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Finals Revision > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

What should you cover in a psychiatric history?

A 
HOPC
Past psychiatric hx
PMhx
Drug hx, concordance with meds & side effects of psychiatric medication 
Social hx
Personal hx 
Premorbid personality 
Strengths
Carer responsibility 
Forensic hx
Family hx
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2
Q

What should you cover in a risk assessment for someone with psychiatric symptoms?

A 
Risk to self
Risk to others
Risk of self neglect
Risk of exploitation
Risk to dependents
Other risks - absconding
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3
Q

What should you include in a mental state examination? 8 things

A 
Appearance
Behaviour 
Speech
Mood and effect
Thoughts - form, content, possession 
Perceptions 
Cognition 
Insight
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4
Q

What should you evaluate for the appearance of a person during a MSE?

A 
Distinctive features
Clothing
Posture/gait
Grooming/hygiene
Evidence of self-harm
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5
Q

What should you evaluate for the behaviour of a person during a MSE?

A

Eye contact
Facial expression
Psychomotor activity –motor activity related to mental processes (can be slowed or increased)
Body language / gestures / mannerisms
Level of arousal –calm / agitated /aggression
Rapport / engagement

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6
Q

How should you evaluate the speech of a person during a MSE?

A

Rate of speech– pressured / slowed
Quantity of speech– minimal(e.g.only in response to questions) /excessive speech/complete absence of speech. Spontaneous?
Tone of speech –monotonous / tremulous
Volume of speech –loud / quiet
Fluency and rhythm of speech–articulate / clear / slurred

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7
Q

How should you evaluate the mood and affect of a person during a MSE?

A

Mood – their description
Affect – your observation

Quality of affect:
Sad/agitated/hostile
Euphoric/animated

Range of affect:
Restricted
Normal
Expansive

Intensity of affect:
Normal
Blunted
Flat

Fluctuations in affect:
Labile –easily changed between states

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8
Q

How should you evaluate a persons thoughts during a MSE?

A

FORM
Speed –accelerated / racing / retarded
Flow/ coherence:
Linear – in a logical order
Incoherent – makes no logical sense
Circumstantial – lots of irrelevant/unnecessary details (not to the point)
Tangential – the patient goes off on tangents relating loosely to the initial thought (flight of ideas)
Perseveration –repetition of a particular response despite the absence/removal of the stimulus

CONTENT
Abnormal beliefs/ delusions
Obsessions –patient is aware they are their own irrational
Suicidal thoughts
Homicidal/violent thoughts

POSSESSION
Thought insertion –belief that thoughts can be put into the patient’s mind
Thought withdrawal –belief that thoughts can be removed from patient’s mind
Thought broadcasting –belief that others can hear the patient’s thoughts

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9
Q

How should you evaluate a persons perceptions during a MSE?

A

Hallucinations –a sensory perception without any external stimulation of the relevant sensethat the patient believes IS real(e.g. hears voices but no sound present)

Illusions –illusions are misinterpreted perception such as mistaking a shadow for a person

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10
Q

How can you test someones cognition during a MSE?

A

Basic testing:
Orientation(time/place/person)
Attention and concentration
Short-term memory

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11
Q

How can you test if someone has insight during a MSE?

A

Can they recognise what they’re experiencing is abnormal?
What do they think is the cause of their experiences?
Do they want help with their problem?

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12
Q

What is acute stress reaction?

A

An acute stress reactions that occurs in the first 4 weeks after a person has been exposed to a traumatic events (PTSD is diagnosed after 4 weeks)

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13
Q

features of acute stress reaction

A

intrusive thoughts e.g. flashbacks, nightmares

dissociation e.g. ‘being in a daze’, time slowing

negative mood

avoidance

arousal e.g. hypervigilance, sleep disturbance

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14
Q

Mx of acute stress reaction

A

trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line

benzodiazepines
sometimes used for acute symptoms e.g. agitation, sleep disturbance
(should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation)

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15
Q

What is an illusion?

A

A false perception of a real external stimulus.

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16
Q

What is a hallucination?

A

A percept that is experienced in the absence of an external stimulus to the corresponding sense organ.

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17
Q

What are the different types of auditory hallucinations?

A

Second person hallucinations : voices address the patient directly (depression)

Third person hallucinations : voices talk to one another, referring to the patient as ‘he’ or ‘she’ (schizophrenia)

Gedankenlautwerden : voices speak the patients thoughts as they are thinking them

Echo de la pensee : voices repeat the patients thoughts after they have thought them

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18
Q

What is an over valued idea?

A

An unreasonable and sustained intense preoccupation maintained with less than delusional intensity. The belief is demonstrably false and not normally held by others of the same subculture. There is marked associated emotional investment.

Schizophrenia

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19
Q

What is a delusion?

A

A false belief based on incorrect inference about external reality that is firmly sustained despite what constitutes inconvertible and obvious proof or evidence to the contrary. The persons belief is not normally accepted by other members of the same subculture.

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20
Q

What is passivity?

A

The belief than an external agency is controlling aspects of the self that are normally entirely under ones own control. Includes thought alienation, made feelings, made impulses, made actions and somatic passivity.

