Psychiatry Flashcards
What is ADHD?
It is characterised by 3 main symptoms of inattention, hyperactivity and impulsiveness
How is it defined by the DSM-IV and ICD-10 differently?
- DSM-IV recognises 3 subtypes of ADD, combined when all 3 features are present and just a hyperactive subtype
- ICD-10 definition is that symptoms should be present across time and situations for at least 6 months and starting before the age of 7
1% with ICD criteria and 5% with DSM-IV. It is 4 times more common in males
What are the risk factors for ADHD?
- 80% are genetically inherited
- Low birth weight
- Drug, alcohol or tobacco use pregnancy
- Head injury
- Genetic/metabolic disorders
What are the clinical features of ADHD?
Inattention: Careless with detail, fails to sustain attention, appears not to listen, fails to finish tasks, poor self-organization, loses things,
forgetful, easily distracted, and avoids tasks requiring sustained attention.
- Hyperactivity Most evident in structured situations, fidgets with hands or feet, leaves seat in class, runs/climbs about, cannot play quietly, ‘always on the go’.
- Impulsiveness Talks excessively, blurts out answers, cannot await turn,
interrupts others, intrudes on others.
What are some complications associated with ADHD?
Short term:
- Sleep
- Low self-esteem
- Family and peer relationship problems
Long term:
- Increased criminal activity
- Antisocial personality disorder
- Problems with getting jobs
What is ADHD assesed?
- Interview with family and child
- Observe the child in variety of environments
- Collateral information from school
- Rating scales
- Physical examination
What are the rating scales for ADHD?
- Strengths and difficulties questionnaire
- Connor’s rating scale
What are the medications used to treat ADHD?
- Methylphenidate: a CNS stimulant
- Atomoxetine
- Dexamphetamine:
What are some side effects of ADHD medication?
Headache, insomnia, loss of appetite, stomach ache, dry mouth, nausea
Can Can stunt growth
Need to Monitor weight, height and BP
Methylphenidate is Not recommended to take during pregnancy
What are the triad of symptoms that characterise autism?
- Abnormal reciprocal social interaction
- Communication and language impairment
- Repetitive repertoire of interests and activities
What is the prevalence of autism?
5-10 per 1000 individuals
Ratio of 3:1 boys to girls
What are the clinical features of autism?
- Abnormal social interactions: impaired non-verbal behaviour, poor eye contact, failure to develop peer relationships
- Abnormal communication or play: delay or lack of spoken language, difficulty in initiating or sustaining conversation
- Restricted interests or activities: Encompassing preoccupations and interests, adherence to non-functional routines or rituals, resistance to change
What are some neurological features of autism?
- Seizures
- Motor tics
- Increase head circumference
- Abnormal gaze monitoring
- Increased ambidexterity
What are some physiological features of autism?
- Intense sensory responsiveness
- Absence of typical response to pain or injury
- Abnormal temperature regulation
What are the rating scales for autism?
- Autism behaviour checklist
- Child autism rating scales
- Autism diagnosis observation schedule
What is bipolar disorder?
- Periods of depression and mania
What are the risk factors for bipolar disorder?
Genetic links and environmental stressors/triggers
- Hypothalamic-pituitary-adrenal axis abnormalities which are consistent with reduced HPA axis feedback
- Prolonged psychosocial stressors during childhood, such as neglect or abuse, are associated with HPA axis dysfunction in later life
- People with a history of sexual abuse or physical abuse appear to be more at risk and have a worse prognosis
What is a key question to ask someone presenting with depression?
Whether they have had manic or hypomanic episodes because treating bipolar as depression will cause the patient to become high
What is needed for a diagnosis of bipolar?
- Single episode of mania= Manic episode
- Two manic episodes= Bipolar disorder
What is the definition of a manic episode?
A distinct period lasting at least one week with 3 or more characteristic symptoms of mania:
- Elevated mood
- Increased energy
- Increased self-esteem
- Reduced attention
- Grandiose, overconfident, marked social/sexual disinhibited, reckless
- Severe impact on social functioning / poor or absent insight
- Could also have features of psychosis
What is hypomania?
Elated, overactive, social/sexual disinhibition, overspending, poor sleep
Continues to function
Partial insight retained
NO psychotic symptoms
Tend to last about 4 days
What is the management of acute mania?
- Atypical antipsychotics (Olanzapine/quetiapine)
- Semi-sodium valproate
What is used for long term mood stabilisation?
- Lithium
- Valproate
- Carbamazepine
What are the different types of bipolar?
Bipolar 1 - mania & depression, sometimes more episodes of mania
Bipolar 2 - more episodes of depression and only mild hypomania (easy to miss, always ask Sx of mania in person presenting with depression)
What is cyclothymia?
Cyclothymia - chronic mood fluctuations over 2+ yrs, episodes of depression and hypomania (not mania). Rapid cycling, episodes only lasting few days
What are some differentials that you need to rule out in bipolar disorder?
Substance abuse (amphetamines, cocaine)
Endocrine disease - Cushing’s, steroid-induced psychosis
Schizophrenia
Schizoaffective disorder - Dx when affective and first rank schizophrenic Sx equally prominent
Personality disorders - emotionally unstable, histrionic
ADHD in younger people
What is the treatment of bipolar, for a depressive episode?
– For depression –> Treat with antipsychotics alone or in combination with SSRI’s
– 1st line is Olanzapine, Lamotrigine or Quetiapine and Fluoxetine
– Do not just prescribe SSRIs by themselves as they can precipitate mania
If a patient is taking an antidepressant at the onset of an acute manic episode, the antidepressant should be stopped.
What are some of the side effects of lithium?
L- Leukocytosis
I- Insipidus diabetes (nephrogenic)
T- tremors (if coarse think toxicity)
H- Hydration ( easily dehydrates, need to drink lots
I- increased GI motility
U- Underactive thyroid
M- metallic taste (warning of toxicity), mums beware- teratogenic
lithium and diuretics= dehydration
Lithium + NSAIDs= kidney damage
What are some risk factors for depression?
Prior depression
Family history
Female
Abuse
Drug and alcohol use
Low socioeconomic status
Recent bereavement, stress or medical illness, traumatic life event
Co-existing medical conditions (chronic disease)
What are the 3 key symptoms of depression?
Low mood
Loss of energy
Anhedonia (loss of enjoyment of formerly pleasurable activities)
What are some things you may find on consultation/examination/investigations for depression?
Carry out mental state examination
- Appearance may be normal, or evidence of self beglect. substnace abuse, tearfulllness, anxious, fidegty
Speach may be monotonic and slow - patient may appear distracted
Psychotic features - eg auditory hallucinations, loss of insight
Baseline tests for FBC and TFT may be useful for ruling out anaemia and hypothyroidism, that can lead to depression
What is the name of the questionnaire used in depression?
The Patient Health Questionnaire-9 (scored out of 27) is used to grade depression
– It asks patients to report over the last 2 weeks how often they have been experiencing symptoms
– Made of 9 items which is scored from 0-3
What are the scores for the PHQ-9?
– Mild = 5-9 – Moderate = 10-14 – Moderate/Severe = 15-19 – Severe = >19
What is the treatment for moderate/severe depression?
Moderate/severe depression
* Antidepressants (SSRIs, TCAs) - continued for 6+ mths after Sx stop
* Combination therapy e.g. meds + talking therapy
SSRI - Selective serotonin reuptake inhibitors eg Sertraline, paroxetine, fluoxetine, citalopram
Fluoxetine 1L in children
TCAs (Tricyclic antidepressants):
Imipramine, amitriptyline
SNRIs (Serotonin-noradrenaline reuptake inhibitors):
Venlafaxine, duloxetine, Mirtazapine
What is some treatment for very severe depression
Resistant depression Tx w/ combo of antidepressants +
Lithium
Atypical antipsychotic
Another antidepressant
ECT very effective in severe cases (Electroconvulsive Therapy)
What are some conditions you would want to which have similar symptoms to GAD?
