Mental health Flashcards
[Insert a joke]
Mental health isn’t a joke
What is the structure of a mental health history?
PC HPC Past Psychiatric/ medical history Medications and allergies - illicit drugs, alcohol, OTC FH - inc. personal history SH Forensic history Premorbid personality Informant history
What to include in a HPC?
Detail each symptom
Chronological account
Important +/-ve symptoms
What to ask in HPC if there are voices?
Detail of voice - content, number 2/3 person, commanding
Hallucinations in other modalities - visual, tactile, olfactory, gustatory
What to include in a past psychiatric history?
Episodes or continuous Admissions Diagnosis and treatment Mental health act Deliberate self harm Contact with services
What to ask about alcohol in medication history?
CAGE only for screening calculate units, routine etc. Dependency - physical or mental harm Priorities - bills, other activities Withdraw
What Illicit substances to ask about specifically?
Cannabis Amphetamines Heroin Crack/ cocaine LSD/Ecstacy Mushrooms Novel psychoactive substances
What to ask in a family history?
Alive/ Dead
Quality of relationships
FH of psychiatric conditions
What to ask in personal history?
Birth Childhood milestones Abuse School Employment
What to ask in the forensic history?
Any contact with courts/police
Violence or thoughts of violence
What to ask about premorbid personality?
Describe themselves
Strengths and weaknesses
Hobbies and interests
Activity and socialisation
What are the sections of the mental state examinations?
A Speedy Mental Test Putting Crazies Inside
Appearance and behaviour Speech Mood and affect Thought Cognition Insight
What is waxy flexibility?
A form of catatonia in which tendency to remain in an abnormal posture - schizophrenia
What is negativitism?
A form of catatonia in which there is increased resistance to movement - schizophrenia
Side effects of antipsychotics?
Sedation
Difficulty initiating movement -PD
Extrapyramidal see effects - rhythmic movements
Tardative dyskinesia - lip smaking, tongue protrusion
Ataxia
What is pressure of speech?
Fast speech making little sense with little sense of conecton
What is Echolalia?
Reflection utterance of word said by others - schizophrenia
What is Palilalia?
Involuntary repetition of words, words are from themselves - schizophrenia
How is Mood different from Affect?
Mood is reported (subjective) by the patient. Affect expressed emotions by the patient.
How are the thoughts sections of the MMSE sub divided?
Form - how thoughts are constructed
Content - what e.g: delusion
What may be seen in thought form for a patient with schizophrenia?
Thought block
Derailment
Metonyms
Neologisms
What are metonyms and who get them?
Word approximation - word holder for book
Dementia, schizophrenia, mania
What may be seen in thought form for a patient with mania?
Flight of ideas - understand links
Word salad
Circumstantiality
What is a perversion of thought form?
Repition of thoughts or phrase, commonly cannot move away from that line of thought.
Seen in OCD, psychosis, Frontal lobe dementias
What is a delusion?
A fixed, false belief that lived outside of cultural, religious context
What is an over valued idea?
A thought which takes precedence over other ideas, can be challenged (and therefore isn’t fixed like a delusion)
What is a nihilistic delusion?
I do not exist - typically in depression
What is a Somatic delusion?
A delusion of symptoms - psychosis
What is a referential delusion?
Thinking things are referencing you - TV, Radio
Seen in schizophrenia
Delusion of perception?
External stimuli is contested to a delusion - schizophrenia
What is Othello delusion?
Partner is being unfaithful
What is Capgras delusion?
Someone is replaced by a identical clone
What is Couthards delusion?
Belief that they are dead, do not exist or do not have internal organs
What is Ekboms delusion?
Belief of infection with insect or parasites
What is Fregoli delusion?
Many people are infact the same person
What does Passivity in respect to thought content?
Subtype of delusion - thoughts (insertion, control), feeling and actions (impulses and actions)
What are the three core symptoms of depression according to ICD-10 criteria?
Low moodAnhedoniaAnergia/fatigue
What is a perception?
The process of turning an external stimuli into a meaningful psychological information
Other than the core symptoms what are some other features of depression?
Disturbed sleep with early morning wakeningPoor concentration Low self confidencePoor or increased appetiteSuicidal thoughts or actsPsychomotor retardationGuilt or self blame
What is an illusion?
