Lectures Flashcards
How old are the children in CAMHS?
4-18
Where is CAMHS mainly based?
In the community
Are there inpatient beds in CAMHS?
There are in-patient beds but they are very limited
What is the difference between CAMHS and adult psych?
[1] less pharmacological treatment; [2] wider range of therapies available (especially creative therapies); [3] more emphasis on involving family, school, college and any system around the child.
Which patients might get special transition from CAMHS to adult psychiatry?
ADHD; psychoses; anorexia; high risk patients (early intervention teams can take these patients early if needed)
What is attachment theory?
An infant needs to develop a relationship with at least one primary caregiver for the child’s successful social and emotional development, and in particular for learning how to effectively regulate their feelings.
What is the recovery model in psychosocial treatment?
People can change their attributes , skills and goals.
What is involved in psychosocial treatment?
Help with independent living, money, housing, education, employment, meaningful activities (days structured, back to work, volunteering)
What is the definition of formulation?
Going beyond the diagnosis. Constructing a formulation all focus on the process rather than the finished product.
What are the four different things you ask about in the biopsychosocial formulation?
Predisposing factors (vulnerability); precipitating factors (triggers); prolonging factors (maintaining); protective factors?
What sort of predisposing factors would you ask about?
Genetics, developmental disabilities; sensory impairments; temperament; early trauma; core beliefs; formative relationships; school life; security (housing/finance)
What sort of precipitating factors would you ask about?
Hormones; drug use; physical illness; head injuries; transitions and life stages; life events; bullying; work; relationships
What prolonging factors would you ask about?
Alcohol and drug misuse; non-adherence; unhelpful coping styles; lack of insight; destructive patterns of behaviour; relationships - anger/dependency
What protective factors would you ask about?
Intact cognitive function; physical health and mobility; adherence; insight; motivation for change; goals; supportive relationships; engagement with services
What is IAPT?
Improving access to psychological therapy
Where is IAPT bases?
In the community and GP practices
What conditions does IAPT deal with?
Mainly depression and anxiety but it’s remit is widening
What are some models of psychotherapy
Psychodynamic; CBT; counselling; cognitive analytical therapy; interpersonal therapy; dialectic behavioural therapy; family therapy; marriage therapy
What is Freud’s original model based on?
Focussed on therapy as a process of uncovering past trauma to resolve present day symptoms
How long would you have psychodynamic psychotherapy for?
Once a week for about a year
What are the waves of CBT?
1st wave: behavioural therapy
2nd wave: cognitive behavioural therapy
3rd wave: combines mindfulness and acceptance with the above therapies
How many CBT sessions would you normally have?
They are generally structured and fairly brief (6-20 sessions) but may be longer in some cases
What does CBT focus on?
Mainly focuses on the here and now, and on problems in day to day life rather than on the therapeutic relationships
What are the aims of counselling?
It is fairly short and aims to help patient be clearer about their problems and find answers on their own
When is counselling used?
Often used to help someone cope with recent events that are difficult. It does not aim to change you as a person
What are the aims of cognitive analytical therapy?
Integrates cognitive and psychotherapy. Patient describes how problems have developed from events in their life and their personal experiences. Focuses on their way of coping and how to improve
How often would you have cognitive analytical therapy?
You would have 16-24 sessions over 4-6 months. Each one is about 50 minutes
How does interpersonal therapy work?
Aims to help the patient understand how problems may be connected to the way their relationships work. Helps identify how to improve relationships and find better ways of coping
What disorders is dialectic behavioural therapy focus on?
Helps with problems associated with borderline personality disorder (repeat self harming)
What does dialectic behavioural therapy aim to do?
Goal is to help patients learn to manage difficult emotions by letting them experience, recognise and accept them
What are the three different concepts in phenomenology?
Concrete concept (real objects or situations); defined concept (classes of concepts); concepts systems (sets of related concepts)
What is an illusion?
Illusionsare misperceptions of real external stimuli e.g.if you think a coat rack is a person, the coat rack is real but the interpretation is wrong.
What is a hallucination?
Hallucinationsare perceptions occurring in the absence of an external physical stimulus. Modalities include Auditory, visual, olfactory, gustatory, tactile, somatic. E.g. if you see someone who is not there
What is a hypnopompic hallucination?
