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psychiatry > Affective disorders > Flashcards

Affective disorders Flashcards

1
Q

What is a primary affective disorder?

A

one that does not result from another organic or psychiatric condition

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2
Q

What is a secondary affective disorder?

A

resulting from eg schizophrenia, hypothyroidism, anaemia, substance misuse

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3
Q

What is the epidemiology of depression?

A

• Lifetime risk = 15% • Prevalence – 5% population • F>M 2:1 • Peak prevalence  males = old age, women – middle age

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4
Q

What is the genetic link in depression?

A

o 15% prevalence in first degree relatives o Monozygote twins 46% concordance o First degree relatives at increased risk of depressive disorder but not bipolar/schizophrenia

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5
Q

What is the monamine hypothesis in relation to depression?

A

 Depression results from the depletion of monoamine neurotransmitters noradrenaline, serotonin and dopamine (or change in receptor function)  This makes sense in medical treatment eg SSRIs  Reserpine (antipsychotic) decreases level of MA neurotransmitters and can depress mood  Functions of serotonin  mood, anxiety, sleep, apetite, sexuality, vomiting, body temp regulation

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6
Q

How can endocrine issues be linked to depression?

A

o In 50% of depression sufferers plasma cortisol levels are up and 50% depression sufferers fail to respond to dexamethasone suppression test

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7
Q

How can personality be linked with depression?

A

o Neuroticism (negative and anxious) and obsessionability predispose to depression

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8
Q

How can environmental factors impact depression?

A

o Early adverse life events o An excess of life events o Seasonal affective disorder - a depressive disorder that recurs every year at the same time of year and may be marked by increased sleep and carbohydrate craving. Thought to result from changes in the seasons (esp. the length of daylight). There is usually full remission

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9
Q

What psychological theories are there related to depression?

A

o Bowlby’s attachment theory - maternal deprivation o Freud’s psychoanalytical theory - loss of the loved object and mixed feelings of love and hatred, so called ambivalence o Beck’s cognitive theory - Beck’s triad of negative appraisal of self, present and future and Beck’s cognitive distortions (perceiving reality inaccurately)

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10
Q

What are some organic causes of depression?

A

Neurological - Stroke, AD, PD, HD, MS, epilepsy, IC tumour Endocrine - Cushing’s, Addison’s, hypothyroidism, hyperparathyroidism Metabolic - IDA, B12 deficeiny, hypercalcaemia, hypomagnesia Infective - Influzenza, infectious mononucleosis, hepatitis, HIV/AIDs Neoplastic - Non-metastatic effects of carcinoma Drugs - L-dopa, steroids, b-blovkers, digoxin, cocaine, amphetamines, opioids, alcohol

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11
Q

What are the three core symptoms of depression?

A
  1. Low mood a. May have diurnal variation – worse in the morning 2. Low energy 3. Anhedonia
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12
Q

What are the other symptoms that people can get in dementia?

A

• Sleep disturbance o (early morning waking = 2 hours before normal) o difficulty getting to sleep • Change in appetite o Usually loss, but can be gain • Reduced concentration and attention • Reduced sex drive • Loss of confidence • Psychological Sx – o Feelings of guilt, worthlessness, hopelessness, irritability, restlessness or anxiety • Somatization – physical pain • Psychomotor retardation • Suicidal thoughts • Hallucinations/delusions o Nihilistic – if severe

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13
Q

Which patients are most likely to present with COGNTIIVE, BEHAVIOURAL and SOMATIC symptoms ?

A

children and elderly

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14
Q

How do you classify mild depression?

A

1 core + 2 other (for 2+ weeks) • None of the Sx should be present to an intense degree • The patient is usually distressed but should be able to continue with most activities

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15
Q

How do you classify moderate depression?

A

2 core + 3 (pref 4) other (for 2+ weeks) • Several symptoms are likely to be present to a marked degree but not essential if a wide variety of symptoms are present. • The patient is likely to have considerable difficulty in continuing with ordinary activities.

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16
Q

How do you classify severe depression?

A

3 core + 4 others • Note that if symptoms such as agitation or retardation are marked, the patient may be unwilling or unable to describe many symptoms in detail. • Symptoms should last for at least 2 weeks, but if the symptoms are particularly severe and of rapid onset, it may be justified to make the diagnosis after less than 2 weeks. It is very unlikely that the sufferer will be able to continue with ordinary activities, except to a very limited extent.

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17
Q

How do you classify Severe depressive disorder w/psychotic Sx ?

A

severe + delusions, hallucinations, or depressive stupor are present (entirely unresponsive, only responds to basal stimuli such as pain). • Delusions usually involve ideas of sin, poverty, or imminent disasters, responsibility for which may be assumed by the patient. • Auditory or olfactory hallucinations are usually of defamatory or accusatory voices or of rotting filth or decomposing flesh. Severe psychomotor retardation may progress to stupor. If required, delusions or hallucinations may be specified as mood-congruent or mood-incongruent.

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18
Q

What are your differentials for depression?

A

• Normal reaction to life event or situation or to fresh insight • Organic disorder • Psychiatric disorder - adjustment disorder, bereavement, SAD, dysthymia, cyclothymia, Bipolar, mixed affective states, schizoaffective disorder, schizophrenia, delusional disorder, GAD, OCD, PTSD, eating disorder.

