Three features of autism required for diagnosis?
Impaired social relationships Ritualistic and compulsive phenomena Global impairment of language and communication
What screening tool is used to diagnose post natal depression?
Edinburgh Postnatal Depression Scale >13 is positive Important to distinguish between baby blues, post natal depression and puerperal psychosis Baby Blues : 3-7 days, anxious fearful and irritable. Health visitor PND: 1/12-3/12, resembles depression. CBT, SSRIs (preferable paroxetine due to low milk/plasma ratio. Avoid fluoxetine due to half life)
Postnatal depression: Best Drug Pick Worst Drug Pick
Paroxetine - Low milk/plasma ratio - SSRI Fluoxetine - Long half life - SSRI
Which SSRI has a the highest incidence of discontinuation syndrome ?
Paroxetine When stopping SSRI the dose should be gradually reduced over a 4 week period (except with fluoxetine).
What anti depressant is recommended for patients on warfarin or heparin?
Features of PTSD
Re experiencing Emotional Numbing Avoidance of resembling situstions Hyperarousal Depression Substance Misuse Anger Somatisation
How many symptoms are required from the DSM - IV criteria to be diagnosed with depression?
5. Mild, moderate and severe refer to the interference with functioning PHQ9 - 9 questions marked 0-3 each. Not depressed: 0-4 Mild: 5-9 Moderate: 10-14 Moderately Severe: 15-19 Severe: 20-27 HAD - 14 questions each 0-3 Normal : 0-7 8-10 : Borderline 11+ : Depressed/Anxious
Drug Management for Alzheimer's: mild - moderate: Moderate - Severe:
mild - moderate: ACHesterase Inhibitors (Donepezil, Galantamine and Rivastigmine) Moderate - Severe: NMDA receptor antagonist (Memantine)
Pharmacological Management for Sleep Paralysis?
Therapeutic Drug Monitoring Timing: How long after each of these drugs is administered should the dose be measured? Lithium, Cyclosporine, Digoxin, Phenytoin
Lithium: 12 hours post dose. Cyclosporine: Trough levels immediately before dose Digoxin: 6 hours post dose Phenytoin: If adjusting dose, suspected toxicity or non adherence is suspected then the TROUGH dose should be checked immediately before the next dose
What is the therapeutic Range for lithium?
0.4-1.0 mmol/l Taken 12 hours after dose
Adverse effects of clozapine
Agranulocytosis Neutropenia Reduced seizure threshold
What seasons are suicide more common in?
Spring and early summer
What term is given to a strong belief that regarding someone of a higher status being in love with them?
What are features of catatonic schizophrenia?
Motor immobility Strange movements excessive negativism
Features of EPS following administration of antipsychotic medication - what drug?
Procyclidine - anti muscarinic agent
Multiple physical symptoms 2 years Refuses to accept reassurance or negative test results 6 or more symptoms from 14
motor or sensory loss non-conscious feigning of symptoms
Safest antidepressant post-MI
SSRIs contraindicated in people with long QT risk or taking other QT prolonging drugs
SSRI of choice in adolescents and children
Which SSRIs have a higher rate of drug reactions (2)
NICE guidelines on giving SSRI alongside NSAID
AVOID but if you have to give alongside PPI
NICE guidelines on giving SSRIs alongside warfarin or heparin
AVOID and give mirtazapine
NICE Guidelines on giving SSRIs alongside triptans
Which SSRI doesn't need four week discontinuatiojn period
Which SSRI has a higher risk of discontinuation symptoms
Mood change Restless Difficulty Sleeping Unsteady Sweating GI sx Paraesthesia
ICD 10 for depression diagnosis Severity system
2 Weeks of: 2 + core sx: Low mood, Anhedonia, Low energy AND 2 +: -inattention, low self esteem, guilt, pessimistic views, self harm, suicide, disturbed sleep, diminished appetite Mild - 4 + sx Moderate - 5 + sx and difficulty in continuing normal activities Severe - 7+ sx including all core sx. Unable to continue normal activities Severe with psychosis - delusions, hallucinations or psychomotor retardation
BPAD: Type 1 Type 2 Rapid cycling
Type 1: Manic predominantly + depressed episodes type 2: long recurrent depressive episodes + hypomanic Rapid cycling - 4 or more affective episodes per year.
What drug is thought to help in rapid cycling BPAD?
