MENTAL HEALTH Flashcards
Lewy body dementia treatments
Donepezil is a cholinesterase inhibitor which is the first-line treatment for cognitive impairment and behavioural symptoms in DLB.
Carbidopa/Levodopa are dopaminergic agents used to treat motor symptoms which present in Lewy body dementia
Clonazepam is used to treat REM sleep behaviour disturbances and should be given in low doses 30 minutes before bedtime.
Sertraline is an SSRI which are the preferred drugs to treat depression with Lewy body dementia because they have limited side-effects and favourable pharmacokinetics
Hypertrophic obstructive cardiomyopathy - is associated with
Wolff-Parkinson White
kidny stones gold standard investigation
The gold standard investigation is a spiral non-contrast CT scan.
Adult-onset Still’s disease features
Features arthralgia elevated serum ferritin rash: salmon-pink, maculopapular pyrexia typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash lymphadenopathy rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative
Adult-onset Still’s disease management
Management
NSAIDs
should be used first-line to manage fever, joint pain and serositis
they should be trialled for at least a week before steroids are added.
steroids
may control symptoms but won’t improve prognosis
if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered
Short-term side-effects of ECT
Short-term side-effects headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia
Erotmania
specific form of delusional disorder that is characterised here by the patient’s belief that a famous actor is in love with her, alongside no other symptoms suggesting psychosis or mood disturbance.
Other subtypes of delusion include grandiose and persecutory.
Antipsychotics in the elderly
ncreased risk of stroke and VTE
Anorexia features
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
r borderline personality disorder
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
personality disorder management
Management
PDs are often thought to be ‘untreatable’ by definition
however, a number of approaches have been shown to help patients, including:
psychological therapies: dialectical behaviour therapy
Schizotypal
Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent
Schizoid
Indifference to praise and criticism Preference for solitary activities Lack of interest in sexual interactions Lack of desire for companionship Emotional coldness Few interests Few friends or confidants other than family
Histrionic
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
NICE published guidelines on the management of schizophrenia in 2009.
Key points:
oral atypical antipsychotics are first-line
cognitive behavioural therapy should be offered to all patients
close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
Rapid tranquillisation
- intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine for rapid tranquillisation in adults.
- If there is insufficient information to guide the choice of medication for rapid tranquillisation, or the service user has not taken antipsychotic medication before, use intramuscular lorazepam.
haemophilia A cause
clotting factor VIII deficiency
haemophilia B cause
which is caused by a factor IX deficiency
Typical symptoms of haemophilia may include
Severe epistaxis
Bleeding gums
Haematuria: gross or microscopic (i.e. detected on dipstick).
Intra-articular or intramuscular bleeds: commonly affected joints include the knees, ankles and elbows.
Excessive bruising/ecchymoses, contusions or spontaneous haemorrhage during childhood play.
Prolonged bleeding after a surgical or dental procedure, or post-venepuncture.
Findings associated with haemophilia include:
Normal platelet count on FBC
Normal prothrombin time (PT), bleeding time (BT), fibrinogen levels and von Willebrand factor levels.
Prolonged activated partial thromboplastin time (APTT): although this can be normal in mild disease.
Reduced factor VIII or factor IX activity level: for haemophilia A or B respectively.
haemophilia vs VWD
Haemophilia A/B/C only APPT increased
VWD Bleeding time increase APPT normal or increased
ADHD management
DHD is managed with behavioural techniques and stimulant medicines such as methylphenidate. These medicines increase function of the frontal lobe to increase executive function to increase attention and reduce impulsivity.
ADHD may impair a child’s ability to perform well at school, and they might benefit from extra support. However, ADH does not generally affect intellectual ability.
e Mental Capacity Act - 5 key principles
A person is assumed to have capacity unless proven otherwise
Steps must be taken to help a person have capacity
An unwise decision does not mean a person lacks capacity
Any decisions made under the MCA must be in the person’s best interests
Any decisions made should be the least restrictive to a person’s rights and freedoms
Munchausen’s syndrome:
patients intentionally fake signs and symptoms (e.g. adding blood to urine and complaining of pain) in order to gain attention and play “the patient role”.