A hallucination that happens when you’re waking up
What is a hypnogogic hallucination?
A hallucination that happens when you’re falling asleep
What is a reflex hallucination?
Experience stimulus in one modality and feel it in another modality. Modality = sense “When you write, I can hear your pen pressing on my heart”
What is an extracampine hallucination?
Hallucination that cannot possibly be experienced. ” I can hear people talking to me from Australia.”
What are the types of auditory hallucinations?
1st person, 2nd person, 3rd person (running commentary)
What is an over-valued idea?
A false or exaggerated belief sustained beyond logic or reason but with less rigidity than a delusion, also often being less patently unbelievable. (eg. I’m the best employee ever, lecture week would fail without me!) not as fixed as a delusion, can be changed with evidence
What is a delusion?
Delusion is a false, unshakeable idea or belief which is out of keeping with the patient’s educational, cultural and social background. It is held with extraordinary conviction and subjective certainty. It is a phenomenon that is outside normal experience. They are held without insight
What are the types of delusions?
Persecutory – outside agency to cause harm
Grandiose – inflated importance / self-esteem
Self-referential – television, tie, etc
Nihilisitic – bowels rotted, already dead etc
Religious – more refers to the content of a delusion, all can contain religious reference
Hypochondriacal – illness, somatisation
Guilt – responsibility for harm
What is the Capgras delusion?
The Capgras delusion is the belief that (usually) a close relative or spouse has been replaced by an identical-looking impostor.
What is the Fregoli delusion?
The Fregoli delusion is the belief that various people the believer meets are actually the same person in disguise.
What is intermetamorphosis?
Intermetamorphosis is the belief that people in the environment swap identities with each other whilst maintaining the same appearance.
What is a delusional perception?
Delusional perception describes a delusional belief resulting from a perception. For example, a perfectly normal event such as the traffic lights turning red may be interpreted by the patient as the defining moment when they realised they were being monitored by the government
What are the different thought symptoms?
Thought insertion; thought withdrawal; thought broadcast; thought echo; thought block
What is concrete thinking?
Lack of abstract thinking, normal in childhood, and occurring in adults with organic brain disease and schizophrenia . Very literal (would not understand a metaphor e.g. don’t throw stones in a glass house)
What is loosening of association?
there is a lack of logical association between succeeding thoughts. It gives rise to incoherent speech (in the absence of brain pathology). It is impossible to follow the patients train of thought (knight’s move thinking/derailment). Not related thoughts at all.
What is circumstantiality?
Irrelevant wandering in conversation. Talking at great length around the point. Lots of little stories , like when dad spoke about oskar and started talking about Norway
What is perseveration?
Repetition of a word, theme or action beyond that point at which it was relevant and appropriate
What is confabulation?
Giving a false account to fill a gap in memory. Severe end of schizophrenia and in alcohol misuse disorder
What is somatic passivity?
Delusional belief that one is a passive recipient of bodily sensations from an external agency. Something is brushing on my arm, it’s the devil passing over my arm
What is made act/feel/drive?
Made bit – the object in question is experience or carried out by the person, but is considered as alien or imposed. Act – action, feeling – feeling, drive – impulse. “The devil is making me sidestep across the room”
What is stupor?
More or less complete loss of activity with no response to stimuli; may mark a progression of motor retardation; found in a wide range of neurological and psychiatric conditions
What is psychomotor retardation?
Slowing of thoughts and movements, to a variable degree. Occurs in depressionbut other causes include psychotropics, Parkinson’s disease etc
What is flight of ideas?
Rapid skipping from one thought to distantly related ideas, the relation often being so tentative as for instance the sound (rhyming) of different utterances. Volume of speech is increased (not loudness but amount of it).
What is pressure of speech?
Manifest in a very rapid rate of delivery, a wealth of associations which may be quite unusual, (e.g. rhymes and puns) and often wanders off the point of the original conversation. This is highly suggestive ofmania. (doesn’t have to be connected)
What is anhedonia?
The inability to experience pleasure from activities usually found enjoyable
What is apathy?
Loss of interest in things, loss of energy and motivation
What is incongruity of affect?
