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Phase 3a > Psychiatry > Flashcards

Psychiatry Flashcards

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1
Q

Ways of assessing alcoholism

A
  1. CAGE (>2 problem)
  2. AUDIT (10 questions)
  3. TWEAK (tolerance, worried, eye opener, amnesia, cut down)
  4. FAST (4 questions - used in A+E)
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2
Q

Alcohol limits

A

women and men max = 14 units/week
Binge drinking = 10 units/day
Dangerous = 50 units/week

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3
Q

Investigations for chronic alcoholism

A
  • raised MCV / macrocytic anaemia
  • deranged LFTs
  • Thrombocytopenia (low plts)
  • breath test + screening
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4
Q

How would you manage alcohol DEPENDENCE?

A
  1. Acamprosate - reduce cravings
  2. Disulfiram - hangover if alcohol consumed
  3. Naltrexone - less pleasure from alcohol
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5
Q

Symptoms of alcohol withdrawal

A

tremors / sweating / vomiting
sleep and mood disturbance
autonomic hyperactivity - tachycardia, HTN, pyrexia
SEZIURES AT 36 HOURS

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6
Q

When does delirium tremens occur and what are the symptoms?

A
  • day 3 of alcohol withdrawal*
  • altered consciousness and cognitive impairment
  • hallucinations and paranoid delusions
  • Lilliputian and formication
  • tremor
  • autonomic arousal
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7
Q

Acute management of alcohol withdrawal

A
  1. Chlordiazepoxide
  2. IV pabrinex - B12 replacement
  3. Thiamine 100mg BD
  4. BDZ if delirium
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8
Q

What is Wernicke’s encephalopathy?

A 
Acute brain damage due to thiamine deficiency.
Triad:
1. Delirium
2. Ocular signs
3. Wide based gait ataxia
Tx = IV Pabrinex + chlordiazepoxide
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9
Q

What is Korsakoff’s syndrome?

A

Brain damage due to chronic thiamine deficiency.
Triad:
1. Anterograde amnesia
2. Confabulation
3. Psychosis (Lilliputian, formication)
Tx = IV pabrinex + chlordiazepoxide (same as wernicke’s)

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10
Q

Signs of opioid intoxication

A 
drowsiness
mood change
bradycardia, HTN
pupillary constriction
respiratory depression
low body temp
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11
Q

Complications of opioid misuse

A
  • needle sharing –> HIV, hepatitis B/C
  • infections
  • VTE
  • Overdose
  • psychosocial problems
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12
Q

Management of opioid toxicity / dependence

A

Acute toxicity = IV/IM Naloxone

Detoxification = 4 weeks residential or 12 weeks community:
- Methadone or Buprenorphrine

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13
Q

Common causes of delirium (PINCH ME)

A 
Pain
Infection / intoxification
Nutrition (low thiamine, B12..)
Constipation
Hypoxia . hydration
Medication / drugs
Environmental

Other - post op, vascular, trauma, metabolic

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14
Q

3 common syndromes of delirium:

A
  1. Hypoactive - quiet confusion
  2. Hyperactive - agitation, delusions
  3. Mixed
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15
Q

Management of delirium

A
  1. Identify + treat cause
  2. orientate / aids
  3. sedation - Haloperidol, Olanzapine
  4. MMSE + review
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16
Q

Management of aggressive patient

A
  1. environmental
  2. behavioural
  3. Oral lorazepam 1-2mg
  4. IM lorazepam 1-2mg
  5. repeat every 45-60 mins
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17
Q

What is generalised anxiety disorder (GAD)

A

Persistent anxiety not isolated to specific environments.

