Psych Flashcards
Components of a psych history
Introduciton and PC: name, age, occupation, ethnic origin, circumstances of referral and whether voluntary or compulsory
HPC: NOTEPAD ICE. Impact on life/work. Mood, sleep, appetite, Risk. +Collateral
PPHx: dates, hospitalisations
PMH/SHx
DHx and allergies
FHx: mental health. If deceased close relative: cause of death and time in patients life.
Personal Hx: Early life and development (pregnancy and birth, any serious illness, bereavements, abusde, separation, developmental delay. Regligious background)
Educational Hx: school, relationship with peers. Bullying
Occupational Hx: job titles and durations and reasons for change of work.
Relationship hx: marriages etc.
Drug Hx and ETOH use + Smoking
Forensic Hx: any arrests/ imprisonments
SHx
Premorbid personality: how would you describe yourself before you became unwell?
Components of MSE
ASEPTIC
Appearance and behaviour
Speech
Emotion: mood and affect
Perception: hallucination and illusion
Thought content and process
Insight and judgement
Cognition
Factors of note in apperance
General appearnce and personal hygiene. Dress
Manner, rapport, eye contact, facial activity
Motor activity (psychomotor agitation or retardation)
Abnormal movements
Abnormal movements
Tremor
Braykinesia: slowness of movement
Akathisia
Tardive dyskinesia
Dystonia
Tics
Chorea
Stereotpyp
Mannerisms
Gait abnormalities
Bradykinesia
Slowness of movements
Akathisia
Restlessness
Tardive dyskinesia
Usually affects the mouth, lips and tongue. Roling of the tongue or licking the lips
Dystonia
Muscular spasm causing abnormal face and body movement or posture
Factors of note in speech
Tone, rate and volume
Pressure of speech: increased rate and volume
Normal speech
Spontaneous, logical, relevant and coherent
Circumstatnial
Speech that takes a long time to get to the point
Perseveration
Sign of?
Repeating words or topics
Frontal lobe impairment
Neologisms
Seen in
Invention of words
Schizophrenia
Variations in thought form
Normal
Flight of ideas: abnormal connection between statements
Looseness of association: no discernible link between statements
Thought block
Mood and affect
Mood= climate
Affect= weather
Mood
Subjective/objective
Underlying emotion
Objective described as dysthymic, euthymic, hyperthymic
Different types of affect
Blunted/unreactive (e.g. negative symptoms in Schizophrenia)
Labile
Irritable (mania and depression)
Perplexed
Suspicious
Incongruous
Normal affect described as
Reactive
Disorders of thought content
Negative (depressed) cognitions e.g. guilt, hopelessness
Ruminations (persistent, disabling preoccupations)
Obsessions
Depersonalisation or derealisation (NB not psychotic)
Abnormal beliefes: overvalued ideas, ideas of reference (not held with delusional intensity)
Delusions: fixed, false, firmly held beliefs
Depersonalisation
Feeling detatched, unreal watching oneself from the outside
Derealisation
“The world is made out of cardboard”
Different delusional types
Persecutory: someone/something interfering with person in a malicious/destructive way
Grandiose: being famous/supernatural power or wealth
Of reference: actions of other people, events, media are referring to the person/communciating a message
TI/TW/TB
Passivity: actions feelings/impulses can be controlled by outside influence
TI/TW/TB
Thought insertion
Withdrawal
Broadcast
Assessing suicide risk
Thoughts
Do you evel feel that life is so bad you don’t want to live anymore?
Plans
Have you ever reached a point where you have thought you might harm yousrelf
Intent
Do you think you would actually do this?
Protective factors
Components of perception
Have you seen or head thing sthat other people can’t see or hear
Illusions
Hallucinations
Pseudo-hallucinations
Illusions
Misinterpretations of normal perceptions: can occur in healthy people
Hallucinations
Perceptions in absence of abnromal stimulus, experienced as true and coming from the outside world
Can take any medium, though auditory and visual are most common
Pseudo-hallucination
Internal perceptions with preserved insight
Cognition
GOAL-CRAMP
Can be tested formally using MMSE
Should test:
G- general: Alertness and Co-operation
O- orientation: Time and Place
A- attention: WORLD backwards and Serial Sevens
L- language: Naming and Repetition
C- calculation: Division and Subtraction
R- right Hemisphere Function: Intersecting pentagons and Clock-face
A- abstraction: Proverbs and Similarities
M- memory: Short term and Long-term memory
P- praxis: Wave good-bye and Comb hair
Insight
Patient’s understanding of their own condition and its cause
Difference between a discriminating and characteristic symtpoms
Discriminating: occur commonly in a defined syndrome but rarely in other syndromes
Characteristic: occur frequently in the defined syndrom eubt also occur in other syndormes
Risk assessment
Self-harm
Harm to others (including children!!)
