Lecture ILO’s Flashcards
Aetiology of psychosis
• Obstetric complications
• Parasitic infections (toxoplasma gondii -> 2.5x greater
risk).
• Viral infections in second trimester of pregnancy?
• Neuroinflammation
• Reaction of the individual to stress
• Socioeconomic status
• Expressed emotion: hostility, critical comments and
emotional overinvolvement.
Differentials of schizophrenia
• Anatomic abnormalities
– Brain space occupying lesions, Intracranial bleeding, Idiopathic calcification of basal ganglia
• Metabolic problems
– Wilsons disease, Porphyrias – Acute intermittent porphyria, Delirium
• Vitamin Deficiency
– B12, B2, or folate deficiency
• Infectious illness
– Lyme disease, lupus, encephalitis (syphilis, HIV, herpes), Creutzfeldt-Jakob disease (CJD)
• Autoimmune disease
– MS, NMDAR encephalitis etc.
• Drugs
– LSD, cannabis
• Endocrine
– Hypo or hyperthyroidism, Addison’s disease, Cushing’s, Hypo- or hyperparathyroidism
What is psychosis?
WHAT IS PSYCHOSIS
▪ Syndrome associated with dysregulation of the neurotransmitter’s dopamine and serotonin and abnormal functioning of key brain circuits, particularly involving frontal, temporal, and mesostriatal brain region.
Psychosis is characterised by significant changes to perception, thoughts, moods and behaviour
▪ Primary (“non-organic”) psychiatric disorders
▪ Secondary to substance use or specific medical (“organic”) aetiologies ie brain tumours
Acute behavioural disturbance sign and symptoms
▪ Acute behavioural disturbance
▪ Presentation that includes abnormal physiology &/or behaviour
▪ Signs & symptoms
▪ Agitation
▪ Constant physical activity
▪ Bizarre behaviour
▪ Fear panic
▪ Unusual or unexpected strength
▪ Sustained non-compliance with police or ambulance staff
▪ Pain tolerance , impervious to pain
▪ Hot to touch, sweating
▪ Rapid breathing
▪ Tachycardia
Assessment of psychosis
• Physical examination:
• detailed neurological examination
• complete mental status examination, with the following areas of focus:
• mood and affect,
• thought process and content (including an assessment of
delusions, abnormal perceptions,
• suicidal and homicidal ideation, and insight),
• and a cognitive examination
▪ complete blood count,
▪ comprehensive metabolic profile,
▪ thyroid function tests,
▪ urine toxicology,
▪ measurement of parathyroid hormone, calcium,
▪ vitamin B12, folate, and niacin
▪ Based on clinical suspicion,
▪ testing for HIV infection and hepatitis C,
▪ brain neuroimaging (e.g., CT or MRI)
How to assess capacity
1) Does the patient have the relevant information about the decision ie do they know the positives and negatives of leaving hospital / not being treated
2) Is the patient supported well in making their decision ie have they got a translator if needs be, are they being informed by someone they have a good rapport with
3) Do the assessment to see if they have capacity: (the functional test)
Understand information
Retain information
Weight up information
Communicate it back (positives/negatives of leaving hospital/ not receiving treatment)
4) Is any functional inability due an to impairment of the mind?
Mental capacity act: statuary best interests
What are the patients wishes and feelings
What are the patients past wishes and beliefs
What are the available options
What are the opinions of the professionals
Views of family/other people interested in welfare of the patient
The mental health act - 3 stage test
“3 stage test”.
1) Does the patient have a Mental Disorder of a degree and/or nature
that requires detention for assessment / treatment?
2) Are there risks to patients own health, safety or protection of others
that warrant detention?
3) Is there no less restrictive way of providing the required care and
treatment? (Proportionality)
If the answer is yes to these questions then the person meets the
statutory criteria for detention under the Act
Types of anxiety disorders
Generalised Anxiety Disorder (GAD)
Acute stress reaction
Post-traumatic Stress Disorder (PTSD)
Phobias including Social Phobia, Agoraphobia
Panic Disorder
Obsessive Compulsive Disorder (OCD)
Eating Disorders
Management of anxiety
CBT is usually first line
Drug Therapy
Rapid response
̈ Sedative antihistamines ̈ Benzodiazepines
Do not use beyond four weeks
Dependence may occur
Apparent dependence may be because anxiety symptoms have returned
Buspirone less sedative and less addictive
Long-Term Treatment
̈ Antidepressants are often good at alleviating anxiety, even if there is no true depression.
̈ SSRI is first choice (or venlafaxine)
NICE recommends sertraline first-line
Licenced SSRI are escitalopram and paroxetine
If one SSRI not suitable or no improvement after 12 weeks offer another
Long-term treatment and doses at upper end of indicated dose range may be necessary.
