Psychiatry Flashcards
When can involuntary admission be implemented?
- Patient has mental disorder
- Needs detention for assessment/treatment of it
- Admission is to protect themselves or others
What is section 2 of the mental health act
- Admission for assessment for up to 28 days
- 2 doctors and AMHP present
What is section 3 of mental health act
- Admission for treatment for up to 6 months
- Can be renewed indefinitely
- Exact mental disorder stated and appropriate treatment available
- Two doctors sign and find reason that community treatment is contraindicated
- Treatment must be likely to benefit patient, prevent deterioration, necessary for health or safety of patient or protection of others
What is section 4 of the mental health act
- Admission for emergency treatment for up to 72 hours
- Admission must be urgent necessity
- AMHP makes application after recommendation from one doctor
- Patient must be seen within 72 hrs by doctor to decide whether to put section 2/3, voluntary admission or discharge
What is section 5(2) of mental health act
- Detention of patient already in hospital for up to 72 hours
- Doctors holding powers
Section 5(4) of mental health act
- Nurse’s holding powers for up to 6 hours
- Detain patient who is taking discharge against advice
- During 6 hours nurse must find personnel to sign section 5(2) or allow discharge
Section 135 of mental health act
- Allows police to force entry into someone’s premises to allow assessment under MHA to be made or bring them to place of safety
- Warrant from Magistrates court required and accompanied by AMHP and/or doctor
Section 136 of mental health act
- Allows police to arrest person ‘in a place to which public have access’ who they believe to be suffering from a mental disorder in order to convey them directly to a place of safety
- Held under section 136 for up to 72 hrs during which they should be seen by doctor and AMHP to choose to complete MHA assessment, admit them informally or discharge them
Mental capacity act (2005)
- Presumption of capacity
- Individuals supported to make their own decisions
- Unwise decisions
- Best interests
- Less restrictive option
What is a hallucination
- Occur in any sensory modality without an external stimulus
- Felt to occur in the external world along other objects, have the same qualities as everything else and cannot be consciously manipulated or stopped
- To the person experiencing them, these experiences are real
- Auditory = thoughts spoken aloud, second-person hallucinations, third-person hallucinations
- Visual = More common in eye pathology and epilepsy than psychosis
What is a delusion
beliefs held unshakably, irrespective of counter-argument, that are unexpected and out of keeping with patient’s cultural background
Loosening of association
thought disturbance demonstrated by speech that is disconnected and fragmented with individual jumping from one idea to another unrelated or indirectly related idea
Circumstantiality
including a lot of unnecessary and insignificant details in your conversation or writing
Confabulation
production or creation of false or erroneous memories without intent to deceive. Or, falsification of memory by person who believes they are genuinely communicating truthful memories
Somatic passivity
experience of bodily sensations (including actions, thoughts or emotions) imposed by external agency
* E.g. voices commentating on one’s action
* E.g. voices describe patient’s activities as they occur
Anhedonia
inability to feel pleasure
Thought alienation
subjective experience of one’s own thoughts being under control of an outside agency
* Thought Insertion = foreign thoughts places into one’s mind
* Thought Withdrawal = thoughts suddenly disappearing (having been taken by external thought)
* Thought Broadcast = thoughts being transmitted to everyone around as though being played on a radio
Thought echo
form of auditory hallucination in which a patient hears their thoughts spoken aloud
* Associated with schizophrenia
Thought block
someone loses a train of thought for no apparent reason, which may cause them to suddenly stop speaking
* Can occur at any time due to tiredness or stress
Akathisia
inability to remain still
* Neuropsychiatric syndrome associated with psychomotor restlessness
* Experience intense sensation of unease or inner restlessness
Catatonia
group of symptoms that usually involve movement and communication
* Agitation, confusion, restlessness
Flight of ideas
Subjective quickening of thoughts so most are not carried to completion before being overtaken
* Meaningful connections between ideas are kept although often linked by distracting environmental cues or form words themselves spoken aloud
o E.g. puns, rhymes, clang associations