Risk of self-neglect and accidental harm
Vulnerability to abuse
Risk of Self harm
Risk of self harm: current thoughts and plans
Protective factors
Previous episdoes
Factors predisposing to deliberate self-harm/suicide:
- Fhx
- Social isolation
- Substance Misuse
Any Hx of previous disengagemnt from support services
In MSE: thoughts of hopelessness and worthlessness. Command hallucinations inciting self harm
Risk of harm to others
Acts/threats of violence
Deliberate arson
Sexually inappropritae behaviour
Epsiodes of containemnt
Extent of compliance
Increased risk if:
- Recent discontinuation of Rx
- Change in use of recreational drugs
- Alcohol or drug misuse (or other disinhibiting factors)
- Impulsive/unpredictable behaviour
- Recent stressful life events
In MSE look for:
- Expressed violent intentions or threats
- Irritability, disinhibition, suspiciousness
- Persecutory delusions
- Delusions of control/passivity
- Command hallucinations
Risk to children
Risk to vulnerable adults: HOW SAFE
HOme safety
Wandering
Self-neglect
Abuse, neglect, crime vulnerability
Eating (malnutirition)
Suicide
DIEA
Intentional self- inflicted eath
1/10,000 p annum
M>F (older men)
RFs:
- Availability of means
- Social support
- Life events
- Mental illness:
- Depression
- Schizophrenia
- Substance misuse
- Emotionally unstable or antisocial personality disorder
- Eating disorder
Chronic painful illnesses
FHx
Deliberate self harm
DIEA
Intentional non-fatal self-inflicted harm
2-3/1000 pa
F>M (younger women
RFs:
- Availability of means
- Social support
- Life events
- Mental illness:
- Depression
- Schizophrenia
- Substance misuse
- Emotionally unstable or antisocial personality disorder
- Eating disorder
Unemployed, divorce
Socio-economic deprivation
Psychiatric disorders implicated in suicide
Depression
Bipolar
Schizophrenia
Alcoholism
Substance misuse
Prsonlaity disorder (persent in 30-60% of completed suicides especially emotionally unstable/borderline
Anorexia nervosa
Psychosis
Misinterpretation of thoughts and perceptions that arise from the patient’s own mind/imagination as reality and include delusions and hallucinations
Psychotic disorders include
Schizophrenia
Schizoaffective disorder
Delusional disorder
Brief psychotic episodes
BPAD
Drug-induced
Psychotic depression
Epidemiology of schizohprenia
15-20/100000
0.7% lifetime risk
Men>Women
Peak incidence in late teens or early adulthood
First Rank Symptoms
- Third-person auditory hallucinations (discussion/giving running commentary)
- Thought echo (hear own thoughts out loud)
- Delusional perception (a bunch of flowers->therefore I knew terrorists were after me)
- TI/TB/TW
- Passivity
Rank symptoms
First rank are discriminatory: also occur in 8% of patients with BPAD, whil 20% with chronic schizophrenia never show them
Second rank sympomts: characteristics, include catatonic behaviour and 2nd person auditory hallucinations
Schizophrenia: diagnostic criteria
First Rank symptom or persistent delusion
Present for at least a month (ICD10) (6 monhts in DSM)
No drug intoxication, withdrawal, organic disease or prominent affective symptoms
Common delusions in schizophrenia
Persecutory
Delusions of reference
Thought disorder often seen in schizophrenia
Loosening of associations
Neologisms
Concrete thinking (inability to deal with abstract ideas)
Word salad
Symytom triad in schizophrenia
Positive (hallucinations/delusions)
Negative (poverty of speech, flat affect, poor motivation, social withdrawal)
Cognitive (poor attention and memory)
Subtypes of schizophrenia
Paranoid
Cataotnic
Hebephrenic (disorganised)
Residual
Undifferentiated (simple)
Paranoid schizophrenia
Most common, delusions and auditory hallucinations
Catatonic schizophrenia (7%)
Typical symptoms:
Psychomotor disturbances (alternating between morot immobility and excessive activity)
Rigidity
Abnormal posturing
Echolalia (copying speech)
Echopraxia (copying behaviours)
Hebephrenic schizophrenia
(Disorganised)
Early onset and poor prongosis. Behaviour is irresponible and unpredictable
Mood inappropriate and incongruous affect.
Thought incoherence, fleeting delusions and hallucinations occur
Resdiual schizophrenia
Falls into one of the other types but negative symptoms predominate
Undifferentiated schizophrenia
Negative symptoms without preceding over psychotic symptoms
What are the characteristics of the prodromal period for acute psychotic illness
Anxiety, depression and ideas of reference
Aetiology of schizophrenia
Genetics: FHx/sibling hx specifically
Neurodevelopmental hypothesis:
- (increased rates associated with winter births, obstetric complications, developmental delay, soft neurological signs, temporal lobe epilpepsy, smoking cannabis in adolescence.)
- Social factors: socioeconomic deprivation, urban area, excess of life events.
- High er in Afrocarribean
Neurochemical:
- Dopamine excess in mesolimbic pathways
- Increased serotonin activity
- Decreased glutamate activity.
Schizoaffective disorder
Affective and schizophrenic symptoms occur together and with equal prominence
Delusional disorder
Fixed delusion or delusional system with other areas of thinking and funcitoning well preserved
Brief psychotic episodes
Last less time than required for schizophrenia diagnosis.
- Mental state
a Derealisation
b Compulsion
c Delusion
d Illusion
e Hallucination
f Obsession
g Overvalued idea
h Pseudohallucination
i Rumination
What psychiatric sign is being described in these examples? Choose
one option.
1 A man tries unsuccessfully to keep violent, sexual images from
entering his head.
2 A 52-year-old man spends over an hour checking the gas is
turned out on the stove before leaving the house.
3 A woman describes hearing a voice that frightens her inside her
head.
4 A woman complains that she feels as if the world is lifeless, as
if made out of cardboard.
5 A man gazing at the sky starts to see the face of a goblin in the
clouds.
6 A man is becoming increasingly worried that his neighbours are
monitoring him. He sees them out so often it feels like ‘more
than just a coincidence’. He acknowledges he might be wrong
about this, although thinks it unlikely.
7 An anxious man continually reviews the events leading to him
losing his job.
1 f (obsessional images)
2 b
3 h
4 a
5 d
6 g
7 i
- Delusions
a Delusional perception
b Thought withdrawal
c Delusion of reference
d Grandiose delusion
e Nihilistic delusion
f Folie à deux
g Persecutory delusion
h Somatic passivity
Which delusion is being described in these examples? Choose one
option.
1 A man believes the government removes his thoughts.
2 A woman believes she can feel her blood temperature rising and
that it must be being controlled using lasers by an outside force.
3 An 84-year-old lady and her learning disabled son are refusing
to pay their rent because they believe the council are winding
the meter on remotely to extract more money from them.
4 A 34-year-old lady is detained by police for causing a public
nuisance. She believes she has been invested with special healing
powers, and that God has told her she is the next Messiah.
5 A man with depression erroneously believes he has lost all his
possessions and his house has been destroyed.
6 A man fled the country after seeing a red car parked outside his
house. He was convinced this was a sign left for him by the FBI
that they wanted him dead.
2 Delusions
1 b
2 h
3 f
4 d
5 e
6 a
- A full assessment of a patient newly admitted to a psychiatric
unit can be complete without:
A A full history and mental state examination
B A risk assessment
C A physical examination
D Psychometric testing
D
- According to the diagnostic hierarchy, where patients potentially
meet criteria for two disorders, precedence should be
given to a diagnosis of:
A Borderline personality disorder rather than depression
B Generalised anxiety disorder rather than hyperthyroidism
C Acute psychotic episode rather than dementia
D Schizophrenia rather than mood disorder
- D; Psychotic disorders take precedence over mood disorders.
