CNS 6 Serious Mental Illness Flashcards
What does a diagnostic interview involve
History (patient and informant)
Mental state examination
Physical examination
Risk assessment
Summary
Management plan
What does a psychiatric history taking involve
Presenting complaint Past psychiatric history Past medical history Family history Medications Personal history Forensic history Drug and alcohol history Premorbid personality
What does the mental state examination assess
Appearance and behaviour Affect (appropriate behaviour) Speech (form and content) Mood (objective and subjective) Thoughts / preoccupations Abnormal beliefs Abnormal perceptions Suicidal or homicidal ideation / intent Cognition Insight
What are the parts of the risk assessment in the diagnostic interview
Danger to self eg self neglect, self harm, vulnerable to exploitation by others
Danger to others eg violence, theft, arson
Damage to property eg arson, destruction
ICD 10 features of schizophrenia
Characteristic symptoms for 1 month
Not attributable to organic brain disease or substance abuse
At least 1 of the following:
Thought echo, insertion, withdrawal or broadcasting
Delusiosn of control
Voices commenting or discussing
Persistent delusions that are culturally innapropriate
Or 2 of the following Persistent hallucinations in any modality when accompanied by delusions Catatonic behaviour Negative symptoms Neologisms
What are negative symptoms
Marked apathy
Paucity of speech
Blunting or incongruity of emotional responses
What are the 4 core positive psychopathologies seen in psychosis
Delusions: a false belief that persists despite evidence to the contrary and is not associated with any cultural, religious or political norms
Hallucinations: a perception in the absence of a stimulus
What is the blood brain barrier
An extreme form of lipid barrier with
- few intercellular pores
- numerous tight junctions
- surrounded by glial cells
Lipid soluble drugs can penetreate and water soluble / polar drugs have limited access
Why is loratadine non sedating antihistamine when cetirizine hydrochloride is sedating
Loratadine is more polar so doesnt penetrate the blood brain barrier and so has no side effects eg drowsiness
What happens to the blood brain barrier in meningitis
It is less effective (causes the BBB to become leaky)
So can give antibiotics which would normally not pass throuhg eg benzylpenicillin
What is the difference between domperidone and metoclopramide
They are both anti emetics (prevent N&V)
Both dopamine receptor antagonists
Metoclopramide penetrates the BBB and can cause drug induced parkinsonism - only used short term
Domperidone does not penetrate the BBB so is less likely to cause parkinsonism
What is the fatal chemotherapy drug
Vincristine if given intrathecally (only use intravenously)
What is propofol
An induction anaesthetic given by IV infusion
Then replaced with a maintenance anaesthetic
Is a highly lipid soluble drug
Unconsciousness occurs within about 20 seconds and lasts for 5-10 mins (while anaesthesist is infusing)
Describe the concept of zero order kinetics
Eg phenytoin, ethanil
The enzymes become saturated so the rate of elimination is no longer proportional to [drug]
Eg small changes in dose of phenytoin lead to disproportionate increases in [phenytoin]
Effects of phenytoin if taken during pregnancy
Craniofacial abnormalities
Hypoplasia of distal phalanges
Growth deficiency
Mental deficiency
(Carbamazepine has similar effects but a decreased risk)
Effects of valporate if taken during pregnancy
Associated with neural tube defects
Learning difficulties
Use of antidepressants in pregnancy
SSRIs (esp citalopram and sertraline) are associated with cardiac septal defects
Therfore tricyclic antidepressants are favoured
Increased risk in first trimester hence why you should ask if there is any risk pt could be pregnant before prescribing
Interaction of Cyt P450 inducing agents with contraceptives
Can lead to a failure of therapy eg phenytoin, carbamazepine and phenobarbital
Therefore favour non inducing agents or use alternative contraceptive methods
Interaction of lamotrigine and oral contraceptives
Oral contraceptives can reduce plasma concentrations of lamotrigine
This is because lamotrigine activity is decreased by oestrogen
What are the clinical features of serotonergic syndrome
Headache
Confusion
Nausea
Twitching
What is the casue of serotonergic syndrome
SSRIs and 5HT agonists (triptans) can lead to increased 5-HT
What is st johns wort
has SSRI like actions
Can cause serotonergic syndrome if used with SSRIs so always ask pt if on any herbal medications
Negative effects of st johns wort
Oral contraceptives - can cause contraceptive failure
Anti HIV drugs- can stop them from working
Ciclosporin - used for organ rejection so could cause an organ to be rejected
What does the diagnostic interview involve
History taking (patient and informant)
Mental state examination
Physical examination
Risk assessment
Summary
Management plan
Information needed to refer a patient to eating disorder service
Height and recent weight and a comment on how they appear on inspection
Some anorexia symptoms
Background medical printout
Rate of weight loss is important in terms of risk and urgency
What is anorexia nervosa
A disorder characterised by deliberate weight loss and sustained by patient
Most common in adolescent girls and young women
Associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour as an intrusive overvalued idea and patients impose a low weight threshold on themselves
Disturbances of bodily function eg stopping periods
Symptoms of anorexia nervosa
Restricted dietary choice
Excessive exercise
Induced vomitting
Purgation
Use of appetite suppressants
Diuretics
Predisposing risk factors for anorexia
High conscientious personality
History of nutritional struggle (allergies, inflammatory conditions)
Tendency towards anxeity and low self esteem
Normal level of emotional neglect
Maternal behaviour and attitudes towards food and thinness
Precipitating effects leading to anorexia
Major life event: Puberty Parents separate or dysharmony Going to school-bullying and exams Going to uni Bereavement Other mental disorder
Psychopathology of anorexia
Frequent intrusive thoughts about fatness and its catastrophic consequences
Dysmorphic perceptions of being fat associated with anxiety and disgust
Intrusive thoughts about being greedy or lazy
Grossly exaggerated expectation of weight gain from eating
Behaviours of anorexia nervosa
Complaints of fatness and denial of hunger
Obsession with checking weight
Avoiding eating especially in front of others
Obsessing over and avoiding high calorie food
Social withdrawal
Over - exercise
Self induced vomiting
Excessive laxative abuse
Complaints of cold intolerance
Quad weakness and tiredness
Cognitive struggle
Signs and symptoms of anorexia nervosa
Weight loss / emaciated appearance Poor state of hair and skin Lanugo (downy baby hair) Amenorrhoea or irregular menses Calluses on finger joints Thinning of enamel Cold mottled hands and feet Swelling of feet Muscle weakness Persistent bradycardia First degree heart block
What is bullimia nervosa
Anorexia with binges and purges more than once a week for 3 months
Tend ot have normal or higher BMI hence less risk of misadventure due to binges
How is bullimia nervosa linked to emotional neglect
Insufficient episodes of maternal attunement and reciprocal mirroring for that person
Results in delay of development of the affect regulating circuitry in the right supraorbital cortex which leads to failures of unconscious affect regulation later in life
Consequences usually present in puberty when the entire system is under increased stress
What determines whether a patient present with anorexia nervosa or bullimia nervosa
The balance between the degree of neglect and the strength of the persons inhibitory capabilites ie perfectionism, conscientiousness
