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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

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1
Q

What is akathisia?

A

A feeling of inner restlessness and inability to stay still

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2
Q

What are the side effects of first generation antipsychotics? (4)

A

Sedation
Antimuscarinic effects
EPSEs
Hypotension

+ prolonged QT interval

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3
Q

Give examples of EPSEs (4)

A

Acute dystonic reactions (involuntary Parkinsonian movements / muscle spasms)
Akathisia
Neuroleptic malignant syndrome (rigidity, confusion, autonomic dysregulation - life threatening)

After a long time
Tardive dyskinesia (pointless, involuntary, repetitive movements eg lip smacking)
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4
Q

Overall, how do antipsychotics work?

A

Block post-synaptic dopamine D2 receptors

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5
Q

What drug class is Venlafaxine?

A

SNRI

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6
Q

How should you stop SSRIs eg citalopram, sertraline?

A

Gradually over 4 weeks

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7
Q

Why are lots of people put on Fluoxetine?

A

Longer half life so doesn’t matter if they forget to take it / stop taking it suddenly

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8
Q

Which antidepressant would you use in under 18s?

A

Fluoxetine

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9
Q

What happens 6-12 hours after alcohol withdrawal?

A

Symptoms - tremor, sweating, tachycardia, anxiety

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10
Q

When is the peak incidence of seizures following alcohol withdrawal?

A

36 hours

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11
Q

When is the peak incidence of delirium tremens following alcohol withdrawal?

A

48-72 hours

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12
Q

Describe the course of what happens following alcohol withdrawal

A

6 hours = symptoms
36 hours = seizures
72 hours = delirium tremens

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13
Q

What are the symptoms of alcohol withdrawal? (4)

A

Tremor
Sweating
Tachycardia
Anxiety

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14
Q

What are the features of delirium tremens? (6)

A 
Coarse tremor
Confusion
Delusions
Auditory / visual hallucinations
Fever
Tachycardia
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15
Q

Give the features of SSRI discontinuation syndrome (7)

A 
Mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI stuff - pain, cramps, diarrhoea, vomiting
Paraesthesia
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16
Q

What are the risks of using SSRIs in the first trimester of pregnancy?

A

Congenital heart defects

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17
Q

What are the risks of using SSRI in the third trimester of pregnancy?

A

Pulmonary hypertension of the newborn

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18
Q

What is the first line management for a patient with delirium tremens?
+ route

A

Oral lorazepam

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19
Q

What would you do if the symptoms of delirium tremens persist in a patient treated with oral lorazepam

A

Parenteral lorazepam or haloperidol

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20
Q

What would you need to give to an alcoholic long term

A

Thiamine - Pabrinex

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21
Q

How do you treat alcohol withdrawal?

A

Benzodiazepines - reducing regime

Chlordiazepoxide

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22
Q

What are the adverse effects of antipsychotics in the elderly population?

A

Increased risk of stroke and VTE

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23
Q

What are the 2 features of conversion disorder?

A

Loss of motor or sensory function

Doesn’t consciously fake the symptoms

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24
Q

What are the risk factors for depression?

A

Separation / divorce
Adverse life event / loss
Shit childhood - sexual abuse, loss of parent, parental alcoholism
Physical illness
Personality traits - obsessive, impulsive, anxious