ECT in depression
For severe depressive episodes that are life-threatening or require a rapid response, NICE guidelines recommend Electroconvulsive Therapy (ECT).
It is not known exactly how ECT works but there is evidence to suggest that the induced seizure has more of a treatment effect than ‘placebo’ ECT or ‘sham’ ECT. Short-term side effects of ECT can include headache, muscle aches or pains, nausea, temporary memory loss, confusion. Long-term side effects of ECT can include persistent memory loss. Due to the induced seizure, there is a risk of damage to the teeth or mouth, and due to the general anaesthetic, there is a small risk of death.
CO2 poisoning treatment
Treatment is largely supportive, with 100% oxygen and early intensive care involvement. Hyperbaric oxygen can be considered in more serious cases.
Obstructive sleep apnoea
A diagnosis of OSA is made using sleep studies.
Treatment of OSA includes lifestyle changes such as weight loss and smoking cessation; night time CPAP and consideration of surgical interventions.
nausea, vomiting, colicky pain and increased secretions can be treated with a number of agents;
Hyoscine butylbromide
Octreotide
Ondansetron
Atropine
a fib management
According to the NICE guidelines;
Rate control should be offered first line, except for patients with new onset AF, reversible causes or heart failure. Rate can be controlled using a beta blocker or calcium channel blocker
Digoxin should be considered in patients with heart failure
Amiodarone should not be given for long term rate control
Rhythm control can be pharmacological or by electrical rhythm control
DC cardioversion should be done in patients with unstable atrial fibrillation
Patients with new onset AF should be started on anti-coagulation as they are high risk for stroke
Clozapine Mac and side effects/risk
Dibenzodiazepine (tricyclic derivative)
• Works in treatment resistant schizophrenia (no one knows why)
• Reduces suicide risk
• It causes agranulocytosis in 1%
• Thus there is a national monitoring system in place: a recent FBC result is mandatory for dispensing.
• Tachycardia is common s/e. Rarely, it causes myocarditis (usually 1st month of treatment).
• Stronglyassociatedwithgastrointestinalhypomobility– obstruction -> toxic megacolon.
• Very sedating (but that’s not why it works better)
• Low risk of EPSEs
• Reducesseizurethreshold
• Serum monitoring has utility – 0.35 - 0.6 mmol/L
Lithium
Effective in type 1 bipolar disorder
• Antimanic and antidepressant. Better for prophylaxis
than acute treatment (use antipsychotic)
• Reduces suicide risk
• MUST BE PRESCRIBED BY BRANDNAME e.g. Priadel, camcolit.
• Must check U+Es, TFTs prior to Rx.
• Trough level (12 hours post dose) serum monitoring is
essential
• Aim for serum levels between 0.6-0.8 mmol/L.
• Narrow therapeutic index. DANGEROUS IN OVERDOSE.
• Long term side effects are renal failure and thyroid dysfunction
• Adverse interactions with NSAIDs and many diuretics -> leads to toxic levels -> BEWARE!
Monoamine Oxidase Inhibitors
Phenelzine (most common), isocarboxazid and tranylcypromine
• Irreversibly bind monoamine oxidase type A in the CNS
• Can cause sympathomimetic crises (malignant hypertension) in combination with a high tyramine diet
• Conversely, the most common side effect is postural hypotension, also insomnia and GI disturbances.
• Probably underused now – particularly for TRD
• Not as dangerous as they are made out to be. Nonetheless, specialist only
prescription. We use them at the Maudsley.
• If prescribed with SSRIs, then high risk of serotonin syndrome (potentially fatal). They can be prescribed with NET TCAs and mirtazapine, agomelatine, trazodone, lithium etc.
• Phenelzine and isocarboxazid (not tranylcypromine) irreversibly bind pyridoxine (Vit. B6). In theory -> skin problems, glossitis, neuropathy. Very rare.
• Low threshold for seeking highly specialist advice (Maudsley National Affective Disorders Service, or local equivalent) if your patient is having problems with them. Most psychiatrists don’t know how to manage them.
