Psych Flashcards
Acute presentation of opiate overdose
DROWSINESS
- Resp depression leading to acidosis
- Hypotension
- possible Tachycardia
- PINPOINT PUPILS
Chronic opiate presentation
Constipation
Treatment for opiate overdose
ABCDE
IV NALOXONE IF COMA OR RESP DEPRESSION (Or IM if bad veins)
Oral activated charcoal if invested a lot
What are characteristics of OCD compulsions/obsessions
- present most days
- have lasted at least 2 weeks
Acknowledge they originate in the mind
- try to resist but it’s unsuccessful
- the act is unpleasurable
Interferes with functioning
Treatment for OCD
Mild - CBT/group CBT or Exposure and Response Prevention therapy. SSRIs only if not responding to treatment.
Moderate - high intensity CBT or ERP. Can have SSRIs instead of therapy.
Severe - high intensity CBT or ERP AND SSRIs (in combination)
Schizophrenia
Chronic / relapsing remitting for of psychosis caharacterised by both POSITIVE AND NEGATIVE Sx
Symptoms have to be present for AT LEAST 1 MONTH and causing SIGNIFICANT IMPAIRMENT
Subtypes of schizophrenia
- Paranoid schizophrenia (Delusions + hallucinations)
- Catatonic schizophrenia (motor disturbances + waxy? flexibility)
- Hebrephenic (disorganised thinking, emotions + behaviour)
- Residual schizophrenia (some sx persisting after major episode)
- Simple Sz (gradual decline in function WITHOUT prominent +ve sx)
Cause/RFx of Scz
- Genetic: FHx
- 50% risk if both parents or identical twin is affected
- 10% if one parent or sibling
- Environmental factors
- Childhood trauma
- Heavy childhood cannabis use
- Maternal health issues (malnutrition, infections)
- Birth trauma (hypoxia / blood loss)
- Urban living / immigration to more developed countries
Schz Sx
Positive:
- Auditory hallucinations
- Thought disorder (insertion, withdrawal)
- Passivity phenomenon etc
- Delusions
Negative:
- Speech poverty (Alogia)
- Anhedonia
- Affective incongruity / blunting
- Avolition (lack of motivation)
Risk indicators of Scz Sx
- Command hallucinations
- Hx of deliberate self-harm / Suicidal ideation
- Fixation on specific individuals
DDx for Schizophrenia
- Substance -induced psychotic disorder
- Organic psychosis (physical neuro change)
- Metabolic disorders
- Depression + dementia
- Autoimmune encephalitis
- Schizoaffective Disorder (mood disorder + psychotic Sx)
Schizophrenia Ix
Mainly clinical Dx - then Ix to exclude DDx:
- Brain imaging
- Blood tests to exclude infectious (e.g. syphilis) or metabolic causes (e.g. thyroid)
- DRUG SCREENING
Schezophrenia Mx
- Atypical (2nd gen) antipsychotics: RISPERIDONE
If acute
-> Sedatives (lorazepam / prometazine) OR Haloperidol - to manage dangerous behaviour
- Oral (sometimes IM/depot injection) ATYPICAL ANTIPSYCHOTICS
Maintainance antipsychotics determined on a person by person basis
Consider CLOZAPINE if resistant - INTENSIVE MONITORING due to potentially LETHAL SE
+ Psychotherapy
Schitzoaffective disorder
A disorder which is a combination of scz Sx alongside mood disorder Sx
2 types:
- Bipolar type (Mania + sometimes major depression)
- Depressive type (only major depression)
What is the bidirectional relationship to old age mental health
- Physical illnesses can cause/put at risk of mental health disorders
- Esp SENSORY IMPAIRMENT (direct risk factor)
- Consequences of mental health on physical health
Considerations for Tx in older adults
- ↑body fat; ↓ body muscle; ↓ relative body water
- ↓ renal blood flow and function
Bipolar definition
Chronic + combination of manic/hypomanic and Depressive episodes.
- Manic/hypomanic episodes should be characterised by a PRESISTENTLY ELEVATED, Expansive / Irritable mood
- Major depressive episode should last at least 2 wks
- There should be a marked disturbance of mood during episodes
Suptypes of Bipolar Affective Disorder
- BPAD Type 1: One or more manic episodes lasting longer than a week with or without depressive episodes.
- most common type
- BPAD Type 2: At least one major depressive episode (at least 2 weeks) AND hypomanic episodes (lasting at least 4 days).
