Psychiatry Flashcards
MSE component sections?
Appearance & Behaviour
- Assessed as going along
Speech
- Flow, form (speed, tone), content
Mood
- Subjective (pt) then objective (yours)
- Assess Sleep, eating, interest, attention, SUICIDE/SELF HARM, energy levels etc.
Affect
- Reactive/non-reactive (can be on spectrum)
- Congruent/non-congruent
- Normal/Flattened/Blunted
Thought Form
- Ordered free flowing, making sense
Thought Content
- Preoccupations/obsessions, self-harm/suicide, delusions
- Ask are your thoughts your own.
Perceptual disturbances
- Have you seen/felt/heard anything that others have not that scares you or seems a bit intimidating?
Cognition
- Orientation, Memory, concentration, MMSE if appropriate.
Insight
- Understanding of illness - what do you think is going on, do you think this is a mental illness?
- Agreeing to treatment
- Capacity to consent to treatment (if appropriate)
First order symptoms for schizophrenia?
Auditory hallucinations (Commentary, thoughts spoken aloud and 3rd person)
Thought withdrawal, insertion and broadcasting.
Somatic hallucinations (touched, strangled, sexual pleasure)
Delusional perception - see something real but make a delusion about it.
Three types of delirium?
Hypoactive: lethargy, reduced motor activity - most common
Hyperactive: agitation, irritability, restlessness
Mixed
Clinical features of delirium?
DELIRIUM:
Disordered thinking: slowed, irrational and incoherent thoughts
Euphoric, fearful, depressed or angry
Language impaired: rambling speech, repetitive or disruptive
Illusions, delusions and hallucinations
Reversal of sleep-wake cycle
Inattention
Unaware/disorientated
Memory deficits
ICD-10 criteria for diagnosis of delirium?
Impairment of consciousness and attention
Global disturbances in cognition
Psychomotor disturbance
Disturbance of sleep-wake cycle
Emotional disturbances
Rough pathophysiological changes in Alzheimers disease?
Degeneration of cholinergic neurones in the nucleus basalis of Meynert (leading to a deficiency of acetylcholine)
Microscopic changes: neurofibrillary tangles (intracellular) and B-amyloid plaque formation (extracellular).
Macroscopic: cortical atrophy (globally), widened sulci and enlarged ventricles
Types of dementia?
Alzheimers
Vascular
Dementia with lewy bodies
Fronto-temporal
Other causes: Infections (CJD, HIV), vitamin deficiencies and some others.
Causes of Lewy body dementia?
Abnormal deposition of protein (lewy body) within the neurones of the brainstem, substantia nigra and neocortex. Loss of acetylcholine outside of the brainstem and loss of dopamine within (some parkinsonian symptoms)
Pathophysiology in fronto-temporal dementia?
Specific atrophy of frontal and temporal lobes.
Main divisions of the types of dementias, in terms of dysfunction?
Cortical: Alzheimers, fronto-temporal.
Subcortical: Lewy body
Vascular is mixed.
Differences in cortical dementia and subcortical dementia?
Severe memory loss in cortical, moderate in sub
Mood is low in subcortical, normal in cortical
Speech and lang shows early aphasia in cortical and dysarthria in subcortical
Coordination is impaired in subcortical dementia, normal in cortical
Dyspraxia in cortical dementia, normal in subcortical dementia
Motor speed slow in subcortical dementia
Genetic basis in Alzheimers?
Presenilin 1 and 2 and amyloid precursor protein associated with early onset alzheimers
Apoe-4 susceptibility for late onset AD.
ApoE-2 is protective.
ICD-10 classification for dementia?
A: Evidence of the following:
1. decline in memory: anterograde amnesia. (can be retro)
- Decline in other areas of cognition
B: preserved consciousness
C: Decline in emotional control or motivation, change in social behaviour:
- Emotional lability, irritability, apathy, reduced social behaviour
D: For at least 6 months
Raja’s criteria for dementia diagnosis
Dysfunction in at least 2 cognitive functions
Present in normal consciousness
With evidence of functional decline
For 6 months.
Cognitive dysfunction in early alzheimers?
Memory lapses, difficulty finding words, forgetting names of places/people.
Cognitive dysfunction in progressing alzheimers?
Dyspraxia, speech and language dysfunction, difficulty with executive functioning
Cognitive dysfunction in late stage alzheimers?
Disorientation to time and place
Incontinence
Apathy
Depression
Agitation
Definition of a delusion?
A fixed, false belief which is firmly held despite evidence to the contrary and goes against the individuals social and cultural belief system.
Definition of a hallucination?
A perception in the absence of an external stimulus.
Definition of a thought disorder?
Inability to form thoughts from logically connected ideas.
Cuases of psychosis?
Organic:
- Drug induced
- Iatrogenic
- Complex partial epilepsy
- Delirium
- Dementia
- HD
- SLE
- Syphilis
- Endocrine disturbances & metabolic disorders
Non-organic causes
- Schizophrenia
- Schizotypal disorder
- Schizoaffective disorder
- Acute psychotic episode
- Mood disorders
- Drug-induced
- Delusional disorder
What is schizotypal disorder?
