - haemodialysis
71
What is an oculogyric crisis?
An example of an acute dystonic reaction Fixed position of eyeballs Can be caused by typical antipsychotics and metoclopramide Treated with Procyclidine
72
When should mirtazapine be considered?
In patients on warfarin/heparin In elderly patients
73
What can cause a rise in Clozapine levels?
Smoking cessation
74
What is the first line SSRI in children and adolescents ?
Fluoxetine
75
What level of lithium is classed as toxicity?
1. 6 - 2.0 = mild toxicity 2. 1 - 2.5 = moderate toxicity More than 2.5 = severe toxicity
76
When should clozapine be used for schizophrenia?
In treatment resistant schizophrenia | When others have failed
77
How long should antidepressants be continued for?
For at least six months after the patients recover
78
When can bipolar disorder be diagnosed?
When there has been at least one manic/hypomanic episode
79
How long do symptoms have to be present for before making a diagnosis of depression?
Two weeks
80
What are the three personality clusters?
A - paranoid, schizoid, schizotypal B - antisocial, borderline, histrionic, narcissistic C - avoidant, dependant, anankastic
81
What is a paranoid personality disorder?
Hypersensitive Unforgiving Questions the loyalty of friends Misconstrues the actions of others as attacks
82
What is a schizoid personality disorder?
Indifference to praise or criticism Lack of interest in sexual interactions or companionship Preference for solitary activities Emotional coldness
83
What is a schizotypal personality disorder?
Odd beliefs and behaviour Lack of close friends Inappropriate affect Ideas of reference
84
What is an antisocial personality disorder?
Failure to conform to social norms Will decent for personal profit/pleasure Disregard for the safety of self or others Irresponsible Lack of remorse or guilt
85
What is a borderline personality disorder?
Unstable interpersonal relationships Unstable self image Unstable behaviour Impulsivity of reckless behaviour Recurrent suicidal behaviour
86
What is a histrionic personality disorder?
Need to be centre of attention Shallow expression of emotions Inappropriate sexual seductiveness Over emotional Physical appearance used for attention-seeking
87
What is a narcissistic personality disorder?
Sense of self importance Lack of empathy Takes advantage of others
88
What is an avoidant personality disorder?
Fear of rejection/criticism Views self as inferior to others Hypersensitive to rejection
89
What is a dependent personality disorder?
Difficulty in making decisions without reassurance from others Lack of imitative Allows others to have responsibility over their life Perceives self as helpless
90
What is an anankastic personality disorder?
Perfectionist Occupied with details / lists / rules Rigid on morality / ethics / values Stubborn
91
What is an impulsive personality disorder?
Lack of impulse control Outbursts of violence Emotionally unstable
92
What is obsessive-compulsive disorder?
Characterised by presence of Obsessions - thoughts Compulsions - acts May be one or both Symptoms cause functional impairment/stress
93
How is OCD managed?
Mild functional impairment - CBT/ERP (exposure and response prevention) Moderate functional impairment - SSRI / more intensive CBT Severe functional impairment - SSRI + CBT
94
What drug can be used to help with sleep paralysis?
Clonazepam
95
What is classed as insomnia?
Difficult initiating or maintaining sleep for at least 3 nights a week for 3 months or longer
96
What is anorexia nervosa?
Restriction of energy intake (also may use laxatives/over-exercising/vomiting) Intense fear of gaining weight/becoming fat Body dysmorphia
97
What are clinical features of anorexia nervosa?
Low BMI Hypotension Bradycardia Lanugo hair Amenorrhoea Hypothermia Cardiac complications - arrhythmia, cardiac atrophy, sudden cardiac death
98
What biochemistry results are typically seen in anorexia?
Hypokalaemia Hypercholesterolaemia Low sex hormones (FSH, LH, oestrogen, testosterone) Raised growth hormone Raised cortisol Low T3 Impaired glucose tolerance
99
How is anorexia managed?
Treat any medical complications e.g. hypokalaemia Controlled re-feeding to prevent refeeding syndrome In adults - CBT-ED In children - anorexia focused family therapy
100
What is bulimia nervosa?
Eating disorder characterised by episodes of binging followed by purging May be a normal BMI
101
What are clinical features of bulimia nervosa?
Binge eating - eating an amount of food that is more than most people would eat at once Compensatory behaviour - vomiting laxatives, diuretics, fasting, excessive exercise Recurrent vomiting signs - dental erosion, Russel’s sign (calluses on knuckles), parotid gland swelling
102
How is bulimia managed?
