Mental Health/Psychiatry Flashcards
Section 2
non-renewable section for admission up to 28days
2 doctors and AHMP - one doctor being a psychiatric consultant
treatment given against pts wishes
Section 3
renewable section for admission for up to 6 months of treatment
AHMP and 2 doctors who must have seen the pt within the past 24hrs
treatment given against the patients wishes
Section 4
section for 72hr assessment often used as an emergency - when section 2 will have a delayed
changed to section 2 on arrival to hospital
Section 5(2)
patient already voluntarily in hospital
section enables legal detainment by doctor 72hrs
Section 5(4)
patient already voluntarily in hospital
section enables nurse to detain pt for 6hrs in hospital
Section 17a
used to recall a pt who is usually under community treatment to hospital for treatment
often due to non-compliance with treatment given in community
Section 135
court order obtained to allow breaking into property and removing person to place of safety
section 136
removal of a person, who appears to have a mental disorder to a place of safety - found in public place
section for 24hrs - allows MHA assessment
What are cluster A personality disorders?
the odd and eccentric
- paranoid
- schizoid
- schizotypal
Characteristics of paranoid
hypersensitive and unforgiving
attitude when insulted
questions loyalty of friends
reluctance to confide in others
preoccupation with conspirational beliefs/hidden meanings
percieve attacks on their character
Characteristics of Schizoid
indifference to praise and criticism
prefer solitary activities
ack on interest in sexual relationships
& lack of desire for companionship
emotional coldness
few interests and friends/confidants - except family
Characteristics of Schizotypal
odd beliefs and magical thinking
unusual perceptual disturbances
paranoid ideation & suspciousness
odd and eccentric behaviou r
lack of close friends - except family
odd speech but coherent
inappropriate affect
What are Cluster B personality disorders?
dramatic, emotional and erratic
antisocial
borderline (emotionally unstable)
histrionic
narcissistic
Characteristics of Antisocial PD
failure to conform to social norms
deception - repetitive lying, conning of others for profit/pleasure
impulsiveness, failure to plan ahead
irritable and aggressive
reckless and disregards personal and other’s safety
consistent irresponsibility - failure to sustain work behaviour or honour financial obligations
Characteristics of Borderline (EU) PD
efforts to avoid real/imagined abandonment
unstable interpersonal relationships
unstable self image
impulsivity which are self-damaging (spending, sex, substance abuse)
recurrent suicidal behaviour
affective instability
chronic feeling of emptiness
difficulty controlling temper
partially psychotic thoughts
Characteristics of Histronic PD
inappropriate sexual seductiveness
need to be centre of attention
rapidly shifting & shallow expression of emotions
physical appearance used for attention seeking purpose
impressionistic speech lacking detail
self dramatization
relationship considered to be more intimate
Characteristics of Narcisstic PD
grandoise sense of self importance
fantasies - unlimited successm power or beauty
sense of entitlement
taking advantage of others - achieve own needs
lack of empathy
excessive need for admiration
chronic envy
arrogant and haughty attitude
What are Cluster C personality disorders?
anxious and fearful
obssessive-compulsive
avoidant
dependent
Charcateristics of Obssessive-Compulsive
occupied with details, rules, lists, order, organisation or agenda
demonstrates perfectionism
extremely dedicated to work & effeciency - eliminates spare time activities
meticulous, scrupulous, rigid on etiquettes, ethics, morality and values
unwilling to pass on tasks and work with others unless they abide by their ways
hoarding despite no sentimental meaning
stingy spending style towards themselves and others
stiffness and stubborness
Characteristics of avoidant PD
avoidance of occupational activities - fear of criticism/rejection
- often preoccupied by being criticised rejected in social situations
unwilling to be involved and certainty of being liked
restraint form intimate relationships - fear of being ridiculed
reluctance to take risks - fear of embarrasment
views self as inferior to others
social isolation accompanied by craving for social contact
Characteristics of Dependent PD
difficulty making everyday decisions without excessive reassurance
needs other to take responsibility with major areas of life
difficult expressing disagreement with other - fear of losing support
lack of initiative
unrealistic fears for being left to care for themself
urgent search for another relation when a close relation ends - need care and support
unrealistic feelings - cannot care for themselves
How are personality disorder managed?
psychological therapies - dialectal behaviour therapy
tx for any coexisting psychiatric conditions
What criteria is used in Depression diagnosis ?
depression diagnosed using the DSM-5 criteria
main symptoms low mood & hopelessness disturbed sleep appetite/weight changes fatigue/low energy/enthusiasm/motivation poor concentration feeling worthless/hopeless inappropriate guilt suicidal ideation and element of self-harm may also be present
depression
Criteria for subthreshold depression
at least two but less than 5 symptoms of depression
criteria for mild depression
few symptoms out the 5 in excess
minor functional impairment
Criteria for moderate depression
symptoms or functional impairment between mild and severe
Criteria for severe depression
most symptoms of depression that markedly interferes with functioning - can have some psychotic symptoms
Investigations done in depression work up?