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19
Q

What is dysthymia?

A

mild chronic depressive symptoms that are not sufficiently severe to meet criteria for mild depressive disorder. • Chronically depressed mood that occurs for most of the day, more days than not, for at least 2 years. • Sometimes regarded as a ‘depressive personality’. • If it develops into a depressive disorder, it is referred to as ‘double depression’. • Lifetime prevalence = 3%, chronic condition. • May respond to drug treatment and psychological treatments (but no firm evidence base for psychological treatments)

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20
Q

What investigation should you do in depression?

A

• Not routinelty requested unless another condition is suspected • Bloods o FBC, U+Es, LFTs, TFTs, ESR, Vitamin B12 and folate o Toxicology screen, antinuclear antibody o Dexamethasone suppression test (cortisol) o HIV test • Always risk assess of DSH (deliberate self-harm) and suicide risk

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21
Q

In an OSCE what 10 things must you ask in a depression history?

A
  1. Severity of depression - ask Sx 2. Risk of suicide/self-harm 3. Comorbid conditions assoc with depression a. Anxiety b. Alcohol and substance misuse c. Eating disorders d. Psychotic symptoms e. Dementia 4. Stresses contributing to development of depression a. Employment or financial worries b. Poor living conditions c. Interpersonal relationship problems d. Bereavement e. Illness 5. Past Hx of depression a. Including past experience and response to treatment 6. FH of depression 7. Sources of support that may be available to the individual a. Family, friends, counsellors, health visitors 8. Safeguarding concerns a. For children or vulnerable adults in care of someone with depression b. Or concerns for the patient themselves – are they vulnerable? 9. Screen for psychotic or manic Sx 10. Rate mood on scale of 1-10 a. Can you remember last time you felt happy/mood above 6/7? i. Depression can remember a time, personality disorder cant?
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22
Q

Overview of psychosocial management of depression

A

• Watchful waiting and assess within 2 weeks • Sleep hygiene, exercise, mindfulness, social interaction, support groups, art therapy • Identify and address current life difficulties • Low intensity psychological therapy e.g. counselling, advice, CBT based self-help, book prescription or online resources o Accessed through IAPT (improving access to psychological therapies) o Provided through primary care o Counselling for mild depression may just be listening to life problems and providing reassurance • If persistent, higher intensity psychological therapy (CBT 1st line) (6-8 sessions) including problem-solving therapy o Or IPT

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23
Q

Overview of biological management of depression

A

• Consider antidepressants only if other interventions haven’t worked, complicated medical/social problems, Hx of more severe depression, or persistent for 2 years, due to poor risk:benefit ratio. • 1st line SSRI • 2nd line = a different SSRI • Over 70% of depressive episodes will respond to an antidepressant but only 1/3 will respond to the first antidepressant they try (see whatever worked last time)

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24
Q

What are the indications for ECT?

A

o Severe depression and treatment resistant depression, psychotic features, pronounced psychomotor retardation or high suicidal risk. o Mania - uncommon and restricted to acute mania that is refractory to drug treatment or if drug treatment is contraindicated. o Schizophrenia - uncommon, restricted to acute episodes of schizophrenia in the presence of marked catatonia or affective symptoms.

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25
Q

What are relative contraindications to ECT?

A

potentially life-saving treatment and so it has no absolute contraindications. • Relative contraindications include:  Cardiovascular disease.  Raised intracranial pressure.  Dementing illnesses.  Epilepsy and other neurological disorders.  Cervical spine disease. - Old age and pregnancy are not contraindications to ECT

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26
Q

Briefly, how is ECT given?

A
  • The patient is given a standard anaesthetic such as propofol and a muscle relaxant such as suxamethionium and the seizure duration is monitored using an EEG recording. - A constant current, brief pulse ECT that is the voltage above the patient’s individual seizure threshold is used. - 2 treatments are given twice a week for up to 6 weeks (12 treatments).
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27
Q

What are the two types of ECT?

A

o Bilateral ECT  More effective but more side effects. o Unilateral ECT  (usually right sided)  less side effects but requires a higher dose of electricity to be as effective.

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28
Q

What are the potential side effects of ECT?

A

 SE of anaesthesia o Risk of mortality = 1 in 22,000 – similar to risk of death from anaesthesia alone  Headaches  Muscle aches  Nausea  Confusion o Temporary anterograde memory impairment o (but most patients report that they feel their memory improving as their depression lifts). o Mortality is similar to that of any minor surgical procedure and mostly results from cardiovascular complications such as arrhythmias.

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29
Q

When do you refer to secondary care in depression?

A

• Significant risk of self-harm, danger to others, psychotic symptoms or severe agitation – patients should be referred as an emergency • Significant depression with functional impairment persists despite adequate treatment in primary care setting. • When additional community support from community mental health team or day hospital staff is required. • Indication for specialist psychological treatment

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30
Q

photo of biopsychosocial interventions in depression

A
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31
Q

What is CBT?

A
  • Identification of cognitive distortions and associated behaviours.
  • Cognitive restructuring and behavioural modifications.
  • Talking therapy, homework and behavioural experiments
  • Use diaries to monitor & identify problematic thoughts. Perform experiments – go to the party to see what happens – see if exercise lifts your mood?
  • Help patient to learn to think in more helpful ways
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32
Q

What causes of depression is CBT helpful in?

