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finals > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Parts of a mental state examination?

A 
Appearance
Behaviour
Speech
Mood and affect
Thought- form, content, possession (insertion, withdrawal, broadcasting)
Perceptions- hallucinations and illusions
Cognition- MMSE, orientation
Insight
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2
Q

what is the difference between hallucinations and illusions?

A

hallucinations- false perception

illusions- misinterpreted perception

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3
Q

what is a biopsychosocial formation?

A

biological, psychological, social (X-axis)

predisposing (vulnerability), precipitating (triggers), prolonging (maintaining), protective (strengths) (Y-axis)

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4
Q

screening questions for depression?

A

1) During the last month, have you often been bothered by feeling down, depressed or hopeless?
2) During the last month, have you often been bothered by having little interest or pleasure in doing things?

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5
Q

screening tools for depression?

A

HAD scale

PHQ-9

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6
Q

DSM-IV criteria for depression?

A

SIG E CAPS
Sleep changes- insomnia or hypersomnia
Interest (loss)- in activities
Guilt (worthless)

Energy (fatigue)

Cognition/Concentration- both reduced
Appetite- weight loss
Psychomotor- agitation (anxiety) or retardation
Suicide thoughts

9th criteria- depressed mood most of the day, nearly every day

Mild depression- 5+ symptoms
moderate- between mild and severe
Severe- most symptoms, markedly interfere with functioning

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7
Q

tx of depression?

A

mild- sleep hygiene, self-help, computerised CBT, group-based CBT

pharmacological tx- SSRIs, SNRIs, TCAs, MAOIs, noradrenergic and specific serotonergic antidepressants

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8
Q

SSRIs: examples, SEs, CIs?

A 
e.g. fluoxetine, sertraline, citalopram
Need 3 weeks for peak effect, continue for 6 months after remission of symptoms, withdraw over 4 weeks
CI- mania
SEs- 4S's
Stomach upset- GI disturbance
Sexual disturbance
Suicidal thoughts (increased anxiety)
Serotonin syndrome
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9
Q

what is serotonin syndrome?

A

Cognitive impairment- confusion, agitation
Autonomic dysfunction- increased SNS
Neuromuscular hyperactivity- clonus, ataxia, hypertonia

tx= benzodiazepines or cryprohepatadine

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10
Q

examples of SNRIs and CI?

A

venlafaxine, duloxetine

CI-cardiac arrhythmia

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11
Q

examples and SEs of tricyclic antidepressants?

A 
amitriptyline, clomipramine, lofepramine
SEs- anticholinergic muscarinic receptor blockade
Can't see- blurred vision, dry eyes
Can't wee- urinary retention
Can't spit- dry mouth
Can't shit- constipation
lengthening of QT interval

less commonly used due to side effects and toxicity in iverdose

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12
Q

MAOIs?

A

Monoamine oxidase inhibitors
e.g. phenelzine
SE- hypotension, anxiety, anticholinergic SEs, hypertensive crisis
CI- cheese and wine, adrenaline, amphetamines, L-DOPA

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13
Q

noradrenergic and specific serotonergic antidepressants?

A

e.g. mirtazapine
SE- increased appetite and weight gain, sedation at lower doses
CI- mania

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14
Q

mx of generalised anxiety disorder?

A

1- education and active monitoring
2- low intensity psychological intervention (self-help/groups)
3- high intensity psychological interventions (CBT) or drug treatment (SSRIs, buspirone, benzos)
4- high specialised input

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15
Q

risk of SSRIs in GAD?

A

Increased risk of suicidal thinking and self-harm if under 30
weekly follow-up is recommended for the first month

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16
Q

Mx of panic disorders?

A

1- recognition and diagnosis
2- primary care- CBT and SSRIs
3- review and consideration of alternative treatments
4- review and referral to specialist mental health services
5- care in specialist mental health services

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17
Q

features of PTSD?

A

Features most be present of >1 month:

  • re-experiencing- flashbacks, nightmares etc
  • avoidance
  • hyperarousal- hypervigilance for threat, exaggerated startle response
  • emotional numbing- lack of ability to experience feelings
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18
Q

mx of PTSD?

A

Watchful waiting for mild symptoms <4 weeks
Military have access to treatment provided by the armed forces
CBT or 1st line EMDR (eye movement desensitisation and reprocessing) therapy may be used in more severe cases
Drug tx- venlafaxine or SSRIs e.g. sertraline. Risperidone may be used in severe cases

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19
Q

what is mania vs hypomania?

A

Mania- >7 days, severe functional impairment, may require hospitalisation, may present with psychotic symptoms

Hypomania- lasts <7 days, typically 3-4 days. Doesn’t impair functional capacity in social or work setting.Unlikely to require hospitalisation. No psychotic symptoms

mood is predominantly elevated, pressured speech, flight of ideas, poor attention, insomnia, loss of inhibitions, increased appetite

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20
Q

what are psychotic symptoms?