- Doctors should always break confidentiality if:
A A victim of domestic abuse refuses help
B A victim of elder abuse refuses help
C A patient threatens to kill his cousin
D A patient admits to regular shoplifting
- C; There is always a duty when you are made aware of a specific
risk to a named indvidual. For A and B, whether to do so would
depend on whether the victim had capacity to make decision to
refuse help. For D, there is a duty to disclose information that
may help prevent or detect serious crime, but not all crime.
- Safe management of a person seen in A+E after an overdose
must include:
A At least a brief period of psychiatric admission for
assessment
B A medical assessment
C An assessment by the Crisis Resolution Team (CRT)
D A collateral history
- B; All may be useful, but only B is essential in all cases. Patients
may underestimate or not disclose the full extent of their
overdose.
- The most common subtype of schizophrenia is:
A Paranoid schizophrenia
B Hebephrenic schizophrenia
C Catatonic schizophrenia
D Simple schizophrenia
- A.
- Psychosis is best described as:
A An illness characterised by symptoms such as depersonalisation
and illusions
B A mild form of schizophrenia
C Loss of the ability to distinguish reality from fantasy
D A split personality
- C; Note it is hallucinations, not illusions, that are characteristic
of psychosis.
What is the first line treatment for the majority of patietns with depression?
Examples
What is used post-MI
What is used in children and adolescents?
SSRIs
Citalopram and fluoxetine
Sertraline as there is more evidence for safe use in this situation
Fluoxetine
What are the common adverse effects of SSRI?
What is an important consideration in a patient taking NSAIDs
For what should patients be vigilant?
Which SSRIs have a higher propensity for ADIs
GI symptoms
Increased risk of GI bleed therefore a PPI should be co-prescribed
Patients should be counselled to be vigilant for increased anxiety and agitation
Fluoxetine and paroxetine
What is a significant safety issue with Citalopram
What is the consideration that should be made?
What is the maximum daily dose?
Citalopram and escitalopram are associated with dose-dependant QTI prolongation
Should not be used in patients with congenital long QT, known pre-exisiting QT interval prolongation or in combination that prolong the QT intrval
40mg for adults
20mg for >65y/o or those with hepatic impairment
What are the drug interactions of SSRIs
NSAIDs (not normally recommended, if necessary add PPI)
Warfarin/heparin, avoid SSRI and consider mirtazapine
Aspirin (as above)
Triptans: avoid SSRIs
Mirtazapine drug class
Common SEs
Noradrenergic and specific serotonergic antidepresssant
Constipation, dry mouth, increased appetiete
Somnolence
Weight gain
ALT
raised TGs
Dizziness
When stopping an SSRI what is the timescale
What are the common discontinuation symptoms
Tapered over 4 weeks
Increased mood change
Restlenssness
Difficulty sleeping
Unsteadiness
Sweating
GI symptoms
Paraesthesia
What is the mechanism of St John’s Wort
P450 Inducer.
Effective as TCA in treatment of mild-moderate depression
Thought to be similar MOA to SSRIs.
Adverse effects of St John’s Wort
Can cause serotonin syndrome
P450 inducer, may also reduce effectiveness of OCP
Should St John’s Wort use be advised?
No as uncertainty about dose, variation in preparations and potential serious ADIs.
Factors associated with risk of sucidie following episode of DSH?
Effforts to avoid discovery
Planning
Note
Fina acts e.g. will
Violent method
What should happen following SSRI Rx?
R/v at 2 weeks (
If a patient makes a good response they should continue on treatment for at least 6 months as this reduces risk of relapse
What are the advantages of atypical antipsychotics
What are the important adverse effects
Reduciton in extra-pyramidal side effects
Weight gain
Clozapine is associated with agranulocytosis
What are the important considerations of atypical antispsychotics in the elderly
Increased risk of stroke (espedcially olanzapine and risperidone)
Increased risk of VTE
Which atypical antipsychotics are most significantly associated with increased risk of stroke in elderly patients?
Olanzapine and risperidone
Give 5 examples of atypical antipsychotics
Clozapine
Olanzapine
Risperidone
Quetiapine
Amusulpride
When is clozapine used?
What are its adverse effects
Should only be used in patients with psychosis that is resistant to other antipsychotics
Agranulocytosis and neutropenia
Reduced seizure threshold: can induce seizures in up to 3%
What are the common side effects of TCAs?
Drowsiness
Dry mouth
Blurred vision
Constipation
Urinary retnetion
Due to anti-muscarininc effects
What are the more sedative TCAs?
Less sedative?
Amitryptilline, clompiramine, dosulepine, trazodone
Imipramine, lofepramine, nortriptyline
What are the side effects most commonly associated with imipramine?
Blurred vision and dry outh?
When is low-dose imipramine commonly used?
Management of neuropathic pain and headache prohpylaxis
What are the most dangerous TCAs in OD?
Safest?
Amitryptilline and dosulepin
Loferpramine
What are the MMSE cut offs?
no cognitive impairment=24-30;
mild cognitive impairment=18-23;
severe cognitive impairment=0-17
What are the clinical features of anorexia?
Reduced BMI
Bradycardia
Hypotension
Enlarged salivary glands
What are the physiological abnormalities in AN?
Hypokalaemia
Low FSH, LH and sex hormones
Raised cortisol and GH
IGTT
Hypercholesterolaemia
Hypercartoniaemia
Low T3
Whata are the features of PTSD?
Flashbacks
Avodiance
Hyperarousal
Emotional numbing
Derpession, drug or ETOH misues, anger, unexplained physical symptoms
What is the management of PTSD?