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25
What are the core symptoms of depression?
Low mood Anergia Anhedonia
26
What are the non-core symptoms of depression? (other symptoms)
``` Change in appetite Change in sleep - early waking, slow to get to sleep Decreased concentration Suicidal ideation Loss of libido Diurnal mood variation Loss of confidence Feeling guilty Hopelessness ```
27
How do you make a diagnosis of mild depression?
2 core symptoms 2 other symptoms Difficulty continuing with normal work + social functioning
28
How do you make a diagnosis of moderate depression?
2 core symptoms 3 other symptoms Considerable difficulty in continuing with normal work, social functioning + domestic stuff
29
How do you make a diagnosis of severe depression?
3 core symptoms 4 other symptoms With or without psychotic symptoms - different diagnoses Very limited work / social functioning
30
How do you treat mild depression?
Psychological therapies - CBT - Interpersonal therapy - Family / marital interventions - Mindfulness based cognitive therapy
31
How would you treat moderate or severe depression, first-line?
Psychological therapy + SSRI If there are psychotic symptoms + antipsychotic
32
What are the options for management of treatment-resistant depression?
Lithium / other antidepressant ECT Psych inpatient care Crisis service
33
For which conditions is ECT used as a therapy?
Severe, treatment-resistant depression Severe mania Catatonia Schizophrenia
34
What are the adverse effects of SSRIs?
``` GI upset GI bleeding (avoid NSAIDs) Appetite and weight changes Hyponatraemia QT prolongation Reduce seizure threshold ```
35
What groups of people would you avoid giving SSRIs to?
Peptic ulcers Arrhythmias Epilepsy
36
What is serotonin syndrome? (pathophysiology)
``` Caused by increased serotonin - overdose of SSRIs or use in combination with other antidepressants Triad - Autonomic hyperactivity - Altered mental state - Neuromuscular excitation ```
37
What are the symptoms associated with sudden withdrawal from SSRIs?
Sleep disturbance GI upset Neurological signs Flu-like symptoms
38
What are tricyclic antidepressants used for?
Depression | Neuropathic pain
39
What are the side effects of tricyclic antidepressants?
- Dry mouth - Constipation - Urinary retention - Blurred vision - Sedation - so give at night - Hypotension - falls in the elderly + arrhythmias and ECG changes - prolonged QT and QRS + can cause convulsions, hallucinations, mania
40
What groups of people would you be cautious about giving tricyclic antidepressants to?
``` Elderly Epilepsy Suicidal Arrhythmias Constipation Raised intraocular pressure Prostatic hypertrophy ```
41
What are the symptoms associated with tricyclic antidepressant overdose?
``` Hypotension Arrhythmias Convulsions Coma Respiratory failure ```
42
What is bipolar affective disorder?
Depression + mania or hypomania
43
What are the types of bipolar affective disorder?
Bipolar I = multiple episodes of mania + mixed episodes or one or more episodes of depression Bipolar II = multiple episodes of depression + hypomania
44
What is cyclothymia?
Persistent instability of mood - numerous periods of mild depression and mild elation, not sufficiently severe or prolonged to fulfil the criteria for bipolar affective disorder or recurrent depressive disorder
45
What are the risk factors for developing bipolar affective disorder?
Female Younger - average age of onset 21 years Family history - of bipolar and schizophrenia
46
How long do symptoms have to be present for someone to have hypomania?
4+ days
47
How long do symptoms have to be present for someone to have mania?
7+ days
48
What are the features of hypomania?
``` Decreased concentration Hyperactivity / increased energy Elevated mood Increased self-confidence / ideas of self-worth (confidence) Spending more money Sexual disinhibition Sociability Talkativeness Reduced sleep Reduced appetite ```
49
What are the features of mania?
``` Extreme elation Hyperactivity Flight of ideas / pressure of speech Grandiosity Social disinhibition Inappropriate sexual encounters Overfamiliarity Very reduced sleep Decreased concentration Extreme risk taking / reckless behaviour Hyperacusis ``` Can have psychotic symptoms Marked effects on work + life
50
How would you treat a bipolar patient presenting with an acute manic episode?
