Psychiatry Flashcards
What are some risk factors for bipolar disorder? x6
no single cause
- genetic factors (SNPs)
- prenatal exposure to Toxoplasma gondii
- premature birth <32 weeks gestation
- childhood maltreatment
- postpartum period
- cannabis use
What are the clinical features of bipolar II and II?
Bipolar I - at least one episode of mania
Bipolar II - at least one episode of hypomania, but never an episode of mania. Also at least one episode of major depression
What are the characteristic clinical features of a manic episode?
Lasting for at least seven days and have a significant negative functional effect on work and social activities
Elevated mood excessive to circumstance
Elation with increased energy –> overactivity, pressure of speech, decreased need for sleep
Inability to maintain attention, often with marked distractibility
Inflated self-esteem with grandiose ideas of self-importance
Loss of normal social inhibitions
What are some differentials for bipolar disorder? x6
Schizophrenia
Organic brain disorder
Drug use
Recurrent depression
Emotionally unstable personality disorder (EUPD)
Cyclothymia
What is the acute management of mania?
secondary care management with oral antipsychotics:
- haloperidol
- olanzapine
- quetiapine
- risperidone
What medications are used in the acute management of depression in bipolar disorder?
Fluoxetine + olanzapine
Quetiapine alone
Olanzapine alone
Lamotrigine alone
What is the long-term management for bipolar disorder?
Mood stabilising medications e.g. lithium
2nd line Sodium valproate (NOT in pregnant women)
What are some potential complications of bipolar disorder? x4
increased risk of death by suicide
increased risk of death by general medical conditions such as cardiovascular disease
side effects of antipsychotics
socioeconomic effects
What are the 3 categories of personality disorders?
anxious
suspicious
emotional or impulsive
What are some examples of anxious personality disroders?
Avoidant - severe anxiety about rejection and avoidance of social situations/relationships
Dependent - heavy reliance on others to make decisions and take responsibility for their lives
Obsessive compulsive - unrealistic expectations of how things should be done by themselves and others, catastrophising
What are the types of suspicious personality disorders?
Paranoid - difficulty trusting others
Schizoid - lack of interest or desire to form relationships with others
Schizotypal - unusual beliefs, thought and behaviours, as well as social anxiety
What are the types of emotional/impulsive personality disorders?
Borderline - fluctuating strong emotions and difficulties with identity and maintaining healthy relationships
Histrionic - need to be centre of attention, having to perform to maintain that attention
Narcissistic - feeling that they are special and need other to recognise this
What are personality disorders?
Personality disorder (PD) is an umbrella term that covers a number of variations of maladaptive personality traits that cause significant psychosocial distress and interfere with everyday functioning.
characterised by patterns of thought, behaviour and emotions which differ from what is normally expected by society
leads to difficult relationships, reduced quality of life and poor physical health
What are the 3 main categories of personality disorders according to the DSM-5?
Cluster A - Suspicious
Cluster B - emotional or impulsive
Cluster C - anxious
What are the management strategies for personality disorders?
Risk management (mainly harm to self and others)
Psychological treatment - CBT, DBT (dialectal behaviour therapy)
Medications are not recommended for long term treatment however sedative medications are sometimes used in a crisis short-term
What is post-traumatic stress disorder?
a mental health condition resulting from traumatic experiences, with ongoing distressing symptoms and impaired function
What are some examples of traumatic events which may result in PTSD?
violence e.g. sexual assault, domestic violence, abuse
major car accidents
major health events e.g. traumatic childbirth, serious illness or death of a loved one
natural disasters
military, combat and war zones
What are some of the key symptoms of PTSD x10
intrusive thoughts
re-experiencing (flashbacks, images, nightmares)
hyperarousal (feeling on edge, irritable and easily startled)
negative emotions
negative beliefs
difficulty with sleep
depersonalisation
derealisation
emotional numbing
How is PTSD diagnosed?
