Revise Notes Psych Flashcards

Question

Answer 1

Management 1st Line: SSRI

Answer 2

Considered in cases of severe depression which is REFRACTORY to medical management Absolute contraindication: Raised intracranial pressure Adverse effects Short term: Headache, short term memory loss, Arrhythmias Long term: Impaired memory

Answer 3

Seasonal Affective Disorder Depressive symptoms occurring within the winter months Management is the same as ‘typical’ depression (i.e. CBT and SSRIs if required etc.)

Answer 4

: Male sex History of deliberate self harm (DSH) History of alcohol/drug misuse Background of mental health illness History of chronic disease Increasing age Unemployment, lack of social network/isolation Living alone, loneliness Single/widowed or divorced

Answer 5

A preoccupation with an imagined defect in appearance resulting in distress (and does not fit diagnostic criteria of anorexia nervosa or bulimia nervosa).

Answer 6

Management: 1st Line: Bulimia-nervosa focussed guided self help 2nd line: (if BN-self help is ineffective or unacceptable) - Eating disorder focussed CBT (CBT-ED) Children & young people: Bulimia nervosa focussed family therapy (FT-BN) Pharmacological: Fluoxetine can be used in combination with therapy, but not alone.

Answer 7

Management Psychological treatments - include: eating disorder focussed CBT (CBT-ED), Maudsley Anoxrexia Nervosa Treatment Adults (MANTRA).

Answer 8

Mania & Bipolar Affective Disorder Mania Clinical features Abnormally elevated mood, agitation or irritability Hyperactivity, restlessness Speech - pressured, flight of ideas Disinhibition and increased libido Impulsive behaviours - gambling, spending sprees etc. There may be a history of psychotic symptoms - grandiose delusions, or auditory hallucinations Symptoms persist for at least 7 days for a formal diagnosis, and result in significant functional impairment

Answer 9

Similar features to mania - but to a less severe extent, with less of a functional impairment (e.g. socially or at work). Psychotic features are NOT present Symptoms include a mild elevation of mood, irritability, hyperactivity, over-familiarity and talkativeness.

Answer 10

Mixed episode Suggested by rapidly alternating symptoms of depression and the above features of mania or hypomania.

Answer 11

Bipolar affective disorder is a chronic mental health condition which is characterised by episodes of depression and hypomania or mania. The DSM-5 diagnostic criteria defines BAD as follows: Type 1 BAD: At least one episode of mania with or without a history of depressive episodes Type 2 BAD: One or more depressive episodes and at least one hypomanic episode (without mania)

Answer 12

Treatment of acute mania or mixed episodes Step 1: Oral antipsychotic (haloperidol, quetiapine, risperidone or olanzapine) Step 2: If not effective or not tolerated, try an alternative antipsychotic from above Step 3: If not effective, add lithium (or sodium valproate as an alternative) Other: Stop or taper dose the dose of antidepressant medications

Answer 13

Treatment of depression Options include: Quetiapine Lamotrigine Olanzapine Olanzapine and fluoxetine

Answer 14

Four weeks following acute episode, either: Continue the antipsychotic/ current treatment for mania Or commence long term lithium to prevent relapse (and add valproate if req.) In addition, offer psychotherapy to all patients with BAD, or a high-intensity therapy for depression (e.g. CBT).

Answer 15

Hyperprolactinaemia - oligo-/amenorrhoea, loss of libido and erectile dysfunction, galactorrhoea Remember - dopamine inhibits prolactin release Extrapyramidal side effects - parkinsonism, dystonias, akathisia, tardive dyskinesia Antimuscarinic effects - dry mouth, blurred vision, urinary retention, constipation Impaired glucose tolerance Reduced seizure threshold - caution in patients with epilepsy

Answer 16

Drug induced parkinsonism Classically of rapid onset and features are symmetrical. Unlike IPD - symptoms are of gradual onset, and typically asymmetrical Akathisia A feeling of severe restlessness Tardive Dyskinesia Involuntary, slow writhing movements Classical movements include chewing, grimacing, tongue protrusion, lip smacking. Dystonias Sustained muscle contractions - oculogyric crisis / torticolis Torticolis - also referred to as 'wry neck' - severe neck muscle spasm/contraction resulting in involuntary head tilting Oculogyric Crisis - involuntary, extreme upward deviation of gaze +/- the presence of torticolis, tongue protrusion, jaw spasm

