Psych Flashcards
Psych Hx Checklist
1) PC
2) HPC
Incl important symptoms:
- Mood
- Appetite
- Weight
- Sleep
- Energy
- Hallucinations
- Concentration/memory
3) Past psychiatric Hx - seen psychiatrist? been diagnosed with anything? had any medication or treatment?
4) Past medical Hx
5) Family Hx (psych or medical)
6) Personal Hx
- Problems during pregnancy, labour, birth?
- Illnesses as a child?
- School - enjoy it? problems making friends? ever expelled from school?
- Qualifications when left school? Jobs?
- Relationships
7) Social Hx
- Who living with? where living? Current job? benefits?
8) Smoking, ETOH, other recreational drugs
9) Forensic Hx
- Ever in trouble with police, ever convicted of anything?
10) Premorbid personality?
- When did this all start? When did you last feel normal/well? How would you describe yourself before this? How would others have described you
RISK ASSESSMENT (On another card)
Risk Assessment
1) Risk to self (deliberate)
- Negative feelings (hopeless, helpless, worthless)
- Ever felt life wasn’t worth living?
- Felt like not wanting to wake up in the morning?
- Ever self harmed before? Attempted suicide?
- Thought? Intent? Plan? (3/2/1 = high/moderate/low risk)
- What prevents you from ending your life?
2) Risk to self (not deliberate)
- Pressure sores, dehydration, malnutrition
- Medications, falls, accidental fires, self neglect, dementia
- Reckless behaviour (driving, alcohol/drugs, gambling, poor financial decisions)
3) Risk to others (deliberate)
- Seeing others as suffering, wanting to end that
- Believing others are trying to harm you
- Fire/arson/theft
4) Risk to others (not deliberate)
- Gambling, alcohol use, driving
- Do they have children/dependents?
5) Risk from others
- Safeguarding issues, theft, abuse
Mental State Examination
Appearance + behaviour, Mood/Affect, Speech, Thought, Perception, Cognition, Insight
Appearance & Behaviour
- Age, Gender, Ethnicity, Occupation
- Dress + self care: Provocative –> disinhibited. Dischevelled –> depression or schizophrenia.
- Manner: Were they inappropriate with you?
- Posture and Movement: Helpful/hostile? Amiable/aggressive? Tense/relaxed/overactive? tardive dyskinesia –> antipsychotic use.
- Easy to build rapport?
Mood & Affect
- Mood: subjectively (report what patient says)
- Affect: objectively (expansive, euthymic, blunted, depressed.
Speech
- Rate, Rhythm, Volume, Tone
- Pressure or poverty of speech
- Were they coherent?
Thought
- Content: Thought insertion, withdrawal, broadcasting?
- Form: Pressure or poverty of thought? Thought blocking? Loosening of Association? Flight of ideas?
Perception
- Overvalued ideas (delusions), hallucinations, illusions Depersonalisation (feeling one’s thoughts aren’t ones own), Derealisation (Feeling one’s surroundings aren’t real)
Cognition
- Orientation: To time, place, person
- Attention: Subjective report. Serial 7s (or count 20-1), spell WORLD backwards
- Memory: Immediate, recent, remote
- Grasp: Current prime minister? current topical events?
Insight
- Do you think you are unwell in any way? mentally unwell?
- If so, what do you think is wrong?
- Do you need any treatment?
- If so, what will make you better?
Also present risk assessment
Self harm approach
ABC
Antecedent
-Impulsive or planned (stockpiling pills, steps to avoid discovery)
- Made will/suicide note
- Drugs and/or alcohol
- Psychotic symptoms (e.g. command hallucinations)
Behaviour
- Chosen method of suicide
- Perceived lethality? Actual lethality?
- Drugs and or alcohol at the time
Consequences
- How were they found and brought to hospital?
