General Adult Flashcards
Genetic risk of schizophrenia
Population risk - 1%
Grandchildren - 5%
Half-sibling - 6%
Full sibling - 9%
Child - 13%
Fraternal twin - 17%
Child (dual mating) - 46%
Identical twin - 48%
Risk of pueperal psychosis
Baseline risk - 1-2/1000
BPAD - 50%
Subsequent pregnancies 50-80%
OCD (history)
HPC (onset and duration)
Elicit core Sx (origin, nature, obsessions, compulsions)
Impact on functioning
Risk assessment (self, others, children)
Comorbidity (mood, enjoyment, sleep, appetite, hallucinations, delusions, passivity)
Substance use
Psychosis (MSE)
Core delusional belief (evidence, challenge)
Other delusions (persecution, grandiose, reference)
Hallucinations (auditory and other modalities)
Thought interference
Passivity experiences
Impact on mood
Substances
Risk
Questions about auditory hallucinations
Do you hear sounds or voices that others cannot?
How many voices?
Are they as clear as me speaking to you now?
What do they say?
Do they speak to you or about you or both?
Do they give you instructions or commands?
Do they comment on your actions?
How do you feel about them?
Could there be any alternative explanation?
Questions about non-auditory hallucinations
Has there been anything wrong with your sense of smell recently?
Have you noticed that food or drink tastes differently to normal? Strange taste in your mouth at other times?
Have you had any strange feelings in your body?
Have you been able to see things that others cannot? What kinds of things do you see?
Questions about thought interference
Do you feel that somebody is interfering with your thoughts? Who?
Do you ever feel that you have thoughts in your head that are not your own? Where do you think these come from?
Do you ever feel that other people can know what you are thinking?
Do you ever feel as though thoughts are being removed from your head?
Mania (history)
HPC (onset, duration)
Core mania symptoms (elation, irritability, energy, sleep, appetite, racing thoughts)
Grandiose delusions
Hallucinations (all modalities)
Thought interference and passivity
Risk (Police, spending, substances, promiscuity, self, others)
Delirium Tremens (history)
HPC (onset, duration)
Visual hallucinations (content, clarity, alternative explanation)
Hallucinations in other modalities
Orientation (time, place, person)
Alcohol history (quantity, duration, last drink, withdrawal, prev abstinence)
Risk (self, others)
Panic disorder (history)
HPC (onset, duration, first episode, frequency, triggers)
Physical symptoms
Psychological symptoms
DDx (generalised anxiety, social anxiety, phobia, OCD, PTSD, depression)
Impact on life and coping strategies
PPHx, FHx, brief PHx, PMHx, medications
Pass review (MSE)
Reason for admission and change since then
Auditory hallucinations
Delusional beliefs
Thought interference and passivity experiences
Mood (sleep, appetite, enjoyment)
Insight (understanding, medication)
Risk (plans at home, self, others, plan to return)
Psychotic depression (history)
HPC (onset, duration)
Nihilistic delusions (challenge these)
“How were things for you before you died”
Mood (sleep, appetite, enjoyment, energy, future)
Other psychotic symptoms
Risk
Adult ADHD (history)
Core features (hyperactivity, inattention, impulsiveness)
Impact on functioning (work, leisure, relationships, Police)
Childhood history (childhood symptoms, academic attainment, previous treatments, comorbid disorders)
Mood and substances
Risk (violence, impulsivity, driving)
Address other concerns
Panic disorder (explanation)
Clarify diagnosis and explain symptoms
Explain aetiology (stressors, FHx, personality)
Pharmalogical treatment
Psychological treatment (CBT)
Other concerns and leaflets
Hyperprolactinaemia (explanation)
Explain result and cause
Elicit symptoms (abnormal periods, breast changes, sexual dysfunction, fractures)
Screen for pituitory tumor (headaches, blurred vision, weakness, numbness)
Explain long-term side-effects (osteoporosis, risk of breast cancer)
Options for management (change antipsychotic, add aripiprazole)
Clozapine (explanation)
Clarify rationale and response rate (60%)
Explain side-effects
Explain monitoring (bloods - initially weekly, obs, ECG)
Missed doses (as soon as remembers, unless 4hours until next dose, retitrate if >48hrs)
Smoking and alcohol
Other concerns and leaflet
Lithium augmentation (explanation)
Lithium use: prophylactic in bipolar - ‘mood stabliser’.
Augement for treatment reistant depression.
Lowers risk of suicide.
Proven with scientific study - however unclear on how it works.
Interacts with ACE-I, diuretics, NSAIDS.
Risk of dehydration
Risk of damage to thyroid and kidneys.
