Psychiatry Flashcards
What blood test results would you expect to see in neuroleptic malignant syndrome?
Raised creatine phosphokinase Leukocytosis Raised ALP and lactic acid dehydrogenase Electrolyte abnormality Metabolic acidosis
What is neuroleptic malignant syndrome?
Adverse reaction to psychotropic meds particularly classical antipsychotics
Tetrad of high grade fever, altered mentation, bradykinesia/rigidity and autonomic instability (tachycardia, labile BP, wide PP) over few days course
What is psychopathology?
Systematic study of abnormal experience, cognition and behaviour; the study of the products of a disordered mind
What are the different domains of psychopathology?
Explanatory: psychodynamic, behavioural
Descriptive: observation, phenomenology
What different disorders are covered under psychopathology?
Disorders of perception Disorders of thoughts and speech Disorders of emotion Disorders of experience of self Disorders of memory Disorders of consciousness Motor disorders Abnormal and psychopathic personalities
What is perception?
Process of becoming aware of what is presented through the sense organs
What categories of disorders of perception are there?
Sensory distortions: changes in intensity, quality, spatial form
Sensory deception: illusions, hallucinations
What is an illusion?
Misperception of a real object/external stimulus
What is a hallucination?
Perception experienced in the absence of an external stimulus in any modality
What are the different types of hallucination?
Auditory Visual Tactile Olfactory Gustatory Hypnagogic (when falling asleep) and hypnopompic (when waking)
What is a pseudo hallucination?
Separate form of perception from a true hallucination
Not concretely real
Experienced in internal subjective space, In the mind’s eye
patient can distinguish them from reality
What categories of disorders of thought and speech are there?
Stream of thought: tempo - flight of ideas, retardation of thinking, continuity - perseveration, thought blocking
Possession: obsessions, thought alienation
Content: delusions
What tempo related disorders of thought and speech are there?
Pressure of speech: rapid and frenzied, urgency
Flight of ideas: jumps topic to topic based on discernible associations
Inhibition / retardation of thinking
Circumstantiality: non linear thought pattern, unnecessary details and irrelevant remarks cause delay in getting to the point
What continuity related disorders of thought and speech are there?
Perseveration: repetition of a word, phrase or gesture despite absence or cessation of stimulus
Thought blocking: stop speaking suddenly, without explanation in middle of sentence
Derailment/Loosening of associations/knight’s move: sequence of unrelated ideas
Tangentiality: speak about topics unrelated to main topic of discussion
Rhyming, clang association: association of words based on sound rather than concept
Neologisms: making up new words
Verbigeration: repetition of words or phrases
What are the 5 features of formal thought disorder
Derailment- disruption of continuity of speech by insertion of novel and inappropriate material to the chain of thought
Substitution- major thought substituted by subsidiary one
Omission- sudden discontinuation of a chain of thought
Fusion- merging and ‘interweaving’ of separate ideas
Drivelling- muddling of elements within an idea to extent that the meaning is totally obscured to the listener
What is an overvalued idea?
Acceptable, comprehensible idea pursued by person beyond bounds of reason and causes suffering or disturbed functioning
What is an obsession?
Recurrent, intrusive, usually unpleasant thoughts that person recognises as their own and tries to resist
What is thought alienation?
Thought withdrawal, Thought insertion, Thought broadcasting
What abnormal possession of thoughts can occur?
Overvalued Ideas
Obsessions
Thought alienation: withdrawal, insertion, broadcasting
Delusions of control (passivity)
What is passivity?
Delusion of control
Feeling that some aspect of themselves is under external control of another
What is a delusion?
Fixed, false idea
Belief that is firmly held on inadequate grounds, is not affected by rational argument or evidence to the contrary (unshakable),
and is not a conventional belief that the person might be expected to hold given his educational, cultural and religious background
What abnormal thought content can occur?
Persecutory: think harm is going to occur
Reference: experience coincidence and believing it has strong personal significance
Grandiose: fantastical beliefs of fame, power, wealth
Guilt: believe they have done something sinful or shameful
Hypochondrical: fixed belief of poor state of health despite medical evidence to contrary
Nihilistic: they are dead, do not exist
Religious: preoccupied with religious subjects
Jealous: preoccupied with thought that spouse or partner is being unfaithful without any real proof
Sexual/amorous: believes they are loved by someone they have never met or is inaccessible
Dysmorphophobia: body dysmorphia, obsessive preoccupation that some aspect of appearance is severely flawed
Misidentification: belief that identity of person/object/place has changed
What is affect?
