Mental health Flashcards
Condition and Presentation
Anorexia nervosa
serious mental health disorder characterized by self-imposed starvation and a relentless pursuit of extreme thinness.
Subtypes of anorexia
*. Restrictive Subtype: Characterized by minimal food intake and excessive exercise.
- Bulimic Subtype: Involves episodic binge eating followed by behaviors like laxative use or induced vomiting.
ICD-11 Criteria AN:
- Significantly Low Body Weight
- Fear of Gaining Weight
- Distorted Body Image
- Restrictive Eating
DMS-5 criteria anorexia
- Restriction of Energy Intake
- Intense Fear of Gaining Weight
- Body Image Disturbance
Anorexia nervosa pattern patient
- more common in females
- more common in dev countries
- co-occurs with other psychiatric disorders, such as depression and anxiety
Signs and symptoms of anorexia
Hypotension
Bradycardia
Enlarged salivary glands
Lanugo hair (fine hair covering the skin)
Amenorrhoea
BMI- AN vs Bulemia
- bulemia may have normal BMI
AN blood investigations q
- Deranged electrolytes - typically low calcium, magnesium, phosphate and potassium
- Low sex hormone levels (FSH, LH, oestrogen and testosterone)
- Leukopenia
- Raised growth hormone and cortisol levels (stress hormones)
- Hypercholesterolaemia
- Metabolic alkalosis, either due to vomiting or use of diuretics
Managment of AN
- CBT
- MANTRA
- SSRI
When to admit patients for ano
USS test (sit-up, squat, and stand). Admission is also indicated if proximal muscle weakness suggests weak respiratory muscles.
If patients are very unwell the MARSIPAN checklist should be used to guide management.
Refeeding syndrome
A potentially fatal disorder that occurs when nutritional intake is resumed too rapidly after a period of low caloric intake
Symptoms of refeed syndrome
oedema, confusion and tachycardia
Electrolytes in refeed syndrome
Rapidly increasing insulin levels lead to shifts of potassium, magnesium and phosphate from extracellular to intracellular spaces‚ these need to be replenished
Managment of refeed syndrome
- high-dose vitamins (eg. Pabrinex) before feeding commences
- Monitoring with daily bloods and replenishing electrolytes early
- Building caloric intake gradually with the help of a dietitian‚ NICE recommends that refeeding is started at no more than 50% of calorie requirement
cardiac symptoms assoicated with cardiac arrhythmias
Bradycardia and prolonged QTc are often seen
Negative prognostic factors for ano
- Presentation after the age of 20 years‚ difficult to reverse fixed beliefs
- BMI <16 kg/m2
- Marked anxiety when eating in front of others, which indicates issues with socialisation
- Binging/vomiting responds less well to CBT than starvation
Cautions of SSRI
- Avoid in mania
- Should be used with caution in children and adolescents
- Sertraline is best for patients with ischaemic heart disease
SSRI side effects
- GI upset
- Anxiety and agitation
- QT interval prolongation (especially associated with citalopram)
- Sexual dysfunction
- Hyponatraemia
- Gastric Ulcer
Seretonin syndrome triad
- mental status changes
- autonomic hyperactivity
- neuromuscular abnormalities
Managment of Seretonin syndrome
discontinuation of the offending drug and supportive care.
SNRIs side effects
- Nausea
- Insomnia
- Increased heart rate
- Agitation
NaSSAs side effects
Sedation
Increased appetite
Weight gain
Constipation/diarrhoea
TCA cautions
- Contraindicated in those with previous heart disease
- Can exacerbate schizophrenia
- May exacerbate long QT syndrome
- Use with caution in pregnancy and breastfeeding
- May alter blood sugar in T1 and T2 diabetes mellitus
- May precipitate urinary retention, so avoid in men with enlarged prostates
- Uses the Cytochrome P450 metabolic pathway, so avoid in those on other CP450 medications or those with liver damage
TCA side effects
Urinary retention
Drowsiness
Blurred vision
Constipation
Dry mouth
TCA toxicity signs
drowsiness, confusion, arrhythmias, seizures, vomiting, headache, flushing, and dilated pupils
Investigations of TCA overdose
blood tests (FBC, UE, CRP, LFTs), Venous Blood Gas, and an ECG to check for QT interval prolongation.
Managment of TCA overdose
- Supportive care based on patient symptoms
- NAC or charcoal in 2-4 hours
Cautions of MAO inhibitors
Cerebrovascular disease
Manic phase of bipolar disorder
Phaeochromocytoma
Severe cardiovascular disease
Side effects of MOA inhib
Hypertensive reactions (‘cheese reaction’) with tyramine-containing foods (so patients need to avoid pickled herring, Bovril, Oxo, Marmite, cheese, salami).