Excessive worry about every day things (>6 months or less in children)

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18
Q

Risk factors for GAD

A

Aged 35-54
Female
Single or single parent
Protective factors = cohabitation, aged 16-24

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19
Q

Causes of GAD

A 
Stressful event
Neurobiological:
- loss of cortisol regulation
- reduced expression of BDZ receptors due to high cortisol
- Issues with amygdala
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20
Q

Diagnosing GAD (1)

A

3 clinical features:

  • restlessness
  • irritability
  • fatigue
  • difficulty concentration
  • muscle tension
  • sleep disturbance
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21
Q

Diagnosing GAD (2)

A

+ 4 other symptoms:

  • Autonomic
  • abdo/chest
  • general
  • mental state
  • non-specific
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22
Q

GAD management

A
  1. Self-help
  2. CBT, applied relaxation
  3. Sertraline
  4. Clomipramine / another SSRI

BDZ = Rapid response

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23
Q

What is panic disorder?

A

Recurrent panic attacks not secondary to substance misuse or another disorder

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24
Q

Risk factors for panic disorder

A

Peak onset - 15-24 + 45-54yrs

Risk factors - single, living in city, limited education, early parental loss, physical or sexual abuse

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25
Management of panic disorder
1. Self-help 2. CBT 2. Sertraline /SSRI 3. Clomipramine
26
What are the 3 main types of phobia?
Agoraphobia - panic in places where escape is difficult Simple phobia - specific object or situation Social - social situations, suicidal thoughts common
27
Agoraphobia treatment
Behavioural = exposure + relaxation Cognitive = education + coping 1st line = sertraline Short term = BDZ
28
Simple / specifc phobia treatment
Behavioural = exposure and relaxation Cognitive = education + coping BDZs only to enable exposure therapy
29
Social phobia treatment
1. Self-help 2. CBT, Graded exposure therapy 3. Sertraline 4. PRN propanolol 5. MAOI *short term BDZ?*
30
What is OCD
``` Obsessions = recognised as patients own thoughts - death, sex, blasphemous Compulsions = repetitive behaviours or mental acts ```
31
OCD treatment
1. Self-help 2. CBT and exposure and response prevention (ERP) 3. SSRI - Fluoxetine or sertraline 4. Clomipramine - specific non-obsessional action
32
Risk factors for PTSD
``` low education / social class Female Black / hispanic FHx of psych conditions Previous traumatic events ```
33
The 4 clinical features of PTSD
1. Re-experiencing 2. Avoidance 3. Hyperarousal (startle response) 4. Emotional numbing (detached)
34
ICD-10 for PTSD
- Symptoms arise within 6 months of event | - symptoms present for at least 1 month with significant distress
35
PTSD treatment
1. Watchful waiting if <4 weeks since trauma 2. CBT or EMDR if >4 weeks since trauma 3. Paroxetine or Mirtazapine 4. BDZ for sleep disturbance 5. ?antipsychotics
36
Diagnostic criteria for Anorexia
Weight <85% predicted BMI <17.5 Fear of weight gain Feel fat when underweight
37
Signs of anorexia
General - fatigue, cold intolerance, altered sleep cycle Repro - subfertility, amenorrhoea, failed 2nd sex characteristics CV - brady, low BP, long QT Derm - lanugo hair, yellow tinge, dry skin, brittle hair
38
Anorexia bloods
Low: Glu, K+, phosphate, TSH, sex hormones, renal function High: LFT, amylase, growth hormone, glucose, cortisol
39
SCOFF questionnaire
``` Sick - make yourself Control - lost over eating One stone lost in 3 months Feel fat Food dominates life ```
40
Red flags for anorexia
``` BMI <13 or below 2nd centile Weight loss >1kg / week Temp 34.5 BP <80/50 SATS <92% Long QT, flat T waves Muscle weakness ```
41
Treatment of anorexia (adults)
1. Restore nutritional balance + treat complications 2. Involve family 3. ED unit if severe 4. Psychological - ED-CBT
42
Treatment of anorexia (children)