Give an atypical antipsychotic - haloperidol, olanzapine, risperidone, quetiapine - -> switch to another - -> add Lithium - -> add valproate - -> ECT + STOP ANTIDEPRESSANT (if taking one)
51
How would you initially treat a bipolar patient presenting with an acute depressive episode?
Psychological therapy
52
After psychological therapy, what medications would you use in a bipolar patient presenting with a depressive episode?
Check lithium / valproate levels if on this and increase Then (or if not on treatment): Fluoxetine + olanzapine OR quetiapine alone
53
If a bipolar patient who is on long-term therapy presents with a depressive episode, what would your first-line management be?
If lithium or valproate - check levels and increase to maximum tolerated dose
54
How would you treat someone with bipolar disease long-term (BEFORE MEDICATION)
Education Structured psychological interventions Individualised assessment, help with problem-solving and monitoring thoughts and behaviour
55
What medical treatments are used for bipolar affective disorder?
Lithium = most effective | Sodium valproate or olanzapine if Lithium not tolerated or unsuitable
56
What are good prognostic features for bipolar disorder?
``` Short manic episodes Late onset Fewer suicidal thoughts Few psychotic symptoms Good response to treatment ```
57
What are bad prognostic features for bipolar disorder?
``` Rapid cycling Depressive episodes Alcohol abuse Male sex Non-compliance with treatment ```
58
What is the therapeutic range for Lithium plasma concentration?
0.6-1.2mmol/L
59
When should you measure plasma concentrations of Lithium?
12 hours after last dose | If new dose --> 1 week after they have been on that dose
60
What are the short term side effects of Lithium use?
``` Dry mouth Metallic taste Nausea Fine tremor Polydipsia ```
61
What are the long term side effects of Lithium use?
``` Diabetes insipidus Ataxia Weight gain Hypothyroidism Hypokalaemia --> arrhythmias Teratogenicity ```
62
If a lady with bipolar disorder becomes pregnant, which medication would you put her on?
Lithium + sodium valproate are both teratogenic | But Lithium less so --> put her on this but make sure to check levels etc more regularly
63
What baseline tests would you do in someone on Lithium treatment + how often?
``` General physical including weight U&E LFTs TFTs Pregnancy test Calcium ECG ``` Every 3 months (more often if pregnant / on diuretic)
64
What are the signs of Lithium toxicity?
``` D&V Visual disturbance Hypokalaemia Ataxia Severe tremor Dysarthria Coma ```
65
What level of Lithium would be classed as toxic?
Over 1.5mmol/L
66
What are the side effects of sodium valproate use?
``` Valproate (mnemonic) Appetite increase Liver failure Pancreatitis Regrowth of hair curly Oedema Ataxia Teratogenicity / tremor / thrombocytopaenia Encephalopathy ```
67
What is a paranoid personality type?
Suspicious
68
What is a Schizoid personality type?
Cold, emotionless, stays by themselves with no friends, not bothered by criticism or praise
69
What is an emotionally unstable personality type?
``` Borderline = attention seeking, in the worst possible way aka pretend to be suicidal, clingy in relationships Impulsive = unpredictable ```
70
What is a schizotypal personality disorder?
Schizophrenia basically - ideas of reference, odd beliefs, eccentric, inappropriate affect
71
What is a dissocial personality disorder?
Needs an ABSO basically | Gets into fights, doesn't turn up to work, doesn't pay bills, general dickhead
72
What is a histrionic personality disorder?
Manic Inappropriate sexually, wants to be centre of attention, self dramatic, considers relationships to be more intimate than they are
73
What is a narcissistic personality disorder?
Grandiose, crave compliments, high self importance, manipulative
74
What is an anankastic personality disorder?
OCD
75
What is an anxious personality disorder?
Anxious person
76
What is a dependent personality disorder?
Reckon they are dependent on everyone, can't do anything by themselves, always need to be in a relationship, can't make decisions alone
77
What is an avoidant personality disorder?
Avoid things because they can't take criticism / think everyone doesn't like them Crave social situations but don't go to them
78
What are the first rank symptoms (major symptoms) of Schizophrenia?
Thought alienation Delusions of control or passivity 3rd person auditory hallucinations Delusional perception
79
What are the minor symptoms of Schizophrenia?