* Retardation of thinking is slowing of train of thought although is remains goal directed
* Opposite is pressure of speech
Dissociation
hysteria
* Amnesia
* Depersonalisation = feeling being detached from one’s body or ideas
* Dissociative identity disorder = patient has multiple personalities which interact in complex ways
* Fugue = inability to recall one’s past, loss of identity or formation of new identity
What is generalised anxiety disorder
Excessive state of anxiety across different situations that last >6m and interferes with daily life
Causes of GAD
Genetic predisposition
Stress = work, noise, hostile home
Events = losing/gaining spouse/job, moving house
Faulty learning or secondary gain
Clinical features of GAD
Psychological symptoms
* Unpleasant feeling of suspense
* Recurrent automatic thoughts about negative outcomes
* Reduced concentration
* Hypervigilance
Behavioural symptoms
* Avoidance of anxiogenic stimuli
* Restlessness/agitation
* Irritability
Physiological symptoms
* Palpitations
* Dyspnoea
* Muscle tension
* Disturbed sleep (initial insomnia)
* Fatigue
* Nausea
Children’s symptoms
* Thumb-sucking
* Nail biting
* Bed wetting
Signs of GAD
Tachycardia
Tachypnoea
Tremor
Sweating
Pallor
Pupil dilation
Severity scoring of GAD
GAD2 or GAD7
Management of GAD
Self-help based on CBT principles
Meditation and Progressive relaxation training
SSRI
What is panic disorder
Anxiety disorder associated with panic attacks
Presentation of panic disorder
Physical
* Palpitations
* Chest pain
* Choking
* Tachypnoea
* Dry mouth
* Urgency of micturition
* Dizziness
* Blurred visions
* Parasthesiae
Psychological
* Feeling of impending doom
* Fear of dying
* Fear of losing control
* Depersonalisation
* Derealisation
Management of panic disorder
Acute treatment = propranolol
1st line = CBT + SSRI (sertraline)
2nd line (no response after 12wks or CI) = imipramine or clomipramine
3rd line = pregabalin or clonazepam
What is obsessive-compulsive disorder
Compulsions = senseless, repeated rituals
Obsessions = stereotyped, purposeless words, ideas or phrases that come into mind
Presentation of OCD
Compulsions (ACTS)
* Usually a way to reduce stress from obsessions
* Often resisted by patient but if chronic patient may have given up resisting
* Repetitive behaviours
* Checking, washing, counting, symmetry, repeating certain words or phrases
Obsessive thoughts
* Unpleasant = death, sexual, blasphemous
* Intrusive
* Irrational
* Recognised as patient’s own thoughts
Presents with
* Derm, genital or anal, HIV/illness worries
Severity of OCD
Yale-Brown OC scale
Management of OCD
CBT = Exposure and response prevention
SSRIs = sertraline, fluoxetine
Clomipramine
What are phobic disorders
Group of disorders in which anxiety is experienced only or predominantly in certain well-defined situations that are not dangerous
Types of phobic disorders
Agoraphobia = fear of crowds, travel, events away from home
Social phobias = situations where closely observed
Simple phobia = e.g. dentists, spiders, clowns
Fear of fear
Presentation of phobic disorders
Situations are avoided or endured with dread
Become disorder when they cause marked distress and/or significantly impair ability to function
Can lead to panic attacks
Management of phobic disorders
Panic attacks
* CBT
* SSRI, TCA, pregabalin, clonazepam
What is PTSD
Develops after an exceptionally stressful, life-threatening or catastrophic event or situation and lasts for over 4 weeks
Presentation of PTSD
Re-experiencing event in vivid nightmares or flashbacks
* Any sensory modality: visual, smell, sound, touch
Precipitating anxiety or panic attacks
Avoidance of things that associated with event (place, person, thoughts)
Hypervigilance
Sleep disturbance
Poor concentration
Inability to recall key features of trauma
Overly negative thoughts and assumptions about oneself or the world
Exaggerated blame of self or other for causing trauma
Negative affect
Decreased interest in activities
Feeling isolated
Irritability or aggression
Risky or destructive behaviour
Heightened startle reaction
In children
* Re-enacting experience
* Repetitive play
* Frightening dreams without recognisable content
Associations of PTSD
Depression
Emotional numbing
Drug and alcohol misuse
Anger
Management of PTSD
Watchful waiting if <4wks = acute stress disorder
Trauma-focused treatments
* CBT
* Eye movement desensitisation and reprocessing (EMDR)
* Hypnotherapy
Stress management
Medication (2nd line to therapy)
* SSRIs or venlafaxine
* SGA
Treat comorbidity (depression)
No debrief or counselling
What is anorexia nervosa
Compulsive need to control eating and body shape
Epidemiology of anorexia nervosa
F>M
Men likely to be underdiagnosed
Typical age of onset mid-adolescence (16-17)
Risk factors for anorexia nervosa