Should also avoid broad bean pods as these contain dopa.
class A personality disorders
- PARANOID PERSONALITY DISORDER
- SCHIZOID PERSONALITY DISORDER
- SCHIZOTYPAL PERSONALITY DISORDER
PARANOID PERSONALITY DISORDER
Characterised by a pervasive and enduring pattern of irrational suspicion and mistrust of others
Demonstrates hypersensitivity to criticism and potential slights
Exhibits reluctance to confide in others due to fear of information being used maliciously against them
Often preoccupied with unfounded beliefs about perceived conspiracies against themselve
Schizoid personality disorder
Characterised by an enduring pattern of detachment from social relationships and a restricted range of emotional expression
Displays a pervasive lack of interest in or desire for interpersonal relationships, often preferring solitary activities
Shows an emotional coldness, detachment, or flattened affectivity
Often has few, if any, close relationships outside of immediate family
Schizotypal personality disorder
Characterised by a chronic pattern of impaired social interactions, distorted cognitions and perceptions, and eccentric behaviours
Demonstrates inappropriate or constricted affect, and peculiar, eccentric or bizarre behaviour
Displays odd thinking and speech, such as magical thinking, peculiar ideas, paranoid ideation, and belief in the influence of external forces
Shares certain cognitive or perceptual distortions with schizophrenia, but maintains a more intact grasp on reality
Class B personality disorders (4)
ANTISOCIAL PERSONALITY DISORDER
BORDERLINE PERSONALITY DISORDER
HISTRIONIC PERSONALITY DISORDER
NARCISSISTIC PERSONALITY DISORDER
ANTISOCIAL PERSONALITY DISORDER
Defined by a pervasive pattern of disregard for and violation of the rights of others.
Individuals with this disorder exhibit a lack of empathy and frequently engage in manipulative, impulsive actions.
Manifestations include aggressive, unremorseful behaviour, and consistent irresponsibility, which often results in a failure to obey laws and social norms.
Children diagnosed with conduct disorder are at increased risk of developing this as they grow older. Prevention can be through parenting programmes, as well as trialling group-based CBT.
BPD
Characterised by a recurring pattern of abrupt mood swings, unstable personal relationships, and self-image instability.
The propensity towards self-harm is commonly observed in these patients.
Relationships often fluctuate between extremes of idealisation and devaluation, a process known as “splitting”.
There is often an inability to control temper and manage affective responses appropriately.
Also known as emotionally unstable personality disorder (EUPD) there may be a history of previous trauma, including sexual abuse.
Management is with dialectical behavioural therapy (DBT).
Histronic personality disorder
Predominantly characterised by attention-seeking behaviours and excessive displays of emotion.
Individuals may display inappropriate sexual behaviours.
Their emotional expressions tend to be shallow, dramatic, and often perceived as exaggerated.
They often perceive relationships as being more intimate than they truly are, reflecting a distorted perception of interpersonal boundaries.
Narcissistic personality disorder
Characterised by a persistent pattern of grandiosity, a strong need for the admiration of others, and a marked lack of empathy.
Individuals with this disorder often display a sense of entitlement and will exploit others to fulfil their own desires.
Tendency to be arrogant and preoccupied with personal fantasies and desires, often at the cost of disregarding others’ feelings and needs.
Class C personality disorder
AVOIDANT PERSONALITY DISORDER
DEPENDENT PERSONALITY DISORDER
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
OCD
Characterised by an excessive preoccupation with orderliness, perfectionism, and control, often at the expense of flexibility, openness, and efficiency
Contrary to obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD) is not associated with recurrent, intrusive thoughts or rituals
Indications may include strict adherence to routines, perfectionism to the point of dysfunction, and a persistent reluctance to delegate tasks to others
Symptoms are generally ego-syntonic, meaning the patient perceives them as rational and desirable, thereby differentiating OCPD from OCD, where symptoms are typically ego-dystonic and distressing to the individual.
Dependant personality disorder
Characterised by a pervasive and excessive need to be taken care of, leading to submissive and clinging behaviour
Individuals often lack self-confidence and initiative, relying excessively on others for decision-making
Patients may urgently seek new relationships as a source of care and support when existing ones end
Avoidant personality disorder
Characterised by intense feelings of social inadequacy, fear of rejection, and hypersensitivity to criticism
* Patients often self-impose isolation to avoid potential criticism, despite a strong desire for social acceptance and interaction
Bullimia nervosa
binge-eating episodes followed by compensatory behaviors, such as self-induced vomiting, laxative abuse, diuretics, fasting, or excessive exercise
epidemiology of Bulimia nervosa
Affects adolescents and young adults, with onset in late adolescence or early adulthood.
Prevalence: Lifetime 1-2% in women, less than 0.5% in men.
Female to male ratio: Approximately 10:1.
Relatively stable prevalence over the last few decades.
Psychological symptoms of bulimia
- Binge Eating: Loss of control, consuming large amounts of high-caloric food urgently.
- Purging: Induced vomiting, laxative or diuretic misuse, and excessive exercise.
