General Mental Health Flashcards
who can make an assessment order?
any health practitioner or mental health practitioner
what is a ‘mood episode’
any period of time that a patient feels abnormally sad or happy
what is the significance of negative symptoms and cognitive impairment in schizophrenia?
there is no treatment for negative and cognitive impairment in schizophrenia, and it indicate poor prognosis as both impair normal functioning
main differential diagnoses for schizophrenia?
bipolar disorder with psychotic features and major depressive disorder with psychotic features, schizoaffective disorder, schizophreniform disorder, alcohol/drug induced psychosis or medical illness causing psychosis
what is conduct disorder?
antisocial behaviour
what is the difference between transgender and transsexual?
transgender- person identifies with the gender other than their biologically assigned gender
transsexual- person has begun the hormonal/surgical process of transitioning to their identified gender
what group of patients are most likely to have dissociative identity disorder?
female patients who are sexually abused
what are the three types of cluster A personalities?
paranoid, schizoid, schizotypal
what are some characteristics of catatonia?
immobility, mutism, catalepsy, stupor, negativitism, echo-phenomena, repetitive purposeless movements
what drug is used for PTSD?
paroxetine
how might we manage delirium?
- ix and then treat the cause
- usually non-pharmacological management is sufficient (calm, reassurance, close monitoring)
- if significantly agitated/disruptive an anti-psychotic (haloperidol/olanzapine/risperidone) may be used. consider if patient can take oral or whether it needs to be IM
risk factors for bipolar disorder
• Genetic • Head injury Organic CNS disease • AIDS • Childbirth • Circadian rhythm disruption Sleep disruption
what are some issues that can arise from poor maternal mental illness?
• Poor attachment between mother and child
• Child may have problems with emotional interaction and development/failure to thrive
• Shown to have some structural neurological differences in neglected children
• Poor mental health while pregnant can cause effects such as foetal alcohol syndrome, IUGR, etc
• Psychotropic medication can pass through breast milk
• Increased risk of STIs–> vertical transmission
Medications can be teratogenic
what are the risks of refeeding syndrome
acute cardiac failure acute renal failure Wernicke's encephalopathy sepsis respiratory failure
what metabolic disturbances do you see in refeeding syndrome?
hypomagnesium
hypokalemia
hyponatremia
hypophosphatemia
and hyperglycaemia
describe panic disorder
Individual experiences recurrent unprovoked panic attacks, worries excessively about future panic attacks and often has maladaptive behavioural changes as a result of the panic attacks
A 21 year old female presents to ED with BMI of 11. Didn’t want to come in but GP completed an assessment order.
What is your management in the acute setting?
- Exclude organic cause e.g. thyroid/malabsorption
- What did you eat yesterday?
- Assess compensatory mechanisms (purging/fasting/exercise/laxatives/thyroxine)
- Assess their cognition about their weight- e.g. anorectic? Stress?
- Assess risk of refeeding syndrome (how quickly have they lost weight? Is it new onset?)
- Assess risk of physical sequelae (acid base issues, lack of poor sympathetic response, hypoalbuminaemia, amenorrhoea, infertility, osteoporosis/fractures)
- Assess psychiatric risk- Suicidal intent, DSH, risk of absconding
- Assess pyschiatric comorbidities- OCD, borderline personality disorder, anxiety, depression
- Physical examination- hypothermia, vitals (postural tachycardia and hypotension), poor peripheral circulation
- Investigations: FBE,UEC, TFTs, lipids, random BG, LFTs (albumin), coags, DEXA scan
- Admit to medical ward
- With dietician help commence refeeding slowly
- Give thiamine and other electrolytes
- Provide ongoing psychological support
what does depersonalisation mean?
feeling of detachment from patient’s mind to body
what are the three types of symptoms for schizophrenia
positive symptoms
negative symptoms
disorganisation symptoms
what are some structural abnormalities in the brain of patients with schizophrenia?
reduced grey matter
enlarged ventricles
reduced volume in frontal lobe, hippocampus, amygdala
what are the indications for ECT?
- melancholic depression
- psychotic depression with catatonia
- severe depression in pregnancy
- ?Bipolar/mania
what does lithium in high doses and ECT for bipolar patients result in?
acute delirium
define stupor
episode of mutism and absence of movement but no impairment of consciousness
what do we mean by ‘difficulty with affect regulation’?
commonly refers to patients with borderline personality traits who have fluctuating affects/mood and difficulty controlling it
differential diagnosis for deliberate self harm?