- NO mania
- Cyclothymia: episodic depression and hypomania over the course of 2 years or more which doesn’t meet the criteria for BPD 1 or 2 diagnosis (symptoms usually less severe)
Mania vs hypomania
- Mania - severe functional impairment OR psychotic changes lasting AT LEAST 7 DAYS
- Hypomania - Change in functioning WITHOUT psychotic Sx or severe social/occupational impairment for at least 4 DAYS (but usually <7 days)
Mania is more likely to require hospital admission due to risk of harm
Both have EXPANSIVE, ELEVATED mood OR intense IRRITABILITY +/- PHYSICAL Sx (Increased energy / Decreased sleep)
Bipolar epid
- Typically develops in late teens
- Both genders affected equally
Causes/RFx of Bipolar/BPAD episodes
- GENETIC (FHx)
- TRIGGERS:
- stress / childhood trauma, physical illness, DRUG ABUSE, DEPRESSION/Anxiety - MEDICATION-INDUCED: antidepressants taken for a depressive episode can trigger a manic switch
Bipolar Sx
Depression:
- Low mood, ANHEDONIA, worthlessness, Decreased energy, Suicidal ideation
Mania/hypomania:
Mood:
- Elevated mood / Irritability
- expansive mood (unrestrained emotional expression)
Speech and thought:
- Inflated self-esteem
- PRESSURED speech
- Flight of ideas
- Poor attention
Behaviour:
- INSOMNIA (can also trigger an episode)
- IMPULSIVITY (pursuit of more dangerous activities)
- believes capable of more than they are actually able to do
- DISTRACTIBLE
- Psychomotor agitation (Pacing, wringing hands)
- LOSS OF INHIBITION (risk taking, overspending, sexual promiscuity)
Other features:
- Psychosis
DDx for mood disorder Sx
- Major depressive disorder
- Cyclothymic Disorder (chronic mood fluctuations over 2 yrs)
- Schizoaffective Disorder
- Generalised Anxiety Disorder
- Substance-induced Mood DIsorder (use OR withdrawal)
Bipolar Ix
- If first presentation -> RULE OUT DDx:
- Bloods
- CT/MRI
- Urine dip / toxicology
- TFTs
- Vitamin levels
Bipolar Mx
- Hypomania -> ROUTINE referral to COMMUNITY MENTAL HEALTH TEAM (CMHT)
- Mania / severe depression -> URGENT referral to CMHT
- if ACUTELY AGITATED -> admission + IM Benzodiazepine / neuroleptic (e.g haloperidol, risperidone) if the benzo doesn’t work
New/Acute:
- Stop SSRIs if recently started
- Mania with AGITATION:
- IM NEUROLEPTIC / BENZODIAZEPINE
- Consider psych admission
- Mania WITHOUT agitation:
- Oral Antipsychotic MONOtherapy
- Haloperidol, Olanzepine, Quetiapine, Risperidone- Switch to diff one in same class if first unsuccessful
- Consider adding SEDATIVES / MOOD STABILISERS (e.g. LITHIUM)
- Electroconvulsive therapy
- Oral Antipsychotic MONOtherapy
- Acute DEPRESSION: Mood stabiliser; consider SSRIS + atypical antipsychotic
Chronic/Maintanence:
- MOOD STABILISERS: Lithium 1st , Valproate 2nd
- NB: NOT IN PREGNANCY they are teratogenic - Just use antipsychotics
- High-intensity Psychological Therapies: CBT; IPT
Complications of Bipolar
- Suicide Risk: Estimated at 10%.
- Also can unintentionally be danger to self if v impulsive
- Recurrence: Approximately 90% experience recurrence of manic episodes.
Types of depression
- 3-4 Sx = Mild
- 5-6 Sx = Mod
- 7-8 Sx = Severe
Bulimia Mx
- Bulimia Nervosa Focused Guided Self-Help: First-line treatment, targeting eating behaviors, thought patterns, body image, and self-esteem.
- Specialist Referral: Essential for ongoing management.