Answer 17

: Procyclidine (anticholinergic) or Benzatropine

Answer 18

Typical APs should be prescribed with caution in elderly patients, increasing the risk of stroke and DVT/PE. Neuroleptic Malignant Syndrome - see below Polymorphic VT/ Torsades de pointes - due to prolongation of the QTc (esp. with haloperidol)

Answer 19

Mechanism of action Act on a wider variety of receptors (D2, D3, D4, 5-HT) Examples Olanzapine Risperidone Aripiprazole Quetiapine Clozapine Amisulpride Advantages Lower risk of extrapyramidal side effects (EPSEs) vs typical APs

Answer 20

: Agranulocytosis - FBC monitoring is essential Seizures Myocarditis - a baseline ECG is required before commencing treatment Constipation Clozapine induced Hypersalivation - a significant side effect, affecting approximately 1/3rd of patients. Hyoscine butylbromide can be prescribed to relieve hypersalivation

Answer 21

Side effects Metabolic syndrome - weight gain, insulin resistance/diabetes, dyslipidemia - therefore associated with accelerated cardiovascular disease. Stroke and VTE (esp in elderly patients) EPSEs + hyperprolactinemia - less common

Answer 22

Examination findings Reduced or absent reflexes Normal pupils Differential diagnosis - serotonin syndrome - characterised by dilated pupils, myoclonus and brisk reflexes. Complications Rhabdomyolysis and resultant AKI Management Stop antipsychotics IV fluids Dantrolene Bromocriptine/ dopamine agonists may be beneficial

Answer 23

Contraindications (NICE) Current mania Poorly controlled epilepsy Avoid citalopram/escitalopram if QT prolongation or in combination with other drugs which increase the QTc - risk of TDP Avoid sertraline in severe hepatic impairment SSRIs in cardiovascular disease Sertraline is safest Side effects of SSRIs Gastrointestinal side effects are the most common Consider PPI co-prescription (e.g. if on NSAIDs

Answer 24

Interactions/contraindications Use with caution with aspirin or NSAIDs – increased risk of PUD/GI bleed Avoid with warfarin or heparin due to bleeding risk – give mirtazapine instead Avoid co-prescribing triptans or MAOIs – risk of serotonin syndrome Follow up Patients should be followed up shortly after commencing SSRIs due to the risk of increased anxiety and suicidal ideation If < 30 years of age, follow patients up in 1 week If > 30 years – follow up in 2 weeks Stopping SSRIs If patients show a good response, they should continue SSRIs for at least another 6 months before discontinuation, or there is a high risk of symptom relapse. Stopping SSRIs suddenly can result in high risk of discontinuation syndrome Clinical features: restlessness, anxiety and agitation, GI symptoms (diarrhoea etc.) Gradually reduce dose over 4 weeks before stopping to reduce this risk Paroxetine - highest risk of discontinuation syndrome

Answer 25

Clinical Features Neuromuscular excitation: Increased reflexes, myoclonus, rigidity Autonomic lability – tachycardia, hypertension, pyrexia Confusion, agitation, aggression Note: Myoclonus is a useful differentiating feature from neuroleptic malignant syndrome Management IV fluids Benzodiazepines – the mainstay of management In severe serotonin syndrome – cyproheptadine or chlorpromazine can be used (serotonin antagonists)

Answer 26

Examples Venlafaxine Duloxetine

Answer 27

Examples Phenelzine Side effects MAOIs are associated with hypertension particularly if used whilst tyramine containing foods are eaten (cheese, herring, broad beans)

Answer 28

Adverse effects Antimuscarinic effects – dry mouth, constipation, urinary retention, blurred vision Drowsiness Prolongation of the QTc (risk of TDP)

Answer 29

Clinical features Drowsiness Dry mouth, blurred vision Pupils - dilated Arrhythmias Seizures Metabolic acidosis Coma ECG: Long QTc interval, widened QRS, tachycardia – broad complex tachyarrhythmia with long qt. Management IV Sodium Bicarbonate is the mainstay of management – indications include widened QRS > 100 or ventricular arrhythmia

Answer 30

Clinical Features of BZD withdrawal Anxiety, tremor, irritability, tinnitus, sweating and seizures – last up to 3 weeks after last dose.

