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
What do you do if someone is experiencing mania in primary care?
URGENT referral to community mental health team
What do you do if someone is experiencing hypomania in primary care?
ROUTINE referral to community mental health team
this is indicated for hypomania and non-severe depression
When is sodium valproate used in bipolar disorder?
NICE guidelines advice is ‘Do not start valproate in primary care to treat bipolar disorder.’
- it should only be used for patients in whom antipsychotic medication has already been tried
How many types of bipolar are there and what do they consist of?
2 types
- type I disorder: mania and depression (most common)
- type II disorder: hypomania and depression
What is mania/hypomania?
- both terms relate to abnormally elevated mood or irritability
- with mania there is severe functional impairment or psychotic symptoms for 7 days or more
- hypomania describes decreased or increased function for 4 days or more
- from an exam point of view the key differentiation is PSYCHOTIC SYMPTOMS (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
What is the management of bipolar?
- psychological interventions specifically designed for bipolar disorder may be helpful
- LITHIUM remains the mood stabilizer of choice. An alternative is valproate
- management of mania: consider STOPPING antidepressant if the patient takes one; ANTIPSYCHOTIC THERAPY e.g. olanzapine or haloperidol
- management of depression: talking therapies (see above); FLUOXETINE is the antidepressant of choice
- address co-morbidities - there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD
What is the management of schizophrenia?
- oral ATYPICAL antipsychotics are first-line
- cognitive behavioural therapy should be offered to all patients
- close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
What is akathisia?
Severe restlessness - sense of inner restlessness and inability to keep still
It is a side effect of antipsychotic medication - extrapyramidal side effects
What is agranulocytosis the life-threatening side effect?
Clozapine
Clozapine in schizophrenia
This is not a first line medication
Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
Symptoms of depression (other than the cardinal)
- Reduced concentration and attention
- Decreased self-esteem and confidence
- Feelings of guilt and unworthiness
- Bleak and pessimistic views of the future
- Ideas or acts of self-harm or suicide
- Disturbed sleep
- Diminished appetite and weight loss
- Psychomotor agitation or retardation
- Marked loss of libido
Diagnostic criteria for a mild depressive episode
- At least 2 of the main 3 symptoms of depression, and at least two of the other symptoms, should be present for a definite diagnosis. None of the symptoms should be present to an intense degree
- Minimum duration of the whole episode is about 2 weeks
- Individuals may be distressed by symptoms, but should be able to continue work and social functioning
Diagnostic criteria for MODERATE depressive episode
- At least 2 of the main 3 symptoms of depression, and at least three (and preferably four) of the other symptoms, should be present for a definite diagnosis
- Minimum duration of the whole episode is about 2 weeks
- Individuals will usually have considerable difficulty continuing with normal work and social functioning
Diagnostic criteria for SEVERE depressive episode
- ALL THREE of the typical symptoms should be present, plus at least four other symptoms, some of which should be of severe intensity
- The minimum duration of the whole episode should last at least 2 weeks, but if the symptoms are particularly severe then it may be appropriate to make an early diagnosis
- Can also experience psychotic symptoms with severe depressive episodes
- Individuals show severe distress and/or agitation
Factors shown to be associated with an increased risk of suicide
- male sex (hazard ratio (HR) approximately 2.0)
- history of deliberate self-harm (HR 1.7)
- alcohol or drug misuse (HR 1.6)
- history of mental illness
depression
schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide - history of chronic disease
- advancing age
- unemployment or social isolation/living alone
- being unmarried, divorced or widowed
If a patient has actually attempted suicide, there are a number of factors associated with an increased risk of completed suicide at a future date - there are:
- efforts to avoid discovery planning - leaving a written note - final acts such as sorting out finances - violent method
ICD - 10 of someone with schizoid PD
- Few, if any, activities provide pleasure.
- Displays emotional coldness, detachment, or flattened affectivity.
- Limited capacity to express warm, tender feelings for others as well as anger.
- Appears indifferent to either praise or criticism from others.
- Little interest in having sexual experiences with another person (taking into account age).
- Almost always chooses solitary activities.
- Excessive preoccupation with fantasy and introspection.
- Neither desires, nor has, any close friends or confiding relationships (or only one).
- Marked insensitivity to prevailing social norms and conventions; if these are not followed this is unintentional.
