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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

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1
Q

Define Bipolar disorder

A

A mood disorder characterised by episodes of depression and mania or hypomania

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2
Q

Aetiology of bipolar disorder?

A

Genetic factors: having a first degree relative affected with bipolar disorder increases an individual’s risk of developing bipolar and unipolar mood disorders, as well as schizoaffective disorder. It is a type of polygenic inheritance.

Environmental factors: environmental factors are not specific to this condition. Negative life events can trigger a manic or depressive episode

Neurobiological factors: increased dopamine activity may be important in the aetiology of mania.

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3
Q

Risk factors for bipolar disorder?

A

Genetic factors
Prenatal exposure to toxoplasma gondii
Premature birth <32 weeks gestation
Childhood maltreatment
Postpartum period
Cannabis use

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4
Q

What are the 2 main forms of bipolar disorder?

A

Bipolar I
Bipolar II

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5
Q

What is the difference between bipolar I and bipolar II?

A

Bipolar I: the person has experienced at least one episode of mania
Bipolar II: the person has experienced at least one episode of hypomania but not an episode of mania. They must also have experienced at least one episode

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6
Q

Describe the features of mania

A

ICD 10:
Elevated mood out of keeping with the patient’s circumstances
Elation accompanied by increasing energy resulting in overactivity, pressure of speech and a decreased need for sleep
Inability to maintain attention, often marked with distractibility
Self esteem which is often inflated with grandiosity and increased confidence
Loss of normal social inhibitions

The manic episode should last for at least 7 days and have a significant negative functional effect on work and social activities.

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7
Q

Describe the features of hypomania

A

Less severe than mania and is characterised by an elevation

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8
Q

Management of bipolar disorder?

A

Acute manic episode: atypical antipsychotic eg olanzapine or risperidone OR 2nd line try sodium valproate

Depressive episodes: avoid antidepressant as could cause rapidly cycling moods → try atypical antipsychotic eg olanzapine or quetiapine

General Maintenance:
1st line= lithium

Patients must not drive during an acute episode & must inform DVLA of diagnosis

CBT can be used as a psychological therapy

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9
Q

Define depression

A

Low mood lasting >2 weeks

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10
Q

Signs and symptoms of depression?

A

Core triad: low mood, anhedonia, anergia

Slow speech, withdrawn, sleep problems, change in appetite/libido, diurnal mood variation, agitation, guilt, hopelessness

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11
Q

Investigations for depression?

A

PHQ-9 Questionnaire
<4= none
5-9= mild
10-14= moderate
15-19= severe
>20= severe

Risk assessment: self harm and suicide
Bloods: rule out other causes of tiredness eg anaemia or hypothyroidism

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12
Q

Management of depression?

A

Mild: watch & weight w/ group CBT, individual self help etc
Moderate/Severe: SSRIs eg sertraline or citalopram if these are unsuccessful try SNRIs eg venlafaxine

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13
Q

Define GAD?

A

Excessive anxiety about a number of situations associated w/ heightened tension for >6 months

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14
Q

Define agoraphobia?

A

Fear of public spaces or fear of entering public spaces which immediate escape would not be possible. Marked avoidance of at least 2 of: crowds, public spaces, travelling alone, travelling away from home

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15
Q

Define social phobia?

A

Fear of social situations which may lead to embarrassment or humiliation or scrutiny or criticism from other people

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16
Q

Define panic disorder?

A

Acute attacks which are unpredictable in nature and not restricted to any particular circumstance or situation. Often first present to A&E

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17
Q

Symptoms of GAD?

A

Mental: restlessness, poor concentration, fatigue, irritability, nervousness, fear of losing control

Physical: increased muscle tension, light headedness, palpitations, tachycardia, GI disturbance, breathing difficulties, chest pain, sweating

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18
Q

Investigations for GAD?

A

GAD-7:
<4= normal
5-9= mild
10-14= moderate
15+= severe

Bloods/ECG= to rule out other causes

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19
Q

Management of GAD?

A

Psychoeducation and explaining GAD to the patient
Self help or psychoeducational groups
CBT

Medication:
SSRIs (sertraline or citalopram) or SNRIs (duloxetine)

Specialist input if cannot tolerate medication or medication/CBT not working

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20
Q

Define OCD?

