Psychiatry Flashcards
(96 cards)
1
Q
describe the management of generalised anxiety disorder
A
- education about GAD + active monitoring
- low intensity psychological interventions (self-help)
- high-intensity psychological interventions (CBT) or drug treatment
drug treatment
- sertraline as first-line SSRI
- if ineffective, alternative SSRI or SNRI e.g. duloxetine, venlafaxine
- offer pregabalin if not tolerated
- propranolol for acute anxiety
2
Q
list the SSRIs of choice in the following patient populations
- breastfeeding women
A
- breastfeeding women: sertraline or paroxetine
3
Q
list different types of personality disorders
A
Cluster A: odd or eccentric
- paranoid “accusatory”
- schizoid “aloof”
- schizotypal “awkward”
Cluster B: dramatic, emotional or erratic
- antisocial “bad”
- borderline (emotionally unstable)
- histrionic “flamBoyant”
- narcissistic “best”
Cluster C: anxious and fearful
- obsessive-compulsive “compulsive”
- avoidant “cowardly”
- dependent “clingy”
4
Q
describe paranoid personality disorder
A
cluster A: “accusatory”
- Hypersensitivity and unforgiving attitude when insulted
- Unwarranted tendency to question the loyalty of friends
- Reluctance to confide in others
- Preoccupation with conspirational beliefs and hidden meaning
- Unwarranted tendency to perceive attacks on their character
5
Q
describe schizoid personality disorder
A
cluster A: “aloof”
- 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
6
Q
describe schizotypal personality disorder
A
cluster A: “awkward”
- Ideas of reference (differ from delusions in that some insight is retained)
- Odd beliefs and magical thinking
- Unusual perceptual disturbances
- Odd, eccentric behaviour
- Inappropriate affect
- Odd speech without being incoherent
7
Q
describe antisocial personality disorder
A
cluster B: “bad”
- Failure to conform to social norms with respect to lawful behaviours
- more common in men
- deception: repeatedly lying, use of aliases, conning others for personal profit or pleasure
- irritability and aggressiveness: physical fights / assaults
- reckless disregard for the safety of self or others
- Consistent irresponsibility: repeated failure to sustain consistent work behaviour or honour financial obligations
- lack of remorse: indifferent to or rationalizing having hurt, mistreated, or stolen from another
8
Q
describe borderline personality disorder
A
cluster B: borderline
- 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
management: dialectical behavioural therapy
9
Q
describe histrionic personality disorder
A
cluster B: “flamBoyant”
- 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
10
Q
describe narcissistic personality disorder
A
cluster B: “best”
- 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
11
Q
describe obsessive compulsive personality disorder
A
cluster C: “compulsive”
clinical features
- overly occupied with details, rules, lists, order, organization, or agenda
- perfectionism that hampers with completing tasks
- extremely dedicated to work and efficiency to the elimination of spare time activities
- meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
management: dialectical behavioural therapy
12
Q
describe avoidant personality disorder
A
cluster C: “cowardly”
- 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
13
Q
describe dependent personality disorder
A
cluster C: “clingy”
- 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
14
Q
list risk factors and protective factors for suicide
A
increased risk of suicide
- male sex
- history of deliberate self-harm
- alcohol or drug misuse
- history of mental illness
- history of chronic disease
- advancing age
- unemployment or social isolation/living alone
- being unmarried, divorced or widowed
If a patient has actually attempted suicide, factors associated with an increased risk of completed suicide at a future date:
- efforts to avoid discovery
- planning
- leaving a written note
- final acts such as sorting out finances
- violent method
reduce the risk of a patient committing suicide
- family support
- having children at home
- religious belief
15
Q
describe panic disorder and its management
A
diagnosis requires at least 1 month of symptoms
clinical features
- panic attacks
management
- CBT / drug therapy
- SSRIs are first-line, try imipramine or clomipramine if unsuccessful
16
Q
describe depression and its management
A
features
- fatigue
- low mood
- anhedonia
- cognitive: poor concentration, poor memory, slow thoughts
- poor libido
- anxiety