Objective, synonymous with emotion and also meaning a short-lived feeling state; related to cognitive attitudes and understandings, and to physiological sensations
What is mood?
Subjective, emotional tone prevailing at any given time -adequate to a surrounding situation and matters discussed; a ‘mood state’ will last over a longer period
What is a pathological affect?
Very strong, abrupt affect with a short change of consciousness on its peak
What are the 2 pathological poles of mood?
Manic
Depressive
What is a phobia?
Persistent irrational fear and wish to avoid a specific situation, object, activity
What disorders of emotion exist?
Pathological affect
Pathological mood
Phobia
What are pathological features of mood?
Euphoria: intense excitement and happiness
Mania: excitement, delusion, overactivity
Hypomania: mild form of mania
Depression: depressed mood, loss of interests
Apathy/anhedonia: lack of interest/pleasure
Blunted, flattened affect: reduction in intensity of emotional response
Emotional lability: involuntary crying/laughing
What are the characteristics of pathological mood?
Origin – based on pathological grounds
Duration – unusually long-lasting
Intensity – unusually strong, large changes in intensity
What is depersonalisation?
Change of self-awareness, person feels unreal, unable to feel emotion
What is derealisation?
Environment feels flat, dull unreal, loss of the sense of reality of surroundings, usually involving a visual perceptual distortion; usually associated with a change in mood
What is loss of emotional resonance?
Lack of feeling , emotional reactivity
What is disturbance of continuity of self?
Not the person they were before the illness
What are disturbances of boundaries of self?
Loss of differentiation of one’s body and rest of the world e.g. anosognosia
What are the different disorders of experience of self?
Depersonalisation Derealisation Loss of emotional resonance Disturbance of continuity of self Disturbances of boundaries of self
What are the different types of memory?
Sensory stores: retains sensory information for 0.5 sec
Short term memory (working memory): verbal and visual information, retained for 15-20 sec, low capacity
Long term memory: wide capacity and more permanent storage, declarative (explicit) memory – episodic (for events) or semantic (for language and knowledge)
procedural memory – for motor arts
priming – unconscious memory
conditioning – classic or emotional
What are disorders of memory?
Amnesia: inability to recall past events
Jamais vu: unfamiliarity in familiar situation
Déja vu: familiarity in unfamiliar situation
Confabulation: production of fabricated, distorted or misinterpreted memories about oneself
Amnesic disorientation
Korsakov’s syndrome: anterograde and retrograde amnesia, confabulation
Pseudologia fantastica: pathological lying
Hypomnesia: abnormally poor memory of the past
Hypermnesia: abnormally strong memory of the past
What is consciousness?
Awareness of the self and the environment
What is hypnosis?
Artificially incited change of consciousness
What is syncope?
Short-term unconsciousness
What are the quantitative disorders of consciousness?
Clouding of consciousness: disorientation in time, place, person, disturbances of perception and attention, and amnesia
Drowsiness: further reduction in level of consciousness, with
unconsciousness if unstimulated, but can be stimulated to a wakeful state
Stupor: further loss of responsiveness, can only be aroused by
considerable stimulation. Awareness of environment is maintained in depressive/ catatonic stupor, but not in organic stupor
Coma: profound reduction of conscious level with very little or no
response to stimulation
What is delirium?
Confusional state characterized by disorientation, distorted perception, enhanced suggestibility, misinterpretations and mood disorders
What are qualitative disorders of consciousness?
Disturbed perception, thinking, affectivity, memory and consequent motor disorders:
Delirium (confusional state)
Obnubilation (twilight state)
What is obnubilation?
Twilight state, starts and ends abruptly, amnesia is complete, patient is disordered, his actions are aimless, sometimes aggressive, hard to be understood
What are quantitative motor disorders?
Hypoagility
Hyperagility
Agitated behaviour
What are qualitative motor disorders?
