Year 3: Psychiatry Flashcards
Depression, BPAD, Schizophrenia, Detention Orders, Anxiety, PTSD, OCD, ADHD, ASD, LD, Personality Disorders, Eating Disorders, Addiction (187 cards)
1
Q
Depression is due to
A
Decreased Serotonin (5-HT)
But also due to decreased Dopamine
2
Q
What 3 dopamine pathways are affected in depression
A
Nigrostriatal
Mesolimbic
Anterior Cingulate
Hence side effects like anhedonia etc
3
Q
3 core symptoms of Depression
A
- Persistent low mood (2 weeks+)
- Anhedonia
- Decreased energy, increased fatigue
4
Q
F32 Criteria
(Severity of Depression)
A
- Mild: 1/3 core features
- Moderate: 2/3 core features + 3 additional symptoms
- Severe: 3/3 core features + 5 additional symptoms
5
Q
Depression immediately becomes BPAD when
A
there are any manic symptoms
6
Q
First line treatment for depression
A
Escitalopram (SSRI)
7
Q
An SSRI that is to be used in pregnancy, cardio patients and anxiety patients
A
Sertraline (SSRI)
“As you are certain that it’s okay in pregnancy etc”
8
Q
Anti-depressant that increases weight gain (appetite) and is good for sleep
A
Mirtazipine (Tetracycline)
9
Q
Anti-depressant used for resistant depression
- Tried many drugs and they don’t work
A
Venlafaxine (SNRI)
10
Q
Side effect of Citalopram (SSRI)
A
Can cause long QT syndrome
11
Q
An anti-depressant with little side effects
Can be used in kids
A
Fluoxetine (SSRI)
12
Q
Why are tricyclic anti-depressants bad in patients with suicidal risk
A
They are cardiotoxic, and so are easy to overdose on
13
Q
Contraindications of Monoamine Oxidase Inhibitors
A
A tyramine rich diet
- Cheese
- Red wine
- Cured/processed meats
- Sauces and gravy
14
Q
Why are tyramine rich food avoided in MAOIs
A
Can cause a hypertensive crisis
15
Q
Contraindications with SSRIs
A
NSAIDs
Elderly (can cause hyponatraemia)
16
Q
What is seen in Direct Self Harm?
A
Decreased activity in the pre-frontal cortex
17
Q
Hallucinations seen in Psychotic Depression
A
Second person hallucinations
“You are fucking crazy son, kill yourself”
18
Q
DSM-V Criteria for BPAD
(Subtypes of Bipolar Affective Disorder)
A
Type 1: More manic than depressed
Type 2: More depressed than manic
Type 3: Hypomanic due to chronic use of antidepressants
19
Q
Examples of Type 1 BPAD
A
The “classic Bipolar person”
- Have a manic episode lasting 1 week+
- Has been depressed in the past
- Flight of ideas, grandiosity, increased activity etc
- On an absolute high
High 15% of the time
20
Q
Examples of Type 2 BPAD
A
Most common form of BPAD
- Hypomania lasting 4 days
- Has been depressed in the past
- Reckless behaviour (spending money rashly)
- Increased libido
High 5% of the time
21
Q
ICD-10 Criteria for BPAD shows
A
The severity of Bipolar Affective Disorder
22
Q
ICD-10 Criteria for a hypomanic episode
A
Increased mood sustained for 4 consecutive days
Need 3/6 symptoms
23
Q
ICD-10 Criteria for a manic episode
A
Increased mood sustained for 1 week
3/9 Symptoms
Symptoms are a bit more mental
24
Q
If a BPAD patient is manic and on an antidepressant then
A
Take them off the antidepressant
25
1st line drug for BPAD
**Lithium carbonate**
To stabilise long term mood
26
If a patient is on lithium you should
* 12-hour monitoring when first started
* U&Es - as nephrotoxic
* TFTs- as thyrotoxic
27
Main rule for 2nd line prescribing in BPAD
* If you prescribe an antidepressant then you must also prescribe an antimanic drug
* If you prescribe an antimanic drug you must also prescribe an antidepressant drug
28
If BPAD patient is mainly manic what is the 2nd line drug combination
Sodium valproate (antiepileptic) and fluoxetine (SSRI)
29