A
  • “Cognitive triad”:
    • negative view of self, world and future
  • “Cognitive biases”
    • faulty thinking patterns:
      1. Catastrophising: My husband is home late. He must have had an accident
      2. Jumping to conclusions: That girl is laughing. She must be laughing at me.
      3. All or nothing/black - white thinking: Unless I win it’s not worth doing
      4. Personalising: It’s all my fault
      5. Generalising: One bad thing
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33
Q

Give an overview of low intensity psychological interventions.

A
  • Advice – provide patient with information about good sleep hygiene and importance of regular exercise
  • CBT based self-help – There are numerous CBT-style self-help books or computer packages that show some efficacy. The patient usually receives 6-8 sessions delivered by trained practitioner, where they work through book with patient over 9-12 weeks.
  • Structured group-based physical activity programme – usually consists of 2-3 sessions per week of moderate duration (1 hour) over 10-14 week period.
  • Group CBT – 10-12 meetings of 8-10 participants for 12-16 weeks
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34
Q

Give an overview of high intensity psychosocial interventions.

A
  • CBT – 16-20 sessions over 3-4 months (consider doing 2 sessions/week in first 2-3 weeks; follow-up sessions are 3-4 over the following 3-6 months)
    • It is not the event that causes the problem but how we appraise it.
    • See below
  • IPT – 16-20 over 3-4 months
    • main focus of IPT is on difficulties in relating to others and helping the person to identify how they are feeling and behaving in their relationships.
    • When a person is able to interact more effectively, their psychological symptoms often improve.
    • Looks at conflicts, life changes, grief & loss, relationship problems
  • Behavioural activation – 16-20 sessions over 3-4 months (evidence less robust than for CBT and IPT)
    • Based on idea that when we are depressed we stop doing things we enjoy and isolate ourselves à perpetuating depression
    • Involves encouraging patients to do things (e.g. walking the dog) before they feel happy in order to stimulate happiness
  • Behavioural couples therapy (not commonly used) – 15-20 sessions over 5-6 months
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35
Q

ECT councelling OSCE (long)

A
  • INTRO
    • Wash hands, introduce self, confirm name/DOB
    • Explain reason for consultation
      • “I understand you have a diagnosis of depression and have not felt any benefit from several antidepressant medications. I am here today to discuss an alternative treatment called electroconvulsive therapy, or ECT, that we feel may be beneficial”
  • ICE
    • Ideas
      • “Have you heard of ECT before? What do you know about it?”
        • be prepared for negative comments and misconceptions due to media portrayal
    • Concerns
      • “What is it that concerns you the most?”
        • offer to address these concerns
    • Expectations
      • “I would like to give you some more information about ECT. I will discuss why it is used, what happens during treatment, and the benefits and risks of treatment. If you have any questions at any point please don’t hesitate to ask. Is there anything else you would like me to discuss today?”
  • What is ECT?
    • “ECT is a psychiatric treatment where a patient is put to sleep and a small amount of electrical current is directed towards the brain. This will result in a small and controlled seizure, lasting a few seconds. This is thought to alter the chemical imbalances in the brain, improving illness.”
      • Used in:
        • severe depression that is unresponsive to treatment
        • severe depression where there is serious risk to the patient’s life e.g. suicide
        • catatonia
  • Benefits
    • “ECT is one of the most effective treatments that exists for severe depression and around 80% of people improve as a result. Improvement is also seen faster than in other therapies, with most people beginning to feel better within 2 weeks.”
  • Treatment length
    • “A course usually consists of 6-12 treatments, with two treatments a week. So in total between 3-6 weeks. If no improvement is seen after 6 weeks, the treatment is stopped”
  • ECT procedure
    • Before
      • Pre-op assessment carried out by an anaesthetist
      • Patient must be NBM for 6 hours before (same as an operation)
      • Done in an ECT suite (in hospital – usually psychiatric hospital)
      • Short acting anaesthetic and a muscle-relaxant is given so patient is asleep and muscles are relaxed to prevent injury during minor seizure
      • The patient is attached to an EEG monitor to monitor their brain activity
    • During
      • The procedure is carried out by a psychiatrist and can be done bilaterally or unilaterally
        • On both sides of brain – which is more effective but slightly more SE
        • Or just one side of the brain (non-dominant) – less effective – require more treatments
        • Small amount of energy is directed through electrodes, towards the brain
          • 5 seconds of energy
          • nothing inside brain! Just electrodes, similar to the ones put on your chest when you have an ECG!
        • produces a controlled seizure
          • lasting around 20 seconds
          • this may result in some fluttering of eyelids or minor muscle contractions but is often not visible
    • After
      • You will wake up and have no memory of the treatment (like you have been asleep)
        • There will be a team of doctors and nurses to look after you in the recovery room
      • You will probably not be well enough to drive home
  • Side effects
    • Usually mild and most patients return to normal cognitive abilities after treatment ends
    • Commonly – short-term memory loss (long-term = rare), retrograde amnesia, headache, brief confusion/drowsiness after anaesthetic
  • Risks
    • Main risk is from anaesthetic. Same as any other operation
  • Summarise
    • Give summary, ask if they have any questions, “I understand this is a lot of information to take in so here is a leaflet that outlines the main things we have discussed today. Take some time to have a think about this option and I can book a follow-up appointment for further discussion and I can arrange a visit to the ECT suite if you would like to see where your treatment could take place”
    • Thank patient
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36
Q

define assisted suicide

A
  • the making available to a person of the means to end his or her life
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37
Q

define voluntary euthanasia

A
  • the deliberate ending of the life of another person who has requested it and is physically unable to commit suicide.
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38
Q

define attempted suicide

A
  • intentionally trying to kill oneself but failing to do so.
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39
Q

define parasuicide

A

an act that looks like suicide but that does not result in death.