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21
Q

Name some types of delusions

A 
Delusion of control
Persecutory delusion 
delusion of poverty
Delusion of reference 
Delusion of self accusation 
Erotic delusions
Delusion of infidelity 
Delusion of grandeur 
Delusion of doubles 
Nihilistic delusion
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22
Q

What is de Clerambault’s syndrome?

A

Delusional belief that another person is deeply in love with one (usually occurs in women, with the object often being a man of much higher social status). The supposed lover is usually inaccessible.

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23
Q

What is delusional jealousy/Othello syndrome?

A

Delusional belief that ones spouse or lover is being unfaithful. Jealousy is used on unsound evidence and reasoning.

More common in men.

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24
Q

What is a delusional perception?

A

A new and delusional significance is attached to a familiar real perception without logical explanation.

Is a 1st rank symptom of schizophrenia

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25
Q

What is thought alienation?

A

The delusional belief that ones thoughts are under control of an outside agency, or that others are participating in ones thinking. Includes thought insertion, thought withdrawal and thought broadcasting.

Is a 1st rank symptom of schizophrenia

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26
Q

What is thought insertion?

A

A belief that thoughts are being put into the mind by an external agency

1st rank symptom of schizophrenia

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27
Q

What is thought withdrawal?

A

A belief that thoughts are being removed from the mind by an external agency

1st rank symptom of schizophrenia

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28
Q

What is thought broadcasting?

A

A belief that thoughts are being read by others, as if they’re being broadcast

1st rank symptom of schizophrenia

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29
Q

What is thought block?

A

A sudden interruption in the train of thought occurs, leaving a ‘blank’, after which what was being said cannot be recalled

Schizophrenia

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30
Q

What is concrete thinking?

A

A lack of abstract thinking, normal in childhood, and occurring in adults with organic brain disease and schizophrenia. Theres inability to understand abstract concepts + theres extreme literalism.

Schizophrenia and ASD

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31
Q

What is perseveration?

A

Persistent and inappropriate repetition of the same thoughts or movements. Mental operations carry on beyond the point at which they are appropriate.

Dementia / frontal lobe injury

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32
Q

What is flight of ideas?

A

The speech consists of a stream of accelerated thoughts, with abrupt changes from topic to topic and no central direction. The connections between the thoughts may be based on chance relationships, verbal associations (e.g. alliteration and assonance), clang associations ( a second word with a sound similar to the first), puns, rhymes and distracting stimuli.

Mania

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33
Q

what is loosening of associations?

A

A loss of the normal structure of thinking. To the interviewer, the patients thoughts seem muddled, illogical of tangential to the matter in hand. With further questioning, the less clear the patients thoughts are.
3 characteristics of loosening of associations : talking past the point, Knights move & Verbigeration

Schizophrenia

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34
Q

What is knights move speech?

A

Odd, tangential associations between ideas, leading to disruptions in the smooth continuity of speech.
A transition from one topic to another, either between sentences or mid sentence, with no logical relationship between the 2 topics and no evidence of the associations described in flight of ideas.

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35
Q

What is verbigeration (world salad)?

A

When speech is reduced to the senseless repetition of words, sounds or phrases. This occurs with severe expressive aphasia + in schizophrenia.

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36
Q

What is tangentiality?

A

Tendency to speak about topics unrelated to the main topic of discussion. The patient wanders from the topic and never returns to it or provides the information requested.

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37
Q

What is conversion disorder?

A

a person has blindless, paralysis or other neurologic symptoms that cannot be explained by medical evacuation

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38
Q

Define tolerance

A

Takes place when the desired CNS effects of a psychoactive substance diminish with repeated use, so that increasing doses need to be administered to achieve the same effects.

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39
Q

Define dependence

A

A cluster of psychological, behavioural and cognitive phenomena in which the use of psychoactive substances takes on a much higher priority for the individual than other behaviours that once had higher value. There is a desire, which is often strong and overpowering, to take the substance on a continual or periodic basis. There is the development of tolerance, Dependence can be physical or psychological or both

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40
Q

Define withdrawal

A

A group of physical + psychological symptoms occurring on absolute or relative withdrawal of a psychoactive substance after repeated, and usually prolonged or high dose, use of that substance. It lasts for a limited time

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41
Q

Define alcohol dependence

A

Need 3+ of the following:

  • Strong desire to drink
  • Difficulty in controlling drinking behaviour
  • Withdrawal when drinking stops
  • Tolerance to alcohol
  • Neglect of alternative pleasures or interests
  • Keep drinking despite harmful consequences
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42
Q

Risk factors for problem drinking

A 
Male
High stress job 
Family hx
Depression
Bereavement 
Schizophrenia
Bipolar disorder
Peer group / lifestyle
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43
Q

What are the questions in the CAGE questionnaire?

A

(answer yes to 2 or more questions = problem drinking) :
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had drink first thing in the morning (Eye opener) to steady your nerves or get rid of a hangover?

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44
Q

What questionnaires are used to screen for alcohol dependence?

A

AUDIT - 10 screening questions

CAGE questions

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45
Q

What are withdrawal symptoms from stopping alcohol?