- adjustment disorder
- depression/substance abuse/personality disorder
- schizophrenia
non psychiatric ddx for anxiety?
- depressive illness
- thyrotoxicosis
- alcohol withdrawal
- excessive caffeine
- hypoglycaemia
what type of hallucinations are more common in schizophrenia?
auditory
how many treatments of ECT are generally needed for a patient?
most patients remit between 6-12 treatments but some require more
what are some exacerbating factors for depression
poor maternal child attachment/bond, child sexual abuse, unemployment, poor parenting
what do you think with late onset mania/personality changes?
organic cause
what is dissociative identity disorder also known as?
multiple personality disorder
what is the general age of onset for schizophrenia?
15-20s (adolescence)
what are the characteristics of cluster C personalities?
dependent, low self esteem, avoidance of conflict, obsessive compulsive, depressed mood
what is the dopamine hypothesis for schizophrenic positive and negative symptoms?
positive symptoms- overactivity of mesolimbic dopamine pathways
negative symptoms- underactivity of mesocortical dopamine pathways
what are the radiological and biochemical abnormalities seen in OCD?
Frontal cortex overactivity on PET scan
abnormality of serotonin pathways
explain why refeeding syndrome occurs?
In extremely malnourished patients the primary mode of metabolism is through use of fat/muscle. They also have reduced electrolytes however serum levels are normal. When undergoing nutritional support in the hospital, they are given CHO. CHO induces insulin to rise, insulin causes potassium/phosphate and Mg to enter cells, reducing serum levels of these electrolytes. Hyperglycaemia also occurs
what is a tic?
sudden repetitive involuntary motor movement or vocalisation involving specific muscle groups
what is agoraphobia?
difficulty going out alone e.g. crowded places/public transport
describe cyclothymic bipolar disorder?
Cycling between hypomania and depression ~4 episodes per year
why aren’t diuretic medications given prior to ECT?
to minimise the amount of urine in the bladder during the procedure, to prevent urinary incontinence as a result of the seizure
what do we mean by thought broadcasting?
patient feels that their thoughts that are shared by others
define an unhealthy personality disorder in general terms
an unhealthy personality has a restricted range of characteristics which makes the person unable to adapt to the world, hence limiting their functioning. It permeates all areas of their life
a patient is delirious on the ward. What ix would you order?
oxygen saturation with or without blood gas measurement
electrocardiogram (ECG)
blood glucose concentration
serum urea, creatinine, electrolyte and calcium concentrations
liver biochemistry
full blood count
urine dipstick analysis (and urine microscopy and culture if appropriate)
What exactly is ECT?
inducing a generalised cerebral seizure under general anaesthetic
what is schizoaffective disorder
for at least a month, patients have basic symptoms of schizophrenia accompanied by depressive or manic episodes
risks of ECT
retrograde and anterograde amnesia
memory disturbances
seizures
what are the three types of B personalities?
borderline
narcissistic
antisocial
classic triad of manic symptoms?
pressured speech, increased motor activity, heightened self esteem
what is schizophreniform disorder
patients have basic symptoms of schizophrenia but only has been unwell for less than 6 months
what is a differential diagnosis for depression?
cluster C personality disorder, hypoactive delirium, negative symptoms of schizophrenia, bipolar depression
what are the three types of C personalities?
obsessive compulsive
avoidant
dependent
describe neuroleptic malignant syndrome
Severe muscle rigidity and elevated temperature, autonomic instability and elevated CK! associated with the use of neuroleptic medication
what is child bonnet syndrome?
complex visual hallucinations in a partially or legally blind patient- usually seen in elderly blind patients
describe serotonin syndrome?
rigidity, myoclonus, hyperreflexia, increased temperature, confusion, agitation, tremor
describe borderline personality?
