Flashcards in Psychiatry Core conditions and Drugs Deck (114):
Which document is used to classify and diagnosis mental health disorders?
What model is used to approach psychiatric assessments and management plans?
State the 3 core symptoms of depression.
Fatigue/ decreased energy
If a patient had 2 of the core features of depression and 3 other symptoms, what classification of depression would that be?
7+ = severe
In severe depression what psychotic features can be present?
You do a risk assessment for a patient who has features of depression and you ask them to fill in a questionnaire in the GP. Which questionnaire is it?
In which members of society is depression more common in?
2 females > males
List the differentials for depression
Frontal lobe epilepsy
In mild-moderate depression, what is the first line treatment?
CBT (6-12 sessions in 4 months)
A 65 y/o lady with trouble sleeping and moderate depression requests medication for her mood. What is the most appropriate drug and what are the side effects you need to warn her of?
- drowsy/ sleepy (take at night)
- weight gain
- dry mouth
Give the side effects of Mirtazipine, what drugs should not be taken with it?
St John's wort
Anti-epileptics (reduces its effects)
What anti-depressant would be give to a 30 year old with moderate depression?
SSRI - Sertraline, Citalopram
Loss of apetite
The above are all examples of side effects of which psychiatric drug?
Name the SSRI that can lead to prolonged QT interval.
SSRIs are used for what other conditions?
The contraindication for SSRI use is ___________
A 50 year old man with a previous history of heart attacks comes to the GP for an anti-depressant after loosing his job. Which antidepressant would you NOT give?
(contra in CVD, can increase QT)
A 46 y/o lady was started on Venlafaxine for depression. In the 4 week review, she stated she has been experiencing side effects. What are these likely to be?
Drowsiness, Dizzyness, Postural hypotension
A 45 y/o lady with long-standing severe depression has tried different anti-depressants which havn't worked and she is now not eating. What is the last resort therapy for her?
How long are you meant to take antidepressants for?
6-9 months post-recovery
12 months post-recovery if recurrent depression
What safety-net would you give for those taking anti-depressants?
Come back if sudden changes to mood, increased energy levels, reduced need for sleep
What is the criteria for diagnosis of bipolar or manic depression?
2 or more episodes of manic episodes with seasons of major depression
What is the difference between Type 1 and Type 2 Bipolar?
Bipolar type 1 = mania + depression
Bipolar type 2 = hypomania + depression (no psychotic symptoms)
Bipolar can be caused by _________ or __________
The presentation of manic episode include __________
Increased energy levels
Reduced need for sleep
Increased sex drive
Disinhibition, reckless behaviour
Flight of ideas
Delusions of grandiosity
You are an F1 on the psychiatric male ward and an 18 year old man comes in with increased energy levels and ideas of grandiosity and is irritable. What initial medication would you want to give?
What would you give in the long-term to help prevent this?
2. Lithium OR Valproate
State how bipolar can be managed from the psychosocial perspective
Psych - IAPT, CBT, Psychdynamic therapy
Social: support,sleep hygeine
Anxiety is a normal psychiological response to stress. When does it become pathological?
When it interferes with ADLs
When its PROLONGED
When its DISPROPORTIONATE to the stimulus
When it is present with NO STIMULUS
A 36 y/o females is admitted into hospital to investigate for suspected appendicitis. You notice that she continues to pace the floor despite receiving confirmation that she doesn't have any serious pathology. Name questionnaires that can help you to screen for a possible psychiatric problem
A 25 y/o banker has to drink coffee throughout the day to stay awake. She often doesn't get enough sleep and has a steady income from her job. She is concerned that sometimes her hand shakes and can appear anxious. What are possible causes of anxiety?
Anxiety is a spectrum of disorders, how many months of persistent worry/ apprehension and tension about everyday problems does it have to be to diagnose Generalised Anxiety Disorder (GAD)?
GAD compromises of 4 types of symptoms/ signs:
Psychological + ________ + ____________ + _____________
Autonomic: CV, Resp, GI, Urinary, Neuro
Motor - stiff legs, cramps, tremors, headache
Hyperarousal - hypervigilant, restless, startled
You can use SSRIs like Citalopram or SNRI like Venlafazine or Pregabalin to treat GAD.
What short-term medication can be used?