- irritability
- hopelessness about future
- abnormal sleep (early morning wakening)
in elderly can be distinguished from dementia due to short history and rapid onset of global memory loss
dysthymia refers to persistent low mood not meeting criteria for depression
management
- active monitoring and self-help: first-line for less severe depression
- CBT
- pharmacological
> SSRIs
- fluoxetine or citalopram
- sertraline if useful post-MI
- ECT if severe/resistant
17
Q
list adverse effects of SSRIs
A
- GI symptoms: nausea, diarrhoea
- increased risk of bleeding: gastrointestinal, intracranial, post-partum
- headaches
- sexual dysfunction
- hyponatraemia (SIADH)
- sometimes increased anxiety/agitation after starting SSRI or increased suicidal thoughts
- citalopram: prolongs QT interval
18
Q
list discontinuation symptoms of SSRIs
A
continue for at least 6 months after remission of symptoms to reduce risk of relapse
reduce dose over 4 weeks (not necessary with fluoxetine)
symptoms
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- GI symptoms: pain, cramping, diarrhoea, vomiting
- paraesthesia
19
Q
describe ADHD
A
diagnostic features
- inattention
> doesn’t follow instructions
> easily distracted
> difficult to organise tasks
> forgetful/loses things
> does not listen when spoken to directly
- hyperactivity/impulsivity
> unable to play quietly
> talks excessively
> spontaneously leaves seat
> run/climb when inappropriate
management
- following presentation, 10 week watch and wait
- if persistent refer to secondary care
> positive approach, structured routines, clear boundaries, physical activity - drug therapy only if 5 years or more
> methylphenidate first-line, then lisdexamfetamine
20
Q
list monitoring and side-effects of ADHD drugs
A
both methylphenidate and lisdexamfetamine potentially cardiotoxic
methylphenidate
- abdominal pain
- nausea and dyspepsia
- stunted growth in children
> monitor height and weight every 6 months
21
Q
describe seasonal affective disorder
A
recurrent episodes of depression occurring during the same season every year, usually winter
at least 2 consecutive winters for diagnosis
22
Q
describe cyclothymic disorder
A
alternating periods of hypomanic symptoms and depressive symptoms that do not meet the criteria for major depressive episodes
23
Q
describe atypical depression
A
distinguished from other types of depression by
- mood reactivity (mood brightens in response to positive events)
- increased appetite / weight gain
- hypersomnia
- leaden paralysis (heavy feeling in arms/legs)
- sensitivity to interpersonal rejection
24
Q
describe schizophrenia
A
symptoms
- auditory hallucinations
- delusions (commonly persecutory)
- thought insertion / removal / broadcasting
- passivity phenomena: bodily sensations controlled by external influences
- ideas of reference
- impaired insight
- catatonia
- neologisms: made-up words
- disorganised thinking or behaviour
- sleep disturbance
- negative symptoms
> social withdrawal
> flattened affect
> anhedonia
> avolition
> alogia
management
- first-line: atypical antipsychotic e.g. olanzapine
- trial of at least 2 antipsychotics before clozapine
- if poor compliance opt for depot antipsychotic
25
describe anorexia nervosa
features
- weight loss (BMI <17.5)
- amenorrhoea
- lanugo hair
- parotidomegaly
- hypotension
- hypothermia
- mood changes (anxiety, depression)
biochemical:
- raised growth hormone, cortisol, glucose, cholesterol, carotinaemia
- low FSH, LH
- hypokalaemia
forms
- restrictive: restricting food intake
- binge-purge: excessive use of diuretics, laxatives, excessive exercise, induced vomiting
complications
- cardiac: arrhythmias, sudden cardiac death
- refeeding syndrome
- low bone mineral density
26
describe bulimia nervosa
features
- normal BMI
- binge eating followed by purging which leads to
> erosion of teeth
> swollen salivary glands
> mouth ulcers
> GORD
> calluses on knuckles (Russell's sign)
> alkalosis may occur due to repeated vomiting
management
- CBT-ED, self-help resources
27
describe binge eating disorder
features
- episodes of binge eating not followed by purging due to psychological distress
- usually high BMI
- binges may be planned or unplanned
- eating very quickly with loss of control
- unrelated to hunger, becoming uncomfortably full
management
- CBT-ED, self-help resources
28
describe refeeding syndrome
occurs when someone with an extended severe nutritional deficit resumes eating
features
- hypogmagnesaemia
- hypokalaemia
