Mental Health Flashcards
Assessment of capacity
- Understand information
- Retain information long enough to make a relevant decision
- Weigh information as part of the process of making a decision
- Communicate the decision (talking/sign language or other means)
Key Principles of Mental Capacity Act
A person must be assumed to have capacity unless it is established that he lacks capacity
A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
A person is not to be treated as unable to make a decision merely because he makes an unwise decision
An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
Features of Mental Health Act
- Presence of a mental disorder as defined by law (any disorder or disability of the mind)
- Disorder is of a certain nature or degree
- Significant risk to persons health and safety, safety of others or a risk of self neglect
- No alternative to hospital admission as a means of safeguarding that risk
Impairments in autistic spectrum disorder
TRIAD Social interaction - Difficulty with interpretation of sensory information - Can affect any sense -->Over/under sensitive - Sensory seeking/avoidance Communication - Problems in expressive and receptive language - Non-verbal communication problems - Literal understanding/humour - Visual learning - Problems with social communication; Worse when anxious Rigidity of thinking - Rituals and routines - Obsessions (not as in OCD) - Problems with imaginary play - Impaired theory of mind - Reduced empathy - Difficulty generalising
Management of autistic spectrum disorder
- Mainly educational
- Speech and language therapy
- Occupational therapy
- Behavioural management
- Medication (rarely used)
- Visual strategies – TEACHH, PECS
- Dietary – GF/CF, fish oils, additives
Problems associated with the autistic spectrum disorder
- Learning Difficulties
- Dyspraxia/ dyslexia
- Hyperactivity
- Special abilities
- Behavioural difficulties
- Anxiety
- Sleep and eating problems
Core features of ADHD
Poor attention and concentration
- Poorer than expect for age. Often seen when doing school work or ‘flitting’ from toy to toy. Cant watch whole tv programme. Poor academic achievement- reading often affected
Hyperactivity
- Significantly more active than expected for the age, therefore difficult to assess in very young children
- Running off, Fidgeting, appearing full of energy constantly, Difficulty in sleeping
Impulsivity
- Acting without considering the consequences.
- Interrupting conversations. Crossing the road without looking. Risk taking behaviour. - Aggression can be a consequence
Complications of ADHD
- difficulties in education
- risk of accidents
- low self-esteem
- rejection by peers
ICD - 10 classification of ADHD
Both are necessary for diagnosis:
- Impaired attention – manifested by a lack of persistent task involvement and tendency to move from one activity to another without completion
- Overactivity – characterised by restlessness, talkativeness, noisiness and fidgeting, particularly in situations requiring calm
Early onset – behavioural symptoms present prior to 6 years of age, and of long duration
Impairment must be present in two or more settings (e.g. home, classroom, clinic)
Diagnosis of anxiety disorders, mood affective disorders, pervasive developmental disorders and schizophrenia must be excluded.
Management of ADHD
Bio –> If severe
- Methylphenidate/ Atomoxetine/ Dexamfetamine
Psycho –>Parent education programmes/ interventions
• CBT
Social –> Social skills training
Actions and SE of drugs used for ADHD
Methylphenidate/Ritalin (short or long acting)
- Stimulant. Acts only in daytime
-About 2.3 of patients show significant improvement in their symptoms
-↑ Da and NAdr in synapse, as frontal lobe deficit – could cause personality changes.
- S.E – HTN, insomnia, headaches, weight loss/anorexia- ↓ appetite; tics; anxiety and dysphoria
-Abuse potential
Atomoxetine
- Acts on NAdr system–>Maintains NAdr levels and enhances frontal lobe
- 2 months to become effective.