Symptoms common in both Mania and hypomania
Mood
- predominately elevated
- irritable
Speech and thought
- pressured
- flight of ideas: characterised by rapid speech with frequent changes in topic based on associations, distractions or word play
- poor attention
Behaviour
- insomnia
- loss of inhibitions: sexual promiscuity, overspending, risk-taking
- increased appetite
Hypomania vs mania
MANIA
- Lasts for at least 7 days - Causes severe functional impairment in social and work setting
- May require hospitalization due to risk of harm to self or others
- May present with psychotic symptoms
HYPOMANIA
- A lesser version of mania
- Lasts for < 7 days, typically 3-4 days (but can be longer than 7 days). Can be high functioning and does not impair functional capacity in social or work setting
- Unlikely to require hospitalization
- Does not exhibit any psychotic symptoms
Are sleep changes a feature of schizophrenia?
yes
Circadian rhythm disturbance- most commonly insomnia
What are purging behaviours in bulimia?
not only vomiting, can be use of laxatives or diuretics or exercising
Purging does NOT have to occur with each meal, and occurs, on average, once a week, usually following a binging episode
Define bulimia nervosa
An eating disorder
characterised by episodes of uncontrolled consumption (binging) followed by purgative behaviours (which incise inducing vomiting , taking laxatives or diuretics, or intensely exercising)
Define anorexia nervosa
Fasting which is defined as restricting or ceasing eating
DSM 5 diagnostic criteria for a diagnosis of bulimia nervosa
- recurrent episodes of binge eating (eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances)
- a sense of LACK OF CONTROL over eating during the episode
- recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
- the binge eating and compensatory behaviours both occur, on average, at least once a week for three months.
- self-evaluation is unduly influenced by body shape and weight.
- the disturbance does not occur exclusively during episodes of anorexia nervosa.
Management of bulimia nervosa
- referral for specialist care is appropriate in all cases
- NICE recommend bulimia-nervosa-focused guided SELF - HELP for adults
If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend that we consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) - children should be offered bulimia-nervosa-focused FAMILY THERAPY (FT-BN)
- pharmacological treatments have a limited role - a trial of high-dose FLUOXETINE is currently licensed for bulimia but long-term data is lacking
What is Kallman syndrome?
Anosmia + delated/absent puberty
What is the most commonest electrolyte abnormality in anorexia?
HypOkalaemia
Do people with anorexia tend to have high or low cholesterol?
High
Features of anorexia nervosa
- reduced body mass index
- bradycardia
- hypotension
- enlarged salivary glands
- failure of secondary sexual characteristics
- cold - intolerance
What are the physiological abnormalities of anorexia nervosa
- hypokalaemia
- low FSH, LH, oestrogens and testosterone
- raised cortisol and growth hormone
- impaired glucose tolerance
- hypercholesterolaemia
- hypercarotinaemia (therefore yellow tinge on the skin)
- low T3
- lanugo hair - fine downy hair growth in response to loss of body fat
What are the specific warnings when antipsychotics are used in elderly patients?
- increased risk of STROKE
- increased risk of VTE
What can lithium precipitate?
Benign leucocytosis
What is the most common mood stabiliser used in bipolar?
Lithium
When is benign leucocytosis a common finding in?
Various drugs - most commonly corticosteroids, lithium and beta blockers
When is lithium used?
Most commonly prophylactically in bipolar disorder
Also used as an adjunct in refractory depression
What electrolyte disturbance may be seen in bulimia nervosa?
The low chloride suggests the cause of this metabolic alkalosis is loss of hydrochloric acid from the stomach (through vomiting). Severe vomiting would also account for the hypokalaemia shown on ECG.
This patient’s ECG shows features of hypokalaemia. This is likely the cause of the palpitations.
What electrolyte imbalance is SSRIs associated with?
hypOnatraemia
What is the treatment for alcohol withdrawal?
Chlordiazepoxide
What is aripiprazole?
Antipsychotic usually used in the treatment of schizophrenia and the manic phase of bipolar disorder
What would differentiate a psychosis from an obsessive-compulsive disorder?
Obsessive-compulsive disorder can be differentiated from psychosis by the level of INSIGHT into their actions
- In OCD the patients normally have a good level of insight into their condition and understand that if they did not perform the acts their obsessive though would not come true. However, they still get the urge to perform them anyway, just to put their mind at ease.
- E.g. if someone think that if they didn’t perform certain acts their obsessions wouldn’t come true.
Why is depression a differential of dementia?
Depression can cause what appears to be memory loss, due to lack of concentration.
