Clinical Handbook - Main Conditions 1 Flashcards
What psychiatric support is available in the community?
CMHT- MDT
Crisis resolution team - psych emergencies, 24/7, short term interventions to prevent admission
Outreach team - for chroncially unwell patients, community nurses can visit multiple times a week
Care programme approach (CPA) - help after inpatient admission once discharged
Early intervention in psychosis team - for under 35s in first episode
List the key members of the psych MDT
Psychiatrist
Community psychiatric nurse (CPN)
Occupational therapist
Social worker
Clinical psychologist
Secretary/Administrator
Define a delusion. How would you ask a patient about it?
Fixed false beliefs, which are firmly held despite evidence to the contrary and go against the individual’s normal social and cultural belief system.
‘Do you have any personal beliefs that others find strange?’
What is a grandiose delusion?
a false fixed belief that one has special powers, is talented, wealthy or important. Grandiose delusions may be religious in nature, e.g. one is chosen by God.
What is a persecutory delusion?
a false fixed belief that other people are conspiring against them in order to inflict harm or destroy their reputation.
what are delusions of reference?
a false fixed belief that random events, objects or the behaviour of others, have a special significance to oneself.
What are nihilistic delusions?
a false fixed belief that they are worthless or dying. In severe cases they claim that everything is non-existent including themselves (Cotard’s syndrome)
What are obsessive thoughts? How would you ask a patient about them?
Distressing thoughts that enter the mind despite the patient’s effort to resist them. This is a feature of obsessive–compulsive disorder.
‘Do certain ideas or images keep entering your mind, even when you try to keep them out?’
What are preoccupations / overvalued ideas?
Strongly held beliefs which are particularly important in four disorders: depressive, anxiety, eating and sexual. Preoccupations differ from obsessions in that they can be put out of the mind with effort, whereas obsessions repeatedly enter the patient’s mind despite their attempted resistance.
What is loosening of association?
loss of the normal structure of thinking, occurs mainly in schizophrenia.
There are three types:
(1) Derailment of thought (Knight’s move thinking): unrelated or only remotely related ideas.
(2) Tangential thinking: The person diverts from the original train of thought but never returns to it.
(3) Word salad: speech that is reduced to a senseless repetition of sounds and phrases
Give 3 abnormalities of thought flow
Acceleration: can manifest as: (1) Pressured thought and (2) Flight of ideas, often occurs in manic illness.
Retardation: Slow speed of thinking which occurs in depressive illnesses.
Thought blocking: Refers to the sudden cessation of flow of thoughts. The previous idea may then be taken up again or replaced by another thought, mainly occurs in schizophrenia.
How would you ask a patient about passivity phenomena?
‘Do you ever feel that your mood or actions are being controlled by someone or something else?’
What are the different types of auditory hallucinations?
Second person – voice(s) directly addressing the patient
Third person – voices talking amongst themselves, or about the patient
Running commentary – voice(s) giving account of what the patient is doing
What are the different types of hallucinations that you should ask about in a psychotic patient ?
visual
auditory
olfactory (unpleasant smell)
gustatory
somatic (unusual sensation e..g insects crawling on skin)
Hallucinations may be confused with the following:
- Pseudohallucination: Would include the experience of hearing voices inside your head, not true external hallucinations.
- Illusion: A false mental image produced by misinterpretation of an external stimulus. Often occurs in normal people.
- Depersonalization (feature of neurosis): Feeling of detachment from the normal sense of self. ‘Do you ever feel unreal or that a part of your body is unreal?’
- Derealization (feature of neurosis): Feeling of unreality in which the environment and people are experienced as unreal.
Causes of visual hallucinations?
more characteristic of an organic brain disease or substance misuse (they are rarer in schizophrenia)
Causes of secondary person auditory hallucinations?
schizophrenia, severe depression with psychosis and mania with psychosis
Define mood
Refers to a patient’s sustained, experienced emotional state over a period of time. It may be reported subjectively (in the patient’s own words) or objectively as dysthymic (low), euthymic (normal) or elated (elevated).
Define affect
Refers to the transient flow of emotion in response to a particular stimulus
What are the different mood disorders identified in the ICD-10 classification?