- Consider fluoxetine
Konrad Lorenz
Geese imprinting experiment
Harry harlow
Wire mother cloth mother
- emotional needs are crucial
- Poor emotional comfort in the baby monkeys led to behavioural issues later on
Attachment
A unique emotional bond between caregiver and child: involves exchange of comfort, care + pleasure
Evolutionary function to improve survival
Strange assessment stages
- Mother, baby, and experimenter
- Mother and baby alone
- A stranger joins the mother and infant
- Mother leaves baby and stranger alone
- Mother returns and stranger leaves
- Mother leaves; infant left completely alone
- Stranger returns
- Mother returns and stranger leaves
Secure attachment characteristics in children and adult
Child:
- Separates from parent
- Self-confident, good self-esteem
- Seeks comfort when frightened
- Greets return with positive emotions
- Prefers parents to strangers
Adult:
- Trusting, lasting relationships
- Good self-esteem
- Comfortable sharing feelings with partners/friends
- Seeks out social support
Insecure avoidant characteristics in child and adult
Child - Occurs when caregiver largely emotionally unavailable/unresponsive / has Unrealistic expectations of child emotional independence (‘stop crying’ ‘grow up’ ‘toughen up’):
- Passive/withdrawn behavior
- Avoids closeness of others, seldom seek comfort
- Poor self-esteem
- Outbursts /erratic behaviors
- Minimises expectations of others
Adult:
- Poor self-esteem
- Can shun intimacy, struggle making emotional connections
- Often dismissive attitude, may be quick to find fault in others
- Difficulty seeking support from others, struggle to express emotional needs
- Perpetuation of trauma in relationships e.g. struggle to form healthy attachment to own children
Insecure resistant characteristics in child + adult
Can result from inconsistent/unpredictable caregiver behavior
Child:
- Can be distrustful of parent but also clingy/desperate
- Can express distress but difficulty getting comfort from caregiver
- Fear of abandonment -> anxiety
Adult:
- Self-critical and insecure
- Seek approval/reassurance from others
- Fears of rejection, difficulties trusting in relationships
Attunement meaning
How reactive an individual is to another’s emotional needs + moods
esp in context of parental figure responding to child
Not preventing negative feelings in child BUT more to do with how you mend a relationship breakdown - not allowing the breakdown to persist
Risk Fx for Attachments disorder
- Abuse / neglect
- Loss of caregiver
- Maternal POSTPARTUM DEPRESSION
- Frequent change in caregiver (e.g. foster care)
- Parental issues (substance abuse, mental health, criminal)
- Prolonged separation from caregivers
Reactive attachment disorder
- Starts in 5 years of life
- Persistent abnormalities in pattern of social relationships: associated emotional disturbance + reactive to changes in environmental circumstances
- e.g. not seeking / responsive to comfort when distressed
- limmited positive affect / unexplained irritibilaty - Associated with severe neglect, abuse / serious mishandling
Daumrind’s parenting styles
- Authoritarian (imposing rules, expecting obedience, low warmth)
- Permissive (low discipline, high warmth, low maturity expectations)
- Authoritative (high communication, moderate warmth + maturity expectations, high warmth)
What is a personality disorder
Ingrained / enduring patterns of behaviour that are abnormal in the culture the individual exists within: leading to subjective distress both to self and others and functional impairment
- impairments in relating to self and/or others
- Isn’t developmentally appropriate
- STABLE OVER TIME (>= 2 yrs) + INFLEXIBLE across diff situations
- Not due to another underlying condition / meds / drugs
CAN’T be Dx un UNDER 18s
Cluster A personality disorders
‘Odd / eccentric’
- Paranoid
- Schizoid
- Schizotypal
Cluster B personality disorders
‘Dramatic, Emotional / Erratic’
- Antisocial
- BORDERLINE (Emotionally Unstable)
- Histronic
- Narcissistic
Cluster C personality disorders
‘Anxious and Fearful’
- Obsessive-Compulsive
- Avoidant
- Dependant
(Paranoid personality disorder)
- Pattern of IRRATIONAL suspicion of others - questions loyalty
- Hypersensitivity to criticism + potential slights
- Reluctance to confide in others due to fear it will be used against them
- Preoccupation with CONSPIRATIONAL BELIEFS + HIDDEN MEANING
(Schizoid personality disorder)
- DETACHMENT from SOCIAL relationships + RESTRICTED emotional expression
- Lack of interest in interpersonal relationships
- EMOTIONAL COLDNESS / FLATTENED AFFECT
- Few close relationships outside immediate family
(Schizotypal personality disorder)
- Impaired social interactions AND distorted cognition / perceptions
- Eccentric behaviours - inappropriate / constrained affect
- Magical thinking, paranoid ideation, belief in influence of external forces
- MORE INTACT grasp on reality than in Schz
Types of higher order personality disorder presentations
Internalising:
- Negative affectivity
- Detachment
- Anankastia (compulsion)
Externalising:
- Dissociality
- Disinhibition
- Borderline pattern
Borderline Pattern Px
- Unstable affect (temper, quasi psychotic)
- IMPULSIVITY
- Self-harm / suicidal
- Feelings of emptiness
