Psychiatry Flashcards

1
Q

Schizophrenia

A

the most common form of psychosis, generally a lifelong condition that can take a chronic or relapsing & remitting form with episodes of acute illness

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2
Q

Schizophrenia epidemiology

A

usually presents in adolescences & early 20s
generally females have a later age of occurrence

responsible for 25% of all psychiatric hospitalisations of 10-18 year olds

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3
Q

Risk factors for schizophrenia

A
family history*
cannabis use
obstetric/perinatal complications 
ACEs
psychological stress
migrant status
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4
Q

Presentation of schizophrenia

A

deterioration in functioning over the preceding months

4 symptomatic domains

Positive symptoms:
hallucinations (usually auditory), delusions, thought disorders (e.g. broadcasting, withdrawal, insertion), speech disorder, derealisation

Negative symptoms:
asocial behaviour, affective blunting, anhedonia, alogia (↓ speech), abolition (↓ motivation), social withdrawal, self neglect

Catatonia:
extreme loss or malignant excess of motor activity
catatonic stupor/rigidity/negativism/excitement

cognitive deficits/affctive symptoms/physical symptoms:
problems with language/memory/attention/excutive function, depression, elation, motor coordination deficits, left-right disorientation, sensory integration deficit

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5
Q

Positive symptoms of schizophrenia

A
hallucinations (usually auditory)
delusions
thought disorders (e.g. broadcasting, withdrawal, insertion)
speech disorder
derealisation
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6
Q

Negative symptoms of schizophrenia

A
asocial behaviour
affective blunting
anhedonia
alogia (↓ speech)
abolition (↓ motivation)
social withdrawal
self neglect
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7
Q

Catatonic symptoms fo schizophrenia

A

extreme loss or malignant excess of motor activity

catatonic stupor/rigidity/negativism/excitement

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8
Q

cognitive deficits/affective symptoms/physical symptoms of schizophrenia

A
problems with language/memory/attention/excutive function
depression
elation
motor coordination deficits
left-right disorientation
sensory integration deficit
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9
Q

DSM-5 criteria for schizophrenia

A

Schizophrenia can be diagnosed if the following conditions are met.

Two or more of the following symptoms are present: delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour, or negative symptoms. At least one of the symptoms must be a positive symptom.

Symptoms occur for a period of at least 1 month (less, if treated) and are associated with at least a 6-month period of functional decline

Symptoms do not occur concomitantly with substance use or with a mood disorder episode.

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10
Q

ICD-11 criteria for schizophrenia

A

Criteria for schizophrenia require a combination of at least one first-rank psychotic symptom or at least two other symptoms, including other positive psychotic symptoms, disorganised thinking or speech, negative symptoms, or catatonia.

First-rank psychotic symptoms include thought echo, thought insertion or withdrawal and thought broadcasting, delusions of control, influence or passivity, delusional perception, other strange delusions, and auditory hallucination commenting on the patient’s behaviour or talking about the patient in the third person.

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11
Q

Investigating schizophrenia

A

clinical diagnosis

consider FBC & LFTs, urine drug screen

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12
Q

Management of schizophrenia

A

1st line: PO atypical antipsychotic e.g. risperidone/olanzapine

NB clozapine = antipsychotic of choice for treatment resistant schizophrenia

Cognitive behavioural therapy (CBT)
electroconvulsive therapy (ECT) - if resistant to pharmacological treatment
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13
Q

Monitoring of treatment for schizophrenia

A
  • extrapyramidal effects/metabolic syndrome/excessive prolactin
  • cardiac abnormalities (baseline ECG, motor for QT prolongation)
  • postural hypotension
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14
Q

poor prognostic factors for schizophrenia

A
↑ duration of untreated psychosis
early/insidious/gradual onset of schizophrenia
male sex
negative symptoms 
FHx
continued substance misuse
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15
Q

Bipolar disorder

A

Also known as bipolar affective disorder
chronic episodic mental illness associated with behavioural disturbances which is characterised by episodes of mania (or hypomania) and depression

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16
Q

Types of bipolar disorder

A

Type I: presents with manic episodes interspersed by major depressive episodes (most common type)

Type II: pt do not meet criteria for full mania & are described as hypomanic, has ↓ associated dysfunction

NB: rapid cycling - defined as four or more cycles of depression and mania a year, with no intervening asymptomatic episodes

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17
Q

Bipolar disorder epidemiology

A

usually develops in late teen years

usually seen <25 y/o

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18
Q

Risk factors for bipolar disorder

A
family history (50-10x ↑ risk)
onset of mood disorder <20y/o
stressful life events
ACEs
history of depression
history of substance misuse
presence of anxiety disorder
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19
Q

Presentation of bipolar disorder

A

Manic phase:
elevated mood, ↑quantity&speed of physical/mental activity, grandiose ideas, pressure of speech, ↑energy, racing thoughts/flight of ideas, overactivity, ↑appetite, sexual disinhibition, ↓need for sleep, hallucinations, delusions, lack of isnight

Hypomanic phase:
persistent mild elevation in modd
↑ activity/energy levels
NO psychotic symptoms

Depressive phase:
low mood (worse in mornings), ↓energy levels, unkempt, anhedonia, ↓self-esteem, despair, guilt, ↓appetite, weight loss, loss of libido, altered sleep pattern, self neglect 

Psychological functioning:
difficulties in relationships & at work

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20
Q

Manic symptoms of bipolar disorder

A
elevated mood
↑quantity&speed of physical/mental activity
grandiose ideas
pressure of speech
↑energy
racing thoughts/flight of ideas
overactivity
↑appetite
sexual disinhibition
↓need for sleep
hallucinations
delusions
lack of insight
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21
Q

Depressive symptoms of bipolar disorder

A
low mood (worse in mornings)
↓energy levels
unkempt, anhedonia
↓self-esteem
despair, guilt
↓appetite
weight loss
loss of libido
altered sleep pattern
self neglect
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22
Q

Differentiating hypomania and mania

A

NO psychotic symptoms in hypomania
Hypomania does not impair functional ability significantly
hypomania is shorter lasting than mania

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23
Q

ICD-10 criteria for bipolar disorder

A

≥2 episodes of a persons mood & activity levels being significantly disturbed (at least one of which is mania/hypomania)

3 of the following confirm mania
-grandiosity/inflated self esteem, pressured speech, ↓need for sleep, flight of ideas, distractibility, psychomotor agitation, excessive involvement in pleasurable activity without thought for consequence
±psychotic symptoms e.g. hallucinations/delusions

frequency & duration of episodes are variable and may even vary day to day/within a day between mania/depression/hypomania

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24
Q

Management for bipolar disorder

A

self help/support groups
CBT/interpersonal therapy

Mood stabilisers
1st line: lithium (valproate/olanzapine if lithium not tolerated)
2nd line: add valproate if lithium alone ineffective

For acute mania:
give antipsychotic e.g. haloperidol/olanzapine/risperidone
consider IM sedation e.g. bentos

