1 Flashcards
Subtypes of delusions
delusional disorders
grandiose
persecutory
Erotomania
What is erotomania?
The presence of delusion (of a famous person being in love with them) with the absence of other psychotic symptoms
How would a patient with schizotypal personality disorder present?
Hold ‘odd’ beliefs and display bizarre behaviours but do not hold their beliefs with delusional conviction
How would a patient with narcissistic PD be?
They display LONG term pattern of inflated self- importance, excessive need for admiration and lack of empathy
How would a patient with histrionic PD be?
excessively attention -seeking
What is. De Clerambault’s syndrome?
AKA erotomania, is a form of PARANOID DELUSION with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
Alcohol withdrawal - mechanism, features and management
Mechanism:
- chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
- alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
Features:
- symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
- peak incidence of seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Management
- patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
- first-line: benzodiazepines e.g. chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
- carbamazepine also effective in treatment of alcohol withdrawal
- phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
Common features of PTSD
- re-experiencing e.g. flashbacks, nightmares
- avoidance e.g. avoiding people or situations
- hyperarousal e.g.hypervigilance, sleep problems
Post-traumatic stress disorder - features and management
Features:
- re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
- avoidance: avoiding people, situations or circumstances resembling or associated with the event
- hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
- emotional numbing - lack of ability to experience feelings, feeling detached
from other people:
- depression
- drug or alcohol misuse
- anger
- unexplained physical symptoms
Management:
- following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
- watchful waiting may be used for mild symptoms lasting less than 4 weeks
- military personnel have access to treatment provided by the armed forces
- trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
- drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used
What is somatisation disorder?
- multiple physical SYMPTOMS present for at least 2 years
- patient refuses to accept reassurance or negative test results
What is hypochondrial disorder?
- persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
- patient again refuses to accept reassurance or negative test results
What is conversion disorder?
- typically involves LOSS OF MOTOTR OR SENSORY FUCNTION
- the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
- patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
What is dissociative disorder?
- dissociation is a process of ‘separating off’ certain memories from normal consciousness
- in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
- dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
What is Factitious disorder?
also known as Munchausen’s syndrome
the intentional PRODUCTION of physical or psychological symptoms
Malingering and give an example
fraudulent simulation or exaggeration of symptoms with the intention of FINANCIAL or other gain e.g. someone hep fakes whiplash after a road traffic accident for an insurance payment , or patient reporting symptoms with deliberate intention of getting morphine
Depression vs dementia
Factors suggesting diagnosis of depression over dementia:
- short history, rapid onset
- biological symptoms e.g. weight loss, sleep disturbance
- patient worried about poor memory
- reluctant to take tests, disappointed with results
- mini-mental test score: variable
- global memory loss (dementia characteristically causes recent memory loss)
What is the SADPERSONs score?
Is used to calculate suicide risk, and might be appropriate if this patient revealed a suicidal intent
(NOT used for an initial assessment of depression)
What is the DSM-V?
he Diagnostic and Statistical Manual of Mental Disorders V is used to DESCRIBE mental health disorders, but does not in itself provide a scoring system.
What are the 2 questions asked initially to screen for depression?
- During the last month, have you often been bothered by feeling DOWN, depressed or hopeless?
- During the last month, have you often been bothered by having LITTLE INTEREST or pleasure in doing things
If yes to either q then this prompts a more in depth assessment
What are the names of the tools used to assess the degree of depression?
- Hospital Anxiety and Depression (HAD) scale
- Patient Health Questionnaire (PHQ-9)
- Hamilton Depression Rating Scale (HAM-D)
What is paroxetine?
An SSRI
Antisocial PD?
- Failure to conform to social norms with respect to LAWFUL behavioUrs as indicated by repeatedly performing acts that are grounds for arrest;
- More common in men;
- Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
- Impulsiveness or failure to plan ahead;
- Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
- Reckless disregard for safety of self or others;
- Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
- Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Avoidant PD?
- Avoidance of occupational activities which involve significant interpersonal contact due to FEARS OF criticism, or REJECTION.
- Unwillingness to be involved unless certain of being liked
- Preoccupied with ideas that they are being criticised or rejected in social situations
- Restraint in intimate relationships due to the fear of being ridiculed
- Reluctance to take personal risks doe to fears of embarrassment
- Views self as inept and inferior to others
- Social isolation accompanied by a craving for social contact
Borderline PD?