Marked impulsivity, unstable interpersonal relationships, self destructiveness
- -> angry and volatile
- -> think childhood trauma/abuse
describe generalised anxiety disorder GAD
over 6 months, excessive anxiety and worry on most days, with three or more of difficulty concentrating, easily fatigued, sleep problems, irritability, muscle tension
define affect
external representation of internal emotion
contraindications for ECT?
raised ICP`
hyperthyroidism
recent cerebrovascular event
what is the difference between factitious disorder and somatisation disorder and malingerering?
factitious disorder- patients feign symptoms to gain attention/sympathy etc
somatisation disorder- patients truly experience psychosomatic symptoms with no intention to deceive
malingering- patients feign symptoms for an ulterior motive such as work cover, financial/insurance/forensic reasons
what is conversion disorder?
patient presents with neurological symptoms e.g. seizures, paralysis, blindness, dysphagia, dysarthria but no organic neurological cause has been found
for example- psychogenic seizures
often associated with maladaptive personality traits, hx of abuse, derealisation/depersonalisation and dissociative amnesia
does not fit concretely into malingering/factitious behaviour
patient symptoms are often incongruent and often they show a strange lack of concern for the severity of their presentation which is called the ‘la belle indifference phenomenon’
define delusional disorder?
at least 1 month of delusions but no other major schizophrenic symptoms (e.g. hallucinations, unless related to the delusions) or impaired functioning. delusions are not attributable to other organic physiological cause/drugs/alcohol
what is an easy way of thinking about the three clusters of personalities?
MAD- cluster A
BAD- cluster B
SAD- cluster C
what do we mean by negative symptoms?
avolition, blunt affect, asociality, anhedonia, alogia (diminished speech output)
what possible ix would we order for a newly admitted psych patient and why?
FBE: looking for agranulocytosis (clozapine), macrocytosis (alcohol abuse), anaemia (eating disorder), platelet counts (carbamazepine + valproate)
UEC: renal function (lithium), electrolyte disturbance (SSRI/SNRIs)
LFTs: looking for deranged (alcohol abuse, hepatitis B/C, antipsychotic meds especially chlopromazine)
TFTs: looking for organic cause (thyrotoxicosis), lithium side effects
Fasting glucose + lipids: metabolic screen when on anti-psychotics
PRL level: for antipsychotics like olanzapine and risperidone
Lithium blood test- looking for levels of Li2+ in bipolar patients (may indicate compliance)
Drug and alcohol levels- looking for substance abuse cause (urine test and blood test respectively
Serology: hep B/C, HIV
Vitamins: B12/thiamine/folate
what are the positive symptoms of schizophrenia
delusions and hallucinations
ddx for OCD
anxiety
depression
DSM criteria for bulimia
- recurrent episodes of binge eating
- recurrent inappropriate compensatory behaviours to prevent weight gain
- these behaviours and binge eating occur at least once per week for three months
- selfevaluation is influenced by body shape and weight
a patient presents with an episode of psychosis- what do we need to exclude?
- organic/medical cause
- substance abuse induced psychosis
- masquerading mood disorder such as depression/anxiety/bipolar
when taking an adolescent psych history, what do we need to cover?
- You need to take a detailed family and developmental history
- Try to ascertain the patterns of dealing with adversity
Consider the goals of adolescence- identity and independence (both practical and that of thinking)
what is psychosis? and what are the differentials for this acute presentation?
psychosis= group of symptoms delusions/hallucinations/psychosis
first thing- rule out organic cause (thyroid/brain infections, bleeds, masses, seizures)
ddx: first presentation of schizophrenia schizophrenia relapse alcohol/drug induced psychosis delirium other psychiatric disorder e.g. bipolar head injury personality disorder
2nd thing- affective or non affective (will indicate management e.g. antipsychotic +/- mood stabiliser)?
look for depressive symptoms (delusions of guilt/poverty/nihilistic, psychomotor retardation, vacant affect, avolition)
look for manic symptoms
define illusion
misinterpreting a visual phenomenon
how do we generally describe cluster A personalities?
withdrawn, cold, isolated
describe schizoid personality
Pervasive detachment from social surroundings, restricted expression
differential for negative symptoms of schizophrenia?
Depression, alcohol issues, sleep disturbance, SE of antipsychotics
what are the usual methods of treating catatonia?
benzodiazepine (usually lorazopam) challenge
+/- ECT
do not use dopamine blocking anti-psychotic medications
what is the difference between fear and anxiety?
fear= emotional response to imminent threat
anxiety- anticipation of future threat
define a phobia?
unreasonable fear leading to avoidance
how to manage serotonin syndrome?
stop all serotonergic medication, supportive therapy (ABC, fluids, intubation if necessary, management of hyperthermia), 5HT3 antagonist cryproheptadine
Define delusion
a fixed false belief out of keeping with the patient’s social/educational/religious upbringing
what are the three forms of auditory hallucinations?