Biological
* Genetics
* Serotonin dysregulation
Psychological
* Depression
* Anxiety
* Obsessive compulsive features
* Perfectionism
* Low self-esteem
* Absent sense of identity
Developmental
* Adverse life events and difficulties
* Dietary/feeding problems in early life
* Parents preoccupied with food
* Psychosexual immaturity
Sociocultural
* Substance abuse
* Negative body images due to media exposure
* Image-aware activities
* Past teasing or criticism for fatness
* Asexuality
Presentation of anorexia nervosa
Weight loss becomes over-valued idea
Marked distortion of body image
Males with anorexia tend to want high muscle mass rather than thinness
Ideal body shaped achieved by food refusal combined with over-exercising, induced vomiting, laxative abuse
Many have episodes of binge eating, followed by remorse, vomiting and concealment
Low self-worth
Comorbid depression/insomnia
Signs of anorexia nervosa
Most due to starvation and vomiting
Fatigue
Decreased cognition
Altered sleep cycle
Sensitivity to cold
Dizziness
Constipation
Fullness after eating
Psychosexual problems
Subfertility, Amenorrhoea
Decreased visuo-spatial ability
Decreased visual memory
Increased speed of information processing
Peripheral neuropathy
Caries
Dry skin
Brittle hair
Lanugo hair
Diagnostic criteria for anorexia nervosa
Weight <85% of predicted or BMI <17.5
Intense fear of gaining weight, becoming fat with persistent behaviour that interferes with weight gain
Feeling fat when thin
Endocrine change (Amenorrhoea, decreased libido)
Screening for anorexia nervosa
SCOFF questionnaire
* Sick (make yourself)
* Control (lost over eating)
* One stone lost in 3m
* Feel fat
* Food (dominates life)
Red flags for anorexia nervosa
BMI <13 or <2nd centile
Weight loss >1kg/wk
Temp <34.5
Hypotensive (BP <80/50)
Pulse <40
O2 sats <92%
Limbs blue and cold
Weakness in muscles = Unable to get up without using arms for leverage
Purpura
K+ <2.5
Na+ < 130
Phosphate <0.5
Long QT, flat T waves on ECG
Management of anorexia nervosa
Aim to restore nutritional balance
* Weight gain 0.5-1kg/wk
* 3500-7000 extra calories/wk
* Final BMI 20-25
Treat complications of starvation
Explore comorbidity
Involve family/carers (Family therapy = 1st line in children)
Address factors maintaining illness
Eating disorder CBT
Maudsley anorexia nervosa treatment for adults (MANTRA)
Specialist supportive clinical management (SSCM)
Complications of anorexia nervosa
Re-feeding syndrome
Cardiac
Amenorrhoea
Osteopenia
What is bulimia nervosa
Recurrent episodes of binge eating characterised by controlled overeating
Epidemiology of bulimia nervosa
F>M
Increased prevalence in developed countries
Young, Asian women increased risk
Risk factors for bulimia nervosa
Homosexuality/bisexuality in males
Urbanisation
Premorbid obesity
Female relatives of anorexics
Genetic contribution 54-83%
Presentation of bulimia nervosa
Preoccupation with control of body weight
Regular use of mechanisms to overcome fattening effects of binges (starvation, vomit-induction, laxatives, overexercise)
Fatigue
Lethargy
Feeling bloated
Constipation
Abdominal pain
Oesophagitis
Gastric dilation with risk of gastric rupture
Heart conduction abnormalities
Cardiomyopathy (if laxative use)
Tetany
Occasional swelling of hands and feet
Irregular menstruation
Erosion of dental enamel
Enlarged parotid glands
Calluses on back of hands (Russell’s sign) = from tooth marks during induction of vomiting
Oedema = use of laxatives and diuretics
Metabolic acidosis (if laxative use)
Diagnostic criteria for bulimia nervosa
Recurrent episodes of binge eating and feeling loss of control
Recurrent compensatory behaviour to prevent weight gain
Episodes occur at least once a week for 3m
Self-evaluation is influenced by body weight or shape
Disturbance does not occur exclusively during episodes of anorexia nervosa
Management of bulimia nervosa
Mild symptoms
* Support
* Self-help books
* Food diary
Referral to EDU if
* No response
* Moderate/severe symptoms
Refer to medical unit if medical complications
Antidepressants
* Decrease binges and purging
* First line = SSRIs (Fluoxetine)
CBT
Children = family therapy
What is refeeding syndrome
Metabolic abnormalities due to rapid initiation of food after >10 days of undernutrition
Presentation of refeeding syndrome
Rhabdomyolysis
Resp/cardiac failure
Low BP
Arrhythmias
Seizures
High risk of refeeding syndrome if
BMI <16
Unintentional weight loss >15% over 3-6m
Little nutritional intake >10 days
Hypokalaemia, hypophosphatemia or hypomagnesaemia prior to feeding
Hx of alcohol abuse, drug therapy including insulin, chemotherapy, diuretics, antacids
Management of refeeding syndrome
Slow refeeding
Thiamine and multivitamins
Monitor phosphate, potassium, glucose and magnesium levels