Pregabalin if cannot tolerate SSRIs.
Beta-blockers and monoamine-oxidase inhibitors NOT appropriate long-term
Acute Stress reaction
Acute Stress Disorder
A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days.
Usually the precipitating event is, or is perceived as, life-threatening.
Examples include serious accidents, natural disasters, violent assaults, terrorist incidents
Those at risk include refugees, asylum seekers, first responders, military personnel
Predisposes to post-traumatic stress disorder (PTSD)
n Initial state of ‘daze‘
̈ constriction of the field of consciousness and narrowing of attention
̈ inability to comprehend stimuli ̈ disorientation
n Followed either by further withdrawal from the surrounding situation, or by agitation and over-activity
n Autonomic signs of panic and anxiety (tachycardia, sweating, flushing)
n Symptoms appear within minutes and disappear within two to three days (often within hours)
n Partial or complete amnesia may be present
Acute stress disorder
Acute Stress Disorder
Persistence of PTSD type symptoms up to a month after event
̈ After this it becomes PTSD n Symptoms include
̈ Flashbacks where it seems as if the event were happening again.
̈ Nightmares, which are common and repetitive.
̈ Distressing images or other sensory impressions from the event,
which intrude during the waking day.
̈ Distress with reminders of the traumatic event
Majority resolve spontaneously
PTSD management
Management
Trauma Focused CBT (TF- CBT) should be offered first- line
Eye-Movement Desensitisation and Reprocessing (EMDR)
If intrusion or arousal symptoms predominant
Non-trauma focused psychological therapy
̈ If above fail
Drug therapy is second line but fluoxetine, paroxetine and venlafaxine may be helpful
Benzodiazepines should only be used short-term
Stellate ganglion block (to reduce epinephrine and nor- epinephrine levels) has been effective in the most severe cases
Treatment for Panic/ Phobic Disorders
CBT
+/- SSRI such as sertraline, escitalopram
If not helpful try alternative such as venlafaxine
Bulimia nersova examination findings
Examination Findings
̈ Normal or low normal weight
̈ Callouses on back of hands or enamel wear on teeth from repeated vomiting
̈ Electrolyte disturbances (hypokalaemia usually) from repeated vomiting or laxative abuse
̈ Painless enlargement of salivary glands
̈ 10-15% develop anorexia
Types of personality disorders
COGNITIVE/ PERCEPTUAL (ODD)
Paranoid
Schizoid
Schizotypal
IMPULSE DSYCONTROL (IMPULSIVE)
Anti social
Emotionally unstable
Histrionic
Narcissistic
AFFECTIVE DYSREGULATION (FEARFUL)
Avoidant
Dependent
Obsessive compulsive
Personality disorder descriptions
̈ Paranoid - pervasive distrust and suspicion, such as others exploiting or deceiving them, friends and associates untrustworthy, information confided to others will be used maliciously, hidden meaning in remarks or events others perceive as benign.
̈ Schizoid - withdrawal from affection, social and other contacts. Isolation and limited capacity to experience pleasure and express feelings.
̈ Schizotypal – difficulty forming close relationships, eccentricity, perceptual distortions and ideas of reference. Social anxiety, even in familiar situations.
̈ Antisocial - tendency to act outside social norms, disregard for the feelings of others and inability to modify behaviour in response to adverse events (eg, punishment). Low threshold for violence and a tendency to blame others.
̈ Emotionally unstable - impulsive and unpredictable. Act without appreciating consequences. Outbursts of emotion and quarrelsome behaviour. Unstable relationships, suicidal gestures and attempts.
̈ Histrionic - Shallow and labile affectivity and theatricality. Lack of consideration for others and a tendency for egocentricity. Craving of excitement and attention.
̈ Narcissistic - sense of self based on grandiosity and need for admiration, interpersonally exploitative, has difficulty accepting diagnoses that challenge sense of self as infallible. Often exists alongside intense degree of shame, rage in the face of humiliation.
̈ Obsessive Compulsive - preoccupation with orderliness, perfectionism, and mental/interpersonal control (and subsequent lack of flexibility, openness, and efficiency); overconscientious, stubborn, and excessively devoted to work.
̈ Anxious (avoidant) - feelings of tension and apprehension, insecurity and inferiority. Desire to be liked and accepted, sensitive to rejection. Exaggeration of potential dangers and risks and avoidance of everyday activities.
̈ Dependent - reliance on others to take decisions and fear of abandonment. Excessive reliance on authority figures and difficulty in acting independently. Difficulty dealing with intellectual and emotional demands of daily life.