If BPAD patient is mainly depressed what is the 2nd line drug combination
Lamotrigine (antiepileptic) and fluoxetine (SSRI)
30
1st line for acute mania management
Olanzapine (atypical antipsychotic)
31
2nd line for acute mania management
Quetiapine (atypical antipsychotic)
Has a sedative effect
32
Risk factor for schizophrenia
Cannabis use
33
Pathophysiological changes in schizophrenia
* Reduction in grey matter
* Enlarged ventricles
34
Neurochemical changes in schizophrenia
Increase in dopamine
35
3 first rank symptoms of schizophrenia
* Delusions
* 3rd party hallucinations
* Thought interference
Patients often have a lack of insight
36
ICD-10 Criteria states that you need
* 1/3 first rank symptoms
* 2/4 additional symptoms
- blunting of emotion, catatonic behaviour etc
37
Bad prognosis of schizophrenia
Quick onset
38
Good prognosis of schizophrenia
If patient is depressive
39
Atypical Antipsychotics work on
Serotonin and dopamine
40
Typical Antipsychotics work on
Dopamine
41
Name some Atypical antipsychotics
* Risperidone
* Quetiapine
* Clozapine
* Aripiprazole
42
Name some typical antipsychotics
* Chlorpromazine
* Haloperidol
43
First line drug for schizophrenia
Risperidone
44
Which antipsychotic class has the least side effects
Atypicals
45
Side effects of atypical antipsychotics
**Metabolic syndrome**
* HTN
* Hyperglycaemia
* Hypercholesterolaemia
* Increased body fat around the waist
46
Side effects of typical antipsychotics
**Extrapyramidal symptoms**
* Acute dystonia (muscle contraction/spasm)
* Akathisia (motor restlessness)
* Bradykinesia (slow movement)
* Tremor
* Tardive Dyskinesia (irregular jerky movements)
Basically, you give them Parkinson's due to blocking dopamine
47
Side effect of Clozapine (atypical antipsychotic)
Agranulocytosis
| (decreased WCC)
48
What is good about aripiprazole (atypical antipsychotic)
It has the least side effects
49
Patient can't move their neck
Acute neck dystonia due to haloperidol
50
Risk factor for puerperal psychosis
BPAD
51
Mum gave birth a few weeks ago and is batshit crazy, killing baby
Puerperal psychosis
52
Management for puerperal psychosis
Admission to specialised unit
53
Olfactory hallucination is usually due to
epilepsy / stroke
54
Auditory hallucination is usually due to
Psychosis
2nd person: Depressive psychosis
"You are useless"
3rd person: Schizophrenia
"He wants to kill her"
55
Visual hallucination is usually due to
An organic cause:
* Lewy Body Dementia
* Delirium
* Eye problems
56
Tactile hallucinations are usually due to
* Schizophrenia: Skin stretched across their head
* Parkinsonism, Ekbom's syndrome and alcohol and cocaine use: Bugs underneath/ on skin
57
Gustatory (taste) hallucinations are usually due to
Epilepsy
58
Haptic hallucinations (inside of body/organs) are usually due to
Mood disorders
"My insides are dying"
59
What is the Common Law
If a psychiatric patient is going absolutely fucking mental then sedate them to fuck
60
Drugs used in common law
1st line: **Lorazepam**
* If patient is know to be on antipsychotics then add on haloperidol
Give orally if possible
If not, then give IM, if that doesn't work wait 30mins and go IM again
61
The 5 pillars you need to detain someone
1. Danger to themselves or others
2. There must be treatment available that works
3. Patient can't make their own decisions
4. No other alternative
5. Confirmed mental health problem (THAT IS NOT ALCOHOL/DRUG RELATED)
62
Emergency Detention Order
72 hours
Section 36
63
Who do you need to consent to emergency detention
No one to begin with
**ACT FIRST THINK LATER**
MHO is required to consent while detainment is happening
64
Short Term Detention Order