- Efforts to avoid real or imagined abandonment
- Unstable interpersonal relationships which alternate between idealization and devaluation
- Unstable self image
- Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
- Recurrent suicidal behaviour
- Affective instability
- Chronic feelings of emptiness
- Difficulty controlling temper
- Quasi psychotic thoughts
Dependent PD?
- Difficulty making everyday decisions without excessive reassurance from others
- Need for others to assume responsibility for major areas of their life
- Difficulty in expressing disagreement with others due to fears of losing support
- Lack of initiative
- Unrealistic fears of being left to care for themselves
- Urgent search for another relationship as a source of care and support when a close relationship ends
- Extensive efforts to obtain support from others
- Unrealistic feelings that they cannot care for themselves
Histrionic PD?
- Inappropriate sexual seductiveness
- Need to be the centre of attention
- Rapidly shifting and shallow expression of emotions
- Suggestibility
- Physical appearance used for attention seeking purposes
- Impressionistic speech lacking detail
- Self dramatization
- Relationships considered to be more intimate than they are
Narcissistic PD?
- Grandiose sense of self importance
- Preoccupation with fantasies of unlimited success, power, or beauty
- Sense of entitlement
- Taking advantage of others to achieve own needs
- Lack of empathy
- Excessive need for admiration
- Chronic envy
- Arrogant and haughty attitude
Obsessive-compulsive PD
- Is occupied with details, rules, lists, order, organisation, or agenda to the point that the key part of the activity is gone
- Demonstrates PERFECTIONISM that hampers with completing tasks
- Is extremely dedicated to work and efficiency to the elimination of spare time activities
- Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
- Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
- Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
- Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
Paranoid PD?
- Hypersensitivity and an unforgiving attitude when insulted
- Unwarranted tendency to questions the loyalty of friends
- Reluctance to confide in others
- Preoccupation with conspirational beliefs and hidden meaning
- Unwarranted tendency to perceive attacks on their character
Schizoid PD?
- Indifference to praise and criticism
- Preference for solitary activities
- Lack of interest in sexual interactions
- Lack of desire for companionship
- Emotional coldness
- Few interests
- Few friends or confidants other than family
Schizotypal PD?
- Ideas of reference (differ from delusions in that some insight is retained)
- Odd beliefs and magical thinking
- Unusual perceptual disturbances
- Paranoid ideation and suspiciousness
- Odd, eccentric behaviour
- Lack of close friends other than family members
- Inappropriate affect
- Odd speech without being incoherent
Schizophrenia features?
Schneider’s first rank symptoms may be divided into
auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions
Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour
Thought disorder:
thought insertion
thought withdrawal
thought broadcasting
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
Other features of schizophrenia include - impaired insight - incongruity/blunting of affect (inappropriate emotion for circumstances) - decreased speech - neologisms: made-up words catatonia negative symptoms: - incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
What is a Section 2?
- admission for ASSESSMENT for up to 28 days, not renewable
- an Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors
- one of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)
- treatment can be given against a patient’s wishes
Section 3?
- admission for TREATMENT for up to 6 months, can be renewed
AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours
treatment can be given against a patient’s wishes
What is Cotard syndrome?
- Is associated with severe depression
- a rare subtype of nihilistic delusions, in which they believe they or part of them is dead or does not exist
This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.
- Cotard syndrome is associated with severe depression and psychotic disorders
How many additional symptoms are required to make a diagnosis of major depression ?
At least 5 on top of the 3 major criteria for major depressive symptoms
What electrolyte imbalance can SSRIs cause?
HypOnatreamia
e.g. sertraline
Protective factors for suicide?
Family support
Having children at home
Religious belief
Thought disorder list e.g. tangentiality
- CIRCUMSTANTIALITY - the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point.
- TANGENTIALITY - wandering from a topic without returning Toit
- NEOLIGISMS - are new word formations, which might include the combining of two words.
- FLIGHT OF IDEAS
- PERSEVERATION -the repetition of ideas or words despite an attempt to change the topic.
- ECHOLALIA - the repetition of someone else’s speech, including the question that was asked.