Trauma screening questionnaire
DSM-5
ICD-11
What are the management options for PTSD?
psychological therapy
eye movement desensitisation and reprocessing
Medication e.g. SSRIs, venlafaxine or antipsychotics
What is obsessive compulsive disorder?
characterised by obsessions and compulsions
obsessions = unwanted and uncontrolled thoughts and intrusive images which the person finds difficult to ignore
compulsions = repetitive actions which the person feels they have to do
What are the 4 steps of the OCD cycle
- Obsessions
- Anxiety
- Compulsion
- Temporary relief
Which diagnostic tools are used to confirm OCD diagnosis:?
DSM-5 and ICD-11
Yale-brown obsessive compulsive scale is used to assess the severity of symptoms
What are the management options for OCD?
Mild cases can be managed with education and self-help resrouces
CBT with exposure and response prevention (ERP)
SSRIs
Clomipramine (TCA)
What are dissociative disorders?
when people feel a sense of disruption between their consciousness, body, perceptions, memories, identity and emotions which normally people experience as connected and integrated
What are 3 examples of dissociative disorders?
Depersonalisation-derealisation disorder
Dissociative amnesia
Dissociative identity disorder
What is catatonia? what causes it?
abnormal movement., communication and behaviour which can look like unusual postures, performing odd actions, repeating sounds or words or remaining blank and unresponsive
most often caused by severe depression and bipolar disorder, rarely physical health conditions like strokes or brain tumours can lead to catatonia
What is reactive attachment disorder?
difficulty forming close relationships or attachments with poor response to affection or discipline as a result of severe neglect and trauma in early childhood
What is attachment theory?
The importance of creating healthy consistent and secure attachments to at least one nurturing individual during early childhood, particularly for the first 2 years of life
What is factitious disorder/Munchhausen syndrome?
where a conscious effort is made to fake illness and seek medical attention for personal gain
symptoms are invented, exaggerated or induced to invoke attention, affection, relationships and care from others
may have repeated presentations with inconsistent and dramatic symptoms which do not fit with examination and investigation findings
What is alien hand syndrome? cause?
where the patient loses control of one of their hands so that it acts independently
usually the result of an underlying brain lesion such as brain tumours, injuries, aneurysms or following surgery
What is cotard delusion? causes?
The false belief that they are dead or actively dying
also known as walking corpse syndrome
most coften caused by psychiatric conditions like depression and schizophrenia but also can be caused by brain tumours and migraines
What is capgras syndrome?
false belief that an identical duplicate has replaced someone close to them
What is De Clerambault’s syndrome?
also called erotomania
false belief that a famous or high-social status individual is in love with them leading to inappropriate harassment of the individual by the patient
frequently occurs without any other psychiatric or neurological disease
What is Alice in wonderland/Todd syndrome?
incorrectly perceiving the sizes of body parts or objects
also associated with changes to the perception of time and symptoms of migraines
causes include migraine, epilepsy, brain tumours
What is Koro syndrome/
a false belief that the sex organs are retracting or shrinking and will ultimately disappear resulting in anxiety and panic attacks
has been linked to cultural beliefs in asia
What is body integrity dysphoria?
a strong feeling that a part of the body does not belong to them typically associated with a desire to removed that part of their body
What is foreign accent syndrome?
sudden change in a person’s voice most commonly caused by a stroke in the left hemisphere
What is schizophrenia? at what age does it usually present?
a severe long-term mental health disorder characterised by psychosis
often presents between age 15-30 and earlier in men than women
symptoms must be present for at least 6 months before schizophrenia is diagnosed
What is schizoaffective disorder?
a combination of the symptoms of schizophrenia with bipolar disorder so patients have psychosis with symptoms of depression and mania
How is schizophreniform disorder different to schizophrenia?
presents with the same features as schizophrenia but lasts less than 6 months
What are some other causes of psychosis?
