CNS 6 Serious Mental Illness Flashcards

1
Q

What does a diagnostic interview involve

A

History (patient and informant)

Mental state examination

Physical examination
Risk assessment
Summary
Management plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What does a psychiatric history taking involve

A
Presenting complaint 
Past psychiatric history 
Past medical history 
Family history 
Medications 
Personal history 
Forensic history 
Drug and alcohol history
Premorbid personality
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What does the mental state examination assess

A
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the parts of the risk assessment in the diagnostic interview

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

ICD 10 features of schizophrenia

A

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are negative symptoms

A

Marked apathy
Paucity of speech
Blunting or incongruity of emotional responses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the 4 core positive psychopathologies seen in psychosis

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the blood brain barrier

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Why is loratadine non sedating antihistamine when cetirizine hydrochloride is sedating

A

Loratadine is more polar so doesnt penetrate the blood brain barrier and so has no side effects eg drowsiness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What happens to the blood brain barrier in meningitis

A

It is less effective (causes the BBB to become leaky)

So can give antibiotics which would normally not pass throuhg eg benzylpenicillin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the difference between domperidone and metoclopramide

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the fatal chemotherapy drug

A

Vincristine if given intrathecally (only use intravenously)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is propofol

A

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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe the concept of zero order kinetics

A

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]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Effects of phenytoin if taken during pregnancy

A

Craniofacial abnormalities
Hypoplasia of distal phalanges
Growth deficiency
Mental deficiency

(Carbamazepine has similar effects but a decreased risk)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Effects of valporate if taken during pregnancy

A

Associated with neural tube defects

Learning difficulties

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Use of antidepressants in pregnancy

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Interaction of Cyt P450 inducing agents with contraceptives

A

Can lead to a failure of therapy eg phenytoin, carbamazepine and phenobarbital

Therefore favour non inducing agents or use alternative contraceptive methods

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Interaction of lamotrigine and oral contraceptives

A

Oral contraceptives can reduce plasma concentrations of lamotrigine
This is because lamotrigine activity is decreased by oestrogen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the clinical features of serotonergic syndrome

A

Headache
Confusion
Nausea
Twitching

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is the casue of serotonergic syndrome

A

SSRIs and 5HT agonists (triptans) can lead to increased 5-HT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is st johns wort

A

has SSRI like actions

Can cause serotonergic syndrome if used with SSRIs so always ask pt if on any herbal medications

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Negative effects of st johns wort

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What does the diagnostic interview involve

A

History taking (patient and informant)

