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
Ekbom’s syndrome
Delusional parasitosis
W>M (2:1)
Believe that insects are colonising their body, including skin and eyes. Claim to feel sensations and see bugs.
Delusions may be circumscribed or part of a schizophrenic/depressive ilnness
Rx Antipsychotics
Folie a deux
A delusional belief that is shared by >2 people of whom only one has a psychotic illness
Delusion is usually persecutory or hypochondriacal
Principle diagnosis is schizophrenia but may also be affective/dementia
De Clerambault’s syndrome
Erotomania
Patient has the unfounded and delusional belief that someone is in love with her
Patient makes inappropriate advances to the person and becomes angry when rejected
May be part of affective (manic) disorder or more rarely schizophrenia.
Rx treatment of underlying disease/ antipsychotics
Othello syndrome
Morbid/pathological jealousy
Usually male, convinced partner is being unfaithful.
May occur in LT ETOH abuse, dementia, schizophrenia, cocaine addiction and a side effect of dopamine agonism in PD.
Risk of violence/homicide
Cortard’s syndrome
Nihilistic delusions in which ptients believes parts of his or her body are decaying/rotting/don’t exist.
Patients may also believe they are dead/unable to die
Psychotic depression
ECT often required due to the severity of the associated depression
Munchausen’s syndrome
Factitous disorder
Deliberately feinged symptomatology, usually physical but sometimes psychiatric
Multiple presentations to A&E
May use multiple aliases, have no fixed GP
Characteristically occurs in severe PD
DDx for Munchausen’s
Somatisation
Dissociative
Undiagnosed illlness
Couvade syndrome
Experience of symptoms resembling pregnancy (abdo swelling, N&V) in expectant fathers
Anxietry and psychosomatic symptoms also common
Ganser’s syndrome
Apporximate, absurd and inconsistent answers to simple questions
Clouding of consciousness
True/pseudo-hallucinations
Somatic symptoms
Dissociative disorder against intolerable stress
How does the ICD-10 classify substance abuse
What are the categories?
Substance and type of disorder
Acute intoxication
Harmful use
Dependance
Withdrawal state
Psychotic disorder
Amnesic disorder
Residual and late onset psychotic disorders
What are the signs of dependance?
C
A
N
T
S
T
O
P
Compulsion to take
Aware of harms but persist
Neglect other activities
Tolerance
Stopping causes withdrawal
Time preoccupied with substance
Out of control of use
Persistent futile wish to cut down`
What are the early and late withdrawal symptoms of opiate abuse?
Craving, flu-like, sweating and yawning, (24-48h)
Mydriasis, abdo pain, diarrhoea, agitation, restlessness, piloerection and tachycardia occur later (7-10d)
What are the Rx options for opiate detoxification
Relapse prevention?
OD?
Methadone (agonist)/ buprenorphine (partial agonist) are first line
Lofexidine sometimes used for short detox treatments
Naltrexone used to prevent relapse
Naloxone used for OD
Options
A. Akathisia
B. Parkinsonism
C. Tardive dyskinesia
D. Mannerisms
E. Stereotypies
F. Tics
G. Compulsions
H. Catatonia
I. Intention tremor
J. Dystonia
GE is a 46 year old man who has been treated for paranoid schizophrenia for the last 12 years. His family have noticed that recently he has been grimacing and pulling faces. This seems to be getting worse and they are concerned that he is reacting to hallucinations again.
Learning points :
•Answer : C . Contrast acute EPSE’s (Parkinsonism, acute dystonias etc) to chronic side effects like TD. Tardive dyskinesias (TDs) are involuntary movements of the tongue, lips, face, trunk, and extremities that occur in patients exposed to long-term dopaminergic antagonists (commonly first generation antipsychotics ). Note that even a single exposure to a dopamine antagonist in people with brain disorders i.e. LD or fetal alcohol syndrome can precipitate it. Older patients and women with chronic psychotic illness are particularly susceptible.
Options
A. Akathisia
B. Parkinsonism
C. Tardive dyskinesia
D. Mannerisms
E. Stereotypies
F. Tics
G. Compulsions
H. Catatonia
I. Intention tremor
J. Dystonia
ES is a 24 year old woman who was admitted with an acute psychotic episode and has been taking Risperidone for 3 weeks. You are a senior house officer working on her ward, and have been asked to see her by nursing staff, since she “keeps pacing by the door”. Staff are concerned that she is trying to abscond. During the consultation you notice that she seems on edge and unable to settle. On several occasions she rises from her seat to pace up and down.
Learning points :
- Answer : A. Akathisia is most commonly experienced in the first few weeks of treatment then generally reduces in intensity or wears out completely. In a minority, it starts later on in treatment cycle.
- may also be involved with disrupted NMDA channel
- increased levels of the neurotransmitter norepinephrine
•
- Propranolol
- Clonazepam
Options :
A. Sodium valproate
B. Cognitive behavioural therapy
C. Sertraline
D. Minimise cardiovascular risk factors
E. Donepezil
F. Olanzapine
G. Lithium
H. Levothyroxine
I. Diazepam
J. Encourage to avoid crowded places
•Answer is D. On the basis of this history, vascular dementia is a concern, though delirium must be excluded first. The evidence for using anticholinesterases for VD is reasonable (despite what NICE say) , in practice differentiating VD from Alzheimer’s is quite tough .This gentleman needs to minimise his cardiovascular risk factors as a first line of treatment by addressing his smoking, concordance and diabetic management.
A. Sodium valproate
B. Cognitive behavioural therapy
C. Sertraline
D. Minimise cardiovascular risk factors
E. Donepezil
F. Olanzapine
G. Lithium
H. Levothyroxine
I. Diazepam
J. Encourage to avoid crowded places
The son of an 80 year old woman asks you to conduct a home visit as he is concerned that his mother’s memory “isn’t what it was”. She has not been dressing herself in the morning and no longer reads or does the crossword. She has put on weight, become increasingly withdrawn, lethargic; her movements are slowed. Her only significant past medical history is T2 N0 M0 carcinoma of the larynx, successfully treated with radiotherapy 4 years ago.
Answer is H. The slowed thoughts and movements, lethargy , weight gain , self neglect could all suggest depression with atypical features, but in the context of her medical history, hypothyroidism should be excluded as cause of her affective and cognitive symptoms. If her TFTs are normal, atypical depression would be the next diagnosis to consider.
Options :
A. Sodium valproate
B. Cognitive behavioural therapy
C. Sertraline
D. Minimise cardiovascular risk factors
E. Donepezil
F. Olanzapine
G. Lithium
H. Levothyroxine
I. Diazepam
J. Encourage to avoid crowded places
The daughter of a 72 year old man asks you to see him at home as he has been losing weight and no longer leaves the house. When you visit he appears disheveled. You know him well as you were involved in the palliative care of his wife who died last year, however he doesn’t recognise you. He is orientated to time but not place, and scores 16 / 25 on the MMSE, saying he “doesn’t know” and becoming frustrated with your questioning. He has been feeling very lethargic and sleeps poorly.
•Answer is E. This is likely to be Dementia with Lewy Bodies (suggested by new parkinsonian signs, vivid visual hallucinations). Acetylcholinesterase inhibitors are used in both DLB and Alzheimer’s disease. Revise the presenting features of DLB. The full Parkinson’s syndrome is tremor, rigidity , bradykinesia and postural instability.
•
•There is eveidence for Donepezil’s benefit in these patients: Donepezil for Dementia with Lewy Bodies: A Randomized, Placebo-Controlled Trial, Ann Neurol. Jul 2012; 72: 41–52.
2.You are in A&E assessing a man with a known diagnosis of schizophrenia. He is extremely difficult to talk to and says things like… “The train rain brained me. He ate the skate, inflated yesterday’s gate toward the cheese grater”
A.Dysarthria B. Dysphasia
C.Clang associations D. Punning
E.Pressure of speech F. Perseveration
G.Loosening of assoc. H. Poverty of speech
C
•3. A 73 year old woman is on the medical ward after a fall. She has a diagnosis of dementia with Lewy bodies. When you ask her how she is feeling, she replies… “Not too bad, I don’t really know who you are though, are you sure you’re a doctor, doctor, doctor, doctor?”
A.Dysarthria B. Dysphasia
C.Clang associations D. Punning
E.Pressure of speech F. Perseveration
G.Loosening of assoc. H. Poverty of speech
F
A.Amisulpride B. Citalopram
C.Moclobamide D. Haloperidol
E.Lithium F. Donepezil
G.Lorazepam H. Propranolol
•
•For each of the side-effects listed below, choose which drug from the list above is most likely to be responsible…
Loss of outer third of eyebrows
Cogwheel rigidity
HT Crisis
Anxiety
E
D
C
B
A.Catatonic schizophrenia
B.Hebephrenic schizophrenia
C.Paranoid schizophrenia
D.Persistent delusional disorder
E.Post-schizophrenic depression
F.Residual schizophrenia
G.Schizotypal disorder
- An 18 year-old man has a Hx of shallow affect, mannerisms, multiple somatic complaints and incoherent speech. He is withdrawn and describes hearing multiple voices
- A 40 year-old woman has been on an antipsychotic for 7 months. Her delusions and hallucinations have resolved. She has developed low mood, feelings of hopelessness and low energy levels for the last six weeks.
- A 24 year-old man has a 6 month Hx of talking and laughing to himself. he hears voices talking to him and neglects his personal hygiene. He is uncommunicative most of the time. He has also damaged property and assaulted strangers for no apparent reason. Often he assumes uncomfortable postures for hours.
1.An 18 year-old man has a Hx of shallow affect, mannerisms, multiple somatic complaints and incoherent speech. He is withdrawn and describes hearing multiple voices
B
2.A 40 year-old woman has been on an antipsychotic for 7 months. Her delusions and hallucinations have resolved. She has developed low mood, feelings of hopelessness and low energy levels for the last six weeks.
E
- A 24 year-old man has a 6 month Hx of talking and laughing to himself. he hears voices talking to him and neglects his personal hygiene. He is uncommunicative most of the time. He has also damaged property and assaulted strangers for no apparent reason. Often he assumes uncomfortable postures for hours.
A
A.Creutzfeldt-Jacob disease
B.HIV dementia
C.Huntington’s disease
D.General paralysis of insane
E.Parkinson’s dementia
F.Multi-infarct dementia
G.Pick’s disease
- 50 year-old male has developed rapidly progressing dementia for the last 30months which is associated with tremor, rigidity, myoclonus and triphasic waves on the EEG.
- 55 year-old woman has a slow progressive dementia of 9 years duration with choreiform movements of the face and hands and has abnormal gait. There is a positive family history of the same.
- 60 year-old man has a Hx of impaired cognitive functions that are unevenly impaired associated with Hx of hypertension, emotional lability and transient episodes of delirium.
1.50 year-old male has developed rapidly progressing dementia for the last 30months which is associated with tremor, rigidity, myoclonus and triphasic waves on the EEG.
A
2.55 year-old woman has a slow progressive dementia of 9 years duration with choreiform movements of the face and hands and has abnormal gait. There is a positive family history of the same.
C
- 60 year-old man has a Hx of impaired cognitive functions that are unevenly impaired associated with Hx of hypertension, emotional lability and transient episodes of delirium.
F
What are the ICD classification of alcohol abuse disorders?
Acute intoxication
Alcohol withdrawal
Alcohol dependance
Psychotic disorders (alcoholic hallucinations, jealousy)
Amnesiv syndrome
Residual and late onset disorders: include depression and dementia
What are the signs of alcohol dependanc?
CANTS STOP
Compulsion/strong desire to drink
Aware of physical/psychological harms
Neglect of other activites
Tolerance
Stopping causes withdrawal
Stereotyped pattern of drinking
Time preoccupied with alcohol
Out of control use
Persistent, futile wish to cut down.
CAGE questionnaire
Cut down
Annoyed by suggesting you do so
Guilty about drinking
Eye-opener
What is the scoring system for FAST?
>2= hazardous drinking
What are the features of Wernicke’s?
Confusion
Ataxia
Opthlamoplegia
What are the features of Korsakoff’s?
Profound anterograde STM loss
Confabulation
What is the treatment of alcohol dependance?
Acute detox?
Psychological?
Pharmacological?
Acute detoxiciation: tapering chlordiazepoxide/diazepam
Delerium tremens treated with lorazepam or antipschotics
Rehydration, correction of electrolye disturbance and oral/parenteral thiamine
Motivational; interiewing, psychological therapies, self-help groups
Disulfiram: increased acetaldehyde accunulation
Acamprosate: acts on GABA to reduce cravings and risk of relapse
Give 5 examples of atypical antipsychotics?