List other conditions other than GAD within the anxiety spectrum.
PTSD, Acute stress reaction, adjustment disorder
Loss of physical function with no underlying cause = ?
How long does symptom fixation have to be before it is diagnosed as somatisation?
Hypochondrial disorder = illness/ condition fixation
A 16 y/o girl has 3 panic attacks every 2 weeks which last for 5 mins with symptoms of palpitations, choking sensation and dizziness.
What is the diagnostic criteria for Panic D?
4 attacks in 4 weeks > 10 mins
A 23 y/o woman has a fear of being in a crowded bus and not being to get out so he tends to walk to university. She sometimes feel anxious at the thought of going on a bus.
What 5 behaviours would satisfy a diagnosis of Phobic Anxiety disorder
1. Anxiety restricted to specific object/ situation
2. Fear disproportionate
3. Fear not reasoned away
4. Anticipatory anxiety
5. Avoidance behaviour
OCD is definied as _______________
Recurrent obsessional thoughts leading to compulsive acts
(try to resist thouhts but need to act to make them or anxiety go away)
What screening questions would you ask to diagnose OCD?
1. Do you wash or clean things a lot?
2. Do you check things a lot?
3.Do you have thoughts that bother you that you try to get rid of but you can't?
4. Does it take you a long time to finish your daily activities?
5. Do you have a special order for items?
OCD cannot be diagnosed if the patient has obsessional ruminations in the prescence of depression.
What is the biopsychosocial management of OCD?
Psych: CBT, Exposure & response prevention (ERP)
A life-threatening or catastrophic event leading to pervasive distress is a definition for __________
When does it tend to occur?
Post-traumatic Stress Disorder (PTSD)
1-6 months post-trauma
List symptoms of PTSD.
How is it managed?
Re-experiencing symptoms: flashbacks, intrusive memories, nightmares
Anxiety, avoidance, detachment
Depression, suicidal ideation
2. Trauma-based CBT
A patient with a diagnosis of schizophrenia is due for their annual mental health review. You conduct a risk assessment. What are the domains of the risk assessment to ask?
Self-harm - incl E/D, neglect, driving
Harm to others
State the questions you would ask in any suicide risk assessment
1. Feel life is HOPELESS and NOT WORTH LIVING?
2. THOUGHTS of suicide?
3. PLANS of suicide?
4. MEANS of suicide?
5. Anything STOPPING you?
6. How do you feel about it NOW?
Psychosis is an umbrella term for experiences that are out of touch of reality and is a serious presentation.
Psychosis compromises of 3 things: ______, ______, ________
Psychosis is confined to a mental disorder. True or False?
Organic: Dementia, Delirium, Brain Dsiorders, Porphyria
The 1st episode of psychosis requires urgent referral to secondary care.
A gateway to this is through the _______
1st point of contact
(Google the number)
Schizophrenia is defined as distortions of thinking and perception with maintainence of consciousness and intellect.
It is more common in males, peaking from 20-28yrs. 1% population.
What are the biopsychosocial aetiological factors?
Bio: Greater occupancy of dopamine receptors, FH, CNS pathology: Neurosphyillus, TL epipelsy, Cannibis, Perinatal trauma
Psych: Any traumatic life event, childhood abuse, high expressed emotions
Social: Winter births, Urban living, Migration kids, Social exclusion
Which category of schizophrenia is the most common, presents early, is quite stable and usually has just auditory hallucinations
Hebephrenic has a more rapid development of -ve symptoms, has more of a change on affect and constast psychosis.
True or false?
Has fleeting psychosis
Which category of schizophrenia is an emergency if they stop E/D?
(Increase in muscle tone - rare, often seen if untreated)
The core symptoms of schizophrenia should be present for >1 month and all symptoms present for > 6 months for a formal diagnosis.
List Scheider's First Rank symptoms (+ve symptoms)
- 3rd person auditory hallucinations --- often running commentary, thought echo
- Delusions of though interference --- thought insertion/ withdrawal/ broadcast
- Delusions of control --- passivity of affect/ violition/ impulse/ somatic
- Delusional perception
List the -ve symptoms of schizophrenia which manifest more so in Hebephrenic.
(-ve symptoms often are late features & can mimic Affective D)
Avolition = lack of motivation
Alogia = poverty of speech
Asociality = lack of desire of relationships
In Schizophrenia the dopamine receptors have greater occupancy.