Presence of a stimulus which leads to a misperception
Important questions to ask in depression to rule out other things?
Hypomanic or manic episodes- bipolar disorderNormal reaction to griefMedical disorders - chronic eg hypothyroidism, MS, alcohol and substance abuse
What might a fluctuation, polymorphic (in respect to modalities) indicate?
Delusion
Medication associated with depression
Corticosteroids Beta blockersStatinsOral contraceptives Isotretinoin
What Acronym can be used for insight?
RATE
Rationalisation
Attribute
Treatment
Engagement
Manic symptoms
Symptoms that affect social or occupational functioning or psychosis or hospitalisation distinguishes it from hypomanic Abnormally elevated, expansive or irritable mood Abnormal and persistent increased activity or energy Inflated self esteem, grandiosity, flight of thoughtsUnrestrained buying, spending or gambling spreesNo drugs or other causes
Side effects of sertraline
GI upset, dry mouth, decreased libido or sexual activity, reduced ability to orgasm, mild nausea, drowsinessUncommon- weight gain, tremor, palpitations, urinary incontinence, urinary retention
When to refer to psychiatric services ?
- significant perceived risk of suicide, harm to others or severe self neglect - if there are psychotic symptoms- if there is a history or clinical suspicion of bipolar disorder- in all cases where child or adolescent is presenting with major depression
Assessing suicide risk
Thoughts of suicide or self harmWhat precipitated attemptWhy then, there and nowPlanned or impulsiveSuicide note leftIntoxicatedAny precautions against discoveryPrevious attempts at suicide or self harmHow do they feel nowDo a PHQ9Is there support at homeAny risks to anyoneAre there children at homeHow do they feel about the future
What increases risk of suicide ?
Age over 45MaleFamily history of depression, substance misuse or suicide UnemployedPhysical illnessPsychiatric illnessDivorced or widowed or singlePersonal substance misusePrevious attempts
Treatment of mild depression
Do not routinely medicate but consider use if there is moderate to severe recurrent depression or depression has persisted for more than 2-3 months Offer low intensity psychosocial intervention eg self guided CBT, computerised CBT, structured group physical activity programme
Treatment of moderate or severe depression
Provide a combo of antidepressant meds and high intensity psychological intervention such as CBT 1. SSRI- sertraline or citalopram2. SNRI- venlafaxine, mirtazapine3. Add an augmenting agent eg second gen antipsychotic such as quetiapine or lithium4. Tri cyclic - amitriptyline 5. MAOI
Important things to check in treatment resistant depression
Check diagnosisCheck alcohol or drug abuseFurther antidepressant trialsECTNeurosurgery
Electroconvulsive therapy
Most effective treatment for severe depression, life threatening depression, prolonged or severe mania, CatatoniaSE- memory loss, short term retrograde amnesia, confusion, headaches, clumsiness
Generalised anxiety disorder symptoms
Psychological- constant worries, pervasive feeling of apprehension or dread, poor concentration, frustration, instability to tolerate uncertainty Physical- trembling, sweating, nausea, SOB, difficulty swallowing, hot flashes, headaches, muscle ache or tension, twitching, irritability, insomnia, feeling in the edge, restlessnessBehavioural-putting things off due to feeling overwhelmed, avoidance, drug taking More than 6 months and not tied to specific situation or OCD
Things to exclude in GAD
PhobiaHyperthyroidism AnginaAsthmaExcessive caffeineAlcohol Drugs
Treatment for GAD
Simple lifestyle changes- increase exercise, improve work life balance, avoid excess caffeine and stimulant drugs, avoid excess alcohol Long term interventions such as CBT, SSRI self help Benzos not to be used for more than 2-4 weeks due to tolerance and dependence
Benzodiazepines
Symptoms of anxiety reduces in 30-90 minutes SE- sedation, reps depression, tolerance, dependence, impaired cognition
Discontinuation of antidepressants
Do slowly over a period of at least four weeks to prevent withdrawals and a recurrence of symptoms Stop at an appropriate time and not during times of stress
Antidepressant discontinuation syndrome
Common symptoms- dizziness, headache, nausea, lethargyRarer- ataxia, electric shock sensations, EPSE, hypomania or mania
Differentials of psychosis
SchizophreniaBipolarDeliriumDrug induced EncephalitisThyroid diseaseBrain tumourHugh dose steroidsTemporal lobe epilepsyDementiaBrain injuryMetabolic disordersLupus Drug withdrawal
Treatment of psychosis
Antipsychotic medication CBTSocial support
Questions to ask in psychosis
Describe experienceWhen did last feel normalHow have things changed since thenAsk about social life, family, friends, interestsAuditory hallucinations - describe the voice, what does it say, what does it sound like, Other strange or frightening experiencesTv or radio talking about or to youParanoiaSpecial powers?