Typical?
What is the only antipsychotic to have demonstrated superior efficacy to other antipsychotics?
Clozapine: reduces overall mortality from schizophrenia due to reduction in the rate of suicide.
What is the location of action of atypical antipsychotics
D2/D3 antagonists. (Aripriprazole is a partial D2 agonist, full binding decreases dopamine availability by 30%.
Most atypicals are also potent 5hT-2A antagonists
What isthe location of action for typicals?
D2/D3.
Also potent antagonists at cholinergic, adrenergic and histaminergic Rs.
Which atypicals are licensed for the treatment of acute mania?
Risperidone, olanzapine and quetiapine
Which antipsychotic can be used for treatment of violent/agitated behaviour that doesn’t respond to de-escalation?
Haloperiodl in combination with a BZD
What are the side effects assocaited with both atypical and typical antipsychotics?
Cardiac
Anti-cholinergic
Anti-histaminergic
Anti-adrenergic?
Cardiac: prolonged QTc
Dry mouth, urinary retention, constipation, confusion
Sedation
Postural hypotension
AND: Neuroleptic malignant syndrome
What are the features of neuroleptic malignant syndrome?
Hyperpyrexia
Autonomic instability/confusion
Hypertonia
Raised serum CK
What are the side effects seen more commonly in atypicals?
Metabolic?
Clozapine?
Weight gain, impaired GT, dyslipidaemia
Clozapine: hypersalivation, constipation, hypo/HTN, weight gain, fever, nausea, noctuneral enuresis
Seizures. Agranulocytosis
What are the symptoms more commonly seen in typical antipsychotics
Anti-dopaminergic?
Phenothiazines?
Movement disorders: parkinsonism, akathisia
Acute dystonic reactions: torticollis, oculogyric crisis
Tardive dyskinesia
Hyperprolactinaemia: amenorrhea, galactorrheoa, sexual dysfunction, increased risk of breast cancer
Blood dyscrasias
Retinal pgimentation
Photosensitvity
Cholestatic jaundice
What can be used to treat acute dystonia and parkinsonism?
Why?
Procyclidinge.
Reflect drug-induced dopamine/acetylcholine imbalance
What can be used to treat akathisisa?
Beta blockers
BZD
What is the Px for tardive dyskinesia?
What is a potential treatment option?
Irreversible in 50%
Clozapine may treat tardive dyskinesia as well as psychosis
What are the considerations for relapse on antipschotics?
98% relapse if discontinue after 2 years
If patients discontinue medication, taper over at least 3 weeks as stopping suddenly doubles the relapse risk.
What are the tests required prior to commencing antipsychotics?
BMI
ECG
Blood tests: FBC, U&E, lipids, LFT, glucose, prolactin
What class of drug is
Fluoxetine Citalopram Paroxetine Sertraline Fluvoxamine
SSRI
What class of drug is
Venlafaxine
Duloxetine?
SNRI
What are the side effects common to SSRI and SNRI?
Headache
Anorexia
Nausea
Indigestion
Anxiety
Sexual dysfunction
Increased suicidal ideation (not recommended
Withdrawal syndrome
What are the side effects more commonly associated with SSRIs?
GI bleeding
Hyponatraemia in older?
What are the side effects more commonly associated with Venlafaxine?
HTN/hypotension
Cardiotoxic in OD?
What class of antidepressant is mirtazapine?
What are some side effects?
NSST (noradrenergic and specific serotonergic antidepressant)
Dry mouth, drowsiness and weight gain?
Give 4 examples of TCA
What are the common side effects?
Amitriptyline, dothiepine, imipramine, lofepramine
Anticholinergic, antiadrenergic, cardiac arrhythmia, seizures
What are 2 examplers of MAOI and their side effects?
Phenelzine, tranylcypromine
Anticholinergic, antiadrenergic, tyramine reaction
What is an example of a melatonergic agonist?
What are the side effects?
Agomelatine
N, diarrhoea, constipation abdo pain
Increased serum transaminases
Headache, dizziness, drowsiness, anxiety, insomnia, fatigue
Back pain, sweating
AMTS
Orientation (5)
Memory (5)
Score?
Age?
Time?
Year?
Where are we?
Who am I, who is that?
Remember this address: 42 West Street (recall at end)
What is your date of birth?
Who is the prime minister?
When did the 2nd world war end?
Can you count down from 20 to 1?
7-8/10: impairment
What to ask about in psychiatric assessment of children
Current behavioural/emotional difficulty
School behaviour and academic perfromance
Daily routine
Family structure and function
Look for signs of abuse or neglect
What is the aetiology of child abuse
Child
Parent
Chil:
Low birthweight, intellectual or physical impairment, persistently restless or crying
Parents:
Young/single, disadvantaged, isolated, own history of abuse, didn’t want child, unrealistic discipline
What are the signs of childhood abuse?
Physical
Sexual
Other
Unexplained injuries
Age inappropriate sexual talk/behaviour, secondary enuresis, STI, nightmares
Withdrawal/fearful of parents, failure to thrive
What are the effects of child abuse?
Chidhood
Adulthood
Childhood: emotional, conduct, developmental disorders
Adulthood: depression, PD, conversion disorders, deliberate self harm, child-rearing problems
What to do if ?child abuse
Report suspicions to UK social services
Involve police if neede
Individual/family therapy
Disorders specific to childhood:
Behavioural and emotional
Hyperkinetic disorders
Conduct: socialised, unsocialised, oppositional defiant
Emotional: separation anxiety, social anxiety, sibling rivalry disorder
Social functioning: Elective mutism, reactive attachment disorder
Other: enuresis, encopresis
Disorders specific to childhood:
Disorders of psychological development
Pervasive developmental: autism, asperger’s, childhood disintegrative disorder
Specific developmental disorder
What are the disordesr with onset in childhood or adulthood?
Depression
Anxiety: phobias, OCD
Adjustment: bereavement
Psychotic
Sleep problems
What are the diagnostic criteria for ADHD
Core symptoms present for at least 6 months:
Short attention span
Distractibility
Overactivity
Impulsivity
Almost always present by age 7 and present in at least two settings (home/school)
With what comorbidities does ADHD frequently coexist?
Conduct disorder
Anxiety/depression
Language delay
Specific reading retardation
Antisocial behaviour
Clumsiness
Comorbidity has a poorer prognosis (those with comorbid conduct disorde are at particular risk of substance disorders in adolescence)
What is the aetiology of hyperkinetic syndrome
Genetic loading
Social adversity
Parental ETOH abuse
Dietary constituents
Tranquiliser exposure
Management of ADHD
Prsechoold children
School-age and young people (moderate)
Severe
Parent-training/education problems are first line, drugs not recommended.
Group-based parent training/education usually first line. May include CBT/social skills training. Individual psychological therapy may be more appropriate in older children.
Drug treatment next line (reserved for those with severe symptoms and moderate levels of impairment)
Drug treatment first line. (if refused- group-parent training/education.
Methylphenidate, atomoxetine or dexamfetamine
What should be done before starting Rx in ADHD?
History of: syncope, breathlessness and other CV symptoms
HR and BP
Height and weight
FHx of CVD and CV exam
(ECG if FHx of CVD/sudden death)
(Risk assessment for substance misuse)
Methylphenidate indications
ADHD without significant comorbidity/conduct disorder
Methylphenidat or atomoxetine
When tics/tourette’s, anxiety, substance misues or stimulat diversion are present
What is second line Rx for ADHD
What is an adequate trial of methylphenidate?
Atomoxetine
6 weeks
What is the Mx of ADHD in adults
Methylphenidate
If control inadequate/symptoms persist consider second line/CBT if there is persistnet functional impairment
What is the differnece between socialised and unsocialised conduct disorder
Socialised: viewed as normal within peer group or family
Unsocialised: solitary with peer and parental rejection
What is the Mx of conduct disorders
Group/individual parent-training/education programmes
CBT and social skills therapies may target child’s aggressive behaviours or poor social interactions
What is the difference between conduct disorder and oppositional defiant disorder
Characterised by persistent, angry and defiant behaviours
Similar but withoutsevere aggressive or dissocial acts
Rx for OCD in childhood?
Fluoxetine may be prescribed cautiously
What are the 3 peaks of school refusal
5-6y: separation anxiety
10-11y: school transition
Adolescents: low self-esteem and depression
Definition of Enuresis
Non-organic, involuntary bladder emptying after the age of 5
Secondary if there had been a period of urinary continence
What is the Mx of enuresis?
Exclusion of physical pathology (UTI)
Addressing excessive or insufficient fluid intake or abnormal toilating patterns
Reward system for adherence to programme rather than dryness
Enuresis alarms: sense moisture and alert child of need to go
Rx: desmopressin (synthetic ADH) or imipramine (TCA)
Definition of encoporesis
Deposition of stool in inappropriate places in the presence of normal bowel control.
Voluntary faecal retention with subsequent overflow is present in some cases
Mx of encopresis
Exclude organic causes e.g. Hirschprung’s or pain on defecation
Treatment aims to restore normal bowel habits and restore normal parental child relationships. Parents encouraged to ignore soiling and not punish child.
What are the essential diagnostic features of autism?
What may affected children exhibit?
Pervasive failure to make social relationshipships (aloofness, lack of eye contact, poor empathy)
Major difficulties with verbal and non-verbal communication/language development.
Resistance to change with associated ritualistic and or manneristic behaviours.
Inappropriate attachments to unusual objects, restricted range of interests, stereotyped behaviours, unpredictable outbusts
95% have IQ
What is the DDx for autism?
LD, deafness and childhood schizophrenia
What are the aetiological associations of autism?
Fragile X
Tuberous sclerosis
Perinatal complications
Mx of autism
Specialist, intensive behavioural treatments (>25 hours a week)
Family support and counselling
Consider antipsychotic medication for managing behaviour that challenges in children and young people with autism when psychosocial or other interventions are insufficient or could not be delivered because of the severity of the behaviour. Start low and slow
Childhood disintegrative disorder
Characterised by normal initial development and the subsequent onset of a dementia with socail, language and motor regression with prominent stereotypes.
Aetiology includes infections (especially subacute sclerosing panencephalitis) and neurometabolic disorders
Features of childhood schizophrenia
May be acute in onset (better prognosis) or have a prodroe of apparent developmental delay.
As in adulthood, presentation is with hallucinations, delusions and thought disorder but with a greater preoponderance of motor disturbance (particulalry catatonia).
Antipsychotics are the mainstay
NB INCREASED RISK OF WEIGHT GAIN AND METABOLIC SYNDROME.
ADR chlorpromazine
Skin photosensitivity, advise using sunscreen
What are the common presentations of psychiatric disorders in adolescnece?
Emotional upset, identiy issues, conflict with parents, delinquent behaviour and poor school performance
Comorbidity is even more common than in adults
Mx of conduct disorder in adolesence
Psychosocial intervention should be first line
Medciation may be used cautiously if problems are severe:
Atypcial antipschotics (risperidone) may reduce aggressive behaviour, especially in the context of coexisiting PDD (e.g. autism)
SSRI may reduce impulsivity, irritability and lability of mood
Mx of depression in adolescents
Family therapy
Individual psychotherpay (particulalry CBT)
Antidepressants, only fluoxetine is generally recommended due to increase in risk of suicidal thoughts and self-harm in young people on SSRIs
When is the peak age of onset of schizophrenia?
What is the usual presentation?
In younger adolescents?
Late adolescence
Deteriorating school pefromance
Similar clinical presentation
Bizarre behaviour, social withdrawal and anxiety, fleeting first rank symptoms
DDx of schizophrenia in adolescents
Organic states, mood disorder, drug-induced psychosis, adolescent crises and schizoid personality
Indications of Lithium
Prophylaxis in recurrent affective disorder
Acute treatment of mania
Augmentation of antidepressants in resistant depression
Schizoaffective illness
Control of aggression
MOA Lithium
Unknown
Interacts with biological systems in which sodium, K, Ca or Mg involved
At therapeutic blood levels it has effects on neurotransmission
Its interference with cAMP linked receptors explains it action on the thyroid and kidney
What is the therapeutic range for Li
What should be monitored
0.4-1mmol/l
Thyorid and renal function prior to starting and every 6 months whilst taking it
Serum Li levels initially weekly, therafter every 12 weeks. Bloods taken 12 hours after last dose
What are the side effects of Li
nausea
fine tremor
weight gain
oedema
polydipsia and polyuira
exacerbation ofpsoriasis and acne
Hypothyroidism
What are the signs of Li toxicity?
