Psychiatry Flashcards
Postnatal Depression
DDx
Hx
Risk
Dx
Rx
RFs
Inpatient Indications
Baby blues <7 days, PND 2-3 weeks, PPP 3-4 weeks
Hx - Birth, Pregnancy, Breastfeeding, Interaction with baby, Support, Low age, Unwanted baby, Lack of support, Single mother, Difficult childhood. Normal affective questions. Past history of PND
Risk - Suicide, Infanticide, Neglect, substant abuse, do you feel safe.
Dx- Edinburgh postnatal depression (<13/30), TFTs, B12/Folate, FBC
Rx - Bio (Sertraline, Paroxetine) Psycho (Breastfeeding classes, CBT, Mentalising) Social (Groups, Health Visitor, Social worker, Review weekly, Scheduling, involve key people in patient’s life)
RFs - Low maternal age, Unwanted baby, Traumatic, Not supported, History of sexual abuse, FH, PPH,
Inpatient indications - Psychosis, Suicidal, Infanticidal, Risk of neglect of baby/ mother
Delirium
Hx
Dx
Mx
Rx
Hx - Acute confused state. Fluctuates in mood or cognition. Presence of perceptive disturbance.
Dx - Confusion Assessment Method - Questionnare for delirium.
Look for evidence of recent infection, change in drugs, change in drug levels, addition of drugs, hip fracture.
Delirium can be both hyperactive or hypoactive so watch for both
Try to ascertain baseline level of function and get collateral
Investigate - ABCDE, Examination general, Temperature, Urine dip, FBC, Us and Es, CRP, ESR, Toxicology for drugs. Imaging - CT/MRI if considering stroke or underlying brain pathology.
Mx - ABCDE. Treat underlying cause.
To manage the delirium: Keep orientated (near a clock, calendar), near the nursing bed, keep pictures around the bed, will need OT and PT input, neuropsychological input as follow up to assess deterioration in baseline function.
Short term for agitated patients: IM Haloperidol - But if they have parkinsons/LBD then IM Lorazepam.
Alcohol Counselling
Screening- CAGE (>2), AUDIT-C (>15 for men/ >13 for women), FAST, TWEAK
Dependence - CANT STOP -
Compulsion,
Aware of physical harms,
Neglects other activities,
Tolerance to alcohol,
Stopping drinking leads to withdrawal symptoms,
Time spent with alcohol increases,
Out of control use,
Persistent futile efforts to cut down
Extra history - Past psychiatry history, Forensic History, Impact on social history, other substances, Drive? (inform DVLA if they don’t agree to stop driving)
Managemental
Biological
For withdrawal - Chlordiazepoxide, For cravings - Acamprosate (NMDA/GABA) Naltrexone - antagonist of endogenous endorphins., Deterrent Disulfiram - Acetaldehyde dehydrogenase inhibitor
Deficiencies - Thiamine, B12, Folate, Iron Deficienceis
Tests - FBC, Us and Es, LFTs, Vitamins, Glucose, Clotting Screen, Albumin,
Detoxifications - inpatient generally
Psychological
Motivational Interviewing
CBT
Social
Alcoholics anonymous
Involve family
Intensive support
Psychological Consequences
Withdrawal - 6-12 hours (sweating, tachycardia, anxeity, autonomic hyperactivity, coarse tremors worse at night, hallucinations, nausea)
Seizure - 36 hours
Delirium Tremens - 72 hours (Sweating, tachycardai, lilipuchens, formication)
Affective - anxiety and depression
Alcohol induced psychosis
Dementia
Delusional Disorders i.e. morbid jealously
Increased risk of suicide
Manic Episode
Core Sx: Elation, impulsivity, increased energy, irritation, risky behaviour (drugs, sexual activity). Differentiation between hypomania and mania is mania has psychotic elements. Lasts longer than a week
Hallucinations: When did they start - before or after mood features? How many voices? Nature of voices? Command hallucinations?
DDx: Acute mania, Bipolar affective disorder, Drug induced mania.
Dx: Reversible causes: Drug screen, TFTs, organic pathology,
Mx: Bio - Atypical antipsychotic +/- lithium augmentation(Aripirazole if younger than 18) Psycho (CBT, Family therapy, rapid access services) - Social - (support groups, OT, back to work programme)
Rx - Atypical (Olanzapine, Quetiapine, Risperidone) / Typical - Haloperidol. Drug monitoring. - Checks before you start (ECG, BMI, FBC, Us and Es, Lipids, Glucose, Waist circumference). Take note of smoking and other CVS risk factors
Lithium Monitoring
0.4-1.0 Therapeutic Range / 0.8-1.0 Therapuetic range for mania
Weekly until stable and then three monthly Lithium Levels: when starting treatment or adjusting dose
Baseline and 6 monthly - renal functioning, TFTs and ECG
PTSD
Dx categories:
Mx:
Rx:
4 Categories:
i) Reliving the event
ii) Avoid situations
iii) Emotional Numbness / Hyperarousal
iv) Inability to recall part or all of the experience of the stressor
non - core: not leaving house, irritation, alcohol/drug abuse, violence/aggression, suicidality, assess for risk to others
Ask about movement and sensation - somatisation disorder/ conversion disorder
Dx: Symptoms for more than 4 weeks, starting in between 1 month to 6 months of the incident. Graded into mild, moderate and severe based on severity of social activity impairment
Mx:
Bio: Mirtazipine/ Paroxetine
Psycho: Don’t initially Debrief - can make it worse after the event. DO - Trauma based CBT (Challenges negative thoughts and beliefs abotu the event and helps to develop better coping strategies) , Eye Movement Desensitisation therapy (asked to move eyes while thinking about the event)
Social - Family involvement, Involve workplace/ school, encourage outdoors activities.