- Lack of sense of self / UNSTABLE SELF-IMAGE
- INTENSE UNSTABLE RELATIONSHIPS (including with medics)
- Fears + attempts to avoid attachment
(Can get transient stress induced paranoia / dissacociation - including hearing voices)
DDx for BPD
- Bipolar - Bio Sx
- ADHD / ASD (esp in women) - concrete thinking
- Psychotic conditions
- cPTSD - presence of PTSD Sx
Main theory for cause of BPD
Biosocial model:
Emotional sensitivity + Invalidationg environment (abuse/neglect) = Pervasive emotion dysregulation
(soothing from parent teaches baby how to self-sooth)
Common BPD co-morbidities
- Psychosis
- Affective/ anxiety disorders
- Alcohol dependence / Hazardous drinking
- Substance dependence
- Eating Disorders
- Functional Disorders, eg chronic pain, non-epileptic seizures
Reasons why people may self-harm
- Feel concrete pain
- Inflict punishment
- Reduce anxiety/ despair
- Feel in control
-Express anger - Feel something when numb
- Seek help
- Keep away bad memories
- Suicidality
BPD complications / prognosis if untreated
- Poor QoL
- Substance use
- Difficulty keeping jobs
- Increased risk of being victim of violence
- Self harm / suicide (10%)
- Poor physical health (20 year reduction in life expectancy)
BPD Mx
VALIDATION + Consistancy where possible in services + clinicians
- Medication NOT MAINSTAY but can help in crisis / comorb
- Psych therpaies:
- Dialectical behaviour therapy; Structured clinical management; Mentalisation Based Therapy
- Cognitive Analytical Therapy / CBT
- Trauma processing
PTSD aet theory
The information from the traumatic experience is retained but not fully processed / not integrated into memories -> flashbacks
- can be caused / exacerbated by nightmares (which are a form of flashback) waking people up from REM sleep so they are unable to completely integrate the information
PTSD Definition
- Direct or indirect EXPOSURE to TRAUMATIC event
- Has characteristic Sx
- Persists for MORE THAN 6 MONTHS
PTSD Px
Intrusive Sx:
- Recurrent distressing memories, NIGHTMARES or FLASHBACKS (hallmarks)
AVOIDANT:
- Any trauma-related reminders
Negative alerations in mood + cognition:
- Persistent negative beliefs / Pervasive negative emotions
- DISTORTED BLAME
AROUSAL:
- HYPERVIGILANCE
- Exaggerated startle
- Poor concentration
- Disturbed sleep
Classification of severity of PTSD
- Mild - managable distress + social / occupational functioning not significantly impaired
- Mod - More significant distress / impaired functioning but no significant risk of self-harm, suicide, harm to others
- Severe - Unmanageable distress AND/OR significantly impaired social AND/OR occupational functioning AND/OR significant risk of harm to self/others or suicide
PTSD DDx
- Acute Stress Reaction (ASR)
- same Sx but in the days/weeks directly following a traumatic experience (PST lasts >6 months)
- Adjustment disorder (maladaptive resposnes to stressors - not necessarily linked to major trauma but can persist up to 6 months)
PTSD Mx
If moderate / severe -> reffer to specialty psych:
- TRAUMA-FOCUSED CBT
- Eye-Movement Desensitisation + Reprocessing if more severe
+ RISK MANAGEMENT for other co-morbs / Mx co-morbs - SNRI / SSRI if comorb / declining psychotherapy
Veterans can be referred more rapidly
Panic disorder definition
- Recurrent, unexpected PANIC ATTACKS
- AVOIDANCE of situations/triggers related to attacks
- Persistent concern about further attacks after initial attack (for at least 1 month for !CD 11)
Panic disorder epid
- 2-3x more prevelant in females
- Biomodal incidence: peaks at 20 and 50 y/o
- Oft concurrent Agoraphobia
- Increased risk of suicide with comorbid depression / substance abuse
- 1-2% prevalence in general population
Panic disorder Px
- DIFFICULTY BREATHING
- PALPS
- Chest DISCOMFORT
- HYPERVENTILATION -> glove and stocking / perioral peristhesia from RAISED blood pH and calcium binidng to albuimin
- SHAKING, SWEATING, DIZZINESS
- Depersoalisation / Derealisation
Fear of panic triggering situations / agoraphobia -> Conditioned fear-of-fear pattern
Panic disorder Mx
- CBT (effective 80-100%)
- SSRIs
- Clomipramine (tricyclic) - 2nd line
- Propanolol for Sx relief
What would CBT for panic disorder involve
- Education
- Cognitive restructuring + detecting locic flaws
- Interoceptive exposure techniques (e.g. stimulating somatic Sx, like palps with exercise, in controlled environment)
- Situational exposure + anxiety Mx techniques if also agoraphobic
Phobias definition
Anxiety disorders charachterised by excessive / irrational fear restricted to highly specific situations.
Includes:
- Specific phobia
- Social Anxiety disorder (impedes daily functioning)
- Agoraphobia (anxiety in situations where escape would be difficult / help unavailable)
Common features of AVOIDANCE + ADL IMPAIRMENT
Clinical features of phobias
- Usually apparent in early adulthood
- AVOIDANCE BEHAVIOUR
- Blood/injury related can -> Bradycardia + hypotension on exposure (fainting)
- Severity dependant on QoL
ALWAYS: rule out co-morb depression
Agoraphobia definition
Fear of open spaces and associated factors like the presence of crowds or the perceived difficulty of immediate easy escape to a safe place - usually home
(with or without panic disorder)
Agoraphobia presentation
- Typically begins in 20s or mid-thirties.