- Body Image Distortion: Distorted perception despite maintaining normal or slightly above average weight.
Physical symptoms of bulimia
Dental Erosion: Resulting from recurrent self-induced vomiting.
Parotid Gland Swelling: Resulting from recurrent self-induced vomiting.
Russell’s Sign: Scarring on the back of the hand or knuckles from repeated self-induced vomiting.
Amenorrhea: Present in 50% despite normal weight.
Excessive Vomiting Complications: Boerhaave syndrome or Mallory-Weiss tear.
Wernicke’s encephalopath
Acute neurological syndrome resulting from a deficiency in thiamine (vitamin B1).
Related to chronic alcohol abuse
Wernicke’s encephalopath triad
- mental status changes (confusion)
- ataxia,
- ophthalmoplegia/nystagmus.
Korsakoff’s syndrome symptoms
- Profound anterograde amnesia
- Limited retrograde amnesia
- Confabulation (patients fabricate memories to mask their memory deficit)
Investigations of Wernicke’s encephalopathy
- Thiamine level testing: Low levels are indicative of deficiency.
- FBC
- Urea and Electrolytes
- Liver Profile
- Clotting
- Bone Profile
- Magnesium
- MRI can show typical changes in specific regions of the brain, as well as mamillary body atrophy in Korsakoff’s syndrome.
Management of Wernicke’s encephalopath
- find underlying issue
- Thiamine supplementation
Management of Korsakoff’s syndrome (3)
- thiamine suplements
- rehab (+alcohol support)
- managment of patient’s environment
Transient global amnesia (TGA)
sudden, transient neurological condition primarily characterized by acute disruption of both short-term and long-term memory.
epidemiology of TGA
middle-aged and elderly individuals
Features of TGA
- Sudden onset of memory loss
- retrograde amnesia
- anterograde amnesia
- confusion/ dejavu
*preserved personality
*motor skills normal
- Spontaneous resolution of symptoms, typically within 24 hours
TGA investigations (4)
- Brain CT or MRI
- EEG
- Neuropsychological tests
- Blood tests: To exclude metabolic causes such as hypoglycemia or electrolyte imbalance
Managment of TGA
- Reassurance:
- Supervision
- Follow-up: A neurological review is advised, especially if episodes are recurrent.
- There are no specific pharmacological treatments for TGA.
TGA and DVLA
No need to inform
criteria to be detained mental health act
- They must have a mental disorder
- There must be a risk to their health/safety or the safety of others
- There must be a treatment (however this can include nursing care, not just drugs)
MHA Section 2
- Admission for mental health assessment and treatment for up to 28 days,
- non-renewable.
- The application for admission is initiated by an Approved Mental Health Professional (AMHP) or the patient’s nearest relative.
- This section necessitates the recommendation of two doctors, one of whom must be ‘approved’ under Section 12(2) of the MHA
MHA section 3
- Permits admission for treatment lasting up to 6 months, with the provision for renewal.
- Mandates the involvement of an AMHP and two doctors, both of whom should have examined the patient within the last 24 hours.
MHA section 4
- Designed for emergencies when applying Section 2 would cause an unnecessary delay.
- Requires the recommendation of a single doctor and the involvement of either an AMHP or the nearest relative.
- The patient can be detained for a maximum of 72 hours, typically followed by a transition to Section 2.
MHA Section 5(2)
Holding power which enables a doctor to legally detain a voluntary patient in the hospital for a period of 72 hours.
MHA section 5(4)
Section 5(4) is comparable to a Section 5(2) but is enacted by registered nurses and has a duration of 6 hours.
Section 17a
Allows for a Supervised Community Treatment (also known as a Community Treatment Order).
Section 135
Court order enabling the police to enter a property to escort a person to a Place of Safety (either the police station or, more commonly, an Accident and Emergency Department (A&E)).
Section 136
Provides police officers the authority to take an individual, who seems to be suffering from a mental disorder and is in a public place, to a Place of Safety.
Investigations for paracetamol overdose
Full Blood Count (FBC)
Urea and Electrolytes
Clotting Screen
Liver Function Tests
Venous Blood Gas - Severe metabolic acidosis
Paracetamol level
Managment of paracetamol overdose
Charcoal
NAC
Classificiations of paracetamol overdose
Acute overdose - excessive amounts in less than 1 hour, usually in context of self-harm)
Staggered overdose - excessive amounts of paracetamol ingested over longer than 1 hour, usually in context of self harm)
Therapeutic excess - excessive paracetamol taken with intent to treat pain or fever and without self-harm intent, ingested at dose greater than licensed daily dose (more than 75mg/kg/24 hours).