Complications of refeeding syndrome
Hypomagnesaemia = torsades de pointes
Abnormal fluid balance
Death
What is depression
Chronic feelings of low mood, low energy and loss of interest
Causes of depression
Biological
* Genetic susceptibility
* Decreased monoamine
* Structural brain change ventricular enlargement and raised sucal prominence
Psychological
* Personality traits neuroticism
* Low self-esteem
* Childhood experiences
Social
* Disruption due to life events
* Stress associated with poor social environment, social isolation
* Social drift to lower social class
Diagnosis of depression
Symptoms present every or nearly every day without significant changes throughout day for over 2 weeks and represent change from normal personality without alcohol/drugs, medical disorders or bereavement
2 Core symptoms
* Low mood
* Loss of interest or pleasure (Anhedonia)
* Loss of energy
2 or more typical symptoms
* Change in appetite (marked with weight loss without dieting)
* Change in sleep = initial insomnia or early waking
* Psychomotor retardation or agitation
* Change in libido
* Reduced ability to concentrate
* Loss of confidence
* Feelings of worthlessness, inappropriate guilt, self-reproach, hopelessness
* Recurrent thoughts of death, suicide ideation or suicide attempts
* Diurnal mood variation
Severity of depession
ICD-10
Mild = 4 symptoms
Moderate = 5-6 symptoms + functioning affected
Severe = 7+ symptoms + suicidal + loss of functioning
Severe with psychotic Sx = Nihilistic, guilty delusions, derogatory voices
Investigations for depression
PHQ9 0-27
Management of mild depression
- Low-intensity psychological interventions
- Sleep hygiene
- Anxiety management (mindfulness)
- Problem-solving techniques
- Computerised CBT
- Structured group-based physical activity
Management of moderate depression
- SSRI
- CBT or interpersonal therapy
Management of severe depression
- Rapid specialist mental health assessment
- Inpatient admission
- ECT
Antidepressants for depression
1st line = fluoxetine, citalopram, sertraline
2nd line = different of first line
3rd line = mirtazapine, venlafaxine
4th line = try any other = lithium, tricyclics, monoamine oxidase inhibitors, serotonin agonist and reuptake inhibitor
Epidemiology of suicide
Most common cause of death in men <35
M > F
Elderly
Widow > divorced > single > married
Unemployed and retired
Seasonal variation = higher in spring, summer
Risk factors for suicide
Bipolar disorder
Depression
Borderline personality disorder
Anorexia
Substance abuse
Past self-harm
Past suicide attempts
Assessment of suicide risk
Circumstances of act
* What happened that day?
* How they feel about it?
* Feeling and events leading up
Background of act
* How things over last few months?
* Previous attempts
* Plans in place
Relevant family and personal history
Intention lying behind act
* Present feelings and intentions
* Try again?
* Wish it had been successful?
SAD persons score
Sex: male
Age: <19, >45
Depression
Previous suicide attempt
Ethanol (or other substance abuse)
Rational thinking loss (psychosis, psychotic depression)
Single/separated
Organised
No social support
Sickness (chronic illness)
Prevention of suicide
- Promote access to help
- Limit access to lethal means
- Shift position from unstable to stable
- Social support
What is self harm
Self-poisoning or injury, irrespective of apparent purpose of act
Expression of personal distress not an illness
Methods of self harm
Overdose
Laceration
Reasons for self harm
Communicating a message
Gaining power by escalating conflict often after argument with partner
Emotional immaturity
Inability to cope with stress
Weak religious ties
Availability of drugs
Offers release from psychological pain
Risk factors for self harm
Witness deliberate self-harm
* FHx of DSH
* Learned behaviour from friends/ celebrities
* Exacerbated by social media
Biological
* Reduced endorphin response to emotional arousal (traumatic brain damage)
* Abnormalities in serotonin release
Developmental
* Poor early care
* Physical, Emotional, Sexual abuse
* Parental separation
Peer relations
* Conflicts
* Bullying
* Poor interpersonal skills
Psychological
* Identity problems
* Low self-esteem
Antisocial behaviour
* Conduct disorder
* Impulsivity
* Substance misuse
Management of self harm
Prioritise treating physical effects of DSH
Psychiatric assessment
* Initial risk management (suicide risk, admission)
* On-going risks with subsequent DSH
* Relevant psychiatric, medical, social issues
Types of bipolar disorder
Bipolar I = mania and depression (sometimes only mania)
Bipolar II = more episodes of depression, only mild hypomania
Rapid cycling = episodes only last few hours or days
Cyclothymia = highs and lows milder and don’t meet criteria for bipolar