For acute depression:
offer fluoxetine ± olanzapine/quetiapine

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25
Depression
refers to both negative affect (low mood) and/or absence of positive affect (loss of interest/pleasure in most activities) which is usually accompanied by a variety of emotional/cognitive/physical/behavioural symptoms
26
Risk factors for developing depression
``` female gender history of depression/suicide family history of depression/suicide significant/chronic physical illness history of other mental health problems psychosocial factors (ACEs, unemployment, poverty) ```
27
Presentation of depression
``` depressed/low mood anhedonia functional impairment weight change loss of libido sleep disturbance low energy/fatigue poor concentration suicidal ideation excessive guilt ↓ self-esteem feeling of worthlessness ```
28
Screening for depression
PHQ-2 questionnaire over past month have you: -felt low/depressed/hopeless -had little interest/pleasure in doing things
29
Assessment of depression (assessing degree)
PHQ-9 questionnaire 9 items from DSM-5 criteria scored 0-3 (0 not at all, 3 nearly everyday) HAD scale 14 questions, 7 for anxiety, 7 for depression scored 0-3
30
DSM-5 criteria for depression
Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure: Depressed mood most of the day, nearly every day, as self-reported or observed by others Diminished interest or pleasure in all or almost all activities most of the day, nearly every day Significant weight loss when not dieting, weight gain or decrease, or increase in appetite nearly every day Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt nearly every day Diminished ability to think or concentrate nearly every day Recurrent thoughts of death, recurrent suicidal ideation without a specific plan. In addition, these symptoms: Cause functional impairment (e.g., social, occupational) Are not better explained by substance abuse, medication side effects, or other psychiatric or somatic medical conditions.
31
Management of sub-threshold or mild-to-moderate depression
1st line: Cognitive behavioural therapy (CBT), exercise programmes, counselling antidepressants not routinely used
32
Management of unresponsive or severe depression
antidepressants + CBT/interpersonal therapy antidepressants: SSRIs = 1st line e.g. citalopram, fluoxetine, sertraline SNRIs = 2nd line e.g. venlafaxine, duloxetine
33
Schizoaffective disorder
psychiatric condition with features of both schizophrenia & mood disorders which commonly presents in early adulthood generally more responsive to mood stabilisers than schizophrenia generally a non-deteriorating course
34
DSM-5 criteria for schizoaffective disorder
uninterrupted period of illness during which there is an episode of mood disorder (major depression/mania) concurrent with a schizophrenic episode characterised by 2 of the following symptoms present for a considerable part of 1 month: delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms (affective flattening, apologia, avoliiton) should have period of at least 2 weeks of hallucinations/delusions in absence of prominent mood disorder
35
Management of schizoaffective disorder
atypical antipsychotics e.g. clozapine antidepressants e.g. fluoxetine, sertraline mood stabilsiers e.g. lithium or valproic acid
36
Generalised anxiety disorder (GAD)
syndrome of ongoing anxiety & worry about many events or thoughts that the pt generally recognises as excessive & inappropriate maybe chronic & debilitating
37
Risk factors for generalised anxiety disorder (GAD)
``` family history of anxiety physical/emotional stress history of physical/emotional/sexual trauma chronic health conditions social isolation ```
38
Screening for generalised anxiety disorder (GAD)
``` GAD-7 score screening tool & severity measure 7 items scored 0-3 score of 5 = mild score of 10 = moderate score of 15 = severe ```
39
DSM-5 criteria for generalised anxiety disorder (GAD)
excessive anxiety&worry regarding several issues are present most of the time for >6months difficulty controlling worry ≥3 symptoms associated with anxiety for >6 months restlessness/feeling on edge, easily fatigued, difficulty concentrating, muscle tension, sleep disturbance (restless sleep/difficulty falling asleep) anxiety causes significant distress or impairment in social/occupational/other areas of functioning
40
Symptoms of generalised anxiety disorder (GAD)
``` persistent nervousness trembling muscular tension light headedness palpitations dizziness epigastric discomfort sleep disturbance (restless sleep/difficulty falling asleep) ```
41
Management of generalised anxiety disorder (GAD)
Step 1: education & active monitoring Step 2: low intensity psychological intervention e.g. CBT Step 3: high intensity psychological intervention or drug therapy e.g. CBT or Sertraline (1st line) NB alternative to sertraline is venlafaxine
42
Drug therapy of generalised anxiety disorder (GAD)
Sertraline = 1st line Venlafaxine = alternative consider pregabalin if SSRI/SNRI not tolerated
43
Panic disorder
severe & disabling illness common in primary care which often coexists with agoraphobia NB agoraphobia rarely occurs without panic disorder common condition, more frequent in women
44
DSM-5 criteria of panic disorder
recurring & unexpected panic attacks least one of which is followed by a 1-month period in which the individual worries about having additional attacks or their implications + the individual has changed they behaviour in a maladaptive way Panic attacks are characterised by sudden surge in intense fear/physical discomfort reaching peak within a few minutes ≥4 of the following symptoms are present during panic attacks palpitations/heart pounding/tachycardia, sweating, muscle trembling/shaking, SOB, choking sensation, dizziness/lightheadedness/instability/feeling faint, fears of losing control, numbness/tingling
45
Management of panic disorder
- avoid anxiety inducing substances e.g. caffeine - trigger avoidance - CBT - SSRIs e.g. fluoxetine/sertrlaine (1st line) - TCAs e.g. imipramine/clomipramine (2nd line)
46
Agoraphobia
fear of open spaces, especially those in which getaway/escape may be difficult which leads to avoidance of these situations being in a provoking situation usually leads to panic attacks
47
the 3 basic elements of agoraphobia
Phobia severe anxiety avoidance of situations that might provoke anxiety
48
DSM-5 criteria for agoraphobia
marked fear/anxiety in ≥2 of the following group situations: public transport, open spaces, being in shops/cinemas/theatres, standing in line/being in crowd, being outside of home alone person fears/avoids these situations due to thought that escape may be difficult or help not available situations are actively avoided, require a companion or are endured with marked fear/anxiety
49
Management of agoraphobia
CBT + medication 1st line SSRIs eg. fluoxetine/sertrlaine 2nd line imipramine/clomipramine (if no improvement after 12 weeks of SSRI)
50
Social anxiety disorder (SAD)
the fear of being around people & having to interact with them one of the most common anxiety disorder especially in young people
51
Symptoms of social anxiety disorder (SAD)
trembling, blushing, sweating palpitations chronic insecurity about their relationships with others excessive sensitivity to criticism profound fear of being judged negatively fear of being rejected by other fear of being mocked
52
Management of social anxiety disorder (SAD)
CBT based supported self help SSRIs e.g. escitalopram/sertraline if no response consider paroxetine or vanlafaxine
53
Post traumatic stress disorder (PTSD)
may develop at nay age following exposure to 1 or more traumatic events such as deliberate acts of interpersonal violence/sevre accidents/disasters/military action or any situation of exceptionally threatening/catastrophic nature
54
PTSD risk factors
``` precipitating events is life threatening refugees/asylum seekers first responders (police/ambulance/fire department) combat exposure low morale poor social support history of drug/alcohol abuse history of psychiatric illness ```
55
Presentation of PTSD
re-experiencing: flashbacks, nightmares, repetitive & distressing intrusive images avoidance: avoiding people/situations/circumstances resembling or associated with event hyperarousal: hyper vigilance for threat, exaggerated startle response, sleep disturbance, irritability, difficulty concentrating, reckless/self-destrcutive behaviour Emotional numbing: feeling detached, lack of ability to experience feelings, persistent negative/distorted beliefs, distorted ideas of blame, anhedonia Other: depression, alcohol/substance misuse, anxiety, angerq
56
Length of symptoms for diagnosis of PTSD
>1 month
57
Management of PTSD
watchful waiting if symptoms mild & ,4 weeks trauma focused CBT or eye movement desensitisation & reprocessing (EMDR) ``` drug therapy (not 1st line): SNRIs e.g. venlafaxine or SSRIs e.g. sertraline/paroxetine ```
58
Phobias
involves intense fears of specific objects or situations that are triggered upon actual/anticipated exposure to the phobic stimuli more common in women One of the most common & most treatable psychiatric conditions
59
Presentation of phobia
``` usually set in childhood/early adulthood nausea dizziness disgust fainting tachycardia hyperventilation exaggerated startle ```
60
Types of phobias
``` animals (e.g. spiders, snakes, rats) situations (e.g. flying) environmental (e.g. heights) blood/needles/injuries others (e.g. clowns) ```
61
Management of phobias
CBT including exposure therapy | SSRIs
62
Obsessive compulsive disorder (OCD)
characterised by obsessions or compulsions but most frequently both onset usually in late adolescence & early 20s
63
Risk factors for OCD
Family history*
64
DSM-5 criteria for OCD
Must exhibit obsessions, compulsions, or both. The obsessions and/or compulsions cause marked distress, are time consuming (take more than 1 hour per day), or interfere substantially with the person's normal routine, occupational or academic functioning, or usual social activities or relationships. The obsessions and/or compulsions are not attributable to the physiological effects of a substance or other medical condition. The disorder is not better explained by the symptoms of another mental disorder, such as obsession with food in the context of an eating disorder. Obsessions are: Recurrent and persistent thoughts, urges, or images experienced, at some time during the disturbance, as intrusive and unwanted and in most individuals cause marked anxiety or distress. There is some effort by the affected person to ignore or suppress such thoughts, impulses, or images, or to neutralise them with some other thought or action (i.e., by performing a compulsion). ``` Compulsions are: Repetitive activities (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. These behaviours or mental acts are performed in order to prevent or reduce distress, or prevent some dreaded event or situation. However, they are either clearly excessive or not connected in a realistic way with what they are designed to neutralise or prevent. ``` specify the degree of insight specify if the disorder is tick related