>1mmol/l
Vomiting
Diarrhoea
Coarse tremor
Slurred speech
Ataxia
Drowsiness and confusion
Convlusions and coma
What is the treatment of Li toxicity or overdose?
Fluid therapy to restore GFR
Contraindications of Li
Should be avoided in renal, cardiac, thyroid and Addison’s disease
What can lead to lithium toxicity?
What are the adverse interactions with other drugs?
Dehydration and diuretics
NSAIDs, CCV and some antibiotics
What is an issue with mood stabilisng drugs?
Carbamezapine, litihum and valproic acid are teratogenic nd should be avoided during pregnancy (especially first trimester) and lactation
May affect metabolism of other drugs including OCP necessitating other contraceptive precautions
WWhat are two other antimanic drugs?
Valproic acid (sodium valproate) and carbemazepine
What are te main side effects of carbamazepine?
Nausea
Drowsiness
Dizziness
Blood dyscrasia (monitor FBC every 6 months and warn that unexplained sore throat may herald agranulocytosis)
What are the main side effects of Valproic acid
Nausea
Gastric irritation
Diarrhoea
Weight gain
What are the indications for BZDs?
Anxiolytic, sleep inducing, anticonvulsant and muscle relaxants
Insomnia
ST use in GAD but not phobias or panic disorders
Alcohol withdrawal states
Control of violent behaviour
Also used as 2nd line drugs in refractory epilepsy
What are the uses of zopiclone and zolpidem
Hypnotics without anticonvulsant or msucle relaxing properties
What are the long acting BZDs?
Shorter acting?
Diazepam, chlordiazepoxide, nitrazepam
Lorazepam, oxazepam and temazepam
What is a BZD used in ST treatment of anxiety?
Buspirone
What is the MOA of BZDs?
Potentiate the inhibitory effects of GABA
Buspirone is a 5HT1a partial agonist
What are the side-effects of BZDs
Drowsiness
Ataxia
Amnesia
Dependance
Disinbinition
Ptoetniate alcohol and other sedatives
What are the signs of BZD overdose?
Mx
Respiratory depression
Drowsiness
Dysarthria and ataxia
Flumazenil- a selective BZD antagonist (can be hazardous in mixed OD e.g. with TCA or in BZD-dependant patients)
What are the features of BZD withdrawal?
Marked anxiety
Shakiness
Abdo cramps
Perceptual disturbance
Persecutory delusions
Seizures
What are the side effects of stimulants
Decreased appetite and weight loss
Anxiety
Agitation
Insomnia
What drugs are currently available to treatt AD, LBD and PD dementia?
Cholinesterase inhibitors: donepezil, rivastigmine and galantamine
Glutamate antagonist: memantine
Rivastigmine can be fiven as a transdermal patch
What are the common side-effects of cholinesterase inhibitors?
GI: ND anorexia
Dizziness, syncope, bradycardia
Rash
Muscle cramps
Urinary incontinence (and potentially retention)
What are the common side effects of memantine
Constipation
HTN
Dyspnoea
Headache
Dizziness
Drowsiness
Genetic basis of DS
Chromosome 21
95% trisomy
5% translocation
Genetic basis of fragile X
X linked dominant condition. accounts for 8% of males with LD
M>F
Features of DS
LT
Flat occiput
Oblique palpebral fissures
Small mouth
High arched palate
Broad hands, single transverse palmar crease
50% have caridac septal defects
15% have mild LD, other moderate or severe
5% have autistic traits
Alzheimers develops after age 50
Hypothyroidism
Features of Fraglie X
Most males and a third affected females have LD
15-55% have autism
Large head and ears
Poor eye contact
Abnormal sppech
Hypersensitivity to touch, auditory, visual stimuli
Hand flapping
Hand biting
What are the two most common specific causes of LD?
DS and Fragile X
What is the definition of LD?
Low intellectual performance
Onset at birth or in early childhood
Reduced lifeskills
What are some genetic causes of LD?
Chromosomal
X0linked
Autosomal dominant
Autosomal recessive
What else?
Chromosomal: DS
X-linked: Fragile X, Lesch Nyhan
AD: Tuberose scelrosis, neurofibromatosis
AR: usually metabolic disorders e.g. PKU
Autism is usually associated with LD
What are some antenatal causes of LD?
Infective: toxoplasma, rubella and CMV
Hypoxic or toxic or related to maternal disease
What are some perinatal causes of LD?
Prematurity, hypoxia, intracerebral bleed
What are some post natal causes of LD?
Infection, injury, malnutirtion, hormonal, metabolic, toxic, epileptic
How is LD classified?
Proportion of LD?
Mild: 50-70 80%
Moderate: 35-49 %12
Severe: 20-34 %7
Profound
What are the causes of mild vs other classifications of LD?
Mild is usually due to limited social/learning opportunities and genetic low IQ
Moderate-Profound LD is more typically associated with a specific biological cause
Self care for different classifications of LD?
MIld: can live independently and have employment May have difficulty coping with stress and more complex social functioning.
Moderate: usually need supported accomodation
Severe-Profound, very limited skills
Language, motor and sensory abnormalities in different classifications of LD?
Mild: slight or absent, 6% have epilepsy
Moderate: Limited but useful language
Severe-Profuound: very limited language, 1/3rd have epilepsy, 10% incontinent, 15% cannot walk
What is the prevalence of psychiatric disorders in LD?
Why?
Increased in people with LD
Genetic, organic (esp. epilepsy), psychological and social factors eg stigma
Why is making a psychiatric diagnosis difficult in LD?
Diagnostic overshadowing
What are some disorders with increased prevalence in LD?
Behavioural disorder (increases with severity of LD)
Depression (diagnosis relies on motor or and behavioural changes rather than verbal expressions of distress)
Anxiety disorders (eg. OCD and phobias)
Dissociative symptoms
Schizophrenia (3% prevalence in LD, presents with simple and repetitive hallucinations and unelaborated, usually persecutory delusions
Mania: usually presents as overly irritable behaviour
What is Makaton?
A communication system used in LD using signs and gestures
What is the prevalence of depression in pregnant women?
When is it more common?
How does pregnancy effect the risk of psychosis?
What about other mental illnesses?
10%
More common in those with, PPHx, conflicting feelings about the pregnancy, a history of sexual abuse as a child, USS showing fetal anomalies
Only increased if prophylactic medication is stopped, e.g due to teratogenicity.
Substance misuse decreases, suicide also decreases (those that occur often associated with substance misuse)
What is the risk of recurrence of serious mood disorder postpartum? (either affective or affective psychosis)
1/
2-1/3
What are the features of postpartum blues?
First 10 days postpartum, 50-70% of delivers
Symptoms: emotional lability, crying, irritability and worries about coping with the baby
Self-limiting but severe blues increases risk of depression
No intervention required apart from reassurance although if symptoms persist, assess for depression
Features of postpartum depression
Cllinical features for depression but incudes
guilt and anxiety re baby
feelings of inadequate mothering
unreasonable fears for the baby’s health
reluctance to hold/feed the baby
thoughts of harming the baby.
Can persist for a year or more
What are the risk factors for post-partum depression
Mother: Hx of depression, low monthly income, no post-16 education, unemployment
Relationships: unmarried, relationship dissatisfaction, domestic violence, few confiding relationships
Baby: premature, severe cardiac defects, multiple births
What is a consideration for pregnant women taking an antipsychotic
Metabolic syndrome/gestational diabetes
What is the Mx for a women with mild-moderate depression in preganancy or the postnatal period?
Facilitated self help
Mx for a woman with a history of severe depression who initially presents with mild depression in pregnancy or the postantal period?
Conisder, TCA, SSRI or SNRI
Mx of a woman with moderate or severe depression in pegnancy or the post natal period?
High intensity psychological intervention i.e. CBT
TCA/SSRI/SNRI
What should be done if a woman taking TCA, SSRI or SNRI for anxiety/depression becomes pregnant?
Stopping medication gradually
Continuing medication if she understands risk
Chaning medication
Combining medication with a high intensity psychological intervention
If a pregnant woman develops mania or psychosis and is not taking psychotropic medication?
Offer antipsychotic
If a woman with bipolar disorder becomes pregnant, action
Offer antipsychotic if she is stopping lithium or plans to breastfeed.
Consider psychological intervention
For pregnant women with severe depression, severe mixed affective states or mania, or catatonia, whose physical health or that of the fetus is at serious risk, Mx?
ECT
Risk of Li to fetus
Increased risk of teratogenicity, we are not sure of degree of risk
Mx of postpartum psychosis
Usually hospitalisation, should be with baby to a specialist mother-and-baby unit
Treatment is usually with antipsychotics
ST prognosis is excellent
What is a consideration for breast feeding women and psychotropic medications?
Should be advised to time feeds to avoid peak drug levels in milk and how to recognise ADRs in child
What antidepressants are indicated in pregnancy and why?
TCAs have lower known risks during pregnancy however most have a higher fatal toxicity index than SSRIs
Sertraline has the lowest known risk during pregnancy (avoid paroxetine as associated with fetal heart defects and neonatal pulmonary HTN), SSRIs are associated with a neonatal behavioural syndrome
Which antidepressants are found in breast milk?
Imipramine, nortiptyline and sertraline are present in breast milk and relatively low levles.
Citalopram and fluoxetine at relatively high levels
What type of antipsychotics have lowest known risks in pregnancy?
Typical antipsychotics e.g. haloperiodl, chlorpromazine or trifluoperazine
What can BZD cause in pregnancy?
Cleft palate and other fetal malformations
What is premenstrual dysphoric disorder
Symptoms include low mood, insomnia, poor concentration, irritability, poor impulse control, food craving and physical complaints
Onset after ovulation with rapid relief within 24 hours of the onset of menstrual flow.
With what symtpoms of depression are older adults more likely to present?
Disturbed sleep
Multiple physical problems for which there is no obvious cause
Motor disturbance
Dependancy having been previously independant
MX for depression in older people
SSRI, (TCA shouldn’t be started in primary care, although amitryptilline often prescribed for those with chronic pain, shoulnd’t coprescribe SSRI and TCA)
Mirtazepine is useful when poor sleep and anxiety and main symptoms
Psychological therapies
Physical activity e.g exercise
Psycho-social interventions
Why are TCAs often avoided in older people?
Due to risk of postural hypotension and subsequent falls
What is an issue with depression and dementia?
There is some evidence that antidepressants are not effective in dementia, so consider other treatment first unless severe depression/risk of suicide
What are some secondary treatment options in the treatment of depression in an older person?
Trial SSRI for 4 weeks, if inadequate resposne consider switching to alternative class. NB can take up to 8 weeks to have an effect.
Lithium augmentation is effective in some patients with refractory depression
ECT is very effective in more severe depression, particulalry in patients with delusions, psychomotor retardatio or those refusing food or fluid in whom the risk of irreversible physical deterioriation is high
Px of depression in older people?
Depression doubles mortality rate due to increased medical morbidity and increased risk of suicide
Prognosis improves with early intervention, there is high risk of chronicity and of relapse.
Secondary prevention, i.e. continuing antidepressant therapy to prevent relapse is highly effective
What is seen in about 20% of cases of new onset mania in older age?
Precipitated by acute physical illness such as stroke
What are the features of mania presenting in older age?
1/10 of new onset mania in >60.
Overt elation tends to be less present although patient has grandiose ideation.
The clinical picture more commonly consists of irritability, lability of mood and perplexity, much like deleirum but distinguishable by clear consciousness
What are the considerations for the Mx of mania in older patients?
Antipsychotics effective as acute treatment and some, e.g. Olanzapine are effective at preventing relapse.
Atypicals should be used with caution due to increased risk of VTE or stroke
Lithium may also be used although 25% of older people develop neurotoxicity (particulalry in those with PD or dementia), therapeutic and toxic levels may be lower
When is the second peak for the incidence of schizohprenia?
40-60= late onset
>60= very late onset
What are the aetiological factors in schizophrenia first occuring in an older person?
Genetic component
Sensory deprivation eg deafness
Social isolation
Brain imaging abnormalities
Organic brain disease
What is a consideration for typical antipsychotics in older patients?
At incresed risk for tardive dyskinesia
ICD-10 defintiion of somatoform disorder
>2 years of multip[le physical symptoms with no physical explanation
GI and skin complaints are the most common
W>>M
What are dissociative convulsions?
