PSYCH Flashcards
(354 cards)
1
Q
What is psychosis?
A
= a syndrome characterised by a loss of contact with reality.
2
Q
What are the key symptoms of psychosis?
A
Delusions = fixed, false, unshakeable beliefs
Hallucinations = perception of something in the absence of external stimuli
=> Auditory (most common), visual, smell, taste
Formal thought disorder = pattern of disordered language reflecting disordered thoughts.
3
Q
What kind of delusions are common in psychosis?
A
Persecutory – being stalked/spied-on, etc.
Grandiose – elevated self-importance
Somatic – think something is physically wrong with themselves.
4
Q
DDx of Psychosis
A
Organic cause - delirium, endocrine, medication-induced, epilepsy
Other Psychiatric Disorder -
=> Schizophrenia, Depression, Schizotypal disorder, Schizoaffective disorder, Delusional disorder
Substance-induce - e.g. cannabis, hallucinogens, caffeine, alcohol
Systemic - e.g. MS, SLE, HIV, hypoglycaemia, etc.
5
Q
What medications can induce psychosis?
A
Dopamine agonists,
Corticosteroids,
Stimulants
6
Q
Schizotypal disorder
A
disordered thoughts but hallucinations/delusions not prominent
7
Q
Schizoaffective disorder
A
Prominent mood disorder alongside 1st rank schizophrenia symptoms
8
Q
Delusional disorder
A
delusions not so bizarre and no hallucinations
9
Q
Acute Transient Psychosis
A
= Sudden onset psychotic symptoms lasting <28 days, with no identifiable organic cause
Linked to stress
10
Q
What is schizophrenia?
How common is it?
A
= a psychotic disorder characterised by the presence of first rank symptoms for >28 days with no organic cause.
- 1 in 1000
- M=F
- Peak = 23-26 years (then 30-40 years)
11
Q
What are considered the 1st rank symptoms of schizophrenia?
A
Hallucinations (auditory):
=> 3rd person/being talked about
=> Thought echo / Running commentary
Delusional perception – attribute false meaning to an external stimulus.
Delusions of thought interference – insertion/withdrawal/broadcasting.
Passivity Phenomena:
=> Control of impulses/actions/feelings/sensations by an “external force”
12
Q
Other symptoms of schizophrenia (i.e. not 1st rank)
A
Positive – delusions, hallucinations, formal thought disorder
Negative – blunted/flat affect, social withdrawal, poverty of speech, anhedonia, decreased motivation
Cognitive – poor attention, learning, problem solving
Motor – catatonic movements, waxy flexibility.
13
Q
Schizophrenia - cause / risk factors
A
A mixture of genetics (80%) and environment.
RFs:
- FHx
- Obstetric complications, maternal illness in pregnancy, low birth weight
- Urban living, migration, adverse life events, poor pre-morbid personality, abnormal family dynamics
14
Q
Schizophrenia - Prodrome
A
period of symptoms development but not yet at diagnostic criteria.
- Non-specific negative symptoms
- Distress/agitation
- Transient psychotic symptoms
15
Q
Schizophrenia - Acute phase
A
relapsing and remitting positive and negative symptoms
16
Q
Schizophrenia - outcomes
A
20% only have 1 episode
50% recover but relapse in future
30% develop chronic schizophrenia
10-15% commit suicide
17
Q
Good Prognostic Factors for schizophrenia
A
Female Married Acute Onset Prominent mood symptoms Good premorbid personality Early Tx with good response
18
Q
Poor Prognostic Factors for schizophrenia
A
Male and Unmarried FHx of schizophrenia Early onset or insidious onset Prominent negative symptoms Substance abuse Lack of insight/non-compliance
19
Q
What are the aims of investigation in ?schizophrenia
A
- Establish if there is any organic cause
2. Prepare for Tx with antipsychotics
20
Q
Schizophrenia - investigations
A
History (+ collateral Hx) and MSE
Physical examination
=> BMI, neurological
Bloods
=> FBC, U&E, LFT, TFT, glucose, lipids, cholesterol
Urine drug screen = most important
ECG
+/- brain scan, EEG
21
Q
What is the most important investigation in diagnosis of schizophrenia?
A
Urine drug screen to rule out substance misuse as cause of Sx
22
Q
Schizophrenia - management
A
- Biological:
=> Antipsychotics
=> Annual physical health review – smoking, alcohol, BP, BMI, bloods, ECG - Psychological:
=> CBT
=> Psychoeducation – signs of relapse, prevent relapse, crisis plans
=> Education and support for carers - Social:
=> OT assessment of functioning – ADLs, occupation, hobbies
=> Social assessment for housing, benefits, finances, education/career
23
Q
Aims of management of schizophrenia
A
Recovery isn’t necessarily about completely stopping hallucinations/delusions, BUT rather:
- How to deal/cope with them
- Providing social support
- Reducing stigma
- Reducing risk to self and others
24
Q
Treatment Resistant Schizophrenia
A
= no response to TWO different antipsychotics
- Check Dx, check compliance and check for substance misuse
- Mx = CLOZAPINE:
25
What are the most important side effects of the antipsychotic clozapine?
SEs – agranulocytosis, neutropaenia, cardiomyopathies
Patient will need weekly FBCs
26
Non-compliance in schizophrenia Tx
Can be due to:
- Side effects
- Lack of insight
- Delusions about medications/prescriber
- Gains remission and thinks medication no longer needed
27
Antipsychotics - mechanism of action
Block post-synaptic receptors in dopaminergic pathways.
=> Decreases psychotic symptoms
=> Can cause hyperprolactinaemia
=> Can cause extra-pyramidal side effects
The aim is to reduce positive and negative symptoms, with minimal side effects.
28
Typical/first generation antipsychotics
e.g. chlorpromazine, haloperidol, sulpiride, flupentixol, trifluperazine.
= D2 receptor antagonists
29
Side effects of Typical/first generation antipsychotics
Extrapyramidal SEs
Decreased seizure threshold
Sedation
Neuroleptic malignant syndrome (NMS) = EMERGENCY
Apathy, confusion, depression
Dry mouth, blurred vision, constipation, urine retention
Arrythmias, hyperprolactinaemia, hypotension, weight gain
30
Extrapyramidal SEs
* Akathisia – uncontrollable urge to fidget (e.g. pacing, crossing and uncrossing legs) => Increased risk of suicide
* Acute dystonia – involuntary muscle spasms, causing abnormal movement/posture (fatal if laryngeal mm.)
* Parkinsonism – tremor, rigidity, bradykinesia
* Tardive Dyskinesia – involuntary hyperkinetic movements
31
Features of neuroleptic malignant syndrome (NMS)
= EMERGENCY
* Hyperthermia
* Muscle rigidity
* Tremor
* Acidosis
* Tachycardia
* Confusion
32
Atypicals/Second Generation antispychotics
e.g. aripiprazole, onlanzapine, risperidone, clozapine
= D2 receptor antagonists +/- 5-HT receptor antagonists.
33
Side effects of Atypicals/Second Generation antispychotics
```
General – nausea, constipation, dizziness (postural hypotension)
Weight gain
Sedation
Metabolic syndrome
+/- insomnia, hyperprolactinaemia
```
(Risperidone has EPSEs)
(Clozapine – agranulocytosis, neutropaenia, cardiomyopathy)
34
What is the 1st line class of antipsychotic and why?
Generally, atypicals are 1st line as they have the same efficacy but fewer EPSEs than 1st-generation antipsychotics.
35
Eating Disorders - Risk factors
* Adolescence (peak onset)
* Female (F:M = 10:1)
* Perfectionism
* Low self-esteem
* Early sexual development
* Hx of abuse
* Personality disorder
* Hx of eating disorder
* Exposure to “diet culture"
* Middle/upper class
36
Definition of anorexia nervosa
BMI <17.5
Persistent restriction of energy intake
Often excessive exercise
Intense fear of gaining weight/becoming fat
Lack of insight into seriousness of low BMI
37
DDx of anorexia
- Hyperthyroidism
- Depression, OCD, psychosis
- Body dysmorphic disorder
38
Anorexia nervosa - psychiatric Sx
```
Inflexible thinking,
obsessions/habits,
poor concentration,
irritable/flattened mood,
interests centred around food
```
39
Anorexia nervosa - cardiac Sx
Low BP and pulse
| Increased risk of arrythmias/heart failure
40
Anorexia nervosa - reproductive Sx
Reduced libido,
Amenorrhoea/low testosterone,
Reproductive dysfunction
41
Anorexia nervosa - MSK Sx
Muscle wasting/cramp
| IRREVERSIBLE osteopenia/osteoporosis
42
Anorexia nervosa - hair/skin Sx
Broken skin
Dry, brittle hair
Hair growth on face/body for warmth (Lanugo hair)
43
Anorexia nervosa - Other Sx
Cold extremities/hypothermia
Infections
Metabolic disturbances
Iron deficiency anaemia, leucopaenia, thrombocytopaenia
44
Anorexia Nervosa - Biological Management
Weight restoration
Regular monitoring
=> Weight, FBC, U&Es, LFT, glucose, (magnesium, Ca, CK, B12)
+/- DEXA scan
+/- ECG
45
What is there a risk of in weight restoration in anorexia?