Mannerisms: unusual habit which can be modified
Stereotypies: repetitive movement
Posturing: odd or inappropriate bodily position
Waxy flexibility: decreased response to stimuli, immobile
Echopraxia: imitation of movements of others
Schizophrenic impulse: failure to resist temptation
Negativism: resists movement and does opposite to what asked
Automatism: sequences of activity which occur without conscious control
Agitation: unpleasant state of extreme arousal
Tics: sudden, rapid, non rhythmic movements
Abulia: lack of will or initiative
Compulsions: repetitive behaviour
What is personality?
Complex of persistent mental and physical traits of a person
What disturbances of personality can occur?
Transformation of personality
Multiple personality (alteration of personality)
Specific personality disorder: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic (attention seeking), anankastic (obsessive compulsive), anxious (avoidant) and dependent
Deprived personality
What are the categories of a mental state examination?
Appearance & Behaviour Speech Mood Thoughts Perception Cognition Insight
What is serious mental illness?
People with psychosis
Schizophrenia
Bi-polar affective disorder
What general health problems are people with schizophrenia at higher risk of than the general population?
Mortality rates from respiratory, circulatory, endocrine and digestive disorders 3-4 X higher
Risk of metabolic syndrome for those with schizophrenia is 2–4 times greater than for the general population
Risk of sudden death in schizophrenia increases incrementally with each additional psychotropic medication taken by a patient
2 x death rate from cardiovascular disease
4x death rate from respiratory disease
2 x more likely to have diabetes
People with schizophrenia die 10-25 years earlier than general population
What proportion of schizophrenics are smokers as compared with the general population?
61% schizophrenics smoke
33% of general population
Why do people with mental illness have more physical illness?
Lifestyle: self neglect, smoking, jobs, lack of exercise, poor diet
Poor access to healthcare
Side effects of treatment – mainly Antipsychotics
Suicide contributes to higher mortality rate
What patient related factors may contribute to the poor physical health of people with mental illness?
Difficulty comprehending health care advice or carrying out
required changes in lifestyle due to psychiatric symptoms
(cognitive deficits, negative symptoms, poor insight, suspicion)
Adverse consequences related to mental illness (low educational attainment, reduced social networks, lack of employment and family support, poverty, poor housing)
Severity of mental illness (fewer medical visits, with most severely ill patients making the fewest visits)
Less compliant with treatment
Unawareness of physical problems due to cognitive deficits or to a reduced pain sensitivity associated with psychotropic medication
Lack of social skills and difficulties communicating physical needs
Migrant status or cultural and ethnic diversity
What clinician related factors may contribute to poor physical health of patients with mental illness?
Tendency to focus on mental rather than physical
Poor communication with patient and/or primary care health
workers
Physical complaints regarded as psychosomatic symptoms
Suboptimal and worse quality of care offered by clinicians to
patients with SMI. Lack of assessment, monitoring and continuity
of care of the physical health status of people with SMI
Erroneous beliefs (SMI patients are not able to adopt healthy
lifestyles, weight gain is mainly adverse effect of medications, lower cardiac risk medications are less effective)
Underfunded teams to handle behavioural and emotional problemsof patients with SMI
What service related factors may contribute to poor physical health of patients with mental illness?
Financial barriers, especially in developing countries
High cost of integrated care
Lack of access to health care
Lack of clarity and consensus about who should be responsible for detecting and managing physical problems in patients with SMI
Fragmentation or separation of the medical and mental health systems of care
Under-resourcing of mental health care
What modifiable risk factors may contribute to poor physical health of mental illness patients?
Overweight / Obesity Diabetes/ hyper-glycaemia Dyslipidemia Exercise Smoking Anti Psychotic Drugs
Give some possible reasons for the high levels of type 2 diabetes in schizophrenic patients
Genetic link between schizophrenia and diabetes
Impact of lifestyle
Medication effect increasing insulin resistance by impacting insulin receptor or post-receptor function
Drug effect on caloric intake or expenditure (obesity, activity)
What is metabolic syndrome?
High BP, high blood Sugar , unhealthy Cholesterol level and belly fat
Name some typical and atypical antipsychotics
Typical: chlorpromazine and haloperidol
Atypical: quietapine and olanzapine
What cardiac side effects can some anti psychotics have?