65
Presentation of OCD
obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one's mind.
66
OCD associated diseases
``` depression schizophrenia Tourettes anorexia nervosa body dysmorphic disorder easting disorders ASD ```
67
Management of OCD
Mild functional impairement: low intensity psychological interventions e.g. CBT +exposure and response prevention (ERP) Moderate functional impairment: SSRI e.g. fluoxetine or high intensity psychological interventions e.g. CBT + ERP severe functional impairment: high intensity CBT + ERP & SSRI
68
Seasonal affective disorder
a variant of depression characterised by depressive episodes that recur annually at the same time each year usually during winter months
69
Presentation of seasonal affective disorder
onset of depressive symptoms in autumn/winter full resolution of symptoms during spring/summer atypical vegetative symptoms of depression are common e.g. hypersomnia, weight gain, hyperphagia, lethargy
70
Diagnosis of seasonal affective disorder
over last 2 years ≥2 major depressive episodes have occurred that demonstrated the temporal seasonal pattern
71
Management of seasonal affective disorder
Education CBT SSRIs
72
Postnatal depression (PND)
refers to the development of a depressive illness following childbirth & may form part of a bipolar or more usually unipolar illness onset of depression within 6 weeks of childbirth affects ~9% of new mothers
73
Presentation of postnatal depression
depressive symptoms e.g. low mood, anhedonia, ↓appetite, poor concentration, low self-esteem, fatigue, ↓energy, ↓ libido, suicidal ideation fears about babies health/maternal deficiencies marital tension
74
Assessment of postnatal depression
via Edinburgh postnatal depression scale
75
Management of postnatal depression
self-help strategies antidepressants (SSRIs/SNRIs) at lowest effective dose CBT/interpersonal therapy
76
Postnatal blues
occurs in ~50% of women after childbirth usually 48-72h post partum, symptoms peak at 5-7 days and subside by 10-14 days Symptoms include tearfulness, irritability, poor concentration, anxiety about the baby, emotional lability, mood swings if persistent >14 days = postnatal depression
77
Postpartum psychosis/puerperal psychosis
severe mental illness which develops acutely in the early postnatal period which is a psychiatric emergency usually develops within 1 month of birth, most commonly within 3-14 days rapidly develops over 48h generally
78
Risk factors for postpartum psychosis
personal history of postpartum psychosis history of bipolar disorder family history of postpartum psychosis.bipolar disorder
79
Presentation of postpartum psychosis
rapid transition form normal state/sudden onset early symptoms: perplexity, fear, restless agitation, insomnia, purposeless activity, uncharacteristic behaviour, irritation, fleeting anger, resistive behaviours, elation & grandiosity fear for her own/babys health late symptoms: psychosis (hallucinations, delusions, mania, depressive symptoms)
80
Management of postpartum psychosis
psychiatric emergency admission to mother-baby-unit antipsychotics ± mood stabilisers (give rapidly to reduce impact on mother-baby relationship)
81
Risks of postpartum psychosis
major ↑ in risk of maternal suicide
82
Delirium (acute confusional state)
hard to define clinical syndrome involving abnormalities of thought, perception level of awareness typically with acute onset and fluctuating change in mental states
83
Risk factors for delirium
``` age ≥65 history of dementia polypharmacy severe comorbidity previous episodes of delirium substance misuse frailty multimorbidity drug/substance use/misuse/dependance ITU admission dehydration visual/hearing impairment ```
84
Aetiology of delirium
- infection: particularly urinary tract infections - metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration - change of environment - any significant cardiovascular, respiratory, neurological or endocrine condition - severe pain - alcohol withdrawal - constipation
85
Presentation of delirium
acute/subacute presentation with fluctuating course disorientation, impaired cognition, change of consciousness, poor concentration, memory problems, mood changes, agitation, withdrawal, poor attention, disturbed sleep cycle, emotional lability, abnormalities of perception (hallucinations, illusions), psychotic signs (delusions, hallucinations)
86
Sub types of delirium
hypoactive: apathy/quiet confusion/withdrawal, easily missed hyperactive: agitation/delusions/disorientation are prominent mixed
87
Management of delirium
- treat underlying cause - supportive management (clear communications, reminders of time/location, staff consistency, familiar objects from home) - environmental measures (avoid sensory extremes, side room, adequate nutrition) NB if medical management needed 1st line = PO Lorazepam 2nd line = PO haloperidol
88
Dementia
a syndrome characterised by an appreciable deterioration in cognition resulting in behavioural problems/impairment in the activities of daily living decline of cognitive function often affects multiple domains of intellectual functioning
89
Symptoms of dementia
Cognitive impairment: causing difficulties with memory, language, attention, thinking, language, orientation, calculation, problem solving Psychiatric/behavioural problems: changes in personality/emotional control/social behaviour, depression, agitation, hallucinations, delusions difficulties in activities of daily living
90
Alzheimers disease
involved progressive degeneration of cerebral cortex with widespread cortical atrophy most common cause of dementia
91
Risk factors for Alzheimers
``` ageing caucasian Down's syndrome hyperlipidaemia smoking obesity alcohol abuse high fat diet diabetes HTN ```
92
Genetic factors of Alzheimers
Presenilin-1 (PSEN1) - most common form of familial AD Presenilin-2 (PSEN2) - rare amyloid precursor protein (APP) - linked to early onset AD ApoE4 (apolipoprotein E4) - risk of late onset AD, NB ApoE2 is protective
93
Presentation of Alzheimers
insidious onset of 7-10 years memory lapses/short term memory impairment (especially episodic memory) forgetting appointments/names/places/people trouble finding words language impairment temporal/spatial disorientation impaired executive function & judgement behavioural change (apathy/agitation/aggression/irritability)
94
pathophysiology of Alzheimers
wide spread cerebral atrophy cortical/senile plaques (extracellular deposition of beat-amyloid) neurofibrillary tangles (intracellular aggregation hyperphosphorylated tau protein)
95
Investigating Alzheimers
``` neurophysiological Testung (MMSE, MoCa) FBC, U&Es, TFTs, Vti B12, urine drug screen, CT?MRI head ```
96
Management of Alzheimers
MDT approach with multiple therapies & support e.g. memory enhancement strategies Pharmacological: 1st line: accetylcholinesterase inhibitors e.g. donepezil, galantamine, rivastigmine 2nd line: memantine (NMDA receptor antagonist)
97
Vascular dementia (VD)
a group of syndromes of cognitive impairment caused by different mechanisms that cause ischaemia or haemorrhage secondary to cerebrovascular disease (multiple infarcts, single strategic infarct, small vessel disease) 2nd most common form of dementia
98
Risk factors for vascular dementia
``` obesity HTN smoking AF history of TIA CHD diabetes family history of CVS disease/stroke genetics e.g. CADASIL ```
99
Presentation of vascular dementia
progressive disease with sudden deteriorations in a stepwise manner* focal neurological abnormalities e.g. visual disturbances, sensory/motor symptoms etc seizures difficulty with attention & concentration memory disturbance mood disturbance emotional lability bladder symptoms gait disturbance speech distrubance
100
Management of vascular dementia
MDT approach with therapies, cognitive stimulation programmes and structured exercise programmes Pharmacological: no specific approved pharmacological treatment
101
Lewy body dementia
neurodegenerative disorder with parkinsonism, progressive cognitive decline, prominent executive dysfunction & visuospatial impairment dementia characterised by eosinophilic intracytoplasmic neuronal inclusion bodies formed of alphasynuclein
102
Lewy body dementia presentation
dementia is usually the presenting feature with memory loss, ↓ problem solving ability, spatial awareness difficulties earlier impairments of attention & executive function compared to AD fluctuating cognition Parkinsonism (bradykinesia, resting tremor, rigidity, poverty of facial expression) frequent falls sleep disorders (REM sleep disorders)
103
Management of lewy body dementia
MDT approach with therapies, cognitive stimulation programmes and structured exercise programmes Pharmacological: AChE inhibitors e.g. donepezil or memantine may be used NB avoid neuroleptic drugs (may cause permanent parkinsonism)
104
Alcohol use disorder
common psychiatric condition that is multifactorial in aetiology, chronic in nature & associated with a wide variety of medical & psychiatric sequelae major problem in the UK
105
Risk factors for alcohol use disorders
``` family history of alcoholism male sex ACEs stressful life events low socio-economic status other substance related disorders mood disorders ```
106
Presentation of alcohol dependence
``` withdrawal symptoms tolerance (↓ response to alcohol) signs of liver disease peripheral neuropathy (due to thiamine deficiency) impaire nutritional status ```
107
DSM-5 criteria for alcohol use disorder