Causes of bipolar disorder
Medication
* Steroids
* Illicit substances (cocaine, amphetamines)
* Antidepressants
Physical
* Infection
* Stroke
* Neoplasm
* Epilepsy
* MS
* Metabolic disturbances (hyperthyroidism)
Presentation of a manic episode
(>1wk)
* Mood = irritability, euphoria, lability
* Grandiosity
* Distractibility/poor concentration
* Fight of ideas/racing thoughts
* Confusion
* Lack of insight
* Rapid speech
* Hyperactivity
* Decreased need for sleep
* Change in appetite
* Hypersexuality (increased libido/sexual disinhibition)
* Inflated self-esteem
* Reckless/ extreme risk-taking behaviour
* Extravagance (manic overspending)
* Social disinhibition
* Delusions
* Hallucinations
* Impairment severe enough to limit function
Presentation of hypomania
- No psychotic symptoms
- No impairment of daily functioning or need for inpatient treatment
- Sociability/overfamiliarity
- Lasts less than a week (4 days)
Management of bipolar disorder
Treatment of manic episode Stop antidepressant and start antipsychotic (olanzapine)
Risk assessment
Mood stabiliser for longer term control = lithium or valproate
Psychosocial interventions for bipolar disorder
Emotional consequences of cycling disorder with periods of acute illness, stigma, fear of recurrence
Psychoeducation
CBT
Support groups
Complications of bipolar disorder
Mood swings increase risk of suicide
* Previous suicide attempt
* FHx of suicide
* Early onset of bipolar disorder
* Extent of depressive symptoms
* Increasing bad affective signs
* Mixed affective states
* Rapid cycling
* Abuse of alcohol or drugs
Risk factors for substance misuse
Individual factors Age, Gender, Family
External factors Culture, Price, Availability, Advertising
Being a novelty seeker
Impulsive
Inherited vulnerability
Presentation of substance misuse
Acute intoxication Administration of psychoactive substances resulting in disturbances of level of consciousness, cognition, perception, affect, behaviour
Harmful use Pattern of psychoactive substance use causing damage to mental/physical health or social functioning
Dependence syndrome
* Strong desire or send of compulsion to take substance (craving)
* Difficulty in controlling substance use
* Physiological withdrawal state when reducing or ceasing substance use
* Tolerance = increased doses required to produce original effect
* Progressive neglect of alternative pleasures or interests
* Persisting use despite clear evidence of harmful consequences
Associations of substance misuse
Arrests for theft (to buy drugs)
Odd transient behaviour (visual hallucinations, elation, mania)
Unexplained nasal discharge (cocaine sniffing/ opiate withdrawal)
Withdrawal symptoms (red eyes, shaking)
Injection stigmata (marked veins, abscesses, hepatitis, HIV)
Repeated requests for analgesics, only opiates acceptable, sedatives
Management of substance misuse
Opiate detoxification
Methadone maintenance (transition to abstinence)
* Free (no crime)
* Safer (no injecting)
* Still an addiction
* Daily observed dosing
Naltrexone = opioid antagonist
Psychological support
* Counselling
* Motivational therapy
* Cognitive therapy
* Counsel on HIV and Hep C risk, needle exchange, safe sex
Relapse prevention of substance misuse
Barbiturate withdrawal may cause seizures (+-death) so admit as inpatient
Anti-craving drugs (unvalidated approach)
Opioid withdrawal presentation
Intoxication
* Drowsy
* Mood change
* Bradycardia
* HTN
* Pupil constriction
* Resp depression
* Decreased body temp
Withdrawal
* Muscle cramps
* Low mood
* Insomnia
* Agitation
* Diarrhoea
* Shivering
* Flu like Sx
Management of opioid withdrawal
IV naloxone = rapid onset and short
Opioid detoxification
Methadone
Buprenorphine
Needle exchange
Testing for HIV, Hep B and C
Complications of opioid misuse
Infection (sharing needles) = IE, septic arthritis, septicaemia, necrotising fascitis
VTE
Overdose = resp distress
Crime/prostitution
Risk factors for alcohol dependence
Male
Unemployment and stress
Peer pressure
Younger age of usage/mental illness
History of substance abuse
Genetics
Presentation of alcohol dependence
Increased tolerance to alcohol
Narrowing of drinking repertoire
Difficulty or failure of abstinence
Withdrawal = sweats, nausea, tremor
Priority to maintain alcohol intake
Often aware of compulsion to drink
Gradual deterioration in function
Alcohol dependence overtakes work, relationships, financial stability, health
Patient’s drinking habits excessive within their own social context
Screening for alcohol dependence
CAGE questionnaire
* Have you ever felt you should CUT down on your drinking?
* Have you ever become ANNOYED by criticisms of your drinking?
* Have you ever felt GUILTY about your drinking?
* Have you ever had a morning EYE opener to get rid of a hangover?