Depression and OCD
Hyperthyroidism
Pheochromocytoma
Lung disease- excessive salbutamol use
CHF medication
Hypoglycaemia
Do bloods and BP
What are some risk factors/causes of developing GAD?
Family Hx anxiety
Physical/emotional stress
Financial, bereavement etc
Hx physical/sexual/emotional trauma (in childhood)
Excessively pushy parents in childhood
Other anxiety disorder - coexisting depression
Chronic physical health condition
Worries about physical health
Female 2:1 Male
Environmental triggers/contributors: family relationships, friendships, bullies, school pressures, alcohol and drug use e.g. benzodiazepines
What is the neuropathology of GAD?
Low levels of GABA, contribute to anxiety. The frontal cortex and amygdala undergo structural remodelling due to maternal separation and isolation
- Heightened amygdala activation occurs in response to disorder-relevant stimuli in post-traumatic stress disorder, social phobia and specific phobia
Basically overfiring/activation of the amygdala
What is the non pharmalogical management of GAD?
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
CBT
What is the pharmacological management of GAD?
SSRI (sertraline is first-line SSRI)
– Be careful in young people as the SSRI increases anxiety initially and can lead to suicidal thoughts
Pre-gabalin
– If acutely anxious –> Benzodiazepine (but not for > 4 weeks)
Beta blockers e.g. bisoprolol for physical Sx
What is meant by obsessions and give some examples?
Obsessions= unwanted/uncontrolled thoughts and intrusive images
Aggressive impulses
contamination e.g. – becoming contaminated by shaking hands with another person
need for order e.g. – intense distress when objects are disordered or asymmetric
religious e.g. – blasphemous thoughts, concerns about unknowingly sinning
repeated doubts e.g. – wonder if a door was left unlock
What is meant by compulsions in OCD?
Repetitive actions someone feels like they must do, generates anxiety if this action is not done
checking e .g. – repeatedly checking locks, alarms, appliances
cleaning e.g. – hand washing
hoarding e.g. – saving trash or unnecessary items
What are some risk factors for OCD?
Genetic predisposition (twins, especially monozygotic)
Developmental factors
Emotional/physical/sexual abuse
Neglect
Social isolation
Teasing, bullying
Parental over protection
Psychological factors
Over-inflated sense of responsibility
Intolerance of uncertainty
Belief in controllability of intrusive
Stressors
Pregnancy
Postnatal period
Rarely
In adults: neurological conditions e.g. brain tumour, Huntington’s chorea, frontotemporal dementia, complication of brain injury to frontal lobe/basal skull
What is the pharmacological treatment of OCD?
or drug therapy (SSRI, e.g. fluoxetine 20–40mg od)
* Severe functional impairment Offer psychological therapy + drug treatment.
If inadequate response at 12wk, offer a different SSRI or
clomipramine (a TCA that also acts as a serotonin reuptake inhibtior).
Refer if symptoms persist
What are the 3 types of phobias?
Simple phobias: inappropriate anxiety
Social phobias: intense/persistent fear of being scrutinized or negatively evaluated by others leads to fear and avoidance of social situations
Agoraphobia: fear of fainting and/or loss of control are experienced in crowds away from home
What is the treatment for phobias?
For simple phobias - Treatment is only needed if symptoms are frequent, intrusive, or prevent necessary activities. Exposure therapy is effective.
For social and agoraphobia -
drug therapy SSRIs, and TCAs eg Clomipramine
Psychological therapies CBT (cognitive restructuring) +/- exposure
What is PTSD?
Develop (immediately/delayed) post exposure to stressful event/threatening, catastrophic situation
What are the common causes of PTSD?
Serious accident
Witness of violence: school, domestic, torture, terrorist attack and rape
Combat exposure
Natural disaster
Sudden death of a loved one
What are the clinical features of PTSD?
Symptoms: must be present for at least a month
- Persistent intrusive thoughts and re-experiencing
- Autonomic hyperarousal: overaction to a stimulus such as being startled, hypervigilance or insomnia
- Emotional detachment- feeling detached from people and lacking the ability to experience feelings
What are some non-pharmalogical managements for PTSD?
CBT- education about nature of PTSD and management of symptoms
Eye movement desensitisation and reprocessing (EDMR): using voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts
What are the pharmalogical treatments of PTSD?
SSRIs
It may be helpful to target specific symptoms such as sleep being improved with mirtazapine
For Hyperarousal/anxiety: consider BDZs clonazepam and propranolol
- Intrusive thoughts/hostility/impulsiveness: some evidence for use of carbamazepine, valproate, or lithium.
- Psychotic symptoms/severe aggression or agitation: may warrant use of an antipsychotic (some evidence for olanzapine, risperidone etc)
What are some primary causes of insomnia?
Fear/anxiety about falling asleep
Change of environment
Inadequate sleep hygiene
Idiopathic insomnia
What are some secondary causes of insomnia?
Sleep related breathing disorder e.g. sleep apnoea
Circadian rhythm disorders
Shift work
REM behavioural disorder e.g. Lewy body dementia, PD
Psychiatric disorders - depression (early morning waking), anxiety (early/middle insomnia)
Drugs/alcohol - steroids, antidepressants, stimulants
What are some nonpharmacological management options for insomnia?
Encourage good sleep hygiene
Sleep restriction
What are some pharmalogical management options for insomnia?
Medication (once good sleep hygiene proved unsuccessful)
Z drugs: Zopiclone, Zolpidem, Zaleplon
Sedating antidepressants: mirtazapine, amitriptyline
Melatonin
What is paraphrenia?
Psychotic illness characterised by delusions and hallucinations, without changes in affect
It’s the most common form of psychosis in old age
What are some things you might see in paraphrenia?
*no evidence of dementia w/ later onset cases - no memory problems
Delusions, hallucinations - often about neighbours
Paranoid - often re. neighbours spying, taking things
can also be misidentification, hypochondraical, religious
Partition delusion - believe people/objects can go through walls
Less -ve Sx (blunting/apathy) and formal thought disorder compared to early onset
What is the treatment steps in paraphrenia?
Relieve isolation and sensory deficits.
Low-dose atypical antipsychotics preferred as elderly are very sensitive
to side-effects, but non-compliance secondary to lack of insight is often
an issue.
What is seen in cognitive impairment?
Minor problems with cognition- mental abilities: memory, thinking
Not severe enough to interfere with everyday life
Mild cognitive impairment= pre-dementia
What are some causes of cognitive decline?
Depression
Sleep apnoea and other sleep disorders
Physical illness
Vitamin and thyroid deficiencies
Medications
Drugs and alcohol
What are some causes of delirium?
- Infection- UTI, pneumonia
- Toxicity- substance misuse, intoxication, withdrawal
- Vascular
- Epileptic
- Metabolic - hyper/othyroidism, hyper/oglycaemia, hypoxia, hypercortisolaemia
- Medications - anticholinergics, Parkinson’s meds, benzodiazepines, drug accumulation, polypharmacy, post surgery, steroids
- Nutritional/dehydration - thiamine B1 deficiency, B12 deficiency, folate deficiency
What health conditions can cause delirium and can be differentiated from schizophrenia?
Bipolar disorder – often may present with symptoms of schizophrenia
Psychotic Depression
Alcohol hallucinations, due to withdrawal
Drugs - especially Cannabis, Cocaine, LSD, magic Mushrooms (Psilocybin)
Dopamine Agonists, like Levo Dopa in Parkinsons
Encephalitis
Epilepsy’s
Dementia
What are the 4 main things seen in schizophrenia?
A form of psychosis is characterised by distortion to thinking and perception and inappropriate or blunted affect
See hallucinations and delusions, thought and speech disorders and negative symptoms
What are hallucinations?