Alcohol-use disorder is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least 2 of the following criteria over the same 12-month period: - Alcohol used in larger amounts or over a longer period of time than intended - Persistent desire or unsuccessful attempts to cut down or control alcohol use - Significant time spent obtaining, using, and recovering from the effects of alcohol - Craving to use alcohol - Recurrent alcohol use leading to failure to fulfil major role obligations at work, school, or home - Recurrent use of alcohol, despite having persistent or recurring social or interpersonal problems caused or worsened by alcohol - Recurrent alcohol use, despite having persistent or recurring physical or psychological problems caused or worsened by alcohol - Giving up or missing important social, occupational, or recreational activities due to alcohol use - Recurrent alcohol use in hazardous situations - Tolerance: markedly increased amounts of alcohol are needed to achieve intoxication or the desired effect, or continued use of the same amount of alcohol achieves a markedly diminished effect - Withdrawal: there is the characteristic alcohol withdrawal syndrome, or alcohol is taken to relieve or avoid withdrawal symptoms.
108
Assessment of alcohol use disorder
CAGE (cut down, annoyed guilt eye opener) | alcohol use disorder identification test (AUDIT)
109
Investigating alcohol use disorder
Alcohol level | FBC, LFTs, clotting, U&Es
110
Management of alcohol use disorder
advise & education avoidance of drinking triggers CBT assisted withdrawal (usually community based) if drinking >15 units/day or AUDIT score ≥20 with chlordiazepoxide + pabrinex acamprosate (to ↓ cravings for alcohol) naltrexone & nalmefene (↓ pleasurable effects from alcohol) disulfiram (amplifies negative effects of alcohol by blocking acetaldehyde dehydrogenase)
111
Alcohol withdrawal
occurs in pts who are alcohol dependent & who have stopped/↓ their alcohol intake within hours/days of presenting symptoms typically begin 6-12h after last alcoholic drink
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Presentation of alcohol withdrawal
typically after 6-12h without drink tremor, sweating, tachycardia, anxiety, nausea&vomiting, headache, restlessness, agitation, insomnia cravings fro alcohol ``` alcoholic hallucinosis (12-24h after last drink) auditory/visual/tactile hallucinations ``` ``` withdrawal seizures (24-48h after last drink) generalised tonic clonic seizures ``` delirium tremens (48-72h after last drink)
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Management of alcohol withdrawal
admit if previous difficult withdrawal or <18y/o chlordiazepoxide (reducing dose over 5-7 days) Pabrinex (Vit B complex to replace thiamine)
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Delirium tremens
medical emergency die to hyperadrenergic state usually occurring 48-72h after alcohol withdrawal features include a coarse tremor, altered mental state (severe agitation/hallucinations/confusion), disorientation, tachycardia, HTN, nausea, sweating, insomnia, hyperreflexia managed with IV benzodiazepines + parbinex
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Substance use & addictive disorders
substance related disorders are a class of psychiatric disorder characterised by craving for, the development of tolerance to, difficulties controlling the use of a particular substance/set of substances and withdrawal symptoms upon cessation of substance use generally more common in males
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Features of a substance disorder
≥2 within 1 year - impaired control (e.g. repeated failed attempts to cut down use, intense desire to obtain/use substance, spending a great deal of time on substance related activities such as buying/using/recovering) - social impairment (problems fulfilling educational/family/social/occupational obligations, problems with interpersonal relationships, social isolation) - risky use (use in physically hazardous situations e.g. while driving, continued use despite awareness of problems related to substance use) - pharmacological indicators (tolerance & withdrawal)
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Opioid use disorder
e.g. with fentanyl, heroin, oxycodone, morphine biggest cause of drug related death overdose = mitosis, respiratory depression, CNS depression, ↓ GCS, apnoea Overdose management with naloxone (400 micrograms IM/IV) detoxification using substitutes such as methadone or buprenorphine needle exchanges
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cocaine use disorder
stimulant drug intoxication: euphoria, arousal, tachycardia, hypertension, mydriasis, sweating withdrawal: depression, fatigue, sleep disturbance, anhedonia, suicidal thoughts overdose: tachycardia, coronary vasospasm, hypertension, hyperthermia, agitation, diaphoresis, mydriasis, seizures management: benzodiazepines, CBT, motivational interviewing
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Complications of cocaine use
``` psychosis excited delirium hypertensive crisis cerebrovascular event seizures crack lung MI tachyarrythmias mood disorders serotonin syndrome ```
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Cannabis use disorder complications
psychosis (cannabis induced) anxiety disorders sleep disorders cannabinoid hyperemesis syndrome
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Benzodiazepine overdose
myadirasis (dilated pupil), hypotension, bradycardia, respiratory depression, apnoea, ↓GCS, ataxia, slurred speech management with supportive care ± flumazenil
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Personality disorders
characterised by deeply rooted egosyntonic behavioural traits that differ significantly from the expected & accepted norms of an individuals culture
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personality disorders epidemiology
generally more common in men histrionic & borderline disorders occur more frequently in women
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Cluster A of personality disorders
includes paranoid, schizoid, schizotypal PD general behaviour: odd, eccentric, unable to form close interpersonal relationships, classically no psychosis
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Cluster B of personality disorders
includes borderline, histrionic, antisocial, narcissistic PD general behaviour: dramatic, erratic, emotional
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Cluster C of personality disorders
includes avoidant, dependent, obsessive-compulsive PD general behaviour: fearful, avoidant, anxious
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Paranoid personality disorder
``` pervasive distrust & suspicion distrust of others reluctance to confide in others unwarranted tendency to question loyalty of others unjustly suspicious of others deceiving/harming them suspicion of infidelity in partners holding grudges fears others are exploiting them ```
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Schizoid personality disorder
voluntary detachment from social relationships prefers solitary activities no/little interest in sexual relationships lacks close friends/people they trust indifferent to promise/criticism restricted emotional expression comfortable with social isolation
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Schizotypal personality disorder
odd/eccentric behaviour/physical appearance magical thinking social awkwardness excessive social anxiety ideas of reference bizarre thinking/speech (metaphorical & overelaborated) paranoia & suspicion of others social anxiety & preference for social isolation
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Anti social personality disorder
deceitfulness/manipulative history of hostility & repeated aggression deception repeatedly engaging in criminal activity impulsivity/failure to plan ahead reckless disregard for one's own safety / the safety of others lack of remorse emotional indifference to the plight of others
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Borderline personality disorder
unstable mood intense anger that can be difficult to control feeling of emptiness self damaging acts (unsafe sex, alcohol, drugs) self harm/suicidal behaviour splitting (relationship categorically good or bad) fear of abandonment difficulty controlling temper unstable personal relationships
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Histrionic personality disorder
``` attention seeking dramatic seech exaggerated emotional expression feeling often shallow & unstable sexually provocative and/or seductive behaviour overestimating degree of intimacy suggestibility wants to be centre of attention ```
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Narcissistic personalty disorder
excessive sense of self importance fantasises disproportionately about power/success believe in being special/feeling of superiority great need for affirmation exploitation of others to achieve own goals lack of empathy fragile self-esteem struggles to deal with criticism
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avoidant personality disorder
avoidance of interpersonal contact due to fear of criticism/rejection restrained intimate relationships due to fear of being shamed preoccupation with & hypersensitivity to criticism feeling of inadequacy low self esteem avoids taking risks & seldom engaged in new activities strong desire for social relationships but limited by extreme shyness & social anxiety
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Dependent personality disorder
disproportionate need for support difficulty making everyday decisions avoids disagreeing with other due to fear of losing their support always seeking support from others feeling of helplessness when alone seeking new relationships when one fails often stuck in abusive relationships
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obsessive compulsive personality disorder
excessive preoccupation with rules/lists/details obsession with work & productivity at the expense of social relationships/pleasurable activities perfectionism interferes with task completion unwillingness to delegate work or collaborate with others inflexible about matters of morality/ethics rigid routines perfectionism & obsession with control NB unlike OCD there are no intrusive thoughts or repetitive behaviours
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Management of personality disorders
``` psychotherapy group therapy cognitive therapy interpersonal therapy CBT ```
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Anorexia nervosa
An eating disorder characterised by restriction of caloric intake leading to low body weight an intense fear of gaining weight and body image disturbance most common cause of admission to child&adolescent psychiatric ward 90% of pts are female usually seen in young adults & adolescents
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Risk factors for anorexia nervosa
``` female gender adolescent & puberty obsessive/perfectionist traits middle/upper socioeconomic classes high pressure career/sports unrealistic beauty standards Family history of eating disorders ```