Mild symptoms
CBT and EMDR used in more severe
Drug treatment is not first line
If drug treatment used: paroxetine or mirtazapine recommende
Section 2
28d not renewable
AMHP makes application on recommendation of 2 doctors
One of the 2 doctors must be Section 12 approved
Section 3
Admisison for treatment up to 6 months, renewable
AMHP and 2 doctors both of whom should have seen patient in last 24
Section 4
Emergency order in community
72hr assessment order
GP, AMHP or NR
Often changed to section 2 on hospital arrival
Section 5(2)
Voluntary patient can be detained by a doctor for 72 hours
Section 5(4)
As for 5 (2) but nurse for 6 hours
Section 17a
Comminuty treatment order
Section 135
Court order allowing police to break into a property to remove person to place of safety
Section 136
someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
Next question
Somatisation disorder
- multiple physical SYMPTOMS present for at least 2 years
- patient refuses to accept reassurance or negative test results
Hypochondrial disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Conversion disorder
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
Dissociative disorder
dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Munchausen’s syndrome
also known as factitious disorder
the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Features of neuroleptic malignant sydnrome
10% mortality
Occurs with atypical antipsychotics. May also occur with dopaminergic drugs, usually occurs when drug is suddenly stopped or dose reduction
More common in young males
Onset in first 10d of treatment
Pyrexia
Rigidity Tachycardia
Raised CK and leukocytosis
Management of NMS
Stop antipsychotic
IV fluids to prevent renal failure
Dantrolene in selected cases
Bromocriptine (dopamine agonist) may also be used
Extra-pyramidal side effects
Parkinsonism
acute dystonia (e.g. torticollis, oculogyric crisis)
akathisia (severe restlessness)
tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
Side effects of antipsychotics
Extra-pyramidal
Increased risk of stroke and VTE in elderly
Other side-effects
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin: galactorrhoea, impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
Clozapine: agranulocytosis/neutropenia + increased seizure activity
What is the importance of early intervention in schizophrenia?
° The longer the period between symptom onset and effective treatment (Duration of Untreated Psychosis), the worse the average outcome. ° The first few years after onset can be particularly distressing with a high risk of suicide. ° Therefore, in many developed countries, specialist Early Intervention in Psychosis teams support people in the first few years of their illness
What is important WRT to monitoring of antipsychotics?
AEs include weight gain, cardiac arrythmias and DM. Therefore regular monitoring of weight, lipid, glucose profiles + ECGs
When is there a risk of relapse WRT schizophrenia?
If antipsychoic mediacation is stopped
General approach to psychiatric illness
Meical
Psychological
Social
Prognosis for first psychotic episode
70% well within a year
80% relapse within 5 years
Adherence to antipsychotic medication
75% will discontinue within the first 18 months and those that do are 5x more likely to relapse over this period.
Good prognostic factors for schizophrenia
FINDING PLANS
Female
In relationship, good social support
No negative symptoms
aDheres to medication
Intellgience
No stress
Good premorbid personality
Paranoid subtype
Late onset
Acute onset
No substance misuse
Scan normal (CT/MRI)
When is the risk of suicide higher in Schizophrenia?
Young men
First few years of illness
Persistent hallucinations or delusions
History of illicit drugs
Previous suicide attempts
Lifetime risk in schizophrenics is 10%
What is a consideration re smoking and schizophrenia
Potenital impact on the metabolism, particulalry colazpine and olanzapine whena patient stop smoking
When is there a risk of developing psychosis?
Person is distressed and haqs had a decline in social functioning and:
- transient/attenuated psychotic symptoms or
- other experiences or behaviour suggestive of possible psychosis
- or first-degree relative with psychosis or schizophrenia
Refer to specialist assessment for early intervention
What are the treatment options to prevent psychosis
CBT +/- family intervention and offer interventions for people with any of the anxiety , depression, emerging personality disorder, or substance misuese
Do not offer antipsychotics
Treatment of first episode of psychosis:
Oral antipsychotic in conjunction with psychological interventions
Adverse effects of antipsychotic medication
Metabolic
Extrapyramidal
CV
Hormonal
Other
Weight gain/DM
Akathisia, dyskinesia and dystonia
QT prolongation
Raised plasma prolactin
Unpleasant subjective experiences
What should be done before starting antipsychotics
Baseline investigations
Weight
Waist circumference
Pulse and BP
Fasting blood glucose, HbA1c, lipid profile and prolactin
Assessment of movement disorders
Assessment of nutritional status, diet and level of physical activity
+/- ECG if indicated, either by CV exam or on SPC.
Monitoring of antipsychotic resposne
Resposne
Side effects
?Movement disorders
Weight, 6w, 12w, 1y
Waist circumference annualy
Pulse and BP at 12w, 1y then annualy
FBG and HBA1c at 12w then annualy.
What is an ADR specifically assocaited with chlorpromazine?
Skin photosensitivity
Treatment of people whose schizophrenia has not responded adequately to treatment
R/V diagnosis and adherence. Engagement with psychological therapy. Consider other causes of non-response
If 2 sequential antipsychotics have been used at appropriate dose (at least 1 of which should ne non-cloazpine-second generation antipsychotic) use clozapine (4-6 week trial of each)
If clozapine at opitmised dose does not lead to respond, consider adding a second antipsychotic.
What is used to assess post-partum mental health?
What is the score?
Edinburgh post-natal depression scale
>13/30 indicates a derpessive illness of varying severity
What are features of baby-blues?
Management?
60-70% of women
3-7d post-partum
Anxious, tearful and irritable
Reassurance and support
What are the features of postnatal depression?
Management?
10% of women, starts within 1m and peaks at 3m
Similar smyptoms to depression
Reassurance and support.
SSRIs may be used if symptoms are severe. Paroxetine or Sertraline. (Paroxetine has low milk/plasma ratio)
Why do the SIGN guidelines preferentially recommend paroxetine for postnatal depression?
Due to low milk/plasma ratio
What are the features of puerpal psychosis
Management
0.2% of women
2-3w following birth
Severe mood swings and disordered perception (e.g. auditory hallucinations).
Admission to hospital
Px: 20% risk of recurrence following future pregnancies
What differentiates mania from hypomania?
Psychotic symptoms: delusions of grandeur, auditory hallucinations
What are the symptoms common to both hypomania and mania?
Mood: elevated, irritable
Speech and thought: pressured, flight of ideas, poor attention
Behaviour: insomnia, loss of inhibitions, increased appetite
What is the most common psychiatric problems in Parkinson’s?
Depression
What is the classical triad of features in PD?
Bradykinesia, tremor and rigidity
What are the medications of choice in psychosis in pt with dementia?
Haloperidol or olanzapine
NB in PD, all antipsychtoics can aggravate symptoms.
How should you switch from citalopram, escitalopram, sertraline, or paroxetine to another SSRI?
the first SSRI should be withdrawn* before the alternative SSRI is started
Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- an exceptions is fluoxetine which should be withdrawn prior to TCAs being started
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly
Switching from fluoxetine to venlafaxine
withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly
What are the classical symtpoms of depression?