Emotional responses which seem grossly out of tune with the situation or subject being discussed. They might be genuinely upset and just not presenting it. Wrong expression
What is blunting of affect?
An objective absence of normal emotional responses, without evidence of depression or psychomotor retardation. No expression at all
What is belle indifference?
Lack of concern and/or feeling of indifference about a disability or symptom. Links to conversion. Patient suffering from domestic abuse, presents with arm that can’t move, arm is physically fine but the patient believes they can’t move their arm, but are indifferent about the fact that they can’t move it.
What is depersonalisation?
A feeling of some change in the self, associated with a sense of detachment from one’s own body. Perception fails to awaken a feeling of reality, actions seem mechanical and the patient feels like an apathetic spectator of his own activities. Loses the experience of themselves, could be a response to trauma.
What is derealisation?
A sense of one’s surroundings lacking reality, often appearing dull, grey and lifeless. They believe they are real but the world is not. “the world is made out of paper”.
What is dissociation?
An experience where a person may feel disconnected from himself and/or his surroundings. It’s like being locked in a wardrobe in my mind. They know what’s going on but feel they cannot control it
What is conversion?
Unconscious mechanism of symptom formation, which operates in conversion hysteria, is the transposition of a psychological conflict into somatic symptoms which may be of a motor or sensory nature
What is a mannerism?
A sometimes bizarre elaboration of normal activities on response to stimulation. (twirling hair when speaking in public) Alone, not an example of mental health problem
What is stereotyped behaviour?
Uniform, repetitive non goal-directed actions not related to stimulation (may take a variety of forms from simple movement to an utterance)
What is an obsession?
A recurrent persistent thought, image, or impulse that enters consciousness unbidden, is recognised as being ones own and often remains despite efforts to resist
What is a compulsion?
Repetitive, apparently purposeful behaviour performed in a stereotyped way accompanied by a subjective sense that it must be carried out despite the recognition of its senselessness and often resistance by the patient. Recognised as morbid by the affected individual
What is Akathisia?
A condition marked by motor restlessness, ranging from anxiety to inability to lie or sit quietly or to sleep,. Common side effect of treatment.
What the affective (mood) disorders?
Depression; bipolar; cyclothymia
What are the core symptoms of depression?
Low mood; loss of energy (anergia); loss of pleasure (anhedonia)
What are the non-core symptoms of depression?
Change in sleep; change in appetite; change in libido; diurnal mood variation; agitation; loss of confidence; loss of concentration; guilt; hopelessness; suicidal idealation
What is mild depression?
Core symptoms and 2-3 others
What is moderate depression?
Core symptoms and 4 others and functioning affected
What is severe non-psychotic depression?
Several symptoms, suicidal, marked loss of functioning
What is severe psychotic depression?
Typically mood congruent (nihilistic and guilty delusions, derogatory voices)
What are the two types of bipolar?
Bipolar 1 - both mania and depression
Bipolar 2 - more episodes of depression, very few episodes of mania, only mind hypomania
Rapid cycling - episodes only last a few hours
What is cyclothymia?
A milder form of bipolar
What are the symptoms of mania?
Extreme elation (uncontrollable); overactivity; pressure of speech; impaired judgement; extreme risk tasking behaviour; social disinhibition; inflated self-esteem; psychotic symptoms; mood congruent
What are the conditions that can cause psychosis?
Schizophrenia; delusional disorder; schizotypal disorder; depressive psychosis; manic psychosis; organic psychosis
What age is schizophrenia common?
Onset typically in 2nd-3rd decade but 2nd (smaller) peak incidence in late middle age
How does schizophrenia differ between women and men?
Men tend to get it earlier than women
What is schizophrenia?
Splitting of thoughts or loss of contact with reality
Affects - thoughts, perceptions(sight, smell, taste, touch, sounds), mood, personality, speech, volition, sense of self……
What are the first rank symptoms of schizophrenia?
Thought alienation
Passivity phenomena
3rd person auditory hallucinations
Delusional perception
What are the secondary symptoms of schizophrenia?
Delusions 2nd person auditory hallucinations Hallucinations in any other modality Thought disorder Catatonic behaviour Negative symptoms
What are the positive symptoms of schizophrenia?
