Psych - 10th Nov Flashcards
3 major and name a few of the 7 minor sx of depression
Low mood, anhedonia, fatigue / low energy
Disturbed sleep, appetite change, poor concentration, low self esteem, guilt, suicidal thoughts, bleak and pessimistic thought of future
Diagnosis of depression?
> 1major sx present most of every day
Mild - 4 sx but still mostly functioning
Moderate - 5/6 and impact on normal functioning
Severe - 7 or more sx and severe impact on social functioning
Psychotic - severe + psychotic sx
Management of mild, moderate, and severe depression?
ALWAYS assess suicide risk
Mild - low intensity psychological Eg CBT self help, active monitoring
Moderate- medication, psychosocial interventions
Severe - medication, inpatient care, ECT if catatonic
Some sx of mania
Elated mood and increased energy Feeling of mental and psychical well-being Reduced need for sleep Loss of social inhibition Over-spending Increased sexual energy Pressure of speech Increased self esteem, grandiosity Insight is usually lost
Diagnosis of mania
Sx for >1wk
Impact on normal functioning
Social rejection due to bizarre behaviour
Usual time of episodes of bipolar? How long do manic / depressive episodes usually last?
Following stressful life events
Manic - 4 months
Depressive - 6 months
Management of manic? Depressive? Maintenance of bipolar?
Manic - don’t make important decisions until better
- antipsychotics
- mood stabilisers can be used 2nd line acutely
Depressive - fluoxetine + antipsychotic
Maintenance - lithium / sodium valproate
3 clusters of personality disorders
Cluster A ‘Odd or eccentric’ (MAD) Schizoid Schizotypal Paranoid Cluster B ‘Dramatic, emotional or erratic’ (BAD) Antisocial/Dissocial Emotionally unstable/Borderline Histrionic Narcissistic Cluster C ‘anxious or fearful’ (SAD) Anankastic Anxious/Avoidant Dependant
Talk about schitzoid ? Eg of who ?
emotionally ‘cold’
don’t like contact with other people, often uninterested in sexual contact
have a rich fantasy world
day dream a lot
Sheldon Big Bang theory
Schitzotypal features ? Eg of who?
eccentric behaviour
odd ideas
difficulties with thinking
lack of emotion, or inappropriate emotional reactions
see or hear strange things
You wonder if they are psychotic
sometimes related to schizophrenia, the mental illness
David tennant in doctor who
Paranoid personality disorder features? Eg?
suspicious
feel that other people are being nasty to you (even when evidence shows this isn’t true)
feel easily rejected
tend to hold grudges
The husband who always thinks his wife in cheating on him
Antisocial personality disorder features? EG?
don’t care much about the feelings of others
easily get frustrated
tend to be aggressive
commit crimes
find it difficult to makeclose relationships
impulsive - do things on the spur of the moment without thinking about them
don’t feel guilty about things you’ve done
The joker from batman
Features of borderline / emotionally unstable? Eg?
find it hard to control your emotions feel bad about yourself often self-harm, and use it as a threat make relationships quickly, but easily lose them can feel paranoid or depressed clingy, falls in love easily
A certain person post break up
Features of histrionic ? Eg?
over-dramatise events
self-centered, attention seeking behaviour
have strong emotions which change quickly and don’t last long
can be suggestible
worry a lot about your appearance
crave new things and excitement
can be seductive, sexually promiscuous
Reality TV stars
Features of narcissistic? Eg?
Sense of self importance
Dream of unlimited success, power and intellectual brilliance
Crave attention, but show few warm feelings in return
Asks for favours but doesn’t like doing them
Kanye west
Features of Anankastic (obsessive compulsive) Eg?
Worry and doubt Perfectionist Cautious - pre occupied with detail Worry about doing the wrong thing Find it hard to adapt to new situations High moral standards Judgemental Sensitive to criticism Obsessional thoughts
Eg behrouz
Features of avoidant ? Eg?