OCD managment
Postpartum psychosis
serious psychiatric disorder that typically develops within the first two weeks following childbirth
Postpartum psychosis syptoms
Paranoia
Delusions
Capgras delusions - misidentification syndrome characterised by the belief by the patient that the close person is replaced by an imposter who looks physically the same
Hallucinations
Manic episodes
Depressive episodes
Confusion
Managment of postpartum psychosis
- Antipsychotic medications - olanzapine and quetiapine are safe to take while breastfeeding
- Mood stabilisers in some instances
Schizophrenia
hronic or relapsing and remitting form of psychosis characterized by positive symptoms (such as hallucinations, delusions, thought disorders) and negative symptoms (including alogia, anhedonia, and avolition)
Criteria for Schizophrenia
ICD-11 Criteria: Symptoms present for at least 1 month, causing significant impairment.
DSM-5 Criteria: Symptoms persist for at least 6 months, encompassing at least one month of active-phase symptoms (must include one prominent ‘ABCD’ symptom).
Subtypes of schizophrenia (5)
Paranoid Schizophrenia: Characterized by delusions and hallucinations, often with a persecutory theme.
Catatonic Schizophrenia: Features motor disturbances and waxy flexibility.
Hebephrenic Schizophrenia: Marked by disorganized thinking, emotions, and behavior.
Residual Schizophrenia: Residual symptoms persist after a major episode.
Simple Schizophrenia: Characterized by a gradual decline in functioning without prominent positive symptoms.
Typical antipsychotic
- first-generation’ antipsychotics
- antagonists to D2 receptors but also on cholinergic, adrenergic and histaminergic receptors
Extrapyramidal symptoms of typical antipsychotic 4
- Acute Dystonia: Involuntary muscle contractions causing spasms.
- Akathisia: Restlessness and an inability to sit still.
- Parkinsonism: Tremors, rigidity, and bradykinesia (slowed movements).
- Tardive Dyskinesia: Involuntary, repetitive movements, especially of the face.
Hyperprolactinemia
Histamine H1 Receptor Blockade
Drowsiness and sleepiness
Alpha-1 Adrenergic Receptor Blockade
Orthostatic hypotension
Anticholinergic Effects of typical antipsychotic (4)
Dry mouth.
Constipation.
Blurred vision.
Urinary retention.
Atypical anti psychotic
D2, D3 and 5-HT2A antagonists, with less overspill into other receptors.
Examples of atypical antipsychotics
risperidone, quetiapine, olanzapine, aripiprazole and clozapine
EPS (Extrapyramidal Symptoms) atypical
- lower risk of causing EPS compared to typicals.
Lower risk of tardive dyskinesia.
5-HT2A Receptor Blockade atypical
Atypicals have a reduced risk of causing EPS due to serotonin receptor blockade.
Monitoring atypical antipsychotic
- weight (weeks, then at 12 weeks, at 1 year, and then yearly.)
- fasting blood glucose, HbA1c, blood lipids
- Prolactin baseline
- ECG
- blood pressure (12 weeks and one year)
Clozapine
- atypical antipsychotic that is indicated if there is failure of treatment of 2 other antipsychotic medication
- treatment- resistant schizophrenia
Side effects of clozapine (6)
- agranulocytosis
- neutropenia
- reduced seizure threshold
- myocarditis,
- slurred speech (due to hypersalivation),
- constipation
Monitoring clozapine
FBC
Blood lipids and weight
Neuroleptic malignant syndrome
potentially life-threatening, idiosyncratic reaction to antipsychotic medications, particularly those that block dopamine receptors.
Clinical features of NMS
- hyperthermia
- altered mental state
- autonomic dysregulation
- rigidity
NMS investigation
FBC - Monitoring for potential leukocytosis or signs of infection.
Creatine Kinase (CK) Levels: Markedly elevated CK levels are often observed due to muscle breakdown.
Renal and Liver Function Tests: monitoring organ function due to the potential systemic effects.
Management of NMS
- discontinue causative agent
- supportive care ( aggressive cooling)
- benzodiazepines
- dantrolene
- intensively monitoring
ICD-11 criteria GAD
Excessive worry and apprehension.
Difficulty controlling worry.
Associated symptoms: Restlessness, muscle tension, fatigue.
Duration: At least 6 months.
DSM-V Criteria: GAD
Excessive anxiety and worry about various domains.
Difficulty controlling worry.
Associated symptoms: Restlessness, muscle tension, fatigue, irritability.
Duration: At least 6 months.
GAD epidemiology
- common in females
- associates with depression, substance abuse and personality disorder
- onset 35-40 years is more likely indicative of depressive disorder or organic disease.
Risk factors of GAD
lower socioeconomic status, unemployment, divorce, renting rather than owning a home, lack of educational qualifications, and urban living.
