liason psych day 1

Question 1

name 5 psych disorders that are classified as anxiety disorders

Answer 1

1 - PTSD
2 - panic disorder
3 - OCD
4 - Generalised anxiety disorder
5 - phobias

Question 2

name psych disorders that are classified as mood disorders

Answer 2

1- depression (there are subclassificiatons eg dysthymic disorder)
2 - bipolar disorders (several subclassificaitons)

Question 3

gross breakdown of symptoms of depression

Answer 3

1 - core
2 - psychological
3 - somatic

Question 4

3 core symptoms of depression

Answer 4

1 - low mood with diurnal variation
2 - loss of interest and anhedonia
3 - fatigueability

Question 5

4 psychological symptoms of depression

Answer 5

1 - poor concentration
2 - low self esteem
3 - guilt
4 - pessimism

Question 6

3 somatic symptoms of depression

Answer 6

1 - sleep disturbance esp early morning waking
2 - anorexia or weight loss
3 - loss of libido

Question 7

how to ask a patient about mood - stock phrases

Answer 7

“Have you been feeling sad or tearful?”

“Have there been things you have been able to enjoy over the last couple of weeks?”

“Have you found ways of keeping your spirits up while you have been in hospital?” [visits/phone calls from relatives, watching TV, reading etc]

Do you ever wake very early and are not able to get back to sleep?”

Question 8

give some psychological symptoms of anxiety

Answer 8

Psychological
 Feeling of fear or “impending doom”
Restlessness, dizziness, faintness 
Exaggerated startle response Poor concentration Irritability Insomnia and night terrors Depersonalisation and Derealisation
 ‘Globus hystericus’

Question 9

give some physical symptoms of anxiety

Answer 9

Physical

Cardio: Tachycardia, Palpitations, Chest Pain
GI: Dry Mouth, Globus, Nausea, Abdo Pain, Loose stools
Resp: Shortness of breath, chest tightness
GU: Frequency, Erectile Dysfunction, Amenorrhoea Neuro: tremor, headache, muscle pains, paraesthesia

NB. These arise from autonomic arousal, hyperventilation and muscle tension

Question 10

how to ask a patient about anxiety - stock phrases

Answer 10

“Have you been feeling anxious?”

“Could you tell me more about those worries?”

“What coping techniques do you have for when you feel under stress, or upset?”

Question 11

asking about self harm

Answer 11

Sometimes if people are feeling particularly stressed, worried or low, they can have thoughts about harming themselves, or ending their lives. Have this ever happened to you?”

“If it did, who would you be able to talk to this about?”

Question 12

prevalence of mental disorders in hospitals

Answer 12

•>1/4 hospital patients have a mental disorder
–2/3 of hospital beds occupied by older people, of which 60% have, or will develop, a mental health condition during their stay
–Most commonly dementia, delirium, depression*

Question 13

effect of physical ill health on mental ill health

Answer 13

~1/4 of people with physical health problems develop psychological problems as a consequence of the stress of their physical problems:

–Loss of identity/role
–Loss of function
–Change of lifestyle/restrictions/disability
–Dependency on others
–Impaired capacity to maintain relationships
–Deterioration in health/threat to life
–Impact on body image, self-esteem

Question 14

5 factors that influence the mental response to illness

Answer 14

•Illness perception
•Coping strategies
•Individual factors/personality
•Type of illness – increased levels of psychiatric morbidity with
–Increased levels of pain, advanced disease, high levels of disability
–Neurological disorders directly affecting the brain
•Therapeutic setting

*Guthrie E & Nayak (2012). Psychological reaction to physical illness

Question 15

what is adjustment disorder

Answer 15

• Onset of symptoms must occur within 1 month of exposure to an identifiable psychosocial stressor, not of an unusual or catastrophic type
• Symptoms or behavioural disturbance may be a depressed or anxiety reaction or conduct disorder (in children)
• Except in prolonged depressive reaction, the symptoms do not persist for > 6 months after the cessation of the stress or its consequences

Question 16

risk of mental health issues in those with other chronic medical conditions

Answer 16

• “People with diabetes, hypertension and coronary artery disease have double the rate of depression compared with the general population. They are also at risk of developing vascular dementia.
• Those with chronic obstructive pulmonary disease, cerebro-vascular disease and other chronic conditions have triple the rate of depression.
• People with two or more chronic physical conditions are 7 times more likely to have mental health problems.”

Question 17

Kubler-Ross 5 stages of grief

Answer 17

The Kübler-Ross model, or the five stages of grief, is a series of emotional stages experienced when faced with impending death or death of someone. The five stages are denial, anger, bargaining, depression and acceptance.