Some other common symptoms
Low mood, anhedonia, anergia
- Reduced concentrationa and ttention
- Decreased self-esteem and confience
- Guilt/worthlessness
- Bleak/pessimisticabout future
- Ideas or acts of self-harm
- Disturbed sleep
- Diminished appetite and weight losee
- Psychomotor agitation or retardation
- Loss of libido.
What are the ICD-10 diagnostic criteria for a mild depressive episode?
At least 2 of the main symptoms and at least 2 of the other symtpoms. None of which should be present to an intense degree
>2w.
Should be able to continue work and social functioning
What are the ICD-10 diagnostic criteria for a moderate depressive episode?
At least 2 of the main 3. And >3-4 of the other symptoms
>2w
Individuals will usually haev considerable difficulty continuing with normal work and social functioning
What are the ICD-10 diagnostic criteria for a severe depressive episode?
All 3 of the main +4 of the other which should be of severe intensity.
>2w but if particularly severe, appropriate to make early diagnosis
May be evdience of psychosis
Individuals show severe distress and or agitation.
What are the two screening questions for depression?
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
What does NCIE use to grade depression?
DSM-IV
What are the DSM-IV criteria to grade depression
All should be for most of the day or nearly every day:
- Depressed mood
- Anhedonia
- Significant weight gain
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or oloss of energy
- Feelings of worhtlessness or excessive or inappropriate guilt
- Diminished ability to think or concentrate
Recurrent thoughts of death and thoughts about suicide
Mild depression DSM
>5 symptoms but mild with minor functional impairment
Moderate depression DSM
Symptoms or funcitonal impairmeent are between mild and severe
Severe depression DSM
Most symptoms and the symtpoms markedly interfere with functioning. Can occur with or without psychotic symptoms
What is the risk of developing schizophren if
MZ?
Parent
Sibling
No relatives
50%
10-15%
10%
1%
What is the diagnostic criteria for agranulocytosis
FBC with neutrophil count
What are some drug classes that can cause agranulocytosis?
- Antipsychotics (predominantly Clozapine)
- Antiepileptics
- Antithyroid Drugs (Carbimazole)
- Antibiotics (Penicillin, Chloramphenicol and Co-Trimoxazole)
- Cytotoxic Drugs
- Gold
- NSAIDs (Naproxen, Indomethacin)
- Allopurinol
- Mirtazapine
What is an oral tranquiliser if a patient is prescribed a regular antipsychotic?
If not on a regular antipsychotic?
lorazepam or promethazine
Olanzopine, quetiapine, risperidone or haloperidol (avoid using more than one)
Buccal midazolam can also be used to avoid IM treatment
What are the IM treatment options for tranquilsation?
Lorazepam, promaethazine, aripriprazole, haloperidol
Consider IV diazepam
How are extrapyramidal SEs managed?
Procylcidine
Can also be used for acute dystonia
Treatment of akahisia
Propanalol +/- cyproheptadine
Treatment of tardive dyskinesia
May be irreversible but try tetrabenzine
Rank the atypicals in terms of likelihood of EPSEs
Quitiepine
Clozapine
Aripriprazole
Zotepine
Occur at high dosese of olanzapine, amisulpride and risperidone
Which atypicals have no impact on serum prolactin?
Which does at high doses?
Aripiprazole, clozapine and quetiapine
Olanzapine
What is a significant SE of antipsychotics that contributes to noncompliance?
Sexual dysfunction (ED, anorgasmia, libido etc)
What additional therapy may reduce negative side effects
Minocycline
What is aconsideration of dual therapy in failure to resond?
Aripriprazole and non-clozapine atypicals may worsen psychosis
TWEAK
+ve?
Tolerance
Worry about drinking
Eye opener
Amnesia
Attempts to Cut down
>2= +ve for dependance
?more sensitive than CAGE
What are the features of childhood depression not seen in adults?
Defiance- running away from home
Separation anxiety and school refusal
Boredom
Antisocial behaviour
Insomnia (early rather than EMW)
Hypersomnia
Eating problems
Core symptoms of depression
Low mood, anhedonia, anergia
What is Beck’s cognitive tria?
The Self
The World
The Future
Guilt/worthlessness
Death or Sucidide
Are also common depressive thoughts
What is diurnal variation?
Maximal lowering of mood in the morning
What are the features of atypical depression
Initial anxietry related insomnia
Subsequent oversleeping
Increased appetite and a relatively bright, reactive mood.
More common in adolescence
Whata re the mood-congruent features of depressive psychosis?
Nihilistic delusions
Hallucinations are usually auditory, in second person and accusing/condemning or urging the individual to commit suicide
What differentiates psychotic depression from schizophrenia?
Temporal sequence and the basis of thought content (i.e. mood congruent psychosis)
Epidemiology of depression
10-20% with rates almost doubled in women
Typically in third decade (earlier for bipolar disorder)
Strongly associated with socio-economic deprivation
What is thought to be the final common physiological pathway in depression
Reduced BDNF which results from hypercortisolaemia (hypo in aypical) and decreased NAdr and 5-HT
When is psychiatric referral for depression indicated?
High suicide risk
Severe derpession
Unresponsive to initial treatment
Bipolar or recurrent
Mx of depression
Mild- CBT
Moderate/Severe: CBT + antidepressant
What Rx may resistant depression respond to?
Combining antidepressant with lithium, an atypical or another antidepressant (e.g. mirtazapine)
What is antidepressant augmentation?
When an antidepressant is used with a non-antidepressant
Combination is two anti-depressants used together
What should be done when prescribing lithium
Monitor renal and thyroid function before treatment and every 6 months during treatment (more often if renally impaired)
Consider ECG monitoring in those at increased risk of CV disease
Monitor [Li] 1w after initiation and each dose change until stable and every 3 months thereafter
How are the individual epsidoes of BPAD calssified?