Non-epileptic seizures (NB can co-iccur with epileptic seizures)
Ganser syndrome
(aka nonsense snydrome, balderdash syndrome, syndrome of approcximate answers, pseudodementia, or prison psychosis)
Rare dissociative disorder
Nonsensical or wrong answers to questions or doing things incorrectly, other dissociative symptoms such as fugue, amnesia or conversion disorder, often with visual pseudohallucinations and a decreased state of consciousness
Reaction to extreme stress although can be grouped with fictitious disorders
What are the features that suggest organic problems?
FLAVOUR
Fluctuating symptoms
Localised specific cognitive deficits
Associated neurological signs
Vague or transient paranoid delusions
Olfactory or visual hallucinations
Untypical symptoms of a functional disorder
Record of cognitive disorder before other psychiatric symptoms
What are the acute effects of brain injuries and stroke?
Disturbance of consciousness
Amnesia
Behavioural disorders
In TBI/CVA what is associated with worse cognitive outcomes?
Longer duration of post-traumatic amnesia (loss of memories about the injury and subsequent events)- more accurate than retrograde amneisa
Duration of LOC >24h
What is the aetiology of hte psychiatric sequalae of CVA and TBI?
Direct neurophysiological effects e.g. cognitive disorders, temporal lobe injuries and psychosis.
Psychosocial impact of sudden disbility-> anxiety and depression
Lability of mood and apathy may be particulalry prominent
What are the categoires for psychiatric symptoms in people with focal neurological disorders?
Personlaity and behavioural changes
Depression and anxiety
Cognitive disorders
Psychiatric disorders
What are personlaity/behavioural changes seen in focal neurological disorders?
Frtonal lobe injury: disinhibition, aggression, impullsivity, apathy
Catastrophic reactions: bursts of aggression, anxiety, crying and uncontrolled crying or laughing (20% post stroke)
What are the cognitive disorders seen following focal neurological disorders?
Punch drunk syndrome: e.g. in boxers
Vascular dementia from CVA
Chrnic cognitive impairment: visuospatial neglect, impaired learning, decreased attention, apraxia
Dementia pugilistica
Punch drunk syndrome
Chronic traumatic encephalopathy: neurodegenterative disease with features of dementia.
Symptoms include dementia, problems with memory, ataxia, parkinsonism
May be prone to inappropriate or explosive behaviour
What are the psychotic disorders associated with TBI?
BPAD: especially rapidly cycling which is increased after TBI
Psyhcosis common after temporal lobe injury
What are the affective disorders seen after TBI?
Depression in 1/3
Anxiety in 1/4
Increased risk of suicide (5% after TBI)
What are the features of post-concussional syndrome?
Anxiety, irritability, insomnia, reduced concentration, depression, emotional lability, hypersensitivity to noise/light, chronic tiredness.
Maybe organic basis
No specific treatment
What is the UK prevalence of epilepsy?
Epidemiology?
0.5-1%
M>F
Onset
Most common type is complex focal
Present in 25% of people with LD
What are some aetiologies of epilepsy?
Cerebrovascular disease (15%)
Cerebral tumours (6%)
Alcohol related seizures (6%)
Post-traumatic seizures
What are the psychiatric aspects of epilepsy, categorised by stage in seizure?
Pre-ictal: depression can occur, psychosis rare
Ictal: depression can occur, psychosis rarely occurs as part of simple, partial, complex parital or absence seizures
Post-ictal: depression is relatively common, psychosis in 6-10% with intractable epilepsy, begins months
Inter-ictal (disturbances are chronic and not related to the ictal electrial discharge): depression very common, psychosis can develop in those with recurrent post-ictal episodes, usually associated with temporal lobe epilepsy, symptoms very similar to schizophrenia
Features of depression in epilepsy
Aetiology
Mx?
Affects 30-50% of people with epilepsy at some point
Aetiology includes: demoralisation/stigma, possibly lesion location, anti-epileptic drugs (phenobarbitone and vigabatrin, FHx of depression), adverse life effents
Depression can indirectly increase seizure frequency through the mechanism of sleep deprivation.
Careful Rx with antidepressants, SNRIs and SSRIs are recommended as lower seizure threshold.
ECT if necessary
Carbamezapine and lamotrigine are anti-epileptic agents that may also improve mood
Which SSRI is recommended in the treatment of depression in epileptics?
Citalopram as it is least likely to interact with anti-epilepsy drugs
What are the features of post-ictal psychosis
Most common form of pschosis in epilepsy
Should be distinguished from delerium
Can occur up to a week after seizure.
Symptoms include delusions, depressive or mani psychhosis, bizarre thoughts and behaviour, visual hallucinations are common.
What is the treatment of psychosis in epilspy?
Rx with antipsychotis, preferably those with least effect on seizure threshold e.g. sulpiride and haloperiodl
What are pseudo seizures?
AKA dissociative convulsions
Can simulatem real seizures and occur in 20-30% of people with chronic treatment-resistant epilepsy
Frequent, occur when other people are present, have an emotional precipitant, associated with a history of childhood sexual abuse
EEG is normal during the attack
What are the psychiatric complications of MS?
Cognitive deficits, dementia (demyleniation)
Depression (stress rather than disease process, or drug treatment: steroids, baclofen, beta interferon)
Mania: disease process, drugs e.g. steroids, baclofen
Euphoria/elation, emotional lability, pathological laughing/crying: disease process
Affective disorders increased but nonaffective psychosis is no more common.
Those with psychosis are more likely to have plaques in bilateral temporal horn areas
What are the psychiatric complications in SLE?
Cognitive impairments: disease process, usually acute confusional states (due to CNS vasculitis/encephalopathy
Depression: psychoscoial stress, disease process, iatrogenic (e.g. steroids)
Psychosis uncommon
What is the pathogenesis of PD?
Deficient striatal dopaminergic activity
What are the psychiatric complications of PD
Depression and anxiety (40%): diease process (dopaminergic, serotonergic, cholinergic limbic pathway dysfunction), psychosocial factors
Dementia (30%): disease process
Other cognitive impairments: disease process, iatrogenic or related to depression
Psychosis (25%): iatrogenic, disease process
Apathy (40%): disease process
Impulsivity (
What are the features of psychosis in PD?
Visual hallucinations and persectuory delusions, sometimes with pathological jealousy.
More common in people with cognitive impairment and on increasing antiparkinsonian medication
Rx of depression and pschosis in PD?
Drugs with a relatively low risk of extrapyramidal SEs
e.g. quetiapine
citalopram
Features of psychiatric considerations for HD?
Cerebral atrophy and reduced GABA resulting in dopamine hypersensitivity.
Songitive impariments usually progress to subcortical dementia.
Psychiatric disturbances are common in HD. Depression can preced other symptoms
Increased risk of suicide (
Treatment is symptomatic and dpression and psychoses should be treated with standard medications.
Atypicals preferred due to reduced impact on motor symptoms
Hepatolenticular degeneration
Psychiatric complications
Wilson’s Disease
Cognitive impairments that usually progress to subcortical dementia (disease process)
Irritablity/aggresion (inability to communicate, executive dysfunction
Apathy: iatrogenic, depression
Depression: psychosocial stress, disease process
Mania and psychosis: disease process
Cause of Wilson’s?
Rx?
Excess Cu deposition in the lenticular nuclei (autosomal recessive)
Penicillamine
Symptoms of narcolepsy
Mx
Excessive daytime sleepiness, cataplexy, sleep paralysis, hypnogogic hallucinations
Methylphenidate or modafinil
Features of REM sleep disorder
Individuals act out dreams due to lack of atonia during rem sleep
Treatment with clonazepam and making sleep environment safe
Can be idiopathic or associated with PD, LBD or GB
Coprolalia
Copropraxia
Involunatry swearing
Involuntary rude sign
Difference between stereotypy and mannerism
Stereotypy: involuntary patterned, coordinated repetitive, rhythmic and nonreflexive features. Tend to occur in clusters and are asoociated with periods of stress, excitement fatigue or boredom- suppressible
Mannerism: odd, idiosyncratic METHOD OF PERFORMING A TASK that is unique to an individual and serves no apparent function (ie, a person who cocks an arm in a peculiar way in order to drink from a cup; a ballplayer who performs ritualistic acts “for luck.”).
Note that stereotypies have no function/purpose while mannerisms are a purposeful movement.
Treatment of tourettes?
Psychoeducation
Medication: antipsychotics for tics, clonidine +/- stimulants for ADHD
Behavioural therapy
Why is there a sizeable populaton of people suffering from both HIV and psychiatric illness?
HIV increases the likelihood of psychiatric illness e.g. crises following diagnoses
Impulsive behaviour associated with some mental illnesses may lead to HIV infection
What are the psychiatric considerations for HIV patients?
Depression is common at all stages. Dx may be difficult: apathy and fatigue may be due to retroviral therapy. Fatigue and weight loss may be due to progression/decline in CD4 count/
AIDS-related dementia may also present as a depression like illness. Occurs with a very low CD4 count, thought to be a direct manifestation of HIV infection in the brain. Opportunistic infections may also contribute to the dementia syndrome
What is the most common cause of viral encephalitis in the Wst?
What are the psychiatric consideratoins
Herpes simplex
Presentation ussually with severe headache, vomiting and reduced consciousness but occasionally can present with psychosis, seizures of delerium.
At least 50% of survivors experience disturbed behaviour, concentration or social adjustment. Some with chronic cognitive impairment
What is a type of tertiary syphillis? Symptoms?
What is the diagnostic test and Rx?
General paralysis of the insane: personality changes (disinhibition, irritability, lability), cogntive changes (poor concentration), dementia, depression, grandiosity and rarely mania and schizophrenic-like psychoses.
VDRL
IM penicllin
What is the presentation of prion disorders?
Rapidly fatal dementia associated with myoclonic jerks.
sCJD presents with physical symptoms
vCJD presents more frequently with psychiatric symptoms (mood swings, fatigue, social withdrawal)
What is a psychiatric consideration for acute intermittent prophyria?
Clinical presentation may be abdominal or neurological. Psychiatric distrubances can include delerium, depression, emotional lability and schizophrenia like psychoses.
What is a psychiatric consideration for B12 deficiency?
Pernicious anaemia which may be accompanied by subacute degenration of the spinal cord
Psychiatric symptoms include slowing of mental processes, confusion, memory problems, intellectual impairment, depression and paranoid delusions
How can hyperthyroidism present?
Depression/anxxiety
Behavioural disturbance
Psychosis
Cognitive changes
Anxiety/depression
Irritability, apathy and poor appetite in older people
Psychotic depression reported
N/A
How can hypothyroidism present
Depression/anxxiety
Behavioural disturbance
Psychosis
Cognitive changes
Depression/anxiety
Acute aitation
Hallucinations
Dementia/delerium
How can hyperparathyroidism present?
Depression/anxxiety
Behavioural disturbance
Psychosis
Cognitive changes
Depression
apathy/emotional lability
Hallucinations occasionally reported after parathyroidectomy
Occasionally memory deficits, poor concentration, cognitive impairment, delerium after parathyroidectomy
How may hypercorisolaemia present (usually iatrogenic)
Depression, mania
How may hypocortisolaemia present?
Depression, apathy
How may hypopituitarism present?
Depression, iritability, impaired memory
How may phaeochromocytoma present?
Episodic anxiety
What are the diagnostic criteria for delerium?
Impaired consciousness and attention
+
perceptual disturbance (usually visual hallucinations or distortions of perception (macro/micropsia)
or cognitive disturbance (decreased concentration, memory, orientation, thinking slow or muddled, distractible with incoherent/difficult to follow speech)
+
Developed over short period of time and fluctuant (often worse at night)
+
Evidence it may be related to a physical cause
What are the three subtypes of delerium?
What are the other features?
Hypoactive
Hyperactive
Mixed
Mood and affect may fluctate and may be accompanied by irritability/perplexity or apathy and depression
Transient delusions are common, may be secondary to abnromal perceptions and often persecutory with associated ideas of reference.
Sleep/wake cycle distrubance
What are the at risk groups for delerium?
>65 y/o
People with diffuse brain disease e.g. demetnia
People with current hip fracture
Severely ill
What is an important consideration for the ddx for delerium?
Other possible diagnoses?
Difficult to distinguish from LBD in which cognition typically fluctuates
Functional psychiatric conditions (mania, depression and late-onset schizophrenia)
Response to major stress
Dissociative disorders
What are the clinical features that differentiate delerium and dementia?