Risk of refeeding syndrome
46
What might be identified on an ECG in anorexia?
Prolonged QTc,
HR <50,
arrythmias
47
Anorexia Nervosa - Psychological/social Management
Psychotherapies – CBT, motivational interviewing, mindfulness
Family therapy if <18 years old
SOCIAL - Involve family and friends for support, carer support.
48
Indications for hospitalisation in anorexia nervosa
BMI <13.5
Very deranged bloods
Syncope/arrythmias
49
Anorexia Nervosa - 10-year Prognosis
50% recovered
40% chronic problem
10% mortality (1/3 suicide)
50
Anorexia Nervosa - Poor prognostic factors
- Low body weight
- Bulimic features
- Family difficulties
- Personality problems
- Longer illness duration
51
Features of Bulimia Nervosa
Features = once a week (or more) of the following, for 3 months:
- Recurrent binge eating
- Recurrent compensatory behaviour (vomiting, laxatives, diuretics, fasting, exercise)
52
Bulimia Nervosa - Sx
Poor concentration, irritable
Tooth decay/erosion, hoarse voice, bleeding, swollen parotid glands (=> “chipmunk face”)
Callouses, scars, abrasions on backs of fingers due to self-induced vomiting.
Electrolyte imbalances:
=> Seizure, muscle paralysis, arrythmias
Swollen/painful stomach, constipation, delayed gastric emptying, oesophagitis, rectal prolapse, renal failure.
53
Bulimia Nervosa - Biological Mx
Anti-depressant – SSRI, usually fluoxetine.
Advise laxative and alcohol cessation
Regular monitoring
=> Weight, FBC, U&Es, LFT, glucose
54
Bulimia Nervosa - Psychological/social Mx
Psychoeducation – coping mechanisms
Psychotherapies – CBT, compassion-focussed, mindfulness
Social:
- Involve family/friends for support
- Carer support
55
Bulimia Nervosa - prognosis
10-year prognosis:
- 70% recovered
- 1% mortality
Poor prognostic factors:
- Low body weight
- Comorbid depression
56
Prevalence of depression
10-20%
Late 20s = peak onset
F:M = 2:1
57
Prognosis of depression
50% recover within 1 year
25% go on to have chronic depression (>2 years)
5-15% commit suicide
58
Core symptoms of depression
1. Low Mood (worse in the morning)
2. Anhedonia
3. Fatigue
59
Other symptoms of depression
```
Guilt/hopelessness
Appetite changes (weight loss/gain)
Poor memory, pessimism, psychosis
Sleep disturbances
Self-harm/suicidal thoughts
Self-esteem = low
```
60
ICD-10 criteria for depression
symptoms for 2+ weeks:
- Mild – 2 core and 2 other
- Moderate – 2/3 core and 3/4 other
- Severe – 3 core and 5 other
61
What are the 3 biggest risk factors for depression?
Life events
FHx
Substance misuse
62
Risk Factors for depression
Social – life events, isolation, loss, childhood abuse
Biological – FHx, hormonal changes, chronic/severe illness
Psychological – negative thoughts, high expressed emotion, criticism, personality disorder
Medications – steroids, antipsychotics, substance misuse
63
Depression - differentials
Psychiatric – dementia, schizophrenia, anxiety disorder, SAD, bipolar
Neurological – PD, MS, head injury, cerebral tumour
Endocrine – hypothyroidism, hyperparathyroidism, Cushing’s, Addison’s
Infections – HIV/AIDs, glandular fever, STIs
Systemic – malignancies, SLE, RA, renal failure
64
Management of depression - biological
Biological Interventions:
- Antidepressants
- Atypical antipsychotics (if psychosis)
- Augmentation with Lithium (Tx resistant)
65
Management of depression - psychological
```
Psychoeducation
CBT
Mindfulness
Sleep hygiene
Self-help (e.g. apps)
```
66
Management of depression - social
Support for education, training, employment
Support for housing/benefits
Carer support – info, support groups, assessment
CPN (monitor Sx, mood, mental state) if severe
67
Mild/ moderate depression - management
Manage in Primary care
Low-intensity psychological interventions
Consider 1st line medication (SSRI)
68
When is an SSRI not indicated in depression
SSRI is not indicated if only mild/subthreshold symptoms for <2 years and no Hx of depression.
69
Moderate/severe Depression or Tx-resistant - management
Manage in primary care (may consider referral to 2o)
1st line medication (SSRI) or alternative
High-intensity psychological interventions
70
Severe depression - Management
Inpatient or Crisis Resolution and Home treatment
1st line medication or alternatives/adjuncts
High intensity psychological interventions
?ECT
71
Counselling newly diagnosed depression patients
Make sure you have a good Hx and risk assessment
Be aware of stigma
Explain different courses, outcomes, treatments
Remain positive and highlight the benefits of Tx
72
What is important to do before starting anti-depressant Tx?
Rule out bipolar before starting antidepressant monotherapy!
73
Starting anti-depressants
1. Consider SEs, cautions, CIs
2. Start an effective but tolerated dose
=> Trial for 3-4 weeks before deciding if it is working
=> 70% will respond to 1st Tx
3. Review regularly
74
Anti-depressant withdrawal
DO NOT STOP ABRUPTLY – taper dose over 4 weeks
Withdrawal symptoms particularly noticeable with paroxetine and venlafaxine.
- Dizzy, numb/tingling
- Nausea/vomiting
- Headache
- Sweating, shaking
- Anxiety
- Sleep disturbances
75
How long should anti-depressants be used for?
Continue for at least 6 months after resolution of Sx.
76
SSRIs - mechanism of action
How long does it take to take effect?
Inhibit pre-synaptic 5-HT reuptake.
Take up to 6 weeks for effect.
Sx may worsen before improving.
77
SSRIs - side effects, cautions, CIs
SEs – nausea, headaches, drowsiness, insomnia, diarrhoea, dizziness, SEXUAL DYSFUNCTION, restlessness
Cautions – Long QTc, bleeding disorders (especially citalopram)
CIs – poorly controlled epilepsy.
=> Paroxetine = teratogenic
78
Which medication is 1st line for depression
SSRIs (due to fewer SEs)
Although TCAs are 1st line in pregnancy
79
SNRIs - mechanism of action
Inhibit 5-HT and NA reuptake
80
Which medication is 2nd line for depression?
SNRIs (venlafaxine, duloxetine)
81
SNRIs - side effects, cautions, CIs
SEs – more prominent sedation and sexual dysfunction, and same as SSRIs.
Cautions – diabetes, uncontrolled HTN, bleeding disorders, epilepsy
82
TCAs - mechanism of action
Inhibit 5-HT and NA reuptake
83
TCAs - side effects, cautions, CIs
SEs – sedation, weight gain, dizziness, HTN, delirium, antimuscarinic SEs
Cautions – bipolar, diabetes, epilepsy, high suicide risk (dangerous in overdose)
CIs – arrythmias, heart block, post-MI
84
MAOIs - mechanism of action and use
Irreversible MAO A & B inhibition
Tx resistant/atypical depression
85
MAOIs - side effects, cautions, CIs
SEs – nausea, diarrhoea, constipation, dry mouth, sleep disturbance, postural hypotension, headache
Cautions – bleeding disorders, diabetes, elderly
Interact with many drugs/tyramine containing foods (hypertensive crisis) => so not often used
86
NaSSA (mirtazapine) - mechanism of action and use
Alpha2-receptor antagonist – increases NA and 5-HT
Adjunct in Tx-resistant depression
87
NaSSA (mirtazapine) - side effects, cautions
SEs – increased appetite and weight gain, sedation
Cautions – diabetes, seizures, urinary retention, elderly
88
Alcohol and antidepressants
With SSRIs and SNRIs advise against alcohol as this will have additive sedation effects.
89
St John’s Wort
= an unlicenced herbal remedy for treating depression => some evidence of efficacy but difficult to guide on dosing.