Answer 31

Monitoring Lithium levels - measure one week after starting treatment and one week after making any adjustments to dose. Once stable, check 3 monthly. 6 monthly - BMI, UE, Calcium, TFTs If urea/cr increases or eGFR decreases, measure lithium levels more frequently than 3 monthly as higher risk of toxicity.

Answer 32

Diagnosis of OCD The ICD-10 criteria for OCD for a diagnosis of OCD are the presence of recurrent, obsessional thoughts or compulsive acts: Obsessional thoughts: Ideas, images, impulses which enter someone's mind and are invariably distressing. Compulsive acts or rituals: Repeated, non-useful & stereotyped behaviours, often performed to prevent an unlikely but negative or harmful event. For example, hand-washing, counting, checking things repeatedly.

Answer 33

Management should be based upon the degree of functional impairment the OCD is causing the patient. Mild functional impairment 1st Line: Low intensity CBT including ERP (exposure and response prevention) 2nd line: treat as per moderate impairment Moderate functional impairment 1st Line: intensive CBT (including ERP) or SSRI (or clomipramine (TCA) as an alternative) Severe functional impairment 1st Line: SSRI AND intensive CBT

Answer 34

The mainstay of management for PD is talking therapies / psychotherapies - dialectical/talking behaviour therapy.

Answer 35

Poor social skills and avoidance of social situations due anxiety Delusions or unusual beliefs - e.g. that they can communicate with animals, or that they are able to telecommunicate They may describe a history of unusual perceptual disturbances / experiences

Answer 36

Patients with schizoid PD may show indifference and a lack of interest to many things, anhedonic. They often have limited relationships, prefer solidarity Emotionally cold, detached or blunt.

Answer 37

Highly distrusting, even of friends and colleagues Overly sensitive, and may be unforgiving to people by whom they feel insulted. They might be paranoid and preoccupied by perceived attacks on their personality/ character Worried that their partner is unfaithful or people are acting against them

Answer 38

Classically obsessed with minute details, organisation and may be 'perfectionists' in nature. They are meticulous and also might have inflexible moral or ethical views.

Answer 39

Patients with Narcissistic PD may be self-centred / self important & see themselves as better than, or superior to other people Preoccupied with power, success and hierarchy They may take advantage of others to achieve success, and may have a lack of empathy. May come across as arrogant and exaggerate their abilities and achievements Feelings may be interspersed with fearing that they are worthless

Answer 40

Excessively outwardly emotional which can appear insincere May behave inappropriately, with flirtation, seduction, attention-seeking Inappropriate sexual behaviour Swinging moods

Answer 41

DEPEND on excessive reassurance in order to make decisions. They prioritise making relationships with others, so that they might be able to seek help/reassurance & care from these relationships. Need others to take responsibility for their decisions and choices Moving quickly into a new relationship if the last one ends.

Answer 42

Patients with borderline PD often have fears of abandonment Feelings of emptiness They may have a history of unstable & chaotic relationships with friends/family/partners. Fears of abandonment Emotionally unstable Impulsive behaviour, with a history of self harm, often as a coping mechanism "Ups and downs" There is usually a history of previous trauma

Answer 43

Patients are preoccupied with feelings that they are being judged, criticised or rejected, particularly in social situations. They may have a fear of being embarrassed and belittled. May appear very shy and reluctant to engage socially due to feelings of inadequacy As a result, they AVOID social interactions and limit working/interacting with others

Answer 44

Failure to conform to social norms - patients will often have a history of antisocial behaviour, lying, aggression and fighting, law-breaking. They may demonstrate a lack of remorse for these behaviours, and for causing harm, stealing etc. Difficulty in maintaining meaningful relationships

Answer 45

Common, affecting 1 in 10 women postpartum Symptoms occur 1-3 months postpartum (useful differentiating factor from baby blues) Clinical features are in keeping with classical depression – anhedonia, low mood, fatigue, altered sleep/wake cycle, altered appetite Assessment: PHQ-9 OR the Edinburgh Postpartum Depression Scale Scored out of 30 – a score of > 13 suggests a depressive state Management If persistent less severe depression - refer for facilitated self help New depression: If moderate or severe PND Refer for high-intensity therapy - CBT Pharmacological Tx: SSRI / SNRI / TCA (if psychological interventions declined/not effective, or she expresses a preference for medication). If breastfeeding, paroxetine and sertraline are the SSRIs of choice – lowest milk ratio