Anxious and tense Worry a lot Insecure and inferior Have to be liked and accepted Sensitive to criticism Avoid people due to feeling
Eg
Features of dependant
Passive Rely on other to make your decisions Do what other people want you to Find it hard to cope with daily chores Hopeless and incompetent feeling Feel easily abandoned
Define hallucination / delusion
Delusion
a belief that is held with strong conviction despite superior evidence to the contrary
Hallucination
an experience involving the apparent perception of something not present
Parts of the mental state examination? Mnemonic
ASEPTIC Appearance and behaviour Speech Emotion Perceptions Thoughts Insights Cognition
Diagnosis of schitzophrenia
ICD 10
1 clear 1st rank symptom
Or at least 2 other symptoms
For > 1 month
1st rank symptoms Thought echo, insertion, withdrawal or broadcasting Delusions of control 3rd Person auditory hallucinations Delusions of perception
Other symptoms Persistent delusions in other modalities Breaks in train of thought Catatonic behaviour -ve symptoms
Features of paranoid schitz
Most common form
(a) delusions of persecution, reference, exalted birth, special mission, bodily change, or jealousy;
(b) hallucinatory voices that threaten the patient or give commands, or auditory hallucinations without verbal form, such as whistling, humming, or laughing;
(c) hallucinations of smell or taste, or of sexual or other bodily sensations; visual hallucinations may occur but are rarely predominant.
Features of Hebephrenic schitz
Affective changes prominent
Hallucinations fleeting
Behaviour is irresponsible and unpredictable
Features of catatonic schitz
(a)stupor (marked decrease in reactivity to the environment and in spontaneous movements and activity) or mutism;
(b)excitement (apparently purposeless motor activity, not influenced by external stimuli);
(c)posturing (voluntary assumption and maintenance of inappropriate or bizarre postures);
(d)negativism (an apparently motiveless resistance to all instructions or attempts to be moved,
or movement in the opposite direction);(e)rigidity (maintenance of a rigid posture against efforts to be moved);(f)waxy flexibility (maintenance of limbs and body in externally imposed positions)
(g)other symptoms such as command automatism (automatic compliance with instructions),
and perseveration of words and phrases
Features of residual schitz
- (a)prominent “negative” schizophrenic symptoms, i.e. psychomotor slowing, underactivity, blunting of affect, passivity and lack of initiative, poverty of quantity or content of speech, poor nonverbal communication by facial expression, eye contact, voice modulation, and posture, poor self-care and social performance;
(b) evidence in the past of at least one clear-cut psychotic episode meeting the diagnostic criteria for schizophrenia;
(c) a period of at least 1 year during which the intensity and frequency of florid symptoms such as delusions and hallucinations have been minimal or substantially reduced and the “negative” schizophrenic syndrome has been present;
(d) absence of dementia or other organic brain disease or disorder, and of chronic depression or institutionalism sufficient to explain the negative impairments.
What is a schitzoaffective disorder? Types?
Features schitz and affective symptoms at the same time
But does not meet the criteria for schitz, mania or depression
Manic type
Depressive type
Mixed type
How is monitoring of clozapine? How does it work
Weekly for 18 weeks, then fortnightly for 1 year then monthly
Titration with initiation as an inpatient
Missing 2 days -> re initiation of treatment
Neuroleptic malignant syndrome
What is it? Who does it affec? Diagnostic features? Complications?
What drug can you use
What is it?
Imbalance of dopaminergic neurotransmitters following neuroleptic drug use
Who does it affect?
≈ 0.5% patients
≈ 10% mortality
Diagnostic features
Muscular rigidity
Hyperthermia
5 of: Altered mental status, tachycardia, Unstable BP, tremor, sweating, incontinence, ∆CPK, metabolic acidosis, leukocytosis
Complications
Rhabdomyolysis, Renal/hepatic failure, CV collapse
Bromocriptine
Risk factors for suicide ? Mnemonic
SAD PERSONS S - sex (male) A - <19, >45 D - Depression P – Previous Attempt E - ETOH R – Rational thinking loss S – social support lacking O – Organised plan N – No spouse S - sickness
20yo girl presents to A&E saying she took 18 paracetamol and 500ml vodka. She broke up with her bf 2 weeks ago. Has previously seen GP for low mood. Has evidence of superficial cuts on arms.