Can exaccerbate acne and psoriasis.
Pregnancy: Used in caution due to teratogenic risks.
Baseline bloods: FBC, U+E, TFT, ECG, Calcium.
Monitoring is weekly until steady state. Lithium levels 3 monthly. TFTs U+Es 6 monthly. Annually BMI (risk of weight gain).
Narrow therapeutic window.
Side effects:
Increased thirst, fine tremor, weight gain.
Long term: Nephrotoxic, thyroid/parathyroid.
Signs of toxicity - Diarrhoea, coarse tremor, confusion, neurological symptoms, coma.
Discontinuation may lead to relapse.
ECT (explanation)
Medically induced seizure
Life threatening depression - requiring urgent treatment
6-12 sessions 2 x per week
Amnesia around event. Headache. Disorientation:
Rarer and longer term - more persistent memory loss -typically - autobiographical memory loss.
Supervision of anaethetist - risk of anaesthetic 1:100000
Can return home or to ward, will need adequate support around this.
Not like media. It is painless, controlled.
Relapses can be common, may need further ECT sessions/other treatments.
Schizophrenia (explanation)
Type of psychotic disorder
Severe mental illness - often misrepresentated
+ve symptoms:
Hearing/seeing./feeling/smelling things that are not there (hallucinations)
Unshakable belief something that is objectively untrue (delusion)
Confused/muddled thoughts (thought disorder).
-ve symptoms:
similar to depression
Social isolation
anhedonia
Self-neglect
Loss of motivation.
-ve often develop for years - prodromal stage. Missed diagnosis ie depression.
Psyhotic - for acute +ve symptoms.
Genetics, enviromental (drugs/ trauma),
Antipsychotics mainstay treatment. CBT P also helpful. Chronic, relapsing emiting
Schizophrenia (Hx from CPN)
Timecourse
Fluctuations in symptoms
Thought interference:
Insertion, withdrawal, broadcast.
Auditory hallucinations: commentary, arguing, thought echo.
‘Made’ experiences (created externally).
Passivity phenomena (physical sensations felt coming into body from external).
Delusional perception: Real perception lead to sudden strong belief with no relation to initial experience.
Screen -ve symptoms
MHx and Drug Hx.
Assess functioning.
FHx.
Rule out mood disturbance, other psychotic illness, ?relapse
Bipolar disorder (explanation)
mental health disorder that is
characterised by severe shifts in mood state that can affect energy, thinking, behaviou, risk and sleep.
Chronic disorder. Typically involving relapses - periods stability followed by mania/depression
Mania: excited, happy, energetic, irritable, hypersexual, risk taking, aggression, less sleep, racing thoguhts, over confidence.
Depression: low mood, anhedonia, anergia, poor sleep/over sleep, poor ocncentration, social isolation, suicidal thoughts.
Hypomania: Less than week, less intesne symptoms.
Can be associated with psychosis - loss of touch with reality, delusions such as grandiosity in mania, or belief that dead when depressed - mood congruent + hallucinations.
1-3% affected. Delay in diagnosis.
Mood stablisers mainstay Tx. Many types.
Lithium in pregnancy (explanation)
Teratogenic - risk of ebsteins anomoly (heart defect - tricuspid valve abnormality). Small increase in risk (found in some studies)
1:20,000 base risk. 1:1000 if on Li.
General risks: Insufficient evidence if Li causes miscarriage, stillbirth, low birth weight.
Evidence of reduced muscle tone, issues feeding, sedation.
Alternative options:
Can swap to antipsychotic (quetiapine)
If well/stable, can consider no medication - but HIGH risk of relapse due to incr risk secondary to mania.
Can consider continuing Lithium - accepting risk of teratogenicity - as changes in physiology during pregnancy.
Lithium levels tend to DECREASE - dose need to INCREASE.
After birth - this is reversed.
During: 4 weekly blood tests - at 36 weeks, weekly.
No impact on conception
Lithium not whilst breast feeding.
Treatment-resistant Depression (treatment)
ECT
Combination therapy - SSRI + mirtazapine or venlafaxine and mirtazapine.
Use of antipsychotic adjunct
Use of lithium adjunct
Utilising psychological therapies in combination.
Ongoing research into new medications such as Esketamine spray
OCD (explain medications)
SSRI’s used - often high doses.
Clomipramine - Can be added
Antipsychotic medications can be used second lien.
Combination with therapy ERP best.
PTSD (history)
Trauma - single or multiple/repeated
Re-experiencing: flashbacks, recorring memories/nightmares, intrusive thoughts, phsyical sensations.
