Psychiatry Flashcards
Describe sectioning
Sectioning under mental health act used when the patient is suffering from a mental health disorder, poses a risk to their own or other’s health (or there are previous patterns of deterioration to the point of risk) and all other options have been explored
Sectioning requires an AMHP and 2 doctors (1 section 12 trained, do not work with each other, know the patient). At any point they have right to tribunal review
Sections: 2 - assessment (no treatment) for 28d, 3 - assessment and treatment up to 6m, 5.2 - holding powers for 72h (already in hospital, no treatment), 5.4 - nurse holding powers 6h, 136 - police detained from public place, 135 - police from home
Describe a mental state examination
Appearance and behaviour: clothing, hygiene, body language, eye contact, weight, physical signs
Motor: agitation, psychomotor retardation, catatonia, extra pyramidal side effects, tics, tremor
Speech: spontaneous, brief vs prolonged, rate + pressure (can interrupt?), volume, rhythm, tone, clanging (how it sounds over sense - rhyme etc)
Mood and affect: subjective and objective, congruity, range of emotions
Mood = climate, weather = affect (how they are immediately observable, expression)
Thinking: form (structure of sentences), content (delusions), mood congruent?, obsessions / compulsions, depersonalisation, intrusive thoughts, depressive, perception / hallucinations / illusions
Withdrawal, insertion, derailment, flight of ideas + tangential, thought blocking, broadcasting, circumstantial (too much detail)
First rank (schizophrenia): special type auditory hallucinations (3rd person, running commentary, thought echo), delusions of thought interference (withdrawal / insertion / control), passivity phenomena (thoughts + actions out of their control), delusional perception
Types of delusion: capgras - friend or pet replaced by identical imposter, fregoli - someone you know in disguise, cotard - you are missing body parts / dead, de clerambault - erotomania
Cognition: orientation, attention (months backwards) + concentration, memory
MoCA, MMSE
Insight: how aware they are of being ill, do they want help
Risk: to themselves - self neglect, to others MOST IMPORTANT
Remember as ASEPTIC(R): appearance (+ behaviour), speech, emotions, perception, thoughts, insight, cognition, risk
What extra information needs to be included in a history
History also needs to include: full exploration of presenting complaint and check for other symptoms, suicide / self harm risk, personal circumstances, upbringing / childhood, forensic, premorbid personality, alcohol + drugs, risk to others
Describe delusions and hallucinations
Delusions - fixed, false / illogical, out of sociocultural norms: persecutory - going to be harmed / harassed / conspired against; grandiose - self importance + special; erotomanic - someone is in love with them, often higher status; jealous - partner is being unfaithful; somatic - something about their body / health; nihilistic - nothing matters, there is no future, often at least part of them is dead
Hallucinations - sensory perception without stimulus, are experienced as one of the 5 senses, auditory then visual are the most common. Most common causes of hallucinations are schizophrenia, parkinson’s, alzheimer’s (Lewy body), migraine, tumour, Charles Bonnet (poor vision)
Illusion - incorrect perception of stimulus
Depression - presentation, score, screening
Depression, screen with PHQ-9: feeling down / hopeless, anhedonia + loss of interest, poor sleep / eating / concentration, psychomotor retardation, thoughts of self harm / suicide
Core symptoms: low mood, anhedonia, anergia (energy). Somatic / biological symptoms: early morning waking, psychomotor, loss of appetite + libido, diurnal mood variation
Have to screen for self harm + suicide: can’t keep going, don’t want to wake up, ending your life, previous attempts. If so: plans, final acts, what stopped you
PHQ-9: > 16 = moderate / severe, indication for SSRI (as well as CBT), mild self guided / CBT. Electroconvulsive therapy can be used in severe - especially in treatment resistant
Anxiety - presentation, scoring, types
Anxiety: persistent worry or fear that impacts daily life, several different types of anxiety disorders, assess with generalised anxiety disorder (GAD-7) questionnaire
GAD-7: not at all 0 / several days 1 / more than half 2 / nearly every day 3; feeling as if something bad will happen, easily annoyed, so restless hard to sit still, trouble relaxing, worrying too much, net being able to stop worrying, feeling on edge. 5/10/15 - Mild / M / S
Presentation: excessive worrying, restlessness, unexplained pain, tachycardia, sweating, trembling, fatigue, difficulty concentrating, irritability, sleep disturbance
Types: GAD, panic disorder (frequent attacks), social anxiety, phobias, OCD, PTSD
Schizophrenia - definition, presentation, first rank symptoms
Schizophrenia: persistent psychosis, disordered thinking and cognitive impairment. Strongly linked to childhood adversity, commonly presents early 20s in men and ~ 30 in women