Psychological symptoms GAD
Fears, worries, poor concentration, irritability, depersonalization, derealization, insomnia, night terrors
Motor symptoms GAD
Restlessness, fidgeting, a feeling of being on edge
GAD Neuromuscular (5)
Tremor, tension headache, muscle ache, dizziness, tinnitus
GI GAD symptoms
Dry mouth, dysphagia, nausea, indigestion, “butterflies” in the stomach, flatulence, frequent or loose bowel movements
Cardiolovascular symptoms GAD
Chest discomfort, palpitations
Genitourinary GAD symptoms
Urinary frequency, erectile dysfunction, amenorrhea
Respiratory symptoms GAD
Dyspnea, tight/constricted chest
Management of GAD
Psycho- education
Self help
CBT
SSRI
Propranolol
Patients under 30 should therefore have a follow-up appointment within 1 week to monitor progress.
ICD-11 criteria panic disorder
Recurrent, unexpected panic attacks.
At least one attack followed by a month of persistent concern.
Avoidance behaviors related to attacks.
DSM-V criteria panic tracks
Recurrent, unexpected panic attacks.
Persistent concern about future attacks.
Behavioral changes: Avoidance of situations associated with attacks.
Epidemiology of panic disorder
Prevalence of 1-2% in the general population.
2-3 times more prevalent in females.
Bimodal incidence, peaking at ages 20 and 50.
Agoraphobia is concurrent in 30-50% of cases.
Increased risk of attempted suicide with comorbid depression, alcohol misuse, or substance misuse.
Clinical feature of panic disorder
Difficulties in breathing.
Chest discomfort.
Palpitations.
Hyperventilation
Numbness
Shaking, sweating, dizziness.
Depersonalization/derealization.
May result in fear of situations where panic attacks occur or lead to agoraphobia.
Development of a conditioned fear-of-fear pattern.
Management of panic disorder
- CBT
- fear of fear cycles
*SSRI - Clomipramine
increased risk of going on to complete suicide:
- hx self harm or prev suicide attempt
- mental health disorder (e.g depression, bipolar disorder)
- male
- drugs and alcohol use
- planned attempt
- poor social support
Risk management suicide
- mild risk - primary care as long as patient as established support network with GP follow ups
- moderate severe risk A&E/admitted and reviewed by Psychiatry liaison team
Delirium symptoms
Disorientation
Hallucinations - visual or auditory
Inattention
Memory problems
Change in mood or personality. Sundowning is agitation and confusion worsening in the late afternoon or evening.
Disturbed sleep
Management of delirium
- sleep hygiene
- haloperidol or lorazepam. Olanzapine
What is the concordance rate for schizophrenia in twin studies?
50%
This indicates a significant genetic component in the risk of developing schizophrenia.
What psychological factors often precede psychosis?
Anger, depression, and ideas
These factors may lead to interventions such as CBT to reduce the risk of full psychosis.
What social factors are linked to the onset of psychosis?
Social deprivation, urbanization, and stressful life events
These factors can contribute to increased stress, which is associated with psychotic disorders.
What was the original name for schizophrenia?
Dementia
This reflects historical perspectives on the disorder before it was redefined as schizophrenia.
Which gender is more frequently affected by schizophrenia?
Men
Schizophrenia typically arises before the age of 40 and is more prevalent in men.
What neurotransmitter activity is thought to give rise to positive symptoms of schizophrenia?
Excessive dopamine activity
Positive symptoms include delusions and hallucinations.
Where in the brain is dopamine important for executive function?
Mesocortical (Pre-frontal cortex)
This area is associated with negative symptoms such as apathy and anhedonia.
What symptoms are associated with dopamine activity in the basal ganglia?
Increased voluntary motor activity
This explains the extrapyramidal side effects seen with antipsychotic medications.
What is a hallucination?
A sensory experience that appears real but is created by the mind
Patients may hear voices or see things that are not present.
Define delusion.
A false belief maintained with strong conviction despite contradictory evidence
Delusions are often culturally incongruent.
What is thought disorder?
An impaired capacity to sustain coherent discourse
This can manifest in both written and spoken language.
What is catatonia?
Abnormal movements experienced by some patients
This can include a range of behaviors from immobility to excessive movement.
Fill in the blank: The most famous psychotic condition is _______.
Schizophrenia
Schizophrenia is widely studied and recognized in the field of psychiatry.
What is waxy flexibility in patients?
A condition where a patient can be moved into a position and remains frozen there.
Waxy flexibility is often observed in catatonic states.
Define catatonic stupor.
A state where a patient suddenly stops and remains immobile.
This is a key feature of catatonic disorders.
What are passivity phenomena?
The belief that one’s thoughts or actions are no longer one’s own.
This includes thought insertion, thought broadcasting, and thought withdrawal.
What is thought insertion?
The belief that someone else is putting a thought into one’s head.
This is one of the types of passivity phenomena.
What is thought broadcasting?
The belief that everyone can read your thoughts.
This is another form of passivity phenomena.
What is thought withdrawal?
The belief that thoughts are being taken out of one’s mind.
This completes the triad of passivity phenomena.
What are negative symptoms in the context of schizophrenia?
Symptoms defined by their absence, such as lack of emotion or social withdrawal.
