Psychiatry Flashcards
Schizophrenia - define, clinical features, dx & management
Schizophrenia is a form of psychosis characterised by distortion to thinking & perception and inappropriate or blunted affect
Most common form of psychosis with an onset typically early in life (15 to 35). Chronic condition characterised by acute episodes of psychosis
Hallucinations - ‘‘perceptions in absence of stimuli’’
○ Most commonly auditory
Delusions - fixed false belief
Thought & speech disorders
Negative symptoms
○ alogia (poverty of speech), emotional blunting, social isolation, self-neglect and avolition (lack of self-will).
Clinical dx - investigate to r/o infection, metabolic abnormalities & organic brain disease
• Particular interest in autoimmune encephalitis (esp anti-NMDA R)
Pharmacological
• Atypical antipsychotics - 6 to 8 week trial
○ Olanzapine, quetiapine
• Treatment resistant schizophrenia (not responding to 2+ antipsychotics)
○ Clozapine
• Depot Antipsychotic - IM injection every 2-4wks
Psychological • Education & support • CBT • Family interventions Art therapy
Schizoaffective Disorder - define
Characterised by symptoms of schizophrenia & a mood disorder (depression or mania) in the same episode of illness
Mood symptoms should meet the criteria for either a depressive illness or a manic episode together with one or two typical symptoms of schizophrenia
Post Natal Depression - define, RFs, S&S & management
DEFINITION: Low mood in the post-natal period, occurs in about 1 in 10 women, with a peak around 3mths after birth
Often starts within 1-2mths of giving birth but can start several months after having the baby
Aetiology & Risk factors:
Possible causes/reasons why:
• Environmental/situational circumstances e.g. recent stressful situations, domestic violence in the past,
• Previous mental health problems, including depression
• Depression or anxiety during pregnancy
• Poor support from partner, family or friends – or marital difficulties
Risk Factors: • Pre-existing mental illness • Family history • Depression in pregnancy • Significant social stressors • Physical health – anaemia/ hypothyroid
Presentation/Clinical Features: Classical triad of: low mood, anhedonia & low energy • Persistent low mood • Insomnia • Loss of appetite • Loss of energy/drive • Reduced motivation/self care • Feelings of inadequacy as a mother • Suicidal thoughts • Thoughts of harm to baby & psychotic symptoms in severe cases --> Puerperal Psychosis
Management:
• Support – various dependent on severity
• Severe cases may require specialist support or admission to MBU
• Self help for mild/moderate cases
• Talking Therapies
• Medication
Puerperal Psychosis - define, risk factors, S&S & management
DEFINITION: A psychiatric emergency - psychosis which develops shortly after giving birth
Rare but serious condition, which approx. 1 in 1000 women develop & typically occurs 2-3weeks after delivery
Aetiology & Risk factors:
• Previous post-natal psychosis
• Women w/ past history of bipolar or schizoaffective disorders
Cause is unknown but may have genetic factors & the hormonal changes and sleep deprivation which occurs in new mums may be a factor
Presentation/Clinical Features: Symptoms can vary & change rapidly - within hours • High mood • Depression • Confusion • Hallucinations • Delusions • Changes in personality
Management: Preventative support • Mum's who may be at risk should have preconception counselling • Specialist support during pregnancy • Pre-birth planning care plan
Treatment • Urgent assessment & diagnosis • Transfer to mother & baby unit • Pharmacological options inc: antipsychotics, mood stabilisers • CBT
Prognosis
Most severe symptoms 2-12 weeks & a full recovery can take 6-12mths (most women do make full recovery)
Depression - define, RF, S&S, investigations & management
DEFINITION: An affective mood disorder characterised by persistent low mood, loss of pleasure and/or lack of energy accompanied by emotional, cognitive & biological symptoms