investigations not routinely indicated for ppl with depression
basic bloods such as biochemistry (glucose, U&Es, creatinine, LFTs, TFTs and calcium levels
haematology - FBC and ESR
Management of subthreshold or mild depression
general measures such as sleep hygiene and active monitoring for those refusing intervention
not routinely given antidepressants but consider in hx of moderate-severe depression
initial presentation present 2yrs and persistence after interventions
low-intensity psychosocial interventions - CBT (behavioural activation and problem-solving techniques) or computerised CBT or group based CBT
Management of unresponsive, moderate and severe depression
SSRI - citalopram, fluoxetine, paroxetine or sertraline
high-intensity psychological interventions
- individual CBT
- interpersonal therapy (IPT)
- behavioural activation
- behavioural couples therapy
Bipolar disorder
periods of mania/hypomania alongside eps of depression
Type 1 Bipolar includes
mania and depression
Type 2 Bipolar includes
hypomania and depression
Mania features….
abnormally elevated mood extremely mood, extreme irritable, agressive increased energy/activity restless decreased need for sleep/insomnia pressure of speech/incomprehensible speech racing thoughts or flight of ideas poor concentration delusions - grandoise hallucinations - usually voices
Hypomania
milder manic symptoms
diagnosis
abrupt onset of symptoms - manic episodes ~7days
hypomanic are ~4days
need confirmation from mental health service in adults
or CAHMS in children
Management of bipolar:
bipolar specific psychological interventions
lithium mood stabiliser - alternative is valproate
mania hypomania mx - stop antidepressants - initiate antipsychotics (olanzapine or haloperidol)
mx for depression - talking therapies, fluoxetine
reduced BMI bradycardia hypotension enlarged salivary glands hypokalaemic, low FSH/LH/oestrogens/testosterone - amenorrhea and menstrual irregularities raised cortisol and GH low T3 hypercholesterolaemia
Anorexia Nervosa
Diagnostic criteria for anorexia nervosa
DSM-5 criteria
- restricting energy intake relative to requirements
- intense fear of weight gain despite being underweight
- Body dysmorphia - denies seriousness of the current low body weight
Management of Anorexia Nervosa
adults
- eating disorder focused CBT
- maudsley anorexia tx for adults (MANTRA)
- specialist supportive management
children
- first line = family focus therapy
- second line = CBT
episodes of binge eating followed by purgative behaviour and vomiting
Bulimia Nervosa
Examples of purgative behaviours
excessive laxative use
diuretics
excessive exercise
Diagnosis of bulimia Nervosa
DSM-5 criteria used
binge eating and compensatory behaviour both occur on average weekly for 3/12
recurrent eps of binging and reporting a lack of control in during a binge followed by purgative bevaiours to prevent weight gain
Management of Bulimia Nervosa
referral to specialist care
bulimia-nervosa-focused guided self help for adults
- consider CBT-ED
- children should be offered BN focused family therapy (FT-BN)
- pharmacological tx: fluoxetine
recurrent eps of binge eating with the absence of compensatory behaviour
lack of control during episodes
binge eating disorder
resembled anorexia, Bulimia nervosa and or binge eating - but not precisely meeting diagnostic criteria
Atypical eating disorders
when a person experiences things differently from those around them
Psychosis
How can psychosis present?
hallucinations (auditory) delusions disorganised thoughts and thought disorders agitated/aggressive neurocognitive impairment depression self-harm
causes of psychosis?
prescribed med - corticosteroids illicit drugs - cannabis, LSD and amphetamines depression/schizoaffective bipolar neuro conditions - PD or huntington's
How to manage Schizophrenia?
first line - oral atypical antipsychotics
CBT offered to all pts
monitor CVD risk factors - more at risk of CVD in SZ
tremor sweating tachycardia anxiety seizures - peaks at 36hrs
~48-72hrs - altered mental status, delusions/hallucinations, fever, tachycardia, coarse tremor
Etoh withdrawal
Management of etoh withdrawal
first line = long-acting benzo (clordiazepoxide or diazepam)
pabrinex- vitB12 replacement
carbamazepine - used an adjunct
Outline the 5 stages of a normal grief reaction
- denial - feeling numb, pseudohallucinations
- anger - directed against family members or medical professionals
- bargaining - acting particular ways makes us feel better
- depression - sadness and longing
- acceptance - pain eases and we accept what has happened
not everyone goes through all 5 stages
atypical grief reactions
delayed grief - grief begins more than 2 weeks after passing
prolonged grief - difficult to define some may take up to or go beyond 12months
Side effects of typical antipsychotics
hyperprolactinaemia
Extrapyramidal side effects
What are the 4 EPS?