- hypophosphataemia
- fluid overload
complications
- arrhythmias
- heart failure
management
- slow reintroduction of food with limited calories
- magnesium, phosphate, potassium, glucose and fluid balance monitoring (ECG monitoring in severe cases)
- supplementation particularly B vitamins and thiamine
29
describe ARFID
avoidant restrictive food intake disorder
features
- unrelated to body image
- may occur in individuals with ASD due to distress regarding food texture/taste
- may occur due to fear of choking
- low BMI
30
Describe OSFED
other specified food or eating disorder
features
- eating disorder which does not fit the typical features of other eating disorders
31
describe the management of drug addiction
management
- detoxification (home/inpatient)
- medication to maintain abstinence
- CBT
- ongoing support e.g. support groups
opioid dependence
- methadone, buprenorphine: bind to opioid receptors
- naltrexone: helps prevent relapse
nicotine dependence
- bupropion
- varenicline
- nicotine replacement therapy: patches, gum, lozenges
32
describe the management of alcohol dependence
acute:
- benzodiazepines:
> chlordiazepoxide
> lorazepam (if liver disease)
> diazepam
- IM or IV high dose B vitamins i.e. Pabrinex
- scoring systems: GMAWS, CIWA-Ar
chronic:
non-pharmacological
- specialist alcohol service
- alcohol detoxification programme
- CBT
- support groups e.g. AA
- informing DVLA
pharmacological
- disulfiram: aldehyde dehydrogenase inhibitor
- acamprosate: taurine derivative
- naltrexone: opioid antagonist
- oral thiamine
33
describe Wernicke-Korsakoff syndrome
alcohol excess leads to thiamine (vitamin B1) deficiency
Wernicke's encephalopathy
- confusion
- oculomotor disturbance e.g. nystagmus
- ataxia
- medical emergency: treat with pabrinex
Korsakoff syndrome
- memory impairment (retrograde/anterograde)
- confabulation
- behavioural changes
- irreversible, requires full-time institutional care
34
describe alcohol withdrawal
- 6-12h: tremor, sweating, headache, craving, anxiety
- 12-24h: hallucinations
- 24-48h: seizures
- 24-72h: delirium tremens: medical emergency associated with alcohol withdrawal
> features
- acute confusion
- severe agitation
- delusions and hallucinations
- tremor
- tachycardia
- hypertension
- ataxia
- arrhythmias
35
describe the calculation of alcohol units and recommended alcohol consumption
volume of alcohol (L) x ABV %
e.g. 750ml of wine (12%)
0.75 x 12 = 9 units
recommended <14 units per week
binge: women >=6 units, men >=8 units
36
describe complications of alcohol excess
- alcohol-related liver disease
- cirrhosis and its complications (oesophageal varices, ascites, hepatocellular carcinoma)
- Wernicke-Korsakoff syndrome
- pancreatitis
- alcoholic cardiomyopathy
- alcoholic myopathy
- cardiovascular disease
- cancer
- bloods: raised MCV, raised ALT and AST (AST:ALT ratio >1.5 suggestive of alcoholic liver disease), raised GGT
37
Describe the dosage and monitoring of lithium
normal range: 0.4-1.0 mmol/L
concentrations >1.5 mmol/L lead to lithium toxicity
after dose changes re-check dose
- 7 days post-dose change, 12h after last dose
- re-check every week until stable concentration
- then re-check every 3 months
monitoring
- TFTs, U&Es 6 monthly
38
Describe the causes and features of lithium toxicity as well as its management
Toxicity may be precipitated by:
> dehydration
> renal failure
> drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
Features of toxicity
> coarse tremor (a fine tremor is seen in therapeutic levels)
> hyperreflexia
> acute confusion
> polyuria
> seizure
> coma
Management
> mild-moderate toxicity may respond to volume resuscitation with normal saline
> haemodialysis may be needed in severe toxicity
39
describe adverse effects associated with lithium treatment
features
- nausea, vomiting
- diarrhoea
- fine tremor
- nephrotoxicity: polyuria secondary to nephrogenic diabetes insipidus
- hypothyroidism
- ECG: T wave flattening/inversion
- weight gain
- idiopathic intracranial hypertension
- hyperparathyroidism - hypercalcaemia
40
describe benzodiazepine withdrawal
features
- anxiety, agitation, irritability
- diaphoresis
- confusion
- nausea
- palpitations
- insomnia
- seizures
- hallucinations
- psychosis
41
describe opioid withdrawal
features
- rhinitis
- lacrimation
- yawning
- dilated pupils
- diaphoresis
- insomnia
- nausea, vomiting, diarrhoea
- piloerection
- abdominal cramps
- dysphoria
- tachycardia, hypertension
42
describe extra-pyramidal side effects (EPSEs)