A 
agitation
Nervousness
Seizures
Delirium
Shaking / tremors 
Dilated pupils
tachycardia 
Hypertension 
Hallucinations 
Delirium tremens
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46
Q

Ix to see if someone is alcohol dependent

A 
Breath and blood alcohol levels
CDT - carbohydrate deficient transferrin
Gamma-GT (raised in 70% of alcohol misusers)
MCV - raised in 60% of alcohol misusers 
FBC - low Hb and Low platelets 
AST & ALT - elevated if liver damage
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47
Q

Consequences of problem drinking

A 
Falls / ataxia
Vomiting / inhalation of vomit
Hypothermia 
Impulsivity 
Respiratory depression 
Confusion / reduced LOC / coma 
Gi conditions
Malnutrition 
Liver: fatty infiltration, alcoholic hepatitis, cirrhosis
Pancreatitis
Iron deficiency anaemia & macrocytosis
Delirium tremens
Wernicke's encephalopathy
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48
Q

Clinical features of delirium tremens

A 
delirium
agitation
confusion
paranoia
visual/auditory hallucinations
tremor
disorientation
sweating
hypertension
tachycardia

DT begins 2-4 days after last drink and usually lasts 3-4 days

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49
Q

Tx for delirium tremens

A

Oral lorazepam

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50
Q

What is wernickes encephalopathy?

A

A neurological emergency resulting from thiamine deficiency secondary to alcohol abuse

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51
Q

Clinical features of wernickes encephalopathy

A

delirium, ataxia, pupillary abnormalities, eye movement abnormalities, nystagmus, peripheral neuropathy, impaired concentration, apathy

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52
Q

Tx of wernickes encephalopathy

A

IV thiamine
Magnesium sulfate
Multivitamin

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53
Q

What is korsakovs syndrome

A

an amnesic syndrome that follows the acute phase of wernicke’s encephalopathy

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54
Q

Tx of alcohol withdrawal

A

Benzodiazepines - choldiazepoxide or diazepam
Thiamine, folic acid and magnesium sulphate
Supportive treatments

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55
Q

What questionnaire is used to assess if someone who is alcohol dependent will have a difficult withdrawal?

A

Use ‘The Severity of Alcohol Dependence Questionnaire’ (SADQ) to assess the risk of a patient having difficulty during withdrawal. Score of 15-30+ is indication for inpatient detoxification

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56
Q

Mx for alcohol misuse

A

Motivational interviewing
Detoxification - inpatient or at home (decide using SADQ questionnaire)
If inpatient = chlordiazepoxide or diazepam/lorazepam (use these if liver failure)
CBT
Alcoholic anonymous

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57
Q

Drugs used to prevent relapse of drinking

A

Acamprosate - stimulates GABA and decreases glutamate like alcohol does = less urge to drink

Naltrexone - opioid antagonist that blocks the effects of alcohol

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58
Q

What is the reason behind alcohol withdrawal?

A

chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors

alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

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59
Q

When after stopping alcohol do symptoms of withdrawal start and what are those symptoms?

A

6-12 hours later = tremor, sweating, tachycardia, anxiety

36 hours - peak incidence seizures

48-72 hours - DT (coarse tremor, confusion, delusions, hallucinations, fever, tachycardia)

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60
Q

What is the pathology behind Korsakoff’s syndrome

A

marked memory disorder often seen in alcoholics

thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus

often follows on from untreated Wernicke’s encephalopathy

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61
Q

symptoms of korsakoffs syndrome (RACK)

A

(RACK)

  • retrograde amnesia
  • anterograde amnesia: inability to acquire new memories
  • confabulation
  • Korsakoff’s psychosis
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62
Q

symptoms of wernickes encephalopathy (COAT)

A

COAT

  • Confusion
  • Ophthalmoplegia
  • Ataxia
  • Thiamine deficiency
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63
Q

Mechanism of action of benzodiazepines

A

Benzodiazepines enhance the effect of the inhibitory neurotransmitter GABA by increasing the frequency of chloride channels opening.

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64
Q

Symptoms of benzodiazepine withdrawal syndrome and when does it happen?

A

If patients withdraw too quickly from benzo
Can occur up to 3 weeks after stopping a long acting drug

INsomnia 
Irritability
Anxiety
Tremor
Loss of appetite 
Tinnitus
Perspiration 
Perceptual disturbances
Seizures
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65
Q

What is generalised anxiety disorder?

A

at least 6 months of persistent anxiety associated with chronic uncontrollable and excessive worry.

It may fluctuate in severity but is NOT paroxysmal (as with panic disorder), situational (as with phobia), life long (as with personality disorders) or clearly stress related (as with stress related disorder).

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66
Q

Symptoms of generalised anxiety disorder

A

Theres anxiety with excessive, disproportionate and uncontrollable worry for at least 6 months
Easily startled, on edge (exaggerated startle response)
Sleep disturbance
Fatigue
Restlessness
Irritability
Poor concentration
Somatic symptoms include : multiple chronic aches, headaches, tension, sweating, dizziness, GI symptoms, increased HR, SOB, trembling, dry mouth, dysphagia, frequency of urination, flushes
Associated with : depression

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67
Q

Risk factors for generalised anxiety disorder

A 
Family Hx of anxiety 
Physical or emotional stress
Hx of physical or emotional trauma
Other anxiety disorder
Female sex
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68
Q

Mx of generalised anxiety disorder

A 
Antidepressant e.g. SSRI
Benzodiazepines
CBT
Applied relaxation 
Meditation training
Sleep hygiene and education 
Exercise
Self help
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69
Q

What is post traumatic stress disorder?