The model was first introduced by American Psychiatrist Elisabeth Kübler-Ross in her 1969 book, On Death and Dying, and was inspired by her work with terminally ill patients

Question 18

problems of comorbid mental health issues in those with T2DM

Answer 18

Prevalence of depressive disorders is ~9% (around two fold higher than in healthy controls)

•Comorbid depression associated with:
–poorer glycaemic control;
–diabetes complications;
–and increased risk of death*

Question 19

effect of schizophrenia and bipolar disorder on longevity

Answer 19

•People with schizophrenia and bipolar disorder die on average 16 to 25 years sooner than the general population.*

•They have higher rates of
–Respiratory disease
–Cardiovascular disease
–Infectious disease
–Obesity, abnormal lipid levels and diabetes**

Question 20

effect of SSRIs on bleeding

Answer 20

Serotonin released from platelets in response to vascular injury promotes vasoconstriction and morphological changes in platelets that leads to aggregation.
SSRIs inhibit the serotonin transporter which is responsible for the uptake of serotonin in to platelets

SSRIs significantly increase the risk of GI bleeds

LOTS OF ANTIPSYCHOTICS HAVE LISTS OF PHYSIOLOGICAL SIDE EFFECTS THAT CAN BE SERIOUS.

Question 21

why might there be such a high prevalence of psychiatric disorders in hospital

Answer 21

High prevalence of psychiatric disorders in the acute hospital setting. This can be due to:
–Relapse of primary mental illness
–New onset mental illness
–Organic illness

•Comorbid mental disorder and physical illness increase morbidity and mortality

Question 22

diagnosis of a learning disability

Answer 22

DSM V uses a generic IQ<70 indicating LD but level is based on limitations in adaptive functioning

criteria:

1. Impaired intellectual function
2. Impaired adaptive function
3. Arising in developmental period

Question 23

5 causes of learning disabilities

Answer 23

• Idiopathic
• Genetic
• Substance misuse
• Perinatal problems
• Environmental

Question 24

what is down’s syndrome

Answer 24

Trisomy 21 but also translocation & mosaics

•1/650-1/1000 Live births, maternal age related, common in males

Question 25

comorbidities often found in down’s syndrome patients

Answer 25

• Dementia, depression
• Physical disorders e.g. Hypothyroidism
• Leukaemia
• Congenital heart defects : AVSD, TGA, PDA
• Coeliac disease
• Hirschprung’s
• Imperforate anus
• Secretory otitis media
• Cataracts
• Squints

Question 26

What is the most widespread single-gene cause of autism and inherited cause of mental retardation among boys?

Answer 26

Fragile X
•Fragile site in distal end of long arm X (>50 CGG repeats)
•0.5-1:1,000 males
•Learning disability variable
•20% males unaffected
•30% carrier females affected

Question 27

characterisation of Fragile X syndrome

Answer 27

• Worsens through generations
• Characteristic appearance
• Hyperactivity, social deficits, speech disorders
• FX associated tremor/ataxia (older carrier males)
• Premature Ovarian Failure (POF) in carrier females

Question 28

the effects of alcohol on the fetus

Answer 28

Fetal alcohol syndrome (FAS) is the more severe end of a continuum of birth defects known as fetal alcohol spectrum disorders (FASDs).

Fetal alcohol effects (FAEs), otherwise known as alcohol-related birth defects (ARBDs), may represent the milder end of the spectrum.

Other terms for conditions which come under the umbrella of FASD are alcohol-related neuro-developmental disorder (ARND) and partial fetal alcohol syndrome (pFAS). These are caused by maternal use of alcohol during pregnancy.

There are three main components of FAS:

Typical facial abnormalities

Intrauterine growth restriction and failure to catch up.

• Miscarriage, stillbirth, premature birth and small birth weight are all associated with a mother’s drinking during pregnancy.
• Foetal exposure to alcohol was recognised as a leading known cause of intellectual disability in the 1980’sNeuro-developmental abnormalities causing learning disability, cognitive impairment and behavioural problems

Question 29

what is Akathisia

Answer 29

Subjectively unpleasant sense of inner restlessness where there is a strong compulsion to move
–Foot stamping
–Constantly crossing/uncrossing legs
–Rocking from foot to foot
–Constantly pacing up and down
–Weakly linked with suicide
•Side effect of antipsychotic medication
•~25% prevalence, less with atypicals
•Management: Reduce/change antipsychotic; propranolol; clonazepam; 5-HT2 antagonists eg mirtazapine.

Question 30

what is mania

Answer 30

Elated/irritable mood
•Increased activity
•Pressured speech
•Flight of ideas
•Loss of social inhibitions
•Decreased need for sleep
•Grandiosity
•Distractibility
•Reckless behaviour
•Marked sexual energy

Question 31

what is psychosis

Answer 31

The word psychosis describes a set of symptoms that include delusions (believing something that is unlikely to be true – that members of a secret society are conspiring to hurt you, for example), hallucinations (hearing voices, for example) and confused and disturbed thinking.

People who have a serious mental illness such as schizophrenia, bipolar disorder, schizoaffective disorder and psychotic depression experience some or all of the symptoms of psychosis. People who have some types of personality disorder can also experience these symptoms.

