PSYCH 3: Memory, Stress Disorders, Speech Disorders, Sectioning Flashcards
What is dementia?
Acquired, chronic and progressive cognitive impairment sufficient to impair ADLs
Most common form = Alzheimer’s, then vascular then lewy body
What is the aetiology of Alzheimer’s disease?
Hippocampus affected first and then cortex:
1. Amyloid - AB protein forms which forms toxic aggregate
2. Tau - hyperphosphorylated tau protein forms neurofibrillary tangle aggregates
3. Inflammation - increased inflam mediators and decreased neuroprotective proteins
What are RFs for Alzheimer’s disease?
Primarily age
Genetics
Head injury
Down’s syndrome
What are the key symptoms of Alzheimer’s disease?
4 A’s:
Amnesia - recent memories lost first
Aphasia - difficulty finding correct words (Broca’s), speech muddle/disjointed
Agnosia - typically visual (i.e. prosopagnosia = recognising faces)
Apraxia - typically dressing (skilled tasks, despite normal motor functioning)
+ psychiatric presentations e.g. delusions, depression, GAD
+ GRADUAL DETERIORATION
How do the other subtypes of dementia present?
VASCULAR = stepwise decline, retained pre-morbid personality, neuro signs related to infarct sign, CVD hx or RF
LEWY BODY = fluctuating confusion w/lucid intervals, visual hallucinations, parkinsonism
FRONTOTEMPORAL = more common in <65yo, change in personality and behaviour
How is dementia investigated?
BEDSIDE = AMTS <7 indicates cognitive impairment, MMSE, MOCA
(NICE just indicates a validated cognitive assessment)
BLOODS = dementia/delirium screen
- FBC, U&Es and dipstick, TFTs, LFTs, HbA1c, B12 and folate, calcium
Consider if indicated: urine MC&S, CXR, ECG, syphilis serology, HIV serology
IMAGING/FURTHER TESTS =
- Alzheimer’s = MRI to check for grey matter atrophy, wide ventricles
- Vascular = ECG, CT/MRI
- Memory assessment clinic = risk assess patient and conduct MMSE for cognition assessment
How is Alzheimer’s disease managed?
BIOLOGICAL
- Mild = anticholinesterases e.g. donepezil, galantamine, rivastigmine (DGR = dementia got real): used for mild AD, lewy body + parkinsons dementia. SEs = GI, muscle spasms, bradycardia, miosis
- Severe = NDMA (glutamate receptor) antagonist e.g. memantine (blocking excessive excitation w/glutamate preserves neurones, prevents neuronal death)
PSYCHOLOGICAL
- structural group cognition stimulation sessions, group reminiscence therapy, validation therapy
- charities to help with carer support e.g. dementia UK
- mental health issues signposting
SOCIAL
- future wishes, discuss LPA, advanced directives
- care package
- social support measures e.g. meal support, ADL support, alt. accomm
- pt orientation
- safety measures
- follow up every 6mths w/Dr and named care manager
What is Charles Bonnet Syndrome?
Persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness
Generally against background of visual impairment e.g. age related macular degeneration, glaucoma, cataracts
insight usually preserved
in absence of any other significant neuropsychiatric disturbance
What is the difference between a normal and abnormal grief reaction?
NORMAL = denial, anger, depression, bargaining, acceptance cycle, can last up to 2yrs but diagnosed generally if lasting >6mths
ABNORMAL = delayed onset of grief, greater intensity, not ‘progressing’ through cycle, suicidal/psychotic sx, more likely if sudden death/problematic relationship/lack of support
What are pseudohallucinations?
false sensory perception in absence of external stimuli when affected person is aware they’re hallucinating - common in grieving people
What is adjustment disorder?
Subjective distress <6mths, usually interfering w/social functioning, arising in period of adaptation (1 month) to a significant life change e.g. divorce, death, unemployment, moving
What is the difference between acute stress disorder, PTSD and chronic PTSD?
Acute stress disorder = stress reaction that occurs in first 4w following a traumatic event, sx must last for >3d to warrant diagnosis
PTSD = stress reaction occurring for >4w following exposure to traumatic event
Chronic PTSD = last >1yr
How does PTSD present?