- Regret about attempt or regret about failure
- Compliance with medical intervention
Presenting psych management plan
Confirm diagnosis
- Full Hx and physical examination
- Collateral Hx
- Basic tests to rule out organic disease (FBC, urine dip and urine drug screen)
Location of Rx
- Ideally manage in the community under CMHT or Crisis resolution team (or Early Intervention Service, EIS, if <35)
- However, if high risk, admit first
- Ideally informally, however if not compliant, use section … of Mental Health Act)
Management
- Bio, Psycho, Social approach
- Short term: stabilise patient with [medication/therapy] with the aim of returning them to their state before this acute episode
- Long term: once stabilised, offer (prophylactic?) medication and therapy (CBT, psychodynamic therapy…) with the overall aim of getting to the root of the problem and reintegrating the patient into the community
Psych disorder heirarchy (with ICD-10)
Organic disorders (F00-09) - F00: Dementia - F05: Delirium Substance use disorders (F10-19) - F10: Alcohol use disorder Psychotic disorders (F20-29) - F20: Chronic psychotic disorder - F23: Acute psychotic disorder Mood/Affective disorders (F30-39) - F31: bipolar - F32: depression Neurotic disorders (stress/anxiety): (F40-49) - F40: phobia - F41: panic dosorder (41.1 generalised, 41.2 associated w/depression) - F43: Adjustment disorder - F44: dissociative disorder - F45: unexplained somatic symptoms - F48: neurasthenia Physiological disorders (F50-59) - F50: Eating disorder - F51: Sleeping disorder - F52: Sexual disorder Personality disorder (F60-69) Developmental disorders (F70-79) - F70: Mental retardation Disorders of childhood (F90-99) - F90: Hyperkinetic disorder - F91: Conduct disorder - F98: Enuresis
Dementia vs Delirium
Onset: acute vs gradual Duration: hours to weeks vs months+ Course: Sudden vs gradual Altered consciousness: Yes vs No Hallucinations: Yes vs only if severe Altered sleep/wake cycle: Yes vs No
Differential diagnosis for dementia/delirium
Fall Hx: Subdural haematoma
Incontinence: Normal pressure hydrocephalus
Sexual Hx: HIV and/or syphillis
Vascular Hx: Vascular dementia
Family Hx: Huntington’s
Rapidly fluctuating symptoms: Lewy-body dementia
Assessing cognition
AMTS: 10Qs, could be asked to do in the exam
1) Age
2) Current time
- [Give an address, e.g. 42 West Street]
3) Current location
4) Current year
5) Recognise 2 people
6) DOB
7) Dates of e.g. WW2
8) Current Prime Minister
9) Count from 20 to 1
10) Recall address
MMSE: Score out of 30, template given in exam
Addenbrooke’s cognitive assessment: Score out of 100, picks things up sooner but takes around 15 mins
Frontal lobe testing
- Verbal fluency: name as many words beginning with A in 60s (>10 is OK)
- Cognitive estimates: Educated guessing. e.g. “how many camels are there in Holland?” or “how tall is the average woman”
- Abstract reasoning: explain a proverb, e.g. “let the cat out of the bag”
Depression screening (DQ2, DQ9, Hamilton score): all useful as depression is a common cause of apparent cognitive impairment.
Dementia: definition & types
Definition: Disorder of 5 As
- Anterograde amnesia
- Agnosia
- Apraxia
- Aphasia
- Executive function (abstract reasoning)
Types:
Alzheimer’s
- Most common
- Insidious onset memory loss, distant memories relatively well preserved
- Apathy, occasional depression and paranoid features
- Risk factors: Age, low IQ, FHx, Down’s, previous mental health issues (>1 major depressive episode), previous head trauma
Vascular dementia
- Insidious onset (ischaemic) or step-wise progression (multi-infarct)
- Known vascular Hx or disease
- See changes on CT or MRI unlike Alzheimers
Pick’s disease
- Disinhibition and severe mood lability
Lewy-body dementia
- Motor symptoms of Parkinson’s
- Visual hallucinations and fluctuating consciousness
- Dx is important, severe sensitivity to antipsychotics
Dementia: Investigations and managememt
Dementia screen:
- Blood (U&E, LFT, TFT, FBC, B12, Folate, CRP, Calcium)
- Full neuro exam and more detailed cognitive assessment (MMSE or Addenbrooke)
- Urinalysis (UTI, drugs)
- Syphillis serology, antibody screen, CT scan, serum cholesterol
Management:
- MDT approach, involve family and carers
- Refer to memory clinic
- Alzheimers: If MMSE 10-20: Give donezipil (cholinesterase inhibitor), 6/12 follow up: 1/3 benefit, 1/3 somewhat improve, 1/3 bad side effects
Delirium: Definition and symptoms
Definition: Acute clouding of consciousness –> acute confusional state
Symptoms:
- Clouding of consciousness and reduced awareness of surroundings
- Impaired cognition
- Disorientation to time, place, person
- Hallucinations
- Varied rate of speech
- Psychomotor: rapid, random shifts between hypo and hyperactivity
- Sleep wake cycle disturbance
Delirium: Causes and Management
Causes: DIMTOP Drugs (Alcohol/analgesia, Beta-blockers, Corticosteroids, Digoxin) Infection (UTI, pneumonia, meningitis) Metabolic Trauma (head) Oxygen (lack of) Poisoning
Management
- Treat underlying cause
- Reduce environmental stimulation, help reorientate with a room with lots of clocks, calendars etc
- Antipsychotics/Benzodiazepines are a last resort, used only if at immediate risk to self or others
Substance use definitions
Acute intoxication
- reversible physical and mental abnormalities caused directly by use of a given substance
At risk use
- Substance use at levels which, if continues, are likely to cause physical and/or mental harm
Harmful use
- Continued substance use despite evidence of harm caused (often downplayed by user), including physical, mental, social, familial.