It would also have the depressive like symptoms of fatigue and lack of pleasure in normal activities
What is the most appropriate first line drug treatment of panic disorder?
SSRI
When there is a dose change with lithium - when should lithium levels be checked ?
after a change in dose, lithium levels should be taken A WEEK LATER and 12 HOURS after the last dose
Once lithium levels are stable within therapeutic range should be taken 3 monthly
What is Seasonal Affective Disorder and how do you treat it?
- Describes depression which occurs predominately around the winter months.
- SAD should be treated the same way as depression
- Psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration.
- Following this an SSRI can be given if needed.
- You should NOT give the patient sleeping tablets as this can make the symptoms worse
When should you stop an antidepressant?
If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 MONTHS after remission as this reduces the risk of relapse.
How long does it take to stop an SSRI?
Should be gradually reduced over a 4 WEEK PERIOD
When is ECT indicated?
- In treatment- resistant depression
- catatonic schizophrenia
- severe mania
- life threatening catatonia (definition: abnormality of movement and behaviour arising from a disturbed mental state)
- an episode of moderate depression know to respond to ECT in the past
What are the short term effects of ECT?
- headache
- nausea
- short term memory impairment
memory loss of events prior to ECT - cardiac arrhythmia
What are the long term effects of ECT?
Impaired memory
What is the most common endocrine disorder developing as a result of chronic lithium toxicity?
When does it usually manifest?
HyPOthyroidism
between 6 and 18 months after initiation of treatment
What things should be avoided if taking an monoamine oxidase inhibitor?
And why?
Tyramine containing foods (e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans)
As it increases the risk of developing a HYPERTENSIVE CRISIS
What is the first line treatment for someone experiencing mild depression for 6 months?
Psychological intervention
What does the scores on the PHQ-9 mean? also what does PHQ-9 stand for ?
Patient health questionnaire-9 (PHQ-9) is used by GP’s as a tool to characterise severity of depression:
- 0-4 no depression identified
- 5-9 mild depression
- 10-14 moderate depression
- 15-19 moderately severe depression
- 20-27 severe depression
Some examples of they you think a patient has depression rather than dementia?
Sleep disturbance, stress triggers and normal mini-mental test score with global memory loss suggests depression rather than dementia
What is associated with a poor prognosis of schizophrenia?
Gradual onset schizophrenia
What are prognostic indicators in Schizophrenia?
Factors associated with poor prognosis:
- strong family history
- gradual onset
- low IQ
- premorbid history of social withdrawal
- lack of obvious precipitant
What are things to consider when managing a patient with depression?
- Manage suicide risk (this may include voluntary/compulsory admission)
- Manage any safeguarding concerns for children or vulnerable adults in their care
- Manage any co-morbid condition associated with depression (for example, alcohol or substance abuse)
- Psychotic symptoms seek expert advice
- Eating disorders seek expert advice
- Dementia treat the underlying depression.
- Discuss practical solutions to stresses contributing to depression.
How to manage someone with mild depression or subthreshold depressive symptoms?
Consider a period of active monitoring, and:
- Provide information about the nature and course of depression.
- Arrange follow up, normally within 2 weeks (consider contacting the person if they do not attend follow-up appointments)
- General measures - e.g. sleep hygiene
How to manage someone with subthresold depressive symptoms or mild-to-moderate depression?
- Consider a PSYCHOLOGICAL INTERVENTION. This is accessed by referral or self-referral to IAPT (Improving Access to Psychological Therapies).
- Avoid the routine use of antidepressants, but consider this for people with a history of moderate or severe depression, subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years) or mild depression that is complicating the care of a chronic physical health problem.
- General measures : sleep hygiene
How to manage someone with moderate or severe depression?
Offer an antidepressant and a high-intensity psychological intervention
How to manage someone if this is their first episode of depression?
Prescribing a generic selective serotonin reuptake inhibitor (SSRI), such as citalopram, fluoxetine, paroxetine, or sertraline.
If someone has a chronic physical health problem - what antidepressant would you prescribe?
Sertraline may be preferred, because it has a lower risk of drug interactions.
How to differentiate between Knight’s move and flight of ideas?
Knight’s move thinking there are ILLOGICAL leaps from one idea to another, flight of ideas there are DISCERNIBLE LINKS between ideas
What is neologisms?
Thought disorder
New word formation
What are clang association
Thought disorder
Ideas are related to each other only by the fact that they sound similar
What drugs should be avoided when taking an SSRI?