- Onset may be gradual or precipitated by a sudden panic attack.
- Comorbid depression is common
BEWARE: drugs / alcohol COPING
What is the most common anxiery disorder
Social anxiety disorder (SAD)
Social anxiety definition
- Fear of scrutiny by others in relatively small groups resulting in avoidance of social situations
- generally from groups ~5-6 ppl (can oft tolerate 1-2 ppl) - Specific (public speaking) or General
- Physical Sx of blushing / fear of vomiting characteristic
SAD Sx
- BLUSHING
- PALPS
- Trembling
- Sweating
- Nausea / fear of vomiting
Differentiated from other forms of anxiety by the fact it is triggered specifically by social situations of some sort
RFx/exacerbating factors for SAD
- Stressful / humiliating experiences
- Parental death / separation
- Chronic stress
- Possibly genetic predisposition
Alcohol / drug abuse (which can also be CAUSED BY SAD)
Phobias Mx
-
CBT
- Exposure -> Systematic desenitisation (e.g. graded hierarchy approach, Flooding, Modelling - pt watches therapist interacting with phobic stimulus) - SSRIs if not responding to CBT / severe impairment
- Propanolol if persistent somatic Sx
Delerium
Acute confusional state (fluctuating attention + cognition / change in consiousness) caused by organic factors - commonly seen in elderly
- usually reversible
Delerium subtypes
- Hyperactive = increased PSYCHOMOTOR activity - Agitation, restlessness, hallucinations
- Hypocative = Decreased activity - LETHARGY, reduced responsiveness, Withdrawal
- Mixed
Causes of delirium
DELIRIUMS:
- Drugs + Alcohol
- Eyes, Ears + EMOTIONAL DISTURBANCES
- Low Output state
- INFECTION
- RETENTION (urine / stool)
- ICTAL (seizure related)
- UNDER-hydration / -nutrition
- METABOLIC disorders (electrolytes, thyroid, Wernicke’s)
- Subdural Haematoma, Sleep deprivation
Which medications are particularly likely to cause delirium
- ANTI-CHOLINERGICS
- Opiates
- ANTI-CONVULSANTS
Delerium Sx
- Disorientation
- Hallucinations
- Inattention
- Memory problems
- Change in mood + personality (e.g. Sundowning)
- Disturbed sleep
Can be sedated or very agitated depending on subtype
Delirium Ix
Initial examination + Infection scan
- Assess delirium:
- 4AT (alertness, Cognition, Attention, acute change / fluctuating course)
- Confusion assessment Method (CAM)
Everything else based on clinical suspicion:
- Bedside:
- Bladder scan; ECG; Review meds; Urine MC+S (no point urine dipping anyone > 65) - BLOODS:
- FBC, U+E; LFTs; TFTs; CLUTURES
- Imaging:
- CXR, US abdo
- CT / MRI only if no other cause identifiable
Delirium Mx
NON-PHARM:
- Well lit environment
- Regular sleep-wak cycle
- Regular ORIENTATION + REASSURANCE
- Ensure any aids (glasses, hearing aids) are used
HALOPERIDOL or LORAZEPAM if v agitated/risky
- Olanzepam = risk of SE but can still use if needed
Frontal lobe syndrome
Damage to higher functioning process. Areas include:
- anterior cingulate
- lateral prefrontal cortex
- orbitofrontal cortex
- frontal poles
Frontal lobe syndrome Sx
Specific Sx depends on area affected - commonly can cause impairment/change in:
- Motivation
- Planning / working memory
- Social behaviour / personality
- Language / speech production
- Weakness / impaired motor function
etc think Phineas Gage
Causes of lobe syndrome
- Trauma
- CVD
- TUmours
- Neurodegenerative
Also: Focal epilepsy, HIV, MS, Early-onset dementia
Lobe syndrome pathophys
- Dorsolateral lesions = APATHETIC / Impaired decision making / impaired WORKING MEMORY
- Venteromedial orbitofrontal lesions = IMPULSIVITY / personality change
- Left hemispheric = depression-like assocociation
- Right hemispheric lesion = more MANIC Px
More significant if bilateral
Lobe syndrome Ix
- Neuro + mental status exam
- RULE OUT DDx
- BLOODS: B12, thyroid, syphilis serology
- MRI: atrophy / vascular / microvasc pathology
- CT = acute bleeds, hydrocephalus
- Deoxyglucose PET (FDG) if suspected frototemporal demetia
Lobe syndrome Mx
Tx underlying cause
- Physio/occupational therapy
- SALT
- Support at home if needed
Addictive behaviours
REPEATED patterns of behaviour that DOMINATE patient’s life to DETRIMENT of social, occupational, material + family values / commitments
Features of substance misuse
- Acute intoxication
- Hazardous use
- Use despite harmful effects
- TOLERANCE
- WITHDRAWAL
- Dependence
- Compulsion to take
- Prioritising over commitments
- Residual disorder
Need 3 or more Sx for > 1 MONTH
Substance misuse Ix
- MSE + Physical exam
- BLOODS
- Urine toxicology
- CXR, ECG, Echo
Substance misuse Mx