28 days
Section 44
65
Who do you need to consent to a short term detention order
MHO before detention begins
66
Compulsory Detention Order
6 months
67
Who do you need to give consent to a compulsory detention order
Goes to court: Tribunal
Application is needed: MHO and 2 medical reports
68
Do not detain
Alcoholics or drug users
69
4 types of thought interference
* Insertion: "There are thoughts being put in my head"
* Withdrawal: "They are extracting my thoughts from my head"
* Broadcasting: "Everyone knows what I'm thinking"
* Blocking: "I get halfway through thinking and then my thoughts vanish"
70
What to say in an OCSE to someone that is clearly nuts
"I think that there is evidence to suggest that you are actually unwell, and I think that for your own wellbeing you need to receive treatment, even if that means you need to be in a hospital, although I recognise that you don't agree with this"
71
Biggest comorbidity in general anxiety disorder (GAD)
Depression
72
Criteria for GAD
* Must feel anxious and have associated symptoms most days for 6 months
* Loss of function/ affects daily life
* Not controllable
* Irrational
73
Short term treatment for GAD
BZD (e.g. Diazepam)
74
Long term treatment for GAD
Sertraline
"Because you're certain that it works"
75
Panic disorder principles
* \>10mins
* Unpredictable
76
50% of panic disorders lead to
Agoraphobia
(avoidance of places or situations due to anxiety)
77
What physiological signs are seen in panic attacks
Increased lactate and CO2
| (Due to being so stressed)
78
Gold standard treatment for Panic Disorder
CBT
79
Treatment of phobias
Gradual Exposure
80
Criteria of Obsessive Compulsion Disorder (OCD)
* Must be debilitating
* Obsessions over behaviours due to overwhelming compulsions
81
Treatment for OCD
Clomipramine (Tricyclic Antidepressant)
82
Two types of PTSD
Type 1: Single incident (RTA)
Type 2: Repetitive trauma (Abuse)
83
Tonic immobility is seen in
Sexual Assault
84
Physiological signs in PTSD
* Decreased cortisol (probably due to increased sensitivity)
* Atrophy of the hippocampus
* Deactivated Broca's area when reliving the event (so they literally can't speak about it)
85
DSM-V Criteria for PTSD
Need all within 1 month:
* 1 x intrusive symptom (e.g. flashback)
* 1 x avoidance symptom
* 2 x increased arousal symptoms
* alongside a negative mood change
86
1st line treatment for PTSD
Eye Movement Desensitization and Reprocessing (EMDR)
87
2nd line treatment for PTSD
CBT and Venlafaxine (SNRI)
Sometimes other drugs are used:
* Primary care: Paroxetine (SSRI) and Mirtazapine (Tetracyclic)
* Secondary care: Amitriptyline (Tricyclic) and Phenelzine (MAOI)
88
Mammalian brain
Works down
89
Reptilian brain
Works up
90
Three eating disorders
* Anorexia Nervosa
* Bulimia Nervosa
* Binge-eating Disorder
91
Differentiation between eating disorders
* Anorexia: Restricted eating and purging
* Bulimia: Binge-eating and purging
* Binge-eating disorder: Binge-eating and no purge
92
DSM V Criteria for Anorexia
* Persistent restriction
* Intense fear of gaining weight
* Persistent purging
* Body dysmorphia
* Lack of insight
93
DSM V Criteria for Bulimia
* Recurrent binge eating
* Recurrent purging to compensate
* Decreased body image confidence
* Happens 1/7 for 3/12
94
Binge eating criteria
* Eat ridiculous amounts of food
* No purging
* Happens 1/7 for 3/12
* Often over-weight
95
Physiological effects on the body due to anorexia/bulimia
Decreased grey and white matter in the brain which leads to poor concentration etc
96
Treatment for eating disorders
CBT and supportive therapy
97
Re-feeding syndrome