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40
Q

what is self harm most commonly caused by (aeitiology)?

A
  • express and relieve bottled-up anger or tension
  • feel more in control of a seemingly desperate life situation
  • punish oneself for being a ‘bad person’
  • combat feelings of numbness and deadness and feel more ‘connected’ and alive.
  • About 40% of cases have a major psychiatric disorder excluding personality disorder, alcohol misuse, and substance misuse, and about 25% report high suicidal intent on the Beck Suicide Intent Scale
  • More common in women à 170,000 cases for both men and women
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41
Q

what percentage of DSH cases repeat in first year?

A

25%

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42
Q

What questions should you ask in a risk assessment in DSH?

A
  • Have you ever felt that life is not worth living?
  • How long do these feelings last?
  • Do they come and go or are they there all the time?
  • Can you manage the feelings?
  • Have you thought about acting on the feelings?
  • Have you made any plans?
  • How close have you come to acting on the thoughts?
  • What stopped you doing anything?
  • Have you tried anything before?
  • How can I trust that you will be able to keep yourself safe?
    • If the feelings of self-harm are pervasive and there is an urge to act on them and plans have been made, the risk is high.
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43
Q

What questions should you ask about before the DSH?

A
  • Obtain information about the events leading to the act of DSH. It is helpful to know if any single incident (e.g. argument with partner or parents) led to distress which in turn led to impulsive DSH.
  • It is of greater concern in terms of risk if the person had thoughts of self-harm for a period of time and cumulative factors led them to act on these feelings.
  • Was it planned?
44
Q

What question should you ask about during the DSH?

A
  • The means (eg. Pills – what type/how much) and the effect the individual thought would result.
  • Did they inform anyone/hide a note? Take action to prevent being found? How were they found/make it to hospital?
  • Were they drinking any alcohol?
  • Did they leave people money/write a will?
  • What did you think was going to happen? Did you think you would die?
    • If the patient thought it would be fatal there is greater intent.
    • The seriousness may not correlate with the nature of the attempt, more important is what the patient thought would happen.
      • If a patient has DSH and did not expect to be found, this may indicate a greater intent.
45
Q

What question should you ask about after the DSH?

A
  • It is important to establish what happened after the attempt.
  • Many patients will almost immediately regret the incident and/or be overwhelmed by guilt, panic or fear, especially if the act was impulsive.
    • How did you feel?
      • Some may be very distressed that they have been found out.

There may be anger and hostility and it is likely that for many there is ambivalence about the situation in which they find themselves.

46
Q

What is the management of DSH?

A
  • The first priority is to ensure that they are medically fit and well (medical treatment will be determined by the nature and severity of the method of DSH.
  • Unless the person is considered to be at high risk of a further attempt at suicide or is insisting on being discharged, assessment of DSH itself is best left for a period of time, commonly until the following day, as admission with DSH is often in the evening or at night.
  • This may allow what can be an unduly emotional situation to settle and facilitate a clearer assessment of the underlying mental state and level of on-going risk.
  • In cases of self-poisoning or intoxication, it gives a chance for the effects of the drugs or alcohol to wear off.
47
Q

what are some good coping strategies/ distraction techniques to talk about?

A
  • A useful coping strategy is to find someone you trust such as a friend, relative, or teacher, and to be with them and share your feelings with them. If no one is available or there is no one you feel comfortable with, there are a number of emergency telephone lines that you can ring at any time.
  • Engaging in creative activities such as writing, drawing, or playing a musical instrument can also take your mind off thoughts of harming yourself, and additionally help you to express your feelings and understand them better.
  • Other coping strategies include reading a good book, listening to classical music, watching a comedy or nature programme, or even just cooking a meal or going out to the shops.
48
Q

What should you avoid in DSH?

A
  • alcohol and drugs as these can make your behaviour more impulsive, and significantly increase your likelihood of harming yourself.
49
Q

What other things can you do to minimise the risks in self harm?

A
  • holding ice cubes in your palm and attempting to crush them, fitting an elastic band around your wrist and flicking it, or plucking the hairs on your arms and legs.
50
Q

What should you do after DSH?