Triad of sx =
- Reexperiencing: flashbacks, nightmares, repetitive intrusive images
- Avoidance: avoiding people/places/situations/associations w/event
- Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, difficulty concentrating
+/- mood disorders, self-harm/destructive behaviours, somatic sx
How does PTSD present differently from ASD?
- sx in clusters not necessarily totality
- dissociative subtype but depersonalisation/derealisation rare in ASD
- non-fear based sx whereas rare in acute stress
How are stress disorders investigated and managed?
IX = full and thorough history, TSQ (trauma screening questionnaire), CRIES8 (child revised impacts of events scale)
If ?PTSD - routine referral to CAMHS for formal diagnosis
Rule out organic causes for depression w/blood tests
MX =
ASD - conservative mx (sleep hygiene, support groups etc.)
PTSD - trauma based CBT, EMDR (if more severe)
Meds not routinely considered but if so SSRI then antipsychotics considered
How does panic disorder present?
Recurrent attacks of anxiety not triggered by any particular situation or set of circumstances i.e. unpredictable
- don’t satisfy criteria for GAD, depression or other psych disorders, concern regarding attacks has persisted >1 month
Sx = palpitations, sweating, tremor, chest tightness, sudden onset, thoughts of doom/urgently seeking safety
How is panic disorder managed?
Education, reassurance and self-help (IAPT)
Medication in severe cases - SSRI, then trial TCA or benzo if no improvement.
NO BENZOS BECAUSE:
- only sx relief of anxiety, only for short term use
- very addictive
- tolerant within 2w
- delays other treatments and people who take them perform less well in psych therapy sessions
- also risk of withdrawal
What is a phobia?
Fear reaction to a specific stimuli that impacts daily life.
SOCIAL PHOBIA = fear of scrutiny by other people leading to avoidance of situation
AGORAPHOBIA = cluster of phobias defined by being unable to escape a place of people e.g. leaving home, crowds, entering shops, planes/buses etc.
How are phobias investigated and managed?
Ix =
Full history
SPIN/social phobia inventory or Liebowitz social phobia scale to assess degree of social phobia
Mx = conservative + CBT w/ERP (exposure and response prevention) focus
Indications for CBT?
Depression
Anxiety
BPD
Alcohol abstinence
PND
Delusional disorder
Panic disorder
Schizophrenia
Somatisation
Indications for counselling/talking therapy/psychotherapy?
Adjustment disorder
Baby blues
Dissociative disorder
Grief reaction
Indications for family training programme?
Eating disorders (1st line)
ADHD
Conduct disorder
Indications for dialectical behaviour therapy?
Personality disorders
Indications for eye movement desensitisation and reprocessing (EMDR)?
severe PTSD
What are the subtypes of CBT?
Trauma focused - acute stress disorder, PTSD
ED focussed - eating disorders second line
w/ERP - OCD, phobias
What is circumstantiality?
inability to answer a question without giving excessive, unnecessary detail, person DOES eventually return to the original point
What is tangentiality?
wandering from a topic without returning to it
What is Knight’s move thinking?
severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another; schizophrenia
What is flight of ideas?
leaps from one topic to another but with discernible links between them
What is perseveration?
repetition of ideas or words despite an attempt to change the topic
What is thought interference?
That someone is withdrawing/inserting outside thoughts into the patient, or that patient’s thoughts are being broadcast
What is pressure of speech/thought?
fast and difficult to interpret; mania
What is poverty of speech/thought?
much slower w/little or nothing to say; depression
What is thought block?
complete emptying of thoughts, sudden halt; schizophrenia
What is clang assocations?
rhyming connections to bridge thoughts (bang, sang etc.)
What is punning?
play on words w/homophones
What is neologism?
made up words
What is word salad?
completely incoherent speech where real words are strung together into nonsense sentences
What is depersonalisation?
the sensation of being outside of your body and observing your actions as a third party
What is derealisation?
the sensation of belief that the world is not real; things around seem “foggy” or “lifeless”
What is othello syndrome?
believing partner is unfaithful
What is the difference between the Mental Health Act and Mental Capacity Act?