mania
psychotic depression
drugs
stroke
brain tumours
cushing’s syndrome
hyperthyroidism
huntington’s disease
What causes schizophrenia?
thought to be a combination of genetic and environmental factors
How does schizophrenia typically present>
a prodrome phase with subtle symtpoms like poor memory, reduced concentration, mood swings, sleep disturbance etc.
then the positive symptoms of psychosis including delusions, hallucinations and thought disorder
lack of insight
What are some key positive symptoms seen typically in schizophrenia?
auditory hallucinations
somatic passivity
thought insertion or withdrawal
thought broadcasting
persecutory delusions
ideas of reference
delusional perceptions
What are the 4 A’s which are negative symptoms of schizophrenia?
affective flattening
alogia (reduced speech)
anhedonia
avolition (lack of motivation in working towards goals or completing tasks)
What are the different patterns of schizophrenia that can be observed over time?
continuous
episodic
single episode only
How is a diagnosis of schizophrenia made?
used the DSM-5 criteria
symptoms must have been present for at least 6 months with active phase symptoms present for at least one month
What is the management for schizophrenia?
antipsychotic medications
cognitive behavioural therapy
What are some examples oral antipsychotics?
chlorpromazine
haloperidol
quetiapine
aripiprazole
olanzapine
risperidone
What are some examples of depot antipsychotics?
helpful where adherence may be an issue
aripiprazole
flupentixol
paliperidone
risperidone
What are some key complications of clozapine use?
agranulocytosis
myocarditis or cardiomyopathy
constipation
seizures
excessive salivation
What 4 monitoring requirements are required before starting and during antipsychotic treatment ?
Weight and waist circumference
Blood pressure and pulse rate
Bloods, including HbA1c, lipid profile and prolactin
ECG
WHat are 5 side effects of antipsychotic drugs?
Weight gain
Diabetes
Prolonged QT interval
Raised prolactin
Extrapyramidal symptoms
What are some extrapyramidal side-effects of antipsychotic drugs?
Akathisia (psychomotor restlessness, with an inability to stay still)
Dystonia (abnormal muscle tone, leading to abnormal postures)
Pseudo-parkinsonism (tremor and rigidity, similar to Parkinson’s disease)
Tardive dyskinesia (abnormal movements, particularly affecting the face)
What is an illusion?
False perception of real, existing sensory stimulus
What is a hallucination?
False sensory experience when there is no stimulus present, can be visual, auditory, olfactory, tactile or gustatory
What is a delusion?
A false belief that is firmly held despite contradictory evidence.
What is an overvalued idea?
An unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. the person is able to acknowledge the possibility that the belief may or may not be true)
What is thought alienation?
A symptom of psychosis which occurs when someone feels that their thoughts are no longer under their control. Can include thought insertion, broadcasting, withdrawal
What is thought insertion?
When a person feels that thoughts are being spoken to them or are occurring outside of their mind, but they recognize that they are the one thinking them
What is thought withdrawal?
When a person feels that their thoughts have been taken out of their mind and they have no power over this.
What is thought broadcast?
A type of thought alienation where the person believes that others are able to read their thoughts.
What is thought echo?
A symptom of psychosis where someone hears their own thoughts being spoken aloud, shortly after thinking them.
What is thought block?
A neuropsychological symptom expressing a sudden and involuntary silence within a speech, and eventually an abrupt switch to another topic.
What is concrete thinking?
Reasoning which is based on what you can see, hear, feel and experience in the here and now. Also called literal thinking, because it focuses on physical objects, immediate experiences and exact interpretations.
What is loosening of association?
Also known as derailment.
A thought process disorder which is characterised by a lack of connection between ideas. Speech is vague and confusing.
What is circumstantiality? How is it different to tangentiality?
Circumstantiality is circuitous and non-direct thinking or speech that digresses from the main point of a conversation but is still linked to the topic.
Whereas tangentiality is where the person strays very far from the main point they’re trying to make and don’t reach a main point or answer questions.