Cytochrome P450 inducer, causing metabolism and therapy failure of OCP, digoxin, warfarin, phenytoin, carbamazepine.
90
Acute Stress Reaction
= a brief response (<1 month) to a severely stressful event
91
What is the link between acute stress reaction and PTSD?
~80% formally diagnosed with acute stress reaction develop PTSD.
92
Acute Stress Reaction - Sx
(overlap with anxiety/depression Sx)
- Numbness, detachment, decreased concentration, derealisation.
- Insomnia, restlessness, anger
- Autonomic Symptoms
93
Acute Stress Reaction - Coping strategies
- Avoid thinking/speaking of event
- Denial/cannot remember event
- Alcohol
94
Acute Stress Reaction - Mx
- Taking to friends/family/professionals to relieve anxiety
- Encourage recall
- Learning effective coping strategies
Anxiolytics (if severe anxiety)
Hypnotics (if insomnia)
95
Adjustment Disorder
= physiological reaction to adapting to a new set of circumstances (e.g. new job/home, divorce, bereavement).
Starts within 3 months (more gradual than acute stress reaction)
96
Adjustment Disorder - Sx
(overlap with anxiety/depression Sx)
- Autonomic symptoms
- Irritability/aggressive outbursts
- Social functioning impaired
97
Adjustment Disorder - Coping strategies
Alcohol/drug abuse
98
Adjustment Disorder - Mx
Talking to friends/family/professionals to relieve anxiety
Help natural process of adjustment – avoid denial/avoidance, encourage problem solving behaviour
99
What is the normal bereavement process?
1. Alarm/panic
2. Numbness
3. Pining
4. Depression
5. Recover/reorganisation
100
Abnormal grief
Symptoms of normal grief, persisting >6 months
=> Low mood, guilt, worthlessness, disturbed sleep and appetite, suicidal thoughts
Significant psychomotor retardation
Prolonged, serious functional impairment
Hallucinatory experiences other than those relating to the deceased person
101
What is abnormal grief, which does not meet the depression criteria?
this is considered to be an adjustment reaction
102
What is PTSD?
= delayed (often a few months) response to a stressful event of an exceptionally threatening/catastrophic nature (an event which would distress anyone).
Symptoms persists >6 months after the event.
103
Symptoms of PTSD
1. HYPERAROUSAL – persistent anxiety, irritability, insomnia, poor concentration.
2. RE-EXPERIENCING – “flashbacks”, recurrent dreams, cannot recall event at own will
3. AVOIDANCE – of reminders, detachment, numbness, anhedonia
104
Complex PTSD
Complex PTSD has an added emotional element – often resulting from ongoing/multiple experiences of “trauma” (e.g. abuse)
105
PTSD - coping strategies
Alcohol/drug abuse
106
PTSD - prognosis
50% recover in 1st year
Poor prognosis if comorbid mental illness, long duration, poor support
107
PTSD - Mx
1. Psychological – psychoeducation, CBT, eye movement desensitisation reprocessing.
2. Biological – antidepressants (SSRI) +/- antipsychotic
3. Social – educate family, social reintegration, alcohol avoidance
108
Indications for ECT
- Treatment-resistant depression
- Life-threatening severe depression
- Treatment-resistant mania
- Catatonia
109
What is catatonia?
| What forms can this come in?
Catatonia is a psychomotor syndrome occurring in acute psychiatric illness.
RETARDED – immobility, staring, mutism, rigidity, withdrawal and refusal to eat, posturing, grimacing, negativism, waxy flexibility, echolalia, automatic obedience
EXCITED – severe psychomotor agitation, potentially leading to life-threatening complications such as hyperthermia, altered consciousness, and autonomic dysfunction.
110
What is the most common indication for ECT?
depression
111
How often do ECT sessions occur?
A patient will typically receive between 4 and 12 sessions in a course of ECT.
The sessions usually occur twice per week.
112
How does ECT work?
The exact mechanism of action of ECT is unknown.
The mechanism of action is likely to be a combination of:
- Modulation of neurotransmitter functioning
- Changes in regional blood/activity
- Modulation of neuronal connectivity
- Alterations of neuronal structures, including hippocampal neurogenesis
113
Why is the use of ECT falling?
ECT remains to be quite an effective treatment, especially for depression.
Decreased usage is likely to be due to:
1. increasingly available treatments,
2. concerns over side-effects
3. public/clinicians’ perceptions.
114
What is an absolute contraindication for ECT?
cochlear implant
115
What are relative contraindications for ECT?
- Raised intracranial pressure
- Intracranial aneurysm
- History of cerebral haemorrhage
- Recent myocardial infarction (less than 3 months)
- Aortic aneurysm
- Uncontrolled cardiac arrhythmias
- Decompensated cardiac failure (ECHO may be helpful)
- Acute respiratory infection
- Deep vein thrombosis
116
Common side effects of ECT
- Headache
- Confusion
- Impaired cognitive function
- Temporary retrograde and anterograde amnesia
117
Longer-term side-effects of ECT
a specific component of retrograde memories before ECT may be affected longer term, this usually related to autobiographical memories
118
What is an important side effect to mention to patients when explaining/gaining consent for ECT?
Though the evidence for this is somewhat inconsistent, patients should ALWAYS be advised that their memory of some events in the previous years could potentially be affected.
119
What are the two different types of ECT?
| Which is more effective?
BILATERAL ECT – one pad on each side.
UNILATERAL ECT – both pads on one side.
=> Bilateral placement is probably more effective but may well give rise to more cognitive side-effects.
120
Give a brief explanation of the ECT process
ECT is given in a hospital setting, under anaesthetic with muscle relaxant. A mouth guard is used to protect the tongue/teeth
Two electrical pads are placed on the patient’s head.
The ECT machine delivers a series of brief electrical pulses, for three to eight seconds, to induce a seizure
The patient’s body will stiffen and then there will be twitching, but the muscle relaxant reduces the amount of movement involved.
=> This usually lasts for less than 90 seconds.
The muscle relaxant wears off within a couple of minutes. The mouth guard will then be removed, and the patient will recover from the anaesthesia
121
How is the dose of ECT decided?
During the first session of ECT, a dose titration is carried out to establish the seizure threshold.
The effective treatment dose can then be calculated.
122
what is echolalia?
repetition of another person’s speech
123
what is echopraxia?
mimicry of another person’s movements
124
Acute Intoxication
= transient physical and mental abnormalities shortly after administration.
125
Harmful substance use
= continued use despite evidence of damage to physical/mental health or social wellbeing.
126
Substance withdrawal
= physical dependence causes symptoms on abrupt cessation
127
Substance tolerance
= need to take more of the drug to have the same effect.
128
ICD-10 criteria for substance dependence syndrome
5/6 in the past year of:
- Tolerance
- Control loss
- Primacy (i.e. priority in life)
- Tremor (withdrawal Sx)
- Compulsion
- Persistence despite harm
129
What is the trend of drinking in the younger/older populations?
Younger people drink more heavily, older people drink more frequently.
130
Risk Factors for alcohol misuse
Genetics and gender – M>F
Mental illness
Stress, low self-esteem, social anxiety/isolation
Significant life events – bereavement, trauma
Lower socio-economic status
Occupation – bartenders, farmers, healthcare professionals
131
Medical complications of alcohol misuse
CNS – cognitive/memory impairment, reduced brain volume, Wernicke-Korsakoff Syndrome
PNS – peripheral neuropathy, optic atrophy
Hepatic – fatty liver, hepatitis, cirrhosis, malignancy, pancreatitis
Gastric – gastritis/ulcer, malignancy, varices, Barret’s, Mallory-Weiss tear
Renal – CKD, hepato-renal syndrome
CVS – cardiomyopathy, arrythmias, HF, cerebrovascular events
Reproductive – sexual dysfunction, infertility, foetal alcohol syndrome
132
Psychiatric complications of alcohol misuse
Alcoholic Hallucinosis
Pathological jealousy
Alcohol-related Brain Damage (cognitive/memory impairment and dementia)
Anxiety & Depression
Suicide (10-15% risk)
Schizophrenia (increases risk of relapse and violence)
133
Alcoholic hallucinosis
hallucinations while sober (usually auditory)
=> Responds well to anti-psychotics
134
Pathological jealousy
Primary delusion that partner is unfaithful
| Associated with violence.
135
Social complications of alcohol misuse
```
Relationship problems
Domestic violence
Risky sexual activity
Missed work/poor performance
Financial and legal problems
```
136
Wernicke-Korsakoff Syndrome - why does it occur and what are the features?