A
  • If you have harmed yourself and are in pain or unable to control the bleeding, or if you have taken an overdose of any kind or size, call 999 immediately, or get a relative or friend to take you to Accident and Emergency as soon as possible. Going to Accident and Emergency not only enables you to get medical treatment, but also gives you an opportunity to spend time with someone and talk to him or her about your feelings.
  • Once things are more settled, consider getting yourself referred for a talking treatment such as counselling or CBT. This can give you the opportunity to talk through your feelings in a safe and supportive environment, ad to better understand why you sometimes feel the way you do. It can also help you to identify solutions to your problems, as well as alternative strategies for coping with them.
  • Joining a local support group enables you to meet other people with similar problems to yours, who are likely to accept you and understand you, and with whom you may feel better able to share your feelings.
    • However be aware of joining unmonitored online forums and chat groups which are open to all which can sometimes leave you feeling even worse than before.
51
Q

how many suicides are there each year?

A

5500 - one of the leading causes of death

52
Q

who is suicide most common in?

A
  • Completed suicide is 3x more common in men - use more violent and effective means or they find it difficult to engage with help
  • Men in 15-44 highest risk of suicide
53
Q

what are the most common methods for suicide?

A
  • Hanging is most common British men
  • Self-poisoning is most common in British women
54
Q

what are the risk factors for suicide?

A
  • Sociodemographic
    • Male sex 3x
    • Age (25-44)
  • Clinical
    • Hx of DSH
    • Mental disorder
    • Physical illness
    • FH
55
Q

How do you assess risk in suicide?

A
  • Ask about the history of the current episode of DSH (if any) to determine the degree of suicidal intent (higher or lower intent).
  • Ask about the risk factors for suicide.
  • Examine the mental state, especially current mood.
  • Assess the current situation
  • Assess suicidal risk/Does the patient have any protective factors?
56
Q

What questions can you ask to ask about current episode of DSH (if any) to determine the degree of suicidal intent?

A
  • What was the precipitant for the attempt? (Serious precipitant/trivial precipitant)
  • Was it planned? (Planned/unplanned)
  • What was the method of DSH? (Violent method/non-violent method)
  • Did the patient leave a suicide note (Suicide note/no suicide note)
  • Were they alone? (Alone/not alone)
  • Were they intoxicated? (Depends on individual case)
  • Did they take any precautions against discovery? (Precautions/no precautions).
  • Did they seek help after the attempt (Did not seek help/did seek help)
  • How did they feel when they were found? (Angry or disappointed/relieved)
57
Q

how do you ask about the current situation in suicide patients?

A
  • Ask if the patient is going to be returning to the same situation i.e has anything changed?
  • Ask about outlook on the future.
  • Ask about current suicidal intent. Has he or she made any plans?
  • Ask about homicidal intent.
58
Q

What is the management plan in suicide?

A
  • Dependent on assessment of risk.
  • In most cases the patient can be discharged back into the community, particularly if they have a strong social support network upon which they can rely upon.
  • In some cases, a discharge can be facilitated by the Crisis Team, which can step in to provide the patient with additional support.
  • The patient should also be referred to his or her GP for follow up and in some cases, also to the local community mental health team.
  • If the patient is already under the care of the local community mental health team, they should be referred to their care coordinator as soon as possible, preferably by telephone or answerphone.
59
Q

What are good phrases for OSCE station on suicide?

A
  • Remember whatever thoughts you are having and however bad you are feeling, you have not always felt this way and you will not always feel this way”
  • “Never underestimate the importance of a good night’s sleep, sometimes things can seem very different when you wake up”
  • “Try to take precautions against harming yourself by removing possible dangerous objects from your home or making them difficult to access”
  • “Is there anyone who can stay with you at the moment?”
  • “If you were to have feelings of hurting yourself, is there anyone you feel you could call? Would you feel more comfortable speaking to someone anonymous, who didn’t know who you were?
    • Can provide number of Samaritans or community crisis team etc
  • Create a SAFETY PLAN for when you have feelings of hurting yourself
    • What actions will you take to prevent harm?
      • Remove objects, call a friend, avoid drugs and alcohol
  • Also write a list of all the POSITIVE things about yourself and your life. Keep it with you to read when you feel low
60
Q

What is maternity blues and how common is it?

A

minor mood disturbance occurring in about 50% of mothers (especially primiparous mothers) on the third or fourth day postpartum. Clinical features include tearfulness, irritability, and lability of affect. The condition usually resolves in a matter of days and no specific treatment needed, other than explanation and reassurance.

61
Q

what is postnatal depression and how common is it?

A

10–15% of mothers in the first month postpartum. It is more common if the mother has a past psychiatric history or lacks social support. Tiredness, irritability, and anxiety are often more prominent than depressed mood, and the baby may be at short-term risk of neglect and harm. Management involves explanation and reassurance, and, in some cases, treatment as for depression (antidepressants or psychological treatments). If hospital admission is required, it should be to a mother-and-baby unit so as not to compromise bonding between the pair.

62
Q

What scoring system do you use in postnatal depression?

A

The Edinburgh Postnatal Depression Scale = 10 item questionnaire (maximum score = 30, score >13 suggests depressive illness).

63
Q

Which antidepressant is recommended in postnatal depression?

A

Paroxetine is recommended in SIGN guidelines because of low milk: plasma ratio.

64
Q

What is peurpural psychosis and how common is it?

A

0.2% of mothers at about 7-14 days post-partum. It is more common in primiparous mothers and mothers with a psychiatric history or family history of mental disorder.

the mother may harbour delusions about the baby, for example that it is abnormal or evil. This can put the baby at a high risk of neglect and harm. Hospital admission is often required and treatment often involves antidepressants and antipsychotics.