- parkinsonism
- tardive dyskinesia: late onset of choreoathetoid symptoms, abnormal and involuntary, most commonly chewing and pouting of jaw
> treat with tetrabenazine
- akathisia: severe restlessness
> treat with propranolol
- acute dystonia: sustained muscle contraction (torticollis, oculogyric crisis, opisthotonus)
> more common in first generation antipsychotics
> treat with procyclidine
43
describe the mechanism of action of antipsychotics and their associated side-effects
typical antipsychotics: haloperidol, chlorpromazine
> dopamine D2 receptor antagonists
> more EPSEs and hyperprolactinaemia
atypical antipsychotics: olanzapine, clozapine, risperidone
> act on many receptors (D2, D3, D4, 5-HT)
> fewer EPSEs and hyperprolactinaemia
> metabolic side-effects
other side-effects
> weight gain (most common)
> sedation
> antimuscarinic effects: dry mouth, blurred vision, urinary retention, constipation
> impaired glucose tolerance
> neuroleptic malignant syndrome
> reduced seizure threshold (greater with atypicals)
> prolonged QT interval
> increased risk of stroke and VTE
44
describe depot antipsychotics
long-acting antipsychotic IM injections e.g. olanzapine
helpful in patients who struggle with compliance, reduces reliance on patient adherence
clozapine not available in depot injection
45
differentiate between hypomania and mania
common symptoms
- predominantly elevated mood, can be irritable
- pressured speech and thought
- flight of ideas: rapid speech with frequent changes in topic
- poor attention
- behaviour: insomnia, sexual promiscuity, risk-taking, excessive spending, increased appetite
hypomania
- lasts less than 7 days, usually 3-4 days
- can be high functioning and does not impair social/work function
- no psychotic symptoms
mania
- at least a week or longer
- severe functional impairment in social and work setting
- risk of harm to self or others
- may require hospitalisation
- may have psychotic symptoms
46
describe psychotic depression
depression with added symptoms of psychosis
- hallucinations
- delusions
- thought disorder: abnormal communication and behaviour
treatment involves combination of antipsychotics, antidepressants, ECT
47
describe bipolar affective disorder
features
- recurrent episodes of depression and mania/hypomania
- bipolar I: at least one episode of mania
- bipolar II: at least one episode of major depression and at least one episode of hypomania
- cyclothymia refers to milder symptoms of low mood and hypomania
management
- acute manic episode: admission
> stop antidepressant if they're taking it
> start anti-psychotics first-line e.g. olanzapine, quetiapine
> can also use lithium or sodium valproate
- acute depressive episode
> olanzapine + fluoxetine
> antipsychotics
> lamotrigine
- long-term management: lithium
48
describe generalised anxiety disorder
excessive and disproportional anxiety lasting at least 6 months
symptoms are persistent and occur most days
not caused by substance use or another condition
features
- excessive worrying
- difficulty relaxing
- muscle tension
- palpitations
- sweating
- tremor
- GI symptoms
scoring system: GAD-7, HAD
49
describe panic disorder
recurrent panic attacks which are unexpected and appear randomly, often without a trigger
50
describe post-traumatic stress disorder (PTSD)
can result from any traumatic event e.g. violence, natural disasters, major health events
symptoms should be present for at least 4 weeks, otherwise called acute stress reaction
features
- intrusive thoughts
- re-experiencing (flashbacks, nightmares)
- hyperarousal (easily startled, on edge)
- avoidance of triggers
- negative emotions and beliefs
- difficulty with sleep
- depersonalisation
- derealisation
- emotional numbing
trauma screening questionnaire: screening
management
- trauma-focused CBT
- eye movement desensitisation and reprocessing (EMDR)
- medication
> first-line: SSRIs or venlafaxine
> antipsychotics
51
describe dissociative disorders
depersonalisation-derealisation disorder
> feeling of being separated or outside of the body and of the world not being real
dissociative amnesia
> forgetting autobiographical information typically following a traumatic experience and leading to gaps in memory
dissociative identity disorder
> lack of clear individual identity
> multiple separate identities with unique names, personalities and memories
> associated with severe stress and trauma in childhood
52
describe catatonia
abnormal movement, communication and behaviour
