Psychiatry Flashcards
1
Q
Explain Fixed affect, Restricted affect, Labile affect
A
- Fixed affect: the patient’s affect remains the same throughout the interview, regardless of the topic.
- Restricted affect: the patient’s affect changes slightly throughout the interview, but doesn’t demonstrate the normal range of emotional expression that would be expected.
- Labile affect: characterised by exaggerated changes in emotion which may or may not relate to external triggers. Patients typically feel like they have no control over their emotions.
2
Q
MSE Exam: In healthy individuals, thoughts flow at a steady pace and in a logical order. However, in several mental health conditions, the flow and coherence of thoughts can become distorted.
Abnormalities of thought flow and coherence include:
A
- **Loose associations: **moving rapidly from one topic to another with no apparent connection between the topics.
- Circumstantial thoughts: these are thoughts which include lots of irrelevant and unnecessary details but do eventually come back to the point.
- Tangential thoughts: digressions from the main conversation subject, introducing thoughts that seem unrelated, oblique, and irrelevant.
- Flight of ideas: seen with fast, pressured speech. Ideas run into one another, making it difficult for the observer to follow the flow of speech.
- Thought blocking: sudden cessation of thought, typically mid-sentence, with the patient unable to recover what was previously said.
- Perseveration: refers to the repetition of a particular response (such as a word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a patient is asked what their name is, and they then continue to repeat their name as the answer to all further questions).
- Neologisms: words a patient has made up which are unintelligible to another person.
- **Word salad: **speaking a random string of words without relation to one another.
3
Q
MSE Exam: Abnormalities of thought possession include
A
- Thought insertion: a belief that thoughts can be inserted into the patient’s mind.
- Thought withdrawal: a belief that thoughts can be removed from the patient’s mind.
- Thought broadcasting: a belief that others can hear the patient’s thoughts.
4
Q
MSE Exam: Preception
What sort of things do you look for in the persons perception?
A
Abnormalities of perception include:
- Hallucinations: a sensory perception without any external stimulation of the relevant sense that the patient believes is real (e.g. the patient hears voices, but no sound is present).
- Pseudo-hallucinations: the same as a hallucination, but the patient knows it is not real.
- Illusions: the misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).
- Depersonalisation: the patient feels that they are no longer their ‘true’ self and are someone different or strange.
- Derealisation: a sense that the world around them is not a true reality.
5
Q
What is PTSD?
A
Post-traumatic stress disorder (PTSD)
PTSD may develop following exposure to an extremely threatening/horrific event or series of events. It is thought to result from impaired memory consolidation of experiences too traumatic to be processed normally, which leads to a chronic hyperarousal of fear circuits.
6
Q
Characteristic features of PTSD include (remember using the mnemonic HARD):
A
- Hyperarousal: persistently heightened perception of current threat (may include enhanced startle reaction)
- Avoidance of situations/activities reminiscent of the events, or of thoughts/memories of the events
- Re-experiencing the traumatic events (vivid intrusive memories, flashbacks, or nightmares).
- Distress: strong/overwhelming fear and physical sensations when re-experiencing
Major traumatic abuse, shell shock. Symptoms have to present for >1m
7
Q
Management for PTSD
A
1st: Watchful waiting 4w if mild, trauma focused CBT (70% effective) if moderate. EMDR Eye-Movement Desensitization and Reprocessing (EMDR) therapy
2nd: Venlafaxine or SSRI or Risperidone ?Mitazipine
8
Q
What is an acute stress reaction?
A
An acute stress reaction occurs when a person experiences certain symptoms after a particularly stressful event. The word ‘acute’ means the symptoms develop quickly but do not last long. The events are usually very severe and an acute stress reaction typically occurs after an unexpected life crisis. This might be, for example, a serious accident, sudden bereavement, or other traumatic events. Acute stress reactions may also occur as a consequence of sexual assault or domestic violence.
Acute stress reactions have been seen in people who experience terrorist incidents, major disasters, or war. Military personnel are at more risk as a result of extreme experiences during conflicts.
An acute stress reaction usually resolves within 2 to 3 days (often hours).
9
Q
What are presentations of acute stress reaction?
A
Acute stress, within 4 weeks after traumatic event
Intrusive thought, dissociation, negative mood, avoidance
10
Q
What is the Ix for acute stress reaction?
A
Detailed history
11
Q
Management for acute stress reaction?
A
Trauma based CBT
Benzodiazepines, for acute symptoms, sleep disturbance
12
Q
What is Generalised anxiety disorder
A
Generalised anxiety disorder (GAD) is a mental health condition that causes excessive and disproportional anxiety and worry that negatively impacts the persons everyday activity. Symptoms are present on a daily basis for months at a time.
13
Q
What is the assessment for generalised anxiety disorder?
A
- The GAD-7 anxiety questionnaire can help establish the severity of the diagnosis
- Assess for co-morbid mental health problems, such as depression and obsessive compulsive disorder
- Assess for environmental triggers and contributors, such as family relationships, friendships, bullies, school pressures, alcohol and drug use
14
Q
What is the management for generalised anxiety disorder?
A
**Mild anxiety **can be managed with watchful waiting and advice about self-help strategies (e.g. meditation), diet, exercise and avoiding alcohol, caffeine and drugs.
Moderate to severe anxiety can be referred to CAMHS services to initiate:
- Counselling
- Cognitive behavioural therapy
- Medical management. Usually an SSRI such as sertraline is considered. (Sertraline, Duloxetine) + Propanolol
15
Q
What is phobias?
A
Specific fear, avoidance. Agoraphobia – fear of being in helpless situation.
16
Q
What is Mx for phobias?
A
Lifestyle, avoid caffeine. Exposure therapy, Agoraphobia, social anxiety: CBT. CBT, SSRI. BZD for specific phobias
17
Q
What is the risk factors for panic disorders?
Mx?
A
FHx, Female, Episodes of trauma.
Mx: CBT, SSRI
18
Q
What does alcohol withdrawal look like?
A
6-12 hrs: Tremor, sweating, tachycardia, anxiety
36 hrs: Seizures
48-72 hrs: Coarse tremor, confusion, delusions, tachycardia
19
Q
Chronic alcohol, ________ (inhibits CNS), and inhibits _______ _______ receptors
A
Chronic alcohol, GABA (inhibits CNS), and inhibits NMDA Glutamate receptors
20
Q
How to do assess alochol withdrawal?
A
Monitor complications, delirium tremens, seizures, blackouts
21
Q
Mx for alochol withdrawal?
A
1st: Long acting benzodiazepines, chlordiazepoxide or diazepam. Pabrenix.
Carbamazepine for alcohol withdrawal symptoms
Safe: 14 units / week. Harmful > 35 units a week women, 50 units a week men.
Acamprosate – reduces craving
Disulfiram – induces flushing
22
Q
How to calculate unit of alcohol
A
Unit of Alcohol = (Volume) x (Percentage) / 1000
23
Q
What is Substance misuse disorder
A
is the consumption of substances that leads to the involvement of social, psychological, physical, or legal problems.1
24
Q
Among people aged 16-59, What is the most common used substance and what it its functions?
A
cannabis, followed by cocaine and ecstasy
Cannabis: Exacerbates existing mood. Slowed memory, reflexes,
25
______ ______ is the fifth biggest risk factor for death across all ages.
**alcohol misuse** is the fifth biggest risk factor for death across all ages.
26
Substance dependence requires at least two of the following:
* Impaired control over substance use
* Increasing priority over other aspects of life or responsibility
* Psychological features suggestive of tolerance and withdrawal
27
Pathophysiology of addiction
When an individual consumes a substance, this affects the **mesolimbic dopamine system** in the n**ucleus accumbent and dorsal striatum** in the basal ganglia.4 The release of **dopamine** gives off pleasurable feelings which trigger the reward system and positively reinforce the behaviour of substance consumption. This process is known as **operant conditioning** and is the basis of **addiction** and cravings.