Prolonged QT interval
What physical health checks should be carried out on patients with mental illness?
Weight gain and obesity: Body Mass Index (BMI), Waist Circumference (WC)
Dietary intake
Activity level and exercise
Use of tobacco and alcohol or other substances
Blood pressure
Fasting glucose and lipid levels (esp. TG and HDL-C)
Cardiovascular disease risk and ECG parameters
Prolactin levels (if symptomatic)
Dental check
Liver function tests, blood count, thyroid hormone, electrolytes (periodically, as indicated)
What are targets for blood pressure control in patients with mental illness? How is this achieved?
Target BP levels of less than 130/85 mmHg recommended
Lifestyle changes: stopping smoking, reducing salt intake, weight reduction, increased exercise, may be sufficient to reduce mildly elevated BP
Some patients are likely to require pharmacological therapy
What blood sugar monitoring should be carried out in patients with mental illness?
Baseline measure of plasma glucose level for all patients pre treatment
Conduct blood glucose measurement in fasting patients. If problematic, conduct a random blood glucose test or haemoglobin A1C test)
Patients with significant risk factors for diabetes should be monitored at baseline, 6 and 12 weeks after starting medication and then approximately every 3-6 months
Patients who are gaining weight (>7%) should be monitored every 4 months
What are the monitoring guidelines for cardiovascular disease in patients with mental illness?
Ask patients about heart risks: F/H of early sudden cardiac death (
Antipsychotics or antidepressants known for causing QT prolongation should not be prescribed to which patient set?
Patients with known heart disease
Personal history of syncope
Family history of cardiac disease at an early age (
What is recommended in patients presenting with Torsade de pointes who are on antipsychotics/antidepressants?
Withdrawal of any offending drugs and correction of electrolyte abnormalities
What monitoring for weight gain and obesity should be carried out in patients with mental illness?
Monitor and chart BMI and WC of every SMI patient at every visit, regardless of medication prescribed
Encourage patients to monitor and chart their own weight
BMI and WC assessment is simple, inexpensive and can easily been done with a weighing scale and waist tape measure
What healthy eating behaviours should be encouraged in patients with mental illness?
Cutting down on fast food Increase healthy food items (fruits, vegetables, fish) Decrease processed fat free food Making healty snack choices Controlling portion size Consume 4-6, but small meals Eating more slowly Minimising intake of soft drinks with sugar sweetener Reading food labels Keeping food diaries/plans/exchange tables Learning cooking skills Healthy food shopping
What physical activity recommendations should be made for patients with mental illness?
Keeping activity diaries, daily activity list
Increasing physical activity such as moderate intensity walking
Reduce sedentary behaviors (TV watching, video/computer games)
Treating/reducing sedation and extrapyrramidal effects of medications
What advice on smoking should be given to patients with mental illness?
Treating tobacco dependence is effective in patients with SMI and does not worsen mental state
Advice and encourage SMI patients strongly to stop smoking (cessation associated with approximately a 50% decrease in CHD risk)
Assist patients in developing a quit plan, and arrange follow-up. If necessary and possible, patients should be referred to a smoking cessation service
What is the gold standard treatment for patients with mental illness to aid with smoking cessation?
Pharmacotherapy: nicotine replacement therapy,
bupropion or varenicline
Coupled with individual or group psychological support. Care to avoid adverse medication interactions & monitor antipsychotic medication in particular as cigarette consumption reduces
What harm reduction can you attempt in a patient with mental illness who does not want to quit smoking?
Awareness raising
Advising on, providing & selling licenced nicotine containing products
Self help materials
Behavioural support, education & training for practitioners
Nicotine is highly addictive but it is primarily the toxins and carcinogens in tobacco smoke that cause death
What is the health improvement profile?
Risk assessment tool for physical health
Nurses can be trained to be competent in using HIP in 3 hours
Physical health of all patients can be profiled
A HIP for every patient once a year
Enables nurses to plan care/make appropriate referrals
Guides nurses to evidence based interventions
Bridges communication between primary and secondary care
What is the general structure of a psychiatric history?
