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
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
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
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’
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
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
What is psychosis
A set of symptoms
Loss of connection with reality
Often characterised by positive symptoms: delusions, hallucinations, thought disorder
What is schizophrenia
One of the psychotic disorders
Characterised by recurrent psychotic episodes and a more chronic deterioration in cognitve, executive and social functioning
What is a psychotic symptom
Delusion
Hallucination
Thought disorder
Smoking cannabis can cause these same symptoms
What is a psychotic episode
Symptoms persist for a period of time (2-3 days)
What is a psychotic disorder
Illness / clinical disorder characterised by psychotic symptoms eg schizophrenia, schizoaffective disorder, bipolar affective disorder
What is a psychotic relapse
Where individuual with a psychotic disorder has another psychotic episode
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
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
Negative symptoms of psychosis
Avolition (lack of will / motivation Apathy Flattened affect (decreased reactivity of mood) Social withdrawal Alogia / poverty of thouhgt
What are the cognitive impairments seen in psychotic disorders
Attention Working memory Planning and executive function Verbal learning Problem solving
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
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
What is classic schizophrenia
Recurrent / ongoing psychotic episodes + deterioration in mental and social functions over chronic course. Occurs in 0.7% of population
What is schizoaffective disorder
Psychotic episodes + affective ie mood component
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
What is depression with psychosis
Where delusion is often characterised by mood congruent symtpoms such as nihlistic delusions or delusions of guilt
What is persistent delusional disorder
Delusions only present
What is substanced induced psychosis
Where symptoms have been precipitated by substance use. Usually resolve wihtin 30 days after stopping drug
What is schizophreniform illness
Like schizophrenia but symptoms <30 days
What is ATPD
Brief psychosis, often stress induced
What is schizotypy
Subclinical trait whihc does not meet threshold for schizophrenia. Useful for research purposes
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
Psychological treatments of schizophrenia
CBT for psychosis
Family therapy
Psychoeducation
Substance misuse work
When is the typical onset of schizophrenia
Adolesence
Men 15-25y, women 25-35y
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
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)
Genetic effects of schizophrenia
Family high risk (1 parent = 12% risk) and 50% risk in identical twins
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
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
What is the role of dopamine antagonists
Increase prolactin release which correlate with clinical improvement
What neuronal / cortical changes does schizophrenia cause
Neurodevelopmental - change in cortex / hippocampus
Reduced cortical glutamate function
Secondary increase in limbic dopamine function
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
Define selective attention
Required to limit entry to a finite capacity processing system by selecting only a subset of all available information
Define divided attention
Attention itself is a resource of limited capacity which can be divided between tasks
What is sustained attention
Processing capacity and attentional capacity linked to arousal
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
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
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
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
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
Examples of distress as a feature of primary presentation
Acute stress
Life events
Bereavement
Types of distress as a result of injury or acute illness
MI Labour pains Previously undiagnosed illness Adverse drug reaction Delirium
Types of distress resulting from mental illness
Anxiety
Depression
Psychosis
Types of distress from alcohol and substance misuse
Intoxication
Withdrawal
Types of distress from consultation
Bad news
Resulting from discomfort, pain, embarassment of self / others
Emotional signs of distress
Affect, sadness, tearful, shock, anger, disbelief, incongrous eg laughter
Behavioural signs of distress
Agitation, withdrawal, aggression
Cognivive - verbal signs of distress
Silence
Shouting