What is perseveration?
The repetition of a particular response (word, phrase or gesture) regardless of the absence or cessation of a stimulus.
What is confabulation?
A neuropsychiatric disorder wherein a patient generates a false memory without realising it’s not true. Sometimes called “honest lying”.
what is somatic passivity?
Experience of bodily sensations (thoughts, actions, emotions) imposed by external agency. e.g. voices commenting on one’s actions
What is delirium?
A mental state of confusion and disorientation which can develop suddenly and is often temporary
What is catatonia?
A state of apparent unresponsiveness to external stimuli and apparent inability to move normally in a person who is apparently awake.
What are some common behavioural responses to stimuli seen in catatonia?
Mutism (absence of speech)
Negativism (performing actions contrary to the commands of the examiner)
Echopraxia (repeating the movements of others)
Echolalia (repeating the words of others)
Waxy flexibility (slight, even resistance to positioning by examiner)
Withdrawal (absence of responses to the environment)
What is psychomotor retardation?
The slowing down or hampering of mental or physical activities
What is flight of ideas?
A thought disorder which refers to rapid and erratic speech that jumps from one topic to another.
What is poverty of speech?
Also known as alogia, a speech disturbance which involves a reduction in the amount and quality of speech.
What is poverty of thought?
a thought disorder characterised with a reduction in thought spontaneity and productivity, and vague or repetitive speech
sometimes called intellectual impoverishment
What is anhedonia?
A symptom of many mental health conditions which refers to the inability to feel pleasure or joy
What is flattening of affect?
A clinical sign where the person has reduced or absent displays of emotion
What is incongruity of affect?
When the person’s emotional demeanor doesn’t match what’s happening around them.
What is blunting of affect?
decreased ability to express emotion through facial expressions, tone of voice and physical movements.
What is belle indifference?
A paradoxical absence of psychological distress despite a serious medical illness or symptoms of a health condition.
What is depersonalisation?
When the person feels disconnected from their body, feelings and environment
What is derealisation?
A mental state where you feel detached from your surroundings and people and objects may seem unreal.
What is conversion?
Conversion is a defense mechanism by which individuals reduce acute anxiety by converting psychological suffering into physical symptoms.
What is dissociation?
A mental process where a person disconnects from their thoughts feelings, memories or sense of identities
What is stereotypy?
a seemingly purposeful, coordinated, but involuntary, repetitive, ritualistic gesture, mannerism, posture, or utterance e.g. repetitive grimacing, lip smacking etc.
What are mannerisms?
Strange or bizarre ways of carrying out normal activities
What is an obsession?
a persistent, unwanted, and intrusive thought, urge, or image that causes anxiety, distress, or unease.
What is a compulsion?
a repetitive behaviour or mental act that a person feels driven to perform in response to an obsession
What are the 3 core behaviours of ADHD?
- Hyperactivity.
- Inattention.
- Impulsivity.
(HII)
These symptoms occur in every child from time to time but when they are persistent and impact on daily functions, more investigation is needed
ADHD core behaviours: give 3 signs of impulsivity.
- Blurts out answers.
- Interrupts.
- Difficulty waiting turns.
- When older, pregnancy and drug use.
ADHD core behaviours: give 3 signs of inattention.
- Easily distracted.
- Not listening.
- Mind wandering.
- Struggling at school.
- Forgetful.
- Organisational problems.
Does not appear to be listening when spokento directly
Makes careless mistakes
Looses important items
What is the diagnostic criteria for ADHD? According to DSM-5 (Diagnostic and Statistical Manual of Mental Disorders)
ADHD definition <17 Years
6/9 inattentive symptoms and 6/9 hyperactivity/impulsivity.
Present before 12 years
Developmentally inappropriate
Several symptoms in 2 or more settings
Clear evidence symptoms interfere/reduce the quality of social/academic/occupational function
.
Describe the nn pharmalogical treatment for ADHD.