Depressive
Manic
Hypomanic
Mixed (both present or rapid alternation)
DSM IV classification of BPAD
BPAD 1
BPAD2
Cyclothymci disorder
One or more manic or mixed epsidoes and usually one or more major depressive episodes
Recurrent major depressive and hypomanic (BUT NOT MANIC) episodes
Chronic mood fluctuations over at least 2 years with epsidoes of depression and hypomania of insufficient severity to meet diagnostic criteria
What are the cardinal features of mania/hypomania
Alteration in mood: elated and expansive
May be characterised by intense irritabilty
What are the assocaited features of mania
Increased psychomotor activity
Exagerrated optimism
Inflated self-esteem
Disinhibtion: sexual, spending, driving, business/religious or political intitiatives.
Heightened sensory awareness
Rapid thinking and speech: Pressured. Flight of ideas
Mania only: mood-congruent delusions and hallucinations (usually auditory)
Insight often absent
What is the peak age of onset for BPAD?
Early 20s, often starts in childhood and adolescene
Management of mania/hypomania if patient is taking an antidepressant as monotherapy
Consider stopping antidepressant and offer antipsychotic (regardless of whether the antidepressant is stopped)
Mx of acute mania/hypomania and not taking mood stabiliser or antipsychotic
Offer atypical (olanzapine, quetiapine, risperidone or haloperidol)
If doesn’t work consider an alternative from the drugs listed above
If alternative not sufficiently effective at the maximum licensed dose off Lithium (if patient refuses Li due to blood monitoring, consider valproate)
If someone is already taking lithium and develops (hypo)mania
If already taking VPA
Check [plasma]
Consider adding haloperidol, onalzapine, quetiapine or risperidone)
Consider increasing to maximum livesned dose, if no improvement consider adding one of the above.
Mc of Bipolar depression if not taking mood stabiliser
If taking mood stabiliser?
Psychological: CBT, interpersonal therapy
Pharmacological:
If someone develops moderate or severe bipolar depression offer fluoxetine combined with olanzapine or quetiapine on its own
Check plasma level, increase if not at maximal. If at maximal add eithe fluoxetine combined with olanazapine or quetiapine on its own
Same for VPA
What is the long-term treatment of BPAD to preent relapse?
Lithium as first line (if ineffective consider adding VPA)
If cannot tolerate Li, switch to VPA or olanzapine
What is a consideration in women of child bearing age in terms of mood stabilisation?
Teratogenic so should ideally be avoided
What is the prognosis for BPAD in those with rapid cycling
Seldom respond to lithium, respond bettwer to anti-epileptic mood stabilisers.
What is the prognosis for cyclothymia
30% risk developing full blown BPAD
What are some manifestations of acute dystonia?
Torticollois, oculogyric crisis
What is associated with a poor prognosis in schizophrenia?
Strong FHx
Gradual onset
Low IQ
PRemorbid history of social withdrawal
Lack of obvious precipitant
What are the common side-effects of ECT?
When is it used?
What is the only absolute CI?
Headache
Nausea
STM impairment
Memory loss of events prior to ECT
Arrythmias
LT: impaired memory
In severe depression refractory to medication or those with psychotic symptoms
Raised ICP
What are the features of ADHD
Extreme restlessness
Poor concentration
Uncontrolled activity
Impulsiveness
Mx of ADHD?
What is ADHD called in UK?
Specialist assessment
Food diary- ?link with certain foods
Methylphenidate (atomoxetine)
What are the side effects of methylphenidate?
Abdo pain
Nausea
Dyspepsia
Growth should be monitored
?Psychaitric disorders should be monitored
BP/ pulse every 6 months
Features of atypical grief reactions include
Delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Different types of stress reation and input
Adjustment disorder: life adversities
Grief/abnormal grief reaction: bereavement
Acute stress reaction: exceptional stress; can lead to ->
PTSD: exceptional stress
Features of adjustment disorder
Treatment
Life adversity e.g. job loss, house move, divorce
Onset within weeks, last
Symptoms: depression, anxiety, autonomic arousal
Practical support: ventilate feelings, problem solving, CBT
Features of normal grief reaction
DAGDA
Lasts up to 2 years
Stages:
Denial
Anger
Guilt
Depression
Acceptance
Features of abnorml grief reaction
Categroised as adjustment disorder
Delayed onset, greater intensity and duration
More likely when: difficult relationship with deceased, death was sudden, there are constraints to normal grieving
Features of acute stress reaction
Treatment
Eceptional stress e.g. accident, war, rape
Onset: minutes to hours
Lasts
Mixed symptoms: dazed/perplexed, intense anxiety
Give practical support:
reorientate
brief CBT
Features of PTSD
Treatment
Can be precipitated by acute stress reaction
Weeks to months
Symptoms >1m:
Intrusive thoughts/flashbacks/nightmares
Avoidance
Numbing/detachment
Increased arousal
Trauma focused CBT
EMDR
Antidepresssants
What predicts increased risk of PTSD in acute stress reaction?
Dissociative symptoms
Characteristic features for PTSD
Risk
Vulnerability factors
Persistent intrsuive thinking/re-experiencing
Avoidance
Numbing, detachment and enstrangement/loss of interest in significant activites
Increased arousal: autonomic symptoms, hypervigilance,
ETOH/substance misuse
Depression may be comorbid or 2o to PTSD
Proportional to magnitude of the stressor.
Vulnerability factors: lac of social support, presence of other adversities and pre-morbid personalityy
Treatment of PTSD
>3m
First line
Rx?
Rx if failed on first Rx
Mild symptoms: watchful waiting, with 1m follow up
PTSD within 3m of event: psychological therapy, drug treatment e.g short term hypnotic Rx.
PTSD for >3m after event: trauma focussed psychological therapy. Rx not first line However:
Mitrazapine/Paroxetine for general use.
Amitriptyline or phenelzine (mental health specialists)
Rx should be offered to PTSD sufferers who cannot start psychological therapy e.g. due to ongoing threat of further trauma eg domestic violence
Rx should be offered if comorbid depression/severe hyperarousal
Alternative class or adjunctive olanazpine.
Considerations for Rx PTSD
Suicide risk
Akathisia
Treatment of PTSD in children
Psychological therapy
Rx should not be routinely considered
What are the anxiety disorders?
GAD
Panic disorders
Phobias
OCD
Epidemiology of anxiety disorders
Women, younger adults and middle aged
Less prevalent in men and the elderly
Aetiology of anxiety
Reduced GABA
Heigthened amydala activation
ETOH and BZD may cause attacks
What are the childhood associations for anxiety?