Side effects of antipsychotics
Weight gain, diabetes. Metabolic syndrome, hyperlipidaemiaSedationMovement disordersProlonged QTRaised prolactin (mainly in clozapine)
Monitoring with antipsychotics
Weight Waist circumferencePulse BPFasting blood glucoseBlood lipid profileProlactin levelsAssess for movement disordersECG if necessary
What is section 2 of MHA?
Person can be detained under section two if suffering from mental health condition which warrants their detention in hospital with a view to the protection of themselves or othersUnder section two if not assessed in hospital before or have not been assessed for a whileLasts 28 days
Section 3 of MHA
Detained in hospital for treatmentCan follow a section two Up to 6 monthsForce treatment for first three months but needs reassessing after 3 months
Section 4 of MHA
72 hour emergency hold for treatment
Positive symptoms of schizophrenia
Delusions Hallucinations
Negative symptoms of schizophrenia
Blunted moodReduced speechPoor self careLoss of volition
Thoughts changes in schizophrenia
Disorders of speech Tangential Knights moveNeologisms
Causes or increased risk of schizophrenia
Birth asphyxia, childhood encephalitis, sexual abuse, cannabis, separation from parent, born in cityIncreased risk in Afro Caribbean and south Asian patientsPoor prognosis gradual onset, strong family history, low IQ, premorbid hisorur of social withdrawal and lack of obvious precipitation
Types of schizophrenia
Paranoid- commonest subtype, hallucinations and delusionsHebephrenic- age of onset 15-25, poor organisms, flu testin affect prominent with fleeting fragmented delusions and hallucinations Catatonic- characterised by stupor, posturing, waxy flexibility, negativity Simple and residual- negative symptoms predominant
Risk factors for delirium
CHIMPS PHONED ConstipationHypoxiaMetabolic disturbancePainSleepnlessnessPrescriptionsHypothermia or PyrexiaOrgan dysfunction eg hepatic or renal failureNutritionEnvironmental changesDrugs
What to ask in delirium history
History of dementia or depression Look for infection Medications- opiates or calcium supplementsVascular problems-previous MI, limb ischaemia (vascular dementia RF)Other presenting complaintsHistory of recurrent admissions
What is involved in a confusion screen?
Early warning scoreBP and pulse (check for sepsis, dehydration, hypotension)ObsCT head- bleeds, strokes, SOLBloods- FBC (anaemia, WCC, MCV), U&Es (electrolyte imbalance high calcium, dehydration), LFT (alcohol intake, liver failure), TFTs, calcium, b12, glucose, CXR, blood cultures upfield query sepsis, urine dip for UTI
Differentials for memory problems
Alzheimer’sVascular dementiaDementia with Lewy BodiesTraumatic brain injuryFrontotemporal dementiaSemantic dementiaCreutzfeldt Jakob diseaseNormal pressure hydrocephalus Wernicke KorsakoffPseudo dementia secondary to depressionConfusion secondary to infection
Tests and tools to assess confusion and cognition
Addenbrookes cognitive assessmentMontreal cognitive assessment- MoCAMini mental state examHospital anxiety and depression scale
Vascular dementia
Usually caused by an acute, such as stroke or TIACan also develop over time from small blockages or slowing of bloodRisk factors- diabetes, hypertension, high cholesterol, CHD, peripheral artery disease Step like decline in memory or cognition Lower the vascular risk- aspirin and statins
Alzheimer’s
Most common form of dementiaUsually Begins in 60sRisk factors- age, geneticsGradual downward slope decline, starting from memory, thought and language,
Clinical presentation of Alzheimer’s
Involvement in cortical function eg aphasia, agnosia, apraxiaDecrease of motivation and drive Slow rate of progression CT and MRI show cerebral atrophy Hallucinations, delusions, anxiety, marked agitation, aggression, agitation, wandering, hoarding, sexual inhibition
Genetics with dementia