Rapid vs slow
Fluctuant vs progressive
Clouded vs alert consciousness
Vivid complex and muddled thought content vs impoversihed
Hallucinations very common and predominantly visual vs auditory or visual in 1/3
DDx
D
E
L
E
R
I
U
M
S
Drugs
Eyes, ears and other sensory deficits
Low O2 states (i.e. heart attack, stroke and PE)
Infection
Retention of urine/stool
Ictal state
Underhydration/undernutrition
Metabolic causes (DM, post-operative state, Na abnrormalities)
Subdural haematoma
Ddx Delerium
I
W
A
T
C
H
D
E
A
T
H
Infection: HIV, sepsis, pneumonia
Withdrawal: ETOH, barbiturate, sedative-hypnotic
Acute metabolic: acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure
Traemua: closed-head injury, heat stroke, postoperative, severe burns
CNS pathology: Abscess, haemorrhage, hydrocephalus, SDH, infection, seizures, stroke, tunmours
Hypoxia: Anaemia, CO poisoning, hypoTN, pulmonary or cardiac failure
Deficiencies: B12, folate, niacin, thiamine
Endocrinopathies, hyper/hypoadrenocorticism, hyper/hypoglycaemia, myxoedema, hyperPTH
Acute vascular: hypertensive encephalopathy, stroke, arrythmia, shock
Toxins/drugs: prescription durgs, illicit drugs, pesticides, solvents
Heavy metals: lead, Mn, mercury
Ix Delerium
Collateral history: premorbid level of function
MSE
Physical examination, focal neurology
Breathalyser
MSU, pregnancy test, urine drug screen
CXR
CT/MRI Head
Bloods:
FBC: anaemia, macrocytosis, leucocytosis
ESR/CRP
U&Es: dehydration, electrolye imbalance
Glucose
TFT
LFT
Ca
Folate and B12
VDRL
Consider EEG if epilepsy is ddx
How to prevent delerium
Maximise orientation: treat senosry impairment, clear signage, clocks and calendars, appropriate lighting
Prevent causes of deleirum: polypharmacy, constipation and dehydration, infection (avoid unnecessary catheterisation), assess for hypoxia and maximise O2 sats
Promote well-being: encourage mobilisation, good pain control, diet, sleep hygiene, social interaction.
Mx of delerium
What is a consideration for PD or LBD?
Treat underlying cause(s)
If person is distressed/risk to him-self and not responding to verbal de-escalation consider using pharamcology: low dose and ST antipsychotics: haloperidol and antipsychotics.
Do not use antipschotics in individuals with PD or LBD
What is CAM?
Confusion Assessment Method
A: acute onset and fluctuating course
B: inattention
C: disorganised thinking
D: altered level of consciousness
Px of delerium
Increases risk of dementia
Mortality
Length of hospital stay
Risk of new admission to LT care
Diagnostic criteria for dementia
What is often present?
Multiple cognitive deficits e.g. memory, orientation, lanuage, comprehension, reasoning, judgement
+
Resulting impairment in ADLs
+
Clear consciousness
Behavioural proglems, depression and anxiety, psychotic symptoms, sleep problems
What is the epidemiology of dementia?
25% >90
What factors increase the risk of later life dementia?
Low educational attainment
Obesity
Untreated systolic HTN
Depression
Mental, social and physical inactivity
What are the relative prevalences of the most common types?
AD 55%
Mixed AD and vascular 25%
LBD 10%
Frontotemporal dementia 5%
Other 5%
How can dementias be classified?
Cortical or subcortical altough usually pathology involves both areas and the clinical features overlap
What areas of the brain are affected in Cortical dementia
Eg?
Typical symptoms?
Cerebral cortex
AD, LBD, frontotemporal
Memory impairment, dysphasia, visuo-spatial impairment, problem-solving and reasoning deficits
What are the areas of the brain affected in subcortical dementias?
Eg?
What are the typical symptoms?
BG, thalamus
PD, HD, AIDs dementia, ETOH-related dementia
Psychomotor slowing, impaired memory retrieval, depression, apathy, executive dysfuntion, personality change, language relatively preserved
Features of AD?
Gradual onset usually with memory loss
Features of vascular dementia
Patchy cognitive impairment, focal neurological symptoms that appear in a stepwise fashion rather than continuous deterioriation
NB many people have a mixed picture
What are the considerations for vascular dementia and stroke
Stroke-> 9x increased risk of dementia in the following year
What are the vascular risk factors for VD and AD?
HTN
Hypercholesterolaemia
DM
Smoking
What are the features of LBD?
Fluctuating cognition and alertness, vivid visual hallucinations, spontaenous parkinsonism, sensitivity to neurlopetics and sleep disorder
Associated with LB and neurites in the basal ganglia and the cerebral cortex
What is Parkinson’s disease dementia?
Where Parkinson’s disease predates the dementia by more than a year
What are the features of frontotermporal dementia?
Younger mean age of onset, characterised by early personality changes and relative intellectual sparing.
What are the features of normal pressure hydrocephalus?
May be idiopathic or due to SAH, head injury or meningitis
Marked mental slowness, apathy, wide-based gait and urinay incontinence.
Ventriculoatrial shunting leads to frequent complications and tends to benefit only patients with prominent neurological signs and mild dementia
What is seen in motor neuron disease
Dementia is FTD
Mx of dementia (AD)
Exclude treatable cause, NB superimposed acute confusional state, depression sometimes precedes or complicates established dementia and has a poor SSRI response. Control vascular risk factors
Structured group cognitive stimulation programme.
Rx: AChE inhibitors for management of mild-moderate AD: donepezil, galantamine and rivastigmine
Memantine: NMDAR antagonist indicated in those with moderate AD who have intolerance to AChE or in severe AD
What are the consideration in people with Alzheimer’s disease, vascular dementia or mixed dementias with mild-to-moderate non-cognitive symptoms
Should not be prescribed antipsychotic drugs due to the possible increased risk of CVA
What is pseudodementia
Severe depression in old age which may present with prominent forgetfulness and self-care
What are the features of supportive therapies
Indications
Unstructured
6-10 sessions
Establishing rapport, facilitating emotional expression, reflection, reassurance
Non-directive problem solving
e.g. for adjustment disorders, stress, bereavement, mild depression or anxiety
Feature of CBT
Indications
Structure
Explicit
Time limited 6-12 sessions
Cognitive: identify automatic negative thoughts and core beliefs, behavioral graded exposure, activity scheduling
Behavioural therapy: ABC (antecedents, beaviour, consequences
e.g. for depression, anxiety, eating disorders, personality disorders, psychotic disorders
Features of psychodynamic therapies
Indications
Unstructured
Often for years
Freee association
Transference (the redirection to a substitute, usually a therapist, of emotions that were originally felt in childhood (in a phase of analysis called transference neurosis)
Counter-transference (Countertransference occurs when a therapist transfers emotions to a client. It is often a reaction to transference, a phenomenon in which a client redirects his or her feelings for others onto the therapist.)
PD
Features of DBT
1 year. BPD
What is the aim of CBT?
To help individuals identify and challenge automatic thoughts and then to modfiy any abnormal underlying core beliefs.
What are the basis of behavioural therapy
Operant condition: support (reinforcement), witholding reinforcement (negative)
Criteria for giving ECT in England (MCA)
Patient consents (before every treatment)
Patient lacks capacity and it does not conflict with advance decision
It’s an emergency and independant consultant has not yet assessed or agrees
What are the indications for ECT?
Severe depressive illness
Prolonged, severe episode of mania that hasn’t responded to treatment
Catatonia
Moderate depression that has not responded to mltiple drug/psychological treatments
What is a consideration following CT
Patients would need subsequent treatment for depression to prevent relapse e.g. with psychological and pharmacological therapy
What are the realtive contraindications to ECT?
Raised ICP
Recent stroke
Recent MI
Crescendo angina
(No absolute contraindications
What are the adverse effects of ECT?
What is the Mx of these?
Patients have reported that it can cause cognitive impairment.
Anaesthetic complications
Dyshythmias due to vagal stimuation
Post-ictal headache.
Confusion
Retrograde and anterograde amnesias
Cognitive function should be assessed before, during and after course of treatment.
If there is evidence of any significant cognitive impairment at any stage consider chaning from
bilateral to unilateral electrode placement
stimulus dose
stopping treatment
What are the only two neurosurgical psychiatric procedures currently performed?
Indications?
Bilateral anterior capsulotomy or anterior cingulotomy are performed
Severe treatment-resistant depression and OCD
40-60% success rates reported
What proportion of primary care consultations relates to mental health?
How do mental health issues impact on the likelihood of a primary care consultation?
1/4
Doubles tthe likelihood
What is IAPT and its function?
Improving access to psychological therapies
To increase the avaialbility of psychological therapies for depression and anxiety either through computer-aided CBT or are stepped up to CBT or other evidence based psychological treatments
What constitutes a CMHT?
Psychiatrists, community pschiatric nurses, social workers, OTs and psychologists
What is the CPA?
How is it reviewed?
Care Programme Approach
CPA meetings take place every 6 months to devise a care plan documenting those involved in patient’s care, the treatment plan, early relapse indicators and a crisis plan should the patient’s mental health deteriorate
Each patient has a care coordinator who implements the plan, sees the pt monthly and monitors their metnal state
What are the three main types of supported accomodation
Who runs them?
Residential care
Supported housing
Floating outreach
Social services, voluntary and independent sector organisations.
What determiens the level of support a patient receives?
Their ability to self-care and the nature of their illness
What is STaR
Support, Time and Recovery, help service users to access a range of daytime activities
What is the function
Service
For Whom
Aim
of CRT
Intensive home support
People in MH crisis
To prevent admissions and support early discharge
What is the function
Service
For Whom
Aim
of AOTs?
Assertive outreach teams provide treatment and support in the community
People who are chronically unwell with a history of disengaging from mental health services
To provide care in a difficult to reach treatment group
What is the function
Service
For Whom
Aim
of EIS
Early Intervention in psychosis provide inensive treatment for the first 2-3 years of illness with a focus on promoting return to employment and education
Patients newly diagnosed with psychosis.
Promoting recovery in early stage of psychotic illness where evidence suggests treatment may be most effective
What is the function
Service
For Whom
Aim
of Community rehabilitation team
Provide treatment and support for adults with especially complex mental health needs
What is the function
Service
For Whom
Aim
of Memory services
To aid with diagnosis and management of dementia in people with memory problems
To increase diagnosis of dementia (
What increases the risk of violent crime in schizophrenia?
Substance abuse
How can risk of violence be assessed?
Important for assessing compulsory detention
Distinguish between:
Crime against property and violence against person
Crimes occuring during periods of illness and those during remission
Precursors to past violence and the risk of recurrence.
What are the criteria for capacity?
Understand information relevant tot he decision
Retain, use and weight that information
Communciate that decision
What does the MCA allow?
If capacity: advance decision, LPA
and
says how to decide if someone has capacity
and
For adults without capacity allows professionals to
act in best interests
consult family/friends about decisions
appoint IMCA for important decisiosn
Apply DoLs to anyone deprived of liberty
What are the criteria for DoL?
>18y/o
It would not conflict with LPA,Court of Protection or advanced decision
Person lacks capacity to decide whether to be admitted
Suffering from mental disorder
Not detained under MHA
Application is not to enable mental health treatment in a hospital (should be under MHA0
It is in person’s best interests and necessary and proprotionate to prevent harm
2 assessors must agree
R/V at least annually. Patient or representative may appeal
Compulsory admission (Section 2,3 (4))
A patient is judged to have a mental health disorder sufficiently severe to need detention i hospital in the interests of hisher own health/safety or for the protection of others.
For those detained under longer sections, appropriate medical treatment must be available to them
People cannot be detained due to LD alone, must be associated with dangerous conduct
Process of sectioning
Appliation made by AMHP (social workers, nurse, psychologist, OT, NR)
Application is made on the recommendation of two approved clinicans (Section 12 approved- can be doctors, doctors with previous knowledge of the patient can make the recommendation even if they are not section 12 approved)
For section 3 the AMHP has to consult NR and if they disagree the responsible clinician takes legal action to displace the NR.
Features of CTO
Treatment in community of patient previously detained under 3/37.
6 months
Section 4
Urgent assessment from community with no time to arrange section 2
1 doctor (AC)
72 hours
5(2)
Urgent detention of in-patient. (not A&E)
1 doctor
72 hours
5(4)
Urgent detention of psychiatric inpatient in absence of doctor
RMN
6 hours
Section 135
Removal from home to place of safety.