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associated mental health conditions with anorexia nervosa
OCD anxiety disorders mood disorders personality disorders
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Presentation of anorexia nervosa
``` refusal to maintain normal body weight ↓BMI (generally BMI <18.5) dieting/restrictive eating practices significant preoccupations with thoughts on food rapid weight loss fear of gaining weight body image disturbance excessive exercise amenorrhoea fatigue fainting cold intolercane bradycardia ```
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Investigations for anorexia nervosa
``` FBC (normocytic normochrmic aneamia, thrombocytopenia) U&Es (↓K+, ↓Na+, ↓Cl-, ↓Mg2+, ↑bicarb) LFTs (↑cholesterol, ↓ albumin) TFTs (↓T3) amylase (↑) FHS/LH/oestrogen/testosterone (↓) impaired glucose tolerance ECG DEXA scan (↓bone mineral density, osteopenia) ```
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Management of anorexia nervosa
assess physical risk via MARSIPAN criteria Family therapy (if <18y/o) eating disorder focused CBT (if >18y/o) nutritional support (vitamin/mineral supplements)
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Criteria for hospital admission in anorexia nervosa
``` BMI <15 bradycardia/hypothermia/hypotension arrhythmias hypoglycaemia dehydration/electrolyte disturbances rapid weight loss suicide risk medical complications ```
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Bulimia nervosa
An eating disorder characterised by recurrent episodes of binge eating followed by behaviours aimed at compensating the binge i.e. purging mainly affects women, usually in their 20s
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Risk factors for bulimia nervosa
parental/childhood obesity family dieting body dysmorphia personal/family history of eating disorders/depression/substance misuse
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Presentation of bulimia nervosa
recurrent episodes of binge eating (occurs ~1x per week for 3 months) recurrent inappropriate compensatory behaviour i.e. purging (vomiting/laxatives/enemas) or non purging (exercise/fasting) BMI maintained >17.5 concerns about weight/body shape dental erosion Russel's sign (scarring of dorm of hand from inserting into mouth) preoccupation of food
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Investigating bulimia nervosa
``` normal BMI U&Es (↓K+, ↓Cl-, ↓Ca2+) ABG (↑pH, metabolic alkalosis) FBC (-/↓ Hb) LFTs, creatinine ```
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Management of bulimia nervosa
In adults: bulimia focused guided self help programme (1st line) individual eating disorder focused CBT (CBT-ED) In <18s: bulimia focused family therapy (1st line) CBT-ED trial of fluoxetine
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Binge eating disorder
recurrent episodes of binge eating without purging behaviour, feeling lack of control over the amount of food consumed with ≥1 of eating faster than normal/eating until uncomfortably full/feeling of disgust and/or guilt after eating treatment: CBT ± SSRIs or Lisdexamfetamine
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PICA (eating disorder)
eating disorder characterised by appetite for & ingestion of nonnutritive substances treatment: nutritional rehabilitation & behavioural intervention
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Avoidant/restrictive food intake disorder (ARFID)
people eat in a extremely narrow repertoire of foods or having restricted intake in terms or overall amount eaten or both ``` Treament: CBT in adults systematic desensitisation (in children) ```
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Body dysmorphic disorder
An excessive preoccupation with an imagined defect in appearance or excessive concern over a slight physical anomaly onset often in adolescence
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Body dysmorphic disorders associated conditions
often associated with OCD and may often coexist with OCD
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Diagnostic criteria for body dysmorphic disorder
persistent preoccupation with a perceived flaw in one's physical appearance flaws mild/not observable by others repetitive behaviours (constantly checking the mirror) or thoughts about ones appearance
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management of body dysmorphic disorder
Adults: CBT + exposure & response prevention (ERP) SSRIs <18s: guided self help CBT+ERP
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Dissociative disorders
characterised by the disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment with abnormalities seen in behaviour, control of motor function & body representation usually manifests in childhood due to overwhelming traumatic experience in childhood
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Dissociation
creative mechanism of survival whereby the mid shields itself by segregating the experience or splitting off into its constituent parts rather than experiencing it as what would be an unendurable whle
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Types of dissociative disorder
Dissociative amnesia: most common inability to recall autobiographical information about stressful/traumatic event Depersonalisation/derealisation: recurrent/persistent episodes of sense of unreality & detachment from oneself (depersonalisation) or sense of unreality with detachment from ones environment (derealisation) Dissociative identity disorder: alternation of at least 2 separate personality sates that cause identity disruption & dominant at different time with frequent gaps of recall in normal daily events/personal information
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Somatic symptom disorder
individuals have multiple physical symptoms causing significant distress & also have a history of extensive & fruitless diagnostic testing/medical procedures excessive preoccupation with their symptoms & health concerns over an extended period of time pt often refuses to accept negative test results symptoms & motivations are unconscious, symptoms are not intentionally produced
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Conversion disorder
pt presents with neurological symptoms (e.g. sensory/motor symptoms) that are not fully explained by a neurological condition motivation is unconscious, symptoms are not intentionally produced pts may be calm & unconcerned when describing symptoms
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Hypochondriasis/Illness anxiety disorder
presents with persistent preoccupation with having/developing a serious illness despite recurrent medical examinations finding otherwise major anxiety over helath somatic symptoms are usually mild/absent motivation is unconscious
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Pseudocyesis
false belief of being pregnant associated with physical signs/symptoms of early pregnancy common in women who wish to conceive & have a history of several failed attempts
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Factitious disorder/Münchausen syndrome
may be imposed on self (Münchausen) or imposed on others (Münchausen by proxy) individuals intentionally falsify symptoms/signs (physical) even through self harm to assume role of pt or intentionally falsifies disease signs/symptoms or intentionally induces injuries in others (often a child/ageing parent) associated with willingness to undergo invasive/risky interventions occurs in the absence of external rewards
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Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
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Adjustment disorder
maladaptive emotional or behavioural response to a stressor lasting <6months following resolution of the stressor
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Acute stress disorder
distressing symptoms related to traumatic events that last between 3 days to 1 month following exposure similar to PTSD but lasting <1 month
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Self harm
intentional act of self-poisoning or self injury irrespective of motive or apparent purpose of the act not an attempt at suicide in most cases ~5% lifetime prevalence more common in younger people (up to 10% of girls/3% of boys) 50-100x ↑ risk of suicide in 12 month period
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Management of self harm
risk assessment care plan including crisis support psychological interventions
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Suicide
refers to the act of intentionally ending ones life, if that action fails = attempted suicide
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suicidal ideation
a preoccupation with ending ones life
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Suicide demographics
Males = 3/4 suicides highest risk in 45-49 y/o age group NB overall suicide attempts are more common in women but more often unsuccessful men tend to chose more violent methods e.g. hanging while women chose things like overdose
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Risk factors for suicide
``` previous suicide attempt psychiatric disorders male sex (↑ risk of completed suicide) previous self harm unemployment social isolation/living alone being unmarried/divorced/widowed history of chronic illness recent contact with mental health services ```
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protective factors for suicide
having children at home having a support network strong religious faith family support
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Indicator for upcoming suicide attempt
sudden improvement of symptoms in a depressed pt may indicate imminent suicide plan
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Risk factors for completed suicide after attempted suicide
``` efforts to avoid discovery previous planning leaving a written note violent method finals acts e..g sorting finances perception of no social support hopelessness no plans for future feeling of entrapment regret at being found significant pain/chronic physical illness ```
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Management of suicide
suicide risk assessment care plans (MDT focused with short & long term management) counselling regular follow up take care with medication e.g. SSRIs may initially ↑ suicidal ideation/behaviour
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Autism spectrum disorder (ASD)