Describe the 4 dopamine pathways in the brain and what physiology/ processes they affect.
This explains the SE of anti-psychotics that counteract these pathways.
Nigrostrial - affects EPSEs
Tuberoinfundibular - affects prolactin
Mesolimbic - Memory, arousal, behaviour (+ve symptoms)
Mesocortical - Cognition, socialisation (-ve symptoms)
Don't diagnose schizophrenia if...
- Have depression or mania before psychotic symptoms
- Existing brain pathology e.g. frontal lobe epilepsy
- Substance abuse
Delusional disorder have a delusion as the pre-dominant symptoms that is persistent and often life-long. It can also feature with schizophrenia.
Define the following types of delusional D:
2. Othello syndrome
3. De Clerambault's
1. Persecutory = belief that someone is seeking to harm them
2. Othello = morbid jealously (belief that partner having sex with others). Ass: alcohol dependence
3. De Clerambaults = erotomania (belief that a famous person is in love with them
Name is type of delusion based on the descriptions below:
1. Delusional parasitosis. Risk of self-harm, often presents to dermatology.
2. delusional misidentification = belief someone you know has been replaced by an imposter
3. severe nihilistic delusions = belief being being dead.dying/ rotting
4. induced delusional disorder from dominant to less dominant partner in relationship
5. belief that everyone is a single person in disguise
1. Ekbom's syndrome
2. Capgras syndrome
3. Cotard's syndrome
4. Folie a Deux
5. Fregoli syndrome
Don't diagnosis a delusional D if the patient also has...
Delusions of control
Marked blunt affect
Evidence of brain pathology
(Schizophrenia, Affective D, Organic D)
If it is a patient's 1st episode of psychosis in 1" care then you must do an URGENT REFERRAL to 2" via _________________
The psych team will do an early assessment to decide the best service --> Early intervention team/ crisis/ in-patent.
Then an MDT assessment takes place to formulate a ________ plan and __________ plan
Single point of access
How is psychosis managed in the short and long-term?
- Bio: Anti-psychotics
- Psych/ Social: Education, support helplines
- Bio: Anti-psychotics, Antidepressants/ Lithium
- Psych: CBT/ FT (red expressed emptions + manage ass anxiety/ stress)
- Social: Supported employment, Art therapy
A 28 y/o male who's parents were from Turkey, have now settled in England. He used to take cannabis regularly and lives in London. He has had episodes for 7 months of hearing voices talk about how ugly he is and that he doesn't know how to use any machinery. His mood is fine, although he becomes anxious when he hears the voices
What is the likely diagnosis?
Give an overview of the drug profiles of anti-psychotics.
Types: 1st generation vs 2nd generation
Mechanism of action: reduces occupancy of dopamine receptors in brain
Indications: Psychosis, Schizophrenia, Affective D with psychosis, Hyperactive delirium, manic episode, sedation
Contra: Parkinsons, Dementia, caution: CVD
SE: EPSE, Prolactin, Anti-cholinergic, Anti-adrenergic, Anti-histiminic
Anti-psychotics have numerous SE.
What investigations should you do before starting anyone on an anti-psychotic?
PHYSICAL check: Weight, Pulse, BP
BLOODS: FBC, U&Es, LFTs, Prolactin, Cholesterol/lipids, HbA1c
IMAGING: ECG (QTc)
After a patient has tried 2 different antipsychotics, 1 being a 2nd generation; both taking for 8 weeks and they are not working - what is the last resort, often used in resistant schizophrenia?
What are the SE of this drug?
General: constipation, drowsiness
EPSEs, Metabolic: hyperglycaemia, hyperlipidaemia, weight gain
Because of the risk of agranulocytosis in the use of Clozapine - how is this monitored?
(esp in 1st year)
Regular FBC (neutropenia)
Weekly for 1st 6 months
Fortnightly for next 6 months
Monthly for the duration of treatment
In schizophrenia: 1/3 relapse, 1/3 raise families, 1/3 live independently.
True or False?
Alcohol is a CARCINOGEN that affects in GABA system in the brain.
What is the recommended safe limit?
How do you calculate units of a drink?