Police officer
72 hours
Section 136
Removal from public place to place of safety
Police office
72 hours
Process after 5(2)
Must either be assesssed for section 2/3 or discharged to become an informal patient
Guardianship (sections 7 and 8)
A guardian (usually an AMHP) nominated by local authority is empowered to ensure that an individual resides at a pecific palce, attends specific places for treatments etc and allows specified people access to their residence
Discharge from a section 2/3 before its expiration
Section 17 requires that patients on compulsory sectiosn can only have leave subject to the RC’s specific instrcution.
Patients can be fully discharged from a section before its expirationb y the RC, a MHRT (to whom patients can appeal within 14d for Section 2 or at any time during the first 6 m of a section 3). By a Mental Health Act managers (community members who act as nonexecuitve directors of a hospital) if patient appeals to them. By NR if not overuled by RC.
Section 35
Remands an accused person to hospital for a report
1 doctor
Crown/magistrates court
28d
Section 36
Remans accused person to hospital for treatment
2 doctors
Crown court
28d
Section 37
Orders hospital admission or guardainship of a person convicted of imprisonable offences (except murder)
2 doctors
MC/Crown Court
6m
Section 38
Sends convicted pesron to hospital to treatment prior to senetencing
2 doctors
CC/MC
28 days
Section 41
Applies restriction that patient on another hospital section may notbe given leave, transferred or discharged without the Home Secretary’s consent
1 doctor
Crown Court
Duration of section
Section 47
Transfers sentenced prisoner to hospital for treatment
2 doctors
Home office
6 months
What are the emergency sections?
Can patients be treated without consent?
5(2), 135, 136, 4
No except in an emergency
What are the provision for treatment under section 2 and 3
May be given medication for first 3 months
Section 58, may be given medication/ after 3 months only with patient consent or an independent second opinion approved doctor agrees treatment after interviewing patient and discussing treatment with RC and two other professionals involved in the patients treatment
SOAD also required for ECT if given to patients without capacity
ECT cannot be given to patients with capacity without consent
Section 57
Psychosurgery/surgical hormone implants
Needs both consent and SOAD
Section 62
Life-saving treatment
Exempt from 58 and 57
Diagnosis
a 1 week
b 2 weeks
c 3 weeks
d 1 month
e 6 months
f 1 year
g 18 months
h No time duration specified
1 ICD-10 requires that symptoms are present for at least
_________ for a diagnosis of schizophrenia.
2 DSM-IV-TR requires that symptoms are present for at least
_________ for a diagnosis of schizophrenia.
3 ICD-10 requires that symptoms are present for at least
_________ for a diagnosis of a depressive episode.
4 ICD-10 requires that symptoms are present for at least
_________ for a diagnosis of generalised anxiety disorder.
5 ICD-10 requires three panic attacks in _________ for a diagnosis
of panic disorder.
6 ICD-10 requires that symptoms are present for at least
_________ for a diagnosis of a specific phobia.
1 d
2 e
3 b
4 c
5 c
6 h
a Obsessive–compulsive disorder (OCD)
b Post-traumatic stress disorder (PTSD)
c Panic disorder
d Agoraphobia
e Social phobia
f Complicated grief
g Specific phobia
h Acute stress reaction
1 Avoiding crowded places is a common symptom.
2 The phobic disorder most commonly referred to secondary care.
3 Often associated with depersonalisation or derealisation.
4 A phobic disorder that is equally common in men and women.
5 Disorder with an increased prevalence among those with
Tourette’s syndrome.
6 Onset is typically rapid (e.g. within hours).
1 d
2 d
3 c
4 f
5 a
6 h
- Personality disorders
a Anankastic
b Narcissistic
c Avoidant
d Dependent
e Dissocial
f Borderline
g Paranoid
h Schizoid
i Schizotypal
Which personality disorders are described below? Choose one
option.
1 Not included as a diagnosis in ICD-10.
2 A middle-aged man is referred by Social Services because his
hoarding of newspapers is a fire hazard. He has kept every
newspaper he has bought for the last 30 years. They are piled in
the kitchen. He is preoccupied by cleanliness and the flat smells
of bleach. He used to work as a picture editor for a newspaper
but lost his job because his work was impractically slow.
3 A 72–year-old lady has been unable to cope with life since the
death of her husband ten years ago. She has always hated being
alone. She lived with her parents until she married. Her husband
made all the decisions and she never disagreed, because she did
not like upsetting him. She is fit and well but is asking to move
to a nursing home.
4 A 28-year-old man presents to A+E after slashing his wrists. He
has self-harmed on over 50 previous occasions. He describes
chronic feelings of emptiness, and feels he doesn’t always know
who the real he is.
5 A personality disorder that is more common among those with
relatives who have schizophrenia.
6 The personality disorder that is most prevalent among male
prisoners.
1 b
2 a
3 d
4 f
5 i
6 e
- Unusual syndromes
a Fregoli syndrome
b Capgras syndrome
c Ekbom’s syndrome
d Cotard’s syndrome
e Folie à deux
f Othello’s syndrome
g De Clerambault’s syndrome
h Munchausen’s syndrome
i Couvade’s syndrome
j Ganser’s syndrome
Which of these syndromes are described below? Choose one
option.
1 Symptoms are consciously produced
2 Also known as delusional parasitosis.
3 Seen in expectant fathers.
4 Usually seen in psychotic depression.
5 Classified as induced delusional disorder in ICD-10.
6 Can be a side effect of Parkinson disease treatment.
7 May carry an increased risk of violence to members of general
public.
1 h
2 c
3 i
4 d
5 e
6 f
7 a (the patient believes that their persecutors are taking the form
of other people so may be aggressive to a member of the public
they believe to be their persecutor in disguise)
alcohol misuse
7. Substance misuse
a Alcohol
b Amphetamines
c Benzodiazepines
d Cannabis
e Cocaine
f Ecstasy (MDMA)
g Heroin
h Khat
i LSD
j Solvents
To which drug do these statements most apply? Choose one
option.
1 Paradoxical aggression is a known side-effect.
2 Methadone replacement is a common treatment.
3 There is good evidence that adolescents using this drug are more
likely to develop schizophrenia in adult life.
4 A red rash around the mouth is a common sign of abuse.
5 Deaths from hyponatraemia caused by drinking too much water
after taking this drug have been reported.
6 The substance that most commonly causes mild cognitive
impairment.
1 c (see Chapter 36) 2 g
3 d
4 j
5 f
6 a
- Diagnoses in childhood and early adulthood
a Birth
b 3 months
c Age 2
d Age 5
e Age 8
f Age 15
g Age 22
h Age 26
Which of these ages would be the most typical time for the following
disorders to be diagnosed? Choose one option.
1 Encopresis
2 Oppositional defiant disorder
3 Attention-deficit and hyperactivity disorder
4 Emotionally unstable personality disorder
5 Bulimia nervosa
6 Anorexia nervosa
7 Autism
1 d
2 e
3 e
4 h
5 g
6 f
7 c
- Epidemiology of psychiatry of demographic groups
a 0.1%
b 1%
c 6%
d 10%
e 25%
f 30%
g 50%
h 60%
i 80%
Which of these most accurately estimates? Choose one option.
1 The percentage of the prison population who have an IQ of 85
or more.
2 The percentage of rough sleepers who use illicit drugs.
3 The percentage of rough sleepers with mental illness.
4 The percentage of women who experience significant depression
or anxiety during pregnancy.
5 The percentage of births that are followed by puerperal
psychosis.
6 The percentage risk of cardiac malformations in neonates born
to mothers taking lithium.
1 g
2 g
3 h
4 d
5 a
6 c
- Cognitive impairment
a Alzheimer’s disease
b Mild cognitive impairment
c Acute confusional state
d Alcohol withdrawal
e Vascular dementia
f Lewy body dementia
g Normal pressure hydrocephalus
h Frontotemporal dementia
i Parkinson’s disease dementia
j Depressive disorder
Which of these would be the most likely diagnosis in the following
situations? Choose one option.
1 Three-year gradual onset of memory loss. The patient now
forgets to eat without prompting. No abnormal findings on
physical examination and dementia blood screen. CT head scan
shows mild involutional change but no other findings.
2 A patient’s husband describes onset in last six months of poor
concentration, forgetfulness, apathy and urinary incontinence.
You notice a wide-based gait on examination. MRI head scan
shows enlarged ventricular system.
3 The patient presents with concerns about her memory, forgetting
where she has put things. The forgetfulness dates from the
loss of her husband nine months ago. She reports poor sleep and
loss of appetite. She is tearful and low in mood with anxiety
about her memory loss. Objective clinical cognitive tests are
within the normal range.
4 A patient presents with forgetfulness and disorientation to time
and place with associated impairment in activities of daily living.
Relatives date the onset to a documented cerebrovascular accident
two years ago. CT head scan shows a mature infarct in the
caudate nucleus and internal capsule.
5 A patient presents with gradual onset of forgetfulness, with a
poor memory for recent events. This has not interfered with his
daily life, although he now writes a shopping list rather than
relying on his memory. Objective clinical cognitive tests are in
the borderline range, below those expected given his high educational
attainment.
6 A 56-year-old lady is brought to the GP by her husband, who
reports a change in her behaviour over the last year. She has
become more extrovert, making inappropriate jokes and on one
or two occasions acting aggressively towards him. She has noc oncerns, although when asked did admit to word-finding
difficulties. Clinical cognitive tests demonstrated poor performance
on verbal fluency and executive functioning.
7 A patient being treated for a urinary tract infection is noted to
have poor concentration. Her speech is confused and rambling
and she appears to be visually hallucinating. The nurses report
fluctuations in her confusion
1 a
2 g
3 j
4 e
5 b
6 h
7 c
- Psychiatric disorders and physical symptoms
and signs
a Somatisation disorder
b Factitious disorder
c Hypochondriacal disorder
d Munchausen disorder by proxy
e Dissociative disorder
f Dysmorphophobia
g Ganser’s syndrome
h Depressive disorder
i Panic disorder
Which of these are best described below? Choose one option.
1 Someone with this disorder may typically reply to the question
‘What is 2+2’ with the answer ‘Five’.
2 A possible differential in a child repeatedly presenting with haematuria
of unknown cause.
3 Might typically involve a presentation to A+E with complete
memory loss for personal information including name and
identity.
4 A patient is discovered to be consciously feigning a left-sided
weakness.
5 Often presents first to plastic surgeons.
6 Ten times more common in people with chronic obstructive
airways disease.
1 g
2 d
3 e
4 b
5 f
6 i (see Chapter 11, aetiology section)
- Psychological therapies
a Cognitive–behavioural therapy (CBT)
b Interpersonal psychotherapy
c Behavioural activation
d Behavioural management therapy
e Dialectical behaviour therapy
f Eye movement desensitisation and reprocessing
g Psychodynamic psychotherapy
h Therapeutic community
i Cognitive analytic therapy
j Person-centred counselling
Which of these are best described below? Choose one option.
1 A residential therapy.
2 A therapy for which transference and counter-transference are
key therapeutic tools.
3 Mostly used to treat PTSD.
4 Designed for treatment of borderline (emotionally unstable)
personality disorder.
5 A useful intervention in severe dementia, in which the therapy
would primarily be conducted with the carer.
6 Focuses on activity scheduling to encourage patients to approach
activities that they are avoiding.
1 h
2 g
3 f
4 e
5 d
6 c
- Treatment of psychosis and depression
a 2 weeks
b 3 weeks
c 4 weeks
d 3 months
e 6 months
f 2 years
g 10 years
1 Risk of relapse is increased significantly if antipsychotics are not
continued for _____________after recovery from a psychotic
episode.
2 Maintenance antidepressant medication after recovery from
depressive episode is typically recommended for _____________.
3 Antidepressants usually take ___________ to manifest their
clinical effectiveness.
4 A typical duration of treatment for psychoanalytic psychotherapy
is __________.
5 A typical duration of CBT treatment is __________.
6 Depot antipsychotic medication is typically administered with a
frequency of between once a week and every ________.
1 f
2 e
3 c
4 g
+5 d
6 c
- Treatment in psychiatry
a Antipsychotic medication
b Benzodiazepine
c CBT alone
d Electroconvulsive therapy (ECT)
e Family therapy
f Mood stabiliser
g Psychodynamic psychotherapy
h Selective serotonin reuptake inhibitor (SSRI) and CBT
i SSRI only
j Cholinesterase inhibitor
Which of these would be the most appropriate treatment for the
following situations? Choose one option.