Dependence
- Includes physical (biological adaptations to taking the drug) and mental (altered behaviours to support taking the drug)
Withdrawal
- If dependent, patient suffers symptoms due to absence of the drug. Symptoms usually opposite those of acute intoxication (e.g. agitation and insomnia from BDZ withdrawal)
Alcohol abuse: screening/diagnosis
CAGE screening questionairre:
- C: Ever felt you should Cut down?
- A: Anyone ever Annoyed you by criticising your drinking?
- G: Ever felt Guilty about your drinking
- E: Ever had an Eye opener?
- Score of 2 or more raises concerns
AUDIT is a more detailed questionairre for alcohol abuse
Longitudinal approach: When was your first drink? When did you realise it was a problem? Previous efforts to cut down?
Cross sectional approach: Current effects of drinking (physical, mental, social (jobs/relationships, police))?
CIWA-Ar is a tool to formally assess alcohol withdrawal. Around 50% of alcoholics get clinical symptoms of withdrawal.
Alcohol abuse: management and complications
Management of alcoholic patients in hospital
- 3/7 IV Pabrinex (multivitamin, including B1 (thiamine)) and reducing BDZ regimen (chlordiazepoxide)
Detox managed in community by specialists, unless:
- Previous failed attempts to detox
- Vulnerable or poor social circumstances (e.g. alcoholic partner)
- Vulnerable people at home (e.g. kids)
- Previous seizures from withdrawal
Complications
- Wernicke’s encephalopathy: due to lack of B1. Causes Ataxia, Nystagmus, Ophthalmoplegia, acute confusional state
- Korsakff’s psychosis: develops from long standing Korsakoff’s. Causes anterograde amnesia and confabulation
Schizophrenia: Symptoms/ICD-10 diagnosis
At least one of these (Schneider’s first rank symptoms)
- Thought insertion/broadcasting/withdrawal/echo
- Bizarre delusions
- Auditory hallucinations (usually 3rd person, running commentary, coming from within the body)
- Delusions of control, passivity or delusional perceptions
OR at least 2 of these
- Other hallucinations (often associated with fleeting delusions or persistently overvalued ideas)
- Negative symptoms (apathy, poverty of speech/thought, Inappropriate/blunted affect)
- Thought disorganisation (loosening of association, flight of ideas)
- Change in personal behaviour (loss of interest, aimlessness, social exclusion)
- Catatonic symptoms
Must have been present for at least 4 weeks
Schizophrenia: definitions and types
Perceptual disturbances:
- Hallucination (perception without stimulus) vs illusion (incorrect perception of real stimulus)
- Hallucinations: Visual (often organic), Auditory (1st, 2nd, 3rd person), Gustatory, tactile, somatic
Thought disorder
- Delusion: unshakeable belief despite clear proof to the contrary. E.g. nihilistic, control, grandiose, persecution
- Overvalued idea: plausible, fairly sound explanation but patient is obsessed with it
Types of schizophrenia
- Paranoid: mostly positive symptoms (hallucinations, delusions), better prognosis
- Hebephrenic: disorganised thoughts. Inappropriate/flat mood/affect. Inappropriate behaviour. Early onset, poor prognosis
- Catatonic:. Waxy flexibility, stiffness. stupor, tics, mannerisms. rare
- Residual. at least a year of mostly negative symptoms preceded by at least one clear cut psychotic episode
Schizophrenia: DDx and investigations
DDx:
Organic: Intoxication, Withdrawal, Side Effects (anti-parkinsonian), Brain (infarction/neoplasm), dementia, delirium, epilepsy
Psychotic: Acute psychotic episode, Schizoaffective disorder, delusional disorder
Mood: Bipolar with psychosis, Depression with psychosis
Personality disorder: Schizoid, paranoid, borderline, schizotypal
Investigations
- Full collateral Hx (work, relationships, finances) and examination
- FBC (important for clozapine (agranulocytosis))
- U&E, LFT (renal and liver function help choose drug)
- TFT, ESR, syphillis serology (rule out organic causes)
- CT/MRI: Rule out brain infarct or neoplasia
- ECG: Antipsychotics can cause prolonged QT
- EEG/CT - rule out epilepsy/brain tumour
Schizophrenia: management
Setting:
- Hospital acutely to stabilise the patient (esp if psychotic and risk to others or self)
- Community once stable (OPD, care coordinator) to manage and prevent relapse
Bio:
- BDZ to calm an acutely agitated or aggressive patient, esp if immediate risk to self or others
- ECT to treat acute, severe catatonic symptoms
- Antipsychotics (can give 2-4 weekly depot injections if compliance is likely to be an issue)
- typical (haloperidone) cause extra-pyramidal side effects (tardive dyskinesia, neuroleptic malignant syndrome (fever, acute confusional state, rigidity, autonomic dysfunction))
- atypical (olanzipine, respiridone) cause weight gain, hyperlipidaemia, diabetes
- Clozapine is used after 2 drugs (at least one atypical) has failed, for treatment resistant schizophrenia. Can cause agranulocytosis.