- third person commentary
- echo- hearing thoughts aloud
- command
define bipolar 2 disorder
episode of hypomania and depressive episode
what are the four types of biological temperament traits?
- harm avoidance
- novelty seeking
- persistance
- reward dependence
what is the long term management for eating disorders?
• Family based therapy
• CBT ‘e’ individual based therapy
DBT for borderline personality disorder
what are the three main groups of youths who suicide?
- depressive perfectionistic youths
- aggressive impulsive youths
- disintegrating/psychosis cluster
how might we manage psychotic depression?
ECT can be used for acute episode
Antidepressants +/- antipsychotics
what does derealisation mean?
surroundings around the person appear dreamlike or not real
hallmark features of delirium?
acute/fluctuating course
inattention
disorganised thinking
+/-altered conscious state
(use the CAM assessment)
-also know that delirium can also be hypoactive
how long does a temporary treatment order last for?
28 days
what do we mean by referential ideas/beliefs?
misinterpreting environmental stimuli in context of delusion
describe some forms of visual hallucinations
• Distortions- palinopsias (visual perseveration), micropsia (smaller)/macropsia(bigger), distortion of face, increased colour
Hallucinations- dendropsia (branching patterns), animals, peoples, landscapes or scenes, worse at dusk or early morning, geometric repeating patterns
list the types of anxiety disorders
• Generalised anxiety disorder GAD • Social anxiety • Agoraphobia • Separation anxiety • Panic disorder Substance/medication induced anxiety
in the formulation for a psych history- what types of factors are we looking for
precipitating, perpetuating and protective factors
what are some prenatal risk factors for schizophrenia
Maternal anaemia, toxoplasmosis, IUGR
what are compulsions
Repetitive behaviours that patient feels driven to perform in response to an obsession
what are some drugs commonly implicated in delirium?
anticholinergics
benzodiazepines
opioids (including pethidine and tramadol)
corticosteroids
nonsteroidal anti-inflammatory drugs (NSAIDs)
dopaminergic drugs (eg levodopa, dopamine agonists,
catechol-O-methyltransferase [COMT] inhibitors)
sotalol and propranolol (unlikely with other beta blockers)
alcohol and illicit drugs (eg cannabis, methamphetamine).
define hallucination
an experience whereby the patient reports a perception of an external stimulus, which has the quality of a real stimulus.
what are some considerations for treatment of schizophrenia?
• Ongoing treatment with anti-psychotics is useful
• Adherence can be a problem
• Prevent use of recreational drugs
Address family/social network as psychosocial factors can determine prognosis
how can we manage negative symptoms of schizophrenia?
Very hard to treat.
Some patients may respond to clozapine
try an anti-depressant to exclude depression
what are some physical signs of bulimia?
poor dentition
Russell’s sign (knuckle callus secondary to inducing vomiting)
enlarged parotids
normal body weight or even overweight
what is tardive dyskinesia
Movement disorder from prolonged anti-psychotic use
involuntary movements usually in face and jaw such as grimacing, lip smacking, lip pursing, excessive blinking.
hard to treat
4 key risk factors for major depression?
predisposing anxiety disorder
bipolar
substance abuse
personality disorder
what is a panic attack
brief intense episode of anxiety- associated with physiological and somatic symptoms
what do we mean by blunt affect
almost no emotion
how many genes are implicated in schizophrenia?
107
describe catatonic behaviour
marked decrease in reactivity to the environment
what are obsessions
Intrusive, inappropriate, recurrent and persistent thoughts- not simply excessive worries about real life problems
difference between pseudohallucination and hallucination?
pseudohallucination- the ‘voice’ they hear still comes from within themselves, whereas hallucination- they typically describe a separate, external, autonomous entity
describe DSM criteria for agoraphobia
2 or more from the following list:
- marked anxiety when using public transport
- marked anxiety when outside home along
- marked anxiety when in a crowd/standing in line
- marked anxiety when in open spaces
- marked anxiety when in enclosed spaces
intense anxiety is provoked in these situations where the individual feels like they ‘cannot escape’
anxiety is out of proportion to social situation
leads to avoidance of these situations
symptoms are greater than 6 months duration + impaired functioning
exclude other physiological/medical/drug cause
what is the difference between hypomania and mania?