Name 4 blood tests
Name 4 risk factors in this patient for repeated self harm
Treatment for paracetamol overdose
She was assessed by a psychiatrist on the ward. Which section of the mental health act should be implemented?
U&E, LFTS, Clotting, glucose
Young, alcohol, life stressor, previous self harm
Acetylecistine
A&E doesn’t count as hospital -> Section 2
3 types of anxiety?
Generalised AD
Panic disorder
Phobic anxiety
Definition of GAD ? Needed for diagnosis?
A period of at least 6 months with prominent tension, feelings of apprehension about everyday events and problems
At least 4 of the following Palpitations Sweating Trembling and shaking Dry mouth Difficulty inhaling Chest pain or discomfort Sensation of lump in throat, difficulty swa[llowing, choking Feeling of nausea or abdominal distress Dizzy, unsteady, faint, light headed Numbness or tingling sensation Tinnitus Muscle tension/ aches and pains Restlessness Feeling on edge
Does not meet criteria for phobic anxiety, panic disorder, OCD, hypochondriacal disorder
Not sustained by physical disorder- hypothyroidism or psychoactive substance use
GAD risk factors? Precipitating factors? Predisposing? Perpetuating? Protective?
35-54, separated / divorced, living alone, lone parent
Stressful events especially threatening eg employment, relationships, ill health
Genetic, childhood, anxious/avoidant personality
Stressful events / ways of thinking
Age 16-24, married, cohabiting
Panic disorder definition ? What is a panic attack? Moderate / severe panic disorder?
Recurrent panic attacks that are not associated with a specific situation, and often occur spontaneously. They are not related to marked exertion or exposure to dangerous events
A panic attack is a
Discrete episode of intense fear or discomfort
Start abruptly
Reaches crescendo within a few minutes and last few minutes
4 symptoms from the list of generalised anxiety disorder
Moderate- 4 attacks in a 4 week period
Severe- 4 attacks per week in a 4 week period
3 common types of phobia ?
Acrophobia (heights)
Social phobia
Specific isolated phobia
Agoraphobia (places that’s hard to escape / no help)
Questionnaire for GAD?
GAD-7
Over the last 2 weeks, how often have you been bothered by any of the following problems (not at all, several days, more than half the days, nearly everyday)
Feeling anxious, nervous, on edge
Not being able to stop or control worrying
Worrying too much about different things
Having trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something scary might happen
Mx of anxiety disorders? (3 categories) when do you refer?
Conservative
Education and active monitoring
Low intensity psychological - individual self help
High intensity - CBT , applied relaxation
Pharmacological
SSRI (sertraline)
Pregabalin
Referral to specialist mental health service
With risk of self harm / suicide
Significant co-morbidity - substance misuse, complex physical illness, personality disorder
Self neglect
Inadequate response to psych / pharma interventions
Which psychotic features can indicate psychotic depression
Delusions, hallucinations
Catatonic (depressive stupor) - motionless, mute, refuses to eat or drink
What tool is used to monitor the severity of depression and response to treatment in GP?
PHQ-9 (patient health questionnaire)
Most important complication of bipolar? Others?
The most important complication of bipolar disorder is suicide and deliberate self-harm.
Other consequences of acute episodes are:
Financial ruin arising from overspending.
Traumatic injuries and accidents.
Damage to reputation, occupation, and relationships.
Self-neglect, exhaustion, and dehydration.
Exploitation by others.
Alcohol and substance misuse.
Harm to others from:
Neglect.
Depressive or paranoid delusions.
Difference between mania and hypomania ? How long do they last? How long does depressive episode have to last?
Hypomania has no psychotic features
Mania must be present for 7 days
Hypomania only 4
Depressive at least 2 weeks
Bipolar treatment of mania
Trail of haloperidol, olanzapine, quetiapine, or risperidone
Ineffective / not tolerated -> another one offered
Ineffective / not tolerated -> add lithium (if not suitable -> sodium valproate)
Stop antidepressants if develop mania
Options for treatment of depression in bipolar
Quetiapine alone,or
Fluoxetine combined with olanzapine,or
Olanzapine alone,or
Lamotrigine alone.