Hallucinations Delusions Passivity phenomena Thought alienation Lack of insight Disturbance in mood
What are the negative symptoms of schizophrenia?
Blunting of affect (not very expressive) Amotivation poverty of speech Poverty of thought Poor non-verbal communication Clear deterioration in functioning self neglect Lack of insight
What are the symptoms of generalised anxiety?
Excessive anxiety across different situations
>6 months
Tiredness
Poor concentration
Irritability
Muscle tension
Disturbed sleep (usually initial insomnia rather than EMW)
What are the physical symptoms of panic disorder?
Palpitations chest pain choking Tachypnoea Dry mouth Urgency of micturition Dizziness Blurred visions Parasthesiae
What are the psychological symptoms of panic disorder?
Feeling of impending doom Fear of dying Fear of losing control Depersonalisation Derealisation
What are the characteristics of the obsessions in OCD?
Often unpleasant – death/ sexual/ blasphemous Repetitive Intrusive Irrational Recognised as patient’s own thoughts
What are some examples of compulsions in OCD?
Checking, washing, counting, symmetry, repeating certain words or phrases
What are the subtypes of dementia?
Alzheimer's Fronto temporal (Pick’s Disease) Vascular Lewy Body Parkinson’s Normal pressure Hydrocephalus
What are the clinical features of Alzheimer’s disease?
Insidious changes – missing appointments, lack of self-care, wandering
Cognitive Fx - 4As
Amnesia – recent memory, disorientation for time>place
Apraxia – clothes, using appropriate cutlery
Agnosia – recognise parts of the body
Aphasia – late, mixture of receptive & expressive speech
What are the neuroradiological signs of Alzheimers ?
Cerebral and hippocampus atrophy, enlarged ventricles
What are the clinical features of vascular dementia?
Onset and progression Acute Stepwise decline Focal neurology CVA Expressive dysphasia
What are the neuroradiological signs of vascular dementia?
Cortical and subcortical lesions, seen as white dots of MRI
What are the clinical features of fronto-temporal lobe dementia?
Onset 50-60 years (a lot younger than Alzheimers)
Personality change
Apathy, disinhibition, emotional blunting (no reactivity to things that are happening around them), coarsening of sociability (undress inappropriately in public)
Language Changes (not being able to name things as well)
Intellectual functioning (can’t manage the bills)
Progressive
Memory imp may occur later (quite good preserved memory)
What are the clinical features of Lewy body dementia?
Onset and progression
Fluctuating onset and progression with a more rapid decline (quicker decline than Alzheimers)
Visual Hallucinations
Small children, animals, complex scenes
Parkinsonian signs
REM sleep behaviour disorders
Frequent falls (postural hypertension from the dementia)
What should you look at in the mental state examination?
Appearance Behaviour Mood Speech Thoughts Perception Insight
What does the Addenbrookes Cognitive Examination look at?
Attention/Orientation 18/18 Memory 26/26 Language 26/26 Visuospatial 16/16 Fluency 14/14
How would you treat Alzheimers?
NMDA antagonist - Memantine
Acetyl-cholinisterase inhibitors - Rivastigmine
How would you treat vascular dementia?
Statin Antihypertensive medication Aspirin Treat diabetes No benefits of acetylcholinesterase inhibitors, but still get all the side effects
What is BPSD?
Behavioural and psychological symptoms of dementia: Anxiety Depression (more in early dementia) Agitation Psychosis Disinhibition
What causes BPSD?
Pain (they can’t tell you they’re in pain, so if they’re aggressive they may be showing distress)
Infection
Nutrition
Constipation
Hydration
Medication (may be having side effects such as hallucinations, look to see if any new drugs)
Environment
What are the non-pharmacological treatments of dementia?
INFORMATION Carer Support Life story Psychological Target symptoms Mood etc Occupational therapy Physiotherapy Social Inclusion Social activity
What psychotic disorders occur in the elderly?
Late onset Schizophrenia Persistent Delusional disorder Psychotic depression Dementia - Delusions - Hallucinations eg Lewy Body Dementia
What is late onset schizophrenia?
Onset after 45 years old
How does late onset schizophrenia differ from schizophrenia?
Patients have less emotional blunting and personality decline compared to younger onset
Why is late onset schizophrenia often misdiagnosed?