TWEAK questionnaire
* Tolerance (2)
* Worried (2)
* Eye opener (1)
* Amnesia (1)
* Cut down (1)
* >3 points indicates problem with alcohol
Management of alcohol dependence
Immediate management
* Water
* Vitamins (B1, B6, B12)
* Food (calories and protein)
* Benzo (Diazepam, chlordiazepoxide)
Treat co-existing depression
Refer to specialists
Self-help/group therapy
Disulfiram (drugs that produce nasty reaction if alcohol taken)
Naltrexone (reduce pleasure alcohol brings and cravings on withdrawal)
Acamprosate (improve abstinence rates by reducing cravings)
Complications of alcohol dependence
Liver = fatty liver, cirrhosis
CNS = Poor memory/cognition, Cortical/cerebellar atrophy, Retrobulbar neuropathy, Fits, Falls, Neuropathy
Gut = Vomiting and diarrhoea, Peptic ulcer, Erosions, Varices, Pancreatitis
Heart = Arrhythmias, Increased BP, Cardiomyopathy
Increased osteoporosis risk
Sperm = Decreased fertility, Decreased sperm motility
GI and breast cancer
Marrow = Decreased Hb, Increased MVC
Violent crime
Suicide
Stages of alcohol withdrawal
6-12 hrs – symptoms
12-24 hrs = hallucinations
24-48 hours = seizures
48-72 hours = delirium tremens
Presentation of alcohol withdrawal
Tachycardia
Hypotensive
Tremor
Fits/seizures (generalised tonic clonic) = seen at 36 hrs
Visual or tactile hallucinations
Diarrhoea and vomiting, nausea
Shaking
Sweaty
Anxiety
Insomnia/sleep disturbance
Mood disturbance
Management of alcohol withdrawal
Water
Vitamins = thiamine, IV pabrinex
Food
Chlordiazepoxide 5-7 days
Complex withdrawals may need admission to hospital
Presentation of delerium tremens
- Confusion state
- Hallucinations (tactile or visual)
- Vomiting
- Extreme paranoia
- Coarse tremor
- Delusions
- Fever
- Tachycardia
What is wernicke’s encephalopathy
Thiamine (B1) deficiency related to alcohol abuse
Causes of wenicke;s encephalopathy
Chronic alcohol consumption
Brain tumour
Malabsorption
Prolonged vomiting
Hyperemesis gravidarum
Chemotherapy
Presentation of wernicke’s encephalopathy
Triad = confusion, wide-based gait ataxia, ophthalmoplegia (nystagmus, conjugate gaze, bilateral lateral rectus palsies)
peripheral neuropathy
Clouding of consciousness
memory disturbance
hypotension
hypothermia
ptosis
Management of wernicke’s encephalopathy
MEDICAL EMERGENCY
High dose IV/IM thiamine over 1 wk
Oral supplementation until no longer at risk
Give before glucose if hypoglycaemic
What is Korsakoff’s syndrome
Hypothalamic damage and cerebral atrophy due to thiamine deficiency
Presentation of korsakoff’s syndrome
Anterograde amnesia = inability to acquire new memories
Confabulation
Retrograde amnesia
Lack of insight
Apathy
Management of Korsakoff’s syndrome
IV pabrinex + chlordiazepoxide
Classification of personality disorders
- Cluster A = odd or eccentric
- Cluster B = dramatic, emotional, erratic
- Cluster C = anxious and fearful
Paranoid personality disorder
- Suspicious, preoccupied with conspiratorial explanations, distrusts others, holds grudges
- Hypersensitivity and unforgiving attitude when insulted
- Unwarranted tendency to question loyalty of friends
- Reluctance to confide in others
- Preoccupation with conspirational beliefs and hidden meaning
- Unwarranted tendency to perceive attacks on character
Schizoid personality disorder
- Emotionally ‘cold’, lacks interests in others, rich fantasy world, excessive introspection
- Indifference to praise and criticism
- Preference for solitary activities
- Lack of interest in sexual interactions
- Lack of desire for companionship
- Few interests or friends other than family
Schizotypal personality disorder
- Ideas of reference
- Odd beliefs and magical thinking
- Unusual perceptual disturbances
- Paranoid ideation and suspiciousness
- Odd, eccentric behaviour
- Lack of close friends
- Inappropriate affect
- Odd speech without being incoherent
Antisocial personality disorder
- Aggressive, easily frustrated, callous lack of concern for others, irresponsible, impulsive, unable to maintain relationships, criminal activity, lack of guilt, conduct disorder
- Failure to conform to social norms
- Deception, repeatedly lying, conning others for personal profit or pleasure
- Impulsiveness or failure to plan ahead
- Irritability and aggressiveness
- Reckless disregard for safety of self or others
- Consistent irresponsibility
- Lack of remorse
Emotionnally unstable personality disorder
- Feeling of emptiness, unclear identity, intense and unstable relationships, unpredictable affect, threats or acts of self-harm, impulsivity, pseudohallucinations
- Inability to control anger or plan, unpredictable affect and behaviour
- Quasi psychotic thoughts
- Efforts to avoid real or imagined abandonment
Histrionic personality disorder
- Over-dramatise, self-centred, shallow affect, labile mood, seeks attention and excitement, manipulative behaviour,
- Inappropriate sexual seductiveness
- Need to be centre of attention
- Rapidly shifting and shallow expression of emotions
- Suggestibility
- Physical appearance used to attention seeking purposes
- Impressionistic speech lacking detail
- Relationships considered more intimate than they are
Narcissistic personality disorder
- High self-importance, lacks empathy, grandiose, needs admiration
