Psychiatry Flashcards
(238 cards)
1
Q
What is dementia?
A
An umbrella term for conditions of the brain that cause a disturbance of higher mental functions
2
Q
What are the 4 main types of dementia?
A
Alzheimers, vascular, lewy body and frontotemporal
3
Q
What are important investigations to do for dementia in primary care and why?
A
Bloods (FBC, U&Es, LFTs, calcium, glucose, TFTs, vitamin b12 and folate) to rule out organic, treatable causes of memory loss
4
Q
What tests are used for cognitive screening in dementia?
A
MOCA, MMSE, Addenbrooks
5
Q
What dementia is commonest?
A
Alzheimers
6
Q
What is seen macroscopically with regard to the brain in Alzheimers?
A
Cerebral atrophy, particularly of the cortex and hippocampus
7
Q
What is seen micoscopically with regard to the brain in Alzheimers?
A
Cortical plaques due to beta amyloid protein
Neurofibrally tangles caused by Tau protein
8
Q
What is seen biochemically in Alzheimers?
A
Reduced acetylcholine
9
Q
What are symptoms of Alzheimers?
A
Usually begin after 60 years. Memory loss with evidence of varying change in planning, reasoning, speech and orientation
10
Q
How does Alzheimers progress?
A
Slowly and gradually over time
11
Q
What is the pathogenesis of vascular dementia?
A
Vascular events (multiple infarcts, small vessel disease, single infarct) leading to degeneration. Commonly affects white matter, grey nucleus, thalamus and striatum
12
Q
What are risk factors for vascular dementia?
A
Cardiovascular disease, hypertension, stroke
13
Q
What are symptoms of vascular dementia?
A
Cognitive impairment, functional deficits, mood disorders, psychosis, delusions, emotional lability
14
Q
How doe vascular dementia progress?
A
Stepwise degeneration
15
Q
What is the pathogenesis of Lewy Body Dementia?
A
Spherical lewy body proteins, composed of alpha synuclin, deposited around the brain. More widespread deposits than in PD
16
Q
What are symptoms of Lewy Body Dementia?
A
Visual hallucinations, parkinsonism, fluctuation in cognitive ability, sleep disorders, problems with multitasking
17
Q
How does Lewy Body Dementia progress?
A
Rapidly
18
Q
What is the commonest cause of dementia in under 65s?
A
Frontotemporal
19
Q
What is the pathogenesis of frontotemporal dementia?
A
Neuron damage and death in the frontal and temporal lobes. Atrophy due to deposition of abnormal proteins
20
Q
What are the 3 main types of frontotemporal dementia?
A
Picks disease, semantic and non-fluent
21
Q
How does Picks disease present?
A
Altered emotional responsiveness, apathy, disinhibition, impulsivity, progressive decline in interpersonal skills
22
Q
What are Pick bodies and how are they seen?
A
Spherical aggregations of Tau protein, seen on silver stain
23
Q
What is the non-pharmacological management of dementia?
A
Behaviour management, cognitive stimulation, recreational activities
24
Q
What drugs are available for Alzheimers disease?
A
Cholinesterase inhibitors (Donepezil, galantamine, rivastigmine) NMDA agonists (memantine) if severe
25
What drugs are sometimes used for lewy body dementia?
Donepezil, rivastigmine
26
What are side effects of cholinesterase inhibitors?
diarrhoea, vomiting, deranged LFTs, incontinence, headache, dizziness
27
What is the effect of depression on life expectancy?
Reduces it by 5-10 years
28
What are risk factors for depression?
Genetics, female gender, personality, early life experiences, stressors, physical illness, drugs
29
What are the core symptoms of depression?
Low mood
Anhedonia
Anergia
30
What are additional symptoms of depression?
Loss of confidence, guilt, recurrent thoughts of death, self harm, suicidal intent, reduced concentration, sleep disturbance, change in appetite
31
What is seen in MSE of a person with depression?