65
Q

If you get peurpural psychosis once what are the stats for recurrence of it and other psych conditions and how is this risk reduced?

A

Risk of recurrence of PP = 30-60%, risk of developing any other psychiatric illness = 75%, risk of reccurent PP can be reduced with lithium or oestrogen therapy

66
Q

In a suicide/DSH risk assessment what questions should you ask about the current episode? (19)

A

4 Was there a precipitant? 5 Was it planned or impulsive? 6 Did the patient carry out any final acts? 7 Were any precautions taken against discovery? 8 Was the patient under the influence of alcohol or drugs? 9 What method of self-harm was involved? 10 Was the patient alone? 11 Where were they when they self-harmed? 12 Did they think the self-harm would kill them? 13 What did the patient do after self-harm? 14 Did the patient make anyone aware of the self-harm afterwards? 15 How did the patient end up in hospital? 16 How did they feel when help arrived? 17 How does the patient feel about the suicide attempt now? Do they regret it? 18 What is the patient’s current mood? 19 Does the patient still feel suicidal? 20 If the patient went home today, what would they do? 21 If the patient felt like this again, how might they manage it differently? 22 What would prevent the patient from doing this in the future? 23 Will the patient accept treatment?

67
Q

What specific overdose questions should you ask in a suicide risk assessment?

A

What medications/drugs were involved? 25 How much of the medications/drugs did the patient take? 26 Where did they get the medications/drugs from? 27 Did they take the medications/drugs with anything else? (e.g. alcohol) 28 What did the patient think taking the overdose would do?

68
Q

What specific questions should you ask about cutting in a suicide risk assessment?

A

Where are the cuts? 30 How many cuts are there? 31 How deep are the cuts? 32 How did the patient feel when they were cutting themselves? 33 What was the patient hoping the cutting would do?

69
Q

What else should you do in a suicide risk assessment?

A

SCREEN FOR OTHER MENTAL HEALTH ISSUES 34 Depression (low mood / anhedonia / fatigue) 35 Psychosis 36 Alcohol dependency 37 Anorexia nervosa

PREVIOUS EPISODES OF SELF-HARM 38 Has the patient carried out self-harm in the past? 39 What methods of self-harm were involved? 40 Did they gain any help as a result of their self-harm?

PAST PSYCHIATRIC HISTORY 41 Does the patient have any psychiatric diagnoses? 42 Has the patient ever been admitted to hospital due to a psychiatric problem?

PAST MEDICAL HISTORY 43 Any recent medical illness that has impacted on mood? 44 Long term medical conditions

DRUG HISTORY 45 Take a thorough drug history (including over the counter medications)

FAMILY HISTORY 46 Have any family members attempted or completed suicide? 47 Do any first-degree relatives have a psychiatric illness?

SOCIAL HISTORY 48 Living situation (Where do they live? / Who do they live with?) 49 Support network 50 Does the patient have any dependants? 51 Occupation 52 Alcohol intake 53 Recreational drug use

70
Q

what is the prevalence of mania and mean age?

A
  • Prevalence = 1%
  • Mean age = 21
71
Q

what is the onset of mania like?

A

abrupt

72
Q

what are the important risks in manic patients?

A
  • Impulsive behaviour, pleasure seeking, gambling
  • Dangerous/casual sex
  • Self-neglect - Lack of sleep, eating, drinking
73
Q

what is hypomania and what are the Sx?

A
  • increased talkability, sociability overfamiliarity, increased sexual energy and decreased need for sleep
    • but not present such that they lead to severe disruption or result in social rejection
  • some people enjoy being hypomanic à get lots done
  • irritable, conceit and boorish behaviour may take the place of the more usually euphoric sociability
74
Q

What are the differential diagnosis for mania?

A
  • Psychiatric Disorders - mixed affective states (simultaneous manic and depressive symptoms), schizoaffective disorder, schizophrenia, cyclothymic disorder, anorexia (weight loss), ADHD, drugs inc. alcohol, amphetamines, cocaine, hallucinogens, antidepressants, L-Dopa and steroids
  • Medical/neurological disorders - organic brain disease of the frontal lobes (CVA, MS, intracranial tumours, epilepsy, AIDS, neurosyphilis), endocrine disorders (hyperthyroidism, Cushing’s), SLE, sleep deprivation.
75
Q

What are the ICD 10 criteria for Hypomania?

A
  • mild elevation of mood (or irritability)
  • increased energy
  • not to the level of severe disruption
  • duration of at least several days on end - usually 4
  • no psychotic symptoms
76
Q

What are the ICD 10 criteria for Mania?