- Education.
- Parenting programmes and school support.
Behavioural interventions, e.g. encouraging realistic expectations, positive reinforcement of desired behaviours (small immediate rewards), consistent contingency management across home and
school, break down tasks, reduce distraction.
Implementing Routines
Evidence base for fish oils in diet
Learning support
What are some medicine for ADHD?
Methylphenidate (ritalin, concerta, Equasym)
Atomoxetine (Strattera®) A non-stimulant NE reuptake inhibitor licensed for the treatment of ADHD.
What are some things you need to consider/ SE of ADHD medication?
headache, insomnia, loss of appetite, stomach ache, dry mouth, nausea
Can stunt growth
Need to Monitor weight, height and BP
Methyphenidate is Not recommended to take during pregnancy
What are the 3 main features of the deficits seen in ASD?
They can be categorised as deficits in social interaction, communication and behaviour
Outline some social interaction issues often seen in those with ASD
NO DESIRE TO INTERACT WITH OTHERS
BEING INTERESTED IN OTHERS TO HAVE NEEDS MET
LACK OF MOTIVATION TO PLEASE OTHERS
AFFECTIONATE ON OWN TERMS
Touches inappropriately
Poor Eye contact
Plays alone
Finds it stressful to be with other people
Outline some communication issues often seen in those with ASD
Repetitive use of words or phrases
Delay, absence in language development
Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others, and sharing interest
Lack of desire to communicate at all
PEDANTIC LANGUAGE, VERY LITERAL, POOR OR NO UNDERSTANDING OF IDIOMS AND JOKES
Outline some behavioural issues seen in Autism
USING TOYS AS OBJECTS
INABILITY TO PLAY OR WRITE IMAGINATIVELY
RESISTING CHANGE
PLAYING SAME GAME OVER AND OVER
OBSESSIONS/RITUALS
There may be self-stimulating movements that are used to comfort themselves, such as hand-flapping or rocking.
Extremely restricted food preferences
Describe the treatment for ASD.
- Education and games to encourage social communication.
- Visual aids and timetables.
- Parenting workshops and school liaison.
Manage Comorbidity
There are no medications available for ASD
Diagnosis should be made by a specialist in autism. This may be a paediatric psychiatrist or paediatrician with an interest in development and behaviour. A diagnosis can be made before the age of 3 years. It involves a detailed history and assessment of the child’s behaviour and communication..
What are some risk factors for depression?
Prior depression
Family Hx depression
Female
Hx 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 some things you may find on consulation/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 non pharmalogical measurements for mild depression?
Mild depression
* Watchful waiting (GP monitoring progress post diagnosis)
* Guided self-help: workbook/online course + therapy support
* Exercise
* Talking therapies - CBT, interpersonal therapy (IPT), psychodynamic psychotherapy
○ CBT:
§ Aim to help understand thoughts/behaviour + how they affect you
§ Recognises events in past but concentrates on how can change thinking/feeling/behaviour in present
§ Available on NHS for depression/mental health problems
○ IPT:
§ Focus on relationships with others and problems within them
§ E.g. issues with communication, coping with bereavement
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
Outline what bipolar disorder consists of - what is the ICD-10 definition
Bipolar affective disorder - recurrent episodes of altered mood and activity
Involving upswings and downswings (hypomania/mania + depression)
Hx of 2 mood disorders, at least one:
Hypomania < 4d
Mania >7 d
What are some things you might see in an episode of hypomania? How long do these tend to last?
Lasts about 4 days
Elevated mood
Increased energy, talkativeness
Poor concentration
Mild reckless behaviour (overspending)
Sociability/overfamiliarity
Increased libido/sexual disinhibition
Increased confidence
Decreased need to sleep
Change in appetite
Types of bipolar - outline what is seen in cyclothymia -
What differentiates mania from hypomania?