A

a delayed response, usually within 6 months, to an exceptionally severe traumatic event, which is likely to cause pervasive distress to almost anyone.

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70
Q

what are the 5 key symptoms of PTSD? and how long do they need to be present for a diagnosis to be made

A

Symptoms present for more than 1 month

1 Experience of a major trauma
2 Intrusive recollections - thoughts, nightmares and flashbacks
3 Sense of numbness and emotional blunting. Avoidance of reminders.
4 increased arousal and hypervigilance
5 onset follows the trauma after a latency period of a few weeks to months (no more than 6 months)

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71
Q

Mx of PTSD

A

Eye movement desensitisation and reprocessing (EMDR)

Trauma focused CBT

Antidepressants - venlafaxine or SSRI

Treat comorbid psychiatric disorders/substance abuse

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72
Q

What is obsessive compulsive disorder?

A

a non-situational pre-occupation in which there is subjective compulsion despite conscious resistance. Such pre-occupations can be thoughts (ruminations or obsessions) or acts (rituals or compulsions).

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73
Q

Define obsession

A

an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.

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74
Q

Define compulsion

A

repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

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75
Q

risk factors for ocd

A

genetic
psychological trauma
pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)

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76
Q

mx of OCD

A
  • CBT
  • Exposure and response prevention – learning to cope with the increasing tension associated with increasing tension from not performing rituals
  • Thought stopping technique – therapist shouts ‘stop’ as the patient ruminates
  • SSRI e.g. fluoxetine
  • Tricyclic antidepressant e.g. clomipramine
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77
Q

What can be used to grade the severity of OCd?

A

Yale-Brown Obsessive-Compulsive scale

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78
Q

Symptoms of OCD

A

Obsessive thinking - recurrent and intrusive thoughts
Ruminations - recurrent thoughts that are absurd/unwelcome to the patient
Compulsions - repetitive actions to provide relief from anxiety
Rituals - repetitive time consuming and done to relieve an anxiety
Anxiety
Egodystonic - behaviour patterns that aren’t in agreement with ideal self image

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79
Q

What is bipolar disorder?

A

the occurrence of at least one episode of mania, usually but not necessarily accompanied by at least one depressive episode.

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80
Q

Symptoms of mania

A
  • Elevation of mood – can manifest as elation or can be irritable/angry
  • Increased energy
  • Overactivity
  • Pressure of speech
  • Reduced sleep
  • Loss of normal social and sexual inhibitions
  • Elated self-esteem / grandiosity
  • Flight of ideas
  • Increased goal directed activity or psychomotor agitation
  • Poor concentration and attention
  • Overspending
  • Start unrealistic projects
  • Neglect of eating/drinking/personal hygiene
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Perfectly
81
Q

Risk factors for bipolar disorder

A
  • Family history of bipolar disorder
  • Stressful life events
  • History of depression
  • Presence of anxiety disorder
82
Q

Mx for bipolar disorder

A
  1. Hospitalisation of patients suffering from mania
  2. a. MOOD STABILISERS e.g. lithium (lithium carbonate or lithium citrate) or carbamazepine
  3. ECT
  4. Psychosocial therapy
83
Q

CIs for lithium use

A

renal insufficiency, cardiovascular insufficiency, Addison’s disease, untreated hypothyroidism

84
Q

What monitoring is required for lithium and why?

A

Has a very small therapeutic range = 0.4-1.0 mol/L

Has a long plasma half life (excreted mainly by the kidneys)

Check lithium levels 12 hours post dose
After starting - check lithium levels weekly and after each dose change until stable

Once stable, check lithium levels every 3 months

After a change in dose, check lithium levels a week later then weekly until stable

Check TFTs and U&Es every 6 months

85
Q

Side effects of lithium

A 
Nausea vomiting diarrhoea
Fine tremor
Nephrotoxicity - polyuria, secondary to nephrogenic diabetes insipidus 
Hypothyroidism
ECG - T wave flattening/inversion
Weight gain
Idiopathic intracranial hypertension 
Leucocytosis
Hyperparathroidism = Hypercalcaemia
86
Q

Symptoms of lithium toxicity

A 
Coarse tremor (is fine tremor at therapeutic levels)
Hyperreflexia
Acute confusion 
Polyuria
Seizure
Coma
87
Q

Mx for lithium toxicity

A

Mild-moderate = normal saline

Severe = haemodialysis

88
Q

Causes of lithium toxicity

A 
Dehydration
Renal failure
Diuretics
ACei/ARBs
NSAIDs
metronidazole
89
Q

Mx for patient presenting with mania/hypomania

A

stop any antidepressants

start an antipsychotic e.g. olanzapine or haloperidol

90
Q

How long should patients stay on antidepressants for?

A

Continue antidepressants for at least 6 months after remission of depression symptoms to decrease the risk of relapse

91
Q

What is cotard syndrome?

A

patient believes that they (or in some cases just a part of their body) is either dead or non-existent.

92
Q

What is somatisation disorder?

A

multiple physical SYMPTOMS present for at least 2 years

patient refuses to accept reassurance or negative test results

93
Q

What is illness anxiety disorder (hypochondriasis)?

A

persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results

94
Q

What is conversion disorder?

A

typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)

patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

95
Q

What is dissociative disorder?

A

dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor

96
Q

what is factitious disorder?