difficult to distinguish and both have the same characteristics (e.g. pressured speech, reduced need for sleep, high self esteem) but hypomania is generally shorter (less than 4 days) whereas mania is typically defined as a week, and the inference is that hypomania does not lead to loss of function/overt psychosis (hospitalisation/drugs) whereas mania does. So shorter and less severe= hypomania
how might we manage patients with both schizophrenia and depression?
treat according to the severity of depression with antidepressants but keep the anti-psychotics on.
e.g. +/- SSRI, +/- ECT +/- CBTP
what is akathisia
this is the feeling of extreme restlessness- patient has to pace up and down, cannot sit still etc. Side effect of anti-psychotics and anti-depressants
describe what we mean by personality?
a personality is the enduring set of characteristics that define ourselves
what is the gold standard positioning of electrodes in ECT?
bitemporal or bilateral
what does mixed state bipolar disorder mean?
both manic and depressive symptoms at the same time. Not very common
what type of positioning for ECT electrode leads is associated with least cognitive impairment?
right unilateral positioning
what is the biggest risk factor for schizophrenia?
genetics/FMH
KEY CONCEPTS OF SUICIDE PREVENTION?
always ask, do a thorough suicide history!
start anti-depressants when in doubt!
what do we think when a patient has a visual hallucination?
search for the organic cause
how might we reduce the cognitive impairment associated with ECT?
using one electrode (unilateral)
spacing treatments in time
using squared pulses
what are the major predictors of suicide?
- hopelessness
2. insomnia
what are some protective factors for depression?
employment/financial independence, support system (at least 1 good relationship), happy marriage, high IQ
what do we mean by the passivity phenomenon in schizophrenia?
this is known as the ‘as if’ phenomenon. Patients will describe it is as though their behaviour/functions are taken over by an external influence
how to medically manage acute mania episode?
antipsychotic +/- benzodiazepine for sedation
what is hypnosis?
a state of increased access to the higher CNS centres due to reduced activity in the reticular activating system
what is echolalia and echopraxia?
repeating the same words as the interviewer
repeating the same motor movements as the interviewer
what are some types of obsessions for OCD disorder
• Contamination • Counting • Ordering/arranging • Touching rituals • Sexual thoughts • Pulling out hair • Body dysmorphic disorders Eating disorders
what ix would you do for Anorexia Nervosa?
• ECG (look for hypokalemia, prolonged QTc)
• UEC (HCo3>30mmol where there is vomiting/laxative misuse)
• LFTs (looking for hypoalbuminemia)
• Lipid profile
• FBE (normocytic normochromic anaemic, reduced WCC/PLT and ESR)
• Endocrine- LH/FSH (reduced) , oestrogen(reduced), TFTs (low T3), cortisol (raised)
• DEXA scan to look for osteoporosis
Random blood glucose
treatment of agoraphobia?
- CBT (set up a hierarchy, desensitisation, relaxation/hypnosis)
- SSRIs
- Anxiolytics of very limited use
define stereotypies?
repetitive movements that have no purpose- often seen in schizophrenia
define bipolar 1 disorder
one episode of mania, and can often associated with severe depression
DSM criteria for depression?
- cause significant functional impairment
- not due to other medical illness/substance
- not due to other mental illness
- either or both low mood most of the day for 2 weeks or anhedonia
- five or more of: guilt, worthlessness, psychomotor retardation/agitation, difficulty concentrating, loss of weight, fatigue, hypersomnia/insomnia, recurrent thoughts of death
what are some ddx of visual hallucinations?
Cerebrovascular disease Charles Bonnet Syndrome Peduncular hallucinosis- cerebral peduncle, vascular, neoplastic, demyelinating lesions Narcolepsy Neurodegenerative disorders- HD Lewy body dementia + PD + FTD Migraine Temporal lobe epilepsy Delirium Hallucinogen drugs Autoimmune disorders/infections Closed head injury
What are the risk factors for Anorexia Nervosa?
Family Hx: eating disorders, parental obesity, restrictive dieting, cultural factors
Personal Hx: body dissatisfaction, restrictive dieting, childhood obesity, early menarche, depression, substance abuse, obsessive compulsive disorder, social anxiety, adverse life events
Personal characteristics: perfectionistic and obsessional traits, borderline personality disorder
what are the 5 axises of mental health
Axis 1= Psychiatric disorder
Axis 2= developmental/personality disorders,
Axis 3= Medical disorders
Axis 4= psychosocial stressors
Axis 5= overall function- give score 0-100 (GAF scale)
what is borderline personality disorder often associated with?
sexual abuse during childhood
what characteristics of a patient psychiatric history would make you think that a personality disorder was involved?