- S.E - upset stomach, ↓ appetite, n&v, dizziness, tiredness and mood swings
Dexamphetamine
- sympathomimetic amine with central stimulant and anorectic activity (also used in narcolepsy)
SE - restlessness, headache, reduced appetite
Complications ADHD can cause in adulthood
- Increased criminality
- Decreased academic performance
- Increased substance abuse
- Increased aggression
- Poor relationships
- Poor employment record
- Girls have increased pregnancy and STD rates
Core symptoms of Depression
- Continuous low mood for at least 2 weeks
- Anhedonia
- lack of energy
Other and somatic symptoms of Depression
Other:
- reduced self-esteem/confidence
- guilt and self-blame
- hopelessness
- hypochondrical thoughts
- poor concentration/ attendence
- suicidal thoughts/ self-harm
- irritably
Somatic:
- loss of libudo
- psychomotor agitation
- Early morning wakening
- weight loss/ anorexia
ICD 10 classification of depression
Mild - 2 core symptoms and 2 others
Moderate 2/3 core and 3/4 others
Severe 3 core and 4+ others (or some very severe)
Severe with psychotic symptoms
- hallucinations (2nd person auditory)
- delusions (hypocondrical guilt, nilhilistic, persecutary)
Treatment of depression
Mild - reassess in 2 weeks –> exercise/ lifestyle and self-help/ CBT
Moderate - CBT/ Antidepressants
Severe - CBT and Antidepressants +- ECT
- Fluoxetine is antidepressant of choice
Psych–> psycho-education (about illness, relapse signatures meds), CBT (stop patterns of negative thinking), IPT, peer support and supportive counselling
Social –> family, housing, education, finance, employment, general coping strategies, assess physical needs
ICD-10 classification of Bipolar
at least 2 episodes in which a patients mood and activity are significantly disturbed
1) 1+ manic/mixed +/- 1+ depression
2) 1+ depression + 1 Hypomania
Criteria and Symptoms of mania
Elevated/expansive/irritable mood (1 week) and 3+ or more other symptoms
• ↑ energy/activity (including agitation)
• Grandiosity/ ↑ self-esteem
• Flight of ideas/racing thoughts; Pressure of speech; Distractible (poor concentration)
• Reduced need for sleep; ↑ libido
• Social inhibitions lost- sexual indiscretion (and reckless behaviour e.g overspending)
• Psychotic symptoms (of mood congruent nature) - hallucinations, grandiose delusions
• Psychomotor agitation - risk of self-injury, dehydration
• Thoughts of self-harming self or others
Criteria and symptoms of hypomania
3 or more characteristic symptoms for at least 4 days, not severe enough to interfere with social or occupational functioning
• Mildly elevated, expansible or irritable mood; ↑ energy/activity (can still function)
• ↑ self-esteem; Difficulty focussing on one task alone
• Sociability; talkativeness; over familiarity
• ↑ sex drive (out of character); Reduced need for sleep
Management for bipolar
Biological:
• Mood Stabilisers: Lithium
• Atypical anti-psychotics e.g. risperidone, olanzapine, quetiapine
Psychological- CBT, psychoeducation (about illness, relapse, medication, supportive psychotherapy)
Social- targeted interventions (family, housing, finance, employment, general coping strategies)
Environmental risk factors for ADHD
- Premature birth
- prenatal tobacco exposure
- single-parent household
- maternal depression
- lower social class
Pre-disposing factors for depression
- genetics
- abuse in childhood
- personality traits
- family support
Precipitating factors for depression
- brain illness
- physical illness
- iatrogenic
- family relationships
- increased workload
- life events
- substance use
- change in routine
Perpetuating factors for depression
- substance use
- difficult relationship
- financial difficulty
- work
- housing
Indications for ECT
- severe depressive illness, where other treatments haven’t been effective
- life-threatening illness
- prolonged/severe manic episode
- catatonia- high suicide risk
- stupor
- severe psychomotor retardation
Components of Mental State Examination
Appearance/Behaviour Speech Emotion (mood and affect) Perception - hallucinations Thought - content, form Insight Cognition
Features of a cognitive assessment