- parkinsonism
- Akathisia
- acute dystonia
- Tardive dyskinesia
What is Neuroleptic Malignant syndrome (NMS)?
reaction to antipsychotic drugs - presents with fever, muscle rigidity, autonomic instability, delirium with muscle breakdown/raised CK
risk factors - high doses/highly potent drugs, paraenteral admin
How would you manage NMS?
stop antipsychotic and supportive measures - IV fluids
What are side effects for atypical antipsychotic?
weight gain
metabolic - hyperprolactinemia, lipid/glucose levels
clozapine - Agranulocytosis/neutropenia and ECG changes due to myocarditis
What risks are associated with antipsychotic use
Stroke and VTE
Intrusive thoughts - flashbacks or nightmares, time
being in a daze/dissociated
negative mood
avoidance
arousal - hypervigilant or disturbed sleep
4 weeks or less
Acute reaction to stress
How is acute reaction to stress managed?
first-line trauma-focused CBT
Benzodiazepines - if agitated, sleep disturbance
What are the 5 stages of uncomplicated bereavement/Grief?
- denial = numbness, pseudohallucinations of deceased
- anger
- bargaining - may feel better if they do certain things
- depression = longing and upset
- acceptance
Inattention - wandering off task, lacking persistence, difficulty focusing/organising
hyperactivity - excessive motor activity, fidgeting, tapping or talkativeness
impulsivity - hasty action, social intrusiveness
ADHD
criteria for ADHD
features of inattention, hyperactivity and impulsivity - persistent
element of devlopmental delay
16yrs - need 6 features present
17yr+ - need 5 features present
Management of ADHD?
10 week watch and wait period - see if symptoms change/resolve
secondary care referral - paediatric consultant or CAHMS
last resort - drug therapy
- methylphenidate is first line in children
- alternative lisadexafetamine
What check/monitoring is required for ADHD medications?
cardiotoxic medications - perform a baseline ECG prior to treatment,
refer to cardiologist if significant PMHs/FHx or ambiguity
If symptoms of ADHD are mild-moderate what can we also offer parents?
useful for parents to attend education and training programmes
Describe the 4 main symptoms of PTSD?
- re-experiencing - flashbacks, nightmares, images
- avoidance - people/situations and cicrumstances with resemble to event
- Hyperarousal - hypervigilant difficulty sleeping/concentrating
- Emotional numbing - lack feelings and is detached
Management of PTSD?
mild symptoms 4weeks - watchful waiting
more severe cases - Trauma-focused CBT or EMDR
Drug treatments
venlafaxine or SSRI (sertraline)
severe cases - risperidone
gradual loss of memory (episodic in particular), difficulty with executive function and nominal dysphasia
alzheimers dementia
assessment tools for Alzheimer’s
- 10 point cognitive screener - 10CS
2. 6- item cognitive impairment test (6CIT)
Management of Alzheimer’s
cognitive stimulation and cognitive rehabilitation
meds - acetylcholinesterase Inhibitors = donepezil & rivastigmine
- second line = memantine (intolerance to first line or severe disease)
Antidepressants and antipsychotics = if having associated depression or psychotic symptoms
What can we do for Alzheimer’s pts in primary care
Blood-screen - exclude any reversible causes for cognitive decline.
Generalised anxiety disorder characterised by
disproportionate, pervasive and uncontrollable and widespread worry
Range of somatic, cognitive and behavioural symptoms
DSM-5 diagnostic criteria for GAD?
- 6/12 months of excessive uncontrollable, disproportionate worry
- not confined to any other mental/medical/substance diagnosis
- 3 more symptoms - restless, easily fatigued, poor concentraton, irritable, muscle tension and sleep distrubance
ICD-10 diagnostic criteria?
generalised and persistent anxiety
variable dominant symptoms
expressions of fear - illness or accidents
What medications cause anxiety as a side effect?
salbutamol corticosteroids beta-blockers theophylline some antidepressants herbal medications
Physical signs of anxiety?
increased HR and SOB
trembling
exaggerated startle response
How to interpret GAD-7 questionnaire
5 -10 = mild anxiety disorder
10 - 15 = moderate anxiety disorder
15+ = severe anxiety
Management approach for GAD?
- educate about GAD and active monitoring
- Low-intensity psychological interventions
- High-intensity psychological interventions or drug treatment
- high specialist input
Drug treatment for GAD?
first line = SSRI - sertraline
if unable to tolerate try alternative SSRI or SNRI e..g venlafaxine or duloxetine
if not tolerating either - offer pregabalin
Side effects of SSRIs?
Gi symptoms - increased risk of GI bleed - PPI co-prescription
Hyponatremia
increased/worsened symptoms after initiaion
stopping SSRIs?
continue for 6months after remission of symptoms
when cessating - down titrate gradually over a 4 week period
Citalopram associated risk?
prolongation of QT interval
be cautious in hepatic impairment - longer time taken to excrete
What is panic disorder?
recurrent eps of sudden onset anxiety
absence of multi-themed worry
How do panic attacks usually present?
shaking SOB palpitations/sometimes CP nausea hot/cold flushes dizziness fear of dying
How is panic disorder managed?
CBT or Drug Tx
- SSRI (sertraline) first line
- if ineffective after 12/52 of SSRI offer TCA (imipramine or clomipramine)
What to do if panic disorder is not being responsive to primary care?
review and consider alternative tx
refer to specialist mental health services - they my receive more specialist care