1. 14 units/ week (spread over 3+ days)
2. [vol (ml) + % ] / 1000
A 40 y/o male comes into the GP as his wife is worried about his drinking habits for the last 2 years,
What key areas will you cover in your alcohol assessment?
1. Drinking pattern
2. CAGE (2+ = significant) / AUDIT
3. Signs of dependency (3+ in >12m)
5. Risk assessment - inl driving, behaviour, children
6. Impact/ICE - self/relationships/ work
7. PMH/PPH - past detox attempt? Biopsychosocial consequences
The two goals in alcohol dependency treatment can be ___________ or _____________
(if heavy dependence, physical illness or failed controlled drinking attempt)
When do withdrawal symptoms of alcohol tend to present?
What are the symptoms?
Name the emergency neurological disorder caused by thiamine def?
What are the differentials for the causes?
What are the 3 cardinal features?
How is it managed to avoid Korsafoffs psychosis?
Differentials: Chronic alcohol abuse, hyperemesis gravidarum, HIV, starvation
3 cardinal features: DELIRUM + CEREBELLAR DYSFUNCTION + OCULAR DYSFUNCTION (nystagmus, lateral gaze)
Management: IV thiamine + VitBs (Pabrinex)
Name the emergency where there is a rapid onset of delirium in alcohol withdrawal - often post-op.
When does it peak?
How does it present?
What is the mortality rate?
Peak: 48hrs post alcohol
Present: clouding consciousness, disorientation, amnesia, agitation, Lilliput hallucinations
How is alcohol dependency managed in the short and long-term?
- Bio: IV or Oral Vit Bs (incl thiamine B1), Chordiazepoxide 20mg qds.
- Psych - counselling/ advice, MET
- Social: support accessing housing/ job etc
- Bio: Disulfiram, Acamprosate/ naltrexone
- Psych: Behavioural therapies (prevent relapse), CBT
- Social: AA, Rehab
Those who are alcohol dependant are more at risk of Dementia.
True or False?
Alcoholic dementia (mild/moderate cognitive impairment)
1 in 3 16-24y/o and 1 in 12 adults who see a Dr, will have used street drugs within the last year.
List some harmful effects of illicit drugs from a biopsychosocial perspective
Drug effects: Intoxication/withdrawal, overdose
CV – DVT, Thrombophlebitis
Resp – Resp failure (opiates/benzo), pulmonary oedema (opiates/cocaine)
Needle sharing: Hep b/C/d, HIV, abscesses, tetanus
Neuropsych – depression, psychosis, neuropathy
Social: Legal, financial, family, work
1. Heroin, Methadone, Dihydrocoedine and Buprenorphine fall into which category of drug?
Which street drugs are stimulants?
Cocaine, Amphetamines, MDMA, Ecstacy
Benzodiazepines and Alcohol are depressant drugs.
Which drugs are hallucinogens?
Cannabis, Ketamine, LSD, Magic mushrooms, Phencyclidine
How many classes of drugs are there according to the Misuse of Drugs Act 1971.
Name drugs in each catagory
Class A: Heroin, Cocaine, LSD< Ecstacy, Methamphetamine, Magic mushroom, any injectable Class B
Class B: Amphetamines, Cannibis, Ketamine, Mephedrone, Codeine, methylphenidate
Class C: Benzo, Tramadol, Anabolic steroids, Khat
Which descriptions match which street drug?
1. Class A drug that makes you feel warm and in large doses sleepy or relaxed or respiratory failure. It damages veins if injected.
2. Is used as a general anaesthetic, Class B drug that gives floaty feelings, paralysis, delirium and hallucinations. It can cause serious bladder problems and injury to self due to lack of sensations.
3. The most common street drug, in Class B making you feel relaxed, happy and can cause hallucinations and "the munchies". Its ass with diff learning from poor [c] and affective D
3. Cannibis "weed", "skunk"
Which street drug is a stimulant often used as a study aid, in class B and gives feeling of alertness, confidence, focus and energy? It increases HR/RR/Temp/dilated pupils and ass with strain on heart and suppressed immunity.
Which drug is a short-acting stimulant making you feel "on top of the world", confident and risk taking? Ass with MI, raised body temp and seizures.
2. Cocaine - "crack", "coke"
Old Age psychiatry (>65s) can be summarised by the 3D's which are...