1. Anorexia focussed family therapy | 2. CBT
43
Signs of re-feeding syndrome
* drop in phosphate after >10 days of undernutrition* - rhabdomyolysis - resp / cv failure - arrhythmia - seizure
44
Management of re-feeding syndrome
``` Slow refeeding thiamine + multivits Monitor for: 1. low phosphate 2. low potassium 3. high glucose 4. high magnesium ```
45
Additional ED signs for bulimia
``` vomiting callouses on back of hands (Russel's sign) Oedema (lax + diuretics) gastric dilation carrdiomyopathy (lax) ``` ``` Metabolic alkalosis (vomiting) Metabolic acidosis (lax) ```
46
Management of Bulimia
Support, self-help, food diary EDU referral Fluoxetine - reduces binging and purges
47
Diagnosis of depression
3 core symptoms: 1. low mood 2. low energy 3. anhedonia Mild - 2 core + 2 other Mod - 2 core + ≥3 other Sev - 3 core + ≥4 other
48
Other symptoms of depression (other than 3 core)
``` Early morning waking Change in appetite agitation loss of libido self harm suicide ideation psychotic symptoms if severe (nihilistic/ guity delusions) ```
49
2 assessment tools for depression
PHQ-9 and HADs (hospital anxiety and depression scale)
50
Management of MILD depression (2 core sx + 2 other)
1. lifestylediet/exercise/socialising 2. computerised CBT (self-referral) 3. Psychoeducation
51
Management of MODERATE depression (2 core + ≥3 others)
1. lifestyle 2. anti-depressants 3. high intensity psychological therapy (CBT)
52
Management of SEVERE depression (3 core + ≤4 other)
1. MH assessment and consider inpatient | 2. ECT - electroconvulsive therapy
53
How do you diagnose bipolar disorder?
>2 episodes, one of which must be mania / hypomania
54
What is the difference between Bipolar I and Bipolar II?
Bipolar I = mania >1 week and not able to function normally (more likely to have psychotic symptoms) Bipolar II = Hypomania 4+ days and still able to function
55
Symptoms of mania
``` elevated mood increased energy pressured speech risk taking grandiosity incongruency of affect decreased need for sleep may have psychotic Sx ```
56
What is cyclothymia
cyclical mood swings with subclinical features
57
Treatment of an acute manic episode in bipolar
Lithium Antipsychotics stop or reduce SSRIs severe episode = ECT
58
Long term treatment of bipolar disorder
``` education/ lifestyle Lithium (thryo + nephrotoxic) Valproate Lamotrigine CBT ```
59
1st line medical management of depression
SSRIs - fluoxetine / citalopram / sertraline Monitor FBCs + U+Es long QT in citalopram
60
Other depression medications after SSRIs
1. NaSSA - mirtazapine (drowsiness and weight gain) 2. TCA - amitryptiline (anti-cholinergic and muscarinic -- dry mouth, tachy, blurred vision, urinary retention, drowsiness)
61
Medical management of post natal depression
1. SSRIs = sertraline or paroxetine ONLY 2. TCAs All other SSRIs are secreted in breast milk and are harmful
62
What are the 5 types of dementia
1. Alzheimers 2. Vascular 3. DLB 4. Frontotemporal 5. Mixed
63
Dementia features specific to Alzheimers? What are the Alzheimers specific medications?
apathy, depression, difficulty remembering recent events and names. Late stage = psychosis + primitive reflexes Tx = Donepazil, memantine if severe
64
Dementia features specific to vascular dementia?
STEPWISE DETERIORATION, 3 syndromes: 1. single stroke 2. multi-infarcts (stable periods) 3. Binswanger's disease (multiple microvascular infarcts)
65
Dementia features specific to DLB? Specific drug?
Quicker onset and more likely to have early symptoms like sleep disturbance and visual hallucinations. Slow gait and parkinsonian movement. Tx = rivastigmine
66
Types of Frontotemporal dementias? Main symptoms?
1. Behavioural-variant FTLD 2. Primary progressive aphasia 3. Pick's disease 4. Corticobasal degeneration 5. Progressive supranuclear palsy - Change in personality and behaviour
67
Cognitive screening tools for dementia?
ADDENBROOKES = most diagnostic. <82 = abnormal MMSE MoCA AMT
68
What are the differentials for memory problems / dementia?