Due to thiamine (vit B1) deficiency – due to poor diet and decreased absorption/hepatic storage.
Wernicke’s Encephalopathy:
1. Acute confusion
2. Ophthalmoplegia/nystagmus
3. Ataxic gait
Progresses to Korsakoff Syndrome:
1. Antero/retrograde amnesia
2. Confabulation (false memories)
3. Apathy (indifference/decreased interest)
15% mortality if left untreated
137
Treatment of Wernicke-Korsakoff Syndrome
IV Pabrinex (Vit B&C) and alcohol withdrawal Tx
138
Alcohol misuse History
- Lifetime pattern of consumption
- Current pattern of consumption
- Signs of dependence:
Withdrawal Sx in morning/after not drinking
Having to drink more for the same effect
Episodes of memory loss/blackouts
- Social/Occupational problems
- Any previous services or Tx ?
139
What are 4 screening questions to detect alcohol misuse?
= CAGE
1. CUT DOWN – have you ever felt you should cut down your drinking?
2. ANNOYED – have you ever been annoyed with others criticising your drinking?
3. GUILTY – have you ever felt bad/guilty about your drinking?
4. EYE OPENER – have you ever drunk first thing in the morning?
140
Alcohol Withdrawal Sx
Last 2-5 days.
Tremor, restless, sweating, tachycardia, insomnia, N&V
Anxiety, confusion, visual hallucinations
141
Delirium Tremens
Can occur during alcohol withdrawal
= EMERGENCY ADMISSION
Decreased consciousness, amnesia, hallucinations
Tremor, fever
Mx = lorazepam PO, thiamine, hydration and investigations to r/o other causes of delirium.
142
Alcohol abuse - investigations
- MCV – remains raised 3-6 months after abstinence
- GGT – alcohol-related liver inflammation
- Liver USS – if indicated
143
In what setting is alcohol misuse managed?
Manage in the community unless severe/high risk of delirium tremens/liver failure.
144
Psychological management of alcohol misuse
- Drug and alcohol services (e.g. alcoholics anonymous)
| - Motivational interviewing, CBT, counselling, self-help resources.
145
What are the aims of biological management of alcohol misuse?
Detoxification/Withdrawal Management
Maintaining Abstinence
146
Detoxification/Withdrawal Management for alcohol
A reducing regimen over 7-10 days.
Chlordiazepoxide – a BZD to treat withdrawal Sx.
Thiamine (B1) – avoid/treat Wernicke-Korsakoff Syndrome
147
Medications to help maintain Abstinence from alcohol
Disulfiram – irreversible inhibition of ALDH, causing acetaldehyde to build up, causing unpleasant Sx of flushing, headache, and nausea to deter further alcohol consumption
Acamprosate – enhances GABA transmission to reduce alcohol cravings.
148
Opiates - mechanism and effects
mu-opioid receptor agonist = GABA inhibition = reduced inhibition of dopamine release.
Effects = euphoria, sedation, strong analgesia
149
Opiates - side effects
N&V, constipation, respiratory depression, decreased consciousness, pinpoint pupils
150
Opiates - withdrawal
```
irritable/anxious,
sweating, shaking, restlessness, insomnia,
fever/chills,
diarrhoea,
arthralgia/myalgia,
blown pupils
```
=> Very unpleasant but rarely serious
151
Which drugs are depressants?
Alcohol, cannabis, barbiturates, BZDs
152
Effects of depressants
What are the side effects?
Suppressed CNS activity, anxiolytic.
SEs – sedation, dizziness, impaired concentration/coordination, depression.
153
Withdrawal from BZDs
Agitation, anxiety, insomnia, seizures, delirium, psychosis.
=> Can be fatal
154
Which drugs are stimulants?
Cocaine (snorted), crack cocaine (smoked), amphetamines, MDMA
155
Mechanism of cocaine
monoamine reuptake inhibition (increased DA, NA, serotonin)
156
effects of stimulant drugs
euphoria, feelings of extreme well-being,
increased mental & motor activity, alertness, energy and confidence,
=> leading to risky/aggressive behaviour.
157
Side effects of cocaine
tachycardia, arrythmias, septal necrosis, panic disorder/paranoia, psychosis.
158
Side effects of MDMA
nausea, blurred vision, dehydration, depression/anxiety
159
Withdrawal from stimulant drugs
Dysphoria/anxiety, fatigue, muscle aches/tremors, craving.
=> Unpleasant but rarely serious.
160
Which drugs are Hallucinogens?
Cannabis, LSD, PCP (phencyclidine), ketamine, psilocybin (magic mushrooms).
161
Mechanism of cannabis
THC = active chemical, binds CB1 receptors to cause effects.
162
Mechanism of LSD
5HT receptor agonist.
163
Effects of hallucinogens
altered sensory/perceptual experiences (delusions/hallucinations), detachment.
164
Side effects of hallucinogens
```
Dizziness,
Dilated pupils,
Tachycardia,
HTN,
Increased appetite,
Anxiety/panic attacks.
```
165
How can you assist with detoxification/withdrawal from drugs
```
Symptom reduction:
• Lofexidine – alpha-blocker for autonomic Sx
• Loperamide – diarrhoea
• Metoclopramide – nausea
• Z-drugs – insomnia
• Analgesia
```
166
Methadone in drug detoxification
long-acting opioid, causes constant receptor occupation so taking illicit opioid on top has no effect.
167
Buprenorphine in drug detoxification
opiate replacement
168
Psychosocial management of drug misuse
- Drug and alcohol services
- Motivational interviewing, CBT, counselling, self-help resources.
- Housing, financial, child-care support.
- Harm reduction – promote use of sterile needles/don’t reuse or share needles.
169
What is an anxiety disorder?
= pathological responses to minimal environmental triggers, resulting in persistent symptoms that impair function and/or cause disabling behaviours (e.g. avoidance).
170
Psychological symptoms of anxiety
```
Worrying thoughts
Irritable
Sensitive to noise
Fearful anticipation
Poor concentration
```
171
Physical symptoms of anxiety
Sleep disturbance (insomnia, night terrors)
Muscle tension (aches, tremors)
Hyperventilation (causing dizziness and tingling numbness)
Autonomic arousal (dry mouth, sweaty, SOB, hot/cold, chest pain, palpitations, diarrhoea, urgent micturition) feels like MI
172
Which anxiety disorders have episodic symptoms?
Phobias, PTSD, OCD, Panic disorders
173
Which anxiety disorders have constant symptoms?
Generalised anxiety disorder
174
ICD-10 criteria for generalised anxiety disorder
Generalised and persistent somatic and psychological symptoms.
- Apprehension/fear of the future
- Motor tension
- Autonomic overactivity
- Over-cautious behaviour.
Present most days for at least several weeks at a time.
175
ICD-10 criteria for Panic Disorder
Recurrent attacks of severe anxiety (lasting <10 minutes)
- Sudden onset of threatening body sensations (e.g. dizziness, choking, palpitations).
- Loss of touch with reality/catastrophic thoughts (e.g. losing control, going mad, dying).
Comparative freedom from symptoms between attacks.
In circumstances of no objective danger.
- Not restricted to particular situations, so unpredictable.
176
Agoraphobia
Marked fear and avoidance of at least 2 of:
- Crowds/public places
- Travelling alone
- Travelling away from home
177
Social Phobia
Marked fear and avoidance of being the focus of attention and scrutiny/humiliation.
- Blushing/shaking
- Fear of vomiting
- Urgency of micturition.
178
Specific (Isolated) Phobia
Marked fear and avoidance of a specific object/situation:
| => Animals, birds, insects, heights, thunder, flying, small spaces, blood, injections, dentists, hospitals.
179
Obsessive Compulsive Disorder
Obsessions (thoughts, impulses, images) AND/OR compulsive acts/rituals (physical behaviours).
=> Originate in the mind of the patient, acknowledged as excessive/unreasonable.
Present most days for at least 2 weeks.
Cause distress and interference with activities.
180
OCD in children
Obsessions and compulsions are common in kids (average onset = 9 years) and considered normal at this age.