MHA = compulsory admissions and treatment of MENTAL illness
MCA = consent and capacity, regarding PHYSICAL illness
What are the 5 aspects of the MCA?
- Presumption of capacity
- Individuals supported to make their own decision whenever possible
- People have the right to make unwise decisions, and this cannot be seen as ‘lacking capacity’
- Best interests of person should always be priority when making decisions
- When acting in best interests of someone lacking capacity, least restrictive treatment option should be chosen
What is the purpose of a section 2?
Assessment +/- treatment (non-renewable)
RECS: 2 doctors
APPLICANT: AMHP (approved mental health professional)
DURATION: 28d
NOTE: this can usually be done straightaway on a mental health ward/facility bc everyone there is trained vs in a normal hospital ward where you would do a section 5(2) before progressing to a section 2. SETTING IS KEY
What is the purpose of a section 3?
Treatment (can be given for 3mths w/o consent, then required form) - renewable after 6mths
RECS: 2 doctors
APPLICANT: AMHP
DURATION: 6mths
What is the purpose of a section 4?
EMERGENCY SECTION
Allows patient to be admitted to a mental health unit and cared for whilst arrangements for detention under S2 or S3 are made.
RECS: 1 doctor who is S12 approved
APPLICANT: AMHP
DURATION: 72hrs
What is the purpose of a section 135?
EMERGENCY SECTION
Allows police to enter house and remove patient to place of safety
RECS: Police officer (should try to confirm w/doctor or nurse)
DURATION: 72hrs
What is the purpose of a section 136?
EMERGENCY SECTION
Allows police to take someone from a public place to a place of safety
RECS: Police officer (should try to confirm w/doctor or nurse)
DURATION: 72hrs
What is the purpose of a section 5(2)?
Doctor can detain inpatient for assessment (used when there is no time for S2)
Used on pts who withdraw consent (if they have capacity) or show objection (without capacity).
Cannot be used on patients in ED as they have not been formally admitted.
RECS: 1 doctor
DURATION: 72hrs
What is the purpose of a section 5(4)?
For pts in hospital, nurse detains inpatient for assessment when doctor comes.
RECS: Mental health nurse
DURATION: 6hrs
What is a lasting power of attorney (LPA)?
When a person legally nominates a person of their choice to make decisions on their behalf if they lack mental capacity.
LPA only comes into effect if the patient lacks the capacity to decide for themselves.
It does not give the person with LPA control over a decision if they can still make that decision themselves.
What is deprivation of liberty safeguards (DoLS)?
An application made by a hospital or care home for patients who lack capacity to allow the to provide care and treatment.
Whilst in hospital, or a care home, the patient is under control and is not able to leave. This means they are “deprived of their liberty” and require a legal framework to protect them.
What is section 17?
Allows temporary leave from specialist psychiatric unit.
Can be revoked if needed, and section 18 issues to forcibly return pts who breached section 17 agreements.
Outline the process of rapid tranquilisation?
- Aim to calm pt via verbal de-escalation
- IM lorazepam OR IM haloperidol + IM promethazine
- if one doesn’t work try the other, or if one is working partially consider another dose - Monitor side effects (acute dystonic reaction) and service user’s pulse, BP, RR, temp, level of hydration and level of consciousness
- at least every hour until no further physical health concerns
- every 15mins if pt sedated/drugs or alcohol use/physical health problem/experienced harm from restrictive intervention
What questions to ask in a risk assessment?
Have you ever thought about/attempted to end your life?
Have you ever purposely hurt yourself or want to hurt yourself? (if so do before, during and after Qs)
Have you ever felt as though someone is out to harm you?
Have you ever felt like you have wanted to hurt someone else?
What are RFs for suicide?
SAD PERSONS
Sex (male)
Age (young, elderly)
Depression
Previous attempt (highest RF)
Ethanol or drug use
Rational thinking loss e.g. psychosis
Sickness (medical illness)
Organised plan
No social support
States future intent
What are RFs for increased risk of completed suicide at a future date?
- efforts to avoid discovery
- planning
- leaving a written note
- final acts such as sorting out finances
- violent method
What are protective factors against suicide?
Family support
Having children at home
Religious belief