Sodium Valproate
Antiepileptic with antimanic, mood stabilising properties (also used in migraine)
• Commonly prescribed in bipolar disorder (sometimes as divalproex or valproic
acid (same thing))
• It is a teratogen
• 1 in 10 babies have serious congenital abnormalities
• 4 in 10 babies have neurodevelopmental disorders
• In 2018, the MHRA banned its use in women of childbearing age unless they were on a fool proof method of contraception and signed a yearly declaration confirming knowledge of risks.
Monitor with LTF’s
Neuroleptic Malignant Syndrome
Muscle cramps, tremor, fever, sweating, autonomic instability, rhabdomyolysis, renal failure, agitation -> delirium -> coma -> death
• Medical emergency
• More common with 1st gen. antipsychotics but can
occur with any
• Treatment is cooling, dantrolene (+/- bromocriptine), benzodiazepines, stopping all antipsychotics.
• Early identification -> much lower mortality rate
• A similar syndrome can occur in the absence of antipsychotics -> malignant catatonia. Similar treatment.
• Rule out an organic cause -> autoimmune/infective encephalitis, illicit drugs etc.
Serotonin Syndrome
Similar to NMS, but occurs with ≥2 serotonergic drugs
• Rare (I’ve never seen it in clinical practice)
• Muscle cramps, tremor, fever, sweating, autonomic instability, rhabdomyolysis, renal failure, agitation -> delirium -> coma -> death
• Medical emergency
• Most dangerous combination is MAOi + SSRI or SERT
TCA.
• Also occurs with high doses of MDMA (ecstacy), amphetamine, cocaine
• Treatment is supportive, cyproheptadine, benzodiazepines, stopping all antidepressants, olanzapine (5HT antagonist).
• Early identification -> much lower mortality rate
Management of generalised anxiety disorder (GAD)
NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
Drug treatment
NICE suggest sertraline should be considered the first-line SSRI
if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI)
examples of SNRIs include duloxetine and venlafaxine
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first mont
Management of panic disorder
Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Treatment in primary care
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
Medically-unexplained symptoms
Somatisation disorder
Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
hypochondriasis presentation
llness anxiety disorder (hypochondriasis)
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Conversion disorder
Conversion disorder
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Psychosis
Psychotic features include:
hallucinations (e.g. auditory)
delusions
thought disorganisation
alogia: little information conveyed by speech
tangentiality: answers diverge from topic
clanging
word salad: linking real words incoherently → nonsensical content
Post-partum mental health problems screening
The Edinburgh Postnatal Depression Scale may be used to screen for depression:
10-item questionnaire, with a maximum score of 30
indicates how the mother has felt over the previous week
score > 13 indicates a ‘depressive illness of varying severity’
sensitivity and specificity > 90%
includes a question about self-harm
‘Baby-blues’
Seen in around 60-70% of women
Typically seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
Management = reassure and health visitor
Postnatal depression presentation
Affects around 10% of women
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
Postnatal depression management
As with the baby blues reassurance and support are important
Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant
- paroxetine is recommended by SIGN because of the low milk/plasma ratio
- *fluoxetine is best avoided due to a long half-life
Puerperal psychosis features
Affects approximately 0.2% of women
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Puerperal psychosi
Admission to hospital is usually required
There is around a 25-50% risk of recurrence following future pregnancies
Management of cocaine toxicity
in general, benzodiazepines are generally first-line for most cocaine-related problems
chest pain: benzodiazepines + glyceryl trinitrate. If myocardial infarction develops then primary percutaneous coronary intervention
hypertension: benzodiazepines + sodium nitroprusside
the use of beta-blockers in cocaine-induced cardiovascular problems is a controversial issue. The American Heart Association issued a statement in 2008 warning against the use of beta-blockers (due to the risk of unopposed alpha-mediated coronary vasospasm) but many cardiologists since have questioned whether this is valid. If a reasonable alternative is given in an exam it is probably wise to choose it
Alcohol - problem drinking: management
Nutritional support
SIGN recommends alcoholic patients should receive oral thiamine if their ‘diet may be deficient’
Drugs used
benzodiazepines for acute withdrawal
disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms. Contraindications include ischaemic heart disease and psychosis
acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials
Factors favouring delirium over dementia
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions
Vascular dementia RF
isk factors History of stroke or transient ischaemic attack (TIA) Atrial fibrillation Hypertension Diabetes mellitus Hyperlipidaemia Smoking Obesity Coronary heart disease A family history of stroke or cardiovascular
Vascular dementia presentation
Patients with VD typically presents with
Several months or several years of a history of a sudden or stepwise deterioration of cognitive function.