1 An 85-year-old lady diagnosed with mild Alzheimer’s disease.
2 A 64-year-old man has been severely depressed for several
months, and his condition is deteriorating despite treatment
with antidepressants. He is very distressed, suicidal and refusing
to eat.
3 A 31-year-old mother of a two-month-old baby asks her GP for
help. Her GP diagnoses mild depressive disorder.
4 A 28-year-old man with severe OCD. He is no longer able to go
to work because it takes him several hours to get dressed every
morning as a result of his compulsive rituals.
5 A 34-year-old lady seeks help from her GP. She is concerned
that she has problems in intimate relationships due to sexual
abuse that she experienced as a child. She feels this is making
her very anxious.
1 j
2 d
3 c
4 h
5 g
6 e
- Psychiatry and the English law
a Mental Capacity Act
b Deprivation of Liberty safeguards
c Mental Health Act (MHA), section 2
d MHA, section 3
e MHA, section 5(2)
f MHA, section 17
g MHA, section 37
h MHA, section 58
i MHA, section 135
j MHA, section 136
Which legal act, or section of legal act, is most appropriate to use
in these situations?
Choose one option.
1 A man who is actively suicidal asks to self-discharge. The
medical team contact you, the psychiatry Foundation Year 2,
to ask advice; they need to do something immediately to prevent
him leaving.
2 A woman with a known diagnosis of schizophrenia has been
shouting at neighbours that they are trying to poison her. When
the mental health team visit, she refuses to open the door. They
think she needs a psychiatric assessment.
3 You are called to assess a woman with dementia who is refusing
potentially life-saving intravenous antibiotics for treatment of
cellulitis. She does not believe she is ill.
4 You assess a man with no previously documented psychiatric
history who was brought to A+E by his wife. He has threatened
to set fire to next door’s house because he believes MI5 are using
it as a monitoring station. He wants to go home.
5 A consultant psychiatrist treating a man for a psychotic episode
under Section 3 of the MHA wants to send him home on leave
for a few hours.
6 A 28-year-old woman was arrested after attacking a passer-by,
whom she believed was possessed by a demon that was trying
to kill her. The courts find her guilty of grievous bodily
harm, and accept the recommendation that she should be
detained in a psychiatric hospital for treatment of a psychotic
disorder.
7 A man with moderately severe learning disabilities who is not
allowed to leave his group home alone for his own safety persistently
bangs on the front door in the morning saying he wants
to go for a walk.
1 e
2 i
3 a
4 c
5 f
6 g
7 b
- When initiating antipsychotics in a patient with a new diagnosis
of schizophrenia:
A Consider clozapine
B Start with a typical antipsychotic
C Start at lowest recommended dose for your choice of drug
D Consider that it is often preferable to use depot medication
to prevent relapse once well
C; Clozapine is only used when two other antipsychotics have
failed because of side-effects (page 76); depot is only used where
specifically indicated (e.g. because of patient preference or very
poor adherence; NICE recommends commencing new patients
on an atypical antipsychotic.
- First-line treatments for mild depression do not usually include:
A Antidepressants
B Self-help group
C Computer-aided CBT
D Advice about decreasing alcohol intake
A; Antidepressants are generally only recommended for moderate
and severe depression
- Bipolar affective disorder is more common in:
A Men
B People from lower socioeconomic groups
C Pregnant women
D People with a history of sexual abuse
D; It is more common in women, with high rates postpartum but
not during pregnancy, and in higher socio-economic groups.
- An appropriate initial treatment for post-traumatic stress disorder
would be:
A Debriefing
B Eye movement desensitisation therapy
C Quetiapine
D Lorazepam - Symptoms that often occur in recently bereaved people
without mental illness include:
A Hearing the voice of the deceased
B Suicidal intent
C Agoraphobia
D Recurrent panic attacks
- B (page 75).
- A (page 27).
- First-line treatments for panic disorder do not usually include:
A CBT
B SSRIs
C Benzodiazepines
D Self-help materials along CBT principles
- C; Benzodiazepines are not recommended.
- A patient tells you he is concerned he may jump in front of a
train. He is terrified of doing so, does not want to die but
cannot get the thought out of his head. Is this symptom most
likely to be:
A Suicidal ideation
B An obsessional impulse
C Anxious rumination
D A compulsion
- B; It is egodystonic (the thought is unwelcome and recognised
as alien; it is not what he thinks).
- In the treatment of anorexia nervosa, hospitalisation is almost
always indicated if:
A There is an absence of insight
B The patient does not comply with treatment
C The patient has a Body Mass Index of below 13.5
D The patient has suicidal ideation
- C.
- Borderline (emotionally unstable) personality disorder:
A Is the most prevalent personality disorder in the general
population
B Is usually a lifelong condition
C Is associated with bulimia nervosa
D Can be expected to worsen with age
- C.
- In the context of sexual identity disorders, which of the following
is not true:
A Boys who show gender atypical behaviour usually grow up
to be homosexual
B Pre-surgery psychotherapy is associated with a favourable
outcome to gender reassignment therapy
C Transsexual people believe their biological sex is inappropriate
D Cross-dressing is not associated with sexual excitement
- A; They usually grow up to be heterosexual.
- Munchausen’s syndrome is synonymous with:
A Somatisation disorder
B Dissociative disorder
C Hypochondriacal disorder
D Factitious disorder
- D (page 39).
- Drugs often used to treat opiate dependence include:
A Buprenorphine
B Bupropion
C Naloxone
D Morphine
- A.
- Which of the following is true:
A Alcohol dependence is no longer more common in men
B A quarter of primary care attendees have an alcohol use
problem
C The CAGE questionnaire is a useful means of diagnosing
alcohol dependence
D Increasing the cost of alcoholic drinks is an effective means
of reducing alcohol dependence in a population
- D; Not the CAGE is a useful screening, not diagnostic, test.
- Before the age of ten, girls and boys are equally likely to suffer
from:
A Tourette’s syndrome
B Autism
C Enuresis
D Depression
- D (see Chapter 19).
- With regard to autism:
A Onset is usually before nine months
B Around half of patients have normal intelligence
C It is more common in girls
D It is more common in higher social classes
- D (page 46).
- Which of the following is not true of a 15-year-old:
A They may consent to a serious operation if a doctor judges
they have capacity to do so
B They may be detained under the Mental Health Act
C They may be given treatment that neither they nor their
parent consents to if they are made a ward of court and the
court agrees it is in their best interests
D They can be detained under the Mental Capacity Act (in
England) so long as Deprivation of Liberty Safeguards
procedures are followed
- D (see Chapter 40; the Mental Capacity Act applies to those
aged 18 and over).
- People with mild learning disability:
A Often have sensory impairments
B Rarely live independently
C Are usually diagnosed by three years of age
D Usually have parents with low IQ
- D.
- The prevalence of schizophrenia is higher in African Caribbean
people. Possible reasons do not include:
A Higher rates of socio-economic disadvantage in African
Caribbean people living in the UK
B A genetic predisposition to psychosis in African Caribbean
people
C The stress of migration
D The stress of racism
- B; This cannot be true, because rates of schizophrenia in the
Caribbean are similar to those in the UK among the indigenous
populations
- Which is true of prisoners with severe mental illness:
A May require treatment in the prison hospital wing under
the Mental Health Act
B Can be transferred to a secure psychiatric unit without the
consent of the court for urgent treatment
C Are more likely to have a learning disability than people
with severe mental illness in the community
D Are less likely to commit suicide than people with severe
mental illness in the community because of high levels of
observation
- C; Treatment under the Mental Health Act may not be given in
prison; transfer always requires court approval; prisoners with
mental illness are at high risk of suicide
- Which of the following is true of prescribing psychotropic
medication in pregnancy:
A Sertraline and lithium carry similar risks to the foetus
B Prescribing psychotropic medication in pregnancy should
always be avoided
C Benzodiazepines are generally safer than antidepressants
D Sodium valproate and carbemazepine are among the most
teratogenic psychotropic drugs
- D; The risks of prescribing and not prescribing need to be carefully
weighed; lithium is more likely to be teratogenic than
sertraline.
- Compared with depression in younger people, an incident case
of depression in a 65-year-old man is:
A More likely to be treated
B More likely to have a strong genetic component
C Less likely to be associated with brain imaging
abnormalities
D Likely to have a higher risk of mortality
- D; Incident depression in older age is more likely to be associated
with brain imaging abnormalities, less likely to be associated
with a positive family history, and less likely to be treated
compared with depression in a younger person.
- Compared with dissociative disorders, somatisation disorders
are:
A Less common
B More likely to present with symptoms than clinical signs
C More likely to have complaints that involve the nervous
system
D More likely to have symptoms that are deliberately feigned
- B; They are more common than dissociative disorders; dissociative
disorders generally involve the nervous system; in neither
disorder are symptoms deliberately feigned; if so, factitious disorder
would be the correct diagnosis.
- A single ischaemic cerebrovascular accident (CVA) is unlikely
to cause the onset of:
A Tourette’s syndrome
B Vascular dementia
C Delirium
D Depression
- A; The others are more common after CVA
- Which of the following endocrine disorders is more likely to
present with episodic anxiety than with depression:
A Phaeochromocytoma
B Hypothyroidism
C Hypopituitarism
D Hypocortisolaemia
- A.
- Useful preventative strategies to avoid delirium on an acute
hospital ward do not include:
A Benzodiazepines for poor sleep
B Family photos and other familiar objects around the bed
C Clear signage
D Regular visits from family and friends
- A; Benzodiazepines can contribute to or cause confusion.
- In Alzheimer’s disease, a treatment associated with beneficial
cognitive effects is:
A Electroconvulsive therapy
B Memantine
C Selective serotonin re-uptake inhibitors
D Antipsychotics
- B (pages 72, 81); Note that antipsychotic use is associated with
cognitive decline.
- Psychodynamic psychotherapy is usually contraindicated in
patients with:
A A history of sexual abuse
B Narcissistic personality disorder
C Alcohol dependence
D Psychopathic personality disorder
- C; It is often used as a treatment for the others. It is important
that substance misuse problems are under control before initiating
psychodynamic psychotherapy, because exposing unconscious
conflicts can increase stress in the short term and this
could lead to increased substance misuse as an unhelpful coping
strategy.
- Antipsychotics:
A Are usually given as depot injections to increase
adherence
B Usually take four weeks to demonstrate an effect
C Should be continued for ten years after a severe psychotic
episode
D If atypical, are commonly associated with metabolic sideeffects
- D; Most authorities recommend continuing for 2–5 years after
a psychotic episode; they generally demonstrate some effect
within a week; they are usually taken orally.
- Antidepressants are not usually used to treat:
A Anorexia nervosa
B Psychotic depression
C Obsessive–compulsive disorder
D Bulimia nervosa
- A.
- Lithium:
A Has a wide therapeutic window
B Must never be prescribed to pregnant women
C Should not be started without a full assessment including
liver function tests
D Reduces the risk of suicide
- D (page 80); It is teratogenic so female patients should always
be advised to consult their doctor if planning a pregnancy
because usually they will be changed to safer medication;sometimes patient and doctor decide the risks of stopping
(relapse with increased risk of self-harm, accidents and stress)
outweigh those of continuing to take it when pregnant.
- Which of these treatments requires no local or general
anaesthetic?
A Eye movement desensitisation therapy
B Electroconvulsive therapy (ECT)
C Deep brain stimulation
D Anterior cingulotomy
- A (see also Chapter 33).
- Around 15% of the general population have at some time
experienced:
A Mental illness
B Suicidal ideation
C Psychosis
D Personality disorder
- B; Psychosis ( common; mental illness is more common (25%); see Chapter
38.
- Shoplifting is not known to be more common than in the
general population among people with:
A Substance misuse
B Learning disability
C Emotionally unstable personality disorder
D Generalised anxiety disorder
- D.
- The Mental Capacity Act (England and Wales) does not give
the legal authority to give the following treatment to a person
without capacity to consent:
A An antidepressant to a person with learning disability in a
residential home
B Antibiotics to a psychiatric inpatient detained under the
Mental Health Act
C Life-saving treatment to a medical inpatient
D Urgent ECT to a psychiatric inpatient detained under the
Mental Health Act
- D; If a patient is detained under the MHA they receive psychiatric
treatment under it
- To be detained under a Community Treatment Order:
A The patient must be detained under Section 2 or 3
B The approved mental health professional (AMHP) must
agree to it
C The patient must agree to it
D The patient must be over the age of 18
B
What is he template for generating a treatment plan?