Avoidance: staying away from reminders, keep busy all time, use of substances, emotionally numb, detached from body, amnesia of trauma details
Alertness: jumpy, tense, on edge, panic attacks, self-distructive, hypervigilance to sounds
C-PTSD - dfficult to connect, difficult relationships, worthlessness, emotional dysregulaiton - associated multiple trauma
Parasuicide assessment
Pre, during, post
Thoughts feelings actions.
Planning
Feelings of the event
Attempt not to be found.
How found?
Geeting affairs in order
Suicide note?
Substance misuse?
Method?
Did patient believe method fatal?
Continued access to method?
Hopelessness?
Hx of DSH/prev attempts?
FHx suicide
Physical illness?
Protective factors
Grief reaction (history)
Take history surrounding bereavement - time, events around it, expected, what kind of support received
Reaction - Denial, Anger, Bargaining, Depression, Acceptance
Screen for Depressive illness - including hopelessness and suicidal ideation
Perceptual disturbances - differentiate from psychotic - eg: patient has insight, brief, related to sense of person being ‘present’
Normal - Mourning, sadness, missing and yearning, hallucinations near to the death, should not persist for months / years
Abnormal - pathological (depression, excessive guilt, psychosis, functional loss)
Body dysmorphic disorder (history)
Definition - Intrusive thoughts about perceived physical defects that cause a degree of distress and psychosocial impairment.
Thoughts are responded to by repetitive behaviors, checking, concealing / use of makeup /camflage.
Risks - as per usual
Differential diagnosis - OCD, psychosis, anxiety, eating disorders
Explore the impact that these beliefs are having on the patients life.
Show empathy, avoid stating the perceived defect is true.
Management:
Surgery is usually contraindicated - explain lack of success of this approach
Treat depression if present
Reassurance and practical support
SSRI may be helpful - high doses, long periods of time - especially in context of depressive symptoms
NICE Guidelines - CBT or SSRIs
Insomnia (history)
Sleep History:
Sleep and waking function
Precipitating factors
Comorbid medical or psychiatric illness
Sleep:
Time of bedtime and waking
Awakening - frequency, cause eg: full bladder, anxiety, SOB, Heartburn
Pre Sleep - bedroom, good sleep hygiene, caffeine intake, medications, recent life events, naps during the day
Impact:
Refreshing sleep
Headache, dry mouth
Daytime somnolence
Screening for OSA
Screening for depression
Restless leg syndrome
Parasomnias
Investigations:
Sleep diary
Physical health exam - exclude physical health causes
Sleep study - Polysomnography
Management:
z-drugs for short term insomnia expected to resolve, not for chronic use as efficacy wanes with use
Treating physical health conditions
Addressing psychiatric conditions
CBT-I
Capacity for medical procedure
Time and decision specific
Capacity is present until proven otherwise
1) Take in and retain information
2) Understand the information
3) Weigh up the information
4) Communicate the decision
- If patient has capacity but chooses the ‘wrong’ decision, express your concerns and explain that the best possible decision has not been made. -
- Patient is free to make the decision, but it is contrary to the advice of professionals.
- Encourage them to speak with other professionals, agree to see them again.
- Be aware that refusal may be due to misunderstanding treatment/illness and spend as much time understanding patients concerns as possible. Avoid jargon, offer multiple forms of information.
- Has the patient been influenced by others - is refusal due to coercion?
(If lacking capacity - Best interest decision to be covered elsewhere)
Capacity for social care
The legal position for where a patient should live is the same as for medical decisions
Usual context is patient wishing to live alone at home, but physical and cognitive difficulties pose risk
Assessment of capacity in keeping with MCA
Consult with the family - ensure patients best interests are being met
Apply for court of protection - supervise welfare decisions via court appointed deputy
Document thoroughly decisions being made
Has capacity:
Accomodate patients wishes
Express concern that this is not the best possible decision
Explain this being contrary to professional advice
Removal of dangerous items / set up alarm systems, wear pendant alarm, carer visits - facilitate wishes
MDT conference - patient, carers, professionals
Come back a second time to assess capacity
Does not have capacity:
Duty of care not to discharge dangerously
Consult NOK
As per usual - best interest decision making
IMCA (Independent mental capacity advocate) - if no NOK or relatives suitable
Second medical opinion if disagreement between medical team and relatives
Neuroleptic malignant syndrome (explanation)
Rare, potentially life threatening reaction to antipsychotics
Fever, rigidity, altered mental stated, autonomic disturbance.
Related to D2 blocade or dopamine depletion in brain.
Causes abnormal homeostasis - EPSEs, temp control, diarrhoea, confusion, tachycardia, hyper or hypotension,
Cannot predict it. 0.01-0.02% incidence
Higher: under 40, males, high dose, catatonia or agitation, high ambient temp.