It’s latent schizophrenia
- eccentric behaviour
- suspiciousness
- unusual speech
- deviations of thinking
What is schizoaffective disorder?
A disorder characterized by both symptoms of schizophrenia and a mood disorder in the same episode of illness. Mood symptoms need to meet criteria for depression or mania, as well as two symptoms of schizophrenia.
Pathophysiology of schizophrenia? (5)
- Genetic role - monozygotic twin studies show 48% concordance rate.
- Dopamine hypothesis - mesolimbic pathway has overactive dopamine stimulation - positive symptoms.
Mesocortical pathway has underactive stimulation leading to negative symptoms. - Factors that interfere with early neurodevelopment e.g. low birth weight, fetal injury. Lead to abnormalities in teh developing brain.
- Adverse life events and stress. Different fluffy psychological arguments here:
Stress-vulnerability model predicts that schizophrenia occurs due to environment stressors interacting with a genetic predisposition or brain injury.
- Some involvement of glutamate - perhaps a reduction of glutamate in the frontal lobe, leading to negative symptoms
Positive symptoms of schizophrenia? (5)
- Delusions, including gradiose, persecutory, nihlistic (everything is meaningless) or religious. Also includes ideas of reference (common events refer directly to them).
- Hallucinations: a perception in the absence of external stimulus.
- Formal thought disorder
- Thought interference (insertion, withdrawal, broadcast)
- Passivity phenomena (actions, feelings or emotions controlled by external force).
Negative symptoms of schizophrenia? (6)
The A’s:
- Avolition (inability to initiate and persist in goal-driven behaviour)
- Asocial behaviour
- Anhedonia
- Alogia (poverty of speech)
- Affect blunted
- Attention deficits
Types of schizophrenia?
Paranoid schizophrenia (most common- positive symptoms)
Postschizophrenic depression (depression after a schizophrenic episode in the past 12 months)
Hebephrenic schizophrenia (early onset and thought disorganization dominates)
Catatonic schizophrenia
Simple schizophrenia
Undifferentiated (meets criteria but not a subtype)
Residual schizophrenia (1 year of chronic negative symptoms preceded by a clear cut episode)
Management of schizophrenia?
Bio:
- Atypical Antipsychotics (resperidone or olanzipine)
- Clozapine in tteatment resistance
- Depot of there are compliance issues
- Adjuvants such as benzos or mood stabilisers/SSRIs
- ECT in catatonia, and treatment resistance
Psychological:
- CBT
- Family intervention
- Art therapy (for neg. symptoms)
- Social skill training.
Social:
- Support groups and peer support
- supported employment programmes
Things to ask/rule out in psychiatric history for depression, psychosis and anxiety disorders?
Depression:
- Low mood
- Anhedonia
- Anergia
Psychosis:
- Delusions (any specific worries? Do you feel safe)
- Hallucinations (signpost, then do you ever see or hear things that other people are unable to?)
- Auditory hallucinations: are the voices talking about you or directly to you? Are they doing a running commentary?
Anxiety:
- GAD: would you say you are an anxious person, do you worry about everyday things?
- Panic attacks
- Phobias: any fears that others may consider irrational
- Obsessions: any thoughts that keep coming back into your mind?
What is a personality disorder? (6)
(1) A deeply ingrained enduring pattern of inner experiences and behaviour that (2) deviates markedly from expectations in the individuals culture, that is also (3) pervasive and inflexible, (4) has an onset in adolescence or early childhood and (5) is stable over time, and (6) leads to distress or impairment.
R/Fs for Personality disorders?
Societal:
- Low SES
Genetics:
- Monozygotic twin studies
- Family history
Dysfunctional family:
- Poor parenting
- Parental deprivation
Abuse during childhood:
-Physical, sexual, emotional and neglect
Prevalence of personality disorders?
4-13% General population
20% of GP attendees
Types of WEIRD personality disorders? (2)
WEIRD - odd/eccentric
Paranoid:
- suspicious of others/no trust
- Unforgiving/doesn’t like criticism
- Spouse fidelity questioned
- Envious of others
Schizoid (like asperges):
- Flattened affect
- Low libido
- Absence of close friends
- No emotion
Types of WILD personality disorders?
WILD - Dramatic/emotional
EUPD:
- Mood unstable
- Fear of abandonment
- Short unstable and intense relationships
- Feel empty
- Impulsive and no temper control
- Usually grow out of when older
Anti-social
- Callous, unfeeling, no guilt
- Blames others
- No regard for safety
- Deceitful
- Impulsive
- Within this you get psychopathic and sociopathic
Narcissistic
- Trump
- Need admiration, don’t give a shit about others
Histronic:
- Provocative behaviour, attention seeking, seductive
- Concern for physical attractiveness and vain
- Influenced easily
- Need drama all the time
Types of WORRIER personality disorders?
WORRIERS - Anxious/Fearful
Dependent:
- Requires reassurance
- Lack self-confidence
- Abandonment feared
Anxious (avoidant):
- Restricts lifestyle in order to maintain security
- Feels inadequate
- Social inhibition
Obsessional:
- Preoccupied with detail, to the point where this is damaging
- Can’t complete tasks
- Workaholic
- inflexible/stubborn
Management of personality disorders?