Pathophysiology & Aetiology
• Genetic x Environment model; multi-factorial & influenced by number of bio-psychosocial factors
• Twin studies estimate hereditability of depression as 40-50%, multiple genes likely involved
• Monoamine hypothesis - deficiencies causing depression
• HPA overactivity
• Psychosocial factors can increase the likelihood of developing depression
○ .e.g. personality type, stressful life events and failure of effective stress control mechanisms
Risk factors - ‘FF, AA, PP & SS’
• Female & family hx
• Alcohol/adverse events
• Past depression/physical co-morbidities
• Lack of social support/socioeconomic status
Presentation/Clinical Features:
Symptoms can be divided into: core, cognitive, biological & psychotic
Core
• Anhedonia
• Low mood
• Lack of energy
Cognitive • Lack of concentration • Negative thoughts • Excessive guilt • Suicidal ideation
Mild depression = 2 core symptoms + 2 other symptoms
Moderate depression = 2 core symptoms + 3–4 other symptoms
Severe depression = 3 core symptoms + ≥4 other symptoms
Severe depression with psychosis = 3 core symptoms + ≥4 other symptoms + psychosis
Biological • Diurnal variation in mood • Early morning waking • Loss of libido • Psychomotor retardation • Weight loss/LOA
Psychotic
• Hallucinations
• Delusions
Differentials - BPD, thyroid dysfunction, r/o organic illness, substance abuse, normal bereavement
Investigations & Diagnosis:
• Thorough hx & full risk assessment if actively feeling suicidal
○ Diagnostic questionnaires e.g. PHQ-9, HADS
• Bloods
○ FBC - Hb (anaemia)
○ TFTs - hypothyroidism
○ U&Es, LFTs, Ca
○ Glucose
• Imaging
○ MRI or CT if atypical i.e. unexplained headache or personality change
Management: Mild-Moderate Depression • Watchful waiting; lifestyle, self help & reassess in 2wks • Antidepressants • Exercise • Self-help programmes • CBT
Moderate-Severe Depression
• Full suicide risk assessment
• Psychiatry referral if:
○ Suicide risk is high, or depression is severe, recurrent depression, or unresponsive to treatment
• Antidepressants
○ 1st line: SSRIs e.g. sertraline, citalopram
○ Others inc TCAs, SNRIs, MAOI
• Psychotherapy
○ Refer for CBT and interpersonal therapy (IPT).
• Social support:
○ Engaging with activities in the community that the individual is avoiding or attending social support groups with others.
Bipolar Disorder - define, RFs, S&S, inx & management
DEFINITION: Chronic episodic mood disorder, characterised by at least one episode of mania/hypomania & a further episode of mania or depression
Mean age onset 19yrs of age, M=F at 1:1
Risk factors:
• Age - early 20s
• Anxiety Disorders
• After depression
* Strong family hx * Substance misuse * Stressful life events
Presentation/Clinical Features: Manic Symptoms • Irritability • Distractibility • Disinhibited e.g. spending, social, sexual • Grandiose delusions • Flight of ideas
* Activity * Increased appetite * Sleep decreased * Talkative * Elevated mood/energy * Reduced concentration
Differentials - remember to always screen for mania in depressed patients, as may not necessary reveal this
Investigations & Diagnosis:
• Thorough history - screen for clinical features
○ ‘Have you had any new interests or exciting ideas lately?’ (delusions/overvalued ideas).
○ ‘Do you have any special abilities that are unique to you?’ (grandiose delusions).
○ ‘Are you afraid that someone is trying to harm you?’ (persecutory delusions).
○ Also ask about family history of bipolar affective disorder and substance misuse.
• Self-rating scales
○ Mood disorder questionnaire
• Bloods
○ FBC (routine), TFTs (both hyper/hypothyroidism are differentials), U&Es (baseline renal function with view to starting lithium), LFTs (baseline hepatic function with view to starting mood stabilizers), glucose, calcium (biochemical disturbances can cause mood symptoms).
