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.
Define bipolar affective disorder
a chronic episodic mood disorder, characterised by at least one episode of mania (or hypomania) and a further episode of mania or depression
What are the risk factors for bipolar affective disorder?
(Aggressive Spenders)
Age in early-20’s
Anxiety disorders
After depression
Stressful life events
Substance misuse
Strong family hx
Give some sxs of mania
I DIG FASTER
Irritability
Distractibility / Disinhibited
Insight impaired / increased libido
Grandiose Delusions
Flight of Ideas
Activity / Appetite Increased
Sleep decreased
Talkative - pressure of speech
Elevated mood / energy increased
Reduced concentration / reckless behaviour
Describe hypomania
Mildly elevated or irritable mood present for > 4 days
symptoms of mania are to a lesser extent than true mania
considerable interference with work and social life but not severe disruption
partial insight may be preserved
Describe mania without psychosis
symptoms present for > 1 week with complete disruption of work and social activities
may have grandiose ideas, excessive spending, sexual disinhibition, exhaustion due to lack of sleep
Describe mania with psychosis
severely elevated or suspicious mood with psychotic features e.g. grandiose or persecutory delusions and auditory hallucinations that are mood congruent
How can bipolar affective disorder be classified?
Bipolar 1 - Involves periods of severe mood episodes from mania to depression
Bipolar 2 - Milder form of mood elevation, involving milder episodes of hypomania that alternate with periods of severe depression
Rapid cycling - More than four mood swings in a 12-month period with no intervening asymptomatic periods. Poor prognosis.
What is the ICD-10 criteria for mania?
Mania requires 3/9 symptoms to be present:
(1) Grandiosity/inflated self-esteem
(2) Decreased sleep
(3) Pressure of speech
(4) Flight of ideas
(5) Distractibility
(6) Psychomotor agitation (restlessness)
(7) Reckless behaviour, e.g. spending sprees, reckless driving
(8) Loss of social inhibitions (leading to inappropriate behaviour)
(9) Marked sexual energy
ICD-10 diagnostic criteria for bipolar affective disorder?
at least two episodes in which a person’s mood and activity levels are significantly disturbed – one of which MUST be mania or hypomania
ICD-10 divides bipolar disorder into five states:
(1) Currently hypomanic; (2) Currently manic; (3) Currently depressed; (4) Mixed Disorder; (5) In remission
Describe typical MMSE appearance of a patient with bipolar
Flamboyant/unusual combination of clothing, heavy makeup and jewellery. Personal neglect when condition is severe.
Describe typical MMSE behaviour of a patient with bipolar
Overfamiliar, disinhibited (flirtatious, aggressive), increased psychomotor activity, distractible, restless.
Describe typical MMSE speech of a patient with bipolar
Loud, ↑ rate and quantity, pressure of speech, uninterruptible, puns and rhymes, neologisms.
Describe typical MMSE mood of a patient with bipolar
Elated, euphoric, and/or irritable.
Describe typical MMSE thought of a patient with bipolar
Optimistic, pressured thought, flight of ideas, loosening of association, circumstantiality, tangentiality, overvalued ideas, grandiose/persecutory delusions.
How may you investigate bipolar affective disorder?
Self-rating scales: e.g. Mood Disorder Questionnaire.
Blood tests: FBC (routine), TFTs (both hyper/hypothyroidism are differentials), U&Es (baseline renal function with view to starting lithium), LFTs (baseline hepatic function with view to starting mood stabilizers), glucose, calcium (biochemical disturbances can cause mood symptoms)
Urine drug test: Illicit drugs can cause manic symptoms
CT head: to rule out space-occupying lesions (can cause symptoms such as disinhibition).
DDx for bipolar affective disorder?
Mood disorders: hypomania, mania, mixed episode, cyclothymia
Psychotic disorders: schizophrenia, schizoaffective disorder
Secondary to medical condition: hyper/hypothyroidism, Cushing’s disease, cerebral tumour (e.g. frontal lobe lesion with disinhibition), stroke
Drug related: illicit drug ingestion (e.g. amphetamines, cocaine), acute drug withdrawal, side effect of corticosteroid use
Personality disorders: histrionic, EUPD
When would hospitalisation be required for a manic patient?