When these symptoms are experienced as part of a mental illness, mental health professionals say people are having a psychotic ‘episode’. Psychotic episodes can vary in length: they can last for just a few days; they can continue indefinitely until they are treated; the symptoms can come and go.

When people have a psychotic episode, they are often unaware that they are unwell. They believe that what they are worrying about is actually happening to them – that they really are being followed, that their life is at risk, that they are being threatened, for instance. Mental health professionals call this ‘lack of insight’.

The symptoms of psychosis can also occur as a result of a physical health problem or disease. Urinary tract, chest or other infections, particularly in older people, can cause delirium, which can give rise to the symptoms of psychosis. People who have brain diseases such as Parkinson’s disease, or dementia (see Older people page), or some types of epilepsy, may experience the symptoms of psychosis. The symptoms can also occur as a result of a brain tumour. Regular and excessive consumption of alcohol and illicit drugs can prompt psychotic symptoms. Sometimes psychotic experiences can be triggered by severe stress or anxiety, by sleep deprivation, or as a side effect of some medication.

Question 32

guiding principles of the management of mental illness

Answer 32

•Ensure your own and other staff member’s safety
•Rule out organic causation
•Obtain all relevant information but act swiftly
•Patient confidentiality does not override issues surrounding significant risk to self or others
•You are not alone – work as part of a team, consult with a senior colleague, etc
•Transfer to most appropriate setting asap
•Keep contemporaneous records
Above all, do no harm

• Attempt to put the patient at ease; be clear; elicit useful information; achieve a safe and dignified resolution
• Be conscious of verbal and non verbal language
• Be honest, neutral, divert any negative train of thought

Question 33

management of mentally unwell patient trying to leave

Answer 33

Patient wanting to leave the ward:
–often only reassurance needed
–consider temporary holding power under Section 5(2) or Section 5(4) (nurses)

•Patient wanting to leave A&E:
–can’t use S5(2) but can hold under Mental Capacity Act

Question 34

Mental Health Act vs. Mental Capacity Act

Answer 34

•(Possibly) suffering from a mental disorder:
–grounds for detaining under the MHA for assessment/treatment of mental illness only

•For a dissenting patient:
–lack of capacity would be grounds for enforced medical treatment under the MCA if condition severe/life threatening and treatment in the patient’s best interests

Question 35

when is a patient rapidly tranquilised

Answer 35

• Pharmacological strategy used to manage high risk of imminent violence
• Used when appropriate psychological and behavioural approaches have failed to de-escalate the situation
• It is essentially an option of last resort

Question 36

what is acute dystonia

Answer 36

a Specific risks of rapid tranqulization with some drugs.

• Contraction of muscles to maximum limits eg eyes rolling upwards (oculogyric crisis), head and neck twisted (torticollis)
• Patient may be unable to speak or swallow
• In extreme cases the back may arch or the jaw dislocate
• 10% prevalence, more common in young, neuroleptic-naïve males and with ↑ potency drugs, eg haloperidol
• Management: oral/IM procyclidine (anticholinergic)

Question 37

what is neuroleptic malignant syndrome

Answer 37

• Rare, but potentially life-threatening effect of all antipsychotics
• Incidence 0.1%
• Mortality 5-10%. Usually due to respiratory failure, cardiovascular collapse, myoglobinuric renal failure, arrhythmias or DIC
• Pathophysiology - DA antagonism; impaired Ca mobilisation in muscle cells; SNS dysfunction

•Characterised by:
–fever
–muscular rigidity
–altered mental status
–autonomic dysfunction

Question 38

describe Respiratory depression and its management

Answer 38

drug induced
•<90%
•Management:
–Give oxygen
–Raise legs
–Give flumazenil if benzodiazepine-induced
–If unconscious - recovery position, protect airway

Question 39

method of rapid tranquilization

Answer 39

Offer oral route before parenteral (systemic action, but delivered by routes other than the GI tract))
•Lorazepam 1-2mg (4mg/24h)
•+/- haloperidol 5-10mg (30mg/24h PO; 18mg/24h IM)
Oral: Repeat every 45-60 minutes, up to 2 times
IM: Repeat up to 2 times at 30-60 minute intervals

Question 40

prevention/management of acutely disturbed behaviour

Answer 40

Intervention selected must be a reasonable and proportionate response to the risk posed by the patient
•Diversional activity
•Provide structure, boundaries
•Low stimulus environment (eg side-room)
•Search patient and their belongings
•Attempt to verbally reassure and also use non-verbal cues
•“Talking down”
•Increase nursing levels
•De-escalation - Involves making a risk assessment of the situation and using both verbal and nonverbal communication skills in combination to reduce problems

Question 41

how would you ask about suicidal thoughts?

Answer 41

“Sometimes if people are feeling particularly stressed,
worried or low, they can have thoughts about
harming themselves, or ending their lives. Have this
ever happened to you?”

“If it did, who would you be able to talk to this about?