• Urine drug test
○ Illicit drugs can cause manic symptoms
• CT head - r/o SOL
Management: • Full risk assessment - suicide, ask about driving ○ Consider Mental Health Act • ''CALMER'' ○ Consider hospitalization/CBT ○ Antipsychotics (Atypical) ○ Lorazepam ○ Mood stabilizers (e.g. lithium) ○ Electroconvulsive therapy ○ Risk assessment
Management of Bipolar Affective Disorder - ‘‘CALMER’’
• ''CALMER'' ○ Consider hospitalization/CBT ○ Antipsychotics (Atypical) ○ Lorazepam ○ Mood stabilizers (e.g. lithium) ○ Electroconvulsive therapy ○ Risk assessment
Emotionally Unstable Personality Disorder - S&S & management
• Abandonment feared • Mood instability • Suicidal behaviour • Unstable relationships Intense relationships
• Control of anger poor • Impulsivity • Disturbed sense of self (identity) Emptiness (chronic) • Full review & assessment of patient ○ Co-morbid psychiatric illness and substance misuse are common in patients with PD. § recognition and treatment are essential. ○ Risk assessment is crucial § Potential stressors that induce crises should be identified and reduced. • Pharmacological management will not resolve the PD, but may be used to control symptoms. ○ Low-dose antipsychotics for ideas of reference, impulsivity and intense anger ○ Antidepressants may be useful in emotionally unstable personality disorder. ○ Mood stabilizers can also be given (i.e. quetiapine) • Safety Netting ○ Give the patient a written crisis plan. At times of crisis, if dangerous and violent or if there is a suicide risk consider the Crisis Resolution Team and detention under the Mental Health Act.
Generalised Anxiety Disorder - define, aetiology, risk factors, clinical features, differentials, investigations & management
Syndrome of ongoing, uncontrollable, widespread worry about many events or thoughts that the patient recognises as excessive & inappropriate. Symptoms must be present on most days for at least 6mths duration
Aetiology of GAD can be divided into biological (genetic & neurophysiological) & environmental causes
• Biological
○ Genetic; twins & family hx (5x increase in 1st degree relatives)
○ Neurophysiological; theories around dysfunction in hippocampus & amygdala. Alterations in GABA, serotonin & noradrenaline
• Environmental
○ Stressful life events; hx of child abuse, problems w/ relationships, personal illness, employment of finances
○ Substance dependence or exposure to organic solvents
Risk Factors Pre-disposing • Genetics, childhood upbringing, personality type & demands for high achievement • Being divorced • Living alone or as a single parent • Low socioeconomic status
Precipitating
• Stressful life events; domestic violence, unemployment, relationship problems
• Personal illness e.g. chronic pain, arthritis, COPD
Maintaining
• Continuing stressful events, martial status, living alone & ways of thinking which perpetuate anxiety
Presentation/Clinical Features:
‘‘WATCHES’’ (specific to GAD)
• Worry - excessive & uncontrollable
• Autonomic hyperactivity - sweating, increase in pupil, tachycardia
• Tension in muscles & tremor
• Concentration difficulty & chronic aches
• Headache/hyperventilation
• Energy loss
• Restlessness
• Startled easily & sleep disturbances - difficulty getting to sleep then intermittent awakening and nightmares
Differentials - depression, schizophrenia, personality disorders, excessive caffeine or alcohol consumption, withdrawal from drugs, organic (anaemia, hyperthyroidism, pheochromocytoma, hypoglycaemia)
Investigations & Diagnosis: Bloods • FBC - infection & anaemia • TFTs - hyperthyroidism • Glucose - hypoglycaemia
Questionnaires
• GAD-2 or GAD-7
• Hospital Anxiety & Depression Scale
• Beck’s Anxiety Inventory
Management - bio-psychosocial model
• Biological; first line is SSRI (sertraline is recommended)
○ SNRIs can also be used
○ Medication should be continued for at least 1yr
• Psychological; low vs high intensity
○ Low intensity form - psychoeducational groups
○ High intensity form - cognitive behavioural therapy & applied relaxation
• Social;
○ Includes self-help methods & support groups
○ Exercise - encouraged & may benefit