- dementia - Organic causes: 1. Alcohol 2. Wilson's / PD / huntingtons 3. Renal / hepatic failure 4. Hypothyroid 5. Viral - syphillis / HIV - vascular - stroke - malignancy
69
What could the DDx be for hallucinations or delusions?
1. Schizophrenia 2. Psychotic disorders - bipolar/ severe depression 3. Dementia - DLB, PD 4. Other - trauma, stress, drugs, alcohol
70
What are the first rank symptoms for schizophrenia?
1. Hallucinations - 3rd person or somatic 2. Delusional perception - attribute false meaning to real stimuli 3. Thought alienation 4. Passivity phenomena - feel external control of thoughts/ feelings
71
What are the non-first rank symptoms for schizophrenia?
- Incongruous mood - Abnormal speech and thoughts - Negative symptoms - Catatonic behaviour - Any persistent hallucination
72
What are the 6 subtypes of schizophrenia?
1. Paranoid 2. Hebephrenic / disorganised 3. Catatonic 4. Undifferentiated 5. Residual 6. Simple
73
What are the features of paranoid schizophrenia?
- Persecutory and/or grandiose delusions | - no thought disorder or flat affect
74
What are the features of Hebephrenic / disorganised schizophrenia?
- Thought disorder and flat affect both present
75
What are the features of catatonic schizophrenia?
- Catatonic stupor or waxy flexibility
76
What are the features of undifferentiated schizophrenia?
Psychotic symptoms present but criteria for other subtypes not met
77
What are the features of residual schizophrenia?
Positive symptoms are present at a low intensity
78
What are the features of simple schizophrenia?
Progressive and prominent negative symptoms with no history of psychotic episodes
79
What investigations would you do for hallucinations / delusions?
- rule out drugs - urine screen - rule out alcohol - LFTs. FBC, macrocytes - rule out syphillis - serology - rule out SOL - CT head
80
Schizophrenia management?
1. Atypical antipsycotics (Respiridone, Olanzipine) 2. Typical antipsycotics (Haloperidol, Chlorpromazine) 3. Clozapine in treatment resistant schizophrenia CBT
81
What is schizoaffective disorder?
Symptoms of both mania/depression and hallucinations/delusions in a small time frame. Tx = Mood stabilisers and antipsychotics
82
What is the definition of a personality disorder?
enduring and pervasive disturbance in several areas of the personality which impairs functioning, and is present in a broad range of situations.
83
What is the management for personality disorders?
- Dialectical behavioural therapy (DBT) for EUPD - CBT - Interpersonal therapy * medication only helpful to encourage engagement with therapy*
84
What are the subtypes of Cluster A schizophrenia?
1. Paranoid 2. Schizoid = voluntary social withdrawal 3. Schizotypical = socially awkard, odd, spiritual thoughts
85
What are the subtypes of cluster B schizophrenia?
1. EUPD = self harm/ suicide risk 2. Antisocial = manipulative, impulsive, lack empathy 3. Histrionic = Preoccupied with appearance, sexually inappropriate 4. Narcissistic
86
What are the subtypes of cluster C schizophrenia?
1. Avoidant = desire companionship but fear rejection 2. Dependent = unwilling to take self-responsibility 3. OCPD = perfectionism
87
What is complex PTSD?
Mix of EUPD and PTSD, patients have usually experienced significant trauma
88
Name 4 types of sleep disorder?
1. Narcolepsy 2. Sleep apnoea 3. Circadian rhythm disorders 4. Parasmonia (nightmares, sleep walking/talking, restless leg syndrome)
89
How are sleep disorders managed?
Sleep hygiene advice (limit caffeine, alcohol, smoking / daily exercise, relaxing activities in evenings) CBT Medications: 1. Lorazepam 2. Z drugs (Zopiclone, Zaleplon, Zolpiderm) 3. Sedating hhistamines - promethazine
90
Suicide risk assessment (SAD PERSONS)
``` Sex (male) Age (peaks in young and old) Depression Previous attempts/ severity of means Ethanol Rational thinking lost (schiz) Support network lost Organised plans No significant others Sickness ``` - 5-6 = hospitalisation? - 7-10 = definite hospitalisation
91
What is section 2 of the mental health act?
Detained for assessment 28 days long Approved by 2 doctors + 1 AMHP