characterised by persistent impairments in social communication/interaction & restrictive, repetitive and stereotyped patterns of behaviours/interests/activities
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Epidemiology of autism spectrum disorder
~1% of population affected 4:1 male:female ratio ~50% have intellectual disability
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Presentation of autism spectrum disorder in childhood
delay/absence of spoken speech lack of pretend play not engaging with others lack of imitation of activity/social play impaired non-verbal communication unusual repetitive hand/finger mannerisms unusual/lack of reaction to sensory stimuli easily overwhelmed by social stimuli
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Presentation of autism spectrum disorder in adults/adolescent
long standing difficulties in social behaviours/communication/coping with change socially naive language/social/non-verbal communication problems difficulty making/maintaining friendships lack of awareness of personal space & social norms rigid thinking & behavioural preferences trouble obtaining/sustaining employment/education
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Management of autism spectrum disorder
``` early educational & behavioural interventions family support & counselling social programmes CBT psychosocial interventions ``` Pharmacological - SSRIs (for anxiety, aggression, repetitive stereotyped behaviours) - antipsychotics (for aggression & self-injury) - methylphenidate (for ADHD)
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ADHD
neurodevelopment disorder presenting with inattentiveness, impulsivity & hyperactivity persisting into adulthood affected ~5% of children usually diagnosed around age 3-7 yrs 3:1 male:female ratio
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Diagnosis of ADHD
≥Six of the following symptoms of inattention have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social or academic/occupational activities. For older adolescents and adults (age 17 years and older), at least 5 symptoms are required. - Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). - Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). - Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). - Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). - Often has difficulty organising tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganised work; has poor time management; fails to meet deadlines). - Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). - Often loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). - Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). - Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). Hyperactivity-impulsivity ≥Six of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social or academic/occupational activities.For older adolescents and adults (age 17 years and older), at least 5 symptoms are required. - Often fidgets or taps with hands or feet, or squirms in seat. - Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). - Often runs about or climbs excessively in situations where it is inappropriate (note: in adolescents or adults, may be limited to feeling restless). - Often unable to play or engage in leisure activities quietly. - Is often 'on the go' or acting as if 'driven by a motor' (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). - Often talks excessively. - Often blurts out an answer before a question has been completed (e.g., completes other people's sentences; cannot wait in turn in conversation). - Often has difficulty waiting his or her turn (e.g., while waiting in line). - Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
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Management of ADHD
Behavioural interventions = 1st line Pharmacotherapy: 1st line = methylphenidate 2nd line = lisdexamfetamine/atomoxetine NB lower threshold for pharmacotherapy in adults
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Tourettes syndrome & tic disorders
Tourettes is a childhood onset neurodevelopment disorder characterised by motor & vocal tics and often accompanied by psychiatric problems e.g. OCD & ADHD peak of symptoms usually around start of puberty more common in males
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Presentation of tourettes
Tics: temporarily suppressible, an urge/sensation preceding the tick is relieved by its onset vocal tics: e.g. throat clearing, grunting, lip smacking, barking, swearing motor tics: e.g. facial grimacing, blinking, head jerking other features: echolalia (copying others words), palalia (repeating one's own words), copropraxia (making obscene gestures), coprolalia (compulsively saying dirty words) NB coprolalia is pathognomonic
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Management of tourettes
behavioural & psychosocial interventions habit reversal training pharmacological Haloperidol (only licensed drug) alpha adrenergic agonists e.g. clonidine
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Learning disabilities
defined as a reduced intellectual ability & difficulty with everyday activities with onset in childhood degree of disability can vary NB this is presentation not a diagnosis, is usually linked to conditions such as Down's syndrome or Turners syndrome
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Core criteria of Intellectual disability
↓ intellectual ability (IQ<70) significant impairments of social/adaptive functioning onset in childhood
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Examples of Typical antipsychotics
haloperidol chlorpromazine perphenazine fluphenazine
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MOA of typical antipsychotics
dopamine D2 receptor antagonists, blocking dopaminergic transmission in mesolimbic pathways of brain
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Route of administration for typical antipsychotics
all can be given oral NB haloperidol & fluphenazine can be given as long acting depots
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typical antipsychotics available in depot form
haloperiodl | fluphenazine
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Side effects of typical antipsychotics
Extrapyramidal side effects hyperprolactinaemia (leading to gynaecomastia, amenorrhoea, galactorhoea) sedation anticholinergic effects (dry mouth, constipation, urinary mention, blurred vision) Cardiac affects (prolonged QTc especially with haloperidol) orthostatic hypotension neuroleptic malignancy syndrome
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Cause of hyperprolcatinameia with typical antipsychotics
duo to blockage of dopamine receptors in the tuberoinfundibulnar pathway which usually inhibit prolactin production
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Cardiac side effect of of typical & atypical antipsychotics
↑QT interval which can lead to arrhythmia
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Examples of atypical antipsychotics
``` clozapine olanzapine risperiodne aripripazole quetiapine ```
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MOA of atypical antipsychotics
serotonin-dopamine receptor antagonists working on a variety of receptors, mainly 5-HT2 & D2 receptors
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atypical antipsychotics available in long acting forms
risperidone olanzapine aripriprazole
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Side effects of atypical antipsychotics
``` metabolic side effects (↑ weight, metabolic syndrome) agranulocytosis (mainly clozapine) ↓ seizure threshold (mainly clozapine) hyper salivation (mainly clozapine) cardiac (prolonged QT interval) sedation hyperprolactinaemia (most common with risperidone) anticholinergic effects (uncommon) neuroleptic malignancy syndrome ```
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Side effects that are more common in typical antipsychotics
anti pyramidal side effects hyperprolactinaemia (more severe with typical antipsychotics) anticholinergic effects
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Monitoring patients on antipsychotics
FBC/U&Es/LFTs: at beginning & then annually NB clozapine needs weekly FBC initally Lipids & weight: baseline, at 3 months, then annually Fasting glucose, prolactin: at baseline, at 6 months, then annually BP: baseline ECG: baseline, then every 1-3 months
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Extrapyramidal side effects
more common with typical antipsychotics may occur with atypical but usually on dose escalation occur due to inhibition of nigrostriatal dpomainergic pathways
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Acute dystonia presentation
develops over hours to days painful & sustained muscle spasms & stiffness predominantly affecting the head, neck, tongue include torticollosis, facial grimacing, tongue protrusion, oculogyric crisis (episodic spasmodic upward movement of eye lasting several minutes)
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Management of acute dystonia
anticholinergics or antihistamines: 1st line: procyclidine or benztropine switch antipsychotics consider secondary prophylaxis with benztropine/procyclidine
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Pseudoparkinsonism
acute onset usually within 1 week presents with cogwheel rigidity, stiff gait, bradykinesia, tremor NB bilateral symptoms are common in drug induced parkinsonism Management: dose reduction/switching antipsychotics anti cholinergic e.g benztropine/procyclidine dopamine agonists e.g. amantadine/bromocriptine
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Akathisia
onset usually in first 8 weeks movement disorder characterised by restlessness/a compelling urge to move & inability to sit/stand still, being fidgety management: ↓ dose/switch antipsychotic beta blockers: propanol (1st line)
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Tardive dyskinesia
develops after years, ↑ risk with age characterised by abnormal involuntary movements of mouth/face/tongue/limbs/respiratory muscles including repetitive chewing, lip smacking, choleric movements, pouting of the jaw, tongue protrusion, body rocking NB may be irreversible Management: discontinue antipsychotics switch to atypical especially clozapine/quetiapine
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Neuroleptic malignant syndrome (NMS)
rare but potentially life threatening idiosyncratic complication of treatment with antipsychotic medication the underlying mechanism is not fully understood relatively rare