Abuse
Separations
Demands for high achievement
Excessive conformity
Features of panic disorder
Recurrent episodic anxiety attacks which are not restricted to any particular situation.
At least 3 panic attacks in a 3 week period for Dx
Characteristic symptoms
May also develop anticipatory fear.
Classical symptoms of panic attack
Autonomic: palpitations, breathlessness, sweating, trembling, breathlessness
Feeling of choking
Chest pain/discomfort
Nausea/abdo pain
Dizziness, paraesthesia
Chills and hot flushes
Derealisation/depersonalisation
Fear of losing control
Management of panic disorder
SSRI and CBT
TCA where SSRI ineffective
BZD not recommended.
Features of GAD
Generalised, persistent, excessive anxiety or worry about a number of events that the individual finds difficult to control lasting at least 3 weeks (ICD10) or >6m (DSM-IV)
Usually associated with apprehension, increased vigilance, restlessness, sleep dififculty (initial/middle insomnia, fatigue on waking), motor tension (tremor), autonomic hyperactivity
May be comorbid with other anxiety disorders, depression, ETOH and drug abuse
Rx of GAD
SSRI and CBT
SNRI
Pregabalin
BSD not to be used.
Mx of agoraphobia
Social phobia
Specfic phobias
CBT (+/- SSRI)
CBT, Rx not first line, SSRI can be used
Graded exposure therapy and response prevention. ST BZD eg foor flying can be considered
Features of OCD
2-3% prevalence
M=F
Dx= obsessions and compulsions for >1h/d for >2w + distressing impact on life
Rx: SSRIs, CBT
Features of Anakastic PD
Obsessional and compulsive life symptoms but not egodystonic, not resisted
Features of body dysmorphic disorder
Obsessional preoccpation with imagined or mild phsyical defects
What are obsessions
Unwelcome, persistent, recurrent, intrusnive, senseless and uncomfortable to the individual who attempts to suppress them and recognises them as absurd (egodystonic)
May be: thoughts, images, impulses, ruminations, doubts
Different from volitional fantasies which are not displeasurable (egosyntonic)
What are compulsions
Repetitive, purposeful physical or metnal behaviours performed with reluctance in response to an obsessions
Carried out in a stereotyped fashion and are designed to neutralise/prevent discomfort
Not connected to the trigger in a realistic way
Individual realises the behaviour is unreasonable
Can include: hand washing, counting, touching and rearranging onjects to achieve symmetry, mental compulsions, hoaridng, arithmomania, onomatomania, folie du pourquoi (irresistable habit of seeking explanations for commonplace facts), inappropriate and excessive tidiness
What happens if an individual resists and obsession or compulsion?
Anxiety increases until the compulsive activity is performed.
What are the 4 OCD subtpyes
What are the complications?
Obsessions and compulsions concerned with contamination
Checking compulsions
Obsessions without overt compulsive acts
Hoarding
Depression and abuse of anxiolytics or ETOH.
What is PANDAS
Paediatric Autoimmune Neuropsychiatric Disrders associated with Streptococci
OCD and related disorders occuring suddenly in children following streptococcal infection
Mx of OCD and BDD
First line Rx in OCD
BDD?
Second line?
Third line?
In children?
CBT (including Exposure Response Prevention)
SSRI (fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram)
BDD should be fluoxetine (more evidenc)
Can be either or dependant on degree of functional impairment and ability to engage in CBT
Combination therapy in those with more severe functional impairment
Clomipramine should be considered in the treatment of adults with OCD or BDD after an adequate trial of at least one SSRI has been ineffective or poorly tolerated, if the patient prefers clomipramine or has had a previous good response to it.
If clomipramine fails can consider additional CBT, adding antipsychotic to SSRI or clomipramine or combinaing clomipramine and citalopram.
If combination Rx fails, buspirone.
If unable/unwilling to undertake psychological therapy. Rx with SSRI with careful monitoring.
Features of anankastic PD
Rigidity of thinking
Perfectionsim that may interfere with task completion
Preoccupation with rules
Objectively high standards are seldom achieved and tendency to hoard
Excessive cleanliness and orderliness
Emotional coldness
Egosyntonic traits
Definition of A nervosa
Morbid fear of fatness, distorted body image, delibrate weight loss, amenorrhoea, BMI
Definition of B nervosa
Morbid fear of fatness, distorted body image.
Craving for good and uncontrolled binge-eating
Purging/vomiting/laxative abuse
Fluctuating weight (normal/ecessive)
Epidemiology of A + B Nervosa
13-20
Men later
F:M 3:1
Kleine-Levin Syndrome (Sleeping beatuy syndrome)
Hypersomna and cogntiive or mood changes
Hyperphagia and hypersexuality,
Recurrent episodes (1w-1m but resolve spontaneously)
KLS is a diagnosis of exclusion
Li may be helpful
Klüver–Bucy syndrome
Syndrome resulting from bilateral lesions of the medial temporal lobe
Hyperphagia, hypersexuality, hyperoralitiy, visual agnosia and docility
Prognosis of AN
40% recover
35% improve
20% become chronic
5% death
LT risk of osteoporosis
Px of BN
Poor if low BMI, high frequency of purgring
30-40% remission with CBT/IPT
What is the diagnosis if there is a mixed Anorexic/bulimic picture?
Easting disorder NOS
ICD Dx of AN
a morbid fear of fatness
° deliberate weight loss
° distorted body image
° Body Mass Index (BMI, weight [kg]/ht [m]2 )
° amenorrhoea (primary prepubertally, or secondary; oral contraceptive pill may still cause vaginal bleeds)
° loss of sexual interest and potency in men; in prepubertal boys development will be arrested.
Associated clinical features of AN
Preoccupation with food
Self-consciousness about eating in public
Vigorous exercise
Constipation
Cold intolerance
Depressive and OC symtpoms
What are the physical complications/signs associated with AN?
Emaciation
Dry/yellow skin
Lanugo hair on the face and trunk
Bradycardia and hypotension
Anaemia and leucopenia
Consequences of repeated vomiting: hypokalaemia, alkalosis, pitted teeth, parotid swelling and scarring of the dorsum of the hand
What is Russel’s sign?
Scarring of the dorsum of the hand
What are appropriate screening questions for AN?
Do you think you have an eating problem?
Do you worry excessively about your weight?