This can be remembered by the 5 A’s.
List the 5 A’s associated with negative symptoms.
- Affect blunted
- Alogia
- Asociality
- Anhedonia
- Avolition
These terms describe various aspects of diminished emotional expression and social engagement.
What does affect blunted refer to?
Restricted emotion with poor emotional display.
This is one of the 5 A’s of negative symptoms.
What is alogia?
Paucity of speech.
This is another aspect of negative symptoms.
Define asociality.
Social isolation or lack of interest in social interactions.
This is also part of the negative symptoms.
What is anhedonia?
Lack of pleasure or interest in activities.
This symptom is significant in various mental health disorders.
What is avolition?
Lack of motivation to initiate and sustain activities.
This is the fifth A in the negative symptoms framework.
What are the criteria for diagnosing schizophrenia?
At least 2 of the following experienced for 1 month:
* Delusions
* Hallucinations
* Disorganized speech
* Disorganized or catatonic behavior
* Negative symptoms
At least one of the first three must be present.
What characterizes paranoid schizophrenia?
Prominent hallucinations and delusions with mostly normal intellectual functioning and emotion.
Patients often feel suspicious and persecuted.
What is catatonic schizophrenia?
An uncommon type characterized by prominent psychomotor disturbances.
Symptoms may include rigidity, posturing, and abnormalities of voluntary movement.
What characterizes Paranoid schizophrenia?
Delusions of persecution and grandeur
Patients may believe they are being targeted or possess special powers.
What are the symptoms of Undifferentiated schizophrenia?
Symptoms that don’t clearly fit one of the other types
This subtype lacks specific characteristics of other classifications.
What phases are involved in Catatonic schizophrenia?
Excitement and stupor phases
Patients may alternate between extreme agitation and lack of movement.
What defines Disorganized schizophrenia?
Bizarre behavior, delusions, and hallucinations
Symptoms can include incoherent speech and inappropriate emotional responses.
What are the features of Hebephrenic/Disorganized schizophrenia?
- Early onset
- Unpredictable behavior and speech
- Inappropriate affect and mood
- Fleeting hallucinations and delusions
This type often presents with immature behaviors.
What is Residual schizophrenia?
A long-term subtype where most symptoms have gone but negative symptoms remain
Patients may retain some cognitive or emotional deficits.
What is the primary management for schizophrenia?
Oral antipsychotics in a staged approach
Treatment is tailored based on the patient’s response and needs.
What is considered the 1st line treatment for schizophrenia?
Oral atypical antipsychotics (quetiapine, alanzapine, risperidone)
Atypical antipsychotics are preferred due to a better side effect profile.
What are examples of 2nd line treatment options for schizophrenia?
Oral typical antipsychotics (haloperidol, chlorpromazine)
These medications are often used if atypical antipsychotics are ineffective.
What is the 3rd line treatment for schizophrenia?
Clozapine, used for psychosis refractory to other treatments
Clozapine requires careful monitoring due to potential side effects.
What should be regularly monitored when prescribing antipsychotics?
- Weight
- Lipids
- Glucose
- ECGs
Monitoring helps manage the risk of metabolic syndrome and other side effects.
What is the minimum dose strategy for prescribing antipsychotics?
Always start at the minimum dose with monotherapy and then titrate up the medication
This approach helps minimize side effects and assess patient tolerance.
What is the minimum length of treatment for schizophrenia?
6 months
This is necessary to allow for stabilization and symptom management.
For a single episode of schizophrenia, how long should medication be continued?
6-24 months
Duration depends on the patient’s response and risk of relapse.
What is the recommended treatment duration for the second episode of schizophrenia?
5 years medications
Extended treatment helps prevent relapse.
What is the treatment approach for the third episode of schizophrenia?
Life-long medication
Ongoing treatment is necessary to manage chronic symptoms.
What is Delusional Disorder?
A rare mental illness in which a patient experiences delusion without accompanying hallucinations, thought disorder, mood disorder, or flattening of affect.
Delusional Disorder is characterized by the presence of one or more delusions that persist for at least one month.
What must a patient show for a diagnosis of Delusional Disorder?
Delusions in absence of any other psychotic symptoms or reversible cause (e.g., drugs).
This means that the delusions cannot be attributed to other mental health conditions or substance use.
What is the main line of treatment for Delusional Disorder?
Psychotherapy (Cognitive Therapy) and Antipsychotics.
Cognitive Behavioral Therapy (CBT) is specifically mentioned as helping to challenge delusions and develop coping strategies.
True or False: Delusional Disorder includes hallucinations.
False.
Patients with Delusional Disorder do not experience hallucinations.
What role does social support play in the management of Delusional Disorder?
Social support is needed for appropriate housing and financial advice.
This support helps patients manage their everyday life and can aid in their overall treatment.
Fill in the blank: CBT is offered to all patients to help challenge _______ and develop coping strategies.
delusions.