Some substances, such as alcohol and opioids, interact with the **inhibitory neurotransmitter GABA,** which disrupts the equilibrium between GABA and glutamate. It is believed that the number of natural stimulants (glutamate) and natural sedatives (GABA) are roughly the same. When an individual consumes substances, this **disrupts the equilibrium** as there are more** sedative hormones (GABA).**
When exposed chronically, this results in neuroadaptation. The brain will **upregulate the natural stimulants** to achieve equilibrium. **Withdrawal symptoms** occur when there is a sudden drop in GABA, resulting in disrupted homeostasis and too much glutamate. The excess natural stimulants lead to withdrawal symptoms such as anxiety, sweating, and shaking.
28
Relevant laboratory investigations in the context of alcohol misuse include:
* Full blood count: raised MCV, raised platelets, anaemia
* Liver function tests: increased GGT, AST:ALT > 2:1
* Haematinics (B12/folate): alcohol can cause folate deficiency
* Thyroid function tests
29
What are some screening questionnaires that can be used for dependency of alcohol misuse?
The **AUDIT-C questionnaire** is a common screening tool that looks at the risk of dependency of alcohol misuse.7
Other questionnaires include the **SAD-Q** questionnaire which looks at the severity of alcohol dependence and the **CAGE** questionnaire. For more information, see the Geeky Medics guide to **alcohol history taking.**
30
How can naltrexone be used in alcohol detox?
Name some side effects?
Naltrexone is an opiate blocker that makes **alcohol less enjoyable** and less rewarding. It can be administered as an injection once a month or oral tablets.
Common side effects are nausea, vomiting, decreased appetite, pain at the injection site, and increased liver enzymes. It is contraindicated in opiate use and patients with liver failure.
31
How can Acamprosate be used in alcohol detox?
Name some side effects?
Acamprosate is a medication that increases GABA and decreases excitatory glutamate which **reduces cravings. **
It has a good side effect profile and is generally well tolerated.
32
How can Disulfiram be used in alcohol detox?
**Disulfiram** inhibits acetaldehyde dehydrogenase which causes the accumulation of acetaldehyde with alcohol. It causes **unpleasant symptoms** such as flushing, sweating, headache, nausea and vomiting, arrhythmias, and hypotensive collapse. Patients should avoid alcohol for 24 hours before taking disulfiram and 1 week after cessation of the medication. When taking the medication, they must a**void all contact with alcohol**. Disulfiram is contraindicated in patients with heart disease, psychosis, and those felt to be at high risk of suicide
33
Alcohol misuse can cause multiple physiological complications including:
* Neurological: ischaemic stroke, encephalopathy, seizures, peripheral neuropathy
* Cardiovascular: increased rate of myocardial infarction and stroke, hypertension, dilated cardiomyopathy
* Hepatology: alcoholic liver disease, liver cirrhosis, liver fibrosis, pancreatitis
* Oncology: increased risk of head and neck cancer, oesophageal cancer, liver cancer, breast cancer, colorectal cancer
* Psychiatric: alcoholic hallucinosis, delirium tremens, Wernicke-Korsakoff syndrome
34
Relevant laboratory investigations in the context of opioid misuse include:
* HIV and hepatitis B/C: due to the increased risk of blood-borne infection is greater through needle sharing
* Tuberculosis testing
* Urea & electrolytes
* Liver function tests and clotting screen: to check hepatic function
* Drug levels: to check for drug toxicity
35
There are several drug screening questionnaires which can be used:
* Drug abuse screening test (DAST): assess drug use in the past 12 months
* CAGE-AID (adapted to include drugs)
* Addiction severity index (ASI): looks at the effect of the use of substances on law, family, social life, work and mental health
* Clinical opiate withdrawal scale (COWS): rates common signs and symptoms of opiate withdrawal and monitors symptoms
*
36
The main intervention for opioid misuse is opioid detox using _____________ _____. An alternative to this is _______________ _______. It can be helpful to refer the patient for counselling and rehabilitation.
The main intervention for opioid misuse is opioid detox using **methadone reduction. **An alternative to this is **buprenorphine reduction**. It can be helpful to refer the patient for counselling and rehabilitation.
37
Opioid misuse also increases the risk of blood-borne diseases such as ____ ______ ____ __
Opioid misuse also increases the risk of blood-borne diseases such as **HIV, hepatitis B, and C.**
38
Benzodiazepine misuse includes the use of _________ ________ ___ ________
Benzodiazepine misuse includes the use of **diazepam, oxazepam and lorazepam.**
39
Benzodiazepines are another example of central nervous system ____________
Benzodiazepines are another example of central nervous system **depressants.**
40
The clinical features of benzodiazepine misuse include:
* **Physiological effects:** altered mental status, slurred speech, ataxia, respiratory distress, hypothermia, and coma if overdosed
* **Psychological effects: **euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood
Withdrawal from benzodiazepines may result in a wide range of clinical features including tremor, nausea & vomiting, tachycardia, postural hypotension, headache, agitation, malaise, transient illusions or hallucinations, paranoid ideation and seizures.
41
Ix for benzodiazepines misuse
The clinical institute withdrawal assessment scale – benzodiazepines (CIWA-B) can be used to determine the severity of withdrawal from the substance.
42
The main intervention for benzodiazepine misuse is _________ _____________ and supportive treatments.
The main intervention for benzodiazepine misuse is **assisted withdrawal **and supportive treatments.
43
Name some Central nervous system (CNS) stimulants.
Amphetamine use (e.g. Adderall and methylphenidate) and cocaine
44
Cocaine
Mx
stimulant, powder. Acute seizures and psychotic episodes, ischaemic colitis, vasospastic ACS.
Mx: Benzodiazepines (short term) + GTN. Support groups.
45
Heroin:
Mx
Injected, strong sense of relaxation. Risk of overdose. Withdrawal: sweating, watery eyes, anxiety.
Mx: Lofexidine (a2 agonist) +/- Benzodiazepines for symptom. Opioid substitution using Methadone
46
What are hallucinogens
Hallucinogens include lysergic acid diethylamide (LSD – ‘acid’), marijuana, ecstasy and phencyclidine or phenylcyclohexyl piperidine (PCP). When consumed, they can cause **euphoria, visual and auditory hallucinations and psychosis.**
47
Hallucinogens mainly cause visual or auditory hallucinations and the feeling of euphoria.
Specific clinical features depend on the substance used:
**LSD:**
**Marijuana:**
**Ecstasy: **
**PCP: **
**LSD:** lethargy, psychomotor agitation, craving, insomnia, and unpleasant dreams
**Marijuana:** increased appetite and conjunctival injection
**Ecstasy: **bruxism, hyperthermia, hyponatremia, and hepatotoxicity
**PCP: **loss of painful stimuli, vertical nystagmus, psychosis with hallucination, violence, and agitation
48
Screening tools used for hallucinogens are
the drug abuse screening test (DAST), CAGE-AID (adapted to include drugs) and addiction severity index (ASI).
49
Opioid and benzodiazepine misuse cause ________ ____________ resulting in drowsiness, respiratory depression, and lethargy
Opioid and benzodiazepine misuse cause **sympathetic depression** resulting in drowsiness, respiratory depression, and lethargy
50
What is Anorexia Nervosa
In patients with anorexia nervosa, the person feel they are overweight despite evidence of normal or low body weight. It involves obsessively restricting calorie intake with the intention of losing weight. Often the person exercises excessively and may use diet pills or laxatives to restrict absorption of food.