Mr Goodwins resource
Dementia is an umbrella term for a syndrome due to CHRONIC & PROGRESSIVE disease of the brain causing deterioration of MULTIPLE HIGHER CORTICAL FUNCTIONS.
What areas of cognition can it affect?
Orientation- time, place, person
The there are 5 theories of the pathogenesis of dementia.
Lewy bodies/ defective Tau / Ubiquitin/ extracellular B-Amyloid
>50% of Dementias are ________.
The 2nd most common Dementia in >65yrs is __________
The 2nd most common Dementia in <65yrs is ___________
List the other types of dementia
Mixed (Alzheimer's + Vascular)
The risk factors for Vascular Dementia are the same as CV risk factors. It is treated by using ________.
What are the risk factors for Alzhiemer's?
Smoking, High cholesterol
What are the 5A's which are the symptoms of Alzheimer's?
Associated behaviours - Disinhibition, Swearing, Agitation, wandering, crying. Depression, anxiety, insomnia, psychosis
The 1st sign of Dementia s often _________.
Other signs include...
Memory (new info) >6 months
Social behaviours (disinhibition)
You take a history and a collateral history from a family member about a 78 y/o lady with memory problems for the last 9 months. She often wanders out of the house and lives on her own.
What examination/assesment would you like to do?
Cognitive assessment: AMTS, Clock face drawing, Frontal and Parietal lobe testing
What investigations would you in someone who you suspect has Dementia?
BLOODS - FBC, U&Es, LFTs, TFTs, B12/Folate, Ca, glucose, Vit D
IMAGING: ECG, CT head
A mneumonic for differentials in older people's health is DEMENTIA which stands for...
D - Dementia, Delirium, Depression, Drugs
E - Emotions, pseudo-dementia
M - Metabolic (Ca, urea, c02)
E - Eye/ Ear impariement
N - Nutritional def
T - Tumours, Toxins, Trauma
I - Infections (esp UTI, pneumonia)
A - Alcohol, atherosclerosis
You diagnose a 53 y/o man with Alzheimer's Dementia, who also has Down's syndrome. He has a VSD from birth and pathological Q waves on ECG.
He is able to manage with getting dressed but often forgets where he is. He already has a carer.
How would you manage him?
BIO - ACh-esterase In (Momentine as has cardiac problems, Donepezil etc)
PSYCH - orientation, reminiscence therapy, memory aids, emotional support, treat co-morbid illness eg CBT
SOCIAL - Adapt home
environment (OT), Safety, LPA for finances, Alzheimers Society, (already has carer)
Name the type of dementia described below:
1. A stroke/TIA leading to loss of cognitive functioning which then plateaus. After another vascular event cognition declines. You treat this with aspirin and CV risk modifying drugs.
2. 3 core features are fluctuating cognition + motor features of Parkinson's D + visual hallucinations. It is investigated using a DaT scan & CT (atrophy)
3. The patient has Parkinson's for > 12 months then develop long-standing cognitive impairment
4. Change in personality, interpersonal skills & behaviours. Some loose their language skills or semantic memory. They display perseveration on examination.
1. Vascular dementia (step-wise decline - 2nd most common in >65s)
2. 'Lewy-body Dementia (Dementia 1st then develop PD. Treat with Rivastigmine)
3. Parkinson's Dementia
4. Frontal-lobe Dementia
(do MRI - fronto-temporal atrophy. Treat symptoms)
Delirium is defined as an acute reversible change in cognition/ mental state/ consciousness.
What are the key features of delirium?
Cognitive changes - inattention, disorientation, disorganised thinking, change in consciousness
Often general deterioration not E/D, change in mobility/mood
With delirium, there is generally a medical cause behind it.
What mneumonic is used to remember the main causes?
You would do an AMTS + a top-to-toe examination.
What investigations would you do?
Pain, Infection, Constipation, Hydration, Medication, Environment
BLOODS: FBC, U&Es, LFTs, TFTs, Ca, glucose, B12/folate, CRP
IMAGING: ECG (forgotten MI), CT head (falls/ focal neurology, change in GCS)
Delirium can be classified into hyperactive and hypoactive.
How do they differ?
Which one can you use an anti-psychotic as sedation?