Identify and treat co-morbid mental health disorders
Treat any co-existing substance misuse
Risk assessment. Crucial. Crisis plan.
Psychological intervention:
- CBT, DBT and psychodynamic
Social:
- Support groups
- Supported employment programmes
Biological:
- Atypical antipsychotics for transient psychotic periods
- Mood stabilisers
- Antidepressants
Definition of deliberate self-harm?
(1) Intentional act of (2) self-poisoning and injury, (3) irrespective of the motivation or apparent purpose of the act, (4) usually an expression of emotional distress.
R/Fs for self harm?
Divorced/single/living alone Life stressors Drug alcohol abuse <35 Chronic physical health Domestic violence or childhood abuse SES disadvantage Psychiatric diagnosis (depression/psychosis)
Investigations for self harm? (5)
- Intentions before and during the act?
- Suicidal ideation now?
- Current life stressors
- Psychiatric disorders?
- Collateral history?
Clinical R/Fs for suicide?
History of DSH or attempted suicide
Psychiatric illness
Childhood abuse
Family history
Medical illness
Socio-demographic R/Fs for suicide?
Male gender
40 to 44 (men)
low SES or unemployed
Occupation: Vets, doctors, nurses and farmers.
Access to lethal means (guns)
Low social support
Single/divorced marital status
Recent life crisis (e.g. bereavement)
Protective factors for suicide?
Children at home
Pregnancy
Strong religious beliefs
Strong social support
Positive therapeutic relationship
Fear of act of suicide (i’ma coward)
Hope for the future
Questions to determine risk of second suicide attempt?
Note Planned Attempts Are Very Frightening
Note left
Planned attempt
Attempts to avoid discovery
Afterwards help not sought
Violent method
Final acts: sorting out finances, writing a will.
Risk assessment areas to cover for a suicidal person?
- Explore suicidal ideation
- Explore suicidal intent
- Exploring R/Fs
- Protective factors
- Risk to others
- MSE
Management of suicidal patient?
Ensure safety
Medically stabilised
Risk assessment
Admission to hospital - section if appropriate
Referral to appropriate centre of care
Psychiatric treatment
Treatment for alcohol withdrawal?
Hospital treatment: Give benzo then taper it down in hospital. Chlordiazepoxide. Similar receptor action, short course. Safely manage withdrawal.
Community
1. Disulfuram - to maintain it, makes you feel rubbish when you drink, inhibits the break-down of alcohol. Some cardiac risk if drinking on top.
- Naltrexone - partial agonist, doesn’t give pleasure and reward of alcohol
- Acamposate - safest. Possible liver damage. Stops craving
R/Fs for PTSD?
Exposure to major traumatic event
Pre-trauma: previous trauma, Low SES, female
Peri-trauma: Severity of trauma, perceived threat to life, adverse emotional reaction.
Post-trauma: concurrent life stressors, absence of social support.
Management of PTSD, within first 3 months?
Within 3 months:
- Watchful waiting at first
- Trauma focused CBT
- Short term drug treatment e.g. of sleep
- Risk assessment
Management of PTSD, > 3 months?
Trauma-focused psychological greeting:
- CBT
- EMDR
Drug treatment:
- Paroxetine
- Mirtazipine
- Amitrypiline
- Phenelzine
Clinical features of depression?
Core symptoms:
- Anhedonia
- Low mood
- Anergia
Cognitive symptoms:
- Lack of concentration
- Guilt
- Suicidal ideation
Biological symptoms:
- Diurnal variation in mood
- Early morning wakening
- Loss of libido
- Weight loss/appetite loss
- Psychomotor retardation
Psychotic symptoms (hallucinations/delusions)
Management of mild-moderate depression?
Watchful waiting should be considered
Antidepressants not recommended unless:
- long-lasting depression
- past history of moderate-severe depression
- failure of other interventions
- complicated the care of other physical health issues.
Self-help manual with a healthcare professional
CBT
Physcial activity
Psychotherapies
Management of moderate-severe depression?
Suicide risk assessment
Psychiatric referral:
- suicide risk is high
- severe depression
- recurrent
- unresponsive to treatment
Mental health act detention
Antidepressants: - SSRI (e.g. citalopram, sertraline) - TCAs - SNRI - MAOI - by specialists Continued for 6 months after resolution of symptoms if first episode, 2 years if second episode.
adjuvants to antidepressants include lithium or antipsychotics
Psychotherapy: CBT/IPT/counselling/behavioural activation/psychodynamic therapy.
Social support
ECT if:
- Failure of other treatments
- Psychomotor retardation
- Rapid response required
- Psychotic features
Difference in typical and atypical antipsychotics?
Atypical are the second generation drugs that are specific for D2 receptors, but also for other receptors such as serotonin, histamine, adrenergic, acetylcholine:
- EPSEs (less of)
- Anti-muscarinic: ‘can’t see, wee, spit or shit’
- Anti-adrenergic: postural hypotension, tachycardia
- Endocrine/metabolic
- Neuroleptic malignant syndrome
- Prolonged QT interval
- Clozapine comes with agranulocytosis
ICD-10 criteria for substance misuse disorder?