181
Differentials of Anxiety Sx
Endocrine - Thyroid dysfunction, Phaeochromocytoma
Cardiac/Hypoxia - Arrythmias, CCF/angina, COPD
Metabolic - Acidosis, Hyper/hypothermia
Drug Withdrawal/Intoxication - Alcohol, Opiates, Amphetamine/cocaine
Psychiatric - Depression, Personality disorders
182
Steps of management of anxiety disorders
```
Step 1:
Psychoeducation
Active monitoring
¯
Step 2:
Guided self-help
Low-intensity psychological interventions
¯
Step 3:
High intensity psychological interventions (e.g. CBT, psychodynamic psychotherapy)
OR drug treatment
¯
Step 4:
Refer to 2o care (MDT)
Complex therapies
Complex drug regimens
```
183
Psychological Interventions in anxiety disorders
For mild-moderate anxiety.
1. Psychoeducation – improve patient and carer understanding of illness.
=> E.g. process, causes, treatment, prognosis.
2. Guided self-help/ low-intensity psychotherapy
3. CBT:
- Phobias – systematic desensitisation/graded exposure
- OCD – exposure and response prevention
- PTSD – eye-movement desensitisation reprocessing
4. Others:
=> Counselling, relaxation techniques, social skills training (for social phobia)
184
Pharmacological Interventions in anxiety disorders
For severe anxiety/psychological treatment failed.
1. Antidepressants (SSRI) – proven efficacy long-term (especially combined with psychological treatments)
=> Do cause a short-term increase in anxiety.
2. Beta-blockers – symptom control (reduce HR and autonomic arousal).
3. BZDs – acute management only (max 4 weeks)
=> Dependence
=> SEs – drowsiness, ataxia, reduced concentration
=> Lorazepam = short half-life, Diazepam = long half-life
185
What is health anxiety?
= an umbrella term encompassing:
- Excessive/unrealistic health-related concerns
- Somatic perceptions – preoccupied with bodily sensations
- Behaviours – reassurance-seeking, repeated symptom checking, avoid medications/doctors
186
Possible pre-disposing factors to health anxiety?
* Personal experience of previous illness
* Significant illness of a loved one
* Early life trauma
* Family members with health anxiety
187
What disorders come under health anxiety?
Hypochondrial Disorder
Factitious Disorder/Munchausen's
Malingering
Dissociative (conversion) Disorder
188
Hypochondrial Disorder - definition
At least 6 months of:
Belief of 1 or 2 serious physical diseases (specifically named by patient)
OR
Preoccupation with presumed deformity/disfigurement
189
Factitious Disorder
The patient feigns/exaggerates symptoms for no obvious reason (internal motivation to adopt the sick role).
May inflict self-harm to produce signs/symptoms.
190
Malingering
the patient feigns/exaggerates symptoms for secondary gain (e.g. benefits).
191
Dissociative (conversion) Disorder
A traumatic event disrupts consciousness, memory, identity or perception.
=> Patient converts anxiety into more tolerable symptoms to attract benefits of the sick role.
Variable presentation – amnesia, stupor, trance, motor disorders, anaesthesia, convulsions.
192
Differentials of Health Anxiety/Somatisation
* Depression/anxiety
* Personality disorder
* Schizophrenia/psychosis (hypochondrial delusions)
* Organic causes with vague symptoms (MS, lupus, porphyrias).
193
Somatisation Disorder
At least 2 years of complaints of multiple and variable physical symptoms from at least 2 body systems.
Complaint may change frequently
Symptoms are real but cannot be explained by a detectable physical disorder.
Causes persistent distress, significant functional impairment (especially relationships) and refusal to accept medical reassurance.
194
Somatisation Disorder - management
General – build rapport (acknowledge suffering, regular appointments), minimise investigations (although ensure suitable investigations are done).
Psychological therapy – CBT, psychoeducation, self-help
Social – encourage normal functioning, normal ADLs/hobbies, involve social network/support.
Biological – anti-depressants (evidence of long-term efficacy is weak)
195
What HCPs are required for a MHA section 2/3?
1. At least 1 “section 12” approved doctor.
2. Another doctor (ideally one who knows the patient (e.g. GP))
3. Approved mental health practitioner (AMHP)
196
MHA section 2
- Type – assessment
- Length – up to 28 days
- Staff – 2 doctors and AMHP
Used when diagnosis is unclear.
Allows detention for a period of assessment (and Tx if needed).
After 28 days, must decide on section 3 or informal Tx (cannot implement back-to-back sections).
197
MHA section 3
- Type – treatment
- Length – up to 6 months
- Staff – 2 doctors and an AMHP
Used when diagnosis is certain.
Allows detention and Tx against the patient’s will.
Can be renewed after 6 months.
198
MHA section 4
- Type – emergency
- Length – up to 72 hours
- Staff – 1 doctor and AMHP
Allows emergency detention if only 1 qualified mental health doctor present. Can convert to section 2/3 after 2nd doctor assessment.
199
MHA Section 5(2)
- Type – emergency (“doctor’s holding power”)
- Length – up to 72 hours
- Staff – 1 doctor (NOT F1, ideally most senior doctor available)
Allows detention by any ward doctor until a formal assessment can be done. This only applies to inpatients (excludes A&E).
AHMP or psychiatrist needs to be informed that this in place ASAP.
Cannot treat under this section and cannot implement back-to-back sections.
200
MHA Section 5(4)
- Type – emergency (“nurse’s holding power”)
- Length – up to 6 hours
- Staff – 1 registered mental health nurse
Allows detention until an appropriate doctor can assess.
201
MHA Section 135
- Type – power of entry
- Length – up to 72 hours
- Staff – magistrate
Allows police to enter a home and remove a person believed to be suffering from a mental health disorder to a place of safety for assessment
202
MHA Section 136
- Type – place of safety
- Length – up to 72 hours
- Staff – Police Officer
Allows police to remove a person to a place of safety where they can be formally assessed (e.g. police station, A&E, 136 suite).
203
MHA Section 17A
- Type – community treatment order
- Length – as needed/indefinitely
- Staff – AMHP
Allows Tx under MHA while living in community or on leave from hospital.
This only relates to psychiatric care (not physical health).
Non-compliance can result in recall to hospital/detainment.
204
What components do you need to cover in a full psychiatric assessment
```
PC + HPC
PMHx
DHx
FHx
SHx
```
```
Past Psych Hx
Forensic Hx
Pre-morbid personality
MSE
Risk Assessment
```
205
How should you undertake a past psych history?
What age did they first present to the mental health services?
Give a chronological account of events and list the known diagnoses:
- When diagnosis made
- Treatment and progress in the community
- Psychiatric admissions
206
Important aspects of a social Hx in psychiatry
• Birth complications, developmental milestones
• Childhood
=> Parents, siblings, attachment/separation problems; growing up in care
• School:
=> Friends, bullying, academics; further education; qualifications
* Occupation history
* Relationships, marital history and children
* Any traumatic experiences, including abuse
• Social history (current)
=> Living circumstances (type of accommodation; household members; additional care they receive)
=> Income and any financial difficulties
=> Activities of daily living; level of functioning
=> Social activities, hobbies
• Substance use/misuse
207
Forensic History
Ask the patient about any “trouble” with the police
Specifically looking for offences, charges, convictions, community orders, prison sentences (dates)
208
How do you identify a person's pre-morbid personality?
Ask:
- How they would describe their personality;
- How others close to them would describe them;
- Temperament and interpersonal relationships.
Identify their reaction to stressful times in their life and coping mechanisms.
Try to screen for personality disorders.
209
Components of a mental state examination
A – Appearance and Behaviour
S – Speech
E – Emotion (mood and affect)
P – Perception
T – Thought
I – Insight
C – Cognition
210
MSE - Appearance/behaviour
- Gender, race, age, build, clothing, cleanliness/kempt
| - General disposition, rapport, eye contact, mannerisms
211
MSE - speech
- Rate, Tone, Volume
212
MSE - emotion
Identify patient's mood and affect:
- Subjectively – according to the patient;
- Objectively – as per your observation
Dysphoric (depression, anxiety, guilt),
Euthymic (normal),
Euphoric (implying a pathologically elevated sense of well-being)
213
Mood vs Affect
Affect = the patient's immediate expression of emotion
=> affect is inappropriate when there is no congruence between what the patient is experiencing/describing and the emotion he is showing at the same time
Mood = more sustained emotional makeup of the patient's personality
214
MSE - perception
- Visual/auditory/tactile hallucinations – Ask if they are experiencing these, further details if present
- If not reported, do they seem to be responding to unseen stimuli?
215
MSE - thought
1. FORM
- Any evidence of formal thought disorder?
2. CONTENT
- Delusional content?
- Thoughts of self-harm, suicide, homicide?