IV benzo’s, IV fluids, discontinue drug, external cooling, bromocriptine - ECT has been used.
Borderline PD (history)
Emotional instability
Unstable relationships,
Impuslive
Disturbed self-image.
Feelings of abandonment
Recurrent self-harm
Feelings of emptiness.
Anger outbursts
Transient psychotic/dissociative symptoms
Risks to self and others
Eating disorder (history)
How much oral intake
Thoughts around food/weight
Any sensory issues when eating
Purging behaviours
Guilt associated with eating
Pattern of eating
Rapid weight loss
Weakness
Palpitations/Chest pain
Reduced libido
Amenorrhea
Fractures
Anorexia (d/w student)
Risk factos:
Young age
Genetics
Female
FHx ED or other MH disorder
Social pressures
Adverse life events
Personality traits - perfectionise.
Co-morbid mental health
High mortality.
BMI, sit-up-squat-stand (SUSS), blood abnormalities (low electrolytes, immunocompromised), ECG Changes - brady, prolonged QTc,
Anorexia (explanation to relative)
Low body weight caused by abnormal eating behaviours outside of social or cultural norms.
BMI under 18.5kg
Deliberate weight loss induced by patient (e.g. not healht related or scarcity)
Weight gain prevented by various means (vommiting, purging, diarrhoea, exercise, retricting.
Preoccupation with weight and shape or overestimation of weight.
50% make a full recovery
Community or hosptial dependent on need (particularly if risk of refeed).
Dietician support, psychological therapy (modified CBT), medication for co-morbid psychiatric - some offlicense such as olanzapine have been used VERY cautious.
Re-feeding syndrome (explanation to nurse)
Occurs when food reintroduced after period of abstinence.
Depletion of bodily stores of electrolytes
Insulin released in response to food (and rising blood glucose)
Body begins to synthesis glycogen, fat, protein
Shifts serum levels down. (mag, phos, potass)
Low serum levels can lead to heart arrhythmias which can be fatal.
Food reintroduced by dietician gradually.
Thiamine, vit B co-strong, multivitamin prescribed
If not detained for ED - nurse will need to request formal capacity assessment if deemed incapacitous to refuse treatment.
Postnatal depression or psychosis (history)
History re: Birth - Date, Complications
Timeline of symptoms
Past psychiatric history
Family history of perinatal psychiatric concerns
Social isolation
Domestic abuse
Differentials:
Baby Blues - few days post childbirth - mild depressive symptoms, irritability, emotional lability - Usually resolve within 2 weeks - is very common
- Post Partum Depression - Depressive symptoms lasting longer than 2 weeks post delivery - Risks of neglect / lack of drive to feed (formula vs breastfeeding)
- Post-partum psychosis - within days / weeks, can develop suddenly. Risks with FH and personal Hx of BPAD, extreme mood disturbance and psychosis - potentially life-threatening - Urgent treatment - RISKS: screen about harm to baby / harm from baby / other babies
- Perinatal OCD - intrusive thoughts, compulsive behaviours, time spent performing these
Management:
Depression - SSRI (not fluoxetine)- Standard depression management (biopsychosocial)- Paroxetine drug of choice, sertraline, citalopram or SNRI / Mirtazapine - Mother and Baby unit / ECT / TMS - Breastfeeding or not influences options available - social groups (mother and baby groups, early years worker, OT)
Psychosis - Standard psychosis (biopsychosocial) - Antipsychotic Quetiapine/Olanzapine, consider urgent MBU
OCD - Standard OCD treatment - SSRI/CBT with ERP or combination, clomipramine
Postnatal psychosis (explanation to relative)
Begin with explain psychosis - more predisposed than others, characterised by loss of touch with reality - hallucinations, behaviour, delusions, thought disorder, functional loss
Pregnancy and perinatal period bodily changes can lead to vulnerabilities
Increased risk from past history of Post partum psychosis, FH of psychosis, BPAD
Treatment response rate is good
Recurrence may occur in future pregnancies
Acknowledge patient-specific details
Discuss the risks that you would be concerned about - Risks to mother, risks to baby
Discuss management - Antipsychotics, mood stabilisers, inpatient admission to MBU, close monitoring
Perinatal referral
Provide leaflet / additional information
Depot (explanation)
Type of medication that is injected into a large muscle of the leg or buttock.
Slow releasing medication, designed to maintain the level in your body until your next injection.
Typically 2-4 weekly.
In community setting/clinic by trained nurse.