OCD
Dx
Rx
Dx: Characterised by Obsessions (Unwanted thoughts that enter their heads. Are unwanted and intrusive) Compulsions (Acts that must be performed and if they’re not lead to distress until they are performed)
Forms of OCD: Manifest as i) Checking , ii) Clearning and iii) Excessively orderly behaviour and iv) Ritualistic behaviours
Important distinctions:
Recognise they are occuring from within their own mind (not psychotic)
are egodystonic (not pleasurable)
Key Questions:
Do you wash or clean a lot?
Do you check things a lot?
Do you find that you take a long time with your daily activities?
Are you concerend about order/ upset by mess?
Assess for risk (suicide can be prevalent)
Assess for risk to others
Screen for substance abuse and other co-morbid psych conditions (overlap with affective disorders)
Rx:
Talk about methods of though redirection - Rubber Band etc.
Bio - SSRIs (In Moderate/ Sever or if in mild where adult is unwilling to commence psychological treatment). Children –> SSRIs are reserved for more severe cases. fluoxetine, paroxetine, sertralline, citalopram
NB for BDD the treatment of choice is fluoxetine.
Psycho - Low/More intensive CBT - Including exposure response prevention
Social - OCD support groups, Work and study support
Overdoses
History
Dx
Mx
Rx
Abstinence regimens
History: (PPH, PMH, PSH, DH, FH, SH, Education, employment, premorbid personality)
What drug? With anything else (alcohol usually)?
When? How many/much? Over what time period? Have they been treated yet? Any symptoms
Antecedents:
Planned or impulsive?
Was there a trigger?
Final acts? avoiding discovery? Past history of OD/DSH? Did you tell anyone?
During:
Seek help? What did you wnat to happen?
Consequences:
Did you want to die? How were you found?
Feelings about it - regret? disappointment at not dying?
Hope?
Protective factors
Plans for the future? - Will you do it again? Have you got plans to do it again?
Screen for substance abuse
Mx: ABCDE, stabilise, obs, IV fluids
Medical - Treat overdose. <1 hour activated charcoal (1-2 hours for TCAs)
Consult Toxbase -
i) paracetomal: Check levels between 4-15 hours and assess need for N-Acetylcysteine/ Liver transplant
ii) Benzodiazepines : Give flumanezil in small doses - only done by trained staff
iii) Salicylates: have mixed respiratory alkalosis (tachypnoea and tachycardia) + metabolic acidosis. Bicarbonate infusison
iv) Opiod: worry is respiratory depression. treatment is with lowest dose nalaxone to start with. Lofexidine for withdrawal symptoms.
v) TCA - Cardiotoxic effects (QRS widening and right axis deviation), sedation, seizures. Bicarbonate infusion
vi) SSRIs - seizures, arrhythmias, rhabdomyolysis, high temperature. seratonin antagonists- cyproheptatidine
Long term management
Bio-psycho-social
Biological - After treatment of the overdose, biological mangement should be based upon clinical findings of mental illness. Consider discussions regarding anti-depressants with patients but patients should be warned of transient worsening of mood up to 6 weeks after treatment initiation. (they should be reviewed within a week of commencement). Lithium augmentation can be considered as this has been shown to be effective in treatment of suicidality.
Consider antipsychotics etc. where appropriate.
treatment of concurrent substance abuse
Psychological - treatment options should be discussed with patient and discussions should be noted in the discharge letter to the GP. CBT, DBT/Mentalising - BPD, Family Therapy.
Screen for substance abuse
Social - Discussion of social precipitants should occur. These should be elicited and may include - employment and relationship discord. Recent bereavement etc.
Should be given information regarding help services i.e. samaritans etc. give leaflets phone numbers etc.
Treatment of abuse
Alcohol: Chlordiazepoxied (reducing dose) , Acamprosate, Disulfiram
Opiate: withdrawal - Lofexidine, abstinence - buprenoprhine (partial), methadone (full)
screen for mental health
Mental Health Service Teams
Psychological therapy Services
Community Mental Health Teams
Early Intervention Team
Home Treatment Team
Eating Disorder Services
Forensic mental Health Services
Liasion psychiatry Team
Memory Assessment services
Perinatal mental Health Services
Learning Disability Services
Older Adult’s Services
Substant Misuse Services
CAMHS
Mental Health Rehabilitation
Psychological therapy Services - Low intensity- high intesity psychological interventions
Community Mental Health Teams - MDT, walk
Early Intervention Team
Home Treatment Team
Eating Disorder Services
Forensic mental Health Services
Liasion psychiatry Team
Memory Assessment services
Perinatal mental Health Services
Learning Disability Services
Older Adult’s Services
Substant Misuse Services
CAMHS
Mental Health Rehabilitation
MSE
ASEPTIC
Appearance and behaviour - eye contact, dress, hygiene, abnormal motor activity (akathisia, dystonia, tardive dyskinesia, bradykinesia)
Speech - Tone rate and volume (pressure, loosness of association, knight’s move, word salad, circumstantial, tangiential), Spontaneous, Logical and Coherent.
