psych Flashcards
what questionnaire can be used to screen for depression?
PHQ-9
HAD
Beck’s
what is sub-threshold depression ?
fewer than 5 symptoms
what are the key symptoms of depression?
low mood
anhedonia
fatigue/lack of energy
what are some of the symptoms of depression
low mood anhedonia fatigue weight change decreased concentration decreased libido agitation disturbed sleep retardation thoughts of death and suicide
what are some psychotic symptoms of sever depression?
delusions of poverty guilt personal inadequacy responsibility for worlds events hallucinations - usually auditory olfactory hallucinations - bad smells visual hallucinations - tormentors catatonic behaviour
what factors increase risk of depression?
fam history
chronic illness
adverse life events
what are the different types presentations of depression?
without somatic symptoms with somatic symptoms with psychotic symptoms atypical seasonal affective
what is the initial management for sub-threshold depression?
educate on sleep hygiene
active monitoring
low intensity psychosocial interventions (CCBT, provision of written materials, physical activity programmes
when should you consider drug treatment for persistent sub-threshold or mild/moderate depression?
if the have a past history of moderate or severe depression
if the symptoms of threshold depression have lasted for more than 2 years
if the symptoms of sub-threshold or mild have persisted after other interventions
what is the third step of depression management?
for persistent sub-threshold symptoms or mild/moderate depression with inadequate response to initial interventions and moderate and severe depression.
The options are an antidepressant or a high intensity psychological intervention (CBT, IPT, couple therapy)
Combination of CBT and medication
what is step 4 of depression management?
for severe and complex depression - risk to life, refer to specialist mental health team
impatient care and crisis resolution and home treatment crisis team
what is the first line drug for depression?
SSRI’s (fluoxetine, sertraline, paroxetine, citalopram)
what are the second line drug treatments for depression?
TCA’s (amitriptyline, clomipramine)
MAOIs (phenelzine, tranylcyromine)
SNRIs (venlafaxine, duloxetine)
SARIs - trazodone
What is bipolar?
chronic mental health disorder characterised by periods of mania/hypomania alongside periods of depression
what is the ICD-10 diagnostic criteria for bipolar?
at least 2 episodes, one must be hypomanic, manic or mixed
what is the DSM-V criteria for bipolar?
occurrence of at least one manic episode. thus by definition any previously well person experiencing their first episode of mania would be classified as bipolar
Type 1 - mania and depression
Type 2 - hypomania and depression
what are the symptoms of a manic episode?
distinct period of abnormally/persistently elevated moof for at least one week plus at least 3 characteristic symptoms:
- energy - over reactivity, pressure of speech, flight of ideas, racing thoughts, decreased sleep.
- self esteem - over optimistic ideation, grandiosity, decreased social inhibition
- distractibility
- inappropriate behaviour - without considering consequences, reckless with money, inappropriate sexual encounters
- disruption of work, family and social life
- psychotic symptoms - grandiose ideas +/- delusions related to identity or role, persecutory delusions, incomprehensible speech, violent behaviour, catatonic behaviour (manic stupor), lack of insight.
what are the symptoms of a hypomanic episode?
elevated mood plus at least 3 other symptoms lasting for more than 4 days:
- increased energy, decreased need for sleep, increased sociable and talkative, increased feelings of self esteem, increased sex drive and easily distracted.
Does not interfere with social or occupational function. They have no delusions or hallucinations
What is the acute management for bipolar
admit if severe - may be due to impaired judgment, high risk of suicide/homicide, severe psychotic, depressive, rapid cycling or catatonic symptoms.
Stop drugs that may be causing mania
give antipsychotic meds for mania and if the are in low mood give anti-depression
what is the first, second and third line treatment for someone having an acute manic episode?
1st line - antipsychotic - haloperidol, olanzapine quetiapine or risperidone
2nd line - increase dose of AP, or use a mood stabiliser (lithium)
3rd line - valproate
what is the first and second line drug treatments for bipolar depression?