51
What are the features of anorexia nervosa:
* Excessive weight loss
* Amenorrhoea
* **Lanugo hair** is fine, soft hair across most of the body
* Hypokalaemia
* Hypotension
* Hypothermia
* Changes in mood, anxiety and depression
* Solitude
52
With anorexia nervosa there can be cardiac complications which include:
arrhythmia, cardiac atrophy and sudden cardiac death
53
What is Bulimia Nervosa
Unlike with anorexia, people with bulimia often have a normal body weight. Their body weight tends to fluctuate. The condition involves binge eating, followed by **“purging”** by inducing vomiting or taking laxatives to prevent the calories being absorbed.
54
What are the features of bulimia nervosa:
* Alkalosis, due to vomiting hydrochloric acid from the stomach
* Hypokalaemia
* Erosion of teeth
* Swollen salivary glands
* Mouth ulcers
* Gastro-oesophageal reflux and irritation
* Calluses on the knuckles where they have been scraped across the teeth. This is called Russell’s sign.
55
What does a typical exam question look like with Bulimia nervosa?
Look out for the teenage girl with a normal body weight that presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas. The presenting complaint may be abdominal pain or reflux.
56
What is Binge Eating Disorder?
Binge eating disorder is characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress. This is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight.
Binges may involve:
* A planned binge involving “binge foods”
* Eating very quickly
* Unrelated to whether they are hungry or not
* Becoming uncomfortably full
* Eating in a “dazed state”
57
Management of Binge Eating Disorder
Patient and carer education is key to the condition. Management is centred around changing behaviour and addressing environmental factors:
* Self help resources
* Counselling
* Cognitive behavioural therapy (CBT)
* Addressing other areas of life, such as relationships and past experiences
Severe cases may require **admission** for observed refeeding and monitoring for **refeeding syndrome.**
**SSRI medication** may be used by a specialist in child and adolescent mental health.
58
What is Refeeding Syndrome?
Refeeding syndrome occurs in people that have been in a severe nutritional deficit for an extended period, when they start to eat again. Patients are at higher risk if they have a BMI below 20 and have had little to eat for the past 5 days. The lower the BMI and the longer the period of malnutrition, the higher the risk.
59
Refeeding Syndrome
Metabolism in the cells and organs dramatically slows during prolonged periods of malnutrition. As the starved cells start to process glucose, protein and fats again they use up magnesium, potassium and phosphorus. This leads to:
Hypomagnesaemia
Hypokalaemia
Hypophosphataemia
These patients are also at risk of cardiac arrhythmias, heart failure and fluid overload
60
Refeeding Syndrome Mx
Management will be according to the local protocol under specialist supervision:
* Slowly reintroducing food with restricted calories
* **Magnesium, potassium, phosphate and glucose** monitoring along with other routine bloods
* **Fluid balance** monitoring
* **ECG monitoring** may be required in severe cases
* **Supplementation** with electrolytes and vitamins, particularly B vitamins and thiamine
61
Mx of Anorexia Nervosa
1st: CBT-ED. Maudsley Anorexia Nervosa Treatment, Specialist supportive clinical management
10% of patients will eventually die
62
What is Bipolar disorder
Bipolar disorder is a mood disorder characterised by episodes of depression and mania or hypomania.
63
The incidence of bipolar disorder follows a bimodal distribution, with two peaks in the age of onset at around?
15-24 years and 45-54 years.
64
Aetiology of bipolar disorder
The aetiology of bipolar disorder is complex and involves **genetic, environmental**, and **neurobiological** components.
65
The genetic risk associated with bipolar disorder is a type of ________ inheritance
The genetic risk associated with bipolar disorder is a type of **polygenic** inheritance
66
RF for bipolar disorder?
* Genetic factors: combined effect of many single nucleotide polymorphisms (SNPs)
* Prenatal exposure to Toxoplasma gondii (the parasite that causes toxoplasmosis)
* Premature birth <32 weeks gestation
* Childhood maltreatment
* Postpartum period
* Cannabis use
67
How many types of bipolar disorders are there? What are they?
Type 1: Mania and depression
Type 2: Hypomania and depression
68
What is the difference between bipolar 1 and 2?
* In **bipolar I**, the person has experienced at least one episode of **mania**
* In **bipolar II**, the person has experienced at least one episode of **hypomania,** but never an episode of **mania. ** They must have also experienced at least one episode of major depression.
69
The characteristic clinical features of mania are
**elevated mood, increased activity** level and **grandiose ideas** of self-importance. In the ICD-10, mania is characterised by:
* **Elevated mood **out of keeping with the patient’s circumstances
* Elation accompanied by **increased energy** resulting in overactivity, pressure of speech, and a decreased need for sleep
* Inability to maintain attention, often with marked distractibility
* Self-esteem which is often inflated with **grandiosity **and increased confidence
* Loss of normal social inhibitions
70
Diagnosis for Mania
For a diagnosis, the manic episode should last for at least **seven days** and have a **significant negative functional effect** on work and social activities. Mood changes should be accompanied by an **increase in energy** and several of the other symptoms mentioned above.
As well as these features, mania can also occur alongside psychotic symptoms such as delusions and hallucinations, which are often auditory
71
Clinical features of Hypomania?
Hypomania is less severe than mania and is characterised by an **elevation of mood** to a lesser extent than that seen in mania. In ICD-10, an episode of hypomania is characterised by:8
* Persistent, mild **elevation of mood**
* **Increased energy** and activity, usually with marked feelings of wellbeing
* Increased sociability, talkativeness, over-familiarly, increased sexual energy and a decreased need for sleep (but not to the extent that there is a significant negative effect on functioning regarding work or social activities)
* Irritability may be present
* Absence of psychotic features (delusions or hallucinations)
72
Diagnosis for hypomania
For a diagnosis, more than one of these features should be present for at least several days.
Although hypomania does involve some extent of **functional impairment,** this is lesser than that seen in mania and is not severe enough to cause the more marked impairment in occupational or social activities.
73
Differential diagnoses of bipolar disorder?
Schizophrenia
Organic brain disorder
Drug use
Recurrent depression
Emotionally unstable personality disorder (EUPD)/borderline personality disorder
Cyclothymia
74
Investigations for bipolar disorder?
Investigations can be used to exclude organic causes of a patient’s clinical presentation and are largely context-dependent. Relevant investigations may include:
* Baseline blood tests: FBC, U&Es, LFTs, TFTs, CRP, B12, folate, vitamin D, ferritin
* HIV testing
* Toxicology screen
* Physical examination including neurological examination
* CT head
75
Diagnosis for bipolar disorder
Bipolar disorder should be considered when there is evidence of:
* **Mania: **symptoms should have lasted for at least seven days
* **Hypomania:** symptoms should have lasted for at least four days
* **Depression** (characterised by low mood, loss of interest or pleasure, and low energy) with a history of manic or hypomanic episodes
To confirm a diagnosis of bipolar disorder, a referral should be made to a **specialist mental health service**. This varies regionally but may take the form of a bipolar disorder service, a psychosis service, or a specialist integrated community-based service
76
Bipolar disorder
A mixture of both manic and depressive features is sometimes called?
a mixed affective state.
77
When a child or young person under the age of 18 is suspected of having bipolar disorder, they should be referred to
Child and Adolescent Mental Health Services (CAMHS).