Mental state examination

Physical examination
Risk assessment
Summary
Management plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
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
26
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
27
Symptoms of anorexia nervosa
Restricted dietary choice Excessive exercise Induced vomitting Purgation Use of appetite suppressants Diuretics
28
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
29
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 ```
30
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
31
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
32
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 ```
33
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
34
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
35
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
36
What things are useful in monitoring of bullimia nervosa
Mood and event diaries: food and love are shared- look for instances of patient being stood up, let down or otherwise neglected by others as an antecedent to the binge Meal planning: reduces binge frequency by not allowing hunger to develop and also provides a framework for a secure unconscious attachment
37
Differential diagnoses for disordered eating
Other specified feeding and eating disorders Binge eating disorder Avoidant restrictive food eating disorder- eating is linked to trauma and avoided for this reason rather than an obsession with weight and figure Atypical anorexia - anorexia with normal weight BN- with low purging frequency Purging disorder - just purging Night eating disorder Orthorexia - unhealthy foucs in eating in a healthy way
38
What are the ways in which people with eating disorders can fall through service provision gaps
Hospital wards can find them resistive to help and too ‘mental health’ while general psychiatric units can find them intimidatingly ‘too medical’
39
What is the whack a mole concept
Common that anxiety disorders go hand in hand with depression So for example success in treatment of OCD and AN can lead to a worsening of other symptoms such as depression and anxiety
40
What medications are used in anorexia
Antidepressants - SSRI Anxiolytics- benzodiazepines ideally as reassurance, short term Propranolol- safer to use regularly Antipsychotics - Quetiapine - used for impulse control in bulimic end and also has anxiolytic and mood regulating effect Sedation can help sleep Olanzapine- good for anxiety, powerful appetite increase and weight gain effects
41
What is psychosis
A set of symptoms Loss of connection with reality Often characterised by positive symptoms: delusions, hallucinations, thought disorder
42
What is schizophrenia
One of the psychotic disorders Characterised by recurrent psychotic episodes and a more chronic deterioration in cognitve, executive and social functioning
43
What is a psychotic symptom
Delusion Hallucination Thought disorder Smoking cannabis can cause these same symptoms
44
What is a psychotic episode
Symptoms persist for a period of time (2-3 days)
45
What is a psychotic disorder
Illness / clinical disorder characterised by psychotic symptoms eg schizophrenia, schizoaffective disorder, bipolar affective disorder
46
What is a psychotic relapse
Where individuual with a psychotic disorder has another psychotic episode
47
What is a clinical high risk of psychosis or an ultra high risk of psychosis
Where we are worried that the individual may develop a psychotic disorder but is currently demonstrating subthreshold symptoms and may be experiencing a prodromal illness
48
Describe the positive symptoms of psychosis
Hallucinations in the absence of a stimulus: auditory, visual, olfactory, sensory, gustatory Delusions: Belief held in the absence of evidence which is culturally atypical can have bizarre content usually held with delusional conviction Thought disorder: breakdown in the form or structure of thought Fragmented or incoherent speech, difficult to follow
49
Negative symptoms of psychosis
``` Avolition (lack of will / motivation Apathy Flattened affect (decreased reactivity of mood) Social withdrawal Alogia / poverty of thouhgt ```
50
What are the cognitive impairments seen in psychotic disorders
``` Attention Working memory Planning and executive function Verbal learning Problem solving ```
51
What is insight in psychosis
The patient can recognise and accept that thier experiences are abnormal and caused by a mental illness Lack of insight in 90% of patients Can change over time
52
What questions can be used to assess insight
1) identifying unusual experiences - how do you explain them 2) awareness of illness - do you think you have an illness? Could there be a mental health explanation to this? 3) willingness to take treatment - would you agree with taking medication or having therapy
53
What is classic schizophrenia
Recurrent / ongoing psychotic episodes + deterioration in mental and social functions over chronic course. Occurs in 0.7% of population
54
What is schizoaffective disorder
Psychotic episodes + affective ie mood component
55
What is bipolar affective disorder with psychotic features
Characterised by depressive and manic episodes where psyhcosis may be evident Functioning may be less impaired between episodes
56
What is depression with psychosis
Where delusion is often characterised by mood congruent symtpoms such as nihlistic delusions or delusions of guilt
57
What is persistent delusional disorder
Delusions only present
58
What is substanced induced psychosis
Where symptoms have been precipitated by substance use. Usually resolve wihtin 30 days after stopping drug
59
What is schizophreniform illness
Like schizophrenia but symptoms <30 days
60
What is ATPD
Brief psychosis, often stress induced
61
What is schizotypy
Subclinical trait whihc does not meet threshold for schizophrenia. Useful for research purposes
62
Medication for schizophrenia
Antipsychotics: D2 receptor antagonists since strong relationship between striatal dopamine release and clozapine is used in treaatment resistive schizophrenia Antidepressants or mood stabilisers if there is a mood component to illness
63
Psychological treatments of schizophrenia
CBT for psychosis Family therapy Psychoeducation Substance misuse work
64
When is the typical onset of schizophrenia
Adolesence | Men 15-25y, women 25-35y
65
Neuronal influences that cause schizophrenia
Over activity of mesolimbic dopamine neurones Under activity of mesocortical dopamine neurones Post synaptic dopamine D2 and D 3 receptors Cortical glutamate hypofunction and loss of GABA interneurones Dysfunctional development of frontal cortex
66
Cognitve effects of schizophrenia
Brain structure abnormalities present at onset of psychosis and not progressive Suggests developmental rather than degenerative Enlarged ventricles + reduced temporal lobe volume 6-10% (particularly hippocampus)
67
Genetic effects of schizophrenia
Family high risk (1 parent = 12% risk) and 50% risk in identical twins
68
Environmental triggers for schizophrenia
Early lesion hypothesis: - foetal or perinatal event eg virus, hypoxia or premature birth interacting with normal development - altered asymmetric development Late lesion hypothesis - deviation in maturation during adolesence
69
What are the extrapyramidal side effects blockade of nigrostriatal D2 receptors
Acute dystonia - neck or spine spasms or rigidity and oculogyric crisis Pseudo-parkinsonism- rigidity, tremor and bradykinesia Akathisia - inability to sit still, restlessness and agitation Tardive dyskinesia - abnormal movement of the face, mouth or jaw, lip smacking, tongue protrusion, grimacing, bodily writhing
70
What is the role of dopamine antagonists
Increase prolactin release which correlate with clinical improvement
71
What neuronal / cortical changes does schizophrenia cause
Neurodevelopmental - change in cortex / hippocampus Reduced cortical glutamate function Secondary increase in limbic dopamine function
72
What is simultanagnosia
Are functionally blind except for the perception of one object in the visual field at a time Inability to see more than one object at a time associated with bilateral posterior parietal damage
73
Define selective attention
Required to limit entry to a finite capacity processing system by selecting only a subset of all available information
74
Define divided attention
Attention itself is a resource of limited capacity which can be divided between tasks
75
What is sustained attention
Processing capacity and attentional capacity linked to arousal
76
What is top down attention directing mechanism
When attention is active (controlled by top down attention directing mechanism) Includes a persons own intentions and expectations eg searching for a friend in the lecture theatre
77
What is bottom up attention
Attention is passive if it is controlled by a bottom up attention capturing mechanism Bottom up influences are directed by stimuli in the world that ‘catch’ our attention Eg if someone taps you on the shoulder while reading, the tap will direct attention toward that person
78
What is neglect syndrome
Unawareness of the side of space opposite to the lesion (left usually) contra-lesional space No primary deficits of sensation or perception
79
What is the difference between stress and distress
Stress is physical, mental or emotional strain whereas distress is extreme anguish or pain of the mind or body
80
What are the 7 stages of grief
Shock- initial paralysis at hearing the bad news Denial - trying to avoid the inevitable Anger - frustrated outpouring of bottled up emotion Bargaining - seeking in vain for a way out Depression - final realisation of the inevitable Testing - seeking realistic solutions Acceptance - finally finding the way forward
81
Examples of distress as a feature of primary presentation
Acute stress Life events Bereavement
82
Types of distress as a result of injury or acute illness
``` MI Labour pains Previously undiagnosed illness Adverse drug reaction Delirium ```
83
Types of distress resulting from mental illness
Anxiety Depression Psychosis
84
Types of distress from alcohol and substance misuse
Intoxication | Withdrawal
85
Types of distress from consultation
Bad news | Resulting from discomfort, pain, embarassment of self / others
86
Emotional signs of distress
Affect, sadness, tearful, shock, anger, disbelief, incongrous eg laughter
87
Behavioural signs of distress
Agitation, withdrawal, aggression
88
Cognivive - verbal signs of distress
Silence | Shouting