Psych basics Flashcards
What is mnemonic for MSE?
ASEPTIC
- Appearance & behaviour
- Speech
- Emotion (mood)
- Perception (all 5 senses)
- Thought
- Insight
- Cognition
What should be reported in Appearance and behaviour in the MSE?
-
General appearance
- Age, gender, build, ethnicity
- Hair, make-up, clothing, piercings, tattoos
- Physical problems
- Self-care (well-kempt or self-neglecting)
-
Body language
- Facial expression, e.g. smiling, scowling, fearful
- Eye contact, e.g. responsive and appropriate, avoidant, too intense
- Posture, e.g. hunched shoulders in depression
- Activity level
- Describe what they are doing, e.g. pacing around the room, responding to hallucinations
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Other movements
- Extrapyramidal SEs
- Repeated movements
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Rapport:
- Withdrawn and cold, polite and friendly, guarded (suspicious/deliberately withholding info), disinhibited (e.g. removing clothing)
Give some examples of repeated movements that may be seen, and their defintions
- Mannerism: appear goal-directed (e.g. sweeping hair from face)
- Stereotypes: not goal-directed (e.g. flicking fingers at hair)
- Tics: purposeless, involuntary movements involving a group of muscles (e.g. blinking)
- Compulsions: rituals the patient feels compelled to undertake (e.g. hand-washing)
- Echopraxia: patients senselessly imitate actions of those around them; associated with echolalia
- Catatonic symptoms: extreme negativism, lack of response to stimuli
What should be commented on in the speech section of the MSE?
- Rate: fast, slow, normal
- Volume: loud, soft, normal
- Tone: emotional quality of speech, e.g. sarcastic, angry, calm
- Flow: speech may be spontaneous, only when prompted, hesitant, with long pauses before answers, uninterruptible etc.
Name some disorders of speech and give their defintions
- Dysarthria: impaired articulation
- Dysphasia: impaired ability to comprehend or generate speech
- Clang association: rhyming connections (e.g. gang, bang)
- Punning: playing on words with the same sounds but different meanings (e.g. tyre, tire)
- Neologisms: made-up words
- Pressure of speech: reflects underlying pressure of thought will be hard to interrupt the patient
- Poverty of speech: reflects underlying poverty of thought typically seen in depression
- Thought block: complete emptying of the mind of thoughts shown as a sudden halt in speech; may be seen in schizophrenia
- Circumstantial speech: reflecting underlying over-inclusive thinking which adds excessive details and subclauses to every sentences, but eventually reaches the original destination
- Tangential speech: patient diverts from the initial train of thought and never returns to the original destination
- Flight of ideas: patient’s ideas jump from one to another, but may eventually come back to the point; may be linked normally (i.e. via rhymes, puns, distractions in the room)
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Derailment/loosening of associations/knights move thinking: thoughts start at one place but end up in a completely unrelated place to the original route
- Word salad is its worst form → mixture of incoherent words and phrases
- Perseveration: thoughts remain in one place, e.g. “what is your name?” “John”, “how are you?” “John”
- Echolalia: senselessly repeating words or phrases spoken by others, like a parrot
What should be commented on in the mood and affect section of the MSE?
-
Mood:
- subjective
- objective
-
Affect (how they express their emotional state):
- Appropriateness or congruity
- Range of emotional expressivity
What should be commented on regarding thought in an MSE?
-
Form (can be ordered or disordered)
- e.g. circumstantial and tangential thinking, loosening of association, neologisms, flight of ideas, thought blocking
- Content
Give some examples of disorders of thought content
- Delusions
- Overvalued ideas
Give some examples of disorders of thought content
- Delusions
- Overvalued ideas
Define delusion
a fixed belief, held despite rational argument or evidence to the contrary, which cannot be fully explained by a patient’s cultural, religious or educational background
What are the different classifications of delusions?