Perceptions in the absence of stimuli. Most commonly auditory but may be visual or affect smell, taste or tactile senses
What are delusions?
A fixed or false belief no in keeping with cultural and educational background
What is thought to cause schizophrenia?
Increased size of ventricles and reduced whole brain volume
There is an increased activity of dopamine in the mesolimbic region
What are some risk factors for developing schizophrenia?
- Genetic link
- Affected brain development in early ;life
- Smoking cannabis in adolescence
- Severe childhood bullying/physical abuse
- Adverse life events
- Social isolation
- Typical age onset 20-30s
What are the positive (psychotic) symptoms of schizophrenia ?
- Delusions
- Hallucinations
- Disorganised speech
- Disorganised behaviour
- Cationic behaviour
They are all things that add to someone’s character
What are the negative symptoms of schizophrenia (removal of normal processes)?
- Less emotions
- Loss of interest
- Poverty/decreased speech
- Less motivation
What are the cognitive symptoms of schizophernia?
- Decline in cognition
- Decline in memory
- Bad learning
How can schizophrenia be diagnosed?
At least ** 1 first rank symptom** or 2 second rank symptoms
FOR AT LEAST A MONTH
What are the first rank symptoms of schizophrenia?
- Delusional perceptions- Do you ever see or hear things that you feel are giving a message that is specific to you
- Persecutory of delusions: do you have any enemies/ do you feel anyone is out to get to you
- Thought insertion/withdrawal/broadcast- are your thoughts being interfered with or controlled
- Passitivity: can another person control what you do/feel directly
- Third-person auditory hallucinations: do you hear people talking whom others can’t hear
What are the second rank symptoms of schizophrenia?
Formal thought disorder (words come out wrong, thoughts muddled)
Catatonic behaviour - excitement, posturing or waxy flexibility, negativism, mutism and stupor.
Negative symptoms - marked apathy, paucity of speech, and blunting or incongruity of emotional responses (it must be clear that these are not due to depression or to neuroleptic medication).
Any other type of hallucination, not third person auditory
What are some tests you would do on someone with suspected schizophrenia?
Bloods for organic causes of psychosis
FBC
LFT
TFT
Syphilis screen
Bloodborne virus screen
Autoimmune causes -anti–NMDA receptor antibodies for autoimmune encephalitis,ANA, anti-DS DNA for Lupus
Collateral Hx from someone else
Blood, hair or urinary screens may be used for illicit drugs and alcohol, particularly in those presenting with acute psychosis of unknown cause.
MSE, risk assessment
What are some atypical anti psychotics and how do they work?
They work by blocking dopamine and serotonin
Quetiapine
Olanzapine
Risperidone
Clozapine
Aripiprazole
They are first lone other than clozapine
What are some typical anti-psychotics and how do they work?
They work by dopamine blockade of D2 receptors:
- Haloperidol
- Chlorpromazine
When should you trial clozapine as an antipsychotic?
If 2 others have not been effective.
Why is clozapine not used as a first-line treatment?
It requires close monitoring as it has a tendency to cause aplastic anaemia
CPMS – Clozepine monitoring system. A national service in the UK, that gives advice on the drug dosage to use, depeninding on the blood test results you send to them. Compulsory for anyone on clozepine. Only consultant psychiatrists can prescribe clozapine
Check for agranulocytosis
What checks need to be done regularly for people on antipsychotics?
ECG- as QTC prolongation can occur
Glucose and lipids- antipsychotics can lead to diabetes and metabolic syndrome
If on CLOZAPINE: regular FBCs to check for AGRANULOCYTOSIS
What are some other side effects of antipsychotics?
- Urinary retention
- Blurred vision
- Dry mouth
- Weight gain
- Hyperprolactinaemia (due to dopamine blockade and dopamine down regulates prolactin)
What are the extra-pyramidal side effects of antipsychotics?
Muscle spasm, eyes rolling back
Parkinsonism
Akathisia- “inner restlessness, pacing and agitated, often intolerable. They literally can’t stop moving e.g. shaking legs, touching table
Massive RF for suicide in young males with schizophrenia
Tardive dyskinesia (months to years)
Grimacing, tounge protrusion, lipsmacking
Very difficult/impossible to treat as you’ve upregulated all the D2 receptors
These side effects are worse and more common in the older antipsychotics
What is the treatment for the side effects of the antipsychotics?
Procyclidine an anticholinergic drug
What are some non pharmacological treatments of schizophrenia?
Individual CBT: normally consists of at least 16 one-on-one sessions. It helps patients create links between their thoughts, feelings and actions with their experience of schizophrenia.
Family intervention: should include the patient suffering from schizophrenia if possible as well as their main carer. Normally consists of 10 sessions over 3 months - 1 year.
Art therapies can be particularly helpful for negative symptoms.
Self-help groups and forums (e.g. Hearing Voices groups) enable people with psychosis to share experiences and ways to cope with symptoms
This should be done alongside antipsychotic medications
What is somatisation disorder?
Characterised by at least 2 years of physical symptoms with no physical explanation
What are some causes/risk factors for somatisation disorder?
More common in women
Hx of sexual or physical abuse
Adverse childhood events
Hx trauma related disorders
What are the most common symptoms in somatisation disorder?
Speech disturbance
Swallowing disturbance
Distractible
Often GI/skin complaints
Cognitive complaints - forgetfulness, short term memory problems
Refusing to believe no organic cause
What is seen in conversion disorder?
Physical signs
Would prevent with neurological signs rather than symptoms
What are some signs seen in conversion disorder?
Paralysis
Loss of speech
Sensory loss
Seizures
Amnesia
The examinations and findings will be inconsistent
What is the difference between somatisation and conversion disorder?
-Dissociative disorders differ from somatisation in that they more often present with signs rather than only symptoms and are often acute in their presentation.
What is hypochondrial disorder?
- Where patients believe they have a serious underlying disease
- There are no physical signs or symptoms of the disease
Who is hypochondrial disorder most common in?
- It’s more common in men and people who have more contact with disease
What is hypochondria also associated with?
Dysmorphophobia
What is dysmorphophobia?
It is an excessive preoccupation with imagined or barely noticeable defects in physical appearance. For example, patients may
become preoccupied by the size of their nose, believing an objectively normal nose to be ugly and deformed
What is the management of hypochondria?
Allow patient time to ventilate their illness anxiet-ies. Clarify that symptoms with no structural basis are real and severe.
Explain negative tests and resist the temptation to be drawn into further exploration
Uncontrolled trials demonstrate antidepressant
benefit, even in the absence of depressive symptoms. Try fluoxetine 20mg, and CBT
What are dissociative disorders?
This is a group of conditions that involve disruptions or breakdowns in memory, identity or perception
- In these disorders, psychiatric symptoms occur in the absence of pathology
- More painful memories are cut-off from conscious self and instead converted into more bearable ones. It is seen as a way to cope with previous emotional trauma
What are some different types of dissociative disorders?
- Dissociative amnesia- A patient has no recollection of upsetting and personal information
- Dissociative fugue- A form of dissociative amnesia in which the patient flees away from their home. They will have no idea of actual self
-
Dissociative identity disorder- It is a condition where the patient develops multiple personalities which can take over
– It is strongly linked to early childhood trauma e.g. sexual abuse
– Patient has amnesia for when the different personalities take over, but maybe aware of their existence
What is the management of dissociative disorder?
- Involves checking if there is an organic cause
- Psychotherapy (e.g. hypnosis) is the main line to explore trauma and recall true identity
What is cortards syndrome?
Holds the delusional belief that they are dead and do not exist
What is Charles-Bonnet syndrome syndrome?
