Psych 3 Flashcards
How long is section 136?
24h
MHAA - who is needed?
2 section 12 approved doctors and 1 AMHP
all need to agree!
Which pathway is associated with positive sx of schizophrenia?
mesolimbioc pathway (delusions, hallucinations)
Which pathway is associated with positive sx of schizophrenia?
mesolimbioc pathway (delusions, hallucinations)
Which pathway is associated with negative sx of schizophrenia?
mesocortical pathway
(flattened affect, alogia, avolition, anhedonia)
Which symptoms usually occur first in onset of schizophrenia?
negative symptoms first
followed by positive symptoms
ICD 10 F20 Schizophrenia Criteria - Add
> = 1 of the following
OR
> = 2 of the following
Assessment in new dx of schizophrenia
Full psychiatric and physical health assessment
BMI
HR
BP
?diabetes
Bloods:
FBC
U&E
LFTs
Lipids
HbA1c
PRL
HIV and syphylis to exclude infective causes
CK only if NMS is suspected.
ECG (looks at QTc)
Urine drug screen
Imaging not used routinely
Name some 1st and 2nd Generation antipsychotics
1st
haloperidol (also as tranq)
flupenthixol
chlorpromazine
thioridazine
trifluoperazine
2nd
aripiprazole (less sexual dysfunction and metabolic SE)
quetiapine
risperidone
olanzapine
amisulrpide
clozapine
What type of antipsychotics are better for +ve Sx?
1st get are more effective for positive sx
but have more SE
Which antipsychotic should be used with extreme caution in elderly patients with psychosis?
- aripiprazole
- clozapine
- olanzapine
- risperidone
- quetiapine
- Clozapine
Intervention for Schizophrenia
Antipsychotics
Psychological intervention
- CBT for psychosis
- psycho education
- family therapy
- art therapy
- compliance therapy
Social support
- social reintegration (finance, housing supports, education and employment support)
- carer support
RFs for puerperal psychosis
PMH of schizophrenia and BPD
previous puerperal psychosis or PP mental illness
FH of puerperal psychosis
Perinatal risk assessment
- disclosure of harmful or potentially harmful acts (to themselves or baby or others?)
- any delusions/overvalued ideas or hallucinations involving the baby or other children?
- any thoughts/plans/intentions of harming the unborn baby/other children/partner?
- hostility and/or irritability towards the unborn baby or other children?
- any concern about any other person who may pose a risk to the unborn child or other children?
- thoughts and behaviours about estrangement from the baby and/or inadequacy as a parent?
EDPS questionnaire
Edinburgh postnatal depression scale
When should you change from using EDPS to PHQ9 scale?
EDPS usually in first 3-6 months
however perinatal psychosis services provided for up to 1-2 years
these are not hard and fast rules
Which psych drugs should be avoided in perinatal MH?
carbamazepine and valproate
Which is the recommended treatment option for a pregnant female with opiate dependance stable on methadone?
- continue methadone
- stop methadone gradually
- switch to buprenorphine
- switch to codeine
- switch to naltrexone
- Continue methadone
there would be a risk of relapse otherwise which would be even worse for the baby
Binge Eating disorder
XXX
Peak age in anorexia and in bulimia nervosa
AN: 15-19
BN: 15-25
AN weight requirements
<17.5 Kg/m2
OR
at least 15% below expected (either lost or never achieved)
ICD-10 criteria for anorexia nervosa
BMI/weight
- weight loss was self-induced, body image distortion
- widespread endocrinological dysfunction (e.g. amenorrhoea, high cortisol)
- minimisation or severity
2 types: resctrictive and ?binge
PACES questions to ask in anorexia nervosa cases
Comprehensive assessment in anorexia nervosa
- psychiatric assessment including co-morbidities
- physical health assessment (weight, height, BMI; trend and rate of weight loss >0.5-1 kg/week is significant)
- add!!!!!
Screening questionnaire for unusual eating habit
When is inpatient treatment needed in eating disorders?
try to avoid if possible
only in extreme circumstances:
- BMI <13
- high risk of suicidal acts
When is inpatient treatment needed in eating disorders?
try to avoid if possible
only in extreme circumstances:
- BMI <13
- high risk of suicidal acts
Management of binge eating disorders
1) BED focused self-help programmes (e.g. BEAT group self help)
2) if unacceptable or ineffective after 4w consider group CBT-ED
3) if unacceptable or ineffective, consider individual CBT-ED
What is atypical anorexia nervosa?
Disorders that fulfil some of the features of AN but in which the overall clinical picture does not justify that diagnosis.
E.g. one of the key symptoms, such as amenorrhoea or marked dread of being fat, may be absent in the presence of marked weight loss and weight-reducing behaviour.
This diagnosis should not be made in the presence of known physical disorders associated with weight loss.