Positive: hallucinations, delusions, disorganised thinking (illogical + confused speech), impaired insight
Negative: affective (emotional) flattening, alogia - poverty of speech, anhedonia, lack of motivation, social difficulties and withdrawal
First rank symptoms: special type auditory hallucinations (3rd person, running commentary, thought echo), delusions of thought interference (withdrawal / insertion / control), passivity phenomena (thoughts + actions out of their control), delusional perception
Describe psychosis
Psychosis: hallucinations, delusions, disorganised thinking, impaired insight, emotional dysregulation, all lead to functional impairment
Many causes: bipolar, schizoaffective disorder, major depressive disorder, drug induced (withdrawal), postpartum, neurological, PTSD
After first episode of psychosis, looked after by early intervention team for 3 years
Seen as emergency - longer untreated the worse the outcome. Antipsychotics needed 18m following first episode to prevent relapse
Describe schizoaffective disorder
Schizoaffective disorder: types bipolar / depressive, mood component more present than not, less decline in function than in schizophrenia
Treatment the same: atypical antipsychotic, SSRI for depressive, lithium / valproate for bipolar, CBT, psychoeducation, family / group
Describe bipolar, different types, management
Bipolar: cycling periods of depression and mania lasting minimum days (have to have 2 periods of mania). I: manic episode, often followed by depression / hypomania; 2: major depressive and hypomanic episodes; cyclothymic (milder): mood swings between hypomania and depression
Mania: elevated, irritable, overactive, poor concentration, racing thoughts, pressured speech, grandiose, social / sexual inhibition, poor insight, may have psychotic symptoms
Hypomania: elated, overactive, social disinhibition, overspending, poor sleep, continues to function partial insight, no psychotic. Often feel good and may improve performance. Lasts less long than mania
Also have typical depression periods
Acute: mania: antipsychotic, lithium / sodium valproate if required, taper antidepressants; depression: antipsychotic or fluoxetine with olanzapine or lamotrigine. Quetiapine drug of choice for type 2
Olanzapine has quick onset and good at mood stabilisation, helps sleep
Long term: lithium (valproate, olanzapine if not tolerated)
Describe OCD
OCD: intrusive + distressing thoughts (obsessions) and repetitive behaviours (compulsions) to reduce the anxiety caused by the obsessions, temporary belief reinforces the cycle.
Tends to have significant impact on life, often aware the thoughts are irrational, can be as extreme as causing suicide
CBT, exposure and response prevention (ERP) therapy, SSRI (min 12w), severe - clomipramine (TCA)
Describe anorexia, screening, investigations, management
Anorexia: SCOFF screening tool (sick because full, control lost, one stone lost in 3m, feel fat when others disagree, food dominates life - 2+). Fear of weight gain, other psychological issues, reluctance to help, distorted image of self. Signs: BMI < 18.5, cardiovascular instability, hypothermia, reduced power (sit up squat stand test), electrolyte imbalance
Eating disorder focused CBT, MANTRA therapy (understanding, goal setting, motivation etc), nutritional counselling
G+Cs raised: growth hormone, glucose, glands (saliva), cortisol, cholesterol, carotenaemia
Describe refeeding syndrome
Refeeding syndrome: hypophosphataemia + hypokalaemia + hypomagnesaemia (due to insulin spike, can cause Torsades de pointes), untreated leads to organ failure + arrhythmias. If haven’t eaten for 5 days first 2d only 50% requirements. Also risk in elderly after critical illness / surgery
Describe PTSD and complex PTSD
PTSD: single period of trauma (may have several experiences close together), recurrent intrusive thoughts, avoidance, persistent negative mood, hypervigilance
Typically within 3m of event, can last for life. Diagnosed 4w after the trauma, until then acute stress disorder
Intrusive: flashbacks, nightmares, emotional distress. Mood: feelings of detachment, distorted thinking patterns. Hypervigilance: irritability, aggression, heightened startle response, difficulty concentrating
Trauma based CBT / DBT, EMDR. Drugs for persistent: SSRI / venlafaxine, amitriptyline
Complex PTSD: repeated / chronic exposure to traumatic experiences. Shares flashbacks, avoidance, hypervigilance. Also: emotional dysregulation, self identity + relationship issues.
Emotions: mood swings, anger + aggression, sadness. Self: deep sense of worthlessness, shame, guilt. Difficulty forming and maintaining meaningful relationships
Describe postpartum mental health conditions
Baby blues seen in 60-70% 3-7d post, change in hormones, reassure and support
Postnatal depression: 1-3m post, presents like normal depression typically with doubts about being a mum; use Edinburgh postnatal depression score (score >13 = depression); CBT + support groups etc; paroxetine (low milk expression) or sertraline in severe
Puerperal psychosis: 2-3w, mood swings like bipolar, disordered perception and delusions; admit to mother and baby unit