- if they can’t tell you anything about their interests/hobbies
- when they have trouble maintaining interpersonal relationships
- when they have trouble maintaining employment/work well with others
what are some associated features of anorexia nervosa?
• Reduced bone mineral density • Depression + increased suicidality and DSH • OCD behaviours • Substance abuse • Electrolyte disturbance esp hypokalemia (constant purging may lead to metabolic alkalosis) • Sinus bradycardia • Low blood pressure • Amenorrhoea • Hypothermia • Lanugo (fine downy hair over body) • Poor dentition Constipation
what do we mean by ‘waxy flexibility’?
also known as catalepsy, this is a rare motor symptom of schizophrenia where you can passively move the person’s limbs into an abnormal position which they maintain
describe schizotypal personality
Schizoid + eccentric behaviour, cognitive perception disorder
Huntington’s disease brain abnormalities?
bilateral caudate nucleus atrophy
describe the characteristics of borderline personality disorder?
self harm, volatile interpersonal relationships, anger
what is a secondary psychiatric syndrome?
Not related to primary psychiatric disorder but related to brain disease and systemic illness
who makes a treatment order?
authorised psychiatrist + mental health tribunal
how might you ask about thought insertion?
Thought insertion: do you ever think that all the thoughts in your mind are not your own?
tell me about the characteristics of delusional disorder?
- Tends to come on later (40s-50s)
- Preoccupied with specific circumscribed delusion
- Non-bizarre delusion- plausible
- E.g. jealousy/infidelity
- Can be quite dangerous
Not as responsive to biological treatment however biological treatment can dull down the severity of the delusions
first line, second line, 3rd line and adjunct medications for bipolar? also how to manage an acute manic episode (e.g. which medications?)
1st line- lithium or other mood stabiliser (valproate)
2nd line- mood stabiliser +/- atypical antipsychotic (e.g. olanazapine)
3rd line- clozapine
adjunct is benzodiazepam such as clonazepam and SSRI
acute- IM injection olanzapine
what are anorexia nervosa inpatients at risk of?
refeeding syndrome
what is the purpose of an assessment order?
An Assessment order enables an authorised psychiatrist to examine the person without the person’s consent to determine whether they have mental illness and need compulsory mental health treatment.
An Assessment order enables a person subject to that Order to be taken to and detained in a designated mental health service for assessment if necessary.
what can negative symptoms be secondary to?
psychotropic medications, depression and anxiety
what do we think if someone who is depressed is not responding to multiple anti-depressant changes?
think either personality disorder or bipolar depression
what are some treatment options for anxiety?
- Explanation of symptoms
- CBT
- Relaxation techniques (including hypnosis)
- Benzodiazepines short term
- Antidepressants for chronic symptoms
- Busipirone 10mg tds (rarely used)
- Atypical antipsychotics
- Formal psychotherapy for personal vulnerabilities
how is delusional disorder different to schizophrenia?
patients with delusional disorder simply have delusions without any other symptoms of schizophrenia
define overvalued ideas
comprehensible idea carried beyond bounds of reasoning and having an impact on the patient’s functioning such as morbid jealousy etc
what are some potential precipitants/causes of delirium?
infection surgery metabolic disturbances (e.g. blood sugar) pain medications alcohol/substance withdrawal other intercurrent illness cardiovascular/cerebrovascular/ictal event
what are some typical phases of a grief response?
- Shock and denial
- Preoccupation with memories or thoughts of the deceased
- Searching or pining for the deceased
- Despair and temporary loss of social functioning (ie social withdrawal)
- relapses/recurrences (on anniversaries etc)
how do we manage neuroleptic malignant syndrome?
cease antipsychotic
ICU supportive care mx including cooling and ventilation if required
manage hyperkalemia
can use anti-cholinergics or bromocriptine
how might we distinguish between NMS and serotonin syndrome?
