Psych CBLS Flashcards
Who is involved in a mental health act assessment:
- Approved mental health professional (AMHP)
- Section 12 approved docto
What physical health monitoring is recommended for any patient prescribed anti-psychotic medication:
Set baseline before giving medication, at 12 weeks, at 1 year then annually.
Check
- weight, waist circumference
- Full set of observations: BP, HR etc.
- ECG (risk of long QT)
- HBA1C level
- serum cholesterol
- Lipid profile
- Serum prolactin (risperidone particularly bad for prolactinaemia)
Key components of metabolic syndrome
- Essential HTN
- Truncal obesity
- Insulin resistance
- Low glucose tolerance
- Dyslipidaemia
What is schizophrenia:
- long term mental health problem
- affects thinking, perception and affect
Early Intervention in Psychosis Team
- accept referrals between 14-65 who are felt to be at risk of developing first episode of psychosis
- may remain under team for up to three years
Positive symptoms of schizophrenia
Hallucination
- visual
- audible
Delusional thinking
Disorganised thinking
Agitated or repetitive movements
Negative symptoms of schizophrenia
Alogia
- Poverty of speech, doesn’t engage in anything
Anhedonia
- Inability to derive pleasure
Incongruity
- Blunting of affect
Avolition
- Poor motivation
Apathy
- Don’t care about anything
Summarise extrapyramidal side effects
- Acute dystonia
- uncontrolled muscle spasms - PARKINONISM
- rigidity
- bradykinesia
- tremor - Akathisia
- restlessness - NEUROLEPTIC MALIGNANT SYNDROME
- muscle rigidity
- fever
- unstable BP
- myoglobinaemia - Tardive dyskinesia
- involuntary painless movements of face and upper limbs
When might Clozapine be given
If patient has failed to respond to two different anti-psychotic’s of an adequate trial (4-6 weeks)
Side effects of clozapine
- BLOCKS serotonin receptors
- causes anticholinergic effects
—> sedation
—> dizziness
—> tachycardia
—> feeling hot
—> decreased sweating
—> dry mouth
—> dry throat
—> constipation - BLOCKS histamine H1 receptors
—> DROWSINESS - Blocks ADRENERGIC A1 receptor
—> orthostatic hypotension - EXCESSIVE SALIVATION
- INCREASED APPETITE
- CONSTIPATION
What blood monitoring is required and why for a patient on clozapine
- Immediate risk —> myocarditis
- Risk of agranulocytosis (very low neutrophils)
- Troponin also gets checked
Every week for 18 weeks. Then every 2 weeks for the rest of the year. Then every 4 weeks.
Section 5(2)
72 hours holding powers of a doctor
Section 5 (4)
detained by nurse for up to 6 hours
Section 4
- admission for assessment in emergency
- 72 hours
- can be made by AMHP, nearest relative, requires support of 1 doctor
Section 135
Section 135is a court order that allowspolice officersto enterprivate property, by force, to remove a person suffering from amental health disorderand place them in aplace of safety
Section 136
allowspolice officersto detain someone suspected of suffering from a mental health disorder, from apublic placeto a place of safety without a warrant, for up to24 hoursto allow them to be assessed by a medical practitioner.
Section 17a
- patients who are on a section 3 can leave hospital for treatment in the community
- will be recalled if there is non-compliance or if they do not attend appointments
Be aware of the numerous rating scales for depression
- Hamilton depression rating scale (HRDS)
- BECKS depression inventory
- Montgomery Asbery Depression rating scale (MADRS)
Rating scales for MANIA
Young mania rating scale
Altman self rating mania scale (ASRM)
Rating scale for suicide
Beck’s scale for suicidal ideation
Columbia scale for suicide rating (C-SSRS)
Side effects associated with lithium toxicity:
L-leukocyte
I-increase
T-tremors
H-hypothyroidism
I-increase
U-Urine
M-mothers —> Ebstein anomaly (congenital tricuspid atresia)
How does the ICD-10 classify mild, moderate and severe depressive episodes:
2 weeks needed to diagnose depression
- low mood
- anhedonia
- lack of energy
Symptoms should be present for a month or more and every symptom should be present most of the day.
