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Psychiatry Flashcards

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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
monitoring of lithium?
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
26
level of lithium toxicity?
concentration >1.5mmol/L
27
precipitations of lithium toxicity?
dehydration renal failure drugs- diuretics, ACEi/ARBs, NSAIDs and metronidazole
28
features of lithium toxicity?
``` coarse tremor hyperreflexia acute confusion seizures coma ```
29
tx of lithium toxicity?
mild/moderate- may respond to volume resuscitation with normal saline severe toxicity- haemodialysis sodium bicarb is sometimes used
30
ICD-10 criteria for OCD?
- 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
tx of OCD?
mild/moderate- individual self-help group or group CBT (with exposure response prevention) moderate/severe- CBT pharmacological therapy- SSRIs
32
what is a hallucination?
a perception without an external object
33
what is a delusion?
a strong belief which is fixed and unshakeable. Not explained by cultural, religious or educational belief
34
RFs for schizophrenia?
family history black Caribbean ethnicity cannabis use
35
features of schizophrenia?
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
other features of schizophrenia?
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
Ix to rule out physical causes of schizophrenia?
``` bloods drug and alcohol screen EEG fasting glucose MSU CT brain ```
38
1st line Mx of schizophrenia?
oral atypical anti-psychotics e.g. clozapine, olanzapine, risperidone, apiprazole CBT
39
SEs of atypical antipsychotics?
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
risks of typical and atypical antipsychotics for elderly people?
increased risk of stroke and VTE
41
How do typical antipsychotics work?
dopamine D2 receptor antagonists e.g. haloperidol, chlorpromazine, prochlorpromazine
42
SEs of typical antipsychotics?
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
what is neuroleptic malignant syndrome?
pyrexia, muscle stiffness, rigidity, tachycardia
44
Ix of neuroleptic malignant syndrome?
raised serum CK increased WCC metabolic acidosis
45
mx of neuroleptic malignant syndrome?
STOP antipsychotic supportive- O2, IV fluids, cooling blankets benzodiazepines (agitation) IV dantrolene (malignant hypothermia)
46
monitoring of typical antipsychotics?
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
what is bipolar disorder?
chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression
48
types of bipolar disorder?
Type I disorder-> mania and depression | Type II disorder-> hypomania and depression
49
mx of bipolar disorder?
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
when should GPs refer to if symptoms of hypomania? or mania/depression in bipolar?
hypomania- community mental health team (CMHT) | mania/depression- urgent referral
51
DSM 5 criteria of anorexia nervosa?
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
features of anorexia nervosa?
``` 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
mx of anorexia nervosa?
CBT- eating disorder MANTRA SSCM- specialist supportive clinical management
54
mx of anorexia nervosa in children and young people?
anorexia focused family therapy (1st line) | CBT
55
what is bulimia?
episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising
56
mx of bulimia?
1st line- bulimia nervosa focused self help for adults 2nd line- CBT-ED Children- family based therapy
57
features of borderline personality disorder?
efforts to avoid real or imagined abandonment unstable interpersonal relationships impulsivity, temper, recurrent suicidal behaviour
58
features of schizoid personality disorder?
preference to praise and criticism, lack of interest in sexual interactions, lack of desire for companionship
59
features of schizotypal PD?
ideas of reference, odd beliefs and magical thinking, unusual perceptual disturbances
60
mechanism of alcohol withdrawal?
chronic alcohol consumption enhances GABA mediated inhibition in the CNS alcohol withdrawal does the opposite
61
features of alcohol withdrawal?
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
mx of alcohol withdrawal?
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
blood signs of alcohol withdrawal?
``` LFTS- GGT, AST FBC- high MCV, low Hb low BG high uric acid CDT- detects alcohol consumption ```
64
features of alcohol dependence?
- 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
what is wernicke's encephalopathy?
a neuropsychiatric disorder caused by thiamine
66
triad of wernicke's encephalopathy?
opthalmoplegia, confusion, ataxia
67
Ix of wernicke's encephalopathy?
decrease in red cell transketolase | MRI
68
Tx of wernicke's encephalopathy?
urgen replacement of thiamine | if untreated -> Korsakoff's syndrome-> amnesia, confabulation
69
examples of opioids?
morphine, buprenorphine, methadone
70
features of opioid misuse?
``` rhinorrhoea needle track marks pinpoint pupils drowsiness watery eyes yawning ```
71
complications of opioid misuse?
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
emergency management of opioid dependence?
IV or IM naloxone
73
mx of opioid dependence?
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
what is a risk assessment for suicide?
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) ```

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