ICD-10 AN summary
- deliberate weight loss, induced and sustained by the patient.
- The disorder is associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves.
There is usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function.
Symptoms include
- restricted dietary choice
- excessive exercise
- induced vomiting and purgation
- use of appetite suppressants and diuretics.
What causes refeeding syndrome ?
intracellular shift of ions due to switching to carbohydrate metabolism
What is AFP-AN?
Adolescent focussed psychotherapy - anorexia nervosa
2nd line treatment (other option is CBT-ED) for AN treatment in children
What % of poeple with AN will die because of AN?
10%
CEDS
community eating disorder services
AN referral pathways
Mild (BMI >17, no additional co-morbidity) -> monitor/advice/support for 8w, recommend BEAT support, routine referral to CEDS if failure to respond.
Moderate (BMI 15-17, no evidence of system failure) -> routine referral to CEDS
Severe (BMI <15, rapid weight loss, evidence of system failure) -> urgent referral to CEDS
Adult AN management
Psychoeducation (advice on nutrition and health)
Treat co-morbid psych illness (depression, OCD, substance misuse)
Nutritional management and weight restoration (realistic 0.5-1 kg/week, set eating plan)
Psychotherapies:
1st line
- CBT-ED
- MANTRA
- SSCM
If one of these has not worked try another one or offer FPT.
2nd line
CBT-ED
AFP-AN
Do you make yourself Sick because you feel uncomfortably full?
* Do you worry you have lost Control over how much you eat?
* Have you recently lost One stone in a 3 month period
* Do you believe yourself to be Fat when others say you are thin
* WouldyousayFooddominatesyourlife?
* Go to further history if positive (≥2, or clinical suspicion)
What are the 3 main drugs used in BPD?
lithium
sodium valproate
carbamazepine (anticonvulsant)
therapeutic range of lithium
0.6 - 1.0 mmol/L
aim for 0.6-0.8 mmol/L
When does lithium become toxic?
> 1.2 mmol/L
What to check before starting lithium
BMI
FBC
U&Es
TFTs
-> monitor U&Es and TFTs every 6 months in pts on lithium (b/c can cause renal impairment and hypothyroidism)
How often do you need to check lithium levels?
initially weekly
once a steady therapeutic dose is established, check every 3 months
When should lithium levels be measured?
12h
What is the aim of CBT in BPAD?
understand BPAD
identify triggers
relapse prevention strategies (e.g. routine, good sleep, healthy lifestyle promotion, avoiding excessive stimulation/stress, adressing substance misuse, ensuring drug compliance)
helps pts test out their excessively positive thoughts to fain a sense of perspective
identification and use of personal and professional support networks
What psychological therapies can be used in BPAD?
CBT
psychodynamic psychotherapy can be useful if mood is stabilied
What are the core sx of depression
low mood
anergia
anhedonia
What are the different groups of sx you might have in depression?
Core (low mood, anhedonia, anergia)
Biological (poor sleep, loss of appetite, low libido, worse concentration)
Negative cognitions (hopelessness, helplessness, worthlessness, guilt)
Psychotic (mood congruent delusions (e.g. nihilistic), hallucinations, catatonia)
What is dysthymia?
chronic low grade depression sx present for >2y
What is atypical depression?
improved mood in response to positive events
increased appetite
increased sleep
leaden paralysis
fatigue
what kind of therapy does SAD respond to?
light therapy
What gender is at higher risk of developing depression
females (1 in 4 will develop depression)
F:m 2:1
-> compared to 1 in 10 men
Factors necessitating admission in depression
not responsive to treatment
psychotic symptoms
risk of suicide/self-harm
risk to others
self-neglect
poor social support
lack of insight
Mean age of onset of bipolar
18-21
What is the point prevalence of BPAD?
1.5
What can cause secondary mania?
Drugs (steroids, levo-dopa)
organic brain damage (esp R hemisphere, more common in the elderly)
recreational drugs (stimulants)
hypothyroidism can cause depressione, hyperthyroidism could cause hypomania or agitated depression
What mood stabiliser can be used to treat acute mania?
sodium valproate
Mx of acute mania
stop all meds that may induce sx (e.g. antidepressants, recreational drugs, steroids, DA agonists)
monitor fluid and food intake to prevent dehydration
if not on rx give an antipsychotic and a short course of benzodiazepines
if already on rx, optimise medication, check compliance, adjust doses, consider adding another medication
short term benzos may help
ECT may eb useful in patients that are unresponsive to medication
social interventions in BPAD
family support and therapy
help in return to school/work
What are the core features of Lewy Body dementia?
Parkinsonism
fluctuating cognition
visual hallucinations
What are alpha-synuclein cytoplasmic inclusions ?
Lewy bodies
deposits in the brain seen in LBD