216
MSE - Insight
1) recognition of the disease itself (awareness)
2) the ability to recognise symptoms (attribution)
3) compliance with treatment (acceptance)
217
MSE - Cognition
Mention scores of tests or summarise findings of cognitive assessments
If formal cognitive assessment was not done, can comment on:
• Attention and Orientation to time, place and person
• General impression short and long term memory as observed during the consultation
218
Presenting a full psychiatric assessment
State your impression of the patient’s problem(s) or diagnosis
Mention the relevant factors contributing to this:
=> 3 P’s – predisposing, precipitating and perpetuating factors
219
What is personality?
= combination of consistent thoughts, feelings and behaviours shown over time and in a variety of settings.
Thought to develop during childhood and adolescence.
220
What is a personality disorder?
= when unhelpful personality traits cause functional difficulties/distress.
1. Pervasive – occur in most/all areas of life.
2. Persistent – evident from adolescence and into adulthood, enduring rather than discrete episodes
3. Pathological – cause distress to self/others and impair function (occupation, relationships, etc.)
221
Causes of personality disorder
= multifactorial
- Genetics/neurochemical imbalance
- Childhood temperament – innate/biological disposition to an emotional response
- Childhood experience – neglect, trauma, abuse
- Attachment problems with primary caregiver
222
What conditions are commonly co-morbid to personality disorder?
- Anxiety disorder
- PTSD, OCD
- Depression
- Adjustment disorder/stress reaction
- Substance misuse/alcoholism (can often cause delayed diagnosis of PD)
223
DSM-5 Clusters of Personality Disorders
Cluster A = “mad”
- Paranoid
- Schizoid
- Schizotypal
Cluster B = “bad”
- Antisocial
- Histrionic
- Borderline
- Narcissistic
Cluster C = “sad”
- Obsessive compulsive (not OCD)
- Anxious/avoidant
- Dependent
224
Which cluster of personality disorders is most linked with higher rate of suicide?
cluster B
| but all PDs are associated with increased risk of suicide
225
ICD-10 classification of personality disorders
```
Paranoid
Schizoid
Dissocial
Emotionally Unstable
Histrionic
Anankastic
Anxious/Avoidant
Dependent
```
226
Paranoid personality disorder
Suspicious, Unforgiving, Sensitive, Possessive/jealous, Excessive self-importance, Conspiracy theories, Tenacious sense of self-rights
227
Schizoid personality disorder
Anhedonic, lack relationships, only small emotional range, Normal conventions ignored, Excess fantasy world
228
Dissocial personality disorder
Guiltless/heartless, no concerns for others, irresponsible, easily loses temper, Blames others
229
Emotionally Unstable personality disorder
1. Borderline – Self-image unclear, Chronic emptiness, abandonment fear, Relationships unstable/intense, Self-harm/suicide, Labile emotions, Impulsive, Emotions very intense
2. Impulsive – lacks impulse control, aggressive outbursts, inability to plan, thoughtless of consequences
230
Histrionic personality disorder
Attention-seeking, Concerned about self, Theatrical, Open to suggestion, Racy/seductive, shallow
231
Anankastic personality disorder
Perfectionist, excessive detail, doubtful, inflexible, intrusive thoughts, excludes pleasure/others
232
Anxious/avoidant personality disorder
Avoids social contact, fears rejection/criticism, restricts lifestyle, apprehensive, desires acceptance
233
Dependent personality disorder
Subordinate, relies on others to make decisions, seeks reassurance, abandonment fears
234
Personality Disorder - management
LONG-TERM MANAGEMENT:
- Psychoeducation
- Self-help – mood diary, coping behaviours, maintain physical health, sleep hygiene
- !!!Talking therapies !!! – CBT, DBT, MBT, CAT
- Social support
MEDICATION ( little evidence in treating PDs - all meds are currently “off licence” for PD Tx and only indicated for comorbidities)
- Antipsychotics – for transient psychosis, reducing impulsivity/agitation
- Antidepressants – for comorbid anxiety/depression
- Mood stabilisers
- Short-term sedative/minor tranquilisers – in crisis situations, max 1 week.
235
Splitting
The individual tends to think in extremes (i.e., an individual's actions and motivations are all good or all bad with no middle ground).
236
Transference
the feelings a person has are unconsciously redirected or transferred to the present situation
(e.g. people transferring feelings about their parents to their partners or children)
237
Why is there commonly treatment failure in personality disorders?
Usually due to poor engagement/insight
238
Dysthymia vs depression
Dysthymia = chronically low mood but no episode justifying a diagnosis of depression
239
What is acute mania?
= 1 episode of mania
240
What is mania?
Mania is a syndrome characterised by abnormally elevated arousal, affect and energy level.
241
what is Cyclothymia?
= persistent mood instability with numerous subthreshold manic and depressive periods.
242
Symptoms of hypomania
= symptoms for 4 days
```
Mildly elevated or unstable mood
Increased energy
Mild over-spending and risk-taking
Increased sociability and overfamiliarity
Distractibility
Increased sexual energy
Decreased need for sleep
```
243
Symptoms of mania
= symptoms for 1 week
```
Elevated, expansive or irritable mood
Increased activity (often goal-directed)
Reckless behaviour (overspending, sexual)
Disinhibition
Marked distractibility
Marked increased sexual activity
Flight of ideas and pressured speech
Grandiose/persecutory delusions
Auditory hallucinations
```
244
What is bipolar disorder?
What are the types?
= periods of profound depression alternating with periods of mania.
Type 1 = at least one episode of major depression and one episode of mania.
Type 2 = at least one episode of major depression and at least one episode of hypomania
245
when is the peak age of onset of bipolar disorder?
early 20s
246
Risk factors for bipolar disorder?
Genetics – FHx of bipolar
Life events – prolonged stress, childbirth
Substance misuse – amphetamines, cocaine, steroids
247
Bipolar disorder - prognosis
Average episode = 6 months
Recurrence = 90%
10% commit suicide
248
Reasons for relapse in bipolar disorder
```
Non-compliance with medication
Life events/stress
Substance misuse
Childbirth
Disrupted circadian rhythm
```
249
Bipolar disorder - differentials
```
Substance misuse
Hyperthyroidism, Cushing’s
Metabolic disturbance
Space-occupying lesion
Epilepsy
```
250
Pharmacological management of acute mania
1. Antipsychotic (haloperidol, risperidone, quetiapine, olanzapine)
2. + 2nd antipsychotic
3. + lithium or valproate
4. May consider BZDs
STOP routine anti-depressants
251
Pharmacological management of bipolar disorder
1. Antipsychotic (2nd gen)
2. + routine antidepressant
3. + Lamotrigine/other mood stabiliser
Only prescribe routine antidepressants alongside anti-manic agents.
LONG-TERM: Lithium OR Valproate/Olanzapine (if lithium not tolerated)
252
Psychosocial management of bipolar disorder
Psychological:
- Psychoeducation – recognising relapses
- CBT
- CPN visits – monitor mood, mental state, symptoms
Social:
- Support for education, training, employment
- Support for carers/family
253
Which drugs are mood stabilisers?
Lithium, valproate, lamotrigine, carbamazepine
254
Indications for use of lithium
acute hypomania/mania,
bipolar disorder,
Tx-resistant depression.
255
Cautions/CIs of lithium
Cautions = cardiac disease, epilepsy, elderly
Contraindications = pregnancy (teratogen => cardiac defects), arrythmias, long QT
256
Monitoring of lithium
Narrow Therapeutic Window – measure lithium levels at day 5 and then 3-monthly.
Monitor U&Es and TFTs 6 monthly
Monitor Calcium
257
Lithium toxicity - Sx and Mx
Diarrhoea, dehydration, coarse tremor, ataxia, muscle weakness, fasciculations, nystagmus, decreased consciousness, confusion, seizures, coma, renal failure, death.
Mx – Stop lithium immediately, rehydration, diuresis/haemodialysis if severe
258
Indications for valproate (in psychiatry)
acute hypomania/mania,
| bipolar disorder
259
Indications for Lamotrigine (in psychiatry)
bipolar depression,
treatment resistant depression,
bipolar affective disorder.
260
Which is the least teratogenic mood stabiliser?
Lamotrigine
261
Indications for Carbamazepine
acute hypomania/mania,
bipolar disorder,
bipolar depression
262
Screening for risk of postnatal mental disorder
1. All women should be screened at antenatal clinic for previous/current/FHx of psychiatric disorder
2. Refer necessary cases for psychiatric assessment and referral
=> Pregnant/postpartum women should have priority in psychiatric service pathways.
3. Regularly monitor mental state of all peri/postnatal women, regardless of whether they’ve been referred.
263
Which pregnant women should be referred to psychiatric services for assessment?