ICD for schizophrenia
One or more First Rank symptom lasting more than one month: Delusion, auditory hallucinations, thought disorder, passivity phenomena OR 2 or more: non auditory hallucination, thought disorganization, catatonic symptoms, negative symptoms, change in behavior PRESENT for A MONTH
Features of catatonic schizophrenia
Stupor - unresponsive Excitement - purposeless motor activity Abnormal positing Waxy flexibility Automatic obedience Perseveration - also seen in frontal lobe diseases
Young onset Changes to affect Disorganised speech Fleeting delusions and hallucinations
Negative symptoms - Social decline
Social withdrawal after a period of treated psychosis
Residual - Have to have had a clear cut psychotic episode
Sudden onset psychotic episode following intense bereavement
Dependence Syndrome criteria (6)
1. Strong compulsion to take drug 2. Difficulties in controlling drug use 3. Withdrawal symptoms 4. Tolerance to drug 5. Neglect of other activities 6. persistence despite awareness of harms
Delirium features (4)
1. Acute changes to mental state with fluctuating course 2. Inattention 3. Disorganised thinking 4. Altered level of consciousness
Cortical blindness but the person has no insight into this blindness
Anton Syndrome - often following bilateral occipital lobe injury
Left Right disorientation Dyscalculia Finger agnosia Agraphia
Gestmann's Syndrome - Parietal lobe injury
dementia unsteadiness urinary incontinence
Normal pressure hydrocephalus
Rapidly evolving myoclonus and cerebellum signs High signal in anterior basal ganglia
Puvlinar Sign - posterior thalamus high signal
Tx of Parkinson's Dementia
Parkinson's Dementia : Motor sx should precede the dementia by at least a year Tx: anti- parkinson + anticholinesterase
Generalized Anxiety Disorder: ICD 10
6 months < Apprehension Motor Tension Autonomic Hyperactivity Non specific trigger
i) Fear of unable to easily escape to safe place ii) Fear of scrutiny and humiliation iii) Sudden attacks of panic with physical symptoms without an identified trigger
i) agoraphobia ii) social phobia iii) panic disorder
PTSD: Symptom duration requirement?
Precipitate between 1-6 months after event and symptoms present 1 month< Symptoms: Re- Experiencing, avoidance, hyperarousal etc. you
3 Specific examples of somatiform Disorders:
Heart : da costa Resp: Psychogenic hyperventilation GI: IBS psychogenic polydypsia
i) Deliberate production of symptoms to get medical treatment ii) Deliberate production of symptoms to get a reward iii)Parent induces or fabricates illness in child
i) Factitious disorder ii) Malingering iii) Münchausen Syndrome
Loss of a domain of function following an acutely stressful event
Anorexia Nervosa: ICD 10. 4 domains for diagnosis
1. Low BW: 15% below expected/ <17.5 kg/m^2 2. Intent to lose weight 3. Overvalued idea of being overweight 4. Endocrine disturbance due to the weight loss
Bullemia: ICD 10 4 domains for diagnosis
3. Prevenging (weight gain - purging, exercise)
4. Obsessing (ideas about being overweight)
BMI should be above 17.5 otherwise consider AN
ADHD/ Hyperkinetic Disorder: Age limit?
Onset before <6 years old >1 year of symptoms
Learning difficulties Mild IQ Range Moderate IQ range Severe IQ range Profound IQ Range
Mild IQ Range - 50-69 Moderate IQ range - 35-49 Severe IQ range -20-34 Profound IQ Range - <20 Mild is more heritable than the severe and profound causes
Personality Disorders: Describe characteristics of each cluster and specifically what personality disorders
Cluster A - Odd/ Eccentric - schizoid, paranoid, schizotypal Cluster B - Dramatic/ Erratic / Emotional - Histrionic, Emotionally unstable, dissocial, narcisstic Cluster C - Anxious/ Fearful - Anankastic, Anxious, Dependent Remember REPORT: Relationships affected Enduring Pervasive Onset in childhood Results in distress Trouble in occupation/ socially
Define Primary Insomnia
Lack of sleep not associated with other psychiatric or medical illness or with substance abuse
What is Narcolepsy? Four features of narcolepsy
Narcolepsy is the abnormality of the REM inhibiting mechanism 1. Sudden irresistible bouts of refreshing sleep at any time 2. Cataplexy - sudden bilateral loss of muscle tone caused by emotion 3. Hypnogognic (upon sleeping) and hypnopompic (awakening) hallucinations 4. Sleep paralysis - at the end or beginning of sleep
Cognitive and behavioural techniques and relaxation techniques.