Personal details: Name, Age, Occupation, Address, pMarital status
Presenting complaint: in patients own words
History of presenting complaint
Past Psychiatric history
Past Medical and Surgical History
Family History: genograms, history of mental illness, suicides, suicide attempts, substance/alcohol abuse, neurological disorders
Personal History: Birth and any complications, Neonatal illnesses, Developmental milestones, Education – schools attended, any learning difficulties, truanting, bullying, other traumas, achievements, interests, exams passed, age at leaving school, physical and sexual abuse, be mindful of patient’s clinical condition and whether or not discussion of such events could be traumatising or intrusive, Occupational history:- details of jobs, duration, reason for leaving, level of satisfaction with employment and ambitions. Assess what impact the illness will have on patient’s job, Psychosexual history: – first experiences, relationships, orientation, marriage history, any children, Present social circumstances: – own or rented
accommodation – financial problems, debts, who patient lives with
Substance and alcohol use history
Forensic History: Previous contact with the police, Get all details including nature of offences, charges, sentencing including fines, custodial sentences, History of violence – against people or property, all details including severity
Premorbid Personality
What information about informants and referrals needs to be made with a psychiatric history?
Record place and time patient seen
Voluntary or detained
Source and reason for referral (Self, GP, general hospital, police)
Informants – who the history and other information is taken from
What is the general structure of a mental state examination?
Appearance and behaviour Speech Mood Thought: Form, Content Perception Cognition Insight
What features are you looking at in the appearance and behaviour section of a mental state examination?
Dress Self care Calm/agitated/anxious Posture Facial expression Appropriateness of dress/behaviour Abnormal movements/gait Eye contact Rapport
What aspects of speech are you looking at in a mental state examination?
Spontaneity (poverty of speech) Reaction time to questions Rate (slow/fast/pressured?) Volume Tone (monotonous or not) Fluency (dysphasia/dysarthria)
What aspects of mood are you looking at in a mental state examination?
Subjective vs. objective
Affect vs. mood
Nature of mood: Depressed, Elated, Anxious, Angry, Irritable
Variability of mood: Blunting/flattening, Reactivity, Lability, Incontinence
Incongruity of mood
Depersonalisation
Derealisation
What symptoms of mood changes would you look for in a patient with depression?
Anhedonia Low energy Low confidence Guilt Poor concentration Sleep disturbance Appetite Suicide
What aspects of thought form are you looking at in a mental state examination?
How thoughts are organised and expressed: Amount/volume of thoughts, Connection/flow of thoughts
Objectively = speech
Amount of thought: Pressure of thought, Poverty of thought, Thought blocking
Thought flow: Flight of ideas, Loosening of associations
What aspects of thought content are you looking at in a mental state examination?
Delusions: Delusional Mood, Delusional Perception, Delusional Memory
Thought Possession: Insertion, Withdrawal, Broadcast
Delusions of control
Ideas of reference
Overvalued ideas
Obsessive thoughts
What is a delusion?
False, unshakeable idea or belief, out of keeping with patient’s educational, cultural and social background. It is held with extraordinary conviction and subjective certainty
What types of delusions exist?
Persecutory
Jealousy/infidelity
Grandiose
Nihilism
What is obsessional thought?
Intrusive thoughts, impulses or images Persistent and repetitive Recognised as own thoughts Recognised as senseless Patient resists them
What are compulsive rituals?
Repetitive Seemingly purposeful Subjective sense of compulsion Resisted, but this results in anxiety Often associated with obsessive thoughts
What aspects of perception are you looking at in a mental state examination?
Hallucination: percept in the absence of a stimulus
Pseudo hallucination: Doesn’t fully have the character of external reality
Illusion: misperception of a stimulus
Voices: Who, when, where? Inside head? Same as me talking to you?Which “person”? Third person ≈ schizophrenia, Second person (commands) – important for risk assessment
What are first rank symptoms of schizophrenia?
Thought control: Insertion, Withdrawal, Broadcast Delusional perception Passivity (delusions of control) Thoughts spoken aloud Third person auditory hallucinations
What aspects of cognition need to be assessed in a mental state examination?
Attention and Concentration: WORLD backwards
Orientation: Time, place and person
Immediate Memory (registration): Repeat 3 objects
Recent memory: Recall 3 objects 5 minutes later, Recent events
Remote memory: Remote personal events
General knowledge: Name Queen, PM, US president– Dates of WW2, Current news events
Executive function
What aspects of insight are you looking for in a mental state examination?