features
- unusual postures
- odd actions
- repeat sounds or words
- remain blank and unresponsive
common causes - severe depression and bipolar disorder
management
- benzodiazepines
- ECT
53
describe reactive attachment disorder
severe neglect and trauma in early childhood
features
- emotional withdrawal and inhibition
- sadness, irritability
- impaired cognition
- struggle to form close relationships
- do not respond well to affection or discipline
54
describe factitious disorder
aka Munchausen syndrome
features
- conscious effort to fake illness and seek medical attention for personal gain
- symptoms are invented, exaggerated or induced
repeated presentations with inconsistent and dramatic symptoms that do not fit with examination and investigation findings
55
describe hoarding disorder
features
- excessive accumulation of possessions and emotional difficulty getting rid of items
- may have enormous amounts of clutter in home
- may or may not have insight
- can be associated with depression or anxiety
56
describe alien hand syndrome
patient loses control of one of their hands
may move independently without conscious control
often due to underlying brain tumour, injuries, aneurysms
57
describe Cotard delusion
false belief that the patient is dead or actively dying
aka walking corpse syndrome
most often caused by depression or schizophrenia
can be caused by brain tumours, migraines
58
describe Capgras syndrome
delusion that someone close to them has been replaced by an identical duplicate
may involve suspicion or aggression towards imposter
can be caused by schizophrenia, dementia
59
describe de Clerambault's syndrome
delusion that somebody famous or high status is in love with the patient
can lead to inappropriate harassment of the individual by the patient
often without other psychiatric condition
60
describe Alice in wonderland syndrome
aka Todd syndrome
incorrectly perceiving the sizes of body parts or objects e.g. hands perceived as being excessively large or small
associated with changes to the perception of time (e.g., time passing fast or slow) and symptoms of migraines (e.g., aura and headache).
symptoms intermittent
causes - migraine, epilepsy, and brain tumours
61
describe Koro syndrome
delusion) that the sex organs are retracting or shrinking and will ultimately disappear
causes anxiety and panic attacks
Cases primarily reported in Asia, particularly China and India
62
describe body integrity dysphoria
strong feeling that part of the body, for example, one or both of the legs, does not belong to them
healthy body part causes = distress, and they want it removed
not associated with psychiatric or neurological conditions
63
describe foreign accent syndrome
sudden change in a person’s voice
they are aware that their voice has changed
new speech pattern or accent is not connected with someone’s previous experience
most common cause is stroke in the left hemisphere.
64
describe functional neurological disorder (FND)
aka conversion disorder
sensory and motor symptoms that are not explained by any neurological disease and may be caused by underlying psychosocial factors (significant trauma/stress)
Symptoms
- weakness / paralysis
> Hoover's test positive to differentiate non-organic paresis
- gait disturbance
- seizures
- sensory loss e.g. blindness
- vision disturbances
symptoms are not under the patient’s control and can cause considerable distress and functional impairment
65
Describe schizoaffective disorder and schizophreniform disorder
schizoaffective disorder
- symptoms of psychosis as well as bipolar disorder (depression, mania)
schizophreniform disorder
- symptoms of schizophrenia lasting less than 6 months
66
describe adverse effects associated with clozapine
usually reserved for when two antipsychotics have not worked in treatment resistant cases
no depot form available
adverse effects
- agranulocytosis
- myocarditis
- constipation
- seizures (reduces seizure threshold)
- excessive salivation
67
describe autistic spectrum disorder
features
- deficits in social interaction: lack of eye contact, avoiding physical contact, unable to read non-verbal cues
- deficits in communication: delay in language development, repetitive use of words or phrases
- deficits in behaviour: greater interest in objects than people, stereotypical repetitive movements e.g. rocking (stimming), anxiety with experiences outside regular routine
management: MDT
> CAMHS, clinical psychologists, speech and language therapists...