Cyclothymia - chronic mood fluctuations over 2+ yrs, episodes of depression and hypomania (not mania). Rapid cycling, episodes only lasting few days
**presence of psychotic Sx e.g. auditory hallucinations/grandiose delusions differentiates mania from hypomania
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 are some side effects of lithium
L - leukocytosis
I - insipidus diabetes (nephrogenic)
T - tremors (if coarse, think toxicity)
H - hydration (easily dehydrates, need to drink lots, is renally cleared)
I - increased GI motility
U - underactive thyroid
M - metallic taste (warning of toxicity), mums beware - teratogenic
Lithium + diuretics -> dehydration
Lithium + NSAIDs -> kidney damage
& weight gain, hypothyroidism
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 are the clinical feautres of PTSD? How long must they be present for?
Symptoms – These must be present >1 month
– Persistent intrusive thoughts and re-experiencing –> flashbacks, nightmares and intrusive images
– Autonomic hyperarousal –> persistent activation gives startle, hypervigilance, insomnia
– Avoidance –> patient avoids situations and stimuli associated with the event
– Emotional detachment –> feeling detached from people and lack of ability to experience feelings
– Higher risk of depression, substance misuse, unexplained physical symptoms
What are some non pharmalogical managements for PTSD
CBT - eg education about the nature of PTSD, selfmonitoring of symptoms, anxiety management, breathing techniques
Eye movement desensitization and reprocessing (EMDR): Using voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts
Stress management
Hypnotherapy
What checks need to be done regulary for people on antipsychotic medications?
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 antipsyhcots?
Diabetes/insulin resistance and dyslipidaemia
QT segment changes on ECG
Agranulocytosis – clozapine
Extra-pyramidal side effects due to the dopamine blockade -
Urinary retention
Blurred vision
Dry mouth
Weight gain
Hyperprolactinaemia (due to dopamine blockade and dopamine down regulates prolactin)
What are some extra pyrimidial side effects of antipsycotics, and how can they be treated?
Acute dystonic reaction (hours)
Muscle spasm, acute torticolis, eyes rolling back
Parkinsonism (days)
Tremor, bradykinesia
Akathisia (days to weeks)
“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
Treat with Procyclidine, an anticholinergic drug
Outline some differential diagnosis for medically unexplainable symptoms
Factitious, symptoms are fabricated and not experienced as real by the patient
Somatoform disorder - Symptoms are unconsciously generated by the mind, but experienced as real by patient
Undiagnosed - symptoms are arising from a physical cause that hasn’t been identified yet
Give the definition of personality
The characteristics and relatively
permanent sets of behaviours, cognitions,
and emotional patterns that evolve from
biological and environmental factors
‘Characteristic lifestyle and mode of relating
to others’ (ICD – International
Classification of Diagnosis)
Outline what is seen in Muchausens syndrome
This is a condition where patients will produce physical or psychological symptoms to attain a patient’s 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.
Define paranoid personality disorder and list some of its features (A)
unwarranted tendency to interpret the actions of others as demeaning or threatening
Thinks the world is – a conspiracy
Think people are – devious
Acts as if – always on guard, suspicious
Define schizoid personality disorder and list some of its features (A)
pervasive pattern of indifference to social relationships and a restricted range of emotional experience and expression aloof
Thinks the world is – uncaring
Thinks people are – pointless, replaceable
Thinks they are the only person they can depend on
Commonest behaviour – withdrawal
Least likely to be – emotionally available and close
SchizoiD - = Distant
deifne schizotypal personality disorder and list some of its features (A)
pervasive pattern of deficits in interpersonal relatedness and peculiarities of ideation, experience, appearance and behaviour
Strong desire to have relationships, unable to maintain them - poor at gauging others perception of them
SchizoTypical -
magical thinking
What are some similarities and differences between cluster A personality disorder 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 the personality disorders grouped together in Cluster B?