A

Characterised by obsessive thoughts and compulsive acts that cause functional impairment and/or distress

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21
Q

What other conditions are associated with OCD?

A

Depression, schizophrenia, anorexia, tourette’s

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22
Q

Signs and symptoms of OCD?

A

Obsessive thoughts: patient’s own thoughts. Unpleasant, repetitive, intrusive and irrational thoughts that are regarding sexual or blasphemous subjects or surrounding death.

Compulsions: Repetitive behaviours or mental acts that the patient cannot resist performing and may be overt or covert → washing, checking, contamination, fears, doubts, symmetrical insistence, aggressive thoughts

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23
Q

Diagnostic criteria for OCD?

A
  1. obsession and/or compulsion
  2. time consuming
  3. causes distress or the patient knows it is unreasonable
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24
Q

Management of OCD?

A

Mild: low intensity psychological intervention eg CBT or ERP, may consider SSRI

Moderate: SSRI & high intensity psychological intervention.

Severe: refer to specialist and combine SSRI with ERP & CBT

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25
Define PTSD?
Heightened state of stress occurring after a traumatic event or lots of little traumatic events and must occur over >4 weeks
26
Signs and symptoms of PTSD?
HEAR: Hyperarousal, emotional numbing, avoidance, intrusive recollections others may notice depression, drug/alcohol misuse, anger issues
27
Management of PTSD?
<4 weeks: acute stress reaction- watch & wait 1st line: (1 month after trauma) trauma focused CBT 1st line (3 months after trauma or 2nd line): EMDR
28
Define schizophrenia?
Splitting of thoughts or loss of contact with reality, affecting thoughts, perceptions (sight, smell, taste, touch, sounds), mood, personality, speech etc
29
Epidemiology of schizophrenia?
onset typically 2nd-3rd decade and second peak in middle age
30
Risk factors for schizophrenia?
family hx, black Caribbean ethnicity, migrated, live in urban environment, cannabis use
31
1st rank schizophrenia symptoms?
Auditory hallucinations: talking about the patient, thought echo or commenting on the patient's behaviour Thought disorders: thought insertion, thought withdrawal, thought broadcasting Passivity phenomena: bodily sensations controlled by something else, actions, impulses or feelings controlled by others Delusional perception: normal object perceived and then intense delusional insight into the object's meaning
32
2nd rank schizophrenia symptoms?
Auditory hallucinations: 2nd person hallucinations, hallucinations in any other modality Negative symptoms: incongruity, blunting of affect, amotivation, poverty of speech, poverty of thought, self neglect, lack of insight, anhedonia Delusions: delusions of reference, paranoid or accusatory delusions
33
Investigations and diagnosis of schizophrenia?
Bloods- rule out other causes & ECG Diagnosis: 1x first rank symptoms and 2x 2nd rank symptoms for >1 month
34
Management of schizophrenia?
1st line: atypical antipsychotics eg olanzapine, quetiapine CBT: to modify CVD risk factors due to behaviours like smoking and links with antipsychotic medication DVLA: must inform DVLA and must not drive until symptoms have been resolved for 3 months + letter from psychiatrist
35
Definition of personality disorders?
Life long, ingrained, maladaptive behaviours that characterises an individual and deviates markedly from cultural or accepted norm with onset in early childhood or late adolescence
36
What are the type A personality disorders?
(Mad) Paranoid Schizoid Schizo-typal
37
What are the type B personality disorders?
(Bad) Antisocial personality disorder Borderline/EUPD Histrionic Narcissistic
38
What are the type C personality disorders?
(Sad/Anxious) Avoidant Dependant OCPD (anankastic)
39
Describe EUPD/Borderline personality disorder?
Instability in relationships Instability in self image Impulsivity- sex, money, eating Repetitive suicide/self harm Frantic efforts to avoid abandonment
40
Describe typical/1st gen antipsychotics?
Principally antagonise dopamine D2 receptors, having an immediate quietening effect and have a good effect on positive symptoms Haloperidol, Chlorpromazine
41
Describe atypical/2nd gen antipsychotics?
Have lower D2 receptor affinity but also cause an additional block of 5-HT receptors so better at controlling positive and negative symptoms
42