78
Acute management of mania
n an acute episode of mania, people with a new diagnosis of bipolar disorder should be managed in secondary care with a trial of oral antipsychotics:11
* Haloperidol
* Olanzapine
* Quetiapine
* Risperidone
If the patient is on **antidepressant medication**, this should be tapered off and discontinued.11 **Benzodiazepines** may be used as an adjunct to manage symptoms of increased activity and allow for better sleep.
79
Acute management of depression in bipolar disorder
The recommended pharmacological options for managing depressive episodes in the context of bipolar disorder are:11
* Fluoxetine + olanzapine
* Quetiapine alone
* Olanzapine alone
* Lamotrigine alone
As well as these pharmacological options, psychological interventions such as cognitive behaviour therapy (CBT) may also be useful.11
80
Long-term management of bipolar disorder
After the acute episode has resolved, long-term pharmacological management usually involves a** mood stabilising medication **such as **lithium.**
If lithium is not effective, **sodium valproate** may be added.11 Sodium valproate should not be used in pregnant women due to its **teratogenic effects** and is not recommended in women of childbearing age unless the illness is very severe and there is no effective alternative. In this circumstance, the patient should have a **pregnancy prevention plan.**
**Lithium** is associated with a **significant reduction** in the risk of relapse with a manic episode, though evidence for its effectiveness in preventing depressive relapse is less clear.
The use of lithium is also associated with a **significant reduction in death by suicide**.13 Around half of patients will show a good response to lithium, although those with rapid-cycling bipolar disorder, mixed affective states or mood-incongruent features of psychosis may be less likely to respond well.1
81
Complications of bipolar disorder include
* Increased risk of death by **suicide**
* Increased risk of death by general **medical conditions** such as cardiovascular disease
* **Side effects** of antipsychotic drugs: these can include metabolic effects, weight gain and extrapyramidal symptoms
* **Socioeconomic effects**: major mental illness is associated with a negative drift down the socioeconomic ladder
81
Prophylaxis in bipolar disorder
Consider initiation of a mood stabiliser after remission of a manic episode.
* First-line treatment for mood stabilisation is **Lithium Carbonate** or Depakote
(Depakote must not be used in women of childbearing potential because
of its teratogenicity - significantly increased risk of neural tube defects).
* Second-line - **Carbamazepine** (= CYP450 inducer and so can lower serum
level of some medications and make them less effective).
* **Lamotrigine** should be considered if the patient is more prone to bipolar
depressive episodes rather than manic / hypomanic episodes
82
What is Charles Bonnet Syndrome
Recurrent hallucinations with visual impairment
83
Rf for Charles Bonnet Syndrome
RF: Age, peripheral visual impairment, social isolation, sensory deprivation
84
Mx Charles Bonnet Syndrome
Treat age related macular degeneration, glaucoma or cataracts
85
What is depression
Depression is a mood (affective) disorder characterised by persistent low mood, low energy and loss of interest/enjoyment in everyday activities (anhedonia)
86
Depression can be ________ (first occurrence or recurrent) or ________ (with occurrences of mania and depression).
Depression can be **unipolar** (first occurrence or recurrent) or **bipolar **(with occurrences of mania and depression).
87
Biological factors which increase the risk of depression include:
* Genetics: family history of depression in the nuclear family increases the risk to almost 30-40% and up to 50% in monozygotic twins
* Personality: dependent, anxious, impulsivity and obsessional traits
* Physical illness: neurological illnesses such as Parkinson’s disease and multiple sclerosis, hypothyroidism or chronic illnesses
* Biochemical theories/monoamine deficiency: serotonin imbalance causes depressive symptoms
* Neuroendocrine: hypothalamic-pituitary-adrenal axis
* Co-morbid substance misuse
* Medications: beta-blockers, steroids
* History of other mental illnesses: anxiety
88
Psychological factors which increase the risk of depression include:
* Traumatic life events/childhood experiences: adverse experiences including loss of a loved one, lack of parental care and childhood sexual abuse
* Environmental factors (e.g. support)
* Low self-esteem and negative automated thoughts (e.g. helplessness, hopelessness, worthlessness)
* Lack of education
89
Social factors which increase the risk of depression include:
* Poor social support
* Poor economic status or support
* Marital status: separated or divorced
90
A diagnosis of a depressive episode (following ICD-10/ICD-11 criteria) requires the following:
* The presence of symptoms for at least 2 weeks (this may be less if depression is severe)
* The symptoms are not attributable to other organic or substance causes (e.g. normal bereavement)
* The symptoms impair daily function and cause significant distress
91
The three typical core symptoms of depression include:
* Low mood
* Anhedonia: low interest or pleasure in most activities of the day
* Lack of energy (anergia)
92
Other core symptoms of depression include:
* Weight change: exclusion of intentional dieting
* Disturbed sleep: insomnia or hypersomnia
* Psychomotor retardation (slowed down actions) or psychomotor agitation (increased restlessness)
* Reduced libido
* Worthlessness or guilt feelings
* Decreased concentration
* Recurring thoughts of harm, death or suicide: nihilistic thoughts
93
Somatic symptoms of depression (also often referred to as the biological symptoms of depression) may include
* Anhedonia
* Loss of emotional reactivity
* Diurnal mood changes: mood often worse in the morning
* Early morning wakening: typically 2-3 hours earlier than usual
* Psychomotor retardation or psychomotor agitation
* Appetite loss
* Weight loss
94
Psychotic symptoms of depression (if present, these are usually mood-congruent) may include:
* Delusions: often revolving around guilt and personal inadequacy
* Hallucinations: can be auditory, olfactory or visual
95
With depression it is important to do a risk assessement. This includes?
* **Risk to self: **self-harm, suicide or neglect (commonest in depression)
* **Risk to others:** when depression presents with psychotic features, such as command hallucinations, they may be at risk of harming others
* **Risk from others:** patients with depressive symptoms may be more vulnerable to abuse, criminal acts or neglect
96
Differential diagnoses for depression?
* Depressive episode linked to substance/medication use
* Bipolar affective disorder
* Premenstrual dysphoric disorder
* Bereavement
* Anxiety disorders
* Alcohol-use disorder
* Hypothyroidism
* Cushing’s disease or syndrome
* Vitamin B12 deficiency
97
Diagnosis of depression
Screening questionnaires such as the **patient-health-questionnaire-9 (PHQ-9)** can be used to screen for symptoms of a depressive episode.
Investigations may be considered to **exclude physical/organic causes **of the patient’s symptoms. These may include:
* **Full blood count:** anaemia
* **Thyroid function test:** hypothyroidism (elevated thyroid stimulating hormone)
* **Vitamin B12:** vitamin b12 deficiency
**Imaging and other investigations** (e.g. a CT head) may be performed in patients with** atypical features** and signs indicative of an **organic pathology** (e.g. low mood associated with a sudden loss of memory and change in personality).
98
Depression is graded, following the ICD-11 criteria, as mild, moderate or severe:
* **Mild depression** requires two typical core symptoms plus two other core symptoms
* **Moderate depression** requires two typical core symptoms plus at least three other core symptoms
* **Severe depression** requires all three typical core symptoms plus at least four other core symptoms.