Bad
borderline (emotioanlly unstable)
antisocial,
histrionic
narcissist,
BAHN
Define borderline personality disorder and list some of its features
Aka emotionally unstable - intense joy <–> rage
Most common type
Definition = pervasive pattern of instability of mood, interpersonal relationships and self-image
- Self-damaging impulsivity (spending, sex,
substance abuse, reckless driving, binge-eating)
Thinks people are – untrustworthy
Ashamed of themselves
Commonest behaviour – self-harm
Terrified of abandonment - might do extreme things to keep from leaving
Least likely to be – able to show self-compassion
Charlotte from Strike?
Define antisocial personality disorder and list some of its features
- Gross irresponsibility
- Incapacity for 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
Define histrionic personality disorder and list some of its features
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
Define narcissistic personality disorder and list some of its features
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
Least likely to be – humble
Name some other conditions that are thought to have a genetic link with personality disorders seen in Cluster B?
Depression
Bipolar
Substance abuse disorder
Define anankastic/obsessive compulsive personality disorder and list some of its features
How can it be distinguished from OCD (obsessive compulsive disorder)
pervasive pattern of perfectionism and inflexibility
- Excessive doubt, caution, rigidity and stubbornness
- Preoccupation with details, rules, lists, order
- Perfectionism interfering with task completion
Outline some of the management optiosn seen in helping those with personality disorders
Structure, consistency and clear boundaries (i.e. agreement of behaviour that is acceptable and unacceptable)
help with housing and other social
matters
Drugs are sometimes used to treat specific PD traits, e.g. mood stabilisers for impulsivity (not generally recommended because of lack of evidence).
Continuity of care very important – changes in doctors etc. may invoke strong emotional reactions
What are some drugs that SSRIs interact with, that you would need to provide w PPI cover?
NSAIDs, Aspirin and Heparin - give a PPI cover
NB - fluoxetine and paroextine have higher risk of interaction, as particulary good at inhibiting Liver enzymes
What are some drugs that can precipitate serotonin syndrome in people with SSRIs?
Linezolid
Monoamine oxidase inhibitors (MAOIs)
Lithium
MDMA
Tramadol
St. John’s wort
Tricyclic antidepressants (TCAs)
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
NB - fluoxetine and paroextine have a higher risk of interaction, as particularly good at inhibiting Liver enzymes
Outlline the MOA of tricyclic antidepressants
Action on the presynaptic neurone - inhibit the uptake of monoamines at the presynaptic membrane (bind to ATPase monoamine pump)
Increase serotonin, noradrenaline
Decrease acetylcholine, histamine, sodium and calcium
What are some side effects of lithium at lower dose?
Side effects - at lower doses 0.4-1 mmol/L
* Nausea
* Fine tremor
* Weight gain
* Oedema
* Polydipsia and polyuria
* Hypothyroidism
What are some side effects of lithium toxicity? Above 1.0 mmol/L
Above 1.0 mmol/L
Signs of toxicity
* Vomiting
* Diarrhoea
* Coarse tremor
* Slurred speech
* Ataxia
* Drowsiness and confusion
Lithium is Teratrogenic!!
What are some side effects of Sodium valporatte and lamotrigine ?
Lamotrigine
Skin reactions (including Stevens–
Johnson syndrome)
aseptic meningitis drowsiness
diplopia
leucopenia
insomnia
Sodium valpoarate
Nausea
Gastric itrartaion
diarrhoea
Weight gain
They are Teratrogenic!!
Name 3 broad kinds of psychological therapies
1 Supportive therapy
Explorative pyschotherapies=
2 Cognitive and Behavioural therapies
3 Psychodynamic therapies
Outline what is seen in CBT
This 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.
Outline what is seen in psychodynamic/pyshcoanalyitc 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 the general procedure seen in Psychodynamic therapies?
e. g. Psychoanalysis + Psychodynamic Psychotherapy
– The patient explores their subconscious by using free association (says whatever is on their mind)
– The therapist interprets these statements to link the patient’s past experience with their current life and their relationship with the therapist. This uses 2 skills:
– Transference –> when the patient re-experiences strong emotions from early relationships with the therapist
– Counter-transference –> When the therapist experiences strong emotions towards the patient
The relationship heals!!!!!!