Acute intoxication
Harmful use
- recurrent use associated with biopsychosocial consequences
Dependence - addiction, tolerance
Withdrawal state
Psychotic disorder within 2 weeks of substance use
Amnesic syndrome
Residual disorder
Pathophysiology/aetiology of substance misuse disorder?
Biological
- Genetic variability in the enzymes that metabolise drugs causing different effects
- Abnormalities in the dopamine, GABA and opioid systems.
Environmental
- peer pressure
- life stressors
- parental use
- cultural acceptability
- personal vulnerability, incompetent coping mechanisms
Positive reinforcement (behavioural)
- psychosocial factors from peers
- biological reinforcement - mesolimbic dopamine reward pathways
Eventually dependence
Four features of dependence?
Drug Problems Will Continue To Harm
Desire to consume
Preoccupation
Withdrawal state
Inability to Control use
Tolerance
Harmful effects
Management of substance dependence (non-pharmacological?
Keyworker with therapeutic alliance
Hep B immunization
Motivational interviewing and CBT
Contingency management
Supportive help in terms of housing, finance and employment
Self-help groups
Biological therapies in opioid dependence for detox, maintenance and in acute OD?
Methadone or buprenorphine for detox, and maintenance (slowly tapered down)
Risk factors for alcohol abuse?
Male
Younger adult
Some genetic role
Antisocial behaviour
No facial flushing - less in east asian pops
Life stressors - financial issue, marital issues
When does delirium tremens strike?
Between 24 hrs to 7 days
Peak is at 72 hours
Features of delirium tremens?
Dehydration and electrolyte disturbances
Cognitive impairment
Perceptual abnormalities, hallucinations or illusions
Paranoid delusions
Marked tremor
Autonomic arousal - tachycardia, fever, mydriasis
Management of delirium tremens?
Large doses of BDZ, haloperidol for psychosis and pabrinex
What are the two neuropsychiatric complications of alcohol dependence?
Wernicke’s encephalopathy - acute encephalopathy due to thiamine deficiency:
- Delirium
- Nystagmus
- Opthalmoplegia
- hypothermia
- ataxia
Korsakoff’s psychosis
- Profound irreversible STM loss
- Confabulation (to fill gaps)
- Disoriented to time
What is the acute detox regime for alcohol patients?
High dose benzos (chlordiazepoxide), then dose tapered down over 5-9 days
In addition to thiamine orally or IV (pabrinex)
Long term alcohol dependence management?
Disulfuram
- unpleasant reactions to alcohol
Acamposate
- enhances GABA - reduces craving
Naltrexone
- Blocks opioid receptors and reduces the pleasurable effects of alcohol
Motivational interviewing and CBT as psychological interventions
AA and support
What does neurosis, anxiety and when does this become an anxiety disorder?
Neuroses are psychiatric disorders characterised by distress, non-organic with a discrete onset, no delusions or hallucinations.
Anxiety is the unpleasant emotional state involving fear and somatic symptoms
When anxieties become excessive or inappropriate they are classed as a disorder
What is the ICD-10 classification of neurotic and stress related disorders?
Phobic anxiety disorders
- Agoraphobia (with or without panic)
- Social phobia
- Specific phobias
Other anxiety disorders
- Panic disorder
- GAD
- Mixed anxiety and depression
OCD
Reaction to stress and adjustment disorders
- PTSD
- Adjustment disorder
- Abnormal grief?
Clinical features of GAD, ICD criteria?
WATCHERS
Worry - uncontrollable. excessive
Autonomic arousal - sweating, mydriasis, tachycardic
Tension/Tremor - in muscles
Concentration difficulty/chronic aches
Headache/hyperventilation
Energy loss
Restlessness
Sleep disturbances
ICD-10:
6 months of worry, tension and feelings of apprehension
Four symptoms of
- autonomic arousal (one HAS to be)
- the others (above)
R/Fs for GAD?
Predisposing
- Genetics
- Childhood
- Personality type (high achiever demands)
- Divorced
- Living alone
- Low SES
Precipitating
- Stressful life events e.g. domestic violence
- Unemployment
- illness
- relationship difficulties
Perpetuating
- Chronic illness, continuing stressful events
- Living alone
- unhelpful thinking patterns (anxious about being anxious)
Management of GAD?
Biological
- First line treatment is SSRI (sertraline)
- Then SNRI (venlafaxine)
- Pregabalin
- BDZ are only for short term relief during crises
Psychological
- Psychoeducational groups - low intensity
- High intensity e.g. CBT and applied relaxation
Social
- Self-help and support groups
- Encourage exercise
Investigations for GAD?
Bloods
- FBC for infection or anaemia
- TFTs (hyperthyroidism)
- Glucose for hypoglycaemia
ECG
- Tachycardia
- Palpitation origins?
Questionnaires
- GAD-2/GAD-7
- Becks anxiety inventory
- hospital anxiety and depression scale
What is a phobia? What are the types of phobia?
A phobia is an intense irrational fear of an object, place, situation or person that is excessive or unreasonable
Agoraphobia
- fear of public spaces where immediate escape would be difficult (in the event of a panic attack)
Social phobia (SAD) - Fear of social situations which may lead to humiliation criticism or embarrassment
Specific phobia
- a phobia isolated to a specific thing (that is not agoraphobia or social phobia
Clinical features of phobic anxiety disorders?