Symptoms and the speed of progression vary but may include:
Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
The difficulty with attention and concentration
Seizures
Memory disturbance
Gait disturbance
Speech disturbance
Emotional disturbance
Lewy body dementia features
Features
progressive cognitive impairment
in contrast to Alzheimer’s, early impairments in attention and executive function rather than just memory loss
cognition may be fluctuating, in contrast to other forms of dementia
usually develops before parkinsonism
parkinsonism
visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
Lewy body dementia management
Management
both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer’s. NICE have made detailed recommendations about what drugs to use at what stages. Please see the link for more details
neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent
Factors suggesting diagnosis of depression over dementia
Factors suggesting diagnosis of depression over dementia
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
Pick’s disease features
Frontotemporal lobar degeneration (FTLD)
characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.
Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease.
Macroscopic changes seen in Pick’s disease include:-
Atrophy of the frontal and temporal lobes
normal pressure hydrocephalus
Urinary incontinence + gait abnormality + dementia
PTSD features
AT LEAST 1m
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing - lack of ability to experience feelings, feeling detached
NICE management of PTSD
Management
following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
watchful waiting may be used for mild symptoms lasting less than 4 weeks
military personnel have access to treatment provided by the armed forces
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used
Section 2
Admission for assessment for up to 28 days, non-renewable
The application for admission is made by an Approved Mental Health Professional (AMHP) or the patient’s nearest relative
Requires the recommendation of 2 doctors, one of whom must be ‘approved’ under Section 12(2) of the MHA
Section 3
Admission for treatment for up to 6 months, renewable
Requires an AMHP and 2 doctors, both of whom must have seen the patient in the past 24 hours
Section 4
Used in emergencies where a section 2 would cause “an undesirable delay”
It requires the recommendation of only one doctor and either an AMHP or the nearest relative
Allows a person to be detained for up to 72 hours, whereby it is usually converted to a section 2
Section 5(2)
A voluntary patient in hospital may be legally detained by a doctor for 72 hours
Section 5(4)
A section 5(4) is similar to a section 5(2) but is used by nurses and only lasts for 6 hours.
Section 17a
Supervised Community Treatment (also known as a Community Treatment Order)
Section 135
court order that allows the police to enter a property to remove a person to a Place of Safety (either the police station or more commonly A&E)
Section 136
The police can bring someone from a public place who appears to have a mental disorder to a Place of Safety (either the police station or more commonly A&E)
first rank symptom is highly suggestive of a diagnosis of schizophrenia.
Primary delusions Delusion of perception Thought insertion Thought broadcast Thought withdrawal Passivity feelings Somatic hallucinations Auditory hallucinations of third person
SCZ treatment
First choice antipsychotic medication might include:
Olanzapine Resperidone Quetiapine Aripiprazole The choice of medication is usually guided by previous response, side effect profile and compliance.
Therapeutic Trial
A minimum six week therapeutic trial is warranted before changing to a different medication.
Treatment Resistance
More than 25% of patients are resistant to treatment and about 12% of first episode patients do not respond to treatment at the end of the first year.
Clozapine is considered the drug of choice for treatment resistant schizophreni
DDx for phycotic symtoms
Encephalitis
Brain tumour
Epilespy
Substance use
Drug-induced psychosis
Acute onset
Concurrent substance use
Often hallucinations & delusions
Often resolves in hours – days after substance stopped
Charles Bonnet syndrome
adjustment to visual loss - phantom vision