92
What is section 3 of the mental health act?
Detained for treatment 6 months long (can be renewed) Approved by 2 doctors + 1 AMHP
93
What is section 4 of the mental health act?
Emergency order + not enough time for 2nd doctor to attend 72 hours long Approved by 1 doctor + 1 AMHP
94
What is section 5(2) of the mental health act?
Doctor's holding power for patients admitted but wanting to leave Cannot be coercively treated 72 hours long
95
What is section 5(4) of the mental health act?
Nurse's holding power Cannot be coercively treated 6 hours long
96
What is section 135 of the mental health act?
Allows police to enter a property for a MHA assessment
97
What is section 136 of the mental health act?
People who need immediate help can be taken away from public areas to a place of safety and detained by police for up to 72 hours.
98
What is section 17 of the mental health act?
Allows ward leave for patients detained under section 2 or 3, agreed by consultant psychiatrist
99
What is a compulsory treatment order?
For patients being discharged from section 3 but still require compulsory treatment in the community. It lasts for 6 months and pts can be brought back to hospital if not compliant. Done under section 17.
100
What are the 5 principles of the mental capacity act?
1. Assume capacity 2. Individual supported to make own decision 3. Unwise decisions do not mean lack of capacity 4. Best interests 5. Least restrictive practice
101
How do you assess capacity?
``` Does the person have impairment of mind? Understand? Retain? Weigh up? Communicate decision? ```
102
What is an Independent mental capacity advocate (IMCA)
Appointed for someone who lacks capacity but has no one to support them in decisions
103
What is an advanced statement?
Non-legally binding written document stating a persons wishes should they lose capacity.
104
What is an advanced directive / decision?
Legally binding document for the REFUSAL of certain medical interventions, made when person has capacity.
105
What is the lasting power of attorney?
Designated person to make decisions on patients behalf if they lack capacity in the future.
106
What is the court of protection?
Make decisions if no lasting power of attorney and resolves disputes with treatment plans in complex cases.
107
What is a DOLS (deprivation of liberty safeguards)?
For a person who lacks capacity and is in a hospital or care environment
108
What is a somatisation disorder?
Multiple physical SYMPTOMS present for at least 2 years | Patient refuses to accept reassurance or negative results
109
What is a hypochondrial disorder?
Persistent belief in a serious underlying DISEASE (eg.cancer) Patient refuses to accept reassurance or negative results
110
What is a conversion disorder?
Typically involves loss of sensory or motor function Patient doesn't consciously feign symptoms (factitious disorder) or seek materialistic gain (malingering) Patients may be indifferent to apparent disorders (La Belle indifference)
111
What is dissociative disorder?
A process of separating off certain memories from normal consciousness Involves psychiatric symptoms (amnesia, stupor...) Dissociative identity disorder is the new term for multiple personality disorder and is the most severe type
112
What is factitious disorder?
Also known as Munchausen's | Intentional production of psychological or physical symptoms
113
What is malingering?
Simulation or exaggeration of symptoms with the hope of financial or material gain
114
NICE guidelines quality statements for self harm
1. Dignity + respect 2. Initial assessment of physical health, mental state, safeguarding concerns and social circumstances including risk of repeat harm or suicide 3. Comprehensive psychosocial assessment 4. Monitor while in healthcare setting to reduce risk of further harm 5. Safe environment 6. Continued support 7. Psychological interventions (3-6 counselling sessions) 8. Collaborative plan for moving between services

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