68
describe Alzheimer's dementia
features
- gradual onset, gradual decline
- short-term memory loss
- word-finding difficulty
- emotion (apathy)
- language impairment
- impaired olfaction
- behavioural change (wandering, aggression)
- poor insight
causes
> early onset
- genetic risks: presenilin 1/2
- amyloid precursor protein (trisomy 21)
> late onset
- sporadic
- age, family history, apolipoprotein E
investigations: SPECT-CT
> medial temporal lobe / hippocampal atrophy
pathology: beta amyloid plaques, neurofibrillary tangles (intracellular hyperphosphorylation of tau)
69
describe vascular dementia
features
- stepwise decline in cognition
- risk factors for cardiovascular disease e.g.hypertension, hypercholesterolaemia
- Emotional lability and focal neurological deficits
investigations
- CT head: established infarcts, small vessel disease
70
describe Lewy Body Dementia
features
- dementia BEFORE motor symptoms (parkinsonism)
- silent visual hallucinations
- fluctuating cognition
- sensitivity to antipsychotic medications
pathology: lewy bodies in cerebral cortex, aggregates of alpha synuclein
investigations: DaT scan
management
- donepezil, rivastigmine
- memantine for visual hallucinations
71
describe the management of Alzheimer's dementia
management
- mild-moderate: 3-acetylcholinesterase inhibitors
> donepezil, galantamine, rivastigmine first-line
> neostigmine second-line
- severe: NMDA antagonist
> memantine
- group cognitive stimulation therapy: mild and moderate dementia
-group reminiscence therapy and cognitive rehabilitation
72
describe frontotemporal dementia
features
> impulsive and socially inappropriate behaviour + personality changes
> expressive dysphasia / language difficulties
> onset typically earlier, usually 45-65 and rapid progression
CT head: frontal and temporal lobe atrophy
treatment: avoid cognitive enhancers
73
describe progressive supranuclear palsy (PSP)
parkinson's plus syndrome
onset 60s, more common in males
features
- parkinsonism
- oculomotor disturbance (vertical gaze palsy)
- dementia
- postural instability / falls
- early bulbar involvement (speech and swallowing difficulty)
MRI brain - midbrain atrophy
74
describe multiple systems atrophy
features
- parkinsonism
- cerebellar and autonomic dysfunction
> orthostatic hypotension
> urinary or faecal incontinence / retention
75
describe a brief psychotic disorder
episode of psychosis lasting less than a month with return to baseline functioning
76
describe the monitoring of SSRIs
patients <=25 who have been started on an SSRI - review after 1 week
patients >25 who have been started on an SSRI - review after 2 weeks (unless deemed at high risk of suicide)
77
differentiate between somatisation disorder and hypochondriasis
somatisation disorder
> multiple physical symptoms present for at least 2 years
> patient refuses to accept reassurance or negative test results
illness anxiety disorder (hypochondriasis)
> persistent belief in the presence of an underlying serious disease e.g. cancer
> patient refuses to accept reassurance or negative test results
78
describe electroconvulsive therapy
indications
- severe refractory depression (life-threatening
- catatonia
- prolonged or severe manic episode
prep: reduce the SSRI dose
side-effects
- short-term memory loss (rarely long-term)
- headache
- nausea
- cardiac arrhythmia
contraindication: raised ICP
79
describe Charles Bonnet syndrome
features
- persistent or recurrent complex hallucinations (usually visual or auditory)
- occur in clear consciousness
- background of visual impairment
- preserved insight
associated ophthalmological conditions: cataracts, ARMD, glaucoma
80
describe clozapine dosing
if missed for >48h must retitrate clozapine doses again slowly
> can make side effects worse e.g. dizziness, BP changes, drowsiness
81
define the following terms
- echolalia
- copropraxia
- echopraxia
- palilalia
echolalia: repetition of someone else's speech including questions being asked
copropraxia: involuntary performing of obscene or forbidden gestures or inappropriate touching
echopraxia: meaningless repetition or imitation of movement of others
palilalia: automatic repetition of one's own words, phrases or sentences
82
list medications to avoid while taking SSRI
precipitate serotonin syndrome
- triptans
- tramadol
increased risk of GI bleeding
- NSAIDs (if necessary co-prescribe PPI)
83
describe REM sleep disturbance disorder and chronic insomnia
REM sleep disturbance disorder
- abnormal behaviours during REM sleep e.g. acting out dreams