ICD-11 further classifies depressive episodes as
1. **Mild depressive** episode, with or without somatic symptoms
1. **Moderate depressive** episode, with or without somatic symptoms
1. **Severe depressive **episode, with or without psychotic symptoms: these may be mood-congruent or incongruent psychotic symptoms
1. Recurrent depressive disorder: when one has two more depressive episodes
99
Mild depression
Short-term management
First-line management should involve initiating primarily** low-intensity psychosocial interventions.**
In the United Kingdom, the 2022 NICE guidelines recommend the following interventions, based on implementation, clinical and cost-effectiveness:3
* Guided self-help
* Group cognitive-behavioural therapy (CBT)
* Group behavioural activation
* Individual CBT
* Group behavioural activation
* Structured group physical activity programme
* Group mindfulness and mediation
* Interpersonal psychotherapy
* Selective serotonin reuptake inhibitor (SSRI) antidepressants
* Counselling
* Short-term psychodynamic psychotherapy
100
Antidepressants should not be routinely offered unless that is the patient’s preference. Exceptional cases to consider starting on biological therapy (i.e. antidepressants) include:
* Past history of moderate or severe depression
* Presence of mild depression that has been present for at least 2 years
* Presence of mild depressive symptoms after other interventions
101
Long-term management
Longer-term management of mild depression includes:
* Risk assessment
* Ongoing review: response to low-intensity psychosocial intervention, compliance and symptoms. An SSRI antidepressant should provide benefit within 4-6 weeks.
* Measurement scales to assess response to treatment and quality of life
* Relapse prevention plan
* Assess for social support, and review previous issues flagged up during consultations
* If taking antidepressant therapy review compliance, side effects and adjust doses if appropriate
102
Moderate or severe depression
Short-term management
**First-line **management involves a number of treatment options, which may include a combination of antidepressant therapy (biological treatment) and high-intensity psychosocial interventions.
In the United Kingdom, the 2022 NICE guidelines recommend the following interventions in descending order, based on implementation, clinical and cost-effectiveness:3
* Combination of individual CBT and an antidepressant (e.g. SSRI)
* Individual CBT
* Individual behavioural activation
* Antidepressants (e.g. SSRI) alone
* Individual problem-solving
* Counselling
* Short-term psychodynamic psychotherapy
* Interpersonal psychotherapy
* Guided self-help
* Group exercise
103
Moderate or severe depression
Short-term management
If they are presenting with a severe depressive episode with psychotic symptoms, then treatment should be
augmented with an antipsychotic (quetiapine or olanzapine).
104
Electroconvulsive therapy (ECT) should be considered in severe cases of depression where:
* The patient has a strong preference for ECT: this usually applies when patients have responded to ECT well before
* Rapid treatment of the patient is needed: cases of life-threatening depression where the patient is not eating or drinking
* Multiple other treatments have been trialled unsuccessfully
105
Long-term management of moderate or severe depression includes
* Risk assessment
* Review their response to high-intensity psychosocial intervention compliance and symptoms
* Review their response to antidepressant therapy, compliance, side effects and adjust doses if appropriate
* Measurement scales to assess response to treatment and quality of life
* Relapse prevention plan
* Assess social support and previous issues flagged up during the consultation
106
Complications of depression include
* Suicide: the risk of suicide in patients with depression is four times higher than in patients without depression
* Substance misuse and alcohol use problems: patients are at increased risk of becoming dependent on substances
* Persistent symptoms: 10-20% of patients will have persistent symptoms over 2 years
* Recurrence of depressive episodes: most patients have a recurrence in later life
* Reduced quality of life: patients may struggle with employment and relationships
* Antidepressant side effects: may include sexual dysfunction, risk of self-harm, weight gain, hyponatraemia and agitation
107
What is insomnia
Difficulty initiating or maintaining sleep
108
RF for insomnia
Females, Increase age, Economic inactivity, unemployment, lower educational attainment. Corticosteroids, alcohol abuse, chronic conditions
109
Diagnosis of insomnia
Patient history
Sleep Diaries, actigraphy
110
Mx for insomnia
Identify causes, advise person to not drive, good sleep hygiene
Hypnotics if severe: Short acting benzodiazepines, non benzodiazepines (Zopiclone, Zolpidem, Zaleplon). Diazepam
Use lowest effective dose for shortest period possible
111
What is psychosis?
Loss of contact with reality. Associated features: agitation, aggression, neurocognitive impairment, depression
Hallucinations, delusions, fixed beliefs, world salad. Thought insertion, withdrawal or broadcast. Social withdrawl.
112
Ix psychosis?
Urine: Drug induced
CT Head
Ca2+, Glucose, FBC, TFT, U&E, B12 & Folate.
Before Antipsychotics check HbA1c, LFT, Chol, QTC
113
Psychosis is linked to what other conditions
Linked to other conditions: Schizophrenia, depression, bipolar disorder, puerperal psychosis, brief psychotic disorder, corticosteroids.
114
What is schizophrenia?
It is a mental disorder characterised by impairments in the way reality is perceived and associated changes in behavhiour
115
Schizophrenia:
Symptoms are split into three catergories which are?
Psychotic
Negative
Cognitive
116
Schizophrenia: Psychotic symptoms
Hallucinations - auditory 80%
Delusions
Disorganised speech
Abnormal Movement
Thought disorder
117
Schizophrenia: Negative symptoms
Marked apathy
* Poverty of thought
* Poverty of speech
* Blunting of affect
* Social isolation
* Poor self-care
* Cognitive deficits (especially executive functions)
118
Schizophrenia: Cognitive symptoms
Predictor of day to fay functioning
Low attention
Poor Decision making
Lack of problem solving
119
What is the onset of Schizophrenia symptoms
- Prodomal phase: gradual cognitive and negative symptoms
- followed by first episode of psychosis
- Residual phase: Baseline
- Then they cycle starts again
120
The time period between first episode fo psychosis and treatment is called?
Duration of untreated psychosis
121
Diagnosis of Schizophrenia
DSM 5:
At least 2 of these symptoms
1. Delusions
2. Hallucinations
3. Disorganised speech
4. Disorganised/ catatonic behaviour
4. Negative symptoms
1, 2 or 3 must be present
active symptoms for > 1 months
significant impairment.
122
Schizophrenia
What do you have rule out first
Symptoms cannot be due to substances or medical conditions
123
Causes of Schizophrenia
Exact cause is unknown
Neurochemical abnormality: imbalance of Dopamine, glutamat. These are the 4 dopamine pathways.
1. Nigrostriatiatal -
2. Mesocortical -
3. Mesolimbic -
4. Tuberolinfundibular -
124
RF of Schizophrenia
Genetic
Environmental: low birth weight, gestational diabetes, pre eclampsia , emergency c section, winter birth, cannabis, life events
Brain abnormalities
more common in african america
25 males 27 females
125
What is Schizophrenia Treatment resistant classed as?
no response to at least two antipsychotics over 12 weeks
- consider clozapine
126
What is depression?
“…concurrent presence of at least five out of a list of ten symptoms, which must occur **most of the day, nearly every day, for at least 2 weeks**. The mood disturbance must result in significant functional impairment and not be a manifestation of another health condition, due to the effects of a substance or medication
127
How would you ask about the two 'core' symptoms of depression?
3 core features are?
* During the last month have you often been bothered by feeling down, depressed, or hopeless?
* Do you have little interest or pleasure in doing things?
* - Low mood - Anhedonia - Anergia
128
Physical associated symptoms of depression
* Disturbed sleep (decreased or increased compared to usual).
* Decreased or increased appetite and/or weight.
* Fatigue/loss of energy.
* Agitation or slowing of movements
129
Cognitive associated symptoms of depression
* Poor concentration or indecisiveness.
* Feelings of worthlessness or excessive or inappropriate guilt.
* Hopelessness about the future.
* Suicidal thoughts or acts.
130
Brainstorm the key features in the history for a patient with Depression
131
Brainstorm the key features in the exam for a patient with Depression
132
Screening for Depression
What is the simple 3 point question?