A

also known as Munchausen’s syndrome

the intentional production of physical or psychological symptoms

97
Q

What is malingering?

A

fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

98
Q

What is delirium?

A

Acute generalised psychological dysfunction and change in mental status, that usually fluctuates in degree and includes inattention, disorganised thinking & altered levels of consciousness.

99
Q

What are the symptoms of delirium?

A
  • Prodrome: agitation & sensitive to light/sound
  • Impairment in consciousness
  • Hallucinations
  • Mood changes e.g. anxiety, lability, agitation, combativeness or depressed mood
  • Cognitive impairment e.g. disorientation in time and place, poor concentration and impaired new learning, registration, retention and recall
  • Develops over hours to days
  • Symptoms fluctuate throughout the day (typically worse in the evening = sundowning)
100
Q

Causes of delirium - I WATCH DEATH

A

Infections e.g. UTI, pneumonia, meningitis, HIV, syphilis
Withdrawal e.g. alcohol
Acute metabolic disorders e.g. DKA
Trauma
CNS pathology e.g. stroke / brain tumour
Hypoxia e.g. anaemia, cardiac failure, COPD, pulmonary embolism
Dehydration / deficiencies e.g. B12, folic acid, thiamine
Endocrine e.g. hyperthyroidism/hypothyroidism, Addison’s disease (Primary hypoadrenalism), Cushing’s syndrome
Acute vascular e.g. MI, shock, vasculitis
Toxins/drugs e.g. Anticholinergics, benzodiazepines, antidepressants, antipsychotics, antihistamines, opioids, diuretics, recreational drugs, alcohol use disorder
Heavy metals e.g. arsenic, lead, mercury

101
Q

Causes of delirium PINCH ME

A 
Pain
Infection 
Nutrition 
Constipation 
Hydration 
Meds
Environment/electrolytes/endocrine
102
Q

Mx of delirium

A
  1. Identify and treat underlying cause
  2. Supportive care
    a. Hydrate and good nutrition
    b. Avoid drugs that can worsen delirium e.g. benzo’s, anticholinergics, opioids
    c. Reorientate the patient regularly
    d. Reduce the amount of noise, procedures and medication administration at night
    e. Arrange regular visits from family and friends & for constant observation (by family or friend)
    f. Physical and occupational therapy to mobilise the patient
    g. Minimise use of restraints
  3. Pharmacology
    a. Haloperiodol (antipsychotic) oral or IM – to reduce agitation
  4. Pharmacology for the prevention of delirium:
    a. Dexmedetomidine – a sedative that doesn’t cause respiratory depression like opioids do
    b. Cholinesterase inhibitors e.g. rivastigmine or donepezil
    c. Second generation antipsychotics
103
Q

2 screening questions for depression

A

‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’

‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’

104
Q

What tools can be used to assess if someone is depressed?

A

Hospital anxiety and depression score (HAD)

Patient health questionnaire (PHQ-9)

105
Q

Criteria for diagnosing depression

A
  1. Depressed mood most of the day, nearly every day
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
  3. Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
  4. Insomnia or hypersomnia nearly every day
  5. Psychomotor agitation or retardation nearly every day
  6. Fatigue or loss of energy nearly every day
  7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
  8. Diminished ability to think or concentrate, or indecisiveness nearly every day
  9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
106
Q

what is depression?

A

Depression is a mental state characterised by persistent low mood, loss of interest and enjoyment in everyday activities, neurovegetative disturbance, and reduced energy, causing varying levels of social and occupational dysfunction.

107
Q

How can the severity of depression be graded?

A
  1. Mild depressive episode - 2-3 clinical features & patient can continue functioning
  2. Moderate depressive episode - 4+ clinical features & patient may have difficulty functioning
  3. Severe depressive episode without psychotic symptoms - several clinical features that are marked & distressing. Theres loss of self-esteem, ideas of guilt and worthlessness. Suicidal. Biological/somatic symptoms present.
  4. Severe depressive episode with psychotic symptoms - as with severe depressive episode + hallucinations/delusions/psychomotor retardation/stupor. There’s increased risk of suicide, dehydration & starvation.
108
Q

what is seasonal affective disorder?

A

a regular temporal relationship between the onset of the depressive episode and a particular time/season of the year. During the depressive episode theres carb craving, hypersomnia (excessive sleepiness) & weight gain.

109
Q

Ix for person presenting with depression

A 
Clinical diagnosis
U&E, LFT, TFTs, LFTs
Vitamin B12 and folate
Syphilitic serology 
EEG/CT/MRI if indicated
110
Q

What are the dementia screening bloods?

A 
FBC
Folate
B12
LFT
U&E
TFT
BMs
Cholesterol 
Calcium
111
Q

Risk factors for depression

A

Post natal
Personal/family hx depression
Co-existing medical condition
Psychosocial stressors

112
Q

Mx of mild depression

A 
Sleep hygiene 
active monitoring 
Individual guided self help
CBT
Group physical activity programme 
Group CBT

don’t give antidepressant unless hx of severe depression, symptoms present for long time, mild depression persists despite above interventions or patient has chronic health condition

113
Q

Treatment of moderate to severe depression

A

Hospitalise when there is risk to self

i. Selective serotonin reuptake inhibitors (SSRIs) - fluoxetine & sertraline
ii. Serotonin-noradrenaline reuptake inhibitor (SNRI) – venlafaxine & duloxetine
iii. Noradrenaline reuptake inhibitor (NARI) - reboxetine
iv. Monoamine oxidase inhibitors (MAOIs) - phenelzine (is a non-selective one used for atypical depression)
1. Subclass of this: Reversible inhibitor of monoamine oxidase A (RIMA)
v. Noradrenergic and specific serotonergic antidepressant (NaSSA) - mirtazapine

Other mx:

  • Electroconvulsive therapy
  • Phototherapy for SAD
  • CBT
  • Group therapy
  • Family/marital therapy
114
Q

How long should antidepressants be taken for?