Answer 46

Clinical Features Symptoms occur shortly after birth – 3-7 days postpartum Anxiety, irritability, tearfulness, fatigue. Management: Reassurance, health visitor support

Answer 47

Management: Admit Risk in subsequent pregnancies = up to 50% risk of recurrence

Answer 48

Management Event debriefing and single session interventions following a traumatic event are not recommended. Mild symptoms (for < 4 weeks) - watchful waiting Clinically important PTSD (mod-severe symptoms with functional impairment) 1st line: Psychological therapy - trauma focussed CBT or EMDR (eye movement desensitisation and reprocessing) Drug treatment - if coexisting depression, declines or limited benefit from therapy - SSRI (sertraline) or venlafaxine. Risperidone can also be used in severe cases

Answer 49

Management 1st Line: Trauma based CBT Pharmacological management: Benzodiazepines may be of use

Answer 50

A differential diagnosis for those experiening visual or auditory hallucinations. In Charles-Bonnet syndrome, hallucinations occur in clear, lucid consciousness, and patients demonstrate insight. They are aware that the perceptions are hallucinatory. Causes: CBS occurs in the context of visual impairment – the most common predisposing conditions include ARMD, glaucoma, cataracts

Answer 51

The delusion that multiple people are in fact the same person, who is in disguise or has the ability to change appearance at will.

Answer 52

The delusion that a friend or family member has been replaced by an identical impostor

Answer 53

Two individuals share the same psychiatric symptom

Answer 54

Describes pathological jealousy – the patient is convinced beyond all reason that their partner is having any affair, without any evidence.

Answer 55

The patient has a fixed, false belief that they are infested by bugs or parasites

Answer 56

The patient has a delusion that a celebrity or idol is in love with them

Answer 57

The patient believes that they are/or part of their body is dead Typically occurs in severe depression or psychosis

Answer 58

Atypical (second generation) antipsychotics are usually first line in schizophrenia due to their lower risk of EPSEs. They include: Olanzapine Risperidone Aripiprazole Quetiapine Clozapine Amisulpride Clozapine is typically reserved until the failure to control symptoms adequately despite the use of 2 or more antipsychotics for 6-8 weeks due to its risk of adverse effects (e.g. agranulocytosis).

Answer 59

Schneider’s first rank symptoms are highly suggestive of schizophrenia and include: Auditory hallucinations 2 or more voices, commonly 3rd person May be thought ‘echo’ or commentary Disorders of thought Thought insertion – the belief that one’s thoughts have been planted by another Thought withdrawal – the belief that one’s thoughts are being ‘stolen’ Thought broadcast – the belief that one’s thoughts are being broadcast to others Passivity phenomena The feeling that certain actions or feelings are being imposed on the patient, or that bodily sensations are being controlled externally Delusional perceptions Describes the process where a normal perception is interpreted to have certain delusional meanings. E.g. It is windy today, therefore I will score 100% in the MSRA Other symptoms of schizophrenia include Social withdrawal and isolation Apathy and loss of emotional response Catatonic behaviour

Answer 60

Risk factors for schizophrenia Schizophrenia is thought to result from a combination of genetic predisposition and environmental triggers. The strongest risk factors in order of risk are: Family history – risk ratio (RR) 8 Ethnicity – Afro-Caribbean patients are highest risk – RR 5 Migration – RR 3 Cannabis use – RR 1.5

Answer 61

Purpose: Allows the police to remove a person from a public place to a place of safety for assessment. Criteria: The person appears to be suffering from a mental disorder and is in immediate need of care or control. Application: The police can exercise this power directly without a warrant.

Answer 62

Purpose: Allows for the police to enter a property to remove a person to a place of safety for assessment. Criteria: There is reasonable cause to suspect that a person is suffering from a mental disorder and is being ill-treated or neglected, or is unable to care for themselves. Application: A warrant is issued by a magistrate, based on an application by an AMHP.