- Preoccupation with fantasies of unlimited success, power, beauty
- Sense of entitlement
- takes advantage of others to achieve own needs
- Chronic envy
- Arrogant and haughty attitude
Obsessive-compulsive personality disorder
- Worries and doubts, orderliness and control, perfectionism, sensitive to criticism, rigidity, indecisiveness, pedantry, judgemental
- Stingy spending style towards self and others
- Meticulous, scrupulous, rigid about etiquettes of morality, ethics or values
Anxious avoidant personality disorder
- Extremely anxious and tense, self-conscious, insecure, fearful of negative evaluation by others, timid, desires to be liked
- Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism or rejection
- Unwillingness to be involved unless certain of being liked
- Preoccupied with ideas of being criticised or rejected in social situations
Dependent personality disorder
- Passive, clingy, submissive, excess need for care, feels helpless when not in relationship, feels hopeless and incompetent
- Difficulty making everyday decisions without excessive reassurance from others
- Need for others to assume responsibility for major areas of life
- Difficulty in expressing disagreement with others due to fears of losing support
- Lack of initiative
- Unrealistic fears of being left to care for themselves
- Urgent search for another relationship as source of care and support when close relationship ends
Management of EUPD
No evidence for medication
Psychological therapies
* Dialectical behaviour therapy = self-soothing, distraction techniques, radical acceptance, wise mind vs emotional mind
* Therapeutic communities
* Cognitive analytic therapy
* Mentalisation based therapy
Risk factors for post-partum depression
History of postpartum depression
Unipolar/bipolar depression
Unplanned pregnancy
Lack of support
Marital problems
Social circumstances
Sleep deprivation
Hormonal changes
Screening for post-partum depression
Edinburgh postnatal depression scale
- Low threashold for referring to MDT in mother and baby units
Management of post-partum depression
Involve partners/ other parent of child
Short-term antidepressants Stop breastfeeding as antidepressants can end up in breast milk
CBT
ECT (if severe, stop eating/drinking, suicidal)
Complications of post-partum depression
Impairs infants cognitive and social skills
Suicide is leading cause of maternal death postpartum
Risk factors for post-partum psychosis
Previous postpartum psychosis
Single parenthood
Reduced social support
Previous mental illness
Presentation of post-partum psychosis
Psychotic episode usually peaks 2w post-partum
Prominent affective symptoms (depression or mania)
Rapidly fluctuating symptoms
Mood lability
Insomnia
Disorientation
Prevention of post-partum psychosis
High-risk patients need individualised care plan with antenatal specialist perinatal mental health input
Early detection essential
Management of post-partum psychosis
Medication to target affective symptoms
* Mood stabiliser
* Antidepressant
* ECT
Medication to target psychotic symptoms
* SGA
* Long-acting benzodiazepine
Therapy
Reassurance
Emotional support
Refer to local mental health services and health visitors at discharge
Causes of lithium toxicity
Dehydration
Renal failure
Drugs
* Diuretics (thiazides)
* ACE inhibitors/angiotensin II receptor blockers
* NSAIDs
* Metronidazole
Presentation of lithium toxicity
Coarse tremor
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma
Management of lithium toxicity
Mild-moderate Volume resuscitation with normal saline
Severe Haemodialysis
What is neuroleptic malignant syndrome
Neurotoxicity and muscle damage from antipsychotics
Presentation of neuroleptic malignant syndrome
Occurs within hrs to days of starting antipsychotic
Fever
Muscle rigidity
Autonomic dysfunction
* Hypertension
* Tachycardia
* Tachypnoea
Agitated delirium with confusion
Decreased reflexes
Investigations in NMS
Raised creatine kinase
AKI (secondary to rhabdomyolysis)
Leucocytosis
Management of NMS
Stop antipsychotic
Transfer to medical ward
IV fluids (prevent renal failure)
Dantrolene (benzos)
Bromocriptine, dopamine agonist
Causes of serotonin syndrome
SSRIs and SNRIs
MAO-I
Ecstasy
Amphetamines
Drug interactions with
* St Johns Wort
* Triptans
* TCAs
* Linezolid
Presentation of serotonin syndrome
Neuromuscular abnormalities = myoclonus, tremor, hyperreflexia, ataxia, incoordination, seizures
Altered mental state = agitation, confusion, euphoria, hallucinations, LOC
Autonomic dysfunction = tachycardia, HTN, fever, diaphoresis, arrhythmias, tachypnoea, sweating, shivering, diarrhoea
Rapidly onsets after increased dose of serotonin boosting drug
Management of serotonin syndrome
Benzos
S blocking drug = cyproheptadine (5-HT2 antagonst)
Stop SSRI/SNRI
Monitor
types of psychoses
- Schizophrenia
- Delusional disorder
- Schizotypal disorder
- Depressive psychosis
- Manic psychosis
- Organic psychosis = head injury, drug induced
Positive psychotic symptoms
- Thought insertion, thought broadcasting, thought withdrawal, repeating thoughts, thought alienation
- Persistent delusions (culturally inappropriate and completely impossible)
- Persistent hallucinations
- Passivity phenomena
- Disturbance in mood = Sudden excitement, posturing, waxy flexibility, negativism, echopraxia