Psycho:
- CBT: challenge delusions, help come to terms with illness
- Family therapy: Prevent relapse
Social:
- Appoint care coordinator in community: Check mental status regularly and provide rapid access to treatment when needed
- Rehabilitation: Social skills, daytime activities, help with benefits, employment. Aim to reintegrate with comunity.
Depression: assessment and symptoms
Assessment:
PHQ2:
- Have you felt hopeless or depressed in the last month?
- Have you experienced little joy in doing things in the past month?
- If yes to either, ask if they would like help. If so:
- GP: PHQ9 (Patient Health Questionnaire for depression)
- Hospital: HADS (Hospital Anxiety and Depression Scale)
Core symptoms
- Low mood, Anergia, Anhedonia
Associated symptoms
- Poor sleep
- Poor concentration and indecisiveness
- Poor or increased appetite
- Poor self confidence
- Poor libido
- Guilt
- Psychotic symptoms
- Agitation or Slowed movements
- Suicidal thoughts or acts
Diagnosis:
- Subthreshold: 1 or 0 core symptom or <2 weeks
- Mild: 2 core and 2 associated symptoms, >2weeks
- Moderate: 2 core and associated symptoms, >2weeks
- Severe: 3 core and 4 associated OR psychosis, >2weeks
Depression: Management
Location:
- Acute: risk assess and decide whether to admit
- Long term: manage in community
Bio
Antidepressants
- NOT recommended for acute mild depression
- recommended for dysthymia, persistent mild depression, moderate-severe depression or any depression with a Hx of severe depression
- SSRIs (Fluoxetine, sertraline): currently first line, relatively safe in OD. Inhibit 5-HT reuptake, little effect on NA or DA. SE: nausea, vomiting, diarrhoea, headaches. Tolerance usually builds up in 7-10 days. Can cause GI bleeds (esp in elderly) and increased risk of suicide.
- TCAs (Amytryptiline, Nortryptiline): Inhibit reuptake of 5-HT and Na and DA. SE: sedation, anticholinergic (dry mouth, blurred vision, urinary retention, constipation), cardiotoxic (long QT, ST elevation), discontinuation syndrome (nausea, ataxia, more dreams). Can cause switch to mania in bipolar patients.
ECT: Used in severe depression, often as a last resort, e.g. concerns about not eating
Psycho: CBT: for mild: support, education, problem solving. Monitor for severe depression
Social: Self help books/websites (mild), support groups
Mania: Symptoms
Elevated or irritable mood + at least 3 of the following for at least a week
- Increased energy (reduced need for sleep, racing thoughts, flight of ideas, overactivity)
- Increased ambition
- Increased sex drive (with whom?)
- Increased spending (how do they afford it)
- Delusions of grandeur
- Increased use of drugs or alcohol
- Reduced attention span
Also ask
- Past psych Hx (e.g. depression), compliance to psych meds
- Forensic Hx
Bipolar: Types and management
Bio (Acute)
- Antipsychotic if acutely manic or behavioural disturbances due to mania
- Lithium or valproate if patient has responded to these before and is compliant
- Lithium only if less severe, as it has a slower onset of action
- BDZ if agitated++
Bio (long term)
- Lithium or valproate. Don’t use valproate in women of childbearing age. Consider patient wishes
Psycho: CBT to challenge delusions, come to terms with illness/ Family therapy to avoid relapse
Social: Appoint care coordinator to monitor and provide rapid clinic access if needed