CBT is a common therapeutic approach used in various mental health disorders.
What is an adjustment disorder?
A psychological response to identifiable stressors leading to significant distress or impairment.
True or False: Adjustment disorders can only occur after a major life event.
False
Adjustment disorders can occur in response to various stressors, not just major life events.
List some common stressors that may lead to an adjustment disorder.
- Job loss
- Divorce
- Illness
- Death of a loved one
- Moving to a new location
Fill in the blank: Adjustment disorders typically develop within _______ of the stressor.
[three months]
What are some symptoms of adjustment disorder?
- Anxiety
- Depressed mood
- Behavioral changes
- Trouble concentrating
- Difficulty sleeping
How long do symptoms of adjustment disorder typically last?
Symptoms usually last for no longer than six months after the stressor has ended.
True or False: Adjustment disorders are classified as a mental illness.
True
Adjustment disorders are recognized in the DSM-5 as a group of conditions related to stress.
What is the primary treatment for adjustment disorders?
Psychotherapy is the primary treatment, often complemented by medication if necessary.
Fill in the blank: The main goal of therapy for adjustment disorder is to help the individual _______.
[adapt to the stressor]
What can happen if an adjustment disorder is left untreated?
It can lead to more severe mental health issues, such as anxiety disorders or major depressive disorder.
List some therapeutic approaches used to treat adjustment disorders.
- Cognitive Behavioral Therapy (CBT)
- Supportive therapy
- Family therapy
- Group therapy
What are psychotic defenses?
Pathological defenses that distort experiences to eliminate the need to deal with reality.
Examples include denial, distortion, and splitting.
Name three types of psychotic defenses.
- Denial
- Distortion
- Splitting
These defenses refuse to accept reality, reshape reality to meet internal needs, and involve intolerance of ambiguity.
What is denial in the context of psychotic defenses?
Refusal to accept reality.
Denial involves rejecting the existence of a painful reality.
What does distortion refer to in psychotic defenses?
A gross reshaping of reality to meet internal needs.
Distortion can involve altering perceptions to avoid facing uncomfortable truths.
What is splitting in psychotic defenses?
Intolerance of ambiguity leading to self/others being perceived as wholly good or bad.
Splitting is often seen in borderline personality disorder.
What are immature defenses?
Defense mechanisms that include projection, acting out, and projective identification.
These defenses are less effective and more self-destructive than neurotic defenses.
Define projection in the context of immature defenses.
Attributing uncomfortable thoughts or feelings to others.
This mechanism allows individuals to avoid confronting their own negative emotions.
What does acting out mean in terms of immature defenses?
Acting on thoughts or emotions forbidden by the superego.
Acting out often manifests as impulsive or reckless behavior.
Explain projective identification.
The object of projection invokes in that person precisely the thoughts, feelings, or behaviors projected.
This can create a cycle where the projected feelings influence the behavior of others.
What are neurotic defenses?
Defense mechanisms that tend to have short-term advantages but lead to problems when used in the longer term.
Neurotic defenses are more adaptive than immature defenses but can still create issues over time.
What is Capgras syndrome?
A disorder where a person holds a delusion that a friend or partner has been replaced by an identical-looking impostor.
What characterizes Cotard syndrome?
A rare mental disorder where the patient believes they (or a part of their body) are dead or non-existent.
Which mental disorder is associated with severe depression and psychotic disorders?
Cotard syndrome.
What is De Clerambault’s syndrome also known as?
Erotomania.
What is delusional parasitosis?
A condition where a patient has a fixed belief that they are infested by ‘bugs’.
What distinguishes mania from hypomania?
The length of symptoms, severity, and presence of psychotic symptoms.
What are common symptoms of both hypomania and mania?
- Mood: elevated, irritable
- Speech and thought: pressured, flight of ideas, poor attention
- Behaviour: insomnia, loss of inhibitions, increased appetite.
What is lithium used for?
A mood stabilizing drug used prophylactically in bipolar disorder and as an adjunct in refractory depression.
What is the therapeutic range for lithium?
0.4-1.0 mmol/L.
What are some adverse effects of lithium?
- Nausea/vomiting
- Fine tremor
- Nephrotoxicity
- Thyroid enlargement
- Weight gain.
What is the first step in managing generalized anxiety disorder (GAD) according to NICE?
Education about GAD + active monitoring.
What is the first-line SSRI recommended for GAD?
Sertraline.
What are the steps in managing panic disorder?
- Step 1: recognition and diagnosis
- Step 2: treatment in primary care
- Step 3: review and alternative treatments
- Step 4: referral to specialist mental health services.
What defines personality disorders (PD)?
Persistent patterns of thinking, feeling, and behaving that significantly differ from cultural expectations.
What are the key features of personality disorder according to ICD-11?
- Persistent Pattern
- Impairment
- Duration
- Distress or Dysfunction.