A

Risk of relapse reduced if antidepressants used for a continued 6 months after the end of an episode

115
Q

Give 3 examples of an SSRI and when should you prescribe each one?

A

Citalopram, fluoxetine, sertraline

1) Citalopram - preferred SSRI for 1st line depression tx
2) Fluoxetine - preferred SSRI for 1st line depression tx and chosen for treating children/adolescents
3) Sertraline - useful post MI as there’s more evidence for its safe use in this situation

116
Q

Side effects of SSRIs

A

GI symptoms
GI bleeding risk increased
Anxiety/agitation after first starting
Hyponatraemia
Increased risk of suicide in first 2 weeks
Stay on for 6 months after remission to reduce risk of relapse

117
Q

ECG changes with citalopram

A

QT interval prolongation (dose dependent)

118
Q

Drug interactions with SSRIs

A

NSAIDs/aspirin - increased GI bleed risk (prescribe with PPI)

Warfarin/heparin - prescribe mirtazapine instead of SSRI

Triptans - increased risk of serotonin syndrome

MAOIs - increased risk of serotonin syndrome

119
Q

How do you stop an SSRI?

A

Gradually reduce the dose over 4 weeks

Don’t have to taper the dose of fluoxetine, can just stop

120
Q

Discontinuation symptoms of SSRIs

A 
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
121
Q

Are SSRIs safe in pregnancy?

A

Weigh up risk v benefits

Use during the first trimester gives a small increased risk of congenital heart defects

Use during the third trimester can result in persistent pulmonary hypertension of the newborn

Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

122
Q

How do serotonin and noradrenaline reuptake inhibitors work?

A

Inhibiting the reuptake increases the concentrations of serotonin and noradrenaline in the synaptic cleft leading to the effects

123
Q

Give 2 examples of SNRIs

A

venlafaxine and duloxetine

124
Q

Side effects of monoamine oxidase inhibitors

A

hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans

anticholinergic effects

125
Q

Example tricyclic antidepressants and what they’re used for

A

used less commonly now for depression due to their side-effects and toxicity in overdose but used for neuropathic pain

Sedative ones:
Amitriptyline
Clomipramine
Dosulepin
Trazodone

Less sedating ones:
Imipramine
Lofepramine
Nortriptyline

126
Q

Common side effects of tricyclic antidepressants

A 
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval
127
Q

ECG change with tricyclic antidepressants?

A

Lengthened QT interval

128
Q

How does mirtazapine work?

A

works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters

129
Q

Side effects of mirtazapine

A

Sedation (take in the evening)
Increased appetite

Useful SEs for people who aren’t sleeping or eating

130
Q

What can cause serotonin syndrome?

A

monoamine oxidase inhibitors

SSRIs
(St John’s Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome)

ecstasy
amphetamines

131
Q

Symptoms of serotonin syndrome

A

neuromuscular excitation:

  • hyperreflexia
  • myoclonus
  • rigidity

autonomic nervous system excitation:

  • hyperthermia
  • sweating

altered mental state:
- confusion

dilated pupils
tachycardia

132
Q

Mx of serotonin syndrome

A

1) supportive including IV fluids
2) benzodiazepines
3) more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine

133
Q

Mx of paracetamol overdose

A

activated charcoal if ingested < 1 hour ago
N-acetylcysteine (NAC)
liver transplantation

134
Q

Mx of salicylate overdose (aspirin)

A

urinary alkalinization with IV bicarbonate

haemodialysis

135
Q

Mx of opioid overdose

A

naloxone

136
Q

Mx of benzodiazepine overdose

A

1) supportive

2) flumazenil - risk of seizures so use in severe cases or iatrogenic overdoses

137
Q

Mx of tricyclic antidepressant overdose

A

1) IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
2) arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias
3) dialysis is ineffective in removing tricyclics

138
Q

Mx of lithium overdose

A

1) mild-moderate toxicity = normal saline
2) haemodialysis may be needed in severe toxicity
3) sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion

139
Q

Tx of warfarin overdose

A

Vitamin K

Prothrombin complex

140
Q

Mx of beta blocker overdose

A

1) if bradycardic = atropine

2) in resistant cases glucagon may be used

141
Q

Mx of ethylene glycol (antifreeze, solvents, paints) overdose

A

1) fomepizole
2) ethanol
3) haemodialysis

142
Q

Mx of methanol poisoning

A

fomepizole or ethanol

haemodialysis

143
Q

Mx of digoxin overdose

A

Digoxin-specific antibody fragments

144
Q

Mx of iron overdose

A

Desferrioxamine, a chelating agent

145
Q

Mx of lead poisoning

A

Dimercaprol, calcium edetate

146
Q

Mx of carbon monoxide poisoning

A

100% oxygen

hyperbaric oxygen

147
Q

What is anorexia nervosa?