``` Other hallucinations ie 2nd person auditory Other delusions Thought disorganisation Catatonia Negative symptoms ```
80
How do you make a diagnosis of Schizophrenia?
1 or more major symptoms or 2 or more minor symptoms | Present for most of the time for at least 1 month
81
How long do symptoms have to be present to make a diagnosis of Schizophrenia?
1 month
82
How would you treat a first episode of psychosis?
Antipsychotic medication | Psychological intervention - CBT / family therapy
83
How would you pharmacologically manage someone with psychosis / Schizophrenia?
SGA Another SGA FGA (so 2 non-Clozapine antipsychotics, at least 1 being SGA) Then Clozapine
84
What must be taken into consideration when deciding what antipsychotic medication to put someone on?
``` Sedation needs Patient choice, taking into account: - EPSEs - Metabolic effects eg weight gain - Other side effects ```
85
What do the early intervention team aim to do?
Reduce duration of untreated psychosis Provide the most effective intervention at an early stage Increase likelihood of re-integration into school / work Reduce death
86
How do you make a diagnosis of Schizoaffective disorder?
Symptoms of an affective disorder and Schizophrenia in about equal proportions - meet criteria for manic / depressive episode, and 1 or more symptoms of Schizophrenia In the same episode of illness - not separate episodes Episodes not in the context of substance abuse or another mental health disorder
87
How do you classify Schizoaffective disorder?
Manic type = Prominent elevation of mood + 1 or 2 Schizophrenic symptoms Depressive type = 2 classical depressive symptoms + 1 or 2 Schizophrenic symptoms
88
How do you treat Schizoaffective disorder?
As you treat depression / mania / Schizophrenia
89
What is persistent delusional disorder?
Persistent non-bizarre (not typical schizophrenic) for >3 months
90
What are the risk factors for developing persistent delusional disorder?
``` Advanced age Low socioeconomic status Premobid personality disorder Sensory impairment, especially deafness Recent immigration Family history History of head injury History of substance abuse Social situations: - Jealousy - Distrust - Isolation - Low self-esteem ``` Acutely = stress
91
What types of delusions would be experienced by a patient with persistent delusional disorder?
``` Grandiose Persecutory Hypochondriacal Jealousy Erotomanic Somatic ```
92
How would you treat someone with persistent delusional disorder?
Psychological therapy Medication - antipsychotics + SSRI (overlaps with depression) Separation from focus / source of delusional ideas
93
What is acute and transient psychosis?
Short-term psychosis - resolves in a few days / weeks / months Can occur in the context of an acute stressor eg bereavement, marriage, accident, childbirth
94
What are the risk factors for developing acute and transient psychosis?
Acute stressors - bereavement, marriage, accident, childbirth Social isolation - so more in developing countries Certain personality disorders - paranoid, borderline, histrionic
95
What are the subtypes of acute and transient psychosis?
Broadly with or without the symptoms of schizophrenia
96
How would you manage a patient with acute and transient psychosis?
Short term admission Medication - antipsychotics / benzodiazepines / antidepressants Address specific social issues - supportive psychotherapy
97
What is generalised anxiety disorder?
Anxiety that is generalised and persistent but not restricted to, or strongly predominating in, any particular environmental circumstances (ie is free-floating anxiety)
98
What are the symptoms associated with generalised anxiety disorder? (how do you make a diagnosis)
- Persistent nervousness - Trembling - Muscular tensions - Sweating - Lightheadedness - Palpitations - Dizziness - Epigastric discomfort (and other physical manifestations eg headaches --> so is important to check for this if the patient has chronic pain of any sort that they are repeatedly presenting to primary care for) + often express fears that the patient or a relative will shortly become ill or have an accident apprehensive on most days for 6 months
99
What are the physical signs of anxiety (related to generalised anxiety disorder)
Tachycardia Dyspnoea Trembling Exaggerated startle responses
100
How would you assess a patient with generalised anxiety?
GAD-2 or GAD-7 questionnaires
101