Appearance & behaviour = may be variable
Speech = reduced rate, volume, intonation, low pitch
Mood & affect = low
Thoughts = slow, poverty of thought, obsessions, ruminating, thoughts of guilt/death
Perception = hallucinations - mood congruent (persecutory)
Cognition = poor memory, slow thinking
Insight = typically preserved
32
What is dysthymia?
Chronic low mood that does not fit definition of recurrent depression. Tired and depressed for months at a time, unable to cope with demands of life
33
What non pharmacological treatment is helpful in depression?
CBT, sleep hygiene, physical activity
34
What is the first line drug for depression?
SSRI
35
What are examples of SSRIs?
Fluoxetine, sertaline, citalopram, paroxetine, escitalopram
36
How do SSRIs work?
Prevent pre-synaptic uptake of 5-HT
37
What are common side effects of SSRIs?
GI upset, GI bleeding, rebound anxiety as drug started, increased suicide risk, insomnia, mania
38
What do SSRIs interact with?
NSAIDs (use PPI), warfarin, heparin, triptans
39
What are discontinuation side effects of SSRIs?
Mood disturbance, restlessness, GI upset
40
How is switching from one SSRI to another achieved?
Withdraw the first drug then start the new drug
| In fluoxetine - withdraw first then wait 4-7 days before starting new drug (long half life)
41
How is switching from an SSRI to venlafaxine/TCA achieved?
Cross tapering of both doses
42
What SSRI is used in pregnancy?
Sertraline
43
What SSRI is used in children?
Fluoxetine
44
What SSRI is used post-MI?
Sertraline
45
What are examples of tricyclic antidepressants?
Amitriptyline, clomipramine, imipramine
46
How do TCAs work?
Block serotonin and noradrenaline transporters to prevent reuptake
Also antagonise muscarinic, histamine and adrenergic receptors
47
What are the indications for TCAs?
Depression (2nd line)
| Panic disorder, OCD
48
What are contraindications for TCAs?
MI, arrythmia, liver disease, porphyria, mania in bipolar
49
What are side effects of TCAs?
Constipation, dry mouth, blurred vision, urinary retention, sedation
50
How does TCA overdose present?
Arrhythmia, seizure, coma
51
What blood gas is seen in a TCA overdose?
Metabolic acidosis
52
What ECG changes are seen in TCA overdose?
Sinus tachycardia and widening of QRS
53
How is TCA overdose managed?
IV bicarbonate to fix acid/base balance
54
What drug is considered to be 'TCA like'?
Trazadone
55
What are examples of monoamine oxidase inhibitors?
Phenelzine, moclobemide, isocarboxazid
56
How do MAOIs work?
Inhibits monoamine oxidase to prevent neurotransmitter breakdown
57
When are MAOIs used?
Atypical depression
58
What are side effects of MAOIs?
Postural hypotension, hypertensive crisis
59
What may precipitate hypertensive crisis in MAOIs?
Tyramine containing foods (eg. cheese, yoghurt, yeast, meat)
60
What are examples of SNRIs?
Venlafaxine, duloxetine
61
What is the mode of action of SNRIs?
Inhibit serotonin and noradrenaline reuptake
62
What is the indication for SNRIs?
Severe depression
63
When are SNRIs contraindicated?
Hypertension, arrythmia
64
What are side effects of SNRIs?
Nausea, dry mouth, GI upset, drowsiness, urinary retention, tachycardia, vasodilation
65
What is an example of a NaSSA?
Mirtazapine
66
What is the mode of action of mirtazapine?
Antagonist of noradrenaline, serotonin and histamine receptors
67
When is mitrazapine used?
2nd line in depression
68
What are side effects of mirtazapine?
Dry mouth, GI upset, increased appetite and weight gain, sedation, agranulocytosis
69
What are symptoms of mania?
Elevated mood, increased energy levels, overactivity, pressure of speech, decreased need for sleep, disinhibition, grandiose ideas, tasking risks, overspending, delusions, hallucinations
70
What is hypomania?
Milder elevation of mood with no psychosis
71
What is rapid cycling of mood?
4 or more episodes of mania in 1 year. Can be interspersed with periods of wellness
72
How is bipolar disorder defined?