Complex visual hallucinations with partial or severe blindness
Patients understand that the hallucinations are not really and often have insight compared to other disorders
For those experiencing CBS, knowing that they have this syndrome and not a mental illness seems to be the most comforting treatment so far, as it improves their ability to cope with the hallucinations.
What is Munchausen?
A condition where patients will produce physical or psychological symptoms to attain a patients role
- Patients can feign the symptoms, exaggerate them or deliberately hurt themselves to produce symptoms
- Typically, patients take hallucinogens, inject faeces to make abscesses and contaminate urine samples
What is malingering?
This is when a patient feigns or exaggerates their symptoms purely for a financial rewards
- Unlike Munchhausen syndrome, it is not to play a patient’s role but to receive compensation, personal damages or get off work
– It is not a medical diagnosis, but can lead to a large economic burden on health care systems
What is erotomania?
Belief that another person (famous/important) is in love with them
What is a grandiose delusion?
overinflated sense self worth, power, identity, believe have talent/made important discovery
What are some other types of delusion?
Jealous - spouse/sexual partner unfaithful without any concrete evidence
Persecutory - believe someone/something is mistreating/spying on/attempting to harm them, may repeatedly contact legal authorities
Somatic - physical issue/medical problem e.g. parasite, bad odour
What is the definition of personality?
The characteristics and relatively permanent sets of behaviours, cognitions, and emotional patterns that evolve from biological and environmental factors
What is personality disoder?
Deeply ingrained, repetitive patterns of behaviour abnormal in a particular culture
- Increase distress and risk to self and others
- Decrease function typically apparent by adolescence, causes long-term difficulties in personal relationships
What are the 3 clusters of personality disorders?
Split into cluster A,B,C mad, bad and sad
What are the cluster A personality disorders?
Paranoid: Characterized by pervasive distrust and suspicion of others, interpreting motives as malevolent, without sufficient basis.
Schizoid Personality Disorder: Involves detachment from social relationships and a restricted range of emotional expression.
Schizotypal Personality Disorder: Features odd beliefs, magical thinking, perceptual distortions, and eccentric behaviour, often leading to social isolation.
What are the cluster B personality disorders?
Borderline Personality Disorder/ EUPD (BPD): Characterized by instability in mood, self-image, and interpersonal relationships, often accompanied by impulsivity and intense fear of abandonment.
Antisocial Personality Disorder (ASPD): Involves a pervasive pattern of disregard for and violation of the rights of others, along with a lack of empathy and remorse.
Narcissistic Personality Disorder (NPD): Marked by a grandiose sense of self-importance, a need for admiration, and a lack of empathy for others.
Histrionic Personality Disorder: Features excessive emotionality and attention-seeking behaviour, often characterized by dramatic expression, shallow relationships, and a desire to be the centre of attention.
What are the cluster C personality disorders?
Avoidant Personality Disorder (AVPD): People with AVPD tend to be extremely sensitive to rejection and have a pervasive feeling of inadequacy. They avoid social interactions and relationships due to fear of criticism or disapproval.
Dependent Personality Disorder (DPD): Individuals with DPD have an excessive need to be taken care of, leading to submissive and clinging behaviour. They have difficulty making decisions without reassurance and support from others and fear being alone.
Obsessive-Compulsive Personality Disorder (OCPD): This disorder involves a preoccupation with orderliness, perfectionism, and control. People with OCPD may be overly focused on rules and details, leading to rigid and inflexible behaviour. They often have difficulty delegating tasks and may be seen as stubborn or controlling
What are some features of paranoid personality disorder?
- Tendency to interpret the actions of others as demeaning or threatening
- Thinks the world is a conspiracy
- Thinks people are devious
- Reacts severely if they feel like they have been lied to
- Holds grudges
Describe some features of schizoid personality disorder?
- Has an indifference to relationships and a restricted range of emotional experience
- Often described as aloof
- Thinks world is uncaring
- Thinks people are pointless and should depend on themselves
- Withdrawal and less likely to be emotionally available
SchizoiD - = Distant
What are some features of schizotypal personality disorder?
- Pervasive pattern of deficits in interpersonal relatedness and peculiarities of ideation, experience, appearance and behaviour
- Strong desire to have relationships but unable to maintain them due to poor at gauging other perceptions of them
- Overconfidence, self-centred speech and socially inappropriate
- Magical thinking
SchizoTypical -
magical thinking
What are some similarities and differences between cluster A personality disorders and schizophrenia?
Similarities - can have paranoia, and will experience the negative symptoms - of flat affect, and blunted emotions
indeed, maybe a genetic link between the two? ask about FH of one in relatives when taking a history for the other*
Differences - Paranoia is more intense in schizophrenia, and in schizophrenia, you have delusions, as well as positive symptoms like hallucinations and racing thoughts
What are some of the features of BPD/EUPD?
Pervasive pattern of instability of mood, interpersonal relationships and self-image
- Emotionally unstable, intense joy to rage very quickly
- Self-damaging impulsivity (spending, sex, substance abuse, reckless driving, binge eating)
- People are untrustworthy
- Shame
- Self-harm
- Terrified of abandonment - might do extreme things to keep from leaving
- Least likely to be – able to show self-compassion
- Own self-image is unclear don’t really know what you are, poor relationships with others
What are some of the features of antisocial personality disorder?
- Gross irresponsibility
- Incapable to maintaining relationships
- Irritability
- Disregard for moral values
- Manipulative
- Often charming
- Low threshold for frustration and aggression
- Incapacity for experiencing guilt
- Deceitfulness
- Disregard for personal safety
Have to be over 18 to get the diagnosis of this, with a history of conduct disorder
Overrepresented in the prison population
- Will make friends but won’t keep them
What are some features of histrionic personality disorder?
Definition = pervasive pattern of excessive emotionality and attention seeking
Thinks the world is – their audience
Thinks people are – in competition for attention
Thinks they are vivacious (attractively lively and animated)
Commonest behaviour – exhibitionism
Least likely to be – able to listen to others
Few meaningful relationships, v superficial
What are some features of narcissistic personality disorder?
Pervasive pattern of grandiosity, lack of empathy and hypersensitivity to the evaluation of others
- Thinks the world is a competition
- Thinks people are inferior
- Thinks they are special
- Commonest behaviour- competitiveness
What are the features of anankastic/obsessive compulsive personality disorder?
Pervasive pattern of perfectionism and inflexibility
- Excessive doubt, caution, rigidity and stubbornness
- Preoccupation with details, rules lists order
- Perfectionism interfering with task completion
- Excessive conscientiousness
- Preoccupation with productivity to the exclusion of pleasure and interpersonal relationships
In OCD is ego Dystonic - aka the person wishes they could stop their habits
OCPD is Ego syntonic - they are happy w how they are, and they don’t feel a need to change
What are some of the features of avoidant personality disorder?
- Pattern of social discomfort, fear of negative evaluation and timidity
How old do you have to be to be diagnosed with a personality disorder?
18
What are some other criteria and symptoms of Personality disorder?
- Can’t have any other diagnosis
- Long lasting and is there in every context
- Appears in childhood and adolescent
- Ask question about bullying at school
What are some examples of SSRIs?
Sertraline
Citalopram
Fluoxetine
What is the treatment for personality disoder?
DBT-dialectal behavioural therapy
What are some side effects of SSRIs?
- Nausea
- Sexual dysfunction
- Weight gain
- Suicidal thoughts in younger people
- Serotonin syndrome
What are some drugs that SSRIs interact with and you would need to cover with a PPI?
NSAIDs
Aspirin
Heparin
Fluoxetine and paroxetine have higher rates of interactions
What are some drugs that can cause serotonin syndrome in people with SSRIs?
- Linezolid
- Monoamine oxidase inhibitors
- Lithium
- MDMA
- Tramadol
- St. John’s wort
- TCAs
- SNRIs
Give some roles of serotonin in the brain?