Bio-psycho-scoial with considerations for predisposing, precipitating and perpetuating factors
Include a risk management plan making use of all available statuatory and nonstatutory resoruces
What are BPSD?
Behavioural and psychological symptoms of dementia (BPSD) refer to the often distressing non-cognitive symptoms of dementia and include agitation and aggressive behaviour.
he spectrum of BPSD includes: (Adapted from5)
Aggression
Agitation or restlessness; screaming
Anxiety
Depression
Psychosis, delusions, hallucinations
Repetitive vocalisation, cursing and swearing
Sleep disturbance
Shadowing (following the carer closely)
Sundowning (behaviour worsens after 5pm)
Wandering
Non-specific behaviour disturbance e.g. hoarding
Age of treatment consent in psych
Parental responsibility?
Implications for treatment of 18
16, under 16s can be made by someone with Gillick competence or someone with parental responsibility
Ends at 18.
Under 18s can rarely refuse treatment as it is often not in their best interests (4th Gillick criteria).
Under 18s refusal with parents can be overturned by courts
Over 18s refusal is finalas long as they have competence
Under 16s who are not Gillick competence may have their confidentiality breached. Confidentiality can be breached up to 18 if in child’s best interests.
Advance decision can only be?
Features of advance decision?
Refusal rather than demand of treatment
- Have to be seen by the doctor
- Informed, competent, voluntary
- Can be oral
- Can’t refuse nursing care, oral hydration/nutrition
- Inapplicable if there’s a large change in circumstances e.g. pregnancy
- Inapplicable if there’s been a large change in treatment given (e.g. AIDS) since decision was made. So it should be kept up to date
- If there are doubts over validity/applicability , it can be overridden in an emergency
Withdrawal may be oral
- Have to be seen by the doctor
- Informed, competent, voluntary
- Can be oral
- Can’t refuse nursing care, oral hydration/nutrition
- Inapplicable if there’s a large change in circumstances e.g. pregnancy
- Inapplicable if there’s been a large change in treatment given (e.g. AIDS) since decision was made. So it should be kept up to date
- If there are doubts over validity/applicability , it can be overridden in an emergency
Withdrawal may be oral
What is Beck’s cognitive triad?
Negative views about the world
->
Negative views about the future
->
Negative views about oneself
-> cycle
Mx of a dangerous psychotic patient
De-escalation: call for help, reasssure, talk calmly, use simple language, non-hostile, don’t invade personal space, remove weapons, separate from other patients
Offer oral medication: antipsychotics, BZDs
IM rapid tranquilisation: lorazepam, haloperidol + promethazine (to prevent dystonia)
Seclusion
Post-incident review
1st and 2nd line treatment of dangerous pt with acute confusiona state
IM haloperidol (risk of ESPEs)
BZDs (2nd line): NB can cause paradoxical increase in confusion
Reversible types of demenita
Hypothyroidism
B12
Syphillis (argyll-robertson pupils, accomodate but don’t react to light)
Lyme disease
Pellagra (niacin, nictonic acid, B3 deficiency): dermatitis+diarrhoea+dementia, sunlight hypersensitivity
MMSE cut off points?
19-24= mild
Dementia screening questionnaires
MMSE
MoCA
Addenbrookes Cogntiive Examination (/100)
AMTS: /10,
What are the features of the psychotherapies in dementia?
Cognitive stimulation therapy: memory training
Validation therapy: respecting the patient’s reality
Reminiscence therapy: allowing them to talk about the past
Multisensory therapy: variety of stimuli in specialised room
Social methods in dementia
Home adaptation: notes, dictaphone, ID, contact number, dosset boxes, change from gas to electric
Keep mind stimulates
Social services
Involve therapy
Plan for deterioration
Pathophysiology of AD
Cerebral atrophy: hippocampal esp
Amyloid plaques
NFTs
Cholinergic longs
4As of AD
Other syptoms
Amnesia, Aphasia, Agnosia, Apraxia
Wandering, personality changes, mood lability, apathy, poor insight, aggression
AD Px
5-10y survival
Dx of Vascular dmentia
Hachinski’s ischaemic score, MRI
Hachinski Ischaemic score
Used in the diagnosis of vascular dementia
What are Lewy bodies?
Eosinophllic cytoplasmic inclusions, clumps of alpha synuclein
Pathophysiology of Pick’s disease
Frontal and temporal lobe atrophy
Pick bodies made of Tau
Frontal lobe tests
Set shifting/response inhibition
Luria test
Abstract thinking
Verbal fluency
Cognitive estimates
Clock drawining
Tap on table, ask them to rais finger, stop tapping and they still raise finger
Fist, edge, pal, repeat
Interpret a proverb
Name words beginning with S
What is the best paid job in Britain?
Clock drawing
Pulvinar sign
Dx of vCJD?
The pulvinar sign refers to bilateral FLAIR hyperintensities involving the pulvinar thalamic nuclei. It is classically described in variant Creutzfeldt-Jakob disease (vCJD). It is also described in other neurological conditions:
Fabry disease (although the hyperintense signal is seen on T1WI)
bilateral thalamic infarcts
ADEM
Tonsi biopsy
What is AUDIT?
Alcohol Use Disorders Identification Test (10 question test by WHO)
What are the Stages of Change Model
Pre-contemplation
Contemplation (acceptane)
Preparation
Action
Maintenance
Relapse: common part of learning process, not a sign of failure
Formication
Sensation like inescts crawling over the skin, seen in delerium tremens.
ARMS for schizophrenia
At Risk Mental State
Mild psychotic symptoms
Brief limited intermittent psychotic symptoms (BLIPs)-
Good Pxic factors for Schizophrenia
Precipitating cause
Intelligent
Acute
Normal premorbid personality
High social class
Female
Late onset
Poor Pxic factors for Schizophrenia
Gradual onset
Young
Negative symptoms
Fhx
Low IQ
Social withdrawal before
Lack of obvious precipitant
DDx for Schizophrenai
Organic
Acute and transient psychosis
Depression/BPAD
Schizoaffective disorder
Persistent delusional disorder
Schizotypal/Schizoid PD
Features and Rx of atypical depression
Reactive mood, hypersomnia, hyperphagia, heavy limbs, rejection sensitivity
MAOIs e.g. phenelzine
Plan for Rx resistant depression
* Review diagnosis
o Consider co-morbid conditions
* Check compliance e.g. blood test
* Check for substance misuse
* Change dose
* Change or augment medication
* Review psycho-social management
* ECT
Mx of SAD
Ligth therapy
CBT
SSRis
Cut of Edinburgh PDS
>13/30 indicates depression
Risk assessment in Suicide
Past
Present
Future
o Past
* Trigger?
* Planned or impulsive?
* Method?
* Final acts?
* Did you isolate yourself?
* Efforts to avoid discovery?
* Suicide note?
* Who called the ambulance?
* Did you believe it would kill you?
o Present
* How do you feel about trying to harm yourself?
* Do you regret trying to kill yourself?
* Do you regret failing to kill yourself?
* Has anything changed since the attempt?
o Future
* How do you see the future?
* Do you have any plans to harm or kill yourself?
* Do you think you might kill yourself?
* Can you think of anything that might stop you?
Dx if GAD
GAD7 score (/21)
Symptoms of panic attack
Hyperventilation
Palpitations
Dizziness/faints
Tingling lips
Tinnitus
Sweating
Depersonalisation/derealisation
Sense of doom
Personality traits
OCEAN
* Openness
o Curious vs cautious
* Conscientiousness
o Organised vs impulsive
* Extraversion
o Extrovert vs introvert
* Agreeableness
o Friendly vs detached
* Neuroticism
o Insecure vs secure
Charles Bonnet Syndrome
Complex visual pseudohallucinations due to visual impairment
Name of dxic questionnaire in hyperkinetic disorder
Conner’s questionnaire
Types of attachment disorder
Inhibited/reactive: fail to respond to social interactions
Disinhibited: overly friendly to strangers, danger of abuse, socially inappropriate behaviour
Features of ME
* Extreme fatigue, aches and pains
* >6 months
* Usually follows viral infection
* Management
o Set realistic exercise goals
o CBT
How to reduce EPSEs in antipsychotics
Lower dose
Switch from depot
Switch to different
Procyclidine: worsens anti-cholinergic side effects + tardive dyskinesia
Effect of procyclidine on tardive dyskinesia
Worsens
Mx of TD- lower dose
What are the dopamine pathways
Mesolimbic: emotion- antipsychotics reduce positive symptoms
Mesocortical: cognition- antipsychotics reduce negative symptoms
Tubulo-infundibular- endocrine: antipsychotics cause hyperprolactinaemia due to reduced dopamine inhibition of prolactin
Nigrostriatal- movement: antipsychotics cause EPSEs
SSRI drug interactions
NSAID
Warfarin
Tryptans
Rx PPI
Avoid SSRIs, mirtazapaine instead
Avoid due to risk of serotonin syndrome
Side effects of SSRIs
N+V
Gastric ulcers
Anxiety
Insomnia
Increased suicidal ideation
Sexual dysfunction
Hyponatraemia (SIADH in elderly)
Anticholinergic
Loss of appetite
Platelet dysfunciton: increased bleeding
Mx of serotonin syndrome
Stop SSRIs
5HT antag: cyproheptadine
IV fluids
BZDs
Cooling blankets
Buspirone features and indications
SEs
5HT agonist, indicated for ST treatment of anxiety disordesr
Compared to BZDs: doesn’t cause tolerance or dependence, less powerful, slower acting
Side effects include headaches, dizziness, drowsiness
Why is propanolol CIed in DM?
Reduces hypo symptoms
How is ACh increased by antipsychotics?
Because dopamine antagonists reduce dopamine inhibition of ACh
How can delusions be classified?
Mood congruent: BPAD
Mood incongruent: schizophrenia
Systematised: delusions which revolve around a cental theme e.g. government
Unsystematised: delusions which are disconnected/unrelated.
Primary/autochthonous: sudden, out of the blue with no obvious cause
Secondary: understandable in context of patients mood
Classification of hallucinations
Functional: normal stimulus that activates same sensory modality e.g. voice when tap is running
Reflex: stimulus in one sense triggers hallucination in another e.g. face when tap is heard
Extracampine: outside the normal range of sensory perception e.g. hearing voices 2 miles away
Description of auditory hallucinations
2nd person: talking to patient
3rd person: talking about patient to each other
Though echo
Command hallucinations
Running commentary
Thought process=
Formal thoguht disorder
Circumstantiality
Long sidetrack leading back to original point
Tangentiality
Patient goes of on tangent failing to return to original point
Flight of ideas
Thinking moving rapidly between loosely related topics manifested by pressure of speech i.e. BPAD
Knight’s move/derailment/loosening of association
Changing topic randomly with every sentence
Schizophrenia
Thought block
Patient’s thought stop mid-sentence
Schizophrenia
Echolalia
Patient repeats back what is said to them
Schizophrenia
Perseveration
Repeating same word or gesture and being unable to stop@ organic brain disease
Palilalia= whole word
Logoclonia= last syllable
Word salad
Random words forming meaningless sentences
Schizo/BPAD
Circulocutions
Vague phrases used instead of words e.g. whatsits
Schizophrenia, dementia
Clanging
Words used are related by sound rather than meaning
BPAD
Alexithymia
Inability to describe mood
ASD, eating disorders, depression (esp somatisation)
Features of CBT
Pragmatic, goal based, thought diary
Collaborative effort
Challenges NATs
Splitting
Black and white thinking
Personalisation
Deeming failures to be caused by self
Overgeneralisation
Making generalisations based on past experiences
Labelling
Calling oneself names
Selective abstraction
Dwelling on insignificant detail
Magnification/minimalisation
Dwelling on bad, ignoring good
What are some CBT techniques
Graded exposure
Response prevention
Relaxation techniques
Thought stopping- interrupting thought e.g. elastic band
Flooding
Aversion therapy
Features of DBT
Acceptance
Address coping mechanisms- replace maladaptive behaviours with more appropriate ones
Individual and group therapy
BPD
Uses of family/systemic therapy
CAMHS
Schizo
Eating disorders
BPAD
Substance misuse
Gerstman’s syndrome
Particular syndrome of parietal lobe injury:
Left-right disorientation
Dyscalculia
Finger agnosia
Agraphia
Anton syndrome
Cortically blind but continues to confirm ademantly that they can see
of amnesia and confabulation are very typical of tumours
involving
the wall or floor of the third ventricle