- CBT
- Meds for opiod dependance:
- Detox: METHADONE; Buprenorphine; Dihydrocodeine
- Lofexidine (for withdrawal)
- Naltrexone (prevent relapse)
- NALOXONE (if overdose!) - For smoking:
- NRT
- Champix/Varenicline (reduce cravings)
- Bupropion?Zyban (reduce pleasure)
Sx of Intoxication
- Slurrded speech
- Ataxia
- Impaired judgement
- If severe:
- Coma
- Hypoglycaemia
Alcohol withdrawal Sx
6-12 hrs after last drink:
- Insomnia
- Sweating
- Anxiety
- Tremor
- Palpitations
- Agitation
- Nausea + vomiting
12-24 hours after last drink:
- HALLUCINATIONS
> 36 hours after:
- SEIZURES
72 hours after = DELERIUM TREMENS
- Delusions
- Confusion
- Seizures
- TACHYCARDIA
- HYPERTENSION
- Hyperthermia
Ix for Alcohol abuse / withdrawal
- AUDIT, CAGE, SADQ, FAST
- BLOODS: LFTs + ELECTROLYTES
- CT head if seizures persist
- ECG
Alcohol withdrawal Tx
- Reducing regimen of CHLORDIAZEPOXIDE
- More rapid acting (e.g. IV LORAZEPAM) if having seizures - PABRINEX (IV thiamine) to prevent Wernike’s (if already Wernike’s -> increased dose)
- ORAL LORAZEPAM for Delerium tremens (can give IV if needed)
What are the criteria for when inpatient withdrawal Tx should be considered
- Drinking > 30 UNITS per day
- Score > 30 on SADQ
- At High risk of SEIZURES
- Concurrent withdrawal from benzodiazepines
- Significant CO-MORB (med / psych)
- Vulnerable patients / Patients < 18
Tx options for alcohol abuse
- CBT / AA / Social support
- Disulifram (N+V if drinking)
- Naltrezone (decreased pleasure)
- Acamprosate (reduce cravings)
Wernicke’s encephalopathy
Acute neuro Sx from THIAMINE (vit B1) def - typically from alcohol abuse
- thiamine def -> neuronal death
Korsakoff syndrome pathophys
Prolonged thiamine def -> Neuronal degeneration - most notably in MAMMILLARY BODIES which are part of the CIRCUIT OF PAPEZ - playes role in MEMORY FORMATION
Classic signs of Wernicke’s
- CONFUSION
- Ataxia
- Ophthalmoplegia (paralysis of ocular muscles) / nystagmus
not all Sx needed for Dx
Hallmark Sx of Korsakoff
- ANTEROGRADE AMNESIA
- Retrograde amnesia (semantic and episodic specifically affected)
- CONFABULATION (fabricating memories to mask amnesia)
(these 3 things make up the syndrome basically)
Also:
- lack of insight
- apathy
- Minimal content in conversation
Wernicke’s Ix
- THIAMINE LEVEL TESTING
- BLOODS: FBC, U+E, LFTs, CLotting, Bone profile, Mg
- MRI brain (hyperintensity on T2 weighted due to oedema - usually in mammillary area)
Wernicke’s Mx
- THIAMINE SUPP
- Mx underlying (oft alcohol so counselling / rehabilitation)
Korsakoff Mx
- THIAMINE SUPP
- Cognitive REHAB (cognitive function / memory loss do not return to previous baseline)
- Control pt environment to reduce confusion
- Tx underlying (typically alcoholism)
Major depressive disorder vs Persistent Depressive Disroder
Major dep = Depressive episode lasting AT LEAST 2 WEEKS + desplaying at least 5 of the main Sx nearly every day
Persistent dep = lasts at least 2 YEARS
Defining charactersitics of a depressive episode
- LOW MOOD / MOTIVATION
- ANHEDONIA
- Reduced energy
All for AT LEAST 2 WKS
Depression Sx
- Low mood / irritability
- Anhedonia
- Change in WEIGHT / APPETITE
- Change in SLEEP
- Change in ACTIVITY LEVELS - oft loss of energy
- GUILT / FEELINGS of WORTHLESSNESS
- Cognitive impairment: difficulty thinking/CONCENTRATING or INDECISIVENESS
- SUICIDALITY
If v severe, can develop:
- psychotic features or
- Depressive stupor (immobile, mutism, not eating / drinking)
Depression Dx
Rule out:
- Bloods
- FBC; TFTs; U+E; LFTs; glucose; B12/folate; cortisol - Toxicology screen
- CNS imaging (potentially)
Usually clinical diagnosis:
- Interviews
- Questionnaires (Patient Health Questionnaire 9; Hospital Anxiety and Depression Scale)
Depression Mx
Usually in community
Mild to moderate:
- Individual self help / computerised CBT (low level psych)
- individualised CBT / IPT
- Consider antidep
Unresponsive / mod-severe:
- CBT/IPT + SSRIs
- Switch antidep then use adjuncts (SNRI, Tricyclic)
Severe / stupor / psychosis:
- ECT
Recurrent:
- Antidepressant + lithium
N/B: Follow up starting antidep within a week in young adults (<25) - increased risk of suicide/impulsivity
Side effects of ECT
Short term:
- Headache
- Muscle ache
- Nausea
- Temporary memory loss
- Confusion
Long term:
- Persistent memory loss (potentially)
Meaning of PHQ-9 scores
- <16 - less severe
- > =16 - more severe
Anxiety definition
Excessive worry about a number of different events associated with heightened tension, extending across various domains of life.