What is the problem? Is it an illness? Is it a mental illness? Does he/she need treatment and what? Are they taking prescribed medication?
What proportion of adults with a mental illness had a prior diagnosis as an adolescent?
Over 80% of people with mental health disorder had a
prior mental health diagnosis: 74%were present before age 18 and 50% before age 15
What is an organic psychiatric disorder?
Demonstrable pathology or aetiology, or which arise directly from a medical disorder
Excludes disorders that develop as a result of a psychological reaction to a condition
What are functional psychiatric diseases?
Do not have an identifiable underlying pathological cause and are typically multifactorial: Genetic component, Exposure to certain environmental materials in utero, Changes in brain chemistry
What classes of organic psychiatric disorders are there?
Dementia
Other conditions presenting with psychiatric symptoms but having physical cause
Substance misuse disorders
Psychiatric disorders which are considered psychological reactions to
illness (becoming depressed after being told you have cancer) are excluded
Give examples of psychiatric syndromes which arise from a physical cause
Organic brain syndromes: Dementia, delirium, amnesic syndrome
Organic delusional: Systemic lupus (psychotic) erythematosus
Organic mood disorders: Multiple sclerosis
Organic anxiety disorders: Thryotoxicosis
Organic personality disorders: Head injury
What is sulfasalazine?
DMARD used in treating IBD, RA
What is dementia?
Umbrella term to describe change/impairment of cognitive
functions, resulting from disease of the brain, which is severe enough to affect day to day functioning
What are the main causes for dementia?
Alzheimer’s disease
Vascular dementia
Dementia with Lewy bodies
What is normal pressure hydrocephalus?
5% of dementia
Commonest potentially reversible type
CSF pressure is often increased
Clinical triad of: confusion, gait apraxia, urinary incontinence
Treatment: ventricular shunting; 50% respond well
What is delirium?
Transient, usually reversible, cause of cerebral dysfunction, manifesting clinically with a wide range of neuropsychiatric abnormalities
Also known as acute confusional state or acute brain syndrome
Common on medical and surgical wards, a third of elderly patients in
hospital have an episode of delirium during their admission
What are symptoms of delirium?
Clouding of consciousness: most important diagnostic sign Drowsiness Decreased awareness of surroundings Disorientation in time and place Distractibility Fluctuating course, worse at night Visual hallucinations Transient persecutory delusions Irritability and agitation, or somnolence and decreased activity Impaired concentration and memory
What are common causes of delirium?
Prescribed drugs: Tricyclic antidepressants, Benzodiazepines and other sedatives, Digoxin, Diuretics, Lithium, Steroids, Opiates
Alcohol: intoxication, withdrawal and delirium tremens
Medical conditions: Postoperative hypoxia, Febrile illness, Septicaemia, Organ failure (cardiac, renal, hepatic), Hypoglycaemia, Dehydration, Constipation, Burns, Major trauma
Neurological conditions: Epilepsy (postictal), Head injury, Space occupying lesion, Encephalitis
What is delirium tremens?
Psychotic condition in withdrawal of alcohol from alcoholics, tremors, hallucinations, anxiety and disorientation
What are differences between delirium and dementia?
Onset: acute vs insidious Course: fluctuating vs progressive Attention: poor vs good Delusions: common vs not common Hallucinations: simple/stable vs fleeting
What are predisposing factors for delirium?
Elderly Male Pre-existing dementia Pre-existing frailty or immobility Previous episode of delirium Sensory impairment
What are treatments for delirium?
Environmental components: Quiet surroundings (side room), constant lighting, clock, calendar
Regular routine: Clear simple communications, Limit numbers of staff (e.g. key nurse), Involve family
Medical components: Monitor vital signs, Investigate and treat underlying cause (e.g. antibiotics,oxygen, stop drug), Control agitation or psychotic symptoms with antipsychotics
What is the prognosis for delirium?
Prognosis depends on the cause
Within a week the patient is usually better or has died
No good evidence that delirium progresses to dementia
Pre-existing dementia is a risk factor for delirium
Older individuals experiencing delirium are twice as likely to die than those who do not
What is Amnesic syndrome?