CNS
Modulates thermoregulation, behaviour and attention
PNS
Regulates GI motility, Vasoconstriction, bronchoconstriction and uterine contraction
Other
Promotes platelet aggregation (combined use with antiplatelet can increase bleeding risk
What is serotonin syndrome?
A group of symptoms that may occur with the use of certain serotonergic drugs
A diagnosis is made based off a person’s symptoms and medication use
What should be ruled out in serotonin syndrome?
Meningitis
What are the symptoms of serotonin syndrome?
Triad of abnormalities
Cognitive affects: Headache, agitation, mental confusion, hallucinations, coma
Autonomic effects: Shivering, sweating, hyperthermia, vasoconstriction, tachycardia, diarrhoea
Neuromuscular hyperactivity: Muscle twitching, hyperreflexia, tremor
What is the treatment for serotonin syndrome?
IV fluids, cooling measures
Benzodiazepines
Consider cyproheptadine (serotonin antagonist if symptoms persist)
What are some SNRIs
Venlafaxine
Duloxetine
How do SNRIs work?
Lead to the increased concentration of norepinephrine in the synaptic cleft
At low doses, they act like an SSRI - noradrenaline changes don’t occur much at low doses
What are some of the side effects of SNRIs?
Raise BP
Sweating
Dose-dependant hypertension
What are some examples of tricyclic antidepressants?
Amitriptyline
Imipramine
Clomipramine
Dosulepin
High dose for depression, lower dose used for pain
How do tricyclic antidepressants work?
The inhibit the uptake of monoamines at the presynaptic membrane
This increases serotonin and noradrenaline
Decreases acetylcholine, histamine, sodium and calcium
What are some side effects of tricyclic antidepressants?
Dangerous due to it affecting sodium and calcium very cardiotoxic
Check ECG
Anticholinergic side effects:
- Blurred vision- pupil dilation
- Urinary retention
- Dry mouth
- Constipation
- Confusion
- Agitation
When would you consider using monoamine oxidase inhibitors?
MAOIs are seldom used, then only in treatment of:
- Resistant depression or atypical depression
- Depression with increased sleep, increased appetite and phobic anxiety
How do monoamine oxidase inhibitors work?
MAOIs inactivate monoamine oxidase enzymes that oxidase the monoamine neurotransmitters, such as dopamine, noradrenaline, serotonin and tyramine
This creates more of them in the CNS
What are some side effects of MAOIs?
Can cause v. v. high BP if taken with tyramine (aged cheese, cured meats, broad beans). Tyramine reaction crisis can lead to SAH
anticholinergic side - effects, weight gain, insomnia, postural hypotension, tremor, paraesthesia of the limbs, and peripheral oedema
Name some MAOIs?
Selegiline, phenelzine
Name a atypical antidepressant
Mirtazapine
What are some side effects of mirtazapine?
Drowsiness
Weight gain
When would you prescribe lithium?
Acute manic episode and long-term prophylaxis of bipolar affective disorder
It should only be prescribed if there is a clear intention to carry on treatment for at least 3 years otherwise can cause rebound mania
What are some side effects of lithium at a lower dose?
Side effects between 0.4-1:
- Nausea
- Fine tremor
- Weight gain
- Oedema
- Polydipsia
- Hypothyroidism
What are some side effects of higher dose lithium/lithium toxicity?
Above 1.0 mmol/L
Vomiting
Diarrhoea
Coarse tremor
Slurred speech
Ataxia
Drowsiness and confusion
Lithium is also teratogenic
What psychiatric disorder could you use sodium valproate and carbamazepine, and lamotrigine for?
Bipolar, prophylactically
They are Teratogenic!!
What are some side effects of sodium valproate and lamotrigine?
Lamotrigine
Skin reactions (including Stevens–
Johnson syndrome)
aseptic meningitis drowsiness
diplopia
leukopenia
insomnia
Sodium valproate
Nausea
Gastric irritation
diarrhoea
Weight gain
They are Teratogenic!!
Name 3 broad kinds of psychological therpies?
- Supportive
- Cognitive behaviour
- Psychodynamic
What is seen in supportive therapy and what is it used for?
Explanation and reassurance
Establishing rapport, and facilitating emotional expression
- Non-directive problem-solving,
e.g. for adjustment disorders, stress, bereavement - Mild depression or anxiety
Counselling is similar to supportive therapy
in that it involves explanation, reassurance, and support.
What is CBT?
his is a therapy with works on the interplay between thoughts, emotions and behaviours. Its aim it to tackle both negative the cognitive thinking and behaviour in mental illness.
a) Cognitive –> Aim is to help people identify and challenge automatic negative thoughts and abnormal beliefs
b) Behaviour –> This is based on learning theory of operant condition (positive and negative reinforcement)
– If people have habitual wrong behaviours (e.g. avoidance in anxiety) it teaches people relaxation techniques and gradual exposure with positive reinforcement to change their behaviour.
What are psychodynamic/psychoanalytic therapies?
psychoanalysis stems from the work of Sigmund Freud.
- views human behaviour as determined by unconscious forces derived from primitive emotional needs.
Therapy aims to resolve longstanding underlying conflicts and unconscious defence mechanisms (e.g. denial, repression).
Helping the person to become more aware of the unconscious processes which are giving rise to
symptoms or to difficult repeating patterns
Helping the person construct a narrative of their life and give meaning to symptoms
What is seen in eye movement desensitisation and reprocessing?
– Patients then recall the disturbing events and the emotion they felt at the time (e.g. sexual abuse and feeling powerless
– They then work together to create a positive belief about the event (“I am stronger now and so not powerless”)
– The therapist then activates both sides of your brain using Dual Activation Stimulation (DAS) by making they do eye movements usually involves the therapist directing the patients’ lateral eye movements by asking them to look first one way then the other
(saccadic eye movements)
– This allows the brain to reprocess the upsetting memories by removing the old emotion and replacing it with the more positive, empowering emotion
– This means the memory is no longer experienced as a traumatic
What is ECT? For what can it be used for?
It uses electrodes to induce a modified cerebral seizure
Severe depression
Prolonged episode of mania that hasn’t responded to treatment
Catatonia
ECT should be used to induce fast and short-term improvement of severe symptoms after all other treatment options have failed, or when the situation is thought to be life-threatening (because of high risk of suicide or not eating and drinking).
How does ECT work?
It uses electrodes in the brain to induce a modified cerebral seizure in the brain
- This leads to neurotransmitter release, hormone secretion and an increase in the permeability of the blood brain barrier
- It is used if all other treatment options have failed
When can ECT be given under the mental health act?
Patient gives informed consent
(before every treatment)
The patient lacks capacity, and it does not conflict with
advance decision
AND
It’s an emergency, and the independent consultant has
not yet assessed (Section 62 of Mental Health Act)
OR
An Independent Consultant (appointed by Mental Health Act Commission) agrees to it
IF A PATIENT HAS CAPACITY AND REFUSES, IT CANNOT BE GIVEN
What are some contraindications for ECT?
- Raised intracranial pressure
- Previous stroke or MI
What are some side effects of ECT?
Can cause cognitive impairment and function should be assessed prior to, during and after a course of treatment
What is neuroleptic malignant syndrome?
It is a psychiatric emergency that is caused by an excess of neuroleptic medications e.g. antipsychotics which reduce dopamine
Can also be caused by withdrawal from dopamine agonists like Parkinson’s medications
Also caused by cocaine and ecstasy
What are the symptoms of neuroleptic malignant syndrome?
Occurs over hrs to days
- Hyporeflexia
- Hyperpyrexia
- Sweating
- Palpitations
- Reduced consciousness
- Diffuse rigidity
- Raised CK can cause rhabdomyolysis
What is the management of neuroleptic syndrome?
- Stopping the drug and supportive measures such as oxygen, fluids and cooling blankets
- Can also use lorazepam for muscle rigidity
What are the symptoms of an opiate overdose?