Hyperactive - agitated, restless, aggressive, tend to wonder on wards. USE ANTI-PSYCHOTIC
Hypoactive - less movement, quiet, appears to have low mood (mimics depression)
What are the differentials of delirium?
Organic brain pathology: Head injury, stroke, cancer (1" or mets), dementia
Electrolyte disturbance (Ca, urea, Mg, Pi)
How do you manage a patient with delirium?
Address PINCH ME
- Hx + Informant Hx (know baseline)
5. Medications review - opiods, benzos, give anti-psychotic if hyperactive D
7. Bladder scan (urinary retention)
Delirium has a high risk of mertality and morbidity.
What % of people die within 5 yrs of having a delirium episode?
What are the risk factors
> 65s, children
Surgery - esp Hip #, Vascular
What are the 3 main categories of eating disorders?
ED-NOS (Eating disorder not otherwise specified)
In which groups of people should an urgent referral be made if you suspect an eating disorder?
Anorexia is defined as a BMI of < _____ with core psychopathology features.
It affects 1 in 250 females and 1 in 2000 males.
What are the two types of behaviour manifestation?
< 17.5 (BMI needs to be < 17 to access services)
- restriction of calories OR
- binge/ purge then restrict
Ass with high SES
Bulimia is defined as a BMI of > ______.with core psychopathology + regular binge/ purge 2x/week
Is it more or less common than anorexia?
What are the signs?
More common. 1 in 50 females. 1 in 500 males
Signs: eroded teeth, chipmunk face
What are the core psychopathology features in Eating disorders?
Intense fear of weight gain --> Pursuit of thinness
body image distortion
Self-evaluation based on weight
The general psychopathology features in eating disorders are arising from "starvation syndrome".
What are they...?
Depression (low weight --> mood fluctuations)
Anxiety (social phobia around eating, OCD)
Suicidal ideation, Self-harm
List the common behaviours around eating disorders to loose weight?
A 17 y/o female comes into the GP with her mum who s worried that she is rapidly loosing weight, has stopped her periods, has brittle hair and nails and often feels tired.
You exclude thyroid D and diabetes. What questionnaire would you use to screen for eating disorders?
SCOFF (2+ --> possible ED --> refer)
1. Do you make yourself SICK because you feel uncomfortably full?
2. Do you worry that you have lost CONTROL over how much you eat?
3. Have you recently lost > ONE stone in a 3 month period?
4. Do you believe you are FAT when others say you are thin?
5. Would you say that FOOD dominates your lfe?
Eating Disorder can affect every system in the body manifesting in different signs.
What are the most concerning signs?
CV - bradycardia, hypotension, arrhythmias, cardiac failure
RISK OF CARDIAC ARREST
How would you manage a person presenting with a possible eating disorder?
Hx - rapid weight loss >1kg/week, core psychopathology, common behaviours, SCOFF. CV symptoms. DM, preg?
Exam: CV, BMI, proximal myopathy, hypothermia
- BLOODS: FBC,U&Es, LFTs, TFTs, glucose, CK, Pi, Mg, Ca, Zn
- IMAGING: ECG (80% ab - tented T waves, brady, prolonged QT)
Where would you refer the following patients with an eating disorder?
1. Under section 3 as BMI <13
3. Electrolyte disturbance
1. Specialist ED unit
2. Gastro ward
3. Acute medical ward
IF CRITICAL THEN ALWAYS TREAT PHSYICAL HEALTH 1ST!!
What is the biopsychosocial management of eating disorders?
Bio - nutrition (oral/NG) - FEEDING SYNDROME. Fluoxetine (Bulimia)
- Child - FT/ CBT / MET
- Adult - CBT/ IPT/ psychodynamic/ self-help, food diary
Social - support groups, meal planning, shopping, eating out
Complications of treating anorexia are Bulimia
Eating disorders do not have the highest mortality rate in psychiatric disorders.
True or False?
They have the highest mortality rate (cardiac events)
Personality disorders affect 10% of the population and 50% of psychiatric in-patients.
How would you define a personality D?
From what age can it be diagnosed?
How is it classified?
= severe disturbance in character and behaviour in many areas of personality that interferes with functioning, associated with childhood personal or social disruption.
Cluster A - isolated, eccentric
Cluster B - dramatic
Cluster C - anxious, fearful