- difficult to control worry
- Associated: Restlessness, muscle tension + fatigue
- LASTING AT LEAST 6 MONTHS
Anxiety RFx
- Lower socioecon
- Unemployment
- Divorce
- Renting rather than home owning
- Lack of educational qulaifications
- Urban living
Anxiety Sx
Psych:
- Worries
- Poor conc
- irritability
- Depersonalisation/Derealisation
Somatic:
- Tremor
- Headache / muscle aches
- Dizziness
- Tinnitus
- Dry mouth, Dysphagia, nausea, indegestion, Butterflies, flatulence, increased/loose bowel movements
- Chest discomfort ; palps
- SOB
- Urinary frequency; Amenorrhoea; ED
Anxiety DDx
- Hyperthyroid
- Cardiac
- Medication induced
- SALBUTABOL, Theophylline; Corticosteroids; Antidep - Substance misuse
- Amphetamines; benzodiazepine/alcohol withdrawal
- Or just CAFFEINE
- Amphetamines; benzodiazepine/alcohol withdrawal
- personality disorder
- Early stage dementia or schizophrenia
GAD (generalised anxiety disorder) Mx
- EDUCATE + active monitoring
- Low intensity psych (self-help (guided / non-guided); psychoeducational groups)
- High intensity psych (CBT; Applied relaxation) OR DRUGS
- SSRIs then SNRIs (monitor for suicidality in <30s)
- other = Pregabalin - SPECIALIST MDT INPUT
When to refer for specialist Tx of depression
- High suicide risk
- BIPOLAR Sx
- PSYCHOSIS Sx
- Severe, unresponsive depression
Psychotic features (Psychosis)
- Hallucinations + Delusions
- Thought disorganisation
- Alogia (little info convaeyed by speech)
- Tangentiality
- Clanging
- Loose associations / flight of ideas
Oft associated:
- Agitation / aggression
- Neurocog impair
- Depression
- Thoughts of self-harm
Causes of psychotic Sx
- Schizophrenia
- Depression
- Bipolar
- Postpartum psychosis
- Neuro conditions e.g. Parkinson’s Huntington’s
- Prescribed drugs e.g. CORTICOSTEROIDS
- Illicit drugs e.g. CANNABIS, PHENCYCLIDINE
- Brief psychotic disorder (Sx last LESS THAN A MONTH)
Somatisation disorder definition
Multiple, RECURRENT and frequently CHANGING physical Sx lasting at least 2 YEARS.