Dialectic Behvioural therapy
Antipsychotic particularly associated with prolonged QT
What differentiates hypomania from mania?
The presence of psychotic symptoms points towards mania diagnosis: - Delusions of grandeur - Auditory hallucinations
TCA - drug examples - side effects (5)
Amitryptilline, Imipramine, Dosulepin, Lofepramine Drowsiness, Dry Mouth Blurred Vission Constipation Urinary Retention
Neuroleptic Malignant Syndrome: Common precipitants? Features? Management
Common Precipitants - commencing a new drug or increasing a dose Features - Young male patients, within 10 days of drug change. - Pyrexia, rigidity and tachycardia - Increased CK Management- stop drug, IV fluids (prevent renal failure due to rhabdomyolysis), dantrolene, dopamine agonists (bromocriptine)
Four indications of commencing antidepressant treatment for persistent subthreshold depressive symptoms/ mild-moderate depression.
- A past history of moderate or severe depression - Initial presentation of subthreshold depressive symptoms (if lasting for long period of time >2 years) - Subthreshold depressive symptoms or mild depression continuing after psychological therapy - Chronic physical health problem alongside mild depression
Neuroleptics should be avoided in which type of dementia?
LBD - severe risk of irreversible parkinsonism
Progressive cognitive impairment Parkinsonism Visual Hallicination
Lewy Body Dementia Dx: Clinical New imaging: DaTscan
28 Days admission assessment
Section 2 - AMHP or nearest relative makes the application - 2 doctors recommendations one of which section 12 approved
6 months treatment
Section 3 - AMHP, 2 doctors - both having seen patient within last 24 hours
72 hour emergency assessment order
Section 4 - Used where section 2 would take too long - GP, AMHP or Nearest Relative
Voluntary general hospital patient detained by doctor for 72 hours
Voluntary patient detained by a nurse in a hospital for 6 hours
Section 17a - Community treatment order
Court order to grant police permission to enter a property and remove person to safe place
Public place with mental disorder can be taken by the police to a place of safety
Women with PMH of unprovoked DVT being treated with long term warfarin. She is diagnosed with moderate depression. Which pharmacological therapy could you initiate?
Mirtrazapine is thought to be the best idea where warfarin/heparin are being used Don't start SSRI
Elderly Women presents to GP with symptoms of moderate depression. She is being treated for ACS with aspirin How do you manage?
Add Sertralline and Add Lansoprazole
When do you review patients after starting them on antidepressants? When do you stop them?
Review period: >30 year old/ low risk of suicide : 2 weeks <30 years old/ high risk of suicide: 1 week review Stopping: Antidepressants should be stopped >6 months after remission from symptoms
First-line treatment of acute confusional state (delerium)? What are contraindications to this treatment and what would you use in this instance?
First line: 0.5mg Haloperidol as sedative Contraindicated in: Parkinson's, Lewy Body Dementia - Lorazepam probably best here as - short acting benzodiazepine class drug.
In elderly patients, antipsychotics + acetylcholinesterase greatly increases the chance of what
Bad prognostic markers for schizophrenia (5)
Strong FH Premorbid social withdrawal Lack of precipitant Gradual Onset Low IQ
Side effects of ECT: 5 short term 1 long term
Short term: -Headache -Nausea -short term memory impairment -loss of memory of time priod just before ECT -cardiac arrhythmias Long term: - Impaired memory
oral, live attenuated virus Theoretical risk of intussusception if given after 24 weeks
Oral Rotavirus -given at 2 and 3 weeks
ADHD characteristics (4)
Methylphenidate (norepinephrine-dopamine reuptake inhibitor)
Atomoxetine (norepinephrine reuptake inhibitor)
Alcohol Withdrawal timeline When do the following occur following alcohol cessation? symptoms: seizures: delirium tremens:
Symptoms: 6-12 hours Seizures: 36 hours Delirium Tremens: 72 hours
MMSE of less than ? indicates depression
What is DBT
DBT is Dialectic Behavioural Therapy Specifically for Borderline Personality Disorder Involves accepting the way the patient is: "It makes sense that you feel like that in certain situations" Then making positive changes. i.e. in response to DSH and Suicide. Developing new strategies
What is mentalisation based treatment?
Type of psychodynamic psychotherapy Used in BPD Helps separate the clients own thoughts and feelings from those around them. Helps identify the clients intentions and those of others.