emotion - Mood and affect. Subjective and objective
Perception - hallucinations and illusions
Thought - Content ( negative, ruminations, obsessions, depersionalisation/derealisation, abnormal belifs, delusions) and process (flight of ideas, looseness of associations, thought block)
Insight - and judgement
cognition - time, person and place
Dementia
History: Memory, Mood, ADLs, Cognitive functioning, Dangers - driving, oven, swimming, stairs ,
What timescale?
Worsening? When it’s worse?
Movement problems?
Falls?
Hallucinations/ Delusions?
Social withdrawal?
Carer - Are you coping, Do you have health problems in yourself?
substance abuse, depression, incontinence, balance problems.
PPH
Dx:
AMTS (<8/10), MOCA,
Mx:
First - I would like to rule out organic causes
Bio - Acetylcholinesterase Inhibitors (Rivastigmine), Memantine, Avoid antipyschotics (if he’s admitted tell them antipsychotics)
Psycho - CBT, Behavioural therapy, Memory Clinic,
Social - Carers, Support Groups, Carer Support, Carer Respite, ADvanced directives, lasting power attorneys
AMTS
Where to seek advice about toxicity
Toxbase
Lactmed
and BUMPS ( for mums )
Schizophrenia
Hx
Dx
Mx
Imbalance in dopamine in the brain too much dopamine in mesolimbic (positive) and too little in mesocortical pathway (negative)
Hx:
Social withdrawal, delusional perceptions, overvalued ideas, negative symptoms (Blunted affect etc.), hallucinations (auditory usually),
First Rank Symptoms:
Third person Auditory Hallucinations
Delusional Perceptions
Passivity Phenomena
Thought DIsorder - TI, TW, TB
Need to present for more than a month
may be related to drug/alcohol abuse
Dx
Clinical diagnose, Say you would exclude organic causes and screen for alcohol/ drug abuse.
Consider other causes - structural, drug use,
If <1month = Acute and transient episode
Schizophreniform Disorder = Acute traumatic experience
Schizoaffective = 50% mood 50% psychotic component
Depression with psychosis = more than mood than psychotic features
Mx
Bio - Atypical Antipsychotic (unless elderly due to stroke or VTE risk) - Aripiprazole has least metabolic/weight gain side effects, Risperidone, Olanzapine, Quietiapine
Try two antipsychotics for 4-6 weeks (one being atypical) then start clozapine ( clozapine monitoring. Once a week for 18 weeks, Two times a week for upto a year and then monthly)
Consider depot in poor compliance
Newly diagnosed patients are advised to be treated for 2 years
Screen for concurrent mental health
Psycho - CBT, Family therapy, Counselling for alcohol/drug use.
Social - Support groups, Back to work schemes, Educational Schemes
Anorexia Nervosa
Bullimia Nervosa
AN
Hx: Obsession with being fat, obsession with food, Obsession with purging/exercise/laxative use, Avoidance of food, Avoidance of social activities involving food
ICD-10 : BMI >17.5, self induced wieght loss, distorted body image and endocrine disturbance
Derm - Hiar changes (lenugo), dry skin, brittle hair, Thickening on dorsum of hand
Oral - teeth chains (erosions), parotid gland enlargement,
Endocrine - amenorrhoea, signs of hyperglycaemia, hypothyroidism (low T3/T4), delayed puberty, electrolytes(Hypokalaemia, hyponatraemia, hypothermia, amenorrhoea), peripheral neuropathy, lack of concentration
Screen for concurrent psych conditions
Dx:
Weight, Height, BMI. FUll examination
Investiagte - urine dip ketones, glucose, toxins
FBC, CRP, ESR, BMs, Endo screen
ECG
Mx:
Biological: dietician, slow re-feeding (in hospital 1kg a week or outpation 0.5 kg a week), Monitor electrolytes, Consider SSRI (Fluoxetine
Psycho: CBT, Psychodynamic, CAMHS
Social: Family therapy, SUpport groups,
Refeeding Syndrome:
Sx- Cardiac arrhythmias, convulsions and coma
Caused by fatal shifts in fluids and electrolytes after reinstutition of feeding.
Bullemia Nervosa
i) BMI >17.5 ii) Purging activities iii) Bing eating/ cravings for food iv) morbid fear of being fat
Managemenet similar to AN. But moreso use of high dose fluoxetine (60mg). Generally not treated in hospital.
SCOFF questions
Make your self sick
Loss of control of how much you eat
One stone loss in a 3 month period
Think you’re fat when others say you are thin
Would you say food dominates your life
