- admission for assessment in emergency - 72 hours - can be made by AMHP, nearest relative, requires support of 1 doctor

- 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

Psych CBLS Flashcards by Andrea Jayawardena

Who is involved in a mental health act assessment:

Approved mental health professional (AMHP)
Section 12 approved docto

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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)

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Key components of metabolic syndrome

Essential HTN
Truncal obesity
Insulin resistance
Low glucose tolerance
Dyslipidaemia

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What is schizophrenia:

long term mental health problem
affects thinking, perception and affect

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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

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Positive symptoms of schizophrenia

Hallucination
- visual
- audible

Delusional thinking

Disorganised thinking

Agitated or repetitive movements

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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

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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

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When might Clozapine be given

If patient has failed to respond to two different anti-psychotic’s of an adequate trial (4-6 weeks)

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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

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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.

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Section 5(2)

72 hours holding powers of a doctor

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Section 5 (4)

detained by nurse for up to 6 hours

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Section 4

admission for assessment in emergency
72 hours
can be made by AMHP, nearest relative, requires support of 1 doctor

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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

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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.

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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

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. 1. **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) 2. **Mentalisation-based therapy (MBT)** - allowing individual to better understand what is going on in his and her mind and in the minds of others. 3. **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