What are the severity classifications in ICD-11 for personality disorders?
- Mild
- Moderate
- Severe.
What are the personality disorder trait domains in ICD-11? (5)
- Negative Affectivity
- Detachment
- Dissociality
- Disinhibition
- Anankastia.
What are the clusters of personality disorders?
- Cluster A: Odd or Eccentric
- Cluster B: Dramatic, Emotional, or Erratic
- Cluster C: Anxious and Fearful.
What characterizes Cluster A personality disorders?
- Paranoid
- Schizoid
- Schizotypal.
What are the features of antisocial personality disorder?
- Failure to conform to social norms
- Deception
- Impulsiveness
- Irritability and aggressiveness.
What is a common management approach for personality disorders?
Psychological therapies such as dialectical behaviour therapy.
What is a significant feature of post-traumatic stress disorder (PTSD)?
Re-experiencing traumatic events through flashbacks or nightmares.
What management is recommended for PTSD?
- Trauma-focused cognitive behavioural therapy (CBT)
- Eye movement desensitisation and reprocessing (EMDR).
Single-session interventions are not recommended following a traumatic event.
What are common symptoms of drug or alcohol misuse?
Anger, unexplained physical symptoms
These symptoms often co-occur with various mental health issues.
What management approach is not recommended following a traumatic event?
Single-session interventions (debriefing)
These interventions have been found to be ineffective and potentially harmful.
What is a recommended management strategy for mild symptoms lasting less than 4 weeks?
Watchful waiting
This approach allows for natural recovery without immediate intervention.
What treatment options are available for military personnel experiencing trauma?
Access to treatment provided by the armed forces
This includes mental health services tailored for military needs.
What therapies may be used in more severe cases of PTSD?
Trauma-focused cognitive behavioural therapy (CBT), eye movement desensitisation and reprocessing (EMDR)
These therapies are evidence-based treatments for PTSD.
What should not be used as a routine first-line treatment for PTSD in adults?
Drug treatments
Psychotherapy is preferred, with medications as a secondary option.
If drug treatment for PTSD is used, which medications should be tried?
Venlafaxine or a selective serotonin reuptake inhibitor (SSRI) like sertraline
SSRIs are commonly prescribed for various anxiety and mood disorders.
In severe cases of PTSD, which medication does NICE recommend?
Risperidone
This antipsychotic may be considered in treatment-resistant cases.
What are the two main categories of antipsychotics?
Typical antipsychotics, atypical antipsychotics
These categories differ in their mechanisms and side effects.
What is the mechanism of action for typical antipsychotics?
Dopamine D2 receptor antagonists
They block dopaminergic transmission in the mesolimbic pathways.
List two common adverse effects of typical antipsychotics.
- Extrapyramidal side-effects * Hyperprolactinaemia
These side effects are less common with atypical antipsychotics.
What is a key adverse effect of atypical antipsychotics compared to typical ones?
Less common extrapyramidal side-effects and hyperprolactinaemia
Atypical antipsychotics were developed to reduce these side effects.
What are extrapyramidal side-effects (EPSEs)?
Motor control issues such as Parkinsonism, acute dystonia, akathisia, tardive dyskinesia
These effects can significantly impact quality of life.
What is the most common manifestation of tardive dyskinesia?
Chewing and pouting of jaw
Tardive dyskinesia can be irreversible and occurs in a significant percentage of patients.
What specific warnings has the Medicines and Healthcare products Regulatory Agency issued for antipsychotics in elderly patients?
- Increased risk of stroke * Increased risk of venous thromboembolism
These risks necessitate careful monitoring in elderly patients.
List three common side effects of antipsychotics.
- Dry mouth * Blurred vision * Urinary retention
These antimuscarinic effects can complicate treatment.
What is the strongest risk factor for developing a psychotic disorder?
Family history
Having a parent with schizophrenia significantly increases risk.
What is the relative risk (RR) of developing schizophrenia if a monozygotic twin has the disorder?
50%
Genetic factors play a significant role in the risk of schizophrenia.
What is Schneider’s first rank symptoms?
Auditory hallucinations, thought disorders, passivity phenomena, delusional perceptions
These symptoms are key in diagnosing schizophrenia.
What are some features of schizophrenia?
- Impaired insight * Negative symptoms * Social withdrawal * Catatonia
These features can vary greatly among individuals.
What do NICE guidelines recommend as first-line treatment for schizophrenia?
Oral atypical antipsychotics
These medications are preferred due to their safety profile.
What is a significant factor associated with poor prognosis in schizophrenia?
Strong family history
Other factors include gradual onset and low IQ.
most likely SSRI to lead to QT prolongation and Torsades de pointes
Citalopram
checking lithium levels
taken 12 hours post-dose
Metabolic side effects of antipsychotics
dysglycaemia, dyslipidaemia, and diabetes mellitus
What drug should be avoided in patients taking a SSR
Triptans