1. Body is used to decreased nutrients
2. When you give a starved patient a good amount of food, their body will then think it's fine, and use up all possible nutrients including its own stores
3. Stores become depleted
98
Prevention of re-feeding syndrome
Taper food and supportive therapy
Monitor nutrient levels etc
99
3 major signs of anorexia and bulimia
* Dental caries (due to acid reflux)
* Russell's sign (scratching of knuckles from front teeth)
* Metabolic problems (e.g. bone fractures, hair thinning)
100
Low-risk BMI for anorexia/bulimia
16-17.5
101
Moderate-risk BMI for anorexia/bulimia
15-15.9
102
High-risk BMI for anorexia/bulimia
13-14.9
103
Very high-risk BMI for anorexia/bulimia
\<13
104
DSM V Criteria for Personality Disorders
* Can be traced back into childhood
* Remains stable and unfluctuating
* Abnormal to social norms
* Impairs individual's functioning/ has an impact on their life
105
3 clusters of personality disorders
* Cluster A: Mad **"Odd and Eccentric"**
* Cluster B: Bad **"Emotional"**
* Cluster C Sad **"Anxious and Avoidant"**
106
Subtypes of Cluster A: **Mad**
* Paranoia "Alex Jones"
* Schizoid "Willy Wonka"
107
Subtypes of Cluster B: **Bad**
* Antisocial: "A ned"
* Borderline: "Unstable girl who breaks up with bf"
* Histrionic: "Seductive lady"
108
Subtypes of Cluster C: **Sad**
* Avoidant: "Loner that lives with his mum"
* Dependant: "Needy girlfriend"
* Obsessive-compulsive/ Anakanistic: "Germaphobe"
109
Difference between Obsessive-compulsive personality disorder and OCD
* Obsessive-compulsive personality disorder is egosyntonic (in line with your own thinking)
* OCD is egodystonic (makes you do things you don't actually want to do)
110
Treatment for Borderline Personality Disorder
CBT
111
"Alex Jones" - conspiracy guy, government are spying on us
Paranoia Personality Disorder
112
"Willy Wonka"- eccentric, no emotion, seclusive
Schizoid Personality Disorder
113
"A ned" gets in fights, destroys stuff, doesn't think about other people's feelings
Antisocial Personality Disorder
114
"Unstable girl" - breaks up with boyfriend, makes rash decisions
Borderline Personality Disorder
115
"Seductive lady" trys to flirt with doctor
Histrionic Personality Disorder
116
"Loner that lives with his mum"- doesn't socialise
Avoidant Personality Disorder
117
"Needy girlfriend"
Dependant Personality Disorder
118
"Germaphobe" - repeatedly washes hands, and cleans worksurfaces to feel better
Obsessive-compulsive Personality Disorder
119
Behavioural disorders in children
"Young Antisocial Personality Disorder"
- Repeatedly gets in fights
- Suspended from school
* \<12: Oppositional deficit disorder (ODD)
* \>12: Conduct disorder
120
Treatment for anger in personality disorders, usually Borderline or Antisocial
Topiramate (anticonvulsant)
121
Learning disabilities increase the risk of
* Epilepsy
* Psychiatric conditions
122
Learning difficulty triad
* Difficulty understanding new or complex information
* Difficulty with learning new skills
* Difficulty coping independently
123
Normal IQ
70- 130
124
Learning Difficulty definition
IQ \<70
125
Mild Learning Difficulty IQ
50-69
126
Moderate Learning Difficulty IQ
35-49
Mental age of 6-12
127
Severe Learning Difficulty IQ
20-34
Mental age of 3-6
128
Profound Learning Difficulty IQ
\<20
Mental age of \< 3
129
Assessment tool for Learning Difficulty
Wechsler Adult Intelligence Scale (WAIS)
130
Attention Deficit Hyperactivity Disorder (ADHD) Triad
* Inattention
* Hyperactivity
* Impulsivity
131
Pathophysiology of ADHD
* **Decreased Dopamine in the frontal lobe,** this is due to increased dopamine transporters that take away dopamine faster than usual