-
Primary, secondary and systematised:
- Primary: arise completely out of the blue in someone without prior mental health problems
- Secondary: follow another abnormal experience, such as an abnormal mood or hallucination (e.g. perception of hearing a voice, so patient believes they are being stalked)
- Systematised: when delusions grow and build on each other, connecting into a delusional system
-
Mood congruent or incongruent:
- Mood congruent are commonly seen in depression or mania
-
Bizarre or non-bizarre:
- Bizarre are completely impossible (characteristic of schizophrenia
Name some themes of delusions
- Grandiose
- Persecutory
- Nihilistic
- Delusions of reference
- beliefs that ordinary objects, events or other people’s actions have a special meaning or significance for the patient (e.g. news reports related to them)
- Delusions of control
- Delusions of thought interference
- Passivity
- Delusions of infidelity/morbid jealousy/Othello syndrome
- Erotomanic
- Delusions of guilt
- Hypochondriacal/somatic delusions
- Religious delusions
- Delusions of misidentification
- Delusions of infestation
Name 2 types of delusions of misindentification
-
Capgras syndrome
- belief that a familiar person has been replaced by an imposter;
-
Fregoli syndrome
- belief that a complete stranger is actually a familiar person already known to the patient
What is Ekbom’s syndrome?
i. e. Delusions of infestation
* delusion that body is infested with small but visible organisms. May occur secondary to tactile hallucinations
What is an overvalued idea?
- Plausible belief that a patient becomes preoccupied with to an unreasonable extent, leading to distress to patient/those around them
- Distinguished from delusions due to lack of gross abnormality of reasoning → can give fairly logical reasons for their beliefs
What is an illusion
- Illusions: misperception of a stimulus
- Can occur if patient is drowsy, very emotional, seen in delirium
Define hallucination
- Hallucinations: perception in the absence of a stimulus
Name the types of auditory hallucinations
-
1st person (audible thoughts): patients hear own thoughts spoken aloud as they think them
- Thought echo: thoughts are echoed after being thought
-
2nd person: voice(s) addressing patient directly
- May be persecutory, critical, complementary, command
- Often mood congruent
- 3rd person: voices speak about the patient, e.g. running commentary, conversation
- Elementary hallucinations: simple sounds, e.g. whistling, single words (voices are complex)
What do visual hallucinations suggest? give an example of one
- Suggest organic illness or psychoactive substance use
- E.g. Lilliputian hallucinations: miniature people or animals
When may visual hallucinations occur in the absence of pathology?
- occur briefly when waking (hypnopompic hallucinations) or
- falling asleep (hypnagogic hallucinations) or
- following a bereavement (still seeing loved one)
What are:
- extracampine hallucinations
- functional hallucinations
- reflex hallucinations
- Extracampine hallucinations: outside the limits of a person’s normal sensory field, e.g. hearing voices 100 miles away
- Functional hallucinations: normal sensory stimulus is needed to precipitate the hallucination in the same modality (e.g. hear voices when doorbell rings)
- Reflex hallucinations: normal sensory stimulus precipitates hallucination in another modality (e.g. hear voices when light is switched on)
What is the difference between depersonalisation and derealisation?
-
Depersonalisation: person feels unreal, detached, numb, distant
- “Do you ever feel as if you aren’t quite real?”
-
Derealisation: the world feels unreal, e.g., like a film set
- “Do you ever feel as if the world around you is not quite real?”
What does cognition mean in the MSE?
- Umbrella term covering thinking and remembering
- Includes:
- orientation,
- attention,
- concentration
- memory,
- all of which are affected by a patient’s level of consciousness
- Any concern → formal testing (e.g. MMSE)
What is the Abbreviated Mental Test Score (AMTS)?
A quick way to assess confusion with 10 questions – screening tool
Score ≤6 is significant for dementia/delirium
What are the qs in the Abbreviated Mental Test Score (AMTS)??
Questions:
- How old are you?
- What is your DOB?
- What time is it? (to nearest hour)
- What year is it?
- Where are we?