- Drowsiness
- Respiratory depression
- Hypotension
- Tachycardia
- Pinpoint pupils
- Constipation
What is the management of an opiate overdose?
ABCDE approach
Give naloxone
What are some signs of opioid withdrawal?
Withdrawal is mediated by noradrenaline overactivity:
- Dilated pupil
- Tachycardia and hypertension
- Insomnia
- Abdo pain
- Diarrhoea and vomiting
- Watering eyes
- Muscle aches
What is the treatment for opioid withdrawal?
Lofexidine
What is used to help with opioid withdrawal?
- Methadone (opioid agonist) or buprenorphine (opioid partial agonist) are first line; they are less euphoriant and have a
relatively long half-life than opioids of abuse. - Lofexidine is sometimes used for short detoxification treatments or where abuse is mild or uncertainNaltrexone (opioid antagonist) blocks the euphoric effects and
is occasionally used to help prevent relapse.
What are the different substances that can be abused and there classes?
ICD - 10
F10 Alcohol
F11 Opioids
F12 Cannabinoids
F13 Sedatives or hypnotics
F14 Cocaine
F15 Other stimulants, including caffeine
F16 Hallucinogens
F17 Tobacco
F18 Volatile solvents
F19 Multiple drug use and other
What are the different types of substance abuse disorders?
ICD - 10
.0 Acute intoxication
.1 Harmful use
.2 Dependence syndrome
.3 Withdrawal state
.4 Withdrawal state with delirium
.5 Psychotic disorder
.6 Amnesic syndrome
.7 Residual and late-onset psychotic disorder
.8 Other mental and behavioural disorders
What are some risk factors for substance abuse?
Addiction liability - depends on:
How substance taken: orally, injection, inhaling
Rate substance crosses blood brain barrier and triggers reward pathway in brain
Time takes to feel effect of substance
Substance ability to induce tolerance ± withdrawal symptoms
Male
Aged ~ 18-25
Mental health conditions: ADHD, bipolar, depression, GAD, panic disorder, PTSD
Adverse childhood experiences: childhood abuse/neglect, witnessing domestic violence, family members with SUD
How many g and ml is one unit if alcohol?
10ml or 8g of pure alcohol
Outline the physiological effects that alcohol has on the body?
- Alcohol increases the GABA function
- GABA is the main inhibitory neurotransmitter in the brain
- Glutamate is inhibited, it is the main excitatory neurotransmitter in the brain
What are some signs of alcohol dependance>
CANT STOP
C- Compulsion to drink
A- Aware of harms but persists
N- Neglect of other activities
T- tolerance to alcohol
S- Stopping causes withdrawal
T- time preoccupied with alcohol
O- Out of control use
P- Persistent, futile wish to cut down
What are some signs of alcohol withdrawal?
Tremors
Anxiety
Nausea
Headache
Tachycardia
Irritability
Delirium
What are some investigations/questionnaires to screen for alcohol dependency?
CAGE questionnaire screening
C - do you ever think about cutting down
A - do you get annoyed when others comment on drinking habit
G - ever feel guilty about drinking
E - ever drink in morning (eye-opener)
AUDIT questionnaire
Developed by WHO
Multiple choice for harmful alcohol use screen
What are some blood test results you would see in an alcoholic?
Bloods:
- Raised MCV
- Raised ALT and AST ( AST:ALT ratio above 1.5 suggests ALD
Raised GGT
Raised bilirubin
Low albumin
Deranged U+Es in hepatorenal syndrome
What is the management for someone who is alcohol dependant?
- Disulfiram- this inhibits acetaldehyde dehydrogenase, so people feel hungover as soon as they drink alcohol
- Acamprosate- this is a weak NMDA antagonist which is used to reduce alcohol craving
Outline the pathophysiology behind delirium tremors?
Alcohol boosts GABA, which inhibits the brain and dampens excitatory glutamate receptors. Over time the brain adapts, becoming more sensitive to excitatory signals
When alcohol stops, the brain becomes overactive, causing symptoms like confusion and agitation
What are some symptoms of delirium tremors?
0-12 hours: increased anxiety, with sweating and agitation
After 24 hours: seizures with visual hallucinations
From 48-72 hours: coarse tremors, agitation, delusions and severe visual hallucinations
What is the management for delirium tremens?
Management – 1st line is benzodiazepine chlordiazepoxide
How can we gauge the severity of alcohol withdrawal?
The CIWA-Ar is used to guide the pharmacological management of alcohol withdrawal
Clinicians add up scores for all ten criteria. The total CIWA score can be used to assess the presence and severity of alcohol;
Absent or minimal withdrawal: score 0-9
Moderate withdrawal: score 10-19
Severe withdrawal: score > 20
The total CIWA score influences the frequency at which further observations are made:
Initial score >8: repeat hourly for 8 hours
Then if stable 2-hourly for 8 hours then if stable 4-hourly
Initial score <8: assess 4 hourly for 72 hours and if score <8 for 72 hours, discontinue assessment.
The total CIWA score guides clinicians with regards to the need for pharmacological management of alcohol withdrawal:
Symptom-triggered regimen (not prescribed regular withdrawal medication): give PRN medication when CIWA score is ≥ 8
Fixed-dose reducing regime with PRN medication (prescribed regular withdrawal medication): give additional PRN medication if CIWA score is ≥ 15
What is Wernicke’s encephalopathy?
It is a neurological emergency resulting from thiamine deficiency with varied neurocognitive manifestations
What is Korsakoff’s syndrome? How is it related to Wernickes?
Hypothalamic damage& cerebral atrophy due to thiamine (vitamin B1 deficiency)
Wernicke’s encephalopathy is the acute, reversible stage of the syndrome, and if left untreated it can later lead to Korsakoff syndrome, which is chronic and irreversible
How can chronic alcoholism lead to thiamine?
It block the phosphorylation of thiamine stopping it from being converted into its active form
Ethanol reduces gene expression of thiamine transporter, so can stop it getting absorbed in the duodenum
Alcoholic tend to have a poor diet, relying on alcohol for calories so will not get enough thiamine (b1) anyway
How can a lack of thiamine (Vit B1) affect the brain?
- Thiamine deficiency impairs glucose metabolism and this leads to a decrease in cellular energy
- The brain is particularly vulnerable to impaired glucose metabolism since it utilises so much energy
What is the classical triad seen in Wernicke’s encephalopathy?
- Confusion
- Ataxia
- Ophthalmoplegia (nystagmus, lateral rectus or conjugate gaze palsies)
What does Wernicke- Korsakoff syndrome predominantly target? What symptoms does this cause?
- Mainly targets the limbic system, causing severe memory impairment:
- Anterograde amnesia inability to create new memories
- Retrograde amnesia inability to recall previous memories
- Confabulation creating stories to fill in the gaps in their memory which they believe to be true
- Behavioural changes
What investigations would you do in suspected Wernicke’s encephalopathy?
- Diagnosis is typically made based in clinical presentation
- Bloods including LFTs: measure thiamine levels, measure blood alcohol levels, liver function may be deranged in alcoholism
- MRI/CT: can confirm diagnosis by showing degeneration of the mammillary bodies
Lumbar puncture to rule out other causes of the symptoms of wernickes
What is the management for Wernicke’s encephalopathy?
Urgent replacement to prevent irreversible Korsakoff’s syndrome. Give thiamine
Oral supplementation
Correct magnesium deficiency as well if there is coexisting deficiency as well
Why do you need to give thiamine before you give glucose in a patient with Wernicke’s?
It’s important to normalise the thiamine levels first, because without thiamine pyrophosphate most of the glucose will become lactic acid and that can lead to metabolic acidosis
Make sure thiamine is given before glucose as Wernicke’s can be caused by glucose administration to thiamine-deficient patient
How do cocaine and amphetamines work?