NB screen young people with T1DM and poor treatment adherence for the presence of an eating disorder
Mx of AN
Rx
Physical
When to admit?
Psychological intervention: Cognitive analytic therapy (CAT) CBT, interpersonal psychotherapy (IPT), focal psychodynamic therapy and family interventions
Rx for comorbid conditions
Medication should not be used as sole or primary treatment for AN
NB SFx, particulalry cardiac related.
Physical managment: 0.5-1kg weight gain in-patient should be aim. Reglar physical montiroing with multi-vitamin supplementation. TPN should not be used in absence of significant GI dysfunction.
Moderate to high physical/suicid risk, where patient has not improved despite appropraite out-patient treatment.
Mx of BN
Physical:
- Self-help programme/SSRI- fluoxetine (60mg/daily, higher than depression) (alternative/additional)
- CBT (+ other psychological therapy if CBT-BN has not worked), IPT can be offered but takes longer to get resuts.
No other pharmacological therapy recommended
Physical:
Fluid/electrolyte balance
What is the threshold for high risk of fatal arrhythmia or hypoglycaeia?
BMI
What are the associated clinical features of BN?
Normal or excessive fluctuant weight
Loss of control during bingeing
Intense self-loathing and associated depression
Multi-impulsive bulimia: ETOH and drug misuse, deliberate self-harm, stealing/sexual disinhbition co-exist
Phsical signs of BN
Amenorrhoea
Hypokalaemia
Signs of excessive vomiting (acute oesophageal tears can occur during forced vomiting)
Management of paracetamol poisoning:
otherwise
Activated charcoal
N-acetylcysteine
Liver transplant
Mx of salicylate poisoning
Haemodialysis
(urinary alkalinisation
How can you divide the first rank symptoms of schizophrenia?
Auditory hallucinations
Thought disorders
Passivity phenomena
Delusional perceptions
What are the typical features of post-concussion syndrome?
Headache
Fatigue
Anxiety/depression
Dizziness
When is the best time to monitor Li levels?
What is the range?
12hrs post-dose
0.4-1mmol/l
When is the best time to monitor digoxin levels
6hrs post-dose
When is the best time to monitor ciclosporin levels
Trough levels immediately before dose
When is the best time to monitor phenytoin levels?
When should they be checked?
Do not need routine monitoring
Adjustment of dose, suspected toxicity, detection of non-adherence
A 65-year-old female with a history of ischaemic heart disease is noted to be depressed following a recent myocardial infarction. What would be the most appropriate antidepressant to start?
Sertraline is the preferred antidepressant following a myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
Cluster A PD
(Mad)
Paranoid
Schizoid
Schizotypal
Cluster B PD
(Bad)
Borderline (DSM)/ EUPD (ICD)
Histrionic
[Narcissistic- DSM only]
Antisocial (DSM)/ Dissocial (ICD)
Cluster C PD
Sad
Avoidant (DSM)/ Anxious PD
Dependent PD
Anankastic (DSM)/ OC PD
Features of paranoid PD
Cold affect
Pervasive distrust and suscpiciousness
Preoccupied by mistrust of friends or spouse
Bears grudges
Reluctance to confide
Interprets remarks negatively
Hypersensitivity to rejection
Grandiose sense of personal rights
Schizoid PD
Social withdrawal
Restricted emotional range
Restricted pleasure
Lacks confidants
Indifference to praise or criticism
Aloof
Insensitivity to social norms
Schizotypal PD
Pervasive social and interpesronal deficits
Ideas of regerence
Magical thinking
Unusual perception
Vague/circumstantial/tangential thinking
Inappropriate/constricted affect
Eccentricity/suscpiciousness
Excessive social anxiety
Borderline/EUPD
DSM/ ICD
Unstable and intense interpersonal relationships, self image, affect
Self-damaging impulsivity: criminal, sex, substance abuse, binge-eating
Identity confusion
Chronic anhedonia
Recurrent suicidal or self-mutilating behaviour
Transient Paranoid ideation
Frantic efforts to avoid abandonment
Histrionic PD
Excessive shallow emotionality
Attention-seeking
Suggestibility
Shallow/labile affect
Inappropriate sexual seductiveness but immaturity
Narcissism
Grandiosity
Exploitative actions
Narcissistic PD
Pervasie grandiosity
Lack of empathy
Need for praise
Antisocial/dissocial PD
Persistent disregard for rights/safety of others
Gross irresponsiblity
Incapacity to maintain relatoinships
Irritability
Low threshold for frustration and aggression
Incapacity to experience guilt
Deceitfulness
Impulsivity
Disregard for personal safety
Proneness to blame others
Avoidant/anxious PD
Persistent feelings of tension and inadequacy
Social inhibitions
Unqillingness to become involved with people unless certain of being liked
Restriction in lifestyle to maintain physical security
Dependant PD
Excessive need to be taken care of
Fear of separation
Excessive advice to make decisions
Difficulty in expressing disagreement
Needs others to assume responsiblity
Low selflconfidence
Undue compliance with others wishes
Unwilling to make demands on people
Preoccupation with fears of being left alone
Anankastic/OC PD
Excessive doubt, caution, rigidity and stubborness
Preoccupation with details
Perfectionism leading to interference with task completion
Excessive conscientiousness
Excessive pedantry
Obsessional thoughts or impulses without resistance
Hierarchy of diagnosis in psychiatry
Organic
Psychosis
Affective
Neurosis
PD
Mx of borderline PD
Adapated CBT, DBT and mentalisation based treatments
What PD is associated with increased risk of BPAD?
Borderline
Which PDs predispose to OCD? (also to depression)
OC PD
Which PD increase risk of psychosis?
Paranoid
Schizotypal
How can psychosexual disorders be subdivided?
Disorders of function
preference
identity
What is a paraphilia?
Disorder of sexual preference
Can be classifiied into variations of sexual object or variation of sexual act
Capgras’ syndrome
Delusional misindentification syndrome (psychotic)
Belief that a person known to the patient has been replaced by an imposter who is their exact double
Fregoli’s syndrome?
Delusional misidentification syndrome (psychotic)
Strangers or other people patient meets are the patient’s persecutors indisguise
Seen in schizophrenia, affective disorders, dementia or other organic illness.
Treat the primary disorder.
NB Risk
Give 5 examples of atypical antipsychotics?
Typical?