1. PHx +/- FHx of:
- Schizophrenia/psychosis
- Bipolar disorder
- Puerperal psychosis
- Severe depression – i.e. required secondary care input (depression treated by GP doesn’t need referral)
2. On mood stabilisers
264
Normal Post-partum Psychiatric Symptoms
‘The Pinks’ - within 48 hours postpartum
Excitement, euphoria, overtalkative, overactive, insomnia.
‘The Blues’ - Day 3-10 postpartum
Emotional lability, tearful, anxious, irritable.
Both should have spontaneous Resolution
265
Onset of post-partum depressive illness
Bi-peak onset = 2-4 weeks and 3 months postpartum.
Prevalence = 10%
Risk Factors:
- Previous postpartum depression
- Serious depressive illness
266
Symptoms of post-partum depressive illness
Symptoms = similar to normal depressive illness:
- Guilt and concerns over parental ability = common
- Anxious preoccupation with baby’s health
- Reduced affection for baby/impaired bonding
- Obsessional phenomena (may involve harming baby)
267
Prognosis of post-partum depressive illness
With treatment – 2/3 resolve within 2-3 months
Without treatment – can take >6 months to recover
268
Management of post-partum depressive illness
RISK ASSESS
CBT
Sertraline/Paroxetine – if severe
=> Small amounts are transferred in breast milk but can still breast feed.
Admission to mother-baby unit/ECT – if very severe/high risk to self or baby
269
Onset of Puerperal/Postpartum Psychosis
Onset normally within 2-3 weeks postpartum.
Prevalence = 0.2%
Risk Factors:
- Previous postpartum psychosis
- Bipolar disorder
- Primiparity, obstetric complications, unmarried.
270
Prognosis of Puerperal/Postpartum Psychosis
Good short-term progress if treated early
- Most severe symptoms last 2-12 weeks
- Most make a full recovery within 12 months
BUT associated with significant morbidity and mortality
271
Management of Puerperal/Postpartum Psychosis
Treat has high risk
Admission to mother and baby unit – may need MHA
High intensity physical and psychological care
Support services – support groups, help with childcare/housework, etc.
272
What are considered psychiatric emergencies?
```
Suicidal Patients
Agitated/Violent patients
Grief reaction
Rape
Panic attacks
Neuroleptic Malignant Syndrome & Serotonin Syndrome
Delirium
Overdose/withdrawal
```
273
Causes of acute behavioural disturbance
Psychiatric symptoms,
Non-psychiatric symptoms,
Substance misuse.
274
Assessment of acute behavioural disturbance
HISTORY:
• Establish any diagnoses and medication
• Any previous similar episodes and cause/Tx
• Consider medication compliance or SEs
• Use of alcohol/illicit drugs
• Recent changes in social life (e.g. employment, relationships)
• History of self-harm/suicide/violence – risk assessment
```
Factors to Consider – deciding the need for urgent Tx/admission:
• Severity of illness
• Level of insight
• Risk of harm to self/others
• Other support available
```
275
Acute behavioural disturbance - de-escalation
- Encourage patient to move area away from others
- Speak confidently, slowly, clearly
- Non-threatening body language
- Explore concerns with patient – try to build rapport
Pharmacological Management/Physical Restraint
= LAST RESORT
=> Rapid Tranquillisation – calm patient without full sedation
=> BZDs, antipsychotics, promethazine – minimum dose, PO if possible.
276
what is Neuroleptic Malignancy Syndrome ?
A rare (<1%) adverse reaction to antipsychotics (dopamine blockade causes hyperactivity of SNS).
277
Symptoms of neuroleptic malignancy syndrome?
- Fever, sweating
- Rigidity
- Confusion, fluctuating consciousness
- Autonomic instability (fluctuating BP, HR, salivation, incontinence).
278
Neuroleptic malignancy syndrome - risk factors
- Hx – previous NMS, brain damage, alcoholism
- Mental state – agitation, hyperactivity, catatonia
- Physical – dehydration
- Treatment – recent increase/decrease in dose, high dose, IM injections.
279
Neuroleptic malignancy syndrome - investigations
- Raised CK (may be >1000 units/L)
- Raised leucocytes
- Deranged LFTs
280
Neuroleptic malignancy syndrome - Treatment
WITHDRAW ANTIPSYCHOTIC MEDICATION
- Rehydration
- Monitor temperature, BP, pulse
- Consider BZDs for sedation
281
What is serotonin syndrome?
= increased serotonin due to increased synthesis, decreased uptake/metabolism, or direct receptor activation.
282
Common causes of serotonin syndrome?
- Switching antidepressant
| - Combining antidepressants (with other ADs or supplements)
283
Symptoms of serotonin syndrome
- Psychiatric – restlessness, confusion, agitation
- Autonomic – hyperthermia, diarrhoea, tachycardia, hypo/hypertension, mydriasis
- Neuromuscular – myoclonus, rigidity, tremors, hyperreflexia, ataxia, convulsions.
284
Serotonin syndrome - treatment
STOP precipitating medication
- Rehydration
- BZDs if agitated
- If severe, transfer to ED.
285
How do NMS and serotonin syndrome differ in onset?
```
NMS = Slow (days-weeks)
SS = Rapid
```
286
How do NMS and serotonin syndrome differ in progression?
```
NMS = Slow (24-72 hours)
SS = Rapid
```
287
How does muscle rigidity differ in NMS and serotonin syndrome ?
```
NMS = Severe
SS = Less severe
```
288
How do blood results differ in NMS and serotonin syndrome ?
```
NMS = Raised CK, raised WCC
SS = Normal
```
289
Who is most at risk of self-harm?
- F>M
- 2/3rd are <35 years old
- Divorced > Single > Widowed > Married
290
Risk factors for self-harm
BIOLOGICAL – genetics, age (teens/young adults), personality disorder
PSYCHOLOGICAL – Abuse (sexual, physical, emotional), bullying, bereavement, relationship breakdown, endings/changes
SOCIAL – substance misuse, friends who self-harm, financial/living conditions, work/school pressures, isolation/loneliness.
291
Self-harm - Management
1. Assessment:
• Physical and mental health
• Safeguarding concerns
• Further self-harm and suicide risk
2. Treatment:
• Of physical injuries
• Specialist psychosocial assessment
• Monitor in a healthcare setting to reduce risk of recurrence.
292
Factors predicting repetition of self-harm
```
Number of previous episodes
Personality disorder
History of violence
Alcohol misuse
Unmarried
```
293
Factors indicating suicidal intent
Risk of suicide is 66x greater if self-harmed
```
Trying to avoid intervention
Planning suicide
Leaving a note
Anticipatory acts (e.g. leaving a will, settling debts)
Use of violent methods
```
294
Who is most at risk of suicide?
M>F
Second leading cause of death in 15-29 year olds.
Hanging/strangulation is most common method
Vulnerable groups – prisoners, asylum seekers, LGBTQ backgrounds, veterans.
295
Screening questions for depression
During the past month, have you often been bothered by feeling down, depressed or hopeless?
During the past month, have you often been bothered by having little interest or pleasure in doing things?
296
Assessment of post-natal depression
1. Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) for screening
2. Assess severity of depression
3. RISK ASSESSMENT – risk of self-neglect/self-harm/suicide, and any risk to the infant.
297
What is a formal thought disorder?
= a disruption of the form/structure of thought presenting as disorganised speech.
298
Poverty of speech
= loss of speech production, either in amount or content.
299
Thought blocking
= an abrupt stop in the middle of a train of thought which may or not be able to be continued
300
Circumstantial thinking
= an inability to answer a question without giving excessive, unnecessary detail
(but the person DOES eventually return to the initial point)
301
Clanging
a severe form of flight of ideas whereby ideas are related only by similar or rhyming sounds rather than actual meaning
302
In which disorders is clanging most often seen?
Most commonly seen in bipolar disorder (manic phase),
Often also observed in patients with primary psychoses.
303
Derailment/Loose Association/Knight’s Thinking
= thought frequently moves from one idea to another which is obliquely related or unrelated.
304
Distractible Speech
= during mid-speech, the subject is changed in response to a nearby stimulus
305
Echolalia
= echoing of another's speech
306
Flight of Ideas
= abrupt leaps from one topic to another, possibly with discernible links between successive ideas.
307
In which disorders is flight of ideas most often seen?
Most characteristic of the manic phase of bipolar illness.
308
Incoherence/Word Salad
= speech that is unintelligible because, though the individual words are real words, the manner in which they are strung together results in incoherent gibberish.