A

An eating disorder characterised by restriction of caloric intake leading to deliberate weight loss and low body weight, an intense fear of gaining weight and body image disturbance

148
Q

Symptoms of anorexia nervosa

A

Restriction of calorie intake
Significantly low body weight
Disturbance of body image
Preoccupation with maintenance of low body weight
Denial of seriousness
Amenorrhoea
Poorly developed secondary sexual characteristics
fatigue / poor concentration
bradycardia, prolonged QT, AV heart block
lanugo hair

149
Q

Risk factors for anorexia nervosa

A

female
adolescent
family hx depression
adverse parenting

150
Q

Mx of anorexia nervosa

A

structured eating plan with oral nutrition
give multivitamin, phosphorus, magnesium, calcium and thiamine
CBT
Family interventions
Potassium repletion
fluoxetine/sertraline if depression

151
Q

what is bulimia nervosa?

A

Recurrent episodes of uncontrollable binge eating and compensatory behaviour (vomiting / fasting / excessive exercise / misuse of laxatives, diuretics or enemas)

Binge eating episodes are characterised by eating a larger amount of food than normal, in a discrete period of time and a sense of lack of control during the episode. Theres an irresistible & recurrent urge to overeat.

152
Q

Risk factors for bulimia nervosa

A 
Female sex
Personality disorder / impulsivity
Body image disturbance
Hx of sexual abuse
family Hx alcoholism, depression, eating disorder, obesity
Exposure to media pressure
Early onset of puberty
153
Q

Mx of bulimia nervosa

A

CBT
Nutritional and meal support : help from dietician about their concerns, feelings, habits and beliefs about eating
SSRI or SNRI e.g. fluoxetine, sertraline or venlafaxine
Psychological therapies e.g. interpersonal psychotherapy, family therapy in younger patients and self help groups

154
Q

What is a personality disorder?

A

Severe disturbance in the personality and behavioural tendencies of an individual.
Behaviour is inflexible, maladaptive and dysfunction.
Distress is caused to self and others.
Presentation is stable & longstanding (starting in childhood/adolescence)

155
Q

What are the 3 clusters of personality disorders?

A

Cluster A = withdrawn, odd and eccentric

Cluster B = dramatic, emotional and erratic

Cluster C = dependent and inhibited

156
Q

What are the personality disorders in cluster A?

A

Paranoid
Schizoid
Schizotypal

157
Q

What are the personality disorders within cluster B?

A 
Antisocial
Emotionally unstable (borderline)
Impulsive 
Histrionic
Narcissistic
158
Q

What are the personality disorders within cluster C?

A 
Avoidant (anxious)
Dependent
Obsessive compulsive (anakastic)
159
Q

What are the traits of someone with a paranoid personality disorder?

A

Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character

160
Q

What are the traits of someone with a schizoid personality disorder?

A 
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
161
Q

What are the traits of someone with a schizotypal personality disorder?

A 
Ideas of reference (differ from delusions in that some insight is retained)
Odd beliefs and magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent
162
Q

What are the traits of someone with an emotionally unstable personality disorder?

A

Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts

163
Q

What are the traits of someone with an antisocial personality disorder?

A

Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for the safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

164
Q

What are the traits of someone with a histrionic personality disorder?

A

Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are

165
Q

What are the traits of someone with a narcissistic personality disorder?

A 
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power, or beauty
Sense of entitlement
Taking advantage of others to achieve own needs
Lack of empathy
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
166
Q

What are the traits of someone with an obsessive compulsive personality disorder?

A

Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness

167
Q

What are the traits of someone with an avoidant personality disorder?

A

Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact

168
Q

What are the traits of someone with a dependent personality disorder?

A

Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves

169
Q

Mx of personality disorders

A

psychological therapies: dialectical behaviour therapy

treatment of any coexisting psychiatric conditions

170
Q

symptoms of schizophrenia in the acute syndrome

A

Positive symptoms are seen in the acute syndrome and positive symptoms include a specific set of symptoms called (Schneider’s) first rank symptoms that are given particular weight in the diagnosis.
There may be a prodrome of negative symptoms/psychosis.

  • First rank symptoms:
    o Hearing thoughts spoken aloud
    o Third person hallucinations
    o Hallucinations in the form of a commentary
    o Somatic hallucinations: feel something touching them / insects crawling about inside their body
    o Thought withdrawal or insertion
    o Thought broadcasting
    o Delusional perception
    o Passivity - feelings or actions experienced as made or influenced by external agents

Other symptoms:

  • impaired insight
  • incongruity/blunting of affect
  • decreased speech
  • neologisms - made up words
  • catatonia
  • persecutory delusions
171
Q

symptoms of schizophrenia in the chronic syndrome

A

many recover from the acute syndrome but some progress to the chronic syndrome

Negative symptoms:

  • Apathy
  • Anhedonia
  • Social withdrawal / antisocial behaviour
  • Poor self care
  • Blunted affect
172
Q

risk factors for schizophrenia

A 
family history 
black/caribbean 
Migration
urband environment
cannabis use
173
Q

Mx of schizophrenia - acute psychotic episode

A

1) hospitalisation
2) 1st line = second generation antipsychotic e.g. risperidone, paliperidone, quetiapine
3) 2nd line = other second generation antipsychotics e.g. olanzapine, clozapine or a low potency 1st gen antipsychotic e.g. chlorpromazine
4) 3rd line = high potency 1st gen antipsychotic e.g. haloperidol, fluphenazine, perphenazine
5) don’t respond to 2 adequate trials of 2 different 2nd gen antipsychotics = clozapine

in pregnancy - 1st gen seem less harmful than 2nd gen antipsychotics

Extreme agitation/violence = IM lorazepam

Electroconvulsive therapy

174
Q

What shouldn’t you combine with IM lorazepam?