* Felt down, depressed or hopeless?
* Found that you no longer enjoy, or find little pleasure in life?
* Been feeling overly tired?
133
Screening for Depression
Specific Tools
* PHQ-9 (to monitor severity and response to treatment, can help with diagnosis)
* HAD Scale (assess both anxiety and depression)
* Edinburgh Postnatal Depression Scale (a self-rating scale for puerperal depression)
* Geriatric Depression Scale (suitable for older patients)
134
Management “Less Severe” Depression
* “Active monitoring”
* Low-intensity psychosocial interventions
-individual guided self-help based on the principles of (CBT)
- computerised cognitive behavioural therapy (CCBT)
- a structured group physical activity programme
* Consider Group CBT
* Sleep hygiene
* Routine use of medication not recommended
135
What does Patient Health Questionnaire 9 (PHQ-9) results suggest
136
Management “More Severe Depression”
* High-intensity psychological intervention (CBT, interpersonal therapy (IPT))
* Antidepressant
* Or a combination of both
137
What are the medications used in Depression?
* First line: SSRI unless specific CI/interactions, previous SE, patient preference
* Important points in consultation: timeframe, review points, dose changes, withdrawal symptoms
SSRI’s:
* Issues: bleeding risk (?PPI), interactions (SJW, serotonin syndrome), hypersensitivity reactions
* Side effects: minor sedation, dizziness, anxiety, anti-muscarinic, GI, sexual dysfx, hyponatremia (elderly), increased suicidal ideation (young)
138
What is the General Prescribing Strategy for Depression
Consider previously successful drugs first.
1st Line – SSRI
2nd Line – Alternative SSRI
3rd Line - Mirtazapine or SNRI or Trazodone or Tricyclic
Consider combining/augmenting medications if not fully effective
139
What are the Factors in Complex Depression
* Significant co-existing medical or psychiatric problems
* Substance Misuse
* Significant Psycho-social stressors (relationships, personality)
* Treatment Resistance or Recurrent Episodes
* Identified Risks (suicide, self-harm, self-neglect)
* Psychotic Symptoms
140
Management of Complex & Severe Depression
* Referral to specialist mental health services for a programme of coordinated multi-professional care
* Collaborative care if chronic physical health problem with associated functional impairment
* Discuss place for in-patient care, crisis resolution and home treatment teams
* ECT
141
ICD-11 classification of Personality Disorder
Personality disorder is characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships) that have persisted over an extended period of time (e.g., 2 years or more)…..”
142
What does a risk assessment involve in a patient with mental health problems
Basic assessment would include to ask the patient about suicidal thoughts and plans
* Other frameworks suggests to look at:
* Previous suicidal behavior
* Current suicidal thoughts and plans
* Hopelessness
* Stressors
* Presence of mental disorder symptoms
* Themes of impulsivity and self control
* Ready access to highly lethal methods eg firearms
* Protective factors (what are these?)
143
RF for suicide
Some examples of risk factors for suicide:
* Family history suicide
* Mental health disorders, especially depression
* Alcohol/substance misuse
* Feelings of hopelessness
* Isolation
* Loss (job, bereavement, relationships etc)
* Physical illness
* Easy access to lethal methods
* Previous attempts and more…
144
Suicide Protective Factors
* Good clinical care of mental and physical health conditions
* Access to immediate/ongoing support
* Family and community support
* Learned personal skills with problem solving, anger management etc
* Cultural or religious beliefs that discourage suicide
145
The donts of Risk assessment?
146
If you felt the patient was at imminent risk of suicide what should your management plan be?
* Refer secondary care – how?
* Crisis resolution team – may support in hospital or at home
* Ask if family member or friend can take her
* Check she arrives at referred location
* If refusing admission maybe due to lack of insight or intent on plan, then you may need to section the patient under the Mental Health Act (1983)
147
What are the Symptoms of Anxiety?
Physical symptoms
* “Fight or Flight” response, adrenaline causes palpitations, nausea or churning stomach, headache, poor sleep, shaking, dizziness, tiredness, sweating, dry mouth, shortness of breath
Psychological symptoms
* Eg. Restlessness, fear of impending doom, irritability, difficulty concentrating, feeling “on edge”
148
When is Anxiety a Medical Problem?
Symptoms persist for several months, more days than not
Impacting on an individual’s life
149
Differentials for anxiety disorder
* Generalised Anxiety Disorder
* Obsessive Compulsive Disorder
* Panic disorder
* Social phobia
* PTSD
* Physical cause for symptoms (eg phaeochromocytoma, hyperthyroidism)
150
What questionaire can be used for generalised anxiety disorder?
GAD-7 Questionnaire
This self-administered patient questionnaire can be used to support diagnosis, and for establishing a severity measure for generalised anxiety disorder.
For each of the seven criteria there are four possible answers: Not at all = 0 points; several days = 1 point; more than half the days = 2 points; nearly every day = 3 points
The scores represent: 0–5 mild anxiety, 6–10 moderate anxiety, 11–15 moderately severe anxiety, 15–21 severe anxiety.
151
ICD – 11 definition Generalised Anxiety Disorder
Generalised anxiety disorder is characterized by marked symptoms of anxiety that persist for at least several months, for more days than not, manifested by either general apprehension (i.e. ‘free-floating anxiety’) or excessive worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as muscular tension or motor restlessness, sympathetic autonomic over-activity, subjective experience of nervousness, difficulty maintaining concentration, irritability, or sleep disturbance. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. The symptoms are not a manifestation of another health condition and are not due to the effects of a substance or medication on the central nervous system.”
152
Management Plan for Generalised Anxiety Disorder?
Low intensity psychological interventions
* Individual non-facilitated self-help
* Individual facilitated self-help
* Psycho-educational groups
Follow up – Active monitoring by GP
Treat concurrent medical conditions, hyperthyroid, depression etc
152
Anxiety
Self Help may also include:
Talking to someone the person trusts
Managing worries (e.g. writing worries down or allowing specific time to think about them)
Look after physical health
Breathing exercises
Peer support
Keep a diary
Complementary and alternative therapy e.g. yoga, meditation, aromatherapy…
153
Other Management Options for Anxiety
Psychotherapy – Cognitive Behavioural Therapy or applied relaxation (high-intensity psychological intervention)
Medication - SSRI e.g. sertraline, if not tolerated pregabalin
If symptoms severe and risk harm to self or others, risk of neglect, has significant co-morbidity inadequate response to treatments refer to specialist mental health team.
Note pregabalin is a Class C controlled substance so prescribe with caution and evaluate patients thoroughly before use
154
What are delusions?
Fixed unshakeable belief that is not in keeping with patients social, cultural
and educational background
155
Name different types of delusions?
- **Persecutory:** one is about to be harmed or mistreated by others
- Delusions of love
- Religious
- **Grandiose:** one has special powers, wealth, mission, or identity
- Delusions of infidelity
- Delusions of infestation
- Delusions of reference
- Delusions of misidentification
- **Somatic:** completely convinced there is something medically, physically, or biologically wrong with them
156
What are hallucinations?
percept experienced in the absence of an external stimulus.
157
Name different types of hallucinations?
- Auditory
- Gustatory
- Somatic (e.g. tactile, hygric)
- Visual
- Olfactory
- Pseudohallucinations
158
Name some thought disorders?
* Circumstantial and tangential thinking
* Flight of ideas
* Loosening of association (derailment / “Knight’s move” thinking)
* Thought blocking
* Neologisms and idiosyncratic word use
* Perseveration
* Echolalia
* Irrelevant answers
159
What are catatonic symptoms in schizophrenia?