These drugs block the reuptake of dopamine and noradrenaline (and 5-HT) increasing transmission at synapses
What are some signs of a cocaine/amphetamine overdose?
Main effect- Increased energy and concentration and hyperactivity
Side effects:
- Cardiovascular -> increased pulse, blood pressure, hyperthermia, can lead to aortic dissection
- Heart -> QRS widening and QT prolongation
- GI -> reduced appetite and ischaemic colitis
– Psychological –> Insomnia, agitation and hallucinations e.g. formication (sensation of ants under the skin)
– If you take a prolonged large dose, the euphoria can turn to depression and anxiety
– Can get psychosis –> delusions, visual and auditory hallucinations
What is the management of a cocaine overdose?
- IV benzodiazepines+ treat complications
What are the 5 key principles you must consider when assessing mental capacity?
1) A person is assumed to have capacity until it is established the person does not have it
2) A person should not be treated as unable to decide unless all practicable steps to help them have failed
3) A person should not be treated as unable to decide just because it is unwise
4) Decisions made on behalf if an incapable person must be in their best interests
5) Regard should be taken to find the solution which is least restrictive of the person’s rights and freedom of action
Under the MCA what are the 3 reasons why you may provide treatment for someone who does not have capacity?
- If a valid advanced decision to refuse treatment exists
- If a valid lasting power of attorney for health and welfare exists
- If neither exists, then person providing treatment should act in the patient’s best interests
What are the 2 stages of a MCA?
- Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?
- Does the impairment mean the person is unable to make a specific decision when they need to? People can lack capacity to make some decisions but capacity to make others.
When is a person said to be unable to make a decision for themselves?
- Understand the information relevant to the decision
- Retain the information relevant to the decision
- Use or weigh up that information as part of the process of the making the decision
- Communicate their decision in any way
In order to section someone (forcibly admit someone to hospital/secure setting), for assessment what is grounds/personal is required and for how long? What part of the MHA?
Under section 2 of the mental health act
Need 2 Drs: One section 12 approved, one ideally previous contact with the patient and then approval from approved mental health professional to confirm the section
Patient suffering from mental disorder to degree that warrants detention in hospital for assessment
Pt should be detained for own health/safety or the protection of others
Lasts 28 days, cannot be Cannot be renewed
In order to section someone (forcibly admit someone to hospital/secure setting), for treatment what is grounds/personal is required and for how long? What part of the MHA?
Under section 3 of the mental health act
Again, Need 2 Drs: one section 12 approved, one ideally previous contact w/ pt, and then approval from approved mental health professional (AMHP) to confirm the section.
Patient suffering from mental disorder to degree that warrants detention in hospital for treatment.
Pt should be detained for own health/safety or the protection of others
The treatment needed cannot be effectively provided unless the patient is detained.
Appropriate medical treatment is available to them.
lasts 6 months, can be renewed
What is outlined in section 4 of the MHA?
Patient suffering from mental disorder to degree that warrants the detention in hospital for assessment
Pt detained for own safety/safety of others. Not enough time for 2nd Dr to attend
1 Dr (does not need to be section 12 approved)
Lasts for 72 hours
What is outlined in section 5 of the mental health act, both in 5(2) and 5(4)?
For pt already admitted (to psychiatric/general hospital) but wanting to leave
Section 5(4) says nurses can detain patients in hospital (this is their holding power until a Dr can attend) for 6 hours
Section 5(2) says doctors (this is their holding power until section 2/3 can be put place)
NB- has to be DR on a specific ward, cannot be done in A&E lasts for 72 hours
What is outlined in section 135 of the mental health act
135- allows police to enter a house and move a patient to a place of safety
136 allows police to take someone to a place of safety for an assessment
Both can be done by police, but t
If a patient has been detained under section 2,3,35,36 or 37, is consent required for treatment
onsent to Treatment
As a general rule, once a patient is detained under S2, 3, 35, 36 or 37 of the MHA, consent is not required for the administration of psychiatric treatment.
– The justification for treatment is provided by S63 which states that:
“The consent of a patient shall not be required for any medical treatment given to him for the mental disorder from which he is suffering”
Treatments are Covered by S63
All medical treatment for the mental disorder, including:
Treatments for the disorder itself (e.g. antipsychotics for schizophrenia)
Treatment for conditions causing the disorder (e.g. hypothyroidism causing depression)
Treatments for the physical consequences of the disorder (e.g. NG in anorexia)
Safe holds and physical control and restraint (when necessary)
What is self-harm and what are some of the reasons for it?
Intentional non-fatal sel-ifnflicted harm
a desire to interrupt a sequence of events seen as inevitable and undesirable
* a need for attention
* an attempt to communicate/express themselves
* a true wish to die
What are some risk factors for self-harm?
- It is more frequent in women
- More common in under 35s
- Associated with psychiatric illness, particularly depression and personality disorder
What are some clinical signs of self-harm?
- Cuts on arms and legs
- Picking at skin
- Burns
- Bruising
- Weight loss/gain
- Hair loss (pulling at hair)
When assessing self harm/suicide attempt, what are the 3 domains you should split factors into?
Before
During
After
Suicide and self-harm risk assessment - what things should you try to find out about BEFORE they attempted suicide/self-harm?
Precipitants - specific event/build up?
Planned/impulsive?
Precautions taken against discovery? (left the house, turned off phone etc)
Alcohol/recreational drugs at time of event? - suggests more impulsive
Suicide and self-harm risk assessment - what things should you try to find out about DURING they attempted suicide/self-harm?
Method (if drugs - what did they take, how much)
Was pt alone
Where was it - more remote = higher risk
What went through mind at the time
Did they think their self-harm would end their life?
What did they do straight after the self-harm?
Suicide and self-harm risk assessment - what things should you try to find out about AFTER they attempted suicide/self-harm?
Did pt call anyone? Go to A&E?
Who were they found by
How they felt when help arrived
Current mood
Still feel suicidal? - would they attempt again
What are some management options for self harm?
A good first step is to agree with patients what their problems
are and what immediate interventions are both feasible and
acceptable to them.
* Ensure that they know who they can turn to if suicidal intent
returns (e.g. A & E).
* Crisis Resolution Team referral may be necessary if suicidal
ideation is present.
* Think about reducing access to means of suicide if possible –
for example, by encouraging patients to dispose of unneeded tablets from the home, and by prescribing antidepressants of lower
lethality (e.g. SSRIs rather than tricyclics) and in small batches.
* Consider psychological therapy and encouraging engagement
in self-help and community social and support organisations.
What are some risk factors for suicide?
SAD PERSONS
Sex (male)
Age <19 or >45
Depression
Previous suicide attempt
Excess alcohol or substance use
Rational thinking loss
Separated or single
Organised plan
No social support
Sickness
What are some clinical signs of suicidal behaviour?
Warning signs:
* Obsessive thinking about death
* Feelings of hopelessness, worthlessness, helplessness
* Behaviours suggestive of absolute death wish:
○ Put financial affairs in order
○ Visiting people to say goodbye
in community, awareness of pts who:
Frequently, repeatedly attend
Disengaged w/ services
Prescribed several antidepressants
Heightened concern from family members
what are some principles around suicide prevention?
- Detect and treat psychiatric disorders.
- Be alert to risk and respond appropriately to it.
- Prescribe safely
- Give urgent care at appropriate level of patients with suicide intent – refer to Crisis Resolution and Home Treatment Teams.
- Can also admit for hospitalization (consider detention under the Mental Health Act) if patients considered unsafe outside hospital even with intensive support.
*Provide careful management of deliberate self-harm (DSH)
- Act at the population level, tackling unemployment and reducing access to methods of self-harm.
What are the questions to ask someone to screen for an eating disorder?