Two or more episodes of mania +/- depression
73
What is the average age of onset of bipolar disorder?
21
74
What is bipolar 1?
More pronounced mania
75
What is bipolar 2?
Hypomania, severe depression more common
76
What are risk factors for bipolar disorder?
Genetics, stressors, childbirth, drugs
77
What is the lifetime risk of suicide with bipolar disorder?
12-15%
78
What symptoms are mood stabilisers generally better at treating in bipolar?
Manic rather than depressive
79
What are examples of drugs used for mood stabilising?
Litihium, lamotrigine, sodium valproate, olanzapine, aripiprazole
80
How does lithium work?
Mechanism unclear - may interact with cation transport, glutamate or cAMP
81
What are indications for lithium?
Bipolar disorder, treatment resistant depression, schizoaffective disorder
82
What are cautions for lithium?
Hyponatraemia, renal impairement, dementia
83
What are short term side effects of lithium?
GI upset, fine tremor, muscle weakness, polyuria and polydipsia
84
What are long term effects of lithium?
Oedema, weight gain, diabetes insipidus, renal damage, tardive dyskinesia, teratogenicity
85
What ECG changes are seen with long term lithium use?
T wave flattening
86
What is the teratogenic condition associated with lithium?
Ebsteins anomaly
87
At what levels does lithium toxicity occur?
>1.5mmol/L
88
What are symptoms of lithium toxicity?
GI upset, CNS upset, psychosis, collapse, death
89
How is lithium toxicity treated?
Fluid resuscitation, haemodialysis, sodium bicarbonate
90
What does lithium interact with?
NSAIDs, ACEis, thiazides, carbemazepine
91
What is the therapeutic window of lithium?
0.4-1mmol/L
92
How often should lithium be monitored until a stable dose is reached?
Weekly
93
How often should lithium be monitored for the first year?
Every 3 months
94
How often should lithium be monitored after the first year?
Every 6 months
95
How do anti-convulsants work in bipolar?
Potentiate GABA transmission to stabilise mood
96
What are indications for anti-convulsants in bipolar?
Bipolar disorder, patients unresponsive to lithium alone
97
What are cautions of anti-convulsants?
Risk of bleeding, osteoporosis, steven-johnsons-syndrome, hepatic/renal impairement
98
What are the side effects of anti-convulsants?
GI upset, weight gain, rash, ataxia, hair loss, DIC,pancreatitis, teratogenicity
99
What is the first line treatment for prophylaxis of bipolar disorder?
Lithium
100
What is the second line treatment for prophylaxis of bipolar disorder?
Lithium & valproate
101
If lithium is not well tolerated, what drug can be used for monotherapy in prophylaxis of bipolar?
Valproate, olanzapine, quetiapine
102
What drugs should be stopped during an episode of mania?
Anti-depressants
103
What drugs can be added to prophylactic treatment in an episode of mania?
Anti-psychotic - olanzapine/quetiapine/risperidone
104
What drugs are used on top of prophylaxis for bipolar depression?
Fluoxetine + olanzapine OR
Quetiapine OR
Lamotrigine
105
What is the definition of psychosis?
Inability to distinguish between subjective experience and reality, characterised by a lack of insight
106
What are hallucinations?
Sensations occurring without any stimulus. May be audtiory, visual, gustatory, tactile
107
What are pseudohallucinations?
Sensations occurring without any stimulus but patient retains insight that stimulus is in mind
108
What are delusions?
Beliefs held strongly irrespective of counter argument
109
What is passivity?
Delusion of control/one is no longer in control of their own body
110
What is though interference?
Withdrawal, insertion and broadcasting of thoughts
111
What is flight of ideas?
Speech jumps topic to topic due to rhyming etc
112
What is knights move thinking?
Speech jumps from topic to topic with no clear relation between topics
113
What is tangential thinking?
Wandering from topic to topic and never answering the orignal questions
114
What is circumstantiality?
Wandering away from original question and answering with unnecessary detail
115
What are neologisms?