(1) reckless behaviour causing risk to patient or others; (2) significant psychotic symptoms; (3) impaired judgement; (4) or psychomotor agitation.
Mx of bipolar affective disorder?
CALMER
Consider hospitalization/CBT
Antipsychotics (Atypical)
Lorazepam
Mood stabilizers (e.g. lithium)
Electroconvulsive therapy
Risk assessment
Lithium is the standard long-term therapy in bipolar affective disorder. It minimizes the risk of relapse and improves quality of life. What are the key side effects?
polydipsia, polyuria, fine tremor, weight gain, oedema, hypothyroidism, impaired renal function, memory problems and teratogenicity (in 1st trimester)
Signs of lithium toxicity (1.5–2.0 mmol/L):
N+V, coarse tremor, ataxia, muscle weakness, apathy
Signs of severe lithium toxicity (>2.0 mmol/L) :
nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions and coma
How should lithium tx be monitored?
Lithium levels – 12 hours following first dose, then weekly until therapeutic level (0.5–1.0mmol/L) has been stable for 4 weeks. Once stable check every 3 months.
U&Es – every 6 months; TFTs – every 12 months.
What mood stabilisers may be used in an acute manic episode?
lithium or sodium valproate
Define psychosis
Psychosis is defined as a mental state in which reality is greatly distorted.
It typically presents with:
1. Delusions: A fixed false belief, which is firmly held despite evidence to the contrary and goes against the individual’s normal social and cultural belief system.
- Hallucinations: A perception in the absence of an external stimulus
- Thought disorder: An impairment in the ability to form thoughts from logically connected ideas.
List some non-organic causes of psychosis
Schizophrenia
Schizotypal disorder
Schizoaffective disorder
Acute psychotic episode
Mood disorders with psychosis
Drug-induced psychosis
Delusional disorder
Induced delusional disorder
Puerperal psychosis
List some organic causes of psychosis
Drug-induced psychosis
Complex partial epilepsy
Delirium, Dementia
Huntington’s disease
Systemic lupus erythematosus
Syphilis
Endocrine disturbance, e.g. Cushing’s syndrome
Metabolic disorders including vitamin B, deficiency and porphyria
What mnemonic can you use to remember key causes of psychosis?
‘Schizophrenia And Schizoaffective Persist For >1 Month, Paraphrenia Presents Late’
Schizotypal disorder
Acute and transient psychotic disorders (< 1 month)
Schizoaffective Disorder (schizophrenia + mood disorder)
Persistent delusional disorder (delusion is only/most prominent symptom)
Folie a deux
Mood disorders with psychosis
Puerperal psychosis
Late paraphrenia - late onset schizophrenia
Define schizophrenia
Schizophrenia is the most common psychotic condition, characterized by hallucinations, delusions and thought disorders which lead to functional impairment. It occurs in the absence of organic disease, alcohol or drug-related disorders and is not secondary to elevation or depression of mood.
Give some predisposing factors for schizophrenia
family hx
childhood abuse
substance misuse
low socioeconomic status
migrants
African-Carribean background
urban living
Give some precipitating factors for schizophrenia
Smoking cannabis or using psychostimulants
Adverse life events
Poor coping style
Peak age of onset of schizophrenia?
15–35 years
What are the positive sxs of schizophrenia?
mnemonic: Delusions Held Firmly = Think Psychosis
Delusions
Hallucinations
Formal thought disorder
Thought interference
Passivity Phenomena
Schneider’s first-rank symptoms of schizophrenia are symptoms which, if one or more are present, are strongly suggestive of schizophrenia. What are they?
Delusional perception: A new delusion that forms in response to a real perception without any logical sense, e.g. ‘the traffic light turned red so I am the chosen one.’
Third person auditory hallucinations: usually a running commentary
Thought interference: thought insertion, withdrawal or broadcast
Passivity phenomenon
What are the negative sxs of schizophrenia?