- aspirin
- triptans - increased risk of serotonin syndrome
- monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
What is the screen tool used for alcohol withdrawal?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale
determines the severity of withdrawal by collating scores of symptom severity.
Is borderline PD more associated with males or females?
Females
in early adulthood
4 symptoms of Borderline PD
Emotional instability -‘affective dysregulation’
- Disturbed patterns of thinking or perception
- impulsive behaviour
- intense but UNSTABLE RELATIONSHIPS with others
Features of depressive PD
In depressive personality disorder, a patient has always had a low mood and a negative, gloomy outlook on life. These patients may complain of low mood, but have few or no other symptoms of depression.
Cyclothytmic PD?
tend to alternate between depression and elation.
Torticollis
Acute dystonia
sustained muscle contraction
- normal facial movements.
- unilateral pain and deviation of the neck with pain on palpation and restricted range of motion.
Neuroleptic malignant syndrome - when occurs and features
Neuroleptic malignant syndrome is a medical emergency which occurs in patients taking antipsychotics. It is characterised by altered mental state, generalised rigidity, fluctuating blood pressure and high temperature.
Is tardive dyskinesia a long or short term feature? and of what?
Tardive dyskinesia occurs in patients on long term typical antipsychotics and is characterised by uncontrolled facial movements such as lip-smacking.
Is akathisia a long or short term feature? and of what?
Akathisia is characterised by severe restlessness with patients having difficulty in sitting still. Patients may rock, tap their legs or cross and uncross the legs. It typically occurs with long term use of antipsychotics.
Echolalia - what is it?
repeating exactly what someone has said.
Neologism - what is it ?
making up new words.
Word salad - what is it?
disorganised speech, sentences that do not make sense.
- is associated with psychosis and mania
What is sleep paralysis?Features, management
Sleep paralysis is a common condition characterised by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures
Features
- paralysis - this occurs after waking up or shortly before falling asleep
- hallucinations - images or speaking that appear during the paralysis
Management
- if troublesome clonazepam may be used
What is a dystonic reaction?
It is an extrapyramidal side effect
usually managed with procyclidine
What is used to reverse side effects of haloperidol ?
Procyclidine
What is a way to remember the features of anorexia nervosa?
most things low
G’s and C’s raised: Growth hormone, Glucose, salivary Glands, Cortisol, Cholesterol, Carotinaemia
(Carotinaemia - clinical condition characterised by yellow pigmentation of the skin (xanthoderma))
What is a pseudo hallucination ?
A FALSE SENSORY PERCEPTION in the absence of external stimuli when the affected is AWARE that they are hallucinating.
Pseudohallucinations commonly occur in people who are grieving.
What drug class is Venlafaxine in?
SNRI
What could cause a rise in clozapine levels in the blood?
- Smoking cessation
- Alcohol binges can increase the level
What could cause a fall in clozapine levels in the blood?
- Omitting doses will cause a reduction in clozapine levels
- Stopping drinking can also reduce levels (as alcohol binges can increase the level)
Panic disorder vs GAD?
- Panic disorder: a panic disorder is more associated with random panic attacks, on a BACKGROUND OF NO ANXIETY usually.
- GAD: PERSISTENT, ‘free-floating’ anxiety, with associated features. Treatment with SSRIs and CBT is key.
Management of GAD
- SSRI anti-depressants
- buspirone (5-HT1A partial agonist)
- beta-blockers
- benzodiazepines: use longer acting preparations e.g. diazepam, clonazepam
- cognitive behaviour therapy
For a diagnosis of PTSD how long should the symptoms be present for?
At least one month
Risk factors for the development of GAD?
Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent
Side effect of lorazepam in terms of the brain?
Anterograde amnesia
What is the first line therapy for a child/adolescent with anorexia nervosa?
What is the second line?
- anorexia focused family therapy
- second line: CBT
What is a side effect of Mirtazapine? Also what class of drugs is Mirtazapine in?
Antidepressant
sedation and increased appetite
What is the strongest risk factor for psychotic disorders?
Family history
Define catatonia
Stopping of voluntary movement or staying still in an unusual position = catatonia
Othello syndrome?
DELUSIONAL JEALOUSY, usually believing their partner is unfaithful
What is the first line drug treatment for GAD?
Sertraline (SSRI)
What is a good treatment for borderline personality disorder?
dialectical behaviour therapy (DBT)
(this is a targeted therapy that is based CBT, but has been adapted to help people who experience emotions very intensely.)