Oft associated with disruption of social, interpersonal + family behaviour
Potentially aets of somatisation disorder
- attempt to cope with stress
- increased incidence if Hx of ABUSE - Heightened sensitivity to internal sensations
- Catastrophic thinking oversensitising mild ailments
Somatisation disorder Tx
CBT
Ways of assessing risk
- Risk assessment tools eg DRAM, FACE
- Clinical Assessment - psychiatric history + MSE
- Static risk factors - do not change
- Dynamic risk factors - may change
Consider Hx, environment, Mental state + info from other sources, MDT etc -> How serious + immediate is risk
Static RFx for harm to self/others
- History of self-harm/ overdoses
- Seriousness of previous suicidality
- Previous hospitalisation
- History of mental disorder
- History of substance use disorder (overdose or suicide)
- Personality disorder/traits
- Childhood adversity
- Family history of suicide
- Age, gender and marital status
Dynamic RFx
- Suicidal ideation, communication, and intent
- Hopelessness
- Psych Sx – ?command hallucinations
- Treatment adherence
- Substance use
- Psychiatric admission and discharge - risk when discharged
- Psychosocial stress
- Problem-solving deficits
Risk Mx
- Assess risk
- Risk Mx plan
- communicate plan with pt
- Ensure plan is carried out
- Evaluate outcome
- Clinical review
Lithium SE
Common: Nausea, diarrhoea, dry mouth, metallic taste, thirsty, mild tremor
Rare: RENAL DYSFUNCTION, HYPO/HYPERTHYROIDISM, TERATOGENICITY
Lithium TOXICITY Px
- Polyuria / Incontinence ; Nausea
- Drowsey, Confusion, Blackouts, Faints, Blurred vision
- Shaking / muscle SPASMS in face, neck + tongue
TOXICCC:
- coarse TREMOR
- OLIGURIC RENAL failure
- ATAXIA
- INCREASED REFLEXES
- CONVULSIONS
- decreased CONSIOUSNESS
- COMA
Lithium toxicity Ix
- U+E
- TFTs
- LITHIUM LEVELS
Lithium toxicity Mx
- STOP LITHIUM
- High FLUID + IV NaCL
- Haemodialysis if severe
Neuroleptic Malignant Syndrome
Adverse reaction to ANTIPSYCHOTICS (dopamine receptor agonists) or; ABRUPT DOPAMINERGIC WITHDRAWAL (levodopa)
Neuroleptic Malignant Syndrome Sx
- Altered mental state, CONFUSION
- FEVER
- TACHYCARDIC
- HTN / HypOtension
- Muscular HYPOactivity
- Severe lead pipe RIGIDTY
Neuroleptic malignant syndrome Ix
- BLOODS
- CK, LFTs, FERRITIN (LOW) - CT/MRI head
- INFECTION SCREEN (exclude sepsis)
- WCC
Neuroleptic malig syndrome Mx
STOP CAUSATIVE DRUG + SUPPORTIVE Mx
Neuroleptic malig syndrome Complications
- PE (due to immobilisation?)
- RENAL FAILURE
- SHOCK
Serotonin syndrome
High SYNAPTIC CONC of serotonin caused by SSRIs/SNRIs, OPIOIDS, MAOi, Lithium, Tricyclics etc
Serotonin sydrome Sx
- CONFUSION
- HALLUCINATIONS
- Tremor
- Hyperreflexia
- HTN
- Tachycardia
- Hyperthermia
- Sweating + shivers
N/B can differentiate from NMS as WCC NORMAL in Serotonin Sydrome
WHat is the acute Tx of SSRi overdose
Activated charcoal
Acute Dystonic Syndrome
Painful contraction in:
- Eyes = Oculogyric crisis
- Neck = TORTICOLLIS
- Jaw
Classic Px = Arm held in dystonic posture, neck spasm to side, mouth open, upward eye gaze, pain and distress
Tx = IM PROCYCLIDINE 5-10 mg
PHQ-9 (for depression) score catagories
- 0-4 no depression identified
- 5-9 mild depression
- 10-14 moderate depression
- 15-19 moderately severe depression
- 20-27 severe depression
Indications for ECT + absolute contraindication
- treatment resistant severe depression
- manic episodes
- an episode of moderate depression know to respond to ECT in the past
- life threatening catatonia
Contraindication = raised ICP
Side effects of ECT
- headache
- nausea
- short term memory impairment
- memory loss of events prior to ECT
- cardiac arrhythmia
usually only gets short term side effects but some people get long-term memory impairment
Cotard syndrome: meaning
Rare condition where an individual has the irrational, unshakable belief that they (or part of their body) is dead, rotting or non-existent
Complications of Cotard syndrome
Patients can stop eating and drinking as they deem it unnecessary
Cotard syndrome is associated with which conditions
- Severe depression + psychotic disorders
- Schizophrenia
- Parietal lobe lesions
Capgras delusion meaning + possible causes
Fixed, false belief that a close relative/partner has been replaced by an imposter
Could be psychotic illness or brain trauma
Ekbom syndrome meaning + Px
Delusional belief that patient feels that they are infected with parasites.
Often complain of crawling feeling under skin
Can appear as part of psychotic illness or 2ndry to organic disease e.g. B12 def, hypOthyroid, neuro disorder
Othello syndrome + complications + associations
An individual has the fixed belief that their partner is unfaithful despite the absence of proof
- Oft presents in males
- Can result in stalking / homicide
- Associated with alcohol abuse, psychosis and right frontal lobe damage
De clerambault’s syndrome
AKA eratomania
The patient has a specific, fixed, false belief that someone else is in love with them. The patient is usually a woman and the person they are fixated upon is usually of a higher social status, despite only a brief or non-existent acquaintance.
There is not normally any unusual behaviour or hallucinations accompanying the delusion
AKA parasocial stalker behaviour
Fregoli’s syndrome
The fixed, false belief that strangers are familiar to the individual or a group of different people are in fact a single person who is in disguise
(think the ‘umbra meets aliens’ scene from vy spy)
Folie a deux
A shared delusion between two people in close association