* Decreased NorA = affects focus
* Decreased Serotonin = affects mood
132
When do you treat ADHD
Only in moderate to severe cases
133
Management for everyone with ADHD
Supportive social care etc
134
First line treatment for ADHD
* Methylphenidate "Ritalin"
* Dexamphetamine "Adderall" - requires monitoring
135
Mechanism of action of Methylphenidate
Blocks dopamine transporters, so less dopamine is taken away
## Footnote
**So increases dopamine**
136
Mechanism of action of Dexamphetamine
Blocks transporters of dopamine, NorA and serotonin
**So increases Dopamine,** **NorA** **and Serotonin**
137
Second line treatment in ADHD
Atomoxetine (SNRI)
138
Third line treatment in ADHD
Clonidine (Alpha receptor agonist)
139
Fourth line treatment in ADHD
Imipramine (TCA) and Risperidone (Atypical antipsychotic)
140
Autism Spectrum Disorder (ASD) Triad
* Decreased Communication
* Decreased Social Interaction = "Plays alone"
* Decreased Imagination = "Repetitive behaviours, no imaginative play"
141
Comorbidities in ASD
* ADHD
* Depression
* Epilepsy
* Dyslexia
* OCD
* Tourettes
142
What is the spectrum
Mild end: Asperger's Syndrome
Moderate: Pervasive developmental disorder, not otherwise specified (PDD-NOS)
More severe: Autistic Disorder
Severe: Childhood disintegrative disorder
143
Asperger's Syndrome
**"High functioning"**
Doctor Asperger created this syndrome during WWII to save his patients from going to Nazi Concentration camps
144
Rett's Syndrome
Associated with ASD due to similar symptoms, however, is not part of the spectrum
* Small head and seizures
* Only found in girls, as boys die early on
145
Pathophysiology in ASD
Increased activity in Frontal lobe: explains "obsessions"
Increased activity in amygdala: explains "social anxiety"
Increased activity in cerebellum: explains "arm flapping"
146
Treatment for ASD
* Supportive social care
* In aggressive patients: **Risperidone** (atypical antipsychotic)- decreases dopamine
147
Medication to aid sleep in ASD
Melatonin (secreted by the pineal gland)
148
Mechanism of GABA
1. GABA increases the frequency of open GABA Cl- channels
2. When GABA Cl- channels are open, more Cl- is allowed through which lowers the resting membrane potential (because it is negative)
3. Lowered resting membrane potential makes it more difficult for a stimulus (neuron) to reach the transmission threshold to generate a transmission signal
149
Increased GABA
**"Relaxed effect"**
Decreases neurons firing in the brain due to the lowered threshold
* Calming effect
* Sedative effect
* Muscle relaxant
* Anterograde amnesia (can't make new memories)
150
Decreased GABA
**"Excited effect"**
* Insomnia
* Anxiety
151
Mechanism of action of BZDs
Increase GABA to cause a relaxed effect
152
Withdrawal effect from BZDs
Excited effect
Due to neurons being used to decreased Cl - levels, that have lowered the resting membrane potential. When the resting membrane returns to normal there are over-firing of neurons
153
ICD-10 Criteria for Addiction
* Strong desire
* Difficulty controlling addiction
* Absence of stimulus causes a withdrawal state
* Developed tolerance
* Neglect of other pleasures
* Persistence despite harm
154
Pathophysiology of addiction
* Dopamine D2 receptors become desensitized
* Orbital frontal cortex: increased in situations of opportunity for stimulus and in cravings
* Pre-frontal cortex: is overpowered
155
Action of orbital frontal cortex
Motivator to act
156
Action of Mesolimbic pathway
Responsible for incentive behaviour and is involved in normal pleasure
157
Action of pre-frontal cortex
Rational self
158