= Motor disturbances:
- rigidity
- posturing
- negativism
- waxy flexibility
- excitement
- stupor
160
Name some psychotic disorfers?
- Schizophrenia
- Schizoaffective disorder
- Schizotypal disorder
- Acute and transient psychotic disorder
- Delusional disorder
- Symptomatic manifestations of primary psychotic disorders
161
What are the different types of schizophrenia?
- Schizophrenia, first episode
- Schizophrenia, multiple episodes
- Schizophrenia, continuous
- Other specified episode of schizophrenia
- Schizophrenia, episode unspecified
162
What is Acute and transient psychotic disorder
It is a schizophrenia-like psychotic disorder
- Acute onset of psychotic symptoms, which can include delusions,
hallucinations, disorganised thinking, or experiences of influence, passivity
or control, that emerge without a prodrome, progressing from a non-psychotic
state to a clearly psychotic state within two weeks.
- **Psychomotor disturbances** may also be present, including catatonia.
- **Symptoms change rapidly, both in nature and intensity**. Such changes
may occur from day to day, or even within a single day.
- **Absence of negative symptoms**
- **Duration of the symptoms does not exceed three months, **and most
commonly **lasts from a few days to one month**
163
What are Schizoaffective disorder?
- All diagnostic requirements for schizophrenia are met concurrently with mood
symptoms that meet the diagnostic requirements of a moderate or severe
depressive episode, a manic episode, or a mixed episode.
- The onset of the psychotic and **mood symptoms is either simultaneous or occurs
within a few days** of one another.
- Duration of symptomatic episodes is at least one month for both psychotic and
mood symptoms.
- Symptoms or behaviours are **not a manifestation of another medical condition**
and are not due to the effects of a substance or medication on the central nervous
system, including withdrawal effects (e.g. from alcohol)
164
What is delusional disorder?
-Presence of a delusion or set of related delusions, typically persisting for at least
three months
- Delusions are variable in content across individuals, while showing remarkable
stability within individuals, although they may evolve over time.
- **Absence of clear and persistent hallucinations**, severely disorganised thinking
(formal thought disorder), experiences of influence, passivity, or control or negative
symptoms characteristic of schizophrenia.
- Apart from the actions and attitudes directly related to the delusional system,
affect, speech, and behaviour are typically unaffected.
- Symptoms are not a manifestation of another medical condition, are not due to the
effects of a substance or medication on the central nervous system including withdrawal
effects (e.g. from alcohol).
165
What are the different teams are involved in psychosis and Schizophrenia depending on the stage of illness?
- First episode: **Early Intervention in Psychosis Team** (for individuals aged 14 to 65,
duration of follow-up is up to 3 years)
- Chronic psychotic illness: Care transferred to local **CMHT**
- Early stage of relapse: **Crisis Resolution and Home Treatment** Team (short-term only)
166
Biological treatments fo schizophrenia
1st line:
* Second generation (get to optimum dosage). Commonly **Olanzapine.**
* Preferably oral rather than depot preparation.
* 2nd line:
* Review the diagnosis, check concordance with antipsychotic medication and
screen for any concomitant use of illicit substances.
* Try a different oral second generation (get to optimum dosage). **Risperidone**
* Could consider a **depot** if the patient is adamant he / she does not want to take
oral medication
**Also consider Benzodiazepines for acute phase **
167
What is a depot injection?
depot injection is a slow-release form of medication. The injection uses a liquid that releases the medication slowly, so it lasts a lot longer.
A depot injection might be a good option for you if:
you find it difficult to swallow medication
you find it difficult remembering to take medication regularly
you prefer not to have to think about taking medication every day.
168
Before starting any antipsychotic medication, check:
patient’s weight, waist
circumference, B.P, pulse rate, ECG, HbA1c level, serum cholesterol level, lipid
profile and serum prolactin level
169
With taking anitpsychotic medication there is a risk of metabolic syndrome. This has five components which are?
1. Essential hypertension
2. Truncal obesity
3. Insulin resistance (hyper-insulinaemia)
4. Low glucose tolerance
5. Dyslipidaemia
170
What are the Physical health monitoring with antipsychotics?
* Patient’s weight, B.P, pulse rate, HbA1c level, serum cholesterol level and lipid
profile checked **at 12 weeks**, then **at one yea**r and then **annually**
thereafter.
* Patient’s weight should be checked weekly for the **first six weeks, then at 12
weeks,** then at one year and then **annually** thereafter.
* Waist circumference should be measured on an **annual basis**.
* Mental health services should assume responsibility for monitoring patient’s
physical health for at least the **first 12 months**following initiation of antipsychotic
treatment. Thereafter, responsibility for this may pass to the G.P under shared
care arrangements
171
What monitoring do you need to do if a patient is on Clozapine?
baseline FBC, CRP and
Troponin-T level; weekly FBC for first 18 weeks, then fortnightly up to one year
of treatment, then four-weekly thereafter. CRP and Troponin-T to be checked
weekly for first six weeks)
172
What are the psychological treatments for schizophrenia?
Psychoeducation (awareness of diagnosis, relapse prevention and early
warning signs of becoming unwell). Useful starting point, especially in the
early stages following the diagnosis being made.
* Cognitive behavioural therapy (CBT).
* Family therapy. Useful not only for the patient, but also the family. May help
reduce high expressed emotion (a risk factor for relapse in schizophrenia).
* NICE guidelines recommend that CBT and family therapy should be available
for all patients with schizophrenia and those at increased risk of developing
psychosis
173
What are the different types of depressive disorders?
- Single episode depressive disorder
- Recurrent depressive disorder
- Dysthymic disorder
- Mixed anxiety and depressive disorder
174
What is Single episode depressive disorder
Characterised by the presence or history of one depressive episode
when there is no history of prior depressive episodes
175
Describe a depressive episode?
A depressive episode is characterised by a period of depressed mood or
diminished interest in activities occurring most of the day, nearly every
day during a period lasting at least two weeks accompanied by other
symptoms such as difficulty concentrating, feelings of worthlessness or
excessive or inappropriate guilt, hopelessness, recurrent thoughts of
death or suicide, changes in appetite or sleep, psychomotor agitation or
retardation, and reduced energy or fatigue.
176
What are psychotic symptoms the a depressed patient might experience?
Psychotic symptoms:
- Delusions (commonly delusions of guilt, nihilistic delusions, delusions
of poverty, persecutory delusions, self-referential or hypochondrical
delusions)
- Hallucinations (typically second person, derogatory in content)
- Depressive stupor
- Occur in severe depressive episodes only
177
Rating the severity of a depressive episode
178
Biological treatment for depression
* Start with SSRI antidepressant (typically Sertraline, Fluoxetine or Citalopram).
* Assess within two weeks of initiation.
* Increase the dose if no response after three - four weeks (check
concordance!).
* Warn about risk of suicidal thoughts in patients < 30.
* If no response, try an alternative SSRI
* Augment the antidepressant with an antipsychotic (Quetiapine,
Risperidone or Aripiprazole are the recommended options)
179
What happens if there is no response to SSRI in depression
- If no response with a second SSRI, try an SNRI (Venlafaxine).
- If no response, refer to secondary care for specialist opinion.
- Could try Mirtazapine (helps with sleep disturbance and appetite
disturbance).
- Then, combination of antidepressants - either Venlafaxine +
Mirtazapine or SSRI + Mirtazapine.
- Lithium Carbonate can be added in (can help to reduce suicidality)
180
What medications do we avoid for depression
* Avoid MAO inhibitors (tyramine-containing foods can provoke
hypertensive crisis).