Late-onset schizophrenia often goes undiagnosed because older patients with the disorder tend to be socially isolated
What are the clinical features of late onset schizophrenia?
delusions and hallucinations prominent
primarily paranoid
many symptoms similar to younger onset
Hallucinations in very late-onset schizophrenia are often prominent and can occur in multiple modalities, including auditory, visual, and olfactory partition” delusion, which leads the patient to believe that people or objects can transgress impermeable barriers
Less negative symptoms (less emotional blunting) and formal thought disorder compared to early onset schizophrenia
What are the risk factors for late onset schizophrenia?
Social Isolation
Sensory deficits
Reclusive and suspicious premorbid personality (always been very difficult)
More common in women than men
Relatives of very-late-onset patients have a lower risk for schizophrenia than the relatives of early-onset schizophrenia patients
What is the prognosis of late onset schizophrenia?
Chronic with partial remissions and exacerbations
Better outcomes than that in early-onset
Responsive to low dose antipsychotics?
Factors associated with positive outcome include early identification and treatment and good social support
When and who does delusional disorder F22 occur?
Population prevalence – 0.03%
Middle to late adulthood
Higher among women
Age of onset is earlier for men
What are the clinical features of delusional disorder F22?
Long standing Delusions main feature
Over 3/12 Hx
- single or related
- culturally appropriate
- No persistent Hallucination
- Can be transitory
- NOT 3rd Person
- No passivity or blunting of affect
- No Organic causeWhat are the common delusions in elderly F22 diagnosis?
skin infestation
Illness or cancer (believe they had it or the doctors failed to diagnose it)
being spied on
Followed
Poisoned
Infidelity (quite high risk as people can act on this delusion)
What are the clinical features of psychotic depression?
Mood congruent delusions (depressed, low mood delusions)
Nihilistic Delusions
Cotard’s Syndrome (sensation that all your organs have gone rotten and smell)
Owing money (think they owe money to people)
Burden to others (very high risk of suicide)
Somatic Delusions
- unable to swallow (think they can’t do it, difficult to treat as they don’t take their medication, always check that it is a delusion and they don’t have an actual GI issue)
pain
Olfactory Hallucinations
2nd person derogatory Auditory hallucinations
What is Charles-Bonnet Syndrome?
Experience of complex visual hallucinations in a person with partial or severe blindness
Patients understand that the hallucinations are not real and often have insight compared to other disorders
What are the underlying principles behind the mental health act?
respect for patients’ past and present wishes and feelings
respect for diversity generally
minimising restrictions on liberty,
involvement of patients in planning, developing and delivering care and treatment appropriate to them,
avoidance of unlawful discrimination,
effectiveness of treatment,
views of carers and other interested parties,
patient wellbeing and safety, and
public safety.
What is section 2 of the mental health act?
Duration – 28 days (cannot be renewed)
Purposes – assessment (although treatment can be given without patients’ consent)
Professionals involved - 2 doctors (one S12 approved), AMHP
What is section 3 of the mental health act?
Duration – 6 months (and can be renewed for another 6 months, and then yearly)
Purposes – treatment (can treat without consent for first three months, after that consent is needed)
Professionals involved – 2 doctors, 1 AMHP
What evidence is needed for section 2 of the mental health act?
Evidence required:
a) The patient is suffering from a mental disorder of a nature or degree that warrants detention in hospital for assessment; and
b) The patient ought to be detained for his or her own health or safety, or the protection of others
What evidence is required for section 3 of the mental health act?
Evidence required:
(a) The patient is suffering from mental disorder of a nature or degree which makes it appropriate for the patient to receive medical treatment in a hospital; and
b) The treatment is in the interests of his or her health and safety and the protection of others; and
c) Appropriate treatment must be available for the patient
What is section 4 of the mental health act?
Duration – 72 hrs
Purposes – only in an “urgent necessity” when waiting for a second doctor would lead to “undesirable delay. no power to treat
Professionals required – 1 doctor and 1 AMHP
What evidence is needed for section 4 of the mental health act?
Evidence required –
a) The patient is suffering from a mental disorder of a nature or degree that warrants detention in hospital for assessment; and
b) The patient ought to be detained for his or her own health or safety, or the protection of others
c) There is not enough time for 2nd doctor to attend (risk)
What is section 5(4) of the mental health act?