- Remember the address 42 West Street (recall later)
- Do you know who I am? Do you know who that is (point to nurse/family member)
- Do you know who the prime minister/queen is?
- Dates of WW2? (or other memorable date)
- Count down from 20-1
Address recall
What is the Mini Mental State Exam (MMSE)?
- Test to assess cognitive impairment,
- usually as a screening tool for dementia (also used to assess progression of cognitive impairment)
-
Marked out of 30
- 20-24 suggests mild dementia;
- 13-20 suggests moderate dementia;
- <12 suggests severe dementia
What are the qs in the Mini Mental State Exam (MMSE)?
Name some members of the psych MDT
- Psychiatrists
- Psychiatric nurse
- Community psychiatric nurse
- Social worker
- OT
- Clinical psychologist
Name the levels in the Hierarchy of Diagnosis
What is its use and why is it used?
- Consider higher levels first (e.g. first rule out/treat organic brain disorder)
- This is because higher levels can lead to conditions below it, e.g. organic brain disorder can cause psychosis; depression (affective disorder) can cause anxiety (neurotic disorder)
What are the different types of psychotropic medication?
antidepressants,
antipsychotics,
mood stabilisers
sedatives/hypnotics
What is the common mechanism of action of antidepressants?
common action is to elevate levels of monoamines (NA, DA, 5-HT)
Give some e.g. of SSRIs. What is their mechanism of action?
- E.g. fluoxetine, citalopram, paroxetine, sertraline
- Mechanism: selective presynaptic blockade of serotonin reuptake pumps
What are the side effets of SSRIs?
-
GI: N+V, diarrhoea, anorexia/weight loss
- Usually resolve in time
- Sexual: low libido, delayed orgasm
- Neuro: headache, anxiety, sleep disturbance, restlessness
- Fewer anticholinergic SEs than TCAs; not sedating
What are the contraindications of SSRIs?
- Mania use with caution in bipolar
How long do SSRIs take to work? What can abrupt stopping of SSRIs cause?
- May take 2wks for any effect & 6wks for full effect
- May cause suicidal ideation/anxiety/restlessness on initiation
- Esp citalopram in young adults
- Warn patients of this and follow-up
- Abrupt withdrawal of any antidepressant can cause discontinuation syndrome
- Most common in SSRIs with short half-lives (paroxetine, sertraline)
- Therefore, need to taper the dose down (except fluoxetine which has long half-life)
- Do not cause dependence (don’t become addicted or crave them)
What are the symptoms of discontinuation syndrome?
- GI: GI disturbance
- Neuro: agitation, dizziness, headache, tremor,
- insomnia
Give some e.g. of TCAs. What is their mechanism of action?
- E.g. amitriptyline, iofe-, clomi-, imi- pramine,
- Mechanism:
- presynaptic blockade of both NA and 5-HT reuptake pumps (and to a lesser extent DA);
- also blockade of muscarinic, histaminergic and alpha-adrenergic receptors
What are the indications of TCAs?
- Depression
- OCD (clomipramine)
- Neuropathic pain (amitriptyline)
- Nocturnal enuresis in children (imipramine)
What are the SEs of TCAs?
- Antimuscarinic: dry mouth, blurred vision, constipation, urinary retention, confusion
- Alpha-adrenergic blockade: postural hypotension, dizziness, syncope
- Histaminergic blockade: weight gain, sedation/drowsiness
- Cardiotoxic effects: arrhythmias, heart block, QT interval prolongation, ST elevation
- Toxic in overdose: cardiotoxic, respiratory failure, seizures, convulsions, coma
What are the contraindications of TCAs?
- Recent MI
- Arrhythmias
- Severe liver disease
- Mania → use with caution in bipolar
- High suicide risk (as lethal in overdose)
How long do TCAs take to work? What is a major caution that patients should be warned about regarding TCAs?