Biological
- Tachycardia, however vasovagal responses in some phobias leading to syncope.
- Other autonomic symptoms as in GAD
Psychological
- Include unpleasant anticipatory anxiety, urge to avoid the situation and a fear of dying
management of phobic anxiety disorders?
Avoid anxiety inducing substances e.g. caffeine
screen for co-morbidities such as substance misuse and Personality disorders
Agoraphobia
- CBT inc. graduated exposure
- SSRIs
SAD
- CBT inc graduated exposure
- SSRI
- SNRI
- MAOI
- Psychodynamic therapy (if they decline CBT or medication)
Specific phobias
- Exposure self help or CBT
- BDZ for short term management of acute stressful events (i.e. CT scan in claustrophobia)
Summary of operant conditioning?
Positive reinforcement
- following wanted behaviour something is added in
Negative reinforcement
- following wanted behaviour something is taken away
Positive Punishment
- Following unwanted behaviour something is added
Negative punishment
- Following unwanted behaviour something is taken away
Levels of validation?
Level 1
- Be 100% present in the conversation
Level 2
- Accurate reflection including summarising, check that you have it right
Level 3
- Draw inferences as to their unspoken emotions, check accuracy
Level 4
- Acknowledge safe behaviour
- i.e. not self-harm or suicide
Level 5
- Acknowledge thoughts and feelings
Level 6
- Radical openness
- Own feelings in open, honest and optimistic talk
What is panic disorder, what are the clinical features and ICD diagnostic criteria?
Recurrent, episodic, severe panic attacks, unpredictable and not restricted to any particular situation or circumstance.
ICD-10
A - recurrent panic attacks not consistently associated with a specific situation or object, often occur spontaneously.
B - Need ALL
- Discrete episode of intense fear or discomfort
- Starts abruptly
- Reaches peak within a few minutes and lasts at leasts some minutes
- Autonomic arousal
- Other symptoms of Panic like in GAD
Risk factors and aetiology of Panic disorder?
Risk factors
- FH
- Major life events
- Age 20-30
- White
- Female
- Co morbid mental health disorders
- Asthma
- Smoking
- Medication
Aetiology
- Most heritable anxiety disorder along with OCD, so some genetic component
- Sympathetic nervous system negative spiral as more stimulation can lead to more worry (adrenaline, increased HR etc.)
- Some cognitive component in the misinterpretation of somatic symptoms - palpitations means i’m gonna die
- Environmental - life stressors
Management of Panic disorder
SSRIs are first line trial for 12 weeks and if no improvement then can prescribe a TCA (e.g. imipramine)
CBT
Self-help, including written info, support groups and encourage exercise
Referred to specialty if two interventions have been trialed without improvement
PTSD definition and ICD 10 diagnosis?
PTSD is an intense prolonged, delayed reaction following exposure to an exceptionally traumatic event
ICD 10
A Exposure to a stressful event or situation that is extremely threatening or catastrophic
B persistent remembering or reliving of the event
C Actual or preferred avoidance of similar situations to the precipitating event
D Either 1 or 2:
- inability to recall some of the important aspects
- Persistent symptoms of increased psychological arousal
E The above must have occurred within 6 months of the event or at the end of a period of stress
Another clinical feature is emotional numbing, difficulty feeling emotions and distancing themselves from others
Features of abnormal bereavement?
> 6 months
Delayed onset
More intense
What is OCD, what are the features and the ICD 10 diagnostic criteria?
A disorder characterised by recurrent (1) obsessional thoughts and (2) compulsive acts
Obsessional thoughts are unwanted thoughts, images or urges that repeatedly enter the individuals mind, are distressing.
Compulsions are repetitive, stereotyped behaviours or mental acts that a person feels driven to performing, can be overt or covert (mental acts)
ICD 10
A:
Obsessions/compulsions on most days for at least 2 weeks
B:
- Obsessions and/or compulsions must have some features:
- FORD CAR
- Failure to resist
- Originate from the patients mind
- Repetitive
- Distressing
- CARrying out obsessive thought or act is not in itself pleasurable, but reduces anxiety levels.
C
- The obsessions and compulsions all must interfere with the patients social or individual functioning.
Pathophysiological and aetiological factors of OCD?
Biological
- Some evidence of serotonin dysfunction in the frontal cortex and basal ganglia
- Twin and family studies suggest a genetic contribution
- Group A strep infection link - autoimmune reaction in basal ganglia (PANDAS)
Psychoanalytic
- filling the mind with obsessional thoughts in order to prevent undesirable ideas from entering the consciousness
Behavioural
- Operant conditioning maintains the behaviour, as anxiety is reduced upon performing the behaviour: negative reinforcement
Management of OCD?
- CBT including ERP (exposure and response prevention)
- exposed to anxiety causing situation and prevented from doing compulsive behaviour - Pharmacological therapy
- SSRIs e.g. fluoxetine
- Clomipramine as alternative
Systemic
- Self-help
- psychoeducation
Mild - low intensity psychological therapy
Moderate - High intensity psychological therapy or pharmacotherapy
Severe - CBT with ERP and SSRI
What are somatoform disorders, and what are dissociative (conversion) disorders?