A

olanzapine

  • risk of sudden death
175
Q

what’s another name for 1st and 2nd generation antipsychotics

A

1st gen = typical antipsychotic

2nd gen = atypical antipsychotics

176
Q

What side effects are second generation antipsychotics less likely to cause than 1st gen?

A

extra-pyramidal side effects

but they are more likely to cause metabolic side effects - weight gain and hyperglycaemia

177
Q

How do 1st gen/typical antipsychotics work?

A

Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways

178
Q

Side effects of 1st gen/typical antipsychotics

A

Extrapyramidal side effects:

  • Parkinsonism
  • Acute dystonia - sustained muscle contraction (torticollis, oculogyric crisis). Mx with procyclidine
  • Akathisia - severe restlessness
  • tardive dyskinesia - late onset of abnormal. involuntary movements that may be irreversible e.g. chewing and pouting of the jaw

Hyperprolactinaemia = galactorrhea

antimuscarinic SE = dry mouth, blurred vision, urinary retention, constipation

sedation 
weight gain
impaired glucose tolerance
neuroleptic malignant syndrome
prolonged QT interval
179
Q

what is acute dystonic reaction, symptoms and management

A

an acute neurological condition, commonly seen in the emergency department that is characterized by involuntary muscle contractions that may manifest as torticollis, opisthotonus, dysarthria and/or oculogyric crisis

caused by antipsychotics (1st gen), antiemetics, antidepressants

mx = procyclidine

180
Q

ECG changes with haloperidol

A

prolonged QT interval

181
Q

Side effects of 2nd gen/atypical antipsychotics

A

weight gain
clozapine = agranulocytosis (low neutrophils)
hyperprolactinaemia

182
Q

Specific warnings about antipsychotics in elderly patients

A

Increased risk of stroke

increased risk of VTE

183
Q

examples of 2nd gen/atypical antipsychotics

A

clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation

184
Q

Side effects of clozapine

A 
agranulocytosis
neutropenia 
reduced seizure threshold 
constipation 
myocarditis
hypersalivation

might need to dose adjust if smoking is started/stopped during treatment

185
Q

example 1st gen/typical antipsychotics

A

haloperidol

chlorpromazine

186
Q

what is neuroleptic malignant syndrome?

A

: a potentially life-threatening side effect of both first generation and second generation antipsychotics.

187
Q

symptoms of neuroleptic malignant syndrome

A

muscle rigidity,
hyperthermia,
autonomic instability (tachycardia, labile blood pressure, tachypnoea, diaphoresis, dysrhythmias) mental status change (confusion, delirium, stupor)

188
Q

Diagnosis of neuroleptic malignant syndrome

A

high creatinine kinase & leucocytosis

189
Q

Tx of neuroleptic malignant syndrome

A 
stop antipsychotic
supportive measures (ICU),

dantrolene (a ryanodine receptor antagonist that prevents the release of calcium in striated muscle = reduced muscle rigidity & hyperthermia)

190
Q

what monitoring/ix are required on starting an antipsychotic?

A 
FBC - then annually 
U&E - then annually 
LFT - then annually 
lipids - then at 3 months & annually 
weight - then at 3 months & annually 
fasting blood glucose - then at 6 months & annually 
prolactin  - then at 6 months & annually 
BP - check frequently at dose titration 
ECG

+ do cardiovascular risk assessment annually

191
Q

How often should FBC be checked in patients on antipsychotics?

A

Annually

But more often with clozapine - weekly intially

192
Q

What is Wernicke’s encephalopathy?

A

a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics (is the acute phase)

193
Q

Causes of wernickes encephalopathy

A

Alcohol
Persistent vomiting
stomach cancer
dietary deficiency of thiamine

194
Q

Triad of symptoms seen in wernickes encephalopathy

A

confusion
ophthalmoplegia/nystagmus
ataxia
(thiamine)

COAT

195
Q

Symptoms of wernickes encephalopathy

A 
nystagmus (the most common ocular sign)
ophthalmoplegia
ataxia
confusion, altered GCS
peripheral sensory neuropathy
196
Q

ix for wernickes encephalopathy

A

decreased red cell transketolase

MRI

197
Q

mx of wernickes encephalopathy

A

thiamine

198
Q

complication of untreated wernickes encephalopathy

A

Korsakoffs syndrome

anterograde and retrograde amnesia + confabulation

199
Q

what is ECT

A

electroconvulsive therapy

treatment for severe depression refractory to medication

200
Q

CI for ECT

A

raised ICP

201
Q

Short term side effects of ECT

A 
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
202
Q

Long term side effects of eCT

A

some patients report impaired memory

Finals Revision (18 decks)

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