What are ‘flight of ideas’? and where is this feature seen?
- when a patient speaks very quickly and rapidly jumps between different topics
feature of MANIA- commonly found in BIPOLAR
Discontinuation symptoms?
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- gastrointestinal symptoms: pain, cramping, diarrhoea,
- vomiting
- paraesthesia
What is Charles-Bonnet syndrome?
- is characterised by visual hallucinations associated with eye disease. Most common visual hallucinations are faces, children and wild animals.
- peripheral visual impairment is a risk factor
What is a key feature that is in both antisocial PD and borderline PD?
Impulsivity
What are the key features of borderline PD?
Unstable affect with fluctuating self image and recurrent suicidal ideation and self harm
What are the key features of antisocial PD?
Repeated failure to conform to social norms or rules and reckless disregard for their own safety as well as others with a lack of sense of remorse when these actions are discussed
Does antisocial disorder more often affect men or women?
Men
Does borderline PD more often affect men or women?
Women
PTSD - comment on the onset of symptoms and its course
Onset of symptoms are usually DELAYED and it tends to run a PROLONGED course
After what amount of time can ‘chronic’ insomnia be diagnosed by?
And what does it entail?
3 months
- if a person has trouble falling asleep or staying asleep at least three nights per week
What are the 2 forms of insomnia?
Acute or chronic
What is acute insomnia more typically caused by?
Typically related to a life event and resolves WITHOUT treatment.
What features do those with insomnia present with?
Patients typically present with
- decreased daytime functioning,
- decreased periods of sleep (delayed sleep onset or awakening in the night) or
- increased accidents due to poor concentration.
Often the partner’s rest will also suffer.
What is the epidemiological features that insomnia is associated with?
- Female gender
- Increased age
- Lower educational attainment
- Unemployment
- Economic inactivity
- Widowed, divorced, or separated status
What are the risk factors for insomnia?
- Alcohol and substance abuse
- Stimulant usage
- Medications such as corticosteroids
- Poor sleep hygiene
- Chronic pain
- Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population.
- Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.
Less common diagnostic factors of insomnia may include:
- Daytime napping
- Enlarged tonsils or tongue
- Micrognathia (small jaw) and retrognathia (abnormal posterior position of the mandible)
- Lateral narrowing of oropharynx
Investigations for insomnia?
- Diagnosis is primarily made through PATIENT INTERVIEW, looking for the presence of risk factors.
- SLEEP DIARIES and actigraphy may aid diagnosis. Actigraphy is a non-invasive method for monitoring motor activity.
- Polysomnography is not routinely indicated. It may be considered in patients with suspected obstructive sleep apnoea or periodic limb movement disorder, or when insomnia is poorly responsive to conventional treatment.
Short term management of insomnia?
- Identify any POTENTIAL CAUSES e.g. mental/ physical health issues or poor sleep hygiene.
- Advise the person not to drive while sleepy.
- Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc.
- ONLY consider use of hypnotics if daytime impairment is severe.
What drugs are not recommended for managing insomnia?
Antidepressants Antihistamines Choral hydrate Clomethiazole Barbiturates
NOT RECOMMENDED
What is the recommended medication for insomnia?
benzos
non -benzos (z drugs)
What diagnosis needs to be ruled out before making a diagnosis of anxiety?
THYROID disease
- hyperthyroidism can be a cause and an exacerbating factor.
What are potential differential diagnosis for anxiety - that are physical causes?
Hyperthyroidism Cardiac disease Medication induced anxiety - medications that can trigger include: - salbutamol - theophylline - corticosteroids - antidepressants - caffeine
Management of generalised anxiety disorder (GAD)?
NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.
step 4: highly specialist input e.g. Multi agency teams
- Drug treatment
NICE suggest SERTRALINE should be considered the first-line SSRI
interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
Management of panic disorder?
A stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
- Treatment in primary care
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine (TCA) should be offered
What needs to be considered before a diagnosis of psychotic disorder?
Organic causes must be considered and excluded before the psychosis can be attributed to a primary psychotic disorder.
A CT head scan should be considered in elderly patients with new sudden onset psychosis to rule out an organic cause for their presentation
What is the key differentiating symptoms that suggest mania rather than hypomania?
The presence of psychotic symptoms and significant functional impairment - mania