For a patient ALREADY admitted (can be psychiatric or general hospital) but wanting to leave
Nurses’ holding power until doctor can attend
6 hours
Cannot be treated coercively whilst under section
What is section 5(2) of the mental health act?
For a patient ALREADY admitted (can be psychiatric or general hospital) but wanting to leave
Doctors’ holding power – 72 hours
Allows time for Section 2 or Section 3 assessment
Cannot be coercively treated
Can police section people on the mental health act?
Yes.
S136 – person suspected of having mental disorder in a public place, compulsory detention from public place (not home) to a place of safety. Upto 24 hours – MHA assessment
S135 – needs court order to access patient’s home and remove them to
What is a community treatment order?
Extension of section 3 into community.
Conditions – take meds, attend appointments
Break conditions – 72 hours to return to hospital
Review 6 monthly
What is section 117 of the mental health act?
Duty to provide after care for people wo have been subject to certain sections of the act (3)
Support their mental health as long as required
Don’t have to pay for services
Must be discharged by local authority
What are the 4 key neurotransmitter systems?
Dopamine; serotonin; acetylcholine, glutamate
What pathways does dopamine effect and what conditions are the linked to?
Mesocortical - negative symptoms of psychosis
Mesolimbic - positive symptoms of psychosis
Nigrostriatal - Parkinson’s disease
What is the dopamine hypothesis behind schizophrenia?
Overactivity of dopamine receptors (D2)
- Mesolimbic = hallucinations
Underactivity of dopamine receptors (D1)
- Mesocortical = blunted and apathetic
What is the main mechanism of anti-psychotic treatment?
Block D2 receptors
What are the side effects of D2 antagonists?
Extrapyramidal side effects: acute dystonic reaction [eyes roll back in head, neck spasm] (hours); Parkinsonism [days]; akasthesia (inner restlessness, pacing and agitated)[days to weeks]; tardive dyskinesia (grimacing, lip smacking, tongue protrusion [months to years]
What are some examples of some anti-psychotics?
Haloperidol; chlorpromazine; pipothiazine; olanzapine; clozapine is used in treatment resistant schizophrenia
What neurotransmitter is in the pathophysiology of depression?
Serotonin and noradrenaline
What are some types of antidepressants?
SSRIs (selective serotonin reuptake inhibitors); SNRIs (serotonin and noradrenaline reuptake inhibitors)
How do SSRIs work?
Reuptake pumps and transporters recycle any serotonin within the synapse
Inhibiting the reuptake pumps increases free serotonin
How do SNRIs work?
Inhibits the reuptake pumps
Inhbits the noradrenaline transporter
Give some examples of SSRIs
Sertraline; Citalopram; Fluoxetine
Give some examples of SNRIs
Venlafaxine; Duloxetine
What are some side effects of SSRIs?
Sexual
Weight gain
Increased bowel motility
Agitation
How do tricyclics work?
Blocks both seratonin and noradrenaline pumps
BUT also blocks muscarinic and cholinergic receptors = “anticholinergic” side effects
Dry mouth
Blurred vision
Urinary retention
How would you treat bipolar?
Lithium Sodium Valproate Carbamazepine Lamotrigene antipsychotics
What is lithium used to treat?
Acute treatment of mania
Relapse prevention
How does lithium work?
Inhibits cAMP production
What are the side effects of lithium?
Level (of lithium)- 0.6 to 1.0 mmol/L, Leukocytosis
Insipidius - Nephrogenic Diabetes (Increase in ADH)
Tremors = mild, Tremors = coarse ?Toxicity
Hydration - Dry mouth, diarrhoea, thirsty - must drink
Increased - GI, Skin, memory problems
Under active thyroid (decreased TSH)
Metallic taste, Mums beware = Ebsteins Phenomena
What levels would give you lithium toxicity?
Usually levels greater than 1.0mmol/L
What are the clinical features of lithium toxicity?
Onset usually sudden Sudden dehyration - on holiday Overdose Other medications Systemic illness Coarse tremor, hyperreflexia,seizures, Heart block
How do you treat lithium toxicity?
STOP lithium, rehydrate, haemodialysis