Early onset is autosomal dominant so 50% chance of getting it. 50% of those with Down’s syndrome who live to 60 will get AD Late onset genetics- apolipoprotein E (E4 increases risk, E3 normal risk, E2 reduced risk)
Pharmacological management of Alzheimer’s and Lewy Body
Cholinesterase inhibitors - donepezilRivastigmineMemantine- NMDA receptor blockers Meds slow down progress of the disease Delays worsening of dementia for 6-12 months
Non pharmacological treatment for dementia
CBTreminiscence therapyAromatherapy Sensory stimulationMusic therapy
Criteria for dementia
Decline in memory, decline in emotional control or motivation ApathyCoarsening of social behaviourMust not have deliriumMust be present for at least 6 monthsShould be irreversible
Lewy body dementia
Memory impairmentSleep disturbances- nightmares, aggressive movements, disturbed sleep cycleAutonomic dysregulationVariable cognition Urinary incontinence Visual spatial difficulties, language impairment, dyspraxiaMemory, motor and psychosis Deposits of alpha synucleinMemory difficulties and problems develop at least one year before motor Give rivastigmine and maybe memantine
Parkinson’s dementia
One third with PD develop dementia Memory and psychotic symptoms develop one year after motor difficulties Also alpha synuclein deposits
Front- temporal dementia
Frontal lobe- behaviour, problem solving, executive function (planning)Temporal lobe- language, recognising objects and peopleLost inhibitions, lose empathy, apathy, change in eating habits
Borderline personality disorder
Impulsive aggression, affective lability, self injury and identity diffusionUnstable self image, fears of abandonment, transient psychotic symptoms, Maladaptive patterns of thought and behaviour Treatment- co morbidities such as anxiety and depression, CBT, DBT,
Mental state exam
Appearance- overall impression, physical conditions suitability of dress, cleanlinessBehaviour- appropriateness of behaviour, distractibility, eye contact, rapportSpeech- rate, rhythm, volume, tone, coherence, relevance, quantity and fluency, abnormal associations, flight of ideasMoodPerception- delusional perception, illusion, hallucinationThought- form- linear, tangential, circumferential, derailmentContent- suicidal or violent thoughts, delusions, overvalued ideasCognition- alert, attention concentration, orientation to time and place, short term memory Insight- recognition of illness and need for treatment
What are the Core symptoms of depressive disorder?
- Persistent low mode - Loss of pleasure/ interest- Fratigue/ low energy
What other (not core) symptoms of depression are there?
- Insomnia - early morning waking - Loss concentration - Change in appetite - Suicidal ideation - Psychomotor retardation- Guilt
What investigations might be done for a low mood?
Bedside - BP, Pulse, ECG, BMI Bloods - Baseline, TFT, HbA1c, Vit B12, Folate Special - PHQ-9
What is the PHQ-9?
A questionaire used to measure the severity of depression
What treatment are there for depression?
Conservative - lifestyle, watch and waitMedical - SSRI, CBT
What are the common side effects of SSRI?
DrowsinessDry mouth GI upset Nausea Decreased labido, anorgasmia
What RF increase risk of suicide?
Divorced, widowedUnemployed Illness - psych or physical Substance >45yo Previous attempt Male
How should a SSRI be stopped?
Tapering dose over a minimum of 4wAvoid during stressor events
What are the symptoms of SSRI withdraw?
Mood changesRestlessness NauseaLethargyHeadaches Dizziness
What differentials are there for low mood/ depression?
Depressive disorderBipolar Grief reaction Schizophrenia/ Psychosis Organic cause
What organic causes are there for depression?
hypothyroidism CushingsAnaemia Drugs…
What drugs can contribute for depression?
Steroids Interferon-beta - MS treatment PPIAnti-hypertensiveDRUGS AND ALCHOL
What SSRI is used post MI?