CORE SYMPTOMS
- Persistent sadness / low mood
- Loss of interest / pleasure
- Fatigue or low energy
OTHER SYMPTOM
- Disturbed sleep
- Poor concentration
- Low self confidence
- Poor or increased appetite
- Suicidal thoughts or acts
- Agitation or slowing of movements
- Guilt or self blame
Not depressed < 4
Mild 4 symptoms (2 core and 2 other)
Moderate 2 core and 3 other
Severe 3 core, 5 others
- suicidal ideations
Management of severe depressive episode with psychotic symptoms
- Antidepressant + antipsychotic
- Quetiapine, olanzapine, Risperidone or Aripiprazole
- Short term use of a regular benzodiazepine (e.g. Diazepam) if patient is very distressed / agitated
- Consider short term use of hypnotic (Zopiclone) to aid sleep
- Quetiapine, olanzapine, Risperidone or Aripiprazole
ICD-10 diagnostic criteria for a manic episode
- elevated mood
- increase in quantity and speed of physical and mental activity
- decreased need for sleep
Manic episode atleast 7 days
Pharmacological treatment for episode of acute mania:
- oral antipsychotic: olanzapine, risperidone
- benzodiazepine if agitated (depot)
- stop anti-depressants
- short term hypnotic (zopiclone for sleep)
Once the patients manic episode is treated what treatment might you consider:
consider initiation of oral mood stabiliser (Lithium carbonate) or possibly carbamazepine
How does treatment differ for bipolar vs unipolar depression:
Bipolar
- most effective treatment = olanzapine + fluoxetine
- lithium carbonate
- anti-depressant mediation can precipitate manic/hypomanic episodes
Side effects of Lithium Carbonate:
- Polydipsia
- Polyuria
- Weight gain
- Peripheral oedema
- Fine resting tremor
- Worsening or precipitation of skin complaints, such as psoriasis
Clinical signs and symptoms of lithium toxicity
SERUM LEVEL 1.5-2
- nausea
- vomiting
- apathy
- coarse tremor
- ataxia
- muscle weakness
SERUM LEVEL > 2
- nystagmus
- dysarthria (difficulty speaking caused by brain damage)
- impaired consciousness
- hyperactive tendon reflexes
- oliguria
- hypotension
- convulsions
- coma
Treatment for acute lithium toxicity
- supportive management
- stop lithium carbonate
- ensure adequate hydration with IV fluids
- monitor renal function and electrolyte balance
- If acute renal failure: haemodialysis
What classes of medications should be avoided in patients prescribed lithium due to risk of causing lithium toxicity?
- NSAIDS
- DIRUETICS
- ACEi / ARB
Clinical indications for ECT
- severe depressive illness not responsive to medication
- schizophrenia
- catatonia (marked changes in muscle tone or activity)
- mania (elated, euphoria or irritable mood and increased energy)
anti-social personality disorder characterised by:
- lack of remorse
- callous disregard for feelings of other
- incapacity to maintain enduring relationships
- low tolerance to frustration and aggression
What are the three clusters of personality disorder
Cluster A - MAD
Cluster B - BAD
Cluster C - SAD
CLUSTER A personality disorders
PSS he’s MAD
Paranoid
Schizoid
- emotional coldness, prefers solitary activities
- doesn’t enjoy close relationships
- like a roboid
Schizotypal
- eccentric behaviours, odd beliefs
- magical thinking
- unusual
CLUSTER B - BAD
Emotionally unstable
- unstable, intense relationships, impulsivity, fluctuations in mood, abandonment anxiety, transient paranoia
Anti-social
- AKA dissocial, repeated unlawful or aggressive behaviour, deceitfulness, lying, reckless irresponsibility
Histrionic
- Dramatic, exaggerated expressions of emotion, attention seeking. Seductive behaviour.
Narcissistic
- Grandiose sense of self importance, need for admiration
CLUSTER C
Dependent
- Excessive need to be cared for, submissive clinging behaviour.
Avoidant / Anxious
- Hypersensitivity to critical remarks or rejection.
OCD
- preoccupation with orderliness, perfectionism and control
Management of borderline personality disorder
Drug treatment SHOULD NOT BE USED specifically for BORDERLINE PERSONALITY DISORDER.
-
Dialectical behavioural therapy (DBT)
- used combination of cognitive and behavioural therapies with some relaxation techniques.
- involves individual and group work
- long term therapy (12-18 months)
-
Mentalisation-based therapy (MBT)
- allowing individual to better understand what is going on in his and her mind and in the minds of others.
-
Therapeutic community
- residential form of therapy
- group setting
- individual stays for weeks or months
What is the preferred approach for supporting behaviour that challenges?
Positive behavioural support plan
- values led
- patient centred
- about relationships and communication
- function based
- data led decision making
- adding new skills and opportunities
- teamwork
Fragile X syndrome
Caused by increase in number of CGG repeats on the Fragile X mental retardation (FMR1) gene on the X-chromosome
Associated with autism spectrum disorder
What assessment tool may show a patient meets the criteria for childhood autism?
DISCO assessment tool