A
  • elated mood (occasionally predominant irritability)
  • increased energy
  • plus
    • decreased need for sleep, grandiosity, excessive optimism, pressure of speech, loss of social inhibitions, inability to sustain attention, impulsivity, extravagance, aggression
  • perceptual disorders may occur à appreciation of colours as especially vivid, subjective hyperacusis (sensitive to sound) and preoccupation with surfaces/textures
  • episode of at least 1 week duration
  • can go on for a long time
  • severely disrupts work and/or social activities
  • psychotic symptoms may be preent
    • hallucinations
    • excessive motor activity
      • may be aggressive
    • flight of ideas so extreme that patient is incomprehensible

if no hallucinations, even if still delusions its mania without psychosis

77
Q

Describe a typical MSE for a manic patient

A
  • Appearance
  • Flamboyant clothing, unusual combination of clothing, heavy make-up and jewellery, inappropriate accessories e.g. sunglasses, hats, giant crucifix
  • Behaviour
  • Hyperactive, entertaining, flirtatious, hypervigilant, assertive, aggressive.
  • Speech
  • Pressured speech, neologisms, clang associations.
  • Mood/affect
  • Euphoric, irritable, labile
  • typically euphoric, optimistic, self-confident and grandiose
    • but they may also be irritable or tearful with rapid and unexpected shifts from one extreme to another.
  • Thought
  • Content
    • optimistic, self-confident, grandiose,
    • mood-congruent delusions
      • often that they have special status, purpose or abilities
    • less commonly mood-incongruent delusions.
  • Form
    • flight of ideas (thoughts racing through head)
    • loosening of associations
    • tangentiality
      • tends to digress readily from one topic under discussion to other topics that arise in the course of associations
    • circumstantiality
      • excessive, unuseful detail before answering original question
      • focus of conversation drifts away but then returns
  • Perception
  • Hallucinations
  • Cognition
  • Poor concentration but intact memory and abstract thinking.
  • Will typically have many grand plans that they initiate but lose interest in and never complete
  • Insight
  • Very poor insight.
    • Or like ACMH pt, aware they having manic episode but believe only they can cure it
78
Q

What is your management plan in mania?

A
  • Intitial treatment = antipsychotic
    • Allow some time before introducing mood stabiliser
    • If mood stabiliser is started during a manic episode when patient cannot participate in decision may get issues with long term compliance
    • Continued until full remission
  • Other drugs potentially used
    • Lorazepam – fast acting sedative
    • Zopiclone – sleeping difficulties particularly in hypomania stages
    • Any anti-depressants should be rapidly tapered off and stopped - These can precipitate manic episodes! And make them more difficult to manage
  • Psychological treatments
    • Education
    • Advice about lifestyle – sleep deprivation, substane misuse
    • Identification of early signs of relapse
79
Q

what is the course and prognosis for an episode of mania?

A

average length of a manic episode is 4 months

80
Q

How often is lithium effective in mania and how long should it be taken for?

A

75% but takes several days to have an effect.

Lithium should only be started if there is a clear intention to continue it for at least three years as poor compliance and intermittent treatment may lead to rebound mania

81
Q

why do you have to be careful with lithium?

A
  • Lithium is eliminated unchanged by the kidney and its half-life is related to renal function.
  • It is therefore important to check renal function before starting the drug.
  • if kidney function goes then can get lithium toxicity
82
Q

what is the therapeutic range for lithium?

A
  • 0.4 – 1.0 mmol/L (0.8-1.0 mmol/L for acute treatment of mania).
83
Q

what are the Sx of lithium toxicity?

A
  • occurs beyond 1.5 mmol/L and is characterised by GI disturbances (inc. anorexia, nausea, vomiting, diarrhoea), nystagmus, coarse tremor, dysarthria, ataxia and in severe cases LOC, seizures and death.
84
Q

How should lithium be monitored?

A
  • Serum levels should be taken at 12 hours post dose (usually in the morning) and monitored at 5-7 day intervals until the patient is stabilised, and at 3-4 monthly intervals thereafter.
  • Renal and thyroid function should also be monitored.
85
Q

What are the short term side effects of lithium?

A
  • Fine tremor
  • GI disturbances
  • Muscle weakens
  • Polyuria
  • Polydipsia
  • Stuff nose, metallic taste in the mouth.
86
Q

What are the long term side effects of lithium?

A
  • Weight gain
  • Oedema
  • Goitre and hypothyroidism (check TFTs before starting and monitor every 6 months)
  • Hyperparathyroidism
  • Nephrogenic diabetes insipidus
  • Irreversible renal damage (check U&Es before starting therapy and monitor every 6 months).
  • Cardiotoxicity (perform ECG before starting therapy. During therapy, lithium cardiotoxicity manifests as T-wave flattening).
87
Q

what cautions are there in pregnant/breastfeeding women?

A
  • Lithium is teratogenic and the risk of CV malformations in the foetus is 0.5-1 per 1000 live births (most commonly Epstein anomaly  downward displacement of the tricuspid valve into the right ventricle).
  • Breast feeding is not advisable as lithium is excreted into breast milk.
88
Q

How should you stop lithium?

A
  • If not tolerated, Lithium can be stopped abruptly but it should only be stopped gradually (over two or three months) following successful long-term treatment as stopping it abruptly can precipitate an episode of rebound mania.
89
Q

What advice should you give to someone taking lithium?

A
  • Drink plenty of fluids
  • Avoid changes in salt intake
  • Dehydration and sodium depletion can precipitate lithium toxicity.
90
Q

What are some common interactions with lithium?