Sertraline - least affect on QT interval and electrolytes
What additional side effects are there fore SNRI over SSRI?
Increased drowsiness Increase BPIncrease dry mouth
What SSRUs used for young people and DM?
fluoxetine
What electrolyte abnormality can SSRIs cause?
Hyponatraemia via SIADH
In elderly what causes are there in particular for low mood?
The 3Ds Dementia Depression Drugs
Why does SSRI increase bleeding risk?
serotonin receptors on platelets, can lead to thrombocytopenia
How long does an SSRI take to become effective?
2-4 weeks
What is the bigger SE with mtrazapine?
Weight gain
What SSRI is used in patient with an eating disorder?
Fluoxetine as less weight gain
What are the indications for ECT?
Treatment resistance Pregnancy (benefit:risk) Quick response needed
What are the contraindications for ECT?
Any contraindications for general anaesthesia
What is the main side effect of ECT?
retrograde amnesia
What structure for a risk assessment should be used?
1 - Now/ current episode2 - How they feel now 3 - Past attempts/self harm
How long should SSRI be continued if there is low risk of depression relapse?
6-9 months
How long should SSRI be continued if there is high risk of depression relapse?
2 years
What is serotonin syndrome?
Serotonin excess leading to autonomic dysfunction, abdominal pain, myoclonic seizures, cardiovascular shock
What are the symptoms of anticholinergics?
Dry mouth, blurred vision, urinary retention, confusion
What are the symptoms of anti-adrenergics?
postural hypotension, sexual dysfunction, tachycardia
What are the symptoms of anti-histamines?
Sedation, weight gain
When are MAOI used?
severe depressionWatch out for hypertensive crisis
What classes of mood stabilisers are there?
Lithium Anticonvulsanst - NaValproate, Carbamazapine, lamatrogine Antipsychotics - Olanzapine, resperidone, Quetiapine
What is the advantage of lithium?
- Prophylaxis of mania and depression - Decreases suicide risk
What risk are there for lithium in pregnancy?
- Teratogenic in 1st trimester- Ebsteins anomaly
What monitoring is required for lithium?
Trough levels UE - creatinineTSH
What SE are there of lithium?
GI distress - nause, D&V Tremor ADH antagonism - polydipsia, polyuria (DI)
What advice should be given to patient with Li treatment?
Teratrogenic Drink plenty of water
What is Autistic spectrum disorder (ASD)?
A developmental triad of - impaired social interactions - Impaired communication - rigidity in thinking
What is the Triad for attention deficit disorder (ADHD)?
- Inattention- Impulsivity - Hyperactivity
What criteria for ADHD diagnosis?
Symptoms with significant functional impairment for at least 6m under the age of 7y years.
Treatment of ADHD?
- lifestyle, information- behavioural stratergies- Methyl phenidate
What should be considered when the diagnosis is not ASD or ADHD?
Behavioural issuesAdditionally usually seen in one environment (unlike ASD ADHD)
7yo struggling in large groups, fidgets, aggressive at school, Picky with food and difficult getting to sleep at home. Keeps running away when going shopping with mum. MLD?
ADHD
4yo with delayed speech seen by SLT. Does not make friends and plays with same cars. flaps hands, picky with food at home. MLD?
ASD
Fussy with food, disobedient to mother, fights sister. Doesn’t stay on naught step. Normal at day care. MLD?
Behavioural issues, isolated to one environment (the home).
What assessment tool is used for ADHD?
CONNERS questionnaire
What assessment tool can be used for ASD?
ADIADOS-2DISCO
what does the Sally Anne test assess?
Theory of the mind - assessment of deficits in empathy and understanding other. Indicates ASD
What pharmacological treatment is there fore aggressive behaviour in children?
Respiridone
What are positive symptoms of psychosis?
Hallucinations Delusions Thought disorders
What are the negative symptoms of Psychosis?
The A’s: Apathy Affect - flat Anhedonia Avolition Alogia - poverty of speech
What is the pathophysiology of psychosis?
Dopamine deficit in mesocortiyal pathway leading to negative symptoms. dopamine excess in the mesolimbic pathway leading to positive symptoms.
What are the extrapyramidal SE of antipsychotics?