Side effects more typical of 1st gen/typical antipsychotics?
Acute dystonia- sustained muscle contraction Akathisia- severe restlessness Tardive dyskinesia- abnormal & involuntary. Has late onset and involves chewing/pouting jaw Parkinsonism- tremor & bradykinesia Mx of s/e: Valbenazine/Tetrabenazine General treatment: procyclidine (anticholinergic)
43
Side effects more typical of 2nd gen/atypical antipsychotics?
Reduced seizure threshold Metabolic syndrome- weight gain and poor glucose control/diabetes Olanzapine gives most weight gain Risperidone gives most hyper-prolactinaemia
44
Side effects of both types of antipsychotics?
ACh block- dry mouth, diplopia, blurred vision Sedation Prolongation of QT interval Increased prolactin due to D2 block → gives galactorrhoea and amenorrhoea SIADH Postural hypotension
45
Describe paranoid personality disorder
Excessive sensitivity to insults, unforgiving of insults, perceiving neutral or friendly actions as hostile, recurrent suspicions without justification, often regarding sexuality of spouse or infidelity, often obsessive self reference and self obsession
46
Describe schizoid personality disorder
Characterised by withdrawal from social and affectionate company, preferring own company, fantasies and solitary introspection. Limited capacity to express feelings or experience pleasure.
47
Describe dissocial personality disorder
Characterised by disregard for social norms, social obligations and others' feelings. Disparity between behaviour and social norms. Behaviour is not easy to change, even by punishment. Low tolerance for frustration & quick to anger, especially to violence. Tendency to blame others
48
Describe emotionally unstable personality disorder
Characterised by tendency to act impulsively and without thought of consequences. Incapacity to control emotions or behavioural outbursts. Impulsive type- emotional instability & impulsivity. Borderline type- disturbances in self image, aims and and internal preferences. Intense and unstable relationships. Frequent suicide attempts & gestures.
49
Describe histrionic personality disorder
Characterised by shallow and labile affectivity, self-dramatization, theatricality, exaggerated expressions of emotions, suggestibility, self indulgence, need to be centre of attention, constant searching for excitement and attention
50
Describe anankastic personality disorder
(OCPD) Characterised by perfectionism, feelings of doubt, excessive conscientiousness, checking and preoccupation with details, stubbornness, rigidity, & caution.
51
Describe anxious/avoidant personality disorder
Characterised by feelings of tension, apprehension, insecurity and inferiority. Continuous yearning to be liked and accepted, a hypersensitivity to rejection or criticism. A tendency to avoid certain activities by habitual exaggeration of the dangers
52
Describe dependent personality disorder
Characterised by passive reliance on other people to make their minor and major life decisions. Great fear of abandonment, feelings of helplessness and incompetence, passive compliance with the wishes of elders and others and a weak response to daily life and demands.
53
Signs and symptoms of opioid overdose/misuse?
Rhinorrhoea, needle track marks, pinpoint pupils, respiratory depression, drowsiness, watering eyes, yawning
54
Management of opioid misuse/overdose?
Acute overdose: IV/IM naloxone Opioid withdrawal: methadone, buprenorphine Relieve withdrawals: iofexidine Prevent relapse: naltrexone
55
Define delirium tremens?
Up-regulation of NMDA receptors and down regulation of GABA receptors → leading to CNS hyperexcitability
56
Signs and symptoms of delirium tremens?
Cognitive impairment, Lilliputian hallucinations (little people), paranoid delusion, tremor, fever, tachycardia, sweating, dehydration
57
Management of delirium tremens?
Acute: 1st line= IV Pabrinex, long acting BZDs eg chlordiazepoxide, lorazepam in hepatic failure & IM haloperidol if psychotic features Nil acute: Disulfiram- gives bad sx when drinking acamprosate- reduces cravings naltrexone- reduces pleasure CBT, motivational meetings, AA, family support
58
Therapeutic/ toxic range of lithium?
Normal therapeutic range: 0.4-1.0mmol/L and is excreted renally Toxicity is >1.5mmol/L
59
Risk factors for lithium toxicity?
Dehydration, renal failure, drugs - ACEi, ARBs, metronidazole, especially thiazides.
60
Signs and symptoms of lithium toxicity?
TOXICC Tremor Oliguric renal failure Ataxia Increased reflexes Convulsions Coma Consciousness reduced
61
Management of lithium toxicity?