A
  • Diuretics (esp. thiazides) - sodium depletion increases lithium levels resulting in lithium toxicity.
  • Carbamazepine - can result in neurotoxicity, prefer valproate.
  • NSAIDs - most NSAIDs can increase lithium levels, resulting in lithium toxicity.
  • ACEi - lithium toxicity
91
Q

What counts as bipolar afective disorder?

A

Four or more episodes of depression/mania/hypomania

  • Mania + mania = BAD
  • Mania + hypomania = BAD
  • Mania + depression = BAD
  • Hypomania + depression = BAD
  • Depression + depression = recurrent depressive disorder
92
Q

What is the aetiology of BAD?

A
  • GENETICS
    • 1st degree relative = 10% risk
  • NEUROCHEMICAL
    • Monoamine hypothesis
      • Mania caused by increased NA, serotonin & dopamine?
  • LIFE EVENTS
    • Severe stress and disruption can provoke 1st episode
  • Peak in late spring/summer and in post-partum period
93
Q

What is the epidemiology of BAD?

A
  • Lifetime risk = 0.3-1.5%
  • Races and sexes equally affected
  • Mean age of onset = 21
    • 1st episode of mania >50 years suggests organic brain disease or endocrine/metabolic disorder
94
Q

What is cyclothymia?

A
  • Mild chronic BAD
  • Not sufficient to meet diagnostic criteria
  • Onset = early adulthood
  • Common in relatives of BAD
  • May progress to BAD
95
Q

What are your differentials for BAD?

A
  • Medical conditions - Hypothyroidism, Cushing’s, MS, Epilepsy, CVA, Cerebral tumours, head injuries.
  • Substance misuse - alcohol, psychostimulants, cannabis.
  • Medication - corticosteroids, L-dopa, dopamine agonists, thyroid hormones, MAOI and TCAs.
96
Q

What is the general management of BAD?

A
  • The choice of medication in BAD is largely determined by current symptoms.
  • Manic episode - antipsychotic
  • Depressive episode - antidepressant, with a mood stabiliser to avoid manic switch (over treatment into mania).
  • In rare instances a depressive episode may be so severe or unresponsive to medication that ECT may be indicated.
  • In the long term a patient should be prescribed a mood stabiliser to prevent further relapses into mania and depression.
97
Q

Why are anticonvulsants used in BAD and which ones?

A
  • The use of anticonvulsants (principally valproate and more recently lamotrigine) in the prophylaxis of BAD is increasing.
  • Anticonvulsants enhance the action of the inhibitory neurotransmitter gamma aminobutyric acid (GABA) but their precise mode of action in the prophylaxis of BAD is as yet unclear.
98
Q

Why is valproate used in BAD?

A
  • used alone or as an adjunct to lithium or other drugs in the treatment and prophylaxis of BAD.
  • Compared to lithium it has a similar efficacy but a quicker onset of action and is of particular benefit in rapid cycling BAD.
  • Although valproate can have a number of SE it is often better tolerated than lithium, particularly if lithium levels need to be maintained above 0.8 mmol/L.
    • May have better adherence than lithium
99
Q

What are the negative impacts of Valproate in BAD?

A
  • SE = nausea, tremor, sedation, weight gain, alopecia (regrowth may be curly), blood dyscrasias (low platelets), hepatoxicity and pancreatitis.
  • Valproate can cause NTD and other malformations in the foetus and for these reasons it should be avoided in women of child bearing age.
    • Also long term use may cause ovarian cysts - infertility
  • It is important to check blood cell counts and LFTs before valproate is started and to continue monitoring these at 6-12 month intervals.
100
Q

Why is Lamotrigine used in BAD?

A
  • is more effective against relapses of depression than it is against relapses of mania and it can be used in the treatment of relapses of bipolar depression and in the prophylaxis of BAD.
  • Compared with lithium and valproate, lamotrigine has fewer SE and does not usually require long term monitoring with blood tests.
101
Q

What are the side effects of Lamotrigine?

A
  • N&V, headaches, dizziness, clumsiness, blurred vision and dipolopia, flu like symptoms, sedation, insomnia, skin rash and severe skin reactions.
102
Q

When is carbamazepine used in BAD?

A
  • generally used as a second or third line drug in the prophylaxis of BAD and is thought to be of particular value in treatment resistant cases and in rapid cycling.
103
Q

What are the negative impacts of Carbamazepine?

A
  • SE = nausea, headaches, dizziness, sedation, diplopia, ataxia, skin rashes, rare but potentially fatal blood dyscrasias (agranulocytosis) and hepatotoxicity.
  • Bloods should be monitored regularly for leukopaenia, hyponatraemia and raised LFTs.
  • Carbamezipine can cause spina bifida if used in pregnancy but it is not excreted in breast milk and so can be used by breast feeding mothers.
  • As it is a strong inducer of hepatic microsomal enzymes as it increases the metabolism of a number of other drugs.
104
Q

What is the course and prognosis in BAD?

A
  • The average length of a manic episode is about 4 months.
  • After a first manic episode, about 90% of patients experience further manic and depressive episodes and the inter-episode interval tends to become progressively shorter.
  • The prognosis is therefore quite poor but it is more so in rapid cycling and less so in bipolar II.
  • About 10% go on to commit suicide, but the rate of attempted suicide is much higher.
105
Q
A

psychiatry (12 decks)

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