What is seen in Dialetcai ldehvaiour therapy? When may it be used?
similar to CBT and also provides group skills training to equip the individual with alternative coping strategies
Skills such as mindfulness (bringing one’s attention back to thepresent moment), which is derived from Buddhist meditation.
Used for those with Boarderline personality disorders, eating disorders
Outline what is seen in Eye movement desensitization 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?
Electroconvulsive Therapy - uses electrodes to induce a modified cerebral seizure
Severe depression
Prolonged or severe episode of mania that has not responded to treatment
Cataonia
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 is ECT thought to work?
This is a treatment option which uses electrodes to induce a modified cerebral seizure in the brain
– This leads to massive amounts of neurotransmitter release, hormone secretion and a transient increase in blood brain barrier permeability.
– It is used to induce fast improvement after all other treatment options have failed
When does English Mental Health Act permit
ECT to be given?
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
Outline the procedure of ECT
Procedure:
– Patient is nil-by-mouth for 4 hours before intervention
– Patient is given short-acting anaesthetic + muscle relaxant drug
– Preoxygenation is given to increase SpO2
– A shock is delivered to the scalp either bilaterally or unilaterally
– This evokes a 20-60s seizure within the brain
What are some symptoms of opiate overdose
Acute presentation = drowsiness
Respiratory depression -> resp acidosis CO2 retention)
Hypotension
Tachycardia
Pinpoint pupils
Chronic = constipation
What are some signs of opioid withdrawal?
Clinical features of withdrawals are mediated by noradrenaline overactivity:
* Dilated pupil
* Tachycardia + hypertension
* Insomnia, restlessness, anxiety, irritability,
tremor
* Abdo pain, nausea, vomiting, diarrhoea
* Watering eyes
* Muscle aches
Treatment Lofexidine
Give some risk factors for a substance abuse disorder
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
Outline some of the physiological effects that alcholol has on the body
- Alcohol increases GABA function (GABA-A receptor activation)
- GABA is the main inhibitory neurotransmitter in the brain - calming effect
- Alcohol reduces glutamate function - inhibitory action at NMDA glutamate receptors
○ Glutamate is the major excitory neurotransmitter that is involved in brain processing such as learning and memory
○ Effects on glutamate lead to amnesia and sedation
What are some signs of alchohol 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
Withdrawal
Tremors
Anxiety
Nausea, vomiting
Headache
Tachycardia
Irritability, aggression
Delirium
What are some investigations/questionaires 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
Outline the pathophysiology behind delirium tremens
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.
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 withdrawal:
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 is ≥ 8: repeat hourly for 8 hours. Then if stable 2-hourly for 8 hours. Then if stable 4-hourly.
Initial score < 8: assess 48-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 the classical triad seen in Wernicke’s encephalopathy?
1 confusion
2 ataxia (wide-based gait; fig 2)
3 ophthalmoplegia (nystagmus,
lateral rectus or conjugate gaze palsies).
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. (often the case in
this group of patients),
make sure thiamine is given before glucose, as Wernicke’s can be caused by glucose administration to a thiamine-deficient patient -
NOT GIVING THIAMINE AS YOU JUST THINK ITS HYPOGLYCAEMIA IS A COMMON MISTAKE DOCTORS MAKE
What is outlined in section 135 of the mental health out
135 - allows police to enter house and mreove 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 a police, but the should try and confirm this with a doctor or nurse
Both for a duration of 72 hours
Define what self harm is - what are some reasons for it?
Intentional non-fatal self-inflicted 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
Used to express something hard to put into words, change emotional pain into physical pain, have a sense of being in control, punish themselves for feelings/experiences…
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 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.