chronic insomnia
- difficulty falling/staying asleep/early morning wakening
- for at least 3 nights a week for at least 3 months
- management:
> good sleep hygiene and hypnotics if daytime impairment is severe e.g. zopiclone, zolpidem
84
describe the management of anorexia nervosa
management
adults
- individual eating disorder focused cognitive behavioural therapy (CBT-ED)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- Specialist supportive clinical management (SSCM)
- admission for controlled refeeding
children and adolescents
- first-line: anorexia-focused family therapy
- adolescent-focused psychotherapy
- CBT-ED
85
list interactions with MAOIs
MAOIs e.g. phenelzine, rasegiline
tyramine containing foods e.g. cheese, pickled herring, bovril, marmite, broad beans - can precipitate hypertensive crisis
avoid co-prescribing SSRIs due to risk of serotonin syndrome
86
which antipsychotic has the most tolerable side-effect profile
aripiprazole
87
describe obsessive compulsive disorder
intrusive thoughts (obsessions) which can be distressing /sexual
compel the individual to engage in repetitive behaviours (compulsions)
e.g. excessive hand washing/repeating phrases internally
classification: Yale-Brown Obsessive Compulsive Scale
> degree of distress / disruption to patient's life and their level of control over symptoms
management
- mild: exposure and response prevention therapy (ERP), variant of CBT
> if insufficient offer SSRI
- moderate: SSRI or more intensive CBT; clomipramine if SSRI contraindicated
- severe: refer to secondary care
88
list side effects of tricyclic antidepressants
TCAs: imipramine, clomipramine, amitriptyline, dosulepin
side-effects
- histamine antagonism: drowsiness, weight gain
- muscarinic antagonism: can't see can't pee can't shit can't spit
> blurred vision, urinary retention, dry mouth, constipation
- adrenergic receptor antagonism: postural hypotension
- QTc prolongation
89
describe post-concussion syndrome
features
- headache
- fatigue
- anxiety/depression
- dizziness
90
differentiate between sleep paralysis and night terrors
sleep paralysis:
- inability to move or speak when transitioning between sleep and wakefulness
- can be accompanied by vivid hallucinations
- management: if troublesome, clonazepam
night terrors:
- episodes of intense fear and agitation during deep non-REM sleep
- more common in children
- individual may scream, thrash around, or exhibit other signs of distress
91
describe fibromyalgia and its treatments
features
- chronic pain at multiple sites
- lethargy
- cognitive impairment: fibro fog
- sleep disturbance, headaches, dizziness
management
- aerobic exercise
- cognitive behavioural therapy
- medication: pregabalin, duloxetine, amitriptyline
92
describe multisystem atrophy
features
- parkinsonism
- autonomic disturbance
> atonic bladder
> postural hypotension
93
describe Tourette's syndrome and tics
Tourette's: development of tics that are persistent for over a year
tics - involuntary movements/sounds that the child performs repetitively throughout the day, more pronounced under pressure/excitement
examples
- simple tics: clearing throat, blinking, head jerking, sniffing, eye rolling
- complex tics: copropraxia (obscene gestures), coprolalia (obscene words), echolalia (repeating words)
management
- reassurance and monitoring; reduce stress and triggers
- if severe:
> habit reversal training
> exposure with response prevention
> medications in very severe cases: antipsychotic medications
94
describe corticobasal degeneration
parkinson's plus syndrome
age of onset 60s
clinical features
- asymmetrical parkinsonism
- apraxia
- dystonia
- alien limb phenomenon
- cortical sensory loss
- aphasia
MRI brain
- asymmetrical cortical atrophy affecting superior parietal lobe
95
Describe neuroleptic malignant syndrome and its treatment
Rare dangerous condition seen in patients taking antipsychotic medication, occurs within hours to days of starting antipsychotics
can also occur with dopaminergic drugs such as levodopa for PD, usually when the drug is suddenly stopped or dose reduced
Features
- pyrexia
- decreased reflexes
- lead pipe muscle rigidity
- autonomic lability: hypertension, tachycardia and tachypnoea
- agitated delirium with confusion
- AKI can occur secondary to rhabdomyolysis
diagnosis: increased creatine kinase and WCC
Management
- stop antipsychotic
- IV fluids to prevent renal failure
- dantrolene in selected cases
- bromocriptine, dopamine agonist
96