Complications of schitz
Suicide and accidents
Physical disorders
- CVD: stress, genetic, lifestyle, antipsychotics
- T2DM: lifestyle, antipsychotics
- COPD: lifestyle
- infections: HIV HCV, TB
Social disability - due to negative sx
Substance misuse
Diagnosis of schitz
Sx present for most of the time for at least 1 month
One or more of the following features if they are clear-cut (1st rank symptoms)
3rd person auditory hallucinations
Thought alienation :thought echo, withdrawal or broadcasting
Passivity phenomena: delusions of control or passivity
Delusional perception: persistent delusions that are culturally inappropriate and completely impossible (superpowers)
Or any 2 of the following (secondary symptoms)
Persistent hallucinations in any form: includes 2nd person auditory hallucination
Breaks in train of thought, resulting in incoherence
Negative symptoms: apathy, emotional blunting, social withdrawal
What interventions would you use to prevent psychosis ? What would you not do ?
Individual CBT / those for anxiety, substance misuse …
Not antipsychotic
How should you manage first episode of psychosis
Offer oral antipsychotic AND
Psychological interventions
What should you do if a patient (1st episode of psychosis) does not want oral medication?
Offer family intervention and CBT
Agree a time (within a month) for a review of treatment options
Monitor sx and functioning regularly
What criteria before MHA can be applied? Exclusions?
Patient has a mental disorder
Detained for their own safety / safety of others
Nature of mental disorder warrants the detention of a patient in hospital
Informal admission / community assessment not appropriate (Eg refusal of treatment)
Learning disability - unless abnormally aggressive
Drug/alcohol dependance
Tricyclic Eg? Mechanism ? Effects? Side effects?
Amitriptyline
Blocks resp take of 5HT and NA. Also affects histamine and muscarinic receptors
Effects - drowsiness, confusion, motor in coordination but these resolve when anti depressive effects develop in 1-2 weeks
Side effects
Anticholinergic - dry eyes, mouth, burred vision, constipation, urinary retention
∂ receptor blocker - Drowsiness, postural hypotension, sexual dysfunction
CVS - tachycardia, hypotension, conduction defects
CNS - sedation, seizures
Other - Weight gain
SSRIs
Eg?
Mechanism?
Side effects?
Sertraline, citalopram, fluoxetine
Inhibits 5HT reuptake
Side effects
- may increase suicidal ideation as it is a stimulant -> motivation to take own life
GI - nausea, anorexia, diarrhoea, GI bleed (long term use)
CNS - insomnia, restlessness, irritability, agitation, headache, tremor
GU - ejaculatory delay, anorgasmia
CVS - conduction defects -> long QT
MAOI Eg? Mechanism? Would you use it first line? S/E?
Iproniazid, phenelzine
Regulates the free intraneuronal concentration of 5HT -> release of these transmitters
Not first line use
Hypotension, central stimulation (tremor, excitement, insomnia, convulsions) Weight gain from appetite Anticholinergic Hepatotoxic Tyramine reaction
Triad of serotonin syndrome? Mx?
1: Cognitive impairment - agitation, headache, confusion, delirium, pressure of speech
2: Autonomic - shivering, sweating
3: Neuromuscular dysfunction - Akathisia
Mx Stop drug Give charcoal IV fluid + benzo ABCDE 5HT block - chlorpromazine Severe-> Cyproheptadine (prevents serotonin production)
Lithium blood levels - how long to decrease?
Half of oral is excreted in 12 hours
Remainder taken up by cells and excreted over 1-2 weeks
When is lithium dangerous?>
Dehydration, sodium depletion, thiazide, renal disease
When should you monitor litmus levels?
12 hours after last dose and 4-7 days after starting drugs
What level of lithium is toxic? Signs/sx? Management?
> 1.5mmol/l
Coarse tremor, nausea / vomiting / diarrhoea, ataxia, muscle twitching, hyperreflexia, renal failure, confusion/coma/convulsions
Mx
Stop lithium, check levels, refer for urgent assessment
If severe - admit as emergency for total bowel irrigation
Want to start tricyclic in 75yo man - what investigation need to do firsT?
ECG