Somatoform
- Symptoms take the form of a physical disorder but the patient lacks the physiological illness, can be any number of symptoms e.g. GI pain, bloating Nausea and vomiting to parasthesia, dysuria and frequency.
Dissociative
- symptoms that cannot be explained by a medical disorder, there is a causal link in time to stressful life events the events a ‘converted’ into the symptoms
Examples
- Dissociative convulsions, resemble epilepsy but no loss of consciousness
- Dissociative fugue - unexpected physical journey
Also amnesia and stupor
What is a factitious disorder and malingering?
Both are faking symptoms
Factitious (munchausen’s syndrome)
- Faking in order to adopt the ‘sick role’
- For primary gain
Malingering
- Fakes for advantageous consequences of being diagnosed, e.g. to evade criminal prosecution
What is mild cognitive impairment?
Complaints of poor memory corroborated by informant
Objective evidence of episodic memory impairment
Largely intact general (non-memory) cognitive abilities
Normal activities of daily living
Not reaching ICD/DSM criteria for dementia
10-20% progress to dementia every year
Difficulties in vascular dementia?
More impaired on semantic memory, executive/attentional functioning, and visuospatial and perceptual skills.
Some emotional and personality changes.
Less impaired on episodic memory.
Difficulties in Dementia w/ lewy bodies and Parkinsons disease dementia?
Presnt similarly but DLB within 12 months of parkinsons/dementia onset, PDD is >12 months apart
Fluctuations in cognitive performance
Recurrent visual hallucinations
Features of Fronto-temporal dementia?
Under the age of 65 FTD is as common as AD
Loss of social awareness and insight
Disinhibition and impulsivity
Apathy, inertia and spontaneity
Mental rigidity and inflexibility
Personal neglect
Stereotypic behaviours and rituals
Change in eating habits and food preference
Loss of empathy and mentalising ability
Features of B12 dementia?
Signs of peripheral neuropathy and myelopathy can be observed: distal paresthesias, impairment of vibratory and position sense, reduced ankle jerks
Mood changes (agitation, depression, mania) to psychotic episodes (paranoia, auditory and visual hallucinations, delusions) to cognitive impairment (slow mentation, memory deficits, confusion, dementia)
Mental or psychological changes may precede haematological signs by months or years
Non-cognitive symptoms of dementia?
Affective symptoms:
- Anxiety
- Depression
- Apathy
- Elation
- Disinhibition
Psychotic symptoms:
- Hallucinations
- Delusions
- Misidentification
Behavioural Symptoms:
- Aberrant motor behaviour
- Agitation/aggression/irritability
- Sleep disturbance
- Eating disturbance
- Hypersexuality
Features of Alzheimers?
Executive dysfunction
- planning, organization, problem solving.
Visuospatial abilities
- Impairments in copying, driving, may get lost
Dysphasias:
- Word finding difficulty
- decreased vocab
- global aphasia (difficulty in comprehension and production of language).
Dyspraxia:
- inability to carry out previously learned purposeful movements
Agnosia
Disorientation to time and place
hallucinations/delusions/emotion/behaviour
Triad of dysfunction in autism?
Social interaction impairment
- few social gestures
- lack of eye contact
- lack of interest in others
Restricted interests and lack of imagination
- Rocking and twisting
- Upset at any change in daily routine
- Restricted interests in food, games, telly
- Fascination in sensory aspects of the environment
Impaired communicative ability
- Distorted or DELAYED speech
- Echolalia (repetition of words)
Pathophysiology and aetiology of autism?
Prenatal
- Genetics there is a polygenic relationship which is complex, increased risk associated with fragile X and tuberous sclerosis
- Parental age
- Drugs e.g. valproate
- Infection - rubella
Perinatal
- Obstetric complications at birth, hypoxia, preterm and low birth weight
Postnatal
- Toxins such as lead and mercury
- pesticide exposure
When does autism normally present?
Onset is before 3 years, parents will normally have cause for concern by 12-18 years old.
ICD 10 diagnostic criteria for ASD?
A Presence of abnormal or impaired development before the age of 3
B Qualitative abnormalities in social interaction
C Qualitative abnormalities in communication
D restricted, repetitive and stereotyped behaviour, interests and activities
E not attributable to another type of developmental disorder
Management of autism?
Local multidisciplinary teams should be employed and a keyworker assigned
CBT is the child is developed enough to engage
Social skill training
Family and carer support
Special schooling
May consider melatonin for sleep disorders persisting despite behavioural interventions
Core features
- Social-communication intervention (e.g. lego play therapy)
- DO NOT use pharmacological agents
Behaviour
- Treat co-morbidities
- Modification of environmental factors
- Antipsychotics (e.g. resperidone) for really challenging behaviour
Medical conditions associated with autism?
Epileptic seizures (20%) Visual and hearing impairment Infections Constipation Sleep disorders PKU, Fragile X, Tuberous sclerosis Other psychiatric conditions (OCD, mood disorders e.t.c)
Features of ADHD? ICD 10 diagnostic criteria?
Early onset, persistent pattern of inattention, hyperactivity and impulsivity, more frequent and severe than individuals at a comparable stage of development.