A

delusions of grandeur

auditory hallucinations

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21
Q

mx of mania or hypomania?

A

remove anti-depressants

mood stabilisers- lithium, lamotrigine, carbamazepine, sodium valproate

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22
Q

mechanism of lithium?

A

interferes with cAMP formation

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23
Q

why is lithium monitoring essential?

A

narrow therapeutic index
0.4-1.0mmol/L
long plasma half life

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24
Q

side effects of lithium?

A 
Leukocytosis
Insipidus (diabetes)
Tremors
Hypothyroidism
IU increased urine
Mum's beware (teratogenic)
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25
Q

monitoring of lithium?

A

lithium levels performed weekly and after each dose change until concentrations are stable
once established- lithium blood level should normally be checked every 3 months
thyroid and renal function should be checked every 6 months

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26
Q

level of lithium toxicity?

A

concentration >1.5mmol/L

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27
Q

precipitations of lithium toxicity?

A

dehydration
renal failure
drugs- diuretics, ACEi/ARBs, NSAIDs and metronidazole

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28
Q

features of lithium toxicity?

A 
coarse tremor
hyperreflexia
acute confusion
seizures
coma
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29
Q

tx of lithium toxicity?

A

mild/moderate- may respond to volume resuscitation with normal saline
severe toxicity- haemodialysis
sodium bicarb is sometimes used

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30
Q

ICD-10 criteria for OCD?

A
  • Obsessions or compulsions must be present for at least 2 successive weeks and area source of distress or interfere with the patient’s functioning
  • They are acknowledged as coming from the patient’s own mind
  • The obsessions are unpleasantly repetitive
  • At least one thought or act is resisted unsuccessfully
  • A compulsive act is not in itself pleasurable
31
Q

tx of OCD?

A

mild/moderate- individual self-help group or group CBT
(with exposure response prevention)
moderate/severe- CBT
pharmacological therapy- SSRIs

32
Q

what is a hallucination?

A

a perception without an external object

33
Q

what is a delusion?

A

a strong belief which is fixed and unshakeable. Not explained by cultural, religious or educational belief

34
Q

RFs for schizophrenia?

A

family history
black Caribbean ethnicity
cannabis use

35
Q

features of schizophrenia?

A
  1. Auditory hallucinations of either:
    - 2 or more voices discussing the patient in a 3rd person
    - thought echo
    - voices commenting on the patient’s behaviour
  2. Thought disorder
  3. Passivity phenomena- bodily sensations being controlled by external influence or experiences whch are imposed on to the individual (actions, impulses, feelings)
  4. Delusional perceptions e.g. the traffic light is green therefore I am king
36
Q

other features of schizophrenia?

A

impaired sight
neologisms (made up words)
catatonia- motor symptoms

Negative symptoms:

  • Flat affect/ blunting
  • Loss of motivation
  • Anhedonia (lack of pleasure)
  • Poverty of speech
  • Social withdrawal
37
Q

Ix to rule out physical causes of schizophrenia?

A 
bloods
drug and alcohol screen
EEG
fasting glucose
MSU
CT brain
38
Q

1st line Mx of schizophrenia?

A

oral atypical anti-psychotics e.g. clozapine, olanzapine, risperidone, apiprazole
CBT

39
Q

SEs of atypical antipsychotics?

A

weight gain
DM
hyperprolactinaemia- galactorrhoea and amenorrhoea in women, hypogonadism or ED in men

clozapine- risk of agranulocytosis (severe leukopenia)- FBC weekly monitoring is essential
- should only be used if 2 drugs fail
also risks of reduced seizure threshold, constipation, myocarditis (baseline ECG needed), hypersalivation

40
Q

risks of typical and atypical antipsychotics for elderly people?

A

increased risk of stroke and VTE

41
Q

How do typical antipsychotics work?

A

dopamine D2 receptor antagonists e.g. haloperidol, chlorpromazine, prochlorpromazine

42
Q

SEs of typical antipsychotics?

A

extra pyramidal SEs- ADAPT

  • Acute Dystonia (sustained muscle contractions)
  • Akathisia (severe restlessness)
  • Parkinsonism
  • Tardive dyskinesia (chewing and pouting of jaw)
anti-muscarinc SEs
sedation, weight gain
raised prolactin- galactorrhoea, impaired glucose tolerance
prolonged QT syndrome
reduced seizure threshold
neuroleptic malignant syndrome
43
Q

what is neuroleptic malignant syndrome?

A

pyrexia, muscle stiffness, rigidity, tachycardia

44
Q

Ix of neuroleptic malignant syndrome?

A

raised serum CK
increased WCC
metabolic acidosis

45
Q

mx of neuroleptic malignant syndrome?

A

STOP antipsychotic
supportive- O2, IV fluids, cooling blankets
benzodiazepines (agitation)
IV dantrolene (malignant hypothermia)

46
Q

monitoring of typical antipsychotics?