- May take 2wks for any effects and 6wks for full effect
- May cause drowsiness → advise patients to avoid driving
- Sedation can be useful in patients with insomnia
- Prominent sedative effects → amitriptyline, clomipramine
- Less sedative effects → iofepramine, imipramine
- Sedation can be useful in patients with insomnia
Give some e.g. of MOAIs. What is their mechanism of action?
- E.g. phenelzine, moclobemide, tranylcypromide, isocarboxazid
- Mechanism: non-selective and irreversible inhibition of monoamine oxidase A and B → decreased degradation of monoamines
- Moclobemide is a RIMA (reversible inhibitor of monoamine oxidase) → less risk of hypertensive crisis
What are the indications of MAOIs?
- Refractory/atypical depression (2nd line due to SEs)
What are the SEs of MAOIs?
- Postural hypotension
- Antimuscarinic: dry mouth, blurred vision, constipation, urinary retention, confusion
- Increased appetite, weight gain
- Hepatotoxicity
- Hypertensive crisis
- Serotonin syndrome
Why can a hypertensive crisis occur in MAOI use?
- Due to interaction between MAOIs and tyramine-containing foods
- Inhibition of MAO A causes accumulation of monoamine NTs and impairs metabolism of tyramine → accumulation of amines (esp NA) → tachycardia, HTN, vasoconstriction
- May lead to intracerebral or subarachnoid haemorrhage
What is serotonin syndrome? What is the Tx for it?
- Occurs because MAOIs increase 5-HT
- Giving other antidepressants with a strong serotonergic effect (SSRIs, clomipramine, imipramine) at the same time increases the risk of serotonin syndrome; so does giving opiates
- Triad of neuromuscular abnormalities, altered consciousness, autonomic instability
- Tx: Cyproheptadine
What are the contraindications for MAOIs?
- Mania → use with caution in bipolar
- Hepatic impairment
- Cerebrovascular disease
- Phaeochromocytoma
What are some things that patients should be advised about when starting a MAOI?
- Patients must carry a card indicating that they are taking a MAOI; must be education and given written info about diet
- Foods to avoid: cheese, degraded protein (smoked fish, chicken liver), yeast and protein extract (Marmite/Oxo), broad beans, unfresh/overripe foods, decongestants, alcohol (esp beer)
What is the advised timing of starting another antidepressant alongside an MAOI?
- Should be prescribed at least 1wk after cessation of other antidepressants;
- other antidepressants should not be prescribed until 2wks after discontinuing MAOIs
- → to decrease risk of serotonin syndrome
Give some e.g. of SNRIs. What is their mechanism of action?
- E.g. venlafaxine
- Mechanism: presynaptic blockade of both NA and 5-HT reuptake pumps (also DA in high doses); negligible effects of muscarinic, histaminergic or alpha-adrenergic receptors
What are the indications of SNRIs?
- Generalised anxiety disorder
What are the SEs of SNRIs?
- Similar SEs to SSRIs (but tend to be more severe)
- GI: Constipation, nausea
- Neuro: Dizziness, Sleep disturbances
- Cardio: HTN
What are the contraindications of SNRIs?
- High risk of cardiac arrhythmia
- Uncontrolled HTN
- Pregnancy
Which medical professional needs to supervise SNRI use? What monitoring is required?
- Should be used as 2nd-line treatment under specialist supervision
- Requires BP monitoring
Give some e.g. of Noradrenergic and specific serotonergic antidepressants (NaSSA).
What is their mechanism of action?
- E.g. mirtazapine
- Mechanism: presynaptic alpha-2 receptor blockade results in increased release of NA and 5-HT from presynaptic neurons
What are the indications of NaSSA?
- Depression (esp when sedation or increased oral intake is wanted)
What are the SEs of NaSSA?
- Increased appetite, weight gain
- Oedema
- Sedation
- Few antimuscarinic SEs → useful in elderly
What are the contraindications of NaSSA?
- Hypersensitivity
- Mania → use with caution in bipolar
- Patients taking MAOIs