A Abnormality of attention, activity and impulsivity at HOME - for age and developmental level
B Abnormality of attention activity and impulsivity at SCHOOL or NURSERY
C Directly observed abnormality of attention or hyperactivity
D does not meet criteria for other psychiatric conditions
Onset before 7
Duration of atl 6 months
IQ above 50
Risk factors for ADHD?
Male
FH (70% in twin studies)
Environmental:
- Social deprivation, family conflict, cannabis and alcohol exposure
Symptoms of inattention, hyperactivity and impulsivity?
Inattention
- Not listening when being spoken to
- Highly distractible
- Reluctant to engage in activities that require persistent effort
Hyperactivity
- Restlessness, fidgeting or tapping
- recklessness
- Won’t do quiet things
- Excessive talking or noisiness
Impulsivity
- Difficulty waiting their turn
- Interrupting others
- Prematurely blurting out answers
- Disobedient
Management of ADHD?
General
- Support groups (parents and teachers)
- There is a clear link between diet and behaviour
Pre-school
- Parent training and education programmes - first line
- Parent training is behavioural, helped to use operant conditioning and reinforcement as well as dealing with troubling behaviour
- No pharmacotherapy at this age
School-goers
- Psychoeducation and CBT (and or social skills training)
- If severe then methyphenidate (CNS stimulant)
- If Methylphenidate fails then atomoxetine (norad reuptake inhibitor)
- Has S/Es of nausea, headache, insomnia, loss of appetite and weight loss - need to do some measurements.
Common co-morbidities of ADHD?
70% have co-morbidities e.g. ASD, Dyslexia, dyspraxia and mood disorders
Conduct disorder
- 50% of ADHD
- Severe, repetitive antisocial behaviour
- Violations of law, physical aggression e.t.c.
ODD
- less severe than conduct disorder
- Defiance against authority
- Less violations of law and physical abuse than conduct disorder
What are the two types of attachment disorder?
Reactive
- Cant form intimate relationships with others
Disinhibited
- Form attachments to pretty much anyone who will have them
These form from lack of a proper bond to their attachment figure, normally displaying disorganised attachment (in the SST). Start <5 years old.
Risk factors for depression?
FF AA PP SS
Female/Family history
Alcohol/Adverse life events
Past depression/Physical co-morbidities
Lack of social support/Low SES
How do you stratify depression to mild-severe?
Mild
2 core symptoms and 2 others
Moderate
2 core with 3-4 others
Severe depression
3 core and >4 others
Severe with psychosis
3 core, >4 others and psychosis
Bipolar disorder classifications?
Bipolar I
- Periods of severe mood episodes from mania to depression
Bipolar II
- Milder form, basically may have hypomania, both still have depression though
Rapid cycling
- More than 4 mood swings in a 12 month period, no no intervening free periods
- Bad prognosis
Symptoms of mania?
I DIG FASTER
Irritability
Distracted/disinhibited
Insight impaired/increased libido
Grandiose delusions
Flight of ideas Activity increased Sleep decreased Talkative Elevated mood Reduced concentration
Pathophysiology of bipolar?
Biological and environmental factors
Monoamine hypothesis
Dysfunction of the HPA axis
40-70% heritability (in monozygotic twin studies)
May be precipitated by adverse life events, exams, grief
Substance misuse
Male to female ratio is actually equal
ICD 10 criteria for bipolar diagnosis?
3/9 symptoms
Needs at least two episodes in which a persons mood and anxiety levels are disturbed, one needs to be mania or hypomania (don’t need depression as it will inevitably come)
Management of bipolar?
Full risk assessment
Consider section under MHA
CBT can be used for bipolar depression
Pharmacologically :
Mania/mixed:
- Antipsychotic (olanzipine best)
- Then mood stabiliser: Lithium or valproate
- Benzos for sleep or agitation
- If rapid tranquillisation required then haloperidol or lorazepam
Depressive disorder
- Atypical antipsychotics e..g olanzipine (can also give quetiapine)
- Mood stabiliser e.g. Lithium or lamotrigine
- Can give antidepressants but with caution as they may induce mania
Extra risks/precautions when using lithium?
Has narrow therapeutic window so you need to monitor its blood levels
Before starting need Us and E, TFTs and pregnancy status and ECG
Difference in mania and hypomania?
Hypomania
- Mildly elevated mania
- > 4 days
- interference with social and work life but not severe
Mania
- > 1 week
- Complete disruption of work and social activities
- grandiose ideas, sexual inhibition, exhaustion due to decreased sleep
ICD 10 criteria for anorexia nervosa?
FEED
Fear of weight gain Endocrine disturbances e.g. amenorrhoea Emaciated (low BMI) Deliberate weight loss Distorted body image
Present for at least 3 months
Does not have:
- Recurrent episodes of binging
- Preoccupation or craving to eat
Differences in Anorexia and Bulimia?
Anorexia
- Significantly underweight
- More likely to have endocrine abnormalities
- Do not have cravings for food
- Do not binge eat
- Other weight loss behaviours
Bulimia
- Normal or overweight
- Less likely to have endocrine abnormalities
- Strong cravings
- Episodes of binge eating
- Other weight loss behaviours
What is binge eating disorder?