Helpful for: compliance, difficulty taking tablets, prefer not to think about medicaiton daily.
Risks:
Abscess, bleeding, bruising, irritation, lumps, numbness, pain, redness, soreness, swelling.
Note - as continue to act for e.g 2 weeks, if unpleasant side effect, cannot just stop giving tablet, so may experience for that period until medication washes out.
Reduce risks by cycling injection sites.
MHA (explanation to relative)
MHA Law:
Section 136 -
24hrs - Police - Reason to suspect a patient is behaving in a way that is warranting assessment by mental health team - triggers MHA
Section 2 - 28 days - Assessment, treatment can be initiated (only mental health conditions or consequences of MH condition)
3 independent clinicians, 2 doctors, at least one section 12 approved doctor which is usually a psychiatrist, Approved mental health professional (AMPH) typically social workers (offering a non-medical opinion, helping organize the process, knowledge of local services). Interviewed and decided if there is sufficient evidence of a mental health condition that cannot be safely managed in the community.
Can be converted to Section 3
Can be rescinded prior to finishing
For a treatable MH condition
No least restrictive option available
Do not consent / cant consent to admission voluntarily
Nearest relative - can apply for mental health tribunal hearing should they disagree, which take place within 7 days of application. Can apply for nearest relative discharge then RC has 72 hours to respond, if in disagreement then goes to hospital managers meeting.
Tribunal - can appeal against section - tribunal will be set up to make the decision - can get free legal representation
Section 3 - 6 months - For Treatment - has been assessed under Section 2 -> section 3. Or has known mental health problem, presenting with same difficulty, section 3 can be initiated. Treatment can be given against the will of the patient (only for MH diagnosis). (6 months, 6 months, then 1 year). Can be rescinded prior to 6 months as per Section 2.
Section 17 leave - the patient is detained under section to the hospital. Can be allowed specific leave whilst under this section, which will be written up as S17 leave.
Right to access IMHA - advocate for you
Right to having legal representation
Second opinion appointed doctor (SOAD) - 3 months - independent review
Section 5(2) - 72 hrs
Best Interest Decisions
All relevant cirumstances considered (diagnosis, care needs, etc)
Persons own beliefes / values
Persons past / present wishes and feelings
Consult others who are involved in their care (NOK, family, relative, carers, attorneys)
Any other factor the person would consider?
Will they regain capacity? Can it wait?
Is there a least restrictive option?
Encourage patient to be involved as much as possible
Decision not made solely based on age, condition, behaviour
Life sustaining treatment - decision not motivated by wanting to bring about person’s death - consider all of the above and have a reasonable belief about person’s best interest
r-TMS
What is it:
‘It also works in a similar way to ECT by simulating the brain, although with magnetic fields rather than electricity. This promotes the brain to mend and make new connections’
Non invasive
Does not require sedation
How is it given: Centre specific but, usually 30 minute sessions given 5 days per week for 2-6 weeks. Length of treatment tends to depend on responce.
Why do we give it:
Depression or anxiety that has not responded to conventional antidepressant
Risks:
Absolute Contraindications - MRI - Metal in the head /
Relative contraindications - pacemakers / medical devices / tumours or vascular events
Discomfort around administration site - ‘clicking’
Headache, dizziness
Twitching in the face
Rare (1/60,000) risk of seizure
Blood glucose if diabetic
Benefits:
Can see benefits within one week, but some people will take the full course to see the benefit.
Extras:
Able to drive between sessions provided side effects not too severe
Vagus Nerve Stimulation
What is it?
The VNS procedure happens using anaesthetic. This will either be general anaesthetic, which sends you to sleep. Or local anaesthetic, where you are awake but a part of your body is made numb.
Doctors will place a small electric device under the skin of your chest, just below your collar bone. This device is a bit like a pacemaker.
They will attach this device with some wires to a nerve in the left side of your neck. This is called the vagus nerve, which naturally sends signals to your brain.
The VNS device sends electrical pulses to your vagus nerve to stimulate this process. This stimulation will happen automatically for 30 seconds every 5 minutes.
The VNS device will stay in until it runs out of battery. This can take 3 to 8 years. If you need to, you can have the device turned off or removed.
How long does it take to work?
VNS may help to improve your mood and reduce your symptoms of depression. Some people can feel a little better straight after surgery. Others may take 6 months or longer before noticing any improvements in their symptoms.
Risks:
Feeling hoarse or having other changes to your voice
Coughing
Headaches
Neck pain
Feeling prickles or tingles in your skin
Sore throat
Difficulty breathing
Difficulty swallowing
Feel the pulse
Surgical complications
Benefits:
Improve mood and reduce symptoms of depression