(the A factor)
Avolition (↓ motivation)
Asocial behaviour: Loss of drive for any social engagements
Anhedonia: Lack of pleasure in activities that were previously enjoyable to the patient
Alogia (poverty of speech): A quantitative and qualitative decrease in speech
Affect blunted: Diminished or absent capacity to express feelings.
Attention deficits: May experience problems with attention, language, memory, and executive function.
What are the different types of schizophrenia according to ICD-10?
paranoid
postschizophrenic depression
heberphrenic
catatonic
simple
undifferentiated
residual
Describe paranoid schizophrenia
most common type, dominated by positive sxs such as hallucinations and delusions
Describe hebephrenic schizophrenia
onset of illness is earlier (15-25) and has poorer prognosis, thought disorganisation predominates
Describe simple schizophrenia
rare form where negative sxs develop without psychotic sxs
describe residual schizophrenia
1 year of chronic negative sxs preceded by a clear cut psychotic episode
Describe appearance and behaviour of a typical schizophrenia patient in MMSE
Appearance can be normal (positive), or inappropriate with poor self-care (negative)
Behaviour: Preoccupied, restless, noisy or suspicious (positive). A few show sudden, unexpected changes in behaviour. Withdrawn, poor eye contact and apathy (negative)
Describe speech of a typical schizophrenia patient in MMSE
May reflect underlying thought disorder (loosening of associations, pressured and distractible speech), interruptions to flow of thought (thought blocking), and poverty of speech (negative)
Describe mood of a typical schizophrenia patient in MMSE
Incongruity of affect or mood changes such as depression, anxiety or irritability. Flattened affect (negative)
Describe thought of a typical schizophrenia patient in MMSE
Delusions (e.g. persecutory, delusions of control, delusions of reference)
thought insertion/withdrawal/broadcast
formal thought disorder (loosening of associations, word salad, concrete thinking, circumstantiality/tangentiality)
Describe cognition of a typical schizophrenia patient during MMSE
Normal orientation. Attention and concentration often impaired (positive). Specific cognitive deficits (negative)
What investigations could you do for a patient with suspected schizophrenia?
Blood tests:
FBC: anaemia, infection
TFTs: thyroid dysfunction can present with psychosis
serum calcium: hypercalcaemia can present with psychosis
U&Es and LFTs : assess renal and liver function before giving antipsychotics
glucose or HbA1c, cholesterol: as atypical antipsychotics cause metabolic syndrome
vitamin B12 and folate : deficiencies can cause psychosis
Urine drug test
ECG: Antipsychotics cause prolonged QT interval
CT scan: To rule out organic causes such as space-occupying lesions
EEG: To rule out temporal lobe epilepsy as possible cause of psychosis
What are the options for biological mx of schizophrenia?
Atypical antipsychotics are first-line, e.g. risperidone and olanzapine
Depot formulations should be considered if there is a problem with non-compliance
Clozapine is used for treatment-resistant schizophrenia (failure to respond to two other antipsychotics)
Adjuvants:
Benzodiazepines can provide short-term relief of behavioural disturbance, insomnia, aggression and agitation.
(Lorazepam doesn’t work as quickly as diazepam but has less risk of respiratory depression)
Antidepressants and lithium can be used to augment antipsychotics
ECT if tx resistant or catatonic
What are the options for psychological mx of schizophrenia?
CBT
Family intervention
Art therapy : good for negative sxs in young people
Social skills training
What are the options for social mx of schizophrenia?
Support groups - Rethink and SANE
Peer support
Supported employment programs
What are the factors associated with a poor prognosis in schizophrenia?
Strong family history
Gradual onset
↓ IQ
Premorbid history of social withdrawal
No obvious precipitant
Give the potential side effects of atypical antipsychotics
extrapyramidal side effects (e.g. parkinsonism)
blurred vision
urinary retention, dry mouth, constipation
sedation
weight gain
postural hypotension, tachycardia
ejaculatory failure or sexual dysfunction reduced bone mineral density
menstrual disturbances
breast enlargement, galactorrhoea
impaired glucose tolerance, hypercholesterolaemia
neuroleptic malignant syndrome
prolonged QT interval