Made up words
116
What is the differential diagnosis of psychosis?
Schizophrenia, psychoactive substance misuse, mania, severe depression, schizoaffective disordr, delirium, dementia
117
What is schizophrenia?
Common relapsing remitting condition wtih characteristic distortions of thought, perception, behaviour and emotion
118
What are risk factors for schizophrenia?
Family history, genetics, neurodevelopmental delay, race, cannabis use
119
What is the prevalence of schizophrenia?
1%
120
When are the peak incidences of schizophrenia?
Males 15-25
| Females 25-35
121
What are Schneiders first rank symptoms?
Auditory hallucinations - usually 3rd person
Delusions of though interference - insertion/broadcasting/withdrawal
Delusions of control - passivity phenomena
Delusional perception - delusional belief arising from normal perception
122
What are the positive symptoms of schizophrenia?
Delusions, hallucinations, thought disorder
123
What are the negative symptoms of schizophrenia?
Apathy, avolition, poverty of speech, blunting
124
What symptoms in schizophrenia respond better to treatment?
Positive symptoms
125
How long do symptoms need to go on for in schizophrenia before a diagnosis can be made?
One month
126
What are good prognostic indicators in schizophrenia?
Older age at onset, female sex, marked mood disturbance
127
What are bad prognostic factors in schizophrenia?
Long duration of untreated psychosis, insidious onset, early onset, cognitive impairment, enlarged ventricles
128
What is the first line treatment for schizophrenia?
Oral atypical antipsychotics
129
What are other important parts of treating schizophrenia?
CBT
| Cardiovascular risk modification
130
What are examples of typical antipsychotics?
Haloperidol, Chlorpromazine, prochloperazine, levomopromazine, flupentixol
131
How do typical antipsychotics work?
Block dopamine D2 receptors
| Antagonise M1, H1 and alpha1 receptors
132
What are typical antipsychotics with a higher affinity for the D2 receptor (e.g. haloperidol) more likely to cause?
Extra-pyramidal side effects
133
What are indications for typical antipsychotics?
Schizophrenia, mania, psychotic depression, acute anxiety, delirium
134
What are cautions for use of typical antipsychotics?
CVS disease, hepatic/renal impairement, epilepsy, Parkinsons
135
What are contraindications for typical antipsychotics?
CNS depression, phaeochromocytoma
136
What are extra-pyramidal side effects of typical antipsychotics?
Parkinsonism, acute dystonias, akathisia, tardive dyskinesia
137
What are some other side effects of typical antipsychotics?
Drowsiness, apathy, agitation, insomnia, weight gain, photosensitivity, anticholinergic side effects (e.g. dry mouth, urinary retention)
138
When does neuroleptic malignant syndrome occur?
Within 10 days of starting a new neuroleptic
139
How does neuroleptic malignant syndrome present?
Pyrexia, rigidity, tachycardia, raised CK
140
How is neuroleptic malignant syndrome treated?
Stop antipsychotic
IV Fluids
Benzodiazepines, dantrolene, bromocriptine
141
What are examples of atypical antipsychotics?
Olanzapine, quetiapine, risperidone, aripiprazole, clozapine
142
What is the mechanism of action of atypical antipsychotics?
Dopamine and serotonin receptor antagonism
143
What are the indications for atypical antipsychotics?
Schizophrenia, mania, psychotic depression
144
What are contraindications to atypical antipsychotic use?
Phaeochromocytoma, PRL secreting tumours
145
Are EPSEs more or less common in atypical antipsychotics?
Less common
146
What EPSE may aripiprazole cause?
Akathisia
147
What is akathisia?
Feeling of inner restlessness
148
What are side effects of atypical antipsychotics?
Hyperprolactinaemia, weight gain, metabolic syndrome, hyperglycaemia, diabetes, increased stroke risk
149
What is the notable side effect of clozapine?
Agranulocytosis
150
When clozapine therapy is initiated, how often should bloods be monitored?
Every 2 weeks for 6 months
151
After 6 months, how often should clozapine be monitored?
4 weekly
152
After stopping clozapine, when should bloods be taken?