- Manic episode: including hypomania, mania without psychotic symptoms and mania with psychotic symptoms
- Bipolar affective disorder
- Depressive episode: including mild, moderate, severe and severe with psychotic symptoms
- Recurrent depressive disorder
- Persistent mood disorders: cyclothymia, dysthymia.
- Other mood disorders
- Unspecified mood disorder
How can mood disorders be classfied?
- Primary mood disorder: a mood disorder that does not result from another medical or psychiatric condition, either unipolar (depressive disorder, dysthymia) or bipolar (bipolar affective disorder, cyclothymia)
- Secondary mood disorder: a mood disorder that results from another medical or psychiatric condition.
Define depressive disorder
an affective mood disorder characterized by a persistent low mood, loss of pleasure and/or lack of energy accompanied by emotional, cognitive and biological symptoms
Risk factors for depression?
Risk factor mnemonic ‘FF, AA, PP, SS’:
Female/Family history
Alcohol/Adverse events
Past depression/Physical co-morbidities
↓ Social support/↓ Socioeconomic status
What are the core symptoms of depression?
low mood (at least 2 weeks)
anhedonia
anergia (low energy)
Give some biological sxs of depression
Diurnal Variation in Mood (DVM) : The patient’s low mood is more pronounced during certain times of the day, usually in the morning.
Early Morning Wakening (EMW) : waking up 2 hours earlier than they would premorbidly
Loss of libido
Psychomotor retardation
Changes in weight and appetite
What is Beck’s cognitive triad (depression)?
three types of negative though
The triad involves negative thoughts about: the self (i.e. the patient feels worthless), the world/environment (i.e. the world is unfair), and the future (i.e. the future is hopeless).
Outline the ICD-10 classification of depression
Mild depression = 2 core symptoms + 2 other symptoms
Moderate depression = 2 core symptoms + 3–4 other symptoms
Severe depression = 3 core symptoms + ≥4 other symptoms
How would you investigate for depression?
Diagnostic questionnaires: e.g. PHQ-9, HADS and Beck’s depression inventory
Blood tests: FBC (e.g. to check for anaemia), TFTs (hypothyroidism), U&Es, LFTs, calcium levels (biochemical abnormalities may cause physical symptoms which can mimic some depressive symptoms), glucose (diabetes can cause anergia).
Imaging: MRI or CT scan may be required where presentation or examination is atypical or where there are features suspicious of an intracranial lesion e.g. unexplained headache or personality change.
DDx for depression?
Other mood disorders: Bipolar affective disorder, recurrent depressive disorder, SAD, PMDD, dysthymia , postnatal depression
Secondary to physical condition e.g. hypothyroidism
Secondary to psychoactive substance abuse
Secondary to other psychiatric disorders: Psychotic disorders, anxiety disorders, adjustment disorder, personality disorder, eating disorders, dementia.
Normal bereavement
Outline the mx of mild-moderate depression
Watchful waiting: reassess the patient again in 2 weeks
Antidepressants: Not recommended as a first-line therapy unless: (1) depression has lasted a long time; (2) past history of moderate–severe depression; (3) failure of other interventions; (4) or the depression complicates the care of other physical health problems
Self-help programmes
Computerized cognitive behavioural therapy (CBT): educating them about depression and challenging negative thoughts
Physical activity programme
Outline the mx of moderate- severe depression
Psychiatry referral: Indicated if: (1) suicide risk is high; (2) depression is severe; (3) recurrent depression; (4) or unresponsive to initial treatment
Mental Health Act may become necessary in some cases
Antidepressants: First-line antidepressants are SSRIs e.g. citalopram. Other antidepressants include TCAs, SNRIs and MAOIs
Adjuvants: Antidepressants may be augmented with lithium, or antipsychotics
Psychotherapy: Refer for CBT and interpersonal therapy (IPT)
Social support
ECT
How long should antidepressants be continued for after remission?
Should be continued for 6 months after resolution of symptoms for first depressive episode, 2 years after resolution of second episode, and long term in individuals who have had multiple severe episodes
Indications for ECT tx in depression?
(1) acute treatment of severe depression which is life-threatening; (2) rapid response required; (3) depression with psychotic features; (4) severe psychomotor retardation or stupor; (5) or failure of other treatments.