New diagnosis consisting of recurrent episodes of binge eating without compensatory behaviour such as vomiting, fasting or excessive exercise
Management of anorexia?
Biopsychosocial
Risk assessment, consider section if <14 BMI or severe electrolyte disturbances and psychiatric reasons
Aim of inpatient treatment is weight gain of 0.5 - 1kg a week, 0.5 in outpatient
Have to be aware of refeeding syndrome
Biological
- Treat medical complications
- SSRIs for co-morbid depression or OCD
Psychological
- Psychoeducation
- CBT
- Cognitive analytic therapy
- Interpersonal psychotherapy
- Family therapy
Social
- Voluntary organizations
- Self-help groups
Features and ICD 10 criteria for bulimia diagnosis?
ICD 10 Bulimia Patients Fear Obesity
Behaviours to prevent weight gain
- Vomiting
- Starvation for alternating periods
- Drugs e.g. laxatives
- excessive exercise
- Diabetics may try to omit their insulin
Preoccupation with eating
- Craving to eat which leads to bingeing typically with regret or shame afterwards
Fear of fatness
- self-perception of being too fat
Overeating
- Two episodes per week
- Period of 3 months
Others
- Normal weight
- Depression or low self-esteem
- Irregular periods
Aetiology of anorexia just generally?
Quite a big genetic link, twin studies and family history
Can have psychological factors such as sexual abuse, low self-esteem pre-morbid anxiety and depression
Societal factors such as (social media), bullying at school around weight, may have an occupational pressure to be slim such as ballet or modelling
Higher SES
Aetiology of bulimia?
Role of genetics is unclear
There is a vicious cycle: 1. Sense of compulsion to eat 2. Binge eating 3. Fear of fatness 4. Compensatory weight loss behaviour (e.g. vomiting or drugs) 1 and so forth
Bulimia is equal across SES
Similar precipitating and predisposing to anorexia:
Can have psychological factors such as sexual abuse, low self-esteem pre-morbid anxiety and depression
Societal factors such as (social media), bullying at school around weight, may have an occupational pressure to be slim such as ballet or modelling
T1DM
Management of bulimia?
Risk assessment and possible section/inpatient admission in severe issues
Biopsychosocial
Biological
- Trial of antidepressants, usually fluoxetine
- Treat medical complications, e.g. hypokalaemia
Psychological
- CBT specific for bulimia
- Psychoeducation
- Interpersonal psychotherapy
Social
- Food diary to monitor eating/purging patterns
- Techniques to avoid bingeing
- Small regular meals
- Self-help programmes
Prognosis of BN and AN?
Bulimia - 50% make full recovery
Anorexia - 20% will make a full recovery
Examples of typical, first gen antipsychotics
Chlorpromazine (first 1951)
Haloperidol
Sulpiride
Examples of atypical second gen antipsychotics?
Olanzipine
Risperidone
Quetiapine
Aripriprazole
Clozapine
What are the extra pyramidal side effects?
Parkinsonism
- Bradykinesia
- Rigidity
- Coarse tremor
Akathisia
- Unpleasant feeling of restlessness
- First months of treatment
Dystonia
- Acute painful spasms of muscles in the neck, jaw and eyes
Tardive dyskinesia
- jaw thrust type stuff
What is neuroleptic malignant syndrome? How does it present, how is it managed?
Rare, but life threatening SE of antipsychotics. (also other dopaminergic drugs)
Normally after starting or upping dose of antipsychotic
Pyrexia, muscle rigidity, confusion, fluctuating consciousness and autonomic instability.
CK is raised
Stop drug, monitor signs, IV fluids, cooling, could use bromocriptine - a dopamine agonist
What things may you have to monitor when putting patients on antipsychotic medication?
FBC, U&Es and LFTs
Fasting blood glucose
Blood lipids
ECG
BP
Prolactin
Weight
Physical health
Creatine kinase
Antipsychotics associated with weight gain?
Olanzipine
Quetiapine
Lozapine
Antipsychotics less associated with weight gain?
Aripriprazole
Amisulpiride
Lurasidone
What antipsychotics can be given by depot?
Atypicals
- Risperidone
- Paliperidone
- Olanzipine
- Aripriprazole
What is the biggest contraindication to donepezil use in dementia, what would you use instead?
CVD - hypotension/bradycardia?
Risk factors for serotonin syndrome?
Old, female, overweight, decreased renal function.
What antidepressant has the least discontinuation symptoms due to its really long half-life?
Fluoxetine
What antidepressant do you need to monitor blood pressure on?
Venlafaxine
What antidepressant can cause weight gain, but unlikely to cause sexual dysfunction?
Mirtazipine
What antidepressant is less likely to cause cognitive problems?
Vortioxetine
What antidepressant is dangerous in OD and can be used for neurological pain in low doses?
Amitriptyline
What are the significant antidepressant interactions that you should be aware of?
Risk of bleeding with NSAIDS (normally prescribe PPI, or stop NSAID)
Risk of serotonin syndrome when combining with serotonergic drugs e.g. tramodol
Risk of hyponatraemia with carbamazepine or diuretics
How long do you have to stay an an antidepressant once symptoms have subsided?
6 months after in first episode, 2 years in second, and just forever if more than 2 severe episodes