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Presentation of neuroleptic malignant syndrome (NMS)
autonomic instability: hyperthermia, tachycardia, dysrhythmias, labile BP, tachypnoea, diaphoresis, urinary incontinence ``` muscle rigidity (lead pipe rigidity) akinesia tremor hyporeflexia confusion delirium stupor agiatation ``` Onset: usually hours to days (within 10 days) after starting an antipsychotic gradual onset over 1-3 days
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Investigations for neuroleptic malignant syndrome (NMS)
``` creatine kinase (↑↑) FBC (↑WBC) U&Es (normal) Ca2+ (↑) LFT (↑ transmainases) myoglobin in urine/blood ABG (metabolic acidosis) ```
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Management of neuroleptic malignant syndrome (NMS)
stop antipsychotics transfer to ITU/HDU IV fluids to counteract renal failure Dantrolene
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Serotonin syndrome vs neuroleptic malignant syndrome (NMS)
Serotonin syndrome caused by SSRIs/MAOIs/MDMA/Ecstasy NMS caused by antipsychotics serotonin syndrome has faster onset (~24h) while NMS usually develops over 1-3 days serotonin syndrome presents with hyperreflxia while NMS has hyporeflexia
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Examples of selective serotonin reuptake inhibitors (SSRIs)
``` fluoxetine paroxetine sertraline citalopram escitalopram ```
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Preferred SSRI post MI
sertraline
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Preferred SSRI in children
fluoxetine
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MOA of SSRIs
inhibit reuptake of serotonin in CNS synapses thus leading to ↑ intrasynaptic serotonin levels
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Indications for SSRIs
``` depression OCD Generalised anxiety disorder PTSD panic disorders bulimia nervosa social anxiety disorder binge eating disorder ```
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Adverse effects of SSRIs
GI symptoms = most common (diarrhoea, nausea, constipation) sexual dysfunction agitation insomnia ↑ QT interval (with citalopram/escitalopram) serotonin syndrome
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SSRIs in pregnancy
↑ risk of congenital heart defects ↑ risk fo PPHN NB paroxetine has highest risk associated
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Onset of action of SSRIs
roughly 4-6 weeks after commencing NB there may be ↑ suicidal thoughts in the period before effect is shown
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Interactions of SSRIs
NSAIDs (if given together must prescribe PPI) warfarin/heparin/aspirin (use mirtazepine) serotonergic drugs e.g. MAOIs/triptans/St Johns wart (↑ risk of serotonin syndrome)
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Examples of serotonin noradrenaline reuptake inhibitors (SNRIs)
duloxetine venlafaxine desvenlafaxine
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MOA of SNRIs
inhibition of serotonin & noradrenaline reuptake in the CNS synaptic cleft leading to ↑ serotonin & noradrenaline levels
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Indications for SNRIs
GAD Depression (2nd line) neuropathic pain stress incontinece (duloxetine) fibromyalgia (duloxetine) SAD/OCD/PTSD (venlafaxine)
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Adverse effects of SNRIs
``` insomnia GI symptoms sexual dysfunction ↑ BP ↑ cholesterol/triglycerides serotonin syndrome ```
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Tricyclic antidepressants (TCAs) examples
amitriptyline imipramine clomipramine lofepramine
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MOA of TCAs
inhibition of serotonin & noradrenaline reuptake in syntactic cleft but less selectively than SNRIs or SSRIs
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Indications for TCAs
depression neuropathic pain chronic pain (including fibromyalgia) migraine prophylaxis ``` OCD (clomipramine) nocturnal enuresis (imipramine) ```
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Adverse effects of TCAs
risks of lethal overdose orthostatic hypotension cardiac effects (↑ QT interval, wide QRS arrhythmia) tremor anticholinergic effects (tachycardia, sedation, constipation, dry mouth, dry skin) serotonin syndrome
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Monoamine oxidase inhibitors (MAOIs) examples
selegiline | phenelzine
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MOA of MAOIs
non-selective: inhibition of monamine oxidase = ↓ monoamine breakdown (noradrenaline/adrenaline/serotonin/dopamine) ↑monamine levels selective MAO-B inhibition (e.g. selegiline) = mainly ↓ dopamine breakdown
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Adverse effects of MAOIs
sexual dysfunction weight gain orthostatic hypotension hypertensive crisis when eating food counting thiamine e.g. cheese
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Serotonin antagonist & reuptake inhibitor
e.g. trazodone used in insomnia, depression may cause priapism, sedation, orthostatic hypotension
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Mirtazepine
atypical antidepressant that blocks alpha2-adrenergic receptors causing ↑ release of neurotransmitters useful in older people, those with insomnia/poor appetite Side effects: sedation (take in evening) ↑ appetite/weight gain
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Bupropion
used for smoking cessation & depression not associated with sexual dysfunction or weight gain contraindicated with pt has eating disorders or seizures`
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Antidepressant discontinuation syndrome
caused by abrupt withdrawal/dose reduction of antidepressants take for ≥4 weeks typically occurs within 3 days of drug cessation presentation: flu like symptoms, insomnia, nausea, imbalance, sensory disturbance (electric shock sensations), hyperarousal, irritability
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Management of antidepressant discontinuation syndrome
restart antidepressant therapy (slowly tapper dose if trying to change dose/stop) taper dose over 4 weeks (not necessary with fluoxetine) NB paroxetine has ↑ risk of this syndrome
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key uses for mirtazepine
underweight/poor appetite pts with depression elderly people ( due to fewer side effects and interactions) pts with insomnia & depression
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Serotonin syndrome
a life threatening condition cause by serotonergic overactivity due to excess of synaptic serotonin in the CNS usually due to therapeutic use or overdose of serotonergic drugs
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Causes of serotonin syndrome
generally if combination of sertonergic drugs (i.e. taking ≥2, or when switching serotonergic medications without tapering) MAOIs, SSRIs, SNRIs, TCAs lithium, tramadol, fentanyl, ondansetron, metoclopromide cocaine, MDMA, amphetamines, LSD
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Presentation of serotonin syndrome
classic triad of neuromuscular excitability, autonomic dysfunction, altered mental state with onset over ~24h neuromuscular excitation: hyperreflexia, myoclonus, rigidity, tremor, ataxia autonomic dysfunction: hypertension, tachycardia, hyperthermia, diaphoresis, mydriasis altered mental state: anxiety, agitation, confusion, coma, psychomotor agitation, delirium, seizures
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Management of serotonin syndrome
immediate discontinuation of serotonergic drugs supportive care (IV fluids, bentos, antihypertensives) serotonin antagonists: cryptoheptadine or chlorpromazine
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Mood stabilisers
a type of drug used to treat acute mania and/or prevent relapses of manic or hypomanic episodes drugs include lithium, valproate/valproic acid, lamotrigine, carbamazepine
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Lithium
psychiatric mood stabilising drug with a very narrow therapeutic window range (0.4 - 1.0mmol/L) & long plasma half life primarily excreted by the kidney
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Lithium therapeutic range
0.4-1.0mmol/L
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Indications for lithium therpay
1st line mood stabiliser for bipolar disorder | adjunct therapy in refractory depression
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Adverse effects of lithium
``` nausea, diarrhoea, weight gain, dry mouth fine tremor (none progressive, symmetric, fine postural tremor) acne worsening psoriasis nephrogenic diabetes insidious chronic interstitial nephritis idiopathic intracranial hypertension leucocytosis T wave flattening & inversion Teratogenic ```
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Key drug interactions of lithium
ACE-Is diuretics (particularly thiazide diuretics) NSAIDs SSRIs
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Monitoring lithium
TFTs & Renal function: check baseline & every 6 months ECG: at baseline and regularly during treatment
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Monitoring lithium levels
take 12h post dose take levels 7 days post change of dose take weekly when initiating treatment or after changing dose until levels are stabilised when levels stabilised measure 3 monthly for first year & then 6 monthly thereafter
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Lithium toxicity
generally occurs in levels >1.5mmol/L may be precipitated by dehydration, ↓renal function, concurrent infections Features: nausea, vomiting, diarrhoea, coarse tremor, altered mental state, slurred speech, fasciculations, renal failure Management: IV fluids, electrolyte correction stop lithium
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Sodium Valproate/Valproate/Valprooic acid
1st line medication used in general tonic clonic seizures but used in established status epileptics 2nd line mood stabiliser in bipolar disorder ``` adverse effects teratogenic P450 inhibition thrombocytopenia alopecia ``` Monitoring: LFTs FBC
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Carbamazepine
1st line treatment of partial seizure but also used in trigeminal neuralgia & bipolar ``` Adverse effects: P450 inducer Steven Johnson syndrome SIADH agranulocytosis teratogenic ```
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Lithium in pregnancy
Teratogenic, especially causing cardiac malformations particularly Ebstein anomaly (characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle. It is sometimes referred to as 'atrialisation' of the right ventricle.)