Negative psychotic symptoms
- Reduced speech
- Loss of motivation
- Self-neglect
- Social withdrawal
- Apathy, blunting or incongruity of affect
- Poverty of thought
- Poor non-verbal communication
- Clear deterioration in functioning
- Lack of insight
Psychotic terms
Knights move = no links
Flight of ideas = flight from one place to another
Circumstantiality = comes back round
Perseverance = same point
Tangentiality = off on tangent, never returns
Echolalia = repeat same word/phrase
Clanging/clang associations
Word salad
Othello = delusional jealousy
Fregoli = stranger is family in disguise
Capgras = family member has evil twin
Cotard = nihilistic, dead body
Charles bonnet = hallucinations due to sight loss
Management of psychoses
Oral antipsychotic
Psychological interventions = CBT, family therapy
What is schizophrenia
Common chronic relapsing condition with psychotic symptoms, disorganisation symptoms, negative symptoms and sometimes cognitive impairment
Risk factors for schizophrenia
Early use of cannabis
Genetic susceptibility (Family history)
Brought up in cities
Migrant groups (Asians, African-Caribbeans)
Presentation of schizoprenia
First rank symptoms (>1)
* Thought alienation
* Passivity phenomena
* 3rd person auditory hallucinations
* Delusional perception
Second rank symptoms (2+)
* Delusions
* 2nd person auditory hallucinations
* Hallucinations in any other modality
* Thought disorder
* Catatonic behaviour
* Negative symptoms
Prodromal symptoms in schizoprenia
- Precedes most first episodes of psychosis by up to 18m
- Gradual deterioration in functioning
- Transient and/or attenuated psychotic symptoms
- Odd thoughts, beliefs and behaviours
- Concentration problems
- Altered affect
- Social withdrawal
- Reduced interest in daily activities
Management of schizoprenia
Anti-psychotics (started ASAP)
Psychosocial interventions
* CBT
* Treating substance misuse
* Addressing housing, benefits, social skills training
* Supported employment
Support for family
* Family therapy
* Support groups
Referral to Early Intervention Service
Schizoprenia prognosis better if
- Sudden onset
- No negative symptoms
- Supportive home
- Female (better social integration)
- Later onset of illness
- No CNS ventricular enlargement
- No family history
Schizoprenia prognosis worse if
- Strong family history
- Gradual onset
- Low IQ
- Prodromal phase of social withdrawal
- Lack of obvious precipitant
Somatisation disorder
- Multiple physical symptoms present for at least 2 years
- Patient refuses to accept reassurance or negative test results
Illness anxiety disorder
- Persistent belief in presence of underlying serious disease
- Patient refuses to accept reassurance or negative test results
Conversion disorder
- Loss of motor or sensory function
- Patient doesn’t consciously feign symptoms or seek material gain
- individual experiences neurological or physical symptoms that cannot be explained by neurological or medical causes
Dissociative disorder
- Separating off certain memories from normal consciousness
- Psychiatric symptoms = amnesia, fugue, stupor
indications for ECT
o Prolonged or severe manic episode
o Severe depression
o Catatonia
Cautions for ECT
o Recent subdural/subarachnoid haemorrhage bleed
o Stroke
o MI
o Arrhythmia
o CNS vascular anomalies
Side effects of ECT
o Memory loss
o Short term retrograde amnesia
o Confusion
o Headaches
o Clumsiness
o Common anaesthetic S/E
Withdrawal symptoms of benzos
o Insomnia
o Irritability
o Anxiety
o Tremor
o Loss of appetite
o Tinnitus
o Perspiration
o Perceptual disturbances
o Seizures
Side effects of SSRIs
o headache, nausea, insomnia
o Indigestion, stomach aches, diarrhoea, constipation
o Loss of appetite
o Dizziness
o Loss of libido
o Erectile dysfunction
o increased risk of GI bleeding = PPI if taking NSAID
o Hyponatraemia
o Increased anxiety and agitation
o Fluoxetine and paroxetine higher risk of drug interactions
o Citalopram QT interval prolongation
Contraindications to SSRIs
o Do not use with warfarin/heparin = switch to mirtazapine
o Avoid triptans
o In first trimester = congenital heart defects (particularly paroxetine)
o In third trimester = persistant pulmonary hypertension of newborn
Side effects of TCA
o tachycardia,
o dry mouth
o blurred vision
o Constipation
o Problems passing urine
o anticholinergic/muscarinic effects,
o postural hypotension
o sedation
o weight gain
o Excessive sweating (especially at night)
o Arrhythmias, palpitations, tachycardia
side effects of first generation antipsychotics
o Extrapyramidal: parkinsonism, acute dystonia (sustained muscle contraction), akathisia (severe restlessness), tardive dyskinesia (movements)
o Hyperprolactinaemia
o Increased risk of stroke and VTE in elderly
o Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
o Sedation and weight gain
o Neuroleptic malignant syndrome
o Reduced seizure threshold
o Prolonged QT (haloperidol)
o Olucogyric crisis
Side effects of second generation antipsychotics
o Metabolic effects
o Weight gain
o Hyperprolactinaemia
o Hypercholesterolaemia
Side effects of clozapine
agranylocytosis, constipation, hypersalivation, reduced seizure threshold, sedating, postural hypotension, toxic megacolon, cardiomyopathy