Dystonia Akanthisia Psuedoparkinsons Tardative dyskinesia
What is Akathisia?
Restlessness, compulsion to move
What examples of tardative dyskinesia?
Lip smoking Tongue protrusion Chorea pelvic thrusting
What is are the symptoms of hyperprolactinaemia?
gynecomatia, galactorrhea, decreased labido, interference with labido
What is the pathophysiology of a raised prolactin?
Dopamin antagonism in the tuberoinfundibular pathway stops the inhibition of prolactin
Psych patient has a fever, with altered mental state and autonomic dysfunction. MLD?
Neuroleptic malignant syndrome
What complications are there from neuroleptic malignant syndrome (NMS)?
Rhabdomyolysis Hyperkalaemia Renal failure Seizures
What blood test can be done to confirm NMS
CK - should be raised
How is NMS treated?
- Cessation of medication - ICU - Active cooling - Medications
What medications are used for NMS?
Bromocriptine Dantrolene Amantadine
What do typical antipsychotics target?
Antagonism of D2
What do atypical antipsychotics target?
Antagonism of dopamine and serotonin (but in an atypical way)
Why is the cardiovascular risk greater in atypical antipsychotics?
high cholesterolhigh triglycerides hyperglycaemia
What monitoring is required for Clozapine?
FBC - agranulocytosis - weekly then biweekly for 6m LFTCardiovascular risk
What DD for psychosis?
Schizophrenia DementiaDrugsSevere depression Mania - bipolar
What treatment is used for first episode Psychosis?
AntipsychoticCBT or gamily intervention
What are the common SE of antipsychotic medications?
Raised prolactinSedation DM
What is section 135 used for?
For Police to gain asses to property
What is section 136 used for?
Removal of a patient from a public place
What is section 2 used for?
Admission and assessment for uptimes o 28 days. Can start treatment
What is section 3 used for?
Admission and Treatment for 3m before 2nd opinion.
What is a section 4 used for?
Assessment for treatment. 72 hours. Recommendation by doctor
What is section 5 (2) for?
RN for emergency holding for 6hours
What is section 5(4) for?
Doctor for emergency holding for 72 hours.
Which have more EPSE, typical or atypical antipsychotics?
typical antipsychotics have more EPSE SE.
What type of antipsychotic is clozapine?
typical
What is included in a risk assessment?
HealthSelf Others
What is Lofepramine?
An SNRI with a lower overdose profile
What is included in the health assessment?
Nutrition Dehydrations Medical conditions and medication taking
What is Donepezil, rivastigmine and galantamine?
Acetylcholinesterase inhibitors
What is memantine?
A glutamate receptor antagonist
When is rivastigmine used for memory?
Parkinson’s diseaseLewy body dementia
When Memantine used?
Severe a Alzheimers disease or AChE intolerance/ contraindication
What is the cholinergic hypothesis?
Deteriorating cognition is associated with decrease in cholinergic neurones and therefore ACh
What is the MOA of memantine?
Decreasing glutamate decreases excitotoxicity
Where is donepezil metabolised?
At the liver - therefore affected by liver enzymes inducers etc.
Where is mamentine metabolised?
it is excreted from kidney, therefore do UE
Side effects of cholinergic activity?
Nausea, vomiting, diarrhoea Insomnia Dizziness Urinary incontinence
What may make the SE of AChE inhibitors worse?
Beta blockers
What may make the side effects of mamentine worse?
Glutamate receptor antagonists like ketamine. Can lead to a pharmacological psychosis
What investigation should be done before starting AChE inhibitor?
ECG - QTc interval, LBBBUE - mamentine
When should AChE inhibitors be prescribed with caution?
Gastric ulcer seizures
hat are the side effects Clozapine side effect?
Sedation Hyper-salivationConstipation
Why is an ECG used for antipsychotics?
QTc prolongation Myocarditis
How long does psychosis have to last until diagnosable as schizophrenia?
1 month
Why is sodium valproate used in psychiatry with an antipsychotic?
Used for low mood Treatment of a lower seizure threshold due to antipsychotics
What is he time course of pupura psychosis?
Within 2 weeks of birth. Insidious onset with behavioural and confusion learning upto psychosis.Thought to be part of underlying bipolar/effective disorder.