Answer 63

Purpose: Allows a registered mental health nurse to detain an inpatient for up to 6 hours. Criteria: The person is suffering from a mental disorder. It is necessary for the health or safety of the person or for the protection of others. The doctor or approved clinician in charge of the patient’s care is not immediately available to exercise their holding power under section 5(2). Application: Initiated by a registered mental health nurse.

Answer 64

Purpose: Allows an inpatient who is already voluntarily receiving treatment in a hospital to be detained for up to 72 hours, enabling an assessment for possible longer-term detention. Criteria: The person is suffering from a mental disorder. It is necessary for the health or safety of the person or for the protection of others. Application: Initiated by a doctor or approved clinician in charge of the patient’s care.

Answer 65

Purpose: Allows for the emergency detention of a person for up to 72 hours to enable a Mental Health Act (e.g. section 2) assessment to take place. Criteria: The person is suffering from a mental disorder. It is of urgent necessity for the person to be admitted and detained under section 2. Obtaining a second medical recommendation would involve an undesirable delay. Application: Made by an AMHP or the nearest relative, supported by one medical recommendation.

Answer 66

Purpose: Allows for the detention of a person for treatment for up to six months, which can be renewed. Criteria: The person is suffering from a mental disorder of a nature or degree which makes it appropriate for them to receive medical treatment in a hospital. It is necessary for the health or safety of the person or for the protection of others. Appropriate medical treatment is available. Application: Made by an AMHP or the nearest relative, supported by two medical recommendations as above.

Answer 67

Purpose: Allows for the detention of a person for assessment (or assessment followed by treatment) for up to 28 days. Criteria: The person is suffering from a mental disorder. Detention is necessary for the person's health or safety, or for the protection of others. Application: Made by an Approved Mental Health Professional (AMHP) or the nearest relative, supported by two medical recommendations (one must be a psychiatrist, the other another doctor (GP/another psychiatrist).

Answer 68

The Mental Health Act 1983 (amended in 2007) is the key legislation in the UK that governs the assessment, treatment, and rights of individuals with mental health disorders . It provides the legal framework for detaining and treating people who pose a risk to themselves or others due to mental health issues. The Act aims to balance the need for care and control with respect for patients' rights and liberties.

Answer 69

Key Learning: The Mental Health Act 1983 governs the assessment, treatment, and rights of individuals with mental disorders. People may be detained according to the following sections. Section 2: Admission for assessment up to 28 days. Section 3: Detention for treatment up to 6 months. Section 4: Emergency assessment up to 72 hours. Section 5(2): Doctor's holding power - Detention of an inpatient for assessment up to 72 hours. Section 5(4): Nurse's holding power - Detention of an inpatient for up to 6 hours. Section 135: Police search and remove from a property to place of safety for assessment. Section 136: Police power to remove from a public place to place of safety for assessment.

Answer 70

The Mental Health Act 1983 (amended in 2007) is the key legislation in the UK that governs the assessment, treatment, and rights of individuals with mental health disorders. It provides the legal framework for detaining and treating people who pose a risk to themselves or others due to mental health issues. The Act aims to balance the need for care and control with respect for patients' rights and liberties.

Answer 71

Patient complains of multiple physical symptoms and refuses to accept negative test results Tip: Somatisation = Symptoms

Answer 72

Also known as illness anxiety disorder, hypochondriasis describes an irrational belief that oneself has an underlying serious condition (such as cancer) to such an extent that they will even refute the validity of negative test results Tip: HypoChondriasis = Condition/Cancer

Answer 73

Conversion disorder presents with a loss of motor or sensory function (which is not consciously feigned by the patient). May be associated with la belle indifference (a paradoxical lack of concern regarding a seemingly serious issue) - the patient might not seem to care

Answer 74

A range of psychiatric disorders, usually as a result of trauma/stress (e.g. childhood trauma) with features including A feeling of disconnect from the world Amnesia - forgetting important personal information/ memories Identity problems - feeling uncertain about who one is, multiple personality disorder Patients can have episodes of dissociation (with above symptoms) for hours to months. The 3 main dissociative disorders include: Depersonalisation-derealisation DID (dissociative identity disorder) Dissociative amnesia

Answer 75

FD is the intentional feigning of symptoms without a clear motivation

Answer 76

Feigning of symptoms for personal gain (e.g. financial compensation, time off of work) etc.