NMS usually caused by anti-psychotics (dopamine blocking agents) whereas SS usually caused by anti-depressants (serotonin agents)
NMS has a slower onset and slower recovery time than SS
NMS is associated with very elevated CK
NMS usually has leadpipe rigidity, hyporeflexia, EPSE whereas SS has myoclonus, hyper-reflexia and dilated pupils
there is greater mortality with NMS
what are some key differences between complicated grief and a normal grief response?
normal grief is associated with declining grief over time, and greater adaptability/return to normal functioning or activities
complicated grief leads to impaired functioning and marked social withdrawal. response may have a more protracted time period then normal
describe some typical MSE findings in a depressed patient?
appearance- withdrawn, teary, looks older than age, signs of self-neglect or poor self care, signs of DSH
behaviour- psychomotor retardation, little eye contact, crying, social withdrawal, anhedonia
speech- latent speech, diminished volume, short one word answers, delayed response
thought- poverty of thought, thought blocking, mood congruent delusions/hallucinations e.g. delusions of poverty/nihlism etc
Cognition- some issues with memory and concentration but usually normal orientation
insight/judgement- may be impaired
what are the physical admission criteria for A.N
BMI less than 14, rapid weight loss HR less than 40 temp less than 36 hypoglycaemia electrolyte disturbance- hypokalemia myopathy petechial rash and platelet suppression
what are some psychiatric admission criteria for A.N
- Active suicidal plan
- Anorexic cognitions
- Other psychiatric disorder requiring hospitalisation
- Eating- need supervision of every meal NGT
• Compulsive, uncontrolled purging
Severe family problems
define psychoeducation
provision by the therapist of general information
to the patient (and their family and significant others, as indicated) regarding the nature of their mental illness and the potential therapeutic interventions available
what is another term used for exposure response therapy- what is it used for?
behavioural therapy using a fear heirarchy
OCD, agoraphobia, PTSD, phobias (general)
describe the cognitive component of CBT
Cognitive therapy involves helping individuals identify and challenge negative automatic thoughts.
describe DBT
Dialectical behaviour therapy (DBT) is a skills-based therapy that follows CBT principles, but with an emphasis upon acceptance of and by the person of their current maladaptive behaviours, combined with an expectation that these behaviours need to change.
–> BORDERLINE PERSONALITY DISORDER
it which psychiatric conditions is psychodynamic analysis NOT appropriate?
psychosis
severe major depression
what is clang association?
type of thought form
-associations based on sounds of words
what is a term used to encompass circumstantial and word salad thought form?
loosening of associations
what is different about tangential vs circumstantial thought form?
in tangential thought form, the patient never gets back to the original topic whereas in circumstantial thought form the patient does eventually
thought form can be accelerated, interrupted or slow. What are the terms used for these variations of thought form?
accelerated- usually referring to flight of ideas- mania
interrupted- thought blocking
slow- latent, retardation of speech
what is the natural history of ‘postpartum blues’?
transient feelings of irritability, tearfulness, anxiety etc are normal in the immediate postpartum period. This is colloquially called postpartum blues.
Usually peaks at day 3-5 and self resolves by 10 days.
needs to be distinguished from early presentation of postpartum depression
usually associated with exhaustion, change in lifestyle, change in relationships, acquisition of responsibility
when is the peak for postnatal depression, and what are some treatment options?
Postpartum depression usually emerges around the 3 month mark post birth of child.
It should be risk stratified for mild/moderate/severe and a proper risk assessment should be performed.
in mild/moderate p.depression, psychological support (CBT/IPT) +/- SSRI is usually sufficient. Referral to community perinatal mental health services may be of benefit.
For severe cases, associated with suicidality or other risk, admission to a specialist mental health mother and baby unit is required.
a woman with a previous psychiatric history (bipolar) becomes pregnant. She is currently on mood stabilisers. what do you need to do with her medications?
Current medication review! what types of mood stabilisers is she on? Which trimester of pregnancy is she in? e.g. worried about teratogenicty of the medications for neonate.
You need to weigh up risk to infant vs risk of untreated maternal illness. In low risk cases, you may consider weaning the mood stabiliser and putting on an antipsychotic instead, but in high risk cases you may need to persist with the mood stabiliser (lithium usually) with close monitoring and with consultation with maternity psychiatric services and consultant obstetrician.
ECT may also be an option.
DSM criteria for PTSD?
A) Significant traumatic event
B) Patient relives event
C) Patient attempts to avoid thinking about the event
D) Patient’s mood is negatively affected e.g. dissociative symptoms/negative symptoms
E) Patient becomes hyper vigilant and hyperaroused by surroundings
F) Must be chronic- not acute traumatic stress (i.e. greater than 1 month)