1st line - fluoxetine combined with olanzapine or quetiapine.
2nd line - if unresponsive to first line consider lamotrigine
what is the intermediate management of bipolar?
monitor psych status, drug side effects, compliance and therapeutic levels of mood stabilisers
make sure to identify and address significant episodes early.
what is the long term management of bipolar?
1str line - lithium
2nd line - carbamazepine
what are the causes/risks of schizophrenia?
genetic - lifetime risk is increased 10% for first degree relatives - associated with DISC1 gene
substance misuse hostile family adverse life events social disadvantage Caribbean have highest rates
what are the Schneider’s first rank Symtoms
TAPP thought disorder (thought insertion, withdrawal or broadcasting, may interfere with speech
Auditory hallucinations - thought echo, running commentary.
passive phenomenon - belief that the body is controlled by an external agency
delusional perceptions - where a real perception is followed by a delusional misinterpretation
what is the ICD-10 diagnostic criteria for schizophrenia?
at least one month of either:
at least one of - delusions of control, auditory hallucinations, bizarre persistent delusions
or
at least two of the following
persistent hallucinations
interpolation breaks in train of thought, catatonic behaviour, negative symptoms (apathy, paucity of speech, anhedonia, loss of motivation etc..), significant change in overall behaviour
what are the subtypes of schizophrenia?
paranoid - delusions and hallucinations
hebephrenic - disorganised speech behaviour, flat or inappropriate affect.
Catatonic - psychomotor disturbances
undifferentiated - no specific symptoms
post schizophrenic depression - some residual symptoms, depressive picture dominates
residual schizophrenia - less marked previous positive symptoms, prominent negative symptoms.
simple schizophrenia - no delusions or hallucinations
when treating acute schizophrenia what factors should you take into consideration?
the risk to self, risk to others and the risk of victimisation
the degree of insight
their social circumstances and support resources.
what is the first line pharmacological treatment for schizophrenia?
a second generation antipsychotic - risperidone or olanzapine
what would you prescribe when there is a patient with schizophrenia who failed to more than two antipsychotics given for at least 6 weeks?
clozapine
what is the schizoaffective disorder?
symptoms of a mood disorder and schizophrenic symptoms within the same episode of illness can be manic or depressive symptoms
the management is the same as for schizophrenia and as for bipolar or depression.
what is schizotypal disorder?
a type of personality disorder
they have a lifelong state of eccentricity with abnormal thoughts and affect.
they often appear suspicious, cold, aloof.
there are no definite schizophrenic symptoms
the main treatment is risperidone
what are cluster a personality disorders?
paranoid
schizoid
schizotypal
what are cluster b personality disorders?
(antisocial personality disorder) histrionic emotionally unstable antisocial narcissistic
what are cluster c personality disorders?
avoidant/anxious
dependant
anankastic
what are the symptoms of paranoid personality disorder?
Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent
what are the symptoms of schizoid personality disorder?
Indifference to praise and criticism Preference for solitary activities Lack of interest in sexual interactions Lack of desire for companionship Emotional coldness Few interests Few friends or confidants other than family
what are the symptoms of an anxious/avoidant personality disorder?
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks doe to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
what are the symptoms of dependant personality disorder?
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
what are the symptoms of anakastic personality disorder?
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
what are the symptoms of histionic personality disorder?
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
what are the types of emotionally unstable personality disorder?
borderline or impulsive
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
what are the symptoms of antisocial personality disorder?
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
what are the symptoms of narcissistic personality disorder?