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Lamotrigine
2nd line medication for epilepsy also used as mood stabiliser in bipolar Adverse effects: steven johnson syndrome Gi symptoms
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Benzodiazepine examples
Lorazepam/Diazepam/Clonazepam (long acting) | midazolam/oxazepam (short acting)
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Indications for benzodiazepines
``` sedation hypnotics anxiolytics anticonvulsants muscle relaxants ```
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Adverse effects of benzodiazepines
dizziness confusion headache tolerance commonly develops
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Benzodiazepine overdose
Features: CNS depression, respiratory depression, ataxia, slurred speech, hypotonia, hyporreflexia, management: supportive therapy Flumazenil
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Benzodiazepine dependence
can develop quickly over a couple fo weeks should be prescribed as short courses of 2-4 weeks if stopping benzodiazepines withdraw them slowly in stepwise dose reduction
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Barbiturates
Examples phenobarbitol, thiopental rarely used due to superior safety of benzodiazepines worse side effects and easier to overdose than benzodiazepines
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Electroconvulsive therapy (ECT)
involves unilateral/bilateral electrode placement over non dominant hemisphere to induce tonic-clonic seizures under sedation Indications: refractory/life threatening psychiatric conditions (e.g. catatonia, depression with psychiatric features, schizophrenia, bipolar) may be used in pregnancy for example adverse effects: reversible memory loss transient muscle pain N&V
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Behavioural therapy
treatment approach based on clinically applying theories of behaviour aim= change harmful & unhelpful behaviours and individual may have
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Cognitive therapy
clinically applying research into role of cognition in the development of emotional disorders looking at how people think about & create meaning about situations/symptoms/events in their lives and their development of beliefs about themselves/others/the world challenging ways of thinking to help produce more helpful & realistic patterns of thought
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cognitive behavioural therapy (CBT)
indications: depression, GAD, panic disorder, OCD, body dysmorphic disorder, PTSD, eating disorders) Aims: to adjust distorted, harmful, irrational or ineffective beliefs, attitudes & behaviour patterns and teaches skills & strategies to help pt alter abnormal behaviour/beliefs
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Family therapy
identifies family dysfunctions & individual problems used in schizophrenia & eating disorders
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Psychodynamic therapy
psychological interpretation of mental & emotional processes to help people develop insight into their behaviours, feelings, thoughts, emotions used in anxiety disorders
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Interpersonal therapy (ITP)
aims to develop understanding of problematic interpersonal relationships to enable pt ti better control their mood & behaviour used in depression, bipolar, postpartum depression
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Mental health act (MHA)
legislation from 1983 | mainly piece of legislation covering assessment, treatment and rights of people with mental health disorders
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Pts specifically excluded from mental health act
pts under influence of drugs/alcohol pts with learning disabilities unless associated with abnormally aggressive or seriously irresponsible conduct
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Applying mental health act (MHA) and mental capacity act (MCA)
the MHA always trumps the mental capacity act, so in a situation where both can be applies the MHA should be used
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Key points of mental health act
mental disorder: any disorder/disability of the mind act is only for treatment of mental disorders not physical health problems use principle of least restraint
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Criteria for detention under mental health act
pt must be suffering from a mental disorder of a nature and/or degree that makes it appropriate & necessary for them to be detained in hospital in the interest of their own health/safety or the protection of others appropriate treatment must be available
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Section 2
detention for assessment and/or treatment Duration: 28 days (cannot be renewed) allows for compulsory treatment against pts wishes requires 2x section 12 approved doctors + 1x approved mental health practitioner
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Section 3
detention for treatment Duration: 6 months (can be renewed for 6 months & then annually) treatment may be given against pts wishes requires 2x section 12 approved doctors + 1x approved mental health practitioner
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Nearest relative (NR) role under mental health act (MHA)
is identified by approved mental health practitioner (AMHP) NR has rights under MHA inculding - apply for sectioning of pt - object to a section - apply for pt to be discharged
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Section 4
emergency detention for assessment Duration: 72h, cannot be renewed does not allow for treatment against pts wishes requires 1x doctor or approved mental health practitioner (AMHP)
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Section 5
Detention of hospital inpatients only applied to pts that are admitted to hospital (does not apply to pts in A&E) Does not allow treatment against pts wishes Section 5(2) = doctors holding power, pt detained for up to 72h Section5(4) = nurses holding power, pt involuntarily defined for up to 6h
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Section 135
Approved mental health practitioner (AMHP) applies to magistrate court for warrant to enter private premises & remove pt with help of police when there is a reasonable cause to suspect mental disorders/neglect/unable to care fro themselves held up to 72h in place of safety
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Section 136
Police detain someone found in a public place who appears to have a mental disorder/be in immediate need for care/risk to self or others and bring them to a place fo safety (e.g. hospital) pt held for 24h, may be extended by 12h for assessment
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Fitness to plead
assessed via Pritchard criteria - understands charges - deciding whether to plead guilty or not - exercising right to challenge a juror - follow course of proceedings - instructs lawyer - giving evidence in own defence
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Insanity in the eye of law
Assessed by McNaughton rules: at the time of committing of the act the party accused was labouring under such a defect of reason, from disease of the mind as to not know the nature & quality of the act they were committing or if they did know they did not know what they were doing was wrong if legally insane = hospital order/supervision/treatment
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Mental health review tribunal (MHRT)
pts have right to appeal their MHA detention Section 132 requires pts to be read their rights weekly MHRT is completely independent Pt is allowed 1 appeal per detention period & is represented by a solicitor the burden of proof is with the detaining authority not the pt
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Mental capacity act (MCA)
provides the legal frame work fro acting & making decisions on the behalf of an individual who lacks the mental capacity to make particular decisions for themselves NB mental disorder does not guarantee lack of capacity
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Key points of Mental capacity act (MCA)
The Act contains 5 key principles: 1) A person must be assumed to have capacity unless it is established that they lacks capacity 2) A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success 3) A person is not to be treated as unable to make a decision merely because they makes an unwise decision 4) An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in their best interests 5) Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is least restrictive of the person's rights and freedom of action
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Two stage test of capacity
1) does the person have an impairment of the mind or brain or is there some sort of disturbance affecting the way their mind works 2) if so does they impairment or disturbance mean that the person is unable to made the decision in question at the time it needs to be made
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When are people assumed to lack capacity
Individual is presumed to have capacity & make decision unless they: 1) are unable to understand the information material to the decision (must be able to provide info at appropriate levels & in an understandable way e.g. with translator) 2) are unable to retain that information 3) are unable to use or weigh up the information provided as part of the process of decision making 4) are unable to communicate their decision
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Deprivation of liberties (DoLS)
applied when MCA is used in such a way to deprive a person of their liberties i.e. their not free to leave / subject to continuous supervision & control authorisation lasts up to 1 year & cannot be extended
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Reasons causing elevated clozapine levels
smoking cessation can significantly raise clozapine levels
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Management of catatonia
Electro convulsive therapy used for severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.
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Adverse effects of ECT (Electroconvulsive therapy)
Short-term side-effects - headache - nausea - short term memory impairment - memory loss of events prior to ECT - cardiac arrhythmia Long-term side-effects -some patients report impaired memory