Effect on the brain of dopamine
Allows you to set new goals and focus on them
159
Dopamine levels in ADHD
Decreased
As they have no new goals to concentrate on hence why they cannot concentrate on one thing at a time
160
Dopamine levels in ASD
Increased
Which means they become too focused on one goal hence their obsessions
161
Why is it easier to become addicted to something when you are younger
Frontal lobe areas are still developing and so your rational self is overpowered more easily, and you have more motivation to act etc
162
Pathophysiology of tolerance
1. Due to repeated dopamine release, D2 receptors become desensitised to dopamine
2. This means that to get a stronger high you need to get more dopamine to elicit the same response
3. Hence why you increase your dose to get the same high
4. This is tolerance building
163
CAGE questionnaire in addiction
* "Have you been thinking about **C**utting down addiction habit"
* "Do you or other people get **A**nnoyed at your addiction"
* "Do you feel **G**uilty about your addiction"
* "Do you use it as an **E**ye-opener in the morning, like coffee?"
1/4 = Raises suspicion
2/4 = indicative of abuse
164
Pathophysiology of Alcohol Addiction
* Alcohol increases the effect of GABA
Hence why you have less inhibition when drunk
* Chronic effect of this causes a tolerance to GABA and to alcohol
* Glutamate channels (NMDA) don't work in Alcohol
165
Delerium Tremens peaks at
2 days
166
Seizures happen in Delirium Tremens within
24 hours of withdrawal
167
Delirium Tremens resolves in
5-7 days
168
Pathophysiology of Delirium tremens
Due to the tolerance of alcohol, the neurons in the brain are more used to a lowered resting membrane potential (as GABA works better in the presence of alcohol)
In a withdrawal state: this causes the resting membrane potential to be increased due to the absence of alcohol, so the neurons over fire the threshold "hyperexcitability" causing excitatory symptoms like:
* Seizures
* Tremor
* Confusion- due to inhibited glutamate (used in memory)
169
Treatment of Delirium Tremens
* **Chlordiazepoxide** (BZD) or diazepam (BZD)- cause a relaxing effect
* Thiamine (B1) supplements
170
Liver function test raised in Alcoholism (liver injury)
GGT
171
Haematological marker raised in alcoholics
Increased MCV
172
Calculation for Alcohol units
1 unit = 10ml pure ethanol
units = (% x volume) / 10
173
Ethanol is broken down into
Acetaldehyde
174
Enzyme responsible for breakdown of ethanol to acetaldehyde
Alcohol dehydrogenase (ADH)
175
Acetaldehyde is responsible for
Hangovers
176
Acetaldehyde is broken down into
Acetate
177
Enzyme responsible for the breakdown of acetaldehyde into acetate
aldehyde dehydrogenase (ALDH)
178
Some Asian populations lack
ALDH
This causes them to have a build up of acetaldehyde which causes them to experience hangover symptoms instantly instead of the next morning
179
Drugs used to prevent Alcohol addiction relapse
* 1st line: Naltrexone
* Disulfiram
* Acamprosate
*
180
Effect of Naltrexone
Reduces reward from alcohol
181
Effect of Disulfiram
Inhibits ALDH causing hangover symptoms immediately
182
Effect of Acamprosate
Reduces alcohol cravings
183
Antidote to Opiate overdose
Naloxone
184
Predetermined person to make decisions on your behalf if you are not deemed to have capacity
Power of Attorney
185
Court assigns a guardian to make decisions on a patient once they are incapacitated
Guardianship
186
Doctors making the best decisions on behalf of the patient until a guardian is decided
Adults with Incapacity Act
187
Authorises treatment of someone without capacity
Mental Health Act 2003 (Section 47)