1 month after
153
What bloods should be checked on initiation of an antipsychotic?
FBC, U&Es, LFTs, lipids, glucose, PRL
154
What other investigations should be done on initiation of an antipsychotic?
BP, ECG, cardiovascular risk assessment
155
How many antipsychotics should be trialled before initiation of clozapine?
2
156
What part of the brain is the emotional filter?
Amygdala
157
What effect does acute anxiety have on hormones?
Increased cortisol and catecholamines
158
What are physical symptoms of anxiety?
Sweating, hot flushes, shaking, muscle tension, numbness, tingling, dry mouth, palpitatons, chest pain
159
What are cognitive symptoms of anxiety?
Fear of losing control, on edge, mentally tense, difficulty concentrating, mind going blank, depersonalisation, hypervigilence, metaworry
160
When is anxiety pathological?
When it is in extent or out of context
161
What is generalised anxiety disorder?
Generalised and persistent anxiety not restricted to one environment and not due to substances
162
When is the usual onset of GAD?
20-40 years, commoner in females, chronic fluctuating course
163
How is GAD treated non-pharmacologically?
Education, psychological interventions
164
How is GAD treated medically?
SSRI (sertaline), venlafaxine
| Betablockers for symptom relief
165
What is panic disorder?
Recurrent attacks of severe anxiety which are not restricted to one environment and are therefore unpredictable
166
When is the usual onset of panic disorder?
From mid 20s, chronic waxing and waning course
167
How is panic disorder treated?
CBT
| SSRIs - try TCAs 2nd line (imipramine)
168
What are the 3 main phobias?
Agoraphobia
Specific phobia
Social phobia
169
What is agoraphobia?
Cluster of phobias encompassing fear of leaving home, entering shops, crowds etc
170
What is specific phobia?
Marked or persistent fear that is excessive or unreasonable (e.g. flying, needles) Exposure causes an immediate anxiety response
171
What is social phobia?
Persistent fear of social/performance situations where the person is exposed to unfamiliar people/scrutiny from others
172
How are phobias treated?
CBT
| SSRIs, moclobemide
173
What is OCD?
Common, chronic, disabling condition marked by obsessions and compulsions. Percieved by patient as non-sensical
174
What is the prevalence of OCD?
2-3%
175
When is the average age of onset of OCD?
20 years
176
What are obsessions in OCD?
Recurrent, unwanted, intrusive thoughts/memories/impulses. Unwanted, usually resisted
177
What are common obsessions in OCD?
Contamination, fear of harm, order, symmetry, sexual or violent thoughts
178
What are compulsions in OCD?
Repetitive, senseless behaviours that individuals feel driven to perform to reduce anxiety
179
What compulsions are common in OCD?
Checking, cleaning, mental compulsions
180
What does neuroimaging in OCD show?
Increased blood flow in orbitofrontal cortex and caudate nucleus
181
What is the treatment of OCD?
CBT, SSRI, clomipramine
182
What is type 1 trauma?
Single incident (e.g. rape, earthquake, RTA)
183
What is type 2 trauma?
Complex trauma (e.g. sexual abuse, genocide, hostage)
184
What are features of PTSD?
Re-experiencing (flashbacks, nightmares, intrusive images), avoidance, hyperarousal, emotional numbing, anger, anxiety
185
What is the neurobiology seen in PTSD?
Paradoxically low cortisol
Hippocampal atrophy
Increased amygdala activity
186
Which type of trauma is more likely to cause PTSD?
Type 2 trauma
187
How is PTSD managed non pharmacologically?
CBT
| Eye movement desensitisation and reprocssing (EMDR)
188
How is PTSD managed pharmacologically?
SSRIs, mirtazapine, amitriptyline, prazosin, atypical antipsychotics, mood stabilisers
189
What is the hippocampus important for?
Memory
190
What is a personality disorder?
Enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture
191
What are the 3 clusters of personality disorders?
Cluster A = odd and eccentric
Cluster B = dramatic eratic and emotional
Cluster C = anxious and fearful
192
What personality disorders are in cluster A?