- Do you ever throw up after eating food
- Do you eat food to have a sense of control
- Have you lost more than 1 stone in 3 months
- Do you feel like you’re fat when other people tell you you’re not
- Does food dominate your life
SCOFF
What are the findings on FBC and U&Es in someone with anorexia?
- Hypokalaemia
- Low white cell count neutropenia
- Anaemia (either of chronic disease or iron deficient)
What will an ECG show on a patient with an eating disroder?
- Will often show long Qt syndrome as as result of hypokalaemia
What is a bedside test used as a good indicator for cardiac health in an eating disorder?
Sick squat test: Should be able to deep squat, if they can’t do this without using hands, proximal muscles must be weak therefore so must the heart.
What is important to monitor if refeeding a patient with an eating disorder?
Magnesium and phosphate. Can both go low when refeeding. Known as refeeding syndrome
What is done to assess risk in an eating disorder in an emergency setting?
MEED risk assessment for eating disorders:
Red flags: Recent weight loss more than a 1kg over 2 weeks, under 13 BMI, Postural drop, MUAC <18cm, other clinical state, ECG abnormalities, duration.
What is the most common eating disoder
1) Binge eating disorder is the most common form of eating disorder.
2) Anorexia
3) Bulimia
What is the treatment for different eating disorders?
Anorexia: CBT, SSCM
Bulimia: Fluoxetine 60mg once a day, CBT
What are some long term problems of eating disorders?
Hormonal problems, loss of periods and erections, bone scans and calcium levels
What is used to treat delirum?
Haloperidol
Definitions: Concrete thinking
Concrete thinking refers to a cognitive process characterized by a focus on literal, tangible, and specific details rather than abstract or hypothetical concepts.
This type of thinking is grounded in the here-and-now, dealing with concrete objects and straightforward facts rather than ideas or possibilities that require imaginative or theoretical consideration.
Definitions: Loosening of associations (LOA)
Loosening of associations (LOA), also known as derailment, is a cognitive disturbance where there is a significant disconnection or fragmentation in the logical flow of thoughts and ideas.
This phenomenon is often observed in certain psychiatric conditions, most notably schizophrenia, and is characterized by speech that is disorganized and difficult to follow.
Definitions: Circumstantiality
a communication disorder characterized by an overabundance of unnecessary and irrelevant details in conversation or writing
Definitions: Perseveration
Perseveration is a cognitive and behavioural phenomenon where an individual repeatedly performs the same action, says the same words, or persists in the same thought despite the absence or cessation of the original stimulus.
Definitions: Confabulation
Confabulation is a memory disturbance where a person creates false memories without intending to deceive.
These fabricated or distorted memories can include incorrect details about real events or entirely invented scenarios. Confabulation often occurs in individuals with certain brain injuries or neurological conditions and is typically not recognized by the person as false.
Definitions: Somatic passivity
Somatic passivity is a symptom often associated with certain psychiatric conditions, particularly schizophrenia. It refers to a sensation where an individual feels that their bodily experiences, movements, or sensations are being controlled or influenced by an external force or entity.
This can include feelings of physical sensations, movements, or even thoughts that seem imposed upon the person, rather than originating from their own will.
Definitions: Belle indifference
Belle indifference is a term used in psychiatry to describe a paradoxical lack of concern or apparent indifference to significant physical symptoms.
This phenomenon is often observed in individuals with certain psychological disorders, particularly conversion disorder (also known as functional neurological symptom disorder).
Definitions: Akathisia
is a distressing neurological condition characterized by an intense feeling of inner restlessness and an irresistible urge to move. It is a common side effect of certain medications, particularly antipsychotic drugs, although it can also occur spontaneously or as a result of other medications.
Akathisia can significantly impair a person’s quality of life and may lead to agitation, anxiety, and difficulty sitting still or relaxing.
Definitions: Catatonia
Catatonia is a neuropsychiatric syndrome characterized by a range of motor disturbances that can include immobility, excessive motor activity, negativism, mutism, and peculiarities of voluntary movement.
It is associated with various psychiatric and medical conditions, including schizophrenia, bipolar disorder, major depressive disorder, and neurological disorders.
Definitions: Stupor
Stupor is a serious mental state where people don’t respond to normal conversation, but only to physical stimulation.
What is the criteria of learning disability?
Global impairment, below 18, IQ below 70
What are the IQ test used for children?
Wechsler scale for adults and children
Mean IQ: 100
Genius: 145
LD: below 70
What is the life expectancy for people with LD’s?
66 for men
67 for women
What are the causes of LD’s?
Infective, Infections, toxic, trauma, genetic, metabolic
What are some features of anorexia
Anorexia features
most things low: hypokalaemia
low FSH, LH, oestrogens and testosterone
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, Cholesterol, carotinaemia
What are some issues with anti-psychotic medications?
- Parkinsonism
- Akathisia
- Tardive dyskinesia
- Dystonic reactions
- Neuroleptic malignant syndrome
What are the symptoms are the pathophysiology behind drug induced parksionism?
- Bradykinesia
- Ridgity
- Resting tremor
Although less pronounced and symptoms are always bilateral
Caused by D2 receptor blockade by the medications
What is the treatment of drug-induced parkinsonism?
- Dose reduction
Switching to a different medication - Use procyclidine
What is Akathisia?
- It means to not be able to sit still
- A subjecitve component of feeling like they need to move
- Manifests with symptoms such as pacing, inability to stand, sit or lie still
What are the different types of Akathisia?
- Acute which occurs within hours to weeks of starting medication
- Acute persistant
- Tardive akathisia: usually develops after 3 months of treatment
What is the treatment for Akathisia?
- Try choloropromazine/quitiapine
- Try beta-blocker
- Mitrzapine
What is tardive dyskinesia?
- Involuntary, repetitive purposeless movements, occuring with long-term antipsychotic treatment
What are the signs and symptoms of tardive dyskinesia?
- Tongue, lips and jaw movements
- Trunk twisiting
- Torticollis
- Pelvic thrusting
What are the treatments of tardive dyskinesia?
- Tertrabenazine
- Dopamine agonists
- Clonazepam if dystonia also present
When does a dystonic reaction occur?
- Usually occurs within 1wk of commencing or rapidly increasing the dose of the antipsychotic medication
What are the signs and symptoms of a dystonic reaction?
- Muscles of head and neck are most commonly affected
- Forceful protrusion of tongue
- Occurs in the mouth most commonly
What is the treatment of a dystonic reactions?
- IM Procyclidine
What is neuroleptic malignant syndrome?
- A rare life-threatning reaction to anti-psychotic medication
What are the characteristics of neuroleptic malignant syndrome?
- Fever
- Muscle ridigity
- Alterned mental status
- Autonomic dysfunction
What are the signs and symptoms of neuroleptic malignant syndrome?
- Hyperthermia
- Muscle ridigity
- Confusion
- Hyporeflexia
- tremor
- Raised CK (can cause rhabdomyolsis)
What is the treatment for neurolepetic malignant syndrome?
- Stop drug
- Give fluids and oxygen
- Cool body temperature
- Lorzepam/Dantrolene
- Can also give bromocriptine
- Give bicarbonate to prevent alkalisation of urine
What is De Clerambault syndrome?
De Clerambault’s: This is the presence of a delusion that a famous person is in love with them, with the absence of other psychotic symptoms as is the case, here.
What is Capgras syndrome?
Capgras syndrome: This is the delusion that a person closely related to the patient has been replaced by an impostor.
What is De Fregoli syndrome?
De Fregoli syndrome: This is the delusion of identifying a familiar person in various people they encounter.
What is Othello syndrome?
Othello syndrome: This is a delusion of sexual infidelity on the part of a sexual partner.
What is Ekbom syndrome?
Ekbom syndrome is: This is delusional parasitosis and describes the delusion of infestation.
What are the hormonal changes in anorexia?
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia