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psychiatry Flashcards

1
Q

Section 2
Duration
Professionals
Evidence

A

Assessment
28 days (not renewable)
TWO doctors (one S12 approved)
ONE approved mental health professional (AMHP)
When a px is suffering a mental disorder of a nature that warrants detention in hx for assessment (+ they are not consenting)
When a px needs to be detained for their own/others safety

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2
Q

Section 3
Duration
Professionals
Evidence

A

Treatment
6 months (renewable)
TWO doctors (one S12 approved)
ONE approved mental health professional (AMHP)
When a px is suffering a mental disorder of a nature that makes it appropriate for them to receive tx in hx (+ they are not consenting)
Their tx is in the interests of theirs/others health + safety
There must be appropriate tx available

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3
Q

Section 4
Duration
Professionals
Evidence

A

Emergency order - urgent necessity to hold px until assessment by S12 doc
72 hrs
ONE doctor, ONE AMHP
There is not enough time for a second doctor to attend

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4
Q

Section 5 (4)
Duration
Professionals
Evidence

A

For a px already admitted (can be under psych or general hx) + is wanting to leave
6 hrs
NURSES holding power until a doctor can attend
Cannot be tx coercively whilst under this section

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5
Q

Section 5 (2)
Duration
Professionals
Evidence

A

For a px already admitted (can be under psych or general hx) + is wanting to leave
72 hrs
DOCTORS holding power
Allows time for a section 2/3 assessment

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6
Q

Section S136

A

Police section
Person suspected of having a mental disorder in a public place (A&E counts!)
24 hrs

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7
Q

Section S135

A

Police section
Needs court order to access px home + remove them
36 hrs

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8
Q

what are the factors assoc w poor prognosis in schizophrenia

A

strong FHx
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant

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9
Q

what are first rank sx

A

thought alienation
passivity phenomena
3rd person auditory hallucinations (he/she)
delusional perception

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10
Q

risk of developing schizophrenia if
monozygotic twin has it
parent
sibling
none

A

50%
10-15%
10%
1%

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11
Q

RFs for dev schizophrenia (in order of biggest to lowest)

A

FHx
Black caribbean
Migration
Urban environments
Cannabis use

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12
Q

risk factors for suicide

A

SAD PERSONS

Sex - male 2.0
Age - <19, >45
Depression

Prev attempt
Excess alcohol/substance use
Rational thinking loss
Social support lacking
Organised plan
No spouse
Sickness

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13
Q

depression sx

A

fatigue
low mood
anhedonia

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14
Q

mild depression

A

> 2 wks sx, 2/3 main sx, 5+ generalised sx

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15
Q

how to end SSRIs if gd response

A

continue for 6 months after remission to decrease relapse risk
then reduce dose over 4 wk period (don’t need to w fluoxetine)

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16
Q

when to avoid citalopram

A

if taking meds that cld prolong QT interval, check hx cardiac disease
will need to do ECG monitoring

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17
Q

what does paroxetine have increased incidence of

A

discontinuation sx

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18
Q

which SSRI to used post MI/unstable angina

A

sertraline

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19
Q

electrolyte abnormality to observe for w SSRIs

A

hyponatraemia
be careful in elderly especially

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20
Q

which SSRI to use in children

A

fluoxetine

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21
Q

what to check before starting SNRI

A

BP as can dev HTN

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22
Q

side effects of mirtazapine (SNRI)

A

weight gain + sedation

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23
Q

SEs of tricyclic antidepressants

A

can’t pee, can’t see, can’t shit, can’t spit
weight gain
long QT

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24
Q

SNRI egs

A

mirtazapine
duloxetine
venlafaxine

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25
Q

what to do if on SSRI + NSAID

A

take PPI as increased bleeding risk

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26
Q

tricyclic antidepressant (amitriptyline) OD

A

confusion
seizure
tachy
hypotension
dilated pupils

metabolic acidosis

long QT, wide QRS

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27
Q

tx tricyclic antidepressant (amitriptyline) OD

A

IV sodium bicarbonate

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28
Q

triad in wernicke’s encephalopathy

A

nystagmus
ophthalmoplegia
ataxia

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29
Q

korsakoff’s syndrome

A

untreated wernicke’s encephalopathy
- antero + retrograde amnesia
confabulation

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30
Q

what is wernicke’s encephalopathy

A

neuro dis caused by thiamine (v B1) deficiency
most common in alcoholics

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31
Q

tx wernicke’s encephalopathy

A

give thiamine (pabrinex)

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32
Q

what is Disulfiram

A

alcohol detox drug
to Discourage
give you unpleasant sx within 20-30 mins of drinking alcohol

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33
Q

what is alcomposate

A

alcohol detox drug
enhancing GABA transmission
anti-craving

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34
Q

what is naltrexone

A

alcohol detox drug, an opioid antagonist
decreases cravings + pleasurable ex

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35
Q

6-12 hrs alcohol withdrawal

A

sweaty
tremor
tachy
anxiety

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36
Q

peak incidence of seizures in alcohol withdrawal

A

36 hrs

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37
Q

what is delirium tremens

A

48-72 hrs after alcohol withdrawal
coarse tremor
confusion
delusions
auditory + visual hallucinations
fever
tachy

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38
Q

tx delirium tremens

A

long acting benzos - chlordiazepoxide

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39
Q

what is malingering

A

faking sx for material gain

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40
Q

what is munchausens / factitious disorder

A

self inflicted sx / fabricated illness
you create sx
can be by proxy

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41
Q

what is somatisation

A

multiple physical sx for 2+ yrs w no medical explanation
px refuses to accept reassurance/-ve tests

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42
Q

what is hypochondriasis

A

persistent belief in presence of underlying serious disease (usually focuses on one body system / cancer)
px refuses to accept reassurance/-ve tests

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43
Q

what is conversion disorder

A

loss of motor/sensory function with no neuro cause
may be caused by stress
Don’t consciously feign/seek gain

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44
Q

what is akathisia

A

inner restlessness, inability to keep still

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45
Q

difference between depersonalisation + derealisation

A

depersonalisation is yourself derealisation is everything around you

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46
Q

what is hoover’s sign

A

used to differentiate organic from non-organic leg paralysis
If non-organic will feel oressure under paretic leg when lifting normal leg against pressure (invol contra hip extension)

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47
Q

PTSD sx + when is it dx

A

re-experiencing - flashbacks, nightmares
avoidance
hyperarousal - hyper vigilance, sleep probs

4 wks after event (b4 4 wks it is acute stress disorder)

emotional detachment

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48
Q

PTSD tx

A

eye movement desensitisation + reprocessing therapy

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49
Q

acute stress disorder tx

A

trauma focused CBT

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50
Q

SEs clozapine

A

decreases seizure threshold
agranulocytosis (need FBC monitoring)
neutropenia
constipation
myocarditis (take baseline ECG b4 starting tx)
hypersalvation

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51
Q

when to give clozapine in schizophrenia

A

if it does not respond to 2 consecutive trials of antipsychotics

52
Q

what to do if clozapine doses missed for >48 hrs

A

re titrate again slowly

53
Q

clozapine + smoking

A

smoking cessation can cause an increase in clozapine levels

54
Q

when would you get an abnormal grief reaction

A

6+ months after

55
Q

when do you have chronic insomnia

A

3+ months 3/7 nights a week

56
Q

tx chronic insomnia

A

sleep hygiene
hypnotics only if daytime impairment is severe - short acting benzos/nonbenzos - zopiclone
lowest effective dose for shortest time
review after 2 wks + consider CBT

57
Q

features assoc w insomnia

A

Female gender
Increased age
Lower educational attainment
Unemployment
Economic inactivity
Widowed, divorced, or separated status

58
Q

RFs insomnia

A

Alcohol and substance abuse
Stimulant usage
Medications such as corticosteroids
Poor sleep hygiene
Chronic pain
Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population.
Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.

59
Q

knights move

A

unexpected and illogical leaps from one idea to another w no logical assoc
feature of schizophrenia

60
Q

flight of ideas

A

leaps from one topic to another but with discernible links between them
feature of mania

61
Q

clang associations

A

when ideas are related to each other only by the fact they sound similar or rhyme

62
Q

neologisms

A

new word formations, which might include the combining of two words

63
Q

word salad

A

completely incoherent speech where real words are strung together into nonsense sentences

64
Q

Tangentiality

A

wandering from a topic without returning to it

65
Q

Circumstantiality

A

excessive, unnecessary detail but the person does eventually return to the original point

66
Q

derailment

A

series of unrelated ideas

67
Q

Perseveration

A

repetition of ideas or words despite an attempt to change the topic

68
Q

Echolalia

A

repetition of someone else’s speech, including the question that was asked

69
Q

lithium therapeutic range

A

0.4-1.0 mmol/L

70
Q

lithium SEs

A

N&V, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia

71
Q

lithium monitoring requirements

A

when checking lithium levels, the sample should be taken 12 HOURS POST DOSE

after starting lithium LEVELS should be performed WEEKLY and after each dose CHANGE until concentrations are STABLE

once established, lithium blood LEVEL should be checked EVERY 3 MONTHS

after a CHANGE in dose, lithium LEVELS should be taken a WEEK later and WEEKLY until the levels are stable.

THYROID AND RENAL FUNCTION should be checked every 6 MONTHS

patients should be issued with an information booklet, alert card and record book

72
Q

what can precipitate lithium toxicity

A

dehydration
renal failure
drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.

73
Q

features of lithium toxicity

A

coarse tremor (a fine tremor is seen in therapeutic levels)
hyperreflexia
acute confusion
polyuria
seizure
coma

74
Q

mx lithium toxicity

A

mild-moderate toxicity may respond to volume resuscitation with normal saline

haemodialysis may be needed in severe toxicity

sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion

75
Q

what can lithium cause in preg

A

Ebstein’s abnormality (where tricuspid valve is in the wrong position)
so stop in 1st trim

76
Q

when would you use ECT

A

severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms

77
Q

absolute CI to ECT

A

raised intracranial pressure

78
Q

SEs ECT

A

short term:
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia

long term:
impaired memory

79
Q

tx for acute dystonia 2ndary to antipsychotics

A

procyclidine

80
Q

what is acute dystonia

A

sustained muscle contraction (e.g. torticollis, oculogyric crisis)

example of a extrapyramidal SEs of antipsychotics

81
Q

what is tardive dyskinesia

A

late onset of choreoathetoid movements, abnormal, involuntary
most common is chewing and pouting of jaw

82
Q

tardive dyskinesia tx

A

tetrabenazine

83
Q

mechanism of action of typical antipsychotics

A

Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
(can get prolactinaemia as SE)

84
Q

mechanism of action of atypical antipsychotics

A

Act on a variety of receptors (D2, D3, D4, 5-HT)

85
Q

warnings when antipsychotics are used in elderly patients

A

increased risk of stroke
increased risk of venous thromboembolism

86
Q

SEs typical antipsychotics
eg Haloperidol
Chlopromazine

A

Extrapyramidal side-effects (EPSEs)

antimuscarinic: dry mouth, blurred vision, urinary retention, constipation

sedation, weight gain

raised prolactin
may result in galactorrhoea
due to inhibition of the dopaminergic tuberoinfundibular pathway

impaired glucose tolerance

neuroleptic malignant syndrome: pyrexia, muscle stiffness

reduced seizure threshold (greater with atypicals)

prolonged QT interval (particularly haloperidol)

87
Q

Extrapyramidal side-effects (EPSEs)

A

Parkinsonism
Acute dystonia
Akathisia (severe restlessness)
Tardive dyskinesia

88
Q

SEs atypical antipsychotics

A

weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia

89
Q

Examples of atypical antipsychotics

A

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

90
Q

palilalia

A

automatic repetition of own words / phrases

91
Q

echopraxia

A

meaningless repetition/imitation of movements of others

92
Q

othello syndrome

A

pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.

93
Q

Delusional parasitosis

A

fixed, false belief (delusion) that they are infested by ‘bugs’

94
Q

Cotard syndrome

A

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

95
Q

De Clerambault’s syndrome / erotomania

A

a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.

96
Q

capgras syndrome

A

delusional/misidentification syndrome
px believes someone significant in their life has been replaced by an identical imposter

97
Q

fregoli syndrome

A

px believes multiple ppl are the same person

98
Q

charles bonnet syndrome

A

px w vision loss have hallucinations
these px have insight

99
Q

ekbom syndrome

A

px believes they are infested w parasites
sx B12 def?

100
Q

anorexia physiological abnormalities

A

hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3

101
Q

anorexia features

A

reduced body mass index
bradycardia (long QT)
hypotension
enlarged salivary glands

102
Q

metabolic consequences of refeeding syndrome

A

hypophosphataemia
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance

103
Q

who is high risk of refeeding syndrome

A

ONE + of:
BMI < 16 kg/m2
unintentional weight loss >15% over 3-6 months
little nutritional intake > 10 days
hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

TWO + of:
BMI < 18.5 kg/m2
unintentional weight loss > 10% over 3-6 months
little nutritional intake > 5 days
history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

104
Q

Russell’s sign

A

calluses on the knuckles or back of the hand due to repeated self-induced vomiting

105
Q

acid base in bulimia

A

hypokalaemic metabolic alkalosis

106
Q

MOAs with tyramine containing foods (cheese, pickled herring, bov + marmite, oxo, broad beans)

A

causes hypertensive reactions

107
Q

tx heroin withdrawal

A

lofexidine (alpha 2 receptor agonist)
sx mx - benzos, antiemetics, loperamide (immodium)

108
Q

Semantic dementia

A

form of fronto temporal dementia
55-65 yrs
px has a fluent progressive aphasia.
The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.

109
Q

pick’s disease

A

type of fronto temporal dementia
characterised by personality change and impaired social conduct.

Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.

110
Q

Pick’s disease ix

A

Focal gyral atrophy with a knife-blade appearance

Macroscopic changes:-
Atrophy of the frontal and temporal lobes

Microscopic changes:-
Pick bodies - spherical aggregations of tau protein (silver-staining)
Gliosis
Neurofibrillary tangles
Senile plaques

111
Q

what is creutzfeldt-Jakob disease (CJD)

A

rapidly progressive neurological condition caused by prion proteins
causes misfolded proteins leading to cell death

112
Q

features CJD

A

rapidly progressive dementia
myoclonus

113
Q

CJD ix

A

CSF is usually normal
EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus

114
Q

stages of AI encephalitis

A

early sx:
fever
headaches
diarrhoea
URTIs
2nd stage:
confusion
paranoid
word finding
later:
seizures
rigid
temp dysreg

115
Q

causes of 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
- tramadol may also interact with SSRIs
ecstasy
amphetamines
multiple antidepressants

116
Q

features serotonin syndrome

A

neuromuscular excitation
- hyperreflexia
- myoclonus
- rigidity
autonomic nervous system excitation
- hyperthermia
- sweating
altered mental state
- confusion

presents in hrs

117
Q

what is neuroleptic malignant syndrome

A

are but dangerous condition seen in patients taking antipsychotic medication.
It may also occur with dopaminergic drugs (such as levodopa) for Parkinson’s disease, usually when the drug is suddenly stopped or the dose reduced.

dopamine blockade induced by antipsychotics triggers massive glutamate release and subsequent neurotoxicity and muscle damage

118
Q

features of neuroleptic malignant syndrome

A

within hours to days of starting an antipsychotic and the typical features are:
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion

RAISED CREATININE KINASE
AKI if severe
leukocytosis

119
Q

pxs at an increased risk of developing hepatotoxicity following a paracetamol overdose

A

patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John’s Wort)
malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days

120
Q

paracetamol OD tx

A

<1hr ago + does >150mg/kg = activated charcoal
staggered OD/ ingestion >15 hrs ago = n-acetylcysiene asap
ongestion <4hrs ago = wait 4 hrs to take a level + tx w n-acetylcysiene based on level
ingestion 4-5 hrs ago = immediate level based on nonogram + tx

121
Q

n-acetylcysiene adverse effects

A

commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release). Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate

infused over 1 hour

122
Q

what is semantic paraphasia

A

words are inappropriately substituted; e.g. ‘I baked the cake in the dustbin, then I put the butter back in the dog’

123
Q

SSRI discontinuation symptoms

A

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

124
Q

overview of refeeding syndrome + how it happens

A
  • sudden introduction of glucose after prolonged starvation
  • causes insulin to be released which pushes glucose into cells
  • causing demand for phosphate, potassium, magnesium
  • leading to them all being low
125
Q

Clinical Consequences of Hypophosphatemia:

A

Cardiac Dysfunction
Respiratory Failure - due to muscle weakness as needed for ATP prod
Neurological Complications
Haematological Effects - hypoxia + haemolysis
Rhabdomyolysis

finals (27 decks)

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