Paranoid
Schizoid
Schizotypal
193
'Suspicious of others, has a preoccupation with conspiracy theories and thinks his friends are always criticising him'
Paranoid
194
'Few friends and emotionally cold. Indifferent to any praise. Shows no interest in companionship or sexual activity'
Schizoid
195
'Odd thinking and eccentric behaviour. Unusual perceptions, no real close friends. Suspicious of those around her'
Schizotypal
196
What personality disorders are in cluster B?
Antisocial, borderline, histrionic, narcissistic
197
'Boy who has scammed his friends out of money and set 3 cars on fire. Thinks its funny, shows no remorse'
Antisocial
198
'Short temper who has had 5 boyfriends in the last year. Disinhibition, loves taking coke and sleeping aroud. Has attempted suicide multiple times'
Borderline
199
'Has seduced her friends dad at a party and loves being the centre of attention. Very shallow emotions'
Histrionic
200
'Self important and a preoccupation with power and success. Chronically jealous of others. Arrogant. Will use people to achieve needs'
Narcissistic
201
What personality disorders are in cluster C?
Avoidant, dependent, Obsessive Compulsive
202
'Views self as inferior. Does socialise with others but would love to. Feels inadequate'
Avoidant
203
'Clings to boyfriend, cannot care for themselves, excessive need to be taken care of'
Dependent
204
'Obsessed with rules, lists, order. Perfectionism that hampers with completing tasks. Stingy. Does not see issue with stubborness'
Obsessive compulsive
205
How is borderline PD managed?
Dialectical behaviour therapy (DBT)
206
How can avoidant PD be managed?
Social skills training
207
How can haloperidol affect an ECG?
QT prolongation
208
What biochemical side effect can SSRIs cause?
Hyponatraemia
209
What benzodiazepine is used for alcohol withdrawal?
Chlordiazepoxide
210
What is paraphrenia?
Paranoid delusions occuring later in life (60+) - very late onset schizophrenia
211
What is the heritability of schizophrenia?
80%
212
What is the biggest risk factor for borderline personality disorder?
Sexual abuse
213
What neurotransmitter is found in aversive and defensive systems?
Serotonin
214
Which psychiatric disorder has the highest mortality rate?
Anorexia
215
What is a borderline LD an IQ of?
Around 70
216
What is a mild LD IQ?
50-69
217
What is a moderate LD IQ?
35-49
218
What is a severe LD IQ?
20-34
219
What is a profound LD IQ?
Less than 20
220
Which neurotransmitter is involved in appetitive and approach systems?
Dopamine
221
What abnormality of the HPA axis do you get in depression?
Adrenal enlargment
| Increased cortisol and increased ACTH
222
'Spect scan shows reduced attenuation throughout brain'
Vascular dementia
223
Which learning disability has the highest risk of schizophrenia?
Velocardiofacial syndrome
224
Patient complains of sore/immobile neck following administration of antipsychotic
Acute dystonia
225
Which antipsychotics are associated with metabolic syndrome?
Atypical antipsychotics
226
Patient has taken antipsychotic for years and has excessive blinking
Tardive dyskinesia
227
What are short term side effects of ECT?
Headache, nausea, memory loss just prior to ECT, arrhythmias
228
What are long term side effects of ECT?
Memory loss
229
What causes the positive symptoms of schizophrenia?
Overactivity of the mesolimbic system
230
What causes the negative symptoms of schizphrenia?
Underactivity of the mesocortical system
231
What drug is useful for akathisia?
Propranolol
232
What drug is useful for acute dystonia?
Procyclodine
233
How do benzodiazepines work?
Enhance GABA
234
What is oculogyric crisis an example of?
Acute dystonia
235
What are indications for ECT?
Catatonia
Severe or prolonged mania
Severe depression
236
When do seizures occur in alcoholics?
36 hours into withdrawal
237
When do delirium tremens occur in alcoholics?
72 hours into withdrawal
238
What do atypical antipsychotics increase the risk of in the elderly?
Stroke and VTE