309
Neologisms
= the person forms completely new words or phrases whose origins and meanings are usually unrecognizable.
310
Perseveration
= persistent repetition of words or ideas even when another person attempts to change the topic.
This may also involve repeatedly giving the same answer to different questions.
311
Pressured speech
= rapid speech without pauses, difficult to interrupt.
312
Referential Thinking
= patients’ tendency to view innocuous stimuli as having a specific meaning for the self.
313
Semantic Paraphasia
= substitution of inappropriate word
314
Stilted Speech
= sentences may be stilted or vague; speech characterized by the use of words or phrases that are flowery, excessive, and pompous.
315
Tangential Speech
= wandering from the topic and never returning to it or providing the information requested.
316
Child/adolescent psychiatry - when is pharmacological management considered?
Usually less common/little evidence as first-line treatment
Consider in ADHD/depression.
317
Child/adolescent psychiatry - pharmacological management options
Antidepressants are only prescribed by specialist (child psychiatrist), due to – concerns of suicidal behaviour in teens taking SSRI
Use FLUOXETINE ONLY.
318
Child/adolescent psychiatry - psychosocial management
- Psychological – most commonly used are CBT and family therapy.
- Social – very important, especially regarding education and social services
319
Definition of Intellectual Disability
= significantly sub-average intellectual functioning (IQ <70)
Onset before 18 years
320
Mild intellectual Disability
IQ - 50-69
Prevalence - 1.5-3%
Functioning - Only need help if problems arise (often not recognised as ID)
321
Moderate intellectual Disability
IQ - 35-49
Prevalence -0.5%
Functioning - May need supervision in some elements of daily living/work
322
Severe intellectual Disability
IQ - 20-34
Prevalence - 0.5%
Functioning - Need help with many ADLs (often physical disability, limited communication)
323
Profound intellectual Disability
IQ - <20
Prevalence - 0.05%
Functioning - Extensive/total help with ADLs, minimal communication.
324
Cause of intellectual Disability
30% have no identifiable cause
1. Genetic/Chromosomal (most common = Down's Syndrome)
2. Pre-natal, peri-natal, post-natal Factors
325
Prenatal factors causing intellectual disability
- Congenital hypothyroidism
- Foetal alcohol syndrome
- Pre-eclampsia
- Placental insufficiency
- TORCH infections
326
Peri-natal factors causing intellectual disability
- Birth trauma/hypoxia
- Intraventricular haemorrhage
- Hyperbilirubinaemia
327
Post-natal factors causing intellectual disability
- Brain infection / tumour
- Head injury
- Chronic lead poisoning
- Neglect/ abuse / malnutrition
328
Mental illness and intellectual disability
The risk of mental illness is 3 times higher in those with ID.
Mental illness may present differently, or the patient may have difficulty describing symptoms.
329
What is the basic premise of CBT?
= that you feel the way you think and changing negative cognitions can change behaviours and feelings
330
Indications for CBT?
Stand-alone Treatment:
- Depression
- Anxiety disorders (e.g. generalised anxiety disorder, Obsessive Compulsive Disorder, Post-traumatic Stress Disorder and Phobias)
Adjunct to Treatment:
- Schizophrenia
- Bipolar Disorder
331
CBT - initial sessions
- Spent building a therapeutic relationship.
- The therapist explains the model and its rationale to ensure that the patient has a good understanding of the way thoughts, behaviours and feelings are connected.
332
CBT - ongoing sessions
- Sessions tend to take place weekly or fortnightly.
- Sessions tend to last 50-60 minutes
- Patients are expected to complete homework between sessions
- The focus is on challenging and correcting cognitive errors, and replacing maladaptive with more adaptive coping mechanisms.
333
what is the basis of psychodynamic psychotherapy?
that our feelings and behaviours are influenced by unconscious motives that are the result of early childhood experiences
334
Psychodynamic psychotherapy - how do you assess the unconscious?
Dream analysis
Free association
=> Speaking whatever comes to the mind
"Slips of the tongue"
=> Freud suggested that these are not “accidents” – but the unconscious mind trying to make itself heard.
Transference and counter-transference
=> i.e. being aware of the feelings generated in oneself during therapy (and in the patient) can be useful clinical information.
335
Counter-transference
= the process of the therapist transposing his/her feelings that they may have held for significant others in their childhood to the patient
336
The process of psychodynamic psychotherapy
establish a therapeutic relationship with the patient that helps draw links between a triad of the patient’s:
1. Early childhood experiences (including early trauma),
2. Defence mechanisms
3. Current symptoms
337
Psychoanalysis vs. Psychodynamic Therapy
PSYCHOANALYSIS
Quite rigorous
3-5 times/week
50-60 mins/session
Patients need to be able to tolerate intensive self-reflection and not become dependent or impulsive
PSYCHODYNAMIC THERAPY
Also called insight-oriented psychotherapy
1-2 sessions/week
50-60 mins/session
Can last 1-2 years but brief psychodynamic therapy only 14-20 sessions
338
When is psychoanalysis indicated?
Indicated for long-term personality difficulties
339
when is psychodynamic psychotherapy indicated?
Indicated in the treatment of personality disorders, certain cases of mood and anxiety disorders especially when co-morbid personality difficulties present
340
When is dialectical behavioural therapy indicated?
for the treatment of emotionally unstable personality disorder
341
What is the aim of DBT?
to help people manage difficult emotions by letting them experience, recognise and accept them.
This model says that, with acceptance, people become more able to change damaging behaviours
342
What are the 4 typical elements of DBT?
1. Individual therapy – weekly 1-1 therapy with a DBT therapist lasting about an hour
2. Skills training in groups – focussing on developing practical skills (tolerating distress, managing personal relationship issues, mindfulness)
3. Telephone crisis coaching – gives service receivers telephone contact with their therapist outside of therapy sessions
4. Therapists’ consultation groups – members of the team of people providing DBT may meet together weekly to discuss issues that have come up in treatment sessions
343
How long does a course of DBT usually last?
about a year
344
DBT vs. CBT
- DBT better meets the needs of people who experience particularly intense emotional responses.
- DBT focuses on changing unhelpful behaviours, while allowing acceptance of the whole person – including unhelpful thoughts (rather than challenging thoughts like in CBT)
- In DBT, the relationship between the service user and the DBT therapist is key. This relationship is used to actively motivate change.
345
Forms of psychotherapy
```
CBT
DBT
Family therapy
Inter-personal therapy
Problem-solving therapy
```
346
Why does risk need to be reviewed regularly?
Risk is MULTIFACTORIAL and DYNAMIC
=> changes with time, people, place, mental state, etc.
Therefore, needs to be considered in the short-term and long-term, and reviewed regularly
347
Types of risk to assess
```
1. Self:
• Self-harm
• Accidental harm
• Suicide
• Self-neglect
• Deterioration of mental health
• Deterioration of physical health
• Risk of vulnerability/exploitation
```
2. To Others
• Risk of physical aggression/violence
• Risk to vulnerable others (including children)
• Gun licence
3. Property
• Risk to their/others property
• Do they drive?
348
Suicide Hx - before the incident
- Any trigger/precipitant?
- Planned/impulsive?
- Final acts? (leaving notes, settling debts, leaving a will)
- Precautions against discovery? (closing curtains, locking doors, going somewhere remote, etc.)
- Was alcohol used?
349
Suicide Hx - during the incident
- What method? (e.g. overdose, cutting, hanging, etc.)
- Specific details of the method – e.g. what medication/how much, etc.
- Were you alone?
- Where?
- What was going through your mind at the time?
350
Suicide Hx - after the incident
- Who found them/did they present themselves?
- How did they feel when help arrived?
- How do you feel about the attempt now? Regret?
- Current mood? Still feel suicidal?
- If you were to go home today, what would you do?
- Do you feel you have anything to live for?
351
Risk assessment - identifying risk to others
Historical – previous violence, past mental illness, stability of relationships
Current – ongoing symptoms, response to treatment, insight, hallucinations.
Compliance to medication
Plans
Access to Weapons
Any Children/dependants?
352
What is considered prolonged QTc?
> 440ms in men
| > 460ms in women
353
Which psychiatric drugs can cause prolonged QTc?
Antipsychotics - e.g. Chlorpromazine, Haloperidol, Quetiapine, Olanzapine
TCAs - e.g. Amitriptyline, Nortriptyline, Imipramine
Other antidepressants - e.g. citalopram, Escitalopram, Venlafaxine, Bupropion
354
How is acute dystonia secondary to antipsychotics/metoclopramide usually managed?
Procyclidine