Stop lithium immediately High fluid & IV NaCl Can use sodium bicarb If severe- dialysis
62
When should lithium levels be measured?
12 hours after the dose
63
Define serotonin syndrome
High synaptic concentration of serotonin
64
Causes of serotonin syndrome?
Normally when a serotonergic medication is given to a patient and they are already taking one, can rarely occur if patient is switching medications and don't have a long enough 'wash out' period. Or seen in accidental child drug overdosing. SSRIs SNRIs Opioids MAOi Lithium TCAs St John's wort Stimulants eg amphetamines
65
Signs and symptoms of serotonin syndrome?
Neuromuscular excitation- hyperreflexia, myoclonus & rigidity. Autonomic NS excitation- hyperthermia & sweating Altered mental state- confusion, hallucinations
66
Management of serotonin syndrome?
Stop medications responsible Supportive treatments- IV fluids & BZDs Severe cases- serotonin antagonist eg chlorpromazine or cyproheptadine SSRI overdose- activated charcoal
67
Differential diagnosis for serotonin syndrome?
Neuroleptic malignant syndrome - WCC will be ↑ in this but normal in serotonin syndrome
68
How long does a section 2 last?
28 days
69
What is the purpose of a section 2?
to assess and treat a patient (without their consent)
70
Which professionals are involved in a section 2?
2x doctor & AMHP
71
What are the requirements for a section 2?
Patient must be suffering from a mental disorder that requires them to be detained in hospital for assessment and they must be detained for their own health and safety and/or that of others
72
How long does a section 3 last?
6 months (can be renewed)
73
What is the purpose of a section 3
For treatment
74
Which professionals are involved in enacting a section 3?
2x doctors and an AMHP
75
What is the purpose of a section 3?
Patient must be suffering from a disorder that requires them to be in hospital and the treatment is in their best interest for their health and safety and the protection of others AND appropriate treatment must be available
76
How long does a section 4 last?
72 hours
77
What is the purpose of a section 4?
It is an emergency order where waiting for a second doctor would lead to undesirable delay
78
Which professionals are involved in a section 4?
1x dr and 1x AMHP
79
What are the requirements for a section 4?
Patient must be suffering from a disorder that requires them to be in hospital for assessment and patient must be detained for their own safety and that of others and there is not enough time for a second doctor to attend
80
How long does a section 5(4) last?
6 hours
81
What is a section 5(4)?
For a patient already admitted in either a general or psychiatric hospital but wants to leave- allows nurses to keep patient in hospital until doctor can attend BUT cannot be treated coercively under this power.
82
How long does a section 5(2) last?
72 hours
83
What is a section 5(2)?
Doctors' holding power. Allows doctors to detain a patient in hospital (must already be admitted) in order to allow enough time for a section 2 or 3 assessment. Cannot be treated coercively under this section.
84
What is a section 136?
Police section lasting 24 hours for a person suspected of having a mental disorder in a public place.
85
What is a section 135?
A police section lasting 36 hours needing a court order to remove a patient to either a place of safety (police cell/psychiatric unit) or for further assessment (section 2 or 3)
86
Side effects of MAOIs?
Cheese- react with tyramine rich foods eg cheese causing a hypotensive tension Extensive drug interactions
87
Side effects of tricyclic antidepressants?
Anticholinergic effects Overdose can lead to seizures
88
Side effects of SSRIs?
GI upset- N&V Agitation, anxiety, akathisia Sexual dysfunction Insomnia Hyponatraemia
89
Signs and symptoms of neuroleptic malignant syndrome?
Tremor, muscle cramps, fever, autonomic instability, delirium
90
Key investigation finding in neuroleptic malignant syndrome?
Creatinine kinase will always be raised- if not raised, is not NMS
91
Side effects of clozapine?
Agranulocytosis (monitoring needed), hypersalivation and constipation
92
Side effects of atypical antipsychotics?
QT prolongation Weight gain Reduced seizure threshold 0 Orthostatic hypotension Sexual dysfunction
93
Difference between atypical and typical psychotics?
Both very similar and no difference in efficacy Typical have a smaller therapeutic window Atypical have a larger therapeutic window

Phase 3a (8 decks)

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