Anterograde and retrograde amnesia Confabulation Minimal content in conversation Lack of insight Apathy: patients lose interest in things quickly and generally appear indifferent to change Time disorientation Immediate recall intact
What causes Amnesic syndrome?
Damage to the mammillary bodies, hippocampus or thalamus
Usually alcohol induced thiamine deficiency (Korsakov’s syndrome)
Other causes: herpes simplex encephalitis, severe hypoxia and head injury
Memory deficits are often irreversible
What are the most common psychiatric disorders?
Anxiety and depression
What psychiatric side effects can phenytoin have?
Ataxia, delirium
What psychiatric presentations can occur with temporal lobe epilepsy during a seizure?
Impaired consciousness Hallucinations and other distorted perceptions: olfactory, somatic (especially epigastric) Sense of déjà vu Depersonalisation and derealisation Speech and memory affected Stereotyped behaviour
What psychiatric presentations can occur with temporal lobe epilepsy after a seizure?
After seizure (Postictal, hours to days): Transient, florid psychosis Between seizures: Schizophrenia-like psychosis, Depression, Sexual dysfunction and lack of libido
What is a poor prognostic feature in a head injury?
Anterograde amnesia >24 hours predicts a poor
long-term outcome, including persistent cognitive deficits
What psychiatric symptoms may occur with a head injury?
Personality changes
Mood disorder, anxiety disorders and schizophrenia
Postconcussional syndrome
Which patient groups are most likely to be confused?
Elderly Memory problems Poor hearing or eyesight People who have had recent surgery Terminal illness Brain disorder eg stroke, tumour
How can we talk to patients with delirium?
Stay calm
Talk to them in short, simple sentences
Check they have understood and repeat things if necessary
Make sure they have their glasses and hearing aid
Reassure them about where they are and how they are doing
Keep history taking short
How can we diagnose delirium?
DSM diagnosis of delirium due to a medical condition
Disturbance of consciousness with decreased clarity of awareness and difficulties of attention
Change in cognition: memory deficit and disorientation or presence of perceptual abnormalities. Changes not the result of previous or evolving dementia
Disturbance develops over a short period of time and fluctuates
Evidence that disturbance is the result of a general medical condition
What is the confusion assessment method?
Feature 1: Acute Onset and Fluctuating Course: obtained from a family member/nurse
Feature 2: Inattention: difficulty focusing attention, easily distractible, or having difficulty keeping track of what was being said
Feature 3: Disorganized thinking or incoherence
Feature 4: Altered Level of consciousness
The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4
What are types of delirium?
Hyperactive delirium: heightened arousal and can be restless, agitated or aggressive
Hypoactive delirium: people who become withdrawn, quiet and sleepy
What supportive management of delirium can be provided?
Clear communication Consistency of staff Family and carer involvement Prompts to day and time Familiar environment Adequate nutrition & fluids Low stress environment
What community involvement should there be in the management of a delirious patient?
Admission prevention- CERT (community emergency response team), admission prevention beds
District nurses
Social worker
GP
What are risks of medical management of delirium?
Sedation can cause delirium
Increased risk of falls
Increased risk CVA
What are risk factors for delirium?
Advanced age
Underlying brain diseases such as dementia, stroke, or Parkinson disease, particularly when there are current problems with memory
Use of multiple medications (particularly psychiatric drugs and sedatives), or multiple medical problems
Sudden withdrawal of a regular medication or cessation of regular alcohol use
Frailty, malnutrition, immobility
Advanced cancer
Undertreated pain
Immobilisation, including physical restraints
Use of bladder catheters
Limb fractures
Interventions, including diagnostic tests
Poor eyesight or hearing
Sleep deprivation
Organ failure, eg, chronic lung disease, heart, kidney, or liver failure
What environmental factors are important in preventing delirium?
Provide appropriate lighting and clear signage. A clock and a calendar should also be easily visible to the person at risk
Reorientate the person by explaining where they are, who they are, and what your role is
Introduce cognitively stimulating activities (reminiscence)
Facilitate regular visits from family and friends
What sensory input is important in preventing delirium?
Make sure patients have their hearing aids and glasses