What are the risk factors associated with a diagnosis of generalised anxiety disorder?
- Female sex - Family history of anxiety - Current physical or emotional stress - History of physical or emotional trauma - History of other anxiety disorders eg panic disorder, social phobia or specific phobias - Chronic pain or physical illness (eg arthritis, cancer, coronary heart disease, cerebrovascular accident, COPD) - History of substance abuse - Repeated visits with the same physical symptoms which do not respond to treatment (eg insomnia, headache, fatigue)
102
How would you treat someone with generalised anxiety disorder?
Manage co-morbidities Address environmental stressors Education CBT or SSRI / SNRI
103
What is dementia?
Irreversible global cognitive decline that can't be attributed to a different cause
104
What is the most common cause of dementia in older people?
Alzheimer's dementia
105
What are the symptoms of Alzheimer's dementia?
``` 4 A's Amnesia Apraxia Agnosia Aphasia ```
106
What are the pathophysiological features of Alzheimer's dementia?
Neurofibrillary tangles | Amyloid plaques
107
What are the pharmacological treatments for Alzheimer's dementia?
Acetylcholinesterase inhibitors - Donepizil, Rivastigmine | Antiglutaminergics - Memantine
108
What are the risk factors for developing Alzheimer's disease?
``` Down's syndrome Parkinson's disease Increased age Previous head injury Family history Family history of Down's syndrome or Parkinson's ```
109
What are the features of Vascular dementia?
Acute onset | Stepwise deterioration
110
What would you look for in a patient with vascular dementia (risk factors)?
``` Hypertension Previous strokes or MI Diabetes + peripheral vascular disease Hypercholesterolaemia Focal CNS signs ```
111
What are the features of Lewy body dementia?
``` Fluctuating in nature Rapid cognitive decline Hallucinations - often visual, of small animals and children REM sleep disorders Frequent falls Later --> parkinsonism ```
112
What are the features of fronto-temporal dementia?
Personality change - apathy, disinhibition, emotional blunting, coarsening of sociability Language changes Intellectual functioning Initially memory stuff / orientation preserved - distinguishing feature from Alzheimer's, but can be lost later
113
What are the reversible causes of dementia?
``` B12 deficiency Pellagra - B3 deficiency Hypothyroidism Thiamine deficiency - alcoholics Syphilis Tumours Normal pressure hydrocephalus Whipple's disease ```
114
How would you manage challenging behaviour in a patient with dementia?
Rule out infection / pain as a cause | Trazodone (at night) or Lorazepam
115
How do you generally treat a patient with dementia?
``` Advance care planning Monitor physical + mental health Cognitive stimulation Life history etc Routines Pharmacological - for Alzheimer's / vascular Occupational therapy Physiotherapy Social activity / inclusion ```
116
What is delirium?
Acute confusional state
117
What are the features of delirium?
``` Impaired consciousness Impaired cognitive function - Short term memory and recent memory loss - Relative preservation of remote memory - Disorientated to time and place - Language abnormalities eg rambling, incoherent speech, impaired ability to understand Perceptual and thought disturbance Sleep-wake cycle disturbance Mood disturbance ```
118
What are the causes of delirium?
``` Infection - UTI, pneumonia, meningitis Metabolic - anaemia, uraemia, electrolyte disturbance Intracranial - head injury, tumour Substance intoxication / withdrawal Hypoxia ```
119
How would you assess a patient with delirium?
CAM - confusion assessment method MOCA MMSE Bloods for causes ECG EEG? CXR Urinalysis
120
How would you treat a patient with delirium?
Identify / treat the cause and precipitating factors Make the environment safe Optimise stimulation - lighting, reduce noise, mobilise, hearing aid, glasses Orientation techniques - same staff, big clock, newspapers with the date on
121
How would you treat a delirious patient who is severely agitated?
Haloperidol | Lorazepam if they are really bad
122
What are the complications of delirium?
``` Infections Pressure sores Falls Functional impairment Continence problems Over-sedation - also leads to falls ```
123
What are the features of Wernicke's encephalopathy?
Confusion Ataxia Ophthalmoplegia - nystagmus, 6th nerve

Phase 3a (11 decks)

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