General - alert/ conscious Orientation Attention and Concentration Language Calculation R hemisphere function Abstraction Memory Praxis
Sections in the MHA
136 - police can move to a place of safety from public place - 72h
5 (4) - nurse can detain inpatient for up to 6h for medical assessment
5(2) - consultant can detain inpatient for up to 72h
2 - 2 doctors and MH practiioner - section for assessment (+/- treatment IM) for 28d
- can appeal within 14d
3- 2 doctors and 1MHP can section up to 6m for treatment
17 - leave when on section 2/3
ICD-10 classification of OCD
Obsessions and compulsions present for at least 2 weeks on most days and are a source of distress
- Obsessions - involuntary and unwanted thoughts, images or compulsions - often intrusive, distressing and repeptitive
- compulsions - repetitive mental operations/physical acts - feel compelled to perform to help reduce anxiety - not pleasurable
Acknowledges as coming from patients own mind - patient knows irrational
Management of OCD
- CBT - exposure and response prevention
- SSRI - fluoxetine. 2nd line - clomipramine
- help with work, peer support group
ICD-10 definition of PTSD
Presents for at least 1m, <6m from stressor
A) exposure to a stressful event or situation of exceptionally threatening or catastrophic nature
B) Persistent remembering or ‘reliving’ the stressor by intrusive flashbacks, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor
C) Avoidance of circumstances resembling/ associated with the stressor
D) 1- inability to recall some important aspects of the period of exposure to the stressor
2- persistent symptoms of increased physiological sensivity and arousal - 2 of:
> difficulty in falling/ staying asleep
> irritability
> difficulty concentrating
> hypervigilence
> exaggerated startle response
Predisposing factors for developing PTSD
- personality traits
- previous hx of neurotic illness
- childhood trauma
- poor social support
Management of PTSD
- trauma focused CBT or EMDR
- psychoeducation
- short term hypnotics
- mirtazepine, paroxetine, amitriptylline
ICD 10 classification of schizophrenia
FOR AT LEAST 1M
1) At least 1 of the following:
a - thought echo, insertion, withdrawal or broadcasting
b - delusions of control, influence or passivity
c - hallucinatory voices
d - persistent delusions
OR 2) At least 2 of the following a - persistent hallucinations b- breaks in train of thought c - catatonic behaviour d- -ve symptoms (apathy) e - significant and consistent change in overall quality of personal beaviour
Classifications of schizophrenia
Paranoid - delusions and hallucinations
Disorganised - disorganised speech, behaviour and flat/inappropriate affect
Catatonic - psychomotor disturbance
Simple - no delusions or hallucinations
Management of schizophrenia
- CBT - reality testing
- Olanzapine/ Haloperidol
- Psychoeducation
- Family interventions
Differentials of mania
- normal fluctuation in mood
- drug intoxication
- PD
- Thyrotoxicosis
- PTSD
- Dementia
ICD-10 definition of dependence
3+ at the same time in the preceeding year
- strong desire to take the chemical
- ↑ tolerance
- difficulties controlling use
- continue to use despite clear evidence of harm
Presentation of alcohol intoxication
- slurred speech
- ataxoc
- dishevelled
- tremulous
- sweating
Management of alcohol dependence
- In patient detox (if delirium tremens, seizers, cognitive impairment etc)
- disulfarim (acetaldehyde dehydrogenase I)
- Acamprosate (prevents cravings - SE - GI)
- Chlordiazepoxide (prevent seizures)
- thiamine
- Motivational interviewing/ AA
Symptoms and mx of alcohol withdrawal
- restlessness
- tachycardia
- sweating
- tremor
- anxiety
- n+v
- loss of appetite
- insomnia
- HTN
- Delirium tremens
- Seizures
Mx - IV diazepam; fluids; manage electrolytes
Features of delirium tremens
- hallucinations
- confusion
- disorientation
- seizures
- paranoid ideation
- ↑ HR and RR
- fever
- ataxia
- risk of suicide
Features of Wernicke’s encephalopathy
- nystagmus
- ataxia
- opthamoplegia
+/- altered consciousness, com, fever, consusion, ptosis
Features of Korsakoff’s
- irreversible
- impaired recent and remote memory
- disordered time sense
- cant learn new things +/- confabulation