Grandiose sense of self importance Preoccupation with fantasies of unlimited success, power, or beauty Sense of entitlement Taking advantage of others to achieve own needs Lack of empathy Excessive need for admiration Chronic envy Arrogant and haughty attitude
what is delirium?
delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking and altered levels of consciousness
what are the causes of delirium?
drugs primary neurological injury (stroke, intracranial bleeding, meningitis) acute illness(pneumonia, UTI, sepsis), cardiac illness (MI), hypoxia, shock, dehydration, fever, constipation, iatrogenic complications metabolic abnormalities pain prolonged sleep deprivation drug withdrawal recent surgery
what are the four key features of delirium?
a disturbance in attention - reduced ability to focus, sustain or shift attention
a change in cognition - memory deficit, disorientation, language disturbance
the disturbance develops over a short period of time, also tends to fluctuate
there is evidence from the history, physical examination or laboratory findings that the disturbance is caused by
what are the three types of delirium?
hyperactive delirium - a condition where a patient might have heightened arousal, with restlessness, agitation, hallucinations and inappropriate behaviour
hypoactive delirium - a condition where a patient might display lethargy, reduced motor activity, incoherent speech and a lack of interest
mixed delirium - a combination of hyperactive and hypoactive signs and symptoms
how do you manage delirium?
treat underlying cause
modification of the environment
0.5mg haloperidol as a first line sedative
or olanzapine
what can cause a delusional disorder?
neurological lesions: temporal lobe, limbic system, basal ganglia
- cortical - simple, poorly formed and persecutory
- basal ganglia - less cognitive disturbances, more complex content
social - certain situation, decreased self esteem
what are the risk factors for delusional disorder?
age sensory impairment family history heady injury substance abuse social isolation low SES recent immigration
what is a delusional disorder/
the core feature is the development of a delusion or delusional system - often no identifiable organic basis
.
The patient does not suffer from schizophrenia or a mood disorder although depressive symptoms may be present
how do delusional disorders present?
acute or insidious but variable course
speech and mood affected by tone of delusional content
their thoughts are generally unimpaired
hallucinations - usually olfactory/tactile although hallucinations are not prominent
often insight is impaired to the degree that delusions influence thought and behaviour
delusions can be persecutory, hypochondrial or grandiose - - they are often concerned with litigation or jealousy
what are the different types of delusional disorder?
Erotomania - they believe that someone, usually of higher status, is in love with them
Cotard’s syndrome - when the patient believes all of their wealth has gone or that all relatives or friends no longer exist. They may believe that some of their own body parts do not exist.
Capgras syndrome - the patient believes that a person familiar to then has been replaced by a double
Fregoli syndrome - patient believes that a familiar person (often their persecutor) has taken on a different appearance
pathological (delusional ) jealousy - believes partner is being unfaithful, also called the othello syndrome. sometimes associated with organic disorder and psychoactive substance use disorder, cerebral tumours and paranoid schizophrenia
Persecutory delusions (querulant) - most common, the patients believe that they are being persecuted in various ways
delusional perception - true perception to which patient attaches a false meaning
Nihilistic - believing themselves to be dead of the world to no longer exist - psychotic depression
self referential
how are delusional disorder managed?
antipsychotics - pimozide
SSRIs benzos - if there is marked anxiety
CBT
minimise risk factors
what are the classical three drugs which cause dependance and withdrawal?
alcohol
benzodiazepine
opiates
what are the features of dependance syndrome?
Salience - obtaining and using substance takes priority over all other activities and interests
Narrowing of repertoire - loss in variation of substances, setting, route and individuals with whom substances is taken with may become stereotypes
increased tolerance - larger dose required to achieve the same effects, less clinical signs of intox ification
Loss of control of consumption
Continued use despite harm
withdrawal
reinstatement after abstinence
what are the initial symptoms and and continued consumption effects of alcohol intoxication? (acute)
initially - elevation of mood, increased socialization and disinhibition
continuing consumption - lability of mood, impaired judgement, aggressive, slurred speech, unsteady gait and ataxia
what is the recommendations for units of alcohol per week?
14
what is the screening questionnaire for alcohol addiction?
CAGE
C - have you ever felt you should cut back your drinking
A - has anyone ever annoyed you by criticizing your drinking
G - have you ever felt guilty about your drinking
E - have you ever had a drink early in the morning as an eye opener
add questions
what is the most alcohol you have drank in a single day?
what is the most alcohol you have drank in a single week?