A

FBC, U&E, LFT- at start of therapy, annually, clozapine more frequently needed
lipids, weight- at start, 3 months, annually
fasting BG, prolactin- at start, 3 months, annually
BP- baseline, frequently during dose titration
ECG- baseline
CV risk assessment- annually

47
Q

what is bipolar disorder?

A

chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression

48
Q

types of bipolar disorder?

A

Type I disorder-> mania and depression

Type II disorder-> hypomania and depression

49
Q

mx of bipolar disorder?

A

psychological interventions
mood stabilisers- lithium
if mania -> antipsychotic e.g. olanzapine or haloperidol
if depression -> talking therapies, fluoxetine
address co-morbidities- DM risk, CV disease risk

50
Q

when should GPs refer to if symptoms of hypomania? or mania/depression in bipolar?

A

hypomania- community mental health team (CMHT)

mania/depression- urgent referral

51
Q

DSM 5 criteria of anorexia nervosa?

A
  1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age/sex
  2. Intense fear of gaining weight or becoming fat
  3. Disturbance in the way they feel about their body weight
52
Q

features of anorexia nervosa?

A 
reduced BMI
bradycardia
hypotension
enlarged salivary glands
G's and C's raised- cortisol, GH, cholesterol, carotin, glucose
low- hypokalaemia, low FSH/LH, low T3
53
Q

mx of anorexia nervosa?

A

CBT- eating disorder
MANTRA
SSCM- specialist supportive clinical management

54
Q

mx of anorexia nervosa in children and young people?

A

anorexia focused family therapy (1st line)

CBT

55
Q

what is bulimia?

A

episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising

56
Q

mx of bulimia?

A

1st line- bulimia nervosa focused self help for adults
2nd line- CBT-ED
Children- family based therapy

57
Q

features of borderline personality disorder?

A

efforts to avoid real or imagined abandonment
unstable interpersonal relationships
impulsivity, temper, recurrent suicidal behaviour

58
Q

features of schizoid personality disorder?

A

preference to praise and criticism, lack of interest in sexual interactions, lack of desire for companionship

59
Q

features of schizotypal PD?

A

ideas of reference, odd beliefs and magical thinking, unusual perceptual disturbances

60
Q

mechanism of alcohol withdrawal?

A

chronic alcohol consumption enhances GABA mediated inhibition in the CNS
alcohol withdrawal does the opposite

61
Q

features of alcohol withdrawal?

A

symptoms start at 6-12 hours: tremors, sweating, tachycardia, anxiety

peak incidence of seizures at 36 hours

peak incidence of delirium tremens at 72 hours- coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

62
Q

mx of alcohol withdrawal?

A

patients admitted if withdrawal unstable
1st line- benzodiazepines e.g. chlordiazepoxide
lorazepam preferable if hepatic failure
reducing dose protocol

2nd line- carbamazepine

others- disulfram- promotes abstinence by producing severe symptoms -> N&V, hypotension, facial flushing, headache
Acamprosate- reduces cravings
Thiamine (pabrinex)

63
Q

blood signs of alcohol withdrawal?

A 
LFTS- GGT, AST
FBC- high MCV, low Hb
low BG
high uric acid
CDT- detects alcohol consumption
64
Q

features of alcohol dependence?

A
  • strong desire/compulsion to drink
  • difficulty controlling drinking
  • physiological withdrawal state
  • tolerance
  • neglect
  • persisting with drinking over other activities
  • narrowing of drinking repertoire
  • reinstatement after abstinence
65
Q

what is wernicke’s encephalopathy?

A

a neuropsychiatric disorder caused by thiamine

66
Q

triad of wernicke’s encephalopathy?

A

opthalmoplegia, confusion, ataxia

67
Q

Ix of wernicke’s encephalopathy?

A

decrease in red cell transketolase

MRI

68
Q

Tx of wernicke’s encephalopathy?

A

urgen replacement of thiamine

if untreated -> Korsakoff’s syndrome-> amnesia, confabulation

69
Q

examples of opioids?

A

morphine, buprenorphine, methadone

70
Q

features of opioid misuse?

A 
rhinorrhoea
needle track marks
pinpoint pupils 
drowsiness
watery eyes
yawning
71
Q

complications of opioid misuse?

A

viral infection secondary to sharing needles- HIV, HEP B&C
bacterial infection- IE, septic arthritis, septicaemia, necrotising fasciitis
VTE
Psychological problems
Social problems- crime, prostitution, homelessness

72
Q

emergency management of opioid dependence?

A

IV or IM naloxone

73
Q

mx of opioid dependence?

A

1st line- buprenorphine or methadone
Compliance is monitored using urinalysis
Detoxification should last up to 4 weeks as an impatient and 12 weeks in the community

74
Q

what is a risk assessment for suicide?

A

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

Previous suicide attempt
Ethanol
Rational thinking loss e.g psychosis
Single or separated
Organised
No social support
Sickness (chronic)

finals (14 decks)

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