1. Bulimia focused self help 2. If ineffective after 4 weeks - CBT-ED In children - bulimia focused family therapy
103
What biochemistry results can be seen in bulimia nervosa?
Hypokalaemia Low chloride Metabolic alkalosis (due to vomiting hydrochloridic acid from stomach)
104
What biochemical results can be seen in refeeding syndrome?
Low phosphate Low potassium Low magnesium
105
What are symptoms of alcohol withdrawal?
Tremor, sweating, tachycardia, anxiety
106
When do seizures peak during alcohol withdrawal?
At 36 hours after last drink
107
When does delirium tremens present and what are the features?
48 to 72 hours after having last drink Coarse tremor Confusion Delusions Hallucinations – visual/tactile (feeling of insects crawling on skin) Sweating Hypertension Fever
108
How can acute alcohol withdrawal be managed?
Benzodiazepines First line is usually chlordiazepoxide Can also use diazepam Also prescribe Pabrinex (thiamine) to prevent Wernicke’s encephalopathy
109
What is Wernicke’s encephalopathy and what is the triad of symptoms?
Neuro psychiatric disorder caused by thiamine deficiency Ophthalmoplegia/nystagmus Ataxia Confusion
110
What is Korsakoff syndrome and what are the features?
Memory disorder caused by thiamine deficiency Anterograde amnesia (inability to form new memories) Retrograde amnesia (forgetting old memories) Confabulation
111
What are clinical features of opioid intoxication?
Drowsiness Confusion Reduced respiratory rate and heart rate Constricted pupils Maybe evidence of needle marks
112
What are clinical features of opiate withdrawal?
Agitation Anxiety Muscle aches and cramps Chills Runny eyes and nose Sweating Insomnia GI disturbance Goose skin
113
What is an indication for electroconvulsive therapy?
Severe depression not managed by medication Catatonia
114
What is a contraindication to electroconvulsive therapy?
Raised intracranial pressure
115
What are side effects of electroconvulsive therapy?
Headache Nausea Short-term memory impairment (Retrograde amnesia) Cardiac arrhythmia Memory loss
116
What is somatisation disorder?
When there are multiple physical symptoms and the patient refuses to accept reassurance
117
What is conversion disorder?
When there is a loss of motor function or sensory symptoms Patient is not faking or trying to get material gain No cause found
118
What is malingering?
Fraudulent stimulation or exaggeration of symptoms for financial or material gain
119
 which section of the mental health act is used for admission for assessment for up to 28 days?
Section 2
120
Which section of the mental health act is renewable every six months?
Section 3
121
And which section of the mental health act can be acted on by police to bring them to a place of safety?
Section 136
122
What is section 4 of the mental health act?
Used in emergencies where a section 2 would cause an undesirable delay Only needs one Dr rather than two needed by section 2 A person can be detained up to 72 hours and then is converted to do a section 2
123
What patients are a risk of refeeding syndrome?
BMI of less than 16 weight loss of more than 15% over 3 to 6 months Little nutritional intake for more than 10 days Hypokalaemia hypophosphataemia or hypermagnesaemia prior to feeding
124
What are the four parts of a capacity assessment?
1. Can they take in information? 2. Can they weigh up the information? 3. Can they make a decision? 4. Can they communicate their decision?
125
What are a patient's rights if they are detained under the Mental Health Act?
To be told why they are detained To get legal advice To know where he is To get mental health treatment
126
Can someone detained under the Mental Health Act be given medical treatment against their will?
No - only under the Mental Capacity Act
127
How to manage an acute depressive episode in bipolar disorder?
Psychoogical intervention e.g. CBT If not already taking any medication --> Fluoxetine + Olanzapine. Or just Quetiapine If already taking Lithium --> Check plasma lithium level. If level is fine, add drugs listed above.
128
How to manage an acute manic episode?
Consider stopping any antidepressants If not taking any long term antipsychotics or mood stabiliser: 1. offer antipsychotic (Haloperidol/Olanzapine/Quetiapine/Risperidone) 2. Offer alternative from list 3. If antipsychotic not effective – Add lithium. 4. Add sodium valproate if lithium is not suitable (e.g. if routine blood monitoring will be an issue). Do not offer to women/girls of childbairing age unless no other choice. If already taking lithium: Check lithium levels to optimise treatment Consider adding antipsychotic
129
What ECG signs may be seen in anorexia nervosa?
Small T waves, prolonged PR, U waves (due to hypokalaemia)
130
What are non psychiatric causes of catatonia?
Locked in syndrome Vegetative state Stroke Encephalitis Meningitis

Medicine Finals (32 decks)

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