* Avoid tricyclic antidepressants (cardiotoxic in overdose and poorly
tolerated)
181
What is the first line in psychotic depression
Electroconvulsive therapy (ECT)
182
Name some psychological treatment for depression
**Low-intensity psychological interventions** - for mild depression:
* Individual guided self-help, based on principles of CBT. Usually consists of 6 - 8
sessions.
* Computerised CBT. Usually takes place over 9 - 12 weeks.
* Structured group-based physical activity programme. Usually consists of 2 - 3 sessions
per week of moderate duration (45 mins to 1 hour), over 3-month period.
* Group-based peer support. Usually consists of one session per week over 8 - 12 weeks.
**High-intensity psychological interventions** - for moderate or severe depression:
* Group based CBT, Usually consists of 12 x 2-hour sessions over 8 - 12 weeks.
* Individual CBT. Usually given over 16 - 20 sessions over 3 - 4 months. For severe
depression, 2 sessions per week might be provided for the first 2 or 3 weeks.
* Interpersonal therapy. Duration and no. of sessions similar to CBT.
* Behavioural activation. Duration and no. of sessions similar to CBT.
Psychological treatment
183
What are some social interventions for depression?
* Regular exercise
* Sleep hygiene
* Healthy diet
* Reduce alcohol intake
* Address any financial worries
* Address any housing issues
184
What are the risk factors for suicide?
* Male
* Age > 45 years
* Unemployed
* Divorced, widowed or single
* Physical illness
* Mental disorder present
* Substance misuse
* Previous suicide attempt
* Family history of mental disorder
* Family history of suicide attempt
185
What is the Management of the suicidal patient?
* Take a thorough history of the suicide attempt.
* Screen for any evidence of any illicit substance use or alcohol abuse.
* Do a mental state examination and formulate a risk assessment.
* If the suicide attempt is an OD of a psychotropic medication(s), consult
Toxbase on how best to manage the patient medically.
* Ensure the patient is medically fit to undergo a mental health assessment!
186
Following psychiatric assessment for suicidal patient, there are four management options
1) The patient is discharged with advice to be reviewed by the G.P within
the next couple of weeks.
2) The patient is discharged with a referral made to the local CMHT to
monitor the patient’s mental health.
3) The patient is discharged with follow-up from the Crisis Team (can visit
daily if required). They may then refer to the CMHT for ongoing follow-
up.
4) The patient is admitted to a psychiatric inpatient unit - either voluntarily
or detained under the Mental Health Act 1983 (usually section 2).
187
What is dementia?
* Impairment in intellectual function affecting more than one
cognitive domain
*Interferes with social or occupational function
* Decline from a previous level
* Not explained by delirium or major psychiatric disease
188
What are the cognitive domains of dementia?
*Executive function (frontal, hemispheric white matter)
* Memory (medial temporal lobes / hippocampus)
* Language (left hemisphere, usually)
*Visuospatial (occipital, parietal)
189
What is the ICD-10 definition of dementia?
Requires impairment in two or more cognitive domains,
sufficient to interfere with social or occupational
functioning
190
What is Mild Cognitive Impairment (MCI)
* Cognitive decline abnormal for age and education but does
not interfere with function and activities.
* = “At risk” state to develop a degenerative dementia.
* When memory loss predominates, it is termed amnestic MCI.
* 10-15% per year of conversion to Alzheimer’s dementia.
190
Symptoms of dementia that are too mild are called?
Mild Cognitive Impairment (MCI).
190
Examples of Subcortical dementia?
Huntington’s disease, Parkinsons’s Disease,
Focal Thalamic & Basal Ganglia Lesions, Multiple Sclerosis.
190
Examples of Cortical dementia?
Alzheimer’s disease, Frontotemporal dementias
191
Examples of mixed dementia?
Vascular dementia, Dementia with Lewy Bodies,
corticobasal degeneration, neurosyphilis
192
Examples of Primary dementia?
AD = Alzheimer’s dementia
LBD = Lewy Body dementia
PDD = Parkinson’s disease dementia
FTD = Frontotemporal dementia
Vascular dementia
FTD = Frontotemporal dementia
193
What is the most common type of dementia?
Alzheimer’s disease (AD)
*Prevalence doubles every five years after the age of 65;
~50% of those older than 85
194
RF of Alzheimer’s
Age!!
* Mild cognitive impairment (MCI)
*ApoE4 positivity
* Family Hx in first degree relative (especially if younger onset)
*Vascular risk (diabetes, heart disease, etc.)
* Low education and physical / social activity
* Female gender
195
Clinical features of Alzheimer’s
*Earliest cognitive symptoms are usually poor short-term
memory and loss of orientation
*Smooth, usually slow decline without dramatic short-term
fluctuations
* Other domains involved with time
*So common that many variations are seen
196
Behavioural and psychological symptoms of Alzheimer's
* Depression, anxiety
*Irritability, hostility, apathy
* Delusions, hallucinations
*Sleep-wake changes
*“Sundowning”
*Agitation
197
What is Dementia with Lewy Bodies (DLB)
* Relatively earlier occipital and basal ganglia degeneration
*Similar to Parkinson’s disease dementia
* α-synuclein aggregates into Lewy bodies
* Concurrent AD pathology is common
198
Clinical features of DLB
* Dementia (early on, visuospatial and executive) +
* Core features
*Parkinsonism
* Recurrent early visual hallucinations
* Fluctuations (clue: recurrent delirium evaluations)
*Suggestive features include REM sleep disorder (dream
enactment) and neuroleptic sensitivity
199
What is the second most common dementia in under 65
Frontotemporal Dementia (FTD)
*Average age of onset is only 58
200
What are the proteins involved in FTD
TDP43 (DNA binding protein)
TAU
201
When do you suspect vascular dementia?
*Suspected when :
1. Abrupt onset and / or stepwise decline
2. Fluctuating course
3. Hx of stroke
4. Focal neurologic symptoms or signs
5. Usually see bilateral infarcts
6. Often associated with executive dysfunction, gait disorder,
apathy, incontinence
202
Differential diagnosis in dementia: commoner
treatable causes
Structural brain lesion (subdural bleed)
* Thyroid disease
* Vitamin B12 deficiency
* Untreated obstructive sleep apnoea
* Depression or anxiety
* Alcoholism
* Medications: benzos, opioids, anticholinergics (diphenhydramine,
bladder drugs, tricyclics), neuroleptics, dopaminergics, other sedatives
203
What examinations would you do in a patient suspected of dementia?
* General neurological exam
*Any signs of stroke?
*Signs of parkinsonism or a gait disorder?
* Cognitive screen bloods
* Mini-Mental State Examination (MMSE)
*ACE-R (Addenbrooke’s)
* Mini-cog
* Montreal Cognitive Assessment (MoCA)
204
What is used to differentiate Alzheimer’s from Frontotemporal Dementia
* FDG-PET
205
For slowly progressive “typical” dementia in adults >65 What are the most essential
tests
Vitamin B12, TFTs, neuroimaging (CT is o.k)
206
Drug treatment for dementia?
* No current treatment slows down neuronal loss in the brain
* Cholinesterase inhibitors (donepezil, rivastigmine,
galantamine)?
- Modest symptom improvement in AD
- Sometimes marked improvements in PDD / DLB
* Memantine? Modest benefit in AD
207
What the reactions to trauma in children?
* Denial, shock, irritability, anger, fear, isolation, shame
* Avoidance, not talking about it, clamming up vs
preoccupation, nightmares, flashbacks, enacted through play
208
